Sleep disturbance experiences among perimenopausal women in Taiwan

Authors

  • Hsiu-Chin Hsu,

    1. Authors:Hsiu-Chin Hsu, MSN, RN, Instructor, School of Nursing, Chang-Gung Institute of Technology, Tao-Yuan, Taiwan; Doctoral student, Department and Graduate School, National Taipei College of Nursing, Taipei, Taiwan; Ning-Hung Chen, MD, Director, Sleep Center; Chief, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, Chang Gung Institute of Technology, Taipei, Taiwan; Hei-Jen Jou, MD, Vice President, Department of Obstetrics and Gynecology, Taiwan Adventist Hospital, Taipei, Taiwan; Chi An, MSN, RN, Instructor, Department of Early Childhood Care & Education, Nanya Institute of Technology, Tao-yuan; Lee-Ing Tsao, DNSc, RN, Professor, Nursing Department and Graduate School, National Taipei College of Nursing, Taipei, Taiwan
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  • Ning-Hung Chen,

    1. Authors:Hsiu-Chin Hsu, MSN, RN, Instructor, School of Nursing, Chang-Gung Institute of Technology, Tao-Yuan, Taiwan; Doctoral student, Department and Graduate School, National Taipei College of Nursing, Taipei, Taiwan; Ning-Hung Chen, MD, Director, Sleep Center; Chief, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, Chang Gung Institute of Technology, Taipei, Taiwan; Hei-Jen Jou, MD, Vice President, Department of Obstetrics and Gynecology, Taiwan Adventist Hospital, Taipei, Taiwan; Chi An, MSN, RN, Instructor, Department of Early Childhood Care & Education, Nanya Institute of Technology, Tao-yuan; Lee-Ing Tsao, DNSc, RN, Professor, Nursing Department and Graduate School, National Taipei College of Nursing, Taipei, Taiwan
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  • Hei-Jen Jou,

    1. Authors:Hsiu-Chin Hsu, MSN, RN, Instructor, School of Nursing, Chang-Gung Institute of Technology, Tao-Yuan, Taiwan; Doctoral student, Department and Graduate School, National Taipei College of Nursing, Taipei, Taiwan; Ning-Hung Chen, MD, Director, Sleep Center; Chief, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, Chang Gung Institute of Technology, Taipei, Taiwan; Hei-Jen Jou, MD, Vice President, Department of Obstetrics and Gynecology, Taiwan Adventist Hospital, Taipei, Taiwan; Chi An, MSN, RN, Instructor, Department of Early Childhood Care & Education, Nanya Institute of Technology, Tao-yuan; Lee-Ing Tsao, DNSc, RN, Professor, Nursing Department and Graduate School, National Taipei College of Nursing, Taipei, Taiwan
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  • Chi An,

    1. Authors:Hsiu-Chin Hsu, MSN, RN, Instructor, School of Nursing, Chang-Gung Institute of Technology, Tao-Yuan, Taiwan; Doctoral student, Department and Graduate School, National Taipei College of Nursing, Taipei, Taiwan; Ning-Hung Chen, MD, Director, Sleep Center; Chief, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, Chang Gung Institute of Technology, Taipei, Taiwan; Hei-Jen Jou, MD, Vice President, Department of Obstetrics and Gynecology, Taiwan Adventist Hospital, Taipei, Taiwan; Chi An, MSN, RN, Instructor, Department of Early Childhood Care & Education, Nanya Institute of Technology, Tao-yuan; Lee-Ing Tsao, DNSc, RN, Professor, Nursing Department and Graduate School, National Taipei College of Nursing, Taipei, Taiwan
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  • Lee-Ing Tsao

