How do Restless Legs Syndrome (RLS) symptoms change in a middle-aged woman during perimenopause and menopause?

RLS Symptoms During Perimenopause and Menopause

RLS symptoms frequently worsen during the menopausal transition, with prevalence increasing with age and a strong association with vasomotor symptoms (night sweats), though hormone replacement therapy does not appear to reduce RLS risk. 1

Epidemiological Pattern Through Menopause

• Women experience RLS at approximately twice the rate of men (2:1 ratio), and prevalence increases progressively with age through the perimenopausal and menopausal years. 2, 1

• Among Swedish women aged 18-64 years, overall RLS prevalence was 15.7%, with a clear age-dependent increase that corresponds to the menopausal transition period. 1

• RLS severity typically worsens through the first seven to eight decades of life, meaning perimenopausal and menopausal women (typically ages 45-55) are in a period of progressive symptom intensification. 2

Specific Menopausal Associations

• Women experiencing vasomotor symptoms (particularly night sweats) during the menopausal transition have significantly higher rates of RLS, suggesting a hormonal or autonomic nervous system link. 1

• Despite the association with vasomotor symptoms, hormone replacement therapy (HRT) use shows no statistical relationship with RLS prevalence or severity, indicating that simply replacing estrogen does not prevent or treat RLS symptoms. 1

• Postmenopausal state itself does not show a direct statistical relationship with RLS beyond the age-related increase in prevalence. 1

Clinical Impact During This Life Stage

• RLS during perimenopause and menopause compounds sleep disturbance, as approximately 90% of RLS patients already experience insomnia, which is further exacerbated by menopausal sleep disruption. 3, 1

• Women with RLS during the menopausal transition more frequently report symptoms of depressed mood and affected sleep quality compared to women without RLS. 1

• The circadian pattern of RLS (worsening in evening and night) directly overlaps with the timing of menopausal night sweats, creating a "double hit" to sleep quality. 4, 1

Pathophysiological Considerations

• The mechanism linking menopause to RLS worsening likely involves central dopaminergic dysfunction and altered iron homeostasis rather than direct hormonal effects, given the lack of HRT benefit. 5, 2, 1

• Iron deficiency becomes increasingly relevant during this period, as the American Academy of Sleep Medicine recommends checking ferritin and transferrin saturation in all clinically significant RLS cases, with supplementation if ferritin ≤75 ng/mL or transferrin saturation <20%. 3, 6

• Secondary RLS causes that may emerge or worsen during middle age include iron deficiency, renal dysfunction, and metabolic changes—all of which should be screened for in perimenopausal women with new or worsening RLS. 5

Critical Management Pitfalls

• Do not assume HRT will improve RLS symptoms—the evidence shows no benefit, and clinicians should instead focus on RLS-specific treatments including iron optimization and alpha-2-delta ligands (gabapentin, pregabalin) as first-line therapy. 3, 1

• Avoid attributing all leg discomfort to "menopause" without proper RLS diagnostic criteria assessment: urge to move legs, worsening with rest, relief with movement, and circadian pattern with evening/night predominance. 6, 4

• Screen for exacerbating medications that may be newly prescribed during this life stage, including SSRIs for mood symptoms, antihistamines for sleep, or antipsychotics, as these can trigger or worsen RLS through dopamine antagonism. 3, 5