For the love of a good sleep

GPs are well placed to help women who are experiencing problematic sleep patterns.

Sleep disturbances are common in older women, affecting 40-60% of perimenopausal or postmenopausal women.

Insomnia

Poor sleep in this cohort is associated with cardiovascular and metabolic disease, as well as mood disorders.1

Various premenopausal health-related factors seem to predict poor sleep in menopausal transition.2

Menopause itself appears to have only minor effects.

Although hormonal changes can influence sleep patterns and sleep activities, other factors — such as medical history (for example, chronic pain, cardiovascular disease), age, and the existence of mood disorders — can affect a woman’s sleep at midlife.

Thorough inquiry by GPs can help to identify at-risk women and enable tailored interventions with the potential to prevent the development of sleep disturbances at menopause.

Background

Studies show that during times of hormonal change, women are at an increased risk of sleep problems such as poor sleep quality and sleep deprivation, as well as sleep disorders, such as obstructive sleep apnoea, restless legs syndrome and insomnia.

Primary sleep disorders become more prevalent in older age, affecting more than 53% of postmenopausal women.

There are many potential mechanisms by which sleep quality is affected during the latter part of a woman’s life.

These relate to vasomotor symptoms, hormonal changes, age-related changes, and increases in comorbid conditions, such as depression and sleep-disordered breathing.

Chronic insomnia may develop in as many as 42% of women by the end of their menopausal transition.

The perimenopausal and menopausal life phase can be a hectic time for a woman, when she may have multiple roles and stressors.

The influence of these factors in sleep disturbances should not be underestimated.

Working with the patient to identify any life stressors (including work and family issues), as well as pre-existing medical conditions (for example, cardiovascular disease, depression, anxiety), can assist with developing a treatment plan tailored to the individual.

Timely intervention to reduce the more bothersome symptoms can help restore healthy sleep patterns and reduce the likelihood of chronic insomnia.

Management

Sleep hygiene

Sleep hygiene refers to habits that encourage a good night’s sleep. These include:

  • Maintaining a regular bedtime and wake-up time each day, as this helps to set a sleep pattern.
  • Creating a sleeping environment that is conducive to rest. Invest in a comfortable mattress, make sure the room is dark and at the right temperature, and only use the room for sleeping and intimacy (no electronic devices/screens in bed).
  • Avoiding drugs. Nicotine is a stimulant and alcohol is a depressant. Neither help sleep.
  • Relaxing the mind. Relaxation exercises or meditation can help, or for chronic bedtime worriers, allow some ‘worry time’ before going to bed to decrease worrying during the night.

Lifestyle – nutrition and exercise

Some foods may contribute to restful sleep and others to wakefulness.

Tryptophan, an amino acid found in many foods, aids sleep.

Tryptophan produces serotonin, which is associated with relaxation, restfulness, and sleep.

Tryptophan also produces the hormone melatonin, which regulates the sleep-wake cycle.

Unfortunately, eating tryptophan-containing foods is unlikely to help sleep; although purified tryptophan increases brain serotonin, foods containing tryptophan do not.

Being physically active can help to reduce sleep problems.

Encourage daily exercise, but caution patients not to exercise within four hours of bedtime due to risk of overstimulation.

Psychological factors

Careful assessment for, and management of, contributing stressors, as well as anxiety and depression is important in addressing sleep disturbance in women.

Simple self-management strategies can include sleep hygiene, regular exercise, relaxation, mindfulness practices and journalling.

Targeted psychological therapies may be of benefit in managing specific stressors and for treating underlying mood or anxiety disorders.

In addition, the antidepressants venlafaxine and paroxetine might reduce hot flushes.

These agents may be considered in the setting of vasomotor symptoms of menopause in the context of mood or anxiety disorders, particularly those that are non-responsive to psychological therapies.3

Hormonal therapy

Menopausal hormonal therapy, also known as hormone replacement therapy, may assist in reducing vasomotor symptoms.

Hot flushes and night sweats are the hallmark of menopause, and can affect sleep quality in menopausal women.

Menopausal hormone therapy has been shown to improve sleep quality and should be considered for treating ongoing sleep disturbance.

Referral to sleep physician

If the patient has ongoing sleep disturbances after addressing sleep hygiene, nutrition, exercise and taking menopausal hormone therapy for several months, refer to a sleep physician.


Resources:


Dr Elizabeth Farrell is a consultant gynaecologist and Medical director at Jean Hailes.


References:

  1. Martino F, et al. Sleep in Women Across the Life Span. Contemporary Reviews in Sleep Medicine. Epub 2018 April 19
  2. Lampio, Laura et al. Predictors of sleep disturbance in menopausal transition Maturitas, Volume 94, 137-42
  3. Therapeutic Guidelines: eTG, Sexual and Reproductive Health, 2019     

This column is supplied by Jean Hailes for Women’s Health - a national, not-for-profit organisation focusing on clinical care, innovative research and practical educational opportunities for health professionals and women.