Difficulty sleeping is one of the more common signs of menopause, with upwards of 40% of women between late 40s and early 50s reporting symptoms. (1) It can range from trouble falling and staying asleep, to diagnosable sleep disorders such as chronic obstructive sleep apnea and insomnia.

A few weeks back, Proper teamed up with Elektra Health—a company on a mission to smash the menopause taboo through expert education and care—to discuss the science behind why menopause is so impactful on sleep and what women can do about it. Below, we break it all down.

Menopause only officially begins once you’ve gone 12 consecutive months without a period, which means it’s marked retrospectively. The average age is 51, and the time leading up to that is what’s called “perimenopause,” which can last anywhere from seven to ten years. It’s during this time that many women start experiencing symptoms commonly associated with menopause, such as hot flashes/night sweats, mood changes, increased anxiety, irregular and/or heavy periods, and difficulty sleeping.

"Perimenopause can appear as early as the late 30s, and it’s often missed by traditional healthcare providers. Most women won’t experience ALL of the symptoms, but they will experience a few, so it’s important to know what they are."

Jacqueline Giannelli, MSN, RN, FNP-BC, NCMP (Elektra Health)

Once you’ve hit menopause, your ovaries will stop producing estrogen and, as a result, stop releasing eggs. Once this happens, you’re in what’s called “postmenopause.”

Generally speaking, both men and women experience decreases in deep sleep — aka “delta sleep” — after adolescence. However, this is compounded for women who, in addition to aging, are traversing a menopausal transition marked by fluctuations in several key hormones: estrogen, progesterone, serotonin, and melatonin.

  • Estrogen
    Pre-menopause, estrogen works to decrease sleep onset latency (aka the amount of time it takes to fall asleep). It also improves sleep quality by reducing the number of times you wake up throughout the night and increasing total sleep time. Also worth mentioning is the fact that estrogen regulates body temperature at night. So when levels begin fluctuating during perimenopause and eventually decline, it can cause night sweats and sleep disruptions.

  • Progesterone
    Progesterone begins to decline during the early stages of perimenopause. Because this hormone is related to the drive for breath, it functions as a protective factor against snoring and sleep apnea (a condition causing abnormal, extended pauses in breath due to an upper airway obstruction). When levels decline, it increases the chances of fragmented sleep.

  • Serotonin
    As estrogen and progesterone drop during menopause, so too does serotonin, the “happy hormone” that helps stabilize mood and promote general feelings of well-being. This may serve as a risk factor for anxiety and depression, both of which disrupt sleep.

  • Melatonin
    Melatonin is a hormone our bodies naturally produce. Quantities increase as the sun goes down and decrease during daytime hours in order to regulate the sleep-wake cycle. As women age, levels of melatonin decrease, which affects the circadian rhythm.  

Hormonal changes are important, but they don't always tell the whole story. Remember, women are going through a lot during these years! Stress due to things like finances, aging parents, career, and body image can all add up to cause or exacerbate sleep difficulties.

  • Insomnia
    When difficulty falling asleep is chronic (i.e. occurring more than three nights/week for three months or longer), it’s classified as insomnia which, if not addressed, may contribute to increased anxiety, impaired concentration and memory, and increased headaches.

  • Obstructive Sleep Apnea (OSA)
    Studies indicate that 20% of women develop some form of OSA during menopause—although they may not even know they have it. (2) The condition is marked by temporary pauses in breathing, which causes an increased risk of snoring. And as we all know, snoring doesn’t bode well for quality sleep.

    READ MORE: When To See A Sleep Specialist: 6 Signs + Symptoms

  • Hot flashes + night sweats
    Hot flashes are classified as a vasomotor symptom (VMS) affecting about 85% of menopausal women. (3) The cause? Fluctuating hormone levels—specifically estrogen, which affects the temperature-regulating part of the brain: the hypothalamus. Hot flashes occurring at night are known as night sweats, and because they’re associated with an increase in adrenaline, they often cause sleep disturbances.

Proper’s Head Sleep Science Advisor, Dr. Allison Siebern, PhD, CBSM, outlines a few key interventions to address sleep problems during menopause—with the caveat, of course, that sleep isn’t one-size-fits-all. Any treatment plan should be tailored to individual needs and goals.

