Ending sleepless nights: 5 tips to help patients conquer sleep disturbances in perimenopause and menopause

About half of patients going through perimenopause and menopause will have difficulty sleeping, experts say.“It’s very hard to correct many of the symptoms of menopause without addressing the sleep,” said Dr. Michelle Jacobson, a menopause specialist in Toronto. Related symptoms can include depressive mood, low energy, low libido and not feeling like themselves. “I would put it quite high on the list of things to address early on.”The Society of Obstetricians and Gynecologists of Canada (SOGC) published guidelines on menopause and sleep in 2021, but more advice may be needed to help these patients.We asked Dr. Jacobson and Dr. Alison Shea, lead author of the guidelines and associate professor in the department of obstetrics and gynecology at McMaster University in Hamilton, for tips on how to manage sleep problems. Both Drs. Jacobson and Shea sit on the board of the Menopause Foundation.1. Complete historyMake sure you know what kind of sleep disturbance your patient is experiencing, Dr. Jacobson advised. There are three different times in the night where sleep is disrupted. Some patients have trouble falling asleep, some wake up earlier than expected and can’t go back to sleep, but the most common for people in perimenopause or menopause is waking up in the night and not being able to fall back to sleep. Usually, people wake up between two and five o’clock in the morning and may take up to two hours to fall back to sleep, Dr. Shea said.There are a number of reasons why sleep disturbances may happen at this stage of life. Physiological changes are happening and there’s a shift in the circadian rhythm of hormones, Dr. Shea noted. Melatonin also starts to decrease in your 40s, partly mediated by the ovaries. Alterations in estradiol and progesterone contribute to poor sleep. Other symptoms of perimenopause and menopause might impact sleep, such as vasomotor symptoms like night sweats or genitourinary symptoms that make patients need to urinate in the night.Note that sleep disruption can often be more jarring and severe for people going through the menopause transition due to surgery or chemotherapy, Dr. Shea said.2. Screen for other sleep disordersMake sure you rule out other causes of sleep problems. First, check what Dr. Shea calls “the low-hanging fruit.” Is your patient anemic? Is there a disruption of the thyroid hormone? Ask about signs of restless leg syndrome.Next, screen the patient for sleep apnea. “It’s important to know that not all women with sleep apnea will actually snore loudly. A lot of people don’t know that,” Dr. Shea said. “Ask if they have headaches in the morning, if they’re very sleepy during the day and, if they have a bed partner, if the bed partner notices any pauses in their breathing.” If there’s any suspicion of sleep apnea, send them for a sleep study or to get a prescription for the proper apparatus.Investigate if the patient has depression or anxiety, and if present, work with the patient to treat it. “We know that mood disorders are quite common in perimenopause. It’s a time of vulnerability,” Dr. Jacobson said.Another thing that can affect sleep is chronic pain. Dr. Shea advises to help the patient manage the pain as much as possible, making use of physiotherapy and massage therapy.3. Encourage CBTThe first-line treatment for sleep disorders related to perimenopause or menopause is cognitive behavioural therapy (CBT) for insomnia. Both Drs. Shea and Jacobson recommend Sleepwell.ca for resources on CBT for insomnia. It lists specific books and websites that patients can access.Dr. Jacobson said she tends to refer patients to a website called CBTforinsomnia.com, a Harvard-developed program where patients can purchase a downloadable $50 booklet and other resources. “That way they can do it in their own time and their own environment.”If a patient works with a therapist, it will take four to six sessions, with each session lasting one hour, Dr. Shea said. The patient will also have to do exercises to combat negative thinking about sleep and possibly observe sleep restriction (only going to bed when you’re sleepy to get used to the body’s signals).Following through with CBT takes effort. “It’s very easy to take a pill,” Dr. Jacobson said. “It’s very hard to enable a behavioural change that you have to put the work in.” Those who followed through with the CBT program told Dr. Jacobson they found it very helpful.The good thing about CBT for insomnia is that it’s a transferable skill. “If you’re adept at cognitive behavioural therapy you’ll also be more successful in other areas of your life where your brain really impacts your ability to function,” Dr. Jacobson said.4. Consider medsOnce a patient has tried CBT for insomnia and other disorders have been addressed, then pharmaceutical treatment may be appropriate. Chronic insomnia that leads to five to six (or fewer) hours of sleep a night can result in poor health outcomes, so it’s important to protect sleep.“I tend to reserve sleeping medication for patients who are really distressed about a pattern of sleep disturbance, where every once in a while they need that guarantee that they’re going to sleep that night because the anxiety about a bad sleep is impeding them from falling asleep,” Dr. Jacobson explained.If patients are taking hormone therapy for perimenopausal or menopausal symptoms, progesterone can help with sleep. The doses of 200 to 300 mg of micronized progesterone have been studied for sleep, which are higher than typical doses of hormonal therapy.“Progesterone is certainly not a panacea for everyone for sleep, but if it is appropriate for the patient to be using hormonal therapy and the patient has no contraindications for that, then sometimes progesterone at bedtime can also help,” Dr. Jacobson said, adding that it can help them get to sleep, but not stay asleep.The pharmaceutical treatment of choice for insomnia is the new dual orexin receptor antagonists (DORA). They’ve been shown to help with sleep latency. Unlike other sleeping pills, with DORAs, patients don’t develop a dependence or tolerance and the drugs don’t suppress REM sleep.“It’s a much more restful sleep, and you don’t feel as groggy the next day,” Dr. Shea said. Even though these drugs appear safer than alternatives, Dr. Jacobson added that she still encourages people not to take them every night.While benzodiazepines and “Z drugs” might be necessary for short-term treatment, they’re not appropriate for long-term as patients can develop a tolerance and/or dependence. They bring long-term effects on cognition, an increased risk of falls, a high chance of a drug-drug interaction, and patients shouldn’t drive 12 hours after taking them. Work on weaning patients off these drugs, but go very slowly if a patient has been on them for a long time, Dr. Shea said.5. Support patients when trying other treatmentsCertain supplements have mixed evidence suggesting they help with sleep. These include valerian extract, magnesium and black cohosh in recommended doses. Dr. Shea notes these aren’t regulated the same way and so doses may vary.“On an individual level I think that if patients are taking these and they find them helpful, then we have reason to be supportive of that,” Dr. Jacobson said.Patients may also turn to cannabis for relief. The research on cannabis is scattered because there are so many different preparations and routes of delivery. Dr. Jacobson said she refers patients to a physician who is knowledgeable about cannabis.“Whatever works for them, if they’re sleeping, and they feel good then that’s fine,” Dr. Shea said. “Better to do it in an oil form or an edible form rather than smoking because of the health effects of inhaling something into your lungs.”Metabolism of alcohol changes as you age, so while it may have helped your patients get to sleep when they were younger, that might not be the case in perimenopause. It often means patients wake up as the body is metabolizing the alcohol. “If you’re going to have alcohol, try to do it at least three hours before bedtime so you can metabolize it before you go to sleep,” Dr. Shea advised.Measuring sleep with wearable fitness trackers may not be a good idea. Dr. Shea noted that sleep physicians consider them to be a poor indicator of sleep because they simply record movement. Fitness trackers can increase stress for patients struggling with sleep, especially if they wake feeling rested but the fitness tracker reports poor sleep. The best measure of a good sleep is if you feel rested and ready to take on the day, she said.All discussions about sleep should include education on sleep hygiene, especially when it comes to limiting screen use before bed, the SOGC guidelines state.

Ending sleepless nights: 5 tips to help patients conquer sleep disturbances in perimenopause and menopause

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