eMedicine Specialties > Neurology > Sleep-Related Diseases

Sleep Dysfunction in Women

Gila Hertz, PhD, ABSM, Director, Center for Insomnia and Sleep Disorders, Clinical Associate Professor of Psychiatry and Behavioral Sciences, State University of New York at Stony Brook
Mary E Cataletto, MD, Associate Director, Division of Pediatric Pulmonology, Winthrop University Hospital; Professor of Clinical Pediatrics, State University of New York at Stony Brook; Director of Children's Sleep Services, Winthrop University Hospital

Updated: Dec 15, 2008

Introduction

Background

Women are twice as likely as men to have difficulties falling asleep or maintaining sleep, although before puberty no significant differences are apparent. Hormonal factors, psychological issues, most particularly depression as well as pain syndromes, are common concerns when addressing insomnia in women. Poor sleep quality and inadequate sleep affect many of the measures of quality of life.

Restless legs syndrome (RLS) is more prevalent in women and occurs at higher rates during pregnancy.

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)
• Restless legs syndrome - Characterized by the urge to move legs or other limbs during periods of rest or inactivity

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 and insomnia. Decreased estrogen also plays a role in the etiology of sleep apnea.
 
In addition to hormonal factors, psychiatric conditions, particularly mood disorders, as well as chronic pain conditions are closely associated with insomnia.

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). Obesity is a known risk factor for OSA. Women with OSA are likely to be more obese than men, though fat distribution is different. The prevalence, nature, and severity of OSA in women changes with menopause.
 
Postmenopausal women have twice the rate of OSA as compared to premenopause. Women demonstrate more partial obstructive events (hypopneas) than complete OSAs. In addition, the duration of hypopneas, when present, tends to be shorter in women than in men. OSA is mostly evident during REM sleep. 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 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 than 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. Iron deficiency has been implicated in the pathophysiology of RLS. The possibility of a genetic basis has been suggested for primary RLS. 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.

Circadian rhythm disorders: The most common circadian sleep disorder is delayed sleep phase syndrome (DSPS), with typical onset at puberty. DSPS is characterized by a significant delay (3-4 h) in both bedtime and wake time in the presence of a normal overall total sleep time. DSPS may also relate to an eveningness chronotype, an individual preference for increased activity at night. A Spanish study, investigating chronotypes in students aged 18-30 years, has shown a greater preference toward eveningness in men. Thus, gender differences are possibly the result of sex influences on the regulation of the biological clock.

Frequency

United States

The difficulty most frequently reported by women is insomnia. Insomnia rates during puberty have been described in girls but not boys. Women are at 41% greater risk for developing insomnia as compared with men and this risk increases with age. By age 65 years the insomnia risk is approximately 73% greater for women. In addition, insomnia is a significant comorbidity in many disorders. The most common disorders associated with insomnia are psychiatric illnesses. Major depression and dysthymia are most closely associated with insomnia. Numerous studies have also shown a close association of chronic pain syndromes with insomnia.

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. Higher rates of RLS have been reported in women as compared with men and Europeans as compared with Asians. Reported rates among Caucasians and African Americans are similar. Smoking, diabetes mellitus, pregnancy, increasing age, and greater body mass index significantly increase the incidence of RLS. Iron deficiency anemia has also been associated with RLS.

International

Estimated prevalence of SDB in a study from Iceland has been reported at 2.5% for women aged 40-59.

Mortality/Morbidity

Studies have shown that sleep problems are linked to more physical and emotional disturbances in women than in men. Among women, those with worse sleep showed more emotional distress and depression. They also had higher body mass index (BMI), more inflammation, and less sensitivity to insulin. Specifically, the most common comorbidities with sleep disorders are as follows:

• 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.
• 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 cardiovascular complications.
• OSA has been associated with hypertension and more recently with insulin resistance and metabolic disease.
• Older women who sleep more than 9 hours of sleep are at higher risk for ischemic stroke.
• Psychiatric conditions, particularly depression and anxiety disorders, are the most common comorbidities with insomnia.
• RLS may be secondary to medical conditions that have iron deficiency, including iron deficiency anemia, renal disease, and pregnancy.

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.

No significant differences were found between Caucasians and African Americans in the risk for RLS.

