The messy relationship between (peri)menopause and insomnia

By Specialised Sleep Therapist Tracy Hannigan. A collaboration between Uma Health and Mirror SleepWise.

How (peri)menopause disrupts sleep

It's 3am. Again.

You were asleep until you weren't.

You're sweaty, hot, the covers are kicked off, and your brain has come alive. You're awake, AND you're wired. You're counting the hours you got, or the hours you've got left before the alarm forces you out of bed and to work. And of course the counting doesn't help; it's virtually a guarantee that the physical and mental arousal will keep sleep away. The frustration of being awake triggers another rush of heat and sweat, and around in circles it goes.

A narrative review in the Journal of Clinical Medicine (2025) found that (peri)menopause is closely tied to worsening sleep.¹ (peri)menopause has met insomnia, and they are having a relationship - and you're stuck in the middle.

For now. There is a way out.

(peri)menopause can be sneaky. It's slow… maybe not even noticeable…and then years of hormonal symptoms that cause nighttime symptoms, more anxiety, and soft tissue changes that affect not just that weird spot on our knees that suddenly has new skin…but our airways too. A study in BMC Endocrine Disorders (2025) found that menopause was associated with higher rates of obstructive sleep apnoea, independent of weight and height (BMI).² Oestrogen and progesterone are both involved, but it's rarely only hormones having an impact.

(peri)menopause biology doesn't happen in isolation: aging parents, teenagers, and career pressure are the environment. A study in Menopause (2013) found elevated odds of anxiety across (peri)menopause compared with premenopause.³ Anxiety is more common for both biological reasons and simply as a result of a more transition-oriented life.

Then add in laying awake worrying about not sleeping, which makes sleep worse over time. Hormones might start the sleep disruption but they aren't the thing that makes it worse or keeps it going longer term.

Falling asleep versus staying asleep

Falling asleep and staying asleep problems have different nuances to them when it comes to the biology of (peri)menopause.

Progesterone, a key reproductive hormone, works to calm the brain's systems in much the same way that anti-anxiety medications may - through the GABA system. A review in Pharmaceuticals (2023) found that progesterone's metabolite allopregnanolone acts on GABA-A receptors, producing calming and sedative effects.⁴ When progesterone falls, it can take longer to fall asleep simply because it is harder to slow down and lower our arousal enough for satisfying sleep.

Oestrogen is another key hormone and it is implicated in problems with staying asleep. Oestrogen receptors are everywhere in our bodies, but especially in the temperature regulation areas of the brain. We need to have a cooler body temperature to sleep than we do when we are awake, and oestrogen helps this.

When oestrogen begins to rise and fall, women can have hot flushes (or more rarely feel very cold). A review in the Journal of Steroid Biochemistry and Molecular Biology (2014) found that falling oestrogen narrows the brain's thermoneutral zone, triggering hot flushes and night sweats.⁵

Supported by studies back to a review in Neurologic Clinics (2019)⁶, our body temperature trends downward to a low between 3 and 4am (and we need this to anchor the next night's sleep. If we are too warm, it is challenging to sleep) and when we wake up sweating it can take some time to settle. A longitudinal study in the Journal of Clinical Endocrinology & Metabolism (2022) found that estradiol and FSH levels were linked to more nighttime awakenings in perimenopausal women.⁷

This isn't a rule but a guideline to understanding the biological part of sleep disruption: If you can't get to sleep, that's often a progesterone-flavoured problem. If you can't stay asleep, oestrogen and temperature are usually more of a factor.

This creates a certain level of disruption, but there is much more to (peri)menopause insomnia - and luckily the 'fix' is not only evidence-based but much more straightforward.

Why insomnia outlasts the initial hormonal trigger

So perhaps the night sweats settled or you're on Hormone Replacement Therapy (HRT) and that's helped. (Check with your doctor if this is an option for you.) But you're still not sleeping.

Or you still have symptoms, but now there's a different element to your sleeping issue: the stress of not sleeping.

When you've spent a long time not sleeping well, having repeated wakings or difficulty falling or staying asleep, your brain learns that bed is a place where struggle happens. Humans don't like to struggle, and we can become 'threatened' by the idea of not sleeping well. That fearful brain creates arousal to 'manage the danger'. Which is a recipe for maintaining the poor sleep that might have started out with hormones becomes an alert brain keeping an eye out to keep you safe. This low-grade fight and flight interferes with sleep, so the 'threat' of not sleeping keeps the sleeplessness problem front and centre.

So how do we attempt to fix it?

You use your human brain to try to solve the problem the same way other problems in life are solved. You try harder. You search more. You experiment with all the supplements, staying in bed longer, and more research.

Every one of those efforts tells your brain that being awake at night must be really dangerous, which makes sleep worse. That's the trap. The harder you chase sleep, the faster it runs. A review in the Journal of Clinical Sleep Medicine outlined the 3P model, describing how an initial trigger can become a self-perpetuating cycle of worry and effortful sleep attempts.⁸

That's the loop. And it's why the original hormonal trigger can fade while the insomnia keeps going.

There is effective treatment

The good news is that there are two kinds of complementary treatment for (peri)menopause insomnia.

