Perimenopause: Counting Sheep and Still No Sleep

Case Report

A48-year-old woman seeks evaluation of sleep difficulties. She is perimenopausal and notes that over the past year she has had problems with sleep initiation and maintenance. Even though she has no prior history of depression, she has struggled recently with depressed mood. She has had progressive weight gain and snoring. She endorses a dry mouth in the morning, often with frontal headaches that subside within the first hour or two after awakening.

Her past medical history is notable for obesity, glucose intolerance, and recent blood pressure elevations. She is not on hormone replacement therapy (HRT). Physical examination is notable for body mass index (BMI) of 35, neck circumference of 16 ½ inches, and central obesity. She has mild retrognathia with resultant crowding of the oropharynx such that only the hard palate can be visualized.

The next best step in managing this patient is:

A. Refer her to a sleep specialist for evaluation of suspected sleep apnea.

Discussion

Of perimenopausal and menopausal women, 28%–64% report sleep disturbance. ^1,2 A 2005 National Institutes of Health (NIH) panel reported that sleep disturbance is a key perimenopausal symptom. ³ Sleep complaints are twice as prevalent in women, yet 75% of sleep research is performed on men. ⁴ Waking during the night is the most common complaint in perimenopause, although sleep initiation and early morning awakenings are also reported. ⁵

There are many theories about why we sleep, but the exact reason is still unknown despite much research in this area. What is known is that there are serious health implications from sleep disturbance. There is an increased risk of obesity and diabetes, hypertension, cardiovascular events, stroke, mood disturbance, substance abuse, and all cause mortality. ^6,7 In addition, there can be decreased daytime function, increased pain complaints, and increased severity of hot flashes reported with sleep disruption. ^8,9

In perimenopause, sleep disturbance tends to be multifactorial. There are extrinsic and intrinsic factors that contribute to sleep difficulties. Typically, women of this age group are stretched, with family and work demands compounded by stressors related to aging parents, changing family dynamics, and death of friends and family members. ^10,11 Behavioral maladaptations frequently occur as a result of these stressors, such as napping during the day and excessive intake of caffeine and alcohol. ¹² Mood disturbance tends to be bidirectional, with sleep disturbance and vasomotor symptoms. ^13,14 Hot flashes related to decreased estrogen levels in perimenopause are frequently implicated as the etiology of sleep disruption during this period of life. ¹⁵ Although treatment of hot flashes improves subjective sleep complaints, this is only part of the solution. ¹⁶

Primary sleep disorders, including obstructive sleep apnea (OSA) and restless leg syndrome (RLS) with periodic limb movements of sleep (PLMS), increase in prevalence with age. In one study, 53% of women aged 44–56 with reported sleep disturbance had OSA, RLS, or both. ¹⁷ Risk factors for OSA include elevated BMI, neck circumference>16 inches (40 cm), advanced age, increased waist-hip circumference ratio, and airway crowding. ¹⁸ Symptoms typically include loud snoring, witnessed apneas, gasping or snorting, dry mouth, and morning headaches.

RLS is diagnosed by four clinical criteria, including (1) discomfort in the lower extremities, (2) an urge to move or restlessness, (3) temporary improvement in the discomfort on movement, and (4) occurs in the evening hours while trying to fall asleep or during quiescent times of the day. ¹⁹ Approximately 80% of people carry RLS into sleep in the form of PLMS. ²⁰

Answer: The Correct Answer is A

The patient demonstrates risk factors and clinical history of concern for significant OSA, so referral to a sleep specialist is the best next step. The other therapies have a role in treating this patient but should be considered after a formal evaluation to rule out sleep apnea.

HRT has been found to markedly improve subjective complaints in sleep. ¹⁶ Estrogen seems to decrease frequency and duration of night awakenings, improves rapid eye movement (REM) sleep duration, and improves mood, somatic, and vasomotor symptoms. ²¹ Progesterone alone has shown improvement in wakefulness and increased REM. ²²

Nonpharmacologic approaches to improving sleep should not be underestimated. Encouraging regular physical activity can help with weight management, decreasing the risk of OSA, and sleep quality and vasomotor symptoms. ²³ Other nonpharmacologic approaches include cognitive behavioral therapies (CBT) for insomnia, which have proven to be more effective long term than pharmacologic approaches for insomnia. ²⁴ These include relaxation techniques, sleep hygiene education, and addressing distorted beliefs that can develop related to sleep. CBT can be helpful in managing climacteric symptoms. ²⁵

Nonbenzodiazepine sedative hypnotics have been shown to improve menopausal symptoms, quality of life, and mood ²⁶ while having a more favorable side effect profile than the older benzodiazepine preparations. However, when there is a high index of suspicion for severe sleep-disordered breathing, this possibility should be pursued before sedative hypnotics are initiated.

In summary, sleep difficulties in perimenopause tend to be multifactorial and require a multidisciplinary approach. Addressing sleep issues can promote improvement in mood, climacteric symptoms, and other health risks.