Vasomotor and depression symptoms may be associated with different sleep disturbance patterns in postmenopausal women

Unraveling sleep quality in menopausal women: objective assessments and self-reported experiences - a mini-review

Sleep is a cornerstone of health, playing an integral role in both physiological and psychological functions. However, it is vulnerable to a variety of factors including menopause. According to available research, the onset of the menopause transition may not necessarily worsen sleep architecture and could even enhance it, leading to conflict between assessment of subjective and objective sleep complaints. This discrepancy highlights the complex relationship between subjective and objective sleep quality. Understanding this relationship remains challenging due to the limited number of longitudinal studies and small sample sizes. This review explores findings from both subjective and objective sleep assessments in menopausal women and examines the impact of menopausal hormone therapy on sleep quality.

Factors influencing sleep disorders in perimenopausal women: a systematic review and meta-analysis

Background

To determine the influencing factors of sleep disorders in perimenopausal women by Meta-analysis.

Methods

A comprehensive literature search was conducted by PubMed, Embase, CINAHL, and Web of Science(from inception to December 1,2023). Two researchers independently performed literature screening, quality evaluation and data extraction, and Stata16.0 software were used for Meta-analysis.

Results

A total of 12 studies involving 11,928 perimenopausal women with sleep disorders were included. The results of Meta-analysis showed that depression(OR = 2.73, 95%CI 1.65 ~ 4.52), hot flashes (OR = 2.70, 95%CI 1.81 ~ 4.02), chronic disease (OR = 1.39, 95%CI 1.24 ~ 1.56) and psychotropic drug use(OR = 3.19, 95%CI 1.31 ~ 7.77) were risk factors for sleep disorders in perimenopausal women (p < 0.05).

Conclusion

Sleep disorder is one of the most common symptoms in perimenopausal women, and its influencing factors should be paid attention to. Healthcare managers can further improve and standardize the prevention and management of sleep disorders in perimenopausal women according to the influencing factors, accurately identify high-risk groups, implement intervention measures, and reduce the severity and incidence of sleep disorders in perimenopausal women.

Impact of family care on sleep quality in perimenopausal women: mediating roles of anxiety and depression

BACKGROUND

This study aimed to investigate the relationship between family care, anxiety, depression, and sleep quality in perimenopausal women. Furthermore, it also aimed to examine the role of anxiety and depression in mediating family care and sleep quality. The study findings aim to provide theoretical support for alleviating anxiety and depression levels and improving sleep quality in perimenopausal women.

METHODS

Perimenopausal women (n = 860) in Gansu Province were surveyed using the self-rating scale of sleep, self-rating anxiety scale, self-rating depression scale, and family adaptation partnership growth affection resolve.

RESULTS

The sleep quality, anxiety, and depression scores of the perimenopausal women in Gansu Province were 25.33 ± 5.00, 40.74 ± 10.89, and 40.77 ± 10.03, respectively, and the family care score was 6.64 ± 2.36. Family care was negatively correlated with sleep quality, anxiety, and depression scores; anxiety was positively correlated with depression and sleep quality scores, and depression was positively correlated with sleep quality scores. Anxiety and depression in perimenopausal women partially mediated family care and sleep quality, with mediating effects accounting for 15.74% and 60.69% of the total effect, respectively.

CONCLUSION

Anxiety and depression are mediating variables between family care and sleep quality in perimenopausal women. It is recommended that hospital and community staff pay attention to the role of good family care in perimenopausal women, actively implement intervention strategies aimed at reducing anxiety and depression pathways, and improve their sleep quality.

Sex-specific changes in sleep quality with aging: Insights from wearable device analysis

Prior studies evaluating sleep quality have found that women often have better polysomnography-defined sleep quality than men, but women subjectively report a greater frequency of sleep disturbances. Although these studies can be partially attributed to study design, it is currently unclear what may be causing these discrepancies. In this study, we aim to identify potential differences in objectively assessed sleep quality between men and women with further emphasis on subgroup analysis based on age. We hypothesize that women's sleep worsens after menopause. Sleep quality was assessed by comparing the Sleep Quality Index, Arousal Index, sleep efficiency and apnea-hypopnea index, as provided by the SleepImage Ring@ 2.3.0, between men and women, with a sub-group analysis performed by age (18-40 years, 41-50 years, 51-60 years, 61-70 years, and > 70 years), run separately for women and men. In total, 1444 subjects (704 women and 740 men) with a mean age of 53.6 ± 14.71 years were enrolled in this analysis. In women, a significant drop in Sleep Quality Index was noted after age 51 years. Regression analysis demonstrated that age, Arousal Index, sleep efficiency and apnea-hypopnea index correlated significantly with Sleep Quality Index - with age, Arousal Index and apnea-hypopnea index negatively correlated, and sleep efficiency positively correlated. The highest correlation coefficient was obtained for Arousal Index in both women and men. In women, age older than 50 years was associated with a more rapid decrease of sleep quality than men, as defined by an increase in Arousal Index and apnea-hypopnea index with a concurrent decrease in Sleep Quality Index.

