Sleep Problems in Women
Sleep Problems Grow During Pregnancy
by Suzanne Krell, MD
From Sleep Center News, Fall 2005
Given the multitude of hormonal, physical, and emotional changes associated with pregnancy, it’s not surprising that pregnant women have trouble sleeping. According to a 1998 poll by the National Sleep Foundation, 78 percent of women report their sleep was more disturbed during pregnancy than at any other time of life.
Sleep complaints tend to change during pregnancy. In the first trimester, surging progesterone levels often result in severe fatigue and sleepiness during the day and, ironically, difficulty sleeping at night. Nausea, breast tenderness, and increased frequency of waking to urinate may disrupt sleep, and anxiety or excitement about the new baby may contribute to poor quality sleep.
The second trimester often brings temporary relief. While progesterone continues to increase, it does so more slowly, resulting in less fatigue, nausea, and breast tenderness. Nighttime urination also decreases as the uterus moves out of the pelvis and into the abdomen, lessening pressure on the bladder.
With these changes, sleep quality and energy improve. In the third trimester, sleep problems are at their worst. As the baby and belly grow larger, heartburn, back pain, and frequent urination increase. Finding a comfortable sleeping position can be difficult. Breast discomfort, nasal congestion, leg cramps, and the baby’s increasing movement all interrupt sleep. Fears and concerns about labor or caring for a new baby can foster insomnia. Snoring, sleep apnea, and restless legs syndrome are sleep disorders that can occur any time during a pregnancy, but they tend to be most severe during the final trimester.
About 30 percent of pregnant women start snoring, partly due to weight gain and increased nasal congestion narrowing the upper airway. If airway narrowing is severe, sleep apnea may occur. People with sleep apnea often snore loudly and may have irregular breathing or frank breathing pauses during sleep. This results in increased sleep disruption, fatigue, and sleepiness. Moreover, several studies suggest that sleep apnea may lead to complications of pregnancy such as low birth weight, high blood pressure, and a blood-pressure-related condition called preeclampsia.
Restless legs syndrome is another sleep disorder aggravated by pregnancy. Approximately 15 percent of pregnant women experience these uncomfortable “crawling” or restless feelings in their lower legs, which are worse in the evening hours. The discomfort is relieved by movement such as stretching or walking but recurs when sitting or resting quietly, making it difficult to fall asleep or stay asleep. Iron and folate supplements may help, and fortunately the condition usually resolves after birth.
Some people believe that the lack of sleep during pregnancy is merely nature’s way of preparing a mother for the demands of caring for a newborn. But sleep disturbance that is severe or associated with loud snoring should be discussed with a healthcare provider.
Tips for Better Sleep During Pregnancy
- Get extra sleep by napping, going to bed early, or sleeping in.
- Establish a relaxing bedtime routine. Sleep on your left side. This will reduce pressure from the uterus on the bladder, stomach, and blood vessels in the belly.
- If heartburn is a problem avoid meals close to bedtime and elevate the head of the bed.
- Don’t sleep flat on your back. This can aggravate back pain, heartburn, and swelling in the legs and can worsen frequent urination.
- To improve bedtime comfort use strategically placed pillows (between the knees, under the belly).
- To improve sleep quality and energy levels exercise regularly, but not too close to bedtime.
- To reduce trips to the bathroom drink plenty of fluids during the day, but cut back 2 to 3 hours before bedtime.
- To relieve leg cramps and restless legs, try regular stretching and increase your iron and calcium intake.
Source: J R Santiago, M S Nolledo, W Kinzler, and T V Santiago. Sleep and sleep disorders in pregnancy. Ann Intern Med. 2001; 134:396–408.
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Women and Sleep Disorders
From Sleep Center News, July 2004
Women uniquely experience sleep problems secondary to their different reproductive phases in life. Common normal sleep complaints surrounding the menstrual cycle include an increased number of awakenings, vivid and more frequent dreams, and occasionally increased daytime fatigue and sleepiness.
Pregnancy-related sleep disruption is widely reported by nearly all pregnant patients, and complaints include poor sleep quality with frequent awakenings and increased daytime sleepiness despite increased sleep time. These pregnancy-related changes in sleep are largely felt to be related to changes in progesterone levels. Later in pregnancy, many complaints are secondary to the physical discomfort associated with the third trimester.
Through menopause the sleep pattern changes normally as well. Typically, the amount of deep sleep decreases, sleep is generally lighter and thus is associated with an increased number of awakenings at night. The immediate period surrounding menopause usually carries the greatest number of complaints secondary to hot flashes and night sweats.
In terms of specific primary conditions, insomnia tends to be one of the most common complaints in women. Much of the insomnia can be related to certain hormonal changes, psychosocial influences and secondary medical problems. However, women compared to men have been found to respond equally well to common therapeutic interventions including pharmacologic and non-pharmacologic interventions.
Common successful non-pharmacologic interventions include reinforcing proper sleep hygiene, stress reduction techniques, screening for depression and anxiety, and counseling.
Restless legs, a condition of chronic nightly discomfort in the legs which can lead to insomnia and sleep disruption, has an increased incidence in women compared to men and can be more prevalent during pregnancy. Interestingly, there is an association between restless legs and iron-deficiency anemia, which is common in menstruating females. Restless legs generally can be easily controlled with dopaminergic agents or benzodiazepines in women and men.
Sleep apnea is certainly less common in women than in men in younger age groups, but the incidence of sleep apnea in women nearly equals that of men once women approach their sixth decade of life. Interestingly, recent studies have shown that changes in estrogen and progesterone levels that occur after menopause can directly lead to an increased incidence of sleep apnea syndrome. This is also found to occur in women who undergo surgical menopause and seems to be delayed in those who remained on estrogen and progesterone replacement after menopause. This increased incidence in sleep apnea occurs secondary to a reduced muscle tone and increased collapsibility of the airway in response to reduced estrogen levels.
The health consequences of untreated sleep apnea, including increased risk of heart disease, heart attacks, heart failure, recurrent arrhythmias, strokes, and lung diseases is equally shared by men and women. On a positive note, these risks are equally reduced in men and women when sleep apnea is optimally treated.
Overall, poor sleep, as measured by the number of hours slept, is associated with a higher mortality. It has been demonstrated that people who sleep more than eight hours a night or are unable to achieve at least six hours have an increased mortality. Recently, this was extended to a study of just women and had the same conclusion.
In summary, sleep disorders are a common affliction of women that are unique in many ways when compared to sleep disorders in men. However, the health consequences associated with poor sleep and sleep disorders are equally shared by women and men. As sleep physicians, we would recommend considering routine screening of patients for sleep disorders and would highlight that many women may present with atypical complaints of sleep disorders, including chronic fatigue, depression, and chronic pain as well as more typical complaints of excessive daytime sleepiness or sleep disruption.
Research Offers New Insight
Over the last two decades the growth in knowledge regarding sleep disorders and sleep medicine as a field has been explosive. Much of the initial work centered on men, and those results were then generalized to women. Recent work, however, has highlighted both differences and similarities between the sleep disorders encountered by women and men.
Like men, women complain of more sleep problems as they age. The incidence of sleep complaints, however, affects a far greater percentage of women than men, anywhere between 14 and 30 percent. This increased incidence is reflected by a larger number of women suffering from insomnia; sleep disruption associated with premenstrual symptoms, pregnancy, and menopause; sleep disruption from an increased incidence of other chronic illnesses such as fibromyalgia and arthritis; sleep disruption related to their psychosocial environment; as well as other sleep disorders including restless legs and sleep apnea syndrome
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