Many women begin to experience sleep difficulties years before menopause itself. Perimenopause—the transitional phase leading up to menopause—can significantly disrupt sleep and is a common yet often overlooked cause of insomnia. For many, these sleep problems are compounded by anxiety, nighttime rumination, and increased sensitivity to stress. Understanding the connection between perimenopause and insomnia is an important step toward effective, lasting treatment.
Why Perimenopause Disrupts Sleep
Perimenopause typically begins in the late 30s to 40s and can last several years. During this time, levels of estrogen and progesterone fluctuate unpredictably. These hormonal changes affect sleep in multiple ways.
Estrogen plays a role in regulating body temperature, mood, and circadian rhythms. When estrogen levels drop or fluctuate, women may experience night sweats, hot flashes, and frequent awakenings. Progesterone has a calming, sleep-promoting effect; declining progesterone can make it harder to fall asleep and stay asleep.
However, insomnia during perimenopause is not only physiological. Many women notice that once sleep becomes disrupted, anxiety about sleep quickly follows. Worrying about whether you will sleep, how tired you will feel the next day, or how poor sleep affects your health can activate the nervous system and further interfere with rest.
The Role of Anxiety in Perimenopausal Insomnia
Anxiety and insomnia are closely linked during perimenopause. Hormonal fluctuations can increase emotional reactivity and stress sensitivity, making it harder to “turn off” the mind at night. Racing thoughts, anticipatory anxiety about sleep, and heightened awareness of bodily sensations often become part of the bedtime experience.
Over time, this can lead to conditioned insomnia, where the bed itself becomes associated with wakefulness and frustration. Even on nights without hot flashes or physical symptoms, sleep remains elusive because the brain has learned to stay alert.
This is why treating perimenopausal insomnia effectively requires addressing both sleep behaviors and anxiety—not just hormones.
Why CBT-I Is the Gold-Standard Treatment
Cognitive Behavioral Therapy for Insomnia (CBT-I) is the most effective, evidence-based treatment for chronic insomnia, including insomnia related to perimenopause. CBT-I works by targeting the patterns that keep insomnia going, even when the original trigger was hormonal.
CBT-I helps individuals:
- Rebuild a strong association between bed and sleep
- Reduce sleep-related anxiety and nighttime rumination
- Regulate sleep schedules and circadian rhythms
- Challenge unhelpful beliefs about sleep and fatigue
- Calm the nervous system through behavioral and cognitive strategies
Importantly, CBT-I does not require medication and has been shown to produce long-lasting improvements in sleep. For women in perimenopause, CBT-I can be especially helpful because it treats insomnia directly, rather than waiting for hormonal stability to return.
Telehealth CBT-I for Perimenopause and Anxiety
Telehealth therapy makes CBT-I accessible and convenient, especially for women juggling work, caregiving, and changing energy levels. Research shows that CBT-I delivered via telehealth is just as effective as in-person treatment.
Working with a psychologist via telehealth allows for personalized treatment that addresses:
- Sleep disruption related to night sweats or awakenings
- Anxiety and hyperarousal at bedtime
- Stress, perfectionism, or burnout that worsens insomnia
- Emotional changes associated with perimenopause
Telehealth also allows clients to apply strategies in their real-world sleep environment, which can enhance treatment effectiveness.
When to Seek Professional Help
Occasional sleep disruption during perimenopause is common. However, if insomnia occurs three or more nights per week, lasts for several months, or causes daytime fatigue, irritability, or anxiety, professional treatment can help.
Insomnia does not need to be endured as an inevitable part of perimenopause. With the right support, sleep can improve—even during hormonal transitions.
A Path Toward Restful Sleep
Perimenopause can be a time of significant physical and emotional change, but chronic insomnia does not have to define this phase of life. CBT-I offers a structured, compassionate, and highly effective approach to restoring sleep and reducing anxiety.
If you are experiencing perimenopause-related insomnia, working with a psychologist trained in CBT-I through telehealth can help you regain confidence in your ability to sleep and feel more rested, resilient, and balanced.
Dr. Sara Michelson is a Licensed Psychologist in Chapel Hill N.C.
I am a doctoral-level licensed psychologist in Chapel Hill North Carolina; I have expertise in various evidence-based treatments for adults and am committed to providing scientifically validated interventions. I work with a diverse population, including trauma, insomnia, mood disorders, anxiety, and relationship problems. I take my work and clinical specializations seriously and continue to devote a considerable amount of time and effort to advance my training and professional development. For your convenience, my services are provided via telehealth.