Is sleeplessness a peri/menopausal problem?

Oh yes! Around half of us experience difficulties with our sleep. And yes! It is a problem. No matter how good we get at powering through, sleep is really good for us. It helps our memory, it helps create an appetite for healthy food and exercise, it helps our immune system — it even helps protect against serious illness such as cancer and dementia.

And more than that — a good night’s sleep is like moisturiser for the soul. It just makes our days go better. Our mood is better, our interactions with others are better, our capacity for pleasure is greater.

Wanting to sort out your sleep is about as far away from making a fuss about nothing as you can get.

So, how do we sort it out?

Before you figure out what to do about it, you probably have to figure out what’s causing it. There can be several different factors involved and they can overlap and get tangled up together.

It’s worth keeping a record of what’s going on. One way would be to keep a notebook in which you record a few facts about your day before bedtime and then record some notes about your sleep in the morning. There are also a number of apps which can track sleep against other lifestyle factors and one or two menopause specific apps. Or if you’re old school like me, you can download and print out the trackers I designed.

I have learned for example that I don’t sleep well if my bedroom isn’t ice-cold, or if I’ve been working late or eating late — although funnily enough my bladder doesn’t seem to care if I drink late. Someone I work with was fed up because she’d been waking at 3.50 each morning — so we googled the sunrise time in the UK at that time of year, and guess what?

Here’s what you’re looking out for

• Is it hot flushes or other temperature issues that’s waking you?
• Are you struggling to sleep or waking because of pain?
• Is it frequent trips to the bathroom that are disturbing your sleep?
• (But also remember that your body’s actually really good at not letting you pee while you’re asleep! It uses a hormone called vasopressin (or ADH) to keep water in your blood stream and out of your kidneys while you sleep — and makes sure your brain cells are hydrated while it’s at it. But as soon as you begin to wake vasopressin levels drop and your bladder fills really very quickly. So it might be that your full bladder is due to your wakefulness and not the other way round).
• Or is it the gurgling in your bowels?
• Is it a dry mouth, or even breathing issues?
• Is it the churning anxiety that so often comes with peri/menopause?
• Or even rage?
• Have you become more sensitive to triggers like noise and light?
• Or is it still a bit of a mystery?

What are the options?

The options might overlap too, but if I go through them one at a time, you can figure out what might fit for you.

HRT

Not for everyone but always the top of the list. The brain is struggling because of the drop in oestrogen so why not replace the oestrogen, at least for those of us who can?

It’s not always the answer. It doesn’t always help. The official line is the if the sleeplessness is connected to temperature issues then HRT usually resolves them, otherwise it won’t really help sleeplessness.

I have to say, though, I talk to a lot of women who disagree — who say that HRT also helps with anxiety, with pain, and sometimes even bowel and breathing issues.

Also, progesterone has a habit of calming the nervous system and some women — myself included find themselves sleeping like a log on the progesterone days of the HRT cycle. There are those of us, however, who struggle with progesterone — even our own — and find that progesterone has the opposite effect — causing agitation and anxiety or fatigue and a raft of other physical symptoms.

It’s also worth mentioning here, that if it’s your bladder waking you, then both systemic (whole body) HRT and vaginal HRT can also have a beneficial effect on the tissues of the bladder. Oestrogen helps keep those tissues strong and stretchy and much more able to hold urine without complaining.

Gabapentin

Some doctors prescribe drugs such as gabapentin for menopausal symptoms. Gabapentin started off as an anti-seizure drug, but it has some serious impact on nerve pain, anxiety and insomnia.

I’m prescribed Pregabalin, a very similar drug. Both drugs help the body create gamma-Aminobutyric acid — GABA- which is a chemical which naturally occurs in the nervous system and has a calming influence on nerves. It works really well for me.

You can buy GABA over the counter but I’m not going to recommend it. Pharmaceutical companies may well be flawed, but they generally don’t spend millions working out how to give you a precursor to a chemical, if they could just give you the chemical and have it get to where it’s needed. There’s no evidence that GABA taken as a supplement has any impact at all.

Interestingly, progesterone also has an impact on GABA levels in the body.

Cannabis

THC, Tetrahydrocannabinol, the psychoactive ingredient of cannabis also has an effect on the GABA levels in the nervous system. I also know a lot of people who swear by cannabidiol (CBD) as a sleep aid and a pain reliever.

Contrary to popular belief there’s not a great deal of high quality evidence that CBD, THC, cannabis or synthetic cannabinoids help with either sleep or pain. There is also evidence that cannabis is an endocrine disruptor, and that heavy use of cannabis can affect bone density.

Natural Remedies

A lot of them contain valerian. It’s a rather pretty plant that often grows in hedgerows as well as in my garden. It’s been used as a medicinal plant since Ancient Greek times, and the English herbalist Culpepper recommended it as a cure for just about everything except insomnia — including the plague.

