Restless legs

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.

An iron-driven dopamine story, often unmasked by perimenopause.

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 people in exactly this zone.

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.

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.

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.

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.

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.

Prescription options, when needed. First-line is now usually an alpha-2-delta ligand (gabapentin or pregabalin) rather than dopamine agonists, which can cause 'augmentation' (RLS getting worse over time on treatment). A sleep specialist or RLS-aware neurologist is the right route if oral iron and lifestyle don't do it.

MHT sometimes helps. Anecdotally and in small studies, stabilizing estrogen reduces RLS severity for some people. Not first-line, but worth raising if you're already considering MHT for other reasons.