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Contents lists available at ScienceDirect
Maturitas
journal homepage: www.elsevier.com/locate/maturitas
Self-compassion weakens the association between hot flushes and
night sweats and daily life functioning and depression
Lydia Brown a,∗ , Christina Bryant a,b , Valerie M. Brown a , Bei Bei a,b,c,d , Fiona K. Judd b,d
a
Melbourne School of Psychological Sciences, Redmond Barry Building, University of Melbourne, VIC 3010, Australia
Centre for Women’s Mental Health, Royal Women’s Hospital, Locked Bag 300, Grattan St & Flemington Rd, Parkville, VIC 3052, Australia
c
School of Psychological Sciences, Monash University, Building 17, Clayton Campus, Wellington Road, VIC 3800, Australia
d
Department of Psychiatry, University of Melbourne, Level 1 North, Main Block, Royal Melbourne Hospital, VIC 3050, Australia
b
a r t i c l e
i n f o
Article history:
Received 28 March 2014
Received in revised form 14 May 2014
Accepted 19 May 2014
Available online xxx
Keywords:
Menopause
Self-compassion
Hot flushes
Night sweats
Midlife
Well-being
a b s t r a c t
Objectives: Some women find hot flushes and night sweats (HFNS) to interfere more in daily life and
mood than others. Psychological resources may help to explain these individual differences. The aim of
this study was to investigate the role of self-compassion, defined as healthy way of relating toward the
self when dealing with difficult experiences, as a potential moderator of the relationship between HFNS
and daily life activities, which in turn influences symptoms of depression.
Study design: This was a cross-sectional study using questionnaire data from 206 women aged 40–60
who were currently experiencing hot flushes and/or night sweats. Path analysis was used to model relationships among menopausal factors (HFNS frequency and daily interference ratings), self-compassion
and mood.
Main outcome measure: Hot flush interference in daily activities and depressive symptoms.
Results: On average, women experienced 4.02 HFNS per day, and HFNS frequency was moderately correlated with interference ratings (r = 0.38). In the path analytic model, self-compassion made significant
direct contribution to hot flush interference ratings (ˇ = −0.37) and symptoms of depression (ˇ = −0.42),
and higher self-compassion was associated with lower interference and depressive symptoms. Selfcompassion also moderated the relationship between HFNS frequency and hot flush interference. Higher
self-compassion was associated with weaker effects of HFNS frequency on daily interference.
Conclusions: Self-compassion may weaken the association between HFNS and daily life functioning, which
in turn, could lead to less HFNS-related mood problems. These findings imply that self-compassion may
be a resilience factor to help women manage hot flushes and night sweats.
© 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction
Hot flushes and night sweats (HFNS) are common during the
menopausal transition and early postmenopause, affecting up to
75% of midlife women [1]. HFNS cause substantial burden on quality
of life [2], sleep [3], work [1] and mood [4], and they are one of the
leading reasons why women seek medical help at midlife [5].
Abbreviations: HFNS, hot flushes and night sweats; HFI, Hot Flush Related Daily
Interference Scale; CES-D, Centre for Epidemiologic Studies Depression Scale; BMI,
body mass index.
∗ Corresponding author at: Melbourne School of Psychological Sciences, Redmond
Barry Building, University of Melbourne, VIC 3010, Australia. Tel.: +61 437 552 208.
E-mail addresses: lbrown@pgrad.unimelb.edu.au, brown.lydia@gmail.com
(L. Brown).
Women’s experience of HFNS is heterogeneous, influenced by
physiological, symptom detection and appraisal components [6].
Physiological studies have shown that women underestimate up
to 75% of objective hot flushes in their self-reported frequency ratings [7]. Self-reported HFNS have at least some direct influence
on well-being outcomes, such as depressive symptoms [4] and
also contribute to subjective appraisals of distress, bothersomeness
and interference with daily life functioning. It is these subjective
appraisals that most strongly relate to well-being outcomes [6].
