Women & Insomnia: What Else Could it Be?

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.

Written by Steven Park · Filed Under Blog | Leave a Comment

Is Your Throat Sore Just Before Your Period?

January 28, 2010

Here’s an interesting observation by more than a handful of my female patients: Their throats are sore for a few days just before their monthly periods. It doesn’t go on to a cold or other more severe symptoms. Just a transient sore throat. Then it goes away.

If you’ve been following my blogs, articles, and especially if you read my book, Sleep, Interrupted, there’s a simple explanation. During your monthly cycles, progesterone levels increase with ovulation, but drops when there’s no egg fertilization. One relatively unknown property of progesterone is that it’s an upper airway muscle dilator. It literally tenses your tongue muscles. When in deep sleep, your muscles (as well as your tongue and other throat muscles) tend to relax to various degrees depending on your sleep stage. If you have less progesterone on board, then it’s more likely to fall back, obstructing your breathing, leading to a temporary vacuum effect in the throat, suctioning up small amounts of normal stomach juices. All this causes a temporary deep sleep deficiency. If you eat a late meal, more of these juices will come up. But once progesterone levels begin to increase again, the tongue tenses, and sleep quality improves as well.

Sometimes, the inflammation in the throat increases to the point of significant deep sleep deprivation, leading to some of the more severe symptoms as pre-menstrual headaches, fatigue, irritability, and weight gain.

For you women out there, do you experience sore throats just before your periods? Please enter your responses in the comments box below.

Written by Steven Park · Filed Under Blog | 166 Comments

Hair Loss and Sleep Apnea?

January 15, 2010

This is what I posted to the NY Times Blog for an article on hair loss in women:

Hair loss in women is a serious condition with lots of conventional explanations. One area that's never mentioned is the connection to poor sleep quality, especially due to breathing problems at night. A significant percentage of men and women have undiagnosed sleep-breathing problems, with the end extreme being called obstructive sleep apnea.

It's estimated that about 1/4 of all men and 1/10 of all women have at lease mild sleep apnea, and 90% are not diagnosed. However, there's a variation of sleep apnea called upper airway resistance syndrome (UARS), where you'll stop breathing while sleeping, but not long enough to be called obstructive sleep apnea.

Typically these people (more typically thin women) will have colds hands or feet, prefer not to sleep on their backs, feel tired all the time, no matter how long they sleep, and will usually have at least one parent that snores heavily.

These multiple arousals lead to a chronic low-grade physiologic stress response which heightens the nervous system (and immune system). During times of stress, blood is shunted away from low-priority organs like the GI system, reproductive organs, the distant extremities and the skin. Chronic lack of blood flow can lead to a number detrimental effects, including hair loss.

It's also been shown that chronic physiologic stress also raises your cortisol levels, lowers your thyroid levels, and alters your estrogen/progesterone/testosterone balance.

There are also anecdotal reports of people who report hair regrowth after starting sleep apnea treatment.

If you have any of the symptoms mentioned above, you should get checked for UARS. In many cases, UARS progresses into obstructive sleep apnea, especially after menopause. Even if it doesn't help your hair loss, being diagnosed may prevent complications of sleep apnea, including hypertension, diabetes, weight gain, anxiety, depression, and heart disease.

Written by Steven Park · Filed Under Blog | 2 Comments

Women and Heart Disease: What Most Doctors Don’t Know

February 14, 2009

If you’re a woman having chest pain or shortness of breath, it’ll take longer for you to be evaluated by EMS and taken to the emergency room than if you’re a man. This finding was reported this month’s Circulation: Cardiovascular Quality and Outcomes, and summarized for the lay public in the New York Times. What’s worse is that even if women get to the emergency room quickly, a heart attack diagnosis is made much slower than in men.

What this article doesn’t address, however, is how to prevent heart disease in women in the first place. Sleep apnea is a very common condition that if left untreated, can cause anything from depression, anxiety, high blood pressure, diabetes, obesity, heart disease, heart attack or stroke. It’s estimated that up to 1/4 of all men and 1/10 of all women may have at least some degree of sleep apnea. The frightening statistic is that about 90% of women with sleep apnea are not diagnosed. Instead they are being treated for the complications of untreated sleep apnea, rather than the cause itself.

