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Addressing the emotional challenges of perimenopause and menopause with Simona Stokes

Simona Stokes is an experienced counselling psychologist who uses CBT (Cognitive Behavioural Therapy) and EMDR (Eye Movement Desensitisation and Reprocessing) to help people with stress, depression and anxiety. After 20 years working in the NHS and voluntary sector, she then founded her own clinic in Birmingham, and has developed an interest and specialist knowledge in helping women with the emotional and psychological challenges of the peri/menopause. Simona’s personal experience of hormonal changes hit her hard and this led her to develop and successfully implement the psychological tools she had at her disposal to support her own journey and made her realise many women need help to understand the impact their hormones have on their moods, thoughts and emotions.

In discussion with Dr Louise Newson, Simona explains the power of estrogen as our primary fuel and the problems that can arise when estrogen falls. She explains the difference in perimenopausal depression compared to general depression, what CBT is and how it can help women at this time of life that can often be a pinch-point on our emotions. Simona advises how to look after yourself and your emotions and elaborates on why so many women feel a sense of loss of one’s role, of identity, and loss of purpose at this time.

Simona’s advice for women experiencing emotional challenges:

  1. Menopause is unavoidable but suffering is optional. CBT helps us to change the narrative we create about the difficulties we’re facing, and allows us to let go of the struggle against the changes we’re feeling. An attitude of compassion, kindness and curiosity to yourself will help you understand your difficult emotion in a more helpful way than being harsh, self- critical, and just wanting a feeling to go away.
  2. It’s really important to make peace with all your emotions. We’ve been conditioned to think that difficult emotions are undesirable and we must strive to feel happy and grateful. Increase your openness to difficult emotions and this will help you be more resilient and emotionally ‘fit’ to cope with your peri/menopause.
  3. ‘Emotion follows motion’, so engage in physical activity, even if you don’t feel like it, as physical activity is a powerful tool to change how you feel. Use your body to calm down your mind either through breathing and relaxation techniques or getting out there and being active.

Simona’s clinic and website details can be found here.

The ‘Meno D’ rating scale to detect depression that Simona refers to can be found here.

If you would like to access psychological therapies via the NHS explore your options here.

You can find Simona on her social media pages at:

Instagram – @menopausebtclinic

Facebook – Thriving Beyond 40

Episode Transcript

Dr Louise Newson [00:00:09] Hello. I’m Dr Louise Newson and welcome to my podcast. I’m a GP and menopause specialist, and I run the Newson Health Menopause and Wellbeing Centre here in Stratford-Upon-Avon. I’m also the founder of the Menopause Charity and the menopause support app called balance. On the podcast, I will be joined each week by an exciting guest to help provide evidence-based information and advice about both the perimenopause and the menopause.

Dr Louise Newson [00:00:46] So today on the podcast, I’m going to introduce to you Simona Stokes who I was first introduced to a few years ago actually by one of our clinicians, and we’ve since done quite a lot of work together, and she is very interested in all sorts of things related to the power of our minds, but especially the way our hormones can affect and control any of us when it comes to the way we think. So Simona, thank you so much for coming today.

Simona Stokes [00:01:11] I’m delighted to be here Louise. You know, I’ve been following you for a number of years, and I think you’ve done an amazing job to put menopause on a map and bring it into day to day conversation. So, you know, we owe you a lot for the work you’ve done, so I’m delighted to be here with you today.

Dr Louise Newson [00:01:29] Oh, thank you. Well this is great, as you know, a great team effort, and this is only the beginning of so much that needs to be done. So before we start talking too much about the menopause, are you able to just explain a bit about your background and what you do and how you got into what you do as well, which should be really interesting?

Simona Stokes [00:01:45] Yes, sure. So as you know, Louise, I’m a counselling psychologist. I specialise in cognitive behavioural therapy and the EMDR, and I’ve got over 20 years experience in a clinical field. Now I have worked clinically for all these years in spite of holding, you know, senior positions within NHS management positions. But I love so much the clinical work and that kind of one-on-one contact. I just couldn’t get away from it. So when I go to the point of deciding that I want to do something different after being by then about 18 years in voluntary sector NHS, I decided to move in a private sector. I have a small, independent psychology practise in Birmingham. I founded the Enable Wellness Consultancy and two years ago I founded the Menopause CBT clinic, which is very close to my heart. Now in terms of why did I get into this and how I develop an interest in menopause? Well, I can say that I’ve got first hand experience of it once through my clinical work, but I have to put my hand on heart and say that, you know, I’ve got a personal experience of it as well.

