Insomnia: reset your inner clock and get back to sleep

by Marcelle Pick, OB/GYN NP

Getting a good night’s sleep is something we all take for granted — until we don’t have one. Nothing can cause your mood and well-being to unravel faster than trouble falling asleep or getting back to sleep — and for women with insomnia this frustration can last for weeks or months. Sleeplessness is one of the most common complaints I hear from my patients at the clinic, and one of the most serious. It affects a myriad of biological activities, including metabolism, immunity, cognitive function, weight gain, and adrenal, neurotransmitter, and hormonal balance.

One of the single most beneficial things you can do for your health is to get adequate rest. So why is this so hard to do, especially as women enter menopause? The National Sleep Foundation cites that seven out of ten people report sleep problems. As many as 63% of women in their perimenopausal and post-menopausal years encounter some form of insomnia, and it’s common in post partum women as well. Despite various possible organic causes, many conventional practitioners turn first to sleep medications, like Ambien. At Women to Women, we see sleep as a fundamental part of a woman’s biological rhythms — a process that will naturally reset itself once underlying physical and psychological issues are addressed.

Sleeplessness, like most health issues, stems from within, and it means your body is trying to tell you something. So let’s learn how to listen to ourselves and support a good night’s sleep — naturally and permanently — at any age.

Sleep and the circadian rhythm

Our sleep patterns are ruled by our circadian rhythm. This rhythm, present in most living beings, operates around an approximately 24-hour cycle that is tightly linked to the rising and setting of the sun. The phrase “circadian” has Latin roots and means “about a day.” While there may be small differences between societies, individuals and the seasons, the majority of humans, if deprived of artificial stimulants and sleep aids, would likely go to bed a couple hours after dusk and awake at dawn. Before Thomas Edison discovered the light bulb, it’s estimated that the average person slept ten hours a night. Now we’re lucky to fit in six to seven.

So how does the body know when to sleep? Deep in your brain lies a tiny but powerful cluster of nerve cells called the suprachiasmatic nucleus (SCN) that works 24/7 as your internal clock. It is not just a sleep clock, but governs many biological activities such as cell regeneration, detoxification, patterns of brain activity, and production of important hormones that regulate the sleep/wake cycle.

Exposure to light — natural or artificial — stimulates the back of our eyes to send a message to the SCN, which then raises the body’s temperature and prompts the release of stimulating hormones like cortisol. Cortisol is released by the adrenal glands in response to stress; it’s one of our “get up and move” hormones that turns proteins into energy. During stages of light, the SCN is also responsible for inhibiting the hormone that makes us sleepy: melatonin. On the other hand, when it gets dark, the SCN begins to lower body temperature and stimulates the release of melatonin.

Because these pathways are so sensitive to light and darkness, it is easy to throw them off. Think about being in a dark room in the middle of the day — you may grow drowsy even if you aren’t tired. Or, more commonly, the lights we burn at night to work, watch television and read in keep us feeling more awake than perhaps our circadian rhythm would like. Just switching on the lights can shift the circadian cycle by more than 40 minutes!

The sensitivity of our natural rhythm

Your circadian rhythm can also be reset by changing your habits. If you work the night shift, travel, or have a newborn, for instance, your inner clock will recalibrate itself to meet your demands. This may not always be the healthiest thing for you (as anyone with jet lag knows), but it enables you to function in the short term. Severe circadian rhythm disturbances can lead to brain and organ damage, even psychosis.

For the majority of sleepless women, though, subtle physiological imbalances can throw off their inner clocks. These imbalances can range from hormonal fluctuations and diet to daily habits and stress. Today’s go-go, technology-saturated culture entices us to overrule our bodies’ organic sleep signals. We ignore the natural energy shift that occurs after dinner so we can watch a favorite TV show or call a friend. We sleep with an illuminated clock radio by our beds or fall asleep with the radio on — all of which can lead to sleepless nights or poor quality sleep.

What you’re missing while you’re sleepless

Without sleep your body pays a price. Your brain does its best work for your body during the deepest sleep phases, called delta sleep (stages III and IV). Delta sleep is the hardest stage to wake from. After age 50, a person tends to spend less time in deep sleep and more time in the lighter phases of sleep known as stages I and II. In light sleep, a person will wake up more easily and more frequently, making a night of sleep less restful.

Sleep is a time when your body detoxifies and tissues get repaired. Muscle is built during the period of rest after activity. Think of it this way: when you sleep, your immune system is freed up to deal with any nagging issues, unfinished work and toxins. Sleep is a time of biological processing. Without it we simply can’t meet the demands of our waking lives, let alone keep our hormones balanced.

