Sleep Changes for Women in Midlife – Is it Menopause or Aging?

For a lot of women, sleep problems explode during middle age, and throughout the menopausal transition. The transition through menopause has long been associated with disruption to sleep. Sleep problems are linked to the hormonal changes of menopause, and to both the physical symptoms and psychological effects that often occur for women during menopause.

We also know that aging itself brings changes—and challenges—to sleep. Sleep architecture—the structure of our nightly rest as we move through the different stages of sleep—changes with age. Broadly speaking, we spend less time in deep sleep and more time in light sleep as we get older.

Health issues often complicate sleep as we age, everything from increasing pain and stiffness, to illness and its treatment, to weight gain.

And declining production of hormones, beyond those associated with menopause (and with andropause in men), also affect sleep. Melatonin levels drop with age, and with declining melatonin comes a lack of robustness and consistency in the body’s daily circadian timing. As a result, our natural sleep-wake cycles often become less regular the older we get. We may be more apt to wake during the night (having to go to the bathroom is also a factor here), and wake earlier in the morning, and to feel sleepy during the day. Aging is a privilege, but one that often comes with a more complicated picture for sleep.

While sleeping in midlife and older age poses challenges for both men and women, menopause can create additional hardship for sleep. And there remain open questions about the long-term effects of menopause on sleep.

New research by a group of scientists in Finland sheds some light on how menopause and age may affect women’s sleep. The big-picture news here is GOOD: the results of this research indicate that over the long-term, menopause does not worsen women’s sleep.

There’s a lot to talk about here. Let’s first take a closer look at this study’s intent, and its results.

How does sleep change in the menopausal transition?

For this study, scientists investigated changes to sleep architecture connected to menopause. They were interested in distinguishing between the effects of menopause and the effects of aging on sleep during the years when most women undergo the transition from pre-menopause to post-menopause. Put another way, scientists asked the question: what changes to sleep architecture can be attributed to menopause, and what changes can be attributed to aging?

The study included 57 premenopausal women, with an average age of 46 at the time the study began. Scientists observed and measured women’s sleep using polysomnography, both at the start of the study and again 10 years later. They also took measurements of follicle-stimulating hormone (FSH) at the outset and the 10-year mark, to pinpoint where women were in their menopausal transitions. FSH is a hormone that stimulates production of estrogen in the ovaries. As estrogen production declines throughout perimenopause, FSH levels rise. A higher FSH is a signal that women are further along in their transition to menopause.

Their results may surprise you. This scientific analysis found that sleep did not worsen over a 10-year period as a result of menopause. Most of the changes to sleep architecture were attributable to AGE, not to menopause.

Aging 10 years was associated with changes to time spent in light sleep, and in deep sleep, as well as to changes to the time it takes to fall asleep and the time it takes to reach stage 2 sleep, the deeper of the 2 light sleep stages.

Menopause, they found, was linked only to a longer sleep latency, meaning a longer time to fall initially to sleep.

What’s the takeaway for women here? While menopause may have short- and medium-term effects on sleep—remember, the study looked only at a 10-year time span—this study suggests their long-term sleep does not worsen because of menopause, and that changes to sleep architecture over the long-term are linked to aging itself.

Other recent research supports these findings. In a recent discussion of the depression symptoms of menopause and their impact on sleep, I wrote about a study that found no correlation between the likelihood of reporting poor sleep before menopause, during menopause, and after menopause. This means that women who had insomnia during menopause were not more likely to have insomnia after menopause. This latest research delivers more good news for women who may be struggling with their sleep during their transition to menopause.

Of course, this encouraging news about the long-term impact of menopause on sleep doesn’t mean women don’t grapple with significant sleep disruptions during the menopausal transition. Many do.

I’ve written extensively about the physical and psychological effects of menopause on women’s sleep. You can access my full library of menopause-sleep articles here.

Here are some of the key things to know about what can happen to sleep in menopause, and what to do about it.

