Sleep Dysfunction in Women


Background
Women are twice as likely as men to have difficulties falling asleep or maintaining sleep. Yet, physicians often overlook women's complaints about sleep. Scientific research only recently has focused on the incidence and causes of sleep problems in women, particularly sleep patterns and the changing needs and problems associated with sleep throughout women's life spans. In general, sleep is sounder and less prone to disturbances during young adulthood; however, some women are prone to sleep problems during their reproductive years. Hormonal fluctuations associated with menstrual cycle and pregnancy may affect circadian rhythms and stress reactivity, thereby rendering women more vulnerable to emotional stress and to concomitant sleep disturbances.
For other women, psychosocial factors pose certain challenges. Many young women coping with work as well as with their roles as mothers and wives may cut back on their sleep, ignoring signs of fatigue and other effects of insufficient sleep. As women age, physical and hormonal changes take place that make sleep lighter and less sound. Older women get less deep sleep and are more likely to wake up at night. Physical factors, such as physical discomfort, pain, disorders of breathing, and menopausal symptoms may also disturb sleep. Studies have shown that about 30% of employed women report having problems with their sleep, and the problems are more frequent in women older than 40 years. Getting enough sleep has an enormous impact on a woman's life as it improves job performance, concentration, social interaction, and general sense of well-being.
Definitions and terminology
• Insomnia - Difficulty with falling asleep or staying asleep
• Sleep-onset insomnia - Difficulty with falling asleep
• Sleep-maintenance insomnia - Fragmented sleep, difficulty with maintaining sleep
• Circadian rhythm - Approximately 24-hour cycles that are generated endogenously by an organism
• Sleep-disordered breathing (SDB) - Some degree of sleep-related upper airway obstruction, ranging in severity from upper airway resistance syndrome (UARS) to obstructive sleep apnea (OSA)
Pathophysiology
In general, sex steroids play a role in the etiology of sleep disorders in women, either by having a direct effect on sleep processes or through their effect on mood and emotional state. Sex steroids influence EEG sleep during the luteal phase by increasing the EEG frequency and core body temperature. Lack of estrogen, later in life, contributes to vasomotor symptoms, including hot flashes that cause sleep disturbances. Decreased estrogen also plays a role in the etiology of sleep apnea.
Pathophysiologic factors in some of the major sleep disorders seen in women are as follows:
Sleep-disordered breathing: This 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 anatomical abnormalities that increase airway occlusion (eg, enlarged tonsils, macroglossia). The nature of OSA in menopausal women is different than that of age-matched men. Women demonstrate more partial obstructive events (eg, hypopneas) than complete OSAs. In addition, the duration of hypopneas, when present, tends to be shorter in women than in men. 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.
In a recent 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 compared to the follicular phase. Progesterone levels are elevated during the luteal phase.
Restless Legs Syndrome (RLS) and Periodic Limb Movement Disorder (PLMD): 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. 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.
Narcolepsy: 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.
Frequency
United States
The difficulty most frequently reported by women is insomnia. As many as 80% of women report premenstrual symptoms that include insomnia. However, only 10-15% of women experience premenstrual dysphoric disorder (PMDD). About two thirds of perimenopausal women have sleep-related problems. Menopausal and postmenopausal women are more likely to report frequent insomnia (56%) than premenopausal (49%) women and also are more likely to use a prescription sleep aid (20%) than premenopausal women (8%).
The prevalence of pathological SDB has been estimated at 5.2% for women aged 40-64. Over 30% of elderly persons demonstrate at least mild sleep-related breathing abnormalities, as defined by an apnea/hypopnea index of 5 or greater. Postmenopausal women are 2.6 times more likely than premenopausal women to have an apnea-hypopnea index (AHI) greater than 5.
The incidence and prevalence of SDB during pregnancy is unknown. Generally, sleep studies have found no evidence of significant SDB during pregnancy, possibly reflecting increased circulating levels of progesterone.
