Menopause, Insomnia and Chronic Disease – Is There A Connection?
Sleep is one of the most vital elements of achieving good health and its importance cannot be overestimated. Nearly every system of the body depends on satisfactory sleep quality and quantity for routine healing, repair and restoration. Insufficient sleep robs the body of renewable energy sources and cell restoration, creating a suboptimal environment in the body, and eventually leading to dysfunction, imbalance and poor health.
Women over the age of 50, struggle with insomnia more than at any other time in life. In fact, as premenopause comes to a close, the prevalence of insomnia sharply increases from 16 to 42 percent. It continues a steady uphill climb through the menopausal years, and takes another sharp ascent to over 60 percent in the postmenopausal years. Shifting sex hormones trigger a cascade of hormone imbalances that make sleep difficult. Progesterone has a calm, sedative effect that promotes good sleep; therefore, as progesterone drops and new feelings of anxiety sweep in, both the quality and quantity of sleep is compromised. Plummeting estrogen can trigger vasomotor symptoms such as hot flushes, rapid heart rate, mood swings, irritation, anxiety, and stress. These changes cause frequent nighttime awakenings, making sleep quality shallow. Complicating matters even more, melatonin – the hormone that puts us to sleep and keeps us sleeping – is significantly reduced during menopause, in addition to the normal decline in endogenous melatonin secretion known to occur as both sexes age. Unfortunately, as aging women suffer from continual insomnia, their risk for chronic disease increases. This is especially true for chronic pain and fatigue disorders such as fibromyalgia, of which women over the age of 50 years are the predominant sufferers.
The human body functions on an internal 24-hour cycle, known as a circadian rhythm, which functions to align the body’s internal activities with its external environment. This rhythm dictates both physiological and behavioral activities, including the sleep-wake cycle, body temperature, metabolism, eating schedules, hormone secretion, blood sugar balance, and cell reproduction. A healthy circadian rhythm will be synchronized to the earth’s rotation, meaning light is the most influential trigger for determining an individual’s circadian rhythm. Other elements that can influence the rhythm include genetics, eating schedules, activity, and hormones such as melatonin. As women age, many of the factors that maintain a healthy circadian rhythm are disrupted, leading to poor health.
The sleep-wake cycle is one of the initial activities damaged by a disrupted circadian rhythm, prompting chronic insomnia and sleep disturbances. The inability to fall asleep or stay asleep, excessive daytime sleepiness, chronic fatigue, and randomly falling asleep at unusual times are all roadblocks to quality sleep that will result in a lack of restoration and healing. Establishing a healthy sleep-wake cycle by means of supporting a natural circadian rhythm is foundational for anyone struggling with suboptimal health, but especially aging women at risk for chronic pain and fatigue syndromes.
Stages of Sleep
While a healthy circadian rhythm will promote a routine sleep schedule, the next goal for establishing quality sleep is to ensure the body successfully passes through all 5 stages of sleep. Stage 1 sleep is a light sleep in which muscle activity slows (sometimes sudden muscle jerks are experienced during this stage), preparing us for stage 2. Nearly 50 percent of our sleep time is spent in stage 2, during which eye movement ceases and brain activity slows, for the purpose of healing and restoration. As the body passes into stage 3 and stage 4 (collectively known as deep sleep), extremely slow delta brain waves are active, while muscle and eye activity remain silent. Finally, the body spends approximately 20 percent of its total sleep time in REM (rapid eye movement) sleep. In this final stage, breathing is rapid, irregular and shallow, while blood pressure and heart rate increase. The eyes rapidly move in various directions, and muscles are temporarily paralyzed. Each night, the body consecutively passes through the stages of sleep multiple times. Each cycle may last up to two hours. As the night progresses, REM sleep lengthens while stage 3 and 4 sleep shorten. Waking up during a sleep cycle can often disrupt the continuity of the sleep stages as the body decides whether it should resume the previous sleep stage or start over, leading to insomnia and common sleep disturbances. Both increasing age and hormone status, in women, has been shown to contribute to lesser amounts of deep sleep and frequent night awakenings.
Sleep and Chronic Pain and Fatigue Syndromes
Chronic pain and fatigue syndromes such as fibromyalgia and chronic fatigue syndrome are most commonly diagnosed among women between the ages of 50 and 70 years, and may be initiated by the sleep disturbances that affect these women. Pain can act as both a cause and consequence of sleep disturbances, and in the case of chronic pain and fatigue syndromes, both elements are present. Neuroimaging studies on fibromyalgia patients have revealed functional sleep disturbances including reduced short-wave sleep and abnormal α-rhythms (usually present when we are awake, but relaxed), which suggest frequent awakenings during non-REM sleep (stages 1-4), as is regularly described among aging, menopausal women. Deprivation of stage 4 deep sleep is common with these findings and can exacerbate pain and impair pathways that function to inhibit pain. These pathways are already compromised in fibromyalgia patients, leading to abnormal pain sensitivity. Improving sleep has resulted in better pain management and less fatigue while impaired sleep in healthy individuals has created pain and fatigue. This not only illustrates the critical role of sleep in pain management and its importance in those with chronic pain and fatigue syndromes, but at least partially explains why aging women are among the highest population group at risk for fibromyalgia.
