​This may not be a popular or widely accepted idea – in fact, in some circles, it may even be considered controversial. But here it is: I don’t believe that CBT helps eradicate perimenopausal symptoms.

CBT stands for Cognitive Behavioral Therapy. The American Psychological Association (APA) defines CBT as “a form of psychological treatment that has been demonstrated to be effective for a range of problems, including depression, anxiety disorders, alcohol and drug use problems, marital problems, eating disorders and severe mental illness.”

According to the APA, CBT helps people change their thinking patterns. The premise is that psychological problems are rooted in untrue or unhelpful thinking styles and behaviors. Additionally, the notion is that if people learn different ways of coping, they are achieve relief from symptoms and lead better lives.

It doesn’t elude me that the APA and other professional organizations whose members offer services like CBT have a vested interest in promoting it as a solution. Doing so keeps their appointments booked and a steady flow of clients who are hopeful that the remedies for what ails them is CBT.

So when I hear about women being recommended counseling or CBT for perimenopausal symptoms, I want to scream. Why?!

Perimenopause Is Not All In the Mind

Well, for starters, perimenopause is increasingly being considered as a complex, dynamic “neurological transition state.” Some go a bit further and classify it as a neuro-endocrine process that affects multiple body systems all at once – the brain, the reproductive organs, the adrenal system and all sorts of involved hormones and neurotransmitters.

What this means, exactly, is pretty involved. At a minimum perimenopause is not relegated to the reproductive tract. It affects more than the ovaries and includes the involvement of the brain, its structures and its chemicals, and every place and function in a woman’s body that estrogen touches. Estrogen-related systems include those responsible for temperature control, sleep and circadian rhythms, cognitive function, mood, bone health and more.

Some of the most common symptoms of perimenopause are not just those hot flashes and night sweats so many people hear about. Instead, some of the most disruptive consequences of the hormonal changes are the emergence of anxiety or depression, trouble with sleep, the onset of headaches, the occurrence of new aches and pains and even dryness of the skin, tissues and eyes.

When women present to their doctors with these symptoms, many are often told one of two main things:

1. “You’re too young to be in menopause.” This is frequently said by doctors who are pretty unfamiliar with the difference between perimenopause and menopause, and who have limited knowledge of the fact that hormone changes begin in the 30s. They tend to think of menopause as the end of menstrual cycles – and only that – discounting the many associated symptoms that can offer beforehand.
2. “Let’s get you an antidepressant.” This is usually offered by gynecologists and general medicine doctors who are afraid to prescribe hormone replacement therapy, who know almost nothing about perimenopause or who are going for the lowest common denominator in terms of menopause management.

Sadly, when some women hear this, they walk out of the doctor’s office feeling dejected and unheard. And, moreover, they begin to think that maybe all these symptoms really are in their minds – that they need some emotional help – aid that comes in the form of therapy.

Perimenopause Is a Time Ripe for Spending Money Unnecessarily

Also, even more sadly, there are many social workers, counselors and therapists ready and willing to take women’s money and time, claiming that therapy sessions will help resolve their physical perimenopause symptoms. Some promote the concept that 1:1 counseling will temper the night sweats, the racing heartbeats and the sudden feeling of doom. The problem with this is that these perimenopause symptoms are physiological in nature – that means they stem from the way we, as human organisms, and our actual internal bodily systems, are working (or not working). Most of the time, these disruptions boil down to the same thing: the consequences of erratic and shifting hormones.

Fortunately, more is coming out about the ineffectiveness of CBT. For example, “After analyzing 70 studies conducted between 1977 and 2014, researchers Tom Johnsen and Oddgeir Friborg concluded that CBT is roughly half as effective in treating depression than it used to be.” The paper, titled The Effects of Cognitive Behavioral Therapy as an Anti-Depressive Treatment Is Failing: A Meta-Analysis, is long and extensive and available online.

There’s even information about CBT for menopausal insomnia, known as CBTMI. Between 30-60% of perimenopausal and menopausal women experience insomnia, sometimes related to night sweats and often not related to any vasomotor symptoms. CBT for insomnia features strategies like sleep restriction (limiting time in bed), stimulus control (going to bed or the bedroom only when time for bed – no other activities) and sleep hygiene.

Every perimenopausal woman I’ve heard of who suffered from insomnia has tried these tactics on her own, often with no success. Why? Because the issue, at its core, is hormonal!

