Abstract
[Purpose]
We compared sleep quality and mental health in healthy menopausal women and healthy young women. In addition, the impact of the severity of menopausal symptoms on each variable was determined.
[Methods]
Twenty menopausal women (MW; 49 ± 3 years) and 20 young women (YM; 20 ± 1 years) were recruited. Body composition, mental health scores (evaluated using the Center for Epidemiologic Studies Depression Scale [CES-D], the Depression Anxiety Stress Scale-21 [DASS-21], the School Form-8 [SF-8, health-related QOL]), and sleep score (evaluated using the Pittsburgh Sleep Quality Index [PSQI]) were assessed.
[Results]
Body composition did not significantly differ between the groups. In the MW group, the CES-D and DASS-21 scores were significantly higher. Also, PSQI scores were significantly higher, indicating impaired sleep quality. Moreover, women with more severe menopausal symptoms had significantly lower sleep quality and inferior mental stress (evaluated by DASS-21 [Stress]) than those with less-severe symptoms.
[Conclusion]
Sleep quality and mental health are negatively impacted by menopause, especially among those with severe symptoms.
Keywords: CES-D, DASS-21, SF-8, Sleep, Mental health, SMI
INTRODUCTION
Menopause is a natural physiological phenomenon that typically occurs in women around the age of 50 [1]. Symptoms include trouble sleeping, dysfunctional body temperature regulation, vasomotor disorders, and temporary mood disorders, among others [2-4]. These problems reduce quality of life [5].
Sleep disorders are a significant global health concern for menopausal women [6], with 37.3% of women aged 40 to 55 years reportedly experiencing them [7]. However, few studies have specifically focused on the sleep characteristics of menopausal women [3]. Furthermore, impaired sleep quality in this population may be linked to autonomic nervous system dysfunction [8].
Impaired mental health is also common among menopausal women [9], with depression, lack of motivation, and anxiety frequently reported [10]. Women tend to have a higher rate of depression (18.2%) than men (9.2%) [11], potentially due to fluctuating estrogen levels [10]. While there are significant individual differences in the degree of mental health impairment [12], the relationship between impaired mental health, reduced sleep quality, and the severity of menopausal symptoms remains unclear. Also, although previous studies [13] mainly focused on postmenopausal women, fewer studies investigated specific physio- and psychological condition in women with menopausal transition.
In the present study, we compared sleep quality and mental health between menopausal women and young women. We hypothesized that menopausal women would present impaired sleep quality and mental health, which would be associated with the severity of menopause.
METHODS
Participants
In total, 20 young women with regular menstrual cycles (YM group) and 20 middle-aged women (MW group). For MW group, they were involved in at least one of the menopausal symptoms (vasomotor symptoms, depression, sleep disorders, physical symptoms) [14]. The mean age, height, and weight were 20.4 ± 0.2 years, 161.4 ± 1.3 cm, and 52.9 ± 1.4 kg in the YM group and 49.1 ± 0.6 years, 159.5 ± 1.1 cm, and 53.7 ± 1.6 kg in the MW group (Table 1). All participants were informed about the experimental design and provided informed written consent. The study was approved by the Ethical Committee for Human Experiments at Ritsumeikan University, in accordance with the Declaration of Helsinki.
Table 1.
Age, height and weight in each group
| Age | Height (cm) | Weight (kg) | BMI (kg/m²) | |
|---|---|---|---|---|
| YM | 20.4 ± 0.2 | 161.4 ± 1.3 | 52.9 ± 1.4 | 21.1 ± 0.5 |
| MW | 49.1 ± 0.6 | 159.5 ± 1.1 | 53.7 ± 1.6 | 20.3 ± 0.4 |
Values are means ± SE.
Experimental Overview
Participants visited our laboratory and completed questionnaires about sleep quality, mental health, and quality of life. In addition, the MW group answered questions about severity of menopausal symptoms. All participants completed these questionnaires between February and April. In the YM group, all measurements were conducted during the early follicular phase.
Measurements
Sleep quality
Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI), which allows subjective assessment of sleep quality and disturbance over the prior month [15]. The PSQI consists of 19 items, and each score is classified into seven components: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, use of sleep medication, and daytime dysfunction [16].
