What are insomnia and sleep disturbances?

Insomnia is the most common sleep disorder, characterized by difficulty sleeping for days, weeks or even months. It may include having trouble falling asleep or waking early and being unable to get back to sleep. Insomnia has lasting effects into the day, causing lingering feelings of tiredness and/or “brain fog” – impaired brain function leading to memory loss, trouble concentrating and loss of ability to plan. Sleep loss caused by the environment (too much light or noise) is not insomnia. Chronic insomnia can be experienced by about 10% of adults but it is more common in women during the menopausal transition.

For women in the menopausal transition, insomnia can be the primary disorder or it can be a secondary condition associated with hot flashes, mood disorders, psychosocial factors, or other sleep disturbances such as obstructive sleep apnoea (OSA) or restless legs syndrome (RLS). This secondary insomnia is triggered by hormonal changes during perimenopause and postmenopause1.  

Estrogen and progesterone decline may be involved, as well as the sleep hormone melatonin. These hormones are involved in maintaining daily (circadian) biorhythms. Pre-menopause, about 12% of women report trouble sleeping. This increases to 40% during the menopausal transition and up to 60% postmenopause.

Insomnia during menopausal transition is often coupled with physical pain, chronic stress, anxiety, depression and/or hot flashes. Depression and insomnia are bidirectional: they reinforce each other, becoming a feedback loop – depression leads to insomnia, which leads to more depression, which leads to more insomnia, and so on. Similarly, chronic stress often increases anxiety, and both interfere with sleep. 

Insomnia is a serious condition. Deep sleep is crucial for overall health and muscle and nerve repair. Lack of deep sleep due to insomnia increases headaches and inflammation. It can also lead to an increased risk for cardiovascular disease, obesity, depression and other illnesses. Even without insomnia postmenopausal women are already at a higher risk of developing those health conditions.

Self-care for insomnia

It is important to seek medical help if insomnia lasts for a few weeks or more. A physician can help rule out any underlying health conditions that might interfere with quality sleep. 

You can also take steps at home to address sleep issues, starting with improvements to your sleep hygiene.

  • Use your bedroom only for sleep and sex. The bedroom is not for watching TV or spending time on electronic devices. This helps train the brain to leave worries and stress from the day outside of the sleeping environment.
  • Sleep in a cool, very dark room.
  • Don’t look at bright lights before bedtime, especially those in the blue light range. While all visible light suppresses secretion of melatonin, blue light is particularly disruptive. Smartphones, televisions and computers emit in the blue light range, so minimize screen time on phones and computers 2 hours before bedtime.
  • Keep a similar bedtime every day, and eat at regular times during the day.
  • Avoid alcohol two hours before bedtime.
  • Quit or cut back on smoking or other use of tobacco products, as nicotine is a stimulant also known to disrupt sleep.
  • Melatonin therapy may help short term insomnia but may not help over the long term. Sunshine boosts melatonin production, and studies have shown an improvement in sleep with exposure to sunshine during the day.
  • Exercise, particularly in outdoor daylight, to improve circulation and relaxation and to increase your natural sleep drive.
  • Journal the events in your life to see how they correlate with insomnia. 
  • Some people find that meditation and mindfulness exercises before bedtime improves sleep.

Shift work harms sleep quality, which is further disrupted during menopausal transition. Shift workers may need professional therapy to help with the combined effects of the menopausal transition and altered schedules.

Sad depressed woman suffering from insomnia, she is sitting in bed and touching her forehead, sleep disorder and stress concept

Therapy for insomnia

If you do not already have a healthcare practitioner who is familiar with identifying and treating symptoms of menopause, the North American Menopause Society provides a list of menopause practitioners  here.

Anti-anxiety and anti-depression medications combined with psychological counseling may be very helpful. Cognitive Behavioral Therapy (CBT) is a short-term therapy technique used to alter behaviours by changing thought patterns which has been shown to be quite effective for insomnia. 

There is not yet clear data that supports the usefulness of current Hormone Therapies (HT) for helping insomnia. However, HT can be effective at treating hot flashes that can be the primary cause of insomnia for some women. Hormone therapy (HT) with estrogen may be helpful for preventing short-term memory loss and minimizing sleep loss resulting from hot flashes. HT with progestogens may also help.

Physiotherapy may be able to help sleep quality by decreasing physical pain and increased mobility.

Check if you (or your bedmate) have obstructive sleep apnea (OSA), characterized by snoring, gasping or disrupted breathing while asleep. Apnea can be dangerous, so consult a physician if you suspect it may be a contributing factor.

