While the most common symptoms discussed in relation to perimenopause and menopause are typically hot flashes or weight gain, one of the most frustrating symptoms that can impact quality of life during this hormonal transition is the onset of sleep problems. Whether it's suddenly waking up in the middle of the night, having trouble falling asleep, or not sleeping at all, sleep disorders affect 39-47% of perimenopausal women and 35-60% of menopausal women.
A functional medicine approach to perimenopause and menopause may help identify underlying factors contributing to poor sleep and pair personalized plans with lifestyle recommendations to support sleep quantity and quality for women during this time.
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What is Perimenopause?
Perimenopause is a hormone transitional time leading up to menopause. During perimenopause, the overall levels of estrogen and progesterone start to decrease due to changes in ovarian function. Fluctuations in estrogen can lead to symptoms like irregular periods, hot flashes, sleep changes, and other symptoms. The perimenopause experience varies greatly, though the average duration is three to four years. Some women may start to experience perimenopause in their mid-30s, while others may not start the transition until their early 50s.
What is Menopause?
Menopause refers to a point in time when a woman no longer has a period. If a woman goes 12 months without a period, she has "reached" menopause. After this 12-month timeframe, a woman then enters "post-menopause." The average age of menopause in the United States is approximately 51 years old, though this can vary from woman to woman. Menopause can also be triggered by surgical procedures like a hysterectomy or removal of the ovaries at younger ages.
The significant decrease in hormones like estrogen and progesterone that is characteristic of the menopause transition can lead to symptoms for some women, including brain fog, hot flashes, sleep disturbances, mood changes, and even weight gain.
How Does Perimenopause Affect Sleep?
A significant number of women experience changes in their sleep during perimenopause, with the prevalence of sleep disturbances ranging from 39 to 47% during this time. The increase in sleep problems likely occurs due to a combination of hormone shifts happening as ovarian function changes, aging-related factors, and lifestyle changes that may occur at midlife.
While estrogen levels may fluctuate during perimenopause, ultimately, the pattern seen is a decline in estrogen over time; that decline can be associated with hot flashes, night sweats, and anxiety, all of which can lead to issues falling asleep, staying asleep, or changes in quality of sleep. Estrogen also plays a role in the regulation of body temperature, and low levels may impact the ability of the body to stay cool at night, which is an important factor in restful, quality sleep.
The hormone progesterone also decreases in perimenopause. Since progesterone is important for its calming effect and its impact on brain neurotransmitters like GABA, low progesterone can make it difficult to fall asleep and experience a sense of calm and ease in general.
Hormone changes can also impact the gut microbiome, as sex hormones have been shown to impact microbe diversity and other aspects of the gut microbiome. Since gut health is closely tied to physiological stress and the production of neurotransmitters, the relationships between perimenopause and gut microbiome changes may also indirectly impact sleep through these mechanisms.
Functional Medicine Labs to Explore Sleep Issues in Perimenopausal & Menopausal Women
From a functional medicine perspective, there are many ways to use laboratory testing to help detect and address factors that may be contributing to sleep issues in perimenopause and menopause. Some of the most common functional medicine labs for exploring sleep issues can be found below.
Comprehensive Female Hormone Testing
As levels of estrogen and progesterone start to fluctuate and decrease in perimenopause and menopause, women can experience challenges with regulating their body temperature, maintaining a regular circadian rhythm, hot flashes, and other symptoms. Understanding which hormones may need support and how to best support them can be accomplished by looking at levels of estrogen, progesterone, cortisol, testosterone, etc. Comprehensive hormone testing can also help guide hormone replacement therapy (HRT) that may support a woman's quality of life during this transitional period.
Comprehensive Adrenal Profile + Cortisol Awakening Response
During perimenopause and menopause, the adrenal glands start to take over steroid hormone production. This added role may affect the adrenal glands' other physiological roles, including the production of cortisol to help maintain a normal circadian rhythm and stress response. Evaluating a 24-hour adrenal profile to investigate cortisol levels and adrenal function can help a functional practitioner determine if adrenal support is needed to help regulate sleep in perimenopausal and menopausal women.
Additionally, including the cortisol awakening response (CAR) as part of an adrenal profile, such as in the DUTCH Plus test, can help look at the hypothalamic-pituitary-adrenal axis function, an important communication pathway between the brain and adrenal glands. When the HPA axis is functioning well, cortisol is produced in higher quantities upon waking, allowing you to feel energized and wake up out of sleep. Changes in the HPA axis can lead to poor stress responses, sleep disturbances, fatigue, trouble getting up in the morning, and other symptoms.
Neurotransmitter Evaluation
Neurotransmitters also play an important role in sleep. Estrogen and progesterone are both linked to neurotransmitter levels, so as these female sex hormones decrease during perimenopause and menopause, neurotransmitters important for sleep (like serotonin or GABA) may be impacted. Serotonin is an important precursor to melatonin, the hormone needed for sleep. Since serotonin is closely tied to estrogen, it's important to evaluate serotonin levels if sleep problems occur during perimenopause and menopause.
Thyroid Panel
Perimenopause and menopause symptoms have been associated with thyroid hormone levels, making it important to include a complete thyroid panel as part of any evaluation during the menopause transition. Both hypothyroidism and hyperthyroidism may contribute to sleep disturbances, and the presence of thyroid changes can worsen menopause symptoms.
