Menopause is characterized by a loss of estrogen and other hormones that usually happens during a woman’s 40s and 50s. While menopause is defined by the absence of a menstrual period for 12 consecutive months, the menopausal transition (also known as perimenopause) typically lasts for several years leading up to when a woman reaches menopause. The average Canadian woman reaches menopause at age 52.
Dr. Sheryl Green is an Associate Professor of Psychiatry & Behavioural Neurosciences at McMaster University and a clinical and health psychologist within the Women’s Health Concerns Clinic (WHCC) at St. Joseph’s Healthcare Hamilton. She is particularly interested in women’s health across the reproductive timeline, including during the menopause transition.
In a pilot study supported by the Canadian Institutes of Health Research, Dr. Green found that a type of talk therapy known as cognitive behavioural therapy (CBT) can improve perimenopausal symptoms specifically related to sexual concerns including body image and relationship satisfaction. In September 2024, Dr. Green presented these remarkable findings at the annual Menopause Society conference in Chicago.
During perimenopause, hormone levels don’t decrease steadily over time – they go through a lot of fluctuations on their way down. It’s these fluctuations that often result in physical, emotional, and mental symptoms including hot flashes/night sweats, depression, sleep difficulties and sexual concerns.
Many perimenopausal symptoms such as low desire, vaginal dryness and discomfort, or pain during sex, can contribute to sexual concerns as well as poor body image and relationship satisfaction, leading to poor sexual health. Unfortunately, these symptoms are often overlooked.
“68 to 87 percent of women in perimenopause are experiencing sexual concerns,” said Dr. Green. “It’s not like it’s just a couple of people here and there. But women often don’t feel comfortable bringing up sexual concerns to their healthcare practitioners, or their healthcare practitioner just doesn’t ask about it. Women may also feel that it’s not that important, compared to other physical symptoms like hot flashes or night sweats, and that the sexual concerns are just something they have to live with.”
Dr. Green wants women to better understand how menopause can impact sexual health, and how they can effectively cope with these changes. She believes that CBT is a promising solution for this.
CBT is a type of psychotherapy that practitioners have used to treat a variety of both mental and physical symptoms and disorders. It involves working with a therapist to identify unhelpful thoughts and problematic behaviours, and replace them with more accurate thoughts and useful behaviours.
Dr. Green and other researchers have previously demonstrated that CBT can be effective in treating some perimenopausal symptoms, including hot flashes, depression, anxiety, and sleep difficulties. Dr. Green is one of the first researchers to develop and evaluate a CBT protocol targeting sexual concerns in peri- and post-menopausal women.
“A lot of times, the menopause transition can be a very challenging experience,” said Dr. Green. “For example, during menopause women are more prone to gaining weight and fat becomes distributed in different areas of the body. Someone experiencing this might think that their partner must not find them attractive anymore, and because of this will start discouraging their partner’s advances of intimacy. This might cause their partner to stop making these advances altogether, which can exacerbate sexual concerns.”
“In this example, perimenopausal women may use CBT treatment to change their thoughts and behaviors by starting to think more positively about their body and make more advances themselves while engaging in helpful communication,” Dr. Green continued. “These strategies can help someone reestablish intimacy during perimenopause.”
The results of this study were very promising, as each and every participant experienced benefits after treatment. The study participants reported decreased sexual concerns (e.g., desire, arousal, pain) as well as significant improvements in body image, relationship satisfaction, mood, anxiety and hot flashes/night sweats. On average, each participant’s rating of their sexual function increased by 40 percent. Although many participants wished that the treatment was longer – it only included four 90-minute sessions of CBT – they all stated that they felt they had the tools and strategies to continue to make gains on their own.
“For a lot of these women, the CBT sessions were the first time they were really able to talk about their sexual concerns,” Dr. Green pointed out. “This treatment involves one-on-one therapy where participants can express their unique needs and difficulties, and find solutions specifically tailored to meet their needs.”
Unlike the medications including menopause hormone therapies (MHT) that perimenopausal women commonly take, CBT is considered a low risk treatment where side effects and adverse outcomes are uncommon. While MHT can be effective for many women, it can also result in side effects like headaches, chest pain, nausea, and more. For some people, the cons outweigh the pros, and other treatment options such as CBT may be a better option. For others, MHT may not be enough to produce improvements, and CBT can supplement this treatment.
“50 percent of the participants in this study were taking hormone therapy,” said Dr. Green. “This tells us that some people who are taking this first line treatment for menopausal symptoms are still at a clinical level of distress. Hormone therapy is useful for treating a number of common menopausal symptoms, including sexual concerns, but CBT can complement it.”
Dr. Green is eager to continue investigating the potential of CBT for treating sexual concerns during peri-and post-menopause. Her next step is to conduct a randomized controlled trial (RCT) to further validate the results she found in this study. RCTs are known as the gold standard of determining causal relationships between interventions and results. Dr. Green hopes the RCT will lead to data confirming her pilot results demonstrating the success of CBT treatment.
Dr. Green also notes that most participants in this study were Caucasian, and plans to expand her research demographics moving forward. “I want CBT to be not only a helpful and effective treatment for one group of people, but for a variety of people of ethical and cultural backgrounds,” she said.
Finally, Dr. Green would like to expand her research to look at the long-term effects of this CBT treatment. “For depression, anxiety, and worry, we’ve seen the effects of CBT last for months or even years after treatment,” she said. “So there’s a lot of confidence that the benefits of this treatment will last in the long run.”