In this 'Women's Health' article for Medical Observer, Jean Hailes Medical Director and gynaecologist Dr Elizabeth Farrell looks at how GPs can recognise and help treat sleep disturbances in women.
Jean Hailes is proud to provide a monthly column in the medical newspaper, Medical Observer. Designed to give GPs and health professionals a short informative summary of important women's health topics and conditions, these articles provide practical information to inform and enhance clinical practice.
Sleep disturbances are common in older women, affecting 40-60% of perimenopausal or postmenopausal women.
Poor sleep in this cohort is associated with cardiovascular and metabolic disease, as well as mood disorders.1
Various premenopausal health-related factors seem to predict poor sleep in menopausal transition.2
Menopause itself appears to have only minor effects.
Although hormonal changes can influence sleep patterns and sleep activities, other factors — such as medical history (for example, chronic pain, cardiovascular disease), age, and the existence of mood disorders — can affect a woman's sleep at midlife.
Thorough inquiry by GPs can help to identify at-risk women and enable tailored interventions with the potential to prevent the development of sleep disturbances at menopause.
Studies show that during times of hormonal change, women are at an increased risk of sleep problems such as poor sleep quality and sleep deprivation, as well as sleep disorders, such as obstructive sleep apnoea, restless legs syndrome and insomnia.
Primary sleep disorders become more prevalent in older age, affecting more than 53% of postmenopausal women.
There are many potential mechanisms by which sleep quality is affected during the latter part of a woman's life.
These relate to vasomotor symptoms, hormonal changes, age-related changes, and increases in comorbid conditions, such as depression and sleep-disordered breathing.
Chronic insomnia may develop in as many as 42% of women by the end of their menopausal transition.
The perimenopausal and menopausal life phase can be a hectic time for a woman, when she may have multiple roles and stressors.
The influence of these factors in sleep disturbances should not be underestimated.
Working with the patient to identify any life stressors (including work and family issues), as well as pre-existing medical conditions (for example, cardiovascular disease, depression, anxiety), can assist with developing a treatment plan tailored to the individual.
Timely intervention to reduce the more bothersome symptoms can help restore healthy sleep patterns and reduce the likelihood of chronic insomnia.
Sleep hygiene refers to habits that encourage a good night's sleep. These include:
Some foods may contribute to restful sleep and others to wakefulness.
Tryptophan, an amino acid found in many foods, aids sleep. Tryptophan produces serotonin, which is associated with relaxation, restfulness, and sleep. Tryptophan also produces the hormone melatonin, which regulates the sleep-wake cycle. Unfortunately eating tryptophan-containing foods is unlikely to help sleep; although purified tryptophan increases brain serotonin, foods containing tryptophan do not.
Being physically active can help to reduce sleep problems.
Encourage daily exercise, but caution patients not to exercise within four hours of bedtime due to risk of overstimulation.
Careful assessment for, and management of, contributing stressors, as well as anxiety and depression is important in addressing sleep disturbance in women.
Simple self-management strategies can include sleep hygiene, regular exercise, relaxation, mindfulness practices and journalling.
Targeted psychological therapies may be of benefit in managing specific stressors and for treating underlying mood or anxiety disorders.
In addition, the antidepressants venlafaxine and paroxetine might reduce hot flushes.
These agents may be considered in the setting of vasomotor symptoms of menopause in the context of mood or anxiety disorders, particularly those that are non-responsive to psychological therapies.3
Menopausal hormonal therapy, also known as hormone replacement therapy, may assist in reducing vasomotor symptoms.
Hot flushes and night sweats are the hallmark of menopause, and can affect sleep quality in menopausal women.
Menopausal hormone therapy has been shown to improve sleep quality and should be considered for treating ongoing sleep disturbance.
If the patient has ongoing sleep disturbances after addressing sleep hygiene, nutrition, exercise and taking menopausal hormone therapy for several months, refer to a sleep physician.
Dr Elizabeth Farrell is a consultant gynaecologist and Medical director at Jean Hailes. Read more.