Abstract Introduction Non-24 Hour Sleep Wake Disorder (N24SWD) is rarely observed among sighted individuals. The diagnostic criteria can be summarized as progressive daily delays in sleep–wake timing documented by sleep diaries or actigraphy for at least 14 days, with symptoms persisting for ≥ 3 months and sleep disturbance not better explained by another condition. Limited literature describes circadian rhythm disorders in transgender populations. We present the first documented case of N24SWD in a sighted transgender patient on gender-affirming hormone therapy. Report of case(s) 32-year-old transgender woman on gender affirming hormone therapy (Estradiol) with psychiatric and neurodevelopmental comorbidities including: anxiety, ADHD, autism spectrum disorder (ASD), depression, and chronic fatigue who presented for sleep medicine evaluation with complaints of progressive disrupted sleep since high school. She endorsed non-restorative sleep, daytime sleepiness, morning dry mouth, periodic nightmares, intermittent sleep paralysis and difficulty initiating as well as maintaining sleep. Actigraphy (14 days) showed irregular sleep timing with concern for progressive phase shift. Sleep logs were consistent with free-running, progressive nightly sleep delay (1-2 hours). Diagnostic polysomnography found mild obstructive sleep apnea (AHI 13.5/hour) and REM without atonia. Notable absence of dream enactment behavior. Patient started on auto-titrating CPAP with symptomatic improvement. Multimodal circadian intervention using morning bright-light exposure and scheduled melatonin (0.5–1 milligrams nightly) successfully entrained a stable sleep–wake pattern over time. Conclusion This case of sighted N24SWD does not have a clear root cause. The typical driver in sighted N24SWD is by behavioral and environmental misalignment. However, this patient also suffers from many risk factors associated with circadian rhythm interference including depression, neuro-developmental disorders (ADHD, ASD), and current hormone therapy. This case highlights the need for better understanding of sighted N24SWD and other circadian rhythm disorders in the context of transgender populations, particularly in the setting of hormone therapy and neurodevelopmental vulnerability. Support (if any)
Moore et al. (Fri,) studied this question.
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