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15 Articles in Volume 18, Issue #5
Chronic Pelvic Pain: The Need for Earlier Diagnosis and Diverse Treatment
Cross-Linked Hyaluronic Acid for the Management of Neuropathic Pelvic Pain
Fentanyl: Separating Fact from Fiction
Gender Bias and the Ongoing Need to Acknowledge Women’s Pain
Letters to the Editor: 90 MME/day Ceiling; Ehlers-Danlos; Redefining Pain
Post-Menopausal MSK Pain and Quality of Life
PPM Welcomes Dr. Fudin and Dr. Gudin as New Co-Editors
Practitioner as Patient: Understanding Disparities in CRPS
States Take Action to Manage Opioid Addiction
Step-by-Step Injection Technique to Target Endometriosis-Related Neuropathic Pelvic Pain
The Many Gender Gaps in Pain Medicine
The Need for Better Responses to Vulvar Pain
Topical Analgesics for Chronic Pain Conditions
Topical Medications for Common Orofacial Pain Conditions
What’s the safest, effective way to taper a patient off of opioid therapy?

Post-Menopausal MSK Pain and Quality of Life

Linking chronic MSK pain and insomnia in post-menopausal women.

With the increase in life expectancy, more than one-third of women will spend their lifespan in the post-menopausal stage, and as a result, are likely to experience menopausal symptoms caused by hormonal alterations. Core menopausal symptoms include musculoskeletal pain and insomnia, together with vasomotor symptoms. Individuals with chronic musculoskeletal (MSK) pain presenting with insomnia often report higher pain intensity, longer sleep latency, more fragmented sleep, and lower total sleep time than non-insomniac patients. Sleep is a crucial factor for women with chronic MSK pain; there is a great body of evidence showing that sleep disturbances increase pain sensitivity,2 and aggravate the risk of pain-related disability, depression, and health problems.3

Sleep in the Post-Menopausal Period

The authors have been studying1 the impact of chronic MSK pain and insomnia on women in the post-menopausal stage for 5 years. They defined the post-menopausal stage according to the Stages of Reproductive Aging Workshop (STRAW) staging system,4 with amenorrhea for at least 1 year and follicle-stimulating hormone (FSH) concentrations of more than 30 mIU/mL. The post-menopausal climacteric refers to the period of transition from the reproductive phase to the non-reproductive phase and may be associated with specific symptoms, called climacteric symptoms, such as vasomotor and MSK conditions (22 to 85% of post-menopausal women report MSK pain),5-7 and sleep disturbances, influenced by the decrease of the ovarian hormones estrogen and progesterone. Specific nomenclature such as “menopause arthralgia”8 or “menopausal syndrome”9 has been given to these conditions. Further, the World Health Organization recognizes MSK conditions as key drivers for the global burden of disease,10 as these conditions affect hundreds of millions of individuals globally.

Insomnia may occur as a symptom of menopause or as a disorder on its own. As a symptom, insomnia refers to the complaint of sporadic episodes of insufficient sleep and encompasses a large contingent of individuals, with or without diurnal consequences of dissatisfaction with the quantity and quality of their sleep. Symptoms of insomnia are highly prevalent in the general population and also in post-menopausal women. Insomnia as a disorder requires diagnosis by a physician and appropriate treatment. The insomnia disorder is defined by the International Classification of Sleep Disorders (ICSD-3)11 and in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5)12 as a sleep complaint that occurs at least three times per week, for at least 3 months, and is associated with diurnal impairment. Insomnia is considered a chronic disturbance of the sleep-wake cycle, leading to diurnal consequences and significantly impacting mental and physical health. Further, insomnia increases the risk for psychiatric and cardiovascular diseases, as well as morbidity and mortality.

