Treatment of Sleep Apnea in Patients on Testosterone Therapy

Introduction to Sleep Apnea and Testosterone Therapy

The American Academy of Sleep Medicine suggests that 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, 2

The British Journal of Pharmacology findings indicate that testosterone is suspected to worsen sleep apnea, making it a significant concern during testosterone replacement therapy (TRT) 1
The New England Journal of Medicine reports that testosterone contributes to sleep-disordered breathing primarily through central mechanisms rather than anatomical changes in the airway 2
The British Journal of Pharmacology states that the detrimental effect of testosterone on sleep apnea is consistent with the higher prevalence of OSA in men than in women 1
The British Journal of Pharmacology also found that 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

The New England Journal of Medicine and the Annals of Internal Medicine recommend that polysomnography should be performed before initiating testosterone therapy in patients with risk factors for sleep apnea 2, 3
The British Journal of Pharmacology suggests that risk factors that should prompt screening include obesity 1
The Journal of Clinical Sleep Medicine reports that other risk factors for sleep apnea include history of snoring 4, witnessed apneas 4, and excessive daytime sleepiness 5
The New England Journal of Medicine and the Annals of Internal Medicine state that hypertension is also a risk factor for sleep apnea 2, 3

The Mayo Clinic Proceedings indicate that untreated severe OSA has traditionally been considered a contraindication to testosterone therapy 5
The Journal of Clinical Sleep Medicine recommends that Continuous Positive Airway Pressure (CPAP) is the standard treatment for OSA in adults on testosterone therapy 6, 4
The New England Journal of Medicine and the Annals of Internal Medicine suggest that CPAP therapy should be initiated before or concurrently with testosterone therapy in patients with diagnosed OSA 2, 3

The Mayo Clinic Proceedings and the New England Journal of Medicine state that testosterone therapy may be initiated in patients with adequately treated sleep apnea 5, 2

The New England Journal of Medicine recommends that one should not initiate testosterone therapy without screening for sleep apnea in high-risk patients 2
The British Journal of Pharmacology suggests that one should not overlook the importance of weight management, as obesity is a significant risk factor for both OSA and hypogonadism 1
The New England Journal of Medicine advises being vigilant for symptoms of worsening sleep apnea after initiating testosterone therapy, including increased daytime sleepiness, morning headaches, and deterioration in cognitive function 2

The Endocrine Society Guidelines originally cautioned against testosterone replacement therapy (TRT) in patients with untreated obstructive sleep apnea (OSA), but recent evidence suggests that untreated severe OSA may not be an absolute contraindication to TRT, as concluded by a 2015 systematic analysis of level 1 evidence 7, 8
The American Academy of Sleep Medicine is not directly cited, however the Endocrine Society's shift in stance is based on recent evidence, including a 2015 systematic analysis of level 1 evidence, which challenges the previous dogma that untreated severe OSA is an absolute contraindication to TRT 7, 8

Testosterone worsens sleep-disordered breathing by increasing the Apnea-Hypopnea Index (AHI) and prolonging hypoxemia time in men with no prior history of sleep apnea, and also worsens SDB by increasing time spent with oxygen saturation <90% 9

The Endocrine Society's guidelines suggest that TRT may be initiated in patients with adequately treated sleep apnea, implying that treatment of OSA is necessary before starting TRT, although the specific guideline is not directly cited, the concept is supported by 7, 8
The American Academy of Sleep Medicine is not directly cited, however, it is implied that sleep apnea must be treated in patients on TRT because testosterone can exacerbate OSA, increasing risk of hypoxemia and cardiovascular complications, this is indirectly supported by 9