Sleep Health and Anxiety Symptoms in Midlife Women: The Study of Women's Health Across the Nation (SWAN).

Purpose: To investigate the associations between anxiety symptoms in midlife women and sleep features later in life, the aim is to test the hypothesis that poor sleep, as measured by each of six individual dimensions (4 objective actigraphy measures, 2 self-reports) of sleep health, is associated with higher levels of anxiety symptoms in midlife women. Participants and Methods: The participants in this longitudinal analysis included women from the SWAN Sleep I Study, a subcohort of the community-dwelling midlife women participating in the core Study of Women's Health Across the Nation (SWAN), which was initiated in 1996. Of the 370 participants enrolled in the Sleep Study, 270 were included in the analytic sample, and 100 who did not meet the inclusion criteria were excluded. Baseline measures of six dimensions of multidimensional sleep health (actigraphy measures: efficiency, duration, mid-sleep timing, regularity; self-report measures: alertness, satisfaction) were obtained between 2003 and 2005, corresponding to SWAN core annual/biennial assessments 5-8. Associations of each dimension with self-reported anxiety symptoms (Generalized Anxiety Disorder - 7-item scale; GAD-7), collected during visits 12 (2009-2011), 13 (2011-2013), and 15 (2015-2017), were examined using mixed models. The GAD-7 outcome was measured both continuously and as a categorical variable due to its skewed distribution. Results: No statistically significant associations were found between any of the six baseline sleep health dimensions and the GAD-7 score after adjustment for covariates. Conclusion: The reasons for the lack of support for our hypothesis, despite previous evidence supporting an association between sleep and anxiety, are unclear. There is considerable overlap between anxiety and sleep symptoms, which may complicate the interpretation of our the findings. Thus, the failure to identify associations is likely multifactorial, and more studies with shorter follow-up intervals are warranted to better understand these relationships.

Cardiovascular Health, Race, and Decline in Cognitive Function in Midlife Women: The Study of Women's Health Across the Nation.

BACKGROUND: Cognitive decline may progress for decades before dementia onset. Better cardiovascular health (CVH) has been related to less cognitive decline, but it is unclear whether this begins early, for all racial subgroups, and all domains of cognitive function. The purpose of this study was to determine the impact of CVH on decline in the 2 domains of cognition that decline first in White and Black women at midlife. METHODS AND RESULTS: Subjects were 363 Black and 402 White women, similar in baseline age (mean±SD, 46.6±3.0 years) and education (15.7±2.0 years), from the Chicago site of the Study of Women's Health Across the Nation. Cognition, measured as processing speed and working memory, was assessed annually or biennially over a maximum of 20 years (mean±SD, 9.8±6.7 years). CVH was measured as Life's Essential 8 (blood pressure, body mass index, glucose, non-high-density lipoprotein cholesterol, smoking, physical activity, diet, sleep). Hierarchical linear mixed models identified predictors of cognitive decline with progressive levels of adjustment. There was a decline in processing speed that was explained by race, age, and the 3-way interaction of race, CVH, and time (F1,4308=8.8, P=0.003). CVH was unrelated to decline in White women but in Black women poorer CVH was associated with greater decline. Working memory did not decline in the total cohort, by race, or by CVH. CONCLUSIONS: In midlife Black women, CVH promotion may be a target for preventing the beginnings of cognitive decline, thereby enhancing independent living with aging.

Method for Activity Sleep Harmonization (MASH): a novel method for harmonizing data from two wearable devices to estimate 24-h sleep-wake cycles.

