Keywords
sleep disorders - sleep quality - women’s health - gynecologist
Schlüsselwörter
Schlafstörungen - Schlafqualität - Frauengesundheit - Gynäkologe
Introduction
Sleep issues affect roughly 35% of people, presenting challenges with initiating or
maintaining sleep, or experiencing non-restorative sleep, significantly impacting
daily functioning [1]. The American Psychiatric Association defines sleep or sleep-wake disorders as conditions
that affect sleep quality, timing, and quantity, leading to daytime impairment [2]. It is widely acknowledged, by nearly 97% of psychiatrists, that evaluating sleep
disorders is crucial during initial psychiatric assessments due to their potential
connection with emotional or medical conditions [2]. Such disorders are linked to several factors including aging, chronic diseases,
obesity, depression, and physiological changes like menopause and pregnancy, all of
which can deteriorate sleep
quality and quantity, especially a reduction in NREM and REM sleep phases [3].
Notably, women are twice as likely as men to experience sleep disorders, a disparity
influenced by hormonal fluctuations and changes associated with menstrual cycles,
pregnancy, adolescence, and perimenopause [3]
[4]
[5]. These conditions not only degrade sleep quality but also contribute to broader
economic and social impacts through reduced productivity, increased healthcare costs,
and elevated risk of accidents [1]
[6]. Furthermore, sleep disorders can diminish quality of life by fostering daytime
fatigue, irritability, and susceptibility to chronic diseases like diabetes and cardiovascular
disease [7]
[8]
[9]. In older adults, poor sleep quality increases the risk of falls and related complications,
highlighting the need for careful management of sleep health across all ages [6].
Despite the higher incidence of sleep complaints among women, research has predominantly
focused on men, overlooking gender-specific factors [10]. However, studies such as the meta-analysis by Ohayon et al. have begun to address
this gap, comparing sleep patterns across genders and identifying both similarities
and distinct differences in how aging affects sleep disorders in men and women [11].
Sleep is a fundamental physiological process, and its role extends beyond mere rest.
It is essential for cognitive function, emotional regulation, and overall health.
Physiological changes in sleep patterns occur with aging, with implications for both
sleep quality and health outcomes. Poor or unrefreshing sleep is linked to a range
of negative health outcomes, underscoring the clinical importance of understanding
and addressing sleep disorders across all ages [12]. This review highlights the critical aspects of sleep, particularly focusing on
changes throughout life stages, and emphasizes the need for healthcare professionals
to assess and manage sleep issues proactively.
Sleep Patterns in Women from Infancy to Aging
Sleep Patterns in Women from Infancy to Aging
Research indicates that sleep patterns in women are influenced by both intrinsic factors
like circadian and endocrinological changes and extrinsic factors such as psychosocial
elements from infancy through aging. Studies reveal that male and female newborns
exhibit differences in electrocortical activity and sleep arousal, although these
distinctions often diminish over time and remain inconsistent during infancy and childhood
[10]
[11]. The onset of puberty marks significant sex-related changes in sleep patterns, largely
due to increases in sex steroids, which can affect the circadian timing system and
contribute to the development of sleep disorders such as insomnia [13]
[14]
[15]. Women, for example, display different estrogen receptor expressions and melatonin
levels compared to men, impacting their sleep-wake cycles [16]. Moreover, sleep disturbances become more prevalent during the perimenopausal period,
with a reported incidence of 40–60% among menopausal women [17]
[18]. This study aims to delve into sleep disorders in women as classified by the ICSD-3
[19] ([Table 1]).
Table 1
Classification of Sleep Disorders in ICSD-3 Classification [1].
|
Sleep Disorders (ICSD-3 Classification)
|
|
ICSD = International Classification of Sleep Disorders
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Insomnia
Insomnia, defined as difficulty falling or staying asleep, is a prevalent sleep disorder
affecting more than one-third of adults at some point, with a significant portion
developing chronic conditions [20]. The underlying mechanisms of insomnia are multifaceted, involving behavioral, cognitive,
emotional, and genetic factors [21]. In particular, adolescent girls exhibit a higher prevalence of insomnia following
puberty, emphasizing the impact of hormonal changes and psychological stressors [22]
[23]
[24]
[25]. This trend continues into adulthood, where
women report higher rates of insomnia, often attributed to physiological changes and
hormonal fluctuations during menstrual cycles, pregnancy, and menopause [26]
[27]
[28].
