Синдром обструктивного апноэ сна у женщин: проблема недодиагностики и новые подходы к лечению

Obstructive sleep apnea (OSA) has been classically understood as a male condition, but emerging evidence shows that the disorder is underdiagnosed and misunderstood in women. Screening and diagnostic tools often miss OSA in women because of a sex-specific symptom profile and clinical findings. Underdiagnosis of OSA in women leads to worse health outcomes, such as higher rates of cardiovascular disease, metabolic syndrome, and dementia. Addressing this sex disparity requires increased awareness, better clinical investigation, and sex-specific screening and diagnostic thresholds to improve outcomes for women. What Is OSA? OSA is characterized by recurring partial or complete obstruction of the upper airway from pharyngeal collapse. This collapse reduces or eliminates airflow, resulting in sleep arousals, drops in oxygen saturation, and significant fluctuations in intrathoracic pressure.1 Maintaining a patent airway during sleep requires adequate neuromuscular tone and proper structural anatomy of the upper airway.1 An apneic episode completely disrupts respirations for at least 10 seconds, and a hypopneic event causes at least a 30% reduction in airflow for longer than 10 seconds. Frequent apneic or hypopneic events trigger a cascade of systemic effects, such as oxidative stress, inflammation, increased cardiac workload, and sympathetic nervous system overactivation.1 These effects underlie the link between OSA and metabolic, cognitive, and cardiovascular comorbidities, as well as premature mortality. An estimated 1 billion adults worldwide have OSA, representing nearly 14% of the global adult population.2 The leading cause of OSA is upper airway narrowing from fat deposition around the pharyngeal structures. Increased fat distribution makes the airway more prone to collapse, which is why obesity is the leading risk factor for sleep apnea. Advanced age is another common risk factor because of age-related loss of upper airway neuromuscular tone. Other causes include neuromuscular degenerative disorders and craniofacial malformations. Because of rising obesity rates and increased life expectancy, OSA prevalence is projected to increase and remain a significant global health burden.2 Diagnosing OSA The classic presentation of OSA is an overweight, middle-aged man with daytime hypersomnolence and reported snoring.3 Diagnosis relies heavily on patient-reported symptoms and the use of in-office screening tools, such as the STOP-BANG questionnaire and the Epworth Sleepiness Scale. Polysomnography remains the leading diagnostic tool, with an apnea–hypopnea index (AHI) of 5 or more events per hour confirming an OSA diagnosis. In women, fewer than 5 AHI events per hour may still warrant an OSA diagnosis in cases involving a higher proportion of hypopneas. The Sex Gap in OSA The longstanding belief that OSA is primarily a male disorder has shaped clinical research, public awareness, screening tools, and diagnostic approaches. Increasing evidence shows that OSA is more prevalent and severe in women than once thought.1-16 A global analysis of airway sleep disorders by Lyons et al found that OSA has considerable health effects across populations, with notable underestimation in women.2 OSA was believed to have a male-to-female ratio ranging from 3:1 to 10:1, but new data suggest that the true sex ratio is closer to 1.5:1.6 Growing evidence that women are disproportionately underdiagnosed suggests that the true epidemiology of OSA has been misrepresented and misunderstood. Nearly 90% of women with severe sleep apnea are estimated to be undiagnosed or undertreated.12 OSA is often overlooked in female patients because their symptoms differ from the classic presentation, presenting with more subtle and variable symptoms.6 Witnessed apneas, snoring, and daytime tiredness are the hallmark symptoms identified through standard screening, whereas women more commonly report insomnia, fatigue, mood disturbances, nightmares, and headaches.6,10 These symptoms are often attributed to other, more common conditions affecting women, such as menopause, which delays OSA screening, referral, diagnosis, and treatment. Consequences of OSA in Women The systemic effects of OSA are well studied: hypertension, acute coronary syndrome, arrhythmias, stroke, dementia, type 2 diabetes, and obesity.6,7 Understanding the variation and severity of health outcomes for subpopulations, such as women, is imperative to address the sex disparity in OSA diagnosis. Research shows that women with undiagnosed or undertreated OSA suffer worse health outcomes than their male counterparts.4 Women face a greater risk for OSA complications and higher rates of comorbidities,4 driven in part by sex-specific immune responses and hormonal factors that exacerbate the systemic effects of OSA and warrant further investigation. These findings underscore the importance of timely diagnosis and treatment in women and confirm that the sex gap in OSA is an urgent health issue.4 Undiagnosed OSA can cause significant metabolic dysfunction that leads to metabolic syndrome, which consists