Low testosterone can cause a lot of problems in life like low sex drive, erectile dysfunction, and fatigue. And sleep apnea can cause problems, too, like fatigue, difficulty concentrating, and memory problems. But the two health issues may actually be linked.
And taking testosterone supplements or getting injections may not be the best idea if you have sleep apnea. There’s evidence to show testosterone replacement therapy may cause sleep apnea or make it worse, but we still don’t know for sure.
Below, we’ll dive into the connection between testosterone and sleep apnea, and whether it’s safe to take testosterone if you have the sleep disorder.
If you’ve got low testosterone levels, you may be thinking about taking supplements or speaking to a doctor about testosterone replacement therapy (TRT). But, if you’ve got sleep apnea as well, taking testosterone may not be safe.
As a quick definition, obstructive sleep apnea (OSA or obstructive sleep apnea syndrome) is a sleep disorder that causes your upper airways to collapse during the night, cutting off your breathing temporarily.
Risk factors for developing sleep apnea include obesity, having a medical condition like type 2 diabetes or hypertension (high blood pressure), smoking, and consuming alcohol.
You can learn more about how to know if you have sleep apnea here.
More research needs to be done, but from what we do know, testosterone may make sleep apnea worse, or even cause people to develop the sleep disorder if they don’t already have it.
One study gave three high-dose testosterone injections to healthy men over 60. The results showed an increased duration of hypoxemia — or low blood oxygen levels — and more disrupted breathing during sleep. The researchers stated that more research needs to be done into long-term lower-dose testosterone therapy on breathing during sleep, however.
Another study measured the disordered-breathing events in hypogonadal men (men with low testosterone) on and off testosterone replacement therapy. When taking testosterone, the number of disordered-breathing events rose from about six per hour to about 15.
And another study on premenopausal women found testosterone may facilitate the development of central sleep apnea — when your brain doesn’t send the correct signals to the muscles in your airways during sleep.
There’s also some evidence that suggests testosterone therapy may cause sleep apnea symptoms, but the symptoms may stop when therapy is discontinued. And a 2018 study suggested testosterone replacement therapy increased the risk of developing sleep apnea.
For those who already have sleep apnea, research shows testosterone replacement therapy can make symptoms worse. But it may depend on how severe your sleep apnea is. For now, it’s generally recommended people with severe sleep apnea don’t get replacement therapy. Or, if they do, they’re prescribed it cautiously, especially if they’re not sleeping with a continuous positive airway pressure (CPAP) machine — which pushes air into the airways to keep them open as you sleep.
One 2019 paper on the topic concluded that sleep apnea treatment with testosterone replacement therapy may improve testosterone levels, sexual dysfunction, and erectile dysfunction, but patients should be asked about sleep apnea symptoms before and after starting replacement therapy. However, it said that testosterone replacement therapy should “probably be avoided” in patients with severe untreated sleep apnea as it may make it worse in some people.
And a 2020 paper concluded that testosterone replacement therapy “likely plays a small role in exacerbating or inducing changes” in sleep apnea, but says they may be time limited. Instead of avoiding it altogether, the paper said that healthcare professionals should prescribe testosterone with caution to those with severe sleep apnea.
Testosterone replacement therapy may cause or worsen sleep apnea, but what happens if your levels of the hormone are too low? Unfortunately, testosterone deficiency (also called low t or hypogonadism) may also cause sleep apnea.
Your levels of testosterone will naturally go down as you age. Total testosterone levels fall by about 1.6% per year, whilst free and bioavailable testosterone levels fall by 2% to 3% per year.
Beyond age, low testosterone levels can be caused by:
And these low levels can have a huge impact on your sleep. Low levels have been linked to:
One study found that lower testosterone levels were linked with a higher apnea-hypopnea index (AHI). This is the measure of sleep apnea severity. The higher your AHI, the more apneas (when you stop breathing) and hypopneas (when breathing becomes shallow) you experience each hour.
The men in the study with low testosterone levels also had more sleep time with their oxygen saturation levels (the percentage of oxygen in their blood, usually 95% to 100%) below 90%, compared to those with higher testosterone levels.
