Relationship between Personality Characteristics and Sleep Quality in Menopausal Women Referred To Gynecology Clinics of University Hospitals in Mashhad, Iran

Introduction

Menopause is not a sign of deterioration, but is a surprising phenomenon that could be considered as a sign of positive trend (1) the rate of stradiol and progesterone decrease several years before menopause despite menstrual cycles with ovulation.

Decrease of ovarian follicular activity degrades negative feedback inhibition of stradiol on hypothalamus-hypoghysis system and gradually increase follicle stimulating hormone (FSH)(2,3)Therefore ,the follicles with less response to FSH could stay in ovary , menopause occurred when remaining follicles do not respond to high concentration of FSH(3). Transition from fertility to infertility  is accompanying with more vasomotor responses, and physical and emotional symptoms which could be lasted several years(4). The most common complication of estrogen deficiency is night flash or nocturnal sweating.

Consequently, sleep pattern is interrupted and result in fatigue, concentration problems, excitability, activity daily problems, mood disorders, anxiety and memory loss. Serotonin, of important factor for sleep decreases as well.(3) about one-third of  aduld experience sleep disorders across the world. Which aggrevate by aging and chronic illness by 69% (5).  Sleep disorders in menopaused women could be chronic or temporary. Most of them are manifested by problem in falling asleep ,frequent waking during night and difficulty in falling sleep again and light sleeps and early waking(4)

Sleep is one of the indispensible elements of human life; it is a combination of comfort and calmness due to stop in apparent senses of animals and humans. The aim of sleep is not clear, however, sleep deprivation could lead to harmful physical and emotional changes such as daily fatigue, cognitive ability defect, recovery delay and auditory and visual illusion, sleep also decrease stress, anxiety. It helps energy restore for better concentration.         

Some women suffering from  flashing  and severe sleep problems during their menopausal period , however the others have no reactions or react less which do not paid more attention(1)Difference of symptomatic reaction of menopause in different  people has not been realized(4). It is believed that of a most women are a lot in common for nature and incidence of menopause. and these differences are not due to physiological factors, but due to different style communities and individual perception(1) No two individual are similar, so, no similar  reaction could seen  from two humans in similar situation or similar psychological stimuli(6). Personality as a determining factor influences on all human behaviors personally and socially , sometimes maladaptive behaviors cause individual and his family face serious problem (7) Based on 5-factor personality theory by Casta and MoRay , personality include five main elements of neuroticism , extroversion, openness to experience ,agreeableness and conscientiousness (8). Each individuals with every aspect could behave specificly different from others, with specific expectations, and have different abilities, behavioral skills and needs(9) .According to studies , people with neuroticism aspects, probably experience social phobia ,depression and consequently insomnia(5) .Steriani (2009)Showed personality characteristics such as neuroticism , anxiety and paranoia are more accompany with menopausal syndrome(4) In personality domain ,individual differences should be considered and the aim is determining and defining them as much as possible(16) Menopaused women may need more education and intervention for treatment of menpasoal complications and quality of life improvement due to their individual differences, better understanding of these differences lead to better response to therapeutic intervention (14)

Brown(2009) showed that the the higher  score of neuroticism is accompany with hot flashes, night sweat)and sleep problems. The higher score of extroversion  all of the complications decreased (10 Pimenta (2012) Introduced level of education and mental problems as predictive factors for menopause occurrence (11)

As better understanding of personality characteristics and individual differences let determining subgroups of  menopaused women for additional intervention in order to quality of life improvement and sleep problems control (12) and considering the Iranian demographic feature with  almost 5 million women at  menopause (13) and physical and mental problems which individual and family face to, this study aimed to determine relationship between personality characteristics of menopause women  with this quality of  sleep.

Materials and Methods

this correlational study was conducted on 400 menopaused women referred to maternity clinics of Mashhad university of medical sciences from 22Aug to 23 Dec 2012.Sample size was calculated by comparing mean formula at first, a pilot study was performed on 50 menopaused women. Then sample size was determined for personality characteristics aspects . as the maximum estimation was related to extroversion aspect it was considered as sample size. It was calculated 329 by confidence interval = 95% and power=80%. Then 20% increase was considered for non randomization method and final sample size was determined as 400. Inclusion criteria were age of 45-60 year, last menstruation of 1-5 years, literacy of elementary level and normal menopause. Exclusion criteria were estrogen therapy for recent 3 month, spotting in recent year , smoking (drugs, cigarettes , hookah) alcohol, traumatic or stressful event in recent six month, heavy exercises , taking drugs for decreasing menopausal complications, chronic illness, cancer, abnormal findings in breast exam, and thyroid enlargement in physical examination.

