Healthy Mind Healthy Sleeping Habits

It’s Not Just You: Entering Perimenopause Can Throw Your Sleep Out of Whack

Photo: Getty Images/Torwai
If there’s one thing to know about sleep, it’s that it loves a routine, thriving on a regular sleep-wake schedule and consistent nighttime and morning rituals. By contrast, perimenopause (aka the transition to menopause) is all about change, as hormonal fluctuations during this phase of life can throw many physiological processes for a loop, affecting things like your mental state, metabolism, libido, and—yes—your sleep. Though a lesser-discussed symptom, sleep problems affect anywhere from 39 to 47 percent of people in perimenopause, occurring both as the direct result of hormonal shifts and indirectly, due to coinciding lifestyle and aging-related changes.

“Perimenopause is when the reproductive hormones progesterone and estrogen go into a slow decline, which is why you may experience so many new and different sensations and symptoms,” says holistic OB/GYN and menopause expert Kourtney Sims, MD, chief medical advisor at menopause-care brand Phenology. Among the most common—and commonly lamented—are temperature swings, like hot flashes and night sweats, which can certainly stand in the way of good sleep. “Even for perimenopausal women who are not experiencing [temperature changes], problems with sleep, including inability to fall asleep or stay asleep, or poor, un-refreshing sleep quality are also very common,” says Wendy Troxel, PhD, senior behavioral scientist at RAND Corporation, scientific advisor for SleepFoundation.org, and author of Sharing the Covers: Every Couple’s Guide to Better Sleep.

"Alongside hormonal shifts, changes in mood, stress levels, and daily rhythms and activities can cause sleep problems during perimenopause." —Wendy Troxel, PhD, scientific advisor for SleepFoundation.org

While hormone changes are often part of that equation, other elements including “changes in mood, stress levels, and daily rhythms and activities” can also factor into the genesis of sleep problems during perimenopause, says Dr. Troxel. Below, experts break down these reasons and share advice for getting quality shut-eye throughout this phase of life despite them all.

Why can perimenopause cause problems with sleep?

Hormonal changes

Though female reproductive hormones may affect sleep in a variety of different ways, one thing is clear: Changes in the levels of these hormones most definitely disrupt sleep. In fact, during all the life phases characterized by these changes, including puberty (and around menstruation), pregnancy, and menopause, sleep problems are common, says Dr. Troxel.

In perimenopause, specifically, the changes in estrogen and progesterone have unique sleep-related effects. The overall decline in estrogen can trigger the ever-dreaded hot flashes and night sweats, as well as low mood and symptoms of anxiety and depression, “all of which can lead to frequent nighttime awakenings, disrupted sleep, poor sleep quality, and insomnia,” says sleep psychologist Shelby Harris, PsyD, director of sleep health at Sleepopolis and author of The Women's Guide to Overcoming Insomnia. Generally, estrogen also plays a role in regulating your body temperature at night, says Dr. Troxel, which allows for the dip in temperature that helps you fall and stay asleep. Having lower levels of it may cause your body temperature to stay elevated at night, interfering with sleep as a result.

At the same time, the perimenopausal decrease in progesterone—a hormone with a calming, sedative effect—can also make falling asleep more difficult. Additionally, some research links the drop in both estrogen and progesterone during perimenopause with higher rates of snoring and obstructive sleep apnea (a condition marked by pauses in breathing during sleep), both of which can disrupt sleep and interfere with sleep quality.

Aging-related changes

In general, we tend to have more fragmented sleep as we age, which can certainly be a factor driving sleep problems during perimenopause. So can the circadian shifts common with aging, “such as the tendency for older people to get sleepier earlier in the evening and wake up earlier in the morning,” says Dr. Troxel. Toss in other health-related changes linked with aging, “including pain and frequent urination,” and you have a recipe for even more disrupted sleep during the menopausal transition and beyond, she says.

Not to mention, overall melatonin levels also decrease with age, “which can impact the consistency of our sleep-wake cycles,” says Dr. Harris. That is, it can become tougher during perimenopause to fall asleep at your typical bedtime and wake up when you typically rise.

Behavioral and lifestyle changes

The big transitions, stressors, and demands that tend to crop up during the perimenopausal period of life can mess with sleep just as much as the above physiological changes. For example, during perimenopause—which is most common around ages 40-45 (but can start as early as 35)—you might very well find yourself at the height of your career, caring for aging parents, and also raising kids all at once. “Because women are having children later in life, they often have young children at home [while in perimenopause] who may have trouble with sleep that can also make it harder for the women themselves to sleep,” says Dr. Harris.

All of the above can cause significant stress and anxiety, which can also make it difficult to prioritize sleep and time for winding down, adds Dr. Harris. In an effort to carve out some time for themselves while fielding so many demands from others, perimenopausal folks are also prone to “revenge bedtime procrastination,” she says, “scrolling the internet or watching TV at night rather than going to sleep, which can, in turn, make it harder to fall asleep.”

Supportive daily habits also tend to fall by the wayside in this overextended scenario, says Dr. Sims. “Maybe you’re not eating well enough, maybe you’re overly stressed, maybe you don’t have good self-care or restoration rituals,” she says. Any of the above can worsen perimenopausal symptoms across the board, including sleep issues.

