Men vs. Women in Sleep-Disordered Breathing:
Are There Any Differences Besides the Pajamas?
Karyl Scott, RRT
Corporate Manager Clinical Education & Training
ResMed
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2012 © ResMed
Global leaders in sleep and respiratory medicine
Sleep Apnea Risk Factors
Male Gender
Obesity
Family History of
Sleep Problems
Post-menopausal female
Hypertension
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Alcohol or Sedative Use
Anatomic Abnormalities
of the Upper Airway
Endocrine & Metabolic
Disorders
OSA Indicators/Symptoms
3
Excessive
daytime
sleepiness
Loud or
frequent
snoring
Irregular
breathing
during sleep
Morning
headaches
Heart failure
Difficulty
concentrating or
memory loss
Hypertension
Obesity
(BMI > 30)
2012 © ResMed
Main Topics
• Recognize the differences in sleep-disordered
breathing (SDB/OSA) between men and women
• Differentiate the symptoms of OSA between
genders
• Define different diseases and disease processes
that may be at work with the female gender
• Describe how the treatment might be different for
females
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Prevalence of SDB
Obstructive Sleep Apnea (OSA)
•
•
•
•
4% of men, 2% of women (AHI >15)
Most commonly diagnosed in 40-65 year olds
75–85% are undiagnosed
Male to female ratio – 3:1 and 5:1
So . . . Why the difference in prevalence?
•
•
•
•
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Symptoms are different
Women more easily misdiagnosed
Other disease states may affect OSA (vice versa)
Young et al. found that when women did present with “typical” OSA
symptoms, they were less likely to be referred to sleep clinics
2012 © ResMed
Prevalence of SDB
Obstructive Sleep Apnea (OSA)
•
•
•
•
4% of men, 2% of women (AHI >15)
Most commonly diagnosed in 40-65 year olds
75–85% are undiagnosed
Male to female ratio – 3:1 and 5:1
So . . . Why the difference in prevalence?
•
•
•
•
6
Symptoms are different
Women more easily misdiagnosed
Other disease states may affect OSA (vice versa)
Young et al. found that when women did present with “typical” OSA
symptoms, they were less likely to be referred to sleep clinics
2012 © ResMed
Why is Prevalence Lower in Women?
Men’s anatomy different
– more vulnerable to
upper airway collapse
• Longer airways
• Increased pharyngeal
volume
• Softer palate area
Fat deposits
differently in men
• Airway
• Upper body
Respiratory control
• Testosterone affects
chemoreceptors
• More testosteroneeasier to hit apneic
threshold
• Affects OSA, CSA and
CompSA prevalence
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Male vs. Female: What are the differences?
Men
Women
‘Typical’ OSA Symptoms: snoring, witnessed
apneas, EDS
Symptoms: Insomnia, fatigue, daytime
tiredness, headaches, muscle pain
Epworth Sleepiness Scale > 10
ESS – typically lower scores (have higher
threshold for sleepiness)
Severe OSA
Less severe, more mild and UARS
Obstructive apneas
Large amounts of flow limitation/UARS
More body position related (supine)
Sleep stage related (mostly REM)
CVD, Type 2 Diabetes, Stroke
CVD, Type 2 Diabetes, stroke, dementia
Higher AHI’s than women
Lower AHI’s than men (more episodes of
UARS)
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Challenges in Improving the Diagnosis Rate
Women have
fewer
obstructive
apneas and
obstructive
hypopneas per
hour
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PSG shows:
• More apneas in
REM
• Lower AHI total
• May not meet
insurance criteria
for treatment of
OSA
Describe
sleepiness as
‘general
overall fatigue’
Symptoms
typically are
described as:
• Insomnia
• Depression
• Hx of
hypothyroidism
• Morning
headache
Physician will
go down other
pathways first
before OSA
pathway
Specific Medical Conditions Linked to Women
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Global leaders in sleep and respiratory medicine
Specific Medical Conditions In Women
Pregnancy
& Preeclampsia
Hormones
(Menstrual
Cycle)
SDB
PCOS
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Menopause
Hormones – Protective?
• Differing hormone levels a probably ‘culprit’ in explaining OSA
between genders
• Menstrual Cycle:
– Sleep quality will change (may decrease pre-menstrual)
– Hormone levels will change
• Onset of menopause ‘turning point’ in prevalence in OSA
– Heavily studied
• High levels of progesterone or low levels of testosterone may be
protective against OSA
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Pregnancy and Sleep
• Contributor to OSA prevalence in women
• Substantial weight gain
• Elevation of the diaphragm (↓FRC)
• Mallampati score increases by 34% at 38
wks gestation
– n= 242
– Secondary to fluid retention and edema
– Upper airway narrow
• Neck circumference enlarges
• Nasal patency reduced
• All of these factors suggest pregnancy may
precipitate or exacerbate OSA
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Snoring and Preeclampsia
Habitual
snoring:
Best predictor
of preeclampsia
(Kryger)
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Prevalence of
snoring in
women
• Non-pregnant
women 4%
• Pregnant women
14-23%
Snoring affects
infant outcomes
• When mom
snores…
• Infant smaller
• Apgar is less
than 7 at the 1
minute score
Menopause
• Sleep complaints increase as age increases
–
–
–
–
Insomnia
Hot flashes
Mood disorders
SDB
• Prevalence of SDB
– 3:1 ratio pre-menopause
– 1:1 ratio post-menopause
• OSA appears in post-menopause
– Weight gain
– Age
– Reduction in estrogen (estrogen/progesterone seems to be a
‘protective’ mechanism)
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Women with SDB:
Why Should We Pay Special Attention to Them?
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2012 © ResMed
Global leaders in sleep and respiratory medicine
Women with Sleep Apnea:
Why Should we Pay Special Attention to Them?
• Almost 40% of newly diagnosed sleep apnea patients
are women1
• Risk of sleep apnea in women after menopause is equal
to that of men2
• Related to higher risk of depression, high blood
pressure and dementia3-5
• Baby boomers turning 65 around 2010
– Prevalence of sleep apnea in women peaks at 65 yrs
– Men at 55 yrs
• Surveys reveal that women have different therapy
needs than men (TAS Polls)
1 Medicare and Private Payor Sleep Apnea Claims Data, 2009
2 Pickett et al. J Appl Physiol 1989
3 Hue et al. Am J Epidemiol 1999
4 Smith et al. Chest 2002
5 Yaffe et al. J Am Med Assoc 2011
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