By Sophie Burnet, BS

For many of us, major life pressures occur in our 40s and 50s. Whether it’s having greater responsibilities in our careers, enduring changes in our relationships, or caring for both our children and parents, midlife presents a myriad of stressors that can keep us up at night.

On top of these external stressors, women need to add the health and sleep challenges that occur during the menopausal transition. Research shows that 40 to 60 percent of women in perimenopause and menopause experience sleep difficulties; however, most of these women do not receive satisfactory treatment because the problem is often misunderstood or minimized.

“Insomnia is underdiagnosed and undertreated in women in midlife,” says clinical psychologist Natalie Solomon, PsyD, who works with patients at the Stanford Sleep Health and Insomnia Program. “Many of my female patients with insomnia don’t receive treatment because they think it’s a normal part of the menopausal transition. However, there is effective treatment available, so I urge women to seek care and not simply write it off as ‘part of aging’.”

Hormonal Changes During Perimenopause that Impact Sleep

Research shows that hormonal changes that occur during the menopausal transition can negatively impact sleep. Specifically, the hormone levels of estrogen and progesterone begin to fluctuate and decline, contributing to disturbances in sleep. As estrogen levels decline, thermoregulation becomes less stable, causing hot flashes and night sweats. Also, progesterone has sleep-promoting and sedative effects, so its decline contributes to difficulties falling asleep, lighter sleep, nighttime awakenings, and an overall reduction in sleep quality.

“The hormonal changes that occur in perimenopause are largely inevitable, but suffering from the associated symptoms doesn’t have to be,” says Dr. Solomon. “The hot flash itself tends to be brief, and even if it wakes you up, there are tools available to cool yourself down quickly and return to sleep.”

How to Cool Down after a Nighttime Hot Flash:

• Keep a glass of cool water by your bed.
• Choose sweat-wicking and cooling pajamas.
• Maintain a low bedroom temperature (ideally 60 to 67°F).
• Avoid foam or soft mattress toppers that prevent the release of heat.
• Consideration of a mattress cooling device.

If these tips aren’t enough to remedy your nighttime hot flashes, another option is to speak to your gynecologist about hormone therapy.

Mood Changes During Perimenopause that Impact Sleep

During the menopause transition, the prevalence of anxiety and depression also increases, which can negatively affect sleep. Mood changes occur because the fluctuating levels of estrogen and progesterone interact with the neurotransmitters serotonin and GABA, which regulate mood, anxiety, and overall brain function. The result makes women more vulnerable to emotional distress than they would be otherwise.

Research shows there is a bidirectional relationship between sleep and mood, meaning poor sleep can lead to poor mental health, and poor mental health can worsen sleep. For example, heightened anxiety can contribute to difficulties falling and staying asleep and/or can cause early morning awakenings. Research also shows that depression can impair sleep quality, and vice versa.

“There is a strong relationship between menopause and mood symptoms,” says Dr. Solomon. “Many women experience increased rates of anxiety, depression, and panic during the menopause transition, all of which can impair sleep quality.”

For those suffering with mood issues, there are a range of treatment options from talking therapies such as CBT (Cognitive Behavioral Therapy) and ACT (Acceptance and Commitment Therapy) to pharmaceutical anti-depressant medications, including SSRIs (Selective Serotonin Re-uptake Inhibitors) and SNRIs (Serotonin and Norepinephrine Re-uptake Inhibitors). All potential treatments should be discussed with a qualified healthcare provider.

Treatment for Insomnia During Perimenopause

After a hot flash or bout of anxiety in the middle of the night, many health-conscious women lie awake worrying about how this lack of sleep may cause other health problems. This additional worry can ironically prevent them from falling back asleep. Fortunately, there are many behavioral tips and tools regarding how to return to sleep if woken up in the middle of the night.

“We are designed so that if a lion, tiger, or bear is approaching, our ability to respond to the threat is stronger than our ability to fall back asleep,” says Dr. Solomon. “I don’t want to get rid of this hyperarousal system since it’s essential for our survival, but I do offer my patients behavioral tools, such as CBT-I, to help them fall back asleep.”

At the Stanford Sleep Health and Insomnia Program, CBT-I, which stands for cognitive behavioral therapy for insomnia, is the frontline treatment for insomnia and has been proven helpful in the context of perimenopausal symptoms.

It’s also important to note that during the menopause transition, declining estrogen and progesterone levels can lead to weakened throat muscles, increasing the risk of another sleep disorder, obstructive sleep apnea.

“Having both sleep apnea and insomnia is common [for perimenopausal and menopausal women], and it’s important to remember that they are two different disorders which have two different treatments,” says Dr. Solomon. “If you are struggling with frequent difficulty falling or staying asleep, you may be experiencing insomnia and would be a good candidate for CBT-I. But, if your sleep difficulty is more about multiple brief awakenings, snoring, or non-refreshing sleep, you may want to speak to your doctor about getting a sleep study to test for sleep apnea.”