Post-Menopausal and Not Sleeping? It Could Be Sleep Apnea

Beth, 62, a nutritionist from New Jersey, says she never has been a "great sleeper," but in recent years after menopause, "it's become worse. I was ruminating. And like many women my age it's not for nothing — there are things to ruminate about — but I just couldn't fall back to sleep."

She followed the tips and tricks for sleep hygiene that she'd read about in magazines, but nothing worked. So last year, she went first to a sleep specialist and then to her primary care physician. "I wanted to check every option because [the lack of sleep] was really interfering with the quality of my life," she says. She assumed that her sleep issues must be related to age and the post-menopausal complaints she and all her friends shared regarding night sweats, hot flashes and temperature regulation. Surely, they were what was waking her, she thought.

She did an at-home sleep study and was shocked to learn that she "woke up 30 times an hour, and [in some instances] didn't breathe for 30 seconds at a time" — the classic definition for severe Obstructive Sleep Apnea. "I was shocked," says Beth, who had none of the risk factors associated with OSA.

Beth is not alone. Approximately 39 million U.S. adults have OSA, the most common form of sleep apnea. And it's prevalent in about 15%-30% of males and 10%-15% of females, according to an August 2024 report from the physicians research site UpToDate.

In OSA, breathing ceases (apnea) or decreases (hypopnea) in short bursts "when the back of your throat is blocked or constricted in your sleep," says Sullafa Kadura, M.D., who specializes in internal medicine and sleep medicine at the University of Rochester Medical Center in Rochester, New York. The other form is Central Sleep Apnea, in which the brain doesn't send the right signals to the muscles that control breathing.

The majority of women with OSA are post-menopausal. "Pre-menopause, women are less likely than men to have sleep apnea. In the perimenopausal stage, when someone is transitioning into menopause, that prevalence for sleep apnea goes up to 1 in 4 women, and when they're post-menopausal, the likelihood of sleep apnea is 1 in 3, a similar prevalence to men of the same age," Kadura says.

According to the American Academy of Sleep Medicine, about 80% to 90% of adults go undiagnosed for OSA. Experts agree women in particular go un- or underdiagnosed and that can be a huge problem for their future health outcomes.

Menopause and its myriad symptoms are partly to blame. Men with sleep apnea — or their bed partners — typically report snoring or gasping for breath during the night. They complain of sleepiness during the day. Women present differently. They complain of joint pain, hot flashes, night sweats, insomnia, tiredness, concentration issues, trouble falling and staying asleep — symptoms that overlap with an extended list of sleep apnea symptoms, but "which can be chalked up to menopause," Kadura says.

If a doctor is "using a classic definition of sleep apnea, and it's not on their radar for women, it's kind of like a formula for them to ignore it," and dismiss the symptoms as menopause, says Meagan Williams, M.D., the director of women's health at Harbor Health in Austin, Texas, and clinical assistant professor at Dell medical school at the University of Texas at Austin.

In addition, says Andrea Matsumura, M.D., an internal medicine/sleep medicine physician in Portland, Oregon, the data on sleep apnea is skewed because of gender bias. "Women weren't involved in any studies around sleep apnea until 1993 because of hormones [under the assumption hormones would impact the data]. Subsequently, screening tools are biased, and they're focused on symptoms related to men."

There's a certain irony in that the hormones involved in a woman's transition to menopause would in fact affect the data. Estrogen, which helps with muscle tone in the upper airways, and progesterone, which is a respiratory stimulant, both decline during menopause. "Before menopause, these hormones can help stabilize our breathing and actually may reduce the risk of OSA. Once a woman starts to go though the transition, these hormones start to decline, and the risk for sleep apnea increases," explains Suzette Johnson, M.D., a board-certified gynecologist with Atlantic Health System in New Jersey.

It might seem that hormone replacement would be an answer to the problem. But there are limited studies and mixed results on the few studies that have been done, Johnson says. "Hormone therapy is not a first line of treatment for a woman who has a diagnosis of sleep apnea. We need more studies and more awareness."

Ultimately, says Monica Christmas, M.D., associate medical director for the Menopause Society (formerly known as the North American Menopause Society), "it's not enough to say [these symptoms] are due to menopause. It's really looking at each person individually, and at all of their risk factors and saying, 'You're having sleep issues' and evaluating them for sleep apnea should be at the top of the list."

It is no small thing to wake up many times during the night deprived of oxygen. Women (and men) are more at risk for "hypertension, coronary artery disease, heart failure, stroke and diabetes," Johnson says. "When you're in this low O2 environment, there is some impact on your brain so there's possible cognitive decline, increasing risk of dementia, depression and anxiety because you're sleeping poorly. Women going through the transition to menopause are already having a lot of anxiety and depression and now they're having sleep apnea on top of it."

While Beth went straight to a sleep specialist, most people start with their primary care physician. Unfortunately, because of lack of knowledge and possible gender bias, women may not get the care they need. Even women who think they don't have the risk factors for sleep apnea — being overweight, snoring, having a family history — should ask their doctor to consider it if they are peri- or post-menopausal. The doctor can at least order up an in-home sleep test, which is far less expensive than an overnight stay at a sleep lab, and which insurance might be more inclined to cover.

But be aware, says Katherine Sharkey, M.D., medical director of the Sleep for Science Research Laboratory at Brown University, that the in-home study "only records breathing. What's missing is the brain [study]." Patients might have "arousals [wake ups] that need to be measured by an EEG [electroencephalogram] that don't get scored and get overlooked, which can underestimate sleep apnea." And with each of those arousals, there is a chance to wake all the way, which is "suboptimal," Sharkey says. "As we [transition to menopause] one of the things that changes is that the depth of our sleep isn't as deep."

If, like Beth, someone stops breathing 30 times in an hour, it might be an easy diagnosis. As Sharkey says, "if it looks like a duck and quacks like a duck, it's a duck." But there are varying levels of sleep apnea: severe, 30 or more respiratory events per hour; moderate, 15 to 30 per hour; and mild, 5 to 15 per hour. A night in a sleep lab will give a much broader picture by studying brain waves, eye movements, heart rhythms and air flow.

After her diagnosis, Beth got a CPAP (continuous positive airway pressure) machine, which is the most common device for those with OSA, but there are oral appliances such as a mandibular advancement device, which pulls the lower jaw forward to open the airway. There is even an implanted device, that can be used in certain cases, Matsumura says.

Patients should check with their insurance company for what it will pay for in terms of studies and devices and know that insurance doesn't always cover mild sleep apnea unless there is a comorbid condition.

"It's a thing to wear this at night," Beth admits. "You have to feel comfortable with your partner. And it takes time to get used to." She says the CPAP does help, but she admits she's not consistent and it adds to her worries. "I know my risks for stroke, for cardiovascular disease is way higher with sleep apnea. It's mind blowing to think of the risks. Here, I have this healthy lifestyle but all this increased risk due to sleep apnea."

Stacey Freed 
Stacey Freed is a freelance writer who covers construction, lifestyle issues, education and pets. Her work has appeared in The New York Times, AARP.org, Forbes.com, Real Simple and USA Today. She is the co-author of "Hiking the Catskills: A Guide to the Area’s Greatest Hikes." Read More