Gender differences in sleep apnea: epidemiology, clinical presentation and pathogenic mechanisms

doi:10.1053/smrv.2002.0260

Sleep Medicine Reviews

Volume 7, Issue 5, October 2003, Pages 377-389

https://doi.org/10.1053/smrv.2002.0260 Get rights and content

Abstract

Sleep apnea syndromes are a common cause of sleepiness and neurocognitive impairment and have been implicated as an independent risk factor for cardiovascular disease. While both epidemiological and sleep clinic-based studies indicate that sleep apnea syndromes are more common in men than in women, the gender difference in prevalence is more marked within the sleep clinic. Reasons for the relative failure of women to attend sleep clinics and the pathophysiologic differences that give rise to the male predominance of sleep apnea syndromes are unknown. The purpose of this review was to examine the literature with regard to these aspects, to provide clinical guidance to improve the reduced attendance of women to sleep laboratories and to stimulate research interest into the causes of these differences.

References (98)

C Guilleminault et al.
Women and the obstructive sleep apnea syndrome
Chest
(1988)
JA Leech et al.
A comparison of men and women with occlusive sleep apnea syndrome
Chest
(1988)
RD Chervin
Sleepiness, fatigue, tiredness, and lack of energy in obstructive sleep apnea
Chest
(2000)
DD Sin et al.
Hypercapnic ventilatory response in patients with and without obstructive sleep apnea: do age, gender, obesity, and daytime PaCO(2) matter?
Chest
(2000)
RJ van Klaveren et al.
Determinants of the hypercapnic and hypoxic response in normal man
Respir Physiol
(1998)
BA Jonah
Sensation seeking and risky driving: a review and synthesis of the literature
Accid Anal Prev
(1997)
RI Harik-Khan et al.
The effect of gender on the relationship between body fat distribution and lung function
J Clin Epidemiol
(2001)
MC Khoo
Determinants of ventilatory instability and variability
Respir Physiol
(2000)
V Mohsenin
Gender differences in the expression of sleep-disordered breathing: role of upper airway dimensions
Chest
(2001)
DD Dexter et al.
Obstructive sleep apnea due to endogenous testosterone production in a woman
Mayo Clin Proc
(1998)

Sleep

(1999)

F Kapsimalis et al.

Gender and obstructive sleep apnea syndrome, part 1: Clinical features

Sleep

(2002)

F Kapsimalis et al.

Gender and obstructive sleep apnea syndrome, part 2: mechanisms

Sleep

(2002)

T Young et al.

The occurrence of sleep-disordered breathing among middle-aged adults

New Engl J Med

(1993)

EO Bixler et al.

Prevalence of Sleep-disordered Breathing in Women. Effects of gender

Am J Respir Crit Care Med

(2001)

S Redline et al.

Gender differences in sleep disordered breathing in a community-based sample

Am J Respir Crit Care Med

(1994)

J Duran et al.

Obstructive sleep apnea-hypopnea and related clinical features in a population-based sample of subjects aged 30 to 70 yr

Am J Respir Crit Care Med

(2001)

DW Hudgel et al.

Pharmacologic treatment of sleep-disordered breathing

Am J Respir Crit Care Med

(1998)

BD Crocker et al.

Estimation of the probability of disturbed breathing during sleep before a sleep study

Am Rev Respir Dis

(1990)

E Ballester et al.

Evidence of the effectiveness of continuous positive airway pressure in the treatment of sleep apnea/hypopnea syndrome

Am J Respir Crit Care Med

(1999)

N McArdle et al.

Long-term use of CPAP therapy for sleep apnea/hypopnea syndrome

Am J Respir Crit Care Med

(1999)

JF Faccenda et al.

Randomized placebo-controlled trial of continuous positive airway pressure on blood pressure in the sleep apnea-hypopnea syndrome

Am J Respir Crit Care Med

(2001)

M Barnes et al.

A randomized controlled trial of continuous positive airway pressure in mild obstructive sleep apnea

Am J Respir Crit Care Med

(2002)

C O'Connor et al.

Gender differences in the polysomnographic features of obstructive sleep apnea

Am J Respir Crit Care Med

(2000)

JC Ware et al.

Influence of sex and age on duration and frequency of sleep apnea events

Sleep

(2000)

E Shahar et al.

Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study

Am J Respir Crit Care Med

(2001)

A Ambrogetti et al.

Differences in the symptoms of men and women with obstructive sleep apnoea

Aust N Z J Med

(1991)

T Young et al.

The gender bias in sleep apnea diagnosis. Are women missed because they have different symptoms?

