2012 © ResMed11 Global leaders in sleep and respiratory medicine

Men vs. Women in Sleep-Disordered Breathing:Are There Any Differences Besides the Pajamas?

Karyl Scott, RRT

Corporate Manager Clinical Education & Training

ResMed

2 2012 © ResMed

Sleep Apnea Risk Factors

Endocrine & Metabolic Disorders

Obesity

Post-menopausal female

Anatomic Abnormalities of the Upper Airway

Family History of Sleep Problems

Male Gender

Alcohol or Sedative Use

Hypertension

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OSA Indicators/Symptoms

Excessive daytime sleepiness

Loud or frequent snoring

Irregular breathing during sleep

Morning headaches

Heart failureDifficulty concentrating or memory loss

Hypertension Obesity (BMI > 30)

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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?• 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

6 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?• 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

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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 testosterone- easier 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

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

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Specific Medical Conditions Linked to Women

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Specific Medical Conditions In Women

SDB

PCOS

Pregnancy & Pre-

eclampsia

Hormones (Menstrual

Cycle)

Menopause

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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)

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

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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)

2012 © ResMed1616 Global leaders in sleep and respiratory medicine

Women with SDB:Why Should We Pay Special Attention to Them?

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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, 20092 Pickett et al. J Appl Physiol 19893 Hue et al. Am J Epidemiol 1999 4 Smith et al. Chest 20025 Yaffe et al. J Am Med Assoc 2011