Sleep problems in midlife women: causes and fixes

Key takeaways

• The NHS lists difficulty falling or staying asleep as a common perimenopause symptom, often worsened by night sweats.
• Insomnia lasting three months or more is long-term insomnia. It deserves proper treatment, not just more tea in the morning.
• Loud snoring, gasping or pauses in breathing at night, with daytime sleepiness, can mean sleep apnoea, which needs testing.
• Cognitive behavioural therapy (CBT) helps sleep problems, low mood and hot flushes, according to the NHS.
• Sleeping pills are for short periods only, because of side effects and the risk of dependence.

Why does sleep fall apart in midlife?

See, I'll tell you what I hear almost every single day: "Doctor, I fall asleep fine, but I'm awake at 3 am and my mind starts running." That pattern is very typical of the perimenopause years. And the misunderstanding is that there must be one cause. There rarely is. Poor sleep in midlife is usually like a tangled ball of wool, with three or four threads pulling at once.

The NHS describes trouble falling or staying asleep as a common symptom of perimenopause and menopause, often made worse by night sweats. Symptoms can last 7 to 9 years, sometimes longer, and change over time. Hot flushes may ease and be replaced by low mood or anxiety, which also disturb sleep.

Common causes in midlife women:

And it never stays in the bedroom. A woman who hasn't slept properly for months carries that tiredness into her job, her marriage and every conversation with her children.

Is it insomnia, or something else?

The NHS defines insomnia as regularly having trouble sleeping. Short-term insomnia lasts under three months. Long-term insomnia lasts three months or more. Most adults need about 7 to 9 hours.

Some sleep problems are not insomnia at all:

Sleep apnoea. This is where breathing stops and starts during sleep. The NHS lists loud snoring, gasping or choking noises, waking often, morning headaches and daytime tiredness as symptoms, with weight gain and a larger neck as risk factors. Weight around the middle often increases in midlife, so this is worth considering. Untreated sleep apnoea raises the risk of high blood pressure, stroke, type 2 diabetes and heart disease. It is diagnosed with an overnight sleep study, often done at home.

Restless legs. An uncomfortable urge to move the legs in the evening can be linked to low iron, which is common after years of heavy periods.

If you have any of these, tell your doctor. They need specific treatment.

What can I change tonight?

These steps are based on NHS insomnia advice, adapted for Indian homes.

• Fix your wake-up time. Get up at the same time every day, including Sundays. This matters more than bedtime.
• Go to bed only when sleepy. Lying awake in bed trains the brain to link bed with wakefulness. If you are awake for a long time, get up, sit in dim light, and return when sleepy.
• Stop tea and coffee six hours before bed. The NHS advice is to avoid caffeine, alcohol and smoking for six hours before sleep. That means the 5 pm chai is often the culprit.
• Eat dinner earlier and lighter. A heavy 10:30 pm dinner, common in Mumbai households, can worsen reflux and night sweats.
• Keep the room cool and dark. Cotton sheets, a fan or AC, curtains that block street light. Keep a glass of cool water and a spare cotton nightdress by the bed for night sweats.
• Put the phone away. Not in bed, not for "just five minutes" of reels.
• Exercise in the day. Morning walks and strength training help sleep, but avoid hard exercise within four hours of bedtime.
• Avoid daytime naps if you struggle at night.
• Wind down for an hour. A warm bath, reading, or slow breathing.

If you share a room with a partner who snores or keeps the TV on, it is reasonable to discuss separate arrangements for a while. Good sleep is not a luxury. It is medicine.

Does CBT for insomnia really work?

Yes. The NHS recommends cognitive behavioural therapy (CBT) for sleep problems, and notes it can also help with low mood, anxiety and hot flushes in menopause. CBT for insomnia teaches you to:

• Change the worrying thoughts about sleep that keep you awake
• Use the bed only for sleep, so the brain relearns the link
• Gradually build a steady sleep window rather than spending long hours awake in bed

It can be done face-to-face or through structured online programmes. It takes a few weeks of effort, but the benefits tend to last because you have learned a skill, like learning to swim.

What about medicines and hormone therapy?

Sleeping pills. The NHS says doctors rarely prescribe them for insomnia because of serious side effects and the risk of dependence. If used, it is usually for a few days or weeks at most, when insomnia is severe and other treatments have not worked. Over-the-counter sleep aids should not be used for more than one or two weeks.

Hormone therapy. When poor sleep is driven by night sweats and hot flushes, treating those symptoms often improves sleep. Hormone therapy is one option, and there are non-hormonal choices too (see non-hormonal treatments for hot flushes). These are prescription decisions made after assessment of your personal risks and benefits.

Supplements and herbal products. The NHS advises checking with a doctor before taking herbal remedies, as some interact with other medicines.

How I approach this at Dr Tvacha

At Cocoon × Dr Tvacha in Thane West, sleep is one of the symptoms I go through carefully in the long consultation within The Right Stop Programme. I look at hormones, mood, bladder, breathing and habits together, order only the tests needed, and refer you for a sleep study or therapy when that is what will help.

Written by

Dr Anagha KarkhanisGynaecologist and Fertility Specialist · Reg. No. 2006/02/1187

Leads midlife women's health at Cocoon × Dr Tvacha, Thane.