Hormonal fluctuations during pre-menopause, menopause, and post-menopause can significantly
disrupt sleep patterns, leading to shortened sleep duration and increased nighttime
awakenings [29]
[30]. The effects of hormones like estrogen and progesterone on sleep are critical to
understanding and managing insomnia among women. Similarly, during other critical
life stages such as adolescence and reproductive years, hormonal changes can exacerbate
sleep disturbances [31]. For instance, hormonal fluctuations during different phases of the menstrual cycle
can induce sleep problems, particularly pronounced during the luteal phase when progesterone
levels rise [32].
In clinical practice, addressing insomnia involves a detailed evaluation of the patient’s
hormonal profile and, if necessary, an endocrinological assessment. Effective treatment
approaches include cognitive behavioral therapy (CBT) and pharmacological interventions,
which focus not only on sleep issues but also on comorbid conditions such as anxiety
or depression [33]
[34]. Ensuring that current guidelines and treatment protocols for sleep disorders consider
these hormonal interactions is vital. This integrated approach can significantly improve
the management of insomnia, enabling healthcare providers to offer more targeted interventions
and ultimately enhancing the quality of life for patients.
Sleep-related Breathing Disorders
Sleep-related Breathing Disorders
Sleep-related breathing disorders (SRBDs), including obstructive sleep apnea (OSA),
are characterized by interruptions in breathing during sleep. OSA prevalence is significant
among adults, especially women with conditions like polycystic ovary syndrome (PCOS),
where up to 35% may experience OSA compared to 9–38% in the general population [35]
[36]. Metabolic syndrome components in PCOS patients notably influence sleep disorders,
with treatments ranging from conservative approaches to CPAP for obstructive sleep
apnea [37]
[38]
[39].
Central Disorder of Hypersomnolence
Central Disorder of Hypersomnolence
Central disorders of hypersomnolence, a condition characterized by increased daytime
sleepiness, has a known pathophysiology linked to hypocretin deficiency and is associated
with an increased risk of premature puberty [40]
[41]. These aspects are particularly relevant for gynecologists and should be highlighted,
correcting the earlier assertion that the pathophysiology of conditions involving
increased daytime sleepiness is not known.
This compact synthesis provides a concise overview of the key points from the original
sections, incorporating references directly to maintain academic integrity while ensuring
readability.
Circadian-Rhythm Wake Sleep Disorders
Circadian-Rhythm Wake Sleep Disorders
Circadian-Rhythm Wake Sleep Disorders: The endogenous circadian rhythm, crucial for
controlling sleep, involves physiological processes such as cortisol and melatonin
secretion, body temperature changes, and urine volume variations. Menstrual and circadian
rhythms interact, with circadian changes occurring in response to the menstrual cycle
phase in women. Disrupted circadian rhythms are linked to menstrual irregularities
and disorders. Factors like shift work or increased nighttime light exposure can increase
breast cancer risk in women. Polysomnographic studies generally find stable sleep
continuity and efficiency across different stages of the ovulatory menstrual cycle
in young, healthy women [42]
[43]. Sleep homeostasis is maintained throughout the menstrual cycle [44], with REM sleep slightly affected during the menstrual phase. Studies suggest REM
sleep onset is earlier and the percentage of REM sleep decreases with increased body
temperature during the luteal phase [45]
[46]. The luteal phase also sees increased daytime sleepiness and naps, indicating a
greater need for slow-wave sleep (SWS) [47]. [Fig. 1] in our review illustrates the complicated dynamics between hormonal fluctuations
and their effects on sleep behavior during the menstrual cycle. This figure summarizes
findings from seminal work in this field, particularly that of Pengo et al. (2018)
and the comprehensive review by Haufe et al. [32]
[48]. Pengo et al. discuss the nuanced role of estrogen and progesterone in sleep regulation,
highlighting in particular the increased sleep disturbances during the luteal phase
when progesterone levels peak. Similarly, the Haufe et al. review further elaborates
on how these hormonal elevations disrupt sleep quality, increase nighttime awakenings
and increase daytime sleepiness. Together, these studies provide an important foundation
for our understanding of the interactions between sleep and hormones, as illustrated
in [Fig. 1], and emphasize the importance of hormonal considerations in the clinical management
of sleep disorders in women. Women aged 18–50 report more sleep disturbances premenstrually
and during the initial days of menstruation [49]
[50]. Even young women with ovulatory cycles and no menstrual complaints experience poorer
sleep quality premenstrually and during menstruation’s first four days [49]. These changes are more pronounced in PMS and premenstrual dysphoric disorder (PMDD).
