Ask an Expert: Q&A – April 2023

Question 1

I have a 48-year-old female patient who is fit and well. She recently fell asleep whilst driving home, rolled her car, and gave herself and her family a fright but luckily and miraculously wasn’t injured.

She complains of excessive daytime sleepiness despite ‘sleeping like a log’ and that she could ‘sleep anywhere anytime’. She’s not overweight, all her blood tests (thyroid, iron etc) are normal and she denies snoring, and is not yet experiencing or reporting menopausal symptoms such as night sweats.

She sleeps alone due to the disturbance of her husband’s long-term loud snoring. They’ve happily slept in separate beds for the past few years. Any ideas about where to from here with her? Was thinking about sleep apneoa but she just doesn’t fit the typical profile.

Answer

From health psychologist and CEO of the Sleep Health Foundation Dr Moira Junge

Even though your patient denies snoring and reports sleeping all night, I would be highly suspicious of undiagnosed obstructive sleep apnoea (OSA). We often associate OSA with overweight men yet once a woman hits menopause the risks are similar, and if they sleep alone they won’t be aware of their snoring or any restlessness at night.

I would suggest a referral to a Respiratory and Sleep Disorders Physician for an overnight sleep study and most likely she’ll need a trial of Continuous Positive Airways Pressure (CPAP) or a mandibular advancement splint.

If she is resistant to CPAP therapy there are many psychologists and CPAP therapists, often attached to the major sleep centres at hospital, that can provide some evidence-based support for CPAP adherence and help with the often tricky transition to having to wear a mask and machine at night during sleep.

Question 2

I have a 53-year-old patient complaining of difficulty maintaining sleep. She’s perimenopausal and she is opposed to sleep medications (as so many hypnotics haven’t worked or have given her awful side effects). There are no psychologists available at all, let alone ones with sleep specific expertise. I have heard that Cognitive Behavioural Therapy for Insomnia (CBTi) would be great but just don’t know where to send her. She is also quite opposed to medical solutions for hormonal disruptions.

By the way I still call it HRT, I recently notice the acronym of MHT is being used more now, which is correct?

Answer

From health psychologist and CEO of the Sleep Health Foundation Dr Moira Junge

Thanks for your question, as you’re aware sleep can be really challenging in the menopausal and perimenopausal years. I would recommend your patient accesses CBTi via telehealth from one of many practitioners around Australia who have expertise in sleep, check out all the major sleep centres across the nation.

Some of the elements of CBTi can be done in the medical setting, in as little as 15-minute appointments. See this helpful link for some tips and hints: RACGP - Brief behavioural therapy: insomnia in adults. No matter what caused the sleep difficulty, even hormonal changes, sometimes it’s similar issues such as worry and maladaptive habits that keep the sleep issues going longer than they should. Unfortunately, there is no current register or list of CBTi practitioners in Australia but we’re working on it. The Sleep Health Foundation website also has some helpful fact sheets, see these two on Menopause and CBTi.

Often by addressing the concerns about the lack of sleep, the sleep can improve enough to no longer be debilitating however if she’s having severe night sweats and the like then it’s worth addressing the hormonal disturbance.

By the way re MHT and HRT, both terms are acceptable but I know here at Jean Hailes for Women’s Health that MHT is now the preferred term. It could be helpful to spend some time asking why she’s so opposed to MHT, it’s possibly worth hearing her concerns and educating her about the benefits and spending some time answering her questions about the risk (which might be based on incorrect or outdated information). This can really open up the possibilities of a trial of some medical options for her hormonal changes.