Hot flashes aren’t the only thing stealing sleep in menopause

Key takeaways

• In a large U.S. study of midlife women, about 41% of those past menopause said they woke often during the night³.
• In a trial funded by the National Institute on Aging, six short phone sessions of insomnia therapy cut insomnia scores about twice as much as menopause education did⁵⁶.
• The Menopause Society’s 2023 review recommended cognitive behavioral therapy and clinical hypnosis for hot flashes, but not paced breathing, black cohosh, soy, yoga or herbal supplements¹².
• Two newer hormone-free pills treat hot flashes: fezolinetant, which carries a boxed warning for rare liver injury, and elinzanetant, approved in October 2025⁷⁸.
• In February 2026, the FDA approved new labels for six hormone therapy products that drop boxed warnings about heart disease, breast cancer and probable dementia¹¹¹².

At the SLEEP 2026 meeting of sleep researchers, Pauline Maki presented a fresh look at a long-running U.S. study of women in midlife⁴. Her team sorted 2,066 women into four groups: hot flashes only, sleep trouble only, both, or neither⁴.

Women with sleep trouble alone scored worse than women with neither problem on all three quality-of-life measures. Women with hot flashes alone didn’t differ significantly on two of the three⁴. “The bottom line is that sleep has a bigger effect than hot flashes,” Maki said⁴.

That was a meeting talk, not a published paper we could review.

Hot flashes do wake people. According to the report on her talk, women wake after a hot flash about 75% of the time⁴. But menopause brings other sleep thieves, too, and some of them need a different fix.

We walk through what keeps women awake, which treatments passed fair tests, what the FDA changed, and a plan to start this week.

Sleep trouble climbs as periods wind down

The Study of Women’s Health Across the Nation, or SWAN, enrolled more than 3,000 U.S. women aged 42 to 52 and checked on them yearly for up to seven years³.

In a 2008 report led by Howard Kravitz of Rush University Medical Center, trouble falling asleep and staying asleep both rose as women moved through menopause³. Waking too early rose through late perimenopause, the final stretch before periods stop, then eased afterward³.

After menopause, about 16% of the women said they had trouble falling asleep. About 41% said they woke often during the night³.

Hormones and hot flashes both tracked with the problem. Women who had hot flashes on more days were more likely to sleep poorly, and lower levels of estradiol, the main form of estrogen, went with trouble falling asleep and frequent waking³.

Women who’d had surgical menopause and weren’t taking hormone therapy were the most likely to report trouble sleeping³. SWAN is an observational study, so it shows links, not proof that hormones cause every bad night.

Five things that wake women in midlife

Night sweats get the attention. But the European Menopause and Andropause Society lists a wider set of sleep problems common around menopause: trouble falling asleep, waking too early, waking from night sweats, unrefreshing sleep, sleep apnea and restless legs syndrome¹³.

Each leaves different clues, and the fix depends on which you have.

What’s waking you	Clues to notice	Where to start
Hot flashes and night sweats	Waking hot, flushed or damp	Hot flash treatments, below2
Insomnia	Lying awake long after you’ve cooled off; dreading bed	CBT for insomnia25
Sleep apnea	Loud snoring, snorting, gasping or pauses in breathing; daytime sleepiness14	A sleep evaluation; see our sleep apnea article
Restless legs	Creeping or tingling legs at night that ease when you move14	A clinician visit; see our restless legs article
Low mood or anxiety	Irritability, sadness, loss of enjoyment; waking too early15	Therapy, medicine or both15

Mood deserves its own word. The National Institute of Mental Health (NIMH) says some women develop depression during the transition, with intense irritability, anxiety, sadness or loss of enjoyment¹⁵. In midlife, depression can show up as waking in the middle of the night or too early¹⁵.

If low mood comes with hopelessness or thoughts of harming yourself, call or text the 988 Suicide & Crisis Lifeline at 988, any time¹⁵.

Six phone calls eased insomnia in a federal trial

In 2013, researchers in western Washington State began testing cognitive behavioral therapy for insomnia, or CBT-I, in women with hot flashes⁵. CBT-I is a structured program that changes sleep habits and the anxious thoughts that keep you awake.

They randomly assigned 106 women aged 40 to 65, meaning chance decided who got which program⁵. Each had at least moderate insomnia and two or more hot flashes a day⁵.

Half got CBT-I. The other half got menopause education, with the same number of calls but none of the sleep techniques⁵⁶. Both groups had six phone sessions over eight weeks, each under 30 minutes⁶.

The coaches weren’t sleep specialists: one was a social worker, the other a psychologist, and each got one day of CBT training⁶.

