What is disrupted sleep?
- Trouble falling asleep
- Waking in the middle of the night
- Waking very early in the morning
I wake up in the middle of the night and am awake for 1 hour or more
The loss of sleep has been awful. Attempting to use sleeping pills just leads to other side effects (heart palpitations). Much more research is needed in this area. It made it really, really hard to work and I lost a great deal of respect, which was devastating to my career.WLB Community Member
4 things to know about disrupted sleep during perimenopause
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Disrupted sleep is common during perimenopause. Like many other aspects of perimenopause, research hasn’t unraveled exactly why sleep becomes a challenge during midlife. What we do know: sleep disruption can be related to fluctuating hormones, to night time hot flashes/night sweats/heat ups and it can be associated with mood changes. Sleep also changes as we age.
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If you struggle with sleep, consider studying your sleep and creating a sleep strategy (see below).
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Cognitive Behavioral Therapy for Insomnia (CBT-I) works! — more info below.
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Research links poor sleep to negative health outcomes such as increased risk for cardiovascular disease, insulin resistance, and negative changes in mood. In particular, a metric of sleep continuity called Wake After Sleep Onset (WASO) is related to poorer cognitive performance. All good reasons to focus on improving your sleep.
Study your sleep and create a sleep strategy
Study your sleep: Take a week and note what things improve or worsen your sleep. Some variables to test: late meals, alcohol or amount of alcohol, late-in-the-day workouts, afternoon chocolate or caffeine, intense or worrisome content before bed, checking work emails.
Create a sleep strategy: If you begin to struggle with sleep in your late 30s/early 40s, accept that this may be part of your life for a while and devise a sleep strategy.
- Prioritize sleep/earlier bedtime: If you have to be up by 6:30 a.m., can you go to bed at 9:30? Even if you are awake for an hour or two, you still have a chance of getting 7-8 hours of sleep.
- Set a schedule: I didn’t believe this would help, but the more consistent I am with going to bed at around the same time, the better my sleep seems to be.
- Prepare for an awakening: Try various back-to-sleep remedies to find the ones that work best for you. (See “remedies: once you’re awake” below for ideas to try.)
- Set sleep hygiene as a foundation: all the sleep hygiene stuff you’ve heard before is important too! (See “remedies: before bed” below.)
*** Other sleep disrupters that can arise in midlife are obstructive sleep apnea and restless leg syndrome. If you suspect either of these as the cause of your sleep challenges, see a health care provider for solutions.
My sleep has definitely been affected. I will wake up and not be able to fall back to sleep for a few hours or wake up multiple times a night.WLB Community Member
In our research and others2,3 we found “waking in the middle of the night” to be the most common new experience at the beginning of perimenopause. To investigate this in more detail, we asked about 3 types of “waking in the middle of the night.”
I have a hard time falling asleep
I wake in the middle of the night and feel panic, anxious, worried
I wake up very early in the morning
The night wakings come and go. No obvious reason why. I am also much more alcohol sensitive in the last few years, night wakings always happen when I have had that one glass too many, which I try to limit as they are so miserable!WLB Community Member
Remedies to consider
Cognitive Behavioral Therapy (CBT-I)
It works! Lots of recent research supports the use of CBT-I as effective for sleep challenges. The (“I”) is for insomnia. It’s best and most effective to learn cognitive behavioral therapy from a practitioner one-on-one but it can be hard to find someone. There are online programs and apps available that if you stick with them are also effective.
For a deeper dive:
- A telephone based, CBT-I program showed improvements in the Insomnia Severity Index (ISI) scores at the end of the 8 weeks and the improvement versus the control group which was menopause education was sustained at 24 weeks. There were 106 women in the trial.
- This article from the New York Times gives a good overview of options about how to find a CBT therapist, online options and the apps (free and paid) available.
- This study evaluated an online CBT-I program in a randomized controlled trial because as noted above, there is a shortage of CBT practitioners. The online program was effective.
- Comparison of drug and non-drug remedies for sleep. The MSFlash trials compared SSRIs, exercise, yoga, estrogen and CBT-I on sleep outcomes. There are great charts in this paper showing the difference. CBT-I had the best effect and was the only one to have a lasting benefit at a follow up time point.
Sleep hygiene before bed
Set up your space
- Cover your clock: You may still wake up, but you’ll reduce the anxiety that keeps you up by watching the minutes tick by.
