Menopause and Trouble Sleeping: Strategies for Better Rest

Maybe you've been told it's just stress, or just getting older. The research points somewhere more specific.

Perimenopause is the transition around your final period, from the first changes in your cycle to a year after it.

• In SWAN, a large US survey of 12,603 women aged 40 to 55, 38% reported difficulty sleeping in the past two weeks.^[2]
• Menopausal stage was associated with sleep difficulty independent of other factors. Within this 40-to-55 age range, age on its own was not.^[2]

A 2018 review adds that long-term studies link sleep difficulties with menopausal stage and with changes in estradiol and follicle-stimulating hormone, over and above the effects of age.^[1]

Canadian data add a nuance. Among 6,179 women aged 45 to 60:

• Postmenopausal women more often reported taking 30 minutes or more to fall asleep (20.4% versus 15.5%).^[3]
• They also more often met criteria for possible sleep-onset insomnia (10.8% versus 7.3%). Staying asleep did not differ.^[3]

Here's the thing: it isn't the same for everyone. In a study that followed 255 women for up to 16 years, moderate-to-severe poor sleep was common (about 28% to 35% a year) but did not rise overall around the final period. Women who already had moderate-to-severe poor sleep beforehand had about 3.5 times the odds of it around menopause.^[4] So if your sleep was already shaky, that's a good reason for us to work on it now.

Often, but not always. In a lab study of 34 perimenopausal women, 69% of 222 recorded hot flashes were associated with an awakening. Time awake linked to hot flashes averaged 16.6 minutes a night.^[5] It was a small study, but it measured sleep and hot flashes directly.

Another lab study found something different. In women aged 46 to 51, screened for conditions such as sleep apnea and drug use, the researchers found no evidence that hot flashes produced sleep disturbance. Of awakenings within two minutes of a hot flash, 55.2% came before it and 40% after.^[6] The authors suggested earlier findings may reflect disorders that were screened out of their sample.

A 2018 review puts it fairly: many, although not all, hot flashes are linked with awakenings.^[1] So hot flashes at night, often called night sweats, deserve attention. But if we stop there, we may miss something else.

It's the one I'd hate for you to miss. Sleep apnea means repeated pauses or shallow stretches in breathing during sleep. In a Wisconsin study of 589 women, postmenopausal women had about 3.5 times the odds of 15 or more of these events an hour (moderate sleep apnea) as premenopausal women. That is after adjusting for age, body size and smoking. The margin of error was wide, and perimenopause showed no clear increase.^[7]

In Canada, 14.6% of postmenopausal women screened positive for apnea, versus 10.4% of pre- and perimenopausal women.^[3] And in a study published in 1997, an estimated 93% of women with moderate to severe sleep apnea had not been diagnosed at the time (among middle-aged employed adults in Wisconsin).^[8]

These studies show links, not cause. Still, the Wisconsin authors recommended evaluation for sleep-disordered breathing for menopausal women who have snoring, daytime sleepiness or unsatisfactory sleep.^[7] If that sounds like you (say, a partner has mentioned your snoring), talk to your physician. The good news: it can be checked.

In a lab study of 102 women with disturbed sleep, recruited through newspaper ads, 53% had apnea, restless legs or both. Anxiety scores and hot flashes in the first half of the night were the best predictors of how well the women said they slept, though the link was modest.^[9]

Alcohol is another, and the nightcap that helps you drop off is a classic example. In healthy volunteers, it shortened the time to fall asleep but increased sleep disruption in the second half of the night.^[10] As I teach it, alcohol gives you "the perception that alcohol worked. I did fall asleep." The second half of the night pays for it.

Often more than one thing is going on. Here's a simple way we can sort the possibilities, together:

Tap to enlarge

Let's start with the first-line option. For chronic insomnia, the first-line treatment is a skill, not a pill.^[14] Cognitive behavioral therapy for insomnia (CBT-I) is a structured, drug-free program. In one trial it included sleep restriction, stimulus control, sleep hygiene education, cognitive restructuring and behavioral homework.^[11]

That trial enrolled 106 peri- and postmenopausal women with insomnia symptoms and at least two hot flashes a day. After six phone sessions over eight weeks, 70% of the CBT-I group were in the no-insomnia range (84% at 24 weeks), versus 24% (43%) with menopause education. Hot flashes were no less frequent, but they interfered less.^[11]

A second trial of 150 postmenopausal women with chronic insomnia found remission rates of 54% to 84% with CBT-I, versus 4% to 33% with sleep hygiene education alone.^[12] CBT-I also improved fatigue, energy, sleepiness and work function.^[13] In my experience, that fits: tips alone rarely fix it. Timing and behavior do.

