How do you approach pharmacologic treatment of sleep disturbances in perimenopausal or menopausal patients with vasomotor symptoms?

CBT-I is still the gold standard approach in this population, and sleep hygiene, relaxation, and sleep efficiency would likely be helpful whether you are also addressing vasomotor or other contributing factors. But it can be so helpful to directly treat vasomotor symptoms. I use gabapentin 100-400 mg qhs to help with vasomotor symptoms, anxiety, and sleep disruption; the SNRI's or even SSRI's for vasomotor symptoms, and refer to a gyn or PCP to discuss hormone replacement therapy.

For sleep disturbance related to vasomotor symptoms, I had success using 0.1 mg clonidine at night for one patient who did not respond to SSRIs, doxepin, or trazodone and wasn't interested in hormone replacement therapy. Clonidine is worth considering if other options failed trying but certainly not a silver bullet; a similar patient of mine did not respond to clonidine.

This comes up a lot in my practice, especially with patients who already have longstanding problems with anxiety and sleep. Everything has to be individualized based on the person's age and prior history. Though hormones may relieve symptoms even in the absence of vasomotor symptoms, they aren't my first choice, especially for women well past menopause. Taking acetaminophen at night may help with the low-grade aches and pains that come with age and may affect sleep and the ability to go back to sleep upon awakening. SSRIs and Trazodone may be helpful. I have found a research report that gabapentin may work for menopausal symptoms (including hot flashes); I have used it successfully with one patient. Though I rarely use it, very low dose sin...