Why Women Are Not Sleeping (And What to Do About It)

If you have ever found yourself wide awake, staring at the ceiling at 2 AM, convinced something is fundamentally wrong with you, this is for you. According to board-certified sleep medicine specialist Dr. Andrea Matsumura, poor sleep in women is not a personal failure. It is an underdiagnosed, undertreated medical reality that deserves real attention and real solutions.

Here is what the science says, and what you can actually do about it.

First, Understand That Your Sleep Problems Are Real

One of the most important things Dr. Matsumura does when a patient walks into her office is validate their experience. Chronic insomnia is an organic medical condition. It is not caused by weakness, laziness, or anxiety alone. For women in perimenopause and menopause, sleep disruption is a predictable and common consequence of hormonal shifts, not a character flaw.

Up to 50% of menopausal women will struggle with sleep apnea and never know it. Up to 30% of the general population lives with chronic insomnia. If you are exhausted and your doctor has shrugged it off, you are not imagining things.

Dr. Matsumura’s Top Tips for Better Sleep

1. Know the Real Role of Melatonin

Melatonin is not a sleeping pill. It is a hormone and a circadian rhythm regulator. Think of it as a clock starter that signals to your brain that darkness has arrived and sleep should follow. The problem is that melatonin production drops by up to 50% by age 50, because the pineal gland is the first gland in the body to calcify with age.

If you are going to supplement with melatonin, less is more. Dr. Matsumura recommends no more than 3 milligrams. Taking 10 mg (which is commonly sold over the counter) is likely contributing to the groggy mornings and vivid nightmares many women report. Also worth knowing: studies have found that at least 70% of melatonin sold over the counter contains ingredients beyond just melatonin. Quality sourcing matters, which is why Dr. Matsumura and Dr. Haver formulated Pause Sleep with premium, research-backed ingredients and had it third-party tested for purity.

2. Get Your Ferritin Checked

This one surprises a lot of people. Restless leg syndrome, that crawling, irresistible urge to move your legs at night, affects up to 30% of postmenopausal women, far more than men. One of the most common and overlooked causes is low iron stores, specifically low ferritin.

Ferritin levels drop well before you become anemic, so a standard blood test might come back "normal" while your levels are still too low to support healthy sleep. If you have restless leg syndrome, Dr. Matsumura recommends a ferritin level closer to 100. The previous lab standard of 15 was far too low, and even the updated range of 45 may not be sufficient for women experiencing RLS symptoms. If oral iron is hard on your stomach or not absorbing well, ask your doctor about IV iron infusions.

3. Do Not Ignore Snoring, Even If It’s Mild 

The stereotype of sleep apnea is a loud, overweight man who stops breathing dramatically. That picture has missed millions of women. Women with sleep apnea often do not snore loudly. They may describe themselves as "purring." They may have not experienced breathing pauses at all. Their most common symptoms are insomnia, brain fog, morning fatigue, and a general sense of not feeling right.

Menopause significantly increases the risk of sleep apnea, and 90% of women who have it do not know. The tools doctors use to screen for it are historically designed around male presentations, so women consistently score lower and get missed.

If you feel unrested no matter how many hours you sleep, if you have brain fog that will not lift, or if you experience any snoring at all, ask your doctor for a sleep study. A home sleep test is a reasonable starting point.

4. Consider Hormone Therapy for Sleep

Estrogen, progesterone, and testosterone each play a distinct role in sleep quality. Estrogen helps regulate body temperature, which is why hot flashes wreck sleep so effectively. It also supports REM sleep and the production of sleep spindles, the brain wave bursts during stage 2 sleep that help consolidate memory.

Progesterone has a calming, GABAergic effect on the brain. It helps quiet nervous system activity and supports the airway tissues during sleep. Testosterone is connected to deep, slow-wave sleep and sleep sustainability.

Replacing these hormones does not guarantee perfect sleep for every woman. In fact, Dr. Matsumura notes that up to half of women on hormone therapy still struggle with sleep. But for many, it is a critical first step before looking at behavioral and other medical interventions.

5. Build the Right Sleep Environment

Dark, cool, and quiet. Those are the three non-negotiables for a sleep-supportive bedroom. Light suppresses melatonin production, so blackout curtains or a sleep mask can make a meaningful difference. The ideal sleep temperature for most people is on the cooler side, generally between 65 and 68 degrees Fahrenheit. Noise, even background noise, can prevent you from reaching deep sleep stages.

Equally important: your bed should be associated only with sleep or intimacy. If you lie awake in bed for long stretches, your brain begins to link the bed with wakefulness. That rewiring works against you every night. 

6. Try Cognitive Behavioral Therapy for Insomnia (CBT-I)

This is the gold-standard, first-line treatment for chronic insomnia, and it outperforms sleep medications for long-term results. CBT-I works by retraining the behavioral and cognitive patterns that keep the brain in a state of hypervigilance at night.

It has three core components: sleep hygiene (consistent bed and wake times, no heavy meals before bed, a cool dark room), stimulus control (getting out of bed when you cannot sleep, so your brain stops associating the bed with wakefulness), and sleep restriction (temporarily compressing your time in bed to consolidate sleep and then gradually expanding it).

Dr. Matsumura describes the sleep restriction process as an accordion effect. You compress the sleep first so it has somewhere to expand. It is not a fast fix. She compares it to training for a marathon, not a 5K, but it works, and the results are more durable than medication.

Apps, books, online programs, and sleep psychologists can all guide you through the process. Consistency is what determines whether it works.

7. Honor Your Chronotype

Are you an early bird or a night owl? That preference is not laziness or habit. It is written into your clock genes and is about as changeable as your eye color. Forcing yourself to follow a sleep schedule that fights your biology creates chronic sleep deprivation over time.

If you are a natural early riser trying to stay up late to match a partner's schedule, you are working against yourself. Dr. Matsumura has seen many women come in with insomnia that turns out to be a simple chronotype mismatch. Honoring your own internal rhythm, even imperfectly, is one of the most straightforward things you can do for sleep quality. Not sure of your personal chronotype? Visit Dr. Matsumura’s website and take the Sleep Goddess Archetype Quiz.

8. Treat Sleep as a Vital Sign

Dr. Matsumura argues that sleep should be assessed at every medical visit the same way blood pressure is checked. Poor sleep is not just uncomfortable, it is linked to increased cardiovascular risk, higher rates of depression and anxiety, cognitive decline, weight gain, and a greater likelihood of dementia later in life. Untreated sleep apnea alone raises the risk of heart attack, stroke, and neurocognitive issues by up to 25%.

Every 15 minutes of additional sleep matters. If you are only getting five and a half hours, working toward five hours and 45 minutes is a real win worth celebrating. Progress counts.

Where to Start

If you are exhausted and do not know where to begin, Dr. Matsumura recommends starting with your primary care doctor and asking for a referral to a sleep medicine specialist. You can also search the American Academy of Sleep Medicine's online directory to find a clinician near you.

The most important thing to know is this: there is always something that can be done. You do not have to accept poor sleep as an inevitable part of aging or menopause. You were not built to be invisible, and you were not built to be exhausted.

Listen or watch Dr. Haver’s full conversation with Dr. Matsumura on unPAUSED.