A Cool Head: Hypnosis and Hot Flashes
Abstract & Commentary
By Russell H. Greenfield, MD
Synopsis: A randomized controlled trial of weekly clinical hypnosis sessions plus home self-hypnosis practice over 5 weeks for breast cancer survivors with hot flashes resulted in significant symptomatic improvement when compared to a matched group of women who received no additional treatment.
Source: Elkins G, et al. Randomized trial of a hypnosis intervention for treatment of hot flashes among breast cancer survivors. J Clin Oncol 2011;26:5022-5026.
The authors of this prospective, randomized, con- trolled intervention trial had previously explored the potential for hypnotherapy to be an aid in the treatment of hot flashes in women. In response to promising pilot results they expanded their research, the result being the current examination.
Sixty adult women with a history of breast cancer and experiencing hot flashes were enrolled. Subjects had to have a history of primary breast cancer with no current detectable disease, > 14 hot flashes per week for at least 1 month by self-report, and not receiving treatment for hot flashes, including mind-body therapies such as yoga. Women using anti-hormonal therapy (for example, tamoxifen) could participate provided drug dosage had remained stable over the previous month. Subjects were randomized to receive either clinical hypnosis (five weekly 50-minute sessions) or no treatment for 5 weeks. Subjects were then asked to complete a daily hot flash diary for 1 week prior to any intervention. Baseline and post-intervention (after 5 weeks) measures included the Hot Flash Related Daily Interference Scale (HFRDIS), Center for Epidemiologic Studies Depression Scale (CES-D), Hospital Anxiety and Depression Scale-Anxiety Subscale (HADS-A), and the Medical Outcomes Study Sleep Scale (MOS-Sleep Scale).
Hypnosis sessions followed a treatment manual developed specifically for the study, and were delivered by a PhD clinical psychologist who had completed > 40 hours of training with the principal investigator. Hypnotic suggestions for each session included hypnotic induction following a standardized script; "mental imagery" and suggestions for relaxation; mental imagery for coolness; deepening hypnosis and dissociation from hot flashes; positive suggestions and imagery for the future; self-hypnosis; and the alert, "In a few moments, return to conscious alertness." Subjects were instructed in home self-hypnosis and provided with a cassette tape recording of a hypnotic induction and guided in-home practice. While hypnotic induction followed a transcript, specific imagery for relaxation and imagery for coolness were individualized.
The major outcome of interest was a combination of hot flash frequency and hot flash score. Participants' number and severity of hot flashes per day was computed for the baseline and final week, as was severity of hot flashes (one point was given for each mild hot flash, two points for each moderate hot flash, three points for each severe hot flash, and four points for each very severe hot flash). Hot flash score was calculated by multiplying the week's severity average times the week's hot flash frequency. Self-report of the impact of hot flashes on daily activities was a secondary outcome measure.
Eight-six patients were screened, of which 26 either did not meet eligibility criteria or did not want to participate; thus, a total of 60 women were randomized. Some participants who had enrolled were either lost to follow-up (n = 3) or withdrew (n = 6); three had been assigned to the treatment group, six to the control group. Reasons for not completing the study included being too busy/no desire to continue for personal reasons (n = 7), and not able to be reached (n = 2). Baseline average number of hot flashes in the two groups was balanced, and the two groups were otherwise similar save for the fact there were a greater number of subjects with graduate degrees in the treatment group than would be expected by chance (P = 0.04); however, educational levels were evenly distributed between treatment and control groups among those who completed the study.
Using the HFRDIS scale, women rated the degree that hot flashes interfered with 10 different aspects of their lives (work, social activities, leisure activities, sleep, mood, concentration, relations with others, sexuality, enjoyment of life, overall quality of life). Overall impact was statistically significant (F[10,29] = 4.73; P < 0.001); at post-test, hot flashes interfered significantly less in the lives of women in the treatment group compared with those in the control group. Follow-up analyses of each item showed that all items were statistically significantly less interfering (P < 0.05) for those in the experimental group, with the exception of an item asking about interference with sexuality (P = 0.124). Those in the hypnosis group showed statistically significant improvements for both hot flash and interference score. Hot flash scores (frequency X average severity) decreased 68% from baseline to endpoint in the hypnosis arm (P < 0.001). The final measures of hot flashes in the hypnosis group when compared with controls revealed statistically significant lower scores on the multivariate hot flash outcome measure in the intervention group, with an effect size of 0.479 (deemed high magnitude using conventional criteria). Results of the MOS-Sleep Scale at baseline and trial's end were statistically significant, with the hypnosis group experiencing improved sleep compared with both their own baseline scores and controls. Results from HADS-A and CES-D showed that subjects in the hypnosis arm had statistically significant improvements in both anxiety and depression compared with the control group.
The study authors concluded that hypnosis reduces hot flashes in female breast cancer survivors, and may also help relieve anxiety, enhance mood, and improve sleep.
The search for an effective non-hormonal approach to relieving hot flashes continues, and this time with some promising results. The background for the study is the widely acknowledged impairment in quality of life often associated with menopausal or medication-induced vasomotor symptoms. What some readers may not know is the extent to which women being treated for breast cancer may experience hot flashes the study authors cite data suggesting the numbers are 78% of those receiving chemotherapy and 72% who take tamoxifen.1 Imagine the cumulative impact of loss of sleep, mood changes, and impairment in concentration, to name but a few of the many stresses associated with hot flashes, on a woman trying to heal from breast cancer. Practitioners desperately try to help their patients find relief but candidate therapies that are both safe and generally effective have been far and few between. An intervention that not only works but that might also enhance self-reliance could be invaluable; in this regard, clinical hypnosis deserves further attention.
The placebo effect accompanies any intervention designed to relieve hot flashes. When teased out, however, the placebo effect does not typically exceed 30-40%; the current trial showed a 68% reduction in hot flash scores with hypnosis.
Not that the results are cut and dried. The fact that the intervention group had added attention and instruction alone might have a positive influence on symptoms, especially if the interactions were perceived to be caring in nature. There was also no placebo control, but the authors have begun a new trial to address this limitation.
A growing number of practitioners have attained certification in clinical hypnotherapy so the approach is becoming widely available. Hypnotherapists offer a therapy that is potentially effective, generally enjoyable for patients, and that within a short period of time can be performed by patients on their own. Trained hypnotherapists also recognize the contraindications to hypnosis, such as schizophrenia. Yes, further study is warranted, but this low-risk approach to relieving hot flashes and their troubling set of associated symptoms seems a therapeutic investment worth making.
1. Carpenter JS, et al. Hot flashes in postmenopausal women treated for breast carcinoma: Prevalence, severity, correlates, management, and relation to quality of life. Cancer 1998;82:1682-1691.