Why do I sleep less well during the menopause?
“I used to sleep through the night, but now I wake up at three or four.” “I get too hot, which keeps me awake, and then I can’t get back to sleep.” “I sleep for practically the same number of hours, but I wake up feeling exhausted.”
Many women readily recognise this change. They don’t always know exactly when it started, but they do notice that during perimenopause or the menopause, their sleep patterns are no longer the same.
The link exists and is well documented. However, it is too simplistic to attribute it solely to ‘hormones’. During this stage, hormonal changes, hot flushes and night sweats may occur, but so too can insomnia, certain mood changes, pain, urinary symptoms and specific sleep disorders such as obstructive sleep apnoea or restless legs syndrome.
That is why, for Dr Alejandro Melcón Villalibre, head of the Neurological Sleep Disorders Unit at the Publio Cordón Memorial Hospital, the truly useful question is not just whether the menopause can affect sleep, but what is causing that particular woman to sleep worse.
‘The fact that a woman starts sleeping less well at the same time as she goes through the menopause does not yet tell us why she is sleeping less well,’ explains Dr Melcón Villalibre. ‘She may be woken by a hot flush, she may have developed insomnia, there may be a case of apnoea that had not previously been detected, or several factors may be at play. The important thing is to identify what is actually disrupting her sleep.”
This distinction is crucial because the same complaint — “I’ve been sleeping terribly for a few months now” — can stem from different mechanisms and, therefore, may also require different solutions.
Changes in sleep patterns can begin before the menopause
Medically speaking, the menopause is defined as twelve consecutive months without a period, provided there is no other explanation for this. However, the changes leading up to it begin earlier, during what is known as perimenopause or the menopausal transition.
Over the course of these years, ovarian function gradually changes and hormone levels fluctuate. Periods may become irregular, and many women experience what are known as vasomotor symptoms, primarily hot flushes and night sweats.
Sleep patterns may also change.
The European Society of Endocrinology’s clinical guidelines on the menopause and perimenopause list sleep problems amongst the common manifestations of this stage and highlight a particularly important point: they may be linked to vasomotor symptoms, but they can also occur independently of them.
This helps to explain why two women going through a similar hormonal transition may sleep in completely different ways.
Why can a hot flush wake us up?
A hot flush is not simply a matter of ‘feeling hot’.
During the menopausal transition, changes occur in the brain mechanisms responsible for regulating body temperature. These include the hypothalamus, a small region of the brain involved, amongst other functions, in thermoregulation and various processes related to sleep.
In some women, the temperature range that the body interprets as comfortable becomes narrower. A small variation can then trigger a response designed to dissipate heat: blood flow to the skin increases, sweating occurs, and the sensation of heat can become intense enough to wake the person up.
Research allows us to quantify the extent to which this occurs. A clinical trial published in the *American Journal of Obstetrics & Gynaecology* studied 141 peri- and post-menopausal women with frequent hot flushes. They experienced an average of 10.8 vasomotor episodes per day, of which approximately 2.6 were night-time hot flushes severe enough to wake them. Furthermore, 62.6 per cent reported waking up for this reason at least twice every night.
Hot flushes, therefore, can be a very real cause of sleep fragmentation. But here lies a distinction that Dr Melcón Villalibre considers particularly important.
‘A hot flush may be the stimulus that triggers waking, but that does not mean it alone explains the whole sleep problem,’ he points out. ‘There are women who wake up, the episode passes, and they fall back asleep within a few minutes. For others, the hot flush ends, but they remain awake for a long time. That’s when we have to ask ourselves what is keeping the patient awake.”
Would you like more information about sleep disorders during the menopause?
Find out how the possible causes of fragmented, non-restorative or persistent sleep during perimenopause and the menopause are assessed.
When the hot flush subsides, but we’re still awake
Let’s imagine two women who wake up at three in the morning because of a hot flush.
