Predictors of sleep disturbance in menopausal transition

Associations of menopausal status and eating behaviour with subjective measures of sleep

Eating and sleeping behaviour are known to interact with each other, yet research is limited in the context of menopausal women. The aim of this study was to examine whether menopausal status is associated with perceived problems in sleeping. Furthermore, we studied different aspects of eating behaviour as potential risk factors for poor sleep in menopausal women. The present study is exploratory in nature, thus the results should be interpreted as hypothesis-generating. We analysed the sleeping and eating behaviour of 1098 women aged 47-55 years and represented different menopausal statuses with regression analyses. Over 20% of them reported fairly poor or poor perceived sleep quality. A higher number of postmenopausal women reported experiencing at least fairly poor sleep quality compared with the other menopausal groups. However, in regression models controlled for several confounding factors menopausal status was not associated with measures of sleep. Women who reported more snacking-type eating behaviour were more likely to report shorter sleep duration, and more daytime tiredness. Externally cued eating was associated with shorter sleep duration and emotional eating was associated with experiencing daytime tiredness. However, after adjusting for multiple testing, it appears that eating behaviour is associated only with daytime tiredness. Menopausal women with sleeping problems may benefit from nutritional interventions targeting eating behaviour.

Insomnia in Postmenopausal Women: How to Approach and Treat It?

Insomnia is one of the major complaints of menopausal women with advancing age and may be complexly related to a variety of causes. However, there is still a lack of standards on the general approach and treatment for insomnia in menopausal women. The aim of this review is to summarize recent pathogenic theories of sleep disturbance in the menopausal period and discuss the approach and management of insomnia in postmenopausal women. Sleep disturbances in menopausal women may be associated with physical and psychiatric factors and other comorbid diseases. Careful history taking and multidisciplinary physical and psychosocial evaluation are necessary and, in particular, comorbidities related to sleep disorders, such as obstructive sleep apnea, must be taken into consideration. A unique aspect of insomnia in postmenopausal women is that menopausal symptoms due to hormonal decline can be closely related to sleep disturbances. Therefore, menopausal hormone therapy (MHT) should be considered as the treatment of choice among pharmacological treatments following cognitive behavioral therapy, which is suggested as the first-line treatment in the general population insomnia treatment guidelines. Additionally, melatonin and 5HT-based drugs, which have fewer side effects, along with MHT should be preferentially recommended in menopausal women.

Associations of adverse childhood and lifetime experiences with sleep quality and duration among women in midlife

OBJECTIVES

Many women experience sleep problems during midlife. Associations of adverse lifetime experiences-more common among women-with sleep outcomes are understudied.

METHODS

We studied 476 women enrolled in Project Viva 1999-2002. At enrollment, participants reported any lifetime history of abuse and/or financial hardship. At midlife follow-up ∼20 years later, they reported a history of up to 10 adverse childhood experiences (ACEs); 7-day sleep quality (patient-reported outcomes measurement information system sleep disturbance and sleep-related impairment T-scores); and past month average sleep duration. We examined associations of adverse experiences with sleep outcomes, adjusted for childhood sociodemographic variables. We also explored mediation by current depression and anxiety symptoms, hot flash severity, general health, and body mass index.

RESULTS

ACEs were common: 301 women (63%) reported one or more. Each additional ACE was associated with higher midlife sleep disturbance (adjusted β = 0.65 points, 95% confidence interval [CI]: 0.27, 1.02) and sleep-related impairment (0.98, 95% CI: 0.54, 1.41) T-scores, and with sleep duration <6 hour/night (odds ratio 1.19, 95% CI: 1.00, 1.42), but not with continuous sleep duration (-2 minutes, 95% CI: -5, 1). Adverse experiences in adulthood were less consistently associated with sleep quality but were associated with sleep duration, for example, financial hardship during the index pregnancy was associated with 75 minutes (95% CI: -120, -29) shorter sleep duration 2 decades later. Associations of ACEs with sleep disturbance and sleep-related impairment were mediated by midlife depression anxiety and physical health but not by hot flash severity or body mass index.

CONCLUSIONS

Adverse lifetime experiences have deleterious associations with sleep duration and quality in midlife women.

