Journal of Psychosomatic Research,
Vol. 20, pp. 509 to 513. Pergamon Press, 1976. Printed in Great Britain.
SUBJECTIVE SLEEP DISTURBANCE AT THE MENOPAUSE* C.BARBARA
BALLINGER
(Received 28 January 1976) SEVERAL studies [l-3] of menopausal symptoms and their management note that insomnia is reported more frequently at this time of life. In a survey reported by Jaszmann, Van Lith and Zaat [l] complaints of insomnia increased from 20% in premenopausal women to 40% in those women two to five years post-menopausal. In another survey [2] complaints of sleeplessness did not vary with menopausal status but tended to occur together with complaints of headache, dizzy spells, palpitations, depression and weight increase. In a study of sleep disturbance in the general population McGhie and Russell [4] found that reported sleep disturbance increased with increasing age. In women this increase commenced in “middle-age” but in men there was no significant change until after the age of 65. Other studies [5,6] have shown the increased sleep disturbance as a feature of psychiatric illness. In view of these findings it was decided as part of a study of psychiatric morbidity in relation to the menopause [7] to look at reported sleep disturbance in relation to menopausal status, age and psychiatric morbidity. METHODS All women between 40 and 55 yr old on the lists of 6 general Practitioners were approached by letter and asked to complete the 60 item General Health Questionnaire (GHQ), a self-administered Questionnaire for the detection of non-psychotic psychiatric illness as described by Goldberg [8]. They were also asked to complete a brief Questionnaire about their menstrual periods. The GHQs were scored as recommended by Goldberg [8] and those women scoring 12 or more were considered to have significant psychiatric morbidity and are referred to as the “cases”. Sleep disturbance in the “non-cases” was assessed by looking at the responses to questions 11, 17 and 18 on the GHQ. Question 11 asks about waking early and being unable to get back to sleep, Question 17 asks about difficulty getting off to sleep and Question 18 about difficulty staying asleep for the duration of the night. Those women identified by the GHQ as psychiatric “cases” were asked if they would agree to being interviewed. Those women who were agreeable were interviewed using a standardized psychiatric interview as described by Goldberg et nl. [9]. On this interview schedule insomnia is rated on the scale O-4 according to severity and frequency of sleep disturbance in the week prior to interview. Hypnotic consumption is also rated &4 according to the number of nights hypnotics have been taken in the last week. For the purposes of this study the ratings for insomnia and hypnotic consumption were combined to give an overall rating for sleep disturbance. RESULTS 539 (71%) of the 760 women approached returned completed questionnaires. Women who had had a hysterectomy or who did not give the relevant information were not included in this study. 159 women scored 12 or more on the GHQ and were considered probable psychiatric “cases”, 114 of the “cases” agreed to being interviewed. The “non-cases” and the “cases” were each divided into four groups according to menopausal status. All women having regular menstrual periods were termed pre-menopausal. Those women who *From the Department
of Psychiatry, Ninewells Hospital and Medical School, Dundee, Scotland. 509
510
C.
had missed between termed menopausal.
post-menopausal
3 and 12 menstrual
BARBARA BALLINGER periods
at the time of completing
the questionnaire
were
The post-menopausal group was divided into two; women less than 6 years and women 6 or more years post-menopausal. SLEEP DlSTURBANCE
IN “NON-CASES”
There were 358 women in all, 163 m-e-menopausal (mean age 44.1 yr), 48 menopausal (mean age 48.4 yr), 83 up to five years post-menOpaLIsa1 (mean age 49.6 yr) and 64 six or more years postmenopausal (mean age 52.2 yr). The proportion of women in each group according to menopausal status complaining of rather or much more difficulty in getting off to sleep recently, difficulty staying asleep or early morning waking is shown in Fig. 1. The difference between the pre-menopausal group and the combined post-menopausal groups reaches statistical significance for difficulty in getting off to sleep (x2 = 4.42, 1 dJ‘p -e 0.05) and for difficulty staying asleep (x = 7.59, 1 dfp < 0.01). The difference between these groups for early morning waking does not reach statistical significance.
b
20
4 DIFFICULTY
jlOI rl
0
n
20
.=liyrs. POST-M.
DIFFICULTY
STAYING
ASLEEP
PREMENOPAUSAL
0.
FIG. l.-Reported
1
;-
M.
n
20 J
rl
OFF TO SLEEP
PREMENOPAUSAL
jlO\ o-
GETTING
EARLY
M.
MORNING
PREMENOPAUSAL
sleep disturbance
1:
n
M.
-z 6yrs. POST-M
6 + yrs POST-M
rl
f
6 +yrr. P&ST-M.
