Resources

  1. Guthrie KA, Larson JC, Ensrud KE, et al. 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. 2018 Jan 1;41(1). doi: 10.1093/sleep/zsx190 https://www.ncbi.nlm.nih.gov/pubmed/29165623
  2. Grant, MD, Marbella, A., Wang AT et al. Menopausal Symptoms: Comparative Effectiveness of Therapies review 147 Executive Summary. AHRQ, March 2015.
    https://effectivehealthcare.ahrq.gov/sites/default/files/related_files/menopause_executive.pdf
  3. Effects of Pharmacologic and Nonpharmacologic Interventions on Insomnia  


Transcript

Dr. Frank Domino:
Karen comes to your office today because of her chronically interrupted sleep. She is 52 and started with her menopausal symptoms about a year ago. Her last period was about five months ago. Initially, the symptoms were infrequent, night sweats and trouble sleeping, hot flashes as well. But now they're happening up to four times a week and sometimes more than once a night. She's very frustrated and tired. She realizes this is affecting both her home life, as well as work. To make matters worse, she worked very hard a few years ago to lose about 15 pounds, and now because she's so tired, she finds herself eating late at night and making poor food choices.

Joining me today to discuss how to help patients get through their menopausal symptoms is Jill Terrien. Jill is Associate Professor and Director of the Nurse Practitioner Specialties Program at the University of Massachusetts Medical School's Graduate School of Nursing. Thanks for coming today, Jill.

Jill Terrien:
Thank you, Frank, for inviting me.

Dr. Frank Domino:

Karen sounds like many of our patients. Menopause is very hard and, quite honestly, Karen is suffering. What can you tell us about the best evidence to help her address her sleep issues as she goes through menopause?

Jill Terrien:
Right. This study just came out and it's a series of randomized controlled trials looking at basically seven interventions that work with women that are in perimenopause or are in menopause, that have a variety of symptoms, including insomnia, vasomotor symptoms that include night sweats. They looked at seven interventions over four different randomized controlled trials. And in the final trial, that really focused on the insomnia. The participants in the trial had to have moderate to severe insomnia issues, as well as... What they used was a questionnaire to look at vasomotor symptoms. And they basically had to have at least 14 occurrences of the vasomotor symptoms in the two weeks immediately preceding the trial.

Dr. Frank Domino:

Wow, so quite severe symptoms.

Jill Terrien:
Yes, very bothersome. And we know that 85% of women have a variety of symptoms, that they are very bothered during their perimenopause and their menopause. Anything that we can suggest to them that we know works is really helpful.

Dr. Frank Domino:

Eighty-five percent of half the adult population is a very significant number of people. As we begin trying to think about how we're gonna help Karen, what other things do we need to know about her to try to help make a decision about what interventions to try?

Jill Terrien:

Well, it's important to have this information from these studies, but it's also important to know what has she tried already and where is she at? We already know that she is not happy, that she is making some poor food choices. Especially if she's worked hard to lose weight, it's very difficult for women, especially in menopause, to lose weight. There's a lot of hormonal changes. And you feel up, you feel down. It can be hard. And if you don't have sleep, good sleep, then we know that that's definitely a consequence. We wanna know what is she doing as far as food choices? What is she doing for exercise? What other comorbidities does she have? Is she on meds for any other reasons? And so you can work with what you already know about her. Important to know is alcohol intake, and when she's having her last meal before she goes to bed, 'cause you wonder, could GERD be a problem? It's very, very common.

Dr. Frank Domino:
You mentioned alcohol. Why is alcohol important?

Jill Terrien:
Well, because you wanna know quantity and you wanna know type. We know that some adults, in the general population, can have sleep disturbances based on what they take in for alcohol. Is she going with the recommended guidelines of what we know about alcohol? Red wine, white wine, or hard liquor, and how much is she consuming, and when does she consume it?

Dr. Frank Domino:
All right. So, it's very important to look at her past medical history or her med list, and then take a very good social history, seeing if any of those things play a factor in her symptoms. It looks like this is a fairly comprehensive study. What were the findings? What worked?

Jill Terrien:
Well, a lot worked, which is good to know that you have choices. It's just some things worked better than others. They had looked at exercise, such as yoga. They had looked at active aerobic exercise. They looked at omega-3 fatty acids. They looked at estradiol. And they looked at some SSRI and SNRI interventions. And then they also looked at cognitive behavioral therapy as well. And what they found is that, overall, for insomnia symptoms, cognitive behavioral therapy had very good outcomes overall.

Dr. Frank Domino:
Jill, how do these interventions compare in treating insomnia in the perimenopausal period?

Jill Terrien:
It's interesting to know that, out of the seven interventions, they know that omega-3 supplements did not help at all, and that cognitive behavioral therapy had the greatest effect on sleep and improving it, and that cognitive behavioral therapy intervention had the greatest effect on improving sleep.

Dr. Frank Domino: 
Great. Wow. So cognitive behavioral therapy was actually more effective than things like medications, SSRIs, and estrogen?

Jill Terrien:

Yes. And for those of you that look up the study, you'll see that everything had a benefit except the omega-3. And it was on a little bit... Depending on what they looked at, the cognitive behavioral therapy came out on top.

Dr. Frank Domino: 

Okay. It sounds like, of all the options we have, we should be incorporating cognitive behavioral therapy which is a wonderful idea, but it's very hard to implement in practice. How do we advise Karen today?

Jill Terrien:
Advising Karen, as we talked about, we wanted to know what she was doing on a regular day anyways and how she was problem-solving maybe on her own. But I think that depending on how much you use cognitive behavioral therapy and referrals in your practice, and then talking to the patient if she is interested in it, and then what is gonna be covered for insurance and how easy is it for to get. But there are some online self-help cognitive behavioral therapy programs that Karen could try. So, you have a range from having an actual therapist working with her to her working possibly with you and herself.

Dr. Frank Domino: 

It sounds like we should broaden our approach towards dealing with perimenopause, not to just focus on medications. At a minimum, the most effective being cognitive behavioral therapy, find a way to integrate that for Karen. It doesn't mean we probably still could not add a medication if things didn't improve, but it is good to know that some things don't work, and I think folks have high interest in omega-3 fatty acids and they just often don't help that much. Well, this is really important. Thank you, Jill. I think, going forward, we all need to be more aware of how the perimenopausal period presents challenges and be more effective in trying to help patients address them.

Jill Terrien:
Agreed, Frank. Thank you.

Dr. Frank Domino: 

Practice pointer: 85% of women experience symptoms during the perimenopausal period that include vasomotor symptoms, sleep disturbance, psychological changes, urogenital changes, and sexual changes. Join us next time when we discuss the role of music training in young children's ability to develop executive functioning.