Obstructive Sleep Apnea (OSA) in women is a distinct condition from OSA in men, characterized by different phenotypes, endotypes, and significant hormonal influences across their lifespan, leading to underdiagnosis and undertreatment.
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Uh the next lecture is by Dr. Carolina
from Brazil.
>> She is aologist and sleep medicine
specialist with a masters and PhD
degrees from the University of Sa Paulo
medical school and postgraduate in
clinical research Harvard TH Chen School
of Public Health of Lang
University. Welcome Dr. Karolina.
>> Hi. Hi all. Thank you for this
invitation. Yeah, just one minute.
>> She'll be talking on OS and women
phenotypes, endotypes and clinical
I need to pass here. Okay. So, thank you
for the invitation. And I would like to
really thank you for the all such great
work the Indians are doing to receive us
here and especially like to thank Dr.
Jessica Schwartz that especially invite
me to be here to talk of such
interesting subject. So today I would
like to invite you to rethink OSA on
women not like a milder form of OSA the
men OSA that we are used to do. So we
will move across the lifespan from the
reproductive years until menopause
and see how phenotypes and endotypes and
hormones shapes this diagnosis in
clinical and outcomes. So first of all
is we know that historically OSA was
considered as a rare or at least in the
first paper 100% male disease but it was
changed in early epidemological studies
we have reports that the ratio for
female to male was one or three or even
one to five. However, this perception
was strongly influenced by the criteria,
the threshold that we use in to diagnose
as OSA. Until the 2005, things are
changing and after this we start to
include some complaints that change the
OSA syndrome to a OSA disease that reach
more women and increase in prevalence.
Also the classical presentation that we
always study is a male presentation with
snoring, daytime sweetness and with
sedapin as however women presented the
phenotype is different. We have more
daytime fatigue, nightmares, morning
headaches, mood disturbance and eating
sonia or complaints of fragments.
Uh this is paper is really interesting.
He showed that sometimes the complaints
they start with uh very different
complaints sleep complaints like
restless legs optations insomnia night
urination so when it's really common in
permenopause women they find this and
don't think about OSA probably they are inside
inside
and actually the problem starts with the screening
screening
even that spike is really use the
episcape was never validated to be used
in women and worse step bang or o as
they are excellent in men but they have
low sensitive in detecting OSA between
women so we maybe are missing them
because even previous the poly
sonography we don't have the suspicions
that women have OSA
and it's getting worse depending of the
poly sonography criteria use we can miss
many women here I I like to show you
compare the third column in blue with
the the fourth this is the prevalence if
I use 3% threshold of decrease
saturation if I use four and this is the
criteria used by Medicare us so we can
decrease from 18 to 12 the women
phenotype phenotype we have women have
lower loop uh loop gain, less air
capsibility, lower arousal threshold in
normal sleep. The obstructive uh partial
is not total obstructions, flow
limitations, more rel respiratory for
related arousals and lower AI. Physiologically
Physiologically
women are different. We have a
pathophysiological different archite
right and worst it cames that sometimes
we have very good two big cohorts the
misa and sleep heart health study
demonstrated that accumulating hypoxmic
burden on women is more associated with
subclinical myioardial injury in women
than men and then with the AI. So we
really need to look for different things
with your treating and diagnosing women.
But why we have this differences?
Why we have are so different?
Because we are totally different. We are
biologically shaped in different ways.
We have hormones that make us totally
different. In women, the upper airways
and lungs are smaller, but we grow proportionally.
proportionally.
So which make more less prone to be collapsible.
collapsible.
Another hand men they have longer
airways and they have the chest are
longer and it makes more um negative
pressure. The fragment the diaphrag
women are shorter tending to be more
resistant to fatigue and supporting more
the brein.
Uh a man for the other hand they have
longer upper airways too. So they tend
to be more collapsible. Also sex uh
sexis hormones receptor are present in
many places in our bodies not just in
the lungs but it influence in all the
development of our faces and our bodies.
But women are not just different. We move.
move. So
So
uh that we have fluctuations of strogens
and progesterone levels through the
different stage of our lives and it
change the ventilatory drive, the
operary stability, the carbon dioxide
sensitivity and the sleep architecture.
