Bio-psycho-socio-cultural perspectives on menopause

Best Practice & Research Clinical Obstetrics and Gynaecology Vol. 21, No. 2, pp. 261e274, 2007 doi:10.1016/j.bpobgyn.2006.11.001 available online at http://www.sciencedirect.com

7 Bio-psycho-socio-cultural perspectives on menopause Myra Hunter *

PhD, C Psychol, AFBPS

Professor of Clinical Health Psychology Institute of Psychiatry, King’s College London, London SE1 7EH, UK Department of Psychology, Adamson Centre, St Thomas’ Hospital, London SE1 7EH, UK

Melanie Rendall

BSc, MSc

Clinical Psychologist in Training Salomon’s Centre for Applied Social and Psychological Development, Southborough, Tunbridge Wells, Kent TN3 0TG, UK

The menopause transition is a bio-psycho-socio-cultural process. Recent prospective studies highlight the complex ways in which lifestyle and cultural factors influence women’s experience of the menopause. For the majority of well women, the menopause is a relatively neutral event, although women living in Western countries in general report more symptoms than those from non-Western cultures. Hot flushes and night sweats are the main symptoms of the menopause, and while the exact physiological causes are unknown, the role of norepinephrine is implicated in lowering the threshold for flushing. Psychological factors e including anxiety, stress, thoughts and beliefs and self-esteem e influence the experience of hot flushes, and a cognitive behavioural model is described which is compatible with a bio-psycho-socio-cultural perspective. Relaxation and cognitive behavioural approaches appear to be acceptable to women, and there is some evidence for their efficacy, but larger controlled trials are needed. Key words: menopause; hot flushes; night sweats; vasomotor symptoms; psychological treatment; cognitive behaviour therapy; relaxation.

MENOPAUSE: A BIO-PSYCHO-SOCIO-CULTURAL TRANSITION The menopause occurs on average between the ages of 50 and 51 and literally refers to a woman’s last menstrual period. The menopause is a fairly universal experience for * Corresponding author. Institute of Psychiatry, King’s College London, London SE1 7EH, UK. Tel.: þ44 20 71885413/5408; Fax: þ44 20 79605662. E-mail address: [email protected] (M. Hunter). 1521-6934/$ - see front matter ª 2006 Elsevier Ltd. All rights reserved.

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women if they live long enough, although for some the process of the menopause is influenced by surgery or disease. However, the last menstrual period takes place within a gradual process of physiological change, occurring concurrently with age and developmental changes, and within varied psychosocial and cultural contexts. Psychological perspectives on the menopause include the meanings and definitions of menopause, appraisals and attributions of symptoms to menopause, as well as cognitive, affective and behavioural reactions to the menopause. Assessment and psychological interventions will be described with particular reference to vasomotor symptoms. Depression is the focus of Chapter 8. DEFINITIONS Menopause is defined as the permanent cessation of menstruation and is said to have occurred when there has been 1 year without a menstrual period, although endocrinological changes occur over a number of years.1 The definition of the menopause which until recently has been widely used in research is based on that of the World Health Organization2, which refers to the menopause as the ‘permanent cessation of menstruation resulting from loss of ovarian follicular activity’. The following stages of the menopause transition are based on menstrual patterns. Premenopause is defined by regular menstruation. Perimenopause includes the phase immediately prior to the menopause and the first year after menopause and is defined by changes in the regularity of menstruation during the previous 12 months. Women who have not menstruated during the past 12 months are defined as postmenopausal. Some women who have undergone hysterectomy or those who are taking hormone therapy may be difficult to classify within these definitions and are typically classified separately. Moreover, the classification of postmenopause can only be made in retrospect because it is impossible to know which menstrual period will be the last. In response to criticisms over the conflicting nomenclature and its subsequent detrimental impact on developing shared understandings of menopause, the Stages of Reproductive Ageing Workshop (STRAW) created a seven-stage model to more accurately describe reproductive status in healthy women.3 Using the final menstrual period as an anchor, the steering group proposed five stages preceding this point and two following. Stages 5 to 3 encompass the reproductive phases (menarche and regular menstruation), 2 early menopause transition (regular menstruation but change in cycle length), 1 late menopause transition (two or more missed menstrual periods and at least one intermenstrual interval of 60 days or more), þ1 (early postmenopause) refers to 4 years following the past menstrual period, and þ2 (late postmenopause) the subsequent years. Additional terms, such as ‘climacteric syndrome’ and ‘menopause syndrome’, have been used to refer to a wide variety of physical and emotional experiences that may or may not be related to hormone or menstrual changes, including hot flushes, vaginal dryness, loss of libido, depression, anxiety, irritability, poor memory, loss of concentration, mood swings, insomnia, tiredness, aching limbs, loss of energy and dry skin. ‘The change’ or ‘change of life’ is a commonly used colloquial term in Western cultures, which broadens out the definition even more and reflects the view that the menopause is closely associated with general psychological and social adaptations of midlife. Midlife often coincides with changes in personal and social relationships and with important life events such as illness, death of parents, dealing with adolescent children and children leaving home as well as perceived personal and social consequences of reaching the age