Sex

In general, gender differences have been found in both circadian rhythm regulation and the homeostatic sleep process. Specifically, chronotype studies have found that men have a stronger tendency toward eveningness compared with women. Sex differences in the sleep-wake cycle appear to increase in response to sleep loss, suggesting different regulation of sleep homeostasis between men and women. Compared with men, women show more slow-wave sleep (SWS), more spindling activity during SWS, and slower age-related reduction of SWS.

Insomnia: Starting at puberty the incidence of insomnia in females differs from that of males. At puberty, insomnia rates for girls are almost triple that of boys. As women, the difference is augmented to a 41% greater risk for the development of insomnia as compared with men and by age 65 years, the risk is 73% greater as compared with men. Conditions such as bipolar disorder, stable coronary artery disease, and certain anxiety and depressive disorders that exhibit higher rates in women are associated with insomnia.

Obstructive sleep apnea: Women are more likely to have upper airway resistance syndrome (UARS), less likely to have positional apnea, and more likely to have REM-related OSA.

Narcolepsy: Men have a greater relative risk of narcolepsy with cataplexy (1.2:1).

Restless legs syndrome: Symptoms of RLS are more frequently reported by women. During pregnancy, prevalence rates have been reported between 11-23%

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.
• 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. The prevalence of SDB increases significantly after menopause.
• 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. Polysomnographic changes of elderly women include decreased slow-wave sleep stages 3 and 4, which results from decreased EEG amplitude, and shorter REM sleep latency. In one study, older women who slept more than 9 hours per night had higher risk of ischemic stroke.

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:
  • 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.
  • Difficulties maintaining sleep: Multiple awakenings during sleep are more frequent in older individuals and suggest major sleep disorders, such as OSA, 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
  • Typically, short acute sleep disorder is 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 identify the cause of the sleep problem.
• Sleep-wake pattern
  • 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 restless legs syndrome 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, 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.
  • 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.
  • 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.
  • 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.
  • 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 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.
    • 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.
• 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.
• 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.

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.
• Vital signs: Hypertension has been associated with OSA.
• 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.
• 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.

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.
• 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.
• 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.
• Age: The frequency and severity of major sleep disorders, such as SDB, RLS, and PLMD, increase with age.
• Weight: Obesity plays an important role in the pathophysiology of SDB. RLS has also been shown to have a correlation with body mass index.

Differential Diagnoses

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.
• Workup for sleep-maintenance insomnia should rule out PLMD and SDB.
• Sleep disturbance due to vasomotor symptoms should be differentiated from hormonal abnormalities.
• Abnormal behavior during sleep should be differentiated from nocturnal seizure disorder and REM sleep behavior disorder.
• The workup of excessive daytime sleepiness should include narcolepsy, SDB, and atypical depression.
• 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.

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.
• 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.
• 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.

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).

Behavioral approaches for the treatment of sleep disturbances are effective and should be used as first-line treatment for chronic insomnia. Specifically, in an NIH study, cognitive behavioral therapy for insomnia (CBT-I) has produced longer lasting effects than medication. CBT-I involves the modification of certain sleep-related mal adaptive behaviors and the identification of dysfunctional perceptions and attitudes related to sleep patterns. CBT-I has also been found effective in special populations including geriatric groups and patients suffering from chronic pain conditions.

• Menstruation-related sleep disorder
  • Generally, premenstrual insomnia disappears a few days after menstruation begins.
  • 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.
  • 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.
  • 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
  • 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.
  • Sleep disturbance during pregnancy also can be associated with frightening dreams, postpartum blues, and sometimes even major depression and postnatal psychosis.
  • 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.
  • Because sleeping pills and alcohol can harm the baby, other measures to improve sleep need to be considered.
  • The practice of muscle relaxation technique prior to bedtime may be effective in promoting better sleep and reducing the discomfort of pregnancy.
  • 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.
  • 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.
• Menopause-related sleep disorders
  • 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.
  • They should eliminate caffeine, sugar, and alcohol from their diet.
  • 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.
  • 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.
• Sleep-disordered breathing
  • In the presence of SDB, nasal CPAP and/or an oral device should be offered, along with recommendation regarding weight management.
  • 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.
  • Finally, weight management appears to be an important factor in the management of SDB in menopausal women.
• Sleep disorders in elderly women
  • Older women should be aware of sleep disturbances and not dismiss them as part of the aging process.
  • The presence of significant daytime sleepiness should be investigated and a sleep study may be required to rule out major sleep disorders.
  • 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.
  • General guidelines for better sleep habits should be provided.

