Discuss all medical advice, diagnosis, and treatment with your healthcare provider.

The Basics

What is insomnia?

Insomnia is a condition in which a person gets too little or poor-quality sleep. While the amount of sleep that people need varies between about 5 and 10 hours per night, most people require between 7 and 8 hours. People who suffer from insomnia do not get enough sleep to allow them to function productively during waking hours. They experience excessive sleepiness, fatigue, trouble focusing or thinking clearly, and they may become depressed and irritable. You do not have insomnia simply because you don’t sleep as much as others. You may suffer from insomnia when you experience any of the following:

• Trouble falling asleep
• Waking up repeatedly during the night with trouble returning to sleep
• Having unrestful sleep
• Waking up too early in the morning
• Daytime fatigue or sleepiness
• Daytime irritability

While most people have an occasional sleepless night, it is usually caused by a specific reason. For example, drinking caffeine too late in the day may cause you to toss and turn all night. But people who suffer from insomnia have problems falling asleep, maintaining sleep, or they have restless sleep regularly, often for no clear reason.

Insomnia affects many aspects of your life. Your energy level may be depressed, your mood may be affected, and your health may be compromised. Your immune system relies on sleep to rejuvenate itself. When there is no opportunity to recharge, you become more susceptible to getting sick. Your mental alertness and concentration are affected by a lack of sleep, and this can lead to accidents while driving or working.

The Sleep Cycle:

Sleep is a dynamic activity during which you pass through five different stages. In a normal sleep cycle, you will experience:

• Stage 1: Light Sleep—During this stage we are drifting in and out of sleep and are easily awakened.
• Stage 2: During this stage, our eye movements stop and our brain waves slow down.
• Stage 3:: Deep sleep/delta (1)—Very slow brain waves called delta waves begin to appear. These brain waves are interspersed with the smaller, faster brain waves of Stages 1 and 2.
• Stage 4: Deep sleep/delta (2) —The brain is now producing slow delta waves almost exclusively. It is very difficult to awaken someone from this stage, and if you do, they will probably be groggy and confused for a few minutes.
• REM: Rapid Eye Movement—During this stage, your breathing becomes faster and less regular. Your eyes jerk rapidly in different directions. Your limb muscles become temporarily paralyzed. Your heart rate increases and your blood pressure rises. When you are awakened during REM sleep, you will often be able to tell your dreams in great detail.

Your sleep cycle takes an average of 90 minutes, so in any given night you should experience several complete cycles. You reach the REM stage about 70 to 90 minutes after falling asleep. As the night progresses, you spend increasingly more time in stages 1, 2, and REM, and increasingly less time in deep sleep. By the morning, you may be skipping over stages 3 and 4 entirely.

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What causes insomnia?

There are a number of reasons that you could be experiencing problems sleeping, and many of them are treatable. Below you will find the most common causes of insomnia:

• Stress: Any worries about work, health, family, or other aspects of your life can keep your mind racing. This makes it difficult to fall asleep.
• Anxiety: Normal anxiety about everyday things as well as clinical anxiety disorders may keep your mind too alert to fall asleep.
• Depression: Depression is one of the leading causes of insomnia. It causes people to either sleep too much or to have trouble sleeping. This may be a result of either chemical imbalances in the brain or the worries that accompany depression keeping your mind from relaxing.
• Stimulants: Certain drugs can interfere with sleep. Many over-the-counter drugs may have this effect. Any drugs that cause you to urinate more than usual can also interfere with sleep patterns. Drinking caffeine or smoking cigarettes just before bedtime may also cause insomnia.
• Long-term use of sleep medications: Becoming dependent on sleeping pills can lead to problems falling asleep independently.
• Change in environment: Travel can interrupt your body's natural sleep patterns.
• Painful medical conditions: When pain occupies your mind, you will have a hard time sleeping. Conditions such as arthritis, fibromyalgia, kidney disease, Parkinson’s, and other painful medical problems can keep you up at night. Treating these conditions may help your sleep cycle.
• Behavioral insomnia: Insomnia can become a vicious cycle in which you worry excessively about sleep, and therefore you cannot fall asleep. This can be counteracted by reading a book or sleeping in a different place.
• Eating too late: If you eat a large amount before bed, you may feel uncomfortable when you lie down. You also may experience heartburn, which would make it difficult to fall asleep.
• Aging: As you age, changes occur in your body that may affect your sleep. You spend more time in stages 1 and 2 of the sleep cycle and less time in stages 3 and 4. Because you are sleeping more lightly, you are also more likely to wake up. Also, your internal clock shifts, and you often wake up earlier in the morning and fall asleep earlier in the evening.