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of 50. The interpretation of the consequences of these changes and the extent to which they are attributed to the menopause will in part be a function of the social and cultural context and the health care and economic systems in which women live. Anthropological and cross-cultural studies have challenged the concept of the menopause as a universal phenomenon with wide variations in the symptom perception and reporting in women from different ethnic origins living in different countries. Cultural explanations of these differences need to include lifestyle (diet, exercise, social factors, as well as reproductive patterns) which can affect biological processes, population differences in biology, as well as beliefs and attitudes towards the menopause and the social status of middle-aged and older women. In other words this is a bio-psychosocio-cultural process which may vary within and between cultures and change over time. BIOLOGICAL PERSPECTIVES The function of the ovaries and hormone secretion is regulated by the hypothalamoe pituitaryeovarian axis. The primary factor influencing the transition from regular menstruation to the perimenopause appears to be the number of ovarian follicles. While at birth there are approximately 700,000 follicles in a woman’s ovaries, the numbers reduce markedly in the decade before the menopause, and at the time of the last menstrual period few follicles remain. Follicle stimulating hormone (FSH) concentrations gradually increase and serum inhibin concentrations reduce in the years leading up to the perimenopause, and these are now regarded as useful indices of the number and/or quality of follicles remaining in the ovary.4 There is growing evidence to suggest that it is the decrease in the ovarian secretion of inhibin (particularly inhibin B) that may determine the increases in FSH and reduction in oestradiol in middle-aged women.5 During the reproductive years oestradiol is the main type of oestrogen that is produced, but after the menopause oestrogen production does not stop because another oestrogen, oestrone, is produced from three main sources: the adrenal cortex, indirectly from the bodies fat cells which convert androstenedione to oestrone, and from the ovaries which continue to produce small quantities of androgens which are converted to oestrogens. Testosterone levels stay at approximately the same level after the menopause, being produced by the adrenal glands and by conversion of other hormones. Prospective epidemiological studies carried out during the past 20 years have begun to clarify the process of the menopause transition from both a biological and a subjective perspective. One of the earlier studies e the Massachusetts Women’s Health Study6 e documented the median age of inception of the perimenopause to be 47.5 years and the median duration to be 3.5 years. Current smokers experienced their last menstruation on average 2 years earlier than non-smokers. Evaluation of symptoms reported showed that 10% of premenopausal women reported hot flushes, while 50% of women 3e9 months prior to their last menstrual period did so. Duration of menopause was also highly variable: smokers had shorter duration of the perimenopause. The majority of studies have been carried out with white women (of northwest European ancestry). The Study of Women’s Health Across the Nation (SWAN) is a cross-sectional and prospective study of the natural history of the menopause conducted in seven centres across the USA, including samples of Caucasian, African American, Chinese, Hispanic and Japanese women.7 The results of the cross-sectional phase of the study emphasized the powerful effect of body mass index (BMI) upon hormone levels, with decreases

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in oestradiol and FSH but increases in testosterone as BMI increases within each ethnic group.8 There were also ethnic differences in hormone levels, some of which were explained by smoking and BMI, but differences in FSH (highest in Hispanic and African American and lowest in Japanese women) and testosterone (highest in Hispanic and African American and lowest in Japanese women) were evident when confounding factors were controlled. The Melbourne Women’s Midlife Health Project (MWMHP)9 similarly documented the biological and subjective changes experienced by women during the menopause transition. A large cross-sectional study was followed by a prospective study of 438 women over a period of 9 years. The main hormone changes were increases in FSH and decreases in oestradiol occurring in the late perimenopause and early postmenopause, with maximum change 2 years before the last menstrual period. Oestradiol reached a stable, lower level (below 20 pmol/L) between 2 and 5 years after the last menstrual period. PSYCHOSOCIAL PERSPECTIVES In Western societies the menopause is generally perceived as a time of poor emotional and physical health, and attitudes to the menopause are influenced by social and cultural assumptions about older women. Anthropological studies show how menopause can be a positive event, particularly when it signifies a change in social status.10e12 Much of the early research that influenced the Western view of the menopause was based on clinic samples of women who had actively sought treatment for health problems.13 Women attending menopause clinics have more health problems, life stresses and low mood than those who do not, as well as having differing beliefs about the menopause, seeing it as more akin to a disease.14 Determining the precise relationship between menopause and mood has been a difficult area to research because of numerous methodological issues (defining menopausal stages, measurement of mood, and confounding factors of age and social changes). Longitudinal studies have been designed in order to address these issues.6,14e18 The main findings from these studies suggest that the menopause transition is not directly associated with psychological symptoms in healthy women. Depressed mood should not be attributed automatically to the menopause transition. Instead, features of a woman’s life that contribute to depression should be considered.19,20 Moreover, the menopause is construed as a positive or neutral event for many women.18 These findings have been supported by qualitative studies which describe women’s accounts of menopause and include both positive beliefs and experiences, such as relief from cessation of menstrual periods and risk of pregnancy, but also concerns about aging and negative images of the menopause.21,22 There is a proportion of women who may be at a higher risk of mood changes during the transition to menopause.1 Factors found to be associated with depressed mood during the menopause transition include: past psychological problems14,17,23,24, social, educational and occupational status19,25, poor health16, stressful life events26, BMI, cigarette-smoking18, attitudes to menopause and ageing25,27,28, and early life circumstances and experiences.24 Women who have had a surgical menopause and those who have chronic and troublesome vasomotor symptoms tend to report more psychological symptoms.6,24 Overall, the experience of psychosocial factors has been found to have a much stronger association with psychological symptoms than stage of menopause.19,20