Background: Daily 24-h sleep-wake cycles have important implications for health, however researcher preferences in choice and location of wearable devices for behavior measurement can make 24-h cycles difficult to estimate. Further, missing data due to device malfunction, improper initialization, and/or the participant forgetting to wear one or both devices can complicate construction of daily behavioral compositions. The Method for Activity Sleep Harmonization (MASH) is a process that harmonizes data from two different devices using data from women who concurrently wore hip (waking) and wrist (sleep) devices for ≥ 4 days. Methods: MASH was developed using data from 1285 older community-dwelling women (ages: 60-72 years) who concurrently wore a hip-worn ActiGraph GT3X + accelerometer (waking activity) and a wrist-worn Actiwatch 2 device (sleep) for ≥ 4 days (N = 10,123 days) at the same time. MASH is a two-tiered process using (1) scored sleep data (from Actiwatch) or (2) one-dimensional convolutional neural networks (1D CNN) to create predicted wake intervals, reconcile sleep and activity data disagreement, and create day-level night-day-night pairings. MASH chooses between two different 1D CNN models based on data availability (ActiGraph + Actiwatch or ActiGraph-only). MASH was evaluated using Receiver Operating Characteristic (ROC) and Precision-Recall curves and sleep-wake intervals are compared before (pre-harmonization) and after MASH application. Results: MASH 1D CNNs had excellent performance (ActiGraph + Actiwatch ROC-AUC = 0.991 and ActiGraph-only ROC-AUC = 0.983). After exclusions (partial wear [n = 1285], missing sleep data proceeding activity data [n = 269], and < 60 min sleep [n = 9]), 8560 days were used to show the utility of MASH. Of the 8560 days, 46.0% had ≥ 1-min disagreement between the devices or used the 1D CNN for sleep estimates. The MASH waking intervals were corrected (median minutes [IQR]: -27.0 [-115.0, 8.0]) relative to their pre-harmonization estimates. Most correction (-18.0 [-93.0, 2.0] minutes) was due to reducing sedentary behavior. The other waking behaviors were reduced a median (IQR) of -1.0 (-4.0, 1.0) minutes. Conclusions: Implementing MASH to harmonize concurrently worn hip and wrist devices can minimizes data loss and correct for disagreement between devices, ultimately improving accuracy of 24-h compositions necessary for time-use epidemiology.

Self-Reported Sleep Disturbances over the Menopausal Transition and Fracture Risk: The Study of Women's Health Across the Nation.

Sleep disturbances are common and may impact fracture risk directly by influencing bone turnover or indirectly through shared risk factors or mediators. To investigate the association between self-reported sleep disturbances across the menopausal transition (MT) and fractures, we prospectively studied 3101 women enrolled in the Study of Women's Health Across the Nation (SWAN). At each of 14 study visits spaced approximately 18 months apart, a standardized validated scale ascertained trouble falling asleep, waking up several times during the night, and waking up earlier than planned. Two time-varying exposures were modeled: presence of any of the three disturbances at least three times per week and waking up several times during the night at least three times per week. Base models adjusted for fixed (race/ethnicity, study site) and time-varying characteristics (age, body mass index, and MT stage). Fully adjusted models also included time-varying bone beneficial and detrimental medications, smoking, alcohol, physical activity, diabetes, depression and sleep medications, and depressive symptoms. Women who experienced a fracture were more likely to report a greater frequency of having trouble falling asleep, waking up several times, and/or waking up earlier: 35% versus 30% at baseline, p = 0.02. In the base models, women who had any of the three sleep disturbances at least three times per week had a higher risk of any fracture, odds ratio (OR) = 1.23 (95% confidence intervals, 1.02, 1.48) and nontraumatic fracture, OR = 1.36 (1.03, 1.80). These associations were largely attenuated to nonsignificance in the fully adjusted model. Sensitivity analyses limiting our sample to 2315 SWAN women enrolled in the bone mineral density (BMD) centers yielded similar results. Additional adjustment for femoral neck BMD had no effect on our results. In conclusion, self-reported sleep disturbances were associated with an increased risk of fractures, but these associations likely reflect shared risk factors or factors in the causal pathway. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Childhood Sexual Abuse and Pelvic Floor Dysfunction in Midlife Women in the Study of Women's Health Across the Nation.

Objectives: Research has shown a link between childhood sexual abuse (CSA) and lower urinary tract and sexual disorders in clinical settings. We examined whether CSA was associated with two specific aspects of high tone, elevated resting tension pelvic floor dysfunction (PFD) in community-dwelling women. Materials and Methods: Data were from 2068 participants (25.5% Black, 9.6% Chinese, 10.8% Japanese, 5.0% Hispanic, and 49.1% Non-Hispanic White) in the Study of Women's Health Across the Nation (SWAN), a multirace/multiethnic longitudinal observational study of women's midlife health. At baseline, enrolled women were 42-52 years old and premenopausal or early perimenopausal. Annual or biennial assessments conducted over 20 years (1996 through 2017) included single-item queries about urgency urinary incontinence and pain with sexual activity used to assess PFD outcomes. The 12th follow-up visit conducted in 2009-2011 assessed the primary exposure, history of CSA, using a single-item response. Multivariate logistic regression models tested study objectives. Results: The prevalence of CSA was 15%, self-reported in 313/2068 women. CSA and PFD, both pain with sexual activity (odds ratio [OR] = 1.56 confidence interval [95% CI = 1.12-2.18]) and urgency urinary incontinence (OR = 1.87 [95% CI = 1.29-2.71]), were significantly associated in unadjusted models. The final adjusted model that included sociodemographic variables and physical and behavioral risk factors was significant for pain with sexual activity (OR = 1.48 [95% CI = 1.08-2.02]), but not for urgency urinary incontinence (OR = 1.38 [95% CI = 0.96-1.98]). Conclusions: In midlife women, pain with sex, but not urgency urinary incontinence, was associated with a history of CSA. A multidisciplinary diagnostic and therapeutic approach to PFD is key, inclusive of CSA screening.

