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Assessment of Cognitive Behaviour Therapy utility on emotional and social well beingness among women with surgical menopause

Open AccessPublished:March 25, 2022DOI:https://doi.org/10.1016/j.cegh.2022.101034

      Highlights

      • There are many psychological consequences in women with surgical menopause which can influence their routine activities due to lack of hormones.
      • The psychological profile can be improved by various treatments. Among this Cognitive behavioral therapy is effective to reduce anxiety and depression scores.
      • It can be implemented in women who cannot afford the standard Hormonal replacement therapy.
      • This article describes the impact of Cognitive behavioral therapy on psychological profile improvement.

      Abstract

      Background

      Surgical menopause is the emergency procedure to be carried out in a woman when it is essential due to reproductive pathology. The post-surgical consequences should be monitored and controlled effectively with various intervention protocols. Cognitive-behavioral therapy is one of the commendable protocols to improve the emotional and social profile in women with surgical menopause.

      Objective

      To find the effectiveness of Cognitive Behavioural Therapy on emotional and social wellbeing among women with surgical menopause.

      Material & methods

      It is a randomized controlled trial carried out in 230 women who have undergone surgical menopause. The participants were randomly allocated into the intervention and control groups. After obtaining demographics, CBT intervention was introduced - Cognitive Behaviour Therapy program-, which lasted seven months and included all six sessions. The pre and post-test questionnaires were obtained using the Emotional well-being scale and social concern scale respectively from both groups.

      Results

      The scores were significantly improved after intervention, in the experiment group, in pretest, the mean score was 9.45 and the post-test mean score was 14.18, the mean difference is 4.73 whereas, in the control group, the mean score of 9.06 and the post-test mean score was 9.41, the mean difference is 0.35 for social wellness. Posttest emotional wellness level was increased to 23.65%. Whereas in the control group, the posttest increased to 2.25%.

      Conclusion

      The CBT is an effective therapeutic intervention to improve social and emotional wellbeing among women with surgical menopause.

      Keywords

      1. Background

      Menopause is the natural consequence in a female associated with physiological changes that occur in bodily systems that significantly influence the eminence of women's life. Surgical menopause is an invasive emergency procedure in which the female gonads are removed (Oophorectomy).
      • Meeta L.D.
      • Agarwal N.
      • Vaze N.
      • Shah R.
      • Malik S.
      Clinical practice guidelines on menopause: an executive summary and recommendations.
      The Australian Menopause Society (AMS) suggested the bilateral oophorectomy before attaining natural menopause-like ovarian cysts, benign ovarian tumors, and ovarian torsions.

      Prince R, Smith M, Price RI, Dick I. Symptomatic effects of continuous estrogen and progesterone studies in a double-blind placebo-controlled trial. In Symptomatic Effects of Continuous Estrogen and Progesterone Studies in a Double-Blind Placebo-Controlled Trial 1992 (pp. 49-49). Australian Menopause Society.

