Are you sleeping easy or counting sheep?
We all need sleep. The optimum amount for a healthy adult is deemed to be around seven hours. Insufficient sleep has been shown to have later detrimental effects on things like our mental health, heart health, cognitive functions and even risk of osteoporosis. Further, too much sleep, (more than 8 hours), can be associated with increased risk of cardiovascular disease though cause and effect are unclear; prolonged sleep may be a marker for underlying disease.
The best kind of sleep is non-REM (rapid eye movement), which consists of three separate stages (1, 2 and 3), which follow in order, upwards and downwards as your sleep cycle progresses. Stage 3 is said to be the best kind. This is a deep sleep where we are essentially cut off from the outside world and unaware of any sounds or other stimuli. This usually occurs during the first half of the night and is where our brain activity, breathing, heart rate and blood pressure are all at their lowest levels. It’s the time when we are most likely to dream too.
Your sleep can influence and be influenced by your health and other health conditions as you move through menopause.
Types of disturbance
Types of sleep disturbance include:
- Difficulty getting to sleep
- Difficulty staying asleep (awakening during the night)
- Early morning wakening
- Less total sleep time
- Overall quality of sleep (non-restorative)
- Problems with sense of well-being
- Overall functioning
- Sleepiness/fatigue during the day.
Sleep disturbances are common during the perimenopause, menopause and postmenopause. Figures given for how many women experience sleep disturbance during the menopause range from 28 to 63%. Differences in the ways that studies have measured sleep disturbance may account for the wide range; self-reporting tends to show underestimation of total sleep time and number of arousals, with overestimation of time taken to get to sleep, compared to laboratory sleep studies. Overall, studies consistently show increased likelihood of sleep problems during the menopausal transition, with close association with the presence of flushes and sweats.
The menopausal decline of estrogen contributes to disrupted sleep by causing menopausal symptoms from hot flushes and sweats (vasomotor symptoms) to anxiety and depressed mood; anxiety leading to difficulty getting to sleep, and depression leading to non-restorative sleep and early morning wakening. However, it has been proposed that menopausal sleep disturbance may be the underlying cause of anxiety and depression. Joint aches and pains, and bladder problems such as passing urine at night, are also common consequences of estrogen decline and can cause sleep disruption. Menopausal progesterone decline may also be involved in sleep disturbance since progesterone has a sleep inducing effect by acting on brain pathways. Melatonin, another vital hormone for sleep, decreases with age. Secretion of melatonin is partly influenced by estrogen and progesterone and levels decrease during the perimenopause, often compounding the problem.
Sleep apnoea has been considered, in the past, as a sleeping disorder of men but that view is changing. Studies have shown that night sweats and hot flushes may be linked to increased risk of sleep apnoea, and it appears to be more common in women who have had a surgical menopause compared to natural menopause. It may also be associated with weight gain and there is a possible role of progesterone. Progesterone has an effect on muscle activity at the back of the throat as well as stimulus for breathing, such that decline in progesterone may contribute to partial upper airway obstruction and reduced breathing drive. Sleep apnoea is not just about loud snoring and gasping. Sleep apnoea in women can also manifest itself in other ways including headaches, insomnia, depression or anxiety and daytime fatigue. Not every woman will snore or snort loudly whilst asleep.
Restless legs syndrome
Restless legs syndrome (RLS) is another symptom and women are about twice as likely as men to experience it. Sufferers get tingling, creepy crawly sensations in their legs at night. One study of RLS patients found 69 per cent of post-menopausal women perceived their symptoms as worse than before menopause. However, it is not clear whether restless leg syndrome contributes to sleep disturbance, or if women who are not sleeping well are more aware of the problem.
Treatments for poor sleep
There are some fundamental tenets that contribute towards healthy living in general that can help you sleep well:
- Healthy eating
- Managing stress
- Maintaining health relationships and being socially active
- Intellectual stimulation.
