The Sleep Crisis in Menopause: Insomnia, Sleep Apnea & Solutions

Summary

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unPAUSED with Dr. Mary Claire Haver

Episode: The Sleep Crisis in Menopause – Insomnia, Sleep Apnea & Solutions

Guest: Dr. Andrea Matsumura (Sleep Medicine Specialist)
Date: March 10, 2026

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Episode Overview

This episode of unPAUSED is dedicated to unraveling the often-overlooked sleep crisis among women navigating perimenopause and menopause. Dr. Mary Claire Haver sits down with Dr. Andrea Matsumura, an esteemed sleep medicine specialist, to discuss why women’s sleep is so frequently disrupted and minimized, the unique presentations of sleep disorders in women, and practical, evidence-based strategies for improving sleep and overall health during midlife and beyond.

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Key Discussion Points & Insights

Normalization and Minimization of Women's Suffering

• Why are women’s sleep complaints minimized?
  • Societal conditioning means women are expected to tolerate more suffering, from painful periods to sleeplessness in motherhood and menopause.
  • "We are taught that we are supposed to suffer more. And then you hit menopause, you hit midlife, and then you become invisible, and then you're supposed to suffer." – Dr. Andrea Matsumura (00:05)

Personal Context: Dr. Matsumura’s Journey

• Grew up experiencing medical dismissal; motivated her to become a healthcare advocate for women.
• "I need to take care of all of the people who don't have a voice and who are muffled and silenced and dismissed..." – Dr. Matsumura (07:34)

Sleep in Medical Training & Practice

• Both Dr. Haver and Dr. Matsumura note the lack of sleep education in medical training (09:04).

• Sleep is a foundational pillar of health, impacting cardiovascular risk, cognition, depression, anxiety, and quality of life.

  "Sleep is truly our core pillar of health. That's why I call it a vital sign." – Dr. Matsumura (10:17)

Defining Insomnia

• Insomnia: Inability to fall or stay asleep, feeling unrested upon waking.
• Chronic insomnia: At least 3 times per week for 3 months or more (11:31).

Gender Gaps in Sleep Research & Diagnosis

• Most sleep research and screening tools center men, making women’s presentations easy to overlook (12:04).
• Many women with sleep apnea do not exhibit typical “male” symptoms like loud snoring, delaying diagnosis (14:03).

The Physiology of Sleep

• Four stages: Stage 1 & 2 (light sleep), Stage 3 (deep/slow wave, physical restoration), REM (emotional/memory consolidation).

• Deep sleep is concentrated in the first part of the night; REM occurs more in the latter half (21:37).

  “That deep sleep or slow wave sleep, we're supposed to get in that first one third of the night, and then REM sleep is usually in the last half...” (21:37)

What is Restorative Sleep?

• Waking refreshed, “rainbow and birds chirping” feeling, clearheaded, and emotionally regulated (19:49).

Sleep Trackers: Pros and Cons

• Useful for spotting trends but not diagnostic tools.
• Trust how you feel over the data (22:59).
• "Ask yourself first before you wake up, how you feel before you start looking at your data." (22:56)

Hormones and Sleep Regulation

• Estrogen: Supports temperature regulation and REM.
• Progesterone: Calms the brain, supports airway.
• Testosterone: Aids in deep, sustained sleep (25:49).
• Loss of these fuels midlife sleep changes.

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Notable Quotes & Memorable Moments

• On Sleep as a Core Pillar:

  “If we are not getting the quality, not just the quantity of sleep, then everything is off bets.” – Dr. Matsumura (10:51)

• On Diagnosis Delays:

  “Women tend to have insomnia. They tend to have this... tossing and turning. And I love it: Women never say that they snore. They say that they purr." – Dr. Matsumura (45:53)

• On Hormone Therapy:

  “Hormone therapy helps, but up to half of those who start on it still have trouble sleeping. So we have to look at the other organic causes.” – Dr. Matsumura (61:32)

• On Shift Work:

  “There is good data out there that shows that if somebody has untreated sleep apnea or untreated insomnia, that once we begin to treat it, you can get yourself back to baseline.” (53:02)

• On “Sleep as a Vital Sign”:

  “We could be chasing our tail with high blood pressure if somebody is not getting enough sleep... that's why I think that sleep should be a vital sign.” – Dr. Matsumura (77:12)

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Key Segments with Timestamps

• Why Women’s Sleep is Overlooked & Dismissed – (00:00–01:10)
• Dr. Matsumura’s Background & Motivation – (06:29–08:51)
• Medical Education’s Sleep Blindspot – (09:04–10:15)
• Defining Insomnia & Prevalence – (11:21–11:57)
• Sleep Gender Bias & Diagnosis Challenges – (12:04–14:32, 45:03–48:52)
• Deep Dive: Sleep Stages – (19:35–21:37)
• Wearable Tech and Data Anxiety – (23:39–24:27)
• Hormones & Sleep Science – (25:40–27:43)
• Movement Disorders: Restless Leg Syndrome – (32:04–36:06)
• CBT-I for Insomnia; Behavioral Approaches – (39:24–45:03)
• Under-Diagnosed Sleep Apnea in Women – (45:03–48:52)
• Melatonin: Myths, Realities, and Dosing – (49:04–55:41)
• Medication Risks (Ambien, Trazodone) – (64:18–66:29)
• Chronotypes and Relationship Dynamics – (67:11–68:50)
• Lifestyle: Exercise, Diet, Light Exposure – (69:01–71:24)
• Sleep Supplements Discussion – (71:24–73:55)
• First Steps for Exhausted Women – (74:25–76:22)
• Sleep Myths & Small Wins Matter – (76:28–77:08)
• Dream Sleep Method (Acronym) – (78:47–81:39)
  • D: Daytime Activities
  • R: Resting Environment
  • E: Emotions
  • A: Archetype/Chronotype
  • M: Medical Conditions
• Empowerment in Midlife & Sleep Health Hope – (82:05–83:23)

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Evidence-Based Solutions Discussed

• Hormone therapy can address sleep disrupted by hot flashes and hormonal shifts, but may not be a complete solution.
• Cognitive Behavioral Therapy for Insomnia (CBT-I): Gold standard for reprogramming sleep behaviors and thoughts.
• Addressing Iron Deficiency (esp. for RLS): Ferritin ~100 ng/mL is target for symptomatic relief (35:02).
• Treating co-occurring sleep disorders (apnea, RLS) and considering chronic insomnia as a medical condition.
• Lifestyle Recommendations: Regular exercise, mindful diet (avoid heavy/greasy meals close to bedtime), optimize bedroom (dark, cool, quiet).
• Supplements: Use with caution; melatonin can help if dosed correctly (≤3mg), but more is not better.
• Importance of Personalizing Solutions: There is no “one size fits all”—what works for one may not for another.

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Empowerment & Lasting Takeaways

• Sleep complaints are not just “part of aging”: They are common, but not to be dismissed.
• Women are not broken – sleep challenges in menopause are the product of real physiological shifts and require tailored solutions.
• Every 15 minutes of extra sleep is a win; perfection is not the goal.
  • “Let's focus on the little wins and not have to think that we have to be perfect.” (76:28)
• There is always hope and always something that can be done to improve sleep—women need not simply “live with it.”
• Dr. Matsumura’s “Dream Sleep Method” offers a practical checklist for addressing complex, multifactorial sleep challenges.

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Resources

• Find a Sleep Specialist: American Academy of Sleep Medicine Provider Directory
• Dr. Andrea Matsumura: Instagram @dreamatsumura | sleepgoddessmd.com
• Dr. Mary Claire Haver: Instagram @doctormaryclaire | thepauselife.com
• Book Mention: The New Perimenopause – Available for preorder.

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Closing Thoughts

This episode offers expertise and compassion, challenging the pervasive myth that poor sleep is simply a “normal” or “inevitable” part of menopause and aging. Rather, Drs. Haver and Matsumura equip listeners with practical tools, validation, and hope, affirming that every woman deserves restorative sleep and the chance to thrive in her second half of life.

