Too Stressed to Sleep? Help for Perimenopause Anxiety and Insomnia

Picture it: You’re lying in bed, staring into the dark, trying to quiet racing thoughts and to-dos nagging your brain. If you found this article in the middle of yet another anxiety-filled, restless night, you’re not alone—especially if you’re in perimenopause.

Hormonal shifts can crank up perimenopause anxiety at night, making it nearly impossible to wind down, no matter how many deep breaths or sleep hygiene tips you try. (Avoid your phone? Not happening at 3 a.m.)

It’s time for science-backed solutions that work. Here’s what sleep and hormone experts say can help you finally get some much-needed shut-eye.

About the Experts

Natalie Kunsman, M.D., is a board-certified family physician specializing in functional and anti-aging medicine and hormone replacement.

Emily Oken, M.D., is the head of the Department of Population Medicine at Harvard Medical School. Her work has investigated sleep disturbances in perimenopausal women.

C. Leilani Valdes, M.D., is a board-certified pathologist whose work centers on improving healthcare delivery, including for perimenopause and menopause.

How Common Is Perimenopause Anxiety at Night?

While few studies examine perimenopause anxiety at night specifically, up to 55 percent of women report increased or new anxiety during perimenopause ¹. Other research reveals perimenopause and trouble sleeping are frequent bedfellows: Around 23 percent of women ages 42 to 52 experience persistent insomnia symptoms ². And about half of women reaching midlife report anxiety, trouble sleeping (a common side effect of anxiety), or both ³.

While anxiety can crop up for many reasons, perimenopause is a common culprit among women in midlife, especially if they are experiencing other menopause symptoms like hot flashes or night sweats, says Emily Oken, M.D., a board-certified internist who has researched sleep disturbances in perimenopause.

Luckily, this type of perimenopause anxiety at night doesn’t last forever. A study exploring the relationship between psychological complaints across different stages of menopause found pre- and post-menopausal women reported feeling much less bothered by anxiety and stress than women currently in the throes of perimenopause. ⁴ Interestingly, the researchers found the post-menopause dip in anxiety to be age-related, not symptom-related, with older women experiencing less anxiety because they developed more resilience with time.

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What Causes Perimenopause Anxiety at Night?

In perimenopause, declines in estrogen, progesterone, and melatonin—plus spikes in cortisol—can cause the onset of anxiety. ⁵ These shifts can also heighten pre-existing anxiety. Hot flashes and night sweats also play a role.

Here’s a rundown of precisely how those hormone fluctuations could affect your overall mood—and why menopausal women are more likely to experience anxiety, sleep disturbances, or both:

• Progesterone dips, causing declines in anxiety-calming neurotransmitters: Progesterone activates GABA, a neurotransmitter that helps the brain moderate stress levels and calm anxious thoughts. ⁶ When progesterone declines, GABA’s calming effects dip too, allowing anxiety and racing thoughts to creep in, says board-certified family physician Natalie Kunsman, M.D.
• Estrogen diminishes, throwing mood-regulating hormones out of whack: Estrogen helps your brain produce serotonin and dopamine, hormones that regulate mood. ⁷ When estrogen declines, these feel-good chemicals follow suit, leading to changes in mood and increased anxiety, explains Kunsman.
• Falling estrogen also causes neuroinflammation: Declining estrogen can trigger inflammation in the gut that can activate the amygdala (the part of the brain that controls fear and other emotions), contributing to higher anxiety levels and menopause panic attacks at night. ⁸
• Melatonin decreases with age, making it challenging to sleep: As we age, melatonin, a hormone involved in sleep regulation, gradually decreases, making perimenopause insomnia more common. ⁹
• Cortisol levels become imbalanced, increasing stress: Perimenopausal hormonal changes may also disrupt the hypothalamic-pituitary-adrenal (HPA) axis—your body’s primary stress response system—causing cortisol to spike at night. (¹⁰ Higher cortisol levels can lead to a stressed, panicked state, making it hard to calm your mind. “It’s terribly difficult to ease into sleep if you are wide awake and alert from cortisol,” Kunsman explains.

Anxiety and insomnia often fuel each other: People who don’t get the recommended eight hours of sleep every night are more likely to experience mental distress–and people who experience mental distress are less likely to sleep well. ¹¹

Why Does Perimenopause Anxiety Feel Worse After Dark?

