In midlife, women are told to expect disruption. Sleep may become lighter, nights can feel warmer, and energy harder to come by. Hormones shift, and the body adjusts. But for a large number of women, something else is happening as well: Their airway is collapsing dozens of times an hour while they sleep.
Obstructive sleep apnea (OSA), once framed as a disorder primarily affecting older, heavier men, is increasingly recognized as a far more complex and often undetected condition, particularly in women navigating perimenopause and menopause.
OSA occurs when the upper airway narrows or collapses during sleep, oxygen levels dip, and the brain briefly rouses the body to restart breathing. For years it was framed as a single disorder with a familiar face. Now researchers understand it as far more complex: a heterogeneous condition shaped by different biological mechanisms and expressed through different symptom patterns. Yet the older, larger, male archetype still shapes who gets diagnosed and who doesn’t.
A recent projection in The Lancet Respiratory Medicine journal suggests the problem is far bigger—and more female—than once thought. Researchers estimate that by 2050 nearly 77 million US adults aged 30 to 69 will have OSA, including a 65 percent relative increase in prevalence among women, to around 30.4 million, compared with a 19 percent relative increase among men. The increase reflects aging populations and rising obesity, but hopefully also something more basic: better detection.
Carlos Nunez, chief medical officer at ResMed, which supported the analysis, explains that while over a billion people in the world have sleep apnea, in some countries as many as 90 percent are undiagnosed and untreated. “It is a condition that often lives in anonymity. Most people don’t realize they have it, because you’re asleep when it happens,” he says.
Although OSA can appear at any age—even in children—risk rises, as declining muscle tone makes it harder for the airway to stay open during sleep. For women, however, menopause is a pivotal moment. Studies show that postmenopausal women had a substantially higher risk of OSA. One analysis of a US health survey found postmenopausal women were around 57 percent more likely to report sleep apnea symptoms than premenopausal women, even after adjusting for body weight.
“Women have hormonal protection from estrogens until menopause,” says Marie-Pierre St-Onge, director of the Center of Excellence for Sleep & Circadian Research at Columbia University. Around that time, she explains, fat distribution shifts toward the neck and upper body, increasing pressure on the airway.
Research suggests that estrogen and progesterone have protective effects on breathing regulation and upper-airway muscle activity. As these hormone levels decline after menopause, that influence wanes, which may contribute to a greater likelihood of airway collapse during sleep.
Rashmi Nisha Aurora, professor of medicine and director of Women’s Sleep Medicine Initiatives at NYU Grossman School of Medicine, describes estrogen as a major antioxidant defense. When it declines, protection against oxidative stress weakens, just as OSA itself subjects the body to repeated oxygen drops and inflammatory strain. The result, she argues, is a physiological “double whammy” increasing strain on the heart and metabolic system.
Pregnancy is another time when hormonal fluctuations temporarily increase vulnerability to OSA, Aurora notes.
The paradox is that menopause is also when OSA is easiest to misinterpret, as women’s symptoms—which can differ from men’s—include night sweats, fatigue, and restless sleep, which overlap with menopause itself. “That’s where it’s really overlooked,” Aurora says. “Part of the issue has been case identification and screening.”
The checklists physicians rely on—loud snoring, witnessed breathing pauses, excessive daytime sleepiness—were largely developed and validated in male or mixed cohorts. Many of the most widely used tools for measuring hypersomnia, including the Epworth Sleepiness Scale, were not validated in women across age groups. And the symptom that often triggers CPAP referral, such as excessive daytime sleepiness, may be described or experienced differently by women.
Women’s complaints often lean toward insomnia, mood changes, headaches, or persistent fatigue rather than overt sleepiness. They may report nocturia—“so getting up to use the restroom more often can be a sign,” Aurora says—or fragmented sleep that feels indistinguishable from stress.
Meanwhile, the breathing events themselves can be quieter. A woman “may actually stop breathing and be suffocating multiple times an hour, but it sounds quite quiet,” Nunez says. That subtlety can send patients down familiar detours: insomnia, anxiety, “even depression or other mental health conditions,” as he puts it. Morning headaches or waking sweaty may be dismissed as hot flashes rather than a sign of sleep apnea.
There’s another complication: OSA is not one disease. Researchers increasingly describe it in terms of phenotypes—clusters of symptoms—and underlying biological “endotypes.” A study of 1,886 women diagnosed with OSA found that while many present in the classical snoring-and-sleepiness pattern, others fall into quieter, less obvious categories, including women with few symptoms but significant comorbidities.
Even so-called mild apnea can be physiologically significant. Fifteen breathing disruptions an hour, which is classified as mild, means oxygen deprivation roughly every four minutes throughout the night. Over time, those repeated drops are associated with vascular injury, metabolic dysfunction, and increased risk of cardiovascular disease. Growing evidence also links untreated OSA to cognitive decline and Alzheimer’s.
Although treatment remains straightforward in principle—continuous positive airway pressure, or CPAP, uses pressurized air to keep the airway open—some researchers are beginning to ask whether response to therapy differs by sex.
“There’s evidence that possibly responses to therapy for obstructive sleep apnea might be different in men versus women,” Aurora says. Her team has observed preliminary differences in oxidative stress markers between men and women treated with CPAP. “We need to look at more targeted therapy, more precision medicine and personalized medicine,” she says.
Nunez argues that both sexes benefit from CPAP but does note that the devices are evolving. Algorithms can now adjust pressure dynamically and help account for the fact that “women and their airways respond to different pressures, respond to different parts of the breathing cycle differently than a man will.”
“We’re going to see more advances like that as therapy like this becomes ever more personalized,” he says.
Despite a number of recent studies looking at women and sleep apnea, researchers are emphatic: Further research is needed. Changing hormones often mean women are excluded from certain medical studies, says Aurora, but “that’s exactly why we need to be studied, because we are complicated. We need to be in those clinical trials,” she says.
For now, though, the most urgent shift may be cultural.
“We need to get the word out there more,” Aurora says. “There has to be education at a patient level and provider level. We have to build awareness: It’s not just insomnia; it may be a sign of something else. It’s not just that your bladder is weakening; it may be a sign of something else.”
Nunez agrees that the problem runs deep. “We’ve had a very paternalistic health care system in many countries for too long,” he says. “We mostly study how drugs work in men, how treatments work in men, and now we’re finally recognizing we have to study how things work in everyone.”
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