The link between sleep disorders, premenstrual syndrome and polycystic ovary syndrome

Sleep disorders in premenstrual syndrome

Research indicates that women commonly report sleep disturbances around menstruation, particularly during the late luteal phase (final premenstrual days) and early follicular phase (initial menstrual bleeding days)⁽¹⁾. The most pronounced alteration in the menstrual cycle’s impact on sleep involves changes in electroencephalogram (EEG) activity within the sigma band, corresponding to the higher frequency range of sleep spindles. During the luteal phase, there is a significant increase in sigma EEG activity, associated with heightened spindle density and duration, compared to the follicular phase. Intriguingly, midlife women experiencing insomnia displayed a diminished rise in sigma EEG activity during the luteal phase, potentially indicating a weaker influence of the menstrual cycle on sleep EEG in the presence of insomnia⁽¹⁾.

A study conducted by Baker and Colrain demonstrated that dysmenorrhea significantly diminished subjective sleep quality, sleep efficiency, and rapid eye movement in young women when compared to pain-free phases of their menstrual cycles and controls⁽²⁾. In a study by Mauri et al., a comparison of sleep disturbances between women with and without premenstrual syndrome revealed that those with the syndrome reported more awakenings, unpleasant dreams, and morning tiredness⁽³⁾.

Another investigation proposed an abnormal homeostatic regulation of the sleep-wake cycle in women with premenstrual disorders, linked to altered melatonin secretion⁽⁴⁾. In a study utilizing actigraphy, involving 163 women in the late-reproductive age group, a notable reduction in sleep efficiency and total sleep time was observed during the premenstrual week compared to the preceding week. This decline was more pronounced among individuals with obesity, financial strain, smoking habits, and a higher apnea-hypopnea index. These findings align with those of previous studies, indicating a correlation between the premenstrual phase and poorer self-reported sleep quality. Gupta et al. concluded that women with potential premenstrual disorders had poorer sleep compared to those without such disorders⁽⁵⁾.

Conversely, a study examining sleep patterns in wo­men with menstrual pain found that neither menstrual pain, nor the use of painkillers significantly affected sleep patterns⁽⁶⁾. Van Reen and Kiesner identified three distinct patterns: some women exhibit no discernible relationship, some experience heightened difficulty sleeping during the midcycle, and others encounter increased sleep challenges in the premenstrual phase⁽²⁹⁾.

Several factors contribute to the increased likelihood of sleep problems in women experiencing premenstrual symptoms:

• Hormonal fluctuations, particularly changes in estrogen and progesterone levels. These hormonal shifts can affect neurotransmitters in the brain, potentially disrupting the normal sleep-wake cycle and contributing to sleep disturbances.
• Mood and emotional changes, particularly during the late luteal phase of the menstrual cycle.
• Physical discomfort associated with premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD).
• Pain and discomfort from menstrual cramps.
• Increased sensitivity to environmental factors.
• Psychological factors – the anticipation of experiencing sleep difficulties during the premenstrual phase can create a psychological barrier to restful sleep.    

Sleep disorders in polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders among females, affecting 5-10% of women in the reproductive age. Sleep disturbances are very common in PCOS patients⁽⁷⁾. These disorders include daytime sleepiness, difficulty falling asleep, as well as sleep-disordered breathing, that can significantly reduce the quality of sleep in these patients⁽⁸⁾. However, recent studies suggest that more than 90% of doctors who treat women with polycystic ovary syndrome are rarely trained in sleep disorders in these patients⁽⁹⁾. Poor sleep in patients with PCOS is associated with depression, metabolic syndrome, increased insulin resistance, and cardiovascular disease⁽¹⁰⁾. The most common sleep disorder in patients with polycystic ovary syndrome is obstructive sleep apnea, a period of no airflow for at least 5 seconds⁽¹¹⁾. Obstructive sleep apnea is very common – on average, 2-3 times more frequent in women with PCOS compared to non-PCOS women of the same age and weight. Some clinical signs of obstructive sleep apnea are daytime sleepiness, snoring, breathing disorders, and fragmented sleep at night⁽¹²⁾. Some studies have evaluated the potential precipitating risk factors, including insulin resistance, hereditary and genetic factors, abnormal gonadotropin secretion and ovarian factors, although lifestyle may be the main factor⁽¹³⁾.

