Another sleepless night?
Getting insight into what causes insomnia can be an important step in getting the problem under control.
Around midlife - many women, who previously slept like babies, find that their nights are interrupted by frequent wakings or simply they can’t drop off to sleep. Other women, who may have suffered from insomnia when they were younger, find that midlife sure doesn't make the problem go away. It's one of those double whammies: the arrival of midlife can make insomnia worse.
So what causes insomnia in perimenopause?
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There is a common tendency for everything new about women's bodies that happens at midlife, to get blamed on menopause.
But how much of insomnia in perimenopause is really caused by the hormone changes that happen when our periods stop?
What causes insomnia? Getting data
Like many things connected with the menopause, there's a big debate about sleep and its relation to the end of ovulation. The problem with getting any firm answers on what causes insomnia at midlife is that we're all so different and measuring what a good nights sleep is - well it's a wee bit fraught.
Scientists can measure either subjective perception of sleep, by asking women questions like: "how well do you feel you slept last night?" or they can measure objective sleep, by wiring people up to a recording device and measuring brain waves during the night - this is called polysomnography.
The problem with going by how women feel they sleep is that these reports are very variable, even for the same woman on different days and they are also strongly linked with mood. For instance, if you're feeling down, not only are you more likely to suffer from poor sleep, but you're also more likely to think you slept even less than you really did and to feel as if you need to sleep more. Same the other way around. When we're on a high, we feel we don't need as much sleep and often our cheerful spirits and excitement are enough to make us feel much less tired than we might do on a less happy day. And if you try and compare one woman's idea of a good night's sleep with another's ... well, you may as well ask a group of women to agree on the best colour for a summer dress.
So what about polysomnography to help find out what causes insomnia? This machine gives a reading of how well you slept during the night. Except there's a snag, because sometimes, particularly for women who are feeling stressed, there may not too much correlation between what the machine says about how they slept and how they feel they slept. In other words, you may feel you slept better than a hibernating hamster but the machine may say that you were restless and wakeful - and vice versa.
So what makes us go to sleep?
Getting off to sleep requires a balance between at least three things: the neurochemicals that control our circadian rhythm, other neurochemicals such as melatonin that respond to dark and light, and a combination of good sleep hygiene with a positive mental approach to sleep. What causes insomnia amongst many chronic insomniacs is that they actually make themselves stay awake by perpetuating negative thought patterns. Learning to control our thoughts while at the same time relaxing our body can help to send us off to sleep.
Hormone replacement and insomnia
Sleep is so precious and the feeling of having had a good night's sleep is so wonderful, that many of us are prepared to go to great lengths to find a regular slumber pattern.
A question women often ask about midlife insomnia is "could hormone replacement therapy (HRT) help me sleep better?"
It's a reasonable question but unfortunately there's no easy answer.
A complicating factor in studies of sleep and pills is that mysterious phenomenon known as the placebo effect.
Give someone a pill and by some inexplicable magic, they experience the effect the pill is supposed to have ... regardless of whether the pill was real or just made of sugar. For instance in one study(1), midlife women with mild to moderate depression were given one of three different pills: a hormone, a sleeping pill, or a sugar pill.
Guess who experienced the best symptom improvement?
The surprise was that there was no difference between the groups - all the women had improved symptoms, even the ones who just took a sugar pill!
One of the reasons doctors think that HRT might help sleep is that when women stop taking hormone therapy, they report poor sleep. Between a third and over a half of women report some kind of rebound symptoms after stopping HRT - including hot flashes, pain, stiffness or difficulty sleeping. But there are big questions about how much these effects are a kind of "reverse placebo effect". That is, because women expect their symptoms to get worse, hey presto, they do!
Sleep and menopause expert Joan Shaver(2) recently did a careful analysis of all the evidence to see if she could find a definite answer. She concluded that although the evidence supports a generally positive effect of hormone therapy on sleep, it is difficult to say who may benefit, by how much they may benefit and whether the hormones are really helping sleep directly or are having an effect because they reduce vasomotor symptoms.
Hormone therapy is not usually recommended for treating midlife insomnia in the absence of other really severe menopause symptoms. Simply because the downsides outweigh the upsides.
So what's the answer for sleepless midlife women?
The answer is that there is no simple answer, but there are lots of things that can help.
These include good sleep hygiene, regular exercise and a healthy diet.
Mindfulness meditation, yoga, relaxation techniques and cognitive behavioural therapy can all be helpful. Herbs, infusions and homeopathic or other natural insomnia remedies also help some women.
You are not alone!
The more you get to know yourself and what is stopping you from sleeping, the more control you will gain over your problem. This takes time, inner searching and patience, but you will get there in the end.
And while you're lying there awake, don't forget - you are definitely not alone: millions of other people are lying in their beds awake and counting sheep too!
1. Joffe H Petrillo LF, Koukopoulos A et al, Increased estradiol and improved sleep, but not hot flashes, predict enhanced mood during the menopausal transition. J Clin Endocrinol Metab 2011; 96:E1044-54.
2. Shaver J. Positive effects of hormone therapy on sleep: compelling evidence or not? Menopause 2011;18:1157-9
What causes insomnia? Published January 2012. Last Update June 2013