Women are at greater risk of suffering from insomnia. Even among insomniacs, women tend to experience at least two insomnia symptoms, while men typically report just one symptom. Women also experience more sleep problems, sleep longer, and report needing more sleep than men. They prefer to go to bed earlier and are more likely to be morning types. They use sedative-hypnotic drugs more often. This is what women themselves report.
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What does sleep technology say? Sleep studies reveal that in fact women fall asleep faster and sleep better and deeper than man.
The following article contains everything you need to know about sleep disorders in women.
Menstrual Cycle–Associated Disorders
Obviously, the reason for the differences between men and women in regards to sleep have to do with the menstrual cycle (though some sex differences in sleep can be observed even among infants). Indeed, after the first menstrual cycle, the risk for insomnia increases for girls. Moreover, the risk of depression also increases, which in itself is a risk factor for insomnia.
The menstrual cycle is normally around 28 days long and can be divided into two stages:
- The first phase of the menstrual cycle begins with the first day of bleeding (day 1) and ends with ovulation (around day 14).
- The second phase begins after ovulation and results in pregnancy or a new cycle.
Women aged 18 to 50 report more sleep problems, a decrease in total sleep time, and more wake time, resulting in poorer sleep in the premenstrual week and first few days of menstruation.
During the second stage, among other changes, women experience less REM sleep (which is the stage of sleep characterized by vivid dreams).
Finally, many women experience mood problems, painful menstruation (dysmenorrhea), and endocrinological issues, such as polycystic ovary syndrome (PCOS), conditions which increase the likelihood of suffering from insomnia and excessive daytime sleepiness.
Here are some general suggestions to minimize menstrual problems:
- Eat a balanced diet – consisting mostly of plant-based whole foods, such as vegetables, whole grains, legumes, fruit, nuts, and seeds (especially flaxseeds). Eating plenty of fiber will prevent you from becoming constipated. Avoid alcohol, trans fats, refined vegetable oils, and meat (including poultry). If you must use sweeteners, honey is better than sugar.
- Get adequate exercise and sunshine.
- Avoid tobacco.
- Work toward emotional clarity.
- Avoid using oral contraceptives.
- Make sure you’re getting enough iron, magnesium, zinc, iodine, B vitamins (especially vitamin B6, folic acid, and vitamin B12), vitamin A, and omega-3 fatty acids.
During the menses in particular:
- Avoid heavy physical work
- Avoid emotional stress
- Avoid overexposure to cold and damp conditions by for example keeping your legs and feet warm, keeping covered when in cold places and during the cool seasons, and avoiding working with the hands in cold water
- Get plenty of rest
- Abstain from sex
Severe Dysmenorrhea (Menstrual Pain)
For some women, the menstrual pain itself causes sleep disturbances and increased wakefulness during the night.
Dysmenorrhea (painful menstrual cramps of uterine origin) is the most common gynecological condition, but for up to a quarter of women the pain may be severe.
In some cases (known as Secondary Dysmenorrhea or SD), an organic disease is causing the pains, such as endometriosis and pelvic inflammatory disease (PID), but most cases are Primary Dysmenorrhea (PD) with no underlying organic disease.
Possible risk factors of PD include obesity, anemia, chronic disease, overwork, stress, diabetes, and poor nutrition. Postsurgical adhesions and the IUD (contraceptive intrauterine device) are risk factors for SD.
Besides pain, symptoms may include nausea, vomiting, and increased stool frequency.
Women who experience severe menstrual cramps may experience more significant declines in sleep quality, including poorer subjective sleep quality, lower sleep efficiency, more awake time and light sleep, and less REM sleep (vivid dreams). The resulting sleep deprivation in turn may make the pain even worse as it lowers the threshold of pain.
Conventional treatment: Analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs).
Alternative therapies: Heat and dietary supplementation of thiamine or magnesium.
Make sure you’re getting enough calcium, magnesium, and omega-3 fatty acids in your diet.
Often psychological issues may be involved and in such cases should be worked out. Moreover, it may be possible to develop a higher tolerance to the pain. Mindfulness therapy for instance could be tremendously helpful.
Ginger apparently may be helpful too. Even just one-quarter of a teaspoon of ginger powder three times a day doesn’t only reduce the intensity of pain (as effectively as ibuprofen) but it also shortens the duration of pain and reduces the amount of blood lost.
When symptoms include coldness, keep the body warm and avoid raw, cold-temperature foods. Effective herbs include Angelica sinensis and spearmint (Mentha viridis).
