Perimenopause Insomnia vs Sleep Apnea: Why Both Are Often Missed in Women
Poor sleep in perimenopause can stem from hormonal insomnia or undiagnosed sleep apnea. Learn the key differences and what to ask at your next appointment.
Sleep becomes complicated in midlife
Disrupted sleep is one of the most commonly reported and most debilitating symptoms of perimenopause. Women who previously slept well find themselves lying awake for hours, waking repeatedly through the night, or rising feeling exhausted despite apparently adequate time in bed. The causes are more varied than many women and their doctors realise. Hormonal insomnia driven by perimenopause is one explanation, but obstructive sleep apnea is another, and it is significantly underdiagnosed in women. Distinguishing between the two, or identifying when both are present, is important because the treatments are completely different and using only one approach when both conditions exist leaves a significant gap in care.
How perimenopause disrupts sleep
Estrogen and progesterone both play roles in sleep regulation. Progesterone has a sedating effect through its action on GABA receptors in the brain, and as levels fall during perimenopause this natural sleep support is reduced. Estrogen influences serotonin and other neurotransmitters involved in sleep-wake regulation. Hot flashes and night sweats are a direct cause of sleep fragmentation: the sudden temperature surge wakes women, often repeatedly, and it can take time to cool down and settle again. Anxiety, which is common in perimenopause, also interferes with sleep onset and maintenance. The pattern in perimenopause tends to involve difficulty returning to sleep after waking rather than inability to fall asleep initially, though both occur.
How sleep apnea presents in women
Obstructive sleep apnea occurs when the upper airway partially or fully collapses during sleep, causing repeated breathing pauses that fragment sleep and reduce oxygen levels. It is strongly associated with snoring and excessive daytime sleepiness, and it is these features in men that have historically defined the clinical picture of the condition. However, women with sleep apnea often present differently. They are more likely to report insomnia, fatigue, headaches on waking, and mood disturbance than the classic male presentation of loud snoring and visible breathing pauses. This different symptom profile means sleep apnea in women is frequently attributed to depression, anxiety, or in midlife women, perimenopause, and the correct diagnosis is delayed.
Why sleep apnea risk increases at perimenopause
Progesterone has a protective effect on upper airway muscle tone during sleep, and its decline during perimenopause increases the likelihood of airway collapse. Research shows that sleep apnea prevalence rises sharply after the menopause transition. Women who had no sleep apnea in their thirties may develop it in their forties or fifties. Weight gain around the abdomen and neck, which is also associated with perimenopause, further increases risk. This convergence of risk factors means that perimenopause and sleep apnea frequently coexist, and treating only the hormonal component of poor sleep while leaving sleep apnea unaddressed produces limited improvement in sleep quality and daytime function.
How to tell which is affecting your sleep
A few features help distinguish predominantly hormonal insomnia from sleep apnea. If your sleep disruption is clearly linked to hot flashes and night sweats, with waking moments accompanied by heat, sweating, or heart pounding, perimenopause is likely a significant contributor. If you wake gasping or with a headache, if your partner reports snoring or witnessed breathing pauses, or if you feel more tired than your time in bed should explain, sleep apnea warrants investigation. Daytime sleepiness that is severe enough to be intrusive, particularly if accompanied by poor concentration that is present regardless of how much sleep you got, is more consistent with sleep apnea than with perimenopause-related fatigue. Using PeriPlan to log sleep quality and note when symptoms cluster around cycle events can help identify hormonal patterns.
Testing for sleep apnea
A home sleep apnea test involves wearing a small monitoring device overnight that measures airflow, oxygen levels, and respiratory effort. It is convenient and available through GP referral or privately, and it is appropriate as a first-line investigation for most women. A polysomnography study, conducted in a sleep laboratory, provides more detailed data and is used for complex cases or when a home test is inconclusive. The Epworth Sleepiness Scale questionnaire and the STOP-BANG questionnaire are used in clinical settings to assess pretest probability of sleep apnea. Women score differently on some of these tools than men, so it is worth mentioning that you want sleep apnea specifically assessed, as the referral threshold can differ.
Treating both conditions when they coexist
If perimenopause is the primary driver of poor sleep, addressing hormonal balance through lifestyle changes, improved sleep hygiene, and where appropriate hormone therapy often restores sleep significantly. Night sweats in particular respond well to estrogen therapy. If sleep apnea is confirmed, continuous positive airway pressure therapy is the most effective treatment and produces dramatic improvements in sleep quality, energy, and mood for most women who use it consistently. When both conditions are present, treating one without the other leaves a gap. Some women find that hormone therapy reduces the severity of mild sleep apnea by restoring progesterone's protective effect on airway tone, but this is not a substitute for sleep apnea treatment in moderate or severe cases.
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