- Block out ambient light with darkening shades or an eye mask.
- Use ear plugs if you live in a noisy area.
- Have headphones nearby to listen your way back to sleep should you need it.
- Have a book light nearby. Reading is better for some to return to sleep.
Establish a pre-sleep routine
Try a breathing technique like 4-7-8 or a guided mediation. These two from Insight Timer: Yoga Nidra and Breathing into Sleep are favorites! There are many more at Insight Timer. You may have to try a few to find the voice and length that works for you.
Take a hot bath. It raises your body temperature so that the drop in temperature promoted by your natural sleep-wake cycle will be greater, and this will put you into a deeper sleep. (That, and it’s just so relaxing.) Add some Epsom salts (paid link) which are a form of magnesium for added sleep benefits.
Put a notepad by your bed
Listen to something with earbuds
Use a book light for reading
Block blue light from your devices
Some phones and tablets have a setting to turn on a blue-light blocking feature at night. For those with an iPhone, there is a feature under Settings/Display& Brightness called night shift.
Or check out flux. It’s free and it will automatically remove the blue light according to a time schedule that you set.
Magnesium
Melatonin
Lavender
Over the counter remedies
- Diphenhydramine (the active ingredient in the antihistamine Benadryl). Using the liquid form allows you to try very small doses to start. It’s not recommended to do this regularly but can help when sleep is mandatory.
- Tylenol PM can also be used occasionally but Tylenol in excess and with alcohol can lead to liver damage.
Prescription drugs used for sleep
Research shows sleep disturbance is a hormonally-based symptom and it’s common
Changes in hormone levels, rather than certain baseline levels, are associated with sleep disturbances.
A study that collected daily hormone measurements concluded that sleep was most disrupted the days leading up to menstruation and during the first few days of your period. (Two times in your cycle when hormone levels are dropping and low.)
Melatonin declines as we age. Melatonin levels regulate sleep cycles. Melatonin rises when it gets dark and production stops when it’s light. Guess what screen time does to melatonin? Learn about melatonin from an expert and how to support your natural levels,.
Progesterone, a hormone that can be calming and sleep-inducing, is declining as we approach our final menstrual period due to less frequent ovulation.
What longitudinal studies tell us
- A study that tracked 255 women from premenopause to the final menstrual period over 16 years found that how well or poorly women slept was unchanged from the earliest time points to the latest. That is poor sleepers remained poor sleepers and good sleeper remained good sleeper. There was one group who had few sleep issues in the beginning whose sleep worsened. Hot flashes contributed to poor sleep. Anxiety, stress and to a lesser extent depression were linked to poor sleep, but the direction of the cause and effect is not known.
- Another study looking at 10 years of data found that 31 to 42% of women had insomnia symptoms during perimenopause. This study, in contrast to the one above found insomnia symptoms increased as women got closer to the final menstrual period.
- A third longitudinal study that tracked women over 15 years, found that middle-of-the-night waking got worse as women progressed to the final menstrual period and that lower estrone, a form of estrogen, and higher FSH were related. In this study disrupted sleep was related to hot flashes, depression and perceptions of health.
I am now finding that a change in diet, cutting out caffeine and reducing alcohol, and seeking out healthy foods that stabilize blood sugar (eggs, nut butters, etc) seem to be helping my sleep, but I am just 10 days into this.WLB Community Member
REFERENCES
2. Ciano C, King TS, Wright RR, Perlis M, Sawyer AM. Longitudinal Study of Insomnia Symptoms Among Women During Perimenopause. J Obstet Gynecol Neonatal Nurs. 2017 Nov – Dec;46(6):804-8132.
3. Pengo MF, Won CH, Bourjeily G. Sleep in Women Across the Life Span. Chest. 2018 Jul; 154(1):196-206.
4 Marcelo C. Garcia; Elisa H. Kozasa; Sergio Tufik; Luiz Eugênio A. M. Mello; Helena Hachul. The effects of mindfulness and relaxation training for insomnia (MRTI) on postmenopausal women: a pilot study. Menopause. 25(9):992–1003, SEP 2018. DOI: 10.1097/GME.0000000000001118.PMID: 29787483. Issn Print: 1072-3714. Publication Date: 2018/09/01
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