Hormone replacement therapy, sleep quality and psychological wellbeing

Disturbed sleep is associated with reduced verbal episodic memory and entorhinal cortex volume in younger middle-aged women with risk-reducing early ovarian removal

Introduction

Women with early ovarian removal (<48 years) have an elevated risk for both late-life Alzheimer's disease (AD) and insomnia, a modifiable risk factor. In early midlife, they also show reduced verbal episodic memory and hippocampal volume. Whether these reductions correlate with a sleep phenotype consistent with insomnia risk remains unexplored.

Methods

We recruited thirty-one younger middleaged women with risk-reducing early bilateral salpingo-oophorectomy (BSO), fifteen of whom were taking estradiol-based hormone replacement therapy (BSO+ERT) and sixteen who were not (BSO). Fourteen age-matched premenopausal (AMC) and seventeen spontaneously peri-postmenopausal (SM) women who were ~10y older and not taking ERT were also enrolled. Overnight polysomnography recordings were collected at participants' home across multiple nights (M=2.38 SEM=0.19), along with subjective sleep quality and hot flash ratings. In addition to group comparisons on sleep measures, associations with verbal episodic memory and medial temporal lobe volume were assessed.

Results

Increased sleep latency and decreased sleep efficiency were observed on polysomnography recordings of those not taking ERT, consistent with insomnia symptoms. This phenotype was also observed in the older women in SM, implicating ovarian hormone loss. Further, sleep latency was associated with more forgetting on the paragraph recall task, previously shown to be altered in women with early BSO. Both increased sleep latency and reduced sleep efficiency were associated with smaller anterolateral entorhinal cortex volume.

Discussion

Together, these findings confirm an association between ovarian hormone loss and insomnia symptoms, and importantly, identify an younger onset age in women with early ovarian removal, which may contribute to poorer cognitive and brain outcomes in these women.

Effect of external sleep disturbance on sleep architecture in perimenopausal and postmenopausal women

OBJECTIVE

This study aimed to use external sleep disturbance as a model to evaluate sleep architecture in climacteric women before and after menopausal hormone therapy (MHT).

METHODS

Seventeen perimenopausal and 18 postmenopausal women underwent a polysomnography protocol: an adaptation night, a reference night and a sleep disturbance night with one hand loosely tied to the bed for blood sampling. The sleep architecture of the reference and disturbance nights were compared. The 24-h urinary free cortisol concentration (UFC) was measured. The procedure was repeated after 6 months on MHT or placebo.

RESULTS

Fifteen perimenopausal and 17 postmenopausal women completed the study. The perimenopausal and postmenopausal groups were combined. During external sleep disturbance, sleep was shorter and more fragmented; with less stage 2, slow-wave and rapid eye movement (REM) sleep and more wake time and awakenings, both at baseline and after the treatment period. Compared to the placebo group, sleep disturbance was minor for women on MHT: sleep was not shortened and the amount of slow-wave sleep did not decrease. Increased 24-h UFC was observed only during MHT.

CONCLUSIONS

Sleep in climacteric women is easily disturbed, leading to shorter and more fragmented sleep with less deep sleep and REM sleep. Six months of MHT attenuates the observed sleep disturbance.

The role of ovarian hormones in the pathophysiology of perimenopausal sleep disturbances: A systematic review

Sleep disturbance is a common clinical concern throughout the menopausal transition. However, the pathophysiology and causes of these sleep disturbances remain poorly understood, making it challenging to provide appropriate therapy. Our goal was to i) review the literature about the influence of ovarian hormones on sleep in perimenopausal women, ii) summarize the potential underlying pathophysiology of menopausal sleep disturbances and iii) evaluate the implications of these findings for the therapeutic approach to sleep disturbances in the context of menopause. A systematic literature search using the databases Embase, MEDLINE and Cochrane Library was conducted. Keywords relating to ovarian hormones, sleep disturbances and menopause were used. Ultimately, 86 studies were included. Study Quality Assessment Tools of the National Institutes of Health were used for quality assessment. Results from good-quality studies demonstrated that the postmenopausal decline in estrogen and progesterone contributes to sleep disturbances in women and that timely treatment with estrogen and/or progesterone therapy improved overall sleep quality. Direct and indirect effects of both hormones acting in the central nervous system and periphery, as well as via secondary effects (e.g. reduction in vasomotor symptoms), can contribute to improvements in sleep. To strengthen external validity, studies examining neurobiological pathways are needed.

Pharmacologic and hormonal treatments for menopausal sleep disturbances: A network meta-analysis of 43 randomized controlled trials and 32,271 menopausal women

