Selective serotonin and serotonin-norepinephrine inhibitors (SSRIs and SNRIs) have been shown to be effective for the treatment of hot flashes. However, these agents may carry certain side effects, including sexual side effects and sleep disturbance. These two side effects may be particularly concerning to peri- and postmenopausal women who, in addition to having vasomotor symptoms, are more likely to experience sexual dysfunction and sleep disruption than premenopausal women.
A recent study from Ensrud and colleagues (including Dr. Hadine Joffe of the CWMH) reports on the impact of escitalopram (Lexapro) on sleep quality in a group of healthy postmenopausal women reporting significant vasomotor symptoms. 205 women (95 African American, 102 white, 8 other) were randomized to receive either escitalopram (10-20 mg/day) or placebo. Insomnia was measured using the Insomnia Severity Index (ISI), and subjective sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) at baseline and at weeks 4 and 8.
At baseline, most of the participants experienced insomnia and poor sleep quality. Based on scores on the ISI, a total of 77 (37.6%) women were classified as having mild (subthreshold) insomnia (ISI, 8-14); 55 (26.8%), with moderate clinical insomnia (ISI, 15-21); and 12 (5.9%), with severe clinical insomnia (ISI, 22-28). 40% of women had a PSQI score higher than 8, representing poor subjective sleep quality.
The authors reported that women treated with escitalopram had an improvement in insomnia symptoms and subjective sleep quality, with statistically significant improvements on their ISI and PSQI scores at week 8. Clinical improvement in insomnia symptoms and subjective sleep quality (as defined as a?50% decrease in scores on the ISI or PSQI from baseline) were observed more frequently in the escitalopram group than in the placebo group (ISI, 50.0% vs. 35.4%, P = 0.04; PSQI, 29.6% vs. 19.2%, P = 0.09).
Although certain studies have shown that SSRIs and SNRIs may disrupt sleep, this study indicates that treatment with escitalopram at standard clinical doses may actually improve sleep quality. The authors make note of the fact that insomnia and poor subjective sleep quality were extremely common in this cohort at baseline, despite excluding women with a diagnosis of major depression or anxiety disorder. Given the prevalence of sleep problems in perimenopausal women with vasomotor symptoms, it is reassuring to have these data indicating that not only does escitalopram help to relieve hot flashes, it may also improve sleep quality.
Ruta Nonacs,MDPhD
Ensrud KE, Joffe H, Guthrie KA, et al. Effect of escitalopram on insomnia symptoms and subjective sleep quality in healthy perimenopausal and postmenopausal women with hot flashes: a randomized controlled trial. Menopause. 2012 Aug;19(8):848-855.
An SNRI reportedly does better for vasomotor symptoms because a tract to the hypothalamus keeps glucose transporters maintained; estrogen also stimulates production of these transporters; lack of estrogen, lack of glucose, the hot flashes is percieved hypoglycemia. Those with anxiety have more difficult with menopause. Perhaps treating the anxiety disorder was improved helping sleep.
Personally, after screening, I use an SNRI with clonazepam .5-1 mg for sleep. The architecture may look different but at least it can be measured because they sleep. I haven’t read the study but thanks for your work. Excellent blog