Restless legs syndrome among women: prevalence, co-morbidity and possible relationship to menopause

Sleep in the Athlete

Sleep is important for not only general health but also for lowering injury risk and maintaining athletic performance. Sleep disorders are prevalent in athletes, and taking a sleep history, evaluating sleep quality, and addressing other related factors including mental health are essential in diagnosing and understanding sleep disorders. Other methods such as polysomnography, actigraphy, and sheet sensors can also be used. Treatment options for sleep disorders include sleep hygiene, cognitive behavioral therapy, medication, and addressing contributing factors. For athletes, sleep can also be affected by factors such as travel fatigue and jet lag, which should be taken into consideration.

Sex and Sleep Disruption as Contributing Factors in Alzheimer's Disease

Alzheimer's disease (AD) affects more women than men, with women throughout the menopausal transition potentially being the most under researched and at-risk group. Sleep disruptions, which are an established risk factor for AD, increase in prevalence with normal aging and are exacerbated in women during menopause. Sex differences showing more disrupted sleep patterns and increased AD pathology in women and female animal models have been established in literature, with much emphasis placed on loss of circulating gonadal hormones with age. Interestingly, increases in gonadotropins such as follicle stimulating hormone are emerging to be a major contributor to AD pathogenesis and may also play a role in sleep disruption, perhaps in combination with other lesser studied hormones. Several sleep influencing regions of the brain appear to be affected early in AD progression and some may exhibit sexual dimorphisms that may contribute to increased sleep disruptions in women with age. Additionally, some of the most common sleep disorders, as well as multiple health conditions that impair sleep quality, are more prevalent and more severe in women. These conditions are often comorbid with AD and have bi-directional relationships that contribute synergistically to cognitive decline and neuropathology. The association during aging of increased sleep disruption and sleep disorders, dramatic hormonal changes during and after menopause, and increased AD pathology may be interacting and contributing factors that lead to the increased number of women living with AD.

Sleep and Women's Mental Health

Women have increased risks for both sleep disturbances and disorders and for mental health issues throughout their lives, starting in adolescence. Women have a higher prevalence of insomnia disorder and restless legs syndrome (RLS) versus men, and obstructive sleep apnea (OSA) is more likely as women age. Hormonal transitions are important to consider in women's sleep. For women, insomnia, OSA, and RLS are predictive of depression, and insomnia and sleep-disordered breathing are predictive of Alzheimer disease. These findings underscore the importance of assessment, treatment, and future research examining sleep and mental health in women, given their unique and increased vulnerability.

Hyperhidrosis in sleep disorders - A narrative review of mechanisms and clinical significance

Hyperhidrosis is characterized by excessive sweating beyond thermoregulatory needs that affects patients' quality of life. It results from an excessive stimulation of eccrine sweat glands in the skin by the sympathetic nervous system. Hyperhidrosis may be primary or secondary to an underlying cause. Nocturnal hyperhidrosis is associated with different sleep disorders, such as obstructive sleep apnea, insomnia, restless legs syndrome/periodic limb movement during sleep and narcolepsy. The major cause of the hyperhidrosis is sympathetic overactivity and, in the case of narcolepsy type 1, orexin deficiency may also contribute. In this narrative review, we will provide an outline of the possible mechanisms underlying sudomotor dysfunction and the resulting nocturnal hyperhidrosis in these different sleep disorders and explore its clinical relevance.

Worldwide estimation of restless legs syndrome: a systematic review and meta-analysis of prevalence in the general adult population

This systematic review, meta-analysis and meta-regression assessed the prevalence of restless legs syndrome (RLS) in the general adult population. Studies identified in Scopus, PubMed, Web of Science, and PsycInfo between January 2000 and February 2022 were included if they used a case-control or cross-sectional design and reported data regarding the prevalence of RLS. The protocol was pre-registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42022300709). A total of 97 studies including 483,079 participants from 33 different countries met the eligibility criteria. The Newcastle Ottawa Scale was used to evaluate the methodological quality, and the fill-and-trim method was used to correct probable publication bias, while the jack-knife method was performed to assess small study effect. The corrected overall pooled prevalence of RLS was 3% (95% confidence interval [CI] 1.4%-3.8%). The pooled prevalence of RLS syndrome was affected by methodological quality (no data from non-respondents in the included studies), gender (higher among women), study design (lower prevalence in case-control versus cohort and cross-sectional studies). The figures for corrected pooled prevalence among men, women, alcohol consumers and smokers were 2.8% (95% CI 2%-3.7%); 4.7% (95% CI 3.2%-6.3%); 1.4% (95% CI 0%-4.2%); and 2.7% (95% CI 0%-5.3%), respectively. The prevalence among male and female participants was lower in community-based versus non-community-based studies. Moreover, the prevalence was higher in developed versus developing countries and among elders versus adults. In conclusion, RLS is a common disorder in the general adult population, with a higher prevalence in women; however, prevalence data are affected by study design and quality.

Prevalence of restless legs syndrome in people with diabetes mellitus: A pooling analysis of observational studies

BACKGROUND

Diabetes mellitus (DM) is associated with different clinical complications. The aim of this study was to explore the prevalence of RLS in people with diabetes mellitus and compare the risk of restless leg syndrome (RLS) between diabetic and non-diabetic population.

METHODS

We searched for studies of RLS prevalence in DM through PubMed, Embase, and Web of Science. Two authors independently completed the literature screening, data extraction, and bias risk assessment of eligible studies. All observational studies that assessed the prevalence or risk of RLS in DM were included, where the diagnosis of RLS was based on the International Restless Legs Syndrome Study Group (IRLSSG). Percentages, odds ratio (OR) with 95% confidence intervals (CI) were used to assess pooled estimates of RLS prevalence and risk based on random-effects models. Newcastle-Ottawa-scale (NOS) or a modified NOS were used to evaluate the quality of studies.

