Michael Abrahams | Menopause and sleep

If a woman lives long enough to be a senior citizen, menopause, also known as the climacteric, is inevitable. This is the time when menstrual periods permanently stop, marking the end of a woman’s reproductive stage. It is defined as 12 consecutive months without a menstrual period and typically occurs between the ages of 45 and 55, with the average age being around 51 years. Some women sail through menopause unscathed. However, others experience many unpleasant symptoms, and poor sleep quality is one of the commonest complaints. Up to 60 per cent of perimenopausal and menopausal women report issues with sleep.

There are a multiplicity of reasons why women experience poor-quality sleep at this time. Much of it is due to hormonal changes. As a woman approaches menopause, ovulation becomes less frequent, and decreased levels of the female sex hormone progesterone accompany this. Progesterone has a calming effect on the brain, so decreased levels may make it harder to fall asleep. Along with the decrease in progesterone is an increase in the level of follicle-stimulating hormone (FSH), and elevated levels of his hormone are associated with sleep disturbance. When women are in full-blown menopause, estrogen levels plummet, and this change is associated with difficulty falling and staying asleep.

In addition to the hormones that govern the female reproductive system, others influence sleep quality, too. For instance, spikes in levels of the stress hormone cortisol can disrupt sleep, and regardless of sex, levels of the melatonin, which regulates the body’s circadian rhythm (sleep-wake cycle), decrease as we age.

AFFECT OTHER ORGANS

Besides the effects on the brain, hormonal changes during the climacteric also affect other organ systems. The commonest complaints from women during this time are hot flashes and night sweats, known as vasomotor symptoms, which occur as a result of the decreased levels of estrogen, which cause abnormal blood vessel reactivity. Decreased estrogen and progesterone may also affect the respiratory system by making the airways more susceptible to collapse, leading to the development or worsening of obstructive sleep apnoea (OSA), a condition characterised by repetitive pauses in breathing and sleep disruption. The weight gain that often accompanies menopause is another contributing factor to OSA. The incidence of restless legs syndrome and arthritis is also higher in menopausal women, and these conditions can interfere with getting a good night’s rest.

Mental disorders can also play a role in sleeping issues with women at this stage of life. Depression, anxiety, and mood swings are common during this phase and can interrupt sleep. Likewise, poor sleep can contribute to the development of these dysfunctional mental states, setting up a self-perpetuating cycle. And social situations at this time in a woman’s life can also cause stress and potentially interrupt sleep. For example, menopausal women are part of the “sandwich generation” and may find themselves caring for their children as well as elderly, unwell parents. Some may be experiencing “empty nest syndrome” as their children may have moved out of the house, contributing to loneliness, especially if the women are single.

All these potential challenges place menopausal women at risk because poor sleep is associated with many health issues and disorders, including hypertension, heart disease, diabetes, obesity, and impaired immune function. A sleep debt can also cause irritability and impaired memory, concentration, judgement, and functioning. Unsurprisingly, these sequelae can affect relationships and performance at the workplace, which can affect one’s livelihood.

Poor sleep at this time must be addressed appropriately, and this involves a holistic approach with attention being paid to the general principles of sleep hygiene. The aim should be to sleep for at least seven hours. A routine should be employed, including going to sleep and waking up at the same times, including on weekends. The bedroom environment should be dark, quiet at bedtime, and conducive to sleep. Stimulants such as caffeine and nicotine should be avoided in the hours before going to bed, and alcohol too, as it may cause drowsiness but is also associated with poor sleep quality. Large meals should not be consumed close to bedtime as these increase the likelihood of gastric discomfort and heartburn. Electronic devices with screens should also be avoided during the hour before going to bed as the light emitted from them tricks the brain into thinking it is daytime and reduces melatonin production.

DAYTIME ACTIVITIES

Apart from these bedtime activities, daytime practices such as exposure to sunlight on waking and exercise, contribute to a good night’s sleep. Stress-management techniques such as mindfulness meditation, yoga, and journalling may be useful, and if insomnia persists, cognitive behaviour therapy has been found to help. Some find supplements such as magnesium, melatonin, and L-Theanine, as well as herbs such as valerian and chamomile, to facilitate sleep, as well as aromatherapy with lavender essential oil, which has a relaxing effect.

Menopausal women, especially those who experience night sweats, may benefit further from wearing loose and light clothing with natural fibres to bed. If these natural measures fail to provide relief, hormone replacement therapy (HRT) will usually succeed. Replacing the estrogen that is deficient during menopause often alleviates many of the unpleasant menopausal symptoms. Women who still have a uterus should combine estrogen with progesterone to decrease the risk of uterine cancer, and if testosterone is deficient, administering it may be a good idea. Duavee, which is a combination of bazedoxifene (an estrogen receptor modulator) and estrogen, is also used to treat hot flashes.

In women who are reluctant to take hormones, some antidepressants, such as fluoxetine (Prozac), paroxetine (Paxil), and venlafaxine (Effexor), can provide some relief from hot flashes as well as the antiseizure drug gabapentin, and clonidine, an anti-hypertensive drug.

Sleep disturbance during menopause is an issue that is often overlooked, and the magnitude of its deleterious effects are usually underestimated. If you are menopausal and are not getting a good night’s rest, try some of these techniques, and if they fail to provide relief, do not hesitate to seek help.

Michael Abrahams is an obstetrician and gynaecologist, social commentator, and human-rights advocate. Send feedback to columns@gleanerjm.com and michabe_1999@hotmail.com, or follow him on X , formerly Twitter, @mikeyabrahams.