Does Menopause and Low Estrogen Cause Insomnia?

Having “normal” levels of hormones like estrogen is key to good health, especially for women.

Research shows that abnormal estrogen (too low or high) can cause many health-related conditions.

Low estrogen levels have been linked to insomnia, whether from menopause or any other reason. We’re going to look at the different ways low menopause can cause sleep difficulties, as well as which treatment options are supported by research.

Why Do Low Estrogen Levels Cause Insomnia?

Low estrogen is most commonly caused by menopause, but can also be caused by hysterectomies, nutritional deficiencies, and more.

Regardless, low estrogen levels have a clear link with insomnia, but there are a few different ways that estrogen levels affect sleep.

Low Estrogen and Mood Disorders (Depression and Anxiety)

There is a substantial amount of research that shows there is a correlation between decreased estrogen levels and increased anxiety and depressive symptoms (1,2,3).

This is important since (4):

Nevertheless, best available evidence suggests insomnia is bidirectionally related to anxiety and depression.

In plain English, this means that people with depression are more likely to develop insomnia, and people with insomnia are likely to develop depression. The same relationship applies between insomnia and anxiety.

SummaryLow estrogen levels are linked to increased anxiety and depression, which are 2 of the biggest insomnia risk factors.

Physical Symptoms of Low Estrogen That Affect Sleep

Another way that estrogen levels may affect sleep is by causing enough discomfort to make it difficult to get and stay asleep.

While every individual is different, there are 2 main concerns here in general:

• Hot flashes - Most women going through menopause experience hot flashes, sometimes to the point of breaking out in sweat. The main cause of this is a reduction in estrogen production (5). It shouldn’t be surprising that hot flashes make sleeping harder.
• Mood disturbances - Low estrogen levels are also correlated with mood disturbances (i.e. irritability, mood swings) (6). This can lead to frustration or overthinking, which may cause sleep difficulty.

SummaryWhile it’s not the main cause of insomnia in most cases of low estrogen, symptoms like hot flashes and mood changes can contribute directly to sleep problems.

Low Estrogen Affects Magnesium Utilization

We could spend all day looking at all the interactions of estrogen in the body, but one in particular that I wanted to highlight here is its impact on magnesium.

Magnesium is important for sleep quality for many reasons, and low estrogen levels can inhibit magnesium utilization and uptake (7).

The picture below is just a snapshot of all the side effects a magnesium deficiency can lead to, including depression and insomnia.

It also plays a role in creating melatonin, one of the most important sleep hormones.

SummaryEstrogen is involved in mineral metabolism, so low estrogen levels may lead to a deficiency, with all kinds of indirect side effects.

Comorbidities of Low Estrogen That Impact Sleep Quality

Low estrogen levels may also cause insomnia symptoms indirectly by increasing the risk of developing a condition that makes insomnia more likely.

The most important one is restless leg syndrome (RLS); RLS can be a trigger for insomnia symptoms.

While it’s not fully understood why, women get RLS about twice as much as men, and there appears to be a link between RLS and low estrogen levels (8,9).

A magnesium deficiency can also be a cause of developing RLS, which is one possible explanation of why estrogen may play a role here (10).

As someone who used to have a lot of trouble with RLS, I can speak from first hand experience that it’s very difficult to get to sleep when your legs won’t stop moving and jerking around.

SummaryThere seems to be a link between low estrogen levels and conditions like RLS and sleep apnea, which may then impact sleep quality.

Treatment for Insomnia From Low Estrogen Levels

We looked at the 4 main ways estrogen levels may impact sleep. Depending on the specific situation, a doctor may prescribe a different treatment plan for an individual.

In the following sections, we’re going to look at the results of a meta-analysis that examined the effectiveness of several possible treatment methods (11).

Cognitive Behavioral Therapy for Insomnia (CBT-i)

What that analysis and just about every other recent insomnia treatment study has found is that CBT-i is the most effective treatment for most people (12).

CBT-i is a CBT program specifically designed to help patients “rewire” how they interpret thoughts and feelings that can cause sleep trouble.

It’s widely effective, the results last long term, and there’s very little potential downside.

RLS and Sleep Apnea Workup

The other most important solution from that meta-analysis is for a doctor to do a RLS and sleep apnea workup.

These are easy comorbidities to detect, and they often have relatively simple treatment methods to manage them (depending on the specific cause).