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HOT FLUSHES AND NIGHT SWEATS Prevalence Menopausal hot flushes and/or night sweats (also known as vasomotor symptoms) are reported by 60e70% of menopausal women in Western cultures.28 In general, reports of hot flushes and night sweats increase as women progress from early to late menopause transition. The frequency of bothersome hot flushes begins to rise 2 years before the last menstrual period and reaches a maximum up to 2 years after the final menstrual period. However, following the peak there is a gradual decrease to premenopausal levels in subsequent postmenopausal years.29 Although it makes sense to view these as part of normal development, given their prevalence, they can be problematic for some women in that approximately 10e20% of menopausal women seek help for troublesome hot flushes and/or night sweats, which may in some cases persist for up to 10 years.30 While the prevalence rates of night sweats are lower31, it has been suggested that they may be harder to tolerate than hot flushes because of their association with reduced sleep quality.32 Sleep disruption is reported by approximately one quarter of menopausal women33, and is more common in women who experience frequent hot flushes.34 However, there is marked variation in the duration, severity, and frequency of hot flushes and night sweats. Women of low socio-economic status and education and those who have higher BMI, who are cigarette-smokers and who have low levels of physical activity7,24,35 are more at risk of vasomotor symptoms. There are also considerable cross-cultural differences in hot flush reporting. Reporting of such symptoms around the time of the menopause is much less common amongst Japanese women36, Mayan Indian women37, and women from the Indian subcontinent.38 The explanations of these differences are not clearly understood, but may include diet, lifestyle, reproductive practices, climate, attribution of symptoms and cultural meanings of the menopause and aging. Studies of differences between ethnic groups of women living in Western countries have produced mixed results. In the SWAN study carried out in the USA, African American women were more likely, and Japanese and Chinese women less likely, to report these symptoms compared to Caucasian women.7 In a recent study the experience of menopause and quality of life in a migrated Asian population from the Indian subcontinent living in Birmingham, UK, was compared with a matched sample of Caucasian women living in the same geographical area, and also with a sample of Asian women with similar socio-economic background living in Delhi, India.38 Women living in India reported significantly fewer hot flushes (32%) compared to the UK Asian (75%) and Caucasian groups (61%), but the UK Asian women’s experience of the menopause was very similar to that of the Caucasian women. Further analysis of the qualitative data is in progress. Overall, these findings suggest that assumptions cannot be made about the menopausal experience of women from ethnic communities living in Western countries. Aetiology In terms of the bodily experience, hot flushes are commonly described as sensations of heat in the face, neck and chest, frequently accompanied by perspiration and/or shivering, and often accompanied by increases in skin conductance and finger temperature as well as peripheral blood flow and heart rate.39 The exact aetiology is

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unknown, but appears to be associated with the rate of change of plasma oestrogen, which influences the thermoregulatory system via the hypothalamus.40 Hot flushes are also more prevalent following rapid withdrawal of oestrogen, for example following surgical menopause or adjuvant chemotherapy for breast cancer.41 Alterations in oestrogen levels (but not absolute oestrogen levels) and neurotransmitters, such as norepinephrine and serotonin, and their subsequent impact on thermoregulatory homeostasis, have been widely implicated in the pathogenesis of vasomotor symptoms.42e44 Berendson42 has reviewed evidence that supports the role of serotonin (especially the role of 5-HT2A); hot flushes being the result of activation of oestrogen-withdrawal-induced up-regulated 5-HT2A receptors by mild internal or external stimuli, such as anxiety, high ambient temperatures, coffee or alcohol. The hypothalamic set-point temperature is then altered and autonomic reactions to cool down are activated. This results in flushing and sweating of the skin by peripheral vasodilation. Freedman43 has proposed that there is a narrowed thermoneutral zone in women who have hot flushes, resulting in hot flushes being triggered by small elevations in core body temperature caused by changes in ambient temperature or other environmental triggers. There is evidence from animal research that the zone is narrowed by elevated brain norepinephrine.43 This physiological model provides a framework with which to understand the role of psychological factors and psychological interventions for hot flushes and night sweats. PSYCHOLOGICAL STUDIES There is empirical evidence to suggest that distress and help-seeking for hot flushes is only weakly related to more objective measures such as duration and frequency.31 Symptomatology has been shown to vary dramatically between different cultures, ethnic groups and socioeconomic groups3, and the aetiological model outlined above adds strength to the assertion that psychological and sociocultural factors may have a significant role to play in determining the experience of menopause.34 The association of hot flushes with stress precipitated a number of studies that examined whether psychosocial variables may potentiate or precipitate hot flushes.45,46 Hot flushes have been found to be precipitated by daily ‘hassles’.45 A further study demonstrated that laboratory stress resulted in significantly more objective flushing and subjective reporting, suggesting that the effects of stress cannot be explained by changes in response bias.46 The flushes did not seem to concentrate around the actual stressor, which is consistent with the idea that stress may lower the threshold for, rather than cause, hot flushes directly. A cognitive behavioural model has been proposed to understand the possible role of psychosocial factors in the experience of hot flushes (Figure 1).47 The cognitive behavioural model is based on the belief that emotions arise as a result of the way events are interpreted48, thereby suggesting that cognitions (thoughts, beliefs and attitudes) are mediators between environmental events, subjective reactions and behavioural responses. Leventhal et al49 proposed a self-regulatory model, which is predicated on the assumption that individuals construct their own representations of health problems as a way of making sense of them, and that these cognitive appraisals determine an individual’s emotional and behavioural responses. A recent study that applied this model to menopausal women found that women had developed clear cognitive representations, even in the early stages of menopause.50 Although a significant number of women experienced the end of menstrual and reproductive status as

