Improved screening, more studies needed to better diagnose and treat sleep disorders in women

Clockwise: Christine Won, MD, MS; Hrayr Attarian, MD; Lauren Tobias, MD; Ghada Bourjeily, MD, FCCP
Clockwise: Christine Won, MD, MS; Hrayr Attarian, MD; Lauren Tobias, MD; Ghada Bourjeily, MD, FCCP

Studies suggest that women appear to achieve objectively better sleep than men; subjectively, however, women report more sleep problems, including poor sleep quality, more problems falling asleep, waking up more often, longer periods of wakefulness, and higher rates of daytime sleepiness, according to Lauren Tobias, MD.

“Despite this higher burden of sleep symptoms, we have reason to believe that women are being understudied and undertreated,” said Dr. Tobias, assistant professor in the division of pulmonary, critical care, and sleep medicine at the Yale School of Medicine.

Dr. Tobias served as chair of the CHEST 2020 session, Sleep Disorders in Women Across the Lifespan, which featured a panel of sleep medicine specialists who discussed some of the changes women exhibit in their sleep throughout their lifetimes. The session is available for on-demand viewing on the virtual CHEST 2020 meeting platform through January 18, 2021, for registered attendees.

In the first presentation, Ghada Bourjeily, MD, FCCP, professor of medicine at Alpert Medical School of Brown University, discussed some of the ways in which pregnant women are uniquely impacted by sleep symptoms and disorders.

“Sleep disturbances are quite common during pregnancy,” Dr. Bourjeily said. “And the reasons for sleep disruption increase as pregnancy progresses.”

In the first trimester, for example, she said that pregnant women are commonly disturbed during their sleep by nocturia and musculoskeletal discomfort. In the second trimester, additional contributors to sleep disruption can include fetal movement and uterine contractions. Finally, in the third trimester, further physiological features such as heartburn, orthopnea, and rhinitis/nasal congestion can increase sleep disturbance.

Dr. Bourjeily said it’s important for OB/GYNs, for example, to understand how to effectively screen their pregnant patients for sleep disorders and when to refer those patients to a sleep medicine specialist.

“Some of the factors that influence how we screen for sleep disorders include the fact that sometimes it’s difficult to differentiate what is normal pregnancy physiology in terms of symptoms and what is a pathology,” she said. “There’s a lot that we need to do in terms of education and more.”

While there are some small ongoing pilot studies looking at gestational diabetes and preeclampsia as primary outcomes, Dr. Bourjeily said more studies are needed to explore the impact of sleep disorders on maternal and neonatal outcomes.

“The one very precious thing is the fact that sleep is a modifiable risk factor,” she said. “And we can’t say that about many other risk factors for adverse perinatal outcomes, but there are a lot of gaps that remain in the literature and we need to address those to better care for that pregnant population.”

In the next presentation, Hrayr Attarian, MD, professor of neurology (sleep medicine), Northwestern University Feinberg School of Medicine, discussed the association between menopause and sleep disorders.

Citing a study (Zolfaghari S, et al. Menopause 2020) that looked at the time between menopause onset and onset of sleep disturbance complaints, Dr. Attarian said that symptoms can begin up to a few years before menopause and often tend to decline as a woman transitions beyond menopause.

“Some of the complaints include dissatisfaction in sleep patterns, sleep onset insomnia, sleep maintenance insomnia, daytime sleepiness, sleep apnea, and restless leg syndrome (RLS),” he said. “After adjusting for various variables and other health issues, the ones that show significant odds of being associated with menopause are insomnia and sleep apnea.”

In the final presentation of the session, Christine Won, MD, MS, talked about the prevalence of sleep-disordered breathing in women and the differences in how men and women often present. Dr. Won is an associate professor of medicine, Yale School of Medicine, and medical director of the Yale Centers for Sleep Medicine.

“Men are more likely to present with your classic symptoms of sleep apnea, such as snoring, gasping, witnessed apneas,” she said. “Women have these symptoms as well but are more likely to present with rather atypical symptoms, such as difficulty falling asleep, inability to concentrate, night sweats, or morning headaches.”

Dr. Won said that this, along with other sex differences in symptoms and presentation, may contribute to sleep apneas being underdiagnosed in women. Better screening and testing, she said, could help to identify and treat more women with sleep apnea.