Sleep Disturbances in Women
Sleep Disturbances in Women
According to some estimates, insomnia is almost twice as common in women as in men.1 The condition has been associated with stages of the female reproductive cycle, such as the premenstrual phase, pregnancy, and menopause; thus, some have suggested that sex hormones play a causative role.1 Women with sleep disturbances present challenges to clinicians because treatment strategies must take into account medical, hormonal, and behavioral factors contributing to poor sleep quality as well as to mood changes and impaired quality of life.
Results of the 2005 Sleep in America poll showed that 57% of women had experienced one or more symptoms of insomnia during the month before the assessment; the most common symptom was “feeling unrefreshed upon awakening” (39%). Other complaints included difficulty falling asleep, several awakenings during the night followed by difficulties getting back to sleep, and waking too early in the morning.2 Potential links between sleep difficulties and psychiatric disorders are numerous. For example, insomnia can be a precursor to major depressive disorder; conversely, difficult-to-treat depression or anxiety can cause persistently altered sleep.
Perimenstrual Effects, PMS, and PMDD
For some women, sleep problems can emerge secondary to menstrual symptoms (e.g., cramping, bloating, headaches, and breast tenderness) or dysmenorrhea.3 Polycystic ovary syndrome can be associated with nocturnal disordered breathing leading to sleep fragmentation and daytime sleepiness.4
Significant sleep disruption has been reported in association with premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD).3 Most studies exploring the efficacy of hormonal and nonhormonal treatments for PMDD have focused primarily on mood and anxiety symptoms rather than insomnia.5 As SSRIs are the treatment of choice for PMDD, it is reasonable to expect that sleep disturbances secondary to mood swings and increased anxiety also would respond to such treatment.5 In addition, intermittent use of benzodiazepines is a potential option for women with perimenstrual anxiety and altered sleep (and low risk for substance abuse).6
Sleep is disrupted substantially during pregnancy and postpartum, with prevalence of insomnia ranging from 15% to 80%.7 Altered sleep during pregnancy has been attributed to nausea and vomiting during the first trimester; psychosocial stressors associated with first-time or unplanned pregnancies or absence of good psychosocial support also have been noted.8 During the second and third trimesters, nocturnal awakenings, fatigue, leg cramps, and shortness of breath become more common.8 Pregnant women who report sleep disturbances should be screened for depressive symptoms: Pregnancy does not confer a protective effect against depression, and disrupted sleep in this population might indicate underlying mood changes.
Hormonal changes during pregnancy can underlie sleep-disordered breathing and resultant sleep disruption. Snoring tends to increase during pregnancy as a result of changes in upper airway resistance because of altered progesterone levels.9 Other factors contributing to sleep-disordered breathing during pregnancy include weight gain, mucosal edema, and changes in respiratory mechanics.9 In addition, pregnant women — especially during the final trimester — seem to have heightened risk for sleep apnea and restless legs syndrome (RLS).10 Interestingly, disrupted sleep during pregnancy has been linked to poor obstetric outcomes; for example, getting fewer than 6 hours of sleep nightly was associated with longer labor and increased risk for cesarean delivery.11
Many women in the menopausal transition experience hot flashes that, when nocturnal, can disrupt sleep.3 Women who develop depressive symptoms during the menopausal years often also experience both hot flashes and insomnia, suggesting a potential relation between vasomotor symptoms, sleep disruption, and negative effects on mood and well-being.12 Obstructive sleep apnea syndrome (OSAS) also can occur in menopausal women because of diminishing levels of progesterone, a respiratory stimulant and upper airway dilator. Increased body weight might also play a role, although elevated risk for OSAS has been observed independent of body weight.13
Diagnosis and Management of Sleep Disturbances: Clinical Considerations
The first step in managing a sleep disorder is to establish a clear diagnosis. A careful interview of the patient (and the bed partner, who is an objective observer for behaviors of which the patient might be unaware) is essential. Typical sleep behavior — including sleep onset, sleep maintenance, and daytime alertness — should be documented during a 24-hour period.
Because sleep problems often have medical and behavioral components, both must be addressed to ensure clinical improvement. To that end, medical causes of insomnia (e.g., RLS) should be adequately treated before embarking on behavioral management. Some intrinsic sleep disorders such as RLS can be established purely based on history, while others such as OSAS require polysomnographic assessment.
Behavioral approaches provide similar short-term benefits as do pharmacologic therapies but have better long-term benefits, especially in older women. Stimulus control and sleep-restriction therapies are among the most effective behavioral approaches.14
Most herbal preparations have shown inconsistent results. Valerian (Valerian officinalis), for example, seems to have sedative and muscle-relaxant effects; however, evidence for its efficacy as an insomnia treatment is inconclusive, sleep benefit can be delayed, and some patients experience residual daytime effects.15
For menopausal women with sleep disturbances and vasomotor symptoms, hormone therapy is often appropriate (Journal Watch Women’s Health Jul 1 1998). Antidepressants can have an indirect effect on sleep and quality of life by improving other menopause-related symptoms; therefore, these agents might be an option for symptomatic women who are unable or unwilling to use HT because of safety concerns. Other potential pharmacologic therapies include benzodiazepines and non-benzodiazepine receptor agonists (e.g., zolpidem, zaleplon, and eszopiclone).
Women commonly experience sleep disorders that can result from or precipitate psychiatric problems, particularly mood and anxiety disorders. Many factors contribute to the heightened incidence of insomnia in women, including various somatic symptoms, psychiatric disturbances, and intrinsic sleep disorders. Because insomnia has been associated with impaired quality of life and daytime functioning, its management is crucial. Addressing sleep disturbances throughout women’s life cycles is not an easy task. In working toward a successful treatment strategy, clinicians should take into consideration and carefully assess both medical and psychological factors.
Dr. Murray is Assistant Professor, Division of Neurology, Department of Medicine, University of Toronto; Staff, Sunnybrook Health Sciences Centre and Women’s College Hospital, Toronto, Ontario.