Updated August 2004

Women's Unique Sleep Experiences

Sleep is a basic human need, as important for good health as diet and exercise. When we sleep, our bodies rest but our brains are active. Sleep lays the ground-work for a productive day ahead. Although most people need seven to nine hours of sleep each night to function well the next day, the National Sleep Foundation (NSF) 1998 Women and Sleep Poll found that the average woman aged 30-60 sleeps only six hours and forty-one minutes during the workweek. A more recent 2002 NSF Sleep in America poll of all adults revealed that women are more likely than men to have difficulty falling and staying asleep and to experience more daytime sleepiness at least a few nights/days a week. Research has shown that too little sleep results in daytime sleepiness, increased accidents, problems concentrating, poor performance on the job and in school, and possibly, increased sickness and weight gain.

Getting the right amount of sleep is vital, but just as important is the quality of your sleep. Biological conditions unique to women, like the menstrual cycle, pregnancy and menopause, can affect how well a woman sleeps. This is because the changing levels of hormones that a woman experiences throughout the month and over her lifetime, like estrogen and progesterone, have an impact on sleep. Understanding the effects of these hormones, environmental factors and lifestyle habits can help women enjoy a good night's sleep.

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Understanding Your Monthly Cycle

Changes in women's bodies occur at different times in the menstrual cycle and may affect sleep. For example, 50% of menstruating women report bloating that disturbs their sleep according to NSF's Women & Sleep poll. On average, these women report disrupted sleep for two to three days each menstrual cycle. These changes can be linked to the rise and fall of hormone levels in the body. In general, estrogen (estradiol) increases Rapid Eye Movement (REM) sleep, a deep stage of sleep when we typically dream. The hormone progesterone, which rises after ovulation (when an ovary releases an egg), may cause some women to feel more sleepy or fatigued. However, poor quality sleep is more likely at the beginning of the menstrual cycle when bleeding starts. Other factors that influence sleep are stress, mood, illness, medications, diet, lifestyle and the sleep environment. Women's sleep experiences vary greatly during the menstrual cycle and certain types of sleep problems are associated with each phase of the cycle:

Before Ovulation (days 1-12): Typically, the period (bleeding or menstruation) occurs for about five days. After the period ends, an egg ripens in the ovary. During menstrual bleeding, women tend to get less restful sleep than at other times. 36% of women polled by NSF said their sleep was most disturbed during the first few days of their menstrual periods.

Ovulation (days 13-14): An egg is released. If the egg is fertilized, pregnancy occurs. Otherwise the cycle continues and a menstrual period results in about 14 days.

After Ovulation (days 15-28): If pregnancy doesn't occur, the lining of the uterine wall begins to break down; it is shed during the menstrual period.

• Progesterone levels start off high at the beginning of this phase, reaching their peak level around days 19-21. Then levels begin to decrease toward the end of the phase. Women may find it more difficult to fall asleep. This may be related to the rapidly falling levels of progesterone.
• Premenstrual Syndrome (PMS) symptoms may occur during the later portion of this phase (starting about days 22-28). These include bloating, headaches, moodiness, irritability and abdominal cramps: any or all may contribute to difficulty sleeping well. The most common sleep-related problems reported by women with PMS are: insomnia (difficulty falling asleep, staying asleep, waking up too early or unrefreshed sleep), hypersomnia (sleeping too much), and daytime sleepiness.

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Tips that May Help Sleep

If you have difficulty with your sleep for any reason, here are some tips that may help you get a better night's sleep:

1. Exercise regularly, but finish your workout at least three hours before bedtime. Exercise may relieve some PMS symptoms and increase the amount of deep sleep.

2. Avoid foods and drinks high in sugar (including honey, syrup), caffeine (coffee, colas, tea, chocolate), and alcohol before bedtime. Caffeine and alcohol disturb sleep. Caffeine can also contribute to premenstrual bloating. Nicotine may make it difficult to fall asleep and lead to fragmented sleep. It can also put you at risk for cancer and heart disease. Avoid large meals and limit fluid intake before bed. Try a healthy snack so you are not too full or too hungry.

