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It is that time of life, midlife, menopause, and you aren't sleeping so well. Is melatonin the answer?

Menopause and midlife aging happen at about the same time for most women, but they aren't exactly the same. Menopause is when periods stop because there are not any more eggs to ovulate in the ovary. It's the last period, and it happens at about 50 years of age in most women. Midlife is a little harder to define, but it is that middle of your life from about 40 to 70, after you are young, but before you get old. Maybe it's really from 30 to 60. It depends on where you are as to what range you will embrace. I embrace the 40 to 70, but 30 to 60 is probably better.

We are about as strong and as smart, and I'm not saying wise, as we're ever going to be in normal biologic function at about 30. After that, we begin to age with decreasing muscle mass, bone density, and cognitive speed.

We are usually really great sleepers until midlife. Of course, there are some kids who are naturally short sleepers, and there are those people whose sleep rhythms don't let them really fit into their daily lives. They're night people, but they have to get to work at 7:30 in the morning, so their sleep is disrupted. There are the years of infants and young children that wake us up at night. There are years of jobs that shift hours. But left to our own devices, we are often pretty good sleepers until the middle of our lives.

It's a combination of anxiety, all things for which you're responsible, adolescents in their 20s, finances, juggling stuff keeps us awake. Aches and pains with aging and stiffness keep us awake. And then menopause with hot flushes keeps us awake.

Now, what is melatonin? Melatonin is a small molecule that was originally thought to be made just in the pineal gland in the brain. Its function originally was thought to help us set our circadian rhythm, our internal clock. Pineal melatonin is suppressed by bright light. And when lights get dim, melatonin rises because of its own natural daily rhythm and the lack of suppression by light and helps us signal sleep time. As we age, we make less and less melatonin and that's the midlife aging part.

Now, we know that melatonin isn't only made in the brain, and its function isn't only to help our clock give us daily rhythms. It's found in our gut and may help our gut bacteria have a rhythm, and it's found in the placenta and the ovary and it's an important antioxidant in the body. There is much more that can be said about it, but let's get back to menopause and melatonin.

So you're a midlife menopausal woman and you're having difficulty sleeping. You're having a hard time getting to sleep and your hot flushes wake you up. You're not so interested in taking estrogen hormones for your hot flushes, but you should be and you've read about melatonin. Does it work? Is it safe to take? Can you get addicted to it? Can you take it for a long time?

Does it work? An international group of researchers published a summary of what we know about this in the journal "Sleep Science." Several studies done around the world suggested that a three-milligram dose of melatonin before bed helped with sleep. Women were given melatonin or a placebo and asked about sleep, physical symptoms, hot flushes, and psychological symptoms, and these all got slightly better when people took melatonin over placebo.

Of course, getting better sleep can help with joint aches, psychological symptoms, and hot flushes, but melatonin does a lot of amazing stuff and maybe melatonin was helping.

It was safe with few side effects. Some women in both the placebo group and the melatonin group had side effects of sleepiness and nausea and vomiting and headache, but the incidence was not different in the two groups. People who took placebo and people who took melatonin had the same rate of side effects.

Is it safe to take for a long time? The answer is probably yes. It is not addictive in the traditional sense. There's no evidence that a low dose leads to higher dose usage. There's no evidence that higher doses over three milligrams is more effective. There's no evidence of withdrawal.

The main problem is that there's no control over what's actually in the bottle when you buy it at the grocery store or the health food store. You might be getting melatonin or you might not.

The NIH has a Center for Complementary and Alternative Medicine with a short page about melatonin. They note that a 2017 study tested 31 different melatonin supplements bought from the grocery store and pharmacies. For most of the pills in the melatonin bottle, the amount of melatonin didn't match what was on the label and there were other compounds in the bottle. The biggest concern was 25% of the bottles had serotonin in them, and serotonin is a regulated drug with side effects that can be harmful at low levels.

Melatonin is widely used in Europe as a sleep aid, and supplements are regulated in Germany. So they have to have what they say on the label in the bottle, and no other funny stuff. In the U.S., they could sweep up what's on the lab floor, stick it in a little capsule, and you'd be none the wiser, and no one's watching.

