Effectiveness of Cognitive Behavioral Therapy in Managing Physical and Psychological Distress in Women during the Perimenopausal Phase

ABSTRACT

Background:

Perimenopause encompasses significant physiological, psychological, and emotional changes marked by high distress and deteriorating quality of life (QOL). Although studies have shown that cognitive behavioral therapy (CBT) is an effective treatment during period of transition to menopause, limited psychological based-intervention studies have been conducted in India. The aim of this study was to determine the effectiveness of CBT in managing physical and psychological distress in women during the perimenopausal phase.

Materials and Methods:

A two-group randomized pre- and posttest design was used. Fifty-three women in the perimenopausal age-group presenting to gynecology outpatient clinic with menstrual problems were assessed for associated symptoms such as hot flashes, night sweats, insomnia, anxiety, depression, and other physical complaints. Baseline assessments included the Depression Anxiety Stress Scale, Menopause Rating Scale (MRS), Hot Flush Rating Scale, and insomnia severity index. The participants were randomly assigned to either the CBT or psychoeducation group. The CBT group received four sessions over 6 weeks, whereas the psychoeducation group received a pamphlet on perimenopausal symptoms and their management. Postintervention assessments were conducted after 6 weeks. Data obtained were analyzed using independent and paired samples t-test after check for normality.

Results:

Both the CBT and psychoeducation group showed improvements in depression, anxiety, sleep index, and QOL at 6 weeks. However, a significant group difference was found between the two groups on stress, anxiety, MRS’s somatic and psychological symptom scales, as well as sleep index, with CBT showing greater reduction in their mean values (P < 0.05). There were no differences between the groups in depression, hot flush frequency and rating, and urogenital symptoms.

Conclusions:

Both CBT and psychoeducation was effective in improving the QOL of women in the perimenopausal phase, with results supporting greater effectiveness of CBT as an adjunct treatment for managing menopausal symptoms.

INTRODUCTION

Health issues during menopause are emerging as a matter of concern in middle-aged Indian women.[1] According to the Indian Menopause Society, perimenopause or menopause transition begins on average 4 years before and up to 1 year after the final menstrual period, with the mean age ranging from 40.32 to 48.84 years in Indian women.[2]

The transition, although a natural biological process, marked by endocrine changes, anovulatory cycles, reduced fertility, and erratic menstrual periods, is often associated with a variety of health problems such as hot flushes, night sweats, irritability, depression, anxiety, vaginal dryness, pain during sexual intercourse, and incontinence and insomnia. Long term effects may include lower backache, cardiovascular issues, and joint pain,[3] with severity of these symptoms having highest prevalence during late perimenopause and early postmenopause,[4] varying substantially from person to person, and affect daily activities for a transient period, or several years, further deteriorating their quality of life (QOL).[2]

Perimenopause is influenced by biopsychosocial factors,[5] where the psychological perspective emphasizes that cognitive, emotional, and behavioral reactions to symptoms depend on how women appraise and attribute meaning to their experiences. Vasomotor symptoms (VMS), such as hot flushes and night sweats, often trigger sleep disturbances, fatigue, and low self-efficacy, contributing to low mood and anxiety.[6] Epidemiological evidence indicates that VMS during perimenopause affect almost 39% to 79% of women, with insomnia rates affecting 56.6%, depression 42.47%, anxiety 51%, and sexual problems affecting 68%–86.5% of women.[7,8,9,10] Research shows that more than the frequency, the negative thinking about these symptoms is linked to low perceived control, increased helplessness, heightened distress, and unhelpful coping strategies.[11]

In India, limited awareness, high healthcare costs, and poor access to support systems leave most women untreated, underscoring the need for accessible, evidence-based treatments for menopausal symptoms.[1] While menopausal hormone therapy is the standard treatment, it is not considered for all women, such as those with hormone-dependent cancers.[12] Due to this, there has been a growing interest in psychological interventions such as cognitive behavioral therapy (CBT), mindfulness-based stress reduction, mindfulness-based CBT, and acceptance and commitment therapy to address psychological issues during menopause.[13,14,15,16] Among these, evidence from randomized controlled trials (RCTs) and meta-analyses indicate that CBT has been the most robust and transdiagnostic intervention demonstrating significant improvements in depression, anxiety, insomnia, hot flushes, and overall QOL during menopause.[17,18,19,20] The North American Menopause Society also recommends it as an effective nonhormonal treatment option for troublesome VMS.[21]

