Perimenopausal women demonstrate a notably higher prevalence of obstructive sleep apnea (OSA), yet the condition is often missed because clinical manifestations overlap substantially with menopausal symptoms. Recent research has identified a characteristic polysomnographic (PSG) pattern in this population that departs from classical descriptions of OSA.
Key PSG features described in the literature include a predominance of hypopnea events rather than obstructive apneas, respiratory events that are highly concentrated during rapid eye movement (REM) sleep, a hypoxic pattern characterized as “high-frequency low-amplitude,” and sleep fragmentation manifested as frequent microarousals. Together these findings have been referred to as a PSG “physiological fingerprint” for perimenopausal OSA.
These PSG signatures highlight that respiratory disturbance in perimenopausal women may be temporally and qualitatively distinct from typical presentations, with implications for how sleep studies are interpreted and how severity is estimated.
The review synthesizes mechanistic connections between the described PSG abnormalities and domains of cognitive dysfunction. Three principal pathways are emphasized:
REM sleep disruption: Respiratory events clustered in REM sleep can disrupt REM-dependent processes. The review links REM disturbance to impaired consolidation of emotional memory, suggesting that REM-focused respiratory pathology may preferentially affect memory systems that rely on REM physiology.
Sleep fragmentation and microarousals: Frequent microarousals produce fragmented sleep architecture. This fragmentation is associated with deficits in executive function and attention. The review notes that high-frequency microarousals undermine sustained cognitive processes and daytime cognitive performance.
Intermittent hypoxia: The “high-frequency low-amplitude” hypoxic pattern described in perimenopausal OSA is highlighted as a pathological substrate for cognitive decline. Intermittent hypoxia is implicated in triggering oxidative stress and neuroinflammation, mechanisms that the review associates with progressive cognitive impairment.
These mechanistic links position specific PSG metrics—not solely global indices—as potentially important mediators between OSA and cognition in perimenopausal women.
The review critiques the reliance on the apnea-hypopnea index (AHI) as the central diagnostic and severity metric. It argues that AHI alone may fail to capture the true disease burden in perimenopausal women because it does not reflect several PSG characteristics that may be more closely tied to cognitive risk, such as the REM concentration of events, hypoxia dynamics, and frequency of microarousals.
Accordingly, the authors advocate for a multidimensional assessment framework that goes beyond AHI to include event type distribution (apnea vs hypopnea), sleep-stage distribution of respiratory events (especially REM), hypoxic patterning, and measures of sleep fragmentation. Such an approach would aim to better stratify cognitive risk and to identify patients who might benefit from targeted interventions.
Because OSA symptoms overlap with menopausal complaints, the review emphasizes the high rate of underdiagnosis in this population and the risk that unrecognized OSA poses to cognitive health. By characterizing a distinct PSG fingerprint and articulating mechanistic pathways to cognitive decline, the review seeks to inform earlier recognition and more individualized management strategies.
Specifically, the review suggests that clinicians and sleep specialists should consider comprehensive PSG analysis that documents REM-related events, hypoxic frequency and amplitude patterns, and microarousal burden. These parameters could guide tailored interventions aimed at preventing or mitigating cognitive deterioration, though the review notes that currently targeted intervention strategies are lacking and further work is needed to develop individualized treatment pathways.
This article is a review published in Zhonghua Jie He He Hu Xi Za Zhi (2026) by authors affiliated with Jilin University and Jilin Province People’s Hospital, Changchun, China. The work includes an English abstract.
All authors declared no conflicts of interest. The article notes funding support from the National Natural Science Foundation of China (grant 82470086).
The review's stated aim is to systematically summarize PSG characteristics of perimenopausal women with OSA and their association with cognitive impairment, and to explore multidimensional assessment approaches and individualized intervention pathways to support early identification and precision management of this high-risk population.