A randomised controlled trial of a cognitive behavioural intervention for women who have menopausal symptoms following breast cancer treatment (MENOS 1): trial protocol

Estrogen deprivation effects of endocrine therapy in breast cancer patients: Incidence, management and outcome

Endocrine therapy is one of the standard adjuvant treatments to reduce the risk of recurrence and mortality in patients with hormone receptor positive early breast cancer. Despite its proven efficacy, ET side effects, which persist over time even if low grade, may deteriorate quality of life. During follow-up visits, emphasis is generally placed on the risk of disease recurrence, while the topic of ET side effects is commonly neglected and discussed only briefly. This could lead to poor adherence to therapy and early treatment discontinuation, resulting in worse survival outcomes. The aim of this review is to provide an overview of the available evidence on the incidence and reporting of ET-related side effects (including vasomotor symptoms, musculoskeletal disorders and genitourinary syndrome of menopause, as well as fatigue, psychological and ocular disorders, dysmetabolic effects and loss of bone density) and of the pharmacological and non-pharmacological strategies available to mitigate symptom burden.

Menopause

Menopause, which is defined as the point in time 12 months after a woman's final menstrual period, is marked by a decrease in estrogen and accompanying symptoms including vasomotor and genitourinary symptoms. Hormone therapy is the most effective treatment of vasomotor symptoms and is first-line in women with moderate-to-severe vasomotor symptoms who are early in the menopausal transition and do not have a contraindication. Nonhormonal pharmacologic and nonpharmacologic treatments are also available for the treatment of menopause-related symptoms for women who prefer to avoid hormones or who have a contraindication to hormone therapy.

Vasomotor Symptoms During Menopause: A Practical Guide on Current Treatments and Future Perspectives

Vasomotor symptoms affect as many as 80% of midlife women, but only about one in four women receive treatment due to many factors. Menopausal hormone therapy remains the most effective treatment for vasomotor symptoms, and current professional guidelines conclude that the benefits of treatment typically outweigh the risks for healthy, symptomatic women under age 60 years and those within 10 years from their final menstrual period. For women with medical comorbidities, an individualized approach to treatment is recommended. For women who cannot use or choose not to use menopausal hormone therapy, there are many evidence-based non-hormonal options available including pharmacologic therapies. This review aims to summarize treatment options for bothersome vasomotor symptoms to guide clinicians caring for midlife women.

Impact of the CBT-Meno protocol on menopause-specific beliefs, dysfunctional attitudes, and coping behaviors

OBJECTIVE

A recent clinical trial demonstrated that a group cognitive-behavioral therapy protocol for menopause (CBT-Meno; Green et al. Menopause 2019;26(9):972-980) was effective in reducing menopausal symptoms, including vasomotor and depressive symptoms. The current analyses evaluated the effectiveness of CBT-Meno in improving menopause-specific beliefs, dysfunctional attitudes associated with depression, and menopause-specific behaviors.

METHODS

In a subset of participants from the larger trial, women assigned to CBT-Meno or waitlist and who had completed symptom, cognitive, and behavioral measures at least at baseline were included. Assessments were conducted at baseline, 12 weeks after baseline, and 3 months after treatment. Measures included the Hot Flash Related Daily Interference Scale, the vasomotor subscale of the Greene Climacteric Scale, the Beck Depression Inventory II, the Hot Flush Beliefs Scale, the Dysfunctional Attitudes Scale, and the Hot Flush Behavior Scale (HFBehS).

RESULTS

As reported in the main study outcomes (Green et al. Menopause 2019;26(9):972-980), CBT-Meno participants reported greater improvements than waitlist in terms of vasomotor symptom interference and depressive symptoms (Hot Flash Related Daily Interference Scale, Beck Depression Inventory II; partial eta-squared [ η2p ] = 0.15-0.18), although not in vasomotor severity (Greene Climacteric Scale [vasomotor subscale]; η2p = 0.05). CBT-Meno participants reported greater improvements than waitlist in menopause-specific beliefs (Hot Flush Beliefs Scale; η2p = 0.08-0.12), dysfunctional attitudes (Dysfunctional Attitudes Scale; η2p = 0.09), and menopause-specific behaviors (HFBehS; η2p = 0.08-0.12). Within-group analyses showed improvements in CBT-Meno on all variables ( d = 0.38-1.26) except in cooling strategies ( d = 0.18). Gains in CBT-Meno were maintained from posttreatment to 3-month follow-up, although a decrease in positive coping behaviors was observed (HFBehS-positive behavior subscale; d = 0.99).

