By Monica Prasad Mallampalli, PhD

There is enough scientific evidence to support the fact that women sleep differently than men. For example, women tend to have shorter sleep duration, more slow wave sleep, and longer sleep latency compared to men. Sleep in women can vary over the lifespan, and several factors at specific times—such as puberty, pregnancy, or menopause—can affect sleep quality. These factors can be biological and physiological, but environmental, cultural, social and other factors can also affect a woman’s sleep health.

Certain sleep disorders, such as insomnia, circadian rhythm sleep-wake disorders, and restless legs syndrome (RLS), are more prevalent in women. The risk of insomnia occurs during puberty with the onset of menstruation, and interestingly, the risk of depression coincides with insomnia during this time period. Shift disruption is more common among women, partly because of differences in work patterns: More women tend to work non-traditional hours compared to men. Shift work in women can also increase the risk of breast and endometrial cancer, and nearly 70% of women with breast cancer have poor sleep problems. RLS risk doubles from pregnancy to menopause and increases with the number of pregnancies.

Sleep differences between the sexes, including differences in how sleep problems occur, can contribute to underdiagnosis. Narcolepsy and obstructive sleep apnea (OSA) diagnoses are often delayed or missed in women. Women with narcolepsy carry a greater disease burden than men, with lower health-related quality of life and more sleepiness. OSA also presents differently in women compared to men, with women complaining of more fatigue, unrefreshing sleep, depression and insomnia. The lack of gender-specific screening instruments is a major problem leading to underdiagnosis of OSA in women.

The following implications of these diagnostic problems are important to consider. Women with sleep disorders have an increased risk of cardiovascular and metabolic diseases. Untreated sleep apnea in women can increase women’s risk of heart failure and mortality compared to men. Similarly, sleep problems are common in people living with chronic pain. In fact, insomnia can both cause and contribute to chronic pain – and both conditions disproportionately affect women.

Women’s sleep problems go unnoticed in part because of a lack of awareness among women and their doctors. Sometimes women are misdiagnosed with anxiety or depression; both conditions are often comorbid with sleep disturbances. A lack of gender-specific screening questionnaires or diagnostic tools in a one-size-fits-all approach to treatment can also make it more difficult for women to get an appropriate diagnosis and the care they need.

These kinds of health care gaps not only affect women in sleep medicine, but also exist to varying degrees in other medical specialties, thanks to certain scientific and policy decisions made decades ago.

It has only been 32 years since women were included in biomedical research, and this exclusion of women in biomedical research has compromised women’s health to this day. Given that almost all biomedical research has previously used a 70 kg male as the standard for studying human health, women have lacked appropriate medical treatment for years. Essentially, all information related to female-specific biology, anatomy, pathology, and response to interventions had been ignored under the assumption that women differed from men only in their reproductive health.

This decision to ignore female biology was based on guidance issued by the Food and Drug Administration in 1977, which proposed preventing women of childbearing age from participating in early phases of clinical trials for fear of harming the unborn. The decision came not long after birth defects caused by thalidomide and diethylstilbestrol (DES), a synthetic estrogen, had raised acute concerns about the safety of drug trials during pregnancy.

However, the 1985 Public Health Services Task Force on Women’s Health concluded that the lack of research on women’s health had compromised the quality of information and care for women. This prompted women’s health advocates to push for the inclusion of women and minorities in clinical trials, resulting in the passage of the 1993 NIH Revitalization Act by Congress.

We now know unequivocally, based on a wealth of scientific evidence and data, that women’s health extends beyond their reproductive health or abilities and takes into account all diseases and conditions that affect a woman from head to toe.

Similarly, we have seen a sharp increase in scientific publications on the topic of women and sleep in the last decade. We have also witnessed efforts at the organizational level to advance women’s sleep health, such as those led by the Sleep Network at the Society for Women’s Health Research (2013-2017), the National Institutes of Health Research Conference on Sleep and Health of Women in 2018, and most recently the launch of the Advancing Women’s Sleep Health Task Force by the American Academy of Sleep025 of Sleep025. we also draw attention to women’s sleep health – and provide tools to help women defend their own health. Our educational resources encourage women to seek diagnosis and care if they suspect they have OSA symptoms.

Today, women make up half the population of the United States and spend twice as much time caring for family members compared to men. More importantly, women play an important role in health care decisions for themselves and their families, essentially serving as the chief physician in their home. As the share of women in our workforce has grown, so has their insurance coverage: 39 million women ages 18-64 have their own employment-based coverage, with 29 million women receiving coverage from the private sector. But women have yet to achieve equality in health and the opportunity to be as healthy as possible on an equal footing with their male counterparts.

According to a 2024 national poll, women are getting less sleep than they need. Stress is the primary cause of the decline in their sleep quality. Poor sleep and increased stress can have a significant impact on women’s overall health, even beyond existing inequalities. As members of the sleep community, we can do our part to eliminate some of these disparities and promote women’s sleep health. Together we can:

• Empower women through education and awareness to take an active role in their health and ensure they get quality sleep.
• Make sure sleep professionals are aware of women-specific health issues and concerns.
• Enables sleep researchers to take biological sex into account when designing clinical studies and analyzing data and reporting results based on sex.
• Encourage the sleep industry to consider a personalized approach to diagnostics and treatment by evaluating the safety and effectiveness of interventions in women and men separately.

Recognizing that women experience gaps in care is the first step. We can all now focus on the real work of bridging the gap, one brick at a time, from understanding the effects of sex hormones on the brain to solving access challenges. We must not rest until we eliminate all the health disparities that prevent women from receiving quality health care and quality sleep.

Monica Prasad Mallampalli, PhD, is a subject matter expert in women’s health and executive director of the Alliance of Sleep Apnea Partners, a national nonprofit patient advocacy organization. She is a member of the AASM Advancing Women’s Sleep Health Task Force.

References

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