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SLEEP MEDICINE
Tolle Causum: Treat the Cause
Achieving restorative sleep is the chief goal for anyone experiencing insomnia. This is because the cumulative effects of losing every precious minute of shut-eye leads to chronic sleep dysregulation, increased risks of chronic disease, daytime fatigue and declining cognitive health. Sleep deprivation is a known independent risk factor for motor vehicle accidents, and chronic sleep loss can shave a decade or more off of one's lifespan. Many women in mid-life and beyond experience ongoing poor quality sleep and distressing temperature regulation changes.
Sleep loss is also a known risk factor for weight gain, insulin resistance, cardiovascular diseases and neurobehavioral disorders, and these same conditions worsen during menopause. This means that sleep loss fans the flames of chronic disease development. Regaining restorative sleep is an essential first step towards healing myriad ailments. Addressing the root cause of insomnia makes the therapeutic response more sustainable and effective.
In menopausal women, disruptions in neuroendocrine circuitry and decreases in estrogen and progesterone contribute to insomnia. Lowered estradiol and increased follicle stimulating hormone (FSH) have been associated with increased night sweats. The quantity of night sweats has been used with predictive accuracy in waking episodes in polysomnographic sleep studies (PMID: 2614224). The neuropeptide orexin (known by some researchers as hypocretin) governs sleep and waking synchrony via cholinergic neural pathways. Menopause creates a physiology with low estrogen levels and elevations in orexin, and the use of estrogen therapy has been shown to partially normalize orexin levels (El‐Sedeek et al 2010). Orexins appear to exert, and also be affected by, the integrity of the neuroendocrine system (Russell et al 2001).
Growth hormone deficiency, estrogen decline and progesterone insufficiency are also commonly overlooked causes of poor sleep. Obstructive sleep apnea, periodic limb movement disorder & restless leg syndrome are other forms of sleep disorders which may be impacted by ovarian hormonal changes. Insomnia is actually one of the most common concerns for perimenopausal women, and women in this group are more likely to deny themselves sufficient sleep than postmenopausal women. This sets the stage for increased risk of daytime cognitive errors. Falling estradiol levels has been associated with difficulty falling and remaining asleep, whereas elevated levels of follicle stimulating hormone (FSH is a neuroendocrine hormone which communicates to the ovaries as a request for estradiol production) have been associated with poor sleep maintenance (Kravitz et al 2012). Increased FSH, estradiol fluctuation and lower levels of inhibin B have been correlated with sleep difficulty issues (Freeman et al, 2007, PMID: 17666595). Recent data has also discovered an association between endocrine-disrupting chemicals and increased sleep loss in menopause.
Holistic and integrative treatments are started after a clinical review of symptoms has been performed. Those with greatest risk of sleep apnea are referred to sleep medicine physicians for a polysomnography test.
Select References:
Campbell RE, Kevin L, Grove KL, Smith SM. Gonadotropin‐releasing hormone neurons coexpress orexin 1 receptor immunoreactivity and receive direct contacts by orexin fibers. Endocrinology 2003;144:1542–8.
El‐Sedeek, Korish A & Deef M. Plasma orexin‐A levels in postmenopausal women: possible interaction with estrogen and correlation with cardiovascular risk status. BJOG 2010;117:488–492
Kravitz HM, Joffe H. Sleep during the perimenopause: a SWAN story. Obstet Gynecol Clin North Am. 2011 Sep;38(3):567-86.
Russell SH, Small CJ, Kennedy AR, Stanley SA, Seth A, Murphy KG, et al. Orexin A interactions in the hypothalamo–pituitary gonadal axis. Endocrinology 2001;142:5294–302.
Female Insomnia
Women transitioning into menopause often experience:
- Poor sleep quality
- Lack of restorative sleep
- Insufficient sleep
- Increased night sweats
- Increased nocturnal awakenings
- Hypoxic events / apnea (often unbeknownst to them)