How Does Hormone Replacement Therapy Affect Transgender Males? Risk Factors for Sleep

Transgender men (assigned female at birth) undergoing masculinizing hormone therapy may be more prone to obstructive sleep apnea (OSA), a common sleep disorder which causes the throat muscles to intermittently relax, blocking the airway and causing snoring. The long-term effects of low oxygen levels can cause heart problems, diabetes, fatigue and other serious health issues.

What the Research Shows

BlueSleep’s Medical Director, Jordan Stern, MD, has treated transgender men and concluded that testosterone therapy is likely a risk factor for the development of obstructive sleep apnea. Snoring that develops after the onset of masculinizing hormonal therapy may be the only sign that there is an underlying obstructive sleep apnea syndrome. Gender and sex hormones impact OSA. Sleep apnea is more common in cisgender males, in postmenopausal females, and in women with Polycystic Ovary Syndrome (PCOS).

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The current prevalence of gender dysphoria in the U.S. is in the range of 0.7% of adults 18-24 years old and 0.5% of adults 65 and older. A recent study has found that the ratio of female to male transgender individuals has increased steadily since 1990 and now equals that of male to female individuals.

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Many aspects of sleep are affected by androgens and estrogens, including the risk for sleep apnea. It is well established that OSA occurs more frequently in men, and that the prevalence of OSA in postmenopausal women is 3.5 times that of premenopausal women. However, the impact of administration of testosterone and estrogens on the development of sleep apnearemains controversial. Many studies have evaluated the role of estrogen and testosterone in both men and women, but no studies have evaluated the role of testosterone treatment in transgender men.

What’s Likely Causing Sleep Apnea?

While hormone therapy is unlikely to change the actual shape of the the airway (trachea, cricoid, thyroid cartilage, and hyoid bone), hormonal treatments can change

the deposition of fat in the body. There are known gender differences in fat deposition in the pharynx and tongue which can increase the risk of sleep apnea by narrowing the breathing passages.

Treatment and Management of Sleep Apnea

BlueSleep diagnoses sleep apnea with a home sleep test and generally prescribes a mandibular oral device (MAD) as primary treatment. The device keeps the airway open during sleep, thereby preventing snoring and improving oxygen levels in the body. Transgender males are at a very high risk for developing sleep apnea during their transition from male to female, and their continued use of testosterone replacement. It is very important that they be evaluated to determine if they are suffering from undiagnosed sleep apnea.

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