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Our study objectives were to evaluate the age-related changes in actigraphy measures of sleep duration, continuity, and timing across 12 years in midlife women as they traversed the menopause, and to take into account factors affecting women's sleep that also change with age. Black, white, and Chinese women were recruited from the Study of Women's Health Across the Nation (SWAN) to participate in an ancillary sleep study on two occasions over 3 years apart and a third assessment 12 years after the first (N = 300, mean ages, 52, 55, and 64 at the three assessments). Women had at least four consecutive nights of actigraphy (95% with 7 nights) and sleep diaries, and self-reported sleep complaints measured at each time point. Partial correlations adjusted for time between assessments across the 12 years were significant and moderate in size (r's = .33-.58). PROC MIXED/GLIMMIX multivariate models showed that sleep duration increased over time; wake after sleep onset (WASO) declined, midpoint of sleep interval increased, and sleep latency and number of sleep complaints did not change between the first and third assessments. Blacks and whites had a greater increase in sleep duration than Chinese. Taken together, the results of this longitudinal study suggest that sleep may not worsen, in general, in midlife women. Perhaps, the expected negative effect of aging in midlife into early old age on sleep is overstated.

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Resumen Hay una nueva apreciación de la perimenopausia, definida como las etapas de transición temprana y tardía de la menopausia, también como la posmenopausia temprana, como una ventana de vulnerabilidad para el desarrollo de síntomas depresivos y episodios depresivos mayores. Sin embargo, las recomendaciones clínicas sobre cómo identificar, caracterizar y tratar la depresión clínica están faltando. Para abordar esta brecha, se convocó un panel de expertos para revisar sistemáticamente la literatura publicada y desarrollar lineamientos sobre la evaluación y manejo de la depresión perimenopáusica. Las áreas abordadas incluyeron: 1) epidemiología; 2) presentación clínica; 3) efectos terapéuticos de los antidepresivos; 4) efectos de la terapia hormonal; y 5) la eficacia de otras terapias (por ejemplo, psicoterapia, ejercicio y productos naturales para la salud). En general, la evidencia sugiere que la mayoría de las mujeres de mediana edad que experimentan un episodio depresivo mayor durante la perimenopausia han tenido un episodio previo de depresión. La depresión de la mediana edad se presenta con síntomas depresivos clásicos comúnmente en combinación con síntomas de la menopausia (es decir, síntomas vasomotores, trastornos del sueño) y problemas psicosociales. Los síntomas de la menopausia se complican, coexisten y se superponen con la presentación de la depresión. El diagnóstico implica la identificación de la etapa menopáusica, la evaluación de los síntomas psiquiátricos y de la menopausia (los cuales son concurrentes), apreciación de los factores psicosociales comunes en la mediana edad, diagnósticos diferenciales y el uso de pruebas de detección con instrumentos validadas. Las opciones terapéuticas probadas para la depresión (es decir, antidepresivos, psicoterapia) son la primera línea de tratamientos para la depresión perimenopáusica. Aunque la terapia con estrógenos no está aprobada para tratar la perimenopausia, existe evidencia de que tiene efectos antidepresivos en mujeres perimenopáusicas, particularmente en aquellas con síntomas vasomotores concomitantes. Los datos sobre estrógeno más progestina son escasos y no concluyentes.

Abstract There is a new appreciation of the perimenopause ­ defined as the early and late menopause transition stages as well as the early postmenopause - as a windowof vulnerability for the development of both depressive symptoms and major depressive episodes. However, clinical recommendations on how to identify, characterize and treat clinical depression are lacking. To address this gap, an expert panel was convened to systematically review the published literature and develop guidelines on the evaluation and management of perimenopausal depression. The areas addressed included: 1) epidemiology; 2) clinical presentation; 3) therapeutic effects of antidepressants; 4) effects ofhormonetherapy;and5)efficacyofothertherapies(eg,psychotherapy,exercise,andnatural health products). Overall, evidence generally suggests that most midlife women who experience a major depressive episode during the perimenopause have experienced a prior episode of depression. Midlife depression presents with classic depressive symptoms commonly in combination with menopause symptoms (ie, vasomotor symptoms, sleep disturbance), and psychosocial challenges. Menopause symptoms complicate, co-occur, and overlap with the presentation of depression. Diagnosis involves identification of menopausal stage, assessment of co-occurring psychiatric and menopause symptoms, appreciation of the psychosocial factors common in midlife, differential diagnoses, and the use of validated screening instruments. Proven therapeutic options for depression (ie, antidepressants, psychotherapy) are the front-line treatments for perimenopausal depression. Although estrogen therapy is not approved to treat perimenopausal depression, there is evidence that it has antidepressant effects in perimenopausal women particularly those with concomitant vasomotor symptoms. Data on estrogen plus progestin are sparse and inconclusive.

