Sleep Disturbance and the Menopause

AMS Sleep Disturbance and the Menopause352.96 KB

Many women complain of disturbed sleep during the peri-menopause and after menopause. Complaints about poor sleep include difficulty falling and staying asleep, coupled with early morning and nocturnal awakenings ⁽¹⁾.

Sleep duration of less than seven hours a night has been associated with increased mortality ⁽²⁾, as well as linked to cardiovascular disease, obesity, mood disorders and diabetes ^{(3, 4)}.

Contributing factors

• These include ⁽¹⁾
  • Changing hormone levels (hormones playing a role in sleep include growth hormone, prolactin, cortisol and melatonin)
  • Vasomotor symptoms (sweating and flushing), mood disorders (depression and anxiety)
  • Abnormalities of the circadian rhythm
  • Co-morbid conditions (snoring, airway obstruction, restless legs syndrome, periodic limb movement disorder, musculoskeletal pain and fibromyalgia)
  • Exacerbation of primary insomnia
  • Lifestyle factors (poor sleep hygiene, irregular schedules, caffeine, alcohol, snoring partner).
• It has been noted that insomnia is more common in women than in men, with 25% of women between the ages of 50- and 64-years having sleep difficulties. Sleep difficulties are more common in post-menopausal than in pre-menopausal women, and more severe in those experiencing a surgical menopause ⁽⁴⁾.

Investigation

• Take a thorough history, including the type of sleep disturbances, co-morbid conditions, contributing factors, medications and impact on quality of life ⁽¹⁾.
• The Pittsburgh Sleep Quality Index ⁽⁵⁾ (measures sleep quality) and Epworth Sleepiness Score ⁽⁶⁾ (assesses the degree of sleepiness) may be useful tools. The STOP Bang questionnaire ⁽⁷⁾ is a useful screening questionnaire for snoring and obstructive sleep apnoea.
• Self-reported questionnaires (a sleep diary to assess issues related to sleep hygiene, duration of sleep and circadian rhythm), may provide information regarding perceived sleep quality. However, there are discrepancies between the objective and subjective measures, putting the role of laboratory assessments into question ⁽¹⁾.
• Objective assessment measures of sleep disturbance may include ⁽¹⁾:
  • Wrist actigraphy (to assess sleeping patterns and awakenings on consecutive nights and to provide information on certain sleep disorders, including shift work disorder). This may also be used to assess the response to therapy.
• Tests available during a specialist sleep consultation may include ⁽¹⁾:
  • Overnight polysomnography (PSG) (to assess for breathing disorders, movement and circadian rhythm disorders).
  • Continuous EEG recording will assess the various sleep stages.
  • Respiratory monitoring and leg EMG (to assess disordered breathing or periodic leg movement disorder).
• Multiple Sleep Latency Tests (MSLT) is a specialised test measuring the time taken to fall asleep over 4 nap opportunities during the day in a controlled laboratory setting. It is a useful test for the evaluation of patients describing excessive daytime sleepiness in the absence of causes such as sleep apnoea, sleep loss or certain medication usage.

Management

• Formulating a strategy is dependent on a thorough investigation and evaluation of all contributing factors ⁽¹⁾.
• Strategies may include medications and lifestyle and behavioural modification ⁽¹⁾. (Please refer to AMS Information Sheet Lifestyle and behavioural modifications for menopausal symptoms).
• Lifestyle modification e.g. regular schedules, sleep hygiene, elimination of caffeine and alcohol, appropriate and comfortable bedding and temperatures as well as sleep hygiene should be employed ⁽¹⁾.
• The use of oestrogen, alone or in combination with a progestogen, has been shown to improve the subjective quality of sleep ^(8-11). Women with hot flushes treated with menopausal hormone therapy ( MHT) show a marked improvement in sleep quality ⁽⁴⁾. The newer body-identical micronised progesterone may cause somnolence. For this reason it is suggested to be taken at night and may therefore also help improve sleep.(Please refer to AMS information sheets Oestrogen only therapy and Combined Menopausal Hormone Therapy).
• Hypnotics should not be used in situations other than for acute sleep problems because of their side effects, tolerance and withdrawal issues ⁽¹⁾.
• The serotonin modulating antidepressants have been shown to improve hot flushes, depression and insomnia ^{(12, 13)}. (Please refer to AMS Information Sheet Mood problems at menopause).
• Some SSRIs have useful sedative properties as do Low dose tricyclic antidepressants (TCAs) which may assist in alleviating insomnia ^{(14, 15)}. As with the use of hypnotics their use should be carefully monitored and the side effect profile needs to be taken into consideration.
• A fixed sleep-wake cycle is important to sleep quality. Endogenous melatonin, which declines with age, is an important factor in the maintenance of this cycle ^{(16, 17)}, while exposure to light helps maintain a state of wakefulness ⁽¹⁾. The use of supplemental melatonin in rapid release formulations (eg crushing the prescription forms of modified release melatonin) and light therapy (both at the appropriate time of day) have been shown to improve the circadian rhythm ^{(17, 18)}. In particular, morning light, which can be combined with exercise such as walking, can be helpful in consolidating night-time sleep and reducing morning sleep inertia ⁽¹⁹⁾. The correct timing of these interventions is important and may require specialist input ⁽¹⁹⁾.
• Cognitive Behavioural Therapy, to include stimulus control and sleep restriction therapies have shown improvement in sleep ⁽¹⁾. These approaches are shown to be equally efficacious to pharmacotherapy with longer term sustainability ⁽²⁰⁾. Cognitive therapies alone in the absence of behavioural techniques (stimulus control therapy and sleep restriction) are not as efficacious as the combination.

