Letters to the Editor
JOURNAL OF WOMEN’S HEALTH Volume 24, Number 3, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/jwh.2014.5163
Can Sleep Hygiene Behaviors Improve Sleep Quality in Midlife Women? Zaira F. M. Nicolau, Monica L. Andersen, PhD, Sergio Tufik, MD, PhD, and Helena Hachul, MD, PhD
he core of the article by Kline et al.1 relates to sleep hygiene behaviors in midlife women. It is a great contribution to the medical literature since it touches an issue important in the treatment of sleep disorders. The population chosen by the researchers is highly appropriate, as of the participants all sought help related to sleep disorders such as insomnia. Indeed, insomnia is a prevalent disorder and one of the major complaints of midlife women. We previously noticed that the sleep efficiency is decreased in women of similar demographics as in Kline’s study,2 and there is an increase in the frequency of insomnia after menopause: 4.3 to 3.5 occurrences per week through the first year post-menopause, and up to 5 times per week after 20 years.3 Kline et al support a relationship between a mindful attitude and poor sleep hygiene. This is consistent with results from our own center, where we have observed that women who suffer insomnia rated themselves less mindful than women without insomnia in two different mindfulness scales.4 We invite Kline et al. to include in future studies an analysis on terminal insomnia, since other studies have reported that 20.4% of postmenopausal women have difficulty maintaining sleep at the end of the night, thus waking up earlier than needed.3 In addition, we suggest the inclusion of the Sleep Hygiene Index5 to measure sleep hygiene behaviors. This tool provides a global assessment of sleep hygiene, including items that were not investigated in the current study, and has internal consistency.5 These behaviors that alter the sleep patterns can be more recognized than the term sleep hygiene, which was unknown to 79.2% of the postmenopausal women.6 Thus, in these women those steps lead to improvement in sleep quality. Adoption of positive sleep hygiene behaviors and elimination of negative ones is one way to diminish insomnia complaints. Additional methods to improve the sleep quality should also be considered, especially those that do not involve sedative hypnotics, to avoid introducing their numerous side effects.7 These methods could include physical therapy,8 mindfulness interventions,4 yoga,9 therapeutic massage,10 and acupuncture.11 With this array of techniques, we can tailor methods to the individuals who suffer with sleep disorders, with the goal of improving their quality of life and opening new avenues for complementary Medicine.
T
Acknowledgments
The authors are equally responsible for the concept of this letter and for drafting the manuscript. The final version of the manuscript has been read and approved by all of the listed authors, who have each provided the attention necessary to ensure the integrity of the work. Our studies are supported by grants conceived by Associac¸a˜o Fundo de Incentivo a` Pesquisa (AFIP), Fundac¸a˜o de Amparo a` Pesquisa do Estado de Sa˜o Paulo (FAPESP), and Conselho Nacional de Desenvolvimento cientı´fico e Tecnolo´gico (CNPq). The funding agencies had no role on design, preparation, review, or approval of this letter. Author Disclosure Statement
The authors declare that there are no financial or other relationships that might lead to conflicts of interest. References
1. Kline CE, Irish LA, Buysse DJ, et al. Sleep hygiene behaviors among midlife women with insomnia or sleepdisordered breathing: The SWAN sleep study. J Womens Health (Larchmt) 2014;23:894–903. 2. Hachul de Campos H, Branda˜o LC, D’Almeida V, et al. Sleep disturbance, oxidative stress and cardiovascular risk parameters in postmenopausal women complaining of insomnia. Climacteric 2006;9:312–319. 3. Hachul H, Branda˜o Lde C, Bittencourt LR, et al. Clinical profile of menopausal insomniac women referred to sleep laboratory. Acta Obstet Gynecol Scand 2009;88:422–427. 4. Garcia MC, Pompe´ia S, Hachul H, et al. Is mindfulness associated with insomnia after menopause? Menopause 2014;21:301–305. 5. Mastin DF, Bryson J, Corwyn R. Assessment of sleep hygiene using the Sleep Hygiene Index. J Behav Med 2006;29:223–227. 6. Vigeta SMG, Ribeiro FMN, Hachul H, Tufik S, Haidar MA. Awareness of sleep hygiene in menopause. Revista de APS (Online) 2013;16:122–128. 7. Nowell PD, Mazumdar S, Buysse DJ, Dew MA, Reynolds CF III, Kupfer DJ. Benzodiazepines and zolpidem for chronic insomnia: A meta-analysis of treatment efficacy. JAMA 1997;278:2170–2177. 8. Llanas AC, Hachul H, Bittencourt LR, Tufik S. Physical therapy reduces insomnia symptoms in postmenopausal women. Maturitas 2008;61:281–284.