The prevalence of PLMD increases significantly with age. Studies have estimated that as many as 45% of the independently living population older than 65 years show the minimal criteria for diagnosis of PLMD.
The prevalence of RLS has been reported at 10% for those aged 30-79 years. No gender difference exists in the prevalence of RLS. Smoking, diabetes mellitus, pregnancy, greater age, and greater body mass index significantly increase the incidence of RLS.
International
Estimated prevalence of SDB in a study from Iceland has been reported at 2.5% for women aged 40-59.
Mortality/Morbidity
• Snoring, often a sign of partial airway obstruction, has been shown to be associated with high blood pressure and increased risk for OSA. Snoring increases during pregnancy, particularly during the last trimester. About 14% of women who report habitual snoring during pregnancy had pregnancy-induced hypertension. In addition, snoring may be responsible for nighttime increases in blood pressure in preeclampsia. Finally, infants born to mothers who were habitual snorers more frequently had low birth weights.
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• Snoring is also a risk factor in the development of OSA in postmenopausal women. Other contributing factors are weight and neck size. In addition to sleep disturbances and daytime sleepiness, OSA can lead to hypertension and other cardiovascular complications.
Race
The prevalence of obesity is higher in black women than in white women. Obesity places women at higher risk of developing OSA, particularly after menopause. Sleep apnea is pervasive in non-European–American women. Compared with European–American women, non-European–American women have more blood oxygen desaturations during sleep.
Sex
The prevalence of sleep-disordered breathing (SDB) is significantly higher in young men than in young women. However, the chance of women older than 50 years developing sleep apnea may be equal to that of men. The prevalence is very high (may exceed 50%) in both older women and men.
Age
• In general, sleep is sounder and less prone to disturbances in younger people. As women age, physical and hormonal changes take place that make sleep lighter and less sound. Women older than 40 years are 1.3 times more likely than age-matched men to report insomnia.
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• In the years surrounding menopause, sleep disturbances occur with increased frequency. Women take longer to fall asleep, wake up more often at night, and are more tired during the day. Hot flashes and night sweats, associated with decreased levels of estrogen, may contribute to midsleep awakenings.
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• During postmenopausal years, sleep efficiency further decreases, and waking after sleep onset increases. Factors affecting sleep during this period include pain, certain medical and emotional conditions, and physical discomfort.
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• Polysomnographic changes of elderly women include decreased slow wave sleep stages 3 and 4, resulting from decreased EEG amplitude, and shorter REM sleep latency.


CLINICAL

History
Taking a careful sleep history is an essential part of the evaluation of sleep disorders. This is particularly important for women who present with insomnia, as insomnia constitutes a symptom rather than a disorder and may be related to various problems, including psychiatric and medical conditions. Accurate differential diagnosis is essential before formulation of a treatment plan. The nature of the difficulty, the duration of symptoms, medical and psychiatric history, and careful assessment of current and previous sleep patterns are all essential pieces of information in the differential diagnosis.
• Nature of sleep difficulty: Women typically present with one or a combination of the following:
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o Difficulty falling asleep: The inability to fall asleep suggests psychophysiological or primary insomnia. Typically, this type of insomnia, often termed "learned" insomnia, is more frequent in younger individuals. It is characterized by an initial level of increased somatized and psychological tension, which may lead to occasional sleep disturbance and later may be reinforced by maladaptive behavior targeted at preventing the sleep disturbance. Often, a learned insomnia is associated with anxiety disorder, certain personality styles, and stressful lifestyle.
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o Difficulties maintaining sleep: Multiple awakenings during sleep are more frequent in older individuals and suggest major sleep disorders, such as PLMD, as well as other medical and psychiatric conditions. Older women who suffer from arthritis and other painful conditions, women on certain medications, and women in their last trimester of pregnancy are some of the groups likely to present with difficulties in maintaining sleep.
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o Excessive daytime sleepiness: In older postmenopausal women, excessive daytime sleepiness suggests SDB and PLMD. Severe sleepiness in young women is more likely to be associated with sleep deprivation or narcolepsy.