When symptoms include heat, avoid animal products (including dairy and eggs) as well as sweet foods. Helpful herbs include black cohosh (Cimicifuga racemosa), motherwort (Leonurus cardiaca), and wormwood (Artemisia apiacea).
Other helpful herbal remedies include:
- Wild yam (Dioscorea villosa)
- Skullcap (Scutellaria lateriflora)
- Cramp bark (Viburnum opulus)
- Black haw (Viburnum prunifolium)
Herbal treatment for endometriosis often includes the following herbs:
- Vitex agnus-castus
- Wild yam (Dioscorea villosa)
- Cimicifuga racemosa
- Scutellaria lateriflora
Severe Premenstrual Syndrome (PMS)
Premenstrual syndrome (PMS) occurs just before menstruation. While many women (and their spouses) are familiar with the symptoms associated with PMS, up to 18% of women suffer from a distressing PMS which interferes with their daily function.
PMDD (premenstrual dysphoric disorder) is a severe form of PMS classified as a depressive disorder that occurs in up to 8% of women.
Symptoms: Insomnia, sleep perturbation by body movements and awakenings, disturbing dreams, nervousness, irritability, agitation, depression, anxiety, mood swings, poor sleep quality, sleepiness, fatigue, tension, pain, palpitations, tightening in the chest, hyperventilation, less alertness, and an inability to concentrate.
Causes may include: Hormonal imbalance, fluid retention, hypoglycemia, and magnesium deficiency.
Pharmacologic management of severe PMS/PMDD: Selective serotonin reuptake inhibitors (SSRIs), anxiolytics, and ovulation suppressants
Nonpharmacological approaches: Calcium supplements, L-tryptophan, and cognitive-behavioral therapy (CBT).
Experimental treatments for PMDD: Sleep deprivation and light therapy.
My own approach: Studies have shown that the poor sleep perception is positively correlated with anxiety levels, suggesting that it’s the mood which may be dictating perception of sleep. In fact, hook a woman suffering from PMS to a PSG (polysomnograph) and you won’t notice anything out of the ordinary… So change the mood, improve the mood by taking supplements, eating healthfully, exercising, and practicing meditation, and sleep would automatically appear better.
Changing your diet can help. For example, flaxseeds contain lignans, which can help with menstrual breast pain. Ginger too may help improve mood as well as physical and behavioral symptoms associated with PMS. Make sure you’re getting enough potassium in your diet by eating plenty of legumes, vegetables, and fruit.
If you crave carbohydrates during PMS, succumb to it. Eating even just one meal with lots of carbs and few proteins has been shown to improve the following PMS-associated symptoms: depression, tension, anger, confusion, sadness, and fatigue. However, make them healthy carbs, such as those found in fruit, legumes, and whole grains. Avoid refined sugar. In general you should try to consume a minimum 40% of your calories from carbs and only up to 30% from fat and no more than 1 gram (0.03 oz) of protein per every kg (2.2 lbs) of body weight.
Most importantly, women with severe PMS should avoid consumption of refined oils and animal products, including meat, poultry, dairy, and eggs, while increasing consumption of omega-3 oils (and perhaps GLA as well, a fatty acid found in human milk, but also in evening primrose oil).
Don’t eat too much food in general, and rich and fatty foods in particular. Avoid using too many spices (including salt), licorice, alcohol, chemicals, and drugs. Limit your caffeine intake especially when anxiety is a symptom. Limit the consumption of cold foods, oxalates (found mostly in chard, spinach, and beet greens), and your protein intake.
Helpful herbal remedies for symptomatic relief during PMS include:
- Scutellaria lateriflora
- Valeriana officinalis
- Taraxacum officinale leaf (if there is bloating and edema). Other useful diuretics include foods such as artichokes, asparagus, parsley, and watercress.
- Leonurus cardiaca (if there are palpitations)
Helpful herbal remedies to take consistently throughout the entire month to prevent severe PMS:
- Vitex agnus-castus
- Cimicifuga racemosa
Polycystic Ovary Syndrome (PCOS)
PCOS is associated with an increased risk for sleep-disordered breathing (SDB) and may occur in up to 12% of women. The risk of suffering from SDB is especially high when PCOS is coupled with obesity and excess male hormone production.
Symptoms: Irregular/absent cycles and male hormone excess (resulting in dark, course hair on the face, chest, and back).
Medical management: Control of irregular menses (typically with oral contraceptives), management of infertility if desired, management of sleep apnea with CPAP, and long-term management of insulin resistance and glucose intolerance when these are involved.
