- Email: [email protected]
Multiple component self-control program for menopausal hot flashes
J. Llehov. Ther. &Exp. Psychiar. Printed in Great Britain.
om5-7916/8333.00+ .cm 0 1983 Pergamon Press Ltd.
Vol. 14, No. 2, pp. 137-140. 1983.
MULTIPLE
COMPONENT
SELF-CONTROL
MENOPAUSAL
PROGRAM
FOR
HOT FLASHES
DALLAS W. STEVENSON Wayne State University
Obesity & Risk Factor
Clinic
and DENNIS J. DELPRATO Eastern
Michigan
University
Summary-Four menopausal women served as their own controls in a study of the application of behavioral methods to the treatment of hot flashes. After a 3-or 4-week baseline period, they received 10 sessions of training in a variety of stress and temperature control techniques, including relaxation, self-suggestions of cool thoughts and images, marital contingency contracting and temperature feedback. The percentage reductions in number of flashes between the last 2 weeks of baseline and the last 2 weeks of training were 41, 75, 76 and 90 for the 4 participants. Treatment gains were maintained at 6-months follow-up. These substantial reductions in frequency of hot flashes offer strong support for the further investigation of the use of behavioral methods as alternatives or additions to medicative therapies.
flashing has responded to suggestions of improvement (Clayden, Bell and Pollard, 1974), and temperature changes have been produced by suggestion (Hadfield, 1920). Furthermore, several investigators have noted that hot flashes are related to emotional conditions and life stressors (Molnar, 1975; Reynolds et al., 1941; Sanes, 1920). These considerations led to the development of a multiple component treatment regime for hot flashes that was based upon techniques that have been successfully used to control psychological stress, autonomic imbalance and temperature. Flashing was viewed as related to stress or anxiety reactions. These latter reactions have overt and covert behavioral concomitants not dissimilar to those of flashing. Since treatments that involve training the patient to counteract stress and anxiety have been notably successful in recent years, the present program placed much emphasis on relaxation training and other stress control
Surveys reveal that a high proportion of menopausal women experience hot flashes (Polit and LaRocco, 1980; Sanes, 1920). The hot flash is usually described as a sudden hot feeling accompanied by flushing of the face and sometimes sweating. Traditional treatment for hot flashes consists of the administration of estrogen (Hawkinson, 1938); however, need for an alternative treatment is indicated by potentially harmful estrogenic side effects (Coope, Thomson and Poller, 1975; Mulley and Mitchell, 1976), the failure for estrogen and gonadotropin levels to correlate with flashes (Aksel et al., 1976; Hutton et al., 1978) and questions concerning the effectiveness of estrogen for treating hot flashes (Mulley and Mitchell, 1976). Promising results have been obtained with non-estrogenic compounds (Clayden, Bell and Pollard, 1974; Lightman and Jacobs, 1979), and several considerations suggest that behavioral treatment may be effective in attenuating hot flashes. For example, Requests for reprints should be addressed Ypsilanti, Michigan 48197, U.S.A.
to Dennis J. Delprato,
137
Department
of Psychology,
Eastern
Michigan
University,
DALLAS
138
W. STEVENSON
techniques. Self-management strategies for lowering body temperature were also integrated with stress management training.
PARTICIPANTS
AND METHODS
Four women, from 40 to 57 yr old who had been suffering from hot flashes associated with natural menopause from 1 to 5 yr, participated in the study; each served as her own control. Three participants (Ps) were assigned to a 4-week baseline period and the fourth was studied over a 3-week baseline. At the first meeting, Ps were instructed to record each hot flash and its antecedents on specially prepared forms. Baseline and training sessions were 1-hr long. The baseline period was designed to provide a measure of the participants’ flashes prior to training under placebo-like conditions. At each baseline meeting, the therapist collected Ps’ self-report data, emphasized the importance of data collection, and discussed their hot flashes in a neutral manner. The training period took place over 12 weeks, during which 10 sessions were held. At the first session, the therapist administered relaxation instructions (Delprato and DeKraker, 1976) and gave P a tape recording for home practice; relaxation training continued in session 2. For sessions 3 and 4, the therapist used each P’s hot flash records to construct individualized hierarchies of life situations in which Ps reported flashes. Each P was given her hierarchy and instructed first to imagine the lowest situation (minimally problematic). She was instructed to use relaxation to counteract the hot flash or tension as soon as either was detected in response to imagining the situation. Once P quickly attenuated flashing and/or tension with the lowest hierarchical situation, she began the same process with the next higher situation and progressed up the hierarchy. The hierarchy was taken home for practice. Thought stopping and semantic counterconditioning (Holmes, Delprato and Aleh, 1979) were introduced in session 5. Ps were taught to identify self-thoughts that were compatible with flashes and tension, to stop them, and to replace them with self-statements that were relaxing and non-stressing. The use of cool thoughts and images (Hadfield, 1920) as a coping skill for hot flashes and marital contingency contracting (Weiss, Hops and Patterson, 1973) for reducing marital stress were presented in session 6. Alteration of P’s daily schedule to reduce stress during the times of the day when the flashes were most likely was worked on in session 7. Ps were given three trials of temperature biofeedback training (Taub, 1977) in session 8. A trial consisted of 5 min of rest (baseline) followed by 15 min of training. A Yellow Springs thermistor was taped l-l .5 cm proximal to the tip of the left index finger and a speaker provided variable-pitched tonal feedback at a rate of 52 Hz per 0.1 “C change in temperature. During baseline and training, temperature was recorded the first 30 set of every minute interval by a Coulburn Instrument Multichannel Printout Counter (NP7).
