Estrogen

Estrogen and progesterone are female hormones that participate in the health of our bones, immune system, cognitive power (such as memory), sexuality and very importantly, a good night sleep. The cycles of hormonal surge and dip throughout a woman’s reproductive life mirrors not only insomnia but also an increase in stress level.

So why do women go through so many sleep problems with hormonal fluctuations? After puberty, girls go through cycling of estrogens and progesterone release. An Australian team wrote an article in the Journal of Child Health Care in 2009 with a title “Mad, sad and hormonal: the gendered nature of adolescent sleep disturbance.”  They reported that up to 40% of adolescents experience sleep difficulties, but girls are especially more prone than boys. Although hormonal fluctuations play a role, but this article makes an important point that sleep problems in young women are also linked to puberty-related fatigue, sexual abuse, a higher prevalence of mental illness and domestic expectation placed on girls.

Sleep and menstruation: Right before a woman menstruates, her estrogen and progesterone drop. This drop has an effect on the brain and sleep. For example estrogen, which has a positive effect on sleep, enhances the brain neurotransmitter, GABA. This GABA is the most common brain neurotransmitter and it has a calming effect on the brain. Sleeping pills and anti-anxiety pills work party by increasing GABA. Another brain neurotransmitter serotonin regulates the sleep/wake cycle. Estrogen increases brain serotonin.  So when estrogen drops at specific times of  the month, both GABA and serotonin will be affected, a process that contributes to a suboptimal sleep quality.

Menopause is not the best time for a good night sleep either. Although hormonal fluctuations are diminished by menopause, other sleep problems emerge. The increased risk for insomnia during menopause is believed to be due to a number of factors that include an increased risk of depression, hormonal changes and hot flashes. Decreased estrogen promotes insomnia by either directly affecting sleep (perhaps low serotonin and GABA) or by causing depression- estrogen has an antidepressant effect.

The decline in progesterone is believed to be one of the reasons for the increased prevalence of sleep apnea in postmenopausal women. Progesterone normally has a protective effect on the upper airway or throat muscles, making sure your throat tone is working well and not collapsing so you can breathe well when you sleep. However, when that muscle tone declines with menopause, the risk of sleep apnea increases. Symptoms of sleep apnea include snoring, disrupted sleep, pauses in breathing during sleep, daytime sleepiness or fatigue and morning headaches. Progesterone has an additional benefit on sleep- it has a hypnotic effect, meaning makes you sleepy. So when it drops, it may cause insomnia.

Hot flashes and sleep. Hormonal fluctuations affect body temperature. Temperature drop is associated with falling asleep. Temperature rise helps us with waking up in the morning. We are able to sleep at night when our body temperature drops. However, when the body temperature remains elevated (hot flashes) due to hormonal changes, it is difficult to fall asleep or stay asleep. Progesterone increases the body temperature, yet it has a sedative effect. Estrogen, on the other hand lowers the body temperature. The hormonal effects on sleep are a bid confusing.

Are hormonal supplements good for hormonally-related sleep symptoms or disorders?

  •  According to a study from Belgium published in the April issue of the Journal of Clinical Endocrinology and Metabolism in 2011, progesterone had no effect on undisturbed sleep but was able to restore normal sleep when sleep was disturbed so it acts as a physiological regulator rather than a sleeping pill. Its use in the clinical setting for individuals needs more research.
  •  A 2008 study which was published in the December issue of the International Journal of Gynaecology Obstetrics evaluated the sleep pattern of 33 menopausal women through sleep studies. They were given estrogen alone, progesterone alone, combination of both or placebo (no hormone replacement).  It turns out that the combination therapy (estrogen plus progesterone) was more effective than estrogen alone in decreasing hot flashes, teeth grinding, leg movements during sleep and sleepiness or attention difficulties during the day. Progesterone alone or with estrogen reduced arousals from sleep, anxiety and breathing irregularities.
  • It is important to note that the 2002 Women’s Health Initiative study found an increased risk for breast cancer, stroke, dementia and heart disease in women taking estrogen replacement. This raises the question about the wisdom of hormonal replacement for sleep symptoms such as hot flashes, insomnia and sleep apnea in the menopausal population. More research is needed for the role of hormone replacement in sleep problems.
  •  A 2010 study from the CPMC Research Institute, San Francisco, CA which was published in the May 4 issue of BMC Women’s Health had this conclusion: “Postmenopausal women currently using HT [Hormone Therapy] had improved sleep quality for two out of five objective measures: shorter WASO [wake after sleep onset] and fewer long-wake episodes. The mechanism behind these associations is not clear. For postmenopausal women, starting HT use should be considered carefully in balance with other risks since the vascular side-effects of hormone replacement may exceed its beneficial effects on sleep.”

Tips on management of sleep problems in women

  • At any age, whether puberty, middle age or menopause- it is important to take sleep problems seriously. If you suffer from insomnia, try to find out why: is it stress, depression or poor sleep habits? Or could there be a primary sleep disorder such as sleep apnea or restless legs. Don’t assume the problem is all hormonal and there is no help. Talk to your doctor and consider seeing a sleep specialist.
  • Hormone replacement therapy must be individualized and taken with the appropriate indication and with the understanding of the risks/benefits. Discussion with the doctor is important.
  • If your teenager is suffering from insomnia or other sleep problems, pay attention of possible causes. Is there stress, depression, problems at school? Are they having poor sleep habits: texting or video games in the wee hours of the night?  Teens undergo a physiological change in their circadian sleep regulation (body clock). That is their brain wants them to go to bed later and wake up later. See section on Delayed Sleep Phase and if you suspect it, discuss it with a sleep specialist who is qualified to apply such treatment as light therapy. The use of hormonal therapy for sleep problems in puberty is not indicated.
  • Avoid the use of sleeping pills as your first option to treat insomnia. Sleeping pills have their indications and have helped many people. There are many FDA approved and safe sleeping pills.  But it is important that you step back a little and make sure you have evaluated your sleep problems thoroughly: Work on you sleep habits, look and address medical problems that cause insomnia (sleep apnea, restless legs, side effect of medications) and improve your daytime habits that are conducive to sleep (exercise, less stressful life habits).  If you need a sleeping pill, that is fine. Try to use it on a needed basis.