Lam et al.  recently reported a systematic review and meta-analysis aimed at assessing the efficacy of behavioral interventions on sleep outcomes among peri- and postmenopausal women, as measured by standardized scales and objective methods (polysomnography, actigraphy). Secondarily they evaluated the safety of these methods through the occurrence of adverse events. The authors performed searches within MEDLINE, Embase, Cochrane Central Register of Controlled Trials, PubMed, and Web of Science using an appropriate search strategy in order to retrieve relevant papers of randomized controlled trials (RCTs) evaluating the effects of behavioral interventions on sleep quality. Risk of bias was also assessed with classical tools used for this purpose. All data were pooled in a meta-analysis using a random-effects model. A total of nineteen articles reporting results from 16 RCTs were included, representing a total of 2,108 peri- and postmenopausal women. Overall, behavioral interventions showed a statistically significant effect on sleep outcomes. Subgroup analyses revealed that cognitive behavioral therapy (CBT), physical exercise and mindfulness/relaxation improved sleep, as measured using both subjective (i.e the Pittsburg Sleep Quality Index) and objective measures. Low- and moderate-intensity exercise also improved sleep outcomes. No serious adverse events were reported. Overall risk of bias ranged from some concern to serious, and the certainty of the body of evidence was assessed to be of very low quality. The investigators conclude that their meta-analysis provides evidence that behavioral interventions, specifically, CBT, physical exercise, and mindfulness/relaxation, are effective treatments to improving sleep outcomes among peri- and postmenopausal women.
During the menopausal transition, as the ovarian function declines, there is an increase in the prevalence of various symptoms or complaints that affect female quality of life . In this population, sleep problems (i.e. sleep disruption and insomnia) are frequently reported, with a prevalence ranging from 40 to 48%  and mostly related to vasomotor symptom . Despite this, the cause is most likely to be multifactorial including factors such as premenopausal sleep status, hormone levels, comorbidities, aging, and chronic pain . Although pharmacological interventions such as menopause hormone therapy, antidepressants, and hypnotics have been reported to be effective in treating menopause-related sleep disruption and chronic insomnia, some women are unwilling to begin pharmacological treatments because of adverse effects, contraindications, or personal preference. In this sense, behavioral interventions may be safe alternatives. Frequent behavioral therapies for insomnia include exercise, CBT, sleep restriction therapy (SRT), stimulus control therapy, and mindfulness or relaxation therapy. CBT for insomnia mainly combines several different behavioral techniques including SRT, stimulus control therapy, sleep hygiene, and relaxation therapy . These techniques are supposed to be first line treatments and work through mechanisms such as the alteration of dysfunctional beliefs regarding sleep, education and adjustment of maladaptive behaviors that contribute to sleep problems, and attenuation of cognitive and autonomic arousal levels . Despite this, practitioners still tend to rely on pharmacological interventions and data regarding the effectiveness of behavioral interventions for sleep outcomes has not been well characterized in peri- and postmenopausal women. Bearing this mind, the authors of the present commented research  aimed at evaluating the efficacy of behavioral interventions on sleep outcomes in peri- and postmenopausal women, measured by standardized scales and objective methods, secondarily evaluating the safety of these methods through the occurrence of adverse events. They meta-analyzed data of 16 RCTs that included a total of 2,108 peri- and postmenopausal women. Analysis found that behavioral interventions specifically, CBT, physical exercise, and mindfulness/relaxation, had a positive effect on sleep outcomes. Subgroup analyses revealed that these behavioral interventions improved sleep. Low- and moderate-intensity exercise also improved sleep outcomes and there were no serious reported adverse events. Physical exercise seems to promote sleep through several mechanisms including reduction of anxiety and depression, thermos- and cytokine regulation, changes in neurochemistry, and a phase shift of the circadian system . Nevertheless, the exact mechanism is still unclear but might be related to exercise, type and intensity. In this sense, the authors recommend that future research should perform comparison of the types and intensities of exercise, as well as increase more studies related to CBT and relaxation/mindfulness techniques, in order to provide less vague guidelines for the management of sleep problems during female midlife. We agree with Lam et al .
The authors appropriately expose that their meta-analysis is limited by the high level of heterogeneity within studies, mainly because of the non-standardized nature of the behavioral interventions. A major limitation of all of sleep studies has been the use of tools that perform a subjective assessment of sleep outcomes. However, the authors did aim to only analyze those that used validated objective tools, which indeed is a strength of the meta-analysis. Despite this, investigators conclude that their study provides evidence that behavioral interventions, specifically, CBT, physical exercise, and mindfulness/relaxation, are effective treatments for the improvement of sleep outcomes in mid-life women (peri- and postmenopausal). There is a need for more research in this field.
Peter Chedraui, MD, PhD
Instituto de Investigación e Innovación en Salud Integral
Universidad Católica de Santiago de Guayaquil, Guayaquil, Ecuador
1. Lam CM, Hernandez-Galan L, Mbuagbaw L, Ewusie JE, Thabane L, Shea AK. Behavioral interventions for improving sleep outcomes in menopausal women: a systematic review and meta-analysis. Menopause. 2022 Sep 6. doi: 10.1097/GME.0000000000002051.
2. Chedraui P, Aguirre W, Calle A, et al. Risk factors related to the presence and severity of hot flushes in mid-aged Ecuadorian women. Maturitas. 2010;65(4):378-82.
3. Blümel JE, Cano A, Mezones-Holguín E, et al. A multinational study of sleep disorders during female mid-life. Maturitas. 2012;72(4):359-66.
4. Kravitz HM, Zhao X, Bromberger JT, et al. Sleep disturbance during the menopausal transition in a multi-ethnic community sample of women. Sleep. 2008l;31(7):979-90.
5. Baker FC, de Zambotti M, Colrain IM, Bei B. Sleep problems during the menopausal transition: prevalence, impact, and management challenges. Nat Sci Sleep. 2018;10:73-95.
6. Babson KA, Feldner MT, Badour CL. Cognitive behavioral therapy for sleep disorders. Pschiatr Clin North Am. 2010;33(3):629-40.
7. Youngstedt SD. Effects of exercise on sleep. Clin Sports Med. 2005;24(2):355-65.