Arch Intern Med

(1996)

DJ Gottlieb et al.

Relation of sleepiness to respiratory disturbance index: the Sleep Heart Health Study

Am J Respir Crit Care Med

(1999)

LG Olson et al.

A community study of snoring and sleep-disordered breathing. Symptoms

Am J Respir Crit Care Med

(1995)

CM Baldwin et al.

The association of sleep-disordered breathing and sleep symptoms with quality of life in the Sleep Heart Health Study

Sleep

(2001)

DP White et al.

Sexual influence on the control of breathing

J Appl Physiol

(1983)

DP White et al.

Hypoxic ventilatory response during sleep in normal premenopausal women

Am Rev Respir Dis

(1982)

ML Aitken et al.

Influence of body size and gender on control of ventilation

J Appl Physiol

(1986)

JG Regensteiner et al.

Combined effects of female hormones and metabolic rate on ventilatory drives in women

J Appl Physiol

(1989)

T Young et al.

Sleep-disordered breathing and motor vehicle accidents in a population-based sample of employed adults

Sleep

(1997)

T Young et al.

Population-based study of sleep-disordered breathing as a risk factor for hypertension

Arch Intern Med

(1997)

FJ Nieto et al.

Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study

JAMA

(2000)

EO Bixler et al.

Association of hypertension and sleep-disordered breathing

Arch Intern Med

(2000)

S Ancoli-Israel et al.

Morbidity, mortality and sleep-disordered breathing in community dwelling elderly

Sleep

(1996)

T Young et al.

Epidemiological insights into the public health burden of sleep disordered breathing: sex differences in survival among sleep clinic patients

Thorax

(1998)

AD McGown et al.

Long-term use of mandibular advancement splints for snoring and obstructive sleep apnoea: a questionnaire survey

Eur Respir J

(2001)

KM Flegal et al.

Overweight and obesity in the United States: prevalence and trends, 1960–1994

Int J Obes Relat Metab Disord

(1998)

AN Vgontzas et al.

Sleep apnea and daytime sleepiness and fatigue: relation to visceral obesity, insulin resistance, and hypercytokinemia

J Clin Endocrinol Metab

(2000)

T Young

Analytic epidemiology studies of sleep disordered breathing – what explains the gender difference in sleep disordered breathing?

Sleep

(1993)

T Young et al.

Predictors of sleep-disordered breathing in community-dwelling adults: the Sleep Heart Health Study

Arch Intern Med

(2002)

DC Thut et al.

Tracheal and neck position influence upper airway airflow dynamics by altering airway length

J Appl Physiol

(1993)

WB Van de Graaff

Thoracic influence on upper airway patency

J Appl Physiol

(1988)

DI Loube et al.

Self-reported snoring in pregnancy. Association with fetal outcome

Chest

(1996)

Cited by (152)

