Menopause and insomnia: why menopause affects sleep & the natural remedies that can help

Sleep is fundamental for health and regeneration and the healthy production and balance of hormones. Adults aged 18 to 64 need to sleep for 7 – 9 hours a night, but sleep disturbances are reported by nearly one third of the general population across all age groups, and further increase with advancing age, affecting nearly 50% of individuals over the age of 65¹. As they age, women are more likely to suffer with sleep disturbances such as insomnia, poor sleep quality and sleep deprivation than men.

During menopause transition, there is often an emergence of physiological and psychological symptoms such as hot flashes, mood changes, vaginal dryness and sleep disturbance.

Many women experience such symptoms during and following menopause transition, and studies show that 60-86% of women experience symptoms so bothersome that they seek medical care.

However, after doing so, many women feel misunderstood and disappointed that their concerns haven’t been addressed – and as a result, many will go on to pursue natural treatments.

In fact, about half of women in the menopause transition favour complementary and alternative medicine treatments².

Sleep disturbances are a major complaint of women transitioning through menopause and can have a far-reaching impact on quality of life, mood, productivity and physical health¹.

Sleep disturbance is also common in postmenopausal women³, with some studies showing that up to half of women experiencing a dramatic increase in sleep disturbance during the transition from perimenopause to menopause.

Some studies also show that as many as 42% of women will develop chronic insomnia by the end of their menopause transition.⁴

We are going to explore menopause and insomnia further in this blog.

Skip to Key Takeaways

What is menopause and menopause transition?

Perimenopause, or the menopause transition, is a natural progression in a woman’s life when her reproductive system gradually slows until she hits “menopause”; when she has had an absence of periods for 12 months.

The length of perimenopause differs between individuals, and can occur over just a few months, or up to 10 years – but 4 years is the average duration.

Natural menopause results from a decrease in ovarian function and changes in reproductive hormone levels as the ovaries become less responsive to follicle-stimulating hormone (FSH) and luteinising hormone (LH), leading to reduced circulating levels of oestrogen and progesterone^5.Due to a negative feedback mechanism, FSH and LH increase as the ovarian hormones oestrogen and progesterone decline.

In 2021 an estimated 1.02 billion women were postmenopausal globally, with 1.65 billion anticipated by 2050⁶.

Defining sleep disturbance and insomnia

The term sleep disturbance describes subjectively perceived sleep problems that don’t necessarily meet the criteria for a clinical disorder, despite being bothersome for the individual.

In contrast, insomnia is a clinically defined disorder, diagnosed when an individual reports the following criteria⁷:

• Difficulty initiating or maintaining sleep, or experiencing nonrestorative sleep, despite adequate opportunity
• Daytime functional impairments resulting from nocturnal sleep disturbance

A substantial number of women experience sleep difficulties during the menopause transition, and then through menopause and beyond, with around 26% experiencing severe symptoms that impact their ability to function in the daytime, which is diagnosed as insomnia⁸.

Studies have shown that the incidence rates of sleep problems are 39–47% in peri-menopausal and 35–60% in postmenopausal women, compared to just 16–42% in premenopausal women⁹.

Pathophysiology of menopausal sleep disturbances

The pathophysiology of sleep disturbance during the menopausal period is multifactorial, and we will examine some of the possible contributing factors below. Several of these factors may also interact with each other – creating a challenge when trying to determine the primary cause of sleep disturbance.

When we also consider that some factors may interact to worsen sleep quality, such as several sleep disorders, we highlight the need for a therapeutic strategy that supports the whole person¹⁰.

Figure: Sleep in the menopausal transition¹⁰. SDB, sleep-disordered breathing; PLMD, periodic limb movement disorder; RLS, restless legs syndrome

Changes to reproductive hormones

In addition to menopause, it has been reported that women have specific periods related to vulnerability to sleep disorders, such as puberty, menstruation and pregnancy, suggesting a close link between sleep disorders and female hormones – and insomnia is closely related to hormonal changes¹¹.

Female hormones can have a beneficial effect on sleep, so falling levels through menopause transition and after menopause are likely to be responsible, at least in part, for sleep disturbance during this time.

Oestrogen blocks wake-promoting neurotransmitters, such as acetylcholine, histamine, norepinephrine, serotonin, and dopamine¹². It increases the rapid eye moment (REM) sleep, total sleep time and decreases sleep latency and spontaneous arousals. It is also known to have a thermoregulatory effect at night, which can indirectly improve sleep¹³.

Reductions in oestradiol, the most potent form of oestrogen have been associated with difficulties with both falling and staying asleep¹⁴, as well as sleep-disordered breathing and a high frequency of movement arousals¹⁵.

During the menopausal transition, declining or low progesterone levels, resulting from the failure of a growing follicle to reach sufficient maturation for ovulation, are associated with sleep disturbances.

