Menopause brings additional complications to sleep disturbances
Women’s sleep in midlife can be influenced by general aging and menopause — often at the same time — but health care providers can learn to spot differences to more effectively treat patients. Sleep disturbances are common for aging men and women, but hormonal changes brought on by menopause are unique and can require different, or additional, forms of treatment.
Sleep changes with age
From sleep interruption to early sleep and wake times, changes in sleep begin in midlife and continue to progress as people age.
“The largest difference [with age] is the inability to stay asleep,” said Phyllis C. Zee, MD, PhD, chief of sleep medicine in the department of neurology at Northwestern University Feinberg School of Medicine. “[Older people] have more awakenings ... and also wake up earlier than desired. That is true for both sexes. Some individuals also have difficulty falling asleep, but with age, the factor is really difficulty staying asleep.”
Although these sleep disturbances begin to become more common around age 55 years, they progress over time.
“It’s safe to say that about 20% to 25% of that population [of adults aged 55 years and older] is going to have sleep difficulties — both falling asleep and staying asleep,” Zee said. “If you look at older individuals [aged at least 65 years], it’s really astounding — about 57% have a chronic sleep problem.”
Poor sleep is a risk factor for diabetes, heart disease, hypertension and cognitive disorders, Zee said. Additionally, recent studies have found that sleep helps the brain rid itself of toxins that accumulate during the day.
“With sleep, you can actually flush these [toxins] out more quickly than when you’re sleep-deprived. When you’re sleep-deprived, they accumulate more quickly. It’s really important for brain health, and as we live longer, our brain health is what we are trying to preserve,” Zee said. Sleep also helps the body fight disease, as it aids in immune function, she noted.
Lack of sleep also lessens quality of life over time, according to Hadine Joffe, MD, MSc, executive director of the Connors Center for Women’s Health and Gender Biology at Brigham and Women’s Hospital, Harvard Medical School. “People feel tired and drained,” Joffe said, adding that chronic sleep deprivation makes it more difficult to make healthy lifestyle choices throughout the day and negatively affects work productivity.
Menopause compounds symptoms
Joffe said she believes that menopausal women typically fall into one of four groups based on the trajectory of their sleep as they age. The first three are good sleepers who continue to sleep well through and after the menopause transition, lifelong bad sleepers who continue to deal with sleep disturbances throughout and after menopause, and those who have some sleep problems throughout life, which continue as they age and transition across menopause. “Those groups are pretty much flat” in trajectory, Joffe said. “The fourth group is a smaller subgroup, which is about 15%. They are the ones who come into menopause, they’re great sleepers, they really don’t have trouble, but their line [of sleep trajectory] is like climbing up a slide in terms of developing a new sleep problem.”
One of the most common sleep disturbances specific to menopausal women is waking due to hot flashes, or night sweats — Joffe said night sweats are caused by hot flashes and she only uses the latter term. Joffe noted that in women experiencing hot flashes, verbal memory performance related significantly to the number of nighttime hot flashes.
A lesser-known impact of menopause on women’s sleep is increased likelihood of sleep apnea.
“Women are more protected against having sleep apnea than men until they reach menopause. Then around the menopausal transition they begin to catch up with men. That’s in part because of that hormonal change in estrogen,” Zee said.
Symptoms women should watch for include snoring or gasping in one’s sleep, morning headaches, and sleepiness throughout the day.
Women with mild hot flashes may be able to fall back asleep or make changes in environment to improve their sleep. Joffe recommends working to make the bedroom environment cool and relaxing: Cooler pajamas, fan placement to improve air flow, and special mattresses and sheets can all help.
Women going through menopause often wake up sweating but feeling cold, according to Zee. “I recommend wearing a loose T-shirt or sleeping shirt that’s easy to dry. Thick cotton would be a bad idea. It has great absorbance, but it dissipates really quickly as well,” she said.
Sleep hygiene is important for anyone experiencing sleep disturbances. Paying attention to light exposure and getting more light during the day and less at night can make a big difference, Zee said. Paying attention to meal times is important too, and people with sleep disturbances should try not to eat within 2 to 3 hours of bedtime.
