Symptoms Of Sleep Apnea In Women
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Obstructive sleep apnea (OSA) in women is a disease that is easily overlooked, especially in women, where it is often misdiagnosed or missed. Due to differences in physiological structure, hormone levels, and social cognition, the symptoms and disease progression of female patients are significantly different from those of males. Traditional diagnosis and treatment standards are mostly based on male data, resulting in some female patients not receiving timely intervention.
Typical symptoms of OSA in women may be mistaken for sub-health conditions, such as daytime sleepiness often attributed to work pressure, and frequent awakenings at night are simply labeled “insomnia.” Some female patients do not even have obvious snoring, but have atypical manifestations such as dry mouth in the morning, mood swings, and decreased concentration. When hormone levels fluctuate dramatically during special stages such as pregnancy and menopause, the risk of OSA may suddenly increase, which requires special attention.
OSA is a common and potentially dangerous disease, and is an independent risk factor for many diseases such as hypertension, coronary heart disease, and diabetes. The prevalence in the population is 1% to 6%. Previous studies have mostly focused on male patients, and there are relatively few studies on female patients. Studies have shown that there are certain differences in the pathogenesis, clinical manifestations, and biological characteristics of male and female OSAHS patients.
In 1973, Guilleminault first proposed the concept of sleep apnea syndrome (SAS) and conducted a lot of research. Based on clinical and sleep laboratory data, it was found that the male:female ratio of OSAHS was 8~10:1, so it was concluded that the male prevalence was much higher than that of females. It was believed that OSAHS mainly occurred in men, and the research on its etiology, pathogenesis, and pathophysiology was focused on male patients, with only a few female patients included in the research. Epidemiological surveys in recent years have shown that the prevalence of OSAHS in adult males in the general population is 3%~7%, and that in females is 2%~5%. The prevalence is even higher in obese or overweight and elderly people.
Symptoms Of Sleep Apnea In Women
Typical symptoms of sleep apnea in women include nocturnal snoring, interrupted breathing, daytime sleepiness, morning headaches, and mood disorders. The above symptoms are common and need to be vigilant, especially when accompanied by other health problems. It is recommended to seek medical attention as soon as possible. Symptoms in women may be more subtle than those in men, such as fatigue and emotional problems as the main complaints rather than typical snoring. If sleep apnea is suspected, it can be confirmed by polysomnography (PSG). Early intervention (such as adjusting sleeping posture, losing weight, using a ventilator, etc.) can significantly reduce the risk of cardiovascular and cerebrovascular diseases.
Snoring with breathing interruption at night
Female patients may have loud and irregular snoring during sleep, accompanied by short breathing pauses (more than 10 seconds), followed by waking up due to lack of oxygen and resuming breathing. This repeated “snoring-pause-waking up due to suffocation” cycle is a typical feature of sleep apnea and is often first noticed by the sleep partner.
Excessive daytime sleepiness or fatigue
Due to frequent interruptions of sleep at night, patients may experience irresistible daytime sleepiness, such as falling asleep suddenly during meetings or while driving. Some women may experience persistent fatigue rather than obvious sleepiness, which can be easily mistaken for sub-health or anemia.
Morning headache or dry mouth
Repeated hypoxia at night may cause headaches in the morning, which cannot be completely relieved by drinking water. At the same time, due to mouth breathing during sleep, the mouth or throat may become dry and painful, or even hoarse.
Abnormal emotions and cognitive functions
Long-term poor sleep quality may cause mood swings, anxiety or depression. Some women may also experience decreased attention and memory, which affects work or study efficiency and is often misdiagnosed as a psychological problem.
Increased nocturia or insomnia
Some patients have increased urination frequency (≥2 times/night) due to frequent awakenings at night. In addition, hypoxia caused by apnea may directly interfere with sleep rhythm, leading to difficulty falling asleep or early awakening.
Symptoms Of High-risk Groups
The following groups of women are more likely to have sleep apnea, and regular screening is recommended:
- Those who are overweight or have a thick neck circumference (fat accumulation in the neck compresses the airway).
- Menopausal women (decreased estrogen levels cause relaxation of pharyngeal muscles).
- Patients with metabolic diseases such as hypothyroidism or diabetes.
- People who smoke, drink, or take sedatives for a long time.
The Dangers Of OSA In Women
Although the prevalence of obstructive sleep apnea (OSA) in women is lower than that in men, its harm to women’s health cannot be ignored. The following are the main harms that OSA may bring to women:
1. Damage to cardiovascular health: OSA patients experience apnea during sleep, which leads to a decrease in blood oxygen saturation. If this continues for a long time, it will increase the risk of cardiovascular diseases such as high blood pressure and heart disease.