However, the link between testosterone and sleep apnea in this research was largely explained by obesity. The study concluded: “Clinical trials are necessary to determine whether body weight acts directly or indirectly (via low testosterone) in the causal pathway for sleep-disordered breathing in older men.”
But, as low testosterone can cause weight gain, and weight gain puts you at a higher risk of developing sleep apnea (and it can make existing sleep apnea worse), the link is still one to be aware of.
The link between sleep apnea and low testosterone may go both ways. When you have sleep apnea, you wake up often during the night, which leads to sleep loss, less REM sleep from disrupted sleep cycles, and potential weight gain — and all three are linked to lowered testosterone levels.
Your body’s testosterone production starts as you fall asleep and it peaks when you reach your first bout of REM sleep. So anything that shortens your sleep or messes up your REM cycles will sabotage your testosterone production. And research suggests sleep apnea is linked to dysfunction of the pituitary-gonadal axis, which is responsible for regulating and releasing sex hormones.
One 2011 study and another 2021 study found that sleep apnea is linked to lowered testosterone levels, even after body mass index (BMI) is taken into account. And a 2021 systematic review found men with sleep apnea — especially severe OSA — had lowered testosterone levels, even when BMI and age were taken into account.
But, yet more research says the link between sleep apnea and lowered testosterone is due to “obesity and advanced age and to a lesser degree to sleep fragmentation and hypoxia.” And a 2019 meta-analysis didn’t find a direct link between sleep apnea and testosterone at all.
So, sleep apnea may play a part in low testosterone, but more research needs to be done to know for sure and to know by how much exactly it’s to blame.
Low testosterone may be linked to sleep apnea, but what about if your levels are too high?
High testosterone levels can be caused by:
There’s very little research into whether naturally high levels of testosterone can cause sleep apnea.
One study found there's a high prevalence of sleep apnea in obese women with PCOS, which is characterized by having increased androgen (male hormone) levels.
High levels of testosterone can cause overweight and obese men to have more shallow sleep, however. And it can cause weight gain in both men and women, which can up your odds of developing sleep apnea.
And, as we explained above, side effects of testosterone replacement therapy, may include worsening sleep apnea or developing the sleep disorder.
Having high levels from abusing testosterone — by taking steroids for muscle gains, for example — hasn’t been linked to sleep apnea. But testosterone administration has been linked to other sleep problems such as:
If you’ve got low testosterone and sleep apnea and can’t get testosterone replacement therapy — or want to avoid it — there are still things you can do to increase your natural production of the hormone.
It’s important to address as low testosterone doesn’t just impact men’s health or your sex life. It can lead to low bone density, muscle weakness, weight gain, and fatigue in both men and women.
We’ve covered how to increase testosterone naturally in more detail here, but here are a few ideas to get you started.
Sleep debt is the running total of how much sleep you owe your body compared to your sleep need, the genetically determined amount of sleep you need each night.
The amount of sleep you get has a huge impact on your sex hormones.
Sleeping for only five hours a night for eight nights lowers your testosterone by 10% to 15%, and your serum testosterone levels (the amount of testosterone in your blood) increase as you sleep more all the way up to 9.9 hours.
You should especially prioritize sleep in the second half of the night as this is where most REM sleep happens. Sleep loss at the end of the night lowers testosterone whereas sleep loss at the beginning of the night doesn’t.
Use the RISE app to find out your individual sleep need and how much sleep debt you have.
If you have high sleep debt, you can pay it back by:
You can also use RISE to find out when your body naturally wants to wake up and aim to sleep until this time to stop early mornings from tanking your testosterone production.
We’ve covered the link between testosterone and sleep in more detail here.
Side note: The symptoms of low testosterone are very similar to the symptoms of high sleep debt — think fatigue, low mood, trouble concentrating, and low sex drive. If you haven’t been tested for low testosterone, you may find your symptoms are actually being caused by sleep debt and may improve when you start paying it down.
And even if you do have low testosterone, lowering your sleep debt can help maximize your energy levels, which may be especially low when sleep apnea is disrupting your sleep.
RISE users on iOS 1.202 and above can click here to view their sleep need.
RISE users on iOS 1.202 and above can click here to view their sleep debt.
