Sleep disruptions are very, very common in women. In my sleep medicine practice, female patients tell me, “Yes, I’m tired during the day. But it’s because I work full time, I’m the primary caregiver for my children, and I volunteer on weekends.”
It’s true our lives are busy, but that isn’t the only reason many women have trouble sleeping. Normal hormone and body changes throughout the stages of life – from the teen years to pregnancy, menopause, and beyond – can disrupt sleep, even if we don’t realize what’s causing it. Chronically poor sleep can increase the risk of health problems such as diabetes and heart disease, and it can worsen some physical and mental health conditions, such as high blood pressure, anxiety, and depression.
I recently co-edited a publication called “A Clinical Casebook of Sleep Disorders in Women” with Imran S. Khawaja, M.D., a psychiatrist in Fort Worth. We documented how physiological changes impact sleep volume and quality and how women’s sleep disorder symptoms differ from men’s.
Some sleep problems women experience, such as daytime fatigue, snoring, and waking up frequently at night, may require a doctor’s intervention and specialized care at a facility such as UT Southwestern’s Sleep and Breathing Disorders Clinic, where we provide sleep studies to collect information about your breathing patterns, brain and lung activity, and blood oxygen levels as you sleep.
The good news is many sleep problems can be prevented with changes to our habits and lifestyle. Others may require medication or assistive medical devices. And for patients with complex combinations of mental health and sleep conditions, we provide whole-patient care at our hospital-based sleep medicine clinic with one goal in mind: Getting you the rest you and your body need.
Teens and period-related sleep issues
Adolescence is a time in life marked by mood swings and sleep disturbance. You probably remember those years, or perhaps you’re witnessing them again in real-time with your own child. Girls go through a lot of hormonal swings when they get their first period, a time called menarche, and those changes continue until their cycles become more regular in young adulthood.
While most girls are exposed to “what to expect” education about cramps and bleeding, there is less information circulating about how period-related changes can disrupt sleep.
Women are twice as likely to experience insomnia symptoms before and during their period. Normal hormonal changes in teens can exacerbate those sleep problems.
What’s happening in the body
During the menstrual cycle, luteinizing hormone and follicle stimulating hormones are produced in the brain and stimulate the ovaries to produce the sex hormones estrogen and progesterone. (Remember those, because we’ll talk about them a lot!)
Estrogen peaks at 10-14 days of the menstrual cycle, when ovulation occurs. That’s when the ovaries release an egg. Estrogen declines after ovulation and progesterone peaks, then estrogen peaks again the week before the period starts.
Progesterone acts on the GABA receptors, which help nerves send and receive signals from the brain. In teen girls, this action can cause drowsiness. At the same time, teen girls are entering a delayed sleep phase, meaning they need less sleep than in childhood. Between 13 and 19, they’ll sleep 40-50 minutes less each night. However, more than 70% of high school students don’t get enough sleep.
Bottom line: Teen girls’ hormones are making them sleepy and natural sleep cycle changes are telling their brains they don’t need sleep. No wonder they’re so moody!
When to see a doctor
If your teenager complains of being tired, has noticeable difficulty sleeping, or is struggling at school or in relationships with friends, that’s a sign they might need help from a doctor. Sleep disturbances might be causing them to feel angry, tearful, and overwhelmed.
Try to be patient. Take a deep breath and offer these sleep hygiene tips:
- Iron supplements can help relieve nocturnal leg movements associated with period-related blood loss.
- No devices after a certain time at night to reduce light stimulation, doom scrolling, and friend drama.
- Eat a healthier diet with less caffeine to improve sleep volume and overall health.
- Try over-the-counter sleep aids such as melatonin as directed to fall asleep sooner and stay asleep longer.
Use of alcohol, drugs, or nicotine can also make sleep and mood conditions worse. Parasomnias such as night terrors, bedwetting, or excessive leg movements in sleep should be evaluated by a doctor. Your child may be referred to a neurologist or behavioral health specialist for diagnosis and treatment.
Related reading: 6 tech tips to get a better night's sleep
Pregnancy-related sleep issues
Some sleep disturbance in pregnancy is normal. Along with a swirl of new emotions, your expanding belly might be making sleep uncomfortable, and your brain is producing extra hormones that can disrupt sleep cycles.
Progesterone (there’s that hormone again!) increases in pregnancy, driving changes in breathing and oxygen consumption. And as your abdomen expands, your ability to draw in air decreases. That means you need to take more breaths per minute, even during sleep.
Pregnancy also increases fluid retention in the throat, narrowing your breathing space, which can lead to snoring. Don’t ignore snoring. It can be a sign of obstructive sleep apnea (OSA), a disorder that causes you to stop breathing multiple times per hour during sleep.
Sleep apnea: About 30 million people in the U.S. have OSA, including 20% of pregnant patients. Sleep apnea during pregnancy can lead to long-term health complications, such as increased risk of severe high blood pressure (preeclampsia), gestational diabetes, or premature delivery. OSA also increases the risk of needing a cesarean (C-section) delivery and a longer labor.
If you have OSA symptoms, such as snoring, daytime fatigue, or being told you stop breathing in your sleep, the Ob/Gyn might refer you for a sleep study to learn more. Wearing a CPAP mask is safe and effective in pregnancy.
