Menopause And Sleep Disturbance 

"I think my sleep symptoms are due to my changing hormones" - at The Better Sleep Clinic it's common for us to hear this from women experiencing menopausal sleep disruption. 

It makes sense. Hormones change. Sleep changes.

The assumption then is: Correct your hormones, correct your sleep.
But is this actually true?

Do the hormone changes of perimenopause and menopause actually contribute to symptoms of insomnia? 

The science might surprise you.

Sleep Problems Related To Menopause - What We Know

Menopause is a natural biological process that marks the end of a woman's reproductive life, typically occurring midlife between the ages of 45 and 55. 

During the menopausal transition women will experience a decline in ovarian function that results in a series of biological changes and reductions in hormone levels such as estrogen and progesterone. 

These hormonal changes are often thought to affect sleep and it's commonly held that menopause causes insomnia. 

But surprisingly, only hot flushes aka hot flashes, and night sweats, key symptoms of menopause, have been scientifically linked to disrupted sleep. 

There has actually been a lack of evidence that other hormone changes related to menopause contribute to disturbed sleep. 

So what does contribute?

To answer this question, researchers from Perelman School of Medicine at the University of Pennsylvania conducted a 16 year study, one of the longest in the field, to find out.

Do Menopausal Hormone Changes Affect Sleep?

The Penn Ovarian Aging Study evaluated the sleep patterns of 255 women reaching natural menopause over 16 years, from 1996 to 2012.

At the start of the study the women had an age range of 35 to 48 years and were pre-menopausal. 

In terms of sleep, at pre-menopause baseline:
- 28% of the women reported having moderate-to-severe insomnia symptoms;
- 16% reported mild sleep quality problems ;
- 56% had no sleep issues

It's important to note that the 28% of women reporting insomnia difficulties is roughly the same as the 30% of adults at midlife in the general population that report sleep difficulties.

So at the start the women in the study were basically similar to the population average for insomnia symptoms.

The study then kept comprehensive records of sleep patterns throughout pre-menopause, menopause and postmenopausal period for the women.

The findings?

Menopausal Transition, Hot Flashes, Symptoms Of Insomnia...

Throughout the study the annual prevalence of moderate/severe sleep disturbance stayed at approximately 30% for the group (i.e. no different to the general population).

Hot flushes had a strong relationship with sleeping poorly regardless of sleep status before the transition. That was expected.

But…..

it was also observed that a large portion of menopausal women experiencing sleeping difficulties did not experience hot flashes.

And…

the study found hormone associations with sleep disruption were not significant (i.e. changing hormone levels did not affect sleep).

That's surprising. 

We already know hot flushes impacts sleep. 

But the study found no association between changes in a woman's hormones and menopause-related insomnia symptoms.

So if hormone levels didn't predict difficulty falling asleep and staying asleep, what did?

The researchers found that pre-menopause insomnia was the strongest predictor of moderate/severe sleep trouble during the menopause transition.

In fact, women with moderate to severe insomnia at pre-menopause baseline were 3.5x more likely to have moderate to severe insomnia during menopause than those with no sleep disturbances at baseline.

What about the other women in the study?

Women with mild insomnia symptoms pre-menopause had a significant increase in insomnia symptoms across the 16 years.

These women were 1.5x more likely to have moderate/severe insomnia during the menopause transition.

The lowest risk group were those with no prior trouble sleeping.

Only 25 percent of women who had no prior sleep issues experienced difficulty sleeping over the 16-year period around menopause.

Does Menopause Cause Insomnia?

From the above study, the short answer is: possibly not. 

Lead author, Ellen W. Freeman, PhD, research professor in the department of Obstetrics and Gynecology at the Perelman School of Medicine at the University of Pennsylvania commented:

"our results show that for the majority of women, menopause does not further exacerbate existing sleep issues or cause new ones."

Why?

First, the study found the overall prevalence rate of insomnia in menopausal women was no different to the general midlife population. 

Second, it seems that women with pre-existing sleep difficulties are the ones most likely to experience difficulty sleeping through the menopause transition. 

The study authors noted:

"Sleep problems are a major issue for women approaching mid-life, particularly for women who have moderate or severe sleeping problems before reaching menopause as they are likely to experience increased issues throughout the transition,"

But these women could be thought of as having a continuation of long-term sleep issues.

It's the women with mild issues related to sleep pre-menopause that are likely to find sleeplessness become more common.

