Inside Women’s Sleep Health: Key Influences Across the Lifespan

Welcome everyone to the women's sleep health webinar series on behalf of the American Academy of Sleep Medicine. Uh

the title is uh inside women's health uh women's sleep health across the lifespan and we'll be covering biological

clinical and socioultural perspectives and I welcome you on behalf of myself.

My name is Dr. Reena Mera. I'm a

professor of medicine at the University of Washington and my colleague and co-odder co-odderator Dr. Gonzalo Labara

um who is uh at uh the Mayo Clinic College of Medicine and Science.

And I'll first just review some housekeeping issues before we get started. Uh we'll just ask that you have

started. Uh we'll just ask that you have your audio muted and your camera off please. And we will be taking questions

please. And we will be taking questions uh answers to to questions a question and answer period. um at the end of the

session. So, we'll um have the speakers

session. So, we'll um have the speakers speak and then if you could just put your uh questions into the uh Q&A and

then we will review those at the end of all of the presentations.

Uh and just to remind everyone that this webinar uh is recorded.

So, welcome everybody to this webinar.

Um for today agenda we have the welcome and speaker introduction. Then we have a patient story. Then the first lecture

patient story. Then the first lecture sleep in woman across the lifpan with Dr. Drosio. Then we have the difference

Dr. Drosio. Then we have the difference in diagnostic and treatment responsiveness with Dr. Cynthia Perea.

Then the social and cultural influence with Dr. Molly Billings.

um later the AASM women's health task for update and we will finish this webinar with a question and answer section.

Our first speaker is Katie Paige. Katie

is retired after 24 years working for an electric cooperative. She was diagnosed

electric cooperative. She was diagnosed several years ago after a sleep study for another resive issue and has used CPAP therapy ever since. Because of the

struggle she has with her hip hop therapy, she focused much of her time in on adurance and advocacy. Kitty served

in several organization including myabnia.org.

myabnia.org.

She has served in NIH meeting PCRI grant funding and she also served in participant in three FDA grant post

processes as a patient specialist. She

also participated in drafting the sleep apnnea women's or the society for women's health research. So Katie

please share your story with us. Yeah.

Statistics show that slightly more women than men struggle with sleep issues such as insomnia and restless leg syndrome, sleep apnnea and narcolepsy.

Statistics show that women suffer in with insomnia 40% more than men. Waking

up to use the bathroom at night affects 76% of women and 69% of men. It's

estimated that up to 90% of women go undiagnosed for sleep apnnea.

Statistics like these are great for doctors, clinicians, and researchers.

But women want results, not statistics.

Women need answers that statistics don't give.

Every woman is different and the sleep problems that we face vary due to age, situation, and lifestyle. But for many, sleep problems are only part of the

frustration.

It's the lack of empathy and simply not listening to understand from the medical community that causes women to just give up looking for help.

As a young mother, I went to the doctor because I was always tired and my legs were jumping around. I was told that I should be tired dealing with three little ones and I should just take

aspirin for the pain. He left the room focused on leg pain, which I did not have. A few years later, I went back

have. A few years later, I went back with the same issues.

Of course, you're tired. You work

full-time and you have a family. let's

try a painkiller for your leg pain. And

out the door he went without acknowledging that I had told him I didn't have any pain. I did research on my own and figured out that part of my

problem was restless leg syndrome.

That research helped me when I was finally found a doctor who would listen to me and believe in my symptoms. Later, I had a sleep study done and was

told that my oxygen levels went down to 86%.

And I needed to be on CPAP immediately.

And then the doctor said someone would contact me and out the door he went before I could process anything at all.

I did not have any idea what I was dealing with. I knew I did not want to

dealing with. I knew I did not want to look and sound like Darth Vader by wearing a CPAP mask. And I actually thought 86% wasn't bad at all. It was a decent grade

in high school.

So with no real information, I went back to looking online because I was in denial about using CPAP.

Now then, after discovering what damage low oxygen could do to my body, I finally agreed to CPAP therapy.

They told me I would probably start out with a nasal pillow and left it. a

pillow. I couldn't find anything on the internet of any kind of pillow that would help me with my sleep apnea.

When they actually fitted me for a mask, they did so while I was sitting up and they told me, "Whatever you do, do not move these straps. We have it exactly

where it needs to be. Here's your onoff button." And they sent me on my way.

button." And they sent me on my way.

When I got home and laid down, the mask leaked horribly.

I adjusted the straps.

Now, my story is really only interesting because it shows what too many women go through. Our symptoms are often ignored

through. Our symptoms are often ignored or downplayed.

Many times, we're diagnosed and then turned loose to deal with the details on our own. We're often given treatments

our own. We're often given treatments because they are the popular one for the issue, not because it's the right one for us.

And women still usually go along with whatever the doctor says because he is the doctor and he's always right. We are

not allowed to question them.

Many times we don't even know what questions we should ask. We don't know what we don't know or we don't think of what questions to ask until much later and then we can't get back in with the

doctor for answers.

I do believe any patients, but especially women, need to be educated and informed how to build a relationship with your doctor. I believe women need

to research their issues from reliable sources.

I joined support groups that were great sources of support and learning that I wasn't alone with my issues, but those groups seldom had any

viable in suggestions for actual help.

