Sleep during the perimenopause: a SWAN story

Abstract

Is there evidence for a perimenopausal sleep disorder? We address this question in our presentation of the Study of Women's Health Across the Nation (SWAN) "sleep story," in which we summarize and discuss data addressing sleep quality, objective measures of sleep patterns, and sleep disorders that have been published to date by the SWAN and the ancillary SWAN Sleep Study. We describe what has been learned about sleep during the perimenopause. Analyses exploring racial/ethnic diversity and the role of hot flashes and mood disturbance in sleep-perimenopause associations are described. Implications for clinical practice are considered.

Figure 1

Age-related sex differences in self-reported sleep problems. Adapted using data from Cirignotta et al (1985).

Figure 2

Cross-sectional age-adjusted prevalence of sleep difficulty across the menopausal transition. Pre = premenopausal, EP = early perimenopausal, LP = late perimenopausal, Post = postmenopausal, Surg post = surgically postmenopausal, Post + HT = postmenopausal and using hormonal therapy (HT; this is the only group that includes HT users). Adapted using data from Kravitz et al (2003).

Figure 3

Prevalence of sleep difficulty across menopausal transition during longitudinal follow-up (average rates for each menopausal stage; N = 3,045). Data are reported separately for 3 types of sleep problems occurring 3 or more nights per week in the previous 2 weeks: trouble falling asleep, waking up several times during the night, and waking up earlier than planned. Adapted from Kravitz et al (2008) with permission.

Figure 4

Adjusted odds ratios for each of the three sleep difficulties in pre-/perimenopausal (“undetermined status”), naturally postmenopausal and surgically postmenopausal (“surgically post”) women using hormone therapy (+ HT) compared with premenopausal women not using HT, and naturally and surgically postmenopausal women using HT compared with their counterparts not using HT. All 3 sleep models adjusted for site, age, race/ethnicity, current HT, depressive and anxiety symptoms, sleep medications, smoking, life events, nocturia, physical symptoms, and bodily pain. Model for Trouble Falling Asleep (top figure) also adjusted for financial strain, body mass index, smoking, and education. Model for Wake Several Times (bottom figure) also adjusted for pain medications and self-reported overall health. Adapted using data from Kravitz et al (2008).

Figure 5

Adjusted odds ratios for association of vasomotor symptoms with 3 types of sleep difficulty (trouble falling asleep, waking up several times, waking up earlier than planned) occurring 3 or more nights per week during the past 2 weeks. All models adjusted for site, age, race/ethnicity, current hormone therapy use, depressive symptoms, anxiety symptoms, sleep medication, smoking, life events, nocturia, physical symptoms, and bodily pain. Model for Trouble Falling Asleep also adjusted for difficulty paying for basics, body mass index, smoking, and education. Model for Wake Several Times also adjusted for pain medication and self-perceived overall health. Adapted using data from Kravitz et al (2008).

Figure 6

Adjusted odds ratios for association of 3 types of sleep difficulty (trouble falling asleep, waking up several times, waking up earlier than planned, all occurring 3 or more nights per week during the past 2 weeks) with estradiol (E2) levels (increased sleep difficulty associated with lower levels) and follicle stimulating hormone (FSH) levels (increased sleep difficulty associated with higher levels). All 3 sleep models adjusted for site, age, race/ethnicity, current hormone therapy use, blood draw in cycle day 2–5 window, depressive symptoms, anxiety symptoms, sleep medication, smoking, life events, nocturia, physical symptoms, and bodily pain. Models for Wake Several Times also adjusted for number of med conditions. Adapted using data from Kravitz et al (2008).

Figure 7

Comparison of daily report of self-reported trouble sleeping across one menstrual cycle, by phase of cycle (top) and day-by-day (bottom), both centered on day of luteal transition. Circles represent the premenopausal group (Pre) and triangles represent early perimenopausal group (Peri). In phase of cycle figure, 0 is the day of luteal transition, −1 (days −1 to −5), −2 (days −6 to −10), −3 (days −11 to −15) correspond to late, mid, and early follicular phase, respectively, and +1 (days 1 to 5), +2 (days 6 to 10), +3 (days 11 to 15) correspond to early, mid, and late luteal phase, respectively. Bottom figure adapted from Kravitz et al (2005). Arch Intern Med 2005;165:2370–2376. Copyright © 2005 American Medical Association. All rights reserved.