HJAR Jan/Feb 2023

HEALTHCARE JOURNAL OF ARKANSAS I  JAN / FEB 2023 47 Ken Mitchell, MPAS, PA-C Arkansas Urology the “STOP-Bang” questionnaire to evalu- ate a patient’s risk for sleep apnea, awarding one point for each of the following items to which the patient answers yes: • Snoring? Does the patient snore loud enough to be heard through a closed door? • Tired? Does the patient often feel fa- tigued or tired during the day? • Observed? Has anyone in their house- hold witnessed an episode in which the patient appeared to stop breathing or gasp for air during sleep? • Pressure? Does the patient have high blood pressure, or are they being treat- ed for high blood pressure? • BMI? Is the patient overweight, with a BMI more than 35 kg/m2? • Age? Is the patient over 50 years old? • Neck? Does the patient have a neck circumference greater than 16 inches? • Gender? Is the patient male? 3 Those with a STOP-Bang score of more than five are considered at high risk for moderate to severe obstructive sleep ap- nea. If a patient with a STOP-Bang score of >5 presents with low-libido or erectile dysfunction, it could be caused by testos- terone deficiency due to untreated sleep apnea. The American Urology Association classifies low testosterone as less than 300 nanograms per deciliter in adult men. 4 Ar- kansas Urology has a full range of services to test for and treat low testosterone and erectile dysfunction. Both low testosterone and fatigue can potentially cause erectile dysfunction in- dependently. Couple that with reduced libido due to low testosterone and the overwhelm- ing sense of exhaustion those withmoderate to severe OSA can have while awake, espe- cially in the evening, and the condition can play havoc with both the desire and physical ability to engage in sex. But by considering and investigating pa- tients’ sleep quality and history while keep- ing in mind the potential link between OSA, ED, and lower testosterone, physicians can help patients get the treatment they need for OSA. That may not only potentially boost testosterone and give themmore energy to engage in sex, it could lead to much better health overall. n REFERENCES 1 American Academy of Sleep Medicine. “Rising prevalence of sleep apnea in U.S. threatens pub- lic health.” Press Release (Sept. 29, 2014). https:// aasm.org/rising-prevalence-of-sleep-apnea-in-u- s-threatens-public-health/ 2 Luboshitzky, R.; Herer, P.; Levi, M.; et al. “Rela- tionship between rapid eye movement sleep and testosterone secretion in normal men.” Journal of Andrology 20, no. 6 (November-December 1999): 731-7. PMID: 10591612 3 Chung, F.; Abdullah, H.R.; Liao, P. “STOP-Bang Questionnaire: A Practical Approach to Screen for Obstructive Sleep Apnea.” Chest 149, no. 3 (March 2016): 631-8. doi: 10.1378/chest.15-0903 4 Mulhall, J.P.; Trost, L.W.; Brannigan, R.E.; et al. “Evaluation and Management of Testosterone Deficiency: AUA Guideline.” Journal of Urology 200, issue 2 (Aug. 1, 2018): 423-432. https://doi. org/10.1016/j.juro.2018.03.115 Ken Mitchell, MPAS, PA-C joined Arkansas Urology in 2021, re-entering clinical practice after serving on the faculty at Meharry Medical College in Nashville, Tennessee. He is a certified physician assistant with over 26 years of clinical experience overall and 24 years in men’s health. The OSA/ED/low-T link Deep, uninterrupted sleep is essential to good health. Rapid eye movement (REM) sleep cycles make up about 20 to 25% of a normal night’s sleep. Not only are REM pe- riods the point in our sleep cycle when we usually have dreams, the first 1-to-5-minute REM cycle, which occurs about an hour to an hour and a half after we fall asleep, is usually when testosterone production peaks in men. A 1999 study that sampled testosterone levels in six healthy men every 15 minutes between dusk and dawn found that testos- terone production was at its lowest when subjects were awake. The moment they fell asleep, however, testosterone levels began to increase, climbing until their first REM cycle. Levels remained elevated until the subjects woke the next morning. 2 Men who experience the fragmented, un- satisfying sleep characteristic of OSA may never reach REM, when most testosterone is produced. That’s believed to be part of the reason why serum testosterone has been shown to be lower in men diagnosed with OSA. Put it into practice If a male patient complains of chronic fa- tigue, loss of libido, or erectile dysfunction, be sure to investigate the possibility that these symptoms might be linked to undi- agnosed sleep apnea. That’s especially true for patients who are older or obese. The American College of Cardiology and other organizations suggest what’s called