Sleep is an area of health where symptoms differ widely depending on your sex and life stage. Data from the American Academy of Sleep Medicine show that women are more likely than men to experience trouble sleeping, excessive daytime sleepiness and difficulty concentrating due to tiredness.
It’s estimated that 90% of female patients with sleep apnea may go undiagnosed. Women also may face a lack of understanding from care providers, causing them to dismiss their own symptoms and feel discouraged about seeking help.
That’s what happened to Kathy Page, a now-retired electric cooperative employee who experienced fatigue and restless legs syndrome but didn’t have her symptoms fully recognized by medical professionals. “Of course you’re tired – you work full time and have a family,” one physician said. Page was told to take aspirin despite explaining that her leg discomfort wasn’t pain-related. She ended up having to do her own research on RLS and obstructive sleep apnea, and switched to a doctor with a more collaborative approach.
Page shared her experiences in a recent AASM webinar that focused on how female patients with sleep issues can be better served.
“Our symptoms are often ignored or downplayed,” Page noted. “Many times we’re diagnosed then turned loose to deal with the details on our own. We’re often given treatments because they are the popular ones for the issue, not because it’s the right one for us.”
How age affects sleep
Dr. Carolyn D’Ambrosio of the University of Miami Miller School of Medicine provided a timeline of hormonal changes and other factors that affect sleep as girls and women age. D’Ambrosio noted that there are no particular sex differences in sleep during childhood, but as girls reach puberty and adolescence, reproductive hormones start to increase, and total sleep time is reduced.
During the reproductive years, there is a higher risk of sleep-disordered breathing, particularly during pregnancy and in patients with obesity. There are numerous factors, including musculoskeletal discomfort, nighttime urination, nasal congestion, fetal movement and heartburn, that can interfere with sleep during pregnancy, and the first and third trimesters can be especially trying. Perimenopause and menopause tend to be when clinicians hear most from women about sleep problems and vasomotor symptoms, D’Ambrosio said. And in the older-adult phase, both men and women can experience circadian rhythm and mood disorder issues.
D’Ambrosio also highlighted factors that play a role in sleep health, such as lung and airway size, genetics, socioeconomic status, environmental and occupational exposures, health care access, risky behaviors and level of care.
Sex plays a role
Dr. Cinthya Peña-Orbea of Case Western Reserve University and the Cleveland Clinic pointed out sex-related differences in obstructive sleep apnea, noting that the male-to-female ratio of OSA is about 2:1 in the general population and 8:1 in clinical populations. The prevalence of the condition rises significantly with age, Peña-Orbea noted, from 9% of premenopausal women to 30% of those in post-menopause.
“The presentation is very different compared to men, which can lead to underdiagnosis [in women],” Peña-Orbea said. “Women are more likely to report morning headaches, depressive symptoms, frequent awakenings and nocturia rather than sleepiness and snoring.”
Women also report more fatigue than men, while men say they feel excessive daytime sleepiness more often. However, many OSA screening questionnaires focus on male-typical symptoms, Peña-Orbea said, underscoring a need to adjust them to better represent women’s experiences. Insomnia and RLS are significantly more common in women than men, Peña-Orbea added
More robust study data are required on positive airway pressure outcomes in women, Peña-Orbea said, and clinical trials need to include more female subjects.
Societal, cultural roles
Dr. Molly Billings of the University of Washington shed light on societal and cultural influences that shape women’s sleep health. Traditional social roles of women as caregivers and household managers combine with work and family life to produce stress-related sleep issues, Billings noted.
“Sleep is scheduled socially and shaped by your cultural trends, ecological contexts, personal beliefs, economic forces and family structure. And it is not equally prioritized across all cultures,” Billings said.
In some countries where afternoon siesta is practiced, sleep may be tied to important family and spiritual traditions, whereas in others it may be seen as lazy. All of these factors, plus the cognitive load of family life and unpaid labor, play a role in how well women sleep.
Women tend to prioritize the family’s sleep needs over their own, Billings noted, but this trend diminishes with age and life stage. Also, women of color tend to have shorter sleep durations than their white counterparts. Racial microaggressions and discrimination likely feed into insomnia, as does the cultural expectation that a woman of color should be strong and self-sacrificing at all times.
“This can have a detrimental impact on her mental health and sleep quality, and lead to more daytime sleepiness,” Billings said. “If we’re to improve sleep among women across the globe, intervention should consider all of these different contextual factors.”
Task force makes strides
The AASM Women’s Sleep Health Task Force focuses on advancing women’s sleep-related wellness. Its efforts have included a Women’s Sleep Health Summit, presenting at an American College of Obstetricians and Gynecologists conference, additional webinars on the topic and grant applications.
Dr. Suzie Bertisch of Harvard Medical School and Brigham and Women’s Hospital, who chairs the task force, said a main goal is to advance women’s sleep health in both the clinical and research arenas.
Women need to be better heard and understood on the subject of their sleep health if progress is to be made, Page said.
“They need answers that statistics don’t give,” Page said. “Let’s make sure women’s voices are coming through loud and clear … and they know they are not alone.”
Want to know more?
Visit the AASM’s webpage on women’s sleep health for additional information.
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