What’s the Link Between Erectile Dysfunction And Heart Disease?

February 1, 2013

Erectile dysfunction (ED) is a common condition that’s usually treated by urologists with medications. In the sleep medicine literature, there are numerous studies showing that many men with ED have undiagnosed obstructive sleep apnea (OSA) and that treating OSA can significantly improve or even cure ED. Here’s one of many papers (PDF). Even in my practice, men oftentimes comment that this is a positive side effect of CPAP. 

Here’s another study that reiterates the known association between ED and cardiovascular disease. There’s no mention of sleep whatsoever. We also know that obstructive sleep apnea is a major risk factor for heart disease. It’s frustrating to know that most of these men will never have their obstructive sleep apnea diagnosed or treated.

I’m not saying that all cases of ED are due to OSA. But even if 50% of patients are improved, wouldn’t it be worthwhile looking into this possibility? Not to mention that once you’re able to sleep better, things can begin looking up again :)

How Erectile Dysfunction Can Cause Alzheimer’s

September 28, 2011

Not too surprisingly, focusing on lifestyle habits that control heart disease or taking medications to lower high blood pressure or cholesterol levels can also help symptoms of erectile dysfunction (ED). 

Dr. Stephen Kopecky, professor of medicine and cardiovascular diseases at the Mayo Clinic, and author of the paper published in Archives of Internal Medicine, quotes, “It’s a fascinating thing, but all the arteries are connected. We know that the risk factors for stroke are the same as for heart disease. We know that the risk factors for ED are the same as for heart disease. And we are finding that the risk factors for dementia and Alzheimer’s are the same as for heart disease.”

It’s frustrating that doctors are connecting all the dots, but rarely ever include obstructive sleep apnea as a major component of all these conditions. In this vein, having ED could mean that you’re at higher risk for obstructive sleep apnea, which causes diminished circulation to various parts of the body, including the penis and the brain. You can make a strong argument that everyone with ED should be screened for obstructive sleep apnea. 

What’s your opinion on this issue? Please enter your viewpoints in the text area below.


Nasal Polyps And Erectile Dysfunction: How It May Link To Sleep Apnea

April 21, 2011

I just came across this article showing that treating nasal polyps with sinus surgery can help men with erectile disfunction (ED). My initial reaction was that any type of nasal surgery can help with sleep-breathing problems, whether or not it’s obstructive sleep apnea.

The authors studied 35 patients who were confirmed to have nasal polyps. They excluded anyone with any known risk factors for ED, such as obstructive sleep apnea, diabetes, hypertension, obesity, or any neurologic conditions. All the subjects underwent a validated questionnaire for ED, as well as nocturnal penile tumescence (NPT) testing. Before surgery, 34.5% of these patients had ED based on the validated questionnaires, compared to 3.3% in controls. After surgery, the percent of people with ED dropped to 10.3%. NPT testing improved significantly as well.

Despite the fact the they excluded everyone with obstructive sleep apnea, it’s likely that having nasal congestion potentially aggravated sleep-breathing problems, leading to increased adrenaline levels. Having a stuffy nose causes a vacuum effect downstream in the throat, which allows the tongue to fall back more easily, causing obstructions and arousals. These breathing pauses may not be called apneas, but they can cause deep sleep disruption, leading to inefficient sleep and increased states of physiologic stress. Any type of stress, whether it’s physiologic, emotional, or psychological stress, can aggravate ED by the following mechanism:

Arousal and erection in men is mediated by the parasympathetic nervous system (the relaxation response). Orgasm is activated by the sympathetic nervous system (fight-or-flight response). If there’s too much sympathetic activation, you’re not going to have enough relaxation of the smooth muscle that allows blood to fill up the penis. Relaxing this muscle can be accomplished using medications, relaxation techniques, herbs or supplements.

Add one more option to this list: Better sleep by better breathing.

