Recent research into obstructive sleep apnea (OSA) has uncovered some surprises regarding sleep and the male libido. There exists a relationship between hormones and OSA: men who sleep poorly tend to also have low levels of the testosterone.
What's worse, treating so-called "low T" with hormone therapy products may actually aggravate underlying sleep breathing problems or lead to the development of OSA.
How are low testosterone and sleep apnea linked?
Studies confirm that these two conditions are related, but it's a complex relationship, and not just because both tend to happen in older males.
Studies published in the Journal of Clinical Endocrinology show that men of all ages with low testosterone do not sleep well in general: they sleep less efficiently, enjoy less rapid-eye movement (REM) sleep and awaken more frequently.
We already know that untreated OSA for anyone, at any age, can be held accountable for causing or contributing to many other known chronic health conditions, such as hypertension, depression, diabetes, obesity, stroke, and heart disease. But general overall health can be compromised if OSA is left untreated in the long-term.
How does this relate to sleep apnea and low testosterone? OSA always results in the fragmentation of sleep.
The vicious cycle between poor sleep and low testosterone
Poor sleep, poor T...
Sleep apnea's lengthy pauses in breathing lead to repeated awakenings as the body struggles to recover oxygen in order to stabilize its functions. Sleep fragmentation leads to chronic sleep deprivation and excessive daytime sleepiness, as well as other sleep disorders, like insomnia.
What's key is that these nighttime awakenings prevent the body from doing critical restorative work during sleep. Sleep allows the brain and body to work in tandem to heal damage, recharge energy levels and recalibrate the entire body's systems at the cellular level.
This includes resetting hormone levels to ensure they are in adequate supply. As much as 70 percent of one's human growth hormone is released during deep, restorative sleep, for instance. Most men can produce all the testosterone they need on a nightly basis, but only if they achieve regular deep, restorative sleep.
Testosterone is meant to fall during waking periods, then rise and stabilize during sleep. But poor sleep practically guarantees that the periods of restorative sleep necessary for hormone balance can't be achieved.
In fact, a man with both low testosterone and OSA is destined for perpetual shortages because his body will continue to use up its supply during the day, whether or not it has been naturally replenished at night through the process of sleep. If his OSA is so severe that he never achieves rapid-eye movement (REM) sleep—when the most marked increases of testosterone take place in the sleep cycle—his levels may never rebound.
Erectile dysfunction (ED) may be the most dreaded symptom of low testosterone. A PLOS ONE study confirmed higher rates of ED among men who also have sleep apnea. Even after accounting for age, health problems and other factors, OSA stood out as the primary explanation for their hormone shortages.
...and vice versa
Meanwhile, other research shows that low testosterone can disrupt the brain's ability to cycle into the very sleep stages necessary for its proper replenishment. This turns the hormone balancing into a vicious cycle in which poor sleep leads to low T and low T causes poor sleep.
Throw in recent statistics that show that as many as 15 percent of Americans routinely sleep less than 6 hours a night—one definition of sleep deprivation—and it's no wonder low hormone levels are as problematic as poor sleep for so many.
In addition, a study in 2011 in the Journal of the American Medical Association confirmed that young men who were sleep deprived over one week saw reductions in their testosterone levels as high as 15 percent. For men who also have untreated OSA, the likelihood they have low T increases to as much as 50 percent.
The obesity connection
Low testosterone levels are a key reason for many sexual problems, such as flagging libido, erectile dysfunction, infertility and generalized fatigue. But "low T" can also be to blame for decreased muscle mass, depression, anxiety, irritability, hair loss, and problems with focus.
Aging is often the biggest culprit blamed for drops in testosterone. At age 30, men's testosterone levels tend to gradually decrease as a normal course of aging. By age 40, these men may begin to note sleeping problems. By age 50, they join the majority group who suffer from sleep problems, which coincides with dropping levels of the male hormone.
Dr. Frances Hayes, an endocrinologist at Harvard Medical School, recently reviewed research that shows a complicated relationship between sleep problems, low testosterone and a third compromising factor: obesity.
While most people think of low testosterone as a challenge caused by aging, Hayes asserts that "waist size has a much bigger impact on testosterone than aging."
Carrying excess weight can lead to lowered testosterone levels in men of any age, though there is some good news: the European Male Aging Study in 2013 showed that efforts to lose at least 15 percent of one's weight can result in significant rebound for testosterone levels.
Men with OSA also consistently improve both their hormone levels and their apnea symptoms when they lose weight as part of their therapy.
Hormone therapy: the risks
It's appealing to consider a hormone therapy approach for improving low levels of testosterone, as positive cardiovascular and metabolic outcomes have been reported for many who go this route. However, the risk for developing sleep breathing problems or exacerbating underlying and undiagnosed OSA may outweigh these benefits for some.
The 2008 study in the Journal of Endocrinology showed that testosterone therapy can lead to the development of sleep-breathing issues when there were none before. For those men with preexisting OSA, the odds suggest worsening OSA after trialing testosterone therapy, with significant decreases in blood oxygen and cardiac arrhythmias reported.
Testosterone products have also been shown in other studies to increase the risk of death, heart attack or stroke. Since OSA is also linked to heart attack and stroke, men who suffer from both low testosterone and OSA face double the complications if they proceed with hormone therapy.
Treatment options for Low T
Some men may not even realize they have low testosterone levels until they visit a doctor with complaints of fatigue. In these cases, doctors should review sleep issues as well as take blood tests to determine root cause for the fatigue (if other explanations aren't obvious).
If a man is diagnosed with both OSA and low testosterone, it's imperative that he be proactive about following through on therapy to treat the OSA first. Treating low testosterone alone, without also treating OSA, has been shown to increase the severity and discomfort of preexisting, untreated sleep apnea.
In fact, successful treatment of OSA has been shown to naturally cause a "rebound" in levels of testosterone as soon as adequate sleep was restored. Thus, the solution seems simple enough: treat your OSA, and your body may come through with its own hormone reset and make hormone therapy completely unnecessary. Throw in some weight loss for good measure and Low T should no longer be a problem.
But what about men with low testosterone levels who have not been diagnosed with OSA?
Researchers suggest that doctors pay more mind to the possibility of undiagnosed OSA as an explanation for their low T. A blood test, sleep diary, discussion of symptoms and medical history may all naturally point to the need for a sleep assessment. If your hormone levels are low, but you also have symptoms characteristic of OSA, and/or a bed partner or loved one has witnessed your heavy snoring or gasping as you sleep, it's important to rule in or rule out undiagnosed OSA as the root cause as testosterone therapy is not recommended for those with sleep breathing problems.
For those men who don't have OSA, or who still suffer from low testosterone even after successfully treating their OSA, further investigation by their physician will best determine whether they need a course of hormones.