The two crucial (often forgotten) questions for those struggling with sleep:
Do you snore?
Do you stop breathing during sleep?
Please listen to my presentation to understand why this is important.
The recommendations in the sleep section of the recently updated NICE guideline 'Menopause: diagnosis and management' state:
Consider menopause-specific CBT (cognitive behavioural therapy) as an option for people who have sleep problems (such as night-time awakening) in association with vasomotor symptoms:
• in addition to other management options (including HRT) or
• for people for whom other options are contraindicated or
• for people who prefer not to try other options
I registered as a NICE stakeholder and asked NICE to link their Obstructive sleep apnoea/hypopnoea syndrome (OSAHS) to their Menopause guidelines. Unfortunately their response was:
'The impact of other conditions on symptoms of the menopause is outside the scope of the 2024 guideline update. The outcome sleep disordered breathing for women in transition from perimenopause to post menopause was not in the scope of the 2024 guideline update'
I appreciate NICE can only remain in the scope of the guideline update therefore I am going to discuss how sleep disordered breathing (SDB) significantly increases in women as they transition to post menopause and how this is easily overlooked. SDB refers to a wide spectrum of sleep-related conditions including increased resistance to airflow through the upper airway, heavy snoring, marked reduction in airflow (hypopnea), and complete cessation of breathing (obstructive sleep apnoea/ OSA).
Obstructive sleep apnoea/hypopnoea syndrome (OSAHS) and obesity hypoventilation syndrome in over 16s NICE Guideline was published in August 2021 which states:
Take a sleep history and assess people for OSAHS if they have 2 or more of the following symptoms: |
|---|
Snoring |
Witnessed apnoeas (stopping breathing) |
Unrefreshing sleep |
Waking headaches |
Unexplained excessive sleepiness, tiredness or fatigue |
Nocturia (waking from sleep to urinate) |
Choking during sleep |
Sleep fragmentation or insomnia |
Cognitive dysfunction or memory impairment (brain fog) |
How many perimenopausal or postmenopausal women have these symptoms? We can only assess if 2 or more are present if we ask if the individual is snoring or stopping breathing during sleep.
The link between SDB and the menopause was highlighted over two decades ago by Dr Guilleminault, affectionately known as the ‘father of sleep medicine’, and his colleagues:
‘83% of the postmenopausal women complaining of chronic insomnia had sleep disordered breathing (SDB), usually with low apnea–hypopnea index (AHI). Questions of the role of SDB in the complaint of chronic insomnia are raised’
‘Abnormal breathing during sleep significantly enhanced complaints of daytime fatigue in postmenopausal chronic insomniacs and this complaint improved with SDB treatment. This improvement is significantly better compared to SDB insomniacs treated with a behavioral regimen’
I agree with sleep hygiene recommendations and there is evidence that CBT for sleep is effective however as this paper highlights sleep will be negatively impacted unless underlying SDB is addressed.
In 2017 data from the Wisconsin Sleep Cohort study was published in Menopause journal and demonstrated that there is a 3 times greater risk of moderate or worse OSA in post-menopausal women compared to pre-menopausal women:
‘In this population of mid-life women, menopause was a risk factor for sleep-disordered breathing, independent of age and body habitus. Later menopausal stage and time in menopause were both associated with higher AHI, suggesting an exposure-response relationship between further progression through menopause and sleep-disordered breathing severity’
My approach is:
AWARE – hormones affect how we breathe with a steep increase in SDB around the menopausal transition. Noisy breathing and stopping breathing during sleep negatively impacts sleep quality because the body will choose breathing over sleep.
ASSESS – provide simple assessment tools for health professionals and patients
ACTION – how to change the unconscious breathing pattern. Wearing my GP hat we generally wait until OSA is present before treating however wearing my breathing practitioner hat I see a spectrum that is easier to treat the earlier it is tackled. When asleep we are breathing through a tube in our neck (the airway) that has the potential to narrow or close. We can re-educate our body to open the airway as much as possible with correct tongue position, nasal breathing and strong throat muscles. In addition we can re-educate the body to breath the volume of air we actually need (a lot of us over breathe in modern society), use the correct breathing muscles and breath more slowly.
Breathing re-education will not stop all sleep disordered breathing however the major conclusion from an Official American Thoracic Society Workshop Report was that nasal CPAP should be the initial option for most patients. The report also stated:
Mouth breathing is common among OSA patients.
Nasal symptoms are common among patients with OSA and may compromise CPAP adherence.
Controlling nasal symptoms should be implemented both before and during CPAP use and may improve nasal CPAP adherence.
Most studies suggest that nasal CPAP results in better adherence, lower residual apnea–hypopnea index (AHI), and higher therapeutic levels as compared with oronasal CPAP.
Therefore in my opinion re-establishing 24-hour efficient, nasal breathing with breathing re-education is the most basic method of improving sleep disordered breathing.
Top tips
How we breathe whilst resting, sleeping and moving is important.
We can change how we unconsciously breathe.
We may overlook sleep disordered breathing if we forget to ask the crucial questions do you snore? Do you stop breathing during sleep?
Please share this blog to help me raise awareness that how we breathe matters.
References
American Thoracic Society https://qol.thoracic.org/sections/specific-diseases/sleep-disordered-breathing.html
Chronic insomnia, postmenopausal women, and sleep disordered breathing: Part 1. Frequency of sleep disordered breathing in a cohort. July 2002 Christian Guilleminault et al. https://doi.org/10.1016/S0022-3999(02)00445-2
Chronic insomnia, premenopausal women and sleep disordered breathing: Part 2. Comparison of nondrug treatment trials in normal breathing and UARS post-menopausal women complaining of chronic insomnia. July 2002 Christian Guilleminault et al. https://doi.org/10.1016/S0022-3999(02)00463-4
Young T, Skatrud J, Peppard PE. Risk factors for obstructive sleep apnea in adults. JAMA. 2004 Apr 28;291(16):2013-6. doi: 10.1001/jama.291.16.2013. PMID: 15113821.
Genta PR, Kaminska M, Edwards BA, Ebben MR, Krieger AC, Tamisier R, Ye L, Weaver TE, Vanderveken OM, Lorenzi-Filho G, DeYoung P, Hevener W, Strollo P. The Importance of Mask Selection on Continuous Positive Airway Pressure Outcomes for Obstructive Sleep Apnea. An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc. 2020 Oct;17(10):1177-1185. doi: 10.1513/AnnalsATS.202007-864ST. PMID: 33000960; PMCID: PMC7640631.
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