Psychotherapy in menopause care: Addressing fear, anxiety, and GSM

Psychotherapy remained an underused component of menopause care largely because clinicians did not know enough about its role, according to Sheryl Kingsberg, PhD, who presented “Why psychotherapy is the secret weapon in treating symptoms” at the International Menopause Society 20th World Congress on Menopause in Rio, Brazil.

Kingsberg, chief of the Division of Behavioral Medicine at University Hospitals MacDonald Women’s Hospital/University Hospitals Cleveland Medical Center and a professor in Reproductive Biology, Urology and Psychiatry at Case Western Reserve University in Cleveland, Ohio, advocated a biopsychosocial framework for managing menopausal symptoms and genitourinary syndrome of menopause (GSM). Although these symptoms have biologic causes, she said treatment should incorporate a multidisciplinary approach rather than relying on a single modality. Hormone therapy alone was insufficient, as was pelvic floor physical therapy alone, which Kingsberg described as phenomenal. Incorporating psychotherapy added value by addressing the consequences of symptoms.

“What we know is that if you don’t address how women feel about these symptoms, the catastrophic fear, the behavioral responses, then your treatment just isn’t as effective,” Kingsberg said.

All patients stood to benefit from a behavioral approach to many of their symptoms, according to Kingsberg, although women more vulnerable to anxiety and to the fear response that accompanies symptoms were likely to benefit most.

For vasomotor symptoms, psychotherapy targeted the patient’s reaction rather than the frequency of hot flashes, reducing the impact of the stress and panic these episodes could provoke.

“It’s not that psychotherapy per se can reduce the frequency of these symptoms of hot flashes, but they can certainly impact how women respond to them,” Kingsberg said.

Helping patients cope with anxious, anticipatory thoughts—such as concern about how to manage a hot flash in the middle of a professional obligation—reduced the overall impact of these episodes, Kingsberg said. In a randomized controlled trial of 140 women with problematic hot flashes and night sweats, both group and self-help CBT significantly reduced how problematic women rated their symptoms at 6 weeks compared with no treatment.¹

Most women with GSM were not treated until long after symptom onset, according to Kingsberg, and many developed symptoms before their last menstrual period. She identified 2 priorities to close that gap: first, empowering women to ask for help, and second, teaching clinicians to ask patients about symptoms.

Vaginal dryness, vulvar pain, and anxiety about penetrative sex could create a fear-anxiety-pain cycle in women with GSM. Kingsberg said CBT was the best approach to that cycle, used in addition to treatments such as vaginal estrogen or other vaginal hormone therapy and pelvic floor physical therapy. If the pain-fear cycle is not addressed, she said, those treatments are unlikely to succeed. A review of genito-pelvic pain/penetration disorder similarly highlighted psychological and relational contributors to the fear-avoidance cycle in sexual pain and outlined CBT-based strategies for addressing them.²

References

1. Norton S, Chilcot J, Hunter MS. Cognitive-behavior therapy for menopausal symptoms (hot flushes and night sweats): moderators and mediators of treatment effects. Menopause. 2014;21(6):574-578. doi:10.1097/GME.0000000000000095
2. Dias-Amaral A, Marques-Pinto A. Female genito-pelvic pain/penetration disorder: review of the related factors and overall approach. Rev Bras Ginecol Obstet. 2018;40(12):787-793. https://pmc.ncbi.nlm.nih.gov/articles/PMC10309300/