cbt does not work for perimenopause symptoms

​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.

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