What are some evidence-based solutions for my sleep problems, which are exacerbated by perimenopause, trauma response, and anxiety, despite trying relaxation exercises and medications like Dayvigo (lemborexant) and oral progesterone?

Evidence-Based Solutions for Perimenopause-Related Sleep Disturbances

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be your first-line treatment for addressing perimenopause-related sleep problems, as it is the most effective non-pharmacological approach with minimal side effects and long-term benefits. 1

Understanding Your Sleep Challenges

Your sleep difficulties stem from multiple factors that require a targeted approach:

• Perimenopause-related hormonal fluctuations affecting sleep architecture and quality 2
• Trauma response to your daughter's seizures causing hypervigilance 1
• Early morning awakenings with difficulty returning to sleep 1
• Night sweats (partially managed with hormone therapy) 2
• Anxiety and worrying thoughts during nighttime awakenings 1

Treatment Algorithm

Step 1: Behavioral Interventions (First-Line)

Implement CBT-I Components:

• Sleep Restriction/Compression:

  • Limit time in bed to match your actual sleep time based on a 2-week sleep log 1
  • Gradually increase time in bed by 15-20 minutes every 5 days as sleep efficiency improves 1
  • This helps consolidate fragmented sleep and strengthen your sleep drive 1

• Stimulus Control:

  • Use your bedroom only for sleep and sex 1
  • Leave the bedroom if you can't fall asleep within 20 minutes and return only when sleepy 1
  • Maintain consistent sleep and wake times, even after poor sleep nights 1

• Relaxation Techniques:

  • Practice progressive muscle relaxation, guided imagery, or diaphragmatic breathing before bed and during nighttime awakenings 1
  • Implement a 30-minute relaxation period before bedtime 1

• Cognitive Therapy:

  • Address anxiety about your daughter's seizures and catastrophic thinking about sleep loss 1
  • Challenge worrying thoughts that occur during nighttime awakenings 1

Step 2: Environmental and Lifestyle Modifications

• Light Management:

  • Increase bright light exposure during daytime hours 1
  • Avoid bright light in the evening, especially blue light from screens 1

• Sleep Hygiene Improvements:

  • Avoid caffeine, alcohol, and heavy meals in the evening 3
  • Create a comfortable, cool, quiet, and dark bedroom environment 1
  • Limit daytime naps to 30 minutes and avoid napping after 2 PM 1
  • Engage in regular physical activity, but avoid vigorous exercise within 2 hours of bedtime 3

Step 3: Hormonal Considerations

• Hormone Therapy:
  • Consider discussing with your doctor about resuming oral progesterone (100 mg) if your sleep disturbances persist 4
  • Research shows progesterone can significantly reduce wake time after sleep onset and increase slow-wave sleep quality 4
  • While your doctor believes the Mirena IUD provides sufficient progesterone, oral progesterone has specific benefits for sleep that localized IUD delivery may not provide 4

Step 4: Pharmacological Approaches (When Needed)

• Lemborexant (Dayvigo):
  • Can be used intermittently for short-term management when other approaches are insufficient 5
  • Research shows it's effective for midlife women with insomnia, with benefits sustained over 12 months 5
  • Most side effects are mild to moderate in severity 5

Important Considerations and Pitfalls

• Avoid overreliance on sleep medications:

  • While effective short-term, they don't address underlying causes of insomnia 1
  • Your concern about regular use of Dayvigo is valid; use it strategically rather than nightly 5

• Address trauma response directly:

  • Your hypervigilance to sounds is a specific trauma response that requires targeted intervention 1
  • Consider working with a therapist experienced in both trauma and sleep issues 1

• Be patient with CBT-I:

  • Improvements may take 4-6 weeks to become apparent 1
  • The benefits are more sustainable long-term compared to medication 1

• Monitor hormonal symptoms:

  • Track night sweats and sleep quality to determine if hormone therapy adjustments are needed 2
  • Perimenopause is a transitional state with changing symptoms that may require treatment adjustments 2

By implementing this comprehensive approach starting with CBT-I and addressing both the hormonal and psychological factors affecting your sleep, you can significantly improve your sleep quality during this challenging perimenopause period while managing your trauma response to your daughter's seizures.