Interestingly, self-reported frequency is only moderately associated with daily interference, with published bivariate correlations
in the range of 0.15 [7] to 0.45 [8]. For a given level of perceived
symptoms, therefore, there is a large degree of individual difference in the level of interference experienced in daily life. Why do
hot flushes interfere with daily activities more for some women
than others? The answer to this question is still poorly understood. Cognitive factors including attitudes and beliefs about the
http://dx.doi.org/10.1016/j.maturitas.2014.05.012
0378-5122/© 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Brown L, et al. Self-compassion weakens the association between hot flushes and night sweats and
daily life functioning and depression. Maturitas (2014), http://dx.doi.org/10.1016/j.maturitas.2014.05.012
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2. Materials and methods
2.1. Participants
Participants were selected from a larger sample of men and
women aged between 18 and 101 (N = 7615) randomly recruited
from the electoral roll who had participated in an earlier study of
mental health and wellbeing [19]. Women in the original study
who were aged between 40 and 60 at the time of data collection,
and who had indicated their willingness to be involved in further
research (n = 1450) were invited to participate in this study.
Fig. 1. Hypothesized conceptual model of the roles of self-compassion, HFNS frequency, and hot flush interference in predicting depressive symptoms. Note: HFNS,
hot flushes and night sweats; CES-D, Center for Epidemiologic Studies Depression
Scale.
menopause [9], and the perception of symptoms as having high life
consequences [10] are known to contribute to the burden of symptoms. However, prior studies have only examined the independent
contributions of these factors to problem ratings. To our knowledge
no psychological moderator of the relationship between reported
HFNS frequency and interference with daily life functioning has
been identified to date.
Previously, relatively fixed factors such as health diagnosis and personality have been identified as moderators in the
menopause literature [11,12]. Carpenter et al., for instance, found
that perceived control plays a more important role in how much
HFNS interfere in daily life for breast cancer survivors relative to
healthy midlife women [11]. This finding demonstrates HFNS interference might vary as a function of a woman’s health status, and
opens the possibility that other personal characteristics might be
relevant as well. While diagnosis and personality are reasonably
fixed factors, we were interested in uncovering a more readily modifiable psychological moderator of the relationship between HFNS
frequency and interference with daily life functioning.
Self-compassion is defined as a healthy way of relating toward
the self when dealing with difficult experiences [13]. It incorporates
three interrelated dichotomies: self-kindness (as opposed to selfjudgment), a sense of common humanity (rather than a sense of
isolation), and mindfulness (rather than over-identification) when
considering personal weaknesses or imperfections. Unlike selfesteem, which can be undermined by personal difficulties including
menopause symptoms [14], self-compassion is especially relevant
when times get tough. Self-compassion is a strong predictor of
psychological health among younger and older adults [15,16], and
is also known to attenuate the impact of experiences involving
embarrassment, failure and rejection [17]. Given that some midlife
women find HFNS to be embarrassing, uncomfortable and disruptive [6], it is plausible that self-compassion may similarly lighten
the impact that HFNS have on daily activities and subsequently
well-being. Self-compassion is a skill that can be taught [18] so if
supported, this hypothesis could have clinical implications for the
psychological management of HFNS.
The purpose of the current study is to examine the relationships
between HFNS symptom frequency, HFNS interference in daily
functioning, self-compassion and symptoms of depression using
a path analysis framework. In particular, the possibility that selfcompassion moderates the relationship between HFNS frequency
and daily interference will be explored, such that for a given level
of symptomatology, those with high self-compassion will experience less interference in daily functioning relative to those with low
self-compassion. The hypothesized conceptual model illustrated in
Fig. 1.
2.2. Measures
2.2.1. Frequency of hot flushes and night sweats
Participants were asked to indicate on average how many hot
flushes and night sweats they currently experienced. They were
given the option of reporting their average number of HFNS per
day, per week or per month. All scores were then converted into an
average daily frequency for comparison.
2.2.2. Hot Flush Related Daily Interference Scale (HFI)
The HFI is a 10-item scale measuring the degree to which
hot flushes interfere with nine daily activities including work,
socializing, leisure, sleep, mood, concentration, relaxation, sex and
enjoyment of life [20]. The remaining item assesses overall interference with quality of life. Participants rate the degree of interference
on a scale ranging from 0 (do not interfere) to 10 (completely interfere). A total score is computed by summing items, with a higher
score indicating a greater impact of hot flushes on quality of life. The
HFI has good published reliability and validity [20], and Cronbach’s
˛ was 0.95 in this study.
