Testosterone Deficiency and Sleep Apnea

Sleep and Anabolic/Catabolic Hormonal Profile in Sedentary Middle-Aged Adults: The FIT-AGEING Study

Sleep quality plays an important role in the modulation of several aging markers. This influence could be explained by aging-induced hormonal changes. Indeed, poor sleep quality has been associated with the development of several endocrine-related health complications. This study examined the relationship of both subjective and objective sleep quantity and quality, with basal levels of selected plasma anabolic and catabolic hormones in sedentary middle-aged adults. A total of 74 volunteers (52.7% women; aged 53.7 ± 5.1) were recruited for this study. Subjective sleep quality was assessed by the Pittsburgh Sleep Quality Index (PSQI; higher scores indicate worse sleep quality), and objective sleep quality parameters (total sleep time [TST], wake after sleep onset [WASO], and sleep efficiency [SE]) were measured using a wrist-worn accelerometer. Basal levels of plasma dehydroepiandrosterone sulphate (DHEAS), total testosterone, sex hormone binding globulin (SHBG), somatotropin, and cortisol levels, were determined. Free testosterone was calculated from the total testosterone and SHBG levels. No associations of global PSQI score, TST, WASO, and SE with DHEAS, free testosterone, and somatotropin plasma levels were found, neither in men nor in women (all p ≥ 0.05). Global PSQI score was inversely related to cortisol plasma levels in women (p = 0.043). WASO was positively associated with cortisol plasma levels, while SE was negatively associated with cortisol plasma levels in women (all p ≤ 0.027). Sleep quality is not related to levels of plasma anabolic hormones, but to levels of catabolic hormones, in sedentary middle-aged adults. Therefore, these results suggest that potential changes in aging biomarkers associated with sleep disturbances, could be mediated by age-related changes in the catabolic endocrine system.

Prevalence and Characteristics of Erectile Dysfunction in Obstructive Sleep Apnea Patients

BACKGROUND

Obstructive sleep apnea (OSA) is a common and severe social problem. Erectile dysfunction (ED) is an important health concern. The prevalence of OSA with ED is increasing, which significantly affects the quality of life and work efficiency of patients. However, the mechanism underlying the comorbidity of these two diseases remains unclear.

OBJECTIVES

(1) Investigate the prevalence of OSA with ED; (2) analyze the correlation between OSA and ED; and (3) explore the treatment response to and possible mechanism of uvulapalatopharyngoplasty (UPPP) in patients with OSA and ED. This study aims to provide a theoretical basis for the clinical diagnosis and comprehensive treatment of OSA with ED and improve prevention and treatment strategies.

MATERIALS AND METHODS

In total, 135 subjects were enrolled in the study. Clinical data, polysomnography, the ESS score, Beck anxiety score, Beck depression score, IIEF-5 score and ASEX score were recorded before UPPP and 6 months after UPPP. Sex hormones were measured for all subjects using a Roche electrochemiluminescence analyzer.

RESULT

The prevalence of OSA with ED was 64.52%, and the prevalence of severe OSA with ED was 73.02%. The prevalence of OSA with ED increased with age, BMI and apnea-hypopnea index (AHI) value. Among polysomnography indicators, minimum oxygen saturation and average oxygen saturation may predict the occurrence of OSA with ED. Improving the patient's anxiety and depression is very important for treating OSA with ED. Sex hormone levels were not significantly correlated with the occurrence of OSA with ED.

CONCLUSION

ED is a common symptom of OSA patients. This study showed that sex hormone levels in OSA patients with ED were not significantly correlated with the condition, but further investigation of this relationship is worthwhile. It is recommended that the free and combined types of sex hormones be further distinguished during testing because the free type is the active form. UPPP surgical treatment is effective for OSA with ED, and its possible mechanism is protection of the peripheral nerves of the sex organs by improving nighttime hypoxia and arousal.

Surgical treatments for obstructive sleep apnea decrease the risk of erectile dysfunction: A nationwide cohort study

BACKGROUND

It has been reported that the risk of erectile dysfunction (ED) is significantly higher in patients with obstructive sleep apnea (OSA), compared with patients without OSA. However, there is limited evidence on whether surgical treatments in patients with OSA could decrease ED risk.

OBJECTIVES

To assess the impact of surgical treatments for OSA on the risk of ED by analysis of claims data from the Taiwan National Health Insurance Research Database between 1997 and 2012.

