Sleep disorders in women: clinical evidence and treatment strategies

Perioperative sleep disorders in gynaecological daycase surgery patients and analysis of risk factors: protocol for a cross-sectional study

INTRODUCTION

Sleep disorders are clinical syndromes of disturbed sleep-wake rhythms and abnormal sleep quality. They have various causes, but their main manifestations are difficulty falling asleep, sleep disruption and daytime fatigue. These are common clinical symptoms in perioperative patients, especially in gynaecological patients. There is a lack of research on the factors influencing perioperative sleep disorders in gynaecological patients. The aim of this study is to assess the prevalence of sleep disorders in gynaecological surgery patients and to analyse the possible factors influencing them to provide new ideas for improving sleep disorders in this patient population.

METHODS AND ANALYSIS

This cross-sectional, descriptive and observational survey is planned to include 480 gynaecological day surgery patients. All patients who meet the inclusion criteria are eligible to join the study. The study will record preoperative diagnosis, surgical procedure, duration of surgery, type of anaesthesia, anaesthetic drugs, sleep quality, anxiety and depression levels and pain indices 30 days before and 1, 2, 3 and 30 days after surgery.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of Beijing Shijitan Hospital Affiliated with Capital Medical University (Approval Number: sjtkyll-lx-2022(109)) before the start of recruitment. The results of the study will be disseminated through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

ChiCTR2200064533.

Postpartum Behavioral Sleep Intervention for Smoking Relapse Prevention: A Pilot Trial

OBJECTIVES

Rates of postpartum smoking relapse are high (70-90%) but standard relapse prevention interventions are not effective postpartum. This pilot study evaluated effects of a combined relapse prevention and sleep intervention on sleep and relapse to smoking.

METHODS

Twenty-eight postpartum mothers were assigned to the intervention group-combined relapse prevention and behavioral sleep intervention-or to the comparison group-relapse prevention alone. Questionnaires and actigraphy were completed at baseline (1-week postpartum), post-treatment (8-weeks postpartum), and follow-up (12-weeks postpartum). Sleep diaries were completed weekly for the first 8 weeks postpartum and once at 12 weeks postpartum. To corroborate abstinence, CO levels in expired air were measured weekly for the first 8 weeks postpartum and at follow-up. Timeline Followback (TLFB) and salivary cotinine analysis were conducted at baseline, post-treatment, and follow-up to assess for nicotine and other substance use (TLFB) and to further corroborate abstinence (salivary cotinine analysis).

RESULTS

The sleep intervention lengthened maternal nighttime actigraphic sleep by an average of 48 minutes nightly; lengthened the longest bout of consolidated actigraphic sleep by an average of 42 minutes nightly; increased actigraphic sleep efficiency into the healthy range (> 85%); and lowered subjective ratings of sleep disturbance (ps < .05). Findings were inconclusive regarding whether better sleep was associated with abstinence. Post Hoc analyses identified the presence of an additional support person in the home as well as social and emotional support as being positively correlated with smoking abstinence (p < .05; p < .01).

CONCLUSIONS FOR PRACTICE

(1) Postpartum sleep can be improved with behavioral interventions in women with a history of smoking. (2) Social-emotional postpartum support is an important factor in preventing smoking relapse for these women.

Study on the sleep quality of women pregnant with a second child and the influencing factors

Objectives

To investigate the sleep quality of women pregnant with a second child and the influencing factors and provide a scientific basis for health care guidance to clinically improve the sleep quality of pregnant women.

Methods

A total of 162 women pregnant with a second child at a first-class tertiary hospital in Changsha from January to August 2018 were selected as the research subjects. General demographic characteristics were collected, and the Pittsburgh Sleep Quality Index (PSQI) scale was used to assess their sleep quality. Multivariate logistic regression analysis was used to explore the influencing factors of the sleep quality of women pregnant with a second child.

Results

The PSQI score (except hypnotic drugs) and total score of pregnant women with second birth were higher than those of normal female population, and the difference was statistically significant (P < 0.05). Univariate analysis showed statistically significant differences in sleep quality among women pregnant with a second child of different ages, marital relationships, gender expectations, education levels, monthly family incomes, planned or unplanned pregnancy, and gestational weeks (P < 0.05). The results of the multi-factor analysis showed that the low education level (OR = 0.224, P = 0.001), low family monthly income (OR = 3.035, P = 0.014), expectation of gender (OR = 0.065, P = 0.038), and dissatisfaction with marital relationship (OR = 0.275, P = 0.001) were the primary risk factors of poor sleep quality of in women with second pregnant.

Conclusions

The overall sleep quality of women pregnant with a second child is poor, and 37.65% have sleep quality problems. Low education levels, low family monthly incomes, fetal gender expectations, and poor relationship between husband and wife are the main factors affecting the sleep quality of women pregnant with a second child. Pregnant women with the above factors should pay attention to their sleep quality and take necessary measures for intervention and guidance to improve the level of health care during pregnancy.

Racial/ethnic disparities in subjective sleep duration, sleep quality, and sleep disturbances during pregnancy: an ECHO study

