How to sleep better in perimenopause and menopause: real-life solutions
Are you experiencing frequent night wakings, difficulty falling asleep, or insomnia linked to hot flashes or anxiety? You're not alone.
Sleep disturbances are one of the most commonly reported symptoms during perimenopause and menopause, often driven by hormonal fluctuations affecting thermoregulation, mood, and circadian rhythm. In this article I explore the physiological causes behind menopausal sleep issues and give you evidence-based strategies to improve your sleep to have more restful nights.
Sleep is king for our health. Poor quality and quantity of sleep not only strips you of energy for the day, makes you sluggish and lacking motivation and focus, but it also affects the performance of every function in your body. Poor sleep has an impact on appetite and satiety, and thus negatively affects your metabolism, your immune system regulation, it increases the risk for cardiovascular and metabolic syndrome diseases. Prolonged sleep problems are associated with poor mental health, giving a higher risk for conditions such as depression, anxiety, panic attacks and other mood disorders.
Sadly, more women than men report sleep problems; depression and anxiety issues are also more prevalent in women than men. According to one study (Reference 1) women are 41% more likely than men to experience insomnia, with this risk increasing as we age. Women are more likely than men to “report difficulty falling asleep, maintaining sleep, feeling unrefreshed in the morning, and have excessive daytime sleepiness”. These are the troubles with sleep even before we get into the perimenopause and menopause years.
During the menopause period between 35% to 60% of women report difficulties with quality and quality of their sleep. This is an appalling one in three or two in three women. When it comes to mood disorders affecting women during menopause years, we have a double risk of developing depression when compared to men.
These figures on their own make a depressive read, I am sorry, but bear with me, I will get down to strategies to re-settle your good sleep while you are in perimenopause or menopause with the aim to help you feel better daily.
What are the contributing factors to poor sleep quality and how can can we help ourselves to sleep better during the menopause transition years?
Hormones at play
Examining the factors contributing to sleep problems in menopause, a meta-analysis published in Frontiers of Neurology concluded that “sleep disorders are cited as one of the top health concerns of menopausal women”, where problems with sleep are 1.3 - 1.6 times higher in perimenopausal women than in premenopausal women. Getting off to sleep, having fragmented sleep, waking up too early, experiencing hot flashes and having generally poor sleep quality have been said to be the most common issues with sleep for women during menopause years (Reference 2).
The menopause transition years, which can take between 4 to 12 years, are marked by the declining levels of estrogen and progesterone, both of which are believed to be affecting women’s sleep. During perimenopause, it is rather difficult to understand and observe the exact changes to estradiol - the main estrogen type, present in females during their reproductive years. Most medical practitioners rely on women’s self-reporting of symptoms, as estradiol’s fluctuating patterns are difficult to test for.
When it comes to sleep, several studies say that it could be for the diminishing levels of estradiol that sleep becomes fragmented, with nightly and early morning wakings. While estrogen levels have a high variability of fluctuation during the perimenopause transition, every night could mean a different sleep quality for a woman. Higher estrogen levels are often associated with a better objective sleep quality and fewer movements and arousals during the slow-wave sleep stage (this is primarily designated for the first three quarters of the night in the sleep architecture).
The hormone progesterone also begins to decline in perimenopause. This hormone is often called a ‘calming hormone’. While progesterone is rising in the follicular phase of the cycle, women often report they feel grounded and less stressed than in the luteal phase, when progesterone levels decline. One meta-analysis found that there is a positive relationship between levels of lowered progesterone and sleep in menopause. When women self-reported their quality of sleep, they had “shorter sleep efficiency and shorter sleep” during the luteal phase of the cycle - roughly a week before the period starts - confirming the association between the lowering levels of progesterone and sleep quality (Reference 3).
One of the main complaints in women during menopause transition is hot flashes, the medical term being vasomotor symptoms. Hot flashes include periods of night sweats, or fluctuations between sweating and then turning cold. Having been woken up by a night sweat and then spending the night uncovering and covering the body several times, many women find it really hard to fall back asleep past 3 or 4 am. Once the vasomotor symptoms are addressed (either via lifestyle interventions, of which later) or with a hormone therapy, women rate their sleep quality as much higher.
Vasomotor symptoms can last between 3.4 years to 7.4 years, with a small percentage of women not being able to get rid of them for good (Reference 4).
