Two Sleep Conditions Few People Connect to Menopause: OSA and Restless Legs

Sleep disruption in perimenopause has well-known hormonal explanations: progesterone decline, oestrogen loss, hot flushes breaking up the night, the body clock shifting forward. There are also two other conditions that rise sharply around the menopause transition, contribute substantially to poor sleep, and are significantly underdiagnosed in women. Both carry years of delay between onset and diagnosis, and both are treatable.

The first is obstructive sleep apnoea, the second is restless legs syndrome. Public perception, and much of the clinical literature, associates both predominantly with overweight older men. That framing is a significant part of why both conditions get missed in women.

Obstructive sleep apnoea: not just a snoring man's problem

Obstructive sleep apnoea occurs when the upper airway partially or fully collapses during sleep, causing breathing to pause repeatedly through the night. Each pause rouses the brain from deep sleep, often without the person waking consciously, and the cumulative effect of those micro-arousals breaks the sleep architecture in a way that produces profound exhaustion despite what looks like a full night in bed.

In 2018, researchers from Brigham and Women's Hospital and Harvard Medical School found that women who had undergone surgical menopause, meaning removal of the ovaries, had a 27% higher risk of developing OSA than women who reached menopause naturally. Importantly, the elevated risk was present even in women who were not obese. The abrupt loss of ovarian hormones, not body size, appears to be driving the mechanism, and that finding directly challenges the assumption that OSA in women is primarily a weight problem.¹

Did you know?

Progesterone has a direct effect on upper airway muscle tone and respiratory drive. As progesterone falls in perimenopause, the protective effect it provides against airway collapse during sleep is reduced, independently of weight changes. This is one of the biological reasons the menopause transition raises OSA risk, and one of the reasons OSA after surgical menopause appears even in women who do not fit the stereotype.

How OSA presents in women: what the evidence supports

The classic description of OSA, loud snoring, witnessed breathing pauses, waking with a gasp, describes the condition as it commonly presents in men. Women's presentations are frequently different, with fatigue, low mood, morning headaches, and unrefreshing sleep more common than dramatic snoring. This is part of why the condition is so often attributed to perimenopause itself, or to depression, and the referral for a sleep study is never made.^1,4

If your sleep deteriorated after surgical or early menopause, a sleep study is worth pursuing with your GP regardless of your weight and regardless of whether you snore.

Restless legs syndrome: a perimenopause connection most women have never heard of

Restless legs syndrome (RLS, also called Willis-Ekbom disease) is a neurological condition characterised by an irresistible urge to move the legs, typically in the evening or at night when lying still, accompanied by uncomfortable crawling, tingling, or aching sensations that are temporarily relieved by movement. It is not leg cramps, which are sudden and involuntary. It is a recognised neurological condition that can severely disrupt the ability to fall and stay asleep, and it is nearly twice as common in women as in men.²

Women are disproportionately affected, and the mechanisms centre on iron and dopamine: the brain requires iron to produce dopamine, and the dopamine system is centrally involved in regulating leg movement. Brain iron can be insufficient even when standard blood tests appear normal. Serum ferritin within the laboratory reference range does not mean iron is adequate for the brain's needs, and this is a distinction the standard GP blood test printout will not tell you.²

Women are more vulnerable to both deficits. Reproductive-age women carry lower iron stores than men throughout their lives due to monthly blood loss, and this becomes directly relevant to perimenopause: heavy or irregular perimenopausal bleeding, a common feature of the hormonal fluctuations of this stage, can drive iron stores lower still, at exactly the time when the neurological vulnerability is increasing.²

Oestrogen, dopamine, and why perimenopause is when symptoms flare

It is not the absolute level of oestrogen that matters most for RLS, but the change in oestrogen. This helps explain why RLS symptoms can flare during perimenopause specifically, when oestrogen is fluctuating rather than simply declining. Fluctuating oestrogen disrupts dopamine regulation, and dopamine disruption affects leg movement control.²

