by Debra Gibson, N.D.
Menopause, also called the change of life, has been the focus of much-needed attention over the past several years, resulting in a healing transformation in attitude and consciousness toward this important time in every woman’s life. Yet with all the positive spin on this demarcation between two phases of womanhood, there remains the reality that for many women this is a time of challenging and sometimes uncomfortable shifts in function of body, mind and sexuality.
One of the more common areas of disruption is the sleep cycle – difficulty in getting to sleep or in staying asleep, in returning to sleep once awakened, or poor quality sleep which results in lack of restedness during the day. Yes, there is often an association between night-time wakening and hot flushes (or power surges, depending on your attitude!); but, as many women can attest, menopausal sleep problems also occur independent of night sweats. And, as is suggested by research which shows an association between the severity of hot flushes and the development of chronic insomnia during and after menopause, the two may have underlying factors in common.
The high price of poor sleep
The health consequences of chronic sleep deprivation or poor quality sleep are more serious than just feeling sluggish the next day. Studies show that sleep disruption contributes to cardiovascular disease, depression, inflammation, reduced regeneration of brain cells, and reduced production of hormones which repair tissues and build muscle. Add to this the effect of poor sleep on quality of life, from low productivity to irritability to simple exhaustion, and it becomes a significantly life-limiting health issue. Moreover, sleep deprivation increases the production of stress hormones, which as we shall see, can in turn reinforce a negative cycle and exacerbate sleep issues.
Menopause and the adrenals
Despite the destructive health consequences of sleep problems and the frequency with which they occur during menopause, relatively little research has been directed toward determining their cause. As a clinician who regularly encounters menopausal women seeking natural solutions to sleep issues, I work empirically, “connecting the dots” of what we know thus far from scientific research with what seems to work in practice to effectively resolve the underlying issues which prevent healthy sleep.
Much of the focus of treatment of menopausal symptoms, in both conventional and natural medicine, has been directed toward softening the effects of falling sex-hormone levels as the ovaries gradually cease to function. This approach will be more-or-less helpful some of the time, but in my experience it is not a comprehensive answer to uncomfortable menopausal issues. Each woman must be viewed as an individual with her own particular set of systemic imbalances which contribute to her unique menopausal symptom expression. In the world of naturopathic medicine, in addition to supporting the body through changes in sex hormone levels, treatment of menopausal symptoms often includes assessing the adrenal gland system and treating imbalance in this area.
Why the adrenals? Hang around natural medicine for very long, and sooner or later the term “adrenal fatigue” is likely to come up. This refers to changes in the healthy function of these tricorner-hat-shaped glands that sit on top of our kidneys and play a role in everything from immune system regulation, to electrolyte balance and fluid dynamics in the body, to blood sugar control, sex hormone production and, last but by no means least, helping us to handle stress in all its variety of forms. It’s not surprising, given the many sources of stress in our modern lives: physical, emotional, environmental and biochemical, that for many of us the adrenal glands have, over time, become fatigued through overuse, unable to perform their many tasks as well as they used to.
In order to see the link between the sleep disturbances of menopause and the adrenal glands, it’s helpful to understand more about their function. For starters, the adrenals are lifelong sources of sex hormones such as estrone (a form of estrogen), progesterone and testosterone – which together act as a stabilizing influence as the ovaries begin to cease production of sex hormones (this is the timeframe known as perimenopause). Adrenal sources cannot fully take over the functions of ovarian hormones, but when the adrenals are healthy and producing optimal levels of their own sex hormones, this can make for a much gentler perimenopause and a happier postmenopausal life, hormonally speaking. When the adrenals are depleted and supply lower levels of sex hormones, this can result in a more difficult and prolonged menopausal transition. Sleep quality is one area which may be negatively affected because of the relationship between sex hormones, stress hormones and neurotransmitters; it is in large part the balanced interactions of these hormones and biochemical messengers which create healthy sleep patterns.
