Why do you wake at 3am – and how to fall back asleep?

Waking at 3am with a racing mind is one of the most common sleep complaints from midlife women – and declining oestrogen levels may be the culprit.

Many women describe the same pattern: jolted awake in the early hours, brain immediately spinning, unable to get back to sleep despite feeling exhausted. They’ve tried magnesium, meditation apps, and sleep sounds, but nothing seems to work.

The problem is often HRT dose, says Liz on this week’s Q&A podcast (listen to the full episode below). Many women are prescribed doses too low to control nighttime waking, and around 25% aren’t absorbing their transdermal oestrogen properly at all.

Here we explain why oestrogen decline disrupts sleep, why your HRT dose matters more than you think, and the evidence-based solutions that actually work – from morning light protocols to the brain dump notebook method.

Why does declining oestrogen disrupt sleep?

As oestrogen declines during perimenopause and menopause, many women experience disrupted sleep patterns. This includes difficulty falling asleep, waking multiple times per night, and waking in the early hours with an inability to get back to sleep.

Declining oestrogen affects sleep regulation, circadian rhythm, and temperature control. It’s also linked to the vasomotor symptoms (like night sweats and racing heartbeat) that can jolt you awake.

The good news? For many women, optimising HRT dose can dramatically improve nighttime waking.

The HRT dose problem

Listener Daniela wrote into the podcast to ask Liz about her nighttime waking pattern. She’s 49, does CrossFit four times a week, takes magnesium before bed, and started HRT (Evorel 25 patches) in June – but she’s still waking multiple times per night, unable to get back to sleep.

“Evorel 25 is a very, very low dose,” Liz explains in the episode. “For me, that wouldn’t even touch the sides.”

Liz’s own dose is around 100mcg – four times higher than Daniela’s current patch strength. Under the guidance from a GP or prescriber, many women find that increasing their HRT dose dramatically reduces nighttime waking and the early morning anxiety that comes with it.

“Looking at your age and your stage in life, I would say that is the number one port of call,” Liz advises.

Why some women don’t absorb HRT

Even if you’re using HRT, you need to know whether you’re actually absorbing it, says Liz.

A recent published study showed that around 25% of women using transdermal oestrogen aren’t absorbing it properly. This means the HRT isn’t failing – the dose simply isn’t reaching effective levels in the bloodstream.

“It’s not about dose, it’s about absorption,” Liz explains. “It doesn’t matter how much you put on. What matters is what you’re absorbing to actually control your symptoms.”

If you’re not seeing results from HRT, you may wish to ask your GP for a blood test to check your oestrogen levels.

Nighttime bathroom trips

If frequent bathroom trips are waking you, two interventions might help:

• Vaginal oestrogen can be used alongside patches or gel. Applied locally, it helps restore the pH and tissue structure around the bladder and urethra that changes when oestrogen declines.
• Jude supplements can help to support a healthy bladder both during the day and overnight with pumpkin seed extracts and soy phytoestrogens.

Morning light for better sleep

Getting outside first thing in the morning can also help support sleep late at night.

“If you can get out and see daylight within 30-60 minutes of sunrise, even for just five or 10 minutes, you are setting up your circadian rhythm,” Liz explains.

Researchers now know that seeing early morning daylight sets almost like a timer switch to produce melatonin – the sleep hormone – later in the evening.

“It’s weird, isn’t it?” says Liz. “If we see early morning light, it helps produce our sleep hormone 12-14 hours later.”

Can’t get outside? Open a window and look out while brushing your teeth.

Block blue light

Once it gets dark, Liz puts on blue-blocker glasses and switches off overhead lights, especially LEDs.

“Those white bright lights are really disruptive to our circadian rhythm,” she explains. Use warm-hued lamps, dimmer switches, and red night lights if you need to get up during the night.

Liz also switches off screens by 9pm. If that feels impossible, invest in blue-blocker glasses to reduce the blue light that prevents melatonin production.

The brain dump notebook

One of Liz’s most practical tools costs nothing: a notepad by the bed.

“What happens when we sleep is our brain is doing its filing system,” Liz explains. “If you’ve got stuff that you know you’re going to have to deal with in the morning, your brain will fret about it.”

Her solution? Write down anything concerning you before sleep.

“I know I’ve got a difficult phone call in the morning, so I write it down. I’ve acknowledged this, but actually, brain, you don’t need to worry about that while I sleep because I’m going to look at my notepad in the morning. It’s going to be there. I’m not going to forget it. For now, we can just park it.”

What should you do?

Review your HRT dose with your prescriber: For many women experiencing nighttime waking, the first step is ensuring their HRT dose is controlling symptoms. Consider asking for a blood test to check absorption levels.

Get morning daylight. See bright light within 30-60 minutes of waking, even for just 5-10 minutes. This sets up your circadian rhythm for the entire day, including melatonin production 12-14 hours later.

Manage evening light exposure. Switch off screens by 9pm, or at minimum use blue-blocker glasses. Replace overhead LEDs with warm-hued lamps and use red night lights for bathroom trips.

Keep a brain dump notebook. Write down worries before bed to signal to your brain that you won’t forget them in the morning.

Take magnesium consistently. If you’re already taking magnesium glycinate, make sure you’re taking it every night, not just when you remember.

Address nighttime bathroom trips. Consider vaginal oestrogen alongside your systemic HRT, and explore supplements like Jude that support bladder function.

Listen to the full episode for Liz’s complete sleep protocol, plus answers to questions about dark chocolate safety, rebuilding health after illness, cold sore remedies, and whether supplements damage your liver.

Stream the episode below, or download the recording via Apple Podcasts or Spotify.