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Disrupted Sleep

Many factors contribute to sleep disruption around age 40.

What is disrupted sleep?

There are three types of disrupted sleep during perimenopause:
  1. Trouble falling asleep
  2. Waking in the middle of the night*
  3. Waking very early in the morning
*#2 is most common in perimenopause.
WLB 2020 SURVEY RESULTS

I wake up in the middle of the night and am awake for 1 hour or more

% of Respondents Reporting
Overall Sample
0%
With Regular Periods (LRS)
0%
With Irregular Periods (MT)
0%
The loss of sleep has been awful. Attempting to use sleeping pills just leads to other side effects (heart palpitations). Much more research is needed in this area. It made it really, really hard to work and I lost a great deal of respect, which was devastating to my career.

WLB Community Member

4 things to know about disrupted sleep during perimenopause

  • Disrupted sleep during the menopausal transition is common and many things can contribute: hot flashes, hormonal changes, mood changes, life stressors and other medical conditions and medications. Sleep apnea was found to affect 20% of women in research. See: Many Causes for Sleep Disruption section below.

  • If you struggle with sleep, consider studying your sleep and creating a sleep strategy (see below).

  • Cognitive Behavioral Therapy for Insomnia (CBT-I) works! — more info below.

  • Research links poor sleep to negative health outcomes such as increased risk for cardiovascular disease, insulin resistance, and negative changes in mood. In particular, a metric of sleep continuity called Wake After Sleep Onset (WASO) is related to poorer cognitive performance. All good reasons to focus on improving your sleep.

WLB 2020 SURVEY RESULTS

In our research and others2,3 we found “waking in the middle of the night” to be the most common new experience at the beginning of perimenopause. To investigate this in more detail, we asked about 3 types of “waking in the middle of the night.”

I have a hard time falling asleep

% of respondents from our research (The WLB Study) who reported difficulty falling asleep
Overall
0%
With Regular Periods (LRS)
0%
With Irregular Periods (MT)
0%

I wake in the middle of the night and feel panic, anxious, worried

% of respondents from our research (The WLB Study) who reported waking in the middle of the night and feeling panicked, anxious, worried
Overall
0%
With Regular Periods (LRS)
0%
With Irregular Periods (MT)
0%

I wake up very early in the morning

% of respondents from our research (The WLB Study) who reported waking very early
Overall
0%
With Regular Periods (LRS)
0%
With Irregular Periods (MT)
0%
The night wakings come and go. No obvious reason why. I am also much more alcohol sensitive in the last few years, night wakings always happen when I have had that one glass too many, which I try to limit as they are so miserable!

WLB Community Member

Study your sleep and create a sleep strategy

Study your sleep: Take a week and note what things improve or worsen your sleep. Some variables to test: late meals, alcohol or amount of alcohol, late-in-the-day workouts, afternoon chocolate or caffeine, intense or worrisome content before bed, checking work emails.

Create a sleep strategy: If you begin to struggle with sleep in your late 30s/early 40s, accept that this may be part of your life for a while and devise a sleep strategy.

  • Prioritize sleep/earlier bedtime: If you have to be up by 6:30 a.m., can you go to bed at 9:30? Even if you are awake for an hour or two, you still have a chance of getting 7-8 hours of sleep.
  • Set a schedule: I didn’t believe this would help, but the more consistent I am with going to bed at around the same time, the better my sleep seems to be.
  • Prepare for an awakening: Try various back-to-sleep remedies to find the ones that work best for you. (See “remedies: once you’re awake” below for ideas to try.)
  • Set sleep hygiene as a foundation: all the sleep hygiene stuff you’ve heard before is important too! (See “remedies: before bed” below.)

*** Other sleep disrupters that can arise in midlife are obstructive sleep apnea and restless leg syndrome. If you suspect either of these as the cause of your sleep challenges, see a health care provider for solutions.

My sleep has definitely been affected. I will wake up and not be able to fall back to sleep for a few hours or wake up multiple times a night.

WLB Community Member

Remedies to consider

Cognitive Behavioral Therapy for Insomnia (CBT-I)

It works! Lots of recent research supports the use of CBT-I as effective for sleep challenges. The (“I”) is for insomnia. It’s best and most effective to learn cognitive behavioral therapy from a practitioner one-on-one but it can be hard to find someone. There are online programs and apps available that if you stick with them are also effective.

