Menopause Insomnia Treatments: What Science Says Works Best
Quick Summary
Cognitive Behavioral Therapy for Insomnia (CBT-I) is the most effective treatment for improving insomnia symptoms and sleep quality in menopausal women, significantly outperforming medications and lifestyle changes like exercise and yoga (Guthrie et al., 2018).
Exercise and the antidepressant venlafaxine showed moderate benefits for sleep, making them potential secondary options if CBT-I is not accessible.
Low-dose estrogen, the antidepressant escitalopram, and yoga provided only small improvements in sleep, suggesting they are less effective as primary menopausal insomnia treatments (Guthrie et al., 2018).
Treating hot flushes does not automatically fix insomnia. The study found that some treatments that reduced hot flushes had little effect on sleep, indicating that insomnia during menopause is a distinct problem that requires a targeted approach (Guthrie et al., 2018).
Menopause, Hot Flushes, And Sleep Problems: Is Insomnia Inevitable?
For many women, the menopausal transition brings a host of challenging symptoms, and poor sleep is one of the most frequently reported issues reported by peri-menopausal and post-menopausal women (Guthrie et al., 2018).
Large population-based studies suggest between 40% - 64% of perimenopausal or post-menopausal women report disturbed sleep (e.g. Kravitz et al., 2003).
It’s common to hear from patients that nighttime hot flushes (also called “hot flashes” in the US) and night sweats are the sole culprit when it comes to menopause insomnia, waking women up from an otherwise sound sleep.
But surprisingly, scientific studies have been less clear on the role of hot flushes in insomnia.
Some studies have found that the frequency and severity of hot flushes are associated with increasing self-reported severity of insomnia symptoms, and objective measures of nighttime wakefulness and sleep fragmentation (e.g. Ensrud et al., 2009).
Yet other studies have found no association between objective hot flushes and subjective, or self-reported, sleep quality (e.g. Thurston et al., 2006)
So what exactly is the relationship between menopause, hot flushes, and insomnia? Could it be more complicated than we think?
And more importantly, what actually works to help women get the restorative sleep they need during menopause?
Fortunately, researchers have looked at these very questions and have some firm answers.
But first, why do hot flushes even happen?
Why Do Hot Flushes Occur During Menopause?
The menopausal transition involves significant hormonal shifts, including changes in estrogen and other reproductive hormones, which can affect the brain’s temperature regulation systems (Guthrie et al., 2018).
These changes in the brain’s temperature regulation systems can lead to vasomotor symptoms (VMS), the medical term for hot flushes and night sweats.
At the same time, these hormonal changes can independently disrupt the systems that regulate sleep.
Are Hot Flushes The Cause Of Menopause Sleep Problems And Insomnia?
Studies have shown that while hot flushes are linked with awakenings, it’s not an exclusive one-to-one relationship (Joffe et al., 2013).
Instead, it seems that some underlying process, likely related to the autonomic nervous system - the system that controls involuntary functions like heart rate and temperature - contributes to both waking episodes and the sensation of a hot flush (de Zambotti et al., 2014).
So, given this complicated relationship, what are the best ways to treat these intertwined issues?
What Are Common Treatments Used for Sleep Problems in Menopause?
A wide range of treatments, from medications to lifestyle changes, are commonly used to manage menopausal sleep symptoms (Guthrie et al., 2018). These include:
Cognitive Behavioral Therapy for Insomnia (CBT-I): A structured, non-medication therapy focused on changing the thoughts and behaviors that perpetuate insomnia.
Aerobic Exercise: A structured program of moderate-intensity physical activity.
Yoga: A program designed specifically for menopausal women.
Escitalopram: A common antidepressant known as a selective serotonin reuptake inhibitor (SSRI).
Venlafaxine: Another antidepressant known as a serotonin-norepinephrine reuptake inhibitor (SNRI).
