Sleep disturbance as a result of hormone changes can lead to women feeling constantly exhausted, depressed, unable to function to their normal cognitive ability and wondering why their life feels to be falling apart around them.
In my experience as a BMS menopause specialist, having supported women going through the hormonal changes around the menopause transition, sleep disturbance is one of the most impactful symptoms on a women's quality of life.
Perimenopause and menopause are significant transitional phases in a woman’s life, often accompanied by various physical and emotional changes, including sleep disturbances.
Difficulty falling asleep, staying asleep, or waking up unrefreshed are common complaints during this time. These disruptions stem from hormonal fluctuations and other physiological changes.
In this article, we’ll explore how sleep is affected during menopause, the role of hormones in regulating sleep, and how different treatments—from lifestyle adjustments to hormone replacement therapy (HRT)—can help support sleep.
The Physiology of Sleep and Stages
Sleep is a vital process controlled by a complex interaction of neurological, hormonal, and circadian factors. It typically occurs in cycles that alternate between two main states: non-rapid eye movement (NREM) sleep and rapid eye movement (REM) sleep.
Non-REM sleep includes three stages:
Stage 1 (light sleep) marks the transition from wakefulness to sleep.
Stage 2 is a phase of light sleep where body temperature drops, heart rate slows, and the body prepares for deep sleep.
Stage 3 is deep sleep, essential for tissue repair, energy restoration, and hormone release.
REM sleep, characterised by vivid dreams, is when the brain becomes more active, and memory consolidation and emotional regulation occur.
A healthy adult cycles through these stages 4-6 times each night. Both deep sleep and REM sleep are crucial for physical recovery and cognitive function.
Hormonal Influence on Sleep
Throughout a woman’s reproductive years, hormones such as oestrogen and progesterone help regulate sleep by influencing neurotransmitters like serotonin and gamma-aminobutyric acid (GABA), which promote relaxation and sleep.
Oestrogen supports the sleep cycle by regulating key neurotransmitters, such as serotonin and GABA, which promote relaxation and melatonin production, helping to induce sleep. It aids in body temperature regulation by stabilising the hypothalamus, which controls the necessary drop in core temperature for sleep. Additionally, oestrogen helps maintain the circadian rhythm, aligning sleep patterns with the natural day-night cycle. Its mood-stabilising effects, through increased serotonin and dopamine, further support sleep by reducing anxiety and depression. Oestrogen is thought to support a good sleep architecture or structure, ensuring we move through the different phases of sleep and reach the deep sleep phase and REM phase which are more restorative. As oestrogen levels decline during menopause, these functions are impaired, often leading to sleep disturbances.
Progesterone supports the sleep cycle by enhancing the calming effects of GABA, a neurotransmitter that promotes relaxation and reduces anxiety, acting as a natural sedative to help with falling and staying asleep. It also helps regulate breathing, reducing the risk of sleep disturbances like sleep apnoea.
As women transition through perimenopause (the years leading up to menopause) and menopause (defined by 12 consecutive months without a menstrual period), these hormones fluctuate and eventually decline. This hormonal shift often triggers sleep disturbances.
Sleep Disruptions During Perimenopause and Menopause
Several specific sleep-related issues emerge during this phase, primarily due to hormonal changes:
Insomnia: Declining progesterone levels can reduce GABA activity, making it harder to relax and fall asleep. Difficulty staying asleep or waking up early is also common.
Increased awaking: Oestrogen deficiency means we are less likely to reach deep sleep and REM sleep, we spend more of our time in phase 1 &2 where we can be easily be awoken and have more waking up periods in the night.
Night Sweats and Hot Flushes: As oestrogen levels drop, the body’s ability to regulate temperature is impaired. Hot flushes and night sweats can wake a woman abruptly, disrupting sleep and making it hard to fall back asleep.
Genitourinary syndrome of the menopause (GSM): lower hormone levels in our bladder and vagina can lead to symptoms of urinary frequency, particularly at night, called nocturia, many women report having to go to the loo several times a night.
Mood Changes: Hormonal fluctuations during perimenopause and menopause can lead to anxiety or depression, both of which are linked to sleep difficulties.
Sleep Apnoea and Restless Legs Syndrome (RLS): Menopause is associated with an increased risk of sleep apnoea and RLS, both of which can fragment sleep and reduce overall sleep quality.
Treatments and Strategies to Support Sleep
While menopause-related sleep disturbances can be challenging, several treatments and lifestyle strategies can help:
Lifestyle Adjustments
Lifestyle changes can significantly improve sleep quality:
Regular Exercise: Engaging in daily physical activity can promote better sleep by reducing stress, balancing hormones, and improving mood. Avoid exercising close to bedtime, as it can be stimulating.
Sleep Hygiene: Creating an environment conducive to sleep is critical. This includes maintaining a cool, dark bedroom, following a consistent sleep schedule, and avoiding stimulants like caffeine and alcohol, especially in the evening.
Relaxation Techniques: Practices such as mindfulness, deep breathing, and yoga can reduce stress and anxiety, making it easier to relax and fall asleep.
Dietary Supplements
Several supplements may support sleep during menopause:
Melatonin: This hormone regulates the sleep-wake cycle. Melatonin supplements may be helpful, particularly in women who experience age-related declines in melatonin production.
Magnesium: Magnesium plays a key role in muscle relaxation and sleep regulation. Supplements may help ease insomnia, especially in those with a deficiency.
Herbal Supplements: Herbs like valerian root, passionflower, and chamomile are traditionally used to support sleep. Although scientific evidence is mixed, many women report improvements in sleep quality with these supplements.
Cognitive Behavioural Therapy for Insomnia (CBT-I)
CBT-I is a structured therapeutic approach that focuses on changing thoughts and behaviours that contribute to poor sleep. CBT-I typically involves techniques to control stimulus (e.g., reducing screen time before bed), cognitive restructuring (e.g., addressing negative thoughts about sleep), and sleep restriction therapy.
Localised Vaginal Oestrogen
Localised vaginal oestrogen can be extremely helpful in elevating the symptoms of the genitourinary syndrome of the menopause (GSM). locally restoring oestrogen to the vagina and bladder and reducing nocturia, waking in the night to pass urine. localised vaginal oestrogen can be use independently or safely in addition to HRT.
Hormone Replacement Therapy
HRT is one of the most effective treatments for managing menopausal symptoms, including sleep disturbances. By replacing declining levels of oestrogen and progesterone, HRT restores the natural role of our hormones on our sleep physiology and can alleviate further symptoms like night sweats, hot flushes, and urinary frequency, all of which disrupt sleep.
Conclusion
Menopause-related sleep disturbances are common but manageable with the right combination of lifestyle changes, cognitive therapies, supplements, and or HRT. Understanding the impact of hormonal shifts on sleep physiology helps explain why sleep problems occur during perimenopause and menopause. While these challenges can significantly affect quality of life, a proactive approach that combines appropriate treatments can help restore better sleep and improve overall well-being during this transitional phase of life.
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