Sleep and Menopause

How to Overcome Sleep Disorders in Postmenopausal Women

By Mona Morstein, ND

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 practical strategies, including sleep hygiene, exercise, and hormone therapy, to improve sleep quality.

There is nothing more enjoyable and rejuvenating than a good night’s sleep. As Britannica Encyclopediaⁱ writes: “Sleep is a normal, reversible, recurrent state of reduced responsiveness to external stimulation accompanied by complex and predictable changes in physiology.”

The Importance of Sleep and Its Mechanisms

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

Sleep consists of four cycles of four stages, with 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:

• Stage 2 begins the cooling and relaxation of the body’s functions.
• Stage 3 creates delta waves, where the body focuses on healing, growth, stimulating the immune system, creativity, memory, and insightful thinking.
• 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 innovatively takes that learning and converts it into novel and creative applications. Sleep is also vital for better moods, a healthier heart, controlled appetite and blood sugar, improved mental function and immune system, stress relief, enhanced athletic performance, and rest/recovery from daily activities. Getting poor sleep allows the exact opposite of those benefits: poor mood, poor learning/memory, poor appetite control, weight gain, reduced energy and motivation, and cardiovascular disease. It also increases 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 that induce and maintain sleep in our brains include serotonin, melatonin, acetylcholine, and GABA.

Interestingly, numerous chemicals are needed for the morning wake-up process: histamine, acetylcholine, orexin, dopamine, norepinephrine, and serotonin. If two or three of those chemicals are low, a person can feel sleepy throughout the day. Also, morning sunlight produces adenosine, which initiates waking and signals earlier sleep time.

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 by intermittent episodes of breathing cessation or complete airway collapse. OSA is associated with intermittent hypoxia, sympathetic overactivity, oxidative stress, increased cardiovascular mortality and morbidity, depression, type 2 diabetes, weight gain, and increased inflammatory markers. Estimates are that up to 47-67% of PMWs experience OSA. ⁵

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

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

Restless Leg Syndrome (RLS)

RLS is characterized by an uncontrollable urge to move one’s leg. It is also a problem during menopause and is aggravated by medical comorbidities (hypertension, type 2 diabetes, kidney disease), certain medications, and changes in the 24-hour sleep cycle. It is more common in women who had RLS during pregnancy. RLS usually worsens at night and is associated with low dopamine and elevated glutamate in the brain.

RLS is also associated with iron deficiency, as iron is needed to make dopamine and GABA. Other low 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 asleep, waking frequently, difficulty falling back asleep after awakening, and waking up too early are all considered aspects of insomnia. ¹⁰

Supplements, Hormones, and Other Interventions

There are many supplements to help with sleep: melatonin, magnesium glycinate or threonate, tryptophan or 5-HTP, l-theanine, and 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 highly beneficial when vasomotor imbalance is occurring. Around 75-85% of PMWs suffer, at least for a few years, from night sweats, which often cause multiple episodes of waking during sleep. Dosing bioidentical estrogens has been shown to improve sleep quality, reduce awakenings, increase total sleep time, and affect norepinephrine, serotonin, and acetylcholine neurotransmitters. Typical dosing is a base formula of estriol and estradiol 80/20 percentage, from 0.3 to 2.5 mg/gram daily.

Progesterone is also highly beneficial. Oral micronized progesterone is the best dosing method because most of it is metabolized in the liver to form allopregnanolone (AP), which works on GABA receptors more effectively than benzodiazepines. Typical dosing is 50-200 mg at night.

DHEA and Testosterone do not seem particularly helpful for sleep disorders in PMW. Insomnia is a serious concern in PMW and needs to be addressed. Working comprehensively can be safe and effective in helping women sleep well.

---

---

References

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