Real-world clinical evaluation of natural and induced vasomotor symptoms in the USA and Europe

OBJECTIVE

This study aimed to examine physicians' and patients' perceptions regarding symptom burden and impact in women experiencing natural vasomotor symptoms (nVMS) or vasomotor symptoms induced by endocrine therapy for breast cancer (iVMS).

METHODS

The cross-sectional survey based on real-world clinical consultations was conducted in the USA and five European countries. Obstetrician-gynecologists, primary-care physicians and oncologists provided demographic and symptom data for patients experiencing VMS; patients optionally self-reported their experiences via questionnaires, including their symptom profile and work/activity burden through the Menopause Quality of Life (MENQOL) and Work Productivity and Activity Impairment (WPAI) tools.

RESULTS

Physicians completed survey forms on 2451 consulting patients; patients completed 1029 questionnaires. nVMS and iVMS severity was significantly associated with the severity of mood symptoms and sleep disturbances (p < 0.0001). However, around half of the patients with mild nVMS/iVMS also experienced moderate-severe mood changes (55.4%/43.7%) or sleep disturbances (42.4%/40.4%). Presence of mood/sleep disturbances alongside nVMS increased MENQOL vasomotor scores (p = 0.004/p < 0.001). Presence of sleep disturbances increased WPAI activity impairment (p < 0.001) but mood changes did not. Similar findings were reported for iVMS patients.

CONCLUSION

Significant burden from the triad of natural or induced menopausal symptoms, sleep disturbances and mood changes affected women's daily activities, work and quality of life more than vasomotor symptoms alone.

Insomnia in Postmenopausal Women: How to Approach and Treat It?

Insomnia is one of the major complaints of menopausal women with advancing age and may be complexly related to a variety of causes. However, there is still a lack of standards on the general approach and treatment for insomnia in menopausal women. The aim of this review is to summarize recent pathogenic theories of sleep disturbance in the menopausal period and discuss the approach and management of insomnia in postmenopausal women. Sleep disturbances in menopausal women may be associated with physical and psychiatric factors and other comorbid diseases. Careful history taking and multidisciplinary physical and psychosocial evaluation are necessary and, in particular, comorbidities related to sleep disorders, such as obstructive sleep apnea, must be taken into consideration. A unique aspect of insomnia in postmenopausal women is that menopausal symptoms due to hormonal decline can be closely related to sleep disturbances. Therefore, menopausal hormone therapy (MHT) should be considered as the treatment of choice among pharmacological treatments following cognitive behavioral therapy, which is suggested as the first-line treatment in the general population insomnia treatment guidelines. Additionally, melatonin and 5HT-based drugs, which have fewer side effects, along with MHT should be preferentially recommended in menopausal women.

Association of menopausal vasomotor symptom severity with sleep and work impairments: a US survey

OBJECTIVE

Menopausal vasomotor symptoms commonly disrupt sleep and affect daytime productivity. This online survey evaluated associations between vasomotor symptom severity and perceived sleep quality and work productivity.

METHODS

Participants were perimenopausal or postmenopausal US women aged 40 to 65 years with ≥14 vasomotor symptom episodes per week for ≥1 week in the past month. The women, who were recruited from Dynata panels via email invitation and categorized by vasomotor symptom severity based on the Menopause Rating Scale, were surveyed about sleep and work productivity and completed the Patient-Reported Outcomes Measurement Information System Sleep Disturbance Short Form 8b (primary outcome) and Sleep-Related Impairment Short Form 8a, Pittsburgh Sleep Quality Index, and Work Productivity and Activity Impairment questionnaire.

RESULTS

Among 619 respondents (mean age, 53 y; White, 91%; perimenopausal, 34%; postmenopausal, 66%; 57.5% were never treated for vasomotor symptoms), vasomotor symptoms were mild in 88, moderate in 266, and severe in 265. A majority (58% overall) were employed, including 64.8%, 49.6%, and 64.2% of women with mild, moderate, and severe VMS, respectively. Of the 90.8% who reported that vasomotor symptoms affect sleep (81.8%, 86.8%, and 97.7% of those with mild, moderate, and severe VMS), 83.1% reported sleep-related changes in productivity (75.0%, 73.2%, and 94.2%, respectively). Patient-Reported Outcomes Measurement Information System Sleep Disturbance Short Form 8b mean T scores in the mild (T score, 53.5), moderate (57.3), and severe (59.8) VMS cohorts indicated more sleep disturbance than in the general population (T score, 50; overall P < 0.001 before and after controlling for confounding variables). Sleep-Related Impairment 8a results were similar. Vasomotor symptom severity was positively associated with Pittsburgh Sleep Quality Index mean scores, presenteeism, absenteeism, overall work impairment, and impairment in general activities.

CONCLUSIONS

Greater vasomotor symptom severity was associated with more sleep disturbance, more sleep-related impairment, worse sleep quality, and greater impairment in daytime activities and work productivity.

