Insomnia in midlife
Why You’re Wide Awake at 3am: Insomnia and Menopause
Written by Dr. Madeleine Clark, Naturopathic Doctor, Menopause Society Certified Practitioner
Insomnia is one of the most common complaints among women in perimenopause and menopause, and one of the most frustrating. Whether it’s trouble falling asleep, staying asleep, or waking too early, poor sleep can ripple into every area of your life.
And you’re not alone. Research shows that women in midlife are more likely to sleep fewer than 7 hours and more likely to wake up feeling unrested, even after spending what should be “enough” time in bed.
Let’s break down why this happens, how we assess it, and what actually helps.
What Is Insomnia?
Insomnia is defined as a sleep complaint that occurs at least 3 times per week for at least 3 months, and is associated with distress or impaired daytime function.
In a recent study of midlife women:
27% of women had trouble falling asleep
35% reported difficulty staying asleep
Many also described poor sleep quality not feeling rested even after a full night
Why Does Sleep Get Worse in Menopause?
It’s rarely just one thing. Sleep disruption can come from biological, behavioral, and emotional shifts that occur in perimenopause and aging.
Common contributors include:
Hormonal changes (lower estrogen, progesterone, and melatonin)
Mood swings, anxiety, depression, and stress
Vasomotor symptoms (VMS): hot flashes and night sweats
Primary insomnia (psychophysiologic)
Secondary insomnia (related to medical or psychiatric conditions)
Lifestyle, environmental, and behavioral habits
The SWAN study of perimenopausal women found that sleep disruption was more strongly associated with hot flashes (VMS) than with hormone levels like FSH or estradiol. Anxiety also emerged as one of the strongest predictors of poor sleep quality.
Poor or broken sleep is more than a nuisance, it can become a chronic stressor that affects your physical resilience, emotional wellbeing, and even accelerates aging.
How Do We Diagnose Insomnia?
Sleep is subjective, so tracking matters. Sometimes people feel like they haven’t slept even if they’re getting more than they realize.
To assess insomnia more accurately, we may ask you to complete a sleep diary for 1–2 weeks. This helps track:
Bedtime and wake time
Total time in bed vs actual sleep
Nighttime wakings
Variability in sleep from day to day
We also want to rule out other sleep disorders, including:
Obstructive sleep apnea (OSA)
Restless leg syndrome (RLS)
Periodic limb movement disorder (PLMD)
What Helps: Treatment & Support for Sleep
🔹 Start with Sleep Hygiene
While good sleep hygiene is essential, it may not be enough for chronic insomnia. In fact, the SWAN study showed that sleep hygiene alone was not associated with better sleep outcomes in midlife women. But it’s still a necessary foundation.
🛏 Bed Is Only for Sleep and Sex
Your bed should be a cue for sleep—not scrolling, reading, or overthinking.
A helpful and hilarious rule: ask yourself, “Am I sleeping or having sex?”
If not, get out of bed.
Start by moving nighttime reading or phone time to the couch. Even a few minutes of change per night can help reset your sleep associations.
📱 Limit Screens for 30 Minutes Before Bed
Blue light suppresses melatonin and stimulates your brain. Try:
A calming activity like stretching, journaling, or reading (outside of bed!)
🧠 Set Aside Worry Time
If racing thoughts keep you up, schedule “worry time” earlier in the day. Journaling or writing down to-dos before bed can help your brain stop looping.
❄️ Keep Your Room Cool
Your body naturally drops its temperature to prepare for sleep.
Aim for 18–19°C (65–67°F)
Open a window or use layered blankets to manage temp
Overheating from hot flashes? Cooling pillows and fans may help, and dressing in layers
🌘 Keep Your Room Dark
Use blackout blinds or curtains
Cover electronics that emit light
Keep phones and tablets out of the bedroom when possible
🔇 Keep Your Room Quiet
Noise disrupts deep sleep stages. Try:
Silicone earplugs
White noise machines or fans
Moving electronics out of the room
When Sleep Hygiene Isn’t Enough
Sleep hygiene may be the first step, but it’s not the full picture—especially if insomnia has been persistent for months or years.
Other evidence-informed strategies include:
Relaxation techniques: meditation, yoga, breathwork
Sleep restriction
CBT-i (Cognitive Behavioral Therapy for Insomnia)
Nutritional and herbal supports
What About Hormone Therapy and Medications?
There’s growing evidence that hormone therapy (HT) may improve sleep quality in midlife, especially when hot flashes and night sweats are the root cause. However, HT is not currently indicated as a primary treatment for insomnia.
That said, if vasomotor symptoms are waking you up, hormone therapy can be an important part of your sleep strategy.
What about medications?
In some cases, medications may be used to target:
Anxiety, stress, or depression (which often overlap with sleep and menopause symptoms)
Hot flashes that are interrupting sleep
GABA-related medications (selective agents that help quiet the nervous system)
As a naturopathic doctor, I take a comprehensive, personalized approach. That means:
Reviewing what you've already tried
Supporting your body with targeted supplementation
Addressing lifestyle and environmental contributors
And working with you to create a plan that feels aligned and sustainable
The Bottom Line
Sleep is not optional. It’s a biological necessity, and in midlife, your body may need new strategies to get the rest it once had no trouble finding.
Let’s Create a Sleep Plan That Works for You
If your nights are restless and your days are foggy, it’s time to get the help you deserve. Together, we’ll look at your hormones, stress load, environment, and nervous system and build a plan to help you finally sleep through the night.
Book an appointment to get started.