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What are the different types of insomnia?

• Transient (short-term): This is when insomnia symptoms last from a single night to a few weeks, and then go away.
• Intermittent (on and off): Intermittent insomnia is short-term. It may appear for a few nights, then go away, then recur.
• Chronic (ongoing): Those who suffer from chronic insomnia experience symptoms at least 3 nights a week over the course of a month or more.

Chronic insomnia is divided into two types:

• Primary chronic insomnia: unrelated to other health problems.
• Secondary chronic insomnia: caused by another medical condition, drugs, stress, mental health problems, or a poor sleep environment.

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Insomnia and women: the statistics

• About 60 million Americans per year have insomnia often or for extended periods of time.
• Insomnia tends to increase with age.
• Insomnia affects about 40% of women and 30% of men
• Women are about twice as likely as men to suffer from insomnia.
• Studies show that insomnia affects the unemployed population more than the employed population, but in either group, women are more susceptible than men.

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How does insomnia affect women differently?

Women are at a greater risk of developing insomnia because of various factors. Hormonal fluctuation is a cause of insomnia, and women experience a great deal of hormonal fluctuation throughout their lives: puberty, menstruation, pregnancy, motherhood, perimenopause, menopause, and postmenopause.

Estrogen influences the production of chemicals in the brain that keep you alert. Progesterone is a hormone that can make you sleepy. Levels of progesterone decrease during menstruation. As a result, the fluctuations that women experience throughout any given month while they are menstruating and as they go through menopause can cause transient insomnia.

Puberty

According to a study by the National Sleep Foundation, of 1000 adolescents, 11% had suffered from insomnia. Girls were found to be 2.75% more likely to suffer from insomnia after the onset of menstruation than before. Before menstruation, girls were about as likely as boys to suffer from insomnia, and afterwards, they were twice as likely to experience insomnia.

Pregnancy

In a poll conducted by the National Sleep Foundation, 78% of pregnant women reported that their sleep was more disturbed during pregnancy than at other times. Some common reasons for this disruption are frequent urination, an unquiet mind, stress, leg cramps, or general discomfort. Simple steps to resolve this problem include reducing stress with meditation and using full-body pillows to increase comfort.

Menstruation and Menopause

Both menstruation and menopause can bring about insomnia in some women. The discomfort associated with premenstrual syndrome can keep women up at night. The fluctuating hormones influence brain chemicals affecting sleep. (See above)

The period of time prior to menopause is called perimenopause, when women are most vulnerable to developing insomnia. Hot flashes and night sweats, which are characteristic of this period, often disturb sleep.

Women are also more at risk for anxiety and depression disorders, which are major causes of secondary insomnia. The reasons are not as clear why women are also more likely to develop primary insomnia.

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Diagnosis and Treatment

Diagnosis

Sleep Diary—If you are planning to talk to your healthcare professional about suspected insomnia, it is helpful to keep a sleep diary in the week or two leading up to your visit. Take a daily assessment of the following:

• Write down your sleep patterns: how long it took you to fall asleep, how often you woke up in the night, whether you dreamt, and what time you woke up for the morning.
• Keep track of your menstrual cycle and what (if any) symptoms you experienced as a result of your menstrual cycle.
• Also take note of how you are feeling throughout the day. Note if you are feeling drowsy, wired, detached, confused, or any other strong feeling.
• Keep track of your daily routine and be sure to note any particularly stressful events that occur.
• Note food intake as well as use of alcohol, coffee, cigarettes, and any medications you take, including over-the-counter vitamins or herbal products.

