Are you having trouble falling asleep or struggling to get back to sleep after waking up early? Has your sleep been affected by menopause and long-term cancer treatment? Maybe, you’ve tried improving your sleep habits but haven’t seen any significant changes. Sleep problems are very common and we want to look at all possible solutions for you. We had the pleasure of speaking with Dr. Zoe Schaedel, a sleep and menopause expert, who has extensive experience in helping cancer patients in both the NHS and private practice.

Regardless of how long you’ve been experiencing poor sleep or the reasons behind it, this article will shed light on why sleep problems occur during menopause, cancer treatment and beyond. It will explain the most effective, evidence-based strategies to address these issues and identify factors that may in fact be worsening your sleep. Lastly, it aims to bring you a sense of clarity and hope so you feel less alone in dealing with your sleep difficulties.

How is sleep disturbed during menopause and cancer treatment?

Approximately 50-60% of women going through menopause report experiencing difficulties with sleep, such as poor sleep quality, disrupted sleep patterns, and symptoms of insomnia (1). However, for women who have had cancer and are currently in the menopausal stage, the percentage of those experiencing these issues increases to around 70-80%. This can occur at any stage of a person’s cancer journey, but is particularly common after being diagnosed or while undergoing treatment. It can, however, also persist after treatment has ended, with sleep continuing to be disrupted and not returning to normal (2). With this article ‘sleep problems and solutions in menopause and cancer treatment’ we aim to look at all options available.

Change is possible

Zoe frequently sees many women in menopause, especially after cancer treatment, who feel like their ability to sleep has been taken away from them. Many of them have resigned themselves to the belief that they will never sleep well again. With this in mind, Zoe wants to hep women to shift their perspective on this matter. She wants to reassure you that while cancer or its treatment may trigger sleep issues, they are not necessarily the sole cause of the ongoing problem.

Triggers and Maintenance of Sleep Problems

It’s important to recognise that there is often a distinction between what initially triggers the sleep problem and what keeps it going. Irrespective of the trigger, our brains are always learning and shortcutting and so can easily develop a new habit, which keeps us stuck in a disturbed sleep pattern. Due to the neuroplasticity of the brain, equally, you can also relearn and shift your brain back to a healthier space by employing the right evidence-based techniques.

Do I have insomnia and what is it?

According to the National Institute for Care And Health Excellence (Nice) Guidelines “Insomnia is difficulty in getting to sleep, early wakening or non-restorative sleep which occurs despite adequate opportunity for sleep and results in impaired daytime functioning.”

What is a Cognitive Behavioural Therapy for Insomnia (CBT-I) Plan?

A Cognitive Behavioural Therapy for Insomnia Plan is one example of the way to reset your situation by looking at thoughts, behaviours and what’s happening around sleep. The importance of having a plan becomes even more evident during the early hours of the morning when you wake up, as logical thinking can be particularly challenging during this time.

Daytime Strategies for sleep problems in menopause and cancer treatment

Zoe explains that in this instance, there are things you can do in the daytime such as thinking about what it’s like being up in the early hours of the morning and whether you are feeling anxious or worried. It can often be a time for rumination and catastrophic thinking, which is especially common among cancer patients.

Brain Changes at Night

Often during the night, things feel much worse and are more difficult to solve, and there is good reason for this; our brains work differently at night. Our thinking at this time is driven by the amygdala, the primitive part of the brain that feels emotion. The prefrontal cortex, the rational part of the brain goes offline so our logical functioning is not activated. Zoe reassures people that it is not you, but rather the way the brain is set up. A plan can then be developed which contains effective tools that can address and help this way of thinking.

What does a CBT-I programme cover?

A CBT-I programme takes approximately six weeks to complete. It equips you with effective psychological techniques, timing components and well-defined strategies for waking in the night and getting back to sleep. It helps to improve sleep issues over time and stops their distressing effects. Research has shown that the recovery rate from insomnia with Cognitive Behavioural Therapy is 70-80% (3). Zoe has found that sometimes these numbers are even higher due to the effectiveness of this one-to-one treatment.