So what do you do if you want to take melatonin? It would be good to talk with your clinician and make sure you don't have any contraindications. They should know that you're planning to take it and it should be on your medication list.

Although the USP verified label on supplements is not a guarantee that you're getting what you think you're getting, it's a start. The USP label indicates that the product has been subject to voluntary testing and meets U.S. pharmacopeia convention standards, that's the USP part, meaning the product is accurately labeled and free of harmful substances. This does not mean that it's been tested by the FDA, but it's better than nothing.

Now, of course, melatonin is found throughout the plant kingdom, and a wonderful paper in the journal "Nutrients" from 2017 listed the melatonin contents of common foods. Some mushrooms have a lot of melatonin. Portobello mushrooms are the basic white and brown ones that you can get at the grocery store have a lot. Seeds and nuts have a lot of melatonin. And pistachios win the top melatonin prize in the nut family.

Sprouted seeds also have a lot of melatonin and sprouted lentils are at the top. I can see a dinner salad with sprouted lentils, mushrooms, and pistachios being perfect to help you sleep. Your gut will love it and you won't feel guilty. Both of those factors are important for a good night's sleep.

It turns out that roasted coffee beans have a lot of melatonin, and coffee has some, but coffee is defeating the purpose.

So there are a lot of reasons you may not be sleeping well in midlife. The American Academy of Sleep Medicine would suggest behavioral approaches, such as bright morning light and daily exercise, a bath before bedtime, and no coffee after noon, limit alcohol at night, and no screen time just before bed to suppress your melatonin.

Having said all that, international studies suggest that melatonin in low doses can be helpful for midlife women struggling to get to sleep. So sleep tight, and thanks for joining us on The Scope.

Dr. Jones: For some women, menopause is tough. We have this hormone thing going on, but we're also aging, and our joints hurt. And our teens are trouble, and that makes us cranky. So what are the options and therapy for the menopausal transition? This is Dr. Kirtly Jones from obstetrics and gynecology at University of Utah Health, and this is The Scope.

Announcer: Covering all aspects of women's health, this is The Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: Although hot flashes are the signature symptom of menopause, there are a number of other physical and emotional symptoms that are common for women in their 50s. Insomnia, anxiety, joint aches, and headaches come to mind. Some of these are clearly related to the loss of estrogens, but some are not so clearly related to hormones. Whatever we think the biological cause might be, women don't feel well.

How do we take the women as a whole person and not just the sum of her symptoms? And what are some of the options? Today in The Scope studio we're talking with Dr. Lisa Taylor-Swanson. She's an assistant professor in the College of Nursing and an expert in acupuncture. Lisa, thank you for joining us to help us think this through.

So give us some thoughts about the care of women in menopausal transition thinking about all of these symptoms. You know, women certainly can wander their way through the traditional health care system. They can get estrogen for their hot flashes, they can get a triptan for their migraine, they can get sleeping pills for their insomnia, they can get Ibuprofen for their joints, they can get Prozac for their anxiety. But women don't want to think of themselves like that. They don't see themselves siloed in so many pill prescriptions. So what do we do?

Dr. Taylor-Swanson: That's something I've thought a lot about. And I know as a clinician practicing traditional East Asian medicine including acupuncture and Chinese herbal medicine, I've always been drawn to thinking about the whole person. And in that tradition the way we diagnose, for example, a hot flash in woman A would really depend on how her sleep is, her bowels, her mood, and depending upon compared to say woman B who has no problem sleeping but does have hypertension, I would use different acu-points and different herbal prescriptions to treat the same, say primary concern of hot flashes, because we have to understand the whole person.

So that whole person view is literally at the theoretical foundation of East Asian medicine. And that's why I study that. It's really very interesting.

Dr. Jones: So I would say coming from the church of Harvard medicine, that although I want to know about a woman's hypertension and the way her bowels work, the dose that I would give for her hot flashes would be more just to her hot flashes and not to her guts I'd say?

