Transitioning to Menopause? Don’t Give Up on Sound Sleep

I often hear sleep complaints from women approaching menopause. Hot flashes and mood swings are other common complaints. What can be done to improve sleep and reduce perimenopausal symptoms?

The key, say authors of a review paper published this year, is to use a variety of approaches based on individual women’s symptoms, history and needs.

Insomnia and hot flashes can be relieved with multi-pronged treatmentI often hear sleep complaints from women approaching menopause. Hot flashes and mood swings are other common complaints. What can be done to improve sleep and reduce perimenopausal symptoms?

The key, say authors of a review paper published this year, is to use a variety of approaches based on individual women’s symptoms, history and needs.

Sleep Problems in the Menopausal Transition

The transition to menopause begins 4 to 6 years before menstruation stops (the median age for menopause is 51 years). It’s a time of fluctuating reproductive hormone levels. Not all women suffer ill effects during this period but many do.

Sleep problems are one of the most common complaints, reported by up to 56% of women approaching menopause, say authors of the review, published in the journal Nature and Science of Sleep. In turn, trouble sleeping often compromises midlife women’s quality of life, mood and productivity.

There’s an uptick in sleep-disordered breathing (sleep apnea) among women transitioning to menopause. There’s also an uptick in insomnia. A study involving 982 perimenopausal women interviewed by phone found that 26% had symptoms qualifying them for a diagnosis of insomnia disorder as medically defined.

Not Just in Our Heads

Fluctuating levels of hormones—follicle-stimulating hormone, estradiol (an estrogen) and progesterone—likely play a role in insomnia that occurs during the menopausal transition. Hot flashes, too, which typically emerge as estrogen levels decline, are associated with poorer reported sleep quality and chronic insomnia.

As for objective evidence of menopausal sleep problems, results of population studies of midlife women involving polysomnography (PSG) are inconsistent. But in a recent study published in Psychoneuroendocrinology, investigators found “stark differences in PSG measures in women with, relative to women without, insomnia disorder developed in the menopausal transition.”

Women who developed insomnia during the menopausal transition

  • had poorer sleep efficiency
  • experienced more wakefulness after sleep onset
  • had shorter total sleep time, with 50% sleeping less than 6 hours
  • were more likely to have hot flashes, which predicted their number of awakenings per hour of sleep.

A Role for Depression and Stress

Symptoms of depression typically increase during the menopausal transition. Depression and insomnia are closely linked, with depression sometimes preceding insomnia and insomnia sometimes leading to depression. The results of one interesting study suggest that trouble falling asleep at the beginning of the night is associated with anxiety while nonrestorative sleep is linked to depression.

Chronic exposure to stress could be another factor in midlife women’s greater susceptibility to insomnia. And during the transition to menopause, traits associated with insomnia—increased tendency toward rumination, anxiety, generalized hyperarousal, stress reactivity, and neuroticism—are similar to tendencies predictive of hot flashes and other perimenopausal symptoms.

Treatments for Insomnia in the Menopausal Transition

Since insomnia in the menopausal transition is likely due to many factors, it’s challenging to treat. The reviewers recommend “flexible and individualized” treatments for insomnia depending on each woman’s current symptoms and history.

Hormone Therapy

Hormone therapy generally improves sleep quality in women who experience hot flashes during the transition. It may be a good option if, based on a woman’s history and health concerns, the overall potential benefits outweigh the risks. The reviewers note that abrupt discontinuation of hormone therapy is associated with hot flash relapse, which could in turn lead to insomnia.

