Sex-specific sleep apnea screening questionnaires: closing the performance gap in women

Symptom content analysis of OSA questionnaires: time to identify and improve relevance of diversity of OSA symptoms?

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is a heterogeneous condition covering many clinical phenotypes in terms of the diversity of symptoms. Patient-based OSA screening questionnaires used in routine practice contain significantly varying contents that can impact the reliability and validity of the screening. We investigated to what extent common patient-based OSA screening questionnaires differ or overlap in their item content by conducting a rigorous, methodical, and quantified content overlap analysis.

METHODS

We conducted an item content analysis of 11 OSA screening questionnaires validated in adult populations and characterized their overlap using a 4-step approach: (1) selection of OSA screening questionnaires, (2) item extraction and selection, (3) extraction of symptoms from items, and (4) assessment of content overlap with the Jaccard index (from 0, no overlap, to 1, full overlap).

RESULTS

We extracted 72 items that provided 25 distinct symptoms from 11 selected OSA questionnaires. The overlap between them was weak (mean Jaccard index: 0.224; ranging from 0.138 to 0.329). All questionnaires contained symptoms of the "OSA symptom" dimension (eg, snoring or witnessed apneas). The STOP-BANG (0.329) and the Berlin (0.280) questionnaires exhibited the highest overlap content. Ten symptoms (40%) were investigated in only 1 questionnaire.

CONCLUSIONS

The heterogeneity of content and the low overlap across these questionnaires reflect the challenges of screening OSA. The different OSA questionnaires potentially capture varying aspects of the disorder, with the risk of biased results in studies. Suggestions are made for better OSA screening and refinement of clinical OSA phenotypes.

CITATION

Gauld C, Baillieul S, Martin VP, et al. Symptom content analysis of OSA questionnaires: time to identify and improve relevance of diversity of OSA symptoms? J Clin Sleep Med. 2024;20(7):1105-1117.

Validation of Trøndelag Apnoea Score Proxy for Obstructive Sleep Apnoea in the General Population of Norway: The HUNT Study

The aim was to validate a new seven-item "TASC" (Trøndelag Apnoea Score) proxy for obstructive sleep apnoea (OSA) against polysomnography in the general population. Objectives included validation against different polysomnographic criteria, stratification by age and gender, and estimation of OSA prevalence. From the fourth wave of the Trøndelag Health Study (HUNT4), 1,201 participants were randomly invited to a substudy focusing on sleep and headaches, of whom 232 accepted and 84 (64% women, mean age 55.0 years, and standard deviation 11.5 years) underwent polysomnography. The TASC proxy sums seven binary items for snoring, observed breathing pauses, restricted daytime activities, hypertension, body mass index (≥30 kg/m2), age (≥50 years), and gender (male). A single night of ambulatory (home) polysomnography was analysed using both the recommended and optional hypopnoea criteria of the American Academy of Sleep Medicine (AASM). We found 65% sensitivity and 87% specificity (Cohen's κ = 0.53, 95% confidence interval 0.34-0.72) for TASC ≥ 3 against AHI ≥ 15 (recommended AASM criteria). Validity was similar against AHI ≥ 30 but lower against AHI ≥ 5 and against the optional AASM criteria. Sensitivity and overall validity were higher among men and those above 50 years of age. The prevalence of an apnoea-hypopnoea index (AHI) of at least 5, 15, or 30 using the recommended (and optional) AASM criteria was 73% (46%), 37% (18%), or 15% (5%). A seven-item TASC proxy for OSA showed good validity and may be useful in screening and epidemiological settings. Sensitivity, specificity, and validity vary considerably by cut-off, by polysomnographic scoring criteria, and by gender and age strata.

Sex-dependent GOAL screening performance in adults at risk for obstructive sleep apnea

OBJECTIVE

To evaluate possible sex-related differences in the performance of the GOAL, a 4-item obstructive sleep apnea (OSA) screening instrument in adults.

METHODS

Between July 2019 and June 2021, this cross-sectional study included consecutively recruited patients from one Brazilian sleep laboratory undergoing overnight polysomnography. Individuals with GOAL scores ≥ 2 of a maximum of 4 points are classified at high risk for OSA diagnosis. Actual OSA severity was based on the apnea-hypopnea index: ≥ 5.0/h as any OSA, ≥ 15.0/h as moderate-to-severe OSA, and ≥ 30.0/h as severe OSA. Performance of the GOAL instrument in women and men was assessed by the discriminatory ability (obtained from area under the curve [AUC]-Receiver Operating Characteristic curves) and 2×2 contingency tables.

