In this video, I’ll explain what melatonin is, how it works, and whether or not you should be taking it.
I once did an informal survey on Facebook asking people their biggest sleep concerns. The majority of respondents were women in their 30s and above, and their number 1 concern was this:
→ Difficulty staying asleep
It wasn’t surprising, because hormones do have a known impact on sleep.
Lower levels of estradiol and higher levels of FSH during perimenopause are associated with sleep disturbances, independent of vasomotor symptoms and mood changes. (1)
As for progesterone, it’s known to have sedative properties, thought to act as a GABA-agonist. It also stimulates breathing via acting centrally on brainstem respiratory control centers, and by peripherally affecting upper airway patency. Thus, we see higher rates of sleep when progesterone levels drop in perimenopause and menopause. (2)
Now, whether hormone therapy (HT) is helpful is a bit more complex.
I’ve seen patients experience an initial improvement with HT, but then develop sleep issues again. So why might that be?
This week, we’re digging into hormonal shifts, mental health, and sleep changes with Harita Raja MD.
Dr. Raja is a reproductive psychiatrist specializing in hormone therapy for mental health. If you’re not already following her on Instagram, I highly recommend that you do.
In this interview, Dr. Raja shares:
Click here to watch the interview and don’t forget to claim your CE credits using the Learner+ link below. https://www.youtube.com/watch?v=rboinFa38SA
References:
(1) Coborn J, de Wit A, Crawford S, Nathan M, Rahman S, Finkelstein L, Wiley A, Joffe H. Disruption of Sleep Continuity During the Perimenopause: Associations with Female Reproductive Hormone Profiles. J Clin Endocrinol Metab. 2022 Sep 28;107(10):e4144-e4153. doi: 10.1210/clinem/dgac447. PMID: 35878624; PMCID: PMC9516110.
(2) Boukari R, Laouafa S, Ribon-Demars A, Bairam A, Joseph V. Ovarian steroids act as respiratory stimulant and antioxidant against the causes and consequences of sleep-apnea in women. Respir Physiol Neurobiol. 2017 May;239:46-54. doi: 10.1016/j.resp.2017.01.013. Epub 2017 Feb 9. PMID: 28189710.
I met a friend for a later-than-usual dinner a couple of weeks ago and we were laughing at how incredibly sleepy we both were given that it now becomes pitch black by 5pm in the Bay Area.
The short winter days can make for sleepier evenings, lethargic days, and even Seasonal Affective Disorder (SAD) in patients prone to it.
Bright light therapy, medications, and other conventional treatments are effective for SAD.
But one of the missing pieces is embracing seasonal shifts.
In our modern world, we expect ourselves to maintain the same productivity, energy, and sleep patterns all year round.
Meanwhile, nature does the opposite, as trees become bare, animals hibernate, and the stars come out to say hello in the early evening hours.
I love embracing the Scandinavian concept of “hygge”, with cozy evenings, twinkle lights, homemade soups, a good book and a soft blanket.
Pair that with a purposeful dose of daytime bright light by going for a walk outside, preferably out in nature, my favourite being a brisk midday stroll on the beach.
It often does more than people expect.
But, back to bright light therapy which is one of the most underutilized tools in the clinical toolbox.
Bright light therapy (BLT) is:
Bright light therapy was originally used to treat seasonal affective disorder (SAD). Now it’s also used in the treatment of non-seasonal depression, bipolar depression, fatigue, insomnia, and circadian rhythm disorders.
If you see patients with insomnia, depression, or fatigue, it’s a good idea to learn how to prescribe bright light therapy. See my video here for an in-depth tutorial:
Some clinical pearls to get you started:
I still recommend that my patients go outside for a dose of natural sunlight in the morning and midday hours, while integrating bright light therapy devices into the treatment plan.
References
Galima SV, Vogel SR, Kowalski AW. Seasonal Affective Disorder: Common Questions and Answers. Am Fam Physician. 2020 Dec 1;102(11):668-672. PMID: 33252911.
One of the most common concerns I hear from my patients is that they can’t shut off their mind at night.
They climb into bed and suddenly the mental floodgates open: to-do lists, work problems, holiday logistics, the awkward comment from 2003, existential dread…all of it shows up like clockwork.
These are often the patients asking for a sedative or an anxiolytic to quiet the noise.
While medication can be appropriate in select cases, it rarely solves the underlying issue.
You might suggest relaxation techniques or meditation, but for those with chronic insomnia, those tools often backfire because they increase “sleep effort”, amplifying frustration.
Plus, the mind is doing exactly what it’s designed to do: think. Expecting patients to “turn it off” sets them up for more pressure and disappointment.
So here’s a more effective entry point:
Shift the focus to pre-sleep cognitions. (1)
Pre-sleep cognitions are the mental activities that occur in the window before sleep onset, like rumination, planning, worry, mental rehearsal, intrusive thoughts, and problem-solving.
In chronic insomnia, these thoughts tend to be more intense, more negative, and more sticky than in what I call “effortless sleepers.”
Research consistently shows this cognitive arousal is associated with:
So how can you help patients meaningfully shift their pre-sleep cognition patterns?
Use a tool that’s free, simple, low-risk, and clinically supported: Gratitude.
It’s a timely topic with Thanksgiving in the US this week, but is relevant year-round
Gratitude practices have been shown to:
It’s underused, especially in insomnia care, yet quite easy for patients to do.
Here’s how I coach my patients to start practicing gratitude:
What to do
Choose one specific thing you’re grateful for each day. Keep it concrete, like “I’m grateful for the warm coffee I had this morning.”
How to do it:
Say it out loud, write it in a journal, or drop it on a post-it note into a “gratitude jar.”