The American College of Physicians recommends CBT-I as the first treatment for chronic insomnia disorder in adults.^[14] Both trials above were single-site, so more research is welcome. Ask your physician how to reach a trained CBT-I provider. And you don't have to work out the rest alone.

I'm a PhD, not an MD, so I won't tell you what to take. What I can do is walk you through what the medical societies and reviews say. After that, it's a conversation for you and your physician.

The Menopause Society (formerly NAMS) says hormone therapy remains the most effective treatment for hot flashes and night sweats; whether it suits you depends on your age, time since menopause and health history.^[15] In a meta-analysis, hormone therapy improved sleep quality in women who had hot flashes, but not in women who did not.^[17] The society also recommends several nonhormone options for hot flashes, including CBT and clinical hypnosis, but not supplements or herbal remedies.^[16]

For melatonin, two meta-analyses of small randomized trials found no clear benefit for sleep quality in menopausal women, and both called for larger trials.^[18][19] A 2021 analysis of 43 trials supported combined hormone therapy for sleep problems linked with hot flashes but found no significant effects of hypnotics.^[20]

What I can tell you is my own position: I don't recommend melatonin or sleep medications as a fix. If you're using them, talk to your physician before changing anything. Hormone therapy is a medical decision for you and your physician.

You know the dance: covers on, covers off. Here's how I teach it. We tend to sleep best when we fall asleep after a peak in body temperature and then get a long, slow decline. Heavy bedding that traps heat can work against that. A very cold room has its own problem: when your core temperature reaches its lowest point, you can wake up cold and reaching for covers.

A review of heat and cold exposure found that, with bedding and clothing, heat increased wakefulness and reduced slow-wave and REM sleep. The review wasn't about menopause, and it stressed that bedding and clothing matter.^[22] So I won't give you a magic number.

Be clear about the limit: a cool room is for sleep comfort. The Menopause Society lists cooling techniques among options it does not recommend for treating hot flashes, citing limited or inconsistent evidence.^[16]

Let's make a plan for the next time you're awake at 3 a.m. In my teaching, light, activity and food are all daytime signals to your body clock. So I want you to keep the light low and the night quiet.

It's not just what you do that matters, it's when you do it. Timing is everything. Your body clock relies on time cues: light most of all, plus activity and meals.

This is my coaching approach, not a finding from the menopause studies above. Here's what we'll work on together, as one piece of a plan with your physician:

Build the window and protect it, and your sleep accountant will balance the books. That's what I call the process that keeps track of the sleep your body needs.

Broken sleep can feel like a normal part of this stage of life. Here's the thing: just because it's normal doesn't mean it's healthy, and it doesn't mean it's inevitable.

I think in terms of what I call sleep health status: not just how you sleep tonight, but how you sleep across your whole lifespan. I'd argue that protecting it now is part of protecting your healthspan, your quality of life in later years. So let's treat these rough nights as something to work on, not something to put up with.

Here's when I'd want you to see your physician: if you snore loudly, gasp, wake unrefreshed, feel tired all day, or feel low or anxious. Those are worth raising right away. And if poor sleep keeps going, don't wait it out. We're built to recover from a bout of poor sleep. It's when poor sleep becomes the pattern that it starts to cost you.

If you'd like company on this, we can help. Let's start with your own pattern. The Free Sleep Assessment includes a sleep apnea risk score (a screening score, not a diagnosis). Our Advanced Sleep Assessment reviews your wearable data with you. Your wearable can tell you what happened to your sleep last night. We tell you what to do about it, and what's worth bringing to your physician. We also have a page for women in perimenopause and menopause.

Where you start is entirely up to you. We meet you wherever you are on your journey.

For companies, menopause symptoms carry a cost too. In a Mayo Clinic survey (run in 2021, published in 2023) of 4,440 employed women aged 45 to 60, 13.4% reported at least one adverse work outcome due to menopause symptoms. The authors estimated US$1.8 billion a year in lost workdays in the US. That covers all menopause symptoms, not only sleep, and only 16.1% of invited women responded.^[24] See sleep health for corporations.