Restless Leg Syndrome (RLS)

What It Is

You're lying in bed, trying to sleep, and your legs won't stay still. You feel an overwhelming, irresistible urge to move them. There's an uncomfortable sensation deep in your legs—crawling, pulling, tingling, aching, buzzing—that's only relieved by moving. You kick, stretch, rub your legs, get up and walk. The relief is temporary. As soon as you lie down again, the sensations return. It's maddening. It ruins your sleep. You pace the house at night, exhausted but unable to rest. During the day, sitting still becomes torture—meetings, car rides, movies are unbearable. You worry about nerve damage, circulation problems, or serious disease. But no one told you this could be hormonal.

Restless leg syndrome (RLS), also called Willis-Ekbom disease, is a neurological disorder characterized by:

1. An urge to move the legs (and sometimes arms), usually accompanied by uncomfortable sensations
2. Symptoms that begin or worsen during rest or inactivity
3. Symptoms that are partially or totally relieved by movement (walking, stretching, rubbing)
4. Symptoms that are worse in the evening or night
5. Symptoms not better explained by another condition

RLS is more common in women than men and often emerges or worsens during perimenopause and pregnancy (times of hormonal fluctuation).

Women describe RLS as:

• "My legs feel like they're crawling with ants. I have to move them constantly."
• "It's like an electric current running through my legs. I can't keep them still."
• "I can't sleep. As soon as I lie down, my legs start. I'm up all night pacing."
• "Sitting is torture. I have to constantly shift, stretch, move."
• "It's not pain exactly—it's an uncomfortable, creepy, desperate-to-move feeling."

Why It Happens

Estrogen and dopamine: Dopamine is a neurotransmitter that regulates movement, motor control, and the brain's reward system. RLS is fundamentally a dopamine dysregulation disorder (similar to Parkinson's disease, though RLS is not a degenerative disease). Estrogen enhances dopamine synthesis, receptor sensitivity, and signaling. When estrogen declines, dopamine function becomes impaired, and RLS symptoms emerge or worsen.

Iron and ferritin: Iron is a critical cofactor for dopamine synthesis. The brain needs adequate iron to produce dopamine. Even if serum iron levels are "normal," low ferritin (iron storage protein) in the brain can impair dopamine production and cause or worsen RLS. Ferritin <75 ng/mL is associated with RLS, and treatment targets ferritin >100 ng/mL. Heavy menstrual bleeding during perimenopause depletes iron stores, increasing RLS risk.

Estrogen and iron metabolism: Estrogen affects iron absorption, storage, and transport. Estrogen fluctuations and decline can disrupt iron metabolism and contribute to RLS.

Magnesium deficiency: Magnesium deficiency can cause or worsen RLS. Magnesium regulates nerve and muscle function, and deficiency increases neuromuscular excitability. Night sweats and heavy bleeding during perimenopause increase magnesium loss.

Thyroid dysfunction: Hypothyroidism is associated with RLS. Thyroid hormones affect dopamine metabolism and iron absorption. Treating hypothyroidism can improve RLS.

Peripheral neuropathy: Damage to peripheral nerves (from diabetes, B vitamin deficiencies, chemotherapy, alcohol) can cause RLS-like symptoms. B12, folate, and B6 deficiencies are common in perimenopause and can contribute to nerve dysfunction.

Medications that worsen RLS: Certain medications block dopamine or worsen RLS:

• Antihistamines (diphenhydramine, doxylamine)
• Antidepressants (SSRIs, SNRIs, tricyclics—though some women need them for other symptoms)
• Antipsychotics (dopamine blockers)
• Anti-nausea medications (metoclopramide, prochlorperazine)
• Some cold and allergy medications

Caffeine and alcohol: Both can worsen RLS in sensitive individuals.

Genetics: RLS has a strong genetic component. If family members have RLS, risk is increased.

Common Experiences

The nighttime torment: "Every night, as soon as I lie down, my legs start. I can't sleep. I'm exhausted but I can't rest."

