Sleep On It
A Medical Understanding of Why Mothers can be Challenged to get a Good Night's Rest
Ladies, if you start your day often feeling less-than refreshed, with morning headaches and excessive daytime sleepiness, you may need more than “beauty sleep.” Most women develop sleep issues at some stage of life – whether due to changes in their menstrual cycle, or late-night work-study-lifestyle habits in college and beyond, or later, during pregnancy, postpartum or menopause. The good news is you aren’t “dreaming,” it’s not due to “stress,” it’s not “all in your head,” and you’re not just getting “old.” Sleep affects your brain size, memory, heart health, waistline, sex drive, job performance and a happy peaceful home life – so let’s look at some common causes of poor sleep quality and quantity. We can understand sleep changes by following a woman’s reproductive continuum, starting with a young woman’s menstrual cycle; then pregnancy, postpartum, menopause, post-menopause and beyond.
Menstruation
When a young woman enters the age of menses, the accompanying hormonal swings will cause her to experience decreased REM sleep. Severe mood changes and menstrual pains are likely due to decreases in sleep quality during the nights prior to menstruation. When I treat young women with indications of sleep deprivation, I consider hormonal fluctuations, and I recommend screening for breathing disorders such as apnea. I also look into associated glucose intolerance due to Polycystic Ovary Syndrome (PCOS), a condition that causes women to produce higher-than-normal amounts of male hormones. In addition to wreaking havoc on their sleep, this imbalance causes women to skip menstrual periods, and it later makes it harder for them to get pregnant.
Pregnancy
Ah, the joy, honor, privilege and responsibility that comes with the gift of giving new life! (And the accompanying sleeplessness!) Have you noticed it is even harder to breathe at night during certain points in your pregnancy? Are you aware that there is ¼ of the oxygen available to us here at 6,000 + feet of elevation and this can cause Sleep Breathing Disorders (SBDs)? While we love our mountains, we are compromised compared to folks at sea level. Oxygen is key to every cellular function in our body. When air enters our lungs, oxygen and nitrogen enter our blood, and the heart pumps it to our brain and throughout our body, to every organ and every nerve ending. This is why it is essential that our oxygen levels remain healthy – so we can deliver the oxygen our babies need in utero.
Sleep disorders can begin in the first trimester and become very common in the third trimester due to hormonal changes, along with the discomfort and anatomical changes of a growing uterus. Watch for: daytime sleepiness and fatigue, GERD (heart burn), restless legs, weight gain, nasal congestion, changes in your breathing/ respiratory system, and sleep-related leg cramping. Utero-placental blood flow peaks during the mother’s sleep, which is why five or less hours of sleep are a risk factor for pre-term birth, as well as other sleep-related disorders, such as: preeclampsia, pregnancy induced hypertension, depression, and gestational diabetes mellitus. Low birth weight, failure to thrive, developmental delays and miscarriage are real concerns whenever a patient is diagnosed with a SBD. Treatment will help the mother and the baby during gestation, and also during postpartum recovery and throughout nursing.
Postpartum
Sleep deprivation and infant sleep loss can lead to postpartum depression. It can also cause excessive daytime sleepiness, which can compromise the interaction between mother and infant, and cause increased infection, thyroid issues, anemia and weight retention after childbirth.
As We Age
When you become older you may notice that you’re a bit “flabbier,” not as “tight” and “buff” as before; well the same happens to our airways. (BTW, this happens to men, too.) A flabby airway can vibrate and make snoring sounds or heavy breathing. This is due to partial airway obstruction, which increases with age and other factors, leading to full obstruction with a notable decrease in oxygen, diagnosed as obstructive sleep apnea. This disorder will continue to get worse as you age. Maintaining ideal weight will help your breathing. But it is a myth that you need to be fat or obese to have sleep apnea.
What happens during an apnea attack? When the airway collapses, for 10 seconds or more, multiple times per hour, you will experience a snort, or a sudden awakening gasp, or night sweats, as you struggle through a “fight or flight” response in your sleep. This adrenal rush causes diaphragmatic movements and increased heart rate that will lead to anxiety, and eventually to A-Fib (irregular heartbeat). This stress response leads to the release of the hormone cortisol, which causes an associated weight gain. If not addressed, this condition follows a continuum of progression leading to increased risk for more serious health concerns, such as: heart attack, stroke, dementia, and type II diabetes.
Menopause
The “hot flashes” of menopause initiate insomnia in some women. The increase in FSH 9 (a follicle-stimulating hormone) along with a decrease in Estradiol will make it harder to fall asleep and stay asleep. This fragmented sleep may go on for 5-7 years throughout menopause, and can lead to depression and higher levels of stress – what many experience as a “shorter fuse.” So, you are naturally going to experience hormonal changes that go hand-in-hand with SBDs. Studies show 53% of women who complain of sleep issues mid-life have sleep apnea, periodic limb disorder or both. Women who develop hypothyroidism and the associated weight gain are also more at risk to develop sleep apnea. SBDs put you at higher risk for hypertension (high blood pressure) and heart arrhythmias. Research shows that invasive oblation surgeries of the heart muscle to treat A-FIB are not effective if sleep apnea is not addressed prior to surgery. Further, SDB is a family trait, so if your sibling or parent or grandparent was diagnosed with sleep apnea, get yourself tested.
Diagnosis & Treatment
Consulting a Board-Certified Sleep Physician is recommended for anyone experiencing chronic irregular sleep patterns at any age. The first step in evaluating your sleep health is with a doctor-recommended diagnostic home sleep test (which measures and includes apneas and oxygen saturation); or the gold standard, polysomnogram (PSG). A word of caution: a finger-only oxygen screening device only measures oxygen desaturations, not apneas and can give false negatives.
Once diagnosed, your sleep physician can guide you through your options. Treatment may include using an oral appliance provided by a dentist who is qualified in the area of Dental Sleep Medicine, 2015 AASM Guidelines. The appliance, similar to an orthodontic retainer, positions your jaw to maintain a patent airway while you sleep, so you do not experience the collapse of the airway, associated with sleep apnea. CPAP machines (which create continuous positive airway pressure) are more cumbersome. They can be used alone or in combination with oral devices. Some SBDs can be addressed surgically, depending on one’s anatomy and overall health. Statistically, few people are good candidates for surgery and the natural aging process causes SBDs to worsen with age, making some surgeries only a temporary fix.
Start by creating habits of good sleep hygiene and follow through by bringing your concerns to physicians who can support your healthy sleep through each stage of life. Good sleep health will make you a happier, healthier mother now – and a happier, healthier grandparent years from now – because you can take the steps you need to greet each day feeling well rested and refreshed.