Sex hormones, insomnia, and sleep quality: Subjective sleep in the first year of hormone use in transgender persons

Changes in affect variability after starting gender-affirming hormone therapy

Negative affect variability is determined by how often and how strongly negative affect changes over time. Cisgender women report greater variability in affect than cisgender men. It has been suggested that sex hormone changes may influence affect variability. Transgender people frequently opt to use sex hormones in the form of gender-affirming hormone therapy (GAHT), but the extent to which GAHT can change negative affect variability is not yet clear. Therefore, this study aims to study changes in negative affect variability after starting GAHT. We have included data from 92 participants from the RESTED study: 47 persons starting masculinizing hormones (MH), i.e. testosterone, and 45 persons starting feminizing hormones (FH), i.e., estrogens and anti-androgens. Participants completed up to 7 consecutive daily diaries at each of three time points: before starting GAHT, and after 3 and 12 months of GAHT. The daily diaries collected participants' reports on symptoms related to negative affect: experienced low mood, less interest, tense feelings and restless feelings. We have used linear mixed models to compare negative affect variability during one week, corrected for mean negative affect, between groups (MH versus FH) and measurement time points. Results show that in the MH group, variability in tense feelings and restless feelings decreased after 3 and 12 months of GAHT, respectively. In the FH group, variability in low mood increased after 3 months and 12 months of GAHT, as did variability in restless feelings after 12 months of GAHT. Group comparisons indicate significant group differences in changes in variability in low mood and restless feelings, with stronger increases in variability of negative affect in the FH group compared to MH group after 3 and 12 months of GAHT. Our findings indicate that variability patterns in negative affect in transgender persons change after starting GAHT, with participants who start masculinizing hormones moving to a profile which more closely resembles that of cisgender men and participants who start feminizing hormones moving to a profile which more closely resembles that of cisgender women. Future studies should focus on measuring both negative and positive affect variability during GAHT, preferably through multiple measurements per day, taking into account diverse social and daily contextual factors during GAHT.

Effect of the Interaction Between Depression and Sleep Disorders on Stroke Occurrence: A 17-Year Prospective Cohort Study in Korea

OBJECTIVE

Previous studies have provided inconclusive results on the association between depression and stroke risk, and the potential modifying effect of comorbid insomnia on this association remains unclear. Our study aimed to clarify the independent roles of depression and insomnia as risk factors for stroke and to investigate the possibility of an interaction effect between these two conditions on stroke incidence.

METHODS

We used data from the Korean Genome and Epidemiology Study. The primary exposure was depression, measured by the Beck Depression Inventory. The secondary exposure was insomnia. The main outcome was the occurrence of stroke observed in biennial follow-up surveys. Cox proportional regression analysis was performed to estimate the effects of depression and insomnia on stroke incidence. We also conducted interaction analysis to investigate the interaction between depression and insomnia on stroke incidence.

RESULTS

During 16 years of follow-up involving 3,301 individuals, we documented 172 cases of new-onset stroke (4.3 cases per 1,000 person-years). Cox proportional logistic regression analysis showed that severe depression significantly increased the risk of stroke (hazard ratio [HR]: 2.06, 95% confidence interval [CI]: 1.13-3.75), whereas mild and moderate depression did not increase this risk. Interaction analysis demonstrated that stroke risk was increased with only moderate (HR: 2.04, 95% CI: 1.04-4.00) and severe (HR: 3.01, 95% CI: 1.43-6.31) depression among individuals without insomnia.

CONCLUSION

Although general depression does not significantly increase stroke risk, moderate-to-severe depression may increase this risk, particularly in individuals without insomnia.

The Potential Health Risks and Benefits of Progesterone in the Transgender Woman Population-A Narrative Review

INTRODUCTION

Currently, progesterone is notably absent from conventional feminizing hormone therapies for transgender women. Anecdotal reports indicate the potential for health advantages following the incorporation of progesterone into treatment regimens. The primarily female hormone, progesterone naturally surges in women during the menstrual luteal phase. When administered exogenously, it may expedite bodily changes that are pivotal for gender transition. Progesterone holds promise as a potential remedy for various health conditions prevalent in the transgender woman population.

METHODS

This narrative review synthesizes existing literature and presents a comprehensive account of the administration of exogenous progesterone in transgender women. A literature search was conducted using the PubMed, Embase, ScienceDirect, and ResearchGate databases. The following keywords were used in the search: progesterone, transgender, breast neoplasms, lactation, prostate, testicular neoplasms, and thrombosis. These terms were combined using Boolean operators. The results of the initial search were screened by three independent reviewers based on their relevance to the topic under study.