RESULTS

A total of 2,978 subjects (55.3% males) were evaluated. The frequency of GOAL-defined OSA high-risk was statistically higher in men when compared to women (p < 0.001). The GOAL predictive parameters for screening all severity OSA levels were as follows: in females, sensitivity ranging from 58.2% to 78.3% and specificity ranging from 60.0% to 77.6%, while in males, sensitivity ranging from 90.5% to 96.9% and specificity from 20.7% to 46.8%. The GOAL questionnaire had similar discriminatory properties, assessed by AUC, in women and in men: i) any OSA: 0.741 vs. 0.771 (p = 0.204), ii) moderate-to-severe OSA: 0.727 vs. 0.737 (p = 0.595), and iii) severe OSA: 0.728 vs. 0.703 (p = 0.240); respectively.

CONCLUSIONS

The GOAL instrument emerges as a useful tool for screening adult individuals and displays similar performance in both women and men.

A Narrative Review of Sex and Gender Differences in Sleep Disordered Breathing: Gaps and Opportunities

INTRODUCTION

Sleep disordered breathing (SDB) is a common condition, associated with multiple comorbidities including cardiovascular and metabolic disease. It has been previously established that SDB is more prevalent in men than women, shifting the literature's focus away from the latter population. As such, underdiagnosis, and thus undertreatment, of SDB in women exists.

METHODS

To establish the differences in prevalence, clinical presentation, and pathophysiology of SDB between the two sexes, a narrative review of the current literature was performed.

RESULTS

Rates of SDB are higher among men, likely driven by differences in symptom presentation between men and women, with women presenting with more "atypical" symptoms, and lack of sensitivity in SDB screening tools to detect SDB in women. In addition to the cardiovascular risks of SDB, women with SDB may have worse quality of life, higher prevalence of insomnia, and respiratory issues.

DISCUSSION

More research is needed to better define the unique pathophysiology and clinical presentation of SDB in women. In addition, an increased awareness among health care providers and the lay public of the SDB-specific sex and gender differences will serve to minimize disparities in identification and treatment of SDB in women.

Accuracy and modification of the STOP ‐bang questionnaire for screening patients with obstructive sleep apnea in China

Despite the high sensitivity of the STOP-Bang questionnaire [snoring, tiredness, observed apneas, high blood pressure, body mass index, age, neck size, gender] questionnaire (SBQ), which is widely used to screen individuals at high risk of obstructive sleep apnea (OSA), few studies have evaluated the discrimination related to sex in the SBQ. Therefore, our study aimed to assess whether SBQ performance is gender-related and modified by changing body mass index (BMI) and neck circumference (NC) cut-off values. A total of 470 patients attended the sleep centres. They were divided into moderate-to-severe OSA and non-moderate-to-severe OSA groups based on the apnea-hypopnea index (AHI) and the results of the SBQ screening. The predictive performance of the SBQ screening instrument was evaluated by 2 × 2 contingency tables and discriminatory ability, which was estimated from the area under the curve (AUC) obtained from receiver operating characteristic curve. Our results suggest that when screening for moderate-to-severe OSA, the original SBQ has higher sensitivity and lower specificity for men; however, women have higher specificity and lower sensitivity. The SBQ achieved the maximum AUC of 0.783 for men and 0.634 for women when the BMI cut-off value was established at 30 kg/m² and the NC cut-off value was established at 38 cm in men, and the BMI cut-off value was established at 25 kg/m² and the NC cut-off value at 36 cm in women. Balancing the optimal sensitivity and specificity, the cut-off value of the optimal modified SBQ total scores for men was determined to be ≥4 and ≥3 for women.

The usefulness of the Spanish version of the STOP-Bang questionnaire for screening for moderate or severe sleep apnea syndrome in primary care

Rationale

Sleep apnea-hypopnea syndrome (OSA) is a highly prevalent disease and has been related to cardiovascular diseases and occupational and traffic accidents. Currently, it is estimated that there is a significant underdiagnosis of OSA, mainly due to the difficulty accessing the tests for that purpose.

Objective

To determine the usefulness of the Spanish version of the STOP-Bang questionnaire (SBQ) for screening for moderate or severe OSA in the adult population attending primary care.