CONCLUSIONS

The CBT-Meno protocol is effective in improving menopause-related symptoms and a broader range of outcomes, including problematic beliefs about menopause, dysfunctional attitudes related to depression, and menopause-specific behaviors.

Referral process to further evaluate poor sleep in breast cancer survivors

OBJECTIVE

Breast cancer survivors (BCS) are twice as likely to report symptoms of poor sleep as those without cancer. However, sleep disorders are under-assessed and under-treated among BCS. The purpose of this study was to determine the portion of BCS who completed referral visits to a sleep specialist and identify the acceptability, facilitators, and barriers to the screening and referral process.

METHODS

BCS, who reported having sleep problems, completed questionnaires to screen for symptoms suggestive of sleep disorders. Those with symptoms suggestive of sleep apnea, movement disorders, narcolepsy, insomnia syndrome, or circadian disorders, they were referred to a sleep medicine physician or behavioral sleep medicine psychologist. Two months after the referral, participants were interviewed about their perceptions of the acceptability, barriers, and facilitators to sleep screenings and referrals.

RESULTS

Of 34 BCS assessed for eligibility, 29 were eligible and had sleep problems. Only eight of 29 participants (27.6%) completed the sleep referral process. Most thought the screening and referral process was acceptable. However, BCS identified barriers to completing the referral visit, including time, not seeing the need for treatment, insurance/sick leave concerns, and distance/transportation.

CONCLUSION

Adequate evaluation and treatment of sleep disorders in BCS are rare. Creative solutions to address barriers to timely sleep referrals are needed to reduce long-term negative consequences of inadequate sleep.

Contemporary Non-hormonal Therapies for the Management of Vasomotor Symptoms Associated with Menopause: A Literature Review

Nearly 75% of all menopausal women experience bothersome vasomotor symptoms including hot flushes and night sweats. Yet vasomotor symptoms continue to be an undertreated and underdiagnosed symptom of menopause which can negatively affect a woman's overall quality of life. While hormone therapy has been widely utilized to ameliorate hot flushes, not all women are candidates for use, especially those with increased risk of cardiovascular disease, thromboembolic disease, and/or women at an increased risk of certain hormone-dependent cancers. The current literature provides strong evidence for non-hormonal therapies in women who experience vasomotor symptoms. This article reviews the evidence for the use of non-hormonal pharmacologic therapies for the treatment of menopausal symptoms including antidepressants, gabapentinoids, clonidine and anticholinergics. We also review data on emerging therapies including the latest evidence on neurokinin-1 and -3 antagonists. These therapies should be considered when hormonal options are contraindicated and/or not preferred by the patient. While there are many options available, clinicians should individualize therapy based on the patient's needs and goals while mitigating bothersome side effects.

The menopause after cancer study (MACS) - A multimodal technology assisted intervention for the management of menopausal symptoms after cancer - Trial protocol of a phase II study

Aims

This study will aim to assess if a composite intervention which involves a specific evidence-based intervention for management of insomnia and non-hormonal pharmacotherapy to manage vasomotor symptoms (VMS) of menopause can improve quality of life for patients experiencing troublesome VMS after cancer who are not eligible for standard systemic menopausal hormone therapy (MHT). Participants will be asked to nominate a partner or companion to support them during this process as an additional form of support.

Background

The menopause transition and its symptoms represent a significant challenge for many patients after cancer treatment, particularly those for whom conventional MHT is contraindicated. These symptoms include hot flushes, night sweats, urogenital symptoms as well as mood and sleep disturbance. These symptoms can exacerbate the consequences of cancer and its treatment.

