Why Menopause Disrupts Sleep (and What Actually Helps)

Hormones, hot flashes, and waking up at 3 a.m.: what the research says about getting real rest during perimenopause and menopause.

Many women in midlife describe the same experience: a big shift in their sleep. Once upon a time, you could dependably get good and restorative sleep without much effort, but now it’s a different story. There's a good reason for that shift. Perimenopause and menopause effectively herald a re-engineering and shift in how the body goes about its business, and that, in turn, means a lot of disruption for your sleep.

The good news (and there is genuinely good news) is that we know a lot about why this happens and what can help. Below are four evidence-supported places to start: CBT-I, easing hot flashes and night sweats, hormone therapy, and keeping a steady routine. And, when you’re done reading, you’ll not only have greater understanding of what’s going on, but you’ll also have some more tools in your tool box so you can improve your sleep and get better rest.

How Common Is Sleep Trouble During Menopause?

In a word, very. A review in Nature and Science of Sleep found that women moving through menopause and postmenopause report sleep difficulties at rates between 40% and 56%, compared with 31% of women in the late reproductive stage (Baker, 2018). The same review notes that roughly 26% of women approaching menopause and beyond have symptoms severe enough to affect daytime functioning and qualify for a diagnosis of insomnia.

Other estimates run higher. The Woolcock Institute of Medical Research reports that over 60% of postmenopausal women report insomnia symptoms (Woolcock Institute of Medical Research, n.d.). So "up to 60%" is a fair summary of a range that depends on how researchers define sleep trouble and which stage of menopause they study. And while many of these studies shine light on postmenopausal insomnia, it’s important to understand that these sleep issues started during or just before the onset of menopause.

Why Menopause Disrupts Sleep

Estrogen and progesterone both influence sleep, and both decline across the menopausal transition. A 2022 systematic review of 86 studies concluded that the decline in estrogen and progesterone contributes to sleep disturbances, and that timely treatment with estrogen and/or progesterone improved overall sleep quality (Haufe et al., 2022). Longitudinal studies also link sleep difficulties to menopausal stage and to changes in follicle-stimulating hormone and estradiol (over and above the effects of simply getting older) (Baker, 2018). Progesterone, often described as a natural "calming" hormone, interacts with GABA, one of the brain's main calming chemical messengers. When progesterone falls, your brain may simply have less built-in help to relax and power down at night.

And, then there are the hot flashes. Hot flashes are a major contributor to sleep complaints, with many hot flashes linked to both more frequent awakenings and extra time spent awake at night. And hormones aren't the whole story. Depression, sleep apnea, and restless leg syndrome all become more common around and after menopause, and for some women, age, environment, and daily habits interact to make sleep harder still (Baker et al., 2018).

What Can Help

1. Try CBT-I (cognitive behavioral therapy for insomnia)

Given the nature of my private practice, I am admittedly a bit biased (I hold a certificate in CBT-I and strongly draw upon it with nearly all my sleep clients). But in this case, the evidence is on my side.

In a randomized clinical trial from the MsFLASH research network, 106 perimenopausal and postmenopausal women aged 40 to 65, all with moderate insomnia symptoms and at least two hot flashes per day, received six telephone sessions over eight weeks of either CBT-I or menopause education. The CBT-I sessions included sleep restriction, stimulus control, sleep hygiene education, cognitive restructuring, and behavioral homework. At eight weeks, 70% of women in the CBT-I group were sleeping well, compared with only 24% of the menopause education group. At 24 weeks, the numbers were 84% and 43% respectively (McCurry et al., 2016).

That is a big difference, and it held up months later. CBT-I is also the recommended first-line treatment for chronic insomnia by both the American College of Physicians and the American Academy of Sleep Medicine (Qaseem et al., 2016; Edinger et al., 2021). And the Menopause Society's 2023 position statement lists cognitive-behavioral therapy among its top-rated (Level I) nonhormone options for hot flashes (North American Menopause Society, 2023).

With such strong results, what does CBT-I actually look like? It's a practical, structured approach to the thoughts and habits that keep insomnia going: examining beliefs that fuel sleep anxiety (thoughts like, "If I don't get seven hours, tomorrow is ruined"), strengthening the link between your bed and sleep, and carefully adjusting your sleep schedule so sleep becomes deeper and more consolidated. It is often a attractive option because it isn't a pill, and it doesn't require changing your hormones. Instead, it changes your relationship with sleep itself, which is useful when everything else in your body feels in flux.

A cool bedroom with comfortable, breathable bedding is always helpful—regardless of your sleep struggles.

2. Ease the Hot Flashes and Night Sweats

If hot flashes are waking you up, calming them down is often the most direct route to fewer wake-ups. That, however, is much easier said than done.

In 2023, the Menopause Society (formerly the North American Menopause Society) reviewed the research on nonhormone options for hot flashes. Cognitive-behavioral therapy, clinical hypnosis, certain antidepressants (SSRIs and SNRIs), gabapentin, and fezolinetant received its strongest (Level I) recommendation, with oxybutynin recommended at Levels I-II and weight loss and stellate ganglion block at Levels II-III. Hormone therapy remains the most effective treatment overall (North American Menopause Society, 2023).

What didn't make the cut? According to summaries of the statement, the therapies not recommended included supplements and herbs, soy products, acupuncture, and cooling techniques (DePolo, 2023). A cool, dark bedroom, breathable bedding, and a fan are comfortable and nearly free (I regularly recommend them for all my sleep clients). But the research doesn't show that cooling tricks alone treat the underlying hot flashes. As is often the case, the one-and-done options, quick-fixes, or ‘hacks’ are the least effective.