Female shift workers need to be vigilantly screened for breast cancer, as they have a 48% increased risk for developing breast cancer.

The Science

 

Biological clocks are rooted in biochemistry and gene functions, and control all aspects of body and brain function. Human biological clocks follow a circadian cycle: an intricate daily rhythm of interactions in genes, cells, tissues, and behavior.

Two brain regions, the hypothalamus and suprachiasmatic nucleus, regulate sleep and waking circadian cycles, and are sensitive to fluctuations and decreases in estrogen and melatonin that happen during perimenopause and postmenopause. This may cause disruption of sleep. 

Melatonin, a hormone secreted by the pineal gland at night, primes the brain and body for rest and repair at night. Melatonin secretion may be affected by fluctuations and declines in estrogen and possibly progesterone.

Melatonin suppresses breast cancer tumors, and its disruption may be linked to a higher risk of breast cancer.

Statistics

Insomnia and disrupted sleep during menopause can have short- and long-term impacts on overall health and quality-of-life.

0%

Perimenopausal American women experiencing insomnia symptoms ≥3 times per week

0x

Increased odds of experiencing insomnia when moving from early to late perimenopause

0

Per-year increase in risk of sleep apnea during perimenopause

FALSE

At first alcohol is relaxing, but it actually interferes with the brain and body’s ability to sleep deeply and for long periods.

FALSE

No, insomnia is common, and as a result there are many helpful therapies and self-care actions available to address it.

FALSE

TV may be boring, but bright light and blue light can disrupt melatonin release and biological clocks.

MYSTERY

Insomnia is a very common condition in modern life and is caused by environmental, social and biological factors. Research is actively trying to untangle the complex outcomes of these interactions.

Compiled References

  1. Caretto, M., Giannini, A., and Simoncini, T., An Integrated Approach to Diagnosing and Managing Sleep Disorders in Menopausal Women.Maturitas, Volume 128, October 2019, Pages 1-3
  2. Brinton, R. D., Yao, J., Yin, F., Mack, W. J., & Cadenas, E. (2015). Perimenopause as a neurological transition state. Nature reviews. Endocrinology, 11(7), 393–405. https://doi.org/10.1038/nrendo.2015.82
  3. Baber, R. J., Panay, N., Fenton, A., & IMS Writing Group (2016). 2016 IMS Recommendations on women’s midlife health and menopause hormone therapy. Climacteric : the journal of the International Menopause Society, 19(2), 109–150. https://doi.org/10.3109/13697137.2015.1129166
  4. Bulan, S. E. (2019). Physiology and Pathology of the Female Reproductive Axis. In Melmed, S., Koenig, R., Rosen, C., Auchus, R. & F. Goldfine (Eds.), Williams Textbook of Endocrinology (14th ed., pp. 574-641). Elsevier.
  5. Caruso, D., Masci, I., Cipollone, G., & Palagini, L. (2019). Insomnia and depressive symptoms during the menopausal transition: theoretical and therapeutic implications of a self-reinforcing feedback loop. Maturitas, 123, 78–81. https://doi.org/10.1016/j.maturitas.2019.02.007
  6. Minkin, M.J.(2019). Menopause Hormones, Lifestyle, and Optimizing Aging. Obstetrics Gynecology Clinics of North America, 46(3), 501–514. https://doi.org/10.1016/j.ogc.2019.04.008
  7. Jehan, S., Jean-Louis, G., Zizi, F., Auguste, E., Pandi-Perumal, S. R., Gupta, R., Attarian, H., McFarlane, S. I., Hardeland, R., & Brzezinski, A. (2017). Sleep, Melatonin, and the Menopausal Transition: What Are the Links? Sleep Science, 10(1), 11–18. https://doi.org/10.5935/1984-0063.20170003
  8. Pacheco, D. (2020, October 16). Shift Work Disorder Symptoms. The Sleep Foundation. https://www.sleepfoundation.org/shift-work-disorder/symptoms
  9. Sabia, S., Fayosse, A., Dumurgier, J. et al. (2021). Association of sleep duration in middle and old age with incidence of dementia. Nature Communications, 12(2289). https://doi.org/10.1038/s41467-021-22354-2
  10.  Lockley, S. W., Brainard, G. C., & Czeisler, C. A. (2003). High sensitivity of the human circadian melatonin rhythm to resetting by short wavelength light. The Journal of Clinical Endocrinology and Metabolism, 88(9), 4502–4505. https://doi.org/10.1210/jc.2003-030570