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Who hasn't felt cranky, unfocused, and loopy after a bad night's sleep? Three-quarters of adults have "sleep difficulties" and more than half "often wake up not feeling refreshed," according to a recent national poll. But the damage from sleep deprivation is even worse than you may think. More studies are finding that too little sleep can lead to a wide variety of potentially life-threatening conditions. Among them:
Obesity. Women who reported getting five hours of sleep per night were nearly twice as likely to be obese as women who regularly slept about seven hours; those who got four hours were three times more likely to be obese, according to a 2005 study of more than 2,500 women under age 49. Sleep restriction increases your appetite by lowering your levels of leptin, a hormone that suppresses hunger, and raising your levels of ghrelin, a hormone that stimulates it.
High blood pressure. People under age 60 who sleep five or fewer hours a night are twice as likely to develop hypertension as those who log seven to eight hours, according to a 2006 study of almost 5,000 men and women. Not sleeping enough strains the cardiovascular system and "resets" it to operate around the clock at an elevated pressure.
Diabetes. Studies have found an association between lack of sleep and a risk for diabetes as well as a 45 percent increased risk of heart attack and a 15 percent increased risk of death from all causes.
Women need to be especially concerned since they're much likelier than men to have sleep problems. The reason, says a recent National Sleep Foundation survey: hormonal disruptions (see "Are Your Hormones to Blame?") and other factors, such as depression, that disproportionately affect women.
On top of that, women are more likely to ignore sleep needs. "Many women are so busy caring for their families while holding down jobs that they don't make rest a high priority," says Meir Kryger, MD, past president of the American Academy of Sleep Medicine and author of A Woman's Guide to Sleep Disorders. Even women who don't suffer from sleep disturbances may steal their only "me" time from hours when they should be snoozing.
Signs that you have a sleep deficit include taking more than 30 to 45 minutes to fall asleep, waking up many times a night, rousing after too few hours of sleep and being unable to return to sleep, waking up feeling tired, and feeling sleepy throughout the day.
Most people need seven to nine hours of sleep per night -- but the real cue that you're getting enough is waking up refreshed in the morning and feeling alert all day long. In addition, there's no need to worry if you experience occasional sleep difficulties -- say, a few times a month -- that don't interfere with your daily activities. Among adults with sleep difficulties, half those in the recent national poll reported that sleep problems resulted in "getting easily frustrated" or being unproductive. "It's perfectly common to have problems sleeping every once in a while," says David N. Neubauer, MD, associate director of Baltimore's Johns Hopkins Sleep Disorders Center.
When is a sleep problem classified as full-blown insomnia, the chronic inability to fall asleep or stay asleep? Starting to worry about it is one cue. Another is when the situation has lasted more than a month. Start by seeing your doctor, who will check for underlying health issues. If you're otherwise healthy, he or she may suggest remedies. Or consider asking for a referral to a sleep specialist for an evaluation and techniques for your type of problem. "Treatment takes longer when insomnia lasts more than a year," says Nancy Nadolski, MSN, a family nurse-practitioner in Boise, Idaho, who treats patients who have insomnia.
To see what goes on when you work with a sleep therapist, we sent two women with persistent sleep difficulties to local experts. You'll also learn how hormones affect sleep, which drugs help different sleep problems, and when a sleep lab can be useful (not for garden-variety insomnia, it turns out).
Darlene Holte, 41, is a full-time research-grant administrator at the University of Wisconsin, in Madison. She lives in Stoughton, Wisconsin, with her husband, Greg, a steel-press operator, and their children Brent, 12, and Tara, 7.
Her sleep struggle: "It's very frustrating to lie awake at night, desperately wanting to fall asleep. Every little thing bothers me: The light on my bedside clock is too bright, the sound of the water softener cycling, my son's TV, the cat's having a late-night snack, even my husband letting off steam -- he inhales, then puffs the air out of his mouth. Then I start thinking about all the things I need to do. Insomnia has caused me to become addicted to caffeinated diet sodas just to stay alert during the day. I yawn constantly, my thought processes are slow, and I often have trouble with recall. Most nights I only get four to five hours of sleep. I thought this was normal until I tried Ambien last year. Within five minutes after the first one, I was sleeping like a baby. Although it stopped working -- I don't use it anymore -- it made me realize that it wasn't normal to have trouble falling asleep or to wake four to five times at night."
