Many women I see in my practice have questions about hormone replacement therapy, or HRT. They wonder about the benefits versus the risks. And they want to know how HRT and other medications used for menopause symptoms might influence their sleep—for better or worse.
The decision to use HRT is a highly individualized one, a decision women should make in consultation with their physicians, and with consideration of their health and family medical history, age, where they are in the menopausal transition, the severity of their menopause symptoms and the effectiveness for them of non-hormonal therapies in relieving those symptoms. Here, I’ll talk about what the science says about the benefits and risks of HRT when used to treat symptoms of menopause, including sleep. I’ll also talk briefly about other medications used to treat the symptoms of menopause, and how they can affect your sleep.
Hormone replacement therapy (HRT)
What is HRT?
Hormone replacement therapy is used to supplement the dwindling supply of the body’s own hormones, as production decreases during and after menopause. The most common hormones supplemented with HRT are estrogen and progesterone, though other hormones, including testosterone and DHEA, are also sometimes used in replacement form. Women who have their uterus intact take estrogen and progesterone together, to protect against uterine cancer. Women who’ve undergone hysterectomy can take estrogen alone.
What are the benefits and risks of HRT?
When considering whether hormone replacement is the right choice for treating menopause symptoms, both age and proximity to menopause are key factors. Scientific evidence has demonstrated that women get the greatest benefits, with the lowest risks, when HRT is used in menopausal women under age 60 or within 10 years of menopause. It’s also recommended that women use estrogen and progesterone replacement therapy for no more than 3-5 years. There’s evidence that a longer duration of use increases breast cancer risk. Women using replacement estrogen alone may be able to stay on this treatment for a longer period of time, as the increased risk of breast cancer does not appear to be a factor in estrogen-only HRT.
For women under the age of 60 and within 10 years of menopause, research shows estrogen replacement may have a beneficial effect on cardiovascular health and bone health, and may reduce risk for diabetes. During this window of time, studies suggest hormone replacement therapy may also provide benefits to women’s cognitive health, and protections against neurodegenerative disease and cognitive decline. For women under 60 and within 10 years of menopause, risks associated with HRT include an increased risk of blood clot in the legs and lungs. And use of estrogen and progesterone for longer than 5 years is linked to an increased risk of breast cancer.
Research released in 2017 contained some positive news about the overall safety of hormone replacement therapy for women in menopause. A study looked at more than 27,000 women who took HRT starting in the 1990s, and found no statistically significant difference in mortality for women who used HRT, compared to women who did not. The researchers looked at all-cause mortality, as well as specific mortality rates for cancer, cardiovascular disease and other major causes of mortality, and found no association between HRT use and higher rates of death for the women who used hormone replacement therapy.
HRT is not generally recommended in women who are older than 60, or who are more than 10 years beyond menopause, because of increased risks for cardiovascular disease as well as risks to cognitive health.
For women of all ages who are at elevated risk for blood clots, heart disease, stroke, and breast cancer, HRT may not be a suitable treatment for relief from menopause symptoms.
What about bioidentical hormone replacement therapy?
A number of the patients I see are interested in knowing more about bioidentical hormone therapy. They wonder, what are the differences between bioidentical hormone therapy and traditional hormone replacement therapy?
Bioidentical replacement hormones are made to be an exact bio-chemical match for a woman’s own natural hormones, often in a compounding pharmacy. Conventional hormone replacement products are made from synthetic versions of hormones, or from animal hormones. Bioidentical hormone replacements are not regulated by the FDA. Some scientists and other medical professionals express reservations about bioidentical hormones, specifically regarding variations in levels of dosing and the precision of the saliva testing that’s used in preparing women’s individual hormone compounds.
Most of the studies of the risks, effectiveness, and benefits of HRT for menopause symptoms have been done using conventionally-made replacement hormones. There is some research that’s focused specifically on bioidentical hormones for women in menopause that suggests these hormones can be effective at treating menopausal symptoms. Some reviews of research on bioidentical hormone replacement for menopause show that bioidentical estrogen and progesterone work effectively to improve menopause symptoms, and may carry fewer risks for cardiovascular disease, breast cancer, and blood clots, compared to the conventional versions of these hormones. This is an important area of research that needs more attention, to provide women—and their doctors—with more comprehensive information about bioidentical hormones, their safety and effectiveness.
If you’re a woman considering bioidentical hormone replacement, talk with your physician about whether this form of HRT might be right for your individual needs.
Can HRT provide benefits to sleep for women in menopause? Research indicates it can. Low-dose hormone replacement therapy can improve sleep quality in women who have recently undergone menopause, according to recent research. Another new study also reported improvements to sleep quality in women who use HRT. Estrogen replacement has been shown to help women fall asleep faster, reduce their nighttime awakenings, strengthen their sleep cycles, and boost REM sleep—as well as improving cognitive function.
There isn’t a one-size-fits-all answer to whether HRT is the right treatment for women in menopause with uncomfortable, life-disrupting symptoms. I encourage my patients to consider HRT in consultation with their primary physicians as one of several options for relief from symptoms of menopause, including sleep disruption.
Other medications used for menopause symptoms
Let’s take a look at how these medications might affect sleep:
Low-dose anti-depressants, including SSRI medications. Low-dose antidepressants are sometimes prescribed to women in menopause to treat hot flashes and low mood—particularly women who can’t take estrogen replacement therapy. Antidepressants can have complex effects on sleep, even at low doses. Women may see an improvement to sleep. But antidepressants can lead to sleep disturbances, changes to sleep cycles, increases to REM sleep, and daytime fatigue or sleepiness. They also can aggravate existing sleep disorders, including restless leg syndrome, sleep apnea, and REM behavior disorder. Women who use these medications to treat menopause should be aware of any changes to their sleep patterns or sleep quality, and share those changes with their physicians.
Gabapentin. This medication, used to treat seizures, is also prescribed to women in menopause for hot flashes, especially women who can’t take supplemental estrogen. Research shows Gabapentin may help relieve insomnia, and increase amounts of slow-wave sleep. It also may lead to drowsiness and fatigue.
Clonidine. A blood pressure medication that’s also used to treat hyperactivity associated with ADHD, clonidine is sometimes used to treat hot flashes in menopausal women. Clonidine can induce sleepiness. There have been limited studies on clonidine’s effects on sleep. Research indicates it can alter sleep patterns and time spent in slow-wave and REM sleep. Clonidine is sometimes prescribed to treat insomnia and other sleep disturbances. I generally recommend looking for other, non-pharmacological improvements to address sleep, from lifestyle and behavioral changes, to mind-body treatments and natural supplements.
Next, I’ll talk about the natural supplements that women can use to help manage symptoms of menopause, including sleep problems.
Michael J. Breus, PhD, DABSM
The Sleep Doctor™