It’s 4 am, and Lucy is wide awake, again! Ever since her 45th birthday, she’s noticed a marked decline in the quality and quantity of sleep she gets each night. The sleep deprivation has taken a toll on her physical and mental health, leading her to seek your guidance. What’s going on and how can you help her?
What’s going on?
Women in midlife experience a significant decrease in the quality and quantity of sleep. Studies have shown a high prevalence of insomnia and poor sleep quality in mid-age women, waking up during the night the most frequent complaint. Sleep quality worsens with age and advancement through the menopause transition (Blümel et al., 2012). Sleep efficiency and latency take the biggest hit in midlife, often leading to the increased use of sleep-inducing drugs (hypnotics). Insomnia can occur either as a primary disorder or as a secondary disorder to hot flashes, mood disorders, medical conditions, psychosocial factors, underlying intrinsic sleep disorders, such as obstructive sleep apnea (OSA), or restless legs syndrome (RLS).
In midlife, some of the well-recognized factors implicated in the pathophysiology of insomnia include psychosocial stressors, anxiety, and vasomotor symptoms (e.g., hot flashes, hot flushes, and night sweats). Less well-known causes of sleep disturbances in midlife are digestive issues, chronic pain, breathing problems, and restless leg syndrome.
Digestive Issues
Menopausal women are three times as likely to suffer from Gastroesophageal Reflux Disease (GERD) and other gastrointestinal distress such as heartburn, gas, and bloating (Infantino, 2008). Research has demonstrated a positive correlation between GERD symptoms and postmenopausal replacement therapy (HRT) (Nilsson et al., 2003). Women who have never taken HRT have a lower risk of reflux symptoms than women who have taken or continue to take estrogen replacement therapy (Jacobson et al., 2008), suggesting a hormonal component to the pathophysiology of GERD in women.
Poor digestion can disrupt sleep by causing heartburn, indigestion, gas, and bloating. People with gastrointestinal complaints report more chronic insomnia than individuals with healthy sleep patterns (55.4% versus 20%) (Taylor et al., 2007). Researchers have demonstrated that estrogen and its receptors serve an essential role in the gastrointestinal (GI) tract by keeping the stress hormone cortisol in balance. A decreased estrogen level in menopause can contribute to the circulation of excess cortisol. Cortisol has the effect of slowing down the digestion of food, diverting the body’s energy to preparing to flight or fight.
Chronic Pain
Women experience an increased prevalence, incidence, and severity of hand and knee osteoarthritis (OA) after menopause. In addition, the risk of hip and knee OA in women increases rapidly between the age of 50 and 75 years (Mahajan & Patni, 2018). The pain from this inflammatory disease can disrupt sleep, and lack of sleep can amplify the pain. According to the Arthritis Foundation, approximately 70% of people with OA have sleep disturbances such as difficulty falling asleep, staying asleep, or early awakening (Arthritis Foundation, n.d.)
Breathing Problems (Obstructive Sleep Apnea)
Obstructive sleep apnea (OSA) is a disorder in which a person frequently stops breathing during their sleep due to an upper airway obstruction that occurs because of the inadequate motor tone of the tongue and airway dilator muscles (Park et al., 2011).
Multiple studies have demonstrated that postmenopausal women are more likely to screen positive for obstructive sleep apnea (14.6%) when compared to women who have not undergone the menopause transition (10.4%) (Zolfaghari et al., 2020). The severity of sleep-disordered breathing increases through the menopause transition independent of aging and changes in body weight and composition (Mirer et al., 2017).
Symptoms of OSA include loud snoring, pauses in breathing, and episodes of gasping or choking out of sleep. OSA also shares symptoms in common with those associated with menopause: frequent nighttime awakenings, night sweats, daytime sleepiness, depressed mood, and cognitive complaints such as poor concentration or problems with short-term memory.
The events associated with OSA activate pathways that predispose patients to hypertension (high blood pressure) and atherosclerosis (Sánchez-de-la-Torre et al., 2013). Postmenopause, women have an increased risk of developing cardiovascular disease (CVD) (Crawford & Johannes, 1999). Cohort studies have demonstrated that hypertension is a risk factor for CVD morbidity and mortality.
Restless Legs Syndrome (Willis-Ekbom Disease – WED)
Restless legs syndrome (RLS) is a relatively common neurologic disorder considerably more prevalent in women than in men. In RLS, there is an uncomfortable sensation (i.e., creeping, tugging, or pulling) in the legs and an irresistible urge to move them to make the disagreeable sensation disappear. In addition, because symptoms most often occur in the evening, they can severely impair falling asleep, staying asleep, and overall quality of life (Ekbom & Ulfberg, 2009; Phillips et al., 2000).
Menopause increases the prevalence and severity of RLS symptoms, especially in women with vasomotor symptoms (i.e., night sweats and hot flashes) (Wesström et al., 2008). Yet, paradoxically, a literature review shows that pregnant women are at particular risk as well. Therefore, researchers hypothesize that changes rather than absolute estrogen levels may be responsible for initiating RLS symptoms.
Women in midlife with RLS have a higher prevalence of hypertension, which increases with more frequent restless legs symptoms (Batool-Anwar et al., 2011). In addition, as mentioned above (see Breathing Problems), hypertension is a risk factor for CVD, a chronic disease that women face an increased risk of developing postmenopause (Crawford & Johannes, 1999).
