Welcome to Everyday Wellness Podcast. I'm your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives. This is the start of a new Thursday series called the Midlife Minute that is really designed to address listeners' questions in a little bit longer length of time and or deeper dive into topics. Ideally we're going to keep these podcasts under 20 minutes. Occasionally we may go over to 30, but I'm trying to reinforce some key concepts and ensure that I'm addressing listeners' questions in a way that's really helpful. The questions that I will be addressing topics are going to be items that I'm being asked over and over and over again. I hope you enjoy this series. Please share with your friends. As you know, you can always send your questions to support at synthiethurlow.com. I appreciate each and every listener. Okay, we're back for a Midlife Minute. I counted 15 questions in my spreadsheet that were specific to this very question. Why do I wake up at 2 a.m., 3 a.m., 4 a.m. every single night? I'm going to talk about 10 reasons why this end happens. I've linked some research in the show notes that you can take a look at for those that want to learn a little bit more. We know that waking between 2 and 4 a.m. is not at all unusual. Hopefully if you're experiencing this, it's episodic. It's timed with your cycle, perhaps in the luteal phase when progesterone is declining, plus or minus you're someone that may be dealing with more stress, which is common to see in perimenopause, and or you're a woman in menopause who's struggling with sleep overall, falling asleep, staying asleep, you're struggling. In fact, there was a wonderful nurse in a program that I had a few years ago who said she hadn't slept well in 10 years. Let's dial in on why this happens. Obviously, it's multifactorial. There are multiple reasons why this happens. Some of it's hormones, some of it's stress physiology that starts to change, some of its metabolic factors, but I'm going to give you 10 reasons why it happens. Number one, common to see cortisol spikes that will disrupt sleep. The cortisol spikes themselves will actually initially increase blood sugar and then has the ability to drop them. We know that if your blood glucose or blood sugar drops at night, your body releases counter regulatory hormones to address this. Things like epinephrine and cortisol will be released to save you. We know that we don't need saving per se, but your body doesn't perceive that any differently than you're being chased by a rabid animal. It releases these counter regulatory hormones, which can wake you up. This will actually be what is the precipitant for waking up at night. We know that sometimes this can be exacerbated if we're calorically restricted, if we're doing too much intermittent fasting, maybe too much dieting in general, which can actually drive this phenomenon. Sometimes it's interesting when I have conversations with women, some of the things that they'll share. If you are chronically in diet mode, if you are over-fasting, if you are not properly feeling your body, your body may be stressed. It's not to suggest that you can't safely change body composition in perimenopause or monopause, but if your body perceives it's too much stress for too long a period of time, you can see this happen. Those nighttime arousals can be, again, specific to these counter regulatory hormones being released. There are some people that are just really sensitive to carbohydrates. We know that the average American consumes way too much processed carbohydrate, but there are even women that have a nuance to the amount of carbohydrates their body needs in order to sleep properly. I'll give you an example. We've had women in programs that have had to restrict their carbohydrate intake because they were not consuming nutrient-dense whole carbohydrates. They were consuming bread and pasta and processed carbohydrates and too much of them. Providing them to lean into root vegetables and plus or minus grains if they tolerate that, plus or minus low glycemic berries, et cetera. I've found that there are sometimes thresholds. There are some women that will not sleep well under 100 grams of carbohydrate under 75 grams, under 50 grams. This is where that bio-individual approach really becomes necessary to do a little bit of experimentation. Track, measure, and see how you respond. Next is the cloning progesterone. We know that progesterone is very important for upregulating a metabolite called allopregnenolone that has a nice sedating effect. If we have less circulating progesterone, if we have less allopregnenolone, we have less inhibitory neurotransmitter GABA. GABA is really important for helping us relax and fall asleep. The loss of those GABA effects are quite significant. We know that progesterone activates the GABA receptors, promotes a deeper, more stable sleep. You'll see me looking down because I'm looking at some research. We know that as progesterone starts to decline in perimenopause, we can start having more trouble falling asleep. We may wake up anxious. We may wake up feeling like our mood is off. Those nighttime awakenings can also increase. Just be thinking that oral progesterone, oral micronized progesterone might be better to start earlier rather than later. I actually wish I had done it earlier because