2.2.3. Menopausal status
The Stages of Reproductive Ageing Workshop + 10 criteria
(STRAW + 10) were used to assess menopausal status [21]. Women
were classified into four reproductive stages based on the regularity of their menses, which is the principal STRAW criterion. Women
were classified as being premenopausal (regular menstrual cycles
or subtle changes in length/flow), early perimenopausal (variable
cycle length, with a persistent change of ≥7 days in consecutive
cycles), late perimenopausal (interval of amenorrhea of at least 60
days) or postmenopausal (at least 12 months of amenorrhea). The
STRAW + 10 criteria are validated for use regardless of a women’s
age, ethnicity, body size or lifestyle characteristics [21].
2.2.4. Self-Compassion Scale (SCS)
The SCS is a 26-item scale measuring six facets of selfcompassion: self-kindness, self-judgment, common humanity,
isolation, mindfulness and over-identification [13]. Participants
indicated agreement to statements describing responses to challenging experiences (for example “when I see aspects of my
personality that I don’t like, I get down on myself”) on a 5point Likert scale ranging from 1 “Almost never” to 5 “Almost
always.” Subscale scores were created by averaging across subscale items. A total score was generated through obtaining a
grand mean, after reverse-scoring self-judgment, isolation and
over-identification items. Research demonstrates the SCS has good
test–retest reliability [13] and has convergent validity (e.g. self
ratings correlate with therapist ratings), concurrent validity (e.g.
correlates with social connectedness) and discriminate validity
(e.g. no correlation with social desirability or narcissism). In this
study Cronbach’s ˛ was acceptable for all subscales: self-kindness
˛ = 0.86, self-judgment ˛ = 0.85, common humanity ˛ = 0.77,
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isolation ˛ = 0.82, mindfulness ˛ = 0.78 and over-identification
˛ = 0.81. For the full scale, Cronbach’s ˛ was 0.94.
2.2.5. Centre for Epidemiological Studies Depression Scale
(CES-D)
This is a widely used 20-item scale assessing symptoms of
depression during the previous week on a 4-point scale from 0
(“rarely”) to 3 (“most or all of the time”). A score 16 or greater indicates moderate symptoms of depression [22]. The CES-D has good
internal consistency and validity for use among midlife women
[23], and in this study Cronbach’s ˛ was 0.94.
2.3. Procedure
Data were collected between March and August 2013. Participants (n = 1450) were mailed a questionnaire booklet, a plain
language statement, a consent form, and a prepaid envelope. To
enhance the response rate, a second copy of the questionnaire
and consent form was sent to participants who did not respond
within two months. Ethics approval for the study was sought and
obtained from the University of Melbourne’s Human Ethics Committee (HERC#1136819.1).
2.4. Data analyses
2.4.1. Raw data handling
Scales that had more than two items missing (or 10%, whichever
was lower) were considered incomplete and were therefore
removed from relevant analyses. As a result, 3 (1.5%) responses
from the HFI, 3 (1.5%) responses from the self-compassion questionnaire and 4 (1.9%) responses from the CES-D were removed
from the analysis. This cut-off allowed for the inclusion of cases
with 1 (i.e. 10 on the SCS, 6 on the CES-D and 1 on the HFI) or 2
(i.e. 3 on the SCS and 1 on the CES-D) items missing, thus reducing
bias toward complete responses without compromising the validity of the data. Valid mean substitution [24] was used to impute
remaining missing values. Valid mean substitution involves replacing a missing item with the case mean for the relevant subscale and
is known to offer a good representation of original data when the
rate of missing data is less than 20% [25]. Valid mean substitution
has the advantage over grand mean substitution in that it controls
for individual differences, such that imputed values are not unduly
affected by scores of the rest of the sample [24].
Given the low numbers of women in the early perimenopausal
(n = 6) and late perimenopausal stages (n = 20), these categories
were collapsed to form the perimenopausal group. A logarithmic
transformation was performed on HFNS frequency and body mass
index (BMI) to adjust for significant positive skew. All independent variables were standardized prior to conducting the analysis.
