Menopause and Sleep
Menopause is one of those common lifecycle events that all women experience once they reach a certain age. However, “the Change” is a transition that each woman experiences differently, on a physical, psychological, and emotional level. Each woman’s unique body and the psychological and social make-up of each woman’s life will present her with different symptoms associated with menopause.
One of the most common menopause symptoms is sleep disruption. It is frequently reported in the stages before, during, and after menopause. Sleep disruption and the resulting sleep deprivation can intensify some of the other symptoms of menopause, such as depression, anxiety, irritability, and mood swings.
There are many methods that women can use, both medical and non-medical, that can help with menopause-related sleep issues. Let’s explore what exactly menopause is, how it impacts sleep, and how to manage that impact.
What is Menopause?
Menopause is a natural condition that occurs in all women as they age. It refers to the end of menstruation, and the changes the body goes through before, during, and after that process is complete.
Every woman is born with a finite number of eggs, which are stored in the ovaries. During the menstrual cycle, eggs are released, and either fertilized or passed through the body. Once the body runs out of eggs, the ovaries also stop producing high levels of estrogen and progesterone, which are the hormones that control menstruation and ovulation.
Menstruation typically occurs after the age of 40. However, some women experience menopause before the age of 40, which is referred to as “premature menopause.” Premature menopause can be caused by certain surgeries (such as a hysterectomy), damage to the ovaries (for instance, because of chemotherapy), autoimmune diseases (such as thyroid diseases), chromosomal defects (such as Turner’s syndrome, which causes women to be born with an absent or partial second X chromosome), or simple genetics/family history.
During menopause, women experience a number of symptoms, which vary in intensity from person to person. These symptoms can include hot flashes, vaginal dryness, decreased or increased sex drive, bladder issues, changes in body shape, and changes in mood. One of the most commonly reported symptoms is sleep disturbance.
Stages of Menopause
What we refer to as “menopause”, the actual end of menstruation, is only one part of the process the body goes through in this stage of life. In fact, there are two other important stages that come before and after menopause: perimenopause and postmenopause, respectively. During all three of these stages, women can experience sleep disturbances. If left unaddressed, those sleep disturbances could continue, even after other symptoms go away. In fact, over 60 percent of postmenopausal women report symptoms of insomnia.
In order to understand why these sleep disturbances occur, it’s important to understand what exactly is going on during all three phases in the process.
Also known as “menopause transition”, perimenopause is the period of time when your body starts to reduce estrogen and progesterone production. The average length of perimenopause is around four years, but that can vary significantly from person to person, potentially lasting as long as 10 years and as briefly as a few months before menopause. It often starts around a woman’s 40’s, though it can also start in her 30’s. Women in perimenopause still get their periods, and can become pregnant.
In the last two or so years before menopause, the drop in estrogen and progesterone production speeds up drastically. Generally, this is when women begin to feel the symptoms associated with menopause. In addition to those symptoms (which were mentioned above), perimenopausal women may experience breast tenderness, worsening of PMS symptoms, irregular or skipped periods, and periods that are heavier and/or lighter than usual.
Menopause is when the body actually stops releasing eggs. The term refers to the final menstrual period, which is confirmed when a woman has not had her period for twelve consecutive months (with no other obvious causes). On average, the majority of women experience menopause between 45 and 55 (though some women can experience menopause earlier, and others can experience menopause later). During this time, the symptoms of menopause tend to be most acute, because of the sharp drop-off in estrogen and progesterone.
After a woman has her last period and 12 months have passed, she is considered postmenopausal. This means that she no longer has the capacity to become pregnant, and will no longer experience a menstrual cycle. During this time, women may experience some lingering side effects, including hot flashes, night sweats, vaginal dryness, and urinary issues. Postmenopausal women are also prone to mood changes, such as depression, irritability, or anxiety, and are at increased risk of heart disease, osteoporosis (loss of bone density, causing bone fragility and vulnerability to breaks), and osteopenia (a milder form of osteoporosis).
How Menopause Affects Sleep
It is very common for women to experience sleep disturbances during every stage of the menopause process, from perimenopause to postmenopause. Statistically, there are slight variations in the kind of sleep disturbances reported during the separate stages. According to one study, perimenopausal women were less likely to sleep for 7 hours in a 24 hour period than premenopausal and postmenopausal women. However, postmenopausal women had a harder time falling asleep and staying asleep on a regular basis. Postmenopausal women were also more likely to wake up not feeling well rested more than 4 times a week.
