I jerked awake to the sound of blood pounding like a drum between my ears. I felt part of my face go numb as I struggled to breathe, the prickles spreading from my chin to my cheeks. My bedroom was dark except for the dim red light leaking from the digital alarm clock on the bookshelf. It claimed it was 2:30 a.m. A dull wave of despair hit my chest. If that was true, I’d only been asleep for two hours. And surely after such a terrifying awakening I wouldn’t be getting any more rest that night.
I know now that this awful experience was the result of waking up in the middle of a panic attack, my first and hopefully last such misfortune. But at the time, I thought I’d simply found a new low in my weeks-long battle with insomnia ... a battle I was definitely losing, one night at a time. It was several years before I learned that my sleeplessness was likely tied to changes in my fertility hormones, as my 20-something body shifted into a mysterious early menopause.
The truth that a woman’s sleep is affected by her reproductive cycle was never a topic in my high school health classes. Nor did anyone mention that girls are at a higher risk of insomnia than guys, with one out of four women suffering at this very moment. Still less did we learn that medicines, even natural options like melatonin or Valerian, aren’t the right first-line treatment for people who aren’t getting enough rest. These facts are critical information for any woman who sleeps, or who longs to one day sleep again.
Why can’t she sleep?
It’s actually in adolescence, around the same time when boys and girls are being herded through those health classes, that sleep differences emerge. Up until then, children of both sexes get about the same amount of rest.
Puberty, and the onset of menstruation, is what changes the sleep game for a young woman. Estrogen, the quintessential female hormone that builds a lining in her uterus, also happens to play a role in helping her fall asleep. Progesterone, the ying to estrogen’s yang, works to keep her uterus a healthy environment should it be occupied by a tiny guest. It also has a sedating effect. Without enough progesterone, women are susceptible to mood issues and anxiety.
Both of these hormones are present at low levels on the first day of a woman’s cycle, when her period begins. As the weeks pass and her body prepares for ovulation, her estrogen and progesterone levels soar, making it easier to fall asleep.
If the ovulation doesn’t result in a pregnancy, a young woman’s hormones then plummet, triggering menstruation and starting the cycle over again. If she does conceive, a new hormone joins the party: Human chorionic gonadotropin, or hCG. It’s generated by the baby’s placenta, and peak levels are associated with morning sickness (or more accurately, “all day and all night” sickness). When the baby is born, mom’s body once again enters a hurricane of hormonal changes.
These cycles normally last for decades, until peri-menopause, a time when hormones once again lurch around unpredictably. It’s hard to sleep on a roller coaster, even if it’s your own body running the ride.
The odd thing is, in the midst of all the chaos, women are actually capable of getting better quality sleep than men. Studies have shown that females get more deep, stage-three sleep, even as babies, and our circadian rhythms are less susceptible to age-related disruption. But millions of women may be sabotaging this evolutionary advantage with their choice of contraception: researchers have found that hormonal birth control, with its artificial smoothing of the fertility cycle, correlates with a reduction in the amount of slow wave, stage-three sleep women enjoy.
“It is amazing to me how many women suffer in silence regarding their sleep issues, feeling as if it is a necessary evil of being a woman and juggling various roles along with hormonal changes across the lifespan,” Dr. Shelby Harris told me. She is a clinical psychologist who specializes in behavioral sleep medicine and is the author of The Women’s Guide to Overcoming Insomnia: Get a Good Night’s Sleep Without Relying on Medication, one of the only books to focus on the unique challenges women face when trying to get some rest.
Dr. Harris points out that there is more at play than just the constant changes in our bodies. Women cope with higher rates of depression and anxiety, both of which are associated with sleep problems. We still do the bulk of the housework and childcare, even as we hold down jobs meaning our brains are constantly multi-tasking. And many of us live in a culture that regards sleeplessness as a sign of genius, selflessness, or passion for our work.
“Whenever I hear someone say to me ‘I’ll sleep when I’m dead,’ I get so frustrated,” she said. “We are getting better at prioritizing diet and exercise when possible, and don’t glorify our poor diets and lack of exercise—so why do we glorify lack of sleep? It needs to be considered a pillar of wellness just as we treat diet and exercise, and I might argue it is the backbone that’s the most important of them all.”