In the United States, racial/ethnic minoritized groups experience worse sleep than non-Hispanic Whites (nHW), but less is known about pregnant people. This is a key consideration since poor sleep during pregnancy is common and associated with increased risk of adverse perinatal outcomes. This study reports the prevalence of subjective sleep measures in a multi-racial/ethnic pregnant population from the Environmental influences on Child Health Outcomes (ECHO) program. Participants' self-reported race and ethnicity were grouped into: nHW, non-Hispanic Black/African American (nHB/AA), Hispanic, non-Hispanic Asian (nHA). Analyses examined trimester-specific (first (T1), second (T2), third (T3)) nocturnal sleep duration, quality, and disturbances (Pittsburgh Sleep Quality Index and ECHO maternal sleep health questionnaire). Linear or multinomial regressions estimated the associations between race/ethnicity and each sleep domain by trimester, controlling for body mass index and age, with nHW as reference group. We repeated analyses within maternal education strata. nHB/AA participants reported shorter sleep duration (T2: β = -0.55 [-0.80,-0.31]; T3: β = -0.65 [-0.99,-0.31]) and more sleep disturbances (T2: β = 1.92 [1.09,2.75]; T3: β = 1.41 [0.09,2.74]). Hispanic participants reported longer sleep duration (T1: β = 0.22 [0.00004,0.44]; T2: β = 0.61 [0.47,0.76]; T3: β = 0.46 [0.22,0.70]), better sleep quality (Reference group: Very good. Fairly good T1: OR = 0.48 [0.32,0.73], T2: OR = 0.36 [0.26,0.48], T3: OR = 0.31 [0.18,0.52]. Fairly bad T1: OR = 0.27 [0.16,0.44], T2: OR = 0.46 [0.31, 0.67], T3: OR = 0.31 [0.17,0.55]), and fewer sleep disturbances (T2: β = -0.5 [-1.0,-0.12]; T3: β = -1.21 [-2.07,-0.35]). Differences persisted within the high-SES subsample. Given the stark racial/ethnic disparities in perinatal outcomes and their associations with sleep health, further research is warranted to investigate the determinants of these disparities.

Sleep Quality is an Independent Predictor of Blood Glucose and Gestational Diabetes Mellitus: A Longitudinal Study of 4550 Chinese Women

PURPOSE

To investigate whether pregnant women's subjective sleep quality during the first trimester independently predicted blood glucose and gestational diabetes mellitus (GDM).

METHODS

A total of 4550 pregnant women in the first trimester were enrolled in Chongqing Health Center for Women and Children, China, from January to October 2020.The Pittsburgh Sleep Quality Index (PSQI) was used to measure subjective sleep quality. Depression symptoms and anxiety were measured with the Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7). Oral glucose tolerance tests (OGTT) and blood glucose area under the curve (AUC) were used for estimation of blood glucose and diagnosis of GDM during the second trimester. Linear, mixed model, and logistic regression were used to analyze the association between PSQI and blood glucose as well as GDM.

RESULTS

946/4550 were diagnosed with GDM (20.8%). In the mixed model analysis, the blood glucose level of the highest-scoring group (PSQI score = 18) was 1.94 (95% CI: 0.45~3.43, P = 0.011) mmol/L higher than that of the lowest-scoring group (PSQI score = 0). After adjusting for potential confounders, a one-point PSQI score increase was associated with a 0.014 (95% CI: 0.001~0.027, P = 0.039) mmol/L increase in blood glucose level. Blood glucose AUC was also positively associated with PSQI scores (β = 0.034, 95% CI: 0.003~0.064, P = 0.030). The results for the logistic regression model showed that PSQI was marginal positively correlated with GDM (OR = 1.146, 95% CI: 0.995~1.321, P = 0.059) when age and BMI were not controlled for. When investigating the association between PSQI and the GDM-diagnosed time window, the 1-h diagnosed GDM had a borderline positive correlation with PSQI (OR = 1.182, 95% CI: 0.993~1.405, P = 0.060).

CONCLUSION

Sleep quality during the first trimester may be a risk factor for elevated blood glucose and GDM later in gestation.

Interventions for leg cramps in pregnancy

BACKGROUND

Leg cramps are a common problem in pregnancy. Various interventions have been used to treat them, including drug, electrolyte and vitamin therapies, and non-drug therapies. This Cochrane Review is an update of a review first published in 2015.

OBJECTIVES

To assess the effectiveness and safety of different interventions for treating leg cramps in pregnancy.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (25 September 2019), and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of any intervention for the treatment of leg cramps in pregnancy compared with placebo, no treatment or other treatments. Quinine was excluded for its known adverse effects. Cluster-RCTS were eligible for inclusion. Quasi-RCTs and cross-over studies were excluded.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The certainty of the evidence was assessed using the GRADE approach.

