Perimenopause and Sleep: What You Need to Know
Menopausal symptoms are incredibly common. Approximately 90% of women experiencing menopausal symptoms consult their healthcare professionals for guidance on managing these challenges.
LISTEN NOW: Season 1 Episode 11 – Dr. Val Returns: Perimenopause
On this episode, I am joined by my friend and Colleague, Dr. Val Cacho. Many women undergo a physiological transition where they move from their reproductive years to a period where they can no longer conceive, commonly referred to as perimenopause or the onset of menopause. A notable concern during this transition is sleep disturbance, which is a prevalent issue affecting countless women globally. This episode addresses some sleep disruption concerns we commonly hear in our practice.
Perimenopause facts
How is perimenopause defined?
Perimenopause is a vaguely defined phase encompassing the concluding years of a woman's fertility. It starts when menstrual cycles first show irregularities and concludes after a year without menstruation, marking the final menstrual period (FMP). The perimenopausal or menopausal transition can be split into two phases: the early transition, characterized by largely consistent cycles with minimal disruptions, and the late transition, during which periods of amenorrhea (lack of a period) extend for 60 days or more, leading up to the FMP.
What are the most common symptoms of perimenopause?
Menopausal symptoms are incredibly common. Approximately 90% of women experiencing menopausal symptoms consult their healthcare professionals for guidance on managing these challenges.
Typical menopausal symptoms include: hot flashes (55% of women in perimenopause and 85% of menopausal women!), night sweats, mood instability, decreased libido, anxiety, depression, insomnia, dry skin, and bloating, to name a few.
How common are sleep problems in perimenopause?
Based on data from the Study of Women's Health Across the Nation (SWAN) published in 2011, sleep disorders become more common as women age. In premenopausal women, sleep disorders occur in about 16% to 42% of cases. This rate increases to 39% to 47% for perimenopausal women and further rises to between 35% and 60% for postmenopausal women.
What types of sleep disorders are common in perimenopause?
Insomnia, which is defined as recurrent and chronic perceived poor sleep (difficulty falling asleep and staying asleep despite adequate opportunity to sleep), occurring three or more times per week and causing significant distress and daytime consequences, affects 26% of women and is made worse when vasomotor symptoms (i.e., those pesky hot flashes) are also present. Women often complain of rumination, anxiety and generally find it hard to relax (hyperarousal state).
Obstructive Sleep Apnea (OSA) or sleep-disordered breathing is much more common in menopausal women (3.5 times more likely to have moderate sleep apnea) than pre-menopausal women. There are protective effects of progesterone and estrogen that help the airway stay open at night during sleep, and those protective effects diminish as progesterone and estrogen levels decrease. There is also dreaded weight gain and re-distribution of weight that contributes.
Restless Legs (RLS) and Periodic Limb Movement Disorder (PLMD), which represent disruptive leg movements that occur before or during sleep, predict decreased sleep quality in menopausal women. However, RLS and PLMD are simply more prevalent as we age and appear to be an outside phenomenon related to aging in everyone rather than specifically related to menopause.
Other factors: Dr. Val nicely points out that significant external factors may contribute to poor sleep in perimenopause, including medication side effects that can disrupt sleep. We also tend to have more aches and pains and may find ourselves urinating more frequently, especially if we have had children. Increased urination is due to less estrogen contributing to weakened pelvic floor muscles, loss of bladder elasticity, vaginal dryness contributing to an uptick in urinary tract infections, weight gain, or prior surgery (think C-section). All of these factors, coupled with a gradual reduction in the amount of deep sleep we get as we age, may further disrupt sleep quality.
You know, those abrupt changes in estrogen can also lead to the hot flashes, those pesky hot flashes, which can really dust up your sleep. So I say, you know, those are probably some of the reasons that can affect women and midlife and older, but also, we don't talk about this a lot. And some of the research shows that melatonin starts to decline.
How to improve sleep quality in perimenopause:
Clinical hypnotherapy has been shown to substantially reduce hot flash frequency and sleep quality sustained at three months.
Melatonin is a hormone secreted by your pineal gland in response to darkness. As we age, less melatonin is secreted. Based on a small, open-labeled study, women with impaired sleep may benefit from 3mg of melatonin.
During menopause, ~50-75% of women will have vasomotor symptoms (commonly known as hot flashes), which can disrupt sleep at night. Hormone replacement therapy may improve the quality of sleep.
For women who are not candidates for hormonal treatments, antidepressant medications such as citalopram, desvenlafaxine, escitalopram, gabapentin, paroxetine, and venlafaxine may reduce the frequency of symptoms by 40-65%.
Gabapentin also appears to reduce hot flash frequency, though estrogen is more effective.