      ,
      • Baber R.J.
      • Wright J.
      A brief history of the international menopause society.
      The adversative effects of prophylactic oophorectomy are hormone deficiency-related symptoms, increased risk of attaining certain diseases, and amplified morbidity and mortality.
      • Cooper G.S.
      • Sandler D.P.
      Age at natural menopause and mortality.
      ,
      • Rodriguez M.
      • Shoupe D.
      Surgical menopause.
      There is a large scale of post-menopausal consequences which would transform the women's lifestyle. These include physical, emotional, and systemic changes that compromise the homeostatic mechanisms in day-to-day life activities.
      • Georgakis M.K.
      • Beskou-Kontou T.
      • Theodoridis I.
      • Skalkidou A.
      • Petridou E.T.
      Surgical menopause in association with cognitive function and risk of dementia: a systematic review and meta-analysis.
      Unfortunately, emotional alterations accompanying the longstanding lack of ovarian hormones may destabilize women with unstable psychiatric axes and emotional disturbances that significantly impacted their quality of life.
      • Shifren J.L.
      • Avis N.E.
      Surgical menopause: effects on psychological well-being and sexuality.
      ,
      • Mendoza N.
      • Suárez A.M.
      • Alamo F.
      • Bartual E.
      • Vergara F.
      • Herruzo A.
      Lipid effects, effectiveness and acceptability of tibolone versus transdermic 17β-estradiol for hormonal replacement therapy in women with surgical menopause.
      Depression seems to be increased due to the decline in estrogen levels and its impact on other neurotransmitters. 2.52 lakhs of women with untreated hot flashes were associated with non-symptomatic women.
      • Unni J.
      Third consensus meeting of Indian Menopause Society (2008): a summary.
      The women with hot flashes displayed work-loss over one year period and 1.1 million accessory medical advice, and a health insurance huge cost.
      • Whiteley J.
      • DiBonaventura M.D.
      • Wagner J.S.
      • Alvir J.
      • Shah S.
      The impact of menopausal symptoms on quality of life, productivity, and economic outcomes.
      Hormone replacement therapy (HRT) has been administered and considered a gold standard regimen to reduce the post-menopausal consequences.
      • Lip G.Y.
      • Blann A.D.
      • Jones A.F.
      • Beevers D.G.
      Effects of hormone-replacement therapy on hemostatic factors, lipid factors, and endothelial function in women undergoing surgical menopause: implications for prevention of atherosclerosis.
      The supplementation of Estrogen and Progesterone would be beneficial, but progressively Estrogen binding protein (EBP) increases during the initial days.
      • Jang J.H.
      • Arora N.
      • Kwon J.S.
      • Hanley G.E.
      Hormone therapy use after premature surgical menopause based on prescription records: a population-based study.
      This would decrease the bioavailability of active hormones and immensely affects the physiological actions of Estrogen.
      • Al Kadri H.
      • Hassan S.
      • Al‐Fozan H.M.
      • Hajeer A.
      Hormone therapy for endometriosis and surgical menopause.
      Various intervention protocols have been proposed to control the post-surgical menopause consequences other than HRT. Cognitive Behavioural Therapy (CBT) is one of the effective non-invasive intervention protocols to improve the quality and to reduce the symptoms of surgical menopause especially the psychological concerns of the women.

      Rothbaum BO, Meadows EA, Resick P, Foy DW. Cognitive-behavioral Therapy.

      There are lacunae in the literature using CBT for effective control of post-menopausal symptoms. Therefore, the current study was intended to find out the effectiveness of CBT to ameliorate emotional and social wellbeing among women with surgical menopause .

      2. Materials & methods

      2.1 Study population

      The researchers conducted a randomized controlled trial with 230 women aged 25 to 55 who had a surgical hysterectomy. The host institute's Institutional Ethics Committee examined and approved the complete procedure. The participants underwent complete general medical examinations and had their medical histories taken. Participants were ruled out if they had a well-known psychiatric problem, a history of hysterectomy with malignancy, or were on HRT. Subjects who met the inclusion criteria were explained the study's nature and purpose, and informed consent was obtained under the Helsinki Declaration of 1975 and its amendments. Demographic variables of the study are age, level of education, occupation, residence, marital status, duration of the marriage, level of husband's education, parity, any co-morbid illness, past menstrual problem, family history of surgical menopause, and reason for surgical menopause.

      2.2 Allocation of participants

      Simple randomization was used to assign participants to the intervention and control groups in a 1:1 ratio. The study included 230 women who met the requirements out of 320 who were screened. After that, participants were randomly assigned to one of two groups: the CBT intervention group (n = 115) or the control group (n = 115).