Low-Dose Estradiol 0.5mg/day: A form of oral estrogen therapy
Omega-3 Fatty Acids: A dietary supplement.
Despite the variety of potential treatments, it has been unclear how effective these seven common treatments for menopause insomnia are (Guthrie et al., 2018).
Fortunately, a major research effort, called MsFLASH, has looked to clarify just how effective the common treatments actually are.
What Is The MsFLASH Research Network For Menopause Sleep?
The MsFLASH network is a major research effort aimed at understanding menopausal health. MsFLASH stands for Menopause Strategies: Finding Lasting Answers for Symptoms and Health (MsFLASH) network. MsFLASH has conducted a series of high-quality clinical trials to test the seven most common treatments for menopause sleep issues.
By combining the data from these trials, researchers aimed to gain one of the clearest pictures yet of the most effective science-backed strategies for managing insomnia during this phase of life.
How Were The Common Menopause Sleep Treatments Studied?
The MsFLASH research network conducted four large, rigorous randomized clinical trials to test the seven common interventions in women experiencing both hot flushes and sleep problems.
The four trials were designed with standardized methods so that their results could be compared, providing valuable insight into their relative effectiveness and which provided the most significant relief for insomnia symptoms.
But how did the researchers compare such different treatments in a fair and scientific way?
How Were Menopause Insomnia Treatments Compared Across Studies?
The researchers compared the seven different treatments using a powerful statistical method called a pooled analysis of individual participant data (Guthrie et al., 2018).
This approach involved combining the raw data from 546 women who participated across the four different MsFLASH trials, allowing for a direct comparison of each intervention's effect relative to a control group.
To be included in this specific analysis, all women had to have clinically significant insomnia symptoms at the start of the study, defined by a score of 12 or higher on the Insomnia Severity Index (ISI), a widely used questionnaire that measures a person's perception of their insomnia.
They also had to be experiencing frequent and bothersome hot flushes.
The effectiveness of each treatment was measured by tracking changes in two key areas over 8 to 12 weeks:
Insomnia Severity: This was measured using the Insomnia Severity Index (ISI), where a lower score indicates fewer insomnia symptoms.
Overall Sleep Quality: This was assessed with the Pittsburgh Sleep Quality Index (PSQI), a detailed questionnaire that evaluates various aspects of sleep, with a lower score indicating better sleep quality.
By using this rigorous approach, the researchers could confidently determine the magnitude of improvement each treatment offered compared to a control group (who received either a placebo or general menopause education).
So, after all this analysis, which treatment came out on top?
Which Treatment Was Most Effective for Menopausal Insomnia?
The analysis identified that the most effective treatment for menopause insomnia was Cognitive Behavioral Therapy for Insomnia (CBT-I) (Guthrie et al., 2018).
Compared to the other 6 common menopause insomnia treatments and control groups, CBT-i:
Produced the greatest reduction in insomnia symptoms, and
Resulted in the largest improvement in sleep quality
The positive effects of CBT-I were approximately two times larger than those of any other intervention studied.
Women who received CBT-I saw their scores on the Insomnia Severity Index (ISI) drop by an average of 5.2 points more than the control group. This is considered a very large and clinically meaningful improvement (i.e. it makes a real world difference to the person).
To put it in perspective, this change is often enough to move a person from a category of moderate-to-severe insomnia to mild or no insomnia.
Similarly, CBT-I led to the largest improvement in overall sleep quality, with scores on the Pittsburgh Sleep Quality Index (PSQI) decreasing by 2.7 points more than the control group.
Furthermore, women who received CBT-I were far more likely to experience a full remission of their insomnia symptoms, meaning their ISI score dropped below the clinical cutoff of 8.
The odds of remission, that is full resolution of the sleep problems, were over 8 times higher for the CBT-I group compared to the control group.
It's important to note that in this study, CBT-I was delivered over the telephone in six sessions over eight weeks, demonstrating that this highly effective treatment can be accessible even without in-person visits.
