Womens Health Bull. 2014 September; 1(3): e23651.

Research Article

Published online 2014 September 25.

Quality of Sleep and Its Related Factors in Postmenopausal Women in West

Tehran
Simin Taavoni

1,2,3

4,*

; Neda Nazem Ekbatani ; Hamid Haghani

1Faculty of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, IR Iran
2Research Institute for Islamic and Complementary Medicine (RICM), Iran University of Medical Sciences, Tehran, IR Iran
3Faculty of Medicine, Tehran University of Medical Sciencesm, Tehran, IR Iran
4Faculty of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, IR Iran
5Faculty of Management and Medical Information Science, Iran University of Medical Sciences, Tehran, IR Iran

*Corresponding author: Neda Nazem Ekbatani, Faculty of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, IR Iran. Tel: +98-2146882028, Fax: +98-2166921228,,
E-mail: [email protected]

Received: January 12, 2014; Revised: March 14, 2014; Accepted: April 5, 2014

Background: Sleep disturbance is common in menopausal women.

Objectives: This study aimed to measure the rate of self-reported sleep disturbance and to identify its associated factors in 50-60 year-old
women.
Patients and Methods: This cross-sectional study included 700 healthy volunteer women aged 50 to 60 years, who were in postmenopausal
period for at least 1 year. The participants were interviewed after obtaining informed consents. The study questionnaire covered two main
aspects of personal characteristics and the Pittsburgh Sleep Quality Index (PSQI). Data was analyzed using SPSS 14 software.
Results: The frequency of sleep disturbance was 62.5%. A significant association was found between sleep disturbance and characteristics
of occupation, education, financial status and husbands profession. There were no significant association between sleep disturbance and
other personal characteristics, such as age, partners age, number of children, family size and consumption of tea, coffee or cola.
Conclusion: Sleep disturbance is common in menopausal women. Appropriate interventions based on sleep-related personal
characteristics should be performed to improve sleep quality, which is very important for maintaining the quality of life.
Keywords:Menopause; Sleep Quality; Related Factors

1. Background
Every year, millions of women enter their menopausal
period. The World Health Organization estimated that
1.2 billion women would be 50 years or older by the year
2030 (1). Estrogen decline during menopause may cause
various problems such as vasomotor instability, lowered
psychometric functions, vaginal and urinary infections,
and forgetfulness (2). Other symptoms include irregular
menses, decreased fertility, vaginal dryness, (3) hot flashes, sleep disturbances (3, 4), mood swings, increased abdominal fat, hair thinning, and loss of breast fullness (3).
Sleep is an essential aspect of life (5) and insomnia is associated with negative health consequences including fatigue, impaired daytime function, reduced quality of life,
and increased visits to healthcare providers (2, 6). Sleep
disturbance is also one of the important symptoms observed during menopause (7) and is common and clinically important among elderly individuals (4, 8, 9).
Approximately one-third of the adult population complain symptoms of insomnia (10). Women tend to report
sleep disturbances more often than men of the same age
(11). Furthermore, insomnia is more common in people
with chronic medical problems and observed in up to
69% of patients enrolled in primary care clinics (12).

Moreover, after menopause, prevalence of habitual snoring and obstructive sleep apnea syndrome increases in
women (13). In contrast, a smaller percentage of adults report severe sleep problems (10%-15%), but the prevalence
of severe chronic sleeping disorders increases to 25%
among elderly (14). Kravitz reported that self-reported
sleep difficulties increase during the menopausal transition (15). Furthermore, the overall prevalence of selfreported sleep difficulty was 38%, and in some studies, it
was found to be the lowest in premenopausal group (31%)
and the highest in surgical menopausal group (48%) (16).
According to a study performed in West of Tehran, its rate
in healthy menopause women was 70% (4). Besides, international surveys reported that approximately 30%-40% of
adults would experience sleep disturbances in their lifetime (17, 18).
Young et al. indicated that objectively measured sleep
quality does not diminish with menopause, but the association of menopause and sleep quality differs with
respect to objective and subjective measures. These
findings indicated that menopausal women were more
dissatisfied with quality of sleep than premenopausal
women (19). Various factors such as snoring, aging, hot

Copyright 2014, Health Policy Research Center, Shiraz University of Medical Sciences; Published by DOCS. This is an open-access article distributed under the
terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and
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Taavoni S et al.
flashes, and night sweats could influence the quality of
sleep during menopause (1).

2. Objectives

Based on the results of the aforementioned studies and

due to the fact that sleep disturbance is one of the important symptoms observed during menopause and aging,
this study was conducted to determine the rate of selfreported sleep disturbance in west of Tehran and its associated factors in 50-60-year-old women.

