Written by Dr. Susan Zink, MD — Board-Certified Psychiatrist

Sleep Shouldn't Be This Hard — and It Doesn't Have to Stay This Way

You’re exhausted, but your mind won’t quiet down. Sleep feels just out of reach, and when you finally drift off, you wake a few hours later with all the same thoughts rushing back. Maybe you have a new baby, and everyone tells you to sleep when she sleeps, but the worry won’t let you rest. You keep listening for her breathing, getting up to check, unable to trust that she’s okay. Or you’re in your 40s and suddenly waking at 3 AM for no clear reason, lying there in the dark with your heart racing, wondering what changed. Maybe you’re waking up drenched in sweat, the sheets damp before you even realize what happened.

For some women, it’s the opposite: mood has been low, and now sleep is all you want. Getting out of bed feels like lifting something very heavy. You’re sleeping more than usual but still exhausted — a tired feeling that doesn’t respond to rest. And for others, sleep seems fine on paper, but daytime fatigue has crept in anyway, leaving you foggy and slow in ways that are hard to explain.

Sleep problems are common. They’re also frequently misunderstood and undertreated.

What Causes Sleep Disruption?

Beyond mental health, a number of distinct sleep disorders can cause or worsen sleep problems, independent of psychiatric conditions. Identifying the specific cause matters enormously — the treatment for one type of sleep problem can be ineffective, or even counterproductive, if the underlying problem isn’t identified.

How Hormones Affect Sleep

Hormonal changes across a woman’s life, particularly during the luteal phase of the menstrual cycle and the perimenopause transition, can have a profound and often underrecognized impact on sleep.

As we age, the pineal gland produces and releases less melatonin, making it harder to fall asleep and stay asleep. During the two weeks before menstruation (the luteal phase) in a premenopausal woman, progesterone rises, and often women feel a change in need for or ability to sleep during this time each month. During perimenopause, estrogen and progesterone fluctuate widely before eventually declining. Estrogen plays a key role in regulating the sleep-wake cycle and body temperature. When estrogen is dysregulated, hot flashes and night sweats can cause repeated nighttime awakenings — not just discomfort, but a genuine disruption to sleep architecture. Progesterone is the body’s natural calming hormone; as levels drop, anxiety and insomnia often increase. Progesterone also has an inverse relationship with cortisol, the body’s primary stress hormone. When progesterone is low, cortisol tends to run high. This is one reason middle-of-the-night awakening is so characteristic of the perimenopause transition.

The hormonal shifts of perimenopause can also increase the risk of obstructive sleep apnea (OSA). Estrogen and progesterone help maintain muscle tone in the airway, and as levels fall, the airway can become less stable during sleep. Combined with the abdominal weight gain that often accompanies higher cortisol levels, this creates meaningful risk for obstructive sleep apnea. Studies suggest that at least one-third of women in perimenopause report significant sleep difficulties, and somewhere between half and two-thirds of postmenopausal women have obstructive sleep apnea — a number that tends to surprise people. OSA is one of the most common causes of excessive daytime fatigue and can seriously complicate the treatment of depression and other mood disorders if it goes unaddressed.

Other Common Contributors

Restless leg syndrome is another frequently overlooked cause of disrupted sleep. It’s more common in both pregnancy and perimenopause, and often linked to low iron stores. Women with RLS describe an uncomfortable urge to move their legs — crawling, itching, aching sensations that make it hard to settle into sleep. Repleting iron and optimizing ferritin level and iron stores often provide significant relief. Low magnesium can also worsen symptoms.

Certain medications can interfere with sleep as well. Stimulants and some antidepressants are among the more common culprits — an important consideration when sleep problems emerge after a medication change.

Adolescents and young adults frequently have a delayed circadian phase, meaning their bodies are wired to fall asleep and wake later than the conventional schedule demands. This is often misread as insomnia or laziness, when it’s actually a circadian pattern that tends to normalize with age.

Why Sleep Matters

The downstream consequences of chronic poor sleep are significant. Long-term sleep disruption is associated with higher rates of depression and anxiety, cognitive decline, dementia, cardiovascular disease, diabetes, and reduced immune function. Even in the shorter term, disrupted sleep affects mood, concentration, and emotional resilience. One of the key mechanisms is cortisol: poor sleep raises cortisol levels, which in turn drives anxiety, low mood, difficulty with weight, and further sleep disruption. It becomes a cycle that’s difficult to interrupt without addressing the root cause.

Evaluation and Treatment at EleMental

At EleMental Integrative Psychiatry, sleep evaluation is always thorough. The goal is to understand what’s actually driving the problem, because sleep difficulty is a symptom, not a diagnosis in itself, and the treatment needs to match the underlying cause.

Treatment may include iron or magnesium supplementation for restless leg syndrome or general sleep quality; referral for a sleep study when obstructive sleep apnea is suspected; cognitive behavioral therapy for insomnia (CBT-I), which is considered the first-line treatment for chronic insomnia and works by addressing the thought patterns and behaviors that perpetuate poor sleep; and treatment of underlying anxiety or depression when mood is the primary driver.

Hormonal contributors are taken seriously here. Hormone replacement therapy can be highly effective for sleep disruption rooted in perimenopause, and the decision is made thoughtfully, with a full picture of each patient’s history and risk profile.

Natural supplements, including melatonin, magnesium, and oral lavender, may play a role depending on the clinical picture. It’s worth noting that melatonin is not well studied in pregnancy and is generally not recommended during that time; oral lavender is also avoided in pregnancy due to estrogenic effects. For some patients, over-the-counter or prescription sleep aids are appropriate as a bridge — used carefully and for a defined purpose rather than indefinitely or indiscriminately.

If you’ve been struggling with sleep and haven’t found answers, it may be that no one has looked closely enough. Sleep problems in women are frequently dismissed, attributed to stress, or treated with a single intervention that doesn’t address the full picture. There’s usually more going on and more that can be done.

Often Connected

Sleep and mood are deeply intertwined, and chronic sleep disruption rarely exists in a vacuum. If anxiety or a racing mind are keeping you awake, learn more about how we approach Anxiety, Panic & Overwhelm →.  If low mood, emotional flatness, or exhaustion that doesn't respond to rest are also part of your picture, our page on Depression & Low Mood → may be equally relevant. Women whose sleep disruption is tied to hormonal shifts or reproductive transitions may also find the following useful: [Hormonal Mood Changes →] (coming soon), [Perinatal Depression & Anxiety →] (coming soon), and [PTSD & Birth Trauma →] (coming soon), as hyperarousal and nighttime waking are among the most persistent features of untreated trauma.

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