3. Try to have a standard relaxing bedtime routine and keep regular sleep times. Make sure your bedroom is dark, cool and quiet and that your pillows, sleep surface and coverings provide you with comfort.

4. For reducing PMS symptoms such as bloating, irritability and breast tenderness or other problems, consult your health-care professional.

Pregnancy: Sleeping for Two

Pregnancy is an exciting and physically demanding time. Physical symptoms (body aches, nausea, leg cramps, fetus movements and heart-burn), as well as emotional changes (depression, anxiety, worry) can interfere with sleep. In the NSF poll, 78% of women reported more disturbed sleep during pregnancy than at other times although some women have few sleep problems. Sleep related problems also become more prevalent as the pregnancy progresses. One recent study reported that changes in sleep occur in 13-20% of women in the first trimester and increase to 66-90% by the third trimester. In general, nausea can be experienced early whereas general discomfort may disrupt sleep later in the pregnancy.

• First Trimester (Months 1-3)

Overall, women have lower quality of sleep during the last trimester of pregnancy. High levels of progesterone are produced, increasing feelings of sleepiness. Also, the enlarged uterus can press up against the diaphragm, making it more difficult to breathe. The number of times a woman wakes up during the night to urinate increases as well. Disturbed sleep patterns may begin. Interrupted sleep can cause daytime sleepiness. Women tend to sleep more during this time than before they were pregnant, or later in pregnancy.

• Second Trimester (Months 4-6)

During this trimester, the growing fetus reduces pressure on the bladder by moving above it and decreasing the need for frequent bathroom visits. Sleep quality is still worse than it was before pregnancy and many women become restless as they search for a comfortable position.

• Third Trimester (Months 7-9)

Women experience the most pregnancy-related sleep problems at this time although they may sleep longer and nap more by the end of the pregnancy. They may often feel physically uncomfortable. Heartburn, leg cramps and sinus congestion are common reasons for disturbed sleep, as is an increased need to go to the bathroom. (The fetus puts pressure on the bladder again.) One recent study reported, that by the end of pregnancy, 97% of women were waking during the night.

• Post-Partum

As might be expected, mothers of newborn babies experience a lot of sleeplessness and daytime sleepiness, which may contribute to the "postnatal blues" experienced by 75-80% of most new mothers. This is usually a temporary condition, but it can become extremely serious and even put a new mother at risk for suicide. In general, it is treatable with professional help and will improve as the baby develops and establishes regular, nighttime sleep.

Snoring and Severe Daytime Sleepiness

Pregnant women who have never snored before may begin doing so. About 30% of pregnant women snore because of increased swelling in their nasal passages. This may partially block the airways. Snoring can also lead to high blood pressure, which can put both the mother and fetus at risk. If the blockage is severe, sleep apnea may result, characterized by loud snoring and periods of stopped breathing during sleep. The lack of oxygen disrupts sleep and may affect the unborn fetus. If loud snoring and severe daytime sleepiness (another symptom of sleep apnea and other sleep disorders) occur, consult your physician.

Secondary Restless Legs in Pregnancy

Up to 15 percent of pregnant women develop Restless Legs Syndrome (RLS) during the third trimester. A contributing cause may be iron and/or folate acid deficiency. In general, RLS is more prevalent in women than men. RLS symptoms make it difficult to fall and stay asleep due to an uncontrollable urge to move the legs in response to unpleasant, restless, creepy feelings in the legs. These feelings appear when at rest and often disrupt sleep as well. Moving the legs can stop these symptoms temporarily, but the irritation returns when the limb is still. Fortunately, RLS symptoms usually end after delivery of the baby. Medications used to treat RLS may cause harm to the fetus and should be discussed with a doctor.

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Sleep Tips for Pregnant Women

1. In the third trimester, sleep on your left side to allow for the best blood flow to the fetus and to your uterus and kidneys. Avoid lying flat on your back for a long period of time.

