Original ArticleWomen with symptoms of sleep-disordered breathing are less likely to be diagnosed and treated for sleep apnea than men☆
Introduction
Sleep-disordered breathing (SDB) is a prevalent condition ranging from upper airway resistance to severe obstructive sleep apnea (OSA) with intermittent hypoxia and sleep fragmentation throughout the night. It is typically characterised by symptoms of loud snoring and excessive daytime sleepiness (EDS). Identifying at-risk patients is crucial, as treatment attenuates long-term health effects [1], [2], [3], and both snoring and OSA are associated with cardiovascular disease, stroke, diabetes mellitus and mortality [4], [5], [6], [7], [8], [9].
Community-based surveys reveal that SDB is about twice as common in men compared with women [10], [11], [12], [13], [14]. Women are, however, systematically underrepresented at sleep clinics, with only 20% or fewer females frequently represented in cohorts from clinical laboratories [2], [3], [15]. As a result, less is known about the long-term health effects of SDB in females. In a recent review, Won et al. concluded that, although the prevalence of SDB is lower in females, the consequences of the disease appear to be similar, or worse [16].
The reason why women are under-represented at sleep clinics is unclear. It has been speculated that the symptom profile of women with SDB differs from that of men [17], [18], but studies designed to identify specific SDB symptoms in women have failed [19], [20]. Instead, several studies have reported that snoring and EDS are the predominant symptoms in patients with OSA in both genders [15], [17], [19], [21]. However, women report EDS more frequently than men [22] and sleepiness might hence be a less reliable predictor for SDB in women than in men. Another possibility is that women may be less symptomatic at an early stage, as a result of which they are not referred for assessments of sleep apnea until they develop symptoms. The hypothesis is therefore that men and women with the same level of symptoms are diagnosed and treated to the same extent.
We aimed to analyze whether men and women in the community with symptoms of SDB (ie, snoring and daytime sleepiness) are equally diagnosed and treated for OSA. Another objective was to investigate whether snoring men and women with daytime sleepiness run the same risk of developing hypertension and diabetes mellitus.
Section snippets
Study population
The Respiratory Health in Northern Europe (RHINE) study II and III are the first and second follow-up of a population-based cohort from seven Northern European centres (Bergen in Norway; Umeå, Gothenburg and Uppsala in Sweden; Aarhus in Denmark; Reykjavik in Iceland and Tartu in Estonia) (www.rhine.nu). The cohort was initially recruited as part of the European Community Respiratory Health Survey (ECRHS) stage I (www.ecrhs.org). Random population samples of men and women born in 1945–73
Results
The study population comprised 4962 men and 5892 females aged 26–54 years at baseline. Men were generally somewhat older, more obese and reported hypertension and current smoking more often than women, while ex-smoking was overrepresented among women (Table 1). Snoring was reported by 25.9% of men and by 10.9% of women (p < 0.001). EDS was more common in females than males (23.8 vs. 18.4%, p < 0.001) but the prevalence of EDS was significantly higher among snorers compared with non-snorers in
Discussion
The main finding in this community-based prospective study is that women with SDB symptoms are less frequently diagnosed and treated for sleep apnea than men. We also found that men and women with SDB symptoms ran an equal increased risk of developing hypertension and diabetes mellitus.
There is no clear explanation of this gender difference in being diagnosed or treated for sleep apnea. As far as we know, there are no data supporting the hypothesis that snoring is associated with sleep apnea to
Conclusion
Snoring females with daytime sleepiness are less frequently diagnosed and treated for sleep apnea compared with males, despite running a similar risk of developing hypertension and diabetes mellitus. We recommend that physicians be more cognizant of sleep-disordered breathing in females and also ask females about symptoms of snoring and daytime sleepiness; referrals for those females with positive answers for sleep apnea recordings should also increase.
Authors' contributions
All authors have provided substantive contribution in study design, data collection and interpretation of results. Eva Lindberg performed the data analysis and wrote the first manuscript draft. All authors contributed substantially to revising the article critically for important intellectual content, and to final approval of the version to be published.
Acknowledgments
The work was performed at the Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Sweden. Eva Lindberg had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The Respiratory Health in Northern Europe study (RHINE) was funded by the Norwegian Research Council (Grant 214123), the Icelandic Research Council (Grant NA), Aarhus universitet (Grant 240008), the Swedish
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All authors declare that the article submitted is not related to any financial interest/relationship.