Sleep in Peri-menopause and Post-menopause: A clinician’s primer

As my understanding of sleep has grown, one group of clients I knew little about early on stands out: midlife women. Along with managing the pressures of child-rearing, balancing career progression, and assisting aging parents, comes the hormonal maelstrom of perimenopause and sleep disruption. The individual clinical picture is multifactorial, with exercise, stress management, medications, sleep, and nutrition all playing a role.

Menopause-related sleep disturbance affects roughly two in three women and impairs quality of life, relationships and work performance.¹ A smartwatch study of about 3.8 million nights (SONAR) found that wakefulness after sleep onset (WASO) rises from the early 50s: about +5 minutes at 50–54, +9 at 55–59 and +11 at 60–64 versus women aged 20–24. The rise was steeper than in men, while total sleep time fell only modestly (≤17 minutes).² Menopausal status wasn't recorded, so the link is suggestive, not proven.² 

What it looks like

The typical complaint is frequent awakenings at night. In the Study of Women's Health Across the Nation (SWAN cohort), about 40% reported awakenings, 20% reported waking early in the morning, and about 20% reported trouble falling asleep.¹˒³ This differs from classic insomnia, so asking "Do you wake during the night?" = sleep continuity may be more revealing than "Do you struggle to fall asleep?" = sleep onset.

Likely mechanisms

• Vasomotor symptoms (VMS): night sweats and hot flushes, linked to falling estrogen and overactive hypothalamic KNDy neurons.¹
• Mood symptoms, which are more common at midlife and have a two-way relationship with sleep.²
• Wider thermoregulatory change beyond VMS.¹

Only about 27% of waking time is hot-flush-associated, so treating VMS alone may not resolve every awakening.¹˒⁴

Management

Medication

• Menopausal hormone therapy (MHT): the most effective treatment for VMS, worth considering within 10 years of the final period.⁵ It helps sleep indirectly, isn't indicated for sleep disturbance alone, and is contraindicated for some women.¹
• Nonhormonal prescription options: SSRIs/SNRIs, gabapentin and fezolinetant (Level I), and oxybutynin (Levels I–II).⁵
• Elinzanetant (Lynkuet): a dual NK-1/3 antagonist for women who can't or prefer not to use MHT. In the phase II NIRVANA trial, a strong placebo response removed its advantage at 12 weeks.¹˒⁶
• Sleep outcomes in the MsFLASH trials: escitalopram, estradiol, venlafaxine. Omega-3 did not improve insomnia symptoms.⁷

Non-medication

Best evidence

• CBT for insomnia (CBT-I): supported as first-line in healthy midlife women with insomnia and moderately bothersome VMS.⁷ The trial used six telephone sessions over 8 weeks covering sleep restriction, stimulus control, sleep hygiene and cognitive restructuring.⁸
• CBT for VMS and clinical hypnosis: CBT reduces VMS bother and interference. Hypnosis reduces VMS frequency and severity.⁵
• Weight loss: recommended, though more rigorous studies are needed.⁵
• Exercise and yoga: these did not reduce VMS in the trials, but modestly improved insomnia symptoms.⁵˒⁷ Encourage them for sleep, not as VMS treatment.

1. Layered clothing, breathable bedding, a cool shower, a fan and a cooling neck pack are low-cost and low-risk. However, strong evidence that cooling techniques improve VMS is lacking.⁵ The evidence on alcohol is conflicting .⁹
2. Avoiding exercise and hot drinks before bedtime is standard sleep hygiene.

Not recommended for VMS: paced respiration, supplements and herbal remedies, soy, acupuncture, cannabinoids and chiropractic interventions.⁵

Key points for practice

• Ask about sleep proactively; women may not raise it.
• Probe for night-time awakenings, hot flushes and low mood together.
• Offer CBT-I first when insomnia accompanies bothersome VMS.⁷
• Use MHT or nonhormonal drugs to treat VMS, not as sleep aids.¹
• A sizeable proportion of women may have a primary sleep disorder, so don't attribute every awakening to hot flushes.¹⁰
• Wearable data can start a conversation, but it isn't medical-grade and may underestimate WASO.²

Discussing it with clients

1. Normalise and validate. Increased night waking is common at midlife and not a personal failing.
2. Use their data. A smartwatch or sleep diary can show patterns and support monitoring, but wearables are imperfect.¹˒²
3. Screen broadly. Check VMS, mood, stress, caregiving burden and medications.²
4. Set realistic expectations. Placebo responses in sleep and VMS trials are large, and positive expectations and attention to sleep may themselves be therapeutic.¹

References

1. Lappin JM, Perrault AA, Gordon CJ. Elinzanetant improves sleep in postmenopausal women. So does placebo. Sleep 2026; 49: 10 (zsag210)
2. Soares CN, Dinkel-Keuthage C, Baker FC, et al. Sleep pattern differences in women at midlife: a large-scale multi-country smartwatch study (SONAR). Sleep 2026; 49: (zsag197)
3. Kravitz HM, Janssen I, Bromberger JT, et al. Sleep trajectories before and after the final menstrual period in the Study of Women's Health Across the Nation (SWAN). Curr Sleep Med Rep 2017; 3: 235–50.
4. de Zambotti M, Colrain IM, Javitz HS, Baker FC. Magnitude of the impact of hot flashes on sleep in perimenopausal women. Fertil Steril 2014; 102: 1708–15.
5. The 2023 Nonhormone Therapy Position Statement of The North American Menopause Society Advisory Panel. The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause 2023; 30: 573–90.
6. Baker FC, Kahan TL, Trinder J, Colrain IM. Elinzanetant in postmenopausal women with sleep disturbance: results from the randomized, phase II NIRVANA study. Sleep 2026; 49: 10 (zsag208)
7. Guthrie KA, Larson JC, Ensrud KE, et al. 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. Sleep 2018; 41: (zsx190)
8. McCurry SM, Guthrie KA, Morin CM, et al. Telephone-based cognitive behavioral therapy for insomnia in perimenopausal and postmenopausal women with vasomotor symptoms: an MsFLASH randomized trial. JAMA Intern Med 2016; 176: 913–20.
9. HealthEd. Non-pharmacological strategies for vasomotor menopause symptoms. https://healthed.com.au/?p=2059606 (accessed Oct 18, 2026).
10. Nonacs R. In brief: cognitive behavioral therapy improves sleep in perimenopausal women. MGH Center for Women's Mental Health. https://womensmentalhealth.org/posts/brief-cognitive-behavioral-therapy-improves-sleep-perimenopausal-women/ (accessed Oct 18, 2026).