Dr. Taylor-Swanson: Absolutely. And that's exactly not how East Asian medicine is practiced. And so those symptoms really inform one another, and then, of course, we look at the tongue and feel the pulse as well to have additional signs that we look at.

Dr. Jones: Look at the tongue?

Dr. Taylor-Swanson: Yeah, absolutely. Top and bottom.

Dr. Jones: Okay, ladies you're going to have to wash your mouth out and brush your teeth before you go.

Dr. Taylor-Swanson: But don't brush your tongue.

Dr. Jones: Don't brush your tongue, okay, okay. So what are some of the options in the field of alternative and complementary medicine that women might choose to pursue? I know women are already making these choices, because when they come to see me, they've got bottles of supplements. They've got dong quai. They've got some Chinese herbal medicines, I say I don't know that they . . . these Chinese herbal medicines may not actually have estrogen in them, so I'm always worried about what they're taking with these bags that they're going through.

But I can't stop them. You know, and I probably shouldn't, and I shouldn't negate their efforts to make themselves feel better through options other than my office. So what should we be thinking about and what are the choices?

Dr. Taylor-Swanson: There are many choices. Definitely, acupuncture is one to consider again for the whole person perspective. And what's interesting is that not only kind of clinically or intuitively we can imagine, say if someone receives acupuncture and her hot flashes are better, and then her sleep is a little better, and then her moods a little better that makes sense certainly.

But the fascinating thing as a researcher is that we have basic science, types of data that demonstrate how that happens. So we have changes in our serotonin production and re-uptake. We have changes in our muscles, changes in the connective tissue around the muscles, other changes in the central nervous system, peripheral nervous system changes, etc. And those all happen simultaneously. And so I think it's fascinating to consider. I know you asked what are the various options. But one is acupuncture, and that we know all those symptoms are affected simultaneously and we know more about why.

There's other good options too. There's definitely Ayurvedic medicine, traditional medicine from India that treats the whole person much in the same sort of way. Definitely massage therapy can be helpful for those joint aches and pains, and it's very relaxing and might help a woman sleep better. Reiki healing touch. I mean there are so many options nowadays, and most of them have been investigated to try to find out really do they work. But I think another really important message for our listeners is that acupuncture I can say for sure is safe. It doesn't hurt. It's very relaxing.

Dr. Jones: It doesn't hurt.

Dr. Taylor-Swanson: I know, right? Who would think that?

Dr. Jones: Well, I'm not needle phobic, and you mentioned that you started as an acupuncturist. I'm not needle phobic, but I know perfectly well when I have needles put in my skin, because I'm also a seamstress, so I poke myself with little needles and it's usually my finger, the most sensitive place to poke. But it hurts.

Dr. Taylor-Swanson: So these are different. One they're tiny. They're literally the size of about two hairs, 40 gauge, 36 gauge, for those of you clinicians out in the audience. And they're solid and the interesting thing is blind acupuncturist several hundred years ago figured out if they had a tube around the acupuncture needle, one, to help them locate the points and be safe clinicians because they couldn't see, but two, it was less painful.

So the Japanese tradition of acupuncture and that we've pretty much adopted in the U.S. is to use these guide tubes. So first the patient will feel the pressure of the tube, and what's happening is it sets up those little [node receptors 00:06:21], so they perceive pressure, and then you pop in the needle and you hardly even notice it for the most part.

Dr. Jones: Kind of like when you're giving a horse a shot, if you slap them three times on their skin and then you give them a shot, they don't feel a shot. Okay, okay. Well, I'm feeling better already. I'm feeling more calm about having needles put in my skin.

Dr. Taylor-Swanson: Most people do fall asleep. Or they go to this . . . a colleague of mine calls it acu land. And you just kind of drift off to this really mellow, quiet, relaxing place. Usually, the clinician will turn the lights down and have some nice music, and you're cozy with the needles in place. So it's really a very surprisingly comfortable experience.