Stress hormones and melatonin are the neurohormones involved in the sleep-wake cycle. Melatonin, synthesized in the pineal gland, plays an important role in the regulation of circadian rhythm. The nocturnal secretion of melatonin decreases during the shorter duration of night and day sleep, which leads to lower levels of melatonin. Melatonin also plays a vital role in reproductive processes, especially in ovarian function⁽¹⁴⁾. An abnormal level of melatonin can affect gonadal function and sex hormone secretion, follicular development, oocyte maturation and ovulation. Recent studies have shown that a reduced sleep duration and poor quality of sleep can affect the hypothalamic-pituitary-adrenal axis activity. The sympathetic system is more active in PCOS patients with poor sleep, especially in people who sleep during the day⁽¹⁵⁾. The studies also revealed that the levels of cortisol in PCOS women with a proper sleep of about eight hours were significantly lower than in other PCOS women⁽¹⁶⁾.

The therapeutic approach
to hormone-dependent sleep disorders

Sleep hygiene is known as the set of behavioral and environmental tips that are planned to encourage healthy sleep and treat sleep disorders. In sleep hygiene education, patients receive advice on healthy habits⁽¹⁷⁾. Lifestyle modification is suggested as first-line treatment in the management of polycystic ovary syndrome in women, where diet and exercise are the main considerations, but sleep hygiene is also important⁽¹⁸⁾. According to research on neurohormones and their relationship with the circadian rhythm, it seems that the balance of these hormones and their circadian changes is associated with the quality, but also with the quantity of sleep.

The most common sleep hygiene recommendations are:

• Avoid caffeine consumption close to bedtime⁽¹⁹⁾.
• Avoid smoking. The use of nicotine is associated with more repeated early-morning awakening and suppression of REM sleeps. Thus, avoiding nicotine use leads to better sleep⁽²⁰⁾.
• Avoid alcohol use. When the alcohol is metabolized in the first few hours of sleep, sleep becomes lighter, with more arousals⁽²¹⁾.
• Manage stress. Psychosocial stress is accompanied with impaired sleep. Some techniques, like relaxation, have provided some initial support for stress management⁽²²⁾.
• Avoid daytime napping. Daytime napping has been posited to disturb the sleep drive, and sleep hygiene recommendations often include the advice to avoid naps longer than 30 minutes a day⁽²³⁾.
• Avoiding bedtime technology use. Studies demonstrate a negative correlation between the use of technology and sleep, so one of the most common sleep hygiene recommendations is to limit the technology use close to bedtime⁽²⁴⁾.
• Other recommendations in sleep hygiene include not going to bed thirsty or hungry, sleeping in a comfortable bedroom with proper temperature and comfortable mattress, taking a warm or hot bath 2 hours before bedtime, setting a list of problem-solving tasks to be done the next day, and using the bedroom only for sleep⁽²⁵⁾.

There are several options for PCOS treatment, such as drug treatment and some surgical treatments; however, lifestyle modifications that include diet and exercise represent the first and most important treatment strategy for these patients. Thus, before initiating any intervention, lifestyle modification should be considered^(26,27).

Melatonin’s effectiveness in improving sleep quality and mood can enhance the psychosocial well-being and overall quality of life for patients with polycystic ovary syndrome. Better sleep leads to higher energy levels, improved concentration, and a greater sense of overall well-being⁽²⁸⁾.

Conclusions

Insomnia can play various roles in relation to severe menstrual symptoms, serving as a precursor, occurring simultaneously, or manifesting as a consequence. Sleep deprivation has the potential to induce hormonal imbalances that disrupt the normal menstrual cycle. The menstrual cycle’s physical and emotional changes are governed by multiple hormones, including estrogen, progesterone, prolactin, and growth hormone.

The discomfort and stress linked to severe menstrual symptoms can impede the achievement of peaceful sleep. These hormones not only regulate reproductive functions but also impact the circadian rhythm and sleep. Consequently, disruptions in these hormonal dynamics can lead to both compromised sleep quality and menstrual irregularities. 

Autori pentru corespondenţă: Cristina Vaida E-mail: cristina.vaida@bluewin.ch

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.