Sleep apnea in women: Why the disease is underdiagnosed

Eight years ago, just months after a heartbreaking layoff, I suddenly started snoring.

Instead of a cute little hum, it was a wall of unfeminine, loud noise that started driving my poor husband to the couch every night.

Besides losing my job, this new development makes me feel Even Humiliating, unattractive, helpless. Women shouldn’t snore in a room and chase their spouses out of the room – shouldn’t it be the other way around?

At the same time, I also started struggling to stay awake and generally feeling terrible when I was driving for half an hour or more – although I chalked it up to situational depression.

Still, I never thought about seeing a doctor until a few months later, at a family camp, when a tall, slender woman in her 40s (my age at the time) showed up with a CPAP machine, a device that can wearable device) into our cabin. This woman definitely did it no In line with my view of the human characteristics of sleep apnea.

I always thought apnea—where a sleeping person’s airways often collapse and breathing stops, so they are briefly awakened by a panicked, oxygen-deprived brain (making critical REM sleep nearly impossible)—was just that Being overweight is a problem for older people like my father, who is in his seventies.

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However, as I grilled this woman (a family friend) about her diagnosis, I began to believe that I, too, should be tested.

apnea gender gap

The American Medical Association estimates that approximately 30 million Americans have sleep apnea, but only 6 million have been diagnosed, and women as a group are severely underdiagnosed or misdiagnosed, often with fatigue, insomnia, and/or depression.

“I’ve had [female] Patients tell me how many years after they got diagnosed and treated and felt better, doctors just said to them, “Oh, you don’t get enough sleep.” “You work too hard.” “You eat too much.” You’re too fat,” said Susan Redline, MD, professor of epidemiology and sleep medicine at Harvard University’s Brigham and Women’s Hospital. “Lo and behold, they have something very treatable.”

This diagnostic gap is not only frustrating, but very concerning when you consider the sobering list of health risks associated with untreated sleep apnea: Type 2 diabetes, stroke, heart disease , hypertension, etc.

Although this is still true More men than women suffer from apnea¹— “Men’s upper airways are longer … and tend to collapse more easily,” Dr. Redline explains — and the estimated gender gap has narrowed in recent years from 8:1 to 3:1² (if not less).

Dr. Redline believes the gap is shrinking not because more women are experiencing apnea, but because more women are being accurately diagnosed. “Early reports (of apnea) were based on patients who were referred to subspecialists for sleep studies,” Dr. Redline said. “And, like many conditions, women with sleep apnea are underrecognized. They’re not referred. There’s good data on that. So I think those very early reports said 8:1 or 10 :1 is due to strong suggestion bias.

How apnea presents differently in women

Plus another complicating factor, Apnea often presents differently in men and women¹. Although snoring is the most common symptom of apnea, it is only one of many symptoms (including headaches, anxiety, daytime sleepiness, insomnia, depression); some people with apnea (usually women) snore quietly or not at all. Snoring, that is, not all snorers have apnea, and not everyone with apnea snores.

Also, if someone sleeps alone, she may not even realize she has started snoring; a woman’s risk of developing apnea increases with hormonal changes (pregnancy, perimenopause, menopause) and, more generally, with age. increase.

“On average, women tend to have shorter pauses[while sleeping]than men,” Dr. Redline said. She attributes this to physiological differences, specifically that women have a lower “arousal threshold,” meaning they wake up from sleep more easily. “As a result, women are more likely to experience brief apnea pauses that may not be manifested by a drop in blood oxygen saturation but may be more pronounced by sleep disruption. This may actually cause women to appear insomniac.

Sleep apnea may be missed if a woman with the condition undergoes a sleep study because she may not be as “desaturating” as a man, Dr. Redline said. “Men tend… to have longer periods of paused breathing, so their oxygen levels are more likely to drop more deeply, which is easier to identify in sleep studies.”

Another issue women face with apnea diagnosis involves oximeters (sensors used to measure blood oxygen saturation), which have shown bias related to skin color.

“Black women have the shortest duration of apneas and hypopneas [shallow or restricted breathing] Any group,” Dr. Redline said. “They’re also less likely to desaturate because of skin pigmentation. So I think there’s a real potential for underreporting sleep apnea, which is particularly concerning in black women.

Despite these obstacles, Dr. Redline noted that sleep studies are worthwhile: “The bottom line is, if you do a good representative sleep study in the lab… you’ll probably still get a fair amount of very useful data. .