Simona Stokes [00:03:01] So when the change descended upon me, it hit me really hard. And like many other women, even professionals, I didn’t know what hit me. And it’s been quite a difficult journey to start with. And as you know, the menopausal symptoms are insidious. They come on a drip, drip, drip, and I just didn’t quite understand to start with what’s happening to myself when eventually the penny dropped. I realised that something needs to happen, and I’ve got tools in my psychology tool bag to help me with emotional difficulties. And in that way, I started putting together a little bit of a package of different tools, different kinds of interventions that could help me get back on wheels, as I call it. So now, in short, that’s the story of how I got into the menopause work. And the more that I became aware about my journey, I started being acutely aware of how other women were presenting with these symptoms and not understanding like I did and what was happening to them. And, you know, just helping them along the way and, you know, helping them use the techniques that I found very beneficial and getting very positive results.

Dr Louise Newson [00:04:21]  I mean, it’s very interesting, isn’t it? So when you ask or when we ask people what the menopause means or what symptoms occur or what the commonest symptoms occur, a lot of people will say flushes, sweats, but a lot of people don’t understand about the power of hormones on our brains. And as you know, we see a lot of women and speak to a lot of women who have been misdiagnosed actually with depression, anxiety, even bipolar, all sorts of conditions which can also occur as well as the menopause, of course.

Simona Stokes [00:04:53] Yes.

Dr Louise Newson [00:04:54] But the power of our hormones, especially oestrogen and testosterone in our brains, is really important, isn’t it?

Simona Stokes [00:05:01] Well, definitely. Hormones play such a big role in our mental health as well. We associate usually oestrogen with our sexual organs, and the truth is that oestrogen it’s a master hormone. And, you know, it coordinates not only our sexual kind of characteristics, but it also contributes to how our brain works and how our body works. And every single cell in a body has got oestrogen receptors. And sometimes when I work with the women I see, I tell them in my opinion that oestrogen is like the primary fuel for a woman’s body. So I think that obviously when that fuel it’s running low, you know, we start struggling, and like you said, more often than not, people think about menopause, hot flushes, night sweats, maybe some joint pains. But beyond that, we don’t think that actually dropping levels of oestrogen and progesterone and testosterone as well can lead to quite a range of emotional difficulties like sleep difficulties, which is one of the first domino piece that falls down, that brings down then our mood which brings anxiety with it, and then the brain fog and all kinds of other difficult things. So, you know, I think we need to support women with the mental health side of menopause because menopause is not limited just to the physical symptoms, as you know.

Dr Louise Newson [00:06:37] Yes. So true. And some of it’s very difficult to diagnose, of course, as people listening. Most of them, hopefully by now, will know that there isn’t a test for the perimenopause or menopause. You can’t do a blood test or a urine test or a saliva test. There’s some questions that we usually ask people, but it can be quite difficult to diagnose and so it’s very easy when I see people that come to the clinic because they’ve made the diagnosis themselves. But there’s a lot of people who don’t know what’s going on and then they access other teams. And I know we’ve had this conversation before about mental health teams. And we all know, especially with COVID, that mental health teams are incredibly busy.

Simona Stokes [00:07:16] Yes.

Dr Louise Newson [00:07:17] And under-resourced, sadly. And there’s not enough healthcare practitioners in mental health currently in the UK, for sure. But certainly a lot of women I speak to have been encountered and they’ve had help often for mental health teams. But none of these teams, as far as I can see, have had really robust training in the menopause. And is that the same for you? Did you get any training in the menopause?

