Insomnia During Menopause: Causes, Symptoms, and How to Sleep Better

If you’re not sleeping during perimenopause or menopause, it’s not always just hot flashes.

In this episode, I explain why sleep disruption at midlife is often more complex. While night sweats can wake you up, they account for only about a third of nighttime awakenings. I often see a pattern of fragmented sleep — frequent wake‑ups, long stretches lying awake, and early morning waking.

We discuss other contributors like anxiety, depression, brain fog, sleep apnea, restless leg syndrome, and even medication side effects. I also share practical sleep hygiene strategies and explain how CBT for insomnia and worry can help break the cycle of sleeplessness.

Finally, I review newer non‑hormonal treatments for hot flashes that target the brain’s temperature regulation system and may improve sleep.

If you’re struggling with menopause‑related sleep issues, this episode will help you understand what’s happening — and what you can do about it.

You can write to us at Questions@GynoInfo.net

And follow us on Instagram @gynoinfo

Transcript

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Welcome to Gyno Info, Frank Talk with Dr. Burkey, the podcast dedicated to teaching everyday women what they need to know about their body and how it works to successfully deal with the healthcare system and communicate with their doctors. Each week, I'll provide you with new information and practical tips about gynecology and women's health care. I want to prepare you for your doctor's appointments by teaching you what to expect, what information your doctor will need to know from you, and what questions you will need and should ask her so you can be confident and make the most out of every visit. GynoInfo will give you the knowledge you need to take charge of your health and do this in a clear and frank way that you can understand without having a medical degree, one episode at a time. So now let's begin. Hello. Welcome back to Gyno Info, the podcast about women's health in normal, everyday language that normal, everyday people can understand. No complicated special medical words, no doctor speak. A special welcome to those who just discovered us and are listening for the very first time. Please take a moment now to subscribe to DynoInfo. If you do not, then you might have a hard time getting back to this episode in case you have to interrupt it in the middle and would like to finish the podcast later on. The same episode might not show up in your feed anytime soon, but if you subscribe, it does. Today I'm going to talk about why and how menopause disturbs your sleep. I will also offer you some suggestions about what you can do about that. I spent the first week of March at the International Gynecological Endocrinology Congress in Rome, Italy. A mouthful. But it just means it's a conference about women and their hormones with leading scientists from all over the world. Besides gaining about three pounds eating wonderful Italian pasta, I learned a lot of new and exciting things that I will be sharing with you in my podcasts. As you already know, I spent quite a bit of my time studying to make sure that the information in my podcast is always up to date with the latest science. I then try to translate the latest scientific information into normal everyday language so normal everyday people can actually understand it. I decided to start doing this podcast in the fall of 2025 because I wanted to work against the constantly increasing amount of false and misleading BS that is being peddled on the internet. The lies that are being pushed down your throat by pseudo-experts and uninformed influencers who are only after more and more clicks. But lies don't change scientific facts. That Congress in Rome is held every two years and always brings the latest information on everything having to do with hormones and women by leading experts in their fields from many different countries. I've been attending this Congress regularly for more than 30 years. It's that good and worth my time. And as always, this year too, I had to limit myself to a few topics that I find particularly interesting. And one of those topics this year was menopause and sleep. And I want to share with you today what new things I learned. One of the key new discoveries about sleep and menopause is that it's about more than just hot flashes and night sweats. We have always known for a long time now that yes, having hot flashes at night greatly disturbs your sleep. We also know that treating those hot flashes, those so-called vasomotor symptoms of menopause, the hot flashes and the palpitations and the night sweats with natural, bi-identical ovarian hormones, helps a lot and restores normal, restful sleep in most women. But there are always women who cannot take estrogen for many different reasons. These reasons range from being misinformed and scared about hormones to having blood clotting disorders that make it dangerous for women to take estrogen, or having a type of cancer that likes to eat estrogen and thrives when it is given estrogen. It will grow faster and stronger, so you don't want to feed it. For those women, all these new research findings of the last few years about what centers in the brain actually cause the hop flashes is incredibly important. The new knowledge has brought women new non-hormonal medications that are life-changing for countless women, especially those with certain types of breast cancers. Their