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Stress and life style triggers

Bodily and physical changes

Experience of hot flushes and night sweats

Thoughts and beliefs

Mood and emotional reactions

Behavioural strategies

Developmental, social & cultural factors

Figure 1. A cognitive behavioural model of menopausal hot flushed.

a positive event, others expressed concern over having little control over menopause. A recent study demonstrated a strong association between anxiety and menopausal symptoms in a community sample of menopausal women, with the most anxious women reporting higher frequencies of hot flushes and higher levels of distress.51 Similarly, women who request treatment for hot flushes have been shown to have lower internal locus of control and lower self-esteem.52 In an attempt to explore why some women perceive their hot flushes as more problematic than others, Hunter and Liao31 conducted a descriptive study to outline the cognitive, behavioural and affective components of hot flush reporting in a sample of 61 women recruited from inner-city doctors’ surgeries. The extent to which hot flushes were perceived as problematic was significantly associated with mood, anxiety and self-esteem. Specific cognitions were associated with negative consequences, social embarrassment and feelings of loss of control, as well as physical discomfort and disruption of sleep (Table 1). Women described a number of behavioural strategies to alleviate discomfort, including the removal of clothing, stopping activity and attempts to relax. Similarly Reynolds53 interviewed menopausal women and noted similar themes. She found clear relationships between perceived distress and negative thoughts; highly distressed individuals were noted to have more extreme reactions to the physical sensations of flushing and more negative, shaming attitudes towards the self, including feeling ‘over the hill’ or ‘not attractive’. Interestingly, these women did not report such feelings about their bodies or self-concept at other times. Conversely, women with low

Table 1. Hot flushes and night sweats: problematic aspects and cognitions. Problematic aspects of hot flushes

Cognitions associated with distress

Physical discomfort e heat and sweating (56%) Sleep disruption and tiredness (40%) Social embarrassment (36%) Loss of control (18%)

‘Oh no not again’ e irritation and annoyance (53%) ‘Will this ever end’ e despair and helplessness (20%) ‘Is everyone looking at me’ e social anxiety (17%) ‘Just take a breath and it will go away’ e calm thoughts (8%)

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distress levels reported using encouraging self-talk and other positive behavioural strategies during flushing. Catastrophic thoughts such as ‘I cannot possibly concentrate’, ‘It is terrible and I feel that it is never going to get any better’, ‘It is awful and I feel that it overwhelms me’ and ‘I feel like a different person’ were associated with perceived flush distress.54 Certain situations such as hot crowded places, meetings at work, enclosed spaces, and activities such as rushing, physical exertion, eating and drinking have been reported to precipitate or exacerbate hot flushes.31,54 Conversely, working with female colleagues and being able to joke about hot flushes was seen to be helpful. In a further study Reynolds55 found that appraisals of feeling ‘unattractive’, ‘not needed’ and ‘unsuccessful’ during flushes were related to higher levels of discomfort. These studies together provide evidence that negative thoughts or cognitive appraisals may increase subjective awareness of bodily states and culminate in higher levels of distress. In particular, women with heightened awareness of their bodies and their feelings, negative expectations about menopause, low selfesteem and high general levels of anxiety may be at a greater risk of experiencing hot flushes as distressing. To summarize, physiological research suggests that general levels of stress might narrow the threshold for the triggering of hot flushes, and hence strategies to reduce stress, such as relaxation and paced breathing, might be helpful. Environmental factors e such as rushing, spicy food, alcohol e might trigger hot flushes, and cognitive reactions might exacerbate distress. Behavioural reactions such as avoidance might maintain social anxiety, whereas alternative strategies such as joking might be helpful in certain situations. Low mood and low self-esteem appear to increase the tendency to appraise symptoms negatively, and we know that the extent to which the symptoms are perceived as a problem is less associated with hot flush frequency or duration but more with cognitions (perceptions of ability to cope), mood (depressed mood, anxiety) and lower selfesteem.31 These elements are represented in the cognitive behavioural model (Figure 1). ASSESSMENT Accurate measurement of hot flushes is important in the assessment and evaluation of treatments.56  Questionnaires have been used to record daily or weekly frequency, severity and duration of hot flushes. Many of these suffer from lack of validation. The Hot Flush Rating Scale (HFRS)31 is a short scale which measures hot flush and night sweat frequency and ‘problem-rating’ (three items, including distress, extent to which a problem and interference with daily routine). These two factors were derived using factor analysis and had high testeretest reliability. Frequency ratings correlated highly with prospective daily diary recordings. Depressed mood, anxiety and low self-esteem discriminated between women who regarded flushes as problematic and those who did not. The scale has also been used to evaluate outcome of interventions.57  Daily diaries are regarded as more reliable because the flushes can be recorded at the time. However, night sweats are typically estimated the next morning. These can include frequency or frequency plus a rating of severity.  The most reliable objective measure of hot flushes and night sweats is the sternal skin conductance monitor which correlates well with self-reported data, is specific to hot flushes and can be used under ambulatory conditions.56

