Menopause marks the time in a woman’s life when her ovaries become depleted and no longer make the eggs or the hormones estrogen and progesterone. As a result, her menstrual periods stop. Women also commonly experience other symptoms related to these changes in their hormones, such as hot flashes, night sweats, vaginal dryness, and changes in mood and sexual function. It is also the time at which almost 50% of women report poorer sleep quality, changes in sleep patterns—particularly waking up multiple times per night—and are at risk to develop new sleep disorders.
There are several ways by which menopause and its symptoms impact sleep. Nighttime hot flashes and night sweats are the most common reason that women report sleep problems. However, sleep may be also affected by other changes that occur with menopause and with normal aging. Research studies have identified stress, anxiety, depressed mood, as well as the onset of sleep disorders to be important factors that cause poor sleep quality in women leading up to or after the final menstrual period. In particular, during the perimenopause and in the early postmenopause, the risk of obstructive sleep apnea markedly increases. Approximately 30% of post-menopausal women have at least mild sleep apnea and 10% have moderate or severe sleep apnea. Compared with midlife women who are still premenopausal, peri- and early postmenopausal women are 2–3 times more likely to have obstructive sleep apnea.
There is some evidence that hormone changes associated with menopause make sleep apnea more severe. This can happen in two ways: (1) Hormone changes may impact where fat tends to get distributed on the body (unfortunately, often moving to the “middle”.) That “middle” or “central” fat also may be accompanied by extra fat in the throat, which makes snoring worse and may also lead to apnea. (2) Changes in hormones may also affect breathing patterns, leading to a more unstable breathing pattern, resulting in apneas. Lower levels of estrogen and progesterone (which normally play a role in stimulating breathing muscles) may make the muscles that keep the upper airways open for breathing more susceptible to collapse during sleep.
About 25% of women in the perimenopause period have insomnia, a disorder that is diagnosed based on persistent problems falling and/or staying asleep which affect daytime function and well-being. Insomnia may begin anew during the menopause transition or a previous insomnia condition may become more severe. Insomnia is most closely associated with nighttime hot flashes, but also has been linked with menopause-related hormone changes, age-related sleep changes, anxiety, stress, mood disturbance, sleep apnea, and to periodic limb movements in sleep.
Hormone changes or other age-related changes may also change our body’s natural rhythms and sleep patterns. As women get older, they find that they may get sleepier earlier in the evening, and wake up earlier. Sometimes this shifting sleep pattern can cause wakening so early it feels like practically in the middle of night. In both men and women, restless legs syndrome is more common with increasing age, but restless legs and periodic limb movement syndrome have not been linked with menopause.
Hot flashes are a major cause of sleep disturbance reported by women during peri- and post-menopause. Hot flashes occur in up to 80% of women at some point during this stage of life. While they vary in frequency and severity, on average they last for 7 years. They may have a large and sustained impact on a women’s well-being. Most women experience hot flashes during both the day and at night (also called night sweats). When they occur at night, hot flashes disturb sleep by triggering awakenings, which causes disrupted sleep. Some women may have a hard time falling back to sleep and therefore can spend a lot of time awake in the middle of the night. The more severe and frequent nighttime hot flashes are, the greater the likelihood that someone will have chronic insomnia.
It is important that women do not assume that difficulty falling or staying asleep, poor quality sleep, or new sleep (or daytime) symptoms are part of the “natural changes” of menopause, or that all of their sleep problems are only due to hot flashes.
Menopausal women with sleep disruption should talk to their health care providers about their sleep problems, particularly if they feel that they are experiencing new or worsening symptoms or if their sleep problems do not resolve within a few weeks. While treatment of hot flashes is often an essential component of improving sleep, it is also important to consider the other factors that can be identified and treated to restore sleep. Women should make sure they discuss with their doctor their sleeping environment and habits, alcohol, exercise and caffeine usage patterns, stress level, and any issues related to depressed mood, anxiety, snoring, urge to move the legs at night, as well as excessive daytime sleepiness or fatigue. These symptoms may be signs of sleep disorders, mental health, and other health conditions that may be contributing to poor quality sleep.
It is important to recognize that treatment of the sleep disturbance should be pursued if it interferes with daytime alertness, function, or mood. Research has shown that insomnia can be successfully treated with either medications or behavioral strategies such as CBTi (cognitive behavioral therapy for insomnia). Additionally, sleep disorders are treatable conditions.
Although we understand that many sleep disturbances are associated with sex hormone changes and that sleep apnea increases after menopause, there is a need to better understand the links among sex hormones, aging, menopause and sleep, and to identify more effective prevention and treatment strategies.
There are several research topics we suggest, but want your input, too!
An active research study based in Boston is looking at the relationship between menopause-related hot flashes and sleep patterns in women ages 45 to 65 years with hot flashes. Interested individuals can call 617-525-6459 or email kmccormick5@partners.org for further information.
McCurry SM, et al. Telephone-Based Cognitive Behavioral Therapy for Insomnia in Perimenopausal and Postmenopausal Women With Vasomotor Symptoms: A MsFLASH Randomized Clinical Trial.JAMA Int Med 2016; 176:913-20. A new study that describes the role of a telephone-based behavioral therapy for treating sleep in peri- and post menopausal women.
Joffe H, Massler A, Sharkey KM. Evaluation and management of sleep disturbance during the menopause transition. Semin Reprod Med. 2010; 28: 404-21. A review of the different types of sleep disturbances occurring around the menopause transition.
This article was written by Hadine Joffe, MD, MSc, Associate Professor of Psychiatry and Director of Women’s Hormones and Aging Research Program, Brigham and Women’s Hospital and Harvard Medical School, and Suzanne Bertisch, MD, MPH, Instructor of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School. The article was also reviewed and edited by MyApnea.Org patient leader, Sherry Hanes.