Viagra, Raynaud’s & Sleep Apnea

March 16, 2011

Viagra is still a popular drug that’s used to treat erectile dysfunction (ED) in men. It works by relaxing smooth muscle in blood vessels, allowing blood to enter the penis. A recent study showed that it can also help people with Raynaud’s phenomenon, where small blood vessels in the hands or feet go into spasm and cause cold or numb extremities, sometimes to the point of infection or even gangrene. This condition is commonly seen with autoimmune conditions, especially in lupus. It makes sense that relaxing smooth muscles that constrict blood vessels may increase circulation. Unfortunately, people taking this medication had a number of side effects.

In my book, Sleep, Interrupted, I describe a young woman who had classic Raynaud’s symptoms, needing to wear socks and mittens to bed even in the summer. After undergoing multilevel upper airway surgery for her mild obstructive sleep apnea, her Raynaud’s disappeared completely! Her depression, low blood pressure, irritable bowel symptoms, and daily headaches improved significantly as well.

There are also numerous studies showing the ED is a common complication of obstructive sleep apnea. One of the more common signs that sleep apnea treatment is working (through CPAP, dental devices or surgery) is that men are having erections again upon awakening in the morning. In many cases, ED resolves completely after sleep apnea treatment.

Not getting deep, high quality sleep is known to cause a physiologic state of stress, leading to too much of an adrenaline response. This results in an inability to relax vascular smooth muscles in various parts of the body, including the hands, as well as the digestive or reproductive organs.

If you have obstructive sleep apnea or upper airway resistance syndrome, it’s a given that your body will be under a constant state of stress. This why why after properly treating these conditions, ED and Raynaud’s often improve. These common conditions are not problems specific to the respective body parts—they are the end result of a systemic problem aggravated by not breathing and not sleeping properly.

These sleep-breathing problems are often treated successfully by alternative and complementary practitioners, since they tend to focus on the whole person, including his or her surroundings, rather than the one specific neurotransmitter, hormone, or body part.

However, taking a pill, whether it’s a prescription medication, vitamin or natural herb, or breathing exercises during the day, won’t solve the problem completely if you’re not able to breathe properly at night.

How many of you have had partial or total resolution of your ED or Raynaud’s after treating your sleep-breathing condition?


Is Your Father Going Through Menopause?

June 8, 2010

Over the past year, ever since the birth of our third son, Brennan, I've been more tired than usual. Not too unexpected when you have a newborn, right? Add to this having to help my wife tend to the needs of our two older boys, who are 7 and 10. But even now when Brennan is sleeping well through the night, and I'm sleeping about 7 hours every night, I'm still more tired than I used to be, despite running 3 times per week, and being as fit as ever. Could I be going through male menopause?

The Facts of Male Menopause

I wrote last month about how mothers can suffer from poor sleep due to the effects of menopause on sleep quality, but what about fathers? You may have heard about male menopause, or more precisely, andropause. It's not that well known, and even if it happens, it's so slow and insidious that most men don't realize it's happening.

Well, it turns out that men go through a similar transition during the mid-life years. Not only does testosterone slowly drop, but thyroid levels as well. Our traditional medical culture and even holistic and alternative doctors sometimes argue that aging is a deficiency of certain hormones, vitamins or minerals, and that replacement using synthetic or natural supplements is the answer. But is  that the only answer?

Most people think that this is a natural part of aging, along with the typical memory loss, balding, wrinkles and lowered energy and stamina. But what if I told you that I routinely see even young to middle aged men who complain about hot flashes, night sweats, mood swings, insomnia and irritability—or all the prevailing symptoms of menopause?

Aging As A Consequence of Poor Sleep

In my book, Sleep, Interrupted, I describe a sleep-breathing paradigm where all modern humans are on a continuum, where we're all susceptible to sleep-breathing problems to various degrees.

