Sleep Treatment and Women's Health: The Role of CBT-I in Treating Insomnia for Women, Including in the Contexts of the Menopause and Pregnancy/Postpartum Transitions
Our primary goal is to provide accessible sleep treatment for women, including women navigating pregnancy, postpartum, and all phases of the menopause transition.These life phases include many physiological changes that can significantly impact sleep. Left untreated, chronic insomnia has many adverse outcomes. Given the nuanced link between hormonal changes and sleep disturbances, it is crucial to address and not disregard sleep disruption. Insomnia can be addressed within these transitional contexts, as well as outside of them..Given the intricate link between hormonal changes and sleep disturbances, it's crucial to offer nuanced clinical sleep treatment and coordinated care.
Understanding Insomnia in Women's Health
Insomnia is a common complaint among women across all stages of life. Women often experience sleep disturbances during the premenstrual week and during the first few days of menstruation, in part due to the rise and drop in progesterone (Baker, Joffe & Lee, 2017). Sleep can also be particularly challenging during perimenopause and menopause, due to changing reproductive hormone levels, hot flashes, mood symptoms, life phase, and stress (Baker, Joffe & Lee, 2017). Pregnancy can also introduce or worsen sleep challenges, often due to physical discomfort and hormonal changes (Balserak & Lee, 2017). The prevalence of insomnia can be as high as 30% in the general population, with higher rates among women during pregnancy and menopausal transitions.
Why OBGYNs Should Focus on Insomnia and the Shortcomings of Current Insomnia Management
OBGYNs are uniquely positioned to support patients with insomnia because they understand the hormonal contexts that can precipitate or exacerbate sleep issues. During the perimenopausal and menopausal phases, hormonal changes can disrupt sleep architecture and increase the propensity for sleep disturbances. Similarly, the physical and hormonal changes during pregnancy can lead to insomnia, impacting maternal and fetal health (Kryger, Roth, & Dement, 2021). In the postpartum phase, disturbances stem from a variety of physical, hormonal, and psychosocial factors associated with childbirth and the demands of caring for a newborn and can substantially impact sleep (Kryger, Roth & Dement, 2021). Additionally, rates of insomnia are higher in women than in men. For some, sleep disruption may not be directly tied to a hormonal transition. This sleep disruption still impacts quality of life and warrants thoughtful diagnosis and treatment.
A significant gap exists in the management of insomnia at the primary care level, as highlighted in recent studies. Primary care providers often underutilize non-pharmacological treatments like Cognitive Behavioral Therapy for Insomnia (CBT-I), despite its effectiveness (Schutte-Rodin et al., 2008). Medications are frequently prescribed, but they come with risks and are often less suitable, especially for pregnant and menopausal women due to potential side effects. In studies comparing CBT-I to medication treatment for insomnia, CBT-I demonstrates more durable effects, outperforming sleep medication. We are seeing similar gaps in education for OBGYNs who are not aware of CBT-I as a treatment option for women. Further, many providers struggle to get their patients connected to CBT-I as there are not many providers and wait times can be months long.
Integrating Insomnia Management into Women's Health Care
As OBGYNs, integrating insomnia management into routine care involves several key components:
- Screening and Assessment: Proactively screening for sleep disturbances during routine check-ups can help in early identification. Discussing sleep as part of the overall health conversation is vital.
- Education: Educating patients about the impact of hormonal changes on sleep and vice versa can empower them to seek timely intervention.
- Behavioral and Non-Pharmacological Interventions: Emphasizing CBT-I and other non-pharmacological treatments should be a frontline, gold standard, strategy (Schutte-Rodin, 2008). These methods are safe and effective, without the risks associated with medications.
- Care Coordination and Collaboration: Collaborating with sleep specialists and integrating multidisciplinary approaches can enhance outcomes, especially for complex cases involving comorbidities like anxiety or depression, which are common for many women navigating insomnia.
For OBGYNs, the role extends beyond reproductive health; it encompasses an integrative approach to all aspects of women's health, including sleep. By addressing insomnia through a tailored approach that considers the unique needs of women during critical life transitions, we can significantly enhance quality of life and overall health outcomes. It's time to prioritize sleep in women's health care protocols, ensuring that our patients receive the comprehensive care they deserve during all phases of their lives.
References
- Baker, F. C., Joffe, H., & Lee, K. A. (2017). Sleep difficulties in menopause are commonly associated with hot flashes, depression, sleep disordered breathing, and stress. Sleep Medicine.
- Bhaskar, S., Hemavathy, D., & Prasad, S. (2016). Prevalence of chronic insomnia in adult patients and its correlation with medical comorbidities. Journal of Family Medicine and Primary Care, 5(4), 780-784. https://doi.org/10.4103/2249-4863.201153
- Blair, L. M., et al. (2015). Poor sleep in pregnancy is associated with increased odds of preterm birth and the likelihood of undergoing cesarean section and having longer labor. Sleep.
- Kryger, M. H., Roth, T., & Dement, W. C. (2021). Principles and practice of sleep medicine (7th ed.). Elsevier.
- Lara-Carrasco, J., Simard, V., Saint-Onge, K., Lamoureux-Tremblay, V., & Nielsen, T. (2014). Disturbed dreaming during the third trimester of pregnancy. Sleep Medicine, 15(6), 694-700. https://doi.org/10.1016/j.sleep.2014.01.026
- Mellor, R., et al. (2014). Poor sleep quality is a prospective risk factor for perinatal depression. Archives of Women's Mental Health.
- Naghi, I., et al. (2011). Poor sleep in pregnancy is associated with increased odds of preterm birth and the likelihood of undergoing cesarean section and having longer labor. Journal of Obstetrics and Gynaecology.
- Okun, M. L., et al. (2011). Poor sleep in pregnancy is associated with increased odds of preterm birth. Sleep.
- Schutte-Rodin, S., et al. (2008). Clinical guideline for the evaluation and management of chronic insomnia in adults. Journal of Clinical Sleep Medicine, 4(5), 487-504.
- Skouteris, H., et al. (2009). Poor sleep quality is a prospective risk factor for perinatal depression. Women's Health Issues.
- Sun, J., McPhillips, M. V., Chen, K.-C., Zang, Y., Li, J., Oehlke, J., Brewster, G. S., & Gooneratne, N. S. (2021). Primary care provider evaluation and management of insomnia. Journal of Clinical Sleep Medicine, 17(5). https://doi.org/10.5664/jcsm.9154
- Tomfohr, L., et al. (2015). Poor sleep quality is a prospective risk factor for perinatal depression. Sleep.
- Zhang, B., & Wing, Y.-K. (2006). Sex differences in insomnia: a meta-analysis. Sleep, 29(1), 85-93. https://doi.org/10.1093/sleep/29.1.85
