The patient: “Olivia,” a 43-year old art gallery owner.
Why she came to see me: After consulting with a series of doctors about her persistent inability to sleep, Olivia arrived at my office bleary-eyed, exhausted—and determined to conquer her insomnia naturally.
How I evaluated her: My work with Olivia started with a comprehensive evaluation of not only the state of her body but also of her mind and emotions.
On the whole, Olivia claimed she felt well most of the time. She’d had no major illnesses or surgeries, and while she didn’t necessarily prioritize health she didn’t snub it either. She aimed to eat healthfully and timed her meals to consume the lion’s share of her daily calories mid-day to avoid weight gain. She went to the gym three to four times a week, where she conducted hour-long workouts comprised of cardio and strength training (to say nothing, she noted, of the hours she spent running around the city meeting artists and clients). In many ways, she said, her career was her life. She loved helping artists show and sell their work, which she found meaningful and rewarding, and was rarely away from the gallery for more than half a day. Unmarried and childless, she was in a “great” relationship with an architect, and the two of them were planning on merging their households in the near future.
Every three weeks or so, however, Olivia was besieged by an inability to sleep. These bouts of insomnia began gradually—she would toss and turn for two to three nights before spending four nights “trapped in the misery” of her own mind and staring at her ceiling for hours. She hadn’t been a good sleeper since adolescence, and she’d gotten by on only five to six hours of sleep per night throughout most of her adulthood. This, she said, made the times she did set aside to sleep even more precious. Her primary care physician had prescribed Ambien (which rendered her “a total zombie” the next day) before sending her to a sleep clinic that determined little. Recently, she’d started leaving her boyfriend’s apartment in the middle of the night because her insomnia was so bad. She’d also tried to “fix” the problem herself by drinking wine at night, working out harder and longer, and turning off her electronics an hour before bed. Nothing seemed to work, and she was at her wit’s end.
The more I probed, the more I learned that insomnia wasn’t Olivia’s only symptom. In addition, she was undergoing premenstrual mood swings that left her raging one minute and weepy the next. There were also a handful of days each month where her breasts were tender, and her body so fatigued she had to escape the gallery floor to nap in her office in the back. These symptoms were exacerbated by her insomnia and took a major toll on her facility to concentrate at work and be loving and supportive to her partner. Instead, she felt moody, shaky and fearful that she wouldn’t be able to sleep yet again, which only worsened her ability to do so.
While I was delighted to hear that Olivia’s menstrual cycle “worked like a clock” and that she had a virtually spotless medical history, I suspected her issues were hormonal. To this end, I ordered a 24-hour urine test on the 21st day of her cycle to asses her hormone levels, which typically provides the clearest indication of a woman’s hormone levels. I also conducted a full physical to rule out the possibility of any underlying medical conditions.
What my evaluation revealed: To our relief, Olivia’s health—from her pulse to her PAP—suggested near-optimal wellness. Her hormone levels, however, revealed that she was in perimenopause, a transitional stage in a woman’s life when the ovaries begin producing less estrogen and progesterone as menopause gradually sets in. As I told Olivia, when you have a healthy level of estrogen, it’s your strongest ally. Too little, though, can lead to irritable feelings and unpleasant moods, as well as premenstrual discomforts such as night sweats and lethargy. Too much estrogen can cause breast tenderness, bloating and heavy periods.
What’s more, Olivia’s results demonstrated a deficiency is progesterone. This decline—also normal—tends to begin in a woman’s late 30s/early 40s, and one of its telltale signs is insomnia that occurs during the second half of one’s cycle. Progesterone plays a vital role in mental calmness. When it’s lacking, women like Olivia may struggle to fall and stay asleep, thereby making the rest of life more challenging. Finally, Olivia’s results showed that she had elevated levels of cortisol. When high and/or imbalanced, this too can result in insomnia.
How I addressed her problem: As I explained to Olivia, sleep often gets the short shrift. During Olivia’s 20s and 30s, she was likely influenced by the cultural notion that long nights of sleep were for the indolent. At the time, not sleeping was deemed a sign of productivity and drive (it was even glamorized). Today, fortunately, people are recognizing that sleep is as central to wellbeing as nutrition. It’s one of the body’s greatest healers, regenerating the brain along with every other part of the body. When one is asleep, their blood pressure drops, they breathe more slowly, and their metabolism slows down. Given that we can’t run full-tilt at all times (as much as people like Olivia would like to), these changes during slumber are fundamental for the health of one’s brain and body.
