INSOMNIA

Overall, 40% to 48% of peri- and postmenopausal women report having difficulty sleeping. A study by Tom and colleagues found that women in the menopausal transition were two-to-three-and-a-half times more likely than premenopausal women to report severe sleep difficulty. There’s a significant drop in sleep time in women after the age of 50, and sleep quality and efficiency decrease as well.

Insomnia, defined as difficulty falling asleep or staying asleep that results in daytime impairment or distress, significantly affects women’s lives. It can cause daytime sleepiness, decreased concentration, mood disorders, decreased productivity, decreased quality of life, and job-related and motor vehicle accidents. A study of 5,781 postmenopausal women found that women experiencing night awakenings (n = 141) at least twice weekly had greater activity impairment (including presenteeism) and poorer health-related quality of life than women who didn’t have insomnia and the general population.

Causes of insomnia. Women reporting sleep disturbances should be assessed for the presence of a primary sleep disorder, particularly sleep-disordered breathing (SDB) and periodic limb movement.A 2001 sleep study by Bixler and colleagues included a one-night sleep laboratory evaluation of 1,000 men and women. The prevalence of sleep apnea was 2.7% in postmenopausal women not taking hormone therapy and 0.5% in premenopausal women. A later examination of menopausal status and SDB in 589 women enrolled in the Wisconsin Sleep Cohort Study found that menopause was significantly associated with an increased risk of SDB (defined as repeated episodes of apnea–hypopnea during sleep) even after adjusting for age, smoking, and weight.A recent study of 93 women found that postmenopausal women were one-and-a-half times more likely than premenopausal women to have more than five apnea–hypopnea episodes an hour during sleep.

Periodic limb movement, a parasomnia characterized by bilateral repetitive movements of the extremities (usually the legs but sometimes also the arms), disrupts sleep, and there’s some evidence that it’s more prevalent in postmenopausal women.Vasomotor symptoms can also disturb sleep in peri- and postmenopausal women. Studies consistently find significant associations between sleep difficulty, particularly nighttime and early morning awakening, and hot flashes or night sweats. Sedentarism has been found to be associated with sleep difficulties in menopausal women. In their study of 149 Ecuadorean women, Chedraui and colleagues found that sedentary women had more than three times the risk of daytime sleepiness than more active women did.Managing insomnia involves drug, nondrug, and CAM therapies. Cognitive behavioral therapy (CBT) is the primary nonpharmacologic treatment and should be considered the first-line treatment for sleep problems during menopause. CBT aims at developing thoughts and behaviors that promote sleep and eliminating those that contribute to insomnia (see Table 1). There’s strong support for CBT’s effectiveness in treating insomnia when it’s conducted by a behavioral specialist, such as a licensed therapist or psychologist. Although I found no studies that looked at the effectiveness of CBT in improving sleep in otherwise healthy menopausal women, a meta-analysis that looked at its use in men and women ages 55 and older found moderate-to-large positive effects. Sleep-hygiene behaviors, such as maintaining a quiet sleeping environment and avoiding caffeine, are sometimes considered CBT, but on their own they haven’t been correlated with sleep improvement in people with sleep disturbances.

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Women who don’t have access to CBT may find self-help methods useful. A meta-analysis found small-to-moderate improvements in sleep outcomes after use of self-help cognitive–behavioral methods such as audiotapes, online programs, and sleep diaries.A meta-analysis of 105 studies found that benzodiazepines and nonbenzodiazepines were effective treatments for insomnia, producing shorter delays in sleep-onset times (known as sleep-onset latency) and improvements in sleep as recorded in sleep diaries.In a relatively recent class of sleep medications, the melatonin receptor agonists, there’s only one drug available, ramelteon (Rozerem). It has been shown to decrease sleep-onset latency and increase total sleep time.It’s usually well tolerated; the most common adverse effects, headache and somnolence, are similar to those associated with other sleep medications. CAM. There’s little scientific evidence to support the use of most CAM approaches in managing insomnia. Hachul and colleagues found a positive effect for isoflavones in their study; the percentage of women who reported moderate-to-severe insomnia decreased from 94% to 63% in women in the placebo group and from 90% to 37% in the group using isoflavones. The sample of 38 women was too small, however, to place confidence in the results.

Melatonin may be an effective option for women who have difficulty falling asleep. A recent meta-analysis found that melatonin decreased sleep-onset latency by more than 23 minutes in both children and adults, although it didn’t change the total sleep time or the awakening time.Small doses help to prevent morning sleepiness.