Inadequate or dissatisfying sleep is the most common sleep disturbance in America. Over 40% of adult Americans report at least occasional insomnia and nearly 20% have severe insomnia. Chronic 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.
Many people have transient sleep disturbances and treat them with over-the-counter medications, while others turn to their healthcare provider for prescription medications – and there are plenty of choices for medications. Each has its benefits and risks, indications, and side effects, and these medications are not interchangeable. More importantly, they aren’t safe to use together.
Many things can cause insomnia. Insomnia is not a disorder – it is a complaint. The goal is to find the underlying problem causing the complaint. Almost any sleep disorder can present itself as insomnia including circadian disorders, sleep apnea, restless legs, and the list goes on. So ruling out a sleep disorder can be important for a positive prognosis. Medications, herbs and caffeine can cause insomnia. Most medications will report the possible side effect of insomnia and sleepiness. The same medication can cause both since we all react to medications differently. Life events can cause insomnia but it is usually temporary. Anxiety about falling asleep can also be responsible, however, if the anxiety is due to a long history of insomnia, the anxiety is probably not the problem and you need to find out what is the underlying cause. Once sleep is restored to normal the anxiety will usually go away. Physical problems such as pain can be the underlying cause.
Transient and short-term insomnia generally occur in people who are temporarily experiencing stress, temporary sleep/wake schedule problems (i.e. jet lag), medication reactions, or have conditions in their environment disturbing their sleep. Though annoying, this type of insomnia is not a disorder and can be improved by the use of natural supplements or by medications.
Chronic insomnia is more complex and often results from a combination of factors, including underlying physical or mental disorders. One of the most common causes of chronic insomnia is depression. Other underlying causes include arthritis, kidney disease, heart failure, asthma, sleep apnea, restless legs syndrome, Parkinson’s disease, and hyperthyroidism. However, chronic insomnia may also be due to behavioral factors, including the misuse of caffeine, alcohol, or other substances; disrupted sleep/wake cycles as may occur with shift work or other nighttime activity schedules; and chronic stress.
The most widely used sleep medications are the benzodiazepine and non-benzodiazepine drugs. These medications are believed to be safe because they are difficult to overdose, but long-term studies have not been completed as to their total safety. Tolerance develops quickly, and over time, a higher dose is required to get the same effect as the initial dose. The risk of becoming dependent on these medications is also very high. Taking Ambien®, which is a short-acting sleeping medication, is not meant as a long-term solution since it is habit forming. You will become emotionally if not physically dependent upon it for your sleep. In general, most sleep disorder experts recommend against treating chronic insomnia with continuous sleeping medications. Regardless of the mechanism of action of sleeping medications, they are all “downers”. They depress brain function, and if mixed, overused, or taken in conjunction with alcohol or drugs may create a dangerous health condition where the brain can become depressed where the body begins to stop and breakdown.
Natural supplements, such as Melatonin, have been proven to be effective for both short-term and chronic insomnia. Deficiencies in certain vitamins, minerals, amino acids and enzymes may also disrupt sleep. Calcium, magnesium, B vitamins, folic acid and melatonin deficiencies may impair sleep. Melatonin is a brain hormone (pineal gland) that is secreted according to a person’s biorhythm. It is low during the day and peaks in the middle of the night. It has been well documented to be lower than normal in subjects with insomnia and administration of it may improve sleep problems in most people. Melatonin levels are lower in menopausal women who have insomnia and higher in menopausal women with depression and hyperprolactinemia. The hormone is a marker for circadian rhythm disturbance (as is cortisol) but not necessarily something that needs to be replaced on a daily basis.
Women may 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 nighttime vasomotor symptoms, anxiety, or the effect of hormonal changes on brain neurotransmitters. 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.
There are always more sleeping problems with age. Menopause, however, is a very common time for women to begin or to experience worsening sleep difficulties. We do not know why menopause causes a jump in more sleep disturbances and it may just be that hot flashes associated with menopause tend to wake women up frequently during the night. Taking estrogen replacement (ERT) or estrogen plus progestin (HRT) lowers the incidence of sleep apnea syndrome and generally improves menopausal sleep difficulties that would be classified as insomnia. This estrogen improvement of sleep is typically a long term rather than a short term effect.
Further evidence that estrogen plays a role in sleep disturbances comes from the fact that perimenopausal women who presumably have declining estrogen levels, have a greater degree of sleep disruption than do younger pre-menopausal women. For surgical menopause (i.e. hysterectomy) and for natural menopause within the first 5 years, estrogen replacement should be at higher levels to prevent both hot flashes and sleep disturbances.
If you feel that you are becoming over-medicated with prescriptions, feeling that you are only masking your sleep disorder with drugs, or believe that you are not receiving the results from traditional therapies by your physician you may want to do something pro-active to control and limit this disorder.