Medroxyprogesterone in postmenopausal females with partial upper airway obstruction during sleep

The Effects of Hormonal Contraceptives on the Sleep of Women of Reproductive Age

Research about the effects of hormonal contraceptives on sleep has been performed but is subjected to important levels of methodological heterogeneity. Hormonal contraceptives impact sleep, but the direction of this association is not clear. Most studies describe a negative sleep profile among contraceptive users, including increased sleepiness, insomnia symptoms, decreased sleep efficiency, and a reduced overall sleep quality. Hormonal intrauterine contraceptives are associated with less negative effects. More research on the field, especially randomized controlled trials, is needed to increase the level and certainty of evidence about the effects of hormonal contraceptives on sleep.

Serum Progesterone Levels in Pregnant Women with Obstructive Sleep Apnea: A Case Control Study

BACKGROUND

Pregnancy is a risk factor for sleep disordered breathing, including obstructive sleep apnea (OSA). Progesterone, one of the key hormones in pregnancy, a known respiratory drive stimulant, increases ventilation and may protect against OSA. We aimed to examine the relationship between circulating progesterone and OSA, after accounting for body weight and gestational age.

METHODS

A case control study was conducted of pregnant women with OSA and those at low risk for the disorder. Cases were identified by ICD-9 code and review of medical record. Controls were identified if they scored zero (never) for snoring, apnea, and gasping on the multivariable apnea prediction index questionnaire immediately following delivery. Subjects with available stored first and/or second trimester residual serum samples were then included in this study and serum analyzed for progesterone. Raw progesterone levels were adjusted for the effects of gestational age and maternal weight.

RESULTS

Twenty-seven cases and 64 controls with available serum were identified. Women with OSA had greater maternal weight and higher rates of related comorbidities, compared to controls. Progesterone levels correlated positively with gestational age and negatively with greater weight. Progesterone levels, adjusted for gestational age and maternal weight and expressed as multiples of median (MoM), were significantly lower in OSA cases compared to controls in both the first trimester (MoM = 0.71, confidence interval [95% CI] 0.60-0.83) relative to the MoM in controls of 1.00. In the second trimester levels were also lower in OSA cases (MoM = 0.84, 95% CI 0.73-0.96) compared to the MoM of 1.00 in controls.

CONCLUSIONS

Progesterone levels, after accounting for weight and gestational age, were lower in women with OSA than controls. Progesterone may play a protective role against OSA.

Short-term medroxyprogesterone acetate in postmenopausal women with sleep-disordered breathing: a placebo-controlled, randomized, double-blind, parallel-group study

OBJECTIVE

Menopause predisposes women to sleep-disordered breathing (SDB) and sleep disturbances. Progestin has a potential to stimulate breathing and to induce sleep. Our goal was to test these effects objectively and to compare them with the effects of nasal continuous positive airway pressure (CPAP), which is the standard treatment of SDB.

METHODS

In a placebo-controlled, double-blind, parallel-group trial, we investigated 34 postmenopausal women (17 in the placebo group and 17 in the medroxyprogesterone acetate [MPA] group) whose SDB had been treated with nasal CPAP for 6 months to 8 years prior to study entry. The 6-week trial included measurements with CPAP at baseline, after 14 days of placebo or MPA (60 mg daily), and after a 3-week washout. The participants discontinued their nasal CPAP therapy 1 week after baseline measurements and went on with study medication.

RESULTS

Two weeks after discontinuation of CPAP therapy, nightly oxygen saturation was sustained higher (P = 0.004) and arterial carbon dioxide tension was lower (P < 0.001) with MPA than with placebo. Carbon dioxide was also lower than during CPAP (P < 0.001), and this effect was sustained beyond 3 weeks after the cessation of MPA (P < 0.001). However, the apnea-hypopnea index of CPAP increased and sleep deteriorated similarly on MPA and placebo after withdrawal of CPAP therapy.

CONCLUSIONS

In postmenopausal women with SDB, MPA induces a long-lasting stimulatory effect on breathing without improving sleep quality or the apnea-hypopnea index.

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.

