Appendix 300 feminizing sex hormones have different effects on depressive symptoms, although we find only small to modest changes. Are OC use and GAHT use associated with changes in sleep? Oral contraceptives In Chapter 2 and Chapter 4, we examined the possible effects of OCs on sleep. In Chapter 2, we examined insomnia symptoms in the participants from the NESDA study. Our findings in this chapter show that participants who were using OCs reported slightly more insomnia symptoms than participants who were naturally cycling, especially waking up during the night and early in the morning. We further investigated this in Chapter 4, in which we examined sleep in participants from the Danish Cimbi database. In this study, we compared whether women using OC, women who were naturally cycling and men reported differences in sleep quality or sleep disruptions. Our results show that women on OC reported slightly poorer sleep quality than naturally cycling women and men, but we found no other differences in subjective sleep. We also examined whether differences in sleep were associated with levels of cortisol measured in saliva. Cortisol has a diurnal rhythm: it peaks in the morning, with a spike 30 to 45 minutes after awakening. This peak is also called the “Cortisol Awakening Response” or CAR. Our study found that in women on OCs and in men, the CAR was associated with sleep: women on OCs with a higher CAR woke up less often at night, and men with a higher CAR had better sleep quality. We found no correlation between sleep quality or sleep disruptions and CAR in women who were not using OCs. Altogether, we find that use of OCs could possibly have very small effects on sleep, and that this could be related to the daynight rhythm of the hormone cortisol. Gender-affirming hormone therapy In our studies examining GAHT and sleep, we focused on three components of sleep: subjective sleep, sleep architecture and chronotype. In our study on subjective sleep in Chapter 5, we prospectively investigated sleep quality and insomnia symptoms in transgender participants from the ENIGI study at the start of GAHT, and after 3, 6, 9 and 12 months of GAHT. Our study results show that poor subjective sleep (such as difficulties falling asleep, sleep disruptions or insufficient sleep duration) did not change after starting GAHT. However, participants who started feminizing hormones fell asleep
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