Tired and dragging? Sleep apnea in women
What is sleep apnea?
So many women in my practice are concerned with energy; either feeling like they’re dragging during the day, getting poor sleep or needing a long nap after lunchtime. Inevitably, this leads us to consider sleep apnea. Not to say this is always the case, but it is under consideration and I believe knowing it’s a possibility is an important part of being well informed when you’re advocating for yourself within the healthcare system.
Obstructive sleep apnea (OSA) happens when there is reduced or no airflow during sleep due to partial or complete collapse of the upper airway. As you can imagine, these events are stressful to the brain and body and result in poor sleep quality and daytime sleepiness.
In addition, and significantly, sleep apnea also has an effect on cardiovascular health, mood and safe driving.
Traditionally, sleep apnea has been characterized as a male disease. However, this had led to it being underdiagnosed and under treated in women and we’re now understanding that women present in an atypical way and also the risk factors may be more pronounced in women.
For example, at the same age, compared to men with sleep apnea, the arteries in women seem to be more poorly affected.
Sleep apnea in women
First, let’s review the typical presentation that would make us suspicious of sleep apnea. This gives context for how it may look differently in women. Primarily, sleep apnea was considered a possible diagnosis in men who snored, were overweight or obese, and felt fatigued during the day.
In contrast, women tend to exhibit more nonspecific symptoms like insomnia, depressive symptoms, fatigue, morning headache, and nightmares.
It’s not entirely clear why there are differences in OSA between men and women, but sex differences in aging, hormones, upper airway anatomy, fat distribution, and respiratory stability may play a role.
Also worth noting is that objectively women’s scores on testing may show less apneic events, but this does not mean they’re less symptomatic. Said another way, while a sleep study may show “mild” apnea, the symptoms are not experienced as mild nor is the effect on a woman’s quality of life mild.
Screening and diagnosis of sleep apnea
There are various questionnaires that can be used to screen for the possibility of sleep apnea. Some of those include the Epworth Sleepiness Scale or STOP BANG. There is some discussion that we should maybe adjust our cut off values to more gender specific thresholds.
The summarized version is that in women we may pay closer attention to things like body weight and morning headaches.
After we’ve screened and if we have a high suspicion that OSA might be a possibility, then the gold standard to diagnose is a sleep study, more officially known as polysomnography.
How to treat sleep apnea
Often the hardest part about treating sleep apnea, is that people dread the treatment: Continuous positive airway pressure (CPAP). Understandably, sleeping with a device is not ideal. However, I can not underline enough the negative physiological effect sleep apnea has, especially on the heart, that effective treatment has tremendous benefit.
As a naturopathic doctor, I believe it’s important to look at the entire health picture, so other worthy considerations are:
Weight management
Looking at other conditions and medications like alcohol or asthma and addressing those
The Mediterranean diet has good evidence as being part of an effective treatment plan
Finally, in the case someone can’t tolerate CPAP or wants an alternate treatment, a mandibular device could be an option as outlined in the guidelines by the American Academy of Sleep Medicine.
Whole person medicine
To wrap up, I want to drive the following home: women are not just smaller men. This hold true for many things, but for our discussion, in regards to sleep apnea:
Women present differently than men with more nonspecific symptoms
Women fare worse in terms of quality of life and likely in cardiovascular risk
And aren’t being screened or are diagnosed later which has long term health consequences
There’s a lot tied up in the above! For one, most research has been done on men. Secondly, only so much can be covered in a short medical visit and primary care is overtaxed.
If you’re craving a trusted guide or partner to look at your whole health, including your sleep and energy and whether sleep apnea may be part of the considerations for you, then I invite you to schedule a free discovery call and we can talk through what you’d like to see happen in your health and how our membership works.
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References:
Bouloukaki, I., Tsiligianni, I., & Schiza, S. (2021). Evaluation of Obstructive Sleep Apnea in Female Patients in Primary Care: Time for Improvement? Medical Principles and Practice, 30(6), 508–514. https://doi.org/10.1159/000518932
Faulx, M. D., Larkin, E. K., Hoit, B. D., Aylor, J. E., Wright, A. T., & Redline, S. (2004). Sex Influences Endothelial Function in Sleep-Disordered Breathing. Sleep, 27(6), 1113–1120. https://doi.org/10.1093/sleep/27.6.1113
Georgoulis, M., Yiannakouris, N., Kechribari, I., Lamprou, K., Perraki, E., Vagiakis, E., & Kontogianni, M. D. (2021). The effectiveness of a weight-loss Mediterranean diet/lifestyle intervention in the management of obstructive sleep apnea: Results of the “MIMOSA” randomized clinical trial. Clinical Nutrition, 40(3), 850–859. https://doi.org/10.1016/j.clnu.2020.08.037
Kechribari, I., Kontogianni, M. D., Georgoulis, M., Lamprou, K., Critselis, E., Vagiakis, E., & Yiannakouris, N. (2022). Association of adherence to the Mediterranean diet and physical activity habits with the presence of insomnia in patients with obstructive sleep apnea. Sleep and Breathing, 26(1), 89–97. https://doi.org/10.1007/s11325-021-02351-x
Mou, J., Pflugeisen, B. M., Crick, B. A., Amoroso, P. J., Harmon, K. T., Tarnoczy, S. F., Ho, S. S., & Mebust, K. A. (2019). The discriminative power of STOP-Bang as a screening tool for suspected obstructive sleep apnea in clinically referred patients: considering gender differences. Sleep and Breathing, 23(1), 65–75. https://doi.org/10.1007/s11325-018-1658-y
Pataka, A., Kotoulas, S., Kalamaras, G., Schiza, S., Sapalidis, K., Giannakidis, D., Michalopoulos, N., Koulouris, C., Aidoni, Z., Amaniti, A., Bouloukaki, I., Chatzopoulos, E., Romanidis, K., Oikonomou, P., Steiropoulos, P., Trakada, G., Vagionas, A., Ioannidis, A., Katsios, I. N., … Kosmidis, C. (2020). Gender Differences in Obstructive Sleep Apnea: The Value of Sleep Questionnaires with a Separate Analysis of Cardiovascular Patients. Journal of Clinical Medicine, 9(1), 130. https://doi.org/10.3390/jcm9010130
