Hot flashes are a signature of menopause that can really interfere with a woman’s sleep. When they happen during the day, often women can muscle through them – remove a sweater, turn on a fan. But when they heat up at 3 a.m., they can wake women up and leave them sweaty, restless and tired.
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Holly L. Thacker, MD, Director of Cleveland Clinic Center for Specialized Women’s Health says that chronic sleep disruptions like hot flashes shouldn’t be waved away. Menopause may not even be the culprit, she says.
Weight gain and resulting sleep apnea, iron deficiency, thyroid problems, depression, restless leg syndrome and anxiety that can result from work-related stress or caring for children and aging parents can all disrupt a woman’s sleep.
“People have to be evaluated,” Dr. Thacker says. “A lot of people need more sleep than they think.”
Dr. Thacker cites research that shows women with disruptive hot flashes suffered professionally because they were unable to concentrate. But, she says, “Usually people with really disruptive symptoms have something going on in addition to menopause.”
How menopause can complicate sleep patterns
Obstructive sleep apnea can develop in postmenopausal women related to changes in hormonal control of the upper airway (i.e namely the loss of estrogen and progesterone in menopause), says sleep specialist Sally Ibrahim, MD.
When post-menopausal women are compared with pre-menopausal women and men, studies show that the post-menopausal women have apnea rates closer to those of men, she says.
Also, many women with disturbed sleep and night sweats (from apnea) will confuse this with being menopausal with hot flashes, she adds.
“Premenopausal women have lower rates of obstructive sleep apnea compared with menopausal women. This is likely related to the protective effects of hormones, which are lost with menopause,” Dr. Ibrahim says.
But sleep in menopausal women is complex. There can be natural changes to sleep related to age. Then, there are also changes related to menopause itself related to an increased risk of depression and insomnia.
If sleep apnea is to blame, it may not be the obvious cause. It’s important to note that some women do not have the typical symptoms, such as snoring or gasping for air. Rather, they may just feel depressed or anxious, have trouble staying asleep, or they may just get up and feel tired, unrefreshed and fatigued during the day.
This is why a comprehensive sleep evaluation is sometimes needed to decipher the causes, Dr. Ibrahim says.
Hormone therapy and hot flashes
For those whose sleep disruption does seem mainly due to menopause and hot flashes, the primary treatment is hormone therapy, Dr. Thacker says, although it’s not the only treatment.
“Women who take hormone therapy feel much better,” she says. “If you didn’t have sleep disruptions before, definitely take hormone therapy. For the vast majority of people, the benefits outweigh the risks.”
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The main risk of hormone therapy is a very rare incidence of blood clots, Dr. Thacker says. Many women remember past studies that branded hormone therapy as risky and dangerous, but that is not so.
Another common misconception is that there’s a time limit on how long women should take estrogen and progesterone combined in hormone therapy, Dr. Thacker says.
Typically you know within three months whether hormone therapy is effective, and “one of the reasons I see women who stay on it the longest, are people with trouble sleeping” when they go off the hormones, she says. Doctors re-evaluate symptoms periodically and try to keep the hormones to the lowest effective dose, she adds.
CPAP better bet to control apnea
The risks of hormone replacement therapy generally outweigh the benefits for patients suffering from sleep apnea, Dr. Ibrahim says.
Doctors usually prescribe continuous positive airway pressure (CPAP), as a first line therapy for anyone with obstructive sleep apnea.
“When tolerated, it is very effective,” she says. “CPAP has minimal side effects,” Dr. Ibrahim says.
People sometimes struggle initially with tolerating the mask as it can be hard to get used to wearing it. However, there have been many improvements of the masks and interfaces so with some effort, people can generally find something that works.
“Spending time finding a good mask fit is a good first step. There are other ways to make it comfortable too,” she says. Additionally, there are other therapies for obstructive sleep apnea outside of CPAP, such as dental appliances, she says.