Sleep effects of psychological therapies for menopausal symptoms in women with hot flashes and night sweats: A systematic review

Abstract

Sleep disturbance is frequently reported by women during the menopausal transition due to various physiological changes and environmental factors. Insomnia is a critical treatment target for its deleterious effects on daytime functioning and quality of life and increased risk of developing a depressive disorder. Due to medication side effects and patient preferences, there is increased interest in the use of psychological treatments that address the myriad of menopausal symptoms, including cognitive-behavioural therapy, clinical hypnosis and mindfulness-based therapies. The objective of this article is to review the effects of psychological treatments for menopausal symptoms on sleep disturbance in peri-/postmenopausal women. We conducted a systematic review of the literature using PubMed and reference lists from inception until May 2023, including 12 studies that evaluated sleep as a secondary outcome. Most studies found that group and self-help (guided and unguided) cognitive-behavioural therapies and clinical hypnosis for menopausal symptoms have positive effects on sleep among women with significant vasomotor symptoms. There was preliminary support for mindfulness-based stress reduction. Future research including more diverse samples and women with sleep disorders is needed. Evaluating the implementation of psychological therapies in clinics where menopausal women seek care is an important next step.

Keywords

Sleep disturbance insomnia menopause cognitive-behavioural therapy mindfulness hypnosis

Introduction

Menopause is characterized by several physical and psychological changes and role transitions. Sleep disturbance is often reported by women throughout and following the menopausal transition, and women with pre-existing difficulties sleeping are particularly vulnerable to worsening of sleep during menopause.¹ These sleep difficulties include poor sleep quality,² insomnia symptoms^3–5 and sleep disordered breathing.^5–7 There are multiple factors contributing to sleep disturbance during menopause, including but not limited to vasomotor symptoms (i.e., hot flashes and night sweats [HFNS]), depressive symptoms and the presence of primary sleep disorders with their own etiological factors.⁸ The negative impacts of sleep disturbance during menopause are widespread, including poor quality of life and lower global functioning, cardiovascular disease, increased vasomotor symptoms and mood disturbance.^9,10 Thus, sleep disturbance during the menopausal transition is an important treatment target.

Hormone replacement therapy and other medications may treat sleep disturbance in those experiencing HF-induced awakenings.^11,12 However, these may not be viable or preferable for many women due to side effects, increased health risks, or attitudes towards medication.^13–18 Psychological treatments for insomnia – including cognitive-behavioural and mindfulness-based therapies – are effective in postmenopausal women^19–21, but access to these treatments is limited by a dearth of trained providers and limited availability in gynaecological or primary care settings where women seek care for their symptoms.

Psychological treatments for menopausal symptoms, including cognitive-behavioural therapy (CBT), clinical hypnosis (CH) and mindfulness-based stress reduction (MBSR), have the benefit of targeting the myriad problems associated with menopause, including HFNS, mood/anxiety changes, urogenital symptoms and sleep disturbance across the spectrum of clinical severity.^22–25 Using divergent methods, CBT and MBSR address reactions towards menopausal symptoms that increase distress and worsen the symptoms themselves; increase awareness of internal experiences; and promote acceptance.^23,26–29 CH involves inducing deep relaxation and the use of focused attention, mental imagery and personalized suggestions to reduce core body temperature and increase perceived control.²⁵ These treatments have a positive effect on vasomotor symptoms and depression.^25,30–32 Thus, for women struggling with impairing menopausal symptoms that include but may not be limited to sleep disturbance, these multifactorial treatments are important in facilitating access to treatment outside of speciality sleep clinics. The objective of this review is to evaluate whether CBT, CH and mindfulness-based therapies for menopausal symptoms improve sleep disturbance in women with HFNS.

Method

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Study selection

Included studies (1) were original research examining an intervention including CBT, CH, or mindfulness-based therapy for menopausal/vasomotor symptoms; (2) evaluated an active psychological intervention against a comparison group; (3) included an assessment of HFNS as the primary outcome; (4) included an assessment of sleep (e.g. insomnia symptoms, sleep disturbance and sleep quality) as a secondary outcome; (5) included peri- or postmenopausal women (natural or treatment-induced); and (6) were published in English. We reviewed whether psychological treatments for menopausal symptoms impact sleep among women seeking care for HFNS. Thus, we excluded studies in which the exclusive treatment focus was sleep (e.g. CBT-I) but included multi-component treatments for menopausal symptoms that included a sleep-focused component. These objectives differ on two important points: the treatment focus (menopausal symptoms vs. a sleep disorder), and the population of study (treatment seeking for menopausal symptoms vs. a sleep disorder). For a review of sleep treatments during the menopausal transition, see 21,33,34.

Literature search

Articles were obtained from PubMed using the following MeSH terms: ‘menopause’ AND ‘cognitive-behavioural therapy’ OR ‘hypnosis’ OR ‘mindfulness’ from inception until May 2023. Reference lists of full-texts and review papers were also reviewed. The search was conducted by the first author. The search returned 123 records from PubMed and 10 records from reference lists. All records were screened by title, which led to the exclusion of 59 records not meeting our inclusion criteria. The remaining 74 records were screened by abstract, leading to the exclusion of another 55 records. Fourteen full-texts were assessed for eligibility, leading to the inclusion of 12 full-texts for review (see Figure 1).

Figure 1.

PRISMA flow diagram of study selection.

Data extraction

We collected the following data: first author; year of publication; study location; intervention and control treatments; sample size (per group); description of intervention (n of sessions, frequency and length); assessment timepoints; primary outcome measure and group × time result or between-group difference; and sleep outcome measure and group × time result or between-group difference (when unavailable, separate within-group results are reported).

Cognitive-behavioural interventions

Six RCTs examined sleep effects of CBT for menopausal symptoms in women during natural menopause and in breast cancer survivors with treatment-induced menopause. Table 1 describes the study criteria, interventions and primary and sleep outcomes.

Table 1.

Effect of cognitive-behavioural therapy for menopause on sleep disturbance.