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.
• 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.
• 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.
• Dentist: For patients who are unable to tolerate nasal CPAP, oral appliances may prove effective in the treatment of SDB.

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.

Medication

Treat underlying disease by HRT, hypnotics, antidepressants, and behavioral therapy.

Hypnotics

These agents are used for treatment of acute and short-term insomnia.

Zolpidem (Ambien, Ambien CR)

DOC for treatment of primary insomnia (ie, sleep-onset insomnia). Indicated for acute short-term insomnia for duration that does not exceed a few weeks. The extended-release product (Ambien CR) consists of a coated 2-layer tablet and is useful for insomnia characterized by difficulties with sleep onset and/or sleep maintenance. The first layer releases drug content immediately to induce sleep; the second layer gradually releases additional drug to provide continuous sleep.

Dosing

Adult

10 mg PO hs
Extended-release: 12.5 mg PO hs
Extended-release in elderly patients: 6.25 mg PO hs

Pediatric

Not established

Interactions

Increases toxicity of alcohol and CNS depressants; effect may be delayed if taken with food or shortly after a meal

Contraindications

Documented hypersensitivity; lactation

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Monitor elderly for impaired cognitive or motor performance; extended-release dosage form must be swallowed whole (do not divide, chew, or crush)

Zaleplon (Sonata)

A pyrazolopyrimidine, indicated for short-term treatment of difficulties in falling asleep. Should be used for 7-10 d. Has been shown to cause minimal daytime grogginess.

Dosing

Adult

5-10 mg PO hs

Pediatric

Not established

Interactions

Cimetidine significantly increases levels

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Failure of insomnia to remit after 7-10 d of treatment may indicate need for evaluation of primary psychiatric or medical illness; limit treatment to 7-10 d of use, and reevaluate patient if to be taken for >2-3 wk (do not prescribe in quantities exceeding 1-mo supply); in hepatic function impairment, reduce dose to 5 mg PO hs; caution in patients exhibiting signs or symptoms of depression

Eszopiclone (Lunesta)

Nonbenzodiazepine hypnotic pyrrolopyrazine derivative of the cyclopyrrolone class. The precise mechanism of action is unknown but is believed to interact with GABA-receptor at binding domains close to or allosterically coupled to benzodiazepine receptors. Indicated for insomnia to decrease sleep latency and improve sleep maintenance. Short half-life of 6 h. Higher doses (ie, 2 mg for elderly adults and 3 mg for nonelderly adults) are more effective for sleep maintenance, whereas lower doses (ie, 1 mg for elderly adults and 2 mg for nonelderly adults) are suitable for difficulty in falling asleep.

Dosing

Adult

Nonelderly adults: 2 mg PO hs; may increase to 3 mg PO hs prn
Elderly adults: 1 mg PO hs initially; not to exceed 2 mg PO hs
Severe hepatic impairment: Do not exceed 2 mg PO hs

Pediatric

<18 years: Not established
>18 years: Administer as in adults

Interactions

CYP3A4 and CYP2E1 substrate; potent CYP3A4 inhibitors (eg, ketoconazole, itraconazole, clarithromycin, nefazodone, ritonavir, nelfinavir) increases AUC, C_max, and t_1/2 and therefore potential toxicity (decrease dose); potent CYP3A4 inducers (eg, rifampicin) increase clearance; coadministration with alcohol or other CNS depressants may increase effect and toxicity (decrease dose); coadministration with olanzapine may decrease DSST scores; sleep onset may be delayed if taken with or immediately after a high-fat or heavy meal

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May cause dysgeusia, headache, or coldlike symptoms; rare adverse effects associated with hypnotics include short-term amnesia, confusion, agitation, hallucinations, worsened depression, or suicidal thoughts; high doses (ie, 6-12 mg) produce euphoric effects similar to those of diazepam 20 mg; anxiety, abnormal dreams, nausea, and upset stomach may occur within 48 h after discontinuing; alertness may be affected the following day, use caution while operating machinery or driving a car

Hormone replacement therapy

Estrogen replacement has been shown to improve sleep in menopausal women, primarily by reducing vasomotor symptoms that disturb sleep. In addition, may improve sleep-related breathing disorders. Studies have shown that estrogen, either alone or combined with progestin (but not progestin alone), markedly reduced OSA in menopausal women. Oral Premarin is an example of an oral estrogen replacement. The choice of HRT should be made on an individual basis in consultation with a gynecologist.

