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If your female patients appear to have finished a marathon by the time they visit your office, chances are these women are in the throes of menopause, an often-hellish hormonal imbalance that afflicts 85 percent of women in the United States who are experiencing the beginning of the end of their menstrual cycles.

Although there are numerous negative side effects of menopause, including anxiety, swings in mood and appetite, and diminished libido, one of the most common is insomnia. The insomnia frequently is triggered by nocturnal hot flashes, also known as night sweats, and it puts menopausal women at increased risk for other health problems, according to Dr. Lynda Balint, an OB/GYN who specializes in menopause management at A Place for Women in Celebration.

"The most common cause of sleep disturbances among my patients are hot flashes,'' Balint said. Lack of sleep "can lead to daytime fatigue, which creates a whole host of other problems, including depression, stress, high blood pressure and eating disorders.''
The scientific link between menopause and insomnia is becoming much clearer to researchers. A Stanford University study released in 2006 said more than 80 percent of women who said they experience severe hot flashes also reported insomnia. Most of those women were perimenopausal, which means they were making the transition from having normal menstrual periods to having no periods at all. That process usually takes eight to 10 years, according to the North American Menopause Society, although the severity of the associated symptoms likely will ebb and flow during that time.

Hot flashes are caused by drops in estrogen levels, which prompt the brain's hypothalamus to inexplicably overcompensate for what it falsely perceives as a warning that the body is too hot. Although behavioral adjustments can be made in an attempt to ward off hot flashes during waking hours — avoiding stress, spicy foods, alcohol, too-warm clothes and caffeine are a few — it is more challenging to guard against these thermal invasions while sleeping.

Consequently, most menopausal women awaken numerous times every night feeling as if they are on fire, often ripping off their nightclothes and kicking off the bed covers, only to shiver and cover up a few minutes later as their bodies cool rapidly. This temperature tug-of-war takes an indisputable toll; even if the woman is lucky enough to doze off again, her episodes of sleep are fragmented, which will contribute to her fatigue factor the next day. Less meaningful rest equals less energy, and that tiring pattern can adversely affect all aspects of a woman's life.

Balint said gynecologists sometimes suggest practical lifestyle changes in an attempt to correct the problem. "Lifestyle is hugely important. Diet, weight management, exercise are all factors that can be altered'' to improve sleep during menopause, Balint said.
If that does not work, a doctor will turn to what Balint described as the "gold standard for treating perimenopause and menopause,'' which is hormone replacement therapy (HRT). Depending on a patient's gynecological history, that usually is either estrogen, or a combination of estrogen and progesterone. Sometimes testosterone is in the mix.

Opinions have varied about the side effects of hormone therapy. Some studies have indicated that hormone replacement therapy increases the risk of heart disease and dementia. "Some were scared off" unnecessarily by those reports, Balint said.
But doctors agree that no woman should begin HRT until she has had a detailed consultation about the advantages and possible disadvantages of that approach, as well as other options.

"Look for a doctor who has expertise in menopause management. This is a very hot area now (no pun intended),'' Balint said, referring to the number of baby boomers who are entering perimenopause and seeking help for their symptoms.

Balint said once she explains HRT to her patients, about 40 percent of whom are menopausal, their concerns are eased. "We assure them we will give them the lowest effective dose for the shortest amount of time,'' she said.

Dr. Scott Boone, a 51-year-old OB/GYN practicing in Orlando for 22 years, said his initial advice to patients is "consider a low-dose HRT that would not (contain more estrogen) than their body produced before they went into (perimenopause).''
"For example,'' Boone explained, "birth control pills have five times the amount of estrogen your body produces naturally, and there's not much concern about taking them.''

HRT can be administered several ways, Boone said, including a skin patch, intra-vaginal cream or pill, oral pills and gels applied to the skin. Boone's preferred delivery system is a low-dose patch.

Almost all women experience sleep disturbance as a symptom of menopause, said Dr. Elizabeth Nelson, a gynecologist who has practiced in Orlando for 26 years. Nelson relies primarily on HRT for the majority of patients for whom the regimen poses no documented risk.

When not sleeping well is "just a symptom of menopause and not a sleep disorder,'' the success rate of HRT is high, she said. She also prescribes mild prescription sleep aids, but sparingly because patients "can become dependent on them.''
Nelson, an unassuming 53-year-old who confesses some "personal, intimate knowledge about hot flashes,'' said one of the first things she warns menopausal patients about is alcohol. "It can cause hot flashes to be worse for some women, both in intensity and frequency,'' she said. "And I tell them to turn the (house) thermostat down at night.''

For a small percentage of Nelson's menopausal patients, insomnia stems from a cause other than hormones, such as sleep apnea. In those cases, both she and Boone said they refer patients back to their primary care physician with advice to seek evaluation from a sleep specialist.

Marie-Anne Salvio is a sleep medicine psychologist at the Sleep Disorder Center at Florida Hospital in Orlando. She said much of the time menopausal women who are referred to her do not realize their insomnia is connected to perimenopause.

"Women are coincidentally going through a lot of social stressors like retirement and kids leaving home'' at the same time as perimenopause, Salvio said, so it helps to gauge that influence. But if there is evidence the sleep disturbance is related directly to hot flashes, she counsels them.

"I explain the hormonal changes,'' Salvio said, and she arms them with practical advice to thwart hot flashes: "Wind down, relax and make the bedroom dark, cool and quiet,'' she said.

The consensus of Orlando-area physicians is that doctors should help patients age successfully, and not allow a menopausal woman's inevitable and relatively transitory discomfort to develop into a chronic physiological or psychological ailment.
Indeed, women who have made it this far in life have earned a good night's sleep — and a warm reassurance from a doctor who understands this brand of "hot'' is not cool.



May 2007

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