Sleep & Menopause The Tangled Web

What Can You Do?

Track Sleep. Start by understanding your baseline. Jot down information before you are going to bed as well as in the morning after waking up. This will help validate your recall for what is happening and give some areas to start focusing on improvements. Each day write down:

• Before bed: naps, exercise, caffeine intake, sleep medications or aids, alcohol, time you went to bed, time lights went out, TV/screen time before lights out

• Next morning: time to fall asleep for the first time, number of awakenings, total time awake after falling asleep, time finally woke up, time out of bed

It may be worth getting a sleep study by a professional clinic to understand what is happening with your sleep and rule out other conditions.

Limit Rest Raiders. These are likely common sense reminders but dig deep into your motivation to sleep better, see where you have opportunity to eliminate some sleep raiders or ‘tweak’ them so they are not as harmful to your slumber.

• • • • • Avoid alcohol and nicotine within three hours of bedtime. Drop the ‘night cap’!

        • Limit liquids within 3 hours of bedtime

        • No caffeine after 2 pm. This is not just coffee but also chocolate, tea, sodas, and some medications.

        • Make your bedroom a sleep oasis! Keep your bedroom cool (62-65 degrees), dark, and quiet. If your bedroom is too warm, it makes it harder for the body to drop its temperature, a mechanism the body does to promote quality sleep. Check out your mattress, maybe it is time to invest in a new more fitting bed. We need dark to sleep, even our melatonin hormone works better in a dark environment. If there are noises you cannot control consider a noise machine or earplugs.

        • Take a warm bath or shower. 1.5 to 2 hours before bed to let your body temperature come back down. A hot shower right before bed might actually impact your ability to sleep.

        • Exercise four to six hours before bed. Exercise helps to promote sleep and regulates our circadian rhythm but doing it induces impacts that if done too close to bed may impact your sleep such as having too high a body temperature.

        • Time your meals and pay attention to what you eat. Eating heavy and spicy foods within three hours of bedtime is a bad idea. Also, going to bed on an empty stomach may cause issues, you can have a small snack that is a combination of carbohydrates and protein to help promote sleepiness. Overall eating healthy foods with plenty of leafy greens, lean protein, healthy fats, and complex high fiber carbohydrates promotes overall health.

        • Napping. If you need to nap, limit it to 20 minutes before 2 pm to minimize your sleepiness and ability to sleep at night.

        • Blue light. Melatonin drops when exposed to light, especially blue light coming from electronics like televisions, computers, and phones. The suggestion is to remove blue light one to two hours before bed and if you wake up in the night, do not pick up your phone. If you find it hard to wind down without blue light devices, try blue light blocking glasses. It is not certain this will work but they are affordable and worth the try.

        • 1-hour wind-down strategies & mindfulness. Tap into the mind and body connection, create a wind-down strategy that promotes sleep such as stretching, meditation, or yoga. Relaxation breathing such as BOX breathing can calm your nervous system and support rest. Consider including chamomile tea in the routine to help with relaxation and digestion.

        • If your brain spins when you try and sleep, organized your ‘to-do’ list before bed. If things keep popping in your head focus on relaxation. If you need a ‘crutch’ to get you there, keep a notebook and pen on the side of your bed (do not pull out your phone and send an email to yourself or make notes).

        • Maintain a regular sleep routine, going to bed and waking up a the same time every day. This helps the body stay in a rhythm.

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What Can You DO?

Check out PAUZ Medical Director, Dr. Alison Shea speaking about progesterone and sleep.

Cognitive Behavioral Therapy (CBT-I). There are CBT-I programs that can help you train yourself with thoughts and behaviors to improve your sleep. CBT-I has the most robust evidence for managing insomnia. Dr. Shelby Harris, PsyD, has a great book if you are not ready to try a therapist, it is called the Women’s Guide to Overcoming Insomnia (4).

Hormone Replacement Therapy (HRT). Addressing the roller coaster of hormones in perimenopause can help address symptoms such as night sweats impacting your sleep and with your overall ability to sleep. In particular, evidence for progesterone to support falling asleep. Progesterone acts like a sedative and will not help with staying asleep or waking early. 

Other Evidence-Based Treatments:

Traditional Chinese Medicine (TCM)-Acupuncture. The World Health Organization has listed acupuncture as a treatment for insomnia based on published science. Ensure the acupuncturist is licensed (LAc certification).

Complementary and Alternative Therapy (CAM). In addition to acupuncture, therapeutic touch and music have been found to improve sleep including sleep latency, sleep disturbances, and self-reported sleep quality (5,6). More research is required with larger sample sizes to further validate these therapies, however, it is worth a try to see if it helps!

Herbal Remedies & Supplements

Cherry tart juice contains melatonin and anti-inflammatory properties that help promote sleep.

While some people take melatonin, there is evidence it marginally improves sleep. Melatonin does appear safe if dosed between 0.5 mg and 5 mg. A 0.5 mg dose may be all that’s needed for sleep-cycle regulation, and should be taken three to five hours before bed. The field is unregulated so checking doses if you are switching manufacturers is important. Melatonin can result in nausea, dizziness, among other issues such as stomach problems and headaches. It may negatively interact with some medications such as high blood pressure and diabetes. There is also evidence suggesting it might impact hormones including estrogen receptor binding. To summarize, melatonin is to help regulate circadian rhythm, not as an effective sleep aid. Consuming cherry tart juice instead may help. 