Modern science is a little less enthusiastic. It may or may not be effective. It’s also a little hard to manage dosage with herbal drugs, because you don’t know the concentration of the active ingredient. Too much can lead to drowsiness and there’s also a concern that it is likely to interact with anything else that’s a depressant — including alcohol, prescription drugs and other herbal medicines such as St John’s wort.

There’s some evidence that melatonin is effective in helping us sleep — though it’s more likely to help you get to sleep than stay asleep, and it doesn’t seem to work for everyone.

Lavender on the pillow or in body cream helps a lot of people. There is some evidence that it is mildly effective. Most of the studies I’ve seen are on Lavandula augustifolia, which is English Lavender, which has a more floral and less woody smell than French Lavender.

Magnesium may help. Be careful not to overdo it and make sure you are getting supplements from a reputable source. Leafy greens, nuts and seeds are also great for magnesium. Epsom salts are magnesium sulphate and so a bath might help (if it doesn’t heat you up or dry out your skin!), but please don’t be tempted to ingest them.

Over the Counter Remedies

Many contain old-school anti-histamines. I have to admit I occasionally used the old formulation of Syndol before it was taken off the shelves in the UK - and I believe it is now back. It's a mix of paracetamol, codeine, and doxylamine succinate, which is a non-non-drowsy anti-histamine. At the time I was often kept awake by headaches caused by muscular problems of the neck. Doxylamine succinate is also a muscle relaxant and that suited me just fine. You can also buy it separately as a sleep aid. 

But once it got withdrawn in the UK, I had to resort to yoga to manage my neck issues. So perhaps it was for the best!

Diphenhydramine is another old fashioned antihistamine often used in over the counter sleep remedies. Again you need to be careful about accidental overdoses or drug interactions. It’s only ever recommended as a short term solution — and a lot of people find that it becomes less and less effective over time.

Knocking yourself out with pills….

You might be disappointed to find that your doctor is not particularly keen to prescribe sleeping pills. They’re right.

There are two problems. One is that sedation is not sleep. Your brain doesn’t follow the rhythms and cycles of natural sleep — and so doesn’t derive the benefits of natural sleep. It won’t be as refreshing. The brain won’t have sorted and sifted.

The other is that the brain becomes accustomed to the drugs, and when you stop taking them you can get bounce-back insomnia. You don’t sleep much better with them any more, but you sleep even worse without them. You can also wake up drowsy and reach for the coffee which can quite quickly lead you into an unwanted vicious circle.

Lifestyle changes and sleep hygiene

I saved the best till last. It’s human nature to want to find quick fixes, but they’re not always the best.

I know, nobody likes the people who go on about this kind of thing. I’ve seen the eye rolls. The thing is it works. But only if you are consistent. And only if you are committed to doing it, doing it properly, rather than simply convincing yourself that you’re doing it. And you have to stick at it until you see the results. (Are you rolling your eyes right now?)

1. Make sure your room is comfortable — cool and dark. And that may mean turning down the heating and helping the other people in the house stay warm!
2. Keep a cap on your caffeine content — and keep your caffeine consumption to the morning and early afternoon. I mix really good quality ground coffee with really good quality decaffeinated coffee as a way of halving my caffeine intake without sacrificing pleasure.
3. Avoid too much alcohol. It will depress your nervous system — which will most likely bounce back in the early hours of the morning and yank you back to wakefulness.
4. Get sunlight during the day — it builds up your store of melatonin and helps your brain work out when to be awake and when to be asleep.
5. Avoid bright light — and especially blue light at night, because it confuses your brain when it’s trying to work out when to be awake and when to be asleep.
6. Don’t eat too much, or do too much brain work late at night. Find a bedtime routine that gives you time for calm before bed.
7. Exercise creates endorphins which help you sleep.
8. Manage your stress and anxiety. You might well tell me you’re not stressed, or not ‘that stressed’ right now. But sometimes we don’t realise how stressed we are until a period of stress finishes and we look back. And with the possible exception of Tibetan Monks, everyone is stressed right now.
9. Try a bit of yoga. The corpse pose is perfect for making sure you’re not bringing the tension of your day to your bed, trapped in your body. It also helps to breathe with your belly, focus on your breath and breathe out for slightly longer than you breathe in.
10. Relax your face. Seriously, lie there and pretend it’s melting into your pillow. Then empty your mind. Easily said than done. So lie there and think of nothing. Literally the word ‘nothing’. Every time a thought comes let it go and replace it with the word ‘nothing’. If I can stick at it, it always works.
11. Cooling down your face can help to activate the parasympathetic nervous system and calm you down. This is likely to be particularly helpful if anxiety is behind your insomnia. There are those that recommend wild swimming or a cold shower — but I’m just going to keep a damp flannel in the fridge!
12. If you can’t sleep. Get up. Do something that isn’t sleeping in a place that isn’t your sleeping place and then repeat your routine.

Remember — don’t panic!

There’s nothing worse than not being able to sleep because you are worrying about not being able to sleep. It needs taking seriously. But not so seriously it becomes a bigger problem than it might be. You may not have a choice about insomnia but you have a choice about how bad you let it make you feel.