What CBT Might Help

While I don’t believe CBT does anything for the actual physical manifestations of hormonal changes endemic to perimenopause, it may help for specific issues women are apt to have during this time of life. For example, if a woman is having trouble accepting the fact that she’s aging, therapy could help her reframe her thinking to see maturing, instead, as a welcome life stage. It may help her see this time as a period for renewal and novelty rather than one of irrelevance and burdens.

Similarly, CBT may help those struggling with empty-nest syndrome, changing marital dynamics, finding a sense of purpose and modifying their lifestyle.

What Works (often, anyway)
Perimenopause is a time of vulnerability and fragility for many women. It is a time of mystery and inconvenience, as some are completely caught by surprise by the alien experience they now have in the bodies they occupy and cannot predict how they may feel from one day to the next. CBT and other forms of counseling may help women feel better about this transition and help them start to view the situation more objectively. But it cannot treat the actual physical, physiological symptoms of perimenopause.

For those symptoms, I suggest doing this instead (if medically possible):

• Get on hormone replacement therapy (HRT). HRT for perimenopause usually consists of estradiol and progesterone – the former in the form of a transdermal patch or gel, and sometimes a pill, and the latter as an oral capsule. Research increasingly supports that the sooner, the better with the initiation of HRT before the age of 60. The old WHI study linking HRT with catastrophic health outcomes for healthy women has long been decried as faulty and harmful, even by the North American Menopause Society (NAMS).
• Get on an antidepressant, too, if you need it. For some women, who either 1) are not candidates for HRT, 2) don’t want HRT or 3) are already on HRT but need more support, antidepressants can provide added relief. Antidepressants can help reduce hot flashes and night sweats. They can also help with mood (anxiety or depression) and sleep. In these cases, they are usually prescribed at much lower doses than used for treating standard anxiety or depression. Some are even used off label to help with headaches. I know of two perimenopausal women in their 40s who had never been on antidepressants in their lives until now. One is on an antidepressant for hormonal headaches, which have now abated. The other was put on one for hot flashes, and says she hardly has any now, plus she realizes she had a low level of depression that has lifted.

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If you want to seek therapy, by all means, go ahead and do so. It may help you better contextualize perimenopause and cope with the changes it entails more fluidly. But it will not help with the actual physical symptoms of this change of life. As with all things, one’s mileage may vary, and buyer beware.

In recent years, a burgeoning field of study has hypothesized a connection between adverse childhood events, also known as ACEs, and a more difficult menopause transition.

An ACE could be one of various circumstances, including physical, sexual or emotional abuse, physical and emotional neglect, and parental separation and divorce. In “Researchers Find Link between Childhood Trauma, Recent Abuse and More Severe Menopause Symptoms,” Madison Okuno, a Mayo Clinic researcher, said: “We found that women with a history of abuse, whether in childhood or recent, are more likely than women without these histories to experience more severe menopausal symptoms and more psychological symptoms.”

In their research, the Mayo Clinic studied more than 1,600 women between the ages of 40-65. Nearly 60 percent of research participants reported having endured a prior ACE. Similarly, researchers at the Perelman School of Medicine at the University of Pennsylvania found that “trauma and stress in the teen years increases the risk of depression during menopause.” Teen girls who had experienced traumatic events during childhood or adolescence were more at risk for perimenopausal depression: “In particular, women who experienced their first traumatic event in their teens are especially susceptible to depression during perimenopause, even if they had never previously had depression.”

Past Trauma Leading to Future Health Implications

To what extent are these women more apt to experience depression? More than two times as likely when compared to women who either experienced such events much earlier in life (as infants or toddlers), or never at all. The Penn State team determined that the timing of such events is a critical window into the significant and long-lasting effects on brain development, particularly in the areas responsible for emotions, mood and memory.

Penn State studied the women participants for a long time – 16 years. Each participant was assessed regularly for cognition and mood, and blood samples were collected to determine hormone levels routinely. Approximately 22 percent had experienced one ACE, and almost 40 percent had gone through two or more adverse childhood events. And most of the adverse events occurred before puberty.

Of these women, almost 21 percent experienced depression for the first time during perimenopause, while 22.4 percent were diagnosed with depression before perimenopause started: “Notably, women who reported two or more ACEs after the onset of puberty were 2.3 times more likely to have their first experience of clinical depression during perimenopause, compared to those who did not experience any ACEs.”