Conjugated estrogens (Premarin)

Multiple aspects of menopause respond to estrogen replacement therapy, including vasomotor symptoms and atrophic vaginitis. However, has not been shown effective in treating depression associated with menopause. Decisions for HRT should be made on individual basis in consultation with gynecologist. Dosing may need to be titrated individually, and each patient monitored for risks and adverse effects. Premarin available in tablet form for oral administration in strengths of 0.3 mg, 0.625 mg, 0.9 mg, 1.25 mg, and 2.5 mg.

Dosing

Adult

0.3-1.25 mg PO; use lowest possible effective dose

Pediatric

Not established

Interactions

May reduce hypoprothrombinemic effect of anticoagulants; barbiturates, rifampin, and other agents that induce hepatic microsomal enzymes may reduce levels; pharmacologic and toxicologic effects of corticosteroids may occur as result of estrogen-induced inactivation of hepatic P-450 enzyme; hydantoins may result in loss of seizure control

Contraindications

Documented hypersensitivity; known or suspected pregnancy; breast cancer; undiagnosed abnormal genital bleeding; active thrombophlebitis or thromboembolic disorders; history of thrombophlebitis, thrombosis; or thromboembolic disorders associated with previous estrogen use (except when used in treatment of breast or prostatic malignancy)

Precautions

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

While weight gain, peripheral edema, and breast tenderness are among more frequent adverse effects, patients should be advised to notify their gynecologist of any breast masses, depression, or changes in vaginal bleeding and their internist if they have any chest pain, tingling, or shortness of breath; advise patient to avoid exposure to prolonged or direct sunlight and not to skip doses or alter regimen without consulting physician

Antidepressants

Selective serotonin reuptake inhibitors (SSRIs) are generally well tolerated and are currently the most frequently prescribed drugs for treatment of depression. Pharmacologic treatment with antidepressants is indicated for PMDD, postpartum depression, and clinical depression in patients of any age.

Serotonin noradrenaline reuptake inhibitors (SNRIs) are also used. These agents exhibit both noradrenergic and serotonergic effects in patients with depression.

Sertraline (Zoloft)

Effective for treatment of clinical depression in women. Also indicated for panic disorders and obsessive-compulsive disorders.

Dosing

Adult

50 mg/d PO

Pediatric

Not established

Interactions

Increases toxicity of MAOIs, diazepam, tolbutamide, and warfarin; serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan), discontinue other serotonergic agents at least 2 wk prior to SSRIs

Contraindications

Documented hypersensitivity; concurrent MAOIs

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in preexisting seizure disorders, recent myocardial infarction, unstable heart disease, or hepatic or renal impairment

Escitalopram oxalate (Lexapro)

Insomnia associated with depression. Selective serotonin reuptake inhibitor (SSRI) and S-enantiomer of citalopram. Used for the treatment of depression. Mechanism of action is thought to be potentiation of serotonergic activity in central nervous system resulting from inhibition of CNS neuronal reuptake of serotonin. Onset of depression relief may be obtained after 1-2 wk, which is sooner than other antidepressants.

Dosing

Adult

10 mg PO daily without regard to meal; may titrate up to 20 mg qd

Pediatric

<18 years: Not established
>18 years: Administer as in adults

Interactions

Primarily metabolized by CYP450 3A4 and 2C19; coadministration with alcohol or other centrally acting drugs increases CNS depression; cimetidine increases AUC and maximum serum concentration; coadministration with sumatriptan and SSRIs has caused weakness and hyperreflexia

Contraindications

Documented hypersensitivity; administration within 14 d of receiving MAOI

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Elderly persons have decreased clearance; cognitive and motor function (use caution operating motor vehicles and heavy materials); depression may worsen; suicides have been reported; seizures; activation of mania/hypomania; lactation; physician must be consulted before other medications are added or used

Fluoxetine hydrochloride (Sarafem)

Approved recently for treatment of PMDD. Indicated for treatment of premenstrual insomnia associated with PMDD.