Progesterone stimulates benzodiazepine receptors, causing the release of gamma-aminobutyric acid (GABA), a sedating neurotransmitter¹². Low levels of progesterone have been linked to increased sleep-disordered breathing and a higher frequency of sleep disturbances and insomnia¹⁵.

Higher levels of FSH, as observed in peri-menopausal and menopausal women, have been linked to poor sleep efficiency, lower levels of deep sleep and subjective sleep quality, whereas higher LH levels have been associated with lower sleep efficiency and higher numbers of awakenings¹⁵.

Age and sleep quality

On the whole, women have a better quality of sleep as compared to men, which is evident by longer sleep times, shorter sleep-onset latency, and higher sleep efficiency. Despite all this, women generally tend to have more sleep-related complaints than men.

However, it is important to note that the amount of slow-wave sleep slowly declines with age both in men as well as women. Ageing is independently associated with sleep fragmentation, insomnia symptoms, circadian rhythm disruption, lighter sleep and reduced sleep efficiency¹⁶.

Our circadian rhythm is an internal body clock which initiates various physiological processes. The circadian clock undergoes many changes throughout life, at both physiological and molecular levels.

Melatonin, synthesised in the pineal gland, also regulates the circadian rhythm by detecting changes in the length of day and night or seasonal sunlight hours. Endogenous secretion of melatonin decreases with age and varies with gender, and in menopausal women, is associated with a significant reduction in melatonin levels, thus affecting sleep patterns¹⁷.

Vasomotor symptoms (hot flushes)

Hot flushes, a sensation of heat, sweating, anxiety and chills lasting between 3 and 10 minutes, are a hallmark of the menopause transition, being reported by up to 80% of women¹⁸.

Hot flushes can occur in the day, or the nighttime (night sweats) and the presence of hot flushes is consistently associated with poorer self-reported sleep quality and chronic insomnia, indicating that women link night sweats to waking in the night⁸.

While not all hot flushes are associated with disturbed sleep, there is a strong overlap in timing between hot flush onset and awakenings, which suggests that these events may be driven by a common mechanism within the central nervous system in response to fluctuating oestrogen levels, or that sweating triggered by a hot flush can contribute to, or extend, the interval of waking¹⁹.

It should be noted that not all women who experience sleep disturbance in menopause complain of hot flushes, so it is important to consider other factors that may be contributing to their symptoms.

Mood disorders and sleep

Mood disorders become more common in ageing women and may disrupt sleep. A number of studies have demonstrated that the rate of depression increases at least twofold during the menopause transition, independent of other known factors^20,21.

Depression and anxiety are associated with poor sleep, as well as with vasomotor symptoms, in complex, multidirectional interactions. It is suggested that hot flushes disrupt sleep, intrusive anxious thoughts during nocturnal awakenings trigger daytime mood symptoms (domino effect), and depression links with insomnia, in a vicious cycle²².

Other factors that may worsen sleep quality

Other common sleep disorders that may exacerbate sleep disturbances in menopause include restless leg syndrome (RLS). RLS is characterised by an urge to move the legs during period of rest or inactivity and typically has a circadian pattern with increasing severity at night.

RLS is considered a sleep disorder because deliberate limb movements initiated to provide relief from RLS discomfort delay the onset of sleep. RLS appears to have a slight female predominance, and studies suggest that during times of hormonal alterations, women are predisposed to RLS and other sleep disorders. Individuals with RLS frequently report sleep-onset insomnia and subsequent daytime sleepiness and fatigue⁷.

Obstructive sleep apnoea (OSA), the most common form of sleep-disordered breathing has been observed in 47-67% of postmenopausal women. The combination of weight gain and increased waist to hip ratio after menopause leads to changes in the upper airway and contributes to OSA and other sleep disorders²³.

The role of the microbiome in perimenopause and menopause

Perimenopause and menopause are often associated with dysbiosis and gastrointestinal (GI) complaints. Oestrogen levels can affect the gut microbiota, and the microbiome, in turn can affect serum oestrogen levels as certain microbes in the gut (known as the estrabolome) secret beta-glucuronidase; a bacterial enzyme that deconjugates oestrogens into their active forms, which can then be reabsorbed through the intestine and re-enter the blood stream²⁴ – which suggests that the composition of the gut bacteria plays a role in the onset an progression of some menopause related symptoms.

Nutrition in menopause – supporting sleep and beyond

There are a number of key nutrients that are essential to support optimal health through menopause transition and following menopause:

Probiotics

These live beneficial bacteria, including those belonging to the lactobacilli and bifidobacteria strains have displayed evidence of improving sleep quality and stress²⁵ and improvements in the self-reported parameter of sleep quality and disturbance²⁶.