Gut Microbiome Testing
Gut microbiome health and diversity have been linked to better sleep quality in general. Certain gut microbiota are closely linked to estrogen metabolism, and changes in the gut can cause estrogen levels to elevate or drop - impacting the transitional period where a woman is already experiencing ongoing changes in estrogen levels. Since the hormonal shifts occurring in perimenopause and menopause can also change the gut microbiome, a comprehensive gut microbiome test can help bring to light any imbalances or inflammation in the gut that may be impacting sleep.
Additional Labs That Can Be Helpful
The following test can be helpful in exploring specific underlying conditions that could be affecting sleep patterns.
Sleep Apnea Testing
Menopausal women are 2-3x more likely to develop sleep apnea, likely due to the changes in hormones that occur at this stage. Sleep apnea testing can help clarify if breathing ability is at the root of sleep issues during the menopausal transition.
Continuous Glucose Monitor
Menopause confers a higher risk of insulin resistance and trouble with regulating blood sugar, even in nondiabetic women. Poor quality sleep is also associated with an increased risk of insulin resistance, making balanced blood sugar an important priority for women struggling with sleep in perimenopause and menopause. Using a CGM (continuous glucose monitor) can help guide nutritional and lifestyle habits to support a healthy blood sugar response.
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Complementary and Integrative Medicine Approaches for Sleep Support in Perimenopausal & Menopausal Women
Complementary and integrative medicine approaches can be helpful in managing sleep challenges in perimenopausal and menopausal women. Based on lab results, approaches are modified and individualized. Here are some options that may be beneficial:
Nutrition Options for Sleep Support in Perimenopausal & Menopausal Women
An anti-inflammatory, whole-food diet (like the Mediterranean diet) rich in protein, healthy fats, and fiber (like fruits, vegetables, and complex carbohydrates) can be helpful for women experiencing sleep challenges during perimenopause and menopause. Such a nutritional approach helps keep blood sugar balanced and provides amino acids that are important for hormone and neurotransmitter production. Protein intake, in particular, has been linked to better sleep duration.
The Mediterranean diet is also known for its link to improved gut microbiome diversity and better gut function overall; as mentioned above, optimal gut health is linked with better sleep in perimenopausal and menopausal women.
Reducing things like caffeine, refined sugar, and alcohol can also help to support sleep, as these often negatively impact the ability to fall or stay asleep.
Supplements and Herbs for Sleep Support in Perimenopausal & Menopausal Women
Supplements and herbal therapies can be helpful in addressing some of the underlying hormone changes and factors that can contribute to sleep challenges in perimenopause and menopause. Here are some of the most common:
Melatonin
Melatonin levels slightly decline with aging in general, and as mentioned above, the connection between sex hormones, neurotransmitters, and melatonin means that supplementing with melatonin may support sleep quality during the menopause transition. Studies show that supplementing with melatonin in women ages 40-60 may support endocrine health while supporting sleep quality and the severity of symptoms like hot flashes.
Valerian and Lemon Balm
Valerian has been shown to support sleep quality in perimenopausal women, especially when combined with lemon balm.
5-HTP
There are many studies highlighting the potential benefits of 5-hydroxytryptophan (5-HTP) on sleep. 5-HTP is a known precursor to the neurotransmitter serotonin, an important neurotransmitter for sleep and melatonin production. A dose of 200-400 mg has been shown to help individuals fall asleep easier and stay asleep.
Hops
Hops is not just an ingredient found in beer - hops extract has been shown to support sleep in perimenopause and menopause, especially if hot flashes are waking you up at night. It does have a mild estrogenic effect, so it's not recommended for anyone with a history of estrogen receptor-positive cancers. And hops can make you sleepy, so use caution in the timing of taking the supplement.
Hormone Replacement Therapy for Sleep Support in Perimenopausal & Menopausal Women
Hormone replacement therapy (HRT), including estradiol and progesterone, can be helpful for women experiencing sleep challenges in perimenopause and the menopausal transition. Helping regulate these hormones as they decline may support the management of various symptoms, including sleep disturbances. Studies suggest that including HRT as part of a healthy lifestyle and good sleep hygiene can support sleep duration and quality in perimenopause and menopause.
Acupuncture for Sleep Support in Perimenopausal & Menopausal Women
Acupuncture, along with other forms of Traditional Chinese Medicine (TCM), has been shown in studies to be effective at reducing insomnia and sleep disturbances in perimenopausal women as part of an overall healthy lifestyle.
While acupuncture alone resulted in improvement and, in 26% of cases, a complete resolution of sleep issues attributed to perimenopause in one study, adding the TCM herbal formula Zi Shen Tiao Gan Tang (which supports kidney and liver function) increased the improvement rate and raised the complete resolution rate to 35%.
Sleep Hygiene for Sleep Support in Perimenopausal & Menopausal Women
For anyone struggling with getting a good night's sleep, paying attention to sleep hygiene and one's sleep environment is also important. Making sure your sleep environment is dark, cool, and quiet helps to support sleep while limiting blue light exposure from devices before bed can also help with melatonin production.
Some other sleep hygiene considerations that can help support sleep include keeping the same sleep schedule night to night as best you can, developing a bedtime routine (such as reading, stretching, or meditation), having your last meal 2-3 hours before bedtime, and reducing caffeine and alcohol intake, both of which can be disruptive to sleep.
Additionally, wellness tools such as mattress cooling pads and nasal breathing strips can help ensure a cooler body temperature and improved nasal breathing, respectively, both of which are linked to better sleep.
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Summary
Sleep challenges are quite common in perimenopause and menopause, and taking some time to explore the factors contributing to disrupted sleep - whether it be hormone fluctuations, gut microbiome changes, or something else - can help to support sleep quality and create a personalized sleep hygiene plan.
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