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Transcript

[A]

Why do you think women's sleep complaints are so frequently minimized?

[B]

Well, you know, it goes back to. And this is why I do what I do. I am really tired of the normalization of women suffering in society. That is exactly why I'm doing what I'm doing. Because we get told from a very young age that our baseline for suffering is higher. We should just suffer through those horrendous menstrual periods that we. That we should be anemic. It's okay, you know, sorry, you're losing a lot of blood when if you have children, well, you're just not going to get enough sleep. Well, you have to take care of somebody else. There is mental load in the working environment, in your home environment. We are taught that we are supposed to suffer more. And then you hit menopause, you hit midlife, and then you become invisible, and then you, you're supposed to suffer. Well, you know, you don't have hormones now. It's just the way it is.

[A]

The views and opinions expressed on unpaused are those of the talent and guests alone and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis or treatment. Today's guest is someone I've known and trusted for more than a decade and one of the most important clinicians in my own education as a menopause specialist. Dr. Andrea Matsumura is a board certified sleep medicine specialist who's been shaping the field of women's sleep health long before most of the medical community even recognized how profoundly sleep changes during the menopause transition. When the vast majority of my own patients were coming to me, exhausted, wired, anxious, and unable to sleep through the night, Andrea was the first person I turned to. Quite literally, I was taught almost nothing about sleep in medical school or residency. I knew women stopped sleeping during menopause. I knew the complaints were universal, but I didn't understand the mechanisms, the physiology, or the stakes. Andrea is the one who opened that door for me. She helped me understand why even asymptomatic women on hormone therapy can still struggle. She walked me through the neuroendocrine chaos of perimenopause. And when I began digging into the research myself, I was stunned by what I found. Poor sleep is associated with increased cardiovascular risk, depression, anxiety, weight gain, obesity, impaired cognition, and reduced quality of life. The girls are not sleeping and it's costing them dearly. Andrea has spent her career helping patients reclaim their nights, their energy, their mental health, and their lives. She blends clinical wisdom with evidence based clarity and she teaches in a way that makes the science finally make sense. When I decided to develop a sleep supplement for my community, she is the person I trusted to partner with. Her guidance shaped everything from the science to the formulation to the practical strategies women can use to finally rest again. Andrea is an extraordinary clinician, a generous educator, and a quiet force behind the scenes who has changed countless lives, including mine. I am so grateful to have her here today to help us understand what is really happening to women's sleep during perimenopause and menopause and what we can do about it. I'm Dr. Mary Claire Haver, a board certified obstetrician and gynecologist and certified menopause practitioner. I'm also an Adjunct professor of Obstetrics and Gynecology at the University of Texas Medical Branch welcome to Unpaused, the podcast where we cut through the silence and talk about what it really takes for women to thrive in the second half of life. In business, there's no room for guesswork. Every shipment matters. Every deadline counts. When you're trying to keep operations running smoothly, the last thing you need is uncertainty. That's why reliability is at the core of USPS Ground Advantage. From the moment your package is first scanned in, it moves through a secure nationwide network, aiding in a timely and accurate delivery. You get near real time tracking so you can keep up with your shipments and with affordable upfront pricing. There are no hidden fees or surprise surcharges to throw off your cost sheets. It all adds up to predictable deliveries you can depend on, because knowing your logistics are handled lets you focus on everything else your customers, your team, and the future you're building. Visit usps.com groundadvantage to start shipping with confidence. USPS Ground Advantage we mean business. Unpaused is supported by Claude from Anthropic Midlife comes with questions that deserve more than surface level searching. Maybe you're trying to make sense of conflicting research on hormone therapy. Or you've got a stack of lab results and want to understand what your numbers mean in context. Not just whether they're in range, but what the patterns might suggest over time. Claude is an AI that thinks through those questions with you. It doesn't just hand back a summary, it helps you dig into the research, pushes back when the evidence is mixed, and cites its sources so you can see the receipts and where the info was pulled from. You can now even connect your Apple Health data to Claude, which means Claude can help you Understand fitness patterns, track progress towards goals, and visualize trends with native charts. So when you're prepping for an appointment or just trying to figure out why your sleep has been so off the past week, Claude has the full picture, not just the first Google result. Try Claude for free at Claude aiunpaused and see why problem solvers choose Claude as their thinking partner. So Dr. Matsumura, welcome to Unpaused.

[B]

Thank you for having me.

[A]

I want you to tell me a little bit about where you grew up. Tell us about your background.

[B]

All right. Well I grew up with my mom living in my grandparents house. My mom was a teenager when she had me, so she was really young and we grew up together and I grew up in San Antonio, Texas.

[A]

And what drew you to medicine?

[B]

Well, that's a personal story that I don't get to share that often and it's taken me a while to kind of wrap my head around it, but my mom and I were both on Medicaid when I was little and I had a lot of infections, like allergies, stuff like that. And it was, it was really hard because we'd go to the ER and we were really treated like second class citizens. It was a really tough time. And I realized one day, I guess I was about five or six, I had a June bug fly in my ear and it got stuck on the tympanic membrane and on the earth that

[A]

would be the eardrum to our listeners.

[B]

And I remember going to the ER cause I mean it's stuck on your eardrum, it hurts, right? And the ER doc was probably a lovely resident. Like we've all been so well, how many roaches do you have in your house? And my mom was mortified and she said we don't have roaches in our house. And they ended up drowning the bug that was in my ear, taking it out and said, huh, it's a June bug. Oh well. And I remember at that point in my life I said I need to not only take care of me, but take care of my family and I need to take care of all of the people who don't have a voice and who are muffled and silenced and dismissed because this is a terrible experience. And I was really little. So from that point on I made it my mission to do really well in every science class. So I ended up working on getting my PhD in molecular biology. And it was a snooze vest. Wet bench research is pretty, not for everyone, it's slow. And so I ended up finishing that out, getting my master's and I got into medical school and then I was off to the races.

[A]

When were you drawn to sleep? That was later.

[B]

Yeah. So I was practicing primary care and seeing tons of patients and doing hospital work and outpatient work and nobody can sleep.

[A]

The girls, I say this all the time.

[B]

That's right.

[A]

The girls are not sleeping.

[B]

That's right.

[A]

They're not sleeping. All of my patients, I mean, it's the rare patient who's like, nah, man. I go to bed like, you know, sleep like a rock, get up, I feel refreshed. Like, that is so rare in my practice. So keep going.

[B]

Yeah, the girls aren't sleeping, and it's literally breaking our hearts and our brains, so we gotta do something about it.

[A]

Okay.

[B]

But I got into sleep because nobody could sleep. But it's an afterthought. So after we're done talking about all of the chronic medical conditions, it was this, oh, yeah, can I get something for sleep? I'm not getting enough sleep. So then I started doing more reading about sleep and how important it is, and I thought to myself, wait a minute, I didn't get taught this at all. In medical school. I received nothing about sleep, nothing in residency. I was just learning about obstructive sleep apnea and realized, oh, I am missing tons of people who have sleep apnea and tons of people have insomnia and what's going on here? So then at that point, I left my practice and I went back to school to study sleep and I did a fellowship in sleep medicine.

[A]

What do you do in a sleep medicine fellowship?

[B]

There are over 70 different sleep disorders. The one that everybody knows about is obstructive sleep apnea. The one that everybody lives with is insomnia. And I learned that sleep sleep is truly our core pillar of health. That's why I call it a vital sign.

[A]

Sleep problems are a risk factor for cardiovascular disease, like recognized as a high risk factor. I just happened to interview yesterday two Alzheimer's specialists, and they both were talking about how critical sleep is for cognitive decline. So it's pretty amazing. I never learned any of that 100%.

[B]

I mean, everything that we talk about, exercise, nutrition, how medications work, how our hormones work, if we are not getting the quality sleep, and I like to focus on quality, if we are not getting the quality, not just the quantity of sleep, then everything is off bets. I mean, it's just not going to function as well as it should if we are not getting that foundation set correctly.