    1. Authors:Hsiu-Chin Hsu, MSN, RN, Instructor, School of Nursing, Chang-Gung Institute of Technology, Tao-Yuan, Taiwan; Doctoral student, Department and Graduate School, National Taipei College of Nursing, Taipei, Taiwan; Ning-Hung Chen, MD, Director, Sleep Center; Chief, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, Chang Gung Institute of Technology, Taipei, Taiwan; Hei-Jen Jou, MD, Vice President, Department of Obstetrics and Gynecology, Taiwan Adventist Hospital, Taipei, Taiwan; Chi An, MSN, RN, Instructor, Department of Early Childhood Care & Education, Nanya Institute of Technology, Tao-yuan; Lee-Ing Tsao, DNSc, RN, Professor, Nursing Department and Graduate School, National Taipei College of Nursing, Taipei, Taiwan
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Lee-Ing Tsao, Professor, Nursing Department and Graduate School, National Taipei College of Nursing, No. 365, Ming Te Road, Peitou 112, Taipei, Taiwan. Telephone: 886-2-28227101 (ext. 3184).
E-mail:leeing.tsao@gmail.com; leeing@ntcn.edu.tw

Abstract

Aim.  To generate a descriptive theory framework regarding the experiences of sleep disturbances among perimenopausal women in Taiwan.

Background.  Although studies show that some perimenopausal women are troubled by sleep problems, little information was found about the subjective experiences of sleep disturbances among these women. Research is required to explore women's feelings or perceptions in dealing with their sleep problems. These understandings will be important to help alleviate perimenopausal women's sleep problems.

Design.  A grounded theory research design was applied.

Method.  Twenty-one Taiwanese sleep disturbed women, aged 46–57 years, participated in in-depth interviews.

Results.  ‘Getting back a good night’s sleep’ was the core theme for describing and guiding the process of the women’s sleep disturbance experiences. During the process, ‘disturbed sleep’ was identified as the antecedent condition that included subcategories: easy awakening, difficulty falling asleep, inner worries, physical discomfort and genetic and bodily constitution. Analyses showed five categories (some with subcategories) of the sleep disturbed women: (i) worsening health status – physical exhaustion, impaired social interactions, emotional swings and decreased work performance; (ii) living with lonely nights – self-help and endurance; (iii) a search for resources to relieve sleep difficulties – doctor shopping, trying alternative therapies, exercising and seeking support; (iv) vicious cycle and (v) acceptance of insomnia.

Conclusions.  Women expected to relieve their sleep disturbance by finding comprehensive counselling or by their body constitution responding to treatment. Healthcare providers need to value women’s individual concerns and subjective voices. Providers must seek out sleep counselling instead of simply prescribing drugs for their sleep difficulties.

Relevance to clinical practice.  It is crucial to integrate perimenopausal sleep care by implementing a multidimensional approach such as sleep assessment laboratories, sleep counselling, complementary alternative medicine, sleep strategies and support groups.

Introduction

Previous studies show that 33–51% of 40- – 60-year-old women who complain of sleep disturbance (Kuh et al. 1997, Owens & Matthews 1998) viewed it as significant (Ford et al. 2005). A cross-national study showed that 53·5% of 16 065 community-based women aged 40–45 years experienced sleep disturbance and had extreme difficulty in completing required daily activities (Gold et al. 2000). In Taiwan, middle-aged women are the most prevalent group seeking medical help in sleep disorder clinics (Lee 2000).

Factors contributing to suboptimal sleep quality among perimenopausal women include nocturnal hot flashes, severe night sweats, nocturia, lower back pain and obstructive sleep apnoea (Speroff 1999). In addition, Jones and Czajkowski (2000) found perimenopausal women at a major transition point in their lives. They often have accompanying psychological disturbances, including emotional swings, apathy and decreased work performance.

