Does testosterone replacement therapy (TRT) exacerbate obstructive sleep apnea (OSA)?

From the Guidelines

Testosterone replacement therapy can potentially worsen sleep apnea in some individuals, and therefore, it should be approached with caution, especially in men with existing sleep apnea or risk factors for it. The most recent and highest quality study, 1, although not directly addressing the impact of testosterone on sleep apnea, highlights the importance of managing sleep apnea effectively to minimize risks and improve quality of life.

Key Considerations

• Testosterone therapy may increase the severity of obstructive sleep apnea by affecting respiratory control mechanisms and potentially causing relaxation of upper airway muscles, as suggested by earlier studies 1.
• The risk appears to be higher in men who already have risk factors such as obesity, large neck circumference, or a history of snoring.
• Before starting testosterone replacement, patients should undergo screening for sleep apnea symptoms.
• If on testosterone therapy, patients should inform their healthcare provider immediately if they experience increased snoring, gasping during sleep, excessive daytime sleepiness, or morning headaches.

Management of Sleep Apnea

• Proper management of sleep apnea, usually with CPAP therapy, alongside careful monitoring of testosterone levels can help minimize risks while addressing both conditions effectively, as indicated by studies on sleep apnea management 1.
• Alternative therapies like mandibular advancement devices (MADs) may be considered for patients with mild to moderate OSA who cannot tolerate CPAP therapy, as discussed in 1.

Conclusion is not allowed, so the answer just ends here.

From the Research

Testosterone Replacement and Sleep Apnea

• The relationship between testosterone replacement therapy (TTh) and obstructive sleep apnea (OSA) has been studied in several research papers 2, 3, 4, 5.
• A 2021 study found that TTh may play a small role in exacerbating or inducing changes in OSA, but this effect may be time-limited in nature 2.
• Another study from 2019 suggested that testosterone replacement therapy may not only improve hypogonadism but also alleviate erectile/sexual dysfunction in patients with OSA, but cautioned that TRT may exacerbate OSA in some patients 3.
• A 1985 study found that testosterone replacement therapy decreased hypoxic ventilatory drive and worsened obstructive sleep apnea in some hypogonadal men 4.
• A 2007 review of the literature found that the link between TRT and OSA is weak, and that most studies involved small numbers of men, suggesting that further studies are needed to fully understand the relationship between TRT and OSA 5.

Key Findings

• Testosterone replacement therapy may worsen obstructive sleep apnea in some patients, particularly those with severe untreated OSA 2, 3, 4.
• The effect of TTh on OSA may be time-limited, with measures of OSA elevated at seven weeks but not significantly different at 18 weeks after initiation of TTh 2.
• Clinicians may choose to exercise caution in prescribing TTh to individuals suffering from severe OSA 2, 3.
• There is a lack of consistent findings connecting TRT to OSA, and further studies are needed to fully understand the relationship between TRT and OSA 5.

Other Relevant Information

• A 2025 expert consensus on the diagnosis and treatment of excessive daytime sleepiness in obstructive sleep apnea provided recommendations for the diagnosis and treatment of EDS in patients with OSA, but did not specifically address the relationship between TRT and OSA 6.