MAIN RESULTS

We included eight small studies (576 women). Frequency of leg cramps was our primary outcome and secondary outcomes included intensity and duration of leg cramps, adverse outcomes for mother and baby and health-related quality of life. Overall, the studies were at low or unclear risk of bias. Outcomes were reported in different ways, precluding the use of meta-analysis and thus data were limited to single trials. Certainty of evidence was assessed as either low or very-low due to serious limitations in study design and imprecision. Oral magnesium versus placebo/no treatment The results for frequency of leg cramps were inconsistent. In one study, results indicated that women may be more likely to report never having any leg cramps after treatment (risk ratio (RR) 5.66, 95% confidence interval (CI) 1.35 to 23.68, 1 trial, 69 women, low-certainty evidence); whilst fewer women may report having twice-weekly leg cramps (RR 0.29, 95% CI 0.11 to 0.80, 1 trial, 69 women); and more women may report a 50% reduction in number of leg cramps after treatment (RR 1.42, 95% CI 1.09 to 1.86, 1 trial, 86 women, low-certainty evidence). However, other findings indicated that magnesium may make little to no difference in the frequency of leg cramps during differing periods of treatment. For pain intensity, again results were inconsistent. Findings indicated that magnesium may make little or no difference: mean total pain score (MD 1.80, 95% CI -3.10 to 6.70, 1 trial, 38 women, low-certainty evidence). In another study the evidence was very uncertain about the effects of magnesium on pain intensity as measured in terms of a 50% reduction in pain. Findings from another study indicated that magnesium may reduce pain intensity according to a visual analogue scale (MD -17.50, 95% CI -34.68 to -0.32,1 trial, 69 women, low-certainty evidence). For all other outcomes examined there may be little or no difference: duration of leg cramps (low to very-low certainty); composite outcome - symptoms of leg cramps (very-low certainty); and for any side effects, including nausea and diarrhoea (low certainty). Oral calcium versus placebo/no treatment The evidence is unclear about the effect of calcium supplements on frequency of leg cramps because the certainty was found to be very low: no leg cramps after treatment (RR 8.59, 95% CI 1.19 to 62.07, 1 study, 43 women, very low-certainty evidence). In another small study, the findings indicated that the mean frequency of leg cramps may be slightly lower with oral calcium (MD -0.53, 95% CI -0.72 to -0.34; 1 study, 60 women; low certainty). Oral vitamin B versus no treatment One small trial, did not report on frequency of leg cramps individually, but showed that oral vitamin B supplements may reduce the frequency and intensity (composite outcome) of leg cramps (RR 0.29, 95% CI 0.11 to 0.73; 1 study, 42 women). There were no data on side effects. Oral calcium versus oral vitamin C The evidence is very uncertain about the effect of calcium on frequency of leg cramps after treatment compared with vitamin C (RR 1.33, 95% CI 0.53 to 3.38, 1 study, 60 women, very low-certainty evidence). Oral vitamin D versus placebo One trial (84 women) found vitamin D may make little or no difference to frequency of leg cramps compared with placebo at three weeks (MD 2.06, 95% CI 0.58 to 3.54); or six weeks after treatment (MD 1.53, 95% CI 0.12 to 2.94). Oral calcium-vitamin D versus placebo One trial (84 women) found oral calcium-vitamin D may make little or no difference to frequency of leg cramps compared with placebo after treatment at three weeks (MD -0.30, 95% CI -1.55 to 0.95); and six weeks (MD 0.03, 95% CI -1.3 to 1.36). Oral calcium-vitamin D versus vitamin D One trial (84 women) found oral calcium-vitamin D may make little or no difference to frequency of leg cramps compared with vitamin D after treatment at three weeks (MD -1.35, 95% CI -2.84 to 0.14); and six weeks after treatment (MD -1.10, 95% CI -2.69 to 0.49).

AUTHORS' CONCLUSIONS

It is unclear from the evidence reviewed whether any of the interventions provide an effective treatment for leg cramps. This is primarily due to outcomes being measured and reported in different, incomparable ways so that data could not be pooled. The certainty of evidence was found to be low or very-low due to design limitations and trials being too small to address the question satisfactorily. Adverse outcomes were not reported, other than side effects for magnesium versus placebo/no treatment. It is therefore not possible to assess the safety of these interventions. The inconsistency in the measurement and reporting of outcomes meant that meta-analyses could not be carried out. The development of a core outcome set for measuring the frequency, intensity and duration of leg cramps would address these inconsistencies and mean these outcomes could be investigated effectively in the future.

Identifying the Associated Risk Factors of Sleep Disturbance During the COVID-19 Lockdown in Bangladesh: A Web-Based Survey

BACKGROUND

Bangladesh, a developing country with a lower-middle-income and one of the world's most densely populated areas, has been severely affected by COVID-19. This global epidemic is not only affecting the physical health of the patients but also causing severe psychological effects among those who have not yet been infected. Sleep disturbance is one of the key symptoms of major depression and one of the proven risk factors for suicide. The objective of this study is to identify the risk factors associated with sleep disturbance which has developed as a general impact of COVID-19 and new normal life during the lockdown (a measure to control the spread of COVID-19) in Bangladesh.

METHODS

Demographic characteristics, COVID-19, and lockdown related information have been collected from 1,128 individuals by conducting a web-based survey. Respondent's perspective regarding sleep disturbance during COVID-19 lockdown is considered as the outcome of interest which is dichotomous. Descriptive statistics methods have been applied to explore the distribution of respondent's demographic characteristics. Pearson's chi-square tests have been performed to relate the sleep disturbance status of the respondents to their demographic, personal, and COVID-19 related information. Furthermore, a multivariable logistic regression model has been adopted to identify the significant association of sleep disturbance with the demographic, COVID-19, and lockdown related information of respondents during the COVID-19 lockdown in Bangladesh.

FINDINGS

The prevalence of sleep disturbance during the COVID-19 lockdown is found to be higher among participants aged 31-40 years. Gender disparity has also been observed in favor of male participants, whereas no significant regional heterogeneity has been found. Working from home or doing online classes during the lockdown has been found as a potential predictive factor of sleep disturbance. Losing a job has been considered as an adverse economic effect of COVID-19, which also induces sleep disturbance. Perception regarding the risk of getting infected and anxiety triggered the chance of developing sleep disturbance. The sleeping schedule is also found as a risk factor for sleep disturbance.

CONCLUSION

Evidence-based policies are required to combat psychological challenges that have arisen due to COVID-19, primarily targeting the groups who are largely suffering from sleep disturbance.

Zolpidem and Gender: Are Women Really At Risk?

BACKGROUND

In 2013 the Food and Drug Administration (FDA) claimed the existence of new data showing women to be at risk for excessive daytime sedation and impaired driving proficiency following bedtime doses of zolpidem. The putative explanation was the reduced metabolic clearance of zolpidem and higher morning blood concentrations in women compared to men. The FDA acted to reduce the recommended dosage for women down to 50% of the dose for men. No other regulatory agency worldwide has taken similar action.

METHODS

Gender effects on zolpidem pharmacokinetics, pharmacodynamics, adverse effects, clinical efficacy, and driving performance were evaluated through a further analysis of data from a previous study, together with a literature review.

RESULTS

Women had on average 35% lower apparent clearance of zolpidem than men (236 vs 364 mL/min, P < 0.001). This difference was not explained by body weight. In some laboratory studies, women had greater functional impairment than men taking the same dose, but in all studies active drug was not distinguishable from placebo at 8 hours after oral dosage. On-the-road driving studies likewise showed no evidence of driving impairment in men or women at 8 hours after 10 mg of oral immediate-release zolpidem. No clinical trial demonstrated a gender-related difference in clinical efficacy or adverse reactions, and there was no evidence of a particular risk to women.

