Keep Waking at 4 a.m. During Menopause? Here’s How to Sleep More Soundly

You’re doing everything right: following a sleep schedule, skipping screens before bed, and sipping relaxing herbal tea to wind down. Still, you find yourself repeatedly jolted awake at 3 or 4 in the morning, way before your alarm is set to go off. You lie there, utterly exhausted—and increasingly frustrated—unable to drift back to sleep.

There are countless threads on Reddit from women in perimenopause and menopause trying desperately to understand why they’re suddenly waking up in the wee hours of the morning. Research validates their experience.

One 2019 study found that “sleep disturbances increase…during the menopausal transition.” Nighttime awakenings, researchers say, are the most common complaint ¹.

A flurry of online news headlines—mostly from British papers—claim that the most common wake time for women in menopause is 3:29 a.m. ² Could there be something special about this time of night? The answer is yes…and no.

About the Experts:

Indira Gurubhagavatula, M.D. MPH, is a professor of medicine at the University of Pennsylvania’s Perelman School of Medicine, where she serves as program director for the school’s sleep medicine fellowship. She’s also on the board of the American Academy of Sleep Medicine.

Michelle Drerup, Psy.D., is the Director of the Behavioral Sleep Medicine Program at Cleveland Clinic Sleep Disorders Center. She also serves as Director of the BSM training program and supervises post-doctoral health psychology fellows and sleep medicine fellows in the provision of BSM services.

Carol Lynn, M.D., is an obstetrician and gynecologist who specializes in menopause care. She founded Our Midlife Moxie to help women during the transition and holds menopause retreats.

Waking Between 3 a.m. and 4 a.m. During Menopause

When you see women sharing headlines that talk about a 3:29 a.m. wake-up during menopause, you might wonder if every middle-aged woman is wide awake staring at their phone at this time every night. But the science on this specific wakeup time is shaky.

It came from a survey done by—of all things—a UK housewares retailer and the details and methodology can’t be traced back to any rigorous study—just a Q&A on the store’s website. It appears the retailer simply polled some of its customers.

But setting aside this mythical 3:29 a.m. wakeup time, early waking in menopause is a common and very disruptive occurrence.

About half of all perimenopausal and menopausal women report sleep difficulties, ³ and these sleep disturbances often involve frequent night-time awakenings and having trouble getting back to sleep. ⁴

Progesterone—or more specifically, a lack of it—is a driving factor in these early wakings, says Indira Gurubhagavatula, M.D. MPH, a professor of medicine at the University of Pennsylvania’s Perelman School of Medicine.

Progesterone, a hormone produced in the ovaries, is one of the first hormones to decline during perimenopause. The metabolites of progesterone—substances created in our bodies from the hormone—may act on the parts of the brain that are responsible for making a person feel sleepy, says Gurubhagavatula. It’s not surprising then that lower levels of progesterone during perimenopause and menopause have been linked to insomnia, poor sleep quality, and hot flashes, she says.

Is there something special about 3 a.m.?

Waking up at 3 a.m. or 4 a.m. isn’t unique to perimenopause or menopause, says Michelle Drerup, Psy.D., director of the Behavioral Sleep Medicine Program at the Cleveland Clinic Sleep Disorders Center.

We all tend to cycle through the four stages of sleep throughout the night. We sleep deeper during the earlier stages, but as the night progresses, those deep sleep periods become shorter and less frequent. “Oftentimes those 3 a.m. wakings are associated with being in lighter stages of sleep,” Drerup says.

The lack of shut-eye can lead to fatigue and daytime exhaustion, says Carol Lynn, M.D., an obstetrician and gynecologist specializing in menopause care. “Perimenopause and menopause can make you super fatigued and tired because your progesterone is low and you’re waking up a lot,” she says.

Hot flashes and waking up at 3 a.m.

Another reason women in perimenopause and menopause wake up in the wee hours? Hot flashes. These intense periods of overheating are linked to fluctuations and declines in estrogen.

Estrogen impacts the hypothalamus, which acts as our bodies’ internal thermostat, Lynn says.

