Sleep and Midlife: Part 1 - Why It Gets Complicated (and What You Can Do About It)

Sleep is the foundation of health. If you’ve read Why We Sleep by Matthew Walker, you already know how profoundly it shapes everything from mood to memory to long-term disease risk. For my patients, sleep is something we always come back to—because when it improves, so does almost everything else about how you feel day to day.

This post is the first in a series on insomnia: what it is, why it often shows up for the first time in midlife, and what you can do about it.

What Exactly Is Insomnia?

Clinically, insomnia is defined as:

• Difficulty falling asleep, staying asleep, or both

• Happening at least three nights a week

• Lasting three months or more

• With daytime consequences (fatigue, poor focus, irritability, etc.)

That time frame matters—it helps distinguish chronic insomnia from short-term sleep issues caused by stress, travel, or life events.

Why Sleep Gets Complicated in Midlife—Especially for Women

For many women, midlife brings unique sleep challenges tied to both aging and the menopause transition. The tricky part? It’s often hard to tell whether sleep problems are caused by menopause itself or just the natural effects of getting older.

Experts group midlife insomnia into four main categories:

• Menopause-related insomnia – often linked to hot flashes and night sweats, but still underdiagnosed

• Primary insomnia – sleep difficulties without another clear medical or psychological cause

• Secondary insomnia – tied to other health issues, mental health conditions, or sleep disorders

• Behavioral/environmental insomnia – influenced by stress, lifestyle, or surroundings

Large studies like SWAN and the Penn Ovarian Aging Study found that hot flashes and night sweats—not hormone levels—are the strongest predictors of sleep problems. Women experiencing these symptoms report more sleep complaints and are also at higher risk for depression.

Anxiety adds another layer. It’s the single strongest predictor of poor sleep quality, and it often coexists with depressed mood and vasomotor symptoms. This creates a cycle: poor sleep worsens mood, mood struggles worsen sleep, and both chip away at resilience and well-being.

In short: sleep disturbances during the menopause transition aren’t just about hormones. They’re the result of a complex web of mood, anxiety, and physical changes that feed into one another.

Tackling Insomnia: Treatment Options

Because insomnia is rarely caused by just one factor, the best results usually come from a multi-pronged approach. Here are some of the strategies I often discuss with patients:

• Rule out other conditions – First, make sure other medical or mental health issues aren’t driving the sleep problems.

• Sleep hygiene basics – Lifestyle strategies (consistent bedtime, limiting screens, optimizing your sleep environment) are always worth reviewing.

• Hormone therapy – Progesterone can improve relaxation and reduce anxiety, while estrogen may help reduce hot flashes and night sweats. Together, they can stabilize the hormonal fluctuations that disrupt sleep.

• Sleep-supportive supplements – Extended-release melatonin, passionflower, valerian, hops, and chamomile are some options that may reduce nighttime restlessness.

• Cognitive Behavioral Therapy for Insomnia (CBT-I) – This structured approach, often done with a practitioner or workbook, has some of the strongest evidence for improving chronic insomnia.

The Takeaway

Insomnia in midlife is common, but it’s not inevitable—and it’s not something you have to just “live with.” By understanding the interplay between hormones, mood, and lifestyle, you can take steps to restore better sleep and, with it, better health.

If you’re struggling with sleep during this stage of life, know that you’re not alone—and that there are many effective strategies to help you rest easier.