Methods

We will recruit 205 women who meet inclusion criteria and enrol them on a composite intervention which consists of four parts: (1) use of non-hormonal pharmacotherapy for the management of troublesome vasomotor symptoms of menopause tailored to the timing of predominant symptoms, (2) digital cognitive behavioural therapy for insomnia through the web based Sleepio service, (3) access to information regarding self-management strategies for the common symptoms of menopause and their consequences and (4) identification of a partner or other support person who commits to providing support during the study period.

Outcomes

The primary outcome will be cancer specific quality of life measured by the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ C30). Secondary outcomes will include sleep quality, bother/interference of vasomotor symptoms and communication between couples about their cancer diagnosis and their menopause experience. Sleep will be measured using the Sleep Condition Indicator (SCI) tool, bother/interference of vasomotor symptoms will be measured by the Hot Flush Rating Scale (HFRS) and communication will be measured using the Couples’ Illness Communication Scale (CICS). These validated scales will be administered at baseline, four weeks, three months and six months.

Registration

This study is registered on ClinicalTrials.gov with number NCT 04766229.

Alternative and non-hormonal treatments to symptoms of menopause

Ovarian function can start to decline a few years before the eventual cessation of the menstrual cycle. The average age of menopause in the UK is 51 years, and it is a retrospective diagnosis after 12 months of amenorrhoea. Women can experience many symptoms such as vasomotor and vulvovaginal symptoms that impact them physically, psychologically, sexually and thus their overall wellbeing. Women may have medical contraindications to hormonal therapy or may prefer non-hormonal or alternative treatments. This review looks at the evidence, efficacy, and safety of a range of complementary or alternative treatments and non-hormonal pharmacological treatments for the treatment of vasomotor symptoms and vulvovaginal atrophy of menopause.

Cognitive behavioral therapy for menopausal symptoms

This article describes cognitive behavioral therapy (CBT) for women with problematic menopausal symptoms, and provides the evidence from clinical trials of women going through the menopause, women with breast cancer treatment-induced symptoms and women with problematic symptoms in a work context. The CBT focus is primarily on vasomotor symptoms (VMS) but it also targets stress, low mood and sleep problems. CBT is a brief therapy (four to six sessions) that is theory- and evidence-based; it is acceptable to women and effectively reduces the impact of VMS, improves sleep and has benefits to quality of life. VMS frequency is also reduced significantly in some trials but not others. CBT has been found to be consistently effective when delivered in groups, self-help book and on-line formats (with or without additional support). The MENOS 1 and MENOS 2 CBT protocols are recommended for the treatment of VMS by the North American Menopause Society (2015); CBT has been recommended for the treatment of anxiety and depression for women during the menopause transition and post menopause (NICE, 2015); and telephone CBT has been shown to be an effective treatment for insomnia.

Randomized controlled trial of cognitive behavioural therapy for depressive and anxiety symptoms in Chinese women with breast cancer

Depressive and anxiety symptoms are frequently observed in breast cancer survivors. To date, few randomized controlled trials have been conducted on the efficacy of cognitive behavioural therapy (CBT) for depressive and anxiety symptoms in Chinese population. This study aims to verify the efficacy of CBT in Chinese breast cancer survivors. Women (n = 392) with breast cancer were randomly assigned to 3 groups: CBT (n = 98), self-care management (SCM, n = 98), and usual care (UC, n = 196) using the proportion 1:1:2. Women in the CBT and SCM groups received a series of nine sessions for 12 weeks, while women in the UC group received their usual medical care only. Depressive and anxiety symptoms were assessed using the Hamilton Depression Rating Scale (HAMD) and the Hamilton Anxiety Scale (HAMA) score at baseline, 2, 4, 8, 12, 16, and 24 weeks. A significant intergroup difference was found in the HAMD and HAMA scores. Women in the CBT group showed significantly less depressive and anxiety symptoms compared with women in the SCM and UC groups over time. In conclusion, this study supports the efficacy of CBT for depressive and anxiety symptoms in Chinese breast cancer survivors.

