Tag: Sleep Disorders

A made bed below a bedroom window with autumn leaves visible outside in daylight

Menopause and Sleep: What Is Actually Waking You Up

On By Dr. Scott RennieIn Menopause & Women's HealthLeave a comment

It is almost always three in the morning. You were asleep, and then you were not, and now you are doing arithmetic about how many hours are left before the alarm.

Somewhere along the way you decided this is menopause. It might be. But I have learned not to assume that, and the reason is that four or five different problems all arrive wearing the same costume.

The first thing I ask

What does not sleeping mean for you?

Trouble falling asleep is one thing. Waking up drenched at two in the morning is another. Waking at three for no reason you can name and lying there until five is a third. Those three answers send me down three different roads, and a woman who tells me only that she is not sleeping well has not yet told me the thing I need.

So we start there, before anyone says the word estrogen.

The one I do not want to miss

Here is what surprises patients: I do not automatically blame estrogen.

Menopause genuinely does fragment sleep. It also happens to be the stretch of life when obstructive sleep apnea stops being a mostly male problem. Prevalence climbs sharply after the transition, and in some series the majority of postmenopausal women have at least some degree of it (1). Surgical menopause, after both ovaries come out, roughly doubles the risk, and early menopause raises it as well (2).

The reason it gets missed is that everyone is looking for the wrong thing. The picture in most clinicians’ heads is a heavyset man who snores like a chainsaw and whose wife has watched him stop breathing. Women often do not present that way at all. They present with fatigue, morning headaches, trouble concentrating, waking to urinate, and insomnia (3). Every one of those gets filed under hormones, or stress, or getting older.

I use STOP-BANG. Not everyone does, and I know its performance in women is not what it is in men, but I would rather run a screen that is imperfect than rely on whether somebody’s husband has mentioned snoring.

Now the honest part, and it is a limitation of how I work rather than a clinical opinion. On the platform I currently practice through, I cannot order a home sleep apnea test. I would like that to change. What I can do is recognize the pattern, tell the patient plainly what I think is going on, and get her to someone who can test her. That is not as good as ordering it myself. It is considerably better than calling it menopause and moving on.

When the hot flashes really are the problem

Sometimes the story is simple. She wakes because she is soaked, three or four times a night, and has been for a year.

When vasomotor symptoms are driving the awakenings, treating the vasomotor symptoms usually fixes the sleep. That is the cleanest version of this problem and the most satisfying to treat. Hormone therapy works. Among the non-hormonal options, elinzanetant (Lynkuet) is worth knowing about: approved October 24, 2025, it blocks NK1 in addition to NK3, and the OASIS trials picked up an effect on sleep disruption rather than only on flash frequency (4). Fezolinetant, approved in 2023, works on NK3 alone.

If somebody’s nights are being destroyed specifically by the waking rather than the flashes themselves, the drug with a sleep signal behind it is the more logical place to start.

When insomnia has taken on a life of its own

The other pattern is the one where the hot flashes have settled down, or were never that bad, and she still cannot sleep. The insomnia has detached from whatever started it and become its own condition.

For that, cognitive behavioral therapy for insomnia is first-line. Not a suggestion, not an alternative to try if the pill does not work. It is what the American Academy of Sleep Medicine and the European Sleep Research Society both put ahead of medication for chronic insomnia, and that holds for menopausal women specifically (5).

I refer out for it. We have psychologists who work with us, which makes that referral considerably easier than it is in a lot of settings. I mention that because “CBT-I is first-line” is easy to write and genuinely hard to act on when there is nobody to send people to.

What I will prescribe, and what I will not

I am conservative with sleep medication, and more so after 60.

Before I write anything I want to know what is actually breaking the sleep. Night sweats. Sleep apnea. Restless legs. Alcohol. Pain. Another medication already on the list. Fix the cause and you often do not need the hypnotic at all.

When falling asleep is the main problem and medication is warranted, I may prescribe ramelteon 8 mg. It is not controlled, weight gain is not a typical adverse effect, and it has little dependence potential. The benefit is modest, and I say so upfront rather than letting somebody discover it themselves.

Melatonin can be reasonable when the timing of sleep is part of the problem. I do not present it as a strong treatment for chronic insomnia, and more is not better. Higher doses tend to buy morning grogginess and vivid dreams without buying much additional sleep. Magnesium comes up constantly. I am comfortable discussing a cautious trial when kidney function is normal, particularly if dietary intake is low, but the evidence in insomnia is weak and I will not pretend otherwise.

The list of things I do not do is longer. I do not start chronic benzodiazepines for sleep. I generally avoid zolpidem and the other Z-drugs in older women. Diphenhydramine and doxylamine, no. Quetiapine as a sleeping pill, no. Sedating antidepressants used purely as hypnotics, no. I avoid tricyclics here too, because anticholinergic effects and weight gain are a poor trade for a modest sleep benefit.

After 60 I want the treatment to improve the next day as well. Eight hours of sedation followed by fogginess, a bigger appetite, or a fall is not successful insomnia care.

