When should you change strategies for insomnia?

The sleep hygiene techniques we learned about in graduate school are now proven inadequate as a stand-alone for most insomniacs. Read on to know more about what the recent science says, and for information on a more practical, comprehensive approach.

There is no doubt that insomnia is a major problem for many clients that impacts quality of life and affects our health outcomes. It seems like I have heard the entire range of human sleep circumstances that contribute to insomnia over my career in mental health.

There are work and worryaholics, temporary intense real-world stressors, people who have problems with boundaries and saying "no" to too many obligations, messed up circadian rhythms related to behavioral choices including screen use, or inevitable rhythm disruptions including caretaking, shift work, and loud environments, the co-pet and co-sleeping insomniacs, the biological insomniacs due to issues with serotonin, or HPA axis dysregulation, a myriad of medical factors, hormone imbalances and menopause related challenges including hot flashes/night sweats and nocturia (frequent urination that affects both men and women for different underlying reasons), as well as those with sleep disorders including chronic obstructive sleep apnea, restless leg syndrome, chronic pain and more.

Sleep hygiene should now be considered the standard MINIMUM intervention, and if insomnia is persisting, then a more comprehensive approach is warranted. Giving yourself a real critical evaluation of your pre-bed ritual and sleeping arrangements requires honesty. If there is something in your environment that you need to change. Do that first. Then if the problem isn't resolved in 4-6 weeks, one needs to go further, and often, that means a comprehensive multidisciplinary approach.

Understanding Insomnia

Insomnia — difficulty falling asleep, staying asleep, or obtaining restorative sleep — is one of the most common sleep disturbances. Beyond being a nuisance, it has serious implications for mental health, daily functioning, and overall wellbeing. Research shows that insomnia is closely tied with stress systems, hormonal dysregulation, and neurotransmitter imbalances.

Why it matters

• Poor sleep is strongly associated with increased stress, anxiety, depression, and reduced cognitive performance. (PubMed)

• Insomnia is not just “bad habit” sleep — neurobiological systems (hormones, neurotransmitters, circadian rhythms) are often involved. (PubMed)

• Thus, effective coping must address both behavior (sleep hygiene) and underlying physiology (hormones/neurotransmitters), not just one or the other.

The Role of Hormones & Neurotransmitters

Hypothalamic–Pituitary–Adrenal (HPA) axis & cortisol

• When stress activates the HPA axis, it increases ­‐ among other things – the release of corticotropin‑releasing hormone (CRH), adrenocorticotropic hormone (ACTH), and ultimately cortisol. (PubMed)

• Higher evening or nocturnal cortisol levels have been found in people with insomnia; this may lead to fragmented sleep and more awakenings. (PubMed)

• One study found a positive correlation between insomnia severity (measured by the Insomnia Severity Index) and morning cortisol levels (r ≈ 0.37) in a sample of adults. (PubMed)

• Implication: If your system is “wired” (high stress or cortisol) at night, it becomes much harder to switch into the relaxed physiology required for good sleep.

Melatonin and circadian regulation

• ­Melatonin is the hormone produced by the pineal gland in darkness, signaling “nighttime” to the body, helping initiate and maintain sleep.

• A study found that patients with primary insomnia had significantly lower nocturnal melatonin production compared to healthy controls. (PubMed)

• Implication: If melatonin production is suppressed (e.g., because of light exposure, circadian misalignment, stress), the night‐time “sleep signal” may be weak.

Neurotransmitters: GABA, adenosine, orexin etc.

• Sleep and wakefulness are regulated by multiple neurotransmitter systems: GABA (inhibitory), adenosine (sleep pressure), orexin/hypocretin (wake promotion), monoamines (serotonin, noradrenaline). (PubMed)

• While detailed human research on each system in insomnia is still evolving, the broad takeaway is that neurotransmitter imbalances (for example, too little GABAergic signaling, too much wake‑promoting orexin/noradrenaline) may impair sleep initiation or maintenance.

• Implication: Behavioral interventions (reducing arousal, promoting relaxation) and sometimes pharmacological or supplemental strategies work by indirectly modulating these neurotransmitter systems.

Perimenopause & Menopausal Factors

What to know

• Sleep problems are very common during perimenopause and post‑menopause. One narrative review reports that up to 40 % of women in perimenopause and up to 60 % of post‑menopausal women report poor sleep quality. (Frontiers)

• A large cross‑sectional study of 6,179 women found that post‑menopausal women were more likely than pre‑/perimenopausal women to take ≥30 minutes to fall asleep and to screen positive for possible obstructive sleep apnea (OSA). (Lippincott Journals)

• A meta‑analysis of perimenopausal women (n ≈ 11,928) found significant risk‑factors for sleep disorders: depression (OR ≈ 2.73), hot flashes (OR ≈ 2.70), chronic disease (OR ≈ 1.39), psychotropic drug use (OR ≈ 3.19). (PubMed)

