Is Anxiety Associated with Vasomotor Symptoms in Postmenopausal Women with Insomnia Complaints?

Abstract

Objective

This study investigated the relationship between hot flashes, menopausal symptoms, anxiety, depression, and insomnia in postmenopausal women with insomnia complaints.

Methods

A cross-sectional analysis was conducted with 71 postmenopausal women experiencing insomnia, divided into two groups based on the presence of vasomotor symptoms: 41 participants reported hot flashes in the past month, while 30 did not. All participants completed validated questionnaires, including the Blatt-Kupperman Menopausal Index, Menopause Rating Scale (MRS), Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), and Insomnia Severity Index (ISI).

Results

Women experiencing hot flashes showed a significant association between elevated anxiety levels and menopausal symptoms. Across the entire sample, anxiety levels strongly correlated with the severity of menopausal symptoms. Participants with hot flashes were more likely to be classified as having severe anxiety based on BAI results compared with those without vasomotor symptoms. However, no significant differences were found in depression or insomnia severity between the groups.

Conclusions

Vasomotor symptoms are associated with higher anxiety levels and more pronounced menopausal symptoms in postmenopausal women with insomnia complaints. These findings highlight the potential impact of hot flashes on emotional well-being and overall health during postmenopause.

Keywords

postmenopause - hot flashes - anxiety - depression - insomnia

Introduction

Menopause represents a significant phase in a woman's life, often accompanied by both physical and psychological challenges. It can be defined retrospectively as 12 months of amenorrhea after the last menstrual period.[1] Key concerns during the menopausal transition include irregular menstrual cycles, vasomotor symptoms, hormonal fluctuations, sleep disorders, and emotional health issues such as heightened level of depression and anxiety.[1]

Postmenopause describes the period following menopause, in which mood changes might regulate the relationship between sleep and vasomotor symptoms.[2] [3] The exact mechanisms linking anxiety and vasomotor symptoms remain an area of active research. It is hypothesized that anxiety may influence the hypothalamic-pituitary-gonadal axis, leading to alterations in thermoregulation and increased susceptibility to hot flashes. Additionally, heightened sympathetic nervous system activity associated with anxiety may exacerbate the frequency and intensity of hot flashes. Conversely, the distress caused by vasomotor symptoms may contribute to the development or worsening of anxiety symptoms, creating a cyclical pattern that interferes in sleep quality.[4] [5] [6] Depression and anxiety may affect sleep quality directly, making it difficult to fall asleep and promoting early waking, while hot flashes can increase the frequency of nighttime awakenings and the rate of sleep stage transitions.[2] [3] [6] Moreover, sleep disorders in the menopausal transition can be both a symptom of anxiety and depression, and a risk factor for future depression.[6]

It is known that anxiety and depression increase during the menopause transition and in postmenopause compared with pre-menopause,[7] with anxiety peaking in early transition, with mood swings, irritability, and other common symptoms also occurring in this period.[8] [9] Consequently, menopausal transition and postmenopause, as well as their common psychological symptoms can be considered risk factors for poor sleep quality.[6] Women who have poor sleep quality and more sleep complaints also have higher rates of psychological symptoms and more frequency of menopausal symptoms.[3] This indicates that there is a multidirectional relationship between menopausal symptoms, sleep complaints and psychological conditions. Sleep disturbances can impact other aspects of psychological and physical health in postmenopausal women, as non-restorative sleep can interfere in daily activities, decreasing work productivity and concentration levels.[10]

Menopause and insomnia are potential challenges to female health and can be increased by vasomotor symptoms; however, not all women complain about hot flashes or are affected by them. Therefore, this study aimed to explore the relationships between vasomotor symptoms, menopause-related complaints, and levels of anxiety, depression, and insomnia in postmenopausal women experiencing sleep disturbances.

