Low Testosterone and Sleep Apnea: What's The Connection?

If you suspect you have or have recently been diagnosed with sleep apnea, you may be wondering why you have been affected by this condition. While many of the more “typical” risk factors for sleep apnea can be easily spotted based on physical traits or lifestyle habits, that isn’t necessarily true for all cases. In fact, there are several silent traits that can increase your risk of developing this condition, even if you appear totally healthy on the outside.

Today we will be discussing one of these factors— testosterone! Testosterone and sleep apnea have a complex and interesting relationship, which we will explore further in this article.

We will begin by reviewing how sleep-breathing is affected by apnea before touching on the role and effects of testosterone in the body. We will then discuss the ways that changes in testosterone levels may be linked to the development and/or worsening of both Obstructive and Central Sleep Apnea. Lastly, we will go over the changes that you can make to protect your body from developing these same issues.

In order to understand the link between sleep apnea and testosterone, let’s take a moment to briefly discuss the two main types of sleep apnea and why they occur. While most people are familiar with the obstructive form, fewer people understand Central Sleep Apnea.

Despite the fact that they have very different causes, both conditions are characterized by periods of apnea (no breathing) or hypopnea (reduced breathing). In the event that breathing halts altogether, the brain will send a panicked signal to the rest of the body. This causes you to suddenly wake up and take a deep breath of air.

Obstructive Sleep Apnea (OSA) is triggered when the muscles that line the throat and airway, such as those of the tongue or soft palate, become weakened or over-relaxed while you are asleep. This causes them to collapse into the back of the throat or airway, which results in a partial or total blockage. This form of sleep apnea is more likely to occur in people who have anatomical differences, resulting in a smaller airway.

Central Sleep Apnea (CSA) occurs when there is some sort of issue that arises in the way that the brain directs respiration. This problem stems from an issue with the involuntary (also known as the unconscious) breathing process.

It can be caused by one of two general issues. The first is the brain’s inability to correctly sense or respond to changes in the carbon dioxide levels in the blood. Or it can come from some other issue in the line of communication between the brain and the respiratory muscles. Regardless of the cause, the result is that the muscles are unable to constrict, allowing the lungs to inhale fresh air.

Despite the fact that it is often referred to as a male sex hormone, testosterone plays a key role in several bodily functions in both sexes. While many of these processes are related to sex and sexual development, this hormone is also associated with a long list of non-sexual roles.

That said, it is produced in much larger quantities in males. This is why the effects of testosterone, such as muscle bulk, are often much more pronounced in men compared to women. Research shows that despite its importance in the bodily functions of both sexes, testosterone levels are impacted by several factors, including age and general health.

One reason why testosterone is considered a sex hormone is that it is largely produced by the gonads. In males, these are the testes, but in females, they are the ovaries. Additionally, small amounts of this hormone are produced by the adrenal glands. It is important to note that although it is found in both men and women, testosterone is produced in much larger quantities in males.

Testosterone production is initiated when one part of the brain, called the hypothalamus, senses that testosterone levels are low and sends out a signal to make more. This process is called a negative feedback loop. This means that when hormone levels are high, production is decreased, but when it is low, production increases.

Testosterone is most notable for its impact on the growth and development of the male body. Females tend to produce small amounts of this hormone, but they can still be impacted by changes in the amount of testosterone in their bodies. For example, high levels of testosterone can impact a woman’s ability to produce other hormones and may even delay her menstrual cycle. On the other hand, testosterone production drops during menopause and can lead to its own issues, such as changes in libido.

Testosterone impacts sexual development and function in the following ways:

• Development of male sex organs (in males)
• Voice deepening (in men)
• Increased sperm production (in men)
• Higher libido (in both sexes)
• Increased estrogen production (in women)

The presence of testosterone can also impact the body in ways that have nothing to do with sexual traits. These effects have been documented in both males and females. However, some are more notable in men due to their increased production of this particular hormone. For example, low testosterone is thought to be a partial contributor to osteoporosis in women. But it is considered to be a leading cause of bone density changes in men.