[A]

What is insomnia?

[B]

By definition, insomnia is the Inability to get to sleep and, or stay asleep and you feel, feel like you did not get enough sleep when you wake up for the day.

[A]

And what percentage of the population has this?

[B]

So at any given time, at least I would say 50%, that's what data says will have some form of insomnia that's short lived. But up to 30% of the population will have chronic insomnia. And chronic insomnia is again by definition the inability to get to sleep and, or stay asleep at least three times a week for at least three months.

[A]

So you're doing your sleep medicine fellowship. Were you noticing differences between males and

[B]

females at that point? I was at the va. There's a lot of guys at the va, so I wasn't seeing a whole bunch of women. And we really didn't focus on women's health. So, you know, every single screening tool is really focused on men's health. A lot of the data, I won't say all of the data, but much of the data is focused on population health around men. So I really didn't start to see the connection between women's health and sleep until I actually started going out and practicing sleep medicine.

[A]

So explain to our listeners what does a sleep medicine specialist do and how would you find one? Like, like, yeah, this sounds amazing, but I. You're the first sleep medicine specialist I've ever met in my life. So. And I practiced medicine for a long time.

[B]

Yeah. If you're having trouble sleeping, if you're snoring, if you can't get to sleep or stay asleep, a lot of times a primary care doctor will be referring you to someone like me if somebody has a neuromuscular condition. So anybody who's got any type of neuromuscular condition, like a common one, is multiple sclerosis. People will come and see me. If you have an autoimmune disorder, people will come and see me. Women who are pregnant will come and see me. Because we know that pregnancy, if you have sleep apnea, you're at higher risk for all sorts of potential complications.

[A]

What is sleep apnea?

[B]

It's basically an oxygen deprivation state. So typically it's obstructive, although there are seven different types of central sleep apnea. But the one that everybody knows about is obstructive sleep apnea, and that is one when the back of the throat closes off those soft tissues and you're unable to oxygenate the rest of your body.

[A]

And is that snoring? What snoring is.

[B]

So snoring is a common symptom but it is not a common symptom in

[A]

women with sleep apnea. You can have sleep apnea and not snore.

[B]

You can have sleep apnea and not snore.

[A]

How would you know you had it?

[B]

You don't always know you have it. Even when people are snoring and sleeping, somebody next to them that is sleeping with them in their bed says, hey, you know, you stop breathing, I'm elbowing you, I'm waking you up. Sometimes even that person says, there's no way I have sleep apnea. So you don't always know that you have it.

[A]

So you start your sleep medicine practice. I know you're doing a lot of sleep studies at the time. That's when we were becoming friends.

[B]

Yeah.

[A]

What is a sleep study?

[B]

So a sleep study or a polysomnogram is when we take a look at all of the different stages of sleep. So you have all these little stickies on your head that are. It's an encephalogram. We're looking at the different stages of sleep when you're awake. We have typically three breathing channels that we're looking at for respiratory effort and oxygenation. We're looking at your heart rate, your heart rhythm and movement. A home sleep study is modified. It doesn't look at all of the brain waves, but it is generally capturing all of the breathing channels.

[A]

So you're out there living your best life. When did you start noticing the girls were different than the boys?

[B]

So as soon as I started my sleep medicine practice, I noticed that women were coming in. You could tell that somebody had said, I don't know what to do, and you're not sleeping, so I'll send you to the sleep doctor. And many times women would come in saying, I just don't feel right. And a common phrase would be, you know, I don't know if I'm depressed because I'm sleepy or I'm sleepy because I'm depressed. Oftentimes it was women in midlife, and I was in midlife and I was starting to notice that there were subtle changes in my sleep. So this is me, Andrea. I can sleep anywhere, anytime, any place, and all of a sudden I'm having middle of the night awakenings and I'm thinking, what is going on? And then I also started having myself irregular periods. And so I started asking women these questions. And word gets around fast. So then everybody that was getting an appointment with me was a woman. And then I kind of. The Women's Whisper Network became the expert in women's Health and sleep. And so then I started digging in and realizing that there is a huge connection and we are getting dismissed. And there is no great screening tool to help us identify women who are having trouble sleeping, who might have sleep apnea, restless leg syndrome, chronic insomnia. It's like this perfect storm because that's when our hormones are shifting, and the explosion around cardiovascular and neurocognitive issues kind of rears its ugly head for us. And sleep can be that hinge that either makes it or breaks it in terms of enabling us to help ourselves around cardiovascular health, around neurocognitive function.

[A]

So let's go big picture. Why is sleep such a critical piece here for overall health?

[B]

It's like your CEO. It's for your body. So everything hinges on our ability to get into those sleep stages. So we need to have deep sleep, we need to have REM sleep in order for us to kind of clean all the waste products out of our brain, for all of our hormones to function in the pattern that it needs to function in to continue to support our circadian rhythm. Because every single cell runs on a circadian rhythm, and the master one is the clock genes that are in the brain.

[A]

The what genes?

[B]

Clock genes. What are those? We've got clock genes in the hypothalamus of the brain. We're born with them, and they are the pacemaker of the circadian rhythm for all of the other cells in our body to function.

[A]

We know that, you know, data is showing that poor sleep is increasing the risk, as you said, depression, cardiovascular disease, diabetes. But talk to me about the women. Why is this so important for them?

[B]

Well, because we. We have the same risk factors once we hit midlife, when we're in menopause, and we have this delay in our. In our diagnosis. And that sets us up for. We know that cardiovascular health is so important. That's the number one issue.

[A]

You know, most women think, if you ask them on the street, that the number one killer of women is breast cancer. What is the number one killer of women?

[B]

It is heart attacks.

[A]

And they just feel like that's bad luck.

[B]

I know it's not. And it's so intimately involved in our ability to get good sleep, because we know that when people have chronic insomnia and. And it goes untreated and we don't try to treat it, that you have higher cardiovascular risk.

[A]

So you've quoted that sleep is foundational. But before we talk about fixing it, which we will, can you tell me what restorative sleep is? You know, there's different kinds of sleep, and you briefly talked about sleep stages, so I'd love to dig in here as well.

[B]

Okay. Restorative sleep is when you wake up feeling refreshed. You wake up and you can remember words, connect the dots. You don't have brain fog.

[A]

I call it the rainbow and the birds chirping.

[B]

You don't feel dysregulated. You're looking forward to your day. That's what good sleep feels like. As opposed to when you wake up and you say, oh, my gosh, I only slept a few hours. I don't know if I'm gonna make it through the day.

[A]

So what are the sleep stages? You briefly talked about sleep.

[B]

So there's four sleep stages. So stage one is that light sleep. A lot of people will think that they didn't get any sleep at all, but they may have been hovering in stage one and stage two. Stage two is when your body's more or less preparing for the deeper stages of sleep. And fun fact, stage two is what we spend the most time in. So a little word about wearables or tracking devices that light sleep is. Stage two is in that light sleep. So a lot of people will think, gosh, I have so much light sleep. But you're supposed to have a lot of stage two sleep. And then there's stage three sleep, which is our deep sleep or slow wave sleep. And that's really the big stage where you have all of the body restoring itself, all the physical restoration. And then REM sleep is when we're dreaming. And dream sleep is really important because that is when we're doing a lot of emotional consolidation. That's that emotional regulation piece. Some memory consolidation also happens during REM sleep.

[A]

So I wear a tracker. And, you know, I used to be obsessed. My husband and I would, you know, Chris and I would wake up in the morning and be like, what'd you get? You know, for our scores? Because not like, I'm so competitive. And so I. According to aura, I'm a much better sleeper than my husband. But, you know, what I never understood were the different phases and how much time I spend. Most of my deep sleep is early in the night, in the first half of my sleep. Is that normal?

[B]

That is normal. So that deep sleep or slow wave sleep, we're supposed to get in that first one third of the night, and then REM sleep is usually in the last half of the night. So we, you know, there's a whole method to the madness, if you will. And how. Yeah.