Nonhormonal management of menopause-associated vasomotor symptoms: 2015 position statement of The North American Menopause Society

OBJECTIVE

To update and expand The North American Menopause Society's evidence-based position on nonhormonal management of menopause-associated vasomotor symptoms (VMS), previously a portion of the position statement on the management of VMS.

METHODS

NAMS enlisted clinical and research experts in the field and a reference librarian to identify and review available evidence. Five different electronic search engines were used to cull relevant literature. Using the literature, experts created a document for final approval by the NAMS Board of Trustees.

RESULTS

Nonhormonal management of VMS is an important consideration when hormone therapy is not an option, either because of medical contraindications or a woman's personal choice. Nonhormonal therapies include lifestyle changes, mind-body techniques, dietary management and supplements, prescription therapies, and others. The costs, time, and effort involved as well as adverse effects, lack of long-term studies, and potential interactions with medications all need to be carefully weighed against potential effectiveness during decision making.

CONCLUSIONS

Clinicians need to be well informed about the level of evidence available for the wide array of nonhormonal management options currently available to midlife women to help prevent underuse of effective therapies or use of inappropriate or ineffective therapies. Recommended: Cognitive-behavioral therapy and, to a lesser extent, clinical hypnosis have been shown to be effective in reducing VMS. Paroxetine salt is the only nonhormonal medication approved by the US Food and Drug Administration for the management of VMS, although other selective serotonin reuptake/norepinephrine reuptake inhibitors, gabapentinoids, and clonidine show evidence of efficacy. Recommend with caution: Some therapies that may be beneficial for alleviating VMS are weight loss, mindfulness-based stress reduction, the S-equol derivatives of soy isoflavones, and stellate ganglion block, but additional studies of these therapies are warranted. Do not recommend at this time: There are negative, insufficient, or inconclusive data suggesting the following should not be recommended as proven therapies for managing VMS: cooling techniques, avoidance of triggers, exercise, yoga, paced respiration, relaxation, over-the-counter supplements and herbal therapies, acupuncture, calibration of neural oscillations, and chiropractic interventions. Incorporating the available evidence into clinical practice will help ensure that women receive evidence-based recommendations along with appropriate cautions for appropriate and timely management of VMS.

Cognitive Behavioral Therapy for Insomnia in Breast Cancer Survivors: A Review of the Literature

Background: Insomnia is a common sleep disorder in patients with breast cancer and studies show a higher frequency than in the general population but it appears to be understudied and the treatment seems to be a neglected problem. There is a growing body of evidence about the efficacy of cognitive behavioral therapy for insomnia (CBT-I) in breast cancer survivors (BCS). The aim of this review is to examine the best available scientific evidence related to CBT-I and insomnia in patients with breast cancer and to assess the effect of CBT-I on their psychosocial functioning, sleep, quality of life, and mood.

Methods: Empirical articles published in peer-reviewed journals from the earliest reports available until August 2015 were considered. The research on PubMed generated 18 papers, three of which did not meet the inclusion criteria. Another paper was retrieved by screening the reference list of the previously selected papers.

Results: A total of 16 studies were found that evaluated the effects of CBT-I in breast cancer patients. CBT-I appears to be an effective therapy for insomnia in BCS, improving mood, general and physical fatigue, and global and cognitive dimensions of quality of life. CBT-I may also reduce menopausal symptoms, such as hot flushes and night sweat problems, frequency of medicated nights, level of depression, and anxiety.

Conclusions: CBT-I seems to be an eligible intervention for improving sleep in BCS. Improvements concerning insomnia and sleep quality are durable (usually up to 12 months) and statistically significant.

Management of Hormone Deprivation Symptoms After Cancer

Cancer survivors often experience symptoms related to hormone deprivation, including vasomotor symptoms, genitourinary symptoms, and sexual health concerns. These symptoms can occur due to natural menopause in midlife women, or they can be brought on by oncologic therapies in younger women or men. We searched PubMed for English-language studies from January 1990 through January 2016 to identify relevant articles on the management of hormone deprivation symptoms, including vasomotor, genitourinary, and sexual symptoms in patients with cancer. The search terms used included hormone deprivation, vasomotor symptoms, hot flash, vaginal dryness, sexual dysfunction, and breast cancer. This manuscript provides a comprehensive description of data supporting the treatment of symptoms associated with hormone deprivation.