anti-estrogen hormone treatment can lead to absolutely devastating sleeplessness. I will say more about these new non-hormonal hot flash medications later in this podcast, so stay tuned. But for now, let's get back to how menopause disturbs your sleep. It does this in a pattern that is very specific and typical for perimenopause and menopause. And it happens in many women who never had sleeping problems in all their life before menopause. About four to seven out of ten women going through menopause complain about so-called fragmented sleep. That means, of course, also that three to six out of ten women have no sleep problems at all. But today we're talking about those that do. Those paramenopausal women that do have sleep issues are not typically having problems going to sleep, but they complain about waking up often, having problems going back to sleep when they wake up, staying awake for long stretches of time at night, generally worrying about everything in the world there is to worry about, and then waking up too early. Does that sound all familiar? They complain about poor quality sleep, of not feeling rested and refreshed in the morning because of this fragmented sleep without long stretches of restful, deep sleep. This kind of poor sleep is typical for perimenopausal women. It can be measured as increased WASO time, as increased wakefulness after sleep onset. Wasso. Wasso is the time a woman spends awake between the time when they first went to sleep and the time when they finally wake up for the day. There are some women who also do have problems falling asleep, but that is usually more typical of other types of classical sleeplessness than the perimenopausal sleep problems. Sleep studies show that almost always when a woman has a hop flash at night, she will wake up, even though she may not notice the hop flashes by the time she is actually awake. And it is also a proven fact that women who have more severe hop flashes are three times more likely to have frequent awakenings at night and poor sleep quality. That's not surprising. But what was news to me is that only a third of the time when a perimenopausal woman is awake at night, she was woken up by a hop flash. Obviously, more than just hop flashes play a role in perimenopausal sleep problems. For now, we don't quite understand yet what exactly all these other factors are that wake you up and how they do disturb sleep. But thankfully, this is being studied by many researchers around the world right now, and we will soon have more answers. One thing that certainly seems to play a role is mood and depression. Women who have severe PMS, premenstrual syndrome, with severe mood swings in the week before their menstrual period are much more likely to have sleep problems once they reach perimenopause and menopause. They're also much more likely to suffer from more severe hop flashes than women who do not have PMS symptoms or not bad PMS symptoms. Then again, not sleeping well does certainly not help your mood and will make you more irritable. And that is exactly what the studies show. Treating the sleeping problems will improve people's mood and sense of well-being. Sleeping issues such as poor sleep quality and fragmented sleep are also a major reason for so-called brain fog, problems concentrating and remembering things, such as words, stories, or numbers, difficulties maintaining a train of thought, and forgetting what you wanted to do when entering a room, and also constantly losing your cell phone and your keys. All these symptoms, even though they're normal and expected and can be treated, make you feel incredibly anxious. You worry about not being able to do your job and being fired because of that, because of brain fog and you can't concentrate. You worry that you're losing your mind or becoming demented. Every time you misplace your keys or can't remember a name, you think this is a sure sign that you have severe Alzheimer's. And all these worries then keep you awake at night and prevent you from getting a good night's sleep and be rested in the morning. Then there are other factors that get more common during perimenopause that can also disturb your sleep if they're not treated. One is sleep apnea, when you stop breathing at night and your brain does not get enough oxygen. That becomes more common as women enter the menopause. One of the reasons for sleep apnea is too much weight, which also becomes more often a problem with menopause. The extra weight tends to block off the passage of air in the back of your throat. This is called obstructive sleep apnea. I actually just did a podcast on sleep apnea and on why menopausal women snore more often than before menopause. I did that a few weeks ago. You might want to look at that on YouTube. I say look because it has a lot of pictures and slides. But of course you can listen to it on Spotify or whatever. But looking at the slides might help you understand it better. Another reason for disturbed sleep is restless leg syndrome, an irresistible urge to move one's legs because of a creepy trolley or painful feeling in the leg that only gets better when you move them. Restless leg syndrome also can lead to jerky leg movements that then wake you up just when you're about to fall asleep. Just like sleep apnea, restless leg syndrome gets more common and more severe during perimenopause. One reason for restless leg syndrome is iron deficiency, not having enough iron, which is often caused by the super heavy periods that are typical in