Assuntos

RESUMO

Hay una nueva apreciación de la perimenopausia, definida como las etapas de transición temprana y tardía de la menopausia, también como la posmenopausia temprana, como una ventana de vulnerabilidad para el desarrollo de síntomas depresivos y episodios depresivos mayores. Sin embargo, las recomendaciones clínicas sobre cómo identificar, caracterizar y tratar la depresión clínica están faltando. Para abordar esta brecha, se convocó un panel de expertos para revisar sistemáticamente la literatura publicada y desarrollar lineamientos sobre la evaluación y manejo de la depresión perimenopáusica. Las áreas abordadas incluyeron: 1) epidemiología; 2) presentación clínica; 3) efectos terapéuticos de los antidepresivos; 4) efectos de la terapia hormonal; y 5) la eficacia de otras terapias (por ejemplo, psicoterapia, ejercicio y productos naturales para la salud). En general, la evidencia sugiere que la mayoría de las mujeres de mediana edad que experimentan un episodio depresivo mayor durante la perimenopausia han tenido un episodio previo de depresión. La depresión de la mediana edad se presenta con síntomas depresivos clásicos comúnmente en combinación con síntomas de la menopausia (es decir, síntomas vasomotores, trastornos del sueño) y problemas psicosociales. Los síntomas de la menopausia se complican, coexisten y se superponen con la presentación de la depresión. El diagnóstico implica la identificación de la etapa menopáusica, la evaluación de los síntomas psiquiátricos y de la menopausia (los cuales son concurrentes), apreciación de los factores psicosociales comunes en la mediana edad, diagnósticos diferenciales y el uso de pruebas de detección con instrumentos validadas. Las opciones terapéuticas probadas para la depresión (es decir, antidepresivos, psicoterapia) son la primera línea de tratamientos para la depresión perimenopáusica. Aunque la terapia con estrógenos no está aprobada para tratar la perimenopausia, existe evidencia de que tiene efectos antidepresivos en mujeres perimenopáusicas, particularmente en aquellas con síntomas vasomotores concomitantes. Los datos sobre estrógeno más progestina son escasos y no concluyentes.

There is a new appreciation of the perimenopause ­ defined as the early and late menopause transition stages as well as the early postmenopause - as a windowof vulnerability for the development of both depressive symptoms and major depressive episodes. However, clinical recommendations on how to identify, characterize and treat clinical depression are lacking. To address this gap, an expert panel was convened to systematically review the published literature and develop guidelines on the evaluation and management of perimenopausal depression. The areas addressed included: 1) epidemiology; 2) clinical presentation; 3) therapeutic effects of antidepressants; 4) effects of hormone therapy; and 5) efficacy of other therapies (eg, psychotherapy, exercise, and natural health products). Overall, evidence generally suggests that most midlife women who experience a major depressive episode during the perimenopause have experienced a prior episode of depression. Midlife depression presents with classic depressive symptoms commonly in combination with menopause symptoms (ie, vasomotor symptoms, sleep disturbance), and psychosocial challenges. Menopause symptoms complicate, co-occur, and overlap with the presentation of depression. Diagnosis involves identification of menopausal stage, assessment of co-occurring psychiatric and menopause symptoms, appreciation of the psychosocial factors common in midlife, differential diagnoses, and the use of validated screening instruments. Proven therapeutic options for depression (ie, antidepressants, psychotherapy) are the front-line treatments for perimenopausal depression. Although estrogen therapy is not approved to treat perimenopausal depression, there is evidence that it has antidepressant effects in perimenopausal women, particularly those with concomitant vasomotor symptoms. Data on estrogen plus progestin are sparse and inconclusive.

