Sleep During Perimenopause and Beyond 2: Current evidence-based techniques for managing sleep
So how can we improve sleep during the perimenopause and beyond?
The menopausal transition, also known as perimenopause, is a time replete with physiological changes, particularly vasomotor symptoms (hot flushes and night sweats) and depression (amongst others) - changes that dramatically affect sleep. The management of sleep is complex and requires an understanding of the presenting symptoms as well as other possible health conditions, other sleep disorders, and other medications. In this blog I outline some of the evidence-base for managing sleep during the perimenopause and beyond. *note that I am not a clinician but a sleep scientist – you should always discuss your personal circumstances with a clinical professional and this blog is for an understanding of the scientific research only.
Some research has shown that Hormone Replacement Therapy (HRT) (consisting of oestrogen and progestogen therapies in the UK) contributes to subjective improvements in sleep quality, and possible improvements in sleep fragmentation as measured by polysomnography (the gold standard objective measure of sleep) (1). However, the evidence is mixed as to the robustness of these findings and may only be applicable to women experiencing hot flushes (2). It is likely that HRT reduces hot flushes which consequently improves sleep quality, though firm evidence for this mechanistic link is lacking. It is also not conclusive as to whether HRT reduces symptoms of sleep-disordered breathing (SDB) which is more prevalent in women during the menopause – a recent review of the literature concluded that there are only a few randomised controlled trials (RCTs) evaluating the efficacy of HRT on SDB and that such studies were small and with different HRT regimens administered (3). Despite this, the National Institute for Health and Care Evidence (NICE) confirms that HRT is safe for many women (with some exceptions such as those with a history of, or at high risk for, breast cancer, ovarian cancer or womb cancer; blood clots; high blood pressure or liver disease - please refer to the NICE guidelines (4) and NHS guidance (5) for advice), and may be associated with improvements in quality of life (1).
However, access to HRT has become increasingly challenging, particularly within the UK due to recent shortages in the availability of some preparations. The British Menopause Society have issued updated guidance to practitioners with advice for managing this HRT shortage (6).
Whilst often used off-label to treat sleep disturbances, Selective Serotonin Reuptake Inhibitors (SSRIs) have been shown to improve sleep quality in some women experiencing vasomotor symptoms such as hot flushes (7), and are often prescribed in women who also experience mood disorder. Though it should be noted that some SSRIs can contribute to sleep disruption in some individuals. Therefore, treatment of insomnia and poor sleep quality should be tailored to the individual, taking into consideration age, comorbidities, other sleep disorders, other medications and daily responsibilities.
Perhaps the most common approach to managing disturbed sleep in adults is the use of sedative hypnotic medications such as the ‘Z’- drugs (eszopiclone, zolpidem and zaleplon), despite the fact that these are not considered the first-line of treatment. However, they should only be administered on a short-term basis, and infrequently, due to dependency and withdrawal effects, as well as risk of adverse side effects such as daytime sleepiness and its consequences (cognitive impairments, risk of falls, driving accidents to name a few), parasomnias, rebound insomnia, cardiovascular events and some evidence of increased mortality (8-11).
But what else can be offered to improve sleep? Cognitive Behavioural Therapy for Insomnia (CBT-I) is a multicomponent therapy aimed at tackling the underlying causes of insomnia, and is the first line treatment for insomnia in the general population (12). CBT-I can be adapted to address insomnia symptoms specific to women transitioning through the menopause (13). Numerous randomised controlled trials have demonstrated CBT-I to be more effective at improving sleep compared to pharmacological therapies (14), and has been shown to improve not only sleep but other indices of quality of life in post-menopausal women (15). Whilst CBT-I is traditionally delivered in person with a trained therapist either individually or in group sessions, lack of availability of trained providers has limited its reach. The European Insomnia Network are working towards increasing availability through the development of a training academy (12). That said, digital CBT-I in the form of mobile apps has been demonstrated to reduce insomnia severity, and improve various markers of sleep quality and insomnia (16, 17). Whilst access to some of these apps is available on the NHS in a small number of areas of the UK, it is hoped that access to digital CBT-I is rolled out more routinely nationwide. It is possible to subscribe to such apps without a prescription, with annual subscription costs ranging from £200-£300 in the UK (at the time of writing).
Novel non-hormonal treatments for reducing hot flushes and managing insomnia post-menopause are on the horizon (18, 19), but whether these treatments are effective and safe during the perimenopause is yet to be determined. A surge of interest and understanding of the perimenopause is paving the way towards developments in research and novel treatments.