Other roles of testosterone include:

• Muscle growth and development
• Bone density
• Boosts red blood cell production
• Regulating mood
• Improving certain forms of cognition
• Maintaining heart health
• Stimulating body hair growth
• Contributes to metabolism
• Fat distribution (males store more fat in the upper body, while females do so in the lower body)

Low testosterone is also sometimes referred to as hypogonadism, which references the impact on testosterone production when the function of the gonads is reduced. Men are much more prone to having low testosterone than women. That said, this hormonal shift can impact both sexes, it just happens more often and is much more impactful on men’s health, including the development of sleep apnea.

Causes of low testosterone include:

• Aging: Increased age is often associated with progressively low testosterone.
• Injury to the Gonads: In males, testosterone is largely produced in the testicles. Therefore an injury to the testicles can affect the production of this hormone. The same is true for the ovaries in females.
• Conditions that Impact the Gonads: Because the testicles are responsible for producing testosterone in males, certain conditions can cause them to no longer produce this hormone. Examples include testicular cancer, testicular torsion, and Klinefelter syndrome. Women’s ovaries can be similarly affected by conditions such as Turner syndrome, ovarian insufficiency, and ovarian cancer.
• Changes to Brain Function: Testosterone production begins in the brain, with a signal that is sent from the hypothalamus to the pituitary gland. Therefore, disorders that involve the function of these parts of the brain may impact your ability to produce testosterone.
• Adrenal Gland Inefficiencies: Because they produce a small amount of testosterone, the effects of adrenal gland issues may not be quite of impactful as other causes on this list. However, they have been documented as having a measurable effect on the production of this hormone. These effects are likely to be more notable in females, which have small amounts of testosterone to begin with.
• Obesity: Excess body weight has been linked to a number of hormonal issues, including testosterone production. This effect is particularly prevalent in men.
• Chronic Illness: Conditions such as diabetes, kidney disease, or COPD can trigger hormone imbalances that have been associated with low testosterone.
• Chemo or Radiation Treatments: Chemo and radiation can both be highly damaging to the gonads, particularly when targeting a form of cancer that impacts that part of the body, such as testicular cancer or ovarian cancer.
• Medications: Certain medications have been associated with reduced production of testosterone, including some blood pressure meds, opioids, certain antidepressants, etc.
• Malnutrition: When the body senses that it is not getting enough nutrients to survive, it responds by limiting many of the body’s regular functions, including the production of testosterone.
• Menopause: Menopause leads to decreased production of many types of sex hormones in the body, including testosterone.

As we discussed earlier, OSA is caused by weakness or over-relaxation in the muscles that make up the mouth, throat, and upper airway. One of the biggest risk factors for this is age, largely because our muscles begin to lose strength after the age of 40. While this aging component occurs in both men and women, men are much more likely to develop Obstructive Sleep Apnea, which is why researchers have long suspected that there is some sort of hormonal link.

Experts believe this may be due to a second risk factor that largely impacts men and also decreases with age— testosterone levels. One likely explanation for this is that this hormone is a major contributor to muscle growth and strength. So when testosterone levels fall, the muscles throughout the body are prone to weakening. This includes the muscles in the tongue and soft palate, which both have a tendency to cause airway blockages.

Because testosterone plays a major role in metabolism, low T may also impact your health in other ways that leave you susceptible to sleep apnea. One of the most obvious effects of this hormonal shift is weight gain. Men who have low testosterone levels are more likely to have increased body fat and decreased muscle mass. And studies show that such features are linked to developing both Obstructive and Central Sleep Apnea.

Similar to low T, high testosterone levels are sometimes referred to as hypergonadism, which occurs when the gonads are hyperactive. Both sexes can be impacted by high levels of this hormone. However, the effects tend to be more prevalent in women because they naturally have lower levels of testosterone.

Testosterone levels can be increased naturally by processes that occur within the body, or they can be induced via hormone treatments. Non-injection-related causes of high testosterone in either men or women include:

• Cushing Syndrome: This condition impacts the production of the stress hormone cortisol, which is produced by the adrenal gland. This increase in cortisol can, in turn, impact the production of other related hormones, including testosterone.
• Polycystic Ovary Syndrome: This is one of the most common causes of high testosterone in women specifically. It causes the increased production of certain hormones, including testosterone.
• Congenital Adrenal Hyperplasia: CAH can occur in both men and women. This condition also affects the activity of the adrenal glands, which results in the release of testosterone.
• Tumors: Tumors in certain parts of the brain (the hypothalamus or pituitary gland) or on the adrenal glands can trigger increased testosterone production.
• Medications: Some medications are associated with hormone production, including testosterone— for example, certain types of steroids or hormone stimulators such as Clomid.
• Obesity: Research suggests that obesity may be associated with high testosterone levels in women.