For clinicians

Three things worth holding onto.

Ask what the sleep complaint actually is before reaching for a hormonal explanation. Sleep onset, vasomotor awakenings and maintenance insomnia are different problems and the history separates them in about ninety seconds.

Screen for apnea in this population, and do not wait for a snoring history to prompt you. STOP-BANG underperforms in women relative to men, which is an argument for screening more of them rather than fewer.

And when you tell a patient CBT-I is first-line, have somewhere to send her. The recommendation is only worth what the referral pathway behind it is worth.

The Bottom Line

Menopause can genuinely wreck your sleep, and it is not the only thing that does.

Start by working out what kind of not-sleeping you have. If night sweats are waking you, treating them usually fixes the nights. If the insomnia has become its own problem, cognitive behavioral therapy comes before a prescription. And if you are exhausted, foggy, waking to urinate and getting headaches in the morning, somebody should be thinking about sleep apnea rather than writing it all off to hormones.

That last one is the one I most want not to miss.

Related Reading

Managing Insomnia and Sleep Problems: A Physician’s Perspective
How to Sleep Better: Practical Steps for Patients
Perimenopause and Menopause Symptoms and How to Manage Them
Does Poor Sleep Make You Gain Weight? Sleep and Obesity
Menopause Care by Telemedicine: What a Virtual Visit Can and Cannot Do
More on Menopause & Women’s Health

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

Sources

  1. Advances in the Diagnosis and Treatment of Obstructive Sleep Apnea in Women. https://pmc.ncbi.nlm.nih.gov/articles/PMC12992857/
  2. Type of Menopause, Age at Menopause, and Risk of Developing Obstructive Sleep Apnea in Postmenopausal Women. American Journal of Epidemiology. https://academic.oup.com/aje/article/187/7/1370/4819319
  3. Sleep Apnea in Women Often Missed After Menopause. Medscape. https://www.medscape.com/viewarticle/sleep-apnea-women-often-missed-after-menopause-2026a1000cri
  4. FDA Approves Elinzanetant as First Nonhormonal Therapy for Menopause Vasomotor Symptoms. Pharmacy Times, October 2025. https://www.pharmacytimes.com/view/fda-approves-elinzanetant-as-first-nonhormonal-therapy-for-menopause-vasomotor-symptoms
  5. Insomnia in Postmenopausal Women: How to Approach and Treat It? https://pmc.ncbi.nlm.nih.gov/articles/PMC10816958/

Why Do I Eat at Night? Night Eating Syndrome Explained

On By Dr. Scott RennieIn Weight Loss & Metabolic HealthLeave a comment

Night Eating Syndrome (NES) is one of those conditions that many patients, and even some clinicians, overlook. NES is a recognizable eating disorder where the timing of food intake shifts into the evening and nighttime hours, distinct from occasional snacking after dinner. Patients often feel embarrassed and dismiss it as a bad habit. It has real consequences for weight, sleep, and overall health.

The diagnosis of NES is based on established criteria. To meet the definition, at least 25 percent of daily food intake occurs after the evening meal or there are at least two episodes of nocturnal eating per week. These episodes are not explained by social or cultural norms. People with NES are aware of what they are eating at night, unlike sleep-related eating disorders where the behavior may happen without recall. The condition also needs to cause significant distress or impairment in functioning (Allison & Tarves, 2011).

In practice, this can look two different ways. Some patients skip breakfast, eat a small lunch, and end up consuming half their calories after dinner. Others wake almost every night around 1 or 2 a.m., head to the kitchen, and eat before they can fall back asleep. Over time, the pattern disrupts sleep and drives weight gain.

NES also overlaps with mood and sleep disorders. Patients often report insomnia, depression, or evening stress. Eating becomes a way to cope with anxiety or to induce sleep. That’s why treatment has to be more than calorie restriction. Cognitive behavioral therapy focused on both eating and sleep habits has shown promise, and selective serotonin reuptake inhibitors (SSRIs) have been helpful in some patients (Allison & Tarves, 2011). I prefer CBT-I, but in practice medications often end up being what gets prescribed. I don’t treat night eating syndrome myself. I screen for it before prescribing weight loss medications, then refer out.

The tie between NES and obesity is important. McCuen-Wurst and colleagues (2018) have shown that NES is associated with higher rates of metabolic problems such as type 2 diabetes and hypertension. Timing matters. Eating late into the night throws off circadian rhythms and glucose metabolism, so the impact is greater than just extra calories.

On a video visit, NES surfaces only if you ask about it directly. The question that opens it up is whether a person is eating after they have gone to bed, and whether they believe they need to eat in order to get back to sleep.

Treatment is best when it’s individualized. Weight loss alone won’t fix NES if the underlying behaviors and triggers aren’t addressed. Collaboration between primary care, psychiatry, nutrition, and sleep medicine can make a real difference. For colleagues, the key is asking when patients eat as closely as how much. For patients, understanding that this is a recognized condition with treatment options can take away some of the shame and open the door to better care.