Methods

A descriptive observational multicenter study was conducted. Through an opportunistic search, (patients over 18 years old), were recruited in seven primary care centers. The SBQ was applied to them and home respiratory polygraphy (HRP) was subsequently performed to confirm the diagnosis of OSA. The criterion validity of the SBQ was analyzed, comparing the score obtained by the SBQ with the apnea-hypopnea index (AHI) obtained by RP, establishing the diagnosis of OSA for an AHI>5. The reliability of the questionnaire was evaluated.

Results

A total of 255 subjects, 54.1% men, with a mean age of 54.76 ± 10 years, were recruited in the study. The results showed that 61.57% (95% Confidence Interval: 55.57-67.57) of the subjects presented OSA, presenting 22.75% (17.57-57.92) a mild OSA (530) (11.54-20.62). The Kuder and Richardson coefficient was 0.623 (0.335-0.788) and Cohen's Kappa coefficient was 0.871 (0.520-1.00; p < 0.001). For moderate/severe OSA screening (AHI>15) the SBQ obtained an ROC curve of 0.769 (0.704-0.833) that with an optimal cutoff of 3, achieved a sensitivity of 84.85% (77.28-92.42) and a specificity of 55.10% (44.74-65.46).

Conclusions

The SBQ is very effective for detecting moderate/severe OSA. Its psychometric properties are similar to those obtained in studies on other populations. Because of its ease of use, the SBQ is a very useful tool for primary health care professionals.

A portrait of obstructive sleep apnea risk factors in 27,210 middle-aged and older adults in the Canadian Longitudinal Study on Aging

Determining the prevalence and characteristics of individuals susceptible to present with obstructive sleep apnea (OSA) is essential for developing targeted and efficient prevention and screening strategies. We included 27,210 participants aged ≥45 years old (50.3% women) from the Canadian Longitudinal Study on Aging. Using the STOP questionnaire combined to the percentage of body fat (%BF), we estimated the prevalence of individuals at high-risk for OSA in a sex and age-specific manner, and tested the relation with comorbidities, menopause and systemic inflammation. The prevalence was 17.5%, and was lower in women (13.1%) than in men (21.9%). A high level of high-sensitivity C-reactive protein was the strongest factor associated with OSA risk and this association was 1.3-2.3 times higher in women than in men. OSA risk increased with age, cardiovascular diseases, diabetes mellitus, anxio-depressive symptoms, asthma and arthritis. In women, post-menopausal status was associated with a high OSA risk. Nearly 1 adult out of 5 older than 45 is at risk for OSA in Canada. Comorbidities, menopause and systemic inflammation, more than age, explain increased OSA prevalence. Considering this high prevalence and associations with medical and mental comorbidities, health care practitioners should incorporate systematic OSA screening in their clinical procedures.

A Novel Portable Real-Time Low-Cost Sleep Apnea Monitoring System based on the Global System for Mobile Communications (GSM) Network

Background and objective

Continuous monitoring of breathing activity plays a vital role in the detection of respiratory-based diseases (SA, COPD, etc.). Sleep Apnea (SA) is characterized by recurrent upper airway obstruction during sleep associated with arterial blood desaturation, sympathetic nervous system activation, and cardiovascular impairment. Untreated patients with SA have increased mortality rates compared to the general population. This study aims to design a remote monitoring system for sleep apnea to ensure patient safety and ease the workload of doctors in the Covid-19 era.

Methods

This study aims to design a remote monitoring system for sleep apnea to ensure patient safety and ease the workload of doctors. Our study focuses on a novel portable real-time low-cost sleep apnea monitoring system utilizing the GSM network (GSM Shield Sim900a). Proposed system is a remote monitoring and patient tracking system to detect the apnea event in real time, and to provide information of the sleep position, pulse, and respiratory and oxygen saturation to the medical specialists (SpO₂) by establishing a direct contact. As soon as an abnormal condition is detected in the light of these parameters, the condition is reported (instant or in the form of short reports after sleep) to the patient relatives, the doctor’s mobile telephone or to the emergency medical centers (EMCs) through a GSM network to handle the case depending on the patient’s emergency condition.

