by Tori Hudson, N.D.
Inadequate or dissatisfying sleep is the most common sleep disturbance in America. As many as 40% of adult Americans report at least occasional insomnia, and of those, nearly 20% have severe insomnia. Severe insomnia is defined as difficulty initiating or maintaining sleep at least three times a week for 1 month or more, with the problem being bad enough to cause fatigue during the day or impaired functioning.
Women are 30% more likely than men to report their insomnia, and it is more likely to be more severe. Sleep problems are especially common in peri-menopausal women and increase after age 40 and plateau by age 50. Sleep problems are also more concomitant with medical and psychiatric disorders, which are more prevalent, or at least more reported, in women.
Women and men over 65 are 50% more likely to complain of insomnia than younger individuals. Chronic health problems and increased use of medications associated with aging also increase the risk of sleep disruptions. Twenty-nine percent of women report medications are needed to improve their sleep. Of those, nearly one-third rely on over-the-counter drugs, 13% use prescription drugs, and others use both.
Effects of Sleep Disruptions
Insomnia is associated with quality of life, productivity, depression, anxiety, cognition, and even safety. Individuals with insomnia have significantly greater impairment in their daily life functions than people without insomnia. The good news is that any impairment in mental and physical function is reversible with treatment of the insomnia. Insomnia may also be associated with an increased risk of developing cardiovascular disease. In one study, women who had trouble with sleep onset or who had night time sleep interruption had significantly higher systolic and diastolic blood pressures than women without these sleep problems.
Insomnia is considered a symptom of an underlying problem. Medical conditions and issues that can cause insomnia include hormonal changes, headaches, respiratory problems, arthritis, fibromyalgia, psychiatric and mood disorders, congestive heart failure, esophageal reflux, restless leg syndrome, anxiety, nocturnal hypoglycemia, chronic or intermittent pain, cancer, Alzheimerâ€™s disease, Parkinsonâ€™s disease and peripheral vascular diseases. Other causes can include caffeine, alcohol, nicotine, recreational drugs, medications, and stress.
A qualified practitioner can assist in determining the cause of oneâ€™s insomnia by doing a thorough history and physical, ordering selected tests, and by giving instructions on the use of a sleep diary.
Sleep quality can vary during the menstrual cycle in premenopausal women. More sleep disturbances have been found during the late second half of the cycle compared with the middle of the first half of the cycle although these differences can be small or significant depending on the individual. Women with premenstrual syndrome tend to have greater wakefulness and more disturbed sleep patterns.
Women may also experience many sleep disturbances during the perimenopause transition and menopause itself, especially those who do not take hormone replacement therapy (HRT). These sleep problems may be due to night time hot flashes, anxiety, or the effect of hormonal changes on brain neurotransmitters. HRT is not FDA-approved as a treatment for insomnia. However, oral HRT has been shown to improve nighttime restlessness and awakening and is proven to relieve vasomotor symptoms. HRT has also been observed to decrease sleep disordered breathing. Using natural progesterone versus a progestin may also improve sleep due to the sedative effects of natural progesterone.
Changes in sleep duration and quality are common during pregnancy and especially in the weeks right before delivery. In a study of 100 prenatal women, only 32 reported normal sleep during their pregnancy. As the pregnancy progressed, sleep became more disturbed. These sleep maintenance difficulties are thought to be due in large part to the effects of hormonal changes. Pregnant women can also experience a significant increase in waking after sleep onset in the last trimester. This may be a consequence of nocturia, changes in sleep posture with increased abdominal size, fetal movements and low back pain.
The postpartum period is full of many variables. Early on, sleep may be reduced by discomfort from a cesarean section or episiotomy, hemorrhoids, excitement, anxiety
about the baby, frequent visitors and hospital routines. As time goes on, care of the infant can cause sleep loss due to night time awakenings of the infant and nursing. Postpartum depression related to stressors and hormonal changes can also be a cause of sleep loss.
More than half of patients who seek care for insomnia are diagnosed with a mood disorder. The most common of these is depression. The relationship between insomnia and depression is strong yet not well understood. Insomnia can occur with depression, be a precursor to depression, and can be a result of depression. It is logical that stress and anxiety often induce sleep difficulties. In addition, anxiety and depression may be associated with changes in premenstrual hormone levels, or perimenopausal hormone changes and, as such, may lead to increases in sleep disturbances.
