Why the small hours
Night-time vasomotor events fragment sleep whether or not you wake fully aware of a flush, and they cluster in the second half of the night. Add a falling progesterone contribution — progesterone has a mild sedative effect through its metabolites — and the result is a specific pattern: asleep by eleven, awake at three, unable to settle until five.
What the evidence supports
Cognitive behavioural therapy for insomnia has the strongest randomised evidence in this population and outperforms sleep medication over the long run. Menopausal hormone therapy improves sleep largely by reducing night-time vasomotor events, so it helps most where those are the driver. Alcohol is the most common self-treatment and the most reliably counterproductive — it shortens sleep latency and wrecks the second half of the night, which is exactly the half already under attack.
And the thing to rule out
Obstructive sleep apnoea rises sharply in women after menopause and is dramatically under-diagnosed, partly because the textbook picture is a snoring man. If you wake unrefreshed, snore, or have been told you stop breathing, ask for a sleep study before you ask for anything else.
Key points
- Staying asleep is the problem, and it often comes first.
- CBT-I has the strongest long-run evidence; alcohol reliably makes it worse.
- Rule out sleep apnoea — it is common here and badly under-diagnosed.
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