[A]

And we're fluctuating in and out. Why?

[B]

Yeah, we're cycling. It's fascinating why your brain goes through these different cycles to kind of clean the brain out. And it's kind of like a dishwasher, right?

[A]

Yeah.

[B]

So it keeps cycling through so that it's cleaning out all the waste products of the brain and developing and setting the stage, kind of cleaning the slate so that you can wake up refreshed in the morning.

[A]

We had Louisa Nicola on and she talked about the microglia, the small cells and they shrink during deep sleep and the fluids start pumping through because they can get around. And that's cleaning, that's cleaning it out.

[B]

That's usually in slow wave sleep.

[A]

What is the recommended time?

[B]

So the American Academy of Sleep Medicine says that everybody should sleep seven to nine hours. And everybody kind of knows their sweet spot. But there is some data coming out that all is not lost if you're not sleeping seven hours. That really. Let's focus on the quality and not just the quantity.

[A]

What does that mean?

[B]

So quality.

[A]

So if you're not wearing a tracker, how would you know?

[B]

So we know ourselves better than anything. So I always tell folks, please ask yourself first before you wake up, how you feel before you start looking at your data. Because it primes people. So you, if you're not thinking about it, or you might say, hey, I got pretty good sleep. And then you look at your data and you say, oh my gosh, I got horrible sleep. And then you really wake up for the rest of the day with this perception that you're not getting good sleep. And that's not always true. The trackers are, they're good, but they're not diagnostic tools. So really trust yourself first.

[A]

Has anybody come to your office, you know, because of a tracker? All the time, good and bad. Like, what would be a positive outcome of a tracker for you?

[B]

Positive outcome of a tracker is when somebody notices a trend that something has shifted and it's consistently shifted. And then that's a window for us to then use some diagnostics to kind of figure out like a sleep study or kind of dig deeper. Hey, what's really going on with your sleep? But most people come in because they say, you know, my oxygen saturation is going down for five seconds here or there. You know, great newsflash, that's not abnormal, you know, but when should you be concerned about.

[A]

Cause your oxygen saturation, should you be concerned about that ever?

[B]

If it's consistently low. And again, these are not as accurate. So if it's consistently low and you notice that it's firing off a whole bunch and it's telling you, hey, I think something's going on here. Then that's when you should, you should go in to get evaluated. But even my tracker will say that occasionally I have low oxygen saturations. But I know that I don't have sleep apnea because I test myself and it's very intermittent. But if you see like a sustained window. And for women, this is important because women will often have REM related sleep, abnormal breathing. So they will have REM related obstructive sleep apnea, meaning that they pretty much don't have what we call obstructive sleep apnea in all of the other stages of sleep. But during dream sleep is when they actually start to have low oxygen saturation. Some hypoventilation where you cannot oxygenate well. And that is, that could show up on a tracker where you have a little window of time where you were consistently having low oxygen saturations.

[A]

Okay. Talk about hormones and their role in sleep regulation. So we're talking about sex hormones or, you know, the PET hormones.

[B]

Yep. When we think about estrogen, progesterone, testosterone. So estrogen is really helping us with our thermoregulation, with our temperature control. It also helps with sleep spindle production, which is part of stage two of sleep. It also then helps with REM sleep. Progesterone is really about. It's got a lot of what we call GABA, GABAergic potential. So really helps calm the brain. It also helps to support the structures at the back of the throat. So progesterone helps with supporting the airway while we're sleeping. And then testosterone is really helping with that deep sleep and sustaining sleep. So those are kind of the big components of how these sex steroids really affect sleep.

[A]

This year at the Menopause Society, you were there, right. And the incoming president is a psychiatrist, and he did a presentation on sleep. And at the end, I watched it remotely. And I was very surprised to hear him say, and I may be quoting him incorrectly, at the end of the day, it was like, do not recommend progesterone for sleep. Well, were you surprised by that?

[B]

So I was.

[A]

What is the evidence?

[B]

Yes, so I was surprised by that. I think what he was trying to say, and I'm giving him the benefit of the doubt because I didn't get a chance to snag him and say, hey, hey, what's going on here? There isn't any data that says that progesterone is curative for, let's say obstructive sleep apnea. Right? But we all know that it can help with getting women to sleep and calming.

[A]

I have a thousand patients who will

[B]

testify right now, a hundred percent.

[A]

I'm like, we're not asking the right questions. If, you know, science isn't recognizing how progesterone is helpful for some patients for sleep.

[B]

And we don't have any studies showing whether or not we add progesterone and estrogen if that helps with sleep apnea. And I get asked that question a lot. Women will ask me over and over again, hey, if I start on menopause hormone therapy, will this help me with my sleep apnea? And we don't know.

[A]

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[B]

Because this is.

[A]

You said there's 70 different causes of insomnia.

[B]

So 70 different sleep disorders.

[A]

Sleep disorders.

[B]

Okay. So the big ones are you have a breathing abnormality, you might have a movement abnormality or such as what is a movement abnormality? So restless leg syndrome. So restless leg syndrome can affect up to 30% of women in the postmenopausal state.

[A]

Is that more than men?

[B]

And that is way more than men. And so I did not know that. And it is. And it is under diagnosed. I just had somebody the other day, I was at a party actually, and somebody pulled me aside and said, you know, you were talking about restless leg. That is me. And I didn't realize that that is actually what was causing me to have insomnia.

[A]

So for our listeners, what is restless leg syndrome?

[B]

So it is what I call. So by definition, it is a conscious phenomenon, meaning you have to be awake. Okay, so restless Leg syndrome is this movement in any limb, really?

[A]

Does it have to be your legs?

[B]

Doesn't have to be your legs could be in your torso. It can be in your arms, your legs, and it's basically this uncomfortable feeling that builds and you have to move. It dissipates, and then it builds right back up, and it is preventing you from getting to sleep. And then when you're asleep, it's a little bit of semantics. There is a condition called periodic limb movement disorder, and that is when limb movements are causing constant arousals and preventing you from getting into the right stages of sleep.

[A]

Wow.

[B]

They're two separate things, but they're actually on the same. They share, like, the same loci.

[A]

Yeah. What causes this? Why would someone develop restless leg syndrome?

[B]

So, yeah, one common reason is having low iron stores and. Well, let's not get me started on that.

[A]

I had a pregnant patient who was a pathologist and had horrible rls, and she's the one who taught me about the ferritin.

[B]

Yes.

[A]

And we were getting her iron transfusions in the pregnancy so that she wasn't anemic, but her low ferritin. And it worked beautifully for her.

[B]

And we underutilize iron infusions because sometimes, you know, it takes a long time with iron replacement to feel oral iron.

[A]

Yeah. I had low ferritin for a long time, and I had GI stuff, so very difficult for me to absorb. And finally I was like, fine, I'll go get the iron transfusion. Life changing. Yeah, life changing. I recommend them all the time now for patients who are struggling with absorption.

[B]

Yeah, definitely. And the normal values are not normal. If you have restless leg syndrome, what

[A]

ferritin level are you. I just did a whole post on this today. It's so funny. At what level are you? Like, we need to get this higher.

[B]

So if you have restless leg syndrome, your ferritin should be around 100.

[A]

Okay, so ferritin is the iron storage protein, and it drops way before you become anemic.

[B]

That's right.

[A]

Right. And in our clinic, if they have chronic inflammation, so if their set rate's high or, you know, we have signs of chronic inflammation.

[B]

Right.

[A]

We're not using 60, we're using 100. Because it's an acute phase reactant. The keratin will rise, you know, abnormally in response to inflammation. So we have to move that goalpost for patients 100%.

[B]

And also it crosses the blood brain barrier. That's why you have restless leg syndrome, because it has a role in how dopamine Gets released.

[A]

Amazing.

[B]

And so that's how it works in the brain. That's why you will have restless leg syndrome. And we've had these levels that are standard, that are now changing, right, for normal. But even then, those normals, those normal levels are not normal if you have restless leg syndrome. So now the normal range is like 45.

