Obstructive Sleep Apnea and TRT

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The evidence on the role of obstructive sleep apnea (OSA) in the pathogenesis of hypogonadism and the impact of testosterone replacement therapy (TRT) in OSA patients are still contradictory. OSA is generally considered to be a relative contraindication as TRT is feared to worsen sleep apnea so ventilatory capacity should be strictly investigated in advance and monitored thereafter. Few controlled studies have been released on the long-term effects of TRT in patients with OSA due to methodological limitations at study entry. Data from recent randomized placebo-controlled studies show a time-dependent influence on nocturnal hypoxia and a positive impact after a long time of exposure in selected patients. Since these results await further confirmation from larger studies, we suggest using TRT cautiously in obese hypogonadal patients with hypoventilatory syndrome, especially if they are not on continuous positive airway pressure treatment.

Obstructive Sleep Apnea and TRT.png


In summary, this review summarizes the evidence on the mechanisms involved in the pathogenesis of hypogonadism in patients with OSAS, such as the abnormal circadian rhythm of gonadotrophin secretory patterns associated with obesity. TRT may represent a risk factor for OSA development and therefore, respiratory function monitoring is recommended especially in obese patients during TRT. Scanty evidence has been released on the effect of TRT in patients with OSA. Data from recent randomized placebo-controlled studies address TRT as a time-dependent influence on nocturnal hypoxia, showing a positive impact after a long time of exposure. Also, CPAP and PDE5i can be considered safe procedures to ameliorate sexuality in hypogonadal patients with OSA. We suggest using TRT cautiously in obese hypogonadal patients with hypoventilatory syndrome especially if they are not on CPAP. The latter aspect needs to be further confirmed by larger controlled studies.


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Defy Medical TRT clinic doctor


Super Moderator
Screenshot (1915).png

FIG. 1. Two-sided relationship between OSA, obesity, and testosterone level. OSAS and obesity contribute to reducing the testosterone level in the bloodstream; at the same time, lower testosterone level worsens obesity and sleep disorders. OSA, obstructive sleep apnea; OSAS, OSA syndrome.


Super Moderator
Screenshot (1916).png

FIG. 2. Testosterone replacement therapy worsens OSA symptoms through neuromuscular changes and raised metabolic requirements. This condition causes the collapse of the upper airway and onset of hypoxia.


Active Member
@madman those are great flow charts, easy to understand and makes it clear how all of this ties together. With that being said, is CPAP the only way to manage OSA? The neuromuscular changes are concerning, is there something to help with this? I'm currently on a CPAP machine and it works great, but it seems like that's just addressing the symptoms, not working to resolve or improve OSA. Lastly, what does it mean that TRT results in increased metabolic requirements and why is this?


Super Moderator
@madman those are great flow charts, easy to understand and makes it clear how all of this ties together. With that being said, is CPAP the only way to manage OSA? The neuromuscular changes are concerning, is there something to help with this? I'm currently on a CPAP machine and it works great, but it seems like that's just addressing the symptoms, not working to resolve or improve OSA. Lastly, what does it mean that TRT results in increased metabolic requirements and why is this?

Depends on the severity and CPAP is considered the gold standard when it comes to treatment.

Diagnosis and Management of Obstructive Sleep Apnea A Review (2020)

Are there non-surgical alternatives for patients who are unable to tolerate PAP therapy?

*Mandibular devices, weight loss, exercise, avoiding sleep in the supine position, and abstaining from alcohol can be beneficial for patients who are unable to tolerate PAP therapy. There are no medications currently approved for the management of OSA.

Table 3. Primary Treatments for Obstructive Sleep Apnea (OSA)
Screenshot (1943).png

Not aware of ways to address the neuromuscular changes other than possibly lower T dose if TT/FT levels are too high.

*Dilatation of the upper airway depends on contraction of the airway dilator muscles (e.g., the genioglossus), an effect mediated by parallel serotoninergic and noradrenergic neurons; both types of neurons may be impacted by age and testosterone level

*the possibility of higher metabolic requirements with elevated testosterone levels, which may result in greater oxygen consumption that in turn could lead to hypoxia


Nelson Vergel

Founder, ExcelMale.com
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New Member
I am a 75 year old male soon to begin TRT and I have been on a CPAP for "severe sleep apnea for 6 years now. I do not sleep well. getting up approximately 2 - 3 times many nights with a dry throat from the air pressure. Among other things, I am hesitant to begin TRT as it may result in even more sleep interruptions. Any thoughts on survivors of ongoing CPAP use and TRT?


