Sleep, hormone ratios and the peri-menopausal transition

I’ve often said that if I could only fix only one hormone driven problem encountered in the years leading into menopause, it would be to ensure a deep and restorative night’s sleep.  While there is still much science does not know about how and why sleep is so critical to the human brain, each of us know that when we don’t get it, we pay dearly on almost every level of function and quality in our life.

Sleep problems can start well before menopause

A recent article in Maturitas, the official journal of the European Menopause and Andropause Society, reviewed how risk factors for menopausal sleep disturbances were seen well in advance, during the premenopause years.  It highlighted how much of the impact of sleep problems in menopause were established issues well before one’s periods quit happening.  What the article didn’t talk about is the underlying why and how of premenopausal hormone drift. This time frame, also known as peri-menopause, can stretch anywhere from 2-3 to 10-12 years prior to menopause.  During this pre-retirement phase in their function, the ovaries are gradually decreasing their hormonal output of estrogens, progesterone and testosterone (EP&T).  Until you drop your hormone levels past a threshold determined by your uterus, you will continue to put down and shed the uterine lining as a menstrual period on a cyclic basis.  Unfortunately, the declining amounts of hormone can affect the rest of the body which needs these hormones for non-reproductive purposes.   I’ve had patients relate that their physician had informed them that since they were still having periods, their hormones were ‘OK’.  That might be true if you were just a uterus.  As you have multiple other body parts, with non-reproductive roles that are sensitive to EP&T, their ongoing decline can provoke many peri-menopausal symptoms of relative hormone deficit.

Common symptoms of peri-menopausal hormone drift

Some of these peri-menopausal hormone imbalance and deficit symptoms include:

-hot flashes and night sweats, with associated lost sleep time and less quality deep, restorative sleep.

-weight gain, and the inability to respond positively to exercise.  This often includes the problem of injuring easier and healing more slowly.  Sometimes this serves as a prelude to the fibromyalgia complex of symptoms.

-new or worsened late cycle PMS symptoms

-food cravings

-fluid retention and abdominal bloating

-‘brain fog’ and ‘senior moments’: cognitive losses which include memory, recall, the ability to multi-task or to learn and retain new information or routines.

-being more irritable, angry or intolerant to circumstances you used to routinely manage well.  Or maybe there really are more stupid people out there…hard to say, really.  But then, it could be your hormones.

-depression, social withdrawal, reduced self-esteem or a lack of interest or passion for the things that used engage and positively challenge you.  Reduced sexual interest or responsiveness often overlaps with this picture.

-dry skin, dry eyes and vaginal dryness.

Many times, these symptoms start small, and grow so gradually that you ‘learn to live with them’.  Many of my patients had been suffering 3-5 years before they got to the ‘can’t live with this anymore’ stage.  And many times, they are still having ‘regular periods’.  So, they must be fine, right? Or maybe their serum prozac level is just too low…but as you might guess by now, I think not.

The cause and cost of sleep deprivation

Although insomnia can have many medical root causes, the key hormonal factor at work in the peri-menopause years is estrogen deficiency and a resulting thermoregulation imbalance.  Blood from your core going to peripheral skin gives a sensation of giving off heat, much like blushing.  At night, you are typically cocooned with bedclothes or covers, and the heat is not as easily radiated off as it is in the daytime.  As it builds up, one may even produce a sweat to maximize heat exchange.  Sleep studies have shown that this heat exchange can not only wake you, but can also bring you from deep sleep to light sleep without conciously waking you.  Each times this happens, which can be several times a night, you lose deep, restorative sleep.  This is why affected women can wake up after being unconscious for eight hours, and still feel that they could ‘use another five hours of sleep!’

The repair of brain and body, and the restoration of neurochemicals are optimally performed during the deeper phases of sleep.  When you are robbed of this overnight repair time, you pay dues the next day in terms of physical, mental and emotional energy.  This is a root cause of many of the peri-menopausal symptoms you see listed above.

It’s not just about hormone deficits, it’s also about the ratios

What’s even more challenging about this peri-menopausal shift is that it’s not just the progressive deficit of each hormone that affects you, it is also the changing ratios of one hormone to the other, especially that of the estrogen/progesterone pair.  When both are dropping, you can have an absolute deficit of both.  But when progesterone drops faster, as it often the case in peri-menopause, the ratio favors estrogen to a greater degree progesterone.  In this case, we say that the estrogen action is dominant.  It is common to have the seeming paradox of being both estrogen deficient and estrogen dominant at the same time.  This imbalance requires individualized support hormone therapy that addresses each portion of this puzzle.

The Maturitas article also highlighted the potential role of hormone support therapy for peri-menopausal sleep disturbance, and I would wholeheartedly concur.  A key point to raise in this regard however, is that the common practice of estrogen support without adequate progesterone almost always worsens the estrogen dominance that is the common theme of peri-menopause.  Conventional therapy has two general options, neither of which is typically a good fit.  Oral contraceptives can regulate periods, but may not meet non-reproductive needs (like sleep disturbances).  Estradiol/progestin combinations may reduce temperature exchange problems and help sleep, but also can aggravate the estrogen dominance to an intolerable level.  It is also prone to several potentially serious side effects, as noted in the now famous Women’s Health Initiative studies.

Individualized therapy to manage the deficit/dominance dilemma

If you are in the peri-menopausal years, and have some of the symptoms discussed above, you may benefit from investigating the benefits of individualized bio-identical support therapy.  This is therapy that not only treats your specific version of peri-menopause, but also is flexible over time to adjust to the hormonal changes that will continue to occur as your ovaries move toward full retirement, and beyond.  Many of my patients started with non-prescription topical progesterone from a health food store, taken during their most symptom prone days, usually at the end of the cycle.  I usually see them when this strategy is incomplete in meeting their needs, and their peri-menopausal story and symptoms have gotten more complex and exasperating.  For those who have a more complicated peri-menopausal journey, having a bio-identical hormone knowledgeable practitioner as a partner can be invaluable.

You may know of someone locally who specializes in individualized hormone therapy If not, it can be helpful to look up one or more local compounding pharmacies and ask the pharmacist about nearby options.  These pharmacists fill the individualized and compounded prescriptions used for peri-menopausal support, they see these patients as they go through the process and they have a good sense of who knows what they’re doing.  Their experience can help direct you to a knowledgeable practitioner.  Another option for more suburban/urban areas is the search-by-your-state site  As an example, my page on that site is at  And there are many other online ways to find qualified help in your area.

I can’t recall how many times I’ve heard the phrase “I really didn’t know how bad I was until I got better!’  If you suspect that this might be your peri-menopausal story as well, begin the process of better understanding your transition symptoms, and of finding solutions that lead to better sleep, and with it, all the benefits of waking up each day with ‘a sound mind in a sound body.’

Lampio L, Saaresranta T, Engblom J, Polo O, Polo-Kantola P. Predictors of sleep disturbance in menopausal transition. Maturitas. 2016;94:137-142. doi: 10.1016/j.maturitas.2016.10.004.

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