Perimenopause Sleep Issues

Perimenopause — the transition years before menopause — is full of changes due to fluctuating hormone levels. Whether you’re just entering perimenopause or you’re in the throes of it, you may have experienced a particularly disruptive symptom: sleep issues. 

Because of the multitude of changes your body goes through during perimenopause, sleep challenges can occur for many reasons. Below, we’ll cover why perimenopause affects sleep, common sleep issues, and what you can do to get the rest you need during perimenopause.

How Does Perimenopause Affect Sleep?

Perimenopause can make it more difficult to fall asleep, cause you to wake during the night, or lead you to wake up earlier than usual. Sleep issues are caused by fluctuations in hormone levels, which lead to disruptive symptoms like hot flashes and mood changes. 

Sleep issues during perimenopause are challenging, but they’re also common, with 40 to 45% of perimenopausal people experiencing them.

Hormonal Fluctuations

Perimenopause is the body’s transition to menopause, which is marked by 12 months of not getting a period. During normal menstrual cycles, hormones fluctuate day to day based on the particular phase of the monthly hormonal cycle.

In perimenopause, your hormone levels fluctuate erratically toward a steady decline, leading to a variety of symptoms that can impact sleep. There are two main hormones at play: estrogen and progesterone.

Estrogen

One of estrogen’s many roles in the body is thermoregulation. During perimenopause, irregular estrogen levels often lead to hot flashes, sudden feelings of heat that start in the chest or face and spread to the rest of the body. Hot flashes can be extremely uncomfortable and disruptive to sleep. 

Estrogen levels that fluctuate up and eventually down also affect moods. Some people experience anxiety and/or depression during perimenopause, which can negatively affect sleep.

Progesterone

In addition to regulating reproduction, progesterone interacts with serotonin in the brain. For that reason, higher levels of progesterone are associated with feelings of well-being and improved sleep quality. As levels become irregularly secreted and then eventually drop during perimenopause, it can be more difficult to experience high-quality sleep.

Perimenopause Symptoms

Hormone changes during perimenopause lead to a variety of symptoms that can disrupt sleep. 

• Hot flashes: The body naturally cools at night to encourage sleep, so hot flashes during sleep can be especially disruptive. Hot flashes are also very common, with up to 80% experiencing them at some point during perimenopause.
• Night sweats: Many people think of night sweats as simply hot flashes that occur at night, but new research shows the two are slightly different. Both involve sudden overheating, but night sweats also include longer periods of intense sweating. Night sweats typically keep people awake longer than hot flashes.
• Mood changes: Both estrogen and progesterone interact with neurotransmitters that help regulate mood, so variability in these hormones during perimenopause leads to mood changes. Mood and sleep are highly intertwined, meaning that lack of sleep can make it more difficult to regulate moods, and mood changes can make it more difficult to sleep.
• Anxiety: Fluctuating hormone levels and life changes are also associated with higher rates of anxiety during perimenopause, which can have a substantial impact on sleep. Stress and anxiety can make it harder to fall asleep, and insomnia can also lead to anxiety around sleep.
• Depression: Depression is also common during perimenopause, even in people with no history of depression. In addition to the impact of changing hormone levels on serotonin, perimenopause also coincides with a stressful time in life for many people. Depression can make it more difficult to fall asleep and lead to earlier wake times.
• Increased nighttime urination: Estrogen interacts with the urinary system in a variety of ways, and some people in perimenopause experience an increased need to urinate at night. Obesity is also a risk factor when it comes to nighttime urination.
• Joint and muscle pain: Loss of estrogen can lead to loss of muscle mass and bone density, which can, in turn, contribute to joint and muscle pain. Pain can make it especially challenging to get quality sleep.
• Headaches: Estrogen has anti-inflammatory effects, so its reduction during menopause can lead to more headaches, especially migraines. Headaches can impact sleep, and lack of sleep can also worsen headaches.

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Common Sleep Issues During Perimenopause

Perimenopause can impact sleep in a variety of ways. Common issues include:

• Difficulty falling asleep
• Frequent nighttime awakenings
• Waking too early with an inability to return to sleep
• Poor sleep quality

These issues may be directly linked to perimenopause symptoms — like hot flashes — and might resolve as those symptoms improve. That said, they could also be a sign of an underlying sleep disorder, so it’s always worth talking to your doctor about your sleep challenges. 

Insomnia

Insomnia is a sleep disorder that can lead to issues with falling asleep, staying asleep, or getting quality sleep. While many people experience trouble sleeping from time to time, chronic insomnia is when sleep challenges occur three or more times a week for more than three months.

Insomnia is common during perimenopause (and menopause) for a variety of reasons. Both estrogen and progesterone help regulate the sleep-wake cycle, so when they fluctuate, sleep can be harder to come by. Symptoms like hot flashes or chronic pain can also lead to difficulty falling asleep or staying asleep. 

All of this can combine and lead to true insomnia, including the hallmark symptoms of insomnia, such as anxiety and rumination. Because people in perimenopause are already more prone to stress and anxiety, insomnia during this phase of life can prove especially difficult to overcome.

Sleep Apnea

Sleep apnea is a breathing disorder in which a person stops breathing or experiences shallow breathing while asleep. While more common in men than in women, the chances of developing sleep apnea increase as a person approaches menopause.