Methods

This cross-sectional study used a convenience sample, with data derived from a clinical trial that evaluated the effect of aromatherapy in postmenopausal women with insomnia.[11] Prior to the clinical trial, all potential participants interested in taking part in the study received a recorded voice message describing the protocol. This study was looking for postmenopausal women aged between 48 and 65 years old with insomnia complaints. The non-inclusion criteria were: the use of any medications in the previous month that affected sleep, hormonal therapy in the last three months, the practice of any complementary/integrative treatment for sleep disorders (or not being willing to stop it for a month), previous use of Lavandula angustifolia essential oil, being a shift worker, being illiterate or having a clinical diagnosis of an uncontrolled disease.

Women who believed they met the clinical trial's criteria were then invited to an in-person meeting with the main researcher to complete questionnaires and undergo an anamnesis. The current study is using data from this first meeting, and, for our analysis, we excluded one participant who was using sleep medication. Moreover, in this study we accepted participants who were using non-hormonal treatment for vasomotor symptoms, off-label sleep medications and phytotherapy supplementation. The recruitment period occurred between April 2018 and June 2019, and all participants signed an Informed Consent Form. The clinical trial was approved by the Research Ethics Committee of UNIFESP (#000,316/2018; CAAE: 81665817.7.0000.5505). Additional details about the study design can be found in the publication by Lucena et al., 2021.[11]

Evaluation Instruments and Group Definition

During the anamnesis, sociodemographic information was collected in respect of menarche and menopause age, the practice of physical activity, and the use of medication or treatments (including non-hormonal treatments) for vasomotor symptoms or mood and/or sleep disorders. Using the age of onset of menopause, we calculated the postmenopause stage (early or late), with early postmenopause being characterized as the first 8 years following the last menstrual cycle, and late postmenopause as the remaining lifespan, according to Harlow et al., 2012.[12] Additionally, the participants were also asked whether they experienced hot-flashes (yes or no) and their frequency in the last month, as well as providing a self-reported history of sleep patterns and total sleep time (TST) in the last month. The participants who had complained of hot flashes during the day or at night were designated to the group with vasomotor symptoms (n = 41). Women who did not report hot flashes in the last month were designated to the control group (n = 30).

The following instruments validated for use in Brazilian Portuguese were used. Climacteric symptoms were measured using the Blatt-Kupperman Menopausal Index, which evaluates 11 symptoms on a scale from 0 (absent) to 3 (severe), with total scores categorized as mild (≤19), moderate (20–35), or severe (>35).[13] The Menopause Rating Scale (MRS), which evaluates the severity of menopause symptoms using 11 questions, was also used. The scale score ranges from 0 to 44, distributed in three domains: psychological, somato-vegetative, urogenital, and a total score. For each evaluation, the higher the score, the worse the symptoms.[14]

Anxiety levels were assessed using the Beck Anxiety Inventory (BAI), a 21-item inventory that classifies anxiety into categories: no or minimal (0–7), mild (8–15), moderate (16–25), and severe (26–63).[15] The 21-item Beck Depression Index (BDI) was used to measure depression with scores categorized as minimal (0–9), mild (10–18), moderate (19–29) and severe (30–63).[16] Insomnia complaints were measured using the Insomnia Severity Index (ISI), a 7-item instrument scoring from 0 to 28, categorized as absence of insomnia (0–7), mild (8 to 14), moderate (15–21) and severe (22 to 28).[17]

Statistical Analysis

All analyses were performed using IBM® SPSS software v. 26 (IBM CORP., Armonk NY, USA), and the figures in the panel were built using GraphPad Prism software v. 8 (GraphPad Software, San Diego, CA, USA). In the descriptive data, we used a Generalized Linear Model (GzLM) with normal distribution to calculate continuous variables, and to analyze the association between categorical variables we used the Pearson chi-square test or Fisher's exact test, when the cells had an expected count of less than five.

