Sleep and Menopause: How to Overcome Sleep Disorders in Postmenopausal Women – Mona Morstein, ND

Sleep and Menopause: How to Overcome Sleep Disorders in Postmenopausal Women

Dr. Mona Morstein

Discover how menopause impacts sleep, common sleep disorders in postmenopausal women, and practical solutions to restore healthy sleep.

Sleep disturbances, including insomnia, obstructive sleep apnea, and restless leg syndrome, are common in postmenopausal women. Learn about the connection between hormonal changes and sleep, and explore effective strategies, including sleep hygiene, exercise, and hormone therapy, to improve sleep quality.

There is nothing more enjoyable and rejuvenating than a good night of sleep.  As Britannica encylopedia (1) writes: “sleep is a normal, reversible, recurrent state of reduced responsiveness to external stimulation accompanied by complex and predidctable changes in physiology.”

The Importance of Sleep and Its Mechanisms

Sleep is a complex process that includes many interacting areas of the human brain: hypothalamus, suprachiasmatic nucleus, brain stem, pineal gland, the basal forebrain, midbrain and the amygdala (2). It’s amazing that they all connect in sync to allow sleep to be a smooth, healing process. 

Sleep consists of 4 cycles of 4 stage, stages 2-4 recurring throughout the night (stage 1 is only about initiating sleep). A typical person goes through 4-6 cycles at night, each cycle lasting around 90 minutes: 

1. Stage 2 begins the cooling and relaxation of the body’s functions
2. Stage 3 creates Delta waves, and where the body focuses on healing, growth, stimulating the immune system, creativity, memory and insightful thinking
3. Stage 4 is Rapid Eye Movement (REM), where the brain is most active, the body is atonic, and vivid dreams occur.  (3)

The benefits of sleep are enormous throughout all the stages.  In Non-REM sleep the brain works to convert short term memories into long term memories, while in REM sleep the brain is innovatively taking that learning and converting it into novel and creative applications.   As a whole, sleep is also vital for having better moods, a healthier heart, controled appetite and blood sugar, improved mental function and immune system, stress relief, enhanced atheltic and performations, and rest/recovery from daily activities.  Getting poor sleep allows the exact opposite of those: poor mood, poor learning/memory, poor appetite control and weight gain, reduced energy and motivation, cardiovascular disease. Increased errors, injuries and illnesses. 

The amount of sleep a person needs changes throughout the lifespan.  Babies will sleep for 14-17 hours, teens should get 8-10 hours, and adults ideally should get around 7-8 hours. (4)

A few main chemicals to induce/maintain sleep in our brain include serotonin and melatonin, acetylcholine, GABA

Interestingly, there are numerous chemicals needed to have a complete wake-up process in the morning: histamine, acetylcholine, orexin, dopamine, norepinephrine, and serotonin.  If 2-3 of those chemicals are low, a person can feel sleepy all throughout the day. Also, morning sunlight produces adenosine which initiates waking and signals earlier sleep time at night.  

Unfortunately, 30% of adults do not get 7 hours of sleep a night, due to various conditions. 

Common Sleep Disorders in Postmenopausal Women (PMW)

There are three main sleep disturbances post-menopause: 

Obstructive Sleep Apnea (OSA)  

OSA is a sleep related breathing disorder characterized either by intermittent episodes of breathing cessation or complete collapse of the airway.  OSA is associated with intermitten hypoxia, sympathetic overactivity, oxidative stress and increased cardiovascular mortality and morbidity, depression, Type 2 diabetes, weight gain, and increaesed inflammatory markers.   Estimates are that up to 47-67% of PMW experience OSA. (5)

In premenopausal women, estrogens and progesteron help keep the upper airway less collapsible, and there’s less inflammation and oxidative damage. Progesterone, in particular, seems to stimulate better ventilation during sleep.  (6)

Women with OSA have lower levels of progesterone and estrogen after menopause, and, also tend to gain abdominal weight easier, both which allow a more collapsible upper airway.  Dosing hormones (HRT), at least progesterone, may help reduce OSA in PMW.  (7)  Testosterone may also be helpful, as this hormone promotes waking ventilation and CO2 sensitivity during sleep, and it may be decreased in the menopausal years as well. 

