Sleep apnea in women: symptoms that get missed

Sleep apnea in women often doesn't look like the loud, gasping snorer most people picture. Women are more likely to notice tiredness, insomnia, morning headaches, low mood or waking up again and again during the night, and those symptoms are easy to blame on something else. If that sounds familiar, a doctor or sleep specialist can arrange a sleep test, which is the only way to know.

Is sleep apnea really less common in women?

Sleep apnea is less common in women, but not rare. An American Heart Association scientific statement estimates that about 34% of middle-aged men and 17% of middle-aged women meet the diagnostic criteria for obstructive sleep apnea. The NHLBI says men are more likely to have serious sleep apnea and to be diagnosed at a younger age.

That gap has shaped how doctors think about the condition. A 2019 review in the European Respiratory Review notes that obstructive sleep apnea has long been considered mainly a male problem. Yet women now make up as much as 40 to 50% of people seen at sleep clinics, according to the same review.

Why do the symptoms get missed?

Sleep apnea symptoms get missed in women because, as the review explains, women tend to present differently. They are less likely to report snoring or pauses in breathing that someone else has seen. They are more likely to complain of daytime fatigue, lack of energy, insomnia, morning headaches, mood problems and nightmares.

These differences have consequences. The authors say women with sleep-disordered breathing are often underdiagnosed and undertreated compared with men, and that this "atypical" presentation partly explains why women tend to be diagnosed at older ages and at a higher body mass index.

The pattern on a sleep study can differ too. Compared with men, women typically have a lower apnea-hypopnea index (AHI), shorter pauses, fewer events tied to sleeping on the back, and events that cluster in REM sleep. They also seem to have more prolonged partial narrowing of the airway rather than complete collapse. Even so, the review reports that women appear to be more symptomatic overall, even though their AHI scores tend to be lower. If you want to know more about the back-sleeping pattern, see positional sleep apnea.

Which symptoms should women watch for?

The NHLBI lists symptoms that women more often have:

• Anxiety
• Daytime sleepiness
• Depression
• Headaches, especially in the morning
• Insomnia
• Tiredness
• Waking up often during sleep

On its general symptoms page, the NHLBI marks frequent loud snoring as more common in men, and fatigue, headache and insomnia as more common in women. It also warns that because you may not have symptoms such as snoring, you may not think you have the condition.

Cleveland Clinic makes the same point. Its sleep specialist says obstructive sleep apnea in women commonly shows up as many awakenings during the night with no history of loud snoring. She adds that people who don't snore, or don't realize they do, often assume they can't have sleep apnea and put off getting checked.

So the useful question isn't only "do I snore?" It's also whether you wake up unrefreshed, keep waking in the night, or feel worn out no matter how long you stay in bed. Our guides to waking up tired and morning headaches cover other possible causes worth ruling out with a doctor.

How does menopause change the risk?

The NHLBI says women may have a lower risk of obstructive sleep apnea than men earlier in life, but the risk increases during and after menopause. Hormone changes play a part, and women may also gain weight during menopause, including around the neck.

The European Respiratory Review puts a number on it: prevalence in women doubles after menopause, independent of age and body mass index, peaking around age 65, about 10 years later than in men.

The overlap with menopause can hide the problem. The NHLBI notes that menopause itself can cause insomnia, headaches and fatigue, which may make it harder for you or your provider to recognize sleep apnea. The review says the same thing more directly: in women after menopause, symptoms of sleep apnea may easily be neglected or put down to menopause. If you're going through menopause and your sleep has fallen apart, it's reasonable to ask whether a sleep test makes sense.

What about pregnancy?

Pregnancy can raise the risk of sleep apnea. It changes the upper airway and the way the brain controls breathing, according to the NHLBI, and these changes can raise the risk of sleep apnea or make existing sleep apnea worse. It is often more serious in the third trimester and may improve after the baby is born. Pregnant women who are older or who have obesity have a higher risk.

The NHLBI lists possible complications of sleep apnea in pregnancy, including gestational diabetes, high blood pressure, preterm birth, low birth weight and cesarean delivery. It also says breathing devices such as CPAP are safe for treating sleep apnea during pregnancy, and that the settings may need adjusting during and after pregnancy. If snoring is new or louder while you're pregnant, our guide to snoring during pregnancy explains what to raise with your midwife or doctor.

Are other conditions linked?

Yes, other conditions are linked to sleep apnea in women. The NHLBI says hormone problems in polycystic ovary syndrome (PCOS) may raise the risk, along with low thyroid hormone levels. General risk factors apply to women as well, including older age, obesity, a family history of sleep apnea, alcohol and smoking.

Sleep apnea also matters for heart health. The AHA statement reports that obstructive sleep apnea is found in 40 to 80% of people with conditions such as high blood pressure, heart failure, atrial fibrillation and stroke. Our article on sleep apnea and high blood pressure explains that link.

How is it diagnosed?

Sleep apnea is diagnosed with a sleep test, and the process is the same for women and men. The AASM's diagnostic guideline recommends against using questionnaires, clinical tools or prediction algorithms to diagnose sleep apnea without a sleep test. Diagnosis needs either an overnight study in a sleep lab or, for suitable adults, a home sleep apnea test. Our guide to the home sleep apnea test explains what that involves.

When you see a doctor, describe all of your symptoms, not only snoring. Mention night waking, insomnia, morning headaches, fatigue and mood changes, and say if they started or got worse around pregnancy or menopause. If a bed partner has noticed anything, bring that up too.

Can mouth tape or nasal strips help?

No, mouth tape and nasal strips can't help with sleep apnea. Neither treats sleep apnea, and using them to quiet snoring could delay a diagnosis. If you have symptoms that fit, see a doctor first. Proven treatments include CPAP, oral appliances and other options a sleep specialist can talk through with you, which we cover in sleep apnea treatments explained. For more on who shouldn't use mouth tape, see our safety page.

This article is general information, not medical advice. Talk to your doctor or a sleep specialist about your own symptoms.

Read next

• Snoring vs. sleep apnea: how to tell the difference
• What is a home sleep apnea test?
• Sleep apnea treatments explained

* This content is for informational and educational purposes only and is not medical advice. It is not intended to diagnose, treat, cure or prevent any disease or health condition. Talk to a qualified healthcare provider about your health.