It is important to note here that women universally have more problems with sleep as compared to men, before menopause years start affecting sleep for the worse due to the hormone production. There are several pieces of research that show that when women have poor sleep quality at age 30 or 40, while still in the reproductive years, it becomes a high predictor for sleep problems during their menopause. More exactly, those women who have poor sleep at age 30 or 40, are 3,5 times more likely to experience severe sleep problems around their menopause transition, compared to the women who have no sleep issues during their reproductive years. (Reference 5)
Once sleep troubles become a new norm, or insomnia-like symptoms settle in, it is difficult to shift them, without help of a professional. Insomnia manifests itself in difficulty falling asleep, staying asleep, having prolonged period of sleepiness in the night, all of which affecting the person’s daytime functioning. The pervasive thoughts of not being able to sleep properly, having some physiological anomaly are often an accompanying factor of insomnia. The best management strategies for insomnia are Cognitive Behavioural Therapy for Insomnia (CBT-i), which is also an effective and durable therapy in treating menopause insomnia (I will speak about CBT-i in the sleep reset strategies below).
Anxiety and depression in menopause
Having insomnia or irregular sleep patterns is strongly associated with mood disorders, such as anxiety, depression, panic attacks and other. Waking up with fatigue and mental fog feels disempowering for many women, as a result motivation and energy are lowered for the day, these have a resulting effect on lower appetite, ether entailing problems with eating or having excessive snacking; motivation for exercise, lowered strive to participate in social events and many other - all of these amplifying the harm of insomnia.
Sleep also directly affects metabolism, the hormones of ghrelin and leptin (hunger and satiety respectively) are being down-regulated when sleep quality or quantity are inadequate, serving as a double whammy effect - weight gain is a common feature of the menopause transition years. In my earlier blog post I have covered the strategies to prevent weight gain in menopause and reverse insulin resistance if it is already present.
Prolonged periods of poor sleep can have a serious impact on women’s wellbeing, increasing the risks of chronic inflammatory diseases, such as obesity, diabetes type 2, heart disease, stroke, Alzheimer’s and dementia.
How to sleep better in perimenopause and menopause - strategies to improve sleep
There is one mistake so many people (men and women) make when it comes to sleep issues they have. They try various sleep aids, apps for mindfulness, meditation, natural sleep pills, combined supplement therapies, but the mistake is to view sleep as a standalone function, not is an integral part of the whole body daily functioning. We cannot compartmentalise sleep outside of our metabolic functions, endocrine functions, digestive functions, neurological functions, and all the others.
In the words of one of my clients who have struggled with sleep for over two years during her perimenopause, “Before we worked together, I had tried so many things, so many solutions to sort out my sleep, but only after you showed me this cohesive structure between my sleep, my eating habits, my work patterns and my exercise, I started sleeping well, through the night again. I love my sleep now”. She is 51 as I write this.
Think of sleep as part of your whole body functioning. It could do you a lot of benefit to stop addressing sleep issues in silos, it is exhausting for you mentally and for your physical body too. Everything in the body is interconnected and interrelated. The same is with sleep.
Questions that are useful to ask yourself now:
What are my diet patterns like at the moment? Am I happy with the quality of my diet? Quality is the key word here. If you are not happy with the foods you are eating, you feel sluggish, or irritable, you have food intolerances, or craving foods too often, address this now: un-process your diet. Get rid of as many processed foods as possible. Cut down on sugars, remove packaged goods as much as possible - readymade meals, frozen meals, supermarket bought sandwiches, salad dressings and sauces are the biggest offenders. More about the diet in menopause in my piece I mentioned above.
Your dinner time and your sleep are directly linked. How closely to your bedtime do you have your dinner? If the answer is less than 2,5 hours, your sleep quality will suffer. Your body core temperature needs to drop in order for you to fall asleep and stay asleep. Thus, it’s best to finish all your food (including snacks or cups of tea) before 7:30pm.
Caffeine: I know you have heard this one many times before, the general advice being ‘lower your caffeine intake, don’t drink caffeine close to your bedtime’. This vague advice isn’t helpful. Facts about caffeine you need to know and follow as much as possible: caffeine has a half-life of 5-8 hours. In medicine we speak about ‘half-life’ to refer to the time needed for the body to metabolise and remove 50% of a given chemical (typically a pill). What this means in terms of caffeine intake, if you drank a cup of coffee at 5 pm, at 10 pm there still be 50% of caffeine circulating in your blood stream, making it difficult for you to stay asleep through the night. The half-life of 5 to 8 hours varies among individuals, some people can handle caffeine as close as 5 hours to their bedtime, others need the full 8 or even more. (Reference 7)
Set a regular bed time and stick to it. This one is key. Your circadian clock, which regulates your sleep and wake cycles, produces the hormones cortisol and melatonin to orchestrate your daily cycles of sleep and wakefulness. There is a strong circadian element in this regulation. I won’t go into the details of this now (please let me know in comments if you would like a post on this), what you need to know is that cortisol, the hormone of energy (and stress too) and melatonin (the hormone that helps us sleep) production works in near opposite direction, when cortisol is high, melatonin is low. Make sure your sleep occurs approximately at the same time each night (plus or minus half an hour is ok for the body not to notice), this will help your circadian rhythm regulation for good sleep patterns.
