Hypnosis for menopausal hot flushes

1. Introduction

Version followed: the clinical hypnosis protocol from Gary Elkins and colleagues (Mind-Body Medicine Research Laboratory, Baylor University). The main version is five weekly individual sessions plus daily audio-guided self-hypnosis, as in Elkins et al. 2008 (J Clin Oncol, breast cancer survivors) and Elkins et al. 2013 (Menopause, postmenopausal women; methods published in the 2011 BMC study protocol). The 2025 six-week self-administered audio version (Elkins et al., JAMA Netw Open) and the Evia app built on the protocol are given as alternative delivery formats. Sources behind the procedure: the 2011 BMC study protocol full text (eligibility, exclusions, session 1 and session 3 content, the weekly review in sessions 2–5, a standard induction transcript individualised with relaxation and coolness imagery, the home recording, the control condition, measures, fidelity); a detailed review of the 2008 JCO trial (50-minute sessions, a PhD psychologist with 40+ hours' training, the manual, session components including deepening, dissociation from flushes, future-oriented suggestions, self-hypnosis instruction and re-alerting); The Menopause Society 2023 nonhormone therapy position statement (clinical hypnosis rated Level I, recommended); Elkins' description of session structure (MDedge); the Evia app study (JMIR Form Res 2025); Baylor news 2023 and 2025. Elkins' own transcripts (the trials' standard induction transcript, and the sample transcripts in his book Hypnotic Relaxation Therapy, which has a chapter on menopausal and hot-flash symptoms [source: Springer Publishing book page]) are not reproduced or summarised here, so the exact induction and suggestion wording remains [uncertain]; all example language below is illustrative. Contraindications beyond the trials' exclusions are [synthesis]. [source: BMC 2011 protocol; Clinician.com review of JCO 2008; Menopause Society 2023; MDedge; JMIR Form Res 2025; Baylor news]

What it is. A short course of clinical hypnosis for vasomotor symptoms (hot flushes and night sweats), given by a trained clinician. Each session uses a standard hypnotic induction transcript individualised with the client's own imagery for relaxation and coolness, followed by deepening, dissociation from the hot flushes, positive suggestions and imagery about the future, and instruction in self-hypnosis, which the client practises daily with an audio recording. [source: BMC 2011 protocol; Clinician.com review of JCO 2008; MDedge report of Elkins 2013 trial] Elkins describes hypnotherapy as a mind-body therapy involving focused attention, a relaxed state and therapeutic suggestions. [source: Baylor news 2023]

Position within medical care. This is an adjunct for women whose flushes have already been assessed medically. The Menopause Society's 2023 nonhormone therapy position statement rates clinical hypnosis "Level I; recommended" for vasomotor symptoms, alongside CBT and several prescription options that the client's physician prescribes and manages. [source: Menopause Society 2023 position statement] It is particularly relevant where hormone therapy is unsuitable or declined, as in many breast cancer survivors; Elkins notes that hormone therapy "is not a safe choice for everyone". [source: Baylor news 2025; JCO 2008 review] The same statement does not recommend relaxation alone, paced respiration, cooling techniques or trigger avoidance as flush treatments, so a generic relaxation script is not a substitute for this protocol. [source: Menopause Society 2023] It does not replace medical evaluation of new or unusual symptoms, and it is not a treatment for cancer or any other disease. [synthesis]

How change is thought to happen. Elkins says the method works by "managing how temperatures are perceived and regulated in the brain", and frames practice as teaching the brain to adapt to changing hormone levels. [source: Baylor news 2023] A follow-up analysis of the 2013 trial found benefit was not related to women's expectations of whether hypnosis would work. [source: Menopause Society 2023, citing Sliwinski & Elkins 2017] Elkins' detailed mechanistic papers are not drawn on here. [uncertain] A working clinical model [synthesis]: (a) repeated deep relaxation lowers general arousal and stress, which commonly accompany flushes; (b) cool imagery and suggestions change how a flush is perceived and how strongly it is felt; (c) dissociation puts distance between the client and the sensation, lowering distress and interference; (d) daily self-hypnosis turns these effects into a portable skill. Elkins stresses that gains continue once the skill is learned: "once you learn [self-hypnosis], you keep doing it" (Science News, 2025).