perimenopause, when your hormones become irregular and your bleeding becomes a flood. Yet another reason for not sleeping are the changes in the brain caused by the lack of estrogen. Not just the hop flashes, but other brain effects of not having enough estrogen. And on top of all that, some of the antidepressants that are often prescribed to perimenopausal women for their anxiety can cause problems with sleeping. So you can see that sleeping problems in perimenopause and menopause is more than just about hop flashes and can have many different reasons. Treating the hop flashes and night sweats with natural estrogens in those women who do not have any contraindications and can safely use hormone treatment remains, of course, the most effective and important treatment. And for many perimenopausal women, that is enough. But for other women, more than just those so-called vasomotor symptoms need to be dealt with. They need additional treatments for their sleep apnea and for the restless leg syndrome I just mentioned. Treating those and their causes is certainly very helpful and important for improving sleep quality. For sleep apnea and snoring, it is sometimes enough to just turn to sleep on one side and also to lose weight. But more often, more is needed, as I described in my earlier podcast on sleep apnea. Restless leg issues can be greatly improved with iron infusion if lack of iron is the main cause of it. But there are also more specific medications for restless leg syndrome. Then there are so-called sleep hygiene measures that need to be discussed with all women who have problems with their sleep. Go to sleep and get up roughly at the same time, even on weekends. Try to have a calming and winding down routine starting about an hour before bedtime. Turn off screens, avoid intense work or exercise, take a warm bath and read. I realize that this is not super realistic for many of us, but do try the best you can given your busy life. Turning on bright lights of opening the curtains in the morning to start the day is also important. And then turn off bright lights and screens about one hour before bedtime to let your brain know that it is time to sleep soon. Keep the bedroom cool 65 to 68 degrees Fahrenheit or 18 to 20 degrees Celsius because the brain needs to cool down so it can actually go to sleep. Keep the bedroom dark and use blackout curtains or an eye mask. If it is noisy, try earplugs or a white noise machine to mask the sounds from the outside. Avoid caffeine, coffee, tea, soda, chocolate after 2 p.m. Stop eating heavy meals about three to four hours before bedtime. This also helps with reflux and heartburn by not having a full stomach pushing acid up into your esophagus and throat when you're lying down. And stop drinking alcohol, or better even, avoid it altogether for at least two hours before going to bed. Alcohol has been shown to be a major disruptor of healthy sleep during the night. Stop drinking any fluid about two hours before going to bed, so you don't have to get up all night to go to pee. And also do not drink anything if you get up during the night, because that will guarantee that your bladder will wake you up a couple hours later. If your mouth feels dry, just rinse it, but don't swallow the fluid. As we all know, anxiety and worry is something else that keeps us awake at night. That is something you will also have to work on. The most effective tool for that is so-called CBT, cognitive and behavioral therapy. That is basically just a fancy way of retraining your brain to think differently. Train it to think happy thoughts and focus on the good things that happen during a day before going to sleep and to put off worrying to the morning. Training your brain to let some of the things just go, especially those that are minor in the big picture of life, or the ones you can't do anything about, anyways, and the ones you do not need to do anything about. This retraining of your brain to think about life in a more healthy way sometimes needs the help of a therapist. But there are even some AI artificial intelligence apps now that can help you with it as long as you do not have any major issues that really need professional help. And sometimes you need the help of prescription medications as a medical crutch to deal with your anxiety issues. And that's okay. You would not expect a broken leg to heal without a cast. If your soul needs prescription medications for a while as part of your depression therapy, then that's kind of the same thing as a cast for a broken leg. But beware of the side effects of these medications. They can make both sleeplessness worse and also contribute to brain fog and become addictive. It is very important to get the help of a well-trained and experienced mental health care professional for treating depression and not just pop some benzos you get from a friend. Giving you such drugs is not a very friendly thing to do, is dangerous and not a good thing. Don't take drugs from friends that were not specifically prescribed for you and don't give any to your friends. And now, before we finish this podcast, I want to say a few things about a new class of non-hormonal medications that are very effective in treating hop flashes in women who cannot, for real reasons or do not want to, for all sorts of other reasons, take natural bioidentical human hormones to treat their hop flashes and night sweats that keep them from sleeping. In the past, many different medications from sleeping pills to antidepressants were