Obstructive sleep apnea can adversely affect reproductive function (106), and one study found that androgen therapy can precipitate sleep apnea (107). An observational study reported a high prevalence of obstructive sleep apnea in men on hemodialysis and examined whether testosterone ester injections are causative (108). Sleep apnea symptoms were common (12/29, 41%), particularly in those receiving regular testosterone enanthate injections (250 mg/wk) to stimulate erythropoiesis (9/12, 75%), compared with those not receiving testosterone (6/17, 35%). However, withdrawal of testosterone did not alter the signs or symptoms of sleep apnea in the five men studied both during and 2 mo after cessation of testosterone treatment. Further surveillance has shown that sleep apnea is common in patients with chronic renal failure even before commencement of dialysis or testosterone treatment (109). Hence, the contribution of pharmacological androgen therapy to breathing while asleep (and consequently on daytime wakefulness) remains conjectural with the limited data from well-controlled studies of androgen therapy on sleep and breathing. One randomized, double-blind, placebo-controlled study examined healthy men (with normal renal function) over the age of 65 yr with low baseline serum testosterone levels. Of the 108 men randomized to receive transdermal testosterone or placebo for 36 mo, sleep breathing patterns determined by a portable device were not worsened by testosterone, but formal sleep studies were not performed (110). Although this indicates that androgen replacement therapy in older men does not regularly induce severe sleep apnea, more modest, or infrequent idiosyncractic, effects are not fully excluded, nor are the effects of higher androgen doses clear (111).
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