How to Sleep Well in Perimenopause

Women over 40 (perimenopausal) and menopausal women have unique challenges to getting a good night’s sleep compared to younger women. Here I dig into why this is so, so you can get a better understanding of how to navigate your sleep difficulties.

functional medicine, hormone balance, menopause, perimenopause, sleep, insomnia

Why do women over 40 struggle with sleep?

In a nutshell, these are the top five reasons:

  1. Sex hormone changes.
  2. Adrenal hormone dysregulation.
  3. Depression.
  4. Sleep Disordered Breathing (SDB), including sleep apnea.
  5. Fibromyalgia and other aches and pains.

Let’s dig into these one by one…

1. Sex hormone changes

Your primary female sex hormones are estrogen and progesterone.


During perimenopause, which is the decade before your periods stop completely, progesterone typically lowers first. Sometimes this happens over a long period of time, such as 8 to 12 years. Progesterone has anti-anxiety, calming, and sedative effects. The first symptoms you may feel in perimenopause are anxiety and poor sleep, which are classic signs of low progesterone. Shorter menstrual cycles (less than 28 days), PMS, and periods that start with spotting are other signs of low progesterone.


Estrogen tends to fall more quickly, typically close to menopause, which is the period of time when your menstrual cycles wind down and eventually stop. The average age for menopause is 51.  Estrogen decline often correlates with poor sleep, but this is poorly understood.

It’s not estrogen deficiency that causes poor sleep. This is demonstrated in research that shows not all women get improved sleep with estrogen replacement. It’s more likely that lower estrogen causes wild fluctuations in your pituitary hormones (LH and FSH) which affects the vasomotor center of the brain. This part of your brain regulates your blood pressure, blood vessel dilation, and heart rate. When it is unstable, it can result in fluctuations in temperature (hot flashes, sweats), and heart rate (anxiety, palpitations, adrenalin rushes).

2. Adrenal hormone dysregulation

During menopause, your ovaries retire from producing estrogen and progesterone, and your adrenal glands take over. This is a simplistic way of looking at it, but it’s important.  In order to successfully sleep well through menopause, your adrenal function must be optimal, and the signals between your brain and adrenals (HPA axis) must be “online.” In both Chinese and functional medicine, we always improve adrenal function to support perimenopause. The adrenal hormones we are concerned about are:

The adrenal – estrogen connection

Estrogen helps regulate the spike of cortisol that we experience in the morning. When estrogen declines, cortisol can rise earlier. You may start waking earlier, as early as two, three, or four AM.

In Chinese medicine, estrogen is viewed as a yin substance that cools and anchors the body. It contains (quells) anxiety, adrenalin, sweat, and heat. This is why acupuncture and Chinese herbs are often so effective to treat these symptoms.

3. Depression

What does depression have to do with menopause and sleep? There is a complex relationship between depression, estrogen, and insomnia. There are two ways this connection plays out:

  • The domino effect: When estrogen declines, you can experience changes in vaginal tissue, as well as other changes that may affect you emotionally. This can lead to depression, and depression can cause insomnia.
  • Sleep changes can happen first, because of estrogen-related vasomotor wakings, and sleep deprivation can cause depression. You may even feel apprehensive or anxious about sleep, making the whole cycle worse.

Which comes first, the chicken or the egg? Is it the estrogen decline, or the depression? Studies show that women with a history of depression are more susceptible to insomnia during menopause.

4. Sleep Disordered Breathing

Did you know that menopausal women have a 3.5% increase in what’s known as “Sleep Disordered Breathing (SDB)?” Before menopause, women have SDB less often than men. After menopause, women are just as likely as men to develop SDB.

Unfortunately, most cases of SDB in women go undiagnosed. Women’s symptoms are different than men’s. Women’s snoring can be softer, what some people refer to as “lady-like snoring.” A woman’s primary symptom from SDB is daytime fatigue and sleepiness. However, health practitioners who treat insomnia and fatigue are not always accustomed to screening women for sleep apnea and other types of SDB, unless the woman is obese. These authors write:

“Clinical studies have found that the majority of postmenopausal women who present with insomnia symptoms actually have significant obstructive sleep apnea (OSA).”

Why does SDB increase during menopause?

  • It turns out that both estrogen and progesterone improve respiration.
  • Menopause often comes with weight gain, and the extra weight in your abdomen and neck can cause breathing problems. Since obesity is on the rise, so is SDB.

5. Fibromyalgia and pain

The onset of Fibromyalgia, a widespread pain syndrome, increases significantly during menopause. It’s also much more common in women than men. After menopause, there’s a 7:1 ratio between women and men with fibromyalgia. Fibromyalgia is almost always correlated with poor sleep. It’s a catch-22 because poor sleep increases aches and pains, and fibromyalgia pain increases poor sleep. Many cases of fibromyalgia improve when sleep improves.

Other types of pain correlate with poor sleep. These include arthritis, collagen disorders, and inflammatory conditions. Frozen shoulders are more common in women than men, and more common in women over 40. Hip pain, including bursitis and greater trochanter pain syndrome, is also more common in women compared to men, and more frequent during perimenopause and menopause. Achy hips or shoulders can be sleep disruptors.

There are many ways that pain and inflammation can cause night wakings. One obvious reason is that discomfort causes night wakings. Another reason is that pain and inflammation cause internal biological stress, which can raise cortisol and adrenaline, and contribute to night waking.

What to do?

Fortunately, ALL of these five factors (sex hormone changes, adrenal dysregulation, depression, SBD, and pain syndromes) can be helped! For each one, we can gather data, do a root-cause analysis, and create a customized treatment plan. Bio-identical hormones can be part of the picture, but for some women, this is not a desirable or safe choice.

If you are over 40 and having sleep problems, please reach out, I am here for you.

I’d love your input below,

paris healing arts, doctor laura paris, dr. laura paris, dr laura paris

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One Comment

  1. Interesting website!! For many women, hormonal changes during the day are exacerbated after the sun sets, causing existing hot flashes to become more intense or triggering new hot flashes, as well as night sweats, during the evening and overnight hours. Use a supplement like gummies that make sense to your mind and body during the evening and overnight hours. – Nidra Nutrition

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