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Estrogen therapy reduces nocturnal periodic limb movements
Helena Hachul , Edmund Chada Baracat , Jos´e Maria Soares Jr. ,
Mauro Abi Haidar , Marco T´ulio de Mello ,
S´ergio Tufik , Lia Rita Azeredo Bittencourt
a Department of Medicine and Sleep Biology, Unifesp - Universidade Federal de S˜ao Paulo, SP, Brazil
b Department of Gynecology, Unifesp - Universidade Federal de S˜ao Paulo, SP, Brazil
Received 2 January 2007; received in revised form 27 July 2007; accepted 16 August 2007
Abstract
It is believed that periodic limb movement (PLM) and more specifically, restless leg syndrome (RLS), are a common cause of
insomnia. And one study in the literature examined PLM when associated to the use of estrogens. Polo-Kantola et al. [Polo-KantolaP, Rauhala E, Erkkola R, Irjala K, Polo O. Estrogen replacement therapy and nocturnal periodic limb movements: a randomizedcontrolled trial. Obstet Gynecol 2001;97(4):548–54] observed that estrogen therapy improved subjective sleep quality regardlessof periodic limb movements or related arousals. Herein is a case of a symptomatic postmenopausal patient with high PLM indexwho complained of insomnia and leg pain. Given that the patient had hot flashes and a high Kupperman Menopausal Index (whichevaluates climacteric symptoms), we decided to administer transdermal ESTRADOT 25 g (Novartis, Brazil) twice-a-week. Our patient experienced a significant decrease in PLM as well as a great increase in REM and a slight increase in slow wavesleep (stages 3 and 4), as shown in the polysomnography. The patient reported an overall improvement in her condition. 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Periodic leg movements; Menopause; Estrogen therapy; Sleep; Sleep disturbances
1. Introduction
suffer from insomnia Periodic limb movement(PLM) and restless leg syndrome (RLS) feature as
Sleep complaints increase with age and are more
common in women than in men. It has been found that
Although one study has addressed the effects of
the incidence of sleep disturbance is higher in post-
menopause on PLM and concluded that estrogen did
menopause and over 60% of postmenopausal women
not alter incidence or intensity of PLM stud-ies have demonstrated possible interactions between
∗ Corresponding author at: Rua Thirso Martins 264 apto 41, Vila
Mariana CEP 04120 050, Brazil. Tel.: +55 11 55729539;
The effect of estrogen therapy on periodic limb
movements is not fully comprehended. Estrogen
increases the number of dopamine receptors
0378-5122/$ – see front matter 2007 Elsevier Ireland Ltd. All rights reserved. H. Hachul et al. / Maturitas 58 (2007) 319–322
increases dopamine intake in specific brain areas
gen on the incidence and intensity of periodic limb
and decreases dopamine catabolism Estrogen also
movements with a randomized, placebo-controlled,
reduces dopamine concentration and dopamine
double-masked, cross-over study design. They con-
receptor overactivity Decrease in PLM could then
cluded that estrogen therapy in doses used to control
be explained following administration of estrogen.
climateric symptoms does not alter the incidence or
There is evidence that estrogen can prevent neu-
intensity of nocturnal periodic limb movements
ronal atrophy as well as improve tissue vascularization
The aim of this report was to describe the case of a
thereby leading to higher tissue concentration of oxy-
postmenopausal woman who complained of insomnia
gen. This could be yet another explanation for the
and PLMD before and after hormone therapy.
decrease of PLM through the use of estrogen.
Restless Leg Syndrome (RLS) is a clinical mani-
festation of a desire to move the lower limbs and is
2. Case report
usually associated with paresthesias, dysesthesias andmotor restlessness. Different motor strategies are used
The research project received prior approval by the
to relieve its discomfort. Symptoms of RLS become
local Ethics Committee and informed, written consent
worse at rest with at least partial and temporary relief
was obtained after full explanation of the procedure
through activity. Symptoms are worse however in the
evening or at night and the prevalence of RLS is higher
A patient, 62 years old, consulted her physician
among the elderly. Epidemiological studies reveal a
complaining of insomnia and excess nocturnal peri-
9–20% prevalence of RLS in this age group. Recent
odic leg movements. She stated that she felt leg pain
studies indicate that RLS is twice as prevalent in
which became worse without movement but lessened
older women as in older men and 5–10% of
after movement. She said she had had these prob-
adults in Northern European population-based studies
lems for about 15 years and that they got worse
report RLS symptoms. Additionally, 26% of women
after menopause. She had been amenorrheic for 20
years following a hysterectomy. She did not report any
Periodic limb movement disorder (PLMD) is char-
other clinical problems except for arterial hyperten-
acterized by periodic episodes of repetitive, highly
sion which was controlled with the use of medications:
stereotyped limb movement that occurs during sleep
50 mg/day atenol and captopril. She had a Kupper-
(PLMS) and that, as a clinical sleep disturbance, cannot
be accounted for by any other primary sleep disorder.