2. Framework

Format (in-person version). Individual sessions, five sessions, about once a week, following a treatment manual. [source: BMC 2011 protocol; JCO 2008 review] In the 2008 breast cancer trial each session lasted 50 minutes and was delivered by a PhD clinical psychologist with more than 40 hours of training from the principal investigator. [source: Clinician.com review of JCO 2008] (Elkins' lab feature gives about 45 minutes for earlier exploratory work. [source: Scientia]) In the 2013 trial a research therapist followed the manual, with a checklist reviewed at each session for consistency. [source: BMC 2011 protocol] Each session uses a hypnotic induction with imagery for relaxation and coolness individualised to the client. An audio recording of the induction (a cassette in 2008, a CD in 2013) goes home with the client, who is encouraged to practise daily with and without it. [source: BMC 2011 protocol; JCO 2008 review] Assessments were at baseline, at the end of the five weeks and at 12 weeks. [source: BMC 2012 conference abstract]

Format (self-administered version). In the 2025 trial (250 postmenopausal women, two US universities) women listened to a daily 20-minute audio session for six weeks; the recordings contained relaxation suggestions and cooling mental imagery, and the comparison was white-noise sham audio. [source: 2 Minute Medicine summary of Elkins et al. 2025; Science News; Baylor news 2025] The Evia app, based on the protocol tested in the 2008 and 2013 trials, runs a five-week programme of daily tasks (educational readings, hypnosis audio, hot-flush tracking) with 16 audio files of 13–15 minutes, and users are encouraged to listen at least once a day. [source: Scheffrahn et al. 2025, JMIR Form Res] The Menopause Society notes the programme can be delivered by a trained provider or a smartphone app. [source: Menopause Society 2023] Use this as a stepped-care or maintenance option, or for clients who cannot attend sessions. [synthesis]

Phases (the phase structure and transition criteria are synthesis built around the published five-session format and its measures)

Monitoring used in the trials. Daily hot-flush diaries of frequency and severity, giving a hot flash score (frequency × average severity, severity weighted from 1 = mild to 4 = very severe); 24-hour sternal skin conductance with an ambulatory monitor, the client pressing an event marker when she feels a flush; the Hot Flash Related Daily Interference Scale; anxiety, depression and sleep measures (CES-D, HADS-Anxiety and MOS-Sleep in 2008), sexual functioning and salivary cortisol. Hypnotizability (Stanford Hypnotic Susceptibility Scale, Form C) and expectancy ratings were measured as possible moderators, not entry criteria. [source: BMC 2011 protocol; JCO 2008 review] In routine practice the diary plus an interference rating is usually enough. [synthesis] Licensed questionnaires are named here, not reproduced.

3. Guiding principles

• Adjunct within medical care. Work only after medical assessment, and keep the prescriber informed. In practice: get consent to liaise, and never advise starting, stopping or changing medication. [source: Baylor news on hormone therapy suitability] [synthesis]
• Individualise the imagery. Build the cool imagery from the client's own remembered places and experiences, not a stock scene. In practice: interview for real cool memories before the first induction. [source: MDedge]
• Teach self-hypnosis; aim for empowerment. The therapist's job is to pass on a skill, not to be the source of relief. In practice: every session ends with home practice, and session 5 aims at independent use. [source: MDedge; Scientia; Science News quotes]
• Daily practice is the active ingredient between sessions. The 2013 protocol encouraged women to practise "hypnosis on a daily basis", with and without the recording. In practice: hand over a recording at session 1 and check practice at every session. [source: BMC 2011 protocol; Scientia]
• Combine several hypnotic elements. Each session uses induction, relaxation, direct and indirect suggestion, dissociation and imagery. In practice: don't run a relaxation-only script. [source: MDedge]
• Measure, don't guess. In practice: keep a daily diary from baseline to follow-up and calculate the hot flash score weekly. [source: JCO 2008; BMC 2011 abstracts; Scientia]
• Standardised structure, flexible content. The trials used a treatment manual and a standard induction transcript, individualised with the client's own relaxation and coolness imagery. In practice: keep the session order fixed and change the content of the imagery and suggestions. [source: BMC 2011 protocol; JCO 2008 review; MDedge]
• Consent, transparency and control stay with the client. The 2013 protocol's first session gives information about hypnosis and discusses myths and misconceptions before the first induction. [source: BMC 2011 protocol] In practice: explain what hypnosis is and is not; the client can open her eyes and stop at any time. [synthesis; standard clinical hypnosis ethics]
• Address the whole symptom picture. Flushes come with poor sleep, low mood, anxiety and interference with daily life, and these improved in the trials. In practice: include suggestions for sleep and calm, and monitor mood. [source: JCO 2008 abstract; MDedge; Baylor news] Content of sleep suggestions is [synthesis].
• Work within your competence. In the 2008 trial the therapist was a PhD clinical psychologist with more than 40 hours of training from the principal investigator [source: JCO 2008 review]; The Menopause Society refers to a trained provider without naming credentials [source: Menopause Society 2023]. In practice: deliver it within your licence, and if you are new to hypnosis get training and supervision first, e.g. through a professional clinical hypnosis society. [synthesis]

4. Intervention inventory

Components named in the sources: a session 1 information and myths discussion; a standard induction transcript individualised with relaxation and coolness imagery; deepening; direct and indirect suggestions; dissociation from the hot flushes; positive suggestions and imagery about the future; instruction in self-hypnosis, with a step-by-step handout at session 3 and a home recording; re-alerting; diary monitoring. [source: BMC 2011 protocol; Clinician.com review of JCO 2008; MDedge] The trial transcripts themselves are not drawn on here. All example language below is illustrative paraphrase, and step detail beyond the named components is marked [synthesis].

