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!

Tips for Overheated Sleepers

Feeling cold at night is the pits. Not only is it unpleasant, but it also gives me a whopping case of insomnia. So years ago I bought an electric blanket and a comforter for use in the winter.

But these items may not be good choices for people with insomnia or those who wake up with night sweats, according to recent paper by sleep scientists in The Netherlands. It has to do with the effects of skin temperature on core body temperature at night.

down-comforterFew things bother me as much at night as feeling too cold. It’s sure to keep me up and make insomnia worse. So several years ago I bought an electric blanket and a comforter for use in the winter.

But these items may not be good choices for people with insomnia or those who wake up with night sweats, according to recent paper by sleep scientists in The Netherlands. It has to do with the effects of skin temperature on core body temperature at night.

Core Body Temperature vs. Skin Temperature

Core body temperature is measured internally. It typically hovers around 98.6 degrees in the daytime, but it drops by a degree or more at night. You typically feel sleepiest when your core body temperature is going down. A lower temperature helps you fall asleep quickly and sleep through the night.

Skin temperature, on the other hand, is easily influenced by temperature changes in the environment (and changes in posture, lighting, anxiety, and pain). It typically runs somewhat cooler than core body temperature. But moderately warming the skin tends to promote sleep. It dilates blood vessels close to the skin, facilitating the release of heat from your body and thus lowering your core body temperature.

Here’s the catch, though: warming the skin too much has the opposite effect: it increases your core body temperature, and eventually you may be too hot to sleep. Then you wake up.

Reducing Heat-Related Wake-Ups

If you wake up with night sweats or are prone to insomnia like me, you may need a more subtle approach to warming yourself on winter nights. Here are three suggestions:

  1. Get rid of the electric blanket. Constantly adding heat to the body will eventually increase your core body temperature and likely wake you up.
  2. Comforters are bad news for the same reason. Yes, they make you warm and toasty when you crawl in bed. But they, too, may lead to overheating and nighttime wake-ups. Replace these items with blankets that allow for lesser temperature changes if you get too hot and have to throw one off.
  3. Finally, consider taking a hot bath or shower right before bed. Studies show that warming the skin keeps blood flow high for a few hours after bathing. This will accelerate the release of heat from the body, lower core body temperature, hasten sleep onset, and improve sleep in the early hours of the night.

If you wake up too hot at night, what have you found that helps?

Too Hot to Sleep

Pet peeve: I turn down the bed covers in my hotel room only to discover that the bedding consists of sheets and a comforter, without a blanket in sight.

Maybe the hotel management assumes that adjustments in room temperature will allow this arrangement to work. But no matter whether I turn the heat up or down, my next several hours will be a challenge: Sheets + comforter = a comfortless night.

using comforter can make you too hot at nightPet peeve: I turn down the bed covers in my hotel room only to discover that the bedding consists of sheets and a comforter, without a blanket in sight.

Maybe the hotel management assumes that adjustments in room temperature will allow this arrangement to work. But no matter whether I turn the heat up or down, my next several hours will be a challenge: Sheets + comforter = a comfortless night. I’m either roasting with the comforter on or freezing without it.

Bedding Sold Around Town

Room and body temperature have a huge impact on my sleep, yet the evidence suggests this temperature sensitivity is probably not the norm.

“We sell more comforters than blankets,” said Rob, the sales manager at Sleep Number, an upscale mattress and bedding store not far from my house.

I believe it. At Bed Bath & Beyond, the big box store just across the parking lot, an entire quadrant of the store contains comforters packaged in suitcase-size plastic cases. A “Complete Bed Set” features a comforter, sheets, a bed skirt and two shams. Just think: I could set myself up for nights of roasting and freezing in my very own home!

The blanket section of the store, by contrast, is about the size of a 12-by-12-foot room. It’s labeled “Quilts and Coverlets.” Are blankets becoming passé?

I hope not. Blankets of different weights and thicknesses have been my salvation when it comes to navigating the temperature changes my body goes through at night. But before I go further, let me explain:

Temperature Fluctuations at Night

The best room temperature for sleep is a little lower than is comfortable during the day, sleep experts say, and I’m a believer. The hundred-degree heat I tried to sleep through in southern India was impossible. If it’s true overall that insomniacs have trouble down-regulating body temperature, then I am Specimen Number One.

But body temperature also fluctuates during the course of the night. From a temperature high in the evening, the core body temperature in humans drops to its nadir a few hours before normal wake-up time, then rapidly starts to climb again.

I can’t count the times I’ve woken up early in the morning to a body that’s sweaty and boiling. (If this is night sweats, then I’ve had them all my life.) Being able to peel off the covers in layers—going from hot to cooler rather than from hot to cold—gives me a better way of adjusting to my body temperature and a better chance of falling back to sleep.

So down with comforters, I say, and up with blankets! Temperature fluctuations may be more of a factor in insomnia than we think.

Does anyone else experience body temperature issues at night? How do you manage them?