Hormonal variations of the menstrual cycle affect sleep EEG, with a significant increase
in sleep spindle frequency activity during the luteal phase, suggesting an interaction
between endogenous progesterone metabolites and GABA-A membrane receptors [44]
[51]. Current studies show that while subjective sleep quality is lowest before and during
menstruation, sleep timing and composition remain relatively constant throughout the
menstrual cycle, except for an increase in spindle frequency activity and a minor
decrease in REM sleep during the luteal phase in healthy women. Research has explored
phototherapy and melatonin for treatment, though evidence for chronotherapy’s efficacy
remains limited by the lack of randomized controlled studies [52].
Fig. 1
Hormonal fluctuations and sleep patterns across the menstrual cycle. This figure illustrates
the changes in hormone levels of follicle-stimulating hormone (FSH), luteinizing hormone
(LH), progesterone, and estrogen across the menstrual cycle, and their correlation
with sleep quality, night awakenings, and daytime sleepiness. The phases of the menstrual
cycle are marked as menstruation, follicular phase, ovulation, and luteal phase. Notably,
sleep disturbances increase with rising progesterone levels during the luteal phase.
Parasomnias
These sleep disorders are characterized by abnormal movements, behaviors, emotions,
and perceptions occurring at different sleep stages. There is no randomized controlled
study demonstrating a direct link between parasomnias and gynecological disorders.
Sleep-related Movement Disorders
Sleep-related Movement Disorders
Sleep-related movement disorders encompass a range of conditions manifesting as simple,
typically repetitive movements during sleep. Key disorders classified under this category
in the International Classification of Sleep Disorders, Third Edition (ICSD-3), include
Restless Legs Syndrome (RLS), periodic limb movement disorder, sleep-related leg cramps,
sleep-related bruxism, sleep-related rhythmic movement disorder, benign sleep myoclonus
of infancy, propriospinal myoclonus at sleep onset, and sleep-related movement disorders
due to medications or substances. RLS is notable for causing dysesthesias while awake,
alongside recurrent limb movements in sleep.
RLS, also known as Willis-Ekbom Disease, is a neurological disorder characterized
by an urge to move the legs, often accompanied by uncomfortable sensations [53]. The general population shows a 1.9% to 15% prevalence rate for RLS, with studies
highlighting a significant prevalence among adult females [54]. RLS sufferers experience uncomfortable sensations in the limbs, often worsening
at rest and at night, which can be somewhat alleviated by movement. These sensations
can be described variably, from “creeping” to “tingling” or even as indescribable
discomfort, potentially spreading to the arms or trunk as the condition progresses.
RLS prevalence increases with age and is more common among women, with many patients
reporting a family history of the disorder [55].
The gender disparity in RLS prevalence is thought to be influenced by sex hormones
and physiological states such as pregnancy and iron deficiency. Hormonal fluctuations
during the menstrual cycle, pregnancy, and menopause in women are hypothesized to
contribute to this disparity, though evidence on hormonal roles remains mixed and
unproven [56]. Interestingly, no significant gender differences have been noted in the duration
of RLS, family history incidence, weekly frequency of symptoms, or daytime sleepiness
severity [47]. Secondary RLS, often linked to neurological disorders, iron deficiency, or pregnancy,
generally emerges later in life. Approximately 20% of pregnant women experience RLS,
with symptoms ranging from moderate to severe [57].
The hormonal impact hypothesis on RLS during pregnancy is supported by increases in
estrogen, progesterone, and prolactin levels, although not all pregnant women develop
RLS, indicating that hormones might interact with other factors, such as neurotransmitters
like dopamine, to influence RLS [53]. Hormone replacement therapy (HRT) during menopause has not shown to alter the prevalence
of RLS or reverse age-related sleep changes in women [58]. Similarly, RLS prevalence does not differ significantly among transgender individuals
undergoing hormone therapy [59].
The role of iron during pregnancy is critical in understanding and effectively managing
RLS. During pregnancy, the increased iron demand due to the growing needs of the fetus
and placenta, along with the increased maternal blood volume, is a proven major factor
for RLS in pregnant women. Iron deficiency is not only a risk factor for RLS but also
for other pregnancy-related complications such as anemia, which can exacerbate RLS
symptoms [60]
[61].
A meta-analysis conducted by Chen et al. (2017) revealed that the prevalence of RLS
in pregnant women is significantly higher compared to the general population, with
an average prevalence rate of 21% across all three trimesters. This prevalence increases
as pregnancy progresses, reaching up to 22% in the third trimester [62].
Therefore, pregnant women should be routinely screened for iron status and supplemented
with iron as necessary. The guidelines developed by the German Society for Neurology
and the German Society for Sleep Research and Sleep Medicine suggest initiating iron
supplementation if serum ferritin levels fall below 75 μg/L or transferrin saturation
dips under 20% ([Table 2]). Oral iron supplements should be taken with vitamin C to enhance absorption and
should not be consumed with milk, tea, or coffee, which can interfere with iron uptake.