Vinegar may also help. I recommend consuming one tablespoon of cider vinegar with water right before (or with) every carbohydrate-rich meal. It will also help you consume less calories, which is great if obesity is a concern.
Drinking two cups of marjoram tea on an empty stomach every day appears to help as well.
Kleine-Levin Syndrome (KLS)
KLS, specifically Menstrual Cycle-related Hypersomnia, is a very rare condition which usually begins after the first menstrual cycle.
Symptoms: Persistent, excessive sleepiness during the week before or during menses. (18 hours of sleep per day is not uncommon for sufferers of this condition.)
Treatment: Oral contraceptives.
How is sleep affected by oral contraceptives?
Oral contraceptives are often taken for long periods of time by healthy women to prevent ovulation. They contain progestin and estrogen.
The effects of taking these hormones include: An increased body temperature, possibly a change in melatonin levels, experiencing REM sleep earlier in the night, as well as overall less deep sleep, and more light and REM sleep.
Taking oral contraceptives is far from ideal. At least women who suffer from sleep problems should probably try to avoid them.
Working nights can disrupt the circadian rhythm, causing medical problems. Women who work nights run the risk of suffering from more menstrual cycle irregularities, painful menstruation (dysmenorrhea), and longer menstrual cycles than women who don’t.
These reproductive issues may adversely influence sleep, causing sleep disturbances and difficulty falling asleep. They may also lead to fertility problems and increased risk for preterm birth.
Night workers also report significantly shorter sleep duration, more premature awakenings, and feeling less refreshed upon awakening.
The exposure to artificial light causes suppression of a hormone called melatonin, which is responsible for making us feel tired and ready to sleep when it gets dark. Melatonin naturally peaks in the dark hours, especially between 2-5 am.
Exposure to light during the night can reduce melatonin levels and exacerbate sleep disturbances.
A side note: There is an association between higher vegetable intake and higher melatonin levels in the urine. Meat may lower melatonin production, thereby potentially increasing breast cancer risk.
The suppression of melatonin not only disrupts the body’s ability to tell what time it is, but may also increase the risk of breast cancer since one of the functions of melatonin is to suppress cancer growth.
Even exposure to street light while sleeping may affect the risk of breast cancer, which is why I recommend sleeping in complete darkness.
A recent study suggests that shift workers exhibit a significantly longer total daily eating duration window which potentially can cause weight gain in women working nights. The authors of the study suggest limiting daily eating episodes to a 10-12 hour window “to optimize weight management in shift workers.”
Sleep disturbances (such as insomnia) which affect sleep quality and duration are very common from conception till birth, but especially during the third trimester.
Almost all women report waking up during the night, especially in the third trimester, causing a decline in sleep efficiency and REM sleep, and making sleep shallower.
Even if total sleep time is higher, that is usually due to daytime napping among pregnant women who can afford that. Nighttime sleep often decreases during pregnancy.
Women who never gave birth before, especially if they are employed, may have a higher risk for poor sleep quality and lower sleep efficiency than women with birthing experience.
Age is also a significant risk factor for sleep disorders in pregnancy (including RLS, SDB, and insomnia). Younger women sleep more during pregnancy than older women.
Among other prenatal supplements a pregnant woman ought to take, iodine is very important. It is recommended to take 150 mcg of iodine daily.
It is important to address any sleep disturbances during pregnancy because without proper management, they may increase the likelihood of pregnancy complications.
Why is It Important to Treat Sleep Problems in Pregnancy?
If you want to give your baby the best start possible, make sure you’re sleeping well. Sleep disorders during pregnancy are so common that many women believe they are normal. They are not, and they may hurt you and your child.
Untreated sleep disorders may result in:
- Excessive weight gain and obesity, which may lead to additional sleep disorders, such as SDB.
- Cardiovascular disease, including high blood pressure, which can lead to birth complications.
- High blood sugar or type 2 diabetes, which may cause birth complications as well as future development of type 2 diabetes, obesity, and cardiovascular disease in both mother and child.
- Pregnancy complications, such as longer and more painful labor and cesarean birth.
- Risks to the child: Fetal growth and development may be stunted. The risk of preterm birth, stillbirth, low birth weight, or miscarriage may increase. When the mother sleep well during pregnancy, it may even improve her baby’s Apgar scores.
- Effects on quality of life – Sleep problems during pregnancy may influence your energy levels, mood, interpersonal functioning, concentration, memory, depression, and ability to work efficiently.
Avoid caffeine, alcohol, smoking cigarettes, and other drugs and herbs, unless specifically prescribed for use during pregnancy.