Epworth Sleepiness Scale as 0. Although she
A difficulty to fall asleep or maintain sleep or both is
had already undergone hormone replacement ther-
consistently reported in association with PLMD
apy, she was not under that therapy at the moment
and epidemiological studies estimate the prevalence of
of the project. When under hormone treatment, she
would take equine conjugated estrogen 0.625 mg/day
Previous reports have suggested a high prevalence of
via oral for about 8 months, and then stopped
periodic limb movements of up to 34% individ-
treatment on her own. Normal rates were noted in
uals 65 years of age and older. An elevated periodic leg
exams: hemoglobin = 14.4 g/dL; glucose = 95 mg/dL,
movement index (registered in the polysomnography)
FSH = 67 mUI/mL and estradiol = 7 pg/mL. Clinical
was found to correlate with severity or worsening of a
and laboratory checks informed us that there was no
disorder in certain groups such as in patients with essen-
reason why she should not undertake hormonal therapy.
tial hypertension, end-stage renal disease and alcohol
She took her first polysomnography (PSG) record-
dependency. Early observational studies described an
ing, after which she began using transdermal
increase of PLM in depressed patients treated with psy-
ESTRADOT 25 g (Novartis, Brazil) twice-a-week for
choactive substances such as clomipramine, lithium,
2 months. During the study, the patient wore each patch
for 3.5 days (84 h) on the abdomen, below the waistline.
There is only one study which addressed the
The patches were applied on a clean, dry, non-oily and
effects of menopause on periodic limb movements
non-irritated skin and the initial application was on the
Polo-Kantola et al. evaluated the effect of estro-
right side of the lower abdomen with subsequent appli-
H. Hachul et al. / Maturitas 58 (2007) 319–322
cation alternated to the opposite side. Subsequently a
changes in sleep efficiency, PLM reduced significantly,
second PSG recording was made. An all-night PSG
and the patient reported leg pain had disappeared.
recording was performed consisting of a computerizedSleep Analyzer Computer (SAC version 9.3, OxfordInstruments Inc.). Surface electrodes were used to
3. Discussion
record electroencephalogram (EEG), electromyogram(EMG), electrooculogram (EOG), electrocardiogram
(ECG), pneumographic impedance for recording of
of PLM in postmenopausal women with 48% being
thoracic-abdominal movements, thermal sensors for
administered placebo and 44% on estrogen. They con-
recording nasal and oral airflow, body position sensors
cluded that short-term ET did not alter the incidence or
and infra-red sensor for pulse oxymeter, which was
intensity of periodic limb movements or frequencies of
connected to the distal phalanx for recording oxyhe-
periodic limb movement arousal indices.
moglobin saturation. A snoring sensor was also used.
Estrogen has been linked to movement disorders
A footnote is that the patient has elected to maintain
associated with excessive dopamine activity especially
the use of estrogen ever since the PSG recording.
during pregnancy and while using contraceptives. The
Upon completion of the exam, a trained sleep physi-
hormonal condition associated with pregnancy consists
cian analyzed and staged the recordings according to
of a high serum estrogen concentration accompanied by
the criteria established by Rechschaffen and Kales
high levels of serum progestin. The higher frequency of
The necessary alterations for respiratory events were
movement disorders during those states might depend
incorporated according to the criteria established by
more on progestin than on estrogen concentration. The
the American Academy of Sleep Medicine Committee
estrogen effect might also depend on simultaneous pro-
Practice parameters for the treatment of Rest-
gestin availability. Although unopposed estrogen was
less Legs Syndrome and Periodic Limb Movement
found to increase the number of progesterone recep-
Disorders followed the guidelines established by the
tors the absence of progestin in HT might play
American Sleep Disorders Association Periodic
a key role in any movement effect. The inconsistent
limb movements were scored only if movements were
effect of estrogen on the extrahypothalamic dopamine
part of a series of four or more consecutive ones with
system might depend on the dose, duration and tim-
duration of 0.5–5 s and an interval of 5–90 s
ing of HT. We examined studies showing that exercise
the treatment the patient reported an improvement in
can decrease periodic leg movement in individuals with
sleep quality and fewer leg movements at night. PSG
paraplegia possible explanation for this is
results are shown in Although there were no
the fact that exercise can lead to higher tissue concen-tration of oxygen. It is also possible that once estrogenimproves vascularization additional supply of
oxygen might lead to a decrease in periodic leg move-
Polysomnography results before and after ET
ments. In fact, estrogen may increase NO production
that results in vasodilation of the vascular bed, most
likely increasing the arterial flow to the tissue
estrogen has antiinflamatory action upon the brain
Moreover, there is a circadian variability in PLM fre-
quency, which by itself could explain the decrease of
PLM rather than as a result of estrogen.
Polo-Kantola et al. that the average con-
centrations of estrogen in their study might have been
too low to affect the incidence or intensity of periodic
limb movements. Patients had periodic limb move-
ments without subjective symptoms at the beginning of
AHI: Apnea Hypopnea Index; PLM: periodic leg movement; REM:
their study. They posit that more studies on women with
symptomatic periodic limb movements are warranted. H. Hachul et al. / Maturitas 58 (2007) 319–322
Some investigators believe that periodic limb move-
[10] Hornyak M, Trenkwalder C. Restless legs syndrome and peri-
ment is a common cause of insomnia. Polo-Kantola
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et al. ed that ET improved subjective sleep
[11] Manconi M, Govoni V, De Vito A, et al. Restless legs syndrome
quality independently of periodic limb movements or
and pregnancy. Neurology 2004;28(63(6)):1065–9.
[12] American Academy of Sleep Medicine. International classi-
In our study, the patient was symptomatic, mean-
fication of sleep disorders. In: Diagnostic and coding manual.
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sleep). She did, however, report an overall improve-
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[15] Kupperman HS, Wetchler BB, Blatt MHG. Contemporary
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