Sleep Disturbances During the Menopausal Transition

Sleep plays a central role in women's health, and sleep disturbances can significantly affect quality of life, worsen the prognosis of medical comorbidities, and increase risk for mood and anxiety disorders. Fragmented sleep is twice as prevalent in women as in men, regardless of age.1 Moreover, epidemiologic surveys have suggested that prevalence of perceived sleep disturbances rises from 12% to 40% during the age interval coinciding with the menopausal transition.2 In this overview of common causes of sleep disturbance, we discuss several etiologic factors and therapeutic interventions for disrupted sleep in women as they cope with the menopausal transition.

Causative and Correlative Factors

The etiology of sleep disturbances during the menopausal transition is complex; therefore, organizing the potential causative factors into clinically useful categories may be helpful.

Hormonal Flux

Decreases in estradiol and increases in follicle-stimulating hormone, progesterone, and testosterone across the menopausal transition have been correlated with sleep difficulties during this midlife stage.3

Hot Flashes

Several epidemiologic studies have shown associations between hot flashes and perceived sleep disturbances such as frequent awakenings and lack of restorative sleep,3 and polysomnography studies have confirmed that hot flashes result in an increase in objectively measured awakenings and time spent awake after sleep onset.4

Medical Factors

Medical conditions: Several clinical conditions (some more widespread during midlife) adversely affect sleep; these include cancer, thyroid disorders, obesity, chronic pain, urinary frequency, nocturnal incontinence, and gastroesophageal reflux disease.3

Psychiatric conditions: Sleep difficulties constitute some of the core criteria for many depression- and anxiety-related conditions. Hence, it is not surprising that symptoms of depression and anxiety — themselves more common during the menopause transition — have been correlated with the perception of poor sleep quality at menopause.3

Primary sleep disorders: Prevalence of obstructive sleep apnea, restless legs syndrome, and periodic limb movement disorder rises with advancing age; therefore, these conditions are more common during the menopause transition. Indeed, the menopausal transition is an independent risk factor for obstructive sleep apnea, with women much more likely to have sleep-disordered breathing during the peri- and postmenopausal stages.3

Iatrogenic Factors

Women are more likely to require prescription medication during midlife and thereafter, secondary to the increased incidence of age-related medical problems. An inventory and assessment of existing medications is warranted in relation to sleep disturbances, because various medications (e.g., diuretics, L-dopa/carbidopa, pergolide, L-thyroxine, mianserin, tramadol, several antidepressants, antipsychotic agents) have been linked to disturbed sleep.5

Behavioral Factors

Poor sleep hygiene: Certain habits can have significant adverse effects on sleep quality. Excessive caffeine consumption, frequent daytime naps, self-imposed restriction of sleep opportunities, engagement in stimulating activities close to bedtime (TV in bedroom, loud music, vigorous exercise, arguments), and absence of sleep rituals or routines all contribute to difficulties initiating and maintaining sleep.3

Environmental variables: Several external variables beyond one's control may also disrupt sleep; these include a partner who snores, shift work that disrupts circadian rhythms, noisy neighbors, and other ambient sounds.3

Psychosocial Factors

Marital satisfaction; presence of partner: Conjugal happiness and/or a cohabiting partner can positively affect subjective and objective measures of sleep at midlife.6

Losses and transitions: Midlife and the menopausal transition in particular may be marked by painful losses of loved ones as well as difficult transitions (changes in roles at work, home, and in the community). These sentinel events can adversely affect sleep quality.3

Caring for children, elderly parents, or both: Women are increasingly giving birth at a later age, leading to the potential dual responsibility of caring for elderly parents while rearing children. These increasing demands, juxtaposed with the lack of an established societal infrastructure to accommodate such situations, may adversely affect a woman in many areas of her life, thereby increasing stress levels and cutting into opportunities for sleep.3

Demographics

Race: The Study of Women's Health Across the Nation (SWAN) Sleep Study showed that, at midlife, black women are more likely to report poor sleep quality and to have short sleep duration, poor sleep efficiency, and obstructive sleep apnea measured with polysomnography than are Chinese or white women.7

Age: SWAN Sleep Study participants who became menopausal at younger ages experienced more pronounced sleep impairment than those whose menopause transitions occurred later.8

Socioeconomic factors: The SWAN Sleep Study also showed that financial strain is independently associated with impairments in subjective and objective measures of sleep.7

Treatment

Hormone Therapy

Randomized, controlled trials investigating the effects of hormone therapy (HT) on sleep disturbances during the menopausal transition are scarce. Although some such trials have shown that HT is effective in improving perceived sleep disturbances after menopause (particularly in the presence of hot flashes), observational data from SWAN have suggested that HT may not be sufficient for addressing sleep disturbances during the menopause transition.9

Pharmacologic Approaches

A range of agents, including trazodone, mirtazapine, benzodiazepines, nonbenzodiazepine sedatives, gabapentin, hydroxyzine, diphenhydramine, and melatonin have been used to treat sleep disturbance. Several randomized, controlled trials have demonstrated the efficacy of zolpidem, eszopiclone, and gabapentin in the treatment of insomnia during the menopausal transition.3 In addition, when used for hot flashes, several selective serotonin reuptake inhibitors have been shown to improve sleep quality.10

Sleep Hygiene

Promoting good sleep hygiene involves comprehensive approaches to sound sleep, including refraining from substances or practices that adversely affect sleep (smoking, alcohol or illicit drug use, disruptive environmental variables such as bright lights, loud noises, extreme temperatures) while incorporating habits that improve sleep (exercise, good diet, bedtime rituals).3

Cognitive Behavioral Therapy

Cognitive behavioral therapy for insomnia (CBT-I) is a form of psychotherapy with demonstrated benefits in 70% to 80% of individuals with insomnia. CBT-I focuses on the cognitive-behavioral-emotional triad to address sleep disturbances by challenging and reframing thoughts; behavioral management strategies include relaxation techniques and stimulus control.11 In ongoing studies, researchers are evaluating the efficacy of CBT-I for menopause-related insomnia.

Conclusion

Sleep disturbances are common in women, particularly as they progress through the menopausal transition. A comprehensive diagnostic assessment followed by a tailored treatment plan may improve quality of sleep during this time — with widespread beneficial downstream effects on health, mood, and quality of life.