Menopause Insomnia: Why You Can’t Sleep and What Helps

Why does menopause cause insomnia?

There is rarely a single cause. A 2018 review of sleep in the menopause transition found that sleep problems are linked to menopausal stage and to changes in estradiol and follicle-stimulating hormone, over and above the effect of getting older. Several things tend to stack up.

Night sweats and hot flashes

Hot flashes at night are the biggest single contributor. Many, though not all, are linked to awakenings measured in sleep labs, and the time spent awake after them adds up across the night. Some women don’t remember the sweat, only that they woke. Our guide to why hot flashes happen explains the mechanism.

Hormone changes that make sleep lighter

Estrogen and progesterone both act on brain systems involved in sleep and temperature control. Progesterone’s breakdown products act on GABA receptors, the same calming system targeted by many sleep medicines. As levels fall and swing during perimenopause, sleep often becomes lighter and more broken, even on nights without sweats. More on that in progesterone and sleep.

Mood, anxiety and stress

Depression and anxiety become more common during the transition, and both disturb sleep. Midlife also tends to bring heavy work and caregiving loads. Lying awake worrying about sleep can then become its own problem, which is the pattern behind chronic insomnia.

Other sleep disorders

Sleep apnea and restless legs become more common after menopause, and needing to urinate at night increases. Snoring, gasping, morning headaches or being very sleepy in the day point toward apnea, which needs its own evaluation and won’t improve with hormones or sleep habits alone.

How common is menopause insomnia?

Sleep complaints are among the most common menopause symptoms. In the 2018 review, about 26% of women in the transition had symptoms severe enough to affect daytime functioning and qualify as insomnia disorder. Insomnia is usually defined as trouble falling asleep, staying asleep or waking too early at least three nights a week for three months or more, with effects during the day.

How long does menopause insomnia last?

When night sweats are the main driver, sleep problems tend to follow the course of hot flashes. In the large SWAN study, frequent hot flashes and night sweats lasted a median of 7.4 years in total and continued for a median of 4.5 years after the final period. Women whose symptoms started earlier in the transition tended to have them longer. Our guide to how long hot flashes last breaks this down.

By the numbers

How long night sweats last

7.4 yrsmedian total duration of frequent hot flashes and night sweatsSource: Avis 2015

4.5 yrsmedian time they continue after the final periodSource: Avis 2015

Insomnia doesn’t always end when hot flashes do. After months of broken nights, the brain can learn to associate bed with being awake. That learned pattern is very treatable, which is a good reason not to simply wait it out.

What helps menopause insomnia?

The best plan depends on what is driving your sleep problems. Here is how the main options compare.

Cognitive behavioral therapy for insomnia (CBT-I)

CBT-I is a structured program, usually four to eight sessions, that retrains sleep through techniques such as sleep restriction (temporarily limiting time in bed to build sleep drive), stimulus control (using the bed only for sleep), and changing unhelpful thoughts about sleep. The American College of Physicians recommends it as first-line treatment for chronic insomnia.

It works in women with hot flashes too. In the MsFLASH trial, six phone sessions of CBT-I cut insomnia scores roughly twice as much as menopause education, and 70% of women in the CBT-I group were in the no-insomnia range at eight weeks, compared with 24% in the comparison group. A pooled analysis of four MsFLASH trials found CBT-I improved insomnia more than any of the other treatments tested, including low-dose estradiol, exercise and certain antidepressants. CBT-I is available through trained therapists, telehealth and well-designed digital programs.

By the numbers

CBT-I in women with hot flashes

70%in the no-insomnia range at eight weeks after phone CBT-ISource: McCurry 2016

24%in the no-insomnia range with menopause education aloneSource: McCurry 2016

Hormone therapy

The Menopause Society calls hormone therapy the most effective treatment for hot flashes and night sweats, and for healthy women under 60 or within 10 years of menopause, the benefits generally outweigh the risks. When night sweats are what wake you, treating them often improves sleep. Estrogen’s direct effect on insomnia itself appears more modest, which is why combining treatment with CBT-I can make sense.

Progesterone may add something of its own. A 2021 meta-analysis found oral micronized progesterone shortened the time to fall asleep and improved self-reported sleep in most trials, mainly in postmenopausal women, although results were inconsistent and some studies also gave estrogen.

Amie HRT+ is a compounded cream combining estradiol and progesterone, with the strength chosen by a licensed clinician after an online review, for symptoms including hot flashes, night sweats and sleep problems. It is not FDA-approved, and the studies above used FDA-approved oral progesterone, not a cream. A clinician decides whether it is appropriate for you, and hormone therapy is not suitable for everyone, including many women with a history of breast cancer, blood clots, stroke or liver disease.

Non-hormone prescription options

If hormones aren’t right for you, The Menopause Society’s 2023 nonhormone position statement recommends several treatments for hot flashes with good evidence, including certain SSRI and SNRI antidepressants, gabapentin and fezolinetant. Gabapentin is often taken at bedtime, which can help sleep. Each has its own side effects and interactions to discuss with a clinician.

Sleep medications

Prescription sleep medicines can help some people in the short term, but they carry risks such as next-day drowsiness, falls and dependence with some drugs. The American Academy of Sleep Medicine suggests against using over-the-counter diphenhydramine, melatonin or valerian as treatment for chronic insomnia, because evidence of meaningful benefit is weak. If you use any sleep aid most nights, talk to a clinician.

Supplements

Magnesium, low-dose melatonin and herbal products are popular, but evidence that they treat menopause insomnia is limited, and supplement quality varies. See our guide to magnesium for sleep for what the trials show. Check with a clinician before combining supplements with prescription medicines.

Habits that support better sleep

• Keep the same wake-up time every day, including weekends.
• Keep the bedroom cool and use breathable bedding and sleepwear, which can make night sweats easier to sleep through.
• Limit alcohol, especially in the evening, since it fragments sleep later in the night.
• Keep caffeine to the morning.
• If you can’t sleep after what feels like 20 minutes, get up and do something quiet in dim light until you feel sleepy.

These are helpful foundations. On their own they rarely fix chronic insomnia, which is why the treatments above exist.

When to talk to a clinician