Sleep and menopause

40-60% of women experience sleep problems in menopause. Whether it be difficulty getting to sleep, waking multiple times, starting snoring, developing restless legs or lying listening to our partners snoring, all of these can cause us to have a poor quality sleep and leave us feeling tired the next day. At Rowena Health Menopause Specialist Clinic we can help, let’s discuss sleep and menopause.

What symptoms can affect your sleep?

• Night sweats: women who experience these are often woken by rapid alternations in temperature which wake them, then they need to change their nightwear or bedsheets, and it can be hard to go back to sleep. Tip: leaving sheets and a new nighty by the bed ready can help, sleeping on a thick towel which you can replace can sometimes be easier than changing the sheet. Keeping the room cool is helpful as this makes it easier to sleep and having a separate cover from your partner if you share a bed.
• Anxiety, mood changes and worry: being anxious can make it hard to fall asleep, and can mean it is hard to get back to sleep if you wake. It is best not to lie in bed worrying. Tip: set aside a time in the day to write down your worries, so that at night time you teach your body that your bed is for sleep and sex, not for tossing and turning. If you are awake for longer than what feels like 15 minutes, get up and go to another room which is dark and warm and go back to bed when you feel sleepy. Try the headspace app.
• Stress and life: juggling life in the modern world can have its challenges. Working, managing children, relationships, extended family often lead women put their own care last. There can be so much to do that it is easy not to prioritise our sleep, to bed go to bed too late and not take time to wind down. Daylight on your skin in the morning, is important for sleep. Having a balanced blood sugar is also important to avoid a night time dip in sugar waking you or causing a night sweat. Alcohol can certainly disrupt sleep and mood, it affects R.E.M sleep which leads to problems balancing emotions the following day. Tip: be relentless with self care and time to reduce stress, set regular bed times and time to put the screens away, avoid alcohol, have a walk outside each day, try to eat a balanced healthy diet, with enough protein to keep blood sugar stable.

Hormonal changes:

Our hormones carry messages from one part of the body to the other. Most of our perimenopausal and menopausal symptoms come from a fall in the hormone oestrogen. There are other hormonal changes which happen around menopause which can affect sleep. We see the effect of hormonal changes affecting sleep in our menstrual cycle, the best sleep will often be around ovulation and the worst just before a natural menstrual period.

• Oestrogen, when oestrogen levels drop sleep can be affected, it can be more difficult to regulate body temperature and we may wake more in the night. 
• Progesterone in most women can be sedating, calming, anti-anxiety and anti-depressant. It can help to regulate breathing through the night. Levels fall during the menopause transition as ovulation stops, which can affect sleep. This hormone has been linked to breathing disorders that can affect us at night, like sleep apnoea. Obstructive Sleep Apnoea, can lead to symptoms like morning headaches, mood disturbances and nightmares.
• Cortisol, a stress hormone rises as we age, this can contribute to feelings of stress and anxiety, which can affect sleep.
• Melatonin is a hormone produced by the pineal gland in the brain. It is released about 2 hours before our usual sleep time, sending messages to our internal body clock to get ready for sleep. We produce less melatonin as well age, the levels can decrease during the menopause transition, which can affect sleep. 

Why is sleep so important for our health?

Sleep is important not only important to help us function well, it has an effect upon mental health, cardiovascular health, cognition, immune function, metabolic health and weight management. When we don’t sleep well the hormones Leptin (our feeling full hormone) and Gherlin (which is the hormone that increases our hunger) are unbalanced, which can contribute to weight gain. The brain repairs while we sleep, getting rid of waste products.

What is drive to sleep?

We have a drive to sleep which increases throughout the day, called adenosine. It reaches a peak around the time of our normal bedtime which leads us to sleep. It is affected by drinking caffeine, for some people, and by having a daily nap. If caffeine affects you, then try to avoid this after midday. If you have to nap, try a maximum of 20 mins before 3pm to leave that drive to sleep time to increase again.

What is more important, REM sleep or deep sleep?

Deep sleep is important for things like growing, repairing muscles, tissues and bones, learning and consolidating memory and supporting our immune system. REM sleep is equally important for memory, learning and creativity and  is important for our mental health. It also recalibrates the emotional networks in the brain, like the amygdala, and the prefrontal cortex. If you are having early morning waking, it could be impacting on how much REM sleep you are having, as this usually happens in the latter stages of our sleep. Alcohol can also affect REM sleep, and this in turn can affect our emotions the following day. Both stages of sleep are important. 

What can we do to help our sleep?