Searching for solutions
I agreed with that perspective when I made an appointment with my primary care physician for help with insomnia. I’d been to visit him recently for odd symptoms—numbness and painful electrical shocks in my hands (diagnosis: carpal tunnel syndrome, treatment: wrist braces). He was an incredibly compassionate doctor who had been treating me since childhood, sometimes for free when I didn’t have insurance, writing “N/C” on a little slip of paper for me to hand to the ladies at the billing desk. This happened a few times before it dawned on me that it stood for No Charge, simultaneously solving the mystery of why the ladies were always so unhappy when they saw me coming.
On this visit, however, he had few answers for me, although he was concerned when I told him I was going for days at a time without any shut-eye. I couldn’t stop my brain from flipping through my to-do list like a stack of cards; songs didn’t just get stuck in my head as I lay awake on my pillow—they somehow seemed to play at full volume, with my brain shouting the lyrics. Making sympathetic noises, he printed out a fact sheet on “sleep hygiene” for me.
Sleep hygiene is an unfortunate phrase that suggests to the insomniac that they are not just desperately exhausted, but also grimy, in the manner of an under-showered teenage hockey player. A better term would perhaps be “good sleep habits.” Certain practices, like avoiding caffeine late in the day, turning off screens to wind down for bed, or keeping the bedroom dark and cool like a cave, can help with sleep. The opposite behaviors—drinking coffee with dinner, playing on the phone in bed, or piling on warm blankets, can lead to delayed or broken rest.
The problem is that these are all common-sense suggestions. As someone who couldn’t sleep, I’d already known to try such simple lifestyle changes prior to calling my doctor. It wasn’t long before I found myself back in the doctor’s office, more desperate than ever.
Now the real journey began: we tried melatonin (didn’t work) and Remeron, an antidepressant sometimes prescribed off-label for its drowsy side effects. It made me sleep, but also gave me vivid, Freddy Krueger-level nightmares. Next, I took a swing at the over-the-counter medication Unisom. The first dose gave me glorious sleep. Alas, subsequent nights I spent awake in bed with what I can only describe as Restless Legs Syndrome, but in my hands. “This is weird and unacceptable,” I thought to myself as I compulsively clawed the air like a fatigued, pajama-clad T-Rex.
I can laugh about that now, but it is impossible to adequately describe the sense of loneliness and confusion that can accompany an eruption of insomnia. It’s not just the physical pain, the permanent headache that settles above your tired eyes. Nor is it just the solitary hours spent awake, when you’re alone with the sound of the heater turning on and off and the occasional momentary glow from a stray car headlight. It’s also the sensation of weakness; that everyone else in the world is better rested, better equipped, and not a mess.
At my next appointment, my doctor wasn’t available, and I saw his partner in the practice, who was not impressed by my suffering. He couldn’t sleep during medical school, he told me. “But my hands,” I said forlornly, holding up the wrist that was still clad in a brace. By this time I’d convinced myself that I might have a rare nerve disease, instead of carpal tunnel syndrome. “In medical school,” he replied, “we learn that when you hear hoof beats, you look for horses, not zebras.”
As I sat on the examining table, I felt tired of hearing about his medical school and tired of trying to get better.
As Dr. Harris later told me, this is not an unusual experience for insomniacs, especially women. “I’ve had plenty of patients who have told me that their male—and female—doctors have said something along the lines of ‘Oh, I don’t sleep either, it’s totally common,’ and they’re left feeling as if it is shameful to ask for help,” she says. “Other times, it is thought of as a quick medication fix which isn’t the right way to approach it in most circumstances either—the idea of ‘don’t worry, this pill will fix it all.’” Harris points out in her book that most doctors receive only a few hours of training in sleep disorder diagnosis and treatment.
I decided it was time to find an expert.
CBT-I, the real MVP
There is, in fact, an entire field of healthcare called sleep medicine. I located a doctor at a nearby hospital who specialized in something called “cognitive behavioral therapy for insomnia,” also known as CBT-I. The Google reviews were promising, and at least I looked forward to talking to someone who did nothing but help people get rest. In the waiting room, I found myself studying the other patients, trying to detect in their faces any sign that they were as tired as I was.
