Sleep disruption

Sleep that has changed: harder to fall into, harder to stay in, or ending too early. The British Menopause Society's sleep tool says the most common pattern around the menopause is waking in the night and struggling to get back to sleep. Some women also take a long time to fall asleep, or wake too early.

The cost shows up in the day. The BMS lists tiredness, sleepiness and low mood. The NHS website says broken sleep can leave you irritable, stressed and anxious, and that it may be worse if you also have night sweats.

Lying awake doing sums in your head: school fees, a wedding, the gas bill. Checking the phone and seeing 3:12. Falling asleep just before the alarm, then yawning through the school run, short with the children, foggy by Asr.

In Urdu most women say neend nahin aati, sleep does not come.

The BMS tool lists several causes that often stack on top of each other:

• Hot flushes and night sweats, which sleep studies link strongly to waking.
• The hormone changes themselves. Falling estrogen and rising FSH are linked to more waking, even in women with no other symptoms.
• Mood. Sleep and mental health affect each other both ways, so low mood or anxiety can come before the poor sleep or after it.
• Needing to pee at night, from bladder changes, and aching joints.
• Age, which makes sleep lighter and shifts the body clock earlier.
• Stress, caffeine, screens, and sleep disorders such as sleep apnoea and restless legs.

• The Pakistan Menopause Society lists a regular sleep schedule, no screens or heavy meals in the hours before bed, less caffeine in the evening, and a bedroom kept cool, quiet and dim (section 4.2.3).
• The NHS website adds going to bed only when sleepy, getting up at the same time every day, exercise during the day, no tea, coffee or big meal late in the day, and no naps during the day.
• On chai, the PMS recommendations say excess caffeine may break up sleep, note that tea drinking is high in Pakistan, and ask doctors to talk through timing and amount with you (Table 7).
• The BMS says sleep hygiene advice is sensible but usually not enough on its own to treat a sleep disorder. Sleep hygiene has more.

The BMS tool says HRT can improve sleep quality, partly by treating hot flushes and partly through its effect on mood and other symptoms. The PMS recommendations say MHT, their word for HRT, may improve mood, sleep and quality of life, especially when hot flushes are part of the picture (section 7.2). Whether HRT suits you is your doctor's call.

If HRT is on the table, the progestogen in it may matter for sleep. The European Menopause and Andropause Society (EMAS) says micronised progesterone, one of the progestogens added to estrogen for women who still have a womb, may help sleep more than the others, and The Menopause Society notes it is mildly sedating. Types of progesterone explains the options.

NICE NG23 recommends considering menopause-specific CBT for sleep problems that come with hot flushes, as quoted above. Where a doctor diagnoses long-term insomnia, the BMS says NICE and international guidelines recommend a specific form, CBT for insomnia, as the first treatment, and that it can be done through books, apps, groups or one to one.

The NHS website says to see a GP if changing your sleep habits has not helped, you have had trouble sleeping for months, or it is making it hard to cope with daily life.

Ask specifically about other sleep disorders if any of these sound familiar. The BMS tool's screening questions ask about heavy snoring, a partner noticing you stop breathing at night, and unpleasant, restless feelings in your legs in the evening that ease when you move. It also says that real sleepiness in the day, as opposed to feeling tired, can be a sign of another sleep disorder.

Bring a list of your medicines. The BMS names steroids, some antidepressants, stimulants and beta-blockers among those that can disturb sleep, and thyroid disease, reflux, chronic pain, depression and anxiety among the conditions that can. EMAS's list of causes adds iron deficiency, so it is fair to ask whether your iron should be checked.

Fajr already asks you to wake before dawn. In Ramadan, suhoor and taraweeh cut the night shorter still, and a body that sleeps badly feels every bit of it. Ramadan and fasting has more. Questions about the prayers and the fast belong with a qualified scholar. Questions about when to take a medicine belong with whoever prescribes it.