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Cognitive behaviour therapy (CBT) for menopausal symptoms
Cognitive behaviour therapy (CBT) for menopausal symptoms
Cognitive behaviour therapy (CBT) is a brief psychological therapy which is recommended by NICE (2015 (updated 2024), NG23) and the British Menopause Society (BMS 2019, Cognitive Behaviour Therapy (CBT) for Menopausal Symptoms) as a management option for a variety of menopausal symptoms.
This article was updated in November 2024.
You might also wish to look at our associated articles:
- Mental health in the menopause transition.
- Menopause and the workplace.
What is CBT?
The CBT model is based on the idea that the way people feel is linked to how they think about or perceive a situation or physical symptom, and to the way they behave in response to these challenges (Beck, J. 2020. Cognitive Behavior Therapy, Guilford Press).
CBT helps people identify their thoughts, feelings and behaviours, and develop new coping skills and strategies for dealing with distressing situations or symptoms. Through this process, the individual learns to change any negative thinking patterns or unhelpful behaviours that may be contributing to or maintaining their problem(s).
CBT takes a holistic approach which explores five interconnected areas of any problem. It looks at the person’s:
- Thoughts and beliefs.
- Physical symptoms and body sensations.
- Feelings and emotions.
- Behaviour and actions.
- Environmental factors, life stressors or triggers for symptoms.
Menopause-specific CBT may be offered via face-to-face or remote sessions, either one-to-one or in groups. There are also self-help options (NICE 2015 (updated 2024), NG23).
What’s the evidence for CBT in the menopause?
NICE guidelines in the following table are summarised from the latest guidance: NICE 2015 (updated 2024), NG23. NICE based these recommendations on an evidence review that looked at 14 randomised controlled trials. The strength of the evidence was relatively low quality, but NICE felt that CBT is a safe intervention with few adverse effects compared with other treatments, so it can be recommended despite the lack of clear evidence.
| Vasomotor symptoms and anxiety |
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| Sleep problems |
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| Depression and depressive symptoms |
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| Concentration and memory problems |
How can we access CBT for the menopause?
While CBT has been emphasised as a safe and potentially effective treatment by NICE, access to menopause-specific CBT is extremely limited in much of the UK.
NICE acknowledges that its recommendations represent a significant change to current clinical practice. It highlights the fact that wider use of CBT is likely to increase costs and add pressure to already limited services, but also points out that this gives people more choices for managing their symptoms, including the option to combine CBT and HRT, which may lead to better outcomes.
As awareness of the potential benefits of CBT grows, it is likely that there will be increased patient demand for menopause-specific therapy. However, significant investment in psychological services will be needed if we are to offer treatment choices that are in line with the latest NICE guidelines. For many with limited or no access to menopause-specific therapy, the only option may be to signpost to self-help CBT books, which may offer some benefit (see useful resources, below).
Which menopausal symptoms can CBT help with?
CBT has been specifically adapted to help women cope with common symptoms that can arise during the menopause, summarised below:
We explore these areas in more detail in the rest of this article. The following sections have been summarised from a factsheet aimed at patients produced by the Women’s Health Concern (WHC 2023, Cognitive Behaviour Therapy (CBT) for Menopausal Symptoms), which looks at:
- Vasomotor symptoms and anxiety.
- Depressed mood in the menopause.
- Sleep problems and insomnia.
Other references are cited separately where used.
Vasomotor symptoms and anxiety
- Vasomotor symptoms such as hot flushes and night sweats can be unpleasant and distressing, and lead to feelings of embarrassment and anxiety, as well as causing discomfort and affecting sleep.
- Conversely, being anxious and stressed can make vasomotor symptoms more difficult to cope with.
- Feeling anxious about vasomotor symptoms may be associated with negative or unhelpful thoughts which focus on worst-case scenarios and underestimate the person’s ability to cope. This may include:
- Beliefs about flushes in social situations: They are embarrassing and shameful.
- Fear of being judged negatively by others: Everyone is staring at me! I look like a tomato! My boss will think I’m totally incompetent!
- Beliefs about lack of control: I can’t cope with this! The hot flushes will go on forever…
- Catastrophic thoughts about the meaning of menopausal symptoms: I’m so forgetful – maybe I have dementia like my mum did…
- Unhelpful behaviour in response to vasomotor symptoms includes avoidance of feared situations, and setting unreasonable expectations or pushing too hard and getting exhausted (‘boom–bust’).
- Managing anxiety and stress can improve overall wellbeing and reduce the impact of vasomotor symptoms on daily functioning.