Some of the most commonly reported sleep disturbances among perimenopausal, menopausal, and postmenopausal women include hot sleeping/night sweats, insomnia, and breathing-related sleep disorders such as apnea. Lack of quality sleep can exacerbate depression, anxiety, irritability, and fatigue, all of which are already symptoms experienced by women going through menopause.
These sleep symptoms are often caused by the decreasing levels of estrogen and progesterone in the body. However, there are many other factors, both physical and psychological, that affect women during this time in their lives, and can contribute to sleep issues. Generally, this is a period of transition, in both a woman’s body (through the many changes brought on by aging) and in a woman’s life (for instance, in becoming an empty nester, planning for retirement, taking care of aging parents, etc.) These are all factors that may impact sleep in menopausal women. Hormonal changes do, however, play an important role.
Hormones and Sleep
The main hormonal change that women undergo during menopause is a dramatic decrease in the production of estrogen, progesterone, and testosterone, the three hormones that regulate reproduction and the menstrual cycle; each of these hormones plays a unique role in sleep health.
Estrogen is the primary sex hormone in women. In addition to regulating reproduction and the menstrual cycle, it supports heart health, bone health, and weight management, and has a positive impact on cognitive sharpness, energy levels and mood. When it comes to sleep, estrogen helps the body more efficiently utilize serotonin and other neurochemicals to facilitate higher quality sleep with fewer interruptions.
Progesterone works with estrogen to prepare the body for pregnancy during the monthly menstrual cycle. It also helps to stimulate the growth of bone tissue and promote bone density. Progesterone works against anxiety, and tends to create a sense of general calm. This calming effect promotes sleep. In fact, too much progesterone can actually cause daytime fatigue. We see this often during pregnancy, when the body experiences a huge surge of progesterone. Progesterone also increases the production of GABA, which is a neurotransmitter that facilitates deeper, more restful sleep.
Testosterone has its own role to play in the female endocrine system. In addition to helping the body create estrogen, it contributes to greater bone mass, greater energy, and increased sex drive.
During natural menopause, the body drastically slows down the production of estrogen and testosterone, generally over the course of years, and stops producing progesterone entirely. Without the sleep-supporting properties of these hormones, women can experience trouble falling asleep and staying asleep.
Premature menopause and induced menopause also present their own unique sleep challenges.
Premature menopause, or menopause before age 40, occurs in around 1 percent of women. Women experiencing premature menopause generally experience the same symptoms as other menopausal women. However, because they will now spend more years than average without the benefits of estrogen, the symptoms need extra monitoring, so as not to cause health issues (such as heart disease or osteoporosis) later on. The same is true for sleep: because women with premature menopause have less time with the sleep promoting qualities of estrogen and progesterone, any potential sleep disturbances must be monitored so as not to cause future complications, such as lasting insomnia or sleep deprivation-related health effects.
Like women with premature menopause, women who have induced menopause (by way of a surgery or medical treatment) spend fewer years with the benefits of estrogen and progesterone, and therefore require more monitoring to prevent future health issues. Another challenge unique to women with induced menopause is that their symptoms tend to be more intense on the whole than other menopausal women. This means that they may experience more acute or intense sleep disturbances as well.
Symptoms and Co-occurring Conditions
Sleep disturbance can be considered its own symptom of menopause. However, it can also be aggravated, or even entirely caused, by other co-occurring symptoms and conditions. It is important to consider these possible connections, so that you can zero in on the root cause of your menopausal sleep problems.
Hot flashes are one of the most commonly reported symptoms of menopause: over two thirds of women report experiencing at least one hot flash. It’s not clear exactly what causes them, but it’s possible that hormonal changes alter your body’s thermostat (the hypothalamus), which then becomes more sensitive and reactive to slight changes in body temperature. Hot flashes are experienced as sudden feelings of warmth, which are usually most intense around the head, neck, and chest, though they can spread to the rest of the body. Hot flashes can cause reddening of the skin, as well as sweating. When hot flashes occur at night, they are commonly referred to as “night sweats.” These night sweats can negatively impact sleep: studies have shown that severe night sweats are linked to chronic insomnia.
