As Baby Boomers move into their fifties and sixties, women in this generation will soon (if they have not already) experience menopause. More than half of women can expect to struggle with sleep problems during their menopausal transition years.1 With more female Baby Boomers beginning to experience menopause-related sleep problems, they will likely turn to sleep clinicians for help with diagnosis and treatment.
Menopause has often been affiliated with a number of sleep problems, particularly hot flashes. However, new information2 is revealing that hot flashes may not be as much a factor in menopausal women’s sleep problems as once thought. In fact, many sleep problems previously dismissed as side effects of menopause may instead be attributed to primary sleep disorders.1 Such findings illustrate the need for special consideration when managing sleep problems in menopausal women.
Menopause is defined by the ending of the reproductive phase of a woman’s life.3 This is the time when the production of estrogen becomes irregular and begins to decrease. Menopause does not happen suddenly but rather occurs over time.3 Consensus among clinicians is that menopause is established if menstruation has not occurred for 1 year.3 The typical age at which menopause occurs varies from the early 40s to beyond 50.3
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During the years leading up to menopause, usually 4 to 10 years earlier than the last menstrual cycle, women will notice physical changes. Previous research has shown that a common symptom of menopause is hot flashes, which have been reported in 75% to 85% of women and have been connected to insomnia.4 Hot flashes and increased sweating are related to the loss of the hormones estrogen and progesterone that occurs during menopause.4 These occurrences can make sleeping difficult for women. Lack of sleep can also contribute to cardiovascular problems, including hypertension, diabetes, obesity, and depression.5
Though menopause, hot flashes, and sleep are commonly associated in previous findings, a new study published in the February 2008 issue of Harvard Women’s Health Watch concludes that some of the sleep problems that women typically attribute to hot flashes may instead be caused by primary sleep disorders such as sleep apnea.2
To investigate the cause of poor sleep during the menopausal transition, the researchers assessed the sleep of 102 women who reported having trouble sleeping. The study revealed that 53% of the participants had a primary sleep disorder. Among the entire group, 56% had measurable hot flashes. Based on the findings of this small study, it appears that sleep disorders are underdiagnosed in menopausal women. Sleep problems are often assumed to be a side effect of hot flashes; however, treating hot flashes is not likely to resolve a serious underlying sleep disorder.2
Other studies also have found that sleep disorders should be thoroughly considered before attributing sleep problems to menopause. A study6 by Young et al concluded, “Although perimenopausal and postmenopausal women, relative to premenopausal women, were less satisfied with their sleep, menopause was not a strong predictor of specific sleep-disorder symptoms.” The researchers went on to state, “Symptoms and signs of sleep abnormalities in midlife women should not be attributed primarily to menopause before ruling out underlying sleep disorders.”
Common Clinical Perimenopausal Conditions
Obesity, hypertension, and sleep-disordered breathing (SDB) are strongly associated with one another.1 All three are common clinical conditions in postmenopausal women, and considerable research suggests that menopause contributes to these conditions. The strong association of SDB with obesity, visceral adiposity, and hypertension has led to the suggestion that sleep apnea is a manifestation of the metabolic syndrome.2 The metabolic syndrome is a constellation of closely related symptoms (visceral adiposity, hypertension, insulin resistance, elevated glucose, dyslipidemia) that together convey a substantially increased risk of cardiovascular disease.3 Visceral adiposity is first and foremost among these symptoms, and it is thought by many to be the major determinant of the metabolic syndrome. These features of the metabolic syndrome become much more common in women as they transition from premenopause to postmenopause.3 It may be due to menopause-related hormone changes, because HRT decreases the shift to visceral adiposity.4
- Wolk R, Shamsuzzaman ASM, Somers VK. Obesity, sleep apnea, and hypertension. Hypertension. 2003;42:1067-1074.
- Vgontzas AN, Bixler EO, Chrousos GP. Metabolic disturbances in obesity versus sleep apnoea: The importance of visceral obesity and insulin resistance. J Intern Med. 2003;254:32-44.
- Carr MC. The emergence of the metabolic syndrome with menopause. J Clin Endocrinol Metab. 2003;88:2404-2411.
- Reubinoff BE, Wurtman J, Rojanski L, et al. Effects of hormone replacement therapy on weight, body composition, fat distribution, and food intake in early postmenopausal women: A prospective study. Fertil Steril. 1995;64:963-968.
Research is showing that attributing sleep problems simply to menopause or to hot flashes before screening for sleep problems can potentially leave a patient with an untreated sleep disorder. The above-mentioned findings illustrate that careful attention should be given to primary sleep disorders in menopausal women.