This network meta-analysis aimed at investigating efficacy/tolerability of pharmacologic/hormonal interventions for menopausal sleep disturbances. Major databases were searched for randomized controlled trials (RCTs) examining pharmacologic or hormonal interventions with either placebo or active controlled designs. Primary outcomes were improvements in sleep disturbance severity/tolerability (i.e., overall dropout rates), whereas secondary outcome was adverse event-related discontinuation rates. Analysis of 43 RCTs with 25 treatment arms involving 32,271 women during/after menopausal transition (age: 61.24 ± 4.23, duration: 90.83 ± 66.29 wks) showed therapeutic effect of melatonin-fluoxetine [SMD = -2.47 (95% CI:-4.19-0.74)] against sleep disturbances compared to placebo. Subgroup analysis of 15 RCTs on vasomotor symptoms demonstrated superior benefits of gabapentin [SMD = -1.04 (95% CI:-1.90-0.18)], oral combined hormone therapy [SMD = -0.62 (95% CI:-1.06-0.18)], and bazedoxifene-conjugated estrogens [SMD = -0.50 (95% CI:-0.96-0.04)] to placebo/control. Despite benefits of raloxifene-only [SMD = -1.86 (95% CI:-3.09-0.63)] and raloxifene-oral estrogen [SMD = -2.64 (95% CI:-4.64-0.63)], patient selection may be a confounder. Dropout rates were comparable between interventions and placebo/control. Eszopiclone [RR = 3.84 (95% CI: 1.14-12.87)] and oral combined hormone therapy [RR = 2.51 (95% CI: 1.04-6.07)] were associated with higher rates of adverse event-related discontinuation. The results support combined estrogen-progesterone therapy for menopausal sleep disturbances associated with vasomotor symptoms but showed no significant effects of hypnotics in this clinical setting.

The effects of progesterone therapy in pregnancy: vaginal and intramuscular administration

AIM

This study was performed to evaluate the effects of vaginal versus intramuscular progesterone supplementations on the mood, quality of life, and metabolic changes in pregnant women with the history of previous preterm birth.

METHODS

This study was conducted as a prospective, randomized, open label, clinical trial evaluated 100 pregnant women who referred for prenatal visit, with 16-17 weeks of gestation from September 2014 through October 2015. The mothers were then randomly allocated into two groups: the vaginal progesterone group to receive 400 mg cyclogest vaginal suppositories (Actavis, UK limited, England) once daily, and the intramuscular progesterone group to receive weekly intramuscular injections of 250 mg of 17-hydroxyprogesterone caproate (17-HPC) (Bayer Schering Pharma, Germany), starting from the 16th to the 35th weeks of pregnancy. Demographics, medical and obstetrical history, sleeping disturbances, alteration in sexual desire, nausea/vomiting, serum levels of fasting blood sugar (FBS), high-density lipoprotein (HDL), and low-density lipoprotein (LDL) were evaluated, first and 8 weeks later.

RESULTS

About 11 (11.2%) screened positive for psychosocial disorders; 25 (25.5%) had sleep disturbance, 11 (11.2%) had alteration in sexual desire, and 29 (29.6%) had nausea/vomiting upon enrollment. After 2 months of receiving daily vaginal progesterone, there was a significant increase in the GHQ-28 score (p < .001), and rates of positive screening for psychosocial disorders (p = .001) in this group. No statistically significant differences were observed in the HDL levels (p = .06), LDL levels (p = .15), rates of impaired FBS (p = .08), nausea/vomiting (p = .2), sexual desire alteration (p = .56), and sleep disturbance (p = 1) in the participants who were randomized to this group.

CONCLUSION

Our results indicated that psychosocial disorders increased significantly at 24th week gestational age after 2 months of progesterone consumption in both groups which could show psychological impact of progesterone regardless of the route of consumption. This calls for higher psychological attention in these women.

Sleep and Sleep Disorders in the Menopausal Transition

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

The effect of different progestogens on sleep in postmenopausal women: a randomized trial

BACKGROUND

While progesterone affects sleep, different types of it might affect sleep differently.

METHODS

One hundred Thai women, who complained of insomnia, visited the Menopause Clinic at Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand from February 2014 to March 2015, and were divided randomly into two groups. Both groups received daily hormonal treatment that included estradiol valerate (progynova) at 1 mg. The first group also received dydrogesterone (duphaston^®) at 10 mg and the second group micronized progesterone (utrogestran^®) at 100 mg. The clinical symptoms and Pittsburgh Sleep Quality Index (PSQI) were recorded for three consecutive months after treatment. This study was registered with clinicaltrial.gov (code number NCT02086032).

RESULTS

Sleep quality improved in both groups (10.52 ± 4.27 to 4.91 ± 3.15 in the dydrogesterone group and 10.16 ± 3.60 to 6.27 ± 3.04 in the micronized progesterone group, p value 0.08). Women in the micronized progesterone group had fewer overall side effects than those in the dydrogesterone group.

CONCLUSION

Sleep quality of peri-postmenopausal women with insomnia improved dramatically after the first month of hormonal treatment. However, more participating patients are necessary to ascertain the differences in sleep quality from dydrogesterone and micronized progesterone treatment.