[A]

45. It was 15. They tripled it. Terrible.

[B]

It was terrible.

[A]

Yeah.

[B]

So you'd have these women coming in who had like a ferritin level of, you know, 10.

[A]

You're like, oh, you're borderline.

[B]

You're bor. Right. It's not really that low. And these people, probably these women should have had iron infusions.

[A]

Okay, so we talked about movement disorders. Let's keep going.

[B]

So then you're left with chronic insomnia. And chronic insomnia is when there's not really anything else that could be causing you to not be able to fall asleep. So the other big one is circadian rhythm abnormalities. So let's say you're a night owl, but you really have to get up early because you have to go to work earlier or you've gotta get your kids to school or you're taking care of somebody, whatever. The point is that you're not in sync with your circadian rhythm, which, again, those clock genes are in the brain. You can't really change them. It's kind of like eye color. You're born with them, you can fake them out. So that's called circadian realignment when we try to adjust somebody's circadian rhythm. And the other one is, there's lots of reasons why people will have chronic insomnia. One can be your change in hormones. One can be trauma. Another one can be mental health. There's all sorts of reasons. Anxiety, anxiety, depression. I mean, all kinds of things.

[A]

All right, so what about the patients who go to sleep fine, like. But then 2am, 3am what is happening?

[B]

Yeah, that's learned hyper vigilance, especially in midlife. This is a neuroendocrine neurosteroid change. Right. And so we have a change in cortisol. And sometimes that cortisol spike starts to happen earlier, which causes early morning awakenings. Then your brain, basically that. That neuro pathway for sleep, it changes. Your brain just says, okay, we're going to learn a new. A new path. And so you develop this hypervigilance, this. This hyperarousal in your sleep. And that is a behavioral change. This is why it takes time to treat insomnia. And it is not Typically fixed with any sort of prescription medication or supplement.

[A]

How do we fix it?

[B]

So the, the number one treatment is cognitive behavioral therapy for insomnia.

[A]

What is that?

[B]

So it is basically retraining the brain. It's, it's all about behavioral change. It's about addressing and understanding what is causing that hypervigilance and retraining the brain. Kind of like building muscle. You know, I always tell folks you don't just go to the gym and pick up £50. You can't. Right. You have to start slow, you have to be consistent, and then you can eventually pick up that 50 pound weight. I also tell people it is not a couch to 5K. It is a couch to marathon. It doesn't happen fast. You know, if you were really pressed, you could probably run, you know, three miles. But you can't run a marathon really easily in a week or two without training. This is about changing somebody's way of thinking and also giving them some ideas on how they can kind of give themselves permission to go back to sleep.

[A]

How does that look like, what would you. Okay, so me, all right, I'm waking up at 3am every night and we've ruled out medical causes. I don't have sleep apnea. My hormones are replaced. You know, we haven't put a finger on it. How would you counsel me to do. Is there an app? Do I go to a counselor?

[B]

Yeah, there's so many different avenues. So there are apps out there, there are sleep psychologists out there, there are online programs, there are books. The key is consistency. And you really have to address all of the components that are in cognitive behavioral therapy. So it's kind of what we call a three legged stool. So the first one most people do a pretty good job at, which is sleep hygiene. But more people than we think don't always go to bed at the same time or wake up at the same time. Maybe they're doing things in their daily life that is affecting their ability to get to sleep and they don't even realize it. Maybe they're eating a really heavy meal right before bed. Maybe they're exercising too late. Maybe they are super stressed all day and don't realize that that is gonna affect their ability to kind of shut down and get to sleep. So there's that sleep hygiene component. And also maybe their bedroom is not conducive. Too hot, too cold, too hot, too cold, too loud, too bright. And then the other one is addressing the hypervigilance, the stimulus, like what is causing that middle of the night awakening and I will tell people, let's develop a plan. Let's figure out how to help yourself get back to sleep and not catastrophize when we wake up. So a lot of us wake up in the middle of the night and go, oh my gosh, I'm not going to get back to sleep. What's going to happen? Instead, have a plan. Okay, I'm awake and I know I'm not falling asleep, falling back to sleep anytime soon. So I'm gonna get out of bed and I'm going to go sit somewhere and do the most God awful boring thing I can do, like reading a book or doing some sort of meditation, something that will help induce sleep. So we don't want people cooking, cleaning, working, exercising if they cannot fall back to sleep. And we do want them to get out of bed. That is called stimulus control. Fancy word for making sure that your brain associates the bed with sleep or intimacy and nothing else. Because if you stay in there for a long time, then your brain starts to think that the bed is like the sofa or the kitchen table, it doesn't associate it with.

[A]

So you should get up sleep.

[B]

So you gotta get up, it's painful. Pick something like an insomnia chair, whatever you want to call it, and just do something really relaxing and boring to help yourself get sleepy enough. And when you're sleepy enough, you go back to bed. The last one is the hardest, but it actually works really well, which is sleep restriction. So if you think you're only getting five and a half hours of sleep, then that's how much time you should give yourself. So instead of trying to get into bed at 10, tossing and turning for two hours, or falling asleep and then waking up at 1 and tossing and turning for two hours or whatever, and then getting up at 6, we tell people, well, if you are only getting five and a half hours of sleep, then let's slowly. We don't just say only get five and a half hours, but we start to help people kind of compress their sleep so that they can then expand their sleep. So I call this the accordion effect. So, so you know how you have to. The only way, if you push an accordion in, the only way for it to go is out. So that's the same concept, is that you kind of have to compress the sleep in order to expand the sleep. So you know what I will say about cognitive behavioral therapy for insomnia is that there's a lot of data around it, it is successful, but it is pretty rigid. And you do have to follow all of the components or you have a lower success rate. And what I find is that there hasn't been a lot of studies on chronic insomnia, only in women. Right. And so I think it drives a lot of people's anxiety. So you already have some anxiety about getting to sleep, and then it revs up this sleep anxiety even more. So I like to combine acceptance and commitment therapy with it, which is a different type of therapy altogether, where you give yourself love and grace so that you can actually get up the next day and maybe feel like it's not gonna be the end of the world. So maybe you can't fall asleep in the middle of the night. And instead of saying, oh, my gosh, I'm not gonna do well, tomorrow I've got a presentation or I have to do these things for my children or what have you, that you say, you know what? I'm gonna be awake for 90 minutes tonight, and I'm not gonna let it ruin my day. Maybe I'm not gonna fire off on all cylinders, but I'm gonna make it the best that I can for the next day. And you start to be kind to yourself. So I call cbti the Grit and acceptance and commitment therapy, or ACT the Grace. So if you can combine those two, I think you have a higher success rate. There are very few published studies on this, and there are very few studies Sleep psychologist who practices and combine therapy. But I am. That's what how I practice it. That's what I focus on when I help people with insomnia.

[A]

You've talked a lot about how some of these common sleep conditions like sleep apnea and RLS are missed in women. I learned 0 I heard of RLS more as, like this curiosity. And sleep apnea was old fat guys, you know, and so. And men who snored. I think it's important for our listeners to understand the female presentation, the atypical sleep apnea. Though we're 51% of the population. Like, talk to me about women and how they present with these. And why do we care?

[B]

Yeah, we care because it is a cardiovascular risk factor. So if you have moderate or severe obstructive sleep apnea, we know that you have up to a 25% increase in. In having a heart attack or a stroke or having a neurocognitive issue later on, like memory hypogemphia.

[A]

Yeah. And the inflammation. Yeah.

[B]

So it's the. It's the chronic low oxygen state that then causes all of this reflex physiology in the body that then Puts you at risk. So women don't typically present with loud snoring, witnessed apneas. There's actually a study out there that talks about the fact that if women have a male partner, they're less likely to be identified as having sleep apnea because their male partner will not notice anything abnormal happening in their sleep. But women tend to have insomnia. They tend to have this. They call it tossing and turning. And I love it. Women never say that they snore. They say that they purr.