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• Duration of symptoms
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o Typically, short acute sleep disorder is associated with an identifiable cause and almost always can be traced to an acute medical or psychological event.
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o Chronic insomnia often begins as an acute insomnia, which later develops into a chronic condition.
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o Understanding the patient's coping style and identifying measures that helped in the past may help identify the cause of the sleep problem.
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• Sleep-wake pattern
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o Irregular sleep pattern may point to impaired sleep hygiene or a circadian rhythm disorder.
o In delayed sleep phase syndrome, women consistently go to bed very late and are unable to get up in the morning.
o Women who present with persistent early morning awakenings are more likely to suffer from depressive disorders.
o Loud snoring and restless sleep suggest SDB.
o Multiple brief awakening and periodic leg kicks indicate the possibility of PLMD.
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• Medical history
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o This is an important part of sleep history and should include a thorough investigation of present and past medications that potentially can interfere with sleep, such as antihypertensive medication.
o A number of medical conditions potentially can disturb sleep and need to be ruled out. These include chronic cardiac or lung disease, thyroid disease, gastroesophageal reflux, chronic pain, and other conditions.
o Similarly, psychiatric history should include information regarding previous hospitalization, present and past use of psychoactive medication, and history of alcohol and drug abuse.
o Insomnia, especially with early morning awakening, is one of the most common symptoms of depression. Women who suffer from anxiety disorder or chronic stress may also sleep poorly.
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• Family sleep history: Assessment of family history provides additional information regarding the causes of the sleep disorder. For example, family history of daytime sleepiness may point to a neurological sleep condition such as narcolepsy.
• Hormonal status: Low estrogen levels may be responsible for affective symptoms, including depressed mood, anxiety, fatigue, forgetfulness, and decreased concentration.
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o Premenstrual insomnia: Sleep disturbances have been described as part of a constellation of physical and emotional symptoms occurring during the premenstrual (late luteal) phase of the menstrual cycle, historically described as the premenstrual syndrome (PMS). Women who experience PMS report having sleep disturbances, including increased sleep latency and midsleep awakenings. They also report a significant increase in daytime sleepiness and increased difficulties in waking up.
 Recently, the hormonal fluctuations of the menstrual cycle have been recognized as possible contributors to the pathophysiology of mood disorders. In a small percentage of women, severe symptoms associated with PMS, including sleep disturbances, mood lability, irritability, and anxiety, may interfere with daily activities and cause a mood disorder.
 In its new definition, as PMDD, the syndrome is included in the 1994 Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision (DSM-IV). Women with PMDD often show a pattern of advanced sleep phase with an earlier bedtime and early morning awakening.
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o Premenstrual hypersomnia: This is a rare sleep disorder, occurring in association with the menstrual period, and is characterized by pronounced daytime sleepiness, which typically begins a few days prior to the onset of menstruation and ends a few days after the onset of menstruation.
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o Sleep in pregnancy: During the first trimester, an increase in total sleep time and daytime sleepiness is noted, whereas decreased sleep time and increased number of nocturnal awakenings characterize the third trimester. The most common reasons for sleep disturbances given by pregnant women are frequent urination, heartburn, general discomfort, fetal movements, low back pain, leg cramps, and nightmares.
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o Sleep disorders in menopause
 Insomnia: Difficulties with sleep onset and sleep maintenance are common in menopausal women. In cases of severe hot flashes, women can wake up several times during the night with a sensation of heat, increased heart rate, and, occasionally, a feeling of anxiety. In turn, sleep fragmentation associated with hot flashes can cause daytime fatigue, mood lability, irritability, and memory lapses. For some menopausal women who do not experience distressing vasomotor symptoms, insomnia may be associated with menopause-related mood syndrome.
 SDB: Increased body mass and decreased estrogen level combined with loud snoring may increase the likelihood of upper airway obstruction, leading to SDB.