RESULTS

A total of 104 studies were initially identified as meeting the criteria for inclusion. Following an assessment based on the contents of the title, abstract, and full text, 39 studies were deemed eligible for inclusion. A critical examination of health outcomes was conducted across key sections, including breast development, mental health, lactation, cancer risk (breast and prostate), thrombosis, and nervous and other systems.

DISCUSSION

The use of progesterone in the transgender woman population is a topic that has yet to be sufficiently researched. The limited sample size, short follow-up periods, and lack of randomization restrict the potential for achieving a robust scientific evidence base. In order to gain a fuller understanding of this topic, findings from studies on contraception, hormone replacement therapy, and animal models were considered.

CONCLUSIONS

Progesterone may have a beneficial effect on the bodies of transgender women without significant adverse health effects. Further investigation through well-designed studies is recommended. Randomized controlled trials that include various dosages, broad and long-term effects, and precise demographics are needed. There is an immediate need for more knowledge to create appropriate patent and clinical practice guidelines.

Association between sleep behaviors and stroke in Southwest China: a prospective cohort study

BACKGROUND

Sleep can function as a potential modifiable risk factor in the control and prevention of stroke. Geography significantly influences sleep patterns. The association of sleep with stroke in population of Southwest China has not so far been investigated.

METHODS

A total of 55,001 residents aged from 30 to 79 years in Southwest China were included in this study, obtaining their complete information of baseline survey and follow-up in China Kadoorie Biobank (CKB). Sleep-evaluating score was constructed on the basis of short/long sleep duration, insomnia, and snoring. The multivariate Cox proportional hazards regression was used to analyze the association between sleep behaviors and stroke.

RESULTS

During 11.15 years of follow-up, 3410 stroke cases (572.78 cases/100,000 person-years) were documented. There exists no association of sleep-evaluating score with the risk of stroke in the total population. Male-predisposing association between sleep-evaluating score and risk of stroke was observed (for total stroke, HR = 1.52, 95% CI: 1.03-2.23; for hemorrhagic stroke, HR = 2.31, 95% CI: 1.22-4.34), with anisotropism in male residents with overweight and obesity (HR = 1.93, 95% CI: 1.03-3.63), and those without hypertension (HR = 1.76, 95% CI: 1.01-3.07) in the baseline survey.

CONCLUSIONS

There exists the male-predisposing association between sleep-evaluating score and the risk of stroke in Southwest China. Improving sleep is required for reducing the risk of stroke.

Impact of Gender-Affirming Hormonal Therapy on Cardiovascular Risk Factors in Transgender Health: An Updated Meta-Analysis

Background

Gender-affirming hormone therapy (GAHT) is common among transgender individuals, but its impact on lipid profile and cardiovascular health is not well studied.

Objectives

The authors performed a systematic review and meta-analysis of existing literature to assess the impact of GAHT on lipid profiles and metabolic cardiovascular risk factors in transgender individuals.

Methods

Online databases including MEDLINE/PubMed, Embase, and Cochrane Central registry were searched to find studies on lipid profile changes in women who are transgender, also referred to as transfeminine (TF), and men who are transgender, also referred to as transmasculine (TM) before and after GAHT. Baseline comorbidities were analyzed using descriptive statistics, and R-statistical software was used to analyze the mean difference in lipid profile change between the two cohorts (pre- and post-GAHT therapy) including transgender patients.

Results

Overall, 1,241 TM and 992 TF patients were included from 12 observational studies and 12 randomized controlled trials. The mean age among TM and TF was 28 years and 30 years, respectively. The mean follow-up duration (including pre- and post-GAHT therapy) was 28 months in TM patients and 39 months in TF patients. When compared to baseline measures, TM patients had a significant increase in low-density lipoprotein, triglyceride levels, and total cholesterol while high-density lipoprotein levels decreased. In TF patients, there was a significant increase in triglyceride levels.

Conclusions

GAHT affects lipid profiles in transgender patients; however, additional studies are needed to determine how these changes impact clinical outcomes.

