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THE LONG VIEW

Hot flashes, sleepless nights – and what women can do about it

As if job stress and concerns about children and aging
parents weren't bad enough, women over the age of 40
face a physiological sleep thief: hormonal changes in perimenopause and menopause, Adriana Barton writes –
but there are ways to cope

Learning about the dangers of sleep deprivation is enough to keep anyone lying awake at night.

Researchers have linked chronic sleep loss with higher rates of colon and breast cancers, Alzheimer's disease, obesity and diabetes, writes neuroscientist Matthew Walker, director of UC Berkeley's Sleep and Neuroimaging Lab and author of Why We Sleep: Unlocking the Power of Sleep and Dreams. Just one night of four or five hours' sleep can deplete the body's natural killer cells – the ones that target cancer – by 70 per cent (at least temporarily).

That's scary news for women in midlife. As if job stress and concerns about children and aging parents weren't bad enough, women over the age of 40 face a physiological sleep thief: hormonal changes in perimenopause and menopause.

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Perimenopause marks the start of fluctuations in estrogen and progesterone that eventually lead to changes in a woman's menstrual cycles; this stage continues up until a year after her last period. Menopause comes next.

At least half of women going through these two stages experience sleep problems, writes Judith Davidson, a clinical psychologist and sleep researcher at Queen's University and author of Sink into Sleep: A Step-by-Step Workbook for Reversing Insomnia. Nevertheless, she urges women not to panic if they're getting less than the recommended seven hours a night. Stressing about it doesn't help and "it's only really a problem if is interfering with your [daily] functioning."

For those who feel like walking zombies, she notes that hormone-related issues that rob women of sleep – from night sweats to breathing problems – can improve. Here's how to cope with the most common causes of sleep loss for women in midlife.

Night sweats

These nighttime hot flashes (or "flushes") trigger a sudden feeling of heat, combined with sweating, increased heartbeat and a spike in blood pressure. Roughly three-quarters of women in perimenopause and menopause experience night sweats. The hormonal fluctuations that cause them temporarily reset the body's internal thermostat and alter levels of neurotransmitters, the chemical messengers between nerve cells in the brain. Women tend to wake up just before the surge of heat, Davidson said. Once the heat has subsided, they may start shivering as the body resets its thermostat.

Even so, many women can fall back to sleep if they have a temperature-regulating strategy in place, such as fans to keep the bedroom cool and layers of sheets and blankets that can be pulled on and off. Davidson suggests talking to a partner about bedding in advance, "so you're not fighting over the bed covers at night."

If a woman starts worrying about whether she will get back to sleep after a night sweat, however, "those arousals can turn from lasting microseconds to hours." If this becomes a pattern, Davidson recommends a form of psychotherapy called cognitive behavioural therapy for insomnia (CBT-I), available in face-to-face sessions or online apps. With practice, she said, CBT-I can help calm racing thoughts and turn a trigger for insomnia into something no more disruptive than a nighttime bathroom break.

Night sweats may improve when women eat more soy, a source of phytoestrogens – plant-based molecules that act like estrogens, said Jerilynn Prior, an endocrinologist at the University of British Columbia's Centre for Menstrual Cycle and Ovulation Research. In a 2002 trial, women who drank soy beverages had a 40-per-cent reduction in hot flashes after three months, compared with those who consumed a similar-tasting rice drink.

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Hormone therapy should be a last resort, Prior said. Night sweats are mild to moderate in most women, she said, citing a 2008 survey of 4,400 women aged 40 to 65, published in the journal Climacteric. Overall, just 9 per cent of perimenopausal and 7 per cent of menopausal women reported having seven or more "moderate" to "very severe" hot flushes and night sweats in a typical day.

For severe night sweats, Prior recommends a nightly dose of 300 milligrams of oral micronized progesterone, based on her findings in a 2012 study published in the journal Menopause. After 12 weeks of progesterone treatment, women who began the study with a daily average of seven hot flushes or night sweats reported having three fewer episodes each day – and better sleep. She emphasized that progesterone does not carry the same risks as estrogen therapy and is not the same thing as progestin, a synthetic knockoff associated with adverse effects. "Progestins don't work."

Mid-sleep awakening

In perimenopause, many women fall asleep faster than usual, only to awaken abruptly an hour or two later, "often feeling wired and hyper and just unsettled," Prior said. Unrelated to night sweats, this sleep problem is one of the hormone-related changes in perimenopause that bother women most, she said. The good news: "It gets better in menopause."

In the meantime, relaxation techniques (see below) may help, combined with CBT-I exercises to tame an overactive mind. Davidson suggests jotting down anxious thoughts when a woman is not trying to fall asleep. Seeing these worries in the light of day can help "bring them down to earth."

Breathing problems

One in five menopausal women develop the kind of sleep-disturbing breathing issues that typically affect men. These include "upper-airway resistance" – shallow breathing through a partially obstructed airway – and "sleep apnea," repeated episodes of breathing cessation that last at least 10 seconds. In women, nighttime breathing problems may result from a drop in female hormones, combined with an increase in abdominal fat. Loud snoring, daytime headaches and a lack of energy during waking hours are all telltale signs. Mild cases may improve by adding elevation at the head of the bed, or changing a woman's sleep position, Davidson said. For severe breathing problems, however, women may need a special mask or mouth guard to help keep the airway open.

Midlife stress

While there's no doubt that hormonal changes can affect sleep, Prior encourages women to consider the other pressures in their lives, such as social expectations, her emotional state, "her teenage kids, her sick mom, her work demands." Many women are stressed to the max and "few do all of the sleep hygiene things that are necessary," such as keeping digital screens out of the bedroom and avoiding caffeine and alcohol right before bedtime, which can cause fragmented sleep.

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Prior recommends cutting out refined sugars and deep-fried foods, which increase inflammation in the body, combined with relaxation techniques: meditation, yoga, deep breathing. These steps can lower the central nervous system's stress response, helping women catch more Zs. Evening workouts are a no-no, as they tend to perk people up before bed, but regular exercise generally improves sleep, she said: "Even 30 minutes of walking a day will help."

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