Is Menopause Keeping You Awake?

Many factors can cause sleep disturbances during the menopausal transition; many treatments are available.

Sleep — who ever gets enough of it? Especially women: At any age, they are twice as likely as men to have sleep disturbances. Problems falling asleep, staying asleep, or getting restful sleep (or being sleepy during the day) can worsen your quality of life, make medical conditions harder to control, and lead to mood problems and anxiety.

Women may develop even more sleep problems during the “menopausal transition (MT),” which encompasses the midlife time that begins when your menstrual periods start to change and ends 1 year after your final period. For most women this process starts in the mid to late 40s and ends in the early 50s, although it can happen earlier or later. Around that same age, women are more likely to have sleep problems. It's not clear whether these problems are caused by age, the MT itself, events that happen around midlife, or a combination. Here are some factors known to affect sleep during the MT — and some treatments that can help.

Possible Causes of MT-Related Sleep Problems

Fluctuating Hormones and Hot Flashes: We joke about “changing hormones” during the MT, but sleep problems aren't funny. Rapid, unpredictable shifts in estrogen, progesterone, testosterone, and follicle-stimulating hormone levels could underlie sleep disturbances. Many women report being frequently awakened by hot flashes or not sleeping soundly enough to feel rested in the morning.

Medical Factors: Some medical conditions (cancer, thyroid disease, obesity, chronic pain, frequent urination or leaking urine, reflux disease, depression, anxiety) are more common in midlife than at younger ages. Sleep disorders such as obstructive sleep apnea (briefly stopping breathing many times throughout the night because of airway blockage) become more common too. If household members say that you regularly snore loudly or gasp for breath during the night, you can get a polysomnogram (an overnight test for monitoring brain waves, breathing, blood pressure, and oxygen levels while you sleep) to see if sleep apnea is the problem. Keeping medical conditions (including excess weight) under control may improve sleep.

Prescription Medications: Some medical problems that develop with age require medication treatment, and medications for some conditions (for example, high blood pressure, depression, Parkinson disease, underactive thyroid, pain) interfere with sleep. If you are taking prescription medications, ask your clinician (doctor, nurse practitioner, nurse midwife, physician assistant) or a pharmacist whether your medications may affect sleep. If so, ask if they can be changed. If your current medications are the best or only ones to control your medical condition, consider other sleep remedies.

Behavioral Factors: Poor “sleep hygiene” — your habits and the factors in your environment that influence how well you sleep — can result in nonrestful sleep. Drinking caffeinated beverages in excess or during the evening, napping during the day, not going to bed when you feel tired, watching television in the bedroom, listening to loud music, exercising vigorously around bedtime, and not having a “sleep ritual” (habits you always engage in around bedtime that cue your body it's time to sleep) can make falling and staying asleep difficult. Some of these factors can be easily controlled; others (a partner who snores, variable shift work, noisy neighbors, shared living space) less so.

Psychosocial Factors: Being happily married and living with a partner are associated with restful sleep, but obviously this isn't something your clinician can write a prescription for! Midlife and the MT often coincide with painful losses of loved ones and not-always-welcome changes in roles at work, home, and the community. It's also a time when women may be caring for elderly parents, children, grandchildren, or all of the above. Grief, worry, and time demands may make it difficult to find adequate time for uninterrupted sleep, let alone to sleep restfully through the night.

Demographic Factors: Some factors cannot be changed but nevertheless are interesting to know about. In one large study, black women were more likely to have obstructive sleep apnea, poorer sleep quality, and shorter sleep length than Chinese or white women. Women who started the MT at a younger age and those who were under financial strain also had more sleep problems.

Treatments for Sleep Disturbances

Hormone Therapy (HT): If the problem is hormonal or hot flash-related, it's logical that taking hormones to keep the levels steady might help. Some studies suggest this is true. Estrogen, in the form of a pill or a patch, is usually used for treatment, along with a small amount of progesterone. Hormones may have some unintended effects, so they are prescribed in the lowest possible dose for the shortest length of time. If you can't or don't want to use HT, some nonhormonal prescription medications also help control hot flashes.

Sleep Medications: Many nonprescription products, including herbals and botanicals, promise to help you sleep. For most, there is no good evidence that they work; and for a few, studies show they are either not helpful or may even be harmful.

Three prescription medications have been particularly studied during the MT; two (zolpidem and eszopiclone) are specific “sleeping pills,” and the other, gabapentin, is also used for many other problems. Other prescription sleep medications also may work. Discuss with your clinician how to use them and how long to continue them.

Sleep Hygiene: No matter what else you try, good sleep hygiene promotes restful sleep. This includes avoiding alcohol and illegal drugs, keeping your bedroom cool, dark, and quiet (or using eyeshades and earplugs), and maintaining a regular bedtime and rising time. Drinking only noncaffeinated beverages in the evening, limiting daytime naps, turning off the television, and having a bedtime ritual (for example, a warm bath, soft music, reading) often help.

Cognitive Behavioral Therapy for Insomnia (CBT-I): Cognitive behavioral therapy (CBT) is a psychotherapy treatment that helps you understand the thoughts and feelings that influence your behavior. CBT-I focuses specifically on thoughts and behaviors that interfere with restful sleep and includes relaxation exercises and sleep hygiene elements. It empowers you to control your sleep issues even when you cannot change some of the factors causing them. In general, this treatment helps 7 to 8 out of every 10 individuals with sleep troubles; it is now being studied specifically for menopause-related sleep problems. CBT-I trained providers can be hard to find (see resources, below), but practitioners trained in general CBT techniques may also be helpful.

In Conclusion

Regardless of whether or not the menopausal transition causes sleep problems, this stage of life is associated with them. If you are in the MT and are having sleep problems, think about which of the factors above could be responsible and talk with your clinician about approaches that can help. These might include better sleep hygiene strategies or referral to a specialist.