Research suggests anxiety symptoms are higher in the evenings or at night, regardless of your menopausal status. ¹² Those nighttime anxiety spikes are due to less emotional regulation during the evening phase of the circadian rhythm, the body’s sleep-wake cycle. And the many stressful events around midlife (high-stress jobs, raising kids, helping aging parents, etc.) give us a lot to think about during that circadian dip.

Symptoms of Perimenopause Anxiety at Night

Perimenopause anxiety manifests in a wide variety of ways at night, notes Kunsman. For some, it’s a full-blown panic attack: pounding heart, hyperventilating, sweating, shaking, and feelings of intense dread. For others, it’s a nagging feeling of unease, tension, or restlessness that makes it impossible to sleep.

For some women, anxiety prevents them from falling asleep. Others nod off just fine—but wake up at 4 a.m. in a panic.

Perimenopause Symptoms That Can Trigger Anxiety or Insomnia

Menopause symptoms like headaches, joint aches, itching, and night sweats contribute to anxiety, making it harder to sleep. Some women also find they have to pee more often during the night because menopause sometimes causes a loss of bladder control, which can disrupt sleep quality too.

A full 80 percent of women experience hot flashes in the menopause transition. ¹³ The Menopause Society reports that women who experience hot flashes or sweats at night report higher levels of anxiety and more difficulty sleeping. ¹⁴

Managing Perimenopause Anxiety and Insomnia

Experts say you don’t have to put up with nighttime anxiety in perimenopause. Management and treatment options for perimenopause anxiety at night include behavioral therapy, supplements, hormone replacement therapy, and non-hormonal medications.

Lifestyle Changes

• Practice good sleep hygiene: go to bed and wake up at the same time (even on weekends), install blackout shades, and sleep in a cool room (65º to 68º F). ¹⁵
• Stay active: Exercise improves sleep quality and reduces anxiety. One study found three 30-60 minute workouts a week improved sleep for perimenopausal women. ¹⁶ Slow, low-impact workouts like Qigong may be the most effective for promoting sleep.
• Adjust your diet: While more research is needed, a 2020 study published in the International Journal of Food Sciences and Nutrition reports that eating more phytoestrogens (like soy) could reduce VMS-like hot flashes that may keep you up at night. The study also suggests that a high intake of omega-3 fatty acids could decrease depression and anxiety, which in turn could decrease sleep disturbances. Eating more tryptophan, a precursor of melatonin found in dairy, fish, seafood, meat, whole grains, nuts, and seeds, may also improve sleep. ¹⁷

Behavioral Therapy

Beyond lifestyle changes, many women find it helpful to work with a therapist, especially if the therapist practices cognitive behavioral therapy for insomnia (CBT-I). CBT-I—which is a type of talk therapy that focuses on changing behaviors and thoughts related to difficulty sleeping— can decrease sleep disturbances and improve the overall quality of life in perimenopausal and menopausal women. ¹⁸ CBT and other types of therapy may also be beneficial for the day-to-day challenges of perimenopause, too.

Supplements

Supplements may help ease perimenopause anxiety, says Kunsman. She recommends L-theanine (an ingredient in Hone’s Calm supplement), which helps regulate GABA and cortisol to reduce anxiety.

Even though perimenopause supplements are available without a prescription, it’s best to talk to a doctor beforehand about any side effects or potential interactions with other medications, says C. Leilani Valdes, M.D., a board-certified pathologist.

Hormone Replacement Therapy

Hormone replacement therapy (HRT, also called menopause hormone therapy or MHT) is a safe, effective way to reduce perimenopause anxiety. ¹⁹ It replenishes estrogen and progesterone, easing mood swings, and other symptoms that keep you up at night.

Progesterone, in particular oral micronized progesterone, may help improve deep sleep and mental health symptoms when taken at night. ²⁰

Non-Hormonal Medications

If HRT isn’t right for you, there are other options:

• 5HT drugs, a class of antidepressants that help regulate serotonin which often drop during perimenopause, may be particularly beneficial. ²¹ Since sleep-related anxiety frequently stems from imbalances in neurotransmitters like serotonin, these medications (which include Zoloft, Prozac, and Celexa) may improve sleep too.
• Prescription sleep medications like Ambien, Lunestra, or Sonatacan provide a better night’s sleep; they’re designed to address symptoms (i.e. an inability to sleep), not the root cause of anxiety. ²²