Assessment and treatment for insomnia and fatigue in the symptomatic menopausal woman with psychiatric comorbidity

Sleep effects of psychological therapies for menopausal symptoms in women with hot flashes and night sweats: A systematic review

Sleep disturbance is frequently reported by women during the menopausal transition due to various physiological changes and environmental factors. Insomnia is a critical treatment target for its deleterious effects on daytime functioning and quality of life and increased risk of developing a depressive disorder. Due to medication side effects and patient preferences, there is increased interest in the use of psychological treatments that address the myriad of menopausal symptoms, including cognitive-behavioural therapy, clinical hypnosis and mindfulness-based therapies. The objective of this article is to review the effects of psychological treatments for menopausal symptoms on sleep disturbance in peri-/postmenopausal women. We conducted a systematic review of the literature using PubMed and reference lists from inception until May 2023, including 12 studies that evaluated sleep as a secondary outcome. Most studies found that group and self-help (guided and unguided) cognitive-behavioural therapies and clinical hypnosis for menopausal symptoms have positive effects on sleep among women with significant vasomotor symptoms. There was preliminary support for mindfulness-based stress reduction. Future research including more diverse samples and women with sleep disorders is needed. Evaluating the implementation of psychological therapies in clinics where menopausal women seek care is an important next step.

Cognitive-behavioral, behavioural and mindfulness-based therapies for insomnia in menopause

OBJECTIVES

Insomnia is frequently reported by women during menopause due to physiological changes and environmental factors and is associated with negative daytime sequelae. Due to medication side effects and patient preferences, there is increased interest in the use of psychological treatments for menopausal insomnia. The primary objective of this review is to review the efficacy of cognitive-behavioral, behavioral, and mindfulness-based (CBBMB) therapies in treating insomnia in peri- and post-menopausal women. The secondary objective is to review the effect of CBBMB therapies on relevant secondary outcomes to gain a comprehensive understanding of their impacts.

METHODS

We conducted a narrative review of the literature. A search of PubMed and Google Scholar was conducted between January 2020 and March 2021.

RESULTS

Cognitive-behavioral therapy (CBT) for insomnia is efficacious, with corollary improvements in mood, functional outcomes and potential mechanistic factors (e.g., unhelpful beliefs). Sleep restriction therapy is also efficacious, with somewhat poorer effects on secondary outcomes relative to CBT. Mindfulness meditation and relaxation for insomnia demonstrated promise, but its long-term effects remain unknown.

CONCLUSIONS

Research with more diverse samples and head-to-head comparisons is needed. Dissemination of CBBMBs for insomnia in clinics where menopausal women seek care is an important next step.

Menopausal Symptoms and Their Management

The menopause transition is associated with various symptoms, which can interact to produce morbidity. Vasomotor symptoms are the most commonly reported, but vaginal dryness/dyspareunia, sleep difficulties and adverse mood changes have all been shown to worsen as women approach menopause. For postmenopausal women changes in cognition are more likely to be related to aging and not to hormones. This article reviews the symptoms of hot flashes (vasomotor symptoms), vaginal dryness/dyspareunia, adverse mood, poor sleep/insomnia, and cognitive complaints, describing their epidemiology, diagnosis, and treatment. This article thus reviews the epidemiology, pathophysiology, diagnosis, and treatment of these common menopausal symptoms.

Treatment of Insomnia, Insomnia Symptoms, and Obstructive Sleep Apnea During and After Menopause: Therapeutic Approaches

Understanding sleep complaints among menopausal women is an emerging area of clinical and research interest. Several recent reviews have focused on mechanisms of menopausal insomnia and symptoms. In this review, we present a discussion on the most relevant and recent publications on the treatment of sleep disorders for menopausal women, with a focus on menopause-related insomnia, insomnia symptoms, and obstructive sleep apnea. We discuss both nonpharmacological and pharmacological treatments, including cognitive-behavioral therapy for insomnia (CBT-I), complementary and alternative medicine, hormone replacement therapy, sedative hypnotics, antidepressants, and continuous positive airway pressure. In addition, we briefly discuss methods and considerations of assessment of sleep disorders in menopausal women.