of dyslipidemia, hypertension, central obesity, elevated blood glucose, and insulin resistance, all of which have serious health consequences. Chaudhary et al found that women with OSA are at a higher risk for developing metabolic syndrome than men8; their cross-sectional study noted that approximately 88% of women with OSA develop metabolic syndrome, highlighting a substantial burden on women’s health.8 Sleep apnea has a profound association with cardiovascular health. The cardiovascular consequences of unmanaged OSA include hypertension, arrhythmias, and stroke,6 which early data suggest occur at a higher incidence in women than men.6 Women with moderate sleep apnea also experience more severe endothelial injury than men.6 In a prospective cohort study, Wang et al assessed cardiovascular outcomes among hospitalized women and men with OSA and acute coronary syndrome and found that women were more likely to experience a subsequent cardiovascular event.16 These data suggest that women are more vulnerable to OSA-associated cardiac complications, many of which lead to premature death.6,16 Sleep fragmentation and intermittent hypoxia are recognized mechanisms of neurocognitive decline in men and women with sleep apnea,7 and emerging findings suggest that sex also influences neurocognitive outcomes in patients with OSA.7 A 10-year longitudinal study by Braley et al found that women with OSA were more likely than men to develop dementia,7 representing yet another risk that disproportionately affects women with undiagnosed or undertreated disease. Compared with men, women also face higher costs, loss of productivity, disability, sick leave, and functional impairment.4,6,10 An editorial by BaHammam noted that pre-diagnosis costs are nearly double for women compared with men, in part because women see health care professionals more frequently before receiving a diagnosis, further compounding lost productivity.4 Overall, women face greater economic barriers to an accurate OSA diagnosis. Without early detection and appropriate treatment, women with OSA face greater health and economic consequences that warrant prompt clinical attention, such as higher rates of metabolic dysfunction, cardiovascular events, and dementia. Undiagnosed and undertreated OSA poses a profound threat to women’s health, underscoring the importance of timely recognition and diagnosis in avoiding serious downstream consequences. Clinical Presentation of OSA in Women Understanding the clinical presentation of OSA in women is imperative for accurate diagnosis, as the male-centered presentation historically used to define OSA disproportionately overlooks the disorder in women. Research shows that women have distinct OSA phenotypes and symptom profiles (Figure).10,13,14 Women with OSA are less likely to report snoring or witnessed apneas than men,13 and are more likely to report depression, fatigue, brain fog, insomnia, headaches, anxiety, poor sleep quality, nocturia, teeth grinding, and restless leg syndrome.13,14 Compared with men, women also experience more frequent but shorter apneic episodes during rapid eye movement (REM) sleep, along with higher hypopnea-to-apnea ratios and lower AHI values.6,10 Sex-specific hormones are a factor in many conditions affecting women, and OSA is no exception. Findings support the clinical relevance of estrogen and progesterone in maintaining airway patency.9 Specific subpopulations of women experiencing hormone changes, such as postmenopausal women and those with polycystic ovarian syndrome, have a higher prevalence of OSA and OSA-associated complications and experience the disorder at rates similar to men.13 These findings suggest that women with low levels of estrogen and/or progesterone have the same risk for developing OSA as men and a greater risk for complications.13 Diagnostic Barriers and Challenges Diagnostic criteria and tools for OSA were developed on the premise that the disorder mostly affects men. The AHI is the metric used to establish an OSA diagnosis, and its threshold was determined largely from studies of the typical male presentation, which fails to account for the female OSA phenotype and is one of the key barriers to diagnosis. Women are less likely to meet standard AHI thresholds despite experiencing more symptoms at lower AHI values than men.10 Because the current diagnostic threshold requires an AHI of 5 or more events per hour, women must experience more severe symptoms and suffering before qualifying for treatment. A retrospective study by Votteler et al found that women have more apneic episodes during REM sleep, whereas men have more during non-REM sleep.15 This highlights sex differences in polysomnographic findings that warrant further investigation to help close the OSA sex gap. Insurance coverage criteria also perpetuate this sex-based bias. A retrospective study by Khalid et al found that the Medicaid and Medicare criteria for continuous positive airway pressure (CPAP) eligibility disproportionately exclude women, who often present with lower AHI values despite significant symptoms and therefore do not qualify for insurance-covered treatment.11 Perhaps one of the most difficult