Why am I waking up at 3am? Sleep disturbances in menopause
Sleep is essential for your mental, emotional, and physical health. Adults typically need around seven hours of sleep per night, but during perimenopause and menopause, many women find this becomes harder to achieve. Hormonal shifts, particularly falling oestrogen and progesterone levels, can interfere with sleep quality and increase the risk of fatigue, brain fog, mood swings, and even long-term health issues like heart disease and osteoporosis [1,2].
Sleep plays a critical role in healing and memory. During the deepest stage of sleep (Stage 3 non-REM sleep), your heart rate slows, blood pressure drops, and brain activity quietens. This is when your body does essential repair work: rebuilding muscles, strengthening your immune system, and consolidating memories from the day. Most deep sleep occurs in the first few hours of the night, so going to bed at a consistent time really matters.
Around 40%–60% of women going through menopause report trouble sleeping, including difficulty falling asleep, waking up in the night, or waking too early in the morning [3]. These changes can come on gradually or appear suddenly, even in women who’ve always slept well.
Sleep disturbances don’t happen in isolation. They often occur alongside other menopause-related symptoms like night sweats, anxiety, and changes in mood. Over time, poor sleep can affect your memory, focus, relationships, and resilience. This can have a huge impact on your overall quality of life. Understanding why it happens is the first step toward getting better rest.
What does menopausal sleep disruption feel like?
Sleep difficulties vary from person to person, but common experiences include:
- Trouble falling asleep, despite being tired
- Waking up several times in the night
- Early morning wakings and being unable to get back to sleep
- Feeling too hot or sweaty to sleep comfortably
- Lying awake with racing thoughts or a sense of anxiety
These changes can leave you feeling exhausted, irritable, and mentally foggy the next day. And because the causes can be hormonal, traditional sleep hygiene tips alone may not address the root of the issue.
Why it happens: hormones and sleep
Menopause-related sleep issues are primarily driven by changes in two hormones: oestrogen and progesterone as levels fluctuate and eventually decline throughout perimenopause and menopause. These hormones don’t just regulate your menstrual cycle, they also affect your brain’s ability to regulate sleep, temperature, and stress responses
- Oestrogen supports the production of serotonin and melatonin, both of which are vital for a healthy sleep-wake cycle. As oestrogen levels fall, women may experience more frequent awakenings, reduced REM sleep, and temperature regulation issues like night sweats [4,5]. In a 2023 study published in the Journal of Clinical Endocrinology & Metabolism, lower oestrogen levels were linked to more frequent night-time awakenings and disrupted REM sleep.
- Progesterone has a calming, sleep-promoting effect on the brain by enhancing GABA (gamma-aminobutyric acid) activity. When progesterone levels drop, many women find it harder to relax or fall asleep. Micronised progesterone (e.g. Utrogestan) is often used in HRT and has been shown to improve sleep quality through its action on the central nervous system [6].
- Melatonin, a hormone that helps regulate sleep timing, also naturally declines with age, which may further contribute to fragmented or shallow sleep [7].
- Sleep apnoea becomes more common after menopause due to changes in upper airway tone and body composition. Many women are underdiagnosed because symptoms can present differently than in men, with fatigue or poor sleep rather than loud snoring [8].
In the SWAN (Study of Women’s Health Across the Nation), researchers found that women in the menopause transition reported significantly more frequent sleep disturbances than premenopausal women, with night sweats and hot flushes strongly associated with poor sleep quality [3].
But menopause isn’t always the only factor. As we age, the body naturally produces less melatonin, a hormone that helps regulate sleep timing. Other midlife changes such as increased stress, caregiving responsibilities, or health conditions like sleep apnoea or restless legs syndrome can also interfere with sleep [13].
How long does it last?
There’s no one answer. Some women experience sleep disturbances for a few months, others for several years. The good news is that with the right support, sleep often improves significantly.
What can help?
