We here review principal literature data about sleep disorders in menopause and we compared it with data obtained from a systematical screening of a sample of 161 menopausal women through questionnaires and clinical evaluation. Our data reveal high occurrence of sleep disorders in this group of women if compared to literature data about general population, in the absence of statistically significant differences among the three menopausal stages: we find only a trend toward a higher risk of OSAS (Obstructive Sleep Apnea Syndrome) in PM versus early PM and MT. However, none of women in our survey underwent PSG (polysomnography), essential to confirm the diagnosis of OSAS and none was diagnosed with RLS (Restless Legs Syndrome) (prior to our survey) by the Gynecologist or General Pratictioner: these data reveal the issue of too low attention towards sleep disorders in this contest. Generic “sleep complaints” are clearly associated with depressed mood and worse-quality life along the menopausal process. In our sample, a non-specific definition of insomnia shows a peculiar relationship with a mood disorder: it is only variable not associated with higher BDI and KI scores, in fact. This might suggest that the conditions linked to depression of these women could be more specific sleep disturbances, such as RLS and OSAS.
KeywordsMenopauseSleep DisordersMenopausal StagesRestless Legs SyndromeObstructive Sleep Apnea Syndrome
Cappuccio, F.P., Cooper, D., D’Elia, L., et al. (2011) Sleep Duration Predicts Cardiovascular Outcomes: A Systematic Review and Meta-Analysis of Prospective Studies. European Heart Journal, 32, 1484-1492. https://doi.org/10.1093/eurheartj/ehr007
Ohayon, M.M., Carskadon, M.A., Guilleminault, C., et al. (2004) Meta-Analysis of Quantitative Sleep Parameters from Childhood to Old Age in Healthy Individuals: Developing Normative Sleep Values across the Human Lifespan. Sleep, 27, 1255-1273. https://doi.org/10.1093/sleep/27.7.1255
Harlow, S.D., Gass, M., Hall, J.E., et al. (2012) Executive Summary of the Stages of Reproductive Aging Workshop +10: Addressing the Unfinished Agenda of Staging Reproductive Aging. Menopause, 19, 387-395. https://doi.org/10.1097/gme.0b013e31824d8f40
Lindberg, E., Janson, C., Gislason, T., et al. (1997) Sleep Disturbances in a Young Adult Population: Can Gender Differences Be Explained by Differences in Psychological Status. Sleep, 20, 381-387. https://doi.org/10.1093/sleep/20.6.381
Joffe, H., Massler, A. and Sharkey, K.M. (2010) Evaluation and Management of Sleep Disturbance during the Menopause Transition. Seminars in Reproductive Medicine, 28, 404-421. https://doi.org/10.1055/s-0030-1262900
Woods, N.F. and Mitchell, E.S. (2010) Sleep Symptoms during the Menopausal Transition and Early Postmenopause: Observations from the Seattle Midlife Women’s Health Study. Sleep, 33, 539-549. https://doi.org/10.1093/sleep/33.4.539
Shin, C., Lee, S., Lee, T., et al. (2005) Prevalence of Insomnia and Its Relationship to Menopausal Status in Middle-Aged Korean Women. Psychiatry and Clinical Neurosciences, 59, 395-402. https://doi.org/10.1111/j.1440-1819.2005.01391.x
Cheng, M.H., Hsu, C.Y., Wang, S.J., et al. (2008) The Relationship of Self-Reported Sleep Disturbance, Mood, and Menopause in a Community Study. Menopause, 15, 958-962. https://doi.org/10.1097/gme.0b013e318160dafa
Hachul, H., Bittencourt, L.R., Soares, J.M., et al. (2009) Sleep in Post-Menopausal Women: Differences between Early and Late Post-Menopause. European Journal of Obstetrics and Gynecology and Reproductive Biology, 145, 81-84. https://doi.org/10.1016/j.ejogrb.2009.03.019
Freedman, R.R. and Roehrs, T.A. (2004) Lack of Sleep Disturbance from Menopausal Hot Flashes. Fertility and Sterility, 82, 138-144. https://doi.org/10.1016/j.fertnstert.2003.12.029
