Is there a relationship between menopause and insomnia?

I've noticed I have a lot of trouble sleeping since I've passed through menopause. Although I know I need to work on some things related to getting a better sleep routine, is there a relationship between menopause and insomnia?

Insomnia is common in menopause, and no doubt multiple factors are associated with its development and persistence. However, the actual link between the two conditions has rarely been investigated from a sleep medicine perspective. Nonetheless, Guilleminault et al has shown very convincing evidence that much of the sleeplessness of menopause could be related to obstructive sleep apnea (OSA) or upper airway resistance syndrome (UARS).(1)

These studies are more than a decade old, yet scant research has continued to explore this psycho-physiological connection. Obviously, if OSA or UARS triggers insomnia in menopausal women, it would make sense to treat the breathing disorder to determine its impact on the insomnia episodes. Guilleminault et al also conducted a second study on postmenopausal women and showed insomnia improved when the sleep breathing problem was addressed.(2)

The theory on menopausal insomnia related to OSA or UARS usually speculates on two specific pathways. The first is a reduction in progesterone that leads to a decrease in respiratory drive. If you recall earlier times in sleep medicine, you know progesterone was an actual medical therapy for OSA back in the 1980s despite very mixed reviews on its efficacy.(3) The second theory also involves progesterone, and the speculation is that airway dilator muscles become more lax due to progesterone deficiency. Other theories have also been explored.

One might wonder whether a study on hormone replacement therapy (HRT) as a means for treating OSA or UARS in menopausal women has ever been conducted. In fact, a few studies were conducted about a decade ago that clearly demonstrated improvement in sleep breathing events with the use of HRT.(4) However, as luck, fate, or Providence would have it, this research was published around the time of many emerging concerns about the effects of HRT on cardiac disease or cancer. Thus, even though the benefits noted with HRT were thought-provoking, this area remains largely unexplored due to potential adverse effects in these other areas of health.

To close, it is not unusual for sleep centers to note a much larger influx of female patients seeking treatment coincident with the development of their menopausal symptoms. And, once menopause sets in, most sleep doctors are aware of sleep breathing disorders in this specific cohort. Hopefully, you will find many sleep physicians ready, willing, and able to recommend and conduct overnight polysomnography to assess for possible sleep breathing disorders if you are presenting with insomnia complaints arising in menopause.

REFERENCES

1. Guilleminault C, Palombini L, Poyares D, Chowdhuri S. Chronic insomnia, postmenopausal women, and sleep disordered breathing: part 1. Frequency of sleep disordered breathing in a cohort. J Psychosom Res 2002;53(1):611-615.
2. Guilleminault C, Palombini L, Poyares D, Chowdhuri S. Chronic insomnia, premenopausal women and sleep disordered breathing: part 2. Comparison of nondrug treatment trials in normal breathing and UARS post menopausal women complaining of chronic insomnia. J Psychosom Res 2002;53(1):617-623.
3. Orr WC, Imes NK, Martin RJ. Progesterone therapy in obese patients with sleep apnea. Arch Intern Med 1979;139(1):109-111.
4. Shahar E, Redline S, Young T et al. Hormone replacement therapy and sleep-disordered breathing. Am J Respir Crit Care Med 2003;167(9):1186-1192.


Barry Krakow MD

Author

Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.



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