It’s one of the topics I am asked about most frequently, by patients and non-patients alike:

What’s the deal with menopause and sleep?

What’s happened to my sleep? Why is it so much harder for me to sleep well?

What can I do to sleep better while I’m going through menopause—and after? 

Let me say first: women’s sleep problems in their middle adult years aren’t only about menopause. These years in women’s lives are often profoundly busy and complicated. They may be deeply immersed in demanding careers, raising children, caring for aging parents, volunteering in their communities—or all of the above. And of course, other health conditions can impact sleep, apart from menopause. 

With jam-packed schedules, layer upon layer of responsibility, and often a lot of stress, sleep issues for women in their 40s, 50s and 60s would be likely even without a major biological change unfolding over a period of several years. 

But menopause can bring its own significant challenges to sleep. In order to protect your health, keep your performance sharp, and maintain your quality of life and relationships, it’s essential for you to know how menopause affects your sleep, and what you can do to sleep well throughout all of its stages. 

To get this important menopause-sleep conversation started, I’ll explain first how the hormones estrogen and progesterone influence sleep and other aspects of women’s health. I’ll also break out the stages of menopause and the sleep difficulties that arise within each. 

Women’s hormones and sleep

Menopause is driven by the decline in production of hormones, most significantly the hormones estrogen, progesterone, and testosterone. These hormones work together to regulate a woman’s reproductive function and menstrual cycle. They also affect mood, energy, sexual drive, cognitive and emotional abilities—and sleep—throughout a woman’s life. Let’s quickly take a closer look at each. 

Estrogen

Estrogen is the primary sex hormone in women, the hormone that plays the most significant role in regulating a woman’s reproductive function and her monthly menstrual cycle. Many women I talk with don’t know about the many other ways estrogen contributes to their health and performance. Estrogen supports women’s cardiovascular health, their cognitive performance and mood, their strong bones, and their healthy weight management. 

Estrogen also promotes healthy sleep: It helps the body use serotonin and other neurochemicals that assist sleep and contributes to higher-quality sleep, with fewer awakenings throughout the night and less time needed to fall asleep.

When I talk to my patients about estrogen, I describe it as a great protector of women’s sleep and overall health. Higher levels of estrogen are associated with a more positive mood, clear, elastic skin, greater energy and mental sharpness, and sound sleep. Low estrogen is associated with anxiety and low mood, fatigue, difficulty concentrating, physical pain including headache and migraine, weight gain, and disrupted sleep. Indeed, one of common early signs of menopause is insomnia.

Estrogen levels fluctuate significantly throughout the menopausal transition, then eventually fall to low levels, where they remain throughout a woman’s post-menopausal life.

Progesterone

Progesterone works to balance the effects of estrogen, and to prepare a woman’s body for pregnancy with each monthly cycle. It also plays a key role throughout pregnancy and in preparing a woman’s body for labor and breastfeeding. Progesterone helps regulate mood, protecting against anxiety and depression, and promotes the growth of new bone tissue; the loss of progesterone contributes to the risk of osteoporosis among post-menopausal women.  A woman’s body stops producing progesterone once she enters menopause.

I think of progesterone as largely a sleep-promoting, “feel good” hormone for women. Higher levels of progesterone tend to promote a sense of calm, boosting relaxation and facilitating sleep. High levels of progesterone–especially during pregnancy, when a woman’s progesterone levels surge–can also make you feel sleepy during the day. Progesterone increases production of GABA, a neurotransmitter that helps sleep. Low progesterone can bring about anxiety and restlessness, and trouble sleeping, including a tendency to wake frequently during the night.

Testosterone

Testosterone is produced at lower levels in women than in men. Many of my patients are surprised when I talk about how testosterone is important to women—particularly to their sex drive. For women, testosterone plays an important part in helping the body produce estrogen. It also boosts sexual desire, as well as energy levels, and contributes to greater muscle and bone mass. A woman continues to produce testosterone throughout her life, but levels decline with age. 

As these hormones fluctuate and decline throughout the stages of menopause, sleep often becomes increasingly disrupted. By the time they reach perimenopause, many women are routinely having a hard time falling asleep and sleeping soundly throughout the night. 

The stages of menopause and sleep

Menopause is one part of a lifelong shift in the balance of women’s hormones. Through each phase of her life, a woman’s sleep and health face different risks and challenges. Let’s take a look at the stages of menopause and what they mean for sleep. 

Pre-menopause and sleep 

During a woman’s reproductive years, when she is not experiencing the symptoms of menopause, she is in what is technically considered pre-menopause. Changes to estrogen, progesterone and other hormones can lead to recurring sleep problems well before the transition to menopause actively begins. 