      2.3 Intervention protocol

      CBT (Cognitive-behavioral therapy) is a psychological process that aims to condense distress and dysfunction by exploring the user's integration of thoughts, feelings, and behavior with more positive and acceptable outcomes, which leads to the alleviation of psychiatric problems in a variety of conditions (Trower et al., 1988; Vonk and Early, 2009).
      • Chadwick P.
      • Trower P.
      • Dagnan D.
      Measuring negative person evaluations: the evaluative beliefs scale.
      ,
      • Vonk M.E.
      • Early T.J.
      Cognitive-behavioral therapy.
      The total data collection period was for nine months. As a part of the preliminary assessment, a pretest was done for both the experimental and control group. During the intervention, Psychoeducation, Formulation, Behaviour-Emotional-Cognitive Connection, Behaviour Therapy, Cognitive restructuring, and Relapse prevention were all part of the Cognitive Behaviour Therapy program, which lasted seven months and included all six sessions. Each session was taught to them daily for six days, and it was mixed with the group and individual sessions depending on the nature and demand of the technique. Each group of participants was given two months to practice the sessions. During this time, the participants were directly and telephonically monitored. In addition to CBT sessions for each group, a posttest was administered to those who had completed two months of practice. In the ninth month, the control group underwent a post-test using the same tool.

      2.4 Outcome measurement

      All the demographic variables were obtained from each participant before the CBT intervention protocol. The emotional wellness and social changes scores were collected using the Emotional wellness scale, Post-surgical social concern scale, respectively, before and after the intervention. These scales include the Likert summated scale with multiple options. Based on the scores, the participants can be categorized into various groups. The trained faculty did the data collection from the psychiatry department of the host institute.

      2.4.1 Emotional wellness scale

      This scale is a self-report measure of the emotional dimension of wellness. The total number of items in the questionnaire is 10. A three-point Likert scale is used. The scoring for 10 questions is 0,1, 2 respectively. The highest possible total score for the whole test would be twenty. This would mean the participant circled number two on all ten questions. Since the lowest possible score for each question is zero, the lowest possible score for the test would be zero. The total score reflects the level of emotional wellness dimensions among surgical menopause women. The scores were categorized as 15 to 20 Points - Excellent strength in this dimension, to 14 Points - There is room for improvement and 0 to 8 Points - This dimension needs a lot of work.
      • Thimmapuram J.
      • Pargament R.
      • Sibliss K.
      • Grim R.
      • Risques R.
      • Toorens E.
      Effect of heartfulness meditation on burnout, emotional wellness, and telomere length in health care professionals.

      2.4.2 Post-surgical social concern scale

      It is the scale developed to measure social anxiety-related cognition. Psychometric properties were obtained in all participants to evaluate the social anxiety concerns of the patient.
      • Andresen E.N.
      • Ramirez M.
      • Kim K.H.
      • et al.
      Effects of surgical side and site on mood and behavior outcome in children with pharmacoresistant epilepsy.
      The scores help to categorize as 1–7: Considered Normal, 8–15: Mild problems, 16–23: Moderate problems, and 24–30: Severe problems.

      3. Statistical analysis

      The data sets were expressed in a descriptive and inferential manner. All the data sets were analyzed using SPSS (Ver. 16). The normality of data was tested using the Smirnov Kolmogorov test. As the data sets were skewed, non-parametric tests were applied to determine the differences between pre-post-intervention.

