Menopause is a natural biological transition marked by permanent cessation of menstruation due to loss of ovarian follicular activity, and postmenopause is generally defined after 12 consecutive months of amenorrhea. The Stages of Reproductive Aging Workshop +10 system is a standardized classification system for reproductive aging and menopausal stages that enhances the comparability of clinical and research studies of midlife and postmenopausal women [1].

One of the common health concerns reported during the menopausal transition and postmenopausal period is sleep disturbance. Women may report problems getting to sleep, waking up many times during the night, waking up early in the morning, shorter sleep, poor quality sleep, and daytime sleepiness. Kravitz et al. demonstrated that sleep disturbance was greater with each menopausal stage and was related to ethnicity, vasomotor symptoms, mood, and health-related factors in the Study of Women's Health Across the Nation [2].

Menopause and sleep are a complex mix. Poor sleep quality in postmenopausal women may be due to declining estrogen levels, vasomotor symptoms, night sweats, mood changes, anxiety, depression, weight gain, medical comorbidities, and age-related changes in sleep architecture. Baker et al. highlighted that sleep disturbances in the menopausal transition can manifest as insomnia symptoms, sleep-disordered breathing, and restless legs symptoms, and that these sleep disturbances can have a profound impact on daytime functioning and quality of life [3].

Systematic review data provide evidence for a relationship between menopause and subjective sleep disturbance. In a systematic review and meta-analysis, Xu and Lang found that peri- and postmenopausal women were more likely to experience sleep disturbances than premenopausal women, but the magnitude of the association differed among studies, depending on the study design, population characteristics, and sleep assessment methods [4]. This underscores the need for structured tools to evaluate sleep pattern in certain populations.

Midlife women have also been shown to have a high prevalence of sleep disturbances in large population-based and multinational studies. Blümel et al. reported sleep disorders in women in midlife in several countries and associations with menopausal status, vasomotor symptoms, depressive symptoms and impaired quality of life [5]. These findings suggest that poor sleep in postmenopausal women is not a standalone complaint, but is closely associated with overall physical and psychological health.

One of the most significant menopausal factors that disrupt sleep is vasomotor symptoms. Ohayon showed that severe hot flashes were significantly associated with chronic insomnia, indicating that nocturnal vasomotor symptoms may be a direct cause of sleep fragmentation and chronic insomnia complaints [6]. But vasomotor symptoms are not the only factors that can cause sleep disturbances; mood symptoms, lifestyle, chronic illness, and psychosocial stressors can also contribute significantly.

Longitudinal evidence also suggests that sleep disturbance remains around menopause. In a population-based 14-year follow-up study, Freeman et al. reported that poor sleep was linked to the natural menopausal transition and associated symptoms, highlighting that sleep complaints can continue beyond the transition period [7]. Hence, it is important to actively screen postmenopausal women for sleep-related issues when they are in clinical settings.

Asian data have also indicated that menopausal symptoms and sleep quality are closely related. Zhang et al. found that menopausal symptoms, such as vasomotor and psychological symptoms, were significantly related to poor sleep quality in menopausal transition and postmenopause [8]. Indian studies also indicate that post menopausal women frequently report sleep related symptoms. In a study conducted in South India, Bairy et al. reported that one of the common menopausal symptoms that impact the quality of life is difficulty in sleeping [9].

Although there is increasing evidence, data from the region of Eastern India is still scarce, especially from private medical colleges. Sleep pattern among postmenopausal women may be affected by sociocultural background, lifestyle, nutritional status, comorbidities, family structure and healthcare-seeking behaviour. The current study is designed to evaluate sleep pattern and to determine factors associated with poor sleep in this population.

OBJECTIVES

1. To assess the sleep pattern and sleep quality among postmenopausal women using a structured sleep assessment tool.
2. To estimate the proportion of postmenopausal women with poor sleep quality.
3. To evaluate the association of sleep disturbance with menopausal symptoms, vasomotor symptoms, mood symptoms, comorbidities, and lifestyle factors.
4. To identify clinical and sociodemographic factors associated with poor sleep among postmenopausal women.

