Question 70
Dear Doctor N.
I am 46 years old and have been having some small bouts of depression, and sleeplessness. My doctor was going to begin hormone therapy, but because my mother had breast cancer, we decided to wait.. I am on 50 mg. Of Zoloft per day and that seems to help the depression. I still have the problem with sleeping, though. I have tried everything. I am tired at night, but as soon as I go to bed, my legs bother me. They either itch or ache. At times it is just as if something is crawling on them. I have no problems during the day at all. It is just a restless feeling at night. Once I finally fall asleep, I am fine the rest of the night. (what is left of it.) I am a pre-school teacher, so I need my rest. This has been going on for several months. I usually get maybe one good nights sleep a week. Do you think that hormone therapy would help this problem? I do have occasional hot flashes, but they are not my problem. Thank you for your time.
Reply:
I am sorry that you are having this problem. It is impossible to know exactly what is going on in your situation from where I sit in front of this computer. However, I will share some thoughts based on the history you have provided.
First, the issue of an increased increased risk of breast cancer is poorly understood. That your mother has a history of breast cancer must certainly be disturbing for you. However, that information alone does not necessarily increase your risk and if it did hormone replacement would not likely increase it further. I would consider seeing an oncologist at a university medical center and/or have your physician get a copy of the "Risk Disk" (see the risk disk menopause news clip at the bottom of the home page www.drn4u.com ) to more accurately determine your risk. In addition, there is considerable research evidence that HRT users are less likely to die of their disease if they develop breast cancer. This issue is of some importance as HRT provides significant preventative health benefits as well as preserving quality of life.
Next, your sleep disturbance and related leg problems raise some possibilities. There is a condition called "Restless Leg Syndrome" which is thought to have a neurological basis and causes sleep disturbances. It occurs in as much as 1-15% of the general population and is often unrecognized or misdiagnosed. As your symptoms suggest the possibility that this may be related to your problem. I would consider a neurologist for his/her input. In addition, there is a possibility that in at least one instance that restless leg syndrome was caused by sertraline (Zoloft). I have included a few summaries of medical articles below that address this issue. Please let me know what and how you do.
Dr N
Abstract
Restless leg syndrome exacerbated by sertraline [letter]
Authors: Hargrave R , Beckley DJ
There is no Department for this article
Psychosomatics 1998 Mar-Apr;39(2):177-8
Article Number: UI98245526
Abstract: There is no abstract available for this article
Abstract
Restless legs syndrome: clinical features and treatment.
Authors: Tan EK , Ondo W
Department of Neurology, Baylor College of Medicine, Houston, Texas 77030, USA.
Am J Med Sci 2000 Jun;319(6):397-403
Article Number: UI20331552
Abstract: Restless legs syndrome (RLS), widely recognized as a definite clinical entity, has an estimated prevalence of 1 to 15% in different ethnic populations. However, it remains an under diagnosed condition and its symptoms are frequently ascribed to stress and anxiety. Advancement in modern imaging techniques and clinical drug trials provide evidence of an impaired dopaminergic system in RLS. Management involves investigating and correcting treatable secondary causes, avoidance of aggravating factors, and pharmacologic therapy. Recent controlled trials have demonstrated the effectiveness of dopamine agonists such as pramipexole and pergolide. Additional research is needed to further elucidate the pathophysiology of RLS, through obtaining post-mortem specimens and refinement of neuroimaging and neurophysiologic techniques. Isolation of specific genetic loci in familial cases would enable better characterization of distinct clinical and genetic subsets of RLS and result in better understanding of this disease at the molecular level.
Abstract
Sleep/wake abnormalities in patients with periodic leg movements during sleep: factor analysis on data from 24-h ambulatory polygraphy.
Authors: Bastuji H , Garcia-Larrea L
Sleep Disorders Unit, Functional Neurology Department, H"opital Neurologique, Lyon, France.
J Sleep Res 1999 Sep;8(3):217-23
Article Number: UI99407090
Abstract: Periodic Leg Movements (PLM) in sleep occur in a wide variety of sleep/wake disorders but their relationship with sleep disturbance, and notably with the concomitant existence of a 'restless legs' syndrome (RLS) remains unclear. We performed 24-h ambulatory polygraph in a population of 54 consecutive, unselected patients with PLMs (Coleman's index greater than 5/h) who complained of different sleep disorders. A Principal Component Analysis (PCA) was conducted on seven variables from the sample, namely PLM index, patient's age, sleep stage changes per hour, sleep depth index (SWS+PS/TST), diurnal sleep time, number of awakenings exceeding 2 min and presence of a RLS. PCA yielded four independent factors. The PLM index and the changes of sleep stage clustered in a single factor, linking therefore sleep fragmentation to the frequency of PLMs. The second factor appeared to reflect a circadian sleep/wake disorder, combining diurnal sleep time with the number of long night awakenings. The third factor was mainly loaded by the patients' age and the sleep depth index, thus reflecting a well known relationship. Finally, the variable reflecting the existence of a RLS appeared isolated in a single factor, independent from the three previously described. These results confirm and extend the link between PLMs and sleep fragmentation, as well as the recently described dissociation between PLMs and diurnal somnolence. On the other hand, our analysis suggests that in PLM patients the concomitant existence of a RLS is not related to the frequency of occurrence of PLMs, at least when these latter are quantified independently of their arousal index.