Waking up at 3 a.m. and not being able to fall back asleep. Feeling low or irritable for reasons you can’t quite name. For many people, these are some of the hardest parts of menopause, and now, the guidance is catching up. ACOG's new clinical practice guideline includes specific recommendations for sleep and mood in their own right, not just as side effects of the more talked-about hot flashes. 

What hormone therapy does for sleep

If night sweats are keeping you up, hormone therapy may help. ACOG strongly recommends systemic hormone therapy for sleep problems related to night sweats in people without contraindications. There’s an important caveat, though: most studies included women who also had hot flashes, so ACOG says it's unclear whether hormone therapy helps sleep for people who don’t have them. 

It’s also worth knowing what “help” means here. In a meta-analysis of 15 randomized trials, hormone therapy improved self-reported sleep quality but did not improve objective sleep measures recorded by polysomnography, including how long people slept, how quickly they fell asleep, or how often they woke up.

If you’re considering hormone therapy for sleep, the type may matter. The largest improvements came with transdermal delivery and with 17β-estradiol. Among progestogens, only micronized progesterone or medroxyprogesterone acetate regimens showed improvement.

Read more about ACOG’s new menopause guidance here.

Why antidepressants have stronger evidence for mood than for sleep

ACOG strongly recommends SSRIs or SNRIs for menopausal symptoms, including depression, in people who don't want or can’t take hormone therapy.

For mood, a meta-analysis of seven randomized trials in 1,676 perimenopausal and postmenopausal women found a moderate improvement in depression severity compared with placebo, whether an SSRI or SNRI was used. The main difference was in side effects: people taking  SNRIs were more likely to stop treatment because of them.

For sleep, the evidence is weaker. ACOG notes these medications may offer little to no benefit for menopause-related sleep disruption. One meta-analysis did find a small improvement in sleep quality, but “statistically significant” doesn’t always mean you’ll notice a difference at 3 a.m. So it's reasonable to expect antidepressants to help more with mood than with sleep.

Where elinzanetant fits if sleep is your main complaint

Elinzanetant (Lynkuet) is one of two neurokinin receptor antagonists that ACOG now strongly recommends for hot flashes and related sleep problems. It's also the one with the most direct evidence on sleep. 

In OASIS 1 and OASIS 2, two placebo-controlled randomized trials of about 400 participants each, 12 weeks of elinzanetant significantly reduced hot flash frequency and severity and decreased sleep disturbance. An indirect comparison found elinzanetant and fezolinetant worked similarly for hot flashes, with elinzanetant scoring better on a validated sleep score. 

There are two caveats. The comparison wasn’t a head-to-head trial, and OASIS was placebo-controlled only for the first 12 weeks.

Hormone therapy isn’t proven to treat depression on its own

This is one of the clearest statements in the guidance, and it pushes against a lot of what circulates online. ACOG found the evidence insufficient to recommend for or against hormone therapy for menopause-related depressive symptoms. It may improve depressive symptoms in perimenopausal people specifically and may enhance antidepressant treatment, but studies have not shown it beats placebo for depression in postmenopausal people.

If you meet the criteria for major depressive disorder, or depression is your main symptom, ACOG recommends following standard depression treatment guidelines, with antidepressants and cognitive behavioral therapy as first-line options. Having menopausal symptoms alongside it doesn't change that. The strongest known risk factor is a history of major depressive disorder.

Therapy, mindfulness, and movement

ACOG also suggests cognitive behavioral therapy (CBT), mindfulness-based interventions, and physical exercise for menopause-related sleep and mood symptoms. These are conditional recommendations based on low-to-moderate–quality evidence, and ACOG sees them as working best alongside medication, not in place of it.

CBT isn't about convincing yourself your symptoms aren’t real. It's a structured, short-term approach that helps reduce how much symptoms disrupt your life. Across the meta-analyses ACOG reviewed, 6 to 12 weeks of CBT moderately reduced sleep problems and had a small-to-moderate effect on depressive symptoms, though the benefits may fade over time. The biggest hurdles are usually cost and finding a trained therapist, but ACOG notes that online and phone-based CBT may help.

Mindfulness isn’t just seated meditation. It also includes breathing work and yoga. In a Bayesian network meta-analysis of nonpharmacologic interventions for menopause-related insomnia, mindfulness ranked first for sleep quality and CBT second. Keep in mind that the ranking came from comparing trials indirectly, not head-to-head, so both have good support, and neither is proven better.

Exercise improved sleep across 25 randomized trials, with longer sessions showing larger effects, though shorter ones helped too. There’s one important exception: in nine trials that specifically enrolled women with hot flashes, exercise showed no significant sleep improvement. If you're waking up drenched, movement alone may not be the lever.

Clinical hypnosis and acupuncture also carry conditional recommendations, though the evidence is weaker, and they can be harder to access or get covered by insurance.

What's worth ruling out first

Not all sleep problems in midlife are caused by hormones, and assuming they are can delay getting the right diagnosis. ACOG points to several other possible causes. Sleep disorders like insomnia, sleep-disordered breathing, and restless legs syndrome all become more common with age. Some medications that affect the central nervous system can disrupt sleep, and so can other health conditions and stressors. If your problem is loud snoring and waking unrefreshed rather than waking hot, tell your provider that specifically, since it may point to something other than menopause

Navigating menopause with Maven Clinic

With Maven Clinic, you have a care team in your corner, including OB-GYNs and menopause specialists, who look at the full picture of your health. We look at your symptoms, health history, and goals to help you decide whether hormone therapy, a non-hormonal option, or a combination of both is right for you.

Discover our approach to hormone care.