What are the causes and treatments of night sweats in men?

Night Sweats in Men: Causes and Management

Initial Diagnostic Approach

In men presenting with night sweats, the most critical first step is to distinguish between pure night sweats versus day-and-night sweats, as these may have different underlying causes, and then systematically evaluate for serious conditions including tuberculosis, malignancies (particularly lymphoma), infections (including HIV), hyperthyroidism, and medication effects before considering more common benign etiologies. 1, 2, 3

Key Historical Features to Elicit

When evaluating night sweats in men, obtain specific details about:

• Frequency and severity of episodes, including whether they are drenching and require changing bedclothes 1, 2
• Associated B symptoms: unexplained fever >38°C, unintentional weight loss >10% body weight within 6 months, which suggest malignancy 4
• Respiratory symptoms: persistent cough, hemoptysis, which raise concern for tuberculosis 1
• Sleep disturbances: snoring, witnessed apneas, daytime somnolence suggesting obstructive sleep apnea 4, 5
• Panic symptoms: episodes of intense fear, palpitations, shortness of breath occurring at night 5
• Medication review: SSRIs, SNRIs, antihypertensives, antipyretics, and substances including alcohol 6, 7, 8, 3, 5
• Sexual dysfunction: decreased libido, erectile dysfunction, which may suggest hypogonadism 9

Common Causes in Men

Medication-Induced Night Sweats

SSRIs and SNRIs are among the most common iatrogenic causes of night sweats in men. 6, 7, 8

• Sertraline causes increased sweating in 7% of patients (vs 2% placebo) 7
• Paroxetine causes sweating leading to discontinuation in multiple patients 8
• Citalopram demonstrates dose-dependent increases in sweating 6

Endocrine Causes

• Hyperthyroidism is one of the most frequent hormonal causes of excessive sweating 9, 2
• Hypogonadism in aging men is a relatively rare cause and must be accompanied by sexual dysfunction and repeatedly low morning testosterone levels 9
• Unlike women, men do not experience menopausal night sweats unless receiving androgen deprivation therapy for prostate cancer, where 50-80% experience this symptom 1

Sleep and Psychiatric Disorders

• Obstructive sleep apnea is strongly associated with night sweats in men 3, 5
• Panic attacks occurring at night can present as night sweats 5
• Sleep problems in general are independently associated with pure night sweats in men 5

Serious Underlying Conditions

• Tuberculosis: Consider especially with persistent cough, weight loss, loss of appetite, and risk factors including immunosuppression or residence in high-prevalence areas 1, 3
• Lymphoma: Hodgkin lymphoma classically presents with B symptoms including drenching night sweats 4
• HIV infection: Should be tested in high-risk individuals 1, 2

Other Common Associations

• Gastroesophageal reflux disease (GERD) is commonly associated with night sweats 2, 3
• Obesity and increased weight are associated with both pure night sweats and day-and-night sweats 2, 5
• Alcohol use is associated with night sweats in men 5

Systematic Evaluation Strategy

Initial Laboratory and Imaging Studies

When history and physical examination do not reveal a specific cause, proceed with the following cost-conscious evaluation: 2, 3

1. Complete blood count - to screen for hematologic malignancies and infections 2, 3
2. Tuberculosis testing - tuberculin skin test or interferon-gamma release assay 1, 2, 3
3. Thyroid-stimulating hormone (TSH) - to evaluate for hyperthyroidism 2, 3
4. HIV testing - particularly in high-risk individuals 1, 2, 3
5. C-reactive protein or erythrocyte sedimentation rate - as inflammatory markers 2, 3
6. Chest radiograph - to evaluate for tuberculosis, lymphoma, or other pulmonary pathology 2, 3

Selective Additional Testing

Consider these studies based on clinical suspicion:

• Morning testosterone level (repeated if low) - if sexual dysfunction is present 9
• Chest and/or abdominal CT - if malignancy is suspected and initial imaging is unrevealing 2, 3
• Polysomnography - if obstructive sleep apnea is suspected based on snoring, witnessed apneas, or daytime somnolence 4, 3
• Bone marrow biopsy - if hematologic malignancy is suspected but not confirmed by other means 2, 3

Management Approach

When Specific Diagnosis is Identified

If initial evaluation reveals a specific cause, treat the underlying condition for 4-8 weeks and reassess. 2

• Hyperthyroidism: Treat with antithyroid medications or radioactive iodine
• Tuberculosis: Initiate appropriate multi-drug therapy 1
• GERD: Proton pump inhibitor therapy 2
• Obstructive sleep apnea: CPAP therapy 3
• Medication-induced: Consider dose reduction or alternative agents 6, 7, 8

Medication-Related Night Sweats

For patients on SSRIs with bothersome night sweats:

• Alpha-adrenergic blockers may reduce night sweats in patients taking serotonin reuptake inhibitors 10
• Consider switching to alternative antidepressants with lower sweating profiles
• Weigh risks and benefits of continuing therapy versus symptom burden

When No Cause is Identified

If all initial and selective testing is normal and no additional disorders are suspected, reassurance and continued monitoring are appropriate. 2

• The presence of night sweats alone does not indicate increased risk of death 2, 10
• Life expectancy of primary care patients reporting night sweats is not reduced 10
• Many patients with night sweats in primary care settings do not have serious underlying disorders 2

Important Clinical Pitfalls

• Under-reporting: Most patients do not spontaneously report night sweats to physicians even when frequent and severe; explicit questioning is necessary 5
• Distinguishing pure night sweats from day-and-night sweats: These may have different etiologies and warrant different evaluations 5
• Overinvestigation: In the absence of concerning features (B symptoms, abnormal examination, high-risk factors), extensive workup is not warranted 2, 10
• Assuming hormonal cause: Hypogonadism in aging men is rare and requires both sexual symptoms AND documented low testosterone; do not empirically treat based on night sweats alone 9