This might partly be due to the fact that some people gain weight during perimenopause, and increased weight is a risk factor for sleep apnea, but hormones might also be at play. Progesterone helps to stimulate breathing, and it may also help dilate airway muscles. A loss of progesterone, then, can increase the risk of developing sleep apnea.

Restless Legs Syndrome

Some people in perimenopause experience restless legs syndrome (RLS), which is characterized by a person’s urgent need to move their legs while resting. RLS can make it difficult to fall asleep or stay asleep.

Research is mixed when it comes to a hormonal link to RLS. Some studies have shown that higher levels of estrogen are a risk factor for RLS, while others have shown that estrogen has no effect. Other research indicates that the development of RLS may be due more to aging than to hormone levels. 

How to Sleep Better During Perimenopause

It may feel like quality sleep is impossible during perimenopause, but there are steps you can take to get better sleep. Managing perimenopause symptoms and practicing good sleep hygiene can go a long way toward helping you get the rest you need.

• Keep a consistent sleep schedule: Going to bed and waking up around the same time every day can help signal to your body when it’s time to fall asleep. While life factors like work schedules may get in the way, try to choose a bedtime that matches up with when you are actually sleepy to increase your chances of falling asleep.
• Keep your bedroom cool: Everyone sleeps better in a cool environment, but this is especially true for anyone experiencing hot flashes or night sweats. The best temperature for sleep is around 66 to 70 degrees Fahrenheit, but shoot for an even lower temperature if you find yourself waking up hot.
• Limit alcohol and caffeine: Even though alcohol may help some people fall asleep faster, it impacts your circadian rhythm, leading to more fragmented sleep. Alcohol can also impact your body’s ability to cool down at night. Caffeine’s effects last for about six hours, so ingesting it late in the day can also make it more difficult to fall or stay asleep.
• Exercise regularly: Exercising early in the day can help you fall asleep more easily at night. Just make sure to finish up at least four hours before bedtime, or it might have the opposite effect. Certain types of exercise, like strength training, can be particularly beneficial for perimenopausal people because it increases bone density.
• Practice relaxation techniques: Relaxation techniques, like deep breathing or yoga, can help you prepare your mind and body for sleep. These are especially helpful if you experience anxiety.
• Try cooling bedding: Your sleepwear and bedding can have a large impact on your body temperature. Sheets or sleepwear made from breathable fabrics — like cotton, linen, Tencel, or bamboo — can help you stay cool during the night. If your hot flashes or night sweats are very disruptive, you may want to invest in a cooling mattress topper or even a new mattress.

When to Talk to a Doctor

Just because perimenopause is a natural part of aging doesn’t mean that you can’t get help from your doctor to manage your symptoms. It’s particularly important to talk to your doctor if you experience any of the following.

• Symptoms persist: If your symptoms are persistent and disruptive, talk to your doctor about how to manage them. There are many options, including menopause hormone therapy, therapy for insomnia, medications for anxiety and depression, and others.
• Daytime functioning suffers: Impact on your daily functioning is a sign that your sleep issues are more severe and that you need outside help.
• Loud snoring or gasping, snoring, or choking during sleep: If you or your bed partner notices any of these symptoms, talk to your doctor, as they may be a sign of sleep apnea.
• Restless legs: An urgent need to move your legs or a tingling/burning sensation in your legs could be signs of restless legs syndrome. Tell your doctor about your symptoms so you can learn about treatment options.
• Severe mood symptoms: Severe mood symptoms, especially those of anxiety and depression, require extra attention. Your doctor may be able to help you find a therapist and/or prescribe an antidepressant.
• Irregular bleeding: While irregular bleeding during perimenopause is normal due to fluctuating hormone levels, it can be a sign of an underlying health condition. Tell your doctor about periods that are heavier than usual or any spotting between your periods.

Treating Persistent Symptoms

Perimenopause symptoms can be persistent and disruptive, but relief is possible. Talk to your doctor about the following treatment options.

• Menopause hormone therapy (MHT): MHT (previously referred to as hormone replacement therapy) involves replacing lost progesterone and/or estrogen to help alleviate perimenopause or menopause symptoms. MHT is primarily used to treat hot flashes, but it can also help with mood changes, sleep issues, and joint pain. It can come in the form of pills, topicals, patches, or vaginal rings. Not everyone experiencing perimenopausal symptoms is a candidate for MHT, so it's important to find a doctor who is trained, licensed, and certified to administer these medications, as they require a nuanced approach to administration.
• Cognitive behavioral therapy for insomnia (CBT-I): If your insomnia has become persistent, CBT-I is the gold-standard treatment. It’s a type of therapy that involves identifying behaviors and beliefs that contribute to sleep issues. It focuses on underlying causes and uses cognitive interventions, like sleep education and relaxation training, as well as behavior changes, like healthier sleep habits. 
• Medications: In addition to MHT, there are other medications that might help alleviate symptoms of perimenopause. Talk to your doctor about antidepressants if you’re experiencing anxiety and/or depression. There are also medications that might help with hot flashes, nighttime urination, bone loss, and other symptoms.
• Lifestyle changes: For mild hot flashes, lifestyle changes, like wearing light clothing and avoiding spicy foods or other triggers, might help, though some find them ineffective.