2. Increased metabolic problems: OSA is closely related to metabolic diseases such as obesity and diabetes. Women with OSA are more likely to experience weight gain, insulin resistance, and other problems, which in turn increases the risk of diabetes.
3. Impaired mental health: OSA patients may experience daytime sleepiness, poor concentration, memory loss, and other problems, which not only affect work efficiency but may also cause mental health problems such as anxiety and depression.
4. Increased risks during pregnancy: For pregnant women, OSA may have adverse effects on the development of the fetus and increase the risk of premature birth, low birth weight, and other problems.
5. Reduced immune system function: Women who have long-term OSA may experience a weakened immune system, making the body more susceptible to viral and bacterial infections.
Risk Factors For OSA In Women
The etiology of OSA is complex and has not yet been fully understood. Abnormal upper airway anatomical structure and functional disorders, inflammation, obesity, age, gender, smoking, and drinking are all risk factors for OSA. Since female OSA patients are different from male patients in terms of pathology and physiology, their risk factors for the disease may be different from those of male OSA patients.
Upper airway structural abnormalities and OSA in women
With the increase of age, the anatomical structure and physiological function of the upper airway also change. Studies have found that with the increase of apnea hypopnea index (AHI), the narrowing of the upper airway structure in middle-aged and elderly women is more obvious.
The downward displacement of the hyoid bone is one aspect that affects the severity of OSA in women. With the increase of age and the severity of the disease, the upper airway narrows, and the airway compliance increases.
The increase in the prevalence of OSA in middle-aged and elderly women is the result of the combined action of multiple factors. The occurrence of OSA in women is based on the narrowing of the anatomical structure of the upper airway. Due to the reduction or absence of estrogen, the muscle tone decreases, the structural abnormality is decompensated, and the fat deposition in the upper airway increases relatively, making the pharyngeal cavity more prone to narrowing and collapse, thus causing the occurrence of OSA.
Obesity and OSA in women
Obesity is the strongest high-risk factor for OSA. In the general population, the proportion of obese women is greater than that of men, and the number of morbidly obese women is twice that of men. Body mass index (BMI) is an indicator of the patient’s obesity level.
Young et al. found in the Wisconsin Sleep Cohort Study that an increase of one standard deviation in BMI increased the incidence of OSA by 4 times, and that female OSA patients were more obese than male patients; in terms of age distribution, young women were more serious, so obesity was the main feature of young female OSA patients.
There may be no significant difference in BMI between male and female OSA patients, but the neck circumference and waist-to-hip ratio of male patients were significantly greater than those of female patients, indicating that the fat distribution types of male and female patients were different, with females having a pear-shaped body and males having central obesity. The centripetal distribution of body fat is closely related to the occurrence of sleep apnea.
Obesity may contribute to OSA through the following mechanisms:
(1) Neck fat tissue accumulation and upper airway morphology changes. The neck fat content of obese OSA patients was significantly higher than that of normal controls. Although there was no significant difference in neck soft tissue and total fat volume between non-obese OSA patients and the control group, there was obvious fat deposition in the anterior and lateral neck. It can be seen that OSA patients have more fat in their necks than normal people with the same obesity level.
(2) Changes in upper airway compliance. When upper airway compliance increases, it is more likely to collapse under a certain transmural pressure, leading to airway obstruction. The collapse of the upper airway in OSA patients is strongly correlated with their neck circumference and body mass index, and the upper airway compliance of obese OSA patients is greater than that of normal-weight patients.
(3) Abdominal fat accumulation. OSA patients not only have abnormal distribution of fat in the neck, but also often have accumulation of visceral fat. Visceral fat accumulation affects the movement of the diaphragm, hinders the expansion and contraction of the upper airway and lungs, and causes sleep apnea.
Obesity plays an important role in the onset of OSA, but the causal relationship between the two has not yet been answered. OSA patients repeatedly experience decreased blood oxygen saturation at night, which weakens catabolism.
At the same time, due to daytime sleepiness and reduced activity, patients gain weight. The weight of female OSA patients tends to increase with age, and there is a positive correlation between weight and AHI. Therefore, BMI can be used as an indicator for disease screening and condition assessment.
Age and OSA in women
As age increases, sleep-related problems in men and women become more obvious. Epidemiological surveys show that about 50% of people over 65 years old have sleep disorders. Among women, the prevalence of OSA (AHI>15) in the three age groups of 20-44 years old, 45-64 years old, and over 65 years old was 0.6%, 2.0%, and 7.0%, respectively, showing a linear upward trend.
With the increase of age and weight, the risk of OSA in women increases significantly. The high-risk proportions of BMI<25, 25-30, and >30 kg/m^2 were 8.5%, 21%, and 62%, respectively.
