The relationship between sleep quality and menopausal symptoms among postmenopausal women in Saudi Arabia

Menopause is a natural physiologic event for women in midlife, defined as the permanent cessation of menses for at least one year of amenorrhea after the final menstruation. This occurs due to the aging of the ovaries leading to decrease secretions of estrogen and progesterone and not including factors such as chemotherapy, gland disorders, and hysterectomy.¹

With increased life expectancy, women can spend more than one-third of their lives in the postmenopausal state.^2,3 It is estimated that 1.2 billion women will be menopausal by 2030, with 47 million new additions each year globally.^4,5 Women’s menopause can be influenced by genetic, nutritional, environmental, and psychological factors.^6,7 During menopause, women may encounter declining physical well-being and climacteric symptoms, including vaginal dryness, hot flashes, sweating, nervousness, stress, mood swings, poor concentration, difficulty with memory, and sleeplessness.² The onset of menopause varies across countries, but the average age is around 50-52 years and most Saudi women reach menopause between the ages of 51-55.⁷

Change in estrogen levels cause irregularities in the menstrual cycle and is considered the first sign of menopause. As estrogen deprivations increase, major somatic and psychological problems originate that influence a woman’s well-being. Early somatic indicators of estrogen deprivation are hot flashes, sweating, headache, and sleep disorders. In contrast, late manifestations are mood swings, cardiovascular disease, osteoporosis, urogenital changes, fatigue, decreased sexual desire, stress incontinence, depressed mood, crying, concentration difficulties, and poor memory.⁸

Sleep plays an essential role in the well-being of an individual. It is a vital physiological process that affects physical, neurological, and psychological functions.⁹ Sleep disorder is the most prevalent and clinically prominent symptom observed during menopause and among the elderly. It is linked to unfavorable health outcomes, such as exhaustion, poor daytime function, and increased visits to healthcare providers.¹⁰ Numerous researches have sought to find out the causes of sleep disturbances and have discovered that hormonal changes, somatic symptoms, natural aging, and stressful life events can all affect sleep quality.^10,11 Aging, obesity, hypertension, smoking, and a lack of physical activity have all been associated with sleep disturbances.¹² The prevalence of sleep disturbances affects 39-47% of perimenopausal women and 35-60% of postmenopausal women. These rates are concerning and may require intervention by health care providers.^13-15 Poor sleep has various negative consequences, including poor physical, psychological, cognitive, and social outcomes.¹⁵ Sleep duration strongly influences health, and various studies support the association between sleep problems such as sleeplessness, sleep disturbances, night arousals, excessive daytime sleepiness, apnea, depression, and hot flashes with menopause in women.¹³ Moreover, insufficient sleep has been linked to an increased tendency to gain weight and ultimately, develop diabetes, osteoporosis, and increased fracture risk.^16,17

Thus, health problems related to the postmenopausal period are essential public health concerns in women at the transitional period of life. Health care providers, such as nurses, dietitians, midwives, and doctors must be sensitive and responsive to a woman’s needs during this stage of life. They should provide guidelines and design health education programs that emphasize adopting healthy and active lifestyles, including weight reduction, physical activity, a healthy diet, maintaining regular medical follow-up to improve the general well-being, and minimize the severity of menopause symptoms. The increased number of postmenopausal women raising concerns regarding their health and sleep. In addition, only few studies have researched the topic in Saudi Arabia and there is limited literature available from the Arab countries. This present study examines the association between sleep quality and menopausal symptoms in Saudi Arabian postmenopausal women.

Methods

A cross-sectional study of postmenopausal women attending or accompanying patients visiting outpatient clinics at Prince Mutaib bin Abdulaziz Hospital, Maternity and Children Hospital, and primary healthcare clinics, Sakaka, Jouf, Saudi Arabia, between January and April 2021, were selected based on personal interview for the study. The inclusion criteria included all postmenopausal women between 50-60 years old, having menopause for at least one year and voluntarily ready to participate in the study. The exclusion criteria included women who received psychiatric drugs, hormone replacement therapy, undergoing hysterectomy, or having any acute or chronic surgical conditions, cancer, and cognitive impairments, or physical handicap. A sample of 373 was calculated using Roasoft sample size calculator.¹⁸ The required sample size was computed using a total population size of 12.704 women aged 50-60 years in Sakaka, Jouf, Saudi Arabia, 5% margin of error, 95% confidence interval, and 50% response rate. A large convenience sample of 410 postmenopausal women were recruited to adjust to the dropout rate. The researchers interviewed the eligible participants using a face-to-face structured interview. The study questionnaire was self-administered, and only if the participant could not read or write, the researcher completed the questionnaire based on the participant’s response.