Study design and setting This prospective observational study was conducted at Gouri Devi Institute of Medical Sciences, Durgapur, West Bengal, India, over a period of one year (March 2025 to Feb 2026). The study evaluated sleep pattern and sleep quality among postmenopausal women attending the outpatient department. Study population A total of 100 postmenopausal women were included in the study. Postmenopause was defined as absence of menstruation for at least 12 consecutive months not attributable to pregnancy, lactation, hormonal therapy, or pathological causes. Women who were willing to participate and provided informed consent were enrolled. Women with surgical menopause, current hormone replacement therapy, severe psychiatric illness, known diagnosed sleep disorders under treatment, chronic use of sedatives or hypnotics, malignancy, severe systemic illness, or incomplete questionnaire responses were excluded. Data collection Demographic and clinical details were recorded using a structured proforma. These included age, residence, marital status, education, occupation, body mass index, duration since menopause, parity, lifestyle factors, comorbidities, medication history, and menopausal symptoms such as hot flashes, night sweats, mood changes, anxiety, and musculoskeletal complaints. Assessment of sleep pattern Sleep pattern and sleep quality were assessed using the Pittsburgh Sleep Quality Index (PSQI). The questionnaire evaluated subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction over the preceding one month. A global PSQI score was calculated, and participants were categorized as having good or poor sleep quality according to standard PSQI interpretation. Outcome measures The primary outcome was the proportion of postmenopausal women with poor sleep quality. Secondary outcomes included sleep duration, sleep latency, nocturnal awakenings, daytime dysfunction, and factors associated with poor sleep quality, including vasomotor symptoms, psychological symptoms, comorbidities, BMI, and duration since menopause. Statistical analysis Data were summarized as mean ± standard deviation, median with interquartile range, or frequency and percentage, as appropriate. Poor and good sleep groups were compared using Welch’s t-test for continuous variables, Mann–Whitney U test for ordinal PSQI component scores, and Pearson’s chi-square test for categorical variables. Unadjusted and adjusted odds ratios for poor sleep quality were estimated using logistic regression. The adjusted model included age ≥60 years, BMI ≥25 kg/m², vasomotor symptoms, mood/anxiety symptoms, musculoskeletal complaints, nocturia, and low physical activity. A p-value <0.05 was considered statistically significant. Ethical considerations The study was conducted after approval from the Institutional Ethics Committee of Gouri Devi Institute of Medical Sciences, Durgapur. Written informed consent was obtained from all participants, and confidentiality of patient information was maintained throughout the study.

Study cohort and prevalence of poor sleep quality

A total of 100 postmenopausal women were included in the analysis. Poor sleep quality, defined as a PSQI global score >5, was observed in 59 (59.0%; 95% CI 49.2–68.1%). Baseline characteristics according to sleep quality are summarized in Table 1. The groups were broadly comparable for age, BMI, duration since menopause, and metabolic comorbidities. Musculoskeletal complaints and nocturia were more frequent among women with poor sleep quality, while mood/anxiety symptoms showed a higher, but borderline, association with poor sleep.

Table 1. Baseline sociodemographic and clinical characteristics according to sleep quality

Values are presented as mean ± SD or n (%). Poor sleep quality was defined as PSQI global score >5. Continuous variables were compared using Welch’s t-test; categorical variables were compared using Pearson’s chi-square test.

Sleep pattern and PSQI profile

Sleep-pattern measures and PSQI component scores are presented in Table 2. Women with poor sleep quality had shorter sleep duration, longer sleep latency, more nocturnal awakenings, and lower sleep efficiency. The distribution of PSQI global scores is shown in Figure 1, with most poor sleepers clustering above the standard PSQI cutoff.

Table 2. Sleep pattern and PSQI profile according to sleep quality

Continuous variables are presented as mean ± SD. PSQI component scores are presented as median (IQR). Continuous variables were compared using Welch’s t-test, ordinal PSQI component scores using the Mann-Whitney U test, and categorical variables using Pearson’s chi-square test.

Factors associated with poor sleep quality

Clinical and sociodemographic factors associated with poor sleep quality are shown in Table 3 and Figure 2. In the adjusted model, musculoskeletal complaints remained independently associated with poor sleep quality. Nocturia and mood/anxiety symptoms showed higher adjusted odds of poor sleep, although these associations did not reach conventional statistical significance.