Sleep, Stress and your Overworked Brain
So, if there is a direct connection between adrenal dysfunction and menopausal sleep issues, what is the most common cause of adrenal dysfunction? You’ve probably guessed it: STRESS! The bane of modern life, the go-to culprit in so many health issues, our favorite and largely justified excuse for seemingly everything from road rage to low libido to rudeness on the checkout line – yep, chronic stress (past or present), and the adrenal fatigue which results, is an underlying factor in many a case of menopausal sleep disturbance.
Actually, it is not so much stress itself that is the problem, but rather a prolonged or excessive adrenal response to stress, which eventually leads to abnormal brain center reactions to stress hormones. In particular, it is the brain’s abnormal response to the chronic adrenal stress hormone cortisol which disrupts the normal cycle of waking and sleeping. It’s as though these brain centers which monitor and regulate hormone levels in the body gradually become hard of hearing, fail to understand that you don’t need a stress response at 2 a.m., and continue to send messages to your adrenals telling them to pour on the stress hormones, even though you need to be up at six. And there you are, wide awake and staring at the ceiling at 2, 3 and 4 a.m., tired already at the thought of dragging yourself through the next day, but unable to quiet your mind and rest. Even if you don’t awaken, this out-of-kilter feedback loop of high night-time cortisol interferes with your ability to access restorative REM sleep, where you dream and process psychic material from your day; it also opposes the secretion of growth hormone, which in adults permits tissue repair and regeneration – leaving you unrested and unrejuvenated on every level.
Why for many women do sleep issues begin or worsen during menopause? The answer may lie in the fact that these brain centers mentioned above, the hypothalamus and pituitary gland, are “command central” for our hormone systems, and they are working hard during the perimenopause, receiving feedback from the ovaries about lowered hormonal output and sending out stimulating hormones (Follicle Stimulating Hormone and Luteinizing Hormone) in higher amounts as a response to the under-functioning ovarian situation. In fact, it’s thought that the mechanism of hot flushes/night sweats may relate to stimulation of temperature regulating centers in the hypothalamus, possibly as a side-effect of all this heightened communication to and through the hypothalamic and pituitary areas – “static” along the nerve pathways acting as a trigger for a hot flush. A similar mechanism may be a factor in menopausal sleep issues too – but what is being stimulated in this case is hyperactive, excessive and inappropriately timed stress hormone secretion by an already overworked, “trigger-happy” brain control center.
Running on empty
Menopausal women often drag themselves into my office, hollow of eye and haggard of face, after weeks or months (or occasionally years) of sleep deprivation which began or intensified during the perimenopause. It is a testament to their endurance and inner strength that they continue to function at a high level in their lives, meeting the needs of family, work and community, despite their state of deep exhaustion. It may also be a testament to our cultural and individual tolerance of demands on women’s energy which can verge on inhuman, and to the multiplicity of roles in many women’s lives which contributes to their richness but which can also encourage a state of chronic overdrive.
The perimenopause is the time when underlying adrenal exhaustion and the negative effects of long-term, unhealthy patterns of behavior begin to reveal themselves, like an iceberg rising out of the ocean. And like an iceberg, there’s a lot hidden beneath the surface – chronic lifestyle habits that drain reserves; ways of relating to others that facilitate over-commitment and diminish self-care; energetic and emotional wounds of longstanding, often stemming from childhood, that over stimulate the adrenals by triggering a chronic stress response. These hidden vulnerabilities begin to emerge when the hormonal ebb and flow of perimenopause reveals them.
This is also a time when the circumstances of life can conspire to create more than the usual burden of stress on us and our adrenals – the demands of growing children (teenagers!), aging parents, work and home – the “full catastrophe” of life, in the words of Zorba the Greek, a character in Nikos Kazantzakis’ novel of the same name.
An Invitation to Heal
Uncomfortable though some of its manifestations may be, the menopause is an invitation to heal those elements in our past life experience that no longer serve us, to do the deep work which true healing requires, and to move into the postmenopausal phase of life more healthy, more whole, and more fully ourselves, with more to offer to ourselves and others. Viewed from this perspective, the perimenopausal phenomenon of impaired sleep is an opportunity to do important work of self-care and lifestyle change to heal the adrenal imbalance underlying disturbed sleep.