 Postmenopausal sleep disorders: As women age, sleep becomes lighter and more fragmented. While maintaining long hours of uninterrupted sleep becomes more difficult, maintaining long hours of wakefulness during the day also becomes more difficult. This can result in waking periods during the night and increased daytime fatigue. Compared to young people, older individuals go to sleep early in the evening and get up earlier in the morning. Health issues and chronic conditions together with the aging process can further disturb sleep. Arthritis and other painful conditions, chronic lung disease, certain medications, heartburn, and frequent trips to the bathroom have been shown to be detrimental to sleep continuation. The use of hypnotics increases with age, with usage by women significantly higher than that by age-matched men.
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• Work and lifestyle: Those engaged in rotating and night shifts are likely to experience sleep problems. Women with inactive lifestyles may experience trouble falling asleep. Women who keep erratic schedules or those who go to sleep late on weekend nights and oversleep on weekend days are also more likely to have trouble resetting their body clock to a normal schedule during the week.
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• Drugs and alcohol: Use of caffeine, nicotine, or other stimulating drugs near bedtime may prevent women from falling asleep. Alcohol, often used by women to help them fall asleep, may cause sleep fragmentation and nightmares.
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Physical
The examination of the woman presenting with sleep problems addresses 2 major issues: psychological and physiological findings. General appearance and affect can be assessed early and during the examination. Chronic illness or chronic pain often is evinced in the general appearance and movement of a patient. The examination focuses on addressing any major medical illness that may be associated with sleep symptomatology, as well as on risk factors that direct toward evaluation of sleep-related disorders such as narcolepsy and OSA. Many patients with circadian rhythm disorders and insomnia may have normal physical examination findings.
• General appearance: This includes an assessment of nutritional status as well as body habitus. General care, personal hygiene, and social exchange can also be surveyed. Elderly patients with osteoporosis may be identified for further evaluation by their posture. Chronic pain associated with fractures can disrupt sleep.
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• Vital signs: Hypertension has been associated with OSA.
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• Head and neck examination: Inspection of the head can direct us to further evaluation for hyperthyroidism when exophthalmos is noted and evaluation of OSA when micrognathia or midfacial abnormalities are noted. Deviation of the nasal septum may also be associated with OSA. Myopathic facies is another example that suggests further evaluation of sleep-related breathing disorder, as do findings consistent with atopic disease. Large neck size associated with obesity is predictive of increased risk of OSA; however, a thorough examination of the neck is also indicated to evaluate for tumors.
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• Chest: Chronic obstructive pulmonary disease and congestive heart failure are frequent causes of poor sleep in older patients. Inspection, auscultation, palpation, and percussion are all important elements of the examination. Digital clubbing is associated with chronic cardiac and pulmonary disease, but this may also be familial.
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• Abdomen: Excessive obesity and advanced pregnancy can affect breathing during sleep, especially in the supine position. Abdominal masses and tumors, depending on size and location, may also be problematic.
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• Neurologic examination: Patients with organic brain syndromes, dementia, or Alzheimer disease often have sleep abnormalities. Neuromuscular disease, such as spinal muscle atrophy, can be associated with hypoventilation during sleep and increased daytime sleepiness.
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Causes
Major factors that play a role in causing sleep disturbances in women include the following:
• Hormonal changes: Both estrogen and progesterone influence sleep and possibly daytime sleepiness. Thus, sleep disturbances are more common during the premenstrual period and again later in life during postmenopausal years when hormonal changes are pronounced. In addition, decreased level of estrogen during menopause has been associated with increased upper airway resistance, snoring, and OSA.
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• Psychosocial issues: In today's society, many women cope with multiple roles in their families. With less time for themselves, they often cut back on sleep. In addition to sleep deprivation, increased stress has been associated with sleep-onset insomnia.
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• Psychiatric disorders: Mood disorders are more prevalent in women than in men, primarily those that are unique to the female reproductive system (eg, PMDD, pregnancy affective disorder, postpartum depression, perimenopausal mood disorder). While anxiety disorders often are associated with trouble falling asleep, depression typically is associated with early morning awakening.
