| I had always slept really well, never had any problems falling asleep, sleeping soundly, staying asleep, and waking up feeling rested…until I hit about age 35! Suddenly, for no apparent reason, and no noticeable change in stress or my thyroid status, I began having very restless, fragmented sleep, waking up multiple times a night with my heart racing and it would take awhile to go back to sleep – then it would happen over and over, waking up, looking at the clock, heart pounding, going back to sleep, then waking up again. I started feeling exhausted without good quality sleep. I had all kinds of medical evaluations, including EKG, stress test, and a Holter monitor to check for heart problems – but nothing was found.
Finally, after a series of herniated disks and cervical spine surgeries unusual for my age and overall health and fitness, an astute internal medical doctor had me sent to a fertility doctor to check my ovarian hormone levels! BINGO! Insomnia culprit found! Several miles a day for my exercise and unbeknownst to me had suppressed my ovarian hormone production to the point that my estradiol was too low! This led to disruption of the sleep regulatory center in the brain, that is regulated by estradiol from our ovaries! Since I was doing a lot of work with ovarian hormone cycles and the imbalances that led to PMS karma, PCOS karma endometriosis and other reproductive disorders. The connection immediately made sense to me. It just wasn’t I was thinking about for myself.
Although I was not trying to get pregnant the fertility doctor was the specialist who understood hormone levels and complications that happen when levels are too low. He recommended that I try using a transdermal patch with the FDA-approved bioidentical estradiol hormone to supplement ovarian production. Within 10 days on the estradiol patch, I felt like a new person, my sleep had returned to normal, my foggy brain felt clear and sharp, my energy was back to normal and I felt like a new person! My old self was back! It was like a miracle.
From that day forward, I have known and experienced firsthand the validity of the brain science that showed estradiol’s powerful role in regulating sleep and many other brain functions. Evaluating women’s ovarian hormone levels with state-of-the-art gold standard blood tests has been an ongoing part of my medical practice ever since, and I have discussed this in depth in all my books. I have seen this same overlooked connection work similar miracles in thousands of my patients over the last 45 years of this work as we worked together to restore optimal estradiol in women of many ages who had levels below the threshold needed to maintain normal sleep regulation.
Most women think, and are told by doctors, that stress or thyroid problems are the biggest causes of insomnia and fatigue. They are usually given sleeping pills, melatonin, and/or antidepressants. Those Rx just make the problem worse over time. And, that is a seriously incomplete picture of what really causes far more sleep problems for women over 30! Chronic sleep disruption and loss of sleep then leads to daytime fatigue, memory and concentration difficulties, mood problems, muscle pain syndromes and a host of other health problems as I talked about in my health tip Stress: The Hidden Culprit in Insomnia & Anxiety. Lack of sleep sets up a vicious cycle of increased stress that in turn further suppresses ovarian hormone production, then falling estradiol directly contribute to insomnia and also increases the stress response that also disrupts sleep, which then decreases estradiol levels even more, which negatively affects the quality of sleep, further aggravating the stress response…it goes round and round in a never-ending vicious cycle. Just describing this makes me tired!
The decline in estradiol (E2), our primary premenopausal estrogen, affects nearly every major body system, especially the brain. This is the primary active estrogen at brain centers that regulate sleep, pain, mood, memory, concnetration, focus, appetite, thirst, and sex drive. Other estrogens have different functions and don’t affect the brain centers like we see with estradiol: estrone (E1) is primary a storage form of estrogen in body fat, estriol (E3) is made by the placenta during pregnancy and mainly has benefits on vagina/urogential tissues, estretrol (E4) is only made by the fetal liver during a full term pregnancy, and has quite a few immunological benefits for mother and baby. None of these other estrogens play a major role in sleep regulation.
Disrupted sleep is the earliest hallmark change of estradiol decline, and it occurs long before other symptoms like hot flashes, vaginal dryness or irrgular menses. Estradiol decline can begin in the early 30s depending on many risk factors I describe in my book It’s My Ovaries, Stupid! Estradiol decline happens more rapidly in our 40s as we lose ovarian follicles as we approach menopause. Estradiol drops even more sharply and problems with insomnia increase dramatically when menopause actually hits, defined as the end of monthly periods.