2. Drink lots of fluids during the day, but cut down before bedtime.

3. To prevent heartburn, do not eat large amounts of spicy, acidic (such as tomato products), or fried foods. If heartburn is a problem, sleep with your head elevated on pillows.

4. Exercise regularly to help you stay healthy, improve your circulation, and reduce leg cramps.

5. Try frequent bland snacks (like crackers) throughout the day. This helps avoid nausea by keeping your stomach full.

6. Special "pregnancy" pillows and mattresses may help you sleep better. Or use regular pillows to support your body.

7. Naps may help. The NSF poll found that 51% of pregnant or recently pregnant women reported at least one weekday nap; 60% reported at least one weekend nap.

8. Learn to relax with relaxation and breathing techniques, which can also help when the contractions begin. A warm bath or shower before bed can be helpful.

9. Talk to your doctor if you develop medical problems and/or insomnia persists.

Once her baby is born, a mother's sleep is frequently interrupted, particularly if she is nursing. Mothers who nurse and those with babies that wake frequently during the night should try to nap when their babies do. Sharing baby care to the extent possible, especially during the night, is important for the mother's health, safety, performance and vitality.

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Understanding Menopause

Menopause is a time of major hormonal, physical and psychological change for women although menopausal symptoms vary from woman to woman. During the perimenopause or transition phase, a woman's ovaries gradually (over several years) decrease production of estrogen and progesterone. If a woman has her ovaries surgically removed (oophorectomy), periods end abruptly and menopausal symptoms become more severe. One year after menstrual periods have stopped, a woman reaches menopause, on average around the age of 50. From peri-menopause to post-menopause, women report the most sleeping problems. Most notably, these include hot flashes, mood disorders, insomnia and sleep-disordered breathing. Sleep problems are often accompanied by depression and anxiety.

Generally, post-menopausal women are less satisfied with their sleep and as many as 61% report insomnia symptoms. Snoring has also been found to be more common and severe in post-menopausal women. Snoring, along with pauses or gasps in breathing are signs of a more serious sleep disorder, obstructive sleep apnea (OSA).

Changing and decreasing levels of estrogen cause many menopausal symptoms including hot flashes, which are unexpected feelings of heat all over the body accompanied by sweating. They usually begin around the face and spread to the chest affecting 75-85% of women around menopause. Prior to the hot flash, body temperature rises accompanied by an awakening. Hot flashes last on average three minutes leading to less sleep efficiency. Most women experience these for one year, but about 25% have hot flashes for five years. While total sleep time may not suffer, sleep quality does. Hot flashes may interrupt sleep and frequent awakenings cause next-day fatigue.

Treatment with estrogen (Estrogen Replacement Therapy, ERT) or with estrogen and progesterone (Hormone Replacement Therapy, HRT) has been found to help relieve menopausal symptoms. The effects of HRT and ERT vary among women depending on the form taken (pill, patch, gel, cream or injection) and the number of years used. However, recent large-scale U.S. government funded studies, the Women's Health Initiative, were stopped due to safety concerns since it was found that taking HRT may put women at risk for cardiovascular disease and dementia. For those taking HRT to reduce menopausal symptoms, it is recommended that HRT be prescribed at the lowest effective dose and used only for brief periods, not long-term. It is recommended you talk to your physician about your symptoms, the risks and benefits of HRT and alternative approaches for managing menopausal symptoms, including sleep.

There are alternative approaches for managing menopausal symptoms which may work for you. These include nutritional products and medications such as calcium supplements, vitamin D, and bisphosphonates for the prevention or treatment of osteoporosis (thinning and weakening of the bones); estrogen creams and rings for vaginal dryness; and sleep-promoting drugs for insomnia. All forms of estrogen that enter the blood stream reduce hot flashes.

An alternative treatment for menopausal symptoms may come from soy products (tofu, soybeans, and soymilk). They contain phytoestrogen, a plant hormone similar to estrogen. Soy products may lessen hot flashes, but there are no consistent results for its ability to relieve them. Furthermore, they can have gastrointestinal side effects. Just because it is a natural product does not necessarily mean it is safer to use than other treatments.