Non-Hormonal Pharmacological Therapies

Sleeping pills, which are generally prescribed for short-term or intermittent use, are not a front-line treatment for insomnia in perimenopausal women. Taken nightly over time, many sleeping pills degrade sleep quality and have other negative effects. Following are the medications the reviewers suggest considering for perimenopausal women with insomnia and hot flashes:

  • Low-dose selective serotonin reuptake inhibitors—such as citalopram (Celexa) and escitalopram (Lexapro)—and low-dose serotonin norepinephrine reuptake inhibitors—such as duloxetine (Cymbalta) and venlafaxine (Effexor XR). Note that discontinuation of SSRIs is associated with hot flash relapse, which could lead to insomnia.
  • Gabapentin, shown to improve sleep quality in perimenopausal women with hot flashes and insomnia.
Non-Pharmacological Therapies
  • Cognitive behavioral therapy for insomnia (CBT-I) is the overall gold standard in drug-free treatments for insomnia. In a randomized clinical trial recently conducted on peri- and postmenopausal women experiencing at least 2 hot flashes daily, women who underwent CBT-I “had significantly greater reduction in insomnia symptoms and greater improvements in self-reported sleep quality” compared with controls. The improvements were maintained at 6 months after treatment.
  • Soy isoflavones—phytoestrogens found mainly in legumes and beans—have been shown in randomized controlled trials to reduce menopausal symptoms, including self-reported sleep disturbance. They’re available as dietary supplements.
  • High-intensity exercise and yoga are reported by the reviewers to be modestly beneficial in reducing menopausal symptoms and improving sleep.

Because many factors can combine to disrupt sleep in the period leading up to menopause—sleep disorders, mood disorders, medical conditions, and life stressors—no one-size-fits-all treatment will improve sleep and minimize menopausal symptoms. Instead, the reviewers recommend a multi-pronged approach to treatment based on individual women’s needs.

Insomnia in Midlife and Older Women

Trouble sleeping is common in women at menopause, or so conventional thinking goes. Yet the latest word is that it’s during perimenopause when the trouble starts to brew.

Genetic factors may partly explain why insomnia is more common in women than in men. But hormonal changes during perimenopause and later in life are often cited as a more proximal cause of sleep problems that occur in midlife and older women.

Perimenopause gives rise to hot flashes and trouble sleeping due to fluctuating reproductive hormonesTrouble sleeping is common in women at menopause, or so conventional thinking goes. Yet the latest word is that it’s during perimenopause—the years leading up to menopause—when the trouble starts to brew. In fact, one in three perimenopausal women suffers chronic insomnia, according to data presented at the 2015 annual meeting of the North American Menopause Society.

Genetic factors may partly explain why insomnia is more common in women than in men. But hormonal changes during perimenopause and later in life are often cited as a more proximal cause of sleep problems that occur in midlife and older women. Here are some details.

In Flux

During perimenopause, levels of estrogen, progesterone, and other hormones of the reproductive system are in flux. Estrogen production, in decline overall, is wildly erratic. Progesterone secretion stops during menstrual cycles when no ovulation occurs. Fluctuating levels of these and other reproductive hormones are often cited as factors underlying perimenopausal symptoms: irregular and heavy periods, headaches, and hot flashes.

Hot Flashes

Up to 80 percent of perimenopausal women experience hot flashes. For years women have reported that hot flashes cause night sweats and wake-ups, but only recently has the extent of the sleep disruption shown up in objective testing.

In a study published in 2013 in the journal Sleep, researchers set out to mimic perimenopause by injecting young women with a synthetic hormone that would suppress secretion of estradiol (a form of estrogen). Sixty-nine percent of the women went on to experience hot flashes (called vasomotor symptoms, or VMS, in medical lingo). The researchers hypothesized that nighttime VMS would lead to increased sleep fragmentation—and this is exactly what happened. “The number of nighttime VMS correlated directly with the degree of sleep disturbance,” the investigators concluded.

In another study, published this month in Psychoneuroendocrinology, researchers compared perimenopausal women with insomnia to perimenopausal women without insomnia and this is what they found, as measured by polysomnogram:

  • Insomniacs got an average of 43.5 minutes less sleep than women without insomnia.
  • Insomniacs were more likely to have hot flashes, and the number of hot flashes predicted the number of awakenings they had.

Hot flashes and night sweats are clearly disruptive to sleep and may increase midlife women’s vulnerability to insomnia.

Which Hormones Are Involved?

Hormonal fluctuations may give rise to both hot flashes and disturbed sleep during the menopausal transition. Estrogen is likely involved, since estrogen replacement therapy (less commonly recommended now than in the past) mitigates these perimenopausal symptoms. But there’s little agreement yet as to which hormonal factors are involved in midlife insomnia.

