How hormonal changes affect the way you sleep

If you're a woman, hormonal changes are a fact of life. Smart decisions can keep you one step ahead and feeling your best.

Cindy Moriarty was only 39 years old when she began struggling with insomnia, fatigue, headaches and mood swings. “The silliest things would provoke me, and then I’d be crying,” says Moriarty, a manager at Health Canada in Ottawa. Symptoms such as hers can hit women as early as their mid-30s, when they experience either menopause or its prelude: perimenopause.It’s not easy living with hot flashes and night sweats, especially when they can last up to five years. But what can you do? With research casting doubt on hormone replacement therapy (HRT)—at one time the knee-jerk response to menopause—your decision just got a lot tougher. Should you take HRT despite known risks? Do herbals work? What difference do lifestyle changes make? Here’s how to determine what will work for you.

Raging hormone debate
Few women missed the recent Canadian Cancer Society advisory warning against long-term use of combined estrogen-and-progestin HRT or the results of the Women’s Health Initiative (WHI) HRT study that took the world by storm two years ago. That study of 16,608 women revealed that those taking combined HRT were more likely to develop breast cancer and blood clots and experience heart attacks and strokes than women taking placebos. As a result, part of the study was stopped early.

Sheila Lumsden-Graham, a 61-year-old Halifax resident, had been taking HRT to fend off hot flashes for 20 years when she heard the news. “When you find out that what you’ve been doing could shorten your life, it’s upsetting,” she says. Within eight weeks, she was off HRT completely. She has since been diagnosed with breast cancer and wonders whether HRT increased her risk. She wasn’t the only one to abandon the therapy: three and a half million fewer women took HRT in 2003 than two years earlier, according to IMS Health Canada.

Given the concerns—including recent data noting that combined HRT doesn’t improve general physical or mental health and actually increases the risk of dementia and urinary incontinence—why are nine million women still on some form of HRT? And why, if the WHI estrogen-alone study also found that estrogen by itself may raise the risk of stroke (but not breast cancer), does The Society of Obstetricians and Gynaecologists of Canada (SOGC) insist that HRT “remains a safe and effective option for the short-term treatment of moderate to severe menopausal symptoms”?

First of all, the findings of the initial WHI study weren’t all bad. Women taking combined HRT suffered fewer cases of colorectal cancer, hip fractures and sleep disturbances and experienced improved mobility. Moreover, because the average entry age of women in the WHI study was 63 and two-thirds of them were overweight, the findings may not apply to younger healthier women. “What would I say to healthy women heading into menopause? The WHI study was not really about you,” says Dr. Jennifer Mary Blake, chief of obstetrics and gynecology and corporate head, women’s health at Sunnybrook and Women’s College Health Sciences Centre in Toronto. She says HRT combined therapy is the best option for treating menopause symptoms such as hot flashes, night sweats and mood swings.

Putting it in perspective
To put it in perspective, Dr. Blake says the increased risk of breast cancer is the same as other risk factors such as giving birth late, experiencing menopause later in life or being obese. Women shouldn’t rely on it to prevent heart disease, she says. “But for managing distressing menopause symptoms in women who have no other health risks, HRT remains safe and effective therapy.”

Dr. Blake also stresses that the increased risk of breast cancer is reversible. Once a woman stops taking HRT, within a year her risk of breast cancer returns to what it was before taking the medication.

The research suggests that women and their physicians need to dedicate more time to figuring out whether HRT is the right medicine. “It isn’t a magic bullet in terms of helping women live years longer and having a better quality of life, but it clearly benefits women with tough symptoms in the short term,” says Dr. Timothy Rowe, head of reproductive endocrinology and infertility at the University of British Columbia. “For symptomatic women, nothing matches it.” Note the words “short term,” however: the SOGC recommends women only take HRT for distressing symptoms and to reassess their situation every year with their doctor.

Those who stop taking HRT must talk to their doctors about tapering off gradually. Don’t go off it cold turkey, says Dr. Rowe. “The worst thing is women stopping cold, suffering the consequences and going back to whatever chaos they had before: no sleep, feeling dislocated, hot flashes.” Lumsden-Graham can relate: she’s had trouble sleeping since going off HRT and nearly drove her husband crazy by running the air conditioner all last winter. Still, she would never go back on the medication, no matter how bad her symptoms become.

Natural selections
If you pass on HRT, you may want to consider a variety of herbal, dietary and prescription treatments. These might not provide complete relief but may tone down symptoms. According to Bev Maya, a medical herbalist at the Westcoast Women’s Clinic for Midlife Health in Vancouver, foods such as soy and flaxseed, and herbs including black cohosh and red clover, can help quell the discomfort of menopause and peri-menopause (see Edible medicine and Herbal Rx). She looks at menopause as an adventure, “a great time to pay attention to your body.”

