What’s actually going on
How I think about this.
Insomnia is the most common sleep complaint in adult medicine and one of the most reflexively treated with the wrong tool. The first-line move in conventional care is a hypnotic prescription. Those medications work in the short term but do not address the system that is making sleep difficult in the first place, and most produce dependency or tolerance over time.
The two presentations I see most are sleep-onset insomnia (cannot fall asleep) and sleep-maintenance insomnia (cannot stay asleep). They usually come from different causes. Sleep-onset trouble is almost always a stress-hormone problem: cortisol that should fall through the evening stays elevated, often driven by late eating, screen light, alcohol, or chronic stress arousal. Sleep-maintenance trouble is usually a blood-sugar problem first: glucose drops in the second half of the night, the adrenal system fires cortisol to pull it back up, and you wake.
The other drivers that often hide underneath: subclinical hypothyroid, magnesium and B-vitamin gaps, sex hormone shifts in perimenopause, sleep apnea (especially in men over 40 and women in perimenopause and beyond), and the medication list.
The physician’s lens
How I read this in practice.
I read insomnia against the daily cortisol curve and the glucose response to evening eating. A salivary cortisol panel across the day. Blood sugar tracked with a CGM if the case warrants it. Sex hormones with binding proteins for women in perimenopause and beyond. The thyroid axis with reverse T3. Magnesium and B-vitamin status from the metabolomic panel. For sleep-maintenance complaints in men over 40, I screen for sleep apnea early.
The systems behind it
Where this symptom comes from.
Most cases touch more than one. Open each area to read the biology underneath.
Biological pillars
Pillar
Chronobiology.
Every hormone, immune function, and metabolic process runs on a circadian schedule. The disruption is measurable, and the consequences are systemic.
Read this pillarPillar
Mitochondria.
Mitochondria produce the ATP that powers every function in your body. Directly assessable. Directly correctable.
Read this pillarPillar
Gut-Immune health.
The microbiome runs 70% of your immune system, shapes inflammation, mood, and metabolism. Read the ecosystem directly.
Read this pillarWhat I’d test first
The data that explains it.
Insomnia work needs the cortisol curve, blood sugar in real time, and the hormonal context. The CGM is unusually informative here because the 3am wake is almost always blood-sugar driven.
Blood work
Hormone health blood panels
Reads the cortisol axis, thyroid, and sex hormones together. The hormonal context for both presentations.
Read the panelAdvanced testing
CGM (Continuous Glucose Monitor)
Two weeks of glucose data answers the 3am wake question with more clarity than any lab can.
Read the panelWhile you wait
Moves worth making before testing.
These are the levers I’d pull while we set up the workup. Most of them produce real signal inside two weeks.
- Bright light within an hour of waking. Outside if at all possible. The strongest sleep signal you can give yourself, free.
- Stop eating three hours before bed. Especially carbohydrates. The overnight glucose curve changes.
- Cut alcohol entirely for two weeks. The second half of your night will look different.
- Anchor your wake time, even on weekends. Let bedtime drift toward it for two weeks before changing anything else.
If two weeks of the basics doesn’t move the needle, that is exactly the kind of presentation a Precision Call exists for. Your biology is telling you something the lifestyle layer cannot fix on its own.
More reading
What I’ve written on this system.
Article
The evolution of sleep. Why humans slept in tribes.
For most of human history, people slept in groups, with variable timing, and without the modern apparatus of bedrooms and total darkness. Understanding why helps explain some of the modern sleep paradoxes.
Read thisArticle
Shift work. Surviving and protecting your biology on a night schedule.
Working nights forces your biology to do something it did not evolve to do. The harm is real and the protocols to limit it are specific. Honest about the tradeoffs.
Read thisArticle
Understanding chronotypes. How to find yours and what it changes.
Your chronotype is your innate preference for sleep and activity timing. It is largely genetic, modifiable only at the edges, and one of the more practical variables to know about your own biology.
Read thisBrowse other symptoms
Something else on your mind?
Fatigue and low energy
When the tank stays low no matter how much you sleep.
Brain fog
The lights are on but the signal feels weak.
Poor sleep
Either you can't fall asleep, or you can't stay asleep.
Digestive issues
Bloating, irregularity, sensitivities that keep widening.
Mood and stress
Patience runs short, recovery from stress takes longer.
Hormonal imbalance
Energy, sleep, libido, and weight stop responding to the basics.
Perimenopause
The years when the body's hormonal rhythm changes, before the period stops.
Low libido
Desire that used to be reliable is gone or muted. Both sexes, both directions.
Hair loss
Thinning, shedding, or texture changes that didn't used to happen.
Erectile dysfunction
ED is the canary. The body is telling you something about vascular and hormonal health.
Weight loss resistance
You eat well, you train, the scale doesn't move. Something deeper is in the way.
High cholesterol concern
Your last lab flagged it. You want a second opinion before you take a statin.
High blood pressure concern
The reading came back elevated. You want the full picture before you start a prescription.
Insomnia
You can't get to sleep. You can't stay asleep. Or both.
Athletic recovery problems
You train hard. You don't bounce back. Something physiological is in the way.
Headaches and migraines
Recurring headache patterns the standard workup hasn't solved.
Joint pain
Pain in one joint is often a local problem. Pain that travels, or pain in multiple joints, is usually a systemic one.
Anxiety
Some anxiety is psychological. Much of what shows up in clinic is biological with a psychological face.
Acne and skin issues
The skin is rarely the problem. It is the most visible report on what is happening one layer down.
Thyroid symptoms
Cold all the time. Hair shedding. Sluggish mornings. A 'fine' TSH that explains none of it.
PMS and cycle issues
A difficult cycle is often a window into how your body handles hormones across the rest of the month.
Food cravings
Cravings are biology pulling for what it needs, often dressed up as what it can get easily.
Chronic allergies
New or worsening allergies in adulthood usually point to a barrier and an immune tone, not a specific allergen.
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