Why can't I sleep in perimenopause?

Trouble sleeping is one of the most common parts of perimenopause, the years before your periods stop when hormone levels start to change. The HSE lists difficulty sleeping among the physical symptoms, and Women’s Health Concern, the patient arm of the British Menopause Society, says sleep problems affect around 40 to 56% of women going through the menopause transition. Falling oestrogen can disturb sleep directly, and through night sweats, low mood, aches and needing the toilet at night. The good news is that there are effective treatments, so it’s worth talking to your GP.

Why perimenopause disturbs your sleep

Women’s Health Concern (WHC) explains that falling oestrogen affects sleep in two ways. It acts on sleep directly, and it brings other symptoms that wake you up, including:

• hot flushes and night sweats
• mood changes, such as anxiety or low mood
• joint aches
• bladder changes, so you wake needing to pass urine

Other things can add to it at this stage of life: getting older, stress, everyday habits, and sleep disorders such as restless legs syndrome and sleep apnoea, which WHC says are both more common from menopause onwards.

The HSE says perimenopause symptoms can start 7 to 10 years before your periods stop, so poor sleep in your early or mid-40s could be part of it, even if your periods are still fairly regular.

Is it insomnia?

Insomnia means you regularly have problems sleeping. The NHS describes the signs as finding it hard to get to sleep, waking several times in the night, lying awake, waking early and not getting back to sleep, and feeling tired and irritable during the day.

WHC describes chronic insomnia as trouble getting to sleep, staying asleep or waking too early on at least three nights a week for three months or more, with daytime effects such as tiredness, low mood or poor concentration. It calls this one of the most common sleep disorders during menopause.

Most adults need around 7 to 9 hours of sleep a night, and WHC points out that this need doesn’t drop as we get older.

Two sleep problems that are easy to miss

Sleep apnoea. This is when your breathing repeatedly stops and starts while you sleep. WHC says it’s more common in menopause and may cause loud snoring, morning headaches, tiredness or mood changes, but not all women with sleep apnoea snore. If your GP suspects it, they may arrange a sleep study, and treatment is available.

Restless legs syndrome. This causes uncomfortable feelings in the legs, often in the evening or at night, that ease when you move. WHC says it’s more common after menopause, and suggests asking for a blood test for ferritin (a measure of your iron stores), because low iron can be a cause.

If either sounds familiar, mention it to your GP.

What helps

Habits that help you sleep

The NHS says insomnia usually gets better by changing your sleeping habits. Between the NHS and WHC, the advice includes:

• going to bed and getting up at the same times each day
• keeping your bedroom cool, dark and quiet
• relaxing for at least an hour before bed, and avoiding screens and heavy meals late in the evening
• exercising regularly, but not close to bedtime
• cutting down on caffeine and alcohol, especially later in the day
• if you can’t sleep, getting up after about 20 minutes and doing something relaxing until you feel sleepy (WHC)

For night sweats, the HSE suggests wearing light clothing, keeping your bedroom cool at night, using a fan or having a cold drink, and cutting down on triggers such as spicy food, caffeine, hot drinks, smoking and alcohol.

CBT for insomnia

CBT (cognitive behavioural therapy) is a talking therapy that helps you change the thoughts and habits that keep you awake. WHC says CBT for insomnia, known as CBT-I, is the most effective treatment for chronic insomnia, can work during menopause, and usually takes about 6 weeks. It can be done in person, in a group or online. The NHS says a GP may offer it face to face or through an online programme, and the HSE says CBT can help with hot flushes and sleep problems too.

HRT and other treatments

WHC says HRT can improve sleep, both directly and by reducing hot flushes and night sweats. If you’re already on HRT and still sleeping badly, it suggests it may be worth reviewing the type of progestogen with your doctor. If waking to pass urine is the problem, WHC says vaginal oestrogen can improve bladder function and so improve sleep.

For women who can’t or don’t want to take HRT, WHC says certain non-hormonal medicines that reduce hot flushes can then improve sleep. Your GP can explain which might suit you.

A word on sleeping pills

The NHS says GPs now rarely prescribe sleeping pills for insomnia, because they can have serious side effects and you can become dependent on them. Sleep aids from a pharmacy can’t cure insomnia and, the NHS says, shouldn’t be used for more than 1 to 2 weeks. The HSE advises talking to a GP before taking herbal supplements or other medicines. Always check with your GP or pharmacist before starting, stopping or changing anything.

When to see your GP

The NHS says to see a GP if changing your sleep habits hasn’t helped, you’ve had trouble sleeping for months, or it’s making it hard to cope with daily life. WHC’s message is simple: you don’t have to put up with poor sleep.

The HSE also says to talk to your GP if you have menopause symptoms before 45, and to get any bleeding from the vagina after menopause checked, even if it only happened once.

Ireland and the UK

The advice is the same in both countries: start with your GP. In Ireland, HRT is free at participating pharmacies for women with a medical card or Drugs Payment Scheme card (our guide explains how). In the UK, the NHS says your GP may offer CBT for insomnia face to face or online.

What to do next

• Keep a sleep diary for two weeks. Note when you went to bed, how often you woke and why (sweats, toilet, worry), and how you felt the next day. If you still have periods, note where you were in your cycle.
• Pick two habits to try, such as a fixed wake-up time and a cooler bedroom, and give them a few weeks.
• Book a GP appointment if it isn’t improving, and ask: could this be perimenopause? Would CBT for insomnia or HRT suit me? Could I have sleep apnoea or low iron?
• Ask anyone who shares your room what they notice. Loud snoring, or breathing that stops and starts, is worth mentioning to your GP.