Sleep disturbances are among the most important and common health complaints that occur with the transition through menopause. Hot flashes, feeling down, sluggish, surprisingly surly and the myriad other changes result from the intricate interrelationships of menopause, aging, biology, lifestyle, environment and culture. They all significantly impact and are impacted by sleep. Sleep is a keystone among them, playing a critical role in our health and well-being.

All that is menopause is not hormonal, and all that is hormonal is not menopause.

Given the tremendous variation in the age of onset, symptoms and duration of menopause, multiple factors inevitably play a role in sleep problems. Chronic conditions and age-related factors, independent of menopause, add to the mix, including weight gain, reduced physical activity, physiological changes in our reactions to stress and the increased risk of many conditions and diseases. So all that is menopause is not hormonal, and all that is hormonal is not menopause. Individual, holistic assessments are really important, as a narrow focus on “menopause” may well miss the mark.

The Epidemic of Sleeplessness

Symptoms of insomnia, particularly difficulty falling asleep and fatigue are the most common complaints, with nighttime awakenings and daytime drowsiness also reported in significant numbers.

 

Though up to about 40% of premenopausal women report sleep problems, that percentage and risk may double from the onset of perimenopause through postmenopause. With around 40 million American women of menopausal age and over a million more joining their ranks annually, sleep problems are epidemic. Interestingly, even with such large numbers, there is a paucity of studies providing objective data before, during and after menopause. Given the wide variation of menopausal symptoms, onset and duration, as well as differences in cultural attitudes and expectations that may affect the perception of sleep quality, sleep disturbaces are difficult to objectively study. However, with growing numbers of women’s health initiatives, this may change.

 

Hot Flashes and Hormones: The Bane of Menopause

Though hot flashes and night sweats are most likely evident in late perimenopause and early postmenopause, there are wide and unpredictable variations, so much so that they are not even considered as criteria for determining the phase of menopause. Hot flashes may last from 3 minutes to 20; some women may have 1 or 2 a week, while others more than 20 each day. They frequently occur over years or decades after menopause, with many not even considering them to be hot flashes, because they are so closely associated with the menopause of years past. The effects of chronic hot flashes on sleep are unknown.

 

Menopausal women consistently report that hot flashes disturb sleep. They also report sleep-related problems without hot flashes. Interestingly, one study also showed that some postmenopausal women were unaware of hot flashes objectively documented during sleep. Though not extensive or robust, the existing evidence exists does indicate that hot flashes and night sweats can significantly disrupt sleep and cause nighttime awakenings.

 

How to Keep Cool: Treatment Options for Sleep Problems Associated with Hot Flashes

There are many options for treating sleep problems associated with hot flashes, including hormone replacement therapy (HRT), antidepressants, complementary and alternative therapies.

 

Hormone Replacement Therapy (HRT)

The historical standard for long-term treatment was HRT; however, given the increased risk of breast cancer, stroke, heart disease and vascular dementia revealed by the Women’s Health Initiative, long-term HRT (including estrogen therapy (ET)) has been all but discontinued. It is only considered in menopause-related insomnia clearly associated with frequent and severe hot flashes. Not much is clear about its effects on sleep of midlife and older women without hot flashes.

Studies have shown an association of HRT with a lower prevalence of sleep apnea in postmenopausal women; however, one could not promote its use, given the great variation among individuals, that no clinical trials have proven its efficacy and the substantial health risks.

There is also some evidence to show that HRT reduces symptoms of anxiety and depression. However, it remains to be seen what, if any, sleep-related conditions could appropriately be treated with HRT.

Short-term use of HRT, however, continues in women without a history of breast cancer and stroke, as it is the most effective treatment, providing significant relief from hot flashes and improved self-reported quality of sleep.

Stress Reactivity and Estrogen

Sensitivity and reaction to the daily stressors of life increase with menopause and low estrogen levels. Hormonal and cardiovascular responses are enhanced. So the mind-racing and worrying that keeps many of us from falling asleep and staying asleep may get a booster. Short-term ET reduces this reactivity, providing some relief. Without ET, awareness of and adherence to good sleep hygiene principles (See below.) become even more important.

 

Eszopiclone (Lunesta)

A recent menopausal study showed that eszopiclone reduced the number of nocturnal awakenings due to hot flashes, as well as provided significant improvement in symptoms of insomnia, such as the time it took to fall asleep, the time spent awake after falling asleep and total sleep time.

