Hormones & Sleep: Is Perimenopause Keeping You Awake?

Exploring key factors associated with sleep disturbances during perimenopause

by Bianca Garilli, ND
The demarcations of a woman’s physiological stages of life are often delineated by the various, unique phases and cycles associated with fertility, reproduction, and the hormones at work behind the scenes. These stages include:1

• Signaling of possible fertility at menarche
• Rhythm of monthly menstrual cycles controlled by the peaks and valleys of estrogen and progesterone
• Miraculous growth of new life during pregnancy
• Production of irreplicable nutrition for baby via breastmilk
• Rebalancing dance of hormones during postpartum period
• Eventual decline and shift of hormonal production during perimenopause
• Menopause signals the end of the fertile phase of a woman’s life and, in many women, imparts a sense of liberation and movement into new areas of spiritual and physical health and wellbeing

All of these phases are controlled by and linked to one another through changes in hormones, mostly estrogen, progesterone, FSH, LH, and testosterone.1,2 These natural cycles of a woman’s hormones, however, are not always carefree nor symptom-free. In particular, the transition time between regular menstrual cycles and menopause, known as perimenopause, is a phase frequently marked by changes in a woman’s physical, mental, and emotional health. Some of the more common symptoms experienced during perimenopause include:2 irregular periods, mood changes, vaginal and bladder concerns, decreased fertility, sexual desire changes, bone loss, headaches, changes in cholesterol levels, and commonly, hot flashes and sleep problems.

For many women, after many years of sleep deprivation during the child-bearing and rearing years, a good night’s rest is welcomed. Unfortunately, perimenopause, which typically begins sometime in a woman’s mid-to-late 40s and can last anywhere from 2-10 years, may create a whole new set of sleep challenges.2,3

Prevalence of sleep problems during perimenopause
Compared to men, sleep complaints are approximately twice as prevalent in women of all ages, with a prevalence during perimenopause ranging from 39-47%, underscoring the importance of investigating sleep problems in a female-centric way.3
To this end, sleep duration and quality of a nationally representative sample of women 40-59 years of age were studied by the CDC and broken down categorically by menstrual cycle/menopausal phase; sleep data during the perimenopausal phase revealed that:4

• 56% of perimenopausal women sleep < 7 hours/night, on average. A lower prevalence of postmenopausal and premenopausal women reported sleeping < 7 hours/night (40.5% and 32.5%, respectively)
• 24.8% of perimenopausal women say they have trouble falling asleep ≥ 4x per week
  • 30.8% of perimenopausal women have difficulty staying asleep at least 4 nights per week
• 49.9% of perimenopausal women wake up in the morning feeling tired ≥ 4 days per week

Hormones are at play
Sex hormones
So what is happening during perimenopause that so dramatically and negatively impacts sleep patterns? For starters, the decline in levels of sex hormones (in particular estrogen, progesterone, and testosterone) during the perimenopausal years lead to an array of symptoms, most of which can adversely affect sleep habits. These include: hot flashes, migraines, sleep apnea, circadian rhythm abnormalities, restless legs syndrome, lifestyle factors, as well as mood disturbances such as anxiety.2,4,5

Interestingly, in an analysis reviewing sleep concerns in various stages of menses/menopause, it was found that vasomotor symptoms (hot flashes) and sleep disturbances may work bidirectionally.6 In other words, hot flashes may increase difficulties obtaining appropriate duration and quality of sleep, while sleep problems may worsen vasomotor symptoms,6 a circuitous “what came first?- chicken or egg,” kind of hormonal dance.

