Menopause and Sleep Disturbances: Estrogen, Progesterone, Hot Flashes and What May Help
Sleep disturbances in menopause are rarely a single problem. They arise from the interplay of declining progesterone, fluctuating estrogen, nighttime hot flashes and an altered stress axis. What the research shows, what may really help, and what an integrative, cPNI-oriented strategy looks like.
Many women come into the consultation and say the same sentence: "I never slept badly, and now I lie awake at night." They often think something is wrong with them. Yet the explanation is biologically understandable. In menopause, progesterone declines, which has a calming, GABA-agonistic effect. Estrogen fluctuates and falls; both are involved in thermoregulation and sleep architecture. Nighttime hot flashes tear you out of sleep. The stress axis changes. In the SWAN cohort after Kravitz 2008 in Sleep, women increasingly report sleep problems as the transition progresses, closely linked to hot flashes and declining estradiol. Sleep disturbances in menopause are not a personal failure, but a solvable interplay of hormones, heat and stress. In this spoke I put into perspective what may work and what is overestimated.
This spoke belongs to the sleep cluster and looks at one of the most common causes of difficulty falling and staying asleep in women in midlife. We go through the mechanisms (estrogen, progesterone, hot flashes, cortisol), examine the evidence on hormone therapy, cognitive behavioral therapy and herbal options, view the whole through four cPNI lenses, clear up typical misconceptions and give three concrete levers for the coming weeks.
Why menopause changes sleep
The menopausal transition is a phase of hormonal remodeling. Two hormones are particularly relevant for sleep. Progesterone often falls early in perimenopause, because ovulations become less frequent and with them the luteal phase, during which progesterone is produced. Estrogen first fluctuates strongly and then declines. Both changes hit a sleep system that is finely tuned to hormones, body temperature and stress signals.
Progesterone decline
Progesterone and its metabolite allopregnanolone act on the GABA-A receptor, the same system that calming messengers also use. When progesterone falls, this natural sleep support may drop away. This can explain why some women sleep worse even before their last period.
Estrogen fluctuation
Estrogen is involved in thermoregulation in the hypothalamus and in sleep architecture. Fluctuating and declining estrogen shifts temperature control and can trigger hot flashes, which in turn interrupt sleep.
Vasomotor symptoms
Nighttime hot flashes and sweating episodes often go along with brief awakenings. They are one of the most direct ways in which menopause disrupts sleep continuity.
Stress axis
The HPA axis (cortisol) changes during this life stage and is linked to the intensity of hot flashes. Stress, worries and lack of sleep reinforce one another.
Sleep disturbances increase with the menopausal transition
Cohort Howard Kravitz and colleagues published a longitudinal analysis from the Study of Women's Health Across the Nation (SWAN) in Sleep in 2008. 3045 women of various ethnicities aged 42 to 52 years, pre- or early perimenopausal at baseline, were followed across 7 annual assessments. The adjusted odds (odds ratios) for difficulty falling asleep and staying asleep rose as the transition progressed. More frequent vasomotor symptoms were associated with higher odds of any form of sleep disturbance. Declining estradiol levels went along with more difficulty falling and staying asleep, rising FSH levels with more difficulty staying asleep. Women who took hormones tended to have lower odds of disturbed sleep.
Kravitz HM, Zhao X, Bromberger JT, et al. Sleep. 2008;31(7):979-90. doi:10.1093/sleep/31.7.979 · PMID: 18652093
31 to 42 percent of perimenopausal women with insomnia symptoms
Cohort Colleen Ciano and colleagues analyzed 10 years of publicly available SWAN data from 3302 women (mean age 46 years) in JOGNN in 2017. In each one-year interval, 31 to 42 percent of perimenopausal women reported insomnia symptoms (difficulty falling asleep, waking after sleep onset, early awakening, poor sleep quality). Symptoms were more frequent in late perimenopause than in early perimenopause (odds ratio 1.3, 95 percent CI 1.2 to 1.5, P less than 0.001). The authors point out that this increase may raise the risk of a manifest insomnia disorder.