4.1 Screening, medical liaison and informed consent

• Purpose / when: Before session 1. Confirms this is an adjunct to medical care and that hypnosis is safe for this client.
• Steps:
  1. Confirm that a physician has assessed the flushes. New, atypical or one-sided flushing, drenching night sweats with weight loss or fever, palpitations, or flushing outside the menopausal transition need medical work-up first (thyroid, medications, infection and other causes). [synthesis]
  2. Note the current menopause treatment and any cancer history and treatment. Many breast cancer survivors take endocrine therapy that can cause flushes. Get consent to liaise with the GP, gynaecologist or oncologist. Never advise on medication. [synthesis; trial populations from JCO 2008 abstract and Baylor news]
  3. Screen for exclusions and contraindications. The trials excluded: simultaneous treatment for hot flashes; current mind-body or CAM use for flushes; current use of hypnosis for any reason; any medical or psychiatric condition the investigator judged to put the participant at risk (no list given); and, in 2008, currently detectable cancer. In 2008, women on stable anti-hormonal therapy (e.g. tamoxifen, unchanged for a month) could take part. [source: BMC 2011 protocol; JCO 2008 review] (The trials' requirement to stop other flush treatments was a research rule; never ask a client to stop prescribed treatment. [synthesis]) A reviewer of the 2008 trial names schizophrenia as an example contraindication. [source: Clinician.com] The Menopause Society statement does not address contraindications. [source: Menopause Society 2023] Added standard clinical caution [synthesis]: active psychosis or mania; severe dissociative disorder; untreated PTSD in which relaxation or bodily focus brings on intrusions; current intoxication; cognitive impairment affecting consent; active suicidality (assess and manage risk first by standard practice). Severe depression or anxiety calls for assessment and, where needed, treatment alongside.
  4. Take a history of hypnosis or meditation and of any frightening relaxation experiences, and correct misconceptions (loss of control, stage hypnosis, 'being put under').
  5. Give a short handout on hot flushes and on hypnosis, and discuss myths and misconceptions [source: BMC 2011 protocol]. Get written informed consent covering what will happen, that the client stays in control, that results vary, and that medical care continues. [synthesis]
• Example language (illustrative): "Hypnosis here is a focused, relaxed state that you can enter and leave whenever you choose. You'll hear everything, you can open your eyes any time, and we'll use it to practise cooling and calming your body. This works alongside your doctor's care, not instead of it."
• Watch for: Unexplained flushing patterns (refer back), fears of losing control, a trauma history linked to bodily sensations or relaxation, and expectations of a guaranteed cure.

4.2 Baseline and ongoing hot-flush diary

• Purpose / when: From about a week before session 1 through to follow-up. It provides a baseline, shows change and motivates practice. [source: Scientia (weekly diaries plus a post-treatment diary); JCO 2008 abstract (hot flash score); BMC 2011 abstract (daily diaries, interference scale)]
• Steps:
  1. Give a simple daily log: each flush (or a daily tally), severity on a short scale such as mild/moderate/severe/very severe, and night-time flushes. [severity categories: synthesis]
  2. Each week, calculate the hot flash score = number of flushes × average severity. [source: JCO 2008 abstract]
  3. Add a weekly 0–10 rating of how much flushes interfere with sleep, work, mood and relationships (the trials used a published interference scale, named not reproduced). [synthesis]
  4. Add a practice log: date, minutes, and whether the cue was used during a flush.
  5. Plot the score with the client weekly.
• Example language (illustrative): "Let's look at your week as a graph. Your score went from about 60 to 45. Which days did you practise, and what were the flushes like on those days?"
• Watch for: Over-monitoring that increases attention to flushes (simplify to an evening tally) and missing data. Trial reductions emerged over the five weeks and continued to 12 weeks [source: MDedge], so judge progress across weeks, not single days.

4.3 Rationale and imagery-preference interview (session 1)

• Purpose / when: Session 1, before the first induction. Gives the rationale and builds the client's personal relaxation and cool imagery. In the 2013 protocol session 1 included a hot-flush handout, information about hypnosis, a discussion of myths, and anxiety ratings before and after the induction. [source: BMC 2011 protocol] Imagery is individualised to the client's preferences and her own places and experiences. [source: BMC 2011 protocol; MDedge]
• Steps:
  1. Explain the rationale in plain terms: relaxation, focused attention and imagery of coolness can change how often flushes come and how intense they feel, and the skill is practised at home.
  2. Ask for remembered experiences of being comfortably cool: places, seasons, water, air, shade, snow.
  3. Collect sensory detail across senses: what she saw, the temperature on the skin, sounds, smells, the feel of the air when breathing.
  4. Check for negative associations (e.g. cold water linked to an accident) and drop those scenes.
  5. Pick one main scene and one backup. Write down the client's own words to use in suggestions.
• Example language (illustrative): "Think of a time you felt pleasantly cool, maybe outdoors, near water, or on a crisp day. Where were you? What did the air feel like on your face?"
• Watch for: Scenes that are vivid but emotionally loaded, or a client who struggles to visualise (switch to touch or temperature, sounds or breathing; imagery need not be visual). [synthesis]

