­Insomnia, OSA, and Menopause

 
Medically reviewed by
Dacelin St Martin, MD
Triple board-certified in Sleep Medicine,
Internal Medicine, and Pediatrics.

 
 
Causes  |  Epidemiology  |  Risk Factors  |  Symptoms  |  Diagnosis  |  Treatment

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Introduction

There’s an association between two common sleep disorders: insomnia and obstructive sleep apnea (OSA), and how they manifest during menopause. 

Insomnia is a sleep disorder where you have difficulty falling asleep, remaining asleep, or waking up too early. The frequency of insomnia is increased during menopause based on the intensity of vasomotor symptoms (VMS), like hot flashes, which are more likely to occur at night than during the day.

OSA is a breathing-related sleep disorder that causes soft tissues of the throat to repeatedly block airways, leading to pauses in breathing and sleep interruption. Estrogen withdrawal during menopause can contribute to OSA vulnerability. ^[1]

Both insomnia and OSA during menopause can be attributed to hormonal changes that affect a woman’s physiology. All three conditions can lead to depression and anxiety, which can interfere with sleep and complicate diagnosis. 

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Causes

VMS appears to be a significant cause of insomnia in menopausal patients.^[2] The early onset of perimenopause, the phase where the body is transitioning into menopause, is characterized by frequent hot flashes. These hot flashes are caused by changes within the hypothalamus, which are triggered by lower estrogen levels.^[3]

Night sweats, a result of the same hormonal changes as hot flashes, are a source of nighttime discomfort that can prevent sleep and cause insomnia. 

Anxiety and depression can cause insomnia, and women undergoing menopause are at greater risk for these conditions.^[4] The increased likelihood of anxiety and depression during menopause can be due to several factors, including hot flashes, hormone withdrawal, and the psychological toll of menopause itself. 

Polysomnography (PSG) studies show that hot flashes are more common during NREM sleep, and less common during REM sleep, which includes the suppression of awakenings.^[5]

A higher frequency of OSA in menopause patients is likely due to hormonal changes, specifically lower levels of estrogen and progesterone.  Progesterone is a respiratory stimulant, so a deficiency of this hormone can exacerbate breathing complications that cause OSA. 

The “hunger hormones” ghrelin and leptin regulate appetite; an imbalance in these hormones caused by a menopausal transition can contribute to obesity which increases the risk of OSA.

Epidemiology

One study estimates the frequency of sleep difficulty at 32-40% in the early stages of a menopausal transition, which increases to 38-46% in late transition.^[6][7]

In one study of 102 perimenopausal women, ages 44 to 56, who reported sleep disturbances, 53% had OSA or restless legs syndrome, or both.^[8]

Studies also indicate that patients with pre-existing depression and anxiety disorders face a greater risk of sleep interruptions with the onset of menopause.^[9]

Risk Factors 

The risk for OSA is slightly higher for women transitioning into menopause, as well as postmenopausal patients. This physiological change can be due to estradiol (a form of estrogen) withdrawal, one of the main female hormones, which hinders vasomotor function. 

One study shows a correlation between perimenopause and early postmenopause and clinical depression when VMS are prevalent. ^[10][11]

With or without menopause, the risk of OSA increases in obese patients and smokers. Factors like family history, diabetes, asthma, and naturally narrow breathing passages also increase the risk for OSA in menopause patients.

Like OSA, the risk for insomnia is heightened by these same factors, with or without menopause. Other factors that hinder sleep, like drug abuse, caffeine intake, depression, and anxiety, can also increase insomnia risk.

Symptoms

Symptoms of insomnia and OSA during menopause are similar to those who suffer from these disorders without menopause.

Insomnia carries its own set of symptoms, with or without menopause, including, excessive daytime sleepiness (EDS), fatigue, dehydration, hallucination, anxiety, poor concentration, weight gain, and depression.

There’s a high rate of comorbidity of depression, insomnia, OSA, and menopause. Studies show that there is an increased risk of depression during the menopausal transition, compared to premenopausal years.^[12][13][14]

OSA’s symptoms include snoring, excessive daytime sleepiness, hypertension, headaches, pauses in breathing, and weight gain. Hormones affected by menopause are ghrelin and leptin, which are responsible for regulating the body’s appetite. Ghrelin is an appetite suppressor, so a deficiency of this hormone in menopause patients could contribute to the obesity that heightens OSA’s risk.^[15]

Diagnosis

If you’re going through menopause, talk to your doctor about your symptoms and answer questions about sleeping habits honestly.

Your doctor may use diagnostic measurements, like the Insomnia Severity Index, to gather measurable information and ascertain if insomnia is related to menopause.^[16]

Obstructive sleep apnea is primarily diagnosed through polysomnography (a sleep study) to assess breathing, respiratory function, and blood oxygenation.^[17]

Your doctor may look for common OSA symptoms, like snoring, morning headaches, and excessive daytime sleepiness to decide if a sleep study is required.

Treatment

Insomnia

Menopausal hormone therapy, e.g., estrogen administration, can lessen the frequency of hot flashes.

Sleep aids can be prescribed to help manage sleeplessness; however, cognitive behavioral therapy (CBT-i) is another approach to deal with symptoms but it’s not effective in reducing the frequency of hot flashes.