CONCLUSIONS

Dosage reduction in women is not supported by available scientific evidence, and may in fact lead to underdosing and the consequent hazard of inadequately treated insomnia.

[Loss of quality of sleep and associated factors among menopausal women]

The scope of this article is to identify the prevalence of the loss of quality of sleep and associated factors among menopausal women. It is a quantitative, cross-sectional and analytical study, the variables of which were investigated by applying a structured/pre-tested questionnaire and the Pittsburgh Sleep Quality Index with 819 menopausal women cared for under the Family Health Strategy. Simple Poisson regression was used to screen the variables (p < 0.25). For multiple analysis, Poisson regression was used based on a hierarchical model, at a significance level of 5%. Loss of quality of sleep was identified in 67% of the sample. Variables such as advanced age (PR = 1.09; CI = 1.03-1.16), moderate and severe menopausal symptoms (PR = 1.18; CI = 1.10-1.27), moderate to severe anxiety (PR = 1.17; CI = 1.10-1.25), moderate to severe depression (PR = 1.08; CI = 1.01-1.15) and arthritis/arthrosis/rheumatism (PR = 1. 07; CI = 1.01 - 1.14) revealed statistically significant associations with loss of quality of sleep. The loss of quality of sleep was highly prevalent in the population studied. Factors associated with loss of quality of sleep were advanced age, moderate to severe menopausal symptoms, moderate to severe anxiety and depression, and the presence of arthritis/arthrosis/rheumatism.

Pharmacological treatment for insomnia in patients with major depressive disorder

INTRODUCTION

Insomnia in Major Depressive Disorder (MDD) is highly prevalent and associated with increased suffering and functional impairment. Effective, evidence-based treatments for insomnia in MDD are an unmet need in clinical practice.

AREAS COVERED

Herein, the authors provide a review of the clinical correlates, putative neurobiological mechanisms and treatment options for the management of insomnia in individuals with MDD.

EXPERT OPINION

Sleep disturbances in MDD should be recognized as at least one of the following: (1) a domain of depressive psychopathology; (2) a consequence of rhythm disruptions; (3) a manifestation of comorbidities of sleep disturbances; (4) a manifestation of the influence of sex hormones in the brain in MDD; (5) a general medical comorbidity; and (6) a side effect of antidepressant medications. Assessment of insomnia in clinical practices is routinely performed with the use of non-structured interviews. Other methods such as standardized questionnaires and sleep diaries, along with complementary methods such as actigraphy and polysomnography are more scarcely applied. Smartphones and personal devices offer a promising strategy with the use of passive, long lasting, and ecologically valid assessments despite the lack of studies specifically targeting insomnia in individuals with MDD. New therapeutic approaches are essential, including novel targets such as orexins/hypocretins and the endocannabinoid system.

Evaluation and Management of Behavioral Health Disorders in Women: An Overview of Major Depression, Bipolar Disorder, Anxiety Disorders, and Sleep in the Primary Care Setting

Providers of obstetric and gynecologic care are often the most commonly seen medical providers for adult women, providing primary and reproductive care. Even where psychiatric care is readily available, obstetricians/gynecologists are frequently the front line for recognition, education, and initial management of many mental health problems. In settings where psychiatric treatment is a more scarce resource, obstetricians/gynecologists often are responsible for ongoing treatment of these disorders. This review focuses on the impact of the female reproductive life cycle on the presentation and management of some of the most common behavioral health problems in women: major depression, bipolar disorder, anxiety disorders, and primary sleep disorders.

Interventions for leg cramps in pregnancy

BACKGROUND

Leg cramps are a common problem in pregnancy. Various interventions have been used to treat them, including drug, electrolyte and vitamin therapies, and non-drug therapies.

OBJECTIVES

To assess the effectiveness and safety of different interventions for treating leg cramps in pregnancy.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Register (31 March 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of any intervention (drug, electrolyte, vitamin or non-drug therapies) for treatment of leg cramps in pregnancy compared with placebo, no treatment or other treatment. Quinine was excluded for its known adverse effects (teratogenicity). Cluster-RCTS were considered for inclusion. Quasi-RCTs and cross-over studies were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