Ciano C, King TS, Wright RR, Perlis M, Sawyer AM. J Obstet Gynecol Neonatal Nurs. 2017;46(6):804-813. doi:10.1016/j.jogn.2017.07.011 · PMID: 28886339
Progesterone, GABA and sleep
Progesterone has a direct connection to sleep that runs via the calming GABA system. This is more than a theory; it can be measured on sleep EEG.
Micronized progesterone reduces nighttime wakefulness
RCT Peter Schuessler and colleagues from the Max Planck Institute of Psychiatry published a randomized, double-blind crossover study in Psychoneuroendocrinology in 2008. 10 healthy postmenopausal women (54 to 70 years) received either 300 milligrams of micronized progesterone or placebo over 21 days each, separated by a washout phase. On sleep EEG, intermittent wakefulness decreased under progesterone, and REM sleep in the first third of the night increased. Daytime cognitive performance was not impaired. The authors discuss a GABA-agonistic effect as a possible mechanism. Important for context: very small sample, healthy women, short duration.
Schüssler P, Kluge M, Yassouridis A, et al. Psychoneuroendocrinology. 2008;33(8):1124-31. doi:10.1016/j.psyneuen.2008.05.013 · PMID: 18676087
Sleep quality improves under hormone therapy with progesterone
RCT Ekachai Leeangkoonsathian and colleagues randomized 100 Thai women with sleep complaints in Gynecological Endocrinology in 2017. Both groups received estradiol valerate 1 milligram, plus either dydrogesterone 10 milligrams or micronized progesterone 100 milligrams. Sleep quality (measured with the Pittsburgh Sleep Quality Index) improved markedly in both groups over three months, without a significant difference between the progestogen types. The women in the progesterone group had fewer side effects overall. Limitation: small groups, the question of the pure progesterone contribution remains open.
Leeangkoonsathian E, Pantasri T, Chaovisitseree S, Morakot N. Gynecol Endocrinol. 2017;33(12):933-936. doi:10.1080/09513590.2017.1333094 · PMID: 28609128
Hot flashes as a nighttime sleep thief
Vasomotor symptoms, that is, hot flashes and sweating episodes, are a central mechanism for disrupted sleep continuity. They arise from a narrowed thermoneutral zone in the hypothalamus, which regulates body temperature. Even small rises in temperature then trigger an excessive heat release, with sweating and awakening. Anyone who wants to improve sleep in menopause therefore often has to address the hot flashes first.
Hormone therapy lowers night sweats strongly, insomnia only temporarily
RCT Nanette Santoro and colleagues published data from the Kronos Early Estrogen Prevention Study (KEEPS) in Menopause in 2017. 727 early postmenopausal women (42 to 58 years, within 3 years of their last period) received oral conjugated estrogens 0.45 milligrams or transdermal estradiol 50 micrograms (both with micronized progesterone 200 milligrams for 12 days per month) or placebo, over 4 years. Moderate to severe hot flashes fell from 44 percent at baseline to 28 percent under placebo, 7 percent under estradiol and 4 percent under conjugated estrogens. Night sweats fell from 35 percent to 19 percent (placebo), 5 percent (estradiol) and 5 percent (conjugated estrogens). Insomnia decreased in all groups, but only temporarily more in the hormone groups than under placebo. This shows: hormone therapy may strongly reduce hot flashes, while the standalone effect on insomnia is smaller.
Santoro N, Allshouse A, Neal-Perry G, et al. Menopause. 2017;24(3):238-246. doi:10.1097/GME.0000000000000756 · PMID: 27779568
Sleep disturbances in menopause are often a chain: hormonal remodeling leads to hot flashes, hot flashes lead to awakening, awakening leads to daytime fatigue and worries, worries lead to even worse sleep. Where the greatest lever in this chain lies differs from person to person. For one woman it is the nighttime sweating episodes, for another it is the racing thoughts at 3 a.m. Good treatment begins with the question: what specifically interrupts your sleep? The approach follows from that, not the other way around.
