Menopause and sleep ... or not

By Alison Mitchell, M.D., primary care physician, Providence Medical Group-Cascade 

By the time women hit their 50s, sleep is something that many of us no longer take for granted. Anxieties about teenaged kids and aging parents now churn through our sleepless heads at night. New aches and pains jolt us from foggy slumbers. An uncooperative bladder forces us out of bed in the wee hours, and once we’re up, all hope of returning to sleep is lost as a tsunami of fresh worries washes over our brains. 

At this time of life, our relationship with sleep can be tempestuous, to be sure. But add hot flashes and night sweats to the mix? Now you’ve got the perfect storm for some serious insomnia.

Upwards of 60 percent of women experience some insomnia in the hormone-shifting perimenopausal years. Those with the most severe hot flashes, according to one study, have the most difficulty with sleep; about 80 percent of them experience chronic insomnia. But we can’t blame hormones for all of it. For most women, those stormy nights are brought on by some combination of age, health, hormones and life in general.

So what’s an exhausted, frustrated, sleep-deprived woman to do? At some point, you just have to accept that sleep issues are having a significant impact on your life, and send out a Mayday. Initiate a conversation with your doctor to talk about everything that could be affecting your sleep, from changes in your physical and emotional health to perimenopausal symptoms – even your partner’s snoring. Then work with your doctor to address each issue individually and lash together a life raft of strategies that works for your unique set of circumstances. 

Treating hot flashes

Anything that relieves the blistering, sheet-drenching hot flashes that wake you up throughout the night will improve your sleep. The gold standard in medical treatment is hormone replacement. In follow-up studies, it has not been shown to be the evil that it once was portrayed to be. When used appropriately, in the lowest effective dose and only while symptoms are at their worst, hormone therapy is safe and very effective for most women. If you are absolutely suffering – and there are a lot of you out there – it’s probably your best bet.

For women who can’t take hormones due to other risk factors, or who prefer not to, Gabapentin and Effexor can be effective alternatives. Although these prescription medicines were developed for other purposes (Gabapentine is an anti-seizure medication, and Effexor is an antidepressant), reliable studies show that they do relieve hot flashes for some women. 

As far as natural remedies go, the research is less convincing. I have not found the phytoestrogens – soy, flaxseed, red clover and black cohosh – to be very effective, and the data don’t support them, but some of my patients have found these to be helpful. 

The best approach involves lifestyle changes. Hot flashes tend to be the worst in women who are overweight, inactive and/or smokers. These are very difficult issues to overcome, but women who are able to turn them around do improve their hot flashes, their sleep and their health in general.

Treating bladder issues

For some women, as estrogen levels sink, so does bladder strength. Doing daily kegel exercises and limiting fluids for two or three hours before bed can help reduce the number of nighttime bathroom trips. A visit to your doctor is a good idea, too, to rule out other problems and talk about additional therapies that may help.

Treating other health issues

Restless legs syndrome, sleep apnea, chronic arthritis pain – all of these health issues can affect sleep in a big way. When talking to your doctor about your sleep issues, be sure to go over your entire health history – treating underlying health conditions could make a big difference in the quality of your sleep.

Treating anxiety and depression

Worries and repetitious thoughts that take hold of your brain at night and won’t let go are classic signs of anxiety and depression, both of which increase with age. That’s probably why some studies show that certain antidepressants are effective treatments for menopause symptoms: What they’re more likely treating is underlying anxiety or depression, and once that’s under control, the other symptoms get better.

Other things to try

  • Less alcohol and caffeine: Alcohol has a significant effect on both hot flashes and sleep, and it affects women much more noticeably after 50. Caffeine affects both hot flashes and sleep as well. Cutting back or eliminating these should make a big difference.
  • Sleep medication – occasionally: Some women find over-the counter sleep aids helpful, but many feel groggy and out of sorts the next day. Prescription sleep medications, while definitely helpful on the worst nights once or twice a month, should not be relied on for nightly use. If you need to take something for sleep every night, that’s a red flag – you should probably talk to your doctor about it.
  • Magnesium: Studies show that magnesium can be very helpful for nighttime leg cramps, but there’s no data to support that it actually improves sleep. That said, I’ve had patients who’ve had good luck with it, so it’s worth a try.
  • Melatonin: As with magnesium, the data are not clear cut, but some patients do find melatonin helpful. 
  • A bedroom makeover: Take a fresh look at your bedroom, and turn it into your oasis. Maybe it’s time to install a ceiling fan; to try new pajamas or sheets in breathable fabrics; to invest in total blackout shades.
  • A health journal: I recommend this to women frequently: Keep a journal of what you do, how well you sleep and how you feel every day. Focus on the good nights as well as the bad. If you have a great night of sleep and wake up feeling fabulous, check your journal: What did you do differently? Did you eat something different? Exercise at a different time? Take a warm bath – or cool shower – before bed? A journal can reveal the patterns that help or hinder your sleep.
  • The one thing that makes everything better: Nobody wants to hear this, but the one thing that has consistently been shown to help with both menopause symptoms and insomnia is exercise. It has been clinically proven to reduce hot flashes and regulate sleep patterns. It also helps improve weight control, anxiety, depression and many of the other health issues that affect sleep. Exercise in the mornings to avoid any issues with elevated body temperature at bedtime – and to make sure that no excuses get in the way of your workout later in the day.

Every woman is completely different, but we all age, we all go through menopause, and some of us will experience turbulent nights along the way. You may not be able to change the weather, but with the right strategies and support, you should be able to ride out the storm and make your way to the calmer waters ahead.

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