Insomnia and the menopause (a challenging condition)

Mrs. Joan is a 49 year old lady who was referred with difficulty initiating and maintaining sleep over a 9 month period. She had been seen previously because of night sweats, said to be related to menopause. At the time of presentation she had intermittent menstrual periods suggestive of going through menopausal changes. She has a history of low thyroid hormone treated with hormone replacement. She is a manager of a retail shop working between 9am-5.30pm, 4 days a week and the other 2 days a week she helps in the family business.

She describes herself as a busy person. Her functioning during the day has deteriorated sharply since her sleep problem started about 9 months prior to this presentation.

She goes to bed between 11-11.30pm and not being able to fall asleep until 2am, sometimes 3am. She eventually gets up about 7am but if left undisturbed she sleeps in until 8-9am. This history is already suggestive of an element of delayed sleep phase, which is a body clock problem (see page xx).

She is taking Inderal™ as a prophylaxis for migraine. This medication is a beta-blocker and known to suppress Melatonin secretion, which could be a contributing factor to her timing problem.

On specific enquiry although she is a very busy person she could not recognize any specific reason for the onset of her symptoms 9 months previously. She had no evidence of symptoms suggestive of psychological stress.

The local doctor started her on hormone replacement, but there was no significant benefit.

She was advised to restrict time in bed, going to bed at midnight and getting up by 6.30am, and the use of Melatonin 3mg about 9pm. She was also encouraged to consider review of her busy schedule during the day and instructed on relaxation techniques.

Four weeks later at follow-up there was no significant benefit by the above intervention. She admitted that she had not been able to do any relaxation and of not being able to reduce her activity during the day. Her view was that what she needed was some kind of tablet to help her sleep stating that she was too busy to do any of the strategies recommended during the previous encounter.

A sleep study was arranged which documented poor sleep quality with lengthy time before being able to fall asleep and waking up through the night.

At further follow-up an attempt to modify her bedtime and daytime behavior was unsuccessful with the patient requesting to be given something to help her sleep. She was maintained on Melatonin at 9pm and started on Temazepam (a Valium-like medication of short action) half an hour before bedtime, which was maintained around 11.30pm. The choice of the Temazepam was dictated by the difficulty Sandra had in switching off at bedtime. She reported much improvement in her sleep quality that was actually confirmed by follow-up sleep study showing that the patient fell asleep quickly after switching the lights off and the sleep structure was much improved.

She did not attend follow-up after the second study. However, 3 months later she re-presented indicating that the ‘medication was not working anymore’.

Mrs. Sandra was taken again through the importance of critical review of her daytime functioning and the ‘business’ of her lifestyle and the need for ‘time off’ during the day. The suggestion again was ill received with the comment that she was far too busy to bother with this kind of strategy. She needed something again to fix her problem. She did not return for further advice.

Comment: This highlights some important issues relating to insomnia. In this case there was an element of delayed sleep phase, which was corrected by the use of Melatonin and a more regular sleep pattern. However, the quality of sleep remained poor. The suggestion of modification of daytime functioning was not implemented. This can be related to objective inability to change her lifestyle and an unwillingness to do so.

Of interest is the relationship between difficulty with sleep and the menopause. This is a complex relationship. Not all women who go through menopause do have sleep disturbances. Approximately one third have sleep disturbances associated with the menopause. It is claimed that the hot flushes are the reason for the sleep disturbances. However, when objectively tested there are women with the same amount of night sweats who do not have sleep disturbances, so the link between hot flushes and insomnia is not certain.

Of further interest only a minority of patients who go onto hormone replacement do actually have an improvement in their sleep quality. At present the relationship between menopausal changes and insomnia remains uncertain and needs to be studied further. There is definitely individual variability in how a person responds to hormonal changes.

Estrogens replacement is associated with an increase in the amount of slow wave sleep (“deep sleep”) and REM sleep. Estrogens also has a positive effect on mood, which tends to be depressed at menopause. In practical terms it makes sense to provide a person with hormonal replacement (low dose) and see if that makes a difference to their quality of sleep.

The level of melatonin is also reduced in postmenopausal women with insomnia, and therefore a trial of melatonin (0.5mg to 3mg) should also be considered, 2 to 3 hours before intended bedtime.

This case represents a difficult case in managing insomnia. A situation like the one explained in this case is not uncommon whereby the person is reluctant to take responsibility for her own symptoms and treatment. There is an expectation that the health practitioner will provide a solution with minimal effort on the part of the person herself. This is usually doomed to failure in the long run. It is a common scenario whereby the use of sleeping tablets seems to be helpful for the first few weeks and then the person’s pattern of sleep recurs. The step repeats itself whereby a different medication is sought which will work for a few weeks and the symptoms continue on and off for months, sometimes years.

In the case of insomnia it is important that the person takes charge of her own treatment rather than expecting the health practitioner to provide the full answer. Medications (sleep tablets) have a role and can be used, but they are rarely the solution. In cases where cognitive behavioural therapy is unsuccessful or not accepted (up to 20-30% of cases), the use of sleeping tablets need to be considered provided the patient understand theirs limitations.