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Women and Heart Disease: What Most Doctors Don’t Know

Posted Feb 19 2009 6:21pm

If you’re a woman having chest pain or shortness of breath, it’ll take longer for you to be evaluated by EMS and taken to the emergency room than if you’re a man. This finding was reported this month’s Circulation: Cardiovascular Quality and Outcomes, and summarized for the lay public in the New York Times. What’s worse is that even if women get to the emergency room quickly, a heart attack diagnosis is made much slower than in men.

What this article doesn’t address, however, is how to prevent heart disease in women in the first place. Sleep apnea is a very common condition that if left untreated, can cause anything from depression, anxiety, high blood pressure, diabetes, obesity, heart disease, heart attack or stroke. It’s estimated that up to 1/4 of all men and 1/10 of all women may have at least some degree of sleep apnea. The frightening statistic is that about 90% of women with sleep apnea are not diagnosed. Instead they are being treated for the complications of untreated sleep apnea, rather than the cause itself.

There are three major issues regarding women that prevents proper diagnosis of sleep apnea: The sleep apnea myth, the hormonal factor, and the insomnia bias factor.

Myth #1: Sleep Apnea Is Mostly a Male Problem

One of the biggest myths about sleep apnea is that you have to be a middle to older aged, heavy-set snoring man with a big neck. This stereotypical view of sleep apnea is still common amongst most physicians, so unless you’re in the extreme end of the disease spectrum, a sleep-breathing condition won’t even be considered as a possibility if you’re a woman. When obstructive sleep apnea was first described in the 60s, it was initially described in older, heavy-set snoring men. Even today, medical lecturers continue to put up pictures of this type of patient, and sometimes, a picture of Joe the Fat Boy from Dickens’ The Pickwick Papers. Paper after paper continue to report on associations between weight, neck size, and the male sex and increased risk for sleep apnea.

However, it’s been recently shown what even young, thin women that don’t snore can have significant obstructive sleep apnea. I see patients like this daily in my practice. This also applies to young thin men as well. Whenever these people are diagnosed officially on a sleep study, they always comment that their medical doctors comment, "you don’t look like you have sleep apnea." This just goes to show that there is no "typical" sleep apnea patient.

Myth #2: Men Can’t Have Menopause

It’s commonly known that as women progress through menopause, their rates of heart disease begin to catch up with men (although not completely). The common symptoms of menopause include night sweats, hot flashes, mood swings, weight gain, insomnia and irritability. However, as I’ve alluded to before, young men in their 20s can have the same exact symptoms. How can this be? It’s because these men, as they are slowly gaining weight, are progressing up the sleep-breathing continuum, slowly developing obstructive sleep apnea. It’s the relative change in the anatomy that’s confusing the involuntary nervous system, giving rise the the so-called vasomotor symptoms. Your involuntary nervous system is what controls your heart rate, blood pressure, body temperature, sweating, digestion, and sleep.

In women as they approach the pre-menopausal years, one of the first changes that they go through is that progesterone levels slowly drop beginning in their early 40s. One of the known interesting properties of progesterone is that it acts as an upper airway muscle dilator and stimulant. This is what makes pregnant women breathe harder and faster. It also tenses your upper airway muscles by promoting more muscle tone.

As I’ve alluded to in my book Sleep, Interrupted, most modern human tongues are susceptible to falling back partially when on our backs. When you add muscle relaxation during deep sleep, our tongues can fall back and obstruct our breathing. This is why so many people can’t sleep on their backs. So if you slowly take away progesterone in women, the tongue relaxes more and more, and wake up more and more, usually from deep to light sleep. Inefficient sleep promotes weight gain, and weight gain narrows the throat even more. These multiple obstructions and arousals lead to a confusion of the involuntary nervous system. Later on, as the period of pauses after one obstructs increased, oxygen levels begin to drop, and obstructive sleep apnea worsens.

This is the reason why in general, women sleep better when on hormone replacement therapy, and they have a lower chance of heart disease as well. Now, due to all the conflicting studies regarding hormone replacement options and a possible increased rate of cancer, this is a very delicate and controversial topic that’s beyond the scope of this discussion. Nevertheless, peri-menopausal women have been using bio-identical progesterone creams for years safely to improve their quality of lives as well as their quality of sleep.

Myth #3:  Insomnia Affects Everyone Equally

Lastly, an older study revealed that women who complain of sleep problems to their doctors resulted in a diagnosis of insomnia more often than in men. Oftentimes, these women were prescribed sleeping pills. Men who complains of sleep problems are more likely to be asked if they snore, and it’s safe to say that obstructive sleep apnea is picked up more commonly in men due to this situation. Again, this brings up the OSA stereotypes that doctors have in men versus women.

There are a number of other reasons why women will get less than optimal heart care compared with men. I’ve touched on just three reasons that prevents women from getting diagnosed promptly for obstructive sleep apnea. Untreated obstructive sleep apnea can lead to heart disease. As long as the medical community segregates medical conditions without looking at the whole picture, we’ll continue to have discrepancies in the quality of care for not only for women, but for men as well.

 

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