Feeling uncomfortable and not like yourself? Sleep problems and other symptoms might be involved.
Poor and disrupted sleep are common symptoms of menopause. Insomnia, and changes to typical sleep patterns, are often an early signal of a woman in perimenopause, who is experiencing changes to estrogen, progesterone and other hormones that influence sleep.
So many of my patients cope with other symptoms of menopause that affect sleep. But it’s not always easy to make the connection between those menopause symptoms and the impact they are having on your nightly rest. I’ll run through some of the most frequently experienced symptoms of menopause, and talk about how they might be exacerbating your sleep issues—in ways that might surprise you.
These nighttime hot flashes, a surge of body heat accompanied by intense sweating, are the body’s response to drops in estrogen. For many women, Hot flashes and night sweats begin during perimenopause, and tend to increase in frequency until a couple of years into post-menopause, before beginning a gradual decline.
Night sweats make sleep uncomfortable and difficult. I treat many patients who, throughout menopause, are regularly awakened from sleep drenched in sweat and have trouble falling back asleep, or wake feeling tired and unrested because of restless sleep caused by night sweats.
Night sweats can also make sleeping with a bed partner difficult, and put stress on relationships—sometimes, women experiencing nighttime hot flashes are uncomfortable sleeping close to another person.
New research indicates a link between night sweats, hot flashes and obstructive sleep apnea in menopausal women. Obstructive sleep apnea and other sleep disorders become more common in women as they age, and move through menopause. A recent study shows women with severe hot flashes during the day or night may be at significantly higher risk for obstructive sleep apnea than women who experience mild hot flashes, or none at all.
Wearing the right clothes for sleep and investing in good bedding—natural fabrics, layers that can be removed, not overdressing for bed—can help improve sleep when you’re contending with night sweats.
Anxiety, depression, and mood swings
I often see women in the menopausal transition who are struggling with sleep issues as well as anxiety and erratic, unpredictable changes to mood. In addition to mood swings that take you from sadness to anger to fear, women in menopause are also more likely to experience panic attacks and other physical symptoms of anxiety, including sweating and heart palpitations.
One of estrogen’s functions in a woman’s body is to regulate other hormones and neurotransmitters, including several that affect mood. Serotonin, dopamine, and norepinephrine are hormones and neurotransmitters that work to lift and stabilize mood. They also play direct roles in regulating sleep-wake cycles. When estrogen levels are irregular and erratic, that creates changes to levels of these mood-shaping hormones that can affect how you feel throughout the day—and how you sleep at night.
The decline in progesterone, with its calming, relaxing, estrogen-balancing effects, can also contribute to feelings of anxiety, irritability, and restless agitation. One of the most common complaints I hear from women in perimenopause is, “I can’t turn off my mind at night.” Racing thoughts, and persistent feelings of stress, make it difficult for many women experiencing menopause to unwind.
Anxiety, depression, and sleep have what’s known as a bi-directional relationship. Anxiety and depression can trigger sleep problems, and sleeplessness exacerbates both depression and anxiety. Women going through menopause may develop sleep issues as one symptom of mood problems—and they may be more likely to face struggles with mood because of poor sleep.
If you have a history of anxiety or depression, or are facing high levels of stress in your life, you may be more likely to experience mood swings and the development of a mood disorder in menopause—and therefore at greater risk for sleep problems. It’s important to discuss all of these symptoms with your doctor, so they don’t get worse when left un-treated.
Lack of concentration, focus, and memory
The foggy-headed forgetfulness and difficulty maintaining focus are some of the most frustrating symptoms for many of my patients who are in the menopausal transition. Estrogen helps keep the mind sharp, fueling the production of neurotransmitters that not only support mood, but also support a woman’s executive functioning—complex thinking, reasoning, and decision making. Estrogen plays a critical role in memory, and supports the overall health of the brain. One way appears to do this? By its influence with BDNF, a protein in the brain that is essential for maintaining healthy neurons.
Progesterone also aids in brain health and function—and it’s a hormone that’s important to successful healing in the brain after injury. A recent study found progesterone levels in post-menopausal women are linked to verbal memory and to overall cognitive abilities.
Testosterone in women also contributes to mental sharpness and memory, and decreasing levels of testosterone with age are linked to problems with memory and concentration.
The shifts and declines in these hormones throughout menopause can interfere with waking performance. Many of the women I see in my practice are regularly frustrated by these changes to their focus, memory, and thinking—and say it affects their productivity, and the outlook with which they approach their work. This frustration over a lack of mental sharpness frequently creates stress that directly interferes with their sleep.
Changes to sex drive
As with all symptoms of menopause, changes in sexual drive and sexual function don’t happen for every woman. But for many, decreasing estrogen, progesterone, and testosterone that come with menopause create a reduced interest in, and pleasure from, sex. Some women experience pain during intercourse. Estrogen helps to keep vaginal tissues elastic and lubricated, and low estrogen can lead to thinning of vaginal tissue and vaginal dryness that may make sex uncomfortable.
