Erna opens her eyes, and her body is already tense.
She feels restless and on edge, anxious about something she can’t quite name. It isn’t work or the kids. Nothing in particular is on her mind, but she still can’t fall back asleep.
It’s 3:30. Sometimes it’s 4. This has happened nearly every night for six months. She’s tried going to bed at 9 and at midnight. It makes no difference.
I sleep through it all next to her. If you read my July edition, you know I can fall asleep anywhere, even when I used to have a trauma pager on my chest. That skill doesn’t help the person next to you. Sometimes the bedside light wakes me, and I see her sitting up with a book. Most nights, I don’t even notice she’s not there.
This edition is personal. It’s Erna’s story, and she’s read and approved every word. She wants to share it openly, because there’s nothing to be ashamed of. Every woman goes through this transition. Some barely notice it, while others lose sleep. She says if her story helps even a few women, it was worth sharing.
One more thing before we start. I’m a doctor, but not a gynecologist, and hormones are complicated. What follows is a simplified version: broad strokes, so it’s easy to follow. Almost every sentence has more detail behind it. If you’re making a treatment decision, do it with your doctor.
The woman who couldn’t get up before 7
Fifteen years ago, we lived in New York, and I was focused on self-improvement. I got up at 5, did CrossFit in Brooklyn, had breakfast, then went to work. I had a morning routine I liked to talk about.
Erna was less keen. “I can’t get up before 7,” she told me, “no matter what I do.”
This is from a woman who moved from Kyrgyzstan to a new country at 10 and built a life from scratch. Mornings were the one challenge she couldn’t overcome. Over time, she started waking up earlier, and eventually we went to the gym together in the mornings.
Now she wakes up hours before the alarm she used to need, and she doesn’t choose to.
Two hormones, explained over coffee
To understand why she wakes at 3:30, you need to know about two hormones.
Estrogen is the main one. It controls the menstrual cycle, but it also works in other parts of the body, including the brain. For this story, one area matters most: the brain’s thermostat, the small part that keeps your body temperature steady [1].
Progesterone is the quieter partner. After ovulation, it prepares the womb lining for a possible pregnancy. It also plays a role in sleep. The body turns some of it into a substance called allopregnanolone, which calms the brain [2]. Remember that for a second.
What changes, and when
Menopause is a single point in time: one year after your last period. In the US, the average age is about 51 [1]. Perimenopause is the run-up, and it can last several years.
During perimenopause, ovulation becomes irregular. Estrogen and progesterone don’t decrease in a straight line. They go up and down, sometimes a lot, before they finally drop [1].
That’s why the symptoms are so mixed. These hormones affect so many parts of the body that their loss shows up in many ways: hot flushes and night sweats, irritability, anxiety, low mood, and trouble sleeping [1].
For Erna, sleep is the main problem, and she’s not alone. A large 2026 analysis found insomnia symptoms in about 27% of women in perimenopause and 42% after menopause [3]. These women are in their 40s and 50s. Some run teams, companies, and boards, and some will be in your 9 a.m. meeting after a night like Erna’s.
Why sleep breaks
Most mornings, by the time I wake up, Erna is already in the kitchen. I hug her, and she tells me the time. “At least it was 4 tonight. Not 3:30.” In our house, that now counts as an ok night.
In my July edition, I asked: when you wake at 3am, is it because of a specific worry, or for no clear reason? For Erna, it’s the second. Her body just wakes up. She also tried my July advice: get up, read in dim light, and go back to bed when tired. It hasn’t fixed the problem. Seeing your own advice tested at home is humbling.
So I started reading. Broad strokes again: three things seem to work together.
The first is the thermostat. With less estrogen, it becomes more sensitive, which leads to hot flashes and night sweats [4]. Many night flashes go unnoticed, but they still wake you up. In one study of 168 midlife women, the odds of waking were over five times higher during a measured flash than just before it, whether or not the woman noticed it [5]. So saying “I don’t get hot flashes” doesn’t answer the question.
The second is the missing calm, which I find most interesting. Your brain has a brake pedal, a messenger called GABA. Many sleeping pills work by acting on it. Allopregnanolone, which your body makes from progesterone, works on the same brake [2]. When progesterone goes up and down, some of that natural brake may go with it. The research can’t say if this explains why any one woman wakes up. But it’s a big reason doctors consider progesterone for sleep.
The third is the alarm. After weeks of broken nights, the brain can learn to wake up. Bed starts to mean lying awake and feeling frustrated, and waking becomes a habit. That’s what my July advice was meant to help. For Erna, that hasn’t been enough on its own.