Author	Location	Treatment (n)	Control (n)	Age	Inclusion/exclusion criteria	Description of intervention (n of sessions, frequency, length)	Assessments	Primary outcome^a		Sleep outcome^a
Mann et al³⁵	England	CBT: 43	UC: 45	CBT M = 53.16 SD = 8.10 UC: M = 54.05 SD = 7.76	Inclusion - Women ≥18 years of age - ≥ 10 HFNS per week for ≥2 months - Completed medical treatment for BC - English speaking	Group CBT (6 weekly sessions, 90 mins)	Baseline, 9 weeks, 26 weeks	HFRS problem rating	MD = 1.67, p < .0001	WHQ	MD = 0.26, p < .0001
					Exclusion
					- Evidence of other cancer or metastases
					- Unable to attend sessions
					- Seeking treatment for mood disorders
					- Taking HFNS treatments ≤2 months or not maintaining consistent dose during trial
Ayers et al³⁷	England	Group CBT: 46	NTC: 43	M = 53.09 SD = 5.4	Inclusion- Menopausal transition or postmenopausal (1 year from last menstrual period)- ≥ 10 HFNS/week in past month- English speaking	Group CBT (4 weekly sessions, 120 mins)	Baseline, 6 weeks, 26 weeks	HFRS problem rating	Group CBT: MD = −2.124, p < .001	WHQ sleep problems	Group CBT: MD = n.s



					- Age ≥18 years- Travelling distance of London- Willing to maintain menopause treatments, remedies or supplementsExclusion- History of BC- Medical/psychiatric conditions that could affect ability to participate	SH (4 weekly modules +2 therapist telephone calls)			SH-CBT: MD = −2.078, p < .001		SH-CBT: MD = 0.08, p = .018
		SH-CBT: 40				SH (4 weekly modules +2 therapist telephone calls)
Hardy et al³⁸	England	SH-CBT: 46	WLC: 60	M = 54.09 SD = 3.4	Inclusion	SH-CBT (4 weeks)	Baseline, 6 weeks, 20 weeks	HFNS problem rating	p = .001, d = .77	PSQI	p = .001, d = .51
					- Women age 45-60 years
					- English speaking
					- ≥ 10 HFNS/week for ≥2 months and score >2 on HFRS
					- Employed in participating organizations
					Exclusion
					- Physical or psychiatric problems that would impact participation					WHQ sleep problems	p = .001, d = .49
Green et al³⁹	Canada	Group CBT: 28	WLC: 21	M = 53.08 SD = 4.02	Inclusion- Women age 40–60 years- Meet STRAW criteria for peri-/postmenopause or surgically induced menopause- ≥ 4 HF/day or 28+ HF/week- Score ≥3 on vasomotor subscale of the GCS- Score ≥30 on HFRDIS- Score ≥14 on BDI-II- English speaking	Group CBT (12 weekly sessions, 120 mins)	Baseline, 12 weeks, 24 weeks	HFRDIS	p < .001, η²_p = .21	PSQI	p = .001, η²_p = .17





								BDI-II	p = .001, η²_p = .15

					- Not taking HT or psychoactive medications or maintaining dose for ≥12 weeks before baselineExclusion- Severe depression or active suicidal ideation- Psychosis or SUD- Receiving concurrent psychological treatment
Green et al.⁴⁰ ^b	Canada	Group CBT: 19	WLC: 17	M = 53.56SD = 4.14	Inclusion- Women age 40–65 years- Meet STRAW criteria for peri-/postmenopause or surgically induced menopause- ≥ 4 HF/day or ≥28 HF/week- Score ≥3 on vasomotor subscale of GCS- Score ≥30 on HFRDIS- Score ≥14 on BDI-II- Not taking HT or psychoactive medications or maintaining dose for ≥12 weeks before baseline- English speakingExclusion- Severe depression or active suicidal ideation- Psychosis or SUD- Receiving concurrent psychological treatment	Group CBT (12 weekly group sessions, 120 mins)	Baseline, 12 weeks	Objective severity (SSC)	MD = 1.78, 95% CI = -6.39, 2.83, d = .26	PSQI	MD= -2.96, 95% CI = -5.27, -0.66, d=.89
								Subjective severity (GCS)	MD = 8.00, 95% CI = -14.73, -1.71, d = .87

Atema et al⁴¹	Netherlands	Guided dCBT: 85	WLC: 84	M = 47.4SD = 5.45	Inclusion- Histologically confirmed BC- Age ≥50 years at time of diagnosis- Completed chemotherapy/oophorectomy 4 months to 5 years before trial and/or current/past endocrine treatment- Disease-free at baseline- Treatment-induced HFNS ≥2 months with average problem rating ≥2 on HFRS and ≥10 HFNS in past week- Internet accessExclusion- Prior diagnosis of other cancer type- Serious overt cognitive or psychiatric comorbidity- Non-Dutch speaking- Participating in concurrent studies or rehabilitation programs for menopausal symptoms	Therapist-guided dCBT (6 weekly modules, 90 minutes) + weekly written feedback	Baseline, 10 weeks, 24 weeks	HFRS	Guided: p < .001, η²_p= .63	GSQS	Guided: p < .001, η²_p = .57
		Self-managed dCBT: 85				Self-managed dCBT (6 weekly modules, 90 minutes)			Self-managed: p < .001, η²_{p =}.56		Self-managed: p = .001, η²_p = .41
								FACT-ES	Guided: p = .003, η²_p = .33
									Self-managed: p = .062, η²_p = .20



Fenlon et al⁴²	England	Group CBT: 61	UC: 66	CBT: M = 53.5SD = 9.78	Inclusion- Women age ≥16 years- Primary BC or DCIS- Completed primary treatment- ≥ 7 HFNS/week- Score ≥4/10 on HFRS- Desire and ability to attend group sessionsExclusion- Metastatic disease	BCN-delivered group CBT (6 weekly sessions, 90 minutes)	Baseline, 9 weeks, 26 weeks	HFRS problem rating		PSQI
								9 weeks	MD = −1.83, p = .039	9 weeks	MD = −0.67, p < .0001
				UC: M = 55.2SD = 10.19				26 weeks	MD = −1.96, p < .0001	26 weeks	MD = 2.9, p < .0001