Dosing

Adult

20 mg PO qd

Pediatric

Not established

Interactions

Increases toxicity of diazepam and trazodone by decreasing clearance; increases toxicity of MAOIs and highly protein-bound drugs; serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan), discontinue other serotonergic agents at least 2 wk prior to SSRIs

Contraindications

Documented hypersensitivity; MAOIs within last 2 wk

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hepatic impairment and history of seizures; MAOIs should be discontinued at least 14 d before initiating fluoxetine therapy

Mirtazapine (Remeron)

Relatively new antidepressant, not as widely used as sertraline. Exhibits both noradrenergic and serotonergic activity. In cases of depression associated with severe insomnia and anxiety, has been shown superior to other SSRI drugs.

Dosing

Adult

15 mg (range 15-30 mg) PO hs initially; increase if necessary

Pediatric

Not established

Interactions

May increase effect of CNS depressants; concurrent MAOIs may trigger hypertensive crisis

Contraindications

Documented hypersensitivity; MAOIs within past 14 d

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May cause drowsiness; discontinue use if patient develops sore throat, fever, or other signs of infection; suicide ideation inherent in depression and may persist until significant remission occurs; severe neutropenia reported in clinical trials

Stimulants

These agents may be effective in narcolepsy.

Modafinil (Provigil)

Mechanism(s) of action in wakefulness unknown. Has wake-promoting actions like sympathomimetic agents.

Dosing

Adult

200 mg PO qd

Pediatric

<16 years: Not established
>16 years: Administer as in adults

Interactions

May decrease levels of cyclosporine or steroidal contraceptives, and to lesser degree, theophylline; may increase concentrations of diazepam, propranolol, and phenytoin

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Monitor patients closely for signs of misuse or abuse, especially those with history of abuse of drugs or stimulants such as methylphenidate, amphetamine, and cocaine

Armodafinil (Nuvigil)

R-enantiomer of modafinil (mixture of R- and S-enantiomers). Elicits wake-promoting actions similar to sympathomimetic agents, although pharmacologic profile is not identical to sympathomimetic amines. In vitro, binds dopamine transporter and inhibits dopamine reuptake. Not a direct- or indirect-acting dopamine receptor agonist. Indicated to improve wakefulness in individuals with excessive sleepiness associated with narcolepsy, obstructive sleep apnea-hypopnea syndrome (OSAHS), or shift-work sleep disorder.

Dosing

Adult

Narcolepsy: 150-250 mg PO qam
OSAHS: 150 mg PO qam; may increase dose, not to exceed 250 mg/d
Shift work: 150 mg PO administered 1 h before start of work shift

Pediatric

<17 years: Not established
>17 years: Administer as in adults

Interactions

Weakly induces CYP1A2 and CYP3A; may decrease levels of drugs metabolized by CYP1A2 (eg, theophylline) and CYP3A (eg, cyclosporine, midazolam, triazolam, steroidal contraceptives); may inhibit CYP2C19 activity, thereby increasing serum levels of CYP2C19 substrates (eg, omeprazole, phenytoin, propranolol)

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hepatic impairment and decrease dose with severe hepatic impairment; serious rash, including Stevens-Johnson syndrome, has been reported; other serious hypersensitivity reactions include angioedema, anaphylactoid reactions, and multiorgan hypersensitivity reactions; psychiatric adverse events (eg, mania, delusions, hallucinations, suicidal ideation) have been reported with modafinil; may increase blood pressure; monitor patients closely for signs of misuse or abuse, especially those with a history of drug or stimulant abuse (eg, methylphenidate, amphetamine, or cocaine)

Dopamine agonists

Dopamine agonists may be effective for treatment of restless legs syndrome.

Pramipexole (Mirapex)

Nonergot dopamine agonist with specificity of D2 dopamine receptor, but also has been shown to bind to D3 and D4 receptors and may stimulate dopamine activity on nerves of striatum and substantia nigra.

Dosing

Adult

0.125-1 mg PO hs initially, increase prn

Pediatric

Not established

Interactions

Cimetidine may increase toxicity; increases levodopa levels

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in renal insufficiency and preexisting dyskinesias

Melatonin agonists

Indicated for insomnia characterized by difficulty with sleep onset.

Ramelteon (Rozerem)

Melatonin receptor agonist with high selectivity for human melatonin MT₁ and MT₂ receptors. MT₁ and MT₂ are thought to promote sleep and be involved in maintenance of circadian rhythm and normal sleep-wake cycle.

