In midlife, many women present to primary care providers with insomnia, anxiety, fatigue, nocturia, and low mood. Beneath these symptoms, a significant proportion are living with unrecognized comorbid insomnia and obstructive sleep apnea (COMISA).
Instead of being identified as part of a chronic sleep disorder pattern, these complaints are frequently coded as isolated insomnia and initially managed with short courses of sedative-hypnotic medication. What begins as a time-limited aid, however, often evolves into long-term, repeat prescribing when the underlying COMISA is never diagnosed or treated and women keep returning with the same unresolved symptoms.
Untreated COMISA is linked to higher risks of hypertension, cardiovascular disease, and depression1, meaning each missed or incomplete diagnosis closes off an opportunity for better care and outcomes.
Why the OSA component of COMISA is missed in women
The obstructive sleep apnea (OSA) element of COMISA is often harder to recognize in women because sleep medicine still primarily recognizes OSA through a male-pattern lens. Loud snoring, marked daytime sleepiness, obesity, and high apnea-hypopnea index (AHI) are regarded as the classic symptoms.
However, women tend to present differently with symptoms more likely to include insomnia, fragmented sleep, morning headaches, fatigue, mood symptoms, nightmares, and poor daytime function.2 Women can have clinically significant airflow limitations and severe daytime impairment even when their AHI looks “normal” or only mildly elevated.
When clinicians are less familiar with these non-classic OSA symptoms in women, they can easily be misattributed to conditions like anemia, cardiovascular disease, hypothyroidism, or depression.
OSA in women can also be masked by common comorbidities. Compared to women without OSA, women with OSA have higher rates of cardiovascular disease, hyperlipidemia, diabetes, asthma, arthropathy, and gastric reflux.3,5 Compared to men with OSA, they also have higher rates of gastric reflux, depression, anxiety, and asthma.3,4,5 Emerging evidence further suggests that OSA may confer a greater incremental risk of dementia in women than in men.4
Female-pattern OSA is more likely to involve hypopneas, REM-predominant events, respiratory effort-related arousals (RERAs), and repeated sleep fragmentation.6 These patterns can cause significant impairment even without significant oxygen desaturations.
Because current systems focus heavily on AHI and other male-coded features, women with disabling symptoms are often left undiagnosed or deemed ineligible for structured COMISA care.
Midlife as a tipping point
For many women, midlife is a high-risk period for fragmented sleep. Perimenopause and menopause can bring nocturia, weight gain, thermal dysregulation, and mood changes, all of which contribute to disrupted sleep. In fact, insomnia affects about half of midlife women.7
Menopause is also relevant to the OSA risk context specifically. OSA prevalence and severity rise after menopause, likely in part because of changes in sex hormones. Lower estrogen and progesterone levels have been associated with snoring and symptoms of OSA in middle-aged women.8
The sedative layer over missed OSA
Sedatives can feel like the most practical option for women who report exhaustion and inability to stay asleep, are coded as having anxiety or insomnia, and cannot access formal sleep assessment or cognitive behavioral therapy for insomnia (CBT-I). They may even feel like the best available solution and source of relief if women’s attribution is that insomnia alone, not respiratory events, is responsible for their daytime exhaustion.
Prescription sedatives are fast, familiar and relatively accessible, at least initially. Short-term sedative use can be appropriate, but the repeated prescribing can all too easily take the place of properly diagnosing and treating underlying sleep disorders.
That substitution carries risk. Benzodiazepines are still among the most sought-after sedatives in many countries, despite FDA approval of newer sedatives with much-reduced overdose risk. They can contribute to tolerance, dependence, confusion, and memory problems. They also tend to strengthen the belief that sleep only happens with medication, through a process of intermittent reinforcement. Even if next-morning residual sedation clouds functioning, there is still relief arising from the perceived increased sleep quantity. This experience gives rise to confusion and often, ad hoc self-medicating, once tolerance develops with regular use. Over time, the sedatives’
memory‑impairing effects, combined with habit loops involving nighttime fear of wakefulness, the intermittent ‘wins’ of a better night, and a growing belief that only the sedatives can produce sleep, can lead to both dependence and risky dosing patterns.9
Sedatives also blunt protective arousal responses and raise concern about respiratory depressant effects when combined with other central nervous system depressants, increasing in frequency when tolerance develops.9
One population-based study found benzodiazepine use was associated with increased risk of acute respiratory failure in patients with OSA.10
Of course, broadly, these effects and risks vary by medication class and patient phenotype, so the point is not that every sedative worsens every case. It is that sedative prescribing in a patient with possible untreated COMISA should not be casual, indefinite or disconnected from OSA assessment and appropriate follow-up care. Otherwise, the dynamics brought about by long-term sedative use can delay the right care for years.
Why this is a serious chronic disease issue
COMISA is not simply insomnia plus snoring. People with COMISA often have worse sleep and health outcomes than people with insomnia alone or OSA alone. They report poorer sleep quality, increased daytime fatigue and higher rates of depression and anxiety.11
Patients with COMISA have a higher risk of cardiovascular disease and lower quality of life.12 Recent population-based studies also show that people with COMISA have a 50–70% higher all-cause mortality risk over 10–20 years than people with neither insomnia nor OSA. 12,13 Importantly, after adjusting for other factors, insomnia alone and sleep apnea alone were not linked to higher mortality. The increased risk was seen only when both conditions occurred together as COMISA.13
Treatment is also most effective when both conditions are addressed rather than treated in isolation. Reviews of COMISA management support coordinated treatment that includes both CBT-I and PAP, with the order and timing of care tailored to each patient’s symptoms, preferences and access barriers.14
That is why treating insomnia symptoms alone, without looking for underlying sleep-disordered breathing, can miss a clinically important driver of cardiometabolic and psychological morbidity.
What better care would look like
An evidence-based care model would incorporate sleep disorder screening into routine midlife and menopausal chronic disease assessments alongside blood pressure, lipids, and HbA1c for women.
Women who report insomnia, nocturia, fragmented sleep, fatigue, morning headaches, low mood, or anxiety should be screened not only for insomnia but also for OSA symptoms that may be underdetected by standard tools.
Care pathways should then make the right treatments easier to access than repeat sedative prescribing. That means funded CBT-I, structured benzodiazepine tapering that addresses typical attributions and dependence, and accessible OSA treatment pathways. For women with clinically significant symptoms and impairment, this may include PAP or oral appliance therapy.
It also means funding follow-up that treats adherence support as part of therapy, especially for women experiencing claustrophobia, sensory sensitivity or anxiety during PAP therapy.
The needed reframe
Many women are being managed within a short-term care model that makes sedative prescribing easier to access than comprehensive sleep assessment and longitudinal treatment.
Modern sleep medicine must recognize and act on a pattern more clearly. Many midlife women with insomnia, sedative reliance, and undiagnosed OSA are living with COMISA, not isolated sleep complaints. They need proper diagnosis, structured follow-up, multidisciplinary care, and reimbursement rules that reflect real-world female presentation.
