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What to do next · Sleep

Sleep: what to do next

Evidence-checked · sources listedSources

Information for better conversations, not a diagnosis. This is research with sources, not medical advice. Talk to your clinician about your situation.

What this often points to

Midlife sleep trouble usually has more than one cause. The three to sort out are night sweats, insomnia, and a sleep disorder such as sleep apnea.

  • Night sweats. The Menopause Society's 2022 statement says that during the menopause transition, women with hot flashes and night sweats "are more likely to report disrupted sleep" (Level I) 1. A night sweat is a hot flash that happens during sleep 2.
  • The hormone picture. In perimenopause the ovaries' hormone output becomes "erratic", with "less-frequent release of an egg (ovulation)", per The Menopause Society 2. The Society also describes estrogen levels that fluctuate during perimenopause 2. Over the transition, the FDA says the body "slowly produces less of the hormones, estrogen and progesterone" 3. Testosterone follows a different, gradual path: it declines during the reproductive years, not suddenly at menopause 4. The Global Consensus finds insufficient data to use testosterone for any symptom other than low desire with distress after menopause, and that includes sleep 4.
  • Insomnia that runs on its own. Trouble falling or staying asleep can become its own habit loop, even after the sweats ease. That's what CBT for insomnia (CBT-I) targets 56.
  • Sleep apnea. Breathing that stops and starts during sleep, loud snoring, or gasping are signs to raise with a clinician. The NHLBI notes that insomnia, fatigue and headaches are listed as sleep apnea symptoms that are more common in women 7.

A calm, short read from the National Institute on Aging (NIH): Sleep Problems and Menopause: What Can I Do? It looks at how night sweats, mood changes and the other demands of midlife can pile onto sleep. The NIA says sleep aids may help for a short time but aren't a long-term fix for insomnia, and it sets out bedtime habits worth trying. It also links a fact sheet on sleep findings from the NIH-funded SWAN study. Not endorsed. No affiliate links.

Can a blood test confirm perimenopause? Usually not. ACOG says: "You probably don't need hormone testing." Your age, symptoms and period changes usually tell the story. Testing may be offered if you're under 45 with bleeding changes, especially under 40 8. NICE advises against hormone and ovarian tests to identify perimenopause at 45 or over 9.

What to track for 2 weeks

  • Lights-out time and get-up time.
  • About how long it took to fall asleep, and how many times you woke.
  • Whether a night sweat woke you, or you woke and then felt hot. Both count; note which.
  • How rested you feel, 0–10, each morning.
  • Naps, caffeine and alcohol, with times.
  • Snoring, gasping or pauses in breathing. Ask a bed partner, or use a phone recording.
  • Your period, plus mood and any hot flashes during the day.
  • Medicines and supplements, including anything taken for sleep.

Questions to ask your clinician

  1. "Do my wake-ups line up with night sweats, or does this look like insomnia on its own?"
  2. "Can you refer me for CBT for insomnia (CBT-I), whether in person, by phone or digital?"
  3. "Should I be checked for sleep apnea? Would a sleep study make sense?"
  4. "If night sweats are the main driver, which hormone or non-hormone options fit my history?"
  5. "Could any of my medicines or supplements be affecting my sleep?"

The options on the table

These are the authorities' own grades and words. They aren't a ranking for you.

For insomnia itself

AASM: Strong recommendation
CBT for insomnia (CBT-I) The American Academy of Sleep Medicine's 2021 guideline recommends multicomponent CBT for insomnia for chronic insomnia in adults (strong recommendation) 5. Its April 2026 guideline suggests starting with CBT-I on its own (conditional recommendation, low-certainty evidence), and a guideline author quoted in the Academy's release called CBT-I by itself "the most efficacious first-line treatment for insomnia" 6.

When night sweats are driving it

Menopause Society: Level II
Hormone therapy The Menopause Society 2022 says hormone therapy "improves sleep in women with bothersome nighttime VMS by reducing nighttime awakenings" and that estrogen "may have some effect on sleep, independent of VMS" (Level II) 1. It calls hormone therapy "the most effective treatment" for hot flashes and night sweats 1. ACP 2026 rates it first-line for hot flashes (strong recommendation, high certainty) 10. Contraindications and label changes are in the hot flashes path.
Menopause Society: Level II
Progesterone alone The Menopause Society's 2022 statement reports that micronized progesterone "significantly decreases VMS (hot flashes and night sweats) compared with placebo and improves sleep" (Level II). It also notes there are no long-term results, and that progestogen use without estrogen for this is off-label 1.
Menopause Society: Level I
CBT for hot flashes and night sweats The Menopause Society's 2023 statement grades cognitive behavioral therapy (CBT) at Level I for hot flashes and night sweats 11.
Menopause Society: Not recommended (Level II)
Cooling techniques and avoiding triggers Cooling techniques and avoiding triggers were not recommended for reducing hot flashes (Level II) 11. A cooler room may still help you feel more comfortable. It just wasn't shown to cut the number of flashes.
Elinzanetant (Lynkuet) In the OASIS 1 and 2 trials, sleep disturbance scores improved along with hot flashes 12. It's a prescription medicine with label warnings, listed below 13.