• Longitudinal data (from the Study of Women's Health Across the Nation “SWAN” cohort) show that sleep disturbance worsens during the menopausal transition (for example insomnia symptoms increased from ~31% at baseline to ~42% after 10 years) in a multi‑ethnic cohort of women aged 42–52. (Lippincott Journals)

Mechanisms & contributing factors - hormonal changes

• Declining and fluctuating levels of estrogen and progesterone during perimenopause and menopause are thought to influence sleep. For example, studies found associations between lower estradiol/higher follicle‑stimulating hormone (FSH) levels and increased awakenings in perimenopause. (menopause.org.au)

• Estrogen has multiple roles: regulating thermoregulation (so its decline contributes to vasomotor symptoms like hot flashes/night sweats), influencing neurotransmitter systems (serotonin, GABA) and modulating sleep‑wake states. (JCHR)

• Progesterone also has sleep‑promoting (sedative) effects, though the evidence of its direct role in the menopausal sleep changes is less consistent. (menopause.org.au)

Vasomotor symptoms (VMS)

• Hot flashes and night sweats are strongly correlated with sleep disruption. The sudden surges of heat/night sweats can awaken women, fragment sleep, and reduce perceived sleep quality. (Hopkins Medicine)

• However, the literature makes clear that VMS do not fully explain the sleep disturbance: even women without prominent hot flashes may report worsened sleep, meaning other mechanisms (hormonal fluctuations, aging, psychosocial factors) also contribute. (PubMed)

Aging / physiological changes

• Some of the sleep changes are not unique to menopause but reflect aging (e.g., reductions in slow‑wave sleep, increased awakenings). For example, a 6‑year polysomnography follow‐up found that aging accounted for shorter total sleep time, reduced sleep efficiency, more wake after sleep onset and more transitions from slow‐wave sleep to wakefulness. (PubMed)

• But menopause appears to add an extra burden: hormone changes, hot flashes/night sweats, frequent urination, and other mid‑life changes multiply the risk.

Circadian & other neurochemical changes

• Fluctuations and declines in reproductive hormones may influence circadian regulation and melatonin secretion, contributing to altered sleep‑wake timing or diminished sleep drive. (PubMed)

• Some emerging mechanistic work implicates hypothalamic KNDy (kisspeptin/neurokinin B/dynorphin) neurons in linking reproductive hormone decline, thermoregulation and sleep disturbance. (MDPI)

Psychosocial and health comorbidity factors

• Depression, anxiety, caregiving stress, chronic diseases, medication use (psychotropic drugs), nocturia (frequent urination at night), obesity, and sleep‐disordered breathing all contribute to sleep problems in menopause. For example, meta‑analysis found depression doubled to tripled the risk of sleep disorders in perimenopausal women. (PubMed)

• Sleep disorders like sleep apnea and insomnia may also be under‑recognized in post‑menopausal women, further worsening sleep quality. (Hopkins Medicine)

Implications & treatment considerations

• Because sleep disturbance in perimenopause and menopause is multifactorial, optimal management requires an individualized, multi‑modal approach. The narrative review emphasizes that hormone therapy, behavioral interventions and non‑hormonal pharmacotherapy including taking phytoestrogens from sources like soymilk/soybeans/tofu all have roles. (PubMed)

• Non‑pharmacological interventions (sleep hygiene, cognitive behavioral therapy for insomnia [CBT‑I], cooling bedtime environment for night sweats, stress‐management) are first‑line for many women. (PubMed)

• Hormone replacement therapy (HRT) may improve sleep in some women (especially when VMS are prominent), but it is not a universal remedy, and risks/benefits need to be weighed individually. (Hopkins Medicine). Additionally, medications that reduce urinary urges for nocturia can also be helpful along with treatment of any underlying medical conditions that contribute.

• Because sleep disturbance in peri-menopause and menopause is associated with cardiometabolic risk (e.g., increased body fat, lipid changes, vascular changes) the impact of poor sleep may extend beyond quality‑of‑life to longer‑term health outcomes. (MDPI)

Sleep Hygiene

Sleep hygiene refers to the set of behavioral and environmental practices that support good sleep (regular schedule, comfortable environment, limiting caffeine/alcohol, etc.). But how strong is the evidence?

What the evidence shows

• A systematic review & meta‑analysis found that sleep hygiene education (SHE) alone produced a moderate improvement in insomnia severity (mean difference ≈3.4 points on ISI) across 42 RCTs (n ≈ 4,245). (PubMed)

• However, SHE alone was inferior to fuller programs such as cognitive behavioral therapy for insomnia (CBT‑I). (PubMed)

• Another study found strong positive associations between good sleep hygiene practices (consistent schedule, avoiding caffeine/alcohol late, relaxing routine, sleep‑stimulating environment) and improved sleep quality, especially among younger adults. (PMC)

• Implication: sleep hygiene helps, and is a necessary foundation, but often not sufficient alone for moderate/severe insomnia.

What “good sleep hygiene” means in practice

1. Regular sleep schedule – go to bed and wake up at same times daily (including weekends) to stabilize circadian rhythm.

