Insomnia in the Perimenopause

What’s Perimenopause?

The perimenopause is the name given to the time of your life before our periods stop, but that hormonal shifts start to occur: your cycles might start to become irregular, or you may recognise other changes, which can be emotional, physical (or both). The changes may be abundant and severe, or few and mild, and they may swing from one extreme to the other: for example really long cycles, or much shorter ones.

The perimenopausal years are thought to last anywhere up to ten years, you may not experience any symptoms for a number of those years, but there are changes going on behind the scenes,. 

Some symptoms that you may notice, can include a change to the length of your cycles, more PMS or a heavier bleed: or they may start off with sleep disturbances. 

What causes insomnia in the perimenopause?

Insomnia and sleep issues are definitely one of the less well known and understood elements of the perimenopause, and when we start to investigate the relationship between hormones, our cycles, and sleep - it starts to make sense as to why sleep disturbances can begin to crop up in the perimenopause. Have you ever noticed sleep changes during your cycle? Well when we start to delve deeper, you may recognise something of a pattern!

The hormones that we speak of most when we discuss the perimenopause are our sex hormones oestrogen and progesterone. In the initial phase of our perimenopause, it is thought that it’s the declining levels of progesterone which start to cause the most chaos! Whilst our oestrogen levels haven’t necessarily dropped at this stage, our progesterone levels have. The role that progesterone has in the body is to calm and relax (1) and is typically high in the luteal phase of our cycle, which happens from ovulation to our bleed. Progesterone is primarily produced from the corpus luteum, which is released following ovulation: some is produced in the adrenals, ovaries and brain(2), but to a much lesser extent, and therefore continuing to ovulate is key for progesterone. Oestrogen is mainly produced in the ovaries, and levels can fluctuate a lot in the early perimenopausal days: once our periods have stopped, oestrogen production continues to a small amount in the ovaries, but our adrenals, fat tissue and in our brains (3) pick up some of the slack.

If we consider that progesterone calms and improves the mood, then a reduction of it may be having the opposite effect and cause symptoms such as anxiety and irritability (4). From a physiological perspective, this is going to be impacting our ability to rest and relax, and our ability to have a decent and restorative nights sleep. 

Melatonin - the great sleep-aid

Melatonin is a hormone that we talk a lot about with regards to sleep - it’s a hormone produced in the brain which is responsible for things like circadian rhythm and sleep (5)

Over the course of a day, melatonin levels increase during the evening and peak overnight, helping us to have refreshing and restorative sleep. They reduce in the morning on waking - with cortisol taking over to start the day. Melatonin levels are thought to decrease as we age (6), though they remain higher than post menopause, which is when they’re at their lowest (7, 8), which may explain why we seem to need less sleep as we age. (shall we add something about horrible thatcher hardly needing sleep?.

Our sleep needs do change as we age, but as well as that, hot flushes and night sweats may also disturb our sleep.

As the perimenopausal years progress, some of those fluctuations in oestrogen levels can cause symptoms such as night sweats and hot flushes because of the impact that oestrogen has in temperature regulation (9) which means we can end up with our internal thermostat running amok. Waking during the night to deal with overheating, or waking damp from a sweat, disturbs and disrupts your night, meaning that your sleep is broken and usually less refreshing, as well as having fewer hours asleep. If you’re the type of person who struggles to get back to sleep once woken, this may be an issue for you too. 

One of the other issues that I see, not specific to the perimenopause, but one definitely worth mentioning, is sometimes folk are too tired to sleep, which sounds like a very weird thing to say! We talk about it with babies and children being ‘over tired’ but that’s not quite true - nor what I’m talking about here! Sleep takes some energy to initiate - so if you’re really depleted then what happens is we actually don’t have enough energy reserves to get to sleep, which means we don’t actually drop off. This feels like one of those peculiar phenomena that don’t seem to make any sense when we think about evolution, as it seems to serve no purpose whatsoever - surely if you’re that tired, then falling asleep easily to replenish our energy stores would make the most sense… sadly not, but at least you know now, so we can do something about it!

Waking during the night is something that we all do - often we don’t really recognise that it’s happening, but actually the rhythm of our sleep means that we go into very light sleep approx every hour, and that we are probably wakeful for a portion of that time. It may be that we are awake for such a small period of time that we don’t recognise or remember it, or it may be that we turn over, throw our covers off us, or turn our pillow over, and then drop back off very quickly. Whilst this happens throughout our lives, we may notice that at specific point sin our lives, we struggle to get back to sleep quite so easily: again, this isn’t exclusive to the perimenopause, but it is a part of our lives where our day to day stress levels may be overall higher, and thus we are struggling to get back to sleep again. 

