Sleep and Sex: A Review of the Interrelationship of Sleep and Sexuality Disorders in the Female Population, Through the Lens of Sleeping Beauty Syndrome

INTRODUCTION

For many, sleep and sex are crucial for physical, emotional, and mental well-being. Poor sleep quality is linked to a myriad of ailments from coronary artery disease to major depressive disorder. Likewise, a decrease in the frequency of sexual activity is associated with a decrease in self-rated health status. Kleine-Levin syndrome (KLS) is a rare sleep disorder that provides a unique lens to examine the intricate interplay between sleep and sex as it is one of the few sleep disorders defined by concomitant sexual dysfunction.

OBJECTIVES

This study reviews the literature on links between sleep disorders and sexuality with a focus on women's health followed by a case study of unusual patient with KLS with persistent genital arousal disorder.

METHODS

Literature searches were conducted for English language publications, including foreign language publications with English abstracts with ninety-five articles reviewed. The literature review is followed by a case report.

RESULTS

We review the known literature linking sleep and women's sexual health with a focus on insomnia, circadian rhythm sleep disorder, obstructive sleep apnea, restless leg syndrome, sexsomnia, and KLS. We then present a case of KLS-associated persistent genital arousal disorder, which was amenable to treatment with a multimodal approach aimed at symptomatic relief with intravaginal diazepam suppositories, topical clitoral lidocaine, and duloxetine.

CONCLUSION

This case highlights that hypersexuality and persistent arousal cannot effectively be treated in isolation but rather must be contextualized within a patient's broader medical history and diagnoses. Specifically, sleep quality and potential sleep disorders should be assessed for those presenting with sexual health complaints (and vice versa). Zwerling B, Keymeulen S, Krychman ML. Sleep and Sex: A Review of the Interrelationship of Sleep and Sexuality Disorders in the Female Population, Through the Lens of Sleeping Beauty Syndrome. Sex Med Rev 2021;9:221-229.

Kleine-Levin Syndrome

Kleine-Levin syndrome (KLS) is a rare disorder characterized by discrete episodes of hypersomnia associated with cognitive and behavioural abnormalities, as well as normal alertness and function between episodes. The prevalence of KLS may be underestimated as it is often misdiagnosed and managed as another sleep disorder, neurological disorder or psychiatric condition. KLS is more typically seen in adolescence than at other ages, and is more common in males than in females. There are currently neither standard biomarkers nor specific imaging study findings, making the diagnosis of KLS a challenge. Furthermore, there are no consistently effective therapies. The prognosis, however, is felt to be overall favorable, as episodes become progressively milder and less frequent before resolving entirely in most patients.

[Clinical presentation of Kleine-Levin syndrome]

Objective: To analyze the clinical features of Kleine-Levin syndrome (KLS) patients. Methods: Clinical data of 44 patients with KLS of the Sleep Center of Peking University People's Hospital from January 2002 to July 2013 were systematically reviewed. The predisposing factors and clinical presentations were summarized, and compared with the data from a Western KLS study with a large subjects number. Nocturnal polysomnography (PSG) and multiple sleep latency test (MSLT) were conducted during relapse and remission period, respectively. HLA-DQB1*0602 gene were screened and analyzed. Results: Among the 44 patients, 28(63.6%) were men and 16(36.4%) were women, with a mean age of (18.3±8.9) years old. Most patients developed the symptoms during adolescence. Infection or fever was the most common trigger for episode. The main clinical presentations were 44(100.0%) hypersomnia, 31(70.5%) forgetfulness, 26(59.1%) decreased appetites, 24(54.5%) juvenile behavior, 18(40.9%) depression, etc. Compared with the Western study, it showed that our patients had decreased instead of increased appetite. The PSG testing did not have remarkable findings. MSLT showed mean sleep latency was significantly shorter during relapse than during remission [(10.4±5.4) vs (15.3±3.4) min, P=0.009]. HLA-DQB1*0602 was positive in 12 of 40(30.0%) patients, which was similar to the data in the Chinese population. Conclusions: KLS has various clinical characteristics. The presentation of appetite may be different between Chinese and western KLS patients.

