Sleep Issues Caused by Menopause

Insomnia

We spoke to Dr. Sara Nowakowski, a leading expert on cognitive behavioral therapy for menopausal insomnia (CBTMI), to answer our questions about why so many women struggle with sleep during perimenopause.

Fifty percent of perimenopausal women experience insomnia. Why? 

Perimenopausal and postmenopausal women are up to two times more likely to report sleep issues than non-menopausal women. Fluctuating hormones are one reason women experience insomnia, but they’re not the only factor. Insomnia is often referred to as the Menopause Puzzle due to its multifaceted nature, which includes the effects of aging, individual medical issues, and psychosocial stressors. Women in their mid-forties to early fifties, known as the Sandwich Generation, often experience considerable stress balancing child-rearing, caring for aging parents, and demanding careers. These stressors, combined with hormonal changes, complicate menopausal insomnia. While hormonal changes can trigger insomnia, one’s response to sleep deprivation may perpetuate it.

How does insomnia impact women throughout the daytime? 

Insomnia is clinically characterized by difficulty falling asleep, staying asleep, or waking too early. To meet the DSM-V diagnostic criteria for an insomnia disorder, these difficulties must persist for at least three months and cause daytime impairment, such as decreased work performance, increased fatigue, impaired social functioning, and mood changes. Insomnia sufferers often feel less patient, mentally foggy, and irritable. Many report memory issues and difficulty thinking clearly.

Is there a connection between insomnia and mental health? 

Sleep disturbances, whether sleeping too much or too little, are symptoms of clinical depression and anxiety disorders. Sleep deprivation can significantly impact mood, creating a cyclical relationship between mood disorders and sleep disturbances. Studies have shown that cognitive behavioral therapy for insomnia (CBTi) can improve both insomnia and mood disorders. Chronic sleep disruption can weaken one’s mental state, affecting patience and resilience. Menopause’s impact on mental health is often underestimated, leading women to feel as if something is wrong with them or that they lack control.

Can you describe Cognitive Behavioral Therapy for Menopausal Insomnia (CBTMI) and why it’s so effective in treating insomnia?

CBTMI focuses on the idea that thoughts, both positive and negative, influence physical and emotional well-being. Negative thoughts can perpetuate unhealthy sleep patterns. CBTMI, typically delivered over 4-6 sessions, includes sleep education, sleep restriction, stimulus control, and cognitive restructuring.

CBTi targets how thoughts interfere with sleep. When unable to sleep, the brain tends to engage in active thinking, which can escalate into an unproductive cycle. CBTMI reframes these thoughts more positively. Treatment begins with an evaluation of the patient’s history and habits, including nighttime rituals, relaxation techniques, and responses to sleeplessness. Clients are then instructed to maintain a sleep diary for a week to track sleep patterns. Behavioral strategies are implemented, such as sleep restriction, to build sleep pressure and improve sleep quality. The goal is to trust the body’s natural ability to regulate sleep.

What are some helpful tips for people when they cannot sleep?

1. Go to bed when sleepy. Don’t try to force that time. Allow your sleepiness to tell you when you need to go to bed.
2. If you fall asleep but wake in the middle of the night, as often happens when experiencing hot flashes, follow the 15 – 20 minute rule. If you’re not back to sleep in that time, get up! Use the bathroom, walk around. Leave the bedroom and find something peaceful and non-purposeful to do: maybe read a book or listen to a podcast (note, this is not the time to clean your house or check your emails). The core tenet is to stop the idea of forcing sleep and trust that the body will self-regulate. It’s interesting to know that during a hot flash, the body rapidly heats in just 30 seconds and the “flash” lasts about five minutes, but it takes the body about 20 minutes to fully cool. Abiding the 15 – 20 minute rule allows peaceful cooling while not perseverating about sleep.
3. During an interrupted sleep night, keep the same rise time! This is key—do not chase sleep. If you get a bad night’s sleep, do not try to compensate for it the next morning. Getting up at the regular time builds the body’s sleep hunger. You may feel tired that day but it’s an investment in restorative sleep the following night. Trust the notion that your sleep will naturally reset. Accept where your body is today, commit to letting the consequences happen, and build your sleep appetite to stop the insomnia cycle.

CBT is a behavioral technique. Should it be used in tandem with sleep medication?

Sleep medication tends to work quickly and is designed to be used short-term. It’s not a permanent solution. CBTi builds long-term skills one can use when faced with poor sleep, and because insomnia is episodic, one can use those tools whenever needed. It may be helpful to use sleep medication to provide fast relief, but ideally it should only be used for small amounts of time.

How can women find qualified CBT therapists?

‍The Society of Behavioral Sleep Medicine has a page on its website to help people find local CBT providers. Another helpful resource is the Veteran Association’s free insomnia workbook. Although it was designed for returning veterans, it’s a great way for one to work through their own sleep issues (download the workbook here). I wrote an article for the North American Menopause Society about CBTi for insomnia (access it here). In it, I recommend to clinicians that if they have a client whom they suspect has insomnia to consider referring them to a sleep medicine clinic or behavior sleep medicine provider for evaluation.