February 14, 2009
A couple of years back, when Rosie O’Donnell was still on a popular morning talk show called The View she shared something about herself that many women would feel too ashamed to admit: Rosie declared that she had a sleep breathing problem called obstructive sleep apnea. She even proudly demonstrated to many thousands of women viewers on how she uses the CPAP (continuous positive airway pressure) mask every night. I’m sure that by doing so she was hoping to raise awareness for more women to get tested for this all-too-common yet frequently undiagnosed condition.
Unfortunately, her frank disclosure may have done little to dispel the myths surrounding sleep apnea. Estimates suggest that 85% of sleep apnea patients go undiagnosed with a higher percentage of that number being women.
Listed below are 5 of the most common myths that get in the way of women being treated effectively for this condition. Discover for yourself what, if any ramifications sleep apnea may have on your health and take measures to prevent this problem from affecting you.
Sleep Apnea Then and Now
Obstructive sleep apnea was first described in the 50s and 60′s as a rare condition in very obese, older, snoring men who kept falling asleep during the day. But even now, about 40 years later, every medical lecture I attend about sleep apnea begins with a picture of Joe the fat boy from Dicken’s The Pickwickian Papers. Although anyone who knows anything about sleep apnea these days knows that this is merely a caricature of real sleep apnea, nothing has been done to dispel these prevailing myths.
It’s now known that about a 23% of men and 11% of women in this country have some degree of obstructive sleep apnea. This number gets even higher in older women, especially after menopause. The reason why this is so problematic is that untreated, the sleep apnea patient has a 2 to 3 time increase in risk of cardiovascular complications, such as high blood pressure, heart disease, heart attacks or even strokes. There are also known associations with depression, obesity, sexual dysfunction, and headaches. However, many sleep apnea patients, especially a lot of women aren’t being properly diagnosed due to the many myths surrounding this condition.
Where Do These Myths Come From?
Myth Number One: “I’m Not Rosie O’Donnell”
The first myth is that one has to be an older, heavy-set, snoring man to have sleep apnea. While this may be true in this particular population, it can also occur in young thin women. This has been proven in multiple published research studies. But many young women will look at a celebrity like Rosie O’Donnell and think, "I’m not like her. I’m skinny. I can’t have sleep apnea". The sad truth is, even many doctors still think that a young thin person can’t have obstructive sleep apnea. Therefore, because of these biases, the diagnosis of obstructive sleep apnea is never considered even when you present with many of the common signs and symptoms of sleep apnea. In my practice, there’s an even split with about 1/2 of the men and women who are diagnosed with sleep apnea that are overweight, and 1/2 that are relatively thin.
Myth Number Two: “I’m not lazy”
Another misconception many people have is that those who have sleep apnea tend to sleep too much or are just plain lazy. Yet the truth is, many sleep apnea patients, contrary to their drowsy appearance, tend to be high achievers since they must over compensate for their lack of deep restful sleep. Also, apneas or airway stoppages only happen when you’re in “deep sleep”, so these people, even though they may seem to sleep long hours, aren’t really getting the quality restful sleep they require (for a more in depth discussion on this topic read my recent article: The Real Reason Why Some People Are Lazy).
Myth Number Three : “I don’t snore.”
Many people associate obstructive sleep apnea with severe snoring. Again, in the severe sleep apnea patients this is usually the case, but many people with mild to moderate conditions may not snore at all. Remember that snoring, by definition, means that one is still breathing (somewhat). Apnea means total blockage. So,if you are not breathing, you are not snoring. This is the third myth that must be set straight.
Myth Number Four: “I’m a light sleeper”
"I know that I don’t have sleep apnea." This is one of the most common statements that I hear from women when I even mention a possibility In fact, studies have shown over and over again that you as a patient, are very poor at predicting whether or not you have obstructive sleep apnea. This is because it only happens while you are sleeping. Of course there are various minor exceptions to the rule such as waking up while one is snoring, but in general, the above statement is true. Research has even shown that bedmates are also poor at predicting sleep apnea. Would you know if your spouse’s cholesterol was elevated just by looking at him?
Myth Number Five: “Sleep tests are inaccurate”
The last myth has to do with the actual sleep study itself to determine the degree of sleep apnea you have. Many patients preempt these formalized tests by saying "I won’t be able to sleep in a sleep lab." Being in a strange bed with multiple monitors and leads attached to your body is an uncomfortable and annoying experience, but it’s rare when I have someone that really could not sleep enough to gather useful data. We don’t need an entire night’s sleep; we only need about 3-4 hours of continuous or even interrupted sleep. Some even complain that they did not sleep at all. But the brain waves on their sleep study results, by definition, shows that there was significant sleep present. Another frequent scenario I run across is when a patient undergoes a sleep study and the test does not reveal any significant obstructive sleep apnea. But just because the sleep study did not reveal any apneas does not mean that the quality of your sleep is still good. The reason for this is that an "apnea" is defined as a total stoppage of breathing due to obstruction in the throat for 10 seconds or longer. There is a lesser form of an "apnea" where there is still some airflow, but greatly diminished, yet it lasts more than 10 seconds (hypopneas). If the minimum threshold for obstructive sleep apnea is 15 "apneas" every hour. and if you stop breathing 30 times every hour, but if each episode lasts for only 8 seconds, then you will have zero apneas and hypopneas. As confusing as that sounds, in this case, you are told that you don’t have sleep apnea, but you still feel lousy when you wake up in the morning. This is a common situation with patients who have upper airway resistance syndrome, which is a preliminary stage before they proceed to having OSA (To learn more about UARS listen to our podcast on this topic by clicking here).