Alcohol intake. Alcohol disrupts sleep, any amount of alcohol. It reduces the quality of slow-wave sleep, that deep sleep that we need as a necessity to form memory; it also shortens REM phases from 7 to 2, increases the amount of micro-awakenings by approximately 2-3 times. This means your sleep is disturbed and fragmented, in some cases the micro-awakenings are so many that you are not aware of them, as you are tossing and turning all night long. If you drink alcohol and want to enjoy it, it’s best to leave it for special occasions, or perhaps choose a day in the week when you know you can stay in bed a bit longer to compensate for disruptions in your sleep quality.
The role of stress: Studies have shown that having regularly high levels of the stress hormone cortisol can lead to lower estrogen and progesterone levels. One of the hypothesis, called the “pregnenolone steal”, implies that in periods of high stress, the female body will activate the hypothalamic-pituitary-adrenal axis, which results in the secretion of corticotropin-releasing hormone (CRH), adrenocorticotropic hormone (ACTH) and cortisol, the main stress hormone in humans. This cascade reaction not only has a negative effect on quality of sleep itself, but can also affect ‘the pregnenolone pathway’. The pre-hormone pregnenolone is the precursor to most steroid hormones - including progesterone, testosterone, estrogens and cortisol. When a woman has chronic stress levels for extended periods of time, the elevated cortisol “may reduce or 'steal’ the pregnenolone available for the synthesis of down-stream hormones other than cortisol” (Reference 8). This means that there is not enough ‘building material’ going into the production of progesterone or estrogens due to the “steal”. This hypothesis has been used in several endocrinological studies, however, researchers caution it requires further investigation. The more noticeable and immediate result of high stress on your physiological body. The more noticeable and immediate result of high stress on your physiological body is having disrupted sleep. Experiencing high stress regularly will make you wake up several times in the night, often being unable to fall back asleep after 2 or 3am, all due to high levels of cortisol.
Apps: There is a world of literature out there how to practise mindfulness and meditation, do deep breathing techniques, which there are many, journal and do slow-pace yoga, and many more calming activities that can help you de-stress and improve quality of your sleep in menopause. Unfortunately, there is a misconception out there, that these practices work as a solution. No, they don’t. These practices need to be incorporated into your lifestyle, give them adequate time in your daily routine. Having created habits to slow down and unwind an hour or 90 minutes before bedtime regularly, repeating the routines daily, one time, after a few weeks of practice, you will get good quality sleep - falling asleep easily and sleeping through the night. On the subject of mindfulness and meditation, if you suffer from insomnia, please note that having apps with meditation, white noise or calming music as your repertoire before sleep or in the middle of the night to get back to sleep could be counter-productive. They act as a conditional response for your body, which learns to sleep only with an aid. A human body needs to be able to fall asleep and stay asleep without any aid. Thus, in CBT-i therapy we train people to go off the apps to help them sleep.
CBT-i: Cognitive Behavioural Therapy for Insomnia. This is the first-line treatment for insomnia recommended by sleep experts around the world. CBT-i is different to other methods, as it is a structure programme that gives you the tools to break the insomnia cycle for good. It is a coach-led, highly personalised therapy that helps you assess and re-examine your beliefs about sleep, uncovering thought patterns that may be quietly fuelling your insomnia. Together, the coach and the client make small, gradual changes in the sleeping environment, bedtime routine, and daytime lifestyle choices. The therapy is 6 to 8 weeks long with very high success rates, helping you restore sleep from insomnia that may have gripped you for years. I am a CBT-i practitioner and I can highly vouch for this therapy. Read more about my CBT-i experience here.
There are many tips how to sleep better in perimenopause and menopause, having the whole body approach is what I would recommend to any woman embarking on a journey to feel better, have more energy and restore her drive for life during this challenging period in our lives.
Have you tried the whole body approach for your sleep issues in menopause, with a coach or by yourself, would you like to share your experience in comments below?
Factors influencing sleep disorders in perimenopausal women: a systematic review and meta-analysis, W. Zeng, J. Xu, Y. Yang, M. Lv, X. Chu, Frontiers in Neurology, Feb 7; 16, 2025 https://pmc.ncbi.nlm.nih.gov/articles/PMC11842262/
Actigraphy-defined measures of sleep and movement across the menstrual cycle in midlife menstruating women: SWAN sleep study, H. Zheng, S. D. Harlow, H. M. Kravitz, J. Bromberger, D. J. Buysse, K. A. Matthews, E. B. Gold, J. F. Owens, M. Hall, Menopause, Jan 22(1); 66, 2015 https://pmc.ncbi.nlm.nih.gov/articles/PMC4237700/
Poor sleep in relation to natural menopause: a population-based 14-year follow-up of mid-life women, E. W. Freeman, M. D. Sammel, S. A. Gross, G. W. Pein, Menopause, Jul 22(7); 719, 2015 https://pmc.ncbi.nlm.nih.gov/articles/PMC4481144/