Why You Can't Sleep (and why melatonin isn't the answer)

She wakes up every day at 6 a.m. Sometimes by the end of the day, she can barely stay awake. She falls into bed by 10:30, exhausted. Falling asleep isn’t what’s wrong. It’s 3 a.m. that’s the problem. Lately, it’s been almost every single night; she’s wide awake, and though she’s tried every trick in the book, there seems to be nothing to do but suffer through the hours until the alarm clock goes off. Some nights her mind latches onto a problem and, like a dog with a bone, it won’t let go. She can feel her heart rate rising and tension in her body building. There’s no point lying in bed like this, so she sneaks out of the bedroom, never waking her partner. Then it’s hot tea, a magazine, or a podcast, a blanket pulled over her on the sofa. It’s staring at the ceiling. On the worst days, she’s just getting back to sleep when it’s time to wake up and start the day. Bleary-eyed, she gets out of bed and feels a cloud of sleep-deprived fog through the rest of the day. And the cycle repeats itself. She notices how irritable she’s been with her kids. And that moment at work today when she totally couldn’t remember her boss’s name while she was trying to make an introduction. What the hell?! Is this early dementia? Stubborn belly fat, inexplicable weight gain, low libido, crushing anxiety, not feeling herself. Could it be her hormones? This woman takes good care of herself. She really is trying — working out regularly, drinking water — so much water — because she knows she has to stay hydrated. She eats well, except for the French fries she can never resist off of her kids’ plates when they order burgers (hers has no bun).

I know this story well, and I would guess that you do too, since over half of all women report sleep difficulties during and after the menopause transition. Perimenopausal hormone shifts trigger insomnia, which then worsens the hormonal shifts and causes its own set of symptoms (many of which, themselves, mimic the symptoms of estrogen loss). The most profound of these symptoms relate to the brain--cognitive and mood changes that leave us feeling anxious, depressed, irritable, and sometimes downright forgetful. Memory lapses and brain fog are common among the sleep-deprived. If that weren’t bad enough, the perimenopausal sleep disturbances themselves lead to weight gain from alterations in hormones that control hunger and satiety and increase women’s risk for diabetes, heart disease, obesity, and major depressive disorder.

When women are feeling their worst, I typically start by addressing sleep. It is often the first domino to fall, causing many other downstream problems. When it comes to perimenopausal hormone shifts, we know that progesterone has the largest role to play here. Progesterone, the dominant hormone of our cycle after ovulation (and throughout pregnancy), promotes sleep and a sense of calm. This hormone exerts neurocognitive effects that define sleep architecture, sleep maintenance, and, in particular, the deep, restorative sleep we need. In some women, replacing progesterone makes a dramatic difference in their ability to get restful sleep through the night. If you’ve ever watched a pregnant woman yawning despite her attempts to cling to consciousness as bedtime approaches, you’ve had a front row seat to progesterone at work. For many patients, supplementing with progesterone is life-changing.

For others, it’s a bit more complicated. Midlife brings a seemingly endless stream of personal and professional stressors. Stress about jobs, money, relationships, children, aging parents, you name it, tends to impact our ability to get a restful night’s sleep. Hormone replacement may not be enough to correct long-standing insomnia or sleep problems related to other physical or mental health issues. Physical issues like back pain or waking frequently to urinate may keep us from getting adequate rest. I went through several weeks of sleepless nights before I realized that the warm mugs (plural) of chamomile tea I was having to wind down before bed were resulting in 2 am trips to the bathroom. Once I was up, the wheels in my mind began turning, and it sometimes felt impossible to get back to sleep. Throw in a life event that gives your mind something to really chew on, and you have a recipe for a sleepless night.