The average age of male OSA patients is younger than that of female patients. Most male patients have moderate to severe symptoms, while most female patients have mild to moderate symptoms. This suggests that male patients develop the disease earlier than female patients, and their condition is more serious than female patients.
The high-risk group for female OSA is mainly postmenopausal women. The prevalence of women who have not received female hormone replacement therapy during menopause is 2.7%, while that of women who have received hormone replacement therapy and women of childbearing age is 0.5% and 0.6%, respectively.
Studies have shown that the incidence of sleep apnea in women who use hormone replacement therapy before and after menopause is low, about 0.5% to 0.6%; while the incidence of sleep apnea in women who do not use hormone replacement therapy after menopause increases significantly (2.7%), approaching the incidence in men (3.9%). This suggests that female hormones may play an important protective role in the occurrence of OSA.
Respiratory center regulation function and OSA in women
Studies have found that female OSA patients mainly suffer from hypoventilation, and the proportion of abnormal lowest blood oxygen saturation (LSaO2) at night is higher than that of AHI. In middle-aged and elderly female OSA patients, there is a certain separation between AHI and LSaO2, suggesting that female OSA patients may have brain damage. Therefore, respiratory center dysfunction may also be a cause of OSA in women.
In middle-aged and elderly women in menopause or perimenopause, due to the lack of the protective effect of estrogen, the inherent high stability of the upper airway is destroyed, and the upper airway compliance increases, resulting in an increased prevalence of OSA in middle-aged and elderly women.
Metabolic syndrome and OSA in women
The high risk of OSA in women is also related to comorbid chronic diseases such as hypertension, diabetes, depression, gastroesophageal reflux, anxiety, hypothyroidism, etc., among which hypertension is the most important comorbidity.
Metabolic syndrome (MS), characterized by obesity, hyperlipidemia, hyperglycemia, and hypertension, is a high-risk factor for cardiovascular and cerebrovascular events. 30.1% of female OSA patients have hypertension, and 34.4% of female OSA patients have hypertension. Hypertension and OSA have a causal relationship. The two diseases coexist and need to be treated at the same time to effectively reduce the related risks.
Pregnancy and OSA in Women
During pregnancy, weight gain, diaphragm lifting, and neck circumference increase can cause or aggravate OSA. Studies have found that pregnancy does not increase the incidence of OSA in women, but if pregnant women suffer from OSA, it may lead to serious consequences, such as preeclampsia, premature uterine contractions, premature birth, gestational diabetes, etc. The prevalence of restless legs syndrome in pregnant women also increases significantly.
Smoking, drinking and OSA in women
Smoking and drinking are risk factors for OSA. Smoking can lead to chronic inflammation and mucosal edema of the pharynx, increased upper airway resistance, and increased risk of snoring. Alcohol can inhibit the awakening response, increase the awakening response threshold, prolong the apnea time, and reduce the responsiveness of the upper airway dilator muscles to hypoxia and hypercapnia, making the upper airway prone to collapse. The proportion of men smoking and drinking is significantly higher than that of women. This may be part of the reason why male OSA patients have more severe conditions than female patients.
Treatment Of OSA In Women
Currently, the commonly used methods for treating OSA include weight control, postural therapy, abstinence from smoking and drinking, oral appliances, surgery, and continuous positive airway pressure (CPAP). The most commonly used methods for treating OSA in women are weight loss and postural therapy.
Female OSA patients who have successfully lost weight have significantly improved daytime sleepiness. For patients who receive postural therapy, the symptoms of daytime sleepiness have not been significantly improved, so it cannot be used as the first choice of treatment. CPAP is the most effective treatment for female OSA, and sleepiness has significantly improved.
Fewer patients receive surgery and oral appliances. This may be related to the patient’s fear of surgery, high surgical risks, postoperative pain and discomfort, uncertain long-term efficacy, and poor tolerance of women to oral appliances. About 50% of female OSA patients do not receive any treatment.
Hormone therapy is currently controversial. Although studies have shown that hormone replacement therapy in postmenopausal women can reduce the incidence of OSA and improve the symptoms of female OSA patients, hormone replacement therapy significantly increases the risk of cardiovascular disease, stroke, and tumors, and is not currently recommended for the treatment of OSA.
At present, about 50% of female OSA patients do not receive proper diagnosis and treatment, and patients with a clear diagnosis receive inadequate and irregular treatment, which leads to further aggravation of the disease. OSA has a wide-ranging impact on the quality of life of patients. The ultimate goal of OSA treatment is to reduce disease-related mortality and improve quality of life.
Therefore, it is necessary to evaluate the efficacy and prognosis after treatment. Reasonable treatment measures should be given to female patients with nighttime snoring, daytime sleepiness, drowsiness, morning headaches, etc., to improve nighttime sleep quality and daytime sleepiness and improve the quality of life of patients.
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