diagnostic challenges is the societal view of sleep and snoring as a male issue, which makes women psychosocially reluctant to admit to snoring. This presents a genuine challenge for clinicians.3 Women are also more likely to attend medical appointments alone, meaning that a partner is not present to report sleep sounds of which the patient may be unaware.6,14 Because OSA diagnosis depends heavily on a patient’s ability to report sleep concerns, clinicians should remain aware that a lack of awareness or comfort in reporting can be a key diagnostic barrier in women. Solutions and Conclusion In any medical disorder, identifying the most common presentation is necessary to guide clinical judgment toward diagnosis. However, without considering which patients stand to suffer most from a missed diagnosis, clinicians risk failing underrepresented subpopulations and worsening overall health outcomes. Among patients with OSA, women have been disproportionately underdiagnosed, contributing to a sex disparity in diagnosis and worse OSA-associated health outcomes. To close the OSA sex gap, the medical community must address the barriers women face in receiving an accurate diagnosis. This requires sex-specific OSA screening and changes to diagnostic criteria.4,5 A clinical study by Basoglu and Tasbakan aimed at addressing the OSA sex gap demonstrated that adjusting diagnostic criteria and accounting for the female-specific symptom profile led to more frequent and accurate diagnosis of OSA in women.5 Reducing these barriers to care relies on raising clinical and societal awareness of OSA in women. With fewer barriers to diagnosis, women with OSA can receive appropriate treatment and improve their quality of life and longevity. Clinicians can be confident that therapeutic intervention is effective, as treatment adherence is high in women. Nearly 76% of women prescribed CPAP for OSA were found to be adherent.9 Addressing the sex disparity in OSA diagnosis will require greater clinical understanding of the female presentation and the risks women face, a shift in diagnostic approach, and empowering women to recognize the importance of their sleep health. Only once these barriers to care are addressed will the OSA sex gap be corrected. References: - Gottlieb DJ, Punjabi NM. Diagnosis and management of obstructive sleep apnea: a review. JAMA. 2020;323(14):1389-1400. doi:10.1001/jama.2020.3514 - Lyons MM, Bhatt NY, Pack AI, Magalang UJ. Global burden of sleep-disordered breathing and its implications. Respirology. 2020;25(7):690-702. doi:10.1111/resp.13838 - Romero-Peralta S, Garcia-Rio F, Resano Barrio P, et al. Defining the profile of obstructive sleep apnea in women compared to men. J Womens Health (Larchmt). 2022;31(12):1782-1790. doi:10.1089/jwh.2021.0659 - BaHammam AS. The gender gap in obstructive sleep apnea: unmasking the disproportionate costs on women. Sleep. 2025;48(7):zsaf068. doi:10.1093/sleep/zsaf068 - Basoglu OK, Tasbakan MS. Gender differences in clinical and polysomnographic features of obstructive sleep apnea: a clinical study of 2827 patients. Sleep Breath. 2018;22(1):241-249. doi:10.1007/s11325-017-1482-9 - Bouloukaki I, Tsiligianni I, Schiza S. Evaluation of obstructive sleep apnea in female patients in primary care: time for improvement? Med Princ Pract. 2021;30(6):508–514. doi:10.1159/000518932 - Braley TJ, Lyu X, Dunietz GL, et al. Sex-specific dementia risk in known or suspected obstructive sleep apnea: a 10-year longitudinal population-based study. Sleep Adv. 2024;5(1):zpae077. doi:10.1093/sleepadvances/zpae077 - Chaudhary P, Goyal A, Goel SK, et al. Women with OSA have higher chances of having metabolic syndrome than men: effect of gender on syndrome Z in cross sectional study. Sleep Med. 2021;79:83-87. doi:10.1016/j.sleep.2020.12.042 - Fabozzi A, Pasqualotto F, Laguardia M, et al. Gender differences in obstructive sleep apnea syndrome: a pilot study. Sleep Breath. 2024;28(4):1645-1650. doi:10.1007/s11325-024-03052-x - Greer JH, Hilbert J. Gender issues in obstructive sleep apnea. Yale J Biol Med. 2021;94(3):487-496. - Khalid F, Ayache M, Auckley D. The differential impact of respiratory event scoring criteria on CPAP eligibility in women and men. J Clin Sleep Med. 2021;17(12):2409-2414. doi:10.5664/jcsm.9448 - Kumar S, Anton A, D’Ambrosio CM. Sex differences in obstructive sleep apnea. Clin Chest Med. 2021;42(3):417-425. doi:10.1016/j.ccm.2021.04.004 - Meyer EJ, Wittert GA. Approach the patient with obstructive sleep apnea and obesity. J Clin Endocrinol Metab. 2024;109(3):e1267-e1279. doi:10.1210/clinem/dgad572 - Pataka A, Pepin JL, Bonsignore MR, et al. Sleep apnoea phenotypes in women: s cluster analysis from the ESADA cohort. Sleep Med. 2024;124:494-501. doi:10.1016/j.sleep.2024.10.015 - Votteler S, Knaack L, Janicki J, Fink GR, Burghaus L. Sex differences in polysomnographic findings in patients with obstructive sleep apnea. Sleep Med. 2023;101:429-436. doi:10.1016/j.sleep.2022.11.025 - Wang X, Fan J, Guo R, et al. Association of obstructive sleep apnoea with cardiovascular events in women and men with acute coronary syndrome. Eur Respir J. 2023;61(1):2201110. doi:10.1183/13993003.01110-2022