Trazodone for Sleep in Menopause: What the Evidence Says

What is trazodone, and why is it used for sleep?

Trazodone is an antidepressant. Its FDA label approves it for one thing: major depressive disorder in adults. It's used for sleep because drowsiness is one of its most common effects, so doctors prescribe it at low doses off-label, meaning for a purpose the FDA hasn't approved it for, to help people fall or stay asleep.

How strong is that drowsiness? In the depression trials summarized on the label, 41% of outpatients taking trazodone reported drowsiness, compared with 20% on placebo. Those trials used depression doses, though, which are higher than the amounts usually prescribed for sleep.

A 2020 study in JAMA defined "low-dose" trazodone as under 150 mg a day, noting that this is below the 150 mg starting dose for depression and is commonly used for insomnia.

Being off-label doesn't make a prescription wrong; doctors use many medicines that way. It does mean that no manufacturer has had to prove to the FDA that trazodone works for insomnia, which is why the research on trazodone for sleep specifically is thinner than most people assume.

How often is trazodone prescribed for sleep?

Trazodone is prescribed often, and its use rose over the years studied. A study of US adults with employer-sponsored insurance or Medicare supplemental plans found that the share filling low-dose trazodone prescriptions rose between 2011 and 2018, while zolpidem (Ambien) fell. Among adults with an insomnia diagnosis, the share on low-dose trazodone rose from 8.7% to 14.5%.

The authors point out the timing: trazodone dispensing kept rising for nearly two years after a 2017 US guideline suggested not using it for insomnia, although the increases were modest. Across all adults in the database, not just those with an insomnia diagnosis, the share on low-dose trazodone went from 1.25% to 1.82%.

The sleep medicine guideline describes how the habit began in earlier decades. As worries grew about dependence on older sleeping pills, it says, physicians increasingly prescribed sedating antidepressants off-label, "especially trazodone, despite the absence of efficacy studies" for insomnia.

Does trazodone actually help you sleep?

Trazodone helps sleep a little, but less than its popularity suggests. When the American Academy of Sleep Medicine reviewed the evidence for its 2017 guideline, only one trial of trazodone met its criteria. On every measure, the improvement over placebo fell short of what the guideline counted as clinically significant, meaning large enough to matter in daily life.

A 2018 Cochrane review, which pools trials more broadly, came to a similar place by a different route. Pooling three trazodone studies with 370 participants, it found a moderate improvement in how well people felt they slept compared with placebo. But two trazodone studies that measured sleep objectively in a sleep lab found little or no difference in sleep efficiency.

Two things stand out. First, "small" and "short-term" are doing a lot of work: none of these studies tells us how trazodone performs after months of nightly use, which is how many people end up taking it.

Second, as far as their published summaries show, none of the trials behind these conclusions focused on menopausal women, which brings us to the question that matters most here.

What do sleep medicine guidelines recommend?

The American Academy of Sleep Medicine suggests that clinicians not use trazodone for either trouble falling asleep or trouble staying asleep. It's a weak recommendation, reflecting lower certainty in the evidence. For trazodone, the task force judged that the harms potentially outweigh the benefits, given the absence of demonstrated efficacy. The same guideline puts behavioral treatment ahead of every pill.

For context, the same guideline grades every one of its medication recommendations as weak, which says a lot about the state of sleep-drug research overall. Here is how trazodone sits next to the other medicines it reviewed:

Source: Sateia MJ, Buysse DJ, Krystal AD, et al. J Clin Sleep Med. 2017;13(2):307-349.

If you'd like the bigger picture of prescription sleep aids, our guide to sleeping pills for menopause insomnia compares the main options side by side, and our CBT-I guide explains what the recommended first step actually involves.

Is there research on trazodone in menopause?

Research on trazodone in menopause is thin. Searching Europe PMC, the only trial I found in menopausal women with insomnia was a small 2014 study: 50 postmenopausal women took trazodone or zopiclone for four weeks, and sleep quality improved similarly with both. It had no placebo group, so it can't show how much the drug itself did.

Two small Italian studies from the 1990s also looked at trazodone for broader menopause symptoms. Side by side, the menopause research looks like this:

Sources: Eraslan D, et al. Psychiatr Danub. 2014;26(4):353-357. Pansini F, et al. Clin Exp Obstet Gynecol. 1995;22(4):341-344. Bianco V, et al. Ann Ostet Ginecol Med Perinat. 1991;112(1):54-60 (in Italian).

The Menopause Society's 2023 nonhormone position statement doesn't mention trazodone at all.

That matters because menopause insomnia often has a specific driver. If hot flashes or night sweats are waking you, a sedating pill may help you drift off again, but it doesn't target the flashes themselves. The Menopause Society's statement recommends these nonhormone treatments at its strongest evidence level for hot flashes and night sweats:

• Cognitive behavioral therapy and clinical hypnosis
• SSRIs and SNRIs such as paroxetine and venlafaxine (see our guide)
• Gabapentin (see gabapentin for hot flashes and sleep)
• Fezolinetant (see Veozah and Lynkuet)

It also states that hormone therapy remains the most effective treatment for hot flashes and night sweats, and should be considered for women younger than 60, within 10 years of their final period, who have no contraindications (see HRT for menopause insomnia).