Women suffering from sleep disturbances have anxiety and sustained sleep cycle disruptions, insomnia and feelings of loneliness in handling their sleepless nights. Some women have tried hard to overcome sleep problems due to perimenopause by engaging in ‘doctor shopping’. They visit a neurologist, a cardiologist, a gynaecologist, a psychologist and/or a Chinese medicine physician (Tsao 2002). Most studies on sleep disturbance in perimenopausal women were conducted by surveys or a quantitative measurement using physiological indicators (Jones & Czajkowski 2000, Shaver & Zenk 2000, Hsu & Lin 2005). Few studies are conducted relating to the subjective experiences of sleep disturbance in perimenopausal women. The sleep problems actually experienced by women are therefore not addressed. For this reason, it is reasonable to ask: what are the self-perceived qualities of sleep in perimenopausal women? how do perimenopausal women feel about experiencing sleep disturbances? what issues influence women’s quality of sleep? how do they manage their sleep problems? what do they do while awaking at night? Again, there have been too few studies of these women suffering from insomnia. Further, it has been well documented that the negative impact of sleep disturbance is linked to poorer physical health, poorer memory, poorer work performance and compromised interpersonal relationships (Lee 2000). When perimenopausal women suffer from sleep disturbances for a long period, their deteriorated sleep may become a chronic condition. As a consequence, perimenopausal women’s health status, lifestyle and quality of life are affected. It can become a vicious cycle affecting their quality of life in later years. Therefore, the construction of a descriptive theory of subjective experiences is crucial for the care of sleep disturbances in perimenopausal women.

Aim

The primary aim was to establish a descriptive theory about the subjective experiences (i.e. processes, feelings and perceptions) of sleep disturbances among perimenopausal women.

Methods

Design

‘Grounded theory’ was used as the study approach for developing a substantive theory. ‘Grounded theory’ was commonly used when discovering a new perspective on individuals experiencing the phenomenon under study (Strauss & Corbin 1990). Therefore, it is appropriate to apply this method to explore and explain the process and experiences of sleep disturbance among perimenopausal women in Taiwan.

Sample

The inclusion criteria were: (i) women aged 45–60 years; (ii) self-described as experiencing perimenopause, or experiencing at least one year between the onset of irregular menstruation since the last menstrual cycle; (iii) not diagnosed with a psychiatric illness or other major illness (i.e. malignancies); (iv) willing to share sleep disturbance experiences with researchers and (v) able to communicate in Mandarin, Taiwanese or Hakka.

Theoretical and snowball samplings were used. Some participating women felt that the interview experiences were very helpful for them in expressing their frustrations regarding sleep problems. These women were enthusiastic to encourage their female friends with sleep disturbances to participate in this study.

A total of 21 perimenopausal women with a sleep disturbance were recruited. The average age of the participants was 51 ranging from 46–57. The age of onset of sleep disturbance accompanying perimenopause varied widely from ages 30–52 years. Moreover, the participants had experienced sleep disturbance anywhere from six months to 10 years. All participants were middle-class and 10 were employed.

Ethical consideration

Approval for the conduct of this study was received from the Research Ethics Committee of National Taipei College. The researcher explained the study purposes and obtained both oral and written consents from the interviewees. Formal interviews were conducted. During the interview process, interviewees were guaranteed total privacy. Each participant was informed of the right to withdraw from the study at any point during the interview.

Data collection and analysis

The recruitment period was February 2006–March 2007 and 21 women were recruited to participate in in-depth interviews and data collection. With consent from each interviewee, the entire interview process was anonymously recorded. The length of each interview was between 40 minutes and two hours. The interviewee decided the interview location. It was quiet, comfortable and free from interference so the interviewee could describe subjective sleep disturbance experiences without distraction. The interview guidance content included:

  • 1Talk about your sleep disturbance experiences.
  • 2What are the causes of your sleep disturbances?
  • 3What are your feelings regarding sleep disturbances and how have you been affected?
  • 4What methods have you used to manage your sleep problems? How were they performed?
  • 5From the point of view of someone who has experienced sleep disturbances, what sort of help would you hope to receive?