A CBT-i approach can help increase comfort through healthy sleep hygiene habits, like keeping the bedroom cool, the use of fans, and avoiding triggers, like spicy food.^[18]

Obstructive Sleep Apnea 

OSA might be treated with physical therapy, as in treating the health factors, like obesity and poor circulation, that may be causing it. Studies show that weight loss can be effective in the reduction of hot flashes, which can also improve sleep.^[19]

Continuous positive airway pressure (CPAP) machines that keep airways open are a common solution for OSA. Doctors will also treat associated causes, like asthma and diabetes to lessen the impact of breathing complications. 

Conclusion

With insomnia, the inherent discomfort from hot flashes and night sweats is enough to prohibit restful sleep. Obstructive sleep apnea and menopause are linked to estrogen withdrawal, its effect on the body’s ability to regulate breathing, and weight gain. However, both OSA and insomnia are treatable, so it is possible to manage postmenopausal effects to some degree.

References:

1. Galvan T, Camuso J, Sullivan K, et al. Association of estradiol with sleep apnea in depressed perimenopausal and postmenopausal women: a preliminary study. Menopause. 2017;24(1):112-117. doi:10.1097/GME.0000000000000737
2. Santen, R. J. (2020, April 27). Menopausal Hot Flashes. UpToDate. Retrieved January 20, 2021 from https://www.uptodate.com/contents/menopausal-hot-flashes
3. Casper, R. F., & Yen, S. S. (1985). Neuroendocrinology of menopausal flushes: an hypothesis of flush mechanism. Clinical endocrinology, 22(3), 293–312. https://doi.org/10.1111/j.1365-2265.1985.tb03243.x
4. Casper, R. (2020, March 20). Clinical Manifestations and Diagnosis of Menopause. UpToDate. Retrieved January 21, 2021 from https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-menopause
5. Freedman, R. R., & Roehrs, T. A. (2006). Effects of REM sleep and ambient temperature on hot flash-induced sleep disturbance. Menopause (New York, N.Y.), 13(4), 576–583. https://doi.org/10.1097/01.gme.0000227398.53192.bc
6. Dennerstein, L., Dudley, E. C., Hopper, J. L., Guthrie, J. R., & Burger, H. G. (2000). A prospective population-based study of menopausal symptoms. Obstetrics and gynecology, 96(3), 351–358. https://doi.org/10.1016/s0029-7844(00)00930-3
7. Kravitz, H. M., Janssen, I., Santoro, N., Bromberger, J. T., Schocken, M., Everson-Rose, S. A., Karavolos, K., & Powell, L. H. (2005). Relationship of day-to-day reproductive hormone levels to sleep in midlife women. Archives of internal medicine, 165(20), 2370–2376. https://doi.org/10.1001/archinte.165.20.2370
8. Freedman, R. R., & Roehrs, T. A. (2007). Sleep disturbance in menopause. Menopause (New York, N.Y.), 14(5), 826–829. https://doi.org/10.1097/GME.0b013e3180321a22
9. Ibid, 3
10. Bromberger, J. T., Assmann, S. F., Avis, N. E., Schocken, M., Kravitz, H. M., & Cordal, A. (2003). Persistent mood symptoms in a multiethnic community cohort of pre-and perimenopausal women. American journal of epidemiology, 158(4), 347–356. https://doi.org/10.1093/aje/kwg155Soni, A. (2011, March) Ghrelin, leptin, adiponectin, and insulin levels and concurrent and future weight change in overweight, postmenopausal women. Retrieved Feb 5, 2021 from https://pubmed.ncbi.nlm.nih.gov/21449093/ 
11. Bromberger, J. T., Matthews, K. A., Schott, L. L., Brockwell, S., Avis, N. E., Kravitz, H. M., Everson-Rose, S. A., Gold, E. B., Sowers, M., & Randolph, J. F., Jr (2007). Depressive symptoms during the menopausal transition: the Study of Women’s Health Across the Nation (SWAN). Journal of affective disorders, 103(1-3), 267–272. https://doi.org/10.1016/j.jad.2007.01.034
12. Ibid, 10
13. Bromberger, J. T., Meyer, P. M., Kravitz, H. M., Sommer, B., Cordal, A., Powell, L., Ganz, P. A., & Sutton-Tyrrell, K. (2001). Psychologic distress and natural menopause: a multiethnic community study. American journal of public health, 91(9), 1435–1442. https://doi.org/10.2105/ajph.91.9.1435
14. Avis, N. E., Brambilla, D., McKinlay, S. M., & Vass, K. (1994). A longitudinal analysis of the association between menopause and depression. Results from the Massachusetts Women’s Health Study. Annals of epidemiology, 4(3), 214–220. https://doi.org/10.1016/1047-2797(94)90099-x
15. Ibid, 7
16. Tal, Joshua., & Suh, A., & Dowdle, C., & Nowakowski, S. (2016, Jan 1) Treatment of Insomnia, Insomnia Symptoms, and Obstructive Sleep Apnea During and After Menopause: Therapeutic Approaches. Retrieved Feb 4, 2021 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4607064/
17. Ibid, 9
18. Freedman R. R. (2001). Physiology of hot flashes. American journal of human biology : the official journal of the Human Biology Council, 13(4), 453–464. https://doi.org/10.1002/ajhb.1077
19. Huang, A. J., Subak, L. L., Wing, R., West, D. S., Hernandez, A. L., Macer, J., Grady, D., & Program to Reduce Incontinence by Diet and Exercise Investigators (2010). An intensive behavioral weight loss intervention and hot flushes in women. Archives of internal medicine, 170(13), 1161–1167. https://doi.org/10.1001/archinternmed.2010.162