In the association analysis between groups (Control group x Group with vasomotor symptoms) according to the outcomes (Blatt-Kupperman Index, MRS, BAI, BDI, and ISI), the GzLM was used with normal or gamma distribution according to the minor Akaike's Information Criterion (AIC) value. The data from the Blatt-Kupperman Index and MRS were controlled for the use of non-hormonal treatments for vasomotor symptoms (yes or no). Additionally, our data regarding insomnia severity and anxiety and depression levels were controlled for the use of treatments/off label medication for sleep disorders and mood medications (yes or no), respectively. [Supplementary Fig. S1] presents a Q-Q plot with the residuals of the association analysis. The results were confirmed by the Bonferroni's post hoc, adopting the significance of p≤0.05.

We conducted a multiple logistic regression analysis to observe the odds ratio [Exp(B)] of the group with vasomotor symptoms in respect of each level of anxiety according to BAI score compared with the control group. Moreover, to evaluate the correlation between continuous variables, Spearman's one-tailed correlation (r_s) test was used to assess the relationship between the level of anxiety (according to BAI) and the menopausal symptoms (according to the MRS and the Blatt-Kupperman Index).

Power Analysis

Power analysis was conducted using the online software GLIMMPSE 3.1.3[18] with the original data values. As a result, the statistical power was calculated as 0.99 with a significant level of 0.05 using the Hotelling-Lawley Trace test. For this analysis, we compared the effect of groups (Control group and Group with vasomotor symptoms) on the mean values of the total score of the Blatt-Kupperman Menopausal Index, BAI, BDI, ISI, MRS total, and the three domains of the MRS questionnaire (psychological, somato-vegetative, urogenital). The authors are providing the saved file with the calculations performed to obtain this measurement ([Supplementary Fig. S2]).

Results

[Fig. 1] shows a flowchart regarding the selection of the participants in the study. From the 135 women who expressed an interest in taking part, 72 attended an in-person meeting. The data from one participant was excluded due to the use of sleep medication, so a total of 71 women entered the final analysis (Control group = 30; Group with vasomotor symptoms = 41). [Table 1] presents a comparison of the descriptive data between groups, a significant difference was found in age (p < 0.001) and postmenopause stage (p = 0.014), which means that the vasomotor symptoms group were younger and had a greater proportion in early postmenopause than the Control group. Regarding the postmenopause stage, four participants were classified as “non-conclusive” as they were women with a history of hysterectomy who stopped menstruating prematurely, and a biochemical test would have been necessary to assess the level of follicle stimulating hormone (FSH). No other statistical differences were observed in the other variables, but it is worth mentioning that mean self-reported total sleep time (TST) in both groups was considerably low, compared with what is usually observed in women in this age range.[19]

Fig. 1 Flowchart of participant selection. ^(a)Reasons for ineligibility after the first contact: 16 could not attend the appointment, 9 were not interested, 7 had previously used lavender essential oil, 6 were using hormonal therapy, 5 were older than 65 years old, 5 in perimenopause, 4 were using sleep medication, 4 were younger than 48 years old, 3 had a sleep apnea diagnosis, 2 had no sleep complaints, 2 were using antidepressant. ^(b)Participant was using Zolpidem.

Table 1 Comparison of descriptive data between groups (n = 71)

