Statistical mediation by sleep quality in the association between menopausal symptoms and depressive symptoms in peri- and postmenopausal women: a multicenter cross-sectional study.

OBJECTIVE: This study aimed to examine the associations among menopausal symptoms, depressive symptoms, and sleep quality in peri- and postmenopausal women, with particular attention to the indirect statistical association through sleep quality. METHODS: A multicenter cross-sectional study including 2,330 peri- and postmenopausal women was conducted. Menopausal symptoms were assessed using the Kupperman Menopausal Index (KMI), depressive symptoms using the Patient Health Questionnaire-9 (PHQ-9), and sleep quality using the Pittsburgh Sleep Quality Index (PSQI). Multivariable logistic regression and bootstrap-based statistical mediation models were applied to quantify associations and indirect effects. RESULTS: Depressive symptoms (PHQ-9 ≥5) were observed in 34.0% of participants. Increasing severity of menopausal symptoms was significantly associated with both depressive symptoms and poor sleep quality (P<0.001). Poor sleep quality (PSQI >5) was strongly associated with depressive symptoms (odds ratio [OR]=4.48, 95% confidence interval [CI]: 3.72-5.40). Statistical mediation analysis indicated significant indirect associations through sleep quality, with proportions statistically mediated ranging from 17.08% to 63.39% and the largest proportion observed for hot flashes and sweating. CONCLUSION: Sleep quality statistically accounted for part of the observed association between menopausal symptoms and depressive symptoms. These findings support incorporating sleep assessment into menopause care and provide a rationale for prospective studies evaluating temporal relationships and the potential value of sleep-focused interventions.