Does midlife aging impact women's sleep duration, continuity, and timing?: A longitudinal analysis from the Study of Women's Health Across the Nation

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

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

Race and sex differences in the longitudinal changes in multidimensional self-reported sleep health characteristics in aging older adults

OBJECTIVES

We examined within-individual changes in self-reported sleep health as community-dwelling older adults age as well as potential differences in these changes by self-reported sex and racial identity.

METHODS

Participants were from the United States and enrolled in the Rush Memory and Aging Project, Minority Aging Research Study, or Religious Orders Study (N = 3539, 20% Black, 75% female, mean 78years [range 65-103]), and they received annual, in-person clinical evaluations (median 5 visits [range 1-27]). A sleep health composite score measured the number of poor sleep characteristics among satisfaction, daytime sleepiness, efficiency, and duration. Mixed effects models estimated associations of age, race, sex, and their interactions on the composite and individual sleep measures, accounting for key confounders.

RESULTS

As they aged, Black participants shifted from reporting two poor sleep characteristics to one poor sleep characteristic, while White participants shifted from one poor characteristic to two. Regardless of age, sex, and race, participants reported that they "often" felt satisfied with their sleep and "sometimes" had trouble staying asleep. Females over age 85 and males of all ages reported the most daytime sleepiness, and older White participants (>age 90) reported the most difficulty falling asleep.

CONCLUSIONS

Although self-reported sleep characteristics were typically stable across age, identifying race and sex differences in self-reported sleep health can help guide future research to understand the mechanisms that underlie these differences.

Sleep During Menopause

Postmenopause is defined retrospectively after 12 consecutive months of amenorrhea. It represents the end of the reproductive period and ovarian failure. A decrease in estrogen leads to several changes in the short and long term. Among the early changes, vasomotor symptoms (hot flashes) are particularly common, occurring in about 70% of women. In addition, there are changes in mood, anxiety, depression, and insomnia. Insomnia occurs in almost 60% of postmenopausal women. Psychosocial aspects may also affect sleep. Proper diagnosis may lead to adequate treatment of sleep disturbances during menopause. Hormonal or other complementary therapies can improve sleep quality.

A Review of Hormone and Non-Hormonal Therapy Options for the Treatment of Menopause

Understanding the role of both menopausal hormone therapy (MHT) along with non-hormonal options for the treatment of vasomotor symptoms, sleep disruption, and genitourinary symptoms after menopause is critical to the health of women during middle and later life. Recent updates to the evidence for the treatment of menopausal symptoms pertaining to both hormonal and non-hormonal therapies as well as updated guidance from specialty societies can help guide clinicians in their treatment of women going through natural menopause or with estrogen deficiencies due to primary ovarian insufficiency or induced menopause from surgery or medications. The objective of this narrative review is to provide clinicians with an overview of MHT for the use of menopausal symptoms in women, incorporating updated primary evidence for risk versus benefit profiles, recent specialty society recommendations, and alternative, non-hormonal options. In this review, we summarize literature on the use of MHT for menopause-related symptomatology including options for formulations and dosages of MHT, non-hormonal treatment options, and the risk-benefit profile of MHT including long-term health consequences (eg, cardiovascular disease, cognitive decline, venous thromboembolism, and fracture risk). Finally, we highlight areas in which future research is needed to advance care of women after menopause. In summary, both hormonal (MHT) and non-hormonal options exist to treat symptoms of menopause. There is strong evidence for safety and effectiveness of MHT for the treatment of vasomotor symptoms among women who are less than 60 years of age, less than 10 years since menopause, and without significant cardiometabolic comorbidities. For others, treatment with hormonal versus non-hormonal therapies can be considered based on individual risk profiles, as well as other factors such as drug formulation, therapeutic goals, and symptom severity.

Longitudinal associations between sleep quality and menopausal symptoms among community-dwelling climacteric women: A multi-centered study

STUDY OBJECTIVES

Menopausal symptoms exist in most climacteric women, which can harm the quality and satisfaction of life for them. Moreover, a series of ineluctable negative life changes experienced in middle-age usually make the situation more complicated and stressful. We aimed to determine the trajectories and influential factors of sleep quality and menopausal symptoms and their longitudinal interrelationships among climacteric women.

