Estrogen replacement therapy and nocturnal periodic limb movements: a randomized controlled trial

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.

Restless legs syndrome and pregnancy: prevalence, possible pathophysiological mechanisms and treatment

Restless legs syndrome (RLS) is a common sleep disorder that may be associated with pregnancy. Studies have found that the prevalence of RLS among pregnant women ranged from 10 to 34%. Typically, there is complete remission of symptoms soon after parturition; however, in some patients, they may continue postpartum. RLS has been shown to be associated with a number of complications in pregnancy including preeclampsia and increased incidence of Cesarean sections. Although multiple hypotheses have been proposed to explain this association, each individual hypothesis cannot completely explain the whole pathogenesis. Present understanding suggests that a strong family history, low serum iron and ferritin level, and high estrogen level during pregnancy might play important roles. Vitamin D deficiency and calcium metabolism may also play a role. Medical treatment of RLS during pregnancy is difficult and challenging considering the risks to mother and fetus. However, in some cases, the disease may be severe enough to require treatment.

Are Attributes of Pregnancy and the Delivery Room Experience Related to Development of Autism? A Review of the Perinatal and Labor Risk Factors and Autism

Autism is a neurodevelopmental disorder marked by severe deficits in social communication and interactions. It is a complex condition that lacks an established preventive method, warranting a need for research to identify possible environmental triggers. The identification of external factors particularly perinatal risk factors forms the initial critical step in preventing and alleviating risks. We conducted a literature review to assess evidence suggested in the worldwide literature. Perinatal risk factors that have a suggested association include β2 adrenergic receptor agonists, labor induction and augmentation, maternal infection and disease (i.e., antiphospholipid syndrome), antiepileptic drugs, cocaine use, and oral supplements. Smoking has not been found to have a direct association. Pollutants, selective serotonin reuptake inhibitors, artificial insemination, and fertility medications may have a link, but results are often conflicted. Factors related to the delivery room experience may be associated with meconium aspiration syndrome, birth weight, and labor time. Several risk factors during the pregnancy and labor periods have been associated with autism; yet further studies with large populations are needed to establish definitive associations. The fact that several risk factors during the prenatal and labor periods are implicated in autism should prompt the medical community to focus on the pregnancy and labor periods as preventive measures to curb the incidence of autism.

Sleep during the perimenopause: a SWAN story

Is there evidence for a perimenopausal sleep disorder? We address this question in our presentation of the Study of Women's Health Across the Nation (SWAN) "sleep story," in which we summarize and discuss data addressing sleep quality, objective measures of sleep patterns, and sleep disorders that have been published to date by the SWAN and the ancillary SWAN Sleep Study. We describe what has been learned about sleep during the perimenopause. Analyses exploring racial/ethnic diversity and the role of hot flashes and mood disturbance in sleep-perimenopause associations are described. Implications for clinical practice are considered.

Restless legs syndrome during pregnancy in Brazilian women

OBJECTIVE

The objective of this study was to identify the prevalence of restless legs syndrome (RLS) among pregnant Brazilian women, with individual diagnostic clinical interviews during the trimesters of pregnancy, and to determine the severity.

METHODS

It was a cross-sectional study. We interviewed 524 pregnant women (18-45 years old) who came to the prenatal outpatient clinic to consult an obstetrician. We used a RLS clinical-diagnostic interview and the International RLS Study Group rating scale (IRLS).

RESULTS

The prevalence of RLS during pregnancy was 13.5% in our sample, among which 90.1% of the cases started with their symptoms during pregnancy. More than half of the patients (53.5%) presented severe or very severe symptoms and the largest proportion of them (15.2%) were in their third trimester. We did not observe any demographic differences among the trimesters for RLS prevalence and RLS severity.

CONCLUSION

RLS during pregnancy is more frequent than in the general population, such that more than half of the pregnant women with RLS present it severely or very severely. It occurs especially in the third trimester.

Evaluation and management of sleep disturbance during the menopause transition

Sleep disturbances in midlife women are common and have been associated with the menopause transition itself, symptoms of hot flashes, anxiety and depressive disorders, aging, primary sleep disorders (i.e., obstructive sleep apnea, periodic limb movement disorder), comorbid medical conditions and medications, as well as with psychosocial and behavioral factors. Because there are several common sources of sleep problems in midlife women, the cause of an individual woman's sleep disturbance may be multifactorial. Effective behavioral and pharmacological therapies are available to treat sleep disturbances of different etiologies. This review provides an overview of different types of sleep disturbance occurring in midlife women and presents data supporting the use of hormone therapy, hypnotic agents, and behavioral strategies to treat sleep problems in this population. The review aims to equip clinicians evaluating menopause-age women with the knowledge and evaluation tools to diagnose, engage sleep experts where appropriate, and treat sleep disturbance in this population. Sleep disorders in midlife women should be treated because substantial improvements in quality of life and health outcomes are achievable.

Sleep and menopause

Understanding sleep complaints of menopausal women is an emerging area of clinical and research interest. In this article, we summarize the most relevant and recent literature to provide an update on sleep in perimenopause and postmenopause. Our discussion includes the causes, clinical diagnosis, and treatment of sleep disorders in perimenopausal and postmenopausal women.

