Sleep symptoms, reproductive hormones, and treatment trajectories across the menopausal transition: analyses of two observational cohorts

Study objectives Sleep disturbance is common during the menopausal transition, but whether menopausal context is associated with the pace of improvement during insomnia treatment is unclear. We first examined associations of menopausal stage and reproductive-hormone variation with sleep symptoms in a community cohort, and then sleep-quality trajectories during routine insomnia treatment across estimated menopausal proxy groups in a clinical cohort. Methods Two observational cohorts were analysed separately. The Study of Women’s Health Across the Nation (SWAN) included 3,280 women and 22,925 person-visits; mixed-effects and generalized-estimating-equation models examined stage-related symptom burden, annual persistence, and within- versus between-woman hormone associations. The clinical cohort comprised 431 women receiving insomnia treatment (a hospital-affiliated digital sleep programme delivering cognitive-behavioural and relaxation content, pharmacotherapy, or both) in three estimated hormone-plus-age proxy groups (99 regular-cycling, 89 perimenopausal, 243 postmenopausal), with 2,522 Pittsburgh Sleep Quality Index (PSQI) assessments over 12 months. Linear mixed-effects models estimated average monthly PSQI change (points/month) by group; logistic and Cox models estimated response, remission, and time to first observed response. Results In SWAN, sleep-symptom burden increased across the menopausal transition (ordinal trend +0.23 points per stage on the 3–15 score, p < 0.001); late perimenopause had the largest adjusted burden difference relative to premenopause (β = 0.788, p < 0.001). Persistence odds were higher in early perimenopause (OR = 1.281, p = 0.002) and natural postmenopause (OR = 1.389, p = 0.003). Higher log-transformed follicle-stimulating hormone (β = 0.221) and lower log-estradiol (β = −0.144), relative to each woman’s own mean, were associated with greater burden (both p < 0.001); between-woman hormone terms were not significant. In the clinical cohort, PSQI scores improved in all proxy groups (estimated slopes −0.65, −0.45, and −0.67 points/month in the regular-cycling, perimenopausal, and postmenopausal groups, respectively). The perimenopause-versus-regular slope contrast was +0.198 points/month (95% CI −0.060 to 0.455, p = 0.133; false-discovery-rate q = 0.532), and no perimenopause-focused contrast for response, remission, or time to response was statistically significant. Conclusions Menopausal stage and within-woman reproductive-hormone variation were associated with sleep-symptom burden in SWAN. During routine insomnia treatment, sleep quality improved in all estimated menopausal proxy groups, and average improvement trajectories did not differ significantly between groups. Prospective studies with menstrual-history-based staging and standardised treatment are needed.