Healthy Sleep Habits
A healthy circadian rhythm will establish a sleep-wake cycle that follows the natural patterns of the sun. Most adults benefit most from obtaining at least 8 hours of uninterrupted sleep between the hours of 10 or 11pm and 6 or 7am. Naturally, the body desires more sleep during the longer nights of the winter season. Likewise, the body is more vibrant and energetic during the long days of the summer, when exposure to sunlight is more direct and lengthier. Both quantity and the specific time of the day are important for sleep quality. Sleeping for an adequate length of time during daylight hours when the body’s circadian rhythm is fighting its external environment, creates disrupted, low-quality sleep. This is often seen in third shift workers who may obtain an adequate amount of sleep, but still experience sleep deprivation. Similarly, lack of adequate sleep during an appropriate time can result in sleep deprivation.
Allowing the body to adequately prepare for sleep is equally important. The brain begins releasing melatonin approximately two hours before it assumes sleep, to calm and relax the body, which promotes uninterrupted sleep. Even though melatonin production decreases with age, taking measures to preserve and support its production can be beneficial. Many women prefer to read before turning out the lights. Reading from books, rather than electronic devices and instead, turning off all electronic devices an hour before sleeping, to remove the blue light that cancels the effects and reduced the production of melatonin is important. Some women find that a warm bath with magnesium salts is relaxing and promotes better sleep. Alternatively, taking magnesium can help relax muscles and encourage better rest. Engaging in calming activities, reading encouraging literature, and using an oil diffuser with calming essential oils can like lavender further establish sound sleep. Finally, it is important to sleep in a dark room, void of startling sounds and lights, and distracting pets, to support optimal melatonin production and uninterrupted sleep.
Botanicals and Nutriceuticals to Promote Sleep
Re-establishing healthy sleep habits as the body is aging and defying normal patterns can require patience and perseverance, especially when trying to build them in the context of a chronic pain and fatigue syndrome. In these cases, calming botanicals and nutrients that promote melatonin production and relaxation can help restore good sleep habits. Chamomile has been used as a mild tranquilizer for centuries and helps promote sleep. It makes a delicious bedtime tea. Valerian is another popular botanical, used in many cultures, for improving sleep quality. It has been shown to induce a sedative-like effect by inhibiting the breakdown of GABA, a calming neurotransmitter. Valerian can also help relax muscles, which encourages relaxation and sleep. Both lemon balm and passionflower are useful when sleep is disturbed by chronic stress and anxiety, common associated conditions with chronic pain and fatigue syndromes. Lemon balm and passion flower have been shown, in studies, to significantly improve difficulties in falling asleep and improves the calming activity of GABA, similar to valerian. Additionally, lemon balm may help to decrease pain sensations, leading to better sleep quality. Often a combination of calming botanicals is most effective for improving sleep quality.
Other nutrients that support relaxation and sleep include L-theanine, GABA, phosphatidylserine, and melatonin. L-theanine is an amino acid found primarily in green tea. It is a precursor to the production of the calming neurotransmitter, GABA. However, remember that consumption of caffeinated green tea may counteract this positive effect. In some cases, supplementing with GABA directly can be temporarily helpful while supporting the body’s natural production of this neurotransmitter. GABA’s calming actions can be attributed to its ability to balance excitatory neurotransmitters such as dopamine, promote muscle relaxation, and reduce anxiety, all of which contribute to poor sleep. Phosphatidylserine is particularly useful when chronic stress is inhibiting sleep quality, marked by frequent awakenings in the early morning with the inability to resume sleep. Phosphatidylserine is a fatty substance that is integrated into cell membranes and especially those of the brain cells. It helps improve the transmission of neurotransmitters between brain cells. Finally, melatonin (or a precursor, 5-HTP) may be tremendously helpful for aging women and help regulate the sleep-wake cycle.
Regardless of one’s sex and age, sleep is foundational for regaining health and maintaining health. However, knowing that aging women are more predisposed to sleep issues, which increases their risks for chronic pain and fatigue syndromes such as fibromyalgia, should prepare them for the task of prioritizing this most important element of health. Health challenges sneak up upon us, sooner than we would expect and leave us struggling to regain the health we once possessed. Therefore, it is paramount for aging women to preserve this vital activity if they would choose health.
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- David Brady