I am absolutely thrilled about this webinar that we're having because I know that it can h help advance patient care especially for women and I'm uplifted that the medical

community cares enough to be a part of this. However, it would be even better

this. However, it would be even better if women in the general public knew about the substance of these webinars, about the changes that might come and

about the fact that someone is listening and wants to help. Well, there's an excellent information on the internet about women and sleep. Women don't often

have the time or the internet access or energy to look for it. Plus, finding the right information among all the junk out there is daunting.

The bottom line here is that women do not get the help they need for a vast number of reasons.

And initiatives like this can change, but those changes take time. How do we let women know that change is coming?

How do we educate patients on what their responsibilities are in managing their health?

Where do they go for quality information?

Where are the leading hospitals and doctors?

Women in rural areas especially need information about quality health care because it's often lacking in their area.

Clinicians need evidence-based patient- centered information on the key issues of women's health. To have that, more women need to be heard and understood. The reason for these

understood. The reason for these webinars is to understand what sleep health looks like for women.

Let's make sure women's voices are coming through loud and clear. Let's

make sure they know they are being heard and they are not alone.

Let's give them hope for the future and a reason to hang on.

Thank you for including me in this webinar.

Thank you so much Kathy for sharing your story. Um it really just highlights how

story. Um it really just highlights how much we how how much we have to do to address these important issues that

you're raising. Um and you're right. I

you're raising. Um and you're right. I

think this webinar um allows us the space to be able to discuss some of these issues. Incredibly

important for you to to share this story, which unfortunately I don't think is uncommon. um with symptoms being

is uncommon. um with symptoms being dismissed in women um information not being effectively communicated and

relayed in a in a shared decision-making model and the empathy that you so deserve in in these situations. So

again, thank you very much. We're very

grateful that you could join us uh to share your story.

Um and with that we'll go ahead and have uh our next speaker uh Dr. Carolyn Drosio. It's a pleasure to uh introduce

Drosio. It's a pleasure to uh introduce her. Uh she is associate vice chair of

her. Uh she is associate vice chair of medicine for education, director for pulmonary medicine and professor of medicine at the University of Miami. Uh

in addition to teaching and clinical work, Dr. Dr. De Rojo has conducted research on sleep and menopause. She's

studied sleep and breathing in infants and she's participated as a sleep medicine expert in several systematic reviews on home sleep apnea testing and

fixed versus autotitrating CPAP. We are

very um so happy to have Dr. Dembro uh join us today and she will be speaking on sleep health in women across the lifespan.

Thank you for that kind introduction and thank you to the American Academy of Sleep Medicine for putting this on. It's

a great service to all of us. And Kathy,

I think I'm going to reiterate a lot of what you said here. So, um those are my disclosures and then let's start off

with a nice diagram showing um girls all the way up to aging uh women. And this

is just a nice diagram showing us some sleep measures. wake after sleep onset

sleep measures. wake after sleep onset REM, total sleep time, naps, and then P is for progesterone, E is for estrogen.

And so you see in the child there's no really established sex differences.

Estrogen and progesterone are flat.

Total sleep time remains the same. Naps

go down as the child ages. REM goes down and wake after sleep onset. Then when we get to adolescence and puberty when

reproductive hormones start increasing um in sleep we do see that uh total sleep time is more reduced than in childhood REM and wake after sleep onset

stabilize. We do see though an uh

stabilize. We do see though an uh increased activity of sleep spindles um in non-REM sleep. During reproductive

years quite a bit happens during sleep.

Um there's an increased risk of sleep disordered breathing particularly during pregnancy and in obesity uh during these years and you can see the um uh menstrual cycle here with the rise in

estrogen in the first half ovulation is the dotted line and then the rise of progesterone in the second half and then non-rem sleep spindles happen in the

ludal phase which is after ovulation during pregnancy there are so many factors and I will have a couple slides on this that interfere with sleep and an increased risk of different sleep

disorders. Estrogen and progesterone

disorders. Estrogen and progesterone rise. Uh the first and third trimesters

rise. Uh the first and third trimesters are the worst for sleep with um an increased need for naps, lower total sleep time and um increased wake after

sleep onset. Then once pregnancy is over

sleep onset. Then once pregnancy is over and the reproductive years are done, menopause hits, which is probably uh the area that um uh where you hear the most

sleep complaints I would say as a sleep doctor is post-menopausal women or permenopausal women. We have the uh

permenopausal women. We have the uh alternating and up and down uh estrogen, progesterone until they finally uh taper off uh with lots of wake after sleep

onset, lot of sleep fragmentation and particularly from vasom motor symptoms. And then in aging both male and female there are circadian rhythm disorders

with typically advanced sleep phase um and mood disorders tend to be more common in this age group. So just a quick overview of just simple stuff that happens with sleep and then let's dig

into it a little bit deeper.

So for uh women, women being a term for gender, right? It's a societal construct

gender, right? It's a societal construct versus sex, which is the XX versus XY.

Um for sex, there's endogenous features such as the sex hormones, which we talked about in the different stages of those. Um lung size, anatomical

those. Um lung size, anatomical features. Lung size is important in

features. Lung size is important in sleep disordered breathing. And then um the sex specific regulatory networks play a part here. And then of course

gene expression as we all know for gender which is the more uh societal factors, things that affect sleep. Uh

everything you can think of socioeconomic status, environmental and occupational exposures um particularly environment exposure for

sleep, right? a loud if you live in a

sleep, right? a loud if you live in a loud area or I had one patient who had a street light right outside her window.