Dr. Jones: Well, it sounds like it's a total time out from your week experience. It's not just hopping up on a table and getting poked a couple places. You're actually having some little time out. I can't say . . . well, sometimes the doctor's office, I get to look at magazines I would never ever buy at the store, but if people in the doctor's office are upset, I kind of, you know, while I'm waiting and wanting to say I'm not in a clinic and, you know, I'm just having a quiet time. But other people's moods while I'm waiting affect me. When I get in the room as much as I love my doctors, there's this third patient in the room called the computer that seems to get all my doctor's attention.

Dr. Taylor-Swanson: Well, and I think for women going through the menopausal transition and for midlife women overall there's this sandwich generation phenomenon where often women are working, taking care of kids, like you said in your intro, taking care of parents sometimes, and so to have that little time out just an hour once a week, once every couple weeks it can make a world of difference.

Dr. Jones: Well and when we talked before the interview, we talked about the fact that in medicine sometimes we silo women's symptoms so they get this for this problem, and this for that problem, and that prescription for that. But you talked about the spider web. Can you talk a little bit about that?

Dr. Taylor-Swanson: Absolutely. It's my favorite metaphor for how, again the theory and also the intervention of acupuncture in East Asian medicine works. If you were to imagine a woman as a spider web and say for example, that spider web includes her symptoms, it includes all of her body systems, so the endocrine system, all of your hormones, your digestive system, etc. And also includes your social life, so caring for kids, your friends, your church, your work, etc.

And so if there's a tug on one end of the web, say you're caring for an aged parent and she or he falls, then that's going to affect your whole spider web, your whole person. It's not just that, "Oh, gosh I have to schedule my time differently." But you're probably going to be worrying, and [perseverating 00:09:03], and scheduling appointments, and not sleeping as well.

So I think to really consider a woman as her whole self, not only all of the symptoms, it's great that science is moving that way. We talk about symptom clusters now instead of only a single symptom. But it's a real whole person phenomenon that includes her social life, her work life, her body as well, and not only the symptoms.

Dr. Jones: Well, we're just making you the poster child of our Seven Domains of Health. Because here, The Scope radio we believe in the seven domains, meaning there are many parts of us that have to be well for us to feel well. But I like the Native American, particularly Navajo tradition of the Spider Woman who weaves the web of life into this sense of wholeness. So who should a woman go to if she wants this particular approach?

Dr. Taylor-Swanson: Well, the good news is nowadays acupuncture is regulated by state departments of health in all but just a handful of states in the country, so you can just go to the website for your local Department of Health, look up an acupuncturist in your area. They're absolutely going to be board certified nationally, and they're absolutely going to have a master's degree. They might also have a doctoral degree either in acupuncture or something else. So you can be confident they'll be well trained and properly licensed.

Dr. Jones: Do you go and see if they're a good fit, or do you ask your friends because some might be really good for sports therapy and joint problems, but they don't get women.

Dr. Taylor-Swanson: Right. Well, and modern life definitely most of my patients when I practiced in Tacoma, Washington, where I just moved from most of my patients were either referred from their primary care or other specialty care practitioners or from their friends, and that's always a good way to find an acupuncturist. And modern life most acupuncturist have websites too. So you can check the web and get a sense of who they are from their website.

Dr. Jones: And see if they put midlife women transition kind of stuff.

Dr. Taylor-Swanson: Yeah.

Dr. Jones: Well, we're waiting for you to hang out your shingle now that you're here in town and for you continue your research in the area of midlife women now that you're here at this College of Nursing. And we're here because getting old isn't for sissies. And 50 isn't even old. Many of us want to take an approach to our midlife concerns that helps our body and our mind. And we're grateful for Lisa for coming to help us think about it. And thanks everybody for listening on The Scope.

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Interviewer: Is hormonal therapy a good treatment option for menopause symptoms? Dr. Kirtly Jones, what's your advice?

Dr. Jones: For the two main symptoms of menopause, hot flashes and dryness, estrogen is the best therapy. The new North American Menopause Society guidelines outline the importance of individualizing therapy for each woman, looking at the options, discussing the symptoms, and the patient's own biology.

