"I am 53 and having a terrible time falling
asleep. My doctor has prescribed Ambien® and it
is working. I would love to just be able to sleep
on a regular basis. Can I take this medicine for a
long period of time? Can I take it on a regular basis?
I have a great doctor, but he is not one who wants
to write prescriptions and told me to check this information
about sleep out for myself.
I do all the regular type of things to help i.e.
no exercise late, no caffeine, good sleep setting,
etc. I am on HRT also. None of these things seem to
work. I really think this is all menopause related.
I hate not sleeping. It makes life very difficult.
I still have children at home and cannot just nap
when I feel like it. Please help me on this. Thank
you."
Roxie
Taking Ambien®, which is a short-acting sleeping
medication, is not detrimental in the long run other
than it is somewhat habituating. You will become emotionally
if not physically dependent upon it for your sleep.
I think the doctor is correct that you should investigate
ways about improving your sleep problem without having
to continue the Ambien®. Since you are having
trouble getting to sleep, your problem is most likely
to be classified as insomnia rather than as a sleep
disorder. In general, most sleep disorder experts
recommend against treating chronic insomnia with continuous
sleeping medications.
You have already done some of the things necessary
to improve sleep: avoid exercise and caffeine within
5-6 hours of going to bed, create a good sleeping
environment free of noise, comfortable (cool) with
good temperature control. I assume you are also avoiding
alcohol in that same 5-6 hour pre bedtime period.
You may also want to make sure your HRT dose is adequate
and not too low.
How does menopause affect sleep?
There are always more sleeping problems with age.
Menopause, however, is a very common time for women
to begin or to experience worsening sleep difficulties.
We do not know why menopause causes a jump in more
sleep disturbances and it may just be that hot flashes
associated with menopause tend to wake women up frequently
during the night. The scientific data about this is
not clear (1). Taking estrogen replacement (ERT) or
estrogen plus progestin (HRT) lowers the incidence
of sleep apnea syndrome (2) and generally improves
menopausal sleep difficulties that would be classified
as insomnia (3, 4). This estrogen improvement of sleep
is a long term rather than a short term effect (5).
Further evidence that estrogen plays a role in sleep
disturbances comes from the fact that perimenopausal
women who presumably have declining estrogen levels,
have a greater degree of sleep disruption than do
younger premenopausal women (6). For surgical menopause
especially, and for natural menopause within the first
5 years, estrogen replacement should be at higher
levels to prevent both hot flashes and sleep disturbances
than doses used later in menopause.
What are other causes of sleep difficulties?
In general there are two major categories of sleep
difficulties :
insomnia - difficulty getting to sleep or back to
sleep after awakening (7, 8)
hyperarousal - anxiety, stress
poor pre bedtime and sleep habits
underlying mood disorders
sedative overuse
pain
general medical problems
nighttime urinary frequency
sleep disorders - resulting in excessive daytime sleepiness
(9)
sleep apnea
restless legs syndrome
narcolepsy
circadian dysrhythmias
Women with sleep disorders do not have trouble going
to sleep and when they wake up at night, in general
they are able to go back to sleep without too much
delay. Their main problem is that of waking frequently
or not sleeping deeply enough to get their needed
rest in rapid eye movement (REM) sleep. As a result,
the amount of restful sleep is so poor they have significant
daytime sleepiness. This loss of sleep is often associated
with hypertension and cardiovascular problems if the
sleep problem is long standing (10).
How can I tell if I have a sleep breathing
disorder?
Sleep disordered breathing may take almost 10 years
on the average to be diagnosed in women who have this
condition (11). This is because the disturbance of
sleep is more subtle than it is with insomnia. The
following problems may alert you to a sleep disorder:
restless sleep
morning headaches
memory lapses
irritability
general lethargy/fatigue
slight disorientation
personality changes
sexual arousal dysfunction
obesity (losing weight can become difficult
but obesity may also be a cause)
Sleep apnea may affect 5% of the population. It can
be due to obstruction of the airway at the nasal level
or the back of the pharynx and is often, but not always,
associated with snoring. There may also be a central
nervous system cause of the stopped breathing (apnea).