“It wasn’t the medical community that stopped me from getting a diagnosis in the first place, but[what I call]‘toxic femininity’: my innate sense that apnea is not something women have to deal with or think about.”

Research is slowly changing the way we think about sleep apnea

For years, obesity, or weight gain, was considered the leading cause of sleep apnea, so doctors long directed patients to simply “lose weight.” While some correlations still exist, recent studies in young children and non-obese people complicate the picture, suggesting factors such as air quality and genetics may also play a role.

“Big tongue, sunken chin, big tonsils, [in your body] “There are many personal factors that make your airways more susceptible to collapse when you gain weight,” says neurologist, sleep medicine expert, and best-selling author W. Christopher Winter, M.D. sleep solution.

Dr. Redline recently published a study³ Involves young people with apnea, particularly children living in low-income communities in the greater Boston area. “In children, obesity is not associated with sleep apnea, but poor air quality in the home is,” she said. “Other risk factors include second-hand smoke, air pollution, [and] allergy.

As a result, the potential causes of apnea have expanded greatly, but our understanding of who is most likely to develop apnea has lagged far behind.

“For a long time, that seemed to be a good stereotype,” Dr. Winter said. “You see a 300-pound truck driver and think, ‘I bet that guy has sleep apnea.’ But when a skinny 36-year-old woman snores, people’s first reaction is not That way. Like most stereotypes, it helps initially and then it becomes defining.

Still, the social stigma surrounding the condition persists

In my case, it wasn’t the medical community that initially stopped me from getting a diagnosis, but rather (what I call) “toxic femininity”: my innate sense that apnea is not something women have to deal with, or consider. I run a lot and do yoga, so I consider myself pretty healthy. While I’m not a super girly girl, the thought of my husband leaving our bed while I was snoring every night felt like a weird, physical statement against who I thought I was betrayal.

Even when I finally got a diagnosis and used a BiPAP machine (a device similar to a CPAP machine that helps maintain consistent breathing during sleep), my physical relief was offset by some shame and emotional jet lag.

My primary care doctor referred me to a nutritionist and urged me to lose weight (even though I wasn’t particularly overweight), which also made me feel bad about being “machine dependent” indefinitely at 46 years old.

Both warnings are actually not supported by data. “I don’t think any patient should feel bad about their health, including their weight. Weight does not explain sleep apnea in a significant proportion of people,” Dr. Redline said. “Current data do not include PAP machines, which can lead to adverse clinical outcomes if used correctly, although they may make certain problems such as sinus disease worse. Still, researchers continue to study the issue.

It’s related to how I feel at the doctor’s office, but at home, it’s a completely different, unbearable feeling.

“Wearing a Darth Vader mask is not sexy, and people are hesitant about it,” Dr. Winter said of the PAP machine. “In addition to feeling unattractive, there can be a sense of, Oh my god, I’m wearing this breathing device every night. It feels like I’m getting close to the end.

However, Dr. Winter is quick to add that once someone with apnea gets used to a PAP machine, “it’s like having a pair of reading glasses. I hate glasses, but gosh, they change my life.”

It helps that in recent years, a number of female celebrities (Amy Poehler, Wanda Sykes, Shonda Rhimes, Arianna Huffington, to name a few) have publicly discussed their own apnea diagnoses . (Poehler even played a character wearing a CPAP respirator in the Netflix film wine country.) I hope their message reaches the growing number of women who are struggling and have absolutely no idea why.

But be warned: Suspecting you might have apnea is only half the battle. In a system overwhelmed by growing demand, making the necessary appointments and sleep tests to diagnose can be challenging. I had to be persistent and make regular calls to my insurance company, sleep lab, and doctor’s office to get the BiPAP machine I desperately needed, and it still It took a few weeks longer than I expected.

“Clearly there are not enough sleep specialists and sleep facilities to care for the large number of people with sleep disorders,” Dr. Redline said. “However, technology continues to advance, enabling simpler tools for initial screening and sleep apnea monitoring. At the same time, work is ongoing to address how primary care providers can take a more active role in the management of sleep disorders.

There is hope here. Finally, I’m happy to report that my hard-won BiPAP machine has been quietly and successfully treating my apnea for many years. I get the deep sleep that is essential for good health every night, while my husband dozes next to me.