Periodic limb movement screening as an additional feature of Emfit sensor in sleep-disordered breathing studies

BACKGROUND

The standard method for recording periodic limb movements is anterior tibialis electromyography (EMG) but other methods are also used. A new movement sensor Emfit (ElectroMechanical Film) provides information about sleep-disordered breathing but also shows movements in bed. The aim of the study was to investigate the usability of a small Emfit sensor in revealing periodic movements.

METHODS

Twenty seven consecutive patients were studied. Periodic movements in EMG and Emfit were scored blindly and periodic leg movement index (PLMI) for EMG and periodic movement index (PMI) for Emfit were counted. Spearman's correlation coefficient was used to assess the relationship between Emfit data and EMG results. Sensitivities and specificities were computed for PLMI and PMI levels of 5 and 15 movements/h. Additionally, receiver operating characteristic (ROC) curves were derived and the area under the curve (AUC) was calculated.

RESULTS

The Spearman's correlation coefficient between the PMI of Emfit and the PLMI of EMG was 0.87. The sensitivity of the Emfit sensor to detect periodic limb movements was 0.91 at the level of 5 movements/h and 0.73 when the cut-off level was 15 movements/h. The specificities were 0.75 and 1.00, respectively. AUC in ROC analysis was 0.96 and 0.98 in the levels of 5 and 15 movements/h.

CONCLUSIONS

The results suggest that the Emfit sensor might be suitable for screening of periodic limb movements even if the sensor is placed under the thoracic area of the patient in sleep-disordered breathing studies.

Estrogen therapy reduces nocturnal periodic limb movements

It is believed that periodic limb movement (PLM) and more specifically, restless leg syndrome (RLS), are a common cause of insomnia. And one study in the literature examined PLM when associated to the use of estrogens. Polo-Kantola et al. [Polo-Kantola P, Rauhala E, Erkkola R, Irjala K, Polo O. Estrogen replacement therapy and nocturnal periodic limb movements: a randomized controlled trial. Obstet Gynecol 2001;97(4):548-54] observed that estrogen therapy improved subjective sleep quality regardless of periodic limb movements or related arousals. Herein is a case of a symptomatic postmenopausal patient with high PLM index who complained of insomnia and leg pain. Given that the patient had hot flashes and a high Kupperman Menopausal Index (which evaluates climacteric symptoms), we decided to administer transdermal ESTRADOT 25 microg (Novartis, Brazil) twice-a-week. Our patient experienced a significant decrease in PLM as well as a great increase in REM and a slight increase in slow wave sleep (stages 3 and 4), as shown in the polysomnography. The patient reported an overall improvement in her condition.

The clinical neurophysiology of the restless legs syndrome and periodic limb movements. Part I: diagnosis, assessment, and characterization

OBJECTIVE

The restless legs syndrome is a common sensorimotor disorder impacting on sleep which has been known for centuries, but only recently become recognized as a significant clinical and pathophysiological problem. The definition of RLS has evolved until certain key clinical features have been defined as diagnostic, while others are strongly associated: the urge to move is seen as primary. Epidemiology suggests ethnic variation with highest frequency in populations of European origin; family and genetic studies support a genetic basis to many idiopathic cases while links to secondary disorders usually involving low iron stores are also known. Abnormalities of brain iron transport and consequent dysfunction of the dopamine system are suspected sources of the disorder.

METHODS

The literature was searched for all references relating clinical neurophysiologic investigations to the diagnosis, assessment, and characterization of RLS.

RESULTS

RLS is defined clinically and diagnosed by medical history while its frequent concomitant, periodic limb movements (PLM), must be diagnosed by polysomnography or movement recording. Severity of RLS is generally assessed by subjective measures, but sleep recording and measurement of PLM frequency and association with sleep disruption are also used to measure severity. A provocative test, the suggested immobilization test, can also be used with both subjective and movement recording. RLS and PLM in RLS are both associated with the circadian cycle and are maximal early in the sleep period. PLM appear to be associated both with unstable EEG phases involving the cyclic alternating pattern and cyclical autonomic changes whose initiation may precede the muscle activity.

CONCLUSIONS

While RLS remains a subjective disorder, neurophysiologic measures have been important, especially for assessment. Ambulatory methodologies may offer the most accurate and economical means of assessing motor activity as a key marker of RLS and of accurately measuring PLM from night to night. As the pathophysiology of RLS is better understood, more focused techniques may be developed to measure its presence and severity in individual patients.

Restless legs syndrome and periodic limb movement disorder

Restless leg syndrome and PLMD are nocturnal movement disorders associated with significant adverse effects on the health and well-being of patients and their families [66]. Although the pathophysiological basis remains to be fully described, current research points to abnormalities in CNS function and neurotransmitter systems. The accurate diagnosis of RLS and PMD requires a thorough history, physical examination, diagnostic tests, and often, a referral to a sleep disorders specialist. Considering the prevalence of these conditions and their negative impact, nurses should be well-versed in the assessment and management of these problems as well as in the appropriate education of patients and their families. Nursing research is greatly needed, particularly with regard to the development and testing of biobehavioral interventions designed to decrease associated symptoms and improve clinical outcomes. Finally, because of the complexity of the clinical presentation of RLS and PLMD, this population of patients presents nurse clinicians and researchers alike with an extraordinary opportunity for interdisciplinary collaboration.