We included six studies (390 women). Four trials compared oral magnesium with placebo/no treatment, two compared oral calcium with no treatment, one compared oral vitamin B versus no treatment, and one compared oral calcium with oral vitamin C. Two of the trials were well-conducted and reported, the other four had design limitations. The process of random allocation was sub-optimal in three studies, and blinding was not attempted in two. Outcomes were reported in different ways, precluding the use of meta-analysis and limiting the strength of our conclusions.The 'no treatment' group in one four-arm trial has been used as the comparison group for the composite outcome (intensity and frequency of leg cramps) in magnesium, calcium, and vitamin B versus no treatment. This gives it disproportionate weight in the overall analysis, thus interpretation of these results should be cautious. Oral magnesium versus placebo/no treatmentMagnesium (taken orally for two to four weeks) did not consistently reduce the frequency of leg cramps compared with placebo or no treatment. Outcomes that showed differences were: frequency of leg cramps after treatment: never, and twice a week (risk ratio (RR) 5.66, 95% confidence interval (CI) 1.35 to 23.68, one trial, 69 women, evidence graded low; RR 0.29, 95% CI 0.11 to 0.80, one trial, 69 women), and frequency of leg cramps: 50% reduction in number of leg cramps after treatment (RR 1.42, 95% CI 1.09 to 1.86, one trial, 86 women, evidence graded low). The outcomes that showed no difference were: frequency of leg cramps during two weeks of treatment (mean difference (MD) 1.80, 95% CI -1.32 to 4.92, one trial, 38 women, evidence graded low); frequency of leg cramps after treatment: daily, every other day, and once a week (RR 1.20, 95% CI 0.45 to 3.21, one trial, 69 women; RR 0.44, 95% CI 0.12 to 1.57, one trial, 69 women; RR 1.54, 95% CI 0.62 to 3.87, one trial, 69 women).Evidence about whether magnesium supplements reduced the intensity of pain was inconclusive, with two studies showing that it may slightly reduce pain, while one showed no difference. There were no differences in the experience of side effects (including nausea, flatulence, diarrhoea and intestinal air) between pregnant women receiving magnesium compared with placebo/no treatment. Oral calcium versus no treatmentA greater proportion of women receiving calcium supplements experienced no leg cramps after treatment than those receiving no treatment (frequency of leg cramps after treatment: never RR 8.59, 95% CI 1.19 to 62.07, one study, 43 women, evidence graded very low). There was no difference between groups for a composite outcome (intensity and frequency) for partial improvement (RR 0.64, 95% CI 0.36 to 1.15, one trial, 42 women); however, the same trial showed a greater proportion of women experiencing no leg cramps after treatment with calcium compared with no treatment (RR 5.50, 95% CI 1.38 to 21.86).Other secondary outcomes, including side effects, were not reported. Oral vitamin B versus no treatment Frequency of leg cramps was not reported in the one included trial. According to a composite outcome (frequency and intensity), more women receiving vitamin B fully recovered compared with those receiving no treatment (RR 7.50, 95% CI 1.95 to 28.81). Those women receiving no treatment were more likely to experience a partial improvement in the intensity and frequency of leg cramps than those taking vitamin B (RR 0.29, 95% CI 0.11 to 0.73, one trial, 42 women), or to see no change in their condition. However, these results are based on one small study with design limitations.Other secondary outcomes, including side effects, were not reported. Oral calcium versus oral vitamin CThere was no difference in the frequency of leg cramps after treatment with calcium versus vitamin C (RR 1.33, 95% CI 0.53 to 3.38, one study, 60 women, evidence graded very low). Other outcomes, includingside effects, were not reported.

AUTHORS' CONCLUSIONS

It is unclear from the evidence reviewed whether any of the interventions (oral magnesium, oral calcium, oral vitamin B or oral vitamin C) provide an effective treatment for leg cramps. This is primarily due to outcomes being measured and reported in different, incomparable ways, and design limitations compromising the quality of the evidence (the level of evidence was graded low or very low). This was mainly due to poor study design and trials being too small to address the question satisfactorily.Adverse outcomes were not reported, other than side effects for magnesium versus placebo/no treatment. It is therefore not possible to assess the safety of these interventions.The inconsistency in the measurement and reporting of outcomes, meant that data could not be pooled, meta-analyses could not be carried out, and comparisons between studies are difficult.The review only identified trials of oral interventions (magnesium, calcium, vitamin B or vitamin C) to treat leg cramps in pregnancy. None of the trials considered non-drug therapies, for example, muscle stretching, massage, relaxation, heat therapy, and dorsiflexion of the foot. This limits the completeness and applicability of the evidence.Standardised measures for assessing the frequency, intensity and duration of leg cramps to be used in large well-conducted randomised controlled trials are needed to answer this question. Trials of non-drug therapies are also needed.

A systematic review of the relationship between postpartum sleep disturbance and postpartum depression

OBJECTIVE

To examine the relationship between postpartum sleep disturbance and postpartum depression and describe the characteristics and demographics of the samples.

DATA SOURCES

Electronic databases Medline, PubMed, Cochrane, EPOC, CINAHL, ProQuest, and Psych INFO. In addition, hand searches of bibliographies supplemented the electronic search.

STUDY SELECTION

English language primary studies on the relationship between postpartum sleep disturbance and postpartum depression were included. Thirteen observational studies met the inclusion criteria.

DATA EXTRACTION

Data that specified the relationship between sleep disturbance and postpartum depression were extracted from the studies. The data were organized per author, year, participants, setting, country, demographics, design, sample size, outcomes, evidence, and effect size.

DATA SYNTHESIS

The effect size indicating the relationship between sleep disturbance and postpartum depression across the studies ranged between 0.4 and 1.7. There was evidence of a strong relationship between sleep disturbance and postpartum depression; however, the participants in the 13 studies were predominantly educated, middle class, older than age 30 years, and White. Likewise, the definition and measurement of postpartum sleep varied across the studies, which increased the possibility of bias.

CONCLUSIONS

Further research within the postpartum period involving underserved, younger women and samples with more diversity in race and ethnicity are needed.

Effects of estrogen therapy on postmenopausal sleep quality regardless of vasomotor symptoms: a randomized trial

OBJECTIVE

To determine the effects of estrogen therapy on objective sleep quality in insomniac postmenopausal women without severe vasomotor symptoms and/or recognized hot flushes during sleep. Study design Randomized, double-blinded, placebo-controlled trial, parallel design (ClinicalTrials.gov Identifier: NCT01501422).

METHODS

Forty insomniac postmenopausal women with no severe vasomotor symptoms and/or recognized hot flushes during sleep were randomized into 2 months' treatment with a 50-μg transdermal estradiol patch or placebo. Sleep quality was determined objectively with wrist actigraphy. Sleep efficiency, total sleep time, wake up after sleep onset and number of awakenings were compared before and after treatment. The Insomnia Severity Index (ISI) and Epworth Sleepiness Scale (ESS) questionnaires were used for subjective sleep quality assessment before and after treatment.

RESULTS

The study showed no significant difference in sleep efficiency improvement between women having estrogen alone or placebo (median 85.7% vs. 85.2%, respectively, p = 0.71). Similarly, sleep quality scores assessed by ISI and ESS were not significantly different.

CONCLUSION

Estrogen therapy in insomniac postmenopausal women without severe vasomotor symptoms and/or recognized hot flushes during sleep was not found to improve sleep efficiency during the study period.

