Over a lifetime, there are many ways in which a woman’s sleep experience differs from a man’s. Times of major hormonal change, such as pregnancy and menopause, as well as certain family responsibilities often shouldered by women, can compromise sleep quality.
As with many aspects of sleep health, these female-specific issues are often neglected by or unfamiliar to physicians and the women who may be experiencing them. It is important that women (and the medical community) be aware of the sleep-related problems they can encounter throughout their lifetimes.
Here are a few of them.
Impact of the menstrual cycle
The onset of puberty introduces certain changes, such as menstruation, which can raise the likelihood of sleep disorders. For example, the risk of insomnia increases when menstruation begins. While the reason is still poorly defined, we believe it is linked with hormonal fluctuations that occur during the menstrual cycle.
The negative effects of menstruation on sleep also appear to be most frequent during the last few days of a woman’s cycle, when levels of progesterone and estrogen decline.
In addition, women who have irregular periods are twice as likely to have problems sleeping.
Women who experience premenstrual syndrome (PMS) tend to have symptoms that are detrimental to sleep or can contribute to insomnia, such as cramps, bloating and headaches, reported by a third of women suffering from PMS. Other common sleep-related complaints are frequent awakenings, nightmares, and difficulty returning to sleep after waking up.
It is estimated that women who suffer from PMS are at least twice as likely to report a detrimental level of insomnia and excessive daytime drowsiness.
Whether related to the menstrual cycle or PMS, sleep disorders and insomnia caused by menstruation can lead to other adverse outcomes, such as stress, lethargy, lack of concentration and fatigue during waking hours, as well as depression. Research has shown that insomnia during puberty doubles the risk of depression.
During pregnancy, 30% of pregnant women report rarely getting a good night’s sleep, compared to 15% of women overall.
The most common sleep disorders are anxiety, backache, fetal movements, breast tenderness, leg cramps, heartburn and abdominal discomfort.
Sleep disorders may also be due to increased nighttime urination or restless leg syndrome, which is thought to be related to changes in the metabolism of iron and folate during gestation.
Characteristics of sleep at different stages of pregnancy
Sleep patterns evolve during pregnancy. Although changes can be observed during the first two trimesters, the majority of sleep disorders appear to be most frequent during the third trimester. At this stage, about 21% of women report that their sleep is disturbed to the point that a diagnosis of insomnia can be established.
Time spent sleeping increases.
Sleep efficiency decreases.
Non-REM sleep (stages 1 and 2) increases.
Number of awakenings after sleep onset increases.
Daytime drowsiness increases.
Fatigue and daytime drowsiness decrease.
Time spent sleeping decreases.
Rapid eye movement (REM) sleep decreases.
Sleep disruptions increase, with three to five awakenings per night.
These sleep disorders are not just a minor annoyance. Poor sleep during pregnancy has been associated with a higher risk of gestational diabetes, intrauterine growth restriction and preterm birth, as well as a greater risk of depression in the postpartum period.[2,6] During the third trimester, poor sleep may increase the risk of prolonged labour, cesarean section and small size for gestational age.
Although we know that sleep disorders during pregnancy can be bothersome and even serious, they are often overlooked. According to one study, less than half of pregnant women reported being asked by a health-care professional about the quality of their sleep.
Pharmacological treatment through sedatives, benzodiazepines and certain insomnia medications can be risky, as this may increase the chances of lower birth weight, preterm birth and cesarean section. Non-medication-based treatments, such as cognitive behavioural therapy for insomnia (CBT-I), yoga, meditation and exercise, are often preferred alternatives.
The baby’s first months
Sleep disorders do not stop after a baby is born. A newborn’s sleep is highly irregular and it is not uncommon that a new mother must wake up during the night to care for or feed her child.
Studies have shown that during the first six months after birth, when the baby’s sleep is not yet regular, there is an increase in awakenings after the onset of sleep and a decrease in sleep efficiency compared to sleep during the third trimester of pregnancy.
Poor sleep quality can also take its toll on the budding relationship between mother and newborn. Mothers who sleep poorly may perceive that their infants cry more and are more anxious. It has also been shown that poor sleep quality is a predictor of a weaker bond between mother and child.
Responsibility for child care
Parenthood can continue to be an obstacle to healthy sleep as the child gets older, especially for women. It is estimated that women shoulder nearly twice as much responsibility for child care as men. This includes waking up during the night to care for family members.
This work can be highly detrimental to sleep consolidation and quality. While napping during the day or sleeping longer at night would improve the situation, mothers are not always able to do this due to family and professional responsibilities.
The growth of single-parent families is another factor contributing to women’s increased responsibilities. For example, it is believed that a significant number of women must meet the financial needs of their families through paid work, while also taking on the responsibility of unpaid work related to raising children.