Obstructive sleep apnea in older adults

The "typical" presentation of obstructive sleep apnea (OSA) is chronic loud snoring and excessive daytime sleepiness in middle-aged obese men. OSA can result in increased risk for cardiovascular morbidity and mortality. The diagnostic features of OSA in older adults are similar to those in younger adults; however, the older adult may be less likely to seek medical attention or have the sleep disorder recognized because symptoms of snoring, sleepiness, fatigue, nocturia, unintentional napping, and cognitive dysfunction may be ascribed to the aging process itself or to other disorders. This article reviews the basic terminology and pathophysiology of sleep-disordered breathing, discusses why OSA may be even more prevalent in older adults than in the middle-aged group, and reviews similarities and differences between the two groups in the manifestations, consequences, and treatments of OSA.

Sleep apnea in the elderly: a specific entity?

Sleep apnea is highly prevalent in subjects after age 60, and affects older men and women similarly. Central apneas are often observed in addition to obstructive and mixed events. Pathogenesis of obstructive and central events during sleep in the elderly can be attributed to an amplification of well-established causes of sleep-disordered breathing (SDB) in younger adults. As in middle-aged adults, sleep-related complaints, cardiovascular diseases, depression and traffic accidents should prompt an evaluation by a sleep specialist. However, secondary enuresis and nocturia, cognitive impairment, ophthalmic conditions and repeated falls may be the main complaint in elderly subjects. Sleep studies in the elderly should systematically include reliable means to detect central apneas and periodic leg movements. Untreated SDB in the elderly appears to have a lesser impact on mortality than in middle-aged adults. However, the typical morbidity associated with the disorder in younger adults is observed in the elderly. Elderly symptomatic SDB patients tolerate CPAP no differently than younger patients and should be effectively treated. In conclusion, whether sleep apnea in the elderly represents a specific entity or the same disease as in younger subjects, with some distinctive features, is still unclear. Further research, in particular focusing on the impact of age on SDB outcomes, is needed.

Menopausal estrogen therapy predicts better nocturnal oxyhemoglobin saturation

OBJECTIVES

The respiratory responses in the few previous studies evaluating the effects of short-term unopposed estrogen therapy on breathing in postmenopausal women have been inconsistent. We performed a study to investigate whether long-term estrogen therapy would prevent age-related decline in nocturnal arterial oxyhemoglobin saturation and whether higher serum estradiol concentration is associated with better arterial oxyhemoglobin saturation.

METHODS

Sixty-four healthy postmenopausal women were followed-up for 5 years in a 5-year prospective open follow-up study. The women were users or non-users of estrogen therapy according to their personal preference.

RESULTS

Mean overnight arterial oxyhemoglobin saturation was similar at baseline (94.3 +/- 1.1%) and after follow-up (94.5 +/- 1.6%). Present estrogen users had higher mean arterial oxyhemoglobin saturation (95.2 +/- 1.4%) than present non-users (94.0 +/- 1.5%), when adjusted for age and body mass index (p = 0.042). The change in mean arterial oxyhemoglobin saturation during follow-up was not associated with serum estradiol concentration at baseline but associated with estradiol at follow-up (p = 0.042), when adjusted for age and body mass index. At follow-up, women with higher serum estradiol concentration had also higher mean nocturnal arterial oxyhemoglobin saturation (Pearson r = 0.29, p = 0.019) and lower apnea-hypopnea index (Spearman r = -0.28, p = 0.031). The pooled current estrogen users spent proportionally less time with SaO(2) below 90% than non-users (ANCOVA adjusted for age and BMI, p = 0.017).

CONCLUSIONS

Estrogen use and especially high serum estradiol concentration predict higher mean overnight arterial oxyhemoglobin saturation. The present data suggest that estrogen therapy has favorable respiratory effects.

Sleep, breathing, and menopause: the effect of fluctuating estrogen and progesterone on sleep and breathing in women

BACKGROUND

Sleep-disordered breathing (SDB), such as obstructive sleep apnea (OSA), is more common in men than in women. However, menopause increases the risk for development of OSA. Administration of estrogen and progesterone to postmenopausal women with OSA decreases apnea and hypopnea during sleep.

OBJECTIVE

Because beneficial changes can be observed soon after administration of a short course of hormones, we hypothesized that suppression of these hormones would rapidly result in the development of SDB.