Xu, M., Bélanger, L., Ivers, H., et al. (2011) Comparison of Subjective and Objective Sleep Quality in Menopausal and Non-Menopausal Women with Insomnia. Sleep Medicine, 12, 65-69. https://doi.org/10.1016/j.sleep.2010.09.003
Kalleinen, N., Polo-Kantola, P., Himanen, S.L., et al. (2008) Sleep and the Menopause—Do Postmenopausal Women Experience Worse Sleep than Premenopausal Women? Menopause International, 14, 97-104. https://doi.org/10.1258/mi.2008.008013
Lampio, L., Saaresranta, T., Engblom, J., et al. (2016) Predictors of Sleep Disturbance in Menopausal Transition. Maturitas, 94, 137-142. https://doi.org/10.1016/j.maturitas.2016.10.004
Woodward, S. and Freedman, R.R. (1994) The Thermoregulatory Effects of Menopausal Hot Flashes on Sleep. Sleep, 17, 497-501. https://doi.org/10.1093/sleep/17.6.497
Toffol, E., Kalleinen, N., Urrila, A.S., et al. (2014) The Relationship between Mood and Sleep in Different Female Reproductive States. BMC Psychiatry, 14, 177. https://doi.org/10.1186/1471-244X-14-177
Freedman, R.R., Norton, D., Woodward, S., et al. (1995) Core Body Temperature and Circadian Rhythm of Hot Flashes in Menopausal Women. The Journal of Clinical Endocrinology & Metabolism, 80, 2354-2358. https://doi.org/10.1210/jcem.80.8.7629229
Freedman, R.R and Krell, W. (1999) Reduced Thermoregulatory Null Zone in Postmenopausal Women with Hot Flashes. American Journal of Obstetrics & Gynecology, 181, 66-70. https://doi.org/10.1016/S0002-9378(99)70437-0
Freeman, E.W. and Sherif, K. (2007) Prevalence of Hot Flushes and Night Sweats around the World: A Systematic Review. Climacteric, 10, 197-214. https://doi.org/10.1080/13697130601181486
Gartoulla, P., Islam, M.R., Bell, R.J. and Davis, S.R. (2014) Prevalence of Menopausal Symptoms in Australian Women at Midlife: A Systematic Review. Climacteric, 17, 529-539. https://doi.org/10.3109/13697137.2013.865721
Nelson, H., Haney, E., Humphreyet, L., et al. (2005) Management of Menopause-Related Symptoms. Evidence Report/Technology Assessment 120, Agency for Healthcare Research and Quality, Rockville, MD.
Koster, A., Eplov, L.F., Garde, K., et al. (2002) Anticipations and Experiences of menopause in a Danish Female General Population Cohort Born in 1936. Archives of Women’s Mental Health, 5, 9-13. https://doi.org/10.1007/s007370200017
Joffe, H., Crawford, S., Economou, N., et al. (2013) A Gonadotropin-Releasing Hormone Agonist Model Demonstrates that Nocturnal Hot Flashes Interrupt Objective Sleep. Sleep, 36, 1977-1985. https://doi.org/10.5665/sleep.3244
Ensrud, K.E., Stone, K.L., Blackwell, T.L., et al. (2009) Frequency and Severity of Hot Flashes and Sleep Disturbance in Postmenopausal Women with Hot Flashes. Menopause, 16, 286-292. https://doi.org/10.1097/gme.0b013e31818c0485
Joffe, H., White, D.P., Crawford, S.L., et al. (2013) Adverse Effects of Induced Hot Flashes on Objectively Recorded and Subjectively Reported Sleep: Results of a Gonadotropin-Releasing Hormone Agonist Experimental Protocol. Menopause, 20, 905-914. https://doi.org/10.1097/GME.0b013e31828292d1
Freedman, R.R. and Roehrs, T.A. (2006) Effects of REM Sleep and Ambient Temperature on Hot Flash-Induced Sleep Disturbance. Menopause, 13, 576-583. https://doi.org/10.1097/01.gme.0000227398.53192.bc
de Zambotti, M., Colrain, I.M., Javitz, H.S. and Baker, F.C. (2014) Magnitude of the Impact of Hot Flashes on Sleep in Perimenopausal Women. Fertility and Sterility, 102, 1708-1715. https://doi.org/10.1016/j.fertnstert.2014.08.016
Lentz, M.J., Landis, C.A., Rothermel, J. and Shaver, J.L. (1999) Effects of Selective Slow Wave Sleep Disruption on Musculoskeletal Pain and Fatigue in Middle Aged Women. The Journal of Rheumatology, 26, 1586-1592.
