Are perimenopause and menopause disrupting your sleep?

Kayleigh came to Dr Benita Perch with a plethora of symptoms. Stretched too thin between work and looking after her two kids, she was stressed, experiencing recurrent UTIs and migraines, and sleeping badly.

Getting around four hours of sleep a night, she was running on empty and feeling disconnected from her life.

After listening to Kayleigh’s concerns, and learning that Kayleigh often felt like her periods ‘snuck up on her’ and she couldn’t predict when they would arrive, Benita recommended she undergo testing to check her hormone levels. At 45, it was very possible that the underlying thread linking her symptoms was perimenopause.

How fluctuating hormones affect your sleep

The hormones that fluctuate during perimenopause and menopause are integral to sleep.

During this period, progesterone gradually decreases. One of progesterone’s roles is GABA production – a neurotransmitter that promotes relaxation and regulates your sleep / wake cycle. Lower levels of progesterone lead to lower levels of GABA.

Oestrogen also helps regulate the sleep / wake cycle as well as stabilising your body temperature. During perimenopause you experience cycles of low oestrogen and high oestrogen. Low levels are linked to sleeping problems, hot flashes and night sweats during perimenopause.

Fluctuating levels of oestrogen are also linked to restless leg syndrome (RLS) – a condition which affects sleep quality and duration. RLS is twice as common in women than in men and has increased prevalence when women reach the onset of perimenopause.

During perimenopause, the other sex hormones, FSH and LH usually increase. Studies show that high levels of FSH can increase the number of time you wake up in the night.

“When it comes to testing your hormones, you have to be careful to test at the right time,” says Naturopathic doctor, Benita Perch. “FSH, LH and oestrogen must be tested on day 3 of your menstrual cycle, and progesterone has to be tested on day 21.”

“I recommend the Dutch Plus, which includes your cortisol awakening response (how well you respond to stressors) as part of the breakdown. Cortisol is usually elevated, or fluctuates during perimenopause.”

Kayleigh’s levels revealed that she was perimenopausal. Her oestrogen levels were lower than they should be prior to perimenopause. Typical levels on day 3 should be between 35 and 70, and Kayleigh’s clocked in at 29.

Kayleigh also had low levels of pregnanediol, which is used to measure progesterone levels.

“The Dutch Plus also analyses levels of neurotransmitters which affect sleep – dopamine, melatonin and norepinephrine. These neurotransmitters help regulate sleep and mood – and your mental health during perimenopause plays a big role in your ability to get forty winks.

Kayleigh’s dopamine and melatonin readings came in at the lower end of the normal range – which is typical in perimenopause. While it may seem beneficial that her norepinephrine levels came in slightly elevated, this actually contributes to difficulty regulating body temperature, and for many women could be leading to hot flashes,” says Dr Benita.

Dr Benita asked Kayleigh to track her cycle for a few months – her calendar aligned with the test results. Her periods were irregular and she was entering perimenopause.

The link between your mental health and sleep

The stress that Kayleigh was feeling in her day-to-day life was reflected in her cortisol levels. Normal total cortisol levels are between 36 and 55, but Kayleigh’s were elevated at 68 – which is typical during perimenopause.

Kayleigh’s statement that she felt disconnected from her life, combined with the stress that she was experiencing prompted Benita to have a deeper discussion with her about her mental health – and with her consent, Benita referred her to IMI’s psychology services.

Depression is a major concern during the perimenopausal period, as confirmed by a University College of London study, which found that during perimenopausal women had a 40% higher risk of being depressed than premenopausal women. Studies have also confirmed that women are at higher risk of anxiety during perimenopause.

The hormonal system that governs your stress response and influences your sleep cycle (known as your HPA axis) is tied to the endocrine system (HPG axis) that rules your reproductive function and the process of menopause.

Scientists have found that hormonal changes during perimenopause can alter how GABA interacts with the HPA axis, which makes perimenopausal women more sensitive to stress.

Stress is also known to worsen perimenopausal symptoms like hot flashes and night sweats.

Stress, anxiety and depression have bi-directional relationships with sleep – meaning they have a cyclical relationship and can amplify one another. Breaking this feedback loop is key to improving sleep quality.