METHODS

Production of sex hormones was suppressed with daily administration of leuprolide acetate (LA), a gonadotropin-releasing hormone analogue, for 5 weeks in women who were participating in a study on pharmacologically induced menopause and physiology. The subjects underwent polysomnographic evaluation at baseline and after 5 weeks of LA administration.

RESULTS

In the 12 healthy women aged 18 to 34 years who participated in the study, sleep architecture and respiration were normal at baseline. After LA administration, the subjects stopped their menses, and their plasma concentrations of l7beta-estradiol (preadministration, mean [SD] 33.9 [9.0] pg/mL; post administration, 10.2 [3.4] pg/mL) and progesterone (preadministration, 0.48 [0.05] ng/mL; post administration, 0.40 [0.06] ng/mL) reached menopausal levels. Sex hormone deficiency was associated with climacteric vasomotor symptoms such as hot flashes and sweating. Sleep latencies and architecture did not change significantly with LA administration. The participants subjectively noticed some increased snoring that was not confirmed by polysomnogram. Specifically, there was no change in arousal index and no evidence for sleep fragmentation to suggest the presence of increased upper-airway resistance during sleep. The apnea-hypopnea index, 0.07 (0.02) to 0.22 (0.11) events per hour of sleep, did not change with sex hormone deficiency.

CONCLUSIONS

In this study, sex hormone deficiency in young women resulted in climacteric symptoms and cessation of menses, and was not associated with sleep fragmentation or clinically significant SDB.

Non-invasive respiratory monitoring during wakefulness and sleep in pre- and postmenopausal women

Menopause and aging cause hormonal changes with respiratory consequences. The aim of the present study was to investigate the physiological changes in respiration during wakefulness and sleep across menopause in non-patient population using non-invasive measurements of blood and tissue gases. The arterial oxyhemoglobin saturation (SaO2), heart rate, end-tidal partial carbon dioxide tension (EtCO2) and transcutaneous partial carbon dioxide tension (TcCO2) were measured during wakefulness and sleep in thirteen pairs of BMI-matched pre- and postmenopausal women. Postmenopausal women had lower SaO2 during sleep than during wakefulness, whereas premenopausal women maintained their wakefulness SaO2 levels also during sleep. EtCO2 levels did not change either between wakefulness and sleep or between premenopausal and postmenopausal groups. TcCO2 levels increased from wakefulness to sleep in both groups and the increase was greater in the postmenopausal group. The impact of sleep on the non-invasive measurements of blood and tissue gases is stronger in postmenopausal women.

Medroxyprogesterone improves nocturnal breathing in postmenopausal women with chronic obstructive pulmonary disease

BACKGROUND

Progestins as respiratory stimulants in chronic obstructive pulmonary disease (COPD) have been investigated in males and during wakefulness. However, sleep and gender may influence therapeutic responses. We investigated the effects of a 2-week medroxyprogesterone acetate (MPA) therapy on sleep and nocturnal breathing in postmenopausal women.

METHODS

A single-blind placebo-controlled trial was performed in 15 postmenopausal women with moderate to severe COPD. A 12-week trial included 2-week treatment periods with placebo and MPA (60 mg/d/14 days). All patients underwent a polysomnography with monitoring of SaO2 and transcutaneous PCO2 (tcCO2) at baseline, with placebo, with medroxyprogesterone acetate (MPA 60 mg/d/14 days), and three and six weeks after cessation of MPA.

RESULTS

Thirteen patients completed the trial. At baseline, the average +/- SD of SaO2 mean was 90.6 +/- 3.2 % and the median of SaO2 nadir 84.8 % (interquartile range, IQR 6.1). MPA improved them by 1.7 +/- 1.6 %-units (95 % confidence interval (CI) 0.56, 2.8) and by 3.9 %-units (IQR 4.9; 95% CI 0.24, 10.2), respectively. The average of tcCO2 median was 6.0 +/- 0.9 kPa and decreased with MPA by 0.9 +/- 0.5 kPa (95% CI -1.3, -0.54). MPA improved SaO2 nadir and tcCO2 median also during REM sleep. Three weeks after cessation of MPA, the SaO2 mean remained 1.4 +/- 1.8 %-units higher than at baseline, the difference being not significant (95% CI -0.03, 2.8). SaO2 nadir was 2.7 %-units (IQR 4.9; 95% CI 0.06, 18.7) higher than at baseline. Increases in SaO2 mean and SaO2 nadir during sleep with MPA were inversely associated with baseline SaO2 mean (r = -0.70, p = 0.032) and baseline SaO2 nadir (r = -0.77, p = 0.008), respectively. Treatment response in SaO2 mean, SaO2 nadir and tcCO2 levels did not associate with pack-years smoked, age, BMI, spirometric results or sleep variables.

