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Women, Sex and CPAP
(first in a two-part series)

By Margaret Trussler, MS, APRN, BC

Janet is a 46 year old woman recently diagnosed with obstructive sleep apnea (OSA). Her symptoms had progressed to the point where she didn't want to get out of bed in the morning and was finding it difficult to make it through the day without a long afternoon nap. Her family complained that she just wasn't herself anymore and she was increasingly absent from social and family activities. She contacted her primary care provider because she thought she was depressed. After a thorough evaluation, she was diagnosed with severe OSA. Her physician recommended continuous positive airway pressure (CPAP) therapy and arranged for her to meet with a CPAP counselor.

Initially she was hopeful that treatment for her apnea would make her feel better. However, once she met with the CPAP counselor and saw the CPAP machine and mask, she became tearful. She told the counselor that she just wouldn't be able to use CPAP. It made her feel "old and sick" and she was worried about her husband's response. Because she had been feeling so tired and exhausted all the time, her interest in sex had reached an all time low and it was becoming an issue in her marriage. Sex was just about the last thing on her mind. She felt using CPAP would be one more factor crushing her already flagging libido. She left the appointment without the equipment, but agreed to come back and discuss her concerns with the nurse practitioner.

Despite the proven benefits of CPAP therapy, treatment effectiveness is limited by individual use and acceptance of therapy. Many people refuse to consider CPAP as a treatment because of worries about sleep partner response to the therapy. Concerns about appearance with a CPAP mask on, barriers to post-sexual intimacy, and fears about partner disturbance due to machine noise can cause many OSA suffers to initially reject the idea of CPAP. Even individuals who are regular users of CPAP therapy worry about how to introduce a new sleep partner to their CPAP use. Women seem especially vulnerable to concerns about partner reaction to CPAP and frequently describe CPAP use as "embarrassing".

It's time to take a realistic look at the intrusion factor of CPAP into the privacy of the bedroom and separate sex from CPAP by dispelling three common misconceptions.

"CPAP just isn't sexy"

Many individuals focus on the idea that CPAP just isn't sexy. The machine, mask and tubing can be an uninvited guest in the bedroom. Complaints about barriers to physical contact and cuddling with a mask on are not uncommon. However, most people fail to realize that OSA itself can be responsible for a lack of desire and interest in sex. In addition to the common complaints of fatigue and sleepiness, untreated OSA is associated with reports of poor quality health, decreased quality of life, depression, and concerns about body image as a result of weight gain and inactivity. All of these are a recipe for problems in the bedroom.

A recent study by Koseogul and colleagues (2006) demonstrated that OSA negatively impacts sexual function in women independent of age or other illness such as diabetes, hypertension, and heart disease. In addition, the severity of the apnea was associated with greater sexual dysfunction, meaning that women with severe apnea reported more difficulty with desire, lubrication, and orgasm than women with mild apnea. What's more interesting though, is that most people do not associate apnea or poor quality sleep with decreased sexual desire or performance. A study done by Weaver (2004) found that over 50% of patients surveyed did not link a decrease in desire or sexual performance to their OSA or poor quality sleep. It's easy to point to the CPAP machine as the barrier to sexual activity. In reality, it's probably the sleep disturbance itself that is damping the fires.

"I just know my sleeping partner is going to hate this"

Frequently, OSA sufferers will make an assumption that sleeping partners will reject them based on CPAP use. Most times these thoughts and beliefs are based on the individual's own attitudes about CPAP. An inability to personally accept CPAP therapy creates negative attitudes and emotions. These negative feelings lead to emotional reasoning. Emotional reasoning causes us to base all our decisions on how we feel rather than on objective facts or accurate information. So even before there has been a chance to discuss CPAP with a sleeping partner and gauge their response, the therapy is discarded based upon worry about a presumed reaction.

In reality, most people are happy to have their sleeping partner use CPAP. A study done by Doherty (2003) demonstrated a decrease in quality of life, social functioning and mental health in the bed partners of patients with OSA due to sleep fragmentation caused by their partner's snoring and restless sleep patterns. Creating sleep disturbance in your partner is likely to negatively influence both your personal and sexual relationships. Two angry, sleep deprived people don't make for great sex.

"I'll use CPAP but I don't want my sleep partner to see me"

Many women agree to use CPAP therapy but move out of the bedroom under the pretense of not wanting to disturb their partner. In reality, sleep partners rarely complain about CPAP issues such as noise or drafts from the tubing. The more likely explanation for separate bedrooms is concerns about being seen with a CPAP mask or fears about appearing old or sick. Unfortunately, an inability to discuss your true concerns and feelings about using CPAP with your sleeping partner is the biggest barrier to intimacy and where the confusion between sex, intimacy, and CPAP lies. Not wanting to use CPAP has very little to do with sex and much to do about intimacy.