I was surprised when the sleep therapist told me that my mind, far from being weak, was actually powerful enough to create my symptoms, from the scary nighttime awakening, to the numb hands, to the insomnia itself. “It’s not all in your head, in that your symptoms aren’t imaginary. They’re very real. It’s all in your head, meaning that these experiences are being mediated by your brain,” she said. The theory is that insomniacs have developed negative thought and behavior patterns about sleep. By changing my thoughts, I could change my behavior, and then, my world.
For example, one common thought distortion is catastrophizing. I definitely recognized this tendency in myself. The evening after a rough night of sleep, I’d have an automatic negative thought and engage in a little fortune-telling too: “I’ve got to start getting some sleep. If I don’t, tomorrow is going to be a disaster. I’ll never make it.” Feeling anxious, I’d get into bed earlier to try to force sleep. Not surprisingly, this backfired.
CBT-I involves challenging those negative statements, recognizing that thoughts aren’t always logical and sometimes are based more in emotion than reality. My sleep therapist suggested I identify my thoughts and predictions, write them down, and then ask myself whether they were accurate.
If I don’t sleep, will tomorrow really be a disaster? Well, possibly, but I’ve also gotten through days just fine without much rest. I have, in fact, made it through every single day when this happened, without losing my job or napping at my desk. And what if it is a “disaster”? What’s the worst that could happen? Perhaps I would have a bad day at work? It’s not quite the sinking of the Titanic.
It’s important to note that CBT-I is not the same as forcing positive thoughts. It’s an attempt to help our brains get re-centered in realistic expectations. Sometimes, a specific negative thought may be completely accurate, and in that case there is no benefit to trying (and probably failing) to convince yourself it’s not.
CBTI-I techniques address behavior as well, harnessing those much-maligned “sleep hygiene” rules and enhancing them for effectiveness. One approach involves sleep restriction therapy. The bottom line of this method is that in order to sleep better, one should spend less time in bed. Gradually, an insomniac can train her body to have adequate “sleep hunger” again.
Sound a little too good to be true? CBT-I is evidence-based, with mountains of research showing that it works spectacularly well for curing sleeplessness. It has no negative side effects, does not require spending big bucks at a pharmacy or natural nutrition store, and data even suggests treatment can be effective when done over the phone or with the aid of a self-help book like The Women's Guide.
“CBT-I is the gold standard,” Dr. Harris told me. “Many people still don’t appreciate that it is a very effective—and typically, fast—treatment that needs to have more word out about it.”
The best part is that unlike a pill bottle that runs empty, CBT-I gives you tools you can use going forward for lasting sleep success. CBT-I therapists don’t claim that you’ll sleep like a baby every night for the rest of your life—but if you do experience a hard time going to bed, you can use the simple thought exercises and behavioral changes of CBT-I right away to prevent one bad night from spiraling into a painful bout of insomnia.
Rest ... at last
So what happened to me after I tried CBT-I? I got better—mostly. As my anxiety around sleep faded, the electric shocks in my hands vanished, too. I don’t think I ever had carpal tunnel syndrome. I didn’t recover completely, however, until after I got on hormone replacement therapy following my early onset of peri-menopause. The solution for my insomnia turned out to involve gathering a constellation of treatments, all of which worked with my mind and body, instead of against them.
“Progesterone is an incredible help for women and sleep,” says Teresa Kenney, a womans health nurse practitioner who has been in practice for 20 years. Currently, Kenney works with women struggling with sleep at the St. Paul VI Institute's National Center for Women’s Health, and her work includes evaluating whether patients are experiencing hormonal sleep disturbances common in the fertility life cycle.
“When taken orally, progesterone is quickly broken down into allopregnanolone ... It affects [neurotransmitter] receptors in our brain, promoting relaxation and sleep. I rarely meet a patient who doesn’t love the way progesterone improves their sleep,” she told me. Kenney recommends natural or bio-identical hormones. “The progesterone that is found in birth control pills—progestin—is synthetic and not natural to a woman’s body,” she explains. By sticking with the real deal, women may be able to avoid disruption to the deep, Stage 3 sleep we all long for. Happily, that’s been the case for me.
“When we sleep we are literally detoxifying and resetting our bodies to live joyful, energetic, and healthy lives,” Kenney adds. If you are a woman who can’t sleep, don’t just power through your days, feeling like the only other choice is to depend on medication. Today, that’s no longer true.
“There’s no need to suffer in silence, and we all need to support one another,” says Dr. Harris.