Sleep is essential for overall health and well-being. It helps restore your body, optimize cardiometabolic and mental health, supports your immune system and keeps your mind sharp. But women are more likely than men to struggle with sleep problems, including insomnia and restless leg syndrome. Hormonal changes during the menstrual cycle, pregnancy and menopause can make it even harder to get consistent rest. The good news is that relatively simple changes in daily habits and sleep routines can make a big difference in improving sleep quality.
The AMA’s What Doctors Wish Patients Knew™ series gives physicians a platform to share what they want patients to understand about today’s health care headlines.
In this installment, Lindsay McCullough, MD, a sleep medicine physician at Rush Medical Group in Chicago, took time to discuss what women should know about healthy sleep.
Rush University System for Health is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Sleep needs vary across a lifespan
“The amount of sleep that we need varies throughout the lifespan. Adults typically need somewhere between seven to nine hours for optimal health,” said Dr. McCullough. “Older adults, that range shortens to between seven and eight.
“And then children need more sleep. Kids between 6 and 12 need somewhere between nine to 12 hours of sleep and teenagers need between eight and 10 hours,” she added, noting that for “women, there's some evidence that they may need slightly more sleep than men, but there's individual variations in sleep needs and further research is needed. Hormonal fluctuations throughout puberty, pregnancy and menopause can affect sleep,” so it is important to keep that in mind.
Talk to your doctor about sleep disorders
“Insomnia is significantly more common in women throughout the lifespan. Overall, it's two times more common in women” with about one in four experiencing insomnia, said Dr. McCullough. “But as women get older, it's 70% more common in women than men.”
“Another medical condition is restless leg syndrome. That's often undiagnosed and has a higher prevalence in women,” she said, noting women are twice as likely to develop restless leg syndrome as men.
“And shift work sleep disorder as well. A lot of women are working more health care 24/7-oriented jobs, or are also the primary caregiver for their families,” Dr. McCullough said. “So that can predispose them to that circadian rhythm disorder.”
Seek treatment for menopause symptoms
“Varying stages in life can increase the predisposition for insomnia, and menopause is a big one,” said Dr. McCullough. “There's an abrupt loss of estrogen and progesterone, and that in and of itself can contribute to a lot of vasomotor symptoms like hot flashes and more sleep disruption awakenings at night.”
“In that loss of hormones, there are some changes in the structure of the upper airway,” she said. “Before menopause, sleep apnea is thought to be more common in men, but then that gender gap really shortens once women hit menopause.
“Women with sleep apnea have different symptoms than men, such as insomnia, fatigue and depression rather than loud snoring,” Dr. McCullough added. “So, women are more likely to have some sleep-disordered breathing that's undiagnosed.”
Also, “they may have more chronic pain and mood disturbances with the abrupt loss in estrogen and progesterone—that’s a lot of things contributing to that increased insomnia at an older age,” she said, noting “there's an entity called upper-airway resistance syndrome that's thought to be more of a milder form of sleep apnea that's seen in premenopausal women that can still significantly cause some sleep disruption or fatigue and sleepiness during the day, but it often gets missed.”
That is why it is important for women to work with their physicians to identify menopause symptoms and find appropriate solutions.
It’s OK to sleep more during puberty
“Even when girls enter puberty and they start their menses—all adolescents and teens—they have a delayed circadian rhythm, meaning their internal biological rhythm is later than when you're an adult,” Dr. McCullough said. “And that tends to happen earlier in girls because they enter puberty sooner and so they have trouble falling asleep at night.
“They have more truncated sleep or insufficient sleep related to school start times that are a lot earlier than what their circadian rhythm wants to allow them to sleep longer,” she added. “It has to do with the hormonal fluctuations as you’re experiencing the menstrual cycle.”
“Not all women experience these changes, but a week before menses and then the first few days, particularly if you have a lot of cramps or premenstrual mood symptoms, you can have more disrupted sleep and sleepiness throughout the day,” Dr. McCullough said, noting that girls and women may find they are sleeping more, and that’s OK. It’s also important to speak with your doctor if you continue to struggle with disrupted sleep.
Treating iron deficiency can help
“A condition that’s more common in women after puberty and premenopausal women with having menses is iron deficiency, even without anemia is often missed,” said Dr. McCullough. “And that is highly correlated with restless leg syndrome and is something that we typically don’t ask about.”
“Also, the prevalence significantly increases during pregnancy, often related to iron deficiency, but sometimes it happens even independent of that,” she said. But treating iron deficiency can help.
Recognize symptoms of sleep apnea
“Obstructive sleep apnea is really underdiagnosed in women,” said Dr. McCullough. In fact, about 10–15% of women in the U.S. have obstructive sleep apnea. This number increases to 20–25% in postmenopausal women, adding to the importance of speaking to your physician to identify sleep apnea and create a treatment plan to reduce symptoms and improve sleep.
“In fact, 90% of women with severe apnea are undiagnosed, and this is for a variety of reasons,” she said. “One, it was classically described in men and a lot of the classic symptoms that people think about are those found in men.
“And our screening tools are great for men, but they don’t pick it up in women,” Dr. McCullough added, noting “women often have more fatigue, or they might have some disrupted sleep and they’re often not reporting loud snoring.”
“Women often have what we’ve classically thought as more mild sleep apnea—they don’t have as much of the oxygen desaturations. They have more awakenings at night and sleep disruption,” she said, noting “the home sleep test, while great for diagnosing sleep apnea, can sometimes miss it in women.”
