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.

Conclusions

Sleep disorders are far more common in women than previously appreciated and presenting symptoms often differ from those in men. Although insomnia itself is more prevalent among women, it can constitute an atypical presentation of other sleep disorders such as OSA in women. Women often are incorrectly diagnosed as having and been treated for anxiety, depression, chronic fatigue, and psychosomatic disorders when having OSA instead. Postmenopausal women carry a higher risk for OSA and should be screened with a comprehensive sleep evaluation and sleep study if these symptoms are present. Cardiovascular risks of untreated OSA are high and women should be aware of their individual risks. PAP therapy should be offered to women with OSA and other treatment options should be discussed if they fail to improve with optimal PAP therapy. RLS is common among women of all ages, but it is more frequent during pregnancy. Correction of iron deficiency and use of dopaminergic medications can be helpful for treatment.

Sleep is essential for women to live a functional, productive life. Diagnostic evaluations should be performed and, if needed, treatment prescribed when sleep is disturbed.

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Table 1. CBT for insomnia¹⁴
Elements	Description
Cognitive therapy	Aimed at changing patient's belief and attitudes about insomnia
CBTI	Combined cognitive therapy and behavioral techniques; the behavioral component may include stimulus control and/or sleep restriction therapy with or without use of relaxation therapy
Sleep hygiene education	Making patient aware of health practices and environment, but not a standard recommendation for using it as single therapy.
Relaxation training	Progressive muscle relaxation and guided imagery rehearsal
Stimulus-control therapy	Training patient to reassociate bed and bedroom with sleep and reestablish a consistent sleep-wake schedule
Sleep-restriction therapy	Limiting time in bed, creating mild sleep deprivation, and then lengthening sleep time as sleep efficiency improves
Paradoxical intention	Instructing patient to passively remain awake and avoid any effort to fall asleep; the goal is to eliminate performance anxiety
Biofeedback	Visual or auditory feedback to help control physiological variable to reduce arousal
Multicomponent therapy	Multiple behavioral techniques without cognitive therapy

CBT, cognitive-behavioral therapy; CBTI, cognitive-behavioral therapy for insomnia.

Table 2. Selected sleep apnea clinical trials in which the majority of participants were women
Authors	Type of study	Study participants	N	Length of study		Study outcome
Mortality
Campose-Rodroguez et al 2012⁴⁸	Prospective observational	CPAP treated vs untreated	1116 women		72 mo	Severe OSA is associated with CV death in women and CPAP reduces death rate (P < 0.001)
Yeboah J et al 2011⁵⁰	Prospective observational	Sleep apnea vs snorers vs normal participants	5338: 2643 men, 2695 women		7.5 y	Physician-diagnosed sleep apnea but not habitual snoring was associated with high CV events and all-cause mortality
Punjabi NM et al 2009⁵¹	Prospective observational	Sleep apnea vs nonsleep apnea with baseline PSG, followed for mortality	6441, 53.3% women		8.2 y	Sleep apnea is associated with all-cause mortality; men had a higher mortality rate than women (24.8 vs 16.5; P < 0.0001)
PCOS
Tasali et al 2011⁴³	Prospective observational	CPAP	19 women		8 wk	Young obese women with PCOS improves in cardiometabolic function by using CPAP
Diabetes
Valham F. et al 2009⁴²	Prospective observational	Questions on snoring and witnessed apnea	4047 women, 3858 men		Random selection for 1 visit	58% of the women who snored had diabetes and women with history of witnessed sleep apnea had threefold increase in frequency of diabetes mellitus.
Foster GD et al 2009⁵²	RCT	Intensive lifestyle modification vs diabetes support and education	264, 59% women		1 y	Weight loss improves OSA among obese diabetic patients
Preeclampsia
Blyton DM et al 2013⁵³	Prospective observational	CPAP	40 women		2 nights	CPAP improves fetal activity and fetal hiccups among patients with preeclampsia
Menopause
Tom et al 2011⁵⁴	RCT	Hormone therapy suspension and hormone therapy continuation	1704 women		3 mo	Suspension of hormone therapy increases frequency of sleep problems
Polo-Kantola et al 2003³⁰	RCT (double-blind crossover)	Estrogen vs placebo on postmenopausal women who underwent PSG	62 women		3 mo	Estrogen therapy decreased the occurrence (P = 0.047) and frequency of sleep apnea (P = 0.049), but had no effect on partial upper airway obstruction among postmenopausal women.
Pregnancy
Maasilta P. 2001⁵⁵	Prospective observational	Overnight PSG at 12 weeks (early) and 30 weeks (late) of pregnancy	11 obese and 11 non-obese pregnant women		30 wk	AHI, 4% O2 desaturation and snoring occurs more in obese mothers than mothers of normal weight (P < 0.05, <0.005, <0.001, respectively) when compared with early and late pregnancy readings
CPAP treatment
Ye et al 2009⁵⁶	Prospective observational	CPAP treatment response across sexes	152 men, 24 women		3 mo	CPAP improved OSA symptoms and functional status in both men and women; average CPAP use in women was not different from men (P = 0.265).
Jayaraman et al 2011⁵⁷	Retrospective	CPAP treatment	56 women and 39 men		6 mo	Pressure requirement for CPAP was higher in men than in women (P G 0.0001)
Don Sin et al 2002⁴⁶	Prospective	CPAP treatment	296, 18.9% women		6 mo	Women used CPAP more frequently than men
Battagel et al 1999⁴⁷	Prospective observational	Mandibular advancement device	45 men and 13 women with mildYmoderate OSA			Despite smaller faces and narrower pharynxes than men, women enlarge their pharynx more than men in different measurements of protrusion

AHI, Apnea-Hypopnea Index; CPAP, continuous positive airway pressure; CV, cardiovascular; OSA, obstructive sleep apnea; PCOS, polycystic ovary syndrome; PSG, polysomnography; RCT, randomized