There are few, if any, absolute contraindications to hormonal therapy. It's all a risk/benefit discussion. Be prepared for your visit with your doctor. What are your symptoms? How much do they bother you? What is your medical history, and what are your fears and concerns and hopes? Coming prepared will help you and your clinician focus on your needs.

updated: June 11, 2021
originally published: June 19, 2019

Dr. Jones: What's new in the treatment for menopausal symptoms? This is Dr. Kirtly Jones from obstetrics and gynecology at University of Utah Health Care, and this is The Scope.

Announcer: Covering all aspects of Women's Health, this is the seven domains of women's health with Dr. Kirtly Jones on The Scope.

Dr. Jones: Before the 1960's there wasn't much for the treatment of menopausal symptoms. In the 1970's we found out that women who took just estrogen, had a greater risk of uterine cancer and women and physicians were hesitant to prescribe. In the 1980's and 90's we learned about all the benefits of estrogen and added progestin to protect the uterus, and lots of women took hormones for menopausal symptoms. In 2000, the results of the women's health initiative suggested that women over 60 who took hormones had a higher risk of breast cancer and heart disease. You should be asking yourself what does "higher" mean? For Scope listeners, and prescriptions dropped off.

The North American Menopause Society's older guidelines suggested that the lowest dose of hormones for the shortest period of time, should be offered. And many clinicians only offered for hormonal therapy for five years, but now we have new guidelines informed by research from the past ten years. So what is new now?

What's new isn't really new to those of us who've practiced menopausal medicine. What's new is that the decision to take hormonal therapy for menopausal symptoms or non-hormonal therapy for menopausal symptoms is a conversation that takes more than just a few minutes in your clinicians office. The clinician must be informed about the real numbers involving risks and benefits of hormone therapy and they must have the time to talk to the patient about her symptoms, her options in therapy, her benefits and her risks. And because menopause symptoms change over time, the conversation should happen every year. Most women can safely use hormones if they want and hormones shouldn't be discontinued just because of a women's age. It's an individual risk/benefit analysis.

So this is what often happens. "My period stopped and I'm having terrible hot flashes". The clinician says, "Just wait, they'll go away soon." Well, that's not necessarily true, hot flashes persist for an average of 7.4 years. Some women will feel better in several months but the majority of women with troublesome hot flashes will have them for years.

Another, "I'm only 55 and my bone density shows that I have thin bones. What should I do?" Well here's a prescription for a medicine that will block bone thinning. No, it isn't hormone." Well, drugs like bisphosphonates do decrease bone thinning but they have their own risks and benefits and for young women, meaning within ten years of menopause, estrogen might be a good choice. And estrogens are FDA approved for the prevention of bone thinning. Estrogens have the benefits of protecting bones, treating hot flashes and vaginal thinning that causes pain with intercourse.

For the two main symptoms of menopause, hot flashes and vaginal dryness, estrogen is the best therapy. The new "North American Menopause Society's Guidelines" outline the importance of individualizing therapy for each woman. Looking at the options, discussing the symptoms and the patient's own biology. There are few if any absolute contraindications to hormonal therapy. It's all risk/benefit discussion. If the risks are small and the benefits for the woman is great, than the options should be open. The first ten years after menopause, the last period, are the years when the benefits are the greatest and women who had early menopause for whatever reason might have significant benefits of taking hormones for longer.

Dr. Joanne Pinkerton, who's the executive director of the North American Menopause Society and is the lead author of the new guidelines said, in an interview, "We want to remove the fear of using menopausal hormone therapy for healthy women under 60 and within ten years of menopause and make sure the benefits and the risks are discussed with women in an appropriate way."

What should you do if you're significantly troubled by menopausal symptoms? For those of you who are just getting started, if you're babies about menopause, there is a lot of not very scientific information out there on the web. Be careful and if you need menopause basics go to menopause.org/forwomen. For those Scope listeners who are data driven, you can go the website for the North American Menopause Society which is menopause.org and look at their treatment guidelines and clinical care recommendations. They are free for non-members, and there are guidelines on menopause therapy, treatment of vaginal thinning and non-hormonal treatments for menopause that actually work and which ones don't work.