But here’s the really surprising finding:
Cbt-i had no effect on the frequency or severity of hot flushes.
The success of CBT-I in treating menopausal insomnia suggests that for menopausal women, targeting both the behaviors and the thoughts that perpetuate sleep problems is more effective than targeting the other symptoms of menopause such as hot flushes and night sweats.
So how did the other common treatments fare in comparison?
How Did Other Common Treatments for Menopause Insomnia Compare To CBT-i?
While CBT-I was the clear winner for treating menopausal insomnia, other treatments provided varying levels of benefit with exercise and one type of antidepressant, Venlafaxine, showing moderate improvements, while low-dose estrogen and yoga offered only small gains for sleep (Guthrie et al., 2018).
Here’s a breakdown of how the other six interventions performed:
Moderate Improvement:
Aerobic Exercise: A 12-week program of regular exercise led to a significant reduction in insomnia severity, with ISI scores improving by 2.1 points more than the control group.
Venlafaxine: This SNRI antidepressant also produced a moderate improvement, with ISI scores dropping by 2.3 points more than the placebo group over 8 weeks
Small Improvement:
Low-Dose Estradiol: While often considered a primary treatment for menopausal symptoms, oral estrogen therapy produced only a small reduction in insomnia severity.
Escitalopram: This SSRI antidepressant also resulted in a small but statistically significant improvement in insomnia symptoms.
Yoga: A 12-week yoga program led to small improvements in both insomnia severity and\\\\
No Improvement:
Omega-3 Supplements: Taking 1.8 grams of omega-3 fatty acids daily for 12 weeks showed no effect on either insomnia symptoms or sleep quality compared to a placebo.
These results suggest that for menopausal women whose primary concern is insomnia, exercise and venlafaxine could be considered as secondary options.
However, the improvements they offer for sleep are substantially less than what can be achieved with CBT-I.
This leads to an important question: if a treatment helps hot flushes, shouldn't it also help sleep?
Did Treating Hot Flushes Also Improve Menopausal Sleep?
No, treatments that were effective for hot flushes did not necessarily provide the most benefit for sleep (Guthrie et al., 2018).
For example, previous analyses of these same MsFLASH trials found that low-dose estradiol, venlafaxine, and escitalopram were all moderately effective at reducing the frequency of hot flushes. However, as this analysis shows, their effects on insomnia itself were small.
Conversely, CBT-I, which was the most powerful treatment for insomnia, had no effect on the frequency or severity of hot flushes.
What Is The Real Relationship Between Hot Flushes And Menopausal Insomnia?
The findings of the MsFLASH trials analysis reinforces that insomnia and hot flushes are related but distinct problems.
This disconnect is key to treating menopausal sleep issues, and is one of the most important findings from the MsFLASH trials (Guthrie et al., 2018).
It suggests that while night sweats can be a trigger for awakenings, they do not necessarily cause insomnia.
Instead, once a woman is awake, whether from a hot flush or another cause, a separate cycle of insomnia can begin. The frustration and anxiety about being awake can lead to worry and racing thoughts.
In response, women may start to engage in unhelpful behaviors, such as spending more time in bed hoping to "catch" more sleep or napping during the day.
Ironically, these very behaviors can perpetuate and worsen the insomnia, turning a temporary, menopause-related sleep disruption into a chronic insomnia disorder.
Therefore, a treatment for menopause insomnia must directly target these perpetuating factors to be effective. This is why it’s important to use a targeted treatment like CBT-I for a specific problem like insomnia.
Relying on a treatment for hot flushes to indirectly solve a sleep problem is unlikely to be successful for many women.
Of course, no single study is perfect, so what should we keep in mind about this research?
What Are the Limitations of This Menopause and Sleep Study?
While this pooled analysis provides powerful insights, there are a few limitations to consider when interpreting the results.