  • Smart supplementation
    There are a wide range of natural supplements available, some of which directly promote sleep while others do so indirectly via stress management. In addition to valerian root, ashwagandha, and melatonin, Dr. Siebern indicates that there is promising emerging research (4) on the impact of CBD on sleep symptoms for menopausal women — as well as for sleep improvement in general — although more research is needed before making any definitive claims. (5) 

  • Prescription + over-the-counter sleep medications
    “A lot of people don’t want to go down this route because they’re concerned about side effects and don’t want to become addicted,” explains Dr. Siebern. “But for acute distress caused by extreme stress or grief that affects sleep, it’s worth a conversation with your primary care provider.” Unlike non-habit-forming supplements, prescription medications are not intended for long-term use. Some may negatively interact with other medications, so it’s important to read the fine print and allocate yourself at least eight hours of sleep.

  • Watching what foods you do + don’t eat
    When it comes to foods and drinks that negatively impact sleep, most people immediately think of coffee and other caffeinated items like dark chocolate and black tea. But what you may not know is that there’s a slew of other less-well-known foods that can mess with your ability to fall asleep and get enough sleep. For more information, refer to our full list of 15 foods and drinks that may help or hurt your sleep.

  • Hormone Replacement Therapy (HRT)
    HRT involves taking supplemental hormones (estrogen and/or progesterone) to replace what the body no longer naturally produces during the menopause transition. It is not typically recommended as a course of treatment for sleeplessness alone but rather for ancillary menopausal symptoms that may indirectly affect sleep, such as hot flashes. The decision about whether to pursue this course of treatment should be discussed at length with your women’s health provider (or an Elektra provider) to understand the associated benefits and risks.

  • Behavioral change
    As a Stanford-trained sleep specialist and licensed clinical psychologist board-certified in Behavioral Sleep Medicine, Dr. Siebern is adamant that better sleep cannot be achieved without addressing underlying behavioral and lifestyle change. “It’s important to consider how much time you spend in bed compared to how much time you’re actually sleeping,” explains Dr. Siebern. “And what about your behaviors around bedtime? Are they being prioritized or short-changed due to other chores or activities that can infringe on your sleep? Many people are getting less sleep or poor sleep simply because there’s so much going on.” Here are five tips she recommends:

  1. Avoid clock watching
    What to do:
    Turn the clock around before you go to sleep and avoid the temptation to look at the time should you wake up in the middle of the night.

    The science behind why it's beneficial:
    Seeing the time when waking up in the middle of the night or early morning can trigger a feeling of pressure to get back to sleep, thus activating the sympathetic system. Also, if your alarm clock has a screen, the blue light can trigger the light receptors in your eyes which, in turn, signal the time-keeper in the brain to be awake.

  2. Develop a nighttime routine
    What to do:
    Start your wind-down routine at least one hour prior to bedtime with a relaxing activity, such as reading content that is not too engaging or taking a bath.

    The science behind why it's beneficial:
    Avoiding excitement prior to bedtime is a way to lower sympathetic activation (the body’s fight or flight system). Activities that are too stimulating can engage this system and run interference with the onset and maintenance of sleep.

  3. Limit blue light exposure
    What to do:
    Dim bright light exposure 1-2 hours prior to bedtime.

    The science behind why it's beneficial:
    The light receptors in the eyes are linked to the time-keeper in the brain that regulates when we sleep and when we are awake. Bright light confuses this signal and may keep us awake when we’re exposed to it within 1-2 hours of bedtime.

  4. Practice proper in-bed behavior
    What to do:
    Use the bed for sleep and sex only, not as a hangout area. If this is impossible due to limited space or mobility, have a daytime look for the bed that you swap out at night (e.g., different pillows, sitting up rather than laying down, etc).

    The science behind why it's beneficial:
    If the bed becomes associated in our minds with activity, socializing, and other activities besides sleep, it is confusing for the brain to ALSO associate the bed with sleep. The goal? Bed = sleep, not bed = active mind, worry, and not sleeping.

  5. Try to get on a consistent sleep schedule
    What to do:
    Go to bed and get up around the same time every day—even on the weekends.

    The science behind why it's beneficial:
    The physiological part of our bodies thrive off of routine because there are hundreds of processes based on the consistency of the 24-hour day. If the schedule of when we are awake and asleep varies considerably, it can cause confusion for the body and throw off these physiological processes, resulting in feelings of perpetual jet lag.

Still having trouble sleeping? Here are more science-backed tips, dos, and don'ts:

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