Variable		Control group (n = 30)	Group with vasomotor symptoms (n = 41)		Test value	p value
Age (years)(a)		58.93 ± 0.73	55.51 ± 0.64		12.225	<0.001[*]
Body mass index (kg/m2)(a)		26.53 ± 0.94	27.89 ± 0.85		1.136	0.28
Cervical circumference (cm)(a)		34.16 ± 0.53	35.15 ± 0.46		1.950	0.16
Menarche age (years)(a)		12.90 ± 0.28	12.82 ± 0.24		0.036	0.84
Menopause age (years)(a)		49.26 ± 0.77	48.26 ± 0.66		0.959	0.32
Self-related TST (minutes)(a)		279.00 ± 14.17	259.75 ± 12.12		1.064	0.30
Ethnicity, n (%)(b)					3.585	0.32
European-descent		22 (73.3)	22 (53.7)
Afro-Brazilian		3 (10.0)	6 (14.6)
Mixed-race(c)		5 (16.7)	10 (24.4)
Asian		0	3 (7.3)
Education, n (%)(b)					5.886	0.25
Middle school incomplete		1 (3.3)	0
Middle school complete		0	2 (4.9)
High school incomplete		0	1 (2.4)
High school complete		4 (13.3)	8 (19.5)
Incomplete university		2 (6.7)	7 (17.1)
Above university		23 (76.7)	23 (56.1)
Postmenopause stage (d)					7.644	0.014[*]
Early postmenopause		13 (43.3)	26 (63.4)†
Late postmenopause		17 (56.7)†	11 (26.8)
Non-conclusive		0	4 (9.8)
Physical activity, n (%)(b)					0.510	0.47
Yes		15 (50.0)	24 (58.5)
No		15 (50.0)	17 (41.5)
Frequency of physical activity, days per week (%)(e)
1 to 2 per week		6 (40.0)	7 (29.2)
3 to 4 per week		6 (40.0)	10 (41.7)
5 to 7 per week		3 (20.0)	7 (29.2)
Use of medications [(f)]
Non-hormonal treatment for vasomotor symptoms	yes	1 (3.3)	4 (9.8)
	no	29 (96.7)	37 (90.2)
Off-label sleep medication	yes	3 (10.0)	4 (9.8)
	no	27 (90.0)	37 (90.2)
Mood medication	yes	6 (20.0)	4 (9.8)
	No	24 (80.0)	37 (90.2)
Hot flashes frequency (e)
During the day			1 to 3	15 (55.6)
			4 to 6	3 (11.1)
			≥7	9 (33.3)
At night			1 to 3	21 (61.8)
			4 to 6	6 (17.6)
			≥7	7 (20.6)

Values are expressed as ^(a)mean ± standard error; ^{(b, d, e, f)}number (percentage); P Values are based on a Generalized linear model (GzLM) with ^(a)normal distribution and, for categorical association, the ^(d)Pearson chi-square test or Fisher's test was chosen.

Self-reported TST (average self-reported total sleep time per night). ^(c)Mixed-race: Afro-Brazilian and European-descent ancestry. †Frequency higher than expected. (d) early postmenopause (first 8 years since the final menstrual cycle), late postmenopause (period after early postmenopause), non-conclusive (women with a history of hysterectomy who stopped menstruating prematurely).

^(f)Non-hormonal treatment for vasomotor symptoms: capsules of cyclofenil, Cimicifuga racemosa, Menoron (Ayurvedic medicine), primrose oil, and blackberry tea. Off-label sleep medications: capsules of Valeriana officinalis and melatonin, homeopathic medication, passion fruit tea. Mood medications: divalproex sodium, venlafaxine, fluoxetine, escitalopram, trazodone, oxcarbazepine.

^* Statistically significant difference compared to the other group.

[Table 2] shows a comparison of the groups in respect of the questionnaire data. A significant difference in relation to the menopause symptoms in both the Blatt-Kupperman index (p < 0.001) and in the total score of MRS (p < 0.001) was observed. In respect of the other variables, there was no statistically significant difference in the level of depression (p = 0.20) or insomnia severity (p = 0.36), and the mean score of all participants indicated moderate insomnia. The vasomotor symptoms group had a significantly higher level of anxiety (p < 0.001) than the control group ([Fig. 2d]). [Table 3] presents the results of the correlation analysis between the level of anxiety and menopause symptoms, with a strong and positive correlation being observed in both instruments (Blatt-Kupperman index and MRS), indicating the greater the menopause symptoms, the higher the level of anxiety (MRS total score p < 0.001; ρ = 0.738, and Blatt-Kupperman index p < 0.001; ρ = 0.682). [Supplementary Fig. S3] shows the scatter-plot correlation figure, in which the correlation between BAI and MRS was R² linear = 0.463, and BAI and Blatt-Kupperman index was R² linear = 0.527.