Fibromyalgia and menopause: an open study on postmenopausal hormone therapy

BACKGROUND

Fibromyalgia women (FM) seems to get worse at menopause suggesting some influence of estrogens on its pathophysiology. We aimed to study the influence of postmenopausal hormone therapy (HT) in FM, the relationship with sleep and FM impact.

METHODS

We analyzed prospectively 69 menopausal women, divided in two groups, FM group (FMG; N.=32) and comparison group (CG; N.=28) submitted to HT for twelve weeks (1.2 mg/g transdermal estradiol, 100 mg micronized natural progesterone oral/daily). Data on Utian Quality of Life Questionnaire (UQOL) and Pittsburgh Sleep Quality Index (PSQI) were obtained in both groups, at entrance and twelve weeks after HT. FM patients also completed the Fibromyalgia Impact Questionnaire - Revised (FIQ-R) and fibromyalgia severity (FS).

RESULTS

FM patients improved significantly the FIQ-R (P=0.0001, median FIQ-R score 30% lower), mainly the severity of FM, assessed by FS (P<0.0001). Both groups had improved quality of life and sleep (UQOL: P=0.0001; P=0.001, PSQI: P<0.0001; P=0.007, respectively). Differences between first and second PSQI were greater for CG than for FMG (P=0.008).

CONCLUSIONS

HT improving sleep and quality of life in both groups; it was a significant clinical improvement seen by FIQ and FS in FM patients. These changes characterize improvement of functional status and symptoms severity.

Does self-compassion explain variance in sleep quality in women experiencing hot flushes?

OBJECTIVES

With poor sleep highly prevalent during the menopause transition, there is a need to better understand modifiable psychological resources that may be associated with improved sleep. Hence, we investigated whether self-compassion can explain variance in self-reported sleep quality in midlife women, over and above vasomotor symptoms.

METHODS

This cross-sectional study (N = 274) used questionnaire data from self-report measures of sleep, hot flushes and night sweats, hot flush interference, and self-compassion, with analyses conducted using sequential (hierarchical) regression.

RESULTS

Poor sleep, as measured by the Pittsburgh Sleep Quality Index, was prevalent and significantly worse in the subsample of women with hot flushes and night sweats, g = 0.28, 95 % CI [0.04, 0.53]. The interference of hot flushes in everyday life (β = 0.35, p < .01), but not their frequency, predicted self-reported sleep quality. Once self-compassion was added to the model it was the only predictor of poor sleep (β = -0.32, p < .01). When positive self-compassion and self-coldness were considered separately, the effect on sleep quality appeared to be attributable to self-coldness scores alone (β = 0.29, p < .05).

CONCLUSIONS

Self-compassion may have a stronger relationship with self-reported sleep quality in midlife women than vasomotor symptoms. Future intervention-based research could test the efficacy of self-compassion training for midlife women experiencing sleep disturbances, as this may be an important and modifiable psychological resilience factor.

Migraine and sleep quality: does the association change in midlife women?

OBJECTIVE

The aim of this study was to compare the association between migraine and sleep quality in premenopausal versus perimenopausal women.

METHODS

A cross-sectional analysis from the Data Registry on the Experiences of Aging, Menopause and Sexuality was conducted using questionnaire data from premenopausal and perimenopausal women seen at women's health clinics at 3 geographic locations from 2015 to 2021. Sleep quality and duration were assessed with the Pittsburgh Sleep Quality Index. Associations between poor sleep quality (Pittsburgh Sleep Quality Index >5) and self-reported migraine history (Y/N) were evaluated using a multivariable logistic regression model, adjusting for body mass index, anxiety, depression, and vasomotor symptoms.

RESULTS

Of 2,067 women (mean age 43.2 years) included in the analysis, 594 (28.7%) reported a migraine history. Women were mostly white (92.2%), partnered (75.1%), and educated (86% with at least some college); 46.5% (n = 962) were premenopausal, 53.5% (n = 1,105) were perimenopausal, and 71.2% met the criteria for poor sleep. In univariate analysis, migraine history predicted poor sleep in both premenopausal and perimenopausal women ( P = 0.005 and P = 0.004, respectively). However, in multivariable analysis, migraine history remained associated with poor sleep in premenopausal women ( P = 0.044), but not in perimenopausal women ( P = 0.46).

