Perimenopause Insomnia

Introduction

Perimenopause is the time in which the body goes through changes before menopause. During this period, many people experience symptoms like hot flashes, irregular periods, mood swings, and trouble sleeping, which can negatively impact quality of life.^1,2,3

In this article, we will explain what changes occur during perimenopause, how they are associated with insomnia, how it is diagnosed, and what treatment options are available. 

Understanding perimenopause

Definition and duration of perimenopause

Perimenopause begins with the onset of menstrual irregularities and ends after one year of absence of menstruation (amenorrhea), defining the final menstrual period. Two stages of perimenopause have been described:^1,2

• The early transition, defined by almost regular cycles and only occasionally skipped cycles, with at least one period in the last three months
• The late menopausal transition is characterised by greater menstrual irregularity, with periods of amenorrhea lasting over 60 days until reaching the final menstrual period

These changes have been related to specific hormonal events and consequent different clinical signs.

Hormonal changes during perimenopause

As women go through menopause, their bodies undergo significant changes that affect their menstrual cycles and hormone levels. These changes happen in stages.⁴

During the late reproductive stage, the number of egg-containing follicles in the ovaries starts to decrease. This decline begins even before noticeable changes in menstrual cycles. Hormonal changes occur to compensate for the decreasing follicles, but these changes vary from month to month. Hormones like anti-Müllerian hormone play roles in regulating these changes.⁴

During the early menopausal transition, follicles continue to grow despite the decreasing follicle count. Additionally, follicle-stimulating hormone (FSH) rises earlier and to higher levels during the follicular phase of the menstrual cycle. Follicles develop at a faster rate and appear larger at the beginning of the cycle, but their growth slows down as they reach the later stages.

Because of this, and the earlier rise in FSH, the smaller follicles release an egg earlier in the cycle, making the first part of the cycle shorter. Even though there are fewer granulosa cells (cells that produce oestrogen, progesterone and other hormones), the ovaries make up for it by producing more of a substance called aromatase. This helps keep the levels of oestrogen, the same or higher than what's seen in women who are in the middle of their reproductive years.⁴

In the late menopausal transition, menstrual cycles become more unpredictable, with longer gaps between periods. Hormone levels become more consistently altered, with higher levels of FSH and lower oestrogen levels. Some cycles may not show signs of ovulation at all. Women in this stage may experience varying patterns of menstrual irregularity, but fertility may still be possible until menopause.⁴

Overall, the transition through menopause involves complex hormonal changes that can affect menstrual cycles and fertility. These changes occur gradually over several years and can vary widely from woman to woman.⁴

Common symptoms of perimenopause

Perimenopause-related symptoms include a variety of gynaecological conditions and many women complain about:^1,4

• Hot flushes
• Menstrual irregularities
• Irritability and mood changes 
• Skin changes 
• Musculoskeletal disorders 
• Balance disorders 
• Vaginal dryness
• Decreased sexual desire
• Bladder symptoms
• Poor sleep

Although perimenopause symptoms affect most women, it has been estimated that life quality is significantly impaired in only 20% of them.¹

Insomnia during perimenopause

As you age, your sleep tends to worsen naturally. However, during menopause, this decline in sleep quality often becomes more noticeable. A study of over 12,000 women found that around 40% reported having trouble sleeping, and this was linked to the timing of menopause rather than just age.⁴ 

Chronic insomnia, which means having trouble sleeping for more than three weeks, is often seen in women after menopause, especially if they also have anxiety, depression, or mood disorders. If not treated properly, chronic insomnia can lead to more problems with sleep.³

Short-term insomnia, which lasts between three days and three weeks, is more common overall but can be especially common during menopause. It often needs treatment for more than three weeks.³

Some women might have brief episodes of insomnia lasting one to three days. This can happen at any age, including during menopause. Sometimes, treatment isn't needed for this type of insomnia.³

Causes of insomnia during perimenopause

The changes during perimenopause can make it more likely for someone to develop insomnia for a few reasons:^2,3,4,5

• Hormonal changes can affect how the brain controls sleep and body temperature, which can interfere with sleep patterns. Progesterone aids in falling asleep and reducing anxiety, while oestrogen influences sleep quality by affecting brain neurotransmitters. Furthermore, melatonin, a hormone that helps regulate sleep, decreases as we get older, especially during menopause. This can lead to longer times to fall asleep and more waking up during the night and early morning for women after menopause
• Hot flashes and other symptoms can disturb sleep
• Psychological issues like anxiety, depression and age-related stress can make it hard to sleep
• Sleep-related breathing and movement disorders, as well as chronic pain, may play a role
• Low physical activity can also contribute to sleep problems