First, the women in the first three trials were not specifically recruited for a sleep problem, and none of the women in any of the trials were required to have a formal clinical diagnosis of insomnia disorder. They were, however, all selected for this analysis because they had significant insomnia symptoms, making the findings highly relevant.
Second, because the study focused on women who also had hot flushes, the results may not apply to women who have insomnia without significant vasomotor symptoms.
Finally, women in the CBT-I trial knew they were receiving a treatment designed for insomnia, which could have created a higher expectation for improvement. However, the researchers noted that the placebo or control response in the CBT-I trial was not unusually high, suggesting this was not a major factor.
Despite these points, the study's strengths, such as its large size, the use of randomized controlled trials, and the standardized measures, make its conclusions very reliable.
So, what is the final takeaway for women struggling with sleep during menopause?
What Are the Practical Takeaways for Managing Insomnia During Menopause?
The findings from this large-scale analysis offer clear, evidence-based guidance for women and their healthcare providers.
The most important takeaway is that different treatments have very different levels of effectiveness, and choosing the right one is key to getting relief.
Here are the key practical points:
CBT-I Should Be the First-Line Treatment: The evidence is strong and clear: Cognitive Behavioral Therapy for Insomnia is the most effective intervention for improving sleep in menopausal women with insomnia symptoms. Its benefits are substantially larger than any of the other options studied. This supports the recommendations from major medical organizations, like the American College of Physicians, that CBT-I should be the initial treatment for chronic insomnia in adults (Qaseem et al., 2016).
Don't Assume Treating Hot Flushes Will Fix Your Sleep: While it seems logical, treatments aimed at reducing hot flushes, including low-dose estrogen, may only provide minimal benefit for a significant insomnia problem. Insomnia is a separate issue that requires a targeted treatment.
Consider Exercise as a Helpful Secondary Strategy: If CBT-I is not available, or as a complementary approach, regular aerobic exercise is a good evidence-based option that can provide moderate improvements in sleep.
Discuss Medication Options Carefully with Your Doctor: If medication is being considered, venlafaxine showed more benefit for sleep than escitalopram or low-dose estradiol in this study. However, these benefits were still much smaller than those from CBT-I. We would also note that our clinical experience is that venlafaxine can cause significant sleep difficulties for some individuals. A shared decision-making approach with a healthcare provider is essential to weigh the potential benefits against any side effects.
Omega-3 Supplements Are Not an Effective Treatment for Insomnia: Based on this high-quality trial, there is no evidence to support the use of omega-3 supplements for improving sleep during menopause.
In summary, for women navigating the challenges of menopause, this research provides clear direction: for significant and lasting relief from insomnia, the most effective path is a behavioral one via CBT-i, that directly addresses the habits and thoughts that stand in the way of a good night's sleep.
Frequently Asked Questions About Insomnia and Menopause
Q1: Why was CBT-I so much more effective for menopausal insomnia than other treatments?
A1: CBT-I is more effective because it directly targets the behaviors and thoughts that turn temporary sleep disruptions into a chronic problem. While hot flushes can trigger awakenings, it's often the worry about being awake and the unhelpful habits (like staying in bed while frustrated) that maintain insomnia. CBT-I addresses these root causes, whereas other treatments in the study targeted different symptoms (like hot flushes) or had a less direct impact on the core mechanisms of insomnia (Guthrie et al., 2018).
Q2: Do I have to see a therapist in person for CBT-I to improve my sleep?
A2: No. A key finding from this study was that CBT-I was highly effective even when delivered over the telephone (Guthrie et al., 2018). This shows that remote or telehealth options for CBT-I can be a very successful and accessible way to receive treatment, especially if you live in an area like regional New Zealand with fewer specialists.
Q3: If my hot flashes get better, will my menopausal insomnia improve on its own?