CONCLUSIONS

A migraine history was associated with poor sleep in premenopausal women. The relationship in perimenopausal women seemed to be influenced by confounding factors that are more prevalent during the menopause transition and are known to affect the frequency of migraine and sleep disturbances, such as anxiety, depression, and vasomotor symptoms. These conditions may need to be the focus of management in migraineurs with sleep disturbances during the menopause transition.

Nocturnal Hot Flashes, but Not Serum Hormone Concentrations, as a Predictor of Insomnia in Menopausal Women: Results from the Midlife Women's Health Study

Background: Sleep disruptions are among the most common symptoms experienced during menopause and can be associated with depression, hot flashes, and fluctuating hormones. However, few studies have examined how such risk factors influence sleep in midlife women in a network-based approach that will establish the complex relationship between variables. Materials and Methods: We used a Bayesian network (BN) to examine the relationship between multiple factors known to influence sleep and depression in midlife women, including hormone concentrations, hot flashes, and menopause status among participants of the longitudinal Midlife Women's Health Study. In year 1, 762 women (45-54 years of age) answered questions regarding the frequency of insomnia, hot flashes, and depression; 389 of the same women answered similar questions at year 4. We measured serum hormones and calculated free estradiol index, free testosterone index, and ratios of estradiol:progesterone, and estradiol:testosterone. For our model, we calculated the change in frequency of insomnia, depression, and covariates (body mass index, menopause status, hot flashes at night, and present quality of life) from year 1 to 4. Results: Using a BN, we found that self-reported hot flashes at night, and no other factors, were direct predictors of self-reported insomnia in year 1. Surprisingly, we did not identify an association between hormone concentrations and self-reported insomnia. Frequency of insomnia in year 4 was only predicted by frequency of insomnia in year 1, whereas frequency of depression in year 4 was predicted by year 4 insomnia and frequency of depression in year 1. No other factors were direct predictors of insomnia or depression in our model. Conclusions: Therefore, hot flashes at night, previous insomnia, and depression are stronger predictors of how women will self-report frequency of sleep disruptions and treatment may reduce menopausal sleep complaints.

Persistence of sleep difficulties for over 16 years amongst 66,948 working-aged adults

The objective was to investigate the persistence of sleep difficulties for over 16 years amongst a population of working age. In this prospective cohort study, a group-based trajectory analysis of repeated surveys amongst 66,948 employees in public sector (mean age 44.7 [SD 9.4] years, 80% women) was employed. The main outcome measure was sleep difficulties based on Jenkins Sleep Scale (JSS). Up to 70% of the respondents did not experience sleep difficulties whereas up to 4% reported high frequency of notable sleep difficulties through the entire 16-year follow-up. Heavy drinking predicted sleep difficulties (OR 2.3 95% CI 1.6 to 3.3) except for the respondents younger than 40 years. Smoking was associated with sleep difficulties amongst women younger than 40 years (OR 1.2, 95% CI 1.0 to 1.5). Obesity was associated with sleep difficulties amongst men (OR 1.9, 95% CI 1.4 to 2.7) and women (OR 1.2, 95% CI 1.1 to 1.3) of middle age and amongst women older than 50 (OR 1.5, 95% CI 1.2 to 1.8) years. Physical inactivity predicted sleep difficulties amongst older men (OR 1.3, 95% CI 1.1 to 1.6). In this working-age population, sleep difficulties showed a great persistence over time. In most of the groups, the level of sleep difficulties during the follow-up was almost solely dependent on the level of initial severity. Depending on sex and age, increasing sleep problems were sometimes associated with high alcohol consumption, smoking, obesity and physical inactivity, but the strength of these associations varied.

Association of changes in lifestyle with changes in sleep difficulties: an analysis of 38 400 participants over a 16-year follow-up

OBJECTIVES

To investigate the association between changes in lifestyle risk factors and changes is sleep difficulties.

DESIGN

Longitudinal repeated measures cohort study.

SETTING

University and national institute of occupational health.

PARTICIPANTS

Participants of the Finnish Public Sector study with information on sleep and lifestyle-related risk factors collected in five repeat surveys with 4-year intervals from 2000 to 2017. The participants were those, who had responded at least twice and had a change in sleep difficulties (having sleep difficulties vs not) (142 969 observations from 38 400 respondents (mean age 45.5 (SD 9.2) years, 83% women).