Simona Stokes [00:07:42] Well, as I said, it’s lived experience that I had initially and when I realised what’s happening, I started studying more. But you know, I heard from you many times speaking on your podcasts about the limited training doctors have in menopause. Now I have to say hand on heart that, you know, no training that I have attended over the 20 odd years in my career has mentioned menopause and the links of menopause with mental health. So, you know, I had to do a lot of research and, you know, really educate myself about all of this. And I can say that actually a lot of your podcasts have been a great educational source for me, but also there are, you know, some books, some research that already is emerging in this field of menopause and mental health. You might remember we spoke in the past about Professor Kulkarni from Monash Alfred Psychiatry Research Centre in Melbourne, Australia, and she has done studies that will show that the perimenopausal depression is a unique type of depression, and although it shares some similarities with common depression, it has got some differentiating characteristics. And that’s milder mood presentation, unhelpful thought processes related to the perception of self irritability and anger rather than feelings of sadness displayed in major depressive disorder. So I can say that, you know, trying to educate myself, I search wide and far to come across the latest research in this field, and in this country I have to say that Dr Myra Hunter has done some work on using CBT for helping women with hot flushes, and she has written a few books on this as well. So, you know, that gave me a little bit more scope to think about how I can use the CBT, which stands for, by the way, for cognitive behavioural therapy. So, you know, I started gaining a little bit more confidence that actually CBT can be a great tool to help with menopausal emotional difficulties and using that method in my clinical work, I had great results.

Dr Louise Newson [00:10:00] I mean, there’s lots to talk about there. But I mean, I think initially what strikes me is that we’re very similar in the respect that I now really regret what I missed in so many of my patients that presented over the last 25 years as being a doctor because I hadn’t thought about their hormones. And for me, they were more physical symptoms. So a lot of people who had joint pains or palpitations, urinary symptoms, dry skin, hair loss, dry eyes, tinnitis, you know, the list goes on and on and on. And those people, I didn’t actually think about their hormones, and I’m very embarrassed. And if any of those people are listening, I really want to apologise. But you must feel the same, Simona, for those people that you had helped. And obviously every clinician wants do the best, but you only work the best with the knowledge that you have and the training that you have, and so thinking back, you know, we’ve both missed people, but actually now we realise the importance of not just physical but psychological symptoms. I think there’s a real urgency, and I hope you agree for all mental health workers to have some basic awareness training about the potential impact of the perimenopause and menopause.

Simona Stokes [00:11:10] I completely agree with you, Louise, on this. And yes, looking back at how I worked, even like six or seven years ago clinically. If I would have come across a woman going through the perimenopause and presenting with depression and anxiety, I wouldn’t have questioned about menopause whatsoever. No one in my training has taught me to ask that question and therefore, I wouldn’t have been able to make a link in between, you know, the hormonal changes and how this individual in front of me would’ve felt. And you know, now since I am much more aware of it and I have so much more knowledge about mental health and menopause, I know that just treating depression in menopause in the same way that I was helping women through depression because of general life issues, for instance, but it’s very different. And you know, nowadays I used in my practise the MENO-D, which is a perimenopausal depression scale, which is a clinically validated depression scale developed by Professor Kulkarni and her team. And I find that it’s much more easier to speak on this perimenopausal depression, and therefore I know with a little bit more certainty what I’m dealing with there. And this perimenopausal depression scale can be used for those women that maybe haven’t yet clicked on to the idea that they’re going through the perimenopause. But they are saying that there are some changes there. And when a woman over the age of 40 comes to see me, I give her the MENO-D perimenopausal depression scale to fill in rather than the PHQ9. And that’s much more beneficial to me, and it gives me some more information. And also, I use a menopausal screening tool that again orients me a little bit into what kind of symptoms that women can present . And therefore, when you know, the scores indicate that the individual would be already in a range of perimenopausal or menopausal already, then I know that I can employ the CBT model that I have developed specifically for menopause to help women deal with their emotional difficulties.

Dr Louise Newson [00:13:27] Which is so interesting. And I think with this, it’s very important to say that what you’re doing is not as an alternative to HRT, is it? So for a lot of women, I’m sure you agree, their psychological symptoms often will improve with the right dose and type of HRT, but then also improve even further with the tools that you’re enabling them to learn from and the CBT that you give. So can you just explain just for a few minutes about what cognitive behavioural therapy is because it’s something that’s used a lot and a lot of people think they know what it is, and then when you hear a proper explanation, they might think differently. So do you mind just clarifying?