As you age, it's expected that overall, you'll keep moving up this continuum to the point where sleep breathing problems become much more serious as in obstructive sleep apnea. Not only do we sag and bulge on the outside as we get older, it also happens on the inside, including your upper airway. And as your airway becomes narrower, the more trouble you'll have breathing while sleeping, and this in turn will make you wake up more and obstruct more.

Women experience more dramatic changes in hormone levels (particularly progesterone) that affect upper airway patency, but levels of testosterone and even small amounts of progesterone can also influence upper airway muscle tone in men as well; Not to mention the typical weight gain that occurs in the middle years, leading to even more narrowing of the upper airway. Adding any degree of inflammation to the upper airway (such as from a cold, allergies, or reflux) can cause more frequent obstructions and arousals. Poor sleep efficiency leads to weight gain, and weight gain narrows the throat.

Sleep Apnea And Aging

It's a given that as you age, your upper airway begins to narrow gradually, aggravated intermittently with additional narrowing from inflammation. This is also why men begin to develop cardiovascular disease as they get older. Women are somewhat protected before menopause, but afterwards, they begin to catch up when it comes to rates of heart disease. As you slowly move up the sleep-breathing continuum, your risk of developing obstructive sleep apnea increases, and once it begins, a vicious cycle begins, where poor sleep aggravates weight gain, and weight gain aggravates poor sleep.

Poor sleep (by causing a physiologic form of stress) also causes major hormonal changes by lowering your thyroid levels, as well as your reproductive hormones. So naturally, if you test for thyroid or testosterone levels, it may come back on the low side. Not too unexpectedly, supplementing with replacement hormones helps in some cases, but not all the time.

We know that untreated obstructive sleep apnea (OSA) can aggravate or cause routine medical conditions such as diabetes, high blood pressure, depression/anxiety, heart disease, heart attack and stroke. Your risk of car accidents also increases anywhere from 3 to 10 times normal if you have OSA. Add to this all the other common expected conditions that you may experience as you get older: frequent bathroom trips, balding, erectile dysfunction, hearing loss, and even Alzheimer's.

Taken at face value these seemingly disparate symptoms of old age aren’t all that unexpected. However, if you look at them from the perspective of my sleep breathing paradigm, you’ll begin to see how it’s your breathing and not necessarily your age that’s making you feel sick and tired.

Too Many Bathroom Trip—Risky For Your Health

It's been shown that going to the bathroom frequently at night is not because you're making too much urine, but because you stop breathing and you think you have to go to the bathroom. One recent study showed that going to the bathroom two or more times per night increases your chances of dying by 50%. There have even been many anecdotal reports of hair regrowth after definitive treatment for sleep apnea. Erectile dysfunction (ED) is a very well-known complication of sleep apnea. Having ED can predict the presence of sleep apnea in the majority of patients.

Brain Damage From Poor Breathing While Asleep

Untreated sleep apnea also increases your chances of microscopic strokes and small vessel blockages in multiple, critical areas of the brain. One recent study showed that sleep apnea patients have 20% smaller brain volume in the Mammary bodies. Another showed smaller brain tissue densities in critical areas of the brain that controls memory, executive function, breathing and respiration. Untreated sleep apnea patients have much more viscous (thick) blood that can stagnate and clot in small vessels in the brain. One area that's particularly sensitive are the small vessels that supply the high-frequency sensing areas of the inner ear.

All these issues begin when you're young, but begin to manifest in your middle years, progressing to full-blown medical complications when you reach your 60’s and 70’s. As you can see, how narrow you upper breathing passageways are determines how quickly you age or how often you become sick. Now that I'm in my mid-40s, if I don't get at least 7 hours of sleep, or if I eat later than usual, I definitely feel worse the next day. This is why it's important to do everything possible to breathe well at night while sleeping, in addition to a healthy lifestyle that includes a good diet, regular exercise and smart decisions when it comes to your sleep.