[A]

Yeah.

[B]

So I. I love it. Women always say, I don't really snore. I. I kind of purr when I sleep. That can be mild. Mild snoring. That's enough. And the, the issue is that you don't have to, you know, be obese to have sleep apnea. And especially in.

[A]

Especially women.

[B]

Right, Especially women. You can have a normal body mass index. You don't have to have loud snoring. But if you're menopausal, you're at greater, you know, Whoa.

[A]

Menopause increases the risk of sleep apnea.

[B]

It does. Up to 50% of women will have sleep apnea, not know they have it. 90% of those women do not know that they have sleep apnea. So nine out of 10 women are not diagnosed. And then there's a delay in diagnosis because all of our screening tools are gender biased. I mean, the Stop Bang questionnaire, which is this acronym for these questions, the G is gender. So if you're a woman, you don't

[A]

get a lower score.

[B]

You get a lower score.

[A]

Stop it. Because they don't recognize that women have sleep apnea.

[B]

Yeah.

[A]

Okay. One of my takeaways from all this is if a woman is snoring and her partner recognizes it or she's purring, she might be further along the course than her male counterpart.

[B]

Yeah, exactly.

[A]

So if you're snoring at all, you

[B]

should go get evaluated a hundred percent. I have a very low threshold for testing women because, again, women come in feeling just generally that, you know, I don't feel well. I don't know what's going on. I have brain fog. I can't seem to feel rested when I wake up. You know, I might have some mild snoring. So snoring does increase in midlife, but again, it's not caught. It's not, you know, if it's not big bad snoring or if somebody isn't watching us have trouble breathing, then many times the connection of a woman might be at risk for sleep apnea. That Connection is not made.

[A]

A lot of women try to self medicate their sleep problems and the first thing they usually reach for is melatonin. Talk to me about melatonin, what it is, why it's important.

[B]

Melatonin's a hormone, okay? It's got a lot of different uses in our body, actually. But the one that we know about the most, or the one that's talked about the most is how it starts to set the stage for sleep. So there is this whole concept called dim light melatonin onset. That means in the absence of light, that's when the pineal gland starts to release melatonin. So it's really a clock starter. And it is not a sleep aid. It is starting the cascade of sleep, but it is also a circadian rhythm regulator. And what I did not get taught in my sleep medicine fellowship is that we actually lose melatonin production as we age.

[A]

Like, how much?

[B]

Well up to 50% by age 50, which I had no idea about. And I did not realize that the pineal gland is the first gland in the body to calcify. And that whole stereotype of the older person coming in now, the only thing

[A]

I was taught about sleep is you sleep less as you get older.

[B]

Yeah. And that is.

[A]

And that is norm. That is. That is expected. That is normal.

[B]

Maybe it's expected. But should it be normal? I mean, you know, it's part of quote, unquote, normal aging. But do I have to live like that? Do I have to live with a lower quality of life?

[A]

Why do you think women's sleep complaints are so frequently minimized?

[B]

Well, you know, it goes back to. And this is why I do what I do. I am really tired of the normalization of women suffering in society. That is exactly why I'm doing what I'm doing. Because we get told from a very young age that our baseline for suffering is higher. We should just suffer through those horrendous menstrual periods that we should be anemic. It's okay, you know, sorry, you're losing a lot of blood. If you have children, well, you're just not going to get enough sleep. Well, you have to take care of somebody else. There is mental load in the working environment, in your home environment. We are taught that we are supposed to suffer more. And then you hit menopause, you hit midlife, and then you become invisible, and then you're supposed to suffer. Well, you know, you don't have hormones now. It's just the way it is.

[A]

Sleep is like horrifically Disrupted.

[B]

Yes.

[A]

Okay, so. And we'll get back to melatonin because I have so many more questions.

[B]

Yeah.

[A]

But I chose a field of medicine that, you know, is a lot of shift ish work or staying up late at night or getting up early in the morning for obstetrics to deliver babies. And it was fine when I was 25. You know, it was fine when I was 35, it was fine when I was 40, but man, in my 40s, it was hitting harder and harder and I was not rebounding like I should. And I would bring everything to work so I could perform, and my family was suffering. So when I was about 48, 49, I was having disrupted sleep from hot flashes when I was going through menopause or in the early stages before I, you know, realize HRT wouldn't kill me, I reluctantly went on HRT and I. My sleep went back to normal because I didn't. Wasn't having hot flashes at 2 in the morning. I then transitioned positions to shift work away from the clinic so I could go part time. And so I became a hospitalist. And then Covid hit and I was working 24 hour shifts, three. Three days a week. And I wonder how many years I took off of my life because of this. I was an absolute basket case for like the last year of that. And I've read that shift workers are at super high risk for medical conditions. Can you talk a little bit about that?

[B]

Yeah. Well, the good news is that you can repair what you were. Kind of.

[A]

Because my 50th birthday present to myself was no more shift work.

[B]

No, there is good data out there that shows that if somebody has untreated sleep apnea or untreated insomnia, that once we begin to treat it, you can get yourself back to baseline. Okay. But there is data out there that does state that if you're a shift worker, and let's say you are not a night owl, then yes, you are at higher risk for dementia, for cancer. There are. It is. And that's because the way that our circadian rhythms work in our body, they rely on our ability to get to sleep at a particular time. It's all about timing. Right. And so shift workers have this disruption. And like I said, every cell works on a circadian rhythm. So then every. It's like chaos inside the body. And so our immune system suffers. Our ability to clean all the waste products out of the brain suffer. There's so much oxidative stress on the body. And yes, that then kind of is

[A]

a total setup why are so many women complaining about nightmares with melatonin?

[B]

So, one, you might be taking too much.

[A]

How much is too much?

[B]

So I'd say anything over 3mg. 3mg is the max that I would recommend for anyone you don't really need to take. More is not better.

[A]

The one I was taking when I didn't know what to do was 10. I was like, this is what is in the bottle. It's purple. It looks pretty. I associate purple with sleep. And I was having horrible nightmares. And sometimes it would help, or I'd wake up completely drugged. Grogging.

[B]

Like I said, more is not better. And we also don't know what's out there over the counter. There's lots of different brands. There's lots of, you know, some of them are high quality, some of them varying qualities. And there are. There's a couple of studies that were done that showed that at least 70% of the melatonin that is sold over the counter is not just melatonin. Wow. There's something else in it.

[A]

Wow.

[B]

And so we just need to be really careful. Now, when you do take melatonin, you could even take a low dose of melatonin and have nightmares or intense dreams. And that's because melatonin is what really intensifies dreaming, because you're having more sustained sleep. So then you might have more intense dreams, and that intensity might translate into, you know, having more abnormal dreaming.

[A]

Why do I remember some dreams, and usually the scary ones versus the good dreams?

[B]

Yeah. So, you know, it's all about how the amygdala is reacting when you're dreaming and how you're consolidating and storing the memories. I don't know exactly why somebody is going to remember a nightmare other than the fact that, you know, the way that the brain works. When we're dreaming, it almost looks like we're awake. So all of the parts of the brain that are typically asleep in the other stages of sleep actually wake. You know, they. They wake up. The PET scans show that when you're dreaming, a whole lot of your brain is lighting up. And, you know, that might play a role in how we are consolidating the memory, how we're reliving something that might be when something that was really stressful during the day translates into a nightmare, because it is subconsciously affecting our ability to get to sleep and stay asleep.