On a 28-point insomnia scale, the CBT-I group improved by 9.9 points, versus 4.7 for the education group⁵. The gains lasted⁶. Hot flashes didn’t become less frequent, but they got in the way of daily life less⁶. The National Institute on Aging paid for the study through a research network called MsFLASH⁶.

CBT-I included a steady sleep schedule, limits on time in bed, rules that keep the bed for sleep, and work on worried thoughts⁵⁶. Setting limits on time in bed takes care, so do it with guidance. Our upcoming insomnia article walks through each step.

The Menopause Society weighed the popular fixes

In June 2023, The Menopause Society, then called the North American Menopause Society, published its review of hormone-free treatments for hot flashes¹. A panel led by Dr. Chrisandra Shufelt reviewed studies published since its last statement in 2015¹.

The panel said hormone therapy is still the most effective hot flash treatment². But some women can’t take it, such as those with estrogen-sensitive breast cancer, and others would rather not².

The panel’s recommended list included CBT, clinical hypnosis, weight loss, a nerve block called stellate ganglion blockade, SSRI or SNRI antidepressants, gabapentin, oxybutynin and fezolinetant¹. The two mind-body options stand out. CBT for hot flashes teaches new ways to respond to them, and across studies, 65% to 78% of women who tried it reached a meaningful improvement².

Clinical hypnosis did even better. In a 2013 trial of 187 women, hot flashes fell 74% with hypnosis, compared with 17% in a group that got structured attention instead². The program used five weekly sessions plus practice at home, and it’s offered by trained providers or through a smartphone app². In a smaller trial in breast cancer survivors, hypnosis also improved sleep².

Many popular approaches didn’t make the cut. The panel did not recommend paced breathing, herbal supplements, soy, yoga, exercise, relaxation, acupuncture, cannabinoids, cooling techniques or avoiding triggers for hot flashes¹.

“Not recommended” covers two different verdicts, and the difference matters:

• Tested and failed. In larger trials, slow paced breathing beat neither ordinary shallow breathing nor standard care². A 2012 Cochrane review of 16 trials found black cohosh worked no better than placebo, and after reports of possible liver injury, the U.S. Pharmacopeial Convention, a standards group, required a liver warning on labels².
• Barely tested. No clinical trials have tested avoiding triggers such as alcohol or spicy food². Cooling techniques have only small studies, in which cooling improved how women rated their sleep but measured hot flashes didn’t change². Soy studies were small, short and mixed².

The second group isn’t proven useless. A cool room and light layers cost little and may make nights more comfortable, as our bedroom temperature article explains. Just don’t count on them to stop hot flashes.

The panel also flagged a quality problem: several supplement trials were small or paid for by the makers, and the products themselves are loosely regulated². The statement had no commercial funding, though several panel members reported ties to drug companies².

If you value self-reliance and fewer pills, the strongest news here is on your side. Two of the top-rated hormone-free options, CBT and hypnosis, use no pills at all, and they teach skills you keep.

Two newer hormone-free pills work, with warnings attached

Fezolinetant (Veozah) won FDA approval in May 2023 for moderate to severe hot flashes⁷. In September 2024, the FDA added a liver injury warning⁷. In December 2024, it upgraded that to a boxed warning, its most prominent kind⁷.

The FDA described a case in which a patient developed jaundice and very high liver enzymes within 40 days of starting the drug. It cleared up after the drug was stopped⁷.

If you take it, the FDA advises liver blood tests before you start, every month for the first three months, and at months 6 and 9⁷. Stop and call your prescriber if you notice unusual tiredness, nausea, vomiting, itching, yellow eyes or skin, light-colored stools, dark urine, belly swelling or pain in the upper right belly⁷.

Elinzanetant (Lynkuet), made by Bayer, was approved on October 24, 2025⁸. In two trials published in JAMA in 2024, called OASIS 1 and 2, nearly 800 women aged 40 to 65 took the drug or a placebo⁹.

Women started with about 14 moderate to severe hot flashes a day. At 12 weeks, those on the drug had about 3 fewer a day than those on placebo⁹¹⁰. Their sleep disturbance scores improved more, too⁹¹⁰.

Now look at the placebo group. Women taking dummy pills dropped from about 15 hot flashes a day to about 9¹⁰. Only a placebo comparison shows what a drug adds.

Bayer funded the research, and several authors list Bayer affiliations⁹¹⁰. In a year-long trial, 5.1% of women on the drug reported sleepiness, versus 1.3% on placebo, and 12.5% left the study, versus 4.1%¹⁰.

The label calls for two 60 mg capsules at bedtime, liver tests before starting and at 3 months, and no driving if you feel drowsy or impaired⁸. The drug must not be used in pregnancy because of a risk of pregnancy loss⁸.