Restless Leg Syndrome

Restless Leg Syndrome  (RLS) is a condition whereby there is an uncontrollable urge to move one’s leg.

RLS is also a problem in menopause and is aggravated by medical comorbities (hypertension, T2DM, kidney disease), certain medications, changes in the 24 hour sleep cycle.  It is seen more in women who had RLS during pregnancy.  RLS usually is worse at night, and is associated with low dopamine and elevated glutamine in the brain.  

RLS is also associated with iron deficiency, as iron is needed to make dopamine and GABA.  Other low and nutrients associated with RLS include magnesium, Vitamin D3, and folic acid. (8)

Oddly, estrogens seem to worsen RLS—RLS increases in pregnancy with elevated estrogen levels (especially with lower iron levels) and seems to affect women who have had more pregnancies.  Dosing estrogen doesn’t help RLS In PMW.  (9)

Insomnia

Insomnia is defined as chronic dissatisfaction with sleep quantity or quality.  Problems falling alseep, wake frequently, problems falling back asleep after awakenings, and/or waking up too early are all considered aspects of insomnia.  (10)

There are many potential sleep interferences: anxiety/depression, chronic pain, caffeine/nicotine/stimulants/alcohol, excess cortisol, poor sleep habits, traveling, inconsistent work schedule, past trauma and hormonal changes. (11)

Insomnia is the most common sleep disorder in menopausal women and the PMW is the main population suffering from insomnia. Each year 1/3 of adults report at least 2 weeks of insomnia.  In the PMW up to 35-60% of women experience insomnia. (12)

How can we help the post-menopausal woman regain good sleep?

Sleep Hygiene is always a good start to regaining healthy sleep: 

1. Turn lights off in the home around 8 pm except for lamps to allow melatonin  secretion, which requires darkness.  Using green light bulbs in a lamp creates a soothing, calming atmosphere. 
2. Ensure the bedroom is dark and quiet and used just for intimacy, reading, and sleep.  Do not use TVs or phones in there. 
3. Have the bedroom be at one’s best temperature—whether warmer or cooler. 
4. Get off all screens at least 45 minutes before bed; if one has to be used, use amber glasses or darken screens to reduce blue light, which stimulates the brain. 
5. Have the same bedtime and same waking time in the morning—regular morning waking time is most important to set the circadian rhythms.
6. Get into the first morning sun for 15 minutes; that will reset the evening brain to initiate sleep easier.  
7. Don’t watch violent TV shows or news before bed—focus on funny or interesting information. 
8. Don’t eat or drink for 2-3 hours before bed.  On the other hand, in some patients who get hypoglycemia in the middle of the night and wake from that, having a little snack before bed, even carrots or half an apple, can help the person sleep through the full night. 
9. Have a pad of paper on your nightstand to write down things one needs to do so you do not have to ruminate about them. 

In PMW, a higher glycemic diet, with more carbs and sugars, is associated with having more insomnia.  So, eating a healthy whole foods diet without refined grains and sweets can be beneficial.  Of course, avoiding caffeine and alcohol—which interferes with REM sleep–is important.  (13)

Exercising regularly is associated with reducing the time to fall asleep, increases melatonin production, reduces stress, improves mood, improves the quality of sleep time, reduces the need for sleep medication, and reduces daytime sleepiness. It can also help prevent gaining weight, which can initiate OSA.  (14)

Exercising 30 minutes a day helps sleep last 15 minutes longer.  (15)

The Sleep Foundation says that doing aerobic exercise in the morning can help release melatonin at night; high intensity exercise in the afternoon may reduce wakefulness; and, light resistance or aerobic exercise in the evening may reduce frequent wakings (but not vigorous exercise in the evening). 