PRIMARY AND SECONDARY OUTCOME MEASURES

Changes in sleep quality over time. Longitudinal fixed effects analysis, a method that accounts for time-invariant confounders by design, was used.

RESULTS

At first available response, sleep difficulties were experienced by 13 998 (36%) of the respondents. Respectively, the mean age was 44.3 (10.0) years, 7526 (20%) were obese, 13 487 (35%) reported low physical activity, 3338 (9%) extensively drinking and 6547 (17%) were smoking. Except for smoking, the changes in the studied modifiable risks were associated with changes in sleep difficulties. The ORs for having sleep difficulties were 1.41 (95% CI 1.35 to 1.48) for obesity, 1.10 (95% CI 1.06 to 1.13) for low physical activity and 1.43 (95% CI 1.35 to 1.51) for heavy drinking. For smoking, the association was negative with OR 0.81 (95% CI 0.76 to 0.86). Including all four modifiable risks into model changed the estimates only little.

CONCLUSIONS

The results of this longitudinal study suggest that changes in sleep quality are interconnected with changes in lifestyle.

Sleep during menopausal transition: a 10-year follow-up

Study Objectives

A 10-year observational follow-up study to evaluate the changes in sleep architecture during the menopausal transition.

Methods

Fifty-seven premenopausal women (mean age 46 years, SD 0.9) were studied at baseline and after a 10-year follow-up. At both time points, polysomnography (PSG) was performed, and the serum follicle-stimulating hormone (S-FSH) concentration was measured. Linear regression models were used to study the effects of aging and menopause (assessed as change in S-FSH) on sleep.

Results

After controlling for body mass index, vasomotor, and depressive symptoms, higher S-FSH level was associated with longer sleep latency (B 0.45, 95% confidence interval [CI]: 0.07 to 0.83). Aging of 10 years was associated with shorter sleep latency (B −46.8, 95% CI: −77.2 to −16.4), shorter latency to stage 2 sleep (B −50.6, 95% CI: −85.3 to −15.9), decreased stage 2 sleep (B −12.4, 95% CI: −21.4 to −3.4), and increased slow-wave sleep (B 12.8, 95% CI: 2.32 to 23.3) after controlling for confounding factors.

Conclusions

This study suggests that PSG measured sleep of middle-aged women does not worsen over a 10-year time span due to the menopausal transition. The observed changes seem to be rather age- than menopause-dependent.

Longitudinal Association Between Depressive Symptoms and Multidimensional Sleep Health: The SWAN Sleep Study

BACKGROUND

Depressive symptoms and sleep disturbances disproportionately affect midlife women. While there may be a bidirectional association, few studies have examined whether depressive symptoms are longitudinally associated with subsequent sleep. Sleep is typically considered unidimensional, despite emerging evidence that multidimensional sleep health provides novel information on the sleep-health link.

PURPOSE

The current study examined whether higher depressive symptoms were longitudinally associated with poorer multidimensional sleep health.

METHOD

Depressive symptoms were assessed with the Center for Epidemiologic Studies Depression Scale across six to nine annual assessments in 302 midlife women from the Study of Women's Health Across the Nation. Six months after their last assessment, actigraphy (mean ± standard deviation = 29.3 ± 6.9 days) and self-report were used to assess sleep health components: efficiency, duration, mid-sleep timing, regularity, alertness, and satisfaction, which were dichotomized and summed to create a composite multidimensional sleep health score. Mixed-effects models were used to evaluate the longitudinal associations between depressive symptoms and multidimensional sleep health, as well as individual sleep health components, adjusting for covariates. Exploratory analyses stratified models by race/ethnicity.

RESULTS

Higher depressive symptoms were associated with subsequent poorer multidimensional sleep health (p < .0.001) and lower alertness (p < .0001) and satisfaction with sleep (p < .0001).

CONCLUSIONS

Our finding that higher average depressive symptoms were associated longitudinally with actigraphy-measured poorer sleep health in midlife women is novel and converges with the larger body of evidence that these two common symptoms are strongly associated. The bidirectional relationship between these two prevalent symptoms needs to be studied in prospective longitudinal studies.