Common Sleep Disorders that Increase After Menopause
There are other sleep disorders that hit menopausal women in greater numbers if they are are not using optimal estradiol therapy to restore what is lost at menopause. When the ovaries no longer cycle at menopause, we lose our ovarian estadiol and progesterone, often without a loss in testosterone, so the normal female balance is disrupted. The imbalance in estrogen/progesterone and androgens leads to shifts in circadian rhythm, and a whole cascade of metabolic, endocrine, immune and neurologic changes.
1. Insomnia
Insomnia is the most frequently reported sleep disorder after menopause, affecting up to 60% of women. It is characterized by difficulty falling or staying asleep, early awakenings, and non-restorative sleep. Many women develop chronic insomnia that persists even years after menopause. Taking sleeping pills just makes the problem worse, because they create dependency and alter the normal stages of the sleep cycle.
2. Obstructive Sleep Apnea (OSA)
The prevalence of obstructive sleep apnea increases dramatically after menopause—from less than 20% in premenopausal women to between 47% and 67% post-menopause. Symptoms include snoring, gasping for breath, multiple awakenings due to apnea spells, increased cortisol, increased middle body weight gain, increased risk of diabetes and high blood pressure, mood changes, and daytime fatigue.
3. Restless Legs Syndrome (RLS)
More than half of postmenopausal women experience restless legs syndrome, characterized by uncomfortable leg sensations, twitching and kicking throughout the night, and an urge to move at night. Hormonal changes may influence dopamine and iron metabolism, both implicated in RLS pathophysiology. The condition markedly disrupts sleep and often coexists with insomnia. It can be dramatically reduced with estradiol therapy and restoring ferritin (marker of iron stores) to levels above 100. Doctors rarely check ferritin levels and really need to since most women have chronically low ferritin due to years of menstraul blood loss and iron depletion/low iron stores.
4. Periodic Limb Movement Disorder (PLMD)
PLMD involves repetitive, involuntary leg movements during sleep, typically every 20–40 seconds. It frequently co-occurs with RLS and contributes to nighttime awakenings. Its prevalence rises with age and is more common in postmenopausal women, possibly related to altered dopaminergic signaling.
Estradiol’s Role in Sleep Regulation
Estradiol decline causes significant physiological and neurological changes, which include the following:
- Estradiol interacts with the hypothalamic thermoregulatory center and its loss narrows the temperature tolerance range causing hot flashes and night sweats. These vasomotor symptoms disrupt sleep and amplify fatigue and irritability.
- Estradiol also plays a role in regulating all of the neurotransmitters affecting mood, pain and sleep: serotonin, dopamine, norepinephrine, monoamine oxidase, and acetylcholine, that support sleep-wake cycles, mood, cognition and metabolism. Estradiol decline worsens mood swings, anxiety, and depression, which in turn further impair sleep quality.
- Estradiol decline significantly disrupts circadian rhythm stablity and melatonin secretion amplifying difficulties in maintaining deep, restorative sleep.
- Progesterone, another of the primary ovarian reproductive hormones, has a mild effect to benefit sleep. It typically declines later in the progression to menopause than I see with estradiol when I measure all these hormones. Oral progesterone used in menopausal therapy for women with a uterus is converted to sedative metabolites by the liver, and can be an added benefit of hormone therapy to improve sleep (but the oral form also tends to cause more depression and weight gain, abdominal bloating), so we have to balance benefits versus adverse effects when using oral progesterone. Women after hysterectomy DO NOT need progesterone in their hormone regimens and because the negative side effects, I do not include it for hormone therapy in women without a uterus.
Estradiol Loss, Menopausal Weight Gain and Increased Risk of Sleep Apena:
- The risk of sleep apnea is increased when estradiol declines due to estradiol’s role in maintaining upper airway tone and central regulation. Estradiol decline can make the airway more collapsible, worsening nighttime breathing problems and negatively affecting quality of sleep. As I have described in my book Screaming To Be Heard: Hormone Connections Women Suspect and Doctors still Ignore, this is important because we know that sleep apnea is a significant contributing risk factor for high blood pressure, cardiovascular disease early morning fatal heart attacks, onset of major depression, and in men is also a cause of erectile dysfunction.