Active Member
@Arturo definitely possible TRT could worsen your sleep apnea. I developed mild sleep apnea while on TRT and it has only gotten worse, but losing body fat has helped. My CPAP helps too, but it’s possible your low hormone levels may also be worsening your sleep. Does your CPAP have a built-in humidifier? Mine does and it works great! No dry symptoms. In my clinics our method of treatment is to “prioritize the disease state”. What is most important/essential to your health? Treat that first & foremost. Personally, I think hormones are pretty important. Maybe consider starting at a smaller dose since your normal levels at your age would be on the lower end anyways.


New Member
I just read about taping your lips shut to prevent “mouth breathing” which encourages breathing through your nose which keeps pressure on the soft tissue in your palate or throat and is supposed to help with snoring and mild sleep apnea.

I had never heard of this before. I’ve heard of breathe right strips to pull the nasal passages open (they do help) but never taping the lips shut.
there are even products sold specifically to do this, most of which use versions of medical bandage tape. Don’t use duct tape. A quick search on google or amazon for “Mouth tape” will show these products.

The book Breath by James Nestor explains more about how mouth breathing results in all sorts of issues including Snoring, poor sleep, allergies, asthma, etc. Basically if your mouth is dry in the morning, you are breathing wrong!
@madman With that being said, is CPAP the only way to manage OSA? The neuromuscular changes are concerning, is there something to help with this? I'm currently on a CPAP machine and it works great, but it seems like that's just addressing the symptoms, not working to resolve or improve OSA.

Causes for OSA. A collapsed or narrow airway can be caused by numerous different anatomic changes over time or deformities caused by external forces.

Just to give you one example, in my case, I had bicuspid extractions and braces as a child. What that does potentially is cause narrowing of the arches while the the tongue grows. Over time, that closes off the airway and causes apnea. So that is an anatomic deformity caused by an orthodontic procedure. I think there are many cases that fall under this category of a narrowing of the palate, retruded mandible and midface deficiency.

Modern skulls have changed significantly over time and because we are using our jaws less by eating softer processed foods right from birth our jaws are getting smaller and narrower so the airways are being completely compromised. This is a big problem that most mainstream doctors will never acknowledge or are completely dismissive of. OSA is just as it says, there’s an obstruction. The question is what’s causing that obstruction. And I think that most of it can be traced to anatomic deformities which should be corrected.

I have been researching this for quite some time and I am looking into non-surgical procedures to correct this. I also have TMD which is related. There is no guarantee that any procedure will completely correct sleep apnea but I’m not going to just stop at CPAP and not at least try to see if I can correct it. There’s no reason for us to have it in the first place. It is a deformity that we should not have to live with. CPAP works and saves lives, yes, but it is only a patch and not a cure as it does not address the underlying cause.

There have been many instances in which patients have permanently corrected their apnea via repositioning the maxilla and mandible using orthotics, remodeling them over time using certain appliances via orthodontics, etc. The standard surgeries like UPPP and tonsillectomy only work about 30% of the time and are very painful so I would not opt for either one of those.

Look into non-surgical treatments like neuromuscular dentistry. The surgical procedures like maxillomandibular advancement and palate expansion are highly invasive and risky and only change the anterior/posterior or lateral. They do nothing to remodel in 3 dimensions.

Try this Facebook group for a possible permanent resolution: Facebook Groups
Last edited:


New Member
Some really great responses. Thank you.
With asthma along with sleep apnea, I am afraid to tape my mouth given a few episodes already experienced.
I have now been on testosterone Gel 1% for a week after 3 bone fractures from my testosterone not returning after being treated with Lupron for Prostate Cancer.
So far no noticeable symptoms and sleeping through most of the night.
Oh, the joys of aging!

Nelson Vergel

Founder, ExcelMale.com

Nelson Vergel

Founder, ExcelMale.com


Nelson Vergel

Founder, ExcelMale.com
The sleep apnea episode that won’t put you to sleep. Become a sleep apnea guru with incredible insights from Barbara Phillips MD, MSPH, FCCP an expert in pulmonary medicine, critical care and sleep medicine who is also a past president of CHEST! We discuss high-yield topics in the world of obstructive sleep apnea including: home sleep studies vs in-lab polysomnography, the importance of oxygen saturation (the T90 and ODI) when interpreting sleep study results, tricks to improve CPAP adherence, and alternatives therapies for obstructive sleep apnea.

