Steady Through the Transition: A Therapist Guide to a Third-Wave Protocol for Menopause and Perimenopause

CBT · CBT · Practice-informed

A six-session protocol for adults who are struggling with the psychological side of perimenopause and menopause. It keeps CBT for hot flushes, night sweats and sleep at its core, in line with a meta-analysis of 14 trials, and adds body-first settling, a compassion-focused session before an ACT values session and a DBT-informed surge plan. Each approach carries a colour-coded evidence rating, and the guide states plainly that there are no menopause-specific trials of ACT, CFT, DBT skills or resonance breathing.

Underlying mechanism: CBT-Anchored Protocol for Menopausal Symptoms with CBT-I Informed Sleep Work, Mindfulness and Breathwork, Compassion-Focused Work, ACT Values Work and DBT-Informed Emotion Regulation

What it helps with

  • Giving clinicians a structure that keeps CBT at the centre and adds settling, compassion and values work without overclaiming.
  • Changing how much hot flushes and night sweats bother the client, which is where the evidence for CBT is clearest.
  • Protecting sleep with a conservative sleep window, stimulus control and practical night-sweat tactics.
  • Softening the inner critic that arrives with ageing, body change and feeling "too much" or "not enough".
  • Reconnecting with values and planning for sudden surges of irritability, tears or panic.

How clinicians use it

  • Check medical review, screen for risk and map one recent flush or night sweat in Session 1.
  • Teach nose-low-slow breathing and the flush plan in Session 2. Resonance breathing is optional and later.
  • Keep the compassion session (4) before the values session (5) by design. The order is clinical judgement and has not been tested.
  • Use Session 6 to write the surge plan, review the 0 to 10 bother, sleep, mood and anxiety scores against baseline and book the boosters.

Clinical Implementation Guide

  1. Confirm medical review, screen for risk and agree a 0 to 10 bother rating at Session 1.
  2. Run the sessions in order and keep the compassion session before the values session.
  3. Review bother, sleep, mood and anxiety scores against baseline at Session 6.

What the worksheet looks like

Therapist Guide: Steady Through the Transition — worked example
SessionFocusWorksheet
1Making sense of the transition and mapping the loop (CBT)W1
2Settling the body and handling a flush (CBT, mindfulness, breathwork)W2
3Protecting sleep and managing night sweats (CBT-I informed)W3
4The kind voice in midlife (CFT, before ACT on purpose)W4
5What matters through the change (ACT)W5
6Surge plan and keeping the gains (DBT-informed, relapse prevention)W6

Clinical cautions

Not a diagnostic or medical tool. Psychological support sits alongside medical care: encourage review by a GP or menopause specialist, especially for heavy or unusual bleeding, new or sudden symptoms or any symptom that worries the client, and never advise on starting, stopping or choosing hormone therapy. Screen for depression, anxiety and suicidal thoughts with your usual risk protocol before and during the work, because mood can worsen in the transition. Avoid pathologising a normal life stage or implying that symptoms are psychological in origin, and use inclusive language. Heat, sweating and breath focus can be activating for clients with trauma or panic, so go slowly, offer choice and let the client keep their eyes open. Breathing is taught to settle the body and the fear response and must not be promised to reduce hot flushes (Huang et al., 2015). Sleep window work needs the checks in the guide: avoid or modify it for bipolar disorder, seizure disorder, safety-critical work and suspected untreated sleep apnoea, and keep time in bed at or above about five and a half hours without specialist guidance. After breast cancer treatment or surgical menopause, coordinate with the oncology or medical team.