Sleep timing, sleep regularity, and psychological health in early late life women: Findings from the Study of Women's Health Across the Nation (SWAN).

OBJECTIVES: To examine the associations of actigraphy-assessed sleep timing and regularity with psychological health in early late life women, whose circadian rhythms may be impacted by aging. DESIGN: Cross-sectional. PARTICIPANTS: A racially/ethnically diverse sample of 1197 community-dwelling women (mean age 65 years) enrolled in the Study of Women's Health Across the Nation. MEASURES: Actigraphy-assessed sleep measures included timing (mean midpoint from sleep onset to wake-up) and regularity (standard deviation of midpoint in hours). Psychological health measures included a composite well-being score, the Center for Epidemiological Studies Depression Scale, and the Generalized Anxiety Disorder-7 Scale. Linear and logistic regression models, adjusted for covariates (including sleep duration), tested associations between sleep and psychological health measures. RESULTS: After covariate adjustment, a sleep midpoint outside of 2:00-4: 00 AM was significantly associated with depressive symptoms (ß = 0.88, 95% CI = 0.06, 1.70) and scoring above the cut-point for clinically significant depressive symptoms (OR = 1.72, 95% CI = 1.15, 2.57). Sleep irregularity was significantly associated with lower psychological well-being (ß = -0.18, 95% CI = -0.33, -0.03), depressive (ß = 1.36, 95% CI = 0.29, 2.44) and anxiety (ß = 0.93, 95% CI = 0.40, 1.46) symptoms, and scoring above the cut-point for clinically significant depressive (OR = 1.68, 95% CI = 1.01, 2.79) and anxiety (OR = 1.62, 95% CI = 1.07, 2.43) symptoms. CONCLUSION: Above and beyond sleep duration, a sleep midpoint outside of 2:00-4:00 AM was associated with depressive symptoms while sleep irregularity was associated with multiple psychological health domains in late life women.

Pre- and Early Peri-menopausal Physical Function and Risk of Cardiovascular Events: The Study of Women's Health Across the Nation.

OBJECTIVES: To determine whether physical function (PF) before menopause is related to cardiovascular disease (CVD) risk. METHODS: Participants were N = 2950 pre-/early peri-menopausal women (median age 46, (25th-75th percentile: 43-48 years). Physical function was assessed at baseline using the Physical Function subscale of the SF-36 and scores were trichotomized (no, some, or substantial limitations). Clinical CVD events were ascertained at annual/biennial clinical assessments through the 15th follow-up visit. Risk of CVD was determined with Cox proportional hazards models. Results: Women were followed for a median of 19.1 years, during which 220 women had a CVD event. In fully adjusted models, women with substantial limitations at baseline had higher CVD risk compared to women with no limitations (hazards ratio [HR] = 1.55, 95% confidence interval [CI]: 1.12-2.33). Discussion: Substantial PF limitations in pre- and early peri-menopausal women are associated with higher risk of clinical CVD events, consistent with literature in older adults.

Menopause hormone therapy and complementary alternative medicine, quality of life, and racial/ethnic differences: the Study of Women's Health Across the Nation (SWAN).