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

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

The middle-aged ovariectomized marmoset (Callithrix jacchus) as a model of menopausal symptoms: Preliminary evidence

Menopausal women often suffer from hot flashes and sleep disturbances that significantly impact their quality of life. Both human and animal studies suggest that loss of estrogens during menopause contribute to these symptoms. In the female rat, both core body temperature (CBT) and sleep are sensitive to 17β-estradiol (E2) levels, but important differences between the rat and the human patterns limit the interpretation of the results. The sleep and thermoregulation of the common marmoset (Callithrix jacchus) more closely resemble human patterns. However, no study to date has examined whether E2 influences sleep and thermoregulation in this species. The main goal of the present study was to investigate the suitability of the ovariectomized (OVX) marmoset for studying two major menopausal symptoms experienced by women, sleep disturbance and thermodysregulation. Two middle-aged OVX marmosets (6years old) were implanted with a telemeter that records electroencephalograms (EEG), electromyograms (EMG), and CBT. Sleep patterns and CBT were recorded under baseline, two E2 replacement (6 and 12μg/kg/day, p.o.) conditions and two E2 withdrawal conditions. Relative to both baseline and withdrawal, high E2 replacement was associated with lower nighttime CBT. In addition, fewer nighttime arousals were observed under low E2 replacement compared to baseline. Higher delta power was observed under both E2 replacement conditions suggesting enhanced sleep quality. These preliminary results suggest that E2 modulates sleep and thermoregulation in the OVX marmoset, making it a promising model for studying menopausal symptoms.

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.

Suprachiasmatic nucleus as the site of androgen action on circadian rhythms

Androgens act widely in the body in both central and peripheral sites. Prior studies indicate that in the mouse, suprachiasmatic nucleus (SCN) cells bear androgen receptors (ARs). The SCN of the hypothalamus in mammals is the locus of a brain clock that regulates circadian rhythms in physiology and behavior. Gonadectomy results in reduced AR expression in the SCN and in marked lengthening of the period of free-running activity rhythms. Both responses are restored by systemic administration of androgens, but the site of action remains unknown. Our goal was to determine whether intracranial androgen implants targeted to the SCN are sufficient to restore the characteristic free-running period in gonadectomized male mice. The results indicate that hypothalamic implants of testosterone propionate in or very near the SCN produce both anatomical and behavioral effects, namely increased AR expression in the SCN and restored period of free-running locomotor activity. The effect of the implant on the period of the free-running locomotor rhythm is positively correlated with the amount of AR expression in the SCN. There is no such correlation of period change with amount of AR expression in other brain regions examined, namely the preoptic area, bed nucleus of the stria terminalis and premammillary nucleus. We conclude that the SCN is the site of action of androgen effects on the period of circadian activity rhythmicity.

Treatment of Insomnia, Insomnia Symptoms, and Obstructive Sleep Apnea During and After Menopause: Therapeutic Approaches

Understanding sleep complaints among menopausal women is an emerging area of clinical and research interest. Several recent reviews have focused on mechanisms of menopausal insomnia and symptoms. In this review, we present a discussion on the most relevant and recent publications on the treatment of sleep disorders for menopausal women, with a focus on menopause-related insomnia, insomnia symptoms, and obstructive sleep apnea. We discuss both nonpharmacological and pharmacological treatments, including cognitive-behavioral therapy for insomnia (CBT-I), complementary and alternative medicine, hormone replacement therapy, sedative hypnotics, antidepressants, and continuous positive airway pressure. In addition, we briefly discuss methods and considerations of assessment of sleep disorders in menopausal women.

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.

Sleep and sleep disorders in menopausal women

Sleep disorders in the menopause are common. Although these disorders may be due to the menopause itself and/or the associated vasomotor symptoms, the etiology is multifactorial and includes a number of other associated conditions. They may simply arise as part of the aging process and not be specifically related to the decrease in estrogen levels or, alternatively, because of breathing or limb movement syndromes, depression, anxiety, co-morbid medical diseases, medication, pain and/or psychosocial factors. The most commonly encountered sleep disorders in menopausal women include insomnia, nocturnal breathing disturbances and the associated sleep disorders that accompany the restless leg syndrome, periodic leg movement syndrome, depression and anxiety. This review article addresses sleep and the sleep disorders associated with menopause and briefly the role that hormone therapy may play in alleviating these disorders.

The temporal relationship between growth hormone and slow wave sleep is weaker after menopause

OBJECTIVE

To study the temporal association between growth hormone (GH) and slow wave sleep (SWS) in middle-aged women.

METHODS

Seventeen premenopausal and 18 postmenopausal women were studied using all-night polygraphic sleep recordings and blood sampling at 20-min intervals. The postmenopausal women were re-studied after six months on hormone therapy (HT) according to a randomized, double-blind, placebo-controlled protocol.

RESULTS

The total sleep time (premenopausal 361.9±81.5 min, postmenopausal 358±67.7 min) and the percentages of the sleep stages did not differ between pre- and postmenopausal women. In postmenopausal women the first GH peak after sleep onset occurred later and with a more variable time interval compared to premenopausal women. The percentage of SWS was highest 40-20 min prior to the first GH peak after sleep onset in both groups with a higher SWS proportion in premenopausal women (p=0.048), although the total SWS percent for night did not differ. HT did not affect the distribution of SWS in postmenopausal women.

CONCLUSIONS

The temporal relationship between GH and SWS in premenopausal women is less robust after menopause and is not improved with HT.

Sleepiness and health in midlife women: results of the National Sleep Foundation's 2007 Sleep in America poll

The 2007 Sleep in America poll, a random-sample telephone survey, provided data for this study of sleep in community-dwelling women aged 40 to 60 years. The majority of the respondents were post- or perimenopausal, overweight, married or living with someone, and reported good health. A subsample (20%) reported sleepiness that consistently interfered with daily life; the sleepy subsample reported more symptoms of insomnia, restless legs syndrome, obstructive sleep apnea, depression and anxiety, as well as more problems with health-promoting behaviors, drowsy driving, job performance, household duties, and personal relationships. Hierarchical regression showed that sleepiness along with depressive symptoms, medical comorbidities, obesity, and lower education were associated with poor self-rated health, whereas menopause status (pre-, peri- or post-) was not. These results suggest that sleep disruptions and daytime sleepiness negatively affect the daily life of midlife women.