This type is not associated with snoring although
a woman may stop breathing during sleep for 10 seconds
or more. Sleep studies in which you sleep overnight
in a sleep lab while having EKG and EEG wires attached
to your body is the method of diagnosis.
How is insomnia different than sleep disorders?
Insomnia is a problem of difficulty falling asleep,
difficulty staying asleep, or an unrestful sleep.
Women who have sleep disorders, on the other hand,
do not usually have trouble getting to sleep or going
back to sleep. Both conditions may produce a restless
sleep. Almost everyone has experienced transient insomnia
lasting one or several days. Anxiety, a big event,
or any cause of stress can produce this.
Chronic insomnia lasting more than 3 weeks is a problem
for which most sufferers will seek medical help. There
are many factors which can lead to this problem. Bad
sleep habits, poor eating and drinking habits, medications,
chronic anxiety, and stress or depression are among
some of them. All of these factors must be addressed
to treat insomnia.
In addition it is important for menopausal women
to be at a sufficient estrogen replacement dose. For
example a woman who is within 5 years of menopause
will usually require 1.25 mg of conjugated estrogens
(eg., Premarin®) or 2 mg of estradiol rather than
.625 mg of conjugated estrogens or 1 mg of estradiol
which are often inadequate as replacement doses.
If you have insomnia, ask yourself if you are overly
concerned or worry about daily events and responsibilities
before bed or right upon awakening. Sense whether
or not you feel depressed. If you are taking any medicines,
look up their contents to see if they may play a role.
If you have high blood pressure, you may want your
doctor to check you for obstructive sleep apnea. Discuss
these factors with your doctor.
Is it better to use sleeping pills or a non
prescription medication like melatonin for sleep?
Melatonin is a brain hormone (pineal gland) that is
secreted according to a person's biorhythm. It is
low during the day and peaks in the middle of the
night. Exposure to light and dark controls its secretion
rather than when sleep occurs (12). It has been well
documented to be lower than normal in subjects with
insomnia and administration of it may improve sleep
problems in some people (13). Taking melatonin may
be more beneficial in circadian rhythm disorders such
as jet lag or shift workers (14, 15). Melatonin levels
are lower in menopausal women who have insomnia and
higher in menopausal women with depression and hyperprolactinemia
(16). The hormone is a marker for circadian rhythm
disturbance (as is cortisol) but not necessarily something
that needs to be replaced (17). You can have your
level checked with a home test called SleepCheck.
A dose of 10 mg a day by mouth seems to be safe over
a 30 day period (18) but whether it should be used
on a regular basis for insomnia or circadian sleep
disorders has not yet been determined. Skin cream
with melatonin can also be used. In pregnancy, the
baby is exposed to maternal ingestion of melatonin
(19), and no studies have been done establishing safety
in pregnancy (20). Although it is not likely to be
harmful in pregnancy on a short term basis, it is
not recommended for use during pregnancy.
Short acting sleeping meds are preferred whenever
something is prescribed so that there is not a residual
daytime sedative effect. Most people who take sedatives
for sleep report that their sleep is better, but when
questioned about symptoms, they seem to have the same
amount of symptoms as insomiacs who do not take any
prescribed medications (21). For this reason and also
because sleeping medications can produce undesirable
side effects, most physicians do not recommend long
term treatment with medications. It follows that long
term melatonin treatment would not be recommended
for the same reasons.
What are practical steps to take to improve
my sleep?
If you sense the main problem is a poor quality sleep
and not insomnia, it is important to see your physician
for a sleep study which can diagnose sleep apnea or
restless legs syndrome or other sleep disorders. The
treatment of the problem will be based on what is
found.
For insomnia, the following measures may be useful:
Make sure bedroom noise is controlled and temperature
is cool
have a fixed schedule to going to bed and getting
up. Try not to vary it.
avoid alcohol and exercise within 5-6 hours of bedtime
and no caffeine after noon.
do not look at the bedroom clock after you lie down
in bed or if you get up at night
eat a light snack containing protein, especially tryptophan,
before bed. This would include milk, cheese, yogurt,
cottage cheese, bananas, fish, and turkey.
do not reflect upon the day's events or your "todo"
list in the hour or two before bed
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