Asptects of mental health care in the gynecological setting

Psychological disorders are commonly associated with gynecological conditions, but are frequently undetected and untreated, and may influence the presentation and treatment outcomes of the physical condition. A literature search was conducted in order to provide a narrative review of psychological aspects of menopause, premenstrual syndrome, premenstrual dysphoric disorder, chronic pelvic pain, incontinence and polycystic ovarian syndrome. All the conditions that have been addressed in this review can be associated with an increased risk of psychological symptoms and disorders. Anxiety and depression are common and are associated with significant morbidity. Gynecological conditions, by their nature, are likely to be accompanied by impairments in social, occupational and personal functioning. Greater emphasis should be placed on the mental health aspects of gynecological conditions.

Critical research gaps and translational priorities for the successful prevention and treatment of breast cancer

INTRODUCTION

Breast cancer remains a significant scientific, clinical and societal challenge. This gap analysis has reviewed and critically assessed enduring issues and new challenges emerging from recent research, and proposes strategies for translating solutions into practice.

METHODS

More than 100 internationally recognised specialist breast cancer scientists, clinicians and healthcare professionals collaborated to address nine thematic areas: genetics, epigenetics and epidemiology; molecular pathology and cell biology; hormonal influences and endocrine therapy; imaging, detection and screening; current/novel therapies and biomarkers; drug resistance; metastasis, angiogenesis, circulating tumour cells, cancer 'stem' cells; risk and prevention; living with and managing breast cancer and its treatment. The groups developed summary papers through an iterative process which, following further appraisal from experts and patients, were melded into this summary account.

RESULTS

The 10 major gaps identified were: (1) understanding the functions and contextual interactions of genetic and epigenetic changes in normal breast development and during malignant transformation; (2) how to implement sustainable lifestyle changes (diet, exercise and weight) and chemopreventive strategies; (3) the need for tailored screening approaches including clinically actionable tests; (4) enhancing knowledge of molecular drivers behind breast cancer subtypes, progression and metastasis; (5) understanding the molecular mechanisms of tumour heterogeneity, dormancy, de novo or acquired resistance and how to target key nodes in these dynamic processes; (6) developing validated markers for chemosensitivity and radiosensitivity; (7) understanding the optimal duration, sequencing and rational combinations of treatment for improved personalised therapy; (8) validating multimodality imaging biomarkers for minimally invasive diagnosis and monitoring of responses in primary and metastatic disease; (9) developing interventions and support to improve the survivorship experience; (10) a continuing need for clinical material for translational research derived from normal breast, blood, primary, relapsed, metastatic and drug-resistant cancers with expert bioinformatics support to maximise its utility. The proposed infrastructural enablers include enhanced resources to support clinically relevant in vitro and in vivo tumour models; improved access to appropriate, fully annotated clinical samples; extended biomarker discovery, validation and standardisation; and facilitated cross-discipline working.

CONCLUSIONS

With resources to conduct further high-quality targeted research focusing on the gaps identified, increased knowledge translating into improved clinical care should be achievable within five years.

Risk factors, pathophysiology, and treatment of hot flashes in cancer

Hot flashes are prevalent and severe symptoms that can interfere with mood, sleep, and quality of life for women and men with cancer. The purpose of this article is to review existing literature on the risk factors, pathophysiology, and treatment of hot flashes in individuals with cancer. Electronic searches were conducted to identify relevant English-language literature published through June 15, 2012. Results indicated that risk factors for hot flashes in cancer include patient-related factors (eg, age, race/ethnicity, educational level, smoking history, cardiovascular risk including body mass index, and genetics) and disease-related factors (eg, cancer diagnosis and dose/type of treatment). In addition, although the pathophysiology of hot flashes has remained elusive, these symptoms are likely attributable to disruptions in thermoregulation and neurochemicals. Therapies that have been offered or tested fall into 4 broad categories: pharmacological, nutraceutical, surgical, and complementary/behavioral strategies. The evidence base for this broad range of therapies varies, with some treatments not yet having been fully tested or showing equivocal results. The evidence base surrounding all therapies is evaluated to enhance hot flash treatment decision-making by clinicians and patients.