Some medical conditions are known to interfere with pregnant women’s sleep, including:
- Preeclampsia (high blood pressure which begins during pregnancy)
- Affective disorders and other psychiatric disorders, including anxiety disorders
- Migraine headaches.
Let’s take a look at some of the most common pregnancy-related sleep problems.
The First Trimester (Week 1-12)
Immediately after conception, hormonal changes occur that influence sleep, including:
- Takes more time to fall asleep
- A longer total sleep time
- More awakenings during the night
- Increased urinary frequency
- Physical discomfort/pain
- Sleep is poorer and shallower
- Daytime sleepiness, drowsiness, and fatigue
- More frequent napping
In addition to these sleep-related changes, other hormonal effects include morning sickness and mood changes.
Progesterone levels increase during pregnancy, significantly increasing non-rapid eye movement (NREM) light sleep, resulting potentially in daytime sleepiness and fatigue. It may also make women fall asleep faster, increase their body temperature, start dreaming earlier, and reduce the total amount of REM sleep.
Estrogen is another hormone which has an affect on sleep. It may disrupt sleep by causing congestion, ankle edema, snoring, and RLS. It may also reduce REM sleep.
Prolactin levels increase as well, potentially increasing the amount of deep sleep.
Pituitary growth hormone (GH) is also secreted starting during the eighth week and peaking in the third trimester. It is associated with the deeper levels of sleep.
Relaxin levels peak at the end of the first trimester and may contribute to sleep disturbances in several ways, including: relaxation of the airway, carpal tunnel syndrome, and lower back pain.
Make sure you’re getting enough minerals and vitamins. Asparagus and celery are said to be especially helpful, but all vegetables, fruit, nuts, and seeds as well as whole grains and legumes should be eaten. Have small meals often to avoid drops in blood sugar, especially if you suffer from morning sickness. Avoid refined sugar. Drink lots of water and exercise daily. Sleep as much as you need.
The Second Trimester (Week 13-27)
By the second trimester, many women experience some improvements, including less fatigue, urinary frequency, nocturnal awakenings, and daytime sleepiness as well as more energy and better sleep efficiency.
Leptin levels peak during this trimester. When sleep is too short or too long, it may result in altered levels of leptin, which is involved in regulating body fat, energy expenditure, and fetal growth.
By the end of this period, however, women may experience the following symptoms:
- More nocturnal awakenings
- Shallower sleep
- Sleep disruption due to snoring, heartburn, pain, fetal movements, leg cramps, and RLS
- Vivid dreams
- Daytime sleepiness and fatigue
- Nasal congestion may be experienced during the day, potentially contributing to sleep-disordered breathing.
A physical yoga practice can be helpful during this stage and the next, as well as plenty of rest, deep breathing, and relaxation exercises. Avoid smoking and alcohol.
The Third Trimester (Week 28-40)
By now, sleep is significantly disturbed. It takes longer to fall asleep. Total sleep time may increase slightly during this period, but so do the number of naps as well as the time spent awake or in light sleep during the night. Overall, nighttime sleep decreases. Moreover, sleep efficiency, deep sleep, and REM sleep may decrease.
This period has the highest prevalence of pregnancy-associated insomnia due to waking up to urinate, leg cramps/RLS, GERD, fetal movements and general discomfort, and psychological/interpersonal issues, such as anxiety, relationship problems, etc.
During daytime, women in the third trimester may experience fatigue, drowsiness, impaired vigilance, difficulties with attention, concentration, and memory, and nasal congestion. Napping becomes more frequent.
At night, they may suffer from increased urinary frequency, physical discomfort and pain, shortness of breath, heartburn, dreams and even nightmares, snoring, and restless legs.
The reason for these problems is obvious: The rapidly growing uterus is causing physical changes in addition to hormonal fluctuations.
Levels of cortisol, the stress hormone, start to increase, and can lead to sleep loss, less rapid eye movement (REM, or Dream) sleep, and for some women, to more deep sleep. That sounds not too bad, right? The problem with cortisol is that it can damage brain cells involved in learning. It is also a risk factor for pregnancy-associated insomnia.
Also, melatonin levels increase in the third trimester.
Oxytocin, a hormone which promotes uterine contractions and lactation, reaches its highest levels at night. While it may promote sleep, in high concentrations it could actually cause wakefulness.
If hypertension is an issue (and even if not), make sure you avoid stress, rest as much as you need, maintain a healthy weight, exercise, practice meditation, do not use any drugs and stimulants including coffee and nicotine, and avoid processed foods. Your diet your should emphasize plant based whole foods with plenty of water.