4.4 Hypnotic induction

• Purpose / when: The start of every hypnosis session and every recording. [source: MDedge (induction in each session); Scientia (standardised script with relaxation suggestions)]
• Steps: The trials used a standard induction transcript, individualised with the client's relaxation and coolness imagery [source: BMC 2011 protocol; JCO 2008 review]. Elkins describes the client sitting or lying comfortably, a focus of attention that begins the induction, eyes closed, and suggestions to deepen relaxation [source: MDedge, 'Dealing with hot flashes? Try hypnosis']. The exact induction technique is [uncertain]. A relaxation-based eye-fixation induction consistent with this description [synthesis]:
  1. The client sits comfortably, feet on the floor, and chooses eyes open or closed.
  2. Fix the gaze on a point; suggest heaviness of the eyelids; allow eye closure.
  3. Slow the breathing; pace the outbreath; suggest a feeling of letting go with each breath.
  4. Progressive relaxation from head to feet, or the reverse.
• Example language (illustrative): "Let your eyes rest on one spot… and when your eyelids feel ready, let them close… With each breath out, let your shoulders settle a little more."
• Watch for: Signs of absorption (slower breathing, facial relaxation, stillness). Distress, fast breathing or a startle points to stopping and grounding (see 5).

4.5 Deepening and relaxation

• Purpose / when: Straight after the induction. Deepens relaxation and absorption; deepening is a named session component. [source: JCO 2008 review; MDedge] Elkins describes relaxation imagery of a "safe, pleasant place", such as a mountain walk or a beach. [source: MDedge, 'Dealing with hot flashes']
• Steps [synthesis on technique]: counting down (e.g. 10 to 1) paired with deeper relaxation, or imagery of descending steps or a path; suggestions of comfortable heaviness in the limbs, lightness and ease. Prefer cool, light wording to the 'warm, heavy' wording of standard relaxation scripts, so it doesn't clash with the target.
• Example language (illustrative): "As I count from ten down to one, let each number take you a little further into calm… comfortable, cool and settled."
• Watch for: Standard relaxation wording that suggests warmth can set off a flush (rephrase to cool or neutral). If drowsiness tips into sleep, keep sessions shorter or sit more upright.

4.6 Individualised cooling imagery

• Purpose / when: The core of each session and recording. Brings on felt coolness. [source: BMC 2011 protocol (imagery for relaxation and coolness individualised to preferences); MDedge (e.g. walking down a mountain path on a cool day); Science News (gentle breeze, water over a fountain, crisp mountain air, a snowy path, breathing in cool air); Evia audio themes (moving snow, cool mountain stream, rock by a lake, internal thermostat, hillside breeze, walking in summer rain, cold misty lake: Scheffrahn et al. 2025)] In Elkins' imagery-preference study (51 breast cancer survivors in a hypnosis trial), each woman named her preferred image before each session; all chose cool images and none warm ones, most often water (27%), then cool air or wind, mountains, forest or leaves, and snow. The authors advise building the imagery on the client's own preferences. [source: Elkins et al. 2010, IJCEH abstract; Baylor news 2010]
• Steps:
  1. Bring in the client's chosen scene using her own sensory details.
  2. Move through the senses: sight, then air on the skin, then sound, then breathing cool air in.
  3. Suggest the coolness spreading through the body, e.g. from the face and chest outward. [synthesis]
  4. Link the coolness to the parts of the body where flushes usually start (ask beforehand). [synthesis]
  5. Give time for the client to signal the feeling (e.g. with a finger) and ask her to rate the coolness afterwards. [synthesis]
• Example language (illustrative): "You are on that mountain path again… the air is crisp and clean… with each breath in, cool air fills your chest, and a gentle coolness spreads across your face, your neck, your shoulders…"
• Watch for: Feeling cold or chilled (lighten it to 'comfortably cool'). A warm scene (e.g. a fire): steer to a cool alternative, since in Elkins' report a participant who used a warm fire image relaxed but her flushes did not decrease [source: Baylor news 2010]. Low vividness is not failure; the felt coolness matters more. Rate vividness and coolness 0–10 after each session. [synthesis]

4.7 Direct and indirect suggestions for coolness, comfort and fewer flushes

• Purpose / when: After the imagery is established, in every session. [source: MDedge (direct and indirect suggestions); Science News (hot-flash-specific therapeutic suggestions)]
• Steps [wording and sequence: synthesis]:
  1. Direct suggestions: clear statements that the body is becoming cooler and more comfortable, that flushes can become less frequent, milder and shorter, and that she will recover from them quickly.
  2. Indirect suggestions: permissive, open wording that lets the client's own response emerge ('you may notice…', 'perhaps sooner than you expect…').
  3. Tie the suggestions to the imagery, e.g. coolness growing with each breath.
  4. Keep claims modest and about experience. Do not suggest that flushes will vanish completely or make medical promises.
• Example language (illustrative): Direct: "Your body is learning to stay cool and calm… flushes can come less often and pass more quickly." Indirect: "You might be curious which part of you notices the coolness first…"
• Watch for: Clients who react against authoritative wording (shift to the indirect form), and disappointment if suggestions are taken too literally (frame them as gradual change).

