September 17, 2014
Many women look forward to a radiant, flawless glow that’s expected to come with pregnancy. However, despite the upbeat exterior, many pregnant women suffer from depression, with potentially serious medical consequences for the mother and the baby.
This paper reviews outcomes of pregnancy when mothers have depression. What they found was that having depression during pregnancy is significantly associated with higher rates of pre-term delivery, low birth weights, pre-eclampsia, and spontaneous abortion. In children born to depressed mothers, higher rates of emotional and behavioral problems were seen.
The prevailing theory is that increased stress hormones can potentially cause complications in the mother and the baby. However, it’s interesting that these same complications are very similar to complications of untreated obstructive sleep apnea. We know that poor breathing during sleep (which leads to inefficient sleep) can lead to increased levels of physiologic stress. Added weight gain and snoring are known and normal consequence of pregnancy.
With about 20 to 30% of pregnant women suffering from depression, it’s important to screen for depression. Better yet, perhaps doctors should routinely screen for obstructive sleep apnea in all pregnant women. Of course this paper doesn’t discuss depression that can happen after delivery (postpartum depression).
For the mothers that are reading this, did you suffer from depression during pregnancy, and if so, do you currently snore?
May 7, 2012
Here’s a not-to-surprising study showing that obese women are at higher risk of having children with autism. Obese women were 67% more likely to have an autistic child, and about 2x as likely to have an child with another developmental disorder. Having gestational diabetes also raised by 2x a mother’s risk of having a baby with developmental disorders.
They also note that nearly 60% of women of childbearing age in the US is overweight and about 1/3 are obese. Obesity rates are rapidly climbing. Autism rates are also climbing, with the latest report showing 1/88 children having one of the autism spectrum disorders.
The authors mentioned every possible explanation (diabetes, high blood pressure, fluctuating glucose levels, lack of oxygen) expect for obstructive sleep apnea. I’ve written numerous times in the past about complications of obstructive sleep apnea during pregnancy. If you’re overweight or obese, you’re much more likely to have obstructive sleep apnea. One of the hallmarks of sleep apnea is hypoxia and major physiologic stress on the mother’s body. I wonder what the effect is on the developing baby’s brain? It would make sense to routinely screen for sleep apnea in all women, especially if you’re overweight or heavier.
If you were overweight during pregnancy, did your doctor screen you for obstructive sleep apnea?
February 29, 2012
Some of the questions I answer include:
- Why are women light sleepers?
- How is sleep different in women compared to men?
- How can I go back to sleep if I wake up in the middle of the night?
- Will estrogen supplements help with sleep?
- What’s the difference between bio-identical and synthetic hormones and how do they affect sleep?
- How does estrogen dominance cause sleep problems?
- What causes throat pain just before your periods?
- How can hypertension and diabetes be prevented during pregnancy?
- Which hormone is responsible for sleep problems during menopause?
- And much more….
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January 16, 2012
Researchers combed through 117,892 Quest Diagnsotics records and found that about 15% of women tested positive for gestational diabetes. Based on this finding, they estimate that as many as 483,000 women with gestational diabetes may go undiagnosed every year. Asian women had the highest rates of being tested and being positive for this condition, and older women and overweight women were much more likely to be tested during pregnancy.
Hypothyroidism during pregnancy can lead to lower IQ scores in children after birth.
I’ve written extensively before that pregnancy increases your chances of sleep-breathing problems, especially in light of significant weight gain that occurs. Gaining weight is a major risk factor for obstructive sleep apnea, which has been shown to significantly increase your risk or diabetes and hypertension. Any form of physiologic stress can has been shown to lower your thyroid levels as well. You don’t have to have obstructive sleep apnea to have significant breathing problems at night.
Having low thyroid levels can also promote weight gain. Poor sleep quality also promotes weight gain. Weight gain narrows your throat, causing more breathing problems. It’s a vicious cycle. Regardless of which comes first (sleep apnea or hypothyroidism), it’s a two-way street.
If you consider that our population as a whole is now heavier, and women are having babies at much later ages, then hypothyroidism is one of many conditions related to sleep-breathing problems and pregnancy that is expected to increase in numbers.
Browse several inpatient drug rehab centers!