We know that estrogen and progesterone
receptors are presented in hypoglossal
and frenic nuclei influencing the
ventilation and stability of operary
hormones affect sleep and we have some
premenop premenstrual loop drops in
drogen that maybe in some women presents
as a premonal dysphoric disorder. So
many of the premenstrual disorders could
be aas and maybe we should think about
this when we are performing PSG to
diagnose women and this is we don't have
even a study talking about this we have
suspicions but we don't have studies
well progesterone it's increase in lut
phase and pregnancy we know that is like
um reducing uh the awakenings increasing
the love waves sleep enhances the
ventilator drive uh turning the car
carboh the CO2 sensitivity higher and
the operator's resistance lower. So acts
like a a protective stimulant for
breathing. The strogen depends on the
progesterone levels and it will more
link it with the fat tissues and the
airway morphology. So it's more
important to think in estrogen when we
are growing and after in sight deposits
and how the sensibility is changing
uh has some cardiovascular protective
effects. So the mainly injuries heart
cardiovascular injuries are linking with
decrease in estrogen and may contribute
to mood disorders and sonia complaints
that we find in OSA women. Testosterone
on the other hand shows a different
thing. The testosterone can increase
ventilatory drive but it's associated
with greater soft tissue mass and which
which predisposed to to aas
exogenous tester to increase the
prevalence and worsen sleeping disorders
and we know that women with polycystic
ovar syndrome are higher risk to sleep
briefing disorder. Right?
But something that is really interesting
to be studying now because nowadays we
have a proof of concept observing the
transgender populations. This is one of
the first studies showing three
different cases. The first case is
really interesting is a trans woman. So
it born a man and became a woman.
uh the long history of severe
obstructive slopa with the AHI 52 after
five months of uh strogen and stroon
drops to 0.5 and most interesting this
drop happens in five months without
body uh body weight or neck
circumference changes. So is really
improving the hormonal effects and the
reduction of testosterone. In this case
the testosterone dropped for 4800
to 0.5.
So this is the about to decrease the
testosterone levels. On the other two
cases we have interesting that are
different. So are women that after
testosterone they develop OSA.
I really think this is interesting and
maybe all is not my population but at
least in Brazil I have every week five
or five different patients post menopes
of women taking testosterone and men
taking testosterone youngly because they
want to have shape or performance. So
exorion testosterone is a reality in my
in my consultation and I think for you
too and this is just the first one many
many many other studies in the last few
years start to show this increasing
study transgender but we can think that
this effect hormone effect will be
changing for everyone.
Let's pass through pregnancy. During
pregnancy the minute ventilation
increased by about 40%. So we have more
instability. We have a decrease in the
fragment elevation. Progesterone softens
the joints creep and alter the geometry
of the previous stable lung that women
have. As a result the abdominal muscles
contribute to more breathing to
compensate reducing the movement of the
rib cage. In the end, what is important
is to highlight how it changed the
pregnancy outcomes. So 20% of women
report pregnancy onset snoring. This
increase the chronic hypertension during
the pregnancy preterm birth precion
and five uh points of risk. the the old
radio uh we have risk of adverse
pregnancy outcomes increased mainly in
obese women with 41% of them being
moderate to severe OSA and early
pregnancy SBD increased the risk of
justestinal diabetes in three
in three points
so finally we reach menopause in
menopause we have 4.5 five increasing of
uh OSA and each year after menopause the
AI could increase 4%.
Vasim motor symptoms frequently
frequently
are associated with uh menopause and
could be independent risk for OSA in
women between four and 6
uh five years old.
The role of fat tissue as a source of
strogen and menopause need to be further
studied. But we know that we have
strogen there too but not in the same
way that we have strogen produced by our uh
uh
our females reproductive system. So I
like to close now with some we have we
need to rethink I think we are talking
about phenotypes and the types that we
don't understand when I show you the
hormones I'm showing how much these
endotypes could be important to
understand how these hormones change
everything and we never think of this
when we are performing a surgery but we
should so OSA in women is not a milder
version of saying man is totally
Um
Yeah they decide I need to stop. So
women I think the women deserve to be
properly diagnosed and treated and to
achieve this we must uh shift the lens
and shift the tools we are using. always
say in women is underrecognized because
we continue applying the phenotype study
for men. Why we don't change it? We not
seeing and we not studying the results
and outcomes also and the hormonal
fluctuations across the lifespan
directly influence ventilatory control
and stability.
Finally, I like to really thank you Daniela
Daniela
and I want to join all of you and few
months in Rio. We wait for all you there
>> Thank you very much. It was a very
interesting talk especially for women. Yeah.
Yeah.
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