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Summary

Matthews and colleagues performed a longitudinal study in women (n=300) transitioning through menopause [1]. The women were recruited from the Study of Women’s Health Across the Nation (SWAN). Actigraphy, sleep diaries, and self-reported sleep complaints were measured at baseline and on three other occasions over 12 years ( at mean ages, 52, 55, and 64 years). The study aimed at investigating sleep through time in relation to age and other possible factors, such as health problems, anxiety, and depression, stress levels, season of assessment, self-reported race/ethnicity (Black, Chinese, and White), educational attainment, vasomotor symptoms, postmenopausal status, as well as single marital status. The authors verified whether the decline in sleep duration and continuity would remain significant after adjustment for covariates that impacted sleep. They observed that race/ethnicity, menopausal status, vasomotor symptoms, and work status were key factors that covaried with sleep duration, continuity, and timing in midlife women over 12 years of follow-up. The study suggested that midlife women’s actigraphy measures of sleep characteristics may not worsen with age. Indeed, the authors observed that women experienced longer sleep duration and decreased WASO (wake after sleep onset), even though there were no changes in the number of sleep complaints.

Commentary

This is a fascinating study [1] that highlights several issues and discusses important aspects that may influence menopause and sleep. Although many studies have reported that sleep worsens with age and in postmenopause, this paper shows the opposite. Does sleep worsen in early old age? When evaluating sleep, there are many aspects to be taken into account, which are difficult to measure, such as social environment, spirituality, and expectations. An interesting paper has shown that higher levels of spiritual strength are associated with lower levels of menopausal symptoms [2]. It seems that women with spirituality have an advantage during menopause as they display adaptive coping strategies. Spirituality is a factor that should be taken into account when studying sleep disturbance at menopause [2]. Moreover, placebo-controlled studies have concluded that hormonal therapy produces a higher improvement rate than nonhormonal treatment [3. Subjective expectations affect the treatment efficacy of menopausal symptoms, and so they may affect the perception of sleep quality as a consequence. [3]. Another relevant aspect influencing menopausal symptoms is self-awareness (internal states awareness and self-reflectiveness). In an interesting study [4], researchers observed that greater internal state awareness is associated with increased hot flash severity. They concluded that there are secondary factors such as perceived stress, anxiety, and attitudes toward menopause, health perceptions, and menopausal stage that affect hot flashes. Nnhanced self-awareness may promote women’s ability to evaluate symptom experience [4]. Another study evaluating women in peri and postmenopause showed that 65% did not feel prepared for menopause. This psychological aspect could influence the perception and the frequency of symptoms. Of note, insomnia and hot flashes were the most severe symptoms reported [5]. Biopsychosocial interactions, as well as genetic predisposition (epigenetic role), may influence sleep patterns and menopausal symptoms. Women are essentially a result of body, mind, and soul issues [6]. Further longitudinal studies should be carried out to clarify whether there is a change in sleep patterns during the menopausal transition and in postmenopause. The aspects raised here are of extreme relevance, and we suggest adding other study aspects of religiosity, self-awareness, and perception, as well as age and biological factors. Although, studying subjective aspects, such as sleep and menopausal symptoms, which are dependent on multiple factors, will never be an easy task.

Helena Hachul
MD, PhD, Head of Sleep in Women at Universidade Federal de Sao Paulo – UNIFESP, Sao Paulo, BrazilProfessor at FICSAE (Faculdade Israelista de Ciencias da Saude Albert Einstein), São Paulo, Brazil

References

  1. Matthews KA, Kravitz HM, Lee L, et al. Does mid-life aging impact women’s sleep duration, continuity, and timing?: A longitudinal analysis from the Study of Women’s Health Across the Nation. Sleep. 2019 Oct 21.
    https://www.ncbi.nlm.nih.gov/pubmed/31633180
  2. Steffen PR, Soto M. Spirituality and severity of menopausal symptoms in a sample of religious women. J Relig Health. 2011 Sep;50(3):721-9.
    https://www.ncbi.nlm.nih.gov/pubmed/19641994
  3. Li L, Xu L, Wu J, Dong L, Lv Y, Zheng Q. Quantitative analysis of placebo response and factors associated with menopausal hot flashes. Menopause 2017;24:932-937.
    https://www.ncbi.nlm.nih.gov/pubmed/28399006
  4. Taylor-Swanson LJ, Pike K, Mitchell ES, Herting JR, Woods NF. Self-awareness and the evaluation of hot flash severity: observations from the Seattle Midlife Women’s Health Study. Menopause. 2019;26(5):476–484.
    https://www.ncbi.nlm.nih.gov/pubmed/30531442
  5. Marlatt KL, Beyl RA, Redman LM. A qualitative assessment of health behaviors and experiences during menopause: A cross-sectional, observational study.Maturitas. 2018 Oct;116:36-42.
    https://www.ncbi.nlm.nih.gov/pubmed/30244777
  6. Hachul H, Tufik S. Hot flashes: treating the mind, body and soul. Menopause. 2019 May;26(5):461-462.
    https://www.ncbi.nlm.nih.gov/pubmed/30789456
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