Influence of sex hormone use on sleep architecture in a transgender cohort 169 Thus far, the effect of GAHT on sleep architecture is unclear. Only one study examined effects of feminizing GAHT in seven transgender women (Kunzel et al., 2011), and they found that participants show more light sleep after 3 months of estradiol and cyproterone acetate. This study, however, was limited both in sample size and in participant selection, since they only included transgender women. Therefore, this study aims to examine the changes in sleep architecture after GAHT use. We examine whether characteristics of sleep architecture (e.g. total sleep time, wakefulness after sleep onset, slow wave sleep duration and frequency, number of arousals, number of awakenings, REM sleep duration and REM sleep latency) change after 3 of either feminizing or masculinizing hormone use. We hypothesize that testosterone use in transmasculine persons is associated with shorter total sleep duration, more wakefulness during the night and more arousals and awakenings, shorter slow wave sleep duration and shorter REM sleep latency, and that estrogen and anti-androgen use by transfeminine persons is associated with longer total sleep duration, less wakefulness during the night and less arousals and awakenings, longer slow wave sleep duration and longer REM sleep latency. 2. Methods 2.1. Study setting Data for this study was obtained within the RESTED study (Relationship between Emotions and Sleep in Transgender persons: Endocrinology and Depression), which is an observational prospective study aimed at studying changes in mood and sleep in transgender hormone users during the first year of GAHT. The RESTED study was conducted within the transgender healthcare clinics of the Amsterdam University Medical Center (Amsterdam UMC) and the University Medical Center Groningen (UMCG) and included participants from January 2020 until September 2022. The RESTED study received a declaration stating that Medical Research Involving Human Subjects Act (WMO) did not apply to this data collection (study id: 2019.353). The study was performed in accordance with good clinical practice guidelines and the world medical associations code of ethics (Declaration of Helsinki). All participants provided informed consent for study participation and for use of their medical information for research purposes.
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