Dr Kat Lederle on how menopause can impact sleep

Sleep disruption is a common and difficult experience for women transitioning menopause. Between 40% to 60% of women in midlife report sleep disturbances, and many of these women struggle to stay asleep during the night (frequent night-time awakenings)*. And the consequence? Feeling exhausted, tired and unable to function as you feel you should. Understandably, many women also report feelings of frustration and anxiety.

Let’s first look at why and how sleep changes for women going through the menopausal transition, before we talk about what you can do to help yourself sleep well.

Our ovarian hormones influence sleep and wake

One of the hallmarks of the menopausal transition are the fluctuating levels of your ovarian hormones. And not only do they fluctuate, most also decline over time, particularly oestrogen and progesterone. Both hormones affect a range of different cells in the body including areas in the brain involved in the regulation of sleep.

But when their levels fluctuate and diminish, they are sending mixed or very weak messages to the sleep regulatory system. Brain areas responsible for keeping you awake or asleep, respectively, become confused and don’t know when to promote what. The potential outcome? Sleep disruption.

Hot flushes or night-sweats are another common symptom of the menopausal transition. Around 80% of women experience them. Researchers believe the declining oestrogen levels play a role in this sudden burst of heat that can last for up to 10 minutes. For many – but not all women – HFs are linked to disrupted sleep. They wake as part of or just after the HF but women might also wake before the HF happens. Researchers aren’t quite sure what’s going on exactly, but it is believed that HFs and night-time awakenings share an underlying mechanism yet to be discovered. One thing is certain though: experiencing HFs makes it more likely to suffer from poor sleep.

Apart from hormonal fluctuations and HFs, there are other reasons why a woman might struggle with her sleep during menopause. While sleep is a biological process, it doesn’t happen in isolation from the rest of your life. First of all, ageing can impact our ability to sleep through the night. (Yes, strictly speaking it’s another biological factor, but it affects sleep directly and indirectly.)

Mood, and in particular depression can also affect sleep. Not only are menopausal women at a higher risk of developing depression, and there’s a bi-directional relationship between the mood disorder and poor sleep. Stress is another big and complex factor during the menopausal transition. Midlife women face various physiological and social changes, and for some these can be a source of distress.

Indeed, when compared to premenopausal women, perimenopausal women are feeling more stressed** Also, numerous research studies have shown the relationship between stressful life events or stressors and poor sleep. It is in no way surprising then those menopausal women who are transitioning into a new phase of life – a change that can feel overwhelming in itself – experience poor sleep as a result of accumulating stress levels.

There is a multitude of factors affecting sleep menopausal women face. Different women will face different constellations of these factors, however, for many the outcome is the same: poor sleep leads to a further reduction of quality of life.

How to find your sleep window

Earlier on I said that sleep is not an isolated part of your life. What I mean is that your waking day (and this could include the time spent awake during the night if you experience night-time awakenings by the way) not only are affected by sleep – they also impact your sleep! For an average 8-hour sleeper that means you have 16-hours to support your sleep.

And as we are talking about sleep duration, there are two important sleep myths to bust: Not everyone needs 8 hours of sleep. And sleeping before mid-night does not necessarily give you the best sleep either. Instead, we all have our personal sleep window made up of (1) how much sleep you need and (2) when your body clock says it is time for sleep.

The National Sleep Foundation in the US recommends 7 to 9 hours of sleep for a healthy adult. The best indicator of whether you are getting the sleep you need, is when you consistently wake up feeling refreshed.

Your body clock, a tiny area located in the hypothalamus in your brain, sets the timing for when you sleep and when you are awake. Because this internal clock ticks slightly differently between different people, some of us like to go to bed early and also wake up early, while others naturally want to go to bed later therefore wake up later in the morning. To give yourself the best chance of good quality sleep, allow your body to rest within the sleep window as allocated by your body clock.

How else can you support your sleep?

Develop healthy sleep habits that are right for you. Here are some habits that help most women (and men): Be mindful of when and how much caffeine you consume – if you drink any at all! Consider your diet, and think about what but also when you eat. Ideally, your eating window should not be longer than 12 hours, preferably less. And there are many more of these types of habits you can adopt.

But I think apart from the sleep window what matters the most is how you relate to the sleep problem you are facing. If you tend to wake up at night, which is something that is quite likely related to HFs, how do you react, how do you speak to yourself? Are you frustrated, bothered, perhaps worried even? Do you adopt an angry, harsh and at times critical voice telling yourself off for not managing this ‘situation’ better? If so, let me ask you how does this make you feel deep down? I guess the answer is anxious and upset. And the outcome of these (normal) feelings? More wakefulness.

What if, instead of blaming yourself or fighting against the night-time awakening, you responded to yourself and your struggle with understanding and kindness. What if you held yourself with the compassion you would offer a friend in a time of need? Women who take this compassionate approach say that it helps them to calm down and be less bothered by the HF***. In the context of sleep, this calmness might help a woman relax and fall back to sleep.

What I suggest is to think of self-compassion as a skill to increase your resilience to bothersome menopausal symptoms including poor sleep. Luckily, it is also a learnable skill.

Here are three simple steps to start practising self-compassion:

  1. Start by deliberately paying attention to what thoughts are showing up in your mind from time to time.
  2. Adopt a kind and curious perspective from which you look at these thoughts. If they are judgmental of your current experience, remind yourself to that many, many other women are going through the menopausal transition. And a large part of them is struggling with it too, just like you.
  3. Here are some supportive words you may offer yourself ‘This is a really tough phase of my life and I’m finding it difficult to bear it all. I also realise it’s a phase most women go through and many of us don’t like it. I’m therefore not alone in my struggle. How can I treat myself right now to show myself I care? How can I care for myself in a kind and understanding way?’ As you speak to yourself, do so in a gentle, warm manner.

 

None of this will make the unpleasant symptoms go away. But being open and kind to yourself will help you to feel validated, calm and supported. And with that comes strength and resilience.

Warmly,
Dr Kat

* Nelson HD. Menopause. Lancet. 2008;371(9614):760–770.18313505
** Bromberger JT, Meyer PM , Kravitz HM , et al. Psychologic distress and natural menopause: a multiethnic community study. Am J Public Health. 2001;91(9):1435–1442.11527777
*** Brown L, et al. Self-compassion weakens the association between hot flushes and night sweats and daily life functioning and depression. Maturitas (2014), http://dx.doi.org/10.1016/j.maturitas.2014.05.012

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We understand there’s a lot of information out there on the menopause. You can read through the NICE guidance on menopause management, as well as the NHS overview on the menopause.