In This article

• CBT-I adapted for menopause can improve insomnia and nighttime hot flashes.
• Short-term benefits include improved sleep, mood, and sleep self-efficacy, though effects may diminish over time.
• Shorter interventions may require booster sessions to sustain gains.
• CBT offers a non-pharmacologic option amid evolving hormone therapy guidance.
• Access to trained CBT providers with menopause expertise remains limited.

About 80% of women experience vasomotor symptoms (VMS)—hot flashes and night sweats—as they transition into menopause. For most, symptoms are manageable; however, for a sizable subset of midlife women, these symptoms can negatively affect sleep, mood, cognitive abilities, sexual functioning, and overall quality of life. While clinical guidelines suggest that menopausal vasomotor symptoms typically last from 6 months to 2 years, newer research suggests that for many women, the duration of menopausal symptoms is much longer.

As sleep disruption is one of the most common and troublesome menopausal symptoms, there is a significant need for effective management strategies. A large body of evidence indicates that cognitive behavioral therapy for insomnia (CBT-I) is an effective treatment. This intervention is a structured, short-term, skill-focused psychotherapy that targets maladaptive cognitions (thoughts and beliefs) and behaviors that contribute to insomnia.

CBT-I is based on Spielman’s three-factor model of insomnia. Although insomnia often begins with a combination of a predisposition (e.g., high emotional reactivity) and a precipitating event (e.g., nighttime VMS), the transition to chronic insomnia is typically perpetuated by behavioral and cognitive factors. For example, individuals may spend more time in bed attempting to induce sleep because they are worried about not sleeping, which leads to conditioned arousal (where the bed becomes associated with anxiety rather than sleep) and maintains the problem even after the initial triggers resolve. By applying CBT principles to address distress associated with nighttime VMS, CBT-I may also reduce the perceived burden of these symptoms.

There is evidence that CBT-I and CBT can be tailored for perimenopausal populations. For example, CBT-Meno has been shown to be an effective option for the management of sleep problems in peri- and postmenopausal women.

CBT for Sleep and Vasomotor Symptoms

In a recent study, Arentson-Lantz and colleagues examined the efficacy of CBT-MI, a CBT-based intervention targeting both insomnia and nocturnal vasomotor symptoms in perimenopausal and postmenopausal women. In this pilot study, the standard CBT-I intervention was adapted by incorporating elements of CBT for menopausal symptoms. A total of 43 participants (mean age = 53.6 years) who identified as perimenopausal or postmenopausal, reported at least one nocturnal hot flash per night, and met diagnostic criteria for insomnia disorder were randomized to receive either CBT-MI or menopause education.

The CBT-MI intervention was delivered in four individual 50-minute sessions over 8 weeks by trained social workers, nurses, or psychologists in gynecology clinics.

Participants were assessed at baseline, post-treatment, and at 1- and 3-month follow-up using several measures, including the Insomnia Severity Index (ISI), Sleep Self-Efficacy Scale (SES), and Hot Flash Daily Interference Scale (HFDIS).

CBT-MI was more effective than menopause education and was associated with improvements in sleep self-efficacy and nighttime vasomotor symptoms. The intervention produced meaningful short-term improvements in insomnia severity, hot flash interference, sleep self-efficacy, and depressive symptoms, although these benefits declined over the three months of follow-up. These findings are consistent with other trials of standard CBT-I in perimenopausal women; however, the CBT Meno intervention, which included 12 weekly 2-hour sessions, appeared to demonstrate less decline in benefits at 3-month follow-up.

The Bottom Line

This pilot study indicates that standard CBT-I interventions can be modified to include CBT techniques for menopausal vasomotor symptoms and can result in short-term improvements in sleep, VMS, depressive symptoms, and quality of life. However, improvements appeared to wane over several months of follow-up. The researchers speculate that the four-session format may be insufficient to sustain gains beyond the intervention period; booster sessions or ongoing practice reinforcement may be necessary. They also highlight the importance of developing maintenance strategies and expanding behavioral targets to improve daytime functioning.

Current research indicates that both standard CBT-I and CBT-I adapted for menopausal symptoms are effective strategies for managing insomnia. Clinicians treating menopausal women may consider adapting CBT-I when patients present with bothersome VMS, particularly when nighttime symptoms disrupt sleep.

Addressing Unmet Needs

Many women experiencing symptoms during the menopausal transition—whether vasomotor symptoms, sleep disturbance, or mood changes—struggle to find reliable information on treatment and providers with expertise in this area. At the same time, evolving perspectives on hormone therapy have contributed to confusion for both patients and clinicians.

Perimenopausal and menopausal women often present with a complex clinical picture, including acute symptoms (sleep problems, mood changes, VMS) within the context of multiple life stressors and medical comorbidity. Care is often fragmented, with individuals seeing a gynecologist for vasomotor symptoms, a psychiatrist for mood symptoms, and a therapist for psychosocial concerns. There is a clear need for more coordinated, streamlined care so that women can receive comprehensive, effective treatment from knowledgeable providers.

It is encouraging that CBT offers an effective, non-pharmacologic option for managing multiple menopausal symptoms. However, access remains a challenge. It can be difficult to find providers trained in CBT, and even more difficult to identify those with expertise in treating menopausal symptoms.

For providers interested in learning more about CBT for perimenopausal populations, the National Health Service in the United Kingdom offers several resources:

• Managing Hot Flushes and Night Sweats with Group CBT: An evidence-based treatment manual for health professionals is an evidence-based manual written by the researchers who developed the MENOS CBT intervention, providing clinicians with the knowledge and tools to run group programs.
• A self-help book from the same research team, Living Well Through the Menopause: a self-help guide using cognitive behavioural therapy, is also available.

Although not specific to menopausal populations, several digital tools incorporate CBT-I principles:

• CBT-i Coach is a free mobile app developed by the Veterans Administration that offers CBT-I techniques and helps users build healthier sleep habits.
• SHUTi (now Somryst) is an internet-based CBT-I program designed to improve sleep in adults with insomnia. While SHUTi is no longer available under that name, its approach has been incorporated into Somryst, an FDA-authorized digital therapeutic.
• Sleepio offers a 6-week self-directed program to improve sleep. In the UK, Sleepio can be prescribed through the NHS. In the US, Sleepio is not typically covered by insurance; however, SleepioRx has received FDA clearance, which may support future reimbursement.

In general, treatment should be tailored to the individual, addressing the full range of complaints, including vasomotor symptoms, sleep disturbance, depression, anxiety, and stressful life events.

—Ruta Nonacs, MD PhD