Part 4 of our 6-week menopause series
"I'm exhausted, I'm short with everyone, and I can't remember why I walked into the kitchen. Am I losing it?" If that sounds like you, I want you to hear this first: you are not losing it. Sleep, mood, and focus often shift together in midlife, and there is a lot we can do about it.
So far in this series, we've covered hot flashes and what helps and the early signs of perimenopause. This week, let's talk about the 3 a.m. wake-ups and the foggy afternoons that so many women in Princeton and the surrounding area tell me about.
Why Does Sleep Fall Apart Around Menopause?
According to the Study of Women's Health Across the Nation (SWAN), about half of women report sleep problems during perimenopause, compared with about 30% before it. Trouble staying asleep is the most common complaint. Sleep problems tend to peak in late perimenopause, then often level off or improve after menopause.
There are usually several things going on:
Night sweats. Hot flashes during sleep wake you up, sometimes many times a night.
Insomnia. Even women without hot flashes often say their sleep gets lighter and more broken during this time.
Sleep apnea. Women are at higher risk of sleep apnea once they begin the menopause transition. In one study of midlife women, breathing problems during sleep got more severe as women moved through menopause, independent of age and weight changes. Snoring, gasping awake, or morning headaches deserve a mention at your visit.
Is It Menopause, or Is It Depression?
Mood changes in midlife are real. Expert guidelines on perimenopausal depression, published with The Menopause Society in 2018, describe perimenopause as a "window of vulnerability" for both depressive symptoms and major depression. Women with a history of depression earlier in life are at the highest risk.
Depression in midlife often shows up alongside hot flashes and poor sleep, and the symptoms overlap. Feeling irritable after a week of broken sleep is different from weeks of low mood, losing interest in things you used to enjoy, or feeling hopeless. That's why I ask about mood at menopause visits and may use a short screening questionnaire.
If you are having thoughts of harming yourself or ending your life, don't wait for an appointment. Call or text 988 to reach the 988 Suicide & Crisis Lifeline, available 24/7, or call 911 or go to the nearest emergency room.
What Is Brain Fog, and Will It Last?
Brain fog can mean losing words, forgetting names, having trouble concentrating, or feeling scattered. The Menopause Society notes that 40% to 60% of midlife women report symptoms like these during the transition, and the changes are usually mild and within the normal range.
There's reassuring data, too. In a SWAN study of more than 2,000 women, learning and memory scores dipped during perimenopause and then rebounded to premenopausal levels after menopause. That suggests these changes are often temporary. Poor sleep and low mood make brain fog worse, so treating them often helps your thinking as well.
What Else Should We Rule Out?
Not every sleepless night or foggy day is hormonal. At your visit, we look at the whole picture, which may include:
Thyroid problems, which can affect sleep, mood, energy, and temperature
Anemia, especially if you've had heavy periods
Medications or supplements that disrupt sleep or concentration
Sleep apnea, which may need a sleep study
Alcohol, caffeine, and stress, which all affect sleep in midlife
What Actually Helps?
Treatment depends on what's driving your symptoms, so the plan is always individualized.
Cognitive behavioral therapy for insomnia (CBT-I). The American Academy of Sleep Medicine strongly recommends CBT-I for chronic insomnia. It's a structured program that retrains your sleep habits and thoughts about sleep. Sleep-hygiene tips alone usually aren't enough.
Hormone therapy. When night sweats are what's waking you up, hormone therapy treats the cause. The Menopause Society's 2022 statement notes that hormone therapy improves sleep in women with bothersome hot flashes. Benefit and risk are most favorable when therapy is started before 60 or within 10 years of menopause, but that's a guide, not a hard rule. I do treat women outside that window after a candid, individualized discussion.
Oral micronized progesterone at bedtime. It's mildly sedating and may help you fall asleep faster. It can benefit some women whether or not they have a uterus. If you do have a uterus and take estrogen, a progestogen is required to protect the uterine lining.
Antidepressants and therapy. For true depression, antidepressants and psychotherapy are the proven first-line treatments, according to the 2018 guidelines. Some antidepressants also ease hot flashes.
Nonhormonal options for hot-flash-driven sleep loss. If hormones aren't right for you, elinzanetant (Lynkuet) is my preferred nonhormonal option. It's taken once daily at bedtime and can cause drowsiness. I explained why we favor it in week 1.
You Deserve Rest and a Clear Head
Patients come to us from across southern West Virginia and southwest Virginia, from Beckley and Lewisburg to Peterstown, Giles County, and the Blacksburg and Christiansburg area. Dr. Samantha Snyder, Megan Lingenfelter, PA-C, VaLeah Bradshaw, CNM, and I are here to help you sleep, think, and feel more like yourself.
Summit Women's Health 411 12th Street Ext, Princeton, WV 24740
Next Friday, week 5: vaginal dryness and genitourinary syndrome of menopause (GSM).
This post is for general education and isn't a substitute for personal medical advice.
Call 681-282-5591 to schedule an appointment, and we'll make a plan together.
Sources
1. Study of Women's Health Across the Nation (SWAN). Fact Sheet: Sleep during the Menopausal Transition. https://www.swanstudy.org/wps/wp-content/uploads/2023/04/SWAN-Fact-Sheets-Sleep.pdf
2. Mirer AG, Young T, Palta M, et al. Sleep-disordered breathing and the menopausal transition among participants in the Sleep in Midlife Women Study. Menopause. 2017;24(2):157-162. https://pmc.ncbi.nlm.nih.gov/articles/PMC5266663/
3. Maki PM, Kornstein SG, Joffe H, et al. Guidelines for the evaluation and treatment of perimenopausal depression: summary and recommendations. Menopause. 2018;25(10):1069-1085. https://pubmed.ncbi.nlm.nih.gov/30179986/
4. Greendale GA, Huang MH, Wight RG, et al. Effects of the menopause transition and hormone use on cognitive performance in midlife women (SWAN). Neurology. 2009;72(21):1850-1857. https://pmc.ncbi.nlm.nih.gov/articles/PMC2690984/
5. The Menopause Society. Perimenopause (patient education). https://menopause.org/patient-education/menopause-topics/perimenopause
6. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022;29(7):767-794. https://doi.org/10.1097/GME.0000000000002028
7. Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021;17(2):255-262. https://pubmed.ncbi.nlm.nih.gov/33164742/
8. Bayer HealthCare. LYNKUET (elinzanetant) Prescribing Information. https://labeling.bayerhealthcare.com/html/products/pi/Lynkuet_PI.pdf
9. 988 Suicide & Crisis Lifeline. https://988lifeline.org/