When most people think of obstructive sleep apnea, they usually associate the disorder with a certain type of patient and a certain set of symptoms: men, especially older men, who snore loudly and wake up gasping for air. In the last few years, however, researchers have begun to raise the alarm that sleep apnea — which is characterized by brief cessations in breathing throughout the night — is pretty common in women, too. But women often experience it differently, so they’re much more likely to go undiagnosed.
When women are diagnosed with sleep apnea, it’s often the result of a “last resort” test to try to explain symptoms. “They’ve often already been treated for depression and anxiety, and they’ve already been treated for insomnia,” explains Dr. Helen Driver, assistant professor at the department of medicine at Queens University and the manager of a sleep disorders lab at Kingston General Hospital.
Women often have an airway that is less prone to fully collapsing than men — instead, a woman’s airway is more likely to partially collapse, a condition called a hypopnea. In other cases, the airway narrows during sleep, known as upper airway resistance syndrome. When hypopneas and airway narrowing are severe enough – measured via lab tests – women are categorized as having obstructive sleep apnea.
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Because women are less likely to have complete apnea events in their sleep, they are less likely than men to wake up gasping for air. That gasping is a tell-tale sign, usually observed by a partner. “Men often have what we call witnessed apneas, where the partner will tell them, ‘I see you holding your breath,’” says Driver. Apneas in women, on the other hand, can easily go unnoticed by partners.
But a narrower airway still means women are getting less oxygen, and their bodies have to work harder to breathe – both of which lead to less refreshing sleep. “Women may say that they sweat at night — and that can be due to menopause, but it can also be related to sleep apnea and the increased work of breathing,” adds Driver.
Men with apnea often complain of excessive daytime sleepiness. Women often complain of headaches, pain (which can be caused by fatigue) and insomnia. That’s because women are usually lighter sleepers, making them more likely to wake up due to impaired breathing.
What’s common to both men and women who suffer apnea is “the feeling of having had an unrefreshing sleep,” says Driver. And both men and women with apnea tend to snore, though women’s snoring is often lighter than men’s. Another tell-tale sign for both genders is waking up with a dry mouth.
Current statistics put moderate-to-severe apnea at 3% for women aged 30–49 and 9% for women 50 and above. (That’s compared to rates of 10% and 17% for men in the same age groups.) But according to the Public Health Agency of Canada, the actual rates of sleep apnea could be much higher. About a quarter of Canadians have risk factors for sleep apnea, and most people don’t realize their breathing is stopping and starting or becoming more shallow in their sleep. That has serious implications: untreated apnea can lead to high blood pressure, increasing the risk of a heart attack or stroke.
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Part of the problem is that insomnia and sweating are also common to menopause, so apnea symptoms are often chalked up to that. But the hormone changes that result from menopause increase the risk of apnea, says Driver. “We know that progesterone is a respiratory stimulant so it works to protect us.”
Women who carry weight around their waists (compared to their hips) are also more likely to suffer from sleep apnea, as it can contribute to the airway narrowing when lying down. Women with polycystic ovary syndrome (PCOS) have also been shown to have higher levels of apnea.
The good news is that advances in technology have made it easier to diagnose the subtler apneas that are more common among women. Rather than measuring airflow by the temperature difference of air exhaled and inhaled during sleep, the current tests record the pressure of the air — a more sensitive measurement.
And treatment for sleep apnea is relatively straightforward, if clunky on the pillow. The most common form is the continuous positive airway pressure device, a mask that increases air pressure to help keep the airway open. In some cases, treating an underlying issue can be enough to make sleep apnea go away.
Women who suspect they may have sleep apnea can ask their family doctors for a referral to a sleep clinic. Be prepared to push back if a doctor quickly dismisses the possibility. “Doctors are becoming more aware that we are diagnosing more sleep apnea in women,” says Driver.
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