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.

Additive effect of depressed mood and vasomotor symptoms on postmenopausal insomnia

OBJECTIVE

The aim of this study was to investigate the role of vasomotor and mood symptoms on insomnia in postmenopausal women.

METHODS

One hundred sixty-three postmenopausal women, not receiving hormone therapy, attending a menopause clinic at the University of Athens, Greece, were included in this cross-sectional study. Climacteric symptoms were assessed by Greene's scale, whereas psychological morbidity was measured by Zung Self-Assessment Depression Scale, Symptom Checklist-90-R, and Athens Insomnia Scale.

RESULTS

Vasomotor symptoms were significantly associated with insomnia (P = 0.001). When depressive symptomatology was added to the logistic regression analysis, the predictive ability of the model was significantly improved as defined by the increase in the log likelihood (P < 0.001) and the increase in the area under the receiver operating characteristic curve.

CONCLUSIONS

Insomnia in postmenopausal women attending a menopause clinic is related both to the effects of vasomotor symptoms and depressive symptomatology. Mood symptoms seem to affect sleep independently of vasomotor symptoms, suggesting that depression should be carefully assessed and treated in postmenopausal women with insomnia.

Effects of hormone therapy with estrogen and/or progesterone on sleep pattern in postmenopausal women

OBJECTIVE

To investigate the effects of estrogen and progesterone on sleep in postmenopausal women.

METHOD

The 33 participants were randomly assigned to an estrogen or placebo group after undergoing clinical and hormonal assessments and a polysomnogram, and they underwent the same tests again after 12 weeks. Then, while still taking estrogen or placebo, they all received progesterone for another 12 weeks and underwent a final polysomnogram.

RESULTS

Estrogen plus progesterone was more effective than estrogen alone in decreasing the prevalence of periodic limb movement (PLM) (8.1% vs 2.8%), hot flashes (14.2% vs 0%), and bruxism (11.1% vs 0%) at night, or somnolence and attention difficulty during the day. The prevalences of breathing irregularities, arousal from sleep, anxiety, and memory impairment were decreased in both groups following progesterone treatment.

CONCLUSION

While not significantly affecting sleep quality, hormone therapy decreased the prevalence of arousal in both groups and that of PLM in the group treated with estrogen plus progesterone.

The effect of estrogen plus progestin treatment on sleep: a randomized, placebo-controlled, double-blind trial in premenopausal and late postmenopausal women

OBJECTIVE

In this prospective randomized, placebo-controlled and double-blind study, the objective was to investigate the effects of estrogen-progestin treatment (EPT) on sleep in pre- and postmenopausal women.

DESIGN

Seventeen premenopausal (aged 45-51 years) and 18 postmenopausal (aged 58-70 years) women were studied in a sleep laboratory for two nights (one night for adaptation and one study night) before and after 6 months of treatment with EPT or placebo. During the treatment period, premenopausal women received cyclic EPT or placebo and the postmenopausal women continuous EPT or placebo. Polysomnography and questionnaires were used to evaluate sleep and well-being.

RESULTS

At the end of the treatment period, premenopausal women receiving EPT had more awakenings from stage 1 sleep (p = 0.047) and postmenopausal women with EPT had a greater total number of awakenings (p = 0.031) than the corresponding placebo group. Further, sleepiness decreased less in the premenopausal EPT group than in the placebo group (p = 0.031). In postmenopausal women, EPT decreased and placebo slightly increased slow wave activity during the second non-rapid eye movement sleep episode (p = 0.046).

CONCLUSIONS

In premenopausal and late postmenopausal women, EPT had only random and marginal effects on sleep. Although the limited findings were mostly unfavorable for EPT, one cannot conclude that EPT deteriorates sleep. Further, neither middle-aged cycling premenopausal women nor older postmenopausal women benefit from estrogen-progestin treatment in terms of their sleep quality.

Sleep disorders in women: clinical evidence and treatment strategies

Sleep disorders are more prevalent in women than in men. Sex hormones modulate sleep-wake behaviors and mood and may contribute to heightened risk across the life cycle of women. Sleep disorders may have a unique expression in women, emerging throughout their reproductive life cycle. These conditions require careful treatment strategy to manage medical, hormonal, and behavioral contributing factors to poor sleep efficiency and impaired quality of life. This review focuses on clinical evidence for sleep disorders in women and discusses existing evidence of risk factors and treatment options for insomnia and sleep-disordered breathing in women.

Gender differences in sleep disorders

PURPOSE OF REVIEW

To evaluate recent evidence regarding gender differences in sleep.