Lack of sleep, weight gain, and endocrine function

Along with missing basic biological processes, lack of sleep affects metabolism as well. New studies suggest a link between lack of sleep, obesity and type 2 diabetes. Sleep apnea has long been considered a condition related to weight and diabetes. Now, scientists are turning the table and finding that long-term sleep loss disrupts the body’s endocrine system by triggering increased insulin resistance and tweaking the neuroendocrine regulation of appetite. Lack of sleep leads to a rise in ghrelin (the hungry hormone) and a restriction in leptin (the hormone responsible for satiety). In one study, subjects of average body mass index got 1.9 hours more sleep per week than their obese counterparts, which indicates that even moderate increases in sleep can help maintain a well-balanced endocrine system.

What’s more, sleeplessness can be the result of a body on cortisol overload. Chronic stress, poor diet, excess caffeine, and insulin sensitivity bring up levels of cortisol. Ironically, high levels of cortisol also occur in women with severe adrenal fatigue, where the adrenals pump out cortisol in a desperate attempt to keep up with the demands of an unrelenting lifestyle. High cortisol not only keeps us awake, but leads to a decrease in the production of DHEA. A precursor hormone to estrogen, progesterone, and testosterone, DHEA is also necessary to moderate the balance of hormones in your body. Insufficient DHEA contributes to fatigue, bone loss, loss of muscle mass, depression, aching joints, decreased sex drive, and impaired immune function.

So don’t ignore the importance of sleep. Like nutrition and the ability to detoxify, sleep is one of the essential building blocks of health. It’s important to catch sleep disruptions early, before your body becomes habituated to a new — and unhealthy — pattern that will be harder to break.

The roots of insomnia

Anyone can have a sleepless night or two, but when it happens night after night for more than a few weeks it is characterized as chronic insomnia. Chronic insomnia can be broken down into two types: primary and secondary insomnia. Primary insomnia is diagnosed when there are no contributing physical or psychological conditions at the root. This form of insomnia is likely to be brought on by poor sleep habits, or what we call poor “sleep hygiene.” Problems such as low-level anxiety and stress, poor sleeping environment, alcohol consumption, or the use of stimulants such as caffeine and nicotine can sit at the core of primary insomnia, laying siege to our inner clock and robbing us of sleep.

Secondary insomnia, on the other hand, is sleep deprivation occurring in conjunction with a medical or psychological illness that aggravates a person’s sleeping patterns; or sleeplessness brought on by external factors such as medication, environmental catalysts, or physical issues. Some physical conditions contributing to sleeplessness include arthritis or chronic pain, diabetes, hot flashes and hormonal fluctuations, fibromyalgia, gastrointestinal disorders, respiratory problems, restless leg syndrome, mineral deficiencies, sleep apnea, urinary incontinence and perimenopause. Generally the treatment for secondary insomnia involves a two-pronged approach: one that focuses on the primary health concern, while also treating the ensuing insomnia.

Menopause and insomnia

Secondary insomnia can be one of the first signs of menopause. Many women never have trouble sleeping until they hit perimenopause and they find themselves waking up frequently through the night or unable to fall asleep altogether. Much of this has to do with temperature regulation and the fact that as we age we spend less time in deep sleep, making us more sensitive to disturbances — inner and outer. Because our circadian rhythms are so intimately tied to temperature, even a minor increase in body temperature can cause us to wake from sleep. And, as many of us know, temperature changes and hot flashes can become quite frequent during perimenopause and menopause.

Shifting hormones may also contribute to sleep disturbances during menopause. Some theories propose that the changing tides of estrogen in perimenopause influence how much melatonin we produce and how we respond to it. Melatonin is found to decrease blood pressure and norepinephrine levels in women whose circulating estrogen levels are higher. This tells us that melatonin is clearly affected by estrogen levels, and this relationship may be what’s causing you to lie awake at night, even after an exhausting day.

Menopause, and in some women, perimenopause, is often the time of life when vulnerabilities in our physical and mental health are revealed. The veil of estrogen is lifted and we gain an opportunity to know ourselves more truthfully. When it comes to sleep, pre-bedtime habits that worked fine for us in the past may no longer serve us. Maybe watching television before bed never bothered you before but now it does. Maybe working on your computer before bed leaves you “wired” these days. Maybe the “occasional” wine with dinner has become a little too customary. Maybe it just takes longer to settle your body and quiet your mind than it used to.

