Uncovering the Impact of Sleep Dysfunction in Women: Causes, Consequences, and Solutions
Background
Sleep is a crucial factor for a quality life, and for women, it can be significantly impacted by hormonal imbalances, pain syndromes, and psychological issues such as depression. Women are twice as likely as men to experience difficulty falling or staying asleep, but this disparity only becomes apparent after puberty. Improving sleep quality in women requires addressing these underlying issues.”
Terminology
Terminology relating to sleep dysfunction includes the following:
· Insomnia — Difficulty with falling asleep or staying asleep
· Sleep-onset insomnia — Difficulty with falling asleep
· Sleep-maintenance insomnia — Fragmented sleep, difficulty with maintaining sleep
· Circadian Rhythm — Approximately 24-hour cycles that are generated endogenously by an organism
· Sleep-disordered breathing (SDB) — Some degree of sleep-related upper airway obstruction, ranging in severity from upper airway resistance syndrome (UARS) to obstructive sleep apnea (OSA)
· Restless legs syndrome (RLS) — Characterized by the urge to move legs or other limbs during periods of rest or inactivity
Complications
Persistent insomnia can have severe consequences, including fatigue during the day, decreased functionality, memory and concentration issues, higher incidents of automobile accidents, and depression. Patients suffering from persistent insomnia are also more likely to experience medical and psychological problems in systems such as the respiratory, gastrointestinal, and musculoskeletal. It’s crucial to address persistent insomnia to prevent these dangerous complications.”
Disturbed sleep and weight gain
Over the past decade, there has been growing evidence to support the link between reduced sleep time and weight gain, particularly in healthy individuals. Several mechanisms have been proposed to explain this risk, including fatigue leading to decreased physical activity and additional time for food consumption (1). Additionally, sleep disturbance has been associated with changes in the hormone leptin, which helps to regulate appetite (1).
One study, the Helsinki Health Study, surveyed over 8000 men and women over five years and found that major weight gain was associated with reduced sleep time in middle-aged women (2). This finding supports the idea that women, who are more likely to report insomnia, may be more likely to be obese than men (2).
(1) Vgontzas, A. N., Liao, D., Bixler, E. O., Chrousos, G. P., & Vela-Bueno, A. (2002). Chronic insomnia is associated with nyctohemeral activation of the hypothalamic-pituitary-adrenal axis: clinical implications. The Journal of Clinical Endocrinology and Metabolism, 87(9), 3295–3301.
(2) Partonen, T., & Lindberg, N. (2007). Sleep, obesity, and obesity-related diseases. Journal of Sleep Research, 16(4), 300–305.”
Psychological issues
A study has found that healthy women who reported poor sleep quality also reported greater psychological distress, including depression and anger. This relationship between sleep and psychological distress was not observed to the same degree in men .
These findings highlight the importance of addressing sleep issues in women, as poor sleep can have significant impacts on mental health and well-being.
Heart disease and diabetes
A study has found that women who reported poor sleep quality have increased levels of interleukin 6 and C-reactive protein, which are biomarkers of increased risk for metabolic syndrome . Poorly managed sleep apnea has also been linked to cardiac arrhythmias, hypertension, and congestive heart failure .
These findings emphasize the importance of addressing sleep issues in women, as poor sleep can have serious implications for overall health and well-being. In addition, daytime fatigue associated with poor sleep has been linked to increased neuropsychological impairment .
Types of sleep disorders
Sleep-disordered breathing
SDB involves various degrees of pharyngeal obstruction ranging from UARS to OSA. Obstruction results from high negative pressure generated by the inspiratory effort and failure of the dilating upper airway muscles to maintain airway patency.
Contributing factors are degree of muscle atonia and various anatomic abnormalities that increase airway occlusion (e.g., enlarged tonsils, macroglossia, and even nasal congestion). Obesity is a known risk factor for OSA. Women with OSA are likely to be more obese than men, though fat distribution is different. The prevalence, nature, and severity of OSA in women changes with menopause.
Postmenopausal women have twice the rate of OSA that postmenopausal women do. Women demonstrate more partial obstructive events (hypopneas) than complete OSAs. In addition, the duration of hypopneas, when present, tends to be shorter in women than in men. OSA is mostly evident during rapid eye movement (REM) sleep.
