Disruption of Sleep Continuity During the Perimenopause: Associations with Female Reproductive Hormone Profiles

Circadian rest-activity rhythms and multimorbidity and mortality risks among menopausal women: a trajectory analysis of a UK Biobank cohort

BACKGROUND

Menopausal women undergo substantial physiological changes that can impact their overall health.

OBJECTIVES

We examined relationships between circadian rest-activity rhythms (CRARs) and multimorbidity progression in this population.

METHODS

We used UK Biobank data, involving 10,138 participants, who were initially free of chronic conditions. We primarily focused on the relative amplitude (RA) of CRARs, tracking incident first chronic conditions (FCC), multimorbidity, and all-cause mortality. Multimorbidity was indicated by the presence of any 2/35 chronic conditions during the follow-up period. We used a multi-state model to assess the RA impact on the multimorbidity progression trajectory, encompassing transition from health to an FCC, to consequent multimorbidity, and ultimately to mortality, in parallel with sensitivity analyses to ensure results stability and reliability.

RESULTS

During a mean 8.13-year follow-up period, we identified 855 incident multimorbidity cases and recorded 88 deaths. In a multi-state model, a lower RA was associated with an increased risk of transition from health to FCC onset [hazard ratio (HR): 1.18, 95% confidence interval (CI): 1.07-1.31] and also from an FCC to multimorbidity development (HR: 1.34, 95% CI: 1.12-1.61), even after adjusting for several confounding factors.

CONCLUSIONS

Among menopausal women, circadian rhythm disturbance increased the risk of transitioning from health to a single chronic condition, as well as transitioning from a single chronic condition to multimorbidity.

Sleep disturbance and menopause

PURPOSE OF REVIEW

Sleep problems are among the most prevalent and bothersome symptoms of menopause. This review characterizes menopausal sleep disturbances, describes biopsychosocial predictors, and summarizes the evidence supporting pharmacological and nonpharmacological treatment options.

RECENT FINDINGS

Recent studies found that sleep changes are early indicators of perimenopause and sought to disentangle the respective impacts of menopausal status, hot flashes (HFs), and changes in reproductive hormones on peri-/postmenopausal sleep problems. Both HFs and reproductive hormones predicted sleep problems, but neither solely accounted for the myriad changes in sleep, thus highlighting the contribution of additional biopsychosocial risk factors. Inconsistencies across studies were likely due to differences in study design and methodology, participants' menopausal stage, and the presence of sleep complaints. Recent studies support the use of psychological (cognitive-behavioral therapy for insomnia) and pharmacological (e.g., neurokinin B antagonists) treatments in addition to hormone therapy.

SUMMARY

Sleep problems are common and of critical import to women during the menopausal transition, significantly influencing treatment preferences and satisfaction. Thus, sleep problems should be routinely assessed from a biopsychosocial perspective and treated with evidence-based interventions throughout menopause. Treatment selection should be based on diagnosis and careful assessment.

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.

Association of Sleep Duration With Serum Estradiol Concentrations Among American Men and Women: Evidence From NHANES 2013-2016

Objective: To evaluate the association between sleep duration with serum estradiol concentrations and its variation by sex and age in American adults. Methods: Data were analyzed for 5406 men and women (≥ 20 years old) who participated in the cycles of the National Health and Nutrition Examination Survey 2013-2016, a cross-sectional study. Total estradiol (pg/mL) was measured and categorized (low, normal, and high) based on the NHANES protocol. Sleep duration was classified as ≤ 6, 6-9, and ≥ 9 h. Weighted multivariable adjusted and multinomial logistic regression models were conducted to assess these associations. Results: Our multivariable multinomial logistic regression analysis revealed no significant associations between sleep duration and serum estradiol concentrations among both American men and women. Specifically, comparisons of sleep durations (≤ 6 and ≥ 9 h) to the reference group (6-9 h) across various age categories showed odds ratios for low and high estradiol concentrations that remained statistically nonsignificant in fully adjusted models. These findings suggest that, unlike previous studies linking sleep duration with variations in other hormones, estradiol concentrations do not appear to be significantly affected by differences in sleep duration in either sex across all age groups studied. Conclusion: The lack of significant associations between sleep duration and serum estradiol concentrations indicates that sleep duration may not influence estradiol levels in the general population of American men and women. These results underscore the importance of continued research into how sleep influences hormonal balance. However, it is important to note that the NHANES data we used are from a cross-sectional study, which cannot establish a causal relationship between sleep duration and serum estradiol. Future studies should investigate additional factors, such as genetic predispositions, lifestyle habits, and environmental influences, that may modulate the relationship between sleep and hormone levels.