Sleep disorders have been identified as a major symptom of menopause. In the U.S., the National Institutes of Health (NIH) estimates that 42% of women in premenopause, 47% in perimenopause, and 60% in postmenopause have this symptom. Furthermore, a poll by the National Sleep Foundation found that 25% of perimenopausal and 30% of postmenopausal women report getting a good night’s sleep only a few nights per month.
A woman becomes more prone to sleep disorders largely due to hormonal changes that occur during this time. However, aging also increases the risk of developing health problems (such as depression or sleep-disordered breathing), which contribute to poor sleep.
The issue of hot flashes
Vasomotor symptoms, also known as “hot flashes,” are one of the main obstacles to sleep during menopause. While the cause is not fully understood, it appears to be associated with a drop in levels of estrogen and other hormonal changes.
Hot flashes typically last for up to 30 minutes and are characterized by a feeling of intense heat, sweating and an elevated heart rate. They are estimated to occur in 60% to 80% of women during menopausal transition and persist for about four to five years on average.
Hot flashes do not always cause sleep disruption, but this is often the case. Sleep fragmentation, increased waking after sleep onset and poor sleep efficiency have all been associated with hot flashes during actigraphy and polysomnography tests.
In late menopause, when hot flashes appear to be most common, studies have shown that they significantly alter the quality of a woman’s sleep. Vasomotor symptoms can also impact mental health, as links have been established with symptoms of depression.
Insomnia is another common sleep disorder, affecting up to 36% of premenopausal and 61% of postmenopausal women. This may be associated with hormonal changes, age-related changes in sleep, or the inability to fall back asleep after a hot flash. In addition, approximately 80% of menopausal women who experience severe hot flashes may suffer from insomnia.
Menopause is also associated with an increased risk of obstructive sleep apnea (OSA). Studies have shown that 47% to 67% of postmenopausal women have OSA. This phenomenon is partially related to the fact that women tend to gain weight after menopause, and excess fat around the neck contributes to airway obstruction, which is typical of OSA.
Other common sleep disorders during menopause, such as an increased need for nighttime urination, or incontinence, joint pain or anxiety, can adversely affect quality of sleep and have consequences for quality of life.
Disorders to take seriously
Although studies indicate that women tend to sleep longer than men,  their sleep is suspected to be less restful, which may have consequences for their health.
Research has shown that, compared to men, women who suffer from sleep disorders and insufficient sleep have a higher risk of depression, as well as metabolic and cardiovascular disorders.
As a result, it is important that women pay attention to the quality of their sleep. If they suspect that poor sleep is disrupting their daily life, they should speak with their doctor. For their part, the medical community should also pay attention, as poor sleep can seriously affect a woman’s physical and mental well-being.
Baker FC, Sassoon SA, Kahan T, Palaniappan L, Nicholas CL, Trinder J, Colrain IM. Perceived Poor Sleep Quality in the Absence of Polysomnographic Sleep Disturbance in Women with Severe Premenstrual Syndrome. J Sleep Res. 2012; 21(5): 535-545
Mallampalli MP, Carter CL. Exploring Sex and Gender Differences in Sleep Health: A Society for Women’s Health Research Report. Journal of Women’s Health. 2014; 23(7)
Hachul H, Siqueira Castro L, Gomes Bezerra A, Natan Pires G, Poyares D, Levy Andersen M, Rita Bittencourt L, Tufik S. Hot Flashes, Insomnia, and the Reproductive Stages: A Cross-Sectional Observation of Women from the EPISONO Study. J Clin Sleep Med. 2021; 17(11): 2257-2267
Nowakowski S, Meers J, Heimbach E. Sleep and Women’s Health. Sleep Med Res. 2013; 4(1): 1-22
Pengo MF, Won CH, Bourjeily G. Sleep in Women Across the Life Span. CHEST 2018; 154(1): 196-206
Tobias L, Kryger M. Women’s Sleep Across the Reproductive Life Span. J Clin Sleep Med. 2018: 14(7): 1095-1096
Burgard SA, Ailshire JA. Gender and Time for Sleep Among U.S. Adults. Am Sociol Rev. 2013; 78(1): 51-69
National Institutes of Health State-of-the-Science Conference Statement: Management of Menopause-related Symptoms. Ann Intern Med. 2005; 142(12 Pt 1): 1003-1013
Pien GW, Sammel MD, Freeman EW, Lin H, DeBlasis TL. Predictors of Sleep Quality in Women in the Menopausal Transition. SLEEP. 2008; 31(7): 991-999
Jehan S, Masters-Isarilov A, Salifu I, Zizi F, Jean-Louis G, Pandi-Perumal SR, Gupta R, Brzezinski A, McFarlane SI. Sleep Disorders in Postmenopausal Women. J Sleep Disord Ther. 2015; 4(5)
Mong JA, Cusmano DM. Sex Differences in Sleep: Impact of Biological Sex and Sex Steroids. Phil. Trans. R. Soc. Lond. B. 2017; 371: 20150110