Menopausal Health

Getting a Good Nights Sleep in Perimenopause and Midlife

Julia Schlam Edelman, MD

Women in midlife face many challenges to their physical and mental health. One of these challenges is getting a good nights sleep. Targeting the causes of poor sleep will improve your patients energy levels and quality of life.

n todays society, quality sleep remains elusive. Astonishingly, between 70% and 80% of American women in peri- and postmenopause have sleep-disordered breathing, and more than 40% have insomnia.1,2 Despite the prevalence of sleep disorders in women, most are not accurately diagnosed or treated by their health care providers. The reasons for compromised sleep include the following: primary sleep disorders, such as sleep apnea, insomnia, and restless leg syndrome; midlife and aging; the hormonal changes of perimenopause; medical diagnoses, such as depression and thyroid disease; medications that affect sleep; and lifestyle choices, including caffeine and alcohol consumption.3

Researchers are exploring how sleep disruptions are related to menopause and aging.4,5 During perimenopause, ie, the 5- to 10-year period before the final menstrual period, 75% of women experience hot flashes and night sweats.6 The night sweats may last years or even decades. Clinicians and researchers both agree that night sweats can compromise sleep quality. Until recently, clinicians tended to assume that their menopausal patients sleep disturbances were due

Julia Schlam Edelman, MD, is Clinical Instructor, Harvard Medical School, Boston, MA; Consultant, Massachusetts General Hospital, Boston, MA; Adjunct Clinical Instructor, Brown Medical School, Providence, RI. Dr Edelman was North American Menopause Societys Menopause Practitioner of the Year, 2010.

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Getting a Good Nights Sleep in Perimenopause and Midlife

to night sweats. Researchers, however, have recently demonstrated that night sweats are not responsible for most sleep disruptions in midlife. If you have treated your patients night sweats and she still sleeps poorly, she may have a primary sleep disorder.7 Sleep disturbances in women present overnight sleep test that monitors breathing, body movements, oxygenation, and brain activity. The different forms of sleep apnea are central, obstructive, and mixed. Central sleep apnea is due to a lack of respiratory effort. Obstructive sleep apnea is due to a physical block in the airflow and is often accompanied by snoring.9 When sleep specialists diagnose sleep apnea, their treatment recommendations may include the use of a mouth guard, controlled positive airway pressure, or corrective surgery. Obesity is a risk factor for sleep apnea in women and men. However, normalweight perimenopausal women may develop sleep apnea. Sleep apnea in normal weight perimenopausal women may occur when lower progesterone levels lead to loss of pharyngeal muscle tone. A normal-weight woman with a deviated nasal septum, prominent nasal turbinates, narrow jaw structure, or a narrow mandible is also prone to sleep apnea.1 Insomnia Women are twice as likely to suffer from insomnia as men, and their perception of the quality of their sleep is often different. Women who take an over-thecounter or prescription sleep medication and continue to sleep poorly may be suffering from one or more primary sleep disorders. Insomnia may accompany sleep apnea or restless leg syndrome. Different manifestations of insomnia include an inability to fall asleep, frequent night awakenings, premature morning awakenings, and feeling tired on morning awakenings.10 When assessing women for insomnia, researchers find discrepancies between the sleep concerns that women report and the sleep events evident on monitoring. Even when some women slept well while monitored, they said they slept poorly. If your patients sleep study does not demonstrate poor sleep quality, and she still reports sleeping poorly, cognitive behavioral therapy may be useful in helping her recalibrate her perception of sound sleep.11

FOCUSPOINT Night sweats are not responsible for most sleep disruptions in midlife. If you have treated your patients night sweats and she still sleeps poorly, she may have a primary sleep disorder.
differently than in men and are more difficult to recognize. Consequently, fewer women than men have their sleep disturbances diagnosed and treated. A woman with sleep apnea may have upper airway resistance rather than a complete airway blockage. She may still feel fatigued and have disrupted sleep or trouble falling asleep. She may report waking up during the night, waking up too early in the morning, or waking up tired. These symptoms may persist even after trying a sleep aid. If your patients symptoms persist despite sleep aids, assess her for a primary sleep disorder.7,8 Below is an overview of the three most common sleep disorders and how they differ in women versus men, followed by a review of common medical conditions, medications, and lifestyle factors that compromise sleep in midlife women.