Label warnings to know (FDA label on DailyMed, checked Oct 22, 2026)

  • Lynkuet (elinzanetant). No boxed warning. Its label says:
    • It must not be used in pregnancy, because it can cause pregnancy loss.
    • It can cause sleepiness and other nervous system effects (11.9% of women on it vs 3.5% on placebo in trials). Don't drive or do hazardous activities until those effects have passed.
    • It calls for liver blood tests before starting and during treatment.
    • Since August 2026, it warns of a potential risk of seizure. Grapefruit juice and some medicines interact with it 13.

What the research tested

Telephone CBT-I in midlife women with hot flashes (MsFLASH, JAMA Internal Medicine, 2016). 106 women aged 40 to 65 with insomnia and hot flashes had 6 phone-based CBT-I sessions over 8 weeks, or menopause education.

  • Insomnia severity fell 9.9 points with CBT-I vs 4.7 with education.
  • 70% vs 24% reached the no-insomnia range at 8 weeks, and 84% vs 43% at 24 weeks.
  • Hot flashes didn't become less frequent, but they got in the way of daily life less 14.

What it tested: structured CBT-I by phone. Limitation: it's a small trial, and the comparison was education, not another active treatment.

Valerian for sleep quality in postmenopausal women (Taavoni, Menopause, 2011). 100 postmenopausal women aged 50 to 60 with insomnia took concentrated valerian extract or placebo twice daily for 4 weeks.

  • Sleep quality, on a standard questionnaire, changed significantly more with valerian than with placebo.
  • 30% vs 4% showed improved sleep quality 15.

What it tested: valerian extract against placebo, with sleep quality measured by questionnaire. Limitation: it's a small, 4-week trial in one country, and it measured sleep by self-reported scores rather than a sleep study.

Limitation

Most sleep trials in midlife women are small and short. They also measure sleep by self-report more often than with sleep studies. Your 2-week record helps your clinician tell sweats, insomnia and apnea apart.

Supplements

When you're awake at 3 a.m., a bottle of melatonin looks like the easy answer. Here's what the research found for sleep, one ingredient at a time. Very little of it was done in women at midlife specifically.

How we label evidence: Studied, some benefit means at least some randomized trials found a benefit, usually small or short. Mixed results means trials disagree. Little evidence means few studies, or no clear benefit over placebo. The labels describe the research. They are not recommendations, and the list is not a ranking.

The FDA doesn't approve supplements for safety before they're sold 16.

Melatonin

Little evidence

Safety: NCCIH says it looks relatively safe short term, but its long-term safety hasn't been established. Anyone taking medicine should check with a provider before using it 1718.

What the research found

A 2021 meta-analysis pooled 8 study groups of melatonin in 812 menopausal women. Melatonin brought no clear improvement in sleep quality, mood or hot flashes 19. One score, for physical symptoms, improved when 4 trials were pooled 19. Outside menopause, NCCIH says melatonin may help people fall asleep a bit faster, but two clinical guidelines (2017 and 2019) recommended against it for chronic insomnia 17.

Valerian

Mixed results

Safety: NCCIH notes it's uncertain whether valerian is safe for long-term use 17.

What the research found

In one randomized trial, 100 postmenopausal women aged 50 to 60 with insomnia took valerian extract or placebo for 4 weeks. Sleep quality improved in 30% of the valerian group and 4% of the placebo group 15. Across all adults, though, NCCIH says valerian trials "have had inconsistent results," and a 2017 American Academy of Sleep Medicine guideline recommended against it for chronic insomnia 17.

Magnesium

Little evidence

Safety: NCCIH notes that high intakes from supplements can cause diarrhea, nausea and cramping 17.

What the research found

NCCIH says "there is very little research on magnesium for insomnia." One small 2021 review (3 studies, 151 older adults) hinted that people fell asleep a little faster, but the reviewers rated the studies low quality. A larger 2022 review found conflicting results 17.

Ashwagandha

Studied, some benefit

Safety: ODS says it seems well tolerated for up to about 3 months, but its long-term safety isn't known. There are reports of liver injury. It might affect thyroid function and interact with thyroid medicine, and some experts advise against it in pregnancy 20.

What the research found

According to the NIH Office of Dietary Supplements, a small number of trials suggest ashwagandha extract may improve sleep quality and help people fall asleep faster. In one 6-week trial of 150 adults with sleep problems, sleep quality improved in 72% of those on ashwagandha versus 29% on placebo 20. These trials were in mixed groups of adults, many in India, not in menopausal women.

Chamomile

Little evidence

What the research found

It's a classic bedtime tea, but NCCIH says there's "no conclusive evidence from clinical trials" that it helps insomnia. People allergic to ragweed may react to it 17.