“Even if women have some anatomical predisposition, they don’t need to be overweight, but if they have a smaller jaw or some changes in their jaw structure—that can predispose them to sleep apnea as well,” Dr. McCullough said. “Many people shy away from even getting tested, even if they feel really bad, because they’re afraid of the Darth Vader masks.”
With sleep apnea, though, “women don’t need to be afraid of the CPAP [continuous positive airway pressure] machine as there are smaller mask interfaces and treatment can significantly relieve symptoms,” she said. “There are also alternative treatments if people are unable to use CPAP, including dental appliances, surgical procedures and weight loss interventions.”
Take steps to understand parasomnias
“There's also, for women, parasomnias—which are sleep disorders characterized by unusual or undesirable behaviors or experiences that occur during sleep—to look out for,” said Dr. McCullough. “In patients taking medications such as zolpidem (Ambien), sleepwalking and sleep-related eating disorder can occur as side effects.
“In sleep-related eating disorder, they’re eating things while they’re still asleep and they can unknowingly eat toxic things and high calorie edible things and find evidence the next morning,” she added. “So, if you’re starting a hypnotic, this is something to ask about and stop therapy if it occurs.”
“There’s another sleep parasomnia called REM-behavior disorder, which is where people will act out their dreams and have really violent dreams,” Dr. McCullough said. “In certain cases, if you can’t find a contributing cause, it’s thought to be a potential predisposition to Parkinson’s disease or another alpha synucleinopathy,” which is a class of neurodegenerative diseases such as Lewy body dementia and multiple system atrophy.
“If women have REM-behavior disorder, they often don’t have as violent dreams or their dream enactment isn’t as significant or severe as men,” she said. But it is still important to educate yourself on these parasomnias and seek help from your physician if you suspect this sleep disorder.
Sleep medicine doses may need to be altered
“If cognitive-behavioral therapy for insomnia is not helpful, then considering sleep medications may be a reasonable next step,” said Dr. McCullough. But “another important point with this is with insomnia in women, one of the most common medications—zolpidem, or Ambien as it is marketed—is metabolized a lot more slowly in women than in men.
“So, you have to use a lower dose when prescribing sleep medicines for insomnia in women,” she added.
Try to get sufficient sleep
“Women, especially now, are often having children later and they’re becoming the primary caregivers for their children and aging parents,” Dr. McCullough said. “Women are also working a lot, so there’s a lot of things to fit in the day.
“They may be expected to cook and clean at home, and these responsibilities in societal roles often impact patients with health disparities even more,” she added. “Not having the opportunity to get enough sleep can contribute to not only decreased quality of life and increased sleepiness, but other health conditions.”
“With insufficient sleep, we see an association with obesity, cardiovascular disease, metabolic disease, cancers” and other conditions, Dr. McCullough said.
Don’t ignore postpartum depression
During the postpartum period, especially with a newborn, women often experience sleep disruption, and rightly so. But it is important to keep an eye on postpartum depression during this time.
“At any point, if women are experiencing fatigue or sleep difficulties, I encourage them to talk to their doctor,” said Dr. McCullough, who noted that inequitable access to paid family leave exacerbates the problem.
“Postpartum is a really big period where it happens,” she said, which is why it is important “to advocate for yourself and bring these things up so you can get it addressed.”
“It’s similar with women in menopause—it is assumed they’re going to sleep poorly,” Dr. McCullough said. “In postpartum, of course you’re not going to get enough sleep. But this shouldn’t be the assumption. There are real consequences, and there are things we can implement to help.”
Make appropriate lifestyle changes
“Start with a healthy diet, trying to avoid processed foods and following a more Mediterranean style diet,” said Dr. McCullough. Then, aim to “exercise, about 150 minutes a week or 30 minutes five days a week.
“And then sleep hygiene. If you’re able to, implement basic sleep hygiene practices, including trying to keep not only enough time to sleep, but also regular sleep times—regular wake up times and bedtimes—and having the bedroom dark without a ton of environmental disturbances, if possible,” she added. “Also, limiting caffeine, especially after lunch or if you’re a shift worker, within several hours of bedtime.”
Additionally, “screen and address untreated or undiagnosed sleep disorders,” Dr. McCullough said, adding that it is also important to “avoid alcohol and smoking before bed. All of those things can be helpful.”
“If you’re still having trouble, addressing chronic pain that can disrupt sleep, addressing hormonal disturbances in women post menopause who are having a lot of the vasomotor symptoms, hormone replacement therapy can be helpful,” she said. “Just leaving it open to talk to your doctor if things still persist is key.”
Prioritize your own health and well-being
“Speaking for myself and women who I’ve spoken with and interacted with, we do feel a pressure and also enjoy taking care of people and being responsible for a lot of different things,” said Dr. McCullough. “A lot of times, it’s hard to prioritize your own health and well-being.”
“But, for example, if we’re talking about prioritizing sleep hygiene or just allowing enough time to sleep, modeling that for your kids and your family will help everyone develop healthy sleep patterns,” she added. “That can help because we know that poor sleep can be associated with numerous adverse health outcomes—dementia, cardiovascular disease, diabetes, obesity.”
“If you can do that for yourself, that’s a way to help you and your family too,” Dr. McCullough said.
