Perimenopause, Menopause and Sleep

 Sleep is so essential but can be so elusive, especially for women in perimenopause and menopause. There is a myriad of contributing factors to sleep difficulties including:

• Changing hormone levels
• Hot flushes/ sweating
• Circadian rhythm difficulties
• Lifestyle factors

Perimenopause and menopause are a time of major hormonal, physical and psychological changes for women. A 2017 survey completed by the CDC (Centre for Disease Control) established that 56% of peri-menopausal women sleep less than seven hours a night.  It also showed that 55% of menopausal women are sleeping poorly, enough to wake up not feeling rested, four or more times per week.  

A woman’s ovaries decrease production of sex hormones during perimenopause which can last 7 to 10 years and usually begins in the early 40s. A woman is said to be menopausal one year after her periods have stopped and subsequently, she is post-menopausal.

Perimenopause will begin with irregular periods, missed periods, bleeds that are much heavier than usual and tender breasts as the body is adjusting to different hormone levels. Frequent headaches and sleep issues may occur during the menstrual cycle. A cycle tracking app such as Clue, Period Tracker or MyFlo can help with tracking periods and recording symptoms which can help with finding relief.

As perimenopause shifts towards menopause, periods become increasing irregular, there may be hot flushes, night waking, mood swings (aka perimenopause rage), brain fog and vaginal atrophy (which may feel like cystitis and can be misdiagnosed because of this). 60% of women will experience mild to moderate symptoms at menopause.

The reason to list these symptoms is not to lament this transition but to acknowledge them, because knowledge is a superpower that can be used to inform our health.

The sex hormones are estrogen, progesterone, and testosterone and the roles that they have during puberty and pregnancy are well understood. However, there is a lack of accurate, woman centred information about the roles of these sex hormones in perimenopause and menopause. These two stages tend to be clumped together, a Nature paper has argued that these life phases are hormonally as different as chalk and cheese and consequently so are their symptoms and therapies. The concept that menopause and perimenopause are associated with ‘estrogen loss or deficiency’ may just not be correct. It may in fact be more subtle, the levels may fluctuate at different times and the imbalance of estrogen and progesterone may vary in perimenopause and menopause leading to the different symptoms seen in these stages.

Estrogen promotes the growth and health of the female reproductive organs and keeps the vagina moisturized, elastic, and well supplied with blood. It affects the production of serotonin which is a mood regulator and happiness booster. Progesterone plays an important role in the menstrual cycle and in maintaining the early stages of pregnancy. Testosterone is involved in estrogen production, contributes to libido, and helps maintain muscle and bone mass.

 During perimenopause, estrogen levels fluctuate during the cycle, going up and down at different times, in menopause levels of estrogen are very low. Progesterone begins to decline in perimenopause and production from ovaries stops completely after the last period in menopause. Testosterone declines steadily but production continues even after menopause.

High levels of estrogen and low progesterone in perimenopause can contribute to estrogen dominance symptoms such as heavy bleeding, irregular periods bloating and breast tenderness. Whereas low levels of estrogen can cause headaches, vaginal dryness and can have an impact on mood.

Estrogen and progesterone are thought to affect sleep quality. Low levels of these hormones, especially progesterone, can contribute to problems falling asleep, staying asleep, or achieving deep restorative sleep. This could occur via melatonin. Melatonin is a hormone that is produced by the pineal gland in the brain from tryptophan which is an essential amino acid. Melatonin’s main role is in initiating, maintaining sleep and modulating the circadian rhythm, because of this it is often referred to as the sleep hormone. But it is also an antioxidant, an anti-carcinogen, an anti-depressant and interacts with estrogen and progesterone.

There is little known about the interplay between melatonin and the sex hormones during the menstrual cycle and even less during the perimenopause and menopause stages. But melatonin levels do fluctuate during the menstrual cycle, and this may explain sleep issues seen during different stages of the cycle. The changes in melatonin levels appear to be signalled by progesterone. The correlation between progesterone and melatonin production does mean that sex hormones may in fact regulate women’s sleep, this may also explain the sex differences in sleep that are observed between men and women.

Understanding that progesterone and melatonin may be having an impact on our sleep in perimenopause and menopause does mean that there may be a variety of ways we can enhance our sleep.  We may be able to increase progesterone rich foods and enhance melatonin production.

There are foods that are well known for balancing hormones including: cruciferous vegetables, flaxseeds, calcium rich foods and healthy fats. More specifically progesterone rich foods include pomegranates and flaxseed. Pomegranate contains apigenin which supports healthy progesterone levels. Apigenin is a biofavanoid compound abundant that is also found chamomile tea and exerts anxiety-reducing effects.

Adaptogens are plant substances (often herbs) that have been found to help our bodies manage stress and maintain balance, or homeostasis. Herbs such as, Maca, Shatavari, Holy Basil, Ashwagandha, rhodiola and Schisandra may be helpful. These can be incorporated into your daily routine, as supplements or added to smoothies. It may be beneficial to rotate them on a six-week basis.

Dr. Huberman suggests considering the following supplements as sleep aids:

Magnesium Threaonate, Apigenin, Theanine, Glycine and Gaba. He recommends starting with one to assess the effects before adding another or trying them one after the other.

 There are a variety of way that melatonin production can be enhanced:

• Reduce alcohol and caffeine intake as both reduce production of melatonin
• Eat melatonin rich foods such as Goji berries, sour cherry juice, flaxseed
• Eat tryptophan rich foods such as turkey, eggs, oats, salmon, spirulina
• Eat Vitamin B6 foods such as sunflower seeds, tuna, beans, and avocado
• Turn off screens an hour before or wear blue light blocking glasses
• Watching sunrise and sunset
• Create a bedtime ritual that could include drinking herbal tea, journaling or reading
• Eating an evening 3 hours before bedtime and including protein
• Listen to a yoga Nidra practice as you fall asleep

 Biohacker Ben Greenfield recommends the following sleep rules:

• 10 – The hours prior to sleep in which you will not drink caffeine.
• 3 – The hours prior to sleep in which you will not eat or drink anything other than water.
• 2 – The hours prior to sleep in which you will not work.
• 1 – The hours prior to sleep in which you will not be exposed to screens.
• 0 – The number of times you hit the snooze button.

 Fortunately, there is hope and help for better, natural sleep which will protect your health, help you maintain a better quality of life, improve relationships and keep you sharp mentally.