Sleep disturbances alongside mood disorders urogenital symptoms, altered sexual function, and fatigue are some of the major symptoms associated with menopause. Menopause occurs when menstruation stops permanently due to the loss of ovarian follicular activity. To this end, menopause occurs following the final menstrual period and is diagnosed clinically following 12 months of amenorrhea.
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The stages of menopause
The mean age of natural menopause varies across the world; however, in the United Kingdom menopause occurs at an average age of 51 years. Early menopause occurs between the ages of 40 and 45 years, while premature ovarian insufficiency is a clinical syndrome defined as the transient or permanent loss of ovarian function before reaching the age of 40.
Perimenopause, which is defined as the period before menopause, is characterized by irregular cycles of ovulation and menstruation, ending 12 months after the last menstrual period. Comparatively, postmenopause occurs after the point at which a woman has not had a menstrual period for 12 consecutive months.
Vasomotor symptoms of menopause
The causes of sleep disturbances in menopause can be attributed to several symptoms. Vasomotor symptoms, which are characterized by hot flushes and night sweats, are the most commonly reported symptoms of menopause. Alongside these symptoms is peripheral vasodilatation, which occurs around the face and the chest and is usually followed by sweating, causing evaporative cooling.
The vasomotor symptoms of menopause can also be characterized as a type of climacteric symptom, which also includes the endocrinal, somatic, and transitory psychological changes occurring in the transition to menopause. Additional climacteric symptoms associated with menopause include palpitations, headaches, myalgia (muscular pain), numbness, vaginal dryness, dizziness, and urinary tract symptoms. Several mental symptoms have also been reported during menopause, including anxiety, depression, a decline in libido, reduced concentration, and impaired memory.
Epidemiology of vasomotor symptoms during menopause
It is estimated that approximately 80% of postmenopausal women experience these symptoms, with 25% reporting an impact on their quality of life. The severity and duration of the vasomotor symptoms of menopause are wide-ranging. In general, these occur for approximately 1–2 years; however, approximately 25% of women will experience them for five years with an additional 9% experiencing lifelong symptoms.
A multi-ethnic longitudinal cohort study of women in the United States was found that vasomotor symptoms are more prevalent among African American and Hispanic women. These symptoms were less prevalent among Japanese and Chinese women, with the lowest reported prevalence among non–Hispanic Caucasian women.
The link between vasomotor symptoms and sleep disturbances is well established. In studies of self–reported sleeping problems and climacteric symptoms with over 5,000 women and 12,600 women respectively, the odds ratio for sleeping problems in women with climacteric symptoms was 2.0 compared with asymptomatic women.
Sleep-disordered breathing: an obstruction to sleep
Obstructive sleep apnoea syndrome (OSAS) is the most clinically important abnormality with an incidence of 1–2% of the general population. It is characterized by open airway obstruction, leading to apnoea or significantly decreased airflow (hypopnea), along with snoring episodes.
The diagnosis of OSAS is dependent on daytime sleepiness. In women, particularly those who are in the transition to menopause and after menopause, obstruction of the upper airway is a more common nocturnal breathing disorder than OSAS.
Upper airway obstruction symptoms, which often resemble those of sleep apnea, include excessive sleepiness, snoring, increased tendency to fall asleep, morning headache, sweating, low energy, concentration difficulties, poor memory, and low mental tolerance.
The cause of sleep-disordered breathing is related to physiological or structural variables. Following menopause, body fat is redistributed, which results in an increased waist to hip ratio and increased neck width, which can put pressure on the airways. Another causal link is a decrease in the female sex hormones, particularly progesterone, which has been shown to stimulate the respiratory system.
Menopause, mood, and sleep
Women experiencing menopause report an increase in the frequency of their mood symptoms, particularly depression and anxiety, relative to men.
It is estimated that between 70 and 90% of climactically symptomatic women report feelings of depression. Reduced estrogen may also reduce the serotonin concentration in the brain, which is a critical neurotransmitter for mood regulation. Dopaminergic and androgenic activity can also fluctuate during menopause, which suggests that estrogen may produce an anti-depressive effect.
Dr. Susan Kok - Sleep and Menopause
Restless legs syndrome
Restless legs syndrome (RLS) is a condition that is more prevalent among women. According to a recent survey, approximately 15% of women between the ages of 18 and 64 years were found to have symptoms of RLS. Notably, this study’s findings found that the prevalence of RLS was unaffected by the menopausal status.
However, the experience of menopause can increase the perceived severity of RLS. Several theories have been proposed to explain the reasoning for this, which include iron deficiency or persistently high levels of estrogen during pregnancy. Conversely, the fall of estrogen and melatonin at menopause may be a causative mechanism. These mechanisms are contentious, particularly because menopause does not influence the prevalence of RLS, and hormone replacement therapy does not appear to alter the clinical outcomes in affected women.
Alongside RLS are periodic limb movement syndromes (PLMS) characterized by abrupt and repetitive movements last 0.5–5 s with short intervals. RLS occurs in 5–15% of the adult population and PLMS in 30%.
Alleviating the impact of menopause on seep
Several treatment options are used to treat the symptoms that affect sleep in peri–, post– and menopausal women. The first-line therapy for the alleviation of menopause-related insomnia is often hormone therapy (HT). Climacteric women whose insomnia is related to mood also benefit from HT, with an additional vasomotor asymptomatic subset benefitting from this.
It should be noted that HT is associated with an increased risk of the development of breast cancer. However, as long as these effects are carefully considered and HT is accompanied by yearly breast examination and biannual mammograms, the use of HT is a viable therapeutic route.
Additional pharmacological options for menopause-related sleep insomnia include selective serotonin–reuptake inhibitors, as well as antidepressants, hypnotics, or anxiolytics. Improved sleep hygiene practices such as sleeping in a dark quiet room at a cooler room temperature, avoiding daytime napping, decreasing the intake of caffeinated beverages, and relaxation training such as yoga and progressive muscle relaxation, have also been found to improve the quantity and quality of sleep in affected women. Cognitive-behavioral or sleep restriction and sleep consolidation therapies can also be beneficial.
Menopause and its associated symptoms, particularly climactic symptoms, harm sleep quality. Reduced sleep quality is connected to systemic disease, mental illnesses, and an increased risk of accidents.
Menopause, and especially menopause–associated symptoms like sweating and nocturnal hot flushes, often precipitate and exacerbate sleep disturbances. These sleep issues are common among women and their prevalence is increasing with more women seeking assistance for sleep problems as compared to men across all age ranges.
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