What may really help: the treatment options
Cognitive behavioral therapy for insomnia (CBT-I)
The most effective non-hormonal option with the best evidence is cognitive behavioral therapy for insomnia. It works with sleep restriction, stimulus control, sleep hygiene and dealing with racing thoughts. It is considered the first-line treatment for chronic insomnia and has also been studied in menopause.
Telephone-based CBT-I clearly improves sleep in menopause
RCT Susan McCurry and colleagues published a randomized study from the MsFLASH network in JAMA Internal Medicine in 2016. 106 peri- and postmenopausal women (40 to 65 years) with moderate insomnia and at least 2 hot flashes per day received 6 telephone sessions of either CBT-I or a menopause education program as control over 8 weeks. After 8 weeks, insomnia severity (Insomnia Severity Index) dropped by 9.9 points in the CBT-I group and by 4.7 points in the control group (difference 5.2 points, 95 percent CI minus 6.1 to minus 3.3, P less than 0.001). After 8 weeks, 70 percent of the CBT-I participants were in the no-insomnia range, and 84 percent after 24 weeks. The frequency of hot flashes did not change, but their disruptive impact decreased more in the CBT-I group. The effects lasted up to 24 weeks.
McCurry SM, Guthrie KA, Morin CM, et al. JAMA Intern Med. 2016;176(7):913-20. doi:10.1001/jamainternmed.2016.1795 · PMID: 27213646
Hormone therapy
Menopausal hormone therapy may improve sleep, mainly indirectly through the reduction of nighttime hot flashes (see KEEPS, Santoro 2017). The decision for or against hormone therapy is individual. International professional societies have formulated global consensus recommendations on this, which take into account, among other things, age, time since menopause and risk profile (summarized for example in Gambacciani 2017 in Minerva Ginecologica). This assessment belongs in a medical consultation and not in a blog article. When nighttime hot flashes are the dominant trigger, hormone therapy may be a useful building block. As a standalone insomnia therapy it is less suitable.
Herbal and complementary options
Phytoestrogens lower hot flashes moderately, not night sweats
Meta-analysis Oscar Franco and colleagues published a systematic review with meta-analysis on plant-based therapies for menopausal symptoms in JAMA in 2016. 62 studies with 6653 women were included. Phytoestrogens (such as soy isoflavones) were associated with a reduction in daily hot flashes (pooled mean difference minus 1.31, 95 percent CI minus 2.02 to minus 0.61) and with less vaginal dryness, but not with a significant reduction in nighttime sweating. The authors emphasize the heterogeneous and often suboptimal study quality: 74 percent of the included RCTs had a high risk of bias in several domains.
Franco OH, Chowdhury R, Troup J, et al. JAMA. 2016;315(23):2554-63. doi:10.1001/jama.2016.8012 · PMID: 27327802
Phytoestrogens reduce the frequency of hot flashes
Meta-analysis Mei-Nung Chen and colleagues published a meta-analysis of 15 randomized controlled trials on phytoestrogens for menopausal symptoms in Climacteric in 2014. The pooled analysis of 10 studies on hot flash frequency showed a significantly stronger reduction compared with placebo (pooled mean difference 0.89, P less than 0.005). For the Kupperman index (a general symptom score), in contrast, no significant effect was found. Serious side effects did not occur more frequently. Direct sleep endpoints were not examined separately.
Chen MN, Lin CC, Liu CF. Climacteric. 2014;18(2):260-9. doi:10.3109/13697137.2014.966241 · PMID: 25263312
In practical terms this means: phytoestrogens may be worth a try when hot flashes are the main problem. They do not have a standalone, well-documented sleep effect. If they improve sleep, it is most likely via the detour of reduced hot flashes. Other complementary measures such as sleep hygiene, a cool bedroom, breathable nightwear, and limiting alcohol and caffeine in the evening are simple, low-risk levers.
