Trazodone for perimenopause insomnia: does it help?

Trazodone is not a good first choice for perimenopause insomnia. It is an antidepressant that is widely prescribed off-label at low doses for sleep, but the American Academy of Sleep Medicine suggests against it, the benefit in trials is modest, and it has never been tested against placebo in perimenopausal women. CBT-I and treating night sweats come first.

What trazodone is and how it is used for sleep

Trazodone was approved in the US in 1981 to treat major depression in adults. For depression, the FDA label starts at 150 mg a day and allows up to 400 mg a day for outpatients. Drowsiness is one of its most common side effects: in the outpatient depression trials summarized on the label, 41% of people on trazodone reported drowsiness, compared with 20% on placebo.

That sedation is why trazodone is so often used as a sleeping pill. MedlinePlus lists insomnia among its “other uses,” meaning uses not approved by the FDA. Clinicians typically prescribe a much lower dose at bedtime; the main insomnia trial used 50 mg. The scale is large. A 2025 analysis of national survey data estimated that about 24 million trazodone prescriptions were filled in the US in 2019, and at least 85% were for off-label reasons, primarily insomnia.

Part of the appeal is that trazodone is a cheap generic and not a controlled substance. The American Academy of Sleep Medicine (AASM) also noted that many physicians see it as a “safer” sleep aid, a perception the evidence does not clearly support.

What the evidence shows

The AASM guideline: suggested against

In its 2017 guideline on insomnia medicines, the AASM made a weak recommendation against trazodone for trouble falling asleep or staying asleep. Only one trial met its criteria: 187 adults with trouble falling asleep took 50 mg of trazodone or placebo for 14 nights, and reported their own sleep.

Outcome, trazodone 50 mg vs placebo	Result	AASM judgment
Time to fall asleep	About 10 minutes shorter	Below the threshold for a meaningful benefit
Total sleep time	About 22 minutes longer	Below the threshold
Time awake after first falling asleep	About 8 minutes less	Below the threshold
Sleep quality	No significant improvement	Not meaningful
Headache	30% vs 19%	More common on trazodone
Sleepiness as a side effect	23% vs 8%	More common on trazodone

The task force concluded that none of the sleep outcomes improved to a clinically meaningful degree and that the harms potentially outweighed the benefits.

Later meta-analyses: mixed

Pooled analyses since then paint a slightly more favorable but still cautious picture. A 2018 meta-analysis of 7 placebo-controlled trials with 429 people with insomnia found that trazodone improved how well people felt they slept and reduced the number of awakenings, but did not improve sleep efficiency, time to fall asleep, total sleep time or time awake at night.

A larger 2024 meta-analysis pooled 44 trials with 3,935 participants who had sleep problems from a range of causes, not only insomnia. Trazodone improved sleep quality, cut time awake after falling asleep by about 13 minutes and added about 28 minutes of sleep measured in the sleep lab, yet people did not perceive that they slept longer. It came at a cost: people on trazodone were about 2.3 times as likely to drop out because of side effects. The authors called the effects on sleep latency, efficiency and daytime functioning minor.

Trials in menopause: almost none

No placebo-controlled trial has tested trazodone for insomnia in perimenopausal women. The only study in this group found for this guide is a small Italian study from 1995: 25 menopausal women took 75 mg a day for 3 months, without a placebo group, and their insomnia and anxiety scores improved, while the drop in hot flash intensity was not statistically significant. Without a comparison group, that result cannot show whether trazodone itself helped.

The Menopause Society’s 2023 position statement on nonhormone treatments does not include trazodone among its recommended options for hot flashes or night sweats.