Breast and thyroid examination were performed for women who met inclusion criteria and if there are abnormalities in the breast or thyroid gland enlargement, they were excluded from study and referred to specialist .Exclusion criteria during study were incomplete record  (less than 60%) of daily night sweat questionnaires , spotting  during completing questionnaires and deplorable event during study .women were free to discontinue their participation .After talking informed consent ,they were selected by convenient sampling .Blood pressure, weight and height were measured after entrance to study .Study tools included questionnaires  for demographic data , obstetric , menstrual status  , effective factors on sleep , Pittsburg quality of sleep inventory visual analogue scale for anxiety and fatigue , daily record of night sweat and personality characteristics of NEO FFI .All assessment tools were completed  for women in order. Questionnaire  of  NEO FFI was graded based on 4-point Likerts  scale ( strongly disagree , disagree ,no idea , agree , strongly agree ) some question were scored conversely. This questionnaires covered five dimension of personality, neuroticism, extraversion, openness to experience, conscientiousness and agreement was tested by 60 questions (each personality characteristic was test by 12 question) The score of each personality characteristic was categorized by rate of very low, low, average, high and very high).Pittsburg quality of sleep inventory studied quality of sleep in recent month .It has 9 questions and 7 components. The score ranges 0-21 and overall score more than 5 indicates to bad quality of sleep .Visual analogue scale for anxiety and fatigue include information on anxiety and fatigue of menopaused women .They detected their anxiety and fatigue on the line graded between 0 to 100 in recent month .Daily record of night sweat was completed for two weeks and included number and severity of night seat. Females completed this questionnaire after waking up. Content validity was used for confirming validity of all questionnaires: Ten faculty members of Mashhad nursing and midwifery school read questionnaires and commented on them .Then study tools modified based on their comments. Reliability of NEO FFI was confirmed by Haghshenas (1382?/2005) in Iran .He report alpha Chronbach coefficients of 0.86, 0.77, 0.73,0.68 and 0.81 for neuroticism, extraversion, openness to experience, agreeableness and conscientiousness respectively(14)

Reliability of Pittsburg quality of sleep inventory was confirmed by moghadam(2012) in kerman(a=0.77). Reliability of visual analog scale for anxiety and fatigue was confirmed by Abbasi in Mashhad (1384?/2005) by interrater reliability. Test-retest was used for confirming reliability of daily record of night sweat (r=0.9). Data were analyzed by SPSS:16 .

Descriptive characteristics were reported by central parameters dispersion (mean and standard deviation) and frequency. For objectives of study, Pearson and Spearman correlation coefficient were used.

General linear model was used for controlling confounding variable, Man Withney  and  Kruskal wallis were used for relationship between demographic data,. midwifery/ obstetrics  and sleep quality. Significant level was considered as p=0.5

Results

women aged 52.3 ± 4.07 years old, with menopausal age of 48.8 ± 3.5 years and amenorrhea duration of 3.5 ± 1.5 years, gravida 5.6 ± 2.8 and number of children of 4.6 ± 2.2.  Most women (65.7%) was in elementary level and 87.3 of women were married. Most of them (84%) were housewife and 67.9% reported enough income, 74.6% had BP≤140/90 and 74.5% had BMI > 25. The maximum score of personality dimensions was related to openness to experience (51) and minimum score was allocated to neuroticism (7) .Most women were in average level of personality characteristics (table 1). Most women (73%) experienced bad sleep quality .Pearson correlation test showed negative reverse significant correlation between overal score of sleep quality and extraversion (p=0.013). Direct correlation was found between overal sleep quality score and neuroticism and openness to experience and reverse correlation was found between overall sleep quality and agreeableness and conscientiousness ,however these  correlation were not significant .(table 3). Manwhithney test revealed significant relationship between blood pressure and extraversion score (p=0.003) and openness to experience (p=0.021)

 There was significant relationship between gravida, number of children and age with level of neuroticism , agreeableness  , openness to experience and conscientiousness based on  kruskal  wallis (p>0.05) Man whitney test showed significant relationship between anxiety and fatigue with quality of sleep (p=0.027 / p=0.014). Results of manwhitney and kruskal wallis showed significant relationship between daily nap, nap duration and drinking tea and quality of sleep (table4)

Discussion

Menopausal age in present study was 48.8 which was lower than other studies. In .Elavsky (2012) study menopausal age was 50 years old (12). Mean age of menopause in the US is 51 years (16).Ayati (1387/2008) reported mean age of 47.7 years for menopause (13).

