Abstract
Sleep disturbances are highly prevalent during menopausal transition and postmenopause; however, the underlying mechanisms remain incompletely understood. Epidemiological cohort studies demonstrate a sharp increase in the occurrence of insomnia symptoms in midlife coincident with declining estradiol levels, vasomotor symptoms (VMS), and increased susceptibility to depression and anxiety. These psychological factors interact bidirectionally with insomnia, amplifying its adverse impacts on health-related quality of life. Additional contributors-including lower urinary tract symptoms, musculoskeletal pain, reduced muscle mass, and sleep-disordered breathing-emphasize the multifactorial nature of menopausal insomnia. Management includes hormonal, pharmacological, and nonpharmacological strategies. Although menopausal hormone therapy remains the most effective treatment for VMS, its benefits for sleep are inconsistent and largely limited to subjective improvement. Randomized trials suggest that non-benzodiazepine hypnotics can enhance sleep initiation and maintenance; moreover, traditional herbal formulas (e.g., Kampo) may benefit selected women, although the evidence is limited. Newer dual orexin receptor antagonists, such as suvorexant, daridorexant, and lemborexant, have shown efficacy with regard to sleep onset and maintenance in adults, including women in their midlife. By integrating epidemiological findings, mechanistic insights, and comparative treatment data, this review emphasizes individualized care tailored to symptom profile, risk factors, and patient preference. Future research should bridge gaps between subjective and objective evaluations and delineate biological pathways (neuroendocrine, circadian, orexin, and inflammatory/myokine) to guide targeted therapies.