These twilight hours are when our minds are prone to becoming overactive with worry. When I learned the psychological phenomenon known as “the attention narrowing hypothesis,” I felt seen! This is the theory that we are so busy during the day that our busyness suppresses our anxious thoughts. Once our minds finally get us alone, so to speak, in the middle of the night (lying helplessly there, with nothing to distract us), anxious thoughts that were there all along are free to run wild. I remember lying awake, worrying incessantly about whether my teenager had adequate SAT prep, and whether I was putting too much pressure on him to perform, and whether he would get into a really good school, and whether college was really worth the money anymore. When I greeted him in the kitchen the next morning (no worry about college on his mind), I was astounded by how serious the problem seemed to me at 2 am. When rumination at night is a driving reason for insomnia in my patients, I recommend a worry journal. Writing down problems--naming them and giving them to the page--tends to remove their power. Sleep therapists recommend that you schedule a time of day to sit with your anxieties and worries. I find it helpful to write it all down, even in the middle of the night. Something about naming our fears, and even more so, making them concrete by putting pen to paper, robs them of their power over us. So go ahead, tap into the power of the pen and write down your troubles. It may be the ticket to a good night’s sleep.

What about medications? Supplements? Melatonin? Magnesium? It’s complicated. I think we’d all prefer to fall asleep without a crutch. There are so many options, so many different messages, and unfortunately, we are often misinformed and try using medications and supplements incorrectly. Melatonin is a great example of this. It is an amazing tool when navigating big circadian rhythm changes, such as flying to a different time zone and back. Well-timed melatonin for jet lag at the appropriate dose is a circadian signal, not a sedative. The confusion is that people use it the way they use Benadryl — at high doses to knock themselves out — when its actual mechanism is far more subtle. It’s whispering to the brain’s clock, not hitting it over the head. The evidence-supported dose for circadian shifting is actually 0.5mg to 3mg — far lower than the 5mg, 10mg, even 20mg doses lining pharmacy shelves. Those higher doses are essentially pharmacological rather than physiological — they may make you drowsy but they don’t do the precise circadian work more elegantly accomplished by a lower dose.

There are many habit changes that can significantly impact sleep, and therapy to address habits and beliefs around sleep is now recommended by the American College of Physicians, which in 2016 issued a clinical practice guideline recommending CBT-I (Cognitive Behavioral Therapy for Insomnia) as the first-line treatment for chronic insomnia disorder in adults, before sleep medications. The American Academy of Sleep Medicine (AASM) has reinforced this position as well, and it’s reflected in their clinical guidelines. Our daily habits have an impact, but so do our thoughts and beliefs, be they conscious or unconscious. A therapist trained in CBT-I can help us sift through all of this to improve sleep.

In fact, our thoughts and beliefs carry so much more weight than we’d like to believe. Harvard researcher Ellen Langer, PhD, conducted a study in which participants woke up believing they had slept two hours more, two hours less, or exactly the time they had actually slept. Their objectively measured biological and cognitive functions aligned with their perceived sleep rather than their actual sleep. In other words, what they believed about their rest shaped how their bodies and minds performed — independent of what actually happened during the night. This is where I begin to worry about our obsession with optimization (à la sleep trackers) and escalating worry about the ill effects of sleep deprivation. The data on the health effects of insufficient sleep are real. And so, it turns out, is the research showing that what we believe about our sleep shapes our physiology just as concretely. We are being acted upon from both directions simultaneously.

My best advice to you, as a physician and fellow perimenopause navigator, is to take a deep breath and treat this as another of life’s passing phases. Whisper to yourself each morning, “I am rested and ready to start the day. I am getting the perfect amount of sleep for me.” Because the only secret sauce for this problem is patience. Our ultimate goal really is not perfect sleep; it’s reminding our bodies and minds how to connect to the rhythms of light and dark, work and rest, on and off, that have guided us all these years.

If this resonated, forward it to a woman who needs to read it.

If you recognize yourself in this story and haven't yet found a physician who takes these symptoms seriously, I'd love to be that doctor. Femme Executive Health is a concierge practice in Baton Rouge, Louisiana, serving women who deserve more than a rushed appointment. Learn more at femmehealth.net