Chapter 9 258 months of GAHT. We used exploratory factor analysis (EFA) to assess possible symptom clusters of depressive symptoms, which indicated clusters of mood, anxiety, lethargy and somatic symptoms. We then compared total depressive symptom severity and symptom severity of each cluster between baseline and follow-up measurements. After 12 months of GAHT, participants using feminizing GAHT reported a relative increase in total depressive symptoms compared to participants using masculinizing GAHT. Furthermore, changes in cluster scores indicated transient reductions in lethargy in those using masculinizing GAHT and increases in low mood symptoms in those using feminizing GAHT. 1.2 Sex hormones and sleep In Chapter 2, we also examined differences in insomnia symptoms between OC users and naturally cycling women. The findings of this study showed that OC use was associated with more insomnia symptoms and specifically with more awakenings during the night and early morning. In Chapter 5, we further studied the association between OC use and subjective sleep and we extended the comparison by also including men. The study findings in this chapter did not replicate the findings in Chapter 4, since we found no increase in reported sleep disruptions in OC users compared to naturally cycling women. Analyses examining the associations between sleep and cortisol dynamics showed that in OC users and men, healthy cortisol dynamics (e.g. a higher cortisol awakening response) were associated with a lower probability of disrupted sleep (in OC users) and with better sleep quality (in men), but there were no significant associations between cortisol dynamics and sleep in naturally cycling women. In Chapter 5, we examined subjective sleep before and during the first 12 months of GAHT use. Neither use of masculinizing nor feminizing GAHT resulted in clinically significant changes in insomnia or sleep quality during the first year of GAHT use, although masculinizing GAHT was associated with slightly poorer sleep and feminizing GAHT with a slightly shorter SOL. Furthermore, we found that feminizing GAHT users reported more insomnia Research question 2: Are OC use and GAHT use associated with changes in sleep?
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