Female Sleep: Infancy through Menopause. Fall Focus, 2018 Robyn Woidtke MSN-Ed, RN, RPSGT, CCSH

Transcription

1 Female Sleep: Infancy through Menopause 1 Fall Focus, 2018 Robyn Woidtke MSN-Ed, RN, RPSGT, CCSH

2 2 Objectives Describe the unique changes in sleep in females throughout the life span Hormonal impacts Identify special needs of women Pregnancy and Menopausal changes Describe recent data regarding sleep in women

3 3 NSF-Women s Sleep Proceedings of the symposia published in the Journal of Women s Health in Sept 2008 Sleep in women is unique and poses challenges for the HCP Symposia-2007

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5 5 Gender Differences in Sleep Life Stage Infancy Childhood Adolescent Adults Compared Aspect Less sleep and more awakenings in boys Longer sleep duration in girls, earlier bedtime in girls, more severe sleep problems in boys Longer sleep time in girls, earlier wake time in girls, more sleepiness in girls, more awakenings in boys More stage 1 in men, more SWS in women, more awakenings in men and worse subjective sleep in women Adapted from Principles and Practices of Sleep Medicine, Chap 108. Table 108-2

6 6 Gender Differences-Sleep Architecture Sleep Differences N1% Increases with age, more impactful in women N2% Less % of N2 then age-matched men SWS% Decreases at ~2% per year, but women have greater SWS % than men REM % Slight difference between men and women Sleep Onset Latency TST Adapted from Minarik, P.A., 2011 Women have longer sleep latency then age-matched men; differences were modest Women have longer TST then age matched men

7 7 Sleep and Adolescent Females Longer sleep time Earlier wake up times School week More daytime sleepiness More awakenings Age effect differences (childhood vs. adolescence) More REM Less wakefulness Lower SWS (both sexes)

8 8 Sleep and Adolescent Females Risk for insomnia after the onset of menses Sleep disturbances linked to phases in the menstrual cycle. Premenstrual reporting disrupted sleep from Bloating Cramps Headaches Objective measures yield mixed results Lower sleep efficiency; less REM

9 9 All About Women Ah, those were the days

10 10 Gender Differences-Adult Women 1. Sleep latency is longer in women than men 2. Women < 55 years report more sleepiness than men 3. Older women report 20 minutes less sleep than men 4. Women have more (106%) SWS and less NREM stage 1 sleep than men 5. Men have more NREM stage 1 and stage 2 sleep than women 6. Normalized delta activity in older women is lower than in older men Circadian shift in women to earlier, recovery sleep better and better memory Mallampalli & Carter, 2014 Journal of Womens Health Duffy, et al., 2010 PNAS

11 11 Sleep and Hormones Estrogen linked to sleep promotion Female gonadal hormones organize the stability of the circadian system; promote wakefulness Ghrelin, stimulates appetite, leptin, sends a signal to the brain when you are full Clinical study demonstrated that an injection of ghrelin let to increase in N2, SWS and NREM in men, but not women

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15 12 PMS Severe PMS linked to Hypersomnia Insomnia Fatigue Disturbing dreams

16 16 Menstrual Cycle ~25-35 day fluctuations in hormone levels Gonadal steroids, pituitary hormones, melatonin and cortisol Fluctuations in hormones are associated with sleep changes ~1/3 of menstruating women complain of sleep disturbances during the premenstrual week/menses Mid-follicular phase may elevate core body temperature Upper airway resistance is lower during the luteal phase compared to the follicular phase Possible explain the increase in OSA in menopausal women

17 17 The impact on sleep : the menstrual cycle Estrogen and progesterone, through secondary actions in the CNS, influence sleep and circadian rhythms The circadian rhythm of body temperature is influenced by menstrual cycle phase Increased spindle frequency REM sleep appears to be influenced by the menstrual cycle

18 18 Polycystic Ovarian Syndrome(PCOS) Most common of endocrine disorder of premenopausal women (Vgontzas et al., 2001) Ovaries do not make enough hormones for the ovum to develop The undeveloped follicles turn into cysts The cysts in turn, inhibit normal menstrual cycle by the lack of progesterone production The cysts also produce an abundance of androgen

19 19 Why is PCOS important in women's sleep medicine? Affects 5-10% of women, beginning with menarche Hyperandrogenism Insulin Resistance Reduced progesterone and estrogen Lead to OSA 30 times higher than controls (Vgontzas et al, 2001 JCE&M) 17% of PCOS had dx of OSA/UARS, vs 0.6% controls Increased EDS and inflammatory cytokines