Restless legs syndrome and periodic limb movement disorder
These are idiopathic disorders that can cause profound disruption. RLS, a waking disorder that usually occurs before sleep onset, is associated with discomfort in the calves causing restlessness in the legs, which is relieved by movement. RLS is more prevalent in women than men and occurs at higher rates during pregnancy.
Iron deficiency has been implicated in the pathophysiology of RLS. The possibility of a genetic basis has been suggested for primary RLS.
Periodic limb movement disorder (PLMD), occurring during sleep, involves isolated periodic movements of the lower limbs, usually followed by arousal from sleep. In severe cases, frequent leg movements can cause significant sleep interruption, resulting in complaints of insomnia or excessive sleepiness.
Narcolepsy
The 4 major features of narcolepsy are (1) daytime sleepiness, (2) hypnagogic hallucinations, (3) cataplexy, and (4) sleep paralysis. These features are related closely to features normally occurring exclusively during rapid eye movement (REM) sleep.
Circadian rhythm disorders
The most common circadian sleep disorder is delayed sleep phase syndrome (DSPS), with typical onset at puberty. DSPS is characterized by a significant delay (3–4h) in bedtime and wake time in the presence of a normal overall total sleep time. DSPS may also relate to an eveningness chronotype, an individual preference for increased activity at night. A Spanish study, investigating chronotypes in students aged 18–30 years, has shown a greater preference toward eveningness in men.
REM sleep behavior disorders (RBD)
Once thought to be a male predominant disorder, recent findings suggest that REM sleep behavior disorder may be under diagnosed in women because the intensity of the behaviors is less prominent than in men. RBD is classified as a parasomnia andpresents as vivid dreams with complex, repetitive, and often violent motor behaviors during REM sleep, which classically is a time of muscle atonia. Idiopathic RBD has been associated with the development of Parkinson disease. In the study by Koo et al, women with sleep apnea had a higher prevalence of REM-related sleep disordered breathing compared with men, particularly in those women younger than 55 years. The women younger than 55 years were found to be more obese than those in the older age group.
Etiology
Hormonal factors, chronic pain conditions, and psychiatric conditions, particularly mood disorders, are closely associated with insomnia.
Hormonal changes
In general, sex steroids play a role in the etiology of sleep disorders in women, either by having a direct effect on sleep processes or through their effect on mood and emotional state. Sex steroids influence electroencephalographic sleep during the luteal phase by increasing the electroencephalographic frequency and core body temperature. Lack of estrogen later in life contributes to vasomotor symptoms, including hot flashes that cause sleep disturbances and insomnia. Decreased estrogen also plays a role in the etiology of sleep apnea.
Psycho-social issues
In today’s society, many women cope with multiple roles in their families. With less time for themselves, they often cut back on sleep. In addition to sleep deprivation, increased stress has been associated with sleep-onset insomnia.
Psychiatric disorders
Mood disorders are more prevalent in women than in men, primarily those that are unique to the female reproductive system (e.g., premenstrual dysphoric disorder [PMDD], pregnancy affective disorder, postpartum depression, perimenopausal mood disorder). While anxiety disorders often are associated with trouble falling asleep, depression typically is associated with early morning awakening.
Age
The frequency and severity of major sleep disorders, such as SDB, RLS, and PLMD, increase with age.
Weight
Obesity plays an important role in the pathophysiology of SDB. RLS has also been shown to have a correlation with body mass index (BMI).
Epidemiology
Occurrence in the United States
The difficulty most frequently reported by women is insomnia. Insomnia rates during puberty have been described in girls, but not in boys. Women are at 41% greater risk for developing insomnia as compared with men, and this risk increases with age. By age 65 years, the insomnia risk is approximately 73% greater for women.
The prevalence of pathologic SDB has been estimated at 5.2% for women aged 40–64. Over 30% of elderly persons demonstrate at least mild sleep-related breathing abnormalities, as defined by an apnea/hypopnea index of 5 or greater. Postmenopausal women are 2.6 times more likely than premenopausal women to have an apnea-hypopnea index (AHI) of greater than 5.