As pointed out by Glaser and Strauss (1967), the major characteristics of grounded theory are using the original experience data as a basis plus the continuous comparison and analysis of data as a principle. During the entire data analysis process, data collection, coding and analysis were performed simultaneously. Interview data were continuously collected until there was data saturation and then no new information was recorded. At the conclusion of each interview, researchers listened to the entire interview recording, transcribed the interview process and identified meaningful ideas and concepts. To prevent subjective perceptions of interviewers affecting the validity of the study content, senior researchers and nursing specialists familiar with this field were asked to perform line-by-line, paragraph-by-paragraph, peer debriefing of the original data and the meanings and concepts extracted from the data. If they were in doubt of the explanations given by the researchers, the researchers returned to the original text for further clarification. Continuous data comparison and analysis were performed as follows:

  • 1Open coding. This indicates that open exploration was performed on the data, the data was thoroughly coded, concept categories were sought and categories were given designations. After researcher and peer reviewers read each transcript section, related sleep disturbance experiences in perimenopausal women were identified. The transcript was then reread multiple times to find the preliminary categories related to sleep disturbances.
  • 2Axial coding. By continuous comparison and analysis, researchers identified connections between primary categories and related subcategories.
  • 3Determining the initial theory. Data were systematically organised and an event sequence was constructed from related concept categories. A substantive theory was constructed to explain the relationships between concept categories.

The rigour of this study was evaluated based on four strict criteria used to measure content trustworthiness in qualitative studies, as proposed by Lincoln and Guba (1994). In terms of credibility, data were collected by open, thorough interviews in which participants could communicate realistic and in-depth subjective experiences. Also, the snowball sampling method used in this study increased the faith of the interviewees in the researchers, allowing them to better express their inner feelings, which in comparison increased the credibility of the data. At the same time, after inviting two interviewees to read the finished text, it was found that the results of this study addressed the personal experiences of women suffering from sleep disturbances. In terms of transferability, the interviewees recruited in this study were perimenopausal women from different backgrounds who experienced sleep difficulties and who were willing to share their experiences, which resulted in the accumulation of large amounts of valuable information. Researchers transcribed the essences and meanings of the original data into text, which was thoroughly annotated. Then, nursing professors and specialists familiar with grounding theory were asked to perform a secondary verification to increase the dependability of the study. Finally, in terms of the confirmation process, researchers performed a neutral analysis and recorded summaries of important interview content immediately after each interview. This was compiled into a volume to be used as an evaluation channel reference in future data analysis.

Results and interpretation

‘Getting back a good night’s sleep’ was the core category of the entire sleep disturbance process in perimenopausal women (Fig. 1). When perimenopausal women realised changes in sleep status affected their lives, they attempted to recover quality sleep by going through a behaviour modification process. ‘Disturbed sleep’ was the antecedent category of this process and women who experienced chronic insomnia sank into the situation of ‘self-perceived deterioration in physical, psychological, or social health’. Faced with ‘lonely nights’, women searched for methods to improve sleep themselves and when they became aware of the situation, they strove to ‘search for resources to alleviate sleep difficulties’, a state in which interactive behavioural categories appeared to improve sleep disturbances. Finally, ‘acceptance insomnia’ and ‘vicious cycle’ were compiled as result categories of sleep disturbances.

Figure 1.

 The processes of sleep disturbance experienced by perimenopausal women in Taiwan.

Getting back a good night’s sleep

‘Getting back a good night’s sleep’ was defined as the process undertaken by perimenopausal women to attempt to recover quality sleep to alleviate the physical, psychological and social health changes resulting from their sleep problems. The women indicated that after long periods of an inability to sleep at night, they were physically and psychologically exhausted. Many adverse consequences followed and their quality of life decreased. Women searched for methods to improve sleep from different sources, such as the internet, books, media, or family and friends. Some attempted alternative therapies or changed to a healthier diet. Finally, if sleep disturbances still did not improve, they requested sedatives to help them sleep. Two women indicated:

The suffering of a chronic inability to sleep, I think is really quite agonising and whatever method my friends introduce me to which may help me sleep, I will try. Previously, I tried mountain climbing every day, tried foot massage and chose foods such as soy milk which supplemented female hormones.

