Sleep and Depression
Most of the info in this blog post was learned from the World J Psychiatry. 2024 Oct 19;14(10):1605–1610. It explains the hormonal change mechanisms that provoke sleep and disturbances encountered in the perimenopausal years.
According to studies, 40%-69% of women across the menopause transition report sleep disturbances, particularly nocturnal awakenings and increased awake time after sleep onset.
During the peri- and post menopausal years, the increase in serum follicle-stimulating hormone (FSH) is associated with greater odds of waking up several times, and the decreasing estrogen levels contribute to difficulties staying and falling asleep. At the same time, low progesterone is responsible for lower sleep efficacy, shorter sleep time, and higher wakefulness after sleep onset.
If that weren’t enough, it gets even more layered, as decreased melatonin secretion, disturbance in circadian mechanisms, altered thermoregulation (aka crazy hot flashes), increased need to urinate, and of course, the stress of life, are all players here.
And when you are not sleeping, you know what happens…do you remember, is it on the tip of your tongue….Oh yeah there it is, sleep is crucial for memory consolidation! The decline in sleep quality is associated with cognitive changes and reduced alertness. And in terms of just general mood and motivation, this lends towards the lack of desire to move, and lack of ability to recover well.
The relationship between previously mentioned mood changes, depression in particular, and sleep disturbances is bidirectional. Depressive symptoms emphasize sleep difficulties in menopausal women, and insomnia contributes to mood fluctuations and influences social aspects of life.
A decline in estrogen secretion, together with all the other hormonal changes during the perimenopausal period, is believed to cause dysregulation of the gamma amino butyric acid (GABA) balance between GABA-A and GABA-B receptors in the brain, which can lead to the development of mood swings and the inability or challenge to remain calm and at peace.
What is GABA? It’s a wonderful, calming neurotransmitter that your body makes.
Can HRT help? You guessed it, Yes.
The World Journal of Psychiatry, highlights a study by Liu et al: They investigated the role of HRT in altering mood changes and impaired sleep quality in menopausal women.
After administering three months of combined estrogen-progesterone therapy, they found that the overall treatment effectiveness rate was higher in the treated group compared to the placebo group (96.05% vs 86.84%, P = 0.042).
Improvement in menopausal symptoms (assessed with modified Kupperman menopausal index score) was detected in the treatment group in all 13 measured categories, particularly regarding insomnia, vertigo and sexuality. The emotional state of the HRT treated menopausal women was also improved; the positive and negative affect scale score after three months of HRT therapy was significantly different compared to the placebo group.
The decrease in the self-rating scale of sleep score, suggesting better sleep quality, was detected in both groups after a study period. Still, the magnitude of the decrease was greater in the treatment group. The effect of HRT was the most prominent in reducing the rate of insufficient sleep or wakefulness.
Some additional data was also reported in the journal.
A meta analysis of 14 randomized clinical trials, conducted by Zhang et al showed that estrogen administration in perimenopausal women with depression provides benefits, either alone or in combination with progesterone or antidepressants, primarily by reducing fluctuations in estrogen levels and providing stable hormone levels.
They reported that there is evidence that estrogen therapy (ET) has antidepressant effects of similar magnitude to that observed with antidepressant agents when administered to depressed perimenopausal women with or without concomitant vasomotor symptoms.
BUT, estrogen therapy was ineffective as a treatment (per this meta-analysis) for depressive disorders in postmenopausal women. Evidence suggests that there is a possible window of opportunity for the effective use of ET for the management of depressive disorders during the perimenopause.
Furthermore, he points out that there is also evidence that ET enhances mood and improves well-being in non-depressed perimenopausal women.
Take home messages: HRT may be effective for depression, especially if administered before menopause really sets in, but it certainly is well supported for sleep disturbances.
That said, sleep and mood changes are multi-factorial, and should be acknowledged for its complexities. HRT doesn’t fix everything. These years are filled with physiological transitions, but just as important, there are identity recalibrations and role identification shifts. That can certainly provoke wakefulness, especially in the quiet dark hours.
As always, follow sleep hygiene recommendations. And there are countless supplements and herbal supports that can be of aid. But rather than repeat what you can read on the internet when you google natural sleep support, here are some of my personal favorites.
- Try to settle into meditation or in prayer.
- An amazing resource from meditation teacher, and PhD psychologist, Tara Brach, is her sleep “class.”[1] There are 21 short, 15 minute modules and meditations that help you learn how to release fear and lean into letting go, trusting and self compassion.
- Some women knit menopause shawls. Knitting, akin to the rosary, can keep your mind focused on the moment, or on a mantra of your choice.
- I always recommend that women, “just rest my love.” Sometimes,just resting will be enough.
- I love listening to Clarissa Pinkola Estes audio book, Mother Night,[2] which provides many hours of her soothing voice telling stories, sort of like fairytales, that actually have deep and complex meanings, which she draws upon with her Jungian Analysis. It’s easy to listen to, it won’t challenge you, and she may just lull you to sleep
I hope this helps.
