Symptoms of sleep apnoea in women: What to look out for

For many women, fatigue, brain fog, and even the occasional headache can all just feel like a side effect of the daily grind. Managing the work-family-life balance is never short of something needing attention after all, and it’s never hard to find a colleague or a friend to commiserate with who’s feeling the exact same way.

But if you’re getting your recommended 7 to 9 hours of sleep a night and still waking up weary, it may be a sign that your exhaustion is not about the demands of your days, but rather what’s happening in your body at night. Sleep apnoea and other sleep disorders can have a serious impact on your overall health, which makes understanding what this particular condition entails and whether you might be experiencing it important.

Here, we'll take a look at what sleep apnoea is, how it might be affecting your health, and how you can treat it to ensure you get a healthy sleep.

What is sleep apnoea?

Sleep apnoea (also known as obstructive sleep apnoea [OSA]) is a sleep disorder where your throat muscles relax too much as you sleep, causing the walls of your throat to collapse and narrow, limiting the way air can travel through. This not only restricts your breathing but also causes vibrations in tissues in the back of the throat, resulting in snoring.

These throat obstructions can be partial (hypopnea) or complete (apnoea), but both can lead to your breathing declining or even stopping for between 10 seconds and one minute as you sleep. When this happens, your body will send a message to your brain that something’s wrong, causing your brain to wake up for a few seconds and ultimately disrupting your sleep cycle. Depending on the severity of your sleep apnoea, this can happen hundreds of times over the course of a night, keeping your sleep fragmented and leaving you fatigued in both mind and body.

While obstructive sleep apnoea is the main form of sleep disordered breathing, there is a rare form too, called central sleep apnoea. In this case, it's less about your throat relaxing and more about how your breathing stops during sleep. In this case, the stop and the pause before breathing begins again are due to a disruption to the mechanisms within your body that control breathing's rate and depth [1].

What causes sleep apnoea?

There are many causes for sleep apnoea, and people with OSA often face more than one, but largely speaking, sleep apnoea is a sleep disorder characterised by the following major factors:

• Weight
• Age
• Certain illnesses such as hypothyroidism, metabolic syndrome or nonalcoholic fatty liver disease
• Certain neurological disorders, such as motor neuron disease
• Large tonsils and adenoids
• Nasal congestion and obstruction
• Facial bone shape and the size of your facial muscles
• Certain medications, such as sleeping medicine and sedatives
• Alcohol consumption [1]

How weight affects sleep apnoea

Of all the factors that contribute to sleep apnoea, weight is one of the most significant — and one of the few you may be able to influence. There's a well-established link between carrying excess weight and obstructive sleep apnoea: when fatty tissue builds up around the upper airway, it narrows the space air has to travel through and reduces the muscle activity that helps keep the airway open as you sleep. The result is exactly the kind of partial or complete obstruction that defines the condition, leading to the drops in blood oxygen and fragmented sleep that leave you so tired the next day [10].

The relationship works in both directions over time, too. A four-year study of overweight and obese adults found that changes in weight tracked directly with the severity of sleep-disordered breathing — those who gained the most weight saw the biggest increase in apnoea episodes, and the risk of sleep apnoea rises alongside body mass index [10]. The encouraging flip side is that this is one of the reasons weight loss is so often recommended as a first step for milder cases: easing the load around the airway can improve both the quantity and the quality of your sleep [10].

If you suspect weight may be playing a role in how you're sleeping — or how you're feeling during the day — it's worth speaking to your GP, who can help you understand what's going on and what support might suit you. Building healthier habits around eating, movement and sleep can make a real difference to how you feel, and you don't have to work it out on your own. The Juniper Programme pairs UK-registered clinicians with ongoing support to help you lose weight and keep it off — a step that can benefit your overall health and wellbeing.