3. Ask Your Doctor About Hormone Therapy

The Menopause Society's 2022 position statement affirms that hormone therapy remains the most effective treatment for hot flashes and night sweats. For women younger than 60 or within 10 years of menopause onset who have no contraindications, the benefit-risk ratio is favorable for treating bothersome symptoms. For women who start more than 10 years after menopause onset or who are older than 60, the balance appears less favorable because of greater absolute risks of coronary heart disease, stroke, blood clots, and dementia. Treatment should be individualized and periodically reevaluated (North American Menopause Society, 2022), and some women aren't good candidates because of conditions such as estrogen-dependent cancers or cardiovascular disease (North American Menopause Society, 2023).

When it comes to sleep specifically, the systematic review I mentioned earlier found that timely estrogen and/or progesterone therapy improved overall sleep quality (Haufe et al., 2022). That makes it entirely reasonable to bring your sleep to the conversation, not just your hot flashes. Ask what's appropriate for your health history, what options exist if hormones aren't right for you, and how you'll both know whether the plan is working.

4. Keep a Steady Routine

This is the least glamorous item on the list, and I'd argue it's one of the most powerful. Practicing healthy sleep behaviors, like starting with a regular getting-up time is one of the most helpful things you can do. In my own practice, a consistent wake time is one of the first anchors we set regardless of the kind of sleep struggle a client may have—but especially for women struggling with menopausal sleep issues.

Your body runs on rhythms. When hormones are fluctuating and your nights are unpredictable, a steady routine gives your internal clock something reliable to hold onto, and consistent habits help your body learn (or relearn) when it's time to rest.

• Pick a wake-up time and protect it. Yes, even on weekends.

• Build your day to help your night. No more caffeine after 10 or 11am, limited alcohol, and no heavy foods before bed.

• Build a short wind-down ritual. Dim the lights, put the screens away, and give your mind a runway to land on.

• Keep your bed for sleep. The more your brain associates the bed with rest (and not with scrolling or worrying), the better.

When It's More Than Hormones

As I mentioned earlier, a number of other sleep issues can arise during menopause that lay outside the realm of shifting hormones. Sleep apnea, depression, and restless leg syndrome appear to be more common around and after menopause (Baker et al., 2018). If you snore loudly, wake up gasping for breath, struggle to feel happiness like you used to, or have an urge to move your legs at night, please raise it with your doctor. Those are problems with their own solutions.

A Closing Thought

Poor sleep during menopause is often a physiological reality, not a personal failing, and you have more options to address it than you might think. Many of those options are easily at your disposal—whether it’s things you can do on your own, things you can explore and engage with someone like myself, or questions best served by your physician. If you are experiencing struggles with your sleep, often working with someone like myself can help you navigate and make best use of all the options you have. You don’t have to endure bad sleep and feel exhausted and miserable all the time simply because you are going through a very natural phase of life. Good rest and better sleep are within your reach. And as always, I am here to help you explore what that can look like and help you get the rest you deserve.

Be well.

Adam Scheldt is a holistic counselor, CBT-I based sleep coach, and rabbi based in Kenmore, New York, serving clients in person and online.

References

Baker, F. C., de Zambotti, M., Colrain, I. M., & Bei, B. (2018). Sleep problems during the menopausal transition: Prevalence, impact, and management challenges. Nature and Science of Sleep, 10, 73-95. https://pmc.ncbi.nlm.nih.gov/articles/PMC5810528/

DePolo, J. (2023, June 28). NAMS releases statement on non-hormone therapy for hot flashes, night sweats. Breastcancer.org. https://www.breastcancer.org/research-news/non-hormone-therapy-hot-flashes

Edinger, J. D., Arnedt, J. T., Bertisch, S. M., Carney, C. E., Harrington, J. J., Lichstein, K. L., Sateia, M. J., Troxel, W. M., Zhou, E. S., Kazmi, U., Heald, J. L., & Martin, J. L. (2021). Behavioral and psychological treatments for chronic insomnia disorder in adults: An American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 17(2), 255-262. https://doi.org/10.5664/jcsm.8986

Haufe, A., Baker, F. C., & Leeners, B. (2022). The role of ovarian hormones in the pathophysiology of perimenopausal sleep disturbances: A systematic review. Sleep Medicine Reviews, 101710.

McCurry, S. M., Guthrie, K. A., Morin, C. M., Woods, N. F., Landis, C. A., Ensrud, K. E., Larson, J. C., Joffe, H., Cohen, L. S., Hunt, J. R., Newton, K. M., Otte, J. L., Reed, S. D., Sternfeld, B., Tinker, L. F., & LaCroix, A. Z. (2016). Telephone-based cognitive behavioral therapy for insomnia in perimenopausal and postmenopausal women with vasomotor symptoms: A MsFLASH randomized clinical trial. JAMA Internal Medicine, 176(7), 913-920. https://escholarship.org/uc/item/6f64r52c

North American Menopause Society. (2022). The 2022 hormone therapy position statement of The North American Menopause Society. Menopause, 29(7), 767-794. https://doi.org/10.1097/GME.0000000000002028

North American Menopause Society. (2023). The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause, 30(6), 573-590.

Qaseem, A., Kansagara, D., Forciea, M. A., Cooke, M., & Denberg, T. D. (2016). Management of chronic insomnia disorder in adults: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 165(2), 125-133. https://doi.org/10.7326/M15-2175

Woolcock Institute of Medical Research. (n.d.). Untangling the mysteries of sleep in menopause. https://www.woolcock.org.au/news/untangling-the-mysteries-of-sleep-in-menopause