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Recently, Ballot et al. [1] reported the results of a secondary analysis of a 5-year prospective longitudinal population-based survey conducted in Canada, regarding the natural history of insomnia. They analyzed the association between sleep reactivity, arousal predisposition, sleep disturbances, and menopause. For this, 873 women aged 40 to 60 were divided into 2 groups according to their menopausal status (reproductive stage, n = 408 and postmenopausal stage, n = 465). Women were evaluated annually over 5 years, using questionnaires that assessed the quality of sleep, the severity of insomnia, sleep reactivity and arousal predisposition. The researchers determined that postmenopausal women have more severe insomnia and worse quality of sleep compared to women of reproductive age, with significant predictors being sleep reactivity and arousal predisposition. In addition, an increase in sleep disturbances was revealed within the two years before and after the menopausal transition. Sleep reactivity and arousal predisposition did not moderate the temporal relationship between the menopausal transition and sleep disturbances. The authors conclude that the majority of sleep disorders were reported in the menopausal transition, finding no relationship with sleep reactivity or arousal predisposition, therefore, there may be psychophysiological factors that during the menopause influence the development of sleep disorders.


During the menopausal transition women generally have a poor quality of sleep, which is insufficient or light. Sleep-related problems often begin during the menopausal transition, increasing in prevalence in the postmenopausal stage. Lack of sleep is a risk factor for cardiovascular disease, diabetes, obesity, and neurobehavioral dysfunction. Sleep disorders can affect women’s quality of life by significantly increasing health care costs and decreasing work performance. The transition to the menopause is accompanied by other symptoms such as vasomotor ones. Many studies report an association between vasomotor symptoms and sleep disorders. Data from the SWAN study found that women with moderate to severe hot flashes are nearly three times more likely to have frequent nocturnal awakenings compared to women without hot flashes [2,3].

In the study by Ballot et al, it was found that postmenopausal women had poor sleep quality and a greater severity of insomnia compared to women in the reproductive stage. The results indicated that more than 60% of postmenopausal women presented clinical signs of insomnia and poor sleep quality, confirming a high incidence of sleep disorders during the menopause. There is disagreement regarding the treatment, some authors claim that the use of estradiol improves the quality of life of these women [4,5], while others relate the effect of the progestogen as beneficial [6] and finally there are studies finding no benefit [7,8]. It is known that the timely use of hormone replacement therapy improves the quality of life at the cardiovascular and bone level [9] but in relation with sleep, further research is required. On the other hand, the effectiveness of non-hormonal treatments has been reported, such as cognitive behavioral therapy for the management of insomnia [10]. Taking into account the results of the Ballot study with the possible relationship of sleep disorders with pre-existing psychophysiological factors, it would be interesting to consider this non-hormonal (non-pharmacological) treatment alternative.

The authors report some limitations of their study. For instance, there was no formal evaluation of the diagnosis of insomnia and the fact that data was based on self-report measures. On the other hand, the sample was quite homogeneous and may not represent the minority/ethnic groups in Canada. Despite the mentioned limitations, the study has several strengths including the fact that it was a large, population-based sample, that included well-validated measures to capture key constructs related to sleep/ insomnia, and the repeated assessments over a 5-year period. In addition, the combination of both a cross-sectional and a longitudinal perspective lends further value to their study.

In conclusion, the study evidences the increasing incidence of sleep disturbances during the menopausal transition and potential risk factors such as hyperarousal and sleep reactivity. More research is needed to further delineate the relative contribution of preexisting psychosocial characteristics (i.e sleep reactivity and arousal) and biological (i.e hot flashes) factors, and their interaction, in explaining this increased incidence of sleep disturbances. The monitoring of these biopsychological changes would provide useful information for the improvement of the screening and treatment of menopausal insomnia.

Gabriela Carrión-Silva, MD
Hospital de la Mujer Alfredo G. Paulson
Guayaquil, Ecuador

Danny Salazar-Pousada, MD
Hospital de la Mujer Alfredo G. Paulson
Instituto de Investigación e Innovación en Salud Integral
Universidad Católica de Santiago de Guayaquil, Guayaquil, Ecuador


  1. Ballot O, Ivers H, Ji X, Morin CM. Sleep Disturbances During the Menopausal Transition: The Role of Sleep Reactivity and Arousal Predisposition. Behav Sleep Med. 2021 Jun 27:1-13. doi: 10.1080/15402002.2021.1937171.
  2. Prairie BA, Wisniewski SR, Luther J, et al. Symptoms of depressed mood, disturbed sleep, and sexual problems in midlife women: cross-sectional data from the Study of Women’s Health Across the Nation. J Womens Health (Larchmt). 2015;24(2):119-26.
  3. El Khoudary SR, Greendale G, Crawford SL, et al. The menopause transition and women’s health at midlife: a progress report from the Study of Women’s Health Across the Nation (SWAN). Menopause. 2019;26(10):1213-1227.
  4. Diem SJ, LaCroix AZ, Reed SD, Larson JC, Newton KM, Ensrud KE, Woods NF, Guthrie KA. Effects of pharmacologic and nonpharmacologic interventions on menopause-related quality of life: a pooled analysis of individual participant data from four MsFLASH trials. Menopause. 2020;27(10):1126-1136.
  5. Gava G, Orsili I, Alvisi S, Mancini I, Seracchioli R, Meriggiola MC. Cognition, Mood and Sleep in Menopausal Transition: The Role of Menopause Hormone Therapy. Medicina (Kaunas). 2019;55(10):668.
  6. Hachul H, Bittencourt LR, Andersen ML, Haidar MA, Baracat EC, Tufik S. Effects of hormone therapy with estrogen and/or progesterone on sleep pattern in postmenopausal women. Int J Gynaecol Obstet. 2008;103(3):207-12.
  7. Kalleinen N, Polo O, Himanen SL, Joutsen A, Polo-Kantola P. The effect of estrogen plus progestin treatment on sleep: a randomized, placebo-controlled, double-blind trial in premenopausal and late postmenopausal women. Climacteric. 2008;11(3):233-43.
  8. Xu M, Bélanger L, Ivers H, Guay B, Zhang J, Morin CM. Comparison of subjective and objective sleep quality in menopausal and non-menopausal women with insomnia. Sleep Med. 2011;12(1):65-9.
  9. Cintron D, Rodriguez-Gutierrez R, Serrano V, Latortue-Albino P, Erwin PJ, Murad MH. Effect of estrogen replacement therapy on bone and cardiovascular outcomes in women with turner syndrome: a systematic review and meta-analysis. Endocrine. 2017;55(2):366-375.
  10. Guthrie KA, Larson JC, Ensrud KE, et al. Effects of Pharmacologic and Nonpharmacologic Interventions on Insomnia Symptoms and Self-reported Sleep Quality in Women With Hot Flashes: A Pooled Analysis of Individual Participant Data From Four MsFLASH Trials. Sleep. 2018;41(1):zsx190.


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