Menopause is the time in women’s lives when menstrual periods stop and fertility is lost. It happens usually after the age of 40, when the ovaries no longer produce estrogen and progesterone. Main symptoms of Menopause may include: trouble focusing, memory lapses, anxiety, depression and insomnia.
Menopause and sleep problems
The prevalence of insomnia increases with age and affects almost 50% of adults, most of which (66%) are women 1 . Menopause is a critical transition period that can harm sleep and increase the risk for developing sleep disorders. Many women who are going through menopause have trouble falling asleep, or maintaining sleep because of hot flashes or night sweats 1 2 . The prevalence of sleep disturbance increases with age from pre-menopause to post-menopausephase 2 .
How can menopause cause sleep problems?
Number of reasons could lead to sleep disturbances among menopausal women e.g., normal physiological changes associated with aging, poor health perception, hot flashes, night sweats, nervousness, stress depression, anxiety and additional related chronic health issues 2 3 4 .
Hot flashes, affect 75–85% of women across the menopausal transition and include a feeling of intense heat with or without rapid heart rate. Hot flashes usually last less than 30 minutes for each occurrence. Studies have shown that hot flashes are the primary cause of sleep problems in menopausal women, which are characterized by multiple awakenings, lower sleep efficiency 5 and daytime irritability 6 7 . Hot flashes not only directly and negatively influence sleep but may also have an indirect effect on mood, partly mediated by sleep difficulty 7 8 .
Reduction in Sex steroid hormones
Menopause is accompanied by changes in the sex steroid hormones that have widespread effects on various body tissues, including the brain and the sleep patterns. Estrogen deficiency causes difficulty staying asleep and is the primary factor in night sweats, which can disrupt the sleep cycle 8 9 . It is also thought that Estrogen deficiency can cause breathing irregularities during sleep, resulting in sleep apnea.
Progesterone has both relaxing and anti-anxiety effects, which play an important role in sleep cycle and are important for good quality sleep. With lowered levels of progesterone during menopause, women will find it more difficult to slip into deep sleep, so the night sleep won’t be as restful as it should be 9 10
Anxiety and Depression
Anxiety and depression can be associated with sleep disturbances in menopausal women 10 11 Difficulties in falling asleep leads to anxiety, irritability and non-restorative sleep problems which all correlate strongly with depression 11 . The low estrogen and progesterone level in menopausal women increase the risk of insomnia and mood disturbances in this population 12 13
What are the solutions?
Hormone Replacement Therapy
Hormone Replacement Therapy (HRT) has historically been considered as first line treatment for menopausal insomnia. Estrogen therapy with or without progesterone is very effective in treating hot flashes, mood swings and depression 13 . Moreover, HRT was found to decrease time falling asleep, decrease midnights awakenings and decrease total sleep time in menopausal women 14 . HRT is also associated with numerous risks and side effects which often result in several types of cancers, blood clots, heart disease and strokes. Due to these concerns about the HRT side-effect profile, many women are increasingly seeking alternative treatments.
Sedative hypnotics (benzodiazepines and Z-drugs)
Benzodiazepines and Z-drugs are the most widely prescribed drugs for the treatment of insomnia in the elderly. Some of these agents are effective for shortening the time of falling asleep and a small portion of them are indicated for both sleep onset and sleep maintenance 15 16 . Main concerns with these drugs are risks of dependence, daytime residual disturbances, cognitive and psychomotor impairments, falls and accidents 17 , memory disturbances and dementia 18 . Thus, the efficacy versus safety profiles of BZD and Z-drug hypnotics has a negative risk-benefit ratio in elderly patients 16 .
With age there is a dramatic decline in the melatonin hormone production and secretion 19 . Since melatonin plays a critical role in sleep process and helps to synchronize the body’s biological clock, the decline in melatonin levels, may contribute to insomnia seen amongst the elderly women 20 . Previous studies already showed the beneficial effect of Melatonin in inducing sleep, decreasing wakefulness and shifting the biological clock towards the desired rhythm 21 . Ramelteon (melatonin agonist approved in US and Japan), was shown to improve sleep quality after 6 weeks of treatment (8 mg per day) in perimenopausal women 22 .Treatment with Prolonged Release Melatonin (Circadin 2 mg) alone or as an add-on treatment, shown to improve sleep quality and shortened sleep initiation in perimenopausal women 23 .
Good sleep is essential for living a healthy life, and is an important factor in life expectancy for women. Combination of medications and lifestyle changes may relieve sleep disorders in menopause and post menopause phases. Melatonin treatment, can improve sleep disturbances without harming the central nervous system, whereas other medications, such as sedative hypnotics (benzodiazepines and Z-drugs) used for the same purpose, might cause negative effects that interfere with daily activity. Therefore, nightly treatment of melatonin is a safe and effective way to treat sleep disorders linked with ageing and menopause.