Acknowledging your own feelings about CPAP and discussing treatment with your sleeping partner right from the beginning is one of the best ways to elicit support and improve overall adherence to the treatment. Don't delay introducing your sleep partner to your CPAP machine. Inviting your sleep partner to your appointments to learn about OSA is a good opportunity for them to ask questions and develop a greater appreciation for the commitment necessary to be successful with CPAP therapy. Discuss your concerns about intimacy and sex with your health care provider early in the treatment process. Failure to discuss these issues due to embarrassment can lead to frustration and ultimately rejection of CPAP therapy. Your health care provider can provide you with practical advice and determine whether further evaluation and referral is indicated. Lastly, recognize that CPAP is a treatment not unlike taking medication. The goals of treatment are to sleep better, feel better, and have more energy, all of which should improve sexual interest and functioning.

Janet met with the nurse practitioner to discuss her concerns and possible alternative treatments for sleep apnea. Initially she was quite insistent that she wouldn't consider CPAP therapy even though she admitted that her husband was "all for it". After a long discussion, Janet was able to acknowledge that it had been quite a long time since she had enjoyed sexual activity with her husband and pointed to her chronic fatigue and concerns about the 25 pounds she had put on over the last two year as a cause. She reported that her self esteem was at an all time low. "I just don't feel very attractive anymore - not just in the bedroom." The nurse practitioner was able to help Janet realize that the symptoms she was describing were a result of her long standing untreated obstructive sleep apnea. They did discuss alternative treatments, but based on the severity of Janet's apnea and the degree of her symptoms, the nurse practitioner also recommended a trial of CPAP therapy. Janet did agree to return to meet with the CPAP counselor to obtain a CPAP machine and agreed to bring her husband.

CPAP Counselor's Corner

CPAP and Relationships
by Cindy Sullivan, CRT

I have dealt with many patient issues over the past years, but none have been more challenging than dealing with CPAP as an intruder on a person's relationship with a significant other. It has been my experience that women have a harder time than men. One patient in particular had already resigned herself to sleeping in the guest room as she didn't want to "scare" her husband. However, most people in long term relationships generally have a partner who is very understanding. As I pointed out to this patient, she isn't the only one suffering from tiredness. No doubt her thrashing, snoring, and frequent awakenings have interfered with her partners sleep. When CPAP is used, both people can benefit from a better nights sleep.

Single patients have an even harder time adjusting to wearing CPAP. They can be more self conscious about introducing CPAP to a new sleep partner. Jane, a patient I had set up on CPAP had been doing very well with nightly use and was feeling more energetic. She had lost approximately 25 pounds over the past 4 months of therapy. On her last scheduled follow up visit I noticed that her usage had gone down. She was only using her CPAP 4 out of 7 nights. When I questioned why she wasn't using it the other 3 nights she informed me that she had a new boyfriend and was spending every weekend at his place. She hadn't told him about her sleep apnea and wasn't sure how well he would accept the fact that she had to wear a mask every night for sleeping. She wasn't sure how to open the topic with him. She did note that when she wore the CPAP she did not snore and felt much better during the day. She went on to state that she was snoring when she stayed with him and he had started to make little jokes about it which only made her feel more self conscious. I explained to her that being open with him and providing him with the right educational material would benefit both. On the way out to the checkout counter I picked out some brochures for her to give to her boyfriend along with some website addresses he could go to for additional information.

On Jane's next visit she proudly told me she was now taking her CPAP with her on the weekends and indeed her nightly usage had gone back to her pre-boyfriend days. She was glad she had brought up the topic when she did. She realized how much CPAP was helping her, but if she had waited on addressing the topic she probably would have stopped using the CPAP altogether. She now felt having the CPAP was helping to move her relationship further along.
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Get to Know Your Staff
Cindy Sullivan, CRT, has worked as a respiratory therapist for over 8 years. She has been married for 21 years and has one son, Justin, who is in the Air Force.

Sleep HealthCenters is a recognized network of specialized sleep medicine centers, staffed by board-certified sleep specialists. Sleep HealthCenters' comprehensive care services include diagnosis, evaluation and treatment of patients with all types of sleep disorders including obstructive sleep apnea, insomnia, narcolepsy, and restless legs syndrome. Please visit our website at www.sleephealth.com to learn more about Sleep HealthCenters or contact us at 877-SLEEPHC (877-753-3742) to schedule an appointment.