During labor and immediately after delivery, total sleep time (both REM and NREM) and sleep quality and efficiency decrease. Other than anxiety, women commonly experience uterine contractions during the night (causing awakenings and sometimes an inability to sleep even with sleeping pills) and fatigue and pain during the daytime.
A useful herb for a easier, safer, and quicker childbirth is raspberry leaf (Rubus idaeus).
Postpartum and Early Motherhood
Sleep is greatly disturbed due to infant care and feeding demands and altered circadian rhythms during the first few months after giving birth (especially for first-time mothers), making the new mother sleepy and fatigued during the daytime. There is often a tendency to sleep later into the morning hours or take naps and sleep may become deeper.
Severe sleep loss during this period may lead to:
- Retention of pregnancy weight gain
- Postpartum depression
- Poor maternal-infant interactions
- Potential risk to the health and safety of the newborn.
Management: Find ways to more quickly facilitate the newborn’s sleeping throughout the night (for example, by daytime light exposure, keeping the cradle close to the parents’ bed, using a white noise machine, and avoiding bright lights and screens close to bedtime). Exercise and diet to avoid weight retention/becoming obese.
Returning to work (or regular routine) as early as possible appears to be beneficial for both mother and child.
Make sure you don’t suffer from anemia, common infections, and thyroid dysfunction.
In severe cases (especially when depression is involved), CBTI (cognitive-behavioral therapy for insomnia) may be effective.
Raspberry leaf (Rubus idaeus) continues to be helpful during this period as well, especially for breastfeeding women.
Research shows there may be an association between poor sleep continuity and the inability to sustain sensitivity toward infants. So if you care about the quality of care-giving your child gets, make sure to get enough sleep. Interestingly, the quality of maternal bonding may even influence how well your child will sleep as a grown-up.
Breastfeeding or Formula Feeding – Which is Better?
While there’s no proof that breastfeeding helps with sleep, women who breastfeed do generally experience more REM and deep sleep, less light sleep, and fewer arousals than those who don’t.
There is no evidence that formula provides any sleep benefits over breastfeeding.
Is Bed/Room-Sharing Recommended?
The American Academy of Pediatrics and the Canadian Paediatric Society recommend that the infant and parents share the same room.
The advantages of bed-sharing (cosleeping) is that it may be associated with longer duration of breastfeeding and lower risk of sudden infant death syndrome (SIDS).
On the other hand, the risk of SIDS or asphyxiation may increase when it is very hot, pillows and soft surfaces are used, or when the adults are smokers, extremely fatigued, intoxicated, or obese. Moreover, the sleep of bed-sharing mothers is often disrupted with more arousals and shallower sleep.
Postpartum depression is the most common complication of childbirth with approximately 13% of women suffering from it.
Symptoms: Excessive and unpredictable crying episodes, mood imbalances, sadness, difficulty sleeping when the baby is sleeping at night, and worrying about hurting the baby.
Causes may include sleep deprivation (during the pregnancy and after giving birth), poor sleep quality, and disrupted sleep-wake cycles (of both mother and child).
Risks include a negative impact on maternal-infant bonding, marital satisfaction, and infant development. In rare cases (especially among women with bipolar disorder), it may lead to postpartum psychosis and insomnia.
Management: Treatment of infant sleep problems and developing healthy infant sleep patterns. In extreme cases, cognitive-behavioral therapy, total or partial sleep deprivation, and light therapy may help. It’s also important to get frequent breaks from parenting and enjoy a social life.
Artemisia vulgaris and Hypericum perforatum are two herbs which may help with postpartum depression.
Menopause begins after 12 months of amenorrhea (complete cessation of menstruation), usually around age 40-60 years. It ends several years after complete cessation of menstruation.
It can divided into several stages:
- Early menopausal transition and perimenopause – Increased variability in length of menstrual cycle (by 7 days or more in the length of consecutive cycles).
- Amenorrhea for at least 2 months. Breast tenderness, hot flashes, night sweats, and sleep difficulties become more common.
- Early postmenopause – lasting 5 to 8 years.
- Late postmenopause.
Menopause can also be induced surgically by removal of both ovaries. Surgical menopause may entail an increased risk for more severe hot flashes, depression, or anxiety, and therefore for sleep problems in comparison with natural menopause.
During menopause, there is an increase in sleep disturbances, such as insomnia and intermittent awakenings during the night, especially among neurotic women.
Moreover, the incidence of depression may increase, which can contribute to sleep problems as well, such as difficulty falling asleep and declines in total sleep time and sleep efficiency.