I have not slept well for 4–5 years in a row now. To someone who cannot sleep, the sudden ease of falling asleep experienced after initially taking half a sleeping tablet is wonderful! I am really content and happy.

Disturbed sleep

‘Disturbed sleep’ was defined as difficulty in staying asleep during the night, being easily awakened, or an inability to sleep continuously until morning. The women described several factors that affected sleep, such as a natural sensitivity to the environment and to some foods after entering perimenopause, a tendency to think too much during the night, excessive dreaming and physical discomfort, such as hot flashes and frequent urination. This category included five secondary concept categories: ‘easy awakening’, ‘difficulty falling asleep’, ‘inner worries’, ‘physical discomfort’ and ‘genetics and body constitution’.

Easy awakening: the women indicated that continuous dreaming often interrupted sleep. One woman described:

I don’t think about it, but that dream keeps on coming into your thoughts, especially when sleeping at night. It’s just like that, like a drama series, one dream followed by another, which are linked and the original dream will even continue after you come back from the toilet. So much dreaming, I dream and I awaken. So sometimes you feel that you’ve dreamed until daylight and it is exhausting!

Difficulty falling asleep was defined by an inability to fall asleep. It occurred due to environmental stimuli during the sleep process such as noise, or the consumption of stimulatory foods before sleep. One woman who had difficulty in falling asleep during the night responded:

I hate the clock I have at home. You know the big wall clock with a pendulum? Did you know that the noise it makes is especially loud when you can’t sleep? You toss and turn, unable to sleep and you end up like this. Sometimes I get up as soon as I lie down and lie down again as soon as I get up.

Inner worries perimenopausal women at a life-changing, transitional phase often involuntarily think about life events that concerned them before sleep and cannot fall asleep even after a long time. One woman noted:

I invest in stocks! It sometimes goes up and down you know? I’m nervous because I have lost a large amount of money in the past and you will always feel regretful inside yourself and think I lost so much money in one go and there’s always a feeling of being unable to let go. Also, last year my children had exams, which were very stressful. These worries all resulted in bad sleep during the night.

Physical discomfort: due to physiological changes, some perimenopausal women experience hot flashes, night sweats, palpitations or heightened urination frequency during the night, resulting in fragmented sleep. One woman pointed out:

From the time when I was 45 years old, I found it difficult to sleep and there was a lot of tossing and turning. At that time, I didn’t realise it was due to perimenopause. When I was 46 I would suddenly feel very hot while driving, or while wearing short sleeves when I slept during the cold winter. I sometimes even had to lie against the wall in order to fall asleep. My face was often very red, as if the blood vessels were about to explode or something. I was very ashamed of that and was afraid to go outside.

Genetics and bodily constitution: many interviewees stated that there were no physical or psychological factors to blame for their inability to sleep. They attributed their sleeplessness to physical weakness, or as something inherited from their mother. One interviewee indicated that:

I don’t know if it’s because I inherited a type of neurosis from my mother, or if it’s that more neurotic people tend to think a lot when there are many things happening at once. You keep on thinking deeper and deeper whenever you run into something and as soon as you do that, you can’t sleep.

Worsening health status

When women were trapped by sleep disturbances on a chronic basis, self-perceived physical, psychological or social health changes appeared to be exacerbated. They include ‘physical exhaustion’, ‘impaired social interactions’, ‘emotional swings’ and ‘decreased work performance’.

Physical exhaustion: changes in physical status were common complaints in sufferers of sleep disturbance. One woman described chronic poor quality sleep as follows:

After you wake up you feel really lethargic, really tired! This is because you didn’t really sleep. Problems related to bad sleep appear, such as impaired memory and headaches and when you ride on a bus with a headache, you get carsick!

Impaired social interactions: when in a state of physical discomfort, it is not difficult to imagine that the interactions in interpersonal relationships are affected. One woman indicated:

My job involves a lot of social activities, but long-term sleep problems make me wary of going outdoors. This is because I take sleeping tablets at night and by lunchtime the next day I feel very sleepy. Because I can’t nap, I have to use mental will to interact with friends and that makes me even more tired! That’s why I hardly ever go out anymore.