Why sleep apnoea is often missed in women

While anyone can get sleep apnoea, the original studies for this condition indicated that it disproportionately affected men, with men over-30 in particular being three times more likely to develop sleep apnoea than women of the same age [1]. While this largely seems to be true still, it has meant that in the years since, sleep apnoea studies have skewed towards male patients, with women either being left out of or underrepresented in research trials. This has led to a less-informed understanding of how sleep apnoea symptoms present in women, and as a result, underdiagnosis and undertreatment [5].

That said, increasing efforts have been made in the last decade to have women better represented at sleep clinics and in sleep studies, and we’re excitedly starting to see the benefits of that in modern research [5].

The main symptoms of sleep apnoea in women

As our understanding of sleep apnoea has traditionally been based on research focused on men, you’ve likely heard of the main symptoms that affect them, from loud snoring to erectile dysfunction, fatigue, irritability, memory issues and the feeling they've stopped breathing or need to frequently get up to the toilet [2]. While there is definitely some crossover between the symptoms affecting men and women, some symptoms of sleep apnoea are greater felt by, or unique to women.

Fatigue and daytime tiredness

Everyone who experiences sleep apnoea, regardless of gender, is likely to feel fatigue and excessive daytime sleepiness. A disrupted sleep cycle has a significant impact on both the body and the brain’s ability to rest, and the impact of that is really felt most while we’re awake. This fatigue can have serious consequences too, with people with untreated sleep apnoea seven times more likely to be involved in motor vehicle accidents as a result of exhaustion [3].

Insomnia and disrupted sleep

While it’s common not to realise that you’re waking up when your brain reboots during episodes of sleep apnoea, it’s also not uncommon to wake up completely and have trouble getting back to sleep. Studies have shown that this type of insomnia is likely a physical stress response caused by the disrupted breathing sleep apnoea causes, which can have long term affects, including a higher risk of heart disease [6]. In other words, if you find yourself consistently waking up and unable to fall asleep again, it's worth speaking to your doctor.

Morning headaches

Around 18% of people who experience sleep apnoea get early morning headaches, and this has been found to really impact women in particular. These headaches are generally a dull, pulsing ache, rather than a sharp pain, and while the exact reason sleep apnoea causes these types of headaches is unknown, many researchers believe them to be tied to low blood oxygen levels during sleep as a result of the condition. [7] Not a great way to start the day!

Mood changes, anxiety and low mood

There’s a significant link between depression, anxiety, mood changes and sleep, with it often forming a bit of a self-perpetuating cycle. A lack of sleep, or disrupted sleep, causes a low mood, and a low mood can make sleeping an even greater challenge. Depression and anxiety are one of the most common symptoms of sleep apnoea in women, as a result, and contribute often to women being misdiagnosed when it comes to this sleep disorder [6].

Snoring, gasping or choking during sleep

No one really likes admitting that they snore, but the reality is that a lot of us do, and it can be a symptom of disordered or disrupted sleep, which in turn makes it important to acknowledge if you know you do it. Snoring, gasping or choking during sleep is known to be a hallmark of sleep apnoea because it’s generally caused by a partially obstructed airway, which is at the heart of what this condition is, so if you experience any of these symptoms, parking any embarrassment at the door when you speak to your doctor is a must [6].

Difficulty concentrating and brain fog

Another common symptom of sleep apnoea is difficulty concentrating and brain fog. These symptoms can have a significant impact on a person’s daily activities, from their work to their memory to their ability to navigate relationships, and as a result drastically lower someone’s quality of life. The longer these symptoms go on, the more they can contribute to other symptoms too, particularly when it comes to mood and anxiety.

Restless leg

One of the symptoms that is significantly reported by women over men with sleep apnoea is restless legs. This symptom involves leg jitters, or an unpleasant sensation in the legs that creates the need to move them. Some research has indicated that restless leg symptoms might be particularly tied to hormonal changes affecting women during pregnancy and menopause [6].