Results

A study group was formed of six patients for monitoring apnea events (three males and three females) between the ages of 20 and 60. The patients in the study group have sleep apnea (SA) in different grades. All the apnea events were detected, and all the patients were successfully alerted. Also, the patient parameters were successfully sent to all patient relatives. Patients who could not get out of apnea were called through the CALL feature, and they were informed about their ongoing apnea event and told that intervention was necessary. The proposed system is tested on six patients. The beginning moment of apnea was successfully detected and the SMS/CALL feature was successfully activated without delay. During the testing, it has been observed that while some of the patients start breathing after the first SMS, some others needed the second or the third SMS. According to the measurement result, the maximum breathless time is 46 s among the patients, and a SMS is sent every 15 s. In addition, in cases where the patient was breathless for a long time, the CALL feature was actively sought from the relatives of the patient and enabled him to intervene. The proposed monitoring system could be used in both clinical and home settings.

Conclusions

The monitoring of a patient in real time allows to intervene in any unexpected circumstances about the patient. The proposed work uses an acceleration sensor as a reliable method of the sleep apnea for monitoring and prevention. The developed device is more economical, comfortable, and convenient than existing systems not only for the patients but also for the doctors. The patients can easily use this device in their home environment, so which could yield a more comfortable, easy to use, cost-effective, and long-term breathing monitoring system for healthcare applications.

Graphical abstract

Comorbidities associated with high-risk obstructive sleep apnea based on the STOP-BANG questionnaire: a nationwide population-based study

BACKGROUND/AIMS

We investigated the prevalence, associated factors, and comorbidities of high-risk obstructive sleep apnea (OSA) as determined by the STOP-BANG questionnaire in a Korean adult population.

METHODS

Data were obtained from 7,650 adults (aged ≥ 40 years) who participated in the Korea National Health and Nutrition Examination Survey (2019-2020). Multiple logistic regression analyses were used to evaluate the association of socioeconomic status, lifestyle related factors, and comorbidities with high-risk OSA (STOP-BANG score, 5-8).

RESULTS

The prevalence of high-risk OSA according to the STOP-BANG questionnaire was 12.0 %. Older age, male, current smoking, heavy alcohol consumption, and more comorbidities were associated with higher STOP-BANG scores. In multivariable adjusted analysis, diabetes mellitus (DM) (odds ratio [OR], 1.57; 95% confidence interval [CI], 1.25 to 1.97), hypertension (OR, 4.81; 95% CI, 3.88 to 5.97), and obesity (OR, 2.02; 95% CI, 1.60 to 2.56) were associated with high risk of OSA, and when hypertension, DM, and obesity were combined, the risk increased synergistically (OR, 3.88; 95% CI, 2.94 to 5.11).

CONCLUSION

According to the STOP-BANG questionnaire, the high risk of OSA was more common in males, and was associated with chronic metabolic disease, particularly in those with DM, hypertension, and obesity combined. Active OSA screening, prevention, and management may be beneficial to improving health outcomes related to OSA in these populations.

The influence of sex on anthropometric methods and four scales for screening obstructive sleep apnea

OBJECTIVES

Obstructive Sleep Apnea (OSA) is a kind of respiratory disease that occurs apnea repeatedly during sleep. The purpose of this study was to investigate the influence of sex on anthropometric methods and four scales for screening OSA.

METHODS

The basic data and PSG data of 2108 patients who underwent PSG examination at the Sleep Medicine Center of the First Affiliated Hospital of Guangzhou Medical University from July 2017 to December 2020 were continuously included. Then the sensitivity, specificity, positive predictive value, negative predictive value, AUC and DOR of the anthropometric method and the four scales were calculated.

RESULTS

2108 OSA patients were enrolled from the Sleep Medicine Center, including 1644 males (78.0%). The average neck circumference and waist circumference of male and female patients were respectively (39.4±3.4) cm and (96.7±13.8) cm,(34.6±3.5) cm and (90.1±11.6) cm. In female patients. the AUC of NoSAS was the largest. When AHI was 5, 15, and 30 evens/h as the cut-off point, in male patients, the sensitivity of NHR was the highest,in female patients, the sensitivity of WHR was the highest.

CONCLUSIONS

NHR and WHR are good tools for screening OSA in male and female patients respectively. They are worthy of promotion.