The sleep expert: Michael Flatley, MD, medical director, Waukesha Memorial Hospital Sleep Disorders Center, Greater Milwaukee area
Diagnosis: Classic chronic insomnia
"Our first meeting made it clear that Darlene got too much caffeine too late in the day -- four to six cans of soda, until 5 p.m. -- so she didn't get sleepy until fairly late at night. I advised no caffeine after noon -- not just coffee and soda but chocolate.
"When Darlene did get to bed, she suffered from what we call 'excessive thoughts' -- staying awake thinking too much about problems and then getting even more anxious because she couldn't fall asleep. This kept her from the seven and a half to eight hours of sleep that she needed. I told her to schedule a 'worry time' before bed to write down the things she's anxious about so she doesn't have to worry about them when she should be sleeping.
"She also slept late on weekends to try to make up her sleep deficit. I advised her to avoid daytime naps and practice sleep restriction: Go to bed and wake up at the same time each day; don't get in bed until you're sleepy; if you can't sleep, go into a different room -- one that's dimly lit -- to read or watch TV until you are."
Slumber solution: "I left my first meeting with Dr. Flatley, in December, feeling very optimistic. Because I was afraid of getting headaches from going off caffeine cold turkey, I decided to wean myself off slowly -- on the first day I stopped after 3 p.m. and felt pretty good. The next day I stopped at 2 p.m. By the end of the first week I had reached noon -- still no headaches! And I was already beginning to feel sleepy at 9:30 p.m. -- quite a bit earlier than usual. I'd never have thought that stopping caffeine could make that big of a difference. Writing my to-do 'worry' list and having milk plus peanut butter and toast before getting in bed also helped me sleep because I had a history of waking in the night from hunger. In less than two weeks I was going to bed at 10, falling asleep within 20 minutes and getting up at 6 in the morning.
"I feel more alert and mentally aware. Being tired earlier in the evening is going to take some getting used to because I usually can't get anything done until after my children are in bed. But getting up at 6 a.m. on weekends means that I can get these things done before the kids start their day. Even staying up on Christmas and New Year's Eves didn't affect my ability to sleep. What did was drinking a caffeinated soda at about 5 p.m. one day. I couldn't sleep at my usual 10 p.m. After 30 minutes of tossing and turning I got up, had a small snack, and didn't get back to bed until midnight.
"I can't believe how much better I am functioning at work! I always thought that I was operating at a pretty high level, but I can do even more. What I learned from Dr. Flatley helps me fall asleep much more quickly -- even when I was exhausted after taking my Girl Scout troop to the Madison Children's Museum."
Mary Jo Thomas, 41, works full-time as an associate product manager at a partygoods company. Her husband, Randy, is a factory supervisor. They live in Indianapolis with their kids Melanie, 13, and Cody, 11.
Her sleep struggle: "I've always liked to go to sleep very early -- at 8:30 or 9 -- and wake up before dawn. On a good night I rarely sleep more than 6 hours. Is that normal? I slept much better when I was younger. Dealing with someone else's occasional snoring -- and trying to keep my tossing and turning to a minimum on his account -- has meant less sleep for me. Plus about three years ago we got two miniature dachshunds that insist on sleeping in bed with us. Usually I get up at least once in the night around 2 a.m., to use the bathroom or let the dogs go outside. Often when I've let them in and go back to bed I can't get back to sleep. But when I travel for work and sleep alone, I usually get seven to eight solid hours. So I know I'm capable of that."