The way in which high testosterone leads to disordered breathing during sleep is not yet fully understood. Some experts attribute this change to an increase in the bulkiness of the muscles that make up the neck and throat. That said, most studies that have looked at the effect of testosterone on airway size have reported that the airway does not become smaller as a result of testosterone, so this theory is heavily debated.

Regardless of the cause, increased levels of testosterone have been proven to worsen existing sleep apnea cases. Scientists have known about this link for some time, with some studies dating back several decades. According to one study, participants who were given testosterone saw a large increase in the number of apnea (no breathing) or hypopnea (slow and shallow breathing) episodes each night.

Women are particularly susceptible to the effects of high testosterone. One example of this, which is quite prevalent, is Polycystic Ovary Syndrome (PCOS). This condition involves hormonal imbalances, including increased testosterone. Studies show that individuals with this condition have a higher risk of developing OSA.

Research shows that there does seem to be a relationship between taking TRT and sleep apnea. These patterns have been observed in both males and females who have received testosterone therapy. And experts have warned against this type of hormonal therapy in individuals who have been diagnosed with sleep apnea because it has been linked with significantly worse symptoms.

Additionally, a study published by the Journal of Applied Physiology suggests that there may be a link between testosterone and an increased likelihood of Central Sleep Apnea. During this study, scientists examined the effects of testosterone injections on the brain's ability to respond to changes in the carbon dioxide levels in the blood. They found that participants saw a decrease in their sensitivity to carbon dioxide. As carbon dioxide levels are a big contributor to CSA, these results may give a hint as to why testosterone therapy worsens sleep apnea.

While sleep apnea can have many underlying causes, it turns out that it can also be a catalyst for other health issues as well. This includes low T. But why does sleep apnea cause low testosterone? One likely reason for this relationship is the number of sleep disturbances that are caused by sleep apnea, which can impact the normal sleep cycle.

Sleep and hormone production are delicately intertwined. For example, testosterone is produced during REM sleep, which is one of the stages of sleep that is impacted most by sleep apnea. When this portion of the sleep cycle is interrupted, testosterone production drops.

Because testosterone and sleep apnea have a bit of a complicated relationship, it’s safe to say that sleep apnea and TRT don’t exactly mix. So if you are someone who struggles with low T and sleep apnea, it can feel as though you don’t have a lot of options for treating your testosterone levels. If you have OSA or CSA, it's important to follow the treatment plan suggested by your doctor to ensure that your testosterone levels do not fall even further, despite your apnea.

There are also some lifestyle choices that you can make to improve your hormone levels. These include:

• Exercise regularly
• Take steps to improve your sleep health
• Maintain a healthy weight
• Make healthy diet choices
• Avoid tobacco
• Avoid alcohol
• Manage stress levels
• Avoid opioids

Additionally, some experts suggest taking the following supplements:

• Zinc
• Quercetin
• Grape seed extract
• DHEA

Changes in your testosterone levels can have very significant effects on your sleep health, particularly with regard to sleep apnea. These changes tend to result in Obstructive Sleep Apnea (OSA), specifically. However, they can also leave you prone to developing traits that increase your likelihood of Central Sleep Apnea as well.

These issues have primarily been attributed to low T. However, current research suggests that high levels of testosterone may also leave you at a higher risk of developing sleep-breathing issues. Interestingly, this relationship between testosterone and sleep apnea goes both ways, meaning the sleep-breathing issues caused by testosterone levels can actually make low T even worse.

If you are someone who has both sleep apnea and testosterone issues, your doctor may suggest turning to natural solutions before starting hormone therapy. This is because TRT is linked to worsening apnea. If you are looking to maintain healthy hormone levels, we suggest starting with making healthy dietary choices, exercising regularly, and avoiding harmful substances. As always, if you have any concerns regarding sleep apnea or hormonal changes, it's important to speak with your healthcare provider!