Emotional swings: this was one of the common by-products of chronic sleep difficulty. One woman indicated:

This long-term inability to sleep is driving me crazy. I feel life is not worth living, with no future. What can I do if I can’t sleep? Psychologically, it’s a feeling of uncertainty and insecurity. Now I finally know why people say those who are chronically sick despise being alive, since I suffer through every day like this.

Decreased work performance: when women could not recharge internal and external energies via adequate sleep, decreased work performance became evident. One woman pointed out that:

I’m tired when I’m at work, I can’t concentrate, I become sloppy which is bad. After I get home I don’t want to cook, nor do I want to do chores. Not wanting to do anything, I lie down to rest and only do chores when I have a bit more energy. My whole life rhythm is messed up.

Living with lonely nights

This was defined as a quiet night, when women could not fall asleep. They saw their family members fall asleep fast, while still lying awake in bed, with only the night for companionship. To overcome the inability to sleep during lonely nights, women would attempt sleep improvement activities. The sleep improvement measures these women undertook during ‘lonely nights’ included watching television, listening to music, reading, drinking, changing rooms, sleeping next to a wall, taking sedatives, counting sheep, reciting Buddhist chants, sleeping next to an electric fan, sleeping in a different room than their husbands and making mental notes to improve sleep disturbances. Two women described:

If I can’t sleep, I try sleeping in a different room, or I get up during the night to watch a drama series. Well, actually I don’t really watch it I just listen to the dialogue, which I can’t understand anyway. It’s like finding some music to accompany me to sleep.

I think it’s probably best not to sleep with your husband, since if you can’t sleep you can get up to read or listen to music. You avoid interfering with each other and creating stress.

A search for resources to relieve sleep difficulties

This was defined as searching for resources to solve the sleep disturbance problems and striving to improve the health problems produced by insomnia. The resources searched for by the women included ‘doctor shopping’, ‘trying alternative therapies’, ‘exercising’ and ‘seeking support’.

Doctor shopping: participants continuously tortured by sleep disturbances would seek multiple physicians such as a gynaecologist, a psychiatrist, a cardiologist or a Chinese medicine physician to relief their sleep problems. One interviewee indicated:

While I was sleeping, I suddenly felt that my heart was beating very fast. It felt like something was stuffed in my neck and chest. I could not sleep. Therefore, I went to see a cardiologist for help. The doctor told me my test finding was totally normal. Then I went to see a Chinese medicine physician to seek help but my sleep disturbance was hardly improved. I then turned to a gynaecologist and a psychiatrist. During that time, I visited a psychiatric clinic four times a month. My husband took me to various doctors during those days to solve my sleep problem.

Trying alternative therapies: several participants stated that they decided to use more natural ways to resolve their sleep problems. They tried alternative therapies such as meditation, body massage, vitamins and urine therapy for improving sleep. One woman described:

I even heard from a friend that urine is a panacea and is effective in fighting many poor physical conditions like insomnia or skin problems. I was told to drink the midstream of my very first pee every morning for six months.

Exercising: from the suggestions of family members and friends, many women increased their daily exercise, to promote sleep at night. One woman described:

Many of my friends have suggested to me a number of methods to help me sleep, such as doing Tai Chi, mountain climbing and exercising before sleep, all which I’ve tried and still do. My sleeping has improved slightly from before.

Seeking support: some women mentioned that, when they were suffering from sleep difficulties, the presence of people who could understand and support them was extremely helpful. One woman indicated:

My husband is quite considerate of me. He knows I sleep lightly, so if I sleep first, he’ll do his best to sleep as soon as possible. If he doesn’t sleep until after I have fallen asleep it will affect me. Sometimes when friends call me while I’m asleep, he won’t wake me up, since he knows once he wakes me up, I can’t fall asleep again.