and DENNIS
J. DELPRATO
During session 9, Ps were attached to the skin temperature recording equipment. Following a 5 min baseline they were asked to demonstrate control over their skin temperature by lowering it as much as they could; feedback was not provided until the 15-min trial was completed. Temperature data were collected in the same fashion as the biofeedback data in session 8. Ps filled out questionnaires pertaining to the program and were interviewed regarding the total program during the tenth and final session. Arrangements were made for seven days of follow-up recording at I-, 3- and 6-months after termination of training.
RESULTS
AND DISCUSSION
The mean number of flashes per day over successive weeks of baseline and training is presented in Fig. 1. Diminutions in the frequency of flashes during baseline would reflect placebo-like reactions, and such effects were displayed by Ps 2 and 4. However, these reactions were not durable, as is especially indicated in the case of P 2.
Base line
Trarning
.
2
4
6
8
Weeks
Months
Fig. 1. Mean number of flashes per day during weeks of baseline, training and follow-up. P supply follow-up data at 3.months.
successive
1 failed to
MULTIPLE
COMPONENT
SELF-CONTROL
PROGRAM
All Ps showed a gradual reduction in the number of flashes over the training phase. By the end of the training period, all Ps experienced substantial reductions in flash frequency. The percentage reductions in number of flashes between the last 2 weeks of baseline and the last 2 weeks of training were 75, 41, 90 and 76 for Ps l-4, respectively. Comparable percentage reductions were obtained when the frequencies over the last 2 weeks of training were compared with those of the first 2 training weeks: 74, 64, 88 and 80 for Ps l-4, respectively. Treatment gains were maintained at follow-up for all Ps. The percentage reductions in number of flashes between the last 2 weeks of baseline and the 6-months follow-up period were 63, 91 and 52 for Ps 2-4, respectively. Even P 1, who showed some regression from the final weeks of training to 6-months post-training, exhibited a percentage reduction of 48% from the last 2 weeks of baseline. All Ps responded to biofeedback training conducted during session 8 with a decrease in skin temperature. In three 15 min training sessions the mean reduction of skin temperature between baseline and the last one minute training interval was 2.4”, 3.5”, 1.7” and 1.5”C for Ps l-4, respectively. During session 9, Ps demonstrated temperature control by reducing temperature without feedback at the therapist’s instruction to lower their skin temperature. The reduction in Ps’ skin temperature between baseline and the last interval of the instruction to lower condition (15 min duration) was 2.6’, 1.9”, 1.5” and 3.5”C for Ps l-4, respectively. The basic data in this study were the selfreports of the participants. One could argue that the focus of this study was the manipulation of verbal reports of the participants. The temperature data presented demonstrates that Ps were able to change their temperature. This seems to support the notion that both verbal report and body temperature were affected by the treatment. Further research in this area could use a portable temperature recording device (Molner, 1981) and a self-report device
FOR MENOPAUSAL
HOT FLASHES
139
to examine the relationship between these two behavioral components of the hot flash. The present data lend support to the notion that behavioral factors participate in menopausal hot flashes. These encouraging results justify further exploration of the use of behavioral methods in the treatment of this condition. Furthermore, difficulties in identifying correlations between hormonal variables and menopausal flashing (Aksel et al., 1975; Hutton et al., 1978) may be due, in part, to unidentified behavioral variables that obscure such relationships. There has been the suggestion that the frequency of hot flashes increases as a result of increases in air temperature. Molnar (1981) noted a correlation between air temperature and the number of hot flashes experienced by his wife. Molnar admitted that his wife, “disliked hot weather and always delighted in a gentle flow of cool dry air”. In Molnar’s study it is difficult to determine