Major Sleep Disorders Among Women

(Women's Health Series)

Sadeka Tamanna, MD, MPH; Stephen A. Geraci, MD


South Med J. 2013;106(8):470-478. 

In This Article


Insomnia includes difficulty falling asleep, inability to maintain sleep, and/or early-morning awakening, which negatively affects daytime function. Symptoms should be present for >1 month to diagnose insomnia, which is more common in women than in men. The American Insomnia Survey (7428 respondents) documented a prevalence of 27% in women (vs 19% in men), with substantial associated workplace costs.[2] A range of 10% to 15% of the US population complains of insomnia with resulting impaired daytime function and 30% of the population expresses dissatisfaction with the quality of their sleep.[3] Women are more likely to report sleep disturbances and are 41% more likely than men to experience insomnia.[4]

The reasons for these differences are incompletely understood. Menopause, late-luteal phase of the menstrual cycle, and third trimester of pregnancy are associated with a particularly high prevalence of insomnia,[5] with approximately 50% of perimenopausal woman reporting significant symptoms.[6] Chronic insomnia also is prevalent among cancer patients, especially women with breast cancer.[7]

Women also experience higher rates than men of depression, anxiety, and other psychiatric disorders that can contribute to insomnia, and persistent insomnia itself increases fourfold the likelihood of developing major depressive disorder.[4] Sleep restriction was found to cause aberration of the adrenocortical rhythm, increasing the risk of depression among women.[8–10] Sleep restriction also is associated with a 28% increase in the daytime level of the orexigenic hormone ghrelin, contributing to increased appetite and weight gain among patients with insomnia.[11]

The etiology of insomnia is multifactorial in most women. Insomnia and insomnia-related disorders are classified in the second edition of The International Classification of Sleep Disorders.[12]

The duration of sleep also varies between the sexes and whites and blacks. In the cohort of the Coronary Artery Risk Development in Young Adults (CARDIA) study, the average sleep duration was 6.7 hours in white women, 6.1 hours in white men, 5.9 hours in black women, and 5.1 hours in black men. Increasing income level was associated with increased sleep efficiency and low socioeconomic status with decreased sleep efficiency and increased sleep latency.[13]

Psychological and behavioral interventions are effective and recommended to treat insomnia. The American Academy of Sleep Medicine has developed a practice parameter for these treatments (Table 1).[14] Thirty percent of patients with insomnia have contributory poor sleep hygiene. Good sleep hygiene practices should be prescribed for all patients in addition to other treatments (Fig. 1) because sleep hygiene education alone is ineffective.[15]

Figure 1.

Sleep hygiene practices.12

The current Food and Drug Administration–approved pharmacological treatments for insomnia include benzodiazepine receptor agonists and melatonin receptor agonists. Potential adverse effects of the former include residual sedation, memory and performance impairment, falls, undesired behaviors during sleep, somatic symptoms, and drug interactions. A number of other prescription medications (eg, sedating antidepressants, antiepileptics) also are used off-label, as well as nonprescription drugs (eg, sedating antihistamines) and naturopathic agents (eg, melatonin, valerian) to treat insomnia, although safety and efficacy data are limited.[15]

In general, symptom pattern, previous treatment failure, comorbid conditions, adverse effects, and medication costs should be considered before starting a hypnotic regimen. Short- to intermediate-acting benzodiazepine receptor agonists or melatonin receptor agonists can be started initially. Medications can be changed or dosages increased based upon the degree of symptom improvement and adverse effects experienced (Fig. 2).[15] Because depression and insomnia are present more frequently in women than in men, selective serotonin reuptake inhibitors appear to be uniquely effective in their treatment.[16] Cognitive-behavioral therapy appears to improve insomnia in women with breast cancer;[17] however, there is no consensus on sex-specific insomnia treatment strategies for women.[16]

Figure 2.

Hypnotic management of insomnia. BzRA, benzodiazepine receptor agonist; SMI, sleep maintenance insomnia, SOI, sleep-onset insomnia. Adapted with permission from the American Academy of Sleep Medicine.12