Sadly, ACEs Are Common Events
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The most commonly reported ACEs were parental separation or divorce, emotional abuse, and living with an alcoholic or someone with another substance abuse disorder.

Unfortunately, adverse childhood events may seem like an outlier, but they are much more common than many would like to believe. According to the Crimes Against Children Research Center, 20 percent of all girls are victims of child sexual abuse, and during the course of their lifetime, 28 percent of all 14-17 year-olds (male and female) have been sexually victimized. Those most vulnerable to child sexual abuse are between 7-13 years old.

Then, beyond sexual abuse, are these sobering stats, which illuminate other potential types of adverse childhood events:

• 14.4 percent of U.S. children are in poverty (Children’s Defense Fund)
• 10.5 percent of all U.S. households experience food insecurity, or not having enough food to eat (USDA)
• 2.7 million children in the U.S. have a parent who is incarcerated (National Institute of Corrections)
• 424,000 U.S. children are in foster care (Children’s Rights)
• Hundreds of thousands of children experience stress and sadness due to racism, sexism, lookism (being appraised by one’s appearance and conformity to prevailing beauty standards) and homophobia (life experience)

Why Now, If Not Then?

This is a logical question: If the groundwork for mental-emotional challenges was laid during childhood or adolescence, why does it wait to crop up when women are in midlife?

Given these emerging and new insights into the role of ACEs on future risk of perimenopausal depression, and the role of ACEs on brain development, I have a few of my own thoughts about why this happens to some women:

• The relative predictability of hormones, even with monthly cycles, before the onset of perimenopause help to “shield” a woman from succumbing to the more drastic and unpredictable hormonal highs and lows of perimenopause. By the time perimenopause starts, her body and brain might have already been treading water for quite some time – coping well on the outside with not much resilience left inside.
• Women with ACEs are already more biochemically compromised than women who haven’t endured any ACEs. Perimenopause is akin to taking the brakes off the car; the “wheels” of a woman’s physiology (her brain and its neurotransmitters, her neuroendocrine system and its chemicals) can no longer hold it all in check; there are just too many moving parts at once, and prior coping mechanisms are inadequate.
• Women at this stage of life are already under major stress – financial obligations, career demands, childrearing, maturing marriages, new health diagnoses, aging parents, dying friends or relatives. In the context of also having had ACEs, the added stress of the hormonal hijinks of perimenopause just proves too much.

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What to Do About It?

The past cannot be scrubbed clean and deleted. Women at this phase of life often have some housekeeping to do, and this is true even for those with no ACE history. During a woman’s 40s and 50s, she may be in a new state of flux, and anecdotally, this is a time when women begin making some critical life changes. They take an inventory of their past, present and future, and may start to redesign and revise life according to her terms. This may look like:

• Pivoting careers, perhaps going from a high-stress corporate role to a less stressful consulting job
• Returning to school to retrain to do something else, or learn something new to ignite a hobby or passion
• No longer doing disproportionate amounts of cooking, housework or the emotional labor involved in keeping a household or family going
• Getting a pet for added emotional support and as a comforting companion
• Discontinuation of micromanaging her children, including their activities, classwork, homework, grades, extracurricular activities or social lives
• Taking up new self-care practices, like meditation, yoga or regular exercise
• Increasing reliance on and active practice of her faith, whatever that may be

At the same time, these personal changes are not always enough, especially for women battling moderate to severe perimenopausal depression or anxiety, with a history of ACEs. In such cases, it is advised that they seek the help of a healthcare professional to consider therapy and other interventions.
 

In online perimenopausal communities, two major camps or philosophies quickly emerge: women who are pro-pharma for the treatment of their symptoms and women who are on the naturopathic path. These two schools of thought each have their own merits, and many women, over time, end up combining modalities once they discover the mix that works best for them.
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But what about meditation? It’s often seen as a hocus-pocus, “woo-sah” hobby some people dismiss and make fun of. But when perimenopause strikes, even the most anti-holistic medicine women find themselves turning to it.

In the drive to delay prescribed medical interventions or to incorporate a holistic regimen as part of their perimenopausal game plan, some women meditate to restore a sense of calm to the process. There different types of meditation, such as transcendental meditation, concentrative meditation, mindfulness meditation or progressive relaxation. But meditation is generally defined as “a practice where an individual uses a technique, such as mindfulness, or focusing the mind on a particular object, thought or activity, to train attention and awareness, and achieve a mentally clear and emotionally calm and stable state.”