The sleep expert: Brian Foresman, DO, director, Sleep Medicine & Circadian Biology Program, Indiana University School of Medicine, Indianapolis
Diagnosis: Insomnia from learned behavior and environmental causes
"Mary Jo is a light sleeper who had learned some not-so-good behaviors. The goal was to retrain her into new habits, including a regular bedtime and waking time and getting up if she couldn't sleep. I didn't have to give her any medication -- a lot of times if you change someone's behavior you don't need to.
"She really seems to need only six hours of sleep a night. Her very early bedtime meant that she'd met her sleep needs by the middle of the night -- that's why she couldn't go back to sleep. We pushed her bedtime to 9:30 p.m. so that she would wake at 3:30 or 4. Getting up that early was her strong preference.
"Her habit of watching the clock in the middle of the night made it even harder for her to fall back to sleep. I advised her to cover the bedroom and bathroom clocks, and set an alarm so she wouldn't worry about oversleeping.
"Mary Jo's dogs sleep in bed with her and her husband and wake her up at night. I suggested she keep the dogs out of the bedroom."
Slumber solution: "It really helped to hear Dr. Foresman say that waking up at 3:30 wasn't completely abnormal. The first night, the anxiety of wondering when the alarm would go off was almost as bad as watching the clock. But after a few days I found it's actually kind of nice not knowing just how many more hours I 'should' sleep. I had one episode of waking up and staying awake for about an hour and a half -- I did finally peek at the clock -- but the next night I slept all the way through. We got a new dual alarm, so I can set it for 4 a.m. for me and 5 for my husband.
"Then holidays came and messed up my routine. First, I was waking up between 2:30 and 3 and getting up to wrap presents. Five hours of sleep a night for a week made me a little cranky and spacey. When I tried not using the alarm to catch up on sleep, I started waking up in the middle of the night. What helped: imagining putting all the things that wake me up in a pair of big hands that carry them away until morning.
"After seeing Dr. Foresman again, I went back to going to bed consistently at 9:30 or 10 and waking at 4, using the alarm clock. I also learned to avoid taking a nap -- either I can't get to sleep or it messes up my sleep that night. And we purchased new bedroom curtains that block more of our neighbor's security light. After two weeks I found I was getting up just before the alarm rang, so I stopped using it. At our final appointment, Dr. Foresman said I now had the tools I need -- if things get off course I can go back to using the alarm and being more rigid about bedtimes. I never did make the dogs sleep outside the bedroom -- I think their whining would have been worse than having them in the bed, though I must admit I haven't tried!"
Every mother knows how pregnancy interrupts sleep. Here's what women's other three major hormonal landmarks do.Menstruation
About 50 percent of women report more difficulty getting to sleep and staying asleep right before and during their periods, says the National Sleep Foundation. Causes: tender breasts, bloating, cramps, and/or headache.
The drop in estrogen prior to your period can also affect sleep, but in another way: With less estrogen you get less rapid eye movement sleep, the type of sleep during which we dream.
Abnormal cycles can also take a toll. Frequent, heavy periods increase your risk of iron deficiency, a chief cause of restless legs syndrome -- unpleasant, tingling, achy sensations in your legs that can keep you awake at night. If your periods are few and far between, you could have polycystic ovary syndrome, a hormonal disorder that can go hand in hand with obstructive sleep apnea.
Treatment for most menstruation-related sleep problems can be as simple as taking oral contraceptives.Perimenopause
Sleep disturbances during the transition into menopause are often related to nighttime hot flashes that trigger night sweats. "A woman may thrash and throw the covers off and on in an effort to keep cool, then keep warm," says Meir Kryger, MD, past president of the American Academy of Sleep Medicine. About 70 percent of women going through menopause experience hot flashes at night. The frequency and intensity of flashes vary from woman to woman (and from day to day for the individual); on average, most women have night sweats three nights a week.
Some women find relief with lighter sheets, bedclothes made of special fabrics that wick moisture away from the body, and/or keeping a fan or air conditioner on at night. Short-term hormone therapy can reduce hot flashes, sometimes permanently. Review its benefits and risks with your physician.Postmenopause
After menopause occurs, women finally join men in being at a 4 percent risk for obstructive sleep apnea, a condition in which breathing is blocked by relaxed airway muscles combined with such physical issues as extra tissue in the throat area or enlarged tonsils. After menopause, women are no longer protected by progesterone (which stimulates regular nighttime breathing) and estrogen (which prevents fat from being deposited in the neck, where it can block respiration).
