Simple screening questions about sleep prob- lems and daytime fatigue should be routine for all menopausal patients. Sleep hygiene should also be ...
MenopausaL HEalth
Menopause and Sleep Disorders Sara Nowakowski, MS; Charles J. Meliska, PhD; Barbara L. Parry, MD Menopause is often characterized by both sleep and mood disorders, leading to a complex scenario that can complicate treatment.
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tudies suggest that 40% to 64% of perimenopausal and postmenopausal women have sleep disturbances.1 These may also be exacerbated by nonmenopause−related sleep conditions (eg, obstructive sleep apnea [OSA], periodic limb movements [PLMs]) and mood disorders (eg, anxiety, major depression).
MECHANISMS Hormonal Factors Estrogen decreases sleep latency (ie, awakenings) while increasing total sleep time. Furthermore, low menopausal estrogen levels are associated with increases in peripheral and central temperature, resulting in vasomotor instability and night sweats. Progesterone acts to decrease anxiety and stimulate respiration, such that falling levels may contribute to OSA. Previously, menopausal sleep disruption was attributed to vasomotor instability, but studies now indicate that some sleep problems are independent of estrogen levels.2 Nonetheless, polysomnography (PSG) shows that nocturnal hot flashes increase awakenings and decrease sleep efficiency. Hot flashes tend to disrupt sleep early in the night because of the thermoregulatory effects of rapid eye movement (REM) sleep. Sara Nowakowski MS, is a student, San Diego Joint Doctoral Program in Clinical Psychology, and Charles J. Meliska, PhD, is Chair; both in the Department of Psychiatry, University of California, San Diego, La Jolla, CA. Barbara L. Parry, MD, is Professor, Department of Psychiatry, University of California, San Diego, La Jolla, CA; and Director, Women and Depression Clinic, San Diego Veterans Administration Healthcare System, La Jolla, CA.
Half of midsleep awakenings are associated with hot flashes, and these last twice as long as those without hot flashes.
Other Sleep Disorders
FOCUSPOINT Previously, menopausal sleep disruption was attributed to vasomotor instability, but studies now indicate that some sleep problems are independent of estrogen levels.
The incidence of other sleep disorders that cause awakening—eg, OSA, PLMs—likewise increases after menopause. 2 Risk factors for OSA include excess weight and aging. Physical signs comprise loud snoring, daytime sleepiness, shortness of breath, witnessed apneic episodes, dry mouth, and morning headache. Patients with PLMs or restless legs syndrome (RLS) report strange sensations in their legs leading to disrupted sleep and daytime sleepiness.
Mood Changes Vulnerability to major depressionwhich is also associated with sleep disruption increases during the menopausal transition.3 Depressed menopausal women also report more frequent and longer awakenings than controls.4 Hormonal alterations may further exacerbate depression. Higher/variable levels of follicle-stimulating and luteinizing hormones are associated with depression as well.3
ASSESSMENT Simple screening questions about sleep problems and daytime fatigue should be routine for all menopausal patients. Sleep hygiene should also be queriedeg, bedroom atmosphere, sleep habits. Specific symptoms should be elicited, such as difficulty falling and/or staying asleep; snoring; burning, itching, or tingling sensations in the legs; or daytime sleepiness. Medical, psychiatric, and social histories should be reviewed, as well as other menopausal complaints. Patients with The Female Patient | Vol 33 September 2008
MEnopausalHealth Menopause and Sleep Disorders
suspected OSA, RLS, or PLMs are best referred to a sleep specialist.
TREATMENT Nonpharmacologic Measures With regard to good sleep hygiene, patients should be advised to avoid: • Daytime napping • Consuming caffeine after lunch • Exercising or consuming alcohol within 6 hours of bedtime • Going to bed too hungry or overfed • Using nicotine products at night • Taking sleeping pills • Going to bed before feeling sleepy • Doing other activities in bed (eg, watching television, reading). Patients should use the bedroom only for sleep and sexual FOCUSPOINT intercourse, keep a consistent Many patients try sleep/wake schedule, and exeralcohol or OTC medicise regularly. Stimulus control is recommendedie, if the pacations; these have not tient is not asleep within 20 minbeen shown to be effecutes, she should arise and do tive for insomnia. Some something relaxing in another preliminary data on black room until she feels sleepy. Thus, she will come to view the cohosh are encouragbedroom as a place to sleep, not a ing, but do not support source of frustration. Cognitive behavioral therapy a recommendafor insomnia (CBT-I), relaxtion to date. ation techniques (eg, breathing exercises, biofeedback), and/or sleep restriction therapy are other options for treating primary insomnia. Sleep restriction therapy involves allowing patients only a few hours of sleep at night and gradually increasing the time by 15-minute increments until sleep patterns normalize.
Nonprescription Agents Although many patients try alcohol or various OTC medications (eg, melatonin, valerian, antihistamines), these have not been shown to be effective for treating insomnia. Some preliminary data on black cohosh are encouraging, but do not support a recommendation to date.
Antidepressants Antidepressants should not be used to treat sleep disruption in the absence of depression. For depressed women with sleep disturbance, options include sedating selective serotonin The Female Patient | Vol 33 September 2008
reuptake inhibitors (SSRIs) (eg, paroxetine, citalopram) and tricyclic antidepressants (eg, nortriptyline). Certain antidepressants and mood stabilizers may ameliorate mood and vasomotor symptoms that aggravate insomnia (eg, venlafaxine, gabapentin). Most antidepressants suppress REM sleep, a possible mechanism for treatment effects.
Hypnotics A short-acting nonbenzodiazepine hypnotic may be warranted for short-term use for acute midsleep insomnia. Tolerance, withdrawal, dependence, exacerbation of depression, and increased mortality may occur if hypnotics are used for longer than 2 weeks.5 Furthermore, rebound insomnia may occur after discontinuation. Zaleplon and zolpidem are effective for sleep maintenance, but less so for initiating sleep; although they have less abuse potential than traditional benzodiazepines, they still have addictive properties.
Hormone Therapy Data on hormone therapy (HT) for sleep disturbances are conflicting. Discuss the benefits and risks with your patients, and prescribe the lowest effective dosage for shortest duration necessary.
CONCLUSION Insomnia, anxiety, and depression are closely interrelated. They predominate in women overall, and are even more prevalent in menopausal women. As it can be difficult to determine whether anxiety or depression may be causing insomnia or vice versa, nonpharmacologic measures should be applied first, proceeding to pharmacologic agents only as needed. The authors report no actual or potential conflicts of interest in relation to this article.
REFERENCES
1. Polo-Kantola P, Saaresranta T, Polo O. Aetiology and treatment of sleep disturbances during perimenopause and postmenopause. CNS Drugs. 2001;15(6):445-452. 2. Freedman RR, Roehrs TA. Sleep disturbance in menopause. Menopause. 2007;14(5):826-829. 3. Freeman EW, Sammel MD, Lin H, Nelson DB. Associations of hormones and menopausal status with depressed mood in women with no history of depression. Arch Gen Psychiatry. 2006;63(4):375-382. 4. Parry BL, Meliska CJ, Martinez LF, et al. Menopause: neuroendocrine changes and hormone replacement therapy. J Am Med Womens Assoc. 2004;59(2):135-145. 5. K ripke DF, Klauber MR, Wingard DL, Fell RL, Assmus JD, Garfinkel L. Mortality hazard associated with prescription hypnotics. Biol Psychiatry. 1998;43(9):687-693.
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