Perimenopause and Sleep Apnea: The Connection Most Doctors Miss

The Sleep Problem That Looks Like Everything Else

You're exhausted. You sleep, technically, but you wake up feeling like you didn't. You have brain fog, headaches in the morning, and a fatigue that no amount of rest seems to fix. You've attributed all of this to perimenopause, and some of it probably is.

But a significant number of women in this situation have an undiagnosed sleep disorder layered on top of their hormonal changes. Sleep apnea, a condition in which breathing repeatedly stops and starts during sleep, is dramatically underdiagnosed in perimenopausal and menopausal women.

The consequences of missing it go beyond fatigue. Untreated sleep apnea raises cardiovascular risk, worsens cognitive decline, and makes every other perimenopause symptom harder to manage.

Why Perimenopause Triples Sleep Apnea Risk

Before menopause, women have significantly lower rates of obstructive sleep apnea than men. That protection largely comes from progesterone. Progesterone acts as a respiratory stimulant and helps maintain muscle tone in the upper airway, including the throat muscles that can collapse during sleep and cause apnea episodes.

As perimenopause progresses and progesterone declines, that protective effect weakens. Estrogen also plays a role in keeping airway tissues firm and less prone to collapse. When both hormones decline, the airway becomes more vulnerable.

Studies show that sleep apnea rates roughly triple after menopause compared to premenopausal women of similar age. Perimenopause is the transition period where this risk begins to climb. Women who were never at risk before may develop sleep apnea during this window.

Why Women's Sleep Apnea Gets Missed

The classic picture of sleep apnea comes from research done primarily on men: loud snoring, witnessed gasping, a heavyset build, excessive daytime sleepiness. Women with sleep apnea often don't fit this picture at all.

Women are more likely to report insomnia, frequent waking, fatigue, depression, headaches, and anxiety. These symptoms overlap almost perfectly with perimenopause. When a woman in her late 40s goes to the doctor and describes fatigue, mood changes, and poor sleep, perimenopause is usually the first and sometimes only conclusion.

Snoring, when it does occur in women, is often lighter and more intermittent than in men. This means bed partners may not notice or report it. Women are also more likely to have hypopnea events (shallow breathing that doesn't fully stop) rather than full apneas, which makes the condition harder to detect without testing.

Symptoms That Should Prompt Testing

If any of the following describe you, it's worth asking your doctor specifically about sleep apnea testing, not just assuming everything is hormonal.

You wake up with a headache most mornings. Your fatigue doesn't improve with more sleep or better sleep hygiene. You wake frequently and feel like you're gasping or that your heart is racing. You have unexplained high blood pressure that's hard to control. Cognitive symptoms, especially memory and concentration, are disproportionate to what you'd expect from perimenopause alone.

You don't have to be overweight. You don't have to snore loudly. You just have to be a woman in perimenopause with persistent, unexplained fatigue and poor-quality sleep.

Getting Tested: What to Expect

Sleep apnea is diagnosed with a sleep study. There are two main types. An in-lab polysomnography is the gold standard, where you spend a night in a sleep clinic connected to monitoring equipment. A home sleep apnea test (HSAT) is a simpler device you use in your own bed, measuring airflow, blood oxygen, and breathing effort.

Home tests are accurate enough for most straightforward sleep apnea cases and are increasingly the first-line option. They're more comfortable, usually cheaper, and covered by most insurance.

If your home test comes back borderline or if your doctor suspects a more complex sleep disorder, an in-lab study gives more detailed information. The most important step is simply asking for the referral. If your doctor dismisses the idea without adequate reasoning, you're within your rights to ask again or seek a second opinion.

CPAP and Its Alternatives

Continuous positive airway pressure (CPAP) is the most effective treatment for moderate to severe sleep apnea. It works by delivering a continuous stream of pressurized air through a mask that keeps your airway open during sleep. Many people struggle with CPAP initially, and it often takes a period of adjustment to find the right mask and pressure settings.

But CPAP is not the only option. Mandibular advancement devices (MADs) are custom-fitted oral appliances worn during sleep. They reposition the jaw forward to help keep the airway open. They're less effective than CPAP for severe apnea but work well for mild to moderate cases and are often better tolerated.

Positional therapy is effective if your apnea primarily occurs when sleeping on your back. For some people, simply learning to sleep on their side eliminates most events. Surgical options exist for specific anatomical causes of airway obstruction but are typically considered only when other treatments have failed.

HRT and Sleep Apnea: A Complex Relationship

Given that progesterone loss contributes to sleep apnea risk, it's reasonable to ask whether HRT might help. The evidence is limited but somewhat encouraging. Some studies show that hormone therapy, particularly regimens that include progesterone, modestly reduces sleep apnea severity in postmenopausal women.

Progesterone supplementation alone has been studied as a respiratory stimulant with mixed results. The effect is real but not large enough to treat moderate or severe sleep apnea on its own. It may be most useful in milder cases or as an adjunct to other treatment.

If you're considering HRT for perimenopause symptoms and you also have sleep apnea, this is worth discussing with your provider. The decision about HRT should weigh your individual risk factors, but the fact that it may provide modest airway benefit is worth factoring in.

The Cardiovascular Risk Stack

This is where missing sleep apnea in perimenopause becomes particularly serious. Both perimenopause and sleep apnea independently raise cardiovascular risk. Estrogen loss increases LDL cholesterol, blood pressure, and inflammatory markers. Untreated sleep apnea causes repeated drops in blood oxygen overnight, chronic sympathetic nervous system activation, and raised blood pressure.

Together, these create a risk stack greater than the sum of its parts. The years of perimenopause and early menopause are already a critical window for cardiovascular health. Adding years of untreated sleep apnea on top compounds that risk significantly.

Treating sleep apnea effectively has been shown to reduce blood pressure, improve lipid profiles, reduce inflammation, and lower the risk of cardiovascular events. This is not a minor quality-of-life fix. For women in midlife, it is a meaningful health intervention.

This content is for informational purposes only and does not replace medical advice. Always consult your healthcare provider about your specific situation.