3. Patients and Methods

This was a cross-sectional study conducted at four selected clinics of Tehran University of Medical Sciences in
west of Tehran, from March 2010 to June 2012. This study
was the first phase of a research proposal entitled The
effect of valerian and lemon balm on the sleep quality in
menopausal women, a randomized placebo-controlled
clinical trial. In this phase, volunteer menopausal women were screened to find those with sleeping problems
for entering the second stage of the study. The inclusion
criteria were as follows:
(1) Generally healthy women aging 50-60 years, postmenopausal for at least 1 year, and not receiving hormone
replacement therapy (HRT)
(2) Absence of a medical or psychiatric condition that
could cause sleep disturbance
(3) Having a score of five or higher using the Pittsburgh
Sleep Quality Index (PSQI).
Volunteers included 700 healthy menopause women,
who were informed about the research and its purposes
and requested to complete a questionnaire regarding
their personal characteristics and PSQI. The aim of the
study was explained to all participants qualified for the
first phase of the study and written informed consents
were obtained. The participants were interviewed using a
questionnaire including three main sections of personal
characteristics, perception towards sexual satisfaction
and PSQI. Personal characteristics contained the following 15 items: age, partners age, date of last menstruation,
family size, number of children, number of children living with participants, educational, economic, marital,
occupational and partners occupational status, average
rate of daily consumption of tea, coffee or cola beverages.
Perception of sexual satisfaction was determined using
the visual analogue scale (VAS, scale ranging from 0-10).
The PSQI section was a self-rated questionnaire, which
assessed sleep quality and disturbances over one month
period. The questionnaire had 19 items used to generate
seven composite scores. The composite scores provided
information about subjective sleep quality, sleep latency,
sleep duration, habitual sleep efficiency, sleep disturbances, sleep medication use, and daytime dysfunction.
Scores from the seven components were summed to yield
a single PSQI score. When this single global PSQI score is
greater than five, it is nearly 90% sensitive and specific to
2

Table 1. Demographic Characteristics of the Participants a

Variable
Value
Age, y
52.9 3.3
50-52
462 (66)
53-55
98 (14)
56
140 (20)
Menopause age, y
47.4 3.8
40-44
182 (26)
45-49
350 (50)
50
168 (24)
Age difference with partner, y
6.1 4.2
0
14 (2)
1-4
252 (36)
5-9
168 (24)
10-14
140 (20)
No partner
126 (18)
Marital status
Married
574 (82)
Single
126 (18)
Number of pregnancies
5 2.05
0-2
98 (14)
3-4
238 (34)
5-6
238 (34)
7
126 (18)
Family size
4.4 2.06
1-2
84 (12)
3-4
322 (46)
5
294 (42)
Number of children
4.8 2.02
0-2
112 (16)
3-4
308 (44)
5-6
280 (40)
Number of married children
2.7 2.09
0
70 (10)
1-2
350 (50)
3-4
196 (28)
5
84 (12)
Educational status
Illiterate
336 (48)
Primary school
252 (36)
Secondary school
112 (16)
Occupational status
Employed
28 (4)
Housewife
672 (96)
Economic status
Good
98 (14)
Moderate
392 (56)
Bad
210 (30)
Husbands occupational
status
Worker
154 (22)
Employed
126 (18)
Retired
294 (42)
Other
126 (18)
a Data are presented as No. (%), Mean SD

Womens Health Bull. 2014;1(3):e23651

Taavoni S et al.
diagnose poor sleep. The post-hoc cut off score of five
on the PSQI produced a sensitivity of 89.6% and specificity
of 86.5% in patients versus control subjects.
The sample size was calculated based on 80% power and
5% type one error, resulted in 700 subjects needed for the
study. Therefore, the PSQI questionnaire was delivered to
700 volunteers who met the inclusion criteria. Data was
analyzed using SPSS 14 software (). Descriptive statistics,
including measures of mean and variance, were calculated for each volunteers main outcomes. The inferential
statistics such as Pearson correlation test, T-test, and Oneway analysis of variance (ANOVA) were used to determine
the correlation between the variables and sleep quality.
The level of significance was P < 0.05. This study was approved by the Ethics Committee of Tehran University of
Medical Science (TUMS), the oldest and largest medical
sciences university of Iran. The Ethics Committee followed the progression of the research from the first step
of designing the research proposal to the presentation of
the final report.

