Doc, why am I so fatigued? Let’s talk about sleep

Bio: Dr. Jewel Kling is an Assistant Professor of Medicine and women’s health provider in the Division of Women’s Health Internal Medicine at the Mayo Clinic in Scottsdale, Arizona. She completed her Internal Medicine Residency at Mayo Clinic Arizona, followed by a Chief Internal Medicine fellowship year. Her clinical and research interests are in menopause and sexual health. She is a North American Menopause Society (NAMS) Certified Menopause Practitioner. She is also interested in education and efforts to expand the discipline of Sex and Gender based medicine.

Fatigue is common in women, and can increase with age and during menopause. If you are fatigued, your healthcare provider can help determine the cause and provide you with suggestions for treatment. He or she might start by asking you questions about your symptoms, your stress level and your mood. A physical exam and occasionally laboratory tests are performed looking for causes of fatigue such as thyroid disease, anemia (low blood count) or vitamin B12 deficiency. After other causes have been ruled out, the conversation often turns to sleep. It’s easy to forget how important sleep is to so many aspects of our health and wellbeing including our energy level, mood, productivity, ability to concentrate and even to manage our weight.

The National Sleep Foundation recommends that adults get between 7-9 hours of sleep every night (1). If you are getting this amount of sleep but are still waking up tired, it’s important to see your healthcare provider to rule out sleep apnea (a disorder where you have pauses in breathing or take shallow breaths during sleep) as a cause of your fatigue. Snoring or weight gain, especially around your neck, may put you at higher risk for sleep apnea. Untreated, sleep apnea leads not only to fatigue, but can also increase your risk of high blood pressure, obesity, heart disease and other chronic diseases (2-4). Treatment options include using a breathing mask (continuous positive airway pressure, CPAP) or a dental device at night during sleep. CPAP remains the most effective treatment available today.

If you are having difficulty falling asleep, staying asleep or waking up too early in the morning and experiencing significant daytime fatigue, you may have insomnia (5). Insomnia affects about 6-10% of adults in the U.S. and is more common in women, especially during times such as menopause (6,7). Chronic insomnia is defined as bothersome symptoms that occur at least 3 nights per week for at least 3 months and are not caused by other sleep disorders or medical illness. Available treatments include talk therapy (cognitive behavioral therapy - CBT), educational interventions (sleep hygiene) or medications such as zolpidem (Ambien). The American College of Physicians, an organization that provides evidence-based guidelines to help healthcare providers treat their patients, recommends CBT as the initial treatment for insomnia (6). CBT can be group or individual therapy either in person, through telephone or web-based modules or through self-help books. The decision to add medication on a short-term basis should only be made after a conversation between you and your healthcare provider about the benefits, harms and costs. Medications are not a long-term solution for management of sleep issues. More information on insomnia can be found at mayoclinic.org

Good sleep hygiene is a tool that everyone has access to and can give you back control over your sleep. Sleep hygiene consists of training your body to sleep when you are in bed. Recommendations include going to bed at the same time every night and waking up at the same time every morning; using the bedroom only for sleep or sex (no TV, books, tablets, etc…); keeping the room cool, quiet and dark. And, if you find yourself lying in bed more than 20 minutes without falling asleep, get up and do something calming, then return to bed. The book “No More Sleepless Nights” can give you more guidance on good sleep hygiene.

If you are suffering from fatigue, consider how much restful sleep you are getting. Along with exercise, a healthy diet and stress management, sleep is an important part of a healthy lifestyle. Talk with your healthcare provider if you have concerns about your sleep.

References

1. Hirschkowitz M, Whiton K, Albert SM, et al. National Sleep Foundation’s sleep time duration recommendations: methodology and results summary. Sleep Health 1 (2015): 40-43.
2. George CF. Sleep apnea, alertness, and motor vehicle crashes. Am J Respir Crit Care Med. 2007;176(10):954.
3. Young T, Palta M. Depsey J, Peppard PE, Nieto FJ, Hla KM. Burden of sleep apnea: rationale, design, and major findings of the Wisconsin Sleep Cohort Study. WMJ. 2009;108(5):246.
4. Uyar M, Davutoglu V. An update on cardiovascular effects of obstructive sleep apnoea syndrome. Postgrad Med J. 2016. Doi 10.1136/postgradmedj-2016-125093.
5. Roth T. Insomnia: Definition, Prevalence, Etiology and Consequences. J Clin Sleep Med. 2007;3(Suppl):S7-S10.
6. Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016;doi:10.7326/M15-2175.
7. de Zambotti M, Colrain IM, Javitz HS, Baker FC. Magnitude of the impact of hot flashes on sleep in perimenopausal women. Fertil Steril 2014;102(6):1708-1715.