Treatment of Sleep Apnea in Patients on Testosterone Therapy
Sleep apnea must be treated in patients on testosterone therapy because testosterone can exacerbate or induce sleep apnea, increasing the risk of hypoxemia and associated cardiovascular complications that can significantly impact morbidity and mortality. 1
Relationship Between Testosterone and Sleep Apnea
- Testosterone is suspected to worsen sleep apnea, making it a significant concern during testosterone replacement therapy (TRT) 1
- Testosterone contributes to sleep-disordered breathing primarily through central mechanisms rather than anatomical changes in the airway 1
- The detrimental effect of testosterone on sleep apnea is consistent with the higher prevalence of OSA in men than in women 1
- In men with no history of sleep apnea, testosterone administration has been shown to increase the Apnea-Hypopnea Index (AHI) and prolong hypoxemia time 1
Mechanisms and Evidence
- Testosterone administration can increase upper airway collapsibility during sleep by influencing neuromuscular control of upper airway patency 2
- Studies have demonstrated that testosterone administration can induce or exacerbate OSA, with associated decreases in oxygen saturation and development of cardiac dysrhythmias during sleep 3
- Testosterone therapy has been shown to decrease hypoxic ventilatory drive, potentially worsening respiratory control during sleep 3
- The risk appears higher in men treated with higher doses of parenteral testosterone who have other identifiable risk factors for sleep apnea 1
Clinical Approach to Sleep Apnea in Testosterone Users
Assessment and Monitoring
- Polysomnography should be performed before initiating testosterone therapy in patients with risk factors for sleep apnea 1
- Risk factors that should prompt screening include:
- Obesity
- History of snoring
- Witnessed apneas
- Excessive daytime sleepiness
- Hypertension 1
- Monitoring for symptoms of sleep apnea should continue throughout testosterone therapy 1
Treatment Recommendations
- Untreated severe OSA has traditionally been considered a contraindication to testosterone therapy 1
- However, recent evidence challenges this absolute contraindication. A randomized controlled trial of 67 middle-aged obese men with untreated severe OSA found that testosterone therapy only temporarily increased oxygen desaturation index at 7 weeks but not at the final endpoint of 18 weeks 1
- For patients with diagnosed sleep apnea who require testosterone therapy:
- Continuous Positive Airway Pressure (CPAP) is the standard treatment for OSA in adults on testosterone therapy 1
- CPAP therapy should be initiated before or concurrently with testosterone therapy in patients with diagnosed OSA 1
- Regular follow-up with repeat sleep studies may be necessary to ensure adequate control of sleep apnea 1
Special Considerations
- Testosterone therapy may be initiated in patients with adequately treated sleep apnea 1
- CPAP therapy alone does not appear to significantly affect testosterone levels in men with OSA, so both conditions need separate management 4, 5
- The bidirectional relationship between sleep apnea and testosterone is complex - while testosterone can worsen sleep apnea, OSA itself may contribute to hypogonadism through hypoxia and sleep fragmentation 6
Clinical Pitfalls to Avoid
- Do not initiate testosterone therapy without screening for sleep apnea in high-risk patients 1
- Do not assume that CPAP therapy will normalize testosterone levels in hypogonadal men with OSA - specific testosterone replacement may still be needed 4, 5
- Do not overlook the importance of weight management, as obesity is a significant risk factor for both OSA and hypogonadism 1
- Be vigilant for symptoms of worsening sleep apnea after initiating testosterone therapy, including increased daytime sleepiness, morning headaches, and deterioration in cognitive function 1