Sleep problems during the menopausal transition: prevalence, impact, and management challenges

Abstract

A substantial number of women experience sleep difficulties in the approach to menopause and beyond, with 26% experiencing severe symptoms that impact daytime functioning, qualifying them for a diagnosis of insomnia. Here, we review both self-report and polysomnographic evidence for sleep difficulties in the context of the menopausal transition, considering severity of sleep complaints and links between hot flashes (HFs) and depression with poor sleep. Longitudinal population-based studies show that sleep difficulties are uniquely linked with menopausal stage and changes in follicle-stimulating hormone and estradiol, over and above the effects of age. A major contributor to sleep complaints in the context of the menopausal transition is HFs, and many, although not all, HFs are linked with polysomnographic-defined awakenings, with HF-associated wake time contributing significantly to overall wakefulness after sleep onset. Some sleep complaints may be comorbid with depressive disorders or attributed to sleep-related breathing or movement disorders, which increase in prevalence especially after menopause, and for some women, menopause, age, and environmental/behavioral factors may interact to disrupt sleep. Considering the unique and multifactorial basis for sleep difficulties in women transitioning menopause, we describe clinical assessment approaches and management options, including combination treatments, ranging from cognitive behavioral therapy for insomnia to hormonal and nonhormonal pharmacological options. Emerging studies suggest that the impact of severe insomnia symptoms could extend beyond immediate health care usage and quality of life issues to long-term mental and physical health, if left untreated in midlife women. Appropriate treatment, therefore, has immediate benefit as well as advantages for maintaining optimal health in the postmenopausal years.

Keywords: estradiol; hormone therapy; hot flashes; insomnia; midlife women; vasomotor symptoms.

Figure 1

Progression through the menopausal transition and postmenopause as defined by the Stages of Reproductive Aging Workshop (STRAW). Notes: Schematic changes in follicle-stimulating hormone and estradiol (follicular phase samples) are superimposed on the STRAW criteria, although there is substantial variability in hormone levels across the transition. Menstrual cycle-related fluctuations in hormones are shown in the insert. Data from Soules et al and Harlow., Abbreviations: FSH, follicle-stimulating hormone; LH, luteinizing hormone; STRAW, Stages of Reproductive Aging Workshop.

Figure 2

Age-adjusted odds ratios for self-reported sleep difficulties in women participating in the SWAN prospectively tracked across the natural menopausal transition relative to premenopausal baseline and in women who transitioned to surgical menopause. Notes: *P<0.05; **P<0.01; ***P<0.001. Data from Kravitz et al. Abbreviation: SWAN, Study of Women’s Health Across the Nation.

Figure 3

Amount of PSG-defined wakefulness associated with hot flashes relative to total WASO in individual women who presented with varying numbers of hot flashes, as measured from sternal skin conductance, during overnight laboratory stays. Notes: There was high variability between women in the number of hot flashes measured and in their associated amount of wakefulness. Data from de Zambotti et al. Abbreviations: PSG, polysomnography; WASO, wakefulness after sleep onset.

Figure 4

Assessment and management of insomnia in the context of the menopausal transition. Importantly, chronic sleep maintenance insomnia in women with menopausal symptoms is associated with a negative impact on healthcare utilization, quality of life, and work productivity. Abbreviations: CBT-I, cognitive behavioral treatment of insomnia; HF, hot flash; HT, hormone therapy.