Perimenopausal women (defined in the National Sleep Foundation 2007 Sleep in America Poll as “women during their menopausal transition years”) are more likely to report symptoms of sleep apnea compared to menstruating women.1 The 2007 Sleep in America Poll found that 43% of perimenopausal women report symptoms of a sleep disorder such as sleep apnea, snoring, and/or RLS compared to 34% of menstruating women.1 The prevalence of sleep apnea in menopause has been attributed to changes in hormones. Progesterone, in particular, has an effect on breathing. Progesterones have been shown to stimulate ventilation.7 Following menopause, when levels of progesterone decrease, women may have decreased ventilatory drive and hypotonia in pharyngeal muscles, which can decrease further during sleep and lead to apneic symptoms.8
Sleep apnea is also more common and severe in postmenopausal women. Clinical researchers at the University of Toronto and St Michael’s Hospital compared the prevalence and severity of sleep apnea between 290 pre- and 400 post-menopausal women at the St Michael’s Hospital Sleep Laboratory.9 They measured neck size and obesity to determine if any differences in these variables could explain the differences in apnea prevalence and severity.9 They found that 47% of postmenopausal women suffered from sleep apnea compared to 21% of premenopausal women, and that the condition was more severe in the postmenopausal group.9 The researchers concluded that neck circumference and obesity did not affect prevalence of sleep apnea. They instead suggested that the difference might be due to decreased estrogen and progesterone levels related to menopause.9
Sleep problems can be multi-faceted. For patients with suspected sleep apnea, an overnight PSG should be performed. If symptoms of sleep apnea exist, these can be managed with CPAP, oral appliances, or surgery, depending on the patient’s severity.10
Doctors have suggested that treatment with estrogen (estrogen replacement therapy) or treatment with estrogen and progesterone (hormone replacement therapy) has been found to help relieve menopausal symptoms. However, new information11 suggests that due to increased health risks, women should be prescribed only the lowest dose and it should be used for only brief periods.
There are also alternative ways to manage symptoms. These include nutritional products such as calcium, vitamin D, estrogen creams, and sleep-promoting drugs for insomnia.4 When estrogen enters the bloodstream, hot flashes are commonly reduced.4 Soy products (tofu, soybeans, and soymilk) and herbal products (black cohosh, a perennial plant that is a member of the buttercup family) have also been shown to relieve symptoms in some women.4
For now, professionals treating menopausal women should not simply write off hot flashes, but reevaluating the diagnosis and treatment of sleep problems in menopausal women is worth consideration.The Harvard Women’s Health Watch study was small and may not be representative of all menopausal women with sleep complaints.2 However, the finding that half the women had primary sleep disorders, not just hot flashes, bears further investigation. As researchers uncover more information about the relationship between sleep and menopause, new approaches for treatment of female Baby Boomers will emerge.
Lisa Feierstein, RN, BSN, MBA, is founder of Active Healthcare. She has been serving the medical community for more than 25 years in hospital, outpatient, and home care settings, and she is a specialist in obstructive sleep apnea. She can be reached at [email protected].
- National Sleep Foundation. Stressed-out American women have no time for sleep. Available at: [removed]www.sleepfoundation.org/site/apps/nl~[/removed]. Accessed March 5, 2008.
- Harvard Women’s Health Watch. Nighttime awakenings in menopause may be caused by sleep disorders, not hot flashes. Available at: read.health.harvard.edu/user/user.fas/s=784~. Accessed March 5, 2008.
- Kryger M. A Woman’s Guide to Sleep Disorders. New York: McGraw-Hill; 2004:46.
- National Sleep Foundation. Understanding menopause. Available at: [removed]read.health.harvard.edu/user/user.fas/s=784/~[/removed]. Accessed March 3, 2008.
- Centers for Disease Control and Prevention. Sleep and sleep disorders: a public health challenge. Available at: read.health.harvard.edu/user/user.fas/s=784/~. Accessed March 18, 2008.
- Young T, Rabago D, Zgierska A, Austin D, Laurel F. Objective and subjective sleep quality in premenopausal, perimenopausal, and postmenopausal women in the Wisconsin Sleep Cohort Study. Sleep. 2003;26:652-3.
- Regensteiner JG, Woodward WD, Hagerman DDH, et al: Combined effects of female hormones and metabolic rate on ventilatory drives in women. J Appl Physiol 1989;66:808-813.
- Managing menopause and sleep. Available at: www.sleepreviewmag.com/issues/articles/2005-09_01.asp. Accessed March 11, 2008.
- Sleep apnea more common, severe in post-menopausal women. Available at: www.eurekalert.org/pub_releases/2000-05/UoT-Samc-0705100.php.
- MayoClinic.com. Tools for healthier lives. Sleep apnea. Available at: www.mayoclinic.com/health/sleep-apnea/DS00148/DSECTION=8. Accessed March 18, 2008.
- Age is important in hormone therapy use, study suggests. Available at: www.sciencedaily.com/releases/2007/08/070803144622.htm. Accessed March 17, 2008.