Medical History—Your clinician will look at your medical history to see if you have had any conditions that are commonly linked to insomnia (See causes, above). He or she may want to speak to your bed partner, if applicable, to ask about the quantity and quality of your sleep. Your healthcare professional will also ask a series of questions that may or may not be addressed in your sleep diary, such as:

• Mood
• Physical or mental symptoms or problems
• Daily activities
• Work pattern or history
• Sleep patterns
• Psychiatric and medical history
• Travel patterns
• Eating habits
• Recreational substance use: alcohol, tobacco, other drugs

Specialized Sleep Study—In some cases, you may be referred to a sleep center so that they can conduct more extensive tests, and observe first-hand your sleeping patterns.

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Treatment

If you are diagnosed with intermittent or transient insomnia, your clinician may recommend that you do not use any treatment. If, for example, your insomnia is a result of jet lag or a temporary change in schedule, your biological clock will often naturally return to normal. If your transient insomnia is hindering your daily functioning, your healthcare professional may prescribe short-acting sleeping pills to improve sleep temporarily.

Treatment for chronic insomnia is more comprehensive:

• Diagnose and treat any medical or psychological problems that may be causing insomnia.
• Identify destructive behavior that may worsen insomnia and reduce or stop it.
• Sleeping pills are an option, although the patient should be closely guided by a physician to make sure that they are maximizing effectiveness and minimizing side effects. These drugs are prescribed at the lowest effective dosage for the shortest duration necessary. Sometimes the doses of these medications will be gradually lowered before being discontinued, or the insomnia may recur.
• Behavior modifications may be implemented to improve sleep. The three primary behavior modifications are:
  • Relaxation Therapy: There are specific techniques that you can learn to reduce or eliminate anxiety and body tension. This will help stop the mind from racing, help relax the muscles, and promote restful sleep. Examples of relaxation therapy include progressive muscle relaxation, hypnosis, and meditation.
  • Sleep Restriction: Some people who suffer from insomnia actually spend a great deal of time in bed trying to sleep. Sleep restriction means that you limit the amount of time in bed to only a few hours. Gradually, you increase the time spent in bed until a more normal night’s sleep can take place.
  • Reconditioning: This process changes the association people have with their beds. Some people spend time watching television, reading, or doing work in their beds. Reconditioning usually involves using the bed only for sleep and sex. The patient will be advised to only go to bed when he/she feels ready to fall asleep. If he/she has a hard time falling asleep, the patient is to get up and stay up until ready for sleep, and then to return to bed. During this process, the patient should refrain from napping and should wake up and go to sleep at the same time every day. Eventually, the patient should associate the bed with bedtime and sleep.

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Empower Yourself

Dealing with insomnia

• Sometimes people who suffer from insomnia feel isolated and alone. It is important to first realize that this is a common problem for women, and you can take control of it. By making a few simple changes, you may be able to defeat insomnia.
• Rearrange your bedroom. Make sure that it is comfortable for you. If your mattress is too soft or too firm, make adjustments to make sure that it feels good when you lie down. Adjust the ventilation in the room so it doesn’t feel stuffy. It may help to play music or to use aromatherapy as you are falling asleep to calm you down. Make sure the room is dark enough and block external noise as much as you can.
• Reduce your caffeine intake, especially later in the day. Drinking coffee even hours before bedtime sometimes has the effect of giving you ”the jitters,” making it difficult to relax.
• Quit smoking. Nicotine increases heart rate and alertness, so it may be disruptive to sleep.
• Limit naps to an hour or less. While many people who suffer from insomnia will take sleep any time they can get it, naps may make it more difficult to fall asleep at night, which is when you will be getting the full benefits of your full sleep cycles.
• Fill your days with interesting and engaging activities that use your energy in positive ways. If you are expending energy all day, you are more likely to arrive home tired and ready to sleep.
• Be aware of staying in bed too long. Spending time in bed without sleeping dissociates the bed with sleeping and will hinder any reconditioning treatments you are attempting.
• Regulate your daily schedule so that you can wake up and go to sleep at the same time every day. Your body will get used to this internal clock.
• Exercise. Your body needs to expend energy before it can be at rest. After working your muscles, they will be able to relax more easily. Be sure to complete exercise a few hours before bedtime.
• Do something relaxing before you go to bed. Instead of watching the television until the moment you go to sleep, try reading or meditating. These activities slow your mind down, as opposed to high definition television, which is a constant circus for the eyes.
• Don’t watch the clock. Turn your alarm clock so it is facing away from you.
• Keep a notebook and pen next to your bed so you can write down any thoughts you have during the night. By writing them down, you are putting the thoughts to rest and you won’t dwell on them as much. You can also write down dreams.
• Do not take a hot bath or shower just before bed. The body needs to cool down before it will fall asleep.
• Have a soothing drink, like chamomile tea or hot water with honey and lemon, before bedtime.
• Practice a few restorative yoga poses to calm your muscles.
  • Lying flat on your back, extend your legs straight up the wall. Extend your arms out to either side or overhead. This lets the blood flow from the feet and legs to the core. Take 10 breaths.
  • Or try child’s pose, where you kneel down, then lower your buttocks onto your heels, then extend your arms out straight in front of you, placing your palms on the floor. Let your forehead rest on the floor. Take 10 deep, relaxing breaths.