Departamento de Psicobiologia, Universidade Federal de Sa˜o Paulo Casa de Sau´de Santa Marcelina, Sa˜o Paulo, Brazil.
252
ALTERNATIVE THERAPY CAN IMPROVE SLEEP IN MIDLIFE WOMEN
9. Afonso RF, Hachul H, Kozasa EH, et al. Yoga decreases insomnia in postmenopausal women: A randomized clinical trial. Menopause 2012;19:186–193. 10. Oliveira D, Hachul H, Tufik S, Bittencourt L. Effect of massage in postmenopausal women with insomnia: A pilot study. Clinics (Sao Paulo) 2011;66:343–346. 11. Hachul H, Garcia TK, Maciel AL, Yagihara F, Tufik S, Bittencourt L. Acupuncture improves sleep in postmenopause in a randomized, double-blind, placebo-controlled study. Climacteric 2013;16:36–40.
253
Address correspondence to: Helena Hachul, MD, PhD Universidade Federal de Sa˜o Paulo Rua Napolea˜o de Barros, 925 Sa˜o Paulo 04021-002 Brazil E-mail: [email protected]
JOURNAL OF WOMEN’S HEALTH Volume 24, Number 3, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/jwh.2014.5163
Can Sleep Hygiene Behaviors Improve Sleep Quality in Midlife Women? Zaira F. M. Nicolau, Monica L. Andersen, PhD, Sergio Tufik, MD, PhD, and Helena Hachul, MD, PhD
he core of the article by Kline et al.1 relates to sleep hygiene behaviors in midlife women. It is a great contribution to the medical literature since it touches an issue important in the treatment of sleep disorders. The population chosen by the researchers is highly appropriate, as of the participants all sought help related to sleep disorders such as insomnia. Indeed, insomnia is a prevalent disorder and one of the major complaints of midlife women. We previously noticed that the sleep efficiency is decreased in women of similar demographics as in Kline’s study,2 and there is an increase in the frequency of insomnia after menopause: 4.3 to 3.5 occurrences per week through the first year post-menopause, and up to 5 times per week after 20 years.3 Kline et al support a relationship between a mindful attitude and poor sleep hygiene. This is consistent with results from our own center, where we have observed that women who suffer insomnia rated themselves less mindful than women without insomnia in two different mindfulness scales.4 We invite Kline et al. to include in future studies an analysis on terminal insomnia, since other studies have reported that 20.4% of postmenopausal women have difficulty maintaining sleep at the end of the night, thus waking up earlier than needed.3 In addition, we suggest the inclusion of the Sleep Hygiene Index5 to measure sleep hygiene behaviors. This tool provides a global assessment of sleep hygiene, including items that were not investigated in the current study, and has internal consistency.5 These behaviors that alter the sleep patterns can be more recognized than the term sleep hygiene, which was unknown to 79.2% of the postmenopausal women.6 Thus, in these women those steps lead to improvement in sleep quality. Adoption of positive sleep hygiene behaviors and elimination of negative ones is one way to diminish insomnia complaints. Additional methods to improve the sleep quality should also be considered, especially those that do not involve sedative hypnotics, to avoid introducing their numerous side effects.7 These methods could include physical therapy,8 mindfulness interventions,4 yoga,9 therapeutic massage,10 and acupuncture.11 With this array of techniques, we can tailor methods to the individuals who suffer with sleep disorders, with the goal of improving their quality of life and opening new avenues for complementary Medicine.
