Physiologic and symptomatic burden across sleep-disordered breathing severity in men and women

Sex differences in sleep-disordered breathing (SDB) are well recognized, but whether equivalent disease severity confers similar physiologic and symptomatic burden remains uncertain.

Data from a community-based cohort of 826 adults free of major cardiopulmonary and metabolic comorbidity were analyzed. Study participants were classified as having no SDB (apnea-hypopnea index [AHI] <5 events/h), mild SDB (5.0-14.9 events/h), or moderate-to-severe SDB (≥15 events/h). Within each stratum, men and women were matched 1:1 on age, race, body mass index, and AHI. Objective polysomnographic measures and subjective assessments of daytime sleepiness, insomnia symptoms, and quality of life were compared using regression models with sex-by-severity interaction terms.

Objective sleep measures were largely similar between sexes in the absence of SDB. With mild SDB, men slept 22.2 min less than women (p = 0.006) and had higher overall and NREM arousal rates (p = 0.002 and p = 0.001, respectively). With moderate-to-severe SDB, men had lower sleep efficiency (-8.6%; p < 0.001), longer wake after sleep onset (+22.7 min; p = 0.001), and greater daytime sleepiness (p = 0.06), whereas women had more insomnia symptoms and lower physical and mental quality-of-life scores (both p = 0.001). Across all AHI strata, women had greater N3 sleep (all p < 0.003). Significant sex-by-severity interactions were observed for sleep efficiency, wake after sleep onset, and daytime sleepiness (all p ≤ 0.006).

Comparable levels of SDB severity carry different physiologic and symptomatic consequences in men and women, indicating that assessment should extend beyond AHI alone to include sleep disruption, symptom profile, and functional impact.