Questionnaires were scored using standard scoring methods.
2.4.2. Statistical analyses
To assess the feasibility of the model, bivariate associations
between menopausal factors, self-compassion, depressive symptoms and demographics were tested with one-way analysis of
variance (ANOVA) and Pearson’s r correlation. The conceptual
model in Fig. 1 was estimated using path analysis, and missing data
was handled using full information maximum likelihood. The moderating role of self-compassion in the relationship between HFNS
frequency and HFI was tested by including an interaction term
between HFNS frequency and self-compassion.
Overall model fit was assessed through multiple fit statistics, with p > 0.05 for likelihood-ratio !2 , comparative fit index
(CFI) ≥ 95, the root means square error of approximation
(RMSEA) ≤ 06, and the standardized root mean square residual
(SRMR) ≤ 08, indicating good fit [26,27]. Data were processed with
IBM SPSS Version 21.0, and path analysis was conducted using
Mplus version 6.0 [28].
3. Results
3.1. Descriptive results
Valid consent and questionnaire responses were received
from 517 participants, resulting in a response rate of 35.7%. Of
these respondents 206 reported current hot flushes and/or night
sweats. This subset of respondents constitutes the sample for this
study.
The mean age of the sample (n = 206) was 53.64 years (SD = 4.00).
The majority of subjects were postmenopausal (71.8%), of which
23 (11.2%) had had surgical menopause. Eight women (3.9%) were
currently using hormone replacement therapy (HRT). Most subjects were of an Australian background (92.7%), married (77.7%)
and were living with their spouse either with (34.5%) or without
(47.1%) children. The women were mostly working either full-time
(35.9%) or part-time (44.2%). Table 1 includes detailed information
on the characteristics of the sample.
Table 1
Demographic characteristics of the sample.
Variable
Description
Age
Menopause status
Premenopausal
Perimenopausal
Postmenopausal (total)
Natural menopause
Surgical menopause
Current HRT use
Education
Up to year 10
Up to year 12
Apprenticeship
Undergraduate degree
Postgraduate degree
Other
Missing
Ethnicity
Australian
Indigenous Australian
British
Other
Missing
Employment status
Disability/sickness benefit
Unemployed
Full time house duties
Retired
Working part-time
Working full-time
Missing
Relationship status
Married
Separated/divorced
Widowed
Single/never married
Other
Missing
Living situation
Living with spouse/partner
Living with spouse/partner and children
Lone parent
Living alone
Living with parent(s)
Other
Missing
BMI
M = 53.64; SD = 5.49
30 (14.6%)
26 (12.6%)
148 (71.8%)
124 (60.2%)
23 (11.2%)
8 (3.9%)
66 (32.0%)
25 (12.1%)
64 (30.0%)
29 (14.1%)
16 (7.8%)
4 (1.9%)
2 (1%)
191 (92.7%)
5 (2.4%)
3 (1.5%)
6 (2.9%)
1 (0.5%)
10 (4.9%)
5 (2.4%)
16 (7.8%)
10 (4.9%)
91 (44.2%)
74 (35.9%)
0
160 (77.7%)
27 (13.1%)
11 (5.3%)
4 (1.9%)
4 (1.9%)
0
97 (47.1%)
71 (34.5%)
14 (6.8%)
20 (9.7%)
3 (1.5%)
1 (0.5%)
0
M = 28.47, SD = 6.49
Note: HRT, hormone replacement therapy; BMI, body mass index.
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Table 2
Means and standard deviations of study variables.
Table 4
Standardized parameter estimates (standard errors) of paths predicting HFI and
CES-D.
Variable
Mean (SD)
HFNS daily frequency
Hot flush interference – total
Work
Socializing
Leisure
Sleep
Mood
Concentration
Relaxation
Sex
Joy
Quality of life
Self-Compassion
CES-D
4.02 (5.70)
2.96 (2.39)
2.13 (0.94)
1.77 (0.17)
1.80 (0.17)
5.91 (0.20)
3.45 (0.22)
3.45 (0.21)
2.35 (0.19)
3.49 (0.24)
2.64 (0.21)
2.54 (0.21)
3.25 (0.64)
12.98 (11.14)
Note: HFNS, hot flushes and night sweats; CES-D, Center for Epidemiologic Studies
Depression Scale.
