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women with insomnia

Clinical Pearls for NPs: Insomnia Among Women


Healthcare providers caring for women of any age will find that a substantial proportion of them have difficulty falling and/or staying asleep.

These screening guidelines and non-medication options for sleep therapy are part of a continuing education activity that can be found here.


Even in a busy office setting, HCPs can start with a two-question screen: Do you experience difficulty sleeping? If so, do you have difficulty falling or staying asleep? To elicit more information, HCPs can then ask: Are you dissatisfied with your sleep? Do you suffer daytime fatigue? Affirmative answers to any or all of these questions suggest a diagnosis of insomnia, and may determine the type of treatment needed.

Another screening option is the BEARS Sleep Assessment Tool. Initial letters of the acronym stand for Bedtime problems (e.g., Does the patient have difficulty falling asleep?); Excessive daytime drowsiness; Awakenings during the night (e.g., Is the patient making frequent trips to the bathroom? Is she being interrupted by a crying baby or a sick child?); Regularity and duration of sleep; and Sleep-disordered breathing (e.g., Does the patient have obstructive sleep apnea?).

For a patient whose screening responses suggest she may have a sleep disorder, HCPs should ask these questions: Do you suffer from daytime fatigue? Do you snore or have episodes where you stop breathing when you sleep (based on the report of someone sharing your bedroom or your bed)? How many hours are you in bed each night? How many hours do you sleep each night? Do you feel refreshed upon awakening and throughout the next day? Do you have restless leg symptoms? Do you ever sleepwalk or have vivid dreams?

Role of health conditions, drug or alcohol use, RLS

In addition, HCPs should ask the patient about alcohol or illicit drug use, which can have profound effects on sleep. HCPs should also consider aspects of her current health that may be affecting her sleep; common offenders include overactive bladder, chronic pain, mental health disorders, fibromyalgia, hyperthyroidism, perimenopause, and RLS. In patients complaining of RLS-type symptoms, HCPs should consider checking a ferritin level. RLS can be associated with iron-deficiency anemia and ferritin levels below 50 ng/mL.

If a patient does have ongoing health problems, HCPs should inquire about the over-the-counter (OTC) and prescription medications she is using to treat them. Commonly used medications that can disturb sleep include selective serotonin reuptake inhibitors, dopamine agonists, amphetamines, anticonvulsants, decongestants, corticosteroids, beta agonists, theophylline, antihypertensives, diuretics, and appetite suppressants. In addition, HCPs should ask the patient which treatments, including alcohol, marijuana, OTC preparations, and prescription drugs, she has tried to help her sleep.

Sleepstate misperception

Some patients may have sleepstate misperception; they believe that they are awake much of the night but are actually asleep for a normal period of time. They think that it takes them an abnormally long time to fall asleep (even though it does not) and/or they underestimate how long they remain asleep. To identify this misperception, or to better understand the nature of any patient’s sleep problem, HCPs can recommend a home sleep study.

Non-medication options, sleep hygiene

After treating any co-morbid condition(s) and taking into account medications the patient is already taking, the HCP should evaluate the patient’s sleep hygiene and, if less than optimal, advise her to make changes. Good sleep hygiene entails:

  • being consistent—that is, going to bed at the same time each night and getting up at the same time each morning, including on weekends;
  • making sure one’s bedroom environment is quiet, dark, cool, and relaxing;
  • removing electronic devices from the bedroom;
  • avoiding large meals, caffeine, and alcohol before bedtime;
  • getting some exercise on most days; and
  • receiving daily exposure to sunlight (if possible) and keeping lights on until bedtime.
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