"Escaping the Gender Prison"-Transgender Men's Experience Before and After Hysterectomy: A Qualitative Study

This study aimed to examine the experiences of female-to-male transgendered individuals (FtMs) who underwent gender-affirming hysterectomy (GAH) and to investigate patients' perceptions of GAH and their expectations and support needs from healthcare professionals before and after the surgery. The study used a phenomenological approach and a qualitative research method. Data were collected through in-depth interviews. The sample was selected using diversity sampling, which is one of the deliberate sampling methods. The study included 20 FtMs with a GAH in Turkey between February 2022 and 2023. As a result of the study, participants identified three main themes: experiences with body and gender identity, experiences with health professionals and systems, and mental and physical recovery from surgery. FtMs individuals reported less distress and more happiness after undergoing a hysterectomy. The participants expected health professionals and society to raise awareness, normalize the process, and improve legal procedures. They advocated for legal regulations that address reproductive deprivation and identity issues without surgery and the ability to freeze oocytes before hysterectomy. This study sheds light on the experiences of transgender FtMs before and after GAH. These findings can potentially improve gender-affirming healthcare, particularly in our country.

Chronotype changes after sex hormone use: A prospective cohort study in transgender users of gender-affirming hormones

Chronotype, an individual's preferred sleep-wake timing, is influenced by sex and age. Men sometimes report a later chronotype than women and older age is associated with earlier chronotype. The sex-related changes in chronotype coincide with puberty and menopause. However, the effects of sex hormones on human chronotype remain unclear. To examine the impact of 3 months of gender-affirming hormone therapy (GAHT) on chronotype in transgender persons, this study used data from 93 participants from the prospective RESTED cohort, including 49 transmasculine (TM) participants starting testosterone and 44 transfeminine (TF) participants starting estrogens and antiandrogens. Midpoint of sleep and sleep duration were measured using the ultra-short Munich ChronoType Questionnaire (µMCTQ). After 3 months of GAHT, TM participants' midpoint of sleep increased by 24 minutes (95% CI: 3 to 45), whereas TF participants' midpoint of sleep decreased by 21 minutes (95% CI: -38 to -4). Total sleep duration did not change significantly in either group. This study provides the first prospective assessment of sex hormone use and chronotype in transgender persons, showing that GAHT can change chronotype in line with cisgender sex differences. These findings provide a basis for future studies on biological mechanisms and clinical consequences of chronotype changes.

Screening for sleep apnoea risk in testosterone-treated transgender men

Introduction

Obstructive sleep apnoea (OSA) is more prevalent in men. Several studies suggested that higher testosterone levels were associated with a greater risk of OSA. We aimed to determine whether testosterone administration in transgender men would accentuate symptoms of OSA.

Methods

The study involved 94 adult people undergoing a female-to-male transition with testosterone administration. The participants answered the Berlin Questionnaire (BQ) and a separate question on snoring before starting testosterone treatment and after at least 1 year of being on testosterone treatment.

Results

A higher proportion of participants at the follow-up answered positively to the first category of BQ devoted to snoring. A lower proportion of participants at follow-up answered positively to the second category of BQ devoted to tiredness. The percentage of subjects with a high risk of sleep apnoea, according to BQ, and of those who answered the question on snoring positively did not change significantly.

Conclusion

An increased number of transgender men who reported snoring in BQ after testosterone administration indicate a higher risk of OSA development.

Influence of sex hormone use on sleep architecture in a transgender cohort

STUDY OBJECTIVES

Sex differences in sleep architecture are well-documented, with females experiencing longer total sleep time, more slow wave sleep (SWS), and shorter Rapid Eye Movement (REM) sleep duration than males. Although studies imply that sex hormones could affect sleep, research on exogenous sex hormones on sleep architecture is still inconclusive. This study examined sleep architecture changes in transgender individuals after 3 months of gender-affirming hormone therapy (GAHT).

METHODS

We assessed sleep architecture in 73 transgender individuals: 38 transmasculine participants who started using testosterone and 35 transfeminine participants who started using estrogens and antiandrogens. Sleep architecture was measured before GAHT and after 3 months of GAHT for 7 nights using an ambulatory single-electrode sleep EEG device. Changes in sleep architecture were analyzed using linear mixed models, and non-normally distributed outcomes were log-transformed and reported as percentages.

RESULTS

In transmasculine participants, SWS decreased by 7 minutes (95% CI: -12; -3) and 1.7% (95% CI: -3%; -0.5%), REM sleep latency decreased by 39% (95% CI: -52%; -22%) and REM sleep duration increased by 17 minutes (95% CI: 7; 26) after 3 months of GAHT. In transfeminine participants, sleep architecture showed no significant changes after 3 months of GAHT.

CONCLUSIONS

Sleep architecture changes after 3 months of masculinizing GAHT in line with sleep in cisgender males, while it shows no changes after feminizing GAHT. The sex-specific nature of these changes raises new questions about sex hormones and sleep. Future research should focus on studying possible underlying neural mechanisms and clinical consequences of these changes.