3.2. Bivariate analyses
The women reported an average of 4.02 HFNS per day, and a
mean interference rating on the HFI of 2.96/10. Consistent with normative data [20], hot flushes interfered most with sleep (5.91/10).
Sex (3.49/10), concentration (3.45/10) and mood (3.45/10) were
also moderately affected. Means and standard deviations of these
study variables as well as self-compassion and self-reported
depressive symptoms are shown in Table 2.
Preliminary one-way ANOVA indicated that menopausal status,
menopausal type (surgical versus natural) and ethnicity were independent of all study variables, and were therefore not included
in the model. Higher depressive symptoms were associated with
younger age (r = −0.22, p = 0.001), not having a partner (r = 0.17,
p = 0.02) and being unemployed (r = 0.31, p < 0.001), but not with
HRT use (r = 0.01, p = 0.85) or BMI (r = 0.15, p = 0.53). HFI was associated with current HRT use (r = 0.13, p = 0.048), higher BMI (r = 0.17,
p = 0.02) and being unemployed (r = 0.19, p = −0.006), but not with
education (r = −0.11, p = 0.12), age (r = −0.14, p = 0.05) or relationship status (r = −0.09, p = 0.21).
Intercorrelations between key study variables are summarized
in Table 3. CES-D and HFI were significantly associated with all
study variables, with effect sizes ranging from 0.19 to 0.60 and 0.36
to 0.55, respectively.
3.2.1. Path analysis
The hypothesized path model offered a very good fit for the data
(!2 (1) = 0.52, p = 0.47, CFI = 1.00, RMSEA < 0.001, SRMR = 0.004). The
HFNS × self-compassion interaction term was significant in predicting HFI (ˇ = −0.21, p < 0.001), demonstrating the moderating
role of self-compassion in the model. There was no significant direct
effect of HFNS frequency on depressive symptoms (ˇ = −0.031,
p = 0.57). However, by including HFI as a mediator, HFNS frequency
had a significant indirect effect on mood (ˇ = 0.095, p = 0.001).
Significant covariates in the model included current use of HRT
predicting higher HFI (ˇ = 0.17, p = −0.001), and being without a
Table 3
Intercorrelation matrix of study variables.
Variable
1. CES-D
2. Hot flush interference
3. HFNS frequency
4. Self-compassion
1
1
2
3
**
0.55
1
4
**
0.19
0.38**
1
−0.60**
−0.49**
−0.23**
1
Note: HFNS, hot flushes and night sweats; CES-D, Center for Epidemiologic Studies
Depression Scale.
**
p < 0.01.
Variable
HFI
CES-D
Self-compassion
HFNS frequency
SC × HFNS frequency
BMI
HRT use
Age
Unemployment
Relationship
HFI
−0.37 (0.06)**
0.34 (0.06)**
−0.21(0.06)**
0.099 (0.06)
0.17 (0.06)**
−0.094 (0.06)
0.067 (0.06)
−0.055 (0.06)
NA
−0.42 (0.06)**
−0.031 (0.06)
NA
−0.21 (0.06)
0.018 (0.05)
−0.17 (0.05)**
0.17 (0.05)*
−0.106 (0.05)**
0.28 (0.06)**
Note: HFNS, Hot flushes and night sweats; CES-D, Center for Epidemiologic Studies
Depression Scale.
*
p < 0.05.
**
p < 0.01.
partner (ˇ = −0.17, p = 0.038), unemployed (ˇ = 0.17, p = 0.001) and
of younger age (ˇ = −0.17, p = 0.001) predicting greater depressive
symptoms. Details of parameter estimates (standard errors) and
statistical significance are shown in Table 4. The model explained
approximately 51% of the variance in depressive symptoms, and
41% of the variance in HFI. Significant paths of the model are illustrated in Fig. 2.
To determine the amount of unique variance contributed by the
moderation effect, a nested model that constrained the SC × HFNS
frequency interaction term to zero was constructed. The constrained model caused a drop in HFI r2 of 0.04–0.37. Therefore,
the moderating effect of self-compassion served to explain 4% of
unique variance in HFI over and above the contribution of direct
effects.