Table 3. Clinical and sociodemographic factors associated with poor sleep quality

Odds ratios represent the odds of poor sleep quality. The adjusted model included age ≥60 years, BMI ≥25 kg/m², vasomotor symptoms, mood/anxiety symptoms, musculoskeletal complaints, nocturia, and low physical activity.

Summary of key findings

Overall, poor sleep quality was common among postmenopausal women and was characterized by prolonged sleep latency, reduced sleep duration, frequent nocturnal awakenings, and higher PSQI global scores. Among the evaluated clinical factors, musculoskeletal complaints showed the strongest independent association with poor sleep quality, while nocturia and mood/anxiety symptoms contributed to a higher sleep-disturbance burden.

Poor sleep quality was prevalent in this prospective observational study of 100 postmenopausal women, with 59.0% having PSQI global score >5. Poor sleepers had significantly shorter sleep duration, longer sleep latency, more nocturnal awakenings, lower sleep efficiency, higher PSQI global scores, and more daytime dysfunction. Of the clinical factors assessed, musculoskeletal complaints were most strongly independently associated with poor sleep quality, and nocturia and mood/anxiety symptoms were more likely to be associated with poor sleep quality but did not meet conventional statistical significance after adjustment.

The prevalence of poor sleep in the present study is similar to that found by Valiensi et al., who evaluated 195 postmenopausal women in Argentina with PSQI, Epworth Sleepiness Scale, and Oviedo Sleep Questionnaire. They reported a mean PSQI score of 6.90 ± 4.43, with 46.7% of women having PSQI >5. They also reported snoring in 13%, possible apnea episodes in 10% of poor sleepers, and leg spasms in 7.1%, suggesting that postmenopausal sleep disturbance is not only insomnia but also involves multiple sleep domains [10]. The prevalence was slightly higher in our cohort (59.0%) and poor sleepers also had longer sleep latency, shorter sleep duration, and more awakenings during the night.

Wong et al. offer a relevant regional comparator from Asia. In their study of 1,094 midlife Singaporean women aged 45-69 years, 38.2% reported poor sleep quality (PSQI >5). Independent correlates were low education, irritability, vaginal dryness, moderate to severe disability, urinary incontinence and breast cancer history; Indian women had higher sleep disturbance scores than Chinese women [11]. By contrast, our Eastern Indian group had a higher prevalence of poor sleep, and musculoskeletal complaints were the strongest adjusted association, indicating that physical symptom burden may be a major contributor to poor sleep in clinical settings among postmenopausal women.

The findings of the present study, that musculoskeletal complaints are independent of poor sleep, are strongly supported by Frange et al. They assessed 62 postmenopausal women in control, musculoskeletal pain, insomnia, and combined insomnia–musculoskeletal pain groups. Insomnia with musculoskeletal pain was linked to increased menopausal and anxiety symptoms, increased pain severity and interference, increased number of pain sites, sleep fragmentation, and decreased quality of life [12]. This is similar to our results that women with musculoskeletal complaints were more than three times as likely to have poor sleep quality, which further supports the importance of considering pain and musculoskeletal symptoms when assessing sleep in postmenopausal women.

Another clinically important contributor in our cohort was nocturia. Although its adjusted association was borderline, 75.0% of women with nocturia had poor sleep, and the adjusted odds ratio was 2.84. In a study of midlife women on the edge of menopausal transition, Jones et al. found that 42% of women had poor sleep quality and that the most common cause of poor sleep was waking up to go to the bathroom, which was reported by 81% of the women [13]. This is consistent with the clinical relevance of nocturia in our study, as the number of nocturnal awakenings was significantly greater in poor sleepers.