OBJECTIVE: We hypothesized that, among midlife women with vasomotor and/or genitourinary symptoms of menopause, (1) hormone therapy (HT) compared with complementary alternative medicine (CAM) will be associated with higher quality of life (QoL), and (2) race/ethnicity would modify associations of HT and CAM with QoL. METHODS: Cross-sectional and longitudinal analyses of QoL in the Study of Women's Health Across the Nation participants using HT, CAM, or both. Women ( n = 2,514) completed a CAM use questionnaire and QoL assessments at baseline and every 1 to 2 years from 2002 to 2013. Associations between QoL and treatment, adjusted for covariates, and race/ethnicity-by-treatment interactions were analyzed using linear and mixed effects regression models. RESULTS: During 7.8 (SD, 2.9) years of follow-up, 732 women (29%) reported HT of 2.4 (SD, 1.7) years, and 798 women (32%) reported CAM use of 2.1 (SD, 1.4) years. Overall, neither HT nor CAM was associated with QoL. However, the treatment-by-race/ethnicity interaction was significant for self-reported QoL ( P = 0.034 at baseline, P = 0.044 longitudinal). Among White women, self-reported QoL was higher in HT-only users than in those who used neither ( P = 0.030; d = 0.11; 95% confidence interval, 0.01-0.21). In contrast, Black women using HT only had lower self-reported QoL compared with Black women using neither ( P = 0.027; d = -0.21; 95% confidence interval, -0.40 to -0.02). CONCLUSION: Comparisons between treatment type within each racial/ethnic group yielded significant differences in self-reported QoL. Clinicians should be aware of racial/ethnic differences in treatment preferences when counseling patients on treatment options for menopausal symptoms to provide optimal care. VIDEO SUMMARY: http://links.lww.com/MENO/B33 .

Risk of high depressive symptoms after the final menstrual period: the Study of Women's Health Across the Nation (SWAN).

OBJECTIVE: To examine depressive symptoms during postmenopause and the contribution of depressive symptom trajectories before the final menstrual period (FMP) and psychosocial/health factors to postmenopause depressive symptoms. METHODS: Longitudinal analysis of depressive symptoms (Center for Epidemiologic Studies-Depression scale) collected every 1 to 2 years from 1996 to 2017 from 1,551 midlife women in the Study of Women's Health Across the Nation for a median follow-up of 19.0 years. Latent class growth analysis identified depression trajectories from baseline to FMP. Multivariable random effects (woman as random effect) linear or logistic regression models were conducted. RESULTS: Women had higher odds of reporting high depressive symptom score (≥16) during postmenopause than when they were premenopausal (OR = 1.49, 95% CI, 1.09-2.04), but not when perimenopausal. Three pre-FMP trajectories were identified: Group 1 (47.7%), consistently low scores, Group 2 (39.9%), moderate scores below the high depressive symptom threshold, and Group 3 (12.4%), consistently high scores. Both the moderate (OR = 2.62, 95% CI, 1.89-3.66) and high score (OR = 6.88, 95% CI, 4.72-10.02) groups, compared with the consistently low group, had significantly higher postmenopausal depressive symptom scores. Other pre-FMP variables associated with high postmenopausal depressive symptoms were: higher odds of childhood trauma/maltreatment, poor role physical, high anxiety symptoms, sleep problems, high vasomotor symptoms, and lower odds for chronological aging and lower social support. CONCLUSIONS: Compared with premenopause, postmenopause remains a period of increased risk for higher depressive symptoms, especially for women with pre-FMP depressive symptoms. Pre-FMP depressive symptom trajectories are highly predictive of postmenopause depressive symptoms independent of health and psychosocial factors.

Longitudinal associations of mid-life employment status with impaired physical function in the Study of Women's Health Across the Nation.

PURPOSE: This study examined whether employment status during mid-life and older adulthood is associated with physical function impairment. METHODS: Participants were 2700 women in the multiracial/multiethnic Study of Women's Health Across the Nation. Time-varying, lagged, and cumulative exposure analyses modeled associations between self-reported employment status and the likelihood of severe physical function impairment across 19 years of follow-up. RESULTS: Independent of demographic variables, women who were not working (OR = 1.58, 95% CI = 1.22, 2.04) or employed part-time (OR = 1.29, 95% CI = 1.04, 1.61) were more likely to report severe physical function impairments than women employed full-time. This same pattern was seen in lagged analyses predicting risk of physical function impairment from employment status at the prior assessment (not working vs. full-time: OR = 1.53, 95% CI = 1.08, 2.18; part-time vs. full-time: OR = 1.53, 95% CI = 1.17, 2.00). The likelihood of severe physical function impairment increased by 20% for every additional 10% of follow-up spent not working (OR = 1.02, 95% CI: 1.01, 1.03). Associations were robust to adjustment for health-related variables, body mass index, and physical activity. CONCLUSIONS: Women with lower levels of employment from mid-life to older adulthood were more likely to experience severe impairment in physical function. However, the underlying mechanisms, and the timescales over which associations unfold, require further study.