CBT, adapted to the biopsychosocial model, addresses not only the impact of hormonal changes, but also women’s attitudes, expectations, and mood fluctuations that occur in their social context.[22] It has proven effective in individual, group, and self-help formats with versatile delivery methods, including face-to-face, telephonic, and digital platforms, enhancing accessibility.[23,24,25,26,27] Specific brief CBT protocols, such as the MENOS program and CBT for insomnia, have also shown sustained improvements in symptom reduction.[6,28,29]

While International studies have demonstrated the effectiveness of CBT in alleviating physical and psychological distress during menopause, there is paucity of evidence for its effectiveness among perimenopausal women. This necessitates further exploration of its applicability across diverse Indian contexts as an adjunctive treatment to improve QOL during perimenopause.

MATERIALS AND METHODS

Study design and setting

A randomized two group pre and post-test design was employed. The study was conducted at the obstetrics and gynecology outpatient department (OPD) of a tertiary health care center in the northern part of India.

Study duration

The duration of the study was 9 months (May 2023–January 2024).

Inclusion criteria

Women in the perimenopause stage, on standard treatment, clinically stable, able to comprehend and understand spoken English, or, Hindi, or Punjabi, and reporting mild level of symptoms on any of the scales of Menopause Rating Scale (MRS), Depression Anxiety Stress Scale (DASS), Hot Flush Rating Scale (HFRS), or insomnia severity index (ISI) were included from the study.

Exclusion criteria

Women with known psychiatric illness (severe depression or active suicidal ideation, current psychosis, or substance use disorder), comorbid medical conditions requiring treatment, unwanted pregnancy or undergoing hysterectomy were excluded from the study. Those receiving concurrent psychological treatment for the perimenopausal symptoms were not included in the study.

Sample size estimation

Using g-power, with an alpha of 0.05, 95% confidence interval, 80% power, and an anticipated 40% reduction in pre- and posttest scores, the estimated sample size was 32. Considering a 20% attrition rate, the final estimated sample size was 40.

A total of 44 women, meeting the selection criteria were consecutively recruited from the gynecology OPD after informed consent, and were randomly allocated to either the CBT or psychoeducation group.

Tools used

A sociodemographic and clinical interview was prepared, containing information on key sociodemographic variables, along with a detailed menopausal history, including chief complaints, duration, frequency, severity, symptom checklist, and medical and treatment history.

Primary baseline and outcome measures are as follows:

1. DASS-21: A 21-item self-report scale measuring the severity of depression, anxiety, and stress. Cronbach’s alpha for each of the subscales in clinical samples is 0.96, 0.89, and 0.93, respectively. The scale is freely available in both English and Hindi[30,31]

2. HFRS: A 5 items self-report measure of hot flushes frequency and problem-rating over the past week, under 2 domains – HFRS frequency and HFRS problem rating. The scale has good test–retest reliability (r = 0.8) and internal consistency (α = 0.87)[32]

3. ISI: A 7-item questionnaire assessing the nature, severity, and impact of insomnia over the last month. Cronbach’s alpha of ISI is 0.74. The clinician-rated version was used in our study.[33]

Secondary outcome measure include:

1. MRS: An 11 item self-administered health-related QOL scale used to compare the severity of symptoms over time, and measure changes pre- and posttreatment. It has three dimensions: psychological, somato-vegetative, and urogenital symptoms. The Cronbach’s alpha ranges from 0.6-0.9 across countries.[34,35]

Intervention module

Cognitive behavioral therapy group

The CBT group received a brief CBT intervention based on an established theoretical model of hot flushes.[36] The intervention was delivered in four 50–60-min sessions over 6 weeks. Session one included baseline assessments and psychoeducation on menopause symptoms, prevalence, risk factors, and their psychosocial impact. Session two focused on socialization with the cognitive-behavioral conceptualization, monitoring perceptions and cognitive appraisal related to menopausal symptoms using a thought diary, identifying helpful versus unhelpful coping behaviors and practicing adaptive coping behaviors for example, reducing avoidance, behavioral activation, and activity scheduling. Session three emphasized on cognitive restructuring, i.e., challenging negative beliefs, expectations, assumptions, and anxious thoughts related to their concerns. Relaxation exercises such as diaphragmatic breathing and progressive muscle relaxation for arousal reduction were also introduced. For improving sleep quality, psychoeducation on sleep hygiene was provided, along with cognitive restructuring around anticipatory anxiety related to insomnia. The final session reviewed progress and summarized the previous sessions, set goals, maintain gains, and reinforced healthy coping behaviors.