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• Age: The frequency and severity of major sleep disorders, such as SDB, RLS, and PLMD, increase with age.
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• Weight: Obesity plays an important role in the pathophysiology of SDB. RLS has also been shown to have a correlation with body mass index.
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DIFFERENTIALS
Insomnia
Narcolepsy
Obstructive Sleep Apnea-Hypopnea Syndrome
REM Sleep Behavior Disorder
Sleeplessness and Circadian Rhythm Disorder
Other Problems to be Considered
• Primary insomnia should be differentiated from depressive disorder, anxiety disorder, and circadian rhythm disorder.
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• Workup for sleep-maintenance insomnia should rule out PLMD and SDB.
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• Sleep disturbance due to vasomotor symptoms should be differentiated from hormonal abnormalities.
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• Abnormal behavior during sleep should be differentiated from nocturnal seizure disorder and REM sleep behavior disorder.
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• The workup of excessive daytime sleepiness should include narcolepsy, SDB, and atypical depression.
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• Parasomnias

WORKUP
Imaging Studies
• Imaging studies may be required in the case of patients with OSA and craniofacial dysmorphologies to evaluate potential surgical strategies (eg, jaw advancement). They also may be utilized in the workup of neurodegenerative disorders.
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Other Tests
• Polysomnography: Overnight sleep studies or polysomnograms may be done in sleep-disorder centers, at home, or as inpatient procedures. Indications include risk factors, symptoms or cardiovascular manifestations arising from sleep apnea, disorders of respiratory control, and chronic obstructive or restrictive lung disease.
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• Multiple sleep latency test (MSLT): MSLT is indicated in the assessment of excessive daytime sleepiness. It is performed following a supervised overnight polysomnogram. The presence of 2 or more sleep-onset REMs (SOREMs) in an MSLT following a normal polysomnographic study the night before supports a diagnosis of narcolepsy.
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• Sleep logs: While not technically a laboratory test, sleep logs are sleep-wake cycle diaries, generally kept for a 2-week period and correlated with the patient's subjective assessments of daytime alertness. These diaries can be particularly helpful in diagnosing circadian rhythm disorders.
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TREATMENT

Medical Care
Treatment of sleep disorders is directed at the particular problem and includes behavioral and pharmacological components and implementation of a sleep hygiene program. The treatment of choice for SDB is continuous positive airway pressure (CPAP).
• Menstruation-related sleep disorder
o Generally, premenstrual insomnia disappears a few days after menstruation begins.
o For some women, the associated tension and irritability can result in lingering sleep problems and even in chronic insomnia. These women should pay attention to their sleep needs, maintain a regular sleep-wake schedule, avoid stress when possible, and eat a healthy diet.
o Because of underlying circadian disturbances in women with premenstrual symptoms, evening bright light therapy has been reported to be effective in preventing early morning awakening in women with this complaint.
o Women diagnosed with PMDD are more susceptible to major depressive disorder when their condition goes untreated. Studies have shown that, like patients with major depression, women with PMDD respond to treatment that incorporates sleep deprivation. Both total and partial sleep deprivations have been shown to effectively reduce depressive symptoms, although these methods still are considered experimental.
• Pregnancy-related sleep disorder
o Relatively little is known about the health significance of sleep disturbance in pregnancy. Pregnancy can pose a risk for developing SDB, back pain, and leg cramps. It can trigger episodes of sleepwalking and PLMD.
o Sleep disturbance during pregnancy also can be associated with frightening dreams, postpartum blues, and sometimes even major depression and postnatal psychosis.
o Throughout their pregnancy, women need to pay extra attention to their sleep pattern by making sure that they get enough sleep, maintain a regular sleep-wake schedule, and avoid excessively stressful conditions.
o Because sleeping pills and alcohol can harm the baby, other measures to improve sleep need to be considered.
o The practice of muscle relaxation technique prior to bedtime may be effective in promoting better sleep and reducing the discomfort of pregnancy.
o To avoid exacerbating heartburn, women should maintain a balanced diet and avoid eating heavy meals and spicy food for at least 2-3 hours before bedtime.
o After delivery, getting enough rest continues to be very important, as severely disturbed sleep might place women at risk for postpartum depression and child abuse.