CONCLUSION

MPA-induced respiratory improvement in postmenopausal women seems to be consistent and prolonged. The improvement was greater in patients with lower baseline SaO2 values. Long-term studies in females are warranted.

Neuroendocrine changes in sleep apnea

PURPOSE OF REVIEW

To review recent investigations examining the effects of neuroendocrine changes in obstructive sleep apnea.

RECENT FINDINGS

Gonadal hormones have long been implicated in the pathogenesis of obstructive sleep apnea. Recently, exogenous testosterone has been shown to exacerbate obstructive sleep apnea, whereas hormone replacement therapy in menopausal women may be protective in obstructive sleep apnea. Effective treatment of obstructive sleep apnea with nasal continuous positive airway pressure has been associated with improved insulin sensitivity and testicular function in individuals with obstructive sleep apnea.

SUMMARY

It is important to consider the potential development of sleep apnea in any patient who has an endocrine disorder or is receiving certain hormonal therapies. Effective assessment and management of obstructive sleep apnea with nasal continuous positive airway pressure may lead to a reduction in insulin resistance and hypertension as well as other markers of vascular risk in patients with metabolic syndrome.

Medroxyprogesterone improves cardiac autonomic control in postmenopausal women with respiratory insufficiency

OBJECTIVE

To study the effect of medroxyprogesterone acetate (MPA) on autonomic cardiac control in respiratory insufficiency in postmenopausal women.

DESIGN

A prospective, single-blind study.

SUBJECTS

Eighteen postmenopausal women with respiratory insufficiency and eight asymptomatic postmenopausal women with nocturnal hypoxaemia as controls.

METHODS

Oral MPA treatment was given at 30 mg twice daily for 2 weeks. All-night polysomnography including a two-channel electroencephalogram, an electro-oculogram, an electromyogram, an electrocardiogram, arterial oxyhaemoglobin saturation, maximum end-tidal CO2 partial pressure, a ballistocardiogram and breathing movements were recorded at baseline and at the end of MPA treatment. Heart rate variability (HRV) was calculated in time and frequency domains during various sleep stages on and off MPA, and the results were correlated to respiratory variables.

RESULTS

At baseline, patients had higher heart rate and lower HRV than controls, suggesting increased cardiac sympathetic output. MPA increased HRV in patients, but not in controls. End-tidal CO2 partial pressure decreased, and respiratory rate increased during treatment in both groups.

CONCLUSIONS

HRV is compromised in women with respiratory insufficiency. Peroral MPA increases their HRV to levels comparable with those in controls. This suggests an improvement in vagal cardiac control beneficial to cardiovascular health.

Long-term progestin therapy for female chronic respiratory insufficiency?

End-stage chronic obstructive pulmonary disease often leads to hypercapnic respiratory failure. Oxygen supplementation therapy may further aggravate hypercapnia and not all patients are compliant with non-invasive ventilation. This case documents successful control of chronic respiratory failure with medroxyprogesterone in a postmenopausal woman during 1-year follow-up.