Nocturnal Hot Flashes, but Not Serum Hormone Concentrations, as a Predictor of Insomnia in Menopausal Women: Results from the Midlife Women's Health Study

Background: Sleep disruptions are among the most common symptoms experienced during menopause and can be associated with depression, hot flashes, and fluctuating hormones. However, few studies have examined how such risk factors influence sleep in midlife women in a network-based approach that will establish the complex relationship between variables. Materials and Methods: We used a Bayesian network (BN) to examine the relationship between multiple factors known to influence sleep and depression in midlife women, including hormone concentrations, hot flashes, and menopause status among participants of the longitudinal Midlife Women's Health Study. In year 1, 762 women (45-54 years of age) answered questions regarding the frequency of insomnia, hot flashes, and depression; 389 of the same women answered similar questions at year 4. We measured serum hormones and calculated free estradiol index, free testosterone index, and ratios of estradiol:progesterone, and estradiol:testosterone. For our model, we calculated the change in frequency of insomnia, depression, and covariates (body mass index, menopause status, hot flashes at night, and present quality of life) from year 1 to 4. Results: Using a BN, we found that self-reported hot flashes at night, and no other factors, were direct predictors of self-reported insomnia in year 1. Surprisingly, we did not identify an association between hormone concentrations and self-reported insomnia. Frequency of insomnia in year 4 was only predicted by frequency of insomnia in year 1, whereas frequency of depression in year 4 was predicted by year 4 insomnia and frequency of depression in year 1. No other factors were direct predictors of insomnia or depression in our model. Conclusions: Therefore, hot flashes at night, previous insomnia, and depression are stronger predictors of how women will self-report frequency of sleep disruptions and treatment may reduce menopausal sleep complaints.

Factors associated with poor sleep quality in midlife Singaporean women: The Integrated Women's Health program (IWHP)

Objective

To examine factors associated with poor sleep quality in community-dwelling midlife women.

Methods

Healthy women (aged 45-69 years) of Chinese, Malay and Indian ethnicities attending well-women clinics at the National University Hospital, Singapore, completed the Pittsburgh Sleep Quality Index (PSQI). A PQSI score >5 denoted poor sleep quality. The women filled out validated questionnaires covering menopausal and genito-urinary symptoms, and mental health. Physical performance was measured. Bone mineral density and visceral adiposity were assessed by dual energy X-ray absorptiometry. Binary logistic regression analyses assessed independent factors for poor sleep.

Results

Poor sleep quality was reported in 38.2% of women (n = 1094, mean age: 56.4 ± 6.2 years). Indian women had higher sleep disturbance scores than Chinese women (mean ± SD: 1.33 ± 0.58 vs 1.17 ± 0.49). Malays experienced more daytime dysfunction (0.54 ± 0.60 vs 0.33 ± 0.55) and had a higher overall PSQI score (6.00 ± 3.31 vs 5.02 ± 2.97) than the Chinese. A low education level (aOR: 1.76, 95% CI: 1.01-3.05), feelings of irritability (2.67, 1.56-4.60) and vaginal dryness (1.62, 1.03-2.54) were associated with poor sleep quality in the adjusted multivariable model. Women with moderate to severe disability were ∼3 times (2.99, 1.20-7.44) more likely to experience less than ideal sleep quality, while urinary incontinence (1.53, 1.08-2.17) and breast cancer history (2.77, 1.36-5.64) were also associates of poor sleep quality.

Conclusion

Self-reports of education level, irritability, vaginal dryness, disability, urinary incontinence, and breast cancer history were independently related to poor sleep. Ethnic differences suggest the need for targeted interventions among the ethnic groups.

Depression among Peri- and Post-Menopausal Women during COVID-19 Pandemic in Chandigarh, North India: A Study from Community

Background

Peri- and post-menopausal women are vulnerable to suffer from mental health problems including depression, anxiety, and stress, which might have increased during the COVID-19 pandemic.

Objective

To estimate the prevalence of depression and associated factors among peri- and post-menopausal women during the COVID-19 pandemic in Chandigarh.

Materials and Methods

A community-based cross-sectional study was conducted among 200 urban peri- and post-menopausal women of age 40-60 years in Chandigarh, from May to June 2021. Patient Health Questionnaire-9, Generalized Anxiety Disorder 7, and EuroQol-5D validated tools were used to screen depression, anxiety, and quality of life (QOL). Fear of COVID-19 scale was developed as part of this study was used to assess the fear related to COVID-19 infection. Data analysis was done using the Statistical Package for the Social Sciences (SPSS) software version 26.0. Binary multivariate logistic regression model was used to identify the predictors.

Results

The prevalence of depression was 39% and anxiety 29.5% among peri-and post-menopausal women. The fear of COVID-19 infection (adjusted odds ratio [aOR] 8.43, confidence interval [CI]: 1.99-35.64; aOR 10.54, CI: 2.76-40.24) and sleeplessness (aOR 13.29, CI: 3.22-54.82) were the significant (P < 0.005) predictors of depression and anxiety, respectively. Fearful peri- and post-menopausal women (aOR 5.94, CI: 2.68-13.13) and widow status (aOR 7.08, CI: 1.10-45.28) were the significant (P < 0.005) predictors of poor QOL.

Conclusions

The prevalence of depression was high among peri- and post-menopausal women during the COVID-19 pandemic. Fear of getting COVID-19 infection was significantly associated with depression, anxiety, and poor QOL.