Among my patients who experience this common symptom, the change in sex drive often creates frustration and confusion, as they wonder why their interest in sex feels different—and wonder how to revive that interest. This change associated with menopause also can create tension and distance in women’s relationships with their partners. These emotional and relationship challenges generate worry, frustration and anger that can compromise sleep.
It’s also worth noting here that sleeplessness itself can trigger conflict in relationships. When one or both partners is struggling with sleep issues, tension is more likely. Lack of sleep makes women and men more emotionally reactive, more likely to focus on negative feelings, and less empathic in relationships.
The menopausal transition is accompanied by a broad range of potentially painful and uncomfortable symptoms—all of which can interfere with sleep:
• During perimenopause, when estrogen, progesterone and other hormones are fluctuating sharply, some women experience severe PMS and heavy periods, accompanied by cramping, bloating, and breast tenderness.
• Headache and migraine can be a sign of low estrogen. Painful headaches and migraine arise for some women during pre-menopause, when estrogen levels drop at points during their monthly menstrual cycles. Often women in perimenopause experience headaches in response to the erratic fluctuations and overall decline of their estrogen levels.
• Muscle and joint pain and stiffness also occur for many women during menopause. One of estrogen’s functions in the body is to control and reduce inflammation. When estrogen declines, so does the strength of its work as a natural anti-inflammatory agent. This is one reason women may start feeling arthritis-like pain during menopause.
Sleep and pain influence one another in powerful ways. The presence of pain makes it harder to fall asleep and to stay asleep throughout the night, reducing both sleep quality and sleep quantity. My patients in menopause often remark about how muscle stiffness and pain has come to be part of their nightly sleep experience, to the detriment of how much and how well they sleep. Pain also creates more fragmented, restless sleep, and can cause you to spend less time in slow-wave sleep and REM—two sleep stages when the body is hardest at work in healing itself at the cellular level.
Many of my patients are surprised when I tell them a lack of sleep actually lowers pain thresholds, making you more sensitive to pain. Short on sleep, your pain perception intensifies, and the body aches, headaches, and other physical pain associated with menopause feel even more uncomfortable.
Weight gain during menopause happens to many women. Every woman is different, and weight gain with age can result from several factors, including individual genetics, daily habits of diet and exercise, and other health conditions. The hormone changes associated with menopause do also contribute to weight gain and changes to appetite. Research shows estrogen helps control appetite in the same way as the hormone leptin, triggering feelings of fullness and signaling to the brain that the body has sufficient fat and energy (aka calories) stored. Declining estrogen levels can bring about what are often puzzling, frustrating changes to women’s appetites, making them feel frequently hungry, and increasing cravings for fatty and sugary foods. Low estrogen can also make it more likely for women to gain fat in the abdominal area.
Sleep has a powerful connection to weight, a connection that just becomes more important with age. Short on sleep appetite tends to increase, as does the desire to eat junk food, thanks to changes in brain activity in areas that govern judgment and reasoned decision making. Sleep deprived, studies show we tend to consume more calories throughout the day. Lack of sleep may also push you to eat a greater share of those calories later in the day—especially if you’re already a night owl. Insufficient sleep throws off balance hormones that regulate appetite. Not getting enough sleep reduces levels of leptin, the satiety hormone, and elevates production of ghrelin, a hormone that promotes hunger. Lack of sleep is linked to higher BMI and to greater risks of obesity and metabolic disorders, including type 2 diabetes.
For women in menopause, already coping with declining estrogen, poor sleep can make even harder to avoid weight gain. I tell my patients who are struggling with weight gain during menopause to do all the things they associate with weight management—eating healthfully and moderately, exercising regularly, managing stress—AND to make sleep a priority on equal footing.
I hear from a lot of my patients their irritation at having to pee often both day and night, and feeling the need to urinate even if their bladder isn’t really full. A persistent need to urinate and incontinence are frequent symptoms for women going through menopause. The thinning of vaginal tissue, as well as the tissue’s diminishing elasticity, make bladder control an issue for many women in menopause. So does a weakening of the pelvic muscles. Urinary tract infections also become more common in menopause.
Waking at night to go to the bathroom can feel like a tedious habit—but it’s also an interruption to sleep that interfere with sleep quality and reduce sleep amounts. I remind my patients not to overlook this menopause symptom as a challenge to their healthy sleep routine. It helps to stay hydrated throughout the day, to keep alcohol consumption very moderate, and to avoid drinking too much of anything very close to bedtime.
The constellation of symptoms women experience during menopause often add up to real struggles with sleep. Without enough sound sleep on a regular basis, every part of your life can suffer—your health, your relationships, your energy levels, your work and your daily performance. Sleep and your quality of life are deeply connected. It’s important to pay attention to what is happening in your body, take note of the symptoms that you’re experiencing and remember that in addition to being frustrating in their own right, many of these symptoms may also be compromising your sleep.
Next, I’ll talk about the health risks that women during menopause face, and how sleep plays a role in those concerns. From there, I’ll talk about solutions: therapies and strategies to sleep better and feel better during menopause and beyond, and how you can use natural remedies to help.
Michael J. Breus, PhD, DABSM
The Sleep Doctor™