Improving sleep and overcoming insomnia during perimenopause, menopause and midlife

Sleep issues can be absolutely debilitating during midlife and menopause. Many of our FB group members complain about disrupted sleep and insomnia and the knock-on effect on their ability to work, to function at home and on their relationships can be pretty devastating.

But why do we find sleep so hard as we age? Katie speaks to world-renowned sleep expert, neurologist and author Professor Guy Leschziner about what causes these issues and his expert advice on how to get a better night’s sleep during perimenopause, menopause and beyond.

Listen to the full conversation in The Latte Lounge podcast episode above.

Why is sleep affected in midlife?

Insomnia is incredibly common, about 30% of adults will experience it in a year and around 10% will suffer chronic insomnia in their lifetime. If you are awake in the middle of the night, trying to get back off to sleep then you are absolutely not alone. You’re actually a member of a very large club.

In terms of what physically influences your sleep, there are 2 mechanisms. 1 is your own internal body clock driven by a small area in the centre of your brain. The second mechanism is a homeostatic mechanism which means that the longer you have been awake, the more you want to sleep. In simple terms, that is driven by chemicals that build up while you're awake and then reduce as you sleep.

We know that the sleep cycle is affected by hormones. Women of menstrual age report a difference in sleep quality at different times in their cycle and in the same way, there is also an impact from the fluctuation in hormones during perimenopause and menopause. Other symptoms of menopause also have an impact such as hot flushes, which are common and incredibly disruptive, changes in fat distribution causing sleep apnea and psychological factors such as concerns about our elderly parents' health or for our children.

RELATED ARTICLE: What kind of tired are you?

Some basic habits for good sleep hygiene

Sleep hygiene is simply getting into habits which promote good quality sleep. These habits won’t help chronic insomnia but people with intermittent poor-quality sleep can make small changes to help improve sleep quality. 

Caffeine can hang around in your bloodstream for a long time so being aware of whether you're sensitive to it and therefore shouldn't have it after lunchtime is advisable. Using gadgets which are rich in blue light can affect our body clock, shifting it back and making it harder to drift off to sleep at an appropriate time. Avoid this by putting your phone or tablet down at 9pm and leaving it in another room when you go to bed.

This will help with more than reducing exposure to blue light. Some of the things we do on tablets and phones such as surfing social media really aren’t conducive to a good night’s sleep. Getting into a Twitter spat late at night and raising your blood pressure won’t help!

Regularity has a beneficial impact on sleep so try to go to bed and get up at a regular time. Going to bed before you are tired, however, is counterproductive as your brain will increasingly associate your bed with being awake. Go to bed when you’re tired and get up as soon as you wake up to reconfigure and strengthen the brain’s association between bed and sleep. This aspect of sleep hygiene is a fundamental part of CBT (Cognitive Behavioural Therapy) for insomnia.

women we need our sleep

What else can we do? 

Exercise is good for promoting deep sleep, especially aerobic exercise. Taking regular aerobic exercise is important, but the timing is less so, although we would generally recommend not vigorously exercising in the last couple of hours before sleep.

Lots of dietary supplements claim to boost your melatonin levels but the evidence is limited. The key dietary advice is to avoid large meals in the last couple of hours before bedtime, as going to bed with a full stomach can contribute to abdominal symptoms and can cause reflux at night if that is something you’re prone to. A large, carbohydrate-rich meal can also cause disturbances to your blood sugar overnight which may lead to fragmented sleep.

We know that both psychological and biological changes occur during chronic insomnia. Some of the psychological factors are very conscious, such as anxiety or frustration at the prospect of being unable to sleep, fear of being able to function the following day or even of laying there unable to fall asleep and fear of what the insomnia is doing to long term health (these fears are often unfounded). 

There are also unconscious psychological factors. The brain is a creature of habit as we’ve established. For most of us, bed is a place of comfort where we drift off to a good night’s sleep and wake up feeling refreshed but for those with chronic insomnia, it’s an environment which we associate with struggling to get off to sleep. 

Physical or biological changes occur after a period of poor sleep such as an increase in adrenaline which leaves you feeling wired and jittery even when you’re exhausted, and in stress hormone cortisol which induces insomnia, causing a vicious cycle. 

The previously mentioned CBT for insomnia is considered to be the gold standard in treatment because it works in the vast majority of cases. It helps to rid you of the anxiety related to insomnia and uses the brain's own mechanisms which drive sleep to rebuild those positive associations. 

"The evidence base for non-drug-based therapies even for other conditions such as anxiety, depression and serious mental health issues has been the most important development in recent years."

Can HRT help with sleep? 

HRT is very helpful in resolving sleep issues. It gets rid of the hot flushes which affect your sleep by restoring the hormonal status quo, in turn dealing with the impact of declining hormone levels on sleep quality. It’s a very evidence-based solution for poor quality sleep in perimenopause and menopause and has become a first-line pharmaceutical treatment for sleep issues as well as other menopause symptoms. 

In previous years, sleeping pills would have been prescribed but they are sedatives rather than sleep promoters and so don’t actually promote normal sleep. They can also contribute to feelings of anxiety and become addictive with potential long-term harm. For those who are unable or choose not to take HRT, CBT and other non-pharmaceutical approaches are therefore more commonly recommended. There are drugs which can be prescribed where appropriate but they should never be the first line of treatment. 

The evidence base for non-drug-based therapies even for other conditions such as anxiety, depression and serious mental health issues has been the most important development in recent years. It is still challenging to get in-person CBTI within the NHS but there are digital platforms which are more readily available. 

HRT

What is Restless Leg Syndrome?

It is a neurological disorder suffered by around 5% of the population and is an urge to move their legs (or other parts of the body) which is often accompanied by a tingling or aching. This typically occurs at night or in the evening and is worsened by immobility.

Moving around usually brings relief so this isn’t conducive for sleep. RLS originates in the brain and has a genetic component. One of the most common predispositions is anaemia. 

The evidence as to why RLS is associated with menopause rather than age isn’t clear but it does tend to be worse when we are tired so if women are already struggling to sleep then this may contribute. 

RELATED ARTICLE: Mental Health and menopause

Can magnesium help with restless leg syndrome?

There is some anecdotal evidence that magnesium supplements taken orally or a bath with Epsom salts can be helpful in easing RLS and given that this is a low-risk thing to try, it’s worth doing so. 

The first thing you should do, however, is to see your GP and have some blood tests to make sure that you’re neither iron deficient nor low in Vitamin D. We know that people with RLS need higher levels of iron in their bloodstream so sometimes a supplement or iron infusion will be beneficial. Only a small number of people with RLS will actually need a specific prescribed medication.

And finally

The key message is that there is an evidence-based, effective (in both short and long-term) approach to treating insomnia that doesn’t resort to drugs.

Please do approach your GP if you are struggling and if you have other perimenopause symptoms, chat with them about the possibility of HRT – if this is something that you would like to consider..

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Professor Guy Leschziner's blog posts

How does menopause affect the brain?

Many women in our Facebook group and wider community, complain during midlife and menopause about troubling symptoms such as brain fog, headaches, migraines and a lack of concentration and are often very concerned that this could be the start of something like early onset dementia.

Menopause and fluctuating hormones can have a huge impact on brain health and Katie speaks here to Professor Guy Leschziner, Consultant Neurologist and a Professor of Neurology and Sleep Medicine at King’s College, London to help us understand how to protect our brain health and actually, potentially reduce the risk of developing Alzheimer’s and dementia in midlife, menopause and beyond.

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