Treating insomnia across women’s life stages
Changes during menstruation, pregnancy, and menopause often impact sleep
Table 4
Treating insomnia in menopausal women
| Therapy | Comments |
|---|---|
| Hormone replacement therapy (HRT) | Effective for hot flashes, insomnia,26-28 and sleep apnea29 Long-term safety is questionable4 |
| Behavioral therapy (cognitive-behavioral therapy,30 stimulus control therapy, sleep restriction therapy, sleep hygiene, hypnotherapy, biofeedback) | Limited data in menopausal women |
| Sedatives/hypnotics/antidepressants (eg, zolpidem, 10 mg; eszopiclone, 3 mg; trazodone, 75 mg; ramelteon, 8 mg; SSRIs and SNRIs) | Benzodiazepines may be useful, although not specifically evaluated in menopausal women. Risk of tolerance, dependence, and psychomotor slowing |
| Herbal and dietary supplements (Cimicifuga racemosa [Black cohosh],31 valerian | Popular alternatives to HRT; however, evidence of efficacy as treatment for insomnia is inconclusive |
| SNRIs: serotonin-norepinephrine reuptake inhibitors; SSRIs: selective serotonin reuptake inhibitors | |
Comorbid psychiatric disorders
Women have a higher prevalence of psychiatric disorders such as major depressive disorder and anxiety disorders than men.1 Women have a 10% to 25% lifetime risk of developing major depression. Three quarters of depressed patients experience insomnia.1 Recent literature suggests insomnia is a risk factor for depression,33 which emphasizes the need to screen women who present with sleep problems for depression and anxiety.
Five percent to 20% of women experience postpartum depression. Depression and insomnia are correlated to the rapid decline in estrogen and progesterone after delivery.34
Treatment strategy. Insomnia is a common presenting symptom in patients with psychiatric conditions such as mood and anxiety disorders. Treating the underlying psychiatric disorder often alleviates sleeping difficulties. However, if the insomnia is disabling, treat the psychiatric disorder and insomnia concurrently.
CASE CONTINUED: Perimenopausal insomnia
Based on her history, you diagnose Ms. A with insomnia related to general medical condition (perimenopause). There are no indications to refer her for polysomnography. You educate Ms. A about sleep hygiene and recommend that she discuss her menstrual and physical complaints with her primary care physician or gynecologist. Ms. A is not interested in HRT because she has a strong family history of endometrial cancer. You reassure Ms. A and schedule a follow-up visit in 2 months to re-evaluate her insomnia.
Related resource
- Krahn LE. Perimenopausal depression? Ask how she’s sleeping. Current Psychiatry. 2005;4(6):39-53.
Drug brand names
- Carbamazepine • Carbatrol, Tegretol, others
- Escitalopram • Lexapro
- Eszopiclone • Lunesta
- Fluoxetine • Prozac
- Gabapentin • Neurontin, Gabarone
- Paroxetine • Paxil
- Pramipexole • Mirapex
- Ramelteon • Rozerem
- Ropinirole • Requip
- Sertraline • Zoloft
- Trazodone • Desyrel
- Zolpidem • Ambien
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Acknowledgements
The authors thank Dr. Namita Dhiman and Darrel E. Willoughby for their assistance with this article.