Older options remain. Low-dose paroxetine, an antidepressant, is FDA-approved for hot flashes and improved disrupted sleep in trials². Gabapentin often causes drowsiness, so the panel said a bedtime dose makes sense for women whose hot flashes break up their sleep².

Hormone therapy’s warning label is being rewritten

In SWAN, women with natural menopause who used hormone therapy had less trouble falling asleep and fewer night wakings, though the lead researcher said the pattern wasn’t consistent³. That’s an observational finding, but it fits the Society’s view that hormones treat hot flashes best².

On November 10, 2025, the FDA asked makers of menopausal hormone therapy to remove language about heart disease, breast cancer and probable dementia from the boxed warning¹². It asked them to keep the boxed warning about endometrial cancer on systemic products that contain estrogen alone¹².

The FDA also asked makers to drop the advice to use the lowest dose for the shortest time. It suggested that women under 60, or within 10 years of menopause, be considered for treatment of moderate to severe hot flashes¹².

On February 12, 2026, the FDA approved the first six revised labels; 29 companies had submitted changes¹¹. The agency pointed to randomized trials in which women who started hormones within 10 years of menopause, generally before 60, had lower death rates and fewer fractures¹¹. Warnings about heart disease and breast cancer stay elsewhere on the label for systemic products¹².

We found no FDA announcement of later batches as of October 2026, so your product’s label may not have changed yet. Demand has risen, though. In September 2026, the FDA said some women couldn’t find their usual estradiol patch, even though patches were still available¹².

A new label doesn’t change your own history, such as a past blood clot or breast cancer², so talk it through with a clinician who knows you. Our article on hormone claims covers compounded “bioidentical” products.

How strong is the evidence?

Approach	Evidence level	What the research shows
CBT for insomnia (CBT-I)	Strong evidence	A randomized trial in women with hot flashes found large, lasting gains; a pooled analysis agreed256
CBT for hot flashes	Strong evidence	Recommended by The Menopause Society; makes hot flashes less bothersome2
Clinical hypnosis	Strong evidence	Hot flashes fell 74% vs. 17% in a 187-woman trial2
Hormone therapy	Strong evidence	Most effective hot flash treatment; personal risks vary211
Fezolinetant or elinzanetant	Strong evidence	Fewer hot flashes than placebo in maker-funded trials; liver and sleepiness warnings78910
Cooling tricks or avoiding triggers	Not enough evidence	Few or no trials for hot flashes; may still add comfort2
Soy	Not enough evidence	Mixed results from small, short studies2
Paced breathing for hot flashes	Evidence says no, or unsafe	Failed to beat comparison breathing or standard care in larger trials2
Black cohosh	Evidence says no, or unsafe	No better than placebo across 16 trials; liver injury reports2
Yoga or exercise to stop hot flashes	Evidence says no, or unsafe	No effect on hot flash frequency in pooled trials; this rates the hot flash claim only2

A two-week menopause sleep plan

This plan is our own design, built from the research above. It hasn’t been tested as a package.

Days 1 to 14: track the pattern. Each morning, jot down:

• bedtime, wake time and roughly how long you lay awake;
• how many times hot flashes or sweats woke you;
• whether you woke without feeling hot;
• snoring or gasping your partner noticed, and any leg discomfort;
• your mood, from 1 to 5.

If you mostly wake hot, hot flash treatment is the lever. If you lie awake after cooling off, insomnia care is.

Every night: make comfort easy. Keep a fan, a glass of water and a spare top by the bed. Use light layers you can shed. Our articles on bedroom temperature and sleep comfort cover cooling and fabrics. Rate these as comfort aids, not hot flash cures².

Starting now: borrow from CBT-I. Pick one wake time and keep it daily. Keep the bed for sleep and sex. If you’ve lain awake a long time and feel wound up, get up and do something calm until sleepy. That’s the idea behind CBT-I’s stimulus-control rules⁵⁶.

At your appointment, ask:

• Do my notes point to hot flashes, insomnia, apnea, restless legs or mood?
• Can I get CBT-I or clinical hypnosis, by phone, video or app?
• If I try fezolinetant, what’s my liver-test schedule?
• If I try elinzanetant, how might sleepiness affect driving the next morning?
• Given my age, years since menopause and history, what are my risks with hormone therapy?
• Do any of my supplements or medicines interact with these options?

When to get help

See a clinician if any of these show up regularly:

• falling asleep often takes you longer than half an hour¹⁴;
• you wake several times and struggle to get back to sleep, or you wake too early¹⁴;
• you feel very sleepy during the day or doze off at the wrong times¹⁴;
• you snore loudly, snort, gasp or stop breathing for short spells¹⁴;
• you feel creeping or tingling in your legs that eases when you move¹⁴.