FINDINGS

A total of 42 studies, including 835,986 participants, met the eligibility criteria for the meta-analysis. Among them, 30 studies were included in meta-analysis to analyze the prevalence of RLS. A second meta-analysis was conducted using 31 studies to determine RLS risk between diabetes and non-diabetes. The results indicate that between 25% (95% confidence interval 21%-29%) of people with diabetes showed signs of RLS, and people with diabetes had an increased risk of developing RLS compare to people without diabetes (OR 1.98, 95%CI 1.66- 2.34, p < 0.001). However, the available evidence was limited due to potential risk of bias and variability between studies (I² >75%), all of observational design.

INTERPRETATION

Our study suggests that the prevalence and risk of RLS might be higher in DM patients than in non-diabetes population. However, given limitations in the analysis and study design, the findings need to be corroborated in future studies.

FUNDING

This work was supported by the Basic Conditions Platform Construction Project of Sichuan Science and Technology Department (2019JDPT0015), and the "1・3・5 project for disciplines of excellence, West China Hospital, Sichuan University" (ZYJC18003).

The Long-Term Psychiatric and Cardiovascular Morbidity and Mortality of Restless Legs Syndrome and Periodic Limb Movements of Sleep

Restless legs syndrome (RLS) is a sensory-motor neurological disorder that is associated with high levels of distress and sleep disturbance. Cross-sectional and longitudinal evidence suggests that individuals suffering from RLS may be at an increased risk of certain psychiatric illnesses and cardiovascular diseases. There also is evidence for increased mortality rates in RLS patients, although contrasting results do exist. Periodic limb movements of sleep (PLMS), repetitive leg movement observed in most RLS patients, and sleep disturbance may mediate the relationship between RLS and long-term morbidity. This article summarizes the literature investigating the potential consequences of both RLS and PLMS.

Effects of menopause on sleep quality and sleep disorders: Canadian Longitudinal Study on Aging

OBJECTIVES

Sleep complaints are common during the menopause transition. However, it is difficult to disentangle changes in sleep related to aging from those directly due to menopause. We compared sleep disorders in 45 to 60-year-old women in a large population-based study, according to menopausal status.

METHODS

Women aged between 45 and 60 years who self-reported menopausal status were selected from the Canadian Longitudinal Study of Aging, excluding those with prior hysterectomy. Participants completed assessments for overall sleep satisfaction, hours of daily sleep, sleep-onset insomnia, sleep-maintenance insomnia, daytime somnolence, rapid eye movement sleep behavior disorder (RBD), restless leg syndrome (RLS), and obstructive sleep apnea (OSA). Each sleep variable was compared between postmenopausal and pre/perimenopausal women using multivariate regression, adjusting for potential confounders.

RESULTS

Among 6,179 women included, 3,713 (60.1%; age 55.7 ± 3.3 years) were postmenopausal and 2,466 (39.9%) were pre/perimenopausal (age 49.80 ± 3.1 years). Compared with pre/perimenopausal women, postmenopausal women were more often reported requiring ≥30 minutes to fall asleep (20.4% vs 15.5%; adjusted odds ratio [AOR] 1.24, 95% confidence interval [CI] 1.00-1.53) and were more likely to meet criteria for possible sleep-onset insomnia disorder (10.8% vs 7.3%; AOR 1.51, 95% CI 1.07-2.12). Postmenopausal women were also more likely to screen positive for OSA (14.6% vs 10.4%; AOR 1.48, 95% CI 1.14-1.92). The two groups did not differ on sleep dissatisfaction (32.4% vs 29%), daytime somnolence disorder (1.6% vs 1.3%), sleep-maintenance insomnia disorder (17% vs 14.5%), RLS (23.5% vs 20.9%), or RBD (3.9% vs 4.0%).

CONCLUSIONS

Menopause is associated with increased sleep-onset insomnia. Postmenopausal women also are more likely to screen positive for OSA. However, menopausal status is not associated with sleep maintenance, somnolence, or RLS, and RBD. : Video Summary:http://links.lww.com/MENO/A501.

Restless Legs Syndrome During Pregnancy and 12 Weeks Postpartum and its Links to Cardiovascular Diseases, Stressful Life Events, and Psychiatric History

Restless legs syndrome (RLS) is highly prevalent among pregnant women. In the present study, a neurological-obstetrical sample of 561 postpartum women was retrospectively screened for RLS symptoms during pregnancy and in the first 12 weeks postpartum. The first screening took place within 1 to 6 days of delivery (T0) and the second 12 weeks after childbirth (T1). The pregnancy-related RLS prevalence rate was found to be 21% (n = 119), with the women suffering from RLS being more often affected by psychiatric history and having been more exposed to stressful life events. They were also found to have experienced baby blues more frequently shortly after childbirth. However, RLS in pregnancy did not appear to have any effect on the development of postpartum depression. Additionally, a positive trend was observed toward an association between pregnancy-related RLS and gestational diabetes and hypertension. Of the 119 women, 23 (19.3%) remained affected by RLS 12 weeks postpartum. Body mass index (BMI), weight gain, parity, childbearing history, or chronic stress exposure in pregnancy as measured by hair cortisol were not found to be linked to RLS. In summary, a comprehensive understanding of the interaction of clinical, environmental, and anamnestic factors can help shed valuable light on this pregnancy-related condition.