There are three major issues regarding women that prevents proper diagnosis of sleep apnea: The sleep apnea myth, the hormonal factor, and the insomnia bias factor.

Myth #1: Sleep Apnea Is Mostly a Male Problem

One of the biggest myths about sleep apnea is that you have to be a middle to older aged, heavy-set snoring man with a big neck. This stereotypical view of sleep apnea is still common amongst most physicians, so unless you’re in the extreme end of the disease spectrum, a sleep-breathing condition won’t even be considered as a possibility if you’re a woman. When obstructive sleep apnea was first described in the 60s, it was initially described in older, heavy-set snoring men. Even today, medical lecturers continue to put up pictures of this type of patient, and sometimes, a picture of Joe the Fat Boy from Dickens’ The Pickwick Papers. Paper after paper continue to report on associations between weight, neck size, and the male sex and increased risk for sleep apnea.

However, it’s been recently shown what even young, thin women that don’t snore can have significant obstructive sleep apnea. I see patients like this daily in my practice. This also applies to young thin men as well. Whenever these people are diagnosed officially on a sleep study, they always comment that their medical doctors comment, "you don’t look like you have sleep apnea." This just goes to show that there is no "typical" sleep apnea patient.

Myth #2: Men Can’t Have Menopause

It’s commonly known that as women progress through menopause, their rates of heart disease begin to catch up with men (although not completely). The common symptoms of menopause include night sweats, hot flashes, mood swings, weight gain, insomnia and irritability. However, as I’ve alluded to before, young men in their 20s can have the same exact symptoms. How can this be? It’s because these men, as they are slowly gaining weight, are progressing up the sleep-breathing continuum, slowly developing obstructive sleep apnea. It’s the relative change in the anatomy that’s confusing the involuntary nervous system, giving rise the the so-called vasomotor symptoms. Your involuntary nervous system is what controls your heart rate, blood pressure, body temperature, sweating, digestion, and sleep.

In women as they approach the pre-menopausal years, one of the first changes that they go through is that progesterone levels slowly drop beginning in their early 40s. One of the known interesting properties of progesterone is that it acts as an upper airway muscle dilator and stimulant. This is what makes pregnant women breathe harder and faster. It also tenses your upper airway muscles by promoting more muscle tone.

As I’ve alluded to in my book Sleep, Interrupted, most modern human tongues are susceptible to falling back partially when on our backs. When you add muscle relaxation during deep sleep, our tongues can fall back and obstruct our breathing. This is why so many people can’t sleep on their backs. So if you slowly take away progesterone in women, the tongue relaxes more and more, and wake up more and more, usually from deep to light sleep. Inefficient sleep promotes weight gain, and weight gain narrows the throat even more. These multiple obstructions and arousals lead to a confusion of the involuntary nervous system. Later on, as the period of pauses after one obstructs increased, oxygen levels begin to drop, and obstructive sleep apnea worsens.

This is the reason why in general, women sleep better when on hormone replacement therapy, and they have a lower chance of heart disease as well. Now, due to all the conflicting studies regarding hormone replacement options and a possible increased rate of cancer, this is a very delicate and controversial topic that’s beyond the scope of this discussion. Nevertheless, peri-menopausal women have been using bio-identical progesterone creams for years safely to improve their quality of lives as well as their quality of sleep.

Myth #3: Insomnia Affects Everyone Equally

Lastly, an older study revealed that women who complain of sleep problems to their doctors resulted in a diagnosis of insomnia more often than in men. Oftentimes, these women were prescribed sleeping pills. Men who complains of sleep problems are more likely to be asked if they snore, and it’s safe to say that obstructive sleep apnea is picked up more commonly in men due to this situation. Again, this brings up the OSA stereotypes that doctors have in men versus women.

There are a number of other reasons why women will get less than optimal heart care compared with men. I’ve touched on just three reasons that prevents women from getting diagnosed promptly for obstructive sleep apnea. Untreated obstructive sleep apnea can lead to heart disease. As long as the medical community segregates medical conditions without looking at the whole picture, we’ll continue to have discrepancies in the quality of care for not only for women, but for men as well.

Written by Steven Park · Filed Under Articles | 3 Comments