In cases where oral supplementation fails or is not tolerated, intravenous iron treatment
is recommended, administered in a clinical setting with close monitoring to prevent
any potential allergic reactions and avoid iron overload. The approach underscores
the critical role of iron in managing RLS, promoting a regimen tailored to individual
patient needs based on ongoing monitoring of iron
levels [63]
[64]. In cases of severe deficiency or poor tolerance to oral iron, intravenous iron
formulations like ferric carboxymaltose may be considered. Regular monitoring of serum
ferritin and iron levels is essential to ensure they remain within the target range.
Lifestyle modifications, including regular exercise and proper sleep hygiene, can
also play a supportive role in managing RLS during pregnancy.
The dopaminergic system’s dysfunction is suggested as a potential pathophysiological
pathway for RLS, with pharmacological treatments including dopamine agonists or gabapentinoids,
emphasizing the importance of minimal effective dosages to mitigate symptom exacerbation
over time [65] ([Table 2]).
“Other Sleep Disorders” in ICSD-3 refers to disorders that do not fit neatly into
other categories due to overlap or insufficient data for a definitive diagnosis, including
those primarily related to environmental disturbances.
Table 2
Common sleep disorders related to gynecological situations.
|
Condition
|
Gynecological Situations
|
Defining Features
|
Confirmatory Evaluations
|
Treatment
|
|
Insomnia
|
-
Adolescents
-
Menopause or transition to Menopause
-
Premenstrual syndrome/Premenstrual dysphoric disorder
|
-
Difficulty with:
-
Sleep initiation or
-
Sleep maintenance
-
Results in:
-
Fatigue/malaise
-
Mood disturbance/irritability
-
Reduced productivity
|
-
Primary: clinical history
-
Ancillary: sleep diary
|
-
Non-pharmacological:
-
Cognitive behavior therapy
-
Pharmacological:
-
Hypnotics
-
Antidepressants
-
Melatonin agonists
-
Orexin antagonists
|
|
Sleep related-Breathing Disorders
|
-
Polycystic ovary syndrome
|
-
Snoring/apneas/gasping upon awakening
-
Other nonspecific symptoms
-
Attention deficits
-
Morning headache
-
Mood disturbance
-
Nocturia, night sweats
|
-
Home sleep testing
-
Polysomnography in both cases, diagnosis requires: Apnea-Hypopnea Index > 5/h with
symptoms or Index > 15/h regardless of symptoms
|
-
Continuous or bilevel positive airway pressure
-
Sleep position
-
Weight loss
-
Avoidance of “relaxants” close to bedtime
|
|
Circadian-Rhythm Wake Sleep Disorders
|
Before and during menstruation
|
-
Sleep occurs systematically earlier or later than needed
-
Sleep length is normal and the patient is refreshed when sleeping according to his/her
desired time
|
-
Sleep diary
-
Electroencephalogram
-
Melatonin
|
-
Melatonin
-
Combined with morning blue light
|
|
Sleep Related – Movement Disorder
|
-
Alterations in sex hormones
-
Iron deficiency
|
-
Uncomfortable sensations that cause the patient to move their limbs.
-
Difficulty initiating sleep due to uncomfortable feelings and urge to move
-
Interrupted sleep, discomfort
-
Daytime sleepiness
|
-
Clinical history
-
Polysomnography
-
Periodic limb movement of sleep > 15/h with symptoms
|
-
Dopamine-agonists
-
Gabapentin, enacarbil
-
Fe supplementation if indicated (ferritin < 70 μg/l to be continued until > 100 μg/l,
or transferrin saturation dips under 20%)
|
Conclusion
Sleep is of vital importance for women as well as for all living species. Sleep periods
constitute about one-third of our lives, and thus when disrupted they can have significant
negative consequences on quality of life and daytime function. The interaction of
physiological and psychological factors appears to contribute to gender differences
in the prevalence of sleep disorders in women from puberty to postmenopause. Physiological
changes in a woman’s life observed during adolescence, pregnancy, postpartum period
and perimenopause may lead to sleep disturbances and the gynecologists might encounter
this complain during their daily practice. Moreover, gynecological entities such as
PCOS, PMS are also related with a higher frequency of sleep disorders. Awareness of
the higher risk of sleep disturbances in women is important for gynecologists as women
will initially share these complaints during their gynecological consultations in
most cases. Therefore, the management of sleep
disorders in women requires a careful assessment and management by a multidisciplinary
team that includes gynecologists in a remarkable number of cases.