Restless legs syndrome (RLS) tormented me during pregnancy. I woke up every few minutes for weeks! Later, I learned that RLS is twice as common in women than men. Iron deficiency anemia is more common during pregnancy, and taking iron supplements can relieve RLS. However, drinking caffeine and certain medications can make RLS symptoms worse.
Insomnia is another condition associated with pregnancy. It keeps you awake when all you want to do is sleep! Approximately 20-60% of pregnant women report insomnia symptoms compared to 6-10% of the general population. Stress, lifestyle choices, and – you guessed it – progesterone can increase insomnia during pregnancy.
Your Ob/Gyn or primary care provider can help diagnose the cause of insomnia and advise you on whether it’s safe to take melatonin or other over-the-counter sleep aids while pregnant.
Women’s sleep disorders throughout adulthood
Everyone wakes up in the night to adjust their position or kick off the covers. But if you are sleeping fewer than 5-6 hours at a stretch, you’re told you snore, it feels as if you’re awake more than asleep, or daytime fatigue is disrupting your daily living, it’s time to see a doctor.
Obstructive sleep apnea
Before menopause, estrogen and progesterone protect against airway collapse in the throat, one of the classic OSA symptoms. So, OSA tends to be less severe in women than in men until hormone production slows in menopause. While that protection is good, less disruptive symptoms may lead to later diagnosis of OSA.
Women also often have different OSA symptoms than men. My male patients tell me they snore, but women often say they breath heavily at night or wake up often to use the bathroom. But when we start digging into their symptoms – daytime sleepiness, zapped energy, low motivation – OSA reveals itself.
OSA can be associated with being overweight or obese. However, anyone can develop sleep apnea due to hormone changes or anatomy differences such as having large tonsils or a narrow throat.
For OSA, the doctor likely will recommend CPAP therapy, a device that pushes air through a mask to keep you breathing steadily through the night. CPAP machines have gotten increasingly smaller and quieter, with some masks covering just the nose.
Many patients’ partners say listening to the machine, which sounds like white noise, is far preferable to hearing their partner snore – or waking up afraid they stopped breathing.
Frequent nighttime urination
Nocturia, or frequent nighttime urination, can be its own problem or a symptom of OSA. While you might wake up because you drank too much liquid before bed, it could also be because your brain is waking you up to breathe.
OSA reduces breathing efficiency and lowers your oxygen saturation, which is the amount of oxygen in your blood. That makes the brain think your heart is failing, which sparks production of a hormone called atrial natriuretic peptide (ANP). ANP increases urination to get rid of excess fluid, which is a symptom of heart failure – and all that fluid has to go somewhere.
The doctor might ask you to stop drinking beverages close to bedtime, reduce caffeine intake, and avoid energy drinks and some flavored waters that contain bladder-irritating ingredients. If behavior changes aren’t enough, they may recommend a sleep study to diagnose the condition. Depending on the cause of nocturia, treatment may also involve medication or CPAP therapy.
Hypersomnia and narcolepsy
Hypersomnia is an umbrella term for conditions that cause you to sleep too much when you should be awake. It’s triggered by changes in the neurotransmitters of the brain that are responsible for regulating our sleep and wake cycles. Hypersomnia is usually a symptom of OSA but can also be caused by some medications, autoimmune conditions, or genetics.
Narcolepsy is not common and affects less than 1% of the U.S. population. OSA and hypersomnia are often misdiagnosed as narcolepsy because all three can cause daytime fatigue. But along with tiredness, narcolepsy causes sudden sleep attacks. Patients might be doing something they really enjoy or something that causes intense emotion, and they’ll suddenly fall asleep. Both conditions may be treated with CPAP therapy or medication.
Don’t dismiss your symptoms – taking care of sleep disorders can reduce your risk of many chronic health problems and can de-amplify symptoms of mental health conditions such as anxiety and depression.
Sleep disorders during menopause
During menopause, which for most women begins in the 40s or 50s, production of estrogen and progesterone (there they are again!) starts to decline. This can lead to sleep-disruptors such as:
- Hot flashes, which cause you to suddenly feel warm from the chest up
- Night sweats
- Frequent waking at night
For this group, hormone replacement therapy (HRT) can help relieve symptoms. Modern HRT is safe and effective, when monitored by a doctor and used appropriately. When symptoms are controlled, you can wean off HRT medication after menopause.
Selective serotonin reuptake inhibitor (SSRI) medications such as sertraline, an anxiety medication, also can reduce sleep disturbances and may improve hot flashes. Avoiding caffeine and nicotine can help, too, along with using a fan to stay cool.
Related reading: Sleep: The real Fountain of Youth
Psychiatric conditions and sleep disorders
Sleep disorders can also be inexorably linked with mental health symptoms and conditions such as bipolar disorder, anxiety, and depression. While treating the mood disorder can significantly improve a patient’s symptoms, it’s also essential to their overall health to diagnose and treat the underlying sleep disorder.
In many cases, performing a sleep study is a non-invasive way to get a baseline and start improving quality of life and sleep while working through mental health diagnoses and treatments.
UT Southwestern is an academic medical center, which means we are on the leading edge of sleep medicine research and treatments. You might even say we’ve written the book on treating sleep disorders in women. Together, our multidisciplinary sleep medicine team will answer your questions and get you with the care you need to start feeling better or more rested at any stage of life.