One takes off her covers, waits a few minutes and drifts back to sleep. The other does exactly the same, but once the sensation of heat has gone, she remains wide awake. She looks at the clock, works out how long until she has to get up and starts thinking about how exhausted she’ll be the next day.
The trigger was the same. What happens next, however, is not.
When this situation repeats itself over weeks or months, a vicious circle can develop in which the very worry about sleeping begins to contribute to the problem. The woman goes to bed anticipating what the night will be like, pays excessive attention to any time she wakes up, and consciously tries to ‘force’ herself to sleep.
She may also try to compensate by going to bed earlier, staying in bed for longer or taking longer naps. These are perfectly understandable responses, but some may end up reinforcing the association between bed and wakefulness, effort and frustration.
Dr Melcón Villalibre explains that this distinction between the onset and the perpetuation of the problem is essential for understanding certain types of insomnia: ‘We need to distinguish between what triggered the insomnia and what is perpetuating it. A symptom of the menopause may trigger a period of waking up, and, over time, mechanisms specific to insomnia may develop. When that happens, treating only the initial trigger may not be enough to restore sleep.”
That is why there is no contradiction when a woman explains that her hot flushes have improved, but she continues to wake up for long periods. The problem may have evolved.
Sleeping for eight hours does not necessarily mean you’ve had a good night’s sleep
We also tend to judge sleep almost exclusively by the number of hours.
However, a woman may spend seven or eight hours in bed and wake up feeling distinctly exhausted. Duration matters, but it does not fully describe the quality of rest.
As the specialist explains, ‘we don’t judge sleep solely by the number of hours. We also need to know whether it has been uninterrupted, whether it has allowed the person to recover, and how they feel during the day’.
During the night, micro-awakenings may also occur – brief moments of brain activity so fleeting that they leave no conscious memory. A person may be convinced that they have slept for hours without interruption, yet their sleep may have been repeatedly fragmented.
This phenomenon is particularly relevant when there are respiratory or motor disorders capable of disrupting sleep without fully waking the person.
Not all night-time awakenings during the menopause are down to hormones
Precisely because poor sleep is common at this stage, there is a risk of attributing any night-time problem to the menopause and failing to investigate other possibilities.
One such possibility is obstructive sleep apnoea.
During an episode of apnoea, the upper airway narrows or temporarily closes. Airflow decreases, the body increases its respiratory effort, and the brain may trigger small arousals that allow effective breathing to resume.
These episodes can occur numerous times throughout the night without the person remembering having woken up.
In women, moreover, sleep apnoea does not always fit the classic stereotype of someone who snores very loudly and falls asleep during the day. It can also manifest itself through frequent awakenings, poor-quality sleep, tiredness, insomnia or a headache upon waking.
That is why Dr Melcón Villalibre considers it important to ask specifically about certain signs: ‘If a woman seeks medical advice because she wakes up frequently and also snores regularly, her partner has noticed pauses in her breathing, she wakes up feeling as though she is suffocating, or she experiences marked daytime sleepiness, we must consider that there may be more to it than just the changes associated with the menopause.’
This does not mean that every woman with insomnia needs to be assessed for possible apnoea. It means that the context alters the significance of these awakenings.
Feeling tired and feeling sleepy are not exactly the same thing
Another useful distinction arises when a patient says that during the day she feels ‘exhausted’.
In everyday language, we often use the terms ‘tired’ and ‘sleepy’ as if they were interchangeable, but clinically they describe different experiences.
Fatigue is perceived as a lack of energy, physical or mental exhaustion, or difficulty maintaining one’s usual level of activity. Drowsiness, on the other hand, involves a real tendency to fall asleep.
One woman may feel completely exhausted after a bad night’s sleep and yet be unable to sleep during the day. Another may fall asleep involuntarily whilst reading, watching television or during a sedentary activity.
‘When a patient says she is very tired, we need to know exactly what she means,’ explains Dr Melcón Villalibre. ‘Feeling lacking in energy is not the same as having an irresistible urge to fall asleep. That difference provides information and helps us to pinpoint the possible causes.’