- Such serious consequences of sleep apnea occur because there are dangerous drops in oxygen saturation of the blood when sleep apnea causes you to stop breathing. Menopausal women have a greater vulnerability than men to sudden death or heart attack during sleep because the estradiol drop in women causes combined effects that intensify the heart arrhythmias. The combined drop in oxygen and estradiol cause a catecholamine release in the brain that aggravates instability in heart rate and also causes high blood pressure, both of which decrease blood flow to the heart. A crossover study of the effects of hormone replacement therapy on sleep apnea published in 1999 found that both estradiol alone and estradiol with progesterone as hormone replacement therapy regimens were found to decrease sleep apnea to a statistically significant degree in all subjects tested. They also reported an interesting finding: 40% of the waking episodes these menopausal women had were not associated with vasomotor flushing (“hot flashes”) but were independent manifestations of estradiol decline. This study confirmed what many other sleep studies have suggested: Ovarian sex steroids, particularly estradiol, have a variety of effects on normal sleep regulation, including direct effects on sleep apnea.
- Changes in metabolism and weight gain that are common in post-menopausal women can further contribute to sleep problems such as snoring and obstructive sleep apnea (OSA). This is due to more than just overall increase in body mass index (BMI) it is the changes in fat distribution around the neck and abdomen that contribute to OSA risk.
- During menopause, women tend to accumulate more visceral fat around the abdomen, which places extra pressure on the upper airway structures. This increased fat deposition narrows the airway and makes it more prone to collapse during sleep, leading to obstructed breathing and apneic events.
- Weight gain also contributes indirectly to OSA by promoting metabolic disturbances such as insulin resistance, which are linked to inflammation and impaired neuromuscular control of the airway. Fat deposits around the neck and trunk increase mechanical load on breathing muscles, decrease lung volume, and worsen oxygen desaturation during sleep.
- Insulin resistance also alters brain and hormonal signaling that regulate sleep. Chronically high insulin and glucose levels interfere with melatonin production and circadian timing, leading to delayed sleep onset and reduced deep sleep stages. Insulin resistance also increases sympathetic nervous system activity and cortisol secretion at night, producing fragmented sleep and early awakenings. Studies of diabetic and prediabetic individuals show that those with higher insulin resistance have more frequent nighttime awakenings, lower sleep efficiency, and worse sleep quality.
Effective Treatments for Insomina
I have found that the most effective treatments for menopausal sleep issues combine hormonal (restoring optimal testosterone for men, restoring optimal estradiol for women), nutraceutical, and lifestyle strategies that include nutrition, exercise, and behavioral changes. Evidence supports several strategies for improving both sleep duration and quality in peri- and postmenopausal women. The hormonal approaches I use need to be individualized to each woman, based on blood levels, medical conditions, symptoms, metabolic rate and other variables. I discuss these strategies in my books, available at the Truth for Health Store and on Amazon
Identifying Deficiencies Contributing to Insomnia, and Optimizing Supplementation
Several supplements have demonstrated benefit for sleep disturbances by targeting insomnia, anxiety, night sweats, and disrupted circadian rhythms. These natural and nutritional options can be effective adjuncts or alternatives to hormone therapy, especially when used alongside lifestyle measures.
Key Supplements for Menopausal Sleep Problems
Inositol as myo-Inositol as in our TruInositol™ Complex:
Supports sleep primarily through neurotransmitter modulation, circadium rhythm regulation, and stress reduction mechanisms that collectively enhance sleep quality. Myo-inositol acts as a critical signaling compound in the brain that influences serotonin, dopamine, and GABA. All of these chemical messengers are essential for both mood and sleep regulation. Myo-inositol indirectly enhances melatonin synthesis by supporting serotonin activity to regulate the body’s sleep–wake rhythm and promote deeper, more consistent sleep.
Inositol’s modulation of serotonin and GABA pathways also produces a calming effect that can reduce nighttime anxiety and intrusive thoughts—major factors that interfere with falling and staying asleep.