Insomnia and menopause: a narrative review on mechanisms and treatments

The menopausal transition is associated with an increased frequency of sleep disturbances. Insomnia represents one of the most reported symptoms by menopausal women. According to its pathogenetic model (3-P Model), different predisposing factors (i.e. a persistent condition of past insomnia and aging per se) increase the risk of insomnia during menopause. Moreover, multiple precipitating and perpetuating factors should favor its occurrence across menopause, including hormonal changes, menopausal transition stage symptoms (i.e. hot flashes, night sweats), mood disorders, poor health and pain, other sleep disorders and circadian modifications. Thus, insomnia management implies a careful evaluation of the psychological and somatic symptoms of the individual menopausal woman by a multidisciplinary team. Therapeutic strategies encompass different drugs but also behavioral interventions. Indeed, cognitive behavioral therapy represents the first-line treatment of insomnia in the general population, regardless of the presence of mood disorders and/or vasomotor symptoms (VMS). Different antidepressants seem to improve sleep disturbances. However, when VMS are present, menopausal hormone therapy should be considered in the treatment of related insomnia taking into account the risk-benefit profile. Finally, given its good tolerability, safety, and efficacy on multiple sleep and daytime parameters, prolonged-released melatonin should represent a first-line drug in women aged ≥ 55 years.

Why Are Women Prone to Restless Legs Syndrome?

Restless legs syndrome is a relatively common neurologic disorder considerably more prevalent in women than in men. It is characterized by an inactivity-induced, mostly nocturnal, uncomfortable sensation in the legs and an urge to move them to make the disagreeable sensation disappear. Some known genes contribute to this disorder and the same genes contribute to an overlapping condition—periodic leg movements that occur during sleep and result in insomnia. Dopamine and glutamate transmission in the central nervous system are involved in the pathophysiology, and an iron deficiency has been shown in region-specific areas of the brain. A review of the literature shows that pregnant women are at particular risk and that increased parity is a predisposing factor. Paradoxically, menopause increases the prevalence and severity of symptoms. This implies a complex role for reproductive hormones. It suggests that changes rather than absolute levels of estrogen may be responsible for the initiation of symptoms. Both iron (at relatively low levels in women) and estrogen (at relatively high oscillating levels in women) influence dopamine and glutamate transmission, which may help to explain women’s vulnerability to this condition. The syndrome is comorbid with several disorders (such as migraine, depression, and anxiety) to which women are particularly prone. This implies that the comorbid condition or its treatment, or both, contribute to the much higher prevalence in women than in men of restless legs syndrome.

Restless legs syndrome, periodic limb movements during sleep and cardiovascular risk

Multiple mechanisms may modulate an association between restless legs syndrome/Willis-Ekbom disease (RLS/WED) and cardiovascular disease (CVD), including chronic sleep deprivation, intermittent, periodic limb movements in sleep (PLMS)-related autonomic fluctuations and possible autonomic dysfunction intrinsically associated with RLS per se. The purpose of this paper is to review the existing RLS/WED literature focusing on the pathophysiologic evidence for possible associations between RLS/WED and PLMS with CVD and events (CVE). Specific intrinsic dysautonomic aspects of the disease, which may contribute to generating CVD, are separately discussed. The association between RLS/WED and both CV risk factors and CVD still remains elusive. Although several shared pathophysiological causes could explain these possible relationships, the emerging body of literature focusing on these disorders remains controversial. Not only longitudinal population-based studies and meta-analyses, but also more animal models and therapeutic interventions are needed in order to build a sufficiently robust body of evidence on this topic.

Acceptability and feasibility of a 12-week yoga vs. educational film program for the management of restless legs syndrome (RLS): study protocol for a randomized controlled trial

Background

Restless legs syndrome (RLS) is a common and burdensome sleep disorder associated with profound impairment of health, well-being, and quality of life. Unfortunately, the medications used for RLS management carry risk of serious side effects, including augmentation of symptoms. Yoga, an ancient mind-body discipline designed to promote physical, emotional, and mental well-being, may offer a viable, low-risk new treatment. The primary objectives of this pilot, parallel-arm, randomized controlled trial (RCT) are to assess the acceptability and feasibility of a 12-week yoga vs. educational film program for the management of RLS.

Methods

Forty-four adults with confirmed moderate to severe RLS will be recruited and randomized to a 12-week yoga (n = 22) or standardized educational film program (N = 22). Yoga group participants will attend two 75-min Iyengar yoga classes per week for the first 4 weeks, then one 75-min class per week for the remaining 8 weeks, and will complete a 30-min homework routine on non-class days. Educational film group participants will attend one 75-min class per week for 12 weeks and complete a daily RLS treatment log; classes will include information on: RLS management, including sleep hygiene practices; other sleep disorders; and complementary therapies likely to be of interest to those participating in a yoga and sleep education study.

Yoga and treatment logs will be collected weekly. Feasibility outcomes will include recruitment, enrollment, and randomization rates, retention, adherence, and program satisfaction. Program evaluation and yoga-dosing questionnaires will be collected at week 12; data on exploratory outcomes (e.g., RLS symptom severity (IRLS), sleep quality (PSQI), mood (POMS, PSS), and health-related quality of life (SF-36)) will be gathered at baseline and week 12.

Discussion

This study will lay the essential groundwork for a planned larger RCT to determine the efficacy of a yoga program for reducing symptoms and associated burden of RLS. If the findings of the current trial and the subsequent larger RCTs are positive, this study will also help support a new approach to clinical treatment of this challenging disorder, help foster improved understanding of RLS etiology, and ultimately contribute to reducing the individual, societal, and economic burden associated with this condition.

Trial registration

ClinicalTrials.gov, ID: NCT03570515. Retrospectively registered on 1 February 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3217-7) contains supplementary material, which is available to authorized users.

Comparative Efficacy and Safety of Clonazepam versus Nortriptyline in Restless Leg Syndrome among Forty Plus Women: A Prospective, Open-Label Randomized Study

Aims and Objectives:

The aim of this study is to compare the effect of clonazepam and nortriptyline on rate, frequency, and severity of restless leg syndrome (RLS) in above 40 years women suffering from RLS.