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 The Menopause Representation Questionnaire (MRQ)50 provides a measure of attribution of symptoms to the menopause as well as positive and negative beliefs about the menopause.  There are several quality-of-life (QOL) measures that have good psychometric properties and are used widely in menopause research. These include the Greene Climacteric Scale58, the Women’s Health Questionnaire59, the Menopause Symptom List60, the Menopause Rating Scale61, and the Utian Menopause Quality of Life Score.62 These have been described in detail in an earlier review by Schneider.61 Ideally, all forms of measurement should be used in research studies, while for practical reasons the HFRS, a daily diary and a QOL measure is usually adequate in clinical settings. TREATMENTS It has been estimated that approximately 75% of women may seek information and advice about menopausal symptoms, usually through their general practitioner.63 There are three broad groups of treatment options for menopausal symptoms: hormone therapies, complementary therapies and non-hormonal therapies. Space does not permit detailed discussion of medical treatments, the focus here being upon psychological interventions. Hormone replacement therapy (HRT) is a highly effective treatment for menopausal hot flushes and night sweats. However, since the publication of prospective data from the Women’s Health Initiative64 and the Million Women Study65, which cast doubt on the long-term efficacy and safety of HRT, some women are reluctant to either commence or continue with HRT.66 There is a growing evidence base for the efficacy of selective serotonin reuptake inhibitors (SSRIs) for the reduction of hot flushes67e69, although the long-term efficacy of these interventions has been questioned in a recent comparison of citalopram, fluoxetine and placebo.70 There has been much interest in complementary or alternative therapies for the reduction of vasomotor symptoms, including black cohosh, soy foods, and red clover.71 A recent review concluded that there was little consistent benefit for any botanical or dietary supplements other than black cohosh.72 However, the data in support of black cohosh and phyto-oestrogens remain inconsistent.73,74 The conclusion of several recent review articles and meta-analyses is that further well-controlled studies of complementary therapies and herbal remedies are needed.69,72,74,75

Psychological treatments of menopausal symptoms In one of the earliest psychological treatment studies76, four women were treated with a combination of relaxation, self-suggestions of thoughts and images, and marital contingency contracting, resulting in decreases in frequency of flushing of 41e90%. Four subsequent small-scale studies77e80 have demonstrated the effectiveness of relaxation training, with paced breathing techniques resulting in 50% decreases in hot flushes in samples of well women. In the first study exploring the effectiveness of CBT for menopausal hot flushes in a primary care setting, Hunter and Liao57 used a patient preference design to compare the effectiveness of CBT with HRT, comparing no treatment (monitoring) versus HRT versus CBT. A four-session CBT intervention, combining psychoeducation, relaxation

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and cognitive restructuring, was administered to 24 women to help them cope with their flushes through learning to identify and modify triggers and exacerbators of hot flushes, using relaxation to reduce general levels of stress, and using cognitive therapy to challenge overly negative thoughts and beliefs. Sessions focused on discussing the nature of hot flushes, as well as attitudes and beliefs about the menopause, with the aim of helping women to identify their automatic thoughts and reduce their distress through adopting strategies such as calming self-talk, challenging unhelpful beliefs, relaxation and breathing exercises. Cognitive and behavioural responses to the flushes were role-played in the sessions so that automatic thoughts could be identified and substituted with calming thoughts and relaxation responses. Some women used a mirror to actually see how they looked during a flush and this proved useful for those who worried about the symptoms drawing unwanted attention to themselves. CBT and HRT demonstrated comparable effectiveness, reducing the frequency of hot flushes by 50%, and those with CBT reported greater self-efficacy with respect to their perceived ability to cope. There were no significant changes in the monitoring group. Compared to HRT, CBT also appeared to enhance general mood by lowering levels of anxiety and depression. Keefer and Blanchard81 conducted a pilot study to evaluate the efficacy of a group CBT intervention in reducing hot flushes and associated distress levels. The intervention was a combination of psychoeducation, relaxation training and cognitive restructuring, and was delivered weekly for eight sessions. Nineteen women who had never used HRT were randomized into two groups: immediate treatment and delayed treatment. The primary outcome measures were the total number of hot flushes and their related distress in the 2 weeks before and after treatment. Initial hypotheses were supported; the group who had immediate treatment had significant reductions in the total number of hot flushes and reductions in distress levels compared to the delayed treatment group. With respect to clinical significance, 70% of the total sample experienced at least 30% improvement in symptoms by post-treatment. No change in psychosocial functioning was detected, although overall levels of emotional distress were low before treatment. In a report of two cases, a ten-session, manualized CBT package was delivered to two women who self-referred for treatment due to difficulties in coping with their hot flushes.82 The treatment offered a combination of relaxation, cognitive and behavioural techniques aimed at ameliorating stress, physiological arousal and emotional distress. Both women demonstrated clinically significant reductions in the frequency of their hot flushes and concomitant improvements in emotional and interpersonal stress post-treatment and at 6 months follow-up. Informal feedback revealed that the women particularly valued being taught to monitor their thoughts and feelings, primarily because it provided them with the opportunity to become more aware of psychosocial triggers. Though generalizations are hampered by small sample sizes and therefore subsequent poor statistical power to detect changes81, there appears to be good preliminary evidence for further studies to examine the effectiveness of CBT in reducing the frequency of, and distress associated with, menopausal hot flushes. SUMMARY Prospective studies of the menopause transition illustrate the complex ways in which biological, psychological and cultural factors are inextricably linked. For example,