A plot of the relationship between HFNS frequency and HFI for
women with low (1 SD below the mean), medium (mean) and high
(1 SD above the mean) self-compassion is shown in Fig. 3. The relatively steeper slope for women with low self-compassion indicates
that a given frequency of HFNS will cause more daily interference
for this subgroup.
4. Discussion
The primary objective of this study was to investigate the potential protective role of self-compassion in weakening the association
between HFNS and daily life functioning, which in turn influences
depression. We assessed the hypothesized model with preliminary
bivariate tests followed by path analysis, with HFNS interference
and depressive symptoms included as endogenous outcome variables. Our results indicated that self-compassion was both a direct
predictor of HFNS interference and depressive symptoms, and also
a powerful moderator of the relationship between HFNS frequency
and the degree to which HFNS symptoms interfere with daily life.
Consistent with prior work [6–8], HFNS interference rating was
a significant predictor of depressive symptoms, and a stronger
predictor than HFNS frequency. HFNS frequency was significantly
correlated with depression in bivariate analyses (r = 0.19, p < 0.01),
which is compatible with a recent review [4]. The direct relationship failed to reach significance in the final model, however, when
demographic factors and HFNS interference were also taken into
account. Instead, there was an indirect effect of HFNS frequency
on depressive symptoms via HFNS interference. This demonstrates
that a key mechanism by which self-reported HFNS influence mood
is the degree to which symptoms interfere with daily activities.
Self-compassion was the strongest direct predictor of HFNS
interference (ˇ = −0.37), followed by HFNS frequency (ˇ = 0.34).
Consistent with prior work, this finding adds weight to the argument that emotional and cognitive factors are central contributors
to HFNS appraisals. In a cognitive model of hot flushes, Hunter and
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Fig. 2. Path analysis testing the interaction of self-compassion and HFNS in contributing to HFI and depressive symptoms. Path coefficients are standardized. Note: HFNS,
hot flushes and night sweats; CES-D, Center for Epidemiologic Studies Depression Scale.
Chilcot identified social, control and sleep beliefs as being central predictors of HFNS problem ratings [6]. While these factors
are predominantly cognitive in nature, here we identify an emotional factor, with cognitive components (self-compassion) that is
likewise important. Self-compassion was also the strongest direct
predictor of depressive symptoms in the model, followed by HFNS
interference. This demonstrates that a combination of psychological and menopause-specific factors contribute to mood at midlife,
and these should be considered in tandem when conceptualizing
mood and depression among midlife women.
As hypothesized, self-compassion significantly moderated the
relationship between HFNS frequency and HFNS interference, such
that for a given frequency of HFNS, those women with high selfcompassion experienced less symptom interference in daily life.
This finding helps to explain why some women find symptoms
more interfering than others. Given that HFNS can be disruptive
and embarrassing; self-compassion may provide a psychological
resource to help women deal with the challenge through selfkindness, a sense of common humanity and mindfulness. Those
Fig. 3. Interaction effect between HFNS frequency and self-compassion in predicting
hot flush interference in daily functioning. All variables are standardized Z scores.
Note: HFNS, hot flushes and night sweats.
women low on self-compassion, on the other hand, may reinforce
difficulties related to their symptoms through self-criticism (e.g. ‘I
am stupid for feeling this way’), a sense of isolation (e.g. ‘I am the
only one suffering from hot flushes’) and over-identification (e.g.
‘these symptoms define who I am’). These maladaptive reactions,
in turn, exacerbate the degree to which symptoms interfere with
women’s lives.
A recent randomized controlled trial has demonstrated that the
8 week Mindful Self-Compassion group programme significantly
reduces symptoms of depression relative to waitlist controls, with
gains maintained at 6 month and 1 year follow ups [18]. This
demonstrates that self-compassion is modifiable, and that changes
in self-compassion can have a direct influence on well-being. Given
that the current study has demonstrated the relevance of selfcompassion to menopausal factors in a cross-sectional design, it
is plausible that attempts to bolster self-compassion may serve the
dual purpose of influencing mood and menopause related issues
simultaneously, a hypothesis to be tested in future experimental
research.