Perimenopause and UTIs

The drop in oestrogen during perimenopause can affects the vaginal microbiome, reducing the amount of good bacteria like Lactobacillus. Lower levels of Lactobacillus can also raise vaginal pH, which should be low and slightly acidic. Reduced oestrogen thins the lining of your urinary tract, all of which can lead to recurrent UTIs – with rates increasing among women who are 45 and over. When you transition from perimenopause to menopause, the risk of UTIs increases even further.

The recurrent UTIs meant that Kayleigh was up several times in the night to go to the toilet, and struggling to drift off due to pelvic pain.

Benita recommended the Female Ecologix test to assess Kayleigh’s vaginal microbiome. This simple swab test assesses 23 vaginal microbes, your pH levels and inflammatory markers.

Her data revealed she had low levels of good bacteria from the Lactobacillus family. She also had higher levels of Escherichia coli, a bad bacteria known to cause persistent UTIs.

Perimenopausal migraines

Kayleigh’s lower than normal levels of oestrogen also explained the migraines that were keeping her up at night. She’d experienced migraines in the past, particularly before her period, but they were becoming more frequent.

Drops in oestrogen before menstruation can cause headaches and migraines – sometimes known as ‘menstrual migraines’ – which are more debilitating than other kinds, and become more common during perimenopause.

Sleep’s bi-directional relationship with health concerns

Similarly to your mental health and sleep, UTIs and migraines both have bi-directional relationships with sleep.

“If you have these conditions, they make it harder to fall asleep, and likewise, poor sleep plays a role in developing UTIs, migraines and chronic pain – another condition which you’re more likely to develop in perimenopause, which affects your joint health. The cyclical nature of these conditions with sleep can be a vicious cycle to break free from,” says Dr Benita.

“Start with small changes to improve your sleep.”

What can you do to improve your sleep during perimenopause and menopause?

For most women, symptoms of perimenopause and menopause are inevitable, but there are some controllable factors that can help support better sleep during this period.

If you’re scrolling before bedtime, one of the best things you can do is put your phone down half an hour before bedtime, and replace it with a nourishing bed time routine, free from blue light.

Before bed, try to reduce your overall stress levels – yoga, meditation and mindfulness can be good practices to try, as these increase GABA production. Or, a retreat into a hot bath with lavender or Epsom salts.

If a glass of wine is your typical way of unwinding, you can replace it with some dark chocolate – a treat rich in magnesium and tryptophan which both help promote better sleep.

Tryptophan is an amino acid that supports production of melatonin, regulating the sleep / wake cycle. Dark leafy greens are an excellent source – and they provide the added bonus of magnesium.

Tryptophan is commonly found in sources of protein like red meat, fish, eggs, dairy and poultry produce. Protein rich foods also help protect your bone mineral density and muscle health, which is key during perimenopause, as bone mineral loss and muscle loss is accelerated.

Other sources of magnesium include whole grains, nuts and seeds, legumes and fruits like bananas and avocados.

Tailor your daily schedule for sleep, limiting caffeine after 2pm and opt for caffeine free alternatives like redbush tea – which is rich in magnesium.

Aerobic exercise like running, cycling, swimming and dancing also help boost GABA production to aid sleep. Listening to music provides an extra boost of GABA.

Reduce your stress levels by sharing your mental load – talk to your community, your friends and your partner about what you’re going through. If you find you need extra support, seek professional support. Counselling and psychotherapy offers a protected space for you to explore your feelings with someone outside of your personal life. 

Unsure if your symptoms are caused by perimenopause?

We recommend tracking your periods so you’re not in the dark. This keeps you aware of any irregularities in your cycle. Talking to other women about your experience can also help – not only can you foster a greater sense of community, but someone might spot something that you’re not familiar with.

And above all – if you’re not certain what’s causing your health concerns, or feel like you’re struggling to cope on a daily basis, seek professional help.

Our naturopathic doctors and naturopaths conduct a thorough assessment of your health, taking all symptoms into account. They used clinical tests to clearly connect the underlying cause of your symptoms.

References 
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