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Inside Dentistry
October 2020
Volume 16, Issue 10

OSA Doesn’t Discriminate

Understanding gender-specific factors can improve outcomes for women

Kent Smith, DDS

With nearly 30 million Americans suffering from obstructive sleep apnea (OSA) and an estimated 80% of cases remaining undiagnosed,1 the sleep disorder is a force to be reckoned with. Fortunately, the medical and dental communities and the general public are making progress in recognizing the necessity of diagnosis and treatment; however, one problem is that OSA is still predominately seen as a men's health condition. Although it is true that the condition affects more men than women, diagnosis rates demonstrate a gender bias, and women (even those displaying the telltale signs of OSA, such as snoring and daytime sleepiness) are more likely to be underdiagnosed and, therefore, undertreated.2

The disparity is likely the result of a confluence of factors that include a variance in symptomatology; sociocultural considerations, such as a hesitance among women to report snoring; and a general misunderstanding of the degree to which OSA is a male-dominant disorder. The consequence for women is an unaddressed and unmitigated increased risk for OSA's comorbidities, which include cardiovascular disease, diabetes, hypertension, depression, and stroke.

Some of the symptoms that women commonly present with deviate from the "classic" OSA symptoms or are more ambiguous, and this can lead to either a misdiagnosis or the diagnosis of one of the condition's comorbidities without a corresponding OSA diagnosis. In addition, women are more likely to visit their doctors unaccompanied by their partners, who are often the ones who identify the presence of snoring or gasping at night.3 Although snoring, daytime fatigue, and gasping for breath are the most commonly recognized symptoms of OSA, especially in men, women may more predominantly experience other symptoms, such as insomnia, restless legs syndrome, depression or other mood disorders, nightmares, heart palpitations, and hallucinations.4

Interestingly, women have also been shown to exhibit symptoms at less severe levels of OSA than men do,4 which can lead to earlier and possibly more acute impairment and decreased quality of life. By recognizing the potential indications of OSA in women, we can identify the signs of those who have a problem earlier and help mitigate the disease's associated health consequences. Aside from being male, the list of primary risk factors for OSA is widely independent of gender and includes age, obesity, large neck circumference, genetics or family history, race, and certain lifestyle habits, such as smoking and consuming alcohol. For women, however, there are a few significant gender-specific risk factors that may contribute to the onset or worsening of OSA, including pregnancy, menopause, and polycystic ovary syndrome (PCOS).

The increased risk of OSA during pregnancy is largely due to the body's anatomical adaptations and is compounded if a woman is also obese. Data indicates that OSA affects approximately 15% to 20% of obese pregnant women.5 During pregnancy, the growing uterus lifts up the diaphragm, affecting the mechanics of the lungs. In addition, the circumference of the neck increases, and swelling of the throat is common-both of which can reduce the size of the airway and promote its collapse.4

Menopause is also associated with a marked increase in OSA prevalence, and 47% to 67% of postmenopausal women have been found to have the condition.6 The hormone changes that women experience during this time-particularly the decline in estrogen and progesterone-have an effect on the structure and stability of the airway, increasing its susceptibility of collapsing. In addition, fat accumulation and distribution in the body changes with menopause, which can contribute to an increased risk of OSA.

PCOS is another significant risk factor for OSA in women. One study demonstrated that those with PCOS are 30 times more likely to have the condition.7 Similar to menopause, hormone changes and fat distribution are the primary contributors to the increased risk.8

With 58% of Americans visiting the dentist office at least once per year,9 we, as dental professionals, have a unique opportunity to positively impact their overall health and quality of life. By implementing OSA screening protocols into our routines and educating ourselves about how the condition manifests uniquely across genders, we can improve the likelihood that all of our patients will receive an early and accurate diagnosis.

The references for this perspective are available online with the digital version of the article at:
insidedentistry.net/go/10-20-perspective.

About the Author

Kent Smith, DDS, is the founding director of Sleep Dallas, a dental sleep medicine practice in the Dallas-Fort Worth metroplex.

References

1. Peppard PE, Young T, Barnet JH, et al. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. 2013;177(9):1006-1014.

2. Lindberg E, Benediktsdottir B, Franklin KA, et al. Women with symptoms of sleep-disordered breathing are less likely to be diagnosed and treated for sleep apnea than men. Sleep Med. 2017;35:17-22.

3. Westreich R, Gozlan-Talmor A, Geva-Robinson S, et al. The presence of snoring as well as its intensity is underreported by women. J Clin Sleep Med. 2019;15(3):471-476.

4. Wimms A, Woehrle H, Ketheeswaran S, et al. Obstructive sleep apnea in women: specific issues and interventions. Biomed Res Int. 2016;2016:1764837. doi:10.1155/2016/1764837.

5. Dominguez JE, Krystal AD, Habib AS. Obstructive sleep apnea in pregnant women: a review of pregnancy outcomes and an approach to management. Anesth Analg. 2018;127(5):1167-1177.

6. Jehan S, Auguste E, Zizi F, et al. Obstructive sleep apnea: women's perspective. J Sleep Med Disord. 2016;3(6). pii: 1064.

7. Vgontzas AN, Legro RS, Bixler EO, et al. Polycystic ovary syndrome is associated with obstructive sleep apnea and daytime sleepiness: role of insulin resistance. J Clin Endocrinol Metab. 2001;86(2):517-520.

8. Tasali E, Van Cauter E, Ehrmann DA. Polycystic ovary syndrome and obstructive sleep apnea. Sleep Med Clin. 2008;3(1):37-46.

9. Division of Sleep Medicine at Harvard Medical School. Impact of treatment. Division of Sleep Medicine at Harvard Medical School website. http://healthysleep.med.harvard.edu/sleep-apnea/treating-osa/impact. Reviewed February 11, 2011. Accessed May 18, 2020.

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