METHODS

A total of 1875 community-dwelling climacteric women were included in this study. The Pittsburgh Sleep Quality Index (PSQI) and the Menopause Rating Scale (MRS) were adopted to assess sleep quality and menopausal symptoms, respectively. Data were collected 4 times from March 2019 to December 2019, at a 3-month interval.

RESULTS

The Cross-lagged analysis showed that worse sleep quality and more severe menopausal symptoms over time after controlling for specified covariates, and more severe menopausal symptoms were predicted by declined sleep quality. The Generalized estimation equation model showed that education level, marital status, chronic diseases, life events, income, and age were the influential factors of sleep quality, while menopausal symptoms were impacted by marital status and income.

CONCLUSIONS

Increasing negative sleep quality and more severe menopausal symptoms over time contribute to the health burden of climacteric women. Menopausal symptoms could be alleviated by sleep quality improvement, which is influenced by education level, marital status, chronic diseases, life events, age, and economic factors.

A review of African American women's experiences in menopause

IMPORTANCE AND OBJECTIVE

Little is known and reported about the experiences of African American women as they transition to and experience menopause. Accepted norms are based on the experience of a predominantly White population. The aim of this study is to review available data about the distinct experiences of African American women during the menopause transition and menopause.

METHODS

A literature search was developed and executed by the review team in collaboration with a health sciences librarian. The search combined controlled vocabulary and title/abstract terms related to the health status disparities of African Americans in the menopause transition and menopause. The following databases were searched from inception through April 28, 2022: PubMed, Scopus (Elsevier), and Web of Science Core Collection (Clarivate).

DISCUSSION AND CONCLUSION

African American women experience distinct differences in physical, psychological, social, and quality of life measures during menopause. Increasing awareness about the unique menopause experiences of African American women is critically important to improve the health of this underserved population.

The Sleep Quality of the Frontline Healthcare Workers and the Improving Effect of Tai Chi

BACKGROUND

A number of studies have documented that coronavirus disease 2019 (COVID-19) brought more negative impact on the physical and psychological functioning of frontline healthcare workers. Especially, sleep quality was focused. This study aimed to investigate the sleep quality of frontline healthcare workers, risk factors for sleep quality, and the effect of Tai Chi training.

METHODS

A total of 98 frontline healthcare workers were recruited, coming from the infection department, fever clinic, laboratory, and medical imaging department in a COVID-19-designated hospital in Shanghai. Of them, 50 participated in a 2-week intervention and were randomized to receive a Tai Chi training or relaxation training. Participants were assessed at baseline, 7 and 14 days after participation. Demographic information, sleep quality, and anxiety were measured by using the demographic questionnaire, Pittsburgh Sleep Quality Index (PSQI) and Beck Anxiety Inventory (BAI).

RESULTS

13.3% participants were above the cut-off score (>10) for the PSQI. Regression analysis showed gender, age, working years, and job category had effect on sleep quality. Compared to the control group, participants in the Tai Chi training group had lower scores on both PSQI (p < 0.05) and BAI (p < 0.01) after the 2-week intervention.

CONCLUSION

It was demonstrated that poor sleep quality existed in the frontline healthcare workers, which was related to gender, age, working years, and job category. Tai Chi training can dramatically improve their sleep quality and reduce anxiety symptoms.

Hot flashes, insomnia, and the reproductive stages: a cross-sectional observation of women from the EPISONO study

STUDY OBJECTIVES

To investigate the association of hot flashes and insomnia in women in premenopause and postmenopause.

METHODS

The study was performed using data from the São Paulo Epidemiological Sleep Study. Women in premenopause were classified as having regular menstrual cycles, being anovulatory, or using hormonal contraceptives. Women in menopause were classified as being in perimenopause, early postmenopause, or late postmenopause. Women reporting frequent insomnia symptoms and relevant daytime complaints were classified as having insomnia disorder. Polysomnography alterations suggestive of insomnia were also identified.