Ohayon, M.M. (2006) Severe Hot Flashes are Associated with Chronic Insomnia. Archives of Internal Medicine, 166, 1262-1268. https://doi.org/10.1001/archinte.166.12.1262
Steinberg, E.M., Rubinow, D.R., Bartko, J.J., et al. (2008) A Cross-Sectional Evaluation of Perimenopausal Depression. The Journal of Clinical Psychiatry, 69, 973-980. https://doi.org/10.4088/JCP.v69n0614
Bromberger, J.T. and Kravitz, H.M. (2011) Mood and Menopause: Findings from the Study of Women’s Health across the Nation (SWAN) over 10 Years. Obstetrics and Gynecology Clinics of North America, 38, 609-625. https://doi.org/10.1016/j.ogc.2011.05.011
Bromberger, J.T., Matthews, K.A., Schott, L.L., et al. (2007) Depressive Symptoms during the Menopausal Transition: The Study of Women’s Health across the Nation (SWAN). Journal of Affective Disorders, 103, 267-272. https://doi.org/10.1016/j.jad.2007.01.034
Soares, C.N. (2014) Mood Disorders in Midlife Women: Understanding the Critical Window and its Clinical Implications. Menopause, 21, 198-206. https://doi.org/10.1097/GME.0000000000000193
Sivertsen, B., Salo, P., Mykletun, A., et al. (2012) The Bidirectional Association between Depression and Insomnia: the HUNT Study. Psychosomatic Medicine, 7, 758-765. https://doi.org/10.1097/PSY.0b013e3182648619
Riemann, D. (2007) Insomnia and Comorbid Psychiatric Disorders. Sleep Medicine, 4, 15-20. https://doi.org/10.1016/S1389-9457(08)70004-2
Moe, K.E. (2004) Hot Flashes and Sleep in Women. Sleep Medicine Reviews, 8, 487-497. https://doi.org/10.1016/j.smrv.2004.07.005
Joffe, H., Soares, C.N., Thurston, R.C., et al. (2009) Depression Is Associated with Worse Objectively and Subjectively Measured Sleep, but Not More Frequent Awakenings, in Women with Vasomotor Symptoms. Menopause, 16, 671-679. https://doi.org/10.1097/gme.0b013e3181957377
Terashima, K., Mikami, A., Tachibana, N., Kumano-Go, T., et al. (2004) Sleep Characteristics of Menopausal Insomnia: A Polysomnographic Study. Psychiatry and Clinical Neurosciences, 58, 179-185. https://doi.org/10.1111/j.1440-1819.2003.01214.x
Allen, R.P., Walters, A.S., Montplaisir, J., et al. (2005) Restless Legs Syndrome Prevalence and Impact: REST General Population Study. Archives of Internal Medicine, 165, 1286-1292. https://doi.org/10.1001/archinte.165.11.1286
Earley, C.J., Connor, J.R., Beard, J.L., et al. (2000) Abnormalities in CSF Concentrations of Ferritin and Transferrin in Restless Legs Syndrome. Neurology, 54, 1698-1700. https://doi.org/10.1212/WNL.54.8.1698
Gigli, G.L., Adorati, M., Dolso, P., et al. (2004) Restless Legs Syndrome in End-Stage Renal Disease. Sleep Medicine, 5, 309-315. https://doi.org/10.1016/j.sleep.2004.01.014
Merlino, G., Fratticci, L., Valente, M., et al. (2007) Association of Restless Legs Syndrome in Type 2 Diabetes: A Case-Control Study. Sleep, 30, 866-871. https://doi.org/10.1093/sleep/30.7.866
