Sleepless In Menopause

I won't see it but raise your hand anyway if you are sleepless in menopause. Let me be the first to raise mine. 2 am seems to be a great time to have all of the thoughts I couldn't have all day, and then again at 3 am and 4 am.  I’ve never been a great sleeper, but the sleep disturbances during perimenopause are much more disruptive than anything I’ve ever experienced.  At the beginning of my perimenopausal roller coaster ride, I experienced mild hot flashes and thought, “ok, I can deal with this,” and I did. It wasn’t too bad, and once they disappeared, I thought I got lucky. But, surprise, one year later, here they are again, and this time, they came back with a little bit more spice and heat. During the day, they don’t bother me so much, but at night, I’m unable to get any sleep because of the constant interruptions; I get hot, take off my covers, get cold, put them back on, repeat about 20-30 more times, and that’s become most of my nights. Because I love researching and finding solutions, I’ve dug into the research to find options that may work, and here are some of the things I’ve discovered. 

In his book “Why We Sleep,” Dr. Matthew Walker writes, "sleep is the single most effective thing we can do to reset our brain and body health each day." Well, that’s great to know, but what do we do when sleep doesn’t come easy? Next to hot flashes and night sweats, insomnia is one of the most well-known symptoms of menopause. The link between menopause and sleep disorders is well-established. Studies have shown that 47 to 67% of postmenopausal women have obstructive sleep apnea and suffer from sleep problems. 26% report having such severe symptoms that it affects their daytime functioning. Lack of sleep is possibly the most detrimental of all menopause symptoms because it affects our body’s ability to function properly. Without sleep, nothing else works. Several studies show that even a short period of sleep deprivation affects our cognition, memory, reaction time, and ability to handle stress. One 10-year study of 70,026 women showed that those that slept less than 5 hours per night had a higher risk of being diagnosed with diabetes. Here’s a statement from the 2022 NAMS Position Statement on Hormone Therapy: “Sleep disruptions are strongly associated with VMS and a decreased quality of life. Poorer sleep quality has been associated with mood fluctuations, memory problems, metabolic syndrome, obesity, and other cardiovascular risk factors. Short (or very long) sleep duration, poor sleep quality, and insomnia have been associated with greater cardiovascular disease (CVD) risk.” Further research indicates that sleep affects two important hormones related to appetite: ghrelin and leptin. Ghrelin, which increases appetite, is higher with a lack of sleep.  Leptin, which decreases hunger, is lower with a lack of sleep. 

Menopause is believed to disrupt normal sleep function through two main mechanisms: (1) Hormones: changing levels of estrogen and follicle-stimulating hormone (FSH) have been associated with problems falling and staying asleep. (2) Vasomotor symptoms (VMS): hot flashes and night sweats. 

So what can we do about getting more sleep? It’s worth trying well-known basic sleep tips, but if your insomnia is more severe, here are some research-backed options: 

Cognitive-Behavioral Therapy (CBT)

CBT-I is a well-researched form of treatment for insomnia. It focuses on helping you identify and replace thoughts, attitudes, feelings, and behaviors that cause or worsen sleep problems with thoughts and habits that promote sound sleep. CBT-I aims to improve your ability to respond to challenging and stressful situations.

Physical Activity

In general, it is safe to say that women who exercise are less likely to be depressed, more likely to sleep better, and overall report more positive effects on menopause symptoms. Regular exercise has also been linked to improved sleep. That said, what specific exercise is best for you may vary. I can bury you in lists of studies that show the benefits of resistance training, aerobic training, walking, mindfulness, yoga, tai chi on sleep and insomnia but one may be more beneficial than the other for YOU. So you have to give it a try. 

Here are two tips that seem to work for a lot of people (1) try to avoid exercising close to bedtime; (2) morning workouts may be more beneficial. If you’re just starting out on this journey, these may be two good things to start with.

I have found that for myself, I can’t work out later than 3 pm, and that high-intensity (HIT) exercise gives me hot flashes that might carry over. BUT, I love HIT, so if I choose to do that, I opt to do it early in the morning. It is all about finding what works for you. It may take a little time but it will be worth it rather than trying someone else’s “method” that they so conveniently are trying to sell you. 

Menopausal Hormone Therapy (MHT)  

This is a polarizing topic, and deciding whether to try MHT is very personal. I am not advocating for or against it but I want to present what the science says. Personally, my lack of sleep has caused my quality of life to take enough of a dive that I am consulting my doctor about possibly using MHT to help me through this rough patch. I’ll be happy to report my experience if I decide that it is a beneficial and safe route for me to take. From a research perspective, MHT, also known as HRT, remains the most effective option for specific symptoms. I say specific symptoms because MHT has been recently presented as the end-all-be-all of menopause treatments that can be used for all menopause symptoms. That is just not true. There is abundant research indicating the benefit of MHT on vasomotor symptoms (VMS) (hot flashes and night sweats), genitourinary syndrome (GSM), and insomnia. The latest NAMS position statement states that “Hormone therapy in the form of low-dose estrogen or progestogen may improve chronic insomnia in menopausal women, with 14 of 23 studies reviewed showing positive results. There is some evidence that transdermal ET may benefit sleep in perimenopausal women, independent of VMS.” Additionally, they state, ”Hormone therapy is the most effective treatment for VMS and GSM and has been shown to prevent bone loss and fracture.” If you want to learn more about the pros and cons of MHT, check out my post on this topic. 

What’s your experience? I’d love to hear how you’re coping or if you’ve found anything that has worked for you.