Early-hour waking can be explained by sleep getting lighter and easier to disturb as morning approaches. And no, I couldn’t find good evidence for the “3am cortisol spike” that the internet often blames. Cortisol does rise toward morning. That’s normal.
The doctor who wasn’t in the room
Erna did the sensible thing and went to her gynecologist.
Hormone therapy wasn’t offered to her right away. I encouraged her to ask about it, which isn’t easy for someone who doesn’t like to question her doctor. She came home with an estrogen gel and instructions: start with one pump, then add another, and if your breasts get tender, use less. When she went back and said she still couldn’t sleep, her doctor added a progestin-only pill. Her mood got worse. She came home from those visits feeling like “there’s not much you can do.”
I wasn’t at those appointments, so I only know what she told me afterward. At first, I thought, who am I to question a specialist? My training is in reconstructive surgery. But I got frustrated and started reading the research myself. Now, I feel informed enough to help her ask better questions.
The doctor’s take: Her pill contains desogestrel, a synthetic progestin approved in Germany for contraception, and depressed mood is one of its possible side effects [6]. It isn’t the body’s own progesterone, and it isn’t what the sleep studies tested. Those studies used micronized progesterone, the body-identical version that turns into allopregnanolone and acts as a brake. Its effect is modest. In a review of nine trials, it helped women fall asleep faster [7]. That prescription needed a second look.
Progesterone has another job here. If you have a uterus and use estrogen, you need enough progestogen to protect the womb lining, and not every option has evidence for that [8]. Your doctor should be able to tell you which one does.
The fear that got in the way
Erna had to ask for hormone therapy. I think much of the hesitation goes back to 2002, when a big US trial, the Women’s Health Initiative, was stopped early. Women on a combined estrogen and progestin pill had more breast cancers: 8 extra cases per 10,000 women per year [9]. That risk is real. But in February 2026, the US FDA approved new hormone therapy labels, removing the broad boxed warnings about breast cancer, heart disease, and dementia [10].
The doctor’s take: For women under 60 or within 10 years of menopause, and without reasons to avoid it, hormone therapy usually has a good balance of benefits and risks for bothersome hot flashes and night sweats [11]. Women deserve a clear conversation about these benefits and risks. No woman should have to fight for that conversation.
What helps
This fits into the Recover pillar of my Upward ARC framework: helping the nervous system return to baseline between stressors.
Each of these three things has its own approach.
For the thermostat, hormone therapy can help. It mainly improves sleep in women with hot flashes or night sweats [12]. There are also newer non-hormonal prescriptions for hot flashes.
For the missing calm, ask if taking micronized progesterone at night could help.
For the alarm, there’s CBT-I, or cognitive behavioral therapy for insomnia. For chronic insomnia, it’s the first-line treatment, and US sleep doctors give it their strongest recommendation [13]. In a US trial of women with hot flashes, 70% of those assessed in the CBT-I group were out of the insomnia range after 8 weeks, compared with 24% in a menopause-education group [14]. In Germany, your doctor can prescribe it as an app [15].
Also ask about two similar conditions. Sleep apnea becomes more common after menopause, and in women it often appears as insomnia instead of loud snoring [16]. Low mood can also wake you early. Both deserve an honest conversation with your doctor.
When it comes to supplements, I’d recommend getting a proper sleep assessment before trying anything from the store.
If you’re the one sleeping next to it
Believe her when she says she can’t sleep. Don’t suggest another supplement right away. And never, under any circumstances, tell her how well you slept.
After a bad night, take care of the kids in the morning. She deals with this every night. At the very least, handle breakfast.
Try this today
Keep a sleep diary while you book an appointment. Write down when you wake, how you feel, and any heat, sweating, or racing heart.
Ask about the thermostat: “Could night flashes be waking me, even if I don’t notice them?”
Ask about the calm: “Which progestogen am I on, and what is it for: my womb lining, my sleep, or contraception? Could micronized progesterone fit?”
Ask about the alarm: “Can I get CBT-I?”
Ask about the look-alikes: sleep apnea and low mood.
Seven o’clock
Fifteen years ago in Brooklyn, she couldn’t get up before 7. But she managed it in her own way, and we eventually went to the gym together.
She has now stopped the pill and switched to micronized progesterone. It’s too soon to know how it will affect her nights, but she no longer feels stuck at “there’s not much you can do.” We haven’t solved this yet, but things are looking better. What I want for her is to have the choice again: a night that ends when she decides, and an alarm she actually needs.
If you’re going through this, or supporting someone who is, what did your doctor say when you brought it up? Reply and let me know. I read every message.
Stay healthy.
