Why Women Can’t Afford to Overlook Sleep Apnea

On November 29, 2017, after more than three years of collaborative work, the Society for Women’s Health Research (SWHR) Interdisciplinary Network on Sleep released its Women & Sleep Apnea Toolkit to provide women and their health-care providers with gender-specific information about obstructive sleep apnea and sleep-disordered breathing. This resource is particularly special, because it represents the combined efforts of 12 researchers and clinicians across sleep-related fields, including epidemiology, obstetrics/gynecology, neurology, pain, physiology, psychiatry, pulmonology, and sleep medicine — and it involves real women with sleep apnea, recruited through the patient-led online community myapnea.org.

Approximately 17 percent of women have obstructive sleep apnea syndrome, and it is estimated that up to 90 percent of women with this serious sleep disorder go undiagnosed. The Toolkit has a patient page that asks women to consider whether they are experiencing symptoms or displaying signs of obstructive sleep apnea (OSA). For instance, daytime clues may include mood symptoms, such as feeling depressed, anxious, irritable, or impatient, or always feeling tired or drained. Women with OSA may notice that they struggle to stay awake and may actually fall asleep at the wrong time or place, like at work or in public places. Cognitive difficulties, such as forgetfulness, foggy or fuzzy thinking, and trouble with word-finding, focus, and concentration, are also common experiences of women with obstructive sleep apnea.

As for nighttime signs of sleep apnea, the Toolkit notes that snoring is not the only symptom in women with OSA. Difficulty falling asleep, frequent awakenings, and restless sleep may indicate sleep-disordered breathing. Other less stereotypical signs include changes in dreaming (i.e., more frequent dreams or a lack of dreaming), multiple bathroom visits at night, and nighttime heartburn.

The Toolkit asks health-care providers to consider a diagnosis of OSA in their women patients, and to note that female patients may not describe their symptoms the same way that men do. Women with other common disorders — including high blood pressure, diabetes, stroke, insomnia, atrial fibrillation, anxiety, depression, heart failure, polycystic ovary disease, and even mild cognitive impairment — deserve a sleep apnea evaluation, because treating co-occurring OSA can improve conditions like cardiovascular diseaseand diabetes.

Notably, pregnant women are not immune to sleep apnea. Indeed, pregnancy is a critical time to recognize OSA, because sleep apnea during pregnancy can affect expectant mothers AND their infants. Pregnant women with OSA have higher rates of gestational diabetes and hypertension, pre-eclampsia, and maternal death. When sleep-disordered breathing goes unaddressed in pregnancy, adverse fetal health outcomes can also occur, as shown in a study by SWHR network member, Judette Louis, MD, MPH.

Once the possibility of sleep apnea is raised by a woman or her health-care provider, evaluation for OSA occurs via a sleep study. Home sleep testing can diagnose many women; however, since home testing can give false negative readings in 10 to 20 percent of patients, a negative home test should be followed up with a laboratory sleep study if the suspicion for sleep apnea is high. Indeed, the Toolkit notes that women may be more likely to have a false negative home sleep study, because insomnia and sleep apnea overlap frequently in women.

The overall aim of the Women & Sleep Apnea Toolkit is to facilitate conversations about OSA between women and their health-care providers.  “Healthy sleep is essential for physical, emotional, and cognitive health just as a healthy diet and physical activity are. Yet, the barriers to healthy sleep faced by women are often overlooked, dismissed, or accepted as an unavoidable part of life,” said Susan Redline, MD, MPH, SWHR Network on Sleep Chair, and Professor of Sleep Medicine, Harvard Medical School. “These are not unsolvable problems, and this guide will help women and their health-care providers improve diagnosis, treatment, and management of sleep disorders.”