How to Sleep Better During Perimenopause

Not long ago, my husband Tom joined a group called Fortnite Over Forty — a group of adults, weary of being trash-talked by teen players, who banded together to play video games.

When Tom and his gang of middle-age gamers play late into the night, I tell him to sleep in the guest room. That is because I am in the throes of menopause — and I have learned to be absolutely obsessive about my rest. If that means occasionally banishing Tom from the bedroom, so be it. 

We all know by now that chronic sleep loss wreaks havoc on your health — not only making you confused and irritable, but driving up the risks of developing heart disease, stroke, high blood pressure and type 2 diabetes, according to the Centers for Disease Control and Prevention (CDC). It messes with memory, mood and metabolism.

Menopause can make sleep loss even more intense. Nearly half of women in menopause report having poor sleep, thanks to hot flashes and night sweats. If you’re one of them, says Hadine Joffe, professor of psychiatry in the field of women’s health at Harvard Medical School, you should systematically go through your sleep habits and eliminate anything that interrupts your rest that you are able to control.

My habit of doomscrolling on my phone right before I turned out the light had to go. My cat, who liked to sleep on my chest, was banished from my bedroom, too. I got blackout curtains, a white noise machine and a sleep mask.

And it’s not just sleep hygiene that’s vital, says Yu Fang, a researcher at the University of Michigan’s Neuroscience Institute’s Sen Lab. Keeping a regular sleep-wake schedule, she says, is an unappreciated factor that is as important for mental health as having enough sleep time.

In a 2021 study whose subjects were first-year medical residents — a sleep-deprived group if ever there was one — Fang and her colleagues found that an irregular sleep schedule can increase a person’s risk of depression as much as getting fewer hours of sleep overall.

Experts say that having a consistent waking time in particular, even on weekends, is one of the best ways to regulate our body’s circadian rhythms, our 24-hour internal clock that is cued by light and dark.

That was a game-changer for me. I decided to start going to bed at 10:40 p.m. — a little nutty, I know, but I found that’s exactly when I started nodding off each night. I wake up each morning at 6:40 when my kid gets up for school — and now I do it on weekends, too. Is it rock ’n’ roll? No. But this new habit has done more to regulate my sleep than anything else.     

As for sleep remedies, I’m more inclined to pop melatonin supplements (and I’m not alone, as the number of Americans using melatonin has quadrupled in the past two decades).  

Melatonin, sometimes called the Dracula hormone because it emerges at night, is produced naturally by your brain to cue your body for sleep and to gradually power down. During the menopause transition, your body’s production of melatonin, like estrogen, drops.

For some, it doesn’t work, or makes them feel too sludge-y the next morning, but for others, it’s a godsend. Many people down 5 milligrams or even 10, but experts caution to start low, at .5 milligrams. While you may be tempted to jack up the dosage, more is not necessarily better: MIT researchers found that a mere .3 milligrams of melatonin nightly before bed helped adults over 50 who were plagued by insomnia to sleep through the night.

An even better combination is melatonin with a consistent bedtime, according to a 2018 Australian study. When researchers had subjects take .5 milligrams of melatonin an hour before turning in, combined with going to bed at a set time, the participants dropped off to sleep 34 minutes earlier, had greater sleep time and fewer sleep disturbances.

Many people swear by magnesium’s soporific effects, although a recent meta-analysis found there isn’t solid research behind it. Scientists aren’t sure why it might work; one theory is that magnesium deficiencies disrupt levels of sleep-inducing hormones. There are several forms of magnesium; if you plan on taking it, the Cleveland Clinic recommends 200 milligrams of magnesium glycinate or 200 milligrams magnesium citrate. Avoid magnesium oxide, instructs the Clinic’s website, with what I interpret as sly humor, “which is a stool softener and probably much less helpful for your insomnia.”

If hot flashes and night sweats are your primary sleep stealer, consider hormone therapy. A 2017 review in the journal Sleep Science called it “the most recommendable and well-established” treatment for hot flashes and their related sleep disturbances.

