Is Your Body Keeping You Awake? Outsmart Perimenopause

Night sweats, breathing troubles, midnight bathroom breaks—it’s not easy getting the sleep you crave. Here, the best bets for beating your biology.

By Melanie Haiken • Illustrated by Christopher Silas Neal
counting sheet sleep insomnia moon picture
Photograph: Illustrated by Christopher Silas Neal

Remember what it was like to get eight solid hours of deep, uninterrupted sleep and wake up feeling rested and energetic? If not, you’re probably a member of a not-very-exclusive club: sleep-deprived forty- and fifty-something women. “There’s an enormous rise in sleep problems with the onset of perimenopause, which is usually around your midforties,” says Nancy Collop, MD, director of the Emory University Sleep Center in Atlanta and president of the American Academy of Sleep Medicine. “Even if you were a sound sleeper before, you’re likely to begin having problems now.” And if you’ve always had trouble snoozing, your nights will probably get worse before they get better (improvement may happen in your sixties—one reason to look forward to aging!). Only 45 percent of peri-menopausal women report getting a good night’s sleep almost every night, says the National Sleep Foundation.

What’s to blame: hormonal shifts, coupled with new family obligations, such as needing to take care of elderly parents. “The result is that many women see their sleep quality go downhill,” says Nanette Santoro, MD, professor and chair of obstetrics and gynecology at the University of Colorado in Denver.

Poor sleep does more than make you yawn during meetings; it’s lately been linked to heart disease, diabetes, weight gain, Alzheimer’s and cancer. “Too many women struggle with sleep problems during the menopause years, thinking it’s just something they have to live with,” says Collop. But research shows there are effective solutions.

Hormones Matter (A Lot)
“Hormones are at the crossroads between the brain and the body. When they shift, it affects all your systems,” says psychiatrist Robert Hedaya, founder of the National Center for Whole Psychiatry in Chevy Chase, Maryland. For instance, scientists have recently learned that the hormone progesterone in high oral doses functions like a natural sleeping pill. “It acts on the neurotransmitters in the brain to trigger relaxation, reduce anxiety and decrease sleep disruptions,” says Jerilynn Prior, MD, founder of the Centre for Menstrual Cycle and Ovulation Research at the University of British Columbia in Vancouver. But progesterone levels drop during perimenopause, possibly interfering with the deep REM stage of sleep and increasing middle-of-the-night awakenings, which in turn contributes to the predawn insomnia familiar to many women in their forties and fifties.

The perimenopausal and postmenopausal shifts in sex hormones account for arguably the most sleep--disturbing experience in this stage of life: hot flashes. For reasons that are not quite clear, the inner thermostat goes haywire, causing up to 85 percent of American women to experience hot flashes around the time of menopause. Since a decline in core body temperature is essential to falling (and staying) asleep, anything that raises the temperature at night may wake you up.

The stress connection
A decline in estrogen influences your stress levels—and hence whether you’re relaxed enough to nod off—in a few ways. Estrogen increases the availability of serotonin, the feel-good neurotransmitter that relaxes the nervous system. It is also converted into melatonin, the brain chemical that tells the body it’s time to go to sleep, says Hedaya. When your levels of estrogen plummet during perimenopause, the intricate interplay of signals gets disrupted, and sleep troubles follow.

In addition, if you have been under stress for a long time, you become more sensitive to lower estrogen levels, which means that you get easily worked up during the day and are wakeful during the night, becoming alert at the slightest noise or touch and having trouble falling back asleep. Couple this with “the tremendous number of psychosocial stressors that hit at this age,” from launching teens into the world to caring for aging parents, and you get a “double whammy” that sabotages sleep, notes Jan Shifren, MD, director of the Vincent Menopause Program at Massachusetts General Hospital in Boston.

Unwelcome Wake-Up Calls
Then there’s the bladder problem. Needing to go often or suddenly or simply having heightened bladder sensitivity (leading the body to think you have to go even when you don’t) can prevent you from getting the hours of uninterrupted REM sleep you need. One theory is that thinning tissues in the bladder and urethra lead to increased sensitivity. “Certain women don’t even fully wake up when they start getting those sensations—but just the heightened sensitivity and partial awareness are enough to negatively impact sleep,” says Hedaya.

A Controversial Solution
If biological changes are the root of your sleep problems, does taking prescription versions of sex hormones bring about restful nights? For many women, the answer is You bet!So far, hormone therapy (either a pill that combines estrogen and progesterone, or an estrogen-only pill, which is usually given only to women who have had their uteruses removed) is the single most effective treatment available for hot flashes and night sweats.

However, many women (and their doctors) were scared away from hormone therapy in 2002 when government researchers halted a major study out of concern that the protocol might raise the risk of breast cancer and heart disease. (For the most recent thinking on the safety of HT, go to​update.) Doctors have tried to minimize jeopardy in a few ways. One is to limit your exposure by prescribing the drugs on a short-term basis: You use hormone therapy to get through the years leadingup to menopause (which technically occurs on the day that’s one year after your last period) and possibly a year or two more. This is the regimen now recommended by most experts, says Hartford, Connecticut, ob-gyn Alicia Stanton, author of Hormone Harmony.

Another way to reduce risk is to take estrogen (alone, not in combination with progesterone) transdermally. Low doses of estrogen can be absorbed through the skin directly into the bloodstream via patches, a delivery method that’s less likely to precipitate blood clots and strokes, according to studies done in the last two years.

