Rising Awareness of Sleep Apnea in Women Challenges Long-Held Misconceptions

Obstructive sleep apnea (OSA), traditionally viewed as a condition predominantly affecting older, overweight men, is gaining recognition as a more complex disorder that often goes undetected in women, particularly during perimenopause and menopause. OSA occurs when the upper airway narrows or collapses during sleep, causing oxygen levels to drop and prompting the brain to briefly awaken the body to resume breathing. Historically, the disorder was seen as having a singular profile, but research now shows it is a heterogeneous condition influenced by various biological mechanisms and distinct symptom patterns. Despite this, the stereotype of the older, heavier male continues to influence diagnosis rates.

A projection published in The Lancet Respiratory Medicine journal indicates that by 2050, nearly 77 million U.S. adults aged 30 to 69 will have OSA, with a significant increase in prevalence among women. The study anticipates a 65 percent relative increase among women, reaching approximately 30.4 million, compared to a 19 percent increase among men. This rise is attributed to aging populations, increasing obesity rates, and improved detection methods.

Carlos Nunez, chief medical officer at ResMed, highlights that while over a billion people globally have sleep apnea, up to 90 percent remain undiagnosed and untreated in some countries. He notes that most individuals are unaware of their condition because it occurs during sleep. Although OSA can develop at any age, the risk increases with age due to declining muscle tone, which makes it harder for the airway to remain open. For women, menopause is a critical period, as studies show postmenopausal women have a significantly higher risk of OSA.

Marie-Pierre St-Onge from Columbia University explains that hormonal protection from estrogens diminishes at menopause, leading to fat redistribution towards the neck and upper body, which increases airway pressure. Estrogen and progesterone help regulate breathing and maintain upper-airway muscle activity, but their decline post-menopause heightens the risk of airway collapse during sleep. Rashmi Nisha Aurora from NYU Grossman School of Medicine adds that estrogen acts as a major antioxidant, and its reduction weakens defenses against oxidative stress, exacerbating the strain OSA places on the heart and metabolism.

Menopause is also a time when OSA symptoms can be misinterpreted, as they overlap with menopausal symptoms like night sweats and fatigue. Traditional diagnostic tools, developed primarily for men, may not effectively capture women's symptoms, which often include insomnia, mood changes, headaches, and fatigue rather than overt sleepiness. Women may also experience nocturia or fragmented sleep, which can be mistaken for stress.

OSA is not a singular disease but comprises different phenotypes and biological endotypes. A study of women with OSA revealed that while some exhibit classic symptoms like snoring, others have quieter, less obvious presentations. Even mild apnea, characterized by frequent breathing disruptions, can have significant physiological impacts, including vascular injury and increased cardiovascular risk. Untreated OSA is also linked to cognitive decline and Alzheimer's disease.

Treatment for OSA, typically involving continuous positive airway pressure (CPAP), remains straightforward, but researchers are exploring whether responses to therapy differ by sex. Aurora notes preliminary differences in oxidative stress markers between men and women treated with CPAP, suggesting a need for more personalized medicine. Nunez mentions that CPAP devices are evolving to dynamically adjust pressure based on individual needs, acknowledging that women's airways may respond differently than men's.

Despite recent studies on women and sleep apnea, further research is necessary. Aurora emphasizes the importance of including women in clinical trials, as hormonal changes often lead to their exclusion. She and Nunez stress the need for increased awareness and education about OSA among both patients and healthcare providers, advocating for a shift away from a paternalistic healthcare system that has historically focused on male-centric studies.