Analysis of the long-term beneficial effects of menopausal hormone therapy on sleep quality and menopausal symptoms

A large number of menopausal women report sleep disturbances along with psychological, somatic and urogenital menopausal symptoms. The aim of this study was to evaluate the efficacy of menopausal hormonal therapy (MHT) in improving subjective sleep quality and the severity of menopausal symptoms. An institutional ethics committee approved this retrospective chart review of 342 women treated with MHT for menopausal symptoms. Standard 28-day MHT consisted of the oral administration of 2 mg estradiol daily for 14 days, followed by 2 mg estradiol and 10 mg dydrogesterone daily for the remaining 14 days. A subgroup of 14 participants with a family history of cancer and mammography scores of 3 and above, received only tibolone 2.5 mg daily. Perceived sleep quality was measured with the Pittsburgh Sleep Quality Index (PSQI), while the assessment of menopausal symptoms was performed using the Kupperman Menopause Index (KMI) and menopause rating scale (MRS). Of the 342 patients, 79 were followed-up for 3 years. Compared to the baseline scores, the mean decrease in PSQI scores was 1.53±0.29 points (P<0.0001) at 1 month, 2.21±0.187 points (P<0.0001) at 2 months and 2.26±0.6 points (P<0.0001) after 3 years of MHT. The KMI scores also decreased by a mean of 6.37±1.59 points (P<0.0001) at 1 month and by 8.73±1.92 points after 3 years (P<0.0001). The MRS scores decreased by a mean of 3.56±1.05 points (P<0.0001) at 1 month and by 4.28±2.01 points (P<0.0001) after 3 years, as compared to the baseline scores. Patients receiving tibolone MHT did not report any improvement in sleep quality (P=0.956). On the whole, the findings of this study indicate that conventional MHT has a rapid and prolonged beneficial effect on self-reported sleep quality and menopausal symptoms in women. However, further clinical studies are warranted to compare the effects of different MHT regimens.

The relationship between menopausal symptoms and sexual function

Sexual function could be affected by several factors in postmenopausal women. This cross-sectional study aimed to investigate the relationship between the severity of menopausal symptoms and sexual function. The study was conducted among 405 postmenopausal women aged 40-65 years, in Chalous and Noshahr, Iran, from October 2013 to May 2014. The participants were selected using a multistage sampling method. The instruments used for data collection were the Female Sexual Function Index (FSFI), the Menopause Rating Scale (MRS), and a demographics questionnaire. The relationship between the severity of menopausal symptoms and sexual function was examined using Pearson's correlation coefficient and multiple linear and logistic regressions. The mean unadjusted FSFI and MRS scores were 24.11 and 12.45, respectively; and 61.0 percent of the participants had female sexual dysfunction (FSD) (FSFI ≤26.55). A significant negative correlation was observed between the MRS scores (total and all subscales) and the total scores for FSFI (p < 0.001). The results of the logistic regression analysis showed that with every unit increase in the total score of MRS, the likelihood of sexual dysfunction was 9.6 percent greater. We conclude that menopausal symptoms need to be considered in the design of health initiatives aimed at postmenopausal women's sexual function.

Sleep and Sleep Disorders in the Menopausal Transition

The menopausal transition is associated with an increase in insomnia symptoms, especially difficulty staying asleep, which negatively impacts quality of life. Vasomotor symptoms are a key component of sleep disruption. Findings from polysomnographic studies are less consistent in showing disrupted sleep in menopausal transition independent of aging; further prospective studies are needed. Hormone therapy alleviates subjective sleep disturbances, particularly if vasomotor symptoms are present. However, because of contraindications, other options should be considered. Further work is needed to develop preventive and treatment strategies for alleviating sleep disturbances to ensure better health, quality of life, and productivity in midlife women.

Sleep in Women Across the Life Span

There are many ways in which women experience sleep differently from men. Women contending with distinct sleep challenges respond differently to sleep disorders, as well as sleep deprivation and deficiency, and face particular health outcomes as a result of poor sleep. Idiosyncrasies, including changes that occur with the biological life cycles of menstruation, pregnancy, and menopause, make the understanding of sleep in women an important topic to study. Each phase of a woman's life, from childhood to menopause, increases the risk of sleep disturbance in unique ways that may require distinct management. Indeed, new research is unraveling novel aspects of sleep pathology in women and the fundamental role that sex hormones play in influencing sleep regulation and arousals and possibly outcomes of sleep conditions. Moreover, studies indicate that during times of hormonal change, women are at an increased risk for sleep disturbances such as poor sleep quality and sleep deprivation, as well as sleep disorders such as OSA, restless legs syndrome, and insomnia. This article reviews sleep changes in female subjects from neonatal life to menopause.