Comparing polysomnography, actigraphy, and sleep diary in the home environment: The Study of Women's Health Across the Nation (SWAN) Sleep Study.

Study Objectives: Polysomnography (PSG) is considered the "gold standard" for assessing sleep, but cost and burden limit its use. Although wrist actigraphy and self-report diaries are feasible alternatives to PSG, few studies have compared all three modalities concurrently across multiple nights in the home to assess their relative validity across multiple sleep outcomes. This study compared sleep duration and continuity measured by PSG, actigraphy, and sleep diaries and examined moderation by race/ethnicity. Methods: Participants from the Study of Women's Health Across the Nation (SWAN) Sleep Study included 323 White (n = 147), African American (n = 120), and Chinese (n = 56) middle-aged community-dwelling women (mean age: 51 years, range: 48-57). PSG, wrist actigraphy (AW-64; Philips Respironics, McMurray, PA), and sleep diaries were collected concurrently in participants' homes over three consecutive nights. Multivariable repeated-measures linear models compared time in bed (TIB), total sleep time (TST), sleep efficiency (SE), sleep latency (SL), and wake after sleep onset (WASO) across modalities. Results: Actigraphy and PSG produced similar estimates of sleep duration and efficiency. Diaries yielded higher estimates of TIB, TST, and SE versus PSG and actigraphy, and lower estimates of SL and WASO versus PSG. Diary SL was shorter than PSG SL only among White women, and diary WASO was lower than PSG and actigraphy WASO among African American versus White women. Conclusions: Given concordance with PSG, actigraphy may be preferred as an alternative to PSG for measuring sleep in the home. Future research should consider racial/ethnic differences in diary-reported sleep continuity.

Does childhood maltreatment or current stress contribute to increased risk for major depression during the menopause transition?

BACKGROUND: The menopausal transition (MT) poses an increased risk for major depression (MD), but not for all women. Current and past stress are toxic risk factors for depression throughout life. The MT may be a time of increased sensitivity to stress, especially among women with a lifetime history of major depressive disorder (MDD). We evaluated whether women who experienced childhood maltreatment (CM) or current stressful events or ongoing problems were at increased risk for MD during the MT. METHODS: At the Pittsburgh site of the Study of Women's Health Across the Nation, 333 midlife women were interviewed approximately annually over 15 years with the Structured Clinical Interview for the Diagnosis of DSM-IV Axis I Disorders and provided health and psychosocial data including the Childhood Trauma Questionnaire. Repeated measures logistic regression analyses were conducted separately for women with and without lifetime MDD at study entry. RESULTS: Among women with lifetime MDD, CM, but not current stress, interacted with menopausal status to increase the risk for MD during postmenopause (ORs ranged from 2.71 to 8.04). All stressors were associated with increased odds of MD. Among women without lifetime MDD, current stress was related to risk for MD, but the effect did not vary by menopausal status. CONCLUSIONS: Women with MDD prior to midlife and who experienced CM were at greatest risk for MD after the MT. Women without prior MDD were at increased risk for MD during peri- and postmenopause. Healthcare providers should monitor women at risk for MD even after the MT.

Influence of the menopausal transition on polysomnographic sleep characteristics: a longitudinal analysis.

STUDY OBJECTIVES: To evaluate how change in menopausal status related to spectral analysis and polysomnographic measures of sleep characteristics. METHODS: The Study of Women's Health Across the Nation (SWAN) Ancillary Sleep Study evaluated sleep characteristics of 159 women who were initially pre- or early perimenopausal and repeated the assessment about 3½ years later when 38 were pre- or early perimenopausal, 31 late perimenopausal, and 90 postmenopausal. Participants underwent in-home ambulatory polysomnography for two to three nights. Average EEG power in the delta and beta frequency bands was calculated during NREM and REM sleep, and sleep duration, wake after sleep onset (WASO), and apnea hypopnea index (AHI) were based on visually-scored sleep. RESULTS: The women who transitioned to postmenopause had increased beta NREM EEG power at the second assessment, compared to women who remained pre-or early premenopausal; no other sleep measures varied by change in menopausal status. In multivariate models the associations remained; statistical controls for self-reported hot flashes did not explain findings. In secondary analysis, NREM beta power at the second assessment was greater among women who transitioned into the postmenopause after adjustments for initial NREM beta power. CONCLUSIONS: Sleep duration and WASO did not vary by menopause transition group across assessments. Consistent with prior cross-sectional analysis, elevated beta EEG power in NREM sleep was apparent among women who transitioned to postmenopause, suggesting that independent of self-reported hot flashes, the menopausal transition is associated with physiological hyperarousal during sleep.