Fluctuating estrogen and progesterone, especially shortly before and during menstruation, cause difficulty sleeping, as well as headaches, cramping, anxiety, and low mood—all symptoms that can compound sleep problems. I see many patients in their 20s and 30s experience insomnia and other sleep troubles linked to their monthly menstrual cycle.

During pregnancy, women frequently experience significant sleeplessness—even if they’ve been sound sleepers in their pre-pregnant lives. Changes to the body and intensely shifting hormone levels lead to many pregnant women feeling sleepy during the day and restless and uncomfortably awake throughout the night. 

In 2017, the Centers for Disease Control released new scientific findings about the sleep activity and sleep quality of women throughout the different stages of menopause. For pre-menopausal women, the study found: 

• Nearly one-third (32.5 percent) sleep less than an average of 7 hours a night. That’s broadly on par with the estimates of the sleep habits of the general population.
• Among pre-menopausal women, 16.8 percent have trouble falling asleep four or more times in a week.
• Almost one-quarter of premenopausal women (23.7 percent) have trouble routinely staying asleep throughout the night.
• And nearly half (47 percent) wake feeling un-rested at least four days a week.

Perimenopause and sleep 

This is the transitional stage that leads eventually to menopause. Often, for women, perimenopause begins in their 40s—but I’ve had several patients begin to experience the signs of perimenopause in their mid-to-late 30s. The amount of time a woman spends in perimenopause can vary widely—this stage of the menopause transition typically lasts between 3-5 years, but it can last for as long as 10. 

It’s throughout perimenopause that many of the symptoms of menopause begin to flare. During perimenopause, levels of estrogen, progesterone, and testosterone start to decline significantly—but also fluctuate sharply along that overall decline. Estrogen levels in particular may shift erratically during perimenopause, and this hormone’s perimenopausal highs and lows can contribute to a range of symptoms—from hot flashes and night sweats to anxiety to headaches—that interfere with both sleep and waking performance. 

In my practice, I see many women for the first time when they’re experiencing the challenges of perimenopause to their sleep routines, as physical, mental, and emotional symptoms begin to disrupt their sleep on a regular basis. 

According to the 2017 CDC survey, sleep problems tend to increase significantly during perimenopause.

• More than half of perimenopausal women (56 percent) sleep less than 7 hours a night, on average. That’s a big jump from the third of pre-menopausal women who are sleeping less than 7 hours nightly.
• Nearly one-quarter (24.8 percent) of perimenopausal women say they have trouble falling asleep four or more times in a week.
• Even more common than trouble falling asleep? Difficulty staying asleep. Among women in perimenopause, 30.8 percent say they have trouble staying asleep at least four nights a week.
• Half of perimenopausal women (49.9 percent) wake in the morning feeling tired, rather than rested, four or more days in a week.

Post-menopause and sleep 

A woman has reached menopause when she has not had a period for 12 consecutive months. Beyond this point, a woman is now in post-menopause. What happens to hormone levels at this point? Progesterone, a particularly sleep-friendly hormone, is no longer produced by a woman’s body after she stops menstruating. Estrogen, with its sleep-protective benefits, continues to be produced once fluctuations subside, but at very low levels. The symptoms that begin for many women during menopause—hot flashes, headaches and other physical pain, anxiety, lack of focus, mood swings—often ease after a woman reaches post-menopause.

That’s true for sleep problems, too. With the settling of hormonal fluctuations, insomnia and other sleep problems may gradually improve for some women after menopause. But the post-menopausal experience—like each phase of the menopausal transition—can vary greatly from woman to woman.

I’ve treated women who struggle deeply with sleep and performance throughout perimenopause and who relatively quickly find a “new normal” and improved sleep as they move into post-menopause. But I also see many women continue to wrestle with poor-quality sleep and contend with new sleep disorders, such as obstructive sleep apnea, in their post-menopausal lives. 

As the recent CDC study shows, a great many women during their post-menopausal years continue to struggle with sleep issues—and the symptoms of insomnia may actually increase:

• Sleeping less than 7 hours a night, four or more nights a week, occurs among 40.5 percent of post-menopausal women.
• For post-menopausal women, symptoms of insomnia become somewhat more common than during perimenopause, with 27.1 percent having regular trouble falling asleep and 35.9 percent having routine difficulty staying asleep throughout the night.
• More than half (55.1 percent) are sleeping poorly enough to wake feeling tired, not rested, four or more times a week.

There’s a lot to talk about when it comes to menopause and sleep. In a recurring series over the next several weeks, I’ll discuss the role of sleep in the symptoms of menopause and in menopause-related health risks. I’ll also talk about effective therapies for menopause and its sleep-related issues—including how you can treat sleep and menopause symptoms naturally.