Different temporal relationship between sex hormones and sleep status in midlife women: a longitudinal cohort study

Background

Fluctuation in sex hormones and the occurrence of sleep disturbance are 2 major health challenges among midlife women. However, the temporal relationship between them remains unclear.

Methods

This study included 2488 females (mean ± SD age, 49.0 ± 2.70 years) with an average follow-up of 6.95 years. We constructed a composite score by summing items related to sleep problems to reflect the comprehensive sleep status of the participants in the Study of Women's Health Across the Nation. Cross-lagged path analysis was used to examine the temporal relationship between sex hormones and sleep status. Sensitivity analyses were conducted in nonoverweight and overweight groups and adjusted for vasomotor symptoms in the main model.

Aim

In this study, we aimed to examine the temporal relationship between sex hormones and sleep status in midlife women using cross-lagged path analysis.

Outcomes

The primary outcomes included results of the cross-lagged path analysis between sex hormones and sleep status.

Results

After adjusting for age, race, income, menopausal status, body mass index, hormone therapy use, smoking, and drinking, the cross-lagged path coefficients from baseline follicle-stimulating hormone (FSH) and estradiol (E2) to follow-up sleep status were 0.054 (P = .017) and -0.054 (P = .016), respectively. The path coefficient from baseline sleep to follow-up dehydroepiandrosterone sulfate (DHAS) was 0.042 (P = .017). The path coefficients between testosterone and sleep were not statistically significant. In the nonoverweight group, the patterns of the temporal relationship between sex hormones and sleep were the same as the total sample, and the point estimates were larger. However, the temporal relationships in the overweight group were nonsignificant. After adjustment for vasomotor symptoms in the main model, results were basically consistent.

Clinical Implications

Given the temporal relationship between sex hormones and sleep, our findings will provide scientific perspectives to benefit health management in the transition of menopause.

Strengths and Limitations

This study used a longitudinal theoretical model to distinguish the temporal relationship between sex hormones and sleep status in midlife women. Limitations include limited causal evidence in observational studies, unknown confounders, and careful extrapolation.

Conclusion

There were distinct patterns in the unidirectional temporal relationship between (1) FSH, E2, and DHAS and (2) sleep. Changes in FSH and E2 occurred earlier than the change of sleep, while the change of DHAS was later. In contrast, there was no temporal relationship between testosterone and sleep.

Sleep disturbance associated with the menopause

IMPORTANCE AND OBJECTIVES

Sleep disturbance is one of the most common and debilitating symptoms experienced by women during the menopause transition. However, there are currently no therapies specifically approved for sleep disturbance associated with the menopause. Here, we consider how to characterize sleep disturbance associated with the menopause and discuss its etiology, including the latest advances in our understanding of the neuronal circuits that regulate reproduction, body temperature, sleep, and mood; and reflect on its impact on women's health and well-being. We also examine the current treatment landscape and look to the future of treatment for this condition.

METHODS

We conducted a review of the literature and combined this with discussion with experts in the fields of sleep and menopause as well as experiences from our own clinical practices.

DISCUSSION AND CONCLUSIONS

Sleep disturbance associated with the menopause is characterized by frequent night-time awakenings and increased awake time after sleep onset. Its impacts are wide-ranging, negatively affecting health as well as personal and social relationships, productivity, and work performance. There is currently an unmet need for effective, safe, and well-tolerated treatments to address this important symptom, and wider recognition of the association between sleep disturbances and the menopause is needed. Sleep disturbances associated with the menopause can result from hormone changes as well as vasomotor and mood symptoms. Growing research has contributed to our knowledge of the role of hypothalamic estrogen-sensitive kisspeptin/neurokinin B/dynorphin neurons. These neurons are thought to integrate the gonadotropin-releasing hormone pathway and the pathways responsible for the homeostatic control of body temperature and the circadian regulation of sleep-wake cycles. Understanding these neurons offers the potential to create treatments that target a key cause of sleep disturbance associated with the menopause. Further research to understand their etiology and characterize the neuronal circuits responsible could benefit the development of these targeted treatment approaches.

