Why You Can't Sleep Anymore and What to Actually Do About It

For years I told myself I was just a bad sleeper.

I would lie awake for hours after getting into bed. I would finally fall asleep and then wake up at 2:30 or 3am with my heart racing and my brain immediately running through everything I had to do, everything I had said, everything that might go wrong.

I would stare at the ceiling for an hour or two and then drift back off right around the time my alarm was about to go off. And I would get up exhausted, drag myself through the day on caffeine and willpower, tell myself I would go to bed earlier tonight, and then do the whole thing all over again.

I blamed stress, schedule, the news job that had me waking up before 4am for decades. I blamed menopause in the abstract without understanding what menopause was actually doing to my sleep specifically.

What I did not know is that there were four separate hormonal mechanisms working against my sleep simultaneously, each one with a name and a mechanism and real treatment options that nobody had ever explained to me.

I sat down with Dr. Andrea Matsumura, a board certified sleep medicine physician and menopause expert, on The Tamsen Show. And for the first time the whole picture made sense.

Here is what she told me…

Why sleep falls apart in perimenopause and menopause

Four separate hormones are involved in sleep and all four shift during this transition.

1. Estrogen feeds receptors in the brain that help sustain sleep. When it drops you stop staying asleep. 
2. Progesterone is your calming hormone that prepares your body for sleep. When it drops the anxiety and wakefulness come with it. 
3. Testosterone supports deep sleep specifically. When it drops the quality of whatever sleep you do get decreases. 
4. Melatonin, the hormone that starts the entire cascade of sleep, drops by up to 50% by age 50.

All four of these happening at once is not a discipline problem or a stress problem. It is a biology problem with real treatment options.

What the 3am wake up actually is

When estrogen fluctuates during the night it affects your cortisol. Cortisol starts spiking earlier and your nervous system jolts awake. Then you lie there catastrophizing while the cortisol does its work.

The worst thing you can do is stay in bed. Your brain needs to associate the bed with sleep only.

Get up. Go to what Dr. Matsumura calls your insomnia chair. Read something boring. Write down whatever is racing through your head. When you feel sleepy enough, go back. It feels painful and counterproductive, but it works.

The sleep apnea stat every woman needs to hear

Up to 50% of women in midlife have sleep apnea and 90% of them have no idea.

The symptoms in women look nothing like what we have been told to look for. Women present with insomnia, migraines, general exhaustion, depression, and waking up after a full night feeling completely unrested. Most of it gets attributed to stress or menopause and the sleep apnea goes undiagnosed for years.

Untreated moderate to severe sleep apnea comes with up to a 25% increased risk of heart attack or stroke. If you wake up feeling unrested regardless of hours slept, ask your doctor specifically about a sleep study. Ask about an in-lab study or a type two home study rather than a standard home sleep test which misses a meaningful number of cases in women.

The DREAM method: a framework that actually helps

Dr. Matsumura created this to address sleep from every angle because treating just one piece only gets you halfway.

D is for daily habits. What you eat, how you hydrate, and how stressed you are throughout the day all directly affect how well you sleep at night.

R is for resting environment. Cool, dark, and quiet. Cooler is better. If you and your partner run at different temperatures that is worth solving for.

E is for emotions. Anxiety and depression get louder in bed because there are no distractions. These need to be addressed as part of the sleep plan not separately from it.

A is for archetype. Are you an early bird or a night owl? Fighting your natural circadian rhythm makes sleep harder. Up to 20% of the population is naturally a night owl and that is a real biological trait not a bad habit.

M is for medical conditions. Perimenopause, menopause, sleep apnea, restless leg syndrome, and autoimmune conditions all affect sleep directly. Ignoring the medical piece means only getting halfway to a solution.

On restless leg syndrome

Up to 30% of women in midlife have it and most do not connect it to iron stores. Ask your doctor for a ferritin level specifically. If you have restless leg syndrome your ferritin should be above 70 and ideally closer to 100. It is a simple blood draw and it is worth asking for because it is not part of a standard panel.

On supplements

Supplements support the sleep you already have. They will not fix sleep apnea or chronic insomnia on their own. The ones Dr. Matsumura finds most useful are magnesium glycinate for its calming effect on the nervous system and melatonin in low doses taken a couple hours before bed not right at bedtime. She recommends against combination supplements with many ingredients because you cannot tell what is actually working.

On alcohol

One drink can affect REM sleep, especially in midlife when the body metabolizes alcohol more slowly. REM is when emotional processing and memory consolidation happen. If you are going to drink, earlier in the day is significantly better than close to bedtime.

I linked all of my favorite mocktails here. Give them a try in place of the nightly glass of wine!

The most important thing she said

Hormone therapy should be the first conversation you have with your doctor about sleep, not the last. Estrogen, progesterone, and for some women testosterone address the actual biological mechanisms driving the disruption. 

Up to 50% of women on hormone therapy will still have some sleep issues but for many women hormones are the piece that finally makes everything else work.

If your doctor has not brought up the connection between your hormones and your sleep, bring it up yourself. Come with your symptoms written down, when they are happening, whether you feel unrested in the morning, and how many hours you are actually sleeping versus how many hours you are in bed. Those are different numbers and both matter.

I wish someone had explained all of this to me years ago. This episode is me making sure you do not have to wait as long as I did.

Listen to The Sleep Doctor: The 4 Hormones Wrecking Your Sleep & What to Do About It here or you can watch it here.

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