4. Results

Demographic data obtained from the questionnaire

were shown in Table 1. Regarding PSQI, which assesses

sleep quality and sleep disturbances over one month period, the frequency of sleep disturbance was found to be
62.5% and the mean sleep scale score was 7.84 4.4. Most
women were in mild insomnia group and only 4.5% of
them had severe insomnia (Table 2). Significant associations were found between sleep disturbance and occupation, education, husbands occupation, and economic
status. There was no significant association between sleep
disturbance and age, menopause age, age difference between spouses, number of children, family size and consumption of tea, coffee or cola beverages (Table 3).
Table 2. Frequency of Sleep Scale a
PSQI b

0-4 (Safe)
5-9 (Mild insomnia)
10-14 (Moderate insomnia)
15-21 (Severe insomnia)
a Data are presented as No. (%)
b Pittsburgh Sleep Quality Index

Table 3. Associations Between Personal Characteristics and the Pittsburgh Sleep Quality Index (PSQI) a
Characteristics (Highest Group)

Value
262 (37.5)
224 (32)
182 (26)
32 (4.5)

Value

Analysis b

P Value

Housewife

672 (96)

T Test

0.004

Illiterate

336 (48)

ANOVA b

0.04

Retired

294 (42)

ANOVA

0.02

Moderate

392 (56)

ANOVA

0.000

50-52

462 (66)

Pearson

0.34

45-49

350 (50)

Pearson

1.5

1-4

252 (36)

Pearson

0.9

Married

574 (82)

ANOVA

0.32

3-4

322 (46)

Pearson

3.8

3-4

308 (44)

Pearson

0.56

2-3

322 (46)

Pearson

2.6

Occupational status
Educational status

Husbands occupational status

Economic status
Age, y

Menopause age, y
Age difference with partner, y
Marital status
Family size
Number of children
consumption of tea, coffee and
cola
a Data are presented as No. (%)
b Analysis of variance

Womens Health Bull. 2014;1(3):e23651

Taavoni S et al.

5. Discussion
This study investigated correlations between personal
characteristics and self-reported sleep disturbance in
50-60 year-old menopausal women. Poor sleep quality is
highly prevalent in menopausal women (7, 20). The most
important factor impairing the quality of sleep in menopausal women is reduced hormone levels. Age is not the
only factor associated with difficulty in sleeping (16).
Moreover, unique hormonal and psychological changes
in perimenopausal women have a significant effect on
sleep disturbance (13). The present study showed no correlation between age and sleep quality. This may be because all the participants were postmenopausal aged 5060 years, which was a limited range. This study showed a
correlation between sleep quality and occupation of the
participants, who were mostly housewives. Furthermore,
a correlation was found between sleep quality and husbands occupation. This may be affected by unfavorable
financial status leading to poor access to medical care
services or additional family distress.
Ohayon et al. reported that a high level of education
is associated with sleep difficulty (16) and Leshner et al.
claimed that being less educated is associated with a
higher prevalence of insomnia (21). Habte-Gabr et al. reported that individuals with lower education may have
poor access to optimal medical care that may result in an
overall poor health (22). This is expected to increase the
risk of sleep disturbances (8). We found a correlation between lower educational status and sleep quality, similar
to those of the aforementioned studies.
Leshner et al. indicated that lower income levels are
associated with a higher prevalence of insomnia (21). In
this study, economic status and sleep quality were found
to be correlated. Personal characteristics with highest
significant associations with sleep were economic and
occupational status, husbands occupation and the level
of education. The limitation of this study was its small
sample size. Subsequent studies with larger sample size
are recommended.
Since our investigation included 700 postmenopausal
women, further studies with larger number of menopausal and andropausal subjects are needed to compare
the results. We suggest medical staff to consider personal
characteristics of menopausal women as well as the onset
of their menopause, and conscious of the importance of
sleep quality, to design correct planning and be involved in
supervision of counseling by qualified professionals. This
approach could help menopausal women prevent psychological and social damage caused by sleep disturbance.

itoring the study; Neda Nazem Ekbatani: conducting

the study and writing the paper; Hamid Haghani: data
analysis.

Funding/Support
This study was the first phase of a randomized clinical
trial study entitled The effect of valerian and lemon balm
on the quality of sleep in menopausal women: A randomized placebo-controlled clinical trial, which is supported
by the Vice Chancellor for Research, Tehran University of
Medical Sciences (code: 11933). This study was registered
in the Iranian Registry of Clinical Trials Sciences (Code:
IRCT201106302172N10).

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Acknowledgements

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We are very grateful to the participants of this study for

making this research possible.

17.

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