I spent so many far too many years trying to re-engineer my sleep and what I probably needed was a week or two of oral progesterone. There's randomized controlled trials that show that oral micronized progesterone, which is the inexpensive stuff that's non-sustained release, improves sleep outcomes in menopausal women, a placebo-controlled randomized controlled trial, found progesterone reduce night sweats and improve sleep quality. Active of where you are in the trajectory of perimenopause and menopause. If your sleep's starting to go south, talk to your prescriber. Notice I'm saying the word prescriber. Go to a licensed medical provider who can make the prescription for you. I feel like there's been an influx or an uptick in male non-prescribers giving women misinformation or judging them for taking hormone replacement therapy. Let me be clear. There's a lot of lifestyle that's very important for sleep quality, but no one should shame you whether you do or don't take hormones. If I were to say at 54, if I'd known this at 44, I would have started oral progesterone the way earlier and I would encourage all of you if you're in your late 30s, early 40s, have that conversation earlier rather than later, you do not need to suffer. On the other side is estradiol, right? So this is the predominant form of estrogen our bodies make prior to going into menopause. We know that serotonin is intricately interwoven with estradiol. As estradiol is fluctuating, so perimenopause, we can get 20 to 30% greater levels of estradiol, but we're still seeing fluctuations in estradiol. If estradiol is low, guess what's also going to be low? Serotonin is very intricately involved in mood. It's also involved in melatonin production. So less estrogen, less serotonin, less melatonin, and it impacts thermoregulation. It impacts our ability to control our own internal thermostat. So this is oftentimes when women will say, I mean, they're getting hot flashes, night sweats. I just feel like I can't cool down. I recall in 2018, so this is a long time ago, eight years ago, I was in Morocco with my husband and it was gasly hot. Like I actually describe it as an oven and we had a wonderful time when we were there other than me picking up food poisoning and I was so hot. I could not. I was sweating constantly. It was very warm. But I recall I really struggled with thermoregulation. I was so hot when I was in Marrakesh that I just remember I was sweating buckets walking around and it was warm. I mean, let me be clear. It was very warm. It was over 40 degrees Celsius, very, very hot. But the lack of estrogen in my body made it a whole lot harder for my body to accommodate to the heat, to dissipate the heat. Okay. So when estrogen fluctuates, obviously night sweats, hot flashes, poor thermoregulation, your sleep architecture goes south. Oftentimes with estradiol, we see more staying asleep as opposed to the falling asleep piece with progesterone. And this is where we might get those early awakenings. When women are telling me they're waking up at four o'clock, five o'clock and they don't want to be up that early, that could be estradiol. There was a meta-analysis of 15 randomized controlled trials showed that hormone therapy improved sleep quality in most studies. Other trials showed significant improvements in sleep efficacy with estradiol replacement therapy. Again, make sure you see your prescriber. So if you are at the point where you need estradiol therapy, whether it's a patch, whether it's a gel, whether it's compounded, you do you. So I always say like, find what works for you. I do best with a patch because it's consistent. The other thing was that replacing estradiol, improved sleep in women with vasomotor symptoms, there's a lot to vasomotor symptoms. It's not just the estrogen piece. Oftentimes it can also be blood sugar dysregulation. Okay. Next is chronic stress and sympathetic dominance. If your body thinks you are constantly stressed in this kind of sympathetic dominance, so we have the autonomic nervous system, we have the parasympathetic, the sympathetic, most of us get shit done kind of people are sympathetic dominance. So you have to work harder at showing your body you don't need to be in that get shit done kind of methodology all the time. We know that your cortisol rhythms can be impacted by being sympathetic dominant. We know that you can wake outside your normal kind of natural circadian biology. And so I think a lot about the degree of weight loss resistance that women experience in middle age and this kind of chronic dieting culture that we have all grown up in my entire generation, thin as in that was what we were kind of taught skinny is better. We know that's not the case. And so this chronic dieting culture, especially when women are weight loss resistant or struggling to lose weight, we know that caloric restriction and stress can increase cortisol and cortisol is not a bad hormone. It gets a terrible rap, but I remind women that cortisol, if elevated for too long can impact your immune function can lead to leaky gut can break down your muscle. So catabolism becomes a problem. And so I just want to reaffirm why it's so important to manage your stress properly. We know that it can disrupt your sleep. So I know that episodically, like every human being out there, we