In each installment of Ask a Doctor, your burning questions about hormones, menopause symptoms, sleep, sex, and more are answered by doctors who specialize in treating women in midlife.
This week: Dr. Fiona Barwick, clinical associate professor in psychiatry and behavioral sciences, and director of the Sleep & Circadian Health Program at Stanford University, explains why even sleeping medication you can get without a prescription isn't great for long-term use — and how we can actually get back to sleep.
Dear Doctor,
I’ve had insomnia for a few years and have been on a few different sleep medications; previously I was using prescription ones like Ambien, and now I’m using over-the-counter ones like ZzzQuil and melatonin. Is it risky to keep using over the counter sleeping pills for a long period of time? Is it risky to use any sleeping pills for a long period of time?
Dr. Fiona Barwick:
For various reasons, the go-to strategy in this culture is to use some sort of substance to help with sleep, and sadly, that’s not the best thing to do. Whether it’s a prescription sleep aid, an over-the-counter sleep aid, alcohol, or cannabis, every substance changes normal sleep patterns.
I think pretty much all sleep aids give you less REM sleep — that rapid eye movement sleep, the dream sleep. REM sleep seems to be one of the critical sleep stages that is important for consolidating what we learn during the day, remembering it, and helping us regulate emotions more effectively, so you don’t want to miss out on it.
And some medications prescribed for sleep — in particular benzodiazepines such as Xanax, Valium, and Ativan — can actually suppress your deep sleep.
With prescription sleep aids, you’re essentially knocking yourself out with a chemical baseball bat. If I knock you on the head with a baseball bat, I can render you unconscious, but are you sleeping? Are you getting deep sleep and dream sleep? No, you’re not. Sedation is not sleep.
Medication doesn’t really “make” you fall asleep
People who are taking medication think that it’s producing their sleep. It’s not.
Physical activity is what builds your sleep drive. Sleep drive is a biological drive; it works like hunger for food. The longer you’re awake, the hungrier you get for sleep.
So, our sleep drive builds with physical activity, and the molecule that builds along with it is adenosine. Adenosine results from energy expenditure. So, the more energy you’re expending, the more adenosine you produce, and the more adenosine you produce, the higher your sleep drive. The higher your sleep drive by the time you get to bed, the faster you’ll fall asleep, and the faster you’ll get back to sleep if you wake up. There is no medication that produces adenosine.
But then, if you have insomnia, you’re anxious about sleep at bedtime, and anxiety is incompatible with sleep.
Over the counter doesn’t mean “no side effects”
People often think that over-the-counter sleep aids, because they don’t require a prescription, are safe. I would speculate there are no medications that do not have some negative side effects when taken long-term.
With over the counter sleep medications like Benadryl and Unisom, people can develop a tolerance for them very quickly, so the effects are almost nil after a few nights. Plus, there are potentially concerning long-term effects due to the anticholinergic status of these medications. (Anticholinergic drugs block the neurotransmitter acetylcholine, and some research has suggested a connection between the use of anticholinergic drugs and an increased risk for developing dementia.)
There’s also a huge placebo effect for everything, whether it’s a prescription medication or an over-the-counter one. Placebo effect probably counts for about a third — or sometimes more — of the effects you get with any treatment. So probably some of the improvement in sleep people experience from taking medication is simply due to placebo effect.
Melatonin can be useful…in moderation
There is some evidence that as we get older our natural melatonin levels might drop a bit, by about 10 percent. And certain medications, like beta blockers, reduce melatonin, so sometimes exogenous melatonin or melatonin supplementation could be useful.
In menopause, because estrogen regulates melatonin levels, cortisol levels, and body temperature, the changes in estrogen levels can lead to changes in melatonin. It’s not always contraindicated, and it’s possible it might even be helpful as we get older. In Europe, melatonin is a prescription medication and a recognized prescription for people over 55.
While I don’t necessarily believe that melatonin is a bad thing to experiment with, I do have a problem with the amount people take, because the amount of melatonin our brain releases to help us feel sleepy is one millionth of a milligram.
Taking large amounts — like 10 mg a night — is going to mess up your circadian rhythms. Just like any medicated sleep aid, melatonin can have hangover effects. You can feel a little hungover the next day. When melatonin is in your system, you feel a little foggy, with low energy, a low mood. It’s one of the reasons why we often wake up feeling groggy — not because we didn’t sleep well, but simply because it takes a little time for melatonin to leave our system. Two milligrams is the most you should take.
In this country, unlike most other countries, melatonin is not regulated by the FDA, so there’s a discrepancy between what’s on the label and what is in the pill. Research has confirmed it that if you’re buying OTC melatonin, you actually have no idea what you’re getting.
You want to get pharmaceutical-grade melatonin. Look for something that has the GCP (Good Clinical Practice) label or the USP (US Pharmacopeia) seal of approval. A product with melatonin, one filler, and pretty much nothing else, is your best bet.
The key is knowing why you can't sleep
Many people think that treating insomnia is about figuring out any way to get to sleep. But knowing the source of your sleep disturbance and treating it is key for many reasons.
If you have sleep apnea, for example, medication isn’t going to treat it. That's just going to mask the problem. In fact, if you’re taking sleep medications and you have undiagnosed untreated sleep apnea, you’re making it worse, because when you sedate yourself, you’re unaware of when you’ve stopped breathing. And if you don’t wake up when you stop breathing, those episodes last longer, which leaves you more hypoxemic — getting less oxygen for a longer period of time — and that absolutely has long-term health consequences.
For other common symptoms of menopause that occur, like the vasomotor symptoms, maybe the sedation will keep you asleep for some of those, but there are better, often behavioral, ways to manage them, such as learning your hot flash triggers, trying acupuncture for hot flashes, or getting treatment for lower urinary tract symptoms.
For the insomnia itself, the recommended treatment is cognitive behavioral therapy for insomnia. There are plenty of studies showing that it’s effective for improving sleep in women who are perimenopausal or menopausal. All CBT-I involves is changing the behaviors and the thoughts that are interfering with sleep.
The takeaway
It’s hard to change behaviors and how we think. It takes time, it takes effort, it takes a tolerance of a certain amount of discomfort, and so I get it. Our culture, I think, is inclined in the direction of the quick fix, but unfortunately, that approach can come with ramifications to our health.
I’ve seen thousands of patients and can tell my patients with 100 percent confidence, “If you do these things, your sleep will improve, and if you don’t do these things, nothing will change.” Because whenever people have done it, I’ve seen sleep improve.