The Three Most Common Sleep Disorders

Sleep Apnea Sleep apnea results when breathing stops. The abnormal pauses are typically measured with a polysomnogram, an

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Edelman

Restless Leg Syndrome Restless leg syndrome is diagnosed when spontaneous, continuous leg movements occur, producing unpleasant sensations. These sensations occur at rest and are relieved by movement. Restless leg syndrome is twice as common in women compared to men, and the prevalence increases with age until age 60.12 The syndrome is more common in women with anemia and those with low ferritin levels.9,13 If your patients restless leg movements do not resolve after treating her anemia or low ferritin, she may benefit from treatment with a dopamine agonist or gabapentin.

Medications Specific medications, including overthe-counter and prescription preparations, may interfere with sleep: Steroids will compromise sleep quality and may produce insomnia. Diuretics taken later in the day may induce nocturia. Antihistamines are stimulating and make sleeping more difficult.

Clinical Clues and Lifestyle Factors

A woman experiencing poor quality sleep may tell you she is forgetful, her memory is worse, she is exhausted, or her sex drive is low or nonexistent.17,18 She wakes up tired after a full nights sleep. Her partner says she snores. She has trouble fi nishing her work or completing household tasks. If your patient has insomnia alone, or in combination with another primary sleep disorder, the following may help: Assess her coffee and caffeinated

Factors That Compromise Sleep

Depression During perimenopause, women become vulnerable to depression, whether or not they have a prior history of depression. Depression is associated with abnormal sleep patterns of all types. Women who are not depressed and develop a primary sleep disorder are at higher risk of becoming depressed.11 Since depression and primary sleep disorders often coexist, one must look for both. If your depressed patient is refractory to treatment, look for a sleep disorder. If your patient is being treated for a sleep disorder but is still sluggish, then evaluate her for depression.14 Treatment for depression may include counseling, antidepressant medication, or both. Thyroid Disease Thyroid disease mimics many signs and symptoms of peri- and postmenopause, including vasomotor symptoms and poor sleep quality.15 Thyroid disease is 8 to 9 times more common in women than men, and increasingly prevalent with age. Check a serum thyroid stimulating hormone level if your patient has night sweats, fatigue, or sleep disturbances. Some night sweats result from thyroid disease alone and are unrelated to menopause.16

FOCUSPOINT Women who are not depressed and develop a primary sleep disorder are at higher risk of becoming depressed.
beverage consumption. A large cup of coffee may have more than 200 milligrams of caffeine. It takes 6 hours to eliminate half of the caffeine. High residual caffeine levels delay sleep onset and disrupt sleep. A gradual reduction in caffeine consumption helps prevent caffeine-withdrawal headaches.19 Assess her alcohol consumption. Alcohol makes it easier to fall asleep, but disrupts deep REM sleep.19 If your patient is overweight or obese, the excess pounds may, in part, result

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from a sleep disturbance. Sleep loss is associated with disruptions in ghrelin, an appetite-stimulating hormone, and leptin, a satiety hormone. Obese women and those with disrupted sleep suffer from aberrations in their appetite-contime? Looking at a backlit electronic screen before going to sleep may delay falling asleep due to increased brain stimulation.19 Is your patient exercising less than 3 hours before bedtime? Exercising before bedtime is stimulating and compromises sleep quality.19 Staying hydrated is important for overall health, but consuming extra fluid within 3 hours of bedtime may compromise sleep. Nocturia is associated with insomnia and sleep apnea. If your patient has disrupted sleep and also wakes up to urinate more than once during the night, evaluate and treat the nocturia and sleep condition independently. Your patient may have a bladderfunction issue that could be addressed with bladder retraining or medication.22 Researchers show that 7 to 9 hours of sleep are ideal. Less than 7 hours of sleep is associated with dying younger. Excess sleep beyond 9 hours is associated with a higher risk of stroke.19

FOCUSPOINT Sleeping less, regardless of the cause, was associated with obesity in a large longitudinal analysis.
trol signals.20 Sleeping less, regardless of the cause, was also associated with obesity in a large longitudinal analysis.21 Sleep experts have coined the term sleep hygiene to describe pre-sleep routines that affect sleep quality. The following routines impact the quality and quantity of sleep your patient gets: When does your patient eat in relation to her bedtime? Not eating for 3 hours before bed keeps digestion from interfering with sleep. Patients with gastroesophageal reflux often benefit from elevating the head of the bed to decrease reflux.19 Does your patient watch television, read an electronic book, or look at her computer during the hour before bed-

Conclusion
If your midlife menopausal patient cannot sleep well after taking a sleep aid or having her night sweats treated, evaluate her for a primary sleep disorder, even if she is not overweight. Educate your patients about sleep hygiene, and consider medical causes of sleep disturbances when you evaluate midlife and menopausal patients. Targeting these causes of poor sleep will improve your patients energy levels and quality of life. The author reports no actual or potential conflicts of interest in relation to this article.