MATERIAL AND METHODS

We identified 20,675 male adults with newly diagnosed OSA during the study period; 16,040 patients ever received surgical treatments (treated cohort) and 4635 patients never received surgical treatments (untreated cohort). According to 3:1 propensity score matching, we analyzed 8337 patients in the treated cohort and 2779 controls in the untreated cohort. We estimated the incidence rates (IRs) and hazard ratios (HRs) of incident ED in both cohorts through the end of 2012.

RESULTS

In a total study follow-up of 64,916 person-years, 396 (3.6%) patients developed impotence. The IRs of ED for the treated and untreated cohorts, respectively, were 55.8 (95% confidence interval [CI], 55.6-55.9) and 76.1 (95% CI, 76.0-76.3) per 1000 person-years. Multivariate Cox proportional hazard analysis showed that surgical treatments for OSA patients were associated with a lower risk for ED (adjusted HR, 0.79; 95% CI, 0.64-0.98). Multivariate stratified analysis further verified that significant risk reduction of ED was present in OSA patients without hypertension, diabetes, hyperlipidemia, hyperuricemia, obesity, chronic kidney disease, and chronic liver disease.

CONCLUSIONS

We found that OSA patients who received surgical treatments were associated with a lower risk for developing ED by 21%.

Androgen receptors in areas of the spinal cord and brainstem: A study in adult male cats

Sex hormones, including androgens and estrogens, play an important role in autonomic, reproductive and sexual behavior. The areas that are important in these behaviors lie within the spinal cord and brainstem. Relevant dysfunctional behavior in patients with altered androgen availability or androgen receptor sensitivity might be explained by the distribution of androgens and their receptors in the central nervous system. We hypothesize that autonomic dysfunction is correlated with the androgen sensitivity of spinal cord and brainstem areas responsible for autonomic functions. In this study, androgen receptor immunoreactive (AR‐IR) nuclei in the spinal cord and brainstem were studied using the androgen receptor antibody PG21 in four uncastrated young adult male cats. A dense distribution of AR‐IR nuclei was detected in the superior layers of the dorsal horn, including lamina I. Intensely stained nuclei, but less densely distributed, were found in lamina X and preganglionic sympathetic and parasympathetic cells of the intermediolateral cell column. Areas in the caudal brainstem showing a high density of AR‐IR nuclei included the area postrema, the dorsal motor vagus nucleus and the retrotrapezoid nucleus. More cranially, the central linear nucleus in the pons contained a dense distribution of AR‐IR nuclei. The mesencephalic periaqueductal gray (PAG) showed a dense distribution of AR‐IR nuclei apart from the most central part of the PAG directly adjacent to the ependymal lining. Other areas in the mesencephalon with a dense distribution of AR‐IR nuclei were the dorsal raphe nucleus, the retrorubral nucleus, the substantia nigra and the ventral tegmental area of Tsai. It is concluded that AR‐IR nuclei are located in specific areas of the central nervous system that are involved in the control of sensory function and autonomic behavior. Furthermore, damage of these AR‐IR areas might explain related dysfunction in humans.

Obstructive Sleep Apnea Is Associated With Polycythemia in Hypogonadal Men on Testosterone Replacement Therapy

BACKGROUND

Polycythemia (erythrocytosis) is a known side effect of testosterone (T) replacement therapy (TRT) and appears to correlate with maximum T levels. There is also a well-established association between obstructive sleep apnea (OSA) and the development of polycythemia, which confers additional long-term cardiovascular morbidity. Synergy between TRT and OSA in the development of polycythemia remains poorly understood.

AIM

The objective of this study was to retrospectively assess the relationship of OSA and secondary polycythemia in hypogonadal men receiving TRT.

METHODS

We performed a retrospective chart review of all men treated by a single provider from 2015 to 2019 for the diagnosis of hypogonadism. Patients who developed a hematocrit of 52% or greater were classified as having polycythemia. OSA was identified via clinical documentation or use of nocturnal continuous positive airway pressure. Demographics, laboratory values, treatment details, and comorbidities were recorded. Data were reported as mean ± SD for parametric variables and median [interquartile range] for non-parametric values.

OUTCOME

The primary outcome of this study was the association between OSA and polycythemia in hypogonadal men on TRT.

