Insomnia, nightmares during periods… how to explain it?

Insomnia, lighter sleep, nocturnal awakenings, particularly intense dreams… for some women, the menstrual cycle also influences the quality of sleep. “Sleep disorders during the premenstrual period are not, as such, a very common reason for consultation outside of perimenopause, but they are part of a much broader set of symptoms of premenstrual syndrome », explains Dr Olivier Grosbois, gynecologist-obstetrician. “And above all, they have a real biological basis, linked to hormonal fluctuations.”

Above all, it must be remembered that the sleep is a fragile balance, influenced by many factors.

« The stress and theanxiety play a central role, with difficulty disconnecting and persistent mental or emotional tension,” explains Dr. Grosbois.

The sleep pattern can also be disturbed by irregular hours, night work, jet lag or late bedtime habits. The environment also plays a role, particularly through exposure to screens, including blue light and stimulating content can delay falling asleep.

Certain substances such as coffee, tea, nicotine or alcohol are also known to impair the quality of sleep.

To this are added unsuitable sleep habitslike naps too long, or even psychological factors (anxiety disorders, depression, burn-out, etc.). We can also find medical causessuch as respiratory problems or sleep apnea. And in some patients, a very active brain functioningwith a form of perfectionism or ruminationcan be enough to disrupt falling asleep.

To these different factors are finally added, among women, hormonal variations in the menstrual cyclewhich can accentuate or reveal these disorders.

“Sex hormones, mainly l’estradiol and the progesteronedo not only act on the reproductive organs,” explains Dr. Grosbois. “They have a direct action on the brain and therefore on sleep and emotions.”

“These hormones modulate the hippocampus, the amygdala and the prefrontal cortex in particular,” explains the specialist, “and influence essential neurotransmitters.” Among them, the GABA occupies a central place. “It is the main inhibitory neurotransmitter in the brain,” explains Dr. Grosbois. “It acts as a brake on neuronal activity and promotes relaxation.” This balance between stimulating and moderating effects is essential for the quality of sleep – and this is precisely what can become fragile at the end of the cycle.

It is in particular in the second part of the cyclein the days preceding the rulesthat this imbalance is most often observed. “What most often poses a problem is insufficient secretion of progesteroneoften linked to a ovulation of lower quality,” explains Dr. Grosbois. In this context, the hormonal balance is modified to the relative benefit of estrogens. “The brain structures are then more subject to their excitatory influence, without fully benefiting from the calming effect of progesterone.” This imbalance can be translated as a lighter sleepof the nocturnal awakenings more frequent or a feeling of less restful nights.

Dr. Grosbois points out, however, that these variations are not systematic or strictly correlated with measurable hormonal dosages in all patients: they also depend on individual sensitivity to the cycle.

Some women report, depending on the phases of the menstrual cycle, more restless nights, with lighter sleep, more frequent nocturnal awakenings and more intense or vivid dreams.

This variability is explained by hormonal fluctuations during the cycle. The ovulation phase corresponds to a peak in estrogen, while the end of the cycle is marked by a drop in progesterone. As mentioned above, “at the end of the cycle, there is no longer any secretion of progesterone, and the hormonal balance is then modified”.

In these contexts, sleep can become more fragmented, with more micro-awakenings. These nocturnal interruptions promote memorization of dreams, which can give the impression of more “busy” nights on the dream levelwithout the structure of the dream being fundamentally different.

When sleep disorders are clearly linked to the menstrual cycle et become annoying on a daily basissupport can be considered. The challenge is first to identify the cyclical dimension of the symptoms.

“When the link with the cycle is well established, we can consider a adapted hormonal treatment to the age of the patient,” explains Dr. Grosbois. This may include hormonal contraception, progesterone intake in the second part of the cycle or a hormone replacement therapy during menopause. “The objective is to restore hormonal balance to limit variations that impact sleep and mood,” he explains. In certain cases, this approach also makes it possible to avoid the systematic use of hypnotics or anxiolytics, the effectiveness of which may be limited over time.

More broadly, sleep medicine recommendations also emphasize the overall management of insomnia : regularity of bedtimes and getting up times, reduction of stimulating factors in the evening, and taking into account associated stress or anxiety. THE cognitive-behavioral approaches to insomnia (CBT-I)considered the first-line treatment for chronic insomnia, can also be useful when sleep disorders persist beyond the sole hormonal context.