You’re exhausted. You’re not sleeping well. You assume it’s the hot flashes, the racing thoughts, the general chaos of perimenopause.
But there’s another possibility that often goes unrecognized: sleep apnea.
Before menopause, women have significantly lower rates of sleep apnea than men. After menopause, the gap nearly closes. Something about this transition dramatically increases risk—and many women don’t know to look for it.
The Numbers
The statistics are striking:
- Sleep apnea is 4.5 times more prevalent in postmenopausal women than in premenopausal women
- The Wisconsin Sleep Cohort found a 2.6-fold increased risk of sleep apnea in postmenopausal versus premenopausal women
- Surgical menopause carries even higher risk than natural menopause
This isn’t a small increase. This is a fundamental shift in risk profile that coincides with the menopausal transition.
Why Menopause Increases Risk
Hormones protect against airway collapse. Estrogen and progesterone help maintain muscle tone in the upper airway. As these hormones decline, the airway becomes more prone to collapse during sleep.
Fat redistribution matters. The shift to visceral and central fat distribution that happens during menopause (see Weight & Body Composition) affects neck and airway anatomy.
Progesterone is a respiratory stimulant. It literally drives your breathing. When it declines, respiratory drive decreases.
Recent research (2025) found that visceral fat accumulation specifically mediates the relationship between menopause and sleep apnea symptoms—meaning the way fat redistributes during menopause is itself a pathway to increased risk.
What Sleep Apnea Looks Like in Women
Here’s the problem: the “classic” presentation of sleep apnea—a heavy, snoring man who stops breathing in his sleep—doesn’t capture how it often appears in women.
Women with sleep apnea may report:
- Insomnia (trouble falling or staying asleep)
- Fatigue and daytime sleepiness
- Morning headaches
- Mood changes, depression, anxiety
- Brain fog and memory problems
- Waking frequently at night
- Restless sleep
Sound familiar? These overlap almost entirely with perimenopause symptoms. Which is why sleep apnea often goes undiagnosed in women—it looks like “just menopause.”
Women are also less likely to snore loudly (or may snore more quietly), and bed partners may not notice breathing pauses.
Why This Matters
Sleep apnea isn’t just about being tired. It’s associated with:
- Cardiovascular disease—increased risk of hypertension, heart attack, stroke, and atrial fibrillation
- Metabolic problems—insulin resistance, type 2 diabetes, weight gain
- Cognitive impairment—memory problems, difficulty concentrating
- Mood disorders—depression, anxiety
Your cardiovascular risk is already changing during menopause as estrogen’s protective effects wane. Untreated sleep apnea compounds that risk significantly.
A study from the American Heart Association found that women at high risk for sleep apnea had three times higher risk of poor cardiovascular health scores.
When to Suspect Sleep Apnea
Consider getting evaluated if you have:
- Persistent fatigue that doesn’t improve with better sleep hygiene
- Sleep problems that seem out of proportion to hot flashes alone
- Snoring (ask your partner, or record yourself)
- Waking with headaches or dry mouth
- High blood pressure, especially if new or hard to control
- Any witnessed breathing pauses during sleep
- Daytime sleepiness severe enough to affect functioning
If you went through surgical menopause or early menopause, your risk is even higher.
Getting Diagnosed
Home sleep tests are now widely available—you wear monitoring equipment while sleeping in your own bed. These are sufficient to diagnose moderate to severe sleep apnea in most cases.
In-lab polysomnography (sleep study) may be needed for complex cases or if the home test is inconclusive.
Ask your primary care provider for a referral to a sleep specialist, or request a home sleep test. If your provider dismisses your concerns, remember: this is an underrecognized condition in women.
Treatment
CPAP (Continuous Positive Airway Pressure) remains the gold standard. Yes, it involves wearing a mask. Yes, it takes getting used to. Yes, it works.
Modern CPAP machines are quieter and more comfortable than older versions. Multiple mask styles exist. If you tried CPAP years ago and couldn’t tolerate it, it may be worth trying again with newer equipment.
Oral appliances (mandibular advancement devices) can help mild to moderate sleep apnea by positioning the jaw forward to keep the airway open. These are fitted by dentists trained in sleep medicine.
Weight loss can significantly improve or even resolve sleep apnea for some people. GLP-1 agonists have shown promise here, though research specifically on their effect on sleep apnea in menopausal women is still emerging.
Positional therapy may help if your apnea is worse when sleeping on your back.
Hormone therapy is interesting here. Research shows HT is associated with reduced sleep apnea prevalence—suggesting that replacing hormones may help restore some of the protective effects. This isn’t a reason alone to start HT, but it’s part of the picture.
Surgery is an option in some cases but is usually not first-line treatment.
The Bigger Picture
Sleep apnea is part of the web of changes happening during perimenopause. It connects to:
Treating sleep apnea can improve many of these interconnected symptoms. Sometimes the exhaustion you attributed to perimenopause, the brain fog you thought was hormonal, the mood issues you’ve been struggling with—they improve dramatically when sleep apnea is treated.
If you’re struggling with sleep and fatigue during perimenopause, please consider whether sleep apnea might be part of the picture. It’s common, it’s underdiagnosed in women, and it’s very treatable.
You don’t have to just push through exhaustion. There might be a fixable reason—one that has nothing to do with willpower and everything to do with your airway.