Nearly 50% of women ages 35-55 years have struggles with poor sleep. (1) For the women in my practice, there are many common complaints associated with poor sleep, including:
- Difficulty falling asleep
- Getting a second wind late at night
- Difficulty staying asleep
- Not feeling rested in the morning
- Waking up many times each night to use the restroom, take care of children or pets, because of a snoring spouse, snoring themselves, sleep apnea, or hot flashes/ night sweats
- At least 20% of midlife women have at least moderate-severity sleep-disordered breathing (SDB) (2)
There are many proven strategies to support better sleep quality and quantity, but they take coaching support for women to be able to implement them for the long term in the context of their very busy lives.
What is causing poor sleep in midlife women?
There is a high prevalence of comorbid insomnia and SDB in midlife women. In fact, 31% of those who met criteria for insomnia also had at least moderate-severity SDB and 23% of those with SDB also met criteria for insomnia. (2)
Restless legs syndrome (RLS) also increases in prevalence during midlife. (2) Women are affected by RLS about twice as often as men, in both mild and more severe cases of RLS. (3) RLS often appears for the first time during pregnancy, or can become more severe during pregnancy. With more pregnancies, the risk of RLS later in life, increases. There is some evidence of poor iron metabolism and high estrogen levels as causative factors for RLS, but with menopause RLS doesn’t tend to improve so the details of the hormonal and nutrient deficiency etiologies are RLS are not yet clear.
Hot flashes (otherwise known in the literature as vasomotor symptoms – VMS), are the primary predictor of sleep problems in menopausal women. (1) Women in this age group have lower sleep efficiency, and their sleep is characterized by multiple awakenings. This poor sleep quality increased their daytime irritability (for obvious reasons!) Vincent et al. have shown that VMS not only directly and negatively influence sleep quality and quantity, but also have an indirect effect on mood. (4)
Duh… Women who don’t sleep well are more often in bad moods during the day!
Are hormone shifts related to sleep?
For estrogen, that’s not really clear. It seems as though the estrogen shifts and overall decline of perimenopause and menopause can predispose women to both depression and insomnia, which as noted above seem to be related. (1) But, there does not seem to be a clear association that can be improved with hormone replacement or some other simple therapy. (1)
Progesterone seems to have a more direct effect on sleep. Studies also show that decreases in progesterone levels can cause disturbed sleep. (5) Progesterone has relaxing, sleep inducing, and calming effects, stimulating benzodiazipine receptors, which play an important role in a healthy sleep cycle. (1)
What else can cause sleep disturbance in women throughout the lifespan?
Medical conditions that are known to disturb sleep include obesity, heart problems, gastrointestinal problems, urinary problems, endocrine problems, and chronic pain problems. Plus, medications and self-medications that are often used to address these chronic health concerns contribute to poor sleep, including neuroactive medications, cigarettes, alcohol, caffeine, selective serotonin reuptake inhibitors, bronchodilators, antiepileptic medications, thyroid hormone replacement, and others. (1)
For women with pain, poor sleep is a common struggle. (1) Poor sleep quality with longer duration sleep has been reported in common among women who report high pain score. Rheumatoid arthritis is also associated with poor sleep quality. Women with elevated inflammatory biomarkers, such as elevated C-reactive protein also report poor sleep quality and depression.
Menopause and Sleep Apnea
The prevalence of obstructive sleep apnea (OSA) rises significantly after menopause up to nearly 70% of post-menopausal women. (1) The upper airway becomes anatomically different after menopause and results in compromise in breathing during sleep. Weight gain after menopause often contributes to this anatomical change. But, increased body weight does not appear to be the only factor responsible for this condition, as one study has found that despite comparable body mass index, post-menopausal women had more severe OSA and they spent a larger amount of sleep time with OSA as compared to pre-menopausal females. (6)
The decline in progesterone levels also contributes to increased sleep apnea risk. (1) Due to lack of progesterone, the pharyngeal dilator muscle activity is effected. However, Carskadon et al. showed that hormonal factors play a minor role as compared to anthropometric measures in development of OSA after menopause (7) Progesterone is a direct respiratory stimulant, and has been used to treat mild OSA. (8) Interestingly, during pregnancy, there are few cases of OSA, given the amount of weight gain that typically occurs. (9) The high progesterone levels characteristic of pregnancy function as a respiratory stimulant.
What nutrition and lifestyle medicine strategies can address poor sleep in women?
- Optimize hormone balance. This all begins with improving the resilience of the endocrine system’s stress response. The most common factors in my practice for dysregulated cortisol (stress hormone) levels are work and relationship stressors, sugar, caffeine and alcohol, and a lack of a strong support network. All of these issues can be addressed by skilled health coaching. Plus, using supplements that are supportive of the stress response system – such as adaptogens. I like to start with calming preparations such as CatecholaCalm, which includes calming and cortisol lowering adaptogens, herbs, and amino acid, such as ashwagandha, valerian, B vitamins, phosphatidylserine, magnesium, and l-theanine. If cortisol is too low, licorice tea, or adrenal support supplements with licorice and more balancing adaptogens can be helpful, such as Adrenotone. For many women, however, it’s helpful to start with calming and nourishing adaptogens in low doses, in teas, or with stress reducing lifestyle strategies before using more stimulating supplements because these can be too stimulating when the stress response system is tired AND “wired.” Adding more stimulation, even if cortisol is low, can make women feel even worse – anxious, even less rested, and with jittery energy. Thus, it’s ideal to work with a skilled functional nutritionist to determine the best combination of nutrition, supplementation, and lifestyle medicine to support your client’s (or your) stress endocrine system’s resilience.