Psychoeducation group

A psychoeducation pamphlet was prepared in English, Hindi, and Punjabi including content to raise awareness about perimenopause, signs and symptoms, hormonal changes, risk factors, and self-help strategies for symptom relief along with some preventive measures to avoid worsening of symptoms. The pamphlet was created in consultation with a Senior Clinical Psychology Consultant and Gynecologist.

Treatment fidelity – The sessions were conducted by M.Phil. Clinical Psychology trainee, trained in CBT, and all sessions were discussed with and supervised by the Senior Clinical Psychology Consultant.

Procedure

The study’s design was approved by the institutional ethics committee. The procedure for screening and participation of women is shown in Figure 1. Women with specific complaints of abnormal uterine bleeding (AUB), their details were recorded in the clinical pro forma and were analyzed during the statistical analysis.

Figure 1.

Flowchart for procedure. DASS: Depression Anxiety Stress Scale, MRS: Menopausal Rating Scale, HFRS: Hot Flush Rating Scale, ISI: Insomnia severity index, AUB: Abnormal uterine bleeding

Statistical analysis

Data were analysed using SPSS, version 25.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics summarized demographic information and clinical variables. Chi-square test assessed between-group differences for nominal data. Shapiro–Wilk’s test and Levene’s test checked for normality and homogeneity of variance for: DASS-21, HFRS, ISI, and MRS. Baseline equivalence between the CBT and psychoeducation groups was assessed using independent samples t-test. Pre–post intervention changes in depression, stress, anxiety, insomnia, and menopausal symptoms severity were analyzed using paired and independent samples t-tests.

RESULTS

Preliminary analysis

The mean age of the participants (N = 44) was 46 years (standard deviation = 3.04), ranging from 41 to 53 years. The demographic characteristics of the sample in the CBT and psychoeducation groups are shown in Table 1. The two groups did not differ by age, marital status, education, occupation, socioeconomic status, domicile, health condition (AUB), and standard treatment.

Table 1.

Baseline comparison of the two groups with respect to demographic variables, abnormal uterine bleeding, and women on standard treatment

Baseline characteristics	CBT group (n=22) f (%)	Psychoeducation group (n=22) f (%)	χ2/t
Age in years (mean±SD)	46±2.79	47±3.32	−0.54
Marital status
Married	21 (96)	22 (100)	1.02
Widow	1 (4)	-
Education
Primary educated	1 (5)	1 (5)	0.86
Secondary educated	9 (41)	12 (41)
College educated	12 (54)	9 (54)
Occupation
Housewives	11 (50)	13 (59)	0.37
Working	11 (50)	9 (41)
SES
Upper lower class	2 (9)	1 (5)	0.67
Middle class	19 (86)	19 (86)
Upper class	1 (5)	2 (9)
Domicile
Rural	3 (13)	3 (13)	1.14
Semi-urban	6 (27)	6 (27)
Urban	13 (59)	15 (68)
AUB
Yes	6 (27)	6 (27)	0.00
No	16 (72)	16 (72)
Standard treatment
Yes	13 (59)	11 (50)	0.37
No	9 (41)	11 (50)

f: Frequency, SD: Standard deviation, CBT: Cognitive behavior therapy, SES: Socioeconomic status, AUB: Abnormal uterine bleeding

Baseline assessment

Table 2 shows baseline symptom severity for participants (N = 44), with no significant differences between groups [Table 3].

Table 2.

Frequency and percentage of depression, anxiety, stress, insomnia, and menopausal symptoms severity in the sample at baseline

Outcome variables (n=44)	Normal f (%)	Mild f (%)	Moderate f (%)	Severe f (%)
Depression	21 (47)	12 (27)	8 (18)	2 (4)
Anxiety	22 (50)	3 (7)	13 (29)	4 (9)
Stress	13 (29)	7 (16)	17 (38)	7 (16)
ISI	22 (50)	22 (50)	-	-
MRS	-	2 (4)	14 (32)	28 (64)

f: Frequency, MRS: Menopausal Rating Scale, ISI: Insomnia severity index

Table 3.

