Symptom · Sleep & nerves
Restless legs. The crawling, must-move-them feeling at night.
An urge to move the legs that builds in the evening, gets worse the more still you are, eases the moment you walk — and then ruins your sleep. Restless legs syndrome (RLS) is two to three times more common in women, climbs through perimenopause, and is almost always treatable once you go looking for the right cause.
Educational · not medical advice
RLS sits at the intersection of iron, dopamine and the nervous system. Estrogen drop, low ferritin from years of heavy bleeding, and disrupted sleep all push the system over a line. The good news: the work-up is short (ferritin, the sleep story, a med review) and the treatments are genuinely effective. The bad news: most women never get past 'try magnesium'. This is the longer version of that conversation.
Why this is happening now
An iron-driven dopamine story, often unmasked by perimenopause.
- 01
Low brain iron, even when blood iron is 'normal'
RLS is fundamentally an iron-handling problem in the brain's dopamine system. Ferritin below ~75 ng/mL is associated with RLS even when haemoglobin is fine. Years of heavy menstrual bleeding leave many midlife women in exactly this zone.
- 02
Estrogen modulates dopamine signalling
As estrogen falls, dopamine signalling in the relevant pathways destabilises. This is why pregnancy (a high-estrogen state for some, low for others) and perimenopause are both classic RLS triggers.
- 03
Some medications make it dramatically worse
Many antidepressants (especially SSRIs and mirtazapine), some antihistamines (diphenhydramine), anti-nausea meds (metoclopramide, prochlorperazine) and dopamine-blocking antipsychotics can trigger or worsen RLS. A med review is the cheapest first move.
- 04
Sleep loss feeds the loop
RLS wrecks sleep; sleep loss worsens RLS. Breaking the loop usually requires treating both ends — the legs at night and the sleep architecture during the day.
- 05
It's diagnosed clinically, not on a test
Urge to move + worse at rest + worse in the evening + relieved by movement = RLS by definition. No scan or blood test confirms it; ferritin and a medication review are the work-up.
What tends to help
Fix the iron, review the meds, then look at prescriptions if you still need to.
Get ferritin checked — and aim higher than 'normal'
Ask for ferritin, not just full blood count. The treatment target for RLS is ferritin > 75 ng/mL (some specialists say >100). 'Normal range' on the report is not the same as 'enough for RLS'.
Oral iron, every other day, with vitamin C
Ferrous bisglycinate or ferrous fumarate, alternate-day dosing absorbs better than daily, taken with vitamin C, away from tea and coffee. Re-check ferritin in 12 weeks. Iron infusion is an option if oral doesn't shift it.
Review every regular medication
Bring the list to the doctor and ask specifically: 'Could any of these be making restless legs worse?' Switching from a triggering antidepressant (e.g. mirtazapine) to a kinder one (bupropion is often well-tolerated) is sometimes the whole fix.
Caffeine, alcohol, and nicotine — the classic three
All three worsen RLS reliably. A two-week elimination tells you how much they're contributing.
2 more practices, plus podcasts, books and research, live in Go deeper below.
03When to get help nowWhen to push for more
Emergency red flags, same-week signs, and where to find a menopause-trained practitioner.
When to push for more
4 more signs it needs a doctor this week
Ferritin not above 75 after 12 weeks of oral iron
Time to ask about IV iron, particularly if you also still have heavy bleeding. Iron infusion is a same-day procedure and often transformative for RLS.
Symptoms getting worse on a dopamine agonist
Classic sign of augmentation. Means a change of plan, not a higher dose. Specialist referral.
Numbness, weakness or pain that doesn't ease with movement
Suggests peripheral neuropathy or vascular disease rather than (or as well as) RLS. Wants a doctor's exam.
It's wrecking your sleep most nights for more than a month
That itself is the threshold for treatment. You should not be losing sleep on most nights when this is so treatable.
Go deeper
One place for everything else.
Practices to try this week, voices worth hearing, books worth your bedside table, rooms where members are talking, the candid tips Nila would share over a cup of tea, and the research the editorial team is watching.
Time of day
Evening and bedtime onset is classic RLS. All-day symptoms with no relief from movement is something else and deserves a different look.
Does movement help
Yes = RLS. No = look for another cause (cramps, neuropathy, vascular).
Your ferritin number, written down
Not the range — the actual number. You want it for the next conversation.
Sleep cost
Time to fall asleep, number of awakenings, total sleep. The sleep cost is often the most useful thing to bring to the doctor.
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