Selected Nutritional and Herbal Treatments
Melatonin may be one of the more well known natural treatments for insomnia. One placebo-controlled trial on melatonin found that 0.5mg of melatonin in either immediate or sustained release form for 2 weeks shortened the amount of time it took to fall asleep but had no effect on sustaining sleep or improving the quality of the sleep. In another study, 2mg per day of melatonin was effective in improving sleep efficiency. Melatonin has also been effective in patients with long-term insomnia who were using benzodiazepines. 14 of 18 patients were able to decrease their benzodiazepines by 50% during week 2 and discontinue during weeks 5 and 6 by using 2mg of melatonin nightly. Only 4 of 16 were successful in the benzodiazepine plus placebo group. Six additional patients given placebo in the first phase discontinued their benzodiazepine in the second phase when they were given the melatonin. Nineteen of the 24 patients who discontinued the benzodiazepine and utilized the melatonin were able to maintain good sleep quality. It is thought that individuals who actually have a melatonin deficiency are most responsive to melatonin for insomnia.
5-hydroxytryptophan (5-HTP), a form of tryptophan has been reported in numerous double-blind studies to decrease the time required to get to sleep and to decrease the number of night awakenings. Taking 5-HTP will raise serotonin levels, an important initiator of sleep. Vitamin B6 is important for its role in tryptophan production.
Valerian has been used for decades and centuries as a sedative, including as an aid for insomnia. Studies have confirmed the effectiveness of valerian. In a double-blind study from Switzerland, an aqueous extract of valerian improved sleep latency, reduced night awakenings, and improved sleep quality, especially in women. Several trials have looked at valerian in combination with other herbal sedatives such as passionflower and lemon balm. In one clinical trial, ninety-eight men and women without insomnia took valerian and lemon balm 30 minutes before bed. 33% of the participants in the valerian/lemon balm group reported an improvement in sleep quality. Only 9% reported this in the placebo group.
Numerous plants have sedative actions and have been used historically to promote sleep and improve sleep quality. These include hops and passionflower which are especially helpful for insomnia related to stress, tension and anxiety.
Insomnia is not only a frequent medical problem but can be a difficult problem. Insomnia is usually a symptom of an underlying problem and it is important to attempt to discover what might be the cause- hormonal, nutritional, pharmacologic or psychological. Two primary goals exist: treatment of the specific underlying problem and treating their immediate insomnia in the short term. If the insomnia is worse premenstrual, then treating the PMS plus the insomnia yields the better results. Similarly for perimenopause or menopause. Address the main underlying issue, and in addition, use something specific for the insomnia.
- Owens J, Matthews K. Sleep disturbance in healthy middle-aged women. Maturitas 1998;30:43-50.
- Manber R, Bootzin R. Sleep and the menstrual cycle. Health Physiology 1997;16:209-214.
- Mauri M, Reid R, MacLean A. sleep in the premenstrual phase: a self-report study of PMS patients and normal controls. Acta Psychiatr Scand 1988;78:82-86.
- Schweiger M. Sleep disturbances in pregnancy: a subjective study. Am J Obstet Bynecol 1972;114:879-882.
- Hughes R, Sack R, Lewy A. The role of melatonin and circadian phase in age-related sleep-maintenance insomnia: assessment in a clinical trial of melatonin replacement. Sleep 1998;21:52-68.
- Garfinkel D, Laudon M, Nof D, Zisapel N. Improvement of sleep quality in elderly people by controlled-release melatonin. Lancet 1995;346:541-544.
- Zisapel N. The use of melatonin for the treatment of insomnia. Biol Signals Recept 1999;8:84-89.
- Leathwood P, Chauffard F, Heck E, Munoz-Box R. Aqueous exgtract of valerian root improves sleep quality in man. Pharmacol Biochem Behav 1982;17:65-71.
- Cerny A, Schmid K. Tolerability and efficacy of valerian/lemon balm in healthy volunteers ( a doble-blind, placebo-controlled, multicentre study). Fitoterapia, 1999;70:221-228.