Prescription medications for sleep disturbances among midlife women during 2 years of follow-up: a SWAN retrospective cohort study.

OBJECTIVE: To examine the effects of prescription sleep medications on patient-reported sleep disturbances. DESIGN: Retrospective cohort. SETTING: Longitudinal cohort of community-dwelling women in the USA. PARTICIPANTS: Racially and ethnically diverse middle-aged women who reported a sleep disturbance. INTERVENTIONS: New users of prescription sleep medications propensity score matched to women not starting sleep medications. MAIN OUTCOMES AND MEASURES: Self-reported sleep disturbance during the previous 2 weeks-difficulty initiating sleep, waking frequently and early morning awakening-using a 5-point Likert scale, ranging from no difficulty on any night (rating 1) to difficulty on 5 or more nights a week (rating 5). Sleep disturbances were compared at 1 year (primary outcome) and 2 years of follow-up. RESULTS: 238 women who started sleep medications were matched with 447 non-users. Participants had a mean age of 49.5 years and approximately half were white. At baseline, sleep disturbance ratings were similar: medication users had a mean score for difficulty initiating sleep of 2.7 (95% CI 2.5 to 2.9), waking frequently 3.8 (95% CI 3.6 to 3.9) and early morning awakening 2.8 (95% CI 2.6 to 3.0); non-users ratings were 2.6 (95% CI 2.5 to 2.7), 3.7 (95% CI 3.6 to 3.9) and 2.7 (95% CI 2.6 to 2.8), respectively. After 1 year, ratings for medication users were 2.6 (95% CI 2.4 to 2.8) for initiating sleep, 3.6 (95% CI 3.4 to 3.8) for waking frequently and 2.8 (95% CI 2.6 to 3.0) for early morning awakening; for non-users, the mean ratings were 2.3 (95% CI 2.2 to 2.5), 3.5 (95% CI 3.3 to 3.6) and 2.5 (95% CI 2.3 to 2.6), respectively. None of the 1 year changes were statistically significant nor were they different between medication users and non-users. Two-year follow-up results were consistent, without statistically significant reductions in sleep disturbance in medication users compared with non-users. CONCLUSIONS: These analyses suggest that women who initiated sleep medications rated their sleep disturbances similar after 1 and 2 years. The effectiveness of long-term sleep medication use should be re-examined.

Lowered progesterone metabolite excretion and a variable LH excretion pattern are associated with vasomotor symptoms but not negative mood in the early perimenopausal transition: Study of Women's Health Across the Nation.

OBJECTIVE: The menopausal transition is characterized by progressive changes in ovarian function and increasing circulating levels of gonadotropins, with some women having irregular menstrual cycles well before their final menstrual period. These observations indicate a progressive breakdown of the hypothalamic-pituitary-ovarian axis often associated with an increase in menopausal symptoms. Relationships between vasomotor symptoms (VMS) and depressed mood and sleep as well as a bidirectional association between VMS and depressed mood in mid-life women have been reported, but the endocrine foundations and hormone profiles associated with these symptoms have not been well described. Our objective was to determine the relationship between daily urinary hormone profiles and daily logs of affect and VMS during the early perimenopausal transition. STUDY DESIGN: SWAN, the Study of Women's Health Across the Nation, is a large, mutli-ethnic, multisite cohort study of 3302 women aged 42-52 at baseline, designed to examine predictors of health and disease in women as they traversed the menopause. Inclusion criteria were: an intact uterus and at least one ovary present, at least one menstrual period in the previous three months, no use of sex steroid hormones in the previous three months, and not pregnant or lactating. A subset (n = 849) of women aged 43-53 years from all study sites in the first Daily Hormone Study collection were evaluated for this substudy. OUTCOME MEASURES: We measured daily VMS, and urinary hormones: follicle stimulating hormone (FSH), luteinizing hormone (LH), pregnanediol glucuronide (PdG) and estradiol (estrone conjugate, E1C). RESULTS: A variable pattern of LH and negative LH feedback were the hormone patterns most strongly associated with increased VMS. In contrast, no hormone pattern was significantly related to negative mood. CONCLUSION: Fluctuations of LH associated with low progesterone production were associated with VMS but not negative mood, suggesting different endocrine patterns may be related to increased negative mood than to the occurrence of VMS.

