Sleep Dysfunction in Women Clinical Presentation

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.^{[24, 25]}

Nature of sleep difficulty

Women typically present with 1 or a combination of the following symptoms.

Difficulty falling asleep

The inability to fall asleep suggests psychophysiologic 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 a stressful lifestyle.

Difficulties maintaining sleep

Multiple awakenings during sleep are more frequent in older individuals and suggest major sleep disorders, such as OSA or 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.

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.

Duration of symptoms

Short, acute sleep disorder is typically associated with an identifiable cause and almost always can be traced to an acute medical or psychological event. Chronic insomnia often begins as an acute insomnia, which later develops into a chronic condition.

Understanding the patient's coping style and identifying measures that helped in the past may help to identify the cause of the sleep problem.

Sleep-wake pattern

An irregular sleep pattern may point to impaired sleep hygiene or a circadian rhythm disorder. In delayed sleep phase syndrome, women consistently go to bed very late and are unable to get up in the morning.

Women who present with persistent early morning awakenings are more likely to suffer from depressive disorders.

Loud snoring and restless sleep suggest SDB. Multiple brief awakening and periodic leg kicks indicate the possibility of PLMD.

Medical and psychiatric history

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.

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.

Similarly, psychiatric history should include information regarding previous hospitalization, present and past use of psychoactive medication, and history of alcohol and drug abuse.

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.

Women with sleep apnea often present with other, concomitant sleep disorders, such as RLS and insomnia. The relationship between sleep apnea and hypertension and between sleep apnea and insulin resistance render these conditions suspicious for OSA comorbidity.

Family sleep history

Assessment of family history provides additional information regarding the causes of the sleep disorder. For example, a family history of daytime sleepiness may point to a neurologic 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.

Premenstrual insomnia

Sleep disturbances have been described as part of a constellation of physical and emotional symptoms—historically termed premenstrual syndrome (PMS)—occurring during the premenstrual (late luteal) phase of the menstrual cycle. 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.^[26]

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.^{[27, 28]}

In its current definition, as PMDD, the syndrome is included in the 1994 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Women with PMDD often show a pattern of advanced sleep phase with an earlier bedtime and early morning awakening.

Premenstrual hypersomnia

Premenstrual hypersomnia 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.

Sleep in pregnancy

During the first trimester, an increase in total sleep time and daytime sleepiness is noted, whereas decreased sleep time and an 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.^{[29, 30, 31]}

Sleep disorders in menopause

These include the following:

• Insomnia
• SDB
• Postmenopausal sleep disorders

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.^[32]

Increased body mass and decreased endogenous estrogen and progesterone levels, combined with loud snoring, may increase the likelihood of upper airway obstruction, leading to SDB. Women with SDB are more likely than men to have insomnia complaints and frequently have concomitant depression and other major sleep disorders, such as RLS.

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 with 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.

Work and lifestyle

Women engaged in rotating and night shifts are likely to experience sleep problems. Women with inactive lifestyles may experience trouble falling asleep, while women who keep erratic schedules or those who go to sleep late on weekend nights and oversleep on weekend days are more likely to have trouble resetting their body clock to a normal schedule during the week.^[33]

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.

The examination of the woman presenting with sleep problems addresses 2 major issues: psychological and physiologic 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.

Vital signs

Hypertension has been associated with OSA.

Head and neck examination

Inspection of the head can direct the clinician to further evaluation for hyperthyroidism when exophthalmos is noted and evaluation for 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 for sleep-related breathing disorder, as are 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.

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.

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.

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.