As you can see there are no absolutes when it comes to obstructive sleep apnea. After all, the myths and stereotypes are based on a distortion of the truth. Unfortunately, these myths can lead to or aggravate untreated high blood pressure, diabetes, obesity, heart disease, heart attack and stroke (read my article on Women and Heart Disease: What Most Doctors Don’t Know). It’s my wish that you and others you know will be better educated to dispel these myths to promote better breathing, better sleep, and better health for themselves, their family members and their friends.
January 14, 2009
My wife Kathy is expecting our third son any day now, and her experiences during her current and past pregnancies bring up some important issues that all men and women, pregnant or not, should know about. Even though poor sleep, nasal congestion, post-partum depression, and weight gain are almost an accepted part of pregnancy, these can be especially problematic for those women who struggle to bounce back way beyond their first year after pregnancy. Besides the excess weight that they can’t seem to take off, many of these women find that their health and energy level are considerably worse off than it was prior to being pregnant.
However, there are measures you can take prior to delivery to help you get back to the way you felt before you became pregnant. There are some important concepts related to pregnancy, that are often overlooked by many medical professionals but if looked at from my sleep-breathing paradigm, explains why these events occur, and what you can do about it.
What You Don’t Know Can Harm You
In my book, Sleep, Interrupted I allude to a eureka moment when my wife helped me to realize what helped her to rid herself of her post-partum depression after our first two sons were born.
It’s a given that you’ll gain weight if you’re pregnant. What many of us don’t think about however is that when you gain weight in your abdominal area, the fat cells inside your tongue and throat area get enlarged as well. This fact alone can have significant consequences for pregnant women, during, and especially after pregnancy.
As I explain exhaustively in my book, all modern humans are susceptible to upper airway narrowing and collapse due to various degrees. And because the airway is a uniquely dynamic apparatus that’s modified by any change in the soft tissues surrounding the area, weight gain can dramatically impact the rate of inspiration and expiration especially while we sleep, when the muscles and soft tissues lose tension and lose slack.
As I’ll explain further, this is one reason why, even those who are not pregnant, can progress into the extreme end of this sleep breathing problem called obstructive sleep apnea. Similarly, any amount of weight gain can move you up on this line to some degree. This is why many pregnant women begin to snore, especially in their third trimesters.
Complications During Pregnancy
Pre-eclamspia and gestational diabetes are two common conditions during mid to late pregnancy. These conditions are thought to be distinct clinical conditions specific to pregnant women. Pre-eclampsia is a potentially dangerous condition where the mother to be develops severe high blood pressure with a risk of kidney failure, and death for the baby.
Gestational diabetes is another dangerous condition for both the mother and the baby. There are many studies that have reported an association between obstructive sleep apnea and these two conditions during pregnancy, but they are typically seen as occasional, isolated events. Doctors usually recommend dietary and lifestyle changes and then resort to medications when conservative options don’t work.
But despite numerous studies showing that women with pre-eclampsia can be effectively treated with CPAP (continuous positive airway pressure), it’s thought of as a rare oddity and has not gained attention as a very common way of treating pre-eclampsia. The same situation applies to gestational diabetes.
The Importance of Sleep Position In Pregnancy
Women are recommended to sleep on their left side during pregnancy, presumably due to less pressure on internal vital organs and blood vessels by the growing fetus. This is especially true in the third trimester. But one thing to consider is that as women gain weight, if they go on to develop mild or significant sleep-breathing problems, by necessity, they naturally will prefer to sleep on their sides anyway.
Similarly, many people with sleep-breathing problems already sleep on their sides or stomachs already for the following reasons: Due to various degrees of jaw narrowing, the tongue and voice box (which grow to their normal size), takes up too much space inside the mouth. These are the people who gag easily when a doctor presses the tongue depressor forcefully so that the back of the throat can be seen behind the tongue. For these people when they lie down flat on their backs, the tongue falls back partially due to gravity making the airway that much narrower. In this position, the person usually breathes through a slit only 2-3 mm wide. While awake, breathing is normal since your throat muscle tone increases as you inspire.
