If you put 100 women going through the menopausal transition into a room and asked each one if she has trouble sleeping, roughly half would tell you, “Yes, I do!”
Why are sleep problems so common during this time? You’re probably thinking—hot flashes! And it’s true that waking up in the middle of the night drenched in sweat counts as “trouble sleeping.” But there are many other triggers of sleep problems around the time of menopause. One large 14-year study of sleep and menopause found that while hot flashes were strongly linked with sleep problems for some women, a large percentage of poor sleep happened to women in the absence of hot flashes. Other research has found that some women self-report that hot flashes are the cause of their sleep problems, but when their hot flashes and sleep are monitored in a sleep lab, that link just isn’t there.
This research is important because it suggests that the sleep problems experienced by midlife women may be connected to other causes that may be going unnoticed…and unaddressed. To learn more, we spoke with Michael Breus, PhD, a clinical psychologist and an expert on sleep problems.
If hot flashes aren’t alone on the hot seat for menopausal sleep problems, what other issues are linked to both menopause and poor sleep? One may simply be a coincidence—age. Just getting older is, unfortunately, often a game-changer when it comes to sleep. Brain levels of melatonin, a hormone that helps control sleep and wake cycles, decline with age in both genders. Diagnoses of chronic insomnia—defined as problems falling asleep and/or staying asleep that happen at least three times a week and continue for at least three months—may just happen coincidentally around the time of menopause symptoms.
While there isn’t much you can do about age, there are a few other health issues that you can actively address…
Sleep apnea. This condition, in which breathing pauses or stops multiple times during the night, causing multiple awakenings, may play an important role in menopause-related sleep disorders. Before menopause, women are only half as likely as men to have sleep apnea, but the rate rises steadily after menopause. Why isn’t clear, but a leading suspect is menopausal weight gain. It’s well-established that being overweight or obese greatly increases the risk of having sleep apnea. (Oddly enough, one symptom of sleep apnea in postmenopausal women is nocturnal enuresis…bed-wetting.) What do to: If you suspect you may have sleep apnea, ask your doctor about getting a sleep study—or get a referral to a sleep center (see below).
Restless leg syndrome (RLS). This often-overlooked problem affects up to 10% of the population, mostly women. RLS sufferers describe creeping, crawling sensations in their legs that occur at rest and at night. Sometimes RLS causes involuntarily movements of the legs that can wake up someone from a sound sleep. In one study of 100 perimenopausal and postmenopausal women with poor sleep who underwent a sleep study in which their hot flashes, leg movements, breathing and sleep quality were measured, more than half were found to have either sleep apnea, RLS—or both. And interestingly, laboratory-measured hot flashes were not found to be major predictors of the subjects’ sleep efficiency (how well they slept according to scientific measurements). What to do: If you suspect RLS, ask your doctor to give you a ferritin test to see if you’re anemic. If you are, your doctor will likely recommend iron supplementation, which can be quite helpful for relieving restless leg syndrome. If iron is not the issue, seek out a neurologist who is certified in sleep medicine.
Stress. It may be a ubiquitous catchall, blamed for everything from heart disease to cancer to obesity, but stress is a major contributor to poor sleep. When we perceive danger or a threat, our bodies produce the so-called stress hormone cortisol. This substance floods our bodies with extra energy and heightens awareness. Not exactly a great state for restful sleep! Falling levels of estrogen may also make the brain less resilient to stress. During the transition to menopause, levels of both hormones fluctuate to an unusual degree, often over a period of several years. This state of hormonal flux can make good sleep harder to get.
And let’s be honest…menopause itself can be psychologically stressful. Anxiety and emotional issues surrounding the menopause transition can feed into these physiological processes, making stress worse…and sleep more elusive. What to do: One of the best ways to learn new ways to handle stress during menopause is cognitive behavioral therapy. (Bonus: It also helps with hot flashes and night sweats.)
It’s all well and good that researchers are investigating the causes of sleep difficulties that plague women at midlife, but if you’re staring at the ceiling at night and nodding off during the day, what you really need are solutions. If you’ve ruled out a medical condition such as sleep apnea or RLS, the first step is to get to the basics of good sleep hygiene…using your bed only for sleep and sex…banishing noise…turning down lights and turning off TV and other screens (phones, laptops, tablets) an hour before bedtime…and keeping to a consistent bedtime/wake-up schedule.
