Suvorexant for Menopause Insomnia: Symptoms Versus Awake Minutes

A medicine can improve an insomnia questionnaire without establishing a statistically significant change in every sleep measurement. That distinction matters when the appointment starts with, “How much less will I be awake?”

What did the first menopause trial find?

The 2022 four-week trial¹ analyzed 56 women with chronic insomnia and nighttime vasomotor symptoms. Insomnia Severity Index scores fell 8.1 points with suvorexant versus 5.6 with placebo after adjustment for starting score and race. The unadjusted comparison was not statistically significant; adjustment addressed a racial imbalance between groups.¹

Diary-recorded awake time after falling asleep fell 30.6 versus 12.6 minutes, but the difference was not significant after correction for multiple comparisons. Reported nighttime vasomotor symptoms improved; daytime symptoms did not differ significantly. Reduced recall during better sleep was one possible explanation. Merck funded the trial.¹

Does the newer study settle the awake-time question?

The May 2026 conference abstract describes 29 women in a blinded crossover trial with four-week treatment blocks. Participants had late perimenopause or early postmenopause, nighttime vasomotor symptoms, insomnia and at least one metabolic-syndrome component, such as hypertension or prediabetes.²

Insomnia scores fell 5.8 points during suvorexant treatment versus 2.7 during placebo, a significant difference. Diary-recorded awake time fell 16.8 versus 5.8 minutes, a difference that was not statistically significant (P=.14). The abstract reports no metabolic-health improvement result. It gives insufficient adverse-event detail for a safety comparison and identifies Merck support. A conference abstract provides less detail than a full trial report.²

Neither study establishes the observed minute difference as a benefit a patient should expect. The small samples also leave open the possibility of an effect.¹²

Is it prescribed for hot flashes?

The US BELSOMRA label covers insomnia involving difficulty falling or staying asleep. It does not list hot flashes as an indication. The March 2025 revision requires at least seven hours before planned waking and contraindicates use in narcolepsy.³

Prescribers must consider breathing problems, interacting medicines and daytime impairment. Avoid alcohol. The label cautions people taking 20 mg against next-day driving; lower doses can also impair driving. If sleepwalking or sleep-driving occurs, stop the medicine and contact the prescriber promptly. Our next-day driving article explains why feeling awake is insufficient reassurance.³

What should the follow-up measure?

Ask the prescriber to agree on the outcomes before starting: time spent awake, distress about sleep, nighttime sweating, morning function and adverse effects. A lower questionnaire score can be useful even if the number of awakenings changes little. Record both rather than letting one stand in for the other.

The 14-Night Lights-Out Record in Did I Do That in My Sleep? asks for morning estimates of bedtime, rising time, remembered wakefulness and how you feel. Add whether sweating required a clothing or bedding change. The manuscript advises using a clinician’s instructions when a formal sleep diary is requested.