The 4 cPNI lenses on menopausal sleep
From the perspective of clinical psychoneuroimmunology, sleep is the result of an interconnected system of the nervous system, hormones, immune system and metabolism. In menopause, several of these axes shift at the same time.
Hormonal system
Progesterone decline (GABA effect), estrogen fluctuation (thermoregulation, sleep architecture) and rising FSH are the direct drivers. Kravitz 2008 links declining estradiol to more difficulty falling and staying asleep. This is the hormonal core.
Nervous system and stress axis
The HPA axis changes during this phase. Sauer 2020 in Menopause showed that pronounced hot flashes go along with a blunted cortisol awakening response. Stress regulation, daylight and vagus activation (see Spoke 4) act directly on sleep.
Immune system and inflammation
Declining estrogen shifts the immune balance slightly toward more inflammatory readiness. Low-grade inflammation and poor sleep reinforce one another. An anti-inflammatory lifestyle (nutrition, exercise, sleep) is therefore not a sideshow.
Metabolism and thyroid
In midlife, iron deficiency, vitamin D deficiency and thyroid changes become more common, all of which influence sleep and daytime fatigue. These factors should be evaluated before attributing everything to hormones (see Spoke 12).
Pronounced hot flashes with an altered cortisol awakening response
Real-World Tianna Sauer and colleagues examined 101 perimenopausal women (45 to 55 years) over 12 weeks in Menopause in 2020. Each week the participants documented the frequency and severity of their hot flashes for 24 hours and gave saliva samples for the cortisol awakening response. Women with overall more, more severe and more distressing vasomotor symptoms showed a blunted cortisol awakening response, even after statistical adjustment for estrogen and progesterone metabolites as well as self-reported sleep quality. Short-term weekly fluctuations in hot flashes, in contrast, were not linked to the cortisol response. This points to an altered stress axis in distressing vasomotor symptoms.
Sauer T, Tottenham LS, Ethier A, Gordon JL. Menopause. 2020;27(11):1322-1327. doi:10.1097/GME.0000000000001588 · PMID: 33110049
What does not work: typical misconceptions
Sleep disturbances are common in menopause, but that does not mean you have to accept them. Ciano 2017 shows that there is an increased risk of a manifest insomnia disorder, which in the long term is linked to cardiometabolic consequences. There are effective approaches, from CBT-I through hot flash treatment to stress regulation. Resignation is the worst option.
Hormone therapy may strongly reduce hot flashes and thereby indirectly improve sleep. The standalone effect on insomnia, however, is smaller and only temporary according to KEEPS (Santoro 2017). Anyone who continues to sleep poorly despite good hot flash control additionally needs a behavioral approach such as CBT-I.
According to Franco 2016 and Chen 2014, phytoestrogens moderately reduce the frequency of hot flashes, but have no well-documented standalone sleep effect and do not significantly lower night sweats. They may help indirectly through the reduction of hot flashes, but are not a substitute for a well-thought-out sleep strategy. The study quality is also heterogeneous.
In midlife, iron deficiency, vitamin D deficiency, thyroid changes, restless legs and sleep apnea become more common, all of which can disrupt sleep and disguise themselves as "menopausal sleep disturbance." A good evaluation looks beyond the hormones (see Spoke 12 on thyroid and iron). Alcohol in the evening, often used as a supposed help against hot flashes, also worsens sleep in the second half of the night.
First understand what specifically interrupts sleep, then act in a targeted way.
Hot flashes, racing thoughts, hormonal remodeling or an overlooked iron deficiency call for different answers. Menopausal sleep disturbances are solvable when you address the right causal chain.
Three concrete levers for the coming weeks
Keep a 14-day sleep and symptom diary
Note per night: time to fall asleep, nighttime awakenings, hot flashes or sweating episodes, racing thoughts, alcohol or caffeine in the evening, daytime fatigue. This way you recognize what specifically interrupts your sleep. This is precisely the basis for choosing the right approach, instead of blindly trying a remedy.
