Being a woman is a risk factor for insomnia. Female gender has been consistently identified as an independent predictor of sleep problems, including excessive daytime sleepiness, difficulty in initiating or maintaining sleep, and nighttime awakenings.1,2 More women appear to suffer from sleep disturbances than men, even when other factors, such as age, comorbid medical illnesses (eg, chronic pain), and psychiatric problems (eg, depression, anxiety), are taken into account.
This brief review addresses what is currently known about sleep problems in women. The main focus is on sleep issues that are particularly relevant to reproductive stages in a woman’s life cycle and therefore potentially linked to reproductive and/or hormonal factors. As such, some strategies for management that are specific to women will also be reviewed.
Menstrual cycle–related sleep disturbances
Sleep problems may emerge along with mild to moderate premenstrual symptoms or dysmenorrhea or may even accompany a more severe and disabling form of premenstrual disturbance—premenstrual dysphoric disorder (PMDD). Polysomnographic data suggest that women with dysmenorrhea experience less efficient sleep and more wakefulness than women without painful menstrual cycles.3 On the other hand, changes in sleep architecture have not been systematically documented during the premenstrual phase of the menstrual cycle despite numerous (but subjective) reports of sleep disruption, hypersomnia, and insomnia.
Menstrual cycle–related sleep disturbances could be driven, at least in part, by changes in progesterone, prolactin, and melatonin dynamics. A recent study of polysomnographic data across the menstrual cycle included controls and women suffering from PMDD. The findings revealed high progesterone levels and elevated core body temperature in both groups during the luteal phase compared with the follicular phase of their menstrual cycles.4 Those with PMDD and insomnia, however, showed decreased melatonin secretion and increased slow wave sleep during luteal phases. These findings reinforce the hypothesis of an altered homeostatic regulation of the sleep-wake cycle in PMDD caused by changes in the secretion of melatonin and reproductive hormones.
Improvement of sleep disturbances in women with premenstrual syndrome (PMS) or PMDD is commonly related to symptomatic relief—management of cramping, edema, or painful symptoms with diuretics and anti-inflammatory medications or antidepressants for depressed mood, anxiety, and irritability. In some cases, the use of continuous oral contraceptives is recommended for PMS/PMDD; the effects of oral contraceptives on sleep do not seem to be detrimental but need to be further investigated.5
It is important to highlight that some women might not experience isolated premenstrual problems; instead, they might present with a premenstrual exacerbation of an underlying psychiatric condition such as anxiety, depression, or bipolar disorder. Their complaints might, in fact, represent an exacerbation of sleep disturbances that are commonly associated with these underlying conditions. If well characterized, premenstrual exacerbation often requires a different treatment strategy, such as dose optimization of current therapies (eg, antidepressants, benzodiazepines, atypical antipsychotics) or an add-on treatment during the most symptomatic, bothersome period (eg, 7 to 10 days before the onset of menses).
Pregnancy and postpartum period
Sleep might be disrupted substantially and accompanied by significant physiological changes during pregnancy. Reports of sleep disturbances during pregnancy range from 15% to 80%, depending on the population studied and the time of assessment. Most women attribute their disrupted sleep during the first trimester to physical discomfort caused by nausea and vomiting as well as to stressors related to other factors (poor psychosocial support, unplanned pregnancy, etc). As pregnancy progresses through the second and third trimesters, there are increased awakenings and more fatigue, leg cramps, and shortness of breath.
Changes in sex hormones may contribute to the occurrence of sleep-disordered breathing during pregnancy. Snoring occurs more often, possibly because of changes in progesterone levels and upper airway resistance. Some pregnancies are also accompanied by sleep apnea and restless legs syndrome. Although frank obstructive sleep apnea is not common, its management is important given the potential implications for maternal and fetal health.
Dr Soares is Researcher and Consultant and Former Professor in the department of psychiatry and behavioural neurosciences at McMaster University in Hamilton, Ontario. He reports no conflicts of interest concerning the subject matter of this article.
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