4.8 Dissociation from the flush

• Purpose / when: In sessions 2–5 once the cool imagery is reliable. Reduces the intensity and distress of flushes. Dissociating from the hot flashes is a named component of the 2008 protocol. [source: JCO 2008 review; MDedge] The trials' dissociation wording is not reproduced here [uncertain].
• Steps [synthesis]:
  1. Suggest that the client can notice a flush as if from a distance, like watching weather pass over hills far away.
  2. Or suggest that the heat stays small and on the surface while a cool core remains.
  3. Rehearse in hypnosis: imagine a flush starting, apply the distancing and coolness, and watch it fade.
• Example language (illustrative): "If a warm wave starts, you can notice it from a comfortable distance… like a passing breeze far away… while your centre stays cool and calm."
• Watch for: Clients with a history of dissociation or trauma. Avoid detachment suggestions, or use only mild ones and check for depersonalisation afterwards. If the client feels 'unreal' afterwards, ground her and drop this component.

4.9 Cue (post-hypnotic) suggestion for in-the-moment use

• Purpose / when: Sessions 2–5. Lets the client use the skill when a flush starts. [synthesis: implied by the self-hypnosis and empowerment emphasis (MDedge; Science News); no published cue procedure was found in the sources cited]
• Steps:
  1. Choose a cue together: a slow cool breath in, a word ('cool', 'breeze'), or touching thumb and finger.
  2. Suggest in hypnosis that using the cue brings back the cool scene and feeling within seconds.
  3. Rehearse it several times inside hypnosis, then once with eyes open before the client leaves.
  4. Assign: use the cue at the first sign of a flush and note in the log whether it helped.
• Example language (illustrative): "Whenever you take one slow breath of cool air and say 'breeze' to yourself, that coolness can return, quickly and easily."
• Watch for: Cue use ending up as a panicky effort to stop flushes ('it has to work') and increasing focus on them. Reframe it as allowing coolness, not fighting heat.

4.10 Suggestions for sleep, stress and mood

• Purpose / when: For clients with night sweats, broken sleep or stress-triggered flushes. Sleep, anxiety, depression and interference all improved in the trials, and sleep is a direct target of the newer trials. [source: JCO 2008 abstract; MDedge; Baylor news; Scientia] The 2013 trial's suggestions covered coolness and relaxation, decreasing psychological stress and improving sleep [source: Scientia PDF feature]; their wording is not reproduced here [uncertain].
• Steps [synthesis]: Add suggestions for going back to sleep easily after waking, a cool bedroom in the imagery, letting go of worry at bedtime, and calm in stressful situations. Assign evening self-hypnosis before sleep.
• Example language (illustrative): "If you wake in the night, you can return to this cool, quiet place… and drift back to sleep."
• Watch for: Insomnia that persists despite fewer flushes (consider CBT-I referral), and depressive symptoms that don't lift (assess and treat). [synthesis]

4.10a Positive suggestions and imagery about the future

• Purpose / when: Late in the session, before re-alerting, from session 2 on. Named as a component of the 2008 protocol. [source: Clinician.com review of JCO 2008] The wording and steps below are [synthesis].
• Steps [synthesis]: (1) Beforehand, ask what she would be doing if flushes troubled her less (sleeping through, a work meeting, a social event). (2) In hypnosis, have her picture one such scene a few weeks ahead, feeling cool, comfortable and confident. (3) Link the scene to her daily self-hypnosis and cue. (4) Keep it realistic and gradual, with no promise of a complete cure.
• Example language (illustrative): "Picture yourself a few weeks from now, at that meeting… calm, comfortable and cool… using what you've practised whenever you need it."
• Watch for: Scenes that stir worry about health or recurrence (choose an everyday scene instead), and over-ambitious images that set up disappointment.

4.11 Re-alerting and debrief

• Purpose / when: The end of every hypnosis segment. The 2008 protocol closes with a suggestion to "return to conscious alertness". [source: Clinician.com review of JCO 2008] The steps below are [synthesis: standard clinical hypnosis practice].
• Steps:
  1. Remove any temporary suggestions (heaviness), keeping the cool comfort and the cue.
  2. Count up (e.g. 1 to 5) with suggestions of alertness and energy; open the eyes.
  3. Check orientation; have the client stand and move.
  4. Debrief: what she noticed, coolness 0–10, anything unpleasant, which words helped or didn't. Adjust the script for next time.
• Example language (illustrative): "As I count from one to five, you'll become fully alert, refreshed and comfortable, bringing the coolness with you… five, eyes open."
• Watch for: Grogginess, headache or emotional reactions. Allow time before she drives.