prescribed for women who cannot take estrogen to treat their hop flashes. These medications did not specifically treat hop flashes, but treated more the effects of having hop flashes, like not sleeping, feeling irritable and depressed, but not the hop flashes themselves. For that reason, these medications are not very effective for menopausal symptoms and all have unwanted side effects. But now we understand much better exactly which nerve centers in the brain produce the hop flashes and keep us from sleeping well when the ovaries stop producing hormones at the time of menopause. There are centers in the brain that when they no longer get estrogen make the body's thermostat go berserk, go absolutely crazy. Usually there is a certain temperature comfort zone where we feel comfortable. This zone is called the thermoneutral zone and is about four degrees Celsius or seven and a half degrees Fahrenheit wide and varies a bit between different women and also which time in your monthly cycle you're at or if you're pregnant or not. If it is cooler, we begin to shiver, so we produce more heat. If it is hotter, we start sweating to help cool us down. Those are the body's normal reactions to keep us in the so-called thermo-neutral range, when all our organs function the very best they can. The brain runs the body's thermostat. So it sends out the signs that cause the hot flashes and chills that are the typical signs of menopause. When the ovaries stop producing the normal female hormones at the time of menopause, the brain no longer gets the estrogen it needs. One of the effects of this lack of estrogen is that this thermoneutral zone, the temperature zone that used to be four degrees Celsius wide, becomes much narrower, less than half a degree Celsius. It's more like a line. Most of the time now, you can only be above the line, too hot, or below the line too cold, but definitely not comfortable. Medications have been developed that directly block these brain signals to the recently discovered hop flash making centers. The same connections in the brain also have to do with the brain's regulation of sleep and awake cycles. So again, you can see that all this hangs together somehow. One such medication that has already been approved for the treatment of menopausal vasomotor symptoms, hop flashes, in over 40 countries is called vasolinitant. It lowers moderate to severe hop flashes in menopausal women by about two-thirds. Two-thirds for your hop flashes may not sound all that much, but we're talking about moderate to severe hop flashes being lowered. Severe hop flashes are the ones that stop you in your tracks. They force you to stop whatever you are doing at the moment. Moderate hop flashes are the ones that make you break out in a sweat. So you may still have mild hop flashes where you feel a bit hot, but you do not sweat and have to change nightshirts or get dark armpits during a business meeting. Removing the severe and moderate hop flashes or reducing them a lot makes a lot of a difference. Because the same brain centers that deal with hop flashes are also involved in regulation of body temperature and in regulating sleep and awake cycles, one of the positive side effects of phasolinoton is better sleep. This has been a life changer for women on aromatase inhibitors, estrogen blockers for the treatment of certain types of breast cancers. The only negative side effect to worry about with phasolinoton is that about two out of 100 women can develop abnormal liver tests, abnormal blood tests of the liver, and have to stop the medication. But it also means that 98 of 100 women are feeling a whole lot better with this new medication called phaseolinitant. That's the chemical name. There are different brand names in different countries. This brings us to the end of this episode on menopause, hot flashes, and sleeping problems. It was a bit long, but it is a topic with a lot of new and exciting new science that I wanted to share with you. I hope you found it interesting and useful and will share it with as many other women as you can. And remember that if you have any further questions about the topic I talked today or any other issues having to do with women's health, please don't hesitate to send them to me at questions at gynoinfo.net. Again, that's questions at gynoinfo.net. Please also make sure that you click the subscribe button wherever you listen or watch Gaino Info. So you can get back to it easily whenever you can. And also, the more people subscribe, the easier it will be for others to find us. Thank you. Until next time. Until next time. Thank you for listening. And remember that you and your health are super important and deserve your full attention. Don't ever put off contacting your doctor because you're scared or embarrassed when something feels wrong about your body. Doctors are here to help you, not to judge you. And also, regular well-woman visits are always a good idea that you should make time for. You deserve it and you owe it to yourself, and you owe it to your body and your health. This podcast is part of Pride House Media, hosted by me, Dr. Berkey, produced and edited by Josh Rosenzweig. Original music composed by Nell Balaban. If you enjoyed this episode, please subscribe wherever you listen to podcasts. And while you're there, leave us a rating and a review. It really helps others discover the show. Stay connected and join the conversation by following me on Instagram and Facebook at gynoinfo and on LinkedIn at gyneoinfopodcast.