Insomnia, defined as dissatisfaction with the quality or quantity (or both) of sleep, is a common and distressing symptom of the menopause. It may be experienced as difficulty getting to sleep, lying awake for hours, waking multiple times in the night, or waking early and not being able to get back to sleep. Short-term insomnia is defined as sleep disturbance for less than three months, and insomnia over three months is defined as long-term.
This article was included in issue 105 (Summer 2025) of The Menopause Exchange newsletter.
Adults need an average of seven to nine hours of sleep each night, and the impact of insomnia can mean you wake up feeling unrefreshed and lacking in energy and motivation, resulting in poor concentration, irritability and fatigue. Repeated patterns of poor sleep can leave you exhausted, negatively affecting your ability to function and fully enjoy life.
Insomnia and the menopause
The causes of insomnia at the menopause aren’t fully understood. However, it’s thought that oestrogen plays a role in managing sleep. The symptoms of hot flushes, night sweats and low mood and anxiety may also impact on the quality and duration of sleep.
You may find it hard to settle due to anxiety and stress, then wake because of night sweats or needing to go to the toilet. Once awake, you then fret about stressful situations and are unable to get back to sleep. When you wake in the morning, you’re exhausted before you start the day, which has a knock-on effect on your ability to function. The cycle repeats itself, often amplifying other menopausal symptoms.
Seeking medical advice
It’s important to seek the help of a healthcare professional to identify any underlying conditions that may be contributing to insomnia. For example, an overactive thyroid, restless legs, overactive bladder, some psychiatric conditions and physical pain can all impact on the quality and duration of sleep. Treating these appropriately can be helpful.
Prescription medicines
There’s little evidence that prescription medicines (sleeping pills) for insomnia are effective. They have potential unwanted side effects and a risk of dependency, so these aren’t first-line treatments and are recommended only for short-term use.
Over-the-counter medicines
A wide range of insomnia remedies and supplements are available to buy from pharmacies. These contain substances such as melatonin, antihistamines, valerian root and cannabidiol (CBD). Their components aren’t standardised, there’s a lack of research on their effectiveness and safety, and they can cause side effects including drowsiness, so they’re not recommended for long-term use.
Self-help strategies
Simple lifestyle changes can be extremely effective in restoring a better sleep pattern. Reducing alcohol, recreational drugs, caffeine and screentime before bedtime can reduce stimuli to the brain. Increasing physical exercise in the daytime can tire muscles and release endorphins that encourage sleep. It’s helpful to establish a bedtime routine that includes a calming activity, such as a warm scented bath, reading, listening to a podcast, or practising mindfulness. It may be necessary to reduce noise in the bedroom and make sure the room is dark and well ventilated, with a fan if needed to manage hot flushes at night.
The menopause is a time of transition and is often accompanied by significant changes in work, finances, relationships, family and societal responsibilities that may result in feeling overwhelmed. It can be useful to re-evaluate competing demands to manage work/life balance, ensuring there’s time for rest and recreation.
Hormone Replacement Therapy
Hormone replacement therapy (HRT) is the most effective treatment for menopausal symptoms and works by replacing the depleted levels of oestrogen. Women with a uterus will need to have progesterone as well, to protect their uterine (womb) lining from thickening, which then reduces the risk of endometrial (womb) cancer. HRT isn’t suitable for everyone: for example, women having treatment for breast cancer. However, for most women, the benefits are far outweighed by the risks. HRT can relieve a wide range of symptoms, including hot flushes, night sweats, anxiety and mood changes, which have a knock-on effect of improving sleep. HRT is available in a wide range of products, and it’s important that you’re given an individualised treatment plan. Low-dose vaginal oestrogen in a pessary or cream, used with regular pelvic floor exercises, can be a useful additional treatment for managing urinary symptoms that interrupt sleep.
Cognitive Behavioural Therapy
Cognitive behavioural therapy (CBT) is the most effective treatment for insomnia at the menopause. It’s a non-medical structured programme designed to give practical coping skills to reduce anxiety, promote rest and relaxation and improve sleep with lasting effect. CBT explores the relationship between physical symptoms, thoughts, feelings and behaviours. It’s available through individual or group courses, face to face or online.
Occupational adjustments
The menopause is increasingly recognised as an occupational health issue, and insomnia can have a profound effect on focus and concentration at work. It can be helpful to discuss this with a manager or occupational health department. Many organisations have a menopause policy in place with practical recommendations for supporting staff. Reasonable adjustments, such as changing start and finish times or standardising shift patterns, introducing regular breaks or adjusting the type of work, can significantly benefit sleep patterns.
About the author
Ruth Bailey is an advanced nurse practitioner, a BMS-accredited menopause specialist and Queen’s Nurse working in primary care. She’s chair of the RCN Women’s Health Forum.
Created Summer 2025
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