Sleep and the menopause

Doctor Nicola Barclay, departmental lecturer in sleep medicine at the University of Oxford and Mammoth sleep ambassador.

The menopause is a significant hormonal, psychological and physical change that typically affects women around the age of 50. During the transition phase known as the perimenopause, a woman’s ovaries gradually produce less oestrogen and progesterone.

This shift in hormone balance can cause hot flashes, anxiety and mood disorders. In a recent study, it was also found that 61% of women reported insomnia and sleep-related problems during this transitional phase.

Why is it harder to sleep well during the menopause and how can I fix it?

It is widely understood that the drop in production of oestrogen and progesterone during the perimenopause brings to a close the period in life where a woman is able to naturally conceive a child. But it is often overlooked that the influence of these hormones extends beyond the reproductive organs – playing a role in mood, energy, sex drive, and cognitive and emotional behaviours.

Crucially, oestrogen also promotes good sleep as it is linked to the production and use of serotonin and melatonin in the body – some of the chemicals that dictate the sleep–wake cycle. Once oestrogen levels begin to drop, a woman may notice that she wakes more frequently at night and takes longer to fall asleep in the first place. Additionally, the circadian control of melatonin may be impacted by the menopause, leading women to have advanced sleep timing, fragmented night-time sleep and early morning awakenings.

Oestrogen and progesterone are also closely linked to a woman’s mood. And this, in itself, can have repercussions when it comes to sleep quality. During the menopause it is not uncommon for women to experience low mood, fatigue, anxiety and headaches – all of which can make it difficult for the body to relax and find sleep. Similarly, hot flashes are a major factor that contribute to sleep disturbances during the menopause.

It should be noted that the symptoms of hormone fluctuations are not exclusive to women going through the menopause. Many women in their twenties, thirties and forties report increased insomnia at certain times of the menstrual cycle due to changes in oestrogen and progesterone levels.

Suffering from poor sleep? You’re not alone

The perimenopause typically lasts between 3 and 5 years. The process and symptoms during this period can vary significantly and are highly personalised. Nevertheless, a National Health Interview Survey conducted in 2015[i] found that perimenopausal women trended towards reduced sleep duration and quality. The research showed that among women aged 40-59:

  • 56% of perimenopausal women slept for less than 7 hours a night on average, in contrast to 41% of postmenopausal and 33% of premenopausal women.
  • 27% of postmenopausal women were likely to have trouble falling asleep, compared to 17% of premenopausal women.
  • 36% of postmenopausal women experienced disturbed sleep (waking 4 or more times per night in a week) compared to 24% of premenopausal women.
sleep quality

It is interesting to see that among postmenopausal women, some found that their sleep patterns returned to normal while others found that their sleep quality did not return to its premenopausal state.

As well as reduced sleep and symptoms of insomnia, other sleep disorders appear to rise in prevalence during the menopause. Difficulties breathing during sleep (known as sleep-disordered breathing, and including obstructive sleep apnoea, OSA) also increase during the transition to menopause, and it is likely due to weight gain as well as hormonal fluctuations adversely affecting the upper airway.

Restless Legs Syndrome (RLS) has also been associated with women going through the menopause. This includes tingling sensations in the legs at night making it difficult to get to sleep and stay asleep. It is particularly common in women experiencing nocturnal hot flashes. Correct evaluation and identification of co-occurring sleep disorders such as OSA and RLS is paramount to obtaining effective treatment.

Managing sleep problems

Some of the treatments commonly prescribed to rebalance hormone levels during the menopause have been found to alleviate the more troubling symptoms of the condition – such as hot flashes, anxiety and insomnia. In particular, hormone replacement therapy (HRT) is known to relieve menopausal symptoms, particularly hot flashes, and consequently improves sleep. Though  one must consider the potential health risks of HRT before trialling this type of treatment.

For those suffering from severe sleep problems, over-the-counter melatonin or sleep medications (hypnotics) prescribed by your doctor may be required during the perimenopause. However, it should be made clear that sleep medication is not a long-term solution for insomnia and, while it may make it easier to fall asleep, the quality of that sleep may be poor because sedatives inhibit the brain’s progress through the different phases of sleep. Such medications should only be used on an infrequent basis. Long-term treatment options include the safer anti-depressant medications or gabapentin, both of which have been shown to improve sleep in menopausal women.ii

Herbal and nutritional supplements, such as those containing isoflavones (Estromineral serena) and Valerian root have shown some promise in treating sleep disturbances in menopauseii. Foods such as tofu and soybeans are also thought to help alleviate symptoms as they contain phytoestrogen, a plant hormone similar to oestrogen.

When looking specifically at sleep problems associated with the menopause, making small but important dietary changes can help. Reducing caffeine intake is an obvious starting point for many. Adding nuts such as almonds and tart cherries to one’s diet can also help to improve sleep, as a source of melatonin (the sleep-regulating hormone).

catch up sleep

Finally, cognitive behavioural therapy for insomnia (CBT-I), which is considered the first-line treatment for chronic insomnia, has proven sustained benefits in the pre-, peri- and post-menopausal phases, and should be trialled first and foremost to tackle insomnia whenever it occurs across the lifespan. However you choose to approach the menopause, here are a few guidelines to help you sleep better.

  • Eat a healthy balanced diet with plenty of fruit and vegetables
  • Avoid large meals before bedtime
  • Aim to maintain a healthy, normal weight, and exercise regularly
  • Put time aside to relax – hot baths, massages, reading a book and meditating
  • Keep the sleep environment cool (around 18° Celsius is good for sleep), clean and dark
  • Avoid sleeping on an old mattress offering poor support and pressure relief
  • Avoid screen time within an hour of your bedtime
  • Avoid nicotine and alcohol before bed, and avoid caffeine from midday if you are particularly sensitive to its effects
  • Stick to a regular sleep-wake routine, getting up and going to bed at the same time each day, even on weekends

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[i] https://www.cdc.gov/nchs/products/databriefs/db286.htm

iiAttarian, H., Hachul, H., Guttuso, T., & Phillips, B. (2015). Treatment of chronic insomnia disorder in menopause: evaluation of literature. Menopause22(6), 674-684.