Treatment of chronic insomnia disorder in menopause: evaluation of literature

Sleep During Menopause

Postmenopause is defined retrospectively after 12 consecutive months of amenorrhea. It represents the end of the reproductive period and ovarian failure. A decrease in estrogen leads to several changes in the short and long term. Among the early changes, vasomotor symptoms (hot flashes) are particularly common, occurring in about 70% of women. In addition, there are changes in mood, anxiety, depression, and insomnia. Insomnia occurs in almost 60% of postmenopausal women. Psychosocial aspects may also affect sleep. Proper diagnosis may lead to adequate treatment of sleep disturbances during menopause. Hormonal or other complementary therapies can improve sleep quality.

Management of perimenopausal and menopausal symptoms

Most women worldwide experience menopausal symptoms during the menopause transition or postmenopause. Vasomotor symptoms are most pronounced during the first four to seven years but can persist for more than a decade, and genitourinary symptoms tend to be progressive. Although the hallmark symptoms are hot flashes, night sweats, disrupted sleep, and genitourinary discomfort, other common symptoms and conditions are mood fluctuations, cognitive changes, low sexual desire, bone loss, increase in abdominal fat, and adverse changes in metabolic health. These symptoms and signs can occur in any combination or sequence, and the link to menopause may even be elusive. Estrogen based hormonal therapies are the most effective treatments for many of the symptoms and, in the absence of contraindications to treatment, have a generally favorable benefit:risk ratio for women below age 60 and within 10 years of the onset of menopause. Non-hormonal treatment options are also available. Although a symptom driven treatment approach with individualized decision making can improve health and quality of life for midlife women, menopausal symptoms remain substantially undertreated by healthcare providers.

A Longitudinal Study of Sleep Habits and Leukemia Incidence Among Postmenopausal Women

We sought to assess the relationship between sleep duration, sleep disturbance, and leukemia incidence among postmenopausal women. This study included 130,343 postmenopausal women aged 50-79 years who were enrolled in the Women's Health Initiative (WHI) during 1993-1998. Information on self-reported typical sleep duration and sleep disturbance was obtained by questionnaire at baseline, and sleep disturbance level was defined according to the Women's Health Initiative Insomnia Rating Scale (WHIIRS). WHIIRS scores of 0-4, 5-8, and 9-20 comprised 37.0%, 32.6%, and 30.4% of all women, respectively. After an average of 16.4 years (2,135,109 cumulative person-years) of follow-up, 930 of the participants were identified as having incident leukemia. Compared with women with the lowest level of sleep disturbance (WHIIRS score 0-4), women with higher sleep disturbance levels (WHIIRS scores of 5-8 and 9-20) had 22% (95% confidence interval (CI): 1.04, 1.43) and 18% (95% CI: 1.00, 1.40) excess risks of leukemia, respectively, after multivariable adjustment. A significant dose-response trend was found for the association between sleep disturbance and leukemia risk (P for trend = 0.048). In addition, women with the highest level of sleep disturbance had a higher risk of myeloid leukemia (for WHIIRS score 9-20 vs. WHIIRS score 0-4, hazard ratio = 1.39, CI: 1.05, 1.83). Higher sleep disturbance level was associated with increased risk of leukemia, especially for myeloid leukemia among postmenopausal women.

Efficacy and safety of lemborexant in midlife women with insomnia disorder

OBJECTIVE

Insomnia is common in midlife women. The efficacy and safety of lemborexant (LEM), a competitive dual orexin receptor antagonist, was assessed for 12 months in a subgroup of midlife women (age, 40-58 y) from Study E2006-G000-303 (Study 303; SUNRISE-2).

METHODS

This was a randomized, double-blind, placebo (PBO)-controlled (first 6 mo) study of adults with insomnia disorder ( N = 949). During treatment period 1 (TP1), participants received PBO or LEM 5 mg (LEM5) or 10 mg (LEM10). During TP2 (second 6 mo), LEM participants continued their assigned dose; PBO participants were rerandomized to LEM5 or LEM10. Assessments included patient-reported sleep- and fatigue-related measures and treatment-emergent adverse events.

RESULTS

The midlife female subgroup comprised 280 of 949 participants (TP1: PBO, n = 90 of 318 [28.3%]; LEM5, n = 82 of 316 [25.9%]; LEM10, n = 108 of 315 [34.3%]). At 6 months, median changes from baseline in subjective sleep-onset latency (in minutes) were -17.9, -20.7, and - 30.4 for PBO, LEM5, and LEM10 (vs PBO: LEM5, P = not significant; LEM10, P = 0.0310). At 6 months, mean changes from baseline in subjective wake after sleep onset (in minutes) were -37.0 (59.6), -50.1 (74.5), and -54.5 (65.4) for PBO, LEM5, and LEM10 (vs PBO: LEM5 and LEM10, P = not significant), with benefits sustained through 12 months. Greater decreases from baseline (improvement) in Insomnia Severity Index total score and Fatigue Severity Scale total score were seen with LEM versus PBO at 6 months; benefits continued through 12 months. Most treatment-emergent adverse events were mild to moderate in severity.

CONCLUSIONS

Consistent with the total population, subjective sleep parameters improved, and improvement was sustained over time in midlife women. LEM was well tolerated, suggesting that LEM may be a potential treatment option for midlife women with insomnia.

Optimizing sleep across the menopausal transition

Women frequently experience sleep disturbances, particularly night-time awakenings, as they transition menopause and enter postmenopause. Sleep is essential for optimal functioning and health. Persistent and distressing sleep disturbances across menopause can negatively impact daytime functioning and productivity, and increase risk for mental and physical health conditions. While multiple factors can disturb sleep, two unique factors in the context of menopause are vasomotor symptoms and the changing reproductive hormone environment. Vasomotor symptoms are associated with sleep disturbances and contribute significantly to awakenings and amount of time spent awake during the night. Even after accounting for vasomotor and depressive symptoms, lower estradiol and higher follicle stimulating hormone levels, indicative of menopause, are associated with sleep disturbance, particularly awakenings, suggesting that the hormone environment may directly affect sleep. Management strategies for clinically significant menopausal sleep disturbances include cognitive behavioral therapy for insomnia, which is effective and durable in treating menopausal insomnia. Hormone therapy alleviates sleep disturbances, particularly in the presence of disruptive vasomotor symptoms. Sleep disturbances have a significant impact on women's functioning and health, and there is a need for further research of the underlying mechanisms to advance effective preventative and treatment strategies that ensure optimal health and well-being of midlife women.

