OSA in Women

Barbara Phillips, MS, MSPH, FCCP

CHEST President 2015-2016

Professor, University of Kentucky College of Medicine

Conflict of Interest Disclosures for Speakers

I have the following relationships with entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients:

Type of Potential Conflict Details of Potential Conflict

Grant/Research Support

ConsultantMember of the FMCSA Medical Advisory Board 2008-2011, expert witness Clayton and Beveridge

Speakers’ Bureaus

Financial support

OtherLeadership positions, American College of Chest PhysiciansNational Board of Respiratory CareBoard of Registered Polysomnographic Technologists

The material presented in this lecture has no relationship with any of these potential conflicts

• Sleep complaints skyrocket at the time of menopause

• Sleep apnea increases at the time of menopause

• Women with sleep apnea present differently from men and are harder to diagnose.

• Consequences of sleep apnea in women are significant, and treatment of OSA can improve outcomes for women

Overview

Sleep Complaints Increase at the Time of Menopause (Young T, Sleep 2003)

Peri vs. Pre Post vs. Pre

Repeated waking 0.59 1.58

DFA 4.18* 2.77

EMA 1.43 0.80

Dissatisfied2.01* 2.23*

EDS 0.91 1.70*

Adjusted for age and BMI

What Disturbs Sleep in Menopause?

Hot flashes

Depression/anxiety/insomnia

Sleep-disordered breathing

Moline M. Sleep Med Rev 2003

• Sleep complaints skyrocket at the time of menopause

• Sleep apnea increases at the time of menopause

• Women with sleep apnea present differently from men and are harder to diagnose

• Consequences of sleep apnea in women are significant, and treatment of OSA can improve outcomes for women

Overview

Menopause and Sleep Apnea(Young T, AJRRC, 2003, n=589)

Menopausal State, Age and Weight(Young T, AJRRC, 2003, n=589)

• In 5 year follow-up:• The effects of gender and

BMI change with aging.• AFTER THE AGE OF 50,

GENDER BECOMES AN UNIMPORTANT VARIABLE.

• AFTER THE AGE OF 60, BMI BECOMES AN UNIMPORTANT VARIABLE.

(Tishler PV, JAMA 2003, n=286)

Changes in Airway Age - MRI findings

Soft palate gets longer

Pharyngeal fat pads increase in size

Shape of bony structures around pharyngeal airway change

Response of genioglosus muscle to negative pressure stimulation diminishes

Malhotra A, Am J. Med, 2006.

Midsagittal magnetic resonance image illustrating anatomic structures of interest

• Sleep complaints skyrocket at the time of menopause

• Sleep apnea increases at the time of menopause

• Women with sleep apnea present differently from men and are harder to diagnose

• Consequences of sleep apnea in women are significant, and treatment of OSA can improve outcomes for women

Overview

Women with Sleep Apnea Are Different from Men

Women with OSA are more likely to• present with insomnia• be depressed• have thyroid disease• report nightmares, palpitation, and hallucinations• have comorbid Restless Legs Syndrome

They are less likely to have snoring and witnessed apneas

Valipour A. Sleep 2007

Shepertycky and Kryger, Sleep 2005

Insomnia and OSA

Insomnia and sleep-disordered breathing co-exist frequently (22-54%) (Al-Jawder SE Sleep Breath 2012)

OSA typically is associated with sleep maintenance problems.

Risks for insomnia in OSA are older age, female gender, chronic medication use.

Women with Sleep Apnea Are Different from Men

Women with sleep apnea are more likely to• Have mild or subtle sleep-disordered breathing

(“UARS”)• Have more REM-related apneas (O’Connor

AJRCCM 2003)• Be undiagnosed

The Stereotype….

The Reality.

• Sleep complaints skyrocket at the time of menopause

• Sleep apnea increases at the time of menopause

• Women with sleep apnea present differently from men and are harder to diagnose

• Consequences of sleep apnea in women are significant, and treatment of OSA can improve outcomes for women

Overview

Unadjusted Survival Curves for CHF (SHHS, Gottlieb, DJ, Circ, 2010)

Unadjusted Survival Curves for CHD (Gottlieb, DJ, Circ, 2010)

Survival of Women with OSA by Treatment Status, n=1116Campo-Rodriguez Ann Int Med 2012

Can CPAP Help Insomnia in OSA?(Bjorndottir E Sleep 2013, n=705)

Patients with OSA and insomnia were evaluated before and 2 years after starting CPAP.

Middle-of-the-night awakening was the most prevalent kind of insomnia, and improved significantly among PAP users (59% to 30%).

Sleep-onset insomnia was not affected by CPAP

Early morning awakening was more likely to improve in those who were not adherent.

Sleep-onset and early morning insomnia strongly predicted predicted CPAP non-adherence.

Does HRT Protect Against OSA? Shahar E, AJRCCM 2004, n= 2852 women, aged > 50

Conclusions/Implications (Shahar)

Compared with nonusers, HRT users• Were half as likely to have AHI > 15• Had worse sleep• Had more subjective daytime sleepiness

This was not an RCT, and it’s difficult to draw conclusions about HRT and OSA.

The prevalence of sleep apnea in this sample was high!

• Sleep complaints skyrocket at the time of menopause

• Sleep apnea increases at the time of menopause

• Women with sleep apnea present differently from men and are harder to diagnose.

• Consequences of sleep apnea in women are significant, and treatment of OSA can improve outcomes for women

Overview

Resumen

Quejas del sueño se disparan en el momento de la menopausia

Apnea del sueño aumenta en el momento de la menopausia

Mujeres con apnea del sueño presentan de manera diferente a los hombres y son más difíciles de diagnosticar.

Consecuencias de la apnea del sueño en las mujeres son significativas, y el tratamiento de la apnea de sueno en mujers puede mejorar los resultados para las mujeres.

More than 300 general sessions

Postgraduate courses

Simulation program

Original investigation presentations

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