When to do it:
Begin in the evening. With daily practice, it starts to happen spontaneously throughout the day.
Why it matters:
It builds “emotional fitness,” improves pre-sleep cognitions, and improves sleep quality over time.
As clinicians, it’s important that we practice what we preach. Gratitude takes only a few seconds but compounds quickly.
With that said, I’m grateful you’re here and letting me be part of your sleep education journey.
Did you learn something today? Click here to find out how Learner+ can help you meet your evolving educational goals.
References:
(1) Lemyre A, Belzile F, Landry M, Bastien CH, Beaudoin LP. Pre-sleep cognitive activity in adults: A systematic review. Sleep Med Rev. 2020 Apr;50:101253. doi: 10.1016/j.smrv.2019.101253. Epub 2019 Dec 17. PMID: 31918338.
In this episode, Dr. Nishi Bhopal MD, a sleep physician and psychiatrist, shares valuable insights on using melatonin to manage sleep disorders in perimenopausal and menopausal women. Dr. Bhopal discusses how melatonin can help reset circadian rhythms and improve sleep quality, offering evidence-based dosages and tips for clinical practice. She emphasizes the importance of combining melatonin supplementation with behavioral and environmental adjustments and warns against the potential side effects of high dosages. Tune in for a detailed guide on effectively integrating melatonin into treatment plans for midlife women, along with information about an upcoming masterclass for deeper learning.
We’ve all heard this from our patients:
“Melatonin doesn’t work for me.”
And to be honest, it often doesn’t work…at least not in the way most people are using it.
Melatonin isn’t a sedative. It’s a chronobiotic.
It’s a biological time cue that tells your body what time it is and helps regulate the sleep-wake cycle.
So when a patient says melatonin failed, the problem usually isn’t that melatonin doesn’t work.
It’s usually one of these 3 things:
This week, I’m breaking down why melatonin doesn’t work and what to do about it.
In this 8-minute episode (Part 2 of my 3-part series on melatonin) I share two real clinical cases that illustrate how to make melatonin work for the right patient at the right time:
I’m also sharing:
If you’ve ever wondered how to handle “melatonin doesn’t work” complaints in clinic, this episode will give you a roadmap.
Well worth the 8 minutes of your time.
Then, stay tuned for Part 3, where we’ll explore melatonin use in perimenopause and menopause.
Did you learn something today? Click here to find out how Learner+ can help you meet your evolving educational goals.
In this episode, Dr. Nishi Bhopal, a sleep physician and psychiatrist, dives deep into why melatonin often fails for patients and how to correct its use for optimal benefits. Learn the biological role of melatonin as a chronobiotic, not a sedative, and discover practical strategies for treating conditions like delayed sleep phase disorder and advanced sleep phase disorder. Dr. Nishi Bhopal walks through two compelling cases, highlighting the importance of timing, dosage, and formulation. Get insights on how to use melatonin effectively and explore other critical sleep-promoting behaviors. Join our masterclass for a deeper dive into evidence-based sleep supplements.
A 2023 research letter in JAMA (Journal of The American Medical Association) and 2017 study in JCSM (Journal of Clinical Sleep Medicine) highlighted serious issues with over-the-counter melatonin quality*.
One melatonin gummy was found to contain 347% more melatonin than what the label claimed.
That’s enough to make anyone pause.
It has definitely changed the way I recommend melatonin to patients.
But as I explain in this week’s video, the full story is more nuanced, and perhaps not quite as alarming, as the headlines suggest.
In this 10-minute episode (Part 1 of a 3-part series on melatonin), I unpack what every clinician needs to know about melatonin safety, including:
I also share a patient story that illustrates how melatonin, when used correctly, can retrain the circadian rhythm instead of becoming a nightly crutch.
If you’ve ever had a patient ask whether melatonin is “safe,” or wondered how to approach it in your own prescribing, invest 10 minutes of your time in this high yield video.
Did you learn something today? Click here to find out how Learner+ can help you meet your evolving educational goals.
*References:
Cohen PA, Avula B, Wang YH, Katragunta K, Khan I. Quantity of Melatonin and CBD in Melatonin Gummies Sold in the US. JAMA. 2023 Apr 25;329(16):1401-1402. doi: 10.1001/jama.2023.2296. PMID: 37097362; PMCID: PMC10130950.
Erland LA, Saxena PK. Melatonin Natural Health Products and Supplements: Presence of Serotonin and Significant Variability of Melatonin Content. J Clin Sleep Med. 2017 Feb 15;13(2):275-281. doi: 10.5664/jcsm.6462. PMID: 27855744; PMCID: PMC5263083.
In this episode, Dr. Nishi Bhopal MD addresses recent headlines surrounding melatonin mislabeling and safety. She dives into the accurate use of melatonin, its role as a chronobiotic, and the importance of precise dosing, especially in clinical settings. Learn about melatonin’s applications for various conditions such as circadian rhythm disorders and pediatric neurological conditions, and explore the latest research on its long-term safety. Dr. Bhopal also shares insights from her clinical practice, discusses the variability in melatonin supplement labeling, and offers guidance on selecting high-quality, third-party tested brands. Subscribe for more practical clinical sleep medicine insights.
Join us for a discussion with Drs. Judith Pentz MD and Nishi Bhopal MD on Ayurvedic rituals for better sleep. Dr. Pentz shares her unique perspective as an integrative psychiatrist and dives into Ayurvedic practices such as morning and evening routines, the importance of understanding your dosha, and the role of nutrition and herbs like ashwagandha. Learn about self-care routines, the significance of circadian rhythms, if Ayurveda is evidence-based, and how Ayurveda aligns with modern sleep science. Don’t miss out on valuable tips for managing anxiety and promoting overall wellbeing.
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