4.12 Audio recording and daily self-hypnosis practice

• Purpose / when: From session 1 onward. Turns session effects into a daily skill. The trials gave an audio recording of the induction (a cassette in 2008, a CD in 2013) and encouraged daily practice with and without it; a step-by-step self-hypnosis handout was given at session 3. [source: BMC 2011 protocol; JCO 2008 review] Self-administered recordings ran about 20 minutes a day in the 2025 trial and 13–15 minutes in the Evia app; Elkins describes daily 15-minute sessions. [source: 2 Minute Medicine; Scheffrahn et al. 2025; Baylor news 2023]
• Steps:
  1. Record the session's hypnosis segment, or a tidied version, in your voice with the client's imagery.
  2. Agree a daily slot (e.g. after waking or at bedtime) and a quiet place. About 15–20 minutes matches the published recordings. [source: Baylor news 2023; 2 Minute Medicine; Scheffrahn et al. 2025; Science News]
  3. Update the recording as the imagery and suggestions are refined (e.g. after sessions 2 and 4). [synthesis]
  4. Log practice. Review the log at the start of each session and solve any problems.
• Example language (illustrative): "Let's choose the time you're most likely to keep, even on busy days. Ten good minutes beats a skipped twenty."
• Watch for: Practice dropping off after the first week, and listening while driving (forbid it). Clients who fall asleep during bedtime practice can add a daytime session.

4.13 Independent self-hypnosis (fading the recording)

• Purpose / when: Sessions 3–5 and after. From session 2 the 2013 protocol asked whether she preferred self-hypnosis with or without the recording, and gave a step-by-step self-hypnosis handout at session 3. [source: BMC 2011 protocol] The aim is a lasting skill. [source: MDedge; Baylor news and Science News] The procedure below is [synthesis].
• Steps:
  1. Teach a brief self-induction: settle, three slow cool breaths, eyes close, count down from five.
  2. Bring in the cool scene, give herself one or two of her own suggestions, use the cue, then count up.
  3. Practise it in the session with you silent. Debrief.
  4. Assign alternating days with and without the recording, then mainly without.
  5. Write a maintenance plan: daily brief practice, longer sessions during bad weeks, and what to do in a relapse.
• Example language (illustrative): "This time I'll stay quiet. Take yourself into your cool place the way we practised, and come back when you're ready."
• Watch for: Confidence ("I can do it myself") and the hot flash score holding steady after the recording is faded.

4.14 Self-administered audio or telehealth format

• Purpose / when: When in-person sessions aren't possible, as a lower-intensity first step, or for maintenance. [source: 2025 JAMA Netw Open trial via 2 Minute Medicine, Science News and Baylor news (six weeks of daily 20-minute self-administered audio, 250 women, white-noise sham control); Evia app (Scheffrahn et al. 2025); Menopause Society 2023 (trained provider or smartphone app)]
• Steps: Pick a programme based on Elkins' published recordings, or give your own individualised recording. Do the same screening (4.1) and diary (4.2). Hold brief check-ins (e.g. by phone or video at weeks 1, 3 and 6) to review practice and the score. [check-in schedule: synthesis] Step up to in-person sessions if there is little change by week 6. [synthesis]
• Example language (illustrative): "Over the next six weeks, listen once a day and keep your log. We'll speak briefly every couple of weeks to see how it's going."
• Watch for: Generic imagery that doesn't fit this client, and isolation from medical follow-up. Commercial apps: check content and costs before recommending. [synthesis]

4.15 Follow-up and booster

• Purpose / when: About 12 weeks from the start, matching the trial follow-up. [source: MDedge; Scientia] A booster is [synthesis].
• Steps: Review the diary score against baseline, interference, sleep and mood. If flushes have come back, offer one booster session that refreshes the imagery and makes a new recording. Send a short report to the referring physician, with consent.
• Example language (illustrative): "Your score is still well below where you started. Let's update your recording so it keeps matching what works for you now."
• Watch for: A change in medical status (e.g. a change in endocrine therapy) that affects flushes. Coordinate with the prescriber.

Suggested five-session arc [session 1 and 3 elements and the weekly review: 2011 protocol; component list: 2008 review; placing the other components in particular sessions is synthesis]

5. Handling problems

No published guidance on handling problems was found for this protocol. Everything in this section is [synthesis] unless a source is tagged.