Cognitive-behavioral, behavioral, and mindfulness-based therapies for menopausal depression: a review

Menopause is a natural transition that all women go through in their lives that is often accompanied by a number of physical and emotional symptoms. Upwards of 40% of women report depression symptoms associated with menopause (Timur & Sahin, 2010) [1]. Treatments for menopausal depression include pharmacological agents such as antidepressants and hormone therapy (HT) as well as psychological approaches. This paper provides a review of cognitive-behavioral, behavioral, and mindfulness based (CBBMB) therapies in treating depression during the menopausal transition. After conducting an electronic database search, only two studies specifically using CBBMB methods were found, both had positive results. Since so few studies existed that specifically evaluated CBBMB treatments for menopausal depression (n=2), a larger net was cast. Studies that assessed depression symptoms as an outcome measure in an evaluation of CBBMB treatments for hot flashes or menopausal symptoms more broadly, were included. The review revealed that interventions targeting hot flashes or menopausal symptoms using CBBMB methods mostly proved to have had a positive impact on depression symptoms in the mild range of severity. Directions for future research are discussed including the need for more CBBMB interventions targeting depression during the menopausal transition to establish their efficacy.

Gonadal steroid modulation of sleep and wakefulness in male and female rats is sexually differentiated and neonatally organized by steroid exposure

The paucity of clinical and preclinical studies investigating sex differences in sleep has resulted in mixed findings as to the exact nature of these differences. Although gonadal steroids are known to modulate sleep in females, less is known about males. Moreover, little evidence exists concerning the origin of these sex differences in sleep behavior. Thus, the goal of this study was to directly compare the sensitivity of sleep behavior in male and female Sprague Dawley rats to changes in the gonadal steroid milieu and to test whether the sex differences in sleep are the result of brain sexual differentiation or differences in circulating gonadal steroids. Here we report the magnitude of change in sleep behavior induced by either estradiol (E2) or testosterone (T) was greater in females compared with males, suggesting that sleep behavior in females is more sensitive to the suppressive effects of gonadal steroids. Furthermore, we demonstrated that the organizational effects of early gonadal steroid exposure result in male-like responsivity to gonadal steroids and directly alter the activity of the ventrolateral preoptic area (VLPO), an established sleep-promoting nucleus, in adult masculinized females. Moreover, the nonaromatizable androgen dihydrotestosterone did not suppress sleep in either males or females, suggesting that the T-mediated effect in females was due to the aromatization of T into E2. Together our data suggest that, like sex behavior, sex differences in sleep follow the classical organizational/activational effects of gonadal steroids.

Gender differences in pharmacokinetics and pharmacodynamics of zolpidem following sublingual administration

The effect of dose and gender on the pharmacokinetics (PK) and pharmacodynamics (PD) of zolpidem after administration of a buffered zolpidem sublingual tablet (ZST; Intermezzo®, Purdue Pharma L.P., Stamford, CT, USA) was evaluated in healthy non-elderly male and female volunteers. Subjects received a single morning dose of ZST (1.0, 1.75, and 3.5 mg) or placebo in a four-way crossover study. In male and female subjects zolpidem PK were linear, with area under the curve (AUC) proportional to dose, and apparent oral clearance and elimination half-life independent of dose. However, AUC averaged 40% to 50% higher in females than in males receiving the same dose. The gender effect was incompletely explained by body weight. In females, ZST produced PD changes consistent with benzodiazepine agonist effects, particularly at the 3.5-mg dose. For several PD variables, PD effects were significantly related to plasma zolpidem concentrations when data were aggregated across subjects. However, there was variability in response among individuals. In males, PD effects of zolpidem seldom differed from placebo regardless of plasma concentration. The findings confirm that zolpidem clearance is lower in females than in males. PD effects of zolpidem from ZST are greater in female subjects, due to a combination of higher plasma concentrations and greater intrinsic sensitivity.

Sleep disturbance in menopause

Sleep disturbance during menopause is a common and important complaint faced by many women. There are many factors that may play a role in this problem, including vasomotor symptoms and changing hormone levels, circadian rhythm abnormalities, exacerbation of primary insomnia, mood disorders, coexistent medical conditions as well as lifestyle factors. Sleep can be measured both objectively and subjectively; however, correlation between the two measures is not high. Most of the menopause-related sleep disturbances have been reported as qualitative in nature; however, there have also been studies showing changes in objective measures. This discrepancy has implications with regard to evaluation of research in sleep and menopause, as well as application in the clinical setting. Investigations of inadequate sleep and sleep problems during the menopausal period and obtaining a thorough understanding of the factors contributing to these problems are essential in formulating treatment strategies. Such strategies can vary from hormonal treatment and medications to lifestyle and behavioural modification.

Effects of quetiapine extended release on sleep and quality of life in midlife women with major depressive disorder

Depression during midlife years may lead to significant sleep disturbances and adversely impact quality of life (QOL). In this report, we examined the effects of treatment with quetiapine extended release (XR), 150-300 mg/day, on sleep and QOL in 23 midlife women with major depressive disorder (MDD). Quetiapine XR improved subjective sleep distress, overall sleep parameters, and sleep-related QOL, ultimately leading to significant improvement in menopause-related QOL. While larger, controlled trials are still awaited, these preliminary results are encouraging and suggest that quetiapine XR may be a useful tool in treating symptomatic midlife women with MDD.

DSM-IV psychiatric comorbidity according to symptoms of insomnia: a nationwide sample of Korean adults

PURPOSE

The diagnosis of insomnia is based on the presence of four different symptoms: difficulty in initiating sleep (DIS), difficulty in maintaining sleep (DMS), early morning awakening (EMA), and non-restorative sleep (NRS). This study investigated the differences in sociodemographic correlates and psychiatric comorbidity between the four symptoms of insomnia in the general population of South Korea.

