Characteristics of Sleep Disorders in Women

July 18, 2013

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.

[[{"type":"media","view_mode":"media_crop","fid":"15695","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_1429663829078","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"783","media_crop_rotate":"0","media_crop_scale_h":"133","media_crop_scale_w":"160","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]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.

Upper airway resistance increases throughout pregnancy and may contribute to frequent arousals and subsequent daytime sleepiness. Restless legs syndrome is quite common in pregnancy and may be partially related to lower folate levels and iron deficiency-iron depletion occurs with fetal development, and standard iron supplementation during pregnancy is often insufficient. Nutritional supplements should thus be considered for symptomatic or at-risk individuals.

Disrupted sleep during pregnancy has been associated with poor obstetric and perinatal outcomes, including longer labors and higher incidences of cesarean deliveries and postpartum mood disorders.6 Overall, women in the postpartum period seem to experience lower sleep efficiency, with shorter latency to rapid eye movement sleep (characteristic of depression) and reduced total sleep time. Although it is expected that most awakenings and changes in sleep-wake ratios are related to the newborn’s feeding and direct care, other factors may play a role, including changes in melatonin and progesterone levels and increased irritability and mood swings (postnatal blues). Early detection, monitoring, and effective interventions (if needed) to alleviate mood and anxiety symptoms during pregnancy seem imperative to diminish the risk of postpartum mood and sleep disturbances.

Midlife

Clinicians and patients are frequently puzzled by the complex interactions between sleep problems, aging, and menopause-related hormonal changes. Quite often it is difficult to determine whether sleep problems result from a primary disorder or are secondary to the emergence of hot flashes or depression. Perceived sleep problems (ie, decline in sleep quality) are commonly associated with depression, anxiety, or vasomotor symptoms. Objective sleep measures (polysomnographic studies) may also indicate a primary sleep disorder, such as obstructive sleep apnea or restless legs syndrome. In other words, sleep disturbances during the midlife years are quite frequently multifactorial.

The overall prevalence of obstructive sleep apnea more than doubles (from 6.5% to 16%) among women transitioning into midlife. Several factors may contribute to this phenomenon; reduced progesterone levels may be a factor-progesterone is a known respiratory stimulant and upper airway dilator. Increased body weight may also be an important factor, although an increased risk of obstructive sleep apnea has been observed independently of body weight. Restless legs syndrome may also affect sleep in midlife women and appears to occur more frequently in women with vasomotor symptoms. In addition, fluctuations in estrogen and progesterone levels may alter GABA (γ-aminobutyric acid) function and play a role in menopause-related insomnia, given GABA’s central role in sleep initiation and maintenance.

The use of hormone therapies by women during midlife has been associated with improvements in perceived sleep quality and self-reported sleeping problems; objective measures of sleep, however, have shown more modest results, with a reduction in sleep fragmentation, wakefulness, and arousals.7-9 Non-hormonal strategies, such as eszopiclone and zolpidem, have been successful in improving insomnia in perimenopausal and early postmenopausal women.10,11 It is interesting to note that the use of a sleeping aid led to a reduction in the number of perceived nighttime hot flashes but not daytime hot flashes.11 Other interventions such as quetiapine, when used to manage mood disorders, also have a positive effect on sleep and quality of life in symptomatic menopausal women.12

Sleep hygiene

Sleep problems may have a good response to nonpharmacological interventions, such as sleep hygiene measures and cognitive-behavioral therapies. Sleep hygiene measures include changes in daily routine (diet, exercise, and caffeine and alcohol consumption) as well as environmental changes to minimize the effects of noise, light, and room temperature. Cognitive-behavioral therapies for insomnia are effective when used alone or in combination with sleep aids.13

Conclusion

Sleep problems are more common in women throughout the life cycle and, in some cases, are associated with or exacerbated by reproductive-related events. Underlying primary disorders, such as obstructive sleep apnea and restless legs syndrome, and psychiatric disorders, such as depression and anxiety, should always be investigated and ruled out. Quite often, concurrent treatment strategies are needed. For example, hormone therapy for the alleviation of hot flashes in symptomatic menopausal women in combination with antidepressants, hypnotics, or behavioral strategies may reduce the number and intensity of nocturnal hot flashes and improve sleep. A multiprofessional approach is recommended, particularly when sleep problems are accompanied by poorer quality of life and psychosocial impairment.

This article was acquisitioned and reviewed by Dr Karl Doghramji, Psychiatric Times Section Editor for Sleep Disorders. Dr Doghramji is Professor of Psychiatry, Neurology, and Medicine, and Medical Director of the Jefferson Sleep Disorders Center at Thomas Jefferson University in Philadelphia.

Disclosures:

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.

References:

1. Klink ME, Quan SF, Kaltenborn WT, Lebowitz MD. Risk factors associated with complaints of insomnia in a general adult population. Influence of previous complaints of insomnia. Arch Intern Med. 1992;152:1634-1637.

2. Soares CN. Insomnia in women: an overlooked epidemic? Arch Womens Ment Health. 2005;8:205-213.

3. Baker FC, Driver HS, Rogers GG, et al. High nocturnal body temperatures and disturbed sleep in women with primary dysmenorrhea. Am J Physiol. 1999;277(6, pt 1):E1013-E1021.

4. Shechter A, Lespérance P, Ng Ying Kin NM, Boivin DB. Nocturnal polysomnographic sleep across the menstrual cycle in premenstrual dysphoric disorder. Sleep Med. 2012;13:1071-1078.

5. Freeman EW, Halbreich U, Grubb GS, et al. An overview of four studies of a continuous oral contraceptive (levonorgestrel 90 mcg/ethinyl estradiol 20 mcg) on premenstrual dysphoric disorder and premenstrual syndrome. Contraception. 2012;85:437-445.

6. Lee KA, Gay CL. Sleep in late pregnancy predicts length of labor and type of delivery. Am J Obstet Gynecol. 2004;191:2041-2046.

7. Saletu B, Brandstätter N, Metka M, et al. Double-blind, placebo-controlled, hormonal, syndromal and EEG mapping studies with transdermal oestradiol therapy in menopausal depression. Psychopharmacology (Berl). 1995;122:321-329.

8. Montplaisir J, Lorrain J, Denesle R, Petit D. Sleep in menopause: differential effects of two forms of hormone replacement therapy. Menopause. 2001;8:10-16.

9. Gambacciani M, Ciaponi M, Cappagli B, et al. Effects of low-dose, continuous combined estradiol and noretisterone acetate on menopausal quality of life in early postmenopausal women. Maturitas. 2003;44:157-163.

10. Dorsey CM, Lee KA, Scharf MB. Effect of zolpidem on sleep in women with perimenopausal and postmenopausal insomnia: a 4-week, randomized, multicenter, double-blind, placebo-controlled study. Clin Ther. 2004;26:1578-1586.

11. Soares CN, Joffe H, Rubens R, et al. Eszopiclone in patients with insomnia during perimenopause and early postmenopause: a randomized controlled trial. Obstet Gynecol. 2006;108:1402-1410.

12. Frey BN, Haber E, Mendes GC, et al. Effects of quetiapine extended release on sleep and quality of life in midlife women with major depressive disorder. Arch Womens Ment Health. 2013;16:83-85.

13. Joffe H, Massler A, Sharkey KM. Evaluation and management of sleep disturbance during the menopause transition. Semin Reprod Med. 2010;28:404-421.