November 6, 2011
Here’s a not-too-surprising finding: A 2007 study front the National Sleep Foundation found that 3 out of every 10 women admit to taking a sleeping pill at least a few nights a week. Prescription sleep aids peak amongst women aged 40 to 59. Many women also report that their sleep has never been the same ever since that last pregnancy. Even with older children, being able to either fall asleep or stay asleep can be challenging for many women.
Beyond the obvious reasons for poor quality sleep in women (nighttime feedings, stresses of modern life, hormonal changes, etc.), there’s one important additional factor that wasn’t mentioned in a recent New York Times article on this subject: increasing problems breathing at night.
I’ve written numerous times about how pregnancy predisposes women to obstructive sleep apnea, but due to rising levels of progesterone, their airways are protected (as an upper airway muscle stimulant). But after delivery, progesterone drops, but you still have all that weight. Now you’re narrowed your upper airway, but without the protective benefits of progesterone. Add to this the initial sleep deprivation from routine awakenings at night, and the problem is compounded even further.
Notice also that sleeping pill use peaks around peri-menopause. This is also a period when progesterone levels slowly drop, leading to even more breathing pauses while sleeping. Add to this the typical few more pounds that women gain during menopause, and this can lead to worsening obstructive sleep apnea. No wonder women begin to catch up to men when it comes to rates of obstructive sleep apnea and cardiovascular disease as they go past menopause.
You’ll notice that most women who have chronic insomnia prefer not to sleep on their backs, since that’s then the tongue falls back the most due to gravity. Having smaller jaws create less room for the tongue, making them more prone to sleep-breathing problems. Many of these women will have one or two parents that snore heavily.
It’s also important to realize that you don’t have to have true apneas to have disrupted breathing during sleep. You can have very short obstructions and arousals that don’t count as being apneas if you did a formal sleep study. Younger and thinner women (and men) can have these more subtle events, which can manifest as upper airway resistance syndrome. You can also have different combinations of all these breathing pauses and arousals. The bottom line is that you just can’t sustain deep, continuous sleep. Waking up after 4-5 hours of sleep would be expected when you begin to enter longer periods of REM sleep in the later parts of the night. This is when your throat muscles are most relaxed, and most susceptible to obstructions and arousals.
I’m not discounting all the other reasons why women have so many sleep issues, but untreated sleep-breathing problems is is major source of poor sleep that can frequently masquerade as insomnia, especially in women.
August 3, 2011
As a follow-up to my post last week on why pregnant women may have an increased risk of stroke, here’s a study published this month in the journal Sleep. Researchers compared 34 women with gestational hypertension vs. 26 healthy women with uncomplicated pregnancies. Significant sleep-disordered breathing was defined as a respiratory disturbance index (RDI) of 5. Pregnant women with high blood pressure had significant sleep-disordered breathing in 53%, whereas 12% of healthy pregnant women had sleep-disordered breathing. Hypertension is a known risk factor for preeclampsia and stroke.
This study is in line with my suspicion that pregnant women, while at risk for obstructive sleep apnea, probably have shorter obstructions and RERAs (respiratory-effort related arousals), rather than frank apneas. Increased progesterone and various other physiologic changes seen in pregnancy can increase your respiratory drive and lower arousal thresholds, leading to more frequent arousals from deep sleep.
Notice how commonly pregnant women snore, and they’re extremely tired. If they weren’t pregnant, doctors would suspect obstructive sleep apnea. Then why do we have this double standard? Why can’t women who suddenly gain weight and snore be routinely screened for obstructive sleep apnea?
July 28, 2011
Rates of stroke went up 47% for expectant mothers and climbed to 83% in the first three months after delivery. This was the finding that was published in the journal Stroke: Journal of the American Heart Association. They cite rising rates of additional risk factors such as high blood pressure, obesity, and gestational diabetes, but didn’t give a plausible explanation. Here’s a story about this study published in the Wall Street Journal.
Here’s a simple explanation: Sleep-breathing problems. Whether it’s obstructive sleep apnea or more likely upper airway resistance syndrome, pregnant women tend to have more frequent breathing pauses, especially as they gain weight. One protective mechanism is through progesterone, which acts as a tongue muscle stimulant, but the forces of upper airway collapse is likely to overwhelm these protective effects. What’s even more striking is that the rate almost doubles immediately postpartum. Remember that progesterone drops soon after delivery, but you’re still left with all that additional weight. We know that obstructive sleep apnea can significantly increase your chances of stroke and heart attacks. There are even reports that suggest that preeclampsia can be successfully treated with CPAP.