WAKING
-=6YfS. POST-M.
in “non-cases”
6+yrr. POST-M
according to menopausal status.
The mean age of the 38 women reporting increased difficulty getting off to sleep was 49.2 yr SD 4.2 and the mean age of the other 320 women 47.7 yr SD 4.6. This difference reaches statistical significance (t = 2.25, 357 df p < 0.05). Within each group according to menopausal status the difference did not reach statistical significance. For difliculty staying asleep and early morning waking there was no significant difference between the mean ages of those women reporting increased difficulty and the rest. SLEEP DISTURBANCE
IN PSYCHIATRIC
“CASES”
Of the 114 psychiatric “cases” 53 were pre-menopausal, 26 menopausal, 21 up to five years postmenopausal and 14 six or more years post-menopausal. 18 women in all, 8 pre-menopausal, 4 menopausal and 6 post-menpausal were taking hypnotics. The means of the combined ratings for insomnia and hypnotic consumption in relation to menopausal status are shown in Fig. 2. The increase in sleep disturbance was accounted for by an increase
Subjective sleep disturbance
at the menopause
511
FIG. 2. Mean combined ratings for hypnotic consumption and insomnia in psychiatric “cases” according to menopausal status. in the number of complaints of difficulty getting off to sleep from 15 (28%) of the 53 pre-menopausal subjects to 8 (57%) of the 14 subjects. more than six years post-menopausal. The proportion of women complaining of early morning waking remained between 35 and 40% in each group. DISCUSSION
Although a survey of reported sleep disturbance is open to considerable criticism it remains the most practical way to obtain information from large numbers of people in order to look at patterns of change in sleep disturbance in relation to other variables. The GHQ concentrates on recent events and change in severity of symptoms so avoiding some of the subjective element in the patient’s assessment of how many hours of sleep they have had. Considering first the “non-cases” there is evidence of a significant increase in reports of difficulty getting off to sleep and staying asleep in the post-menopausal group. This does not follow the same pattern of change as vasomotor complaints which have been shown to increase significantly in the menopausal group and decrease in the group of women six or more years post-menopausal [7]. The complaints of difficulty getting off to sleep remain at a higher level in this last group and it seems unlikely that the change in sleep pattern is produced only by vasomotor phenomena occurring at night. The number of complaints of early morning waking did not vary significantly with menopausal status. These findings are consistent with those of McGhie and Russell [4] who found that reports of difficulty getting off to sleep showed a significant increase in “middleage” in women but not in men. In the same study it was found that early morning waking did vary with age but there was no significant increase until 65-74 yr of age and the pattern was the same for both sexes. Those women identified as having significant psychiatric morbidity also showed variation in sleep disturbance according to menopausal status (Fig. 2) but this did not follow the pattern shown by the “non-cases” (Fig. 1). For the “cases” there was a small steady increase in the mean ratings of sleep disturbance from the pre-menopausal group to those women up to five years post-menopausal then a marked increase in those women six or more years post-menopausal. As with the “non-cases”
512
C.BARBARABALLINGER
the change appears to be related mainly to difficulty getting off to sleep and the level of complaints of early morning waking did not vary significantly with menopausal status. Although reported sleep disturbance has been shown to be related to psychiatric illness [S] the change in sleep disturbance with menopausal status is seen to occur both in the women with evidence of psychiatric disturbance and the “non-cases”. Also the change in sleep disturbance does not follow the same pattern as the change in psychiatric morbidity in relation to the menopause in the same population sample [7]. Sleep disturbance reaches a maximum in the post-menopausal groups whereas psychiatric morbidity was highest in the pre-menopausal women of 45-50 years of age and the menopausal group. The change in sleep pattern in women at this time of life does not just reflect changes in psychiatric morbidity. It is possible that the observed changes in reported sleep disturbance with menopausal status is just a reflection of increasing age. The mean age of the post-menopausal group is, as expected, higher than the mean age of the pre-menopausal and menopausal groups. As the majority of women with increased sleep disturbance come from the post-menopausal groups the mean age of the women with increased sleep disturbance tends to be higher than the mean age of the rest. Sleep disturbance is an important symptom and common reason for approaching a doctor. Starting on hypnotics often leads to long-term medication and this is a particular problem in women in middle age and older [IO]. In view of this it would seem reasonable to look in more detail at any physiological factor which may be related to changes in sleep pattern. As reports of difficulty getting off to sleep increase significantly in post-menopausal women perhaps this aspect of sleep disturbance should be looked at in relation to hormonal changes at this time of life. CONCLUSION In a survey of 539 women from the