This alone likely won’t solve all sleep issues, but can have a moderate impact and should be included as part of the diagnoses or treatment plan.

Hormone Therapy

If low estrogen levels are causing sleep issues, the obvious solution is to simply supplement estrogen (typically in the form of estradiol - the most popular form).

It does seem to work, but maybe not as well as you might expect. In relative terms, CBT-i has a high impact, while hormone therapy has a moderate impact.

One study split 339 women randomly into 3 groups to test 2 different treatment methods on sleep quality (13):

• Placebo (control) group
• Oral estrogen supplementation group
• Venlafaxine group (an antidepressant)

Sleep quality improved in all groups, showing the power of the placebo effect.

There was similar improvement in sleep quality in both the estrogen and venlafaxine group:

• Insomnia severity index (ISI) - At the start, mean ISI was 11.1. After 8 weeks, ISI in the estrogen group decreased by 4.1 points, and it decreased by 5.0 points in the venlafaxine group.
• PSQI score - At the start, mean PSQI was 7.5. After 8 weeks, PSQI declined by 2.2 points with estradiol and 2.3 points with venlafaxine.

For reference you can use our online PSQI calculator to get your own score. A score of 5 or below is considered “good”, so both treatment groups got pretty close to that threshold.

SummaryHormone therapy can have a moderately positive effect on insomnia for some people with low estrogen levels, but there are some potential side effects that need to be considered by a prescribing physician.

Pharmacological Aids

Medications and supplements like herbs may or may not have a positive effect on insomnia depending on the substance in question.

They should be included in a treatment plan at a doctor’s discretion.

We already saw that certain antidepressants can have a positive effect on insomnia. This isn’t surprising due to the strong link between depression and insomnia, but they do carry risks of side effects, and are often just temporary solutions.

The meta-analysis mentioned at the start of this section looked at the research behind several substances in this category. Two in particular showed a low, but significant positive effect:

• Valerian - Valerian is a natural sleep aid with some evidence behind it improving sleep quality. It appears to have a small beneficial effect in some people with a low risk of side effects. If you're curious, we've looked at the evidence behind valerian root for insomnia in another post.

• Gabapentin - This is an anticonvulsant that happens to have side effects that may improve sleep by a small amount. However, there are also other potential side effects including withdrawal once medication stops, so it’s not at the top of the list for most doctors to prescribe. See our post on does gabapentin help with insomnia for more details.

Substances in this category are very situational and rarely have a long lasting strong effect on sleep. So while they might be part of a treatment plan, they won’t usually be the main focus.

Relaxation Therapies

Finally, relaxation therapies have a reasonable amount of evidence showing they can have a small positive effect on insomnia with an almost complete lack of adverse effects.

This includes:

• Hypnosis
• Yoga
• Massage therapy
• Exercise

Acupuncture is a bit more controversial but may fall into this category as well.

None of these are going to cure insomnia, but may have a small beneficial effect, so if they are available, they may be included on a treatment plan.

Summary: Low Estrogen and Insomnia

Estrogen impacts several facets of health, especially in women.

Low levels of estrogen can cause both mental and physical side effects, including conditions like depression, insomnia, and anxiety.

There are different treatment methods available, but a treatment plan should be created and monitored by a doctor.

Most treatment plans are based on CBT-i, and may include hormone therapy, medications, and relaxation therapies.

References

1. Estrogen action in mood and neurodegenerative disorders
2. Estrogen-related mood disorders
3. Estrogen and the brain: does estrogen treatment improve cognitive function?
4. A Systematic Review Assessing Bidirectionality between Sleep Disturbances, Anxiety, and Depression
5. Hot Flashes: A Review of Pathophysiology and Treatment Modalities
6. Estrogen-related Mood Disorders
7. Interrelationship of magnesium and estrogen in cardiovascular and bone disorders, eclampsia, migraine and premenstrual syndrome
8. When gender matters: Restless legs syndrome.
9. Restless legs syndrome among women
10. Intravenous Magnesium Sulfate May Relieve Restless Legs Syndrome in Pregnancy
11. Treatment of chronic insomnia disorder in menopause
12. Practice parameters for the psychological and behavioral treatment of insomnia
13. Effects of Estradiol and Venlafaxine on Insomnia Symptoms and Sleep Quality in Women with Hot Flashes