A limitation of the study is the cross-sectional nature of the
findings, meaning that directions of causality cannot be confirmed.
As such, while we have found that self-compassion acts as a
moderator, weakening the association between HFNS and daily
interference, a future experimental study design is needed to clarify
directions of causality. Secondly, the study had a relatively modest response rate of 35.7%. While the study was cross-sectional,
data collection resembled that of a longitudinal design due to
participants’ prior participation in the larger project. The lowerthan-desired response rate was comparable with other longitudinal
studies [29], where attrition is a common problem. Our sample
size was nonetheless large enough to permit robust statistical
analyses, but was arguably skewed toward better functioning individuals. An interesting extension, therefore, could be to consider
self-compassion as a mediator of HFNS and other climacteric symptoms in a clinical setting such as a menopause clinic, where women
are seeking help for more acute symptoms. This study examined
depressive symptoms as the sole well-being outcome variable.
Since a growing body of evidence is linking anxiety with HFNS
[6,30], exploring self-compassion in the context of anxiety and
menopausal factors would be worthy of investigation.
In summary, this study explores the role of self-compassion
in attenuating the impact of HFNS on daily activities and
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depressive symptoms. Prior work has identified cognitive factors
that help explain why some women but not others are troubled
by HFNS [6]. This study extends our understanding of these individual differences through identifying that a woman’s relationship
toward herself, specifically how compassionate she is toward herself, is also worthy of note. Since self-compassion is a skill that
responds well to training [18], this finding has clinically relevant implications for the management of HFNS. Given that the
Mindful Self-Compassion group programme is an evidence-based
approach to bolstering self-compassion [18], women experiencing
menopause related disturbances to well-being may benefit from
taking part in a programme of this type. Finally, this study provides
the impetus for an experimental study to assess self-compassion
training as an alternative or adjunct to CBT and pharmacological
treatments for hot flushes and night sweats.
Contributors
Ms. L. Brown, Ms. V. Brown, Dr. Bryant and Professor Judd formulated the research question and designed the study. Ms. L. Brown,
Ms. V. Brown and Dr. Bryant carried out data collection. Ms. L. Brown
and Dr. Bei were responsible for carrying out the statistical analysis. Ms. Brown wrote the paper, and all authors contributed to its
revision.
Competing interest
None.
Funding
The cost of printing and mailing the questionnaire where all
study data was obtained was covered by a small grant available to
PhD students in the School of Psychological Sciences, University of
Melbourne.
Acknowledgement
We thank the participants for their time and ongoing interest in
this study.
References
[1] Utian WH. Psychosocial and socioeconomic burden of vasomotor symptoms in
menopause: a comprehensive review. Health Qual Life Out 2005;3(1):47.
[2] Avis NE, Colvin A, Bromberger JT, et al. Change in health-related quality of
life over the menopausal transition in a multiethnic cohort of middle-aged
women: study of Women’s Health Across the Nation (SWAN). Menopause
2009;16(5):860.
[3] Brown JP, Gallicchio L, Flaws JA, Tracy JK. Relations among menopausal
symptoms, sleep disturbance and depressive symptoms in midlife. Maturitas
2009;62(2):184–90.
[4] Worsley R, Bell R, Kulkarni J, Davis SR. The association between vasomotor
symptoms and depression during perimenopause: a systematic review. Maturitas 2014;77(2):111–7.
[5] Freeman EW, Sammel MD, Lin H, Liu Z, Gracia CR. Duration of menopausal hot
flushes and associated risk factors. Obstet Gynecol 2011;117(5):1095.
[6] Hunter MS, Chilcot J. Testing a cognitive model of menopausal hot flushes and
night sweats. J Psychosom Res 2013;74(4):307–12.
[7] Carpenter JS, Rand KL. Modeling the hot flash experience in breast cancer survivors. Menopause 2008;15(3):469–75.
[8] Rand KL, Otte JL, Flockhart D, et al. Modeling hot flushes and quality of life in
breast cancer survivors. Climacteric 2011;14(1):171–80.