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Frequently asked questions

Do women suffer from insomnia more than men?

Women are twice as likely as men to suffer from insomnia. Some research suggests that certain social factors, such as being unemployed or divorced, are related to poor sleep and insomnia in women. Also, insomnia tends to increase with age. Sometimes perimenopausal (the time leading up to menopause) women have trouble falling asleep and staying asleep; hot flashes and night sweats can often disturb sleep. Pregnancy can also affect how well a woman sleeps.

How is insomnia diagnosed?

If you think you have insomnia, talk to your healthcare professional. It might be helpful to complete a sleep diary for a week or two, noting your sleep patterns, your daily routine, and how you feel during the day. Discuss the results of your sleep diary with your healthcare professional. He or she may do a physical exam and take a medical history and sleep history. He or she may also want to talk to your bed partner to ask how much and how well you are sleeping. In some cases, you may be referred to a sleep center for special tests.

How is insomnia treated?

If insomnia is caused by a short-term change in the sleep/wake schedule, as with jet lag, your sleep schedule may return to normal on its own. If your insomnia makes it hard for you to function during the day, talk to your healthcare professional.

Treatment for chronic insomnia includes the following:

• Finding and treating any medical conditions or mental health problems.
• Looking for and stopping (or reducing) routines or behaviors, like drinking alcohol at night, that may lead to the insomnia or make it worse.
• Possibly using sleeping pills. You should talk to your healthcare professional about the risks and side effects.
• Trying one or more methods to improve sleep, such as relaxation therapy, sleep restriction therapy, and reconditioning.

What can I do to sleep better?

• Try to go to sleep at the same time each night and get up at the same time each morning. Do not take naps after 3 PM.
• Avoid caffeine, nicotine, and alcohol late in the day or at night.
• Get regular exercise. Exercise during the day—make sure you exercise at least 5 to 6 hours before bedtime.
• Make sure you eat dinner at least 2 to 3 hours before bedtime.
• Keep your bedroom dark, quiet, and cool. If light is a problem, try a sleeping mask. If noise is a problem, try earplugs, a fan, or a “white noise” machine to cover up the sounds.
• Follow a routine to help relax and wind down before sleep, such as reading a book, listening to music, or taking a bath.
• If you can’t fall asleep within 20 minutes or don’t feel drowsy, get up and read or do something that is not too active until you feel sleepy. Then try going back to bed.
• If you lay awake worrying about things, try making a to-do list before you go to bed.
• Use your bed only for sleep and sex.

See your doctor if you think that you have insomnia or another sleep problem.

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Glossary of insomnia terms

Caffeine: A stimulant found naturally in coffee beans, tea leaves, cocoa beans (chocolate) and kola nuts (cola) and added to soft drinks, foods, and medicines. A cup of coffee has 100 to 250 milligrams of caffeine. Black tea brewed for 4 minutes has 40 to 100 milligrams. Green tea has one-third as much caffeine as black tea.

Chronic: This important term in medicine comes from the Greek word chronos, meaning time and lasting a long time.

Depression: An illness that involves the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood. It is not a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.

Heartburn: An uncomfortable feeling of burning and warmth occurring in waves rising up behind the breastbone (sternum) toward the neck. It is usually due to gastroesophageal reflux disease (GERD), the rise of stomach acid back up into the esophagus. Heartburn has nothing to do with the heart. "Heartburn" is a popular nonmedical term. It is medically called pyrosis.

Hygiene: The science of preventive medicine and the preservation of health.

