ReviewSleep problems in midlife and beyond
Introduction
In western society, the incidence of sleep problems is increasing. For many, high demands on both work and leisure time may mean that the time allowed for sleep is too short. In addition, stress and worry are likely to reduce the length and quality of sleep. The impact of sleep on quality of life and health, both mental and physical, has been increasingly recognized in the literature, and, fortunately, there is now good information on the prevalence of sleep problems and the factors associated with them.
Although sleep problems are common in both sexes at all ages, women are more prone to them than men. A series of prevalence studies from different parts of the world reported that women are 1.3–1.8 times more likely to develop sleep problems than men [1], [2], [3], [4], [5]. Although sleep problems are common at younger ages, ageing nonetheless has deleterious effects on length and quality of sleep, through neuronal loss and atrophy, neurotransmitter defects and decreasing cerebral blood flow [6]. Sex hormone receptors, especially oestrogen receptors, have been found in brain areas responsible for sleep regulation [7] and may exert effects on sleep via several neurotransmitters [8]. Menopause has been considered to herald an increase in sleep problems [9], [10], [11]; this is partly because climacteric symptoms in themselves are associated with worse subjective sleep [12]. However, the incidence of sleep problems has been reported to have increased in women already in midlife [13]. Furthermore, studies that have carefully controlled for sleep disorders and examined objective disturbances rather than subjective reports have suggested that there is in fact an increase in primary sleep problems during the menopause, and not simply a decrease in sleep quality or length caused by climacteric symptoms [14].
Primary insomnia is the term used to denote sleep problems that have no specific identified cause [15]. Typically, patients with primary insomnia will always have had a relatively poor quality of sleep, but their sleep problems have worsened with age to the point where they seek medical help. More commonly, however, sleep problems are related to other factors. This is termed secondary insomnia [15]. Several physical (typically respiratory, pain and movement disorders) and mental conditions (notably depression and anxiety) may be involved. Indeed, cardiovascular, neurological, pulmonary, gastrointestinal, endocrinological, rheumatic or neoplastic as well as psychiatric diseases may all cause or otherwise be associated with sleep problems [15]. Sleep problems that are secondary to a chronic disease tend to be more severe and persistent than those that do not occur in the context of chronic illness [16]. Recent studies have suggested that treating both conditions simultaneously may improve the outcomes of each [17]. Use of different medications may affect sleep and cause or exacerbate sleep problems [18].
Finally, circadian rhythm disorders (often arising from shift work or travel) and sleep phase syndromes may lead patients to present with sleep problems [19].
This article discusses women's sleep quality at midlife and the menopause, and explores the effect of hormone therapy. It reviews important sleep-disordered breathing as well as pain and movement disorders that lead to poor sleep, as well as co-morbid somatic and mental conditions. Treatment options are then briefly covered.
Section snippets
Sleep in middle age and at the menopausal transition
Clinicians would hold that the increase in sleep problems at the menopausal transition is obvious among their patients. Although the reasons for these sleep problems are often complex, the typical menopausal symptoms themselves are often responsible. The clinical impression is backed by epidemiological data. In a large French study of women between the ages of 50 and 64 years, 25% reported sleep problems and 15% severe problems [20]. In a survey of 100 patients attending a menopause clinic,
The effect of hormone therapy on sleep quality
Female sex steroids, both oestrogen and progesterone, are not only involved in reproductive behaviour but also control a great number of brain functions, including sleep, cognitive performance and mood [42], [43], [44]. Steroid receptors have been discovered in several brain areas, including the cortex, hippocampus, hypothalamus, amygdala, basal forebrain, midbrain raphe nuclei, pituitary gland, locus coeruleus and cerebellum [45], [46], areas which are also involved in sleep regulation [47].
Sleep-disordered breathing
Sleep-disordered breathing (SDB) is an important cause of sleep problems. It is characterized by heavy snoring, airway obstruction (apnoea), airflow limitations (hypopnoea) and excessive daytime sleepiness [76]. SDB is associated with sweating and awakenings during the night, nocturia, dry mouth, morning headache, lack of energy, memory difficulties, depression and physical morbidity such as cardiovascular, pulmonary or neurological disease, diabetes and hypothyroidism [76], [77]. SDB can be
Medical disorders and sleep
For an adequate evaluation of sleep problems, a comprehensive knowledge of the history of medical disorders is required. Neurological diseases (e.g. epilepsy), pulmonary diseases (e.g. asthma, chronic obstructive pulmonary disease, gastroesophageal reflux), cardiovascular diseases (e.g. hypertension, nocturnal angina, heart failure or atrial fibrillation), diabetes and hypothyroidism, as well as musculoskeletal disorders, may all either cause or aggravate sleep problems [108], [16], [119].
Mood symptoms and sleep
There are consistent reports that mood symptoms, notably depression and anxiety, are connected to sleep problems [4], [119], [120], [121], [122]. Depressive patients typically suffer from sleep problems [119], [120], [121], [122], which in turn may worsen the depression. On the other hand, chronic insomniacs often become depressive [123].
Mood symptoms are more frequent in women than in men [124], [125], [126]. To explain these sex differences, several factors have been proposed, such as
Treatment options in sleep problems
Because of the multifactorial origin of sleep problems in midlife and after, treatment can be difficult. The first step is ensure good sleep hygiene: a comfortable bed and a dark, peaceful bedroom, at a suitable temperature; in addition, daytime naps and irregular bedtimes should be avoided [132]. Beverages like tea, coffee, some soft and herbal drinks, smoking, and alcohol intake before bedtime may interfere with sleep [133] and thus should be avoided.
In women at or soon after the menopausal
Conclusions
Sleep problems in midlife, at the menopausal transition and in the postmenopausal period are common. Sleep problems may be caused or aggravated by climacteric symptoms, especially vasomotor and mood symptoms. However, several other conditions and diseases (medical or mental), pain, medicaments, sleep-disordered breathing or restless legs syndrome may be involved. Neglecting the evaluation of these factors may prolong the correct diagnosis and lead to a sleep problem becoming chronic, which will
Provenance and peer review
Commissioned and externally peer reviewed.
Contributors
Päivi Polo-Kantola is the sole author.
Competing interest
No competing interests.
References (142)
- et al.
Gender differences in insomnia—a study in the Hong Kong Chinese population
J Psychosom Res
(2002) Insomnia in women
Clin Cornerstone
(2003)- et al.
Estradiol and progesterone regulate neuronal structure and synaptic connectivity in adult as well as developing brain
Exp Gerontol
(1994) - et al.
Menopause and perceived health status among the women of the French GAZEL cohort
Maturitas
(1994) - et al.
Climacteric symptoms and sleep quality
Obstet Gynecol
(1999) - et al.
Association of insomnia severity and comorbid medical and psychiatric disorders in a health plan-based sample: insomnia severity and comorbidities
Sleep Med
(2010) - et al.
Circadian rhythms and shift working women
- et al.
Characteristics of menopausal women seeking assistance
Am J Obstet Gynecol
(1987) - et al.
Sleep disruption and mood changes associated with menopause
J Psychosom Res
(1997) - et al.
Impact of climacteric on well-being. A survey based on 5213 women 39–60 years old
Am J Obstet Gynecol
(1993)