[A]

You know, that feeling when a workout just clicks. Meet the new peloton Cross training Tread plus it's powered by Peloton IQ your new Strength coach Peloton IQ takes the guesswork out of every move. It sets your goals and provides weight suggestions to ensure you're always making progress. With the new movement tracking camera, it actually counts your reps and corrects your form in real time. It's about making training safer, lifting smarter, and making every single rep count. When you're ready to switch gears, the swivel screen makes it seamless. Go for a 45 minute run on the tread plus then in one smooth spin transition to a 5 minute stretch on the floor. It offers endless ways to train for a well rounded routine, no matter how busy your day gets. Best of all, Peloton IQ builds your personal workout roadmap. You get one weekly recommended classes led by instructors who match your mood, your vibe and your personality with personalized plans and deeper insights. Peloton IQ helps you finally unlock those new breakthroughs. Let yourself run, lift, sculpt, push and go explore the new peloton cross training tread [e-mail] sometimes you don't need a whole new outfit. You just need the right finishing touch. And for me, that's Jenny Bird. You know that moment when you look in the mirror and you think, okay, this works. But then you add one piece of jewelry and suddenly it's like, yes, there it is. That's the Jenny Bird effect. It honestly feels like all my Jenny Bird pieces work together, so getting dressed is effortless. I can mix and match without thinking about it and still feel completely put together. The pieces are lightweight and easy to wear, perfect for looking polished without spending forever accessorizing. Everything is designed to pull together instantly in a way that feels elevated but not overdone. And honestly, every time I wear it, someone asks where it's from. Every single time. From their iconic hoops to their bracelets and bangles, there's truly something for every style. And they just launched a new fine jewelry collection that feels modern, elevated and really special. If you've been thinking about elevating your everyday look, this is your sign. You can get 20% off your first order with Jenny Bird by visiting jenny-bird.com and using the code unpaused at checkout. Why have we asked our contractor we found on Angie.com to be our kid's legal guardian?

[B]

Because he took such good care when

[A]

redoing our basement that we knew we could trust him to care for our

[B]

kids, all eight of them, should something happen to us.

[A]

Are you my dad now?

[B]

No, sorry. I do basements. Connecting homeowners with skilled Pros for over 30 years, Angie, the one you trust to find the ones you trust. Find pros for all your home [e-mail].

[A]

So let's. Let's talk about solutions.

[B]

Yeah.

[A]

And what actually works. Hormone therapy and sleep. Estrogen, Progesterone. Right. And what we know.

[B]

So we had talked about how the lack of estrogen, then, you know, you. You tend to have more fragmentation of sleep. It is your. It really focuses on thermoregulation. And so if you replace estrogen, then you tend to have more of that temperature regulation, which then allows you to stay asleep, which then allows you to get into all the right stages of sleep and increase your REM percentage. So that's the plus with estrogen, with progesterone. When we give progesterone to folks, that is also then calming. It helps to set the stage for sleep better. And it helps. Probably helps. We don't have data with some of that airway protection, but we don't know if it's curative or not. Okay, so you're kind of like calming the brain and then you're preparing the brain to sleep, stay asleep. Right. And then there are some studies that show that testosterone does help with deep sleep. And for some people, testosterone's a missing link. Like, they still have trouble sleeping even after they've started on estrogen and progesterone, and they're like, okay, let's try testosterone. And that was the missing link for them. It's not as well studied, but it is a potential solution. But up to, you know, at least a third of those folks who start on hormone therapy still have trouble sleeping. Up to half of those folks still will have trouble sleeping. So then we have to start looking at the other organic causes. Right? Like, do you have untreated sleep apnea? Do you have untreated restless leg syndrome? Do you have chronic insomnia? Let's fix that. Let's work together and treat that.

[A]

And that's where you come in.

[B]

Yes. Yeah.

[A]

How do you build the perfect sleep environment? Build me a bedroom.

[B]

Yeah. You want it to be dark, cool, and quiet. Those are your big three. So you don't want extra light. If you need blackout shades, you need an eye mask. I'm a big fan of eye masks. I love a good eye mask.

[A]

Do you have an eye mask on your website? I do.

[B]

I did this collaboration with Kylu Silk and I love it. And I made little eye, little pads, little pillows, so that if you wear eyelashes, it doesn't affect your eyelashes, but you Know, that tiny little bit of pressure around the eye actually induces calming. So for some people, that can really be helpful. For other people, maybe they don't. That's not for them. But you have to figure out what's good for you.

[A]

Catherine works with an eye mask. My daughter.

[B]

Yeah.

[A]

Yeah. I don't. And I've taken him on a plane, like, you know, especially an overseas flight. But I just worry, you know, I've never slept without, and maybe because I had trauma as a kid and was assaulted, but, you know, I sleep with fear that someone's gonna touch me, hurt

[B]

me, you know, 100%. Well, you know, you just brought up.

[A]

And so being blind scares the hell out of me.

[B]

Yep. You brought up trauma. And that was discussed, actually, at the menopause society. And it's something that we don't talk enough about or really bring it up in the menopause state. But those hormones are actually a little bit protective. You know, they're actually allowing us to power through the day. And when that scaffolding starts to diminish, that then you don't have the compensatory mechanisms to power through. And so trauma tends to resurface in midlife when women are going through menopause, and it greatly affects their sleep.

[A]

Wow.

[B]

That's a big deal that we don't talk enough about. I jokingly, or maybe not so jokingly, I carry around a box of tissues with me because every. Literally every single woman that I see will just break down in tears.

[A]

Oh, me too.

[B]

Once we in the menopause clinic, all day, once we get down to the bottom of everything, because a lot of women will not be on hormones, because, again, we still have a lot of work to do. Right. So I'll say let's start with that. And if that isn't going to help with the sleep, then let's start digging deeper.

[A]

Okay. So for women who can't for a contraindication or choose not to use hormones. Yeah.

[B]

What are the.

[A]

Your top strategies for them?

[B]

At the end of the day, there's no medication that's going to cure your inability to get to sleep as we talk. There's no medication.

[A]

Yeah. We haven't talked at all about the sedatives.

[B]

Yeah. So that's true. Such a Pandora's box.

[A]

I took Ambien.

[B]

Yeah.

[A]

I've taken Ambien when I was doing shift work. My husband, when he went overseas. But I have friends, one of my best friends, who cannot sleep without it. Like, will not like it is. It is non Negotiable in her life. And there's an addiction here, you know? Yeah, talk. Let's. Let's go there.

[B]

Okay. So there's again, there's no medication that cures your sleep. And Ambien and those medications like that, the benzodiazepine like receptor agonists is what I like to call them. They're sedative hypnotics, and they're also amnestics.

[A]

Meaning they cause amnesia. Yes.

[B]

You forget waking up in the middle of the night. I don't know how many people that I've reviewed their sleep study with them. And I'll say, oh, look, you were awake here for like, 40, 45 minutes. And I say, no, I wasn't. Yes, you were. Your brainwaves are awake and they don't remember. So their perception is that they're getting good sleep. So these medications taken long term can be pretty detrimental because if you're still not getting into the right stages of sleep, you still have all those risk factors.

[A]

What about Trazodone?

[B]

So Trazodone. Oh, love Trazodone. It's one of those.

[A]

Is that like a bless your heart comment? Like love Trazodone, bless your heart.

[B]

It is used, it's overused. It is labeled as an antidepressant. That was a terrible antidepressant. And at the doses that it works for depression, you're a complete zombie because you need like 300 to 400 milligrams to treat depression. But they realized that everybody was falling asleep all the time. So Trazodone is one of those medications that is used widely. But you really want to get down to the root cause of your problem, because what if that medication stops working? Or there's no medication that works forever? Most people need escalating doses or they need a triad or, you know, five things.

[A]

It used to work, and now it's not working. You have to increase the dose. Yeah.

[B]

So really, you want to get back down to those drivers, those behavioral drivers, and maybe it's masking another sleep disorder that you didn't even know you had. So up to 60% of folks who have obstructive sleep apnea have insomnia. That's a condition that's called comisa. So that is the comorbid condition of having sleep apnea and insomnia. And maybe you're just treating your insomnia and don't even know that you have sleep apnea. In addition, what time should I go to bed? It depends on what your circadian rhythm is set at. So people are either early birds, they're night owls, or they kind of fall somewhere in between.

[A]

Is that your chronotype or.

[B]

Yeah, that's your chronotype. Again, those are clock genes. You're born with them. Again, we can kind of help you reset them, if you will, or align them to fit your needs.

[A]

I am a morning person.