T
Acknowledgments
The authors are equally responsible for the concept of this letter and for drafting the manuscript. The final version of the manuscript has been read and approved by all of the listed authors, who have each provided the attention necessary to ensure the integrity of the work. Our studies are supported by grants conceived by Associac¸a˜o Fundo de Incentivo a` Pesquisa (AFIP), Fundac¸a˜o de Amparo a` Pesquisa do Estado de Sa˜o Paulo (FAPESP), and Conselho Nacional de Desenvolvimento cientı´fico e Tecnolo´gico (CNPq). The funding agencies had no role on design, preparation, review, or approval of this letter. Author Disclosure Statement
The authors declare that there are no financial or other relationships that might lead to conflicts of interest. References
1. Kline CE, Irish LA, Buysse DJ, et al. Sleep hygiene behaviors among midlife women with insomnia or sleepdisordered breathing: The SWAN sleep study. J Womens Health (Larchmt) 2014;23:894–903. 2. Hachul de Campos H, Branda˜o LC, D’Almeida V, et al. Sleep disturbance, oxidative stress and cardiovascular risk parameters in postmenopausal women complaining of insomnia. Climacteric 2006;9:312–319. 3. Hachul H, Branda˜o Lde C, Bittencourt LR, et al. Clinical profile of menopausal insomniac women referred to sleep laboratory. Acta Obstet Gynecol Scand 2009;88:422–427. 4. Garcia MC, Pompe´ia S, Hachul H, et al. Is mindfulness associated with insomnia after menopause? Menopause 2014;21:301–305. 5. Mastin DF, Bryson J, Corwyn R. Assessment of sleep hygiene using the Sleep Hygiene Index. J Behav Med 2006;29:223–227. 6. Vigeta SMG, Ribeiro FMN, Hachul H, Tufik S, Haidar MA. Awareness of sleep hygiene in menopause. Revista de APS (Online) 2013;16:122–128. 7. Nowell PD, Mazumdar S, Buysse DJ, Dew MA, Reynolds CF III, Kupfer DJ. Benzodiazepines and zolpidem for chronic insomnia: A meta-analysis of treatment efficacy. JAMA 1997;278:2170–2177. 8. Llanas AC, Hachul H, Bittencourt LR, Tufik S. Physical therapy reduces insomnia symptoms in postmenopausal women. Maturitas 2008;61:281–284.
Departamento de Psicobiologia, Universidade Federal de Sa˜o Paulo Casa de Sau´de Santa Marcelina, Sa˜o Paulo, Brazil.
252
ALTERNATIVE THERAPY CAN IMPROVE SLEEP IN MIDLIFE WOMEN
9. Afonso RF, Hachul H, Kozasa EH, et al. Yoga decreases insomnia in postmenopausal women: A randomized clinical trial. Menopause 2012;19:186–193. 10. Oliveira D, Hachul H, Tufik S, Bittencourt L. Effect of massage in postmenopausal women with insomnia: A pilot study. Clinics (Sao Paulo) 2011;66:343–346. 11. Hachul H, Garcia TK, Maciel AL, Yagihara F, Tufik S, Bittencourt L. Acupuncture improves sleep in postmenopause in a randomized, double-blind, placebo-controlled study. Climacteric 2013;16:36–40.
253
Address correspondence to: Helena Hachul, MD, PhD Universidade Federal de Sa˜o Paulo Rua Napolea˜o de Barros, 925 Sa˜o Paulo 04021-002 Brazil E-mail: [email protected]
