Is your sleep difficult during perimenopause and menopause? 40-60% of women experience sleep problems in menopause, so please be reassured that you are not alone. Sleep problems can involve difficulty getting to sleep, staying asleep, waking early, not getting enough restorative sleep or a combination of all these. At Rowena Health Menopause Specialist Clinic we can help, let’s discuss sleep and menopause and the hormonal changes we find in the menopause transition which can significantly affect our sleep.
What symptoms can affect sleep?
Women who experience these are most likely to have disturbed sleep in menopause. They 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 after this. 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.
Anxiety, mood changes and worry:
Anxiety and mood changes are very common during perimenopause. Being anxious about things can make it hard to fall asleep a the beginning of the night, and can mean it is hard to get back to sleep if we wake up. It is easy to lie there tossing and turning for hours, 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.
Stress and life:
Juggling life in the modern world during perimenopause can have its challenges, it can be an incredibly busy and stressful time of life. You may be working, managing children, relationships, extended family and often women put their own care last. There can be so much to do that we don’t find time to prioritise our sleep, and often go to bed too late. We may not give ourselves the time the need to wind down at the end of the day. We may not get enough daylight, which is important for sleep. We may eat late in the evening or snack before bed, causing blood sugar changes while we sleep which disrupt our sleep. We may drink alcohol, which can certainly disrupt sleep and mood. 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 and eat meals early in the evening and try to avoid night time snacks.
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.
When oestrogen levels drop our sleep can be affected, it may take longer to fall asleep and the total amount of sleep we get can be reduced. We may find it more difficult to regulate our temperature and we may wake more in the night.
In most women can be sedating and can make us feel sleepy. It also helps to regulate breathing through the night. As we stop ovulating, levels fall during the menopause transition so it can become harder to fall asleep. 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.
Is our stress hormone and levels rise as we age, this can contribute to feelings of stress and anxiety, which can affect our sleep.
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. This can also make it harder to sleep at night.
Why is sleep so important for our health?
Both lack of sleep and menopause can increase the risk of cardiovascular disease and problems with mental health, cognition, bone health, immune function and metabolic health.
Sleep is important for our mental health
30-40% of women report chronic insomnia by the end of menopause , and this can increase their risk of depression by 2-3 times.
Sleep is important for our brain function
Having poor sleep has a detrimental affect upon our memory, and certainly does not help when we suffer from brain fog during the menopausal transition. The brain repairs while we sleep, getting rid of wast products. When sleep is disturbed this cannot happen.
Sleep is important for weight management
When we don’t sleep well it affects our hormones called Leptin (which is the hormone responsible for making us feel satisfied and full when we have eaten enough) and Gherlin (which is the hormone that increases our hunger). There is a reduction in Leptin and an increase in Gherlin so this can make us more hungry and more likely to over eat and gain weight.
Sleep and the immune system
Sleep deprivation has been found to increase our chances of getting infections, including simple viral infections.
Sleep and our general wellbeing
When we are exhausted life is a challenge, work, relationships, even simple tasks become far more difficult. It is hard to enjoy life and think straight when we have not slept well.
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 and it is affected by drinking caffeine and by having a daily nap. It is important to reduce caffeine and try to avoid this after midday, for this reason. It is best not to day time nap, but if you must do this, try to ensure it is before 3pm to allow your sleep drive to increase to a level that you will be able to sleep that night.
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 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, so we may lie tossing and turning which doesn’t help. 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.
- 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?
Obstructive sleep apnoea
Symptoms of sleep apnoea mainly happen while you sleep.
- 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).
If you have symptoms of either of these conditions please do speak with your doctor.
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.
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.
Resources to help:
- The sleep book: how to sleep well every night by Guy Meadows—reading-well.org.uk/books/books-on-prescription/12072514
- NHS self-help leaflets on sleep problems—web.ntw.nhs.uk/selfhelp/ – sleeping
- NHS information on insomnia—www.nhs.uk/conditions/insomnia/
- Sleepio, a digital self-help programme designed for improving sleep that is recommended by NICE as cost effective for treating insomnia symptoms—www.sleepio.com
- The British Snoring & Sleep Apnoea Association website—britishsnoring.co.uk
- The Sleep Apnoea Trust website—sleep-apnoea-trust.org
- The Scottish Association for Sleep Apnoea website—scottishsleepapnoea.co.uk
- The Sleep Charity website—thesleepcharity.org.uk
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 September 2023 Dr Carys Sonnenberg Rowena Health