Exploring the Causes, Magnitude, and Implications of Discrepancies in Objective and Subjective Sleep Measures in Women in the Menopause Transition and Postmenopause

Abstract

Over half of women undergoing the menopausal transition (MT) or postmenopause (PM)experience significant sleep disturbances due to aging, hormonal changes, hot flashes, and night sweats. These issues can severely affect mental health, daily functioning, and overall quality of life. Poor sleep quality during these stages is linked to increased risks of anxiety, depression, and reduced productivity. Accurate assessment of sleep is vital but challenging, as subjective tools like questionnaires often differ from objective methods such as polysomnography (PSG) and actigraphy. However, discrepancies between subjective and objective measures highlight the need for combined approaches to capture the full complexity of sleep disturbances in MT and PM. Despite growing research, the unique sleep challenges faced by women in these stages remain underexplored, emphasizing the importance of targeted studies to inform effective interventions—a gap this dissertation aims to address. This dissertation investigates the discrepancies between subjective and objective sleep assessments in menopausal and postmenopausal women, offering critical insights into how physiological, psychological, and stress-related factors contribute to sleep disturbances. By examining these issues through subjective and objective measures, it emphasizes the need for nuanced approaches in both research and clinical practice, structured around three main topics (Chapters 2, 3, and 4). Chapter 2 reviews 16 studies (2010–2022) that highlight consistent patterns of subjective sleep assessments overestimating total sleep time (TST) and sleep onset latency (SOL) while reporting more nighttime awakenings (WASO) compared to objective measures like PSG and actigraphy. These discrepancies arise as subjective measures reflect personal perceptions—often influenced by menopausal symptoms such as vasomotor symptoms (VMS) and heightened emotional sensitivity—while objective tools provide a more precise account of physiological sleep patterns. This chapter underscores the importance of integrating both methods to capture the multifaceted nature of sleep disturbances, laying the foundation for targeted clinical interventions. Chapter 3 explores how insomnia amplifies the misalignment between subjective and objective sleep measures. Using data from the Finding Lasting Answers for Symptoms and Health (MsFLASH) research network, it examines key sleep parameters (TST, SOL, WASO, and sleep efficiency [SE]) across actigraphy, PSQI, and sleep diaries. Results show that women with insomnia experience greater perceptual discrepancies, often overestimating TST and SE while underestimating SOL and WASO compared to objective data. These biases are more pronounced in PSQI scores, likely due to recall errors inherent in retrospective reporting. The findings highlight insomnia’s role in altering sleep perception through mechanisms such as heightened cortical activation and impaired sensory processing, emphasizing the need for combined assessment methods to accurately evaluate sleep in menopausal populations. Chapter 4 investigates how VMS and stress influence discrepancies in sleep assessment. Using MsFLASH data, the study evaluates SOL, TST, WASO, and SE through actigraphy, PSQI, and sleep diaries, while also considering perceived stress and physiological stress via nighttime salivary cortisol. Results reveal that VMS contributes significantly to overestimations of SOL and WASO and underestimations of TST and SE in subjective reports, particularly PSQI, highlighting the impact of symptom-driven perceptual biases. While perceived stress affected SOL discrepancies, physiological stress (cortisol) showed no consistent relationship, questioning its reliability as a stress marker in sleep studies. This chapter advocates for integrating actigraphy with sleep diaries for a more accurate depiction of sleep patterns in women with VMS and stress, cautioning against overreliance on PSQI for nuanced sleep assessments. This research highlights the interplay between menopausal symptoms and sleep perception, advocating for multifaceted assessment strategies to enhance clinical practices. This dissertation underscores the importance of adopting a comprehensive, multi-method approach to evaluating sleep disturbances in menopausal and postmenopausal women. By exploring the discrepancies between subjective and objective sleep evaluations, it reveals the shortcomings of relying solely on single-method assessments to understand the intricate interaction between physiological and perceptual elements of sleep. Factors such as VMS, insomnia, and stress play a significant role in shaping these discrepancies, emphasizing the value of dual-method approaches that combine objective measurements with subjective accounts.