Effect of Vitamin E Supplementation on Chronic Insomnia Disorder in Postmenopausal Women: A Prospective, Double-Blinded Randomized Controlled Trial

Chronic insomnia disorder is one of the most common problems in postmenopausal women, exacerbated by underdiagnosis and improper treatment. This double-blinded, randomized, placebo-controlled trial was conducted to evaluate the potential of vitamin E to treat chronic insomnia as an alternative to sedative drugs and hormonal therapy. The study enrolled 160 postmenopausal women with chronic insomnia disorder, divided randomly into two groups. The vitamin E group received 400 units of mixed tocopherol daily, while the placebo group received an identical oral capsule. The primary outcome of this study was sleep quality assessed by the Pittsburgh Sleep Quality Index (PSQI), a self-evaluated and standardized questionnaire. The secondary outcome was the percentage of participants using sedative drugs. There were no significant differences in baseline characteristics between the study groups. However, the median PSQI score at baseline was slightly higher in the vitamin E group compared with the placebo (13 (6, 20) vs. 11 (6, 20); p-value 0.019). After one month of intervention, the PSQI score was significantly lower (indicating better sleep quality) in the vitamin E group compared with the placebo (6 (1, 18) vs. 9 (1, 19); p-value 0.012). Moreover, the improvement score was significantly higher in the vitamin E group compared with the placebo (5 (-6, 14) vs. 1 (-5,13); p-value < 0.001). In addition, there was a significant reduction in the percentage of patients using sedative drugs in the vitamin E group (15%; p-value 0.009), while this reduction was not statistically significant in the placebo group (7.5%; p-value 0.077). This study demonstrates vitamin E's potential as an excellent alternative treatment for chronic insomnia disorder that improves sleep quality and reduces sedative drug use.

Association of hormone therapy and changes of objective sleep quality in women of late menopausal transition with sleep disorder: a preliminary study

OBJECTIVE

The aim of this study was to investigate changes in objective sleep quality with hormone therapy (HT) in women with late menopausal transition.

METHODS

Healthy midlife women with sleep difficulty who received HT were included. Those undergoing late menopausal transition were screened. Sleep patterns and self-reported questionnaires were collected before and 10 weeks after starting HT.

RESULTS

Ten women who met the criteria (age, 50.1 ± 2.8 years) showed higher sleep efficiency and shorter wakefulness after sleep onset (WASO) 10 weeks after starting HT. However, no significant change was found in objective sleep quality after adjustment for multiple comparisons: sleep efficiency, 84.2 ± 7.7 versus 88.2% ± 4.7%, P = 0.037, adjusted P = 0.259; WASO, 59.0 ± 27.2 minutes versus 41.4 ± 17.4 minutes, P = 0.020, adjusted P = 0.140; average duration per awakening, 2.9 ± 1.0 minutes versus 2.2 ± 0.5 minutes, P = 0.033, adjusted P = 0.231. A better score of subjective sleep quality in the Pittsburgh Sleep Quality Index was observed 10 weeks after starting HT (2.0 ± 0.0 vs 1.2 ± 0.4, P = 0.006, adjusted P = 0.042), but sensitivity analysis did not show consistent results after adjustment for multiple comparisons (2.0 ± 0.0 vs 1.1 ± 0.4, P = 0.020, adjusted P = 0.140). Total scores of the Insomnia Severity Index and Menopause Rating Scale were better 10 weeks after starting HT (Insomnia Severity Index, 14.7 ± 3.0 vs 9.1 ± 3.8, P = 0.010; Menopause Rating Scale, 29.0 ± 5.2 vs 21.6 ± 3.0, P = 0.009) with consistent results in sensitivity analyses. There was no difference in the Epworth Sleepiness Scale before and after HT (7.2 ± 1.7 vs 8.6 ± 4.5, P = 0.309). The change in each objective sleep quality variable before and after HT showed strong positive or negative correlations with the change in only a few items in subjective sleep quality.

CONCLUSION

Women in the late menopausal transition period showed higher sleep efficiency and shorter WASO after HT; however, multiple comparisons showed no statistically significant difference in objective sleep quality between before and after HT.

Behavioral interventions for improving sleep outcomes in menopausal women: a systematic review and meta-analysis

IMPORTANCE

Perimenopausal and postmenopausal women commonly report sleep disruption and insomnia. Behavioral interventions may be safe alternatives for patients who are unwilling to begin pharmacological treatments because of adverse effects, contraindications, or personal preference.

OBJECTIVE

The primary objective is to assess the efficacy of behavioral interventions on sleep outcomes among perimenopausal and postmenopausal women, as measured using standardized scales and objective methods (polysomnography, actigraphy). The secondary objective is to evaluate the safety of these methods through occurrence of adverse events.

EVIDENCE REVIEW

Searches were performed within MEDLINE (OVID interface, 1946 onward), Embase (OVID interface, 1974 onward), Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, and Web of Science (Core collection) using a search strategy developed in consultation with a health sciences librarian. Title/abstract and full-text screenings were performed in duplicate, and relevant studies were selected based on inclusion and exclusion criteria set to identify randomized controlled trials evaluating the effects of behavioral interventions on sleep quality. Risk of bias assessments were done using the Cochrane Risk of Bias 2 tool, and the Grading of Recommendations Assessment, Development and Evaluation approach was used to assess the certainty of the body of evidence. Data were pooled in a meta-analysis using a random-effects model.

FINDINGS

Nineteen articles reporting results from 16 randomized controlled trials were included, representing a total of 2,108 perimenopausal and postmenopausal women. Overall, behavioral interventions showed a statistically significant effect on sleep outcomes (standardized mean difference [SMD], -0.62; 95% confidence interval [CI], -0.88 to -0.35; I2 = 93.4%). Subgroup analyses revealed that cognitive behavioral therapy (SMD, -0.40; 95% CI, -0.70 to -0.11; I2 = 72.7%), physical exercise (SMD, -0.57; 95% CI, -0.94 to -0.21; I2 = 94.0%), and mindfulness/relaxation (SMD, -1.28; 95% CI, -2.20 to -0.37; I2 = 96.0%) improved sleep, as measured using both subjective (eg, Pittsburg Sleep Quality Index) and objective measures. Low-intensity (SMD, -0.91; 95% CI, -1.59 to -0.24; I2 = 96.8) and moderate-intensity exercise (SMD, -0.21; 95% CI, -0.34 to -0.08; I2 = 0.0%) also improved sleep outcomes. No serious adverse events were reported. Overall risk of bias ranged from some concern to serious, and the certainty of the body of evidence was assessed to be of very low quality.

CONCLUSIONS AND RELEVANCE

This meta-analysis provides evidence that behavioral interventions, specifically, cognitive behavioral therapy, physical exercise, and mindfulness/relaxation, are effective treatments for improving sleep outcomes among perimenopausal and postmenopausal women.

Sex Differences Across the Life Course: A Focus On Unique Nutritional and Health Considerations among Women

In the United States, women, while having a longer life expectancy than men, experience a differential risk for chronic diseases and have unique nutritional needs based on physiological and hormonal changes across the life span. However, much of what is known about health is based on research conducted in men. Additional complexity in assessing nutritional needs within gender include the variations in genetics, body compositions, hormonal milieus, underlying chronic diseases, and medication usage, with this list expanding as we consider these variables across the life course. It is clear women experience nutrient shortfalls during key periods of their lives, which may differentially impact their health. Consequently, as we move into the era of precision nutrition, understanding these sex- and gender-based differences may help optimize recommendations and interventions chosen to support health and weight management. Recently, a scientific conference was convened with content experts to explore these topics from a life-course perspective at biological, physiological, and behavioral levels. This publication summarizes the presentations and discussions from the workshop and provides an overview of important nutrition and related lifestyle considerations across the life course. The landscape of addressing female-specific nutritional needs continues to grow; now more than ever, it is essential to increase our understanding of the physiological differences between men and women, and determine how these physiological considerations may aid in optimizing nutritional strategies to support certain personal goals related to health, quality of life, sleep, and exercise performance among women.