References

1. Ameratunga D, Goldin J, Hickey M. Sleep disturbance in menopause. Internal Medicine Journal. 2012;2(7):742-7.
2. Kripke DF, Garfinkel L, Wingard DL, Klauber MR, Marler MR. Mortality associated with sleep duration and insomnia. Archives of general psychiatry. 2002;59(2):131-6.
3. Matteson-Rusby SE, Pigeon WR, Gehrman P, Perlis ML. Why treat insomnia? Primary care companion to the Journal of clinical psychiatry. 2010;12(1):PCC.08r00743.
4. Polo-Kantola P. Sleep problems in midlife and beyond. Maturitas. 2011;68(3):224-32.
5. Buysse DJ, Reynolds CF, 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry research. 1989;28(2):193-213.
6. Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991;14(6):540-5.
7. Chung, F, Yegneswaran, B, Liao, P, Chung, SA, Vairavanathan , S, Islam, S, Khajehdehi , A, Shapiro, CM. STOP Questionnaire. A Tool to Screen Patients for Obstructive Sleep Apnea. Anesthesiology 2008; 108:812–21.
8. Hale GE, Burger HG. Hormonal changes and biomarkers in late reproductive age, menopausal transition and menopause. Best practice & research Clinical obstetrics & gynaecology. 2009;23(1):7-23.
9. Erkkola R, Holma P, Jarvi T, Nummi S, Punnonen R, Raudaskoski T, et al. Transdermal oestrogen replacement therapy in a Finnish population. Maturitas. 1991;13(4):275-81.
10. Polo-Kantola P, Erkkola R, Helenius H, Irjala K, Polo O. When does estrogen replacement therapy improve sleep quality? American journal of obstetrics and gynecology. 1998;178(5):1002-9.
11. Hays J, Ockene JK, Brunner RL, Kotchen JM, Manson JE, Patterson RE, et al. Effects of estrogen plus progestin on health-related quality of life. The New England Journal of Medicine. 2003;348(19):1839-54.
12. Eichling PS, Sahni J. Menopause related sleep disorders. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 2005;1(3):291-300.
13. Wafford KA, Ebert B. Emerging anti-insomnia drugs: tackling sleeplessness and the quality of wake time. Nature reviews Drug discovery. 2008;7(6):530-40.
14. Winokur A, Demartinis N. The Effects of Antidepressants on Sleep: Sleep Disorders, Depression, Psychopharmacology 2012 [updated 13 JUne 2012].
15. Mayers AG, Baldwin DS. Antidepressants and their effect on sleep. Hum Psychopharmacol. 2005;20(8):533-59.
16. Vakkuri O, Kivela A, Leppaluoto J, Valtonen M, Kauppila A. Decrease in melatonin precedes follicle-stimulating hormone increase during perimenopause. European journal of endocrinology / European Federation of Endocrine Societies. 1996;135(2):188-92.
17. Lemoine P, Nir T, Laudon M, Zisapel N. Prolonged-release melatonin improves sleep quality and morning alertness in insomnia patients aged 55 years and older and has no withdrawal effects. Journal of sleep research. 2007;16(4):372-80.
18. Dodson ER, Zee PC. Therapeutics for Circadian Rhythm Sleep Disorders. Sleep medicine clinics. 2010;5(4):701-15.
19. Cunnington D, Junge MF, Fernando AT. Sleep disorders: a practical guide for Australian health care practitioners. Med J Aust 2013; 199 (8 Suppl): S36-S40. doi: 10.5694/mja13.10718. Published online: 2013-10-21
20. Epstein DR, Sidani S, Bootzin RR, Belyea MJ. Dismantling multicomponent behavioral treatment for insomnia in older adults: a randomized controlled trial. Sleep. 2012;35(6):797-805.

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Content updated September 2018