Materials and Methods:

A prospective, randomized, open-label comparative study was conducted at a tertiary care teaching hospital for 1 year. Restless legs syndrome (RLS) diagnosis was based on four essential clinical criteria established by the International RLS Study Group in 2003. Patients were randomized into two groups. Group 1 received tablet clonazepam 0.5 mg bedtime orally daily. Group 2 received tablet nortriptyline 25 mg bedtime orally daily. The primary efficacy endpoints by the International Restless leg Syndrome Scale (IRLS) were evaluated at 0, 4, and 8 weeks. Adverse drug events and safety assessment for vital signs such as blood pressure, pulse, heart rate, waist circumference, and body mass index were compared between two groups.

Results:

Effect on mean IRLSS was statistically more in clonazepam group in comparison to nortriptyline group with comparable results at 8 weeks (P < 0.001), but at 4 weeks, nortriptyline showed less improvement (P < 0.01) versus P < 0.001 in nortriptyline group. Thus, nortriptyline reported relatively more improvement on IRLSS numerically in comparison to clonazepam. Nortriptyline proved to be statistically better in improving the frequency of RLS with comparison to clonazepam, whereas the results were comparable with regard to rate and the severity of RLS. Both the groups were relatively safe and did not produce any change in biochemical parameters and were free from any serious or severe adverse events and overall, both the treatments were well tolerated.

Conclusion:

Both the drugs provided clinically and statistical significant effect on RLS when compared with their respective baselines. However, nortriptyline proved to be statistically better in improving the frequency of RLS in comparison to clonazepam, whereas the results were comparable with regard to rate and the severity of RLS on intergroup comparison. Both the drugs were well tolerated.

Higher Prevalence of Hypertension among Individuals with Restless Legs Syndrome: A Meta-Analysis

OBJECTIVE

This study investigated the proposed association between restless legs syndrome (RLS) and the prevalence of hypertension.

METHODS

A meta-analysis was conducted based on searches of the PUBMED, EMBASE, Cochrane Library, and Korean electronic databases. Cohort and cross-sectional studies reporting the incidence of hypertension in individuals with RLS were included. Dichotomous data were pooled to obtain an odds ratio (OR) and 95% confidence interval (CI) for the prevalence of hypertension in individuals with RLS. The main outcome measure of the study was prevalence of hypertension in patients with RLS compared with a control group.

RESULTS

One cohort study and eight cross-sectional studies were included in the meta-analysis. Individuals with RLS had an increased prevalence of hypertension (all studies: OR=1.13, 95% CI=1.04-1.23; cross-sectional studies: OR=1.12, 95% CI=1.01-1.24). However, in subgroup analyses controlling for cardiovascular risk factors, such as diabetes mellitus and dyslipidemia, the differences in the prevalence of hypertension between RLS and control patients were no longer significant.

CONCLUSION

Patients with RLS may have a higher prevalence of hypertension, according to a pooled analysis, but the results remain to be confirmed in well-designed prospective studies.

The prevalence of restless legs syndrome and its relationship with demographic characteristics and medical disorders in postmenopausal Iranian women

This study was conducted to evaluate the prevalence of restless legs syndrome (RLS) and its relationship with demographic factors and medical disorders on 980 postmenopausal women. Data was gathered using a demographic questionnaire and the International Restless Legs Syndrome Scale. The prevalence of RLS was 16.02% (157/980). Women with poor economic status were 3.37 and 2.33 times more likely to have RLS than women with a good economic situation and moderate economic status (CI:2.041-5.579, P ≤ 0.0001) and (CI: 1.540-3.551, P ≤ 0.0001) respectively. The risk of RLS was 64% greater in women who smoked than in non-smokers. Women with history of hypertension, diabetes and anemia were 2.82, 2.09 and 2.19 times, respectively, more likely to have RLS than those without (P < 0.001). Also women with higher body mass index were more likely to have RLS and women taking hormone replacement therapy were less likely to have RLS. The prevalence of RLS among postmenopausal Iranian women is quite high and there is a relationship between RLS and factors such as age at menopause, education level, a history of smoking, hypertension, anemia and diabetes.

Prevalence of restless legs symptoms according to depressive symptoms and depression type: a cross-sectional study

BACKGROUND

Restless legs syndrome is a sensorimotor disorder and it is associated with several other diseases especially mental illnesses.

AIMS

To analyze the relationship between the symptoms of restless legs syndrome and the severity of depressive symptoms and the prevalence of restless legs symptoms in depression subtypes.

METHODS

A cross-sectional study of primary care patients in the Central Finland Hospital District. The prevalence of restless legs symptoms was studied in 706 patients with increased depressive symptoms and 426 controls without a psychiatric diagnosis by using a structured questionnaire. The depressive symptoms were evaluated with the Beck Depression Inventory (BDI) and the psychiatric diagnosis was confirmed by means of a diagnostic interview (Mini-International Neuropsychiatric Interview). The subjects with increased depressive symptoms were divided into three groups (subjects with depressive symptoms without a depression diagnosis, melancholic depression and non-melancholic depression).

RESULTS

In the whole study population, the prevalence of restless legs symptoms increased with the severity of depressive symptoms. The prevalence of restless legs symptoms was highest in the melancholic and non-melancholic depressive patients (52 and 46%, respectively) and then in subjects with depressive symptoms without a depression diagnosis (43.4%), but the prevalence was also substantial (24.6%) in subjects without a psychiatric diagnosis.

CONCLUSIONS

Restless legs symptoms are very common in primary care among subjects with depression, regardless of the depression type. The prevalence of restless legs symptoms increased with increasing severity of depressive symptoms, regardless of the diagnosis. These findings should be considered in clinical evaluation and treatment of patients visiting their physician due to restless legs or depressive symptoms.

Investigation of alexithymia and levels of anxiety and depression among patients with restless legs syndrome

PURPOSE

The purpose of this study was to examine alexithymia among restless legs syndrome (RLS) patients, compare with healthy controls, and argue the clinical inferences of this relationship. We searched for anxiety and depression and their clinical outcomes among patients and searched whether the results are similar to previous studies.