To get Olivia into this restorative place, we took a holistic approach…
- First, I asked her to start creating a plan for sleep. While her job had her at events a few times a week, I suggested she endeavor to be in bed by a certain time every night, even if she wasn’t tired, as her brain and body needed regularity.
- We then looked at ways to naturally boost her progesterone. I suggested she take natural bio-identical progesterone (bioidentical means the chemical structure of the hormone is identical to what her body makes), which can be particularly valuable for women who experience insomnia prior to their period. Natural progesterone can influence the GABA receptors in the brain, resulting in a soothing effect. I prescribed 50 mg of progesterone as a transdermal cream to be applied to her vulva before bed from mid-cycle until her period. (I prescribed the progesterone cream through a compounded pharmacy). I also explained that I’d prefer we start with progesterone only, and add in estrogen only if needed in the future. Typically, in perimenopause estrogen levels can fluctuate wildly until post-menopause when the ovaries cease to produce abundant amounts of this hormone.
- To address her cortisol levels, we took a two-pronged approach. The first was to reduce the stress in her life…the second was to regulate her blood sugar. I began with urging Olivia to treat sleep with as much care as she would meeting an important client—in a word, by preparing for it. I asked her to nix the wine—alcohol is notorious for making people wake up in the middle of the night—and to spend two hours before bed decompressing with gentle stretching exercises, meditation, a candle-lit bath, a good book or quiet music and nothing work-related. By taking pressure off of her mind and nervous system, she would have a much easier time telling her body that it was time to rest. Olivia also agreed to delegate more of her work responsibilities when she could, and to declare at least one day a week outside of the gallery to pursue her own enjoyment.
- I also encouraged Olivia to start eating balanced, well-timed dinners that contained both protein and complex carbs. Blood sugar can contribute to insomnia—when it’s low, as Olivia’s was from eating most of her meals during daylight, the body compensates by releasing hormones that can make you feel more agitated. Many common protein sources, such as chicken, turkey, tofu, and salmon, contain an amino acid called tryptophan that can increase your serotonin level and help you sleep. But since tryptophan has to be escorted into your brain by insulin to be effective, eating these foods alone may not be enough; hence the addition of complex carbohydrates, such as brown rice and sweet potatoes.
- Additionally, I urged Olivia to take 300 mg of Valerian Root an hour before bedtime. This Asian herb can calm and restore the nervous system (and is especially helpful for those with a racing mind). It also contains compounds that bind to those aforementioned GABA receptors, thus exerting a relaxing effect.
- Finally, I suggested she take 100 mg of 5-HTP once a day before bedtime. Derived from tryptophan, 5-HTP not only helps boost the level of serotonin in your brain and nervous system, but it can also increase your levels of melatonin, endorphins and other essential brain chemicals.
Olivia understood that as she progressed through her perimenopause and moved onto menopause, that our treatment approach would change depending on her symptoms. Some women sail through this period of time with very little intervention, while others need much more support.
The patient’s progress: Two months later, Olivia returned to my office looking like the paragon of health. Gone were the bags under her eyes and her air of exhaustion. In their place was a woman revived. She’d followed my plan “almost to a T” and had found that the combination of progesterone, herbs, diet and relaxation techniques had made an enormous difference to her premenstrual insomnia and the anxiety and moodiness that arrived with it.
“I may be getting older and my hormones are declining,” she said, “but I feel better than I did in my 20s.” She and her partner had found the “perfect place” to officially start their life together but, moreover, she’d discovered the drive to continue making choices that would optimize the health of her body and mind. “I feel like sleep is some secret weapon I just discovered,” she said. To which I said indeed! It is one of nature’s best defenses.
To learn more, visit Dr. Laurie Steelsmith’s website, https://drsteelsmith.com, or click her to read her most recent book, Growing Younger Every Day: The Three Essential Steps for Creating Youthful Hormone Balance at Any Age.