Mental health
Mental health was assessed using the Center for Epidemiologic Studies Depression Scale (CES-D) and the Depression Anxiety Stress Scales-21 (DASS-21) [17]. The CES-D evaluates the level of depressive symptoms and consists of 20 questions about symptoms that occurred in the week prior to answering [18]. The DASS-21 is a short form of Lovibond and Lovibond’s 42-item evaluation of depression, anxiety, and stress [19].
Quality of life
Quality of life was assessed using the School Form-8 (SF-8), which consists of eight subjective questions about physical and mental status during the prior week [20]. The questionnaire provides a physical component summary score (PCS) calculated from four questions about physical health, and a mental component summary score (MCS) calculated from four questions about mental health [21].
Severity of menopausal symptoms
In the MW group, the severity of menopausal symptoms was assessed using the Simplified Menopausal Index (SMI). The SMI consists of 10 questions related to menopausal symptoms, including vasomotor, psychological, and physical symptoms, designed to evaluate menopausal symptoms in Japanese women [22]. Based on the total scores calculated, participants in the MW group were classified to determine the impact of severity of menopausal symptoms on each variable: those with high scores (n = 7), average scores (n = 5), and low scores (n = 8). Because the scores in group with average scores were close to those in some participants in group with high score or with low score, further comparison was performed between participants with high scores and those with low scores.
Statistical Analysis
Data are presented as mean ± standard error. The normality of the distributions was confirmed using the Shapiro-Wilk test. Variables were compared between the groups using an independent t-test for normally distributed variables and the Mann-Whitney U test for non-normally distributed variables. P-values < 0.05 were considered statistically significant.
RESULTS
CES-D, DASS-21 and SF-8
Table 2 presents the scores for the CES-D, DASS-21, and SF-8 scales. The MW group had significantly higher scores on the CES-D and DASS-21 (Depression, Stress) and significantly lower scores on the PCS component of the SF-8. The scores on the MCS component of the SF-8 did not significantly differ between the groups.
Table 2.
Scores of CES-D, DASS-21 and SF-8
| Group | MW | YM | P value (ES) | |
|---|---|---|---|---|
| CES-D | 11.5 ± 1.0 † | 8.1 ± 0.8 | 0.02 (0.39) | |
| DASS-21 | ||||
| Depression | 2.9 ± 0.5 † | 1.4 ± 0.4 | 0.02 (0.38) | |
| Anxiety | 1.8 ± 0.4 | 1.2 ± 0.2 | 0.36 (0.15) | |
| Stress | 3.9 ± 0.6 † | 1.9 ± 0.8 | 0.03 (0.35) | |
| SF-8 | ||||
| PCS | 47.4 ± 1.3 † | 54.3 ± 0.8 | < 0.01 (0.66) | |
| MCS | 49.6 ± 1.3 | 50.2 ± 1.1 | 0.68 (0.07) |
Values are means ± SE.
: P < 0.05 vs. YM.
PCS: physical component summary. MCS: mental component summary. ES: effect size.
PSQI
Table 3 presents the PSQI global and subscale scores. The MW group (5.3 ± 0.4) had significantly higher global scores compared to the YM group (3.9 ± 0.3, P < 0.05), indicating lower sleep quality. Nine participants in the MW group and three participants in the YM group exceeded the cutoff value. Also, in some subscales (sleep quality and sleep disturbance), the MW group (1.6 ± 0.1 for sleep quality; 1.1 ± 0.7 for sleep disturbance) had significantly higher scores compared to the YM group (0.9 ± 0.8 for sleep quality; 0.7 ± 0.1 for sleep disturbance).
Table 3.
PSQI score in each group
| Group | MW | YM | P value (ES) |
|---|---|---|---|
| Global score | 5.3 ± 0.4 † | 3.9 ± 0.3 | 0.01 (0.40) |
| Sleep quality | 1.6 ± 0.1 † | 0.9 ± 0.8 | 0.02 (0.60) |
| Sleep latency | 0.8 ± 0.2 | 1.1 ± 0.3 | 0.59 (0.09) |
| Sleep duration | 1.2 ± 0.2 | 0.9 ± 0.2 | 0.19 (0.22) |
| Sleep efficiency | 0.05 ± 0.05 | 0.35 ± 0.13 | 0.17 (0.33) |
| Sleep disturbance | 1.1 ± 0.7 † | 0.7 ± 0.1 | 0.02 (0.49) |
| Use of sleep medication | 0.2 ± 0.2 | 0.0 ± 0.0 | 0.78 (0.16) |
| Daytime dysfunction | 0.9 ± 0.2 | 0.6 ± 0.2 | 0.24 (0.20) |
Values are means ± SE.