PATIENTS AND METHODS

Eighty-seven RLS patients and 88 age, gender, and educationally matched healthy controls were assessed in Bezmialem Foundation University Hospital. RLS patients and healthy controls were assessed with the Sociodemographic Data Form constructed for the present study, 20-item Toronto Alexithymia Scale (TAS-20), Beck Depression Inventory (BDI), and Beck Anxiety Scale (BAS). The patient group was also assessed with the International Restless Legs Syndrome Study Group (IRLSSG) RLS Severity Scale.

RESULTS

RLS patients were found to have greater TAS-20, BDI, and BAS scores compared with the control group (P < 0.05). RLS severity score was positively correlated with the scores of anxiety and depression scales. However, no significant relationship was found between scores of IRLSSG RLS scale and TAS-20 total and subscale scores.

CONCLUSION

RLS patients were found to be more alexithymic than healthy controls, whereas no significant relationship was found between RLS severity and levels of alexithymia. Still, alexithymia might be a predictor for early diagnosis and may be considered in the treatment and follow-up of RLS. RLS patients have higher depression and anxiety scores than healthy individuals. Thus, depression and anxiety should be taken into consideration throughout the RLS treatment.

Sex differences in age-related changes in the sleep-wake cycle

Age-related changes in sleep and circadian regulation occur as early as the middle years of life. Research also suggests that sleep and circadian rhythms are regulated differently between women and men. However, does sleep and circadian rhythms regulation age similarly in men and women? In this review, we present the mechanisms underlying age-related differences in sleep and the current state of knowledge on how they interact with sex. We also address how testosterone, estrogens, and progesterone fluctuations across adulthood interact with sleep and circadian regulation. Finally, we will propose research avenues to unravel the mechanisms underlying sex differences in age-related effects on sleep.

Restless Legs Syndrome and Sleep-Wake Disturbances in Pregnancy

STUDY OBJECTIVES

To estimate the association of restless legs syndrome (RLS) and its frequency with sleep-wake disturbances in pregnancy.

METHODS

A cohort of 1,563 women in their third trimester of pregnancy were recruited from prenatal clinics between March 2007 and December 2010. Demographic, pregnancy, and delivery data were extracted from medical records and sleep information was collected with questionnaires. To diagnose RLS, we used standardized criteria of RLS symptoms and frequency that were developed by the International Restless Legs Study Group. Logistic regression models were constructed to investigate the association of RLS and its frequency with sleep-wake disturbances (poor sleep quality, daytime sleepiness, poor daytime function) and delivery outcomes.

RESULTS

Overall 36% of the pregnant women had RLS, and half had moderate to severe symptoms. Compared to women without RLS, those with RLS were more likely to have poor sleep quality (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.7-2.9), poor daytime function (OR 1.9, 95% CI 1.4-2.4), and excessive daytime sleepiness (OR 1.6, 95% CI 1.3-2.0). A dose-response relationship also was evident between RLS frequency and each of the sleep-wake disturbances. There was no evidence for any association between RLS and delivery outcomes.

CONCLUSIONS

RLS is a significant contributor to poor sleep quality, daytime sleepiness, and poor daytime function, all common and often debilitating conditions in pregnancy. Obstetric health care providers should be aware of these associations and screen women for RLS.

COMMENTARY

A commentary on this article appears in this issue on page 857.

Reproductive Steroid Regulation of Mood and Behavior

In this article, we examine evidence supporting the role of reproductive steroids in the regulation of mood and behavior in women and the nature of that role. In the first half of the article, we review evidence for the following: (i) the reproductive system is designed to regulate behavior; (ii) from the subcellular to cellular to circuit to behavior, reproductive steroids are powerful neuroregulators; (iii) affective disorders are disorders of behavioral state; and (iv) reproductive steroids affect virtually every system implicated in the pathophysiology of depression. In the second half of the article, we discuss the diagnosis of the three reproductive endocrine-related mood disorders (premenstrual dysphoric disorder, postpartum depression, and perimenopausal depression) and present evidence supporting the relevance of reproductive steroids to these conditions. Existing evidence suggests that changes in reproductive steroid levels during specific reproductive states (i.e., the premenstrual phase of the menstrual cycle, pregnancy, parturition, and the menopause transition) trigger affective dysregulation in susceptible women, thus suggesting the etiopathogenic relevance of these hormonal changes in reproductive mood disorders. Understanding the source of individual susceptibility is critical to both preventing the onset of illness and developing novel, individualized treatments for reproductive-related affective dysregulation. © 2016 American Physiological Society. Compr Physiol 6:1135-1160, 2016e.

Treatment of chronic insomnia disorder in menopause: evaluation of literature

OBJECTIVE

Insomnia both as a symptom and as part of chronic insomnia disorder is quite common in menopause. Comorbid conditions, such as restless legs syndrome and obstructive sleep apnea, occur with high prevalence among perimenopausal women with insomnia. Insomnia in this population group is associated with adverse health outcomes, and there are no clear standards on how to treat it.

METHODS

Based on extensive literature search, 76 articles were identified. Two authors independently graded evidence according to the Oxford Centre for Evidence-Based Medicine Levels of Evidence.

RESULTS

Evaluation and treatment of other comorbid sleep disorders are recommended, as is cognitive-behavioral therapy for insomnia. Hormone therapy, eszopiclone, escitalopram, gabapentin, isoflavones, valerian, exercise, and hypnosis are suggested. Zolpidem, quiteiapine XL, citalopram, mirtazapine followed by long-acting melatonin, ramelteon, Pycnogenol, Phyto-Female Complex, yoga, and massage may be considered. Kampo formulas are not recommended. Acupuncture may not be suggested, and cognitive-behavioral therapy that is not tailored for insomnia probably should not be considered.

CONCLUSIONS

Although a variety of interventions are shown to be helpful in improving sleep in menopause, there is a need for well-designed head-to-head trials with uniform outcome measures.

