An eHealth approach to treating vasomotor symptoms

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Hot flashes and night sweats (vasomotor symptoms [VMS]), the cardinal symptoms of the menopause, affect more than 80% of women during the menopausal transition.1 A 2016 consensus statement by The North American Menopause Society (NAMS) and other menopause societies concluded that hormone therapy (HT) is the most effective treatment for VMS.2 However, the use of HT declined by 70%3 after the Women's Health Initiative (WHI) identified adverse effects, including cardiovascular disease, cancer, stroke, and thrombotic events,4 particularly after age 60.5 These adverse effects underscored the need for safe and effective nonhormonal therapies for VMS.
The 2015 NAMS position statement, Nonhormonal Management of Menopause-associated Vasomotor Symptoms, recommended cognitive behavioral therapy (CBT) as an effective treatment for VMS.6 This recommendation was based on compelling evidence from two randomized clinical trials.7,8 The first of these trials, MENOS1, included 96 breast cancer survivors who were randomized to receive usual care or usual care plus one weekly 90-minute session of group CBT for 6 weeks.7 Group CBT involved psycho-education, paced breathing, relaxation, and cognitive and behavioral strategies to manage VMS. Psychoeducational and discussion topics included the physiology of VMS, the role of stress in triggering VMS, catastrophic thinking and negative beliefs about VMS, and sleep hygiene. CBT significantly reduced VMS problem ratings at 9 weeks after randomization compared with usual care, and improvements were maintained at 26 weeks. The second randomized trial, MENOS2, showed efficacy of self-guided and group CBT compared with usual care in 140 perimenopausal and postmenopausal women without a history of breast cancer.8 Compared with usual care, both group and self-guided CBT reduced VMS problem ratings, and improvements were maintained at 26 weeks. Thus, both group CBT and self-guided CBT are effective in treating VMS.
Although the group CBT manual9 and the self-guided CBT manual used in the MENOS trials are available,10 CBT is not widely used in the treatment of VMS. First, many women and healthcare providers are unaware of the evidence supporting CBT for VMS. Second, few providers are trained in CBT tailored for VMS, and transportation, time constraints, health coverage, and stigma limit use of face-to-face CBT. Self-guided CBT overcomes those barriers, but providers and patients are generally not aware that a manual is available. Following through on the manual is key to deriving clinical benefit; in MENOS2, women in the self-guided CBT arm who read the entire manual showed greater improvements in VMS problem ratings than those who did not.11 CBT-based eHealth interventions can extend the reach of CBT by circumventing those barriers, and the convenience of a web-based intervention (eg, portability, access) can contribute to higher completion rates than other forms of delivery.12-14
In this issue of Menopause, Atema et al15 describe findings from an open-label intervention study of an internet-based CBT intervention for VMS. Myra S. Hunter, PhD, CPsychol, FBPsS, the Principal Investigator of MENOS1 and MENOS2, guided the research team in adapting the evidence-based CBT for delivery through the internet. The CBT intervention was delivered with telephone-based guidance from a counselor at the initiation of the program and e-mail provided feedback weekly thereafter. The intervention included six modules, one delivered each week. Results from 21 enrolled women showed a high rate of completion (n = 19), high satisfaction, and clinically significant improvement on the hot flush rating scale (HFRS) immediately after program completion. Patients also showed significant improvement in endocrine symptoms assessed on the Functional Assessment of Cancer Therapy questionnaire (FACT-ES). In a responder analysis, 72% of women showed clinically meaningful improvement on the FACT-ES and 61% showed improvement on the HFRS.15 By comparison, in MENOS1, 65% of women showed an improvement on the HFRS immediately after program completion.

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