Researchers at the University of Washington recently analyzed data from the Seattle Midlife Women’s Health Study to see how hormonal factors correlated with the severity of perimenopausal symptoms. Compared with women with moderate and low levels of symptoms, women with severe hot flashes and moderate sleep disturbance

  • had lower estrogen levels and higher levels of follicle stimulating hormone (released in the days leading up to ovulation to stimulate the growth of follicles in the ovary)
  • tended to have lower levels of epinephrine (or adrenaline) and higher levels of norepinephrine. Epinephrine and norepinephrine are stress hormones.

But other research teams have come up with different results. Here’s what researchers publishing this year in the Journal of Clinical Endocrinology and Metabolism found:

  • Estradiol (a form of estrogen) was protective of stable sleep in women ages 18 to 27. But there was no correlation between levels of estradiol and sleep quality in perimenopausal women.
  • In perimenopausal women without sleep complaints, increased levels of follicle stimulating hormone did correlate with increased wakefulness at night. Not so in perimenopausal women with insomnia, in whom sleep duration correlated instead with anxiety and depression.

While hormonal fluctuations that occur during perimenopause can undoubtedly interfere with women’s sleep, the actual mix of hormonal factors underlying midlife insomnia is still unknown.

Melatonin and Older Women’s Sleep

One hormone that may be a factor in the sleep problems of older women is melatonin. Studies of young and middle-aged subjects have shown that women tend to have higher melatonin levels than men.

But results of a cross-sectional study of 528 older people showed that the opposite is true for older women. Investigators found that older women excreted 18.4 percent less melatonin in their urine at night than older men. This suggests that some older women may be deficient in melatonin. Unlike younger insomniacs, for whom melatonin supplements often have no effect, older women with insomnia may find that melatonin supplementation improves their sleep.

Hot Flashes and Sleep: Can Paroxetine Help?

Waking up to hot flashes now that you’re going through “the change?” You’re not alone. Up to 80 percent of women experience them during menopause.

Annoying in the daytime, hot flashes can play havoc with your sleep, making you prone to frequent wake-ups in sweat-soaked sheets. Up to 61 percent of postmenopausal women report hot flash-related wake-ups and other symptoms of insomnia.

Low-dose paroxetine, a drug prescribed at higher doses for depression, holds promise for women looking to cut down on hot flashes and night sweats and improve their sleep.

low-dose paroxetine may cut down on hot flashes and night sweatsWaking up to hot flashes now that you’re going through “the change?” You’re not alone. Up to 80 percent of women experience them during menopause.

Annoying in the daytime, hot flashes can play havoc with your sleep, making you prone to frequent wake-ups in sweat-soaked sheets. Up to 61 percent of postmenopausal women report hot flash-related wake-ups and other symptoms of insomnia.

Hormone therapy (HT) was for years touted as a panacea for women looking to avoid hot flashes, night sweats and other menopause symptoms. HT worked. The use of estrogen or estrogen combined with progestin is still recommended as a front-line treatment for some menopausal women.

For others, the downsides of HT outweigh the benefits. Hormonal treatments increase the risk of heart disease, stroke, bile stones and breast cancer. If you’re vulnerable to any of these serious ailments, you’ll want to think twice about starting HT.

What else is out there for mid-life women looking to stop these eruptions of our inner Vesuvius and get a decent night’s sleep? Low-dose paroxetine, a drug prescribed at higher doses for depression, holds promise.

What Is Paroxetine?

Paroxetine, a.k.a. Paxil, is a selective serotonin reuptake inhibitor (SSRI). Drugs in this class alter the chemical content of the brain by blocking a particular receptor that absorbs serotonin. More serotonin is then available to strengthen neural circuits that regulate and elevate mood.

Like many SSRIs, paroxetine taken at doses recommended for depression (20-50 mg.) has an unpredictable effect on sleep. While some users report improved sleep, other users monitored during clinical trials report experiencing insomnia.

Yet the results of two recent studies show that paroxetine taken at a lower dose (7.5 mg.) cuts down on nighttime awakenings due to hot flashes and increases sleep duration significantly more than placebo.

