What needs to change: Screening tools, clinical practice, policy and research

Q: Most primary care providers (PCPs) don’t receive much training on sleep. What message would you send to PCPs to help them identify sleep apnea, especially in women?

Dr. Morris: OSA is very heterogeneous; it presents differently in women. Many women don’t describe themselves as “sleepy.” Instead, they may say they’re tired, fatigued, or overwhelmed. You’ll hear phrases like “I can’t get through the day” or “I don’t have the energy for what I need to do.”

Primary care providers need to listen for those cues. They may not match classic markers, but they’re just as telling. Too often, women are misdiagnosed with depression or prescribed antidepressants before anyone considers sleep disorders as the underlying cause.

Asking about sleep should be part of routine screening. And clinicians should go beyond “Do you fall asleep during the day?” They should also ask about overall daytime function and energy.

Obesity in younger women is also an important risk factor for OSA. It’s something I hope PCPs are mindful of when evaluating symptoms.

Q: What other differential diagnoses should PCPs consider where sleep issues may be a root cause?

Dr. Morris: Sleep apnea can hide behind many symptoms: depression, fatigue, overwhelm, poor glycemic control in diabetes and even nocturia. If a patient is waking frequently at night to urinate, sleep-disordered breathing could be a factor. And if they’re reporting persistent tiredness without a clear cause, it’s worth screening for a sleep disorder.

Q: STOP-BANG, Epworth and Berlin are commonly used screeners. How effectively do they capture female patients? What questionnaires or tools would you suggest for PCPs?

Dr. Morris: STOP-BANG has a built-in male bias—it gives an extra point just for being male, which disadvantages women. It also doesn’t account for menopause, even though OSA risk increases significantly post-menopause and becomes nearly equivalent to the risk for men, even without factors like obesity.

The Berlin questionnaire is a little better. It doesn’t give that extra point to men, but it relies heavily on questions about snoring. That can be an issue in the U.S., for instance, where many women are single and don’t have bed partners to observe or confirm snoring.

The Epworth Sleepiness Scale (ESS) is largely behavioral; it asks about things like falling asleep watching TV. I think it was designed to capture how men typically think about their sleepiness, not women. That’s just my opinion, but I’d love to test it.

The PROMIS (Patient-Reported Outcomes Measurement Information System) scale is promising. It’s broad and basic, and it goes beyond just behavior-based questions.

Q: You’ve done research on the multivariate apnea prediction (MAP) index. Could you explain what it is and the implications for women?

Dr. Morris: MAP is a pre-screening tool used to predict OSA risk based on non-invasive factors like age, sex, BMI, snoring and observed apneas.

But MAP is more sensitive for men because, again, it gives an extra point for being male. It’s also more sensitive for postmenopausal women than for premenopausal women.

Our research suggests using tailored cut points for women and taking menopausal status into account to improve accuracy. We recently published a study using new cut points for pre- and postmenopausal women, and those adjustments improved the tool’s performance in identifying at-risk women.

Q: If you could list the top things policymakers and payers should change to improve sleep care for women, what would they be?

Dr. Morris: First, revise the apnea-hypopnea index (AHI) definition. Right now, the Centers for Medicare & Medicaid Services (CMS) uses a 4% desaturation threshold, which excludes many symptomatic women who would qualify under the American Academy of Sleep Medicine’s (AASM) 3% desaturation plus arousal rule.

Q: Similarly, what might you wish women knew to do proactively to better recognize their OSA?

Dr. Morris: You don’t have to feel sleepy all the time for it to be a problem. Chronic fatigue isn’t normal. Yes, go to your doctor and get your bloodwork done, but also ask for a sleep evaluation. Sleep studies are painless and can be life-changing.

Don’t assume that being tired is just part of getting older. It could be a sign of OSA. And if positive airway pressure (PAP) therapy doesn’t work for you, there are other options: medication, oral appliances or surgery for example. Don’t give up on treatment because one approach didn’t fit.

Q: Do you have any current or upcoming projects you can share?

Dr. Morris: Yes. We’re working on an observational study examining sex differences in OSA severity and symptoms. We’re using polysomnography and home sleep devices to track sleep across multiple nights, along with ecological momentary assessments that include asking participants how they feel during the day in terms of energy, stress and mood. This helps us connect nightly sleep quality with daytime functioning.

We’re also running a peer support study funded by the American Academy of Sleep Medicine, where experienced female PAP users mentor new users to help improve adherence. Early results suggest that peer support makes a difference.