“In women with hot flashes who go on estrogen, it does improve their sleep,” confirms Joffe, “although we don’t really know if it’s because we’re treating the hot flashes and they are therefore sleeping better, or if it’s something more direct.” Research shows that progesterone, as part of hormone therapy, shortens the time it takes to fall asleep, lessens night time awakening and increases total sleep time.

One of the best ways to bring on sleep, say many experts, is cognitive behavioral therapy for insomnia, or CBT-I. It’s a structured program that helps you stop nighttime ruminating and to identify and replace sleep-sabotaging behaviors with sleep-promoting habits.

The beauty of CBT-I is that unlike the temporary fix of a pill, it helps people overcome the underlying causes of sleep troubles and helps you find cognitive strategies to let the ruminative thoughts go.

The Perelman School of Medicine at the University of Pennsylvania has a searchable database of practitioners that offer CBT-I. You don’t have to go forever — just until you learn the techniques.

Joffe says that science-backed sleep-enhancing apps can also be effective. Many doctors recommend ShutEye, Sleepio and my favorite, CBT-I Coach, a free app developed by Stanford School of Medicine in collaboration with the federal government.  

It has breathing tools, a sleep diary, and gives you alternate thoughts when brooding starts to creep in, such as: Even if I miss some sleep, I will be able to function. I can tolerate this. I will survive even if I don’t sleep at all tonight.

These can replace my typical ruminative thoughts such as Is Sarah out to get me? Should I have included an emoji on that text to the boss? What if I didn’t lock up downstairs, left the door open and the cat gets out? What if the cat gets out and runs in front of a car? What if I am actually driving that car?  

Mindful deep breathing has also been shown to set off a cascade of physiological responses that hasten sleep. One popular formula among sleep specialists is the following: lie down and put one hand on your chest and one on your belly. Inhale through your nose for four counts. Hold for seven counts and exhale through your mouth for eight counts.

Stressful thoughts spike our heart rate and cortisol levels, a fight-or-flight response deeply rooted in primordial human responses to danger. Rafal Pelayo, clinical professor of Stanford University’s division of sleep medicine, has said that for many of us, the only time that we’re alone with our thoughts is when we are in bed.  

If you find that your racing thoughts are keeping you awake, he has recommended to schedule some time in the evening away from your bed where you can be alone with your thoughts. I started taking an after-dinner walk to at least try and process some of the problems that arose during the day.  

While most sleep research focuses on bedtime rumination about past events, bedtime worry about future events — the old What did I forgot to do today that’s going to screw up tomorrow? — may also be a sleep stealer. Incomplete tasks cause a “high level of cognitive activation,” according to one sleep paper.

Joffe tells patients to get a little notebook, preferably with a cover so you can’t see what you write, and put it by your bed. “When you wake up in the middle of the night, write it down, and it’s done. Then you can think, I don’t need to rehearse that, recite that or ruminate on that. It’s there, and I will get to it.”

A 2018 study found that people who spent five minutes creating a to-do list before bed fell asleep faster than a control group.

I started doing that as well. It’s freeing to capture the thought on paper and tell myself it’s handled.

Finally, once you’ve written down all your to-dos, the CBT-I app advises users to keep middle-of-the-night thoughts as soothingly mundane as possible.  

My nighttime thoughts are pretty mundane to begin with, but now I strive to make them even duller and avoid anything that might possibly rile me up. Last night, I thought about cloth napkins. Surely I’m at the age where I should have cloth napkins. Why don’t I have any? Do people still use cloth napkins? 

Then I thought about some of my weird childhood snacks from the ’80s: Marathon bars, Tab cola. By the time I had moved on to contemplating whether I was out of fabric softener, I had bored myself to sleep.

From Hot and Bothered by Jancee Dunn, published by Dutton, an imprint of Penguin Publishing Group, a division of Penguin Random House, LLC. Copyright © 2023 by Jancee Dunn.