Comparing the Effectiveness of Multicomponent Sleep-Promoting Interventions on the Sleep Quality of Menopausal Women: A Quasi-Experimental Study

Sleep disturbance is considered one of the hallmarks of the common symptoms experienced by women during and after menopause. This study aimed to compare the effectiveness of two different multiple-component, sleep-promoting interventions on the sleep quality of menopausal women. A quasi-experimental study and repeated measured design, with a four-week sleep-promoting intervention, was conducted. A total of 123 eligible participants were recruited from a health center in northern Taiwan and divided into the progressive muscle relaxation plus sleep hygiene (PMRS), the meditative movement relaxation plus sleep hygiene (MMRS), or control group at a 1:1:1 ratio. The Chinese version of Pittsburgh sleep quality index and actigraphy were used to assess the sleep disturbances of menopausal women. The subjective sleep data was collected before, immediately after the intervention, 8 weeks, and 12 weeks after the intervention. The results showed that the global score of subjective sleep quality and its components were significantly improved after both interventions. Additionally, the MMRS was superior to the PMRS for subjective sleep quality. Moreover, the objective sleep indices indicated that sleep latency was reduced after both the interventions. These findings can serve as a reference for nurses when caring for menopausal women with sleep disturbance.

Efficacy of cognitive therapy and behavior therapy for menopausal symptoms: a systematic review and meta-analysis

BACKGROUND

T long-term effects of cognitive therapy and behavior therapy (CTBT) for menopausal symptoms are unknown, and whether the effects are different between natural menopause and treatment-induced menopause are currently unclear. Therefore, we sought to conduct an accurate estimate of the efficacy of CTBT for menopausal symptoms.

METHODS

We conducted searches of Cochrane Library, EMBASE, PsycINFO, PubMed, and Web of Science databases for studies from 1 January 1977 to 1 November 2021. Randomized controlled trials (RCTs) comparing intervention groups to control groups for menopausal symptoms were included. Hedge's g was used as the standardized between-group effect size with a random-effects model.

RESULTS

We included 14 RCTs comprising 1618 patients with a mean sample size of 116. CTBT significantly outperformed control groups in terms of reducing hot flushes [g = 0.39, 95% confidence interval (CI) 0.23-0.55, I2 = 45], night sweats, depression (g = 0.50, 95% CI 0.34-0.66, I2 = 51), anxiety (g = 0.38, 95% CI 0.23-0.54, I2 = 49), fatigue, and quality of life. Egger's test indicated no publication bias.

CONCLUSIONS

CTBT is an effective psychological treatment for menopausal symptoms, with predominantly small to moderate effects. The efficacy is sustained long-term, although it declines somewhat over time. The efficacy was stronger for natural menopause symptoms, such as vasomotor symptoms, than for treatment-induced menopause symptoms. These findings provide support for treatment guidelines recommending CTBT as a treatment option for menopausal symptoms.

Tuina for perimenopausal insomnia: A protocol for systematic review and meta-analysis

BACKGROUND

Insomnia in perimenopausal women has a negative impact on quality of life and increases health care costs. With the increasing incidence of the disease, Tuina has been accepted by perimenopausal women. The purpose of this study is to explore the effectiveness and safety of Tuina for perimenopausal insomnia.

METHODS

We will search 9 electronic databases: Chinese Biomedical Literature Database, Cochrane Library, China National Knowledge Infrastructure, EMBASE, MEDLINE, Web of Science, PubMed, Wan fang, Chinese Scientific Journal Database, and 1 clinical trials register platform: WHO International Clinical Trials Registry Platform. All relevant randomized controlled trial using Tuina for perimenopausal insomnia will be included. Two reviewers will independently screen date, and meta-analysis will be performed with RevMan (V5.3.5) software.

RESULTS

This study will provide an evidence of Tuina for perimenopausal insomnia.

CONCLUSION

This study will provide a reliable evidence for the evaluation of the efficacy and side effects of Tuina in the treatment of perimenopausal insomnia.

PROSPERO REGISTRATION NUMBER

CRD42021259017.

ETHICS AND DISSEMINATION

This systematics review will evaluate the efficacy and safety of tuina in the treatment of perimenopausal insomnia. Since all the data included were published, the systematic review did not require ethical approval.

Menopause and sleep disorders

Women are likely to suffer from sleep disorders more in comparison to men during menopause and with advancing age. The incidence of sleep disorders ranges from 16% to 47% at peri-menopause and 35%–60% at postmenopause. Insomnia with or without associated anxiety or low lying depression and Mood disorder is most common associated manifestations. Sleep disorders and insomnia largely remain a clinical diagnosis based on the subjective complaints of patients. Benzodiazepines remain the mainstay of the treatment in majority of the sleep disorders including chronic or acute insomnia. Treatment of associated anxiety, depression, or psychosis is most important. Tricyclic antidepressant, Selective Serotonin Reuptake Inhibitors (SSRI), Melatonin, Duloxetine, Fluoxetine, Imipramine, Nortriptyline or Amitriptyline and other drugs such as Eszopiclone, Escitalopram, Gabapentin, Quiteiapine, Citalopram, Mirtazapine followed by long-acting Melatonin and Ramelteon, also are very useful for the management of various sleep disorders. Hormone replacement therapy presently lacks concrete evidence to be used in menopausal women for sleep disorder. Sleep hygiene practices, self-hypnosis, meditation, and exercise play a very important role.

Attitudes of women towards products containing hormones (hormonal contraceptives or hormone therapy): what changes from pre to postmenopause?

INTRODUCTION

To evaluate the actual perceptions of hormonal contraceptives (HC) in women of reproductive age in comparison with similar concerns of postmenopausal women in relation to hormone therapy (HT).

MATERIALS AND METHODS

A questionnaire-based study was conducted in a population of 370 women, 198 (53.5%) premenopausal and 172 (46.5%) postmenopausal. Perceptions were evaluated using specific questions and Likert scales (-5 to +5).Multivariate regression analyses were adjusted for categories of HC/HT use (never, past and current).

RESULTS

The most reported adverse effect associated with hormonal treatments was venous thrombosis (1.4 ± 0.1), especially for HC use in premenopausal women (p < .0001). According to responses, hormonal treatments can increase the risk of developing venous thrombosis (OR 0.79; 95% CI 0.67-0.96, p = .004) and depression (OR 0.80; 95% CI 0.69-0.92, p = .002) more in pre-menopause, while they can increase the risk of weight gain more in post-menopause (OR 1.24: 95% CI 1.07-1.42, p = .003).The greatest oncological concern throughout life was about breast cancer (0.9 ± 0.1). There was the perception that hormonal treatments can increase the risk of developing ovarian cancer more in post-menopause (OR 1.44; 95% CI 1.19-1.75, p = .0002), while they can increase the risk of uterine cervix cancer more in pre-menopause (OR 0.74; 95% CI 0.52-0.97, p = .03).

CONCLUSIONS

Our data suggest that our patients are primarily concerned about the effects of hormonal treatments on venous thrombosis, mood, breast cancer and cervical cancer risk, and, later in life, about their impact on weight gain, breast and ovarian cancer risk.KEY MESSAGESYoung patients are primarily concerned about the effects of hormonal treatments on venous thrombosis, mood, breast cancer and cervical cancer risk.Older patients are primarily concerned about the effects of hormonal treatments on weight gain, breast and ovarian cancer risk.The greatest oncological concern throughout life was about breast cancer.