• Little change by session 3. First check practice frequency in the log; low practice is the most likely fixable cause. Re-interview for imagery: the scene may be generic or emotionally flat. Try other senses (a cool breath, the feel of cool water) and bring in the cue earlier. Check for medical changes (new medication, a change in endocrine therapy) and refer back to the prescriber. [synthesis] The Menopause Society does not recommend trigger avoidance, cooling techniques or relaxation alone as flush treatments [source: Menopause Society 2023], so don't swap the hypnosis protocol for these. Reductions in the trials built up over the five weeks and grew further by week 12 [source: MDedge; BMC 2012 abstract], so set expectations for gradual change.
• No response after five sessions plus follow-up. Discuss this openly: hypnosis is one option among several. Write to the physician about other treatments (the prescriber decides on medication) and consider CBT for menopausal symptoms, which The Menopause Society also rates Level I, recommended [source: Menopause Society 2023]. Don't keep extending sessions without a change of plan. [synthesis]
• Scepticism or 'I can't be hypnotised'. Frame it as focused relaxation and imagery practice, with nothing done to the client, and offer an eyes-open version. [synthesis] The 2013 trial measured hypnotizability (Stanford Form C) and expectancies only as possible moderators, not entry criteria [source: BMC 2011 protocol], and a follow-up analysis found benefit was not related to women's expectations of whether hypnosis would work [source: Menopause Society 2023, citing Sliwinski & Elkins 2017]. In a small secondary analysis of the breast-cancer-survivor trial (27 hypnosis completers, Stanford Hypnotic Clinical Scale), higher hypnotizability predicted greater flush reduction [source: Elkins et al. 2011, Contemporary Hypnosis and Integrative Therapy, abstract]. Don't screen clients out on hypnotizability or scepticism alone.
• Fear of losing control. Show that she can open her eyes and talk at any time. Let her keep her eyes open for the first induction, and let her choose the wording.
• Imagery that sets off a flush or feels too cold. Some 'warm, heavy' relaxation wording triggers flushes, so change it to cool or neutral wording. If she feels chilled, tone it down to comfortably cool and take out snow or ice.
• Poor home practice. Shorten it (5–10 minutes), tie it to an existing routine, keep the recording on her phone, and use the log as feedback, not judgement. Find out about competing demands (caring roles, work) and solve the problem together.
• Bodily focus increases attention to flushes. Simplify the diary to a nightly tally and stress 'allowing coolness', not watching for heat.
• Overwhelm, an emotional reaction or intrusive memories during hypnosis. Stop the suggestions. Ask her to open her eyes, name things in the room, feel her feet on the floor, and breathe slowly. Debrief without probing the memory. Don't use hypnosis to explore or 'recover' memories. If trauma symptoms appear, pause the hypnosis and assess, then provide or refer for trauma-focused treatment, with safety and stabilisation first.
• Dissociation or depersonalisation after sessions. Drop the dissociation component (4.8), shorten the trance, keep the eyes open, and ground her fully before she leaves.
• Low mood, sleep problems or anxiety beyond flushes. Assess in the usual way, including suicide risk where indicated. Treat or refer, since flushes and mood often go together. Insomnia that persists: consider CBT-I.
• Rupture: the client feels blamed ('it's in my head'). Repair explicitly: flushes are a physiological symptom, and hypnosis is a tool that can change how the body responds and how much the flushes disrupt her life, not proof that they are imaginary. Apologise for wording that felt dismissive.
• Expectation of a cure, or wishing to stop prescribed treatment. Restate that this is an adjunct. Any medication decision goes to the prescriber. Don't encourage stopping endocrine therapy for cancer to reduce flushes; that is a medical decision for the oncology team.
• Breast cancer survivors. Coordinate with oncology. Flushes from endocrine therapy were included in the breast cancer trials [source: JCO 2008 abstract; Baylor news]. Watch for fear of recurrence coming up in imagery. Never describe hypnosis as affecting the cancer.
• Unexpected or changing symptoms (one-sided flushing, palpitations, new night sweats with fever or weight loss). Pause and refer back for medical assessment.
• Self-administered format not engaging her. Step up to in-person individualised sessions.

Sources

Web sources

• Professor Gary Elkins | Hypnosis: A Mind-Body Solution for Hot Flushes and Sleep Post-Menopause and in Breast Cancer Survivors (Scientia). Elkins' lab feature: standardised script, coolness imagery, audio recording, diaries, tele-health trial. Note: the feature gives the exploratory-study session frequency as 'four times per week', which conflicts with the five-weekly-session trials. [uncertain]
• Hypnosis chills out severe postmenopausal hot flashes (MDedge). Session components, individualised imagery, self-hypnosis emphasis, results.
• Self-hypnosis with cooling mental imagery could ease hot flashes (Science News). 2025 self-administered trial, imagery examples, Elkins quotes, app practice time.
• Self-Guided Hypnosis Significantly Reduces Menopausal Hot Flashes (Baylor University news, 2025)
• Randomized Trial of a Hypnosis Intervention for Treatment of Hot Flashes Among Breast Cancer Survivors, abstract (Qigong Institute database)
• Hypnosis for hot flashes among postmenopausal women study: study protocol, abstract (Qigong Institute database)