      4. Results

      Table 1 shows the demographic information of the participants. The individuals in both groups were between the ages range between 25 and 55. In the experimental group, 53.91% of women experiencing surgical menopause were between the ages of 37 and 42. Around 62.6% of postmenopausal women in the control group were between the ages of 37 and 42. In the experimental group, 61.74% of women who had surgical menopause only had a high school education. In the control group, almost 61.74% of postmenopausal women had only an elementary education. In the experimental group, 65.21% of women with surgical menopause were housewives, whereas, in the control group, 72.17% of postmenopausal women were housewives. In the experimental group, 90.43% of women with surgical menopause were married, whereas, in the control group, 95.65% of postmenopausal women were married. In the experimental and control groups, respectively, 79.13% and 86.96% of women undergoing surgical menopause had 1-3 children. Heavy monthly bleeding was a rationale for surgical menopause in 47.83% of women with surgical menopause and 60.87% of women with surgical menopause in the control group.
      Table:1Demographic variables among women in both groups.
      Experimental groupControl group
      No. of. women with surgical menopause (115)Percentage (%)No. of. women with surgical menopause (115)Percentage (%)
      Age
      25 -3065.2232.61
      31 -363026.092723.48
      37 -426253.917262.60
      43 -481210.43108.70
      49 -5554.3532.61
      Level of Education
      No education1210.4397.83
      Primary education7161.747161.74
      Secondary education2118.262420.86
      Graduate65.2286.96
      Postgraduate54.3532.61
      Occupational status
      Coolie2521.742521.74
      Housewife7565.218372.17
      Government employee54.3532.61
      Private employee108.7043.48
      Marital status
      Married10490.4311095.65
      Single00.0000.00
      Divorced21.7421.74
      Widow97.8332.61
      Parity
      Nullipara76.0932.61
      1-3 children9179.1310086.96
      More than 3 children1714.781210.43
      Reason for surgical menopause
      Heavy bleeding5547.837060.87
      Fibroid2925.222320.00
      Family history of ovarian cancer86.9654.35
      Pelvic inflammatory disease32.6132.61
      Endometriosis43.4876.09
      Uterine prolapse1613.9176.09
      The difference in the experimental and control groups' emotional wellbeing scores at the beginning of the study. In the experimental group, 44.35% of them have a score of Needs a lot of work, 55.65% have a score of Room for Improvement, and none have a score of Excellent. In the control group, 49.57% had a score of Needs a lot of work, 50.43% had a score of Room for Improvement, and none had an Excellent score. "There is no substantial difference between the experimental and control groups,". As a result, the two groups are discovered to be homogeneous as shown in fig. 1. The difference in emotional wellbeing score between the experimental and control groups at the posttest. The experimental group contained no participants who scored Needs a lot of work, 41.74% who scored Room for Improvement, and 58.26% who scored Excellently. In the control group, 43.48% had a Needs a lot of work level of the score, 56.52% had Room for Improvement level of the score, and none had an Excellent level of score. "There is a considerable difference between the experimental and control groups," according to statistics as shown in table no:2(Fig. 5) .
      Fig. 1
      Fig. 1Distribution of pretest level of emotional changes among women with surgical menopause.
      Table 2Distribution of pretest and posttest level of social changes among women with surgical menopause (n = 230).
      Level of post-surgical social changesExperimentalControlChi-square test
      PretestPosttestPretestPosttest
      n%n%n%n%Pretest
      Normal00.006859.1300.0000.00χ2 = 1.82

      P = 0.40

      DF = 3(NS)
      Mild affect4337.394740.875245.225850.43
      Moderate affect7060.8700.006052.175749.57Posttest
      Severe affect21.7400.0032.6100.00χ2 = 126.15

      P = 0.001***

      DF = 3(S***)
      Total115100115100115100115100
      NS = not significant DF = Degrees of Freedom P > 0.05 not significant, ***p ≤ 0.001very high significant.
      The social concern scale of both groups and pretest shows "There is no substantial difference between the experimental and control groups,". As a result, the two groups are discovered to be homogeneous as shown in table no:3. The difference in the experimental and control groups' post-test levels of the post-surgery social changes scale score. In the experimental group, 59.13% of the participants have a normal level of the score, 40.87% have a mildly affected level of the score, none have a substantially affected level of the score, and none have a severely affected level of score. Hence, the two groups are found to be homogenous as shown in fig. 2 The difference in the experimental and control groups' post-test levels of the post-surgery social changes scale score. In the experimental group, 59.13% of the participants have a normal level of the score, 40.87% have a mildly affected level of the score, none have a substantially affected level of the score, and none have a severely affected level of score (Fig. 3). None of the participants in the control group have a normal level of the score, with 50.43% having a mildly affected level of the score, 49.57% having a moderately affected level of the score, and none having a severely affected level of score (Fig. 4). "There is a considerable difference between the experimental and control groups," as shown in Table 4, Table 5(Fig. 6) .
      Table 3Distribution of pretest and posttest level of emotional changes among women with surgical menopause (n = 230).
      Level of emotional wellnessExperimentalControlChi-square test
      PretestPosttestPretestPosttest
      n%n%n%n%Pretest
      Needs a lot of work5144.3500.005749.575043.48χ2 = 0.63
      P = 0.43
      DF = 2(NS)
      Room for improvement6455.654841.745850.436556.52Posttest
      Excellent00.006758.2600.0000.00χ2 = 119.55

