ATLANTA — Sleep problems in perimenopausal women can diminish quality of life significantly and should not be minimized or overlooked, according to Hadine Joffe, M.D.
In general, hormonal fluctuations may be to blame, but hot flushes and night sweats in particular are often linked to insomnia, disturbed sleep, and sleep loss during the menopausal period, Dr. Joffe said in a satellite presentation at the annual meeting of the American Psychiatric Association.
“Considering the median duration of perimenopause is 4 years, many women may suffer from issues related to insomnia for a long time if they don't get treatment,” said Dr. Joffe, director of endocrine studies in the perinatal and reproductive psychiatry clinical research program at Massachusetts General Hospital, Boston.
The data on the association between hot flushes and sleep quality and duration during perimenopause are contradictory, Dr. Joffe said. “A number of studies have shown that total sleep time in perimenopausal women who experience frequent hot flushes does not suffer, compared with women who don't have hot flushes, while other studies have shown that what does suffer is sleep quality,” she said. “Hot flushes and night sweats interrupt sleep, causing lower sleep efficiency and longer REM latency, and the frequent awakenings cause next-day fatigue.”
Still other studies have shown that mood symptoms, which are common in perimenopausal women, may influence the perceived intensity of hot flushes as well as self-reported sleep quality, Dr. Joffe said.
Whether driven by mood or the nature and frequency of hot flushes, menopause-related sleep disturbances can improve with treatment. “The most effective treatment continues to be hormonal therapy. Estrogen therapy in particular has been shown to improve subjective sleep quality and continuity and to increase REM and reduce REM latency,” she said. “And the impact of estrogen on sleep is greatest in women with hot flushes.”
However, concerns about using hormonal therapy for long periods as well as its contraindication in some patients have led to the consideration of other treatment strategies for improving sleep, including the use of serotonergic antidepressants and hypnotic agents, she said.
In a recent Finish study, investigators looked at the impact of the selective serotonin reuptake inhibitors fluoxetine and citalopram on menopausal symptoms. While neither appeared to have a significant effect on hot flushes, insomnia improved significantly in the citalopram group versus placebo (Menopause 2005;12:18–26).
Several studies also have shown that paroxetine and venlafaxine can significantly decrease hot flashes, and as such may improve sleep. Similarly, there is some evidence that the anticonvulsant gabapentin and the antihypertensive clonidine can effectively treat the vasomotor symptoms of menopause, Dr. Joffe said.
Hypnotic agents also may improve sleep quality compromised by multiple factors, including hot flushes, she explained.
In one 4-week randomized, multicenter, double-blind, placebo-controlled study, women taking the benzodiazepine receptor agonist zolpidem reported an increase in total sleep time, a decrease in the number of awakenings, improved sleep quality, and improvements in sleep-related difficulty with daytime functioning (Clin. Ther. 2004;26:1578–86).
Preliminary data from an ongoing trial of eszopiclone at Massachusetts General Hospital also has been linked to significantly improved sleep onset, sleep maintenance, total sleep time, and sleep quality, compared with placebo.
When treating menopause-related insomnia, first rule out underlying conditions, then consider patient factors and the severity of the problem, Dr. Joffe advised. Some antidepressants may take 3–4 weeks before noticeable improvement, so patients with severe symptoms might be reluctant to wait that long, she noted. Hypnotics may work faster, but they do have the potential for morning “hangover,” and they are not appropriate in the presence of any coexisting chemical dependency.
Dr. Joffe receives research support from Abbott Laboratories. She also is on the speakers' bureau for Eli Lilly & Co. The APA-sponsored satellite symposium was supported by an unrestricted educational grant from Neurocrine Biosciences Inc. and Pfizer Inc.