The evidence that the menopause disrupts sleep is strong and consistent. For treatment, CBT-I scores highest: multiple guidelines cite it as the first choice. Hormone therapy and prolonged-release melatonin have a reasonable evidence base but require an individual assessment with a doctor. Dietary interventions have not yet been studied sufficiently to base concrete recommendations on them.
Sleep problems are among the most common and troublesome complaints of the menopause. Changes in sleep can occur as early as perimenopause, and nearly nine in ten women consult a healthcare provider about menopausal symptoms, with sleep being a frequently cited reason. The issues involved include difficulty falling asleep, staying asleep, or waking up too early.
A major culprit is hot flushes and night sweats: these wake women in the middle of the night and fragment their sleep. Yet those vasomotor symptoms do not explain everything. Hormonal changes, psychological factors, and broader social circumstances also play a role. On top of that, simply getting older is a factor: objective sleep research shows that it can sometimes be difficult to determine how much of the deterioration in sleep is due purely to the menopause and how much to ageing in general. Depressed mood and anxiety make the picture worse: they are associated with both poorer sleep and more severe hot flushes, and those three factors influence one another in turn.
The treatment with the strongest evidence base is cognitive behavioural therapy for insomnia, abbreviated CBT-I. This is a structured approach in which a therapist helps to change sleep habits and negative thoughts about sleep. CBT-I is the first-line treatment for insomnia in menopausal women, regardless of whether hot flushes or mood complaints are also present. It should therefore be preferred over medication as a first step.
Hormone therapy helps with sleep complaints, particularly when hot flushes and night sweats dominate the sleep disturbance: by dampening those, sleep also improves. However, hormone therapy is not suitable for every woman, and the benefits must be weighed against risks, such as a slightly increased risk of certain conditions. This is a consideration to work through with a doctor. A newer option is neurokinin B antagonists (of which fezolinetant is the best-known example): a new class of medications that recently showed positive results for sleep problems around the menopause, but for which long-term data are still lacking.
For women aged 55 and older with insomnia, guidelines cite prolonged-release melatonin as the first choice for pharmacological treatment. This agent has good tolerability and improves both sleep and daily functioning. Certain antidepressants can also help with sleep problems, but are most relevant when depression or anxiety is present at the same time, and the evidence for this is not straightforward. Finally, there is interest in dietary interventions such as tryptophan-rich foods or tart cherry juice: more than half of the studies examined reported an improvement in subjectively experienced sleep quality, but the methodological quality of this research was generally low and the studies are difficult to compare with one another. Firm recommendations for specific foods cannot yet be made.
Based on four reviews/guidelines (PMID 39820156, 26653408, 30098758, 32880197), an RCT context relating to HT (PMID 31466381), and a systematic review on nutrition (PMID 37695299). The strongest claims about CBT-I and the relationship between menopause and sleep come from multiple guidelines and reviews; the evidence for newer agents such as fezolinetant and for dietary interventions is more limited.