Sleeplessness is second only to hot flushes as a reason why my menopausal and peri-menopausal patients ask me about hormones. Every day in my medical practice more than one patient describes the loss of sleep as the worst part of 'the change'.
You might think the decreasing amount of sleep during menopause and perimenopause is because of interruptions due to hot flushes, but there is more to it than just waking up to sweats. Curiously, though, the scientific data is not very revealing as to the cause. Most large studies have not shown conclusive links between oestrogen decline and sleeplessness, but gynaecologists like me see a strong relationship in their patients. I often hear, 'I would be OK if I could just sleep,' 'I can take the hot flushes, but not the insomnia,' 'I will take hormones the rest of my life if they help me sleep...' So here's what works (and doesn't) for menopause-related insomnia:
The issue here is that sleep is imperative to memory processing, and not just any sleep – specifically healthy sleep, including rapid eye movement (REM) and what is known as slow wave sleep (non-REM). Just being 'drugged' into sleep does not result in the healthy brain processing that's an important purpose of sleep. In fact, the most concerning side effect from long-term use of sleep aides such as Ambien is short-term memory loss.
Often even very low doses of oestrogen will help a person who is willing to accept the risks, and progesterone has been used for years to help coax in drowsiness. A German study in 2000 demonstrated that EEGs (which record brain activity) of sleeping menopausal women were significantly improved with a low dose oestrogen replacement, suggesting improved 'cognitive functioning.' But up to now, larger studies have not demonstrated that hormone replacement is beneficial to sleep, despite many anecdotal stories of miraculous improvement.
Oestrogen is not sedating, but the brain does experience a withdrawal-like syndrome in menopause and the result can be surging levels of noradrenalin. Which means some menopausal women are actually experiencing a flight-or-fight reaction in the middle of the night (due to the brain withdrawing from reproductive hormones that are no longer pouring out of the retiring ovary). So it would follow that oestrogen replacement may ease insomnia in some who are experiencing sleeplessness or early morning wakening. But there are risks, and some women must avoid HRT regardless of benefit (such as those with an active oestrogen sensitive cancer or a history of blood clot or stroke).
If HRT is not an acceptable option, or is not effective, there are several other approaches, including meditation. It's an often-overlooked safe, effective way to mimic the brain healing effects of good sleep. There are even some in the field of meditation who explain that the brain waves achieved with adequate mindfulness resemble those during healthy sleep.
Melatonin, the brain chemical associated with nightfall or darkness, has an important role in overall health and possibly short-term memory. In the UK, melatonin supplements are available on prescription only. In the US where I practise, you can buy them over the counter (3-5mg at bedtime for adults), and even if they are only mildly sedating, their addition may aide in mental clarity the following day, so speak to your GP about it.