Menopause and Insomnia

How is sleep affected by perimenopause, menopause, and post-menopause?

Many female patients who come to my office in their late 30s and 40s with symptoms of insomnia are actually experiencing the beginning of their transition to menopause which is called perimenopause. Sleep can be impacted by many things, such as hormonal and lifestyle changes.

1. Hormonal changes. During the course of perimenopause through menopause, a woman's ovaries gradually decrease production of estrogen and progesterone, a sleep-promoting hormone. The shifting of ratios of hormones can be an unsettling process, sometimes contributing to the inability to fall asleep. Also, waning levels of estrogen may make you more susceptible to environmental and other factors/stressors which disrupt sleep.

2. Hot flashes. A hot flash is a surge of adrenaline, awakening your brain from sleep. It often produces sweat and a change of temperature that can often be disruptive to sleep and comfort levels. Unfortunately it may take time for your adrenaline to recede and let you settle down into sleep again.

3. Depression/Mood Swings. About 20% of women will experience depression during this time frame and some cases have been linked to estrogen loss. However, hormonal changes may not be the only cause. Precipitants such as life stress and a history of menopause are important causes as well.

4. Coincidental Social Issues. Aside from the hormonal changes you may be experiencing, this time in life can present many social changes. Whether your children and moving out of the house, retiring, moving to a smaller home or you are just feeling some of the "midlife crisis" stress of getting to a new phase in life, these issues can interfere with your ability to sleep.

Since hormonal and social issues are at play, it is important for you to be in touch with how your sleep is impacted by this transitional period. The perimenopaual period may last from 3-10 years. Some women ‘learn’ to have insomnia and adjust their life around it – and as their hormones settle down, they have built a lifestyle of insomnia.

What should you do if menopause is preventing you from getting a good night's sleep? How do you know if you need to talk to your doctor?

If you are finding symptoms of perimenopause keeping you up or waking you up every night or on going, see you gynecologist or general practitioner. There are some things you can control (like your sleep habits) and things you can't control (like your hormones, without medication). Using good sleep hygiene, do everything in your power to stack the odds for good sleep and hopefully you can make up for the hot flashes and other natural sleep obstacles.

I stress that women need to be consistent with wake up times and give themselves time to fall asleep at night. Build a very tight sleep structure and sleep environment by paying attention to your sleep environment.

• Make your room dark quiet and safe.
• Keep your room as cool as you can.
• Skip alcohol and tobacco.
• Keep a cloth in a bucket of ice near your bed so you can cool yourself quickly

What treatments are available for women whose sleep is affected by menopausal symptoms?

Hormone replacement therapy (HRT) works by supplementing estrogen hormone that is no longer being made by your body in the same way as it was before perimenopause. Estrogen reduces hot flashes, vaginal symptoms, and difficulty with urination. HRT is recommended for shortest possible term in the lowest possible dose. HRT has been found to help women. I know many women who have gone back on their HRT simply because they need to sleep. Again, sleep is so vital. One has to weigh the consideration of good sleep when we are discussing whether or not to discontinue HRT.

Another of the things that helps some women is a low-dose birth control pill, which acts to stabilize mild fluctuations of estrogen that may be occurring.

What kinds of treatments are available for a woman who does not want to use hormone replacement therapy (HRT)?

There are some herbal products that have been tried but I don't recommend them. The data shows that they are not effective. I try to avoid those. Relaxation therapy, paced breathing and exercise may help -- burn energy while relaxing. Again, if you can get all your sleep ducks in a row, you can combat the hormonal issues. You can try acupuncture or Shiatsu (Shiatsu uses pressure areas like acupuncture but without needles – it is based on the Eastern study of body energies and how they flow). I have had good results with Shiatsu and yoga. Relaxation and exercise helps you focus on yourself and helps you settle down. Some success has been seen with antidepressants such as the SSRIs or anti-epilepsy drugs.

--Joyce Walsleben, RN, PhD is the past director of the New York University School of Medicine's Sleep Disorders Center and Research Associate Professor in the School of Medicine. She currently serves as Head of Behavioral Sleep Medicine at the NYU Center and Sleep Medicine Associates of NYC. She has authored six book chapters and served as co-editor of the "Time Life Medical series on Insomnia," a self teaching video series. She is co-author of A Woman's Guide to Sleep published by Crown books in October 2000. In addition, she is the co-investigator of two multi-center NIH grants to examine aspects of sleep apnea.

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