Why does the menopause affect sleep?

Disrupted sleep is one of the most common complaints of the menopause, affecting almost 1 in 4 women going through this transition. This article explores what the menopause is, why sleep is disrupted, and how your sleep can be fixed. 

What is the perimenopause and menopause? 

The menopause is the name given to the point in a women’s life when menstrual periods have come to an end. It is associated with a decrease in female hormones, mainly oestrogen and progesterone which are made in the ovaries. The menopause is defined as when periods have ceased for 12 consecutive months and in the UK the average age for this to occur is 51 years old.  

The transitional time from fertility to the menopause, known as the perimenopause, is associated with irregular fluctuations of hormone levels that may trigger a range of symptoms  

A wide variety of symptoms can be reported in the perimenopause and menopause including hot flushes, brain fog, bladder and vaginal symptoms, depression, anxiety and joint pains.  

Poor sleep is one of the most common symptoms and affects around 1 in 4 women during the perimenopause and menopause. 

The impact of poor sleep during the menopause 

Poor sleep has a significant impact at any stage of life causing poor concentration, irritability, low mood and fatigue, as well as increasing the risk of a range of serious physical and mental health conditions including high blood pressure, heart disease, stroke, diabetes and depression.  

The reason poor sleep can have such a huge impact specifically around the menopause is that the symptoms of inadequate sleep are very similar to those of the menopause itself. Poor sleep works to magnify the effects of the menopause. 

The pre-menopausal phase of a woman’s life is marked by higher levels of oestrogen, which have a protective effect on the cardiovascular system. This means blood vessels are less likely to fur up, which is the root of the problem in heart attacks and strokes. When the menopause is reached, the protective levels of oestrogen drop. If this is combined with the cardiovascular risk associated with poor sleep, then the overall risk can be much higher. 

Furthermore, there is increasing evidence indicating how poor sleep can cause mental health conditions such as depression and anxiety. The menopause is similarly known to affect these conditions. It is the magnification of symptoms that gives poor sleep a huge health impact it has. 

Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a condition associated with snoring where your upper airway repeatedly closes when you sleep, stopping you breathing. It is more common during the perimenopause and menopause 

Your upper airway is made of hard structures, like the hard palate in the roof of your mouth, or soft structures, such as the back of the throat and the base of the tongue. Hard structures stay in place by themselves but soft structures are held in place by muscles. When you fall asleep these muscles relax, which causes your airway to narrow. Initially this causes the airflow to become turbulent which makes the soft structures vibrate, which we hear as snoring. If the airway gets narrower, the flow starts to get restricted, until the airway actually closes entirely and your breathing stops.  

With no breathing your oxygen levels drop. Your body can only tolerate this for 10 seconds or so, before having to pull you back from this deep state of sleep to a shallower state (or even completely awake) so your airway muscles can pull open your airway again. Breathing often restarts with a large gasp or snort.  

This means that even if you sleep for eight hours, you never fall into that deep, restorative state of sleep that you need to feel refreshed in the morning, because whenever you do your airway closes and your body has to wake you up to re-open your airway. OSA is discussed in more detail here. 

OSA becomes more common during the perimenopause and menopause for to reasons. One is that the reduced female hormones can affect the stability of soft airway structures and cause them to be slightly more floppy. Another reason is that the menopause can be associated with a change in the distribution of weight around the body, with a more central distribution of adipose tissue more likely. This may weigh in on the airway, making OSA more likely. 

Restless Legs Syndrome

Restless legs syndrome (RLS) is an unusual sounding, but common condition causing an uncomfortable, restless feeling in the legs and an irresistible urge to move. It is estimated to affect 10% of the population and is more common during the perimenopause and menopause. It is usually worse in the evenings and can prevent you falling asleep. 

Typically, the feelings in the legs are very difficult to describe. Terms people often use include “squirmy”, “antsy”, “itchy on the inside” or “like the urge to yawn, but in the legs”. 

These uncomfortable feelings are usually accompanied by a strong urge to move, shake or stretch the legs, which temporarily relieves the discomfort, only for it to return shortly after becoming stationary again. 

How can you improve poor sleep during the menopause? 

The good news is that all of these causes of poor sleep can be treated. 

Menopausal symptoms are caused by reductions in the female hormones, mainly oestrogen and progesterone. For some women, replacing these hormones through HRT can reduce the symptoms, and lead to improvements in sleep. 

Each sleep disorder also has its own direct treatment, which are proven to be effective whether you are pre or postmenopausal, or HRT or not, or even male or female. 

The gold-standard treatment for insomnia is cognitive behavioural therapy for insomnia, or CBTI. This is an effective and evidence-based treatment that explores how our thoughts, or cognitions and out actions, or our behaviours, influce the quality and quantity of the sleep that we get. This can be delivered over 1:1 video sessions. 

Obstructive sleep apnea can be diagnosed through a home sleep test, which is a watch-like device worn overnight as you sleep and gives extremely detailed information on how you breathe. The treatment is through CPAP (continuous positive airway pressure), which is a small box that sits on your bedside table and gently blows air at a low pressure through a mask which helps hold your airway open from the inside and stop it closing over.  

This can lead to the brisk return of quality sleep which can make a hige difference to you day-to-day wellbeing, 

Restless legs syndrome has a variety of lifestyle changes and medications that can improve symptoms. It is important to check your iron levels, as correcting this can often alleviate symptoms.