Sleep & Fatigue: Understanding Sleep Changes in Perimenopause and Menopause [Menopause Symptoms & Systems Series (Part 1 of 3)]
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- Apr 1
- 4 min read
Hello and welcome to the Menopause & Me community,
Changes to sleep and persistent fatigue are among the most commonly reported concerns during perimenopause and menopause. Many women describe lighter sleep, frequent waking, early morning waking, or feeling unrefreshed despite adequate time in bed.
Sleep disturbance during this life stage is often multifactorial. While hormonal changes and vasomotor symptoms may contribute significantly, they are rarely the only factors. A thorough understanding of possible contributors supports appropriate, individualised assessment and management. (click on the arrow to the left to open the full article)
Why sleep can change during perimenopause and menopause?
Vasomotor symptoms and sleep disruption
Hot flushes and night sweats can fragment sleep, trigger waking episodes, and reduce overall sleep quality. For some women, effectively addressing vasomotor symptoms may improve subjective sleep quality.
However, not all sleep disturbance during menopause is driven by vasomotor symptoms alone.
Hormonal influence on sleep regulation
Oestrogen and progesterone interact with brain pathways involved in thermoregulation, mood, and sleep–wake regulation. During the menopause transition, fluctuating or declining hormone levels may increase vulnerability to sleep disruption, even in the absence of other health changes.
Importantly, hormonal change is rarely the sole cause of sleep disturbance.
Other contributors common in midlife
Sleep changes during this stage may also be influenced by:
Sleep apnoea or snoring
Iron deficiency or restless legs symptoms
Thyroid dysfunction
Anxiety or low mood
Increased sensitivity to alcohol
Caring responsibilities, work demands, or chronic stress
For this reason, sleep disruption should not automatically be attributed to menopause alone, and other contributing factors may need to be considered and addressed.
How sleep disturbance may present
Women may notice:
Difficulty falling asleep
Frequent night-time waking
Early morning waking with difficulty returning to sleep
Non-restorative sleep
Daytime fatigue, reduced concentration, or irritability
While these experiences are common, they are not insignificant and warrant assessment if they persist or interfere with daily functioning.
An evidence-based approach to assessment
Step 1: Identify your sleep pattern
Tracking sleep for 1–2 weeks can be helpful. This may include:
Bedtime and wake time
Night sweats (if present)
Alcohol or caffeine intake
Exercise timing
Mood or stress levels
Duration and frequency of night waking
Identifying patterns can help differentiate between insomnia, vasomotor-related sleep disruption, circadian rhythm changes, or other sleep disorders.
Step 2: Consider insomnia-focused approaches when appropriate
For women experiencing persistent insomnia, cognitive behavioural therapy for insomnia (CBT-I) is recognised as a first-line, evidence-based management option.
CBT-I is a structured, non-medication therapy that focuses on how sleep habits, behaviours, and thought patterns influence sleep quality. It commonly includes strategies such as:
Improving sleep consistency and sleep drive
Reducing behaviours that unintentionally disrupt sleep
Addressing unhelpful beliefs or anxiety related to sleep
International guidance, including NICE Guideline NG23 (updated 7 November 2024), supports menopause-specific CBT approaches for sleep difficulties associated with vasomotor symptoms, as well as broader cognitive and behavioural strategies for menopause-related sleep disturbance.Recent research continues to support the role of CBT-I in this population.
Step 3: Address contributing symptoms
Where vasomotor symptoms are a major contributor to sleep disruption, symptom-directed approaches may be considered following individual clinical assessment.
For women who are unable or prefer not to use hormone-based therapies, non-hormonal options — supported by evidence such as the NAMS Nonhormone Therapy Position Statement — may also be discussed where appropriate.
Practical strategies that may support sleep
The following approaches may be helpful, depending on the underlying pattern and are aligned with lifestyle guidance from menopause societies such as the Australasian Menopause Society, which emphasise restorative sleep as part of midlife health:
If night sweats are present
Maintaining a cool bedroom environment
Using breathable bedding and layered sleepwear
Limiting alcohol and heavy meals close to bedtime
If difficulty settling or racing thoughts occur
Establishing a consistent wind-down routine
Limiting stimulating activities before bed
Structured insomnia-focused strategies (such as CBT-I principles)
If early morning waking is a concern
Keeping wake times consistent
Exposure to morning daylight
Avoiding long or late naps
When to consider a clinical review
A longer appointment may be appropriate if sleep disturbance:
Persists most nights for more than four weeks
Is associated with loud snoring, gasping, or marked daytime sleepiness
Occurs alongside persistent low mood or anxiety
Is accompanied by symptoms such as restless legs, palpitations, or unexplained weight change
Is associated with bleeding changes or other new health concerns
Assessment may involve reviewing symptoms, medical history, medications, and, where appropriate, further investigation.
Key takeaway
Sleep and fatigue changes during perimenopause and menopause are common and often multifactorial. A structured, individualised approach — identifying contributing factors and tailoring assessment and management accordingly — is strongly supported by current clinical guidance.
If you would like to seek further information about sleep changes during menopause, or learn more about available assessment options, you can contact Menopause & Me:
You’re not alone on this journey: knowledge is power!
Warm Regards,
Jenna Bell
Nurse Practitioner & Menopause Educator
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