Dosing

Adult

8 mg PO 30 min before bedtime on empty stomach

Pediatric

Not established

Interactions

Major substrate of cytochrome P450 CYP1A2 and minor substrate of CYP2C and CYP3A4; strong CYP1A2 inhibitors (eg, fluvoxamine) increase AUC up to 190-fold and C_max 70-fold; strong CYP inducers (eg, rifampin) decrease total exposure by mean of 80%; strong CYP3A4 inhibitors (eg, ketoconazole) and strong CYP2C9 inhibitors (eg, fluconazole) may increase serum levels

Contraindications

Documented hypersensitivity; strong cytochrome P450 CYP1A2 inhibitors (eg, fluvoxamine); severe hepatic impairment

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution with mild hepatic impairment; adverse effects leading to discontinuation in clinical trials included dizziness, nausea, fatigue, headache, and worsening insomnia

Benzodiazepines

These agents have been the hypnotics of choice for many years because of their relative safety compared to barbiturates. By binding to specific receptor sites, these agents appear to potentiate the effects of GABA and facilitate inhibitory GABA neurotransmission and other inhibitory transmitters.

Benzodiazepines are used when additional anxiolytic effects are desired in addition to hypnotic effects. Intermediate and long-acting benzodiazepines are used for sleep-maintenance insomnia.

Triazolam (Halcion)

Short acting; good agent for sleep-onset insomnia; has no significant residual effects in morning.

Dosing

Adult

0.125-0.25 mg PO hs; 0.125 mg PO hs in elderly persons

Pediatric

Not established

Interactions

Phenothiazines, barbiturates, alcohols, and MAOIs increase CNS toxicity

Contraindications

Documented hypersensitivity; narrow-angle glaucoma; untreated obstructive sleep apnea; history of substance abuse

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

High incidence of rebound insomnia; adverse effects include dizziness, drowsiness, and headache, all of which are dose related; use cautiously in depressed patients; caution and close monitoring needed in hepatic dysfunction, low albumin levels, renal or pulmonary disease; may cause residual daytime sedation, impair cognition, and increase risk of falls, especially in older people

Estazolam (ProSom)

Intermediate acting with slow onset of action and long duration; good agent for sleep-maintenance insomnia.

Dosing

Adult

1-2 mg PO hs; 0.5-1 mg PO hs in elderly persons

Pediatric

Not established

Interactions

Phenothiazines, barbiturates, alcohols, and MAOIs increase CNS toxicity

Contraindications

Documented hypersensitivity; narrow-angle glaucoma; untreated obstructive sleep apnea; history of substance abuse

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in depressed patients; most common adverse effects include drowsiness, hypokinesia, dizziness, and abnormal coordination; may have more significant respiratory depressive effects than other agents in its class; caution and close monitoring needed in hepatic dysfunction, low albumin levels, renal or pulmonary disease; may cause residual daytime sedation, impair cognition, and increase risk of falls, especially in older people

Temazepam (Restoril)

Indicated for both sleep-onset and maintenance insomnia. Should be taken at bedtime to prevent daytime aftereffects.

Dosing

Adult

<60 years: 15-30 mg/d PO qhs
>60 years: Use lower doses

Pediatric

Not recommended

Interactions

Phenothiazines, barbiturates, alcohols, and MAOIs increase toxicity

Contraindications

Documented hypersensitivity; narrow-angle glaucoma; untreated OSA; history of substance abuse; severe uncontrolled pain

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution with other CNS depressants, low albumin levels, or hepatic disease (may increase toxicity)

Nonergoline dopamine agonist

These agents may be effective for moderate-to-severe primary RLS. Neuropharmacological evidence suggests primary dopaminergic system involvement in RLS.

Ropinirole hydrochloride (Requip)

Second-generation, nonergoline dopamine agonist that directly stimulates dopamine receptors in brain. Has high specificity for D₃ receptor subtype. Indicated for moderate-to-severe RLS. Take at bedtime.

