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Sleep problems

During menopause, an increased number of sleep disturbance problems are reported by women. Reported sleep disturbance problems include anything from difficulty falling asleep at night, to the inability to stay asleep during the night, fragmented sleep, sleep apnea, waking early without cause.  In some cases excessive daytime fatigue leads to circadian rhythm changes and increased daytime napping. Sleep pattern changes cause persistent feelings of daytime low energy. In extreme cases, a sleep disorder such as obstructive sleep apnea or chronic insomnia may be present. It is common for mood and stamina problems to ripple out at work and home.

By the post-menopausal period, up to 60% of women are reporting sleep disturbance or disorders.

When our sleep is disturbed, our quality of life suffers across the board and to make matters worse it also exacerbates other menopausal symptoms. Unfortunately sleep disturbance is a symptom that is unlikely to go away on its own and can start manifesting as late as post menopause. There is a wide range of effective treatment types available ranging from prescription based medicine to Cognitive Behavioral Therapy and even over the counter products.

The Lowdown on Sleeping Problems

Why it happens and the science behind it, how it may impact your life, how you and your doctor can diagnose it and common triggers or risk factors.

During the peri-menopausal phase, women may find themselves in a perfect storm for sleep problems. While natural aging causes a decrease in melatonin and serotonin, cortisol levels may be increasing at the same time (also tied to aging, as well as daily stress). During menopause, decreases and fluctuations in estrogen and progesterone also contribute to the likelihood of experiencing a sleep disorder. 

The interrelationship between these hormones and peri-menopausal sleep disturbance is not entirely clear. Although we know that melatonin affects the circadian rhythm by blocking arousal mechanisms, it is unclear whether melatonin is directly affected by menopause. However, it is known that estrogen and progesterone levels are declining during menopause, affecting their wide-ranging effects on the nervous system and its ability to regulate sleep. The metabolism of serotonin and other neurotransmitters is also affected by estrogen levels. 

Although each of these hormonal changes during menopause directly causes sleep problems, the bigger problem is that in combination and indirectly they cause the chain-reactions that result in negative sleep pattern effects.

Sleep disturbance can be experienced in a variety of different ways:

  • Difficulty falling asleep at night
  • An inability to stay asleep during the night
  • Fragmented sleep
  • Sleep apnea
  • Waking early without cause
  • Excessive daytime fatigue leading to circadian rhythm changes and increased daytime napping
  • Insomnia
  • Obstructive nighttime breathing or snoring
  • Restlessness during sleep
  • Periodic limb movement disorder

Unfortunately, once a pattern of sleep disturbance is underway, it is self-reinforcing. Poor sleep tends to lead to additional symptoms which contribute to further reduced sleep quality. The vicious circle continues until effective treatment is sought, therefore it is important to seek help immediately.

Poor sleep hygiene affects so many areas of daily life. It can contribute to general fatigue, daytime sleepiness, feelings of exhaustion and, specifically related to menopause, can also exacerbate low libido, weight gain, anxiety, and depression. Poor quality sleep is known to be associated with the following additional menopausal symptoms:

  • Low libido
  • Weight gain
  • Anxiety
  • Depression

The amplifying feedback loop of poor quality sleep means that additional sleep deprivation and extrapolating symptoms are a likely result. It is important to seek treatment for sleep disturbances, regardless of their origin, due to their wide-ranging and negative health effects.

Testing for menopausal sleep disturbance or disorder is conducted by medical professionals on a self-reporting analysis scale.

Using a smartphone-based sleep tracking application to record sleep patterns and quality can help provide insight regarding self-reported symptoms. Examples of these are Sleep CycleHeadspace and Calm.

Menopausal hot flashes experienced during times in bed are referred to as night sweats and these occurrences result in poor quality sleep for many women. Night sweats create an unexpected waking at night which can be sudden and uncomfortable. It can be hard to return to sleep after the episode passes. There is evidence that a menopausal woman will wake shortly before the onset of a night sweat episode. Read more about night sweats here.

Physical health

THIS IS EXHAUSTING

Poor sleep hygiene and stress affects so many areas of daily life and can rapidly deteriate your physical and mental wellbing. It can contribute to general fatigue, daytime sleepiness, feelings of exhaustion and, specifically related to menopause, can also exacerbate low libido, weight gain, anxiety, and depression. Now of course these and other symptoms like an itchy skin or night sweats will in turn make it difficult for you to get a good nights sleep.

The amplifying feedback loop of poor quality sleep means that additional sleep deprivation and extrapolating symptoms are a likely result. Exhausting right?

So if you are experiencing sleep disturbances over a pro-longed period of time, it is important to seek the help of a medical professional and get treatment.

Prevention and Treatment

Learn more about your options for prevention, management and treatment of Sleep Issues. This is not an exhaustive list of the treatment options available, but a good start.

There is a range of effective treatments available to help manage different types of sleep problems. Many women report that lifestyle changes can improve sleep in a meaningful way, while for others (temporary) prescription based medications are needed.

