Why is sleep so terrible during perimenopause (and what can we do about it)?
The most common demographic profile I see in my clinic is a woman in mid-life, between the ages of 35 and 50. Some of the reasons have to do with caregiving as a woman in the “sandwich generation” or anxiety and depression related to life stressors, but the most common throughline for these patients is perimenopause—the host of hormonal and other biological changes that happen to women for the ten or so years leading up to menopause. If you're in your 40’s (or even on the other side of menopause) and experiencing mysterious awakenings in the middle of the night, you're not alone—and you're not imagining things.
Perimenopause is a complex biological journey characterized by significant hormonal fluctuations. Estrogen and progesterone – key players in regulating sleep – begin a delicate dance of decline and unpredictability. This hormonal turbulence can wreak havoc on your sleep architecture and physical anatomy, leading to seemingly inexplicable sleep problems.
Common Sleep Disruptions During Perimenopause
Hot Flashes and Night Sweats: Perhaps the most notorious sleep disruptors, these sudden temperature surges can turn a peaceful night into a rollercoaster. Your body's thermoregulation becomes less predictable, causing abrupt awakenings and fragmented sleep.
Insomnia Patterns: Many women experience insomnia during perimenopause, whether for the first time or a worsening in the difficulty falling/staying asleep they already had.
Mood Changes: Hormonal shifts can amplify mood disorder symptoms and anxiety, which can impact sleep quality through rumination and increased emotional volatility.
Snoring and Sleep Apnea: This one is important–it usually flies under the radar because women’s risk factors and symptoms are different from men’s, so doctors who don’t have expertise in women’s sleep may not catch the signs and recommend screening. Why Sleeping Separately Can Be a Game-Changer
How Do Progesterone and Estrogen Changes Cause These Sleep Problems?
Progesterone acts on the GABAergic pathway in the brain, which is a network that generally calms down brain activity and helps to regulate other brain functions. It is also a respiratory stimulant—meaning that it helps to keep your breathing robust, including during sleep. Declining progesterone levels during perimenopause means a brain that is more prone to being overactive, while at the same time a respiratory system that is more prone to stagnating, leading to more insomnia and higher risk for sleep-related breathing problems like snoring or sleep apnea.
Estrogen may be even more impactful for sleep. It’s often considered the “CEO of the brain” because it helps to regulate the actions of so many brain functions (hormone regulation, thermoregulation, cognitive functions, mood, metabolism etc.). When estrogen levels bounce up and down unpredictably during perimenopause, it can throw all of these other functions into chaos (hence the hot flashes and mood swings), including systems for regulating sleep. For example, sudden estradiol surges are one of the reasons for out-of-nowhere night awakenings.
Estrogen is also anti-inflammatory and helps with muscle elasticity, so when it decreases as we get closer to menopause, we can experience more inflammation and less robust muscles around the airways while sleeping.
The Hidden Sleep Threat: Obstructive Sleep Apnea
One of the most critical – and often overlooked – changes during perimenopause is the increased risk of obstructive sleep apnea (OSA). Many women are surprised to learn that they can develop sleep apnea during this life stage, even if they:
Don’t have a high BMI
Have never snored before, and perhaps still don’t snore
Have always been considered low-risk for sleep breathing disorders
Instead of loud snoring being the cardinal sign (although this can still happen and should also be taken seriously), women’s OSA might show up as:
Frequent nighttime awakenings
Unexplained daytime fatigue
Morning headaches
Morning dry mouth, sore jaw
Mood changes
Difficulty concentrating
What Can We Do About It?
There are some things we probably can’t change—hormones will shift, bodies will change, and mid-life stressors will still come knocking at your door. But there are things we can do to help our sleep.
Medical Management
Talk to your gynecologist about hormone replacement therapy. Keeping your hormone levels steady can help to ease the symptoms that contribute to your sleeplessness.
Review your sleep (and related) medications, including over the counter supplements, with a sleep specialist. Sometimes, when our hormone levels change, medications’ effectiveness changes, too, so you may need changes in your medication dosing/regimen.
Ask your doctor about sleep apnea screening. Err on the side of taking a sleep test (rather than skipping it), even if you’re technically at low risk for sleep apnea. Remember that sleep apnea shows up differently in women, and the vast majority go undiagnosed!
Nutritional and Lifestyle Interventions
Limit Hot Flash Triggers: Reduce caffeine, alcohol, and spicy foods, especially in the evening.
Cool Your Night Environment: Go to bed with breathable, easily adjustable layers so you can regulate your temperature without having to think much about it at night. Also start the night with a glass of ice cubes on your night stand so you can sip cold water throughout the night.
Regular Exercise and Hormone-Friendly Diet: Engage in moderate physical activity, but avoid intense workouts close to bedtime. Consider consulting a nutritionist specializing in midlife transitions.
Learning to Sleep Differently
Allow For Changes In Your Sleep Patterns. Changes in sleep aren’t always bad. When we enter different stages of life, our bodies’ need for sleep adjusts accordingly. You may find yourself sleeping earlier and shorter, with somewhat greater proneness to waking at night. All of this is normal. It’s only a problem if the reduction in sleep quality/quantity is significant and interferes with your functioning.
Only Go To Bed (Or stay in bed) when you’re actually sleepy. Otherwise, you’re forcing sleep, which only backfires. Instead, spend the extra “me” time doing something low key and enjoyable.
Compartmentalize Days and Nights: Protect time during the day to process your thoughts, make your to-do lists, and solve problems. As you start your bedtime routine, set an intention to close the chapter on those activities for today. If ruminations or worries come up at night, defer them to tomorrow and turn your attention to your book, show, or meditation practice.
When to Seek Professional Help
While many sleep changes are normal during perimenopause, persistent or severe symptoms warrant professional evaluation. Consider consulting a healthcare provider if:
Sleep disturbances significantly impact your daily functioning
You experience frequent insomnia lasting more than a few weeks
You suspect you might have sleep apnea, even without the well-known risk factors like snoring
Embracing the Transition
Perimenopause isn't a medical condition – it's a natural life stage. By understanding the physiological changes and implementing appropriate changes, you can navigate this transition with resilience. Even if sleep changes, it doesn’t have to become a chore or battle. Patience, self-compassion, and a willingness to roll with change are key to finding your sleep equilibrium.
Disclaimer: This article is for informational purposes and does not substitute personalized medical advice. Always consult with your healthcare professional for tailored recommendations.
