Sleep Problems Among Women: Who and When?

SEATTLE—Sleep disturbances may be prevalent among women during pregnancy, midlife, and menopause, according to three separate studies presented at the 23rd Annual Meeting of the Professional Sleep Societies. Researchers also suggested that women in midlife do not report significantly more symptoms of sleep disordered breathing with increasing severity of obstructive sleep apnea (OSA) and that actigraphy data is strongly correlated with self-reported symptoms in menopausal women.

SLEEP DISTURBANCES INCREASE SIGNIFICANTLY DURING PREGNANCY

“Despite various sleep problems during pregnancy, little data exists regarding the exact nature and prevalence of sleep disorders in pregnancy,” according to Francesca L. Facco, MD, of the Feinberg School of Medicine at Northwestern University in Chicago, and colleagues.

In a prospective cohort, they sought to evaluate the prevalence of sleep disturbances as well as quantify changes in sleep during the pregnancy of healthy nulliparous women. The study participants completed a sleep survey at the time of enrollment (ie, six to 20 weeks gestation) and during the third trimester (28 to 40 weeks).

The sleep survey consisted of the Berlin Questionnaire (which is used to assess the risk of sleep apnea), the Epworth sleep quality index, the Pittsburgh Sleep Quality Index (PSQI, which is used to assess sleep quality and disturbances over a one-month time interval), the National Institutes of Health/International restless legs syndrome question set for restless legs syndrome, the Women’s Health Initiative Insomnia Rating Scale (WHI-IRS), and questions pertaining to work schedule (ie, conventional schedule, rotating shift work schedule, or consistent night shift).

Women diagnosed with hypertension, pregestational diabetes, chronic renal disease, or any autoimmune disorder, as well as women with significant congenital anomalies and multiple gestations were excluded from the analysis.

In 188 women (mean age, 29.7 years) eligible for inclusion and who completed part or all of both surveys, mean gestational age was 13.8 and 30.0 weeks during first and second survey, respectively. The patient population consisted of 61.2% white, 14.8% black, 11.1% Hispanic, and 12.2% other women. Pre-pregnancy BMI was 24.1 and 84% of women were employed, the study authors reported.

The proportion of patients who screened positive for sleep apnea on the Berlin Questionnaire increased from 10.6% to 19.7% from the first to the second assessment. Using paired t-test and McNemar’s test to compare the initial and third trimester survey, Dr. Facco and colleagues observed that the frequency of poor sleep (ie, PSQI > 5) significantly increased from 39.2% to 53.2% during pregnancy and insomnia (ie, WHI-IRS ≥ 9) significantly increased from 37.3% to 54.1%. Short sleep duration (< 7 hours/night) was significantly more prevalent during the third trimester (26.4% vs 39.6%), the investigators further observed. Frequent snoring (11.1% vs 16.4%) and restless leg syndrome diagnosis (17.5% vs 31.2%) also increased.

“Further research is needed to examine the relationship between sleep disturbances and adverse pregnancy outcomes,” the investigators suggested.

PREDICTORS OF OSA DURING MIDLIFE

In another study, Elizabeth A. Beothy, of the Center for Sleep and Respiratory Neurobiology at the University of Pennsylvania School of Medicine and colleagues evaluated multivariate apnea prediction (MAP) index scores—a questionnaire that incorporates data on age, sex, BMI and symptom frequency—in midlife women with varying degrees of OSA severity.

“The MAP index is a survey screen that has been validated as a predictor of the presence of OSA in general sleep clinic and other, largely male populations,” the study authors explained. Prior research has shown that women tend to underrerport sleep apnea symptoms such as snoring, and often report symptoms differently than do men.

“Since women are thought to underreport symptoms of sleep-disordered breathing,” they added. “We wanted to determine whether the MAP Index and the Apnea Symptoms Score, one of the MAP subscales, are higher among midlife women with more severe sleep-disordered breathing.” The researchers also evaluated whether MAP index scores and OSA severity were higher among black women compared with white women.

In this longitudinal cohort study, patients underwent yearly in-home overnight polysomnography and completed an MAP index questionnaire on the night of the sleep study. MAP index scores range from 0.01 to 1.00, with the higher MAP score indicating increased risk of OSA, the authors explained.

Electroencephalography, electromyography, electro-oculography, nasal pressure, respiratory effort, heart rate, oxyhemoglobin saturation, and body position were also recorded.

