TLDR;
This podcast features Dr. Sharon Hung interviewing Dr. Mera Zayn about insomnia in women, focusing on pregnancy and perimenopause. They discuss the hormonal and physical changes that cause insomnia during these periods, along with treatment options like lifestyle changes, cognitive behavioral therapy (CBT-I), and medications. Key takeaways include the importance of addressing sleep issues for overall health, the effectiveness of CBT-I, and the cautious use of medications and supplements during pregnancy.
- Insomnia is common in women, especially during pregnancy and perimenopause, due to hormonal changes.
- CBT-I is the first-line treatment for insomnia and is more effective than medication.
- Medications and supplements should be used cautiously during pregnancy, with a focus on safety data.
Introduction to Women’s Health Vodcast Series [0:00]
Dr. Sharon Hung introduces the Stanford Women's Health podcast series, which aims to explore various aspects of women's health with leading experts. Today's topic is insomnia across a woman's lifespan, and she welcomes Dr. Mera Zayn, a psychiatrist specializing in women's mental health, to discuss the management of insomnia during pregnancy and perimenopause. Dr. Zayn highlights that insomnia is more prevalent in women due to hormonal fluctuations.
Lifestyle modifications for Insomnia [4:37]
Dr. Zayn recommends lifestyle modifications to improve sleep duration and quality. Consistent sleep schedules, limiting caffeine intake (especially important for pregnant women), avoiding nocturnal eating and artificial light exposure before bed, and establishing relaxing bedtime routines are crucial. Regular physical activity, including aerobic exercise and yoga, can also help improve sleep quality, with the timing of exercise being less important than consistency.
Cognitive behavioral therapy for Insomnia [5:59]
Cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment for insomnia, including during pregnancy. CBT-I includes sleep hygiene, adjusting time spent in bed, and cognitive and behavioral strategies to refocus the brain and manage sleep. It helps patients manage racing thoughts, establish relaxation techniques, and avoid bright light activities before bed. Studies show CBT-I improves sleep quality, sleep latency, and wake after sleep onset, even in patients with comorbid conditions. CBT-I can improve sleep duration by 40 minutes to a couple of hours.
Resources for finding CBT-I [11:04]
Dr. Zayn recommends several resources for finding CBT-I, including provider directories from the Society of Sleep Behavioral Medicine and the University of Pennsylvania. Digital CBT-I options include the free CBT-I Coach app from the US Department of Veterans Affairs, as well as paid programs like Sleepio and Good Path. Mayo Clinic's interactive skilling module is also a helpful web-based resource for learning CBTI strategies.
Pharmacotherapy for Insomnia in pregnant women [13:29]
Pharmacotherapy is reserved for persistent insomnia after lifestyle modifications and CBT-I have been tried, with a careful risk-benefit discussion. Doxylamine (Unisom) and Benadryl are recommended as first-line options, as they are antihistamines with some evidence of safety during pregnancy. Dr. Zayn emphasizes the importance of discussing the risks of untreated insomnia on both the mother and fetus.
Other prescription options if first-line fails [16:09]
If antihistamines are ineffective, low-dose trazodone can be considered, but with caution due to its serotonergic effects. Intermittent low-dose lorazepam may be an option for refractory cases, as studies suggest the risk of congenital abnormalities is low, especially when used sparingly. Gabapentin has also been used, though data is limited. Non-benzodiazepine hypnotics like zolpidem have less data supporting their use compared to lorazepam and cross the placenta more readily.
Safety of supplements during pregnancy [21:31]
While patients may perceive supplements as safer, Dr. Zayn advises caution. Unisom and Benadryl have good evidence, but melatonin lacks sufficient safety data during pregnancy and may affect fetal brain development. Herbal remedies should also be avoided due to a lack of safety data. CBD gummies and marijuana are not safe during pregnancy and can negatively impact fetal development.
Perimenopausal and menopausal insomnia [23:40]
Perimenopausal insomnia is common, affecting about half of women in this transitional period. It's more complex than postpartum insomnia due to aging and hormonal changes. Decreased estradiol and increased FSH are associated with frequent nocturnal awakenings and sleep fragmentation. Estrogen's decline disrupts the hypothalamic system, affecting thermoregulation and sleep-wake cycles.
Menopausal hormone therapy for menopausal insomnia [26:51]
Menopausal hormone therapy (MHT) can improve sleep if vasomotor symptoms are disrupting sleep. Studies show MHT improves subjective sleep outcomes, but the effect size is small. MHT is most effective for women with significant vasomotor symptoms and is not recommended for those without.
Role of micronized progesterone [28:12]
Micronized progesterone can improve sleep quality in women with chronic insomnia during perimenopause and menopause. Studies support its use for improving subjective sleep, sleep onset latency, and sleep efficiency, with a favorable safety profile.
Pharmacotherapy for insomnia during perimenopause and menopause [31:02]
For sleep maintenance insomnia, low-dose doxepin (1-9 mg) is recommended, as well as dual receptor orexin antagonists like suvorexant and lemborexant. Prolonged-release melatonin formulations can be used as an adjunct or for milder symptoms. For both sleep onset and sleep maintenance insomnia, low-dose doxepin and orexin antagonists are effective.
Supplements for insomnia [33:41]
Melatonin has the most robust data among natural supplements. L-theanine and magnesium have some potential, but the evidence is lower quality. Magnesium glycinate (100-200 mg) is preferred over magnesium oxide (400-800 mg) for better absorption and fewer GI effects.
Use of zolpidem for menopause-related insomnia [36:21]
Zolpidem is part of the clinical guidelines for the American Academy of Sleep Medicine and can be used for short-term insomnia. However, it's important to monitor for side effects, use the lowest effective dose, and emphasize CBT-I. Women may experience side effects at lower doses than men.
Digital therapeutics and promising treatments for Insomnia [37:52]
There's limited data on whether sleep tracking with wearables improves sleep quality or duration. Some studies suggest it may decrease sleep latency and improve subjective sleep quality, especially when used with feedback and sleep education. Promising therapies include research on orexin antagonists, neuromodulation techniques, and complementary therapies like acupuncture. Cooling mattress pads for perimenopausal women are also being developed.
Final takeaways for managing insomnia [40:36]
Dr. Zayn advises providers to always ask women about sleep quality and quantity and to offer training in sleep hygiene and basic CBT-I. Asking about vasomotor symptoms in women over 40 is also important. Patients should talk to their doctors about sleep issues, as they are not an expected part of pregnancy or perimenopause and can be treated to improve quality of life.