Furthermore, tiredness during the menopause may have other medical, emotional or pharmacological causes. Not all fatigue is necessarily caused by a poor night’s sleep.
When it’s your legs that make it hard to fall asleep
Some women describe a strange sensation when it’s time to go to bed: a discomfort in their legs that’s hard to pinpoint, and a strong urge to move them. Staying still makes the sensation worse, whilst walking or moving their legs provides temporary relief.
This pattern may be indicative of restless legs syndrome.
It is not the same as the periodic movements of the limbs during sleep. These occur once the person has already fallen asleep and may go completely unnoticed by them. In some cases, they are accompanied by brief awakenings and contribute to a fragmented night’s sleep.
The subjective experience may be similar — ‘not getting any rest’ — but the mechanism is different. And recognising that difference is what enables the assessment to be properly directed.
Mood and sleep are closely interlinked
The menopausal transition does not occur in isolation from the rest of a woman’s life either.
It may coincide with significant family, personal or professional changes and, in some women, with a greater vulnerability to certain emotional symptoms.
Sleep and mood influence one another. Poor sleep over a period of months can increase irritability, make it harder to concentrate and reduce the ability to cope with everyday demands. In turn, persistent worry, anxiety or certain depressive symptoms can make it difficult both to fall asleep and to stay asleep.
That is why it is not always helpful to try to decide whether the problem is ‘hormonal’ or ‘emotional’, as if the two explanations were mutually exclusive.
A review published by specialists at Stanford University on sleep and the menopause describes precisely these issues from a biopsychosocial perspective, in which the menopausal state, vasomotor symptoms, hormonal changes and psychological and social factors may all play a role simultaneously.
A woman does not sleep in a laboratory: she sleeps within the context of her own life. And that life is also part of her medical history.
Headaches, the menopause and sleep: when various factors are interlinked
During perimenopause and the menopause, certain headache patterns – particularly migraines – may also change. Hormonal fluctuations can influence their frequency or intensity and, when attacks are not well managed, the pain can make it difficult to fall asleep, cause night-time awakenings or result in less restful sleep.
As Dr Melcón Villalibre explains: ‘When a menopausal patient experiences frequent headaches and also sleeps poorly, it does not always make sense to examine both problems separately. Pain can disrupt sleep and, in turn, insufficient rest can increase vulnerability to certain types of headache.”
Situations of this kind underscore the need for a multidisciplinary approach. Within the Neurology Department at the Publio Cordón Memorial Hospital, the Headache, Migraine and Women’s Health Unit, led by Dr María Nuria González García, works in a coordinated manner on cases where headaches, hormonal changes and other neurological factors may be jointly affecting quality of life and sleep.
Poor sleep is common, but that doesn’t mean it should be accepted as normal
Sleep difficulties during the menopausal transition are very common. A meta-analysis combining 37 studies and 29,284 women estimated that approximately half experienced poor subjective sleep quality, although the frequency varied according to age, stage of the menopause, the region studied and other factors.
However, just because a problem is common does not mean it is unimportant.
Longitudinal research is also seeking to understand what happens when insomnia persists for years. In the Study of Women’s Health Across the Nation (SWAN), which followed 2,964 middle-aged women for up to 22 years, approximately 23 per cent exhibited a pattern of persistently high insomnia symptoms. This group subsequently showed a higher incidence of cardiovascular events than women with low levels of insomnia symptoms.
It is important to interpret this finding correctly: it represents an association observed over time, not proof that insomnia alone causes cardiovascular disease.
Its significance lies elsewhere. It reminds us that a persistent sleep problem should not simply be dismissed as a minor nuisance associated with the menopause.
Do I need a sleep study?
Not necessarily. Most cases of insomnia are initially assessed through a detailed medical history. It is important to find out when the difficulties began, what happens at bedtime, what causes the patient to wake up, how long these episodes last, what the patient’s daily routine is like, and how they feel during the day.