The types of sleep disturbances most often noted by perimenopausal women include difficulties with initiating and/or maintaining sleep, as well as frequent nocturnal and/or early morning awakenings.5 It’s well known that during perimenopause, estrogen levels drop sharply, corresponding to many of the symptoms associated with this transition period. However, less well known is another hormone whose levels decline and no doubt, play a key role in sleep dysfunction. That hormone is melatonin, which decreases during perimenopause, although the decline in melatonin is more gradual than that of estrogen.7

Melatonin
Melatonin secretion from the pineal gland drops as individuals hit their mid-life years, coinciding with the perimenopausal phase in women.7 An article published in the Journal of Sleep Disorders and Therapy indicates that exogenous use of melatonin may improve some of these sleep challenges, including the nocturnal awakenings observed during perimenopause.5 Further research indicates that the use of slow-release melatonin preparations increase total sleep time and sleep efficiency, as well as reducing sleep latency in patients with insomnia.5

Interestingly, melatonin may also play a role in the modulation of many symptoms and conditions associated with menopause, including reduction in bone density, mood disorders, fibromyalgia, and potentially even neurodegenerative diseases.7 Assuredly, much more research is needed in the area of sleep disorders, perimenopause, and related hormonal fluctuations.

Sociodemographic factors
Sociodemographic variables can also contribute to perimenopausal sleep disturbances:

• Race/ethnicity: Prevalence of sleep difficulties is lowest in Japanese women (28.2%), followed by Chinese women (31.6%), African American women (35.5%), Hispanic women (38%), and Caucasian women (40.3%)8
• Socioeconomic status: One study found that lower income and higher financial stress increase the risk of experiencing sleep disturbances during perimenopausal years9
• Social/partnership health: Improved sleep quality has been associated with marital happiness: “Analysis of women’s relationship histories over the 6–8 years prior to the sleep study showed advantages in sleep for women who were consistently partnered versus women who were unpartnered throughout this interval, or those who had lost or gained a partner over that time course.”10,11

It’s easy to see there are myriad factors that can affect sleep health during perimenopause. It’s also important to understand that effective and individualized solutions are critical, as poor sleep quality and quantity are associated with an increased risk for chronic health conditions such as cardiovascular disease and diabetes.4
Women who are experiencing sleep concerns should work with a healthcare practitioner trained to 1) take a deep dive into the various aspects of lifestyle that may be affecting sleep health and 2) identify and address any deleterious health consequences from inadequate sleep. These areas should encompass the full spectrum of her individual health and wellness, from a focused cardiovascular and metabolic exam, to an in-depth look into the social and emotional aspects of her life. Each of these areas is important to consider and address to effectively and safely treat sleep challenges during the perimenopausal years and beyond.
 Citations

1. Merck Manual. Female Reproductive Endocrinology. https://www.merckmanuals.com/professional/gynecology-and-obstetrics/female-reproductive-endocrinology/female-reproductive-endocrinology. Accessed January 24, 2019.
2. Mayo Clinic. Perimenopause. https://www.mayoclinic.org/diseases-conditions/perimenopause/symptoms-causes/syc-20354666. Accessed January 24, 2019.
3. Kravitz H et al. Sleep during the perimenopause: a SWAN story. Obstet Gynecol Clin North Am. 2011;38(3):567–586.
4. CDC. Sleep duration and quality among women aged 40-59, by menopausal state. https://www.cdc.gov/nchs/products/databriefs/db286.htm. Accessed January 25, 2019.
5. Jehan S et al. Sleep disorders in postmenopausal women. J Sleep Disord Ther. 2015;4(5):1000212.
6. Thurston RC et al. Beyond frequency: Who is most bothered by vasomotor symptoms? Menopause. 2008;15:841–847.
7. Jehan S et al. Sleep, melatonin, and the menopausal transition: what are the links? Sleep Sci. 2017;10(1):11–18.
8. Sowers MF et al. SWAN: a multicenter, multiethnic, community-based cohort study of women and the menopausal transition. In: Menopause: biology and pathobiology.Orlando, Fla: Academic Press Inc. 2000:175–188.
9. Hall M et al. Socioeconomic status as a correlate of sleep in African-American and Caucasian women. Ann N Y Acad Sci. 1999;896:427-430.
10. Troxel WM et al. Marital happiness and sleep disturbances in a multi-ethnic sample of middle-aged women. Behav Sleep Med. 2009;7(1):2-19.
11. Troxel WM et al. Marital/cohabitation status and history in relation to sleep in midlife women. Sleep. 2010;33(7):973-981.