The prevalence of PLMD increases significantly with age. Studies have estimated that as many as 45% of the independently living population older than 65 years show the minimal criteria for a diagnosis of PLMD.
The prevalence of RLS has been reported at 10% for those aged 30–79 years. Higher rates of RLS have been reported in women as compared with men and Europeans as compared with Asians. Reported rates among Caucasians and African Americans are similar. Smoking, diabetes mellitus, pregnancy, increasing age, and greater BMI significantly increase the incidence of RLS. Iron deficiency anemia has also been associated with RLS.
International occurrence
Across Europe, the prevalence of insomnia varies with France having the highest prevalence at 27% and the Netherlands having the lowest prevalence at 14%. However, across all the countries studied, women were significantly more affected by sleep disturbances than men.
In a large study performed in China, the prevalence of reported sleep difficulties in the past month was 25%; slightly lower that the number reported by other countries. Like in other studies, Chinese females reported poorer sleep quality than men. However, the prevalence of general sleep disturbance did not differ between men and women in this very large sampled population.
The prevalence of obesity is higher in black women than in white women. Obesity places women at higher risk of developing OSA, particularly after menopause. Sleep apnea is pervasive in non-European–American women. Compared with European-American women, non-European–American women have more blood oxygen desaturations during sleep.
No significant differences were found between Caucasians and African Americans in the risk for RLS.
Sex-related demographics
In general, gender differences have been found in circadian rhythm regulation and the homeostatic sleep process. Specifically, chronotype studies have found that men have a stronger tendency toward eveningness compared with women.
Sex differences in the sleep-wake cycle appear to increase in response to sleep loss, suggesting different regulation of sleep homeostasis between men and women. Compared with men, women show more slow-wave sleep (SWS), more spindling activity during SWS, and slower age-related reduction of SWS.
Poor sleep affects women more than men. Women who experience sleep disturbance are at higher risk for hypertension, diabetes type-2 weight gain, and psychological distress including anger hostility and depression.
Insomnia
Starting at puberty, the incidence of insomnia in females differs from that of males. At puberty, insomnia rates for girls are almost triple that of boys. As women, the difference is augmented to a 41% greater risk for the development of insomnia as compared with men, and by age 65 years, the risk is 73% greater as compared with men. Conditions such as bipolar disorder, stable coronary artery disease, and certain anxiety and depressive disorders that exhibit higher rates in women are associated with insomnia.
Obstructive sleep apnea
Women are more likely to have UARS, less likely to have positional apnea, and more likely to have REM-related OSA. While women have less prevalence of OSA than men, pregnancy and menopause increase the risk for sleep apnea.
Narcolepsy
Men have a greater relative risk of narcolepsy with cataplexy
Restless legs syndrome
Symptoms of RLS are more frequently reported by women.During pregnancy, prevalence rates of 11–23% have been reported.
Age-related demographics
In general, sleep is sounder and less prone to disturbances in younger people. As women age, physical and hormonal changes take place that make sleep lighter and less sound. Women older than 40 years are 1.3 times more likely than age-matched men to report insomnia. Risk of insomnia, sleep apnea, periodic leg movements, and restless legs syndrome increase as women get older.
In the years surrounding menopause, sleep disturbances occur with increased frequency. Women take longer to fall asleep, wake up more often at night, and are more tired during the day. Hot flashes and night sweats, associated with decreased levels of estrogen, may contribute to midsleep awakenings. The prevalence of SDB increases significantly after menopause.
During postmenopausal years, sleep efficiency further decreases, and waking after sleep onset increases. Factors affecting sleep during this period include pain, certain medical and emotional conditions, and physical discomfort. Polysomnographic changes in elderly women include decreased SWS stages 3 and 4, which results from decreased electroencephalographic amplitude, and shorter REM sleep latency. In one study, older women who slept more than 9 hours per night had a higher risk of ischemic stroke.
Prognosis
When treated, sleep apnea has an excellent prognosis. Shortly after treatment with nasal continuous positive airway pressure (CPAP), patients report increased alertness, decreased nocturnal awakenings, and an improved sense of well-being.