RECENT FINDINGS

Women have better sleep quality compared with men, with longer sleep times, shorter sleep-onset latency and higher sleep efficiency. Despite this, women have more sleep-related complaints than men. The amount of slow-wave sleep decreases with age in men and women. Normal physiologic periods, including puberty, menstruation, pregnancy, and menopause, are associated with alterations in sleep patterns. Gender differences in normal sleep may underlie the observed differences in risk of sleep disorders. Studies of insomnia support a female predominance, with increased divergence of prevalence between men and women with older age. Recent findings for the gender differences in obstructive sleep apnea have focused on differences in local neuromuscular reflexes and central ventilatory control. Restless legs syndrome has a slight female predominance, whereas rapid eye movement sleep behavior disorder and Kleine-Levin syndrome are more common in men.

SUMMARY

Gender differences in sleep become apparent after the onset of puberty. Menstrual cycles, pregnancy, and menopause can alter sleep architecture. Gender-related differences in sleep disorders, such as obstructive sleep apnea, insomnia, and restless legs syndrome, include differences in prevalence, pathophysiology, clinical presentation, and response to therapy.

Sleep dysfunction in women and its management

Women generally have more complaints about sleep, compared with men of the same age. At various stages of reproduction, the reasons for these complaints become rather obvious--menstrual cramps and discomfort, pregnancy and postpartum factors, and menopausal hot flashes can fragment sleep. In addition, there are lifestyle factors, such as going to bed late and getting up early in order to attend to various family responsibilities, restricting the time allowed for sleep. Factors outside a woman's control, such as caregiving for sick family members during the night, can also result in disrupted sleep patterns, with little opportunity to make up for the lost sleep on weekends or days off. This article discusses the types of insomnia commonly experienced by women during key reproductive stages of life and proposes gender-specific assessment and management strategies. Pharmacologic management of sleep problems is useful for brief episodes of insomnia, but not usually desirable during pregnancy and lactation, or for management of chronic insomnia. For most women, regardless of reproductive stage, nonpharmacologic strategies that involve behavioral therapies, or short-term focused use of hypnotics at key time points, are more effective for quality of life than is long-term use of pharmacologic interventions.

Sleep deprivation and hormone therapy in postmenopausal women

BACKGROUND AND PURPOSE

Sleep complaints increase after menopause, but literature on the effect of postmenopausal hormone therapy (HT) on sleep is controversial. The purpose of this study was to determine the effect of ageing and HT on sleep quality, assessed using polysomnography, and on the accuracy of the subjective estimation of sleep quality in women before and after sleep deprivation.

PATIENTS AND METHODS

Twenty postmenopausal women (aged 58-72 years) were recruited: 10 HT-users and 10 non-HT-users. Eleven young women (aged 20-26 years) served as controls. Polysomnography and subjective sleep quality were measured on four consecutive nights: adaptation, baseline, 40-h sleep deprivation and recovery.

RESULTS

Although the postmenopausal women slept worse than the controls at baseline, and in particular during the recovery night, their recovery response to sleep deprivation was well preserved. At baseline, HT-users had a shorter latency to rapid eye movement (REM) (P=0.043), with fewer awakenings from slow wave sleep (SWS) (P=0.029) but more from REM (P=0.033) than non-HT-users. During recovery, the HT-users had more stage 2 sleep (P=0.048) and less slow wave activity (SWA) in the first non-rapid eye movement (NREM) sleep episode (P=0.021) than the non-HT-users. The poor correlation between subjective and objective sleep quality at baseline became significant during recovery.

CONCLUSIONS

Although sleep in postmenopausal women was worse than in young controls, the recovery response following sleep deprivation was relatively well preserved. HT offered no significant advantage to sleep at baseline and slightly weakened the recovery response to prolonged wakefulness.

Secondary insomnia in the primary care setting: review of diagnosis, treatment, and management

INTRODUCTION

Insomnia is associated with a number of medical and psychiatric disorders, including chronic pain and clinical depression. Until recently, it was assumed that effective treatment of the underlying medical condition would also correct the sleep disturbance. However, some evidence indicates that treatment of secondary or comorbid insomnia should be considered separately from, and perhaps in addition to, optimizing treatment of the primary condition.

METHODS

This article reviews the extant literature to examine the impact of secondary and comorbid insomnia on the patient, and on healthcare economics, in the primary care setting, and discusses current diagnostic and treatment approaches. A MEDLINE search was performed for literature published from 1980 to 2005, and retrieved randomized, controlled clinical trials and key review articles for the conditions most often accompanied by secondary insomnia: depression, chronic pain, and menopause/perimenopause. The search terms included those for commonly used pharmacologic treatments and behavioral therapy.

RESULTS

Due to the paucity of clinical trial data in secondary insomnia patients, physicians have had to rely on evidence derived from primary insomnia trials. These data indicate that hypnotic medications are effective in treating sleep onset insomnia. However, few of these agents are effective against the most commonly occurring insomnia symptom - poor sleep maintenance - and many are associated with problematic residual sedation. Nevertheless, the cost of not treating these insomnia symptoms is often greater than the treatment inadequacies. Physicians should thus consider treating what they perceive as secondary insomnia with one of the available forms of therapy.

CONCLUSION

Patients experiencing sleep problems associated with a potential medical or psychiatric primary condition would likely benefit from increased physician awareness of secondary insomnia and the subsequent increased attention to diagnosing and treating this prevalent condition. Recommendations for managing secondary or comorbid insomnia in the primary care setting are discussed.