Management of sleep disorders in the menopausal transition

The menopausal transition is associated with increasing sleep disorders including sleep apnoea and restless leg syndrome. Insomnia is the most common and is recognised as a core symptom of the menopause. Guidelines to support decision making for women with sleep problems during the menopausal transition are lacking. Sleep problems are associated with negative impacts on healthcare utilisation, quality of life and work productivity. Sleep deprivation is a risk factor for cardiovascular disease, diabetes, obesity and neurobehavioral dysfunction. Declining oestrogen is implicated as a cause of menopausal sleep disruption. Vasomotor symptoms (VMS) and menopausal mood disturbance are also factors in the complex aetiology. VMS commonly precipitate insomnia and, due to their prolonged duration, they often perpetuate the condition. Insomnia in the general population is most effectively treated with cognitive behavioural therapy (CBT) (also effective in the menopausal transition.) The associations of menopausal sleep disturbance with VMS and depression mean that other treatment options must be considered. Existing guidelines outline effectiveness of hormone replacement therapy (HRT), CBT and antidepressants. HRT may indirectly help with sleep disturbance by treating VMS and also via beneficial effect on mood symptoms. The evidence base underpinning menopausal insomnia often references risks associated with HRT that are not in line with current international menopause guidelines. This may influence clinicians managing sleep disorders, leading to hesitation in offering HRT, despite evidence of effectiveness. Viewing sleep symptoms on an axis of menopausal symptoms - towards vasomotor symptoms or towards mood symptoms may help tailor treatment options towards the symptom profile.

A Clinical Study of the Effect of Estradiol Valerate on Sleep Disorders, Negative Emotions, and Quality of Life in Perimenopausal Women

In this prospective study, we randomly divided 100 patients with perimenopausal syndrome equally into the control group (n = 50) receiving conventional treatment and the study group (n = 50) receiving estradiol valerate. The indicators observed were endometrial thickness, uterine volume, and the levels of LH (luteinizing hormone), FSH (follicle-stimulating hormone), and E2 (estradiol) of the patients before and after treatment. The Pittsburgh Sleep Quality Index (PSQI), Hamilton Anxiety/Depression Scale (HAMA/HAMD), Kupperman symptom score, and menopause-specific quality of life (MENQOL) were also applied to assess the sleep quality, negative emotions, severity of the condition, and quality of life of all patients, respectively. Our findings were that estradiol valerate is beneficial in improving serum sex hormone levels, sleep disturbances, negative mood, and quality of life in patients with perimenopausal syndrome and that its safety profile is high enough to warrant clinical promotion.

BRCA mutation carriers' perceptions on postmenopausal hormone therapy: An Italian study

Objective

To evaluate the actual perceptions of postmenopausal hormone therapy (HT) in BRCA mutation carriers (BRCAmc) in comparison with women from the general population.

Methods

Questionnaire‐based study of 83 BRCAmc and a control group of 89 women without a genetic mutation. Perceptions were evaluated by specific questions and Likert scales (−5–+5).

Results

Present and past users of HT were more frequent in the control group (p = 0.01), with a longer time of use (p = 0.03). The preferred route of administration of HT was ‘oral’ (54.6%). The most frequently reported adverse effect of HT was venous thrombosis (0.8), while a protective effect on bone health was reported. No noticeable beneficial effects of HT have been recognised for hot flushes (0.2) and vaginal dryness (0.1). The most frequently perceived beneficial and adverse effects of HT were not significantly different between BRCA mutation carriers and controls. The greatest oncological fear was breast cancer (1.0). The protective role of HT on colorectal cancer was not known (0.1). These oncological impacts were mostly overestimated in BRCAmc, however this was not significant. Few BRCAmc would think of taking HT after risk‐reducing surgeries.

Conclusions

Knowledge of the effects of HT on BRCAmc is relatively poor and they are likely to overstate its negative effects and underestimate its health benefits; however, this is not significant in comparison to the general population. More and better information should be given to BRCAmc to allow them to make informed decisions about the use of HT, especially before undergoing risk‐reducing surgeries.

The association of hypnotics with incident cardiovascular disease and mortality in older women with sleep disturbances

BACKGROUND/OBJECTIVE

Insomnia is common in older women and is associated with higher cardiovascular disease (CVD) risk. Nonbenzodiazepine GABA agonists (Z-drugs) are the most commonly prescribed sleep aids. The study objective was to determine whether the use of Z-drugs is associated with the risk of developing CVD and mortality in older women with sleep disturbances.

PATIENTS/METHODS

The study cohort included post-menopausal women who, at baseline, scored ≥9 with the Women's Health Initiative Insomnia Rating Scale (N = 40,728). Members of the cohort were categorized as users of Z-drugs, users of other prescription hypnotics, or non-users. Outcomes were composite CVD (congestive heart failure, stroke, and fatal/non-fatal myocardial infarction) and mortality. Hazard ratios were estimated from Cox proportional hazards regression models adjusted for demographics, medical history, and sleep measures. To address potential confounding by indication, we also adjusted for propensity to be prescribed hypnotics.

RESULTS

The mean age of our cohort was 63.57 years (SD = 7.23) and mean follow-up time after the initial follow-up visit was 14.0 years (SD = 6.3). Z-drug use was significantly associated with an increased risk of composite CVD (HR = 1.35, 95%CI: 1.02-1.79) and all-cause mortality (HR = 1.38, 95%CI: 1.13-1.69). When groups were divided by heavy and casual use, only heavy users (≥3 times per week) had an increased risk of mortality.

CONCLUSIONS

Z-drugs use was associated with an increased risk for death and CVD in post-menopausal women being treated for sleep disturbances. Additional research is needed to evaluate both frequency and duration of Z-drug use.

Nighttime melatonin secretion and sleep architecture: different associations in perimenopausal and postmenopausal women

BACKGROUND

Sleep quality typically decreases after menopause, but the underlying mechanisms are poorly understood. Concentrations of melatonin are lower and its secretion profiles different before and after menopause. However, whether and how melatonin and sleep architecture are associated in women of different reproductive states have not been examined to date.

METHODS

Overnight serum melatonin samples were taken from 17 perimenopausal and 18 postmenopausal healthy women. Sleep quality was measured with all-night polysomnography recordings.

RESULTS

Melatonin concentrations tended to be the lowest during NREM sleep, and were associated with higher odds of transitions from wake to NREM sleep. The curves of predicted overnight melatonin values from linear mixed models varied according to sleep phases (NREM, REM, Wake) in perimenopausal, but not in postmenopausal women. In perimenopause higher melatonin area under curve (AUC) correlated with higher slow-wave activity (p = 0.043), and higher minimum concentrations with shorter slow-wave sleep (SWS) latency (p = 0.029). In postmenopause higher mean and maximum melatonin concentrations and AUC correlated with lower SWS percentage (p = 0.044, p = 0.029, p = 0.032), and higher mean (p = 0.032), maximum (p = 0.032) and minimum (p = 0.037) concentrations with more awakenings from REM sleep. In the age- and BMI- adjusted regression models, the association between higher maximum (p = 0.046) melatonin concentration and lower SWS percentage remained.