The relationship between health-promoting lifestyle and sleep quality in postmenopausal women

BACKGROUND

Menopausal women are widely reported to have poor sleep quality and sleep problems. It is not clear whether increases in sleep disturbance are brought about by hormone changes associated with menopause or due to psychosocial and physical problems.

METHOD

This cross-sectional study was conducted on 600 menopausal women aged between 40 and 60 without any known severe illnesses in the city of Qaen, Iran, from April 2015 to May 2016. Data were collected by Health-Promoting Lifestyle Profile II and Pittsburgh Sleep Quality Index.

MAIN OUTCOME MEASURES

This study was conducted to investigate the relationship between health-promoting lifestyle and sleep quality in Iranian postmenopausal women. Data were analyzed using an independent t-test, Mann-Whitney, Chi-square, Spearman and univariate logistic regression.

RESULT

The univariate logistic regression suggested that the physical activity dimension of lifestyle (OR = 1.095, 95% CI: 1.035-1.158, P < 0.006), non-smoking status (OR = 0.549, 95% CI: 0.331-0.912, P < 0.021) and occupation (women who were farmer compared with housewives) (OR = 0.239, 95% CI (0.074-0.775), P < 0.017) were associated with sleep quality.

CONCLUSION

Postmenopausal women in this study were at high risk for poor sleep quality. Poor sleep quality was associated with low levels of physical activity, smoking and being a housewife compared to being a farmer. Therefore, there is an essential need to educate women about health-promoting behaviors including daily physical activity and avoiding smoking which are associated with quality of sleep.

Sleep problems during the menopausal transition: prevalence, impact, and management challenges

A substantial number of women experience sleep difficulties in the approach to menopause and beyond, with 26% experiencing severe symptoms that impact daytime functioning, qualifying them for a diagnosis of insomnia. Here, we review both self-report and polysomnographic evidence for sleep difficulties in the context of the menopausal transition, considering severity of sleep complaints and links between hot flashes (HFs) and depression with poor sleep. Longitudinal population-based studies show that sleep difficulties are uniquely linked with menopausal stage and changes in follicle-stimulating hormone and estradiol, over and above the effects of age. A major contributor to sleep complaints in the context of the menopausal transition is HFs, and many, although not all, HFs are linked with polysomnographic-defined awakenings, with HF-associated wake time contributing significantly to overall wakefulness after sleep onset. Some sleep complaints may be comorbid with depressive disorders or attributed to sleep-related breathing or movement disorders, which increase in prevalence especially after menopause, and for some women, menopause, age, and environmental/behavioral factors may interact to disrupt sleep. Considering the unique and multifactorial basis for sleep difficulties in women transitioning menopause, we describe clinical assessment approaches and management options, including combination treatments, ranging from cognitive behavioral therapy for insomnia to hormonal and nonhormonal pharmacological options. Emerging studies suggest that the impact of severe insomnia symptoms could extend beyond immediate health care usage and quality of life issues to long-term mental and physical health, if left untreated in midlife women. Appropriate treatment, therefore, has immediate benefit as well as advantages for maintaining optimal health in the postmenopausal years.

Ovarian hormones, sleep and cognition across the adult female lifespan: An integrated perspective

Loss of ovarian function in women is associated with sleep disturbances and cognitive decline, which suggest a key role for estrogens and/or progestins in modulating these symptoms. The effects of ovarian hormones on sleep and cognitive processes have been studied in separate research fields that seldom intersect. However, sleep has a considerable impact on cognitive function. Given the tight connections between sleep and cognition, ovarian hormones may influence selective aspects of cognition indirectly, via the modulation of sleep. In support of this hypothesis, a growing body of evidence indicates that the development of sleep disorders following menopause contributes to accelerated cognitive decline and dementia in older women. This paper draws from both the animal and human literature to present an integrated view of the effects of ovarian hormones on sleep and cognition across the adult female lifespan.