Paced respiration for vasomotor and other menopausal symptoms: a randomized, controlled trial

BACKGROUND

Paced respiration has been internationally recommended for vasomotor symptom management, despite limited empirical evidence.

OBJECTIVE

To evaluate efficacy of a paced respiration intervention against breathing control and usual care control for vasomotor and other menopausal symptoms.

DESIGN

A 16-week, 3-group, partially blinded, controlled trial with 2:2:1 randomization and stratification by group (breast cancer, no cancer), in a Midwestern city and surrounding area.

PARTICIPANTS

Two hundred and eighteen randomized women (96 breast cancer survivors, 122 menopausal women without cancer), recruited through community mailings and registries (29 % minority).

INTERVENTIONS

Training, home practice support, and instructions to use the breathing at the time of each hot flash were delivered via compact disc with printed booklet (paced respiration intervention) or digital videodisc with printed booklet (fast shallow breathing control). Usual care control received a letter regarding group assignment.

MAIN MEASURES

Hot flash frequency, severity, and bother (primary); hot flash interference in daily life, perceived control over hot flashes, and mood and sleep disturbances (secondary). Intervention performance, adherence, and adverse events were assessed.

KEY RESULTS

There were no significant group differences for primary outcomes at 8-weeks or 16-weeks post-randomization. Most intervention participants did not achieve 50 % reduction in vasomotor symptoms, despite demonstrated ability to correctly do paced respiration and daily practice. Statistically significant differences in secondary outcomes at 8 and 16 weeks were small, not likely to be clinically relevant, and as likely to favor intervention as breathing control.

CONCLUSIONS

Paced respiration is unlikely to provide clinical benefit for vasomotor or other menopausal symptoms in breast cancer survivors or menopausal women without cancer.

Women's experiences of Group Cognitive Behaviour Therapy for hot flushes and night sweats following breast cancer treatment: an interpretative phenomenological analysis

OBJECTIVES

Many women with breast cancer experience problematic treatment-related menopausal symptoms (HF/NS). This study explores how these women experienced a Group Cognitive Behaviour Therapy (CBT) intervention to help them manage their treatment-related HF/NS. The study was conducted as part of a randomised control trial/RCT (MENOS 1) evaluating the intervention among this target group.

METHODS

In-depth semi-structured interviews were conducted with twenty trial participants to explore how they experienced the intervention and its effects. The interviews were analysed using interpretative phenomenological analysis.

RESULTS

The analysis revealed four superordinate themes: Making sense of symptom change; new ways of coping and regaining control; tailoring the treatment to meet individual needs and resources; and valuing the group context, social support and social comparisons. All the women found Group CBT improved their ability to cope with their HF/NS, while also developing an appreciation of the role of psychological factors in their symptom experience. Through the knowledge and understanding acquired women developed a more accepting stance to their symptoms, as well as gaining a 'sense of control'.

CONCLUSIONS

The results are consistent with the main RCT outcomes which showed that Group CBT led to a clinically significant reduction in 'HF/NS problem rating' relative to 'treatment as usual', as well as improvements in mood and physical and social functioning. The results complement the trial outcomes by illuminating women's experience of different components of the intervention and highlighting possible mechanisms of change.

Cognitive behavioural treatment for women who have menopausal symptoms after breast cancer treatment (MENOS 1): a randomised controlled trial

Background

Hot flushes and night sweats (HFNS) affect 65–85% of women after breast cancer treatment; they are distressing, causing sleep problems and decreased quality of life. Hormone replacement therapy is often either undesirable or contraindicated. Safe, effective non-hormonal treatments are needed. We investigated whether cognitive behavioural therapy (CBT) can help breast cancer survivors to effectively manage HFNS.