general population aged between 40 and 55 yr, reported sleep disturbance was studied in relation to age, psychiatric morbidity and menopausal status. Difficulty getting off to sleep and difficulty staying asleep for the duration of the night were reported more frequently by post-menopausal women but reports of early morning wakening did not vary significantly with menopausal status. This change in reported sleep disturbance could not be accounted for by the variation in the level of psychiatric morbidity but it may reflect the greater age of the post-menopausal women. It is suggested that it may be of value to look at sleep disturbance in relation to endocrine status at the time of the menopause. REFERENCES 1. JASZMANNL., VAN LITH N. D. and ZAAT J. L. A. The perimenopausal symptoms: the statistical analysis of a survey. Med. Gynaecol. Social. 4, 268 (1969). 2. MCKINLAY,S. M. and JEFFERYSM. The Menopausal Syndrome. Br. J. Prev. Sot. Med. 28, 108 (1974). 3. FOLDESJ. J. Psychosomatic approach to the menopausal syndrome. Treatment with opipranol. Psychosomatic Medicine in Obstetrics and Gynaecology 3rd Int. Congr. London 1971. p. 617, Karger, Base1 (1972). MCGHIE A. and RUSSELLW. M. The subjective assessment of normal sleep patterns. J. Ment. Sci. 108,641 (1962). MCGHIE A. The subjective assessment of sleep patterns in psychiatric illness. Br. J. Med. Psychol. 39, 221(1966).
ORMEJ. E. Duration of sleep and its relationship to age, personality and psychiatric illness. Br. J. Sot. Clin. Psychol. 11,70 (1972). BALLINGERC. B. Psychiatric Morbidity and the Menopause; Screening of General Population sample. Br. Med. J. 3, 344 (1975).
Subjective sleep disturbance
at the menopause
513
8. GOLDBERGD. P. The Detection of Psychiatric Illness by Questionnaire. Oxford University Press, London (1972). 9. GOLDBERGD. P., COOPERB., EASTWOODM. R., KEDWARDH. B. and SHEPHERDM. A standardiized psychiatric interview for use in community surveys. Br. J. Prev. Sm. Med. 24,18 (1970). 10. DUNNELLK. and CARTWRIGHTA. Medicine Takers, Prescribers and Hoarders. p. 112. Routledge & Kegan Paul, London (1972).
Vol. 20, pp. 509 to 513. Pergamon Press, 1976. Printed in Great Britain.
SUBJECTIVE SLEEP DISTURBANCE AT THE MENOPAUSE* C.BARBARA
BALLINGER
(Received 28 January 1976) SEVERAL studies [l-3] of menopausal symptoms and their management note that insomnia is reported more frequently at this time of life. In a survey reported by Jaszmann, Van Lith and Zaat [l] complaints of insomnia increased from 20% in premenopausal women to 40% in those women two to five years post-menopausal. In another survey [2] complaints of sleeplessness did not vary with menopausal status but tended to occur together with complaints of headache, dizzy spells, palpitations, depression and weight increase. In a study of sleep disturbance in the general population McGhie and Russell [4] found that reported sleep disturbance increased with increasing age. In women this increase commenced in “middle-age” but in men there was no significant change until after the age of 65. Other studies [5,6] have shown the increased sleep disturbance as a feature of psychiatric illness. In view of these findings it was decided as part of a study of psychiatric morbidity in relation to the menopause [7] to look at reported sleep disturbance in relation to menopausal status, age and psychiatric morbidity. METHODS All women between 40 and 55 yr old on the lists of 6 general Practitioners were approached by letter and asked to complete the 60 item General Health Questionnaire (GHQ), a self-administered Questionnaire for the detection of non-psychotic psychiatric illness as described by Goldberg [8]. They were also asked to complete a brief Questionnaire about their menstrual periods. The GHQs were scored as recommended by Goldberg [8] and those women scoring 12 or more were considered to have significant psychiatric morbidity and are referred to as the “cases”. Sleep disturbance in the “non-cases” was assessed by looking at the responses to questions 11, 17 and 18 on the GHQ. Question 11 asks about waking early and being unable to get back to sleep, Question 17 asks about difficulty getting off to sleep and Question 18 about difficulty staying asleep for the duration of the night. Those women identified by the GHQ as psychiatric “cases” were asked if they would agree to being interviewed. Those women who were agreeable were interviewed using a standardized psychiatric interview as described by Goldberg et nl. [9]. On this interview schedule insomnia is rated on the scale O-4 according to severity and frequency of sleep disturbance in the week prior to interview. Hypnotic consumption is also rated &4 according to the number of nights hypnotics have been taken in the last week. For the purposes of this study the ratings for insomnia and hypnotic consumption were combined to give an overall rating for sleep disturbance. RESULTS 539 (71%) of the 760 women approached returned completed questionnaires. Women who had had a hysterectomy or who did not give the relevant information were not included in this study. 159 women scored 12 or more on the GHQ and were considered probable psychiatric “cases”, 114 of the “cases” agreed to being interviewed. The “non-cases” and the “cases” were each divided into four groups according to menopausal status. All women having regular menstrual periods were termed pre-menopausal. Those women who *From the Department
of Psychiatry, Ninewells Hospital and Medical School, Dundee, Scotland. 509
510
C.
