Now 61, Mary [name changed per the request of the storyteller] transitioned from ‘model sleeper’ to ‘fragmented sleeper’ 20 years ago. Her sleep issues didn’t appear with small warning signs. “It was sudden, and I wasn’t sleeping enough. I was finishing books in a week, which is generally impossible because I had all the time at night.”
At 41, Mary was going through perimenopause, the transitional phase leading up to menopause that can last up to 10 years. During this time, she experienced severe sleep issues, which gradually improved but never fully resolved.
Spontaneous menopause is a natural continuum in a woman’s life which renovates the brain and body. It spans several years and is not a single event.
Despite millions of women experiencing menopause and spending at least a third of their lives with it, this topic is not openly discussed, and women are expected to endure it in silence.
Mary said, “It’s one of those taboos you don’t talk about unless you go through it. It’s like going through a miscarriage. Nobody talks about them, and you feel like only you had a miscarriage. When one person opens up, many people around them will speak up or know someone who went through one. Then you realize you are not the only one.”
The most well-known sign of menopause – nighttime hot flashes – contributed to Mary’s sleep issues.
I would wake up hot, hot, hot! I would take the sheets off and then fall back to sleep and then wake up three seconds later and put the sheets back on.
It wasn’t just the hot flashes that disturbed Mary’s sleep. She said, “I had insomnia [which started during these years]. I woke up many times without the hot flashes, and then couldn’t fall asleep. It was not because I was thinking or stressing. Also, sometimes, I couldn’t sleep because I felt a pulling sensation in my arms. I don’t know what it was.”
To make matters worse, Mary had to get up 3-4 times a night to use the toilet – a normal routine she had since undergoing two back surgeries in 1990. The only difference now was that, unlike before, falling back asleep was a battle.
Mary’s sheets were going on and off, and so was her sleep. She counted sheep on the clock.
She said, “I would wake up more than ten times a night. I would hit the pillow, and after some time, I would think it’s morning. But it would just be 12 a.m.! Then I would fall asleep, wake up again, it’s 1 a.m., then 2, then 3! At 3 a.m., I was able to sleep” – after which her alarm woke her up at 6 a.m.!
“The last time I could not fall asleep until 2 a.m., I became anxious just thinking about how unprepared I would feel for my early morning meeting.” Mary added, “With work, it was hard. I couldn’t work optimally.”
Mary is a physiotherapist in Quebec who needs to reach work by 8 a.m., on just three hours of sleep, smiling and appearing recharged for her patients. “I was good with my patients. But when I had even the slightest downtime,” – when she was supposed to document patient notes and research – “I would close my office door in-between appointments and try napping on the table. It was very hard to focus or remember things.”
Mary’s exhaustion affected her driving.
At the red light, I would think ‘I will shut my eyes until the light goes green’ and then the car would honk. I think I shouldn’t have always driven home after work.
THIS IS NOT ME
Insufficient sleep impairs cognition and mood, which are also commonly affected by menopause. Moreover, menopause can increase sleep disturbances. Thus, the person experiencing menopause can observe a synergistic impact on behaviour, mood and quality of life.
“I would be extremely tired,” Mary shared. “I had difficulty focusing when I was writing notes. I just felt angry at everything, I was very moody. I was not sleeping enough for my mental health. And it was getting worse and worse.”
“I didn’t like that feeling of myself.”
Let me paint a picture of Mary. She is a happy-go-lucky, helpful, and amiable colleague who genuinely cares about others’ problems. She is passionate about her work, attends conferences to expand her knowledge, paints research ideas based on her observations and spends her weekends hiking or skiing, or canoeing or biking. You can see her eyes sparkle like a child when she describes her weekend adventures.
You get the idea: she is passionate about life.
Suddenly, she was thrown into a spiral of sleeplessness, tiredness, exhaustion, brain fog and lack of articulateness. Mary repeated “It’s not me” many times in several different ways during our conversation.
Apart from other effects, sleepless nights and menopause had clearly given a small blow to her identity. “My thinking was skewed. I did crazy things. One time, I was having a hot flash and was at the peak of insomnia, I decided that I would put on sunscreen at night ‘to catch the wind’. I just had a weird thought process. My friend suggested that I try eating a banana when I wake up like that. That didn’t help. I was also suggested to try acupuncture.”
“I was very bad.”
“I was slow and stupid.”
