Sleep Problems During Perimenopause and Menopause: What's Really Happening?

Many women tell me about a common problem: after years of sleeping well, they suddenly find themselves awake at night, having night sweats, or waking up often—all starting around perimenopause. As a psychologist who helps women through midlife changes, I've seen how these sleep problems can affect mental health, thinking ability, and overall wellbeing.

Why Sleep Gets Difficult During Perimenopause
Perimenopause usually happens in your 40s or early 50s, when hormone levels—especially estrogen—start to change as your body moves toward menopause. These hormone changes affect more than just your periods; they also change how your brain works, including how you sleep.

Research shows just how common these sleep problems are. Between 40-69% of women have sleep troubles during the menopause transition (1). That's a lot of women lying awake at night!

What Makes Menopausal Sleep Different
Studies show that women in perimenopause have worse sleep than women who haven't yet reached this stage. What's interesting is the pattern of sleep problems during menopause:

- While some women have trouble falling asleep, the majority of women during menopause tend to wake up frequently throughout the night or wake too early in the morning and can’t get back to sleep.
- Their overall sleep is more broken up and less restful.

Even though you might be in bed for the same amount of time as before, your sleep quality drops, and you may get less of the deep restorative sleep, as well as more time awake during the night.

More Than Just Hot Flushes
While night sweats and hot flushes do disturb sleep, they're not the only causes. Studies show that only about one-third of nighttime awakenings are directly connected to hot flushes (1). This means other factors are also important.

Three main things contribute to sleep problems during menopause:

1) Hot flushes and night sweats: These can wake you up even when you don't realise it's happening. Research shows that 78% of hot flushes cause an awakening at night (2).

2) Hormone changes: Estrogen helps regulate sleep cycles. As it drops, your sleep patterns get thrown off. Rising levels of another hormone (FSH) make it harder to stay asleep, while falling estrogen affects both falling asleep and staying asleep (3).

3) Mood changes: Depression and anxiety often increase during perimenopause and can make sleep worse.

Progesterone, another hormone that decreases during menopause, normally helps promote sleep and reduce anxiety. As it declines, sleep becomes more difficult (4,5).

Melatonin (your body's natural sleep hormone) also decreases as you age, especially during perimenopause, making it harder for your body to know when it's time to sleep.

The Mood-Sleep Connection
One of the most important things I've noticed as a psychologist is how sleep and mood affect each other during perimenopause. Poor sleep can cause irritability, anxiety, and depression, while feeling stressed or down can make it harder to sleep—creating a difficult cycle.

Research shows that women in perimenopause who sleep poorly have more psychological distress than those who sleep well. When we improve one problem, the other often gets better too.

Health Risks Beyond Feeling Tired
Sleep problems during menopause can lead to serious health issues:

- Heart health: Poor sleep is linked to increased risk of heart disease in midlife women.
- Weight gain: Disrupted sleep changes how your body uses nutrients, making it easier to gain fat—regardless of hormone changes.
- Thinking and memory: Sleep problems can make you less alert and harm your thinking abilities. Studies show sleep is a major factor in memory problems during menopause.
- Work performance: Women with new sleep problems during midlife have higher rates of unemployment and billions are lost in productivity each year.

Sleep apnea (breathing pauses during sleep) also becomes more common after menopause. Before menopause, women have fewer cases than men, but afterward, the rates become similar because female hormones previously helped protect against it.

What Helps With Sleep During Menopause?

Hormone Replacement Therapy
Hormone replacement therapy (HRT) can help some women sleep better, but mainly those who also have hot flushes and night sweats. Taking estrogen with progesterone may be especially helpful for sleep.

However, HRT isn't right for everyone due to medical reasons or personal preference.

Medication Options
Several medications might help with sleep during menopause:

- Sleep medications work quickly but can become habit-forming if used longer than a month, and they often have side effects that can be unpleasant and difficult to tolerate.
- Antidepressants may help women who have both sleep problems and depression, but results are mixed, and some can actually make sleep worse.

For both types of medications, side effects and potential dependency are concerns, so they're usually recommended only for short-term use.

Psychological Approaches
As a psychologist, I recommend several approaches that can help manage sleep problems during perimenopause:

- Cognitive-behavioural therapy for insomnia (CBT-I) or Mindfulness-based CBT-I: This is the most effective non-drug treatment. It helps you change thoughts and behaviours that interfere with sleep. Online versions are now available if you can't see a therapist in person (See our online program)
- Better sleep habits: Keep consistent sleep-wake times, create a cool dark bedroom, limit screen time before bed, avoid caffeine and alcohol several hours before sleep, and exercise regularly.
- Stress management: Mindfulness meditation, relaxation exercises, and deep breathing can reduce the stress that often comes with perimenopause and disrupts sleep.
Self-hypnosis: Research shows this can help improve sleep and reduce hot flushes.
- Light exposure: Getting plenty of natural light during the day helps regulate your body clock and improves both sleep and mood.

Understanding the Bigger Picture
Sleep changes during perimenopause aren't happening in isolation. Scientists have discovered special brain cells (called KNDy neurons) that control hormones, body temperature, and sleep-wake cycles. This explains why these symptoms often happen together during menopause.

Many women in perimenopause are also dealing with busy careers, parenting responsibilities, and caring for aging parents—all while experiencing major hormone shifts. This combination can make sleep problems feel overwhelming.

Help is available
If you're having sleep problems during perimenopause or menopause, remember you're not alone, and help is available. Talk to a healthcare provider who understands menopause. Often, a combination of medical help, psychological support, and lifestyle changes makes the biggest difference.

The perimenopause transition doesn't last forever, and better sleep is possible—even with changing hormones. Understanding what's happening in your body is the first step toward getting the restful sleep you need.

At A Mindful Way we have a range of resources available to help women sleep better at this stage of life, from individual psychologist sessions, to the Restful Nights Through Perimenopause group program, and our clinically validated online mindfulness-based CBT-I program, A Mindful Way to Healthy Sleep. We’re here to help.

References
(1) Maki,P., Panay,N. &  Simon, JA.  (2024) Sleep disturbance associated with the menopause, Menopause: The Journal of The Menopause Society. Vol. 31, No. 8, pp. 724-733

(2) Thurston RC, Santoro N, Matthews KA. Are vasomotor symptoms associated with sleep characteristics among symptomatic midlife women? Comparisons of self-report and objective measures. Menopause 2012;19: 742‐748. Doi: 10.1097/gme.0b013e3182422973

(3) Coborn J, de Wit A, Crawford S, et al. (2022) Disruption of sleep continuity during the perimenopause: associations with female reproductive hormone profiles. J Clin Endocrinol Metab. ;107:e4144‐e4153. Doi: 10.1210/clinem/dgac447

(4) Zheng H, Harlow SD, Kravitz HM, et al. (2015) Actigraphy-defined measures of sleep and movement across the menstrual cycle in midlife menstruating women: study of Women's Health Across the Nation Sleep Study. Menopause, 22:66‐74. doi: 10.1097/GME.0000000000000249

(5) Baker FC, Willoughby AR, Sassoon SA, Colrain IM, de Zambotti M (2015) Insomnia in women approaching menopause: beyond perception. Psychoneuroendocrinology. 60:96‐104. doi: 10.1016/j.psyneuen. 2015.06.005