Increasing Recognition of Undiagnosed Sleep Apnea in Women

Women in midlife often experience various disruptions, including changes in sleep patterns and energy levels due to hormonal shifts. For many, however, an undetected issue arises: obstructive sleep apnea (OSA), characterized by repeated airway collapse during sleep. Traditionally associated with older, overweight men, OSA is now understood as a more complex condition that frequently evades diagnosis among women undergoing perimenopause and menopause.

OSA occurs when the upper airway narrows or collapses intermittently during sleep, leading to reduced oxygen levels and causing the brain to awaken the body to resume breathing. Research now recognizes OSA as a heterogeneous condition influenced by different biological factors, rather than a singular disorder. Still, the existing narrative often overlooks women's experiences, affecting diagnosis rates.

A projection published in The Lancet Respiratory Medicine indicates that by 2050, approximately 77 million adults in the U.S. aged 30 to 69 will have OSA. This includes a forecasted 65 percent relative increase in prevalence among women, reaching around 30.4 million, compared to a 19 percent increase among men. This rise may not only reflect an aging population and rising obesity rates but also improved detection methods.

Carlos Nunez, chief medical officer at ResMed, noted that sleep apnea affects over a billion people globally, yet up to 90 percent remain undiagnosed in some regions. "It is a condition that often lives in anonymity. Most people don't realize they have it, because you're asleep when it happens," he said.

While OSA can develop at any age, including in children, the risk increases with age due to decreased muscle tone. For women, menopause marks a significant increase in risk, with studies indicating that postmenopausal women are about 57 percent more likely to report symptoms of OSA than their premenopausal counterparts, even when accounting for body weight.

Marie-Pierre St-Onge, director of the Center of Excellence for Sleep & Circadian Research at Columbia University, highlighted that estrogen provides hormonal protection until menopause. Post-menopause, shifts in fat distribution can exert more pressure on the airway.

Hormones like estrogen and progesterone contribute to regulating breathing and maintaining upper airway muscle tone. As these hormones decline after menopause, the risks linked to airway collapse during sleep increase. According to Rashmi Nisha Aurora, director of Women’s Sleep Medicine Initiatives at NYU Grossman School of Medicine, estrogen plays a critical role as an antioxidant. Its reduction after menopause amplifies the stress on the body, leading to increased strain on the heart and metabolic system.

Pregnancy also introduces another period of hormonal changes that may heighten vulnerability to OSA. However, menopause presents a unique challenge; many symptoms—such as night sweats, fatigue, and disturbed sleep—overlap with those of menopause, leading to misdiagnosis.

Aurora pointed out that existing screening tools predominantly validate symptoms in male populations, which can lead to underrecognition of OSA in women. The symptoms that typically trigger referrals for continuous positive airway pressure (CPAP) therapy, like excessive daytime sleepiness, may manifest differently in women.