Period-Induced Insomnia: Why Can't I Sleep?

Many people who menstruate experience sleep issues before their period. This phenomenon is known as period insomnia and is often caused by hormonal changes, such as a decrease in melatonin production, that occur during the menstrual cycle. Research suggests that insomnia is more common when a person has premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD). Symptoms of period insomnia include difficulty falling asleep, frequent waking during the night, and low sleep quality. Treatment options for period insomnia include medication, natural remedies, and therapy.

Hormonal changes

The two main hormones that control the menstrual cycle are estrogen and progesterone, which shift up and down throughout a woman's life, affecting sleep. In the week before a person's period, progesterone levels rise to prepare the body for a potential pregnancy. If there is no pregnancy, progesterone levels decrease sharply, causing the uterine lining to shed and starting the menstrual cycle. This dramatic dip in progesterone levels right before the period is one reason why some women struggle to get quality sleep during their premenstrual days.

During the luteal phase of the menstrual cycle, which lasts about 14 days, the body releases the hormones progesterone and estrogen as it gets ready for pregnancy. Research suggests that fluctuations in these hormones during the luteal phase can affect stage two and REM sleep. Additionally, people with premenstrual syndrome (PMS) may experience a decrease in melatonin production during this phase, impacting their sleep quality.

The menstrual cycle can also influence body temperature, which is linked to sleep. Throughout the cycle, core body temperature is higher after ovulation and remains elevated until the start of the period. As body temperature naturally lowers near bedtime, enabling the transition to deeper sleep stages, the higher temperature before and during menstruation may make falling and staying asleep more challenging.

Furthermore, polycystic ovary syndrome (PCOS) can worsen sleep disturbances. Women with PCOS often have irregular periods, higher testosterone levels, and lower progesterone levels. They are also at a greater risk of developing sleep apnea, a condition where breathing briefly stops numerous times during sleep, further disrupting sleep quality.

Progesterone levels

Progesterone is a hormone that plays a significant role in the reproductive system of women and people assigned female at birth (AFAB). It helps to regulate menstruation and maintain the early stages of pregnancy. During the menstrual cycle, progesterone levels rise after ovulation and continue to do so if pregnancy occurs. If pregnancy does not occur, progesterone levels decrease, causing the uterine lining to shed and initiating the menstrual cycle.

In the week before menstruation, progesterone levels rise to prepare the body for potential pregnancy. If pregnancy does not occur, there is a dramatic dip in progesterone levels immediately before bleeding begins. This drop in progesterone levels can make it difficult to get quality sleep in the days leading up to the period. This is often referred to as "period insomnia".

Progesterone is known as the "relaxing hormone" and has a mildly sedative effect. Higher levels of progesterone are associated with sleepiness. Thus, the decrease in progesterone levels before menstruation can disrupt sleep patterns and contribute to insomnia. This effect is more pronounced in individuals with premenstrual dysphoric disorder (PMDD), who experience more severe PMS symptoms, including anxiety and depression. As many as 70% of women with PMDD have insomnia symptoms before their period.

Additionally, during the premenstrual phase, individuals with PMDD produce less melatonin, a hormone that promotes sleep. Their bodies also have a blunted response to melatonin, further contributing to sleep difficulties. The combination of decreasing progesterone levels and reduced melatonin production can disrupt sleep architecture, resulting in more light sleep and less rapid eye movement (REM) sleep.

For individuals struggling with sleep before their period, lifestyle changes and healthy sleep habits can help improve sleep quality. This includes exercising, getting exposure to natural light, maintaining a consistent sleep schedule, optimising the sleep environment, and avoiding caffeine and alcohol close to bedtime.

Body temperature changes

The thermogenic effect of progesterone was first observed in the 1940s and has since been confirmed by numerous studies. The body temperature rise is typically between 0.3°C to 0.7°C and is most evident during sleep or immediately upon waking. This change in body temperature can be used as a retrospective indicator of an ovulatory cycle.

The exact mechanisms behind the thermogenic effect of progesterone are still being studied. One theory suggests that it is caused by a direct effect on the preoptic area of the hypothalamus, which regulates body temperature. Progesterone may inhibit heat loss mechanisms and increase heat production. Another theory posits that progesterone acts indirectly by modulating the hypothermic effect of melatonin, a hormone that aids sleep.

While the link between body temperature and sleep is well-established, the specific impact of body temperature changes during the menstrual cycle on sleep is still not fully understood. More research is needed to determine the underlying mechanisms and microcircuitry involved in these temperature changes and their effects on sleep.

Polycystic ovary syndrome (PCOS)

PCOS can lead to a range of symptoms, including:

• Irregular periods or no periods at all
• Difficulty getting pregnant due to irregular or absent ovulation
• Excessive hair growth, particularly on the face, chest, back, or buttocks
• Thinning hair and hair loss from the head
• Acne, especially on the back, chest, and face
• Obesity, with difficulty maintaining a healthy weight
• Darkening of the skin, particularly in the neck, armpits, groin, and under the breasts
• Skin tags, or small flaps of extra skin, in the armpits or on the neck
• Infertility, as PCOS is a common cause of female infertility

PCOS can also increase the risk of developing other health problems, such as type 2 diabetes, high blood pressure, cardiovascular disease, endometrial cancer, sleep disorders such as sleep apnea, and mental health issues like depression and anxiety.

The exact cause of PCOS is unknown, but it is believed that genetics and obesity play a role. Treatment options include medication, hormonal birth control, insulin-sensitizing medication, lifestyle changes, and surgery. While there is no cure for PCOS, managing symptoms is important to reduce the risk of associated health complications.

Premenstrual dysphoric disorder (PMDD)

The exact cause of PMDD is unknown, but it is believed to be related to an abnormal reaction to normal hormone changes during the menstrual cycle, specifically a decrease in serotonin levels. Serotonin is a brain chemical that affects mood and can cause physical symptoms. People with a family history of PMS, PMDD, or depression may be at an increased risk of developing PMDD.

Symptoms of PMDD include changes in sleep patterns, such as excessive sleeping or difficulty sleeping (insomnia). As many as 70% of women with PMDD experience insomnia symptoms before their period. In addition to sleep disturbances, physical symptoms such as breast swelling, tenderness, headaches, joint or muscle aches, weight gain, and bloating may occur.

PMDD can be treated with lifestyle changes and medications. Lifestyle changes include increasing protein and carbohydrate intake while decreasing sugar, salt, caffeine, and alcohol consumption. Stress management techniques such as relaxation and meditation can also help. Vitamin supplements like vitamin B-6, calcium, and magnesium, as well as anti-inflammatory medications, may be recommended. Selective serotonin reuptake inhibitors (SSRIs) are a type of antidepressant that can help regulate serotonin levels in the brain and are often prescribed to treat PMDD.

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