Why Sleep Gets Worse During Perimenopause (And 5 Evidence-Based Ways to Fix It)

Many women notice sleep changes in their 40s and early 50s. You may wake up at night, struggle to fall back asleep, or feel exhausted despite spending enough time in bed.

This isn’t uncommon.

Research shows about half of women experience sleep disturbances during perimenopause, the years leading up to menopause when hormone levels begin to fluctuate.

Understanding the cause can make it easier to improve sleep.

Why Perimenopause Disrupts Sleep

Hormone fluctuations

One of the major reasons why sleep gets worse during perimenopause. Estrogen and progesterone influence the brain centers that regulate sleep. When these hormones decline, women may experience:

• more nighttime awakenings

• difficulty falling asleep

• lighter, less restorative sleep

Hot flashes and night sweats

These symptoms can cause sudden awakenings and fragmented sleep.

Women who experience hot flashes are significantly more likely to report insomnia.

Stress and mood changes

Midlife can be a stressful stage with work, family responsibilities, and caregiving roles. Anxiety and stress often worsen sleep.

Sleep disorders

The risk of conditions such as Obstructive Sleep Apnea increases after menopause and can lead to frequent awakenings.

Why Poor Sleep Matters

Sleep problems during perimenopause affect more than just energy levels.

Chronic insomnia is associated with:

• increased risk of depression and anxiety

• reduced work productivity

• higher risk of cardiovascular disease

• weight gain and metabolic problems

Improving sleep can therefore play an important role in long-term health and prevention.

5 Evidence-Based Ways to Improve Sleep

1. Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT-I is considered the most effective long-term treatment for insomnia. It helps people change habits and thought patterns that interfere with sleep.

Many programs are now available online.

2. Regular Exercise

Moderate physical activity improves sleep quality and mood.

Aim for 30 minutes of exercise most days of the week.

3. Reduce Stress Before Bed

Relaxation techniques can calm the nervous system and improve sleep.

Helpful options include:

• meditation

• yoga

• breathing exercises

• gentle stretching

4. Consider Hormone Therapy

If insomnia is caused by severe hot flashes, menopausal hormone therapy may help. Treatment should always be discussed with a healthcare professional.

5. Newer Non-Hormonal Treatments

Some women benefit from medications that reduce hot flashes, including Fezolinetant.

Melatonin supplements may also help certain individuals.

Simple Sleep Habits That Help

Small changes can improve sleep quickly:

• keep a consistent sleep schedule

• avoid caffeine late in the day

• keep the bedroom cool and dark

• limit screens before bedtime

• exercise regularly

The Bottom Line

Sleep disturbances are one of the most common symptoms of perimenopause, affecting up to half of women.

Hormonal changes, hot flashes, stress, and lifestyle factors all contribute.

Fortunately, effective treatments exist, and many women see significant improvement with behavioral strategies, exercise, and targeted medical therapies.

If sleep problems last longer than three months or significantly affect daily life, it may be helpful to discuss them with a healthcare professional.

References

1. Menopause Transition and Cardiovascular Disease Risk: Implications for Timing of Early Prevention: A Scientific Statement From the American Heart Association. El Khoudary SR, Aggarwal B, Beckie TM, et al. Circulation. 2020;142(25):e506-e532. doi:10.1161/CIR.0000000000000912.

2. Disruption of Sleep Continuity During the Perimenopause: Associations With Female Reproductive Hormone Profiles. Coborn J, de Wit A, Crawford S, et al. The Journal of Clinical Endocrinology and Metabolism. 2022;107(10):e4144-e4153. doi:10.1210/clinem/dgac447.

3. The Role of Ovarian Hormones in the Pathophysiology of Perimenopausal Sleep Disturbances: A Systematic Review. Haufe A, Baker FC, Leeners B. Sleep Medicine Reviews. 2022;66:101710. doi:10.1016/j.smrv.2022.101710.

4. The Burden of Sleep Disturbances on Quality of Life and Mental Well-Being in Nearly 50,000 Perimenopausal and Postmenopausal Women With and Without Concurrent Vasomotor Symptoms From the United States and Europe. Soares CN, Briggs P, Dinkel-Keuthage C, et al. Menopause (New York, N.Y.). 2025;:00042192-990000000-00543. doi:10.1097/GME.0000000000002654.

5. Optimizing Sleep Across the Menopausal Transition. Baker FC. Climacteric : The Journal of the International Menopause Society. 2023;26(3):198-205. doi:10.1080/13697137.2023.2173569.

6. Sleep Disturbance and Menopause. Carmona NE, Solomon NL, Adams KE. Current Opinion in Obstetrics & Gynecology. 2025;37(2):75-82. doi:10.1097/GCO.0000000000001012.

7. Over 50% of Women Affected by Menopausal Sleep Disorders: Urgent Need to Integrate Sleep Management Into Menopause Guidelines. Huang R, Liu W, Yi Y, Li D, Deng Y. European Journal of Endocrinology. 2026;194(3):L35-L37. doi:10.1093/ejendo/lvag029.

8. Behavioral Interventions for Improving Sleep Outcomes in Menopausal Women: A Systematic Review and Meta-Analysis. Lam CM, Hernandez-Galan L, Mbuagbaw L, et al. Menopause (New York, N.Y.). 2022;29(10):1210-1221. doi:10.1097/GME.0000000000002051.

9. Effects of Pharmacologic and Nonpharmacologic Interventions on Insomnia Symptoms and Self-Reported Sleep Quality in Women With Hot Flashes: A Pooled Analysis of Individual Participant Data From Four MsFLASH Trials. Guthrie KA, Larson JC, Ensrud KE, et al. Sleep. 2018;41(1):4642822. doi:10.1093/sleep/zsx190.

10. Telephone-Based Cognitive Behavioral Therapy for Insomnia in Perimenopausal and Postmenopausal Women With Vasomotor Symptoms: A MsFLASH Randomized Clinical Trial. McCurry SM, Guthrie KA, Morin CM, et al. JAMA Internal Medicine. 2016;176(7):913-20. doi:10.1001/jamainternmed.2016.1795.

11. Effectiveness of Nonpharmacological Interventions for Menopause-Related Insomnia: A Systematic Review and Bayesian Network Meta-Analysis. Wang Z, Yang H, Li S, et al. Maturitas. 2025;202:108713. doi:10.1016/j.maturitas.2025.108713.

12. Italian Association of Sleep Medicine (AIMS) Position Statement and Guideline on the Treatment of Menopausal Sleep Disorders. Silvestri R, Aricò I, Bonanni E, et al. Maturitas. 2019;129:30-39. doi:10.1016/j.maturitas.2019.08.006.