20 20 OSA Depression PCOS Obesity Insulin Resistance

21 21 Sleep Disturbances-PCOS STUDY QUESTION Is there an excess of sleep disturbances in women with polycystic ovary syndrome (PCOS) in a community-based sample? STUDY ANSWER Sleep disturbances are almost twice as common in women with PCOS compared with women of similar age without PCOS, with the association slightly accounted for by body weight and, to a greater extent, by depressive symptoms Morin et al., (2014) Hum. Reprod. doi: /humrep/deu318

22 Pregnancy and Sleep 21 Sleep time is increased over all; REM stable More awakenings, less deep sleep and more light sleep (Lee et al, 2008;J Women's Health) With increased weight gain there is an increase in sleep related breathing problems Data are mixed regarding preeclampsia and lower gestational weight

23 Sleep Disturbances in Pregnancy One hundred eighty-nine women completed both baseline and follow-up sleep surveys. Baseline (Mean Gest Age:13.8 ± 3.8 weeks) Follow Up (mean Gest Age 30 ±2.2 weeks) Mean Sleep Duration 7.4 hrs 7.0 Snoring Frequency (3 nights/wk) 11% 16.4% RLS 17.5% 31.2% PSQI > 5 39% 53.5% Facco et al Obstetrics & Gynecology: January Volume Issue 1 - pp

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25 25 Restless Leg Syndrome- Pregnancy Occurs in about 20-26% by the 3 rd trimester (Lee et al, (2008) J Women's Health; NSF Website Associated with anemia of pregnancy, low iron or folate levels and genetic or familial problems with dopamine and iron metabolism Release of prolactin during pregnancy depressive effect on dopamine Association of RLS and hypertension are mixed

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27 27 Personal Conversation Black Strap Molasses 1 Tbsp 3 gm iron (9 regular tabs) Start slow Diarrhea or constipation 1 tsp until know the effects 1 carb exchange for diabetics This can be found in a natural food store

28 28 Maternal sleep-disordered breathing and adverse pregnancy outcomes: a systematic review and meta-analysis Conclusion Based on published observational studies to date, maternal SDB is associated with an increased risk of gestational hypertension and gestational diabetes after adjusting for potential confounders. However, large-scale, prospective cohort, and interventional studies are needed to further elucidate the relationship between maternal SDB and adverse pregnancy outcomes. Pamidi S, Pinto LM, Marc I, et al. Maternal sleep-disordered breathing and adverse pregnancy outcomes: a systematic review and metaanalysis. Am J Obstet Gynecol 2014;210:52.e1-14.

29 29 Compelling Data

30 30 Retrospective Cross Sectional Study Assess >55K pregnancy related in patient hospital discharges Overall OSA Rate 3/10,000 Rate increasing, average annual increase of 24% After controlling for obesity and other potential confounders, OSA was associated with increased odds of pregnancy-related morbidities including preeclampsia (OR, 2.5; 95% CI, ), eclampsia (OR, 5.4; 95% CI, ), cardiomyopathy (OR, 9.0; 95% CI, ), and pulmonary embolism (OR, 4.5; 95% CI, ) A five-fold increase of in-hospital mortality SLEEP, Vol. 37, No. 5, OSA and Severe Maternal-Infant Morbidity/Mortality Louis et al

31 31 Association Between Sleep-Disordered Breathing and Hypertensive Disorders of Pregnancy and Gestational Diabetes Mellitus? Will SDB be a risk factor for hypertension and GDM 3705 nulliparous women enrolled; HST 6-15 weeks gest =84% ; SDB =3.6% weeks gest=66.8% ; SDB 8.6% Increasing AHI with increasing incidence of GDM in both early and mid-pregnancy, independent of important covariates Modest elevations of AHI in pregnancy are associated with an increased risk of developing hypertensive disorders and an increased incidence of GDM. Facco, et al. Obstet Gynecol January ; 129(1): doi: /aog

32 32 SDB-Fetal Impacts Potential mechanisms for adverse outcomes Oxidative stress from intermittent maternal hypoxia Pre-eclampsia GDM Increased Sympathetic Activity Both Hypertension and GDM are characterized by vasoconstriction Inflammation Pro-inflammatory cytokines: Increased inflammation has been associated with adverse pregnancy outcomes and increased IL-6, TNF-α, C-reactive protein levels and leukocyte counts are reported in gestational diabetes mellitus (GDM),preeclampsia, intrauterine growth retardation, and preterm delivery Thus, the inflammatory response induced by SDB could provide a biological pathway between SDB and adverse pregnancy outcomes.