whether the air temperature or the participant’s dislike of hot weather is associated with the noted increase in hot flashes. Most of the Ps in the present study noted hot air temperature in offices, classrooms, and other situations as antecedent to hot flashes; however, as training progressed the air temperature in these situations remained about the same and the mean number of hot flashes decreased. The positive therapeutic results associated with the present training program suggest it may be worthwhile to investigate treatment regimens for hot flashes that combine behavioral training with medicative procedures. The addition of behavioral techniques to existing therapies might permit lower doses of medication and/or shorter periods of medication to be therapeutically effective. Of course, behavioral methods may be of value in cases where medication is contraindicated. It is possible that the present treatment program would have been effective if only one type of training, e.g. relaxation, were given. Future research, involving more participants and appropriate controls, is necessary to
140
DALLAS
W. STEVENSON
determine if any of the several components we used are superfluous. Indeed because of the limitations of the present design, further work with more rigorous experimental design is necessary to more conclusively demonstrate the contribution of the treatment package as a whole to the observed reductions in the hot flash reports. In conclusion, it appears that behavioral therapy emphasizing relaxation, temperature control techniques, and stress management offers promise in the treatment of menopausal hot flashes.
REFERENCES Aksel S., Schomberg D. W., Tyrey L. and Hammond C. B. (1976) Vasomotor symptoms, serum estrogen, and gonadotropin levels in surgical menopause. Am. J. Obstet. Gynec. 126, 165-169. Clayden J. R., Bell J. W. and Pollard, P. (1974) Menopausal flushing: Double-blind trial of a non-hormonal medication. Br. Med. J. 1, 409412. Coope J., Thomson J. M. and Poller L. (1975) Effects of “natural oestrogen” replacement therapy on menopausal symptoms and blood clotting. Br. Med. J. 4, 139-143. Delprato D. J. and DeKraker T. (1976) Metronomeconditioned hypnotic-relaxation in the treatment of test anxiety. Behav. Ther. 7, 379-381. Hadfield J. A. (1920) The influence of suggestion on body temperature. Lancer 2, 68-69. Hawkinson L. F. (1938) The menopausal syndrome: One thousand consecutive patients treated with estrogen. J. Am. Med. Ass. 111,390-393.
and DENNIS
J. DELPRATO
Holmes P. A., Delprato D. J. and Aleh E. (1979) Multiple component self-control treatment program for air travel discomfort. J. Behav. Ther. & Exp. Psychiat. 10.85-86. Hutton J. D., Jacobs H. S., Murray M. A. F. and James V. H. T. (1978) Relation between plasma oestrone and oestradiol and climacteric symptoms. Lancer 1, 678-681. Lightman S. L. and Jacobs H. S. (1979) Naloxone: Nonsteroidal treatment for post-menopausal flushing? Lancer 2, 107 1. Molnar G. W. (1975) Body temperature during menopausal hot flashes. J. Appl. Physiol. X3,499-503. Molnar G. W. (1981) Menopausal hot flashes: Their cycles and relation to air temperature. Obstet. Gynec. 57, 52S-55s. Mulley G. and Mitchell J. R. A. (1976) Menopausal Flushing: Does oestrogen therapy make sense? Lancet 1, 1397-1399. Polit D. F. and LaRocco S. A. (1980) Social and psychological correlates of menopausal symptoms. Psychosom. Med. 42,335-345. Reynolds S. R. M., Kaminester S., Foster F. I. and Scholoss S. (1941) Psychogenic and somatogenic factors in the flushes of the surgical menopause. Am. J. Obstet. Gynec. 41, 1022-1028. Sanes K. I. (1920) Hot flashes of menopause. The vegetative, nervous and endocrine systems as factors of menopause disturbances. Trans. Am. Ass. Obstet. Gynec. 32, 182-210. Taub E. (1977) Self-regulation of human tissue temperature. In Biofeedback: Theory and Research (Ed. by Schwartz G. E. and Beatty J.), Academic Press, New York. Weiss R. L., Hops H. and Patterson G. R. (1973) A framework for conceptualizing marital conflict: A technology for altering it, some data for evaluating it. In Behavior Change: Methodology, Concepts, and Practice (Ed. by Hammerlvnck L. A., Hardy L. C. and Mash E. J.). Research Press, Champaign.
om5-7916/8333.00+ .cm 0 1983 Pergamon Press Ltd.