7 pointers for getting better sleep during perimenopause, according to sleep specialists and a gynecologist

1. Double down on sleep hygiene

The fact that many of the sleep-related changes of perimenopause are out of your control just makes it doubly important to manage the elements of good sleep that are in your control. And that means going back to the basics of good sleep hygiene, says Dr. Harris: “Limit screen use before bed, limit alcohol and caffeine in the afternoons and evenings, keep your bedroom quiet and comfortable, and try not to compensate for a bad night by sleeping in late or going to bed early the next night.”

2. Get on a consistent sleep schedule

Sleep loves routine, remember? When the changes of perimenopause are putting a wrench in your lifestyle, your best bet for good sleep is to make it as routine as you can, going to bed at the same time each night and waking up at the same time each morning, says Dr. Troxel.

“When sleep problems emerge, the tendency is to try to catch sleep wherever you can—like by sleeping in or going to bed earlier—but the more you ‘chase’ sleep, the more it will elude you,” she says. “Having an erratic sleep-wake schedule disrupts your circadian rhythm and can exacerbate sleep problems, so the best thing to do is keep a consistent sleep-wake schedule seven days a week, even if you have a bad night.”

3. Cool things down as much as possible at night

If you’re having hot flashes or night sweats, this tip will be obvious. But even if you’re not waking up in a puddle, it’s possible that your overnight body temperature isn’t as well-regulated with less estrogen flowing in your system—so it’s worth taking additional measures to stay cool.

“The ideal temperature for humans’ sleep is around 65-68 degrees Fahrenheit, which is colder than what would normally feel comfortable, but a drop in core body temperature is one of the primary signals to our brain that it’s time for sleep,” says Dr. Troxel. “So, having the room temperature cool at bedtime and throughout the night can facilitate better quality sleep.” She also suggests wearing lightweight pajamas that wick away moisture.

4. Focus on nurturing other elements of your lifestyle

If work or family stress is exacerbating your perimenopausal symptoms, it’s important not just for your mental health but for your sleep to spend some time investing in nourishing everyday habits and practicing self care.

Focus on how you’re fueling yourself through nutrition and how you might find moments of recovery and rest throughout your day, suggests Dr. Sims, adding that adjunct treatments such as acupuncture and massage may be helpful, too. “It’s also important to delegate responsibilities that you don’t absolutely have to do because your body is going through a shift where it needs you to take that time for yourself,” she adds.

5. Practice ‘scheduled worry’

If stress and anxiety are keeping you up at night with racing thoughts, consider tricking your brain into worrying less at night by penciling in time to worry earlier in the evening. “Scheduling a 15-minute ‘worry session’ several hours before bedtime can be a very effective way to settle the mind,” says Dr. Troxel. “Set a timer for 15 minutes, and during that time, just write down any thought or worry or thing-to-do in a notebook. When the 15 minutes are up, literally and figuratively, close the book on worry for the night.”

6. Consider hormonal and herbal remedies

Certain hormones and herbs that you can consume may help reduce the severity of perimenopausal symptoms, including sleep problems.

Dr. Sims recommends isoflavones, which are a type of phytoestrogen found in plants like red clover, alfalfa, and soy, and in supplement form. “Phytoestrogens have been shown to mimic the function of estrogen in the body, in turn helping to alleviate effects of some of the hormonal changes during the menopausal transition,” she says. In particular, research has shown that phytoestrogens “appear to reduce the frequencies of hot flushes” in menopausal people (as do isoflavone supplements, specifically). Just talk to your doctor before trying, as they might not be recommended for people who have a history of hormonal cancers like breast or ovarian.

Similarly, Dr. Sims suggests incorporating saffron extract into your diet (either in food or in supplement form), as preliminary research points to its potential ability to reduce the psychological symptoms of perimenopause.

At the same time, you can also supplement your diet with melatonin or melatonin-rich foods like pistachios in the evenings in order to account for the dip in natural melatonin levels that happens with age and help re-balance your circadian rhythm. (If you go the supplement route, just stick to 3 mg or less per day to avoid running the risk of dependency.)

7. Ask your doctor about treatments for poor sleep and/or perimenopausal symptoms

You might need something a little more intensive than the above to combat sleep problems during perimenopause, particularly if they’re happening as the result of a variety of the aforementioned physical and psychological factors.

In that case, talk with your doctor about Cognitive Behavioral Therapy for Insomnia (CBT-I), suggests Dr. Harris. “It is a first-line, non-medication treatment for insomnia—including during perimenopause—that goes far beyond basic sleep hygiene,” she says. This treatment can help you identify unsupportive thoughts, feelings, or associations you may have around sleep and then challenge them in order to change your internal narrative.

If the sleep issues you’re facing are primarily hormonal, it may also be worth addressing the potential of hormone replacement therapy (HRT) with your gynecologist. It’s not a solution for everyone (particularly those who’ve had breast or endometrial cancer) but based on new research, its overall safety, health benefits, and ability to alleviate certain menopausal symptoms make it a great option for some.

If your sleep issues are especially persistent, Dr. Harris also suggests seeing a sleep specialist and getting a screening for common sleep-affecting conditions like sleep apnea, which is often missed in perimenopausal folks.

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