Query: Female menopause sleep disorder

title: Paciente con trastorno del sueno Female patient wi th sleep disorder
abstract: Since the onset of her menopause about ten years ago, a sixty year old patient has been suff ering from hot fl ashes and sleep disorders causing her to become increasingly anxious and nervous. As the patient's mother had died of breast cancer, substitution of hormones was not advisable. Relaxation methods such as yoga and autogenic training could only mildly alleviate the symptoms.  To eff ectively treat the sleep disorder, improve quality of life, lessen frequency and severity of hot fl ashes.  Weekly sessions with ear and body acupuncture for ten weeks.  After the third acupuncture session the patient reported a decrease of nightly waking episodes but suffered from acute pain in the neck as well as shoulder region. After nine therapy sessions, the patient reported a 50 decrease of nightly waking episodes. The hot fl ashes, however, remained unchanged.  In this case, acupuncture signifi cantly improved the patient's sleeping disorder. It also reduced the symptoms of anxiety and nervousness. Other menopausal symptoms such as hot fl ashes and dryness of mucous tissues, could not be infl uenced.

title: Treatment of chronic insomnia disorder in menopause: evaluation of literature
abstract: ObjectiveInsomnia both as a symptom and as part of chronic insomnia disorder is quite common in menopause. Comorbid conditions, such as restless legs syndrome and obstructive sleep apnea, occur with high prevalence among perimenopausal women with insomnia. Insomnia in this population group is associated with adverse health outcomes, and there are no clear standards on how to treat it. MethodsBased on extensive literature search, 76 articles were identified. Two authors independently graded evidence according to the Oxford Centre for Evidence Based Medicine Levels of Evidence. ResultsEvaluation and treatment of other comorbid sleep disorders are recommended, as is cognitive behavioral therapy for insomnia. Hormone therapy, eszopiclone, escitalopram, gabapentin, isoflavones, valerian, exercise, and hypnosis are suggested. Zolpidem, quiteiapine XL, citalopram, mirtazapine followed by long acting melatonin, ramelteon, Pycnogenol, Phyto Female Complex, yoga, and massage may be considered. Kampo formulas are not recommended. Acupuncture may not be suggested, and cognitive behavioral therapy that is not tailored for insomnia probably should not be considered. ConclusionsAlthough a variety of interventions are shown to be helpful in improving sleep in menopause, there is a need for well designed head to head trials with uniform outcome measures.

title: Sleep disorders in menopause: results from an Italian Multicentric Study.
abstract: Menopause in the female life cycle is a special period due to important hormonal, physical and psychological changes. Sleep disruption represents a common complaint for midlife and menopausal women, related to primary sleep disorders, including insomnia, sleep disordered breathing, restless legs syndrome (RLS) mood and anxiety disorder, other medical illness, hormonal related vasomotor symptoms, and aging per se. Aims of our study were to evaluate the prevalence of sleep disorders in a sample of pre and post menopausal women, and to investigate the relationship between sleep and other medical disorders, and life habits. Among workers in the six participant centers, we enrolled 334 women, aged between 40 and 60 years, that completed a questionnaire that included screening on menarche, menstrual cycle, fertility, parity, menopause, life habits, personal medical and sleep history and related treatment, and self administered scales for sleep quality (PSQI) excessive daytime sleepiness [Epworth Sleepiness Scale (ESS) mood disorder [Beck Depression Inventory (BDI) Berlin Questionnaire for sleep disordered breathing (SDB) IRLS diagnostic interview and Rating Scale. Menopausal and perimenopausal women showed an increased prevalence of poor sleep, high risk of SDB, and mood disorder; menopausal women also reported increased RLS severity. Mood disorder had a significant impact on night sleep measures and excessive daytime sleepiness, as well as on RLS severity, and had a greater prevalence in hypertensive women. Sleep disturbances are frequent in menopausal women. Their aetiology is unclear, but probably multifactorial, and many factors contribute to the sleep disruption. Our data suggest the importance of correctly investigate and address sleep problems associated with menopause, through sleep history, and a sleep study could be obtained if clinically warranted. Pharmacological and behavioural treatment strategies should then be aimed at improving sleep and life quality in perimenopausal and menopausal women.

title: Epidemiology of Sleep Disorders in Women
abstract: Sleep disorders are prevalent in women and are characterized by unique clinical presentations that vary throughout different stages of a woman's life. Sleep disordered breathing is not uncommon in women with increased prevalence during pregnancy and post menopause. Insomnia is also a common sleep disorder with female preponderance even in the preadolescent years. In addition, Restless Legs Syndrome occurs with increased frequency during pregnancy and is associated with increased risk for the chronic idiopathic form. In contrary to common belief, REM Behavior Disorder parasomnia is as common in women as in men. This chapter discusses the epidemiology of sleep disorders in women with focus on sleep disordered breathing, insomnia and restless leg syndrome.