 

6 Strategies for Waking up Early:

1. Using Mindfulness and Meditation

If you are waking up and ruminating or experiencing catastrophic thinking, it is important to understand that you cannot prevent thoughts from entering your mind. In fact, attempting to halt them will only amplify their intensity. What we resist tends to persist. Therefore, it is key to find ways to diminish the power of these thoughts and practice distancing ourselves from them. By practising mindfulness and meditation techniques during the day, such as being fully present in the moment and observing thoughts without judgment, we can develop a set of tools that can be utilised in the early hours of the morning.

2. Employing Well-Defined Strategies

It is beneficial to have well-defined strategies for what to do when you wake up early. If you’re dealing with hot flushes, you could try some cooling techniques like going to the bathroom and placing your feet on a cold floor. Another effective approach is visualization; picturing calming images can help slow down your racing thoughts. Specifically, it’s beneficial to visualise with great detail, including sights, smells, and physical sensations. This can help detach yourself from your own thoughts and divert your attention away from overthinking.

3. Getting Out of Bed

Another strategy is to simply get out of bed. It may seem counterintuitive, but when you’re lying in bed, you’re still actively trying to fall asleep. And that’s where the problem lies; all your efforts to sleep actually make it more challenging because your mind and body are focused on achieving something. As a result, this increases alertness and makes it less likely for sleep to occur.

4. Planning when and how to get up

It’s generally recommended that if it’s been 20 minutes and you’ve tried a few techniques but sleep still eludes you, it’s best to get up. Zoe emphasises the importance of planning this ahead of time, as it can be quite difficult to do in the middle of the night. The reasoning behind this strategy is that it does two things: stops you trying to get to sleep and breaks the negative association built up between you and your bed. The aim is to stop you spending a lot of time in bed fretting and trying to sleep. In addition, your body learns that this is a difficult place for you, and the intention is to break that association.

5. Choosing a Supportive Environment

Zoe recommends going into a pleasant space, that is dimly lit and perhaps having a drink.  You could sit down, read a book or maybe listen to a podcast or look through a magazine. She suggests, however, not to eat, work or do anything too stimulating like watching action movies. Specifically, you are looking to do “Something that is reasonably pleasant, not too stimulating, that you can focus on a little.”

6. Recognising Sleeping Cues

In an ideal world, you would wait for sleeping cues to signal when to go back to bed. However, lots of people who have had sleeping difficulties for a long time have a disconnected sense of sleepiness. In that case, the goal is to relearn how to recognise those cues. If you’re not getting those sleepiness cues, it’s recommended to choose a specific time to go back to bed. In addition, you would then bring in diffusion techniques to try and set yourself away from your thoughts, such as meditation and mindfulness. Furthermore, Zoe suggests that using a Sleep Story on the Calm App may be beneficial.

 

What to do if sleep still doesn’t come

If you’re still having trouble sleeping, it’s a good idea to try getting up again. This method should be practiced for about a week or two. In the beginning, you might find yourself getting up multiple times during the night, but as time goes on, your body will start to adjust and it can be very effective.

Making Changes When You Are Ready

Taking a personalised approach and making changes when you feel it’s appropriate is extremely important. For instance, if you’re feeling exhausted during or after cancer treatment, the idea of getting out of bed may seem overwhelming and feel too soon. Therefore, it’s crucial to listen to your body and do what feels right for you.

Additionally, Zoe assures us that it’s okay to have periods of poor sleep and that we can get through it. She recommends discussing your sleep difficulties with your doctor or nurse and keeping options open to find the best solution for your current situation. However, if you’re ready to tackle your sleep problems with a cognitive-behavioural intervention and have the energy for it, then this type of programme can be highly effective.

Why is improving my sleep hygiene not helping?

Whilst improving your sleep habits such as limiting caffeine, alcohol and light in the early evening, keeping a cool sleep environment, developing a good bedtime wind-down routine, and maintaining a regular sleep pattern are good for making healthy sleep better, they are not an appropriate treatment if you have a sleep disorder, like insomnia. Additionally, people will often try to improve their sleep hygiene and start to feel discouraged if nothing is working.

Why is focusing on the benefits of sleep making me feel worse?

There is growing awareness of the importance of sleep and its numerous advantages. For those people who tend to stay up late and work too hard, acknowledging and applying this information can be extremely beneficial. However, if someone struggles to fall asleep, it can become counterproductive and add unnecessary pressure and stress. For instance, people often feel scared that if they can’t sleep, they won’t be able to reap all those benefits. In this instance, Zoe suggests keeping in mind that humans are naturally built to endure extended periods without sleep. This allows us to adjust to new situations and life events.