However there are also times when you cannot control things and you need a little help. At all ages, hypnotics have been used for sleep disturbance, but there are specific treatments to consider for menopausal sleep disturbance.
Can HRT help?
Research says yes. Many studies have consistently shown a benefit of HRT on sleep in women who have vasomotor symptoms, when the vasomotor symptoms are causing the sleep disturbance. The main part of HRT is estrogen, to treat symptoms caused by estrogen deficiency. However, for sleep disturbance, the addition of progesterone may have an added benefit and has been shown to be associated with increased non REM 3 sleep. Progesterone or progestogen is recommended to be taken along with estrogen to prevent estrogenic stimulation of the womb lining, though is not
needed if you have had a hysterectomy. When sleep disturbance is a prominent menopausal symptom, consideration can be given to use progesterone as the womb lining protection, rather than progestogen, which does not have the beneficial effect on sleep.
Other medications that are used for treating vasomotor symptoms and so may help, include low-dose anti-depressants, Gabapentin and Clonidine. HRT is recommended to be used first line for menopausal symptoms but these other prescribed medications can be considered in women who are unable to take HRT.
Studies have shown that Cognitive Behavioural Therapy reduces menopausal symptoms including low mood, anxiety and sleep disturbance. See WHC fact sheet Cognitive Behaviour Therapy (CBT) for Menopausal Symptoms
Isoflavones, yoga, acupuncture and massage may provide some benefit.
If sleep apnoea is thought to be the underlying problem, then general tips on improving sleep and consideration of Continuous Positive Airway Pressure (CPAP) can be helpful. CPAP involves wearing a face or nasal mask during sleep, which, connected to a pump, provides a positive flow of air into the nasal passages to keep the airway open.
With recognition of the role of melatonin in sleep disturbance, interest has been shown in the use of Melatonin, with studies confirming benefit. However, there is some uncertainty around the appropriate dose and possible interactions with other medications. Further research is needed.
It’s important to remember, menopause isn’t a disease or a disorder, it’s a natural stage of life for women. It is also a time in women’s lives when our health risks change. Understanding these can help you to make the right decision to ensure your health and wellbeing through menopause and as you age. Every woman’s particular risk factors will be different, but every woman can benefit from a focus on getting a good night’s sleep, counting our blessings rather than sheep!
Tips for improving sleep long term
- Go to bed and get up at a regular time. Routine is very important for establishing a good sleep pattern. Establishing and sticking to set times may take a few weeks so bear that in mind
- Ideally avoid having a nap in the day. If you do, make it no more than 30-40 minutes in the early afternoon
- Exercise regularly but don’t overdo it within two hours of going to bed
- Get to know what sleep you need. The average is 6-8 hours but this does vary for individuals and reduces as you age
- Other factors can of course interfere with sleep including physical symptoms, other than those associated with the menopause. If you are taking medication for other reasons ensure you take them at the time of day they are prescribed for.
Before going to bed:
- Get yourself into a routine, perhaps have a warm bath or do some light reading
- Avoid going to bed when you’re too hungry or too full. A light snack is OK
- Have your last caffeine drink in the late afternoon/evening, including any fizzy drinks or chocolate
- Alcohol does not help you to sleep so best avoided if you can.
- Ensure your bedroom has a restful feel. Ideally the room should be cool but not cold and screen out as much noise and light as is practical for you
- Get comfy! Good bedding and a good mattress are essentials
- Use your bedroom just for sleep and sex!
- Avoid watching TV in bed or using your laptop and/or phone.
If you wake up in the night:
- If you just can’t get back to sleep after 20 minutes get up and go into another room. Try doing something quiet and once you begin to feel sleepy go back to bed
- Don’t clock watch or sit in front of the TV
- It may be hard but if you have worries or problems try hard not to focus on them during this quiet time.
Menopause: Giving you confidence for understanding and action
Topics in the series include:
Publication: September 2018
Review due: September 2020
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