The Woolcock Institute of Medical Research

Sleep difficulties are common during perimenopause, menopause and in post-menopausal women. Whilst about one in seven adults will experience chronic insomnia, this number almost doubles in women during the menopause phases, with over 60 percent of postmenopausal women reporting insomnia symptoms.

The Woolcock’s Associate Professor Christopher Gordon says the scientific evidence backs this up. “Insomnia can occur across any part of the lifespan, but we know that it is common in the 40–50 year age group, and it’s more common in women than men. There is an increase in insomnia symptoms around menopause, and it's associated with hormonal changes which can contribute to insomnia after menopause. We know that the interrelationship between hormones and sleep is very complex and we're still trying to untangle it.”  

THE ROLE OF HORMONES

In menopause, a woman’s ovaries stop producing oestrogen and progesterone – hormones that affect everything from mood to appetite, sleep, sex drive and more. 

Oestrogen plays a role in the metabolism of serotonin and other neurotransmitters that affect our sleep-wake cycle. It aids the fall in body temperature required for sleep onset and maintenance and there is also an anti-depressant effect. Oestrogen loss around the time of menopause increases abdominal body fat, increasing snoring and partial or complete closures of the airway (factors that can contribute to sleep apnea). Joint aches and pains, and more frequent urination are also common consequences of oestrogen decline and sleep disruption. 

The large decrease in oestrogen and progesterone levels are the main cause of most menopause symptoms. The relationship between oestrogen and progesterone and sleep is complex but research shows that lower levels are related to sleep disturbance and can increase the risk of developing insomnia and sleep apnea.

Melatonin, another vital hormone for sleep, decreases in all of us with age. Research shows that menopause can affect melatonin levels and this may also contribute to sleep problems. 

THE ROLE OF AGE

Our sleep-wake cycles change as we age which reflects the general ageing process. Generally, there is an increase in the number of wakes during the night. Very light sleep is increased, and deep sleep is reduced. A person over the age of 65 will spend most of the night cycling between very light and light sleep. This may partially explain why older adults have an increased risk of insomnia. However, when older adults are active mentally and physically the prevalence of insomnia is equivalent to the general population.

HOT FLUSHES

Menopausal symptoms such as hot flushes and night sweats are often the cause of sleep disturbance during the transition to menopause and post menopause. Prior to a hot flush, a woman’s body temperature rises, and blood flow increases to the face and other parts of the body creating a heating sensation. Hot flushes are extremely energising due to the increase in heat and adrenaline, making it more difficult to return to sleep. There is a decrease in sleep quality when there are frequent wakes and discomfort but learning to manage these is a key to reducing the associated stress at this transient time of life.

“Temperature is intricately related to sleep. We know that people do have changes in temperature, especially with insomnia, that can affect their sleep. So, temperature regulation is really important to understand,” says Associate Professor Gordon.  

Sleeping in a cool room with adequate air flow can also help. Avoid heavy bedclothes or tight bedspreads and wear light sleepwear, preferably cotton. 

INSOMNIA

Mood changes that occur may be linked to hormonal changes or brought on by other stresses that occur around that time of life such as empty nesting or caring for ageing parents. 

Sleep patterns will be impacted during any time of change or stress. "If you take on the burdens of the day with you to bed, you will keep yourself awake because the limbic system in the mid-brain is fired up always to be working on a survival mechanism. If you're giving your brain messages that there's danger – whether it's from worry, planning, whatever it is – you're going to be awake,” says Associate Professor Delwyn Bartlett, a sleep researcher and psychologist at the Woolcock Clinic. 

“The most important thing I believe in sleep is to say to yourself, this is my time, I can't do anything about what happened yesterday, I can't do anything about what may happen tomorrow. This is my time to let go, leave it alone,” she says. “In relation to menopause, and speaking from experience, ‘I just need to cool down and this will pass!”

SNORING AND SLEEP APNEA

Postmenopausal women are two to three times more likely to have sleep apnea compared with premenopausal women. This often goes undiagnosed because women don’t necessarily snore loudly and may have heavy sleeping partners. Symptoms like daytime fatigue/sleepiness may be attributed to menopause and ageing. 

“Most GPs will send their patients to a sleep physician because they want to exclude sleep apnea or any other sleep disorder first,” says Associate Professor Bartlett. “Contrary to what is believed, often middle-aged women can be seen as being anxious and having insomnia when they may, in fact, have untreated sleep apnea.”

STEPS TO BETTER SLEEP

Once a sleep disorder is ruled out, there are a number of pathways to relieve sleep issues, including symptoms associated with menopause. Establishing good sleep habits is paramount.

• Practise healthy sleep behaviours, which includes a regular getting-up time.
• Avoid stimulants from 2pm. Alcohol may make you wired instead of sleepy.
• Regular exercise helps and morning light suppresses melatonin (which in turn promotes wakefulness throughout the day).
• Meditate or have slow-down times during the day.
• Make sure bedroom temperature is just right – not too hot or too cold.
• Avoid drinking increased fluids before bed.
• Daytime naps are OK but keep them to less than 20 minutes and before 3pm.
• Understand and have realistic expectations around your sleep patterns across the life span. Learn to look forward to going to sleep and remind yourself that waking is normal. This is “your time to let go of the day and let sleep happen”.

Cognitive Behavioural Therapy can help you recognise thoughts and behaviours that are negatively impacting your sleep and replace them with healthier behaviours that promote good sleep.

For more information and sleep tips, download our resources: 

• Listen to Delwyn talking with Mary Labrie on the podcast: Sleep and the midlife woman with Dr Delwyn Bartlett - Women of a certain age
• Learning Better Sleep 
• Relaxation Strategies for Insomnia
• Read our latest brochure: Sleep and Menopause: What you need to know

FIND OUT MORE

• Read about our Insomnia Clinic
• To find out about our services, go to www.woolcock.org.au/clinic