Sex inequities in sleep disordered breathing

Sex-related inequities in sleep-disordered breathing (SDB) arise from the intersection of biological differences and gendered diagnostic and therapeutic frameworks. Although obstructive sleep apnea has traditionally been conceptualized as a male-predominant disorder, accumulating evidence indicates that women exhibit distinct pathophysiological mechanisms, symptom profiles and clinical trajectories that may be insufficiently captured. This structured narrative review synthesizes current evidence on sex-related biological differences and gender-based inequities in SDB and examines how male-derived diagnostic constructs may contribute to under-recognition and suboptimal management in women. A comprehensive literature search of PubMed/MEDLINE and Embase (January 1990-January 2026) was conducted. Epidemiologic, mechanistic, clinical, and selected animal studies addressing pathophysiology, presentation, diagnostic performance, treatment response and health-system factors were integrated through narrative synthesis. The evidence indicates that women demonstrate distinct anatomical and hormonal influences on upper airway stability, differences in ventilatory control and arousal threshold and greater susceptibility to REM-predominant and flow-limitation phenotypes. These findings are supported by a combination of epidemiological and physiological studies, although some mechanistic pathways remain incompletely characterized. Despite often presenting with lower apnea-hypopnea index (AHI) values, they report substantial symptom burden and exhibit strong associations with cardiometabolic and neurocognitive outcomes. Conventional screening instruments and AHI-centered diagnostic criteria show reduced sensitivity in women, contributing to delayed referral, underdiagnosis and increased healthcare utilization prior to diagnosis. Emerging data support a shift toward phenotype-informed interpretation of polysomnography, incorporation of REM-specific and flow-limitation metrics and development of sex-sensitive therapeutic strategies. Achieving equity in SDB requires moving beyond an exclusively apnea-centric framework toward a pathophysiology-informed approach supported by sex-stratified research.