CONCLUSIONS

The relationship between melatonin and sleep architecture differed in perimenopausal and postmenopausal women. After menopause, high melatonin concentrations were associated with worse sleep. Whether these different patterns are related to aging of the reproductive system, and to decrease in menopausal sleep quality, remains to be elucidated.

Thermal Comfort Intervention for Hot-flash Related Insomnia Symptoms in Perimenopausal and Postmenopausal-aged Women: An Exploratory Study

Objective/Background: To examine a novel intervention for nighttime thermal comfort and sleep of perimenopausal- and postmenopausal-aged women who experience hot flashes and insomnia symptoms. Participants: Thirty-nine women (ages 45-58, M = 52.1 years) with sleep-disrupting hot flashes and insomnia symptoms. Methods: This was a 4-week randomized cross-over study. The intervention included 2 weeks of nighttime use of a warming/cooling device worn on the wrist and was compared to a 2-week baseline period (no device). All participants completed questionnaires at the end of each 2-week period, including the Insomnia Severity Index, the PROMIS Sleep Disturbance and Sleep-Related Impairment scales, Epworth Sleepiness Scale, and the Hot Flash Related Daily Interference Scale. Results: The intervention resulted in a reduction in sleep onset latency, as well as an increase in nighttime sleep. There was a significant improvement of scores on the Insomnia Severity Index, PROMIS Sleep Disturbance and Sleep-Related Impairment scales, and the Epworth Sleepiness Scale. Significantly fewer women reported that hot flashes interfered with their sleep (90% vs 70%) and more perceived control over the degree of sleep disruption due to nighttime hot flashes while using the device (5% vs 49%). The majority reported a positive experience, with two-thirds reporting that the device improved their thermal comfort and ability to return to sleep after a night waking. Conclusions: Overall, a thermal comfort intervention may offer sleep benefits for women who experience disruptive nighttime hot flashes, particularly in terms of falling asleep at bedtime and subjective perception of control over nighttime hot flash sleep interference.

Agomelatine, A Potential Multi-Target Treatment Alternative for Insomnia, Depression, and Osteoporosis in Postmenopausal Women: A Hypothetical Model

Insomnia, which is associated with menopausal depression, is a common symptom of menopause. Both symptoms have a common etiology, and can affect each other significantly. Pharmacological interventions, including hypnotics and antidepressants, and non-pharmacological therapies are generally administered in clinical practice for insomnia treatment. As another menopausal disorder, osteoporosis is described as a disease of low bone mineral density (BMD), affecting nearly 200 million women worldwide. Postmenopausal osteoporosis is common among middle-aged women. Since postmenopausal osteoporosis mainly results from low estrogen levels, menopausal hormone therapy (HT) is considered the first-line option for the prevention of osteoporosis during the menopausal period. However, almost no study has evaluated novel treatments for the combined prevention of insomnia, depression, and osteoporosis. Hence, it is necessary to develop new multi-target strategies for the treatment of these disorders to improve the quality of life during this vulnerable period. Melatonin is the major regulator of sleep, and it has been suggested to be safe and effective for bone loss therapy by MT-2 receptor activity. As a result, we hypothesize that agomelatine, an MT-1 and MT-2 receptor agonist and 5-HT_2C receptor antagonist, holds promise in the combined treatment of insomnia, depression, and osteoporosis in middle-aged women during menopause.

Insomnia and menopause: a narrative review on mechanisms and treatments

The menopausal transition is associated with an increased frequency of sleep disturbances. Insomnia represents one of the most reported symptoms by menopausal women. According to its pathogenetic model (3-P Model), different predisposing factors (i.e. a persistent condition of past insomnia and aging per se) increase the risk of insomnia during menopause. Moreover, multiple precipitating and perpetuating factors should favor its occurrence across menopause, including hormonal changes, menopausal transition stage symptoms (i.e. hot flashes, night sweats), mood disorders, poor health and pain, other sleep disorders and circadian modifications. Thus, insomnia management implies a careful evaluation of the psychological and somatic symptoms of the individual menopausal woman by a multidisciplinary team. Therapeutic strategies encompass different drugs but also behavioral interventions. Indeed, cognitive behavioral therapy represents the first-line treatment of insomnia in the general population, regardless of the presence of mood disorders and/or vasomotor symptoms (VMS). Different antidepressants seem to improve sleep disturbances. However, when VMS are present, menopausal hormone therapy should be considered in the treatment of related insomnia taking into account the risk-benefit profile. Finally, given its good tolerability, safety, and efficacy on multiple sleep and daytime parameters, prolonged-released melatonin should represent a first-line drug in women aged ≥ 55 years.

The beneficial effects of therapeutic craniofacial massage on quality of life, mental health and menopausal symptoms and body image: A randomized controlled clinical trial

OBJECTIVE

The objective of this study was to determine the effect of massage in the craniofacial area in menopausal women after the treatment and one month after its completion, and to measure its influence on quality of life in relation to symptoms of menopause, mental health, and body image perception.

DESIGN

50 participants with menopause, aged 45-65 years, participated in a single-blind randomized controlled trial. Participants were randomly assigned to two groups: craniofacial massage group (CMG), who received massage treatment (n = 25), and control group (CG), without treatment (n = 25). Prior to randomization, all participants provided demographic and clinical information. Quality of life, mental health and body image perception were evaluated at three time points: at the beginning of the study, at the end, and one month after finishing the treatment.

RESULTS

A repeated-measures multivariate analysis of variance (RM-MANOVA) was used to determine if mean scores in the criteria differed significantly between time points within subjects. The results obtained indicate that the cranial massage techniques had a large, positive between-subjects effect on our three criteria (Wilks Λ = .83, F(_{3, 44}) = 3.04, p. <.05; Partial η = .17; ƒ = .45) as well as a large, positive between-within subjects effect (Wilks Λ = .64, F(_{6, 41}) = 3.91, p. <.01; Partial η = .36; ƒ = .76). In short, our treatment improved participants' mental health, partially ameliorated the decrease in scores on the Menopause Rating Scale and stopped the decrease in Body Image perception's scores.

CONCLUSIONS

The craniofacial massage protocol, applied to the craniofacial sphere, constitutes a complementary and valid therapy-based therapeutic option for clinicians in the treatment of different symptoms that occur in the climacteric period.

Menopausal Symptoms and Higher Risk Opioid Prescribing in a National Sample of Women Veterans with Chronic Pain

BACKGROUND

The greatest increases in long-term opioid use and opioid-related overdose mortality in recent years have been among women in midlife. Common menopausal symptoms broadly affect health and health care utilization in midlife, but their contribution to chronic pain management during this period is unknown.

OBJECTIVE

To examine relationships between menopausal symptoms and long-term opioid prescription patterns among midlife women with chronic pain.

DESIGN

Cross-sectional analysis of national Veterans Health Administration medical and pharmacy records (2014-2015).

PARTICIPANTS

Women Veterans aged 45-64 with ≥ 1 outpatient visit and chronic pain diagnoses spanning ≥ 90 days.

