Psychological therapies and support for early menopause

Because there are so many different factors that can go into this, women who are well-supported seem to do better. If they’re well-supported in their family or if they have a partner who understands what they are going through and they’re able to talk about it, if they have really good friends that they’re able to talk with, then they might not need therapy so much. They might only need a few sessions. They might just need a space where they can talk about this terrible thing that has happened to them and that might be all they need.

Women who have less support or the issues are a bit more complex –if they are in a relationship that already had pre-existing difficulties, then they’re likely to need longer support and if there are other factors, women who have other stresses in their life obviously that are going to come up whilst doing therapy. It may be that therapy will take a little – a deviated path for a while because these issues may well be impacting on how well this woman copes with her early menopause.

With the women who have early menopause we have a whole other range of grief issues that need to be dealt with, and the grief issues, particularly are accentuated in the women who haven’t had children and who have not decided they never wanted to have children. So it’s that group that really experience quite profound depression-related grief, and then complicated by a hormone shift, so you’ve got a double big issue to deal with there. And of course, the psychotherapy in terms of grief loss work is a different sort of psychotherapy to something else.

That’s important work to do, really important to get in early and not ignore that whole side of things. So, it’s again that holistic approach. But psychotherapies need to be targeted. It’s not one thing fits all.

It’s not something that’s for everybody. Not everybody wants to talk to a psychologist. I think a lot of people would probably prefer just to talk with other women who’ve experienced it.

The other thing is that – particularly with psychological approaches, it’s a bit confronting for some women because they think that you’re saying, “Well, it’s all in your head.” So you have to take quite a while to say, “Well, it’s a biological symptom but you can use psychological approaches for it.”

I think the other problem we have is that although there’s very good evidence for CBT approaches and hypnotherapy approaches, there’s not really anyone I can refer to, to do that. So although there are psychologists who could do CBT – there’s maybe one or two that I would feel confident would actually know what a hot flush is, and be able to give suggestions about how to manage that. There’s some online resources but, again – I’m not sure how useful they are.

In a little country town like this, there’s no psychologists in the town. So we can do GP management plans for psychological help but – there’s two sorts of psych; there’s general psychological help, coping and there’s focussed help if there’s self-image issues. And once people have education about the premature menopause they’re often more comfortable with themselves and it’s not just me, and “Oh, I feel funny, I’m not less loveable.” All that sort of stuff.

So it depends on the person very much how they cope with it. If it’s cancer related there’s a normally a large group of counsellors available if they’ve had a premature menopause or they’re in one of those genetic groups that’s got a predisposition to cancer and they decide to have their ovaries removed. So that’s a very different kettle of fish and we would be looking at combined treatment with a number of practitioners in that sort of situation.

We find for here because if someone’s going to see a psychologist it’s often a reasonable wait and they’ve got to go to another town. It’s not easily accessible but online services are, and there’s a few online services becoming available where we can do a referral and they can, Skype in their house. Some women find that very useful. If they want a one on one and there’s other issues we’ll go via a tertiary hospital or privately.

In our rural area like this, if we have someone who’s having psychological issues with this and we contact the regional triage that they get a phone call from a nurse and the nurse will come and visit them and then make an assessment whether they need to see a doctor. And then, we’ll get a letter back later. So this people who are well. It’s a slow service. So for those people who are thinking of seeing them privately they get seen much quicker and it’s better. But it’s really to have an idea if we can actually focus on which problems they need; whether it’s self-image problems, whether it’s mood, whether it’s anxiety, relationships, all sorts of things. If they’re simple things like dryness in intercourse, we can easily deal with that ourselves.

The online stuff’s been around for a little while but now there’s a few services and there’s one called Psych To You. We write a letter to them and we can fax a referral. They contact the patient direct and they have Skype in their rooms; its private – very private. If they want us to be present, we can be present, but they can do it privately. And we provide a room where they can Skype here if they haven’t got good computer access at home, and some of the rural people haven’t. So they can do that and then we’ll get a formal letter back from that service with an assessment and a management plan. Whether it’s further cognitive behavioural therapy or whether it’s going to be medication or both.

Definitely yes, most definitely, and as a matter of fact at the time of diagnosis we also use distress screening tools. And a whole component of that is related to emotion and that type of thing and at the very beginning we do explain to women, “It would be normal for you to be feeling sad, worried, apprehensive, fearful, all of the above and it would be peculiar for you not to experience those sensations.”

“So that’s acceptable and it would also be acceptable to experience that whole gamut of emotion as you go through that whole experience. However at the end if you find that you’re no longer enjoying your usual interests or you just can’t pick yourself up and more on we would certainly address that,” but the feedback that I tend to get keeping in mind that I’ve been in contact with patients for you know possibly a year at this point, at the end of treatment when they start their endocrine therapy, we’ve built a pretty good rapport by that point so often I do offer referral to counselling and support services.

But, more often than not, have the women reply by saying “I’m happy to speak with you, as long as I know you’re here to talk to that’s fine,” and obviously if I find you know my professional boundaries are being exhausted I will definitely initiate referral for further emotional support. Seldom does it happen because it’s often stemming as a result of treatments and we can talk through that process and also not putting a time limit on it. Not saying to a patient “You should be feeling better than this by now.” Saying it takes as long as it needs to take, because you never want somebody to feel as though they need to hurry up or that they’re not getting better sooner enough.

I have the time to dedicate to an individual and sit down and have an hour and a half discussion with them and sometimes I think they feel as though they’re not talking about anything but I can see that they are. I can see the therapeutic nature of the conversation and so it’s about probing them, like you can sense that something’s on their mind. So after a few years of experience you learn to probe a little bit and you eventually get it out and they’ll, at the end say, “I didn’t realise that was upsetting me, but it is,” and it’s very rewarding actually and they walk out of here with a smile on their face and it’s fabulous. But the oncologists are great in that they will definitely provide education about potential side effects and not a hell of a lot of strategy because as oncological nurses, that’s our role – providing the education about the management strategies, of course as it is as a breast care nurse and that’s okay.

I will always say to patients, “Take a note pad in when you see your oncologist, write your questions down. If you feel you don’t have the time to ask them we can help you,” and to stress that no question is a silly question, and talking about menopausal side effects is nowhere near as taboo as it used to be as well. So I think women are more openly discussing it and that’s the key. It really is.

Often if it’s part of a cancer thing, then they’re usually plugged into some psychology people anyway as a part of that. But I always tell people “You’re allowed to change your psychologists. It’s like shoes. You might find one pair that fits better than another pair.” Some people, personality wise, don’t click with some of the psychologists, so I say, “Look. Try as many as you like if that’s going to help.”