Sleep, rhythms and women's mood. Part II. Menopause

This review summarizes studies of sleep and other biological rhythms in menopausal women with major depression compared with healthy control subjects. Where feasible, we focused on studies in women who met DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) criteria for a major depressive episode (MDE) compared with matched normal control subjects and the Staging System for Reproductive Aging in Women (STRAW) criteria. The aim was to review supporting evidence for the hypothesis that a disruption of the normal temporal relationship between sleep and other biological rhythms, such as melatonin, cortisol, thyroid stimulating hormone (TSH) or prolactin, occur during the menopausal transition. As a result, depressive disorders occur in predisposed women. Treatment strategies, designed to correct these altered phase (timing) or amplitude abnormalities, thereby improve mood. Although there may be some common features to menopausal depression compared with other depressive disorders related to the reproductive cycle (e.g. premenstrual dysphoric disorder or postpartum major depression), such as increased morning melatonin secretion, a specific profile of sleep and biological rhythms may distinguish healthy from depressed women during menopause. Further work is needed to characterize more fully the particular abnormalities associated with well-defined menopausal depression in order to develop treatment strategies targeted more specifically to pathogenesis.

Insomnia in women: an overlooked epidemic?

Insomnia is a common and significant healthcare problem, and affects a large percentage of women seen by general practitioners, obstetrician-gynecologists and mental health professionals. Specific risk factors for insomnia may be gender-related, including higher prevalence rates of depression and anxiety among women, environmental and social factors, as well as reproductive-related factors (e.g., peri-menstrual difficulties and menopause-related symptoms). Sleep problems interfere significantly with daytime functioning and overall well-being, and may lead to serious clinical consequences. Treatment options include benzodiazepines, non-benzodiazepines, nonprescription sleep aids, and non-pharmacologic interventions such as sleep hygiene measures. This article reviews the existing literature on the prevalence, clinical characteristics of insomnia in women, and highlights some of the treatment options available. Healthcare providers should be aware of the variety of pharmacologic and non-pharmacologic options for treatment of insomnia and, in particular, be able to weigh their efficacy against the risks of side effects and next-day sedation.

Effects of low-dose, continuous combined hormone replacement therapy on sleep in symptomatic postmenopausal women

Sleep disturbances in peri- and postmenopausal women may result from hormonal changes, vasomotor symptoms, and possibly psychological factors. Hormone replacement therapy (HRT) seems to diminish the disruption of sleep in climacteric women. The aim of this study was to determine the effects of a low dose of conjugated equine estrogens (CE) in combination with different progestins (LD-HRT) and evaluate differences between regimens on sleep in symptomatic postmenopausal women. Postmenopausal women were recruited and assigned to calcium-vitamin (control group) or to LD-HRT with 0.3mg of CE associated with a daily administration at bedtime of a progestin (2.5 mg MPA, CE + MPA, n = 20), or 100 mg natural micronized progesterone (CE + P, n = 20). Subjective symptoms were evaluated by the Greene climacteric scale, and by a visuanalogic graduated scale (0-10) at baseline and after 4, 8, and 12 weeks of study. Greene's scores for the control group were similar to those in LD-HRT group at baseline, and showed no significant modification at all subsequent measurements. Conversely, in LD-HRT group, a significant (P < 0.05) reduction in the scores of all Greene's domains was evident versus corresponding baseline and control group values. Conversely, in LD-HRT group, a significant (P < 0.05) reduction in the scores of all Greene's domains was evident with no difference in the scores of the two treated group. Both CE + MPA and CE + P significantly (P = 0.05) reduced the HF and sleep visuanalogic score in comparison to the control group. The score of sleep was significantly (P = 0.05) lower in the CE + P group in comparison to that measured in the CE + MPA group. No significant correlation between sleep and vasomotor score was found. In conclusion, low estrogen dose may have a value in the treatment of menopausal women in which sleep disturbances may be a symptom of estrogen deprivation. Low-dose estrogen associated with low-dose micronized progesterone may especially benefit women who complain of disturbed sleep.

Effects of menopausal status on sleep in midlife women

Disturbed sleep is a common complaint of midlife women often attributed to menopause, though few studies have examined direct effects of menopausal status on sleep. Our objective was to assess this issue in healthy midlife women. We examined sleep polysomnographically on 2 consecutive nights in 25 women (ages 45 - 56 yrs) without sleep complaints (13 pre-menopausal; 12 post-menopausal). Groups differed in Stage 1% (lower in post-menopausal) and slow wave sleep latency (shorter in post-menopausal). Subjective sleep reports did not differ. Age correlated negatively with Stage 1% and positively with Stage 4%. These results indicate that menopausal status plays a minimal role in sleep quality and sleep stage distribution in healthy midlife women without sleep complaints.

Hormone replacement therapy and health behavior in postmenopausal polio survivors

OBJECTIVES

Little is known about menopause and hormone replacement therapy (HRT) use in women with disabilities. The objectives of this study were to explore the health behaviors, health outcomes, and efficacy of HRT in a group of postmenopausal polio survivors and to compare selected outcomes to nationally representative cohorts.

METHODS

One hundred and thirty-one postmenopausal polio survivors completed self-report surveys on health behaviors, HRT use, functional status, and psychosocial well-being. During a physical examination, fasting cholesterol and body mass index (BMI) were collected. Independent sample t-tests and Chi-square analysis were used to compare HRT users and non-users on health behaviors and health outcomes; logistic regression was used to predict HRT use.