Start CBT-I principles, independent of hormone status
The MsFLASH study (McCurry 2016) shows that cognitive behavioral therapy for insomnia may work in menopause, even by telephone. First building blocks you can implement yourself: a fixed wake-up time, using the bed only for sleep, getting up briefly when lying awake for longer, daylight in the morning. For persistent insomnia, a structured CBT-I with professional support is worthwhile.
Have causes beyond the hormones evaluated
Before attributing everything to menopause, iron (ferritin), vitamin D, thyroid values and signs of sleep apnea or restless legs belong in the evaluation. When nighttime hot flashes dominate, a medical conversation about the individual assessment of hormone therapy is a sensible next step.
What a good strategy ultimately achieves
It breaks down the causal chain and acts where the greatest lever lies. For a woman with many nighttime sweating episodes, the question is "How do I get the hot flashes under control?" and the answer comes through hot flash treatment, possibly hormone therapy and sleep hygiene. For a woman who lies awake at 3 a.m. and cannot fall back asleep, the question is "How do I interrupt the rumination and stabilize the sleep rhythm?" and the answer comes through CBT-I. For a woman with constant daytime fatigue despite long time in bed, the question is "Is there an iron deficiency, a thyroid change or sleep apnea behind it?" and the answer comes through targeted diagnostics.
What does not work: expecting a single remedy as a universal solution. Sleep in menopause is an interconnected system of hormones, heat, stress and metabolism. Anyone who understands this system usually finds more than one effective point of action.
Frequently asked questions about menopause and sleep disturbances
Why do women sleep worse during menopause?
Several factors interact. First, progesterone declines, which has a sleep-promoting, GABA-agonistic effect. Second, estrogen fluctuates and falls; it is involved in thermoregulation and in sleep architecture. Third, nighttime hot flashes and sweating episodes (vasomotor symptoms) occur and can cause awakenings. Fourth, the cortisol and stress axis may be altered. In the SWAN cohort after Kravitz 2008 in Sleep, the odds of difficulty falling asleep and staying asleep rose as the transition progressed, closely linked to the frequency of hot flashes and to declining estradiol levels. Sleep disturbances in menopause are therefore rarely a single problem, but an interplay of hormones, thermoregulation, the stress axis and life stage.
How common are sleep disturbances during menopause?
Very common. In the longitudinal analysis of SWAN data after Ciano 2017 in JOGNN, 31 to 42 percent of perimenopausal women reported insomnia symptoms in any given one-year interval. Symptoms were more frequent in late perimenopause than in early perimenopause (odds ratio 1.3, 95 percent CI 1.2 to 1.5). Kravitz 2008 in Sleep showed in more than 3000 women that self-reported sleep problems increase as the menopausal transition progresses. Sleep problems are therefore among the most common and most distressing complaints of midlife.
What role does progesterone play in sleep?
Progesterone and its metabolite allopregnanolone act on the GABA-A receptor, similar to the body's own calming messengers. Schuessler 2008 in Psychoneuroendocrinology gave 10 healthy postmenopausal women 300 milligrams of micronized progesterone in a double-blind crossover study and measured sleep by EEG: nighttime wakefulness decreased, without impairing daytime cognitive performance. In menopause, progesterone often falls even before estrogen, which may be part of the explanation for early-onset sleep problems. Important: progesterone is not a sleeping pill in the classic sense and the evidence base is small. It may play a role within a medically supervised hormone therapy, but does not replace an individual assessment.
Can hot flashes at night disrupt sleep?
Yes, this is one of the central mechanisms. Nighttime hot flashes and sweating episodes (vasomotor symptoms) often go along with brief awakenings. In the SWAN cohort after Kravitz 2008 in Sleep, more frequent vasomotor symptoms were associated with higher odds of any form of sleep disturbance. Effective treatment of hot flashes may therefore indirectly improve sleep as well. In the KEEPS study after Santoro 2017 in Menopause, estrogen or estrogen-progesterone combinations clearly reduced hot flashes and nighttime sweating (night sweats from 35 percent to about 5 percent on hormone therapy), while insomnia improved only temporarily and to a lesser extent.