Abbreviations: BDI-II, Beck Depression Inventory-II; BC, breast cancer; BCN, breast care nurse; CBT, cognitive-behavioural therapy; CI, confidence interval; DCIS, ductal carcinoma in situ; FACT-ES, Functional Assessment of Cancer Treatment-Endocrine Symptoms; GCS, Greene Climacteric Scale; GSQS, Groningen Sleep Quality Scale; HFNS, hot flushes/night sweats; HFRDIS, Hot Flash Related Daily Interference Scale; HFRS, Hot Flush Rating Scale; HT, hormone therapy; dCBT, internet-based cognitive-behavioural therapy; MD, mean difference; MRS, Menopause Rating Scale; NTC, no treatment control; PSQI, Pittsburgh Sleep Quality Index; SH, self-help; SSC, sternal skin conductance; STRAW, Stages of Reproductive Ageing Workshop; SUD, substance-use disorder; UC, usual care; WHQ, Women’s Health Questionnaire; WLC, waitlist control.

^aOutcomes reported for post-treatment unless otherwise specified.

^bDuplicate sample.

Mann and colleagues compared a 6-week CBT group for HFNS to usual care among 96 breast cancer survivors (MENOS 1).³⁵ The protocol included two sessions focused on sleep, discussing behavioural and cognitive strategies for managing wakefulness after night sweats, respectively. Modified intention-to-treat (ITT) analyses revealed that compared to usual care, CBT led to significant improvements in sleep disturbance, as measured by the Women’s Health Questionnaire sleep problems scale (WHQ), at 9 weeks and 26 weeks post-randomization.

The MENOS 2 RCT (N = 147) compared group CBT, guided self-help CBT³⁶ (involving two phone contacts with a psychologist) and no treatment control (NTC) for HFNS among peri- and postmenopausal women with problematic HFNS.³⁷ Both CBT interventions lasted 4 weeks and included psychoeducation, stress management, paced respiration and cognitive and behavioural strategies. One session reviewed the mechanisms of sleep and cognitive and behavioural strategies for dealing with awakenings and night sweats. Sleep problems were assessed using the WHQ. ITT analyses indicated that compared to NTC, self-help CBT, but not group CBT, was associated with improvements in sleep problems at post-treatment. Differences in sleep problems between self-help CBT and NTC were no longer significant at follow-up (26 weeks post-randomization).

The MENOS@WORK trial included 124 women with problematic HFNS across 8 organizations in the UK who were randomized to receive unguided self-help CBT or waitlist control.³⁸ Self-help CBT was based on the MENOS 2 protocol but was shortened and adapted for a workplace setting and included four chapters to be completed over 4 weeks. The CBT intervention included ‘advice and strategies to improve sleep and CBT is an effective treatment for insomnia’. Women receiving self-help CBT reported significant improvements in sleep problems, assessed with the WHQ, and sleep quality as assessed by a single item from the Pittsburgh Sleep Quality Index (PSQI). The difference between groups demonstrated a medium effect size at both post-treatment and follow-up (20 weeks post-randomization).

The CBT-Meno trial compared a 12-week group CBT to waitlist control (WLC) in 71 women with problematic HFNS and depressive symptoms.³⁹ A module on sleep included psychoeducation, a cognitive-behavioural conceptualization of sleep disturbance, behavioural strategies for sleep (stimulus control and sleep restriction) and cognitive restructuring. ITT analyses revealed a small effect of CBT-Meno on sleep quality (PSQI total score) at post-treatment that was maintained at 3-month follow-up. Women in the WLC did not experience any improvement in sleep quality. Secondary analyses in a subset of participants (N = 36) and compared subjective and objective measures of HFNS (using ecological momentary assessments and sternal skin conductance, respectively) and their relation to sleep quality.⁴⁰ At baseline, the difference on the PSQI between CBT-Meno and WLC was small and not significant; at post-treatment (12 weeks post-baseline), the between-group difference was large and significant. At baseline, sleep quality correlated with subjective momentary ratings of hot flash severity and bother. At post-treatment, sleep quality no longer correlated with hot flash assessments.

One study compared 6-week guided and unguided digital CBT (dCBT) and WLC in women with breast cancer treatment-induced menopausal symptoms (N = 254).⁴¹ Guided dCBT involved one telephone call and weekly written feedback. Unguided dCBT completed the program in a fixed order. The intervention included one module on sleep, including psychoeducation on the relationship between HFNS and sleep problems, assessment of sleep hygiene and setting goals and ‘helpful cognitive and behavioural reactions to night sweats/sleep problems’ (p. 812). Sleep quality was assessed using the Groningen Sleep Quality Scale. ITT analyses revealed that compared to WLC, guided dCBT was associated with significantly greater improvements at 10- and 24-weeks post-randomization. Unguided dCBT yielded a significantly greater improvement than WLC at 10 weeks, but this was not significant at 24 weeks. The study was not powered to compare the two dCBT groups. Compliance was higher in guided dCBT compared to unguided dCBT.

Lastly, the multisite MENOS 4 RCT compared breast care nurse-facilitated CBT group to usual care in women with breast cancer (N = 127) in their regular care setting.⁴² Nurses were trained by a clinical psychologist and expert in CBT for menopause. At baseline, sleep quality assessed by the PSQI was in the nonclinical range in both groups. Modified ITT analyses revealed that CBT was associated with moderate improvements in sleep quality at 9 weeks post-baseline and large improvements at 26 weeks post-baseline. The intervention was delivered with high fidelity and adherence (94%), and sensitivity analyses did not reveal effects of individual therapist or site.

