Summary
Recently, Monterrosa-Castro and collaborators [1] published the results of a sub-analysis of a larger cross-sectional study (The CAVIMEC project [Quality of life in the menopause and Colombian Ethnics]), that aimed at identifying the frequency of sleep complaints (SC) and associated menopausal symptoms in apparently healthy women aged 40 to 59 (n=585), that resided in three different capital cities of the Colombian Caribbean. Researchers performed a door to door survey that included collecting sociodemographic characteristics and applying validated form and scales: Menopause Rating Scale (MRS), Jenkins Sleep Scale (JSS), Perceived Psychological Stress (perceived stress), Goldberg Anxiety and Depression Scale, SCOFF scale (eating disorders), and Loneliness Scale of Hughes. For the analysis women were divided into two groups, those with SC and those without SC, as determined by the JSS. Crude and adjusted logistic regressions were performed using SC as a dependent variable and sociodemographic characteristics and the results of the used scales as independent variables. The authors found that according to the JSS a 16.5% of women had SC, with no observed differences in terms of age, body mass index (BMI), or high blood pressure. More women with SC had depression, anxiety, the perception of loneliness, severe menopausal symptoms (MRS: somatic, psychological, urogenital subdomains), and quality of life severe impairment; with no observed differences found in terms of eating disorders and perceived stress. According to the adjusted logistic regression model, only depression was significantly related to SC (OR: 9.81 95% CI: 1.29-74.3, p<0.05). The investigators conclude that in the studied mid-aged Colombian cohort, SC was present in nearly 17% and associated with depressive symptoms.
Commentary
Sleep is a physiological and vital process that permits the correct functioning of various systems: immunological, metabolic, and cognitive [2,3]. Its rhythm can be altered by endogenous disruption of the sleep-wake cycle or by bio-psycho and social influences [3]. Disturbances of sleep are mainly grouped under the term of sleep disorders and can cause physiological and biological impairment [2Lee]. Men and women are both affected, but the risk of sleep disorders is usually 2 times higher in women; thus implicating the influence of sex steroids [4]. Sleep complaints (SC) are included as part of menopausal symptoms and their frequency may vary depending on ethnic groups, culture, socio-economic levels, or geographical areas; factors that may negatively influence health resources and the menopausal transition, vital female stage in which reproductive function gradually fades away due to the progressive decrease of ovarian estrogenic secretion [2,3]. To highlight this, in a multinational Latin American study, by means of validated tools, it was found that more than 50% of mid-aged women suffered of insomnia, poor quality of sleep, or both. Prevalence increased with age and the menopausal stage. In this cohort of 6,079 women aged 40 to 59, vasomotor symptoms, depressive mood and anxiety were associated to sleep disturbances and higher educational level related to less insomnia and better sleep quality [5]. In the present study [1], the authors aimed at determining the prevalence of SC and menopausal symptoms in mid-aged women, peri- and postmenopausal, as defined by STRAW +10 criteria [6]. It was found that with the JSS, nearly 17% of surveyed mid-aged women presented SC, which were basically correlated with depressive symptoms. This rate was lower than the previously reported by the same researcher, Monterrosa et al. [7], author of the presently commented paper, who addressed sleep quality among Colombian women (n=1,078) and found that more than 50% of women had sleep problems that correlated with the severity of menopausal symptoms, tobacco consumption, and the presence of hypertension. The 16.5% rate of SC was also lower than the 37.5% reported by Ornat et al. [8] using the same JSS among 288 Spanish women aged 40-59. As stated, prevalence of sleep problems during female mid-life are influenced by various factors, and as we can observe differences are also present within the same ethnic group, in this case women from the Colombian Caribbean. Midlife women from different Latin American regions, with different ethnicities, have different habits, traditions, and cultural norms, which can modify the frequency of menopausal symptoms which in turn may affect sleep quality [5,7]. On the other hand, the rates may also vary depending on where the surveys were performed: clinical settings (patients who in one way or another come to the clinic) as compared to communities (that explores women’s opinion).