Does hormone therapy help with sleep disturbances in menopause?
Hormone therapy may improve sleep, mainly indirectly through the reduction of nighttime hot flashes. In the KEEPS study after Santoro 2017 in Menopause, low-dose oral conjugated estrogens or transdermal estradiol (each with micronized progesterone) strongly and durably reduced vasomotor symptoms over four years. Insomnia improved only temporarily more in the hormone groups than under placebo. That means: hormone therapy may be a useful building block when hot flashes are the main trigger, but it is not a standalone insomnia therapy. The decision is individual and follows the global consensus recommendations on menopausal hormone therapy (see Gambacciani 2017), based on age, time since menopause, risk profile and personal preferences. This belongs in a medical consultation.
What does cognitive behavioral therapy for insomnia (CBT-I) achieve in menopause?
A great deal, and without hormones. In the MsFLASH study after McCurry 2016 in JAMA Internal Medicine, 106 peri- and postmenopausal women with insomnia and hot flashes received either telephone-based CBT-I or a menopause education program. After 8 weeks, insomnia severity dropped by 9.9 points in the CBT-I group compared with 4.7 points in the control group (difference 5.2 points). In 70 percent of the CBT-I participants, the score was in the no-insomnia range after 8 weeks, and even 84 percent after 24 weeks. Interestingly, the frequency of hot flashes did not change, but their disruptive impact decreased. CBT-I is considered the first-line treatment for chronic insomnia and may also work in menopause, independent of hormone status.
Do herbal remedies such as soy isoflavones or red clover help?
Partly, and mainly indirectly. The large meta-analysis by Franco 2016 in JAMA (62 studies, 6653 women) found a moderate reduction in daily hot flashes for phytoestrogens (pooled mean difference minus 1.31 per day) and in vaginal dryness, but no significant reduction in nighttime sweating. Chen 2014 in Climacteric (15 RCTs) confirmed a significant reduction in hot flash frequency without serious side effects. Direct, well-documented sleep effects of phytoestrogens are scarce. If herbal remedies improve sleep, it is most likely through the reduction of hot flashes, not through a standalone sleep-promoting mechanism. The quality of many studies is also heterogeneous. Herbal remedies may be worth a try, but their effect is limited and should be put into realistic perspective.
What role do cortisol and stress play in sleep disturbances during menopause?
The stress axis (hypothalamic-pituitary-adrenal axis, HPA for short) is linked to vasomotor symptoms. Sauer 2020 in Menopause examined 101 perimenopausal women over 12 weeks and found that women with more pronounced and more distressing hot flashes showed a blunted cortisol awakening response, even after adjusting for estrogen and progesterone metabolites and sleep quality. This suggests that the stress axis is altered in distressing vasomotor symptoms. From a cPNI perspective this means: sleep, hormones and the stress axis form an interconnected system. Stress regulation, morning daylight, exercise and sleep hygiene are not a side issue, but act directly on the axes that govern sleep.
More from the cluster "Treating Sleep Disturbances Holistically"
- Pillar: Treating Sleep Disturbances Holistically
- Spoke 4: Histamine and Sleep, Vagus and the Stress Axis
- Spoke 12: Thyroid, Iron and Sleep
- Spoke 7: Menopause and Sleep Disturbances (you are here)
Connections to other topics
The pillar article puts all causes of sleep disturbances into perspective, from hormones through stress to metabolism, and connects the individual spokes into an overall strategy.
The stress and vagus axis can act directly on sleep. In menopause, the HPA axis is linked to hot flashes. How stress regulation stabilizes sleep.
Iron deficiency, vitamin D deficiency and thyroid changes become more common in midlife and can disguise themselves as "menopausal sleep disturbance." What should be evaluated.