2. Sleep‑promoting environment – dark, cool, quiet room; comfortable bedding; remove screens/light sources.

3. Pre‑bedtime routine – wind‑down activities (reading, light stretching, relaxation) 30–60 minutes before bed; avoid stimulating activity including online activities and gaming.

4. Avoid stimulants & – caffeine (especially after ~2 pm), and the powerful stimulant nicotine should be avoided if you have insomnia; alcohol may help sleep onset but disrupts sleep later in the cycle.

5. Limit naps – long or irregular daytime naps may reduce sleep pressure.

6. Exercise – regular daytime exercise helps; but avoid vigorous workouts close to bedtime.

7. Mind your light exposure – get bright light in the morning (helps circadian entrainment); minimize blue‑light/bright screens before bed.

8. Limit worry/rumination – if you find yourself lying awake worrying, adopt a “worry time” earlier in the day or use note‑taking to offload thoughts.

9. Implication: Use sleep hygiene as your “baseline” intervention while simultaneously addressing the physiological factors described above.

A Comprehensive Coping Strategy

Here’s a step‑by‑step plan integrating behavioral, hormonal, and neurotransmitter factors:

Step 1: Assess and stabilize your sleep rhythm

• Pick a realistic consistent bedtime and wake time; aim for 7 + hours in bed (for most adults).

• Get morning light exposure soon after waking (for circadian alignment).

• Keep your room dark (ideally < 30 lux) at bedtime to allow melatonin to rise naturally.

Step 2: Manage stress and arousal

• Practice relaxation techniques in the evening: deep breathing, progressive muscle relaxation, mindfulness. These help reduce HPA axis activation (and therefore cortisol).

• If your life/stress load is high (work, family, health issues), consider psychological support (e.g., CBT, counseling) to mitigate chronic arousal.

• If you are having a hard time with the willpower to change behaviors you know are detrimental to your sleep, therapy is indicated.

Step 3: Optimize metabolic/physiological signals for sleep

• Avoid heavy meals, caffeine, nicotine, alcohol in the 4‑6 hours before bed.

• Moderate daytime exercise is beneficial; avoid intense workouts too late.

• Ensure temperature, bedding, and comfort are optimized so your body can transition to physiological sleep mode. Remove or adapt behaviors to address external triggers that could cause awakening.

Step 4: Use targeted strategies for neurotransmitter/hormonal support

• Melatonin: Ensure darkness in the evening; consider a melatonin supplement only under medical advice if endogenous production seems impaired.

• GABA/relaxation systems: Wind‑down routines help shift you from wake‑promoting (noradrenaline/orexin) to sleep‑promoting states (GABA, adenosine).

• Cortisol & arousal suppression: Evening practices that lower cortisol (relaxation, avoiding bright screens, low arousal) help. Remember: elevated evening cortisol correlates with worse insomnia severity. (PubMed)

• Adenosine (sleep pressure): Staying awake long enough builds sleep pressure; overly long naps or too‑early bedtime may reduce this pressure and thus delay sleep onset.

Step 5: When to progress to more intensive treatment

If after 4‑6 weeks of consistent behavioral and physiologic work you’re still struggling with falling asleep or maintaining sleep, then you should consider a next level intervention

• Cognitive Behavioral Therapy for Insomnia (CBT‑I) is first‑line for chronic insomnia and has strong evidence of efficacy. (BioMed Central)

• Consider consultation with a sleep specialist to assess for underlying sleep disorders (e.g., sleep apnea, restless legs), medical contributors (thyroid, pain, urinary problems, hormone imbalance, mood disorders) or appropriate pharmacological support.

• Consult an endocrinologist, urologist, psychiatrist, gynecologist, or neurologist for the appropriate evaluation of hormones/neurotransmitters and pharmacological help. Remember that you are your own best advocate. Do not stop getting consultations until you are satisfied with the expert opinions you have received.

  
  

What to Avoid

• Thinking sleep hygiene alone will “cure” moderate/severe insomnia — as the evidence indicates, hygiene helps but often isn’t sufficient alone. (PubMed)

• Inconsistent routines — going to bed/waking up at wildly different times undermines circadian stability.

• Using the bed for wakeful activities (work, screen time) — creates a mis‑association between bed and wakefulness.

• Napping too long or too late — reduces homeostatic sleep pressure.

• Ignoring physiological underpinnings — if you simply “do the hygiene” but your system remains stressed/aroused (high cortisol, high wake‑promoting neurotransmitters), you need a more comprehensive approach.

• Accepting a "brush off" by a mental health or healthcare provider, or using addictive medication that doesn't address the root cause of your insomnia.

• Expecting immediate perfection or trying to do it on your own when that isn't working — improving sleep takes time; many interventions show a benefit after several weeks of consistency.

  
  

Insomnia is complex — but it’s treatable with a multi‑layered approach. By combining robust sleep hygiene behaviors, stress/arousal management (affecting HPA axis and cortisol), and supporting the proper functioning of sleep‑promoting hormones/neurotransmitters or physical/pharmacological interventions, you stack the odds in your favor.

Be well, get help if you need it.