Phytoestrogens are also available in over-the-counter nutritional supplements (ginseng, extract of red clover, black cohosh). These supplements are not regulated by the Food and Drug Administration (FDA); their proper doses, safety, long-terms effects and risks are not yet known.

Deciding what, if any, product to use and, if so, for how long, are questions a woman should discuss with her doctor. The answer will depend on personal and family medical history.

Sleep Tips during Menopause

• Eat healthy. Avoid large meals, especially before bedtime. Maintain a regular, normal weight. Some foods that are spicy or acidic may trigger hot flashes. Try foods rich in soy as they might minimize hot flashes.
• Avoid nicotine, caffeine and alcohol, especially before bedtime.
• Dress in lightweight clothes to improve sleep efficiency. Avoid heavy, insulating blankets and consider using a fan or air conditioning to cool the air and increase circulation.
• Reduce stress and worry as much as possible. Try relaxation techniques, massage and exercise. Talk to a behavioral health professional if you are depressed, anxious or having problems.

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Most Common Sleep Problems in Women

Nearly 40 million American men and women suffer from sleep disorders.

However, sleep problems affect more women than men. New research exploring women's sleep experiences may lead to specially tailored treatments.

Insomnia

Insomnia is the most common sleep problem. Women are more likely than men to report insomnia. In fact, according to the 2002 NSF Sleep in America poll, more women than men experience symptoms of insomnia at least a few nights a week (63% vs. 54%) and they are more likely to have daytime sleepiness. Sometimes, women begin to have sleepless nights associated with menstruation, pregnancy or menopause and find it difficult to break poor sleep habits. Fortunately, there are a number of approaches to improving sleep, including those you can do yourself such as exercise, establishing regular bed and wake times, dietary changes (less or no caffeine and alcohol) and improving your sleep environment. One recent study found that overweight, post-menopausal women who exercise in the morning experience less difficulty falling asleep and better quality sleep than evening exercisers.

If insomnia persists, and lifestyle, behavioral or diet changes do not help, a doctor may prescribe a sleep-promoting medication (hypnotic). In some instances, there may be an underlying and treatable cause, such as depression (women are twice as likely to report depression as men), stress, anxiety, reflux, bladder problems or pain. Doctors may prescribe antidepressants (for depression), anxiolytics (anti-anxiety drugs), medications for heartburn, incontinence or pain and/or hypnotic medications to improve sleep.

Sleep Apnea

Sleep apnea is a serious sleep disorder that is characterized by snoring, interrupted breathing during sleep and excessive daytime sleepiness. An estimated 18 million Americans have sleep apnea including one in four women over 65. While apnea is more common in men, it increases in women after age 50. Because being overweight is a risk factor for sleep apnea, the increase in abdominal fat during menopause may be one reason menopausal women are 3.5 times as likely to get this sleep disorder. Some attribute the prevalence to hormonal changes such as the decrease in progesterone. Studies have also found that sleep apnea is associated with increased blood pressure, a risk for cardiovascular disease and stroke. If any of these symptoms appear, it is important to address them with your doctor. A number of effective treatment approaches are available.

Restless Legs Syndrome (RLS) and Periodic Limb Movement Disorder (PLMD)

RLS is a neurological movement disorder that affects as many as 12 million Americans. Its symptoms are outlined above. Because the unpleasant feelings occur at rest and are relieved by movement, RLS sufferers have difficulty sleeping. In the NSF 2002 Sleep in America poll, 18% of the female adult population reported RLS symptoms a few nights a week or more. Due to difficulties sleeping, RLS can lead to daytime sleepiness, mood swings, anxiety and depression. One study found that 42% of those with RLS stated that it affected their relationship with their partner.

Although we do not know the exact cause of RLS, recent research indicates that iron or folate deficiency may be a risk factor. Treatment may include iron or vitamin supplements, lifestyle changes and medications.

