Everything You Wanted to Know About Sleep
(But Shouldn’t Stay Up to Read About)
Ah, sleep. It feels so good to sleep well, right?
A good night’s sleep (or preferably many of them) not only feels great, but is also an important part of your health. Poor sleep is linked to increased risk of cardiovascular disease (heart attack and stroke), depression, anxiety, weight gain, substance abuse, and auto accidents.
It is estimated that insomnia–defined as difficulty sleeping or poor quality sleep–affects around 30% of adults, with 10% of them reporting chronic insomnia (difficulty with sleep at least three times a week for three months).
Let’s first look at the different ways in which people struggle with sleep, and then dive into some of the common reasons for insomnia. Then we’ll explore sleep-related issues that are more specific to functional medicine. Finally, we’ll provide a list of a few natural sleep supplements that are safe and effective.
While there are as many as 90 different types of sleep disorders, there are basically two categories of sleep problems: sleep-onset and sleep maintenance insomnia
- Sleep-onset insomnia refers to difficulty falling asleep. This type of insomnia may occur with people who have a hard time relaxing in bed, as well as people whose circadian rhythm is not in sync due to factors like jet lag or irregular work schedules.
- Sleep maintenance insomnia refers to difficulty staying asleep after initially nodding off. This type of insomnia is common in elderly sleepers, as well as people who consume caffeine or tobacco before bed. Certain disorders like sleep apnea and periodic limb movement disorder (restless leg syndrome) can also cause sleep maintenance insomnia. Two other big causes are HPA Axis Dysregulation (commonly known as adrenal fatigue) and hormone imbalance issues, particularly perimenopause and menopause. We’ll discuss these two common functional medicine-oriented causes later in this article.
Common Causes of Sleep Disruption
In addition to the causes of insomnia enumerated above, there are many other reasons why you may not be sleeping well, including:
- Spending too much time in front of a screen prior to bedtime. The light emanating from the screen can decrease melatonin levels. Melatonin is our main sleep hormone and is produced by the pineal gland in the brain. The natural ebb and flow of melatonin in response to light is what defines our circadian rhythm. It would make sense, then, that our pineal gland has a connection to our eyes, where light enters. Our screens can trick our pineal glands into thinking it is daytime, even when it is dark outside. Putting away our screens at least an hour before bedtime can help. Even turning down the brightness of the screen helps.
- Erratic sleep schedules. Staying up until a different time every night makes it hard for us to get into a good sleep schedule. If you have children, you know that if you put them to bed at about the same time each night, you can fairly predictably know when they’ll wake in the morning (notice I said fairly predictably–we’ve all had those nights). The same is true for adults. We each have a natural sleep cycle. Regardless of whether you’re a “morning person” or a “night owl”, going to bed at about the same time each night and getting up at about the same time each morning helps to reinforce your natural schedule, allowing us to sleep better.
- Stimulation too close to bedtime. This can refer to the obvious stimulants, such as caffeine, nicotine, and even certain medications or supplements (think: sudafed in cold medications or activating supplements like SAMe for some people). It can also refer to getting too stimulated as you are trying to wind down. Having a heated discussion with a friend or family member right before bed can derail your sleep efforts, as can exercise right before bed.
- Drinking alcohol. While alcohol is generally sedating, it can be disruptive to sleep. In general, it decreases sleep quality, causing you to wake up as the alcohol is metabolized while you sleep. This is especially true for sugary alcoholic beverages like wine. And for many women in perimenopause and menopause, this response to alcohol is amplified by the hormonal shifts characteristic of this time. Sigh. Not fair!
- Uncomfortable sleep environment. An uncomfortable mattress, overly-heated bedroom, light and noise, and pets who sleep with you can all make good sleep difficult. Investing in a quality mattress and light-blocking shades, turning down the thermostat a few degrees, and to the best of your ability controlling noise in your sleep environment can really help.
Causes of Insomnia Your Functional Medicine Doctor is Thinking About
As mentioned above, when we are evaluating insomnia during a functional medicine consultation, we are often thinking about conditions that are overlooked by the traditional medical community. Let’s discuss a few of those next.