Stress could be higher for a number of reasons: general life, work, family, parenting - or indeed you’re struggling with the changes that come along with the perimenopause. I spoke about this in the blog on depression, and it may be worth revisiting the topic of how well we are able to deal with the changes of the perimenopause, and our emotional relationship with it. 

With a change to the integrity of our bladders, we may find that we need to pee during the night too - or that we are more susceptible to things like urinary tract infections (10) and so that disrupts our sleep in a way that it hasn’t done previously. 

What can we do about it?

1. Turn off screens an hour before bed
2. Avoid any blue light by turning them off or adding blue light filters to your devices
3. Avoid working at least an hour before bed
4. Use a low level light in the night if you need to go to the bathroom or change the sheets as bright lights will interfere with your melatonin (11)
5. If you’re neurodivergent you may find low level background noise useful like ignorable sitcoms
6. Have a routine in your mind of what happens before bed even if it happens at different times in the week
7. Physical therapies like osteopathy, chiropractor or massages may help
8. Some movement/exercise each day helps our circadian rhythm (12)
9. Expose yourself to daylight early in the morning to boost your natural circadian rhythm (13,14)
10. Have a tepid shower or bath before bed so that your body temperature isn’t dramatically changed (15)

Herb wise there are a few things that I like to use to help support sleep

1. Passionflower: I was once told that this ‘pacifies the overactive mind’. Perfect if your brain wakes up when the lights go down.
2. Vervain: vervain is a wonderful calming and cooling herb: I like this because of the fact that it’s cooling, which may be an issue when you’re in the perimenopause, particularly if you’re having overnight heat or sweats. 
3. Motherwort: Leonurus cardiaca, or motherwort is a wonderful nervine herb, and also supportive for circulation, hence the ‘cardiaca’ in the name. I combine it with rose where there is grief, and this can be any kind of grief, and perhaps where we need support with change and transition, particularly as we move into our menopausal years.
4. Rose: Rose is such a powerful herb, it smells and tastes amazing, supports hormone balance and emotions, it’s amazing when combined with Motherwort as I mentioned above, and it’s cooling. It ticks all of the boxes
5. Adaptogens, in particular Ashwagadha. I’m a big fan of adaptogens, and for insomnia I think that Ashwagandha is the one I reach for most. The Latin name is Withania somnifera, with somnifera meaning ‘sleep inducing’. It supports the adrenals, a key organ in terms of stress and sex hormone production, and it is calming, relaxing and restorative. It also helps to nourish and support the body longer term, helping with sleep initiation.

When should you see a doctor or herbalist?

I feel like it can be really helpful to have additional support on board at times, particularly when you’re trying to navigate your own health and wellbeing, and decide what to try and where to start! In these situations, it might be worth speaking to a herbalist, who can give you expert advice and bespoke support, ensuring that herbs are suitable and a regime that’s practical for you. That tailor made support can make all the difference.

If you’re finding that you’re struggling with your mental health and wellbeing as a result of your lack of sleep - do not hesitate in reaching out to your GP, or emergency medical service if the situation has become more immediate.

Final thoughts

When I wrote about depression during the perimenopause, I spoke about the importance of honouring the natural ebb and flow of our menstrual cycles throughout our lives: I will stress the importance here again too, because I don’t think it can be said often enough. Talking about periods, understanding what happens throughout a cycle and over a lifetime of periods, from puberty to menopause, is an important step in opening the conversation and acknowledging and improving awareness to these unavoidable changes in our lives. If we can start to make space for these changes, and accept that we have pockets of time when we may need a bit more care, nourishment and rest, and that we aren't linear beings, then it will help all of us. 

