Filling the Gap in Clinical Care: A Protocol For Incorporating a Digital App in Clinical Management of Hot Flashes and Menopausal Symptoms

The North American Menopause Society [1] has recognized that hypnotherapy can be recommended as a non-pharmaceutical approach for reducing hot flashes and has level I evidence. Evidence includes a NIH-funded clinical trial [2] in which 187 postmenopausal women with at least 50 hot flashes per week were randomized to receive five weekly sessions of either hypnotherapy (n = 93) or structured-attention control (n = 94). The hypnotherapy intervention involved audio recordings and daily practice of self-hypnosis at home. The structured-attention control arm involved discussion of symptoms, attentive listening, and interpersonal exchange. At 12-week follow-up, the mean reduction of hot flash scores from baseline was 80.32% for those that received the hypnotherapy program, while those in the control condition experience only 15.38% reduction in hot flashes (p < .001). 

While a hypnotherapy program has been shown to be very effective, many women may not be aware of the research demonstrating efficacy. Further, access to hypnotherapy has been limited. To meet this gap in health care, Mindset Health developed the Evia app that can effectively deliver the proven hypnotherapy intervention and help women suffering from hot flashes.

Mindset Health’s Evia app is based upon an established protocol for clinical management of hot flashes and menopausal symptoms. The protocol involves education, assessment of symptoms, self-monitoring of progress, engagement in daily hypnotherapy audio recordings, and guidance in regard to practice, engagement, and individualization. 

Hypnosis is defined as: "A state of consciousness involving focused attention and reduced peripheral awareness characterized by an enhanced capacity for response to suggestion”. Hypnotherapy refers to hypnotic inductions and the utilization of hypnosis for improving health care and relief of symptoms. 

The Evia app provides hypnotherapy and may be used alone or in combination with other healthcare recommendations. 

The protocol for guiding patients using the Evia app involves several key steps:

1. Education about hot flashes.
2. Understanding medical hypnosis and hypnotherapy.
3. Information about the efficacy of hypnotherapy for hot flashes.
4. Recording hot flashes and sleep symptoms.
5. Beginning using the Evia app. 
6. Daily use of hypnotherapy audio recordings.
7. Encouraging self-hypnosis.
8. Problem-solving.
9. Individualizing practice of hypnotherapy sessions.
10. Continuing practice and hypnotherapy sessions for maintenance of reduction in hot flashes long term.

Case example

The following case illustrates the effectiveness of hypnosis for hot flashes in a post-menopausal woman and the protocol for incorporating the digital Evia app in the clinical management of hot flashes and menopausal symptoms. 

The patient, Rebecca, was a 54-year-old married Caucasian female, who was experiencing moderate to severe hot flashes post-menopause and had difficulty with her sleep associated with anxiety and night sweats. She began having hot flashes two years ago and was seeking alternatives to being completely reliant on hormone therapy. Her physician gave her the option of considering the Evia app to help manage her hot flashes and improve her sleep.

Rebecca was interested and decided to try it. The Evia app provided her with education about hot flashes and information to help her understand medical hypnosis and hypnotherapy. She had some questions for her physician, who explained that hypnosis is best understood as a natural experience and generally pleasant and relaxing. Also, her physician provided her with information about the efficacy of hypnotherapy for hot flashes, such as the average reduction in hot flashes is 70-80% with the Evia app. 

Rebecca then started using the Evia app. The first step was for her to begin recording and monitoring the frequency and severity of her hot flashes and sleep symptoms using the Evia app.  She recorded the number and severity of each hot flash in each 24-hour period every day of the week. She kept hot flash diaries throughout the duration of the Evia hypnotherapy program (approximately six weeks). 

Rebecca began listening to the hypnotherapy sessions on the Evia app on a daily basis. Each session lasted about 15 minutes and she began her practice by listening to the audio recordings while sitting in a recliner at home in the afternoons. An example of the verbalizations during the hypnotherapy sessions included suggestions such as:

“It is so pleasant there and just notice the coolness while standing at the top of this snow-covered mountain…cool waves of comfort flowing over you and through you…and while you are there it is possible that your mind could drift to other times when you have felt such a coolness and comfort. Perhaps the coolness of standing in front of an air conditioner…feeling the cold air…or the coolness one could experience when opening a refrigerator or having a cool drink of ice water.”

After the second week, Rebecca and her physician discussed her at-home practice with the audio recordings. She was encouraged in the daily practice of self-hypnosis and to remain confident that she would achieve a reduction in her hot flashes. Rebecca found this encouragement to be very helpful.

During the third week, Rebecca discussed with her physician that she was having some difficulties practicing during the day and afternoon, and her sleep had not improved as much as she would like. Her physician engaged her in reflection and problem-solving to find what would work better for her.  Rebecca found that practicing in bed immediately before bedtime worked best. She explained that it was the quietest time of day for her.

During the fourth week, Rebecca provided her physician with an update on her progress. Her hot flashes were significantly decreasing and she was sleeping better. Her physician asked about her preferences for mental imagery to further encourage individualizing her practice of hypnotherapy sessions. Rebecca’s preferred imagery was of snow-covered mountains. She was able to draw from her own memories of time spent in Colorado in the US, such as imagining the coolness of a mountain lake. 

Rebecca stated:

“When listening to the hypnotherapy sessions with mental imagery for coolness in the mountains, I remember a cool breeze blowing through the aspen trees. I can experience being at the top of a mountain and there is snow around. In the distance, I can see a lake. I can remember it so vividly because we went there for vacation last year.”

By the fifth week, Rebecca’s hot flashes had decreased to eight hot flashes for the entire week. Rebecca had achieved nearly 80% reduction in hot flash frequency. She discussed her progress with her physician, shown in the graph below (with a baseline of 6 being mild, 15  moderate, and 18 severe).

When inquired about her hot flash frequency and severity at week six, Rebecca reported a decrease in hot flashes to one to two a day, with some days having none at all. If she had a hot flash during the day, it was mild. She also shared with her physician that the quality of her sleep had improved as well. Her physician was very pleased with Rebecca’s progress, but also emphasized that it would be very important to continue the practice of hypnotherapy sessions for maintenance of reduction in hot flashes long term. 

Rebecca continued listening to the hypnotherapy sessions and found that her hot flash frequency remained low, she felt less stressed, and had less anxiety. This in itself was an encouragement for her as she felt better, was calmer, and felt more in control of her symptoms. Her physician reinforced this use of the Evia app and Rebecca’s progress maintenance was discussed at her future medical appointments.

‍The Wrap Up

While research demonstrates hypnotherapy is an effective tool to support women with problematic menopause symptoms, many are not yet aware of its efficacy and may view it as an inaccessible option. To meet this gap in health care, Mindset Health developed the Evia app to effectively deliver proven hypnotherapy intervention and help women suffering from hot flashes. The protocol for guiding patients using the Evia app involves several key steps: education about hot flashes; understanding medical hypnosis and hypnotherapy; information about the efficacy of hypnotherapy for hot flashes; recording hot flashes and sleep symptoms; beginning using the Evia app; daily use of hypnotherapy audio recordings; encouraging self-hypnosis; and problem-solving.

About Dr. Gary Elkins

Dr. Gary Elkins is a Professor of Psychology and Neuroscience at Baylor University, Director of the Mind-Body Medicine Research Laboratory, and Editor-in-Chief of the International Journal of Clinical and Experimental Hypnosis. He is the expert behind the hypnotherapy for hot flashes program, Evia.

Learn more about Dr. Elkins at garyelkins.org