Menopause Live - IMS Updates

Date of release: 21 September, 2009

Sleep breathing disorders in women

Sleep complaints, which are very common in the menopause, may have a substantial impact on quality of life, but can be improved by hormone replacement therapy through its beneficial effects on nocturnal hot flushes and sweating, periodic limb movements and bruxism. However, sleep quality may be also affected by sleep breathing disorders, a situation that occurs more frequently in women than in men. The typical breathing disorder is called obstructive sleep apnea syndrome, which is characterized by a history of snoring, sleep disordered breathing in the form of short episodes of cessation of respiration, insomnia, excessive daytime sleepiness, sleep fragmentation and symptoms of restless leg syndrome. It is linked to high morbidity and mortality in both men and women. The disorder was thought to be higher in prevalence in men (4% vs. 2% in men vs. women, respectively [1]), but a new study in the USA has recently shown that 25% of the adult female population is at high risk of having the syndrome [2]. The study analyzed data on 1254 women from the 2007 Sleep in America Poll of the National Sleep Foundation, an annual telephone survey of a representative sample of US adults. The Berlin Questionnaire was used to estimate the risk for obstructive sleep apnea syndrome. Among the women at high risk, common symptoms such as habitual snoring (61%), observed apneas (7%) and daytime sleepiness (24%) were highly prevalent. The risk increased with age (p < 0.05), obesity (p < 0.001) and menopause (p < 0.001).


Previously considered as being due to a structural anatomical abnormality in the upper airway, studies have now shown the relationship of obstructive sleep apnea syndrome with advancing age, menopausal state, high body mass index, the presence of metabolic syndrome, hypertension, diabetes mellitus and polycystic ovary syndrome. It was also found that levels of pro-inflammatory cytokines, such as interleukin IL-6, interleukin IL-1β and tumor necrosis factor α, are elevated in persons suffering from sleep apnea [3]. Independently, plasma levels of leptin were high and positively correlated with body mass index and plasma insulin levels [4]. Cytokines and insulin resistance are promoters of atherosclerosis and cardiovascular disease and have likewise been found to be mediators of excessive daytime sleepiness, particularly in women who have polycystic disease [5]. A large study has shown a modest relationship between obstructive apnea/hypopnea and fasting insulin levels but not with fasting blood glucose [6]. Visceral fat was more positively correlated with sleep apnea than total body fat and subcutaneous fat. The incidence of sleep apnea was noted to be higher also in postmenopausal women due to loss of hormones which leads to an increase in body mass index and abdominal fat. The use of hormone therapy in the postmenopausal women studied in the Women’s Health Initiative and the Sleep Heart Health study showed that hormone therapy decreases the incidence of diabetes and insulin resistance, thus protecting these women from sleep apnea [7].
Use of the Berlin Questionnaire can identify those who are at high risk for obstructive sleep apnea syndrome. This questionnaire consists of three categories: the first includes questions regarding frequent snoring (three to four times per week); the second refers to frequent daytime sleepiness (three to four times per week) or sleepiness while driving; and the third refers to a history of high blood pressure and obesity (body mass index > 30 kg/m2). Physicians in sleep clinics must give more attention to female patients as there is increasing evidence of a high incidence of sleep disorders in women. Early diagnosis and treatment of the sleep disorders may reduce morbidity and improve quality of life.


Joan Tan Garcia
Philippine Society of Climacteric Medicine, Quezon City, The Philippines


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