General introduction 29 Thesis outline Section 1: Are OC use and GAHT use associated with changes in depressive symptoms? In this first section, we studied the relationship between OC use and GAHT use and depressive symptoms. In Chapter 2, we investigated depressive symptoms and mood disorders in a subgroup of participants from the NESDA study. We grouped all measurements from reproductive-age women who were either naturally cycling or using OCs, and assessed differences in depressive symptoms, atypical depression symptoms and mood disorder diagnoses between the groups. Due to the prospective data collection setup, we also assessed within-participant and between-participant associations with OC use. The assessment of within- and between-participant effects provided new insights into population effects and the healthy user bias in studies on OC use. In Chapter 3, we assessed depressive symptoms before and after 3 and 12 months of GAHT in the RESTED and ENIGI studies. We conducted an exploratory factor analysis to assess which depressive symptoms formed symptom clusters. Then, we assessed changes in depressive symptom clusters after 3 and 12 months of GAHT use, to determine the effect of GAHT on depressive symptomatology. Section 2: Are OC use and GAHT use associated with changes in sleep? In Chapter 2, we investigated insomnia symptoms in the aforementioned subgroup of participants from the NESDA study who were either naturally cycling or using OCs, and we assessed differences in insomnia symptoms between the groups. In Chapter 4, we used data from the Cimbi database to assess subjective sleep disturbances, sleep quality and their association with cortisol dynamics in naturally cycling women, oral contraceptive users and men. We tested whether oral contraceptive users and men were less or more likely to report sleep disturbances compared to naturally cycling women, and we assessed differences in sleep quality. Additionally, we tested whether the associations between the cortisol awakening response and sleep disturbances or sleep quality differed between the groups. In Chapter 5, we used data from the ENIGI study to assess changes in subjective sleep, including sleep quality and insomnia symptoms, in transgender persons during the first year of GAHT use. In Chapter 6, we used sleep EEG measurements from the RESTED study to assess whether sleep EEG, including total sleep duration, sleep onset latency, wake after sleep onset,
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