• Make sleep a priority, try to avoid staying up late finishing jobs or working or watching TV.
• Try and teach your brain that your bed is for sleep and sex only, this association acts as a power cue for sleep. The longer we lie in bed awake, the more we loosen this association.
• Set a regular bed time and getting up time, and plan a relaxing lead up to this. We often try and recover from a poor nights sleep by having an early night, but our body may not be ready for sleep (the drive to sleep is not high enough) so we may lie tossing and turning. It is much better, if possible, to maintain the same regular bedtime and getting up time.
• Set aside worry time in the day. The amygdala is a small area in the brain which is responsible for how we experience anxiety. It plays a huge role in our emotional functioning and controls our emotional reactions to situations which cause us to feel afraid, stimulating our fight or flight response. It can affect our ability to sleep and if we are anxious in the night it can trigger the flight or fight response, which stops us from sleeping. One way that can help is to think of emotions as being transient and short lived. Feeling them, understanding them and then allowing them to dissolve away will help us regain control of our thoughts, and calm our brains. It can take 90 seconds to identify an emotion and let it pass if you simply just notice it. Calm effective breathing can help, using your diaphragm and the whole of your lungs. Do click on the link to find out more about breathing and sleep.
• Make sure to get some morning day light on your skin, light has a powerful effect on our circadian rhythm, fitting it in with a walk or some form of movement will help, 20 minutes wakes us up and sets our body clock to sleep at night.
• Taking HRT, Hormone replacement therapy, can help improve sleep, replacing oestrogen can help improve night sweats and anxiety. If you have a womb your HRT will include progesterone, in combined HRT, to protect the lining of the uterus. The micronised, body identical progesterone can lead to improved sleep, due to its breakdown product, allopregnanlone, having an effect on the GABA receptors in the brain. It can have a similar sedating effect to benzodiazepine in some women, but not in every woman.
• Cognitive Behavioural Therapy for insomnia (CBT-i) can be helpful. Often we teach our brain’s how to behave and we can form habits which involve negative thinking and behaviours. CBT-i can help to address these and help us teach our brains healthy sleeping habits. It can be done using a self help tool in a book, in a group or in a 1:1 session. It can also be used to help with night sweats and hot flushes. It is recommended by NICE and is very effective. I recommend this book called, ‘Managing Hot Flushes and Night Sweats,’ it is a four-week self-help guide uses cognitive behavioural therapy, providing information and strategies for managing hot flushes and night sweats, as well as stress and sleep.
• Eat a healthy balanced diet, and keep active in the day, as much as possible.
• Prescribed medication can help. Despite the worry over using antidepressants in menopause sometimes they can help either alone or used with HRT, especially if mood is an issue. 
• Restricting time in bed can help. Insomnia sufferers tend to spend much more time in bed than necessary, this lowers the efficiency of their sleep and means they can build a negative association between being in bed and sleeping. In simple terms, sleep restriction limits time in bed to your total sleep time and gradually increases it, thus consolidating your sleep.

Temporary sleep problem or insomnia?

Worrying about sleep can make things worse, temporary sleep problems often pass and we all are built to weather short periods of disturbed sleep, even if they last for weeks. Insomnia has certain diagnostics criteria that separate it from a temporary sleep problem, It is said to be when you have trouble getting to sleep, staying asleep or waking early causing you to feel fatigue and affecting your day to day function, if this is happening for 3 or more days a week, and lasting for 3 months or more, despite adequate opportunity to sleep, and if there is not a condition or drugs causing this.

What other conditions can affect sleep?

Some other conditions that can affect sleep are called Obstructive Sleep Apnoea and Restless legs syndrome. If you have symptoms of either of these conditions please do speak with your doctor.

Obstructive sleep apnoea

Symptoms of sleep apnoea mainly happen while you sleep. They include: breathing stopping and starting; making gasping, snorting or choking noises; waking up a lot; loud snoring. During the day, you may also: feel very tired, find it hard to concentrate, have mood swings, have a headache when you wake up

Restless legs syndrome

Women are twice as likely to develop restless legs syndrome as men. The main symptom of restless legs syndrome is an overwhelming urge to move your legs. It can also cause an unpleasant crawling or creeping sensation in the feet, calves and thighs. The sensation is often worse in the evening or at night. Occasionally, the arms are affected, too. Restless legs syndrome is also associated with involuntary jerking of the legs and arms, known as periodic limb movements (PLM).

Sleeping problems, whether temporary or insomnia, can be very distressing, but as we can see there are many ways to help them, both things we can do ourselves, and professional help is available in the form of CBTi.

Resources to help:

• The sleep book: how to sleep well every night by Guy Meadows
• NHS self-help leaflets on sleep problems
• NHS information on insomnia
• Sleepio, a digital self-help programme designed for improving sleep that is recommended by NICE as cost effective for treating insomnia symptoms
• The British Snoring & Sleep Apnoea Association website
• The Sleep Apnoea Trust website
• The Sleep Charity website
• BMS video on sleep
• The Good Sleep Clinic

For an appointment at Rowena Health Menopause Specialist Clinic online if you are in the UK, or in person at our Guildford Clinic please click the link. We would be delighted to see you.

Last updated January 2024 Dr Carys Sonnenberg Rowena Health