Sleep, Stress, and Social Support Can Affect Menopausal Symptoms

Stress can increase the severity or frequency of menopausal symptoms, but can social supports provide relief? How do social, family, or work stressors affect menopausal symptoms? Developing an understanding of the mind-body connection can help women reduce the frequency or severity of hot flashes and the likelihood of depression after menopause.

The menopausal transition causes nearly 60-80% of women to experience vasomotor symptoms (VMS) such as hot flashes. Despite this tremendous commonality, many women go through this time feeling alone and helpless, out of control. These symptoms can disrupt sleep and dramatically affect a woman’s quality of life. For women going through stressors at work or home (or both), such as a difficult supervisor, a divorce, or raising challenging teens, the menopause transition can be particularly difficult.

The Study of Women’s Health Across the Nation (SWAN) recruited an ethnically diverse group of women in 1996 to study health during the mid-life transition. Research derived from this study has offered insights about what increases the frequency and severity of VMS as well as evidence for which mind-body strategies can help alleviate menopausal symptoms and even the likelihood of developing post-menopausal depression.

What factors are related to hot flashes?

Initial interpretations of the SWAN data focused on identifying risk factors for more frequent or severe VMS. Even when such risk factors as body mass index (BMI), smoking, hormone use, and socioeconomic status are accounted for, Asian women seem to experience fewer or less bothersome VMS. Although this finding suggested that dietary differences may exert some influence on VMS, the high residual variation in symptoms between women prompted researchers to continue exploring other factors that might be protective against the severity or frequency of hot flashes.

Are stressful situations linked to hot flashes?

In a small study exploring the connections between mindfulness, stress, and menopause, a significant interaction was found between stress and menopausal symptoms. Among women who were experiencing high stress, higher mindfulness correlated with lower menopause scores.

Another study of Finnish women seems to support the role of perceived stress and resilience. The authors found that women experiencing high stress and hostility were more likely to use hormone therapy than women with low stress, more optimism, and a greater sense of coherence.

The goal of the Finnish survey was to better understand the contexts in which women seek medical treatment for their menopausal symptoms and to provide more individualized support and guidance. In this respect, the social context in which women experience the menopausal transition may matter as much as physical or genetic risk factors — for instance, the workplace may aggravate menopausal symptoms. Other life stressors also occur during the menopausal transition, such as children leaving home, parents aging, or divorce.

Can social supports provide a buffer against stress?

A recent study using SWAN data found that, indeed, stress can make VMS symptoms worse. The authors measured the woman’s amount of stress related to 18 different events on a 5-point scale. Then they calculated a “stress dose” based on the number of events experienced. The supported variable included how often someone was available to listen to the woman, take her to the doctor and help out if she feels unwell.

The researchers constructed eight different models to estimate the effect of the interaction between stress and social support on menopausal symptoms. Interestingly, the model that best fit the data did not include the social support variable, pointing to the possibility that a woman’s response to stress — not the amount of social support — is the most important predictor of her VMS.

“This is interesting for several reasons,” the study concludes. “These results suggest that experiencing a stressful event in and of itself does not worsen menopause symptoms; rather, it is the woman’s psychological reaction to the stressful event that has the largest effect on VMS frequency.” This finding restores a woman’s agency, allowing her to develop the capacity to respond to stress in ways that avoid exacerbating her VMS.

What is the evidence that therapy can help manage hot flashes?

A meta-analysis to investigate the role of psychotherapy in managing hot flashes reviewed clinical or quasi-experimental studies of various interventions, including mindfulness, cognitive behavioral therapy (CBT), hypnotherapy, and relaxation techniques. Most of the articles found that these interventions helped and that the most effective were CBT and relaxation techniques.

Another study of twelve randomized controlled trials (RCTs) among women undergoing natural or treatment-induced menopause found a similar result. A study among breast cancer survivors found that non-pharmaceutical interventions, such as yoga, hypnosis, mindfulness, acupuncture, and CBT, were all helpful.

Can women also influence their likelihood of developing depression?

While social support may not have had a direct effect on VMS symptoms, it may help avoid the onset or worsening of depression. Referring back to the SWAN data, women who had experienced childhood trauma, had high anxiety, sleep problems, a high frequency of VMS, and lower social support tended to experience more depression following their final menstrual period.

Can the mood trajectory be altered during this time of transition? The notion that midlife depression trajectories can be affected by improved sleep and better social support is evident in the SWAN data as well. When comparing groups of women over 15 years, SWAN researchers found potentially modifiable midlife risk factors for increased depression. Increased sleep problems and decreased social support over time increased the odds of having depressive symptoms.

What else can be done to support women during menopause?

The menopausal transition can be very difficult to manage due to the interplay between influential variables: sleep affects mood and energy for exercise while anxiety affects eating habits which can, in turn, increase weight, and negatively affect self-image and mood. Taken together, the SWAN literature suggests that non-pharmacological interventions like yoga, acupuncture, CBT, and hypnosis can help women cope with VMS symptoms.

Dr. Lucy McBride, an internal medicine physician in Washington, D.C., agrees. “For most of my female patients, the transition to menopause makes clear the inseparability of mental and physical health. We cannot care for one without the other.” In her popular newsletter, Dr. McBride regularly discusses this complex interplay between mind and body, and how important it is to connect with loved ones.

Being mindful of how the stress response can affect VMS may help women proactively adopt habits that can help manage this transition. Clinicians should monitor women in their practice who are going through an accumulation of traumatic life events and help them connect the dots between the natural stress response and a worsening of physical symptoms. Setting in place or renewing nurturing habits of mind and body, such as attention to diet and exercise, providing enough time to sleep, and embracing a network of friends and family members who can offer support can help improve a woman’s quality of life.