Myo-inositol with GABA as in our TruInositol™ Complex supports sleep and contributes to improved relaxation without the sedative effects associated with many sleep aids. Inositol also helps reset circadian rhythms and reduce cortisol levels, which supports both hormonal balance and improved nighttime rest. These effects make it particularly helpful for individuals experiencing sleep disruption from stress, shift work, or hormonal fluctuations.
Research evidence supports myo-inositol’s role in improving global and subjective sleep quality. A randomized controlled study using 2000 mg myo-inositol daily for 10 weeks was found to significantly improved sleep duration and efficiency in pregnant women, indicating its potential to normalize sleep architecture and reduce sleep disturbances. Neuroimaging also linked lower myo-inositol levels in the brain to depression and delayed melatonin rhythms, further suggesting a neurochemical basis for its sleep benefits.
Magnesium as in our TruMagnesium™:
Improves sleep duration and efficiency by acting on several interconnected biochemical and neurological pathways that regulate relaxation, circadian rhythm, and stress. Magnesium helps maintain balance between excitatory and inhibitory neurotransmitters in the brain which calms the nervous system activity and reduce neuronal excitability and creates a sedative-like, anti-anxiety effect that makes falling asleep easier.
Magnesium supplementation has been shown to reduce cortisol concentrations in clinical studies. This is important because elevated cortisol levels impair sleep quality by increasing alertness. Supplementation with magnesium contributes to a calmer physiological state before and during sleep. Magnesium also plays a cofactor role in melatonin synthesis, particularly by stimulating N-acetyltransferase (NAT) activity in the pineal gland. Adequate magnesium enhances natural melatonin secretion as light diminishes, supporting the body’s circadian rhythm and signaling readiness for sleep. Magnesium-facilitated muscle relaxation provides added relief for restless legs by inhibiting NMDA receptors (a glutamate receptor) and modulating calcium transport in muscle tissue to promote muscle relaxation. This not only reduces nighttime muscle tension but can also alleviate symptoms of leg cramps and restless legs syndrome that commonly disrupt sleep.
One of the best forms for sleep support is magnesium glycinate as found in TruMagnesium™. Magnesium glycinate has a high absorption rate, is gentle on the stomach, promotes relaxation and GABA activity and is best for general insomnia and anxiety-related sleep issues. The best timing is 1–2 hours before bedtime, allowing serum levels to rise as melatonin secretion increases. Consistency is important for best results. Daily supplementation for 2–4 weeks is often needed for full restorative effects on sleep quality.
Probiotics:
Certain probiotic strains improve gut health and have been linked to reduced menopause symptoms including sleep disturbances and night sweats. These strains include bifidobacterium longum, lactobacillus plantarum, lactobacillus rhamnosus, and lactobacillus gasseri. Many of these strains are found in TruProbiotic™ Daily and TruProbiotic™ Complex.
B vitamins:
Indirect effects to improve sleep. B vitamins have broad neurochemicl and metabolic roles in pathways to synthesize the brain’s chemical messengers that regulate sleep. The physiological stress of loss of estradiol for women at menopause and testosterone for older men causes more rapid depletion of B vitamins and greater need for dietary intake and supplements. B vitamins don’t directly induce sleep, they help normalize neurotransmitter function, reduce catecholamine surges that cause hot flashes, mood swings, awakenings, and anxiety. As a physician, I regularly check the B vitamin levels of my patients to identify unrecognized deficiencies that cause insomina, memory loss, fatigue, brain fog and other symptoms. Specific B vitamins to check include:
- Vitamin B6: Supports serotonin synthesis, a neurotransmitter known for mood stabilization and promoting sleep. Low B6 is linked to mood swings and disrupted sleep, and adequate intake may reduce hot flashes and improve sleep quality.
- Vitamin B12: Important for nervous system health and cognitive function, B12 deficiency can worsen fatigue, memory loss, and “brain fog,” as well as indirectly contribute to poor sleep due to impaired synthesis of neurotransmitters. Most people eating meat, eggs and dairy get enough from their diet. Vegetarians and vegans, and people with MTHFR mutations are typically quite deficient and need the proper supplementation.