Obstructive Sleep Apnea (or OSA) is a sleep disorder in which breathing stops periodically during sleep, generally triggered by throat muscles relaxing too much during the night. It can present as snoring, gasping for breath, or both. OSA can have a serious impact on your quality of sleep: in some cases, it can cause insomnia and severe sleep deprivation. The odds of experiencing OSA increases in women during and after menopause. This is because estrogen and progesterone, which indirectly help keep airways open during sleep by maintaining muscle tone in the throat, are diminished or absent from the body. Menopause can also lead to weight gain and a redistribution of body fat, which can increase your risk of obstructed breathing during sleep. Your risk of sleep apnea is further elevated if you have family members with sleep apnea, or if you smoke or drink.
Women going through menopause are at an increased risk of developing psychological disorders, such as anxiety and depression, and many report severe mood swings. One of the reasons behind this is the fluctuating level of estrogen in the body during the transition to menopause. There are also many situational causes for depression and anxiety during this time. Concerns about aging, body image, sexuality, life transitions, and other stressors can result in mood swings and, in some cases, clinical depression and/or anxiety. It appears that women who had severe PMS when younger have more severe mood swings during menopause, and women with a history of clinical depression and/or anxiety may be more vulnerable to a relapse of clinical depression and/or anxiety during menopause. Depression and anxiety can both have a negative impact on your sleep. People suffering from depression can experience insomnia (too little sleep), or hypersomnia (too much sleep), and people suffering from anxiety report high rates of difficulty falling asleep and staying asleep.
Another common but less frequently discussed symptom of menopause has to do with changes in urinary function. Women going through menopause may experience the need to urinate more frequently, may have trouble controlling urination, may contract more UTIs, and may develop severe vaginal dryness and itching. One of the main causes of these symptoms is urogenital atrophy, which is a gradual deterioration of the urinary tract and the vagina. In menopause, urogenital atrophy is caused by reduced production of estrogen. Increased need to urinate may cause frequent awakening during sleep, and an increased rate of UTIs, as well as vaginal dryness and itching, can cause severe discomfort, which can lead to insomnia.
Sleep Help for Menopause
The sleep issues frequently experienced during menopause may seem daunting, but there are many ways to manage them and reduce their impact on your life. Each woman is different, and each experience of menopause is different, so it would make sense that each plan for how to deal with or treat menopause symptoms should be catered to each woman’s individual needs. Some women treat their symptoms with lifestyle changes, and others opt for medical intervention or both. It is always best to share your experiences and discuss your options with your doctor, so that the two of you can create an informed treatment plan that is best suited to your individual needs.
Women who opt for medical intervention usually take one of two approaches: treating the underlying hormonal imbalance caused by menopause, or addressing each menopause symptom individually as it comes.
Hormone Replacement Therapy
Hormone Replacement Therapy (HRT) refers to medications containing the hormones that are lost or depleted during menopause. Generally, HRT medications contain estrogen and/or progesterone, but sometimes they include other hormones as well, such as testosterone and DHEA (otherwise known as dehydroepiandrosterone, a hormone produced by the adrenal gland that may slow down certain effects of aging).
HRT drugs are taken to relieve common menopausal symptoms, such as mood swings, hot flashes, vaginal dryness, and sleep issues. HRT has also been proven to prevent bone loss and therefore reduce bone fractures and breaks. Low-dose HRT has been shown to help some women with menopause-related sleep issues, as well as other symptoms (such as night sweats) that may interfere with sleep.
In the past, HRT was much more widely prescribed: the vast majority of women going through menopause were prescribed some sort of HRT. However, more recently, studies have shown that HRT can pose various health risks, including increased risk of heart attack, stroke, breast cancer, and other serious health problems in some women. According to new guidelines put out by the FDA and the American Heart Association, most women should avoid long-term use of HRT. Rather, HRT should be used in the short term to treat menopausal symptoms while the body gets used to the effects of depleted hormones. It is also recommended that women who have a history of cardiovascular disease, certain kinds of cancer, liver disease, blood clots, or vaginal bleeding should avoid HRT.
Age and proximity to menopause are two important factors in the effectiveness of HRT, and in the risks involved. Studies have shown that the use of HRT with the best effectiveness-to-risk ratio is in menopausal women under the age of 60 or within 10 years of menopause, who use HRT for no more than 3-5 years.