Iranian national health study reported 49.6 years old for menopause in (1383?/2004).It seems the probable reasons for difference age of menopause in different communities could be different age range in various studies perhaps, age of peri menopause has been considered.
Personality type, environmental conditions and workplace conditions, exposure to chemicals, pollutants and radiation, climate, nutrition and genetics could be reasons for this difference. (16)

The other reason could be method of sampling which is convenient in present study.

Based on the findings, there was significant reverse correlation between overall score of sleep quality with extraversion. The higher extraversion score leads to lower sleep quality score. So the quality of sleep was improved. In present study no significant relationship was found between overall score of sleep quality with other dimensions of personality characteristic.

Extrovert people are sociable, energetic, kind and attentive (6). Based on Huron and Michell theory, they are away of passive techniques on stress management because of their braveness and warm and intimate communication with others .These people consider stressful events as a challenge and come over them by positive thinking and self-control (18).So, it is expected that extroverts experience calm life with less problems. Results of present study confirm the above.

It would be expected that there was a significant relationship between neuroticism and quality of sleep, because these group of people tend to experience negative emotions such as fear, sadness, distress, anger, feeling of guilt and disgust. These people are anxious, nervous and restless (6).They consider stressful situations as threat.

In present study, there was a direct relationship between neuroticism and overall score of sleep quality, however this relationship was not significant (p=0.080). In Brawna (2009) study, the higher score of neuroticism accompanied with higher score of sleep disorders. Research plan and variables of his study are similar to present study, however, two studies applied different questionnaires for personality. Browna used short form of NEO questionnaire, but present study applied long version which is more careful.

The mean score of neuroticism in present study was 21.6 ± 5.6 and mean of overall sleep quality in neuroticisms was 3.1± 0.7. They were 5.1± 0.2 and 25.2 ± 4.2 in Brawana study. The different could be as a result of using different questionnaires for sleep disorders and personality.

Results of present study was in agreement with Steriani (2009) study .The only difference was related  to non significant  reverse relationship  extroversion and sleep quality in his study.

It seems the difference could be due to using different questionnaires for personality and sleep quality .present study applied Pittsburgh and NEO FFI, where as Steriani Applied pool and Green questionnaires. In present study significant relationship was found between level of anxiety and fatigue with sleep quality, ie, level of anxiety in women with bad quality of sleep was 57.5 ± 22.2, while it was 50.8 ± 22.7 in women with good quality of sleep. Level of fatigue in former group was 60.2 ± 21. 7 , while  in the lather .group was 53.3 ± 26 .Confounding variables  for sleep quality were level of anxiety  and night sweat  due To flashing , however general linear model  showed  that except night sweet which had predictive effect on quality of sleep , level of anxiety and fatigue were not predictive .The results of present study showed that there was a significant relationship between daily naps, nap duration and drinking tea with quality of sleep .The longer daily nap leads to lower quality of sleep ,Consequently the score of sleep quality increases. General linear model showed duration of daily nap as a predictive variable for sleep quality.

In present study score of neuroticism increases with level of education of women and their husbands, level of employment and socioeconomic class, level of anxiety and fatigue .Based on Atkinson and Heligard, personality is behavioral models and certain thinking styles which determine way of adaptation of individuals with environment (18). Neurotic people are anxious, unstable, nervous and severely restless. So it is expected to be in lower levels of education and lower socioeconomic class. As they are nervous, anxious and results (6) it could be predicted that the level of fatigue and anxiety are high in these people.

It is concluded from present study that individual differences in personality plays an effective role in reporting sleep problems. Control and effective treatment of these differences could improve prognosis.  Furthermore, psychological consult as well as pharmaceutical treatment   in women with sleep problems and providing proper state of health before and after menopause and considering them by policy makers could decrease sleep problems in menopaused women and provide higher quality of life for  post menopausal period.

Limitation of this study include individual differences, psychological state, examination induced stress which influenced on the way of answering questionnaires. For control of these conditions it was tried to complete questionnaires before stressful events and before examination in a calm situation. We could not control genetics, nervous system and endocrine system which influenced on personality; however thyroid gland was controlled by examination.

Conclusion

Extroverts have healthy personality characteristics such as braveness, making warm and intimate communication, be energetic and kind. These characteristics could improve quality of sleep.

Acknowledgement

This study is driven from Msc thesis of M.Ghorbani (MUMS identifier code 910207) .Authors offer their special thanks to MUMS vice  president  for research for financial support.

Conflicts of interest

Authors declared no conflicts of interest.