References

  1. Ayers, B., Smith, M., Hellier, J., Mann, E., & Hunter, M. S. (2012). Effectiveness of group and self-help cognitive behavior therapy in reducing problematic menopausal hot flushes and night sweats (MENOS 2): A randomized controlled trial. Menopause, 19(7), 749-759. https://doi.org/10.1097/gme.0b013e31823fe835.
  2. Carmody, J. F., Crawford, S., Salmoirago-Blotcher, E., Leung, K., Churchill, L., & Olendzki, N. (2011). Mindfulness training for coping with hot flashes: Results of a randomized trial. Menopause, 18(6), 611-620. https://doi.org/10.1097/gme.0b013e318204a05c.
  3. Gilbert, P. (2014). The origins and nature of compassion focused therapy. British Journal of Clinical Psychology, 53(1), 6-41. https://doi.org/10.1111/bjc.12043.
  4. Green, S. M., Donegan, E., Frey, B. N., Fedorkow, D. M., Key, B. L., Streiner, D. L., & McCabe, R. E. (2019). Cognitive behavior therapy for menopausal symptoms (CBT-Meno): A randomized controlled trial. Menopause, 26(9), 972-980. https://doi.org/10.1097/GME.0000000000001363.
  5. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). Guilford Press.
  6. Houston, E. E., Brown, L., Jones, K. M., Amonoo, H. L., & Bryant, C. (2023). Does self-compassion explain variance in sleep quality in women experiencing hot flushes? Maturitas, 172, 39-45. https://doi.org/10.1016/j.maturitas.2023.04.003.
  7. Huang, A. J., Phillips, S., Schembri, M., Vittinghoff, E., & Grady, D. (2015). Device-guided slow-paced respiration for menopausal hot flushes: A randomized controlled trial. Obstetrics & Gynecology, 125(5), 1130-1138. https://doi.org/10.1097/AOG.0000000000000821.
  8. Hunter, M., & Smith, M. (2014). Managing hot flushes and night sweats: A cognitive behavioural self-help guide to the menopause (2nd ed.). Routledge.
  9. Laborde, S., Allen, M. S., Borges, U., Dosseville, F., Hosang, T. J., Iskra, M., Mosley, E., Salvotti, C., Spolverato, L., Zammit, N., & Javelle, F. (2022). Effects of voluntary slow breathing on heart rate and heart rate variability: A systematic review and a meta-analysis. Neuroscience & Biobehavioral Reviews, 138, 104711. https://doi.org/10.1016/j.neubiorev.2022.104711.
  10. Lehrer, P. M., & Gevirtz, R. (2014). Heart rate variability biofeedback: How and why does it work? Frontiers in Psychology, 5, 756. https://doi.org/10.3389/fpsyg.2014.00756.
  11. Linehan, M. M. (2015). DBT skills training manual (2nd ed.). Guilford Press.
  12. Mann, E., Smith, M. J., Hellier, J., Balabanovic, J. A., Hamed, H., Grunfeld, E. A., & Hunter, M. S. (2012). Cognitive behavioural treatment for women who have menopausal symptoms after breast cancer treatment (MENOS 1): A randomised controlled trial. The Lancet Oncology, 13(3), 309-318. https://doi.org/10.1016/S1470-2045(11)70364-3.
  13. McCurry, S. M., Guthrie, K. A., Morin, C. M., Woods, N. F., Landis, C. A., Ensrud, K. E., Larson, J. C., Joffe, H., Cohen, L. S., Hunt, J. R., Newton, K. M., Otte, J. L., Reed, S. D., Sternfeld, B., Tinker, L. F., & LaCroix, A. Z. (2016). Telephone-based cognitive behavioral therapy for insomnia in perimenopausal and postmenopausal women with vasomotor symptoms: A MsFLASH randomized clinical trial. JAMA Internal Medicine, 176(7), 913-920. https://doi.org/10.1001/jamainternmed.2016.1795.
  14. National Institute for Health and Care Excellence. (2015). Menopause: Identification and management (NICE guideline NG23). Updated 2024. https://www.nice.org.uk/guidance/ng23.
  15. Neff, K. D., & Germer, C. K. (2013). A pilot study and randomized controlled trial of the mindful self-compassion program. Journal of Clinical Psychology, 69(1), 28-44. https://doi.org/10.1002/jclp.21923.
  16. Norton, S., Chilcot, J., & Hunter, M. S. (2014). Cognitive-behavior therapy for menopausal symptoms (hot flushes and night sweats): Moderators and mediators of treatment effects. Menopause, 21(6), 574-578. https://doi.org/10.1097/GME.0000000000000095.
  17. Robinson, K., Hardy, R., Melville, M., Saidel, S., Desai, R., & Spector, A. (2026). The effectiveness of psychosocial interventions on physiological symptoms of menopause: A systematic review and meta-analysis. BMC Women's Health, 26(1). https://doi.org/10.1186/s12905-026-04563-3.
  18. Rukure, H., & Husted, M. (2025). Cognitive behavioural therapy for menopausal symptoms: A systematic review of efficacy in improving quality of life. BMC Women's Health, 26(1), 58. https://doi.org/10.1186/s12905-025-04142-y.
  19. Stefanopoulou, E., & Grunfeld, E. A. (2017). Mind-body interventions for vasomotor symptoms in healthy menopausal women and breast cancer survivors: A systematic review. Journal of Psychosomatic Obstetrics & Gynecology, 38(3), 210-225. https://doi.org/10.1080/0167482X.2016.1235147.
  20. Ye, M., Shou, M., Zhang, J., Hu, B., Liu, C., Bi, C., Lv, T., Luo, F., Zhang, Z., Liang, S., Feng, H., Qian, C., Cao, S., & Liu, Z. (2022). Efficacy of cognitive therapy and behavior therapy for menopausal symptoms: A systematic review and meta-analysis. Psychological Medicine, 52(3), 433-445. https://doi.org/10.1017/S0033291721005407.

Copyright and use in research

© 2026 Dr Richard Pomfret and Third Wave Therapy Tools. May be used in research with the author and site cited. Version 1.0, approved 20 October 2026, revised as the evidence develops.

Suggested citation (APA 7th edition): Pomfret, R. (2026). Steady Through the Transition: A third-wave protocol for menopause and perimenopause (Version 1.0) [Therapist guide and worksheets]. Third Wave Therapy Tools. https://thirdwavetherapytools.com/

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