"Not feeling like myself" in perimenopause - what does it mean? Observations from the Women Living Better survey

OBJECTIVE

This study aimed to understand the meaning of the phrase "not feeling like myself" (NFLM) when used by those on the path to menopause by exploring the relationship of symptoms reported to ratings of NFLM.

METHODS

Participants responded to the item "Many women report just not feeling like themselves during this phase of life. How often was this true for you over the past 3 months?" choosing from "none of the time" to "all of the time." They rated bother associated with 61 symptoms and provided demographic information. Individual symptoms and the symptom bother scale scores were correlated with NFLM. Symptom scale scores were then entered in a two-stage multiple regression model to identify symptoms associated significantly with NFLM.

RESULTS

Sixty-three percent (63.3%) of participants reported NFLM 50% of the time or more over the previous 3 months. Individual symptom ratings correlated with NFLM ( r > 0.300) included the following: fatigue ( r = 0.491); feeling overwhelmed/less able to cope ( r = 0.463); low feelings ( r = 0.440); anxiety, more nervousness ( r = 0.398); being irritable ( r = 0.380); harder time concentrating ( r = 0.378); difficulty making decisions ( r = 0.357); feeling like "I can't calm down on the inside" ( r = 0.333); being more forgetful ( r = 0.332); tearfulness/crying ( r = 0.306); and worrying more ( r = 0.302). A two-stage regression analysis revealed less education completed and greater overall stress ratings as significant predictors in stage 1. In stage 2, five symptom groups met the P < 0.001 criterion: anxiety/vigilance, fatigue/pain, brain fog, sexual symptoms, and volatile mood symptoms.

CONCLUSIONS

NFLM was associated with anxiety/vigilance, fatigue/pain, brain fog, sexual symptoms, and volatile mood symptoms. Recognizing symptoms associated with NFLM may allow for more accurate expectations and improve perimenopause care.

Associations of adverse childhood and lifetime experiences with sleep quality and duration among women in midlife

OBJECTIVES

Many women experience sleep problems during midlife. Associations of adverse lifetime experiences-more common among women-with sleep outcomes are understudied.

METHODS

We studied 476 women enrolled in Project Viva 1999-2002. At enrollment, participants reported any lifetime history of abuse and/or financial hardship. At midlife follow-up ∼20 years later, they reported a history of up to 10 adverse childhood experiences (ACEs); 7-day sleep quality (patient-reported outcomes measurement information system sleep disturbance and sleep-related impairment T-scores); and past month average sleep duration. We examined associations of adverse experiences with sleep outcomes, adjusted for childhood sociodemographic variables. We also explored mediation by current depression and anxiety symptoms, hot flash severity, general health, and body mass index.

RESULTS

ACEs were common: 301 women (63%) reported one or more. Each additional ACE was associated with higher midlife sleep disturbance (adjusted β = 0.65 points, 95% confidence interval [CI]: 0.27, 1.02) and sleep-related impairment (0.98, 95% CI: 0.54, 1.41) T-scores, and with sleep duration <6 hour/night (odds ratio 1.19, 95% CI: 1.00, 1.42), but not with continuous sleep duration (-2 minutes, 95% CI: -5, 1). Adverse experiences in adulthood were less consistently associated with sleep quality but were associated with sleep duration, for example, financial hardship during the index pregnancy was associated with 75 minutes (95% CI: -120, -29) shorter sleep duration 2 decades later. Associations of ACEs with sleep disturbance and sleep-related impairment were mediated by midlife depression anxiety and physical health but not by hot flash severity or body mass index.

CONCLUSIONS

Adverse lifetime experiences have deleterious associations with sleep duration and quality in midlife women.

