Sleep Disturbances: Menopause and Melatonin

Frederick R. Jelovsek MD, MS

"I am 53 and having a terrible time falling asleep. My doctor has prescribed Ambien® and it is working. I would love to just be able to sleep on a regular basis. Can I take this medicine for a long period of time? Can I take it on a regular basis? I have a great doctor, but he is not one who wants to write prescriptions and told me to check this information about sleep out for myself.

I do all the regular type of things to help i.e. no exercise late, no caffeine, good sleep setting, etc. I am on HRT also. None of these things seem to work. I really think this is all menopause related. I hate not sleeping. It makes life very difficult. I still have children at home and cannot just nap when I feel like it. Please help me on this. Thank you." Roxie

Taking Ambien®, which is a short-acting sleeping medication, is not detrimental in the long run other than it is somewhat habituating. You will become emotionally if not physically dependent upon it for your sleep. I think the doctor is correct that you should investigate ways about improving your sleep problem without having to continue the Ambien®. Since you are having trouble getting to sleep, your problem is most likely to be classified as insomnia rather than as a sleep disorder. In general, most sleep disorder experts recommend against treating chronic insomnia with continuous sleeping medications.

You have already done some of the things necessary to improve sleep: avoid exercise and caffeine within 5-6 hours of going to bed, create a good sleeping environment free of noise, comfortable (cool) with good temperature control. I assume you are also avoiding alcohol in that same 5-6 hour pre bedtime period. You may also want to make sure your HRT dose is adequate and not too low.

How does menopause affect sleep?

There are always more sleeping problems with age. Menopause, however, is a very common time for women to begin or to experience worsening sleep difficulties. We do not know why menopause causes a jump in more sleep disturbances and it may just be that hot flashes associated with menopause tend to wake women up frequently during the night. The scientific data about this is not clear (1). Taking estrogen replacement (ERT) or estrogen plus progestin (HRT) lowers the incidence of sleep apnea syndrome (2) and generally improves menopausal sleep difficulties that would be classified as insomnia (3, 4). This estrogen improvement of sleep is a long term rather than a short term effect (5).

Further evidence that estrogen plays a role in sleep disturbances comes from the fact that perimenopausal women who presumably have declining estrogen levels, have a greater degree of sleep disruption than do younger premenopausal women (6). For surgical menopause especially, and for natural menopause within the first 5 years, estrogen replacement should be at higher levels to prevent both hot flashes and sleep disturbances than doses used later in menopause.

What are other causes of sleep difficulties?

In general there are two major categories of sleep difficulties :

insomnia - difficulty getting to sleep or back to sleep after awakening (7, 8)

hyperarousal - anxiety, stress
poor pre bedtime and sleep habits
underlying mood disorders
sedative overuse
pain
general medical problems
nighttime urinary frequency

sleep disorders - resulting in excessive daytime sleepiness (9)

sleep apnea
restless legs syndrome
narcolepsy
circadian dysrhythmias

Women with sleep disorders do not have trouble going to sleep and when they wake up at night, in general they are able to go back to sleep without too much delay. Their main problem is that of waking frequently or not sleeping deeply enough to get their needed rest in rapid eye movement (REM) sleep. As a result, the amount of restful sleep is so poor they have significant daytime sleepiness. This loss of sleep is often associated with hypertension and cardiovascular problems if the sleep problem is long standing (10).

How can I tell if I have a sleep breathing disorder?

Sleep disordered breathing may take almost 10 years on the average to be diagnosed in women who have this condition (11). This is because the disturbance of sleep is more subtle than it is with insomnia. The following problems may alert you to a sleep disorder:

restless sleep
morning headaches
memory lapses
irritability
general lethargy/fatigue
slight disorientation
personality changes
sexual arousal dysfunction
obesity (losing weight can become difficult
but obesity may also be a cause)

Sleep apnea may affect 5% of the population. It can be due to obstruction of the airway at the nasal level or the back of the pharynx and is often, but not always, associated with snoring. There may also be a central nervous system cause of the stopped breathing (apnea). This type is not associated with snoring although a woman may stop breathing during sleep for 10 seconds or more. Sleep studies in which you sleep overnight in a sleep lab while having EKG and EEG wires attached to your body is the method of diagnosis.