References
1. Tantrakul V, Guilleminault C. Chronic sleep complaints in premenopausal women and their association with sleepdisordered breathing. Lung. 2009;187(2):82-92. 2. Freedman RR, Roehrs TA. Sleep disturbance in menopause. Menopause. 2007;14(5):826-829. 3. Edelman JS. Successful Sleep. In: Edelman JS, ed. Menopause Matters: Your Guide to a Long and Healthy Life. Baltimore, MD: Johns Hopkins University Press;2010:207-220.

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4. Avis NE, Colvin A, Bromberger JT, et al. Change in healthrelated quality of life over the menopausal transition in a multiethnic cohort of middle-aged women: Study of Womens Health Across the Nation. Menopause. 2009;16(5):860-869. 5. Kalleinen N, Polo-Kantola P, Himanen SL, et al. Sleep and the menopause do postmenopausal women experience worse sleep than premenopausal women? Menopause Int. 2008;14(3):97-104. 6. North American Menopause Society. Menopause Practice: A Clinicians Guide. 4th ed. Mayfield Heights, OH: North American Menopause Society; 2010:4-9. 7. Joffe H, Massler A, Sharkey KM. Evaluation and management of sleep disturbance during the menopause transition. Semin Reprod Med. 2010;28(5):404-421. 8. Kapsimalis F, Kryger M. Sleep breathing disorders in the U.S. female population. J Womens Health (Larchmt). 2009;18(8):1211-1219. 9. Polo-Kantola P. Sleep problems in midlife and beyond. Maturitas. 2011;68(3):224-232. 10. Regestein QR, Friebely J, Shifren JL, et al. Selfreported sleep in postmenopausal women. Menopause. 2004;11(2):198-207. 11. Joffe H, Soares CN, Thurston RC, White DP, Cohen LS, Hall JE. Depression is associated with worse objectively and subjectively measured sleep, but not more frequent awakenings, in women with vasomotor symptoms. Menopause. 2009;16(4):671-679. 12. Chasens ER, Twerski SR, Yang K, Umlauf MG. Sleepiness and health in midlife women: results of the National Sleep Foundations 2007 Sleep in America Poll. Behav Sleep Med. 2010;8(3):157-171. 13. Earley C, Silber MH. Restless legs syndrome: understanding its consequences and the need for better treatment. Sleep Med. 2010;11(9):807-815. 14. Nowakowski S, Meliska CJ, Martinez LF, Parry BL.

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Sleep and menopause. Curr Neurol Neurosci Rep. 2009;9(2):165-172. Badawy A, State O, Sherief S. Can thyroid dysfunction explicate severe menopausal symptoms? J Obstet Gynaecol. 2007;27(5):503-505. Pearce EN. Thyroid dysfunction in perimenopausal and postmenopausal women. Menopause Int. 2007;13(1):8-13. Reed SD, Newton KM, LaCroix AZ, Grothaus LC, Ehrlich K. Night sweats, sleep disturbance, and depression associated with diminished libido in late menopausal transition and early postmenopause: baseline data from the Herbal Alternatives for Menopause Trial (HALT). Am J Obstet Gynecol. 2007;196(6):593.e1-7. Woods NF, Mitchell ES, Smith-Di Julio K. Sexual desire during the menopausal transition and early postmenopause: observations from the Seattle Midlife Womens Health Study. J Womens Health (Larchmt). 2010;19(2):209-218. National Sleep Foundation. http://www.sleepfoundation. org. Accessed December 19, 2011. Knutson KL, Spiegel K, Penev P, Van Cauter E. The metabolic consequences of sleep deprivation. Sleep Med Rev. 2007;11(3):163-178. Gangwisch JE, Malaspina D, Boden-Albala B, Heymsfield SB. Inadequate sleep as a risk factor for obesity: analyses of the NHANES I. Sleep. 2005;28(10):1217-1220. Gopal M, Sammel MD, Pien G, et al. Investigating the associations between nocturia and sleep disorders in perimenopausal women. J Urol. 2008;180(5):2063-2067.

For a PATIENT HANDOUT on healthy sleep, see page 55.

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