What are the types of sleep dysfunction in women?

Updated: Jan 31, 2019
  • Author: Gila Hertz, PhD, ABSM; Chief Editor: Selim R Benbadis, MD  more...
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Sleep-disordered breathing

SDB involves various degrees of pharyngeal obstruction ranging from UARS to OSA. Obstruction results from high negative pressure generated by the inspiratory effort and failure of the dilating upper airway muscles to maintain airway patency.

Contributing factors are degree of muscle atonia and various anatomic abnormalities that increase airway occlusion (eg, enlarged tonsils, macroglossia, even nasal congestion). Obesity is a known risk factor for OSA. Women with OSA are likely to be more obese than men, though fat distribution is different. The prevalence, nature, and severity of OSA in women changes with menopause.

Postmenopausal women have twice the rate of OSA that premenopausal women do. Women demonstrate more partial obstructive events (hypopneas) than complete OSAs. In addition, the duration of hypopneas, when present, tends to be shorter in women than in men. OSA is mostly evident during rapid eye movement (REM) sleep.

Regardless of age, OSA is less severe in women than in men. A possible explanation is the effect of a female hormone (probably progesterone) on the activity of the dilator muscle of the pharynx. [4] In a study performed in healthy women with regular menstrual cycles, upper airway resistance was found to be lower during the luteal phase of the menstrual cycle than the follicular phase. [5, 6] Progesterone levels are elevated during the luteal phase. [7]

Restless legs syndrome and periodic limb movement disorder

These are idiopathic disorders that can cause profound disruption. RLS, a waking disorder that usually occurs before sleep onset, is associated with discomfort in the calves causing restlessness in the legs, which is relieved by movement. RLS is more prevalent in women than men and occurs at higher rates during pregnancy.

Iron deficiency has been implicated in the pathophysiology of RLS. The possibility of a genetic basis has been suggested for primary RLS.

Periodic limb movement disorder (PLMD), occurring during sleep, involves isolated periodic movements of the lower limbs, usually followed by arousal from sleep. In severe cases, frequent leg movements can cause significant sleep interruption, resulting in complaints of insomnia or excessive sleepiness. [8, 9]


The 4 major features of narcolepsy are (1) daytime sleepiness, (2) hypnagogic hallucinations, (3) cataplexy, and (4) sleep paralysis. These features are related closely to features normally occurring exclusively during rapid eye movement (REM) sleep. The symptom of cataplexy, for example, which involves sudden loss of muscle tone during waking hours, is identical to muscle paralysis normally experienced during REM sleep. Thus, narcolepsy has been hypothesized to represent a dissociative process of REM sleep mechanisms and an intrusion of these mechanisms into waking hours.

Circadian rhythm disorders

The most common circadian sleep disorder is delayed sleep phase syndrome (DSPS), with typical onset at puberty. DSPS is characterized by a significant delay (3-4h) in bedtime and wake time in the presence of a normal overall total sleep time. DSPS may also relate to an eveningness chronotype, an individual preference for increased activity at night. A Spanish study, investigating chronotypes in students aged 18-30 years, has shown a greater preference toward eveningness in men. Thus, gender differences are possibly the result of sex influences on the regulation of the biologic clock.

REM sleep behavior disorders (RBD) [10, 11, 12, 13]

Once thought to be a male predominant disorder, recent findings suggest that REM sleep behavior disorder may be underdiagnosed in women because the intensity of the behaviors is less prominent than in men. RBD is classified as a parasomnia andpresents as vivid dreams with complex, repetitive, and often violent motor behaviors during REM sleep, which classically is a time of muscle atonia. Both patients and their bed partners are at increased risk of injury from these movements. RBD has been reported in 60-100% of patients with synucleinopathies. Idiopathic RBD has been associated with the development of Parkinson disease. In the study by Koo et al, women with sleep apnea had a higher prevalence of REM-related sleep disordered breathing compared with men, particularly in those women younger than 55 years. The women younger than 55 years were found to be more obese than those in the older age group.

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