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Abstract
Good quality sleep is important for optimal daytime performance and mood.
Women have better sleep quality (shorter sleep onset latency , higher sleep efficiency) compared with men. Despite this, women have more sleep related complaints than men. Different stages in the reproductive life cycle of women (menstrual cycle, pregnancy, post partum, menopause transition, and post-menopause ) are associated with alterations in sleep patterns.
Menstrual Cycles
During menstrual cycles prominent changes in reproductive hormones and body temperature occur. The follicular phase is when estrogen is the predominant hormone; after ovulation, the luteal phase lasts 14–16 days and is when concentrations of estrogen and progesterone are high and body temperature is elevated (about 0.4 oC) compared to before ovulation. The withdrawal of both estrogen and progesterone precedes menstruation. It is during the late luteal (premenstrual) phase and the first few days of menstruation that most negative menstrual symptoms are experienced.
Based on a few controlled laboratory studies in young women with no menstrual-associated complaints and for ovulatory cycles, sleep across the menstrual cycle is remarkably stable. There is a small variation in rapid eye movement (REM) sleep, which tends to decrease in the luteal phase compared to the follicular phase. Although there is no clear-cut difference in sleep architecture, effects on sleep spindles have been observed, with increased EEG power density in the frequency range of sleep spindles (around 14 Hz) during NREM sleep in the luteal compared with the follicular phase. This effect on sleep spindles has been proposed to be an influence of progesterone via the γ- aminobutyric acid (GABAA ) receptor.
Using self-report data, about 70% of women report that their sleep is affected by menstrual symptoms such as bloating, tender breasts, headaches, and cramps, on average 2.5 days every month. Even young women without significant menstrual-associated complaints report poorer sleep quality 3–6 days premenstrually and during 4 days of menstruation compared to other times of the menstrual cycle. Mood, discomfort, and pain can affect sleep during this period.
Premenstrual Symptoms and Premenstrual Syndrome (PMS)
Many women experience premenstrual disturbances that vary in severity and type of symptom. Approximately 60% of women experience mild PMS symptoms, but for 3–8% of women the symptoms are severe and acknowledged as a clinical mood disorder—premenstrual dysphoric disorder (PMDD). Common
symptoms that occur in the last week of the luteal phase and lessen after the onset of menstruation include irritability/anger, anxiety/tension, depression and mood swings, change in appetite, bloating and weight gain, and fatigue. Sleep disturbances include insomnia, hypersomnia, unpleasant dreams, awakenings during the night, failure to wake at the expected time, and tiredness in the morning. However, no significant, reproducible effects on sleep have been found in the few studies with small sample sizes on women with PMS/PMDD.
Primary Dysmenorrhea
Women with Primary dysmenorrhea complain of poorer sleep quality and higher anxiety during menstruation compared to symptom-free women Polysomnographic (PSG) data indicate that women with Primary dysmenorrheal experience less efficient sleep (ratio of time spent asleep to time of PSG recording of time in bed) and more wakefulness than women without painful menstrual cycles .turn, the disturbed sleep may worsen mood and alter the pain threshold.
Polycystic Ovarian Syndrome (PCOS)
Women with PCOS are more likely to develop obstructive sleep apnea (OSA)—a condition associated with snoring, repeated cessation of breathing, and daytime sleepiness. In PCOS menstrual cycles are irregular or absent and the ovaries produce too much of the male sexual hormones (androgens), which causes infertility, facial hair, and weight gain. Increased sleep disordered breathing has been correlated with waist–hip ratio and testosterone in women with PCOS.
Oral contraceptives
Oral contraceptives suppress endogenous reproductive hormones, preventing ovulation; hence, the women taking them do not have normal menstrual cycles. They do not appear to influence subjective sleep quality , but do alter sleep architecture. Women taking oral contraceptives have less SWS , more Stage 2 sleep, a shorter REM onset latency, and more REM sleep, compared with women with natural menstrual cycles. Exogenous steroid hormones therefore appear to exert a different influence on sleep than endogenous progesterone and estrogen
Pregnancy and The Early
Postpartum Period
Getting enough sleep is especially important during pregnancy. During the first trimester, sleepiness increases due to the rise in progesterone, but it also brings on sleep disruption due to morning sickness— waking with nausea, increased urinary frequency, and breast tenderness. The second trimester has been described as more of a settling in period when sleep can improve. However, at this time snoring may start, some women experience heartburn, and leg cramps or restless legs syndrome (RLS) may begin. The third and final trimester is when sleep is most disrupted. Problems include difficulty getting comfortable (many women will sleep on their side with a pillow between their knees), heartburn, leg cramps, snoring, increased need to urinate, more time awake, and morning fatigue.
Polysomnographic studies confirm that women have more frequent awakenings and wake time starting from the first trimester and most evident in the third trimester. However, it is in the first month following delivery that the greatest degree of maternal sleep disruption is found. There is a gradual increase in maternal sleep time over the next 2–4 months with maturing of the infant’s circadian rhythm, but studies indicate that sleep efficiency continues to be lower than prepregnancy. The decline in sleep efficiency is greater in first-time mothers compared to multiparous women. Breast-feeding compared with bottle-feeding has been found to influence sleep, with increased slow-wave sleep, possibly due to high prolactin levels.
Snoring and Obstructive Sleep Apnea (OSA)
While anatomical changes during pregnancy such as weight gain, decreased respiratory functional reserve capacity, and rhinitis (due to estrogen) predispose women to developing SDB, physiological changes—importantly increased respiratory drive (due to progesterone) and a preference for sleeping on their side—may offer protection. Some women begin to snore during pregnancy. Snoring, with complaints of sleep disruption and/or excessive day-time sleepiness, should be treated very seriously due to a higher risk for developing preeclampsia (high blood pressure, swelling especially in the ankles, protein in the urine, headaches) and sleep apnea. OSA may start or worsen during pregnancy, which is of concern as the periods when breathing stops lead to disrupted sleep and decreased blood oxygen levels that can also adversely affect the fetus.
Restless Legs Syndrome (RLS) and Periodic Limb
Movement in Sleep (PLMS)
Leg cramps can develop during pregnancy with about 15% of women reporting symptoms of RLS in the first trimester to 23% in the third trimester. RLS is an irresistible urge to move the legs, especially in the evening and with rest. The feeling of leg discomfort is reduced by movement (e.g., getting up and walking), so that people experience difficulty getting to sleep. If the movements and twitches continue through the night with PLMS, sleep becomes fragmented and this in turn leads to day-time sleepiness. These symptoms generally go away with childbirth. Iron and folate deficiencies are known causes of RLS. Women who develop RLS during pregnancy should have their iron status checked and should probably be prescribed a multivitamin preparation containing folic acid.
Menopause and the transition
to menopause
Between the ages of 45 and 55 years (average 51 years), a woman’s production of estrogen and progesterone starts to decrease and the menstrual cycles become irregular. This transitional or perimenopausal period occurs over a few years (about 4–8 years)and is when up to 80% of women experience hot flashes—suddenly feeling hot then flushed enough to sweat. Hot flashes can be extremely uncomfortable: they can occur during sleep—night sweats that can soak bedclothes followed by chills as the body cools down—and lead to sleep disruption. Only when menstrual periods have stopped for a year is menopause confirmed.