What are the treatment options for sleep disturbances in perimenopausal women?

Treatment of Sleep Disturbances in Perimenopausal Women

Start with cognitive behavioral therapy for insomnia (CBT-I) as first-line treatment, as it provides superior long-term outcomes with effects sustained for up to 2 years without medication-related risks. 1

Initial Assessment and Diagnosis

Before initiating treatment, identify the specific type of sleep disturbance and contributing factors:

• Screen for primary insomnia (difficulty falling asleep and/or maintaining sleep at least 3 times per week for at least 4 weeks with associated distress) 2
• Evaluate for obstructive sleep apnea (OSA) if excessive sleepiness is accompanied by observed apneas or snoring, using the STOP questionnaire as a screening tool 2
• Assess for restless legs syndrome (RLS) if uncomfortable sensations or urge to move legs occur, worsening at night and with inactivity; check ferritin levels, as levels <45-50 ng/mL indicate a treatable cause 2
• Review all medications that may cause or exacerbate insomnia, including β-blockers, bronchodilators, corticosteroids, decongestants, diuretics, SSRIs, and SNRIs 1
• Recognize that sleep disturbances in perimenopause result from hormonal fluctuations (estrogen and progesterone), vasomotor symptoms disrupting sleep, circadian changes, decreased melatonin production, and mood disorders 3, 4

First-Line Treatment: Non-Pharmacological Interventions

Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT-I should be the initial intervention for all perimenopausal women with chronic insomnia, combining multiple behavioral treatments with cognitive restructuring 1:

• Sleep restriction/compression therapy: Limit time in bed to match actual sleep time; sleep compression is better tolerated by older adults than immediate restriction 1
• Stimulus control: Use bedroom only for sleep and sex, leave bedroom if unable to fall asleep within 20 minutes, maintain consistent sleep and wake times 1
• Cognitive restructuring: Address unrealistic sleep expectations and anxiety about sleep 1
• Relaxation techniques: Progressive muscle relaxation, guided imagery, and diaphragmatic breathing to achieve calm state conducive to sleep onset 2, 1

Sleep Hygiene Education

Sleep hygiene is most effective when combined with other CBT-I modalities, not as standalone treatment 2, 1:

• Regular morning or afternoon exercise 2
• Daytime exposure to bright light 2
• Keep sleep environment dark, quiet, and comfortable 2
• Avoid heavy meals, alcohol, and nicotine near bedtime 2
• Avoid caffeine in the evening 1
• Avoid heavy exercise within 2 hours of bedtime 1

Physical Activity

• Standardized yoga interventions improve global and subjective sleep quality, daytime functioning, and sleep efficiency in women with moderate to severe sleep disruption 2
• Regular exercise improves sleep at 12-week follow-up 2

Second-Line Treatment: Pharmacological Interventions

Pharmacotherapy should only be considered when CBT-I alone has been unsuccessful, using shared decision-making that discusses benefits, harms, and costs of short-term medication use 1.

Medication Selection Based on Symptom Pattern

For sleep onset insomnia:

• Ramelteon or short-acting Z-drugs (zolpidem) 1

For sleep maintenance insomnia:

• Low-dose doxepin (3-6 mg) is the most appropriate medication for older adults with sleep maintenance insomnia, demonstrating improvement in total sleep time, wake after sleep onset, and sleep quality 1
• Suvorexant (orexin receptor antagonist) 1

For both onset and maintenance:

• Eszopiclone (start at 1-2 mg in elderly patients) 1, 5
• Extended-release zolpidem 1

Alternative Pharmacological Options

For perimenopausal women specifically:

• Hormone therapy can improve insomnia related to vasomotor symptoms 5, 6
• Gabapentin has shown efficacy for sleep disturbances in menopause 5, 6
• Escitalopram is suggested for perimenopausal insomnia 5
• Isoflavones may be considered, though evidence is limited 5, 6

Other options that may be considered:

• Citalopram, mirtazapine followed by long-acting melatonin 5, 7
• Ramelteon (melatonin receptor agonist) 1, 7

Medications to AVOID

Critical pitfalls to avoid in perimenopausal/older women:

• Benzodiazepines (including temazepam) should be avoided due to higher risk of falls, cognitive impairment, dependence, and potential acceleration of dementia 1, 7
• Over-the-counter antihistamines (diphenhydramine, hydroxyzine) should be avoided due to anticholinergic effects that can accelerate dementia progression 1
• Tricyclic antidepressants should be avoided in older adults with potential cognitive decline due to anticholinergic burden 1
• Barbiturates and chloral hydrate are not recommended 1
• Herbal supplements (valerian, melatonin) are not recommended due to lack of efficacy and safety data, though melatonin 2 mg may have limited benefit in specific cases 1, 5

Treatment of Specific Sleep Disorders

Obstructive Sleep Apnea

• Continuous positive airway pressure (CPAP), surgery, or oral appliances 2
• Weight loss and exercise 2
• Referral to sleep specialist 2

Restless Legs Syndrome

• Dopamine agonists, benzodiazepines, gabapentin, and/or opioids 2
• Calcium channel alpha-2-delta ligands (gabapentin) are helpful in reducing RLS symptoms 2
• Referral to sleep specialist 2

Monitoring and Long-Term Management

• Start all medications at the lowest available dose due to reduced drug clearance and increased sensitivity in perimenopausal/older women 1
• Follow patients every few weeks initially to assess effectiveness and side effects 1
• Employ the lowest effective maintenance dosage and taper when conditions allow 1
• Medication tapering and discontinuation are facilitated by CBT-I, making concurrent behavioral therapy essential even during pharmacotherapy 1
• For chronic hypnotic medication use, administration may be nightly, intermittent (three nights per week), or as needed, with consistent follow-up 1
• Regular reassessment is necessary to evaluate treatment effectiveness and monitor for adverse effects 1

Common Pitfalls

• Do not add hypnotic medication before attempting CBT-I, as behavioral interventions are more effective long-term and avoid polypharmacy risks 1
• Do not assume sleep hygiene education alone will suffice, as it must be combined with other CBT-I modalities for chronic insomnia 1
• Do not overlook medications as culprits, particularly SSRIs which commonly cause or worsen insomnia in perimenopausal women 1
• Do not use long-term benzodiazepines, even at low intermittent doses, as they are associated with increased risk of dementia 1
• Recognize that undiagnosed OSA can have dramatic health consequences; refer women with persisting sleep disturbances to a sleep specialist for comprehensive assessment 6