Menopause can take a hammer to your patients’ sleep quality

Trouble sleeping is one of the biggest concerns women have during menopause.But solving issue isn't straightforward due to several potential underlying causes, according to a review on the topic. Underlying problems can range from discomfort from middle-of-the-night from hot flashes (HFs), to changes in reproductive hormones, to exacerbations of pre-existing sleep problems, authors wrote in Current Opinion in Obstetrics Gynecology. “Effective management requires a thorough assessment and selection of treatments that target maintaining factors and consider patient preferences,” the paper said. Menopause can bring emergent or worsening sleep problems. Upwards of 40% and 60% of peri- and postmenopausal women (PPMW) report sleep problems, which “are distressing and substantially impact quality of life, work productivity, healthcare utilization, and physical and mental health,” the paper said.Women often report experiencing poorer sleep quality, that they don’t feel refreshed after sleeping, have increased sleep fragmentation or have awakenings—and are more likely overall to report insomnia, as distinct from challenges to sleep quality. The authors stated that when it comes to insomnia, suggesting improved sleep hygiene is often fails to help. “Sleep hygiene is not a treatment for insomnia, and insomnia in midlife women is not associated with poor sleep hygiene.” Women with the highest risk for persistent or worsening sleep disturbance during menopause are those who have a history of preexisting moderate-to-severe sleep problems before menopause starts. But others can have emergent sleep problems.Women who face early menopause as a result of hysterectomy also face an increased the risk of sleep problems and changes to sleep architecture. Other medical conditions, medications, weight gain, pain and chronic health conditions can also play a role in sleep disturbances during this time. Plus, psychosocial changes can impact sleep quality including factors such as women’s changing roles (such as becoming empty-nesters, or nearing retirement), depression, anxiety or other stressors can have an add-on impact on sleep quality during menopause.“Many women experience greater difficulty initiating or maintaining sleep during the menopausal transition. These symptoms are persistent and affect daytime functioning in about 26% of women,” the paper said.Some women have insomnia disorder, which is defined as when symptoms occur at least three times per week, for at least three months and interfere with daily activities. But not all sleep disturbances indicate insomnia. For example, awakenings due to hot flashes where there is no trouble falling back to sleep is not considered insomnia.To identify clinically significant insomnia, the authors recommend use of the Insomnia Severity Index (ISI).Other factors that can contribute to sleeplessness during menopause include:Obstructive Sleep Apnea (OSA). “In addition to aging, increased rates of OSA are due to changes in reproductive hormones during menopause and increased adipose tissue. Whereas men display more snoring and witnessed apneas, women with OSA often present with more nonspecific symptoms including insomnia, nonrestorative sleep, daytime sleepiness, and depressed mood.” The authors suggest using the STOP-BANG questionnaire to help screen for OSA.Restless legs syndrome (RLS) and periodic limb movement disorder (PLMD). RLS is associated with a strong urge to move the legs. PLMD involves repetitive leg and/or arm movements or cramping while sleeping. Women are 37% more likely than men to have RLS. Some studies suggest a relationship between FSH and RLS.Treatment optionsThe authors noted that OSA, RLS, and PLMD are best managed by a specialist in sleep medicine.When it comes to hormone therapy, the evidence is mixed in terms of its effects on sleep or sleep quality. But some evidence suggests those with hot flash related sleep disturbances may benefit. Some studies suggest neurokinin B antagonists may also help with hot flash symptoms. Cognitive-behavioral therapy (CBT)CBT as a first line, short-term treatment for insomnia. “With moderate to large effects on subjective and objective insomnia symptoms, and more durable effects than pharmacological interventions, CBT-I is recommended as the firstline treatment for chronic insomnia,” the paper said.CBT treatments can also be used to help with menopausal symptoms and have been associated with sleep improvements related to hot flashes. Lifestyle approaches might help too with some modest evidence suggesting exercise, mindfulness, hypnosis and relaxation can improve sleep quality in women during menopause.

Menopause can take a hammer to your patients’ sleep quality

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