Can medication help sleep problems and are they a good solution for insomnia in menopause after cancer treatment?

It is useful to keep an open mind with your sleep toolbox and look at everything that is available to you.

Different Types of Sleep Medication

Sleeping Pills

Sleeping pills, known for their sedative properties, may provide temporary relief but can lead to long-term issues. Zoe emphasises that while they may be useful in certain situations, such as during a crisis, they do not address the underlying sleep problems in the long run. Over time, their effectiveness diminishes, and they are not recommended as an initial treatment option according to NICE guidelines. Therefore, it is advised to explore alternative approaches, such as CBT-I first.

Antidepressants

Some antidepressants can be helpful for people who struggle with anxiety and have trouble sleeping because of it. These anxious thoughts are especially common among cancer patients, and in such cases, an antidepressant may be beneficial.

Melatonin

Zoe advises that Melatonin, despite its widespread discussion and usage, is not particularly effective in treating insomnia. Moreover, it doesn’t function in the way we want it to. Melatonin is a natural substance produced by our brain, and its purpose is not to make us fall asleep but rather to regulate the timing of our sleep. It simply assists us in signalling that it’s time to drop off. It’s not a sedative and won’t instantly make you fall asleep.

How do I access Cognitive Behavioural Therapy for Sleep Problems?

1. Online Programmes

Sleepio is a web-based self-help programme based on Cognitive Behavioural Therapy,  that is designed to help you manage sleep problems and insomnia. It is free for NHS patients in Scotland and Macmillan has partnered with Big Health to offer free access to anyone who has had a cancer diagnosis.

Sleepstation is a clinically validated sleep improvement programme to combat insomnia. By searching your GP surgery, you can find out if Sleepstation is available on the NHS in your area. 

2. Useful Books

Zoe recommends the following books to help you understand sleep issues further and how to use CBT for sleep problems and insomnia.

Anderson, Kirstie (2018) How to Beat Insomnia and Sleep Problems One Step at a Time: Using Evidence-Based Low-Intensity CBT.

Ellis, Jason (2017). The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems

3. Personalised Cognitive-Behavioural Therapy (CBT) Sleep Treatment Programmes

Some people who are experiencing persistent sleep problems in the menopause transition, during or after cancer treatment may prefer more personalised, one-to-one support.

How can a personalised CBT sleep treatment programme help?

A personalised CBT treatment programme is based on an in-depth assessment of your specific sleep problems. Moreover, you can discuss all your sleep difficulties through menopause and cancer treatment with expert psychologists who will support you.

The programme will include an evidence-based, step-by-step process that is tailored to your sleep issues and can practically guide you to achieve better sleep and well-being. Specifically, this talking therapy programme can help you to “replace thoughts and behaviour that can cause sleep problems or make them worse, with more helpful ones that promote sound sleep.” The Good Sleep Clinic. In addition, CBT can be specifically targeted to help you with menopause symptoms such as hot flushes and night sweats.

References:

(1) Baker, Fiona et al. Sleep and sleep disorders in the menopausal transition. Sleep Med Clin 2018;Sept:13(3):443-456

(2) Hery, Chloe et al. Factors Associated with Insomnia symptoms over three years among premenopausal women with breast cancer. Epidemiology 2023;Aug 202:155-165

(3) Morin, CM, et al. Non-pharmacological interventions for insomnia: A meta-analysis of treatment efficacy. Am J Psychiatry 1994;Aug 151(8):1172-80

Dr Zoe Schaedel (BMBS, BMedSci, MRCGP, DRCOG, DFRSH) possesses a wealth of knowledge and expertise in the fields of menopause care and sleep problems, accumulated over her 15-year tenure as an NHS GP. She is an accredited British Menopause Society (BMS) Menopause Specialist and is a member of the BMS Medical Advisory Council. She is a Menopause specialist for Myla Health and Co-founder of the Good Sleep Clinic.

Disclaimer: The information provided in this article is for informational purposes only and should not be considered as a substitute for medical advice. Always consult your doctor, oncologist, or medical team.

Menopause and Cancer are not affiliated with any product or service mentioned or linked.

Written by Bettina Alderton, MSc Psych, BSc (Hons)

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