Sleep & Mood Changes

Why Sleep Becomes Harder

What's Causing It? ✓✓✓

Night Sweats (The Primary Culprit)

Hot flashes that occur during sleep can wake you 3-5 times per night. You may:

• Wake up drenched in sweat
• Need to change pajamas or sheets
• Have trouble falling back asleep
• Experience heart racing or anxiety

Even if you don't fully wake, night sweats fragment your sleep architecture—you never reach deep, restorative sleep stages.

Hormonal Changes

Estrogen and progesterone both influence sleep:

• Estrogen affects REM sleep and helps regulate body temperature during sleep
• Progesterone has sedating effects; dropping levels make it harder to stay asleep
• Hormonal fluctuations during perimenopause create unpredictable sleep patterns

Aging & Other Factors

• Sleep architecture changes with age: Less deep sleep, more light sleep, more awakenings (happens to men too)
• Sleep apnea: Risk increases after menopause; affects 15-20% of postmenopausal women
• Restless legs syndrome: More common during menopause transition
• Anxiety and racing thoughts: Common during perimenopause, interfere with falling asleep
• Frequent urination: Wakes you 2-3+ times per night

The Sleep-Mood Connection

Poor sleep and mood problems create a vicious cycle during menopause:

Common mood changes during perimenopause/menopause:

• Irritability and mood swings (feeling like PMS but all the time)
• Anxiety (worry, racing thoughts, physical tension, panic attacks)
• Low mood or depression (sadness, hopelessness, loss of interest)
• Emotional volatility (crying easily, feeling overwhelmed by small things)
• Lower stress tolerance (things that didn't bother you now feel overwhelming)

Understanding Mood Changes During Menopause

Are Hormones Causing My Mood Problems? ✓✓

The relationship between hormones and mood is complex:

What we know:

• Women with a history of mood sensitivity to hormones (PMS, PMDD, postpartum depression) are more vulnerable to perimenopausal mood changes
• Perimenopause increases risk of new depression 2-4x, even in women with no prior depression history
• Estrogen affects brain chemistry: It influences serotonin, dopamine, and other neurotransmitters that regulate mood
• Fluctuating hormones (not just low levels) may be most destabilizing—which is why perimenopause is often worse than postmenopause

But it's not just hormones:

• Sleep deprivation from night sweats
• Life stressors that peak in your 40s-50s (aging parents, teenage/young adult children, career pressures, relationship changes)
• Identity shifts and grief about aging
• Chronic stress and burnout

Strategies to Improve Sleep

Address Night Sweats First ✓✓✓

If night sweats are your main problem, treating them is the single best thing you can do for sleep:

• Hormone therapy reduces night sweats 75-90% (see our HRT guide)
• Non-hormonal medications: SSRIs, gabapentin, fezolinetant reduce night sweats 40-60%
• Keep bedroom cool (65-68°F), use fans, moisture-wicking sheets

Sleep Hygiene (Really Does Help) ✓✓✓

Cognitive Behavioral Therapy for Insomnia (CBT-I) ✓✓✓

CBT-I is as effective as sleeping pills but without side effects or dependency risk. It teaches you to:

• Break negative thought patterns about sleep
• Restrict time in bed to increase sleep drive
• Use stimulus control (get out of bed if not asleep in 20 min)
• Practice relaxation techniques

How to access: Work with therapist trained in CBT-I, or use apps like Sleepio (evidence-based digital CBT-I)

Medications for Sleep

Melatonin (3-5 mg) ✓✓

• Helps with falling asleep, especially if circadian rhythm is off
• Take 1-2 hours before desired bedtime
• Safe for most people; minimal side effects

Prescription Sleep Medications

• Short-term use only (2-4 weeks) for acute insomnia
• Options: zolpidem (Ambien), eszopiclone (Lunesta), low-dose doxepin
• Risk of dependency and next-day grogginess
• Not a long-term solution

Strategies to Support Mood

Hormone Therapy for Mood? ✓✓

The evidence is mixed and nuanced:

• If you have hot flashes + mood symptoms: Treating hot flashes with HT often improves mood indirectly (through better sleep, less physical discomfort)
• For mild mood symptoms alone: Some women notice mood improvement on HT, but it's not consistent
• For moderate-severe depression: HT alone is NOT sufficient; you need antidepressant therapy

Bottom line: Don't take HT solely for mood. But if you need it for hot flashes, mood may improve as a bonus.

Antidepressants ✓✓✓

Highly effective for anxiety and depression during menopause. They also help hot flashes (double benefit).

SSRIs/SNRIs that help both mood and hot flashes:

• Paroxetine (Paxil) - only FDA-approved for hot flashes
• Venlafaxine (Effexor)
• Escitalopram (Lexapro)
• Sertraline (Zoloft)

Therapy ✓✓✓

Talk therapy is highly effective, especially combined with medication if needed:

• Cognitive Behavioral Therapy (CBT): Best evidence for depression and anxiety
• Acceptance and Commitment Therapy (ACT): Helps with distress tolerance and life transitions
• Interpersonal therapy: Helps with relationship stress

Exercise ✓✓✓

Exercise is as effective as antidepressants for mild-moderate depression:

• 150 minutes/week moderate exercise (brisk walking, cycling)
• Reduces anxiety, improves mood, helps sleep
• Effect size comparable to medication

Mind-Body Practices ✓✓

• Mindfulness meditation: Reduces anxiety, improves emotion regulation
• Yoga: Helps with anxiety, sleep, hot flashes
• Tai chi: Reduces stress, improves mood and sleep

Lifestyle Basics

• Social connection: Don't isolate; maintain relationships
• Limit alcohol: Worsens sleep, mood, and hot flashes
• Manage stress: Say no more often; delegate; ask for help
• Light exposure: Get morning sunlight to regulate circadian rhythm

When to Seek Help

Don't Wait to Get Help

Many women suffer needlessly because they think:

• "It's just hormones; I should be able to handle it"
• "I don't want to take medication"
• "Other people have it worse"
• "I should be stronger"

Reality: Depression and anxiety during menopause are real, common, and treatable. You don't get extra points for suffering. Effective treatment exists—use it.

Advocate for Yourself

Questions to Ask Your Doctor

Red Flags—When to Push Back or Get a Second Opinion

• Your sleep or mood problems are dismissed as "just part of menopause" without offering treatment
• You're told to "just tough it out" when symptoms are severely impacting your life
• You're prescribed sleeping pills long-term without addressing underlying causes
• Your provider won't discuss antidepressants even though you have clear depression/anxiety
• You're told "you're too young for menopause" when you're in your 40s with classic symptoms
• Your concerns about suicide or severe depression are minimized

Key Takeaways

• 40-60% of menopausal women have sleep problems, primarily from night sweats disrupting sleep architecture.
• Treating night sweats is the best way to improve sleep if they're the primary cause (HT 75-90% effective; non-hormonal meds 40-60%).
• Sleep hygiene and CBT-I are highly effective and should be first-line for insomnia.
• Screen for sleep apnea if you snore, gasp, wake with headaches, or feel exhausted despite sleeping.
• Risk of new depression increases 2-4x during perimenopause, even in women with no prior history.
• Poor sleep and mood problems create a vicious cycle—fixing one often helps the other.
• Hormone therapy may help mood indirectly (through better sleep) but isn't sufficient for moderate-severe depression.
• Antidepressants are highly effective for anxiety and depression during menopause—don't avoid them due to stigma.
• Exercise is as effective as medication for mild-moderate depression (150 min/week).
• Seek help promptly if you have thoughts of self-harm, severe anxiety, or symptoms lasting 2+ weeks. Treatment works.