Morbidity and mortality
Studies have shown that sleep problems are linked to more physical and emotional disturbances in women than in men. Among women, those with worse sleep showed more emotional distress and depression. They also had a higher BMI, more inflammation, and less sensitivity to insulin.
Insomnia is a significant comorbidity in many disorders. The most common disorders associated with insomnia are psychiatric illnesses. Major depression and dysthymia are most closely associated with insomnia. Numerous studies have also shown a close association of chronic pain syndromes with insomnia.
Most common comorbidities with sleep disorders
Snoring, often a sign of partial airway obstruction, has been shown to be associated with high blood pressure and increased risk for OSA. Snoring increases during pregnancy, particularly during the last trimester. It has been reported that about 14% of women who report habitual snoring during pregnancy have pregnancy-induced hypertension. In addition, snoring may be responsible for nighttime increases in blood pressure in preeclampsia.
Other common comorbidities include the following:
· OSA has been associated with hypertension, as well as with insulin resistance and metabolic disease
· Older women who sleep more than 9 hours of sleep are at higher risk for ischemic stroke
· As mentioned, psychiatric conditions, particularly depression and anxiety disorders, are the most common comorbidities with insomnia
· RLS may be secondary to medical conditions that have iron deficiency, including iron deficiency anemia, renal disease, and pregnancy
Patient Education
Women who present with excessive daytime sleepiness should be warned about the dangers of driving and operating heavy machinery. This warning should be documented in the patient’s chart. This is particularly important because in most sleep labs, the time interval between initial evaluation, ordering of a sleep study, and initiation of treatment can be as long as weeks and even months.
Promoting good sleep hygiene
Physicians should educate women about habits and behaviors that help promote good sleep. These behaviors help most women sleep better, regardless of the type of sleep problem. The following sleep hygiene instructions should be emphasized:
· Get up about the same time every day
· Go to bed only when sleepy
· Establish a relaxing presleep routine, such as reading or listening to relaxing music
· Avoid heavy meals or consuming caffeinated beverages within 5–6 hours before bedtime
· Avoid smoking close to bedtime; avoid sleeping pills for periods longer than few weeks; be careful not to drink alcohol while taking sleeping pills
· Maintain a regular daily schedule that includes exercise, downtime, and regular mealtimes; avoid strenuous exercises within 6 hours before bedtime
· Older women should try to take a daily afternoon nap at a regular time to prevent early evening dozing
Treatment and Management
Approach Considerations
Treatment of sleep disorders is directed at the particular problem and includes behavioral and pharmacologic components, as well as implementation of a sleep hygiene program.
Continuous positive airway pressure (CPAP) therapy
The treatment of choice for SDB is CPAP therapy. This treatment uses forced air pressure to keep the upper airways open.
Oral appliance
Oral appliance therapy uses a dental device to effect advancement of the mandible and tongue in order to increase airway opening. Oral appliance therapy is indicated for mild-to-moderate sleep apnea and when individuals are unable to tolerate CPAP therapy. There are many types of oral appliances. Although not as effective as CPAP for the treatment for OSA, oral appliance treatment is less obtrusive and easier to tolerate than the CPAP device.
Cognitive behavioral therapy for insomnia (CBT-I)
Behavioral approaches to the treatment of insomnia are effective and should be used as first-line treatment for chronic insomnia. Specifically, in a study from the National Institutes of Health (NIH), CBT-I produced longer-lasting effects than medication. According to the 2005 NIH consensus statement, CBT-I is as effective a treatment for insomnia as sleeping pills for the short term and is more effective than hypnotics in the long term. CBT-I involves the modification of certain sleep-related maladaptive behaviors and the identification of dysfunctional perceptions and attitudes related to sleep patterns. CBT-I has also been found to be effective in special populations, including geriatric groups and patients with chronic pain conditions.
Menstruation-Related Sleep Disorder
Generally, premenstrual insomnia disappears a few days after menstruation begins. For some women, however, the associated tension and irritability can result in lingering sleep problems and even in chronic insomnia. These women should pay attention to their sleep needs, maintain a regular sleep-wake schedule, avoid stress when possible, and eat a healthy diet
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Because of underlying circadian disturbances in women with premenstrual symptoms, evening bright-light therapy has been reported to be effective in preventing early morning awakening in women with this complaint.