Getting more sleep each night can be hard to do at the best of times, but it’s especially difficult when sleep apnea is causing you to wake up during the night. To stop anything else from disrupting your sleep, focus on maintaining excellent sleep hygiene.
Sleep hygiene is the name for the set of healthy habits you can do daily to help you fall asleep faster, wake up less often in the night, and get healthy, naturalistic sleep.
They include habits like:
The RISE app can guide you through 20+ sleep hygiene habits each day, and tell you the exact time to do them based on your body clock to make them more effective.
RISE users on iOS 1.202 and above can click here to set up their 20+ in-app habit notifications.
If you’re overweight or obese, losing weight may have the win-win effect of improving your sleep apnea and your testosterone levels are the same time.
Testosterone concentration is 50% lower in those who are obese compared to those with a healthy body mass index (BMI). And weight loss has been found to improve sleep apnea, even without CPAP therapy.
It can be hard to lose weight when you have the sleep disorder, however, as sleep apnea causes weight gain. You can learn more about the connection between sleep apnea and weight gain here.
And to make matters worse, low testosterone can also cause weight gain, especially belly fat. But, research is promising if you can make it happen. Weight loss through both high-protein and high-carbohydrate diets has been shown to boost testosterone and improve sexual function in overweight or obese men.
Research suggests when those with moderate-to-severe sleep apnea lose weight, their testosterone levels increase. And the more weight you lose, the more they increase.
The good news is some natural lifestyle changes have been shown to improve both sleep apnea and testosterone levels, as well as your overall quality of life.
These treatments include:
We’ve covered more ways to get rid of sleep apnea here. Unfortunately, CPAP, a common treatment option, doesn’t seem to improve testosterone levels, but it has been shown to lessen sleep apnea symptoms, which can help you get more sleep overall.
It’s important to seek treatment for sleep apnea, even if it can’t increase your testosterone levels, as the sleep disorder increases your risk of health conditions like cardiovascular disease, diabetes, obesity, and even all-cause mortality.
If you’re wondering whether you can get testosterone replacement therapy when you have sleep apnea, unfortunately, science doesn’t have the answer yet. There’s some evidence to suggest that testosterone can make sleep apnea worse — or even cause those without the sleep disorder to develop it — but more research needs to be done.
But, whether you’re avoiding replacement therapy altogether or want to boost your hormone levels naturally alongside careful treatment, you can do so by keeping sleep debt low, improving your sleep hygiene, and losing weight if you need to.
The RISE app can help by working out your individual sleep need and keeping track of your sleep debt each day. Plus, RISE can help you stay on top of 20+ sleep hygiene habits by telling you the ideal time to do them each day to make them more effective.
You’ll be giving your body the best chance to produce testosterone, and you’ll be making sure the sleep you do get with sleep apnea is as healthy and restorative as possible.
The jury’s still out on whether you can take testosterone if you have sleep apnea. There is some research to show testosterone replacement therapy can make sleep apnea worse. However, this may just be the case in those with severe sleep apnea. Speak to your doctor before taking testosterone if you have sleep apnea.
Testosterone therapy may worsen sleep apnea. Studies show it may increase the duration of time you have low blood oxygen levels and increase how disrupted your breathing is during the night.
High testosterone levels may cause sleep apnea. High-dose testosterone injections have been shown to cause more disrupted breathing and an increased duration of low blood oxygen levels. It’s not clear whether naturally high testosterone levels can cause sleep apnea, but they can cause weight gain, which increases your odds of sleep apnea.
Yes, testosterone may cause sleep problems. Low testosterone has been linked to insomnia, nighttime awakenings, and sleep apnea. Naturally high testosterone has been linked to shallow sleep. High testosterone from steroids has been linked to reduced sleep time and increased light sleep. And testosterone replacement therapy has been linked to sleep apnea and reduced sleep time.
Testosterone may help you sleep better. Some studies show when mice with low testosterone are treated with the hormone, they get more sleep overall. But other studies in humans show testosterone therapy can cause you to sleep less and may cause sleep problems like sleep apnea.
CPAP doesn’t appear to increase testosterone. But the airway pressure treatment can help you get more sleep overall and help alleviate sleep apnea symptoms like daytime sleepiness, memory problems, and loud snoring, and lower your risk of heart disease and stroke.
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