Telephone-based cognitive behavioral therapy significantly improves menopause symptoms

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. “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 other half of the women were assigned to a menopause education control intervention. These study participants 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 nondirective,” McCurry said.

The main outcomes of the study were 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 — a dissemination model similar to phone-based smoking-cessation programs that have proven to be effective — potentially allows it to be an efficient, cost-effective way to reach large populations of women seeking treatment for midlife sleep problems.

They also said 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. This is good news for millions of women who are suffering from poor sleep at this time of life,” Guthrie said.

In addition to Guthrie, the MsFLASH research group is led by co-principal investigators Dr. Andrea LaCroix at the University of California, San Diego and Dr. Susan Reed of the University of Washington, both of whom are also co-authors on the paper.

Editor’s note: To obtain a copy of the embargoed JAMA Internal Medicine paper, “Telephone-Based Cognitive Behavioral Therapy for Insomnia in Perimenopausal and Postmenopausal Women with Vasomotor Symptoms,” please contact the journal at mediarelations@jamanetwork.org or 312.464.5262.