Talk with a provider if signs of depression, such as sadness, loss of enjoyment or early waking, don’t go away¹⁵. If you take fezolinetant and notice signs of liver trouble, stop it and call your prescriber⁷. In a crisis, call or text 988¹⁵.

Questions readers ask

The bottom line

Menopause can steal sleep in more than one way. Hot flashes matter, but so do insomnia, sleep apnea, restless legs and mood, and each calls for a different response. Two weeks of notes can show you which is in charge.

Some of the best-supported hormone-free help, CBT for insomnia and clinical hypnosis, uses no pills. Hormone therapy remains the strongest hot flash treatment, and its label is being revised. Newer pills work but need monitoring. Many popular herbs and tricks either failed their tests or haven’t had fair ones yet.

Related reading

• Real hormone problems have names and tests, which “balance your hormones” claims lack
• Your body sheds heat to fall asleep, and the 60 to 67°F rule is only a rough guide
• Who paid for the study matters, even when the science is real
• Placebos ease how you feel but rarely change what doctors measure
• What happens when you don’t tell your doctor about supplements

Sources

1. The North American Menopause Society (now The Menopause Society). “The North American Menopause Society Releases 2023 Nonhormone Therapy Position Statement.” News release, June 1, 2023. menopause.org
2. Shufelt CL, Brown V, Carpenter JS, et al. “The 2023 Nonhormone Therapy Position Statement of The North American Menopause Society.” Menopause, 2023;30(6):573–590 (copy hosted by the University of Washington). depts.washington.edu
3. Rush University Medical Center. “Menopause and Sleep” (news release on Kravitz HM, et al., Sleep, 2008, Study of Women’s Health Across the Nation). ScienceDaily, July 3, 2008. sciencedaily.com
4. Contemporary OB/GYN. “SWAN Analysis: Sleep, Not VMS Alone, Drives Quality of Life Decline in Menopause” (Pauline M. Maki, SLEEP 2026 Annual Meeting). June 23, 2026. contemporaryobgyn.net
5. McCurry SM, Guthrie KA, Morin CM, et al. “Telephone-Based Cognitive Behavioral Therapy for Insomnia in Perimenopausal and Postmenopausal Women With Vasomotor Symptoms: A MsFLASH Randomized Clinical Trial.” JAMA Internal Medicine, 2016;176(7):913–920 (Kaiser Permanente Division of Research record). divisionofresearch.kaiserpermanente.org
6. Fred Hutchinson Cancer Research Center. “Telephone-based therapy improves insomnia, reduces hot flash interference in menopausal women.” ScienceDaily, May 23, 2016. sciencedaily.com
7. U.S. Food and Drug Administration. “FDA Adds Warning About Rare Occurrence of Serious Liver Injury With Use of Veozah (fezolinetant) for Hot Flashes Due to Menopause.” Drug Safety Communication, September 12, 2024; Boxed Warning update December 16, 2024. fda.gov
8. U.S. Food and Drug Administration. “Lynkuet (elinzanetant) Capsules: Prescribing Information,” revised October 2025, and NDA 219469 approval letter, October 24, 2025. accessdata.fda.gov and accessdata.fda.gov
9. Pinkerton JV, Simon JA, Joffe H, et al. “Elinzanetant for the Treatment of Vasomotor Symptoms Associated With Menopause: OASIS 1 and 2 Randomized Clinical Trials.” JAMA, 2024. DOI 10.1001/jama.2024.14618 (George Washington University repository record). hsrc.himmelfarb.gwu.edu
10. MDedge. “Elinzanetant Shows Significant Improvement in Menopausal Vasomotor and Sleep Symptoms” (The Menopause Society 2024 Annual Meeting). September 23, 2024. mdedge.com
11. U.S. Food and Drug Administration. “FDA Approves Labeling Changes to Menopausal Hormone Therapy Products.” Press announcement, February 12, 2026. fda.gov
12. U.S. Food and Drug Administration. “FDA Requests Labeling Changes Related to Safety Information to Clarify the Benefit/Risk Considerations for Menopausal Hormone Therapies,” November 10, 2025; and “FDA Update on Estradiol Transdermal Patch Availability,” September 3, 2026. fda.gov and fda.gov
13. European Menopause and Andropause Society. “Sleep Problems and the Menopause.” Menopause Essentials, 2024. emas-online.org
14. MedlinePlus. “Sleep Disorders.” National Library of Medicine, updated December 4, 2025. medlineplus.gov
15. National Institute of Mental Health. “Depression.” NIH Publication No. 24-MH-8079, revised 2024. nimh.nih.gov