[9] Hunter MS, Mann E. A cognitive model of menopausal hot flushes and night
sweats. J Psychosom Res 2010;69(5):491–501.
[10] Duffy OK, Iversen L, Aucott L, Hannaford PC. Factors associated with resilience or
vulnerability to hot flushes and night sweats during the menopausal transition.
Menopause 2013;20(4):383–92.
[11] Carpenter JS, Wu MJ, Burns DS, Yu M. Perceived control and hot flashes in
treatment-seeking breast cancer survivors and menopausal women. Cancer
Nurs 2012;35(3):195.
[12] Lin M-F, Ko H-C, Wu JYW, Chang F-M. The impact of extroversion or menopause
status on depressive symptoms among climacteric women in Taiwan: neuroticism as moderator or mediator? Menopause 2008;15(1):138–43.
[13] Neff KD. The development and validation of a scale to measure self-compassion.
Self Identity 2003;2(3):223–50.
[14] Elavsky S, McAuley E. Physical activity, symptoms, esteem, and life satisfaction
during menopause. Maturitas 2005;52(3–4):374–85.
[15] Barnard LK, Curry JF. Self-compassion: 1. Conceptualizations, correlates, &
interventions. Rev Gen Psychol 2010;15(4):289.
[16] Phillips WJ, Ferguson SJ. Self-compassion: 1. A resource for positive aging. J
Gerontol B: Psychol Sci Soc Sci 2013;68(4):529–39.
[17] Leary MR, Tate EB, Adams CE, Batts Allen A, Hancock J. Self-compassion and
reactions to unpleasant self-relevant events: the implications of treating oneself kindly. J Pers Soc Psychol 2007;92(5):887.
[18] Neff KD, Germer CK. A pilot study and randomized controlled trial of the mindful self-compassion program. J Clin Psychol 2013;69(1):28–44.
[19] Murray G, Judd F, Jackson H, et al. Rurality and mental health: the role of
accessibility. Aust N Z J Psychiatry 2004;38(8):629–34.
[20] Carpenter JS. The Hot Flash Related Daily Interference Scale: a tool for assessing
the impact of hot flashes on quality of life following breast cancer. J Pain Symptom Manage 2001;22(6):979–89.
[21] Harlow S, Gass M, Hall JE, et al. Executive summary of the Stages of Reproductive
Aging Workshop + 10 addressing the unfinished agenda of staging reproductive
aging. Climacteric 2012;15(2):105–14.
[22] Hertzog C, Van Alstine J, Usala PD, Hultsch DF, Dixon R. Measurement properties
of the Center for Epidemiological Studies Depression Scale (CES-D) in older
populations. Psychol Assess 1990;2(1):64.
[23] Knight RG, Williams S, McGee R, Olaman S. Psychometric properties of the Centre for Epidemiologic Studies Depression Scale (CES-D) in a sample of women
in middle life. Behav Res Ther 1997;35(4):373–80.
[24] Raymond MR. Missing data in evaluation research. Eval Health Prof
1986;9(4):395–420.
[25] Downey RG, King CV. Missing data in Likert ratings: a comparison of replacement methods. J Gen Psychol 1998;125(2):175–91.
[26] Hu Lt, Bentler PM. Cutoff criteria for fit indexes in covariance structure
analysis: conventional criteria versus new alternatives. Struct Equat Model
1999;6(1):1–55.
[27] Schreiber JB. Core reporting practices in structural equation modeling. Res Soc
Admin Pharm 2008;4(2):83–97.
[28] Muthén L, Muthén B. Mplus software version 6.0. Los Angeles, CA: Muthén &
Muthén; 2010.
[29] Martin M, Grünendahl M, Martin P. Age differences in stress, social resources,
and well-being in middle and older age. J Gerontol B: Psychol Sci Soc Sci
2001;56(4):214–22.
[30] Bryant C, Judd FK, Hickey M. Anxiety during the menopausal transition: a systematic review. J Affect Disord 2012;139(2):141–8.
Please cite this article in press as: Brown L, et al. Self-compassion weakens the association between hot flushes and night sweats and
daily life functioning and depression. Maturitas (2014), http://dx.doi.org/10.1016/j.maturitas.2014.05.012