Not much she could do um even with really thick shade she still got that light all night long risk-taking behavior and then of course DNA

modification um etc factors in. So lots

of things that can contribute to women's difficulty with sleep.

So with menarch and puberty we get the um introduction of the reproductive hormones that have a significant influence as I had mentioned before but this is where insomnia starts for women

right in the teenage years and in uh this older study from uh for people 15 to 30 years old it's almost a third 28% higher rate of insomnia and I think

that's probably higher now after the pandemic where anxiety and insomnia has peaked in the teenage years and then as I mentioned before the sleep spindles at in the ludial phase.

And let's just take us a minute to look at the menstrual cycle in a little bit more detail. Um, so this is what we

more detail. Um, so this is what we talked about earlier, the uh sex hormones FSH and LH here. They peak

during ovulation, then go back down. And

then for the felicular phase, just right before ovulation, you have increased upper airway resistance and a decrease in genoglossal muscle activity. So this

is where um women with the reproductive hormones during that age uh have an increased risk of sleep disordered breathing and I said before um pregnancy and obesity do increase that risk and

then in the ludal phase those are better so you have a reduced upper airway resistance and increased genial glossal muscle activity

other things that affect uh women's sleep uh particularly during pregnancy I think there's uh a lot of sleep complaints during during pregnancy. And

of course, pregnancy in and of itself does make uh the patient feel tired or the woman feel tired. Uh but as Kathy said, somebody needs to listen to that and tease it out a little bit more and

not just brush it off. Say, "Oh, you're tired because you're pregnant or you're tired because you have three little kids." In the first trimester, most

kids." In the first trimester, most women will um comment on having to get up to urinate at night and having a lot of um muscularkeeletal pain. Second

trimester is when the fetus starts moving. You get some uterine

moving. You get some uterine contractions and a fair amount of rhinitis and nasal congestion due to the um increased blood volume and swelling of mucosal tissue. Then in the third

trimester, uh pretty much everything happens here. It's very uncomfortable.

happens here. It's very uncomfortable.

People have a very difficult time sleeping particularly as they get closer and closer to the due date. Heartburn,

orthopia, leg cramps come in. And also

throughout all of pregnancy, you can increase risk of insomnia and restless leg syndrome as well as obstructive sleep apnnea uh which I'll talk about in

uh I believe the next slide increasing during the different trimesters and then nobody can get into a comfortable sleeping position. It's really quite the

sleeping position. It's really quite the challenge um particularly in the third trimester.

And so during pregnancy, um about a quarter of women will report snoring.

And um so many times I've heard about patients telling me that they've told people that they were snoring and they think it's cute or it's funny, but it actually, as we all know, can be a sign

of obstructed breathing. So snoring and upper airway resistance are associated with an increased risk of pregnancy induced hypertension, preeacclampsia, and adverse fetal outcomes. higher BMI

and a greater neck circumference are are risk factors for developing OSA in pregnancy. And remember, we do have some

pregnancy. And remember, we do have some patients with OSA before they get pregnant and then pregnancy increases potentially the severity of that uh obstructive sleep apnnea.

And so snoring is actually the most present during the third trimester with up to some studies showing 49% of pregnant patients in the third trimester have snoring. And the prevalence of

have snoring. And the prevalence of obstructive sleep apnnea for those who have been studied goes from about 8.5% in the first trimester all the way up to

again that 49% in the third trimester.

Really really significant and we have to keep our eyes on that. The usual

screening questionnaires that we use up for sleepiness scale stop bang etc are not are poor predictive poor predictive measures for pregnancy. And let's just

take a second and look at stop bang. I

find this to be used very very frequently um amongst most people that I know um and people will refer patients to me and they'll have the stop bang and the referral. The problem is it was

the referral. The problem is it was validated for pre-operative uh risk of OSA. The biggest problem for women is

OSA. The biggest problem for women is that G in the bang is for gender. So

already they start off with a lower number and then for pregnancy age is uh another factor. So

another factor. So the way to do this if you haven't used it before is greater than or equal to three positives on this list is a high risk for OSA. But if women are already

starting off with um one or two measures below I think that greater than three items um under leads to underdiagnosis.

So for pregnancy, I would take the age out and I always take the G out and then I have a lower risk. I have a lower overall number when I think about risk

for OSA.

This is a great study um now published a few years ago of over 3,000 pregnant women who had home sleep apnea testing during early and mid pregnancy. In early

pregnancy you can see the odds ratio adjusted odds ratio for pregnancy induced hypertension 1.46 46 a little bit higher in mid- pregnancy. For

preeacclampsia, it was about the same in early and mid-reg, but both elevated 1.94 and 1.95. And then for gestational

diabetes, look at this 3.47 and 2.79.

Um, and the majority of those who had sleep disordered breathing had mild sleepd disordered breathing. So for mild sleep disordered breathing, you still have this increased risk of these three

um adverse outcomes. And so there was an independent association between sleep disordered breathing, preeacclampsia, hypertension and gestational diabetes after confound after adjusting for

confounding factors.

This is a really nice diagram. I won't

go through it all for you, but this uh shows the different things that are associated with sleep fragmentation, sleep disturbances overall in pregnancy um that lead to the causal pathways

towards adverse outcomes with the uh activation of the AP HPA access, changes in sympathetic activity, oxidative stress, etc. that can lead to glucose um

dysfunction, endothelial abnormalities.

