Can High Serum Testosterone Cause Insomnia?
No, elevated serum testosterone does not cause insomnia. In fact, the relationship between testosterone and sleep is bidirectional: testosterone levels depend on sleep quality rather than disrupting it, and naturally elevated endogenous testosterone is not associated with sleep disorders.
Evidence Against Testosterone Causing Insomnia
Observational Data on High Endogenous Testosterone
Men with naturally elevated testosterone levels (>800 ng/dL) show similar rates of sleep disorders compared to men with normal testosterone (300-800 ng/dL), with no increased prevalence of insomnia or other sleep disturbances 1.
A study of 3,673 men found that only 4% had testosterone >800 ng/dL, and these men experienced no clinically significant adverse effects related to sleep 1.
The Sleep-Testosterone Relationship
Testosterone levels are dependent on sleep, not the other way around. The nocturnal testosterone rise is linked to the appearance of first REM sleep and occurs approximately 90 minutes before the first REM episode 2.
Sleep fragmentation and disruption lower testosterone levels rather than being caused by them—fragmented sleep delays the nocturnal testosterone rise and attenuates it in men who do not achieve REM sleep 2.
Total sleep deprivation lowers testosterone, and sleep restriction in the first half of the night reduces testosterone levels 3.
Sleep Duration and Testosterone Show an Inverted U-Shaped Relationship
Testosterone levels increase with sleep duration up to 9.9 hours, after which they decrease, demonstrating that adequate sleep supports testosterone production rather than testosterone disrupting sleep 4.
This inverted U-shaped relationship also applies to muscle mass and function, suggesting that optimal sleep duration benefits overall physiological function 4.
Testosterone Therapy and Sleep Apnea: A Distinct Issue
While high testosterone does not cause insomnia, testosterone replacement therapy has been associated with exacerbation of obstructive sleep apnea (OSA), which is a separate concern:
Testosterone therapy can worsen or precipitate OSA, generally in men treated with higher doses of parenteral testosterone who have other risk factors 5.
The mechanism appears to be central rather than anatomical, as upper-airway dimensions are unaffected by testosterone therapy 5.
However, in men with OSA, low testosterone is related to obesity rather than the OSA itself, and improves with weight loss but inconsistently with CPAP 3.
Testosterone treatment only transiently worsens OSA severity and need not be considered an absolute contraindication to its use 3.
Clinical Implications
When Evaluating Insomnia in Men
Do not attribute insomnia to elevated testosterone levels—look for other causes such as psychiatric illness (depression is strongly associated with insomnia), medical comorbidities (cardiac/pulmonary disease, pain, nocturia), or medications (SSRIs, SNRIs, β-blockers, bronchodilators, corticosteroids, decongestants) 5.
Sleep disorders and testosterone deficiency often coexist due to shared risk factors (obesity, metabolic syndrome) rather than a direct causal relationship 3.
When Prescribing Testosterone Therapy
Screen for OSA risk factors before initiating therapy, particularly in obese men or those with other predisposing conditions 5.
Monitor for new or worsening sleep-disordered breathing, especially in the first few months of therapy 5.
Recognize that any OSA exacerbation is typically transient and can be managed with CPAP or dose adjustment 3.
Common Pitfalls to Avoid
Do not assume high testosterone causes insomnia—the evidence clearly shows no association between elevated endogenous testosterone and sleep disorders 1.
Do not confuse the effects of testosterone therapy (which can worsen OSA) with the effects of naturally elevated testosterone (which does not cause sleep problems) 5, 1, 3.
Do not overlook the fact that poor sleep lowers testosterone—addressing sleep disorders may improve testosterone levels in hypogonadal men 2, 4, 3.