Clinical hypnosis

Three RCTs evaluated the use of CH for the treatment of HFNS in breast cancer survivors and postmenopausal women (Table 2). The first study compared 5-week CH to NTC in women with a history of breast cancer (N = 60) reporting bothersome HFNS.⁴³ CH was manualized and delivered by a trained and experienced psychologist. CH included a standardized hypnotic induction; personalized suggestions and mental imagery for relaxation, coolness, deepening relaxation, dissociating from HFNS and the future; self-hypnosis and a prompt to return to conscious alertness. Participants were provided with an audiotape recording and instructed to practice self-hypnosis daily. Sleep was assessed using the Medical Outcomes Study Sleep Scale. ITT analyses revealed that compared to NTC, CH was associated with large improvements in sleep at endpoint. The study did not include a follow-up assessment.

Table 2.

Effect of hypnosis interventions for menopausal symptoms on sleep disturbance.

Author	Location	Treatment (n)	Control (n)	Age^b	Inclusion/exclusion criteria	Description of intervention (n of sessions, frequency, length) and control	Assessments	Primary outcome^a		Sleep outcome^a
Elkins et al⁴³	United States	CH: 27	NTC: 24	CH: M = 55.83	Inclusion	CH (5 weekly sessions, 50 mins) + daily self-hypnosis	Baseline, 6 weeks	HF score	p < .001, η²_p = .37	MOS Sleep Scale	p < .001,η²_p = .49
				CH: M = 55.83	- Women age ≥18
				NTC: M = 58.17	- History of BC without evidence of detectable disease
					- Self-report of ≥14 HF/week for ≥1 month
					Exclusion				p < .001, η²_p = .37
					- Receiving chemotherapy, androgens, estrogens, progestational drugs or any treatment for HF
					- Taking antihormonal agents for BC ≤1 month before enrolment and/or not maintaining stable dose during trial
					- Participating in other mind-body therapy or using other complementary or alternative medicines
Elkins et al⁴⁴	United States	CH: 84	SAC: 90	CH: M = 54.52	Inclusion	CH (5 weekly sessions, 45 mins)	Baseline, 6 weeks, 12 weeks	HF frequency (subjective)	p < .001, d = 1.25	PSQI	p < .001, d = 1.04
				CH: M = 54.52	- Women age ≥18			HF score	p < .001, d = 1.23
				Range: 39–75	- No menses in 12 months or no menses in past 6 months+medically documented history of follicle-stimulating hormone ≥40/bilateral oophorectomy			HF frequency (objective)	p < .001, d = .52
					- ≥ 7 HF/day or ≥50 HF/week at baseline
					- Discontinuation of prior estrogen/progestin containing products (see article for specific washout periods)
					Exclusion
				SAC: M = 54.71	- Receiving other treatment for HFs
				SAC: M = 54.71	- Using complementary or alternative medical treatments for HFs
				Range: 39–71	- History of psychosis, BPD, or other serious psychopathology
Barton et al⁴⁵	United States	VH: 14	PS: 15	VH: M = 56	Inclusion	VH (venlafaxine XR; 75 mg, daily+hypnosis; 4 weekly sessions, 20 mins +3 weeks in-home practice, 4 times/week)	Baseline, 5 weeks, 8 weeks	HF score (8 weeks), VS used as referent group	VH: p = .05	Side effects, sleep (5 weeks)	VH: MD = 2.54, p < .05
		VS: 19		VS:M = 54	- Adult postmenopausal women with and without a history of BC who either could not or did not wish to take estrogen for HF relief	VS (venlafaxine XR; 75 mg, daily+sham hypnosis [white noise]; 4 weekly sessions, 15 mins + in-home practice, 4 times/week)			PH: p = .34		VS: MD = 3.35, p < .05
		PH: 21		PH: M = 54	- ≥ 4 bothersome HF/day in past month	PH (placebo medication; daily+hypnosis; 4 weekly sessions, 20 mins +3 weeks in-home practice, 4 times/week)			PS: p = .001		PH: MD = 2.70, p < .05
				PS: M = 56	Exclusion	PS (placebo medication; daily+sham hypnosis [white noise]; 4 weekly sessions, 15 mins + in-home practice, 4 times/week)			Time: p < .001		PS: MD = 2.17, p < .05
					- Discontinuing endocrine therapy during trial				Group × time: n.s.
					- Allergies to venlafaxine or related drugs
					- Taking other pharmacologic agents for HF during trial
					- Use of venlafaxine or hypnosis in past 6 months
					- Use of other antidepressants during trial
					- Uncontrolled hypertension (3 consecutive readings of ≥160 systolic/100 diastolic in past year)

Abbreviations: BC, breast cancer; BPD, borderline personality disorder; CH, clinical hypnosis; HF, hot flushes; M, mean; MOS Sleep Scale, Medical Outcomes Study Sleep Scale; NTC, no treatment control; PH, placebo + hypnosis; PS, placebo + sham hypnosis; PSQI, Pittsburgh Sleep Quality Index; SAC, structured-attention control; VH, venlafaxine 75 mg + hypnosis; VS, venlafaxine 75 mg + sham hypnosis.

^aOutcomes reported for post-treatment unless otherwise specified.

^bStandard deviations not reported; additional information about age distribution is provided when available.

A single-blind RCT compared 5-week CH to a structured-attention control (SAC) in postmenopausal women with bothersome HFNS (N = 187).⁴⁴ CH was delivered by trained therapists and consisted of the same components as^43. Participants were likewise instructed to practice daily self-hypnosis. The SAC intervention matched CH on therapist attention, discussion of symptoms, positive encouragement and monitoring and measurement. SAC participants listened to an audiotape providing information about HFNS. Both interventions were manualized and included fidelity checklists. Modified ITT analyses revealed that sleep quality (PSQI total score) improved by 9% at endpoint and 10% at 6 weeks post-treatment in SAC, and by 44% and 54%, respectively, in CH. Between-group effects at both timepoints were large.

