We’ve all cared for this patient: A 50-year-old woman presents for elective surgery. She tells you that she sleeps poorly, has a history of anxiety or depression, wakes up with a headache, and feels exhausted despite getting what she believes is a full night’s sleep. She has no documented history of OSA, and her STOP-Bang score places her at low risk for the disease. She has a normal neck circumference, denies loud snoring, and reports no witnessed apneas. Based on this preoperative evaluation, few clinicians would suspect undiagnosed OSA. Yet something about her story doesn’t quite fit. This is often how OSA presents in women and why so many remain undiagnosed.
OSA in women continues to be underrecognized because it often presents differently than the classic OSA phenotype that has shaped clinical recognition for decades. Although OSA has traditionally been associated with middle-aged men who snore loudly and have obvious risk factors, women are more likely to present with insomnia, broken sleep, morning headaches, fatigue, depression, anxiety, or nocturia.1 In fact, up to 40% of women with OSA do not report the hallmark symptoms typically associated with the disease, including loud snoring, witnessed apneas, or nighttime choking.1 Too often, these symptoms are attributed to stress, mood disorders, menopause, or aging rather than recognized as manifestations of sleep-disordered breathing.1
This diagnostic discrepancy goes beyond symptoms to the underlying physiology of OSA in women. Compared with men, women are more likely to experience shorter respiratory events, less severe oxygen desaturation, and respiratory effort–related arousals rather than complete upper airway obstruction.2 As a result, sleep-disordered breathing may be underestimated, particularly when diagnostic approaches depend heavily on prolonged airflow cessation and oxygen desaturation.2 These physiologic differences may contribute to delayed recognition and reinforce the need to interpret peri-operative screening tools within the larger clinical context.2
Recognizing OSA before surgery is not simply about assigning a diagnosis; it changes peri-operative management. For women whose OSA has gone unrecognized, the peri-operative period may be the first time the physiologic consequences of the disease become clinically apparent. Sedatives, anesthetic agents, opioids, and the physiologic stress of surgery can worsen upper airway collapse and respiratory depression, increasing the risk of postoperative cardiorespiratory complications.3 Identifying these patients before surgery allows clinicians to individualize anesthetic planning, minimize opioid exposure through multimodal analgesia, and determine the need for enhanced postoperative monitoring. These strategies are particularly important because unrecognized OSA has been directly associated with postoperative pulmonary complications, prolonged hospitalization, and the need for higher levels of intermediate postoperative care.3
In peri-operative medicine, we rely heavily on screening tools such as STOP-Bang to identify patients at increased risk for OSA. While these tools have improved peri-operative risk assessment, they should complement, not replace, a thoughtful clinical history. STOP-Bang includes male sex as an independent risk factor and incorporates neck circumference thresholds largely derived from predominantly male populations. Consequently, women with clinically significant OSA systematically score lower despite symptoms that warrant further evaluation.1
When the patient’s story does not fit the screening score, it is worth asking why. Listening carefully to what a patient says may reveal what the questionnaire cannot.
The questions we ask matter. Rather than relying solely on traditional scoring metrics, clinicians must actively investigate broken sleep, morning headaches, nocturia, persistent fatigue, insomnia, and mood symptoms. Individually, these complaints are common and nonspecific. Together, they show a distinct clinical pattern that should immediately raise suspicion for OSA in women.
The peri-operative evaluation is far more than a compliance checklist for surgical clearance. For many women, this encounter represents the foundational step toward a diagnosis that improves not only immediate peri-operative safety but also long-term cardiovascular, metabolic, and respiratory health.
References
1. Bouloukaki I, Fabozzi A, Schwarz EI, Schiza SE. Advances in the diagnosis and treatment of obstructive sleep apnea in women. Pulm Ther. 2026;12(1):181-199. doi:10.1007/s41030-026-00350-5
2. Pena-Orbea C, Wang L, Srisawat P, Foldvary-Schaefer N, Mehra R. Sex-specific differences in diagnostic approaches of inpatient sleep testing for obstructive sleep apnea. Sleep Med. 2023;102:157-164. doi:10.1016/j.sleep.2022.12.011
3. Chaudhry RA, Arif Zarmer R, West L, Kelly K, Chung F. Obstructive sleep apnea and risk of postoperative complications after non-cardiac surgery. J Clin Med. 2024;13(9):2538. doi:10.3390/jcm13092538