RESULTS

Prevalence of HRT use was 58%. Only BMI predicted HRT use (OR = 0.30, CI: 0.11-0.81). HRT users had better high density lipoprotein (HDL), low density lipoprotein, total cholesterol/HDL ratios, lower BMIs, were more confident when communicating with their physicians, more likely to discuss menopause with their physician, and experienced greater overall stress. HRT was not associated with health behavior, health-related quality of life, mood, or life satisfaction. Compared to non-disabled women, more of these women had higher total cholesterol, obesity, more sleeping problems, and were less likely to vigorously exercise or smoke.

CONCLUSIONS

HRT did not confer substantial benefits in these postmenopausal polio survivors to warrant them using HRT at a higher rate than their non-disabled peers. Comparisons to their non-disabled peers suggested they may be at higher risk for adverse health problems associated with postmenopause.

Validation of the Women's Health Initiative Insomnia Rating Scale in a multicenter controlled clinical trial

OBJECTIVE

The objective of this study was to evaluate the construct validity of the five-item Women's Health Initiative Insomnia Rating Scale (WHIIRS) by comparing women taking hormone therapy (HT) versus those taking a placebo and by comparing women known to differ in vasomotor symptoms.

METHODS

The WHIIRS was included in two phase III randomized trials intended to evaluate the efficacy of a combination estradiol plus and norethindrone acetate transdermal delivery system in reducing vasomotor symptoms. In all, 850 healthy postmenopausal women participated in these studies. Both trials were double-blind, one was placebo-controlled and the other was positive-controlled. The former trial admitted women with > or =8 hot flashes/day and lasted 12 weeks with data collected on the WHIIRS at baseline, 4, 8, and 12 weeks. The other trial had no entry criteria pertaining to hot flashes and lasted 52 weeks with WHIIRS data collected at baseline, 12, 24, and 52 weeks.

RESULTS

The WHIIRS was sensitive to the effect of HT on sleep disturbance over time. The WHIIRS also detected differences in self-reported sleep disturbance between women with mild vasomotor symptoms compared with those with moderate to severe symptoms. As expected, the study using a positive control revealed that sleep improved over time (p <.0001). Also as predicted, the study using a placebo control found that sleep disturbance in the treatment groups improved at a faster rate than in the control groups (p = .035).

CONCLUSION

The construct validity of the WHIIRS was supported because it was successfully used to detect self-reported sleep disturbance differences in women taking HT versus those taking a placebo as well as in groups known to differ in severity of their vasomotor symptoms.

Women's sleep in health and disease

A huge amount of knowledge about sleep has accumulated during the last 5 decades following the discovery of rapid eye movement (REM) sleep. Nevertheless, there are numerous areas of considerable ignorance. One of these concerns the particularities of sleep in women. Most basic and clinical studies have been performed in male subjects, and only very recently research groups around the world have addressed women's sleep in health and disease. In this review, we summarize the present knowledge on the influence of oestrogens on the brain and on the distinctive changes of sleep across the menstrual cycle, during pregnancy and menopause. In addition, studies in female rodents are reviewed as well as the knowledge on female peculiarities regarding the interactions between sleep regulation and age-related changes in circadian rhythms. We also address specific aspects of sleep loss and sleep disorders in women. Finally, very recent studies on the sociology of sleep are summarized and future directions in the field are discussed.

Hot flashes and sleep in women

Sleep disturbances during menopause are often attributed to nocturnal hot flashes and 'sweats' associated with changing hormone patterns. This paper is a comprehensive critical review of the research on the relationship between sleep disturbance and hot flashes in women. Numerous studies have found a relationship between self-reported hot flashes and sleep complaints. However, hot flash studies using objective sleep assessment techniques such as polysomnography, actigraphy, or quantitative analysis of the sleep EEG are surprisingly scarce and have yielded somewhat mixed results. Much of this limited evidence suggests that hot flashes are associated with objectively identified sleep disruption in at least some women. At least some of the negative data may be due to methodological issues such as reliance upon problematic self-reports of nocturnal hot flashes and a lack of concurrent measures of hot flashes and sleep. The recent development of a reliable and non-intrusive method for objectively identifying hot flashes during the night should help address the need for substantial additional research in this area. Several areas of clinical relevance are described, including the effects of discontinuing combined hormone therapy (estrogen plus progesterone) or estrogen-only therapy, the possibility of hot flashes continuing for many years after menopause, and the link between hot flashes and depression.

Hormone replacement therapy: controversies, pros and cons

Hormone replacement therapy (HRT) is a complicated clinical issue that requires an in-depth risk/benefit assessment. The term HRT includes both oestrogen plus progestin therapy (OPT) and oestrogen-only therapy (OT). Much research has been done with the former, but additional research is still needed for the latter. This chapter aims to provide a comprehensive overview of the key risks and benefits in order to assist clinicians and patients confronting this issue. In approaching the vast amount of data on HRT a caveat is in order: many of the issues involved are not black and white. The clinical data are often conflicting and careful analysis is required. Despite the discrepancies between the various HRT studies, there is much to be gleaned from a close examination of the data. The primary risks associated with HRT use are related to breast cancer and cardiovascular health. Recent clinical trial data have pointed to a slight increase in the number of breast cancers among women using HRT compared to placebo. With regard to cardiovascular health, the data have shown an increase in stroke and (VTE) but there is also evidence of a possible cardioprotective effect. The major benefits include relief of menopausal symptoms (including vasomotor instability, sexual dysfunction, mood, fatigue and skin issues) and a decrease in fracture risk.