Methods

In this randomised controlled trial, we recruited women from breast clinics in London, UK, who had problematic HFNS (minimum ten problematic episodes a week) after breast-cancer treatment. Participants were randomly allocated to receive either usual care or usual care plus group CBT (1:1). Randomisation was done in blocks of 12–20 participants, stratifying by age (younger than 50 years, 50 years or older), and was done with a computer-generated sequence. The trial statistician and researchers collecting outcome measures were masked to group allocation. Group CBT comprised one 90 min session a week for 6 weeks, and included psycho-education, paced breathing, and cognitive and behavioural strategies to manage HFNS. Assessments were done at baseline, 9 weeks, and 26 weeks after randomisation. The primary outcome was the adjusted mean difference in HFNS problem rating (1–10) between CBT and usual care groups at 9 weeks after randomisation. Analysis of the primary endpoint was done by modified intention to treat. The trial is registered, ISRCTN13771934, and was closed March 15, 2011.

Findings

Between May 5, 2009, and Aug 27, 2010, 96 women were randomly allocated to group CBT (n=47) or usual care (n=49). Group CBT significantly reduced HFNS problem rating at 9 weeks after randomisation compared with usual care (mean difference −1·67, 95% CI −2·43 to −0·91; p<0·0001) and improvements were maintained at 26 weeks (mean difference −1·76, −2·54 to −0·99; p<0·0001). We recorded no CBT-related adverse events.

Interpretation

Group CBT seems to be a safe and effective treatment for women who have problematic HFNS after breast cancer treatment with additional benefits to mood, sleep, and quality of life. The treatment could be incorporated into breast cancer survivorship programmes and delivered by trained breast cancer nurses.

Funding

Cancer Research UK.

Prevalence, frequency and problem rating of hot flushes persist in older postmenopausal women: impact of age, body mass index, hysterectomy, hormone therapy use, lifestyle and mood in a cross-sectional cohort study of 10,418 British women aged 54-65

OBJECTIVE

Hot flushes and night sweats (HFs/NSs) are the main menopausal symptoms, but few studies have been adequately powered to examine the dimensions or predictors of experiencing HFs/NSs. We report on these variables in a large UK cohort of postmenopausal women.

DESIGN

Cross-sectional cohort study.

SETTING

UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) cohort.

POPULATION

A cohort of 202,638 postmenopausal women, aged 50-74 years, without oophorectomy, recruited to UKCTOCS between 2001 and 2005.

METHODS

Women completed a follow-up questionnaire, and those aged 54-65 years were mailed a survey in July 2008.

MAIN OUTCOME MEASURES

  Hot flush prevalence and hot flush rating scale.

RESULTS

Of the 15,000 women mailed, 10,418 returned completed questionnaires; 90% had previously had HFs/NSs. Despite being on average 10 years postmenopausal, 54% experienced HFs/NSs (frequency of 33 per week with mean problem rating 4/10) that persisted across the age range. Past hysterectomy (OR 1.50, 95% CI 1.19-1.86), ever having smoked (OR 1.27, 95% CI 1.11-1.46) and alcohol consumption (current units) (OR 1.05, 95% CI 1.01-1.09) predicted ever having had HFs/NSs. Anxiety (OR 3.09, 95% CI 2.57-3.72), hysterectomy (OR 2.74, 95% CI 2.32-3.25), depressed mood (OR 1.57, 95% CI 1.24-1.99), years since last menstrual period (OR 0.95, 95% CI 0.94-0.96) and education (above and below 18 years) (OR 0.98, 95% CI 0.97-0.99) predicted the current prevalence of HFs/NSs. Few predictors of frequency were identified, but problem rating was associated with depressed mood, hysterectomy, skirt size increase and frequency of HFs/NSs. Past hormone therapy users who had discontinued treatment were more likely to have HFs/NSs that were more frequent and problematic.

CONCLUSIONS

To date, this is the largest UK study of the experience of HFs/NSs amongst older postmenopausal women. HFs/NSs are more prevalent in this age band than has previously been assumed. These findings and the associations of smoking, hysterectomy, anxiety, depressed mood and hormone therapy use with the experience of HFs/NSs have implications for prevention and symptom management.