Different forms of HRT pose different risks and have different benefits, depending on the dosage, the chemical makeup of the HRT, how long it is taken, and how it interacts with your own physiology. If you’re considering HRT, it’s important to consult with your doctor to find out which type, if any, is best for you.
Supplements and OTC Medicine
Many women choose to treat their menopausal symptoms with non-prescription medication, and/or herbs and supplements. Women have been going through menopause for all of human history, so there is a significant body of knowledge about herbal remedies to treat its common symptoms. In particular, ginseng has been shown scientifically to treat sleep disturbances, and can help some women through menopause to fall asleep and stay asleep.
It is important to note that although over the counter medications, herbs, and supplements are available without a prescription, they should be treated as medications, and should be discussed with your doctor. Some of these supplements can have unintended negative interactions with pre-existing health conditions or other medications you might be taking. Be sure to mention them when discussing your treatment plan.
Another option for treating the symptoms of menopause is the use of prescription medications that are not HRT. There are several types of medication that are commonly prescribed to menopausal women. They include:
A few specific categories of antidepressants related to SSRIs (selective serotonin reuptake inhibitors) and SNRIs (Serotonin and norepinephrine reuptake inhibitors) are often prescribed to menopausal women. They work by impacting the chemical messengers (or, neurotransmitters) that brain cells use to communicate to one another. Generally, they are prescribed to treat the mood issues and potential psychological effects that come with menopause. Additionally, when taken in low doses, they have been shown to reduce hot flashes in some women, which tends to improve quality of sleep.
This class of drugs, which includes the brand names Neurontin, Gralise, and others, is generally used as an anticonvulsant in epileptics, or as a nerve pain and/or migraine management drug. It works by changing the way in which nerves send messages to your brain. Sometimes, Gabapentin is also prescribed to treat depression. In some menopausal women, it has been proven to reduce hot flashes, especially at night, and to improve sleep.
Otherwise known as sleeping pills, this class of drugs includes medications like Ambien and Sonata. Drugs like Ambien are intense muscle relaxants that stimulate a sleep-wake cycle in the body. Drugs like Sonata (otherwise known as zalepon) work by activating GABA-A receptors, which are neurotransmitters in the brain that act as natural calming agents for the nerves, helping keep nerve activity in balance. These drugs are effective in treating short term bouts of insomnia, but are not generally appropriate for long term use, since they have the potential for dependence and addiction.
These drugs are frequently used to treat insomnia in people with acute anxiety disorders. Like Zapelon, they also work by activating GABA receptors and inducing calm. If anxiety is one of the main symptoms of your menopause (and your menopausal sleep disturbances), Benzodiazepines may improve your quality of sleep. However, they are also not generally intended for long term risk, because of a potential for tolerance and dependence, and negative side effects (which can be lethal, especially when mixed with alcohol).
Menopausal women have a higher rate of heart disease and osteoporosis. Your doctor may want to start you on medications to maintain your blood pressure and prevent bone loss. Certain blood pressure drugs called antihypertensives, are often prescribed to menopausal women. They work by changing nerve impulses in the brain, in order to relax blood vessels. When blood vessels relax, blood passes through them more easily, which lowers blood pressure. Certain antihypertensives, such as Clondine, can also provide some relief from hot flashes, which can have a positive impact on sleep.
It is important to remember that your body may respond differently to prescription meds before and after menopause. A medication that worked fine beforehand may no longer work, and vice versa. Consult your doctor to adjust your medication regimen if needed.
Alternative Therapies and Sleep Tips
Many women decide to focus on natural methods to treat their menopause symptoms, either in combination with HRT/meds/supplements, or without them. There are many lifestyle changes and practices you can make to lessen the impact of menopause, and this is especially true when it comes to menopause-related sleep disturbances. Here are the top five steps you can take toward a better sleep:
- Practice Good Sleep Hygiene: Sleep hygiene refers to your habits around going to sleep and your sleep environment. It seems basic, but make sure that the place where you sleep is kept quiet, dark, temperature-controlled, and comfortable. If your bed is no longer comfortable due to your symptoms or its age, consider updating your mattress and bedding. It’s also important to establish a routine around sleep, going to bed around the same time every night, and doing the same activities (ie, brushing your teeth, getting your PJs on, washing your face) beforehand. Once you get into bed, make sure it’s just for sleeping: hanging out in your bed on your phone, or even reading in bed, can associate the bed with activity rather than relaxation, and make it harder to fall asleep.
