Presented by The Royal's Dr. Elliott Lee at our annual Women in Mind Conference. Dr. Elliott Lee is an Assistant Professor and Sleep Specialist at The Royal, where he works in both the Sleep Disorders Clinic and the Anxiety Disorders Clinic.

1. Womens’ Sleep:
Much More Than Just
Beauty Sleep
Women in Mind|Body and Mind
November 15, 2013
Elliott Lee MD, FRCP(C), D. ABPN
D. ABPN Sleep medicine, Addiction Psychiatry
D. Amer Board of Sleep Medicine
Assistant Professor, Sleep Specialist, Royal Ottawa Mental Health Center

2. Journey
CASE

3. Case Study

4. More about Zoe…
• MedHx – Asthma
• Meds:
alesse,
quetiapine (for sleep)
• FHx
- sister “anger issues”
- mother – trauma
• SocHx
Some conflicts with
parents (rel issues)
• Psych Hx
- Mood Sx X 2-3 yrs
- suicide attempt
(2011- CHEO)
- Med trials:
sertraline
citalopram
venlafaxine
mirtazapine
trazodone
- Hx of cutting
- No drug use

5. Normal sleep

6. STAGES OF SLEEP
•
•
NREM & REM
NREM=N1, N2 (light stages of sleep)
N3 (Slow wave sleep (SWS))
•
•
•
Sleep cycles across the night
REM increases as the night progresses
Changes across the lifespan

7. SLEEP HYPNOGRAM
W
N2
1
N1
N3
REM
1
2
3
4
Hours
5
6
7

8. Sleep Stage % by Age

9. Functions of Sleep (?)
• REM sleep functions:
- Dreaming
- Mood regulatory role?
- Memory?
- Modulate emotional
memories?
• Slow Wave Sleep (SWS)
- Declarative memory?
- Cerebral restoration?
• Clear waste?

10. Womens’ sleep

11. Womens’ Sleep Architecture
EEG Power vs. Sleep Cycle
Women
Men
Dijk DJ et al. Sleep 1989; 12(6):500-7

12. Women vs Men: Changes with Age

Young women have short sleep latency
and higher sleep efficiency compared
to young men

A trend was found for older women to
have a higher sleep efficiency, but
elderly males spend more time in bed

14. Sleep in the Menstrual Cycle
Lee KA et al. Sleep 1990;13(5):403-9.

15. Women are more likely to work rotating shifts or
evening shifts
Men
Women
Other
13%
Other
12%
Irregular
25%
Evening
14%
Evening
10%
Irregular
35%
Night
8%
Night
8%
Rotating
41%
Rotating
34%
Source: Williams C. Worklife Balance of Shift Workers, Stats Canada General Social Survey, 2005

16. Shift Work
•
International Agency on Research and Cancer (IRAC) classified shift
work as a probable carcinogen in 2007.
•
40-50% increase in breast cancer risk with >20-30 years of shift
work exposure.
•
Melatonin thought to play a key role; reduces estrogen levels and
shown to have anticancer properties.
Megdal et al. Eur J Cancer. 2005; 41: 2023-32
Grundy A et al. Occup Environ Med. 2013; 70: 831-8
Shernhammer ES and Hankinson SE. Cancer Epidemiol Biomarkers Prev 2009; 18: 74-9

17. Pregnancy

18. Pregnancy
• Pregnancy and postpartum
period physiologically and
psychologically affect sleep
• Sleep disturbance very
common:
- Hormonal alterations
- Fetal enlargement
- Newborn sleep schedule

21. Duration and Efficiency of Sleep in Pregnancy
1Lee
KA T et al. Obstet Gynaecol. 2000; 95(1): 14-8

22. What Affects Sleep in Pregnant Women?
2007 Sleep in America Poll
National Sleep Foundation, 2007

23. Post Partum Depression (PPD)
• Sleep compromised
- infant care
- physiologic changes
• 20% of women report
PPD
• 50% in outpt treatment
for PPD report insomnia
• Poor subjective sleep
quality is associated with
PPD
Park EM et al. Arch Womens Ment Health. 2013; 4 jun

24. Tips for Sleep in Pregnancy:
• Obtain sufficient sleep
(w/o excess time in bed)
• Regular sleep/wake times
• Take naps if needed
• Avoid caffeine
• Report symptoms of sleep
disorders
• Get help at home,
particularly for post
partum period

25. Menopause

26. Menopause (Climacteric)
• Ovarian follicle store is
exhausted
• Estrogen and
progesterone decline
• 90% experience
symptoms1
• 25-50% describe sleep
disturbances2
1Ameratunga
2Guidozzi
D et al. Intern Med J. 2012; 42(7): 742-7
F. Climacteric. 2013; 16(2): 214-9

27. Causes of Disturbed Sleep in Menopause
Depression
Caregiver
responsibilities
Lifestyle
changes
Circadian
influences on
aging
Career changes
SLEEP
Hormone
influences on
sleep
Insomnia
Restless legs
syndrome
Sleep Apnea
Figure courtesy of Sleep in women : Normal sleep and sleep disorders slide presn, prepared by AASM, 2008