Acceptance of insomnia and vicious cycle

In perimenopausal women with accompanying sleep disturbances, after continuous attempts to improve sleep, it was found that the sleep status of some women gradually improved. However, in others, significant improvements were not observed. Nevertheless, all women subsequently chose to readjust and endure, accepting their present sleep situation. In other words, regardless of whether sleep improved or not, women chose to live with the amount of sleep they were getting. Some women who attempted many measures and in whom sleep status did not improve sank deeper into insomnia, with deterioration of physical and psychological health, while also continuing their inability to sleep during lonely nights, producing a ‘vicious cycle’. One woman indicated:

I’m used to it and I just put up with it peacefully. If I can’t sleep then I can’t sleep. I don’t really mind. If I can’t sleep I’ll just read or listen to music.

Another woman mentioned:

If after taking medications I still can’t sleep, I increase the dose of sleeping tablets. If this vicious cycle is continued and if I increase the number to excessive amounts and still can’t sleep, then I have no idea what I’m supposed to do.

Discussion

‘Getting back a good night’s sleep’ is the core category in the present study. Women in this current study considered sleep disturbances to be a natural part of the perimenopausal process. They believe their sleep problems will subside as they pass through perimenopause. Therefore, they have tried several self-help strategies to improve their sleep. Some women preferred to explore complementary and alternative medicine (CAM) such as urine therapy, a Chinese medicated diet, yoga, exercise and meditation to adjust their body constitution before resorting to western medicine. Many of them consider CAM more suitable to their body constitution (Tsao 2002). Some women were afraid to take hormone or sedative medication to relieve their sleep problems because they are concerned that these drugs would be harmful to their health. Conducting further research that relates sleep with CAM as a means to provide safe and healthy strategies for perimenopausal women is crucial.

Some women sought the advice of a variety of doctors who could help them with their sleep problems as these issues continued to have a significant impact on their lives. The finding of our study was similar to Tsao’s (2002) qualitative study. Along with this line, some women stated that they had a difficult time deciding which clinic was the right choice for them to solve their sleep problems. There are currently no sleep centres for perimenopausal women in the health system so it is critical to develop an integrated sleep clinic that can deal with sleep problems from biological, psychological and social perspectives.

Ethnicity is also a significant consideration when studying perimenopausal women with sleep disturbances. Despite several studies demonstrating that hot flashes and night sweats due to hormone fluctuation is the main reason a woman’s sleep is interrupted (Clark et al. 1995, Shaver & Zenk 2000), only a few women in this current study attributed their sleep problems to hot flashes. This finding was congruous with Hsu and Lin’s (2005) study that found few Taiwanese perimenopausal women attributed their sleep disturbances to hot flashes, while many of these women with sleep problems were bothered by troublesome events. For instance, Tsao (1998) found that Chinese perimenopausal women were concerned about their families and how to continue in their careers during perimenopause. Moreover, the study of Bromberger et al. (2001) pointed out that hormone fluctuations causing sleep disturbances during the perimenopausal stage were more prevalent with Caucasians than Asians. Therefore, ethnic consideration should be taken into account for the perimenopausal women’s sleep problems.

Traditional methods of improving sleep, such as taking warm baths, wearing comfortable pajamas, listening to soft music and drinking warm milk have been well documented as being helpful (Lai & Good 2003, Stepanski & Wyatt 2003, Koch et al. 2006). However, in this study, women tried their own ways to overcome their sleep problems such as using electric fans or air conditioners at night, doing housework, reading and even sleeping in a separate bedroom from their husbands. The best approach for several perimenopausal women in minimizing sleep disturbances during the lonely and long nights was to try several different strategies.