Over the counter sleep products consist of doxylamine sulfate and other antihistamines.  Antihistamines like doxylamine (and other first generation ones) are problematically associated with increased risk of dementia. Prescription sleep medications such as trazodone, zolpidem, and eszopicione are habit forming and have very serious possible side effects, such as loss of coordination, suicidal thoughts, hallucinations, aggression, slurred speech, etc.  As much as possible, these should be avoided. 

Supplements, Hormones, and Other Interventions

There are many supplements to help with sleep: Melatonin, magnesium glycinate or threonate, tryptophan or 5-HTP, l-theanine, phosphatidylserine to address elevated evening cortisol, are oftentimes helpful.   Numerous botanicals for sleep include lemon balm, valerian, hops, kava, oats, skullcap, passion flower, ashwagandha, and lavender. (16)

As for using hormones for sleep disorders in PMW, estrogens can be extremely beneficial when vasomotor imbalance is occurring.  Around 75-85% of PMW suffer, at least for a few years, from night sweats, which often cause multiple episodes of waking during sleep.  Dosing bioidentical estrogens have been shown to improve sleep quality, reduce awakenings, increase total sleep time, and affect norepinephrine, serotonin, and acetylcholine neurotransmitters. Typical dosing is a biest formula of estriol and estradiol 80/20 percentage, from 0.3-2.5 mg/gram a day. The percentage of each hormone and the dosing strength are very flexible and must be adapted to each woman’s needs. (17) (18)

Progesterone is also extremely beneficial.  It is considered a hypnotic and sedative. Progesterone is lower in the PMW than during any part of the menstrual cycle and the higher the BMI in the PMW, the lower her progesterone.  (19)

Oral micronized progesterone is by far the best dosing method because most of it is metabolized in the liver and allopregnanolone (AP) is formed. AP works on GABA receptors more effectively than benzodiazapams.  It reduces sleep onset, enhances the ability to stay asleep, and stabilizes the woman’s moods.  Typical dosing is 50-200 mg at night. (20)

So, using progesterone is vital for insomnia and OSA in the PMW, and adding estrogens for night sweats is a great idea.  

DHEA and Testosterone do not seem very helpful, in particular, for sleep disorders in PMW, although one study did show that DHEA at 50 mg a day decreased cortisol levels, increased allopregnanolone, and reduced vasomotor events, so it may be helpful.  (21)

Insomnia is a serious concern in PMW and needs to be addressed.  Working in a comprehensive way can be safe and effective in helping women regularly sleep well. 

1. Britannica.com
2. https://openwa.pressbookspub/nursingfundamentals/chapter/12-2-basic-concepts/   and https://baillement.com/sleep-neurobio.html 
3. Sleepfoundation.org
4. National Sleep Foundation
5. https://doi.org/10.1016/j.maturitas.2019.02.011
6. PMID: 34970158  Gender differences in OSA
7. PMID: 7386511  Sleep disordered breathing in post-menopausal women
8. Neurology: Vol 78, #1, 4/23/12
9. Why are women prone to RLS: PMID: 31935805, PMID: 8363978 and Sleep. 1998; 21:501-505
10. International Classification of Sleep Disorders book by the American Academy of Sleep Medicine
11. https://tinyurl.com/mwp5wf3m
12. National Institutes of Health
13. doi: 10.1093/ajcn/nqz275    WHI study
14. The National Sleep Foundation
15. doi: 10.7759/cureus.43595
16. Sleep Botanicals VA.gov   and doi: 10.1155/2012/740813
17. J Menopausal Med. 2019 Aug; 25(2): 83–87    PMID: 31497577
18. Sleep Disorders and Menopause: doi: 10.6118/jmm.19192
19. Effects of progesterone on sleep: PMID: 17168724
20. PMID: 31780185  A/P ratio across the menstrual cycle and menopause
21. DHEA-S: Six-month oral DHEA-S supplementation in early/late menopause PMID: 11109974