      P = 0.001***

      DF = 2 (S***)
      Total115100115100115100115100
      NS = not significant DF = Degrees of Freedom P > 0.05 not significant, ***p ≤ 0.001very high significant.
      Fig. 2
      Fig. 2Distribution of posttest level of emotional changes among women with surgical menopause.
      Fig. 3
      Fig. 3Distribution of pretest level of social changes among women with surgical menopause.
      Fig. 4
      Fig. 4Distribution of posttest level of social changes among women with surgical menopause.
      Fig. 5
      Fig. 5Effectiveness of cognitive behavior therapy on emotional changes among women with surgical menopause.
      Fig. 6
      Fig. 6Effectiveness of cognitive behavior therapy on post-surgical social changes among women with surgical menopause.
      Table 4Effectiveness of cognitive behavior therapy on post-surgical emotional changes among women with surgical menopause (n = 230).
      GroupTestMax scoreMean score%Mean scoreMean emotional Wellness gain score with 95% Confidence intervalPercentage of emotional Wellness gain score with 95% Confidence interval
      ExperimentPretest209.4547.25%4.7323.65% (20.95%–26.35%)
      Posttest2014.1870.90%(4.19–5.27)
      ControlPretest209.0645.30%0.452.25%
      Posttest209.4147.05%(-0.01 – 0.71)(-0.05%−3.55%)
      Table 5Effectiveness of cognitive behavior therapy on post-surgical social changes among women with surgical menopause (n = 230).
      GroupTestMax scoreMean score%Mean scoreMean post-surgical social changes reduction score with 95% Confidence intervalPercentage of post-surgical social changes reduction score with 95% Confidence interval
      ExperimentPretest6032.0353.38%12.3920.65% (17.95%–23.36%)
      Posttest6019.6432.73%(10.77–14.02)
      ControlPretest6031.4252.37%1.111.85%
      Posttest6030.3150.51%(-0.06 – 2.27)(-0.10%−3.78%)

      5. Discussion

      The goal of this study was to see how Cognitive Behavioural Therapy (CBT) impacted the emotional and social wellbeing of women with surgical menopause. After CBT therapy, emotion levels and social well-being levels were found to be significantly improved.
      The pathophysiology that happens as a result of menopausal symptoms can increase the risk of disease in the future.
      • O'Neill S.
      • Eden J.
      The pathophysiology of menopausal symptoms.
      Hot flashes were linked to a higher incidence of insulin resistance and glucose levels, according to the Study of Women's Health Across the Nation (SWAN). Severe heat flashes were "robustly" associated with increased intima media-thickness (IMT), a key indicator for subclinical cardiovascular disease, according to the SWAN scientists. More frequent and severe symptoms were linked to an increased risk of hypertension, cardiovascular disease, and stroke in the Women's Health Initiative Study (WHI). Following the onset of surgical menopause symptoms, 85% of the women received estrogen medication. Among these women, those who began treatment within five years of surgery and continued for more than ten years had the lowest risk of Alzheimer's disease.
      • Monteleone P.
      • Mascagni G.
      • Giannini A.
      • Genazzani A.R.
      • Simoncini T.
      Symptoms of menopause—global prevalence, physiology, and implications.
      Cognitive-behavioral therapy (CBT) is a comprehensive, sophisticated, and emerging treatment approach that has been developed for and applies to a wide range of mental health and physical issues and diseases. CBT has evolved into one of the most well-known forms of psychotherapy since its inception in the 1970s, and it is widely distributed and used all over the world. The American Psychiatric Association, the Australian Psychological Association, the British National Institute for Clinical Excellence, and many others in different areas of the world have all recognized CBT as an evidence-based treatment for a wide range of problems.

      National Collaborating Centre for Mental Health (Great Britain), National Institute for Health, Clinical Excellence (Great Britain), British Psychological Society, Royal College of Psychiatrists. (Common mental health disorders: identification and pathways to care).

      CBT aims to control the thoughts, feelings, and behaviors of the individual which is essential to improve in women with surgical menopause.