About 80% of those with RLS also have PLMD or involuntary leg twitching or jerking movements during sleep that can occur every 20-30 seconds. These symptoms can be bothersome to a bed partner, but are also treatable.

Narcolepsy

Feeling sleepy during the day or at times you expect to be awake may indicate a need for more sleep, the presence of a serious but treatable disorder such as those already mentioned, or narcolepsy, a chronic neurological disorder that affects approximately one in 2000 people. Narcolepsy symptoms frequently appear in teen years. In addition to excessive daytime sleepiness, people with narcolepsy have sudden "sleep attacks" (an over-whelming urge to sleep), suddenly lose muscle tone or strength (cataplexy) and may have disturbed nighttime sleep. Women who are pregnant or considering having a child should discuss medications with their doctor. Recent scientific break-throughs have led to new understanding of the cause of this condition and new treatments have given doctors more ways to help manage its symptoms.

Nocturnal Sleep-Related Eating Disorder

Persons with nocturnal sleep-related eating disorder (NS-RED), an uncommon condition, eat food during the night while they appear asleep. Since parts of the brain that control memory are asleep, people with NS-RED cannot remember nighttime eating. One study indicates that over 66 percent of sufferers are women. NS-RED can occur during sleepwalking. It can be caused by medications (e.g. some drugs prescribed for depression or insomnia) or by sleep disorders (e.g. sleep apnea, restless legs syndrome) that cause awakenings and trigger sleep eating.

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Pain and Sleep

More women (58%) suffer from nighttime pain than men (48%), according to a 1996 NSF Gallup Poll. In a more recent 2000 NSF Sleep in America poll, one in four women reported that pain or physical discomfort interrupted their sleep three nights a week or more.

Pain conditions like migraine, tension headaches, rheumatic and arthritis conditions as well as heartburn are all more common among women. Pain may make it harder to fall asleep or lead to nighttime or early morning awakenings. Relaxation techniques, biofeedback, cognitive therapy, and over-the-counter and prescription medications may help. Treatment may target the pain, the sleeping difficulty, or both.

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Shift Work

Shift workers - about one in five Americans - work non-traditional hours (not the typical hours of 9 a.m. to 5 p.m. ). Difficulty falling asleep is a common effect as is obtaining quality sleep during the day hours. Women who work on the night shift get less sleep and more disrupted sleep. Shift workers, in general, report more sleep-related accidents and illnesses. Night and rotating shifts can put a strain on a family when less time is available to meet family/home responsibilities and enjoy recreational and social activities. Female shift workers also suffer irregular menstrual cycles, difficulty getting pregnant, higher rates of miscarriages, premature births and low birth-weight babies more than regular day working women, according to several large studies. Still, most shift-working women do have normal, healthy babies. Changes in exposure to light and lost sleep caused by shift work may have biological or hormonal effects that are not yet entirely understood. One large study of women who worked night shifts over a 3-year period found a 60% greater risk for developing breast cancer. Women shift workers should consult their doctor if experiencing menstrual difficulties, infertility, pregnancy or other medical conditions/ problems.

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When to See a Doctor

Many sleep problems can be improved by changing your sleep habits, reducing stress, improving your diet or exercising. If sleep problems persist, it is advised to seek professional help. Your doctor will determine the cause of your sleep problem and may refer you to a sleep disorders center. These centers are staffed with sleep specialists who will ask you questions about your sleep problems and may monitor your sleep overnight.

For More Information

The National Sleep Foundation offers a great deal of information about sleep for women and men as well as for people of all ages. The easiest way to learn more is by visiting:

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www.sleepfoundation.org
At this site, you can conduct information searches or scan a variety of topics. You can also sign up for an e-mail newsletter or order sample materials or purchase supplies of brochures for your workplace or organization. You may also contact NSF at:

National Sleep Foundation
1522 K Street, NW, Suite 500
Washington , DC 20005

return to National Sleep Foundation home page