A sleep study becomes useful when there is a specific issue that needs to be observed objectively during the night.
The head of the Neurological Sleep Disorders Unit explains it as follows: ‘Polysomnography isn’t used to prove that a patient sleeps poorly; she’s already telling us that. We prescribe it when we need to answer a specific question by observing sleep, for example, if we suspect apnoeas, certain movements or other disturbances capable of fragmenting it.”
During a polysomnography, variables such as brain activity, eye movements, muscle tone, breathing, heart rate and oxygenation are recorded simultaneously. This allows us to identify aspects of sleep that the patient herself cannot perceive.
That is why the test is not a general check-up on sleep. Its usefulness depends on there being a prior clinical suspicion that justifies carrying it out.
The consultation begins long before a sensor is fitted
Sleep medicine now has highly sophisticated tools at its disposal, but diagnosis still begins with something much simpler: listening carefully.
It is important to establish when sleep patterns began to change, whether the problem coincided with the onset of vasomotor symptoms, whether it is actually hot flushes that cause the patient to wake up, and what happens afterwards.
It is also important to ask about snoring, breathing pauses, discomfort in the legs, sleep schedules, medication and how it affects the patient during the day.
Dr Melcón Villalibre sums up this process well: ‘A woman might simply say, “I’ve been sleeping worse since the menopause.” Our job is to turn that statement into clinical information: what happens when she goes to bed, what wakes her up, how long it takes her to fall back asleep, how she breathes during the night, whether other symptoms appear, and how she feels the following day. Once we’ve properly pieced together the problem, we also begin to understand what we can do.”
This reconstruction avoids two opposing mistakes: carrying out unnecessary tests or putting up with a treatable problem for years simply because it coincides with a stage in life when poorer sleep is common.
Frequent does not mean inevitable
For one woman, hot flushes may be the main cause of waking up. Another may have developed persistent insomnia. A third may suffer from sleep apnoea, restless legs syndrome or several problems at the same time. Pain, emotional state, certain medicines or other medical conditions may also play a part.
That is why treatment depends on whatever is disrupting sleep in each individual case and, where necessary, may require the involvement of different medical specialities.
Dr Melcón Villalibre summarises the clinical approach in simple terms: ‘We shouldn’t assume that poor sleep is simply the price we pay for the menopause. If the problem persists, affects daily life or symptoms appear that suggest another disorder, it is worth investigating. The issue is not just how much a woman sleeps, but why her sleep is no longer restorative.”
The initial question — “Why do I sleep worse during the menopause?” — therefore has no single answer.
But finding the right answer for each woman is precisely what allows us to stop viewing the problem as something inevitable.
Frequently Asked Questions
Do hot flushes account for all the times you wake up during the menopause?
No. They can be a major trigger and, in some women, cause them to wake up several times a night, but insomnia, sleep apnoea, restless legs syndrome, pain or other factors may also be present.
Why am I still having trouble sleeping even though my hot flushes have improved?
This is because the cause of a sleep problem and the mechanisms that subsequently perpetuate it are not always the same. When persistent insomnia develops, it can continue even if the vasomotor symptoms subside.
Does sleeping for eight hours mean you’ve had a good night’s sleep?
Not necessarily. As well as the duration, the continuity and quality of sleep are also important. Some disorders cause micro-awakenings that the person does not remember and which can impair rest.
Do I need a polysomnography if I’ve been sleeping less well since the menopause?
Not as a matter of routine. It is indicated when the patient’s medical history suggests a respiratory, motor or neurological disorder that needs to be objectively assessed during sleep.
Informative content
The information contained in this article is provided for information and educational purposes only. It is not a substitute for an individual medical assessment, nor does it allow a diagnosis to be made based on the symptoms described.
The information in this article is provided for general awareness and does not replace an individualised medical assessment.
