Is Perimenopause the Reason I Can’t Sleep?

Q: I can’t catch a good night’s sleep lately. Could perimenopause be to blame? 

Sleep problems are common during perimenopause. Hormones like estrogen and progesterone are in flux, which can mess with your body’s sleep regulation and lead to frequent wakeups, night sweats, and restless sleep. “Things like obstructive sleep apnea become more common in women during perimenopause, and mental overload doesn’t help either, especially as it’s a time in life when women have more demands with career, family, and other responsibilities,” says Nishi Bhopal, MD, a sleep physician and psychiatrist. Knowing what’s at play can help you get the rest you deserve.

Up to nearly 70% of women experience sleep issues during perimenopause. One of the most common complaints? Trouble staying asleep, says Bhopal. Many women also deal with insomnia, middle-of-the-night wake-ups, and feeling “tired but wired”.   

Listen, our lives are full. And when our eyes open at 3 am, it can be hard to tell if: 

A. Your to-do list, work problems, or that one thing you said to a friend last week is keeping you up.

B. It’s perimenopause symptoms.  

Short answer: It’s usually not just one thing.

Hormone shifts, stress, vasomotor symptoms (night sweats, hot flashes), and underlying sleep disorders can all play a role. The key is spotting which symptoms are showing up for you — that’s what turns “I can’t sleep” into something you can fix.

The Perimenopause and Sleep Connection

Zoom out: Perimenopause — the transition before menopause — usually starts in your mid-40s and can last four to seven years. But it can begin earlier (mid-30s isn’t unheard of) and, for some, stretch on for a decade. That's a long time to feel off.

And sleep? It’s often one of the first things to go.

It’s not rare, either. In one study, up to 42% of women reported insomnia symptoms during perimenopause, like waking up in the middle of the night or way too early. And Centers for Disease Control and Prevention research found that on most nights, about one in four women struggle to fall asleep, while half said they still felt tired after they woke up.

And here’s the part people miss: Sleep disruptions can be an early sign of perimenopause — even before traditional symptoms like hot flashes show up.

How Perimenopause Affects Your Sleep

During perimenopause, the systems that regulate your sleep — from hormones to your internal clock — start to shift. Let’s take a closer look:

Hormone Changes 

“Hormones like estrogen and progesterone start fluctuating during perimenopause, and that can impact sleep and result in symptoms like night sweats, middle-of-the-night wakeups, and lighter, more restless sleep,” says Bhopal. 

Progesterone has a calming effect on the brain (it supports GABA, the system that helps you wind down). “Progesterone has…sleep-promoting effects, so when it drops during perimenopause, your brain can feel more alert or restless at night,” she says.

Meanwhile, estrogen plays a role in mood and temperature regulation and muscle tone maintenance (making breathing easier while you sleep). When it dips or is in flux, like during perimenopause, it can disrupt sleep. 

Night Sweats and Hot Flashes

Night sweats and hot flashes fall under vasomotor symptoms, which impact the majority of women in perimenopause. Research found that women whose hot flashes were moderate or severe were three times more likely to wake up multiple times a night compared to those who didn’t have them. And another study showed that vasomotor symptoms can lead to fragmented sleep — even if you don't realize they’re happening. 

Mood Changes and Mental Overload 

Oh, those hormone changes we mentioned — they can have a ripple effect. During perimenopause, research shows the risk of depression increases anywhere from two to five times, thanks to hormonal shifts. The chance of perimenopause insomnia also ticks up — and that can create a “bidirectional relationship” (read: one influences the other) with mood disorders, says Bhopal.  “While hormonal changes influence both mood and sleep, there are other factors at play — women at this time of life are often taking care of children and aging parents, experiencing career demands, and other psychosocial stressors,” she says. 

Also important: Sleep and mood feed each other. Bad sleep means worse anxiety. Worse anxiety means worse sleep. (Ugh, wonderful.)  

Circadian Rhythm Changes

Estrogen, ever the multitasker, also helps regulate your circadian rhythm, so as levels dip, your internal clock changes. “During perimenopause, the circadian signal becomes slightly weaker, and there is a shift toward an earlier body clock, which means you may naturally want to go to bed and wake up earlier than before,” says Bhopal. 

Also at play: a decrease in melatonin. This hormone typically rises at night to prep you for sleep, but as levels drop, it also disrupts your circadian rhythm, making it harder to fall asleep. But before you reach for a melatonin supplement, you should talk to your doctor. (Turns out, it’s not a one-pill-fixes-all solution.) 

Why You’re Waking Up at 3 am

“Oh, the dreaded 3 am awakenings. These are super common and influenced by several factors,” says Bhopal. Including:

• Fluctuating hormones. During perimenopause, declining estrogen and rising follicle-stimulating hormone (FSH) levels can disrupt your brain’s sleep-wake control centers, causing you to wake up more frequently — even if you don’t have hot flashes, she says. If you do get hot flashes or night sweats, they often happen between 2 and 4 am, triggering you to wake up. (That’s partly because your body’s urge to stay asleep weakens as the night goes on.) 

• Cortisol spikes. “The hormonal changes can also disrupt your body's cortisol rhythm, making it harder to fall back asleep once you've awakened,” she says.

• Your body starts waking up naturally. By the early morning hours, your brain and body are already beginning the transition toward wakefulness — so once something interrupts your sleep, it can be harder to drift back off.

