During Perimenopause (the transition to menopause), fluctuations in hormones can disrupt sleep leaving you feeling shattered and wobbly. Levels of the hormones oestrogen, progesterone and testosterone fall and at different rates, affecting neurotransmitters in the brain linked to sleep. This can cause the well documented hot flushes and night sweats, but even those women who do not experience these report poor sleep. After menopause, sleep will improve but as perimenopause can last years, poor sleep can take its toll. According to the NICE guidelines, HRT compared with placebo consistently improves menopausal symptoms such as vasomotor symptoms (like hot flushes), sleep outcomes and quality of life generally. However for some women in this life stage, not being able to get to sleep, or get back to sleep becomes cyclical and problematic, significantly disrupting their functioning, and HRT doesn’t help or isn’t right for them.
Perimenopause is linked to an array of different body and brain changes resulting in mood changes, skin irritation, body aches and pains, all of which can cause discomfort and disrupt sleep. Additionally, because Perimenopause occurs at a time in a woman’s life when many social, psychological and familial changes are occurring, such as having teenage or older children, divorce or ageing parents, work stress or dissatisfaction, you might find yourself lying awake worrying. Anecdotally, many women report that during Perimenopause, alcohol can make getting to sleep even more difficult and hot flushes during the night more likely. All of these factors combined, stop us from getting a good night’s sleep. But what exactly is good sleep?
You may need more or less than the average person but usually it’s around 7-9 hours uninterrupted sleep a night. If you are finding it difficult getting to sleep, waking up regularly or waking up too early you may feel that your sleep isn’t restful. This might occur from time to time or it might become a bigger problem. It might be an historical problem that’s become worse during Perimenopause. As we age, sleep changes too, as we spend less time in deeper sleep and have more light sleep phases, meaning that we wake more easily.
Insomnia is diagnosed when sleep problems are present at least three nights per week and have been present for at least one month. Poor sleep and perceived poor sleep can lead to daytime drowsiness, poor concentration, irritability, low mood and higher emotion sensitivity in general. When we’re overtired our emotions become exaggerated but if we don’t link this to sleep, it can lead to more concern, or self blame, for example asking yourself, “What’s wrong with me? Why am I reacting like this?” and this can have a knock on effect to mood, relationships, work and pretty much every area of life. I’ve not personally experienced insomnia, but I know that I need sleep and feel shocking when it’s disturbed. When my youngest was a baby I got nowhere near enough sleep and was woken many times during the night and it’s the closest I’ve felt to losing my mind. It was a pretty scary experience actually, but I now know that this was a sort of dissociative experience, my mind jumbled and shutting off my emotions due to exhaustion and it was short lived.This one day the sun was streaming through the patio doors and it was so blinding I couldn’t see properly. The mess of toys and piles of dishes were screaming at me while the children’s voices blurred into the background and everything seemed dreamlike and unreal. I don’t remember how I snapped out of it but I do remember that was the point when I spoke to my other half and asked him to help me with the baby. That sounds terrible as he did help but because I was on maternity leave and he was working, I felt it was my role to do the nights. This was an early lesson in the need for self care and asking for what you need before you hit breaking point. If you’re reading this you might be able to relate or you might not realise that lack of sleep is the explanation for such a lot including, having a short fuse, tears, clumsiness, forgetfulness, it’s hard to know what comes first, Perimenopause, poor sleep, mental health, stress, the chicken or the egg. It’s all linked.
I’m sure that if you’re reading this saying yep that’s me now tell me what I can do, you could probably tell me! You’ve probably researched and tried everything. It can feel like the most frustrating thing in the world reading articles about sleep hygiene with the usual list of advice:-
1. Avoid blue light exposure at bedtime
2. Have a warm drink and make your room dark and at a comfortable temperature
3. Avoid caffeine
4. Get active during the day….etc etc etc
Don’t get me wrong this is all good advice and a good place to start, but when you feel sleep deprived, a cup of Horlicks or lavender on your pillow isn’t going to cut it.
