Chapter 5 136 Studies on the influence of sex hormone interventions on sleep also show possible sex hormone-induced changes in sleep quality. In cisgender women, an experimental suppression of sex hormone production through administration of gonadotropin-releasing hormone (GnRH) analogs, led to decreased sleep quality (Ben Dor et al., 2013). These effects were unrelated to the mood disturbance effects of the GnRH intervention (Ben Dor et al., 2013). Studies also suggest that oral contraceptives, which most commonly contain exogenous estrogens and progestogens and suppress sex hormone endogenous fluctuations, can increase reported insomnia symptoms (Bezerra et al., 2020; Morssinkhof et al., 2021). On the other hand, the reinstatement of stable sex hormone levels during perimenopause through hormone replacement therapy (HRT), which is a regimen of both estrogens and progestogens, seems to improve sleep quality (Silva et al., 2011). In cisgender men, suppression of testosterone production seems to decrease sleep quality, since it increases sleep onset latency and decreases deep sleep (Leibenluft et al., 1997). In hypogonadal cisgender men with poor sleep, results still seem inconclusive: testosterone replacement therapy seems to improve sleep quality (Shigehara et al., 2018) and shorten sleep duration (Liu et al., 2003), but studies on testosterone use and sleep are still scarce. One limitation of many studies on sex hormones and sleep is that they have mainly included participants who are hypogonadal or going through perimenopause, meaning their endogenous hormone levels are already low or changing and it is difficult to generalize these findings to the wider population (Morssinkhof et al., 2020). Therefore, knowledge of the effects of sex hormones on sleep so far has been limited. The effects of sex hormone use can be studied in transgender persons who use gender-affirming hormone therapy (GAHT). In contrast to cisgender persons, transgender persons experience an incongruence between their sex assigned at birth and their gender identity. Many transgender persons seek treatment with GAHT in order to align their physical features with their identified gender. Generally, the use of GAHT is associated with improved body image and quality of life (van Leerdam et al., 2021). Trans men, who were assigned female at birth, can be prescribed masculinizing hormones, most commonly a form of testosterone. Trans women, who were assigned male at birth, can be prescribed feminizing hormones, often consisting of a form of estrogen combined with anti-androgens. Sleep problems are common in the transgender population: up to 80% of transgender persons
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