Typically, progesterone is taken with estrogen as part of HT to reduce the chances of developing uterine cancer. But lately cutting-edge research has begun focusing on using one particular form of progesterone in a new way, as a sleep aid. This formulation, called micronized oral progesterone (brand name: Prometrium), is derived from plants and is chemically identical to what your body makes. (The progesterone variant in most kinds of HT, progestin, is synthetic and differs importantly from your internal hormone.) According to a study reported at last year’s annual Endocrine Society meeting, women who took micronized progesterone pills slept more soundly and for a longer uninterrupted period than women who did not.

Prior, who has done much research on this pill, believes micronized oral progesterone is safer than most currently available sleeping pills, because unlike those medications, Prometrium is not addictive and does not decrease restorative REM sleep. To help patients sleep better, doctors may prescribe anywhere from 100 to 300 milligrams of Prometrium. Take the pill at bedtime every night for as long as you think you need it, Prior advises.

The problems associated with the combination of estrogen and progesterone have been well researched, but the use of progesterone on its own hasn’t been widely studied. Still, the evidence so far suggests that this hormone causes no serious side effects. Since any kind of treatment with sex hormones is controversial, consult an MD who is up on the latest research. One easy way to find a well-informed physician is to search on the website of the North American Menopause Society (

What You Can Take Besides Sex Hormones
Ambien (zolpidem) and Lunesta (eszopiclone): These prescription sleep aids are relatively safe options as long as you don’t rely on them night after night, which could create a psychological dependency, says Santoro. In addition, most prescription sleeping pills, as well as over-the-counter ones (which are mainly antihistamines), make some people feel drowsy the next morning.

Valerian: Among herbal remedies, this is the most widely used. In a Menopause study of insomniac women ages 50 to 60, a regimen of 530 milligrams taken twice a day for four weeks improved the quality of sleep for ​30 percent of the subjects—and caused no adverse reactions in anyone.

Melatonin: This sleep-inducing hormone is involved in regulating the circadian system, which, among other things, determines your cycle of sleep and wakefulness. The Mayo Clinic reports that “the weight of scientific evidence does suggest that melatonin decreases sleep latency (the time it takes to fall asleep), increases the feeling of sleepiness, and may increase the duration of sleep.” However, the Mayo report adds, “Better research is needed in this area.” Start with 0.3 milligram of melatonin an hour before bed.

It may be a struggle to improve your sleep life, but experts encourage you to keep exploring different options. “Good sleep is so important for your overall health, it’s worth the effort to find a solution,” says Collop.

Upper Airway Resistance Syndrome (UARS) is a breathing problem that’s milder than obstructive sleep apnea but might still be ruining your rest. Whereas apnea happens when the breath completely stops in the throat, UARS occurs when air is getting through but is partially obstruc-ted. As a result, you half-wake repeatedly throughout the night, which prevents the onset of deep, restorative REMsleep. Women are more prone to this condition than to sleep apnea.

The cause of UARS is almost always that your nasal passages are congested or that your soft palate or tongue has collapsed in a position that blocks breathing. Women with small jaws and thin necks are particularly at risk for this condition, says Steven Y. Park, MD, an otolaryngologist at Montefiore Medical Center in New York and author of Sleep Interrupted: A Physician Reveals the #1 Reason Why So Many of Us Are Sick and Tired. “If you had orthodontics as a child for overcrowded teeth, watch out—that’s a sign you have a small jaw and palate, and there’s a good chance you will develop UARS,” he notes.

Changes in hormones play a role in breathing difficulties as well, Park says, because progesterone helps keep the muscles of the tongue and throat strong.

UARS and related breathing troubles can betreated with a spectrum of interventions. You may need to get a gadget from a dentist, sleep specialist or ear, nose and throat doctor. Or, if your condition is mild, you might respond to a simple over-the-counter solution. Here, some of the most common and effective treatments.

CPAP mask Air can be flowed into your nose and mouth by a mask that provides continuous positive airway pressure (CPAP), ensuring that you get enough oxygen to remain asleep. Typically prescribed by sleep specialists, it’s the most reliable and successful nonsurgical treatment for apnea and UARS. Compliance is a problem, though: Many people find the mask uncomfortable.

Breathe Right: You attach these simple adhesive strips, available at drugstores, to the bridge of your nose to help open the nasal passages.

Nozovent: Designed to prevent snoring, this Swedish device, sold at and health food stores, inserts plastic balls into the nostrils to hold them open.

Saline nasal spray: This solution irrigates and expands nasal passages. If you use it before bedtime, it may prevent nasal congestion during sleep.

Jaw positioners: Available in one-size-fits-all or custom-made by dentists, these push the lower jaw forward and keep the tongue from blocking the throat.

If you want a good night’s sleep, step away from the computer. Here’s why: The sleep-promoting hormone melatonin is suppressed by light—any kind, but especially the blue waves given off by LEDs (light-emitting diodes). After a group of researchers exposed subjects prebedtime to two hours of the type of blue-wavelength light produced by modern computers, the participants had a harder than normal time falling asleep. And the effect lingered. “The more blue light in the evening, the less deep sleep there was at the beginning of the following night,” says lead author Christian Cajochen, PhD, head of the Centre for Chronobiol-ogy in Basel, Switzerland. Almost any machine with LEDs (that includes TVsets and the screens of many electronic devices) will undermine the quality of your sleep. Nancy Collop, MD, director of the Emory University Sleep Center in Atlanta, suggests two ways of reducing your blue-light exposure: Don’t bring laptops to bed, and do turn off the TV 30 to 60 minutes before sleep time.

Originally published in the November 2011 issue of More.

Next: Natural Sleep Aids and Strategies

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First Published Mon, 2011-10-10 11:08

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