Dosing

Adult

Administer once daily, 1-3 h before bedtime; after 2 d, may gradually titrate dose upward to desired effect according the following schedule:
Days 1-2: 0.25 mg PO hs
Days 3-7: 0.5 mg PO hs
Week 2: 1 mg PO hs
Week 3: 1.5 mg PO hs
Week 4: 2 mg PO hs
Week 5: 2.5 mg PO hs
Week 6: 3 mg PO hs
Week 7: 4 mg PO hs

Pediatric

Not established

Interactions

Estrogens may reduce clearance by 36%; dose adjustment may be required if estrogen therapy stopped or started during treatment; potential exists for substrates or inhibitors of CYP1A2 to alter clearance; if therapy with potent CYP1A2 inhibitor stopped or started during treatment, dose adjustments may be necessary; dopamine antagonists (eg, phenothiazines, butyrophenones, thioxanthenes, metoclopramide) may diminish effectiveness; coadministration with sedatives and other CNS depressants may cause additive sedation

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Monitor for signs and symptoms of orthostatic hypotension; dopamine receptor agonists may potentiate adverse dopaminergic effects of levodopa and may cause or exacerbate preexisting dyskinesia (decreasing levodopa dose may ameliorate this adverse effect); retroperitoneal fibrosis, pulmonary infiltrates, pleural effusion, and pleural thickening have occurred in some patients treated with ergot-derived dopaminergic agents; complete resolution of these complications does not always occur when drug is discontinued; may cause patients to fall asleep or feel very sleepy while doing normal activities (eg, driving); common adverse effects while treating RLS include nausea, somnolence, vomiting, dizziness, and fatigue

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.
• 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.

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.
• 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.
• Body weight maintenance: Regular exercise and healthy diet promote good sleep. In addition, maintaining normal weight may prevent development of SDB associated with obesity.

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.
• 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.

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.
• 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.

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:
  • Get up about the same time every day.
  • Go to bed only when sleepy.
  • Establish a relaxing presleep routine such as reading or listening to relaxing music.
  • Avoid heavy meals or consuming caffeinated beverages within 5-6 hours before bedtime.
  • Avoid smoking close to bedtime. Avoid sleeping pills for periods longer than few weeks. Be careful not to drink alcohol while taking sleeping pills.
  • Maintain a regular daily schedule that includes exercise, down time, and regular meal times. Avoid strenuous exercises within 6 hours before bedtime.
  • Older women should try to take a daily afternoon nap at a regular time to prevent early evening dozing.
• 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.

Miscellaneous

Medicolegal 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.

Special Concerns

• Pregnancy-related sleep disorder
  • 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.
  • 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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Keywords

insomnia, sleep disorders, sleep-onset insomnia, sleep-maintenance insomnia, circadian rhythm, sleep-disordered breathing, upper airway resistance syndrome, UARS, obstructive sleep apnea, OSA, restless legs syndrome, RLS, periodic limb movement disorder, PLMD, narcolepsy, parasomnias, premenstrual syndrome, PMS, sleep deprivation, sleep hygiene, snoring, fatigue, pregnancy-related sleep disorder, menstrual cycle and sleep

Contributor Information and Disclosures

Author

Gila Hertz, PhD, ABSM, Director, Center for Insomnia and Sleep Disorders, Clinical Associate Professor of Psychiatry and Behavioral Sciences, State University of New York at Stony Brook
Gila Hertz, PhD, ABSM is a member of the following medical societies: American Academy of Sleep Medicine and American Psychological Association
Disclosure: Nothing to disclose.

Coauthor(s)

Mary E Cataletto, MD, Associate Director, Division of Pediatric Pulmonology, Winthrop University Hospital; Professor of Clinical Pediatrics, State University of New York at Stony Brook; Director of Children's Sleep Services, Winthrop University Hospital
Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians
Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

Medical Editor

Carmel Armon, MD, MSc, MHS, Professor of Neurology, Tufts University School of Medicine; Chief, Division of Neurology, Baystate Medical Center
Carmel Armon, MD, MSc, MHS is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Association of Neuromuscular and Electrodiagnostic Medicine, American Clinical Neurophysiology Society, American College of Physicians, American Epilepsy Society, American Medical Association, American Neurological Association, American Stroke Association, Massachusetts Medical Society, Movement Disorders Society, and Sigma Xi
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Norberto Alvarez, MD, Assistant Professor, Department of Neurology, Harvard Medical School; Consulting Staff, Department of Neurology, Boston Children's Hospital
Norberto Alvarez, MD is a member of the following medical societies: American Academy of Neurology, American Epilepsy Society, and Child Neurology Society
Disclosure: Nothing to disclose.

CME Editor

Matthew J Baker, MD, Consulting Staff, Collier Neurologic Specialists, Naples Community Hospital
Matthew J Baker, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Chief Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Gabriele M Barthlen, MD to the development and writing of this article.

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