Sleep Loss In Perimenopause

Dr Kirstey Holland 0:02

Sleep and oral micronized progesterone. How restoring progesterone treats the sleep perimenopause can take from you. You go to bed exhausted and sleep does not repair you the way that it used to. You wake unrefreshed or you wake in the small hours and cannot get back to sleep. If that is your experience, I want to be direct with you. There is a physiological reason for it. And because there is a physiological reason, there is a physiological treatment. And that treatment for a great many women is progesterone. Progesterone is a neurosteroid, it promotes GABA activity in your brain, and GABA in the system that lets you settle GABA is the system that lets you settle and stay asleep. When progesterone converts to its metabolite allopregnenolone, that metabolite acts directly on the GABA A receptor and deepens sleep further. From around the age 35, you begin to have cycles in which you do not ovulate or do not ovulate as robustly, even when your period still looks regular on the calendar. Without ovulation, the corpus luteum does not form, and without the corpus luteum, you produce little to no progesterone. Your cycle can still look normal in length and frequency while you are physiologically progesterone deficient. The hormone that helps you sleep is the hormone that goes missing first. The progesterone I prescribe for this is bioidentical oral micronized progesterone, the same molecule your own body makes, not a synthetic progesterone. It can be taken nightly or cyclically in a rhythm that mirrors the second half of your natural cycle, depending on what your testing shows. Either way, the principle is the same. This is not a workaround for a symptom, it is treatment directed at the actual physiological cause. I want to give you the evidence as it actually stands, including its limits, so that you can make an informed decision rather than take my word for it. The research is genuinely encouraging, with one honest nuance in the main trial that I will walk you through plainly. By the end of this teaching, you will understand what oral micronized progesterone is, why it acts on sleep specifically, what the evidence does and does not show, and the difference between bioidentical progesterone and synthetic progestins, and the questions worth taking to a practitioner who tests before prescribing. Your sleep has changed, and I want to talk to you about why and about what can actually be done about it. Not in the general advice that you've already tried and has halved worked or have not the general advice you have already tried and half worked with, the physiology and the treatment that follows from it. The centre of this teaching is a hormone progesterone. Today I want to walk you through how restoring it becomes a treatment for the sleep that you have lost. I want to start with what you already know in your body. You go to bed exhausted and sleep does not repair you the way that it once did. You wake unrefreshed or you wake at night and cannot settle again. You've tried the earlier nights, the screens away, the calming teas, and some of it helps a little, and now none of it fully resolves the problem. If that is you, understand this clearly. You're not doing sleep wrong. There is a physiological reason your sleep has changed, and because there is a physiological reason, there is also a physiological treatment.

The Brain Chemistry Behind Progesterone

Dr Kirstey Holland 3:34

So the biology. Progesterone is a neurosteroid, which means it acts directly in your brain, not only in your reproductive system. It promotes GABA activity, and GABA is your brain's principal calming and inhibitory system, the one that lets you settle and stay asleep. Progesterone's metabolite, alloprenenolone, acts on the GABA-A receptor and deepens that effect even further. From around the age 35, anovulatory cycles, cycles in which you do not release an egg, become increasingly common, even while your period continues to look regular in length and timing. Without ovulation, the corpus luteum does not form, and the corpus luteum is what produces progesterone after ovulation. Without it, you make little to no progesterone, while estrogen can actually remain very high. This is why progesterone is physiologically more accurately described as a state of relative progesterone deficiency rather than estrogen deficiency. The hormone that supports your sleep is the one that declines first and it is treatable. From mechanism to treatment. Once you understand that falling progesterone is driving the change in your sleep, restoring it is not a workaround. It is treatment directed at the actual cause. The progesterone I use is bioidentical oral micronized progesterone, the same molecule your body makes. It can be taken nightly at bedtime, which supports sleep directly through the mechanism above, or cyclically taken during the second half of the month to recreate the natural progesterone rise that should follow ovulation. Cyclical dosing treats the underlying pattern of progesterone deficiency. Nightly dosing treats the sleep symptom directly. Which one is right for you depends on your testing and where you are in your transition and of course your symptoms. So speak to your provider about that. What the evidence says. In a 2023 Canadian randomized placebo control trial,

Why Progesterone Drops First

Dr Kirstey Holland 5:38

it gave 300 mg of oral micronized progesterone to 189 perimenopausal women with bothersome hot flushes and night sweats. Compared with placebo, the woman taking progesterone reported clinically meaningful reductions in night sweats and significant improvements in sleep quality. Here is the nuance. The trial's primary combined vasomoda symptom score, the single measure it was designed around, did not reach statistical significance. What did reach significance was how the women experienced their night sweats and their sleep. I'm not going to tell you that this settled beyond question, and I'm not going to overstate it. What I will tell you is that the evidence points consistently towards progesterone supporting sleep. Earlier trials found progesterone reduced hot flush intensity and frequency, including in post-menopausal women, not taking estrogen. And unlike estrogen, progesterone produces no withdrawal rebound when it is stopped, which suggests it is acting on the underlying physiology rather than simply masking a symptom. There is one distinction that I want to hold on to for safety, not only for sleep. Biodentical progesterone is not the same as a synthetic progesterone. In the E3N cohort study, estrogen combined with micronized progesterone was not associated with an increased breast cancer risk, while synthetic progestins were. A meta-analysis of 86,881 women found progesterone associated with a significantly lower breast cancer risk than synthetic progestins. Synthetic progesterins have also been linked to a higher clotting risk that bioidentical progesterone