If your clinician isn't a specialist in menopause, these guidelines are available to them too. Be prepared for your visit for with your doctor. What are your symptoms? How much do they bother you? What is your medical history? And what are your fears and concerns and hopes? Clinician time can be limited, but if your questions aren't answered or you need more time, make another visit. But coming prepared will help you and your clinician focus on your needs. For the many main symptoms of menopause, there are lots of options, and there is something that will work for everyone. You can feel better, and being informed is a really great start.

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Dr. Jones: Listen up, this is for ladies only. Gentlemen, kids, adolescents, go listen to stuff that is just for you. We're going to talk to ladies about vaginal dryness and pain after menopause. This is Dr. Kirtly Jones from Obstetrics and Gynecology at University Utah Healthcare and this is The Scope. Guys, change the channel. Ladies, plug in your earphones.

Announcer: Covering all aspects of women's health, this is The Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: There are many reasons why women are less interested in an intimate sexual relationship with intercourse after menopause, but one of the most common is that sex hurts. Menopause marks the end of significant production of estrogen by the ovaries. Estrogen production is linked to egg production, so it's a pretty good thing that we stop being fertile when we get to our 50s.

One of the prime targets of estrogen is the uterus, and after menopause the uterus gets smaller and the lining gets thinner and that's a good thing. That means there's less bleeding and cramping, in fact, if it goes as it should, no bleeding and cramping. However, the uterus is just part of the reproductive tract. Reproductive tract starts at the beginning of the vagina and those tissues get thin as well and sometimes they become very thin. They stop making as much fluids and the lining of the vagina can be painful and even bleed with intercourse. It only has to hurt a couple times and then women aren't so interested anymore. So what can be done about this?

First, how common is this? In a study reported in a menopause journal, 4,200 post menopausal women from Sweden, Finland, the U.K., Canada and the U.S. were surveyed about their symptoms and their knowledge. Thirty-four percent of Canadian women experienced symptoms with vaginal thinning and 43% of women in the U.S. noted symptoms, and two-thirds of them noted that the symptoms were severe and had a significant affect on their quality of life. That's a lot of ladies.

Fifty-one percent of American women didn't know that there was a local treatment for this problem, and 63% of women with symptoms had never been treated, but 67 of those who were treated had an improvement in their symptoms.

So what treatments are out there? Well, first, there's ordinary over the counter lubricants, slippery stuff. For some women, that's enough and it is safe and inexpensive. It's made by the same material that doctors use to make an internal exam more comfortable for women.

Second and most importantly, probably, is estrogen. Estrogen can be applied locally to the vagina twice a week in the form of pills or creams and this is very effective for the majority of women. There are many different ways to apply this local estrogen to the vagina. The dose is tiny and a recent study of half a million women in the Kaiser Healthcare system were studied to see if vaginal estrogens increased the risk of uterine cancer. They compared women who filled prescriptions for vaginal estrogens with women who didn't and the rates of uterine cancer were no different.

Women with a history of breast cancer are never supposed to use estrogens and they suffer, but there's no evidence that low dose estrogens increased the risk of breast cancer. Vaginal estrogen for women who've had breast cancer is controversial, but vaginal estrogen therapy's been used for decades for post menopausal vaginal thinning and pain with a terrific safety profile.

Third, DHEA, this is a weak adrenal male hormone that can be placed in the vagina and that can increase vaginal thickness and decrease pain. The trade name is Prasterone.

Fourth, Ospemifene, the brand name is Osphena. This is a pill that can be taken orally that isn't exactly an estrogen, but it does increase the thickness of the vagina and decrease pain.

So, why don't women get treated? I think we're in sort of a "don't ask, don't tell" situation here. Post menopausal women may not bring up the subject of pain within sex and doctors don't ask, but if there's evidence that sex is part of healthy aging, then doctors should ask and they should know the safety and effectiveness of treatments and, ladies, you should speak up. Sex doesn't have to be painful.

Now you can unplug your earphones and thanks for joining us on The Scope.

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