Baseline mean, standard deviation, and t values on depression, stress, anxiety, menopausal symptoms, hot flushes, and insomnia measures in both groups

Measures	CBT group (n=22) Mean±SD	Psychoeducation group (n=22) Mean±SD	t
Depression	11.45±5.17	9.55±5.41	1.20
Stress	20.27±5.77	18.77±5.22	0.90
Anxiety	10.00±5.13	5.00±6.73	1.11
Menopausal Rating Scale	18.55±5.40	16.32±5.11	1.40
Somatic Symptoms Subscale	6.86±2.59	6.32±2.38	0.73
Psychological Symptoms Subscale	9.64±3.32	8.18±2.54	1.63
Urogenital Symptoms Subscale	2.05±1.56	1.82±1.59	0.48
Hot flush frequency	7.77±4.38	7.50±4.45	0.205
Hot flush rating	5.70±2.10	4.55±1.80	1.96
Insomnia	6.05±4.62	6.36±4.93	−0.22

CBT: Cognitive behavior therapy, SD: Standard deviation

Pre–post intervention changes within the CBT and psychoeducation group:

Paired samples t-test findings indicate a significant improvement (P < 0.05), on all the outcome measures within the CBT group [Table 4]. However, in the psychoeducation group, while significant pre–post intervention changes (P < 0.05) were found for depression, stress, anxiety, hot flushes frequency and severity, insomnia, and MRS’s somatic and urogenital subscale, no significant difference was found on the psychological subscale of MRS [Table 5].

Table 4.

Pre–post intervention changes within the cognitive behavior therapy group on measures of depression, anxiety, menopausal symptoms, hot flushes, and insomnia

Measures	CBT group (n=22)		Mean difference	t	d
	Pre (mean±SD)	Post (mean±SD)
Depression	11.45±5.17	6.09±4.21	−5.36	10.75*	1.14
Stress	20.27±5.77	7.09±2.81	−13.18	11.51*	2.90
Anxiety	10.00±5.13	2.00±1.85	−8	8.43*	2.07
Menopausal Rating Scale	18.55±5.40	8.45±3.16	−10.1	13.79*	2.28
Somatic Symptoms Subscale	6.86±2.59	3.00±1.35	−3.86	10.48*	1.86
Psychological Symptoms Subscale	9.64±3.31	4.32±2.23	−5.32	11.62*	1.88
Urogenital Symptoms Subscale	2.05±1.56	0.95±0.95	−1.1	4.81*	0.85
Hot flush frequency	7.77±4.38	3.00±2.33	−4.77	7.02*	1.36
Hot flush rating	5.71±2.10	2.71±5.22	−3	11.88*	0.75
Insomnia	6.05±4.62	2.18±1.10	−3.87	5.38*	1.15

*P<0.01. CBT: Cognitive behavior therapy, SD: Standard deviation, d: Cohen’s d

Table 5.

Pre–post intervention changes within the psychoeducation group on measures of depression, anxiety, menopausal symptoms, hot flushes, and insomnia

Measures	Psychoeducation group (n=22)		Mean difference	t	d
	Pre (mean±SD)	Post (mean±SD)
Depression	9.55±5.41	7.91±5.25	−1.64	3.81*	0.30
Stress	18.77±5.22	13.64±5.51	−5.14	7.06*	0.96
Anxiety	8.00±6.73	4.45±5.01	−3.54	5.89*	0.59
Menopausal Rating Scale	16.32±5.11	13.00±6.05	−3.32	3.21*	0.59
Somatic Symptoms Subscale	6.32±2.38	4.45±2.06	−1.86	6.81*	0.84
Psychological Symptoms Subscale	8.18±5.54	7.23±5.00	−0.95	1.02	0.18
Urogenital Symptoms Subscale	1.82±1.60	1.00±1.31	−0.81	4.01*	0.56
Hot flush frequency	7.50±4.45	3.68±3.30	−3.82	7.85*	0.97
Hot flush rating	4.55±1.80	3.00±1.47	−1.55	7.98*	0.94
Insomnia	6.36±4.94	3.95±3.33	−2.41	5.20*	0.57

*P<0.05. CBT: Cognitive behavior therapy, SD: Standard deviation, d: Cohen’s d

Between-group analyses post-intervention

Independent samples t-test showed a significant difference between the CBT and psychoeducation group on the severity of stress, anxiety, insomnia, and somatic and psychological subscale of MRS (P < 0.05). However, no significant difference was found for depression, hot flush rating, or MRS urogenital subscale [Table 6].

Table 6.