Vol. 14, No. 2, pp. 137-140. 1983.
MULTIPLE
COMPONENT
SELF-CONTROL
MENOPAUSAL
PROGRAM
FOR
HOT FLASHES
DALLAS W. STEVENSON Wayne State University
Obesity & Risk Factor
Clinic
and DENNIS J. DELPRATO Eastern
Michigan
University
Summary-Four menopausal women served as their own controls in a study of the application of behavioral methods to the treatment of hot flashes. After a 3-or 4-week baseline period, they received 10 sessions of training in a variety of stress and temperature control techniques, including relaxation, self-suggestions of cool thoughts and images, marital contingency contracting and temperature feedback. The percentage reductions in number of flashes between the last 2 weeks of baseline and the last 2 weeks of training were 41, 75, 76 and 90 for the 4 participants. Treatment gains were maintained at 6-months follow-up. These substantial reductions in frequency of hot flashes offer strong support for the further investigation of the use of behavioral methods as alternatives or additions to medicative therapies.
flashing has responded to suggestions of improvement (Clayden, Bell and Pollard, 1974), and temperature changes have been produced by suggestion (Hadfield, 1920). Furthermore, several investigators have noted that hot flashes are related to emotional conditions and life stressors (Molnar, 1975; Reynolds et al., 1941; Sanes, 1920). These considerations led to the development of a multiple component treatment regime for hot flashes that was based upon techniques that have been successfully used to control psychological stress, autonomic imbalance and temperature. Flashing was viewed as related to stress or anxiety reactions. These latter reactions have overt and covert behavioral concomitants not dissimilar to those of flashing. Since treatments that involve training the patient to counteract stress and anxiety have been notably successful in recent years, the present program placed much emphasis on relaxation training and other stress control
Surveys reveal that a high proportion of menopausal women experience hot flashes (Polit and LaRocco, 1980; Sanes, 1920). The hot flash is usually described as a sudden hot feeling accompanied by flushing of the face and sometimes sweating. Traditional treatment for hot flashes consists of the administration of estrogen (Hawkinson, 1938); however, need for an alternative treatment is indicated by potentially harmful estrogenic side effects (Coope, Thomson and Poller, 1975; Mulley and Mitchell, 1976), the failure for estrogen and gonadotropin levels to correlate with flashes (Aksel et al., 1976; Hutton et al., 1978) and questions concerning the effectiveness of estrogen for treating hot flashes (Mulley and Mitchell, 1976). Promising results have been obtained with non-estrogenic compounds (Clayden, Bell and Pollard, 1974; Lightman and Jacobs, 1979), and several considerations suggest that behavioral treatment may be effective in attenuating hot flashes. For example, Requests for reprints should be addressed Ypsilanti, Michigan 48197, U.S.A.
to Dennis J. Delprato,
137
Department
of Psychology,
Eastern
Michigan
University,
DALLAS
138
W. STEVENSON
techniques. Self-management strategies for lowering body temperature were also integrated with stress management training.
PARTICIPANTS
AND METHODS
Four women, from 40 to 57 yr old who had been suffering from hot flashes associated with natural menopause from 1 to 5 yr, participated in the study; each served as her own control. Three participants (Ps) were assigned to a 4-week baseline period and the fourth was studied over a 3-week baseline. At the first meeting, Ps were instructed to record each hot flash and its antecedents on specially prepared forms. Baseline and training sessions were 1-hr long. The baseline period was designed to provide a measure of the participants’ flashes prior to training under placebo-like conditions. At each baseline meeting, the therapist collected Ps’ self-report data, emphasized the importance of data collection, and discussed their hot flashes in a neutral manner. The training period took place over 12 weeks, during which 10 sessions were held. At the first session, the therapist administered relaxation instructions (Delprato and DeKraker, 1976) and gave P a tape recording for home practice; relaxation training continued in session 2. For sessions 3 and 4, the therapist used each P’s hot flash records to construct individualized hierarchies of life situations in which Ps reported flashes. Each P was given her hierarchy and instructed first to imagine the lowest situation (minimally problematic). She was instructed to use relaxation to counteract the hot flash or tension as soon as either was detected in response to imagining the situation. Once P quickly attenuated flashing and/or tension with the lowest hierarchical situation, she began the same process with the next higher situation and progressed up the hierarchy. The hierarchy was taken home for practice. Thought stopping and semantic counterconditioning (Holmes, Delprato and Aleh, 1979) were introduced in session 5. Ps were taught to identify self-thoughts that were compatible with flashes and tension, to stop them, and to replace them with self-statements that were relaxing and non-stressing. The use of cool thoughts and images (Hadfield, 1920) as a coping skill for hot flashes and marital contingency contracting (Weiss, Hops and Patterson, 1973) for reducing marital stress were presented in session 6. Alteration of P’s daily schedule to reduce stress during the times of the day when the flashes were most likely was worked on in session 7. Ps were given three trials of temperature biofeedback training (Taub, 1977) in session 8. A trial consisted of 5 min of rest (baseline) followed by 15 min of training. A Yellow Springs thermistor was taped l-l .5 cm proximal to the tip of the left index finger and a speaker provided variable-pitched tonal feedback at a rate of 52 Hz per 0.1 “C change in temperature. During baseline and training, temperature was recorded the first 30 set of every minute interval by a Coulburn Instrument Multichannel Printout Counter (NP7).