have some moments in our lives that are more stressful than others. We have to do more to manage our stress in middle age. We must. It's not five minutes of meditation. I think I made a list on Instagram stories last week just to kind of reaffirm like these are all the things I'm doing in the midst of a book launch because I have so many things on my plate. I'm so grateful for that. But I have more travel, more podcasts, more press, more demands placed on me than I've ever had in a really long time. And so I have to do more. And so getting sunlight exposures and non-negotiable grounding work when it's not single digits is non-negotiable. Exercise is non-negotiable. Meditation is non-negotiable. PMF therapy, although I didn't even get on my mat this weekend, shame on me. But making sure I'm doing the things that I know alleviate stress and allow me to feel I'm not so feeling that kind of symptomatic way that we feel when we're overtaxed. We just feel irritable. We're grumpy. I jokingly told my own prescriber I was like, I think I need more estradiol right now just because I feel like I'm a little more irritable, a little more edgy. And it's probably because there are more demands placed on me just like there are for many of you. If you're in perimenopause or menopause and are feeling more fatigued, dizzy, lightheaded, struggling with headaches or noticing your workouts feel harder than they used to, electrolytes may be part of the missing piece. As estrogen declines, we lose some of the fluid regulating and vascular protective effects that hormones once provided. That means blood pressure regulation can shift, cortisol can run higher, and many women become more sensitive to dehydration, especially if you're strength training, walking more, intermittent fasting, or reducing processed foods. That's why I love element. It is my favorite electrolyte formulation and I've exclusively used their products for the past six years. Element contains a science-backed ratio of sodium, potassium, and magnesium without sugar, artificial ingredients, or unnecessary fillers. It supports hydration at a cellular level, helps reduce muscle cramps, improves energy, as well as recovery, and can even support better stress resilience. This is particularly helpful in midlife when we're prioritizing metabolic health and muscle preservation. I personally use Element throughout the day and it's become a staple in my routine as well as my household. If you'd like to try it, go to drinkelement.com slash Cynthia to receive a free sample pack with any purchase. Stay hydrated, stay strong, especially in midlife. If you're in your 40s and 50s and feel like your body suddenly stopped responding the way that it used to, you're not imagining it. Bloating, waking, sleep disruptions, food sensitivities, and unpredictable energy are incredibly common in perimenopause and menopause. But here's what most people aren't told. Your gut microbiome is changing right alongside your hormones and those changes can influence everything from how you store fat to how well you sleep to how your body processes estrogen. That's exactly why I wrote my new book, The Menopause Gut. In this book, I walk you through the science of how the microbiome, metabolism, immune system, and hormones are all connected during midlife. But most importantly, I give you practical, realistic strategies you can start using right away without extreme diets or complicated protocols. You'll learn why the same diet that worked in your 30s may not work now, how your gut influences hot flashes, mood, and weight, the truth about fiber, protein, and blood sugar in midlife, and the daily habits that help your body feel safe, stable, and resilient again. If you're tired of blaming yourself for changes that are actually biological, this book will help you understand what's really happening and what to do about it. You can pre-order The Menopause Gut wherever books are sold, and when you do, be sure to check out the special pre-order bonuses I've put together for you. Again, you can go to www.CynthiaTherlo.com. You'll click on the banner. It'll take you to multiple options for where you can order The Menopause Gut in pre-sale. Number five, under-fueling and over-exercising. Common issue. Women tend to, in middle age, they're like, if I am dealing with weight loss resistance, I just need to eat less and exercise more, right? I just need to be more calorically restricted. Too many of you are under-nourishing your bodies, not just one or two days out of the week chronically. You're skipping meals, you're over-fasting, you're overtraining, you're not allowing rest days. We know this impacts these counter-regulatory hormones that I've already mentioned, cortisol, adrenaline, and that can lead to a larger impact on sleep quality. That can impact our recovery. That can impact our ability to get over a simple virus. That can impact our ability to interact in a healthy way with our loved ones or close friends. I think this goes back to, can you consume enough protein in your day-to-day life? If the answer is yes, great. What I see is most women are under-fueling their bodies. They're under-eating protein. They're worsening their muscle loss. The more muscle loss you lose, the less insulin-sensitive you are. It becomes a vicious battle. If you're intermittent