The pacing: "I pace the house at 2 a.m., trying to tire out my legs so I can sleep."

The meeting agony: "Sitting in meetings is torture. I shift constantly, bounce my legs, try not to get up and walk."

The movie misery: "I can't sit through a movie anymore. My legs won't let me."

The relief-seeking: "I rub my legs, massage them, stretch, walk—anything to make the sensation stop."

The sleep deprivation: "RLS has destroyed my sleep. I'm so tired, but I can't rest."

What Helps

Iron supplementation (if ferritin is low): Check ferritin levels. If <75 ng/mL, iron supplementation is often highly effective. Use:

• Oral iron: Ferrous sulfate 325 mg or ferrous bisglycinate (gentler) taken with vitamin C on an empty stomach before bed (iron is better absorbed at night and treats RLS while you sleep). Target ferritin >100 ng/mL.
• Iron infusions: If oral iron is poorly tolerated or ineffective, IV iron infusions can rapidly restore iron stores and dramatically improve RLS.

Magnesium supplementation: Magnesium (400-600 mg daily, glycinate form, taken before bed) can significantly reduce RLS symptoms. Many women report improvement within days to weeks.

Hormone therapy (HT): Stabilizing estrogen levels with HT can improve dopamine function and reduce RLS. Some women report complete resolution of RLS with HT.

Dopamine agonists: Medications that mimic dopamine are first-line prescription treatments for RLS:

• Pramipexole (Mirapex): Very effective, low doses used (0.125-0.5 mg before bed)
• Ropinirole (Requip): Another dopamine agonist
• Rotigotine patch (Neupro): Transdermal option
• Caution: Long-term use can cause augmentation (worsening RLS, earlier onset, spread to arms). Use lowest effective dose.

Alpha-2-delta ligands: Gabapentin and pregabalin are highly effective for RLS and don't cause augmentation:

• Gabapentin (300-1200 mg before bed)
• Gabapentin enacarbil (Horizant): Extended-release formulation specifically approved for RLS
• Pregabalin (Lyrica): Also effective

These medications also help with sleep, pain, and anxiety.

Avoid RLS-worsening medications: Review all medications and supplements with a provider. Avoid antihistamines (use non-sedating alternatives like cetirizine or loratadine if needed).

Reduce caffeine and alcohol: Cut back or eliminate, especially in the afternoon and evening.

Leg massage and heat/cold: Massage, heating pads, or cold packs can provide temporary relief.

Moderate exercise: Regular moderate exercise (walking, swimming, cycling) can reduce RLS. Avoid intense exercise late in the day, which can worsen symptoms.

Sleep hygiene: Maintain a consistent sleep schedule, cool bedroom, dark environment. Avoid screens before bed.

Compression socks or pneumatic compression: Some people find relief with compression garments or pneumatic compression devices.

Treat underlying conditions: Check thyroid function, B12, folate, glucose. Treat hypothyroidism, neuropathy, or diabetes.

Duration and Recovery

RLS often emerges or worsens during the Wild Tide and Henapause stages, when estrogen fluctuates wildly and heavy bleeding depletes iron stores.

Post-menopause, as hormones stabilize and iron stores are restored (if bleeding stops), RLS often improves significantly. However, for some women, RLS persists and requires ongoing treatment.

With iron supplementation, magnesium, hormone therapy, and/or dopaminergic medications, most women achieve significant symptom relief and improved sleep.

The Bottom Line

Restless leg syndrome during perimenopause is not "just restless legs" or a psychological problem. It's a real neurological disorder driven by dopamine dysregulation, iron deficiency, and hormonal changes. With iron supplementation (if ferritin is low), magnesium, hormone therapy, gabapentin or dopamine agonists, and avoidance of RLS-worsening substances, most women find significant relief. Your legs are not misbehaving. Your dopamine and iron systems are hormonally and metabolically disrupted. And they can be recalibrated.