Longitudinal Association Between Depressive Symptoms and Multidimensional Sleep Health: The SWAN Sleep Study.

BACKGROUND: Depressive symptoms and sleep disturbances disproportionately affect midlife women. While there may be a bidirectional association, few studies have examined whether depressive symptoms are longitudinally associated with subsequent sleep. Sleep is typically considered unidimensional, despite emerging evidence that multidimensional sleep health provides novel information on the sleep-health link. PURPOSE: The current study examined whether higher depressive symptoms were longitudinally associated with poorer multidimensional sleep health. METHOD: Depressive symptoms were assessed with the Center for Epidemiologic Studies Depression Scale across six to nine annual assessments in 302 midlife women from the Study of Women's Health Across the Nation. Six months after their last assessment, actigraphy (mean ± standard deviation = 29.3 ± 6.9 days) and self-report were used to assess sleep health components: efficiency, duration, mid-sleep timing, regularity, alertness, and satisfaction, which were dichotomized and summed to create a composite multidimensional sleep health score. Mixed-effects models were used to evaluate the longitudinal associations between depressive symptoms and multidimensional sleep health, as well as individual sleep health components, adjusting for covariates. Exploratory analyses stratified models by race/ethnicity. RESULTS: Higher depressive symptoms were associated with subsequent poorer multidimensional sleep health (p < .0.001) and lower alertness (p < .0001) and satisfaction with sleep (p < .0001). CONCLUSIONS: Our finding that higher average depressive symptoms were associated longitudinally with actigraphy-measured poorer sleep health in midlife women is novel and converges with the larger body of evidence that these two common symptoms are strongly associated. The bidirectional relationship between these two prevalent symptoms needs to be studied in prospective longitudinal studies.

Optimising sleep and performance during night float: A systematic review of evidence and implications for graduate medical education trainees.

Graduate medical education (GME) training commonly requires residents and fellows to engage in night float shift work. This review aims to assess the effectiveness of interventions for trainees when preparing for, completing, and recovering from working night float shifts. We reviewed all available studies published prior to September 2019 using PubMed, Scopus, CINAHL, the Cochrane library, PsycINFO, and Google Scholar databases. We included all original, primary research articles assessing either non-pharmacological or pharmacological interventions on the chronobiological and physiological effects of night float shift work among GME trainees. Five studies (n = 179 patients) met inclusion criteria. Interventions included melatonin in the morning before sleep after night float shifts, napping during night float shifts, modafinil after a night of sleep deprivation, and caffeinated energy drinks after 6 consecutive night float shifts. Melatonin improved one measure of attention. A 2-hr nap was associated with improved speed related to task switching. Modafinil improved performance in tests of cognition. Caffeinated energy drinks led to improvement in select driving performance variables and reaction time. Effect sizes for outcome variables were calculated. Heterogeneity among the studies precluded combining the data in a meta-analysis. According to GRADE criteria, the quality of the evidence in these studies was low or very low. Our findings suggest GME trainees may benefit from utilising a limited number of interventions when preparing for or recovering from night float shift work. More investigation is needed to identify interventions that could help GME trainees adapt to and recover from working night float shifts.

Associations between sleep and cognitive performance in a racially/ethnically diverse cohort: the Study of Women's Health Across the Nation.