The study authors noted:

"A small subgroup of women with only mild sleep disturbance prior to menopause also experienced worsening sleep disturbance during the transition....Our study raises the question of why a significant increase in poor sleep should surface for a group of women who experienced only mild sleep problems earlier, but not among women who had moderate or severe sleep problems,"

But again, these women had difficulties with sleep prior to menopause.

This led the researchers to suggest that menopause itself is not the underlying cause of sleep disruption.

This challenges the commonly held assumption and fear related to this stage of life for women. 

The good news according to the researchers?

"sleep difficulties in the transition to menopause in generally healthy women should not automatically be imputed to ovarian decline.

The study authors noted that clinicians should be alert to the strong possibility that poor sleep in women approaching menopause is not simply caused by menopause or hot flashes.

 "Possible reasons for poor sleep instead may include health problems, anxiety, and stress,"

They advocate that clinicians should ask patients whether women had problems sleeping before midlife, as well as obtain information on the level and duration of earlier poor sleep patterns to devise the most effective treatments.

Clinical Comment

Although research and the sleep medicine community recognise that insomnia is a standalone condition and not the symptom of something else, the public and most medical practitioners still see insomnia as a symptom of some other underlying condition.

Seeing insomnia as a side effect of menopause hormone changes is no different in this regard. - a widely held belief not supported by objective evidence.

This is unfortunate as it potentially leads to wasted money and time (and life quality) looking for hormone solutions for the management of sleep rather than effective science-backed approaches that treat insomnia itself.

The evidence from this study suggests that insomnia prior to menopause is more likely to be impacting sleep during menopause than hormone changes per se.

It also underscores why paying attention to insomnia early on is important. Research shows insomnia isn't likely to go away by itself and potentially worsens for many women as they go through life changes.

It's also very reasonable to assume that postmenopausal women with the most difficulties sleeping will be those with sleep issues prior to menopause

So what can help one get a good night's sleep and sleep better? 

Research shows that CBT-i can help improve insomnia and vasomotor symptoms during menopause. CBT for insomnia is already the first line recommendation for treating insomnia and it is more effective for improving sleep quality and difficulty falling or staying asleep in menopausal women than a range of medications and health interventions (see below).

Further, there are CBT approaches to managing the hot flushes that affect your sleep that have been shown to help lessen the impact of these unpleasant experiences.

If you think you need support, or you're curious about treatment then get in touch or book an appointment directly.

Finally, we should also remember that restless sleep and poor quality sleep can come from other sleep disorders that can arise during menopause, including obstructive sleep apnea (a woman's risk of OSA rises after menopause),  and restless legs syndrome.  

If you think you may need treatment you can book an initial assessment online. Alternatively, you can talk with us first.

Quick Facts On Menopause And Sleep

 

Does Menopause Cause Insomnia?

While research suggests hot flushes (aka hot flashes) can disturb sleep for women across the menopause transition, studies have found overall rates of moderate to severe insomnia, at roughly 30%, are no different between menopausal women and the general adult population.

Can Menopause Cause Sleep Issues?

Sleep complaints are one of the most consistent menopause symptoms, and scientific studies consistently show hot flushes (aka hot flashes) can disturb sleep for women during menopause. However evidence suggests that menopause itself may not be the underlying cause for the disturbed sleep that women often report during menopause.

Is Sleep Disorder Part Of Menopause?

Complaints about sleep are common during menopause. However, the good news is that according to research, women who have no sleep troubles pre-menopause are unlikely to experience new problems sleeping during menopause. Instead, scientific research indicates that women with pre-menopausal insomnia experience a continuation during menopause.

What Causes Sleep Disturbance In Menopause?

While insomnia symptoms during menopause are often attributed to hormonal changes, there is no clear scientific evidence for this idea. Instead, pre-existing problems with sleep, health issues, anxiety and stress may be more likely to play a role in menopausal insomnia.

How Can I Treat Sleep Problems Related To Menopause?

CBT-i aka CBT for insomnia has been compared in randomized clinical trials (RCTs) to interventions such as yoga, aerobic exercise, an SSRI medication (Escitalopram), an SNRI medication (Venlafaxine), omega-3 fatty acids, and oral beta-estradiol. CBT-I was found to be most effective in reducing both insomnia severity index scores (i.e. improving sleep) and bothersome vasomotor symptoms (hot flushes).

The study was published in the journal Menopause (Freeman et al., 2014).

Article Author: Dan Ford Sleep Psychologist