However, once you fall off to sleep, and especially as you enter deeper levels of sleep, by definition, all your muscles, including your throat and tongue muscles, must relax. With only 2-3 mms of opening, and with tongue muscle relaxation, your tongue will fall back, causing obstruction. Most people will wake up consciously or subconsciously after a second or two, and then turn over to the side. However, if you stopped breathing for 10 seconds or longer, then you just had an apnea. Most people compensate partially by sleeping on their sides or stomachs, but this is usually not good enough.
This is why when pregnant women gain weight, the fat cells in their throat will narrow the throat, and aggravate this vicious cycle. During this process, if you happen to also catch a simple cold or suffer and allergy attack, the mild inflammation that occurs in the breathing passageways can further narrow the throat, aggravating more tongue collapse. Once you obstruct, tremendous vacuum pressures in your throat causes mild amounts of normal stomach juices to come up into your throat, causing more inflammation and narrowing in the throat.
It’s also been shown that these same juices can go up into the nose, aggravating nasal congestion. Nasal congestion aggravates further tongue collapse by causing a vacuum effect downstream.
This is why given these circumstances, gaining weight during pregnancy, albeit normal, should be gradual and moderated.
Although pregnancy and in particular the weight gain that it induces many unfavorable side effects for women, there’s one unique advantage that pregnant women have during pregnancy that many men with sleep breathing problems don’t have called progesterone.
Progesterone is a hormone that vitally involved with a woman’s reproductive cycle (along with estrogen). During a woman’s monthly cycle, estrogen helps to stimulate egg development and release, whereas progesterone promotes uterine health, to support any possible embryo development. One little known feature about progesterone that even many doctors aren’t aware of is the fact that it acts as an upper airway muscle dilator. This can have profound effects on your tongue, giving it more muscle tone.
For pregnant women, this slight muscle tone is, in effect, what helps them to counteract what could be a detrimental side affect to their weight gain during pregnancy. However, during post-pregnancy when these levels taper off, is another story.
Studies have shown that tongue muscle tone is lower in post-menopausal women and increased significantly when progesterone is added.
Imagine the effects of diminishing progesterone just before womens’ periods, or during menopause, when progesterone begins to slowly drop beginning in the early 40s. The same thing occurs during pregnancy: progesterone shoots up during pregnancy and drops immediately after delivery. During pregnancy, despite all the expected weight gain, progesterone (besides maintaining uterine health) prevents the tongue from falling back. But once a woman delivers and progesterone drops, you’re left with all the added weight of pregnancy without the added protection of progesterone. No wonder women have trouble sleeping the first few weeks after delivery (besides having to feed the baby every few hours).
In retrospect, these factors severely affected the way my wife felt right after my first son was born. It took her almost a year before her post-partum depression resolved completely after our first son was born. Only after she lost all her pregnancy weight did she begin to feel better.
Breathe Better, Sleep Better, Feel Better
Although pregnancy can impact the way you breathe, and thereby affect the way you sleep during and even after you deliver, there are simple ways to minimize the negative side effects and expedite your post-partum recovery process.
The first thing you must do is to keep all your airway passages clear and congestion free and this includes your nose. If your nose is stuffy, the simplest thing to do is to apply nasal saline, which come in various nasal applicators from sprays to pumps to Water-Pik machines. Another popular way of getting salt water into your nose is a Neti-pot, which is an Indian Alladin’s lamp-like container where you mix your saline and pour it into your nose.
If your nostrils collapse when you breath in, then nasal dilator strips (Breathe-rite is one brand), or internal nasal dilator devices (Nozovent, Breathewitheez, Nasalcones are three examples) may help. Sometimes women are placed on allergy medications for pollens, dust or pets. This should be done under a care of your medical doctor. If none of these options work, it’s time to see an ear, nose and throat doctor.
If you normally like to sleep on your stomach or side, then your tongue may be susceptible to collapse. There are various dental devices that are available for snoring and mild to moderate obstructive sleep apnea. Although not officially designed for use in pregnant women, these devices are not harmful for the baby and can only help the baby since it helps the mother sleep better.
If you have any of the complications of pregnancy or if your fatigue is to severe to the point where you are incapacitated, a consultation with a sleep doctor may be warranted. CPAP, or continuous positive airway pressure, has been studied and found to be useful in a handful of small, preliminary studies.
The most important thing to do after delivery is to try to lose the pregnancy weight. This is obviously easier said than done, but there is a direct correlation between your persistent weight and how you will feel. You may want to consider working with a healthcare professional (your medical doctor, dietician or trainer). The devices mentioned during pregnancy may be appropriate for afterwards the delivery as well.
Whether or not you’re pregnant, breathing well while you’re sleeping is vital to your overall state of health. But if you’re pregnant, it’s even more important that you breathe well, especially in the immediate period just after you deliver.
Click here for Top 10 Tips from our expert fitness consultant, Tara Marie Segundo, on how to lose your post pregnancy weight quickly and easily.