Sleep apnea can be mild to severe. It produces spells of oxygen deprivation as well as brief, frequent awakenings (which you may not remember). Result: You don't feel well rested even after logging eight hours. Women who snore or smoke or who are overweight are most at risk. Treatments range from breathing devices to weight loss to surgery, but the trick is to be properly diagnosed.
"Many doctors still don't realize that postmenopausal women are as vulnerable as men to sleep apnea. They often mistakenly conclude that sleepiness in a female is depression or stress related," says Dr. Kryger. "You may have to say to your doctor, 'I never feel well rested and have been told I stop breathing when I sleep. I'm worried I may have sleep apnea. I think I should be evaluated.'"
When sleep remains elusive -- despite your best efforts to relax, resist caffeine and stick to a regular snoozing schedule -- it's reassuring to know that medications can help. In fact, it was temporarily using a sleep medication that showed Darlene Holte how much better she felt with a good night's sleep and encouraged her to tackle her insomnia with serious sleep therapy.
Today's sleep aids aren't one size fits all: Your Rx can be tailored to your needs and spare you nasty side effects, such as next-day drowsiness. And with your doctor's approval you don't have to use it all the time. "Although some people find they need a sleep aid regularly, others just need help getting through occasional bouts of insomnia, so they use their medication only a few times a month," says David N. Neubauer, MD, associate director of the Johns Hopkins Sleep Disorders Center, in Baltimore. Here, match your sleep symptoms with the most effective formulas on the market.
If you need help falling asleep or getting back to sleep: You regularly lie awake for more than half an hour trying to drift off, but once you're asleep you're out until morning, or you wake up in the middle of the night and can't get back to sleep for the few hours before your alarm clock beckons.
You may want to try Sonata or Rozerem. They work quickly but only stay in your system for two to three hours, so there's practically a zero risk of next-day drowsiness -- even if you take a pill in the middle of the night.
Cautions: Not a good choice for people who wake up repeatedly during the night.
If you need help remaining asleep for a whole night: You want to stop experiencing frequent wakenings at night.
You may want to try Ambien (lasts four to five hours), Ambien CR (lasts six to seven hours), or Lunesta (lasts seven to eight hours). These medicines also help you fall asleep; they can be longer-lasting than Sonata or Rozerem so they help you stay asleep. Your choice depends on how much nightly sleep you need.
Cautions: There have been rare medical reports of sleepwalking, night eating, sleep driving, and short-term amnesia in people using Ambien -- some involved improperly mixing it with alcohol. Since Ambien CR and Lunesta last longer, they may cause daytime sleepiness if you don't get seven to eight hours of uninterrupted sleep.
If you need help falling asleep because of anxiety: Putting your head on the pillow floods you with nonstop thoughts of work difficulties, family illness, etc.
You may want to try an older sleep medicine in the benzodiazepine family, such as Halcion, Restoril, Valium, or Xanax. These sleep aids help release mental and muscle tension as well as induce sleep.
Cautions: These drugs can trigger side effects such as drowsiness or headaches the next day. Addiction (you need ever-increasing doses to fall asleep) is a risk; with use for more than four weeks you need careful follow-ups to check for dependency.
If you need help falling asleep, but you have addiction concerns (you want to avoid anything that could ever be habit-forming).
You may want to try Rozerem. Unlike other approved insomnia drugs, this is not classified as a controlled substance. Has shown no potential for abuse or dependence. Or a low dose of a sedating antidepressant (trazodone, doxepin) may be prescribed off-label for insomnia.
Cautions: Rozerem won't help you stay asleep; its sedating antidepressants can cause side effects such as dry mouth, blurry vision, palpitations, and constipation.
Originally published in Ladies' Home Journal, August 2006.