And so now after pregnancy uh people get women get a little bit of a break and then menopause hits and 40 to 60% of women identify sleep disturbances during

the menopause or menop parmenopausal time. It is considered a core symptom of

time. It is considered a core symptom of menopause. Vasom motor activities, the

menopause. Vasom motor activities, the hot flashes leads to poor sleep quality in women and the severity of those vasom

motor symptoms um directly correlates to the development of chronic insomnia.

Hormone replacement therapy interesting interestingly now that we uh have heard that it's a safer than what we had previously believed can improve sleep quality quality but not a great effect

on the vo vasom motor symptoms but the patients report sleeping better on it as I said before um as women age as

adults age they are more at risk of the um advancely phase syndrome and the morning chronotype uh there The drop in core body temperature is blunted and melatonin secretion is reduced. And the

melatonin supplement, something else that we can use to help these patients, does improve mood and sleep symptoms and sleep quality in patients in the uh

menopause or post-menopausal phase, but melatonin does not have an effect on the vasom motor symptoms. And so overall, just to summarize everything that I just said, screening

tools and diagnosis is not as accurate for women. Sleep is affected by internal

for women. Sleep is affected by internal and external factors unique to women. Um

I believe we have uh upcoming talking about so um social responsibilities and family responsibilities uh that impact sleep in women. Menarch and puberty

that's where it starts with an increased risk of insomnia. Pregnancy is a very vulnerable time uh for women when they are pregnant that it's a very vulnerable uh for them to develop sleep problems if

not sleep disorders. And then menopause brings on even more poor sleep with reduced melatonin secretion and an increased risk of sleep apnea. And I

thank you for your attention.

Thank you Dr. Ambrosio. Impressive

presentation. So there are too many difference and things to look through the woman life. So now the next lecture

it's my pleasure to introduce Dr. Cynthia Penna.

She's an assistant professor of medicine at the Cleveland Clinic Learner College of Medicine of Case Western Research University and a staff physician in the sleep disorder center at Cleveland

Clinic. Her clinical and research

Clinic. Her clinical and research interests focus on advancing sleep health equity by promoting recognition and management of arr

under reppresented population.

I was muted. Uh thank you Gonzalo for the for the introduction and thank you uh to the ASM for putting this uh webinar together. It's an honor to be

webinar together. It's an honor to be here. So right now we're going to talk

here. So right now we're going to talk about the differences in diagnosis and treatment responsiveness in women in different sleep disorders.

Um so um when we talk about obstructed sleep apnnea we we know that sex uh difference exist primarily in prevalence

uh disease uh recognition clinical presentation and in some treatment outcomes even though that is not very clear. Uh we know that the prevalence um

clear. Uh we know that the prevalence um changes between uh the premenopausal ages through the postmenopausal ages.

Overall the prevalence the ratio the prevalence ratio is 2:1 in the com in community uh studies versus 8:1 in clinical populations and this prevalence

switches as I mentioned depending uh on the on the premenopausal status with the postmenopausal status then we know that uh the presentation is very different uh

compared to men which can lead to the underdiagnosis and also there are sex differences in pol polygnographic uh phenotypes that can lead to differences

in disease in disease recognition.

Um women are more likely to report uh morning headaches, depressive symptoms, frequenting awakenings in the middle of the night and noia compared to rather

than sleepiness and snoring. There is

some uh reports that says that fatigue is more commonly in in women uh than men uh with higher fatigue scores where men

most commonly report excessive daytime sleepiness and this will impact us where as well.

How do we recognize and how do we screen uh for sleep apnnea in women? Uh most of the screening questionnaires report uh include typical symptoms of obstructed

sleep apnnea such as daytime sleepiness and snoring and and and it was also previously mentioned that the scores especially when we use the stop when we use the stop bank which is the most

commonest uh screening questioner use tends to inflate the total scoring raising the question whether a different score should be used for women. So for

for instance in this study where they included 43 men women with uh 532 men they included uh most of the womens were

middle age. They suggest that the author

middle age. They suggest that the author suggested that a cutoff of four could have a better diagnos a better diagnosis in women while a cutoff of five was

better in men. This is was to identify to identify moderate to severe obstructed sleep apnnea. For severe

obstructed sleep apnnea, perhaps a C of five would have worked better for for both uh for both groups with a sensitivity of 66% in women and 71% in

men. Likewise, the author described that

men. Likewise, the author described that perhaps incorporating a better threshold for the BMI could improve a better uh utility for OSA detection. In this other

study where they included midlife women, this was a smaller study where they look at the pre uh predictive abil ability and reliability of a stock bank for in identifying obstructed sleep apnnea.

Authors suggested that a cutoff of three um to uh identified moderate to severe obstructed sleep apnnea had a sensitivity of 75%.

However, the um the specificity was lower. Likewise when the stopbound

lower. Likewise when the stopbound cutoff increase from three the sensitivity um decreases decrease to the to detect moderate to severe obstructed

sleep apnnea. However the specificity uh

sleep apnnea. However the specificity uh increase. Therefore, what we what we can

increase. Therefore, what we what we can conclude with this is that popular screening uh tools may need to incorporate um gender specifics and not

unified total scores that could improve the predicted utility of these screening uh questionnaires.

There are also sex differences that influence uh the state specific mechanisms that are reflected uh in in in the sleep testing and these are the

endoypes that we are that we are aware of these that include airway collapsibility, loop gain and arousal arousal threshold. Um women tend to have

arousal threshold. Um women tend to have lower arousal threshold which can explain the findings that we commonly see in in sleep testing. We know that

women have more hypopnas rather than apneas. They have a higher uh rem ah

apneas. They have a higher uh rem ah high even even though the overall a hypopnia index is lower compared to men.

