【特刊综述】男性睡眠障碍和睾酮的关系

The relationship between sleep disorders and testosterone in men

血浆睾酮水平呈现昼夜节律变化，睡眠时达高峰，午后降至最低，伴随一个叠加的具有反映黄体生成素（LH）脉冲式分泌基础节律的每90分钟一次脉冲的超昼夜节律。能促进睾酮增加的是睡眠而不是昼夜节律，依赖并需要至少三个小时正常结构的睡眠。多种睡眠障碍包括睡眠质量、持续时间异常、昼夜节律紊乱、睡眠呼吸障碍可能会导致睾酮水平下降。睡眠限制或昼夜节律紊乱不依赖于性激素结合球蛋白而直接影响睾酮的证据或共存疾病的存在是模棱两可的，总的看起来证据不足。在对年龄和肥胖进行调整后，阻塞性睡眠呼吸暂停（OSA）看起来似乎对睾酮没有直接影响。尽管如此，也许存在一种潜在的由OSA对肥胖的影响所介导的的间接因果过程。大多数研究中采用持续正压通气（CPAP）治疗中到重度OSA并没有真正提高睾酮水平。相反，体重减轻却的确提高了睾酮水平，并且与体重下降情况成线性比例。睾酮治疗除了具有非常短暂的毒副作用，对OSA并没有不利影响。睡眠质量对睾酮影响的研究数据可能取决睾酮给药是作为替代、超治疗剂量还是在滥用的范围。实验数据显示睾酮可以调节睡眠限制的主观症状的个体易患性。睾酮低下可能会影响整个睡眠质量，给予替代剂量可以得到改善。大剂量外源性雄激素和促进合成或促进雄激素产生的甾体激素滥用与睡眠持续时间和结构异常有关。

Plasma testosterone levels display circadian variation, peaking during sleep, and reaching a nadir in the late afternoon, with a superimposed ultradian rhythm with pulses every 90 min reflecting the underlying rhythm of pulsatile luteinizing hormone （LH） secretion. The increase in testosterone is sleep, rather than circadian rhythm, dependent and requires at least 3h of sleep with a normal architecture. Various disorders of sleep including abnormalities of sleep quality, duration, circadian rhythm disruption, and sleep-disordered breathing may result in a reduction in testosterone levels. The evidence, to support a direct effect of sleep restriction or circadian rhythm disruption on testosterone independent of an effect on sex hormone binding globulin （SHBG）, or the presence of comorbid conditions, is equivocal and on balance seems tenuous. Obstructive sleep apnea （OSA） appears to have no direct effect on testosterone, after adjusting for age and obesity. However, a possible indirect causal process may exist mediated by the effect of OSA on obesity. Treatment of moderate to severe OSA with continuous positive airway pressure （CPAP） does not reliably increase testosterone levels in most studies. In contrast, a reduction in weight does so predictably and linearly in proportion to the amount of weight lost. Apart from a very transient deleterious effect, testosterone treatment does not adversely affect OSA. The data on the effect of sleep quality on testosterone may depend on whether testosterone is given as replacement, in supratherapeutic doses, or in the context abuse. Experimental data suggest that testosterone may modulate individual vulnerability to subjective symptoms of sleep restriction. Low testosterone may affect overall sleep quality which is improved by replacement doses. Large doses of exogenous testosterone and anabolic/androgenic steroid abuse are associated with abnormalities of sleep duration and architecture.