Shall we start speaking properly? No, women do not breathe loudly when we sleep; we snore as well. And this does not take away any glamour from the matter; it makes it more real and more human. Female snoring, far from being a cause for shame, may respond to certain health issues and needs to be analyzed and valued. Especially with the arrival of menopause, when snoring becomes an unexpected sleep companion for women.
Traditionally, snoring is associated with weight gain or smoking, but if you have noticed that for a while now the decibels in bed have increased and approach a chainsaw-like roar rather than a light nocturnal sob, the same is worth paying some attention to. Your partner, your dog and, even, your neighbors will thank you.
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No progesterone, but with built-in speaker
The most definitive revenge after years of tolerating your partner’s snoring can arrive during menopause. This is documented by the Sleep Disorders in Postmenopausal Women Insomnia study, which associates the perimenopause, menopause and postmenopause (and their associated hormonal changes) with snoring and the risk of sleep apnea. Also, with an increase in restless legs syndrome.
This goes beyond mere annoyances to your bed partner, as it may be a warning of obstructive sleep apnea (OSA).
Snoring and not resting
“We observe this quite frequently. Many women consult us for the first time after menopause. They arrive worried because they start snoring more, they wake up with a feeling of non-restorative sleep, or their partner notices breathing pauses that didn’t exist before. Sometimes they do not experience it as apnea in the classic sense, but as fatigue, awakenings, insomnia or lack of energy. The important thing is that it doesn’t always appear suddenly,” says Dr. Abraham Brito, sleep specialist at the Sleep Institute in Madrid.
The expert explains that in many patients a combination of factors adds up: hormonal changes, weight gain or redistribution, more fat at the abdominal and cervical level, poorer sleep quality and greater nighttime fragmentation. “All of that can favor the airway collapsing more during the night.”
Not only hormones, not only age
Before menopause, estrogens and progesterone seem to have some protective effect on breathing during sleep. They influence the tone of the airway muscles, ventilatory control and the distribution of body fat. When these hormonal levels fall, the vulnerability to snoring and to developing obstructive sleep apnea increases.
“Menopause also coincides with aging. And with age, other risk factors increase: higher prevalence of hypertension, metabolic changes, weight gain, loss of muscle tone and more fragmented sleep,” adds the expert.
The most honest answer is that it’s not only due to hormones nor only to age: it’s an interaction between both. “Sleep apnea in women is underdiagnosed because for years it has been associated with a very specific profile: man, overweight, snorer, with evident daytime sleepiness. That profile exists, but it does not represent all patients.”
Another commonly overlooked female ailment
“In women, especially from perimenopause to menopause, symptoms can be less ‘typical’. Many do not consult saying ‘I suffocate at night’ or ‘I fall asleep anywhere,’ but they report chronic fatigue, insomnia, frequent awakenings, morning headaches, anxiety, low mood or difficulty concentrating. That more nonspecific presentation makes it sometimes attributed to stress, depression, menopause or aging, and a sleep study is not requested,” explains.
Men tend to consult more for intense snoring, observed breathing pauses and clear daytime sleepiness. In women there can also be snoring and witnessed apneas, but often symptoms such as non-restorative sleep, insomnia, fatigue, morning headaches, irritability, depressive symptoms or anxiety predominate.
“We also see that some women minimize snoring or do not sleep with someone, so no one observes the breathing pauses. That delays diagnosis.”
Attention during the menopausal transition
That no one hears it does not mean it isn’t happening. “In fact, it is one of the consultations I see with increasing frequency. Many women who had never snored begin to do so during the perimenopause or after menopause, and they are often surprised because they have not gained weight nor changed their habits,” responds Dr. Karen Wejbe, expert in Otolaryngology at Maribel Yébenes.
For years, estrogens and progesterone exert a protective effect on our airways. When their levels decrease, the upper airway (palate, pharynx, larynx) loses part of its muscular tone and the airway becomes more vulnerable to collapse during sleep. “The prevalence doubles or triples, approaching that of men of similar age. It is no coincidence that the incidence of snoring and sleep apnea increases clearly from ages 45-50. It is another change that accompanies the menopausal transition, though it is discussed much less than hot flashes or weight gain,” she adds.