Simona Stokes [00:14:03] Yeah, sure. The main concept behind CBT, Cognitive Behavioural Therapy, is that our thoughts, feelings and physical sensations are interlinked. And when we fall into a pattern of unhelpful thinking styles, this can lead to difficult feelings and unhelpful behaviours, which can trap us into a vicious cycle. Now, the female hormonal fluctuations during the menopausal transition often leads to psychological distress by affecting the way we feel physically, emotionally and the way we think. So the emotional suffering in menopause sits at the confluence of a range of physical symptoms, unhelpful cognitive styles and difficult feelings that can lead to behaviours that lock us into this vicious cycle of emotional turmoil. And CBT has a range of techniques and practical strategies to help responding to difficult thoughts and emotions, and allows us to make a much more deliberate choice in respect to how we want to respond to situations that are affecting us. But also, CBT has a very good track record in helping with a range of difficulties like sleep difficulties, even anxiety, mood swings, low mood, irritability, anger, pain, even and even hot flushes. So CBT has got a very good record in dealing with a range of symptoms that women would experience during the menopause and perimenopause.

Dr Louise Newson [00:15:34] Yeah, and that’s so interesting. And also there is now – which I think is absolutely crucially important – a drive to reduce inappropriate antidepressant prescribing. And the numbers are just phenomenal, aren’t they, of people that are prescribed antidepressants and they’ve increased so much. And you know, we see a lot of women who have inappropriatly been given antidepressants, and there’s no evidence that antidepressants do help improve the low mood associated with the perimenopause or menopause. But there are some women who have clinical depression or anxiety who would get help, potentially from antidepressants. But the new revised NICE guidance, the draft is very clear, that we shouldn’t be using antidepressants first line even in people with clinical depression. And that’s where treatment such as CBT can really come into play, can’t they?

Simona Stokes [00:16:23] Yes, definitely. Like you mentioned now, NICE guidelines talks about the use of antidepressants or actually avoidance of antidepressants as the first line of treatment for depression, perimenopausal, menopausal depression. And you know, we need to do a thorough assessment and especially in this kind of circumstances where the hormonal fluctuations induce this kind of mood changes. It’s advisable, you know, to look at the option of HRT if possible, if there are no other contraindications, but then the psychological help and CBT, which has got such a good track record in helping with depression, anxiety, any other emotional difficulties should be employed to support women over complex emotional challenges related by the physical changes they go through, but also by the circumstances that we can find ourselves during this stage of life.

Dr Louise Newson [00:17:20] Yeah, and it’s very important. It’s not just also focussing on the symptoms. So for many of us, the perimenopause or menopause can occur at quite a challenging time. Whether it’s because our work becomes busier, or our relationships change, or our children maybe have left home or we’ve got young children, depending on the age of us. So whether we have menopausal symptoms or not, it’s often quite a pinched time actually for our emotions. And so I really feel very strongly that the part of care that I’d like to give is very holistic so that we’re looking at our physical health, our mental health, we’re looking at nutrition, we’re looking at exercise, looking at everything because all these things just work together, don’t they? You can’t just have a treatment in isolation. Whether it’s a drug or whether it’s something like CBT and expect it to help you. And I think it’s also some of the psychological treatments that can really help give us tools that sometimes we don’t know we need them until we’re in a crisis situation. And so it’s having this sort of toolbox, if you like, we can go to, isn’t it?

Simona Stokes [00:18:30] Well, definitely. I think you made a few points there and you know, you started talking about identity issues that women can experience during the menopause. I do believe that perimenopause and menopause it’s a psychologically loaded stage of life, and it does coincide with other life changes. And then we’ve come across these physical changes that many women experience during this stage of life, like weight gain, shifting body shape, changes in skin, hair, overall look. And this can affect our body image and sense of who we are. So all of this can lead to a sense of loss, loss of who we know we were in a past, loss of role maybe, loss of purpose and direction in life. And it can lead eventually to an identity crisis. And sometimes I see women coming to therapy exactly for this purpose. They might not have very obvious kinds of physical symptoms related to the menopause, but they would struggle with who they are now at this stage of life, when they might be closer to their 50s and thinking, ‘OK, I can put my reproductive years behind me. But what is it beyond this for me now?’ And it’s very important from a psychological point of view to attend to this issue of identity at this stage of life.