Investigation of the relationship between hot flashes, sweating and sleep quality in perimenopausal and postmenopausal women: the mediating effect of anxiety and depression

Background

To investigate the relationship between sweating from hot flashes, anxiety, depression, and sleep quality in peri- and postmenopausal women. And also the role of anxiety and depression in mediating sweating from hot flashes and sleep quality.

Methods

467 women aged 40–60 years with menopausal problems were enrolled. The sleep quality; hot flashes; sweating; anxiety and depression symptoms were quantitatively evaluated by Pittsburgh Sleep Quality Scale (PSQI), Kupperman Menopause Index, Self-rating Anxiety Scale and Self-rating Depression Scale. Spearman correlation analysis and mediating effect model were used to analyze the relationship between the three.

Results

262 patients’ PSQI score were higher than 6 (58.2%). Total scores of sleep quality were positively correlated with hot flashes, sweating and anxiety and depression symptoms. Anxiety and depression played a mediating role between hot flashes, sweating and sleep quality where the mediating effect of anxiety symptoms accounted for 17.86% (P < 0.01) and depression symptoms accounted for 5.36% (P < 0.01).

Conclusions

The hot flashes, sweating, anxiety and depression of peri/postmenopausal women are risk factors affecting sleep quality. By alleviating these risk factors, the sleep quality of peri- and postmenopausal women could be improved, which prevents the physical and mental diseases due to long-term severe insomnia.

How do women living with HIV experience menopause? Menopausal symptoms, anxiety and depression according to reproductive age in a multicenter cohort

BACKGROUND

To estimate the prevalence and severity of menopausal symptoms and anxiety/depression and to assess the differences according to menopausal status among women living with HIV aged 45-60 years from the cohort of Spanish HIV/AIDS Research Network (CoRIS).

METHODS

Women were interviewed by phone between September 2017 and December 2018 to determine whether they had experienced menopausal symptoms and anxiety/depression. The Menopause Rating Scale was used to evaluate the prevalence and severity of symptoms related to menopause in three subscales: somatic, psychologic and urogenital; and the 4-item Patient Health Questionnaire was used for anxiety/depression. Logistic regression models were used to estimate odds ratios (ORs) of association between menopausal status, and other potential risk factors, the presence and severity of somatic, psychological and urogenital symptoms and of anxiety/depression.

RESULTS

Of 251 women included, 137 (54.6%) were post-, 70 (27.9%) peri- and 44 (17.5%) pre-menopausal, respectively. Median age of onset menopause was 48 years (IQR 45-50). The proportions of pre-, peri- and post-menopausal women who had experienced any menopausal symptoms were 45.5%, 60.0% and 66.4%, respectively. Both peri- and post-menopause were associated with a higher likelihood of having somatic symptoms (aOR 3.01; 95% CI 1.38-6.55 and 2.63; 1.44-4.81, respectively), while post-menopause increased the likelihood of having psychological (2.16; 1.13-4.14) and urogenital symptoms (2.54; 1.42-4.85). By other hand, post-menopausal women had a statistically significant five-fold increase in the likelihood of presenting severe urogenital symptoms than pre-menopausal women (4.90; 1.74-13.84). No significant differences by menopausal status were found for anxiety/depression. Joint/muscle problems, exhaustion and sleeping disorders were the most commonly reported symptoms among all women. Differences in the prevalences of vaginal dryness (p = 0.002), joint/muscle complaints (p = 0.032), and sweating/flush (p = 0.032) were found among the three groups.

CONCLUSIONS

Women living with HIV experienced a wide variety of menopausal symptoms, some of them initiated before women had any menstrual irregularity. We found a higher likelihood of somatic symptoms in peri- and post-menopausal women, while a higher likelihood of psychological and urogenital symptoms was found in post-menopausal women. Most somatic symptoms were of low or moderate severity, probably due to the good clinical and immunological situation of these women.

Footbath as a safe, simple, and non-pharmacological method to improve sleep quality of menopausal women

Due to the adverse effects of medication we decided to provide a safe, economic, and easy intervention to decrease sleep problems in menopausal women. This trial aimed to determine the effect of footbath on sleep disturbance in postmenopausal women. One hundred menopausal women were randomly stratified using a permuted block randomization procedure by Random Allocation Software, and assigned to one of two study groups: control (without intervention, n = 50) and intervention (footbath, n = 50). The footbath group was asked to lie their feet into the warm water for 20 min in a container with a depth of 10 cm one hour before the usual sleeping time for 6 weeks. To assess sleep quality, we used the Pittsburgh sleep quality index (PSQI). To evaluate severity of menopause symptoms, the Greene scale was applied. Before the intervention, 96% of the subjects in the footbath group and 94% in the control group were poor sleepers. The results of analysis of covariance showed significant improvement in sleep quality and decrease in severity of menopause signs in the footbath group compared to the control group. At the baseline, there was a statistically significant correlation between the severity of menopause signs and the global score of PSQI in all study individuals (p ≤ .001, r = .464). The present study findings showed that footbath intervention enhanced sleep quality in menopausal women. Thus, footbath as a safe, simple, and non-pharmacological application can improve quality of life in postmenopausal women and inhibit problems due to inadequate sleep quality.

