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Evidence-Based Reviews

Treating insomnia across women’s life stages

Changes during menstruation, pregnancy, and menopause often impact sleep

Vol. 9, No. 7 / July 2010

Discuss this article at

Ms. A, age 44, reports a 3-month history of forgetfulness, difficulty concentrating, and insomnia. She says she can fall asleep but wakes up multiple times during the night and feels tired during the day. She has no history of a mood or anxiety disorder or medications that might be responsible for her symptoms.

Before her current insomnia began, Ms. A could sleep for 7 to 8 hours at night. Her husband suffers from obstructive sleep apnea (OSA), and his snoring occasionally would awaken her, but she slept well overall. Ms. A cannot identify anything that could be causing her sleep complaints. She states “The weird thing is that sometimes I am not sure if I’m cold or hot” and “I sometimes wake up drenched in sweat.” She also reports recent changes in the timing of her otherwise regular menstrual flow.

Ms. A attributes her memory problems to her poor sleep. A recent audit at her company held her responsible for several accounting errors, and Ms. A is worried that she might lose her job. She denies symptoms that would suggest major depression. You are unable to elicit a history of limb movements or excessive snoring.

Compared with men, women have a 1.3- to 1.8-fold greater risk for developing insomnia.Improve sleep with group CBT for insomnia,” Current Psychiatry, April 2009.) Pharmacotherapy during pregnancy and for breast-feeding mothers is guided by evaluating the risk/benefit ratio and safety considerations.

Maintain a high index of suspicion for breathing-related sleep disorders, such as OSA,21 and RLS.22 Atypical presentations of OSA are common in pregnant or postpartum women; compared with men, women with OSA are more likely to report fatigue and less likely than to report sleepiness. Refer patients whom you think may have OSA for polysomnography.

If you suspect RLS, check for low ferritin and folate levels. Nutritional supplements may be necessary for women in high-risk groups, including those who are pregnant or have varicose veins, venous reflux, folate deficiency, uremia, diabetes, thyroid problems, peripheral neuropathy, Parkinson’s disease, or certain autoimmune disorders, such as Sjögren’s syndrome, celiac disease, and rheumatoid arthritis.23 Advise these patients to avoid caffeine.

Although indicated for treating RLS, ropinirole and pramipexole are FDA Pregnancy Category C, which means animal studies have shown adverse effects on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite risks. Opioids, carbamazepine, or gabapentin may be safer for pregnant patients.24

Insomnia during menopause

The prevalence of insomnia increases from 33% to 36% in premenopausal women to 44% to 61% in postmenopausal women.14 Hot flashes, comorbid mood disturbances, sleep-disordered breathing, and RLS contribute to increased insomnia risk in postmenopausal women (Table 3).4,14,25,26

Treatment strategy. Always inquire about sleep in perimenopausal/postmenopausal women, even when her presenting complaint is related to menstrual cycle changes or vasomotor symptoms such as hot flashes.16 Assess patients for OSA, RLS, and mood, anxiety, and cognitive symptoms.26 In addition to pharmacotherapy and behavioral therapy, treatment options include hormone replacement therapy (HRT) and herbal and dietary supplements (Table 4).27-32

Table 3

Sleep difficulties during menopause: Differential diagnoses




Other considerations

Hot flashes (prevalence: 75% to 85%)14

Vasomotor phenomenon characterized by feelings such as ‘spreading warmth,’ diaphoresis, palpitations, nausea, and insomnia Mediated through the preoptic area of the anterior hypothalamus, which regulates temperature and sleep Increased brain norepinephrine metabolism

Discrepancies between objective (PSG) and subjective measures (surveys)4 Discrepancies between self-reported and laboratory reported sleep data might be explained by thermoregulatory differences between NREM and REM sleep24

Nocturnal hot flashes trigger awakenings and insomnia14 Hot flashes can follow arousals and awakenings HRT is highly effective in treating hot flashes; however, data on its direct effects on sleep complaints are inconsistent