Sleep Problems Across the Life Cycle in Women

Across the life cycle of women, the quality and quantity of sleep can be markedly impacted by internal (eg, hormonal changes and vasomotor symptoms) and external (financial and child-care responsibilities; marital issue) factors. This paper will outline some of the major phases of the life cycle in women that have been associated with sleep problems. The main messages from this paper include 1) that very little systematic, large-scale research has been performed in virtually every area reviewed; and 2) once identified, the sleep problem is generally best addressed by the standard therapeutic approach, except in the case of pregnant and lactating women in which concern for the fetus and child must be considered in the treatment decision. This paper is organized into sections that address sleep problems associated with the menstrual cycle, pregnancy, postpartum, and perimenopause. Anecdotal reports recommend treatment that addresses the specific physical discomfort experienced by the woman (eg, analgesics for premenstrual pain, pregnancy pillows for backache, and hormone replacement therapy for hot flashes). The importance of developing standard treatment recommendations is stressed because the development of chronic insomnia has been linked to precipitating events. In addition, primary sleep disorders (eg, sleep apnea or restless legs syndrome) have been shown to increase during pregnancy and menopause, but treatment recommendations may be contraindicated or are not specific for women.

Sleep characteristics of menopausal insomnia: a polysomnographic study

Although menopausal insomnia is of clinical significance, the essential features of this form of disrupted sleep are poorly understood. The aim of the present study was to identify the sleep characteristics of menopausal insomnia by using overnight polysomnography (PSG). Twenty-one subjects with menopausal insomnia (MI) and 13 sex- and age-matched normal control (NC) subjects without sleep complaints took part in the present study. All MI and NC subjects underwent PSG on two consecutive nights. In comparison with NC, MI subjects had non-specific findings such as significantly shorter total sleep time, longer sleep latency, higher wake time after sleep onset, and lower sleep efficiency. As for rapid eye movement (REM) sleep variables, MI subjects had significantly shorter total REM sleep time, fewer numbers of REM sleep periods, longer REM latency, and higher REM density than did the NC subjects. As for the time course of REM density, REM density during the first 3 h period of nocturnal sleep was significantly higher for MI than for NC subjects. Unlike NC subjects, REM density for MI subjects did not tend to rise progressively during nocturnal sleep. The MI subjects had objective evidence of disrupted sleep and the most striking characteristics of this dysfunction were observed in REM sleep variables. The sleep characteristics of MI subjects were found to differ in REM sleep variables from those of patients with major depression (except for REM density). Menopausal insomnia patients appear to be similar to patients with generalized anxiety disorder accompanied by severe sleep disruption. These data lend support to the clinical distinction between menopausal insomnia and insomnia associated with major psychiatric disorders.

A comparative review of the risks and benefits of hormone replacement therapy regimens

The Women's Health Initiative (a large, randomized, placebo-controlled trial) investigated the effect of conjugated equine estrogens combined with medroxyprogesterone acetate on specific potential long-term benefits and risks. A review of the clinical studies that have investigated different types and regimens of estrogens combined with progestins was conducted to assess how applicable the results of the Women's Health Initiative are to hormone replacement therapy regimens in general. The studies that were reviewed were limited to randomized clinical trials and observational studies that have been published over the last 15 years (1987-2002) and to meta-analyses and reviews that may have included the literature before 1987. The increased risks for venous thromboembolism, stroke, coronary heart disease, and breast cancer that were identified in the Women's Health Initiative trial have also been reported with postmenopausal hormone therapies that contain a variety of estrogen and progestin products. The beneficial effects that were noted in the Women's Health Initiative, with respect to reductions in fractures and colorectal cancer, have not been evaluated in large, randomized controlled trials that use different estrogen/progestin combinations; however, observational trials that used a variety of estrogen or hormone replacement therapy products and randomized clinical studies that evaluated bone mineral density (an excellent predictor of fracture risk) with different estrogen/hormone replacement therapy regimens would suggest that results would be similar to those found in the Women's Health Initiative. Although the relief of menopausal symptoms, the primary reason women seek treatment, was not included in the overall benefit/risk analysis of the Women's Health Initiative, numerous trials suggest that all therapies are effective. Overall, these data indicate that the benefit/risk analysis that was reported in the Women's Health Initiative can be generalized to all postmenopausal hormone replacement therapy products.

Sleep and menopause

Many midlife women obtain inadequate sleep, and sleep problems are common during the menopause transition. This article reviews the research literature on sleep and sleep disorders during menopause. Few studies have included subjective and objective measures of sleep quality or studied women during different menopause stages. Potential mechanisms associated with the emergence of insomnia and sleep-disordered breathing during menopause are discussed along with effects of estrogen and progesterone on sleep. It is argued that sleep quality is an important determinant of health status and quality of life for women during and beyond menopause.