Sleep problems and the menopause

Introduction to menopause and sleep

Poor sleep has long-term effects including heart disease diabetes, dementia and obesity, reduced immunity and even cancer. The neuropsychological effects of acute sleep deprivation have been consistently shown to be deleterious. 

These effects include the following:

• A decreased reaction time,
• An increase of repetitive and negative thoughts,
• Impaired sense of humour,
• Increased risk taking,
• Impaired moral judgement,
• Increased negativity with with enhanced memory for adverse events, and
• Increased distractibility

The menopause brings particular challenges for women, including vasomotor symptoms, mood changes and Genitourinary Syndrome of Menopause (GSM). Sleep apnoea, which although more common in men has been found to worsen after the menopause, even when controls are allowed for weight and smoking. 

Hot flushes

There is a strong association between the vasomotor symptoms (hot flushes and night sweats) and poor sleep. Around 75% of women experience hot flushes and night sweats. The vasomotor symptoms are caused by changing hormone levels, including oestrogen and progesterone, affecting the body’s temperature control. It may be at its worst in the perimenopause, but for some women these symptoms may last for up to ten years.

Genitourinary Syndrome of Menopause

Up to 30% of women suffer from urinary symptoms in the menopause. Obviously, that can disturb sleep. Declining oestrogen is associated with overactive bladder - without enough oestrogen, there may be atrophic changes in the lower urinary tract leading to this urge to urinate frequently at night.

Chronic pain / aching muscles and joints

Musculoskeletal symptoms also disturb sleep and an increase in these is associated with menopause. A loss of muscle mass can occur at a higher rate than before and existing problems may be exacerbated. Women with conditions that cause chronic pain - such as fibromyalgia – are at heightened risk of sleep problems. Also certain medications can affect sleep. These include asthma medications, antiepileptic medication and other hormones such as thyroxine.

Restless legs

Willis-Ekbom disease, more commonly known as restless legs, is a condition of the nervous system that affects women more than men. The mechanisms that cause restless legs are not fully understood, but it often affects women during pregnancy and menopause. One study showed 69 per cent of older women said their symptoms worsened since their menopause. Sufferers experience an irrepressible desire to move their legs during the night which inevitably disturbs sleep.

Mood changes

Depression and anxiety may exacerbate insomnia. As women are 2 to 4 times as likely to develop depression around some of the menopause compared to younger women, this can add to sleep problems in this cohort of women. If there is a history of postnatal depression and PMS, there will be a greater risk of developing mood changes around the time of the menopause. Mood changes common in menopause include depression, anxiety, irritability, difficulty in concentrating and forgetfulness. All of these symptoms can lead to poor sleep, but are also worsened by poor sleep. Unfortunately, SRI antidepressants can also lead to insomnia.

So what can be done about sleep problems?

Sleep hygiene

This is the advice that we give to women and men who have difficulty to sleep. This includes avoiding daytime naps, and if you do sleep in the day keep it to a 30 minute minimum.

Other ways to practice good sleep hygiene include avoiding the following:

• caffeine,
• nicotine,
• alcohol and
• rich, spicy foods, particularly at night-time
• electronic devices which radiate a blue light

Ensure you have adequate exposure to natural sunlight during the day, which will increase your body’s ability to produce melatonin at night. Exercise in important, but schedule it for the morning and afternoon rather than evening as this can lead to wakefulness.

Keeping a bedtime routine can also be helpful, such as having a warm bath before bed, signalling to your body that now is the time to sleep. This includes rising at the same time every day and keeping the same bedtime even at weekends. Avoid using electronic devices which radiate a blue light that can prevent you from getting to sleep. Try to ensure that the bedroom is a quiet and pleasant environment which is cool at the body's core temperature. 

Behaviour therapies

Cognitive Behaviour Therapy Insomnia or (CBT-I) can be helpful. This a structured program that identifies negative behaviours and beliefs around sleep and aims to replace them with positive ones. The idea is to tackle the underlying causes of insomnia. It contains techniques that may seem, counterintuitive, such as sleep restriction. Many insomniacs spend hours lying in bed awake, so CBT-I encourages you to get you into a better routine.

Medication

Sleeping pills may be helpful in the short-term. However, there are numerous side-effects with long-term use, including dizziness, memory problems and even increased risk of dementia. Melatonin, which is known as the ‘sleep hormone’ because secretion increases at night has been cited as a treatment for insomnia in menopausal women. While it’s true that the body produces less melatonin with age, the evidence that melatonin actually helps with sleep is very poor. Where is proved to be helpful is in jetlag where the circadian rhythm is out of sync and taking melatonin at night-time helps to mimic the natural circadian rhythm and have a sleep, but it's not beneficial in long-term sleep in men or women.

HRT

Women taking HRT report improved sleep quality, including reduced difficulty getting off to sleep, with less nighttime wakening and chronic pain, improved mood, genitourinary symptoms and, perhaps most of all, an alleviation of vasomotor symptoms.

HRT is extremely effective at relieving hot flushes and night sweats. Getting the right balance of progesterone and oestrogen can improve sleep quality. We suspect that women reporting better sleep on HRT is partially due to improvements in vasomotor symptoms, however we can’t rule out that the HRT is  directly improving sleep. HRT can be safely administered using a transdermal route, which avoids passing through effect through liver with no increased risk of thrombosis.