Restless legs in perimenopause: causes, iron and treatment

Restless legs in perimenopause are common, but hormones are not a proven cause. Restless legs syndrome (RLS) is an urge to move the legs that starts at rest, is worse in the evening and eases with movement. It affects women about twice as often as men, rises with age, and low iron from heavy periods is a key, treatable trigger.

What restless legs syndrome is

RLS is a sleep-related movement disorder. A 2026 review in JAMA describes its core features:

• An overwhelming urge to move the legs, often with unpleasant sensations such as aching or tingling.
• Symptoms brought on by rest, such as sitting in the evening or lying in bed.
• Relief while moving, for example walking or stretching, which lasts only as long as you keep moving.
• A daily rhythm, with symptoms present or worst in the evening or at night.

MedlinePlus lists the sensations people describe: creeping and crawling, pulling or tugging, burning, aching or throbbing, itching, and pins and needles. Your clinician will also look for other conditions that can cause similar symptoms. Most people with RLS also have rhythmic leg movements during sleep, called periodic limb movements.

There is no blood test or scan for RLS itself. The JAMA review notes that it is diagnosed from your history, and that an overnight sleep study is not needed to diagnose it. Blood tests are still important, to look for low iron and other conditions that can cause or mimic it.

Because symptoms peak in the evening, RLS often delays sleep and can wake you in the night. The result can be insomnia and daytime sleepiness; see our guide to daytime sleepiness in perimenopause if that sounds familiar.

How common it is in midlife women

According to the JAMA review, about 8% of US adults have RLS symptoms of any frequency in a year, and about 3% have moderately or severely distressing symptoms at least twice a week. Women are affected about twice as often as men, and prevalence reaches about 10% in adults aged 65 and older.

It is also often missed. In the REST population study of more than 15,000 adults, 416 people had frequent, distressing symptoms. Of those, 81% had discussed them with a primary care doctor, but only 6.2% had been given a diagnosis of RLS.

Does perimenopause cause restless legs?

The honest answer is that the evidence is weak and indirect.

• Pregnancy shows hormones or iron can matter. RLS affects about 22% of women in the third trimester of pregnancy, according to the JAMA review.
• Having children is linked to RLS later. In a German population study of 4,310 adults, women were twice as likely as men to have RLS. Women who had never given birth had rates similar to men’s up to age 64, while the odds rose with each child: about 2 times higher with one child, 3 times with two and 3.6 times with three or more.
• Menopause itself has not been clearly linked. In a survey of Swedish women aged 18 to 64, 15.7% had RLS and prevalence rose with age. RLS was strongly associated with vasomotor symptoms such as night sweats, but not with being postmenopausal or with using hormone therapy.

So perimenopause may make RLS more noticeable, through night sweats, broken sleep or heavier periods, but there is no good evidence that the hormonal transition causes it, and no good evidence that hormone therapy treats it.

Iron, heavy periods and ferritin

Iron is the most important factor you can do something about. A 2025 JAMA review of iron deficiency found RLS in 32% to 40% of people with low iron, and lists menstrual bleeding among the most common causes of iron deficiency. It advises considering an iron test for anyone with heavy menstrual bleeding. If your periods have become heavier, read heavy bleeding and clots.

The American Academy of Sleep Medicine (AASM) guideline, published in January 2025, advises that everyone with clinically significant RLS have iron studies checked, including ferritin and transferrin saturation. Ideally the blood is drawn in the morning, with no iron supplements or iron-containing foods for at least 24 hours beforehand.

Iron result in adults with RLS	AASM advice
Ferritin 75 ng/mL or below, or transferrin saturation below 20%	Iron by mouth or by IV
Ferritin between 75 and 100 ng/mL	IV iron only
Ferritin above 100 ng/mL	Outside the guideline’s iron thresholds

The guideline notes that these thresholds differ from those used for iron deficiency in general. A ferritin level flagged as normal on a routine test may still be low for someone with RLS. Take iron only after testing and with a clinician’s guidance on the form and dose.

Medicines and habits that make it worse

The JAMA review advises stopping, where possible, medicines that are linked to RLS:

• Sedating antihistamines that act on the brain, such as diphenhydramine, found in many over-the-counter sleep aids and allergy pills. This is a common trap: a pill taken to sleep through restless legs can make them worse. Our guide to sleep aids covers better options.
• Serotonergic antidepressants, the SSRI and SNRI families.
• Dopamine-blocking drugs, used for nausea and some psychiatric conditions.

The picture for antidepressants is mixed. A 2018 systematic review of 18 studies found that new or worsened RLS after starting an antidepressant is uncommon, that mirtazapine may carry a higher risk, and that bupropion may reduce symptoms in the short term. If you take an antidepressant, do not stop it on your own; ask your prescriber whether a change makes sense.

MedlinePlus adds caffeine, alcohol and nicotine, certain blood pressure medicines (calcium channel blockers), lithium, and stopping sedatives. Untreated sleep apnea can also worsen RLS, according to a 2022 review.

Treatments the AASM guideline supports

The AASM rates treatments using a formal review of the evidence. The main recommendations for adults:

Treatment	AASM recommendation
Gabapentin, gabapentin enacarbil, pregabalin	Recommended (strong)
IV ferric carboxymaltose, when iron status fits	Recommended (strong)
Oral ferrous sulfate, when iron status fits	Suggested (conditional)
Extended-release oxycodone and other opioids, dipyridamole, peroneal nerve stimulation	Suggested (conditional)
Pramipexole, ropinirole, rotigotine, levodopa	Suggested against standard use (conditional)
Cabergoline	Recommended against (strong)
Bupropion, clonazepam, valerian, carbamazepine, valproic acid	Suggested against (conditional)

Gabapentinoids are now first-line. In trials summarized in the JAMA review, about 70% of people taking them were much or very much improved, compared with about 40% on placebo. Gabapentin is also used for hot flashes, so for some women one medicine may help both; see gabapentin for hot flashes.

Dopamine agonists such as pramipexole and ropinirole were long the standard treatment, and they work well at first. The problem is augmentation: a progressive, long-term worsening of RLS caused by the medicine itself, with symptoms becoming more severe, starting earlier in the day and spreading to other parts of the body, such as the arms. The AASM now advises against their standard use, though they may still suit people who value short-term relief. If you already take one, do not stop suddenly; a 2022 review notes that even small dose cuts can cause severe rebound symptoms, so changes should be planned with your clinician.

Self-care helps alongside treatment. MedlinePlus suggests regular sleep and wake times, a comfortable bedroom, hot or cold packs, gentle stretches and massage. Cutting back on caffeine, alcohol and nicotine can also help.

When to see a clinician

See a clinician if restless legs are keeping you awake, happen several times a week, or come with heavy periods, daytime sleepiness or low mood. Go back if symptoms worsen, start earlier in the day or spread to your arms while you are on treatment, since that can be augmentation. The JAMA review notes higher rates of depression in people with RLS; if you have thoughts of harming yourself, call or text 988.

A two-week sleep diary that notes when symptoms start, what eases them and your period days is useful at the visit. A sleep medicine specialist can confirm the diagnosis, review your iron and medicines and guide treatment.