When you simply can't sleep: chronic insomnia can lead to a host of health woes. Here's what to do about it before it becomes a crisis - Health

Falling asleep is tough enough for most Americans--at least 100 million of us are having bouts of sleeplessness three times or more a week, according to a recent survey. Now researchers are finding that the land of Nod may be especially difficult to reach for women. Factors ranging from hormonal influences to lifestyle stresses are among the culprits.

According to the 2002 Sleep in America Poll, the latest in a series of surveys conducted annually by the National Sleep Foundation (NSF), women are more likely to experience insomnia than men are. Of the women surveyed, 63 percent said they couldn't fall or stay asleep a few nights a week, a complaint experienced by 54 percent of the men.

Those numbers are consistent with field reports from medical professionals who specialize in treating sleep disorders. "We see insomnia as two to three times more common in women than in men," says Lauren Broch, Ph.D., of the Sleep-Wake Disorders Center at New York-Presbyterian Hospital, Cornell, in New York City.

How hormones affect sleep

So what's keeping women up at night? Biology plays a big part, "Women are subject to all the sleep disorders men have, plus those that are related to hormones," says Rochelle Zak, M.D., attending physician at the Sleep-Wake Disorders Center. For instance, during the week prior to the start of the menstrual flow, when both estrogen and progesterone levels fall, women are likely to experience insomnia, disrupted sleep and daytime sleepiness. And the physical discomforts associated with the onset of menstruation, such as cramps, are enough to prevent a good night's sleep for many.

Pregnancy, it comes as little surprise, can drastically interfere with sleep as well. Of the women in the NSF's 1998 Women and Sleep Poll, 79 percent said they had difficulty sleeping due to physical or emotional stresses brought on by childbearing.

A pregnant woman may need to urinate more often during the night, resulting in frequent trips to the bathroom. In the first trimester, that may be compounded by nausea and backache. Sleep may come easier in the second trimester, however, when progesterone is rising. Also, the fetus will have moved above the bladder, reducing pressure. But physical discomforts during the third trimester, such as heartburn, leg cramps, fetal movement, shortness of breath and sinus congestion, can again interfere with sleep.

While being pregnant may hinder sleep, so can a common method for preventing pregnancy. Recent research indicates that the pill may cause insomnia because it alters a woman's natural hormone balance. "What surprised us was that the pill interferes with normal sleep stages. It interrupts the REM and non-REM sleep cycles," says Roseanne Armitage, Ph.D., of the University of Texas Southwestern Medical Center at Dallas. "The changes alter when you go into deep sleep, and whether you'll get deep sleep at all."

Weight gain and insomnia

Forget the notion of the bleary-eyed night owl who stays thin from pacing about. In fact, the effects of insomnia may even cause weight gain. The probable mechanism is complex, but a variety of studies implicate several hormones: leptin, which helps quell hunger; cortisol, the "stress hormone" that also affects fat storage: and insulin, which sweeps excess sugar from the blood to keep blood sugar stable. In a study by Eve Van Cauter, Ph.D., a professor of medicine at The University of Chicago, subjects who were allowed only four hours of sleep each night for a week showed a sustained increase in blood sugar, a condition that is considered a risk factor for diabetes and can lead to increased fat storage. Other research suggests that lack of sleep lowers the body's production of leptin. As a result, it seems possible that appetite is stimulated among the sleep-deprived.

Toward better sleep hygiene

But the news isn't all bad for insomniacs. While tried-and-true methods--exercising during the day, avoiding caffeine and alcohol and eating right--are still the best, the latest approaches favor more focused tactics. New York-Presbyterian's Zak promotes a regimen called good sleep hygiene--a prescription for day-to-day living that results in better sleep at night.

Many of her recommendations are intuitive, but others are not so obvious. For instance, Zak says women suffering from insomnia might benefit from spending less time in bed. Retiring for the evening before drowsiness sets in can lead to frustration at not being able to fall asleep quickly and thus more difficulty drifting off. Zak also tells patients trying to establish good sleep habits to wake at the same time each morning, even if they had trouble sleeping the night before.

Diet is also key in developing good sleep hygiene. Some foods, chocolate being the most common, are sources of hidden caffeine. (See sidebar below, "Is Your Diet Keeping You Awake?")

Most important of all, Zak says, is the fact that sleep will spontaneously overtake the relaxed mind. So entertaining stressful thoughts while in bed is an open invitation to insomnia.

When sleeplessness won't stop

Resistant cases of insomnia may require clinical intervention and drug therapy. Zolpidem tartrate, marketed under the brand name Ambien in the United States by Sanofi-Synthelabo, has become the prescription of choice for physicians dealing with insomniacs and is now the nation's most commonly prescribed sleep aid. That's largely because, unlike drugs in the benzodiazepine class, it's nonaddictive. Still, all sleep medications, including Ambien, are designed only for short-term use to give the body a chance to re-establish its sleep cycle.

Nonprescription sleep aids, such as the supplement melatonin, have less clinical research to document their efficacy.

Some jet-lagged travelers swear by melatonin as a way to adjust sleep. Melatonin can be used to pull the sleep cycle forward so that a westbound traveler gets sleepy earlier in accordance with the new time zone; however, it shouldn't be popped before bedtime like a sleeping pill, Broch advises, rather, it should be taken five hours before the desired bedtime. "You need to take it during the day if you want to get to sleep at a reasonable time that night," she says. The long-term effects of prolonged melatonin use are not known.

If your sleep difficulties persist for more than a few weeks or occur without obvious cause, see your doctor. Prolonged, unexplained insomnia can signal serious physical or psychological ailments.

For example, a physical abnormality in the nasal passage may cause sleep apnea--a lack of oxygen intake that causes sufferers to snore and wake gasping for breath. Corrective surgery may be necessary.

Sleep apnea has been understudied in women, according to an article published earlier this year in the journal Sleep. In women it's "not as rare as it was originally believed," according to authors Fotis Kapsimalis, M.D., and Meir Kryger, M.D. Earlier studies indicated that women make up less than 10 percent of sleep-apnea patients. Now research indicates that number's about one-third. "Sleep apnea in women is harder to detect because the symptoms tend to be more 'feminine'--the snoring isn't as loud," says Charles McPhee of Dreamdoctor.com and former director of the Sleep Apnea Patient Treatment Program at the Sleep Disorders Center of Santa Barbara, Calif.

Treating sleep apnea won't just help you sleep better; it could save your life. Women who regularly experience sleep-related breathing disorders have a higher risk of cardiovascular disease than women who don't, according to a study published in the Journal of the American College of Cardiology.

Only a qualified physician can properly diagnose the causes behind chronic, debilitating insomnia. But for' the rest of us, sticking to a regular sleep schedule, getting plenty of exercise and managing stress may be enough to bring on a night's healthful, peaceful sleep.

RELATED ARTICLE: is your diet keeping you awake?

Eating smart isn't lust a healthy way to keep your weight in check; it can also help you sleep better. The fact is, some foods promote sleep, while others are bound to keep you up at night.