Women and Sleep: The Stages of Life

From The Lung Disease Center of Pennsylvania’s Breathe Magazine

Sleep and sleep disruption or sleep disorders have become a significant issue for both men and women.  The data surrounding sleep dysfunction has, for the most part, been obtained though studies in men. The reasoning being that changes in the hormonal shifts of women presented more problems with study design and the interpretation of results.

Women, from menarche to menopause, report more problems with insufficient sleep and insomnia than men.  Women report more difficulty in initiating sleep, difficulty staying asleep, and more frequent early morning awakenings.  Women appear to need increased amounts of sleep to function at their best during the day compared to men. These gender differences in sleep complaints suggest that women have a higher susceptibility to sleep symptoms.  Hormonal and physiologic changes, which begin in puberty and continue through the menstrual cycle, pregnancy, perimenopause, and menopause, influence a woman’s circadian rhythms, sleep architecture, and sleep quality.  Moreover, these changes can contribute to a wide range of sleep disorders. Women’s sleep architecture and quality can be affected by many different factors, such as weight gain, especially during pregnancy.  Women are also exposed to many different life pressures due to their gender.   Childcare responsibilities, work-life balance, and the caregiver role for the elderly, as well as general stress, can impact a woman’s sleep quality and daytime functioning.

This article will review the problems women have with sleep based on the stages of their lives.  Addressed in this article will be three main stages of a woman’s life and the difficulties these times may present for healthy sleep.  The stages to be considered are: 1) sleep in women of reproductive age, and this will include sleep during the menstrual cycle and perimenopause; 2) sleep during pregnancy and the postpartum period; and 3) sleep during the perimenopausal and menopausal stage.

Menstrual cycles are not uniform in duration for any individual woman, and can vary considerably between women.  Hormonal fluctuations play an important role in sleep quality during the entire menstrual cycle.  Estrogen levels are high just prior to ovulation and progesterone levels rise following ovulation.  Sleep fragmentation is thought to be associated with the rise in progesterone levels.

A significant number of women of reproductive age are affected by what is called the premenstrual syndrome. Alternatively, premenstrual dysphoric disorder (PMDD) is characterized by more intense mood and anxiety swings, along with a variety of somatic symptoms.  Women affected by PMDD report sleep problems such as insomnia, frequent nighttime awakenings, disturbing dreams or nightmares, fatigue, and daytime sleepiness.  Changes in thyroid and cortisol levels, along with melatonin, have been found to be present in PMDD leading to light therapy and melatonin as some of the treatment options.  A rare disorder, menstrual hypersomnia, is characterized by excessive sleepiness and can be associated with compulsive eating, sexual disinhibition and depression. 

“Use of oral contraceptives has been found to be helpful in patients with menstrual hypersomnia, as well as PMDD.” Says Dr. Ryan J. Zlupko of Altoona OB/GYN Associates.

The most common endocrine disorder in women of reproductive age is the polycystic ovary syndrome (PCOS), affecting between 5 and 12 percent of women.  Women with PCOS have enlarged polycystic ovaries, but may also exhibit hairiness, obesity and infertility.  Obstructive sleep apnea is more than nine times more likely to be diagnosed in PCOS patients, likely related to obesity.  Since OSA is associated with an increased cardiovascular risk and diabetes, treatment with continuous positive airway pressure (CPAP) is important in this young age group.

Pregnancy is frequently associated with sleep disturbances. More than 79% of pregnant women indicate that their sleep patterns are different than at any other stage of their lives. The most common cause for sleep awakenings during pregnancy is nocturia (getting up at night to pee), agrees Dr. Zlupko. This problem is most common during the third trimester.  Pregnant women also report increased insomnia, restless leg syndrome (a disorder characterized by an unpleasant tickling or twitching sensation in the leg muscles when sitting or lying down relieved only by moving the legs), snoring and hypersomnia (increased sleepiness and the need for more sleep). Progesterone and estrogen levels rise progressively during pregnancy and exert significant influence over sleep architecture and quality.  Progesterone levels may be the culprit in causing hypersomnia.  Estrogen levels have been shown to reduce the period in the sleep cycle known as the rapid eye movement phase (REM sleep).  REM sleep is the period when we dream and without REM sleep we all experience daytime sleepiness and fatigue.

