In the perimenopausal years — usually when a woman is in her forties — ovarian production of hormones starts to shift. If you've been tracking your cycles you've noticed that many of your symptoms show up monthly, even if your periods are still regular. Or you might be noticing that PMS has gotten worse lately. If you're not sleeping well, take out a calendar and start tracking when it's more prevalent: is it the PMS week? Or is it when you're on your period? Or is it now a chronic condition and nothing helps?
Insomnia is one of the most common symptoms of perimenopause It can show up as:
- difficulty falling asleep
- difficulty staying asleep
- difficulty falling back to sleep after waking in the middle of the night, or
- not getting deep, restorative sleep.
The result from all of these is never feeling refreshed and constantly dragging through the day, feeling like your tank is empty.
What disturbs me most about hearing women describe their insomnia that has been occurring for months, is that women are not sharing this with their friends, nor mentioning this to their doctor. They seem to just accept it as inevitable, an effect of living a full life, or just a natural sign of aging. If this is only happening sporadically, or only after a rare, particularly stressful day or after too many glasses of wine, then there is no real cause for concern and the best approach is to minimize the stress at hand. However, any symptom you are having is a signal from your body that it is out of balance and some intervention is necessary. The primary culprit during perimenopause is a hormonal imbalance or deficiency. It is essential that you seek treatment in order to balance your hormones and get the sleep you need, so that you can juggle all those plates during the day.
Let's look at the research around sleep and hormones:
For starters, take a look at this 2005 title from the Journal of Clinical Sleep Medicine, "Menopause Related Sleep Disorders" — Yes, it's a medical condition! It's not just in your head. Well, actually, it IS in your head, because hormones have direct effects on brain function. We think of hormones as only affecting our sexual function, but there are hormone receptors all over the brain. They have been shown to affect the production of our feel-good neurotransmitters, the way nerve signals are transmitted within the brain and to the rest of the body, as well as even the shape of the brain.
Progesterone and Sleep
Progesterone declines first during the perimenopausal years. Progesterone is only produced during the second half of the menstrual cycle: from ovulation until bleeding occurs. So if you're bleeding more often, spotting between periods, having heavier periods or not ovulating at all and skipping periods, your progesterone levels are low. Progesterone has a direct, sedative effect on the brain, by stimulating the brain's production of the neurotransmitter GABA and stimulating benzodiazepine receptors. Yes, progesterone is nature's Valium! In turn, progesterone deficiency causes insomnia, irritabililty, anxiety and even panic attacks.
Progesterone also is a respiratory stimulant, meaning that it deepens breathing and can prevent sleep apnea. Many untreated perimenopausal women gain weight, causing sleep apnea, which in itself destroys sleep quality. In contrast, sleep apnea rarely occurs during pregnancy weight gain, because high levels of progesterone protects respiration.
Estrogen and Sleep
Hot flashes and night sweats are one of the most disturbing symptoms of perimenopause and menopause, mainly caused by estrogen deficiency and fluctuations in estrogen levels. Although estrogen doesn't always decline first in perimenopause, if you've started skipping periods, that's a clear sign that you have an estrogen deficiency, because you didn't make enough estrogen to ovulate. The most common symptoms of estrogen deficiency are hot flashes, night sweats, vaginal dryness, missed periods, lighter bleeding, and depression. If you're not having any problems falling asleep, but you wake every night at 2:00 AM drenched in sweat, or you feel hot just as you awaken every morning, then you're most likely feeling the effects of low estrogen.
Estrogen is both a serotonin agonist as well as a GABA agonist, two neurotransmitters that promote good mood and a sense of calm. Insomnia and depression are inextricably linked, so if you're suffering from both of these and you're perimenopausal, estrogen deficiency might be the cause.
Cortisol and Sleep
Cortisol is the adrenal hormone that wakes us up in the morning and helps us combat stress throughout the day, then declines at nighttime, allowing us to sleep. When we're stressed, whether from external sources like the economy, or internal sources like infections or hormonal changes, our adrenals pour out massive amounts of cortisol initially, then often crash if the stress is insurmountable. During menopause, cortisol levels have been shown to spike during the night, causing those nighttime awakenings and disturbed sleep. Optimizing adrenal function is another key to that perimenopausal insomnia.
Melatonin and Sleep
Melatonin is the regulator of our circadian sleep-wake cycle. When darkness hits, the brain stops producing cortisol and increases its production of melatonin, causing us to sleep and rest the body. Melatonin is also an antioxidant, so it helps repair tissue and combat free radicals. Everyone has heard grandparents report that they sleep less, because melatonin production does decrease with age. Over-the-counter melatonin supplementation can work wonders for insomnia by restoring age-related decline in melatonin production
Thyroid and Sleep
The typical hypothyroid patient is so steeped in fatigue that she could sleep all day long. However a small subset of hypothyroidism causes insomnia. It's as if the body doesn't have enough energy during the day, then finally spikes at night, preventing the body from recharging and perpetuating the vicious cycle of fatigue. This may also be due to cortisol spikes at night, as mentioned above, but optimizing thyroid function is essential for healthy energy production and sleep-wake balance.
The main takeaway from this article is the understanding that perimenopausal insomnia is a medical condition with a biochemical cause. Hormonal imbalance does trigger imbalances in the brain in specific ways, depending on which hormones are most at fault. Although stressors may be at their all-time high for women in their 40's, breathing, relaxing and minimizing stress might not be enough to treat the deeper hormonal deficiencies caused during perimenopause. It's essential that a perimenopausal woman get all her hormone levels checked and optimized if she is to stay at the top of her game through midlife and beyond. This is essential for her and those around her. Too many people depend on her!
About Dr. Evans
Nancy L. Evans, N.D. earned her Doctorate from Southwest College of Naturopathic Medicine in Tempe, AZ. She is a current Fellow in Anti-Aging and Regenerative Medicine (FAARM) and Board Certified in Anti-Aging Medicine.
Dr. Evans recently launched the Hot Flash Movement, she is on a mission to stop 1M hot flashes worldwide.
1. Menopause related sleep disorders. Eichling PS, Sahni J. J Clin Sleep Med. 2005 Jul 15;1(3):291-300. Review.
2. Sex hormones affect neurotransmitters and shape the adult female brain during hormonal transition periods. Claudia Barth, Arno Villringer, Julia Sacher. Front Neurosci. 2015; 9: 37. Published online 2015 February 20.