Pharmacological and non-pharmacological treatments for chronic insomnia in perimenopausal and postmenopausal women: a systematic review and meta-analysis

INTRODUCTION: Chronic insomnia is highly prevalent during menopause, with or without vasomotor symptoms, and is associated with significantly impaired quality of life, impaired cognitive functioning, mood disturbances, and increased cardiovascular risk. This systematic review assessed the effectiveness of pharmacological and non-pharmacological treatments (acupuncture, yoga, massage) versus placebo or no treatment for chronic insomnia in peri- and postmenopausal women. The secondary aim was to establish the most effective treatment (pharmacological or non-pharmacological) for menopausal-associated chronic insomnia. METHODS: We performed data extraction from PubMed/Medline, EMBASE and CINAHL to include only randomized controlled trials in adult peri-menopausal or menopausal women with chronic insomnia, comparing a pharmacological treatment or a non-pharmacological intervention with placebo, passive control, or active control. The primary outcome was sleep quality, assessed by Pittsburgh sleep quality index (PSQI), insomnia severity index (ISI), or total sleep time (TST). RESULTS: Out of 80 identified studies, 24 were included in the qualitative synthesis and 17 in the meta-analysis. Methodological quality was generally good to excellent (mean PEDro score 8.66/10). The meta-analysis showed a significant effect of non-pharmacological treatment on PSQI and ISI, while pharmacological treatments were only effective on PSQI. Neither objective nor subjective TST was modified by the treatments. CONCLUSION: Despite several limitations, nonpharmacological interventions, particularly cognitive behavioral therapy for insomnia and techniques reducing sympathetic hyperarousal (acupuncture, yoga, massage), seem to be the most robust first-line options for peri- and postmenopausal women suffering from chronic insomnia, whereas pharmacological treatments still require longer and better designed studies to establish their long-term efficacy and safety.