Women have more um raras um and all of these findings explain the poor sleep quality and insomnia that that women complain of. However, these can change

complain of. However, these can change this um this upper airway physiology can change depending on the uh menopausal

status and in later in later ages uh women can have lower airway uh no higher airway collapsability which explained

the higher um the higher AHI finding a sleep test.

In this um community- based uh large study that included like 1,000 women, they described different polyonography features and compare uh these features

between with men. Overall uh women were found to have better sleep quality and this was reflected as a better uh higher total sleep time uh better sleep

efficiency compared to men. Also women

had u more prevalent um N3 and REM sleep. And importantly here we can see the overall uh obstructive

apnea to hypopnia ratio which was higher in men and this ratio is a surrogate of airway collapsability. So the ratio was

airway collapsability. So the ratio was higher in men which which is m which was mainly explained by the by the higher number of apneas compared to hypopnas in

nonrem. But as you can see in REM there

nonrem. But as you can see in REM there was not a stat it was not statistically um different uh this this ratio in the

same study they also look at the um sex differences in OSA severity depending on the on the scoring that we use and we can and these authors conclude that

definitions that use 4% hypopnia scoring the saturation criteria underestimate the AHI in women compared

to using 3% or uh using the arous arouse arousals as well. When we when they look at the sex differences in physiological

endotypes uh women demonstrated lower loop gain, less airway collapsability and lower arr in nonrem uh sleep

compared to men.

Um so what are the outcomes of pop therapy in women? Unfortunately, there

isn't uh too many um prospective studies. Most of these data comes from

studies. Most of these data comes from observational studies and the and the results are are mixed comparing uh who is more aerent uh in with with pop

therapy. There is one randomized control

therapy. There is one randomized control trial that's that suggested that women receiving pop therapy achieve significant greater improvements in quality of life, daytime sleepiness,

anxiety and depression at 3 months compared to conservative treatment.

What are the impact of of pop therapy and cardiovascular outcomes in women?

Unfortunately, women are critically under represented in these randomized control trials. the amount the the

control trials. the amount the the prevalence of women in all in in the biggest uh cardiovascular trials are runs from 16 to 19%.

And unfortunately there are no uh RCDs um to date that has been designed or powered to examine sex specific uh effects on cardiovascular endpoints.

There is a meta analysis was recently uh published in 2023 where they involve the biggest uh they include the biggest cardiovascular trials the safe the isat

and riata trial who which did not find a significant sex-based difference in the effect of p therapy on major

cardiovascular outcomes although um this probably was due to the uh power effect when uh where is the data on other um on

other treatment options such as the hypogloss of nerve stimulation.

Unfortunately, as I mentioned before, women continue to be under represented in the ad uh registered cohort. The

percentage of men is almost 80% compared to compared to women. However, in this uh in this registry, there is a tendency

where uh the responsiveness and aderance in women may be may be greater than male may be greater in females than males.

However, it didn't reach uh a statistical significant but likely due to power effect as well.

So um women in uh insomnia in women so women are at are at at higher risk of developing insomnia compared to men. The

pool prevalence in women um is generally higher. The overall uh prevalence of the

higher. The overall uh prevalence of the general population is about uh 28%.

This um this sleep disturbances in women as it was previously mentioned was more pronounced during episodes of of significant hormonal changes which is

poverty, pregnancy and menopause and kisa which is the comorbid insomnia and sleep apnnea. It is known to be very uh

sleep apnnea. It is known to be very uh which is very kn is known to be more common in women uh than than men. When

we look at uh restless leg syndrome in in women, we know that the prevalence is higher in men uh in women compared to

men uh with a prevalence of a of 9%.

Um when there has when authors have looked at different um symptoms description, women tend have

the tendency to describe more sensory symptoms such as pain pain and awakening uh from asleep and parity increases the

the risk of um restless leg uh in women later in life.

So the conclusions are that women with OSA present uh clinically differently from men with distinct pornograph uh polyonographic characteristics

driven by hormonal influences across the lifespan and differences in upper airway physiology.

Women remain critically underreresented in pop therapy and other type of treatment options and also outcome trials which make it difficult to draw a

definitely a definite conclusion about says a specific cardiovascular benefits or overall treatment outcomes. Other

sleep disorders such as insomnia and restless legs are more prevalent in women than men across the lifespan with restless legs presenting predominantly

with sensory symptoms including pain and nocturnal sleep disruption in women.

Thank you.

Thank you so much Dr. Dr. Pñena Orveo for that excellent presentation um highlighting the key areas of differences and challenges in uh these

sex specific differences in um sleep disorders. Thank you very much. And I

disorders. Thank you very much. And I

just wanted to remind folks especially maybe those who have joined a little bit later uh to um make sure that you uh

list your questions in the Q&A. Uh at

the end of our presentations, we will be reviewing uh questions and taking um and posing those to our our presenters.

Next, we have Dr. Molly Billings. It's a

pleasure to introduce uh Dr. Billings uh who is at the University of Washington with me. She is a professor of medicine

with me. She is a professor of medicine in the division of pulmonary critical care and sleep medicine. Her research

focuses on sleep health disparities, the environmental and neighborhood contribution to sleep health and disorders, and the effects of policies and health structures on adherence. She

has a particular clinical interest in inpatient sleep medicine and has developed tools to improve treatment of sleep disordered breathing amongst hospital hospitalized patients. And

she'll be talking today on the societal and cultural influences on women's sleep health. So, welcome Dr. Billings.

health. So, welcome Dr. Billings.