1. Picazo O, Fernández-Guasti A. Anti-anxiety effects of progesterone and some of its reduced metabolites: an evaluation using the burying behavior test. Brain Res. 1995 May 22;680(1-2):135-41. doi: 10.1016/0006-8993(95)00254-n. PMID: 7663969.
2. Sundström-Poromaa I, Comasco E, Sumner R, Luders E. Progesterone - Friend or foe? Front Neuroendocrinol. 2020 Oct;59:100856. doi: 10.1016/j.yfrne.2020.100856. Epub 2020 Jul 28. PMID: 32730861.
3. Simpson ER. Sources of estrogen and their importance. J Steroid Biochem Mol Biol. 2003 Sep;86(3-5):225-30. doi: 10.1016/s0960-0760(03)00360-1. PMID: 14623515.
4. Ziomkiewicz A, Pawlowski B, Ellison PT, Lipson SF, Thune I, Jasienska G. Higher luteal progesterone is associated with low levels of premenstrual aggressive behavior and fatigue. Biol Psychol. 2012 Dec;91(3):376-82. doi: 10.1016/j.biopsycho.2012.08.001. Epub 2012 Aug 10. PMID: 22906865.
5. Cipolla-Neto J, Amaral FG, Soares JM Jr, Gallo CC, Furtado A, Cavaco JE, Gonçalves I, Santos CRA, Quintela T. The Crosstalk between Melatonin and Sex Steroid Hormones. Neuroendocrinology. 2022;112(2):115-129. doi: 10.1159/000516148. Epub 2021 Mar 26. PMID: 33774638. 
6. Karasek M. Melatonin, human aging, and age-related diseases. Exp Gerontol. 2004 Nov-Dec;39(11-12):1723-9. doi: 10.1016/j.exger.2004.04.012. PMID: 15582288.
7. Toffol E, Kalleinen N, Haukka J, Vakkuri O, Partonen T, Polo-Kantola P. Melatonin in perimenopausal and postmenopausal women: associations with mood, sleep, climacteric symptoms, and quality of life. Menopause. 2014 May;21(5):493-500. doi: 10.1097/GME.0b013e3182a6c8f3. PMID: 24065140.
8. Fernandez B, Malde JL, Montero A, Acuña D. Relationship between adenohypophyseal and steroid hormones and variations in serum and urinary melatonin levels during the ovarian cycle, perimenopause and menopause in healthy women. J Steroid Biochem. 1990 Feb;35(2):257-62. doi: 10.1016/0022-4731(90)90282-w. PMID: 2308340.
9. Deecher DC, Dorries K. Understanding the pathophysiology of vasomotor symptoms (hot flushes and night sweats) that occur in perimenopause, menopause, and postmenopause life stages. Arch Womens Ment Health. 2007;10(6):247-57. doi: 10.1007/s00737-007-0209-5. Epub 2007 Dec 12. PMID: 18074100.
10. Lüthje P, Hirschberg AL, Brauner A. Estrogenic action on innate defense mechanisms in the urinary tract. Maturitas. 2014 Jan;77(1):32-6. doi: 10.1016/j.maturitas.2013.10.018. Epub 2013 Nov 5. PMID: 24296328.
11. Wahl S, Engelhardt M, Schaupp P, Lappe C, Ivanov IV. The inner clock-Blue light sets the human rhythm. J Biophotonics. 2019 Dec;12(12):e201900102. doi: 10.1002/jbio.201900102. Epub 2019 Sep 2. PMID: 31433569; PMCID: PMC7065627.
12. Huang HH, Stubbs B, Chen LJ, Ku PW, Hsu TY, Lin CW, Weng YM, Wu SH. The effect of physical activity on sleep disturbance in various populations: a scoping review of randomized clinical trials. Int J Behav Nutr Phys Act. 2023 Apr 17;20(1):44. doi: 10.1186/s12966-023-01449-7. PMID: 37069626; PMCID: PMC10107572.
13. Saidi O, Colin E, Rance M, Doré E, Pereira B, Duché P. Effect of morning versus evening exercise training on sleep, physical activity, fitness, fatigue and quality of life in overweight and obese adults. Chronobiol Int. 2021 Nov;38(11):1537-1548. doi: 10.1080/07420528.2021.1935988. Epub 2021 Jun 15. PMID: 34128447.
14. Thomas JM, Kern PA, Bush HM, McQuerry KJ, Black WS, Clasey JL, Pendergast JS. Circadian rhythm phase shifts caused by timed exercise vary with chronotype. JCI Insight. 2020 Feb 13;5(3):e134270. doi: 10.1172/jci.insight.134270. PMID: 31895695; PMCID: PMC7098792. 
15. Xu X, Liu X, Ma S, Xu Y, Xu Y, Guo X, Li D. Association of Melatonin Production with Seasonal Changes, Low Temperature, and Immuno-Responses in Hamsters. Molecules. 2018 Mar 20;23(3):703. doi: 10.3390/molecules23030703. PMID: 29558391; PMCID: PMC6017911.