 

Antidepressants

The SSRI (selective serotonin reuptake inhibitors) class of antidepressants has had some success and is an option to explore.

 

Complementary and Alternative Therapies

There may be some benefit to complementary and alternative therapies, but the data are mixed, and so no compelling options emerge. However, clinical trials are currently investigating the efficacy of acupuncture, yoga, phytoestrogens, and herbal treatments.

 

A recent study found the combination of phytoestrogens soy and black cohosh to be no better at curbing menopause symptoms than those given a placebo (a pill with no active ingredients). However, the authors did not dismiss the phytoestrogens outright, as the study raised further questions about issues like the timing of administration, the ingredients, whether one may have cancelled out the other, hopes of the patient

 

Important note about supplements: Non-prescription, over-the-counter supplements (e.g., herbs, vitamins, minerals, nutraceuticals) are not regulated by the FDA (Food and Drug Administration). This means that, among other things 1) There is no guarantee that the any or all of the stated quantity of a substance is actually present, and 2) If the substance is present in whatever amount, it may be in one of a variety of forms, each of which may differ in its ability to actually be absorbed and used by your body. Some may not be absorbed at all.

 

So it is very difficult to know if a supplement actually has the stated substance and has it in a form that can be effectively used by the body. Also Supplements from one company may actually differ from the same supplement from another company.

 

The above is a cautionary note and not a judgment or recommendation on the effectiveness or use of these options.

 

Sleep Hygiene

Akin to dental hygiene, sleep hygiene is those actions you can take to not only minimize the likelihood of hot flashes and sleep disturbances, but optimize your ability to get the critical sound sleep you deserve.

·         Keeping Cool Keeps You Cool

Warmer room temperatures and elevated core body temperature increase the chances of having hot flashes. So keep your room comfortably cool (generally around 68 or so); wear cool, comfortable clothing; try not to get overheated.

·         Tips for Sound Sleep

Man or woman, menopausal or not, the following simple sleep hygiene tips can really make a difference in the quality of your sleep and your life. I encourage you to give them a try.

1.       Avoid watching TV, eating, and discussing emotional issues in bed. The bed should be used for sleep and sex only. If not, we can associate the bed with other activities and it often becomes difficult to fall asleep.

2.       Minimize noise, light, and temperature extremes during sleep with ear plugs, window blinds, or an electric blanket or air conditioner. Even the slightest nighttime noises or luminescent lights can disrupt the quality of your sleep. Try to keep your bedroom at a comfortable temperature, not too hot (above 75 degrees) or too cold (below 54 degrees), as it can disrupt your sleep as well.

3.       Try not to drink fluids after 8 p.m. This may reduce awakenings due to urination.

4.       Avoid naps, but if you do, make it brief, no more than about 25 minutes about eight hours after you awake. But if you have problems falling asleep, then no naps for you.

5.       Do not expose your self to bright light, if you need to get up at night. Use a small night-light instead.

6.       Nicotine is a stimulant and should be avoided particularly near bedtime and upon night awakenings. Having a smoke before bed, may feel relaxing, but it is actually putting a stimulant into your bloodstream.

7.       Caffeine is also a stimulant and is present in coffee (100-200 mg), soda (50-75 mg), tea (50-75 mg),, and various over-the-counter medications. Caffeine should be discontinued at least four to six hours before bedtime. If you consume large amounts of caffeine and you cut yourself off too quickly, beware; you may get headaches that could keep you awake.

8.       Although alcohol is a depressant and may help you fall asleep, the subsequent metabolism that clears it from your body when you are sleeping causes a withdrawal syndrome. This withdrawal causes awakenings and is often associated with nightmares and sweats.

9.       A light snack may be sleep-inducing, but a heavy meal too close to bedtime interferes with sleep.

10.   Do not exercise vigorously just before bed, if you are the type of person who is aroused by exercise. If this is the case, it may be best to exercise in the morning or afternoon (preferably an aerobic workout, like running or walking).

11.   Does your pet sleep with you? This, too, may cause arousals from either allergies or their movements in the bed. Thus, Fido and Kitty may be better off on the floor than on your sheets.