Kim et al. further support the role of menopausal symptom burden in their study of 634 Korean women aged 44–56 years. They found that poor sleep quality increased from premenopause to postmenopause, and that 30.2% of postmenopausal women had poor sleep quality. PSQI scores were positively correlated with vasomotor symptoms and physical symptoms, even after controlling for age, BMI, hypertension, diabetes, smoking, socioeconomic factors, physical activity, depression, stress, and menopausal status [14]. In our study, vasomotor symptoms were not independently associated with poor sleep, but physical symptom burden (musculoskeletal complaints) was. This indicates that for some postmenopausal groups, physical symptoms other than vasomotor may be more significant than hot flashes in sleep quality.

Sun et al. examined 2,046 women aged 40–60 years in China and reported a mean PSQI score of 6.88 ± 3.20, with sleep disturbance being more prevalent in postmenopausal women (40.9%) than in premenopausal women (34.8%). In their logistic regression, they found that menopausal status, vasomotor symptoms, modified Kupperman Index score, history of disease, and age ≥50 years were significant risk factors [15]. Our groups, on the other hand, were similar in terms of age, BMI, years since menopause, hypertension, and diabetes, and musculoskeletal complaints were the main independent factor. This discrepancy could be due to the older postmenopausal population and tertiary-care clinical characteristics of the current cohort.

The results of physical activity in the current study were consistent with previous studies but not statistically significant after adjustment. Creasy et al. found that sedentary time >11 hours/day was associated with increased odds of short sleep, poor sleep quality, and insomnia symptoms, and that increased total, light, and moderate physical activity was associated with decreased odds of poor sleep quality, using data from 75,074 postmenopausal women in the Women's Health Initiative Observational Study [16]. Low physical activity was more common among poor sleepers, but did not independently predict poor sleep in our study, perhaps due to the smaller sample size and greater impact of musculoskeletal symptoms and nocturia.

Objective sleep data also suggest that sleep should be considered a unique postmenopausal health issue. In an epidemiological study from São Paulo, Hachul et al., employed polysomnography and hormone evaluation and observed that postmenopausal women exhibited higher stage N3 sleep, apnea–hypopnea index, and lower oxygen saturation than premenopausal women. They found that menopause had a small but independent effect on sleep patterns and sleep parameters [17]. Although we did not use polysomnography in our study, the poor sleepers had shorter sleep times, longer sleep latency, more awakenings, and lower sleep efficiency, which suggest clinically significant subjective sleep disturbance.

The present study has several implications. First, poor sleep quality was very common in postmenopausal women in a private medical college setting in Eastern India. Second, sleep disturbance was defined as multiple PSQI domains, not a single symptom, such as decreased sleep duration, increased sleep latency, awakening during the night, and daytime dysfunction. Third, musculoskeletal complaints were the strongest independent correlate, suggesting that chronic pain, arthritis, and menopausal musculoskeletal symptoms should be assessed in women with poor sleep. Finally, nocturia and mood/anxiety symptoms, though borderline after adjustment, are clinically relevant and should be evaluated during routine evaluation.

There are limitations to the study. It was carried out in one centre only with 100 participants, and this may restrict generalizability. Sleep quality was evaluated with PSQI, and objective sleep evaluation (actigraphy or polysomnography) was not conducted. Because the analysis was cross-sectional, causal inferences regarding the relationship between musculoskeletal symptoms, nocturia, mood symptoms, and poor sleep cannot be made. The study has some limitations, but it offers valuable regional information that poor sleep quality is common among postmenopausal women and is strongly associated with physical symptom burden.

In general, the results indicate that postmenopausal women have poor sleep quality, which is associated with shorter sleep duration, longer sleep latency, more awakenings during the night, and higher PSQI scores. Musculoskeletal complaints were the most robust independent predictor, and mood/anxiety symptoms added to the overall sleep-disturbance burden. Structured sleep assessment should thus be incorporated into postmenopausal care, focusing on pain, nocturia and psychological symptoms.

Poor sleep quality was common among postmenopausal women, affecting 59.0% of participants. It was characterized by reduced sleep duration, prolonged sleep latency, frequent nocturnal awakenings, lower sleep efficiency, and greater daytime dysfunction. Musculoskeletal complaints were independently associated with poor sleep quality, while nocturia and mood/anxiety symptoms contributed to higher sleep-disturbance burden. Routine sleep assessment should be incorporated into postmenopausal care, with attention to pain, nocturia, and psychological symptoms.

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