Feeling unreal: a functional imaging study in patients with Kleine-Levin syndrome

Kleine-Levin syndrome is characterized by relapsing-remitting episodes of severe hypersomnia, cognitive impairment, apathy, derealization and behavioural disturbances. Between episodes, patients have normal sleep, mood and behaviour. Functional imaging studies performed in small series of patients with Kleine-Levin syndrome with visual or semi-quantitative, uncontrolled analysis yielded equivocal brain changes. Using whole brain voxel-based group analysis, we compared brain perfusion scintigraphy during and between episodes in consecutive patients with Kleine-Levin syndrome versus healthy control subjects and correlated perfusion changes with disease severity and symptoms, focusing on less studied but disabling symptoms, such as apathy and derealization. During asymptomatic periods, 41 patients (mean age of 22.3 ± 8.1 years, 56.1% male) and 15 age- and sex-matched healthy control subjects underwent single-photon emission computed tomography scanning with technetium-99m ethyl cysteinate dimer. Eleven patients repeated the test during a symptomatic period. Compared with controls, patients during asymptomatic periods had persistent hypoperfusion in the hypothalamus, the thalamus (mainly the right posterior part), the caudate nucleus, and cortical associative areas, including the anterior cingulate, (Brodmann area 25), the orbito-frontal (Brodmann area 11) and the right superior temporal cortices (Brodmann area 22), extending to the insula (P < 0.001 in all area). Two additional hypoperfused areas emerged during symptomatic periods (P < 0.001), located in the right dorsomedial prefrontal cortex (Brodmann area 8) and the right parieto-temporal junction (Brodmann areas 22 and 39). These two areas were more affected between episodes, when the mean episode duration was longer (r = -0.53; P < 0.001). The score for the Depersonalization/Derealization Inventory during symptomatic periods strongly correlated with the hypoperfusion of the right (r = -0.74, P < 0.001) and left (r = -0.59, P < 0.005) parieto-temporal junctions. No hyperperfusion was found. Because the parieto-temporal junction (including the angular gyrus) is involved in cross-modal association between somatosensory (body knowledge), auditory and visual information, the robust hypoperfusions and correlations observed in this area may underlie the striking derealization reported by patients during episodes. Defects in the dorsomedial prefrontal cortex may cause apathy. Persistent hypoperfusion in the diencephalic and associative cortical area during asymptomatic periods is a marker of the disease, suggestive of a scenario wherein patients compensate for these deficient circuitries.

Clinical and Polysomnographic Features of Kleine-Levin Syndrome: Case Series

Kleine-Levin Syndrome (KLS) is a rare disorder characterized intermittent hypersomnia, hyperphagia, hypersexuality, abnormal behaviors, and confusion. Patients are asymptomatic between episodes. The aim of this case series study was to determine the clinical features of patients with KLS and to compare the polysomnography (PSG) findings between symptomatic and asymptomatic periods. We compared the results of PSG investigations performed in symptomatic and asymptomatic periods in six patients diagnosed with KLS at Gulhane Military Medical Faculty Sleep Research Center between 1998 and 2005. The age at onset of KLS was approximately 18 years, the diagnosis delayed 2.67 years, hypersomnia episodes lasted approximately 11.5 days, until the correct diagnosis, the patients had experienced on average 5 episodes. Total sleep time in KLS patients during symptomatic period and stage 2 sleep percent was higher than in asymptomatic period. REM latency was shorter and stage 3 and REM percent was lower in asymptomatic period. The clinical features including the age of onset and episode duration are compatible with those from the previous studies. It was observed that the sleep architecture during symptomatic period was different from that in asymptomatic period.

Relationship between Kleine-Levin syndrome and upper respiratory infection in Taiwan

STUDY OBJECTIVES

In Kleine-Levin Syndrome (KLS), new episodes of hypersomnia are often preceded by an acute flu-like syndrome or upper airway infection 3 to 5 days before onset. This study investigated the relationship between the occurrence of mild upper respiratory tract infections (URIs) in the general population and the occurrence and seasonality and hypersomnic episodes in KLS patients.

DESIGN

This investigation was a longitudinal clinical study. Based on data obtained from the National Health Research Institutes between 2006 and 2007, the timing of hypersomnic episodes in 30 KLS patients were compared with calendar reports of URI events, and the results compared with age-matched general Taiwanese population.

MEASUREMENTS

Clinical symptoms, physical examination, polysomnographic recording, SPECT study, and laboratory tests affirming KLS during both periods of hypersomnic attack and non-attack were collected. Every symptomatic episode was then followed up. The cross-correlation function (CCF) and bivariate correlations analysis were performed to see the relationship between KLS and URIs.

RESULTS

A positive finding of CCF analysis and significant bivariate correlations were found between KLS episodes and URI in the general population (r = 0.456*). In onset of hypersomnia, significant correlations existed among "acute upper respiratory infections" (r = 0.446*), "acute bronchitis and bronchiolitis" (r = 0.462*), and "pharyngitis and nasopharyngitis" (r = 0.548*) subtypes of infections. A positive correlation between higher reports of symptomatic hypersomnia and URI also existed in a given season. A positive nonsignificant trend for "allergic rhinitis" (r = 0.400) was also found.

CONCLUSION

The agent behind URI or its consequence (such as fever) is associated with increased incidence of KLS episodes and may explain periodic symptomatic recurrences.