Sleep Apnea and How it Presents Differently in Women

Mar 1

What is sleep apnea?

Sleep apnea is a potentially very serious medical sleep disorder that causes multiple pauses or stops in your breathing while you sleep.

There are two types of sleep apnea: obstructive (OSA) and central (CSA). OSA is the more common of the two and it is caused by a partial blockage (called hypopneas) or complete closure of the airway (called apneas), usually when the soft tissue in the back of the throat collapses during sleep. When this happens, the brain detects there’s not enough oxygen getting into the bloodstream and then sends a signal to your body to wake up and then breathing resumes. But then you fall asleep again and this pattern continues. Sometimes you’re aware of it and sometimes you’re not but these constant awakenings are enough to cause sleep fragmentation and less refreshing sleep.

CSA is more of a neurological disorder, where the brain fails to send signals to the muscles that control breathing. CSA is less common and people seldom snore with this. The most common causes for CSA are nervous system conditions, heart failure or stroke, having low oxygen levels and opioid use.

These pauses and reduced oxygen levels in your body can negatively impact your health in a variety of ways and can increase your risk of conditions like:

Cardiovascular disease
Obesity
High blood pressure
Diabetes
Mood disorders (depression and anxiety)
Sexual dysfunction
Stroke
Abnormal liver function
Metabolic syndrome
Cognitive impairments - eg lack of concentration, memory
Shortened lifespan

Sleep apnea is one of the most underdiagnosed and untreated sleep disorders out there. About 80% of cases fall through the cracks due to a range of factors - access, knowledge, cost and physicians’ misdiagnosis. Women are even less likely to be diagnosed with the condition as they don’t always exhibit the stereotypical loud snoring symptoms and/or their symptoms are often masked or misdiagnosed for something else.

Causes and risk factors

There are a variety of reasons why a person may develop or increase their risk to develop obstructive sleep apnea:

Neck size (circumference greater than 16 inches for women, 17 inches for men)
Obesity
Family history
Increased age (after 50)
Drinking alcohol
Smoking
Taking certain medications like sedatives, benzodiazepines, muscle relaxants, antidepressants
Fat deposits in the neck and upper airway
A larger tongue and its position in your mouth
Tonsils and adenoids (especially in children)
Medical conditions including heart or kidney failure, stroke, thyroid disorders, and endocrine conditions
Extensive time in high altitudes
Infection or injury to the brain stem

Women-Specific Risk Factors

Historically, sleep apnea was associated more closely as a sleep-related breathing disorder that impacted males but there are certain factors that put women more at risk of developing it. Although the exact mechanisms are unknown, differences in weight distribution, upper airway anatomy, breathing control, hormones, and aging are all thought to play a role.

While men are more likely to have obstructive sleep apnea than women before age 50, after that age, the risk is the same for both sexes and this is partly due to hormonal fluctuations that impact airway shape due to the symptoms that accompany menopause. During menopause, women may also gain weight, including around the neck, which may increase the risk of airway disruptions.

Women may also be at increased risk for sleep apnea during pregnancy because of changes in their upper airways or in the way their brain controls breathing, partly as a result of fluctuating hormonal levels (eg. progesterone and estrogen) and partly due to weight gain. The risk increases in the third trimester and pregnant women who are older or who have obesity have a higher chance of developing apnea. Sleep apnea can cause many complications in pregnant women, including high blood pressure, gestational diabetes, giving birth by C-section or having a preterm birth or a baby with a low birth weight.

Hormone problems in women who have polycystic ovary syndrome (PCOS) may also raise the risk for sleep apnea.

Symptoms

Symptoms for apnea can be widespread and include:

Snoring
Waking up gasping or with a choking sound
Uneven breathing patterns: slower, faster, or pauses
Cognitive problems - memory, concentration
Irritability
Reduced libido and/or sexual dysfunction
Daytime fatigue or sleepiness
Unrefreshed waking
Dry mouth or sore throat upon waking
Morning headaches
Night time urination
Weight gain

Diagnosis

Diagnosis for apnea can only be confirmed through a sleep study, called a polysomnography. This involves a home sleep test or sleeping overnight in a sleep lab where you’ll have your brain waves, heartbeat, oxygen levels, breathing and movements charted as you sleep. You always need to be referred for a sleep study by your GP. The severity of your apnea will be determined by how many stops or pauses there are in your breathing each hour.

Differential Diagnosis for Women vs Men

While one should monitor all the above symptoms prior to being tested for a diagnosis, many women go undiagnosed as a result of a few key differences in how apnea presents itself in women vs men. Women are less likely to report loud snoring or have their bed partners witness stops in their breathing while sleeping. Apart from displaying less obvious symptoms of the disorder, women tend to experience greater issues with cognition, concentration, headaches, anxiety and depression and often they get misdiagnosed with a mood disorder instead. They also have a higher sensitivity to sleep disruption, waking up more easily and having fragmented sleep, and sometimes these conditions are misjudged to be another sleep disorder (although many people with apnea have a comorbid condition of insomnia). There are also differences in polysomnographic findings - women may have lower levels of airway obstruction but despite the lowered severity of their apnea, they report a greater impact on their daily functioning and quality of life compared to men. All this may make it harder for you or your primary healthcare provider to recognize sleep apnea in women.

Treatment options

The gold standard treatment for apnea in most moderate to severe cases is using a CPAP machine. It stands for continuous positive airway pressure and it is a mechanical pump, which delivers a steady stream of air during sleep to support the upper airway and to prevent airway collapse. It is a special mask that fits over the nose or mouth and is held in place by a headgear consisting of straps. The mask is connected to a tube through which air is delivered from the pump machine. It’s extremely effective at eliminating breathing pauses so the natural pattern of sleep is restored, without interruption, and daytime symptoms are markedly reduced but it needs to be used long-term. BiPAP or APAP machines may also be recommended.

Advocate for yourself and your loved ones

There is always an underlying reason for sleep disordered breathing. For too long, snoring has been seen as cute at best and annoying at worst and for a variety of reasons, sleep apnea continues to go undetected, especially in the female population. Once treated however, there are so many gains in sleep, cognition, mental and physical health.

Talia Shapero