33 33 SDB-Fetal Impacts Isci-Balserak &Pein, 2010, Curr Opin Pulm Med

34 34 Case Study_2004 Roush SF &Bell L J AM Board Fam Pract 2004:17: yo, gravida 4, Para 2, treated for pre-eclampsia@ 37 weeks gestation Medical Hx included anxiety, allergies, GERD, sleep walking Witnessed apneic episodes (by nursing staff) with desaturations and fetal heart rate decelerations; infant was SGA with other congenital anomalies OSA confirmed by PSG AHI 160; sinus bradycardia in REM with episodes

35 35 Sleep Health-Impacts to Obstetrics HCP in women s health need to be aware of the health consequences Prenatal assessments of sleep Ongoing assessment of sleep during pregnancy Provide the patient with appropriate materials including Sleep hygiene Signs and symptoms of OSA, RLS and GERD

36 36 Sleep Health-Impacts to Obstetrics 78% of women more disturbed sleep during pregnancy than in any other time of life (NSF Sleep in America Poll, 1998) Sleep quality progressively worsens during the last trimester Women who slept <6 hours per night (Lee K, 2004;Am J Obstet Gynecol) 4.5 times likely to have C-Section Had longer labor Increased weight gain Pharyngeal edema

37 37 Post childbirth and the early years Normal expectations Transition to parenthood Partner /marital discord Low birth weight infants Associated with reduced quality of sleep and depression Maternal depression Negative impact on infant sleep Sleep Deprivation

38 38 Menopause and beyond Transitional (Avg age 51) Early menopause Late menopause Timing of menopause is individual Hormonal changes Estrogen and progesterone Sleep disturbance and fatigue most common sleep complaints SWAN Study (12,603 multi-cultural women 40-55) 38% reported sleep difficulty ; higher in the menopause group 46-48%

39 39 Is it hot in here? Vasomotor symptoms Hot flashes 3 out of 4 women Associated with reduced self reported sleep quality Objective evidence limited, but some data point to sleep disruption /waking Night sweats EEG arousals prior to hot flashes explain poor sleep (Minarik, P.A) Less hot flashes last 1/3 of night (REM, no thermoregulation)

40 40 SDB and Menopause Common Less likely to report EDS More likely to have insomnia, RLS, depression OR 2.6 Complex HRT Change in hormone status; reduction in progesterone Weight gain typical; changes in body fat distribution May be useful Minarik, P.A., 2011

41 41 Cardiovascular Impacts

42 42 Sleep Duration and Risk for Hypertension in Women: Results from The Nurses Health Study Both NHS from 1986 and 2001 Women who sleep less than 5 hrs/night had higher prevalence of hypertension then those who slept 7 hrs in women <50 years of age Sleep duration may be a modifiable risk factor for women in this age group Gangwisch, et al, 2013 AJH

43 43 The Thyroid And as if PMS is not enough.. The presence of thyroid dysfunction (hypothyroid) increases with age and has an association with sleep apnea and fatigue; women have higher rates of hypothyroidism than male counterparts

44 Insomnia Increased Prevalence 41% increased risk of developing insomnia May begin as early as puberty May have other health consequences

45 45 What is normal? 2009 Data from Sweden Population based study Randomly selected women 20 in Sweden Survey, 70.4% response rate 400 at home, full night, full PSG on non pregnant women, randomly selected from the respondents of the survey 230 Habitual snorers;170 others from sample Reported data loss 1.5 % Sahlin et al 2009 Sleep Med

46 46 What is normal? 2009 Data from Sweden Data BMI Age (approximation of menopause) Smoking ETOH dependency

47 Results n= With increasing age TST, SE,REM and SWS N1, WASO less time sleeping supine With increasing BMI TST, SE,N2,REM and SWS N1, WASO Hypertension TST, REM, sleep latency Increasing AHI Smoking TST, SE, REM and SWS N1, WASO Longer sleep latency, more n1 and less WASO ETOH Longer sleep latency; reduced REM

48 In general The cumulative effects of sleep loss and sleep disorders have been associated with a wide range of deleterious health consequences including an increased risk of hypertension, diabetes, obesity, depression, heart attack, and stroke (IOM, 2006)

49 49 Summary: Women are special! Sleep of females is impacted by Hormones Direct influence on sleep Indirect influence on mood and chronic pain Age BMI Smoking and ETOH use Overall, women experience more depression and insomnia

50 50 Summary Women s sleep changes over the years Premenstrual Menstrual Pregnancy and post partum Peri and post menopause Each stage is unique in its contribution to sleep or sleeplessness

51 51 Thoughts More research needs to be completed regarding women and sleep Education for HCP regarding sleep and its disorders Pregnancy related Menopause related Integration of sleep screening for women in OB/Gyn offices and primary care

52 52 Acknowledgements Global information and data in this presentation was obtained in part from the section on Women's Health in Principles and Practices of Sleep Medicine (2005) Armitage R, Baker FC, Parry B L Chapter 108 The menstrual cycle and circadian Rhythms Wolfson A, Lee Kathryn Chap 109 Pregnancy and the Postpartum Period Moe, KE Chapter 110- Menopause Sleep Disorders and Sleep Promotion in Nursing Practice Minarik, PA Gender and Sleep

53 53 Contact Information