Two have the best evidence at this point:

Sleepio

  • 6 weeks, six sessions of about 20 minutes each, with one session unlocked per week
  • 18+ clinical trials showing it outperforms placebo and sleep hygiene advice
  • In real-world use, around 6 in 10 users saw meaningful improvement and 4 in 10 achieved full remission from insomnia
  • Recommended by the national Health Service (NHS) in the UK as a first-line treatment; increasingly available free through employer health benefits in the US
  • No prescription needed

Somryst

  • 9 weeks, delivered in modules 
  • Built on SHUTi, one of the original and most studied digital CBT-I programs with 40+ trials behind it
  • In controlled trials, remission rates were around 60% for treated patients vs. 15% for controls — a meaningful difference that held up at 1 year
  • The only digital CBT-I program with full FDA clearance as a Prescription Digital Therapeutic, meaning it’s held to the same regulatory standard as a medical device
  • You need a clinician to prescribe it

For both:

  • Neither is cheap if paying directly
  • Insurance coverage is inconsistent in the US but worth checking on
  • Both are significantly better-evidenced than the majority of sleep apps on the market, and both have stronger long-term data than sleep medication

For a deeper dive:

  • A telephone based, CBT-I program showed improvements in the Insomnia Severity Index (ISI) scores at the end of the 8 weeks and the improvement versus the control group which was menopause education was sustained at 24 weeks.  There were 106 women in the trial.
  • This article from the New York Times gives a good overview of options about how to find a CBT therapist, online options and the apps (free and paid) available.
  • This study evaluated an online CBT-I program in a randomized controlled trial because as noted above, there is a shortage of CBT practitioners. The online program was effective.
  • Comparison of drug and non-drug remedies for sleep. The MSFlash trials compared SSRIs, exercise, yoga, estrogen and CBT-I on sleep outcomes. There are great charts in this paper showing the difference. CBT-I had the best effect and was the only one to have a lasting benefit at a follow up time point.

Sleep hygiene before bed

Set up your space

  • Cover your clock: You may still wake up, but you’ll reduce the anxiety that keeps you up by watching the minutes tick by.
  • Block out ambient light with darkening shades or an eye mask.
  • Use ear plugs if you live in a noisy area.
  • Have headphones nearby to listen your way back to sleep should you need it.
  • Have a book light nearby. Reading is better for some to return to sleep.

Establish a pre-sleep routine

Drink a cup of tea. It’s both the ritual and what’s in the mug. Try a chamomile tea or a special blend for sleep.

Try a breathing technique like 4-7-8 or a guided mediation. These two from Insight Timer: Yoga Nidra and Breathing into Sleep are favorites! There are many more at Insight Timer. You may have to try a few to find the voice and length that works for you.

Take a hot bath. It raises your body temperature so that the drop in temperature promoted by your natural sleep-wake cycle will be greater, and this will put you into a deeper sleep. (That, and it’s just so relaxing.) Add some Epsom salts (paid link) which are a form of magnesium for added sleep benefits.

Put a notepad by your bed

Get your “to-dos” off your mind before you go to sleep. It can be handy when you wake at night to jot things down as well.
Once you’re awake

Listen to something with earbuds

The Insight Timer app has many great sleep meditations. Both Jennifer Piercy and Bethany Auriel-Hagan have lulled us back to sleep many times.

Use a book light for reading

Share a room or bed? A book light is handy so that you can read and hopefully get sleepy without waking your roomie.

Block blue light from your devices

You shouldn’t be, but if you are going to be looking at your phone or other screens before bed, try these blue light blocking glasses. (affiliate link)

Some phones and tablets have a setting to turn on a blue-light blocking feature at night. For those with an iPhone, there is a feature under Settings/Display& Brightness called night shift.

Or check out flux. It’s free and it will automatically remove the blue light according to a time schedule that you set.

