Chapter 9 284 exacerbation of symptoms could consider treatments that regulate the hormone fluctuations in the menstrual cycle, as discussed in point 3. 3. Personalized strategies using hormone therapy In patients in whom there is a possible effect of sex hormones on their mental health, it can be useful to discuss this with a general practitioner or gynecologist to explore possible additional hormonal treatment options. In patients who experience possible hormonal contraceptive-related side effects, alternative contraceptives could be considered. For transgender persons who use GAHT and who experience mental health problems, collaboration with the gender-affirming treatment provider (most commonly endocrinologists or gynecologists) could be relevant to optimize hormone levels, dosages, and administration methods to ensure optimal hormone levels. 5. Conclusion Within this thesis, we examined whether the use of exogenous sex hormones affects depression and sleep. Our results show that both oral contraceptives and gender-affirming hormones affect depression, although we find modest effects. We found differences in the forms of genderaffirming hormones: masculinizing hormones temporarily reduced lethargy and possibly reduced depressive symptoms, whereas feminizing hormones increased low mood and possibly increased depressive symptoms. The results also show that oral contraceptives affect subjective sleep quality and insomnia symptoms, but these effects are modest. Oral contraceptive users show reduced cortisol awakening response, and oral contraceptive users with a lower cortisol awakening response also showed more disrupted sleep. GAHT did not significantly change insomnia or sleep quality. GAHT did affect sleep architecture, but the effects differ between the forms of GAHT: we find changes in slow-wave sleep and REM sleep after masculinizing hormone use, but no changes after feminizing hormone use. Genderaffirming hormones also affect sleep timing in both groups, with those using masculinizing hormones preferring a later bedtime after 3 months of gender-affirming hormones and those using feminizing hormones preferring an earlier bedtime after 3 months of gender-affirming hormones. Lastly, our
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