We all change over time. Those who are willing to listen and change their lifestyles with their changing bodies will continue to enjoy good health. If you are losing sleep, consider it a sign that its time to listen more closely to your body. Discover new ways to soothe it, and embrace these new changes.

Covering up the problem

The use of sleeping pills in America has more than doubled since 2000, and the side effects are still being uncovered. People using the popular pill Ambien have been reportedly sleep-walking and even bingeing on food during the night with no recollection the next morning. Some research shows that sleeping-pill users experience higher rates of mortality than people who use alternative treatments for insomnia.

The truth is, artificial sleep aids such as Ambien and Tylenol PM are like most medications — meant to treat temporary, not chronic conditions. But most pharmacologic sleep aids, also called hypnotics, are by their very nature habit-forming, and many can actually lead to chronic insomnia by undermining your body’s natural sleep mechanisms.

In fact, recent evidence shows that behavioral approaches to insomnia, like cognitive behavioral therapy and relaxation techniques, are much more effective at treating long-term insomnia than medication. Short-term medication use may be necessary for sleep in extreme circumstances — we all need to function at work and in our lives — but sleeping pills will not resolve your insomnia. It’s like turning up the radio so you won’t hear the fire alarm.

If you can’t sleep, you have to take the time to learn why. Sleep is a natural, essential process — like eating. Your body wants to sleep! And it will do so once you learn to give it what it needs.

Getting the measure of your insomnia

The roots of insomnia are individual and often run deep, but your daylight activities can frequently affect your ability to sleep at night. I encourage you to work with a healthcare practitioner to look at your whole health picture, not just the element of sleep. It may also be helpful for you to track your sleep habits with a sleep log for a week or two. We call these habits “sleep hygiene” — and the more you pay attention to it, the better you will sleep.

Common factors you may want to investigate include:

• Specific foods consumed and times of day in which you eat
• Caffeine, nicotine or other stimulants
• Alcohol consumption
• Medications, both prescription and over-the-counter
• Vitamins, minerals, and food supplements
• Level of stress and anxiety
• Exercise routines
• Menstrual cycle patterns
• Stimulating bedtime behavior
• Time to bed
• Bed partner’s behaviors
• Room environment (temperature, light, noise, bedding)

Look to these factors first when you can’t sleep. Nowadays it might seem easier to turn to the medicine chest, but while a pharmacologic sleep aid can be a reasonable last resort, it should never be your first-line choice for treating insomnia.

Getting back to sleep — the Women to Women approach

At Women to Women, we recognize that trouble sleeping means your body is trying to send you a message. Insomnia can make us desperate to grab at any solution available — whether it’s sleeping pills or alcohol or something else. But take a minute to listen; the answer lies within you.

• Foster your natural rhythms. Remember that our circadian rhythms are ruled by the rising and setting of the sun. Though it may be impossible to retire at sunset, you can dim your lights and calm yourself in the hour or two before bed. Give your body a chance to taper cortisol and release the melatonin needed to set the sleep cycle in motion.

  To help this process, set a bedtime and try to stick with it. If you are under extreme stress or struggling with overworked adrenals, you may need help in clearing cortisol from your system naturally. At our practice we use a supplement called SeriPhos (phosphorylated serine), or phosphatidyl choline, with great success.

• Take inventory of your habits. Coffee, cigarettes, and electronics can stimulate the brain and prevent it from recognizing when it’s time to sleep. More than three cups of coffee per day or any caffeine after lunchtime can affect your sleep patterns. If you’re a smoker, you’re significantly more likely to develop chronic insomnia. And while a glass of wine or a nightcap before bed may send you off to sleep more quickly, that same alcohol is likely to interrupt your sleep cycle later on in the night.
• Try nature’s sleep aids. There are many natural sleep aids that promote rest, such as calming herbal teas that can be enjoyed an hour or so before bedtime. You might try passionfruit, chamomile, and valerian root, to name a few.

  A glass of warm milk before bed may also be more helpful than you thought. While it isn’t a miracle cure for insomnia, milk and cheese are good sources of tryptophan, an essential amino acid also found in beans and poultry. Tryptophan is a precursor to melatonin, which may be why it causes drowsiness.

