We spoke to Dr. Sara Nowakowski, a leading expert on Cognitive Behavioral Therapy for Menopausal Insomnia (CBT-mi), to answer our questions about why so many women struggle with sleep during perimenopause.

Fifty percent of perimenopausal women experience insomnia. Why? 

Perimenopausal and postmenopausal women are up to two times more likely to report sleep issues than non-menopausal women. The fluctuation in hormones is one of the reasons women experience insomnia but not the only one. There are so many factors that insomnia experts often call it the Menopause Puzzle as there is a tangle of things to consider such as the effects of aging or a person’s individual medical issues. There are psychosocial factors to weave in as "Sandwich Generation" women in their mid-forties to early fifties feel considerable stress raising their children while caring for their aging parents while working demanding careers. It’s these stressors, combined with the hormonal changes, that make menopausal insomnia complicated. Changes in hormones can certainly bring on insomnia, but it’s one’s reaction to not getting sleep that may habituate insomnia. 

How does insomnia impact women throughout the daytime? 

Insomnia is a clinical disorder characterized by difficulty falling asleep, staying asleep, or waking too early. To meet the DSM-V diagnostic criteria for an insomnia disorder, these difficulties must be present for a minimum of three months and cause daytime impairment, such as negatively impacting one’s functioning at work, increasing levels of fatigue, diminished social functioning, and mood changes. It’s not unusual for people who suffer from insomnia to feel less patient, more muddled, and short-tempered. Many with insomnia report memory issues and a loss of the ability to think clearly. 

Is there a connection between insomnia and mental health? 

With clinical depression and anxiety issues, changes in one’s sleep—whether they’re sleeping too much or too little—are a symptom. And we also know that sleep deprivation can lead to significant changes in mood. There is a deeply circular connection between mood disorders and sleep issues. In studies with people with both clinical depression and insomnia, Cognitive Behavioral Therapy for Insomnia (CBTi) has beneficial effects for both conditions. Just by treating sleep issues, improvements in mood are seen. In basic terms, many nights of disrupted sleep can put a person in a weakened place mentally. Insomnia clearly impacts our patience and ability to handle frustration—it’s not a fun place to be. We don’t talk enough about menopause and its impact on mental health. While the transition is a natural thing, the symptoms can leave people feeling as if there’s something wrong with them, as if they’re a bit “crazy” or not in control. There is a connection between insomnia and clinical depression and anxiety. 

Can you describe Cognitive Behavioral Therapy for Menopausal Insomnia (CBT-mi) and why it’s so effective in treating insomnia?

Cognitive Behavioral Therapy for Menopausal Insomnia is centered upon the idea that your thoughts – both helpful and unhelpful—impact your physical and emotional well-being. Negative thinking may keep a person trapped in an unhealthy sleep cycle. CBTMI is a short-term technique delivered over 4 - 6 sessions that includes sleep education, sleep restriction, stimulus control, and cognitive restructuring.

For CBTi, we focus on how thoughts interfere with sleep. A lot of times when you’re in bed and unable to sleep, your brain is going to want to entertain itself. It’s going to think of things, good or bad. This thinking may begin to loop or spiral, creating the feeling that the thoughts cannot be turned off. The more mental energy one puts into trying to stop such thinking, the worse it affects sleep. 

CBT-mi focuses on reframing one’s thoughts more positively. When I work with a new client, we spend about an hour together so I can evaluate their history: When did your insomnia begin? What was going on? Do you have depression? What medications do you take? I will go through a 24-hour day with them: What is their nighttime ritual? How do they relax? What do they do once in bed? What happens when they cannot sleep? I also ask about their diet and exercise habits – all of the things that factor into overall sleep health.

I then send clients home with a one-week sleep diary in which they track their sleep quality and patterns. From there, I develop a strategy and start on the behavioral piece. When people can’t sleep, they try to compensate, such as by taking a nap or sleeping in. This does not work. Almost counter-intuitively, I ask clients to restrict their time in bed. The goal is to build sleep pressure, respecting that the body has a natural appetite for sleep. The goal is to increase sleep quality, not time spent in bed trying to sleep. I coach people to trust in their body, accept where it is, and allow it to naturally return to sync.

What are some helpful tips for people when they cannot sleep?
  1. Go to bed when sleepy. Don’t try to force that time. Allow your sleepiness to tell you when you need to go to bed.
  2. If you fall asleep but wake in the middle of the night, as often happens when experiencing hot flashes, follow the 15 - 20 minute rule. If you’re not back to sleep within that time, get up! Use the bathroom, and walk around. Leave the bedroom and find something peaceful and non-purposeful to do: maybe read a book or listen to a podcast (note, this is not the time to clean your house or check your emails). The core tenet is to stop the idea of forcing sleep and trust that the body will self-regulate. It’s interesting to know that during a hot flash, the body rapidly heats in just 30 seconds and the “flash” lasts about five minutes, but it takes the body about 20 minutes to fully cool. Abiding the 15 - 20 minute rule allows peaceful cooling while not perseverating about sleep.
  3. During an interrupted sleep night, keep the same rise time! This is key—do not chase sleep. If you get a bad night’s sleep, do not try to compensate for it the next morning. Getting up at the regular time builds the body’s sleep hunger. You may feel tired that day but it’s an investment in restorative sleep the following night. Trust the notion that your sleep will naturally reset. Accept where your body is today, commit to letting the consequences happen, and build your sleep appetite to stop the insomnia cycle.

CBT is a behavioral technique. Should it be used in tandem with sleep medication?

Sleep medication tends to work quickly and is designed to be used short-term. It’s not a permanent solution. CBT-i builds long-term skills one can use when faced with poor sleep, and because insomnia is episodic, one can use those tools whenever needed. It may be helpful to use sleep medication to provide fast relief, but ideally, it should only be used for small amounts of time.

How can women find qualified CBT therapists?

The Society of Behavioral Sleep Medicine has a page on its website to help people find local CBT providers (click here). Another helpful resource is the Veteran Association’s free insomnia workbook. Although it was designed for returning veterans, it’s a great way for one to work through their own sleep issues (download the workbook here). I wrote an article for the North American Menopause Society about CBTi for insomnia (access it here). In it, I recommend to clinicians that if they have a client whom they suspect has insomnia to consider referring them to a sleep medicine clinic or behavior sleep medicine provider for evaluation.

Dr. Sara Nowakowski is a licensed Clinical Psychologist in the state of Texas and Board certified in Behavioral Sleep Medicine. She is an Associate Professor at Baylor College of Medicine Section of Health Services Research in the Department of Medicine, located within the Center for Innovations in Quality, Effectiveness & Safety, a combined Baylor and VA Health Services Research & Development Center for Innovation. She treats patients with insomnia and other sleep disorders in the Baylor Sleep Medicine Clinic in Houston, TX.