Sleep Apnea, Restless Legs and Erectile Dysfunction

January 4, 2010

There are studies linking sleep apnea with restless leg syndrome (RLS) and sleep apnea with erectile dysfunction, but now there's a study linking restless leg syndrome with erectile dysfunction. Not too surprising, since sleep apnea seems to be the common denominator for almost every imaginable disease, known or unknown. You may think that this statement is over the top, but you'll have to admit that not breathing well during the day, and especially not breathing well at night while sleeping can potentially lead to or aggravate almost every disease known to man. 


In this particular study, researchers found that men with RLS  had significantly increased risk for having erectile dysfunction (ED) compared with men who did not have RLS. The lead researcher, Dr. Gao, commented that the findings indirectly support the role of dopamine as a common pathway, in light of another study of his in the past that showed an association between ED and Parkinson's disease. He also points out that these same people with ED were more overweight, more prone to depression and anxiety, and had a greater chance of having hypertension or a history of stroke (sound familiar?)


It sounds like dopamine deficiency is a popular explanation for a number of different conditions. For both PLS and Parkinson's, giving dopamine-like agents help with the respective symptoms. The problem is that it never cures the problem completely, with a number of serious side effects. 


This approach to medicine is the replenish what's missing method. If you're deficient in dopamine, replace it. If you're deficient in Vitamin C, B12, or thyroid hormone, replace it. The problem is that this approach works in some people, but not in everyone. Then the next step is to increase the dosage, and then even more people respond, but not everyone (with more side effects). Ultimately, you're not addressing what's causing the deficiency. 


If you have a sleep-breathing problem, it's been shown that you can easily clot in certain small and large vessels of your brain very easily. If you happen to have a clot in the dopamine area of your brain, or if the brain biochemistry changes as a result of hypoxia, then you'll get various symptoms. But I think even the neurologists will tell you that a lack of dopamine itself won't lead to Parkinsons; it's just one part of a much larger picture. Could it be that obstructive sleep apnea may be that bigger picture, since by definition, all modern humans are susceptible to sleep breathing problems to various degrees?


What's your opinion on this? Should we continue to treat every medical condition in isolation hoping to target that one missing protein or gene, or should we step back and try to connect the dots until we see the bigger picture? Please enter your comments in the box below.

Solutions for Your Bed Partner’s Worst Sleep Problem

March 24, 2009

Anthony Burgess, the novelist, once said: "Laugh and the world laughs with you. Snore and you snore alone". Suffice it to say, there’s nothing worse than trying to sleep next to someone who snores.  Snoring is also a common reason why many married couples sleep apart. Besides the whole host of health problems that snoring is associated with, like high blood pressure, heart disease, diabetes, snoring is even linked to erectile dysfunction in men (see our feature article: What the Makers of Viagra Missed). Fortunately, snoring is something you can get rid of. The problem is in knowing how.

Why Snore?

Snoring is probably one of the most frustrating conditions not only for the snorer, but for spouses and bed-partners as well. It’s also one of the least understood medical conditions by most doctors. One of the main reasons for this is that there are a lot of myths perpetuated both by the media and pop culture about snoring. It’s oftentimes seen as something of a farce. The truth is, however, snoring is a sign that the person who snores is most likely struggling to breathe at night, and therefore, is at a much higher risk of having a heart attack or stroke.

Moreover, textbooks and internet resources further mislead people to think that snoring originates at the soft palate, since that’s where most of the vibrations occur. However, the soft palate doesn’t flutter all by itself: the nose as well as the tongue can be involved. Even most doctors focus way too much attention on the soft palate.

The challenging part of eliminating snoring is in figuring out what’s actually causing the snoring. The vibrations of the soft palate is only the end result and not, as many people think, the thing that causes the snoring. Imagine your upper airway as a long, thin tube that has three main areas that can either narrow or collapse when a slight vacuum pressure is applied. Like a flimsy straw that would collapse in the middle if you pinch the tip, or would collapse at one end if you pinched the middle, your airway is also affected by how well you can breathe through your nose not to mention how tone or relaxed your muscles become as you drift off in to deep sleep. Gravity can also play a part in obstructing your airway, since your tongue, as well as the excess tissues around the back of your throat can naturally fall back partially obstructing the airway, as you lie down on your back to go to sleep.