If the real world and social media are any indication of how perimenopausal women are using meditation, then it appears to be a tactic broadly adopted or, at least, tried. Women seem to use meditation for a number of reasons, many related to mood, as they try to calm anxiety or ease depression. Others test it as a way to relieve physical symptoms, like hot flashes, chills and heart palpitations. And, finally, some women use it as a new lifestyle practice to gain perspective, maintain optimism and boost emotional stability.

But, the real question may be, does it work? Does meditation help? Is it really doing anything?

Axing the Anxious State

It turns out that when it comes to feelings of panic or doom, meditation is a solid tool. According to the University of Washington’s School of Medicine, meditation calms the sympathetic nervous system. This is key because the sympathetic nervous system, when revved up, lends to sensations of fight or flight. They say, “[t]hrough meditation, you are essentially deactivating your sympathetic nervous system and turning on the parasympathetic branch. Initial studies have found that over time this practice can help reduce pain, depression, stress and anxiety.”

This is important, as panic attacks can show up for the first time during perimenopause, when fluctuating hormones take women on a rollercoaster ride. Symptoms of panic attacks include nausea or abdominal distress, chills, hot flushes, rapid heart rate, dizziness, sweating, shortness of breath, chest pain, trembling, sense of losing control, de-realization and a few more (as if these weren’t enough!).

In one study, 56 percent of women surveyed had never experienced panic symptoms prior to perimenopause, and one-third of study participants’ panic disorder symptoms went undiagnosed and untreated.

More than Meets the Mind

Meditation, even short-term stints at it, can have measurable benefits on health. One study from 2009 reported that just five days of meditation at 20 minutes per session improved “physiological reactions in heart rate, respiratory amplitude and skin conductance response.” Brain imaging even showed changes related to emotional regulation.

Additional studies have found that meditation has many other add-on benefits, including delaying brain aging, reducing ruminating thoughts, improving concentration and attention, and even assisting in recovery from substance abuse. Moreover, meditation has been associated with reduced blood pressure, decreased pain and strengthened immune system function.

Worth a Try?

Many of the benefits that meditation allegedly and empirically improves are the very same symptoms women need relief from during perimenopause. Less anxiety? Check. Better focused thinking? Absolutely. Reduced stress and lowered blood pressure? For sure. A regained sense of personal control? Yes.

The problem with meditation, however, may be that it requires a commitment. Sure, some people will feel a difference after just one session. But in order to sustain it, meditation must become a practice – that is, a habit or a routine aspect of daily living. Most sources suggest aiming for 20-30 minutes of meditation a day. Since it can be challenging for women to find that bit of undisrupted time, some suggested time frames to do it are:

• Early in the morning, before anyone or anything demands your attention
• After your workout, as part of your cool-down process
• During or after lunch, especially for those who work from home
• In the evening before bedtime, as everyone else in the house is winding down

How to Find Meditations?
Just as there are many types of yoga (yin, ashtanga, vinyasa, kundalini, and so forth), there are various styles of meditation. Generally two main themes emerge: guided meditation and unguided meditation. In a guided meditation, a speaker sets the tone and verbally walks you through imagery, ideas and themes to reflect and focus on. It may or may not be accompanied by music or nature sounds. In an unguided meditation, there is no one speaking, simply silence or perhaps some accompanying music or sounds to inspire and soothe you.

There are also various types of meditation, often by purpose or topic. Meditations are available on specific themes, like Christianity, relationships, finances, stress and more. And the great thing is, meditation can be obtained for free. A quick YouTube search will unearth more meditations than you’ll ever have time for.

While HeadSpace and Calm are meditation apps popularly used, they come at a cost. Free trials or restricted free access may be available, but the unpaid experience is rather limiting.

Meditations for Menopause

Would you believe it? Yes, there are actually meditations for menopause that some thoughtful creators have put together and made widely available. This isn’t a time to get too wrapped up in particulars though – these meditations are great for perimenopause, too.

Female Hormone Balancer Relaxation Meditation
Guided Meditation for Relieving Menopause Symptoms
Hormone Rebalance Hypnosis
Magical Menopause Full Hypnotherapy Session with Binaural Beats Frequencies
Women of Wisdom Menopause Guided Sleep Meditation