To achieve the study objectives, a 3-structure sectioned and validated questionnaire was used. The questionnaire was administered in the Arabic language to verify that the items were understood by the participants. Before the data collection process, the structure and clarity of this Arabic version were piloted with 40 Saudi postmenopausal women, and no changes to the questionnaire were recommended and the pilot study data were excluded.

Demographic characteristics included information on the participants’ age, education, occupation, marital status, smoking habit, physical exercise, age at menopause onset, time since the menopause onset, having chronic illnesses, and parity were collected. In this section, each participant’s height and weight were measured during the interview to assess their body mass index (BMI) that was calculated by dividing body weight (kg) by height squared (m). Body mass index was classified into 4 groups based on World Health Organization cut-off points: underweight (<18.5), healthy weight (18.5-24.9), overweight (25-29.9), and obese (≥30).¹⁹

Menopausal rating scale (MRS) is a self-reported standardized Likert scale covering 11 items related to aging symptoms or complaints and was developed by Schneider et al.²⁰ Menopausal rating scale was translated from English into simple, understandable Arabic language, which is appropriate for Arab culture by Sweed et al²¹ and was used in the present study. The MRS was categorized into the following 3 subscales: psychological symptoms (4 items that included depressive mood, irritability, anxiety, physical, and mental exhaustion), somatic symptoms (4 items that included sweating/hot flashes, sleep problems, heart discomfort, and joint and muscular discomforts), and urogenital symptoms (3 items that included bladder problems, sexual problems, and dryness of vagina). Each item was scored on a 5-point Likert scale ranging from 0 (no symptoms) to 4 (very severe symptoms). The total score was calculated by adding all the points from each item. The scores ranged from 0 (asymptomatic) to 44, indicating the highest level of complaint and reliability (0.87).¹ The severity classification summation scores were none (0-4), mild (5-8), moderate (9-16), severe and very severe (≥17). Menopausal rating scale validity and reliability were preserved in the Arabic version; with 90% test-retest agreement.²¹ In this study, Cronbach’s alpha was 0.81 indicating good reliability.

Pittsburgh sleep quality index (PSQI) is an efficient self-reporting scale for measuring subjective sleep quality and sleep patterns, developed by Buysse et al.²² An Arabic version is available.²³ The PSQI distinguishes between “poor” and “good” sleeper by evaluating different aspects of sleep using 7 components and 19 items. Responses were scored on a scale of 0-3. Whereas, 3 represented the adverse extreme of the Likert scale. The researchers added the sum of 7 components to calculate the global PSQI score, which ranged from 0-21; a score of >5 denoted a “poor” sleeper, while a cut-off point of ≤5 indicates a “good” sleeper. Thus, a score of 5-7 indicated the need for medical assessment; 8-14 recommended the need for care and medical treatment, and 14-21 suggested a serious sleeping problem. The Arabic version of the PSQI was tested with 35 Arabic bilinguals, and the documented internal consistency reliability was borderline acceptable (Cronbach’s alpha 0.65).²³ The scale had good internal reliability in this study (Cronbach’s alpha of 0.83).

The Local Committee of Bioethics at Jouf University, Saudi Arabia approved the study protocol (no.: 03-03-42) in accordance with the Helsinki Declaration principles. The study was described to the director and nurses’ supervisors at the hospital and clinics for approval to carry out the study and facilitate the data collection process. The study’s purpose, design, and benefits were explained to the participants, and written informed consents were collected before they were asked to complete the questionnaire. The participants were informed that the study was voluntary and that they had a right to withdraw anytime. Code numbers were created for each participant, and confidentiality of data was maintained.