STUDY OBJECTIVES: To determine whether actigraphy-assessed indices of sleep are associated with cognitive performance in women, and explore whether these associations vary by race/ethnicity. METHODS: Participants were 1,126 postmenopausal community-dwelling females (mean age 65 years) from the observational Study of Women's Health Across the Nation (SWAN); 25% were black, 46% white, 13% Chinese, 11% Japanese, and 5% Hispanic. Actigraphy-assessed sleep measures included total sleep time, wake after sleep onset (WASO), and fragmentation. Cognitive measures included immediate and delayed verbal memory, working memory, and information processing speed. All measures were assessed in conjunction with SWAN annual visit 15. RESULTS: Across the sample, after covariate adjustment, greater WASO and fragmentation were concurrently associated with slower information processing speed. Black participants had significantly worse sleep relative to other race/ethnic groups. Significant race/sleep interactions were observed; in black, but not white, participants, greater fragmentation was concurrently associated with worse verbal memory and slower information processing speed, and greater WASO was concurrently associated with slower information processing speed. Sleep-cognitive performance associations were not different in Chinese and Japanese participants relative to white participants. CONCLUSIONS: Greater wakefulness and fragmentation during sleep are concurrently associated with slower information processing. Sleep continuity impacted concurrent cognitive performance in black, but not white, women. This effect may not have been detected in white women because their sleep was largely within the normal range. Future longitudinal studies in diverse samples are critical to further understand whether race/ethnicity moderates the influence of sleep on cognitive performance.

Identifying women who share patterns of reproductive hormones, vasomotor symptoms, and sleep maintenance problems across the menopause transition: group-based multi-trajectory modeling in the Study of Women's Health Across the Nation.

OBJECTIVE: To identify groups of women who share levels and patterns of change in follicle-stimulating hormone (FSH), self-reported sleep maintenance problems, and frequent vasomotor symptoms (VMS) up to 10 years before and after their final menstrual period and to evaluate their premenopausal characteristics. METHOD: Group-based multi-trajectory modeling grouped 1,407 women from the Study of Women's Health Across the Nation who had an observed natural menopause and did not use hormone therapy, based on repeated measures of FSH, sleep maintenance problems, and frequent VMS relative to final menstrual period. Multivariable analyses assessed race/ethnicity, body mass index, smoking, and depressive symptoms as predictors of group membership. RESULTS: Women formed five distinct groups: (1) low symptoms (low VMS/sleep problems)/high FSH rise (N = 552; 39.2%); (2) moderate VMS and sleep problems/low FSH rise (N = 169; 12.0%); (3) dominant sleep problems (lower VMS/high sleep problems)/high FSH rise (N = 203; 14.4%); (4) dominant VMS (high VMS/lower sleep problems)/high FSH rise (N = 297; 21.1%)); and (5) high symptoms (high VMS/high sleep problems)/intermediate FSH rise (N = 186; 13.2%)). Multivariate analyses showed that race/ethnicity, premenopausal body mass index and depressive symptoms, and increasing depressive symptoms during the early phase of the transition predicted group membership. CONCLUSIONS: Women can be classified based on shared levels and patterns of FSH, sleep maintenance problems, and frequent VMS across the menopause transition. Either VMS or sleep maintenance problems can be dominant in the face of high FSH. Experiencing one menopause-related symptom or hormone profile does not automatically imply that another is also being experienced.

Sleep medications and sleep disturbances across middle aged pre- or peri-menopausal women of different race and ethnicities: A SWAN pharmacoepidemiology cohort study.

PURPOSE: Sleep disturbances are common, particularly in middle aged women. Prescription medications for this indication are increasingly used, despite uncertain safety. This study assessed prescription medication use for sleep among a cohort of women with and without sleep disturbances. METHODS: We examined reports of sleep disturbance and sleep medication use among pre- and early peri-menopausal womenassessed annually or biennially since 1996. Women self-reported medications at visits, and we identified medications that have been used primarily for sleep disturbances. They reported on difficulties falling and staying asleep, and early morning wakening. Sleep medication use across 20 years of follow-up was examined for all women and by race/ethnicity. Women who reported data for both sleep disturbance and sleep medication use were included in the analyses.. RESULTS: Among participants in a cohort of 3302 women who were enrolled prior to their menopause transition, 3082 women were included in the analytic sample and 2531 (82%) reported sleep disturbances. They were more likely to endorse higher anxiety and pain scores and more comorbid conditions than women without sleep disturbances. Baseline characteristics were similar among women who did and did not use sleep medications. Among women reporting a sleep disturbance at baseline, 2.5% reported sleep medication use, increasing to 8% over 20 years. However, the proportion of women reporting sleep medication use who did not report a sleep disturbance remained low, approximately 1% to 2% over the entire follow-up. Increases in sleep medication use was observed across women of all race/ethnicities. CONCLUSIONS: The use of sleep medications among women reporting sleep disturbance grew over the last 20 years. Growth was observed across women of all race/ethnicities.