Andre
PS: If you know a woman who’s been lying awake at 3 or 4 and blaming herself, please forward this to her. If you’re her partner, read it first. That’s how this newsletter grows, and it’s the only way I want it to.
PPS: If a friend sent you this, you can get Under Load, my Sunday edition, here:
https://www.andreheeg.com
References
[1] Merck Manual Consumer Version. (2026). Menopause. Retrieved October 24, 2026, from https://www.merckmanuals.com/home/women-s-health-issues/menopause/menopause
[2] McEvoy, K., & Osborne, L. M. (2019). Allopregnanolone and reproductive psychiatry: An overview. International Review of Psychiatry, 31(3), 237–244. https://doi.org/10.1080/09540261.2018.1553775
[3] Balasubramanian, I., Abhijita, B., Krishnamoorthy, Y., Gnanadhas, J., Beg, M. J., & Menon, V. (2026). Prevalence and incidence of depressive, anxiety, and insomnia symptoms in perimenopausal and postmenopausal women: Systematic review and meta-analysis. General Hospital Psychiatry, 100, 325–335. https://doi.org/10.1016/j.genhosppsych.2026.03.010
[4] Prague, J. K., et al. (2017). Neurokinin 3 receptor antagonism as a novel treatment for menopausal hot flushes: A phase 2, randomised, double-blind, placebo-controlled trial. The Lancet, 389(10081), 1809–1820. https://doi.org/10.1016/S0140-6736(17)30823-1
[5] Thurston, R. C., Chang, Y., Buysse, D. J., Hall, M. H., & Matthews, K. A. (2019). Hot flashes and awakenings among midlife women. Sleep, 42(9), zsz131. https://doi.org/10.1093/sleep/zsz131
[6] Fachinfo-Service. (n.d.). Jubrele 75 Mikrogramm Filmtabletten: Fachinformation (Desogestrel). Retrieved October 24, 2026, from https://www.fachinfo.de/fi/detail/013955/jubrele
[7] Nolan, B. J., Liang, B., & Cheung, A. S. (2021). Efficacy of micronized progesterone for sleep: A systematic review and meta-analysis of randomized controlled trial data. The Journal of Clinical Endocrinology & Metabolism, 106(4), 942–951. https://doi.org/10.1210/clinem/dgaa873
[8] British Menopause Society. (n.d.). Progestogens and endometrial protection [BMS Tools for Clinicians]. Retrieved October 24, 2026, from https://thebms.org.uk/wp-content/uploads/2023/04/14-BMS-TfC-Progestogens-and-endometrial-protection-APR2023-A.pdf
[9] Rossouw, J. E., et al. (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women: Principal results from the Women’s Health Initiative randomized controlled trial. JAMA, 288(3), 321–333. https://doi.org/10.1001/jama.288.3.321
[10] U.S. Food and Drug Administration. (2026, February 12). FDA approves labeling changes to menopausal hormone therapy products [Press release]. https://www.fda.gov/news-events/press-announcements/fda-approves-labeling-changes-menopausal-hormone-therapy-products
[11] The North American Menopause Society. (2022). The 2022 hormone therapy position statement of The North American Menopause Society. Menopause, 29(7), 767–794. https://doi.org/10.1097/GME.0000000000002028
[12] Cintron, D., et al. (2017). Efficacy of menopausal hormone therapy on sleep quality: Systematic review and meta-analysis. Endocrine, 55(3), 702–711. https://doi.org/10.1007/s12020-016-1072-9
[13] Edinger, J. D., Arnedt, J. T., Bertisch, S. M., Carney, C. E., Harrington, J. J., Lichstein, K. L., Sateia, M. J., Troxel, W. M., Zhou, E. S., Kazmi, U., Heald, J. L., & Martin, J. L. (2021). Behavioral and psychological treatments for chronic insomnia disorder in adults: An American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 17(2), 255–262. https://doi.org/10.5664/jcsm.8986
[14] McCurry, S. M., et al. (2016). Telephone-based cognitive behavioral therapy for insomnia in perimenopausal and postmenopausal women with vasomotor symptoms: A MsFLASH randomized clinical trial. JAMA Internal Medicine, 176(7), 913–920. https://doi.org/10.1001/jamainternmed.2016.1795
[15] somnio. (2025, August 1). So verordnen Sie somnio Ihren Patient:innen. https://somn.io/fachkreise/somnio-verschreiben/
[16] Dunietz, G. L., Chervin, R. D., Tauman, R., Shaklai, S., & Sankari, A. (2026). OSA in women: Associations with reproductive aging and screening challenges. Chest, 169(3), 803–812. https://doi.org/10.1016/j.chest.2025.08.001