Efficacy and Safety of Kudzu Flower-Mandarin Peel on Hot Flashes and Bone Markers in Women during the Menopausal Transition: A Randomized Controlled Trial

This randomized controlled study aimed to assess the efficacy and safety of an extract mixture of kudzu flower and mandarin peel (KM) on hot flashes (HFs) and markers of bone turnover in women during the menopausal transition. Healthy women aged 45–60 years with the menopausal HFs were randomly assigned in a 1:1 ratio to either KM (1150 mg/day) or placebo arms for 12 weeks (n = 84). The intent-to-treat analysis found that compared with the placebo, the KM significantly attenuated HF scores (p = 0.041) and HF severities (p < 0.001), with a mean difference from baseline to week 12. The KM also improved bone turnover markers, showing a significant reduction in bone resorption CTx (p = 0.027) and a tendency of increasing bone formation OC relative to the placebo. No serious adverse events and hormonal changes were observed in both groups. These findings suggest that KM consumption may improve the quality of life in ways that are important to symptomatic menopausal women.

Free Radical Oxidation and Sleep Disorders in Andro- and Menopause (Literature Review)

This review presents data on changes in the physiology of sleep during reproductive aging. It is noted that insomnia and obstructive sleep apnea syndrome (OSAS) are the main sleep disorders. The results of foreign and domestic studies in the field of free radical oxidation during sleep deprivation in animal models are presented, indicating the dependence of processes on the duration of sleep deprivation. The largest number of studies of free radical processes in a person with somnological pathology was carried out in the study of OSAS. Blood, urine, saliva, condensate of exhaled air can be biomaterial for determining the parameters of free radical oxidation. It was shown that the intensity of oxidative stress depends on the severity of OSAS, as evidenced by the positive correlation of the level of active products of thiobarbituric acid, the products of oxidation of proteins and carbonyl groups with the apnea/hypopnea index, determining the development of not only oxidative, but also carbonyl stress in patients with a severe degree OSAS. Biomarkers such as thioredoxin, malondialdehyde, superoxide dismutase, and reduced iron have shown a more stable relationship between increased oxidative stress and OSA. Despite the results obtained, the question of the association of oxidative stress and hypoxia in OSA remains debatable, which is associated with the opposite results of some studies. Insomnia, which occurs mainly in females, is accompanied by a high level of end products of lipid peroxidation with a decrease in the activity of antioxidants such as paraoxonase, an enzymatic component of the glutathione system. Along with this, menopausal women present low levels of uric acid, which correlates with high scores of the Pittsburgh sleep quality index questionnaire. Recent studies have identified an association between the activity of the «lipoperoxidation – antioxidants» system and the Clock 3111T/C gene polymorphism in menopausal Caucasian women, indicating the protective role of the minor allele.

Depression during perimenopause: the role of the obstetrician-gynecologist

Depression in women is more common during perimenopause (the transition to menopause) than at other times in the life cycle. Symptoms of depression may be different in perimenopausal women compared to younger or older women, and are often dismissed as part of normal menopause. This is an expert narrative review. There are several evidence-based screening modalities which can be integrated into routine women's health visits, and can facilitate distinguishing between depression and normal perimenopausal symptoms. There is emerging evidence regarding the effect of hormonal changes on the development of perimenopausal depression and its optimal treatment, though critical research gaps remain. Obstetrician-gynecologists and other primary care providers play a vital role in the detection and management of depression in women. Providers caring for women during perimenopause have a unique opportunity to diagnose depression in their patients and identify appropriate treatment options.

Management of depressive symptoms in peri- and postmenopausal women: EMAS position statement

INTRODUCTION

Globally, the total number of people with depression exceeds 300 million, and the incidence rate is 70 % greater in women. The perimenopause is considered to be a time of increased risk for the development of depressive symptoms and major depressive episodes.

AIM

The aim of this position statement is to provide a comprehensive model of care for the management of depressive symptoms in perimenopausal and early menopausal women, including diagnosis, treatment and follow-up. The model integrates the care provided by all those involved in the management of mild or moderate depression in midlife women.

MATERIALS AND METHODS

Literature review and consensus of expert opinion.

SUMMARY RECOMMENDATIONS

Awareness of depressive symptoms, early detection, standardized diagnostic procedures, personalized treatment and a suitable follow-up schedule need to be integrated into healthcare systems worldwide. Recommended treatment comprises antidepressants, psychosocial therapies and lifestyle changes. Alternative and complementary therapies, although widely used, may help with depression, but a stronger evidence base is needed. Although not approved for this indication, menopausal hormone therapy may improve depressive symptoms in peri- but not in postmenopausal women, especially in those with vasomotor symptoms.