28. Hot flashes
• Most common symptom
of climacteric (up to 87%
of women)
• Intense warmth with
sweating, chills or flushes
• Lasts 1-5 min, sometimes
1 hour
• Persists 4-5 years
Ameratunga D et al. Intern Med J. 2012; 42(7): 742-7
Freedman R. J Steroid Biochem Mol Biol. 2013; Sept

29. Treatment of hot flashes
• Non pharmacologic
- Reduce core body temp
- cool drinks
- avoid stimulants:
caffeine
nicotine
- Relaxation therapies
- Paced breathing
• Pharmacologic
- Hormone therapy
- Clonidine
- Serotonergic drugs
- Paroxetine
- Fluoxetine
- Venlafaxine
- Gabapentin
• General reduction in
frequency by 50-80%
Freedman R. J Steroid Biochem Mol Biol. 2013; Sept

30. Menopause and Insomnia Treatment
•
Womens Health Initiative study
- 16 500 women evaluated
- Improved sleep with HRT
- Risks:
- Breast cancer
- Stroke
- Heart disease
- Thrombembolic disease
Nelson HD et al. JAMA. 2002: 288(7); 872-81

31. Sleep Disorders:
- Obstructive Sleep Apnea (OSA)
- Upper Airway Resistance
syndrome (uars)
- Restless legs Syndrome (RLS)
- Insomnia

32. Obstructive sleep apnea (osa)
Upper airway resistance syndrome
(uars)

33. Obstructive Sleep Apnea (OSA)
•
•
•
•
Pauses in breathing > 10 seconds in length
Respiratory Disturbance Index (RDI): >5 hr = significant
Prevalence – up to 25% of men, and 9% of women
Key diagnostic questions:
- Do you feel satisfied with the quality of your sleep?
- Does your partner complain that you snore?
Young T et al. N Engl J Med. 1993; 328: 1230-5

34. OSA Clinical Symptoms

35. Upper Airway Resistance Syndrome (UARS)
•
•
Subtle sleep disordered breathing
Sleep disordered breathing events with arousals, but not
hypoxemia
•
More common in women
(UARS - ♂/♀=1:1 vs OSA - ♂/♀ 2:1)
•
Symptoms: fatigue, depression, insomnia, headaches,
irritability
Guilleminault C et al. Chest. 1993; 104: 781-7
Bao G and Guilleminault C. Curr Opin Pulm Med. 2004; 10:461-7

36. Treatments for OSA/UARS
•
•
•
•
**Weight loss - ↓ BMI = ↓ RDI
Avoid alcohol consumption and sedative medications
“Snoreball” technique / positional therapy
Upper airway surgery
o
o
Uvulopalatopharyngoplasty (UPPP)
o
Maxillomandibular Advancement (MMA)
o
•
•
Tonsillectomy (pediatrics)
Tracheostomy
Provent
Oral Appliances - Mandibular Repositioning Devices (MRDs), Tongue Retention
Devices (TRDs)
•
**CPAP – Continuous Positive Airway Pressure

37. GERD
Hypertension
Motor vehicle accidents
OSA Consequences
Impaired
glucose
control
Heart attack and stroke
Amenorrhea (!)
Irritability, mental illness e.g. depression
Memory problems

38. OSA and Mental Illness
•
OSA can exacerbate mental illness:
- Aggression /cognition in schizophrenia
- Mood disorders
- Nightmares in PTSD
- Cognitive dysfunction in dementias
- Relapse to substance abuse
Lee EK and Douglass AB. Can J Psychiatry, 2010; 55(7): 403-12

39. OSA and Attractiveness?
•
Treatment of OSA with
CPAP has been shown to
improve attractiveness
•
Perceived to be
- More alert
- More youthful
- Less forehead creases
Chervin R et al. J Clin Sleep Med, 2013; 9(9): 845-52

40. OSA and Pregnancy
•
•
Sleep complaints are common in pregnancy
14-45% of women may snore in pregnancy (vs. 4% non pregnant
women)
•
Even snoring has been linked with adverse pregnancy outcomes
- Intrauterine Growth Retardation
- Hypertension

41. OSA and Pregnancy
•
OSA in pregnancy – linked to:
- Preclampsia/hypertension
- Gestational diabetes
- Intrauterine growth retardation
•
•
Prevalence - ?
Increased risk:
- Fluid retention
- Nasal congestion/upper airway
edema

42. Mechanism of OSA Affecting Pregnancy
Iczi-Balserak B and Pien GW. Curr Opin Pulm Med, 2010; 16(6): 574-82

43. OSA and Menopause
•
OSA is twice as prevalent in postmenopausal vs premenopausal
women
•
•
Up to 4-44% of post menopausal women may be affected
Several factors may play a role:
- Reduced respiratory stability
- Loss of protective effect of progesterone
- Age/increased soft tissue collapsibility
- Increasing weight

44. Restless Legs Syndrome
(RLS)
(Ekbom’s Disease)

45. Restless Legs Syndrome
•
Uncomfortable sensations in the legs (usually) that bother
patients at night WHILE AWAKE
“URGE”
U – urge to move legs
R – rest – worsened at rest
G – gets better with movement
E – evening – worse in evening

46. Patient Descriptions
•
•
•
•
•
•
“Creepy crawly”
Tingling
“Heebee Jeebees”
Electricity in veins
Aching
Burning
•
•
•
•
•
Coca cola
Itching
Restless
“Like I have to move”
“Nervous”

48. Epidemiology/Pathology - RLS
•
•
•
5-10% of the population affected (♀/♂=2/1)
The leading hypothesis is brain dopamine dysfunction
May involve a circadian mechanism
- circadian fluctuations in dopamine?
•
Deficiencies in other substances, especially iron, likely
play a role.
•
Key diagnostic question:
Do your legs ever bother you at night?

