Chapter 1 22 and wake-up times. Having a late chronotype can affect sleep health, especially when sleep-wake timings are not synchronous with social obligations (Antypa et al., 2016). People’s perception of their sleep can misalign with objectively measured sleep. People with insomnia commonly show underestimations of sleep durations and longer wakefulness at night (Bianchi et al., 2013). The phenomenon of reporting poor sleep or insomnia without objective sleep disturbances is also called sleep state misperception (Moon et al., 2015). Sex differences in sleep In subjective assessments of sleep, women show a higher likelihood of reporting insomnia and poorer sleep quality, including lower sleep efficiency, more sleep disturbances and more use of sleeping medication (Li et al., 2019). However, when assessing sleep using objective sleep measurements, women on average actually show better sleep than men, including longer sleep duration, less wakefulness during the night, longer slow wave sleep (SWS) and longer rapid eye movement (REM) sleep latency (Bixler et al., 2009; Roehrs et al., 2006). Thus far, there is no explanation yet for the paradoxical higher prevalence of poor sleep and insomnia and concurrent better objective sleep in women. Women also generally report an earlier chronotype than men, meaning they prefer an earlier bedtime and earlier wake-up time (Randler & Engelke, 2019). Sex hormones and sleep during the lifespan The sex difference in the prevalence of insomnia specifically increases from the time of the first menarche in girls (Johnson et al., 2006), suggesting that sex hormone changes could contribute to insomnia risk. Incidence of insomnia also increases during pregnancy and perimenopause (Ciano et al., 2017; Hashmi et al., 2016). Experimental studies have provided evidence indicating sex hormones could contribute to this risk of sleep problems: endogenous hormone suppression in reproductive-age women resulted in increased rates of disturbed sleep (Ben Dor et al., 2013). Vice versa, supplementation of estrogen in women going through perimenopause, was associated with improved sleep quality compared to the placebo group (Silva et al., 2011), and Bixler et al. (2009) found that postmenopausal women using hormone therapy showed shorter sleep onset latency and longer slow wave sleep compared to postmenopausal women not using hormone
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