Psychosomatic and vasomotor symptom changes during transition to menopause

Menopause is the condition in which the gradual decline in ovarian function finally leads to the permanent cessation of menstruation. Oestrogen deficiency may cause early symptoms during the menopausal transition and late symptoms after menopause. Menopause is a normal period of life. During this period, women need adaptation to new biological, social, and psychological parameters. Vasomotor symptoms are among the most common menopausal symptoms. Menopause per se is not correlated with specific psychiatric disorders, but data suggest that perimenopausal women are more likely to develop depressive disorders even without a previous history. Vasomotor symptoms are correlated with mood and sleep disturbances, neuroticism, anxiety, decreased cognitive function, and stress. Personality traits, social, and other factors are also important mediators of vasomotor symptoms during the menopausal transition phase.

This is a review based on the existing evidence concerning the correlation between psychosomatic and vasomotor symptoms of menopause during the menopausal transition period. Healthcare providers should take these correlations into consideration when planning the treatment of vasomotor symptoms. Vasomotor symptoms during menopause are associated with significant social costs. There are numerous traditional hormone therapy, and complementary and alternative therapy including over-the-counter treatments and dietary supplements for managing menopause-related vasomotor symptoms. Additional costs include follow-up physician visits, laboratory testing, management of adverse events, and loss of productivity at work. Social support and planning may help women to deal with menopausal symptoms and may reduce overall social costs during this transitional phase.

The associations between menopausal symptoms and sleep quality in Spanish postmenopausal women

Objectives: Around the menopause, sleep disturbances frequently occur or worsen and are associated with decreased health quality and physical and psychological problems. The aim of this study was to analyze sleep quality and its association with the impact of menopausal symptoms in Spanish postmenopausal women. Methods: A total of 278 postmenopausal women (age 60.95 ± 8.01 years) participated in this cross-sectional study. The Medical Outcomes Study Sleep Scale (MOS-SS) and the Menopause Rating Scale (MRS) were used to analyze sleep quality and severity of menopausal symptoms, respectively. Anxiety and depression were measured using the Hospital Anxiety and Depression Scale. Results: The linear regression showed that a greater impact of menopausal symptoms (MRS total score) was associated with worse scores regarding sleep adequacy (p < 0.001, R² = 0.056), snoring (p = 0.020, R² = 0.036), awaken short of breath (p < 0.001, R² = 0.089), and quantity of sleep (p < 0.001, R² = 0.075) domains. Anxiety (p < 0.001) and worse somatic symptoms (p = 0.001) were related to greater sleep disturbances (R² = 0.164). We also found relationships of heightened psychological symptoms (p < 0.001) and low physical activity level (p = 0.003) with increased daytime somnolence (R² = 0.064). Finally, higher MRS total score and anxiety levels were associated with worse sleep quality assessed by MOS-SS Sleep Problems Index I (R² = 0.179, p < 0.001 and p = 0.001, respectively) and Sleep Problems Index II (R² = 0.146, p < 0.001 and p = 0.011, respectively). Conclusions: Anxiety and severity of menopausal symptoms were associated with poorer sleep quality. Furthermore, low physical activity level and worse psychological symptoms in menopause were predictors for increased somnolence. Therefore, screening for these factors in postmenopausal women is important, since they may be susceptible for intervention.

Women's Psychiatry

Brain disorders and mental diseases, in particular, are common and considered as a top global health challenge for the twenty-first century. Interestingly, women suffer more frequently from mental disorders than men. Moreover, women may respond to psychotropic drugs differently than men, and, through their lifespan, they endure sex-orientated social stressors. In this chapter, we present how women may differ in the development and manifestation of mental health issues and how they differ from men in pharmacokinetics and pharmacodynamics. We discuss issues in clinical trials regarding women participation, issues in the use of psychotropic medications in pregnancy, and challenges that psychiatry faces as a result of the wider use of contraceptives, of childbearing at older age, and of menopause. Such issues, among others, demand further women-oriented psychiatric research that can improve the care for women during the course of their lives. Indeed, despite all these known sex differences, psychiatry for both men and women patients uses the same approach. Thereby, a modified paradigm for women's psychiatry, which takes into account all these differences, emerges as a necessity, and psychiatric research should take more vigorously into account sex differences.

INSOMNIA AND CIRCADIAN RHYTHMS OF MELATONIN IN MENOPAUSAL WOMEN

The aim of the review is to analyze literature data about sleep homeostasis and the role of the one of circadian system key elements – melatonin – in the regulation of the sleep-wake cycle in women in menopause. It was shown that the prevalence and structure of sleep disorders depends on the menopausal phase. It was revealed that the melatonin content in the body, determined in various biological media (blood, saliva, urine), depends on age, sex, race, and chronotype. It was shown that morning melatonin can be used as a biological marker for determining the chronotype. Most studies indicated a decrease in melatonin level with aging. Moreover, women have lower melatonin level than men. In case of insomnia, lower melatonin level was found, although the results of the studies are ambiguous. The shift in the peak of hormone secretion in the early morning hours was described in menopausal women. Also, the dependence of melatonin circadian rhythm on the menopausal phase was revealed, which determines different approaches to insomnia therapy. We revealed the association of melatonin secretion circadian rhythms with Clock 3111T/C gene polymorphism in Caucasian patients with insomnia, which allows considering 3111T allele as risky in the formation of melatonin circadian rhythm disturbances in these patients.