 

The Interplay of Aging and Menopause

It is easy to “blame” menopause for sleep problems; however, it is important to recognize that a variety of ailments and conditions occurring throughout menopause are attributable primarily to normal aging and not menopause, per se. Normal aging carries its own health risks and associated conditions and diseases, independent of menopause. As mentioned above, it is the interrelationship of aging and menopause, as well as other factors like chronic physical and/or emotional conditions, lifestyle, and environment that add layers of complexity to understanding what is really going and developing a comprehensive care plan.

 

Sleep Disordered Breathing (SDB)

A couple of large studies demonstrated that menopause does seem to increase the risk of sleep-disordered breathing (SDB, e.g. apnea, snoring). Post menopausal women were shown to have over 2 ½ times the risk for SDB and 3 ½ times the risk for severe SDB. That said, weight gain, which is a primary risk factor for SDB, commonly occurs with menopause but is primarily attributable to normal aging and reduced physical exercise. Hypertension also increases significantly with menopause. Its causes are complex and not entirely understood; however, obesity and SDB are strongly associated with hypertension.

 

So putting this together, as women age and move through menopause, there is a tendency to gain weight, which increases the risk of both hypertension and SDB. If a woman is obese and hypertensive, she is at high risk for SDB and a host of other disorders including cardiovascular disease and type 2 diabetes. Similarly, if a woman is both obese and has SDB, she is at high risk for hypertension. Bottom line: watch out for weight gain, exercise, check your blood pressure regularly and be aware of breathing-related sleep problems.

 

Conditions & Diseases that Negatively Impact Sleep

As we age, there is generally a decline in our sleep quality. The prevalence of thyroid dysfunction, depression, cancer and many other conditions increase with age and impact our sleep. Symptoms of these conditions may occur concomitantly with and be attributed to menopause. So they may easily be overlooked. Following are some selected conditions. There are many others, including arthritis, widowhood, musculoskeletal pain, stress and coping strategies.

 

Cancer

The causes for sleep disruption in cancer are many – from pain and discomfort to physical effects of the cancer itself, depression and anxiety. Side effects of treatment affect sleep as well: long-term breast cancer treatments in particular, may cause hot flashes over a period of years.

 

Thyroid Disease

Thyroid disease, particularly hypothyroidism, increases with age and is much more prevalent in women. Tiredness and fatigue are common, non-specific complaints of hypothyroidism that may be easily overlooked as such in menopausal women. Hypothyroidism may also be a risk factor for SDB. So it is important to be aware of the symptoms, get checked out, and if thyroid disease is present, get treated and also evaluated for SDB.

 

Depression

Depressive symptoms, including mood alterations and nighttime awakenings, increase during menopause and tend to recede postmenopausally; however, it is unclear whether they are menopausal symptoms, per se.

 

As in other conditions, depression negatively impacts sleep, and sleep disruption impacts depression. So, each must be addressed in its own right.

 

Hysterectomy

There are over 600,000 hysterectomies performed annually. Short- and long-term sleep disruptions are common. Hot flashes are more likely to occur, be severe and continue longer in women undergoing surgical menopause compared to natural menopause. Depression and anxiety, with their accompanying sleep problems, may also follow hysterectomy. Be aware of the role of sleep in order to develop an appropriate and effective treatment plan.

 

Make Sleep Awareness an Integral Part of Your Health Plan

The transition through and beyond menopause is difficult. Navigating through innumerable, interacting biologic, aging, environmental, lifestyle, ethnic and cultural factors is complex. Though hormonal changes loom large, they are a part of this stage and so should be considered in that context; that is, menopause-related symptoms are not all hormonal in nature. A broader focus and perspective are needed. Given the high frequency and enormous impact of sleep-related conditions throughout menopause, sleep should be an integral part of that focus and perspective.

Indeed, the clinical consequences of untreated sleep disorders are serious and far-ranging. Sleep-related breathing disorders are associated with high blood pressure, heart attack, heart failure, stroke, obesity, neuro-psychiatric problems including depression and other mood disorders, mental impairment, excessive daytime sleepiness, injury from accidents, disruption of bed-partner's sleep quality and poor quality of life.

If you have trouble sleeping for more than a few weeks, or if sleep problems interfere with daily functioning, speak with your doctor or contact a board-certified sleep specialist.

To learn more and get your free in-depth sleep evaluation and personalized action plan, visit www.soundsleepsolutions.com.