RESULTS

474 men were included in this study. 62/474 (13.1%) men met the criteria for the diagnosis of polycythemia with a median hematocrit of 53.6 [interquartile range 52.6, 55.5]. Univariate analysis demonstrated a strong positive association between polycythemia and the concomitant diagnosis of OSA in hypogonadal men (P = .002). Even after correcting for age, body mass index (BMI), and peak T levels in the multivariate analysis (P = .01), this relationship remained significant with an odds ratio of 2.09 [95% CI 1.17, 3.76]. 37 men on TRT with polycythemia and OSA were included in the final cohort with a mean age of 59.2 ± 11.4 years, mean BMI of 32.4 ± 6.0, and median time from TRT initiation to polycythemia diagnosis of 3 years. All patients diagnosed with OSA were prescribed continuous positive airway pressure with poor compliance noted in 52.8% of men. 37.8% were managed via phlebotomy and 59.5% were managed via dose de-escalation of TRT. In hypogonadal men on TRT with polycythemia, BMI was the only risk factor strongly associated with OSA (P = .013).

CLINICAL TRANSLATION

In hypogonadal men (particularly those with elevated BMI) on TRT who develop secondary polycythemia, a diagnosis of OSA should be strongly considered.

STRENGTHS & LIMITATIONS

This is a single provider retrospective study and further studies are needed to assess generalizability.

CONCLUSIONS

In this retrospective single-center cohort, the development of polycythemia in hypogonadal men on TRT was associated with an increased prevalence of OSA. Lundy SD, Parekh NV, Shoskes DA. Obstructive Sleep Apnea Is Associated With Polycythemia in Hypogonadal Men on Testosterone Replacement Therapy. J Sex Med 2020;17:1297-1303.

Why most patients do not exhibit obstructive sleep apnea after mandibular setback surgery?

Maxillomandibular advancement (MMA) is effective for the treatment of obstructive sleep apnea (OSA). In previous studies, the airway was increased in the anteroposterior and transverse dimensions after MMA. However, the effect of the opposite of mandibular movement (mandibular setback) on the airway is still controversial. Mandibular setback surgery has been suggested to be one of the risk factors in the development of sleep apnea. Previous studies have found that mandibular setback surgery could reduce the total airway volume and posterior airway space significantly in both the one-jaw and two-jaw surgery groups. However, a direct cause-and-effect relationship between the mandibular setback and development of sleep apnea has not been clearly established. Moreover, there are only a few reported cases of postoperative OSA development after mandibular setback surgery.

These findings may be attributed to a fundamental difference in demographic variables such as age, sex, and body mass index (BMI) between patients with mandibular prognathism and patients with OSA. Another possibility is that the site of obstruction or pattern of obstruction may be different between the awake and sleep status in patients with OSA and mandibular prognathism. In a case-controlled study, information including the BMI and other presurgical conditions potentially related to OSA should be considered when evaluating the airway. In conclusion, the preoperative evaluation and management of co-morbid conditions would be essential for the prevention of OSA after mandibular setback surgery despite its low incidence.

May Dyspnea Sensation Influence the Sexual Function in Men With Obstructive Sleep Apnea Syndrome? A Prospective Control Study

INTRODUCTION

Dyspnea sensation is frequently present in obstructive sleep apnea syndrome (OSA) patients; however, its possible influence on sexual function and body image has not been well analyzed.

AIMS

To evaluate sexual function, the prevalence of sexual dysfunction (SD), and body image during sexual activity and its relationship with dyspnea in men with OSA.

METHODS

129 men were included in the prospective study, with 61 diagnosed with OSA (cases) and 68 age- and BMI-matched healthy control subjects. Patients were assessed for the severity of heart failure by the New York Heart Association scale and dyspnea by the Visual Analogue Scale. OSA was confirmed by in-laboratory polysomnography.

MAIN OUTCOME MEASURES

International Index of Erectile Function (IIEF) was used as a measure of sexual function, body image during sexual activity was assessed by the Body Exposure During Sexual Activity Questionnaire, whereas SD was diagnosed using criteria from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition.

RESULTS

The mean age of the studied population was 57.9 ± 10.8 years. Presence of dyspnea interfered with sexual life in 20% of men diagnosed with OSA and with work performance in 33%. Men with OSA had worse scores in IIEF-15 compared with control subjects and higher frequency of sexual distress compared with men with OSA. There were no differences in the rate of SD according to criteria from the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. The presence of OSA worsened the perceived body image during sexual activity. The presence of dyspnea was the only negative factor affecting sexual function in general (IIEF-15 score) and 1 of the factors affecting erectile function and orgasmic function.