Next, practice these tips, based on the latest research, that zero in on the sleep issues that women in menopause and perimenopause are most likely to experience…
Keep your bedroom cool. This is a good idea for everyone, but it’s especially important if you are prone to hot flashes—or their midnight cousins, night sweats. As you sleep, your core body temperature drops a few degrees, which helps trigger your body to fall asleep. Help this process along by keeping your bedroom temperature between 60°F and 67°F. There are also special chilling pillows, blankets and mattress pads that can help keep you cool. I like the Chillow pillow and the ChiliPad Cube.
Practice deep breathing. If you wake up in the middle of the night, what you do in the next few minutes can make the difference between drifting back to sleep or remaining wide-eyed until morning. Just like your body temperature, your heart rate decreases when you’re asleep. If you wake and immediately succumb to being frustrated and angry at your wakefulness and probably allowing worries about the next day to creep in, your heart rate inevitably rises. That makes it harder to fall back to sleep. Since menopause is a time when stress levels rise, it’s particularly important to learn ways to bring your heart rate down quickly—like deep breathing. My favorite: The “4-7-8 method.” To do it, slowly breathe in for four seconds, hold for seven seconds, and slowly breathe out for eight seconds. Repeat this exercise five to 10 times or as long as necessary until you feel more relaxed and drowsy.
Become a quick-change artist. If you’re having hot flashes and waking up soaked to the skin, keep an extra set of PJs by your bed so that you can quickly change without rousing yourself much. It’s not just about getting into dry sleep clothes—you also want, again, to keep your heart rate from climbing, which it might do if you had to get up, flip on the light and rummage through your dresser or closet. The idea is to limit the amount your heart rate climbs.
If all else fails, get up! If your deep-breathing exercises don’t work and you’ve been lying awake in bed for more than 30 minutes, it’s time to get out of bed. Why? You don’t want to train your body into the idea that lying awake for long periods is a normal part of your sleep pattern. You can sit in a chair and read a book (no screen!). I often suggest to my patients that they create a gratitude list—with a pad and pen or pencil, write down a few things or people that you’re glad are in your life. It’s a positive thing to reflect on until you feel tired enough to go back to sleep.
Time your caffeine and alcohol. If you’re experiencing problems with sleep, you probably know that you should avoid having a latte at 6 pm—or even 3 pm. After all, it takes up to five hours for the body to get rid of half the caffeine that you consume. But what about alcohol? Although a drink may make you drowsy at first, a few hours later, as your body processes the alcohol, it can increase your heart rate and body temperature, waking you up from a sound sleep. I ask women to stop drinking alcoholic beverages about three hours before bedtime. (Caffeine and alcohol can also be hot flash triggers for some women.)
Watch out for antianxiety medications. Benzodiazepines (such as Valium and Xanax) are prescribed for anxiety—which menopause can sometimes bring on—and it can be tempting to use them for sleep. While these pills can reduce anxiety, however, they don’t actually help you sleep better…and they’re habit-forming. If you have been prescribed a benzodiazepine for an anxiety disorder, that’s one thing, but don’t use it for the sole purpose of helping you sleep.
Investigate a sleep center. If you have sleep problems that last longer than three months, consult a sleep expert—if you can, at a sleep center. These centers, sometimes located at large academic medical institutions, are stocked with the latest diagnostic equipment and can help determine what is keeping you from a good night’s sleep. You can find a sleep center near you by putting “find a sleep center” into any search engine. (You may also be interested in my recent blog post, “When is it time for a sleep study?”)
Try cognitive behavioral therapy. This specialized form of therapy focuses on changing our cognitive processes (how we structure our thoughts) and our behavior (how we act). Increasingly, sleep experts advocate this approach as a way to tackle many common sleep problems without the use of drugs. CBTI—the “I” stands for insomnia—is specifically designed to help treat insomnia. Finding a therapist who practices CBTI can be challenging, but there are online programs (like Sleepio and SHUTi) that allow you to take a self-guided course.
Getting a good night’s sleep on a regular basis is one of the best things you can do to feel better and stay healthier—even protect against menopause-related depression. Want even more motivation? Good sleep may be the key to a better sex life, too.
