Trouble sleeping? How to reduce night sweats during menopause

You have woken in the night, drenched in sweat, with your pyjamas stuck to you. Menopause-associated night sweats have crept up on you, and have the potential to affect your sleep quality, your relationship, and your self esteem. But why do they occur and what can you do to reduce them?

Menopause is a gradual transition. Perimenopause — the period of time leading up to the point where you stop ovulating completely —  often begins in the late 40s, with irregular periods and vasomotor symptoms, which relate to the constriction or dilatation of blood vessels.

Someone is said to have reached menopause after they haven’t had a period for twelve consecutive months. The mean age for this to happen is 51 years old.¹ Symptoms that menopause is associated with include vasomotor symptoms (relating to blood vessels), vaginal dryness, urinary incontinence, low mood, sexual dysfunction, and trouble sleeping. The presence of these symptoms varies between people, and the severity is also unpredictable.

Vasomotor symptoms includes perspiration, which is experienced during the day (hot flush) and night (night sweats) by over 75% of menopausal people.² With vasomotor symptoms, you may awaken in the night and experience intense internal heat and visible sweating, lasting from two to four minutes.^3,4 The sweating may be so bad as to require you to change pyjamas. Although vasomotor symptoms generally subside after five to seven years, some may have to deal with these symptoms for 10 to 15 years.⁵

Theories that explain vasomotor symptoms of menopause involve the effects of declining levels of oestrogen within the body and an alteration in brain control of body temperature. The gradual reduction in oestrogen during menopause occurs at the same time that the body’s thermostat area in the brain (hypothalamus) begins to sense much smaller changes in body temperature. Consequently, a minor increase in body temperature can bring on profuse sweating.

A gradual reduction in oestrogen is also responsible for decreased serotonin (a key messenger involved in the brain pathway controlling hypothalamus activity, that is often associated with happiness) which alters the body’s baseline temperature, increasing the likelihood of vasomotor symptoms. Your hypothalamus is programmed to maintain temperature, so when the ambient temperature rises, blood pours into blood vessels (vasodilation) in your skin, you become flushed, and start to sweat. Sweating is your body’s way of cooling off and keeping your core temperature stable. However, when sweating is unwanted and disturbs your quality of sleep, then it is highly likely you will seek solutions.

Treatment options

Hormone replacement therapy (HRT) replenishes oestrogen, with over 50 different preparations available in differing combinations of oestrogen and progesterone. HRT can reduce frequency of vasomotor symptoms by over 75%,⁶ making it an effective and attractive option. To make a fully informed decision about HRT, your GP will consider your stage of menopause and discuss the risks and benefits with you. Your clinical history, such as whether you have had a hysterectomy, breast cancer, or stroke will all be taken into consideration, along with your cardiovascular health, when deciding if HRT benefits outweigh the risks for you.

However, for those with premature (under 40 years old) or early (under 45 years old) menopause, current guidelines recommend HRT until the age of 51 years for the treatment of vasomotor symptoms and for bone and cardiovascular protection.⁷

Benefits of HRT

HRT has been found to improve vasomotor symptoms, vaginal dryness, urinary incontinence, low libido, and low mood.^8,9 It has also been said that HRT lowers the risk of osteoporosis.¹⁰

Risks of HRT

HRT does increase the risk of blood clotting (thrombosis),¹¹ which is the reason that it’s not advised for people with a history of blood clots. Risk of stroke is also elevate with oral oestrogen-only or combined HRT, and the effects of HRT on stroke increases with age. Therefore, older people have a greater risk of stroke.¹²

In terms of breast cancer risk, the risk for those around menopausal age varies from one person to another according to the presence of underlying risk factors. It has been found that there is little or no increase in risk of breast cancer with oestrogen-only HRT.¹³ For those receiving combined HRT, risk of breast cancer increases with duration of use (in one study the risk is doubled in women on HRT for 5.4 years, and increased by just over three times in women on HRT for more than 15 years).¹⁴ Therefore, any increase in the risk of breast cancer is related to treatment duration, and your GP will prescribe HRT for the shortest effective period. After stopping HRT, the risk of breast cancer reduces.¹⁵

Alternatives to HRT

Non-hormonal prescription drugs

Selective serotonin reuptake inhibitors (SSRIs) such as paroxetine, and selective noradrenaline reuptake inhibitors (SNRIs) such as venlafaxine are two of the most commonly used treatments as HRT alternatives for alleviating vasomotor symptoms during menopause. One or two tablets per day are prescribed, and common side effects include nausea and reduced libido.¹⁶

Clonidine is recommended by NICE as a second-line treatment for those with solely vasomotor menopause symptoms. Common side effects include dizziness and fatigue.

Gabapentin, which is usually prescribed as an anti-epileptic drug, is effective at reducing vasomotor symptoms. Side effects that are commonly experienced include drowsiness, dizziness, and fatigue.¹⁷

Stellate ganglion block

This involves the injection of local anaesthetic into the stellate ganglion, which is a collection of nerves at the back of the neck, when other treatments for vasomotor symptoms have not been effective. This is also a treatment option for people with breast cancer. Preliminary studies report encouraging effectiveness, with minimal complications.¹⁸

Lifestyle

Recommended lifestyle alterations include wearing light pyjamas and sleeping in a well-ventilated room to keep cooler at night. There is also some evidence that people who are more active can improve their vasomotor symptoms, however, the evidence on this point is limited. High-intensity exercises are not as effective as sustained exercise such as running or swimming.¹⁹

Complementary therapies

Many perceive complementary therapies to be a safer and more natural alternative to traditional hormone therapy. It is worth noting that many herbal options may interact with current prescribed medicines, and that they are not subject to as rigorous testing by government safety guidelines for manufacturing.²⁰

Herbal options

Black cohosh

Some people have reported alleviation of vasomotor symptoms with black cohosh (a North American herb). The NICE guidelines in the UK advise caution, that multiple preparations (which may vary) are available and that their safety is uncertain. Interactions with other medicines have been reported.

Phytoestrogens: soy and red clover

Phytoestrogens such as soy and red clover are plant substances that have similar effects to oestrogens. The trials are conflicting in terms of effectiveness,²¹ and NICE advises that people who wish to try complementary therapies be aware that the quality, purity, and constituents of products may be unknown. Trials are currently ongoing, and more evidence will be published when they are completed.

Vasomotor symptoms such as night sweats can be a highly distressing interruption to daily living. Since there are many treatment options, it is better to be aware of all the risks and benefits so that you can make a fully informed choice. Someone with vasomotor menopause symptoms may choose traditional HRT, or there may be reasons in their medical history such as breast cancer or thrombosis that could lead them to opt for an alternative prescription medicine or a complementary therapy.

There is no need to suffer in silence since there are multiple options available that have been proven as effective in managing those bothersome night sweats. Furthermore, referral to a specialist in menopause is possible if night sweats do not improve following three months of treatment.
 
 
Featured image is of a bed that looks like someone has just got out of it. The pillow and duvet are pale green and the sheets are white. The bedhead is made of dark wood
 
 
Last updated September 2022
Next update due 2025