Lastly, a single-blind pilot RCT in postmenopausal women experiencing bothersome HFNS (N = 70) compared venlafaxine XR (75 mg) + hypnosis (VH), venlafaxine + sham hypnosis (VS), placebo + hypnosis (PH) and placebo + sham hypnosis (PS).⁴⁵ Hypnosis included the same components described above, and sham hypnosis involved listening to white noise. Both hypnosis conditions were described to participants as behavioural interventions for HFNS to control for expectancy effects. All conditions involved four in-person and three at-home sessions and included discussions of HFNS and the intervention with a clinician and problem solving of barriers to adherence. Clinicians had varied educational backgrounds and were trained by an expert in hypnosis. Sleep was assessed using a checklist of possible side effects, with a positive score representing improvement and a negative score representing deterioration. Paired t-tests showed that sleep improved from baseline in all treatment groups; analyses did not assess for group-by-time interactions or provide effect sizes for comparison. Descriptively, the VS condition demonstrated the largest improvement in sleep, followed by PH, VH and PS.

Mindfulness-based interventions

One study evaluated sleep effects of MBSR for HFNS (Table 3).²⁶ The RCT compared 8-week MBSR to WLC among 110 women in the late menopausal transition and postmenopause.²⁶ At baseline, the average score on the Women’s Health Initiative Insomnia Rating Scale (WHIIRS) was in the 85^th percentile for this measure, suggesting clinically significant insomnia symptoms.²⁶ ITT analyses demonstrated that MBSR was associated with a significant reduction in insomnia symptoms at 9-weeks. This effect was maintained at 20-week follow-up; insomnia remained in the problematic range in the WLC, whereas the WHIIRS scores in the MBSR group were below the clinical cut-off.

Table 3.

Effect of mindfulness-based interventions for menopausal symptoms on sleep disturbance.

Author	Location	Treatment (n)	Control (n)	Age	Inclusion/exclusion criteria	Description of intervention (n of sessions, frequency, length) and control	Assessments	Primary outcome^a		Sleep outcome^a
Carmody et al²⁶	United States	MBSR: 57	WLC: 48	M = 53.1 SD = 4.9	Inclusion	MBSR (8 weekly session, 150 mins) + one all-day class	Baseline, 8 weeks, 20 weeks	HF bother	p < .0001	WHIIRS	p = .009
					- Late peri- and early postmenopausal women
					- ≥ 5 HF/day in past week
					- Willing to keep daily HF diary
					- Maintaining regular exercise, diet patterns and dosage of soy supplements or menopausal remedies
					- Maintaining dosage of prescribed SSRI’s or anxiolytics
					Exclusion
					- Medical conditions or medication that could affect HFs
					- < 6 months post BC treatment

Abbreviations: BC, breast cancer; HF, hot flushes; M, mean; MBSR, mindfulness-based stress reduction; MENQOL, menopause-related quality of life; SD, standard deviation; SSRI, selective serotonin reuptake inhibitors; WHIIRS, Women’s Health Initiative Insomnia Rating Scale; WLC, waitlist control.

^aOutcomes reported for post-treatment unless otherwise specified.

Discussion

This review evaluated the sleep effects of psychological treatments for menopausal symptoms. Studies support that CBT, CH and MBSR for menopausal symptoms have some benefit on self-reported sleep problems (e.g. WHQ and MOS Sleep Scale; n = 5), sleep quality (PQSI and GSQS; n = 5), and insomnia symptoms (WHIIRS; n = 1) in women undergoing natural menopause and breast cancer treatment-induced menopause.

CBT was evaluated in various formats, including groups delivered by psychologists^35,37,39,40 and nurses,⁴² and guided and unguided self-help via the internet⁴¹ or a booklet.^37,38,46 In six RCTs, CBT was associated with improvements in sleep disturbance; studies reported small,^35,39 medium^38,41 and large effects^40,42 on sleep. One study did not find an effect of group CBT for HFNS on sleep disturbance.³⁷ This study included a briefer CBT group (4 vs 6-12 weeks) than other studies. Sleep disturbance severity at baseline and magnitude of improvements were similar to a previous study,³⁵ suggesting that this study was underpowered to detect small between-group differences in sleep improvements. Future research should investigate barriers to improvement in group CBT. Effects of self-help CBT were also mixed regarding optimal treatment length and therapist contact to produce lasting improvements. Identifying the variables that yield stronger and more durable effects is an important area for future research. Protocols included components of CBT for insomnia (CBT-I) over 1-2 sessions (psychoeducation, cognitive restructuring, stimulus control and sleep restriction). Sleep improvements with CBT for menopause may be driven by inclusion of single-session CBT-I (a dose that is evidence-based⁴⁷). Qualitative outcomes indicated that participants found key ingredients of CBT-I (e.g., completing sleep diaries and de-catastrophizing sleep loss) helpful to manage sleep.⁴⁸ Some have speculated that improvements in subjective HFNS or mood symptoms may contribute to improved sleep quality.⁴⁰ Given that menopausal sleep disturbance is heterogeneous and multifactorial, mechanisms of improvement may differ across women. Importantly, how much women are bothered by their HFNS at post-treatment seems to be mediated by improvements in sleep and their beliefs about sleep.^49–51 Thus, identifying the mechanisms of sleep improvement with CBT for menopause and the characteristics of women who benefit is an important goal to improve sleep and HFNS-related distress.

CH also improved sleep disturbance and quality^43–45 with large effect sizes at post-treatment compared to no treatment or a structured-attention control.^43,44 In one study⁴⁴ sleep quality continued to improve over a 6-week follow-up. The mechanisms of CH are unknown. Some have suggested that CH is associated with a shift in the balance of sympathetic and parasympathetic tone.⁴⁴ However, evidence of altered sympathovagal balance in people with insomnia is mixed, and HF-induced insomnia is associated with increased psychological arousal but not cardiovascular reactivity.⁵² CH may have similar mechanisms to other relaxation therapies that reduce somatic tension and cognitive arousal.⁵³ Investigation of CH as an intervention for sleep disturbance is still in its infancy. One recent study supports the use of CH for sleep disturbance in postmenopausal women using a different CH protocol.^54,55 Future studies should investigate possible mediators of improvements in HFNS and sleep with longer follow-up periods.