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cigarette-smoking and body weight can affect the timing and experience of menopausal symptoms. Clinically this research draws attention to the importance of being culturally aware and having a curiosity about a woman’s beliefs, lifestyle and cultural traditions. In terms of research, further work is needed to understand the mechanisms underpinning cultural differences in experience of menopausal symptoms. Subjective experience during the menopause transition is influenced by psychosocial factors e such as past problems, life stresses, negative beliefs and expectations about menopause e as well as socioeconomic factors, to a greater extent than by stage of menopause. A cognitive behavioural model of menopausal symptoms is described that outlines possible relationships between biological, cognitive, behavioural and environmental factors. More research is needed to test out the relationships with this model using several methods of measurement, including objective measures of hot flushes. Psychological interventions based on the model offer a collaborative, skills-based approach with promising outcomes, but larger controlled studies are needed. The specific elements of the treatments need to be researched so that the mechanisms can be understood and the treatments refined. In addition, we do not know whether these approaches are effective for different patient groups: for example for women following surgical menopause or adjuvant treatments for breast cancer.83

Research agenda  measurement of hot flushes and night sweats  explanation of cultural differences in experience of menopause  large-scale controlled trials of non-hormonal treatments such as CBT for menopausal symptoms

REFERENCES 1. Dennerstein L & Alexander JL. Mood and menopause. In Castle DJ, Kulkarni J & Abel KM (eds.). Mood and Anxiety Disorders in Women. Cambridge, UK: Cambridge University Press, 2006, pp. 212e242. 2. World Health Organisation. Research on Menopause. Report of a WHO Scientific group. WHO technical report N670. WHO Geneva, 1981. 3. Soules MR, Sherman S, Parrott E et al. Executive summary: stages of reproductive aging workshop (STRAW). Menopause 2001; 8: 402e407. 4. Richardson S. The biological basis of the menopause. In Burger HG (ed.). The Menopause: Clinical Endocrinology and Metabolism. London: Balliere Tindall, 1993, pp. 1e16. 5. Burger HG, Dudley EC, Hopper JL et al. Prospectively measured levels of serum follicle-stimulating hormone, estradiol, and the dimeric inhibins during the menopausal transition in a population-based cohort of women. J Clin Endocrinol Metab 1999; 84: 4025e4030. 6. McKinlay SM, Brambilla DJ & Posner JG. The normal menopause transition. Maturitas 1992; 14: 103e115. *7. Sowers MF, Crawford SL, Sternfeld B et al. SWAN: a multi-center, multi-ethnic, community-based cohort study of women and the menopause transition. In Lobo RA, Kelsey J & Marcus R (eds.). Menopause: Biology and Pathobiology. San Diego: Academic Press, 2000, pp. 175e188. 8. Randolph Jr. JF, Sowers M, Mohr BA et al. Reproductive hormones in the early menopause transition: relationship to ethnicity, body size, and menopausal status. J Clin Endocrinol Metab 2003; 88: 1516e1522. 9. Guthrie JR, Dennerstein L, Taffe JR et al. The menopause transition: a 9 year prospective populationbased study. The Melbourne Women’s Midlife Health Project. Climacteric 2004; 7: 375e389.