There is no one-size-fits-all approach, but the following strategies are backed by evidence and used widely by menopause specialists:
1. Hormone Replacement Therapy (HRT)
Replacing oestrogen (and in some cases progesterone) can reduce hot flushes, improve mood, and support more restful sleep [9]. A study conducted by the Mayo Clinic in 2022 found that low-dose HRT significantly improved both sleep quality and duration in recently menopausal women [10].
2. Cognitive Behavioural Therapy for Insomnia (CBT-I)
CBT-I is a structured, non-drug treatment that helps you identify and change thoughts and behaviours that interfere with sleep. It’s recommended by NICE and the British Menopause Society as an effective treatment for sleep problems in menopause [1,11].
3. Lifestyle and Sleep Hygiene
These strategies form a key part of many treatment plans and can support significant improvements in sleep quality:
Daily Habits:
Stick to a consistent bedtime and wake time. Routine helps train your body for sleep.
Avoid long daytime naps. If needed, keep them under 40 minutes and early in the afternoon.
Exercise regularly, but not within two hours of bedtime.
Understand how much sleep you personally need. Six to eight hours is average, but this varies between individuals and may decrease with age.
Evening Routine:
Establish a relaxing pre-bed routine, such as a warm bath or light reading.
Avoid going to bed too full or too hungry. A small snack is fine.
Cut out caffeine and fizzy drinks from late afternoon onward.
Avoid alcohol, which can disrupt sleep quality.
Bedroom Environment:
Keep your bedroom cool, quiet, dark, and comfortable.
Invest in good bedding and a supportive mattress.
Use the bedroom only for sleep and intimacy. Avoid using screens or working in bed.
If You Wake in the Night:
If you cannot fall back asleep within 20 minutes, get up and do something quiet in another room. Return to bed when you feel sleepy.
Avoid looking at the clock or turning on the TV.
Try not to dwell on worries or problems during the night. Set them aside for the morning.
4. Medical Checks
Fatigue and sleep problems may also be linked to low iron, thyroid dysfunction, vitamin D or B12 deficiency. Blood tests can help identify and treat these issues [12].
When to seek help
If sleep is affecting your daily life, your ability to function, or your mental health, it’s time to get support. Speak to a menopause-informed clinician who can explore both hormonal and non-hormonal options with you.
Sleep should not feel like a nightly battle. With the right treatment and support, better nights are possible.
¹- NICE. Menopause: diagnosis and management. NG23. 2015. https://www.nice.org.uk/guidance/ng23
²- National Institute on Aging. “How Does Sleep Affect Your Heart Health?” 2022.
³- Kravitz HM et al. Sleep difficulty in women at midlife: a SWAN study. Sleep
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⁴- Polo-Kantola P et al. Climacteric symptoms and sleep quality. Obstet Gynecol. 2001;97(3):404–410.
⁵- Cintron D et al. Efficacy of estrogen therapy for sleep disturbance in menopausal women. J Women’s Health. 2017;26(5):509–517.
⁶- Hachul H et al. Effects of progesterone on sleep: a systematic review. Climacteric. 2018;21(4):384–390.
⁷- Brzezinski A. Melatonin in humans. N Engl J Med. 1997;336(3):186–195.
⁸- Jordan AS et al. Sleep-disordered breathing in postmenopausal women: causes and consequences. J Clin Sleep Med. 2014;10(12):1279–1286.
⁹- British Menopause Society. The management of urogenital symptoms of menopause. 2023.
¹⁰- de Zambotti M et al. Hormone therapy effects on sleep in recently menopausal women. Menopause. 2020;27(3):309–320.
¹¹- Mayo Clinic Proceedings. Menopausal hormone therapy and sleep quality: A clinical trial. 2022.
¹²- Freeman EW. CBT for menopausal insomnia. Menopause. 2014;21(9):974–976.
¹³- Women’s Health Concern. Menopause and Insomnia 17-WHC-FACTSHEET-Menopause-and-insomnia-NOV2022-B.pdf