MAIN MEASURES

Long-term opioids (prescribed oral opioids for ≥ 90 days), high-dose long-term opioids (> 50 mg average morphine equivalent daily dose), and long-term opioids co-prescribed with central nervous system depressants (benzodiazepine and non-benzodiazepine sedative-hypnotics, gabapentin/pregabalin, muscle relaxants). Multivariable logistic regression models were used to examine associations between outcomes and menopausal symptoms (menopausal symptom-related diagnoses (i.e., "symptomatic menopausal states") on ≥ 2 encounters and/or menopausal hormone therapy, adjusting for race, age, body mass index, and mental health and substance use disorder diagnoses.

KEY RESULTS

In this national sample of 104,984 midlife women Veterans with chronic pain (mean age 54.5, SD 5.4 years), 17% had evidence of menopausal symptoms, 51% were prescribed long-term opioids, 13% were prescribed high-dose long-term opioids, and 35% were co-prescribed long-term opioids and central nervous system depressants. In multivariable analyses, women with menopausal symptoms had increased odds of long-term opioids (OR 1.21, 95% CI 1.18-1.26), high-dose long-term opioids (OR 1.08, 95% CI 1.02-1.13), and long-term opioids co-prescribed with central nervous system depressants (sedative-hypnotics OR 1.25, 95% CI 1.22-1.30; gabapentin/pregabalin OR 1.23, 95% CI 1.20-1.27; muscle relaxants OR 1.24, 95% CI 1.20-1.28).

CONCLUSIONS

Among midlife women Veterans with chronic pain, evidence of menopausal symptoms was associated with potentially risky long-term opioid prescription patterns, independent of known risk factors.

Cognition, Mood and Sleep in Menopausal Transition: The Role of Menopause Hormone Therapy

During the menopausal transition, which begins four to six years before cessation of menses, middle-aged women experience a progressive change in ovarian activity and a physiologic deterioration of hypothalamic-pituitary-ovarian axis function associated with fluctuating hormone levels. During this transition, women can suffer symptoms related to menopause (such as hot flushes, sleep disturbance, mood changes, memory complaints and vaginal dryness). Neurological symptoms such as sleep disturbance, "brain fog" and mood changes are a major complaint of women transitioning menopause, with a significant impact on their quality of life, productivity and physical health. In this paper, we consider the associations between menopausal stage and/or hormone levels and sleep problems, mood and reduced cognitive performance. The role of estrogen and menopause hormone therapy (MHT) in cognitive function, sleep and mood are also discussed.

Sexual function and distress in postmenopausal women with chronic insomnia: exploring the role of stress dysregulation

OBJECTIVE

Menopause triggers changes in sexual function and many women develop sexual problems. Insomnia is common in postmenopausal women, and disturbed sleep has been linked to poor sexual health. Thus, postmenopausal women with insomnia may be especially vulnerable to developing sexual difficulties. This study estimated rates of sexual distress in postmenopausal women with chronic insomnia and explored associations between various facets of sexual health, insomnia symptoms, and insomnia-related stress dysregulation.

DESIGN

Cross-sectional.

SETTING

Large multi-site health system in the US.

PARTICIPANTS

150 postmenopausal women diagnosed with DSM-5 chronic insomnia disorder (56.44±5.64 years) completed measures of sexual distress, sexual function, hot flashes, insomnia symptoms, depression, and stress dysregulation in the forms of cognitive-emotional arousal (worry, rumination), sleep reactivity, and somatic hyperarousal.

RESULTS

Nearly half of the sample endorsed clinically significant sexual distress (46.9%). Insomnia symptoms were largely associated with poor sexual arousal, orgasmic dysfunction, sexual distress, and sexual dissatisfaction. Insomnia-related stress dysregulation was similarly associated with these facets of sexual health but was also linked to problems with low desire and greater vaginal pain during sex. Hot flashes and depression were negatively associated with sexual health.

CONCLUSION

Postmenopausal women with chronic insomnia endorse high rates of sexual distress. Although compromised sexual function appears directly related to poor sleep itself, our data suggest that stress dysregulation may play vital role in sexual problems endorsed by postmenopausal insomniacs, particularly regarding low desire and vaginal pain. Prospective research is needed to characterize the evolution of these co-occurring symptoms.

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

STUDY OBJECTIVES

Insomnia is a chief complaint among postmenopausal women, and insomnia impairs daytime functioning and reduces quality of life. Recent evidence supports the efficacy of cognitive behavioral therapy for insomnia (CBTI) for menopausal insomnia, but it remains unclear whether treating insomnia improves daytime function in this population. This study evaluated whether CBTI improves daytime fatigue, energy, self-reported sleepiness, work productivity, and quality of life in postmenopausal women with insomnia, and whether sleep restriction therapy (SRT)-a single component of CBTI-is equally efficacious.

METHODS

Single-site, randomized control trial. One hundred fifty postmenopausal women (56.44 ± 5.64 years) with perimenopausal or postmenopausal onset or exacerbation of chronic insomnia were randomized to 3 treatment conditions: sleep hygiene education control (SHE), SRT, and CBTI. Blinded assessments were performed at pretreatment, posttreatment, and 6-month follow-up.

RESULTS

CBTI and SRT produced moderate-to-large improvements in fatigue, energy, sleepiness, and work function at posttreatment and 6 months later. The CBTI group reported better quality of life as indicated by substantial improvements in emotional wellbeing and resiliency to physical and emotional problems, whereas the SRT and SHE groups only showed improvements in resiliency to physical problems. Pain complaints decreased as sleep improved but were not associated with specific treatment conditions. Similarly, insomnia remitters reported fewer daytime and nighttime hot flashes, although reductions were not associated with any specific treatment.

CONCLUSIONS

CBTI and SRT are efficacious options for postmenopausal women with chronic insomnia. Both interventions improve daytime function, quality of life, and work performance, although CBTI produces superior results including the added benefit of improved emotional health.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Title: Behavioral Treatment of Menopausal Insomnia; Sleep and Daytime Outcomes; Identifier: NCT01933295; URL: https://clinicaltrials.gov/ct2/show/record/NCT01933295.

Treating chronic insomnia in postmenopausal women: a randomized clinical trial comparing cognitive-behavioral therapy for insomnia, sleep restriction therapy, and sleep hygiene education

Study Objectives

Insomnia is a leading cause of disability in postmenopausal women. Multicomponent cognitive-behavioral therapy for insomnia (CBTI) is a first-line treatment for chronic insomnia, but support for its efficacy in treating menopause-related insomnia is scarce. The present study evaluated whether CBTI is an efficacious treatment for menopause-related chronic insomnia, and whether sleep restriction therapy (SRT)-a single component of CBTI-is equally efficacious compared with CBTI.

Methods

In a single-site, randomized controlled trial, 150 postmenopausal women (56.44 ± 5.64 years) with chronic DSM-5 insomnia disorder related to menopause were randomized to three treatment conditions: sleep hygiene education (SHE), SRT, or CBTI. Blinded assessments were performed at baseline, posttreatment, and 6 months after treatment. The Insomnia Severity Index (ISI) and sleep diaries served as primary outcomes.

Results

From baseline to posttreatment, ISI decreased 7.70 points in the CBTI group (p < .001), 6.56 points in the SRT group (p < .001), and 1.12 in the SHE group (p = .01). Although average sleep duration increased in all groups by 6 month follow-up, CBTI patients obtained 40-43 more minutes of nightly sleep than those who received SHE or SRT. Remission rates in the CBTI (54%-84%) and SRT (38%-57%) groups were higher than SHE patients (4%-33%) at posttreatment and 6 month follow-up. CBTI patients were generally more likely to remit than SRT patients.