Perimenopause also brings an increase in periodic limb movements, a related condition associated with hot flushes and night sweats, so women who already have RLS may find it significantly worsens during this stage.²

Iron, ferritin, and the question to ask your GP

Ferritin is the storage form of iron, and standard laboratory reference ranges are calibrated to avoid anaemia, not to optimise brain function or manage RLS. While standard laboratory ranges start as low as 15 micrograms per litre, clinical experts generally recommend maintaining ferritin between 50 and 100 micrograms per litre for women in midlife. For RLS specifically, the clinical target is above 75 micrograms per litre, with an optimal target above 100 micrograms per litre, a position consistent with both international RLS expert consensus and the approach aligned with Australian haematology best practice.^3,5

If you experience restless legs and are in perimenopause, asking your GP for a ferritin test is reasonable. Ask for the actual number, not just whether it is within range, and mention that you are asking in the context of restless legs symptoms. Iron supplements are more effectively absorbed at night, with vitamin C, and away from tea, coffee, calcium supplements, and thyroid medication. If oral supplementation does not raise ferritin adequately within three months, intravenous iron is a clinically recognised next option.

What this means for you

If you are experiencing unrefreshing sleep, persistent fatigue, morning headaches, low mood, or an urge to move your legs that worsens at night, and these symptoms are not fully explained by the hormonal changes of perimenopause you already know about, both OSA and RLS are worth raising with your GP by name. Both increase in women around the menopause transition and are diagnosable with straightforward testing: a sleep study for OSA, a ferritin blood test as a starting point for RLS.

Three takeaways

1. Menopause raises OSA risk, and surgical menopause raises it by 27% even in non-obese women.¹ If your sleep deteriorated after surgical or early menopause, a sleep study is worth discussing with your GP regardless of whether you snore.

2. Restless legs syndrome is nearly twice as common in women as in men, and symptoms frequently flare in perimenopause due to the combination of iron vulnerability and the effect of fluctuating oestrogen on the dopamine system.² Heavy perimenopausal bleeding is a direct iron risk factor.

3. For RLS, the clinically relevant question is not whether your ferritin is in range; it is what the actual number is. The clinical target is above 75 micrograms per litre, with an optimal target above 100 micrograms per litre.^3,5 Ask your GP for the specific value and mention you are asking in the context of restless legs symptoms.

This is not your body failing you. It is your body changing and asking for a different kind of support.

Before your next GP appointment, write down your specific symptoms: when your legs are restless, what time of day and night, how long it has been happening, and whether your sleep is unrefreshing despite adequate hours in bed. For OSA, note whether you have been told you snore, whether you wake with headaches, and whether fatigue is your most prominent symptom. Specificity is what opens a clinical conversation about diagnosis.

Download the free Menopause Sleep Tracker: https://www.menopausehub.com.au/sleep-tracker

This information is educational only and does not constitute personal medical advice. Always consult a qualified health professional about your individual circumstances.

© Menopause Hub 2026 | Anna Pattison, Former Registered Nurse, Clinical Myotherapist, Menopause Mentor | menopausehub.com.au

References

1.  Huang T, Lin BM, Redline S, Curhan GC, Hu FB, Tworoger SS. Type of Menopause, Age at Menopause, and Risk of Developing Obstructive Sleep Apnea in Postmenopausal Women. American Journal of Epidemiology. 2018;187(7):1370-1379. doi:10.1093/aje/kwy011.

2.  Seeman MV. Why Are Women Prone to Restless Legs Syndrome? International Journal of Environmental Research and Public Health. 2020;17(1):368. PMC6981604. (University of Toronto.)

3.  Restless Legs Syndrome Foundation. Understanding Iron and RLS. RLS Foundation Blog. 11 January 2023.

4.  Women's Health Concern / British Menopause Society. Understanding and managing sleep problems during menopause. WHC Fact Sheet, reviewed October 2025.

5.  Australasian Menopause Society. Ferritin and iron management in midlife women: aligned with haematology best practice.