Sleep disturbances in women with early-onset menopausal transition: a population-based study

OBJECTIVE

The aim of this study was to investigate sleep disturbances in 46-yr-old women and their association with early-onset menopausal transition.

METHODS

The women of this cross-sectional birth cohort study were divided into climacteric (n = 359) and preclimacteric (n = 2,302) groups by their menopausal status, defined by follicle-stimulating hormone levels and menstrual history. Sleep disturbances were evaluated with Athens Insomnia Scale 5. We performed univariable and multivariable logistic regression models in which sleep parameters were dependent variables and climacteric status, hot flashes, smoking, and education level were independent variables. The use of hormone therapy was also evaluated in women suffering from sleeping disturbances.

RESULTS

On the basis of the scale questions, climacteric women experienced significantly delayed sleep induction (12.2% vs 8.7%, P = 0.047), more problems with awakenings during the night (23.4% vs 14.6%, P < 0.001), earlier final awakening (13.8% vs 9.9%, P = 0.039), and more unsatisfying sleep quality (11.9% vs 7.9%, P = 0.023). Climacteric women who were experiencing hot flashes reported unsatisfactory sleep quality more frequently compared with climacteric women who did not experience hot flashes (17.0% vs 9.2%, P = 0.047). In the univariable and multivariable logistic regression models, being climacteric was independently associated with different impaired sleeping parameters. Most climacteric women who had a scale score of 4 or greater were not using hormone therapy, according to their medicine purchases over the past year.

CONCLUSIONS

Being climacteric was associated with sleep disturbances in women in their mid-40s. However, this association seemed to be particularly driven by hot flashes. Most climacteric women with clinically significant sleeping disturbances were not using hormone therapy.

Perceived quality of sleep across the menopausal transition: A retrospective cohort study

Background and Aims

To compare sleep quality among naturally and surgically post-menopausal women, and to identify lifestyle factors that predict sleep quality in pre, peri, and postmenopausal women.

Methods

This is a retrospective cohort study of data collected from 429 women who participated in Fels Longitudinal Study data. Sleep quality, based on the Pittsburgh Sleep Quality Index and the Epworth Sleepiness Scale, demographics, medical history, depression, quality of life, and physical activity levels were included in the analysis.

Results

The four study groups did not differ on overall sleep quality with either scale (p = 0.61). Both Post-M groups were more likely to have a major sleep problem than the Peri-M and Pre-M groups (p < 0.001), and to have a history of restless leg syndrome (p = 0.016), but the two Post-M groups did not differ on these problems. Predictors of sleep quality included depression, bodily pain, vitality, and surgical menopause (p<0.001).

Conclusion

Menopause is associated with sleep disrupting conditions. This study did not find any significant differences in sleep quality among the three reproductive stages or for natural versus surgical menopause. Women may benefit from addressing other lifestyle factors associated with poor sleep quality including mental health factors.

Optimizing sleep across the menopausal transition

Women frequently experience sleep disturbances, particularly night-time awakenings, as they transition menopause and enter postmenopause. Sleep is essential for optimal functioning and health. Persistent and distressing sleep disturbances across menopause can negatively impact daytime functioning and productivity, and increase risk for mental and physical health conditions. While multiple factors can disturb sleep, two unique factors in the context of menopause are vasomotor symptoms and the changing reproductive hormone environment. Vasomotor symptoms are associated with sleep disturbances and contribute significantly to awakenings and amount of time spent awake during the night. Even after accounting for vasomotor and depressive symptoms, lower estradiol and higher follicle stimulating hormone levels, indicative of menopause, are associated with sleep disturbance, particularly awakenings, suggesting that the hormone environment may directly affect sleep. Management strategies for clinically significant menopausal sleep disturbances include cognitive behavioral therapy for insomnia, which is effective and durable in treating menopausal insomnia. Hormone therapy alleviates sleep disturbances, particularly in the presence of disruptive vasomotor symptoms. Sleep disturbances have a significant impact on women's functioning and health, and there is a need for further research of the underlying mechanisms to advance effective preventative and treatment strategies that ensure optimal health and well-being of midlife women.