Menopause and Insomnia

What is menopause?

Technically, a woman has officially entered menopause once she has gone 12 months without a menstrual cycle.

Before menopause occurs, women go through a 3 to 10 year period that’s known as perimenopause. Perimenopausal symptoms can start in the mid 40s and continue through the early 50s.

During perimenopause, women experience a wide range of symptoms including:

• Irregular periods
• Mood swings
• Hot flashes
• Insomnia
• Increased anxiety and depression
• Reduced sex drive
• Vaginal dryness and overall dryer skin
• Physical changes in the breasts, uterus, ovaries, and cervix
• Increased need to urinate

During perimenopause, women’s body produce reduced levels of estrogen and progesterone hormones. These hormonal changes are responsible for the long list of symptoms you read above.

Hot flashes are one of the first symptoms of perimenopause, and can continue for up to 5 yearsafter the last menstrual period. These extreme sessions of intense body heat can last as long as 30 minutes. They’re also one of the most disruptive symptoms of menopause, especially when it comes to sleep.

How does menopause affect sleep?

Insomnia already affects women to a greater extent than men (see chart below on prevalence of sleep complaints from women vs. men), and how it affects them changes depending on what stage of life they’re in. Pregnancy brings its own unique set of sleep problems, as does perimenopause and menopause.

Sleep problems are a core symptom of perimenopause. Fewer than half of perimenopausal women regularly enjoy a full night of interrupted sleep, according to the National Sleep Foundation.

Severe sleep problems increase 2 to 3.5 times among women transitioning to menopause. The most common sleep problems affecting peri- and postmenopausal womeninclude:

• Sleep onset insomnia (trouble getting to sleep) and sleep maintenance insomnia (trouble staying asleep).
• Hot flashes and night sweats, which in turn contribute to insomnia.
• Obstructive sleep apnea, a form of sleep-disordered breathing where an individual literally stops breathing momentarily while asleep.
• Less time spent in REM sleep, the “dream” stage of sleep connected with learning, memory consolidation, and mood regulation. People who don’t get sufficient REM sleep experience less-refreshing sleep with feelings of fatigue that persist through the daytime.
• Restless legs syndrome, characterized by an uncontrollable and uncomfortable tingling sensation in the lower limbs that occurs when a person is lying down (as one does in bed). RLS may be linked to an iron deficiency, and is more common among women and older adults.

Menopause and insomnia

Surveys indicate that women consider insomnia among the most irritating of menopausal symptoms.

Hot flashes (due to fluctuation in estrogen and progesterone levels) are another common symptom, and many times, the reason for insomnia is due to the body’s inability to maintain a consistent temperature. A hot flash includes a surge of adrenaline, which tends to awaken sleepers.

A large-scale study of over 3,200 adult women found hot flashes occured in 80% of perimenopausal women and 40% of postmenopausal women, compared to only 12.5% of premenopausal women.

The same study found hot flashes strongly corresponded with higher rates of chronic insomnia as well, affecting over half of women in perimenopausal or postmenopausal but only a third of premenopausal women.

Many women also experience night sweats. Both these sweats and the tiredness resulting from insomnia can have a large negative effect on their subjective quality of life. As a result, women are at increased risk for depression and anxiety, mental health conditions that often coexist with insomnia.

What causes these sleep problems?

One idea is that insomnia in menopausal women has two causes: the vasomotor symptoms and depressive symptoms.

As women enter perimenopause, their period doesn’t gradually go away in a steady fashion. It’s more of a roller coaster, as the body starts and stops and figures out a new way of being. Meanwhile, hormone levels go haywire, causing menopausal symptoms.

Hormones are more than just sex. They regulate your energy, the way you function, and how well you sleep. We need both estrogen and progesterone to sleep deeply and at length.

Sleep apnea

Progesterone may be partly responsible for preventing sleep apnea by dilating the upper airways. However, progesterone levels drop during perimenopause, helping explain why postmenopausal women are twice as likely to have OSA than premenopausal women.

Obesity and weight gain are another risk factor for sleep-disordered breathing, which may contribute to its increase among perimenopausal women, since there is a tendency to gain weight during old age.

Hot flashes

The body requires a cool temperature to stay asleep. This is why your core body temperature naturally begins to lower at night, facilitating melatonin production.

Hot flashes do just the opposite, in an especially unsettling way. With 75% of perimenopausal womensuffering from hot flashes, it’s no wonder they’re waking up at night.

Lower estrogen levels are linked with hot flashes, which commonly occur at night.

Emotional stability

Like insomnia, women are also more prone to anxiety (which in turn contributes to insomnia). Anxiety is activated by the stress hormone cortisol, while estrogen helps balance one’s mood. Cortisol levels rise and dip in opposition to estrogen levels.

