The other day, at a friend’s house, she whispered to me, ‘I think I’ve got that thing that you have.’ I looked at her perplexed, mainly because we were alone in her kitchen, yet she was whispering. ‘That sleeping thing.’ It turned out she was suffering from insomnia , but what she really meant was, ‘I think I may be perimenopausal .’
Menopause and lack of sleep are as closely intertwined as a pair of young lovers. There, of course, any similarity ends. I love being horizontal between my linen sheets, and I fall asleep reasonably swiftly. But by three a.m. I am usually wide awake. I know this because I’ve checked the clock three times since I first crept to the loo at one forty-five a.m. Within minutes of my return to bed, I feel the delicious fog of slumber evaporate, my heart rate rise and my brain begin its relentless scan for topics to keep me engaged.
Occasionally, I am able to raise an exhausted smile out of what I dream up as a priority worry, but more often I’m shocked by the banality of some of my thoughts. The part for a kitchen appliance I keep forgetting to order, how to take revenge on the patronizing BBC manager who cancelled my podcast, where’s that blue dress gone? It’s three-fifteen a.m. and I’m getting closer to the moment when I’m going to either have to medicate or decide whether I can afford to be exhausted the next day.
The only upside to this nightly game of insomnia roulette is that I am not alone. According to a 2019 survey in the Sunday Times , an extraordinary sixty per cent of forty-five to fifty-four-year-old women and sixty-five per cent of women aged between fifty-five and sixty-four said their sleep was rubbish. This seems to confirm poor sleep as a symptom of menopause, from peri- to post. Insomnia was the first symptom of hormonal change that affected me, starting with baffling and frustrating nights of jerking awake and not managing to fall asleep again. I’ve now had poor sleeping patterns for nearly a decade, and suffered top-to-toe restlessness, from mind to legs.
The most important thing about sleep isn’t just how the next day feels, but how vital it is for our ongoing health. Not only is sleeping linked to poor brain function, low mood, tiredness (obviously) and stress, but, more ominously, long-term lack of sleep has links to heart disease, diabetes, respiratory problems, dementia and obesity. Those who sleep fewer than six hours a night on average have a thirteen per cent higher mortality risk than those sleeping at least seven hours. So, not sleeping properly is actually risking my health and my life. I dance a slow dance with death every single night.
Authors Mariella Frostrup and Alice Smellie. Image: Copyright Kate Martin
Turn up the heat: how hormones affect sleep
Oestrogen, progesterone and testosterone all play a part in the quality of our slumber. ‘Hormones affect women’s ability to sleep throughout their lives, from the point of puberty, through pregnancy, and menopause,’ says sleep expert Dr Neil Stanley. ‘A recent paper suggested that the effect hormones have on sleep is merely because of the fluctuations in body temperature.’ Whatever the merits of his observation, only a man would say ‘merely’ in that context.
‘Disturbed nights can be a consequence of temperature changes created by hormonal disruption,’ continues Neil. ‘You need to lose around one degree of body temperature to sleep. Otherwise, you’re restless, uncomfortable and fidgeting. Women are hotter than men. It’s as simple as that.’ Your body perceives a rise in heat as being a threat. With your eyes closed, you don’t know whether the house is on fire, or if you’re hot because of hormones. Therefore, our natural defence mechanism wakes us up, and, for many of us, that’s the end of it. Of course, in menopause, temperature increase is likely to come hand in hand with night sweats, the nocturnal version of hot flushes.
There is also the fact that our progesterone levels go down in menopause. This can make you feel sleepy by increasing the production of GABA, a neurotransmitter or brain chemical which helps sleep. It also makes you feel more relaxed.
‘Sleep is immensely complicated, and if sleep is disrupted you activate the stress response, which is fine in the short term, but long term stress can lead to multiple problems,’ explains Professor of Circadian Neuroscience at Oxford University, Russell Foster. (My stress response is easily activated, I suspect, and it’s not always to do with the menopause).
‘Elevated levels of cortisol – the stress hormone – suppress the immune system, which predisposes to infection and, long term, even cancer,’ says Russell. ‘Stress throws glucose into the circulation, leading to insulin resistance and a greater risk of type 2 diabetes. Sleep loss and stress lead to changes in the metabolic hormones ghrelin and leptin; ghrelin is the hunger hormone and goes up when you’re tired, and leptin, the satiation hormone, is reduced. The net effect is increased hunger, more calories consumed and weight gain.’
In summary, you will be fatter and more likely to get ill.
Aching joints are also quite common throughout menopause. I found that, however tired I was, on some nights my restless aching legs were able to counteract the exhaustion of my body, dancing an irritated little jig under the sheets.
The other thing keeping us up is the need to pee. Frequent urination in the small hours is called nocturia.5 The effects of oestrogen are vital for the health of the urethra, bladder and the pelvic floor muscles. One study showed that seventy-two per cent of women aged forty-five to fifty-four needed to go at least once at night, and this can obviously affect sleep. So, if the flushes and anxiety don’t get you, the poor muscle tone will.
