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Treatment of chronic insomnia disorder in menopause

evaluation of literature

Attarian, Hrayr MD1; Hachul, Helena MD, PhD2; Guttuso, Thomas MD3; Phillips, Barbara MD, MPH4

doi: 10.1097/GME.0000000000000348
Review Article

Objective Insomnia both as a symptom and as part of chronic insomnia disorder is quite common in menopause. Comorbid conditions, such as restless legs syndrome and obstructive sleep apnea, occur with high prevalence among perimenopausal women with insomnia. Insomnia in this population group is associated with adverse health outcomes, and there are no clear standards on how to treat it.

Methods Based on extensive literature search, 76 articles were identified. Two authors independently graded evidence according to the Oxford Centre for Evidence-Based Medicine Levels of Evidence.

Results Evaluation and treatment of other comorbid sleep disorders are recommended, as is cognitive-behavioral therapy for insomnia. Hormone therapy, eszopiclone, escitalopram, gabapentin, isoflavones, valerian, exercise, and hypnosis are suggested. Zolpidem, quiteiapine XL, citalopram, mirtazapine followed by long-acting melatonin, ramelteon, Pycnogenol, Phyto-Female Complex, yoga, and massage may be considered. Kampo formulas are not recommended. Acupuncture may not be suggested, and cognitive-behavioral therapy that is not tailored for insomnia probably should not be considered.

Conclusions Although a variety of interventions are shown to be helpful in improving sleep in menopause, there is a need for well-designed head-to-head trials with uniform outcome measures.

From the 1Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL; 2Departments of Psychobiology and Gynecology, Universidade Federal de São Paulo, São Paulo, Brazil; 3Department of Neurology, University at Buffalo School of Medicine, State University of New York, Buffalo, NY; and 4Department of Medicine, University of Kentucky College of Medicine, Lexington, KY.

Received July 4, 2014; revised and accepted August 25, 2014.

Funding/support: None.

Financial disclosure/conflicts of interest: H.A., H.H., and B.P. have no conflicts of interest to disclose. T.G. is the inventor of US Patent 6,310,098 (owned by the University of Rochester) covering the use of gabapentin for treating hot flashes. T.G. does not receive royalties on the sales of generic gabapentin or of brand name Neurontin for any use. T.G. may receive royalties on the sales of a gabapentin-related drug only if such drug receives regulatory approval for treating hot flashes, which has not occurred to date. T.G. has received financial support for research and honoraria for speaking engagements from Teva Pharmaceuticals.

Address correspondence to: Hrayr Attarian, MD, Department of Neurology, Northwestern University Feinberg School of Medicine, Suite 524, 710 N Lake Shore Drive, Chicago, IL 60611. E-mail:

© 2015 by The North American Menopause Society.