Moriarty, who decided against HRT, is doing just that. “Why would I introduce hormones that my body is getting rid of naturally?” she says. By age 43, Moriarty was having hot flashes and temper flare-ups as well. Her answer was natural progesterone, a prescription cream she applies to her wrists and ankles. She combines it with regular exercise and a healthy diet to stabilize her moods and cool her hot flashes. “It doesn’t make everything go away, but I find natural progesterone works for me.” It’s not suitable for everyone, however. Dr. Rowe doesn’t always recommend it because of a lack of evidence on safety or effectiveness.

Moriarty also takes a multivitamin and vitamins C, E and B6, probiotic, acidophilus and a calcium-magnesium supplement. She also has osteoporosis but isn’t ready to go on medication for it, opting instead to increase her weight training and vitamin D intake.

Antidepressant manufacturers, meanwhile, have been touting the benefits of Paxil, Prozac and Effexor as treatments for hot flashes, irritability and anxiety caused by menopause. A study of 165 postmenopausal women by Paxil manufacturer GlaxoSmithKline determined that the drug slashed the severity and frequency of hot flashes by up to 65 per cent. But keep in mind these are potent drugs for severe cases. “They are designed for those with depression—not hot flashes,” says Dr. Rowe.

Living the good life
Maintaining a healthy weight with a low-fat antioxidant-rich diet and regular weight-bearing exercise helps you manage meno-pausal symptoms without a prescription. A Swedish study discovered only five per cent of the physically active women examined experienced severe hot flashes compared to 14 to 16 per cent of those who did little or no weekly exercise. As Dr. Susan Love writes in her book, Dr. Susan Love’s Menopause & Hormone Book (Three Rivers): “If there were a drug that had as many good effects as exercise has, we’d all be buying stock in it and getting rich.”

Leslie Minter, a 57-year-old woman on Vancouver Island, manages menopause through exercise. She’d been on HRT for five years but stopped recently because of excessive bleeding. This left her trying to control her symptoms, including forgetfulness, insomnia and hot flashes, naturally.

Minter’s on the right track according to Drs. Nishi Dhawan and Bal Pawa, co-founders of the Westcoast Women’s Clinic for Midlife Health in Vancouver. Stress reduction through meditation and exercises such as walking, jogging and weight training can make a significant difference for women, they say. Butting out cigarettes and cutting down on alcohol, caffeine and spicy foods will also boost your health. They also recommend topical estrogen in creams, tablets and rings to conquer vaginal dryness, another frustration of menopausal life.

Minter eats a low-fat diet rich in antioxidants and enjoys walking, golf, aerobics and yoga. She also shares menopause stories with friends and stays informed through reading. “I’m happy with where I am now,” she says.

Weighing your options
While there’s no single way to sail through menopause, options exist to ease your journey. Consult your doctor about the severity of your symptoms, health status and your family history of cardiovascular disease, breast cancer and osteoporosis. “I don’t know if the worst is over or if it hasn’t even begun,” says Moriarty. Regardless, she won’t be fighting it along the way. “Menopause is something you incorporate into your life, and I’ll keep doing it in a way that suits me.”

Herbal Rx
Talk to your doctor about whether one of the following herbs might be beneficial to you. Remember that herbal products and supplements won’t be fully tested and regulated in Canada until 2006 or later. Talking to a qualified herbal practitioner can help. Try to buy whole herbs and make a tea out of them, suggests Bev Maya, a Vancouver-based medical herbalist. Brew in a Thermos overnight for maximum effect.

Black cohosh is an estrogenic herb. It is an effective antidote to hot flashes, achy joints and mood swings. Avoid if you have cancer or a family history of the disease.

Red clover is particularly helpful in the perimenopausal phase, says Maya, as it helps balance the hormone surges that you are still producing naturally. Studies of the effect of red clover on hot flashes show mixed results.

Ginkgo biloba increases circulation to the brain and cuts down memory loss. If you take it in capsule form, Maya suggests consuming no more than 30 milligrams a day, as taking more can result in headaches. Don’t take ginkgo biloba if you’re taking anti-inflammatories such as Aspirin and ibuprofen.

California poppy and passionflower offer a gentle way of dealing with insomnia. A stronger herb called valerian is also effective, but Maya warns it can have the opposite effect, causing wakefulness in 10 per cent of her patients.

Edible medicine
Enjoy these foods to get a handle on menopausal symptoms, say experts from the Westcoast Women’s Clinic for Midlife Health in Vancouver.

Flaxseed contains fatty acids that boost health and dim hot flashes, anxiety, insomnia and stress. Aim for four tablespoons (60 mL) of flaxseed oil or ground seeds daily.

Soy flour, nuts, beans, milk and tofu contain isoflavones that help reduce “bad” cholesterol.

Skim milk with calcium and vitamin D helps offset bone loss. Four cups (1 L) of low-fat milk or a calcium supplement with vitamin D helps you get the 1,200 milligrams of calcium and 800 IU of vitamin D post-menopausal women need daily.