MBSR improved insomnia symptoms in one RCT,^26,56 consistent with meta-analytic evidence of a small effect of mindfulness meditation on sleep quality.^57,58 Mindful awareness practices also improve sleep quality and HFNS in young breast cancer survivors.⁵⁹ Mindfulness meditation may improve sleep via improvements in negatively toned cognitive activity, arousal and changes to sleep architecture.^60,61 Recent studies have evaluated MBSR for menopausal symptoms^29,62 but have not included assessments of sleep. This is an important future direction as the effect of MBSR on sleep on menopausal women warrants replication.

Limitations of the studies included samples not selected or screened for sleep disorders and use of outcome measures with variable psychometric properties that assess different constructs, including self-reported sleep quality, ratings of sleep problems and insomnia symptoms. These limitations make it challenging to compare study results and to generalize to women with sleep disorders. Most studies included women who were predominantly White and highly educated. A continued effort to reach marginalized communities is required as socioeconomic status, race and racism, and geography influence sleep health disparities.⁶³ Lastly, many studies did not report effect sizes alongside statistical significance. Our review is limited by lack of quantitative synthesis. As the first review on the effect of psychological treatments for menopause on sleep, and with a small number of included studies, we prioritized a summary of the literature that accounts for nuanced findings that can guide the research agenda. Quantitative syntheses are an important next step and can help identify moderators of clinical outcome.

Notwithstanding, the reviewed studies were mostly methodologically strong with large samples, blind randomization and assessments and ITT analyses. We found support for psychological treatments in menopause on sleep in women in natural menopause with bothersome HFNS, with mild-to-moderate depressive symptoms, and breast cancer patients and survivors. The results also support different modes of treatment delivery that can facilitate increased access to care; this is promising considering the increased demand for remote interventions following the COVID-19 pandemic. Interventions delivered by non-specialist providers also yielded positive effects on sleep and were delivered with high fidelity^42,45; evaluating the implementation of CBT, CH and mindfulness-based interventions for menopause with non-specialist providers in settings where women receive care is an important future direction.

The results may support the use of stepped care in treating sleep disturbance during menopause. Effective low-intensity interventions that can be delivered by various practitioners can improve access to care for those with mild-to-moderate symptomatology, whereas those with clinically significant sleep problems should be referred for targeted sleep interventions delivered by specialized providers. Access to credentialed providers of psychological treatments for menopause remains limited³⁰; self-help protocols with various levels of therapist guidance may overcome this barrier but may not be appropriate for those with more severe clinical presentations. Among those with a diagnosis of insomnia disorder, cognitive-behavioural and behavioural therapies for insomnia are effective.²¹ Given that sleep disturbance is multifactorial in this population, a strong assessment and case formulation is important to guide the selection of the most appropriate clinical intervention.^64,65

Conclusion

Among postmenopausal women and breast cancer survivors, CBT for menopause improves sleep across different formats. CH for HFNS improves sleep, although durability beyond 6 weeks remains unknown. Support for MBSR is preliminary and more studies are needed. Positive effects may be driven by the inclusion of modules that specifically address sleep in CBT (e.g. sleep psychoeducation and behavioural and cognitive strategies for sleep) or by effects on sleep regulatory systems (e.g. decreasing hyperarousal via mindfulness meditation or deep relaxation/hypnosis). Evaluating efficacy in more diverse samples and women with sleep disorders are important next steps. Future research should continue to evaluate the effectiveness of delivering these interventions where women receive care.

Practice points

• Sleep disturbance is common throughout the menopausal transition – presenting as poor sleep quality, insomnia and/or sleep disordered breathing – and is impacted by hot flashes and night sweats that interfere with sleep, worsening mood symptoms and hormonal changes.

• Among women seeking treatment for vasomotor symptoms, psychological treatments for menopause (cognitive-behavioural therapy, mindfulness-based stress reduction and clinical hypnosis) were found to have a positive impact on sleep at post-treatment. Studies supported cognitive-behavioural therapy in various formats and offered preliminary support for clinical hypnosis and mindfulness-based stress reduction. Studies with longer follow-ups are needed to identify the durability of improvements and to identify factors that influence maintenance of treatment gains over time.

• Findings suggest that psychological treatments for menopause may be an effective treatment option for women experiencing mild-to-moderate sleep disturbance in the context of menopausal symptoms and can increase access to interventions that promote sleep health in the settings where they seek care. Studies evaluating whether these treatments improve sleep among women with more severe presentations/diagnosed sleep disorders are an important future direction; these women likely benefit from more specialized sleep treatments. A thorough assessment of the history, causes and current severity of the presenting problem is necessary to inform treatment decisions.

Footnotes

Acknowledgements

We would like to thank Dr Rachel Liebman for her comments on a previous version of this manuscript.

Contributorship

Nicole Carmona contributed to the concept, design, definition of intellectual content, literature search, data acquisition, manuscript preparation, editing and review. Elisha Starick and Geneva Millett contributed to data acquisition and manuscript preparation, editing and review. Sheryl Green and Colleen Carney contributed to manuscript editing and review.

Declaration of conflicting interests

The author(s) declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Guarantor

Nicole E. Carmona.

ORCID iD

Nicole E Carmona

References

Freeman

Sammel

Gross

, et al. Poor sleep in relation to natural menopause: a population-based 14-year follow-up of midlife women. Menopause 2015; 22(7): 719–726.

National Institutes of Health . National institutes of health state-of-the-science conference statement: management of menopause-related symptoms. Ann Intern Med 2005; 142(12 Pt 1): 1003–1013.

Blümel

Cano

Mezones-Holguín

, et al. A multinational study of sleep disorders during female mid-life. Maturitas 2012; 72(4): 359–366.

Ciano

King

Wright

, et al. Longitudinal study of insomnia symptoms among women during perimenopause. J Obstet Gynecol Neonatal Nurs 2017; 46(6): 804–813.

Zolfaghari

Yao

Thompson

, et al. Effects of menopause on sleep quality and sleep disorders: Canadian Longitudinal Study on Aging. Menopause 2020; 27(3): 295–304.

Anttalainen

Saaresranta

Aittokallio

, et al. Impact of menopause on the manifestation and severity of sleep-disordered breathing. Acta Obstet Gynecol Scand 2006; 85(11): 1381–1388.