The Future of Sleep Measurements: A Review and Perspective

This article provides an overview of the current use, limitations, and future directions of the variety of subjective and objective sleep assessments available. This article argues for various ways and sources of collecting, combining, and using data to enlighten clinical practice and the sleep research of the future. It highlights the prospects of digital management platforms to store and present the data, and the importance of codesign when developing such platforms and other new instruments. It also discusses the abundance of opportunities that data science and machine learning open for the analysis of data.

Sex differences in the association between arterial hypertension, blood pressure, and sleep apnea in the general population

STUDY OBJECTIVES

To assess sex-related differences in the relationship between hypertension (HT), blood pressure (BP), and sleep apnea in the general population.

METHODS

We performed home polygraphy in a cohort of 1809 men and women in the general population. Office BP was measured. Presence of HT (drug-treated, physician-diagnosed, or high BP during study visit) was also recorded. HT rate and BP were assessed over a range of 7 sleep apnea severity categories based on the respiratory event index (REI).

RESULTS

The age-adjusted HT prevalence rate increased with higher REI in both sexes. After additional adjustment for obesity the association remained significant in women but not in men. In participants not treated with antihypertensive medications, age-adjusted BP increased with REI. Remarkably, the association was already significant within the normal range (REI < 5 events/h). The REI threshold for higher BP was situated at a distinctly lower cutoff point in women compared to men. After additional adjustment for obesity, the associations remained significant for diastolic but not systolic BP.

CONCLUSIONS

Significant increases in the age-adjusted BP and HT rate in the general population were present at lower REI cutoffs in women compared to men. Even a very low number of respiratory events was associated with higher BP and HT prevalence. Adjustment for obesity attenuated these associations, especially in men. Sex differences in BP susceptibility across the sleep apnea spectrum may be present.

Sex differences in schizophrenia relevant to clinical care

Introduction: Most medical diagnoses present somewhat differently in men and women, more so at specific periods of life. Treatment effects may also differ. This is true for schizophrenia, where premorbid effects are experienced earlier in life in boys than in girls, and where symptoms and outcomes differ.Areas covered: This review does not cover all the differences that have been reported between men and women but, instead, focuses on the ones that carry important implications for clinical care: effective antipsychotic doses, medication side effects, symptom fluctuation due to hormonal levels, comorbidities, and women's requirements for prenatal, obstetric, postpartum, and parenting support.Expert opinion: Of consequence to schizophrenia, sex-biased genes, epigenetic modifications, and sex steroids all impact the structure and function of the brain. Furthermore, life experiences and social roles exert major sex-specific influences. The co-morbidities that accompany schizophrenia also affect men and women to different degrees. This review offers several examples of sex-specific intervention and concludes that gold standard treatment must look beyond symptoms and address all the physiologic, psychologic, and social role needs of men and women suffering from this psychiatric disorder.

Prediction of obstructive sleep apnea using GOAL questionnaire in adults with or without excessive daytime sleepiness: A cross-sectional study

OBJECTIVE

Obstructive sleep apnea (OSA) is a prevalent disorder and excessive daytime sleepiness (EDS) is a frequently associated complaint. Our objectives were (1) to evaluate the predictive performance of the GOAL questionnaire in patients with or without EDS and (2) to compare its discrimination with that of 3 other validated instruments: STOP-Bang, No-Apnea, and NoSAS.

METHODS

A cross-sectional study from July 2019 to March 2020 was designed with consecutive adults undergoing full polysomnography. Participants were grouped into 2 cohorts according to the Epworth Sleepiness Scale (ESS): without EDS (ESS <11) or with EDS (ESS ≥11). Discrimination was assessed by area under the curve, while predictive parameters were calculated using contingency tables. OSA severity was classified based on apnea/hypopnea index thresholds: ≥ 5.0/h (OSA_≥5), ≥ 15.0/h (OSA_≥15), and ≥ 30.0/h (OSA_≥30).

RESULTS

Overall, 2627 patients were enrolled. In 1477 individuals without EDS, for the screening of OSA_≥5, OSA_≥15, and OSA_≥30, GOAL showed sensitivities ranging from 79.3% to 91.5% and specificities ranging from 60.6% to 40.2%. In 1150 individuals with EDS, for the screening of OSA_≥5, OSA_≥15, and OSA_≥30, GOAL reported sensitivities ranging from 86.2% to 94.5% and specificities ranging from 63.9% to 36.0%. In both cohorts, GOAL showed similar discrimination to STOP-Bang, No-Apnea, and NoSAS for predicting OSA_≥5, OSA_≥15, and OSA_≥30 (all P values >.05).