fasting, understand that it is okay to have moments in your life where you don't fast or you just have 12 hours of digestive rest. Because I have made a priority to maintain and build muscle, I'm doing a lot less fasting and I'm doing a lot more digestive rest, which is 12 hours without eating, which is still plenty of time to get a lot of the same benefits. Just have an honest conversation. Track your macros. Get really granular with yourself. What are your goals for all of us that should be building and maintaining muscle and eating enough protein? Make sure you're fueling your bodies. That is the big takeaway of this conversation. Number six is liver glycogen depletion overnight. When we're asleep, our liver does a really good job of maintaining our blood sugar levels. Our liver will actually reduce something called glycogen. One of its primary roles at night is to maintain our blood sugar. If our glycogen is already low, if you've been overexercising, you've been too low carbohydrate, you're super stressed. Guess what happens? If you don't have enough glycogen in your liver or stored there, your body will release cortisol. Cortisol is your emergency backup system. Cortisol spikes, and guess what that does? It can trigger those counter-regulatory hormones that we've talked about and that can wake us up. We know that diet composition significantly impacts cortisol metabolism. Cortisol is that hormone that is secreted that is designed to live a circadian rhythm that is dependent on light exposure and meals and all these things. We have circadian clocks throughout our body, especially the digestive system. If you are under eating, if you are not eating enough of the right foods, you may get some cortisol disruption. Again, this is why I think it's so important that bio-individual approach. Some women do great with 50 grams of carbohydrates, others may not. That's why I'm not per se a fan of everyone doing ketogenic diets because not everyone tolerates ketogenic diets. That's okay. You may just need an abbreviated lower carbohydrate diet if you're trying to change body composition and then maybe adjusting based on your physical activity. Next is alcohol or late night sugar. I'm thinking about celebrations. You go out at someone's birthday and I want to be clear. We have moments in our lives where we should celebrate and have fun. But it's the late night alcohol. It's the discretionary carbohydrates, the cake that you're having or the pizza or the things that you're eating really late at night. We know that alcohol absolutely disrupts sleep architecture. It disrupts both REM and deep sleep. It increases nighttime cortisol and up regulates that sympathetic activity, which will keep you awake. We know that clinical sleep studies consistently show alcohol fragments REM sleep. I've even seen them suggesting it does it with deep sleep and leads to early awakenings. It also dysregulates glucose. If our glucose is dysregulated, that can exacerbate hot flashes or night sweats that can then lead to poor dietary choices the following day. I jokingly say, you don't crave chicken and broccoli. You're going to crave junk because you haven't slept well. Your sleep's been fragmented. You don't feel rested and you're going to go for the junk. Number eight, sleep apnea or breathing disturbances. I did an amazing podcast on sleep apnea earlier in 2025 that I highly recommend. We'll link it up in the show notes. We know that we are at greater risk for sleep apnea in middle age, especially obstructive sleep apnea, upper airway resistance and hormone related airway changes because progesterone is a smooth muscle relaxant. We know that we just start to see more of these. Plus we're also dealing with some body composition changes. Women tend to not get screened as effectively because we may not have the classic signs that men have. I think I've talked about this before that when I was rounding in cardiology, we would oftentimes ask men what their neck size was, like what their shirt size was. Someone that has 17 inches or higher, we're almost always working them up for sleep apnea because we know that that can be a risk factor. Women don't necessarily have to be obese or have very large necks. We just tend to be more prone to these things in perimenopause and menopause. Apnic periods, whether it's overt sleep apnea or upper airway resistance can lead to these micro arousals that can really disrupt sleep quality. These can oftentimes occur in early morning hours. This is where I think doing polysynography, getting evaluated by sleep specialists is really, really important. The podcast I did was with Dr. Andrea Matsumura, who's wonderful and lovely and is a certified sleep specialist. Next is gut dysfunction and inflammation. Obviously, my new book is all about the gut microbiome and all the changes that can impact our sleep quality. We know that our gut health is intricately related to brain health. There's this gut brain access. The vagus nerve is the communication delivery system between both. If we are deficient in certain types of neurotransmitters, whether it's serotonin, whether it is dopamine, whether it's GABA, we know that serotonin production begets melatonin synthesis and melatonin. We tend to have less of it as we are getting older. Again, melatonin is not just a sleep