Frequency of Vigorous physical activity and sleep difficulty in adolescents: A multiply-country cross-sectional study
2024, Complementary Therapies in Clinical Practice
Sleep is an essential health behavior, and sleep difficulties are strongly associated with adolescent health, potentially leading to more severe sleep disorders. The beneficial effects of physical activity (PA) in alleviating sleep difficulties have been well-documented. Numerous investigations reveal influence in moderate to high-intensity physical activity (PA) positively influences sleep quality. Despite these findings, a gap in the literature exists, particularly regarding the association between frequency of vigorous-intensity physical activity (VPA) and sleep difficulties.
This study aims to bridge the knowledge gap by exploring the link between sleep difficulty and frequency of VPA among adolescents. Insights are derived from analyzing data accumulated from the Health Behavior in School-aged Children (HBSC) project.
The analysis in this study utilized cross-sectional data from the HBSC (2017/2018). The study sample comprised a total of 171,233 respondents aged 11, 13, and 15 years, with males representing 51.1% of sample. Measurement instruments included a self-administered questionnaire, providing direct insight into sleep difficulty and frequency of VPA levels. Statistical analysis on the associaiton between frequency of VPA and sleep difficulties was conducted using Generalized Linear Models.
50.0% of adolescents reported no sleep difficulties, while 12.3% experienced sleep issues daily. Additionally, 17.1% of adolescents engaged in frequency of VPA on a daily basis, while 6.4% never participated in such activities. daily VPA was associated with fewer sleep difficulties (OR = 1.07 [1.00, 1.15]), 4–6 times a week (OR = 1.08 [1.01, 1.15]), and 2–3 times a week (OR = 1.08 [1.02, 1.16]). However, no significant association was found between sleep difficulties and frequency of VPA in girls. Furthermore, a negative association was observed between sleep difficulties and all frequencies of VPA (p < 0.05) in 11-year-old adolescents. For 13-year-olds, daily VPA was significantly associated with fewer sleep difficulties (OR = 1.10 [1.02, 1.19]), 4–6 times a week (OR = 1.15 [1.07, 1.24]), 2–3 times a week (OR = 1.19 [1.10, 1.27]), and once a week (OR = 1.13 [1.05, 1.22]). However, no significant association was found between sleep difficulties and frequency of VPA in 15-year-old adolescents.
More participations in VPA would be an effective approach to reduce sleep difficulties in adolescents. Insights gleaned from this research illustrate a discernible link between sleep difficulty and frequency of VPA, particularly notable in male and 13-year-old participants. It is also imperative to underscore the variability in the connection between sleep difficulty and frequency of VPA, distinctly influenced by factors such as gender and age. Consequently, tailoring sleep intervention methodologies to align with the specific needs dictated by these variables emerges as a pivotal recommendation.
Sex differences in rapid eye movement sleep behavior disorder: A systematic review and meta-analysis
2023, Sleep Medicine Reviews
Although rapid eye movement (REM) sleep behavior disorder (RBD) has been widely considered as a male-predominant parasomnia, the existing evidence for the sex difference in the risk of RBD in the general population was conflicting. The present study conducted a systematic review to explore the sex differences in the prevalence, comorbidities, clinical characteristics, and phenoconversion of RBD. One hundred thirty-five eligible studies were identified for the systematic review, and 133 were finally included in the meta-analysis. Males in the general population showed a trend for a higher risk of probable/possible RBD (pRBD), especially among the male older adults (aged ≥60). In the clinical populations, males showed a significantly higher risk of confirmed RBD, but not of pRBD. Among idiopathic RBD (iRBD) patients, males had a significantly earlier age onset of RBD compared with females. Male patients with Parkinson's disease (PD) had a higher risk of comorbid RBD. There was no significant sex difference in the risk of developing neurodegenerative diseases in iRBD patients. Large scale and prospective studies utilizing stringent diagnostic criteria for RBD are recommended to further verify the sex differences in RBD and to investigate the mechanism underlying the sex difference.
Genome-wide association study of obstructive sleep apnoea in the Million Veteran Program uncovers genetic heterogeneity by sex
2023, eBioMedicine
Genome-wide association studies (GWAS) for obstructive sleep apnoea (OSA) are limited due to the underdiagnosis of OSA, leading to misclassification of OSA, which consequently reduces statistical power. We performed a GWAS of OSA in the Million Veteran Program (MVP) of the U.S. Department of Veterans Affairs (VA) healthcare system, where OSA prevalence is close to its true population prevalence.
We performed GWAS of 568,576 MVP participants, stratified by biological sex and by harmonized race/ethnicity and genetic ancestry (HARE) groups of White, Black, Hispanic, and Asian individuals. We considered both BMI adjusted (BMI-adj) and unadjusted (BMI-unadj) models. We replicated associations in independent datasets, and analysed the heterogeneity of OSA genetic associations across HARE and sex groups. We finally performed a larger meta-analysis GWAS of MVP, FinnGen, and the MGB Biobank, totalling 916,696 individuals.
MVP participants are 91% male. OSA prevalence is 21%. In MVP there were 18 and 6 genome-wide significant loci in BMI-unadj and BMI-adj analyses, respectively, corresponding to 21 association regions. Of these, 17 were not previously reported in association with OSA, and 13 replicated in FinnGen (False Discovery Rate p-value < 0.05). There were widespread significant differences in genetic effects between men and women, but less so across HARE groups. Meta-analysis of MVP, FinnGen, and MGB biobank revealed 17 additional, previously unreported, genome-wide significant regions.
Sex differences in genetic associations with OSA are widespread, likely associated with multiple OSA risk factors. OSA shares genetic underpinnings with several sleep phenotypes, suggesting shared aetiology and causal pathways.