What the research tested instead: NCCIH points to small randomized trials in women at menopause where progressive relaxation training, alone or with good sleep habits, helped with insomnia 17. If night sweats are what wake you, see the supplements on our hot flashes path, too.

A question for your clinician: "I'm using (name it) for sleep. Is it safe with my other medicines, and should we look at CBT for insomnia or at what's waking me up?"

The honest caveat: Sleep supplements are mostly tested in small, short trials, and in general adult groups rather than midlife women.

Worth mentioning to your provider: any vaginal bleeding after menopause. The FDA notes it can be a sign of a medical problem, so it's worth checking 3.

Information for better conversations, not a diagnosis.

This is research with sources, not medical advice. Talk to your clinician about your situation.

Evidence-checked · sources listed

Talk to a menopause-trained provider

Sources (all rechecked 2026-10-15)

  1. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022. PMID 35797481. https://pubmed.ncbi.nlm.nih.gov/35797481/
  2. The Menopause Society. Perimenopause (patient education). https://menopause.org/patient-education/menopause-topics/perimenopause
  3. US FDA Office of Women's Health. Menopause. https://www.fda.gov/consumers/womens-health-topics/menopause
  4. Davis SR, et al. Global Consensus Position Statement on the Use of Testosterone Therapy for Women. J Clin Endocrinol Metab. 2019. PMID 31498871. https://pubmed.ncbi.nlm.nih.gov/31498871/
  5. Edinger JD, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021. PMID 33164742. https://pubmed.ncbi.nlm.nih.gov/33164742/
  6. American Academy of Sleep Medicine. Combination treatment for chronic insomnia disorder in adults: clinical practice guideline. J Clin Sleep Med. Apr 13, 2026. https://pmc.ncbi.nlm.nih.gov/articles/PMC13076838/; AASM release: https://aasm.org/combination-treatment-chronic-insomnia-guideline/
  7. NHLBI. Sleep Apnea: Symptoms (updated Jan 9, 2025). https://www.nhlbi.nih.gov/health/sleep-apnea/symptoms
  8. ACOG. Do I need to have testing of my hormone levels during perimenopause? (Sept 2025). https://www.acog.org/womens-health/experts-and-stories/ask-acog/do-i-need-to-have-testing-of-my-hormone-levels-during-perimenopause
  9. NICE NG23, recs 1.3.4–1.3.5. https://www.nice.org.uk/guidance/ng23/chapter/Recommendations
  10. American College of Physicians. Pharmacologic treatment of vasomotor symptoms of menopause. Ann Intern Med. Oct 6, 2026. PMID 42832802. https://www.acpjournals.org/doi/10.7326/ANNALS-26-01205
  11. The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause. 2023. PMID 37252752. https://pubmed.ncbi.nlm.nih.gov/37252752/
  12. Pinkerton JV, et al. Elinzanetant for the treatment of vasomotor symptoms associated with menopause: OASIS 1 and 2 randomized clinical trials. JAMA. 2024. PMID 39172446. https://pubmed.ncbi.nlm.nih.gov/39172446/
  13. DailyMed. Lynkuet (elinzanetant) capsules, label, sections 4 and 5, including 5.4 (revised 08/2026; checked 2026-10-22). https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f42884ff-7dff-419c-8a0c-affe2ed73818
  14. McCurry SM, et al. Telephone-based cognitive behavioral therapy for insomnia in perimenopausal and postmenopausal women with vasomotor symptoms: a MsFLASH randomized clinical trial. JAMA Intern Med. 2016. PMID 27213646. https://pubmed.ncbi.nlm.nih.gov/27213646/
  15. Taavoni S, et al. Effect of valerian on sleep quality in postmenopausal women: a randomized placebo-controlled clinical trial. Menopause. 2011. PMID 21775910. https://pubmed.ncbi.nlm.nih.gov/21775910/
  16. US FDA. Questions and Answers on Dietary Supplements. https://www.fda.gov/food/information-consumers-using-dietary-supplements/questions-and-answers-dietary-supplements
  17. NCCIH. Sleep Disorders: In Depth (complementary health approaches). https://www.nccih.nih.gov/health/sleep-disorders-and-complementary-health-approaches
  18. NCCIH. Melatonin: What You Need To Know. https://www.nccih.nih.gov/health/melatonin-what-you-need-to-know
  19. Yi M, et al. Effects of exogenous melatonin on sleep quality and menopausal symptoms in menopausal women: a systematic review and meta-analysis of randomized controlled trials. Menopause. 2021. PMID 33784263. https://pubmed.ncbi.nlm.nih.gov/33784263/
  20. NIH Office of Dietary Supplements. Ashwagandha: Is it helpful for stress, anxiety, or sleep? Fact Sheet for Health Professionals. https://ods.od.nih.gov/factsheets/Ashwagandha-HealthProfessional/