Evaluation and management of sleep disturbance during the menopause transition

Sleep disturbances in midlife women are common and have been associated with the menopause transition itself, symptoms of hot flashes, anxiety and depressive disorders, aging, primary sleep disorders (i.e., obstructive sleep apnea, periodic limb movement disorder), comorbid medical conditions and medications, as well as with psychosocial and behavioral factors. Because there are several common sources of sleep problems in midlife women, the cause of an individual woman's sleep disturbance may be multifactorial. Effective behavioral and pharmacological therapies are available to treat sleep disturbances of different etiologies. This review provides an overview of different types of sleep disturbance occurring in midlife women and presents data supporting the use of hormone therapy, hypnotic agents, and behavioral strategies to treat sleep problems in this population. The review aims to equip clinicians evaluating menopause-age women with the knowledge and evaluation tools to diagnose, engage sleep experts where appropriate, and treat sleep disturbance in this population. Sleep disorders in midlife women should be treated because substantial improvements in quality of life and health outcomes are achievable.

Effects of sleep disturbance on the quality of life of Turkish menopausal women: a population-based study

OBJECTIVES

The purpose of this study was to investigate sleep disturbances among menopausal women: their prevalence, risk factors for them and the quality of life of women who have them.

DESIGN

A population-based sample of 887 Turkish women aged 45-59 years and living in Malatya was recruited in this cross-sectional descriptive study. The women were administered the Interview Form, which covers sociodemographic, health and lifestyle variables, as well as the Women's Health Initiative Insomnia Rating Scale, the Menopause Specific Quality of Life Questionnaire and the Beck Depression Inventory.

RESULTS

The prevalence of sleep disturbance in this sample of menopausal women was 54%. Logistic regression models revealed that the risk of sleep disturbance was 2.4 times higher in the perimenopausal than in the premenopausal period, 1.7 times higher among those who received hormone therapy than among those who did not, 1.5 times higher among those with a physical disease than among those without, and 3.9 times higher among those with depression than among those without; an increase of one year in age was associated with a 5% increase in the prevalence of sleep disturbance. Average scores on the vasomotor, psychosocial, physical and sexual sub-scales of the Menopause Specific Quality of Life Questionnaire were significantly higher for women with sleep disturbance than for those without (P<0.001).

CONCLUSIONS

The prevalence of sleep disturbance was found to be high among menopausal women. Initiatives aimed at reducing sleep disturbance should be added to menopausal care programmes in order to improve the quality of life of menopausal women.

Depressed mood but not fatigue mediate the relationship between physical activity and perceived stress in middle-aged women

OBJECTIVE

To determine whether depressed mood and fatigue mediate the relationships between physical activity, body mass index, menopausal hot flashes, and perceived stress.

METHOD

This study is a secondary analysis of data obtained from a sub-sample of peri- and postmenopausal women (N=212) from the TREMIN Research Program on Women's Health.

RESULTS

The hypothesized mediational model was tested using path analysis within a structural equation modeling framework in Mplus Version 5.1. In unadjusted analysis, the relationships between physical activity, menopausal hot flashes, and perceived stress were mediated by depressed mood; fatigue mediated the relationships between hot flashes, body mass index, and perceived stress. When adjusting for age, insomnia, menopausal and hormone use status, the mediational effects of depressed mood on stress remained significant only for physical activity, and fatigue mediated the relationship between hot flashes and stress. The adjusted model explained 70% of variance in perceived stress, 82% of variance in depressed mood, and 81% of variance in fatigue.

CONCLUSION

Depressed mood may partially explain the relationship between physical activity and perceived stress in middle-aged women, however further studies are needed to corroborate causality.

Sleep and menopause

Understanding sleep complaints of menopausal women is an emerging area of clinical and research interest. In this article, we summarize the most relevant and recent literature to provide an update on sleep in perimenopause and postmenopause. Our discussion includes the causes, clinical diagnosis, and treatment of sleep disorders in perimenopausal and postmenopausal women.