title: Menopause and depression: keep your eye on the long run.
abstract: symptoms and sleep problems in midlife depression continue M ost researchers and experienced clinicians would agree, in this day and age, that the 'jury is no longer out' on the potential effects of reproductive hormones on mood and the extent to which hormone fluctuations/changes may impact overall functioning throughout the female reproductive life cycle. Premenstrual Dysphoric Disorder, for example, has now been officially recognized and incorporated as a new diagnostic category for the DSM 5, representing an acknowledgment by experts and peers of the severe functional impairment that some but not all women experience during the luteal phase of their cycles. There is also little dispute about the wide spectrum of mood and behavioral changes that may occur during the postpartum period ranging from the commonly observed dysphoria or 'baby blues' to the occurrence of postpartum depression or even the rare but severe postnatal psychosis. On the contrary, after many decades of accumulated research, some of the controversy surrounding the existence of a 'menopause associated depression' still persists. As previously discussed, part of the confusion could be attributed to misinformation and insufficient knowledge dissemination on what is already known about the 'window of vulnerability' for depression in midlife years. Methodologic limitations have also contributed contradictory findings, including the heterogeneity of subpopulations studied, the lack of standardized criteria to define menopause staging, or appropriate diagnostic tools to characterize the nature and severity of psychiatric symptoms. Moreover, the presence of comorbid conditions such as anxiety and/or sleep problem has not always been taken into consideration or even documented, despite their impact on the well being of midlife women. Fortunately, the last few decades have also produced welldesigned, well executed population studies, shedding some light on the risk for new and recurrent depression among women approaching menopause and beyond. Prospective cohort studies have unequivocally demonstrated an increased risk for the development of depression during the menopausal transition and helped us to disentangle some of its various components (sociodemographic, clinical, hormonal) We have learned, for example, that past history of depression is one of the strongest predictors for the occurrence of a major depressive episode during midlife years, and that greater within subject variations in gonadal steroids over time (rather than absolute levels at one point in time) could be associated with heightened risk for developing depression. The nature and magnitude of the role played by vasomotor