Gist of the Studies

Participants in these studies were 1,184 middle-aged women reporting moderate to severe hot flashes and night sweats. They were randomly assigned to 7.5 mg of paroxetine or placebo, taken once a day for 12 or 24 weeks.

The results? Overall, nighttime awakenings due to hot flashes were reduced 38 percent more in the women taking paroxetine than in the women who took a placebo. Also, the paroxetine subjects consistently reported sleeping longer than those taking placebo.

These results are modest. But paroxetine is believed to be safe for long-term use and, at low doses, to have minimal side effects. Paroxetine could give meaningful symptom relief to at least some women. If you’re waking up to hot flashes night after night, it’s worth exploring with your doctor.

Drug-Free Remedies

Looking for a drug-free way to control menopause-related insomnia instead? A new review of alternative treatments for postmenopausal women cites evidence that the following may help:

  • Isoflavones. These compounds exert estrogen-like effects and are found in legumes, especially soybeans.
  • Massage.
  • Yoga.
  • Physical activity.
  • Physical therapy.

If you’ve found a reliable way to cut down on hot flash-related awakenings at night, please share it!

Menopause, Insomnia and Pycnogenol

When female friends hit their 40s and 50s, they start talking to me about their sleep. “I never had insomnia before in my life.” “I wake up with hot flashes.” “I get these feelings of anxiety and I just can’t sleep!”

Perimenopause and menopause cause an uptick in sleep problems, insomnia, chief among them. But now there’s a new plant-based supplement that shows promise for women looking for relief from insomnia and other menopause-related symptoms.

woman-glassWhen female friends hit their 40s and 50s, they start talking to me about their sleep. “I never had insomnia before in my life.” “I wake up with hot flashes.” “I get these feelings of anxiety and I just can’t sleep!”

Perimenopause and menopause cause an uptick in sleep problems, insomnia, chief among them. Hormonal changes are clearly involved. Starting in perimenopause, our bodies secrete less estrogen, and products containing phytoestrogen—a plant hormone similar to estrogen—are said to help with menopausal symptoms. Soy products are high in phytoestrogen, and supplements containing ginseng, red clover extract, and black cohosh are, too.

But insomnia that occurs in midlife women hasn’t gotten much attention from sleep researchers, nor have these phytoestrogen-containing products. Do they help with insomnia and other menopausal symptoms? All we can do is to try these alternative treatments and see.

French Maritime Pine Bark Extract

Another plant-based supplement shows promise for women looking for relief from insomnia and other menopause-related symptoms. It’s made from the bark of the maritime pine, native to the western Mediterranean, and sold in the US as Pcynogenol.

Pycnogenol contains naturally occurring chemicals called proanthocyanidins, found also in peanut skin, grape seed, and witch hazel bark. Compared to placebo, Pycnogenol supplements taken daily for several weeks have lessened menopausal symptoms in three studies published over the past six years:

  1. In Taiwan, Pycnogenol alleviated menstrual pain and all other menopausal symptoms, favorably altering the LDL/HDL ratio of study subjects as well.
  2. In Italy, Pycnogenol significantly reduced the occurrence of hot flashes, night sweats, mood swings, irregular periods, loss of libido, and vaginal dryness.
  3. In Japan, Pycnogenol was found to be especially effective in alleviating insomnia and vasomotor symptoms such as hot flashes, palpitations, and vaginal dryness.

In none of these studies was Pcynogenol associated with significant side effects.

Other Uses of Pycnogenol

Studies also suggest Pycnogenol may

  • improve exercise capacity in athletes
  • increase elasticity in dry and sun-damaged skin
  • reduce the duration and symptoms of the common cold when combined with zinc and vitamin C.

Pycnogenol sounds too good to be true! But remember, these studies are all preliminary. And, as is the case with many plant-based alternative treatments for insomnia, Pycnogenol may have to be taken for several weeks before it has a noticeable effect. So will it help with sleep problems and other menopausal symptoms? The only way to know is to try it and see.

What plant-based supplements have you tried for insomnia, and have they worked?