Diagnosis of perimenopause insomnia

Doctors often diagnose sleep disorders based on what you tell them about your sleep. They will take a detailed history from the patient, their partner, or family members, and may use a sleep questionnaire. They'll ask you about:³

• When sleep problems started 
• Any patterns of symptoms 
• Factors that might contribute like health issues, stress, or lifestyle habits
• Impact of insomnia on your life
• Other things like snoring, restless legs, or daytime sleepiness 
• Family history of sleep problems

Doctors might ask for tests like a polysomnogram (PSG) to monitor sleep patterns overnight. PSG records things like brain activity, eye movement, muscle activity, breathing, and heart rate while a person sleeps. Depending on the diagnosis, other tests like actigraphy might be done.³

Other tools may be used, like the Hamilton Depression Rating Scale and Hamilton Anxiety Rating Scale to check for depression and anxiety associated with insomnia.³

Management and treatment options

Medications

Various medications, including benzodiazepines and newer agents like zolpidem and zopiclone, are commonly used to manage sleep disorders. Benzodiazepines that wear off quickly are preferred for people who have trouble falling asleep, while those that stay in the body longer may be suitable for patients with daytime anxiety. However, caution is needed due to the risk of tolerance and abuse, especially in people with chronic insomnia.³

Additionally, hormone therapy has been explored as a potential treatment for menopausal sleep disturbances. While some studies suggest benefits, others show mixed results or even potential risks, such as increased cancer risk. As a result, hormone therapy is not recommended as the first option in the treatment of sleep disorders in menopausal women.³

Non pharmacological treatment

Non-drug treatments like cognitive therapy and self-hypnosis can also be effective for managing sleep issues in menopausal women. These techniques aim to change beliefs and behaviours associated with sleep problems, offering relief to a significant portion of affected individuals.³

Overall, a comprehensive approach considering both pharmacological and non-pharmacological interventions is essential for effectively managing sleep problems during menopause, tailoring treatment to individual needs and preferences while considering potential risks and benefits.³

Lifestyle changes

In addition to medication, it's important to follow good habits to improve sleep for women going through menopause. Here are some tips:³

• Only go to bed when you're really tired. If you don’t fall asleep after 20 minutes, get up and do something boring until you feel sleepy
• Don't sleep during the day
• Avoid taking naps during the day
• Avoid caffeine, nicotine, and alcohol at least 4 to 6 hours before bedtime
• Eat a light meal before bed
• Don't drink too much water before bedtime
• Drinking warm milk before bed may help because it contains a substance called d-tryptophan, which can make it easier to fall asleep
• Control your sleep environment by making sure your bedroom is quiet and comfortable
• Wear comfortable clothes to bed
• Lie in a comfortable position like the "dead man" position for better sleep
• Turn off your mobile phone
• Try not to dwell on the events of the day or worry about tomorrow
• Stick to a regular bedtime schedule
• Regular exercise can help improve sleep
• Learning relaxation and meditation techniques can also be helpful

Summary 

Perimenopause, the phase leading up to menopause, begins with the onset of menstrual irregularities and ends after one year of amenorrhea, defining the final menstrual period.^1,2

Hormonal changes during perimenopause involve decreases in ovarian follicles and fluctuations in hormone levels, affecting menstrual cycles and fertility, leading to symptoms like hot flashes, mood changes, vaginal dryness, and poor sleep. These symptoms can significantly impact a woman's quality of life.^1,4

Insomnia is common during perimenopause and can be attributed to hormonal fluctuations, hot flashes, psychological issues like anxiety and depression, and lifestyle factors.^2,3,4,5 Diagnosis of perimenopausal insomnia typically involves a detailed history, sleep questionnaires, and sometimes overnight monitoring of sleep patterns.³ 

Treatment options include medications like benzodiazepines and non-pharmacological approaches such as cognitive therapy and lifestyle changes. Hormone therapy, while sometimes used, has potential risks and is not recommended as the first-line treatment for sleep disorders in menopausal women.

Lifestyle changes like maintaining a regular sleep schedule, avoiding stimulants before bedtime, creating a comfortable sleep environment, and practising relaxation techniques can also help manage perimenopausal insomnia. Overall, a comprehensive approach considering both pharmacological and non-pharmacological interventions is crucial for effectively managing sleep problems during perimenopause.³