Insomnia in menopause

Insomnia is a common symptom seen in women throughout their menopause. It is frequently associated with vasomotor symptoms such as hot flushes and night sweats.¹ Behavioural treatments such as sleep hygiene, relaxation techniques play an important role in the overall management of sleep disturbance.¹ HRT (hormone replacement therapy) is beneficial to improve sleep through alleviating the vasomotor symptoms associated with the menopause.¹

Insomnia or sleep problems commonly occurs in women during menopause with a prevalence rate of 33% to 51%. Perimenopausal women frequently complain of poor sleep quality, recurrent awakenings, drowsiness and requirement of extra sleep.¹

Insomnia is characterised by difficulty in falling asleep, difficulty in maintaining sleep and non-restorative sleep, which is the subjective feeling of insufficiently refreshing sleep.²

Chronic insomnia may lead to irritability, sleepiness, increased anxiety, depression, tiredness, impaired work performance, diminished intellectual capability and cardiovascular risk.⁴ It adversely affects the quality of life, and impairs the social and occupational capability.⁴

Changes in hypothalamic, pituitary and ovarian hormones are observed during menopause.¹ Temperature homoeostasis is impaired due to a reduction in estradiol concentration in the hypothalamic temperature-regulating centre.³ There is a close relationship between the temperature-regulating centre and sleep-regulating centre of the brain, which can lead to simultaneous disturbance in the sleep-regulating centre due to hormonal fluctuation during menopause. In addition, the disruption of temperature-regulation axis causes vasomotor symptoms such as night sweats and hot flushes, which may in turn disturb sleep.¹ The severity of insomnia in perimenopausal women is correlated to other factors including overall quality of life, physical and mental health, physical activity, social environment and vasomotor symptoms.⁴

The quality of sleep can be assessed subjectively by self-reporting or objectively through somnography. In somnography, the brain waves, muscle tension and eye movements are recorded and scored for the stages of sleep.¹ It has been observed that vasomotor symptoms such as hot flushes and night sweats increase the occurrence of insomnia in menopausal women. Therefore, effective treatment of these symptoms is beneficial to alleviate insomnia.¹ Behavioural treatment includes counselling the patient regarding appropriate sleep hygiene, regulating the bedtime routine and stimulus control play an important role in the overall management of insomnia.^1,5