Kenzedrsa,T., Kamra, M., Murray, B.J., et al. (2017) Incident Cardiovascular Events and Death in Individuals With Restless Legs Syndrome or Periodic Limb Movements in Sleep: A Systematic Review. Sleep, 40, zsx013. https://doi.org/10.1093/sleep/zsx013
Katsanos, A.H., Kosmidou, M., Konitsiotis, S., et al. (2017) Restless Legs Syndrome and Cerebrovascular/Cardiovascular Events: Systematic Review and Meta-Analysis. Acta Neurologica Scandinavica, 137, 142-148. https://doi.org/10.1111/ane.12848
Allen, R.P. (2015) Restless Leg Syndrome/Willis-Ekbom Disease Pathophysiology. Sleep Medicine Clinics, 10, 207-214. https://doi.org/10.1016/j.jsmc.2015.05.022
Khan, F.H., Ahlberg, C.D., Chow, C.A., et al. (2017) Iron, Dopamine, Genetics, and Hormones in the Pathophysiology of Restless Legs Syndrome. Journal of Neurology, 264, 1634-1641. https://doi.org/10.1007/s00415-017-8431-1
Connor, J.R., Ponnuru, P., Wang, X.S., et al. (2011) Profile of Altered Brain Iron Acquisition in Restless Legs Syndrome. Brain, 134, 959-968. https://doi.org/10.1093/brain/awr012
Wesstrom J, Nilsson S, Sundstrom-Poromaa I, et al. (2008) Restless Legs Syndrome among Women: Prevalence, Co-Morbidity and Possible Relationship to Menopause. Climacteric, 11, 422-428. https://doi.org/10.1080/13697130802359683
Dzaja, A., Wehrle, R., Lancel, M. and Pollmächer, T. (2009) Elevated Estradiol Plasma Levels in Women with Restless Legs during Pregnancy. Sleep, 32, 169-174. https://doi.org/10.1093/sleep/32.2.169
Ghorayeb, I., Bioulac, B., Scribans, C., et al. (2008) Perceived Severity of Restless Legs Syndrome across the Female Life Cycle. Sleep Medicine, 9, 799-802. https://doi.org/10.1016/j.sleep.2007.07.018
Fabbrini, M., AricÃ, I., Tramonti, F., et al. (2015) Sleep Disorders in Menopause: Results from an Italian Multicentric Study. Archives Italiennes de Biologie, 153, 204-213.
Nichols, D.A., Allen, R.P., Grauke, J.H., et al. (2003) Restless Legs Syndrome Symptoms in Primary Care: A Prevalence Study. Archives of Internal Medicine, 163, 2323-2329. https://doi.org/10.1001/archinte.163.19.2323
Marin, J.M., Carrizo, S.J., Vicente, E., et al. (2005) Long-Term Cardiovascular Outcomes in Men with Obstructive Sleep Apnoea-Hypopnoea with or without Treatment with Continuous Positive Airway Pressure: An Observational Study. The Lancet, 365, 1046-1053.
Hall, M.H., Kline, C.E. and Nowakowski, S. (2015) Insomnia and Sleep Apnea in Midlife Women: Prevalence and Consequences to Health and Functioning. Prime Reports, 7, 63. https://doi.org/10.12703/P7-63
Orth, M., Kotterba, S., Rasche, K., et al. (2007) Sleep Apnoea in Women? The Forgotten Gender. Pneumologie, 61, 725-729. https://doi.org/10.1055/s-2007-980128
Jehan, S., Masters-Isarilov, A., Salifu, I., et al. (2015) Sleep Disorders in Postmenopausal Women. Journal of Sleep Disorders and Therapy, 4, Article ID: 1000212.
