A good night's rest: sleep problems and the menopause

Posted 23 Jan 2019

Date: 23 Jan 2019

Author: Dr Heather Currie

Sleep problems are common during the perimenopause and menopause, says Dr Heather Currie, Associate Specialist Gynaecologist, Dumfries & Galloway NHS. So, what’s going wrong, and how can health professionals help?

Written by Dr Heather Currie and Kaye McIntosh

Women report one of the most distressing aspects of the menopause is poor sleep. The immediate effects include exhaustion, lower quality of life, daytime sleepiness and depression. It may also have long term effects such as raised risks of cardiovascular events and osteoporosis, as well as increased total mortality.

“When we have good quality sleep, and the right amount, we have a cardiovascular holiday," Dr Heather Currie told delegates at Current Choices. Factors such as a drop in blood pressure are beneficial. "If we don’t get it then there are increased inflammatory markers and all sorts of things happen.” 

The optimum amount seems to be about seven hours. Sleeping too long can also have detrimental effects but that may to be to do with confounding factors and co-morbidity; underlying health problems are associated with longer sleep.

Quality, not just quantity

More than one in five menopausal women reported sleep disturbance in a survey for the British Menopause Society. Problems include difficulty in getting to sleep, awakening during the night and early morning waking. It’s not merely the length of sleep that matters, but the quality. It’s hard to measure non-restorative sleep, Dr Currie said, but people feel the effects when they haven’t rested well.

The Women’s Health Across the Nation Study of 3,000 women found sleep maintenance and early wakening worsened significantly in the late perimenopause, but the good news is after the menopause this returned to the same levels as before. There was significant dose-response relationship with the presence of vasomotor symptoms (VMS) which affect blood flow.

Surgical menopause affects sleep

Hysterectomy may have much wider impacts than previously thought.

"Women who have had surgical menopause seem to have the worst sleep difficulties. We are encouraging surgeons not to take the ovaries as the sudden drop in hormones seems to have big effects.’ A recent study showed surgical menopause was linked to disordered breathing during sleep as well as cardiovascular events. "said Dr Currie.

Research in the US found hot flushes strongly predict poor sleep, regardless of baseline sleep status. Another study revealed up to 80% of women with severe flushes were waking up. But there are a host of other factors that also disrupt sleep, including hormonal changes, central obesity, anxiety, depression, getting up to go to the loo at night and restless legs.

Women snore too

Sleep apnoea can be a problem. “The menopause affects weight distribution and can change the distribution of weight around the neck, which affects muscle tone,” said Dr Currie. However, women are under-diagnosed as their symptoms are different to men. Women are less likely to be observed stopping breathing or snoring severely, she added.

It’s not clear what effect the standard treatment for sleep apnoea, continuous positive airway pressure (CPAP) has on menopausal women.The important message is that health professionals should offer the right care.

"We know mood changes, which may contribute to sleep problems, or disturbed sleep, which in turn may cause mood problems, are common in menopause and the NICE guidance is clear, we should be offering hormonal treatments, not anti-depressants", Dr Currie said. 

Combined HRT can also help with other symptoms. ‘We are learning that progesterone has benefits, especially in relation to the muscle tone of the upper airway. It also has sleep inducing effects and seems to play a part in disordered breathing, with a positive effect on pharyngeal dilator muscle activity and ventilatory drive.’

Identify what’s important for the individual 

“HRT alone may not be the answer,” said Dr Currie. “We need to help women identify what is the most important factor for them.” HRT can help if the problem is due to night time flushes or sweats. Vaginal estrogen may help if disturbed sleep is due to a deficiency, which can affect bladder function so make women get up at night.

“Sleep hygiene could be useful; having a warm bath before bed and keeping the bedroom clear of all activities except sleeping and sex.”

CBT is effective for some, while there is evidence for yoga and acupuncture.

Useful resources

British Menopause Society
Women's Health Concern Menopause patient factsheet

Dr Heather Currie spoke at our Current Choices conference which took place on 22-23 November 2018 in London. The event gathered 300+ sexual and reproductive healthcare professionals to debate the challenges of sexual and reproductive leadership, workforce and service provision.

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