- Meditation and Relaxation Therapy: There are various different meditation styles and relaxation techniques available to people who are trying to improve their sleep. Mindfulness meditation, which is based on breathing and focusing on the present, is particularly helpful for menopausal women. Another commonly used relaxation tool is progressive muscle relaxation, where you clench and release your muscles for a specific time period in a specific order, concentrating on the sensations of your body, and releasing muscle tension. It has been shown to reduce stress and anxiety in menopausal women, which in turn improves sleep quality.
- Acupuncture: You may be wary of the benefits of an ancient practice like acupuncture, but recent studies have shown that it can actually make a difference when it comes to the most disruptive menopause symptoms–including sleep problems. Even a short-term course of acupuncture with the right practitioner can yield results in some women. Other reported benefits include reduced hot flashes, milder emotional symptoms, and decreased skin and hair problems.
- Change Your Diet: During menopause, your nutritional needs and food sensitivities may change. Eating the right (or wrong) foods can affect your overall health, your mood, and the quality of your sleep. Once a woman hits menopause, it’s especially important to get enough calcium and magnesium to avoid bone loss. Nuts, beans, spinach, broccoli, and whole grains are the best sources of magnesium. When it comes to calcium, leafy greens like collards and legumes are important, as are dairy products. In fact, the amino acid glycine, which is found in milk and cheese, may also help promote sleep in menopausal women. Because of a greater risk of heart disease and a slowing metabolism, it’s recommended that menopausal women adopt a heart-healthy, low-fat, high-protein diet with plenty of whole grains and less-processed fruits and vegetables. Stay away from salt (which can strip the body of calcium and negatively affect heart health), as well as any foods that are too spicy, if that’s a hot flash trigger for you. Avoid smoking, excessive caffeine, high-fat, low-nutrient foods, and alcohol.
- Cognitive Behavioral Therapy: This school of therapy is practical and “problem-solving”, in that it seeks to address a certain behavior or issue, and has a specific goal in mind. Recently, it has been suggested to menopausal women who are having issues with sleep, especially if they are finding it difficult to stick to sleep routines. Cognitive Behavioral Therapy (or CBT) offers patients a set of instructions to carry out, and talks through thoughts and feelings that prevent the patient from sticking to healthy sleep habits. Studies have shown that CBT can lead to meaningful improvements in sleep efficiency, and can help combat insomnia.
Learn More About Menopause and Sleep
Menopause can seem overwhelming, but you don’t have to go through it alone. There are many resources out there for women at every stage of menopause. Don’t be afraid to reach out.
- The North American Menopause Society: A thoroughly researched, extensive catalogue of information on menopause. This is a highly recommended stop when looking for menopause information.
- American College of Obstetrics and Gynecology Menopause FAQ: A comprehensive FAQ about the stages of menopause, as well as menopause symptoms and treatments, developed by the leading menopause authorities at the American College of Obstetrics and Gynecology.
- Finding the Right Menopause Doctor: Everyday Health’s guide to the menopause medical field, and a run-down on what to look for in a good menopause doctor.
- Menopause Practitioner Database: A location-based searchable database of NAMS-approved medical practitioners with experience in menopause care.
- Menopause Glossary: An excellent glossary of words and terms you may encounter when dealing with menopause.
- National Osteoporosis Foundation: A resource to learn more about osteoporosis, and how to avoid bone loss
- Best Menopause Blogs of 2019: On this list, you’ll find an excellent assortment of online writers tackling the issues that affect menopausal women.
- Menopausal Hormone Therapy Information: Up to date news and science from the National Institutes of Health on long term and short term HRT.
- Menopause Support Group (Facebook): This online support group was formed by a woman named Gwen Harris to be a safe haven for women dealing with menopause. It is a private Facebook group, with over 11,000 members, and is a great resource if you want to talk about menopause with other people who are going through it.
- Premature Menopause Fact Sheet and Resources: An excellent compilation of facts and resources for women going through premature or induced menopause, put together by Womenshealth.org.