Dr Louise Newson [00:19:57] Absolutely. It’s great having these therapies, but how do people access them? Because certainly a lot of people tell me it’s really difficult to access CBT or any sort of talking therapies or psychological therapy. So what would you recommend people to do?

Simona Stokes [00:20:13] Well obviously within NHS, we have the improving access to psychological therapy initiatives that have been around for probably around 12 years, if not longer. I lost track really for how long it’s been around. And you know, it’s a service that provides evidence-based therapies to the general public, struggling with what we call common mental health difficulties like depression, anxiety, relationship type difficulties, bereavement. So, the NHS would be the best route to access psychological therapies, but as you know, especially on the back of the COVID pandemic, it’s very difficult to access this help and many psychological therapies services have extensive waiting lists. Now, in terms of support specifically for menopause, psychological support for menopause, regrettably, I’m not quite sure how many services have people that are specialised or they really understand the context of menopausal transition and the impact on mental health and wellbeing. Actually over the past I would say three months, four months, I had quite a few enquiries from NHS trusts wanting me to provide training for professionals to help them scale up in this area of menopause and cognitive behavioural therapy and psychological therapies per se. And you know, I’m looking at putting together some training packages to help professionals scale up in this area.

Dr Louise Newson [00:21:50] Which is so important, isn’t it? Because I think, you know, the psychological impact is often forgotten about and certainly even as a clinician, we’ve been very much taught to focus on disease and treatment. And you know, the power of our mind is huge, isn’t it? And you know, lots of women get very intrusive thoughts, very negative thoughts. And sadly, we know a lot of women really struggle to get the right support when it comes to even receiving HRT. And we did a study not long ago, we found that 19% of women took at least five years to receive treatment. So in that time, their mental health often deteriorates. So even when we improve them by giving them replacement hormones, it can take a long time for these psychological symptoms to improve. And, like you say, things like sleep, if they’ve got bad sleep hygiene, their body takes a long time to recover.

Simona Stokes [00:22:42] Yeah.

Dr Louise Newson [00:22:43] So having some tools is really important. And I know you’ve got resources, haven’t you on your website that people can get some help and because some of it that can be done themselves can’t, they don’t all have to be seen by a specialist?

Simona Stokes [00:22:56] Well, definitely. There are certain things that we can do individually to support ourselves to overcome the emotional difficulties associated with the menopause. I often talk about the importance of regulating our body. You know, menopause it’s a body based type difficulty. It starts in our body because the hormones start playing up. So you know, we can do things to regulate our body. And in this category, we can look at how we can improve our sleep, how can we prioritise self-care to reduce stress? And you know, we can use breathing techniques to calm down our mind and calm down our body. So, you know, there is so much literature out there, you know, that we can access online in terms of how do we improve our sleep? Now we have to recognise that sleep hygiene is not sufficient and many, many kind of magazines, glossy magazines and sites. They give advice on sleep hygiene. But sometimes I talk in my sessions about sleep hygiene is like dental hygiene, you know, if you have something like a serious problem with a tooth that needs dental attention, just dental hygiene is not sufficient. And in the same respect, you know, sleep hygiene sometimes is not sufficient to address the problems with insomnia with some women can develop because of the hormonal changes. But, you know, sometimes we have to start with very basic things like, you know, really being mindful that staying plugged in until 11 o’clock at night in front of a computer or scrolling through Facebook is going to interfere with the melatonin production that’s going to delay the sleep that’s going to interfere with quality of sleep. So, you know, sometimes just going right to the basics and trying to put in place some strategies to make sure that we give our body enough chance to do its best to help us sleep, you know, that can be beneficial. And also in terms of prioritising self-care, you know, I think in this day and age, quite often some of us might wear burnout as a badge of honour, and I think we need to be careful that we need to take care of ourselves. And if we don’t take care of ourselves, we can’t look after others. Quite often I talk about self-care is not selfish, but it’s essential to reduce stress and keep us well. We all can do different things in this category of self-care where we need to look. What are those things that give us a sense of pleasure, that fill us with joy? We need to make time for leisure activities and help us relax finding opportunities to laugh and connect with other colleagues, with other friends, and, you know, it’s very important this social connexion is been so widely research demonstrating its benefits in terms of supporting mental health and wellbeing.