Side effects to know about

The FDA label lists these warnings and common effects:

• Next-day drowsiness and slowed thinking. Trazodone can impair judgment, thinking and motor skills. Do not drive until you know how it affects you.
• Dizziness and fainting on standing. Orthostatic hypotension and fainting are listed warnings. If you get up at night to use the bathroom, sit on the edge of the bed first. MedlinePlus suggests resting your feet on the floor for a few minutes before standing.
• Heart rhythm changes. Trazodone prolongs the QT interval, and dangerous rhythms have been reported at doses of 100 mg or less. Tell your clinician about any heart disease, irregular heartbeat or QT-prolonging medicines.
• Bleeding. Risk rises when combined with aspirin, NSAIDs such as ibuprofen or naproxen, or blood thinners such as warfarin.
• Priapism and sexual effects. In men, trazodone can cause a painful erection lasting hours, a medical emergency. In women, the label lists rare reports of prolonged clitoral engorgement among postmarketing events, and MedlinePlus lists decreased sex drive and difficulty reaching orgasm.
• Other warnings. Angle-closure glaucoma, low blood sodium, and a risk of fetal harm based on animal data, which matters because pregnancy is still possible in perimenopause.

If you are already taking trazodone, do not stop suddenly. The label recommends a gradual dose reduction to avoid discontinuation symptoms such as dizziness, nausea, anxiety and insomnia.

Interactions

• Other serotonin drugs. Combining trazodone with SSRIs or SNRIs, including those used for hot flashes, or with triptans for migraine, tramadol, St. John’s wort or tryptophan raises the risk of serotonin syndrome. See SSRIs and SNRIs for hot flashes.
• MAO inhibitors. These must not be combined with trazodone, or taken within 14 days of each other.
• Alcohol and sedatives. Trazodone adds to the effects of alcohol and other drugs that depress the brain, so skip alcohol on nights you take it.
• Drugs that change its levels. Strong CYP3A4 inhibitors, such as certain antifungals and the antibiotic clarithromycin, raise trazodone levels. Ask about grapefruit.

The boxed warning on suicidal thoughts

Like all antidepressants, trazodone carries an FDA boxed warning: antidepressants increased suicidal thoughts and behaviors in children, teenagers and young adults under 24 in short-term studies. In the pooled data on the label, adults aged 25 to 64 did not show this increase. Even so, the label advises monitoring everyone for worsening mood, especially in the first months and after dose changes. If you have thoughts of harming yourself, call or text 988.

Better options to try first

Option	Best for	Strength of evidence
CBT-I	Chronic insomnia of any cause	Strong AASM recommendation
Treating night sweats	Waking hot or sweaty	Depends on the treatment; hormone therapy and gabapentin both have evidence
Low-dose doxepin, 3 or 6 mg	Waking during the night	Weak AASM recommendation; FDA-approved at these doses for insomnia
Trazodone	Not recommended for insomnia alone	Weak AASM recommendation against

CBT-I first. The AASM strongly recommends multicomponent cognitive behavioral therapy for insomnia for chronic insomnia. See CBT-I for menopause insomnia.

Treat what wakes you. If night sweats break your sleep, treating them works better than sedation. See night sweats, hormone therapy and sleep and gabapentin for sleep in menopause.

Low-dose doxepin. The AASM suggests doxepin at 3 or 6 mg for trouble staying asleep, based on clinically meaningful gains in time awake at night and total sleep, with a mild increase in sleepiness at 6 mg. Our ranking of the best sleep aids for perimenopause compares it with the other prescription options.

When depression is part of it. If low mood and insomnia arrive together, a clinician may choose an antidepressant that treats both. That is a different decision from using trazodone as a sleeping pill.

When to see a clinician

Talk to your clinician before starting or stopping trazodone, and bring a full list of your medicines and supplements. Book a visit if insomnia has lasted more than a few weeks, if you snore or wake gasping, which can signal sleep apnea, or if you feel unsteady or groggy in the mornings. A sleep medicine specialist can arrange CBT-I and testing.

Call 911 for fainting, chest pain, a fast or irregular heartbeat, signs of serotonin syndrome, an erection that lasts more than 4 hours, or painful genital swelling that does not go away. If you have thoughts of harming yourself, call or text 988.