Cognitive Stimulation Therapy in Menopause: Feasibility randomised controlled trial

Testing a Digital Toolkit for Menopausal 'Brain Fog'

Cognitive changes, often described as "brain fog," are a highly prevalent symptom during the menopause transition. While these difficulties with memory and concentration are widespread, clinical treatments specifically designed to target these cognitive shifts remain largely absent. Researchers have recently developed a novel, group-based online intervention called CST-Meno to address this gap. They tested its practical application through a feasibility trial.

Addressing the Cognitive Gap in Menopause

The core challenge lies in the disconnect between how women experience menopause and how medical science treats it. During the menopause transition—the biological process involving hormonal shifts that leads to the end of menstruation—many women report significant cognitive complaints. These typically manifest as difficulty recalling words or numbers, losing items, or struggling to concentrate.

While these symptoms are primarily subjective (meaning they are felt and reported by the individual), they can have profound impacts on daily functioning. Currently, the first-line medical response is often Menopause Hormone Therapy (MHT). However, while MHT is effective for vasomotor symptoms (physical sensations like hot flushes and night sweats), there is no established evidence that it effectively mitigates cognitive changes. This leaves a vacuum for psychosocial interventions. These are treatments that focus on psychological and social strategies rather than purely biological ones.

The Biological and Psychological Landscape

To understand why a new intervention is necessary, one must look at the interplay of hormones and brain function. The menopause transition involves rapid fluctuations in oestrogen and progesterone. These hormones interact with receptors in critical brain regions like the hippocampus. This area is central to memory formation. These fluctuations, combined with disrupted sleep and increased anxiety, create a complex "biopsychosocial" environment.

Existing research has explored several avenues to manage this, but none have provided a definitive solution. Some studies have looked at "cognitive remediation." This is a combination of lifestyle modification and compensatory strategies (techniques used to bypass a deficit, such as using digital calendars to offset forgetfulness). Others have utilized Cognitive Behavioural Therapy (CBT). CBT aims to reframe the negative thought cycles that can exacerbate the distress caused by menopausal symptoms.

The authors of this study sought to integrate these approaches into a single framework: Cognitive Stimulation Therapy (CST). Unlike simple education, CST is designed to promote both cognitive and emotional enhancement through active engagement. The goal was to move beyond mere symptom management. They wanted to provide women with a functional toolkit for maintaining mental clarity.

Designing the CST-Meno Protocol

The researchers developed CST-Meno through an iterative process. This included systematic reviews, surveys, and focus groups to ensure the content met the actual preferences of women in transition. The resulting intervention was delivered as an online group program via Microsoft Teams. It consisted of four two-hour sessions spread over six weeks.

The logic of the protocol follows a multi-modal structure: 1. Psychoeducation: Providing foundational knowledge about brain health and the mechanics of menopause. 2. Skill Acquisition: Teaching specific cognitive strategies. These include using mental imagery to consolidate information or practicing task-switching skills. 3. Psychological Regulation: Incorporating CBT techniques to address the link between thoughts, feelings, and behaviors. This also included mindfulness exercises like progressive muscle relaxation. 4. Peer Support: Facilitating group reflection to normalize the experience of cognitive shifts.

To test if this could work in a real-world research setting, the authors conducted a single-blind feasibility randomised controlled trial (RCT). In this design, participants were randomly assigned to either the CST-Meno group or a "treatment as usual" (TAU) group. TAU refers to the participants' continuation of their standard care without any alterations. As shown in, the study began with 41 eligible participants. After accounting for withdrawals, 33 women were randomised (17 to CST-Meno and 16 to TAU).

Evaluating Feasibility and Early Trends

The primary objective of this study was not to prove that CST-Meno works. Instead, it was to prove that it can be studied. A feasibility trial asks if researchers can recruit enough people and if participants will stay in the study.

The authors report that the trial was a success in terms of logistics. The recruitment rate was 80%. The retention rate—the percentage of participants who stayed from the start through to the final data collection—was an impressive 91%. Attendance for the CST-Meno sessions averaged 68%. This means participants attended roughly 2.7 out of the four scheduled sessions. Crucially, no adverse effects related to the content or the digital delivery were reported.

Regarding the actual effects on cognition and mood, the results were exploratory. They required cautious interpretation because the sample size ($N=33$) was too small to achieve statistical power (the ability of a study to detect an effect if one truly exists). Nevertheless, the data revealed interesting trends. In several cognitive domains, the CST-Meno group showed slight improvements compared to the TAU group. Specifically, the authors noted trends favoring the intervention in delayed verbal memory (RAVLT Delay), forward digit span (auditory attention), and subjective memory strategy use (MMQ Strategy). Conversely, some measures, such as total verbal learning and certain anxiety scales, showed trends that favored the TAU group.

Limits of the Current Framework

While the study confirms that an online cognitive intervention is a viable way to reach women in menopause, it has clear boundaries. First, the sample was not demographically representative. 81.9% of participants identified as "white" or "other white." Additionally, the group was highly educated. This was likely a byproduct of the social media and professional networks used for recruitment.

Second, the methodology faced technical hurdles. Because the neuropsychological assessments were conducted via video calls in participants' homes, researchers could not control for environmental distractions. This "uncontrolled environment" is a common challenge in digital health research. A barking dog or a ringing phone can interfere with sensitive tasks like the Trail Making Test (a measure of visual processing speed and executive function). Finally, the study did not formally measure "fidelity." This refers to whether the facilitators delivered the sessions exactly as prescribed in the manual.

Toward a Definitive Solution

This study moves the needle from "is this possible?" to "how do we prove this works?". By demonstrating that women are willing to engage with online cognitive training, the researchers have laid the groundwork for a much larger trial. Such a trial would be fully powered and feature a more diverse sample.

The next phase of research will need to investigate true effectiveness and cost-effectiveness. Understanding whether these interventions can reduce the economic burden of menopause will be essential. This includes looking at factors like decreased time taken off work due to cognitive struggles. Such findings would be vital for integrating psychosocial support into standard clinical care.

Figures from the paper