How sleep apnoea symptoms differ from men's

Studies have found that women do tend to disclose more mental or emotional symptoms rather than physical symptoms, with the main ones being insomnia, restless legs, depression and nightmares, whereas men tend to report more physical symptoms such as snoring, erectile dysfunction and waking episodes [1][7]. This could partially be because women, generally speaking, feel more comfortable disclosing emotional symptoms than men, while men feel more comfortable disclosing physical symptoms, but the differences are worth acknowledging, particularly when speaking with your doctor.

Both men and women who are diagnosed with sleep apnoea, though, report experiencing fatigue, brain fog, and daytime tiredness [2].

Sleep apnoea, menopause and hormonal changes

Hormonal changes can play a really big role in the development of sleep apnoea, as they generally involve physical changes that can alter the way the body functions. In particular, during pregnancy, women can experience changes in their upper airway or in the way their brain controls breathing, which increases a woman’s risk of developing sleep apnoea, or, if she already has it, make it worse. [2]

Similarly, during and after menopause, studies have shown that women’s risk for sleep apnoea and upper airway obstruction increases. This is largely a result of decreasing estrogen and progesterone levels, two hormones that help to keep your throat open for breathing, but also a product of the very common weight gain that happens during this chapter of a woman’s life, particularly around the neck. Weight loss and other treatments might be recommended [9].

Women who have polycystic ovary syndrome (PCOS) may also have an increased risk of developing sleep apnoea and breathing pauses during sleep [2].

Risk factors for sleep apnoea in women

While sleep apnoea itself may feel like it impacts your life in ways that are more minor annoyances than major medical events, it can have a significant cumulative effect on your overall health. Severe OSA can cause ongoing harm to your blood vessels, leading to an increased risk of high blood pressure, and has been linked to cardiovascular disease, heart arrhythmias, chronic obstructive pulmonary disease, congestive heart failure, heart attack and stroke [1].

Women with sleep apnoea have been increasingly linked to cardiovascular risk, particularly women who have a medical history of hypertension during pregnancy and gestational diabetes, preterm delivery, polycystic ovary syndrome, or who have had a history of breast cancer treated with cardiotoxic chemotherapy or chest radiotherapy [5]. If you have experienced any of these factors in your life, and have been diagnosed with, or are symptomatic for sleep apnoea, you should speak to your doctor.

Adults with untreated sleep apnoea have also been found to have a higher risk of diabetes, memory issues, and depression [4].

When to see your GP about sleep apnoea

If you or your sleeping partner is experiencing any of the symptoms listed above, suspect sleep apnoea, or has concerns about your sleep patterns, you should speak to your general practitioner to discuss sleep disorders. Restful sleep is vital to good health, and if a person stops breathing for any period of time, no matter how brief, it can lead to health complications that go well beyond daytime fatigue and disruptive snoring.

How sleep apnoea is diagnosed and treated

To diagnose sleep apnoea, you need to speak to either a GP or a sleep specialist. The diagnostic process will generally involve a physical exam, an assessment, and a sleep study to get to the root cause of any excessive sleepiness.

The sleep study is conducted by a sleep physician and is a type of medical test that is used to diagnose a range of sleep disorders, including sleep apnoea. In it, you are attached to a portable machine with monitoring leads attached to your finger, scalp and chest that will measure your brain signals, the oxygen levels in your blood, your sleep position and limb movements, heart rate, breathing and snoring as you sleep throughout the night. It can be done at home via a home sleep apnoea testing kit or by staying overnight in a specialist sleep clinic [1][3].

If you’re diagnosed with sleep apnoea, you’re in luck – it’s a very treatable condition! What treatment options look like though will depend on the severity with which you have it, with mild sleep apnoea cases only really requiring some lifestyle changes like weight loss or cutting down on your alcohol intake, or switching up your sleeping position, to more moderate cases being treated with a mouthguard or a machine and mask known as CPAP therapy which pushes increased air pressure into the airway to prevent the throat from collapsing (a process known as nasal continuous positive airway pressure therapy), to severe sleep apnoea cases being treated with internal medicine to generate upper airway stimulation including an upper airway surgery to create more room in the throat and keep the airway open [1][3].

All of these treatment plans should be made with healthcare professionals.

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