Young

Finn

Austin

, et al. Menopausal status and sleep-disordered breathing in the Wisconsin sleep cohort study. Am J Respir Crit Care Med 2003; 167(9): 1181–1185.

Tal

Suh

Dowdle

, et al. Treatment of insomnia, insomnia symptoms, and obstructive sleep apnea during and after menopause: therapeutic approaches. Curr Psychiatr Rev 2015; 11(1): 63–83.

Bolge

Balkrishnan

Kannan

, et al. Burden associated with chronic sleep maintenance insomnia characterized by nighttime awakenings among women with menopausal symptoms. Menopause 2010; 17(1): 80–86.

10.

Beverly Hery

Hale

Naughton

. Contributions of the Women’s Health Initiative to understanding associations between sleep duration, insomnia symptoms, and sleep-disordered breathing across a range of health outcomes in postmenopausal women. Sleep Health 2020; 6(1): 48–59.

11.

Loprinzi

Kugler

Sloan

, et al. Venlafaxine in management of hot flashes in survivors of breast cancer: a randomised controlled trial. Lancet 2000; 356(9247): 2059–2063.

12.

Polo-Kantola

Saaresranta

Polo

. Aetiology and treatment of sleep disturbances during perimenopause and postmenopause. CNS Drugs 2001; 15(6): 445–452.

13.

Amick

Gartlehner

Gaynes

, et al. Comparative benefits and harms of second generation antidepressants and cognitive behavioral therapies in initial treatment of major depressive disorder: systematic review and meta-analysis. BMJ 2015; 351: h6019.

14.

Brower

McCammon

Wojnar

, et al. Prescription sleeping pills, insomnia, and suicidality in the national comorbidity survey replication. J Clin Psychiatry 2011; 72(4): 515–521.

15.

Chlebowski

Anderson

Pettinger

, et al. Estrogen plus progestin and breast cancer detection by means of mammography and breast biopsy. Arch Intern Med 2008; 168(4): 370–377, quiz 345.

16.

Hunter

Liao

. Determinants of treatment choice for menopausal hot flushes: hormonal versus psychological versus no treatment. J Psychosom Obstet Gynaecol 1995; 16(2): 101–108.

17.

Rossouw

Anderson

Prentice

, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA 2002; 288(3): 321–333.

18.

Hunter

Grunfeld

Mittal

, et al. Menopausal symptoms in women with breast cancer: prevalence and treatment preferences. Psycho Oncol 2004; 13(11): 769–778.

19.

Drake

Kalmbach

Arnedt

, et al. Treating chronic insomnia in postmenopausal women: a randomized clinical trial comparing cognitive-behavioral therapy for insomnia, sleep restriction therapy, and sleep hygiene education. Sleep. 2019; 42(2): zsy217.

20.

McCurry

Guthrie

Morin

, et al. Telephone-based cognitive behavioral therapy for insomnia in perimenopausal and postmenopausal women with vasomotor symptoms: a MsFLASH randomized clinical trial. JAMA Intern Med 2016; 176(7): 913.

21.

Carmona

Millett

Green

, et al. Cognitive-behavioral, behavioural and mindfulness-based therapies for insomnia in menopause. Behav Sleep Med. 2022; 21(4): 488–499.

22.

Hunter

. Cognitive behavioral therapy for menopausal symptoms. Climacteric 2021; 24(1): 51–56.

23.

Vélez Toral

Godoy-Izquierdo

Padial García

, et al. Psychosocial interventions in perimenopausal and postmenopausal women: a systematic review of randomised and non-randomised trials and non-controlled studies. Maturitas 2014; 77(2): 93–110.

24.

Woods

Mitchell

Schnall

, et al. Effects of mind–body therapies on symptom clusters during the menopausal transition. Climacteric 2014; 17(1): 10–22.

25.

Roberts

Yek

, et al. Hypnosis for hot flashes and associated symptomsin women with breast cancer. Am J Clin Hypn 2017; 60(2): 123–136.

26.

Carmody

Crawford

Salmoirago-Blotcher

, et al. Mindfulness training for coping with hot flashes: results of a randomized trial. Menopause 2011; 18(6): 611–620.

27.

Hunter

Chilcot

. Is cognitive behaviour therapy an effective option for women who have troublesome menopausal symptoms? Br J Health Psychol 2021; 26(3): 697–708.

28.

Reynolds

. Relationships between catastrophic thoughts, perceived control and distress during menopausal hot flushes: exploring the correlates of a questionnaire measure. Maturitas 2000; 36(2): 113–122.

29.

Wong

Yip

BHK

Gao

, et al. Mindfulness-based stress reduction (MBSR) or psychoeducation for the reduction of menopausal symptoms: a randomized, controlled clinical trial. Sci Rep 2018; 8(1): 6609.

30.

The North American Menopause Society . Nonhormonal management of menopause-associated vasomotor symptoms: 2015 position statement of the North American menopause society. Menopause. 2015; 22(11): 1155–1172.

31.

van Driel

Stuursma

Schroevers

, et al. Mindfulness, cognitive behavioural and behaviour-based therapy for natural and treatment-induced menopausal symptoms: a systematic review and meta-analysis. BJOG 2019; 126(3): 330–339.

32.

Green

Key

McCabe

. Cognitive-behavioral, behavioral, and mindfulness-based therapies for menopausal depression: a review. Maturitas 2015; 80(1): 37–47.

33.

Shabani

Montazeri

Abdolalipour

, et al. The effect of mindfulness training on stress and sleep quality of postmenopausal women: a systematic review and meta-analysis. Post Reprod Health 2022; 28: 223.

34.

Lam

Hernandez-Galan

Mbuagbaw

, et al. Behavioral interventions for improving sleep outcomes in menopausal women: a systematic review and meta-analysis. Menopause 2022; 29(10): 1210–1221.

35.

Mann

Smith

Hellier

, et al. Cognitive behavioural treatment for women who have menopausal symptoms after breast cancer treatment (MENOS 1): a randomised controlled trial. Lancet Oncol 2012; 13(3): 309–318.

36.

