You fall asleep just fine.

Then suddenly it's 3:07 a.m. and you're wide awake, thinking about something you said in 2014.

If this started happening in your 40s, perimenopause may be part of the picture.

Sleep problems are extremely common during the menopause transition. And while night sweats are an obvious culprit, plenty of women tell me their sleep has changed even though they're not waking up hot or sweaty.

Sometimes sleep is actually one of the first things to change.

Why does sleep change during perimenopause?

Perimenopause is a time of hormonal fluctuation. Estrogen and progesterone don't simply decline in a nice, predictable line — they can vary significantly throughout the transition.

At the same time, hot flashes and night sweats can make staying asleep difficult.

But hormones aren't the only factor.

Mood changes, anxiety, increased stress, alcohol, changing schedules and other medical conditions can all affect sleep. Sleep disorders such as obstructive sleep apnea and restless legs syndrome also become increasingly important to consider in midlife.

This is why I don't automatically assume that every woman waking at 3 a.m. simply needs hormones.

I want to know why she's waking up.

Why does poor sleep matter?

A bad night here and there isn't the problem.

It's persistent poor sleep that deserves our attention.

Chronic sleep disruption is associated with changes in mood, concentration, appetite and glucose regulation, as well as increased risk of cardiovascular disease and other health problems.

And you usually feel the effects long before we're talking about long-term disease risk.

You're exhausted.

You're more irritable.

Your workouts feel harder.

You're craving sugar at 3 p.m.

You have less capacity to deal with stress.

Then someone tells you to exercise more, meal prep and meditate.

Not exactly helpful when you're running on five hours of sleep.

Is it hormones or something else?

This is one of the most important questions.

If sleep suddenly changes during your 40s alongside menstrual changes, hot flashes, night sweats or other perimenopause symptoms, hormones may be contributing.

But we also need to consider other possibilities.

Are you snoring? Waking up gasping? Experiencing uncomfortable sensations in your legs? Drinking alcohol close to bedtime? Taking a medication that affects sleep? Is anxiety waking you up? Could iron deficiency, thyroid dysfunction or another health issue be contributing?

Sometimes several things are happening at once.

That's why treating “menopause insomnia” isn't always as simple as taking a sleep supplement.

What actually helps sleep during perimenopause?

The answer depends on what's driving the problem.

The basics still matter: consistent sleep and wake times, regular exercise, morning daylight exposure, limiting alcohol and being thoughtful about caffeine.

For chronic insomnia, cognitive behavioural therapy for insomnia (CBT-I) is an effective first-line treatment and something I wish more women knew about.

If hot flashes and night sweats are driving sleep disruption, treating those symptoms can make a significant difference. For an appropriate candidate, menopause hormone therapy (MHT/HRT) may be one option. Non-hormonal treatments are also available.

The goal isn't to throw everything at your sleep.

It's to figure out what is disrupting it in the first place.

My approach to sleep in midlife

I don't consider sleep a luxury.

It's one of the foundations I want to protect as women move through perimenopause and menopause.

If you're waking every night, dragging yourself through the day and being told this is simply part of getting older, I think we can do better than that.

Your sleep may be giving us useful information.

And sometimes improving sleep is one of the most impactful things we can do to help you feel like yourself again.

Struggling with sleep during perimenopause?

I work with women throughout British Columbia to understand what's changing during perimenopause and menopause and develop an individualized plan for symptoms, sleep and long-term health.

Book a perimenopause or menopause consultation with Dr. Jenny Ma, ND, MSCP.

This article is for educational purposes and is not a substitute for individualized medical advice.