• Prepare a restful sleep environment. Make sure your bedroom is comfortable, uncluttered, and soothing. Investigate any irritating odors, noises or light sources. Buy block-out shades (or a sleep mask) and use them. Invest in bedclothes made of 100% natural fibers, like linen, cotton and wool, which allow your body to better regulate temperature during sleep. If your mattress is giving you a backache, consider replacing it. Your bedroom should be a refuge, not a buzzing activity center.
• Watch what and when you eat. These are simple-to-follow guidelines that can make a big difference in your sleep. To prevent bedtime bloating and discomfort or waking at 2:00 AM with indigestion, finish your last meal of the day at least four hours before going to bed. Avoid overeating, keep bedtime snacks small, limit sugar, and stay away from spicy foods that may cause heartburn. Take your vitamins and drink plenty of water early in the day, when you need them most, and minimize liquids before bed to prevent nocturnal trips to the bathroom.
• Boost your body’s nutrition. Your body is fueled by food, so whenever your energy is negatively impacted, nutrition is a likely culprit. A healthy, well-balanced diet is as critical to good health as is a good night’s sleep, and these two aspects of your daily life are linked. Certain forms of insomnia may stem from a magnesium, calcium, or iron deficiency. A small study showed that people suffering from insomnia due to restless legs syndrome and periodic limb movements during sleep benefited from a magnesium supplement.

  To ensure your body gets what it needs, eat generous servings of vegetables and fruits to keep your immune system healthy, and take a daily multivitamin/mineral supplement like the one we offer in our Personal Program.

• Balance your hormones. Using a bioidentical progesterone cream can help keep your estrogen levels more stable, which may boost the effects of melatonin. During menopause, bioidentical HRT can be a good bridge for some women when hormonal fluctuations are getting in the way of sleep. Once sleep returns, hormones can be tapered off. At the clinic, we occasionally give patients a combination of melatonin and 5–HTP (to offset anxiety). This doesn’t work for everyone, however, and should be administered under the watchful eye of your healthcare practitioner.
• Get fit and keep your date with the Sandman. Daily exercise is a great way to tire your body out and ease your passage into rest. Take care not to engage in high-intensity exercise near bedtime, though, or your body’s temporary stimulation from adrenaline and endorphins may keep you awake.
• Try a catnap — but no longer. Some women cite the relentless daytime fatigue associated with insomnia as their biggest problem. A nap after lunch is a common practice in many other cultures, and by mid afternoon you may be ready to drop your head and catch 40 winks alongside them. A 10–20-minute nap may be a healthier antidote than a caffeine pick-me-up, but don’t make it a snoozefest — your body’s inner clock can become confused by prolonged daytime dozing.
• Write it down. Don’t let your overwhelming schedule or an impending obligation keep you up at night. Anxiety is one of the most prevalent causes of insomnia. Many women’s minds run at full-tilt all day, then fill with unmet expectations of work and home as soon as they close their eyes. Keep a notebook with you during the day and jot down the tasks you need to get accomplished. If you’ve already logged and prioritized your responsibilities, you’ll feel calmer and more organized when it’s time for sleep.
• Don’t fight yourself. If you fall asleep well enough but wake earlier in the morning than you’d like, your body may be trying to tell you something. Maybe it’s time to complete the project you’ve been dreaming of but haven’t made time for. Maybe you need to watch the sun rise or the moon set. Some people feel their most creative hours are those of the wee hours when no one else is awake. If you regularly awaken with your mind ablaze, keep a sleep log or a stream-of-consciousness journal. Give way to your body’s instincts for a few days and see what happens.
• If the above efforts fall short, consider alternative behavioral modifications. There are many non-pharmacological treatments for insomnia and related sleep disorders that have shown very positive results. These are safer, more effective solutions than sleep medications, and they are not unduly time-consuming or costly. Some elements are easy to implement on their own, such as light therapy and guided imagery, while others, such as EFT or cognitive behavioral therapy, are more involved and require some guidance. Most recondition the brain to sleep better through introducing new behaviors and new ways of thinking about sleep. Click here for an overview of several behavioral modification techniques for insomnia.

Time for a rest

Don’t let your wakeful nights continue indefinitely and send you into a tailspin of fatigue and worsening health. Insomnia is a highly treatable condition, whether primary or secondary. But this is really about you and the relationship between your body and your mind. Your own approach to a restful night’s sleep is best determined by you. Accept the reality that we live in a culture that never wants us to turn off. Unplugging yourself may take a concerted effort on your part.

We all have our own unique bodies and lives — and hormonal fluctuations can make us feel like strangers in our own skin. But, whatever your age, consider your sleeplessness to be a sign that your body is trying to talk to you. Take a few nights to filter out the distractions and listen to what it needs. It may be something small; it may be more. With some effort and gentle guidance, it will be no time at all before you’re back to sleep.