Conclusions

CBTI and SRT effectively treat menopause-related insomnia disorder and are superior to SHE. Response to CBTI and SRT is similar, but CBTI outperforms SRT in improving sleep maintenance, which may increase likelihood of remission. Clinical Trial Name: Behavioral Treatment of Menopausal Insomnia: Sleep and Daytime Outcomes. URL: clinicaltrials.gov. Registration: NCT01933295.

Menopause hormone therapy: latest developments and clinical practice

Menopause hormone therapy (MHT) is the most efficient treatment for symptoms of acute climacteric syndrome and for efficient prevention of long-term estrogen deficiency. Vaginal administration of low doses of estrogen is a therapy of choice for treatment and prevention of urogenital atrophy and its consequences. Systemic treatment may include estrogen, but an equally efficient alternative is tibolone. Nonhormonal therapy relies on phytoestrogens, black cohosh extract, and serotonin reuptake inhibitors.

Treating insomnia improves depression, maladaptive thinking, and hyperarousal in postmenopausal women: comparing cognitive-behavioral therapy for insomnia (CBTI), sleep restriction therapy, and sleep hygiene education

INTRODUCTION

Depression increases during menopause, and subclinical depressive symptoms increase risk for major depression. Insomnia is common among postmenopausal women and increases depression-risk in this already-vulnerable population. Recent evidence supports the efficacy of cognitive-behavioral therapy for insomnia (CBTI) to treat menopausal insomnia, but it remains unclear whether treating insomnia also alleviates co-occurring depressive symptoms and depressogenic features. This trial tested whether CBTI improves depressive symptoms, maladaptive thinking, and somatic hyperarousal in postmenopausal women with insomnia; as well as whether sleep restriction therapy (SRT)-a single component of CBTI-is equally efficacious.

MATERIALS AND METHODS

Single-site, randomized controlled trial. 117 postmenopausal women (56.34 ± 5.41 years) with peri-or-postmenopausal onset of chronic insomnia were randomized to three treatment conditions: sleep hygiene education control (SHE), SRT, and CBTI. Blinded assessments were performed at baseline, posttreatment, and six-month follow-up.

RESULTS

CBTI produced moderate-to-large reductions in depressive symptoms, whereas SRT produced moderate reductions but not until six months posttreatment. Treatment effects on maladaptive thinking were mixed. CBTI and SRT both produced large improvements in dysfunctional beliefs about sleep, but weaker influences on presleep cognitive arousal, rumination, and worry. Presleep somatic arousal greatly improved in the CBTI group and moderately improved in the SRT group. Improvements in depression, maladaptive thinking, and hyperarousal were linked to improved sleep. SHE produced no durable treatment effects.

CONCLUSIONS

CBTI and SRT reduce depressive symptoms, dysfunctional beliefs about sleep, and presleep somatic hyperarousal in postmenopausal women, with CBTI producing superior results. Despite its cognitive emphasis, cognitive arousal did not respond strongly or durably to CBTI. NAME: Behavioral Treatment of Menopausal Insomnia: Sleep and Daytime Outcomes. URL: clinicaltrials.gov.

REGISTRATION

NCT01933295.

Sleep and Sleep Disorders in the Menopausal Transition

The menopausal transition is associated with an increase in insomnia symptoms, especially difficulty staying asleep, which negatively impacts quality of life. Vasomotor symptoms are a key component of sleep disruption. Findings from polysomnographic studies are less consistent in showing disrupted sleep in menopausal transition independent of aging; further prospective studies are needed. Hormone therapy alleviates subjective sleep disturbances, particularly if vasomotor symptoms are present. However, because of contraindications, other options should be considered. Further work is needed to develop preventive and treatment strategies for alleviating sleep disturbances to ensure better health, quality of life, and productivity in midlife women.

Acupuncture for perimenopausal insomnia: A systematic review and meta-analysis protocol

BACKGROUND

Perimenopausal insomnia (PI) is one of the most common complaints in women. Acupuncture is used to treat PI increasingly considering its less side effect. The subject of this study is to explore the effectiveness and safety of acupuncture for PI.

METHODS

All the randomized controlled trials(RCT) literatures of acupuncture for PI will be searched in the databases of MEDLINE, Cochrane Library, Web of Science, EMBASE, Springer, WHO International Clinical Trials Registry Platform (ICTRP), China National Knowledge Infrastructure (CNKI), Wan fang, Chinese Biomedical Literature Database (CBM), Chinese Scientific Journal Database (VIP), and other available resources using the subject terms of 'acupuncture" and "perimenopausal insomnia" and their synonyms. The languages are limited as English and Chinese. Non-RCT literatures will be screened and relative information will be extracted. Sleep quality values is considered as the primary outcome. Secondary outcomes include biochemical indicators, such as hormone levels, side effects caused by acupuncture, total scores on the insomnia severity index and traditional Chinese medicine symptom changes.

RESULTS

This systematic review study will provide an evidence of acupuncture for PI.

CONCLUSION

The study will give an explicit evidence to evaluate the effectiveness and side effects of acupuncture for PI.

PROSPERO REGISTRATION NUMBER

CRD42018092917.

The 2017 hormone therapy position statement of The North American Menopause Society

The 2017 Hormone Therapy Position Statement of The North American Menopause Society (NAMS) updates the 2012 Hormone Therapy Position Statement of The North American Menopause Society and identifies future research needs. An Advisory Panel of clinicians and researchers expert in the field of women's health and menopause was recruited by NAMS to review the 2012 Position Statement, evaluate new literature, assess the evidence, and reach consensus on recommendations, using the level of evidence to identify the strength of recommendations and the quality of the evidence. The Panel's recommendations were reviewed and approved by the NAMS Board of Trustees.Hormone therapy (HT) remains the most effective treatment for vasomotor symptoms (VMS) and the genitourinary syndrome of menopause (GSM) and has been shown to prevent bone loss and fracture. The risks of HT differ depending on type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen is used. Treatment should be individualized to identify the most appropriate HT type, dose, formulation, route of administration, and duration of use, using the best available evidence to maximize benefits and minimize risks, with periodic reevaluation of the benefits and risks of continuing or discontinuing HT.For women aged younger than 60 years or who are within 10 years of menopause onset and have no contraindications, the benefit-risk ratio is most favorable for treatment of bothersome VMS and for those at elevated risk for bone loss or fracture. For women who initiate HT more than 10 or 20 years from menopause onset or are aged 60 years or older, the benefit-risk ratio appears less favorable because of the greater absolute risks of coronary heart disease, stroke, venous thromboembolism, and dementia. Longer durations of therapy should be for documented indications such as persistent VMS or bone loss, with shared decision making and periodic reevaluation. For bothersome GSM symptoms not relieved with over-the-counter therapies and without indications for use of systemic HT, low-dose vaginal estrogen therapy or other therapies are recommended.This NAMS position statement has been endorsed by Academy of Women's Health, American Association of Clinical Endocrinologists, American Association of Nurse Practitioners, American Medical Women's Association, American Society for Reproductive Medicine, Asociación Mexicana para el Estudio del Climaterio, Association of Reproductive Health Professionals, Australasian Menopause Society, Chinese Menopause Society, Colegio Mexicano de Especialistas en Ginecologia y Obstetricia, Czech Menopause and Andropause Society, Dominican Menopause Society, European Menopause and Andropause Society, German Menopause Society, Groupe d'études de la ménopause et du vieillissement Hormonal, HealthyWomen, Indian Menopause Society, International Menopause Society, International Osteoporosis Foundation, International Society for the Study of Women's Sexual Health, Israeli Menopause Society, Japan Society of Menopause and Women's Health, Korean Society of Menopause, Menopause Research Society of Singapore, National Association of Nurse Practitioners in Women's Health, SOBRAC and FEBRASGO, SIGMA Canadian Menopause Society, Società Italiana della Menopausa, Society of Obstetricians and Gynaecologists of Canada, South African Menopause Society, Taiwanese Menopause Society, and the Thai Menopause Society. The American College of Obstetricians and Gynecologists supports the value of this clinical document as an educational tool, June 2017. The British Menopause Society supports this Position Statement.