First Aid for Better Sleep
If you are a perimenopausal woman who has “hit the wall” of exhaustion because of lack of sleep or poor quality sleep, you’re desperate for a better night’s rest. Most of the suggestions which follow directly or indirectly influence stress hormone levels and the balance of brain chemicals affected by adrenal stress hormones. These are “rapid response” natural sleep assists which are not addictive, but which augment the ways in which your brain naturally prepares you to go to sleep and stay asleep.
- Gamma amino butyric acid (GABA or 5-hydroxy GABA): this amino acid is one of the most effective sleep promoters. A calming neurotransmitter which your brain uses to balance the stimulating effects of stress hormones and other excitatory brain messengers, 5-hydroxy GABA can be taken in doses of 100-200 mg. at bedtime; or GABA in doses of 500-1000 mg. (the 5-hydroxy form is better utilized so less is required). On wakening during the night an additional 1-2 of either may help you return to sleep more easily. In my office I prescribe either a naturally sourced (not synthetic) GABA or alternatively, a form of GABA formulated to enter the brain more effectively.
- Phosphatidyl (also called phosphorylated) serine is another effective natural way to heal a damaged sleep pattern: it may take effect quickly (within a day or so) or it may take several weeks to create a noticeable shift in sleep quality, but because it is an essential tool in healing damaged lines of communication between the brain and the adrenals, it is part of virtually every treatment plan for poor sleep. For the quickest response I would prescribe 200mg. after dinner and also at bedtime; as improvement occurs I reduce the dosage to 200 mg. only at bedtime.
- Other calming sleep assists include the amino acids Taurine (suggested dosage 1000 mg. 1-2X daily with meals) and L-theanine, derived from green tea (200 mg. after dinner and at bedtime).
- The relaxing herbs Passiflora, Skullcap, and Hops may be taken as a tea during the evening or at bedtime.
- Melatonin (2-3 mg. an hour before bedtime) may encourage the onset of sleep, but it will not help resolve sleep disruption later in the sleep cycle.
Consider testing
Because of the complex interconnections between changing sex hormone levels, adrenal and neurotransmitter imbalance, and sleep dysfunction, seeking out a natural medicine healthcare provider who can use functional testing to evaluate your particular pattern of imbalance in these areas can be an invaluable assist in identifying where imbalance exists and how to most quickly, naturally and effectively restore healthy sleep.
As an example, the amino acid 5-HTP (5-hydroxy tryptophan), which supports production of calming, mood-enhancing serotonin and sleep-inducing melatonin, is often recommended as a remedy for sleep issues; many with adrenal insufficiency do have low serotonin levels, but I do not prescribe it without testing first to determine if this is indeed the case for an individual, and to get the bigger picture of other hormone and neurotransmitter values. (As a side note, if you are taking pharmaceutical SSRI medication, it is inadvisable to take 5-HTP without testing and professional supervision.)
Lifestyle Change for Better Sleep
Using amino acids, herbs, and other nutrient support to manage skewed adrenal/brain dynamics can improve your sleep and go a long way toward supporting adrenal healing, but as a naturopathic physician my goal is always to treat the underlying cause of body/mind/spirit imbalance. A more permanent resolution of sleep difficulties necessitates healing on every level. This can be difficult work, but at the same time it can be the most life-changing, because it creates positive transformation in every area of our lives.
What follows are suggestions for lifestyle behaviors and what I call “inner work,” which restore drained adrenal reserves, thus promoting healthy sleep patterns for the long-term:
- Balance your blood sugar: eat smaller meals and add 2-3 snacks per day (a small bedtime snack if you tend to waken hungry during the night) so you are eating something every 2-3 hours. Combine proteins (fish, fowl, eggs, yogurt, beans, nuts, seeds, beans, quinoa) with complex carbohydrates for a steady supply of food energy to cells and brain. This prevents stress hormone secretion induced by low blood sugar.
