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.