Complaints about sleep quality are one of the most common symptoms of the menopause, affecting 39-45% of women perimenopausal and 35- 60% postmenopausal.
Women report more sleep complaints and are more likely to have insomnia compared to men at all stages in their lives. One of the major influences on women’s sleep is hormones. Hormones affect sleep during puberty, the menstrual cycle, pregnancy and in the menopause transition. In the perimenopausal years, huge changes in hormones start to occur, together with a change in neurotransmitters, the chemicals that transmit messages in the brain.
The level of reproductive hormone, estrogen, fluctuates then reduces from the perimenopausal years onwards, which leads to hot flashes. In order to get to sleep and stay asleep, your core body temperature drops and this triggers a release of melatonin, the hormone that tells your body it’s time to sleep. For this reason, sleep hygiene advice suggests sleeping in a cool room. When hot flashes happen at night, the increase in temperature can cause an awakening as well as making it very hard to get back to sleep.
Progesterone, is another reproductive hormone that plays a role in initiating and maintaining sleep. Progesterone promotes sleep by its effect on GABA, a neurotransmitter that reduces activity in the brain and nervous system. The change in levels of progesterone that starts in the perimenopausal years leads to problems inhibiting brain activity that is essential for sleep.
There are many chemicals in the brain that influence mood. When estrogen levels are low, this affects the production of serotonin which can lead to feelings of depression. The level of neurotransmitters, dopamine and norepinephrine, are also affected by changes in estrogen. An imbalance in these hormones can lead to anxiety, commonly seen during the menopause.
There is a bi-directional relationship between mood and sleep, with low mood and anxiety affecting sleep, and sleep problems affecting emotion regulation.
Furthermore, estrogen affects the level of cortisol, a stress hormone that influences mood and sleep. When estrogen drops, cortisol levels increase, leading to problems with anxiety. When we sleep, cortisol levels drop so sleep is directly affected by the change in this stress hormone. But all the neurotransmitters mentioned above also play a role in sleep.
There are some differences seen in the mechanisms that drive sleep in women compared to men. The circadian rhythm, the internal body clock, is a bit more variable in women and often the circadian period is slightly shorter, so this could make them more vulnerable to sleep issues. During the menopause, problems with circadian rhythm disruption occur, possibly due to changes in melatonin, causing problems with the timing of sleep.
Age is a major factor. Sleep problems unfortunately increase as we get older for both men and women. This is because the systems that regulate our sleep weaken and melatonin production reduces, resulting in more fragmented sleep and more problems initiating and maintaining sleep.
During the menopause changes in hormones and neurotransmitters lead to higher risk of developing the sleep disorders obstructive sleep apnea and restless leg syndrome. These both can significantly disrupt sleep, the former by interfering with breathing during sleep and the latter with uncomfortable sensations in the legs at nighttime that can only be relieved by movement.
There are several medical options that may help but also several behavioural influences that can make a big difference. It’s helpful to remember that, although there are clear biological changes occurring in the menopause transition, our behaviours influence our neurotransmitters which then influence how we feel and our ability to relax and sleep.
Hormone replacement therapy, antidepressants and sleep medication can reduce symptoms of menopause, reduce hot flashes and sleep disruption. If you want to explore these options, speak to your doctor about risks and benefits.
There is growing evidence that soy-based foods can reduce menopausal symptoms and improve sleep quality as they contain phytoestrogens. Try out soya milk and yogurt, tofu and edamame beans. For supplements containing phytoestrogen, there is some evidence that ginseng and black cohosh can help, but more research is really needed for conclusive evidence.
There is good evidence that yoga helps to reduce menopausal symptoms and improve sleep quality. The evidence for acupuncture is promising but is limited and more research is needed.
Lifestyle factors can make a huge difference. Avoid caffeine eight to ten hours before sleep and nicotine one hour before bedtime, limit alcohol and avoid heavy meals two hours before bed. Be aware of spicy or acidic foods which can trigger hot flashes. Reduce fluid intake in the few hours before bed to avoid trips to the bathroom at night.
Regular exercise can benefit sleep but avoid intense exercise two hours before bed to allow your body temperature to cool down for sleep. Gentle stretching completed two hours before bedtime may help as can a warm bath as both these can gently increase the body temperature which leads to a drop prior to bedtime.
Sleep in a cool room (16-18 degrees) and use layers of bedding, made from natural fibres, to regulate body temperature at night. Use “sweat management” bed clothes or none at all and have a change of clothing by the bed with a glass of water to prepare for hot flashes.
Avoid using your bedroom excessively to relax in the evening or during the day and avoid working in the bedroom. Electronics are best kept out of the bedroom to reduce cognitive arousal and light, both which can negatively affect sleep. For more tips on how to improve your sleep routine, click here.
If you struggle with a racing mind or anxiety, try writing down your thoughts in a worry journal in the early evening but then make sure you wind down for at least an hour before sleep with some relaxing, non-stimulating, activities.
If you are still struggling to sleep despite all of this, you could try a course of Cognitive Behavioural Therapy for Insomnia (CBT-i). A wealth of research shows that this treatment improves sleep in most adults, including women going through the menopause transition.
Christabel Majendie October 2022.
Christabel is a Bristol based sleep therapist and consultant, specialising in helping individuals experiencing a wide range of sleep problems. For more information on her work you can visit her website.
Christabel Majendie is not a brand ambassador and does not endorse any product of Sleep Well Drinks Limited.