272 M. Hunter and M. Rendall 10. Flint M. The menopause: reward or punishment. Psychosomatics 1975; 10: 161e163. 11. George T. Women in a south Indian fishing village: role identity, continuity, and the experience of menopause. Health Care Women Int 1996; 17: 271e279. 12. Rice PL. Pog laus tsis khaub hcaws lawm: the meaning of menopause in Hmong women. J Reprod Infant Psychol 1995; 3: 79e82. 13. Avis NE, Stellato R, Crawford S et al. Is there a menopausal syndrome? Menopausal status and symptoms across racial groups. Soc Sci Med 2001; 52: 345e356. 14. Hunter MS. Psychological and somatic experience of the menopause: a prospective study. Psychosom Med 1990; 52: 357e367. 15. Matthews KA, Wing RR, Kuller LH et al. Influences of natural menopause on psychological characteristics and symptoms of middle-aged healthy women. J Consult Clin Psychol 1990; 58: 345e351. 16. Kaufert P, Gilbert P & Tate R. The Manitoba project: a re-examination of the link between menopause and depression. Maturitas 1992; 14: 143e155. 17. Avis N, Brambilla D, McKinlay S et al. A longitudinal analysis of the association between menopause and depression. Ann Epidemiol 1994; 4: 15e21. 18. Dennerstein L, Lehert P, Burger H et al. Mood and the menopause transition. J Nerv Ment Dis 1999; 187: 685e691. 19. Hunter MS. Editorial: depression and the menopause. BMJ 1996; 313: 1217e1218. 20. Woods NF, Mariella A & Mitchell ES. Depressed mood symptoms during the menopausal transition: observations from the Seattle Midlife Women’s Health study. Climacteric 2006; 9: 195e203. 21. Hunter MS & O’Dea I. Menopause: bodily changes and multiple meanings. In Ussher JM (ed.). Body Talk: The Material and Discursive Regulation of Sexuality, Madness and Reproduction. London: Routledge, 1997, pp. 199e222. 22. Hvas L. Menopausal women’s positive experience of growing older. Maturitas 2006; 54: 245e251. 23. Porter M, Penney G, Russell D et al. A population based survey of women’s experiences of the menopause. Br J Obstet Gynaecol 1996; 103: 1025e1028. *24. Kuh D, Wadsworth M & Hardy R. Women’s health in midlife: the influence of the menopause, social factors and health in earlier life. Br J Obstet Gynaecol 1997; 104: 923e933. 25. Holte A & Mikkelsen A. Psychosocial determinants of climacteric complaints. Maturitas 1991; 13: 205e215. 26. Cooke DJ & Greene JG. Types of life events in relation to symptoms at the climacterium. J Psychosom Res 1981; 25: 5e11. 27. Dennerstein L, Smith AM, Morse C et al. Menopausal symptoms in Australian women. Med J Aust 1993; 159: 232e236. 28. Hunter MS. The S.E. England longitudinal study of the climacteric and postmenopause. Maturitas 1992; 14: 117e126. 29. Guthrie JR, Dennerstein L, Taffe JR et al. Health care seeking for menopausal problems. Climacteric 2003; 6: 112e117. 30. Berg G, Gottval T, Hammar M et al. Climacteric symptoms among women aged 60e62 in Linkoping, Sweden. Maturitas 1998; 10: 193e199. *31. Hunter MS & Liao KLM. A psychological analysis of menopausal hot flushes. Br J Clin Psychol 1995; 34: 589e599. 32. Sievert LL, Obermayer CM & Price K. Determinants of hot flashes and night sweats. Ann Hum Biol 2006; 33: 4e16. 33. Eichling PS, Freedman R, Polo-Kantola P et al. Menopause and sleep. Menopause Management 2005; 14: 25e29. 34. Baker A, Simpson S & Dawson D. Sleep disruption and mood changes associated with menopause. J Psychosom Res 1997; 43: 359e369. 35. Ford K, Sowers M, Crutchfield MW et al. A longitudinal study of the predictors of prevalence and severity of symptoms commonly associated with menopause. Menopause 2005; 12: 308e317. *36. Lock M. Cross cultural vasomotor symptoms reporting: conceptual and methodological issues. Menopause 2005; 12: 239e241. 37. Martin MC, Block JE, Sanchez SD et al. Menopause without symptoms: the endocrinology of menopause among rural Mayan Indians. Am J Obstet Gynaecol 1993; 168: 1839e1843. 38. Gupta P, Sturdee DW & Hunter MS. Mid-aged health in women from the Indian subcontinent (MAHWIS): general health and the experience of menopause in women. Climacteric 2006; 9: 13e22.

Bio-psycho-socio-cultural perspectives on menopause 273 39. Ginsberg J, Swinhoe J & O’Reilly B. Cardiovascular responses during the menopausal hot flush. Br J Obstet Gynaecol 1981; 88: 925e930. 40. Ginsberg H, Hardiman P & O’Reily B. Peripheral blood flow in menopausal women who have hot flushes and those who do not. BMJ 1989; 298: 1488e1490. 41. Kronenberg F. Hot flashes: epidemiology and physiology. Ann N Y Acad Sci 1990; 592: 52e86. 42. Berendsen HHG. Hot flushes and serotonin. J Br Menopause Soc March, 2002: 30e34. *43. Freedman RR. Pathophysiology and treatment of menopausal hot flashes: a contemporary approach to the menopause. Semin Reprod Med 2005; 23: 117e125. 44. Mom CH, Buijs C, Willemse PHB et al. Hot flushes in breast cancer patients. Crit Rev Oncol Hematol 2006; 57: 63e77. 45. Gannon L, Hansel S & Goodwin J. Correlates of menopausal hot flushes. J Behav Med 1987; 10: 277e285. 46. Swartzman LC, Edelberg R & Kemmann E. Impact of stress on objectively recorded menopausal hot flushes and on flush report bias. Health Psychol 1990; 9: 529e545. 47. Hunter M. Cognitive behavioural interventions for premenstrual and menopausal symptoms. J Reprod Infant Psychol 2003; 21: 183e193. 48. Beck AT. Cognitive Therapy and the Emotional Disorders. New York: International Universities Press, 1976. 49. Leventhal H, Nerenz D & Steel DJ. Illness representations and coping with health threats. In Baum A, Taylor SE & Singer JE (eds.). Handbook of Psychology and Health. Hillsdale, NJ: Lawrence Erlbaum Associates, 1984, pp. 219e252. 50. Hunter MS & O’Dea I. Development of the menopause representations questionnaire. Psychol, Health & Med 2001; 6: 65e76. 51. Freeman E, Samuel M, Lin H et al. The role of anxiety and hormonal changes in menopausal hot flashes. Menopause 2005; 12: 258e266. 52. Hunter MS & Liao KLM. Determinants of treatment choice for menopausal hot flushes: psychological, hormonal or no treatment. J Psychosom Obstet Gynaecol 1995; 16: 101e108. 53. Reynolds F. Psychological responses to menopausal hot flushes: implications of a qualitative study for counseling interventions. Couns Psychol Q 1997; 197(10): 321e333. *54. Reynolds F. Relationship between catastrophic thoughts, perceived control and distress during menopausal hot flushes: exploring the correlates of a questionnaire measure. Maturitas 2000; 42: 201e207. 55. Reynolds F. Exploring self-image during hot flushes using a semantic differential scale: associations between poor self-image, depression, flush frequency and flush distress. Maturitas 2002; 42: 201e207. 56. Miller HG & Maria R. Measuring hot flushes: summary of a National Institutes of Health Workshop. Mayo Clin Proc 2004; 79: 777e781. *57. Hunter MS & Liao KLM. An evaluation of a four-session cognitive behavioural intervention for menopausal hot flushes. Br J Health Psychol 1996; 1: 113e125. 58. Greene JG. Constructing a standard climacteric scale. Maturitas 1998; 29: 25e31. 59. Hunter MS. The Women’s health questionnaire: a measure of mid-aged women’s perceptions of their emotional and physical health. Psychol Health 1992; 7: 45e54. 60. Perz JM. Development of the menopause symptom list: a factor analytic study of menopause associated symptoms. Womens Health 1997; 25: 53e69. 61. Schneider HPG. The quality of life in the postmenopausal woman. Best Pract Res Clin Obstet Gynaecol 2000; 16: 395e409. 62. Utian WH, Janata JW, Kingsberg SA et al. The Utian Quality of Life (UQOL) scale: development and validation of an instrument to quantify quality of life through and beyond menopause. Menopause 2002; 9: 402e410. 63. Hope S, Wagner E & Rees M. Survey of British women’s views on the menopause and HRT. J Br Menopause Soc 1998; 4: 33e36. 64. Roussouw JE, Anderson GL, Prentice RL et al. Risks and benefits of oestrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health initiative randomized controlled trial. JAMA 2002; 288: 321e333. *65. Beral V. Breast cancer and hormone replacement therapy in the Million Women study. Lancet 2003; 362: 419e427. 66. Hersh AL, Stefanick ML & Stafford RS. National use of postmenopausal hormone therapy: annual trend and response to recent evidence. JAMA 2004; 291: 47e53.

