OSA in Women Barbara Phillips, MS, MSPH, FCCP CHEST President Professor, University of Kentucky College of Medicine

Conflict of Interest Disclosures for Speakers I have the following relationships with entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients: Type of Potential ConflictDetails of Potential Conflict Grant/Research Support Consultant Member of the FMCSA Medical Advisory Board , expert witness Clayton and Beveridge Speakers’ Bureaus Financial support Other Leadership positions, American College of Chest Physicians National Board of Respiratory Care Board of Registered Polysomnographic Technologists The material presented in this lecture has no relationship with any of these potential conflicts

Sleep complaints skyrocket at the time of menopause Sleep apnea increases at the time of menopause Women with sleep apnea present differently from men and are harder to diagnose. Consequences of sleep apnea in women are significant, and treatment of OSA can improve outcomes for women Overview

Sleep Complaints Increase at the Time of Menopause (Young T, Sleep 2003) Peri vs. Pre Post vs. Pre Repeated waking DFA4.18*2.77 EMA Dissatisfied2.01*2.23* EDS * Adjusted for age and BMI

What Disturbs Sleep in Menopause? Hot flashes Depression/anxiety/insomnia Sleep-disordered breathing Moline M. Sleep Med Rev 2003

Sleep complaints skyrocket at the time of menopause Sleep apnea increases at the time of menopause Women with sleep apnea present differently from men and are harder to diagnose Consequences of sleep apnea in women are significant, and treatment of OSA can improve outcomes for women Overview

Menopause and Sleep Apnea ( Young T, AJRRC, 2003, n=589 )

Menopausal State, Age and Weight (Young T, AJRRC, 2003, n=589)

In 5 year follow-up: The effects of gender and BMI change with aging. AFTER THE AGE OF 50, GENDER BECOMES AN UNIMPORTANT VARIABLE. AFTER THE AGE OF 60, BMI BECOMES AN UNIMPORTANT VARIABLE. (Tishler PV, JAMA 2003, n=286)

Changes in Airway Age - MRI findings Soft palate gets longer Pharyngeal fat pads increase in size Shape of bony structures around pharyngeal airway change Response of genioglosus muscle to negative pressure stimulation diminishes Malhotra A, Am J. Med, Midsagittal magnetic resonance image illustrating anatomic structures of interest

Sleep complaints skyrocket at the time of menopause Sleep apnea increases at the time of menopause Women with sleep apnea present differently from men and are harder to diagnose Consequences of sleep apnea in women are significant, and treatment of OSA can improve outcomes for women Overview

Women with Sleep Apnea Are Different from Men Women with OSA are more likely to present with insomnia be depressed have thyroid disease report nightmares, palpitation, and hallucinations have comorbid Restless Legs Syndrome They are less likely to have snoring and witnessed apneas Valipour A. Sleep 2007 Shepertycky and Kryger, Sleep 2005

Insomnia and OSA Insomnia and sleep-disordered breathing co- exist frequently (22-54% ) (Al-Jawder SE Sleep Breath 2012) OSA typically is associated with sleep maintenance problems. Risks for insomnia in OSA are older age, female gender, chronic medication use.

Women with Sleep Apnea Are Different from Men Women with sleep apnea are more likely to Have mild or subtle sleep-disordered breathing (“UARS”) Have more REM-related apneas (O’Connor AJRCCM 2003) Be undiagnosed

The Stereotype….

The Reality.

Sleep complaints skyrocket at the time of menopause Sleep apnea increases at the time of menopause Women with sleep apnea present differently from men and are harder to diagnose Consequences of sleep apnea in women are significant, and treatment of OSA can improve outcomes for women Overview

Unadjusted Survival Curves for CHF (SHHS, Gottlieb, DJ, Circ, 2010)

Unadjusted Survival Curves for CHD (Gottlieb, DJ, Circ, 2010)

Survival of Women with OSA by Treatment Status, n=1116 Campo-Rodriguez Ann Int Med 2012

Can CPAP Help Insomnia in OSA? (Bjorndottir E Sleep 2013, n=705) Patients with OSA and insomnia were evaluated before and 2 years after starting CPAP. Middle-of-the-night awakening was the most prevalent kind of insomnia, and improved significantly among PAP users (59% to 30%). Sleep-onset insomnia was not affected by CPAP Early morning awakening was more likely to improve in those who were not adherent. Sleep-onset and early morning insomnia strongly predicted predicted CPAP non-adherence.

Does HRT Protect Against OSA? Shahar E, AJRCCM 2004, n= 2852 women, aged > 50

Conclusions/Implications (Shahar) Compared with nonusers, HRT users Were half as likely to have AHI > 15 Had worse sleep Had more subjective daytime sleepiness This was not an RCT, and it’s difficult to draw conclusions about HRT and OSA. The prevalence of sleep apnea in this sample was high!

Sleep complaints skyrocket at the time of menopause Sleep apnea increases at the time of menopause Women with sleep apnea present differently from men and are harder to diagnose. Consequences of sleep apnea in women are significant, and treatment of OSA can improve outcomes for women Overview

Resumen Quejas del sueño se disparan en el momento de la menopausia Apnea del sueño aumenta en el momento de la menopausia Mujeres con apnea del sueño presentan de manera diferente a los hombres y son más difíciles de diagnosticar. Consecuencias de la apnea del sueño en las mujeres son significativas, y el tratamiento de la apnea de sueno en mujers puede mejorar los resultados para las mujeres.

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