Ms. Beothy and colleagues included premenopausal, perimenopausal, or postmenopausal women from the Philadelphia area between the ages 40 and 57. Hysterectomy, bilateral oopherectomy, or tracheostomy, current use of hormone replacement therapy, hormonal birth control, or other hormonal medications, currently pregnant and nursing, self-reported drug or alcohol abuse, and serious chronic medical conditions were criteria for exclusion.

A total of 118 women (mean age, 51.9 years) who completed at least one and up to two sleep studies were included in the analysis. The study group had a mean BMI of 31.4 and consisted of 53.4% black women and 46.6% white women. Using apnea-hypopnea index (AHI) scores, investigators classified the patients as normal (AHI 0 ≤ 5 events/hour; 13.6%), or as having mild (AHI 5 ≤ 15 events/hour; 32.2%), moderate, (AHI 15 ≤ 30 events/hour; 40.7%) or severe (AHI ≥ 30 events/hour; 13.6%) OSA.

Of 173 polysomnograms and MAP questionnaires, Ms. Beothy and colleagues found that MAP scores increased with OSA severity. MAP scores among women with severe OSA were significantly higher than among women without OSA; however, at less severe levels of sleep-disordered breathing, MAP scores were not significantly different from women without OSA. Similarly, Ms. Beothy and colleagues found that Apnea Symptom Scores increased in correlation with increasing severity of sleep-disordered breathing; the relationship was not significant, however.

In addition, black women reported significantly more symptoms associated with sleep-disordered breathing than white women. However, “In unadjusted and adjusted models, race was not a significant predictor for AHI in these midlife women,” the study authors noted. “As seen in other populations, BMI and age were significant predictors of AHI.”

ACTIGRAPHY IS USEFUL TO ASSESS SLEEP IMPAIRMENTS

In the third study, Joseph M. Ojile, MD, of the Clayton Sleep Institute in St. Louis, and colleagues assessed sleep quality and daytime functioning in menopausal women (age range, 41 to 59) with sleep onset insomnia complaints.

“During the menopausal transition the incidence of insomnia and other sleep disturbances significantly increase,” Dr. Ojile and colleagues explained. “However, there is limited data investigating the relationships of self-reported sleep quality, daytime functioning, and vasomotor-symptoms with actigraphy in this population.”

Investigators used the Clayton Daytime Functioning Scale, Sleep Self-Efficacy Scale (SSES), Pre-Sleep Arousal Scale, and the Short Form 36 (SF36), a multipurpose, short-form health survey, as the basis for patients’ self-evaluation. In addition, they administered the Digital Symbol Test and the Paced Auditory Serial Addition Test in the morning of the study to assess neurobehavioral parameters of interest. Patients also wore actigraphy on their non-dominant wrist for two weeks, kept a sleep diary, and recorded hot flashed during that time span.

Of 22 women (mean age, 50.8) included in this study, actigraphy sleep onset latency was significantly associated with the SSES, the Pre-Sleep Arousal Scale somatic scale, the sleep diary, as well as the Digit Symbol Test, the investigators observed. In addition, they found that actigraphy sleep onset latency significantly predicted SSES score and accounted for 34% of the variance.

Actigraphy wake time after sleep onset and sleep efficiency was significantly associated with reported diary sleep time, investigators observed; each significantly predicted reported sleep duration. Furthermore, Dr. Ojile and colleagues reported that actigraphy time in bed and sleep time were both significantly associated with the Clayton Daytime Functioning Scale, subjective sleep quality, and several quality of life subscales. The frequency of daytime and sleep-related hot flashes was significantly associated with impaired SESS scores, the study authors observed. The reported intensity of hot flashes was associated and predicted daytime functioning impairments, they further noted.

“In general,” the study authors added, “the frequency of hot flashes (day or night) were significantly correlated to insomnia related complaints, and the intensity of the hot flashes significantly related to sleep quality and quality of life impairments.”

—Frederique H. Theuvenin

Suggested Reading
Pien GW, Schwab RJ. Sleep disorders during pregnancy. Sleep. 2004;27(7):1405-1417.
Foley D, Ancoli-Israel S, Britz P, et al. Sleep disturbances and chronic disease in older adults: results of the 2003 National Sleep Foundation Sleep in America Survey. J Psychosom Res. 2004;56(5):497-502.
Zee PC, Turek FW. Sleep and health: everywhere and in both directions. Arch Intern Med. 2006;166(16):1686-1688

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