Women diagnosed with PMDD are more susceptible to major depressive disorder when their condition goes untreated. Studies have shown that, like patients with major depression, women with PMDD respond to treatment that incorporates sleep deprivation. Total and partial sleep deprivations have been shown to effectively reduce depressive symptoms, although these methods still are considered experimental.
Pregnancy-Related Sleep Disorder
Relatively little is known about the health significance of sleep disturbance in pregnancy. Pregnancy can pose a risk for developing SDB, back pain, and leg cramps. It can also trigger episodes of sleepwalking and PLMD.
In addition, sleep disturbance during pregnancy also can be associated with frightening dreams, postpartum blues, and sometimes even major depression and postnatal psychosis.
Throughout their pregnancy, women need to pay extra attention to their sleep pattern by making sure that they get enough sleep, maintain a regular sleep-wake schedule, and avoid excessively stressful conditions.
Because sleeping pills and alcohol can harm the baby, other measures to improve sleep need to be considered. The practice of muscle relaxation technique prior to bedtime may be effective in promoting better sleep and reducing the discomfort of pregnancy.
To avoid exacerbating heartburn, women should maintain a balanced diet and avoid eating heavy meals and spicy food for at least 2–3 hours before bedtime.
After delivery, getting enough rest continues to be very important, as severely disturbed sleep may place women at risk for postpartum depression and child abuse.
Narcolepsy
Most patients with narcolepsy rely on stimulant and antidepressant medication to maintain daytime alertness and to control cataplexy; therefore, cessation of medication during pregnancy can cause excessive sleepiness or cataplexy, which may result in injury. In addition, withdrawal from medications also may affect sleep patterns.
Menopause-Related Sleep Disorder
Women can alleviate their menopause-related sleep disturbances by paying attention to their sleep habits, controlling their bedroom temperature, adjusting the light, and using comfortable (preferably cotton) bed linen. In addition, they should eliminate caffeine, sugar, and alcohol from their diet.
Estrogen therapy has been found to be quite effective for women with severe sleep and mood disturbances who have no history of affective illness. Hormone replacement therapy (HRT) has also been the treatment of choice for sleep interruptions related to hot flashes. However, study results have caused the safety of this treatment to be questioned.
A combination of antidepressant medications and supportive psychotherapy should be considered for women who have had long-standing difficulties with sleep, depression, and anxiety.
Sleep Disorders in Elderly Women
Older women should be aware of sleep disturbances and not dismiss them as part of the aging process. In addition, the presence of significant daytime sleepiness should be investigated. A sleep study may be required to rule out major sleep disorders.
The physician should be aware of the patient’s medical and psychiatric conditions and target the treatment at the cause of the disturbance rather than at the symptoms. General guidelines for better sleep habits should be provided.
Deterrence and Prevention
Strategies for preventing sleep dysfunction include the following:
· Good sleep hygiene — Maintaining good sleep hygiene improves the sleep of most women
· Stress management — Stress associated with daily life often contributes to sleep problems; learning stress management skills can help women to sleep better and prevent more serious sleep problems
· Body weight maintenance — Regular exercise and healthy diet promote good sleep; in addition, maintaining normal weight may prevent the development of obesity-associated SDB
Medication Summary
Underlying disease can be treated with HRT, hypnotics, antidepressants, and behavioral therapy. Estrogen replacement can improve sleep in menopausal women, primarily through the reduction of vasomotor symptoms that disturb sleep. It may also improve sleep-related breathing disorders. Moreover, studies indicate that estrogen, either alone or combined with progestin (but not progestin alone), markedly reduces OSA in menopausal women.
Antidepressants are indicated for PMDD, postpartum depression, and clinical depression in patients of any age. Selective serotonin reuptake inhibitors (SSRIs) are the most frequently prescribed antidepressive agents.
I hope I tried to satisfy the women on their sleeping problems as I had been involved in this research in my med school. I have tried to simplify the problems as much as possible and made it comprehensible to a common woman.
Thank you