Since estrogen levels lower with menopause, older women are at risk of increased stress, anxiety, and corresponding insomnia.

Old age

The aging process brings its own set of sleep problems that coincides with the same time as menopause. As we age, the parts of our brain responsible for regulating our sleep begins to atrophy. As a result, seniors have  tougher time falling asleep and tend to wake up earlier than they should to feel adequately refreshed.

How to sleep better during menopause

Hormone replacement therapy (HRT), low-dose birth control and antidepressants have all been shown to alleviate the sleep problems associated with menopause, but HRT is used less today than in the past because of problems with it. Although it does improve sleep, HRT has also been associated with increased risk of breast cancer, blood clots, and gallbladder disease, so experts recommend using it as a short-term option if at all.

Fortunately, there are many natural and behavioral remedies for improving sleep during menopause. Any of the following tips should help you sleep better during perimenopause:

1. Follow good sleep hygiene.

Adhere to a regular sleep schedule, sleeping and waking at the same time every day, even on weekends.

Make your bedroom cool and dark, and avoid using it for anything other than sleep or sex. Don’t watch TV, do work, or other hobbies in your bed.

If you wake up during the night or have trouble falling asleep for more than 20 minutes, leave and go to another room. You don’t want your mind to associate your bed with sleeplessness.

2. Create a soothing bedtime routine.

Take a warm bath – as the hot water evaporates from your skin, your body will naturally cool down and make you feel more tired. Practice meditation or deep breathing exercises. If stressful or worrisome thoughts are keeping you up at night, write them down in a journal before bed in order to free them from your mind.

Drink bedtime tea or a glass of milk. Valerian root tea in particular has been shown to promote sleep, and a small 2011 study found it improved sleep quality for 30% of postmenopausal participants with insomnia.

3. Invest in cool, comfortable bedding.

Certain mattresses are better at regulating heat than others. Opt for latex or innerspring beds when possible, and avoid memory foam, which is notorious for trapping body heat. Many latex and hybrid beds feature cooling comfort layers composed of copper or gel.

Beyond the mattress itself, continue the cooling with appropriate bedding. Buy cooling pillows and mattress toppers. Choose sheets made of breathable linen or cotton. You can even get waterproof sheets and mattress toppers that stay odorless, no matter how often you experience night sweats.

For pajamas, wear comfortable clothing with wicking capabilities – think loose gym clothes vs. flannel pajamas.

4. Stay active with exercise.

Exercise regularly, in the morning and outside if possible. The natural sunlight will give you an energy boost if you haven’t been getting enough sleep, while helping your brain maintain regular circadian rhythms.

Plus, the exercise will simply make you feel good, helping preventing the weight gain that often occurs with menopause, while also making you more tired by bedtime.

5. Watch what you eat and drink.

Avoid caffeine in the afternoon and limit your overall intake during the day. Caffeine wakes you up and increases stress, which can make sleep harder.

Also avoid alcohol. While it can help you fall asleep, it creates a rebound effect that wakes you up earlier than you’d like.

Finally, avoid overly sugary or fatty foods. These are bad for your health, hormones, and sleep.

Since increased need to urinate is a symptom of menopause, limit your overall liquid intake late at night and go to the restroom one last time right before you get into bed. However, do keep a cool glass of water by the bed in case you wake up from a hot flash and need one more way to cool down.

6. Consider melatonin.

Scientists are still researching the relationship between estrogen levels and melatonin, but they have noted distinct reduced natural levels of melatonin that correspond with the period immediately preceding menopause. Further, studies indicate melatonin can help treat sleep problems during menopause. Women should speak with their doctor first for advice on dosing as well as to ensure it doesn’t interfere with other medication they may be taking.

Avoid sleeping pills. These can become addictive and are not a recommended treatment for insomnia.

7. Try therapy.

Cognitive behavioral therapy for insomnia (CBT-I) is an effective psychotherapy for treating insomnia. The therapy focuses on helping the patient learn to recognize the troublesome thoughts and behaviors that interfere with their sleep, so they can replace them with healthier, sleep-promoting habits.

One promising study found that 6 CBT-I sessions conducted over the phone during a course of 8 weeks significantly improved sleep for perimenopausal and postmenopausal women.

Additional resources

• Our guide to sleep disorders in women explains the unique sleep problems women may experience throughout their lives, in particular during their menstrual cycle and pregnancy.
• The North American Menopause Society provides resources to learn more about menopausal symptoms, determine whether it’s time to seek out professional help, and if so, easily find a menopause healthcare practitioner.