Comparative effectiveness of electro-acupuncture versus gabapentin for sleep disturbances in breast cancer survivors with hot flashes: a randomized trial

OBJECTIVE

Sleep disturbance is a major consequence of hot flashes among breast cancer survivors. This study evaluated the effects of electro-acupuncture (EA) versus gabapentin (GP) for sleep disturbances among breast cancer survivors experiencing daily hot flashes.

METHODS

We analyzed data from a randomized controlled trial involving 58 breast cancer survivors experiencing bothersome hot flashes at least two times per day. Participants were randomly assigned to receive 8 weeks of EA or daily GP (total dose of 900 mg/d). The primary outcome was change in the total Pittsburgh Sleep Quality Index (PSQI) score between groups at week 8. Secondary outcomes include specific PSQI domains.

RESULTS

By the end of treatment at week 8, the mean reduction in PSQI total score was significantly greater in the EA group than the GP group (-2.6 vs -0.8, P = 0.044). The EA also had improved sleep latency (-0.5 vs 0.1, P = 0.041) and sleep efficiency (-0.6 vs 0.0, P = 0.05) compared with the GP group. By week 8, the EA group had improved sleep duration, less sleep disturbance, shorter sleep latency, decreased daytime dysfunction, improved sleep efficiency, and better sleep quality (P < 0.05 for all) compared with baseline, whereas the GP group improved in duration and sleep quality only (P < 0.05).

CONCLUSIONS

Among women experiencing hot flashes, the effects of EA are comparable with GP for improving sleep quality, specifically in the areas of sleep latency and efficiency. Larger randomized controlled trials with longer follow-ups are needed to confirm this preliminary finding.

Sleep problems during the menopausal transition: prevalence, impact, and management challenges

A substantial number of women experience sleep difficulties in the approach to menopause and beyond, with 26% experiencing severe symptoms that impact daytime functioning, qualifying them for a diagnosis of insomnia. Here, we review both self-report and polysomnographic evidence for sleep difficulties in the context of the menopausal transition, considering severity of sleep complaints and links between hot flashes (HFs) and depression with poor sleep. Longitudinal population-based studies show that sleep difficulties are uniquely linked with menopausal stage and changes in follicle-stimulating hormone and estradiol, over and above the effects of age. A major contributor to sleep complaints in the context of the menopausal transition is HFs, and many, although not all, HFs are linked with polysomnographic-defined awakenings, with HF-associated wake time contributing significantly to overall wakefulness after sleep onset. Some sleep complaints may be comorbid with depressive disorders or attributed to sleep-related breathing or movement disorders, which increase in prevalence especially after menopause, and for some women, menopause, age, and environmental/behavioral factors may interact to disrupt sleep. Considering the unique and multifactorial basis for sleep difficulties in women transitioning menopause, we describe clinical assessment approaches and management options, including combination treatments, ranging from cognitive behavioral therapy for insomnia to hormonal and nonhormonal pharmacological options. Emerging studies suggest that the impact of severe insomnia symptoms could extend beyond immediate health care usage and quality of life issues to long-term mental and physical health, if left untreated in midlife women. Appropriate treatment, therefore, has immediate benefit as well as advantages for maintaining optimal health in the postmenopausal years.

Improving vasomotor symptoms; psychological symptoms; and health-related quality of life in peri- or post-menopausal women through yoga: An umbrella systematic review and meta-analysis

OBJECTIVES

Vasomotor symptoms (VMS), commonly reported during menopausal transition, negatively affect psychological health and health-related quality of life (HRQoL). While hormone therapy is an effective treatment, its use is limited by concerns about possible harms. Thus, many women with VMS seek nonhormonal, nonpharmacologic treatment options. However, evidence to guide clinical recommendations is inconclusive. This study reviewed the effectiveness of yoga, tai chi and qigong on vasomotor, psychological symptoms, and HRQoL in peri- or post-menopausal women.

DESIGN

MEDLINE, Cochrane Database of Systematic Reviews, EMBASE, CINAHL and the Allied and Complementary Medicine Database were searched. Researchers identified systematic reviews (SR) or RCTs that evaluated yoga, tai chi, or qigong for vasomotor, psychological symptoms, and health-related quality of life (HRQoL) in peri- or post-menopausal women. Data were abstracted on study design, participants, interventions and outcomes. Risk of bias (ROB) was assessed and updated meta-analyses were performed.

RESULTS

We identified one high-quality SR (5 RCTs, 582 participants) and 3 new RCTs (345 participants) published after the SR evaluating yoga for vasomotor, psychological symptoms, and HRQoL; no studies evaluated tai chi or qigong. Updated meta-analyses indicate that, compared to controls, yoga reduced VMS (5 trials, standardized mean difference (SMD) -0.27, 95% CI -0.49 to -0.05) and psychological symptoms (6 trials, SDM -0.32; 95% CI -0.47 to -0.17). Effects on quality of life were reported infrequently. Key limitations are that adverse effects were rarely reported and outcome measures lacked standardization.

CONCLUSIONS

Results from this meta-analysis suggest that yoga may be a useful therapy to manage bothersome vasomotor and psychological symptoms.

Acupuncture to Treat Sleep Disorders in Postmenopausal Women: A Systematic Review

Sleep disorders are commonly observed among postmenopausal women, with negative effects on their quality of life. The search for complementary therapies for sleep disorders during postmenopausal period is of high importance, and acupuncture stands out as an appropriate possibility. The present review intended to systematically evaluate the available literature, compiling studies that have employed acupuncture as treatment to sleep disorders in postmenopausal women. A bibliographic search was performed in PubMed/Medline and Scopus. Articles which had acupuncture as intervention, sleep related measurements as outcomes, and postmenopausal women as target population were included and evaluated according to the Cochrane risk of bias tool and to the STRICTA guidelines. Out of 89 search results, 12 articles composed our final sample. A high heterogeneity was observed among these articles, which prevented us from performing a meta-analysis. Selected articles did not present high risk of bias and had a satisfactory compliance rate with STRICTA guidelines. In general, these studies presented improvements in sleep-related variables. Despite the overall positive effects, acupuncture still cannot be stated as a reliable treatment for sleep-related complaints, not due to inefficacy, but rather limited evidence. Nevertheless, results are promising and new comprehensive and controlled studies in the field are encouraged.