MenopauseMenu guest blog post by Milah Frownfelter, MD FACP, Internist at Seattle Medical Associates.
The morning sky emerges, with a soft light filtering through the curtains. A gentle encouragement as your eyelids flutter open with dawn welcoming you to a new day. Your energy begins to surge. You feel clear, motivated and excited to meet the moments that lay ahead. You have rested and are ready.
We know that restorative sleep is foundational to holistic health by reducing internal inflammation, including cortisol levels and other stress-related hormones.
- Immune health: Our immune response is fortified as we are better able to fight pathogens that cause upper respiratory infections; natural killer cells that fight cancer are more plentiful; and vaccinations are more effective as our body can more robustly produce antibodies that offer protection.
- Cardiovascular and metabolic health: Adequate sleep helps to lower our blood pressure and lowers pro-inflammatory hormones that are implicated in heart disease, as well as balancing hormones to stave off metabolic syndromes like diabetes.
- Cognitive health: It mitigates the development of proteins within the brain that can cause memory loss and strengthens short-term memory and new learning; our creativity and problem-solving abilities are also bolstered.
- Musculoskeletal health: Sleep allows our body to recover from micro-trauma during the day and, ultimately, reduces our risk for injury; it improves motor coordination and skill; and it enhances our respiratory and cardiac function while exercising.
But for far too many menopausal women, a restorative nights’ rest is but a dream. Nearly 1.5 million women enter the menopause transition per year, with 40-50% reporting sleep disturbance at some time, and 31-42% developing chronic insomnia at its conclusion.
For many, there can be an overlap of night sweats and hot flashes (vasomotor symptoms), mood disturbances, circadian rhythm disruption and other causes for sleep disturbance, taking on a myriad of manifestations. Quite often it is marked by difficulties falling sleep, restless sleep, or wakefulness throughout the night. Our alarm clocks stare back at us with malice as we see the minutes tick by, slumber elusive.
The effects of estrogen are widespread, activating within serotonin, norepinephrine and dopamine neurotransmitters pathways within the brain. As estrogen decreases, these neurotransmitters can similarly be disrupted, affecting many components responsible for initiating and promoting restful sleep, and regulation of internal temperature (with hot flashes and night sweats).
Compounding these hormonal changes, general life stress, underlying mood disturbances like depression and anxiety, primary sleep disturbances (periodic limb movement disorder, sleep disordered breathing, and restless legs syndrome) and other conditions can further erode sleep quality. With this, there is an emerging recognition of a “co-evolving syndrome” along with a multi-directional quality with one augmenting another (for example, underlying restless legs syndrome exacerbates insomnia which then causes cyclical worsening of each condition).
Although the factors leading to insomnia are complex, a good night’s sleep is still within reach! Your primary care and/or sleep medicine physician will be able to help with successful navigation of this condition, but know there are many options for treatment.
Even though not directly implicated in hormonal sleep disturbance, general sleep hygiene is always recommended:
- AVOID “screen time” for 60 to 90 minutes before bedtime (including smart phone, iPad, television, Kindle)
- Consider using an orange light bulb in the bedside lamp so that you can read without inhibiting melatonin (which is the body’s hormone that helps initiate sleep)
- AVOID alcohol before bedtime and instead use something like chamomile tea for sleep
- Wear socks to keep the core cool which helps you sleep
- Exercise, if possible, in “natural light” at least 2 hours before bedtime
- Keep your room cooled to 68 degrees F
For those with vasomotor symptoms (hot flashes and night sweats) that interrupt sleep, hormone replacement therapy or gabapentin may be helpful. Although not well-studied, Isoflavens (soy), omega-3 fatty acid supplements, and black cohosh can be considered, along with acupuncture (when safe to do so).
Some have mood disturbances that respond to medications like SSRIs (escitalopram/Lexapro or sertraline/Zoloft), SNRIs (venlafaxine/Effexor) or dopaminergics (bupropion/Wellbutrin). Cognitive behavioral therapy – insomnia (CBT-i) is also effective for many. With seasonal symptoms, light box therapy can be beneficial as can exposure to natural light throughout the day.
One may consider meeting with a sleep medicine specialist to evaluate for sleep-disordered breathing syndromes (like sleep apnea) which may present in women more as fatigue and decreased cognition (and not necessarily snoring which may present more commonly in men).
Conditions like restless legs syndrome may be evaluated further with labs (low iron can be implicated), and ultimately treated with medication. There are many options to treat chronic pain syndromes which may exacerbate sleep quality, too.
General stress management techniques like mindfulness-based stress reduction, meditation, yoga, and deep breathing exercises may be helpful.
Restorative, energizing sleep is a pillar of optimal health. With many effective resources available in the treatment of insomnia and its associated conditions, restful slumber need not be in the shadows. Dulcia somnia!
Milah Frownfelter, MD FACP