Key Clinical Summary: Sleep Disturbance, Mood Change & Vasomotor Symptoms (VMS) Across Menopause

This is a micro-learning module summary of Prof Hadine Joffe's Menopause Education session which you can find here.

Before participating please read our CME and disclosure information which can be found here. This program was supported by an independent medical education grant from Bayer. This content is intended for US Healthcare Professionals only.

Why this matters

• Prevalence & persistence – Roughly 80 % of women experience VMS, and symptoms last a median 7-9 years; one-third remain symptomatic ≥10 years after the final menstrual period (FMP).
• Patient priorities – In VMS clinics, sleep complaints are the second-highest reason women seek help.
• Mood burden – Subthreshold depressive symptoms occur in 17-28 % of peri-menopausal women, whereas major depressive disorder (MDD) is less common and usually a recurrence rather than first onset.

Pathophysiological links

• Night sweats → insomnia → low mood – Experimental work shows nocturnal, not daytime, hot flashes trigger sleep fragmentation and subsequent rises in depressive scores.
• Sleep fragmentation phenotype – The dominant sleep complaint is maintenance insomnia (multiple awakenings) that parallels low-oestrogen states and VMS intensity.

Clinical assessment checklist

• Clarify menopausal stage, VMS burden, mood severity, OSA risk and life stressors.
• Elicit lifetime mood history – MDD recurrence is the norm.

Use validated tools:

• PHQ-9 / GAD-7 for mood
• Insomnia Severity Index (ISI) or PSQI for sleep
• HFRDIS for VMS interference
• Apply the “True, true… related?” test to decide whether menopause is causal, coincidental or a susceptibility factor.

Evidence-based management

Behavioural core

• Cognitive-behavioural therapy for insomnia (CBT-I) is consistently effective for VMS-related insomnia and improves mood and quality of life.
• Teach “three no’s” sleep hygiene: no clock-watching, no tossing/turning in bed, no screen light during nocturnal awakenings.

Non-hormonal pharmacotherapy

• SSRIs / SNRIs relieve VMS, improve sleep and treat depression; no single agent outperforms the class.
• Gabapentin, useful when night sweats dominate
• Neurokinin-3 antagonists (fezolinetant; elinzanetant in trials) rapidly suppress VMS; elinzanetant also improves sleep metrics but is not yet licensed.
• Dual orexin receptor antagonists are FDA approved for insomnia and may reduce menopause-related insomnia in RCTs.
• Z-drugs (zolpidem, eszopiclone) are effective but monitor for next-day impairment.

Hormone therapy (HT)

• Low-dose transdermal or oral oestrogen ± cyclic progesterone is off label but may alleviate mild depressive symptoms in peri-menopause with prominent VMS; evidence is limited for MDD, and HT is not first-line for major depression.

Practical clinical pearls

• Treat the dominant distressing symptom first
• Reassess at 4-6 weeks using ISI/PHQ-9/HFRDIS; adjust or layer therapies.
• Educate & empower – Emphasise that menopausal depression is a subgroup phenomenon, not inevitable, and that effective options exist across behavioural, non-hormonal and hormonal spectra.

Key take-home messages for busy clinicians

• VMS, sleep and mood are biologically intertwined; address them in concert rather than in isolation.
• Night-time VMS are the linchpin driving insomnia and mood change—control them aggressively.
• CBT-I is first-line for insomnia; pharmacologic sleep aids are add-ons.
• SSRIs/SNRIs double-duty for VMS and mood make them practical choices.
• Reserve systemic HT for peri-menopausal women with bothersome VMS and subthreshold mood symptoms; taper once symptoms remit.
• New NK3 antagonists may offer non-hormonal rapid VMS relief and may aid sleep.
• Continual shared decision-making and clear patient resources sustain long-term adherence and quality of life.