RESULTS

The frequency of hot flashes was 42% among women in postmenopause (mainly in early postmenopause) and 9% among women in premenopause (mainly anovulatory; P < .01). Approximately 18.7% had insomnia disorder, 48% had isolated insomnia symptoms, and 32.4% had polysomnography alterations. Comparing women in menopause with those in premenopause, the diagnosis of insomnia was similar (premenopause: 18.9% vs menopause: 17.5%), but women in menopause had more frequent isolated insomnia symptoms (premenopause: 43.9% vs menopause: 55.9%; P = .02) and polysomnography correlates of insomnia (premenopause: 26.5% vs menopause: 42.6%; P < .01). Hot flashes were more frequent among women with insomnia disorders (25.5%) and with isolated insomnia symptoms (23.0%) when compared with good sleepers (12.6%) in the entire sample (P = .01). Among women in late menopause, the prevalence of hot flashes was higher in both women with insomnia disorders (42.1%) and with isolated insomnia symptoms (37.5%) when compared with women who were good sleepers (14.3%; P = .05).

CONCLUSIONS

Hot flashes are associated with insomnia and polysomnography alterations suggestive of insomnia. The prevalence of hot flashes among women with insomnia disorder is especially high among women in late postmenopause.

CITATION

Hachul H, Castro LS, Bezerra AG, et al. Hot flashes, insomnia, and the reproductive stages: a cross-sectional observation of women from the EPISONO study. J Clin Sleep Med. 2021;17(11):2257-2267.

Modeling the change trajectory of sleep duration and its associated factors: based on an 11-year longitudinal survey in China

BACKGROUND

Sleep duration is a vital public health topic, yet most existing studies have been limited to cross-sectional surveys or inconsistent classifications of sleep duration categories, and few characterized its continuous development process. The current study aimed to depict its change trajectory in the general population and identify associated factors from a dynamic perspective.

METHODS

A total of 3788 subjects (45.4% male, mean age 46.72 ± 14.89 years) from the China Health and Nutrition Survey were recruited, and their daily sleep duration for five consecutive measurements from 2004 to 2015 was recorded. We adopted latent growth modelling to establish systematic relations between sleep duration and time. Participants' sociodemographic characteristics, lifestyle, and health factors were taken as covariates.

RESULTS

The change in sleep duration could be depicted by a linear decreasing trajectory with the mean yearly decrease at 2.5 min/day. The trajectory did not differ by residence, BMI category, chronic disease situation, smoking status, or drinking status. Moreover, there were sex and age differences in the trajectory, and females and those under 30 were prone to larger decrease rates.

CONCLUSION

The quantified yearly change in sleep duration provided insights for the prediction and early warning of insufficient sleep. Public health interventions focusing on slowing down the decrease rates among females and young individuals are warranted.

Pathophysiology of Obstructive Sleep Apnea in Aging Women

The following review is designed to explore the pathophysiology of sleep apnea in aging women. The review initially introduces four endotypes (i.e., a more collapsible airway, upper airway muscle responsiveness, arousal threshold, and loop gain) that may have a role in the initiation of obstructive sleep apnea. Thereafter, sex differences in the prevalence of sleep apnea are considered along with differences in the prevalence that exist between younger and older women. Following this discussion, we consider how each endotype might contribute to the increase in prevalence of sleep apnea in aging women. Lastly, we address how modifications in one form of respiratory plasticity, long-term facilitation, that might serve to mitigate apneic events in younger women may be modified in aging women with obstructive sleep apnea. Overall, the published literature indicates that the prevalence of sleep apnea is increased in aging women. This increase is linked primarily to a more collapsible airway and possibly to reduced responsiveness of upper airway muscle activity. In contrast, modifications in loop gain or the arousal threshold do not appear to have a role in the increased prevalence of sleep apnea in aging women. Moreover, we suggest that mitigation of long-term facilitation could contribute to the increased prevalence of sleep apnea in aging women.

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

Study Objectives

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

Methods

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

Results

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

Conclusions

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

Influence of the menopausal transition on polysomnographic sleep characteristics: a longitudinal analysis

STUDY OBJECTIVES

To evaluate how change in menopausal status related to spectral analysis and polysomnographic measures of sleep characteristics.

METHODS

The Study of Women's Health Across the Nation (SWAN) Ancillary Sleep Study evaluated sleep characteristics of 159 women who were initially pre- or early perimenopausal and repeated the assessment about 3½ years later when 38 were pre- or early perimenopausal, 31 late perimenopausal, and 90 postmenopausal. Participants underwent in-home ambulatory polysomnography for two to three nights. Average EEG power in the delta and beta frequency bands was calculated during NREM and REM sleep, and sleep duration, wake after sleep onset (WASO), and apnea hypopnea index (AHI) were based on visually-scored sleep.

