And the risks of ignoring it.
By Clare McGorry, DDS, DABDSM
Women face ongoing inequities—particularly in healthcare and clinical research. One such disparity is the diagnosis and treatment of sleep apnea, a condition long considered a men’s health issue, though the reality is far more complex. While men are more likely to be diagnosed, studies estimate that as many as 90% of women with sleep apnea remain undiagnosed.1 This gap is due to a combination of biological differences, underrepresentation in clinical trials, and gender bias in medical screening questionnaires—issues that must be resolved to provide equitable treatment.
Why Some Women Go Undiagnosed
Perhaps the biggest obstacle to diagnosis in women is the way obstructive sleep apnea (OSA) presents itself. While men typically exhibit textbook symptoms like loud snoring and noticeable pauses in breathing, women experience more subtle and atypical symptoms including headaches in the morning, anxiety and depression, chronic fatigue, and insomnia or restless sleep.
Consequently, women are frequently misdiagnosed with anxiety, depression, or migraines and receive symptom-based treatments rather than treating the underlying sleep disorder. Additionally, hormonal fluctuations throughout a woman’s life, including pregnancy, menopause, and the menstrual cycle, influence airway stability and sleep quality.
Estrogen and progesterone keep the upper airway muscles stable. This is a reason OSA is less common in premenopausal women. As these hormones decrease during menopause, the risk of OSA increases. Pregnant women are more likely to develop sleep apnea due to hormonal changes that cause increased fluid retention as well as weight gain, which can contribute to airway obstruction during sleep. Because numerous women attribute menopausal symptoms for their sleep disturbances and fatigue, rather than a potential developing sleep disorder, diagnosis and treatment are delayed.
Screening Disparities
Men and women are not screened equally for sleep apnea in clinical settings. Traditional screening tools, like the Epworth Sleepiness Scale (ESS), rely heavily on classic symptoms like excessive daytime sleepiness—symptoms that women report less often. The ESS has been shown to be less sensitive to mild-to-moderate OSA in women and thus is a less useful tool to inform referrals for sleep studies.2
Additionally, in a busy primary care practice, sleep health is generally assigned a lower priority during a visit unless a patient complains specifically of symptoms like fatigue or snoring. Since women are less likely than men to report snoring or witnessed apneas—two of the primary symptoms that would typically warrant additional evaluation—OSA cases in women tend to go undiagnosed.
Consequences of Missed OSA Diagnoses
If left untreated, OSA significantly increases the likelihood of cardiovascular disease, stroke, diabetes, and cognitive dysfunction. Women who are misdiagnosed or not diagnosed at all needlessly suffer from a treatable condition. They also face increased healthcare costs and a diminished quality of life.
Also, underdiagnosis perpetuates healthcare disparities. As long as women’s experiences of OSA are underrepresented in clinical research and diagnostic standards, they will continue to be underrepresented in treatment policies and decision-making. Bridging this divide is critical to improving outcomes and ensuring all patients receive the care they need.
Moving Towards Equity in Sleep Apnea Care
To close the gender divide in sleep apnea diagnosis and treatment, active steps must be taken by healthcare professionals. These include:
- Expanding screening criteria to account for gender differences in symptoms manifestation.
- Educating general practitioners and dentists about the differential presentation of OSA in women.
- Increasing awareness about sleep health in women, particularly during hormonal transition periods.
- Developing screening tools to target specifically premenopausal, postmenopausal, or pregnant women, as they have different risk factors and prevalence rates.
- Enabling more research on gender-specific differences in sleep apnea to help develop diagnostic protocols and treatment strategies.
By acknowledging and addressing gender biases in sleep medicine, we can ensure women receive the timely, accurate diagnoses and effective treatment they deserve. Acknowledging that sleep apnea is not just a men’s health issue—it is a prevalent, yet underdiagnosed, condition that compromises the health and well-being of millions of women worldwide—is a good place to start.
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References
1. Kapsimalis F, Kryger M. Sleep breathing disorders in the U.S. female population. J Womens Health (Larchmt). 2009 Aug;18(8):1211-9.
2. Lipford MC, Wahner-Roedler DL, Welsh GA, et al. Correlation of the Epworth Sleepiness Scale and sleep-disordered breathing in men and women. J Clin Sleep Med. 2019 Jan 15;15(1):33-8.