and DENNIS
J. DELPRATO
During session 9, Ps were attached to the skin temperature recording equipment. Following a 5 min baseline they were asked to demonstrate control over their skin temperature by lowering it as much as they could; feedback was not provided until the 15-min trial was completed. Temperature data were collected in the same fashion as the biofeedback data in session 8. Ps filled out questionnaires pertaining to the program and were interviewed regarding the total program during the tenth and final session. Arrangements were made for seven days of follow-up recording at I-, 3- and 6-months after termination of training.
RESULTS
AND DISCUSSION
The mean number of flashes per day over successive weeks of baseline and training is presented in Fig. 1. Diminutions in the frequency of flashes during baseline would reflect placebo-like reactions, and such effects were displayed by Ps 2 and 4. However, these reactions were not durable, as is especially indicated in the case of P 2.
Base line
Trarning
.
2
4
6
8
Weeks
Months
Fig. 1. Mean number of flashes per day during weeks of baseline, training and follow-up. P supply follow-up data at 3.months.
successive
1 failed to
MULTIPLE
COMPONENT
SELF-CONTROL
PROGRAM
All Ps showed a gradual reduction in the number of flashes over the training phase. By the end of the training period, all Ps experienced substantial reductions in flash frequency. The percentage reductions in number of flashes between the last 2 weeks of baseline and the last 2 weeks of training were 75, 41, 90 and 76 for Ps l-4, respectively. Comparable percentage reductions were obtained when the frequencies over the last 2 weeks of training were compared with those of the first 2 training weeks: 74, 64, 88 and 80 for Ps l-4, respectively. Treatment gains were maintained at follow-up for all Ps. The percentage reductions in number of flashes between the last 2 weeks of baseline and the 6-months follow-up period were 63, 91 and 52 for Ps 2-4, respectively. Even P 1, who showed some regression from the final weeks of training to 6-months post-training, exhibited a percentage reduction of 48% from the last 2 weeks of baseline. All Ps responded to biofeedback training conducted during session 8 with a decrease in skin temperature. In three 15 min training sessions the mean reduction of skin temperature between baseline and the last one minute training interval was 2.4”, 3.5”, 1.7” and 1.5”C for Ps l-4, respectively. During session 9, Ps demonstrated temperature control by reducing temperature without feedback at the therapist’s instruction to lower their skin temperature. The reduction in Ps’ skin temperature between baseline and the last interval of the instruction to lower condition (15 min duration) was 2.6’, 1.9”, 1.5” and 3.5”C for Ps l-4, respectively. The basic data in this study were the selfreports of the participants. One could argue that the focus of this study was the manipulation of verbal reports of the participants. The temperature data presented demonstrates that Ps were able to change their temperature. This seems to support the notion that both verbal report and body temperature were affected by the treatment. Further research in this area could use a portable temperature recording device (Molner, 1981) and a self-report device
FOR MENOPAUSAL
HOT FLASHES
139
to examine the relationship between these two behavioral components of the hot flash. The present data lend support to the notion that behavioral factors participate in menopausal hot flashes. These encouraging results justify further exploration of the use of behavioral methods in the treatment of this condition. Furthermore, difficulties in identifying correlations between hormonal variables and menopausal flashing (Aksel et al., 1975; Hutton et al., 1978) may be due, in part, to unidentified behavioral variables that obscure such relationships. There has been the suggestion that the frequency of hot flashes increases as a result of increases in air temperature. Molnar (1981) noted a correlation between air temperature and the number of hot flashes experienced by his wife. Molnar admitted that his wife, “disliked hot weather and always delighted in a gentle flow of cool dry air”. In Molnar’s study it is