Pregnant women report more problems with insomnia than non-pregnant women.  Pregnant women with a chronic sleep debt are more likely to develop gestational diabetes, preeclampsia, hypertension, and postpartum depression (PPD).  Appropriate treatment for insomnia is important to help moderate the development of PPD.  Women notice an increased frequency of snoring during pregnancy.  The prevalence of obstructive sleep apnea (OSA) is twice as common during the third trimester compared to the first.  Maternal OSA has been associated with preeclampsia, pregnancy-related hypertension, gestational diabetes, increased risk of pre-term delivery, increased risk of neonatal ICU admissions, low birth weight, and intrauterine growth restrictions. OSA is often misdiagnosed during pregnancy.  The use of CPAP is the treatment of choice and is safe during pregnancy.  Dr. Zlupko advises expectant mothers to sleep on their left side and elevate the head of the bed to avoid compression of the inferior vena cava (the main vein bringing blood back from the abdomen to the heart). A type of CPAP (continuous positive airway pressure) called auto titrating, is the best to use because of the weight changes and fluid shifts occurring during pregnancy. An auto titrating CPAP will adjust on a breath by breath basis to compensate for any dynamic changes in the airway.

Restless leg syndrome is a feeling that one must constantly move the legs when in bed. Gestational restless leg syndrome may occur in as many as 30% of pregnant women, with the frequency increasing from the first to the third trimester.  Interestingly, iron deficiency is often associated with this syndrome.  18% of pregnant women have been shown to have iron deficiency due to increased maternal requirements which include demands from the fetus and placenta and expansion of the maternal blood volume.  Unfortunately, many of the medications used for restless leg syndrome in non-pregnant women and men have not been shown to be safe in pregnant women, or little is known about their affect.

Sleep walking, sleep talking, and nightmares have all been reported during pregnancy.  Treatment here is also limited because of the side-effect profiles of therapeutic drugs during pregnancy.

In the postpartum period, hormone levels fall and the usual unpredictable infant sleep patterns can affect the women’s sleep patterns.  Maternal sleep patterns are affected regardless of whether the baby is bottle or breast fed. Some unusual disturbances have been reported, and these are called parasomnias.  Postpartum parasomnias include sleep walking, arousals at night associated with confusion or total amnesia about the event.  A confused arousal of the mother when the baby is in the bedroom exposes the infant to potential inadvertent harm from the confused mother.

Adult non-pregnant women have higher rates of parasomnias than men, with night eating and sleep-related eating disorder (SRED).  The women often need to eat in order to fall asleep and this behavior may be associated with partial or complete amnesia.

Sleep disturbances are common during the menopausal transition from perimenopause through menopause and post-menopause.  During the perimenopausal period wide hormonal fluctuations occur with some increasing and some decreasing, most notably progesterone and estradiol. The diagnosis of the perimenopausal period cannot be made by measuring hormone levels but rather by clinical symptoms and signs.  Dr. Zlupko indicates that the common symptoms during this period include hot flashes, vaginal dryness and sleep disturbances.  Hot flashes can be associated with frequent nighttime arousals and hormonal replacement, and non-hormonal medications have been found to be helpful.  For example, the role of melatonin as a cause for some menopausal sleep disturbances and as a treatment for some, is currently being debated.

Insomnia in the postmenopausal period may be associated with a variety of causes including advancing age, depression and fibromyalgia, with hormonal factors playing a role as well. Obstructive sleep apnea (OSA) continues to increase during the menopausal and postmenopausal period.  Weight gain and hormonal changes are risk factors.  Progesterone loss can increase the collapsibility of the pharyngeal dilator muscles leading to an increased risk of OSA.

Sleep disturbances are common in women of all ages. Sleep disturbances across a woman’s life span are associated with major changes in hormonal levels and physiology.  More study and insight is needed in how to address sleep disturbances, such as restless leg syndrome (RLS) and insomnia in pregnant and postpartum women who are breast feeding.  How to deal with sleep issues associated with postmenopausal stress levels in women placed in the caregiver role for elderly parents, or who need to care for grandchildren abandoned by their parents, is a growing area of concern.  Sleep disorders and disturbances in women need to be correlated with their stage of life to be fully understood. Finally, Dr. Ryan J. Zlupko recommends “Women should discuss any sleep problems with their family physician or OB/GYN physician.”