Sleep disorders during the post-menopausal period have been associated with numerous health consequences. In this context, menopause has been considered by some researchers to be a precursor of sleep problems.13,14 Collectively, the data point to a worsening of sleep in the post-menopausal period both by endogenous, exogenous and multifactorial factors, demonstrating the complexity of this period of female life. The prevalence of insomnia during post-menopausal stage is alarming, varying from 27% to 73%.15-17

Linking Insomnia to Pain: Study Results

The authors examined four groups of post-menopausal women, with the goal of verifying the association between insomnia and pain at this stage of the biological female life:

  • control (no reports of MSK pain or insomnia) (n = 15)
  • insomnia (clinical diagnosis) (n = 15)
  • self-report of chronic MSK pain (n = 15)
  • self-report of chronic MSK pain + clinical diagnosis of insomnia (n = 17).1

A secondary goal was to establish which group may be more affected by disturbed sleep patterns, pain interference on daily activities, pain intensity, the number of pain sites, climacteric and mood symptoms, and quality of life.

Results demonstrated an association between insomnia and chronic MSK pain in post-menopausal women,1 with a bidirectional relationship confirmed between both conditions, although insomnia was found to contribute to worse clinical outcomes, including the perception of pain. The insomnia group reported more severity and more interference from pain compared to the non-insomnia groups. The group with both comorbidities reported the highest level of impact in terms of pain severity and its interference in daily activities. This group also reported a higher frequency MSK pain in the body (3 or more sites) as well as greater pain intensity throughout the day, compared to the other three groups.

When measuring climacteric symptoms, both groups with insomnia reported more complaints of severe symptoms and worsened quality of life. In the regression model, anxiety, depression, and insomnia were associated with worse climacteric symptoms. The group with both conditions had more somatic and psychological complaints, while the group with insomnia alone had more psychological complaints.1

Although individuals with anxiety are more likely to experience symptoms of insomnia, those with insomnia have an even greater chance (17-fold) of experiencing anxiety.18 Patients with chronic pain and insomnia also report higher rates of anxiety.19 Taken together, these data point to a negatively reinforcing insomnia-pain-anxiety cycle, which is difficult to dissociate.

Depression and pain interference in daily activities were the factors most associated with a worse quality of life in our sample. Again, the group with both comorbidities reported a worse quality of life. When analyzing the domains of quality of life, the insomnia + chronic MSK pain group described a worse quality of life in the psychological domain, and the chronic MSK pain group described a worse quality of life in the physical domain. Potentially, insomnia influences quality of life, regardless of whether or not it is associated with pain.

A full-night polysomnography of the subjects analyzed sleep patterns objectively. Both groups with insomnia demonstrated more fragmented sleep, as was expected; higher apnea-hypopnea indexes; and lower peripheral saturation. Despite being statistically significant, these findings were not clinically relevant, as the study volunteers were excluded for other sleep disorders than insomnia (eg, obstructive sleep apnea), and mean values of the polysomnography exam of the groups were among the normative standards of these variables.

Discussion & Future Research

The authors believe the studied insomnia groups experienced more pain due to increased sleep fragmentation, which may have contributed to a greater perception of their pain and less restorative sleep. This may be further indicated in the stability/maintenance of sleep and a dysregulation of the homeostatic process of the wake-sleep cycle. As in our investigation, sleep fragmentation is one of the most common sleep disturbances observed in a review of the literature describing polysomnographic data of patients with chronic MSK conditions.20 Our polysomnographic findings also showed increases in the apnea-hypopnea indexes of the groups with insomnia. Collectively, these findings point to the influence of sleep disorders, specifically insomnia, on the perception of climacteric symptoms and increased pain in this period of female life.

In conclusion, a review of the literature suggests that sleep disorders may be stronger predictors of pain than pain is of sleep disorders.21 The sleep-pain relationship may not be as bidirectional as previously believed, but rather, greater in one direction.22 In line with this, but not yet in studies of post-menopausal women, some researchers have found that sleep impairments, both in quantity and quality, are risk factors for the development or aggravation of pain over time.22,23

The demonstrated bidirectional association between insomnia and chronic musculoskeletal pain in post-menopausal women, with negative repercussions, requires further attention, including the development of prevention and treatment measures. In addition, these findings may encourage examination of other co-occurring symptoms in this population.

Also featured in this special report on Pain Care & Research in Women

Last updated on: August 1, 2018
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