Question

52 years old female who has difficulty sleeping and missing her work, she sleeps during day time and not night time.

I think she has insomnia and possible menopause because of her age.

• Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit of patient with insomnia, menopause.

Answer 1

Insomnia: A sleeping disorder that is known for its symptoms of unrest and the inbility to sleep . It is characterised by the difficulty in initiation and maintanance of sleep.  

Menopause: The ending of Menstruation due to natural decline in reproductive  hormones ,by the time when a woman reaches her 40sor 50s.

Treatment plan

Pharmacotherapy:

* Insomnia :

- Insomnia associated with Menopause can be treated by Hormone replacement therapy.  

- Sedative Hypnotics :

Benzodiazepines: triazolam, emazepam (sleeping pills that should be used as per physician's order )

- Suvorexant

- Zaleplon

- Antidepressants :

Trazodone ( Desydrel) can be used to treat anxiety and sleeplessness

* Menopause:

Hormone replacement therapy: Effective treatment for menopausal symptoms , such as hot flush, night sweat, aches and pains , insomnia, mood disturbances, cognitive changes, reduced sex drive etc) in the initial years of Menopause , but not suitable for long term use. HRT involves the use of combined treatment with oestrogen and progesterone.

Complementary and Over The Counter therapy:

Complementary therapies such as:

* Relaxation techniques such as deep breathing exercises, meditation etc can improve the wellbeing of the woman with menopausal problems and insomnia.

* Soy products such as Soy beans and tofu may improve insomnia and other symptoms associated with Insomnia. It contains phytoestrogen, can effective in menopausal symptoms.

* Use of a Perennial plant Black Cohosh may be effective in managing the night sweats and hit flashes.

* Dietary supplements should take only as per Doctor's order  

* Cognitive behavioural therapy for insomnia

OTC: Menopause supplements , progesterone cream , Antihistamines for sleep improvement.

Water based vaginal creams to prevent dryness.

Diagnostic tests:

* DSM ( Diagnostic and Statistical manual of Mental disorders) IV criteria for insomnia.

* Blood test for FSH ( follicle stimulating hormone) and oestrogen . FSH shows an increase and estrogen shows a decrease in menopausal women.  

* Blood test for Thyroid problems: underactive thyroid may mimic menopausal symptoms.  

Health education :  life style changes, preventive care and follow up:

* Instruct the woman the tips for improving the sleep:

- Avoid caffeine and alcohol

- Regular exercise is a good strategy, but avoid it before the bed time.

- Ensure a calm and quite environment.

- Manage hot falshes.

* Manage hot flashes, prevent the occurance by

- Avoid the triggers such as hot beverages, spicy food, caffeine, stress, hot weather, warm room etc.

- Dress in layers and be in a cooler place

- Have a cold glass of water.

* Educate the woman regarding the different relaxation techniques such as guided imagery, progressive muscle relaxation, deep breathing exercises etc.

* Life style changes: Healthy lifestyle and behavioural changes such as heart health diet or balanced diet, regular exercise, adequate rest and sleep , avoid smoking and alcoholism etc can help to reduce the symptoms of Menopause.

* Educate the woman on Kegel exercises to strengthen the pelvic floor muscles.  

* Instruct the ways to prevent vaginal discomfort and the care ful use of OTC vaginal creams . Choose that products that don't contain glycerine or it may cause irritation.  

* Follow up : Instruct the woman to come for regular follow up and not to continue any Hormonal supplements for a long time without Doctor's prescription. Educate the importance of medication adherence.