49. RLS prevalence by Age and Gender
(symptoms > 1x/wk associated with distress)
Prevalence (%)
8
RLS sufferers (n=116)
All
Men
Women
6
4
2
0
20-29 30-39 40-49 50-59 60-69 70-79 80+
Age group (years)
Allen RP et al. Arch Intern Med. 2005;165:1286-1292.

50. Treatment
Non Pharmacologic:
• Check ferritin, vitaminB12
• Avoid caffeine, nicotine,
alcohol
• Rule out other sleep/medical
disorders
• Cold/warm compresses
• Massage
Pharmacologic:
• Dopamine agonists
(Pramipexole, Ropinirole,
Sinemet)
• Gabapentin - anticonvulsant
• Benzodiazepines (sedative
hypnotics)
- Clonazepam
- Lorazepam
- Diazepam
• Opioids
- Codeine
- Hydrocodone
- Methadone
Silber MH et al. Mayo Clin Procs. (2004) 79 (7): 916-22

51. RLS and Pregnancy
Extremely common in
pregnancy – 11-56%
•
Especially 3rd trimester
(highest estrogen levels)
- Estrogen may interfere with
dopamine transmission
- Anemia/shared iron supply
25
20
15
10
5
0
>9
s
th
s
s
th
hs
on
on
th
on
t
on
m
m
m
m
8
6
4
Treatment options limited
7-
5-
3-
•
Prevalence by Months of Pregnacy
Prevalence (%)
•
Suzuki K et al. Sleep 2003; 26(6): 673-7.

52. Insomnia

53. Risk Factors for Insomnia:
Specific to Women
Menstrual phase worsens
sleep in 31% of menstruating
women
•
Pregnant women frequently
describe difficulty sleeping
•
Self-reported insomnia
increases with menopause
Manber R, Bootzin RR. Health Psychol 1997;16(3):209-14.
Shaver JL, Paulsen VM. Fam Pract Res J 1993;13(4):373-84.
.
% Affected
•

54. Co-morbid Conditions
 Co-morbid conditions more common in women
 Pain syndromes and fibromyalgia
 Depressive disorders, anxiety disorders
 Restless Legs Syndrome
 Nocturnal sleep-related eating disorder

55. Insomnia and Major Depressive Disorder
•
Insomnia often predates the onset of mood symptoms
-
Metaanalysis by Baglioni et al showed pts with insomnia have a
2-fold increased risk of developing depressive disorder,
especially ♀
•
1
Insomnia symptoms may persist even after mood symptoms abate2
1
Baglioni C et al. J Affect Disord. 2011; 135: 10-9
2
Manber R and Chambers AS. Curr Psychiatr Rep. 2009; 11: 437-42

56. Insomnia predating mood
(Adapted from Benca RM, 2004)

57. What about Zoe…

58. Zoe’s Sleep Study
Respiratory Events
Apnea C
Apnea O
Apnea M
Hypopnea
RERA
CSR
11:07 PM
12:09 AM
1:11 AM
2:14 AM
3:16 AM
4:18 AM
5:20 AM
6:22 AM
12:09 AM
1:11 AM
2:14 AM
3:16 AM
4:18 AM
5:20 AM
6:22 AM
SpO2%
100
90
80
70
60
50
11:07 PM

59. Zoe’s Sleep Study with CPAP
Respiratory Events
Apnea C
Apnea O
Apnea M
Hypopnea
RERA
CSR
11:29 PM
12:29 AM
1:29 AM
2:30 AM
3:30 AM
4:30 AM
5:30 AM
6:30 AM

60. Zoe after treatment…

61. Summary
•
Womens’ sleep is different from men
- Different biological, psychosocial underpinnings
- Menstruation
- Pregnancy
- Menopause
•
Women suffer from sleep disorders, but the presentation may be different, and
often overlooked
- OSA/UARS
- Restless Legs Syndrome
- Insomnia
•
Failure to recognize/address sleep issues can lead to a myriad of consequences:
daytime fatigue, cardiovascular disease, psychiatric illness, cancer, death

62. Tips for Optimizing Sleep
•
•
•
•
•
Have regular sleep times /wake times
Have a relaxing pre bedtime routine
Avoid caffeine/alcohol late at night
Make sleep an appropriate priority
Bed – only for sleep or intimacy
- No backlit screens.
- Bedroom – dark and comfortable*
•
•
•
Avoid clock watching
Exercise in the day, and minimize stress
Seek help/referral if problems persist

63. Questions?