- Folate (B9): Has shown some modest benefit in reducing severity and frequency of hot flashes that often disrupt sleep in menopausal women or hypogonadal men. Taking a multivitamin with folate can translate into improved sleep patterns.
- B Complex Supplements: B vitamins work synergistically in the body. I feel taking a B-complex supplement is generally more beneficial than taking isolated B vitamins. It takes the guess work out proper dosing for optimal benefit. I also recommend supplementing with a methylated B complex, like our new TruB™ Full Spectrum, since up to 70% of the population is estimated to have at least one MTHFR (methylenetetrahydrofolate reductase) gene variant that causes reduced ability to absorb and convert standard forms of B vitamins—especially folate and B12—into their active, usable forms.Taking a balanced B-complex may help reduce anxiety and stress, common exacerbators of sleep problems when we are under stress and also as we age.
Lifestyle and Behavioral Interventions – A Few More Tips
Maintain consistent sleep and wake times, minimize blue light and caffeine after mid-afternoon, and ensure a cool, dark, quiet bedroom environment. See my Health Tip: Dr. Vliet’s Guide to Optial Sleep for more specifics.
Practice mind–body relaxation routines like gentle yoga, slow breathing, or progressive muscle relaxation to dampen sympathetic overactivity before bedtime.
Exercise early in the day to improve sleep architecture but avoid intense exercise in the evenings that raise alertness. A post-dinner walk outside with the setting sun is the ideal evening activity for promoting relaxation and signalling the brain that its time to start slowly down.
Cognitive Behavioral Therapy for Insomnia (CBT‑I) addresses maladaptive sleep behaviors and anxiety surrounding sleeplessness. Randomized trials show CBT‑I reduces awakenings, hot flash–related distress, and improves sleep efficiency more effectively than sleep medication for long-term maintenance. CBT-I is often combined with relaxation and mindfulness routines.
I do not recommend sleeping pills, antidepressants or melatonin as bandaids for sleep, due to many unwanted side effects, including aggravating weight gain, and disrupting normal sleep cycle architecture. In women, but not men, studies from 30 years ago found that melatonin supplements are correlated with depressed mood, daytime fatigue, weight gain, headaches and increased cortisol.
In summary, my recommendations for better sleep include:
- identifying with proper lab tests any key nutrient deficiencies and then supplementing to reach optimal levels, using both nutraceuticals and diet;
- incorporating lifestyle strategies and good sleep hygiene on a consistent basis to optimize sleep quality.
- optimizing estradiol balance particularly during peri-menopause, menopause and post-menopause through use of the FDA-approved bioidentical products we have had in the USA since 1975 (the many products, covered by most insurances, are discussed in detail in all my books and my medical practice website www.vivelifecenter.com, as well as our Faith Over Fear Seminars in the archive on www.TruthforHealth.org
To support you and your sleep please enjoy this week’s 10% discount on our Sleep Support supplements in the Truth For Health Foundation store:
COMING SOON: TruB™ Full Spectrum – a complete Methylated B Complex especially helpful for those with MTHFR mutations.
CAUTION: As always, we urge you to avoid supplements without checking knowledgeable sources to evaluate your medical situation, proper lab tests to verify what is needed, and to make sure to avoid adverse interactions with prescription medicines and other supplements you take.
All Truth for Health Foundation Products Meet or Exceed cGMP Quality Standards, the highest quality standard for supplements sold in the USA
.
For more information, references from studies are listed in the Product Data Sheets for each product, available on our website. Under medical practice regulations, we are unable to answer individual medical questions or make specific individual supplement recommendations for people who are not established patients of Dr. Vliet’s independent medical practice.
I encourage you to consider our other natural medicines with our top quality, cGMP-compliant professional formulas for TruImmune™Boost, TruNAC™, TruImmunoglobulin,™ TruC with BioFlav™ (Vitamin C with complete Bioflavonoids), Tru BioD3™, TruZinc™, TruMitochondrial ™Boost and TruProBiotic™ Daily to replenish critical bifidobacteria depleted by COVID shots, viral illnesses, and antibiotic therapy.
To Your good health and improving resilience!
Elizabeth Lee Vliet, MD |