Thank you so much and thank you so much for including me in this important webinar. Um, I'm going to be touching on

webinar. Um, I'm going to be touching on uh societal influences and um on sleep and kind of looking at the effect of

gender on sleep um as specifically in US society but in many societies. Um, as we all know, there are social roles that

are very gendered. Um, and in general, women have the expectation to manage the household and work as caregivers. And

this can lead to um stresses on sleep as work uh work life and family life and cultural influences can put ro strain on

women and this often leads to excess demands on them and often at the expense of sleep as they try to balance it all.

So as we as you all know sleep is very uh culturally dependent. It's uh

scheduled socially and shaped by your cultural trends, ecological contexts, um personal beliefs, economic forces, and family structure. And sleep is not

family structure. And sleep is not equally prioritized across all cultures.

Um and different cultures have different sleep habits. Um in some termed siesta

sleep habits. Um in some termed siesta cultures, um there's a typical habit of an afternoon nap. uh often in the places where it gets very hot in the afternoon.

Um in Latin America and the Mediterranean, in the western cultures, some may perceive this as being lazy, whereas in other cultures, this is a

very kind of holy and religious tradition and spiritual uh as in some Islamic cultures. In general, women tend

Islamic cultures. In general, women tend to nap across many cultures more than men. Um often they're co-sleeping. Um

men. Um often they're co-sleeping. Um

and this may be reflective of more disrupted nocturnal sleep.

Um in general looking at large uh different large studies um looking at sleep diaries women report getting more total sleep than men. Um but in general

report a poorer sleep quality. Men have

tend to have more paid work. So they

work more often in u jobs that you know reimburse them for their time. uh and

they may have less flexibility. Women by

and large have more unpaid labor um and so as a result they don't have um much leisure time and it's of lower quality than men. Um women tend to prioritize

than men. Um women tend to prioritize family needs over their own sleeping needs. So they tend to sacrifice their

needs. So they tend to sacrifice their own sleep for the privilege of sleep in others.

Uh this does diminish with age and as uh Dr. Dr. Damrosio talked about uh with hormonal changes and life changes. Women

sleep um tends to deteriorate after menopause. Um but it does similarly in

menopause. Um but it does similarly in men um with lower sleep efficiency and longer latency. But in those

longer latency. But in those childbearing years during pregnancy, managing a family and in pmenopause, women tend to have um more worse quality

sleep compared to men. We also know that there are other factors besides um gender that contribute to sleep patterns and sleep health disparities. Um in

general um black, indigenous um and people of color tend to have shorter sleep duration in the United States than white populations. A much higher odds of

white populations. A much higher odds of having less than 6 hours uh of sleep per night. And black Americans especially

night. And black Americans especially have a much lower uh much larger um disparities in sleep with a larger percentage sleeping less than five

hours. They also report worse sleep

hours. They also report worse sleep quality uh with more insomnia symptoms. And this has been also verified the shorter sleep duration with um ecttoraphy studies.

Uh and why might this be? Well, in the United States certainly structural racism and discrimination is playing a role. um specifically looking at the

role. um specifically looking at the intersection of race and gender. Um

there are differences um in sleep and the effect may be more pronounced in uh black women who experience uh gendered racial microaggressions and when they

experience that they have reported worse sleep quality. Um in the sister study

sleep quality. Um in the sister study which is a large cohort study looking at lot big population of women um women who reported discrimination had shorter

sleep and more insomnia symptoms. There is this socialization among uh black women to be strong and like a superhero in terms of managing it all in response

to stress to suppress their own emotions, be invulnerable and self-sacrificing and work as the matriarch and sort of take care of the whole family. Everyone

can rely on her. um she'll take care of everything and you know make sure everyone's well fed and cared for um and help always helping others and as a

result this can have a detrimental impact on her mental health her sleep quality uh and lead to more daytime sleepiness.

Um in regards to the unpaid labor um we know that women do a disproportionate amount of domestic and unpaid care work.

Um this is across many cultures true in the United States but also this is a study done in Japan comparing men and women's um roles in terms of household

work and the women were doing far more domestic labor um and as a result or an association with more domestic labor

they had um more reports of non-restorative sleep lower mental health uh reported and with this greater workload load and this has been found in

similarly in studies in Sweden and Australia and Korea.

Another sort of factor is the cognitive labor. So besides besides actually the

labor. So besides besides actually the physical job of cleaning the house or um making dinner, that's also the cognitive load that many women suffer uh the

disproportionate burden of. And this

includes kind of keeping those running tabs in your mind of all the tasks that you need to do. I'm sure many of us have done this. um keeping track of who needs

done this. um keeping track of who needs a doctor's appointment, um signing up the kids for summer camp, planning dinners each week, um you know, making

sure everyone has the bath, and then making sure that things get done and nagging people if they don't get done.

And the and one study um recently published looked at um differences in in this cognitive load was about 300

parents of about uh children aged 2 to 3 years. And of all of these tasks the

years. And of all of these tasks the cognitive load was um 73% of the time by women and this was associated with a

greater stress and mental health and as it can be have an impact on people's sleep at night. Um, in this study, the only thing that the men predominantly

did was taking out the trash and doing household maintenance.