Thankfully conversations about perimenopause and menopause are opening up, and have lead to the development of excellent support forums offering advice, support and expertise in a range of lifestyle areas, such as The Perimenopause Hub – set up by my amazing Sister-in-law, Emily Barclay. In fact, her experience, passion and motivation to increase awareness of perimenopause inspired me to pursue this as an area of research interest, so you’re reading this today as a result of the fantastic work Emily is doing supporting thousands of women worldwide.
In the next blog in this series, I outline some of my thoughts on where research needs to turn next, and ways that society needs to adapt to increase the chances of a good night sleep during the perimenopause and beyond.
1. Joffe H, Massler A, Sharkey KM. Evaluation and management of sleep disturbance during the menopause transition. Seminars in Reproductive Medicine 2010;28:404-21.
2. Schaedel Z, Holloway D, Bruce D, Rymer J. Management of sleep disorders in the menopausal transition. Post Reproductive Health 2021;27:209-14.
3. Lindberg E, Bonsignore MR, Polo-Kantola P. Role of menopause and hormone replacement therapy in sleep-disordered breathing. Sleep Medicine Reviews 2020;49:101225.
4. National Institute for Health and Care Excellence. Menopause: diagnosis and management 2015.
5. NHS. Overview: Hormone Replacement Therapy. 2019 [cited 2022 04.05.2022]; Available from: https://www.nhs.uk/conditions/hormone-replacement-therapy-hrt/
6. British Menopause Society. British Menopause Society update on HRT supply. 2022 [cited; Available from: https://thebms.org.uk/news/british-menopause-society-update-on-hrt-supply/
7. Ensrud KE, Guthrie KA, Hohensee C, et al. Effects of estradiol and venlafaxine on insomnia symptoms and sleep quality in women with hot flashes. Sleep 2015;38:97-108.
8. Choi J-W, Lee J, Jung SJ, Shin A, Lee YJ. Use of sedative-hypnotics and mortality: a population-based retrospective cohort study. Journal of Clinical Sleep Medicine 2018;14:1669-77.
9. Lan T-Y, Zeng Y-F, Tang G-J, et al. The use of hypnotics and mortality-a population-based retrospective cohort study. PloS one 2015;10:e0145271.
10. Kim Y-H, Kim H-B, Kim D-H, Kim J-Y, Shin H-Y. Use of hypnotics and the risk of or mortality from heart disease: a meta-analysis of observational studies. The Korean Journal of Internal Medicine 2018;33:727.
11. Bragg S, Benich J, Christian N, Visserman J, Freedy J. Updates in insomnia diagnosis and treatment. The International Journal of Psychiatry in Medicine 2019;54:275-89.
12. Baglioni C, Altena E, Bjorvatn B, et al. The European Academy for Cognitive Behavioural Therapy for Insomnia: An initiative of the European Insomnia Network to promote implementation and dissemination of treatment. Journal of Sleep Research 2020;29:e12967.
13. Meers JM, Dawson DB, Nowakowski S. CBT-I for perimenopause and postmenopause. Adapting Cognitive Behavioral Therapy for Insomnia: Elsevier, 2022:333-46.
14. Jacobs GD, Pace-Schott EF, Stickgold R, Otto MW. Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison. Archives of Internal Medicine 2004;164:1888-96.
15. Kalmbach DA, Cheng P, Arnedt JT, et al. Improving daytime functioning, work performance, and quality of life in postmenopausal women with insomnia: comparing cognitive behavioral therapy for insomnia, sleep restriction therapy, and sleep hygiene education. Journal of Clinical Sleep Medicine 2019;15:999-1010.
16. Soh HL, Ho RC, Ho CS, Tam WW. Efficacy of digital cognitive behavioural therapy for insomnia: a meta-analysis of randomised controlled trials. Sleep Medicine 2020;75:315-25.
17. Luik AI, Kyle SD, Espie CA. Digital cognitive behavioral therapy (dCBT) for insomnia: a state-of-the-science review. Current Sleep Medicine Reports 2017;3:48-56.
18. Trower M, Anderson RA, Ballantyne E, Joffe H, Kerr M, Pawsey S. Effects of NT-814, a dual neurokinin 1 and 3 receptor antagonist, on vasomotor symptoms in postmenopausal women: a placebo-controlled, randomized trial. Menopause (New York, NY) 2020;27:498.
19. Simon J, Anderson RA, Ballantyne E, et al. OR11-03 NT-814, a non-hormonal dual neurokinin 1, 3 receptor antagonist markedly improves vasomotor symptoms in post-menopausal women; results of a randomised, double-blind, placebo-controlled, dose-finding study (SWITCH-1). Journal of the Endocrine Society 2020;4:OR11-03.