Q: I’m a woman in my 40s and never seem to get a good night’s sleep. How can I get some rest?
Maybe you toss and turn before dozing off, or you wake at 3 a.m., drenched in sweat, and can’t fall back asleep. These are common scenarios during perimenopause, the time of transition just before menopause when a woman’s period becomes irregular and her estrogen levels start to dip.
Perimenopause typically begins during a woman’s 40s, and having trouble sleeping is “probably the most distressing symptom,” said Dr. Karen Adams, director of the Program in Menopause and Healthy Aging at Stanford Medicine.
But the good news, she added, is that perimenopause-related sleep issues are “absolutely treatable.” Here is why they occur and how to mitigate them.
Why perimenopause affects sleep
Hormonal shifts during perimenopause (and later, during menopause) disrupt the body’s ability to regulate temperature, causing hot flashes and night sweats that can interfere with sleep, Dr. Adams said.
Anxiety and depression, which are also common during this stage, are big sleep sinkers, too, said Dr. Stephanie Faubion, director of the Mayo Clinic’s Center for Women’s Health in Jacksonville, Fla.
Women usually have a lot going on during the perimenopause years, Dr. Faubion said, including caring for children or aging parents and addressing work pressures and lengthy to-do lists. These problems alone may keep them up at night, and not sleeping can compound the issues, creating a vicious cycle, she said. Add in perimenopausal hormone shifts, and it can be even more difficult to get some rest.
Another issue is that women are more likely to develop sleep disorders, such as sleep apnea, insomnia and restless-leg syndrome, during the menopause transition, said Dr. Suzanne Bertisch, a sleep physician at Brigham and Women’s Hospital in Boston.
How to sleep better
Perimenopause, and its treatments, can affect everyone differently, the experts said.
Start by building healthy sleep habits, such as going to bed and waking up at the same times every day; avoiding alcohol and caffeine a few hours before bedtime; sleeping in a cool, dark room; and getting the recommended 150 minutes-per-week of moderate-intensity exercise, as well as two days of strength training.
If these general sleep strategies don’t help, you may need to enlist a specialist.
Find a provider with expertise in menopause. Not all primary care providers (or even some OB-GYNs) are trained in treating perimenopause and menopause symptoms, Dr. Adams said. If yours isn’t, she suggested seeking a practitioner who is. The Menopause Society maintains a directory of certified practitioners and is a good place to start.
Treat your hot flashes. When your sleep is disrupted by hot flashes or night sweats, Dr. Faubion said, the “gold standard” treatment is hormone therapy, which involves replacing lost hormones, including estrogen and progesterone, via pill, patch or gel. Hormone therapy once had a bad reputation after a 2002 study linked it to elevated risks of breast cancer and cardiovascular disease. But many studies have since shown it to be safe and effective at relieving hot flashes, vaginal dryness and mood swings for healthy women under 60.
Another option is the non-hormonal oral medication fezolinetant (Veozah), which helps treat hot flashes by binding to receptors in the brain that regulate body temperature. That may also help with sleep, Dr. Faubion added.
Address your mental health. Hormone therapy may reduce depression symptoms, which will usually help you sleep better, Dr. Faubion said. But it isn’t typically prescribed for sleep problems alone, Dr. Adams said. It also doesn’t solve everyone’s sleep issues; some women still can’t sleep even when they stop having hot flashes or night sweats, she said.
In these instances, Dr. Adams said that she may recommend talk therapy or antidepressants like selective serotonin reuptake inhibitors if anxiety or depression seem to be the cause.
See a sleep specialist. If hormone therapy hasn’t worked for you, it may be tempting to take melatonin or an over-the-counter sleep aid. But Dr. Bertisch doesn’t recommend that strategy, as these substances won’t address sleep disorders or hormonal changes, and they’re not meant for long-term use.
Instead, see a sleep physician, Dr. Bertisch said. If you regularly struggle to fall or stay asleep, you might have insomnia disorder, which can be managed with a type of cognitive behavioral therapy called C.B.T.-I. Prescription sleep medications like zolpidem (Ambien) are also sometimes used to treat insomnia. And Ambien may reduce hot flashes and night sweats, too, Dr. Bertisch said.
If you find that you snore, have mood swings and are sleepy during the day, it could mean that you have sleep apnea, said Dr. Faubion, who regularly recommends that her menopause patients get screened for the condition. Sleep apnea is managed with a continuous positive airway pressure (or CPAP) device that you wear over your nose or mouth while sleeping to improve airflow. Weight loss and other lifestyle changes may also be recommended.
If you’re in perimenopause and never seem to feel rested, seek help, Dr. Adams said. This stage of life may be unavoidable, she said, but not sleeping isn’t. “Suffering is not inevitable.”
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