Overall, the numbers are still very low, but the sudden rise in the rate of stroke in new mothers leaves researchers scratching their heads.
June 19, 2011
Researchers from New Zealand discovered that women who did not sleep on their left side the last night before delivering their babies had twice the rate of stillbirth compared with those that slept on their left side. It’s commonly recommended for pregnant women to sleep on their left side, especially later in pregnancy. There are various explanations for why this is preferred, from placing less pressure on the mother’s major blood vessels to worsening the mother’s snoring.
I’ve mentioned before that a woman’s risk of developing obstructive sleep apnea increases as she gains weight during pregnancy, but progesterone counteracts this effect neuromuscularly, by tensing the throat muscles and increasing the drive to breathe. However, back sleeping is a known aggravator of breathing pauses during sleep due to gravity’s effects on the tongue. Whether or not this leads to apneas (10 seconds or longer pauses), the mother will still stop breathing and wake up more often during the night. This can place a major stress not only on the mother’s body, but on the baby as well.
This study was an observational study, so more prospective studies are needed. But it only goes to show that any additional situation that can aggravate sleep-breathing problems during pregnancy can raise your risk of complications, which also includes gestational diabetes and preeclampsia.
I wonder if the researchers asked the women what their preferred pre-pregnancy sleep position was. I suspect that women who can’t sleep on their backs may have more complications during pregnancy due to narrowed upper airway anatomy.
May 21, 2010
Mother’s Day has come and gone, and despite the short respite that many mothers received from their loved ones, most mothers are in a constant state of exhaustion. There are many explanations for why this is so, including the demands of modern society, family, career, and so on. But as many fathers will argue, these are the same issues and challenges they face. For women however, there are a number of internal, or physiologic factors that can not only contribute to but sometimes cause women, more so than men, in general to be tired all the time.
Blame It On Hormones…Or Your Anatomy?
We all know about hormonal issues, which has been blamed for everything from PMS and menopause to infertility issues. But one relatively unknown fact that most doctors don’t know about is that progesterone is an upper airway muscle dilator. Essentially, it stimulates the tongue, giving it more muscle tone. How is this relevant to how much energy you have?
Modern humans have a number of anatomic issues that makes us predisposed to breathing pauses at night, especially when in deep sleep, due to muscle relaxation. Since our voice boxes are lower in the neck beneath the tongue, our tongues can fall back easily due to gravity, especially when on our backs. Add REM sleep (the dreaming stage) along with muscle relaxation, and the more likely you may stop breathing.
Modern humans are thought to have shrinking jaws with dental crowding due to a major shift in our diets. We went from eating completely off the land (ripping, shredding, grinding, chewing) to eating soft, mushy foods with relatively little nutritional value. Bottle-feeding (another modern, Western invention) is also thought to aggravate dental crowding and malocclusion. The smaller the jaws, the less room there is for the normal-sized tongue, which predisposes it to breathing obstruction at night.
So the less progesterone you have, the more likely your tongue will relax and obstruct your breathing, causing you to wake up and turn over. This condition prevents you from staying in deep sleep. Most people with this condition will naturally like to sleep on their sides or stomachs to compensate.
Life Changes That Aggravate Deep Sleep Deprivation
There are a number of life changes in a woman’s life that promote more frequent obstructions and arousals, leading to increased fatigue and tiredness. During a woman’s monthly periods, estrogen and progesterone cycles up and down. The week before she has her period, progesterone drops, leading to a temporary state of deep sleep deprivation, leading to a low-grade state of physiologic stress. This also causes a heightening of the involuntary nervous system, leading to heightened senses, irritability and moodiness.
During pregnancy, progesterone naturally increases significantly. As women gain 20 to 40 pounds during pregnancy, they would be expected to develop sleep apnea, but most don’t. One major reason is that progesterone helps to protect the upper airway, by tensing the tongue, despite the added throat narrowing from weight gain. But once mom delivers, progesterone drops, and she’s left with all the weight. This only adds to the chronic fatigue, depression and problems with weight loss in the post-partum period for most women.