Primary menopausal insomnia25

Menopausal symptoms (eg, hot flashes) trigger insomnia that persists secondary to behavioral conditioning

Increase in nocturnal skin temperature coincides with decrease in skin resistance and waking episodes in PSG

Behavioral insomnia therapies are useful adjuncts to treatment of menopause symptoms

Sleep-disordered breathing (OSA)

Menopause increases risk for OSA independent of body weight Redistribution of body fat with an increase in the waist-to-hip circumference ratio occurs in menopause Loss of ventilatory drive because of diminished progesterone levels

Sleep fragmentation and daytime sleepiness are common, as opposed to apneic episodes or oxygen desaturation in men

Maintain a high index of suspicion and promptly refer patients to a sleep center

Restless legs syndrome

Related to iron deficiency

Low ferritin and folate levels

Advise patients to avoid caffeine

HRT: hormone replacement therapy; NREM: non-rapid eye movement; OSA: obstructive sleep apnea; PSG: polysomnography; REM: rapid eye movement

Table 4

Treating insomnia in menopausal women



Hormone replacement therapy (HRT)

Effective for hot flashes, insomnia,26-28 and sleep apnea29 Long-term safety is questionable4

Behavioral therapy (cognitive-behavioral therapy,30 stimulus control therapy, sleep restriction therapy, sleep hygiene, hypnotherapy, biofeedback)

Limited data in menopausal women

Sedatives/hypnotics/antidepressants (eg, zolpidem, 10 mg; eszopiclone, 3 mg; trazodone, 75 mg; ramelteon, 8 mg; SSRIs and SNRIs)

Benzodiazepines may be useful, although not specifically evaluated in menopausal women. Risk of tolerance, dependence, and psychomotor slowing

Herbal and dietary supplements (Cimicifuga racemosa [Black cohosh],31 valerian

Popular alternatives to HRT; however, evidence of efficacy as treatment for insomnia is inconclusive

SNRIs: serotonin-norepinephrine reuptake inhibitors; SSRIs: selective serotonin reuptake inhibitors

Comorbid psychiatric disorders

Women have a higher prevalence of psychiatric disorders such as major depressive disorder and anxiety disorders than men.1 Women have a 10% to 25% lifetime risk of developing major depression. Three quarters of depressed patients experience insomnia.1 Recent literature suggests insomnia is a risk factor for depression,33 which emphasizes the need to screen women who present with sleep problems for depression and anxiety.

Five percent to 20% of women experience postpartum depression. Depression and insomnia are correlated to the rapid decline in estrogen and progesterone after delivery.34

Treatment strategy. Insomnia is a common presenting symptom in patients with psychiatric conditions such as mood and anxiety disorders. Treating the underlying psychiatric disorder often alleviates sleeping difficulties. However, if the insomnia is disabling, treat the psychiatric disorder and insomnia concurrently.

CASE CONTINUED: Perimenopausal insomnia

Based on her history, you diagnose Ms. A with insomnia related to general medical condition (perimenopause). There are no indications to refer her for polysomnography. You educate Ms. A about sleep hygiene and recommend that she discuss her menstrual and physical complaints with her primary care physician or gynecologist. Ms. A is not interested in HRT because she has a strong family history of endometrial cancer. You reassure Ms. A and schedule a follow-up visit in 2 months to re-evaluate her insomnia.

Related resource

  • Krahn LE. Perimenopausal depression? Ask how she’s sleeping. Current Psychiatry. 2005;4(6):39-53.

Drug brand names

  • Carbamazepine • Carbatrol, Tegretol, others
  • Escitalopram • Lexapro
  • Eszopiclone • Lunesta
  • Fluoxetine • Prozac
  • Gabapentin • Neurontin, Gabarone
  • Paroxetine • Paxil
  • Pramipexole • Mirapex
  • Ramelteon • Rozerem
  • Ropinirole • Requip
  • Sertraline • Zoloft
  • Trazodone • Desyrel
  • Zolpidem • Ambien


The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.


The authors thank Dr. Namita Dhiman and Darrel E. Willoughby for their assistance with this article.


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