difficult to determine whether the air temperature or the participant’s dislike of hot weather is associated with the noted increase in hot flashes. Most of the Ps in the present study noted hot air temperature in offices, classrooms, and other situations as antecedent to hot flashes; however, as training progressed the air temperature in these situations remained about the same and the mean number of hot flashes decreased. The positive therapeutic results associated with the present training program suggest it may be worthwhile to investigate treatment regimens for hot flashes that combine behavioral training with medicative procedures. The addition of behavioral techniques to existing therapies might permit lower doses of medication and/or shorter periods of medication to be therapeutically effective. Of course, behavioral methods may be of value in cases where medication is contraindicated. It is possible that the present treatment program would have been effective if only one type of training, e.g. relaxation, were given. Future research, involving more participants and appropriate controls, is necessary to
140
DALLAS
W. STEVENSON
determine if any of the several components we used are superfluous. Indeed because of the limitations of the present design, further work with more rigorous experimental design is necessary to more conclusively demonstrate the contribution of the treatment package as a whole to the observed reductions in the hot flash reports. In conclusion, it appears that behavioral therapy emphasizing relaxation, temperature control techniques, and stress management offers promise in the treatment of menopausal hot flashes.
REFERENCES Aksel S., Schomberg D. W., Tyrey L. and Hammond C. B. (1976) Vasomotor symptoms, serum estrogen, and gonadotropin levels in surgical menopause. Am. J. Obstet. Gynec. 126, 165-169. Clayden J. R., Bell J. W. and Pollard, P. (1974) Menopausal flushing: Double-blind trial of a non-hormonal medication. Br. Med. J. 1, 409412. Coope J., Thomson J. M. and Poller L. (1975) Effects of “natural oestrogen” replacement therapy on menopausal symptoms and blood clotting. Br. Med. J. 4, 139-143. Delprato D. J. and DeKraker T. (1976) Metronomeconditioned hypnotic-relaxation in the treatment of test anxiety. Behav. Ther. 7, 379-381. Hadfield J. A. (1920) The influence of suggestion on body temperature. Lancer 2, 68-69. Hawkinson L. F. (1938) The menopausal syndrome: One thousand consecutive patients treated with estrogen. J. Am. Med. Ass. 111,390-393.
and DENNIS
J. DELPRATO
Holmes P. A., Delprato D. J. and Aleh E. (1979) Multiple component self-control treatment program for air travel discomfort. J. Behav. Ther. & Exp. Psychiat. 10.85-86. Hutton J. D., Jacobs H. S., Murray M. A. F. and James V. H. T. (1978) Relation between plasma oestrone and oestradiol and climacteric symptoms. Lancer 1, 678-681. Lightman S. L. and Jacobs H. S. (1979) Naloxone: Nonsteroidal treatment for post-menopausal flushing? Lancer 2, 107 1. Molnar G. W. (1975) Body temperature during menopausal hot flashes. J. Appl. Physiol. X3,499-503. Molnar G. W. (1981) Menopausal hot flashes: Their cycles and relation to air temperature. Obstet. Gynec. 57, 52S-55s. Mulley G. and Mitchell J. R. A. (1976) Menopausal Flushing: Does oestrogen therapy make sense? Lancet 1, 1397-1399. Polit D. F. and LaRocco S. A. (1980) Social and psychological correlates of menopausal symptoms. Psychosom. Med. 42,335-345. Reynolds S. R. M., Kaminester S., Foster F. I. and Scholoss S. (1941) Psychogenic and somatogenic factors in the flushes of the surgical menopause. Am. J. Obstet. Gynec. 41, 1022-1028. Sanes K. I. (1920) Hot flashes of menopause. The vegetative, nervous and endocrine systems as factors of menopause disturbances. Trans. Am. Ass. Obstet. Gynec. 32, 182-210. Taub E. (1977) Self-regulation of human tissue temperature. In Biofeedback: Theory and Research (Ed. by Schwartz G. E. and Beatty J.), Academic Press, New York. Weiss R. L., Hops H. and Patterson G. R. (1973) A framework for conceptualizing marital conflict: A technology for altering it, some data for evaluating it. In Behavior Change: Methodology, Concepts, and Practice (Ed. by Hammerlvnck L. A., Hardy L. C. and Mash E. J.). Research Press, Champaign.