Volume 181 - Issue 5
Androgen deficiency and replacement therapy in men
Authors: David J Handelsman and Jeffrey D Zajac
Med J Aust 2004; 181 (5): 286-287. || doi: 10.5694/j.1326-5377.2004.tb06281.x
Published online: 16 August 2004
Published online: 16 August 2004
David J Handelsman,* Jeffrey D Zajac†
* Director, ANZAC Research Institute, Concord Hospital, Hospital Road, Concord, NSW 2139; † Head, Department of Medicine, Austin Hospital, Melbourne, VIC. djhATanzac.edu.au
In reply: We thank Morton for his thoughtful comment that, in addition to monitoring for obstructive sleep apnoea precipitated by testosterone therapy, it may be worthwhile screening for this condition before starting treatment. Symptoms to be sought include daytime sleepiness and partner reports of loud and irregular snoring, especially among overweight men with large collar size.
Obstructive sleep apnoea rises steeply in prevalence with age and causes mild hypogonadotropic hypogonadism, which is rectified by effective continuous positive airway pressure (CPAP) treatment.1 Obesity, depression, cardiovascular disease and other conditions that become more common with age have similar effects. Together, they contribute to the lower blood testosterone levels found in unselected older men, in whom testosterone remains an unproven treatment.2 This condition differs from classical hypogonadotropic hypogonadism caused by hypothalamic or pituitary disorders, which routinely requires lifelong testosterone replacement, and (occurring in a younger population) is rarely associated with obstructive sleep apnoea.
The prevalence of obstructive sleep apnoea precipitated by testosterone treatment remains unclear. A case precipitated by injectable testosterone has been reported,3 while testosterone has potential adverse effects on sleep in older men.4 Clinical experience suggests that, among younger hypogonadal men, obstructive sleep apnoea is a rare idiosyncratic reaction to testosterone, which, like polycythaemia, may be particularly related to supraphysiological blood testosterone levels. However, the prevalence may be higher among older men. Hence, we agree that pretreatment screening is wise (rather than proven) for older men starting testosterone treatment, but is not routinely necessary for young men with classical hypogonadism.
References
- Grunstein RR, Handelsman DJ, Lawrence SJ, et al. Hypothalamic dysfunction in sleep apnea: reversal by nasal continuous positive airways pressure. J Clin Endocrinol Metab 1989; 68: 352-358.
- Liverman CT, Blazer DG, editors. Testosterone and aging: clinical research directions. Washington, DC: Institute of Medicine, The National Academies Press, 2004. i1085568
- Sandblom RE, Matsumoto AM, Scoene RB, et al. Obstructive sleep apnea induced by testosterone administration. N Engl J Med 1983; 308: 508-510. CBBEBCJF
- Liu PY, Yee BJ, Wishart SM, et al. The short-term effects of high dose testosterone on sleep, breathing and function in older men. J Clin Endocrinol Metab 2003; 88: 3605-3613. CBBFBBCF