1. Sleep problems in Gynecology
Presented by: dr menna shawkat
Prepared by: Dr. heba Mohamed tawfiq
Lecturer of Geriatrics and Gerontology
Ain Shams University

2. Menopause and sleep One of the core symptoms of the menopausal transition is sleep disturbance

3. The Study of Women’s Health across the Nation (SWAN), shows that the prevalence of sleep disturbance increases with increasing age.
The prevalence in the premenopausal age group ranges from 16% to 42%; in peri-menopausal women prevalence varies from 39% to 47%; in postmenopausal females, the prevalence ranges from 35% to 60%

4. Insomnia due to Decreased level of reproductive hormones
Vasomotor symptoms (HRT role is not proved)
Anxiety and depression (prevalence increase with menopause) estrogen may have antidepressant effect
Sleep-disordered breathing (sleep apnea), and restless leg syndrome
Associated medical conditions
Pain in female with uterine carcinoma

5. Estrogen itself may have a direct sleep effect by increasing homeostatic drive for sleep; it supports melatonin release
Progestins are known to exert a direct sleep induction or hypnotic effect mediated through gamma-aminobutyric acid- active metabolites.

6. According to DSM 5 criteria:
Insomnia is defined as a subjective complaint of difficulty initiating sleep, difficulty maintaining sleep, or early morning awakenings that occur at a minimum of 3 nights per week, for 3 months, and are associated with significant daytime consequences.
Examples of daytime consequences include difficulty concentrating, mood disturbances, fatigue, and worry about sleep.

7. Drugs contributing to insomnia

8. Diagnosis
When an individual reports a constellation of symptoms that meets criteria for an insomnia syndrome…..   Sleep log
A diagnosis of insomnia does not require that sleep disturbance be documented objectively.  
In fact, when polysomnography is conducted, abnormalities may or may not be detected and, even if documented, may not correspond to the clinical complaints.

9. Treatment Non pharmacological Practicing good sleep hygiene.
Develop a sleep ritual such as maintaining a 30-minute relaxation period before bedtime or taking a hot bath 90 minutes before bedtime.
Make sure the bedroom is comfortable.
Go to bed only if you feel sleepy.
Avoid heavy exercise within 2 hours of bedtime.
Avoid sleep-fragmenting substances, such as caffeine, nicotine, and alcohol.

10. Avoid activities in the bedroom that keep you awake
Avoid activities in the bedroom that keep you awake. Use the bedroom only for sleep; do not watch television from bed, or work in bed.
Sleep only in your bedroom.
If you cannot fall asleep leave the bedroom and return only when sleepy.
Maintain stable bed times and rising times. Arise at the same time each morning, regardless of the amount of sleep obtained that night.
Avoid daytime napping. If you do nap during the day, limit it to 30 minutes and do not nap, if possible, after 2 pm.

11. Pharmacological
Selective short-acting nonbenzodiazepines [type-1 γ- aminobutyric acid (GABA) benzodiazepine receptor agonists; e.g., eszopiclone, zaleplon and zolpidem] and
Melatonin receptor agonists (e.g., ramelteon)
Are safe and effective for older adults

12. Restless leg syndrome
An urge to move the legs during periods of rest or inactivity….usually at night
Is usually described as “pins and needles” or a “creepy and crawly” sensation that is only relieved with movement.
The diagnosis is made based on history.
Prevalence increases with age and is about twice as prevalent among women compared to men.

13. Why in menopause????
Estrogen increases dopamine uptake & reduces its catabolism through interference with catechol-O- methyl transferase (COMT) enzyme…. And dopamine deficiency has a role in pathogenesis

15. Obstructive sleep apnea
The prevalence of OSA in females rises markedly after menopause.
47% to 67% of post-menopausal women have been found to have OSA.

16. OSA and menopause ???
Estrogen and progesterone enhance ventilatory response to Co2 and O2
Can decrease apnea episodes
Women tend to gain weight after menopause
Higher BMI, larger neck circumference
Redundancy of pharyngeal muscles and increase airway collapsibility

17. Definition Repeated episodes of apnea and hypopnea
Apnea complete airway obstruction despite ongoing respiratory effort with cessation of airflow≥ 10 sec
Hypopnea partial obstruction with persistent effort ≥ 30% ↓ in thoraco-abdominal movement or airflow and with ≥ 4% oxygen desaturation or an arousal with transient reduction of airflow≥ 10 sec
Blood oxygenation returns to baseline immediately after the event.

18. OSA is generally diagnosed when the sleep study demonstrates an AHI ≥5 and there are associated symptoms of excessive daytime sleepiness, non-refreshing sleep, or witnessed pauses in breathing during sleep
The two hallmark symptoms of OSA are snoring and excessive daytime sleepiness

19. Treatment: Non pharmacologic treatment Pharmacologic
Continuous positive airway pressure (CPAP) is the gold standard.
Pharmacologic
Modafinil
Palatal implants for mild to moderate
Tracheostomy for severe cases in CPAP not effective or not tolerated
Uvulopalatopharyngeoplasty

20. HRT as a treatment for sleep disturbances
Results of studies using PSG to measure HRT effects on sleep parameters objectively have been mixed.
The most consistent findings in PSG are less fragmentation of sleep, with a reduction in wakefulness and arousals. They are consistent with subjective reports of improved sleep quality with HRT.
However, the positive effects of HRT on sleep as measured by PSG were small in some studies, which may limit the clinical significance of these findings.
Results of a few studies investigating the effects of hormone therapy in postmenopausal women suggest that HRT may ameliorate apnea symptoms in women without a formal diagnosis of OSA

21. Thank You