A Review of Behavioral Interventions for Improving Sleep in Menopausal Women

When you prefer not to pop pills

Dear Friends! 
Welcome to Part 2 of our series on sleep! In Part 1, I shared my personal sleep solution for the 3am wake-up call in My Sleep Secrets Revealed. Today, Part 2 reviews a recent article published in the journal "Menopause" that focuses on the efficacy of behavioral interventions for improving sleep for those who prefer to minimize their use of pharmacology. 
Enjoy!
-Carla

Sleep disturbance affects 40-48% of perimenopausal and menopausal women and increases throughout the menopausal transition. Difficulty sleeping is strongly associated with vasomotor symptoms and increased emotional and physical impairment, and can severely affect quality of life.

Common behavioral therapies for insomnia include exercise, cognitive behavioral therapy (CBT-I), sleep restriction therapy (SRT), stimulus control therapy, sleep hygiene, and relaxation/mindfulness techniques. These interventions are thought to work through the alteration of dysfunctional beliefs about sleep, adjustment of behaviors that contribute to poor sleep, and attenuation of arousal of the central nervous system.

The American College of Physicians recommends CBT-I as first-line treatment for adults with insomnia, however, studies report that practitioners still rely heavily on pharmacologic therapy. In fact, prescriptions for non-benzodiazepine sedative-hypnotics such as Ambien and Lunesta have increased 30-fold from 1994-2007. Side effects of these medications can include dizziness, lightheadedness, confusion, double vision, and memory impairment, as well as nausea, ataxia (loss of control of bodily movements), slurred speech, slow reflexes, loss of balance and coordination, and vertigo.

I’m certainly not against medication - I’m an allopathic physician. I write hundreds of prescriptions every year. But if we use a variety of sleep strategies and good health practices as our foundation, this may be enough to manage our symptoms. But if we do need to use medication, they will work a whole heck of a lot better on a foundation of lifestyle modifications and healthy habits than they will by themselves. -Carla DiGirolamo, MD

Christine M Lam and her colleagues at McMaster University in Ontario, Canada investigated the efficacy of behavioral interventions for sleep disturbance in menopausal women. This work was published in the October 2022 issue of the journal Menopause and is summarized below with my editorial comments to follow.

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

Christine M Lam, Letician Hernandez-Galan, Lawrence Mbuagbaw, et al.

Menopause: The Journal of the North American Menopause Society 2022 Vol 29, No. 10, pp 1210-1221.

Goal of the study

• Assess the efficacy of behavioral interventions on sleep outcome among perimenopausal and menopausal women.

• Evaluate the safety of behavioral interventions through the incidence of adverse events.

Type of study

• Review and meta-analysis of the published literature evaluating the effects of behavioral interventions on objective and subjective measures of sleep quality using validated questionnaires and indices: polysomnography (PSG) or the Pittsburgh Sleep Quality Index (PSQI)

• 19 articles reporting results from 16 randomized controlled studies (RCTs) representing a total of 2,108 perimenopausal and menopausal women.

• Selected studies evaluated the effects of exercise, mindfulness/relaxation, CBT-I, and SRT on sleep outcomes. Exercise programs included yoga, pilates, moderate-intensity aerobic exercise, and walking.

Results

• Data from 19 articles including 16 RCTs were pooled and statistically analyzed showing that behavioral interventions were associated with a significant improvement in sleep outcomes.

• Analysis comparing the effects of the intervention subtypes found that CBT-I, exercise, and mindfulness/relaxation were associated with statistically significant improvement in sleep outcomes.

• When menopausal women were analyzed separately, behavioral intervention continued to show a statistically significant improvement in sleep outcomes.

• Nine studies measured adverse events. Six reported no adverse events. All study-related adverse events reported were not significantly different from their respective control groups. Reported events included muscle aches, low back pain, changes in strength/sensation in the limbs, and modification of exercise due to a pre-existing condition.

• Risk of bias: 18 of the 19 studies were judged to be at high risk for bias in at least 1 domain - most often “outcome measurement” due to the fact that self-reported surveys were used, and, thus the study subjects could not be blinded.

• Certainty of evidence was evaluated as very low quality due to the risk of bias as noted above, inconsistency, and publication bias.

Author’s Discussion and Conclusions

• CBT-I, physical exercise, and mindfulness/relaxation therapy show promise in improving sleep outcomes in perimenopausal and menopausal women.

• These interventions may be considered safe as no serious adverse events were reported.

• Barriers to CBT-I can include limited access to qualified providers, and time and transportation constraints. More study is needed on alternative delivery methods for CBT-I.

• Study limitations included the heterogeneity within study designs due to the non-standardized nature of behavioral interventions and the use of multiple different sleep scales among the selected studies.

***To learn more about CBT-I, check out this link to resources from the Mayo Clinic!

In my Humble Opinion…..

This study is valuable because it illustrates the effectiveness of an alternative to prescribed medications that can potentially have side effects worse than insomnia itself - such as daytime somnolence (which compounds the already apparent brain fog that mid-life women often experience), slow reflexes (which is NOT good if you are an athlete) and impaired coordination and balance which can lead to falls and potentially fractures.

Just like anything else, interventions that require some investment of time and engagement potentially yield greater long-term results. However, these are certainly not as easy or attractive as a pill that you just need to swallow.

I’m certainly not against medication - I’m an allopathic physician. I write hundreds of prescriptions every year. But if we use a variety of sleep strategies and engage in good health practices as our foundation, this may be enough to manage our symptoms. But if we do need to use medication, they will work a whole heck of a lot better on a foundation of lifestyle modifications and healthy habits than they will by themselves.