Willis-Ekbom disease is not associated with poor cardiovascular health in adults

Background

Willis-Ekbom disease (WED), also called restless legs syndrome (RLS), is a neurologic sensorimotor disease that may be associated with cardiovascular disease. Given high morbidity and mortality rates of cardiovascular disease worldwide, we assessed the relation between WED/RLS and cardiovascular health risks in a native South American population. We prospectively analyzed data from The Atahualpa Project of Ecuadorian adults aged 40 years and older. Physicians interviewed consented persons on the health behavior and health factors of the American Heart Association (AHA) for ideal cardiovascular health in adults and underwent fasting laboratory blood collection and blood pressure evaluation. Certified neurologists conducted face-to-face interviews using the International Restless Legs Syndrome Study Group (IRLSSG) field instrument. Persons testing positive for WED/RLS and age-and sex-matched controls underwent confirmatory physical examinations conducted by a neurologist and a sleep specialist to whom IRLSSG designation was blinded.

Findings

Of 665 persons, 94 (14 %) tested positive in IRLSSG; 40 (6 %) had a diagnosis of WED/RLS after neurologic examination and interview. Patients with WED/RLS were younger (53.5 vs 59.9 years, P = .001), without significant differences in sex ratios. Among AHA risk factors, only obesity was significantly more prevalent among patients with WED/RLS (42.5 % vs 23.5 %, P = .01). However, after adjustment for confounders, body mass index was not significantly associated with WED/RLS.

Conclusions

In adult Amerindians, although obesity and body mass index were associated with WED/RLS on univariate analyses, the association was not present after adjustment for confounders. No other significant associations were found between WED/RLS and AHA cardiovascular metrics.

Restless Legs Syndrome and Hypertension in Mexican Women

Background

RLS is a common chronic disorder characterized by an irresistible need to move the lower limbs that affects sleep. Poor sleep has been associated with increased blood pressure (BP). Thus, we evaluated the cross-sectional relationship between RLS and hypertension (HTN) in a large cohort study in Mexico.

Methods

In 2011, 54,925 female participants from the Mexican Teachers' Cohort responded to a four-item questionnaire based on the International Restless Legs Syndrome Study Group's minimal diagnostic criteria. Women also reported diagnosis and treatment of HTN. We used multivariable logistic regression models to estimate prevalence odds ratios (ORs) for HTN, adjusting for lifestyle and dietary factors. We also estimated adjusted prevalence ORs for HTN by frequency of RLS symptoms.

Results

We identified 9,230 cases (17%) of RLS, and the prevalence of HTN was 13.1% among women with RLS and 9.4% among those without RLS. The multivariable-adjusted prevalence OR for HTN comparing women with to those without RLS was 1.18 (95% confidence interval [CI]: 1.10-1.26). Compared to those without RLS, the prevalence OR of HTN in women reporting a symptom frequency of once a month or less was 1.14 (95% CI: 1.00-1.30); among those with symptoms two to four times a month, the OR was 1.17 (95% CI: 1.05-1.30); and for those with symptoms at least two times a week, the OR was 1.22 (95% CI: 1.10-1.35).

Conclusion

We observed an association between RLS and HTN. Future studies should evaluate the impact of treating RLS on BP.

Restless Leg Syndrome Across the Globe: Epidemiology of the Restless Legs Syndrome/Willis-Ekbom Disease

There are more than 50 epidemiologic studies measuring the prevalence of restless legs syndrome/Willis-Ekbom disease (RLS/WED) across 5 of the 6 inhabited continents (not Australia), most conducted in North America and Europe. Sufficient studies have been conducted in Asia, North America, and Europe to make inferences on RLS/WED prevalence by region. RLS/WED prevalence is thought to be highest in North America and Europe and lower in Asia. These differences across regions may be explained by cultural, environmental, and genetic factors. Future investigation is needed to determine to what extent these factors affect expression of RLS/WED according to world region.

Structural brain lesions and restless legs syndrome: a cross-sectional population-based study

OBJECTIVE

To evaluate the association between white matter lesion (WML) volume, silent infarcts and restless legs syndrome (RLS) in a population-based study of elderly individuals.

DESIGN

Cross-sectional study.

SETTING

Population-based Three-City study.

PARTICIPANTS

1035 individuals from the Dijon, France, centre of the Three-City study who had available information on volume of WMLs from MRIs and who answered questions about the prevalence of RLS.

PRIMARY OUTCOME MEASURE

Prevalence of RLS.

RESULTS

WML volume was measured using an automated tissue segmentation method. Logistic regression was used to evaluate adjusted associations between tertiles of WML volume and RLS and between silent infarcts and RLS. 218 individuals (21.1%) were determined to have RLS. Compared with those in the first tertile of WML volume, individuals in the second tertile (OR=1.09; 95% CI 0.75 to 1.60) or third tertile (OR=1.17; 95% CI 0.79 to 1.74) did not have an increased prevalence of RLS. We also did not observe associations between the volume of deep or periventricular WML and RLS; nor did we observe an association between silent brain infarcts and RLS (OR=0.74; 95% CI 0.40 to 1.39). These findings were not modified by age or gender.

CONCLUSIONS

Higher volume of WML and the presence of silent infarcts were not associated with an increased prevalence of RLS in this population-based cohort of elderly individuals.

