One of the risk factors for obstructive sleep apnea (OSA) is being a man. However, that does not mean that women are not impacted with this disease or its consequences. It is important for women’s overall health to know the symptoms of OSA and treat it if it is present.
Prevalence of OSA in Women
Prevalence of OSA is lower in women than in men, this is especially true earlier in life. However, in post-menopausal women prevalence of OSA is similar to that of men. A study in Switzerland of the general population estimated OSA (assessed as >_ 15 respiratory events per hour of sleep) at 23.4% in adult women and 49.7% in adult men.
Risk Factors for OSA in Women
There are a variety of risk factors for OSA; some apply to women specifically such as menopause, age, pregnancy, and Polyendocrine Metabolic Ovarian Syndrome (PMOS). However, obesity and upper airway alterations are risk factors for OSA in both men and women. OSA is especially frequent in people with a predominant distribution of fat in the abdomen. Women are more likely to have a fat distributed around the hips and thighs, so they are relatively protected compared to men for OSA due to excess fat. OSA is usually less severe in premenopausal women than in men because of other functional factors including fat-distribution patterns, sex-hormone effects, ventilatory control, and lower upper-airway collapsibility. In post-menopause, the distribution of fat in women becomes more central, hormones change, and airway collapsibility increases contributing to an increased risk for women to develop OSA.
OSA Symptoms in Women vs. Men
Among physicians it is becoming clear that the “male model” of OSA does not apply to women. The differences in symptoms reported by women are likely the cause of OSA underdiagnosis. While snoring is the most frequent symptom of OSA independent of sex, women complain more about tiredness, fatigue, and depression than about sleepiness. Insomnia is more frequent in women, and OSA symptoms may be interpreted as secondary to poor sleep quality and insomnia. These misunderstandings lead to OSA being underdiagnosed in women.
Is it Menopause or OSA?
Menopause may cause sleep-related symptoms, but they only partially overlap with the symptoms of OSA. Insomnia, frequent waking, hot flashes, night sweats, and early morning awakening are common sleep symptoms in women during the menopausal transition. Decreased estrogen and progesterone in postmenopausal women may contribute to OSA prevalence and severity. The occurrence of weight gain, snoring, and fatigue are signs that OSA may be present.
OSA Treatments for Women
Many women do not like treatment with continuous positive airway pressure (CPAP) and consequently show a high rate of quitting CPAP treatment over time. When CPAP is the recommended treatment, care should be taken to choose light masks and/or algorithms especially developed for women to optimize comfort. Psychological support may be crucial to increasing the chances of treatment acceptance. In severe OSA cases CPAP remains the treatment of choice. If obesity is severe, bariatric surgery or treatment with anti-obesity drugs may limit the need of CPAP treatment. However, even if other interventions are planned or initiated, CPAP use should begin and continue until substantial weight loss, and OSA remission are achieved. In patients with mild OSA, making lifestyle changes (e.g., increasing exercise and controlling weight), using positional treatment (e.g. avoiding the supine position which can cause respiratory issues) or using a mandibular advancement device may be more acceptable than CPAP, especially in women.
Impact of OSA on Women’s Health
Although OSA in women is typically less severe than in men, the impact of OSA in women’s health is considerable. First, the underdiagnosis and the delayed start of treatment compared to men can lead to severe symptoms. Women also show a higher burden of additional medical conditions compared to men. Second, health care needs decreased after CPAP treatment in men but not in women. Finally, symptoms of disturbed sleep are more common in women than in men with OSA, and poor sleep quality may also negatively affect health. The available data on cardiovascular risk and mortality associated with OSA does not show a clear picture. Some studies underline the higher risk in men, while other studies reported a higher risk in women. This is currently an area of intense clinical research.
Maria Bonsignore PhD is a specialist in Cardiology and Respiratory Medicine. She is a full professor in Respiratory Medicine at the University of Palermo, Italy. Her main research fields are sleep apnea, respiratory failure and exercise. She has published 200 papers. (PUBMED)