Key points
- The risk of insomnia is about 1.4 times higher in women, and the gap widens with age[1].
- At the menopause, CBT-I improves insomnia even when hot flushes are present, without making them go away[3][5].
- During pregnancy, CBT-I has been shown to work both face to face and online, with adapted settings[6][7].
- Sleep can be slightly worse before a period, but the average difference is small[9].
More common in women
A meta-analysis covering more than a million people found the risk of insomnia to be 1.4 times higher in women, a gap that widens with age[1]. Estimates vary between studies and depending on how insomnia is defined.
There are many explanations, and hormones are not the whole story: stages of life (pregnancy, birth, menopause), pain, anxiety and depression, which are more common in women, and the demands of daily life all add up. As with anyone, it is often the habits that keep insomnia going that make it last.
The menstrual cycle
Some women sleep less well before or during their period, especially with premenstrual syndrome or painful periods. But on average the effect is modest: in a study that followed 395 cycles, sleep quality was slightly worse before periods, with a clinically minimal difference that disappeared once stress was taken into account[9].
No trial has yet studied CBT-I specifically for insomnia linked to the cycle. If your difficulties come back every month, noting them in a sleep diary along with the day of your cycle helps you see things clearly and talk about them with your doctor.
In ReSomnia
If you wish, the diary lets you note your periods, the day of your cycle, premenstrual syndrome or hot flushes. A “cycle cannot be tracked” option is there for continuous contraception, a hormonal coil or after the menopause.
During pregnancy
Pregnancy often turns sleep upside down. Two solid trials show that CBT-I helps:
- Face to face: in 179 pregnant women with insomnia, the ISI score fell from 15.4 to 8.0 with CBT-I, compared with 15.9 to 11.2 with a comparison therapy; 64% of the women no longer had insomnia, compared with 52%[6].
- Online: in 208 pregnant women, a digital CBT-I programme clearly reduced the severity of insomnia compared with usual care[7]. Six months after the birth, these women were more likely to have recovered from insomnia[8].
Adapted settings
During pregnancy, sleep restriction is applied more flexibly, to limit tiredness: in ReSomnia, more cautious settings apply (a sleep window never under 5 hours 30 minutes, relaxed adjustment thresholds). Talk to your midwife or doctor. Be aware too that the usual sleep apnoea questionnaires are not reliable during pregnancy; loud snoring, pauses in breathing or high blood pressure should be reported directly to your doctor[10].
After the birth
Waking up to feed or comfort your baby is not insomnia: it is a lack of opportunity to sleep. Insomnia means being unable to sleep when you have the chance.
Among women who had used digital CBT-I during pregnancy, insomnia had more often resolved six months after the birth[8]. Results after childbirth are, however, less consistent than during pregnancy.
Your mood matters too
Sadness that does not lift, overwhelming anxiety or dark thoughts after the birth are reasons to see your doctor or midwife promptly. In an emergency, call 1813 (in Dutch) or 0800 32 123 in Belgium, 116 123 in the UK and Ireland, 988 in the US, or 112 or your local emergency number.
At the menopause
Sleep problems are common during and after the menopause, including in women who have no hot flushes[2]. It is also the stage of life at which CBT-I has been best studied in women:
- With hot flushes: in 106 perimenopausal or postmenopausal women, CBT-I by telephone lowered the ISI score by 9.9 points, compared with 4.7 with an information programme. The number of hot flushes did not change, but they were less bothersome[3].
- After the menopause: in 150 women, the ISI score fell by 7.7 points with CBT-I, by 6.6 with sleep restriction alone, and by only 1.1 with sleep hygiene advice[4].
- Compared with other approaches: in an analysis of four trials, insomnia fell more with CBT-I than with exercise, yoga, oestrogen or certain antidepressants, but each treatment was only compared with its own control group, not directly with the others[5].
CBT-I does not replace care for hot flushes: hormonal or non-hormonal treatment is something to discuss with your doctor or gynaecologist. But the insomnia itself can be treated, even when the flushes persist.
What not to believe
- “It's the menopause, you just have to live with it.” No: menopausal insomnia responds to CBT-I[3][4].
- “CBT-I will make my hot flushes go away.” No: it improves sleep, not how often the flushes happen[3].
- “All women sleep badly before their period.” No: the average effect is small and varies widely from one woman to another[9].
- “It's hormonal, so there's nothing to be done.” Hormones play a part, but it is often habits and worry that keep insomnia going, and those can be worked on[11].