Anxiety and stress (e.g. over financial matters, jobs, family responsibilities, relationships, etc.) may lead to poor sleep quality and difficulties falling asleep in midlife women.
Menopausal women also appear to have an increased risk for development of sleep apnea, restless legs syndrome, and periodic limb movement disorder.
As is the case with women in reproductive age, during menopause too objective measures do not reflect the worsening of sleep during this time. In fact, sometimes improvements are observed in the depth and continuity of sleep.
Causes of sleep disturbances during menopause: Hot flashes, night sweats, leg cramps, obesity, gastroesophageal reflux, chronic pain, hormonal changes, depression, anxiety, perceived poor health, stress, caffeine, smoking, and conditions common during menopause such as cancer (breast cancer in particular), arthritis, fibromyalgia, and thyroid disease (e.g., hypothyroidism).
Having young children at home or grown children leaving home, having to care for elderly spouse/parents, increasing career demands, changes in lifestyle, weight gain, and chronic health conditions may also contribute to sleeping problems during this period.
Sleep disorders, such as obstructive sleep apnea, periodic limb movement disorder, and restless legs syndrome, are additional sources of sleep disturbance during menopause.
Treatment: Hormone therapy (HT) can help when hot flashes are highly disruptive, but only for a short time since it may increase the risk of breast cancer, stroke, heart disease, and dementia. (Withdrawal should probably be done gradually.) Antidepressants (such as escitalopram, venlafaxine, and paroxetine), a synthetic neurotransmitter known as gabapentin, and sleeping pills (e.g., zolpidem and eszopiclone) are also sometimes prescribed.
Nonpharmacologic approaches: Cognitive-behavioral therapy for insomnia (CBTI), maintaining a healthy body weight through proper diet and exercise, and CPAP when there are breathing problems. It is important that your life is relaxed and free of stress as much as possible.
Regarding diet, it may help to consume more soy beans, which can help reduce menopausal hot-flush symptoms. A tablespoon of rice vinegar per day may help too. Make sure you’re getting enough vitamin E, B vitamins, vitamin C, vitamin A, vitamin D, magnesium, and calcium.
Avoid alcohol, nicotine, and animal products, and emphasize whole grains, legumes, seeds and nuts, fruit, and vegetables.
Herbs which can help include Angelica sinensis and the spice saffron. Aloe vera gel can help with heat symptoms. Royal jelly is also said to be beneficial.
Other useful plants include:
- Vitex agnus-castus – Especially helpful for hot flashes.
- Motherwort (Leonurus cardiaca) – When tachychardia accompanies the hot flashes.
- Black cohosh (Cimicifuga racemosa)
- Hypericum perforatum – When depression or distress is involved.
- Life root (Senecio aureus)
Along with menopause, various health conditions may develop, which can interfere with sleep (and to which poor sleep can contribute and exacerbate their severity), including:
- Cancer (especially of the breast, lung, colon, ovary, gallbladder, or thyroid) – may involve pain, discomfort, hot flashes, depression, and anxiety. Medical treatment may in itself possess sleep disrupting side effects (e.g., nausea, vomiting, diarrhea, and urinary frequency.)
- Neurological disorders – Neurodegenerative conditions such as Parkinson’s or Alzheimer’s disease in particular may cause sleep disruption.
- Cardiovascular/lung disease (e.g., hypertension) – Especially among obese women or those suffering from SDB.
- Thyroid Dysfunction – Hypothyroidism involves tiredness and fatigue, and may cause SDB.
- Gastroesophageal reflux disease
- Musculoskeletal disease – In fibromyalgia for instance there is widespread pain, tender points, as well as sleep disturbance and fatigue.
Sleep Disorders in Women
While women are at greater risk for developing insomnia and restless legs syndrome than men, they have a lower risk for obstructive sleep apnea (OSA).
During pregnancy, sleep disorders, such as insomnia, SDB, and RLS, can occur or worsen and pose serious consequences for both maternal and fetal health.
Women have a shorter circadian period, meaning their melatonin levels may peak earlier. This can result in sleep-maintenance insomnia, where one wakes up too early, and cannot go back to sleep.
If you’re pregnant (or gave birth recently) and experience difficulties in falling asleep (or remaining asleep), making you tired and irritable the following day, then you may be suffering from pregnancy-associated insomnia.
Risk factors include having too many responsibilities preventing you from getting the rest you need, napping during the day, sleeping in a noisy or illuminated environment, spending more awake time in bed, being stressed or anxious, smoking, and drinking more caffeine.
Weight gain and obesity can also contribute to insomnia by causing nighttime awakenings due to breathing problems.