Table 2 Comparison of questionnaires data between groups

	Mean ± standard error		Tests of model effects
Questionnaires	Control group (n = 30)	Group with vasomotor symptoms (n = 41)	Wald chi-square	p
Blatt-Kupperman Index(a)	15.79 ± 1.20	27.01 ± 1.76	36.654	<0.001[*]
Beck Anxiety Index (BAI)(a)	12.71 ± 1.23	20.00 ± 1.66	21.594	<0.001[*]
Beck Depression Index (BDI)(b)	14.31 ± 1.24	15.18 ± 1.10	3.196	0.20
Insomnia Severity Index (ISI)(a)	17.92 ± 0.82	17.87 ± 0.72	1.996	0.36
Menopause Rating Scale (MRS)
Psychological domain(a)	7.58 ± 0.60	8.94 ± 0.62	29.925	0.001
Somato-vegetative domain(b)	6.43 ± 0.55	9.05 ± 0.48	0.713	0.70
Urogenital domain(b)	4.38 ± 0.52	5.41 ± 0.45	2.631	0.26
Total score(a)	18.40 ± 1.09	23.41 ± 1.22	33.787	<0.001[*]

P values are based on a Generalized Linear Model (GzLM) with ^(a)gamma or ^(b)linear distribution.

^* Significance confirmed with Bonferroni's post hoc. The results of the Blatt-Kupperman index and MRS were controlled for the use of non-hormonal therapy (yes or no); ISI for the use of off-label sleep medications (yes or no); and the BAI and BDI for the use of mood medications (yes or no).

Fig. 2 Panel presenting the comparison between groups in relation to the level of anxiety. ^{a, c)}The figures exhibit the participants according to the anxiety score in each group. ^b)Table with the multiple logistic repression results. ^d)Box plot shows the comparison between groups regarding the level of anxiety. *Significance confirmed with Bonferroni's post hoc.

Table 3 Correlation analysis regarding the level of anxiety and menopause symptoms (n = 71)

Menopause Rating Scale (MRS)		Beck Anxiety Index (BAI)
Psychological domain	Spearman ρa	0.590
	P-value	<0.001[*]
Somato-vegetative domain	Spearman ρa	0.572
	P-value	<0.001[*]
Urogenital domain	Spearman ρa	0.431
	P-value	<0.001[*]
Total score	Spearman ρa	0.738
	P-value	<0.001[*]
Blatt-Kupperman index		Beck Anxiety Index (BAI)
	Spearman ρa	0.682
	P-value	<0.001[*]

^(a)Spearman's rho correlation coefficient (one-tailed).

^* Represents significance (P≤0.05) in correlations strong or above. Correlation strength values: 0 to 0.20 (very weak); 0.20 to 0.39 (weak); 0.40 to 0.59 (moderate); 0.60 to 0.79 (strong); 0.80 to 0.99 (very strong); 1.0 (perfect).

In [Fig. 2], we included a panel with four analyses. In [Fig. 2a], [b], and [c] we evaluated the chance (odds ratio) of participants in the group with vasomotor symptoms having a minimal, mild, or moderate anxiety score, according to the BAI, comparing them to the Control group and to the severe score. The group with vasomotor symptoms presented Exp(B) = 0.20 to the minimal score. In addition, we also inverted the analysis to observe the chance of the vasomotor symptoms group scoring severely in the anxiety instrument, when compared with the control group and minimal anxiety (Exp(B) = 50.00). Thus, in our sample, women with vasomotor symptoms had a higher chance of having severe anxiety than the women in the control group.

Discussion

The menopausal transition is a period marked by hormonal changes which can lead to unpleasant symptoms and impact women's quality of life. The peak of the vasomotor symptoms occurs between the late perimenopause and the first five years after the final menstruation.[20] Although these symptoms tend to diminish over time, moderate to severe hot flashes may last for more than 5–10 years,[20] [21] interfering in the sleep patterns, mood, and well-being of this population. Our findings revealed that postmenopausal women with insomnia and vasomotor symptoms exhibited significantly higher anxiety levels and more severe menopausal symptoms compared with those without vasomotor symptoms. The vasomotor group also had a greater likelihood of being classified as experiencing severe anxiety.

