The menstrual cycle and sleep

Stages of the menstrual cycle

There are 3 main phases of the menstrual cycle, the follicular phase, ovulation and the luteal phase. The main hormones that vary across the menstrual cycle are oestrogen, progesterone, luteinizing hormone (LH) and follicle stimulating hormone (FSH). For most women, each cycle lasts between 25-35 days, with the average cycle lasting 28 days.

• Follicular phase – starts on day 1 of the cycle, the first day of menstruation and ends around day 14 with ovulation
• Ovulation – occurs mid-cycle, around day 14, following a surge of luteinizing hormone
• Luteal phase – starts from ovulation for the remainder of the cycle until the start of menstruation

Sleep changes across the menstrual cycle

Progesterone has sleep promoting effects, so during parts of the cycle where progesterone is increased, such as after ovulation, women can feel more sleepy. Then when progesterone reduces, towards the end of the luteal phase and before menstruation starts sleep problems can occur. Oestrogen can also promote sleep. Most women who have trouble with sleep at different parts of their menstrual cycle, have problems just before and after the start of menstruation, with 30% of women reporting disturbed sleep during menstruation and 23% reporting disturbed sleep in the week prior to menstruation.

Most changes in sleep across the menstrual cycle can be divided in to changes in the follicular phase versus the luteal phase. Some women also notice an increase in temperature around ovulation.

• Follicular phase – Women often report poor sleep quality during the first 4 days of their period when both oestrogen and progesterone are low
• Luteal phase – Greater feelings of sleepiness are often experienced after ovulation due to increased levels of progesterone. During this part of the luteal phase where progesterone levels are high, there is more non-REM sleep and reduced REM sleep. Women also report poorer sleep quality during the 3 days prior to menstruation at the end of the luteal phase.

Common symptoms that women experience during the week prior to menstruation that impact on sleep and the proportion of those with symptoms who experience them are:

• Tender or painful breasts – 41%
• Headaches – 58%
• Increased anxiety or mood changes – 44%
• Bloating – 51%
• Cramps or pain – 69%

Tips for reducing the impact of hormonal changes on sleep

One of the main ways of reducing the impact of changes in hormones throughout the menstrual cycle is to better understand your sleep at different stages of your cycle. You can get a better idea about this, but keeping a sleep diary for a couple of months to find out whether and how your menstrual cycle plays a role in the quality of your sleep. If you know what to expect, you can put strategies in place to reduce the impact of symptoms on your sleep.

If you are having trouble with sleep despite doing what you can, talk to your health professional about options such as prescription medications. There are 2 main categories of medications that can reduce pre-menstrual symptoms that impact on sleep:

• Oral contraceptive pills (OCPs) – because oral contraceptive pills contain either progesterone or oestrogens or both, they can regulate both the cycle and fluctuations in hormones. By taking active pills continuously to avoid menstruation, the periods of low oestrogen and progesterone where there are symptoms are avoided. Taking OCPs in this way needs to be done in conjunction with your doctor.
• Selective serotonin reuptake inhibitors (SSRIs) – include medications such as sertraline (Zoloft), fluoxetine (Prozac), citalopram (Cipramil) and paroxetine (Aropax). Studies have shown these drugs reduce pre-menstrual symptoms in 60-75% of women.

Related posts & links:

• Pre-menstrual syndrome – UpToDate
• Menstrual insomnia – Reader’s digest
• Sleep problems during menstrual cycle – Sleep Foundation (US)

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