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• Menopause-related sleep disorders
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o Women can alleviate their menopause-related sleep disturbances by paying attention to their sleep habits, controlling their bedroom temperature, adjusting the light, and using comfortable (preferably cotton) bed linen.
o They should eliminate caffeine, sugar, and alcohol from their diet.
o Estrogen therapy has been found to be quite effective for women with severe sleep and mood disturbances who have no history of affective illness. Hormone replacement therapy (HRT) has also been the treatment of choice for sleep interruptions related to hot flashes. However, results from recent studies have caused the safety of this treatment to be questioned.
o The combination of antidepressant medications and supportive psychotherapy should be considered for women who have had long-standing difficulties with sleep and depression and anxiety.
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• Sleep-disordered breathing
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o In the presence of SDB, nasal CPAP and/or an oral device should be offered, along with recommendation regarding weight management.
o HRT may be useful for the treatment of OSA in menopausal women. However, results of the Women's Health Initiative study have raise concerns about the safety of HRT.
o Finally, weight management appears to be an important factor in the management of SDB in menopausal women.
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• Sleep disorders in elderly women
o Older women should be aware of sleep disturbances and not dismiss them as part of the aging process.
o The presence of significant daytime sleepiness should be investigated and a sleep study may be required to rule out major sleep disorders.
o The physician should be aware of the patient's medical and psychiatric conditions and target the treatment at the cause of the disturbance rather than the symptoms.
o General guidelines for better sleep habits should be provided.
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Surgical Care
Uvulopalatopharyngoplasty (UPPP) is a surgical procedure performed to eliminate loud snoring. It involves surgical removal of excess tissues of the soft palate (including uvula) in order to enlarge the area of the upper airways for the purpose of improvement of air exchange.
Consultations
Because of the multidisciplinary nature of sleep disorders, consultation with various specialists often is needed.
• Psychiatrist: A psychiatric consultation often is needed when severe insomnia does not respond to behavioral treatment.
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• Neurologist: In the differential diagnosis of parasomnias (eg, sleep terror, sleepwalking, REM sleep behavior disorder), consultation with a neurologist often is needed to rule out sleep-related seizure disorders.
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• Pulmonologist: SDB is suspected in the presence of loud snoring and daytime sleepiness. Occasionally, a pulmonologist is consulted to rule out related respiratory disease such as alveolar hypoventilation syndrome.
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• Dentist: For patients who are unable to tolerate nasal CPAP, oral appliances may prove effective in the treatment of SDB.
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Diet
In general, women should avoid eating heavy meals within 4 hours before bedtime, as this can have a stimulating effect on sleep. Pregnant women are prone to heartburn, particularly during the last trimester of pregnancy. Therefore, they should maintain a balanced diet and avoid eating spicy food at least 2-3 hours before bedtime.
Activity
For older women, maintaining long hours of sound sleep during the night and long hours of complete alertness during the day becomes increasingly difficult. This can result in waking periods during the night and increased daytime fatigue. In addition, decreased physical activity, irregular sleep-wake schedule, and lack of outdoor light exposure may be involved in changes of the circadian rhythm. Older women should be encouraged to maintain a structured daily schedule that includes physical activity and light exposure and that allows a daily afternoon nap at a regular time.




FOLLOW-UP


Further Outpatient Care
• Compliance with nasal CPAP treatment has been estimated to be 50-73% in the first 6 months of treatment. It decreases sharply to less than 60% by 18 months of treatment; therefore, long-term follow-up is essential to maintain efficacy of this treatment.
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• Treatment of primary insomnia typically consists of a short-term cognitive-behavioral treatment with follow-up visits at 3 and 12 months. In the presence of comorbid psychiatric conditions, psychological treatment typically is combined with medication, and long-term follow-up treatment is needed.