      Murray K, Davidson G, Schweitzer R. Psychological Wellbeing of Refugees Resettling in Australia: A Literature Review Prepared for the Australian Psychological Society.

      The CBT intervention has proved that the emotional wellbeing score in the Experiment group, on average, in posttest after having an intervention, emotional wellness level is increased to the mean % of 23.65% % than pretest score. Whereas in the control group, on average, in posttest with routine, women emotional wellness level is increased to the mean % 2.25% than pretest score. This difference shows the effectiveness of Cognitive Behaviour Therapy on emotional wellness, differences, and generalization of reduction between pretest and posttest scores. Similar results were also observed for social well-being in the Experiment group, on average, in the posttest after having an intervention, the level of the social change is reduced to the mean score of 20.65% than the pretest score. Whereas in the control group, on average, in posttest with routine, women with post-surgical social changes are reduced to the mean score of 1.85% than pretest score. This difference shows the effectiveness of Cognitive Behaviour Therapy on post-surgical social changes differences and generalization of reduction between pretest and posttest scores. The CBT has given enough strong evidence as treatment therapy along with HRT could be more beneficial to reduce the postmenopausal consequences.
      • Kumar C.K.
      • Kumar A.S.
      • Madhurima P.
      • Maruthy K.N.
      • Preetham G.J.
      Assessment of psychomotor skills using finger pulse guided biofeedback tool in young medical students: psychomotor skills using heart rate as a biofeedback tool.
      ,
      • Kumar C.K.
      • Maruthy K.N.
      • Sasikala P.
      • Gurja J.P.
      • Kumar A.V.
      • Kareem S.K.
      Impact of chronic alcoholism on temporal cognition and coordination of motor activity.
      It is a non-invasive, user-friendly protocol than any other behavioral therapy. However, further studies are warranted to increase the strength of results and to produce enough power for CBT intervention.

      Conclusion

      The current study reveals that cognitive-behavioral therapy is a useful intervention tool to improve the quality of emotional and social concerns level in women with surgical menopause. It is a simple, non-invasive, and effective intervention to reduce further consequences in women with surgical menopause. The study findings have to be confirmed with more sample size to rule out further about the implementation and accessibility of CBT.

      Funding source

      Self-funding

      Declaration of competing interest

      None declared.

      Acknowledgment

      The authors would like to express their gratitude to the management of Narayana Nursing College and Hospitals for providing basic amenities and facilities during the study.

      References

        • Meeta L.D.
        • Agarwal N.
        • Vaze N.
        • Shah R.
        • Malik S.
        Clinical practice guidelines on menopause: an executive summary and recommendations.
        J Mid Life Health. 2013 Apr; 4: 77
      1. Prince R, Smith M, Price RI, Dick I. Symptomatic effects of continuous estrogen and progesterone studies in a double-blind placebo-controlled trial. In Symptomatic Effects of Continuous Estrogen and Progesterone Studies in a Double-Blind Placebo-Controlled Trial 1992 (pp. 49-49). Australian Menopause Society.