Described in acknowledgements.
Adult obstructive sleep apnea
2023, Encyclopedia of Sleep and Circadian Rhythms: Volume 1-6, Second Edition
Obstructive sleep apnea (OSA) is a sleep disordered breathing condition characterized by recurrent upper airway collapse. The resultant repetitive hypoxemia, arousals from sleep, and other effects are associated with several adverse health effects including systemic hypertension, cardiac arrhythmias, heart failure, pulmonary hypertension, stroke, and diabetes. Daytime sleepiness and neuropsychiatric effects of OSA are also a considerable burden to patients. Prevalence of OSA is high with an estimated global case load nearing 1 billion. Lab based polysomnography is still considered the gold standard for the diagnosis of OSA. In recent years, the use of home-based sleep apnea testing has increased and has been incorporated in to the American Academy of Sleep Medicine's recommended clinical algorithm for testing and treatment of OSA. The cornerstone of treatment remains positive airway pressure devices along with weight loss and risk factor modifications. Continuous positive airway pressure (CPAP) treatment has been consistently shown to lower blood pressure, reduce sleepiness, and is associated with improvements in heart failure metrics and readmission rates. OSA refractory to CPAP treatment may need bilevel positive airway pressure devices. Additionally, a variety of surgical interventions targeting the oropharynx and surrounding structures are available and can be considered in selected patients. Most surgeries still result in a degree of residual OSA for most patients. A recent innovation in the surgical realm is the ability to implant a hypoglossal nerve stimulator, which stimulates the genioglossus muscle to modulate airway collapsibility. Many advances have been made in our understanding of OSA with concomitant technological advances leading to several treatment options; nevertheless, research opportunities abound in understanding the pathogenesis and consequences of OSA as well the effects on these consequences with therapy.
Nonalcoholic fatty liver disease and obstructive sleep apnea in women with polycystic ovary syndrome
2022, Fertility and Sterility
Citation Excerpt :
It has been consistently noted that men have a higher prevalence of OSA than women. In community-based studies, the male-to-female ratio is usually between 2:1 and 3:1 (98) in contrast to a ratio of 8:1 in clinic-based studies (99). On the basis of these observations, it has been assumed that testosterone must be playing an important role in the development of OSA in PCOS.
Nonalcoholic fatty liver disease (NAFLD) and obstructive sleep apnea are frequently associated with polycystic ovary syndrome (PCOS) but remain underrecognized. Women with PCOS have a 2–4 times higher risk of NAFLD independent of body mass index than healthy weight-matched controls. Insulin resistance and hyperandrogenemia together play a central role in the pathogenesis of NAFLD. Timely diagnosis of NAFLD is important because its progression can lead to nonalcoholic steatohepatitis and/or advanced liver fibrosis that can eventually result in liver-related mortality. The presence of NAFLD has also been associated with increased risks of type 2 diabetes, cardiovascular events, overall mortality, and extrahepatic cancers. The treatment of NAFLD in PCOS should include lifestyle interventions. Glucagon-like peptide 1 receptor agonists have shown promising results in patients with PCOS and NAFLD, but future randomized trails are needed to confirm this benefit. Likewise, the use of combined oral estrogen-progestin contraceptives may provide a benefit by decreasing hyperandrogenemia.
Sleep disordered breathing is common among women with PCOS and is responsible for a number of cardiometabolic derangements. Obstructive sleep apnea is most often found in overweight and obese women with PCOS, but as is the case with NAFLD, its prevalence exceeds that of women who are of similar weight without PCOS. Left untreated, obstructive sleep apnea can precipitate or exacerbate insulin resistance, glucose intolerance, and hypertension.
Sleep architectural dysfunction and undiagnosed obstructive sleep apnea after chronic ischemic stroke
2021, Sleep Medicine
Sleep-wake dysfunction is bidirectionally associated with the incidence and evolution of acute stroke. It remains unclear whether sleep disturbances are transient post-stroke or are potentially enduring sequelae in chronic stroke. Here, we characterize sleep architectural dysfunction, sleep-respiratory parameters, and hemispheric sleep in ischemic stroke patients in the chronic recovery phase compared to healthy controls.
Radiologically confirmed ischemic stroke patients (n = 28) and matched control participants (n = 16) were tested with ambulatory polysomnography, bi-hemispheric sleep EEG, and demographic, stroke-severity, mood, and sleep-circadian questionnaires.
Twenty-eight stroke patients (22 men; mean age = 69.61 ± 7.4 years) were cross-sectionally evaluated 4.1 ± 0.9 years after mild-moderate ischemic stroke (baseline NIHSS: 3.0 ± 2.0). Fifty-seven percent of stroke patients (n = 16) exhibited undiagnosed moderate-to-severe obstructive sleep apnea (apnea-hypopnea index >15). Despite no difference in total sleep or wake after sleep onset, stroke patients had reduced slow-wave sleep time (66.25 min vs 99.26 min, p = 0.02), increased time in non-rapid-eye-movement (NREM) stages 1–2 (NREM-1: 48.43 vs 28.95, p = 0.03; NREM-2: 142.61 vs 115.87, p = 0.02), and a higher arousal index (21.46 vs 14.43, p = 0.03) when compared to controls. Controlling for sleep apnea severity did not attenuate the magnitude of sleep architectural differences between groups (NREM 1-3= $η p 2$ >0.07). We observed no differences in ipsilesionally versus contralesionally scored sleep architecture.
Fifty-seven percent of chronic stroke patients had undiagnosed moderate-severe obstructive sleep apnea and reduced slow-wave sleep with potentially compensatory increases in NREM 1–2 sleep relative to controls. Formal sleep studies are warranted after stroke, even in the absence of self-reported history of sleep-wake pathology.

