This May Be Why You Can’t Sleep

Illustration By Valeriya Simantovskaya

By Kate Clancy

It started maybe seven years ago. I’d wake up at one o’clock, two o’clock, maybe even three. Did I startle from the house settling? An alarm? Did I need to pee? Usually it was nothing, but I would lay wide awake, often for hours.

I tried all the things people tell you to try: sleep meditations, good sleep hygiene, blackout curtains, getting up and doing something until you feel tired again. But when I get a bout of insomnia, very little seems to help. And if anything, the harder I work to get back to sleep, the more elusive it becomes.

Insomnia is defined as trouble falling asleep, trouble staying asleep, or both. While generally speaking 10 to 15 percent of people suffer from chronic insomnia, another 25 to 35 percent experience it more occasionally. Insomnia can worsen quality of life, lower productivity, and even increase the risk for cardiovascular disease.

Over the last year, as my insomnia has worsened, I’ve also started to develop night sweats. Helloooo, perimenopause! I’ve had night sweats at other points in my life, especially in the year or two I was lactating after both of my kids’ births. I’ve even written about it. So I knew the night sweats were vasomotor symptoms that were likely a combination of my lactation, how that affects my ovarian hormones, and the fact that I was exercising close to bedtime.

This time around, I wasn’t lactating or exercising too late at night. Instead, I’m older – 44. Some studies suggest insomnia affects over half of perimenopausal people, with those of us with restless legs (me!) or sleep apnea at the highest risk. Another longitudinal study suggests over a third of perimenopausal people are insomnia sufferers. Out of curiosity, I started tracking when my insomnia seemed to be the worst. Almost without fail, it happened the few days before my period, with other bouts sprinkled in if I was especially stressed about something the day before. (Night sweats are a bit more diffuse – they seem to be worse in the winter, when I bundle up a ton for bed because our house is freezing, and then overheat.)

I am a scientist who studies the uterus, so as I usually do, I went straight to the literature. There is a recent systematic review that looked at estrogen and progesterone, as well as synthetic forms of both from hormone replacement therapy (HRT), and their relationship to sleep. As I suspected, most of the high-quality studies with objective measures of sleep quality do show that the lower your estrogen and progesterone, the worse your sleep. And if you are perimenopausal or menopausal, hormone replacement therapy (on the lowest possible dose, and only if not contraindicated by family history) can improve insomnia. Most of the studies pay more attention to estrogen than progesterone, and it does look to be a bit more of the driving force between the two hormones.

“Sleep disturbance is a common clinical concern throughout the menopausal transition,” they write. “However, the pathophysiology and causes of these sleep disturbances remain poorly understood, making it challenging to provide appropriate therapy.” They conclude that, “Estrogen and progesterone both have a positive effect on total sleep time and subjective sleep quality, with a faster sleep onset latency and less wake after sleep onset.”

As I share in my book Period: The Real Story of Menstruation, in the perimenopausal period estrogen is often higher, not lower, than your earlier years. So what gives? Several studies have shown it may not exactly be the quantity of estrogen that is affecting quality of sleep, but rather how much it declines. If my estrogen at its midcycle peak is higher than it’s been in my younger cycles, the decline I experience is going to be sharper. This is also suggested by the fact that people who have their ovaries removed tend to have harsher sleep disruptions than those who go through natural menopause — they go from physiological levels to zero in moments. As this longitudinal study that looked at women through the perimenopausal into the menopausal period shows, the overall quantity probably matters too, since those close to the menopausal transition were at highest risk of insomnia symptoms.

Despite the fact that there is a growing understanding of how hormonal changes through the perimenopausal years are anything but straightforward, public-facing materials on this topic rarely show much of that nuance. Mostly perimenopause is described as a time hormone levels decline — remember, this isn’t precisely true — and mostly insomnia is blamed on hot flashes. When hormonal therapy is mentioned as an option, it has the usual major cautions around it that we now know were overstated (though see this one counterexample at WebMD that has less HRT fearmongering than usual). By the time someone is really suffering with insomnia, they have probably already tried all of the usual recommendations — like all the ones I mentioned above. What perimenopausal people deserve are clear, accurate information of causes and treatment options, not trite reminders to not use our phones before bed. If they do not know the two phenomena are linked, looking up insomnia on many major sites will not help them draw that conclusion either, since it isn’t always listed as a potential cause.

If your insomnia is really terrible and greatly interfering with your quality of life, you should see a doctor. And if you think it’s influenced by hormonal shifts, ideally this will be a gynecologist with specialist training in menopause to talk through treatment options. Because my insomnia is intermittent and I’ve come up with ways of managing it, it’s just helpful noticing the pattern of when it happens. Then, when I do have a few days in a row of insomnia, and it’s in the days before I get my period, I also know it’s almost over and better sleep is on the way. This knowledge helps calm my brain and not catastrophize my lost sleep. But… we’ll see if my opinion on this changes as I continue to age.