CBT framework of vasomotor symptoms
We can use a CBT framework to explore how vasomotor symptoms can cause emotional distress with negative thinking and unhelpful behaviour.
A CBT approach can help people to develop a calmer, more realistic or accepting view of situations and symptoms, making them easier to cope with. We will explore some strategies to encourage positive change later in the article.
Depressed mood in the menopause
Low mood is not inevitable for women going through the menopause, and, for many, it can be a positive experience. However, the menopause transition may sometimes be a trigger for the development of depressive symptoms, particularly in women with a history of depression.
| Area of CBT framework | Examples |
| Life stressors or problems. |
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| Depressed or self-critical thinking styles. |
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| Physical symptoms. | Fatigue or tiredness, lack of energy, increased pain, poor sleep. |
| Feelings. | Low mood, sadness, hopelessness |
| Behaviour. | Reducing activities that give life a sense of purpose and meaning. Social withdrawal and isolation. |
Sleep problems and insomnia
- Hot flushes, life stresses and low mood can all affect sleep in perimenopausal women. This causes tiredness and increased distress, and can have a negative effect on performance in important activities such as work.
- Insomnia is characterised by:
- Difficulty getting to sleep or staying asleep, early wakening or non-restorative sleep despite adequate time and opportunity to sleep.
- Impaired daytime functioning, e.g. poor concentration, mood disturbance or tiredness, or significant distress.
- Worry about disrupted sleep often creates anxiety at bedtime, which makes sleep even less likely. This includes negative beliefs such as: If I get woken by a night sweat, I’ll never get back to sleep! I’ll feel terrible the next day and I won’t be able to cope.
- Behaviour that can worsen sleep includes having an irregular sleep pattern or routine, frequent daytime naps, engaging in activating activities at bedtime that make it harder to drop off, and excessive clock checking at night.
- CBTi involves a range of strategies, as below. We have included a link to useful resources at the end of this article:
- Sleep education and hygiene.
- Sleep restriction: limiting time in bed and reducing daytime naps to consolidate and improve sleep quality.
- Stimulus control: establishing a consistent sleep routine and limiting activities in bed to strengthen the association between bed and sleep.
- Relaxation training.
- Strategies to cope with hot flushes and night sweats.
- Cognitive restructuring of unhelpful thoughts or beliefs about sleep.
Physical activity and menopause
Physical activity is likely to lift low mood, and may also have a positive impact on vasomotor symptoms and sleep. Many physical activities also encourage social interaction and mutual support.
A national survey explored women’s relationship with sport and physical activity during the menopause (Women in Sport 2018, Menopause, Me and Physical Activity). It found that:
- 30% of women reported becoming less physically active since menopause, yet the desire to be active is high, and is even higher if physical activity is recommended by a health professional.
- Physical and emotional changes during menopause can lead women to experience feelings of loss, including a lack of control over life and a loss of sense of self. This was more apparent for inactive women.
- Barriers to participation in physical activity include menopausal symptoms, low exercise self-efficacy and physical activity knowledge, social stigma and lack of social support.
- Menopause can be a powerful prompt for women to change physical activity behaviour. Active women felt more empowered to take control of their lives, and to manage their symptoms and long-term health through exercise.
CBT strategies to improve menopausal symptoms
Many different CBT strategies can help improve mood and wellbeing, and improve the ability to cope with distressing menopausal symptoms. These include (WHC 2023, Cognitive Behaviour Therapy (CBT) for Menopausal Symptoms):
Environmental factors and triggers
| Clothing and bedroom | Wear loose clothing made of natural, light fabric such as cotton, with layers that are easy to remove. |
| Stimulants and triggers | Cut down or avoid triggers to hot flushes, anxiety and stress such as coffee, hot drinks, spicy foods or alcohol. This is also likely to improve sleep. |
| The environment | Hot flushes may be more problematic in hot or stuffy environments, or with certain activities such as travelling on crowded trains. Try to keep the temperature cool using fans or air conditioning, and consider travelling at quieter times of day. |
Relaxation and paced breathing
Paced breathing can help calm feelings of anxiety and distress. It can be used as part of a wind-down routine to help with sleep at night, or during the day to soothe distress about symptoms such as hot flushes or brain fog.