had missed between termed menopausal.
post-menopausal
3 and 12 menstrual
BARBARA BALLINGER periods
at the time of completing
the questionnaire
were
The post-menopausal group was divided into two; women less than 6 years and women 6 or more years post-menopausal. SLEEP DlSTURBANCE
IN “NON-CASES”
There were 358 women in all, 163 m-e-menopausal (mean age 44.1 yr), 48 menopausal (mean age 48.4 yr), 83 up to five years post-menOpaLIsa1 (mean age 49.6 yr) and 64 six or more years postmenopausal (mean age 52.2 yr). The proportion of women in each group according to menopausal status complaining of rather or much more difficulty in getting off to sleep recently, difficulty staying asleep or early morning waking is shown in Fig. 1. The difference between the pre-menopausal group and the combined post-menopausal groups reaches statistical significance for difficulty in getting off to sleep (x2 = 4.42, 1 dJ‘p -e 0.05) and for difficulty staying asleep (x = 7.59, 1 dfp < 0.01). The difference between these groups for early morning waking does not reach statistical significance.
b
20
4 DIFFICULTY
jlOI rl
0
n
20
.=liyrs. POST-M.
DIFFICULTY
STAYING
ASLEEP
PREMENOPAUSAL
0.
FIG. l.-Reported
1
;-
M.
n
20 J
rl
OFF TO SLEEP
PREMENOPAUSAL
jlO\ o-
GETTING
EARLY
M.
MORNING
PREMENOPAUSAL
sleep disturbance
1:
n
M.
-z 6yrs. POST-M
6 + yrs POST-M
rl
f
6 +yrr. P&ST-M.
WAKING
-=6YfS. POST-M.
in “non-cases”
6+yrr. POST-M
according to menopausal status.
The mean age of the 38 women reporting increased difficulty getting off to sleep was 49.2 yr SD 4.2 and the mean age of the other 320 women 47.7 yr SD 4.6. This difference reaches statistical significance (t = 2.25, 357 df p < 0.05). Within each group according to menopausal status the difference did not reach statistical significance. For difliculty staying asleep and early morning waking there was no significant difference between the mean ages of those women reporting increased difficulty and the rest. SLEEP DISTURBANCE
IN PSYCHIATRIC
“CASES”
Of the 114 psychiatric “cases” 53 were pre-menopausal, 26 menopausal, 21 up to five years postmenopausal and 14 six or more years post-menopausal. 18 women in all, 8 pre-menopausal, 4 menopausal and 6 post-menpausal were taking hypnotics. The means of the combined ratings for insomnia and hypnotic consumption in relation to menopausal status are shown in Fig. 2. The increase in sleep disturbance was accounted for by an increase
Subjective sleep disturbance
at the menopause
511
FIG. 2. Mean combined ratings for hypnotic consumption and insomnia in psychiatric “cases” according to menopausal status. in the number of complaints of difficulty getting off to sleep from 15 (28%) of the 53 pre-menopausal subjects to 8 (57%) of the 14 subjects. more than six years post-menopausal. The proportion of women complaining of early morning waking remained between 35 and 40% in each group. DISCUSSION
Although a survey of reported sleep disturbance is open to considerable criticism it remains the most practical way to obtain information from large numbers of people in order to look at patterns of change in sleep disturbance in relation to other variables. The GHQ concentrates on recent events and change in severity of symptoms so avoiding some of the subjective element in the patient’s assessment of how many hours of sleep they have had. Considering first the “non-cases” there is evidence of a significant increase in reports of difficulty getting off to sleep and staying asleep in the post-menopausal group. This does not follow the same pattern of change as vasomotor complaints which have been shown to increase significantly in the menopausal group and decrease in the group of women six or more years post-menopausal [7]. The complaints of difficulty getting off to sleep remain at a higher level in this last group and it seems unlikely that the change in sleep pattern is produced only by vasomotor phenomena occurring at night. The number of complaints of early morning waking did not vary significantly with menopausal status. These findings are consistent with those of McGhie and Russell [4] who found that reports of difficulty getting off to sleep showed a significant increase in “middleage” in women but not in men. In the same study it was found that early morning waking did vary with age but there was no significant increase until 65-74 yr of age and the pattern was the same for both sexes. Those women identified as having significant psychiatric morbidity also showed variation in sleep disturbance according to menopausal status (Fig. 2) but this did not follow the pattern shown by the “non-cases” (Fig. 1). For the “cases” there was a small steady increase in the mean ratings of sleep disturbance from the pre-menopausal group to those women up to five years post-menopausal then a marked increase in those women six or more years post-menopausal. As with the “non-cases”
