For menopausal insomnia, therapy and yoga beat pills on sleep quality

Chronic insomnia is highly prevalent through perimenopause and beyond, with or without hot flushes, and it travels with impaired quality of life, poorer cognitive functioning, mood disturbance and raised cardiovascular risk. Women and clinicians face a genuine choice between medication and approaches such as cognitive behavioural therapy, acupuncture, yoga and massage. Which route has the better evidence had not been settled. This review set out to compare them directly.

The authors searched PubMed/Medline, EMBASE and CINAHL for randomised controlled trials in perimenopausal or menopausal women with chronic insomnia, comparing a drug or a non-drug intervention against placebo or a control condition. The primary outcome was sleep quality, captured by the Pittsburgh Sleep Quality Index, the Insomnia Severity Index, or total sleep time. Of 80 studies identified, 24 entered the qualitative synthesis and 17 the meta-analysis. Methodological quality was generally good to excellent, with a mean PEDro score of 8.66 out of 10.

Non-pharmacological treatments produced significant improvements on both the Pittsburgh index and the insomnia severity measure. Pharmacological treatments moved only the Pittsburgh index. Strikingly, total sleep time did not change with any treatment, whether measured objectively or reported by the women themselves. The gains, in other words, showed up in how sleep felt and how severe the insomnia seemed, not in extra minutes asleep.

The authors' reading is that non-drug approaches, particularly cognitive behavioural therapy for insomnia and techniques that damp down sympathetic hyperarousal such as acupuncture, yoga and massage, look like the most robust first-line options for this group. Drug treatments, by contrast, still need longer and better designed studies to establish long-term efficacy and safety. The unmoved total sleep time is an open question the field will need to explain.

If menopause has unravelled your sleep, this is a pointer towards where the sturdier evidence currently sits: behavioural and body-based approaches outperformed medication on the measures that improved at all. It is also a useful expectation-setter, since no treatment here lengthened sleep; what improved was the quality and severity picture. Informational rather than prescriptive, but a helpful frame for any conversation about options.