Perimenopause is the stage leading up to menopause, during which ovarian hormone levels fluctuate rather than decline in a steady, predictable way (Maki et al., 2024). During this transition, sleep often becomes less stable. Some women experience difficulty falling asleep, while others fall asleep but wake repeatedly through the night and feel unrefreshed in the morning.
Sleep disturbance is common in the menopause transition and is associated with increased night waking, longer periods of wakefulness after sleep onset, and reduced overall sleep quality (Maki et al., 2024). Vasomotor symptoms such as hot flushes and night sweats are strongly linked to sleep disruption, often fragmenting sleep continuity (The North American Menopause Society, 2023).
It is tempting to attribute perimenopause insomnia solely to declining oestrogen levels. However, current evidence suggests that sleep disturbance during this phase is usually multifactorial rather than purely hormonal (Maki et al., 2024). Mood changes, increased stress sensitivity, nocturia, pain, and age-related changes in sleep regulation can all contribute to disrupted sleep (The North American Menopause Society, 2023; Maki et al., 2024).
What it can feel like
Perimenopausal sleep disturbance does not present in a single uniform way.
Some women report difficulty falling asleep despite feeling tired, while others describe frequent night waking, light or fragmented sleep, early waking, or a general sense that sleep has become more fragile. These patterns are consistent with recognised insomnia presentations during the menopause transition (Maki et al., 2024).
Daytime effects can include fatigue, irritability, reduced concentration, and lower frustration tolerance. Non-restorative sleep is a common feature, particularly when night sweats or repeated awakenings disrupt sleep cycles (Maki et al., 2024).
What usually needs to be considered
When sleep becomes disrupted during perimenopause, the key question is not only how to improve sleep, but what factors are maintaining the instability.
In some individuals, vasomotor symptoms such as hot flushes are the primary driver. In others, insomnia may be more strongly associated with stress, anxiety, conditioned sleep disturbance, pain, or underlying sleep disorders (The North American Menopause Society, 2023).
Clinical guidance highlights that insomnia during the menopause transition may coexist with other conditions such as obstructive sleep apnoea, restless legs syndrome, mood disorders, or nocturia (The North American Menopause Society, 2023; Maki et al., 2024). This reinforces the importance of proper assessment rather than assuming a single cause.
Management is therefore not one-size-fits-all. If vasomotor symptoms are dominant, treatment often targets these directly. If the presentation aligns more closely with chronic insomnia, cognitive behavioural therapy for insomnia (CBT-I) is recommended due to its strong evidence base (The North American Menopause Society, 2023).
Hormone therapy may also be considered in appropriate patients, particularly when vasomotor symptoms are significant, but it is not the only pathway (The North American Menopause Society, 2023).
What research shows
The menopause literature consistently recognises sleep disturbance as a common and clinically significant issue during the transition, often linked to vasomotor symptoms, mood, and circadian changes (Maki et al., 2024).
For acupuncture, the evidence base is growing but remains limited.
A randomised controlled trial by Fu et al. (2017) found that acupuncture led to greater short-term improvements in subjective sleep quality compared with placebo acupuncture, along with changes in some objective sleep measures.
Li et al. (2020) conducted a randomised controlled trial comparing electroacupuncture with sham acupuncture in women with perimenopausal insomnia and reported improvements in sleep quality and quality-of-life outcomes.
A broader trial by Liu et al. (2018), involving women undergoing the menopause transition, found improvements in menopause-related symptoms with acupuncture, although insomnia was not the sole outcome measured.
More recently, a systematic review and meta-analysis by Qin et al. (2024) concluded that acupuncture improved sleep quality compared with sham, waitlist, or medication in the included trials. However, the authors also noted that the overall quality of evidence remains limited and that further high-quality studies are required.
Overall, the evidence can be described as promising but not definitive.
Where acupuncture may fit in practice
In clinical practice, acupuncture is generally considered as part of supportive care rather than as a replacement for medical assessment.
It may be discussed when insomnia occurs alongside vasomotor symptoms, stress reactivity, muscular tension, or a broader cluster of perimenopausal symptoms. Some individuals seek non-pharmacological options, while others may use acupuncture alongside conventional treatments.
Current research suggests that sleep quality may improve in some women, particularly when insomnia is part of the menopause transition rather than an isolated sleep disorder (Fu et al., 2017; Li et al., 2020; Qin et al., 2024).
At the same time, it is important not to oversimplify. If sleep disturbance is driven by factors such as severe vasomotor symptoms, nocturia, sleep-disordered breathing, anxiety, or depression, these require appropriate assessment and management (The North American Menopause Society, 2023).
When further assessment matters
Although sleep disturbance is common during perimenopause, certain patterns require further evaluation.
These include ongoing severe insomnia, loud snoring or witnessed apnoeas, waking with choking sensations, significant mood symptoms, marked daytime sleepiness, or rapidly worsening symptoms.
Menopause guidance highlights the importance of considering other sleep disorders and medical conditions rather than attributing all symptoms to hormonal changes (The North American Menopause Society, 2023; Maki et al., 2024).
Important notice
This information is provided for general educational purposes only and does not replace individual medical advice, diagnosis, or treatment. Outcomes may vary between individuals. Treatment decisions are made based on a personalised assessment. If you have any health concerns, please consult a qualified healthcare professional.
References
Fu, C., Zhao, N., Liu, Z., Yuan, L., Xie, C., Yang, W., Liu, C., Carda, S., & Liang, F. (2017). Acupuncture improves peri-menopausal insomnia: A randomized controlled trial. Sleep, 40(11), zsx153. https://doi.org/10.1093/sleep/zsx153
Li, S., Wang, Z., Wu, H., Zhang, S., Wang, X., Wang, Y., Chen, J., Li, X., Wu, X., Jiang, H., Wang, K., Wang, Q., Yue, Z., Li, R., Li, C., & Liu, C. (2020). Electroacupuncture versus sham acupuncture for perimenopausal insomnia: A randomized controlled clinical trial. Nature and Science of Sleep, 12, 1201–1214. https://doi.org/10.2147/NSS.S282315
Liu, Z., Ai, Y., Wang, W., Chen, X., Wang, H., Wang, L., Yu, C., Cao, H., Xia, T., Zhang, S., Yang, X., Xu, L., Li, Y., Wu, X., Hao, C., Ni, H., & Liu, J. (2018). Acupuncture for symptoms in menopause transition: A randomized controlled trial. American Journal of Obstetrics and Gynecology, 219(4), 373.e1–373.e10. https://doi.org/10.1016/j.ajog.2018.08.019
Maki, P. M., Panay, N., & Simon, J. A. (2024). Sleep disturbance associated with the menopause. Menopause, 31(8), 724–733. https://doi.org/10.1097/GME.0000000000002386
Qin, L., Zhang, Z., Zhang, C., & Zhou, H. (2024). Efficacy and safety of acupuncture for perimenopausal insomnia: A systematic review and meta-analysis of randomized controlled trials. European Journal of Integrative Medicine, 72, 102404. https://doi.org/10.1016/j.eujim.2024.102404
The North American Menopause Society 2023 Nonhormone Therapy Position Statement Advisory Panel. (2023). The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause, 30(6), 573–590. https://doi.org/10.1097/GME.0000000000002200