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Deterrence/Prevention
• Good sleep hygiene: Maintaining good sleep hygiene improves the sleep of most women. Detailed guidelines for better sleep hygiene are listed in Patient Education.
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• Stress management: Stress associated with daily life often contributes to sleep problems. Learning stress management skills can help women sleep better and prevent more serious sleep problems.
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• Body weight maintenance: Regular exercise and healthy diet promote good sleep. In addition, maintaining normal weight may prevent development of SDB associated with obesity.
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Complications
• Persistent insomnia may lead to daytime fatigue, decreased daytime function, memory and concentration problems, higher incidents of automobile accidents, and depression. Patients with persistent insomnia tend to have more psychological and medical problems including those of the respiratory, gastrointestinal, and musculoskeletal systems.
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• Untreated or undertreated sleep apnea may lead to cardiac arrhythmias, hypertension, and congestive cardiac failure. In addition, daytime fatigue has been associated with increased neuropsychological impairment. Patients with sleep apnea are at higher risk for traffic accidents and increased mortality rates related to cardiovascular complications.
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Prognosis
• When treated, sleep apnea has an excellent prognosis. Shortly after treatment with nasal CPAP, patients report increased alertness, decreased nocturnal awakenings, and improved sense of well-being.
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• The prognosis of persistent insomnia is good when the treatment plan involves resolution of the underlying problem. Because of the large number of contributing factors, effective treatment relies on an understanding of the differential diagnosis and available treatment options.
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Patient Education
• Promoting good sleep hygiene: Physicians should educate women about habits and behaviors that help promote good sleep. These behaviors help most women sleep better, regardless of the type of sleep problem. The following sleep hygiene instructions should be emphasized:
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o Get up about the same time every day.
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o Go to bed only when sleepy.
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o Establish a relaxing presleep routine such as reading or listening to relaxing music.
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o Avoid heavy meals or consuming caffeinated beverages within 5-6 hours before bedtime.
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o Avoid smoking close to bedtime. Avoid sleeping pills for periods longer than few weeks. Be careful not to drink alcohol while taking sleeping pills.
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o Maintain a regular daily schedule that includes exercise, down time, and regular meal times. Avoid strenuous exercises within 6 hours before bedtime.
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o Older women should try to take a daily afternoon nap at a regular time to prevent early evening dozing.
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• For excellent patient education resources, visit eMedicine's Mental Health and Behavior Center, Sleep Disorders Center, and Women's Health Center. Also, see eMedicine's patient education articles Sleep Disorders in Women, Disorders That Disrupt Sleep (Parasomnias), Insomnia, Narcolepsy, REM Sleep Behavior Disorder, Periodic Limb Movement Disorder, and Menopause.
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MISCELLANEOUS


Medical/Legal Pitfalls
• Women who present with excessive daytime sleepiness should be warned about the dangers of driving and operating heavy machinery. This warning should be documented in the patient's chart. This is particularly important because in most sleep labs the time interval between initial evaluation, ordering of a sleep study, and initiation of treatment can be as long as weeks and even months.
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Special Concerns
• Pregnancy-related sleep disorder
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o Emotional disturbances are common during childbearing and the early postpartum period. Severely disturbed sleep might place women at higher risk for postpartum depression, postnatal psychosis, and child abuse, even in the absence of a premorbid psychiatric history. Because sleeping pills and other psychoactive medications can harm the fetus, other measures to improve sleep need to be considered.
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o Most patients with narcolepsy rely on stimulant and antidepressant medication to maintain daytime alertness and to control cataplexy; therefore, cessation of medication during pregnancy can cause excessive sleepiness or cataplexy, which may result in injury. In addition, withdrawal from medications also may affect sleep patterns. No adverse fetal outcome has been described in 2 case reports in women with narcolepsy who continued to take amphetamine throughout pregnancy and during nursing. Despite these findings, caution must be used in administration of these medications during pregnancy, because the long-term sequelae have not been assessed fully.
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