Hunter

Smith

. Managing hot flushes and night sweats: a cognitive behavioural self-help guide to the menopause. 2nd ed. Milton Park, Abingdon, Oxon, New York, NY: Routledge; 2021.

37.

Ayers

Smith

Hellier

, et al. Effectiveness of group and self-help cognitive behavior therapy in reducing problematic menopausal hot flushes and night sweats (MENOS 2): a randomized controlled trial. Menopause 2012; 19(7): 749–759.

38.

Hardy

Griffiths

Norton

, et al. Self-help cognitive behavior therapy for working women with problematic hot flushes and night sweats (MENOS@Work): a multicenter randomized controlled trial. Menopause 2018; 25(5): 508–519.

39.

Green

Donegan

Frey

, et al. Cognitive behavior therapy for menopausal symptoms (CBT-Meno): a randomized controlled trial. Menopause 2019; 26(9): 972–980.

40.

Green

Donegan

McCabe

, et al. Objective and subjective vasomotor symptom outcomes in the CBT-Meno randomized controlled trial. Climacteric 2020; 23(5): 482–488.

41.

Atema

van Leeuwen

Kieffer

, et al. Efficacy of internet-based cognitive behavioral therapy for treatment-induced menopausal symptoms in breast cancer survivors: results of a randomized controlled trial. J Clin Oncol 2019; 37(10): 809–822.

42.

Fenlon

Maishman

Day

, et al. Effectiveness of nurse-led group CBT for hot flushes and night sweats in women with breast cancer: results of the MENOS4 randomised controlled trial. Psycho Oncol 2020; 29(10): 1514–1523.

43.

Elkins

Marcus

Stearns

, et al. Randomized trial of a hypnosis intervention for treatment of hot flashes among breast cancer survivors. J Clin Orthod 2008; 26(31): 5022–5026.

44.

Elkins

Fisher

Johnson

, et al. Clinical hypnosis in the treatment of postmenopausal hot flashes: a randomized controlled trial. Menopause 2013; 20(3): 291–298.

45.

Barton

Schroeder

KCF

Banerjee

, et al. Efficacy of a biobehavioral intervention for hot flashes: a randomized controlled pilot study. Menopause 2017; 24(7): 774–782.

46.

Stefanopoulou

Hunter

. Telephone-guided self-help cognitive behavioural therapy for menopausal symptoms. Maturitas 2014; 77(1): 73–77.

47.

Edinger

Wohlgemuth

Radtke

, et al. Dose-response effects of cognitive-behavioral insomnia therapy: a randomized clinical trial. Sleep 2007; 30(2): 203–212.

48.

Balabanovic

Ayers

Hunter

. Women’s experiences of group cognitive behaviour therapy for hot flushes and night sweats following breast cancer treatment: an interpretative phenomenological analysis. Maturitas 2012; 72(3): 236–242.

49.

Atema

van Leeuwen

Kieffer

, et al. Internet-based cognitive behavioral therapy aimed at alleviating treatment-induced menopausal symptoms in breast cancer survivors: moderators and mediators of treatment effects. Maturitas 2020; 131: 8–13.

50.

Chilcot

Norton

Hunter

. Cognitive behaviour therapy for menopausal symptoms following breast cancer treatment: who benefits and how does it work? Maturitas 2014; 78(1): 56–61.

51.

Norton

Chilcot

Hunter

. Cognitive-behavior therapy for menopausal symptoms (hot flushes and night sweats): moderators and mediators of treatment effects. Menopause 2014; 21(6): 574–578.

52.

Bertisch

Wiley

McCormick

, et al. Cardiovascular reactivity and psychological hyperarousal in hot flash-associated insomnia disorder. Menopause 2019; 26(7): 728–740.

53.

Edinger

Arnedt

Bertisch

, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med 2021; 17(2): 263–298.

54.

Elkins

Otte

Carpenter

, et al. Hypnosis intervention for sleep disturbance: determination of optimal dose and method of delivery for postmenopausal women. IJCEH (Int J Clin Exp Hypn) 2021; 69(3): 323–345.

55.

Otte

Carpenter

Roberts

, et al. Self-hypnosis for sleep disturbances in menopausal women. J Wom Health 2020; 29(3): 461–463.

56.

Carmody

Crawford

Churchill

. A pilot study of mindfulness-based stress reduction for hot flashes. Menopause 2006; 13(5): 760–769.

57.

Gong

Liu

, et al. Mindfulness meditation for insomnia: a meta-analysis of randomized controlled trials. J Psychosom Res 2016; 89: 1–6.

58.

Rusch

Rosario

Levison

, et al. The effect of mindfulness meditation on sleep quality: a systematic review and meta-analysis of randomized controlled trials. Ann N Y Acad Sci 2019; 1445(1): 5–16.

59.

Bower

Crosswell

Stanton

, et al. Mindfulness meditation for younger breast cancer survivors: a randomized controlled trial. Cancer 2015; 121(8): 1231–1240.

60.

Nagendra

Maruthai

Kutty

. Meditation and its regulatory role on sleep. Front Neurol 2012; 3: 54.

61.

Winbush

Gross

Kreitzer

. The effects of mindfulness-based stress reduction on sleep disturbance: a systematic review. Explore 2007; 3(6): 585–591.

62.

Yazdani

Javadnoori

Saki Malehi

, et al. A study of mindfulness-based stress-reduction training effects on menopause-specific quality of life in postmenopausal women: a randomized controlled trial. Compl Ther Clin Pract 2021; 44: 101398.

63.

Billings

Cohen

Baldwin

, et al. Disparities in sleep health and potential intervention models: a focused review. Chest 2021; 159(3): 1232–1240.

64.

Alexander

Neylan

Kotz

, et al. Assessment and treatment for insomnia and fatigue in the symptomatic menopausal woman with psychiatric comorbidity. Expert Rev Neurother 2007; 7(11 Suppl): S139–S155.

65.

Schaedel

Holloway

Bruce

, et al. Management of sleep disorders in the menopausal transition. Post Reprod Health 2021; 27(4): 209–214.