512
C.BARBARABALLINGER
the change appears to be related mainly to difficulty getting off to sleep and the level of complaints of early morning waking did not vary significantly with menopausal status. Although reported sleep disturbance has been shown to be related to psychiatric illness [S] the change in sleep disturbance with menopausal status is seen to occur both in the women with evidence of psychiatric disturbance and the “non-cases”. Also the change in sleep disturbance does not follow the same pattern as the change in psychiatric morbidity in relation to the menopause in the same population sample [7]. Sleep disturbance reaches a maximum in the post-menopausal groups whereas psychiatric morbidity was highest in the pre-menopausal women of 45-50 years of age and the menopausal group. The change in sleep pattern in women at this time of life does not just reflect changes in psychiatric morbidity. It is possible that the observed changes in reported sleep disturbance with menopausal status is just a reflection of increasing age. The mean age of the post-menopausal group is, as expected, higher than the mean age of the pre-menopausal and menopausal groups. As the majority of women with increased sleep disturbance come from the post-menopausal groups the mean age of the women with increased sleep disturbance tends to be higher than the mean age of the rest. Sleep disturbance is an important symptom and common reason for approaching a doctor. Starting on hypnotics often leads to long-term medication and this is a particular problem in women in middle age and older [IO]. In view of this it would seem reasonable to look in more detail at any physiological factor which may be related to changes in sleep pattern. As reports of difficulty getting off to sleep increase significantly in post-menopausal women perhaps this aspect of sleep disturbance should be looked at in relation to hormonal changes at this time of life. CONCLUSION In a survey of 539 women from the general population aged between 40 and 55 yr, reported sleep disturbance was studied in relation to age, psychiatric morbidity and menopausal status. Difficulty getting off to sleep and difficulty staying asleep for the duration of the night were reported more frequently by post-menopausal women but reports of early morning wakening did not vary significantly with menopausal status. This change in reported sleep disturbance could not be accounted for by the variation in the level of psychiatric morbidity but it may reflect the greater age of the post-menopausal women. It is suggested that it may be of value to look at sleep disturbance in relation to endocrine status at the time of the menopause. REFERENCES 1. JASZMANNL., VAN LITH N. D. and ZAAT J. L. A. The perimenopausal symptoms: the statistical analysis of a survey. Med. Gynaecol. Social. 4, 268 (1969). 2. MCKINLAY,S. M. and JEFFERYSM. The Menopausal Syndrome. Br. J. Prev. Sot. Med. 28, 108 (1974). 3. FOLDESJ. J. Psychosomatic approach to the menopausal syndrome. Treatment with opipranol. Psychosomatic Medicine in Obstetrics and Gynaecology 3rd Int. Congr. London 1971. p. 617, Karger, Base1 (1972). MCGHIE A. and RUSSELLW. M. The subjective assessment of normal sleep patterns. J. Ment. Sci. 108,641 (1962). MCGHIE A. The subjective assessment of sleep patterns in psychiatric illness. Br. J. Med. Psychol. 39, 221(1966).
ORMEJ. E. Duration of sleep and its relationship to age, personality and psychiatric illness. Br. J. Sot. Clin. Psychol. 11,70 (1972). BALLINGERC. B. Psychiatric Morbidity and the Menopause; Screening of General Population sample. Br. Med. J. 3, 344 (1975).
Subjective sleep disturbance
at the menopause
513
8. GOLDBERGD. P. The Detection of Psychiatric Illness by Questionnaire. Oxford University Press, London (1972). 9. GOLDBERGD. P., COOPERB., EASTWOODM. R., KEDWARDH. B. and SHEPHERDM. A standardiized psychiatric interview for use in community surveys. Br. J. Prev. Sm. Med. 24,18 (1970). 10. DUNNELLK. and CARTWRIGHTA. Medicine Takers, Prescribers and Hoarders. p. 112. Routledge & Kegan Paul, London (1972).
