Sleep problems and mood changes are receiving greater recognition as part of menopause care.
In November 2024, NICE updated its Menopause: identification and management guideline to include new recommendations on cognitive behavioural therapy, or CBT, for some menopause-associated symptoms.
NICE says menopause-specific CBT can be considered for sleep problems linked with hot flushes and night sweats. It can also be considered for some depressive symptoms that occur alongside these vasomotor symptoms.
These recommendations remain in the current NICE guideline. The guideline was updated again in April 2026, but those later changes related to bleeding while taking HRT, not to sleep or mood treatment.
International guidance is moving in a similar direction. The International Menopause Society also identifies CBT as an evidence-based non-hormonal option that may help with vasomotor symptoms, sleep, mood and quality of life.
Why does this matter for women?
Poor sleep can affect far more than how tired you feel the next morning.
Repeated night sweats or hot flushes can interrupt sleep, making it hard to fall back asleep. Over time, disrupted sleep can affect concentration, energy, patience, emotional wellbeing and everyday functioning.
Mood changes can also occur during the menopause transition. Some women experience irritability, anxiety, tearfulness or depressive symptoms.
These experiences should not automatically be dismissed as stress or poor coping.
However, it is equally important not to assume that menopause explains every sleep or mood problem in midlife.
A woman who wakes repeatedly because of night sweats may need a different approach from someone whose insomnia is related to depression, chronic pain, medication, sleep apnoea or another health condition.
This is why individual assessment matters.
What does the evidence say?
NICE reviewed research on CBT for menopause-associated symptoms before introducing its recommendations.
For women experiencing sleep problems alongside hot flushes or night sweats, NICE says menopause-specific CBT can be considered alongside other treatments, including HRT. It may also be an option when other treatments are unsuitable or when a woman prefers not to use them.
Some studies found improvements in sleep quality, including how long it took women to fall asleep and how often they woke during the night.
One UK randomised controlled trial, known as MENOS 2, involved 140 women experiencing at least 10 troublesome hot flushes or night sweats each week.
Women were assigned to group CBT, guided self-help CBT or no treatment. Both CBT approaches reduced how troublesome women found their symptoms compared with no treatment, with benefits still seen at 26 weeks. They also reported improvements in mood and quality of life.
Another randomised study involved 71 perimenopausal and postmenopausal women. Those receiving menopause-specific CBT reported greater improvements in the disruption caused by vasomotor symptoms, depressive symptoms and sleep difficulties than women placed on a waiting list.
These findings are encouraging, but the studies were relatively small.
NICE also found differences between studies in how CBT was delivered and how sleep and mood were measured. Because of these limitations, CBT is recommended as an option rather than something every woman with menopause-related sleep problems should automatically receive.
What is menopause-specific CBT?
CBT is a psychological treatment that looks at the relationship between thoughts, feelings and behaviours.
Menopause-specific CBT adapts these principles to difficulties such as hot flushes, night sweats, sleep disruption and the distress these symptoms can cause.
This treatment can be offered individually or in groups, face-to-face or remotely, but clinicians should consider barriers like access or patient preferences to optimize uptake and effectiveness.
This does not mean symptoms are imagined or that women are being told to think them away.
The aim is to develop practical ways to reduce the distress and disruption caused by real physical symptoms and improve how women manage their impact.
There is also a more specialised treatment called cognitive behavioural therapy for insomnia, or CBT-I, which focuses specifically on persistent sleep difficulties.
A small 2026 pilot trial involving 43 perimenopausal or postmenopausal women with insomnia and night-time hot flushes adds further supportive evidence. However, because the study was small, larger trials are still needed.
What about HRT and other treatments?
CBT is not replacing HRT.
NICE continues to recommend HRT as a treatment option for menopausal hot flushes and night sweats. When these symptoms are repeatedly disturbing sleep, treating them may also improve sleep.
But HRT is not a general sleeping treatment for all women in midlife.
Other non-hormonal treatments may also be appropriate. NICE recommends fezolinetant for moderate-to-severe vasomotor symptoms when HRT is unsuitable. However, fezolinetant is used to treat hot flushes and night sweats, not insomnia or depression themselves.
What do we still not know?
Not every sleep problem during menopause has the same cause.
Hot flushes and night sweats can disturb sleep, but so can depression, anxiety, pain, medication, alcohol, shift work, restless legs syndrome and sleep apnoea.
The evidence for CBT and mood symptoms is also less consistent than some headlines might suggest.
A 2024 review of psychosocial treatments involving 30 randomised controlled trials and 3,501 women found small average improvements in depressive and anxiety symptoms with CBT. However, NICE’s own review found mixed results across studies.
This means CBT may be helpful, but it cannot be assumed to work equally well for every woman.
Depressive symptoms also need to be distinguished from clinical depression. Significant or persistent low mood should not automatically be attributed to menopause.
Our take
The important message is that sleep disruption and emotional changes during menopause deserve proper attention. For some women, menopause-specific CBT may offer a promising, evidence-informed way to manage sleep problems, hot flushes, night sweats, or related mood symptoms, encouraging a proactive approach to their health.
But menopause should not become an explanation for everything that happens in midlife. Good care involves working together to understand the whole picture and identify what may be truly driving the symptoms, fostering a sense of partnership and trust.
For women whose sleep or emotional wellbeing is being significantly affected, these symptoms are worth discussing during a menopause consultation rather than simply accepting them as something to endure.
Sources
Primary source: NICE, Menopause: identification and management (NG23).
NICE evidence review: Cognitive behavioural therapy: Menopause, November 2024.
International source: Simon JA, Davis SR, Lindén Hirschberg A, et al. State of the art in menopause: current best practice approaches from the IMS World Congress 2024, Melbourne. Climacteric. 2025;28(2):98–103.
Supporting research: MENOS 2 randomised controlled trial, and CBT-Meno randomised controlled trial.