274 M. Hunter and M. Rendall *67. Loprinzi CL, Kugler JW, Sloan JA et al. Venlafaxine in management of hot flashes in survivors of breast cancer: a randomized controlled trial. Lancet 2000; 356: 2059e2063. 68. Stearns V, Beebe KL, Iyengar M et al. Paroxetine controlled-release in the treatment of menopausal hot flashes: a randomized controlled trial. JAMA 2003; 289: 2827e2834. 69. Nelson HD, Vesco KK, Haney E et al. Non-hormonal therapies for menopausal hot flushes. JAMA 2006; 295: 2057e2071. 70. Suvanto-Luukkonen E, Koivunen R, Sundstrom H et al. Citalopram and fluoxetine in the treatment of postmenopausal symptoms: a prospective, randomized 9 month placebo controlled double blind study. Menopause 2005; 12(1): 18e26. 71. Warren MP, Shortle B & Dominguez JE. Use of alternative therapies in menopause. Best Pract Res Clin Obstet Gynaecol 2002; 16: 411e448. 72. Geller SE & Studee L. Botanical and dietary supplements for menopausal symptoms: what works, what does not. J Womens Health 2005; 14: 634e649. 73. Krebs EE, Ensrud KE, MacDonald R et al. Phytooestrogens for treatment of menopausal symptoms: a systematic review. Obstet Gynaecol 2004; 104: 824e836. 74. Carroll DG. Nonhormonal therapies for hot flashes in menopause. Am Fam Physician 2006; 73: 396e398. 75. Hanna K, Day A, O’Neill S et al. Does scientific evidence support the use of non-prescription supplements for treatment of acute menopausal symptoms such as hot flushes? Nutr Diet 2005; 62: 138e151. 76. Stevenson DW & Delprato DJ. Multiple component self control programme for menopausal hot flushes. J Behav Ther Exp Psychiatry 1983; 14: 137e140. 77. Freedman RF & Woodward S. Behavioural treatment of menopausal hot flushes: evaluation by ambulatory monitoring. Am J Obstet Gynaecol 1992; 167: 436e439. 78. Germaine LM & Freedman RR. Behavioural treatment of menopausal hot flushes: evaluation by objective methods. J Consult Clin Psychol 1984; 52: 1072e1079. 79. Irvin JH, Domar AD, Clark C et al. The effects of relaxation response training on menopausal symptoms. J Psychosom Obstet Gynaecol 1996; 17: 202e207. 80. Wijma K, Melin A, Nedstrand E et al. Treatment of menopausal symptoms with applied relaxation: a pilot study. J Behav Exper Psychiatry 1997; 28: 251e261. *81. Keefer L & Blanchard EB. A behavioural group treatment program for menopausal hot flashes. Appl Psychophysiol Biofeedback 2005; 30: 21e30. 82. Allen LA, Dobkin RD, Boohar EM et al. Cognitive behaviour therapy for menopausal hot flashes: two case reports. Maturitas 2006; 54: 95e99. 83. Hunter MS, Grunfeld EA, Mittal S et al. Menopausal symptoms in women with breast cancer: prevalence and treatment preferences. Psychooncology 2004; 13: 769e778.