Related Reading

Binge Eating Disorder Signs and Treatment in Adults and Kids Eating Disorders in People With Obesity: Combining Care Does Poor Sleep Make You Gain Weight? Sleep and Obesity Does Meal Timing Affect Your Metabolism and Health? Is Obesity a Brain Problem? How the Body Controls Weight

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.

References:

Allison KC, Tarves EP. Treatment of night eating syndrome. Psychiatr Clin North Am. 2011;34(4):785-796. doi:10.1016/j.psc.2011.08.002

McCuen-Wurst C, Ruggieri M, Allison KC. Disordered eating and obesity: associations between binge-eating disorder, night-eating syndrome, and weight-related comorbidities. Ann N Y Acad Sci. 2018 Jan;1411(1):96-105. doi: 10.1111/nyas.13467. Epub 2017 Oct 16. PMID: 29044551; PMCID: PMC5788730

How to Sleep Better: Practical Steps for Patients

On By Dr. Scott RennieIn Other Diseases and ConditionsLeave a comment

Sleep gets a fraction of the attention we give diet and exercise, and it should not. Research from Dr. Ari Shechter at Columbia University has shown that poor sleep feeds obesity, diabetes, hypertension, and heart disease. It costs people their daily functioning, and underneath that it is quietly setting long-term disease risk. It is not a secondary problem.

When I ask patients about sleep, I keep it practical. When did this start, and is it new or has it always been like this? What is the bedroom like, too warm or too bright or too loud? Do they snore, gasp, or stop breathing, which points toward apnea? Any crawling or tingling in the legs, which points toward restless legs? I ask about weekdays versus weekends, because an irregular schedule can look exactly like insomnia. And I ask about caffeine, alcohol, nicotine, and medications, which patients rarely volunteer.

Formal tools give the conversation structure. The Epworth Sleepiness Scale is quick for daytime sleepiness. The Pittsburgh Sleep Quality Index is broader. STOP-Bang and the Berlin questionnaire flag possible apnea. The Insomnia Severity Index tracks both severity and how much it is costing someone functionally.

For objective data, in-lab polysomnography remains the standard for apnea, limb movement disorders, narcolepsy, and REM sleep behavior disorder. Wrist actigraphy at home gives a more practical picture of sleep and wake patterns over time, which is often what I actually need.

Adults should target 7 to 9 hours, and children and teenagers need more. Hours alone do not settle it. Timing, efficiency, and how someone feels the next day all matter. Patients tell me constantly that they are in bed for eight hours and wake up unrested. That is the point where efficiency and awakenings become the more useful thing to look at.

The consequences of chronic short sleep are well documented. It shifts ghrelin and leptin in the direction of more hunger and weight gain (Spiegel et al., 2004). It degrades glucose control and raises diabetes risk (Tasali et al., 2022). Hypertension, coronary disease, and stroke all track with insufficient sleep, and long-standing sleep problems are associated with cognitive decline and dementia risk (Vorster et al., 2024).

Causes are usually layered. Behavior contributes: irregular schedules, screens late, heavy meals and alcohol close to bed. So do physiologic and psychological factors: apnea, restless legs, anxiety, chronic pain.

Practical work starts with sleep hygiene. A consistent schedule resets circadian rhythm. Bedrooms should be cool, dark, and quiet. Bright light late interferes with sleep onset. Evening caffeine and alcohol come down. A wind-down routine, reading or stretching or a warm shower, makes the transition easier.

Daytime habits matter more than patients expect. Morning light anchors circadian rhythm. Even ten minutes of aerobic activity improves sleep depth. And for anyone waking in the night, what they do next shapes the rest of it: awake more than twenty minutes, get up and do something quiet in dim light rather than lie there getting frustrated.

The behavioral approach I use most is stimulus control. The principle is simple, which is rebuilding the association between the bed and sleep. Go to bed only when sleepy. Use the bed for sleep. Leave it if sleep is not coming. I have watched patients with years of insomnia retrain themselves this way. One had been scrolling his phone in bed for hours every night; once he started leaving the room when sleep would not come and only returning when he felt drowsy, his sleep onset shortened within a few weeks and the nightly frustration went with it.

Sleep is a medical necessity, and it belongs in routine care alongside everything else we screen for. Taking it seriously improves rest, and it also improves cardiometabolic health, mental health, and how people feel about their days.

Related Reading

Managing Insomnia and Sleep Problems: A Physician’s Perspective Sleep Tips to Help You Adjust After the Time Change Vitamin D and Sunshine: Make the Most of a Sunny Seattle Day 5 Health Reasons You Shouldn’t Quit Drinking Coffee

Scott Rennie, D.O.

References

Shechter A. Improving Sleep in Your Patients. Columbia Cornell Obesity Medicine Course, 2024.

Spiegel K et al. Ann Intern Med. 2004.

Tasali E et al. JAMA Intern Med. 2022.

Markwald RR et al. PNAS. 2013.

Vorster A et al. Clin Transl Neurosci. 2024.

Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.