Simona Stokes [00:26:00] And when it comes to control breathing, there are so many studies showing that control breathing can reduce stress, you know, supports us to manage our anxiety symptoms, increase alertness, boost the immune system. And, you know, I always say that’s where the breathing goes. The body follows and then the mind follows. So, you know, through our breath, actually, we can impact on how we feel emotionally. So, you know, that’s a way to hack into our emotional system. In some respect, taking control of our breathing, which is on automatic pilot as we know, we don’t need to think about breathing. But if we choose to take manual control, inverted commas of our breathing, then we can effect, you know, how our body feels and how our mind feels.

Dr Louise Newson [00:26:54] Yes, and that’s something we can all do and certainly one of – there’s so many reasons why I enjoy a regular yoga practice, but often it is to really focus on my breath. And when you really are in control of your breathing, it can be a very powerful sensation and I think you’re absolutely right. You know, I’ve become far more selfish as I’ve got older because I have to look after myself because everything else will fall apart, including me if I don’t. So there’s some really, really pertent messages that I think we can all learn from today in the podcast, Simona and I’m very grateful, and we’ll put some links in the notes associated with the podcast if people can find out more. So before we finish, are you able to give the three tips, really, that you think will really help encourage people, whether they’re suffering a little or not at all, or a lot in the psychological areas of the menopause and perimenopause please?

Simona Stokes [00:27:49] Yeah, sure. One thing that they often say is that menopause, it’s unavoidable. Suffering, it’s optional. We can’t do anything to avoid the menopause, but the suffering that’s attached to that, we can do something about it. So let me explain a little bit what I mean by suffering when we talk about pain. We talk about symptoms which are raw, physical or emotional sensations. On the other side, the suffering is the way we think about these are all sensations, the wrapper we put around, the symptoms, the struggle, the storytelling our mind engages with. And CBT supports us to change our relationship with our sensations we experience during the menopause, helping us transform the narrative around these difficulties to allow us to let go of the struggle against the changes that we are going through. Words are very powerful, so I think that’s very important to choose them carefully and deliberately. And an attitude of self-compassion and kindness and curiosity will help us understand and respond to difficult emotions in a much better way than actually, you know, being harsh and critical and just wanting their symptoms to go away.

Simona Stokes [00:29:10] The second tip I would like to give is that it’s really important for all of us to make peace with our emotions, all emotions. Quite often, I think we’ve been maybe primed to believe that any difficult emotions are undesirable and that we should run away from them. And we should strive always to be happy and joyful and grateful and not really allow difficult emotions to show up in our life. So I think it’s quite important to increase our openness to difficult emotions because this is a trademark of emotional resilience, emotional fierceness. The more that we can tolerate, the difficult emotions, understand them pick up the message from there, the wisdom we can do something about what’s going on rather than trying to bottle them up or trying to forget about them.

Simona Stokes [00:30:10] And last but not least, I use this motto in my sessions with many, many clients that go something like emotion follows motion. By that, I mean that it’s quite important to move our body, engage in positive activities because this is a very powerful tool to change how we feel. Quite often I hear people saying I can do X, Y and Z when I feel better. And I think it’s very important to realise we have to do something and by doing something that’s positive, engaging, moving our body, we will feel better, we can change the way we feel through the things that we do. It’s very hard to fight our mind with a mind. So trying to rationalise the situation when we feel overwhelmed. It’s very difficult, if not impossible. For that reason, it’s very useful to think that we can use our physiology. We can use our body to calm down our mind. So for that reason, I was talking a bit earlier about how we can use our breathing, how we can use movement exercise to calm down our mind. And when the emotional brain is calmer, we can think how to overcome the challenges that came our way.

Dr Louise Newson [00:31:31] Perfect. Lots to think about and really hope that everyone listening can take something from us and really move forward with their mood as well as their life in general. So thanks so much for Simona for giving up some time today and sharing your experience with us.

Dr Louise Newson [00:31:47] Thank you so much, Louise. It’s been a pleasure to be here with you today.

Dr Louise Newson [00:31:53] For more information about the perimenopause and menopause, please visit my website or you can download the free balance app, which is available to download from the App Store or from Google Play.


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