  • It is essential to maintain adequate hydration and to limit the intake of alcohol, mood altering drugs, and nicotine during menopause.
  • General vitamin and mineral supplements, as well as probiotics and Omega-3 fatty acids have health benefits.
  • For optimal sleep hygiene, alcohol and caffeine should not be ingested for many hours prior to going to bed.
  • Tea made with chamomile has been found to have a mild sedative effect that promotes the ability to fall asleep quickly.

Exercise is critical to overall health, menopausal symptom reduction, and circadian rhythm maintenance. Mild to vigorous weekly exercise is associated with improved sleep. A recent study showed that participating in at least 30 minutes of moderate aerobic exercise results in a self-reported improvement in sleep quality the following night.

Consider employing some or all of the following sleep promotion strategies as a first line of defense against poor sleep:

  • Have a predictable bed-time
  • Stop using electronic devices well before you go to bed (yes that means at least 60min before your bedtime)
  • Have a light snack or a cup of bedtime tea to relax and ensure hunger won’t wake you later
  • Enjoy a warm bath to encourage positive body temperature changes as your head to bed
  • Practice stretching, breathing, or relaxation techniques to promote mindfulness and rest
  • Meditate before bedtime
  • Read a book before going to sleep
  • Jot down your thoughts to handle in the morning
  • Make your sleeping environment as comfortable as possible (lower the room temperature, have a comfortable mattress, turn the lights and electronics off, maintain a quiet space)
  • Purchase sleepwear and bedding made of natural fibers

‍Maintaining your mental wellness during times of sleep deprivation can be difficult. The following practical remedies may help:

  • Cognitive Behavior Therapy (CBT)
  • Intentional reduction of stress points in daily life
  • Daily journaling
  • Adequate work/life balance that allows for rest and healthy family life

There are no supplements available to treat sleep disturbances occurring due to menopause, that have strong clinical research proving their efficacy. However, there are many anecdotal and regional references to the following natural products and supplements considered to have sleep inducing properties:

  • Melatonin is an effective over-the-counter treatment for some sleep disorders. Menopause can cause a substantial reduction in natural secretion levels, as well as calcification of the secreting glands. Melatonin supplementation should be used under the advice of a medical professional.
  • Weighted blankets have recently become more popular and claim to help with anxiety and insomnia. These blankets claim to produce something that is called Deep Pressure Touch Stimulation (DPTS) which should make your body and mind feel like it is in a safe space to fall asleep. There is minimal clinical research supporting its efficacy at this point, but many people claim that it helps. In general it can’t hurt to use it, but if you have obstructive sleep apnea, asthma or claustrophobia please consult with your doctor before using it. There are many different types available, but in tropical climates you will want one made of cooling materials such as bamboo fibers, or have a look at the blankets from local Singapore company &Snooze.

Low dose prescriptions of SSRIs (including fluoxetine, paroxetine, venlafaxine) can be used to promote sleep improvements. These medications are classified as antidepressants and may carry side effects, including insomnia and are therefore not the first line remedy.

  • Hormonal Replacement Therapy (HRT) is a common treatment prescribed for peri- and post-menopausal women. HRT involves systemic additions of estrogen and, if a woman has not previously had a hysterectomy, progestin. In studies, women taking HRT were found less likely to suffer from OSA (obstructive sleep apnea) during post-menopause. HRT can have a positive (direct and indirect) effect on a woman’s quality of sleep by managing symptoms that are causing sleep deprivation.  It should be noted, however, that if insomnia is a woman’s primary menopausal symptom, HRT is not considered a suitable first choice for treatment
  • Bazedoxifene is prescribed for menopausal sleep disorders, as a selective estrogen receptor modulator (SERM). This oral medication is part of SERM therapy and is formulated directly with estrogen supplementation. There are risks to treatment, including blood clotting, stroke, heart attack, and cancer.

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Sources used

Medical journals

Jehan, S., Jean-Louis, G., Zizi, F., Auguste, E., Pandi-Perumal, S. R., Gupta, R., Attarian, H., McFarlane, S. I., Hardeland, R., & Brzezinski, A. (2017). Sleep, Melatonin, and the Menopausal Transition: What Are the Links? Sleep Science, 10(1), 11–18.

Vahratian A. Sleep Duration and Quality Among Women Aged 40-59, by Menopausal Status. NCHS Data Brief. 2017 Sep;(286):1-8. PMID: 28922102.

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‍‍Li M, Hung A, Lenon GB, Yang AWH (2019) Chinese herbal formulae for the treatment of menopausal hot flushes: A systematic review and meta-analysis. PLoS ONE 14(9): e0222383. https://doi.org/10.1371/journal.pone.0222383

Other online sources

Harvard Health Publishing. (2011, February). Overcoming insomnia. Harvard Health.

Insomnia treatment: Cognitive behavioral therapy instead of sleeping pills. (2016, September 28). Mayo Clinic

Exercising for Better Sleep. (n.d.). Johns Hopkins Medicine.

https://www.drugs.com/mtm/bazedoxifene-and-conjugated-estrogens.html

https://mpoweredwomen.net/wellbeing/chinese-medicine-and-the-menopause/

https://www.sleepfoundation.org/women-sleep/menopause-and-sleep

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