Insomnia

Sleep Disturbance and the Menopause

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Sleep disturbance, or insomnia, is a common problem in menopause. Having problems sleeping is not only unpleasant, it also affects quality of life, increases the risk of accidents, and can reduce concentration and memory.

Insomnia – unsatisfactory sleep – occurs in up to twice as many women during and after menopause compared to younger women. This deterioration in sleep usually starts a few years before menopause.

Causes

Sleep disturbance in menopause is not due to one single reason. Many factors may affect different women in varying degrees, including:

  • Hot flushes and night sweats: Common at night, hot flushes are often severe enough to disrupt sleep. Women treated for flushes have been shown to have improved sleep. HRT is the most effective treatment for hot flushes and night sweats. ( see AMS pamphlets on HRT and Non-Hormonal Treatments for Menopausal Symptoms)
  • Depression: Women with depressed mood and anxiety experience poor or insufficient sleep; (see AMS pamphlet on Depression and Menopause).
  • Sleep apnoea: Menopausal hormonal changes appear to affect the upper airway, restricting air flow and in some cases causing the disorder, sleep apnoea, usually accompanied by snoring. Oestrogen loss causes body fat to redistribute to the abdomen, a known factor in development of abnormal breathing.
  • Restless legs: This is a surprisingly common reason for poor sleep in women during menopause. The condition involves episodes where women have an irresistible urge to move their legs and may have unpleasant and uncomfortable feelings in the legs. This is often worse at rest.
  • Unknown: there are cases when no cause is found for disturbance in sleep pattern.

Relief

The cornerstone of management is “sleep hygiene”. This is a series of steps women can take to control the environment of their bedroom, the timing of sleep and avoidance of food and drink that may overstimulate.

Steps to follow when you cannot fall asleep:

  1. Get up if you cannot sleep after trying for 15 to 20 minutes. Staying in bed while restless and anxious is unlikely to result in sleep.
  2. Do something quiet and distracting (e.g. cards, reading, jigsaw, knitting, warm bath). If your mind is active or you are worrying about problems in your life engage in an activity requiring mental effort such as a crossword. By distracting yourself from worries you may find it easier to wind down and become sleepy.
  3. Write a list before you go to bed of any worries that you have and then resolve to address this in the day time.
  4. Go back to bed when you feel more relaxed and sleepy.
  5. If you are still awake after a further 15 to 20 minutes of trying to sleep get out of bed again.

Tips for improving sleep long-term

When you wake up:

  • Get out of bed as soon as you wake up. Do not attempt to make up for “lost sleep”.
  • Try to get up about the same time each morning, about 7 – 7.30 am.
  • Go outside into the sun.
  • Do some physical activity, like walking to get the newspaper.

During the day:

  • Do not nap. If you nap you will be less tired when you go to bed and it will take longer to fall asleep.
  • If you are worrying about things during the night, identify the problems that are causing you stress and set aside time during the day for problem solving. Ask your GP about the technique of “structured problem solving”.
  • Aim to be active in the early morning or late afternoon – it helps set your body’s daily clock.

Late afternoon:

  • Avoid drinking caffeine after about 4 pm. Try not to drink more than two cups a day of caffeinated drinks (e.g. coffee, strong tea, cola).
  • Be active while the sun is up.

Before going to bed:

  • Avoid going to bed too early, (not before 10 PM) it is not the right time for deep sleep.
  • Avoid using alcohol to help you sleep. Alcohol is broken down in your body and causes you to sleep less deeply and wake more frequently.
  • Do not smoke within an hour or two of going to bed. Smoking stimulates your nervous system.
  • Do not go to bed hungry or with a full bladder.
  • Regular exercise can improve sleep, but avoid vigorous exercise late in the evening.
  • Allow yourself time to wind down before bed. If you are working or studying, stop at least 30 minutes before bedtime and do something relaxing.
  • Use your bed only for sleep and sex! Avoid reading or watching TV in bed because by the time you turn off the light your body may be restless since it has been lying in bed for a while.
  • Avoid taking sleeping pills. If you do need sleeping pills, try not to take them for longer than a week because they are addictive.
  • Consider using a sleep diary. It would help you to observe your sleep pattern and may help your doctor with management.

While you sleep:

  • Try to make your bedroom quiet, dim and cool.
  • Avoid too many blankets and electric blankets. Too much heat stops deep sleep.

Other treatments for poor sleep

Hormone Replacement Therapy:

Women faced with significant symptoms at menopause may consider hormone therapy (oestrogen and progesterone).

  • Hormone replacement therapy may relieve many menopausal symptoms including sleep disturbance.
  • The decision to take these hormones should be based on the woman’s individual needs and attitude to the possible risks. (see AMS HRT pamphlets)

Alternative therapies:

Many women would prefer to use alternative or herbal treatments rather than prescribed medications.

  • It is unclear how effective these are in sleep disturbance.

Other prescription medications:

Other, less commonly used medications may help at this time.

  • Antidepressants: Where depression or anxiety is present, antidepressants may be helpful in improving sleep.
  • Sleeping pills, such as benzodiazepines (eg temazepam), are not recommended for regular use because of the high risk of addiction. Zolpidem is an alternative sleeping pill (not a benzodiazepine) which is sometimes used short-term for insomnia. However it should be avoided when sleep apnoea is present.

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