Magnesium helps with a variety of things including stress, anxiety, restless leg, and insomnia. It is a natural relaxer and if you have issues with constipation try for magnesium citrate or oxide, if not, magnesium glycinate at a dose of 400 mg at night is typically a safe range. Again, an aid to foster falling asleep versus staying asleep.

Valerian is commonly used however, evidence of its' effectiveness is lacking and it requires 2 to 3 weeks of use before a positive effect at dosing of 800 to 1200 mg. It may negatively interact with some medications such as antidepressants.

Lavender Oil does support calming and soothing of the nervous system, you can diffuse in the room, put it on topically to your body or pillows. You can try any essential oil you find calming and soothing.

Lemon Balm helps with calming and anxiety. It enhances the brain’s reaction to GABA, a relaxation neurotransmitter in the brain.

L-theanine is an amino acid that works similar to lemon balm. You can get it naturally in protein sources and through certain tea. Dosing is 100 mg twice daily or 200 mg 30 minutes before bed.

Herbal Medications-Cannabis. THC, the psychoactive element in marijuana, may induce a sense of alertness and, consequently, potentially disrupt sleep, especially in higher doses. There is some evidence THC at higher doses disrupts REM sleep (4). Research has also shown it helps promote sleepiness but disrupts the sleep cycle and quality of sleep. On the other hand, CBD is more linked to sleep and relaxation, as it appears to soothe the central nervous system and elevate levels of adenosine, a compound that promotes sleep. Edibles containing CBN, a byproduct of THC with mild sedative properties, are frequently marketed as sleep aids, although the supporting data for this claim is limited (6). It is important if you are delving into cannabis to know that smoking, oils, edibles have different impacts. Individual effects vary as well based on what you have eaten, medications, and metabolism.

Other Medications

The first line of medications are DORAs. This stands for Dual Orexin Receptor Antagonists- a newer class of sleep medications that help you fall asleep and stay asleep while targeting the orexin system in your brain.  Orexins are brain chemicals that keep you awake and alert. DORAs work by blocking these orexin signals, which helps the brain naturally transition into sleep without the heavy sedatio or memory issues that come with older sleep drugs (see below).

Some DORAs include: Daridorexant (Quiviviq), Lemborexant (Dayvigo), Suvorexant (Belsomra).

Antihistamines. Many of us take over-the-counter medications like antihistamines to help us sleep like Unisom, Benadryl, Silenor, NyQuil however, they will only work for two weeks of use moreover, they can limit REM sleep meaning you do not have a fully restorative sleep, they can also make you feel groggy and hung over in the morning.

Non-Benzodiazepine Medications. These prescription medications are hypnotic pharmaceuticals like Ambien, Lunesta, Belsomra, Rozerem. These drugs enhance the brain’s reaction to GABA, a relaxation neurotransmitter. These are designed for short-term use only and can cause memory problems, sleepwalking, vivid dreams, hampered memory alertness the next day.

Benzodiazepines. These are anxiety medications used off label to help with sleepiness and can assist in mood disorders. Some that you have likely heard of: Ativan, Xanax, Valium, Klonopin. These are also intended for short-term, we adjust to the medication and require higher doses for any effect.

References

1. Salari N, Hasheminezhad R, Hosseinian-Far A, Rasoulpoor S, Assefi M, Nankali S, Nankali A, Mohammadi M. Global prevalence of sleep disorders during menopause: a meta-analysis. Sleep Breath. 2023 Oct;27(5):1883-1897. doi: 10.1007/s11325-023-02793-5. Epub 2023 Mar 9. PMID: 36892796; PMCID: PMC9996569.

2. Andersen ML, Bittencourt LR, Antunes IB, Tufik S. Effects of progesterone on sleep: a possible pharmacological treatment for sleep-breathing disorders? Curr Med Chem. 2006;13(29):3575-82. doi: 10.2174/092986706779026200. PMID: 17168724.

3. Vahratian, A. Sleep duration and quality among women aged 40-59, by menopausal status. National Center for Health Statistics Data Brief. No. 286, September 2017, https://www.cdc.gov/nchs/products/databriefs/db286.htm.

4. Women’s Guide to Overcoming Insomnia. Dr. Shelby Harris. The Women's Guide to Overcoming Insomnia 

   Combination of therapeutic touch and music key to a better night’s sleep during menopause. The Menopause Society. October 25, 2023. Accessed October 25, 2023.

5. KeskinTore F, Yagmur Y. The effects of therapeutic touch and music on sleep quality, menopausal symptoms and quality of life in menopausal women. Menopause. 2023, doi:10.1097/GME.00000000002269.

6. Vaillancourt R, Gallagher S, Cameron JD, Dhalla R. Cannabis use in patients with insomnia and sleep disorders: Retrospective chart review. Can Pharm J (Ott). 2022 Apr 15;155(3):175-180. doi: 10.1177/17151635221089617. PMID: 35519083; PMCID: PMC9067069.; Corroon J. Cannabinol and Sleep: Separating Fact from Fiction. Cannabis Cannabinoid Res. 2021 Oct;6(5):366-371. doi: 10.1089/can.2021.0006. Epub 2021 Aug 31. PMID: 34468204; PMCID: PMC8612407.