Telephone-based cognitive behavioral therapy significantly improves menopause symptoms

SEATTLE -- Chatting 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 today in JAMA Internal Medicine.

The study also found that such 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 paper co-author Dr. Katherine Guthrie, a member of the Public Health Sciences and Clinical Research divisions at Fred Hutchinson Cancer Research Center.

"Most women experience nighttime hot flashes and problems sleeping at some point during the menopause transition. 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," Guthrie said. "Many women do not want to use sleeping medications or hormonal therapies to treat their sleep problems because of concerns about side-effect risks. For these reasons, having effective, non-pharmacological options to offer them is important."

The research, 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, 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. Guthrie serves as principal investigator of the Fred Hutch-based MsFLASH Data Coordinating Center.

The clinical trial involved more than 100 Seattle-area women (between 40 and 65 years of age) 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 and rated 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. 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 the paper's first and corresponding author Dr. Susan McCurry, a clinical psychologist and research professor at the University of Washington School of Nursing.

"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," said McCurry, principal investigator of the randomized trial.

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.

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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.

At Fred Hutchinson Cancer Research Center, home to three Nobel laureates, interdisciplinary teams of world-renowned scientists seek new and innovative ways to prevent, diagnose and treat cancer, HIV/AIDS and other life-threatening diseases. Fred Hutch’s pioneering work in bone marrow transplantation led to the development of immunotherapy, which harnesses the power of the immune system to treat cancer with minimal side effects. An independent, nonprofit research institute based in Seattle, Fred Hutch houses the nation’s first and largest cancer prevention research program, as well as the clinical coordinating center of the Women’s Health Initiative and the international headquarters of the HIV Vaccine Trials Network. Private contributions are essential for enabling Fred Hutch scientists to explore novel research opportunities that lead to important medical breakthroughs. For more information visit fredhutch.org or follow Fred Hutch on Facebook, Twitter or YouTube.

The UW School of Nursing is one of the nation's premiere nursing schools dedicated to addressing challenges in health care and improving the health of communities locally and globally. For almost 100 years, the UW School of Nursing has been a leader and innovator in nursing science and education. For more information about the #huskynurse community, visit nursing.uw.edu or follow us on Facebook, Twitter or Instagram.

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