Sleep regulation and sex hormones exposure in men and women across adulthood

This review aims to discuss how endogenous and exogenous testosterone exposures in men and estrogens/progesterone exposures in women interact with sleep regulation. In young men, testosterone secretion peaks during sleep and is linked to sleep architecture. Animal and human studies support the notion that sleep loss suppresses testosterone secretion. Testosterone levels decline slowly throughout the aging process, but relatively few studies investigate its impact on age-related sleep modifications. Results suggest that poorer sleep quality is associated with lower testosterone concentrations and that sleep loss may have a more prominent effect on testosterone levels in older individuals. In women, sex steroid levels are characterized by a marked monthly cycle and reproductive milestones such as pregnancy and menopause. Animal models indicate that estrogens and progesterone influence sleep. Most studies do not show any clear effects of the menstrual cycle on sleep, but sample sizes are too low, and research designs often inhibit definitive conclusions. The effects of hormonal contraceptives on sleep are currently unknown. Pregnancy and the postpartum period are associated with increased sleep disturbances, but their relation to the hormonal milieu still needs to be determined. Finally, studies suggest that menopausal transition and the hormonal changes associated with it are linked to lower subjective sleep quality, but results concerning objective sleep measures are less conclusive. More research is necessary to unravel the effects of vasomotor symptoms on sleep. Hormone therapy seems to induce positive effects on sleep, but key concerns are still unresolved, including the long-term effects and efficacy of different hormonal regimens.

Diagnosis, comorbidities, and management of restless legs syndrome

OBJECTIVE

This narrative review describes the differential diagnosis of restless legs syndrome, and provides an overview of the evidence for the associations between RLS and potential comorbidities. Secondary causes of RLS and the characteristics of pediatric RLS are also discussed. Finally, management strategies for RLS are summarized.

METHODS

The review began with a comprehensive PubMed search for 'restless legs syndrome/Willis-Ekbom disease' in combination with the following: anxiety, arthritis, attention-deficit hyperactivity disorder, cardiac, cardiovascular disease, comorbidities, depression, end-stage renal disease, erectile dysfunction, fibromyalgia, insomnia, kidney disease, liver disease, migraine, mood disorder, multiple sclerosis, narcolepsy, neuropathy, obesity, pain, Parkinson's disease, polyneuropathy, pregnancy, psychiatric disorder, sleep disorder, somatoform pain disorder, and uremia. Additional papers were identified by reviewing the reference lists of retrieved publications.

RESULTS AND CONCLUSIONS

Although clinical diagnosis of RLS can be straightforward, diagnostic challenges may arise when patients present with comorbid conditions. Comorbidities of RLS include insomnia, depressive and anxiety disorders, and pain disorders. Differential diagnosis is particularly important, as some of the medications used to treat insomnia and depression may exacerbate RLS symptoms. Appropriate diagnosis and management of RLS symptoms may benefit patient well-being and, in some cases, may lessen comorbid disease burden. Therefore, it is important that physicians are aware of the presence of RLS when treating patients with conditions that commonly co-occur with the disorder.

Prospective study of obesity, hypertension, high cholesterol, and risk of restless legs syndrome

Because previous cross-sectional studies suggest an association between metabolic disorders and restless legs syndrome (RLS), we prospectively evaluated whether obesity, hypercholesterolemia, and hypertension were associated with increased risk of RLS. Our study consisted of 42,728 female participants from the Nurses' Health Study II and 12,812 male participants from the Health Professionals Follow-up Study, free of RLS at baseline (2002 for men and 2005 for women), and free of diabetes and arthritis through follow-up (2002-2008 for men and 2005-2009 for women). RLS symptoms were assessed using the International RLS Study Group's standardized questionnaire. We considered RLS symptoms a "case" if the symptoms occurred ≥5 times/month and met International RLS Study Group criteria. We found that obesity was associated with an increased risk RLS among both men and women (P difference for sex >0.5). The pooled multivariate-adjusted odds ratio (OR) for RLS was 1.57 (95% confidence interval [CI]: 1.33-1.85; P trend <0.0001) for body mass index >30 versus ≤23 kg/m(2) and 1.56 (95% CI: 1.29-1.89; P trend = 0.0001) comparing two extreme waist circumference quintiles, adjusting for age, ethnicity, smoking, physical activity, use of antidepressant, and other covariates. A similar significant association was found for high cholesterol; the pooled adjusted OR for total serum cholesterol >240 versus <159 mg/dL was 1.33 (95% CI: 1.11-1.60; P trend = 0.002). There was no significant association between hypertension and RLS risk (adjusted OR: 0.90; 95% CI: 0.79-1.02). In this large, prospective study, we found that obesity and high cholesterol, but not high blood pressure, were significantly associated with an increased risk of developing RLS. © 2014 International Parkinson and Movement Disorder Society.

Migraine and restless legs syndrome: a systematic review

BACKGROUND

Restless legs syndrome (RLS) is increasingly being reported as a comorbidity of migraine.

METHODS

We conducted a systematic review and meta-analysis of studies investigating RLS in headache/migraine and vice versa. We calculated the prevalence and 95% confidence intervals (CI) of RLS in headache/migraine, of headache/migraine in RLS and controls, and odds ratios (ORs) of the association between the conditions. We then determined pooled effect estimates for the associations.

RESULTS

We identified 24 studies. RLS prevalence in migraine ranged from 8.7% to 39.0% with no apparent differences based on gender and aura status. Prevalence among controls was compatible with the literature. Migraine prevalence in RLS ranged from 15.1% to 62.6%. We did not pool prevalence data because of high unexplained heterogeneity. High heterogeneity with respect to the association between any migraine and RLS could be explained by study design. Pooled analyses showed substantially higher effect estimates in case-control studies (pooled OR = 4.19, 95% CI 3.07-5.71; I (2) = 0.0%) than in cohort studies (pooled OR = 1.22, 95% CI 1.14-1.30; I (2) = 0.0%).

CONCLUSION

Our results support the concept of RLS as an important comorbidity of migraine. However, the degree of association appears to be strongly determined by study design. Potential effects by gender and aura status and the role of RLS in other headache disorders remain unclear.

Pre-pregnancy restless legs syndrome (Willis-Ekbom Disease) is associated with perinatal depression

OBJECTIVES

Both restless legs syndrome ([RLS], also known as Willis-Ekbom Disease [WED]) and depression are common during pregnancy. However, no prior studies have assessed if pregnant women with RLS have an elevated risk of depression during and/or after pregnancy.

