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.

An Insomnia Treatment from China

Sour date seed has been used as a sleep aid in China and other Asian countries for over 2,000 years. The seed of a small tree called Ziziphus jujuba Mill var. spinosa, sour date is used alone or in combination with other herbal medicines to relieve insomnia and anxiety.

Traditional Chinese herbs may relieve insomniaSour date seed has been used as a sleep aid in China and other Asian countries for over 2,000 years. The seed of a small tree called Ziziphus jujuba Mill var. spinosa, sour date is used alone or in combination with other herbal medicines to relieve insomnia and anxiety.

Despite its widespread use in Asia, no randomized controlled trials on sour date seed (also called sour jujuba seed) have been conducted on humans to determine its safety and efficacy. But preclinical tests on animals suggest that sour date seed (or one or more of its chemical constituents) acts on neurotransmitter systems that impact sleep and mood, and one observational study suggests that it may improve sleep in women with menopause-related insomnia. If you’re open to alternative treatments for insomnia, this one may interest you.

The GABA Connection

Exactly how sour date seed achieves its soporific effects is unknown. But laboratory tests have shown that it acts on the GABA system. In the brain, neurons that produce the neurotransmitter GABA are important for sleep. When the GABA neurons start firing, the lights in the brain go out.

Many sleeping pills prescribed today—zolpidem (Ambien), eszopiclone (Lunesta), zaleplon (Sonata), and temazepam (Restoril)—enhance the ability of GABA to do its job. They bind to GABAA receptor complexes on the receiving ends of nerve cells and increase the flow of chloride ions moving into the cells. The cells are then inhibited from firing, which tranquilizes the brain. Anti-anxiety medications such as alprazolam (Xanax), clonazepam (Klonopin), and diazepam (Valium) also bind to GABAA receptors, inducing relaxation.

Research on lab animals has shown that sour date seed also binds to GABAA receptors and has sedating effects. In one such study, investigators administered jujubosides—active components in sour date seed—to rats during the day and at night. The jujubosides significantly increased the rats’ total sleep time both day and night.

Other Calming Activity

In another study, scientists used rats to observe the effects of jujuboside A on the hippocampus, an area of the brain associated with emotion, memory, and the autonomic nervous system. The main finding was that jujuboside A inhibited arousal in key pathways in the hippocampus.

Still other animal studies have been done using suan zao ren tang (SZRT), a traditional Chinese herbal medicine whose main ingredient is sour date seed. It was found to modulate the activity of several neurotransmitter systems associated with sleep and mood alteration.

An Observational Study

SZRT is commonly used to treat insomnia connected with menopause in Taiwan, but its use there is traditional and not the result of scientific evidence attesting to its efficacy and safety. So a group of Taiwanese researchers set out to measure its effects on 67 midlife women with insomnia.

The form of SZRT used was a powdered extract made into a granulated compound prepared by the Kaiser Pharmaceutical Co. in Taiwan. The women took 4 grams 3 times a day.

By the end of week 1, the women reported no changes in their sleep. But after 4 weeks, the women experienced these significant changes:

  • About 74 percent of the participants with mild to moderate menopausal symptoms reported improved sleep quality, and about 82 percent of those with moderate to severe symptoms reported improved sleep quality
  • The women fell asleep about 23 minutes faster, on average
  • The average total sleep time went from 4.7 hours to 5.5 hours a night

Three women withdrew from the study due to stomach ache, diarrhea, or dizziness—symptoms that disappeared once the SZRT was stopped.

Take These Results with a Grain of Salt

The main caveat here is that the study was neither randomized nor controlled. Without a control group taking a placebo, it’s impossible to know to what extent the results reflect the effects of SZRT and how much they reflect a placebo effect.

Also, as the authors of the study point out, the fact that by the end of the first week of the study the participants’ sleep remained unchanged suggests that SZRT—if it does improve sleep—works slowly. This is true of many herbal medicines, which must be taken for days or weeks before having an effect.

But the findings do suggest that sour date seed merits more study as a potential sleep aid. And as alternative treatments for insomnia go, this one—because of its history of use and current popularity in Asian countries—is likely fairly safe.

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?

A Second Look at Valerian for Sleep

Of all the botanicals used for sleep, valerian is the one we hear about the most. I tried it myself several years ago on a trip to Japan. The inky black tincture stank up our bedroom like a pile of ripe wet socks, tasted bitter, and, taken at bedtime, didn’t do a dime’s worth of good for my sleep. So I tossed it on my heap of failed alternative treatments for insomnia and moved on to the next thing.

Now I’m toying with the idea of trying valerian again.

valerian-extractOf all the botanicals used for sleep, valerian is the one we hear about the most. I tried it myself several years ago on a trip to Japan. The inky black tincture stank up our bedroom like a pile of ripe wet socks, tasted bitter, and, taken at bedtime, didn’t do a dime’s worth of good for my sleep. So I tossed it on my heap of failed alternative treatments for insomnia and moved on to the next thing.

Now I’m toying with the idea of trying valerian again. Support for its efficacy as a sleep aid is mixed, but the latest published study shows that it can improve sleep quality in postmenopausal women. One hundred women with insomnia participated in this study, a randomized, controlled trial. Thirty percent of those who used 530 mg of concentrated valerian extract twice a day for four weeks reported significantly improved sleep. Only 4 percent taking a placebo reported a similar improvement.

Why Valerian May Improve Sleep

Why valerian might work as a sleep aid for women aged 50 and above is still unknown. Postmenopausal women are more prone to insomnia than younger women. Menopause brings about decreased levels of estrogen and sleep-protective progesterone, in turn altering the balance of other hormones and neurochemicals helpful and harmful to sleep.

Laboratory studies have shown that valerian should help to promote sleep. It enhances the ability of GABA, the main inhibitory neurotransmitter, to tranquilize the brain at night. To a lesser extent, valerian supports the serotonin system in its efforts to improve mood and promote relaxation and sleep.

But the proof of the pudding is always in the eating, and, while 30 percent of the women taking valerian in the study above had improved sleep, 70 percent did not.

Use It Correctly

If you decide to try valerian, don’t expect to see results overnight, said Jerome Sarris, who studies herbs as alternative treatments for mood disorders and sleep at the University of Melbourne, in an interview two years ago.

“You’re not going to get the same punch from herbal medicine” as you do from a sleeping pill, Sarris said. “The herbal medications generally take longer to work, whereas some people just want that quick fix. I think herbal meds may have more of a role in long-term assistance for sleep rather than as an acute measure” to hasten sleep.

So use valerian and other herbal sleep aids not as you would use Ambien but rather as a vitamin, taken daily to gradually tip the balance of hormones and neurochemicals to favor those friendly to sleep.

Have you tried valerian? What did you use it for, and was it effective?

Effect of Valerian on Sleep Quality

Herbal Medicine for Depression, Anxiety and Insomnia