Cognitive behavioral therapy for insomnia is the most effective non-pharmacological option and is also documented in menopause (McCurry 2016). How the pillar explains the building blocks.
Sources and further reading
- Kravitz HM, Zhao X, Bromberger JT, et al. Sleep disturbance during the menopausal transition in a multi-ethnic community sample of women. Sleep. 2008;31(7):979-90. doi:10.1093/sleep/31.7.979 · PMID: 18652093 [Cohort]
- Ciano C, King TS, Wright RR, Perlis M, Sawyer AM. Longitudinal Study of Insomnia Symptoms Among Women During Perimenopause. J Obstet Gynecol Neonatal Nurs. 2017;46(6):804-813. doi:10.1016/j.jogn.2017.07.011 · PMID: 28886339 [Cohort]
- Kravitz HM, Joffe H. Sleep during the perimenopause: a SWAN story. Obstet Gynecol Clin North Am. 2011;38(3):567-86. doi:10.1016/j.ogc.2011.06.002 · PMID: 21961720 [Review]
- Schüssler P, Kluge M, Yassouridis A, et al. Progesterone reduces wakefulness in sleep EEG and has no effect on cognition in healthy postmenopausal women. Psychoneuroendocrinology. 2008;33(8):1124-31. doi:10.1016/j.psyneuen.2008.05.013 · PMID: 18676087 [RCT]
- Leeangkoonsathian E, Pantasri T, Chaovisitseree S, Morakot N. The effect of different progestogens on sleep in postmenopausal women: a randomized trial. Gynecol Endocrinol. 2017;33(12):933-936. doi:10.1080/09513590.2017.1333094 · PMID: 28609128 [RCT]
- Santoro N, Allshouse A, Neal-Perry G, et al. Longitudinal changes in menopausal symptoms comparing women randomized to low-dose oral conjugated estrogens or transdermal estradiol plus micronized progesterone versus placebo: the Kronos Early Estrogen Prevention Study. Menopause. 2017;24(3):238-246. doi:10.1097/GME.0000000000000756 · PMID: 27779568 [RCT]
- McCurry SM, Guthrie KA, Morin CM, et al. Telephone-Based Cognitive Behavioral Therapy for Insomnia in Perimenopausal and Postmenopausal Women With Vasomotor Symptoms: A MsFLASH Randomized Clinical Trial. JAMA Intern Med. 2016;176(7):913-20. doi:10.1001/jamainternmed.2016.1795 · PMID: 27213646 [RCT]
- Reed SD, LaCroix AZ, Anderson GL, et al. Lights on MsFLASH: a review of contributions. Menopause. 2020;27(4):473-484. doi:10.1097/GME.0000000000001461 · PMID: 31977667 [Review]
- Franco OH, Chowdhury R, Troup J, et al. Use of Plant-Based Therapies and Menopausal Symptoms: A Systematic Review and Meta-analysis. JAMA. 2016;315(23):2554-63. doi:10.1001/jama.2016.8012 · PMID: 27327802 [Meta-analysis]
- Chen MN, Lin CC, Liu CF. Efficacy of phytoestrogens for menopausal symptoms: a meta-analysis and systematic review. Climacteric. 2014;18(2):260-9. doi:10.3109/13697137.2014.966241 · PMID: 25263312 [Meta-analysis]
- Sauer T, Tottenham LS, Ethier A, Gordon JL. Perimenopausal vasomotor symptoms and the cortisol awakening response. Menopause. 2020;27(11):1322-1327. doi:10.1097/GME.0000000000001588 · PMID: 33110049 [Real-World]
- Gambacciani M, Biglia N, Cagnacci A, et al. Menopause and hormone replacement therapy: the 2017 Recommendations of the Italian Menopause Society. Minerva Ginecol. 2017;70(1):27-34. doi:10.23736/S0026-4784.17.04151-X · PMID: 28975776 [Guidance document]