Insomnia in Menopause: Understanding the Causes, Consequences and How to Treat

The menopausal transition is one of the most challenging phases in a woman's life, marked by profound hormonal changes that directly affect quality of life. Among the various symptoms, insomnia in menopause stands out as one of the most frequent and debilitating complaints. Studies indicate that approximately 50% of menopausal women face sleep disorders, a prevalence significantly higher compared to women of reproductive age.

Why is insomnia so common in menopause?

Insomnia during menopause has multifactorial causes, involving hormonal changes, psychosocial factors, aging, and circadian axis dysfunctions. The "3 P's" model of insomnia (predisposing, precipitating, and perpetuating) applies perfectly to this context:

Predisposing: history of poor sleep, aging, emotional vulnerability.
Precipitating: hormonal changes, hot flashes, night sweats, pain, mood disorders.
Perpetuating: dysfunctional sleep patterns, nighttime anxiety, hypervigilance.

The impact of hormones on women's sleep

The decline in estrogen and progesterone during menopause directly affects sleep regulation:

Estrogen

Reduces sleep latency and promotes restorative sleep
Its deficiency is linked to sleep fragmentation

Progesterone

Has anxiolytic and sedative effects
The decline of this hormone increases anxiety and cognitive hyperactivity

Melatonin and aging

Melatonin production also decreases with age, worsening sleep disorders. This reduction, combined with sex hormonal changes, contributes to insomnia with difficulty initiating and maintaining sleep.

Hot flashes and night sweats

Approximately 80% of menopausal women report vasomotor symptoms. These symptoms compromise sleep by causing:

Abrupt awakenings
Fragmented sleep
Direct impact on the feeling of rest upon waking

Relationship between insomnia and mood disorders

Insomnia and mood disorders have a bidirectional relationship:

Women with anxiety or depression have a higher risk of insomnia
Insomnia itself can trigger or worsen these disorders
This creates a vicious cycle of intrusive thoughts and fear of not being able to sleep

Risks associated with insomnia in menopause

Chronic insomnia is not just uncomfortable. It is associated with an increased risk of:

Hypertension
Metabolic syndrome
Type 2 diabetes
Depression
Cognitive decline
Dementia

These effects are related to increased inflammatory markers and dysfunction of the hypothalamic-pituitary-adrenal axis.

How to treat insomnia in menopause?

Treatment should be integrative and evidence-based. The main approaches include:

1. Cognitive Behavioral Therapy for Insomnia (CBT-I)

First-line treatment
Superior results to medications

2. Menopausal Hormone Therapy (MHT)

Replacement of estrogen and micronized progesterone
Can alleviate hot flashes and improve sleep architecture

3. Extended-release melatonin (2mg)

Especially effective for women over 55 years old

4. Judicious use of hypnotics (Z-class)

Only short-term use
Due to risks of dependence and adverse effects in elderly women

Conclusion

Insomnia in menopause is a reflection of a broad dysregulation of the hormonal, emotional, and circadian axes. To ensure effective treatment, a personalized and science-based approach is essential.

Professionals who care for women in this phase must master the fundamentals of this condition to offer safe, empathetic, and high therapeutic impact care.

Authored by Dr. Francisco Tostes, Scientific Director of SottoPelle Brasil