Koo, S.K., Ahn, G.Y., Cho, J.W., et al. (2017) Obstructive Sleep Apnea in Postmenopausal Women: A Comparative Study Using Drug Induced sleep Endoscopy. Brazilian Journal of Otorhinolaryngology, 83, 285-291. https://doi.org/10.1016/j.bjorl.2016.03.011
Liu, Y.-H., Huang, Y. and Shao, X. (2009) Effects of Estrogen on Genioglossal Muscle Contractile Properties and Fiber-Type Distribution in Chronic Intermittent Hypoxia Rats. European Journal of Oral Sciences, 117, 685-690. https://doi.org/10.1111/j.1600-0722.2009.00681.x
Preston, M.E., Jensen, D., Janssen, I. and Fisher, J.T. (2009) Effect of Menopause on the Chemical Control of Breathing and Its Relationship with Acid-Base Status. American Journal of Physiology-Regulatory, Integrative and Comparative Physiology, 296, R722-R727. https://doi.org/10.1152/ajpregu.90865.2008
Bixler, E.O., Vgontzas, A.N, Lin, H.-M., et al. (2001) Prevalence of Sleep-Disordered Breathing in Women: Effects of Gender. American Journal of Respiratory and Critical Care Medicine, 163, 608-613. https://doi.org/10.1164/ajrccm.163.3.9911064
Shahar, E., Redline, S., Young, T., et al. (2003) Hormone Replacement Therapy and Sleep-Disordered Breathing. American Journal of Respiratory and Critical Care Medicine, 167, 1186-1192. https://doi.org/10.1164/rccm.200210-1238OC
Polo-Kantola, P. (2008) Dealing with Menopausal Sleep Disturbances. Sleep Medicine Clinics, 3, 121-131. https://doi.org/10.1016/j.jsmc.2007.10.006
Manber, R. and Armitage, R. (1999) Sex, Steroids and Sleep: A Review. Sleep, 22, 540-555.
Friess, E., Tagaya, H., Trachsel, L., Holsboer, F. and Rupprecht, R. (1997) Progesterone-Induced Changes in Sleep in Male Subjects. American Journal of Physiology-Endocrinology and Metabolism, 272, E885-E891. https://doi.org/10.1152/ajpendo.1997.272.5.E885
Savolainen-Peltonen, H., Hautamäki, H., Tuomikoski, P., et al. (2014) Health-Related Quality of Life in Women with or without Hot Flashes: A Randomized Placebo-Controlled Trial with Hormone Therapy. Menopause, 21, 732-739. https://doi.org/10.1097/GME.0000000000000120
Welton, A.J., Vickers, M.R., Kim, J., et al. (2008) Health Related Quality of Life after Combined Hormone Replacement Therapy: Randomised Controlled Trial. BMJ, 337, a1190. https://doi.org/10.1136/bmj.a1190
Hays, J., Ockene, J.K., Brunner, R.L., et al. (2003) Women’s Health Initiative Investigators. Effects of Estrogen plus Progestin on Health-Related Quality of Life. The New England Journal of Medicine, 348, 1839-1854. https://doi.org/10.1056/NEJMoa030311
Nikolaus, C., Netzer, M.D., Riccardo, A., et al. (1999) Using the Berlin Questionnaire To Identify Patients at Risk for the Sleep Apnea Syndrome. Annals of Internal Medicine, 131, 485-491. https://doi.org/10.7326/0003-4819-131-7-199910050-00002
Walters, A.S., LeBrocq, C., Dhar, A., et al. (2003) Validation of the International Restless Legs Syndrome Study Group Rating Scale for Restless Legs Syndrome. Sleep Medicine, 4, 121-132. https://doi.org/10.1016/S1389-9457(02)00258-7
Beck, A.T., Ward, C., Mendelson, M., et al. (1961) An Inventory for Measuring Depression. Archives of General Psychiatry, 4, 561-571. https://doi.org/10.1001/archpsyc.1961.01710120031004
Johns, M.V. (1991) A New Method for Measuring Daytime Sleepiness: The Epworth Sleepiness Scale. Sleep, 14, 540-545. https://doi.org/10.1093/sleep/14.6.540
Buysse, Daniel J.; Reynolds, et al. (1989) The Pittsburgh Sleep Quality Index: A New Instrument for Psychiatric Practice and Research. Psychiatry Research, 28, 193-213. https://doi.org/10.1016/0165-1781(89)90047-4
Delaplaine, R.W., Bottomy, J.R. and Blatt, M. (1952) Effective Control of the Surgical Menopause by Estradiol Pellet Implantationat the Time of Surgery. Surgery, Gynecology & Obstetrics, 94, 323-333.