The first is medical. For some women, HRT helps with having fewer night sweats. What HRT does is lower the volume on the physical disruption. That's a conversation to take to your healthcare provider. A Cochrane systematic review found that HRT reduces hot flushes and night sweats by approximately 75% compared with placebo.⁹

The second is evidence-based behavioural sleep medicine. Evidence-based sleep therapy based in CBT-I works directly on the three things that keep feeding the insomnia: your sleep drive, circadian system and your arousal system. It helps you to rebuild your 'relationship' with your bed, stop the 'fear-effort' cycle and set a stage for sleep to appear. A meta-analysis in Psychiatry and Clinical Neurosciences (2024) found that CBT-I was the most effective initial treatment for chronic insomnia.¹⁰

These two approaches complement one another - the hormonal noise can be reduced, and the learned patterns that maintain insomnia can be unlearned. Bonus points: CBT-I has also been shown to reduce complaints of hot flushes at night! A randomised-controlled pilot trial in Menopause (2026) found that menopause-adapted CBT-I reduced both insomnia severity and how disruptive night-time hot flushes felt.¹¹

What to take away

If you're struggling with perimenopausal insomnia, this doesn't have to be your new normal. (peri)menopause may have opened the door, but the thing keeping you awake now is very likely a pattern that can be unlearned using CBT-I.

Now you know, so what's next?

If any of this resonates, the first step is to understand what's actually happening with your sleep. We invite you to take our free, science-based insomnia test, based on the Insomnia Severity Index. It takes just a few minutes, is anonymous, and has no strings attached, and, above all, it'll help clarify whether you are suffering from insomnia.

If your results indicate insomnia, our science-based digital programme might help you. It's an 8-week, personalised programme, with short daily content led by experts and built on CBT-I, the leading evidence-based treatment for insomnia. You'll also get a 1-on-1 call with a certified sleep expert, with the option to book more.

And because we stand behind the results: if you complete at least 80% of the programme and don't see meaningful improvement, you'll get a full refund.

Explore the programme at mirrorsleepwise.com

— The Mirror SleepWise Team

References

1. Troìa L, Garassino M, Volpicelli AI, Fornara A, Libretti A, Surico D, Remorgida V. Sleep disturbance and (peri)menopause: a narrative review. J Clin Med. 2025;14(5):1479. https://pmc.ncbi.nlm.nih.gov/articles/PMC11901009/
2. Wang Y, Liu H, Zhou B, Yue W, Wang M, Hu K. Menopause and obstructive sleep apnea: revealing an independent mediating role of visceral fat beyond body mass index. BMC Endocr Disord. 2025;25:21. https://pmc.ncbi.nlm.nih.gov/articles/PMC11765922/
3. Bromberger JT, Kravitz HM, Chang Y, Randolph JF Jr, Avis NE, Gold EB, Matthews KA. Does risk for anxiety increase during the menopausal transition? Study of Women's Health Across the Nation (SWAN). Menopause. 2013;20(5):488-495. https://pmc.ncbi.nlm.nih.gov/articles/PMC3641149/
4. Stefaniak M, Dmoch-Gajzlerska E, Jankowska K, Rogowski A, Kajdy A, Maksym RB. Progesterone and its metabolites play a beneficial role in affect regulation in the female brain. Pharmaceuticals (Basel). 2023;16(4):520. https://pmc.ncbi.nlm.nih.gov/articles/PMC10143192/
5. Freedman RR. Menopausal hot flashes: mechanisms, endocrinology, treatment. J Steroid Biochem Mol Biol. 2014;142:115-120. https://pmc.ncbi.nlm.nih.gov/articles/PMC4612529/
6. Reid KJ. Assessment of circadian rhythms. Neurol Clin. 2019;37(3):505-526. https://pmc.ncbi.nlm.nih.gov/articles/PMC6857846/
7. Coborn J, de Wit A, Crawford S, Nathan M, Rahman S, Finkelstein L, Wiley A, Joffe H. Disruption of sleep continuity during the perimenopause: associations with female reproductive hormone profiles. J Clin Endocrinol Metab. 2022;107(10):e4144-e4153. https://academic.oup.com/jcem/article/107/10/e4144/6649847
8. Lichstein KL. Psychological models of chronic insomnia. J Clin Sleep Med. 2005;1:e459-e460. https://doi.org/10.5664/jcsm.26388
9. MacLennan AH, Broadbent JL, Lester S, Moore V. Oral oestrogen and combined oestrogen/progestogen therapy versus placebo for hot flushes. Cochrane Database Syst Rev. 2004;(4):CD002978. https://pmc.ncbi.nlm.nih.gov/articles/PMC7004247/
10. Furukawa Y, Sakata M, Furukawa TA, Efthimiou O, Perlis M. Initial treatment choices for long-term remission of chronic insomnia disorder in adults: a systematic review and network meta-analysis. Psychiatry Clin Neurosci. 2024;78(11):646-653. https://pmc.ncbi.nlm.nih.gov/articles/PMC11804918/
11. Arentson-Lantz EJ, Muench A, Kokonda M, Meers JM, Swartz M, Manber R, Thurston RC, Nowakowski S. Cognitive behavioral therapy for menopausal insomnia in perimenopausal and postmenopausal women with insomnia and nocturnal hot flashes: a randomized-controlled pilot trial. Menopause. 2026. https://pubmed.ncbi.nlm.nih.gov/42084929/