"Wake Up and Smell the Roses"- Useful Information to Conquer Midlife Insomnia and Depression

"I have lost friends, some by death...others through sheer inability to cross the street." – Virginia Woolf –"The Waves "

A major area of concern for the pre-/peri and postmenopausal women involves poor sleep quality and diminished quality of life secondary, among other things, to symptoms of depression.

These include diminished enjoyment of life, ups and downs (with more downs), poor sleep quality and quantity, diminished desire for an enjoyment of sex, tiredness and fatigue for no good reason, deteriorating decision-making skills, diminished mental clarity, aches, pains, constipation etc.

Poor sleep quality can include difficulty getting to sleep or, more usually at midlife, frequent nighttime awakenings or simply awakening a few hours early, unable to get back to sleep- The “2 to 4 club..."

What happens to women at midlife that impacts on sleep and mental clarity? Mostly, it boils down to estrogen. At times when estrogen levels are down, depressive symptoms increase; when they are too high, anxiety, nervousness, and "feeling manic" ensue.

""Factors Effecting Mood and Sleep""

Risk factors for depressed mood states in women include early perimenopause, greater cycle variability, prolonged menopausal transition, psychosocial factors, personal and family history of abuse, and surgical menopause.

Other factors effecting mood include sleep disturbances and nighttime sweating leading to increasing fatigue and irritability; the vicissitudes of aging and illness; psychosocial factors such as negative attitudes regarding aging and menopause, poor lifestyle (e.g. smoking, little exercise, poor dietary habits), lack of partner/single parenting, stressful life events, etc; and stress (!!). Hot flashes are a biological stressor. Women having significant flashes have higher rates of depression.

Hot flashes significantly affect quality of life. Sleep is disturbed, leading to fatigue and irritability. Hot flashes lead to diminished frequency of orgasm, personal embarrassment at work or in public and feelings of anxiety and lack of control over one's body.

As we age, slow wave sleep (“SWS”) diminishes, not in small part secondary to diminishing hormonal support. Sleep apnea, obstructive symptoms, restless legs, partner’s snoring, arthralgias and myalgias all contribute to this. There is an additional link between non-restorative sleep patterns and worsening GI symptoms, especially IBS and GERD. Less SWS is correlated with weight gain, glucose intolerance, daytime sleepiness, moodiness, and poor health and sexual function.

""Getting Out of the Rut and Onto the Road to Vitality""

The goal is to increase the restorative SWS. Towards this end, many therapeutic modalities are helpful for midlife depression and insomnia:

1. "Talk therapy." Understand what's going on, that your symptoms are part of the transition, and that they can be overcome. For women with mild to moderate anxiety or depression, both interpersonal therapy and cognitive behavioral therapy (CBT) work well. CBT is brief, focused therapy based on the idea that people with depression think in ways that cause unwanted feelings and behavior; CBT teaches people to recognize irrational, depressing thoughts that are causing unhappiness, and replace them with more accurate, happier thoughts.
2. Hormonal therapy. The use of sex steroids- testosterone and progesterone, but especially estrogen is, along with antidepressant medication, the mainstay of therapy for midlife depression and sleep issues. Many randomized, controlled studies have shown that estrogen replacement in the estrogen-deficient women improves mood, sense of well being, quality of life, sleep and depression/anxiety. Estrogen therapy especially works to relieve or minimize day and night-time hot flashes.

Testosterone finds use to both increase energy, quality of life, sexual desire and arousal-all of which helps mitigate depression.

1. Neutraceuticals, herbs, botanicals: Black cohosh and chaste berry stabilize mood and improve hot flashes; St. John’s Wart and SAM-e are mild antidepressants and mood stabilizers; 5-HTP, L-tryptophan and l-theanine are stress reducers.
2. Antidepressants. To adequately cover this subject would require a separate column. Suffice it to say that, although unfortunately shunned by many women, antidepressants are among the safer medications available and are frequently very helpful in moderate to severe depression.

There are several subtypes. “SSRI’s” (Selective Serotonin Reuptake Inhibitors) include Prozac®, Paxil®, Celexa®, Lexapro® and Zoloft®. SSRI’s may blunt sexual desire and arousal (maybe Celexa® and Lexapro® less so) and cause mild weight gain. SSNRI’s (Serotonin and Norepinephrine Reuptake Inhibitors) include Effexor® and Cimbalta® and are frequently useful for peri-menopausal depression, anxiety and hot flashes. Tricyclics such as amitriptyline (Elavil®) and trazodone (deseryl®) are helpful for sleep, as is Remeron®. Wellbutrin® may be added to re-establish sexual desire, or for depression with ADHD overtones.

The keys to better sleep.

The key to improving sleep involves stress reduction and lifestyle changes, hormonal balancing and sometimes herbs and supplements. Sleep medications frequently help “in a pinch”.

There is no substitute for the stress-reducing and sleep-enhancing effects of exercise, especially earlier in the day. By increasing endorphins, thereby bringing more serotonin into the brain, vigorous exercise is truly “…nature’s Prozac”. Limiting fluid intake later in the day and stress-reduction techniques, including meditation, will certainly help.

Estrogen helps mightily by eliminating hot flashes, mediating mood, stopping restless legs and giving more deep and good-quality sleep. Progesterone helps by providing mood stabilization, hot flash relief and somnolence.

And don’t rule out the short term (and sometimes long term) help of sleep medications. The new generation of sleep meds includes Sonata® (fast-acting; works for two to four hours) Ambien® (approximately five-seven hours) and Lunesta® (approximately seven-eight hours) and are lifesavers until other things are balanced, giving better quality sleep usually without a morning hangover.

Michael Goodman, M.D. practices gynecology, perimenopausal medicine and health enhancement at “Caring for Women” in Davis California.