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How to do paced breathing When you feel a hot flush coming on, paced breathing can create a pause and help to calm your body and mind. It involves focusing on your breathing to reduce anxiety and distress. Here are the steps: |
Identify and challenge negative thoughts
Recognising and changing negative thoughts and beliefs about the menopause is an important strategy that can improve wellbeing and quality of life.
| Create a pause to allow more balanced thinking | Take a moment to settle any strong emotions using paced breathing, then look for a calmer or more balanced view of the situation, such as: This hot flush will soon pass. I can breathe through it and get on with my day. Other people probably won’t even notice I’m having a hot flush. |
| Shift perspective | Worries and negative beliefs are not facts; they are just one view of the situation. To gain some perspective, try asking yourself: Is this perspective really accurate? Am I focusing on the negatives? What would I say to a close friend or family member in the same situation? What’s a more helpful or positive point of view? What supportive or kind words can I say? |
| Cultivate more helpful thoughts and beliefs | Begin to develop a positive mindset which focuses on your strengths and ability to cope, e.g.: The hot flushes will gradually reduce over time. There are things I can do to cope. Look at all the amazing women who are healthy and active through the menopause and beyond. If I talk to others who are going through the menopause, I won’t feel so alone. |
| Take a problem-solving approach | Plan how to cope with challenging situations using these steps: |
| Focus on your values and strengths | Write down three things that you value about yourself, or small achievements or things that you appreciated during the day such as: I finished the report, and my boss said I’d done a good job. I enjoyed having a coffee with my friend today. I was proud of myself for getting to the gym even though I felt tired. |
Adopt helpful behaviour
| Reduce avoidance | Trying to face up to situations that are challenging, rather than avoiding or leaving when you feel anxious, helps to build confidence and self-belief in your ability to cope. |
| Increase enjoyable or meaningful activities (behavioural activation) | Spending more time engaged in pleasant activities and creating structure in the day can lead to a greater sense of purpose and improved mood. Try to include more activities that make you feel calm or content, even for just a short time each day, such as listening to music, yoga, walking, reading, journalling, gardening or drawing. |
| Physical activity and exercise | Look for ways to be more active that make you feel good about yourself. Make changes small and realistic, and seek out social support to encourage and motivate you. It may help to find flexible activities that allow you to skip a session when having a tough day. Air-conditioned venues and private changing rooms can also make it easier to get active. |
| Be kinder to yourself | Relax your expectations. Aim for a balance between rest and activity, and pace activities throughout the day. Avoid boom–bust patterns of over-activity and excessive rest, which may worsen fatigue. |
| Seek support | Seeking support and advice from friends, family, colleagues, support groups and health professionals can provide reassurance, guidance and resources, and help women cope better with navigating the challenges of the menopause transition. |
Improve sleep patterns
| Create a positive sleeping environment and develop a winddown routine | Create a calm and relaxing bedroom environment, ensuring the room is dark and quiet. Do a calming and relaxing activity such as paced breathing before bed to relax and prepare for sleep. Limit bright or blue light in the early evening and in the bedroom. Avoid using mobile phones or electronic devices for an hour before bedtime. |
| Keep the bedroom cool at night | Use lightweight cotton sheets and remove heavy duvets. Consider using a cooling pillow or mattress pad. Lying on a towel can help to absorb sweat and prevent sheets from becoming drenched. |
| Maintain a regular sleep pattern | Go to bed and get up at a similar time every day, trying to avoid ‘lie-ins’. Avoid naps if possible, or, if essential, ensure it is before 3pm and short (30 mins or less). Don’t cancel activities or plans after a bad night of sleep because this can create unhelpful thinking patterns and have a negative effect on your mood. |
| Cope with negative thoughts | Set aside time during the day to use problem-solving to seek solutions to any difficulties you are facing. If worries pop up at night, tell yourself: I will deal with this tomorrow when I can think more clearly. Try to shift anxious or catastrophic thoughts into calmer and more helpful ones such as: I’ve coped after a bad night of sleep before so I know I’ll be OK. This is a tough moment, but it will pass. I’ll just do the most important things tomorrow and give myself time to recharge. |
| If woken by a night sweat | Even after making changes in your bedroom and sleep routine, you may still be woken by night sweats. Try to stay calm because becoming stressed or frustrated will have a bigger impact on sleep. Get up and do what you need to do to cool down. Try not to engage with negative thoughts or worries. Instead, use paced breathing to reduce stress and anxiety. Once you have cooled off, get back into bed and continue paced breathing and relaxation. |
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CBT for menopausal symptoms |
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Useful resources: Websites (all resources are hyperlinked for ease of use in Red Whale Knowledge) Patient information leaflet: CBT for insomnia resources: Books |
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