Postintervention mean, standard deviation, and t values on outcome measures between the two groups

Measures	CBT group (n=22) (mean±SD)	Psychoeducation group (n=22) (mean±SD)	Mean difference	t
Depression	6.09±4.21	7.91±5.25	−1.81	−1.27
Stress	7.09±2.81	13.64±5.51	−6.55	−4.96**
Anxiety	2.00±1.85	4.45±5.01	−2.45	−2.15*
Menopausal Rating Scale	8.45±3.16	13.00±6.05	−4.54	−3.12*
Somatic Symptoms Subscale	3.00±1.35	4.45±2.06	−1.45	−2.76*
Psychological Symptoms Subscale	4.32±2.23	7.23±5.00	−2.90	−2.49*
Urogenital Symptoms Subscale	0.95±0.95	1.00±1.31	−0.05	−0.13
Hot flush frequency	3.00±2.33	3.68±3.30	−0.68	−0.79
Hot flush rating	2.71±1.34	2.99±1.47	−0.29	−0.68
Insomnia	2.18±1.99	3.00±2.33	−1.77	−2.14*

*P<0.05, **P<0.01. CBT: Cognitive behavior therapy, SD: Standard deviation

DISCUSSION

Perimenopause and menopause are known to be associated with significant physical and mental changes in body that can disrupt a patient’s QOL. Many of these issues may go unaddressed in a busy gynecologic OPD, especially when the patient clinically presents with only the menstrual or genitourinary symptoms. Assessments of their psychological and mental health and providing remedies to address those issues are likely to improve their QOL.

The aim of the present study was to examine the effectiveness of CBT in managing these symptoms and improving the QOL of women during perimenopause. Women were randomly allocated to the CBT group and the psychoeducation group. Compared to the baseline assessment, results showed a significant difference between the two groups on the outcome variables postintervention.

Outcome on depression

At baseline, 45% of women reported mild-to-moderate depressive symptoms [Table 2]. In the present study, the pre–post intervention change within each group was significant on the depression subscale of DASS-21. However, the difference between the CBT and psychoeducation group at 6 weeks postintervention was statistically not significant. The CBT group received only four sessions, targeting the depressive symptoms to a limited extent, which may explain the lack of between-group difference. Studies reporting significant improvement in depressive symptoms during menopause typically have 6–12 sessions focused solely on depression.[13,24] In addition, social factors such as physical inactivity, relationship issues, financial issues, unemployment, retirement, social isolation, and poor social support or stressful life events are significant risk factors for depression in women during this time.[9] Some of these psychosocial factors, such as interpersonal issues, grief, and financial stress, reported by the participants could not be addressed in our study as they were not primarily related to menopause transition, perpetuating the depressive symptoms in the current sample. Future studies can target depressive symptoms at a larger scale through either alternative interventions or group CBT sessions for better outcomes.[23,25]

Outcome on anxiety

On DASS-21 anxiety subscale, 50% of participants reported symptoms of anxiety [Table 2]. Being a period of vulnerability for women, presence of anxiety symptoms during perimenopause may further increase their vulnerability to a midlife depressive episode.[37] Results [Tables 4 and 5] show significant improvement in anxiety symptoms in both the groups; the between-group difference postintervention revealed that CBT was two points more effective than psychoeducation in reducing anxiety symptoms in perimenopausal women [Table 6]. This may be due to the effectiveness of the CBT module used in our study, targeting the negative cognitive appraisal of the symptoms and helping women to change how they perceived them, enabling them to let go of unhelpful thoughts and focus on healthier alternatives. Techniques reported to be effective in managing menopausal symptoms were cognitive restructuring with regard to catastrophic misinterpretation of the symptoms and health, behavioral activation, encouraging to exercise and engage in recreational activities, and relaxation techniques such as diaphragmatic breathing, progressive muscle relaxation, and meditation.[11,38]

Outcome on stress

On the stress subscale of DASS-21, 71% of women reported mild-to-severe stress [Table 2]. Although participants in both groups experienced significant pre–post intervention change in stress reduction [Tables 4 and 5], results showed a huge difference in stress reduction, with CBT being superior to psychoeducation with a 6.5-point mean difference [Table 6]. The techniques in the CBT module, such as practicing problem solving for coping with anticipated challenges associated with menopause transition, ventilating about stressful life events, and radical acceptance, might have led to a more favorable treatment outcome.[38]

Menopausal symptoms severity and quality of life

The MRS has three subscales that measure the severity of menopausal symptoms: Somatic, psychological, and urogenital subscale. The overall score predicts the QOL of women going through menopausal transition. Table 2 represents the severity of menopausal symptoms in the current sample. Results indicate significant improvement postintervention at 6 weeks in menopausal symptoms within and between both groups [Tables 5 and 6]. While both the interventions were effective, CBT proved to be more effective than psychoeducation in reducing symptom severity and improving QOL. These findings are consistent with a systematic review, indicating that while the self-help modality was more cost-effective, it had less impact than the face-to-face modality.[25]

Outcome on somatic symptom subscale

Participants in the CBT group reported greater improvement than the psychoeducation group on somatic symptoms such as hot flushes, heart discomfort, sleep disturbances and joint and muscular discomfort over a period of 6 weeks. The difference could be attributed to the intervention’s techniques like relaxation training, compared to the psychoeducation that provided only informational pamphlet.