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STUDY OBJECTIVES: Evaluate whether levels of upsetting life events measured over a 9-y period prospectively predict subjective and objective sleep outcomes in midlife women. DESIGN: Prospective cohort study. SETTING: Four sites across the United States. PARTICIPANTS: 330 women (46-57 y of age) enrolled in the Study of Women's Health Across the Nation (SWAN) Sleep Study. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Upsetting life events were assessed annually for up to 9 y. Trajectory analysis applied to life events data quantitatively identified three distinct chronic stress groups: low stress, moderate stress, and high stress. Sleep was assessed by self-report and in-home polysomnography (PSG) during the ninth year of the study. Multivariate analyses tested the prospective association between chronic stress group and sleep, adjusting for race, baseline sleep complaints, marital status, body mass index, symptoms of depression, and acute life events at the time of the Sleep Study. Women characterized by high chronic stress had lower subjective sleep quality, were more likely to report insomnia, and exhibited increased PSG-assessed wake after sleep onset (WASO) relative to women with low to moderate chronic stress profiles. The effect of chronic stress group on WASO persisted in the subsample of participants without baseline sleep complaints. CONCLUSIONS: Chronic stress is prospectively associated with sleep disturbance in midlife women, even after adjusting for acute stressors at the time of the sleep study and other factors known to disrupt sleep. These results are consistent with current models of stress that emphasize the cumulative effect of stressors on health over time.

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OBJECTIVE: We examined whether women reporting nighttime pain would have more actigraphy-measured evidence for disturbed sleep and would report feeling less rested compared with women without nighttime pain. METHODS: Up to 27 consecutive nights of actigraphy and sleep diary data from each participant were analyzed in this community-based study of 314 African-American (n = 118), white (n = 141), and Chinese (n = 55) women, aged 48 to 58 years, who were premenopausal, perimenopausal, or postmenopausal and were participating in the Study of Women's Health Across the Nation Sleep Study. Dependent variables were actigraphy-measured movement and fragmentation index, total sleep time, sleep efficiency, and diary self-report of "feeling rested" after waking up. All outcomes were fitted using linear mixed-effects models to examine covariate-adjusted associations between the independent variable (nighttime pain severity) and sleep outcomes. RESULTS: Higher pain severity scores were associated with longer sleep duration but reduced sleep efficiency and less restful sleep. Women reporting nocturnal vasomotor symptoms had more sleep-related movement and sleep fragmentation, had reduced sleep efficiency, and were less likely to feel rested after wakening whether or not they reported pain. CONCLUSIONS: Midlife women who report higher nighttime pain levels have more objective evidence for less efficient sleep, consistent with self-reported less restful sleep. Nocturnal vasomotor symptoms also can contribute to restlessness and wakefulness in midlife women.

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OBJECTIVE: Depression may be a risk factor for coronary heart disease (CHD) morbidity and mortality, but the mechanism(s) for the association are not established. The present study examined the relationship between one possible mechanism, hemostatic factors, and depressive symptoms in middle-aged women. METHOD: We measured levels of fibrinogen, Factor VIIc, plasminogen activator inhibitor antigen-1 (PAI-1), and tissue plasminogen activator antigen (TPA-ag) in 3,016 women aged 42-52 years enrolled in the Study of Women's Health Across the Nation (SWAN). Depressive symptoms were measured by the Center for Epidemiological Studies Depression Scale (CES-D), with scores > 16 suggestive of depression. RESULTS: Depressed women had high levels of all four hemostatic factors ( all p <0 .01). After controlling for age, smoking, ethnicity, prevalent cardiovascular disease, osteoarthritis, and dia-betes, and use of medications (including psychotropics), depressed women still had elevated levels of fibrinogen (mean, 95% confidence intervals 299, 304 ­ 295 mg/dl vs. 291, 294 ­ 288mg/dl, p= 0.003) and Factor VIIc (124, 127 ­ 121 ng/dl vs. 119, 121 ­ 117 ng/dl, p= 0.01) levels, compared to nondepressed women. CONCLUSIONS: These findings suggest that hemostatic factors may be a key me-chanism accounting for the relationship between depression and CHD. [Castilla RC, Bromberger JT, Zhang Y, Perel JM, Matthews KA. Depressive symptoms are related with hemostatic factors in middle-aged women: A report from the Study of Women Health Across the Nation (SWAN). MedUNAB 2004; 7:57-64

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