Although many patients may have some familiarity with sleep hygiene, Joffe said, few understand good sleep hygiene for the middle of the night, or for waking up mid-sleep.
“The two things that are key are don’t look at the clock — as soon as you look at the clock your brain is more alert, active,” she said. “And the second thing ... is [to] get out of bed. ... You break the association with the bed as a place of frustration with not sleeping.”
Importantly, this time out of bed should not include screens of any kind. Joffe recommends browsing a magazine with low lighting for a short period of time and then going back to bed.
For severe hot flashes, Joffe said hot flash treatments, such as hormones or serotonin-based antidepressants, will help lessen symptoms, but these will only work for hot flashes and menopause-related sleep problems, not for any other sleep disturbances.
Cognitive b ehavioral th erapy
Both Joffe and Zee recommended cognitive behavioral therapy for insomnia (CBT-I) as an alternative to medication. Lee Ritterband, PhD, the Jean and Ronald Butcher Eminent Scholars Professor at the University of Virginia School of Medicine and director of the Center for Behavioral Health and Technology, has served as principal investigator for a number of NIH grants focused on a CBT-I intervention called Sleep Healthy Using the Internet, or SHUTi. Ritterband and his team have created a new version of SHUTi specifically for adults aged at least 55 years called SHUTi OASIS: Sleep Healthy Using the Internet for Older Adult Sufferers of Insomnia and Sleeplessness. They are currently recruiting participants for a new randomized controlled trial of the program.
Ritterband said the SHUTi intervention is based on CBT-I, a gold standard treatment that has been well validated.
“The cognitive part of CBT-I focuses on how we think about our sleep and the issues that revolve around sleep and work to change those,” Ritterband said.
The behavioral piece centers on instituting good sleep habits and avoiding sleep behaviors that are not compatible with sleep.
SHUTi addresses both components as well as related issues, such as sleep hygiene and relapse prevention. In addition to learning about the various techniques and strategies to improve sleep, the program encourages the user to enter daily sleep diaries.
“The sleep diary is a really important part of the program and helps tailor the program to the user,” Ritterband said. “The computer continues to modify that sleep window based on what the user has entered.”
CBT-I can incorporate symptoms caused by menopause.
“Hot flashes tend to be a primary issue for women who are going through menopause, and this can certainly impact sleep. CBT-I addresses issues such as hot flashes by focusing on the related thoughts and behaviors,” he said. For example, the cognitive piece of the intervention for a menopausal woman would focus on the sleep effects of hot flashes.
Menopause just one part of equation
Although hormonal changes should be kept in mind, Zee said, they should not keep providers from looking for other causes of sleep disorders in menopausal women. Sleep difficulties can be caused by metabolic disorders, thyroid disorders, iron deficiencies and depression, among others, and providers who assume menopause is the single cause of sleep disorders in menopausal women could be overlooking health problems that can be addressed in a targeted fashion, she said.
“We don’t want to just chalk it up to [hormones],” she said. “We need to treat sleep difficulties or insomnia symptoms like fever, and try to figure out what the cause of it is.” – by Amanda Alexander
Espie CA, et al. JAMA Psychiatry. 2018;doi:10.1001/jamapsychiatry.2018.2745.
Maki PM, et al. Menopause. 2008;doi:10.1097/gme.0b013e31816d815e.
An interest form to join SHUTi OASIS is available at oasis.shuti.org.
For more information:
More information on SHUTi OASIS can be found at www.shutioasis.org.
Hadine Joffe, MD, MSc, can be reached at firstname.lastname@example.org.
Lee Ritterband, PhD, can be reached at email@example.com.
Phyllis C. Zee, MD, PhD, can be reached at firstname.lastname@example.org.
Disclosures: Joffe reports she has received research funding from Merck, NIH and Pfizer and Merck and has consulted for KaNDy and Sojournix. Ritterband reports he has equity ownership in BeHealth Solutions LLC, a company that has licensed the SHUTi program and the software platform on which it was built from the University of Virginia. The terms of this arrangement have been reviewed and approved by the University of Virginia in accord with its conflict of interest policy. Zee reports no relevant financial disclosures.