I think it’s important to point out that the reasons for our mid-life sleep deprivation aren’t down to menopausal symptoms alone. ‘Sleep quality naturally deteriorates with the ageing process,’ says Neil. ‘Here, unusually, women benefit. Men start to lose the slow, deep-wave sleep, which is restorative, from around the age of thirty-five, and women from fifty-five. Men decline twenty years earlier.’ This is all because deep sleep is to do with memory, learning and physical growth; vital for kids, and obviously less so for adults. We only produce Human Growth Hormone (HGH) in this cycle. ‘Post thirty- five, men are biologically redundant,’ says Neil. You have no idea how cheerful it makes me feel to write this sentence! ‘Women are preserved by nature to both have babies and then to look after them.’ He says that this means women are far more adaptive than men. So possible that you can’t go back to sleep because there’s no physiological need. ‘It’s not vitally important for the survival of the species.’
Lack of sleep can – without exaggeration – ruin your quality of life and threaten your sanity. Whether it’s HRT, yoga, breathing your mind back to a state of calm or taking a hot bath with mineral salts before you go to bed, there are all kinds of ways to help ease yourself into better patterns.
Calling a halt: the solutions to insomnia in menopause
The ridiculously long list of medications and supplements in my armoury rather proves that there’s no simple solution. I take my daily HRT, in the form of oestrogen gel in the morning and a progesterone tablet in the evening. I assume this helps – I have no intention of exploring the landscape of an HRT-free life. HRT is great, but it’s not a cure-all. And it doesn’t quite tick the sleep box for me.
I’ve also tried:
• CBT breath counting – it works, but some nights it proves impossible to stop the thoughts flooding in
• CBD oil – quite helpful
• Having a bath with lavender oil – occasionally helpful
• Sleeping pills – very helpful, but I don’t want to be addicted
• White noise – better than just the sound of my thoughts
• Melatonin – in small doses, and taken regularly, it definitely helps, and it’s available on the NHS for over-fifty-fives
• Horlicks – just makes me thirsty
• Doing less work – works a treat, but hard to pay the bills
• The Calm app – again, better than my own thoughts, but often they break through the rippling watery noises and scare me
• Magnesium – oral or topical – good for aching and restless legs.
• Reading – fortunately, I enjoy reading, which doesn’t send me off to sleep, but helps me while away the small hours.
Professor Kevin Morgan is also a sleep expert, and he – bafflingly – doesn’t necessarily recommend my scattergun approach. ‘Most women will experience some sleep disturbance during menopause,’ he says. ‘It introduces a range of unique but ultimately predictable challenges to sleep, which will be – hopefully – short-lived for many. Very few women emerge from those years with permanently disturbed sleep – but some will. ‘The problem with, say, sleeping tablets or melatonin is that they offer only short-term solutions for what can be a longer-term sleep problem,’ he says.
‘If you address sleep problems with a pharmacological response, it pays to consider your exit strategy, since you may be committing yourself to a product for the rest of your life.’ It’s a valid point but perhaps made by someone who doesn’t seem to have experienced the agonies of permanent exhaustion. Just a few years of insomnia can feel like a life sentence and culminate in ruined careers, relationships and quality of life.
Expert ways to treat menopause sleep problems
This has been shown to help reduce night sweats, which are the whispering fiery demons of the menopausal woman’s night. Progesterone also helps you to relax and is known to increase the production of a brain chemical called GABA. Low testosterone can also affect sleep.
‘Melatonin isn’t a sleep hormone,’ says Russell Foster. ‘It’s a biological marker of the dark and it modulates but does not drive sleep.’ As the day turns to night, the body produces melatonin, as one of many signals that it’s time to go to bed. People with heart problems, on beta-blockers and the elderly have lower levels of melatonin, and this may contribute to the poorer sleep seen in these groups.
As a supplement, it’s been used for slightly inducing sleepiness, and is only available on prescription in the UK in the over-fifty-fives. ‘Sometimes melatonin works and sometimes it doesn’t,’ says Russell. ‘Some people seem to be quite sensitive to it and some aren’t. All the evidence suggests that it isn’t dangerous. The only thing I’d be careful about is if there is a family history of mental illness, as there is some evidence that it might lower mood.’
• CBT(cognitive behavioural therapy)
‘It’s the frontline treatment for insomnia,’ Neil says, and it’s supported by the NHS, the EU and the US. He says it’s as good as, if not more effective than sleeping tablets. CBT is about reframing the fact that poor sleep is just a bad habit, and learning what affects sleep. Free on the NHS is Sleepstation.org.uk (though you have to get a GP referral, otherwise it costs), and Sleepful.me, run by the National Centre for Sport and Exercise Medicine, Loughborough University, is also free.‘
• Natural remedies for sleep
There is some evidence of efficacy for valerian, passiflora and hops. Passiflora is said to reduce brain activity and help sleep. Valerian has sedative effects and it’s thought it might be related to GABA production as well. Hops also appear to affect melatonin and the happy hormone serotonin.
‘Remember that, just because they’re natural, it doesn’t mean there aren’t contraindications with prescription medication. Always check,’ says Neil. I know a few people who swear by the Bach Rescue Night Remedy , £8.50, which contains white chestnut, said to help switch off the mind from unwanted repetitive thoughts. There is also some good evidence of magnesium’s usefulness. It helps with leg cramps and muscle relaxation, and those who have trouble sleeping often have low levels of magnesium. Magnesium and melatonin together are said to be especially effective.