hormone. It is also a master antioxidant. Many times patients do best when they have a compilation of hormonal replacement. That can even include melatonin. We know that there's a lot more inflammation in the gut, which can drive inflammation to the brain. There is a blood-brain barrier, but more often than not, women have some degree of leaky gut, which contributes to what they affectionately call leaky brain. You get kind of mishaps, misfirings between the vagus nerve and communication. We know that inflammation in and of itself can drive early awakenings. The stress response, more cortisol secretion. The gut-brain access absolutely plays a role. I sometimes will say it could be opportunistic infections. It could be a sign that you have more inflammatory species. You just have to have a balance. We know with the loss of estradiol and progesterone, that can impact the beneficial bacteria that we find in the gut microbiome. It can impact inflammation. We get a reduction in things like short chain fatty acids, which are anti-inflammatory signaling molecules, which also impacts blood sugar, which also impacts communication with the brain, because one of those short chain fatty acids actually crosses the blood-brain barrier. The other thing that I want to emphasize is that some of our nervous system is just designed or it has learned. It has maladaptive patterns, whether it's from our childhood, teens or early 20s, 30s, et cetera. We have a learned nervous system hypervigilance. If you've had chronic stress or trauma or long-term sleep dysregulation, which in and of itself can be a trauma, because if someone is fearful, they will not sleep well. Sometimes it's a self-fulfilling prophecy. I want to emphasize that perimenopause is a zone of chaos. If you have not dealt with your stuff in your teens, 20s, 30s, it will come up for you in your 40s and 50s. I like to share the statistic that Dr. Minnie Pelts shared on a podcast we did together. 70% of the divorces in Middle Asia are initiated by women. I think a lot of that has to do with stuff that we just have not resolved. If our nervous system is primed to be fearful and not feel safe, it can be primed to be awake and to be alert, because your body doesn't feel safe. Whether that's something that occurred 20 years ago, 10 years ago, 5 years ago, or you're in a marriage or a situation where you don't feel safe, that makes it really hard to sleep. There are also people that are just more sensitive to cortisol in their bodies. I always say just like there are women who have bad PMS or bad PMDD, it is not their fault. It is not your fault if you are also conversely more sensitive to cortisol alterations, whether it's high or low. I think that the best thing I can recommend is if you are someone that falls into the you've had a lot of trauma, you don't feel safe, that has to be dealt with. I don't think enough of us are talking about it, that you have to deal with your stuff. Otherwise, it's going to make the rest of your life challenging to deal with, whether it's emotional regulation, whether it's underlying anxiety, depression, etc. Or you just have had a lot of stuff happen and that has been the case for so many women. We tend to stuff it down and then we get into our forties and we're just much more vulnerable. We don't have the same level of hormones that we had in our younger years and it can sometimes bring these things up for us. Across multiple randomized controlled trials, without question, hormone therapy improves sleep quality in menopausal women and I would argue it does the same for perimenopausal women. We know the progesterone specifically improves sleep efficacy and reduces night symptoms. I want to reemphasize the food piece. You have to nourish your body. Not overnourished, not undernourished, there's the Goldilocks effect, the right amount of food during your day to ensure that your body doesn't think it's starving. We keep talking about these themes of if your body perceives things are not safe, it is going to drive the stress response. We know that if you're overly restrictive in your caloric intake, if you're too low carbohydrate, that can increase cortisol and that can lead to early awakenings. As I always say, most of our 3 a.m. or 2 a.m. or 4 a.m. wake-ups are driven by physiology, but per se will power or poor habits. Although there are plenty of you that I'm sure probably have some things you need to kind of dial in and I say that with love and trust me, I was there. I was someone that through most of my 30s and 40s got away with really early exercise, really stressful job, had a husband who traveled, had two small kids. I felt like I was getting it from all ends and now I live very differently. I make different choices and so we learn to adapt but we also have to learn to adapt and make sure that we're still feeling like we're having an enjoyable life. So keep your questions coming. Like I mentioned, this is a compilation of 10 or 15 people asking similarly themed questions around why do you wake up somewhere between 2 a.m. and 4 a.m. I gave you 10 answers. See you in the free Facebook group, the midlife pause, backslash my name, or you can send your questions to support at synthiethorlow.com. If you love this podcast episode, please leave a rating and review, subscribe and tell a friend.