Oral Micronised Progesterone Options

Dr Kirstey Holland 7:27

does not appear to carry. The beneficial effects on sleep belong specifically to the bioidential form of progesterone. So testing and practical steps. One of the first tests, or one of the first steps, is testing, not a prescription. But don't forget that perimenopause is a symptoms-based diagnosis, and it becomes very clear when you know what you're looking for that a woman is progesterone deficient. So we don't always need testing, but the right dose of the right hormone comes from knowing your own biochemistry. I do use when necessary the Dutch test in my clinic. A Dutch test shows your progesterone level and how your body is processing your hormones across the day. For example, the cortisol awakening response and the cortisol diurnal pattern. The second step is your own observation. The perimenopausal symptom tracker or vitality tracker, along with the lifestyle, food, mood, and pain diaries already inside the vitality clinic, are really helpful to understand where your symptoms present and why. So track your sleep, your night waking, and how rested you feel in the morning and bring that pattern with you to your practitioner. The third step is finding the right practitioner, one who tests if necessary before prescribing and who understands the difference between bioidentical progesterone and synthetic progestins and their different side effect profiles. If you're still bleeding, you're still in perimenopause, a relatively higher estrogen state, and progesterone is often exactly what is needed to bring it back into balance. Here is what I want you to keep from this week. Your sleep changed because a hormone that supported sleep declined, and that hormone can be restored. You are in control of the first move. You can test rather than guess if necessary, and understanding the difference between the hormone your body makes and the synthetic versions that are not the same is very, very important and allows for informed consent, which is extremely important. So, some questions that you can ask: whether progesterone is safe and how a bioidentical progesterone differs from the progesterens in the pill or in the hormonal IUD, whether you can take progesterone while you're still bleeding, and what still in perimenopause means for treatment, what testing is needed before a prescription and why a Dutch test is preferred over a single blood draw? What the 2023 trial actually showed and why its main vasomoto score not reaching significance does not mean progesterone does not help sleep, and the difference between nightly and cyclical dosing and how that choice is made. So some powerful reflection questions for you. When did you first notice that your sleep changed and what was happening in your life at the time? How would you describe your sleep now, in your own words, on a typical night? And when you wake in the night, how rested or unrested do you feel

What The Clinical Evidence Shows

Dr Kirstey Holland 10:30

the next morning? Have you ever been offered a treatment for your sleep or only advice to manage it? What have you already tried? And what helped a little and what did nothing? How would deep restorative sleep change your days? What do you now know about your own progesterone level right now? Have you ever had proper hormone testing or only a basic blood panel? What would you want to ask a practitioner who tests before prescribing? What has stopped you from seeking treatment for your sleep until now? If a treatment existed that worked with your own work with your own body chemistry, what would you want to understand before starting it? What is the one thing about your sleep you would most like to change? So, some practical implementation for you. Track your sleep if that helps you. Please don't do it if it creates more anxiety. Your night waking and how rested you feel each morning using the perimenopausal symptom tracker and the diaries inside the Vitality Clinic. Ask for proper hormone testing, ideally a Dutch test if needed, before accepting any prescription so that the dose fits your own biochemistry. Learn the difference between bioidentic progesterone and synthetic progestins so you can ask precise questions about what you're being offered. Treat your evening as part of the treatment. An earlier evening meal and a calmer wind-down give progesterone therapy the best foundation to work on. If you're still bleeding, understand that you are still in perimenopause, a relatively higher estrogen state, and that progesterone is often what is needed to bring it into balance. Write your questions down before any appointment so that you can speak clearly with a practitioner who understands perimenopause before prescribing. Most women I see have never had their progesterone properly assessed. They are told their bloods are normal when a single blood draw cannot show the pattern that a Dutch test reveals across the day. The most common confusion I encounter is between bioidentical progesterone and synthetic progestins. Women who had a poor experience with a progesterone often assume progesterone will behave the same way when the molecule and its effect on sleep is completely different. When I explain that the hormone helping them sleep is the one going missing first, women understand their own experience in a way that years of being told to manage stress never gave them. The 2023 trial is a useful teaching example of reading evidence carefully. The headline, Vasamoto's score, did not reach significance, yet the woman's own experience of sleep and night sweats improved significantly. That distinction is exactly what I want women to be able to hold in a consultation so that they can ask precise, informed questions. Testing before prescribing is not a delay, and sometimes it is necessary, often it is not.

Safety: Bioidentical Versus Synthetic

Dr Kirstey Holland 13:46

Cheers.