It is one of life’s treasured pleasures: a peaceful and restful night’s sleep from which you awake in the morning refreshed and ready for a new day.
It is one of life’s feared miseries: feeling tired but being unable to fall asleep, or waking in the middle of the night and lying there sleepless for hours. A poor night’s sleep can leave us ill-equipped to be effective at home or at work the next day.
Insomnia is a constellation of problems:
- difficulty falling asleep
- difficulty staying asleep
- waking too early
- experiencing nonrestorative sleep.
These problems occur in association with impairment of daytime functioning.
In young adulthood, men and women display an equivalent prevalence of symptoms of insomnia. Perimenopausal and postmenopausal women, however, report a rate of insomnia much higher than what is reported by age-matched men.1
Our patients who suffer insomnia symptoms—in particular, those perimenopausal and postmenopausal women—would be deeply appreciative if we used our clinical skills to help guide them to a peaceful night’s sleep. Here are 1) strategies for addressing their needs through pharmacotherapy and 2) useful lifestyle tips to improve their chances of good sleep (see “How you can improve sleep hygiene”).
TIPS FOR PATIENTS: How you can improve sleep hygiene
Here are some useful, proven recommendations to increase the likelihood of a good night’s sleep.
Keep your bedroom cool. Studies have shown that, at night, the higher the bedroom temperature (and, thus, the higher core body temperature) the greater the likelihood of a sleep disorder.
Avoid naps. Never nap in the evening and try to avoid afternoon napping. Afternoon and evening naps break up the body’s natural sleep rhythms, making it difficult for the sleep center to switch central nervous system function to the sleep mode.
Exercise daily. Do so for at least 20 minutes and try to complete your exercise routine more than 4 hours before bedtime.
Stick to a regular sleep–wake schedule. Sleep 7 to 8 hours a night, and then get out of bed.
Keep your bedroom dark and quiet.
Avoid caffeine after lunch and avoid alcohol late in the evening and at night. Caffeine is a stimulant that can reduce the effectiveness of the sleep center.
Stop smoking. Avoid nicotine substitutes, too.
Limit fluids before bedtime. A common cause of nighttime awakening is the urge to urinate; reducing the frequency of awakening to urinate can help to ensure a continuous night’s sleep.
Hormone therapy
Gynecologists are expert, of course, at using estrogen and progestin hormone therapy to treat menopausal symptoms, such as moderate and severe hot flushes. In perimenopausal and postmenopausal women, these hot flushes often occur concurrently with insomnia.
A recent survey, for example, found that the majority of women who reported hot flushes also reported symptoms of insomnia.2 And another group of researchers showed that women who have moderate-to-severe hot flushes are more likely than women who experience mild hot flushes to have greater nighttime wakefulness and a greater number of long-awake episodes.3
Estrogen therapy, in addition to reducing the severity of hot flushes, has been reported to reduce sleep latency and to increase the quantity of rapid eye movement (REM) sleep—thereby improving postmenopausal patients’ perception of the quality of their sleep.4
Non-estrogen treatment
Many women do not want to take estrogen, however; in others, estrogen therapy is contraindicated. This need not be a roadblock: Women in whom the symptoms of troubling insomnia predominate but who report few hot flushes may, in fact, benefit more from a non-estrogen treatment for insomnia. In my gyn practice, I’ve found that the agents gabapentin and eszopiclone—each with its own mechanism of action—are of value for treating insomnia in perimenopausal and postmenopausal women.
Gabapentin
Well known by its brand name, Neurontin, gabapentin is approved by the Food and Drug Administration for the treatment of seizures and postherpetic (shingles) neuralgia. The drug has also been used—but is not FDA-approved—to treat diabetic neuropathy, chronic pain, and restless legs syndrome. In addition, clinical trials have shown that gabapentin is effective for treating insomnia5 and hot flushes—although, again, these are not FDA-approved indications.
To treat insomnia in my perimenopausal and postmenopausal patients, I start gabapentin at a dosage of 100 mg nightly, increasing it by 100 mg to 300 mg nightly. Occasionally, a patient reports the need to take as much 600 mg nightly before the quality of her sleep improves.
The most common side effects reported with gabapentin are somnolence, drowsiness, dizziness, and a “spacey” feeling—most often, during the first 1 to 3 weeks of treatment or when the dosage is escalated. Side effects tend to subside after 4 weeks of treatment.