Um, and then finally, the other difference, um, is the caregiver role.

Women by far, uh, across many societies have a greater role in being the caregiver. Um, despite many, in many

caregiver. Um, despite many, in many cultures, and many places, women are entering the workforce and having, you know, daytime jobs as well. So there's

less time for sleep if they're doing their, you know, paid job and then coming home managing the household and taking care of the baby um or the young

child or their elderly um relative.

Women are more often the one providing care for sick elderly or disabled people and those that do have more anxiety and depressive symptoms. the mental load as

I mentioned before and this caregiving can take a toll on people and that can also impact sleep and then finally they're often getting up at night to

care for their um the children or the elderly person and that can lead to um and giving themselves emotionally um so that can lead to disrupted sleep as

well.

This um put out by the United Nations looking at different roles of women again notes that women in general across the world um in reality are the ones

providing the vast majority of care and that's un unpaid and un um unaccounted for and they're you know changing uh

society to be more you know aware of this these work roles that women do. um

can improve the the lives for everyone.

Um and then finally, I'll touch on how neighborhoods impact sleep. Uh we know that people sleep better if they live in a a healthy sleep neighborhood or a

healthy lifestyle neighborhood where people feel safe. So, especially women that may live alone or have young children, if they live in uh areas where

they feel connected to other people, there's social cohesion, there's green space around, there's tree canopy to keep them cool, um and it's very

walkable. That's all associated with

walkable. That's all associated with better sleep in people living in disadvantaged neighborhoods where um

there's adverse conditions such as um you know unsafe regions, there's broken down homes, there's crime that can lead to less sleep opportunity, poor sleep

quality, delayed sleep onset um and daytime sleepiness.

So together um you know living in a socially connected neighborhood where you can walk around and enjoy the green space and access green um green spaces

and food um you know farmers markets can improve your sleep health versus people that live in more segregated neighborhoods where there's more deprivation and crime where there's more

noise. uh as someone mentioned bright

noise. uh as someone mentioned bright lights um pollution and now with global warming that more heat often in these areas can uh be negative impact on

sleep. So together with the other uh

sleep. So together with the other uh societal forces and um hormonal forces those can all impact the sleep quality.

So in conclusion um sociological, cultural and ecological forces all contribute to sleep patterns and your

own culture, your family can influences um how you sleep and when you sleep and gender roles uh have a large contribution to differences in sleep and

in women caregiving obligations, domestic work um can impact mental health and lead to greater sleep health disparities. So if you're to improve

disparities. So if you're to improve sleep among women across the globe, uh intervention should consider all of these different contextual factors

and that is it. Thank you so much.

Oh great. Thank you Dr. Billings. Um

it's impressive. So there are several other contributing factors for the sleep health neighborhood and all the other socio soio economical factor that it's

worsening and more bias with this gender difference and is even worse in women's.

So to finish it's my pleasure to introduce Dr. Susi Verich. Um Dr. Rover is assistant professor in medicine

Harvard Medical School. Um she's

physician clinician investigator working in the sleep and carian disorder department of medicine at Brian and woman hospital and she's the director of behavioral sleep medicine. Her research

focus in adapting sleep health intervention to a variety of community and clinical population and impact of the sleep disorder consequence influence

on pain and cardiorabolic health. She's

the chair of the woman's sleep health initiative from the ASM. And

yeah, we see the cat next to me.

Yeah, sorry. My my cat is getting involved. Uh Sarah, was there this my my

involved. Uh Sarah, was there this my my slide is in the main slide deck. Um so I wasn't expecting to share because it's one slide. Um

one slide. Um Oh, yeah. Great. Yeah. Um, do you want

Oh, yeah. Great. Yeah. Um, do you want to just go to the next slide about describes the task force?

Yeah, the one after this one. Yeah, it's

the one I Yeah, great. Thank you so much. Um, so I know we're at the end of

much. Um, so I know we're at the end of time and I want to make sure people have questions, but I'm just really here um I'm the chair of the task force, but really rep representing the group of

about um 10 of us who've been working over the past year to um lead the initiative uh from the academy of sleep

medicine with really the goal to uh increase to guide efforts of the academy focused on better understanding and advancing the sleep health of women. So

we had several goals that we've accomplished this year. Our major goal was that in this past November, we ha held a women's sleep uh sleep health summit with about 50 attendees

representing clinicians and researchers and industry members and advocates um from other professional organizations such as the menopause society um uh the

uh representatives of nurse practitioners um to really get a diverse stakeholder. and we spent the day uh

stakeholder. and we spent the day uh spent a full day together really outlining what are the key goals to get uh to advance women's sleep health both

uh clinically and research wise. And we

saw in the presentations today that we're really just at the tip of the iceberg uh and identifying, you know, the sex and gender influences across um

and societal influences across uh sleep disorders. um but really not not be able

disorders. um but really not not be able to translate that into you know how this really makes an impact uh for our patients. Um you know Dr. Pñora gave a

patients. Um you know Dr. Pñora gave a beautiful presentation outlining, you know, sex and gender differences and sleep apnnea, you know, in differences

in and phenotypes and um and potentially how PAP use may how PAP itself may work for women, but we don't but that has yet to really um we don't yet have the evidence to know how that actually

changes how we're treating patients. And

similarly you know um potential risk of sleep disordered breathing across pregnancy um and what the impact that is. So we

really uh looked and identified across the lifespan what are the key factors and what are and ways we can implement sort of a a you know a roadmap for