Putting it into Your Practice
So, how can you help your patients get a good night’s sleep? Uncover the root cause behind their sleeplessness by following these recommendations.
- Screen for GERD and other GI complaints – GERD significantly impacts the quality of life and often goes undiagnosed or misdiagnosed in women currently in the menopause transition. Ask your female patients about any gastrointestinal symptoms and discomforts, especially women ages 45-60.
- Investigate breathing issues – Does your patient experience any of the symptoms of OAS? If so, refer them to a sleep specialist in a sleep center for further evaluation.
- Resolve comorbidities to RLS – The fact that RLS symptoms start within days of initiating treatment of comorbidities such as migraine, depression, and anxiety implicates the drugs used as potential culprits (Seeman, 2020). Using non-pharmaceutical approaches to resolve these disorders could help alleviate RLS, and therefore, improve sleep.
Download our Sleep Protocol to learn more about the causes of and potential solutions to women’s sleep issues in midlife.
References
Arthritis Foundation. (n.d.). Osteoarthritis and Sleep. Retrieved May 9, 2021, from https://www.arthritis.org/health-wellness/healthy-living/managing-pain/fatigue-sleep/osteoarthritis-and-sleep
Batool-Anwar, S., Malhotra, A., Forman, J., Winkelman, J., Li, Y., & Gao, X. (2011). Restless Legs Syndrome and Hypertension in Middle-Aged Women. Hypertension, 58(5), 791–796. https://doi.org/10.1161/HYPERTENSIONAHA.111.174037
Blümel, J. E., Cano, A., Mezones-Holguín, E., Barón, G., Bencosme, A., Benítez, Z., Bravo, L. M., Calle, A., Flores, D., Espinoza, M. T., Gómez, G., Hernández-Bueno, J. A., Laribezcoa, F., Martino, M., Lima, S., Monterrosa, A., Mostajo, D., Ojeda, E., Onatra, W., … Chedraui, P. (2012). A multinational study of sleep disorders during female mid-life. Maturitas, 72(4), 359–366. https://doi.org/10.1016/j.maturitas.2012.05.011
Ekbom, K., & Ulfberg, J. (2009). Restless legs syndrome. Journal of Internal Medicine, 266(5), 419–431. https://doi.org/10.1111/j.1365-2796.2009.02159.x
Infantino, M. (2008). The prevalence and pattern of gastroesophageal reflux symptoms in perimenopausal and menopausal women. Journal of the American Academy of Nurse Practitioners, 20(5), 266–272. https://doi.org/10.1111/j.1745-7599.2008.00316.x
Jacobson, B. C., Moy, B., Colditz, G. A., & Fuchs, C. S. (2008). Postmenopausal hormone use and symptoms of gastroesophageal reflux. Archives of Internal Medicine, 168(16), 1798–1804. https://doi.org/10.1001/archinte.168.16.1798
Mahajan, A., & Patni, R. (2018). Menopause and Osteoarthritis: Any Association ? Journal of Mid-Life Health, 9(4), 171. https://doi.org/10.4103/jmh.JMH_157_18
Mirer, A. G., Young, T., Palta, M., Benca, R. M., Rasmuson, A., & Peppard, P. E. (2017). Sleep-disordered breathing and the menopausal transition among participants in the Sleep in Midlife Women Study. Menopause (New York, N.Y.), 24(2), 157–162. https://doi.org/10.1097/GME.0000000000000744
Nilsson, M., Johnsen, R., Ye, W., Hveem, K., & Lagergren, J. (2003). Obesity and estrogen as risk factors for gastroesophageal reflux symptoms. JAMA, 290(1), 66–72. https://doi.org/10.1001/jama.290.1.66
Park, J. G., Ramar, K., & Olson, E. J. (2011). Updates on Definition, Consequences, and Management of Obstructive Sleep Apnea. Mayo Clinic Proceedings, 86(6), 549–555. https://doi.org/10.4065/mcp.2010.0810
Phillips, B., Young, T., Finn, L., Asher, K., Hening, W. A., & Purvis, C. (2000). Epidemiology of restless legs symptoms in adults. Archives of Internal Medicine, 160(14), 2137–2141. https://doi.org/10.1001/archinte.160.14.2137
Sánchez-de-la-Torre, M., Campos-Rodriguez, F., & Barbé, F. (2013). Obstructive sleep apnoea and cardiovascular disease. The Lancet. Respiratory Medicine, 1(1), 61–72. https://doi.org/10.1016/S2213-2600(12)70051-6
Taylor, D. J., Mallory, L. J., Lichstein, K. L., Durrence, H. H., Riedel, B. W., & Bush, A. J. (2007). Comorbidity of chronic insomnia with medical problems. Sleep, 30(2), 213–218. https://doi.org/10.1093/sleep/30.2.213
Wesström, D. J., Nilsson, S., Sundström-Poromaa, I., & Ulfberg, J. (2008). Restless legs syndrome among women: Prevalence, co-morbidity and possible relationship to menopause. Climacteric, 11(5), 422–428. https://doi.org/10.1080/13697130802359683
Zolfaghari, S., Yao, C., Thompson, C., Gosselin, N., Desautels, A., Dang-Vu, T. T., Postuma, R. B., & Carrier, J. (2020). Effects of menopause on sleep quality and sleep disorders: Canadian Longitudinal Study on Aging. Menopause, 27(3), 295–304. https://doi.org/10.1097/GME.0000000000001462