Outcome on psychological symptom subscale

Psychological symptom subscale assessed for depressive mood, irritability, anxiety, and physical and mental exhaustion. The findings of our study found that the severity of menopausal symptoms was positively correlated with the severity of psychological symptoms. Although both interventions were effective in reducing the psychological symptoms, CBT was superior to psychoeducation [Table 6].

Outcome on urogenital subscale

This subscale assesses for problems regarding sexual activity, bladder control, and dryness in vagina. The CBT group was psychoeducated about these concerns and advised to consult a gynecologist, and a few participants with complaints of increased micturition were guided on Kegel’s exercises.[39] Both the CBT and psychoeducation groups showed significant pre–post intervention improvement [Tables 4 and 5]; however, the between-group difference was not statistically significant [Table 6]. Although recent studies support the efficacy of CBT for sexual concerns during menopause,[23] the present study could not establish the superiority of CBT over psychoeducation; improvement within both groups, can likely be attributed to standard gynecological care, time effects, or under-reporting of sexual problems.

Outcome on hot flushes

Worry, shame, and behavioral reactions to hot flushes in work or social settings were addressed in CBT sessions by challenging beliefs about them and improving its management, potentially contributing to the effect size of 0.75 in the CBT group [Table 4]. These findings align with other studies where women have reported improved ability to cope with hot flashes and “regaining a sense of control” by increased understanding and paced breathing[11,13] The psychoeducation group also reflected effect size of 0.94 post intervention [Table 5], with no significant difference between the groups. This suggests that both interventions are equally effective in reducing hot flush frequency and associated distress, consistent with literature supporting efficacy of CBT and brief self-help booklet version of CBT in improving hot flushes.[6]

Outcome on insomnia severity index

50% of women reported subthreshold insomnia on the ISI. Post-intervention changes were significant in the CBT as well as the psychoeducation group [Tables 4 and 5]. In the CBT group, participants reporting sleep difficulties were helped by sleep scheduling, changing attitudes about sleep patterns, and progressive muscle relaxation; in the psychoeducation group, information on sleep hygiene was provided in the pamphlet. Post-intervention analysis of between-groups difference depicted that CBT was more effective by a 1.7 point mean difference [Table 6]. These findings are also consistent with other similar studies.[28]

To reduce dropouts, some CBT sessions were taken telephonically, increasing the accessibility for women traveling long distances or dependent on others for being taken to the hospital. Literature also supports telemedicine to be effective in improving treatment adherence and treatment outcomes.[40]

Limitations

The shift in the mode of delivery of CBT from face-to-face to telephonic sessions may have diluted treatment effects. Improvements could be partly attributed to standard medical care, suggesting CBT as an adjunct modality in reducing physical and psychological symptoms during perimenopause. Moreover, the lack of control group and small sample size limits the understanding of independent role of CBT and generalizability of findings.

CONCLUSIONS

Both CBT and psychoeducation were effective in improving the QOL of women during perimenopause, with results showing greater effectiveness of CBT as an adjunct treatment. In addition, the psychoeducation pamphlet was also helpful in alleviating mild VMS and insomnia, contributing to improved QOL. Given barriers such as less accessibility, cost, and stigma associated with mental health care, adjunctive therapies like CBT delivered in other physiological conditions, such as menopause, can help people overcome these barriers and develop a positive attitude toward women’s mental health.

Future recommendations

RCTs with a larger sample size and longer follow-up period would make the study design more robust. Further studies should explore the efficacy of stepped care CBT model and other alternate delivery formats such as guided self-help CBT, online or group CBT that reaches more culturally diverse backgrounds. In terms of implications of the study, the psychoeducation pamphlet could also be adapted for other conditions such as surgically induced menopause or breast cancer. Training other primary healthcare providers on the role of psychoeducation can help them to be more sensitized to the psychological distress associated with perimenopause.

Conflicts of interest

This research was conducted as part of the partial fulfilment of the requirements for the M.Phil. in Clinical Psychology at GMCH-32, Chandigarh. The author(s) declare that there are no conflicts of interest related to this work.

Funding Statement

Nil.