During the climacteric, unpleasant vaginal and vasomotor symptoms, sleep disturbances, and a reduction in quality of life, sexual function and mood, are some common complaints.[22] [23] In our data, women with hot flashes presented a significant increased level of menopause symptoms in both questionnaires (MRS and Blatt-Kupperman index), compared with controls. In the literature, it has already been widely reported that vasomotor symptoms are the most frequent complaints related to menopausal women seeking medical treatment.[20] [24] These symptoms tend to be greatest in the first years after menopause, occurring in up to 3 out of 4 women,[20] [21] which is in line with our finding that the vasomotor symptoms group was younger and more prevalent in early postmenopausal stage.

Despite their high prevalence, the etiology of hot flashes is not fully understood and is likely multifactorial. Different ways of experiencing vasomotor symptoms may be reported according to personal features, in addition to variation in their intensity and frequency.[21] [22] [25] A study identified that some individual factors are related to longer vasomotor symptoms duration, such as starting to experience hot flashes in premenopause and having a negative feeling about it, lower educational levels, and greater level of stress, depression, and anxiety.[26] Moreover, racial/ethnic characteristics and seasonality may also have a role in the perception of hot flashes. For instance, a study observed that Afro-American women had longer duration and frequency of vasomotor symptoms than Chinese and Japanese women,[26] while night sweats are more frequent in warmer periods of the year.[27]

Regarding sleep patterns and insomnia complains, a meta-analysis identified that postmenopausal women showed a higher risk of presenting sleep disorders than premenopausal and perimenopausal women.[28] Personal characteristics are also involved in respect of sleep architecture, since women in premenopause who have trouble falling asleep may maintain the same pattern during the menopausal transition and postmenopause.[29] The occurrence of hot flashes and night sweats are closely linked to night waking and decreased sleep quality,[3] and their frequency and severity may contribute to insomnia symptoms.[30] In our data, no significant difference between groups in respect of insomnia was observed, which was expected since all participants presented, on average, moderate insomnia complaints (according to the ISI) and reduced self-reported TST, compared with women in the same age range.[19] According to polysomnography data, hot flashes tend to interfere in the first four hours of sleep,[31] mostly during the N1 sleep stage and wake periods,[2] and are associated with increased duration of wake after sleep onset.[31] Moreover, the perception that hot flashes at night are linked with awakenings seem to produce a subjective memory of the event, which may sensitize the individual and impact their sleep pattern.[2]

Both sleep disorders and the menopausal transition can affect mood and quality of life. For instance, worsening levels of anxiety and depression are common in menopausal transition and postmenopause,[22] [23] impacting sleep patterns.[29] Women who previously had major depression have a risk of relapse in the first two years of postmenopause.[9] A similar tendency is observed regarding anxiety, in which previous experience of high levels of anxiety may recur in menopause transition and after, and anxiety can even increase over time in individuals who previously presented only low levels.[32] Our study identified no significant differences between groups in respect of the level of depression, which may be related to the mean mild score of our entire sample. A similar finding was observed in a study of rural Bangladeshi women, in which no relationship between vasomotor symptoms and depression was observed.[33] Depressive symptoms and insomnia tend to overlap in menopausal women with hot flashes; however, the depression alone may be associated with insomnia, regardless of vasomotor symptoms,[34] although a cross-sectional survey argued that both outcomes played a mediating role regarding the intensity of the vasomotor symptoms and sleep quality. In addition, a Chinese study reported that severe hot flashes and increased levels of anxiety and depression were related with decreased quality of sleep.[6] This relationship is supported by further evidence showing that depression during the climacteric period is prevalent and can significantly impact psychological well-being, especially in association with hormonal fluctuations and sleep disruption.[35] Moreover, studies conducted in older populations in the Brazilian Western Amazonia have demonstrated a strong association between poor sleep quality and depressive symptoms, reinforcing the intertwined nature of these phenomena in aging and transitional phases of life.[36] In our sample, the level of anxiety was associated with vasomotor symptoms and both conditions showed a strong correlation, so the higher the anxiety, the worse the vasomotor symptoms and vice versa. Furthermore, women with hot flashes presented a higher chance of being classified as having severe anxiety compared with women in the control group. Hot flashes can occur during the day or night and are characterized by a sudden sensation of heat and sweating that last between 3 to 10 minutes[37] and are associated with sleep disorders and increased levels of anxiety, which may be a consequence of this phenomenon rather than a cause. According to a cohort study, the manifestation of anxiety symptoms in the body, called somatic anxiety, was strongly associated with predicting moderate/severe menopausal hot flashes.[5] The authors suggested that although both conditions may overlap, somatic anxiety may worsen vasomotor symptoms, therefore being a potential target treatment.[5]