It’s All In Your Jaw Size

Another major factor that determines how well you breathe at night, or how susceptible you are to snoring, is the size of your jaws. It’s been shown that modern human’s jaws are slightly smaller than what we had hundreds of years ago. Various reasons are proposed, but one major reason is thought to be due to a major change in our diets. (For a more complete description of this process, take a look at my book, Sleep, Interrupted: A physician reveals the #1 reason why so many of us are sick and tired.) If your jaw is slightly smaller, then your tongue which grows to its’ normal size, takes up too much space, sitting higher and more backwards in your throat.  As a result, when you lay flat on your back, due to gravity, your tongue will fall back partially, and when you breathe in, a mild vacuum effect is created upstream at the palatal level, which constricts the soft palate closed, which then causes the free edge of the soft palate to flutter and vibrate causing the snoring noise. On the other hand, if your nose is stuffy for any reason, then a vacuum effect is created downstream, which forces the palate and the tongue to slide backwards towards the airway making it narrower and therefore creating sounds we call snoring when the air seeps through the small opening. So this is how a simple cold or an allergy attack can aggravate temporary snoring.

Furthermore, if your muscles relax more than usual (like after alcohol ingestion), then you may even stop breathing altogether. In this circumstance, if these breathing pauses last longer than 10 seconds, then it’s called an apnea (or loss of breath). In those people who have 5 or more of these apneas every hour on average, then are diagnosed with a serious sleep breathing condition called obstructive sleep apnea. Untreated obstructive sleep apnea can then lead to depression, anxiety, weight gain, diabetes, sexual dysfunction, high blood pressure, heart disease, heart attack and stroke.

The really bad news for snorers is that a significant number of heavy snorers have obstructive sleep apnea (about 30-40%, and much higher as you get older or heavier). It’s true that not all snorers have sleep apnea, and not all people with sleep apnea snore. However,  if you’re not snoring, then you may also not be breathing. It’s also been shown that neither you nor your bed-partner can tell if you stop breathing—it can just be silent pauses, without any audible gasping, coking or snorting. When some people say, I used to snore a lot, and now I don’t anymore, but I’m still tired, then there’s cause for alarm since even those that state with certainty, "I know I don’t have sleep apnea" are more often than not, wrong.

What Can I Do To Stop The Snoring?

So, once you’ve found out where the snoring is coming from, the next step to solving your snoring problem is to find the right solutions. Of course you can start by doing the most obvious like:

    • lose weight
    • don’t drink alcohol before bedtime
    • don’t take any medications that are sedating or relaxing
    • sleep on your side
    • sew a sock stuffed with a tennis ball to behind your back to prevent sleeping on your back.
    • use nasal dilator strips.

Sometimes, any of these options may work to various degrees, but for most, the problem will usually come back. The most important issue here, however, is that if you snore heavily, you have to find out if you have obstructive sleep apnea. Even if you are successful in covering up your snoring, you could still have untreated obstructive sleep apnea. And if this is the case, you’re putting yourself at serious risk for heart disease, heart attack and stroke. The best thing to do to avoid this from happening is to see a sleep doctor and undergo an overnight sleep study if you snore.

If you are found to have obstructive sleep apnea, then treating this condition definitively should take care of your snoring. Not only will your snoring improve, you’ll also feel much better in the morning, and have much more energy during the day. In addition, your increased risk for many chronic health problems mentioned above will be improved as well. You may also lose weight. (you may even feel like having sex again-see What the Makers of Viagra Missed).