“The hypothalamus has tons of estrogen receptors, so when your estrogen levels are good, you’ve got plenty of estrogen that’s hitting those receptors. When we lose that estrogen, the hypothalamus thinks, ‘Oh, my gosh I’m cooling down. I need to warm up.’ And then you get a hot flash,” she says.

Nighttime hot flashes—often called night sweats—may seem more intense than daytime hot flashes because the body’s overall temperature drops slightly during sleep.

Research also suggests women experience more hot flashes during the later part of the night, particularly during REM sleep. One study found that 59 percent of hot flashes happened during the second half of the night. ⁵ So your 3 a.m. hot flashes happen because the body’s thermoregulation is typically most unreliable during REM.

Hormones aside, other triggers for hot flashes can include the same triggers that affect women normally. This includes:

• Spicy foods
• Alcohol
• Sugary foods
• Warm clothing or blankets

Lynn suggests avoiding spicy food two to three hours before bed and cutting out alcohol at least four hours ahead of bedtime. “Alcohol takes a while to metabolize out of your system,” she adds.

Night wakings and sleep apnea

Another common contributor to nighttime hot flashes is obstructive sleep apnea (OSA), a condition where the tongue and soft palate collapse into the throat, blocking airflow during sleep. This tends to occur more often during rapid eye movement (REM) sleep.

“During REM sleep, the muscles of the upper airway become paralyzed and collapse together,” says Gurubhagavatula. “In people with sleep apnea, [the tissues] collapse so much that the airway becomes completely shut for a few seconds, which causes a drop in oxygen in the blood.”

Sleep apnea significantly increases during perimenopause and menopause, potentially due to declines in estrogen, which affect the muscles in the throat and upper airway. ⁶

The drop in oxygen from sleep apnea makes the brain release adrenaline, a fight-or-flight hormone that makes your heart beat fast and breathing speed up. This can then cause sweating and potentially trigger a hot flash at 3 am, waking you up.

Anxiety compounds sleep issues

Menopause-related sleep disruptions often lead to anxiety about sleep itself.

If you’ve ever struggled to fall asleep before an important life event—first day at a new job, anyone?—you’ve probably felt the anxiety that comes with needing to fall asleep but being unable to drift off. This exact scenario plays out for many women in menopause who wake up, look at the clock, and panic, assuming they are going to have trouble falling back to sleep.

“You’ve got someone thinking, ‘Now, I’ve only got an hour to get back to sleep. I’ve got to get back to sleep now.’ It becomes this anxiety about sleep that is a chronic insomnia problem,” Drerup says.

How to Get Back to Sleep

Women in menopause or perimenopause experiencing a 3 a.m. or 4 a.m. wake-up can try a few calming activities to get back to sleep. These include:

1. Do a mindful body scan. Focus on breathing and progressively relaxing different muscle groups.
2. Don’t stay in bed for more than 15 minutes if you’re awake and don’t feel sleepy, get up and read, fold laundry, or listen to quiet music. Don’t go back to bed until you start to feel drowsy.
3. Check the thermostat. Researchers have found that the best sleep quality happens between 68 and 77 degrees, ⁷ but you can experiment to see what’s best for your body.
4. Shut the world out. Wear earplugs and a soft sleep mask to block sleep-disrupting noises and ambient light.
5. Write a to-do list. Research shows that people with insomnia who write to-do lists fall asleep significantly faster. Use a pen and notepad so you avoid screens. ⁸

HRT for Waking Up at Night During Menopause

Hormone replacement therapy (HRT, also called menopause hormone therapy or MHT) elevates estrogen and/or progesterone to alleviate hormone-led night wakings. Research shows that women on HRT report improved sleep quality. ⁹

Gurubhagavatula says if your sleep habits and health are typically on point and you are still struggling you may want to ask if you’d be a good candidate for HRT.

One recent meta-analysis that looked at whether HRT could help with menopausal sleep issues confirms that women who went on a combination of estrogen and progesterone had improved sleep quality. ¹⁰

Progesterone is typically prescribed alongside estrogen for women with a uterus to protect against endometrial cancer. But even those without a uterus may benefit from progesterone for improved sleep quality and reduced brain fog, says Lynn.