Time Stamps
00:00 Disclaimer, intro, guest bio
03:00 Guest one liner, book recommendation, advice for trainees
08:10 Clinical case of sleep apnea, some basic stats, and key predictors of sleep apnea
12:38 Barriers to diagnosis and treatment of OSA
15:23 Discussion of T90, hypoxemia and sleep fragmentation
17:05 How to read a sleep study report
21:55 Home sleep apnea testing
24:15 What are the consequences of sleep apnea
28:30 What is the efficacy of cpap for lowering blood pressure and mortality
31:45 Counseling a patient who is new to cpap
33:45 Choice of mask
40:10 Do alternatives to cpap work? e.g. surgery, mandibular advancement devices
44:17 Modafinil and z-drugs
47:15 Driver’s license issues in sleep apnea
48:35 Future of sleep medicine and take home points
51:15 Outro

Clinical Pearls

Metabolic syndrome and obstructive sleep apnea (OSA) are dangerous bedfellows: Estimates suggest at least 60% of folks with the metabolic syndrome have OSA, although, Dr. Phillips suggests the association could be as high as 80+%! (Parish et al. Journal of Clinical Sleep Medicine, 2007 & Drager et al. PLoS One, 2010)

STOP ordering sleep studies on patients who CLEARLY have sleep apnea, if there is anyway to avoid it! In patients with metabolic syndrome who have other signs or symptoms consistent with obstructive sleep apnea (excessive daytime sleepiness, morning headaches, resistant hypertension, large neck diameter) with or without high scores on the STOP-BANG questionnaire or Epworth Sleepiness Scale, the pre-test probability that they have sleep apnea and would benefit from therapy is high enough to obviate the need for time consuming, expensive testing when we have autotitrating CPAP (continuous positive airway pressure). – Dr Phillips

The apnea-hypopnea index (AHI) is not the be-all-and-end-all: The ODI (oxygen desaturation index) and the T90 (time spent, during a sleep study, with an oxygen saturation at-or-lower than 90%) have been shown to be very useful adjuncts to the AHI when evaluating a patient for OSA. Data suggests that it is not the number of hypopneas/apneas but rather the time spent hypoxemic that is most strongly related to the sequelae of sleep apnea. (Chung et al. Anesthesia and Analgesia 2012 & Dr. Phillips)

The data for Home Sleep Testing (HST) is growing: Dr. Phillips cited studies to suggest the data from HSTs is non-inferior to traditional lab-run polysomnography. There is also data that suggests adherence to therapy and improvement in sleepiness is equivalent (if not superior) for patients diagnosed and treated with HSTs and auto-titrating CPAP. (Chai-Coetzer et al. Annals of Internal Medicine 2017, Chai-Coetzer at al. American Journal of Respiratory & Critical Care Medicine & Berry et al. Journal of Clinical Sleep Medicine 2014)

While HST is great, it’s not for everyone: Per the AASM, in lab polysomnography rather than home sleep testing is recommended for patients with “significant cardiorespiratory disease, potential respiratory muscle weakness due to neuromuscular condition, awake hypoventilation or suspicion of sleep related hypoventilation, chronic opioid medication use, history of stroke or severe insomnia.” (Kapur et al. Journal of Clinical Sleep Medicine 2017)

Mild OSA may NOT require treatment: Careful reading of the AASM and ATS guidelines on OSA treatment suggests it is reasonable to defer CPAP therapy for patients with mild OSA who DO NOT endorse excessive daytime sleepiness. Asymptomatic patients with mild OSA who are started on CPAP and have bad experiences may be much more difficult to reach in the future should their disease worsen. (Kushida et al. AASM 2006 & Chowdhuri et al. ATS 2016)

The cost of OSA on society is tremendous: According to the AASM, undiagnosed (and untreated OSA) cost the United States nearly 150 billion dollars in 2015. Of this, 26.2 billion dollars were spent due to car accidents related to sleepiness in the setting of undiagnosed OSA. Nearly 30% of car accidents in the US are associated with drowsy driving which is well-known to be seen in those with sleep apnea. Fortunately, according to the AASM, there is data to suggest that those treated for their OSA are at lower risk. (Hidden Health Crisis Costing America Billions – AASM & AASM Infographic)

OSA is a primary care problem: There are not enough sleep medicine doctors to diagnose, treat and manage all the OSA that is out there. Thus, it is a problem that all primary care doctors need to be comfortable with. After all, OSA is not only a potential cause of morbidity and mortality for the patient, but for those the share highways and roadways with them – especially if they go untreated. – Dr. Phillips
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