So lets say that you don’t officially have sleep apnea. What can you do? Before I go into this discussion, sleep apnea is not something that you either have or don’t have. Everyone is on a continuum. As mentioned before, if your AHI is 5.1, you’re told you have it, whereas if your score is 4.9, do don’t have it, and because you don’t officially meet the formal criteria, it’s not a good enough to cause to ignore your snoring. It’s still a problem that should be addressed as it can make you lose sleep, not to mention put a damper on your love life in more ways than one. 

All Those Snoring Treatments

There are over 300 patented devices and gadgets for snoring (refer to ). Sometimes they work, but with a few exceptions, most of these devices either cover up your snoring without getting to the root cause of your condition, or keeps you awake so that you don’t snore. Three popular anti-snore aids were recently tested for effectiveness in a prospective study: a throat spray, nasal dilator strips and a pillow. None of these three were found significantly better than controls when tested prospectively. There are even devices that wake you up as you enter deeper levels of sleep to prevent muscle relaxation. Regardless of what treatment options you choose, it’s imperative that you first get a proper evaluation from a sleep specialist or a medical professional about your snoring. Doing so could not only help with the snoring, it can help you foster a healthy relationship with your loved ones.

The Male Menopause Myth

October 28, 2008

It’s commonly known that women going through menopause experience hot flashes, night sweats, moods swings, irritability, insomnia and weight gain, but these same symptoms are known to occur in men as well. They generally occur in men in their 40s to 50s, thought to be due to slowly decreasing testosterone levels, along with other symptoms such as loss of sexual desire or functioning, depression, memory loss, or chronic fatigue.

But what if I told you that I see young men in their 20s coming in to see me with the same exact problems? What I’ve discovered is that it’s really not mainly a hormonal issue, but a problem with their breathing. Let me explain.

What I’ve noticed in all these young men is that they all have in common a relatively narrow upper airway. When examined with a thin flexible camera, the space behind their tongues is very narrow, about 2-3 mm wide. This is mainly due to smaller jaw structures and dental crowding. Whenever someone with this anatomy starts to fall asleep, his tongue muscle starts to relax, and in deeper levels of sleep, it relaxes almost completely, leading to partial obstruction, and awakening. Once awakened, the man turns over. In most cases, they usually don’t like to sleep on their backs for this reason.

Most people compensate very well by sleeping only on their sides or stomachs. However, if there’s anything that narrows the upper airway, either due to inflammation (allergies or a cold), or structurally (fat), the tongue collapses much easier and the person gets less efficient sleep due to multiple arousals.

Inefficient sleep leads to an imbalance of the involuntary nervous system, leading to what are called "vasomotor" conditions, such as sweating, heart palpitations, and temperature fluctuations. So is a young man with a predisposed anatomy is slowly gaining weight, he may experience all the above "male menopause" symptoms.  If these obstructions last for more than 10 seconds, they are called apneas.

If you have more than 10 to 15 apneas every hour, then you may be diagnosed with obstructive sleep apnea. Untreated obstructive sleep apnea can lead to depression, anxiety, weight gain, erectile dysfunction, memory problems, hypertension, glucose intolerance, going to the bathroom often, heart disease, heart attack and stroke. The physiologic stress state that’s created also can lower one’s thyroid and testosterone levels, making it seem like he may have either hypothyroidism or low testosterone. 

So in a sense, the "male menopause" phenomenon does happen, but not for the reasons that you may think. The word menopause literally means cessation of menses. Since men don’t have periods, this is not an appropriate word. Instead, it should be renamed something alluding to the progression of a sleep-breathing disorder. Do you have any of these symptoms or know anyone who’s going through "male menopause"?

The material on this website is for educational and informational purposes only and is not and should not be relied upon or construed as medical, surgical, psychological, or nutritional advice. Please consult your doctor before making any changes to your medical regimen, exercise or diet program. Some links may go to products on Amazon.com, for which Jodev Press is an associate member.

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