January 20, 2021

Navigating a New Chapter

By Jennifer Hensley, EdD, CNM, WHNP, RN

When I was asked to write on worsening restless legs syndrome (RLS) during menopause my immediate answer was, “Yes!” My training as a nurse-midwife and women’s health nurse practitioner is all about helping women. Then, I remembered there is no one-size-fits-all answer. Each woman’s experience of the years leading up to and during menopause is different. I could write a book about the physical, physiologic, and psychologic changes during menopause (and many have), but for now, let’s discuss what might work for a better night’s sleep.

During the years a woman has menstrual cycles, hormones (follicle stimulating hormone and luteinizing hormone) are secreted from the pituitary gland in the brain to stimulate estrogen and progesterone production from the ovaries. Luteinizing hormones are necessary to prepare the ovaries for release of an ovum (egg) and the uterus for reception of a pregnancy if it occurs.

Adjusting to new experiences

During the reproductive years, estrogen helps to maintain the health of the heart, bones, vagina, bladder, cholesterol count, and brain. It is thought that estrogen plays an important role in helping to regulate the body’s temperature during sleep. When a woman enters perimenopause/menopause, lower levels of estrogen are insufficient to regulate the thermostat. Frequent awakening during the night can occur due to overheating, leading to insomnia symptoms. Studies conflict as to whether or not taking an estrogen tablet will help with worsening RLS symptoms during perimenopause/menopause, which leads me to wonder if worsening sleep, in and of itself, leads to a worsening of RLS symptoms.

In the US, the average age of menopause—the cessation of menstrual cycles for 12 months—is 52 years, but perimenopause can begin 10 years prior to that. Some 35-ish years after the first menstrual cycle, the ovaries begin to age and stop responding to messages from the brain.This leads to a decrease in the production of estrogen and progesterone, and a variety of physical symptoms, most notably, the “hot flash.” Up to 80% of all women experience this dramatic symptom, including women as young as 42 years of age. Vasomotor (VSM) symptoms are experienced as hot flashes during the day and night sweats during sleep. VSM can occur once a day, or up to 50 times in a 24-hour period and may continue for a year, or off-and-on for a lifetime. VSM symptoms are characterized by a sensation of warmth starting in the chest area, moving onto the face, with onset of minimal to profuse sweating, and perhaps accompanied by heart palpitations. VSM will interrupt sleep: one moment it’s too hot under the covers, and, the next, it’s too cold because of evaporating perspiration.

Living with RLS during menopause

Why, then, does RLS worsen with menopause? We don’t know. What is known is that aging can change sleep patterns. Loss of brain cells that helped us to regulate sleep now cause us to fall asleep earlier and wake up earlier. Could a physiologic change in sleep patterns affect RLS symptoms in aging/menopausal women? If so, retiming when medications for RLS are taken may be a helpful strategy to manage symptoms.

We also know that, with aging, we are more likely to develop a medical condition, such as hypertension, diabetes, kidney dysfunction, thyroid problems, and/or obstructive sleep apnea. These medical problems can worsen if we are not getting restful sleep, and these worsening medical problems can interrupt sleep, and so on. New medications may cause sleep disruption and interactions with medications prescribed for RLS (either making the effect stronger or weaker). A discussion with your healthcare provider, sleep medicine expert, and pharmacist may be helpful.

Here is what we know will worsen RLS:

• Aging
• Comorbidities (hypertension, diabetes, kidney disease)
• Drugs that worsen RLS such as sedating antihistamines, most antidepressants, dopamine agonists, and anti-dizziness drugs
• Changes to the internal 24-hour internal body clock
• Low iron stores in the body

Anemia and VSM

It is not unusual for women to experience irregular menses during perimenopause, which can range from skipped menstrual cycles to excessive and prolonged bleeding. e latter could lead to anemia and low iron stores in the body, which we know can worsen RLS symptoms. A gynecologic provider can help diagnose, treat, and manage this type of bleeding with birth control pills, other hormones, or surgery. When ordering tests to check for anemia, be certain to ask for a ferritin level to check iron stores in your body. We want the ferritin value to be over 75-100 mcg/L, as we know the lower the number, the worse the RLS symptoms are for some individuals. Iron tablets can help to build iron stores; IV iron is considered if a rapid response is required or if oral iron therapy is not helpful.

VSM can be helped during perimenopause with birth control pills, and in menopause with hormone replacement. e hormones in birth control pills regulate irregular menses and prolonged bleeding; thereby maintaining iron stores (ferritin) during perimenopause. By getting a better night’s sleep, not interrupted by night sweats, RLS symptoms may lessen significantly.

For women whose sleep is interrupted by VSM:

• If less than 52 years of age, consider estrogen in the form of a low-dose contraceptive pill, which might help stabilize estrogen levels and improve thermoregulation. It is perfectly safe to take active pills (pills with estrogen and progestin) every day so the levels of estrogen and progestin remain stable in the body. Talk to your gynecologic healthcare provider to see if this is a safe option for you.
• If greater than 52 years of age and experiencing vasomotor symptoms, consider estrogen-progestin or estrogen replacement therapy for up to five years (this is the current recommendation to prevent risk of cardiovascular disease and breast cancer). To maintain a steady level of estrogen and progestin in the body, take active pills (pills with estrogen and progestin) every day. Talk to your gynecologic healthcare provider.
  Medical Editor Note: Any woman who still has her uterus must take a progestin with estrogen to prevent endometrial cancer.
• Gabapentin is one of the medications used for VSM by gynecologic providers, and for RLS.
• Low-dose antidepressants (paroxetine or venlafaxine) have both been shown to reduce vasomotor symptoms. If VSM and RLS symptoms become intolerable, talk to your healthcare provider. A change to your treatment plan will help to manage VSM and RLS symptoms leading to better sleep quality and quantity. VSM, RLS and depression can be managed; it may take several attempts to find the medication combination that works best for you.
  Editor’s note: Antidepressants, even low doses, may worsen RLS for some people. The goal is to treat the depression first then manage the RLS. If the antidepressant medications worsen the RLS, then increased treatment of the RLS may be necessary, rather than decreasing the antidepressant medication.
  
• Clonidine, an older antihypertensive medication, is known to decrease the number of night sweats, and may be used in conjunction with estrogen or in lieu of it.

For women whose sleep is interrupted with worsening RLS symptoms:

• Dopaminergic drugs such as Requip or Mirapex may help. Talk to your RLS healthcare provider. Gabapentin class drugs should be considered before using these drugs.
  
• Have a yearly physical and lab work to check function of the kidneys, liver, pancreas, thyroid and iron stores (ferritin) in the body.

For all of us:

• Stop smoking.
• Eliminate alcohol close to bedtime.
• Eliminate caffeine.
• Consider if other sleep disorders are adversely impacting a good night’s sleep (obstructive sleep apnea, insomnia) and seek help from a healthcare provider.
• Exercise a minimum of 150 minutes a week (6,000 steps five times a week).
• Go to bed and get out of bed at the same time every 24 hours.
• Go outside after awakening so the sun can set your internal clock.
• Take care and be well.

Jennifer Hensley is a certified nurse-midwife and women's health nurse practitioner who serves as the Baylor University Louise Herrington School of Nursing Clinical Professor and Coordinator of the Nurse-Midwifery Program Track in the Doctor of Nursing Practice program. She built her clinical scholarship on restless legs syndrome during pregnancy and sleep disorders in women across the lifespan. She is an active member of the RLS Foundation's Scientific and Medical Advisory Board and serves on the Quality Care Certification and Medical Bulletin Committees.