Chapter 8 238 Both suppression of endogenous sex hormones with leuprolide as well as administration of exogenous hormones through hormonal contraceptives showed negative effects on sleep quality and an increase in depressive symptoms, although the effect sizes varied strongly (Cohen’s d in Toffol et al.: 0.12; in Ben Dor et al.: 58.3) or were calculated from a specific sample that is not easily generalized to the general population (Gingnell et al. tested only women who experienced side effects from OC before; Cohen’s d: 0.66). Two out of the three administration studies showed indications that not all women, but a subgroup of women may be vulnerable to these effects. Toffol et al. (2019) found that women who showed self-harm behavior after starting hormonal contraceptives all reported negative psychological symptoms before starting the hormonal contraceptives. Gingnell et al. (2013) only included women who had previously experienced depressive symptoms while using hormonal contraceptives, and found that, even in a placebo-controlled setup, women who were provided hormonal contraceptives experienced significant depressive mood and disturbed sleep. This suggests that women with a history of psychological problems and women with previous depressive symptoms during hormonal contraceptives use may have an increased risk for developing psychological problems when starting hormonal contraceptives. Interestingly, the studies comparing sleep controls with women who suffer from PMDD, a hormone-related mood disorder seem to show the opposite of the sleep changes that have been found in persons with major depressive disorder. Women with PMDD show more SWS whereas depressed people have less SWS in comparison to healthy controls; women with PMDD have longer and more prominent delta band activity (indicating more deep sleep) whereas depressed people show a decrease in delta activity; in women with PMDD, as well as the women in Lee et al. (2000), a longer REM latency predicts worse mood, whereas in depression a shorter REM latency is seen. These findings suggest that PMDD is not a periodic ‘worsening’ of depression, but may be a truly different disorder with respect to sleep architecture. 4.2. Limitations The studies included in this systematic review have several methodological limitations.
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