METHODS

A sample of the population aged 18-64 (N = 6,510) was questioned using a face-to-face interview. Insomnia was defined as having at least one of the four following symptoms three or more times per week: DIS, DMS, EMA, and NRS. Psychiatric disorders were evaluated using the Korean version of Composite International Diagnostic Interview. Logistic regression analysis was used to test each of the sleep outcomes (DIS, DMS, EMA, or NRS) for an association with sociodemographic and clinical variables.

RESULTS

The prevalence of DIS, DMS, EMA, and NRS were 7.9 % (95 % CI 6.6-9.5 %), 7.9 % (95 % CI 6.5-9.6 %), 4.9 % (95 % CI 3.9-6.0 %), and 14.8 % (95 % CI 12.6-17.4 %), respectively. The overall prevalence of insomnia was 19.0 % (95 % CI 16.1-22.2 %). Being separated, divorced, or widowed, being single, having a part-time job, having a psychiatric illness, and having a physical illness were all significantly related to insomnia. Older age also increased the risk of DMS and EMA, and younger age was a risk factor for NRS. The presence of most psychiatric disorders was significantly related to insomnia. However, the relationship between the psychiatric illness and each insomnia symptom varied and was dependent on the insomnia symptom.

CONCLUSIONS

Most psychiatric disorders were significantly associated with each insomnia symptom in different ways. Differences in sociodemographic and clinical correlates between the four insomnia symptoms implied the heterogeneous characteristics of insomnia as defined by the current diagnostic criteria.

Sleep in postmenopausal women

The aim of this study was to identify factors that most influence the perception of sleep quality in postmenopausal women. We used the methodological strategy of the Collective Subject Discourse (CSD), which is based on a theoretical framework of social representations theory. We obtained the data by interviewing 22 postmenopausal Brazilian women who were experiencing insomnia. The women gave accounts of their difficulties with sleep; a variety of dimensions were identified within the data. The onset of sleep disorders might have occurred during childhood or in situations considered to be stressful, and were not necessarily associated with menopause. We found that hormonal alterations occurring during menopause, psychosocial factors, and sleep-breathing disorders triggered occasional sleep disturbances during this time of life. Participants were aware of the consequences of sleep deprivation. In addition, inadequate sleep hygiene habits figured prominently as determinants in the persistence of sleep disturbances.

Sleep disturbance in late pregnancy and type and duration of labour

In this study, the relationship between sleep quality and type and duration of labour has been evaluated. A total of 88 pregnant women completed the Pittsburgh Sleep Questionnaire three times during their last 3 weeks of pregnancy at their prenatal visits and once postpartum. A mean score of >5 was considered as poor-quality sleep. Duration of labour, type of delivery and weight of the newborn at delivery was considered. Of the study population, 56.2% were categorised as the good-quality sleep group and 43.8% as the poor-quality sleep group. The reported sleeping time per day was 8.47±1.86 hours for the good-quality sleep group and 6.45±2.07 hours for the poor-quality sleep group. The poor-quality sleep women were 20% more likely to undergo caesarean section and had a longer labour duration. Gestational age at delivery and mean gravidity was respectively 38.53±1.17 weeks and 1.91±1.03 in the good-quality sleep group and 38.36±1.59 weeks and 1.86±1.07 in the poor-quality sleep group. Thus, it was found that women with sleep problems experience longer labour duration and are more likely to undergo a caesarean section.

Expert opinion on pharmacotherapy of narcolepsy

IMPORTANCE TO THE FIELD

Narcolepsy is a neurodegenerative disorder resulting in the instability of the sleep-wake cycle and marked by low levels of hypocretin in cerebrospinal fluid. Sleep instability is marked by brisk, sleep-onset REM periods and sleep fragmentation, while the waking state is interrupted by the intrusion of REM sleep and sometimes accompanied by cataplectic attacks.

AREAS COVERED IN THIS REVIEW

Current pharmacologic interventions that aim to address three primary features of this disorder; excessive daytime sleepiness (EDS), cataplexy and automatic behaviors, and sleep fragmentation. We review and compare the use of traditional and new stimulants in the treatment of EDS. For the treatment of cataplexy and automatic behaviors, serotonergic and noradrenergic agents are considered. The role of gamma-hydroxybutyrate (GHB) is also explored in its ability to reduce daytime sleepiness and catapletic attacks and to consolidate sleep. Findings are based on a PubMed literature search of clinical and basic science research papers spanning 1977-2009.

WHAT THE READER WILL GAIN

A comprehensive understanding of the various existing and promising future treatments for narcolepsy. For each of these treatments, we evaluate risks versus benefits of treatment, and proposed pharmacologic mechanisms of action. We conclude with a review of new treatment approaches, including thyrotropin-releasing hormone (TRH), histamine agonists, immunotherapy and hypocretin replacement therapies.

TAKE HOME MESSAGE

Narcolepsy is an autoimmune, neurodegenerative disorder that results in significant sleep-wake instability with or without cataplectic attacks. Current treatments aim symptomatically to reconsolidate the sleep and waking states and to reduce daytime attacks of cataplexy. Future treatments aim primarily towards correcting the causal deficiency of hypocretin or preventing the autoimmune response that results in the loss of hypocretin cells.

Insomnia and its effective non-pharmacologic treatment

Emerging data underscores the public health and economic burden of insomnia evidenced by increased health risks; increased health care utilization; and work domain deficits (absenteeism and reduced productivity). Cognitive behavioral therapy for insomnia (CBTi) is a brief and effective non-pharmacologic treatment for insomnia that is grounded in the science of sleep medicine and the science of behavior change and psychological theory, and in direct comparisons with sleep medication in randomized control trials that demonstrate that CBTi has comparable efficacy with more durable long-term maintenance of gains after treatment discontinuation. The high level of empirical support for CBTi has led the National Institutes of Health Consensus and the American Academy of Sleep Medicine Practice Parameters to make the recommendation that CBTi be considered standard treatment. The aim of this report is to increase awareness and understanding of health care providers of this effective treatment option.