Do not ignore your symptoms or they may last even after you give birth. However, do not use sleeping pills (unless prescribed by a sleep specialist) or alcohol to avoid adversely affecting the fetus.
Treatment: Behavioral and cognitive therapies, such as cognitive-behavioral therapy for insomnia (CBTI), improving sleep hygiene, relaxation techniques, and implementation of lifestyle modifications such as regular exercise and avoidance of smoking and alcohol. Mindful yoga, acupuncture, massage, and some herbal or dietary supplements such as chamomile tea or lavender pillows may help too.
If nothing helps, you should see a sleep specialist and ask if you may take sleeping pills such as diphenhydramine or doxylamine, medications which are unlikely to harm the fetus.
Women going through the menopause transition have a higher risk of suffering from insomnia disorder (especially if they had preexisting insomnia), including a chronic difficulty initiating sleep and nonrestorative sleep along with sleep dissatisfaction.
The risk is especially high in women who suffer from hot flashes, night sweats, chronic pain, and poor health.
Restless Legs Syndrome (RLS)
In restless legs syndrome (RLS), uncomfortable sensations are felt (that are not caused by positional discomfort), which temporarily cease only upon moving the legs. They mostly occur during the night, causing sleep disruption.
RLS is more common in women than men, especially pregnant women (the more pregnancies a women had, the higher her risk for RLS.) Menopause increases the prevalence and severity of symptoms. Changes to levels of estrogen may be responsible as well as iron deficiency. Moreover, RLS is often comorbid with disorders such as migraine, depression, and anxiety, to which women are particularly prone.
Management/Treatment: Make sure you’re getting enough sleep as well as essential minerals and vitamins, especially vitamin D, magnesium, and iron. Avoid drugs which may be causing the condition, including antidepressants, caffeine, nicotine, and alcohol.
Pregnancy-Related Restless Legs Syndrome (Willis-Ekbom Disease)
Pregnancy-related restless legs syndrome may be caused by deficiencies (for instance of ferritin, iron, and folic acid) and hormonal changes, and is especially common during the third trimester. Family history, depression, older age, heavier weight, smoking, peptic ulcer disease (PUD), varicosities, SDB, and previous births are also associated with RLS.
Other risk factors:
- Medications (e.g. SSRIs, antihistamines, and antiemetics)
- Sleep deprivation
RLS reduces the total sleep time and may make it more difficult to fall asleep and remain sleeping throughout the night, resulting in more daytime sleepiness than in women without RLS.
RLS sometimes comes with another condition known as periodic leg movements in sleep disorder (PLMD), in which while sleeping one rhythmically extends the big toe and flexes the ankle, occasionally flexing the knee and hip. This obviously disturbs sleep by causing brief arousals or insomnia and by consequence daytime sleepiness.
Management/treatment: Iron/folic acid supplementation. It is also imperative to maintain good sleep hygiene, including avoiding caffeine, alcohol, and nicotine. Relaxation techniques, walking, stretching, massage, and applying heat may help. In extreme case, low doses of sleeping pills may be prescribed by sleep specialists. Melatonin may help with PLMD.
Pregnancy-related RLS typically resolves after giving birth or a few days beforehand.
RLS/PLMD during Menopause
Restless legs syndrome (RLS) and period limb movement disorder (PLMD) become more prevalent and the symptoms worsen with age, especially among women.
Sleep-Related Leg Cramps
Sleep-related leg cramps are painful muscle contractions in the foot or leg which occur during sleep, causing a sudden awakening with pain that can prevent returning to sleep for hours. They are relatively common and increase in frequency as the pregnancy advanced. By the third trimester, up to 75% of women may suffer from these muscle spasms.
Management: Hyperextension to counter the contraction during the cramp, leg massage, reducing intake of phosphorus (contained in milk and meat), and getting enough magnesium and vitamin B. (Thiamine or B1 and pyridoxine or B6 in particular.)
Nocturnal Gastroesophageal Reflux Disease (GERD)
If after eating a large meal, after eating certain types of foods, or lying down immediately after eating, you experience your gastric contents enter the esophagus, indigestion or heartburn, acid taste, or regurgitation, then you may be suffering from GERD, or gastroesophageal reflux disease.
Other symptoms include: Nausea, vomiting, chest discomfort, coughing, choking, sore throat, and hoarseness.
Pregnancy can make an existing GERD worse, but for most women, it causes GERD. Many women start experiencing this unpleasant condition during the third trimester. It resolves with the birth.
GERD can obviously disrupt sleep.