• Hypnosis for hot flashes among postmenopausal women study: a study protocol of an ongoing randomized clinical trial (BMC Complementary and Alternative Medicine, 2011, full text). Eligibility and exclusions, session 1 and 3 content, weekly review, standard induction transcript individualised with coolness imagery, home CD, control condition, measures, fidelity.
• Hypnosis for hot flashes: results from a randomized clinical trial (BMC Complementary and Alternative Medicine 2012, 12(Suppl 1):O57, conference abstract). Five manualised sessions, therapist fidelity training, assessment points.
• A Cool Head: Hypnosis and Hot Flashes (Clinician.com, review of Elkins et al. JCO 2008). Session length, therapist training, session components, eligibility, closing alert wording.
• The 2023 nonhormone therapy position statement of The North American Menopause Society (The Menopause Society, PDF). Clinical hypnosis Level I, recommended; description of the trials; not-recommended options. The Society's release of 1 June 2023 lists clinical hypnosis and CBT among recommended nonhormone options: press release (PDF).
• User Outcomes for an App-Delivered Hypnosis Intervention for Menopausal Hot Flashes: Retrospective Analysis (JMIR Formative Research, 2025). Evia programme structure and audio themes.
• Managing Menopause: Mind-Body Solutions for Hot Flashes, Sleep and Well-Being (Baylor University news, 2023). Elkins' description of hypnotherapy and the Mind-Body Medicine Research Laboratory.
• Dealing with hot flashes? Try hypnosis (MDedge). Elkins on session structure (position, focus of attention, eyes closed, safe pleasant place).
• Summary of the 2025 JAMA Netw Open self-administered hypnosis trial (2 Minute Medicine). Daily 20-minute audio for six weeks, sham control, entry threshold.
• Preferences for hypnotic imagery for hot-flash reduction: a brief communication (Elkins et al. 2010, IJCEH; University of Arizona research record with abstract). Cool-imagery preferences of 51 breast cancer survivors.
• Baylor Study Finds "Cool" Imagery Lower Hot Flashes Through Hypnotherapy (Baylor University news, 2010). Imagery chosen before each session; imagery categories; the warm-fire example.
• Moderating effect of hypnotizability on hypnosis for hot flashes in breast cancer survivors (Elkins et al. 2011, Contemporary Hypnosis and Integrative Therapy; University of Arizona research record with abstract). Hypnotizability and outcome.
• Gary Elkins feature (Scientia, PDF). Content of suggestions in the 2013 trial (coolness, relaxation, stress, sleep).
• Hypnotic Relaxation Therapy: Principles and Applications (Springer Publishing book page). Table of contents: session-by-session chapters, a chapter on menopausal and hot-flash symptoms, sample transcripts.

Publications cited

• Elkins G, Marcus J, Stearns V, et al. (2008). Randomized trial of a hypnosis intervention for treatment of hot flashes among breast cancer survivors. Journal of Clinical Oncology.
• Elkins GR, Fisher WI, Johnson AK (2011). Hypnosis for hot flashes among postmenopausal women study: a study protocol of an ongoing randomized clinical trial. BMC Complementary and Alternative Medicine, 11:92.
• Elkins G, Fisher WI, Johnson A, Carpenter J, Keith T (2013). Clinical hypnosis in the treatment of post-menopausal hot flashes: a randomized controlled trial. Menopause, 20, 291–298.
• Elkins G, et al. (2025). Self-administered hypnosis vs sham hypnosis for hot flashes: a randomized clinical trial. JAMA Network Open.
• Elkins G (2014). Relief from Hot Flashes: The Natural, Drug-Free Program to Reduce Hot Flashes, Improve Sleep, and Ease Stress. [not drawn on here]
• Elkins G (ed.) (2016). Handbook of Medical and Psychological Hypnosis. Springer. [not drawn on here]

• The North American Menopause Society (2023). The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause, 30(6), 573–590.
• Scheffrahn K, Hall C, Muñiz V, Elkins G (2025). User outcomes for an app-delivered hypnosis intervention for menopausal hot flashes: retrospective analysis. JMIR Formative Research, 9, e63948.
• Sliwinski J, Elkins G (2017). Analysis of response expectancies in the hypnosis for hot flashes trial, as cited in the Menopause Society 2023 statement [uncertain: title as cited secondarily]
• Elkins G, Marcus J, Bunn J, Perfect M, Palamara L, Stearns V, Dove J (2010). Preferences for hypnotic imagery for hot-flash reduction: a brief communication. International Journal of Clinical and Experimental Hypnosis, 58(3), 345–349.
• Elkins G, Fisher W, Johnson A, Marcus J, Dove J, Perfect M, Keith T (2011). Moderating effect of hypnotizability on hypnosis for hot flashes in breast cancer survivors. Contemporary Hypnosis and Integrative Therapy, 28(3), 187–195.
• Elkins GR (2013). Hypnotic Relaxation Therapy: Principles and Applications. Springer Publishing.