CONCLUSIONS

The GOAL questionnaire, a practical 4-item instrument, showed adequate predictive performance for the prediction of OSA. Moreover, its discrimination was satisfactory and non-inferior to that of STOP-Bang, No-Apnea, and NoSAS.

Validation of the STOP-Bang questionnaire for screening of obstructive sleep apnea in the general population and commercial drivers: a systematic review and meta-analysis

Purpose

Obstructive sleep apnea (OSA) is a critical occupational health concern, but is often undiagnosed in the general population and commercial drivers. The STOP-Bang questionnaire is a simple, reliable tool to screen for OSA, which could improve public health in a cost-effective manner. The objective of this systematic review and meta-analysis is to assess the validity of the STOP-Bang questionnaire to detect OSA in these key populations.

Methods

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, Journals @ Ovid, Web of Science, Scopus, and CINAHL for relevant articles from 2008 to March 2020. The quality of studies was appraised using Cochrane Methods criteria. To calculate pooled predictive parameters, we created 2 × 2 contingency tables and performed random-effects meta-analyses.

Results

Of 3871 citations, five studies that evaluated STOP-Bang in the general population (n = 8585) and two in commercial drivers (n = 185) were included. In the general population, prevalence of all OSA (AHI ≥ 5), moderate-to-severe OSA (AHI ≥ 15), and severe OSA (AHI ≥ 30) was 57.6%, 21.3%, and 7.8% respectively. In commercial drivers, the prevalence of moderate-to-severe OSA was 37.3%. The trends of high sensitivity and negative predictive value of a STOP-Bang score ≥ 3 illustrates that the questionnaire helps detect and rule out clinically significant OSA in the general population and commercial drivers.

Conclusion

This meta-analysis demonstrates that the STOP-Bang questionnaire is a valid and effective screening tool for OSA in the general population and commercial drivers.

Trial registration

PROSPERO No. CRD42020200379; 08/22/2020

Supplementary Information

The online version contains supplementary material available at 10.1007/s11325-021-02299-y.

Comparison of NoSAS score with Berlin and STOP-BANG scores for sleep apnea detection in a clinical sample

BACKGROUND

Because of their high costs and low availability, sleep recordings cannot be used as routine procedures for sleep apnea screening. Therefore, it is important to have a performant screening tool allowing to select patients at higher risk for sleep apnea who need further investigations. The goal of the study is to compare the performances of the three commonly used sleep disordered breathing (SDB) screening questionnaires in a clinical sample.

METHODS

Clinical data and sleep studies performed in consecutive adult patients referred to the Lausanne University sleep center for sleep recordings between November 2016 and February 2018 were analysed. Berlin, STOP-Bang and NoSAS screening scores were calculated and compared with the sleep studies' results.

RESULTS

NoSAS score showed a NPV of 0.88, a PPV of 0.43 and a correctly classified rate of 71% for an AHI >15/h. STOP-Bang score had a slightly higher negative predictive value (0.92) but a very low positive predictive value (0.30) and a poor correctly classified rate (47%). Berlin score showed globally poor results (NPV:0.85, PPV: 0.29 and a correctly classified rate: 56%). NoSAS score had the highest area under ROC curves (0.78) compared to STOP-bang (0.71) and Berlin (0.62). NoSAS score however yielded a slightly higher rate of false negative than STOP-Bang score. NoSAS false negatives were mainly female snorers with a low neck circumference.

CONCLUSION

NoSAS score showed a better discrimination capacity compared to Berlin and STOP Bang scores in an unselected clinical population referred to a sleep center.

Three Decades of Progress in Sleep Disorders and Sleep Health for Women

Over the past 3 decades, significant strides have been made in the field of sleep medicine for women. The impact of sex and gender on sleep health and sleep disorders received little attention in the early 1990s, but driven by policies ensuring inclusion of women in medical research, more recent studies have identified sex differences in sleep and investigated gender differences in sleep disorders. Nevertheless, disparities remain: diagnosis of sleep disorders, such as obstructive sleep apnea, narcolepsy, and rapid eye movement (REM) sleep behavior disorder are often delayed and underdiagnosed in women. Future research should continue to examine how biological sex and identity across the gender spectrum influence sleep health and sleep disorders, allowing for more personalized health care for all patients.