The association between SC and the climacteric state is accepted, while the etiopathogenesis is not well clarified and is considered multifactorial [2,5]. Variations of serum estradiol influence the secretion of brain neurotransmitters, serotonin, causing changes in sleep, mood, and memory capacity [5Blumel]. Alterations of the circadian cycle are characteristic of aging in women and may be directly related to hormonal changes [2,3]. On the other hand, it has been reported that nocturnal melatonin secretion decreases in association with menopausal status and age [9].
The authors of the present commented paper acknowledge that their study has the limitations of cross-sectional studies that allow establishing association yet not causality. The results are specific to the studied population that can not necessarily be extrapolated to other communities in Colombia or Latin America. Also, nutritional or dietary factors, hormone levels, sleeping habits, and environments were not determined in the studied, situations that may modify the prevalence of SC. The study has the strength of providing information regarding SC in mid-aged women of community settings, with an adequate sample size for the selected cities, the use of various international validated scales, seeking to raise awareness of the presence of SC in these women, who have not needed of consult due to changes in the sleep patterns.
Finally, I agree with the authors, that data on SC are limited in these ethnical population groups. Furthermore, most studies regarding SC have been performed in patients or in hospital settings and that more information concerning SC is needed, especially in women going through the menopausal transition who have not considered necessary consulting a health professional due to their SC.
Peter Chedraui, MD, PhD
Instituto de Investigación e Innovación en Salud Integral
Universidad Católica de Santiago de Guayaquil, Guayaquil, Ecuador
References
- Castro AM, Beltrán-Barrios T, Mercado-Lara M. Assessment of the frequency of sleep complaints and menopausal symptoms in climacteric women using the Jenkins Sleep Scale. Sleep Sci. 2021;14(2):92-100.
https://pubmed.ncbi.nlm.nih.gov/34381572/ - Lee J, Han Y, Cho HH, Kim MR. Sleep disorders and menopause. J Menopausal Med. 2019;25(2):83-87.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6718648/ - Shaver JL, Woods NF. Sleep and menopause: a narrative review. Menopause. 2015;22(8):899-915.
https://pubmed.ncbi.nlm.nih.gov/26154276/ - Manber R, Armitage R. Sex, steroids, and sleep: a review. Sleep. 1999;22(5):540-55.
https://pubmed.ncbi.nlm.nih.gov/10450590/ - Blümel JE, Cano A, Mezones-Holguín E, et al. A multinational study of sleep disorders during female mid-life. Maturitas. 2012;72(4):359-66.
https://pubmed.ncbi.nlm.nih.gov/22717489/ - Harlow SD, Gass M, Hall JE, et al; STRAW+10 Collaborative Group. Executive summary of the Stages of Reproductive Aging Workshop +10: addressing the unfinished agenda of staging reproductive aging. Climacteric. 2012;15(2):105-14.
https://pubmed.ncbi.nlm.nih.gov/22338612/ - Monterrosa-Castro A, Marrugo-Flórez M, Romero-Pérez I, Fernández-Alonso AM, Chedraui P, Pérez-López FR. Assessment of sleep quality and correlates in a large cohort of Colombian women around menopause. Menopause. 2013;20(4):464-9.
https://pubmed.ncbi.nlm.nih.gov/23096246/ - Ornat L, Martínez-Dearth R, Chedraui P, Pérez-López FR. Assessment of subjective sleep disturbance and related factors during female mid-life with the Jenkins Sleep Scale. Maturitas. 2014;77(4):344-50.
https://pubmed.ncbi.nlm.nih.gov/24529826/ - Krajnak K, Rosewell KL, Duncan MJ, Wise PM. Aging, estradiol and time of day differentially affect serotonin transporter binding in the central nervous system of female rats. Brain Res. 2003;990(1-2):87-94.
https://pubmed.ncbi.nlm.nih.gov/14568333/
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