None of this means trazodone is never right for a woman in midlife. It means it's worth asking what's actually waking you before deciding what to take.

What are the common side effects of trazodone?

In the 50 mg trial the AASM reviewed, trazodone's main side effects were headache and sleepiness. Headache affected 30% of people on trazodone versus 19% on placebo, and sleepiness 23% versus 8%. The Cochrane review also found more morning grogginess, dry mouth and thirst with trazodone than with placebo, though that evidence was rated low quality.

The FDA label lists more, but its numbers come from depression trials at higher doses, so they aren't a direct guide to what happens at a sleep dose. Here's how a few compared with placebo among outpatients in those trials:

Source: FDA prescribing information for trazodone hydrochloride tablets, Table 2 (outpatients: 157 on trazodone, 158 on placebo).

The dizziness line deserves attention if you get up at night, for instance to use the bathroom, which many of us do more often in midlife (see waking up to pee at night). A drowsy, light-headed walk down a dark hallway is exactly the moment to be careful.

Which trazodone warnings matter most in midlife?

A few of the label's warnings are especially relevant to women in their 40s and 50s, because they involve medicines that are common at this stage. The biggest is serotonin syndrome, a potentially life-threatening reaction whose risk rises when trazodone is combined with SSRIs or SNRIs, the same drugs used for hot flashes.

• If you take paroxetine or venlafaxine for hot flashes, or a triptan for migraine, every prescriber needs to know before trazodone is added.
• If you take supplements, say so too: the label names St. John's wort and tryptophan among the serotonergic products that raise the risk of serotonin syndrome.
• If you take aspirin, ibuprofen or a blood thinner, mention it; the label warns these can add to trazodone's bleeding risk.
• If you have a heart rhythm problem or take other medicines that affect the QT interval, the label advises avoiding trazodone. It also flags certain antibiotics and antifungals (strong CYP3A4 inhibitors such as clarithromycin or itraconazole), and says trazodone isn't recommended in the early recovery period after a heart attack.
• If you take blood pressure medicine, mention it: the label says that dose may need lowering, because trazodone can lower blood pressure too.
• If you drink alcohol in the evening or take other sedating medicines, say so: the label warns trazodone may enhance their effects.
• If you drive early in the morning, the label advises caution operating machinery until you know how it affects you.

The label also warns that low sodium (hyponatremia) can occur, with higher risk in older adults, people taking diuretics ("water pills," often used for blood pressure) and people who are dehydrated. Separately, it notes that experience with trazodone in older adults is limited and advises caution.

What should you ask before trying trazodone?

Before starting trazodone for sleep, ask what's actually causing your insomnia, whether you've tried CBT-I, why trazodone rather than a medicine with more sleep evidence, how it interacts with what you already take, how long you'll use it and how you'll stop. A two-week sleep diary makes those answers easier to reach.

In more detail, these are the questions I'd want answered:

• What do you think is causing my insomnia? Hot flashes, anxiety, sleep apnea, pain and needing to pee all point to different fixes.
• Have we tried CBT-I? If not, ask about access, including digital programs.
• Why trazodone rather than a medicine with more sleep evidence, such as those the AASM suggests (weakly) for insomnia?
• How does it interact with what I already take, especially an SSRI or SNRI, a triptan, aspirin, an anti-inflammatory or a blood thinner?
• What dose, for how long, and when do we review it? Short-term use is where the evidence is.
• How will we know whether it's working, and how do we taper off rather than stop suddenly? The label recommends a gradual reduction whenever possible.

A two-week sleep diary before the appointment makes these answers far easier to reach. Our sleep tracking guide shows what's worth writing down.

Where to go from here

If hot flashes are the reason you're awake, our hot flashes guide lists every option with strong evidence. If the waking is more about a racing mind, our night-time anxiety guide and our CBT-I guide are the place to start. And for a side-by-side look at prescription options, see sleeping pills for menopause insomnia.

For how all of this fits into the bigger picture of midlife sleep, start at the complete perimenopause and menopause sleep guide.

Frequently asked questions

Ellen Hayes

Health & Wellness Writer and Researcher

Hi — I'm Ellen. I expected trazodone's popularity to rest on strong sleep research. It mostly rests on habit and on being seen as "safer" than older sleeping pills. That doesn't make it the wrong choice for everyone, but it made me want to ask better questions before reaching for it.

I'm not a doctor. I'm not an expert — and I'm never going to talk down to you like one. I'm a woman in the middle of perimenopause who got tired of vague answers, started reading the actual research, and writes it down here in plain English, the way I'd explain it to a friend over coffee. More about Ellen →