View all citing articles on Scopus

^f1: Correspondence should be addressed to: A. S. Jordan, Brighan and Women's Hospital Sleep Disorders Program, 221 Longwood Av, RFB 486, Boston, MA 02115, USA. Tel: 6172780911; Fax: 6179750809; E-mail:[email protected]

View full text

Clinical ReviewGender differences in sleep apnea: epidemiology, clinical presentation and pathogenic mechanisms

Abstract

Chest

Chest

Chest

Chest

Respir Physiol

Accid Anal Prev

J Clin Epidemiol

Respir Physiol

Chest

Mayo Clin Proc

Sleep

Gender and obstructive sleep apnea syndrome, part 1: Clinical features

Sleep

Gender and obstructive sleep apnea syndrome, part 2: mechanisms

Sleep

The occurrence of sleep-disordered breathing among middle-aged adults

New Engl J Med

Prevalence of Sleep-disordered Breathing in Women. Effects of gender

Am J Respir Crit Care Med

Gender differences in sleep disordered breathing in a community-based sample

Am J Respir Crit Care Med

Obstructive sleep apnea-hypopnea and related clinical features in a population-based sample of subjects aged 30 to 70 yr

Am J Respir Crit Care Med

Pharmacologic treatment of sleep-disordered breathing

Am J Respir Crit Care Med

Estimation of the probability of disturbed breathing during sleep before a sleep study

Am Rev Respir Dis

Evidence of the effectiveness of continuous positive airway pressure in the treatment of sleep apnea/hypopnea syndrome

Am J Respir Crit Care Med

Long-term use of CPAP therapy for sleep apnea/hypopnea syndrome

Am J Respir Crit Care Med

Randomized placebo-controlled trial of continuous positive airway pressure on blood pressure in the sleep apnea-hypopnea syndrome

Am J Respir Crit Care Med

A randomized controlled trial of continuous positive airway pressure in mild obstructive sleep apnea

Am J Respir Crit Care Med

Gender differences in the polysomnographic features of obstructive sleep apnea

Am J Respir Crit Care Med

Influence of sex and age on duration and frequency of sleep apnea events

Sleep

Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study

Am J Respir Crit Care Med

Differences in the symptoms of men and women with obstructive sleep apnoea

Aust N Z J Med

The gender bias in sleep apnea diagnosis. Are women missed because they have different symptoms?

Arch Intern Med

Relation of sleepiness to respiratory disturbance index: the Sleep Heart Health Study

Am J Respir Crit Care Med

A community study of snoring and sleep-disordered breathing. Symptoms

Am J Respir Crit Care Med

The association of sleep-disordered breathing and sleep symptoms with quality of life in the Sleep Heart Health Study

Sleep

Sexual influence on the control of breathing

J Appl Physiol

Hypoxic ventilatory response during sleep in normal premenopausal women

Am Rev Respir Dis

Influence of body size and gender on control of ventilation

J Appl Physiol

Combined effects of female hormones and metabolic rate on ventilatory drives in women

J Appl Physiol

Sleep-disordered breathing and motor vehicle accidents in a population-based sample of employed adults

Sleep

Population-based study of sleep-disordered breathing as a risk factor for hypertension

Arch Intern Med

Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study

JAMA

Association of hypertension and sleep-disordered breathing

Arch Intern Med

Morbidity, mortality and sleep-disordered breathing in community dwelling elderly

Sleep

Epidemiological insights into the public health burden of sleep disordered breathing: sex differences in survival among sleep clinic patients

Thorax

Long-term use of mandibular advancement splints for snoring and obstructive sleep apnoea: a questionnaire survey

Eur Respir J

Overweight and obesity in the United States: prevalence and trends, 1960–1994

Int J Obes Relat Metab Disord

Sleep apnea and daytime sleepiness and fatigue: relation to visceral obesity, insulin resistance, and hypercytokinemia

J Clin Endocrinol Metab

Analytic epidemiology studies of sleep disordered breathing – what explains the gender difference in sleep disordered breathing?

Clinical Review
Gender differences in sleep apnea: epidemiology, clinical presentation and pathogenic mechanisms