Synonyms
• Sleep apnea
• Obstructive sleep apnea (OSA)
• Insomnia
• Sleep disturbance
Subdivisions
General Discussion
Fatigue, or lack of energy, is a common symptom experienced by women throughout their lives.
Oftentimes, an explanation may be found for your fatigue. Your healthcare practitioner can work with you to look for a cause and subsequent treatment. They might start by asking you questions about your symptoms, your stress level and your mood since depression can cause fatigue. An exam and occasionally laboratory tests are done to look for associated disorders like thyroid disease, anemia (low blood count) or vitamin B12 deficiency.
If your testing is normal, then it is time to discuss your sleep. Are you sleeping enough? Do you have issues falling asleep or staying asleep? Do you snore? It’s easy to forget how important sleep is, but time and again, studies show sleep is critical to many aspects of our health and wellbeing including our energy level, mood, productivity, concentration, weight and sex. Good quality and sufficient amounts of sleep are associated with improved female sexual functioning (1,2). Sleep disturbance is very common during the menopause transition and can adversely affect all the health and well-being items listed above.
Signs & Symptoms
The National Sleep Foundation recommends that you get between 7-9 hours of sleep every night (3). If you sleep this much but still wake up tired, it’s important to rule out sleep apnea (pauses in breathing or shallow breathing during sleep). Snoring or weight gain, especially around your neck, may increase your risk for sleep apnea. Sleep apnea is under diagnosed and under treated in women. If sleep apnea is not caught and treated, it can make you tired as well as raise your blood pressure or increase your risk of heart disease (4-6).
If you are having difficulty falling asleep, staying asleep or waking up too early in the morning and are tired all day, you may have insomnia (7). If your symptoms happen at least 3 nights per week for the last 3 months and are not because of other medical illnesses or sleep apnea, you may have chronic insomnia. Things that can help include talk therapy (cognitive behavioral therapy - CBT) or improving your sleep routine (good sleep hygiene). The American College of Physicians, an organization that provides evidence-based guidelines to help doctors treat their patients, recommends CBT as the initial treatment for insomnia (8). Talk therapy can be done in a group or by yourself, on the phone, through the internet (applications such as SHUTi) or self-help books. If and when your doctor decide to add a medication, it should only be temporary. It’s important to ask not only about how the medication may help you, but the risks as well.
Restless leg syndrome is a disorder that includes an uncomfortable sensation in the legs with an urge to move that occurs during times of inactivity, usually at night. Although its cause is unknown, it can be associated with reduced iron stores.
Causes
Affected Populations
Insomnia affects about 6-10% of adults in the U.S.and is more common in women, especially during menopause (8,9). OSA is the second most common sleep disorder, and although the overall prevalence of OSA is higher in men (13% to 33% in men compared to 6% to 19% in women), older men and women (aged 65-69 years old) have a prevalence of OSA up to 49% (10). Restless leg syndrome occurs most commonly in people of northern European ancestry and affects 5 – 15% of people (11).
Diagnosis
Obstructive sleep apnea can be screened for with an overnight oximetry test.This test can be done at home. It involves an oxygen measuring device paced on your finger that monitors your oxygen level during the evening and overnight. If that test is positive, or the suspicion is high, then an overnight sleep study will be recommended. Sleep studies can be done in a special sleep lab or sometimes at home.
Insomnia is diagnosed clinically by your physician or medical practitioner based on signs and symptoms. Restless leg syndrome is also diagnosed clinically and may be accompanied by an assessment of iron stores and sometimes kidney function.
Standard Therapies
Treatment for obstructive sleep apnea is usually with a breathing mask (continuous positive airway pressure, CPAP) or a dental device that keep your breathing tube open at night when you sleep. CPAP is the best treatment available today.
Good sleep hygiene are habits that everyone has access to and can help you feel like you have more control over your sleep (or lack of sleep!). Sleep hygiene is when you train your body to sleep when you are in bed. Options to help do so include going to bed at the same time every night and waking up at the same time every morning; using the bedroom only for sleep or sex (no TV, books, tablets, etc…); keeping the room cool, quiet and dark. And, if you are lying in bed more than 20 minutes without falling asleep, get up and do something calming, then go back to bed. The book “No More Sleepless Nights” can give you more guidance on good sleep hygiene (12).
If you are always tired, think about how much restful sleep you are getting. Along with exercise, a healthy diet and stress management, sleep is an important part of a healthy lifestyle. For women going through menopause with significant night sweats, consider talking to your health care practitioner about menopausal hormone therapy. For most women under age 60 and within ten years from their last menstrual cycle, the benefits of hormone therapy outweigh the risks.
Many medications used for sleep have the side effect of improving sexual desire. Whether solely by improving sleep or by more direct mechanisms, knowledgeable health and sleep professionals can choose medications which have benefits for both sleep and sex if needed.
Investigational Therapies
Support Available
References
1. Kling JM, Kapoor E, Mara K, Faubion SS. Associations of sleep and female sexual function: good sleep quality matters. Menopause. 2021 Apr 19; 28 (6):619-625 PMID: 33878089 DOI: 10.1097/GME.0000000000001744
2. Kling JM, Manson JE, Naughton MJ, Temkit M, Sullivan SD, Gower EW, Hale L, Weitlauf JC, Nowakowski S, Crandall CJ. Association of sleep disturbance and sexual function in postmenopausal women. Menopause. 2017 Jun; 24 (6):604-612 PMID: 28141665 PMCID:5443696 DOI:10.1097/GME.0000000000000824
3. Hirschkowitz M, Whiton K,Albert SM, et al. National Sleep Foundation’s sleep time duration recommendations: methodology and results summary. Sleep Health 1 (2015): 40-43.
4. George CF. Sleep apnea, alertness, and motor vehicle crashes. Am J Respir Crit Care Med. 2007;176(10):954.
5. Young T, Palta M. Depsey J,Peppard PE, Nieto FJ, Hla KM. Burden of sleep apnea: rationale, design, and major findings of the Wisconsin Sleep Cohort Study. WMJ. 2009;108(5):246.
6. Uyar M, Davutoglu V. An update on cardiovascular effects of obstructive sleep apnoea syndrome. PostgradMed J. 2016. Doi 10.1136/postgradmedj-2016-125093.
7. Roth T. Insomnia:Definition, Prevalence, Etiology and Consequences. J Clin Sleep Med. 2007;3(Suppl):S7-S10.
8. Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD. Management of Chronic Insomnia Disorder inAdults: A Clinical Practice Guideline From the American College of Physicians.Ann Intern Med. 2016;doi:10.7326/M15-2175.
9. de Zambotti M, Colrain IM, Javitz HS, Baker FC. Magnitude of the impact of hot flashes on sleep in perimenopausal women. Fertil Steril 2014;102(6):1708-1715
10. Senaratna CV, Perret JL, Lodge CJ, Lowe AJ, Campbell BE, Matheson MC, et al. Prevalence of obstructive sleep apnea in the general population:A systematic review. Sleep Med Rev. 2017;34:70-81.
11. Yeh P, Walters, AZ, Tsuang JW. Restless legs syndrome: a comprehensive overview on its epidemiology, risk factors and treatment. SleepBreath. 2012;16(4):987-1007.
12. Hauri P & Linde Shirley. (1996). No More SleeplessNights. Wiley.