Pro- and prebiotics can also be used in conjunction with menopause hormone therapy and may attenuate the side effects that can arise from hormone replacement²⁷.

Vitamin D

Vitamin D is a fat-soluble vitamin which is synthesised by the body through UV-B radiation in the summer months. With ageing, the rate of hydroxylation of vitamin D precursors in the body decreases, so the importance of exogenous vitamin D intake increases. Routine supplementation from October-March is recommended, at a dose of 2000IU per day, taken with meals.

Vitamin D status is a primary influencer of the absorption of calcium, so plays an important role in protecting bone density²⁸. Vitamin D deficiency is associated with sleep disorders and poor sleep quality, and supplementation has been proposed as a therapeutic option to improve sleep quality²⁹.

B Vitamins

B vitamins play an important role in menopause, through the processing of carbohydrates and the functioning of the immune system. Adequate B vitamin intake significantly reduces levels of homocysteine, high levels of which are associated with osteoporosis and increased risk of bone fracture. Folic acid, and vitamins B6 and B12, along with magnesium and zinc are cofactors in melatonin synthesis, so adequate intake of these nutrients is necessary for good sleep³⁰.

Isoflavones

Isflavones ae phytochemicals which are abundant in soybeans. Active isoflavones found in soy include daidzein, glycitein and genistein. They are considered to be phytoestrogens, and thereby elicit a mild oestrogenic effect.

Phytoestrogens can weakly occupy oestrogen receptors within the body and stimulate a gentle oestrogenic response and may alleviate several of the symptoms associated with menopause³¹.

Studies have also demonstrated that daily isoflavone intake may have a beneficial effect on sleep duration and quality^32,33.

L-Theanine

A key ingredient in tea leaves, is often referred to as “the calming amino acid”. Theanine can increase alpha brain waves and the relaxing neurotransmitter GABA, but also acts as a precursor to serotonin – which is required for melatonin production; the sleep hormone and is central to controlling sleep and wake cycles³⁴.

Magnesium

Magnesium is the second most abundant mineral in the body and serves as a cofactor for several enzymatic reactions. Magnesium may play a role in sleep by activating GABA, and a deficiency can contribute to low levels of melatonin. Supplementing with magnesium can decrease the concentration of the stress hormone, resulting in a calmer central nervous system and potentially better sleep³⁵.

In Magnesium Bisglycinate, magnesium is bound to the amino acid glycine, which itself has the property to enhance the quality of sleep and neurological functions – so this form of magnesium may be particularly supportive for sleep³⁶.

Lifestyle considerations to help with sleep quality during menopause

Reflexology

Along with yoga, walking and aromatherapy massage have all demonstrated a significant impact on decreasing insomnia and depression in menopausal women³⁷.

Accupuncture

This therapy is associated with a significant reduction in symptoms for women experiencing menopause-related sleep disturbances and has been suggested to be adopted as part of a multimodal approach for improving insomnia in menopause³⁸.

Music

Listening to music regularly has been shown to reduce levels of depression as well as improving sleep quality in menopausal women³⁹.

Regular exercise

Exercising at least 3 times a week, for 30-60 minutes has been shown to have beneficial effects on sleep quality and insomnia symptoms in perimenopausal women⁴⁰. As well as improving sleep, increased physical activity can support improvements in cardiometabolic, physical and psychosocial health during menopause⁴¹.

Cognitive Behavioural Therapy (CBT)

For insomnia, CBT is a treatment that can change patients’ beliefs and attitudes about sleep and behavioural techniques to improve their insomnia. In menopause, CBT has proven to be an effective therapy at significantly improving sleep as well as the interference of hot flushes on sleep and reducing depressive symptoms^42,43.

…and here are some more tips to support a restful night’s sleep:

• Take a warm/hot Epsom salt (a handful) bath before bed to aid sleep and relaxation. Hot baths bring blood vessels to the surface allowing your core body temperature to cool which helps the body prepare for sleep as body temperature begins to drop during night
• Ensure daytime full light exposure as well as activity, take a run or walk during daylight hours to top up on serotonin and vitamin D. Ensure you don’t exercise too late in the evening as can delay sleep onset
• Keep noises down (earplugs might help)
• Keep the room cool. Most people sleep best at around 18^oC with adequate ventilation
• Make sure the bed is comfortable. Waking often with a sore back or neck suggests the mattress or pillow may need changing
• Create an aesthetic environment that encourages sleep – use serene and restful colours and eliminate clutter and distraction
• Avoid work or watching television in bed
• Consider using a relaxation, meditation or guided imagery app, any of these may help with getting to sleep and will certainly help with relaxation
• Cut down on caffeine. Ideally no caffeine after midday – some people take 12 hours to metabolise caffeine.

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Key takeaways

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Last updated on 10th April 2024 by cytoffice