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 bidirectional relationship between vasomotor symptoms and depression across the menopausal transition: a systematic review of longitudinal studies

OBJECTIVE

To explore the nature of the bidirectional relationship between vasomotor symptoms (VMS) and depression, and to determine whether hot flashes and night sweats differentially affect the association between VMS and depression through their effect on sleep disruption.

METHODS

Multiple databases were searched from 1961 until July 31, 2016, and a manual search of reference lists of identified articles was conducted. Sixteen articles that involved 10,008 participants were identified and analyzed.

RESULTS

The methods of analyses and measurement of VMS and depression varied across the studies. Two studies explored the bidirectional association, but only one was significant in both directions (odds ratio [OR] depression to VMS 3.06, 95% confidence interval [CI] 1.43-6.58; OR VMS to depression 8.88, 95% CI 2.57-30.68). In both cases, the association between VMS leading to depressive symptoms was stronger than the opposite. Eleven studies examined VMS leading to depression, but only five showed a significant effect (OR 1.57-1.81, P ≤ 0.02). Treating VMS and depressive symptoms as continuous variables (n = 3) diminished the relationship. Three studies showed a significant association of depression leading to VMS (OR 1.62-1.94, P ≤ 0.01). We found little evidence for a specific effect of night sweats on the association between VMS and depressive symptoms. The effect might not be related to sleep disruption.

CONCLUSIONS

There is a bidirectional association between VMS and depressive symptoms. The menopausal transition appears to increase the risk of recurrent episodes of depression that might not be explained only by VMS. Further investigation is needed to explain the differential effect of night sweats and hot flashes on depression.

Sleep quality and its association with postural stability and fear of falling among Spanish postmenopausal women

OBJECTIVE

To analyze the association of sleep quality with postural balance, as measured with objective stabilometric parameters, and fear of falling (FoF), among Spanish postmenopausal women.

METHODS

In all, 250 women (60 ± 8 years) took part in this cross-sectional study. Sociodemographic and anthropometric data were collected, as well as information concerning history of falls and FoF. Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale, and the Pittsburgh Sleep Quality Index was used to analyze sleep quality. Measurements of sway area (S), velocity (V), and mediolateral (RMSX) and anteroposterior (RMSY) displacements of the center of pressure were obtained with a resistive multisensor platform under both eyes-open (EO) and eyes-closed (EC) conditions to assess postural control. The independent associations of sleep quality with FoF and postural control were evaluated by multivariate linear and logistic regressions, respectively, adjusting for potential confounding variables.

RESULTS

SEO was independently associated (adjusted R = 0.073) with sleep duration (P < 0.001) and subjective sleep quality (P = 0.001), VEO (adjusted R = 0.156) with daytime dysfunction (P = 0.006) and sleep duration (P = 0.013), RMSXEO (adjusted R = 0.118) with subjective sleep quality (P = 0.005), and RMSYEO (adjusted R = 0.166) with sleep duration (P = 0.001) and daytime dysfunction (P = 0.046). Under EC condition, SEC (adjusted R = 0.014) was independently related with anxiety (P = 0.034), VEC (adjusted R = 0.148) with daytime dysfunction (P = 0.002) and sleep duration (P = 0.024), RMSXEC (adjusted R = 0.134) with subjective sleep quality (P < 0.001), and RMSYEC (adjusted R = 0.128) with sleep duration (P = 0.013) and daytime dysfunction (P = 0.033). Logistic regression showed that time since menopause (P = 0.003), body mass index (P = 0.001), and anxiety (P < 0.001), unlike sleep quality, were independently associated with FoF. The effect size of the model was medium (adjusted R= 0.162).

CONCLUSIONS

In Spanish postmenopausal women, sleep duration, subjective sleep quality, and daytime dysfunction were independent risk factors for worsened postural stability. FoF, anxiety, time since menopause onset, and body mass index, unlike sleep quality, were independently associated with poor postural stability.

Factors associated with poor sleep during menopause: results from the Midlife Women's Health Study

BACKGROUND

Poor sleep is one of the most common problems reported during menopause, and is known to vary throughout the menopause transition. The objective of this study was to describe the dynamics of poor sleep among participants of the Midlife Women's Health Study and to identify risk factors associated with poor sleep during the menopausal transition.

METHODS

Annual responses to surveys that included questions about the frequency of sleep disturbances and insomnia were analyzed to determine the likelihood of persistent poor sleep throughout the menopausal transition and the correlation of responses to the different sleep-related questions, including frequency of restless sleep during the first year of the study. Responses to questions about a large number of potential risk factors were used to identify risk factors for poor sleep.

RESULTS

Poor sleep in premenopause was not predictive of poor sleep in perimenopause, and poor sleep in perimenopause was not predictive of poor sleep in postmenopause. Frequencies of each of the measures of poor sleep were highly correlated. For all sleep outcomes, high frequency of depression was related to a high frequency of poor sleep. Vasomotor symptoms were also significantly related with a higher frequency of all poor sleep outcomes. A history of smoking was also associated with higher frequencies of insomnia and sleep disturbances.