When you have lived with poor sleep for months or even years, a little more intervention is needed. It might, like me, require looking at your day, the points of stress and dissatisfaction, the burden, the load and considering what you can do there, with boundaries and asking for help. It might be that you are dealing with unresolved trauma or loss, as some people develop fear of going to sleep to try to avoid dreaming and memories related to their hurt. If this is you, therapies such as EMDR for trauma and loss, or counselling for grief might help break through this, and give you a better night’s sleep.
If there’s no deeper issue then Cognitive therapy for insomnia is evidence based and is specifically geared towards sleep . Through careful assessment of your sleep pattern, your beliefs about sleep and the behaviours that you have developed to try to cope with the issue, you can learn to reset your sleep. Whilst it’s understandable to scroll through your phone when you’re lying awake, or go to bed early to try to get more rest, this and other behaviours might inadvertently reinforce the problem. Because the human brain is extremely good at identifying links between stimulus and response, in its drive for efficiency, you can become conditioned to not sleep! Unhelpful patterns can quickly set in coupled with beliefs that reinforce anxiety around sleep. CBT for insomnia helps undo these patterns and reset sleep using the following methods:-
1. Cognitive restructuring
Cognitive restructuring identifies the beliefs you have around your sleep and breaks these down helping you to look at the situation objectively. For example you might be saying to yourself, ‘ Oh no I can’t sleep and I’ll be a wreck tomorrow!” Or, “I’ll be lying awake for ages and won’t be able to get to sleep”. Cognitive restructuring involves changing these thoughts to more constructive, less catastrophic thoughts, such as “Even if it takes a little while to fall asleep, I’ll be fine tomorrow,” or “I can trust in my body’s natural ability to sleep.”
2. Stimulus control
Because of the repeated experience of lying awake in bed, this conditions the brain and body to associate the bed and bedroom with anxiety (conditioned arousal) and wakefulness. To help break this, the person is first told to use the bed only for sleep and sex. All other activities like reading, looking at a phone or laptop, eating, drinking, watching tv are to happen in another room. If the person switches the light off and doesn’t fall asleep within 20 minutes they are to go into another room and do a relaxing activity until they begin to fall sleepy, when they should then return to bed.
3. Sleep restriction
This might sound odd but it works by undoing the behaviour which might be worsening the problem. People with insomnia worry about not getting enough sleep and so might go to bed early and stay in bed longer trying to rest, but in fact this means more time in bed not sleeping. Sleep restriction involves staying awake for longer and out of bed so that the person’s sleep drive builds up and when she finally gets to bed she’ll fall asleep more easily and be more likely to stay asleep.
4. Sleep hygiene, as mentioned above, is an important part of it. Creating the right conditions for sleep plus sticking to a routine for going to sleep and wakening, is important as it helps to re- program the brain’s sleep pattern.
5. Relaxation methods are taught to quieten the mind and calm the body. Breathing techniques and progressive muscular relaxation helps quieten the nervous system and mindfulness techniques plus imagery can be helpful.
So whilst you might have tried points 4 and 5, perhaps consider trying the first three and see how you get on. Otherwise consider seeing a CBT practitioner who can guide you and help you identify the culprit coping behaviours and thoughts that you might need to work on.
This book might be helpful if you’re interested in reading more.
Overcoming Insomnia and Sleep Problems: A Self-Help Guide Using Cognitive Behavioral Techniques https://amzn.eu/d/9Ljb3X6
As a final note, next time you’re lying awake, feeling alone with your thoughts, it can feel very isolating, but remember there’s another woman, possibly many, just like you, in your street, in your town, lying awake right now too. Send out positive thoughts or prayers for her and others you know who might be struggling and I’ll do this for you too 🙏❤️
Photo by Efecan Efe: https://www.pexels.com/photo/tourist-hammock-hanging-between-old-trees-8200207/
Sea change 