title: Telephone based CBT reduced insomnia severity more than menopause education in menopausal women
abstract: In perimenopausal or postmenopausal women with insomnia and hot flashes, what is the relative efficacy of telephone based cognitivebehavioral therapy for insomnia (CBT I) and telephone based menopause education control (MEC) for reducing insomnia?  Randomized controlled trial (RCT) ClinicalTrials.gov NCT01936441. Allocation {Concealed} Blinding Blinded (data collectors) Follow up period 24 weeks. Setting MsFlash research network in western Washington State, USA. Patients 106 perimenopausal and postmenopausal women 40 to 65 years of age (mean age 55 y) who had significant insomnia symptoms (Insomnia Severity Index [ISI] score 12) and 2 hot flashes/d for the past 2 weeks. Exclusion criteria included primary sleep disorder or major illness interfering with sleep, routine use of prescription sleep medication, consumption of >3 alcoholic drinks/d, or shift work. Intervention CBT I (n =53) or MEC (n =53) each of which comprised six 20 to 30 minute telephone sessions led by 2 female coaches over 8 weeks. CBT I included information about age related sleep changes, sleep hygiene, and stimulus control procedures; and teaching about cognitive techniques to reduce physiologic arousal and reduce unrealistic beliefs about sleep loss. Sleep windows were restricted to the average sleep time reported at baseline and extended by 15 minutes weekly when 85% sleep efficiency was achieved. MEC comprised general education and written information about women's health and quality of life, excluding information about CBT strategies for sleep.  Insomnia severity (ISI) Secondary outcome was Pittsburgh Sleep Quality Index (PSQI) score. Exploratory outcomes included no clinically significant insomnia {ISI} and daily interference of hot flashes (Hot Flash Related Daily Interference Scale) Patient follow up 83% at 8 weeks and 76% at 24 weeks (intention to treat analysis) Main results CBT I reduced insomnia (on the ISI and PSQI) and increased the likelihood of no insomnia at 8 and 24 weeks compared with MEC (Table) CBT I also reduced scores on the Hot Flash Related Daily Interference Scale at 8 (P =0.03) and 24 (P =0.003) weeks compared with MEC.  In perimenopausal or postmenopausal women with insomnia and hot flashes, telephone based cognitivebehavioral therapy for insomnia reduced insomnia severity compared with telephone based menopause education control. Telephone based CBT I vs MEC in perimenoausal or postmenopausal women with insomnia and hot flashes Outcomes Time points (follow up rate) Mean change from baseline (95% CI) Difference in mean change from baseline (CI) CBT I MEC ISI score 8 wk (83% 9.9 (11.2 to 8.7) 4.7 (6.1 to 3.3) 5.2 (6.1 to 3.3) 24 wk (76% 10.7 (11.9 to 9.4) 6.7 (8.4 to 5.0) 4.0 (6.0 to 1.9) PSQI score 8 wk (83% 4.0 (5.0 to 3.1) 1.4 (2.1 to 0.7) 2.7 (3.9 to 1.5) 24 wk (76% 4.3 (5.1 to 3.5) 2.7 (3.5 to 1.9) 1.6 (2.7 to 0.5) Event rates Relative benefit increase (CI) NNT (CI) No clinically significant insomnia (ISI score 7) 8 wk (83% 70% 24% 188 (70 to 421) 3 (2 to 4) 24 wk (76% 84% 43% 94 (37 to 198) 3 (2 to 5) CBT I cognitivebehavioral therapy for insomnia; ISI Insomnia Severity Index; MEC menopause education control; other abbreviations defined in Glossary. Relative benefit increase, NNT, and CI calculated from event rates in article. Negative difference indicates more improvement in the CBT I group. Score range 0 to 28; higher score more severe insomnia (6 point change is considered clinically meaningful) Score range 0 to 21; higher score worse sleep quality (3 point change is considered clinically meaningful) Commentary Menopause is associated with various physical disorders that adversely affect quality of life, including vasomotor symptoms (VMSs) sleep disturbance, and urogenital atrophy. Although it has potential adverse effects, estrogen remains the single most effective therapy for menopause related VMSs and urogenital atrophy (1) with positive effects on sleep, mood, bone density, cardiovascular health, and other metabolic conditions (2) Other pharmacotherapies (antidepressants, gabapentin, clonidine, herbal medicine) and alternative treatments (psychotherapy, acupuncture, exercise, and yoga) have measurable but less dramatic benefits in terms of VMS and sleep (1) It is not surprising that the RCT by McCurry and colleagues found that specialized CBT reduced insomnia and VMS. Study weaknesses include self assessment of sleep patterns, which could introduce reporting biasthat is, some patients may have been unaware of, or did not report, excessive caffeine use and such conditions as restless leg syndrome or sleep apnea. Additionally, depression, amenable to CBT, may have confounded the findings. The statistically significant, but modest, effect of the intervention on VMS frequency and intensity is probably not clinically significant and may be comparable to placebo in other studies (1) Finally, the study sample was small and from a single region; further study is needed to determine whether CBT is effective in a larger, heterogeneous population requires. Costs, accessibility, and time commitment could be formidable obstacles to widespread adoption. However, structured CBT may offer another choice to the menopausal management armamentarium, particularly for women who have insomnia, are averse to hormonal therapies, or have contraindications.

title: On the role of menopause for sleep endocrine alterations associated with major depression
abstract: Aging and menopause are associated with alterations of the sleep EEG, while age related changes of the hypothalamo pituitary adrenal (HPA) axis remain controversial. Major depression is also associated with typical sleep endocrine changes, including enhanced activity of the HPA axis, while an influence of age and gender on these alterations is less clear. To test the hypothesis that after menopause sleep endocrine alterations associated with major depression are accentuated, we examined the sleep EEG and nocturnal hormone secretion (ACTH, cortisol, GH, estradiol, LH, FSH, and leptin) in 16 drug free female patients, mostly with the first episode of a major depressive disorder (seven pre and nine postmenopausal subjects) and 19 female controls (10 subjects in the early follicular phase and nine postmenopausal subjects) Nocturnal cortisol secretion was increased in postmenopausal patients with depression, while a decrease was noted in postmenopausal controls. Sleep alterations typically associated with depression, namely a reduction in sleep continuity and slow wave sleep (SWS) and an increase in REM density, were prominent in post but not in premenopausal patients. An inverse correlation was noted between the decline in SWS and sleep continuity and FSH secretion in patients with depression, suggesting a role of menopause for these sleep endocrine alterations typically associated with major depression. In contrast, in premenopausal patients we noted primarily a shift in SWS and delta EEG activity from the first to the second non REM period, which was not related to age or hormone secretion. Though the relatively small number of subjects per group precludes a definitive conclusion, our data open up the possibility that the sleep endocrine changes typically associated with major depression are most prominent in postmenopausal patients. Whether the predominant alteration of the distribution of SWS and delta EEG activity in younger patients with a first episode of major depression has a predictive value for the future course of the disease remains to be investigated.

