Why is quality sleep so important, yet rare in midlife (especially in women), and what can be done about it?
Women and Sleep
Did you know sleep concerns are twice as common in women as in men?
There are many reasons why this might be including hormonal, behavioral, psychosocial, and medical. What’s more, is that these gender differences in sleep seem to be enhanced with age. In other terms, women in their 20’s to 40’s are only 10-15% likely to experience sleep issues, as compared to women in their 40’s to mid 50’s whom almost 40% experience sleep issues.
For some, sleep issues may mean difficulties falling asleep, but for many perimenopausal and menopausal women, it may mean waking several times in the night and not being able to fall back asleep easily. Some women report waking up to 20 times in the night due to intolerable hot flashes! This is a HUGE problem.
Sleep disturbance is a commonly overlooked aspect of the menopausal transition, yet it's almost as common as the infamous hot flash. What's more concerning is the potential negative health consequences of poor sleep quality. Disruptive sleep (as any new mother will know) can reap havoc on your mental and physical health, making it even more difficult to make the right healthy lifestyle choices.
This is why I prioritize adequate sleep in all my patients, not just the peri- or menopausal patients. Adequate sleep can help make weight maintenance or loss easier, it may improve your cognition and memory, reduce illness, and have a positive effect on your mood overall. It seems like a pretty good trade for quality sleep!
What Causes Sleep Disturbance in Aging Women?
First, we need to understand what is causing the sleep disturbance in order to improve it.
One main cause of sleep disturbance is hot flashes and night sweats, or what we call “vasomotor symptoms”. But it’s not just hot flashes - mood disorders, medications, other medical conditions (sleep apnea, restless leg syndrome), and behavioral changes can also be to blame for poor sleep in midlife (perimenopause and menopause). This is why it is essential to discuss with your physician your current sleep patterns, but also your current lifestyle and medical history in order to adequately identify the cause of sleep issues.
Improving Sleep in Midlife
There are some great non-drug therapies that could be tried prior to starting any medications. Priority number one is ensuring your sleep environment and/or sleep “hygiene” is adequate. This means not having cell phones or TV’s on in the bedroom, reducing all lights and noise, having a dark, cool temperature bedroom, and avoiding all stimulants such as caffeine and nicotine in the evening.
Other behavioral changes may include reducing daytime napping and restricting bedroom activity for only 2 things - sleep and sex. Pretty simple, yet difficult to actually strictly adhere to.
In addition to behavioral changes, cognitive therapy may also be helpful for many. For example, cognitive-behavioral therapy for insomnia or CBT-I has shown to be effective in regulating sleep by challenging irrational or distorted beliefs, worries, and anxieties regarding sleep.
Beyond Sleep Hygiene
Like most of my patients that come to see me, they have already tried the sleep hygiene adaptations and still aren’t getting adequate sleep leaving them desperate for more options. Thankfully, that is exactly what I hope to provide to patients – options.
Many sleep medications have gotten a bad rap for causing dependence, withdrawal, and even daytime fatigue and forgetfulness. But these medications are now rarely used and are no longer used as first or even second-line option drug therapies. Rather, the new (or new-old) kids on the block include bioidentical hormone replacement therapy (melatonin, estrogen, and progesterone), and short-term use of other sleep medications with lesser side-effects.
Bioidentical Hormone Replacement Therapy (HRT)
If perimenopause or menopause is the main cause of sleep disturbance, then careful prescribing of bioidentical hormonal therapy is a great initial treatment option. Topical estrogens and oral progesterone have been shown to have better safety profiles, especially when used in younger women, closer to menopause (which should make sense). When women enter menopause, they stop having a menstrual period, meaning there is no more monthly ovulation – or a release of an egg. Normally, this ovulation period called the “luteal phase”, which is a 14-day time-frame where there are higher levels of progesterone. Progesterone is a hormone that does a special dance with estrogen.
Relative to estrogen, progesterone is an anxiolytic (calms anxiousness) and may have a sedative effect. Thus, when menopausal women lose this cyclical rise in progesterone that is usually associated with ovulation, their sleep can be largely affected. This is one reason why sleep disturbance can become such a significant issue in midlife for women, even in those who have never had sleep issues in the past.
Another main cause of sleep disturbance during midlife is hot flashes and night sweats. Hot flashes can range from simple warming feeling to a full body-sweat with pink- or reddening of the skin. This rush of heat can very uncomfortable, especially when it awakes you at night causing you to roll around the bed and throw around the bedsheets. These erratic changes in body temperature are due to rapid changes in the levels of estrogen in the body, reducing your body’s ability to act as a steady thermostat. Therefore, estrogen replacement therapy has been shown to effectively reduce hot flashes and night sweats in women, greatly improving their sleep quality and thus overall quality of life in menopause.
In Summary
A disproportionate number of women in midlife experience significant sleep disturbances.
Hormonal changes in perimenopause and menopause are largely to blame for these sleep difficulties, though other medical conditions such as sleep apnea, restless leg syndrome, and some medications may also play a role.
Hormone replacement therapy such as bioidentical estrogen and progesterone are effective treatment options for sleep disturbance in menopause. A careful discussion with your GP or naturopathic physician should be had about the safety and appropriateness of hormone replacement therapy for you.
Establishing adequate quality and quantity of sleep is a foundation for good health and can help make weight loss easier, improve your cognition and memory, reduce illness, and have a positive effect on your mood overall.
If you are a woman in midlife suffering from sleep disturbance, talk to your doctor about potential causes and treatment options available to you. The most important realization I hope to instill in women is that they have options.
Tip: Fill out this sleep diary and bring it to your visit to discuss your sleep patterns with your physician! You can find a PDF version here.
Interested in hormone replacement therapy but unsure about the potential risks, side effects, or benefits? Click here to book a free 15-minute consultation to discuss safe hormone-replacement therapy tailored to your needs.
Best,
Dr. Randi Brown | Naturopathic Physician
References
Kelsey E. Mills MD, FRCSC, MSc, NCMP. (2020) Gynecology Update. the a, b, zzzz‘s of sleep in the midlife. Victoria BC. Power Point Presentation,
Kathryn A Martin, MD, Robert L Barbieri, MD (2020). Menopausal hormone therapy: Benefits and risks. Up To Date.
Zhang, B., & Wing, Y. K. (2006). Sex differences in insomnia: a meta-analysis. Sleep, 29(1), 85-93.
Kravitz et al 2008. Cross-sectional, age-adjusted prevalence of sleep disturbance of women in the SWAN Study (Study of Women Across the Ages).
NIH Sleep Hygiene Recommendations
Carettoet al, 2019, An integrated approach to diagnosing and managing sleep disorders in menopausal women, Maturitas(128) 1-3.
American Academy of Sleep Medicine Clinical Practice Guideline: The Pharmacologic treatment of insomnia.
Kravtizet al, 2011. Sleep during the perimenopause: A SWAN story, ObstetGynecolClinNorth Am, 38(3): 567-586
Jehanet al, 2017. Sleep, Melatonin and the Menopausal transition: what are the links? Sleep Sci, 10(1). 11-18.