The sleep-disrupting symptoms of menopause

Poor, insufficient, restless sleep are common symptoms associated with menopause.

What’s behind all this sleep disruption? A constellation of physical and psychological effects of the powerful biological changes underlying the menopausal transition.

Night sweats

Nighttime hot flashes are the body’s response to drops in estrogen. Night sweats can make sleep uncomfortable and difficult, whether it’s from waking up in the night sleep drenched in sweat and having trouble falling back asleep, or waking feeling unrested because of restless sleep caused by night sweats. For many women, hot flashes and night sweats begin during perimenopause, and tend to increase in frequency until a couple of years into post-menopause, before beginning a gradual decline.

Wearing the right clothes for sleep and investing in good bedding—natural fabrics, layers that can be removed, not overdressing for bed—can help improve sleep when you’re contending with night sweats. You can also take steps to cool your body and the microclimate of your bed using a couple of products I recommend to my patients. Ebb is a cooling comfort band that reduces activity in the brain while you sleep. Ebb is designed to quiet racing thoughts at night, and can also help ease discomfort of night sweats. Chilipad allows you to manage your body temperature throughout the night, enabling women to counteract the overheating of night sweats. Chilipad is customizable for bed partners, so each of you can adjust your temperature settings independently.

Physical pain

The menopausal transition often includes a range of potentially painful and uncomfortable physical symptoms that can interfere with sleep:

• During perimenopause, when estrogen, progesterone and other hormones are fluctuating sharply, some women experience severe PMS and heavy periods, accompanied by cramping, bloating, and breast tenderness.
• Headache and migraine can be a sign of low estrogen. Painful headaches and migraine arise for some women during pre-menopause, when estrogen levels drop at points during their monthly menstrual cycles. Often women in perimenopause experience headaches in response to the erratic fluctuations and overall decline of their estrogen levels.
• Muscle and joint pain and stiffness also occur for many women during menopause. One of estrogen’s functions in the body is to control and reduce inflammation. When estrogen declines, so does the strength of its work as a natural anti-inflammatory agent. This is one reason women may start feeling arthritis-like pain during menopause.

To improve pain issues associated with menopause and improve nightly rest, I recommend women consider, in consultation with their doctors, the mind-body therapies and natural supplements I discuss in the next section. It’s important to talk with your doctor about any chronic or recurring physical pain you’re experiencing.

Frequent urination

Incontinence and persistent need to urinate are both common symptoms for women going through menopause. The thinning of vaginal tissue, as well as the tissue’s diminishing elasticity, make bladder control an issue for many women in menopause. So does a weakening of the pelvic muscles. Urinary tract infections also become more common in menopause.

We all know that waking at night to go to the bathroom is annoying. But it’s also a real interruption to sleep that interfere with sleep quality and reduce sleep amounts. It’s important not to overlook this menopause symptom as a challenge to your healthy sleep routine.

It helps to stay hydrated throughout the day, to keep alcohol consumption very moderate, and to avoid drinking too much of anything very close to bedtime.

Weight gain

Weight gain during menopause happens to many women. Every woman is different, and weight gain with age can result from several factors, including individual genetics, daily habits of diet and exercise, and other health conditions. The hormone changes associated with menopause do also contribute to weight gain and changes to appetite. Research shows estrogen helps control appetite in the same way as the hormone leptin, triggering feelings of fullness and signaling to the brain that the body has sufficient fat and energy (aka calories) stored. Declining estrogen levels can bring about changes to appetite, increasing hunger and cravings for fatty and sugary foods.  Low estrogen can also make it more likely for women to gain fat in the abdominal area.

For women in menopause, already coping with declining estrogen, poor sleep can make even harder to avoid weight gain. I encourage my patients who experience weight gain during menopause to do all the things they associate with weight management—eating healthfully and moderately, exercising regularly, managing stress—AND to make sleep a priority. Women in menopause face significantly higher risks for obstructive sleep apnea than premenopausal women—and weight gain during the menopausal transition is a major contributor to this elevated sleep apnea risk. One in 5 women develop OSA during menopause, and roughly half to two-thirds of postmenopausal women develop sleep apnea.