HPA Axis Dysregulation
HPA stands for hypothalamus, pituitary, adrenals. HPA Axis Dysregulation, also commonly known as adrenal fatigue, is one of the most common reasons we see for sleep issues. In a nutshell, this condition occurs when chronic stress drives up our stress hormone, cortisol. When this occurs repeatedly, elevated cortisol levels (which should be low at night) make it difficult to fall asleep. Or, our cortisol levels spike too high at night after falling asleep, and we wake abruptly and can’t get back to sleep. The classic time for this type of waking is at 3:00 a.m., when cortisol levels are naturally rising. People with adrenal fatigue often complain of being “tired and wired”: feeling slightly “hyper” at night, but exhausted at the same time. We’ve written extensively about this topic
Addressing HPA Axis Dysregulation involves evaluating your cortisol levels through salivary testing and then introducing the appropriate supportive herbs and nutrients depending on your levels, such as phosphatidylserine, magnesium, rhodiola and ashwagandha. It goes without saying (but I’ll say it anyway) that managing stress is also an important cornerstone for helping you sleep better if adrenal fatigue is the root cause of your insomnia.
Hormone Balance Issues
At any time in a woman’s reproductive years, hormone imbalance can drive issues with sleep. However, the effect becomes significantly more pronounced in perimenopause and menopause. Precipitous falls in estrogen cause hot flashes and palpitations, and low progesterone makes sustained sleep difficult. Regardless of stage in life, evaluating and treating women’s hormone imbalances can be extremely helpful in restoring restful sleep. Natural approaches like DIM (diindoylmethane) to balance estrogen and Chastetree Berry (otherwise known as Vitex) to balance progesterone can be helpful, as can natural hormones, like bioidenticals, in the right woman.
Single Nucleotide Polymorphisms
Single nucleotide polymorphisms, or SNPs, are changes in genes that impact your ability to process certain chemical reactions in your body. SNPs in certain genes, like COMT (C-O-methyltransferase) can make it difficult to break down adrenaline once it is released by the adrenal glands during stress. COMT also impacts hormone balance and detoxification, specifically estrogen. These genomic issues can be overcome with the proper supplementation to support the gene, often with dramatic impact on sleep and anxiety.
Neurotransmitters are chemicals in the brain that are responsible for mood. They are generally divided into two groups: inhibitory and excitatory. Deficiencies in inhibitory neurotransmitters (those that relax us) or an excess of excitatory neurotransmitters (those that stimulate us) can have the unintended effect of causing sleep issues. By measuring neurotransmitters through urine, we can determine if there are imbalances here, and then appropriately target these with supplements like GABA, 5-HTP, or Macuna, or sometimes medications.
Natural Sleep Approaches to Consider
In addition to making sure your sleep environment and habits are supportive of a good slumber, some additional natural approaches you could consider to help with sleep are:
- Melatonin (see “supplement spotlight” in this newsletter)
- Lavender (taken internally as a capsule, or used as aromatherapy, or both)
- Valerian root
Two of the most important hormones involved with sleep are melatonin and cortisol (the chronic stress hormone released by the adrenals). And not just cortisol, but the balance and interplay between cortisol (pro-inflammatory) and cortisone (anti-inflammatory). Both are released by the adrenal gland in response to stress, but because they have different roles, understanding how they are balanced is key.
Using Sleep Balance, a urine-based test done at home that evaluates the diurnal (or daily fluctuations) of melatonin, cortisol, and cortisone, you can better understand your circadian rhythm and where you and your physician can intervene to help improve your sleep.
Melatonin is a hormone made by the pineal gland–a pea-sized gland found just above the middle of your brain. It helps your body know when it’s time to sleep and wake up.
Levels of melatonin naturally rise in the evening once the sun sets, then drop in the morning when the sun comes up. The amount of light you get each day — plus your own body clock — set how much your body makes.
Taking a melatonin supplement can be an excellent way to restore good sleep. There are two basic forms of oral melatonin: immediate release and sustained release.
Immediate release melatonin is absorbed quickly (typically given as a liquid under the tongue or a spray) and can help return you to sleep quickly if you awake and are struggling to go back to sleep. It is also metabolized more rapidly by the body, and therefore, less risk of a “hangover” in the morning.
Sustained release (SR) melatonin, as the name suggests, is a slower-onset form of melatonin. It is generally given in capsule form and tends to help keep you asleep longer. It is possible to use a sustained-release form of melatonin when you go to bed, and if you wake up and are unable to go back to sleep, you take immediate-release melatonin to return to sleep.
The common starting dose for melatonin (either immediate or sustained) is 1-3 mg, but it can safely be given at higher doses (12-15 mg or higher). Until you know how melatonin affects you, we recommend starting a lower dose and increasing as needed. The most common side effect of melatonin is vivid dreams, but in general, it is otherwise very well tolerated.