Abstract
As long ago as 1998 Owens et al. 1 reported that ‘Transition into postmenopausal status is associated with deleterious changes in sleep patterns among women who do not take hormone replacement therapy’. A quick glance at any of the menopause fora will reveal that sleep disturbance is a considerable problem for many women at midlife and beyond. Healthcare professions often consider the disturbance to be secondary to hot flushes and mood change (particularly anxiety) and offer sleep hygiene advice, antidepressants or intermittent use of hypnotics. In the aftermath of the Women’s Health Initiative (WHI) initial publications, women who had stopped their HRT reported problems with sleep even when the night sweats resolved. Subsequent studies have indicated that estrogen-deficient effects on separate brain areas are responsible for the two phenomena.
Given a proposed central mechanism, the prevalence of the problem and the distress caused, I would contend that sleep disturbance should be more widely regarded as a primary symptom of menopause. My observation that it tends to be a staying asleep rather than getting to sleep problem, has little formally published support. Perhaps, this might be a worthy research project to provide the evidence that will avoid women being prescribed psychoactive preparations when hormones are more holistically appropriate.
The meticulous sleep diary showed Penny commonly to be waking up to five times a night with an average total sleep duration of 6.25 h.
Penny had some urogenital symptoms, but it was the sleep and mood effects which she felt were putting most strain on her marriage and her work, as she ran a business with her husband.
Penny had had palpitations investigated a couple of years before with no significant findings and was essentially an uncomplicated, slim active and low-risk woman. She came to ask to try HRT as her GP did not feel able to authorise this.
Penny was of a similar age to the women typically enrolled in the Women’s Health Initiative (WHI) trial. She was aware of their published findings in respect of heart disease, DVT and breast cancer as the study results were accorded media prominence around the time of her last period. We now know from other studies that non-oral estrogens will avoid the thrombotic effects such that at standard doses, there is no increase risk in DVT or stroke risk. At 62, this seemed wise. Subsequent studies have highlighted the ‘window of opportunity’ to protect the coronary arteries and this had been clearly missed. I explained, and Penny was happy to accept the unknown effects of starting non-oral HRT at the age of 62 on her coronary arteries. Bone protection was seen as a plus and breast effects as a minus that could be lived with for better quality of life.
Penny had taken oral combined contraception in her youth with no adverse effects. This was likely to have contain a first or second generation androgenic progestogen and higher dose ethinylestradiol than currently used. There were no apparent issues of tolerance.
There is much experience though only limited evidence that older women need lower doses of HRT to relieve their symptoms. It is worth explaining that this may take longer (up to six to eight weeks) than standard doses before improvement is appreciable. Penny was started on half of a combined 50 µg estradiol with norethisterone patch (off-license) changed twice a week. She was advised to cut it before peeling the backing off so that the remaining half could still be used.
Penny was waking typically twice but occasionally three times at night and sleep duration had extended to 8.34 h which she was delighted with. The need to go to the toilet when she woke was less intrusive and she realised that this had been more of an issue than she had previously appreciated.
There was, however, the sense that more was possible and we agreed an increase to three-quarters of a patch, cutting a strip from the side rather than a quadrant off to deliver 37.5 µg/day estradiol.
Three months later, Penny felt that she had achieved as much as she could reasonably expect. She only ever woke twice in the night and rarely had to go to the toilet more than once. Her average sleep duration was 8.86 h and both her and her husband’s quality of life had improved significantly. For her, the balance of risk over benefit was very much in favour of continuing HRT and we agreed an annual review.
Penny agreed to my telling her tale as she would like other women to be offered the option of HRT. She is one of the generation of women who hit menopause at the time of the WHI and Million Women Study publications and avoided hormones as a result. Those women who have come to regret their earlier decision deserve a chance to consider whether it might still be appropriate.
My plea is for some basic research evidence to inform this process. Could somebody please investigate the issue of sleep, both with and without intervention and provide us with information about prevalence and impact of the problem. We also need information about the comparative efficacy of all interventions (both prescribed and alternative). I am a great fan of an evidence-based approach. Both funding for and interest in research about menopause evaporated after the WHI and MWS. There needs to be something better than the anecdote and experience-based tales that I and others tell. My real worry is that those of us with experience are approaching retirement and those who follow will have nothing to fall back on.