- Naturally increase progesterone. Prior to menopause, Agnus castus L (otherwise known as chaste tree or vitex) may block estrogen receptors by binding to these receptors and exert anti-estrogen activity. A. castus demonstrates a significant competitive binding to estrogen receptors alpha (ER alpha) and beta (ER beta) as well as stimulating progesterone receptor expression (10). Supplementing with vitamin B6 at doses of 200-800 mg/day, and magnesium to bowel tolerance, can also support healthy progesterone levels. (11).
- Reduce blue light screen exposure after sundown (#laptopcurfew #cellphonecurfew). During the darkness of night, melatonin concentrations rise to promote sleep onset and regulate circadian sleep phase. (12) Exposure to light at night strongly suppresses melatonin, which interferes with sleep timing and sleep quality. Individuals who used an eReader (30–50 lux) during the 4 h before bedtime experienced increased latency to fall asleep and decreased morning alertness. (13) The symptoms coincided with a significant suppression of melatonin.
- Wear amber glasses. Twenty adult subjects were randomized to wear either blue-blocking (amber) or yellow-tinted (blocking ultraviolet only) safety glasses for 3 h prior to sleep. (14) Results revealed significant (p < .001) interaction between quality of sleep over the three weeks and experimental condition. At the end of the study, the amber lens group experienced significant (p < .001) improvement in sleep quality relative to the control group and positive affect (p = .005). Mood also improved significantly relative to controls.
- Exercise during the day, ideally outside in daylight. Aerobic exercise (walking or jogging for 30 minutes) outside in daylight has been shown to significantly increase blood melatonin concentration, to promote an earlier bedtime – with improved ease of falling asleep, and improve sleep quality.
Sleep is essential lifestyle medicine for women of all ages. Supporting optimal sleep health is key to optimal hormonal health and general health for women. While strategies for improving sleep are relatively simple, implementing these strategies in the context of a busy lifestyle requires support, planning, accountability strategies, and commitment by the woman, her healing team, and her support network.
- Jehan, S., Masters-Isarilov, A., Salifu, I., Zizi, F., Jean-Louis, G., Pandi-Perumal, S. R., … McFarlane, S. I. (2015). Sleep Disorders in Postmenopausal Women. Journal of Sleep Disorders & Therapy, 4(5), 1000212. http://doi.org/10.4172/2167-0277.1000212
- Kline, C. E., Irish, L. A., Buysse, D. J., Kravitz, H. M., Okun, M. L., Owens, J. F., & Hall, M. H. (2014). Sleep Hygiene Behaviors Among Midlife Women with Insomnia or Sleep-Disordered Breathing: The SWAN Sleep Study. Journal of Women’s Health, 23(11), 894–903. http://doi.org/10.1089/jwh.2014.4730
Manconi M, Ulfberg J, Berger K, Ghorayeb I, Wesström J, Fulda S, Allen RP, Pollmächer T. (2012) When gender matters: restless legs syndrome. Report of the “RLS and woman” workshop endorsed by the European RLS Study Group. Sleep Med Rev, 16(4), 297-307. doi: 10.1016/j.smrv.2011.08.006
- Vincent AJ, Ranasinha S, Sayakhot P, Mansfield D, Teede HJ. Sleep difficulty mediates effects of vasomotor symptoms on mood in younger breast cancer survivors. Climacteric. 2014;17:598–604.
- Guidozzi F, Alperstein A, Bagratee JS, Dalmeyer P, Davey M, et al. South African Menopause Society revised consensus position statement on menopausal hormone therapy, 2014. S Afr Med J. 2014;104:537–543.
- Anttalainen U, Saaresranta T, Aittokallio J, Kalleinen N, Vahlberg T, et al. Impact of menopause on the manifestation and severity of sleep-disordered breathing. Acta Obstet Gynecol Scand. 2006;85:1381–1388.
- Carskadon MA, Bearpark HM, Sharkey KM, Millman RP, Rosenberg C, et al. Effects of menopause and nasal occlusion on breathing during sleep. Am J Respir Crit Care Med. 1997;155:205–210.
Empson JAC, Purdie DW. Effects of sex steroids on sleep. Ann Intern Med 1999;31:141-5
- Liu J, Burdette JE, Xu H, Gu C, van Breeman RB, Bhat KP, et al. Evaluation of estrogenic activity of plant extracts for the potential treatment of menopausal symptoms. J Agric Food Chem. 2001;49:2472–9.
- Abraham GE. (1983) Nutritional factors in the etiology of the premenstrual tension syndromes. J Reprod Med, 28(7), 446-64.
- Bedrosian, T. A., & Nelson, R. J. (2017). Timing of light exposure affects mood and brain circuits. Translational Psychiatry, 7(1), e1017–. http://doi.org/10.1038/tp.2016.262
- Chang AM, Aeschbach D, Duffy JF, Czeisler CA. Evening use of light-emitting eReaders negatively affects sleep, circadian timing, and next-morning alertness. Proc Natl Acad Sci USA 2015; 112: 1232–1237.
Burkhart K, Phelps JR. (2009) Amber lenses to block blue light and improve sleep: a randomized trial. Chronobiol Int, 26(8), 1602-12. doi: 10.3109/07420520903523719