The perfect storm: worse sleep, more snoring
Female hormones are much more than reproductive hormones. The progesterone acts as a natural stimulant of respiration. It helps keep the muscles that keep the airway open active at night. When it decreases, the tendency for the airway to narrow or collapse increases. “Estrogens, for their part, contribute to preserving muscle quality and tissue elasticity, modulate the distribution of body fat and have effects on the inflammation of the mucosa of the upper airway. Therefore, when both hormones decline, many women experience a true perfect storm: worse sleep, more awakenings at night, more snoring and a higher risk of apnea,” she notes.
I’m thin and I snore
One of the biggest myths is thinking that only overweight people snore. Excess weight, as Wejbe assures, “increases the risk, but is not the only cause; BMI is the most studied risk factor, but craniofacial anatomy (retrognathia, arched palate, septal deviation, turbinate hypertrophy or tonsillar hypertrophy) are independent determinants.”
That is why in consultation they assess the airway with nasofibroscopy to diagnose alterations that may increase the risk of snoring or sleep apnea syndrome: “I have seen many thin, active patients with healthy habits who begin to snore coinciding with menopause. In these cases, the determinant factor tends to be hormonal and structural rather than metabolic.”
If you’ve quit smoking!
When you quit smoking, snoring decreases gradually, since tobacco causes chronic inflammation of the airways (nasal and pharyngeal mucosa, smoker’s rhinitis and pharyngitis, vocal cord edema…), in addition to increased mucus production.
However, it is a progressive process “because tobacco leaves structural sequelae: fibrosis and loss of tissue elasticity.” Added to this are non-tobacco-related factors (anatomy, weight, alcohol, sleeping position) that quitting smoking does not modify.
The expert lists some of them:
- Alcohol is one of the most frequent because it relaxes the pharyngeal musculature and favors the collapse of the airway at night.
- Nasal breathing dysfunction also plays a very important role. When you do not breathe well through the nose, the body compensates by breathing through the mouth, which promotes vibrations and snoring.
- Reflux, which can inflame the airway.
- Some medications, especially sedatives, anxiolytics, muscle relaxants or certain antihistamines, which can worsen the problem.
- The position of the head during sleep (use of inappropriate pillows).
And there is a factor we talk little about: the loss of muscle mass associated with aging. “Just as we try to preserve muscle to maintain mobility and strength, we also need to preserve the tone of the muscles that keep the airway open,” she notes.
Take care of yourself and you will take care of your sleep
There is no universal solution because not all snorers are the same. “We know that physical exercise improves overall muscle quality, including the respiratory muscles, and contributes to a more restorative sleep. Regarding mandibular advancement splints, they are a very useful tool in selected patients. They work by slightly advancing the jaw during sleep, which increases the space available for the air to pass,” says Dr. Wejbe.
Tips for sleeping without snoring
- Maintain a healthy weight.
- Avoid alcohol and sedative/relaxant medications in the hours before sleep.
- Properly treat nasal obstruction.
- Maintain regular sleep schedules (sleep hygiene).
- Engage in regular physical exercise.
- Prefer sleeping on your side: when we sleep on our back, gravity favors the tongue and soft tissues to fall back and narrow the airway. Sleeping on the side reduces this effect.
When is CPAP treatment indicated? “CPAP remains the reference treatment for moderate to severe obstructive sleep apnea. It works by delivering a constant air pressure that keeps the airway open throughout the night. Numerous studies have shown it reduces sleepiness, improves quality of life and helps to reduce cardiovascular complications associated with apnea. Adherence is the main clinical challenge, which is why in ENT consultations we also assess alternatives according to the cause,” insists.
Hormone therapy?
Some studies suggest that hormone therapy may have a beneficial effect on certain respiratory parameters during sleep, especially when started in symptomatic women during the menopausal transition. “It can help, although it should not be considered a specific treatment for snoring or sleep apnea,” explains Dr. Wejbe.
Incorporating hormone therapy can be a further piece within a broader strategy of women’s health, but it should never replace an otorhinolaryngology assessment or a sleep unit when indicated. “Sleeping well is not a luxury: it is one of the fundamental pillars of health and longevity. The quality of our days begins with the quality of our nights,”she states.
