Women and Sleep DisordersMen and women are different hormonally, physically, and emotionally. Some sleep disorders are seen with different frequency, and others present much differently when compared between the two sexes. One such case is obstructive sleep apnea which is seen more frequently in men until menopause, at which time the incidence in women increases until it becomes equal for both sexes. A man with apnea may present simply with loud snoring, while a woman more often presents with fatigue and insomnia.
After the first menstrual cycle begins and throughout the rest of life women have a greater incidence of insomnia and are more likely to use sleep aids. The incidence of sleep related eating disorders is greater. Restless leg syndrome is also more frequently seen in women and the risk of developing it increases with age. Women have a lower incidence of narcolepsy, REM Behavior Disorder, catathrenia (sleep related groaning disorder), and sleep enuresis (bedwetting).
Hormonal influences affect a woman’s sleep in a unique and dynamic process throughout her lifetime. Sleep is achieved faster under the influence of estrogen and both more REM and total sleep time are enjoyed. Alternately, progesterone decreases the amount of REM sleep. During the first half of the menstrual cycle estrogen levels rise while the second half of the cycle is dominated by progesterone. These two hormones fluctuate not only during this monthly cycle, but also throughout life during which female disorders, contraceptives, peri and postmenopause, and hormone replacement therapy all influence their levels.
Sleep issues may begin after the onset of the first menstrual cycle. Subjective sleep quality might be less just prior to and during the first several days of a period. Sleep efficiency is poorer during the last half of the cycle, and it may take longer to get to sleep. Oral contraceptives increase lighter, stage 2 sleep, while sometimes decreasing deeper, stage 3 sleep. During perimenopause, the amount of lighter stage 1 sleep increases and remains so during menopause. Unlike men, the amount of deep stage 3 sleep decreases at a much slower rate with aging in women. Hot flashes and night sweats caused by diminishing and fluctuating estrogen and progesterone levels may cause insomnia. This phenomena is also directly related to the environmental temperature just before going to bed (think twice about that hot shower!).
Hormone replacement therapy not only reduces hot flashes, but improves the amount and quality of sleep even in women who have never experienced these symptoms. Estrogen decreases insomnia and obstructive sleep apnea while progesterone decreases the time spent awake after initially falling asleep. This may sound too good to be true and indeed this is the case. Hormone replacement therapy is only recommended for intolerable vasomotor symptoms such as hot flashes due to the potentially serious side effects related to their use. Breast cancer, heart attacks, stroke, and blood clots are on the list. When used for the proper indications in low risk patients, and when managed appropriately they are of significant benefit.
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