DOCTOR TO THE RESCUE
Mary tried melatonin for a brief period, which only gave temporary relief, and her issues kept worsening. After two years of trying some home-based and friend-suggested remedies, Mary was desperate. She, in her words, “broke down” and called up her doctor. “I wasn’t getting an earlier appointment, and I just started crying.”
Mary was told that her tiredness could be due to many other things – her job, her kids, the house chores, and just being a mom.
But this was a different level of tiredness. My doctor didn’t ask me about my sleep. She said, ‘It’s okay.’ But after insisting, she put me on hormone therapy.
“It was magic. Everything went away! I slept better. No hot flashes, and I felt amazing.” Menopause hormone therapy is an FDA-approved therapy for various discomforting effects and physiological changes caused by menopause, which helps millions of women who face these challenges. Importantly, hormone therapy should be individualized, considering a woman’s family medical history, physical examination findings, and risk of specific health conditions. More explanation can be found in this video by the International Menopause Society.
She continued this therapy for four years until they found a lump in her breast.
“It wasn’t cancer.” But she was cautious. “The specialist explained the risk of breast cancer. I remember him saying strongly, ‘You will get over the hot flashes and everybody gets over them.’ I was feeling fine by then, so I stopped the therapy.” More on the history of hormone therapy and misinterpretation of risks, here.
KNOW YOUR BODY
Twenty years since her perimenopause began, Mary still occasionally experiences hot flashes and bouts of insomnia. After stopping the hormone therapy, she found ways to cope with the effects of menopause. Now, she has a better understanding of her body, the triggers of hot flashes and insomnia and the ways to cope with them.
“My hot flashes and sleep issues were better managed when I did high-intensity physical activity, where I am out of breath, like biking to work or hiking. It needs to be high intensity. If I do a low level of activity like on vacation: leisure biking, canoeing, slow hiking while taking stops, then the hot flashes and insomnia come back, sometimes together, sometimes independently.”
High intensity physical activity, sleep hygiene and drinking a lot of water – but not three hours before bed – altogether help Mary manage her issues.
“Sleep hygiene techniques were becoming popular amongst the physiotherapists’ discussions when I was starting with the menopause period [20 years ago]. So, I implemented them in my routine. I hadn’t heard about that before.”
Now, on a good day, Mary gets a consolidated seven hours of sleep if she follows good habits. “If I don’t follow them, I am surprised that I still get the hot flashes and insomnia 20 years later, although they are not as severe.” She gets a bad night of sleep once a week. “When it gets to be three times a week, it’s a bit of a problem.”
A NEED FOR CHANGE
There is still much work to be done to understand menopause, its effects on the body and brain, knowing which treatments work for whom, and finding ways to implement effective solutions. This includes creating workplace accommodations and policies, training healthcare providers, breaking the stigma, correcting misconceptions, and raising awareness, not just about menopause, but about women’s health.
All or many of these remain a significant challenge in most countries. Mary has something to say about what needs to be changed.
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- Knowing is empowering: Despite some research, the effects of menopause on sleep are not widely known or discussed. The sleep disturbances or disorders can come as a surprise to many. Mary wished to be prepared for those. Mary said, “I think knowing is important. For example, we all know childbirth hurts. You know that you won’t sleep enough when the baby is young, but nobody tells you what will happen during the menopause journey. It’s a black box. You know you will stop your periods, and there will be hot flashes. But nothing else.”
- Access to management resources: Mary took years to figure out what works for her through trial and error. “Maybe some awareness. I found that a little bit of exercise really helped me, but it took time to discover that. It’s very hard to find the right resources,” she added.
- Community support: knowing you are not alone: “It would be nice to know that it’s not only me. Everyone could learn from each other’s experiences of what works. People are trying to find ways to help themselves. And I was lucky in that sense. I didn’t have pain. But you don’t talk about solutions unless it’s medication.”
- Doctor’s education: “They could have told me earlier. I didn’t have to hit that rock bottom.” After a certain age, it should be standard practice to have informed discussions with healthcare workers about the effects of menopause, available therapies, and counselling for symptom management. This must be accompanied by promoting menopause-related training in the curriculum for healthcare workers.
Mary concluded with a powerful idea – one that bears repeating, again and again.
I think when you have sleep disturbances, it affects your entire life. You can’t function. It impacts your life and mind – you become irritable, amongst other things. It’s a huge deal. But if we talk about it more widely, we can act sooner.
Sleep health is central to all health.