trying to expedite this change. And

we're currently working on a report that will be posted on the academy website for everybody to see. And our goal is to try to have that wrapped up by by the sleep meeting as well. In addition,

we've we've spent some time um trying to to broaden, you know, there's um one one thing about sleep is often it's just a group of sleep people in a room talking about it, right? But we know that almost

every other field in medicine has a component of sleep um of sleep that's adjacent and can have an influence on all these other health outcomes. So

we're trying to also in terms of women's health submit abstract to other societies um and try to present our work uh both uh clinical work as well as

research presentations to other sleep adjacent societies where sleep has been under represented as well to continue to promote the awareness and important importance of sleep health. Um and also

just so everybody knows that you know uh we've had excellent attendance at today's workshop but we have three additional uh webinars planned um one

focused uh focused um where we can dig a little deeper on a um sleep apnnea on central disorders of hyperomnia as well as insomnia and I did see a Q&A in the

chat about you know how do we actually treat menopause associated insomnia so those questions such as that will be answered in subsequent webinars um And to end, the last goal that we had in our

initiative was to provide input on the academy foundation strategic research grant requests for proposal applications where we developed and uh and deployed a

survey to better understand and rank the importance of where this work needs to be. So it's just an interesting time. Um

be. So it's just an interesting time. Um

I'm going to end now, but thank you so much for attending. Please be on the lookout uh for other webinars as part of the women's uh sleep health task force initiative. So, thank you everybody.

initiative. So, thank you everybody.

Thanks so much for the speakers for volunteering your time today. I know I learned a lot in everybody's presentation.

Thank you so much Dr. Verdes and thanks for your leadership on the women's sleep health task force. Um I also want to thank the American Academy of Sleep Medicine for placing a spotlight on this

really important area. This is the inaugural um ASM task force for um you know addressing this important topic. Uh

we only have a few minutes left. Um and

I I did want to uh see if we can take some questions. Um there was one

some questions. Um there was one question as Dr. Dr. Berish mentioned um in terms of u where where the link is for the recording and that is on uh the

web the women's sleep health page web page and that's where also the future webinars if you would like to register for as Dr. Berish mentioned you're able to do that on the web page as well. So

we have a few questions um one is in Spanish and so I'm really glad Dr. Labar is with me.

Smart comment.

Yeah.

Okay. Okay.

But I'll I think one of these other questions we can start off with first if that's okay. Um which I think um

that's okay. Um which I think um uh I think this is a really interesting one in terms of recruitment of women in research studies.

um finding it more difficult to recruit women than men in research studies related to sleep apnea and insomnia often because women have less available time or mistakenly believe they do not

have obstructive sleep apnea because they do not snore. Um so maybe we can just open that up to the panelists. You

know, anyone can just chime in. Um,

any thoughts on how we can do better to recruit women in research studies?

Okay, now I'm going to pick on somebody.

Let's see.

I can make some comments. So, I think actually we probably don't know the reason why women's are under represented. I don't know if it is as

represented. I don't know if it is as they say in the comment whether it's related because patient because women have less time available or the symptoms present differently than men. I think

that is also an important question to to be asked um in in future research studies to understand what is what is why they are under under represented uh

there that would be my my my opinion on that.

I think you're muted.

Yes.

Also, one thing one thing that I could say as our investigators, we could be more more conscious about this to try to to to create those type of a studies

with with where there is equity in in men and women the the recruitment.

Dr. Drosia.

Yes. I was just going to say I think um the more we can target women's groups or areas where women will look for these type of things uh is very helpful and

many women who you talk to them about their sleep and that this might be a problem are interested in participating in research studies. It it is a little bit of a lift for some of them who have

quite a number of responsibilities both at home and at work though.

And Dr. Berish, thank you Dr. Bish.

Yeah. So I I conduct uh clinical trials on insomnia. So disproportionately we

on insomnia. So disproportionately we actually enroll a lot of women and um from our experience including a current study where we specifically recruit

socioeconomic um disadvantaged women who you can imagine have a lot a lot as you heard today a lot of other responsibilities. We find that the

responsibilities. We find that the flexibility of um of timing of the study visits makes a huge difference towards um uh intervention adherence and

participation in the study. So we in our study we've made everything virtual and we've actually studied um even schedule uh you know intervention visits in the

evening as much as possible to try to make it um you know realistic for people to participate and we use a lot of uh electronic data capture

um and things like that really to just to try to make it accessible for people uh in the real world and we've just found um when you create that flexibility it really goes a long way

towards um towards women participating.

We've done other studies in low outcome in housing committees or actually how to provide child care in order to perform the intervention. Um and all this was

the intervention. Um and all this was really done through engagement early on with the groups as well and asking questions such as you know what needs to be in place in order for you to do a

research study. So again, if you're

research study. So again, if you're going to um if you're having trouble recruiting a certain population, I highly recommend engaging that population to find out what what works

for them.

Well, great. Thank you so much. Um it

looks like we are on the hour and I would love to continue this conversation as there's some additional great questions. Um but uh as uh was discussed

questions. Um but uh as uh was discussed we'll have future webinars and hopefully we can extend this discussion even further. So thank you to the presenters

further. So thank you to the presenters uh thank you to uh my co-odderator Dr. Labara and thank you to the American Academy of Sleep Medicine. Looking

forward to continuing the discussion at the future webinars and thanks to all that who who have joined.