Anxiety, depression, and mood swings

Research shows that women face heightened risks for depression and anxiety during the menopausal transition. The hormonal changes that are happening during this time contribute to these risks.

One of estrogen’s functions in a woman’s body is to regulate other hormones and neurotransmitters, including several that affect mood. Serotonin, dopamine, and norepinephrine are hormones and neurotransmitters that work to lift and stabilize mood.

The decline in progesterone, with its calming, relaxing, estrogen-balancing effects, can also contribute to feelings of anxiety, irritability, and restless agitation. Racing thoughts, and persistent feelings of stress, make it difficult for many women experiencing menopause to unwind.

Anxiety, depression, and sleep also influence each other. Anxiety and depression can trigger sleep problems, and sleeplessness exacerbates both depression and anxiety. Women going through menopause may develop sleep issues as one symptom of mood problems—and they may be more likely to face struggles with mood because of poor sleep.

Mind body treatments, and natural supplementation, can be effective tools to help alleviate the depression and anxiety that’s often part of the menopause transition, and have well-documented benefits directly for sleep. Too often, these psychological symptoms of menopause don’t get the focus and attention they need. It’s critical that women talk with their doctors about not only their physical symptoms during menopause, but also any psychological distress or disruption—and to do so before undertaking any new therapy or regimen. 

Interested in learning more? Here’s an even more in-depth look at the mental and physical symptoms of menopause and their impact on sleep and performance.

How to treat menopause sleep issues

Hormone replacement therapy can be effective in for treating the uncomfortable symptoms of menopause and the sleep issues that accompany them. Research has indicated that hormone replacement therapy, especially estrogen replacement, helps women fall asleep faster, decreases nighttime awakenings, and improves sleep quality.

And hormone replacement therapy also has been shown to act as an antidepressant by interacting with serotonin in the brain.

But using hormone replacement therapy does come with risks, and a lot of women are interested in alleviating symptoms of menopause, and improving their sleep, naturally. More good news here: there’s recent research that suggests making lifestyle changes, and addressing the depression and anxiety that is associated with the menopausal transition, can do more to improve sleep during menopause than hormone replacement therapy. Here’s where you can read about the lifestyle adjustments that I recommend to my patients to help boost your sleep and daily performance during menopause.  

Mind body therapies, including acupuncture, tai chi, yoga, and massage have all shown benefits to sleep for women during the menopause transition. CBT, cognitive-behavioral therapy, can also be highly effective in improving sleep and reducing the symptoms of menopause. Here is a longer discussion of the research behind the benefits of mind-body tools that can make a big difference for how women sleep, feel, and perform during menopause. Mind body therapy can address the physical symptoms of menopause, and the psychological symptoms too—and it’s increasingly clear from research that addressing the mental and emotional challenges of menopause is key to helping women feel and rest better in this stage of their lives.

Natural supplements targeting menopause and sleep also can help with both the physical and psychological symptoms of menopause. So many women I talk with have questions about the right supplements for menopause, with a particular emphasis on sleep. Here’s an in-depth look at some of the most well-studied, effective supplements for menopause. And here is a round-up of some of my favorite recommendations for natural supplements to help sleep, ones that can also address symptoms associated with menopause. A reminder: always check in with your doctor before starting any new supplement.

Even as sleep resets and becomes less disrupted for women after they’ve completed the transition to menopause, women still face potential challenges to sleep that relate to aging. Aging does not have to deprive any of us of consistently restful, refreshing sleep. But many of us, especially those of us who had the good fortune to sleep well in our younger years of adulthood, will need to pay new and different attention to sleep routines and sleep hygiene. You can read about age-related sleep challenges for men and women—and the solutions that set us up for sleeping well as we age.

Sweet Dreams,

Michael J. Breus, PhD, DABSM

The Sleep Doctor

www.thesleepdoctor.com

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