Sleep disturbances in women with polycystic ovary syndrome: prevalence, pathophysiology, impact and management strategies

Figures & data

Figure 1 The number of articles published in PubMed per year on the topic of PCOS and sleep.

Abbreviation: PCOS, polycystic ovary syndrome.

Figure 2 Summary of the bidirectional pathways through which PCOS interacts with sleep disturbances, with potentially detrimental effects on long-term cardiometabolic health.

Abbreviation: PCOS, polycystic ovary syndrome.

Figure 3 A summary of the three sets of criteria for the diagnosis of PCOS: the National Institutes of Health criteria (1990),¹⁰ the Rotterdam criteria (2003)¹¹ and the Androgen Excess Society criteria (2006).¹²

Abbreviation: PCOS, polycystic ovary syndrome.

Table 1 Summary of population- and community-based studies of sleep disturbances and PCOS in women

Study, country	Study design	Study groups	Outcomes of interest	Key results
Hung et al,^Citation47 Taiwan	Retrospective cohort constructed from the National Health Insurance Database (98% coverage)	5431 with PCOS and 21,724 without PCOS matched for age	Diagnosis of new-onset sleep disorders: ICD-9 780.5 (insomnias) and 307.4 (difficulty initiating and maintaining sleep, excluding OSA)	• Women with PCOS were more likely to be diagnosed with sleep disorders: HR = 1.495 (95% CI 1.176–1.899) • Most developed in the first year since diagnosis of PCOS
Lin et al,^Citation46 Taiwan		4595 with PCOS and 4595 without PCOS matched for age and time of enrollment	Diagnosis of OSA during follow-up (2–13 years)	• Women with PCOS had a greater incidence of OSA (1.71 vs 0.63 per 1000 person-years) • HR = 2.63 (95% CI 1.57–4.04) adjusted for demographics (urbanization, income) and comorbidities (hypertension, dyslipidemia, diabetes, obesity)
Moran et al,^Citation48 Australia	Cross-sectional analysis of data from a cohort based on births (1973–1975) at a large maternity hospital	87 with PCOS and 637 without PCOS	Sleep disturbance assessed using modified Jenkins questionnaire	• Any sleep disturbances two times higher in women with PCOS • Difficulty falling asleep: OR = 1.94 (95% CI 1.28–2.95), attenuated but still significant after adjusting for BMI and depressive symptoms • Difficulty maintaining sleep: OR = 1.92 (95% CI 1.12–3.31), mediated by BMI and depressive symptoms • PCOS not associated with early awakening or daytimesleepiness

Abbreviations: BMI, body mass index; CI, confidence interval; HR, hazard ratio; ICD-9, International Classification of Diseases, Ninth Revision; OR, odds ratio; OSA, obstructive sleep apnea; PCOS, polycystic ovary syndrome.

