What are the best sleep aids for perimenopause?

From the Guidelines

To improve sleep during perimenopause, cognitive behavioral therapy for insomnia (CBT-I) is the most effective approach, as it has shown excellent results without medication side effects, and should be considered as the first line of treatment. This approach is supported by the American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment, which found that CBT-I is a effective treatment for chronic insomnia disorder in adults 1. The components of CBT-I include:

• Stimulus control: a set of instructions designed to extinguish the association between the bed/bedroom and wakefulness and establish a consistent wake-time
• Sleep restriction therapy: a method designed to enhance sleep drive and consolidate sleep by limiting time in bed equal to the patient’s sleep duration
• Relaxation therapy: structured exercises designed to reduce somatic tension and cognitive arousal
• Cognitive therapy: a set of strategies including structured psychoeducation, Socratic questioning, use of thought records, and behavioral experiments designed to identify and modify unhelpful beliefs about sleep
• Sleep hygiene: a set of general recommendations about lifestyle and environmental factors that may promote or interfere with sleep In addition to CBT-I, other approaches that may be helpful include:
• Establishing a consistent sleep schedule and creating a cool, dark bedroom environment
• Practicing relaxation techniques like deep breathing or meditation before bed
• Limiting screen time at least one hour before sleeping
• Regular exercise during the day, but avoiding vigorous activity close to bedtime
• Dietary approaches, such as limiting caffeine after noon, avoiding large meals before bed, and considering foods rich in magnesium like nuts and leafy greens
• Hormone therapy, which may be effective for severe sleep disruptions, but should be discussed with a healthcare provider about low-dose estrogen options
• Over-the-counter sleep aids, such as melatonin (start with 1-3mg taken 1-2 hours before bed) and magnesium supplements (300-400mg daily), but these should be used with caution and under the guidance of a healthcare provider. It's also important to note that prescription medications, such as low-dose antidepressants (such as 7.5-25mg of doxepin) or sleep medications, may be appropriate for short-term use, but should be used with caution and under the guidance of a healthcare provider, as they can have significant side effects and risks, as highlighted in the American College of Physicians clinical practice guideline 1.

From the FDA Drug Label

Helps establish normal sleep patterns nighttime sleep aid for occassional sleeplessness

• Melatonin may help with sleep during perimenopause, as it is a nighttime sleep aid for occasional sleeplessness.
• The drug label states it helps establish normal sleep patterns. 2

From the Research

Sleep Help Options for Perimenopause

• Non-pharmacological treatments, such as cognitive behavioral therapy, physical exercise, and mindfulness/relaxation, have been shown to be effective in improving sleep outcomes among perimenopausal and postmenopausal women 3
• Hormone therapy or non-hormonal pharmacological treatments can be considered according to the patient's specific needs and risk factors 4
• Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have been found to be effective in alleviating hot flashes, which can disrupt sleep, with escitalopram, paroxetine, and fluoxetine showing higher efficacy and safety 5
• Selective estrogen receptor modulators (SERMs), such as raloxifene and bazedoxifene, can help prevent postmenopausal osteoporosis, but may not reduce climacteric symptoms like hot flushes 6
• A tissue selective estrogen complex (TSEC), combining a SERM with estrogen, such as bazedoxifene with conjugated estrogens (BZA/CE), has been shown to improve sleep, reduce hot flushes, and protect the skeleton 6

Factors Affecting Sleep in Perimenopause

• Fluctuations in estrogen and progesterone can affect sleep quality 4
• Vasomotor symptoms, such as night sweats, can disrupt sleep 4, 7
• Circadian changes, decreased melatonin production, and physiological changes associated with aging and mood disorders can further exacerbate sleep disturbances 4
• Insomnia, sleep-related breathing disorders, and movement disorders are common among perimenopausal women 4