Many of the older women who come to see us say that their insomnia started during perimenopause. Do you remember the 3P model of insomnia from chapter 3? In some ways, perimenopause is no different than any of the other myriad experiences that we can classify as “What Life Gave You.” Just like any other change or event, perimenopause interacts with your particular risk factors for sleep disruption. And your response to an initial sleep disruption—what you do and how you think about sleep—will determine whether you get caught up in an insomnia spiral.
Still, there is something unique about the link between menopause and sleep. Unlike other life events, menopause involves specific physiological changes. And there is one menopausal symptom in particular that has been linked to insomnia: hot flashes. Hot flashes are sudden feelings of heat in your upper body (face, neck, chest). You may sweat profusely as your body tries to cool itself down, and then you may feel chilled. It is no wonder, then, that nighttime hot flashes disrupt sleep!
If your insomnia started during perimenopause but you did not experience hot flashes, then there is a good chance that aging, rather than menopause, is to blame. Research suggests that we experience more middle-of-the-night awakenings as we age, and this is independent of menopausal status (Eichling & Sahni, 2005). For example, a forty-three-year-old woman who is postmenopause is less likely to report insomnia than a forty-eight-year-old woman who is premenopause.
What does this mean for you? If you have insomnia that started during perimenopause but you did not experience nighttime hot flashes, then you can use the treatment in this workbook without modification. You also do not need to modify this treatment if hot flashes used to disrupt your sleep but no longer do. We expect our combined CBT-ACT approach to work just as well for you as for someone whose insomnia did not start during perimenopause. Remember: what initially triggered your insomnia may be very different than what is keeping it around. And it is the perpetuating factors, not the initial cause, that we need to target in treatment. This is true even if the cause is menopause or aging.
But maybe you do wake up in a sweat, feeling as if a surge of adrenaline is going through your body. What then? You can treat your hot flashes or you can treat your sleep disturbance—or you can treat them both.
Remember, research suggests that it is specifically the phenomenon of hot flashes that links menopause and sleep. Therefore, reducing or eliminating your hot flashes should lead to better sleep. For example, in their review of research on menopause-related sleep disorders, Eichling and Sahni (2005) demonstrate that estrogen replacement therapy reduces hot flashes and improves sleep for women who experience hot flashes.
There are a number of treatment options available for hot flashes, including various forms of hormone replacement therapy, acupuncture, and herbal remedies. A thorough discussion of this topic is beyond the scope of this book. Two popular resources that review these options are The Wisdom of Menopause (Northrup, 2012) and The Menopause Book (Wingert & Kantrowitz, 2009). We encourage you to talk with your physician if nighttime hot flashes are significantly disrupting your sleep.
All of the CBT and ACT strategies discussed in this book can be helpful even if hot flashes are what rudely awaken you from sleep. However, we tend to gravitate toward certain strategies when we are helping women in this situation.
SCT gives you a specific plan that you can execute when you wake up in the middle of the night. By leaving your bed, you are less likely to start to mentally link your bed with the feelings of adrenaline and heat. Leaving your bed also may help you cool off more quickly.
Use the same guidelines outlined in chapter 6 to develop your SCT plan. Think about what might be different in light of your hot flashes. For example, should one of the preparations you make ahead of time be having a change of clothes at the ready? Do you want to have two plans for what to do when you leave your room—one for awakenings triggered by hot flashes and one for other awakenings? Perhaps your standard plan will be to go to the den and read, but you expect to be too uncomfortable to do this if you have just had a hot flash. In that case, perhaps you first will take some steps to help you cool off (or to warm up if you are chilled).
Why do we generally suggest SCT over sleep restriction therapy (SRT) when hot flashes are involved? In SRT we are trying to prevent awakenings by consolidating your sleep. It is not realistic to think that you will sleep through a hot flash no matter how deeply you are sleeping! Also, your experience of night sweats may be pretty erratic. This means that your average sleep efficiency may be over 90%, even though you have some nights with long awakenings. This pattern guides us to SCT over SRT.
You may need a different sleep environment when you are prone to hot flashes. To what temperature is your thermostat set at night? Is there a different setting that would be more comfortable right now? Consider layers of bedding instead of one warm comforter, so you can adjust to your body’s shifting needs. Some women swear by “cooling pillows” to help stave off night sweats.
Your hot flashes also may be related to other sleep hygiene guidelines. Consider adding hot flashes to your sleep log to see if you can see any patterns. For example, too much caffeine can increase hot flashes. Spicy food can, too. Finally, many women report that stress brings on their hot flashes. Consider a relaxing wind-down routine to help you reduce stress at bedtime.
Willingness can help you relate differently not only to your sleep, but also to the hot flashes themselves. Struggling against your experience—wanting the hot flashes to stop!—does not help. You can cultivate self-compassion by acknowledging that you are extremely uncomfortable. You can, simultaneously, accept that this is part of your experience as your body transitions into menopause. Your willingness to experience this particular hot flash, on this particular night—and the sleep disruption that comes with it—will keep you from feeding the insomnia spiral.
Some women find mindfulness meditation exercises helpful in calming their nervous system in the aftermath of a hot flash. Consider practicing mindfulness if you leave your bed as part of SCT. You also may want to seek out mindfulness exercises that are specifically focused on cultivating self-compassion. Your body is experiencing significant changes and it can be a wild ride! Treating yourself kindly can help buffer you from stressful aspects of the menopausal transition.
If you experience nighttime hot flashes that disrupt your sleep, first ask yourself if sleep disruption has taken on a life of its own. Do you have trouble falling or staying asleep that is not directly related to a hot flash? If so, use this workbook to treat your insomnia. Consider the menopause-specific tips in this chapter when you develop your personalized sleep program. Also consider consulting a health professional about strategies for reducing hot flashes.
If your sleep disruption has not taken on a life of its own, consider using this workbook to keep it from doing so. Part 1 should be especially useful. This is where you might focus your attention:
Like so many other life events and transitions, menopause can make you vulnerable to sleep disruption. How you respond can make all the difference. Understanding and making use of CBT and ACT principles can help you avoid, or get untangled from, the insomnia spiral.