Talking on the phone with a “sleep coach” and keeping a nightly sleep diary significantly improve sleep quality and reduce insomnia in women through all stages of menopause, according to a new study.
Published in JAMA Internal Medicine, the study also found that phone-based cognitive-behavioral therapy significantly reduced the degree to which hot flashes, or vasomotor symptoms, interfered with daily functioning.
This is good news for women who do not want to use sleeping pills or hormonal therapies to treat menopause-related insomnia and hot flashes, according to Dr. Katherine Guthrie, a member of the Public Health Sciences and Clinical Research divisions at Fred Hutchinson Cancer Research Center and a co-author of the study.
“Most women experience nighttime hot flashes and problems sleeping at some point during the menopause transition,” she said. “Poor sleep leads to daytime fatigue, negative mood, and reduced daytime productivity. When sleep problems become chronic — as they often do — there are also a host of negative physical consequences, including increased risk for weight gain, diabetes, and cardiovascular disease.”
“Many women do not want to use sleeping medications or hormonal therapies to treat their sleep problems because of concerns about side-effect risks,” she continued. “For these reasons, having effective, non-pharmacological options to offer them is important.”
The research is believed to be the first and the largest study to show that cognitive behavioral therapy for insomnia helps healthy women with hot flashes to sleep better. It was conducted via MsFLASH, a research network funded by the National Institute on Aging that conducts randomized clinical trials focused on relieving the most common, bothersome symptoms of menopause.
The clinical trial involved more than 100 Seattle-area women between the ages of 40 and 65 with moderate insomnia who experienced at least two hot flashes a day.
All of the women were asked to keep diaries to document their sleep patterns throughout the study, rating the quantity, frequency, and severity of their hot flashes at the beginning of the study, at eight weeks, and at 24 weeks.
Half of the women were selected at random to take part in a cognitive behavioral therapy intervention that involved talking with a sleep coach for less than 30 minutes six times over eight weeks.
Importantly, non-sleep specialists — a social worker and a psychologist — delivered the therapy, the researchers pointed out. Before conducting the phone sessions they underwent a day of training in cognitive behavioral therapy techniques.
“Since the intervention was delivered by non-sleep specialists over the phone, it potentially could be widely disseminated through primary and women’s health centers to women who do not have good access to behavioral sleep-medicine specialists or clinics,” said Dr. Susan McCurry, a clinical psychologist and research professor at the University of Washington School of Nursing and the study’s first and corresponding author.
“Such an intervention would be much less expensive to deliver than traditional, in-person cognitive behavioral therapy protocols, which are typically six to eight sessions that are one hour each.”
The goal of the therapy was to get women to the point where they consistently estimated that they were asleep at least 85 percent of the time they were in bed.
To this end, they were given specific sleep/wake schedules and were taught to limit time spent in bed at night, which ultimately helped them fall asleep more quickly and stay asleep.
They also were taught “stimulus-control” rules, which are designed to strengthen the association between bed and sleep, according to the researchers.
“For example, the women were asked to not do anything in bed except sleep and have sex,” McCurry said. “So, no reading, watching television, checking email, or paying bills in bed.”
Stimulus control also emphasizes the importance of getting up at the same time each day and not napping during the day.
The women received an educational booklet about menopause and were given information about how sleep normally changes with age. They learned to create bedtime routines and an environment conducive to sleep, such as turning off electronics at least 30 minutes prior to bed, not drinking caffeine or alcohol after dinner, and keeping their bedroom a slightly cool temperature.
They also were taught a technique called “constructive worry” to practice when ruminating thoughts kept them awake at night, the researchers reported.
The other half of the women were assigned to a menopause education control intervention. They also talked to a sleep coach with the same frequency and duration as the cognitive behavioral therapy group.
They received information about women’s health, including diet and exercise, and how they related to hot flashes and sleep quality. The coaches reviewed their weekly sleep diaries with them and provided the same educational booklet about menopause that the other group received.
The coaches did not, however, teach cognitive strategies such as constructive worry, and they made no recommendations regarding sleep/wake schedules or restricting time in bed.
“This intervention was supportive but very non-directive,” McCurry said.
The study’s findings show that women in the cognitive behavioral therapy group experienced statistically significant, clinically meaningful, and long-term, sustained improvements in sleep as compared to the women in the menopause education group.
The women who received cognitive behavioral therapy also fared better with regard to hot flashes. Although the frequency and severity of their hot flashes did not change, the women reported that the vasomotor symptoms interfered less with their daily functioning than prior to receiving such therapy.
The researchers said that delivering this therapy by phone potentially allows it to be an efficient, cost-effective way to reach large numbers of women seeking treatment for midlife sleep problems.
They also noted that these results support further research, such as testing the effectiveness of phone-based cognitive behavioral therapy for insomnia versus traditional pharmacological approaches.
“This study demonstrates that it is possible to significantly improve the sleep of many women going through the menopausal transition without the use of sleeping medications or hormone therapies, even if hot flashes are waking them up at night,” Guthrie said. “This is good news for millions of women who are suffering from poor sleep at this time of life.”