Postmenopausal women often experience sleep disturbances, mood swings, changes in libido, and other symptoms that create a complex scenario for treatment. In respect of hot flashes, hormonal therapy (HT) is the most effective treatment for this, in addition to being able to prevent bone loss and bone fracture, as well as genitourinary symptoms.[27] However, physicians need to manage and balance the possible risk of using HT, considering clinical and family history.[38] When HT is not recommended, there are some non-hormonal options. In this regard, a review[23] reported that pharmacological options, such as escitalopram[39] and venlafaxine XR[40] were able to reduce HF by ∼50% per day, compared with 30% using placebo.[23] In regard to insomnia, venlafaxine seems to present a modest effect in improving the quality of sleep.[41] The American College of Physicians advocates for cognitive-behavioral therapy for insomnia (CBT-I) as a primary treatment for chronic insomnia,[42] while mindfulness practices have also been shown to effectively reduce insomnia severity.[43] Cognitive behavioral therapy has also shown promise in improving vasomotor symptoms and reducing recurrence of depression in postmenopausal women, offering a therapeutic alternative for this population.[44] Finally, the practice of physical activity and the use of complementary therapies may also help to reduce levels of anxiety and depression[11] [45]; and improve sleep patterns.[11] [46]

This study provides valuable insights into the relationship between vasomotor symptoms, anxiety, and menopausal symptom severity in postmenopausal women with insomnia. The use of validated and widely accepted instruments, including the Blatt-Kupperman Menopausal Index, Menopause Rating Scale (MRS), Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), and Insomnia Severity Index (ISI), enhances the reliability and comparability of the findings. Furthermore, the application of rigorous statistical methods supports a comprehensive analysis of the interrelationships among VMS, anxiety, and insomnia, while controlling for important confounders like age and treatment use. Clinically, the findings support the need for integrated assessment and treatment of anxiety in women reporting hot flashes and sleep disturbances. These results reinforce the importance of screening for vasomotor symptoms and psychological distress during early postmenopausal state to inform therapeutic strategies. Furthermore, the observed bidirectional relationship between anxiety and vasomotor symptoms suggests that interventions targeting anxiety and depression, such as cognitive-behavioral therapy and mindfulness - may also alleviate hot flashes.

Our study had some limitations that should be mentioned. First, sleep patterns and TST were assessed using a self-reporting questionnaire. Although the instrument had been validated, future studies should include objective instruments, such as polysomnography and/or actigraphy. Considering the clinical trial criteria, we were only able to analyze data from the participants who completed the anamnesis, which reduces the total sample size. We could not test FSH levels. Finally, the study location and its cultural specificities might limit the extrapolation of our findings to populations in other countries. Despite these limitations, our study highlighted the association between vasomotor symptoms, worse in the climacteric symptoms and anxiety in postmenopausal women with insomnia complaints.

Conflict of Interest

None of the authors have any conflict of interest to disclose. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this report is consistent with those guidelines.

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Publikationsverlauf

Eingereicht: 30. November 2024

Angenommen: 24. August 2025

Artikel online veröffentlicht:
31. Dezember 2025