Common Signs of Perimenopause Sleep Issues

Bhopal says some symptoms to look out for include:

• Difficulty falling and staying asleep — even when you have enough time to sleep 

• Worrying about sleep

• Not feeling refreshed (no matter how many Zzz’s you get) 

• Trouble staying awake during the day 

• Difficulty concentrating 

• Mood changes 

• Uncontrolled high blood pressure 

• Generally feeling unsatisfied with your sleep quality  

And remember: Sleep — and therefore symptoms — varies widely from person to person. If you think something might be up, talk to your doctor. 

Could It Be Something Other Than Hormones?

“Sleep changes during perimenopause are not just about hormones,” says Bhopal. Perimenopause is also linked to an increased risk of sleep disorders. Yep, that’s a thing. These are some common ones:

• Obstructive sleep apnea, which typically comes with snoring and gasping. But women may have symptoms like: feeling tired during the day, morning headaches, depression/anxiety, and frequent wake-ups.

• Restless legs syndrome, it feels tingly and, living up to its name, gives you the uncomfortable urge to move your legs at night.

• Chronic insomnia, which can mean trouble falling asleep, staying asleep, or waking up too early, several nights a week, for months. It makes it hard to function during the day.

• Thyroid conditions, like fatigue, feeling sweaty/hot, insomnia, and anxiety, can often mimic perimenopause symptoms. 

Also worth noting: Sleep disruptions can be a side effect of some medications, like SSRIs or ADHD medications, so keep an eye on the label. 

Here’s where things get tricky: It can be hard to parse what’s really at play – perimenopause or an underlying sleep disorder (or both) because symptoms of all of these conditions often overlap. Your best bet? Talk to your doctor, who can help with your specific situation. 

How To Actually Get Some Rest 

Focus on your bedtime routine

Start with the basics of sleep hygiene, says Bhopal, including: 

• Sticking to a consistent sleep-wake schedule

• Cutting screen time at night (at least half an hour before lights out) 

• Moving your body (the standard rec: 30 minutes/day, five times a week) 

• Getting outside 

• Eating well (focus on whole foods) 

• Winding down with something chill — not work, email, or doomscrolling

• Revamping your space, especially if you’re dealing with night sweats. Keep the room cooler, use breathable sheets, or layer your bedding 

Also helpful: Track your symptoms. This can offer your doctor a glimpse into what you’re dealing with in real time. (Try this free tracker.)

Work with a professional 

Speaking of talking to your doctor, it’s always a good idea to bring up any sleep issues — but it’s definitely worth a conversation if you’ve already tried changing your sleep habits and it hasn’t moved the needle. 

Experts, like a sleep physician or sleep psychologist, can help you figure out what comes next. 

Ask About Other Treatments 

Some options that may help include: 

• Cognitive behavioral therapy for insomnia (CBT-I): CBT-I focuses on building better sleep habits over time. For example: Using soothing techniques, like deep breathing or progressive muscle relaxation, and sticking to only sleep or sex in bed. It’s considered the gold standard treatment — and has also been shown to help with vasomotor symptoms, like night sweats, says Bhopal.

• Hormone therapy (HRT): “Hormone therapy works well in women experiencing vasomotor symptoms (night sweats and hot flashes), but isn’t shown to be effective in women without vasomotor symptoms,” says Bhopal.

• Medications. “For women who cannot or prefer not to use hormone therapy, some SSRIs and gabapentin (off-label) may help with vasomotor symptoms and sleep,” she says.

• Solutions for underlying sleep issues – like a CPAP machine for sleep apnea.

FAQs

Why am I tired all day but wired at night during perimenopause?

Hormones like estrogen, progesterone, and melatonin fluctuate during perimenopause, which can disrupt your system, including your circadian rhythm and sleep patterns. Add in stress, which can keep your cortisol levels high, and it’s a recipe for that “tired but wired” feeling at night. 

Can perimenopause cause insomnia?

It can — and research shows that even women in early perimenopause experience insomnia symptoms, like middle-of-the-night and early-morning wake-ups. The good news: There’s help, with cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment. 

Why do I wake up at 2 or 3 am during perimenopause?

This is unfortunately common. Bhopal points to a combination of factors: fluctuating hormone levels, including estrogen and FSH levels, which disrupt the brain’s sleep-wake control centers, hot flashes and night sweats, and cortisol fluctuations that make it harder to go back to sleep once you’re up. Oh, and thanks to aging, you're naturally not sleeping as deeply as you used to — so when you add on perimenopause symptoms like hot flashes that hit in the latter half of the night, you're left wide awake.

Can perimenopause cause insomnia even without hot flashes?

It can. In one study, nearly 40% of women without vasomotor symptoms, like hot flashes, still reported sleep issues.

What is the best treatment for perimenopause insomnia?

The gold standard treatment for perimenopause insomnia is cognitive behavioral therapy for insomnia (CBT-I), which focuses on building better sleep habits over the course of multiple sessions with a sleep specialist, like deep breathing or guided imagery. 

Can hormone therapy improve sleep?

It can be helpful for women who are experiencing vasomotor symptoms, like night sweats and hot flashes, says Bhopal — but it isn’t shown to be effective for women who aren’t. Either way, talk to your doctor about what would work best for your individual situation.

How long do perimenopause sleep problems last?

Bad news: “Sleep problems that start during perimenopause usually don't go away on their own after menopause,” says Bhopal. Hot flashes can last seven to 10 years, insomnia can continue even after levels stabilize, and issues like sleep apnea can go underrecognized. 

What you can do is talk to your doctor. “It's important to address sleep issues early rather than waiting for them to resolve naturally,” she says.

The bottom line: “Sleep issues are highly treatable, and you don’t have to struggle,” says Bhopal.