: P < 0.05 vs. YM.
ES: effect size.
SMI, PSQI and DASS-21
As shown in Figure 1, the score of SMI was distributed individually, and each subject was classified into two groups (group with higher SMI; 61.3 ± 4.1, group with lower SMI; 22.3 ± 2.6, P < 0.01, effect size [ES] = 4.23). Consequently, PSQI score was significantly higher in group with higher SMI score (6.4 ± 0.6) than in group with lower SMI (4.4 ± 0.5, P = 0.03, ES = 1.28). Also, DASS-21 (Stress) score was significantly higher in group with higher SMI (5.4 ± 1.3) than in group with lower SMI (2.3 ± 0.6, P = 0.04, ES = 1.17), indicating that aggravated menopausal symptoms were associated with impaired sleep quality and mental health.
Figure 1. Individual SMI scores and PSQI (B) and DASS-22 (stress) (C) scores in group with higher SMI score and group with lower SMI score.
Based on the total scores calculated, participants in the MW group were classified to determine the impact of severity of menopausal symptoms on each variable. Values are means ± SE. †: P < 0.05.
DISCUSSION
Our findings indicated that menopausal women presented with significantly impaired mental health compared to young women. This is in line with previous studies reporting increased risk for depressive disorders during menopause [23] and may be associated with decreases in estrogen levels [4,10,24].
We also found that menopausal women had significantly lower sleep quality. During menopause, the regulation of the autonomic nervous system decreases with vasomotor symptoms [25,26], which can lead to lower sleep quality [8]. Furthermore, menopausal women present decreased disturbance of sleep. Kim et al. [27] reported that overactivity of the sympathetic nervous system during sleep was associated with a decline in sleep quality including less slow-wave sleep and increased frequency of awakenings.
Notably, we also found that menopause severity was significantly associated with lower sleep quality. This is supported by several studies [28,29] including Thurston et al. [30], who found that nocturnal hot flashes (a typical menopausal symptom) are associated with increased wakefulness after sleep onset and reduced sleep efficiency. In addition, abnormal hormonal balance, which disrupts the circadian rhythm of body temperature, negatively affects sleep [31]. Furthermore, menopausal women with depressive symptoms show decreased sleep quality [9,32]. However, the impact of the severity of menopausal symptoms on sleep quality and mental health has not been fully determined. Our findings suggest that aggravated menopausal symptoms are related to further impairments of sleep quality and mental health. Furthermore, it appears red that menopausal symptoms, mental health, and sleep quality interact each other, although detailed mechanism is still unclear.
Our study had several limitations. First, sleep quality was assessed according to PSQI score, and we were not able to collect objective information such as polysomnography data during sleep. Since subjective and objective sleep parameters indicators are not always consistent [33], caution still needs for interpretation. Second, autonomic nervous activity and core body temperature during sleep were not evaluated. Thus, future determinations of nocturnal parasympathetic nervous activity and core temperature data would help clarify how menopause impairs sleep quality. Third, the subjective findings might be specific to the questionnaires we utilized. In addition, since PSQI, CES-D, and others are self-reported scales, the influence of subjective bias needs to be considered. Fourth, the sample size in each group (n = 20 in each group) was minimum, and further investigations with large number of participants may be required. Fifthly, we were not able to determine estrogen and progesterone levels in the MW group. Although the MW group reported menopausal symptoms, association between sex hormone levels and both sleep quality and mental health should be determined in future. Finally, because it was an observational study, our results do not provide effective solutions to improve sleep quality. Currently, hormone replacement therapy is a major treatment to relieve menopausal symptoms [34]. However, none of participants treated hormone replacement therapy, and some side effects (e.g., headache, sexual dysfunction) are of concern [35]. Therefore, it is necessary to develop a non-pharmacological approach. In particular, the effectiveness of exercise therapy has been increasing attention [36], future investigations of the effects of low- to moderate-intensity exercise during the day on sleep quality and menopausal symptoms would be valuable.
In conclusion, sleep quality and mental health are negatively impacted by menopause, especially in women with severe symptoms.
Footnotes
ACKNOWLEDGEMENTS
We would like to thank all subjects who completed experimental trials. We also thank the laboratory members for the technical support. The present study was supported by the Mizuno Corporation, and grant from Ritsumeikan University.
The authors declare that they have no conflict of interest.
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