Similarly, long before menopause begins, progesterone begins to slowly drop beginning the late 30s and early 40s. This leads to a slow and gradual lessening of the woman’s sleep efficiency. Later on as the drop intensifies, the relative changes in the involuntary nervous system causes the typical symptoms of menopause such as night sweats, hot flashes, mood swings, weight gain and irritability. Once the hormonal changes stabilize, the symptoms get better.
The Effect of Estrogen Dominance
Like everything else in life, balance is key. The relative proportions between estrogen and progesterone has a huge impact on a woman’s sleep quality. With the advances in science, medicine, and industrialization, this delicate balance between these two hormones has been significantly altered.
One major shift comes from oral contraceptives. Despite the potential benefits of birth control pills, having excess estrogen of any type can suppress progesterone levels or functional status. Synthetic variants of estrogen are much more powerful than what the body normally makes. There are various combinations of synthetic and bio-identical estrogens and progesterones that are used, but it’s safe to say that the overall relative balance is never perfect. Even the IUD by Mirena that claims to have less hormonal effects still has its own risks. For example, Mirena IUD removal can be painful or lead to much serious complications.
In addition, many of the byproducts of industrialization produces chemicals that can mimic estrogen. Up until recently, Bisphenol-A (or BPA) has been used in plastics that are found in most plastics, including baby bottles. BPA and many other chemicals are though to leech into our environment, acting as endocrine disruptors. There are various reports of earlier onset of puberty and breast development (premature telarche) in young girls compared with even 10 years ago.
Blame It on Stress
One of the major consequences of inefficient sleep is a physiologic form of stress. Your body thinks it’s under attack all the time. This causes hormonal and neurologic changes that not only increases cortisol, it also heightens your involuntary nervous system. It also makes you more hungry in general, with cravings for fatty, sugary or high-carb foods. This can lead to weight gain, which is hard to get rid of since you’re not sleeping well.
Your body also doesn’t care where stress comes from. Modern life is full of stresses including family and career obligations, along with the typical financial and health considerations. Any degree of external stress whether it’s physical, psychological or emotional stress, can also aggravate any internal stress that’s going on.
This is why you should do whatever you can do to help your mother feel loved and more relaxed. Mothers have lots of reasons to feel stressed, sleep deprived, and just plain tired all the time. Now you know the reason why.
February 25, 2010
We know that significant weight gain is a common aggravator of obstructive sleep apnea. If you already have narrowed jaws and gain some weight, then you'll move up the sleep-breathing continuum that I describe in my book, Sleep, Interrupted. But why is it that when women become pregnant, sleep apnea is the last thing that's considered whenever they develop depression, high blood pressure or extreme fatigue?
Two recent published studies perpetuate this myth amongst doctors that sleep apnea can't happen in pregnant women. One study showed that about 2/3 of pregnant women responded to depression using acupuncture. Another study showed that antidepressant use during pregnancy led to small, but measurable developmental delays at 19 months. Depression (during pregnancy or post-partum) is a major problem with many women. But rather than saying that it's pregnancy-related depression, it should be looked at as a sleep-breathing problem, since one major reason for depession is lack of deep, quality sleep that's common with all pregnant women. Pharmaceutical companies promoting anti-depression medications to replace deficiencies in brain biochemistries doesn't help either.
One reason why not every woman that's pregnant goes into depression during or after pregnancy is due to the effects of progesterone, which has been called the "feel good" hormone. One of the interesting properties of progesterone is that it's an upper airway muscle stimulant. It increases tongue muscle tone and tension. During pregnancy, progesterone goes through the roof, since it's needed for maintaining the uterus and development of the baby. But if the weight gain is too much, or if your jaw is too narrow, then the effects of progesterone won't be as helpful. Once you deliver, progesterone drops, but you're still left with all that weight. This is one major revelation that I had when my wife experienced severe post-partum depression after the birth of our first son, Jonas.
We also know that many women who develop pre-eclampsia (dangerous high blood pressure) during pregnancy have various degrees of sleep-breathing problems, which can be treated effectively with standard sleep apnea treatment options.
For the women that's reading this blog, did you have any significant depression during or after pregnancy? How did you deal with it, and if your saw a doctor about it, what did they recommend? Please enter your answer in the comments section below.