        • Baber R.J.
        • Wright J.
        A brief history of the international menopause society.
        Climacteric. 2017 Mar 4; 20: 85-90
        • Cooper G.S.
        • Sandler D.P.
        Age at natural menopause and mortality.
        Ann Epidemiol. 1998 May 1; 8: 229-235
        • Rodriguez M.
        • Shoupe D.
        Surgical menopause.
        Endocrinol Metabol Clin. 2015 Sep 1; 44: 531-542
        • Georgakis M.K.
        • Beskou-Kontou T.
        • Theodoridis I.
        • Skalkidou A.
        • Petridou E.T.
        Surgical menopause in association with cognitive function and risk of dementia: a systematic review and meta-analysis.
        Psychoneuroendocrinology. 2019 Aug 1; 106: 9-19
        • Shifren J.L.
        • Avis N.E.
        Surgical menopause: effects on psychological well-being and sexuality.
        Menopause. 2007 May 1; 14: 586-591
        • Mendoza N.
        • Suárez A.M.
        • Alamo F.
        • Bartual E.
        • Vergara F.
        • Herruzo A.
        Lipid effects, effectiveness and acceptability of tibolone versus transdermic 17β-estradiol for hormonal replacement therapy in women with surgical menopause.
        Maturitas. 2000 Nov 30; 37: 37-43
        • Unni J.
        Third consensus meeting of Indian Menopause Society (2008): a summary.
        J Mid Life Health. 2010 Jan; 1: 43
        • Whiteley J.
        • DiBonaventura M.D.
        • Wagner J.S.
        • Alvir J.
        • Shah S.
        The impact of menopausal symptoms on quality of life, productivity, and economic outcomes.
        J Wom Health. 2013 Nov 1; 22: 983-990
        • Lip G.Y.
        • Blann A.D.
        • Jones A.F.
        • Beevers D.G.
        Effects of hormone-replacement therapy on hemostatic factors, lipid factors, and endothelial function in women undergoing surgical menopause: implications for prevention of atherosclerosis.
        Am Heart J. 1997 Oct 1; 134: 764-771
        • Jang J.H.
        • Arora N.
        • Kwon J.S.
        • Hanley G.E.
        Hormone therapy use after premature surgical menopause based on prescription records: a population-based study.
        J Obstet Gynaecol Can. 2020 Dec 1; 42: 1511-1517
        • Al Kadri H.
        • Hassan S.
        • Al‐Fozan H.M.
        • Hajeer A.
        Hormone therapy for endometriosis and surgical menopause.
        Cochrane Database Syst Rev. 2009;
      2. Rothbaum BO, Meadows EA, Resick P, Foy DW. Cognitive-behavioral Therapy.

        • Chadwick P.
        • Trower P.
        • Dagnan D.
        Measuring negative person evaluations: the evaluative beliefs scale.
        Cognit Ther Res. 1999 Oct; 23: 549-559
        • Vonk M.E.
        • Early T.J.
        Cognitive-behavioral therapy.
        Social workers’ desk reference. 2009; : 242-247
        • Thimmapuram J.
        • Pargament R.
        • Sibliss K.
        • Grim R.
        • Risques R.
        • Toorens E.
        Effect of heartfulness meditation on burnout, emotional wellness, and telomere length in health care professionals.
        J Community Hosp Intern Med Perspect. 2017 Jan 2; 7: 21-27
        • Andresen E.N.
        • Ramirez M.
        • Kim K.H.
        • et al.
        Effects of surgical side and site on mood and behavior outcome in children with pharmacoresistant epilepsy.
        Front Neurol. 2014 Feb 19; 5: 18
        • O'Neill S.
        • Eden J.
        The pathophysiology of menopausal symptoms.
        Obstet Gynaecol Reprod Med. 2012 Mar 1; 22: 63-69
        • Monteleone P.
        • Mascagni G.
        • Giannini A.
        • Genazzani A.R.
        • Simoncini T.
        Symptoms of menopause—global prevalence, physiology, and implications.
        Nat Rev Endocrinol. 2018 Apr; 14: 199-215
      3. National Collaborating Centre for Mental Health (Great Britain), National Institute for Health, Clinical Excellence (Great Britain), British Psychological Society, Royal College of Psychiatrists. (Common mental health disorders: identification and pathways to care).

      4. Murray K, Davidson G, Schweitzer R. Psychological Wellbeing of Refugees Resettling in Australia: A Literature Review Prepared for the Australian Psychological Society.

        • Kumar C.K.
        • Kumar A.S.
        • Madhurima P.
        • Maruthy K.N.
        • Preetham G.J.
        Assessment of psychomotor skills using finger pulse guided biofeedback tool in young medical students: psychomotor skills using heart rate as a biofeedback tool.
        Ann Med Physiol. 2018 Dec 31; 2: 36-39
        • Kumar C.K.
        • Maruthy K.N.
        • Sasikala P.
        • Gurja J.P.
        • Kumar A.V.
        • Kareem S.K.
        Impact of chronic alcoholism on temporal cognition and coordination of motor activity.
        Int J Physiol. 2018; 6: 124-127