How is insomnia different than sleep disorders?

Insomnia is a problem of difficulty falling asleep, difficulty staying asleep, or an unrestful sleep. Women who have sleep disorders, on the other hand, do not usually have trouble getting to sleep or going back to sleep. Both conditions may produce a restless sleep. Almost everyone has experienced transient insomnia lasting one or several days. Anxiety, a big event, or any cause of stress can produce this.

Chronic insomnia lasting more than 3 weeks is a problem for which most sufferers will seek medical help. There are many factors which can lead to this problem. Bad sleep habits, poor eating and drinking habits, medications, chronic anxiety, and stress or depression are among some of them. All of these factors must be addressed to treat insomnia.

In addition it is important for menopausal women to be at a sufficient estrogen replacement dose. For example a woman who is within 5 years of menopause will usually require 1.25 mg of conjugated estrogens (eg., Premarin®) or 2 mg of estradiol rather than .625 mg of conjugated estrogens or 1 mg of estradiol which are often inadequate as replacement doses.

If you have insomnia, ask yourself if you are overly concerned or worry about daily events and responsibilities before bed or right upon awakening. Sense whether or not you feel depressed. If you are taking any medicines, look up their contents to see if they may play a role. If you have high blood pressure, you may want your doctor to check you for obstructive sleep apnea. Discuss these factors with your doctor.

Is it better to use sleeping pills or a non prescription medication like melatonin for sleep?

Melatonin is a brain hormone (pineal gland) that is secreted according to a person's biorhythm. It is low during the day and peaks in the middle of the night. Exposure to light and dark controls its secretion rather than when sleep occurs (12). It has been well documented to be lower than normal in subjects with insomnia and administration of it may improve sleep problems in some people (13). Taking melatonin may be more beneficial in circadian rhythm disorders such as jet lag or shift workers (14, 15). Melatonin levels are lower in menopausal women who have insomnia and higher in menopausal women with depression and hyperprolactinemia (16). The hormone is a marker for circadian rhythm disturbance (as is cortisol) but not necessarily something that needs to be replaced (17). You can have your level checked with a home test called SleepCheck. A dose of 10 mg a day by mouth seems to be safe over a 30 day period (18) but whether it should be used on a regular basis for insomnia or circadian sleep disorders has not yet been determined. Skin cream with melatonin can also be used. In pregnancy, the baby is exposed to maternal ingestion of melatonin (19), and no studies have been done establishing safety in pregnancy (20). Although it is not likely to be harmful in pregnancy on a short term basis, it is not recommended for use during pregnancy.

Short acting sleeping meds are preferred whenever something is prescribed so that there is not a residual daytime sedative effect. Most people who take sedatives for sleep report that their sleep is better, but when questioned about symptoms, they seem to have the same amount of symptoms as insomiacs who do not take any prescribed medications (21). For this reason and also because sleeping medications can produce undesirable side effects, most physicians do not recommend long term treatment with medications. It follows that long term melatonin treatment would not be recommended for the same reasons.

What are practical steps to take to improve my sleep?

If you sense the main problem is a poor quality sleep and not insomnia, it is important to see your physician for a sleep study which can diagnose sleep apnea or restless legs syndrome or other sleep disorders. The treatment of the problem will be based on what is found.

For insomnia, the following measures may be useful:

Make sure bedroom noise is controlled and temperature is cool
have a fixed schedule to going to bed and getting up. Try not to vary it.
avoid alcohol and exercise within 5-6 hours of bedtime and no caffeine after noon.
do not look at the bedroom clock after you lie down in bed or if you get up at night
eat a light snack containing protein, especially tryptophan, before bed. This would include milk, cheese, yogurt, cottage cheese, bananas, fish, and turkey.
do not reflect upon the day's events or your "todo" list in the hour or two before bed

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