Menopausal status and sleep-disordered breathing in the Wisconsin Sleep Cohort Study

Menopause is considered to be a risk factor for sleep-disordered breathing, but this hypothesis has not been adequately tested. The association of premenopause, perimenopause, and postmenopause with sleep-disordered breathing was investigated with a population-based sample of 589 women enrolled in the Wisconsin Sleep Cohort Study. Menopausal status was determined from menstrual history, gynecologic surgery, hormone replacement therapy, follicle-stimulating hormone, and vasomotor symptoms. Sleep-disordered breathing was indicated by the frequency of apnea and hypopnea events per hour of sleep, measured by in-laboratory polysomnography. Multivariable logistic regression was used to estimate odds ratios for having 5 or more and 15 or more apnea and hypopnea events per hour. Odds ratios (95% confidence interval), adjusted for age, body habitus, smoking, and other potential confounding factors, for 5 or more apnea and hypopnea events per hour were 1.2 (0.7, 2.2) with perimenopause and 2.6 (1.4, 4.8) with postmenopause; odds ratios for 15 or more apnea and hypopnea events per hour were 1.1 (0.5, 2.2) with perimenopause and 3.5 (1.4, 8.8) with postmenopause. The menopausal transition is significantly associated with an increased likelihood of having sleep-disordered breathing, independent of known confounding factors. Evaluation for sleep-disordered breathing should be a priority for menopausal women with complaints of snoring, daytime sleepiness, or unsatisfactory sleep.

Effect of medroxyprogesterone on inspiratory flow shapes during sleep in postmenopausal women

We previously showed that medroxyprogesterone acetate (MPA) effectively decreases the arterial CO(2) levels in postmenopausal women with partial upper airway obstruction. The aim of the present study was to analyze the effects of MPA on the inspiratory flow shapes during sleep. Eight postmenopausal women with hypoxemia and partial upper airway obstruction during sleep (patients) received MPA 60 mg daily for 14 days. Four matched postmenopausal women without MPA treatment served as controls. Sleep and nasal pressure were recorded on each visit. Each breath was analyzed for duration, volume and inspiratory flow shape class. MPA shortened inspiration and prolonged expiration. The inspiratory volumes increased consistently in all flow shape classes. The inspiratory shapes with single late peak were transformed to those with double peak. MPA also decreased shapes with mid-peak or mid-plateau. MPA did not have an effect on sleep. Sleep modified the flow shape distribution only in patients but in a similar fashion in stages S2, SWS and REM. The results suggest that postmenopausal women present with a significant proportion breaths with poor initial inspiratory flow, which is reversed with MPA-induced respiratory stimulation.

Hormones and breathing

A number of hormones, including hypothalamic neuropeptides acting as neurotransmitters and neuromodulators in the CNS, are involved in the physiologic regulation of breathing and participate in adjustment of breathing in disease. In addition to central effects, some hormones also control breathing at peripheral chemoreceptors or have local effects on the lungs and airways. Estrogen and progesterone seem to protect from sleep-disordered breathing, whereas testosterone may predispose to it. Progesterone and thyroxine have long been known to stimulate respiration. More recently, several hormones such as corticotropin-releasing hormone and leptin have been suggested to act as respiratory stimulants. Somatostatin, dopamine, and neuropeptide Y have a depressing effect on breathing. Animal models and experimental human studies suggest that also many other hormones may be involved in respiratory control.

Medroxyprogesterone-induced endocrine alterations after menopause

OBJECTIVE

To evaluate endocrine responses to short-term medroxyprogesterone acetate (MPA) administered as a respiratory stimulant in postmenopausal women with mild nocturnal hypoxemia.

DESIGN

Open-label trial with 14-day MPA (60 mg daily) and 3-week follow-up posttreatment. Serum concentrations of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, progesterone, and insulin-like growth factor-I (IGF-I) were assessed at baseline, while on MPA and at the 3-week washout in eight subjects.

RESULTS

With MPA, FSH decreased by 47.5% (p < 0.01) and LH by 64.9% (p < 0.001), whereas IGF-I increased by 39.6% (p < 0.01). FSH and LH remained suppressed at the 3-week washout (-23.8%, p < 0.05 and -44.3%, p < 0.01, respectively). IGF-I returned to pretreatment level at the 3-week washout. Neither serum estradiol nor progesterone concentrations changed during or after progestogen therapy.

CONCLUSIONS

Daily administration of MPA (60 mg) for 2 weeks has both immediate (FSH, LH and IGF-I) and sustained (FSH, LH) effects up to 3 weeks after treatment. Therefore, prolonged MPA-induced effects should be taken into account when interpreting hormone assessments after progestogen therapy.