Women have different levels of estrogen and progesterone than men — perhaps you were aware? — and those levels fluctuate throughout the menstrual cycle. Doctors believe that these hormonal shifts can affect our ability to fall or stay asleep, says Dianne Augelli, M.D., a sleep expert at the Weill Cornell Center for Sleep Medicine
at NewYork-Presbyterian. "Estrogen works on several different neurotransmitter pathways that may have an impact on the regulation of sleep, and progesterone can have a hypnotic property," she says. "Fluctuations in these hormones may have an effect on the circadian rhythm." The timing and severity can be different from woman to woman, and experts don't fully understand how these hormone shifts disrupt sleep but they believe they play an important role, she says.
In addition to keeping you up at night, those hormones are also driving all sorts of menstrual side effects. Bloating, cramping, breast tenderness, and mood and anxiety changes can all make it harder to sleep.
Yes, being knocked up can make you exhausted, but pregnant women also often find their sleep suffering because of physical discomfort, to say nothing of the increased need to pee that often comes with carrying a bundle of joy directly on top of your bladder.
Plus, women are more likely to have obstructive sleep apnea and restless-leg syndrome while gestating, thanks to hormonal changes and relatively low iron counts, respectively. In obstructive sleep apnea, the airway becomes blocked or collapses, which can lead to pauses in breathing that might wake you up. Loud snoring is a hallmark symptom of OSA, but women don't always present with snoring, Dr. Augelli says, and as such this condition is overlooked in women. The American Thoracic Society notes that hormonal changes during pregnancy could lead to inflammation
in the airways but that narrowing could also be the result of weight gain, says Michelle Drerup, Psy.D., a sleep psychologist and behavioral sleep medicine specialist at the Cleveland Clinic Sleep Disorders Center
Restless-leg syndrome is about twice as common
in women than men in general, but pregnancy seems to be when some women first experience the nighttime throbbing sensation and urge to move their limbs. "When you're pregnant, your blood volume expands so you have anemia to some degree," Dr. Augelli says. "One of the theories is that there's not enough iron in a specific part of the brain that produces dopamine and that can trigger restless legs." Women of childbearing age are more likely to have anemia or low iron counts and more commonly experience restless legs, she says.
Congratulations: That sleep-destroying bump has turned into a sleep-destroying baby, who will soon grow into a sleep-destroying toddler. Drerup says a lot of her patients with kids tell her that even after their children start sleeping through the night, they continue to wake up. "They have 'mommy ears' — they're still not sleeping as deeply because they were used to responding to their infant."
For at least one woman, the solution was to wait 18 years: "Interestingly, one patient I worked with had insomnia since the birth of her child, and when her child moved out to go to college she started sleeping. There was probably no physiological impact; that was more of a psychological worry about being up for her daughter."
Finally, the kids are out of the house, you're retired, and you can nap all you want — right? Nope. It's not all smooth sailing as women approach menopause. Yes, the dreaded night sweats and hot flashes can make for uncomfortable evenings, but there's the added wrinkle that the prevalence of obstructive sleep apnea significantly increases as women go through menopause and starts to catch up to men, Dr. Augelli says. If your partner notices you snoring or gasping, or if you feel like you can't stay asleep, bring it up with your doctor — whether you're menopausal or not. "Just like how women present with different heart-attack symptoms than men, women present with different symptoms of OSA than men. And insomnia can be one of those symptoms," she says.
Does it seem like every stage of a woman's life is primed to damage her sleep? And does that fact stress you out? Careful: Stressing about not sleeping can make the problem worse, Dr. Augelli says. You want to worry justttt the right amount. "It's true there's sort of a snowball effect — there's an initial insult and then there's sort of a stress phenomenon
that follows that. Concern and worry and hypervigilance about not sleeping can perpetuate it." It's not always easy to change this line of thinking.
In her practice, Drerup uses cognitive-behavioral therapy, or CBT, to help people become more aware and critical of "catastrophizing" thoughts, which put even more pressure on people to fall asleep, like how am I going to function tomorrow? "It's about helping them gain awareness when they're stuck in those negative-thinking patterns and working on giving them a more fair assessment of the situation," she says.
Drerup also suggests different relaxation strategies that help distract people from the fact that they're not sleeping. Namely, she tells her patients to get out of bed and do something relaxing that doesn't involve a screen, like reading a magazine or whipping out an adult coloring book (she says her patients like using those as a form of meditation).
Anxiety and Depression
There's garden-variety stress-related insomnia, and then there are thornier health conditions that can interfere with sleep and that affect more women than men regardless of age, like depression and anxiety. (The chronic-pain disorder fibromyalgia
also fits in this bucket.) As Dr. Augelli points out, mental-health problems are a bit of a chicken-or-the-egg situation, but we know they're linked. "Anxiety and depression can cause insomnia or insomnia can cause those," she says. Drerup agrees. "We used to think of it as insomnia secondary to depression and anxiety," she says. "We call it comorbid insomnia now; they both impact each other." It should go without saying that if you think you might have depression or anxiety (or you know you do and it's not currently well-managed) you should get it treated.
Drerup says that of the thousands of patients she's seen, there's only been a handful of people whose partners also have insomnia. That means, in most cases, one person is blissfully conked out while the other is lying awake, pissed off.
In situations like these, or when a partner has other habits that disrupt your sleep, like snoring, twitching, or sleepwalking, Drerup suggests sleeping in a different room for a week as a test. If your sleep quality goes through the roof, you could talk to your partner about getting treatment or consider making the room change permanent. "Having separate sleeping areas is more common than most people realize," she says.
If the issue is more about mismatched bedtimes and wake-up times, Dr. Augelli says you should stick to your own clock. "You want to make sure you're not trying to sync up with your partner unless you're really getting up at the same time every day," she says. "Everybody has a little bit of a different sleep cycle." This could mean waiting until you're actually tired before climbing into bed, or, as Drerup suggests, turning in together but leaving the room once your partner falls asleep and heading to your own snooze sanctuary. There, you can do as you wish until you nod off. "That's how a lot of my patients do it — the person who falls asleep first stays there and then I go to my room to sleep. We have time together but it's not going to be disruptive to me."
Bad Sleep Hygiene
If you can't blame your insomnia on a snoring or otherwise annoying partner (or you've already addressed that issue), it's time to take a look inward. For people whose lack of sleep affects their everyday functioning, it is paramount to try standard sleep-hygiene
recommendations, like going to bed at the same time nightly, keeping the room dark and cool, not using one of your many devices before bed, and exercising, but not too close to bedtime, Dr. Augelli says. (And you might suck more at sleep hygiene than you think. Take our quiz
to find out.)
If you've tried literally everything and you still can't sleep as well as you'd like, it might be worth talking to a behavioral sleep specialist who can give you a more structured plan to break the cycle. "Working with someone with insomnia is really individualizing the plan of what's going to work in their situation," Drerup says. You could start with your primary-care doctor but heads-up that they might recommend the same sleep-hygiene tips and, if those don't help, prescription sleep aids, Drerup says. Sleeping pills can give you relief in the short term but they can be habit-forming and are known to have unpleasant side effects
or next-day drowsiness.
Drerup says she's seen women whose sleep difficulties were triggered by a health issue that's since been controlled, but the sleeplessness continues. "Now the insomnia has developed a life of its own; it's become a behavioral pattern," she says. And you can't treat that with a sleeping pill.