Insomnia: The perception or complaint of inadequate or poor-quality sleep because of one or more of the following: difficulty falling asleep, waking up frequently during the night with difficulty returning to sleep, waking up too early in the morning, or unrefreshing sleep.

Jet lag: A temporary disorder that causes fatigue, insomnia, and other symptoms as a result of rapid air travel across time zones.

Medical history: In clinical medicine, the patient’s medically relevant past and present, which may contain clues bearing on her health in the past, present, and future. The medical history, being an account of all medical events and problems a person has experienced, including psychiatric illness, is especially helpful when a differential diagnosis is needed.

Medication: A drug or medicine or the administration of a drug or medicine.

Nicotine: An alkaloid (a nitrogen-containing chemical) made by the tobacco plant or produced synthetically. Nicotine has powerful pharmacologic effects (including increased heart rate, heart stroke volume, and oxygen consumption by the heart muscle) as well as powerful psychodynamic effects (such as euphoria, increased alertness, and a sense of relaxation). As is now well known, nicotine is also powerfully addictive. When someone becomes habituated to nicotine and then stops using it, they experience the symptoms of withdrawal, including anxiety, irritability, restlessness, shortened attention span, and an intense, sometimes irresistible, craving for nicotine.

Onset: In medicine, the first appearance of the signs or symptoms of an illness as, for example, the onset of rheumatoid arthritis. There is always an onset to a disease but whereas the return to good health may be more gradual.

Pain: An unpleasant sensation that can range from mild, localized discomfort to agony. Pain has both physical and emotional components.

Primary: First or foremost in time or development. Primary may also refer to symptoms or a disease to which others are secondary.

Sleep: The body’s rest cycle.

Sleep disorders: Any disorder that affects, disrupts, or involves sleep. The most common sleep disorder is probably snoring, although it is usually not medically significant. Insomnia, sleep apnea, restless leg syndrome, and sleepwalking are also sleep disorders.

Stress: Forces from the outside world impinging on the individual. Stress is a normal part of life that can help us learn and grow. Conversely, stress can cause us significant problems.

Therapy: The treatment of disease.

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Insomnia resources and tools

• Government Agencies
• Private Organizations
• Newsletters, Magazines, and Reports
• Tools

Government Agencies

*Accepts Spanish calls

National Center on Sleep Disorders Research
National Heart, Lung, and Blood Institute, NIH
6705 Rockledge Drive
One Rockledge Centre, Suite 6022
Bethesda, MD 20892-7993
Phone: (301) 592-8573
http://www.nhlbi.nih.gov/sleep


*National Institute of Mental Health, NIH, HHS
Public Information and Communications Branch
6001 Executive Blvd., Room 8184, MSC 9663
Bethesda, MD 20892-9663
Phone: (866) 615-6464
TTY: (866) 415-8051
Fax: (301) 443-4279
http://www.nimh.nih.gov

*National Mental Health Information Center, SAMHSA, HHS
P.O. Box 42557
Washington, DC 20015
Phone: (800)789-2647
TDD: (866) 889-2647
Fax: (240) 747-5470
http://www.mentalhealth.samhsa.gov



Private Organizations

Mayo Clinic
4500 San Pablo Road
Jacksonville, FL 32224
Phone: (904) 953-2000
http://www.mayoclinic.org

* Hormone Foundation
8401 Connecticut Avenue, Suite 900
Chevy Chase, MD 20815-5817
Phone: (800) 467-6663
http://www.hormone.org

American Menopause Foundation, Inc (Publications available in Spanish)
350 5^th Ave, Suite 2822
New York, NY 10118
Phone: (212) 714-2398
http://www.americanmenopause.org

National Women’s Health Network
514 10^th Street, NW, Suite 400
Washington, DC 20004
Phone: (202) 628-7814
www.nwhn.org

Newsletters, Magazines, Reports

Healthy Women Today
The National Women’s Health Information Center
www.womenshealth.gov/newsletter



Tools

Quiz Yourself
Find out if you have insomnia by logging onto this government Web site and clicking on “Patient and Public information.”
http://www.nhlbi.nih.gov/about/ncsdr/

Guide to Healthy Sleep
Download this guide from the National Heart, Lung, and Blood Institute.
http://www.nhlbi.nih.gov/health/public/sleep/healthysleepfs.htm

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