Menopause brings with it noticeable hormonal changes that often result in physical and psychological symptoms.
Symptoms and the intensity of the symptoms may vary. For women who still have both ovaries, there is usually a gradual decrease in production of estrogen and progesterone and typically the symptoms gradually occur in what is known as the perimenopausal period. For those who have the ovaries surgically removed, the symptoms may be more severe.
This hormonal deficiency can affect breathing as well, since progesterone stimulates breathing. The decreasing progesterone level can therefore increase the risk of apnea (cessation of breathing) during sleep. During this time, a woman may also begin snoring. In the largest study of sleep in an average healthy population, The Wisconsin Cohort, there was an overall higher rate of sleep apnea in men compared to women, but the differences in the rate narrowed when the study looked at women after menopause.
However, one of the most disturbing menopausal symptoms that can affect sleep is hot flashes.** A hot flash is surge of adrenaline that causes a rise in body temperature (typically followed by profuse sweating) and awakens the brain if asleep.**
The way to avoid the unpleasant symptoms of menopause is to take some form of estrogen, a treatment now called Hormone Replacement (HRT). Until recently the term used was HRT, Hormone Replacement Therapy. However, results from the Women’s Health Initiative showed that estrogen replacement resulted in increased risk of breast cancer, heart disease, blood clots and strokes.
So the use of estrogen and HT has now become a personal discussion with a women’s gynecologist, with a program tailored to her specific needs and symptoms. Estrogen is now used more cautiously with much shorter periods of treatment for moderate to severe symptoms associated with menopause, including hot flashes and sleep.
The characteristics of sleep during menopause was investigated in a study done in Boston at several noted medical institutions, where pre-menopausal women were given a hormone agonist of gonadotropin-releasing hormone that basically induced symptoms of hot flashes in these younger women. Sleep studies were conducted before administration of the drug, and five weeks after the study concluded. Results from the study indicated that the hot flashes occurred during the transition to wake or the superficial stage of sleep known as Non Rem 1 (N1).
The net effect of this phenomenon is that women are more aware of the symptoms as they awaken (hot flashes are perceived as very strong) and sleep is more fragmented and of poor quality.
The frequency of hot flashes is influenced by environmental temperature prior to bedtime, and tends to increase in warmer environments. This explains why, compared to men, healthy older women are more likely to complain of insomnia, poor sleep quality, insufficient sleep, and need for daytime naps. Older women also report that their sleep is more easily disrupted, and are more likely to request sedative medications.
Current recommendations to treat sleep disturbances (and hot flashes) due to menopause include:
Control the sleep and home environment and keep temperature more conducive (cooler) for sleep
Make the bedroom dark and quiet, which will limit awakenings
Make the room as cool as possible
Keep a wet cloth and cold bottle of water available near bed so you can cool yourself quickly if you do awaken
Knowing your treatment options
As discussed, the risks for long term HT use have been proven, and they include a heightened risk of developing breast cancer. If estrogen therapy is used, it must be accompanied by progesterone in those women who have not had hysterectomy, since the use of estrogen alone increases the risk of uterine cancer. The lowest dose that relieves symptoms should be used for the shortest time span needed.
Some herbal and nutritional products, including soy and black cohosh, are also considered to be estrogen-receptor modulators. Theoretically, these can provide the benefits of estrogen, without the risks of estrogen -- but there is no current convincing scientific evidence in the efficacy. Still, some women seem to find relief using these aids.
Relaxation therapy, paced breathing and exercise may also help as adjuvant therapies. Exercise in particular can help to both relax and tire a woman, and also help with calorie balance during this time when weight gain seems more likely.
The bottom line
It’s most important to realize that although a recent study found menopausal symptoms may last longer than previously considered, these symptoms are likely temporary. To work to improve your sleep, try to follow basic sleep hygiene recommendations, a regular sleep schedule, plus the recommendations I’ve just shared. If necessary, as discussed, consider discussing the use of sleep aids as a short term adjuvant therapy.
Eli Hendel, M.D. is a board-certified Internist and pulmonary specialist with board certification in Sleep Medicine. He is an Assistant Clinical Professor of Medicine at Keck-University of Southern California School of Medicine, and Qualified Medical Examiner for the State of California Department of Industrial Relations. His areas of expertise in private practice include asthma, COPD, sleep disorders, obstructive sleep apnea, and occupational lung diseases.