A3: Not necessarily. This research showed that treatments effective for hot flushes (like low-dose estradiol) had only a small effect on insomnia (Guthrie et al., 2018). This suggests that even if your night sweats are managed, the insomnia may persist because it has become a separate, self-perpetuating problem. It's best to treat insomnia directly with an insomnia treatment such as cognitive behavioural therapy for insomnia (CBT-i).
Q4: Is it worth trying exercise for my sleep problems during menopause?
A4: Yes. While not as powerful as CBT-I, a regular aerobic exercise program was shown to provide moderate, statistically significant improvements in insomnia symptoms (Guthrie et al., 2018). It is a good evidence-based strategy to consider, either as a starting point or as a complementary approach alongside CBT-I.
Q5: Should I take estrogen (estradiol) for my insomnia during menopause?
A5: Based on this study (Guthrie et al., 2018), low-dose oral estradiol is not a very effective treatment specifically for insomnia, as it only produced small improvements in sleep. While it may be prescribed to manage other menopausal symptoms like hot flushes, its direct benefit for sleep appears to be limited.
Q6: How does depression affect insomnia treatment during menopause?
A6: The study by Guthrie et al. (2018) noted that women with signs of depression at the start of the trial actually had a greater improvement in their sleep with CBT-I compared to those without depression. This suggests that CBT-I is a particularly effective treatment for menopausal women who are experiencing a combination of insomnia and low mood.
References
de Zambotti, M., Colrain, I. M., Javitz, H. S., & Baker, F. C. (2014). Magnitude of the impact of hot flashes on sleep in perimenopausal women. Fertility and Sterility, 102(6), 1708-15.e1. https://doi.org/10.1016/j.fertnstert.2014.09.003
Ensrud, K. E., Stone, K. L., Blackwell, T.L., Sawaya, G. F., Tagliaferri, M., Diem, S.J., Grady, D. Frequency and severity of hot flashes and sleep disturbance in postmenopausal women with hot flashes. Menopause. 2009; 16(2): 286–292.
Guthrie, K. A., Larson, J. C., Ensrud, K. E., Anderson, G. L., Carpenter, J. S., Freeman, E. W., Joffe, H., LaCroix, A. Z., Manson, J. E., Morin, C. M., Newton, K. M., Otte, J., Reed, S. D., & McCurry, S. M. (2018). Effects of Pharmacologic and Nonpharmacologic Interventions on Insomnia Symptoms and Self-reported Sleep Quality in Women With Hot Flashes: A Pooled Analysis of Individual Participant Data From Four MsFLASH Trials. Sleep, 41(3), zsx190. https://doi.org/10.1093/sleep/zsx190
Joffe, H., Crawford, S., Economou, N., Kim, S., Regan, S., Hall, J. E., & White, D. P. (2013). A gonadotropin-releasing hormone agonist model demonstrates that nocturnal hot flashes interrupt objective sleep. Sleep, 36(12), 1977–1985. https://doi.org/10.5665/sleep.3244
Joffe, H., White, D. P., Crawford, S. L., McCurnin, K. E., Economou, N., Connors, S., Hall JE. Adverse effects of induced hot flashes on objectively recorded and subjectively reported sleep: results of a gonadotropin-releasing hormone agonist experimental protocol. Menopause. 2013 Sep;20(9):905-14. https://doi.org/10.1097/GME.0b013e31828292d1
Kravitz, H. M., Ganz, P. A., Bromberger, J., Powell, L. H., Sutton-Tyrrell, K., & Meyer, P. M. (2003). Sleep difficulty in women at midlife: a community survey of sleep and the menopausal transition. Menopause (New York, N.Y.), 10(1), 19–28. https://doi.org/10.1097/00042192-200310010-00005
Qaseem, A., Kansagara, D., Forciea, M. A., Cooke, M., & Denberg, T. D. (2016). Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 165(2), 125-133. https://doi.org/10.7326/M15-2175
Written By The Better Sleep Clinic
Reviewed By Dan Ford, Sleep Psychologist
