By: Jacqueline Giannelli, MSN, RN, FNP-BC, NCMP
Jacqueline Giannelli is a board-certified nurse practitioner and a founding member of Elektra Health. Here, she covers a common menopause symptom: sleep problems.
As a board-certified family nurse practitioner specializing in hormonal health, many of the women that I work with come to me about sleep problems during menopause. It makes sense, as it’s one of the more common symptoms of the transition and, as you might imagine, one of the most bothersome. Life can be really tough when you’re tired all of the time.
Sleep problems during menopause can vary. You can have problems falling asleep, staying asleep, and/or waking up way too early. Sleep apnea may also be a factor as well. The two questions women ask most about sleep are: “Why is this happening to me?” and “Please, how can I fix this?” Let’s dive in.
Causes of Sleeplessness
During perimenopause (which literally means “around menopause” — the period of time preceding menopause that can last for up to 10 years), the hormonal orchestra that has been in harmony all this time starts to get a bit out of tune. Hormones do not operate in a vacuum — they affect the whole body and one another. So, when estrogen and progesterone levels start to shift due to menopause, the effects can be far-reaching. But that’s not all. As most women start the menopause transition, there’s another factor at play: aging, and the other natural hormone changes that happen because of that. Combine those two changes and there’s some potential for disharmony.
Several hormonal shifts are involved during the menopausal transition, including the decreased production of estrogen and progesterone. There’s also a decrease in melatonin production and an increase in cortisol due to aging, and they can have a direct and indirect effect. Directly, estrogen plays a role in how long it takes for us to nod off and progesterone helps calm us by affecting certain brain neurotransmitters. Decreased levels of both can lead to sleep problems. Melatonin is important for our circadian rhythm and helps us fall asleep and cortisol is a stress hormone involved in our fight or flight response. So, decreasing melatonin and increasing cortisol can also disrupt sleep.
These hormonal changes can also affect sleep in several indirect ways, including:
Hot Flashes and Night Sweats
About 80% of women experience hot flashes during menopause due to estrogen fluctuations, and for some, they happen at night. They can be intense enough to wake you up and even cause the need to change sleepwear. And if you have problems falling back asleep...it’s not a good situation.
Our 40s and 50s can be a time of increased stress (family, work, pandemic, anyone!?) and menopausal hormone changes and fluctuations can contribute to our levels of anxiety. When we’re stressed, our cortisol levels increase, which affects our ability to relax. We can feel restless, jittery, like we can’t sit still - it can become difficult to physically calm down. Pair that with decreasing melatonin – and it’s not a good recipe for restful sleep. Menopausal restlessness can also include Restless Leg Syndrome, a condition where there is a persistent need to keep moving your legs (and thus can prevent you from falling asleep). This condition is more common in women and most often manifests after age 45. We don’t know why this happens.
Postmenopausal women are 2-3x more likely than premenopausal women to develop obstructive sleep apnea, which is marked by abnormal/restricted breathing during sleep. In women with this condition, the brain senses that something is wrong (i.e. your body isn’t getting enough oxygen) and essentially wakes them up momentarily to resume breathing. Sleep can be interrupted repeatedly throughout the night because of this.
Natural Remedies for Menopause Sleeplessness
Sleep problems can be complex, so they require a holistic approach - there is no single magic bullet. Understanding your unique contributing factors is paramount so an appropriate treatment plan can be developed: one that involves lifestyle interventions like diet, exercise, stress management, and sleep hygiene, as well as the incorporation of supplements or prescription medications. There are a lot of levers we can pull to improve sleep naturally, so here are some of my top tips:
- Create a soothing nighttime routine. We all prepare for our day when we wake up - we might exercise, shower, have some coffee, and get dressed. But we also need to prepare for bedtime as well. Build a routine that involves relaxation - a soothing bath, lavender scents, meditation, journaling, reading from a real paper book...anything that can calm your mind. And stay away from screens and blue light for at least an hour before bedtime, or if that’s not doable, consider trying blue light glasses.
- Meditation or other mind-based relaxation strategies. These can help set the mood for sleep, and they also can be a powerful tool to manage anxiety and stress (other common hot flash triggers), which can help keep those cortisol levels down.
- Consistency is key. Go to bed and wake at the same time daily whenever possible to establish a routine.
- Avoid alcohol at night. Alcohol is a primary culprit for many. Consuming alcohol at night can lead to those middle of the night wake-up calls and can be a trigger for menopausal hot flashes. Red wine is especially notorious for this, so consider switching to white (or another low sugar alcohol) or cut it out as much as possible.
- Switch to a plant-heavy diet low in added sugars and refined carbohydrates. There’s research that shows that those who follow the Mediterranean diet may sleep better at night.
- Exercise. We know that exercise helps relieve stress, improves mood, and can help you sleep better at night. This is a must. High intensity workouts in the evening may make it harder to fall asleep, so I recommend a moderate or low intensity workout (yoga, a walk) in the evening, and saving those high intensity interval training (HIIT) workouts for the morning. Exercising outdoors in the morning has the added benefit of helping with our circadian rhythm so we fall asleep a bit earlier.
- If hot flashes are contributing to sleeplessness, it’s important to address them. Women often have triggers for their menopausal hot flashes or night sweats, so it’s important to figure what yours are so you can avoid them. Some common triggers include: alcohol, stress, caffeine, and hot, spicy foods.
I also get a lot of questions about supplements for managing sleep issues, and fortunately there are a lot of great options out there. I want to mention that supplements, just like medications, can have side effects, or interact with other drugs. Based on your health history, they may not be safe for you to use. It’s incredibly important to make sure what you’re taking is safe for you and that the supplements can actually help (meaning, there is research that shows efficacy). Also, if you’re using a lot of supplements, I always recommend working with an experienced healthcare provider for guidance.
A few supplements for sleep that women may find helpful include magnesium, melatonin, ashwagandha and L-theanine. Cannabidiol (CBD) can be considered as well — there’s some promising research specifically linking CBD + better sleep for women going through menopause.
Treatments for Sleeplessness
An over-the-counter option is diphenhydramine (also known as Benadryl), which is best for occasional use only. It’s not a good idea to default to this as a first resort and it’s not something to be used daily because of potential side effects.
Prescription medications can be effective but they are best for acute, high-stress situations, where use will be temporary or occasional. Antidepressants like trazodone and anti-anxiety medications like Valium and Xanax, are examples.
If hot flashes or night sweats are disrupting your sleep, prescription hormone replacement therapy can help manage those effectively. Speaking of hot flashes, there are a lot of great supplements and lifestyle interventions to help keep them at bay, too.
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Many women assume that menopause always equates to poor sleep, and I want to tell you that this is not the case! While there are a lot of factors that can contribute to sleeplessness during menopause, there are effective ways to address them. If you aren’t sleeping well, don’t just “live with it.” It may take time to see what helps you, but it’s worth the effort.