Associations between sex hormones, sleep problems and depression 235 Lee et al. (2000) showed that women with lower luteal progesterone (because of anovulation) had worse mood scores in the luteal phase compared to their own follicular phase, as well as compared to the high progesterone/ovulatory group. Freeman et al. (2004) found that higher estrogen levels were associated with more depressive symptoms, although their method included long-term changes in estrogen instead of short term changes as reported by Baker et al. (2012) and Shechter et al. (2012). Thus, depressed participants do not seem to have different absolute sex hormone levels than control participants. There are indications, however, that changes in sex hormones, specifically progesterone and estrogen, over time could be accompanied by increasing depressive symptoms. 3.9. Hormone intervention results Ben Dor et al. (2013) suppressed both estrogen and progesterone levels which was subsequently associated with an increase in reported sleep difficulties. In the study of Ben Dor et al. (2013) suppression of both progesterone and estrogen was related to a small increase in depressive symptoms of the participants. Gingnell et al. (2013) only included women who previously experienced side effects from the oral contraceptive pill (88% of participants reported depressive mood and 20% reported disturbed sleep as previous side effects). They used a double-blind placebo-controlled setup and showed that the contraceptive pill, but not placebo, had significant negative effects on sleep and depression in the treatment group. Toffol et al. (2019) showed that symptoms of insomnia are more likely after starting hormonal contraceptives (after controlling for whether the contraceptive method was short term, like the pill, or long term, like an IUD or implant). They also found an increase in odds for self-harm, with 6 out of 68 women (9%) reporting self-harm behavior after starting hormonal contraception, while none of the women in the other groups reported self-harm. All self-harm reporting participants reported some psychological symptoms at baseline, with 2 out of 6 having a previous psychiatric diagnosis. Thus, both suppression of endogenous sex hormones as well as OC use has been associated with an increase in reported sleep problems and sometimes to increased depressive symptoms. Whether these effects are caused by the exogenous hormones in
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