Some women expressed their concern that no one cared about their sleep problems in the past and that there was no one in whom they could confide. Therefore, most women in this study appreciated the in-depth interview that allowed them to fully express their personal experiences, thoughts and feelings about their sleep problems. These women hope to be understood instead of having others think they are just pretending to be sick (Tsao 2002). Healthcare providers should pay more attention to women’s issues with sleep disturbance instead of simply prescribing sedatives or hormone replacement therapy to manage their sleep problems. Perimenopausal women are encountering multifaceted changes in their lives, such as the empty-nest syndrome, the transition of family economics, physical changes and unexpected situation transitions (Buxton-Blake 2003). Each of these factors may interfere with a woman’s sleep. Hence, healthcare providers must be skilled in obtaining information from their patient with the understanding that she is the primary source for help in determining treatment. It is also important to consider referring perimenopausal women to psychological counselling to deal with their sleep problems.

Another interesting finding in this study was that some women complained that dreaming was the main reason for interrupted sleep. Questions about why we have dreams during sleep or how the dreams are generated are still controversial issues. Current psychiatric and neurological studies are exploring the mystery of dreams (Schredl et al. 1998, Mancia 1999). According to Schredl et al. (1998), dreaming occurs more often in those who experience poor sleep. The content of a dream is usually a reflection of one’s stressful life. In this current study, women expressed that they played multiple roles in their families, which caused greater stress. If this stress could not be resolved during the day, then could become a dream at night that would disrupt the women’s sleep. Therefore, it is important to refer these women to psychological clinics for dream analysis to identify the true events that cause women’s sleep disturbances. Questions remain about whether dreams occur more often during the perimenopausal stage as a result of changes in the neurological system during perimenopause or whether women with certain personalities have more dreams than others. Future studies in these areas may be necessary.

Some women in this study indicated that they did not experience any perimenopausal symptoms but were still affected by sleep disturbances. These women were concerned that their sleep problem was caused by their body constitution and heredity. Research of sleep problems in perimenopausal women in relation to genetic issues is still rare. Asplund and Aberg (2001) studied 3669 women between the ages of 40–64 to explore the sleep pattern of parents compared with their children. The findings concluded that poor sleepers often have parents who have sleep difficulties themselves. There would be value in studies comparing one’s body constitution to the use of traditional Chinese medicine as well as genetic studies or exploration to help perimenopausal women who suffer from sleep disturbance.

Finally, changes in a woman’s physical and psychological health that experience sleep disturbances for long periods of time were the main concerns in this study. The symptoms included headaches, fatigue, irritated eyes, poor memory, difficulty in concentrating when interacting with others, emotional fluctuations, bad tempers and feelings of uncertainty and anxiety. When women expressed these discomforts to others, they were frequently seen as being hormone deficient, which is a natural perimenopausal event. Their sleep problems were never addressed. The findings of this study could provide information to health providers who have patients experiencing perimenopausal symptoms. Healthcare providers should assess the potential causes of sleep disturbances and determine the sequence of changes. For instance, as women complained about poor memory or that they were extremely tired in the daytime, the care providers could more carefully evaluate their sleep habits or collect data from their partners to see if they were experiencing severe snoring and then refer them to a medical centre for further examination.

Conclusions

Perimenopausal women in this study sought help in various ways such as doctor shopping, CAM, exercising or consulting with their partner to alleviate their sleep difficulties. Thus, healthcare providers should call attention to these subjective voices to learn more about women’ s sleep counselling instead of simply prescribing drugs for their sleep difficulties.

Relevance to clinical practice

Perimenopausal women are in a complex state of transition and it is crucial to develop multidimensional sleep centres where various sleep counselling approaches can be explored. These approaches should include thoroughly assessing one’s sleep patterns, considering the role of CAM, providing adequate psychological counselling, evaluating genetic issues and using sleep laboratories to provide more comprehensive sleep care for perimenopausal women.

Acknowledgements

Sincere appreciation is extended to the women who participated in the study and to the National Science Council (NSC 95-2314-B-227-009) in Taiwan for funding this study.

Contributions

Study design: CH, LT; data collection: CH, CA; data analysis: CH, LT, NC, HJ and manuscript preparation: CH, LT, NC.

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