RESULTS

The women who transitioned to postmenopause had increased beta NREM EEG power at the second assessment, compared to women who remained pre-or early premenopausal; no other sleep measures varied by change in menopausal status. In multivariate models the associations remained; statistical controls for self-reported hot flashes did not explain findings. In secondary analysis, NREM beta power at the second assessment was greater among women who transitioned into the postmenopause after adjustments for initial NREM beta power.

CONCLUSIONS

Sleep duration and WASO did not vary by menopause transition group across assessments. Consistent with prior cross-sectional analysis, elevated beta EEG power in NREM sleep was apparent among women who transitioned to postmenopause, suggesting that independent of self-reported hot flashes, the menopausal transition is associated with physiological hyperarousal during sleep.

Associations between longitudinal trajectories of insomnia symptoms and sleep duration with objective physical function in postmenopausal women: the Study of Women's Health Across the Nation

STUDY OBJECTIVES

Examine the association between trajectories of self-reported insomnia symptoms and sleep duration over 13 years with objective physical function.

METHODS

We utilized data from 1627 Study of Women's Health Across the Nation (SWAN) participants, aged 61.9±2.7 y at the end of the 13-y follow-up. Latent class growth models identified trajectories of insomnia symptoms (trouble falling asleep, frequent night-time awakenings, and/or early-morning awakening) and sleep duration over 13 y. Physical function tests were performed at the end of the 13-y period: 40-ft walk, 4-m walk, repeated chair stand, grip strength, and balance. Multivariable regression analyses examined each physical function measure according to the insomnia symptom or sleep duration trajectory group.

RESULTS

Five insomnia symptom trajectories and two sleep duration trajectories were identified. Women with a consistently high likelihood of insomnia symptoms and women with a decreased likelihood of insomnia symptoms (i.e., improving) had slower gait speed (3.5% slower 40-ft walk [consistently high], 3.7% slower 4-m walk [improving]; each P≤.05) than those with a consistently low likelihood of insomnia symptoms. In contrast, women with a steep increase in the likelihood of insomnia symptoms over time and women with persistent insufficient sleep duration had lower odds of having a balance problem (odds ratio [OR]=0.36 and OR=0.61, respectively; each P<.02) compared to those with a consistently low likelihood of insomnia symptoms and those with persistent sufficient sleep duration, respectively.

CONCLUSION

These results suggest that women's sleep during midlife has important implications for maintaining physical function during the transition into older adulthood.

Nighttime melatonin secretion and sleep architecture: different associations in perimenopausal and postmenopausal women

BACKGROUND

Sleep quality typically decreases after menopause, but the underlying mechanisms are poorly understood. Concentrations of melatonin are lower and its secretion profiles different before and after menopause. However, whether and how melatonin and sleep architecture are associated in women of different reproductive states have not been examined to date.

METHODS

Overnight serum melatonin samples were taken from 17 perimenopausal and 18 postmenopausal healthy women. Sleep quality was measured with all-night polysomnography recordings.

RESULTS

Melatonin concentrations tended to be the lowest during NREM sleep, and were associated with higher odds of transitions from wake to NREM sleep. The curves of predicted overnight melatonin values from linear mixed models varied according to sleep phases (NREM, REM, Wake) in perimenopausal, but not in postmenopausal women. In perimenopause higher melatonin area under curve (AUC) correlated with higher slow-wave activity (p = 0.043), and higher minimum concentrations with shorter slow-wave sleep (SWS) latency (p = 0.029). In postmenopause higher mean and maximum melatonin concentrations and AUC correlated with lower SWS percentage (p = 0.044, p = 0.029, p = 0.032), and higher mean (p = 0.032), maximum (p = 0.032) and minimum (p = 0.037) concentrations with more awakenings from REM sleep. In the age- and BMI- adjusted regression models, the association between higher maximum (p = 0.046) melatonin concentration and lower SWS percentage remained.

CONCLUSIONS

The relationship between melatonin and sleep architecture differed in perimenopausal and postmenopausal women. After menopause, high melatonin concentrations were associated with worse sleep. Whether these different patterns are related to aging of the reproductive system, and to decrease in menopausal sleep quality, remains to be elucidated.