CONCLUSION

In men with OSA, body image is negatively influenced by the presence of OSA. Furthermore, the presence of dyspnea assessed by the New York Heart Association scale impairs sexual function in that group of men. Skoczyński S, Nowosielski K, Minarowski Ł, et al. May Dyspnea Sensation Influence the Sexual Function in Men With Obstructive Sleep Apnea Syndrome? A Prospective Control Study. Sex Med 2019;7:303-310.

Alternatives to Testosterone Therapy: A Review

INTRODUCTION

Although testosterone therapy (TTh) is an effective treatment for hypogonadism, recent concerns regarding its safety have been raised. In 2015, the US Food and Drug Administration issued a warning about potential cardiovascular risks resulting from TTh. Fertility preservation is another reason to search for viable alternative therapies to conventional TTh, and in this review we evaluate the literature examining these alternatives.

AIMS

To review the role and limitations of non-testosterone treatments for hypogonadism.

METHODS

A literature search was conducted using PubMed to identify relevant studies examining medical and non-medical alternatives to TTh. Search terms included hypogonadism, testosterone replacement therapy, testosterone therapy, testosterone replacement alternatives, diet and exercise and testosterone, varicocele repair and testosterone, stress reduction and testosterone, and sleep apnea and testosterone.

MAIN OUTCOME MEASURES

Review of peer-reviewed literature.

RESULTS

Medical therapies examined include human chorionic gonadotropins, aromatase inhibitors, and selective estrogen receptor modulators. Non-drug therapies that are reviewed include lifestyle modifications including diet and exercise, improvements in sleep, decreasing stress, and varicocele repair. The high prevalence of obesity and metabolic syndrome in the United States suggests that disease modification could represent a viable treatment approach for affected men with hypogonadism.

CONCLUSIONS

These alternatives to TTh can increase testosterone levels and should be considered before TTh. Lo EM, Rodriguez KM, Pastuszak AW, Khera M. Alternatives to Testosterone Therapy: A Review. Sex Med Rev 2018;6:106-113.

Who Gets Testosterone? Patient Characteristics Associated with Testosterone Prescribing in the Veteran Affairs System: a Cross-Sectional Study

BACKGROUND

There has been concern about the growing off-label use of testosterone. Understanding the context within which testosterone is prescribed may contribute to interventions to improve prescribing.

OBJECTIVE

To evaluate patient characteristics associated with receipt of testosterone.

DESIGN

Cross-sectional.

SETTING

A national cohort of male patients, who had received at least one outpatient prescription within the Veterans Affairs (VA) system during Fiscal Year 2008- Fiscal Year 2012.

PARTICIPANTS

The study sample consisted of 682,915 non-HIV male patients, of whom 132,764 had received testosterone and a random 10% sample, 550,151, had not.

MAIN MEASURES

Conditions and medications associated with testosterone prescription.

KEY RESULTS

Only 6.3% of men who received testosterone from the VA during the study period had a disorder of the testis, pituitary or hypothalamus associated with male hypogonadism. Among patients without a diagnosed disorder of hypogonadism, the use of opioids and obesity were the strongest predictors of testosterone prescription. Patients receiving >100 mg/equivalents of oral morphine daily (adjusted odds ratio = 5.75, p < 0.001) and those with body mass index (BMI) >40 kg/m² (adjusted odds ratio = 3.01, p < 0.001) were more likely to receive testosterone than non-opioid users and men with BMI <25 kg/m². Certain demographics (age 40-54, White race), comorbid conditions (sleep apnea, depression, and diabetes), and medications (antidepressants, systemic corticosteroids) also predicted a higher likelihood of testosterone receipt, all with an adjusted odds ratio less than 2 (p < 0.001).

CONCLUSIONS

In the VA, 93.7% of men receiving testosterone did not have a diagnosed condition of the testes, pituitary, or hypothalamus. The strongest predictors of testosterone receipt (e.g., obesity, receipt of opioids), which though are associated with unapproved, off-label use, may be valid reasons for therapy. Interventions should aim to increase the proportion of testosterone recipients who have a valid indication.