CONCLUSIONS

The risk factors identified for poor sleep, depression and vasomotor symptoms, were consistently associated with poor sleep throughout the menopausal transition. The likelihood of these risk factors changed from premenopause, through perimenopause, and into postmenopause, however, which could explain changes in sleep difficulties across the menopausal transition. Treatment of these risk factors should be considered when addressing sleep difficulties in menopausal women.

Vasomotor and physical menopausal symptoms are associated with sleep quality

BACKGROUND

Sleep disturbance is one of the common complaints in menopause. This study investigated the relationship between menopausal symptoms and sleep quality in middle-aged women.

METHOD

This cross-sectional observational study involved 634 women aged 44-56 years attending a healthcare center at Kangbuk Samsung Hospitals. Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI).Multiple linear regression analysis was performed to assess the associations between Menopause-specific Quality of Life (MENQOL) scores and PSQI scores and Menopause-specific Quality of Life (MENQOL)scores.

RESULTS

The mean PSQI score was 3.6±2.3, and the rates of poor sleep quality(PSQI score > 5) in premenopausal, perimenopausal, and postmenopausal women were 14.4%, 18.2%, and 30.2%, respectively. Total PSQI score, specifically the sleep latency, habitual sleep efficiency and sleep disturbances scores, were significantly increased in postmenopausal women. Multiple linear regression analysis adjusted for age, BMI, hypertension, diabetes, smoking, marital status, family income, education, employment status, parity, physical activity, depression symptoms, perceived stress and menopausal status showed that higher PSQI score was positively correlated with higher vasomotor(ß = 0.240, P = 0.020)and physical(ß = 0.572, P<0.001) scores.

CONCLUSIONS

Vasomotor and physical menopause symptoms was related to poor sleep quality. Effective management strategies aimed at reducing menopausal symptoms may improve sleep quality among women around the time of menopause.

Sleep problems during the menopausal transition: prevalence, impact, and management challenges

A substantial number of women experience sleep difficulties in the approach to menopause and beyond, with 26% experiencing severe symptoms that impact daytime functioning, qualifying them for a diagnosis of insomnia. Here, we review both self-report and polysomnographic evidence for sleep difficulties in the context of the menopausal transition, considering severity of sleep complaints and links between hot flashes (HFs) and depression with poor sleep. Longitudinal population-based studies show that sleep difficulties are uniquely linked with menopausal stage and changes in follicle-stimulating hormone and estradiol, over and above the effects of age. A major contributor to sleep complaints in the context of the menopausal transition is HFs, and many, although not all, HFs are linked with polysomnographic-defined awakenings, with HF-associated wake time contributing significantly to overall wakefulness after sleep onset. Some sleep complaints may be comorbid with depressive disorders or attributed to sleep-related breathing or movement disorders, which increase in prevalence especially after menopause, and for some women, menopause, age, and environmental/behavioral factors may interact to disrupt sleep. Considering the unique and multifactorial basis for sleep difficulties in women transitioning menopause, we describe clinical assessment approaches and management options, including combination treatments, ranging from cognitive behavioral therapy for insomnia to hormonal and nonhormonal pharmacological options. Emerging studies suggest that the impact of severe insomnia symptoms could extend beyond immediate health care usage and quality of life issues to long-term mental and physical health, if left untreated in midlife women. Appropriate treatment, therefore, has immediate benefit as well as advantages for maintaining optimal health in the postmenopausal years.

Predictors of sleep disturbance in menopausal transition

OBJECTIVE

This follow-up study aimed to evaluate risk factors for menopausal sleep disturbances already identifiable before menopause.

METHODS

At baseline, all 81 women were premenopausal. At year-five follow-up, 27 of the women were premenopausal, 40 postmenopausal, and 14 postmenopausal and using hormone therapy. We used the Basic Nordic Sleep Questionnaire to study sleep; additional questionnaires evaluated risk factors for sleep impairment.

RESULTS

Sleep quality differed only marginally between the groups. The following baseline variables were associated with impaired sleep quality at follow-up: depressive symptoms increased the risk of nocturnal awakenings (OR 1.16 (95%CI 1.02-1.32), p=0.025), morning tiredness (OR 1.22 (95%CI 1.06-1.40), p=0.007), daytime tiredness (OR 1.24 (95%CI 1.06-1.44), p=0.007) and propensity to fall asleep during work or leisure time (OR 1.18 (95%CI 1.01-1.37), p=0.036). Personal crises increased the risk of longer sleep latency (OR 5.46 (95%CI 1.13-26.32), p=0.035) and of propensity to fall asleep when not active (OR 5.41 (95%CI 1.42-20.83), p=0.014). Use of medications affecting the CNS increased the risk of worse general sleep quality (OR 11.44 (95% CI 1.07-121.79), p=0.044). Perceived impaired general health (OR 2.87 (95%CI 1.04-7.94), p=0.043) and frequent night sweats (OR 10.50 (95%CI 2.25-49.01), p=0.003) increased the risk of difficulty falling asleep.

CONCLUSIONS

Various premenopausal health-related factors seem to predict poor sleep in menopausal transition. Menopause itself appears to have only minor effects. Thus, it is essential to identify high-risk women to allow timely interventions that may prevent the development of sleep disturbances at menopause.