Postmenopausal hormones and sleep quality in the elderly: a population based study

Background

Sleep disturbance and insomnia are commonly reported by postmenopausal women. However, the relationship between hormone therapy (HT) and sleep disturbances in postmenopausal community-dwelling adults is understudied. Using data from the multicenter Study of Osteoporotic Fractures (SOF), we tested the relationship between HT and sleep-wake estimated from actigraphy.

Methods

Sleep-wake was ascertained by wrist actigraphy in 3,123 women aged 84 ± 4 years (range 77-99) from the Study of Osteoporotic Fractures (SOF). This sample represents 30% of the original SOF study and 64% of participants seen at this visit. Data were collected for a mean of 4 consecutive 24-hour periods. Sleep parameters measured objectively included total sleep time, sleep efficiency (SE), sleep latency, wake after sleep onset (WASO), and nap time. All analyses were adjusted for potential confounders (age, clinic site, race, BMI, cognitive function, physical activity, depression, anxiety, education, marital status, age at menopause, alcohol use, prior hysterectomy, and medical conditions).

Results

Actigraphy measurements were available for 424 current, 1,289 past, and 1,410 never users of HT. Women currently using HT had a shorter WASO time (76 vs. 82 minutes, P = 0.03) and fewer long-wake (≥ 5 minutes) episodes (6.5 vs. 7.1, P = 0.004) than never users. Past HT users had longer total sleep time than never users (413 vs. 403 minutes, P = 0.002). Women who never used HT had elevated odds of SE <70% (OR,1.37;95%CI,0.98-1.92) and significantly higher odds of WASO ≥ 90 minutes (OR,1.37;95%CI,1.02-1.83) and ≥ 8 long-wake episodes (OR,1.58;95%CI,1.18-2.12) when compared to current HT users.

Conclusions

Postmenopausal women currently using HT had improved sleep quality for two out of five objective measures: shorter WASO and fewer long-wake episodes. The mechanism behind these associations is not clear. For postmenopausal women, starting HT use should be considered carefully in balance with other risks since the vascular side-effects of hormone replacement may exceed its beneficial effects on sleep.

Sleep quality in women with and without postpartum depression

OBJECTIVE

To compare and measure the effects of sleep quality in women with and without postpartum depression.

DESIGN

A case-control repeated measures matched pairs design.

SETTING

Home and obstetric office.

PARTICIPANTS

Forty-six women who were 6 to 26 weeks postpartum. Two participants were dropped from the final analysis because they were outliers.

METHODS

Participants underwent wrist actigraphy at home for 7 consecutive days to measure sleep quality. The Postpartum Depression Screening Scale measured depression severity. Psychosocial variables were collected during a screening interview. A structured clinical interview was used to diagnose postpartum depression. Correlations, t tests, and hierarchical multiple regressions were run to analyze data.

RESULTS

With the exception of wake episodes, sleep latency (B=1.80, SE=0.73, p<.05), wake after sleep onset (B=6.85, SE=2.85, p<.05), and thus sleep efficiency (B=-6.31, SE=3.13, p<.05) predicted postpartum depression symptom severity.

CONCLUSIONS

Women with postpartum depression experienced poorer sleep quality than women without postpartum depression, and sleep quality worsened with increasing postpartum depression symptom severity. Clinicians need to address measures to improve sleep quality in depressed mothers to decrease symptom severity, and researchers need to develop interventions to facilitate better sleep quality in women with postpartum depression.

Effect of 17alpha-ethinyl estradiol on active phase rapid eye movement sleep microarchitecture

Estrogen treatment decreases active phase rapid eye movement (REM) sleep in ovariectomized rats. Here we explored further the effect of 17alpha-ethinyl estradiol (17alpha-EE) on active phase REM sleep in ovariectomized rats by analyzing spectral properties and the number and length of REM sleep bouts. The greatest suppression of REM sleep occurred on day 4 of 17alpha-EE treatment, was due to decreases in bout length, and was accompanied by decreased EEG theta power. These results further elucidate 17alpha-EE's effects on REM sleep and provide greater understanding of the mechanisms by which estrogens alter sleep-wakefulness patterns.

Subchronic 17alpha-ethinyl estradiol differentially affects subtypes of sleep and wakefulness in ovariectomized rats

In ovariectomized (OVX) Sprague-Dawley rats, estradiol benzoate (EB) has been reported to decrease rapid eye movement (REM) and non-REM (NREM) sleep during the dark phase for up to 3 days. It is unknown, however, if estrogenic effects on sleep extend beyond 3 days or if other estrogens could induce the same changes. Furthermore, it is unclear whether the increased wakefulness in the dark phase was due to changes in active or quiet wakefulness. Therefore, we examined the effects of daily injections of 17alpha-ethinyl estradiol (EE) for 6 days on sleep and wakefulness in the OVX rat. After 3 days of baseline recording using a telemetric system, rats were administered sesame oil (sc) for 3 days followed by injection with EE (20 mug/rat/day, sc) for 6 days. After treatment, sleep was recorded during hormone withdrawal for an additional 5 days. A few sporadic but statistically significant increases in light phase sleep occurred during the last 3 days of EE treatment. Starting on day 2 of the study, EE caused statistically significant decreases in dark phase REM sleep that were maintained throughout the treatment period and persisted until the 3rd day of hormone withdrawal. During the dark phase, statistically significant decreases in NREM sleep and increases in active wakefulness started on the second day of treatment and abated by the end of treatment. This study demonstrated that EE had similar effects on sleep-wakefulness to EB and demonstrates the utility of telemetric polysomnographic recording of the female OVX rat as a model for understanding the estrogen-induced changes on sleep-wakefulness.