Perimenopause and Sleep: Why Nights Change and What Helps

A lot of women in their forties find that sleep, which used to look after itself, stops doing so. It takes longer to drop off, or they wake at 3 a.m. too hot and lie there until the alarm. Because it creeps in slowly, during years that are usually busy with work and family anyway, it’s easy to put it down to stress and leave it there.

Stress may well be part of it. The years around menopause also have their own effect on sleep, though, and it’s one of the better-documented changes of the transition. Knowing that won’t fix a bad night. It does change which remedies are worth trying, and it gives you something specific to raise with a doctor.

What Changes During the Transition

The clearest long-term picture comes from SWAN, a US study that followed more than 3,000 women from several ethnic backgrounds, aged 42 to 52 when they joined, and checked in with them every year. As women moved from regular cycles into the transition, trouble falling asleep and staying asleep became more likely. Frequent hot flushes or night sweats raised the odds of every kind of sleep difficulty the researchers asked about. Hormones showed up too: falling oestradiol and rising FSH (follicle-stimulating hormone) were linked with poorer sleep.

Kravitz, H.M. et al. (2008). “Sleep disturbance during the menopausal transition in a multi-ethnic community sample of women.” Sleep, 31(7), 979-990.

A 2018 review by Fiona Baker and colleagues put the share of women who report sleep problems during the transition at around half. Hot flushes and mood were among the main contributors, along with one that’s easy to miss: obstructive sleep apnoea becomes more common after menopause. Its signs, such as loud snoring, pauses in breathing that a partner notices, or waking unrefreshed however long you were in bed, are easy to blame on hormones or age. They are worth mentioning to a doctor, because apnoea can be tested for and treated.

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.

The link with hot flushes shows up in lab recordings too. In a 2014 study, researchers monitored the sleep of perimenopausal women overnight and found that nights with more hot flushes had more time awake, with a large share of that wake time tied to the flushes themselves. So for women who get frequent flushes, treating them is part of treating the sleep.

What Has Good Evidence

For insomnia itself, the treatment with the strongest evidence is cognitive behavioural therapy for insomnia (CBT-I), a structured course of a handful of sessions that works on sleep timing, what you do when you can’t sleep, and the worry that builds up around bedtime. Most sleep guidelines recommend it before sleeping pills for chronic insomnia. The MsFLASH trial tested a version delivered by telephone to peri- and postmenopausal women who had hot flushes. Their insomnia became less severe than in a comparison group, and the improvement held for at least six months. The phone format is useful in its own right, since trained CBT-I therapists can be hard to find nearby.

McCurry, S.M. et al. (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.

For the flushes, it’s worth talking to a doctor about treatment. Hormone therapy is the most effective option for hot flushes and night sweats, and when they’re what keeps waking you, easing them can help sleep too. It isn’t suitable for everyone, and there are non-hormonal medicines as well, so it’s a decision to make with someone who knows your history. If a sleep complaint gets waved away as “just your age”, asking for a second opinion or a referral to a menopause clinic is reasonable.

A few things at home are worth doing alongside. Keep the bedroom cool and sleep under layers you can push off in the night instead of one thick duvet. Get up at the same time each day, even after a poor night, since a steady wake time helps anchor the rest of your sleep. And look at evening alcohol, which tends to make flushes worse and leaves sleep lighter and more broken later in the night.

Take Two Weeks of Notes to the Appointment

Before you see a doctor, keep a sleep and symptom diary for two weeks. Write down when you went to bed and got up, how the night felt, roughly how often you woke and whether a flush or night sweat woke you, and any drinks in the evening. It takes a couple of minutes each morning. It turns “I sleep badly” into a pattern a doctor can work with, and once you start a treatment, it’s how you’ll tell whether it is helping.

Lamplit’s sleep log is free and covers much of that diary: bed time, wake time, a quality rating from poor to excellent, and tags for the night such as alcohol, caffeine or meds. There isn’t a hot-flush tag, so keep those on a separate note. Period logging is free as well, and changes in your cycle are useful context for the appointment. With Lamplit Pro, cycle tracking adds a perimenopause mode with phase analysis and trends. The app can’t tell you whether you’re in perimenopause, but it does give the doctor who can something concrete to look at.

Start your two-week sleep diary in Lamplit by logging last night. It’s free.