- Dietary “Don’t”s: Avoid “white foods” such as those made with refined sugars and white flour; avoid more than occasional, moderate use of alcohol; gradually reduce and then avoid stimulants such as caffeinated beverages and chocolate.
- Take a high-quality fish oil supplement, one which provides the essential fatty acids EPA (in amounts of about 1500 mg. per day) and DHA (to total about 800-1000 mg. daily) taken with meals in 2-3 doses through the day. Two good brands in health food stores are Barlean’s and Nordic Naturals. Also noted in the “first aid” section above, phosphatidyl serine (100-200 mg at bedtime) works with the essential fatty acids from fish oil to re-sensitize cell membranes of brain neurons, restoring healthy lines of communication with the adrenals. Although the effects may be felt within a few days, if there is more extensive repair work to be done it may be a month or more before improvement is noted.
- The herb Rhodiola rosea is an adaptogen, which in simple terms means it has a balancing effect on adrenal function and helps the body to respond better to stress. As there are a number of species of Rhodiola, it is important to obtain a supplement which has been assayed for the level of rosavins, a class of compounds thought to be necessary for therapeutic effect. While in my practice I work with formulations standardized to contain 16% rosavins, those available to the public usually contain between 2 and about 5% of these compounds, and about 250 mg per capsule of the herb itself. A conservative dose is 2 capsules an hour or more before bedtime (this herb may have a paradoxical stimulating effect and interfere with sleep if taken too close to bedtime). Of course, as is true with many herbs, caution is indicated when pregnant or breast-feeding.
- Consider a program of detoxification: internal (such as from food sensitivities and imbalance in the digestive tract) and external burdens of toxicity are profound and ongoing triggers of excessive stress hormone secretion.
- Moderate exercise has been shown to improve sleep, but be sure you finish exercising 6 or more hours before you want to go to bed, and have a little snack beforehand for blood sugar balance during and after your exercise session. Yoga, Tai Ch’i, and other forms of exercise which enhance the body/mind connection (yoga has been shown in studies to reduce cortisol levels) are wonderful for our purpose of modulating stress hormones.
- Investigate meditation, guided imagery (www.healthjourneys.com has a menu of over a hundred CDs/downloads), and mindfulness-based stress reduction (MBSR) as ways to reduce stress in every moment of your day and night. Programs for learning meditation and MBSR are available in the community to teach you how to change your relationship to the stress of life.
- Start building good self-care muscles and exercise them regularly. For example, don’t push through fatigue, instead take a break or rest even for a few minutes with your eyes closed, focusing on your breathing, when you grow tired. Trust that your rested self will have more available to give to any task – I encourage women to use the mantra, “Less is More”. Learn to say no to requests (or demands) that tax your energy, time or emotions: this is often so difficult for women to learn and practice, and one of the most essential elements of reducing the stress response. If you need help in the area of self-care, read “how-to” books such as The Art of Extreme Self-Care, by Cheryl Richardson, or Tired of Being Tired, by Jesse Lynn Hanley, M.D. (I particularly like the “psychogene” references in this book). If you need more help, work with a therapist or counselor to find out why it’s so hard to care for yourself and to learn how to be as good to yourself as you no doubt are to others in your life.
Given the detriment to health and quality of life associated with chronic sleep disturbance, taking steps to resolve this common menopausal issue and its underlying causes is essential to peri- and postmenopausal health and happiness. While those very early morning hours of wakefulness may allow you to finally organize the photo albums or begin the novel you’ve always wanted to write, they really are better spent as Nature intended, in deeply restorative sleep. You deserve the gift of sleep – this is a gift of healing you can give yourself, and only by doing this healing work can you become rested, balanced, and energized – your most complete self.
Debra Gibson, N.D. practices naturopathic family medicine in her Ridgefield, CT office. She can be reached at 203-431-4443 or at [email protected].