METHODS

1,428 women who were pregnant in gestational week 16-17 were asked to participate in a longitudinal survey. They were followed by web-based questionnaires in gestational week 17 and 32, and 6 weeks after delivery. Data were also retrieved from prenatal and birth records. Two different sets of criteria were used to examine the prevalence of RLS in the cohort (International Restless Legs Syndrome Society Group standard criteria and the later developed CH-RLSQ11 questionnaire). The latter questionnaire attempts to exclude those with common "mimics" of RLS.

RESULTS

Adjusted odds ratio for depression in gestational week 17, 32, and postpartum week 6 in relation to pre-pregnancy RLS onset and moderate to severe symptom severity were 4.74 (2.30 - 9.76), 3.67 (1.85 - 7.28), and 2.58 (1.28 - 5.21), respectively. No significant associations were seen in pregnant women with de novo RLS during pregnancy. When using the standard diagnostic RLS criteria and frequency of symptoms more than 2-3 days per week, the prevalence of RLS was 12.3%. With the CH-RLSQ11 questionnaire and the same threshold for frequency of symptoms the prevalence was 6.5%.

CONCLUSION

Women with RLS onset before pregnancy with moderate or severe symptoms had an increased risk of both antenatal and postnatal depression. The self-reported prevalence of RLS during pregnancy is lower when a questionnaire dealing with "mimics" is used.

Restless legs syndrome and pregnancy: a review

Restless legs syndrome (RLS) is a common sensorimotor neurological disorder that is diagnosed according to the revised criteria of the International RLS Study Group (IRLSSG). The pathophysiology of RLS is still unknown and its prevalence is influenced by ethnicity, age, and gender. RLS is divided into two types by etiology: primary or idiopathic and secondary. Primary RLS is strongly influenced by a genetic component while secondary RLS is caused by other associated conditions such as end-stage renal disease or peripheral neuropathy. Another common condition associated with RLS is pregnancy. The prevalence of RLS during pregnancy is two to three times higher than in the normal population and is influenced by the trimester and the number of parity. The main mechanisms that may contribute to the pathophysiology of RLS during pregnancy are hormonal changes and iron and folate status. Standard medications for treating RLS during pregnancy are not established. Most medications have been used according to the evidence from non-pregnant patients. Therefore, consideration of the medical treatment for treating RLS during pregnancy should be balanced between the benefit of relieving the symptoms and maternal and fetal risk. In general, the prognosis of RLS during pregnancy is good and symptoms are usually relieved after delivery.

The relationship among restless legs syndrome (Willis-Ekbom Disease), hypertension, cardiovascular disease, and cerebrovascular disease

Untreated sleep disorders may contribute to secondary causes of uncontrolled hypertension, cardiovascular disease (CVD), and stroke. Restless legs syndrome, or Willis–Ekbom Disease (RLS/WED), is a common sensorimotor disorder with a circadian rhythmicity defined by an uncontrollable urge to move the legs that worsens during periods of inactivity or at rest in the evening, often resulting in sleep disruptions. Sleep disorders such as insomnia and obstructive sleep apnea (OSA) are established risk factors for increased risk of hypertension and vascular diseases. This literature review outlines the lessons learned from studies demonstrating insomnia and OSA as risk factors for hypertension and vascular diseases to support the epidemiologic and physiologic evidence suggesting a similar increase in hypertension and vascular disease risk due to RLS. Understanding the relationships between RLS and hypertension, CVD, and stroke has important implications for reducing the risks associated with these diseases.

Vascular risk factors, cardiovascular disease, and restless legs syndrome in women

BACKGROUND

Previous studies evaluating the association of cardiovascular disease and vascular risk factors with restless legs syndrome showed inconsistent results, especially for the potential relation between various vascular risk factors and restless legs syndrome. We therefore aimed to analyze the relationships between vascular risk factors, prevalent cardiovascular disease, and restless legs syndrome.

METHODS

This is a cross-sectional study of 30,262 female health professionals participating in the Women's Health Study (WHS). Restless legs syndrome was defined according to diagnostic criteria of the International Restless Legs Study Group. Information on vascular risk factors (diabetes, hypertension, hypercholesterolemia, body mass index [BMI], alcohol, smoking, exercise, and family history of myocardial infarction) was self-reported. Cardiovascular disease events (coronary revascularization, myocardial infarction, and stroke) were confirmed by medical record review. Prevalent major cardiovascular disease was defined as nonfatal stroke or nonfatal myocardial infarction. Logistic regression models were used to evaluate the association between vascular risk factors, prevalent cardiovascular disease, and restless legs syndrome.

RESULTS

Of the 30,262 participants (mean age: 63.6 years), 3624 (12.0%) reported restless legs syndrome. In multivariable-adjusted models, BMI (odds ratio [OR] for BMI ≥35 kg/m(2), 1.35; 95% confidence interval [CI], 1.17-1.56), diabetes (OR, 1.19; 95% CI, 1.04-1.35), hypercholesterolemia (OR, 1.17; 95% CI, 1.09-1.26), smoking status (OR for ≥15 cigarettes/day, 1.41; 95% CI, 1.19-1.66), and exercise (OR for exercise ≥4 times/week, 0.84; 95% CI, 0.74-0.95) were associated with restless legs syndrome prevalence. We found no association between prevalent cardiovascular disease (major cardiovascular disease, myocardial infarction, and stroke) and restless legs syndrome prevalence. Women who underwent coronary revascularization had a multivariable-adjusted OR of 1.39 (1.10-1.77) for restless legs syndrome.

CONCLUSIONS

In this large cohort of female health professionals, various vascular risk factors are associated with the prevalence of restless legs syndrome. We could not confirm the results of previous reports indicating an association between prevalent cardiovascular disease and restless legs syndrome.