Over the counter & supplements for sleep

Magnesium

Magnesium is widely touted to improve sleep, and some proponents claim that deficiency can cause insomnia. But are you actually deficient, and does the research back this up? Nearly 50% of US adults don’t meet the recommended daily intake, so it’s not an unreasonable concern. Magnesium deficiency is associated with poor sleep, though the relationship likely runs both ways — sleep deprivation can also deplete magnesium. A 2023 systematic review suggests that while observational studies show improvement related to sleep outcomes, the randomized controlled trials have mixed evidence. The form of magnesium matters — older studies often used magnesium oxide, which is poorly absorbed. More recent trials suggest magnesium L-threonate and magnesium bisglycinate are better absorbed by the body, with L-threonate in particular thought to cross into the brain more effectively, though research on its sleep benefits is still emerging. Magnesium is more likely to help if you are deficient, or if your sleep is interrupted by leg cramps or restless legs symptoms, though the evidence for the latter is limited.

Melatonin

Melatonin is a hormone made by the pineal gland in our brain that governs sleep and wake cycles. It is also a supplement used as a sleep aid to boost melatonin levels. For more on melatonin, see our Supplements section (“Melatonin” tab). Hear from an expert on supplementing (video).

Lavender

This review looking at lavender oil inhalation for sleep found some benefit, but noted that more research is needed.

Over the counter remedies

  • Diphenhydramine (the active ingredient in the antihistamine Benadryl). Using the liquid form allows you to try very small doses to start. It’s not recommended to do this regularly but can help when sleep is mandatory.
  • Tylenol PM can also be used occasionally but Tylenol in excess and with alcohol can lead to liver damage.

Prescription drugs

Prescription drugs used for sleep

  • In choosing sleep medications, the cause should be considered.
    • If hot flashes are the cause of waking, consider hormonal therapy (estrogen + progesterone if needed for uterine protection)
    • Progesterone alone is sometimes used off-label but has not been approved for sleep.
  • If depression is the cause, an SSRI can work. 
  • Trazodone is sometimes prescribed to help with sleep in perimenopause. Because it has a long half-life (meaning it stays present in your body for a long time), it’s often used for middle-of-the-night waking. It is an antidepressant but is also used “off-label” for insomnia.
  • A new class of sleep medications, promising but not widely covered (June 2026)
    • Dual Orexin Receptor Antagonists (DORAs) are a new type of sleep medication that work with your brain’s sleep/wake system — rather than general sedation.
    • They help you both fall asleep and stay asleep
    • Less risk of dependence, sleepwalking, falls, or a groggy “hangover” feeling in the morning.
    • Side effects are generally mild (some daytime drowsiness or headache)
    • Worth asking about if you’ve struggled with sleep and had bad reactions to other sleep meds
    • Expensive and often not covered by insurance yet ($350–$500/month out of pocket) — but ask your clinician or pharmacist.
  • The Mayo Clinic provides an overview of prescription drugs often used for sleep.

Many causes for Sleep Disruption

Hormonal changes

  • An August 2024 paper suggests disruption to sleep happens as a standalone symptom. More on our blog here.
  • Changes in hormone levels, rather than certain baseline levels, are associated with sleep disturbances.
  • A study that collected daily hormone measurements concluded that sleep was most disrupted the days leading up to menstruation and during the first few days of your period. (Two times in your cycle when hormone levels are dropping and low.)
  • Melatonin declines as we age. Melatonin levels regulate sleep cycles. Melatonin rises when it gets dark and production stops when it’s light. Guess what screen time does to melatonin? Learn about melatonin from an expert and how to support your natural levels,.
  • Progesterone, a hormone that can be calming and sleep-inducing, is declining as we approach our final menstrual period due to less frequent ovulation.
  • Declining estradiol and rising FSH are associated with trouble falling and staying asleep.Hot flashes

Hot flashes lead to middle of the night awakenings for some. Studies in a sleep lab also show that some of us sleep through hot flashes and have more than we know or remember in the morning.

Anxiety and depression are linked to worse sleep. Depression is linked to trouble falling asleep and waking early in the morning. Anxiety is linked to middle of the night awakening. And worse sleep leads to worse mood – it’s bidirectional.

