Reflections on the Relationship Between Sleep and Quality of Life at Midlife
Special Feature
Reflections on the Relationship Between Sleep and Quality of Life at Midlife
By Sarah L. Berga, MD
I hear many complaints from women at midlife about sleep problems. Anyone trained in obstetrics can readily appreciate the generalized malaise that accompanies chronic sleep disruption. But I wondered why this was such a common complaint in perimenopausal and menopausal women and what, if anything, we as women’s health care specialists should do. Fortunately, part of my job involves hearing about clinical research done in National Institute of Health (NIH) sponsored centers around the country. I thought I might share some perspectives that I have gleaned from this experience.
The first distinction is to differentiate poor sleep due to interruptions from that due to what is referred to in the trade as "sleep-disordered breathing." First, let’s consider the interruptions. Hot flashes are a common cause and generally respond to conventional doses of estrogen.1,2 Even women without obvious sleep disruptions due to night sweats have poorer quality "sleep architecture" when hypoestrogenic, so the first line of defense in the treatment of menopause-related sleep disturbances is estrogen replacement. Progestins, especially progesterone, can be sedating, so one of the few benefits of progestins may be to increase sleep propensity. Depression and anxiety cause sleep disturbances. Antidepressants are of help if this is the cause. Also, simple "sleep hygiene" measures such as removing sources of anxiety from the bedroom may be helpful. Some have recommended the creation of a "pious parchment pile" (i.e., all those materials you think you ought to read, but are avoiding, for use when one cannot sleep). Another "sleep hygiene" recommendation is not to lie in bed for hours trying to go to sleep, but to get up and do something, like reading from the pious parchment pile. In one study, women ranked fatigue as their top health concern and attributed it to overwork, poor sleep, and social concerns.3 Nocturia is a common cause of sleep interruptions.4 If the cause is not cardiogenic or neurogenic, then simple lifestyle alterations such as restricting fluids in late evening may help. Did you know that women have a lower auditory threshold than men do? Is this a teleological adaptation permitting the cries of babies and young children to be heard? Possibly. Sleep interruptions due to noise are common. There are a plethora of commercial products designed to block noise and, thereby, aid rest. Noise from the street or highway may be a problem, but another relatively common source of noise is a snoring partner. Snoring is vastly more common in men and increases with age. Snoring is the most obvious sign of "sleep-disordered breathing" and is thought to carry health consequences for he that snores but, obviously, snoring also causes sleep disruption for the partner.5
Here is my take on why sleep disturbances are a common complaint of women at midlife. First, age takes its toll. We sleep less efficiently as we age. If a pure source of melatonin were available, my educated guess is that its use would reduce age-related sleep inefficiencies. Second, the erratic or declining ovarian production of estrogen and progesterone reduces sleep efficiency and alters sleep architecture. We should be able to remediate this problem with hormones. Third, midlife women have accumulated a lifetime of worries and may have "worn out their brains."6 This may yield to specific pharmacologic or nonpharmacologic psychological interventions. Fourth, partners have acquired their own sleep disturbances. Common causes of sleep-disordered breathing are allergies, sinusitis, asthma, obesity, alcohol, and the ravages of tobacco. In one study, the prevalence of habitual snoring among men was 30-40%, and among women, 7-18%.7 It is not clear why men are more prone to sleep-disordered breathing but, clearly, some of these factors are remediable.
The more we know about sleep, the more we learn how important it is for health. For instance, poor sleep has been shown to increase the likelihood of hypertension, other cardiovascular diseases, and traffic accidents.7,8,9 Learning and job performance are diminished in those with chronic sleep disturbances.10 Sleep complaints need to be taken seriously. Exercise, reduced alcohol intake, tobacco cessation, and good sleep hygiene are common-sense measures.11 Hormone therapy may be indicated for menopausal women. For some, evaluation and treatment of specific causes are recommended. For this, referral may be necessary. A common treatment for sleep-disordered breathing is continuous positive airway pressure. It may not be possible to eliminate all the factors contributing to sleep interruptions and sleep-disordered breathing, but it may be possible to reduce the frequency of interruptions and, thereby, reduce the health burden of this common and troublesome complaint.
References
1. Scharf MB, et al. Clin Ther 1997;19:304-311.
2. Purdie DW, et al. Br J Obstet Gynaecol 1995; 102:735-739.
3. Stewart D, et al. J Womens Health 1998;7:69-76.
4. Asplund R, et al. Maturitas 1996;24:73-81.
5. Loth S, et al. Arch Otolaryngol Head Neck Surg 1999;125:64-67.
6. Van Cauter, et al. J Clin Endocrinol Metab 1996;81:2468-2473.
7. Martikainen K, et al. Acta Neurol Scand 1994; 90:437-442.
8. Young T, et al. Sleep 1997;20:608-613.
9. Young T, et al. Arch Intern Med 1997;157: 1746-1752.
10. Ulfberg J, et al. Chest 1996;110:659-663.
11. King AC, et al. JAMA 1997;277:32-37.
Which of the following is rarely a cause of sleep disturbance in menopausal women?
a. partner's snoring
b. hot flashes
c. depression
d. newborn
e. nocturia
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