Independent Contributions of Nocturnal Hot Flashes and Sleep Disturbance to Depression in Estrogen-Deprived Women

J Clin Endocrinol Metab. 2016 Oct;101(10):3847-3855. doi: 10.1210/jc.2016-2348. Epub 2016 Sep 28.


Context: Women are at increased risk for mood disturbance during the menopause transition. Hot flashes (HFs), sleep disruption, and fluctuating estradiol levels correlate with menopause-associated depression but co-occur, making cause and effect relationships difficult to disentangle.

Objective: Using a GnRH agonist (GnRHa) experimental model, we investigated whether depressive symptoms are associated with HFs and/or are explained by concomitant sleep fragmentation in the absence of estradiol fluctuation.

Design and intervention: Depressive symptoms, objective polysomnographic sleep parameters, subjective sleep quality, serum estradiol, and HFs were assessed before and 4 weeks after open-label depot GnRHa (leuprolide 3.75-mg) administration.

Setting: Academic medical center.

Participants: Twenty-nine healthy nondepressed premenopausal volunteers (mean age, 27.3 years).

Results: Serum estradiol was rapidly and uniformly suppressed. HFs developed in 69% of the subjects. On univariate analysis, worsening of mood was predicted by increases in time in light sleep (stage N1), number of transitions to wake, non-REM arousals, subjective sleep quality, and reductions in perceived sleep efficiency (all P < .045), as well as the number of nighttime (P = .006), but not daytime (P = .28), HFs reported. In adjusted models, the number of nighttime HFs reported, increases in non-REM arousals, time in stage N1, transitions to wake, and reduced sleep quality remained significant predictors of mood deterioration (P ≤ .05).

Conclusions: Depressive symptoms emerged after estradiol withdrawal in association with objectively and subjectively measured sleep disturbance and the number of nighttime, but not daytime, HFs reported. Results suggest that sleep disruption and perceived nighttime HFs both contribute to vulnerability to menopause-associated depressive symptoms in hypoestrogenic women.

Trial registration: NCT01116401.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Adolescent
  • Adult
  • Depression / chemically induced
  • Depression / metabolism*
  • Estradiol / blood
  • Estradiol / metabolism*
  • Fertility Agents, Female / administration & dosage
  • Fertility Agents, Female / pharmacology
  • Gonadotropin-Releasing Hormone / agonists*
  • Gonadotropin-Releasing Hormone / pharmacology
  • Healthy Volunteers
  • Hot Flashes / chemically induced
  • Hot Flashes / metabolism*
  • Humans
  • Leuprolide / administration & dosage
  • Leuprolide / pharmacology
  • Menopause / metabolism
  • Middle Aged
  • Sleep Wake Disorders / chemically induced
  • Sleep Wake Disorders / metabolism*
  • Young Adult


  • Fertility Agents, Female
  • Gonadotropin-Releasing Hormone
  • Estradiol
  • Leuprolide

Associated data