Life stressors common in midlife can worsen sleep

  • Caregiving for children and/pr elderly parents
  • Financial strain
  • Work stress
  • Divorce

Other medical factors

  • Restless leg syndrome
  • Heartburn
  • Musculoskeletal pain
  • Some medications interfere with sleep
  • Changes to the way alcohol gets metabolized 

Sleep apnea

Sleep Apnea was found in 20% of women in the SWAN study which was 5 times more than previously thought. Women are often missed as the loud snoring associated with male sleep apnea is less common in women. In women signs can be insomnia, fatigue, morning headaches, mood changes, frequent awakenings.

  • Classic presentation (loud snoring, witnessed apneas) less common in women
  • Women more often present with: insomnia, fatigue, morning headaches, mood changes, 
  • frequent awakenings

What longitudinal studies tell us

  • A study that tracked 255 women from premenopause to the final menstrual period over 16 years found that how well or poorly women slept was unchanged from the earliest time points to the latest. That is poor sleepers remained poor sleepers and good sleeper remained good sleeper. There was one group who had few sleep issues in the beginning whose sleep worsened. Hot flashes contributed to poor sleep. Anxiety, stress and to a lesser extent depression were linked to poor sleep, but the direction of the cause and effect is not known.
  • Another study looking at 10 years of data found that 31 to 42% of women had insomnia symptoms during perimenopause. This study, in contrast to the one above found insomnia symptoms increased as women got closer to the final menstrual period.
  • A third longitudinal study that tracked women over 15 years, found that middle-of-the-night waking got worse as women progressed to the final menstrual period and that lower estrone, a form of estrogen, and higher FSH were related. In this study disrupted sleep was related to hot flashes, depression and perceptions of health.
I am now finding that a change in diet, cutting out caffeine and reducing alcohol, and seeking out healthy foods that stabilize blood sugar (eggs, nut butters, etc) seem to be helping my sleep, but I am just 10 days into this.

WLB Community Member

Dive deeper

Women’s Voices

Women share experiences with disrupted sleep

Hear from others
Research translated

Mounting evidence that sleep disruption is (on its own) associated with perimenopause (finally)!

Read the WLB take

REFERENCES

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2. Ciano C, King TS, Wright RR, Perlis M, Sawyer AM. Longitudinal Study of Insomnia Symptoms Among Women During Perimenopause.  J Obstet Gynecol Neonatal Nurs. 2017 Nov – Dec;46(6):804-8132.

3. Pengo MF, Won CH, Bourjeily G. Sleep in Women Across the Life Span. Chest. 2018 Jul; 154(1):196-206.

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6. Howard M. Kravitz, DO, MPH and  Hadine Joffe, MD, MSc Sleep During the Perimenopause: A SWAN Story. Obstet Gynecol Clin North Am. 2011 Sep; 38(3): 567–586.

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8. Howard M. Kravitz, DO, MPH; Imke Janssen, PhD; Nanette Santoro, MD; et al. Relationship of Day-to-day Reproductive Hormone Levels to Sleep in Midlife Women. Arch Intern Med. 2005;165(20):2370-2376.

9. Arab A, Rafie N, Amani R, Shirani F. The Role of Magnesium in Sleep Health: a Systematic Review of Available Literature. Biol Trace Elem Res. 2023 Jan;201(1):121-128. doi: 10.1007/s12011-022-03162-1. Epub 2022 Feb 19. PMID: 35184264.

10. Woods NF, Mitchell ES. Sleep symptoms during the menopausal transition and early postmenopause: observations from the Seattle Midlife Women’s Health Study. Sleep. 2010 Apr;33(4):539-49. doi: 10.1093/sleep/33.4.539. PMID: 20394324; PMCID: PMC2849794.

11. Freeman EW, Sammel MD, Gross SA, Pien GW. Poor sleep in relation to natural menopause: a population-based 14-year follow-up of midlife women. Menopause. 2015 Jul;22(7):719-26. doi: 10.1097/GME.0000000000000392. PMID: 25549066; PMCID: PMC4481144.

12. Coslov N, Richardson MK, Woods NF. Symptom experience during the late reproductive stage and the menopausal transition: observations from the Women Living Better survey. Menopause. 2021 Jul 26;28(9):1012-1025. doi: 10.1097/GME.0000000000001805. PMID: 34313615; PMCID: PMC8549458.