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Menopause Is the Ultimate Sleep Challenge

Chronic insomnia in menopause is a huge challenge. On every day that I have seen patients, more than one has described the loss of sleep as the worst part of "the change" for them.
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OK, I admit that I am jealous of my teens' ability to sleep...and sleep. Granted, they are up far too late, but when I think back to the best sleep in my life it was decidedly during the hormonal highs of my teens and early twenties.

Sleeplessness is second only to hot flashes as a reason my menopausal and perimenopausal patients ask about hormones. While writing this blog I can say that on every day that I have seen patients more than one has described the loss of sleep as the worst part of "the change" for them. Investigators often relate the decreasing amount of sleep during menopause and perimenopause as interruptions due to hot flashes, but there is probably more to it than just waking up to sweats. Curiously, the scientific data here is not very revealing. Most large studies have not shown conclusive links between estrogen decline and sleeplessness, but gynecologists see a strong relationship in their patients. I often hear, "I would be OK if I could just sleep," "I can take the hot flashes, but not the insomnia," " I will take hormones the rest of my life if they help me sleep..."

Often even very low doses of estrogen will help the patient who is willing to accept the risks, and progesterone has been used for years to help coax in drowsiness. It would seem that during our reproductive years Mother Nature loves for us to have a distinct time of rest that may not be as evolutionarily beneficial when breeding is finished. In fact, anthropologists could argue that wakefulness for those more senior could benefit the entire village by alerting to nighttime threats, adding a layer of protection for those younger folk who may be engaged in other activities of the night...or gestating. My patients are not willing to add their late night list making, racing thoughts, and counting sheep to the benefit of the "village." In fact, more than once I have had a patient tell me she would rather take hormones and accept some risk than to never sleep well again.

Sleep is imperative to memory processing...and not just any sleep, specifically healthy sleep, including rapid eye movement (REM) and what is known as slow wave sleep (non-REM). Just being "drugged" into sleep does not result in the healthy brain processing that we now know is an important purpose of sleep. The pharmaceutical industry's cash cow list of hypnotics does not necessarily induce healthy sleep. In fact, the most worrisome side effect from long-term use of sleep aides such as Ambien is short-term memory loss.

A German study in 2000 demonstrated that the EEGs of sleeping menopausal women were significantly improved with low dose estrogen replacement, suggesting improved "cognitive functioning." Repeated recent studies have suggested that estrogen has a very protective effect on verbal memory, and one could ask if this is due to the positive impact on sleep. But up to now, larger studies have not demonstrated that hormone replacement is beneficial to sleep despite many anecdotal stories of miraculous improvement.

Estrogen is not sedating, but the brain experiences a withdrawal-like syndrome in menopause and the result can be surging levels of noradrenalin. Yes, some menopausal women are experiencing a flight-or-fight reaction in the middle of the night due to the brain withdrawing from reproductive hormones that are no longer pouring out of the retiring ovary. It would follow that estrogen replacement may ease the insomnia in some who are experiencing sleeplessness or early morning wakening, but there are risks, and some women must avoid HRT regardless of benefit (such as those with an active estrogen sensitive cancer, or a history of blood clot or stroke).

Chronic insomnia in menopause is a huge challenge. If HRT is not an acceptable option, or is not effective, there are several approaches. Meditation is an often-overlooked safe, effective way to mimic the brain healing effects of good sleep. There are some in the field of meditation who explain that the brain waves achieved with adequate mindfulness resemble those during healthy sleep. Even if the person meditating is not in full-fledged sleep, if memory processing is performed, the meditator will feel equally rested.

Melatonin, the brain chemical associated with nightfall or darkness, has an important role in over all health and possibly short-term memory. Melatonin supplements are available over the counter (3-5mg at bedtime for adults), and even if they are only mildly sedating, their addition may aide in mental clarity the following day.

Help for Menopausal Insomnia:

• See your doctor for a complete physical and to rule out conditions such as sleep apnea, depression and/or anxiety
• Do not eat within 2 hours of bedtime
• Avoid caffeine, nicotine and other stimulants
• Avoid alcohol before bedtime which can cause early morning rebound wakefulness
• Wear comfortable natural fibers that "breath" to bed
• Consider a remote control fan--ceiling or tabletop
• Avoid highly stimulating books, TV, or movies just before bed
• To ease restless legs try a 6 oz glass of diet tonic water 30 minutes before sleep
• Take Melatonin, 3-5mg 30 minutes to an hour before bedtime
• Learn relaxing yoga poses, such as: Half Tortoise Pose
• Practice meditation or prayer just before, or while in bed

• Consider, with your doctor, hormone replacement therapy
• Consider, with your doctor, non-addicting prescription aides to induce drowsiness such as low dose Amitriptyline

The bottom line is that sleeplessness is commonly associated with menopause, and there is plenty of room for more research in this area. In the meantime I have many patients who are grateful for the relief they often feel on HRT, and others who improve with non-hormonal supplements such as melatonin. For the few who continue to struggle there are a variety of older antidepressants (such as low dose Amitriptyline) that are non-habit forming and can aide in relief, and again, meditation is a viable and valuable option with a long list of other health benefits. It is ironic that in our constant searching for more energy that ultimately being able to unplug and recharge is impossible for so many...and painfully cruel in that it may be a design of nature. Alas, hormones are wasted on the young!

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