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Upper Airway Sleep-Disordered Breathing in Women

Christian Guilleminault, MD; Riccardo Stoohs, MD; Young-do Kim, MD; Ronald Chervin, MD; Jed Black, MD; and Alex Clerk, MD
[+] Article, Author, and Disclosure Information

From the Stanford Sleep Disorders Clinic and Research Center, Palo Alto, California. Toyama Medical and Pharmaceutical University, Toyama, Japan. The Sleep Disorders Center, Ann Arbor, Michigan. Requests for Reprints: Christian Guilleminault, MD, Stanford Sleep Disorders Clinic and Research Center, 701 Welch Road, Suite 2226, Palo Alto, CA 94304. Acknowledgment: The authors thank Michael Gulevich for editing the manuscript. Grant Support: In part by grant AG 07772 from the National Institute of Aging and by GCRC grant MO1 RR 00070 from the National Institutes of Health.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1995;122(7):493-501. doi:10.7326/0003-4819-122-7-199504010-00003
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Objective: To investigate the various clinical presentations of sleep-disordered breathing in women.

Design: A retrospective case–control study.

Setting: A sleep disorders clinic.

Patients: 334 women, aged 18 years and older, seen between 1988 and 1993, who were diagnosed with upper airway sleep-disordered breathing. Controls were 60 women with insomnia and 100 men with sleep-disordered breathing.

Measurements: Clinical, anatomic, and polygraphic information.

Results: The mean lag time (±SD) in women between the appearance of symptoms and a positive diagnosis was 9.7 ±3.1 years; among participants 30 to 60 years of age, the duration of untreated symptoms differed (P <0.001) between women and men. Sleep-disordered breathing was blamed for divorce or social isolation by 40% of the case patients. Abnormal maxillomandibular features were noted in 45% of the women with disordered breathing. Dysmenorrhea and amenorrhea (which disappeared after treatment with nasal continuous positive airway pressure) were reported in 43% of premenopausal women compared with 13% of persons in the control group of women with insomnia. Thirty-eight women (11.4%) with upper airway sleep-disordered breathing had a respiratory disturbance index of less than 5 and were significantly younger, had a smaller neck circumference, and had a lower body mass index than women with a respiratory disturbance index of 5 or more.

Conclusion: Physicians should revise their understanding of upper airway sleep-disordered breathing so that they notice women with certain craniofacial features, a low body mass index, a small neck circumference, and a respiratory disturbance index of less than 5. These revisions may enable more rapid diagnosis and treatment of women with sleep-disordered breathing.


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Figure 1.
Polygraph showing a progressive increase in respiratory effort over time in a woman with symptoms of sleep-disordered breathing.eses1321322es

This 36-year-old woman had symptoms of daytime fatigue and sleepiness in quiet situations. Note that the end-inspiratory pressure peak became progressively more negative; this peak was monitored with the esophageal catheter (P ) on the second channel from the bottom. When the respiratory effort became too great (as indicated by P monitoring), an arousal occurred. It took 15 minutes for the arousal to occur without any monitored oxygen saturation change. Air flow = nose and mouth thermistors; chest = Respitrace (Ambulatory Monitoring, Inc., Ardsley, New York) recorespiratory disturbance indexing (that is, thorax and abdomen); A , C , and O are electrode placement sites (A = left auricular, C = left central, and O = right occipital); EEG = electroencephalogram; EKG = electrocardiogram indexogram (modified V lead); EMG (channel 3 from top) = chin electromyogram and (channel 7 from top) leg electromyogram; EOG = electro-oculogram; Mic = microphone (note the absence of snoring); and P ( ) = esophageal pressure. The last channel measures oxygen saturation obtained from finger pulse oximetric recorespiratory disturbance indexing.

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Figure 2.
Duration of symptoms in men and women as a function of body mass index (top) and age (bottom).

Bars indicate standard deviation.

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Figure 3.
Anatomic abnormalities in a woman with symptoms of sleep-disordered breathing.lefttop rightbottom right

This woman had a respiratory disturbance index of less than 5 and daytime tiredness. Note her slim neck ( ), overjet ( ), and high ogival hard palate ( ).

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Figure 4.
Percentage of women with sleep-disordered breathing by respiratory disturbance index.

Note that 12% of the participants had a respiratory disturbance index of less than 5.

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