Management: Temporary modifications to diet and lifestyle, such as not eating within 3 hours of bedtime, drinking plenty of fluids, avoiding spicy, acidic, and fried foods, and eating smaller, bland meals more frequently. Avoid tobacco and alcohol.
Sleeping upright with more pillows (or on a recliner chair) to support the upper body or sleeping on the left side with the head elevated may also be a good idea.
Antacids may be helpful, but never take any medications without consulting with a sleep specialist.
Parasomnias are unconscious behaviors or events that occur during falling asleep or arousals.
They can occur during REM sleep (dreaming) and manifest as sleep paralysis, nightmares, or REM sleep behavior disorder.
When they occur in other times, they may manifest as confusional arousals, sleepwalking, or sleep terrors.
Sleepwalking is more common right before menstruation.
Another dangerous parasomnia, sleep-related eating disorder (SRED), involves eating and drinking during sleep. It is more common in women than in men.
Nightmares are common among women who are suffering from acute stress disorder (ASD) or post-traumatic stress disorder (PTSD).
Are parasomnias more common during pregnancy?
The incidence of sleep paralysis may increase during the second half of pregnancy
As for sleepwalking, sleeptalking, hypnagogic hallucinations, and sleep bruxism – they actually seem to decrease during pregnancy.
Dreaming in general may increase for some women, and you may even have a bad dream or even nightmares concerning the infant or pregnancy. If this happens more than you’re comfortable with, then get help because it often involves confusional arousals, interfering with the quality of sleep. Dreams may be more vivid, detailed, strange, or disturbing.
The reason for the increase in disturbing dreams (and other parasomnias) which some women experience during pregnancy may have to do not just with hormones such as cortisol, but may result from fragmented sleep (e.g., due to breathing problems), anxiety, and stress.
Management involves maintaining good sleep hygiene, reducing stress and sleep deprivation, and securing the bedroom. Relaxation techniques may help.
Symptoms of narcolepsy include excessive daytime sleepiness, cataplexy (sudden loss of voluntary muscle tone), hypnagogic hallucinations, and sleep paralysis.
Narcolepsy usually emerges during young adulthood, affecting women in the reproductive phase of life. During pregnancy, symptoms may either worsen or improve. Narcolepsy drugs should be avoided.
Obviously, cataplexy in particular would be highly dangerous during pregnancy.
Treatment often includes taking scheduled daytime naps, stress management, avoiding problematic situations, and improving sleep hygiene. It is important to remain physically active in a controlled environment to avoid becoming obese and having breathing problems.
Sleep-Disordered Breathing (SDB)
Premenopausal women are at lower risk for development of SDB, due in part to a protective effect of sex steroids on the upper airway.
Sleep-Disordered Breathing (SDB) in Pregnancy
Pregnant women may be particularly predisposed to obstructive sleep apnea and other major sleep-related breathing disorders
Sleep-disordered breathing (SDB) symptoms are common during pregnancy and worsen as the pregnancy progresses. It can result from added abdominal weight gain, nasal congestion (pregnancy rhinitis), and changes in the respiratory system which are caused by hormones beginning early in the first trimester and increasing progressively throughout the pregnancy.
Risk factors include smoking, obesity, high pre-pregnancy BMI, older maternal age, chronic hypertension, diabetes, previous preeclampsia, and twin pregnancies.
Symptoms: Habitual snoring, chronic hypertension, gasping, choking, difficulty breathing (pauses during sleep), frequent awakenings, sleep deprivation, and excessive daytime sleepiness.
It is important to treat SDB because otherwise it may increase the risk of complications including cesarean delivery, preterm birth, miscarriage, fetal malformations/abnormalities, and stillbirth, impair the growth of the fetus, and cause obesity, diabetes, inflammation, preeclampsia, hypertension, too much fat in the blood, and even death.
According to a 2019 study, during the late stages of pregnancy, women who suffer from obstructive sleep apnea and have no history of depression appear to be more prone to experiencing depressive symptoms, while in those women with a history of depression, OSA may increase depressive symptoms.
Treatment/management: Spend less time sleeping in the supine position. Use continuous positive airway pressure (CPAP) or dental devices.
Sleep-Disordered Breathing during Menopause
Menopause is believed to be a risk factor for obstructive sleep apnea due presumably to excessive weight gain, changes in body fat storage that occur during this period, and hormonal changes.
Prevention/Treatment: While HT (hormonal therapy) may work for some women, CPAP is the preferred treatment as it is safer and more effective. Proper diet and ample exercise and important too in order to maintain a healthy weight. Avoid sleeping pills and alcohol.