Table 2 Summary of clinic-based studies of sleep disturbances and PCOS in women

Study, country	Study design	Study groups	Outcomes of interest	Key results
Fogel et al,^Citation50 USA	Cross-sectional, PCOS and comparison group	18 with PCOS, all obese; and 18 without PCOS matched for age and weight	AHI, AHI (REM sleep), OSA (AHI >5 with EDS), ESS, sleep onset latency, sleep efficiency, % stages 3 and 4 and % REM sleep	• AHI: PCOS 22.5 ± 6.0 vs controls 6.7 ± 1.0, p = 0.008 • AHI (REM sleep): PCOS 41.3 ± 7.5 vs controls 13.5 ± 3.3, p < 0.01 • OSA: PCOS 44.4% vs controls 5.5%, p = 0.008 • ESS: PCOS 9.5 ± 0.9 vs non-PCOS 5.8 ± 0.8, p < 0.01 • No significant differences in other PSG variables
Franik et al,^Citation62 Poland	Cross- sectional, PCOS and comparison group	95 with PCOS and 95 without PCOS	AIS, ISI, ESS and PSQI	• Clinically significant insomnia was higher in PCOS  ○ AIS – 12.6% vs 3.2%, p = 0.01  ○ ISI – 10.5% vs 1.1%, p = 0.004 • No significant difference in ESS or PSQI
Gopal et al,^Citation87 USA	Cross-sectional, PCOS and comparison group	23 with PCOS, all premenopausal and obese; and literature-based historical controls	Snoring, RDI, OSA (RDI ≥5) and other variables (e.g. arterial oxygen saturation)	• 16/23 (69.6%) met the criteria for OSA • 5/23 required CPAP • No correlation was found between degree of obesity and severity of OSA • No results reported for other variables
Mokhlesi et al,^Citation86 USA	Cross-sectional, PCOS and comparison group	17 with PCOS, all nonobese; 27 with PCOS, all obese; 26 without PCOS, all nonobese; and 8 without PCOS, all obese	Berlin questionnaire for assessment of OSA risk	• Women with PCOS had higher prevalence of high-risk OSA (47% vs 15%, p < 0.01) • None of the nonobese PCOS and nonobese control women screened positive for OSA • Obese PCOS vs obese controls had similar prevalence of OSA • BMI was only independent predictors of OSA
Suri et al,^Citation51 India	Cross-sectional, PCOS and comparison group	50 with PCOS, all untreated; and 16 without PCOS, matched for age, who reported snoring	RDI, SDB (RDI ≥5 with symptoms, RDI >15 without symptoms), sleep onset, TST, WASO, REM sleep (minutes), NREM sleep (minutes), sleep efficiency, ESS and RERA	• SDB: OR = 46.5 (95% CI 14.6–148.4), no longer significant after adjusting for BMI and WC • Higher RDI in PCOS with SDB (22.5) compared to controls with SDB (9.0), p = 0.01 • WASO: PCOS 55.4 ± 57.9 vs non-PCOS 30.5 ± 26.4, p = 0.025 • ESS: PCOS 12.5 ± 3.2 vs non-PCOS 9.32 ± 1.7, p < 0.001 • No other significant differences in PSG variables
Tasali et al,^Citation52 USA	Cross-sectional, PCOS and comparison group	40 with PCOS, all nondiabetic, completed questionnaires 8 with PCOS, referred for PSG; and 8 without PCOS, matched for age, nonobese	ESS, PSQI and Berlin questionnaire Sleep efficiency, sleep latency, TST, TWT, REM sleep (minutes) and NREM sleep (minutes) Severity of SDB measured using AHI, MAI and ODI during total, REM and NREM sleep and minimum oxygen saturation	• 62.5% had poor sleep quality (PSQI >5) • 45% had chronic daytime sleepiness (ESS score ≥10) • 75% had high risk of OSA by Berlin questionnaire Measures of sleep efficiency in PCOS vs controls • PCOS women had significantly lower sleep efficiency and REM and NREM sleep compared to controls • PCOS women had significantly higher sleep latency, TWT and TST compared to controls Measures of SDB severity in PCOS women • AHI total (mean ± SE) = 7.0 ± 1.2 • MAI total (mean ± SE) = 17.6 ± 1.8 • ODI total (mean ± SE) = 10.8 ± 2.2 • Minimum oxygen saturation (%) = 80.6 ± 1.6 • All values were higher during REM than NREM sleep
Tasali et al,^Citation53 USA	Cross-sectional, PCOS and comparison group	52 with PCOS; and 21 without PCOS, matched for age and BMI	AHI, OSA (AHI >5), TST, MAI and minimum oxygen saturation	• OSA: adjusted OR = 7.1 (95% CI 1.7–45.7), adjusted for age, BMI and ethnicity • Presence of OSA associated with significantly higher MAI and minimum oxygen saturation among PCOS group. Data not presented for four control women with OSA • No significant difference in TST
Vgontzas et al,^Citation54 USA	Cross-sectional, PCOS and comparison group	53 with PCOS, all premenopausal; and 452 without PCOS	Sleep apnea (AHI ≥10 with clinical symptoms), upper airway resistance syndrome, SDB, EDS, sleep latency (minutes), WASO, total wake time, % sleep time, % stage 1, % stage 2, % SWS and % REM sleep	• Sleep apnea: OR = 28.7 (95% CI 4.9–294.4) • Upper airway resistance syndrome: OR = 27.6 (95% CI 2.1–1423.0) • SDB (all): OR = 30.6 (95% CI 7.2–139.4) • SDB (BMI ≥32.3): OR = 5.1 (95% CI 1.1–31.3) • EDS (BMI <32.2): OR = 10.3 (95% CI 2.5–60.0) • EDS (BMI ≥32.2): OR = 3.8 (95% CI 1.4–11.6) • No significant differences in other PSG variables
Yang et al,^Citation55 Taiwan	Cross-sectional, PCOS and comparison group	18 with PCOS, all nonobese and untreated; 10 without PCOS, matched for age and BMI	AHI (total, NREM sleep, REM sleep), ARI (total, NREM sleep, REM sleep, spontaneous, PLM-related), PLM, ESS, sleep efficiency, sleep latency, % REM sleep and REM sleep latency	• Mean total AHI: PCOS 0.79 ± 0.21 vs non-PCOS 0.29 ± 0.09, p = 0.041 • Mean AHI (NREM sleep): PCOS 0.57 ± 0.19 vs non-PCOS 0.03 ± 0.03, p = 0.014 • No significant differences in other PSG variables • None of the women in the study had AHI >5

Note: Sleep efficiency = TST/TIB.

Abbreviations: AHI, apnea–hypopnea index; AIS, Athens Insomnia Scale; ARI, arousal index; BMI, body mass index; CI, confidence interval; CPAP, continuous positive airway pressure; EDS, excessive daytime sleepiness; ESS, Epworth Sleepiness Scale; ISI, Insomnia Severity Index; MAI, microarousal index; NREM, non-rapid eye movement; ODI, oxygen desaturation index; OR, odds ratio; OSA, obstructive sleep apnea; PCOS, polycystic ovary syndrome; PLM, periodic limb movement; PSG, polysomnography; PSQI, Pittsburgh Sleep Quality Index; RDI, respiratory distress index; REM, rapid eye movement; RERA, respiratory effort-related arousal; SDB, sleep-disordered breathing; SE, standard error; SWS, slow-wave sleep; TIB, time in bed (minutes); TST, total sleep time (minutes); TWT, total wake time (minutes); WASO, wake after sleep onset (minutes); WC, waist circumference.

Figure 4 Summary of psychosocial and behavioral factors that are common among women with PCOS and their potential contribution to sleep disturbances and disorders.

Abbreviations: OSA, obstructive sleep apnea; PCOS, polycystic ovary syndrome.

Figure 5 Model of interdisciplinary care recommended for management of sleep disturbances and disorders in women with PCOS.

Note: Teede HJ, Misso ML, Deeks AA, et al. Assessment and management of polycystic ovary syndrome: summary of an evidence-based guideline. Med J Aust. 2011;195(6 Suppl):S65–S112. © Copyright 2011 The Medical Journal of Australia – figure adapted and reproduced with permission.¹⁹⁵
Abbreviation: PCOS, polycystic ovary syndrome.

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