title: Gender and asthma severity differences in sleep disordered breathing in children with asthma
abstract: We would like to congratulate Dr. Goldstein and associates for the excellent and provocative article on asthma and obstructive sleep apnea in children. Their thoughtful approach has raised interesting questions about potential links among sleep disorder breathing (SDB) asthma, age, and gender. These questions suggest pathways for future studies to clarify further these relationships. The results that have called our attention specifically to the greater risk of SDB in girls, in non asthmatic 13 years old girls (compared to asthmatic population) and in intermittent asthma. The first surprise was the appearance of different risks of SDB in relation to gender in children. That girls are at a greater risk for SDB than boys was unexpected. The frequency of SDB is greater in men than in women and female hormones putatively protect women from SDB until menopause. In children, however, most studies have shown that the prevalence of SDB is equal among pre pubertal boys and girls. Moreover, asthma is more prevalent in boys than in girls. Airway growth progresses more slowly in boys compared to girls, and during infancy, the male airway diameter is reduced compared to that of infant girls. In adulthood men have larger airways than women. As asthma is a risk factor for SDB, we would expect the greater male frequency of asthma in boys to weigh on the side of increased SDB in boys. An alternative approach that may shed light is to focus more specifically on ageand gender related changes in the severity, rather than simple frequency, of asthma. Asthma is more severe in boys than girls between ages 5 and 6 years, while girls have greater severity compared to boys between 10 and 17 years. There is no gender difference between 7 and 9 years. Nonetheless, the decline is asthma symptoms stops at the onset of puberty, at ages 9 years in girls and 10 years in boys. While asthmatic symptoms of boys remain stable after 10 years, the symptoms of girls usually worsen at the same age. Female hormones have a negative effect on asthma and women are more prone to severe asthma and other atopic diseases. The T helper 2 response in women is more developed than in men, and women have an increase in interleukin 4 and immunoglobulin E levels that are related to the actions of progesterone and estrogen action. The menstrual cycle also plays a role in asthma since premenstrual state can be associated with exacerbations of asthma. On the other hand, androgens inhibit leukotriene synthesis, and, at least in guinea pigs, androgens contribute to bronchial relaxation. The current study found a greater risk of SDB among girls with asthma at ages 8 and 13 years. The difference in asthma severity could help to explain the discrepancy discovered at these ages. The unraveling of the biological events that accompany puberty would seem to be a worthy target of future studies examining the links of asthma and SDB, since sex hormones appear to play an important role in the physiology of both asthma and SDB. The second remarkable result was that at age 13 years, girls presented with a greater risk in the non asthmatic population. This is surprising, since neither the natural history of asthma nor of SDB explain or predict this outcome. The large confidence interval suggests that this finding needs to be corroborated in a larger study before pursuing its epidemiologic roots. The third surprise was the lower risk of SDB in children with mild persistent asthma compared to intermittent asthma. A relevant modifying factor worthy of analysis is whether or not those with mild asthma were more likely to have been submitted to adenotonsilectomy. Further progress in these epidemiologic studies is limited in part by the lack of objective, but more cost effective

title: PCOS from Conception to Menopause: A Review of Our Current Understanding
abstract: PCOS from Conception to Menopause: A Review of Our Current Understanding Polycystic ovary syndrome (PCOS) appears to be a part of a lifelong continuum starting in utero, with progressive signs in the adolescent female. It is recognized as the most common endocrinopathy in reproductive age women, and may have sequelae in the menopausal PCOS woman. PCOS is a disorder characterized by hyperandrogenism and chronic anovulation affecting at least 1 in 15 women or approximately 6 7% of reproductive age women. Metabolic and health complications associated with PCOS include obesity, insulin resistance, dyslipidemia, pancreatic beta cell dysfunction, type 2 diabetes, cardiovascular disease, endometrial cancer, sleep apnea, inflammation, and infertility.

title: Restless legs syndrome among women: prevalence, co morbidity and possible relationship to menopause
abstract: Restless legs syndrome (RLS) is a common neurological movement disorder with a female preponderance and an increasing prevalence with age. During the menopausal transition, sleep is affected. Prior studies suggest that female hormones are associated with the clinical manifestation of RLS.  A random sample of 5000 women aged 18 64 years was selected from the general Swedish population. They were sent questions on RLS, general health, sleep problems, reproductive health and menopausal state.  The response rate was 70.3% 15.7% of the women were diagnosed with RLS. Prevalence increased with age. RLS subjects more often had symptoms of affected sleep and depressed mood. Co morbidity with heart disease was more common among RLS subjects, whereas hypertension and diabetes mellitus were not. There was a strong association between vasomotor symptoms and RLS but no statistical relationship between use of hormone replacement therapy, postmenopausal state and RLS.  The prevalence of RLS among Swedish women is high. RLS sufferers more often suffered from depression and heart disease, whereas no such associations were noted for diabetes or hypertension. We found an increased prevalence of RLS among women with vasomotor symptoms (night sweats) during the menopausal transition but not among women using hormone replacement therapy.