[B]

You're a morning person?

[A]

Oh, yeah. I am a badass in the morning. I mean, I could, like, cure cancer in the morning. And then the minute, like by 2 in the afternoon, I am just really kind of just functioning. And I go to bed typically earlier than most people, so. Because I'm up at five.

[B]

Yeah. You know, so you go to bed like at 9?

[A]

Ish.

[B]

Ish, yeah.

[A]

Sometimes. 8:30?

[B]

Yep. 8:30, yep. So that's an early bird. Somebody who wants to go to bed at 8, 9, wake up at 4, 5. People who are night owls by definition, they want to go to bed at 12, wake up at 8, go to bed at 1, wake up at 9.

[A]

What if you marry someone of the different. You know, what if your life partner, your bed partner is in a different chronotype? What do you do?

[B]

You have to honor your own chronotype. It's better for your health. So, you know, that's interesting you say that because a lot of women will come in and they try to follow their partner's chronotype because they are people pleasers and they want to go to bed when they're partner goes to bed. They want to wake up when their partner wakes up, and they're just dying of chronic sleep deprivation because they. Those folks tend to be more of an early bird and they're staying up way too late with their partner. And the other funny thing is that anecdotally, a lot of people marry the opposite chronotype. So, so let's talk about lifestyle.

[A]

Outside of. We're talking exercise, nutrition, all the. All the other pillars of health. How. How. How do these play into how we sl.

[B]

So, you know, when we think about exercise, we know that exercising actually does help you get into all the different stages of sleep better. You just have more sound sleep. So we do want to promote people moving that.

[A]

What kind of movement?

[B]

Any kind of movement. You know, as long as you're out there raising your heart rate a little bit, that's all that counts. I mean, if you can go walk fast, you can go swim lanes fast, you can walk lanes in the swimming pool, you can do whatever it takes to help you.

[A]

Dr. Matsumura is a triathlete. So, like, I don't get in the pool.

[B]

So, you know, whatever it takes to get that dopamine release, it really helps with sleep. And then there is some data that shows that if you eat too heavy of a meal, too close to bedtime, that affects your ability to get into the right stages of sleep.

[A]

What about the quality of our nutrition? Does that really play in at all?

[B]

Yeah, definitely. I mean, you know, if you're eating nothing but greasy junk food, it definitely affects the other parts of your body that then affect your ability to get to sleep. So if you're eating stuff that doesn't. That doesn't allow your stomach to feel good, then that's gonna affect your sleep. High saturated fatty food is not going to be conducive to helping you get into the right stages of.

[A]

Okay, now, I've seen a lot of, in the wellness world, lots of talk about, you know, and I even have a few of these devices. The red light therapy, morning light. Like, how important is all that?

[B]

There's some small studies that say that that might be helpful, but these are all new things that have come out. And what I try to do is let's get down to basics, right? Like if you try to eat the way that we're supposed to eat with, you know, lots of vegetables, fruits, good protein, some carb, and you try to honor your body with exercise and movement therapy, that's really what you need to focus on. I don't want to complicate it too much. You don't need a wearable to get better sleep. You don't need light therapy to get better sleep. This is not about all of the. All the little accessories that we need, right? Sleep is. It's foundational. It's a core thing. We gotta eat, we have to drink water, we have to sleep.

[A]

Full disclosure, Dr. Matsumura and I, and I talked about it in the intro. Have developed a sleep supplement together. So let's talk about supplements with our listeners knowing that, you know, there is a commercial interest here, but let's just talk about it in general. Don't even say what's in our sleep supplement. We talked about melatonin.

[B]

Yeah.

[A]

So yes or no? Yay or nay? You like it, don't like it?

[B]

I like it. And melatonin, I think there's something to it. We don't have enough research out there that we should absolutely 100% replace it. But goodness, if we are losing that much of it, can we check melatonin levels? And you can in saliva. So there's some Tests that you can do to check. To check melatonin levels.

[A]

Do you check them in your patients? No.

[B]

No, I don't. So I think that sleep support, circadian rhythm, support relaxing your body.

[A]

Like you've said, a sleeping pill, it's not a sedative.

[B]

It's not a sedative. It's not a prescription sleep aid. This is about supporting mechanisms that maintain quality.

[A]

So. So what else. Any other supplements you would consider.

[B]

I don't really recommend supplements, typically, because it's usually really personal. Right. Like something that might work, like valerian root might work for somebody, but may not work well for somebody else. Lemon balm might work well for somebody, but might not work well for somebody else. And it's really difficult then to say, well, you should use. You should use this. What I like to focus on are things that are evidence based that we have a lot of data on. So we have a lot of data on the components that we put into this sleep supplement, and we know exactly what they are doing. What I find is that when people come to see me, they're having trouble sleeping, and they come with an entire shopping bag full of supplements and medications. And I start to say things like, well, I don't think we need to actually take all of these. And somebody will say, but I can't sleep without these. And I said, no, wait a minute. You're still here. You're here seeing me because you're still having trouble sleeping. So are they really helping you or what's really going on here? So you're still here because you are still not getting sleep and you're taking $150 worth of supplements.

[A]

Yeah.

[B]

So I don't think that they're really helping you, or else you wouldn't be here.

[A]

So for a woman who's been listening and who's exhausted, who's been exhausted for years, what's the first step that she. You know, because you are talking to, you know, a couple thousand people on the podcast, and there's at least, I promise, 20% of them, at least in my patient. In yours, it's 100% of your patient population, but in mine, it's close to 50. And it's only menopausal women who were like, okay, I'm not sleeping. We need to fix this, because I don't want to die. What is she gonna do?

[B]

So the first thing that I do, which is why I carry those tissues, is I validate and I say, this is not a you problem. This is not an internal problem. This is something that we can work together. It's just not that something's broken in you. We can help. These are organic. Chronic insomnia, which is talked about a lot, is an organic medical condition.

[A]

Would you say that it is a predictable expected consequence of menopause and aging?

[B]

It's pretty darn common, yeah. And we need to do something about it. And we need to say to women, sorry, you don't need to, you know, you don't need to live with this. And again, that validation that telling women that they're not broken, that this is not something inherently wrong with them, they didn't cause it is huge. So I start there.

[A]

I see in my patients, and it's happened to me. Occasionally when you get that middle of the night wake up or you're struggling to fall asleep. I had trouble with falling asleep when I was younger and ended up doing CBT before I realized I was doing it, you know, and you get into that negative spiral in your head, like you. You were describing it of, oh, my God, I'm up. Shit, you know, I'm not. It's going to ruin everything. And why is this happening? It's horrible. You know, you were sitting there spiraling, alone in a room, struggling so hard. I need sleep. I need sleep. I just have to sleep, and I can't sleep. And I think it's affecting our mental health way more than we ever expected.

[B]

It takes a toll on someone's ability to maintain positivity, to feel like there's. Like there is hope for them. And that's what I tell women. That's the other thing I tell women is there is always something we can do to help you get better. Sleep. All is not lost.

[A]

What is one myth about sleep and menopause or just sleep in women and aging in general that you want to debunk?

[B]

Well, one of them is that you don't have to live with it, we don't have to suffer through it, that we can work together, that every 15 minutes counts. That's the other thing a lot of people get stuck. A lot of women come in and say, well, I'm only getting six hours of sleep or I can only get five. And I'll say, well, let's work on achieving an extra 15 minutes. Because if you add that extra 15 minutes times seven times, you know, 12 months, a whole year, that's a whole lot more sleep. So let's focus on the little wins and not have to think that we have to be perfect.

[A]

You've described sleep as a vital sign. What do you mean by that?

[B]

So, you know, why do we check vital signs? Because we know that they're screening tools. They're screening tools. We know that there's something that we can do about them. We know that also treating somebody's high blood pressure, treating somebody who has an abnormal respiratory rate, that actually is going to help them with reduction of other medical conditions.

[A]

Right.

[B]

And so that's why I think that sleep should be a vital sign, because, again, it is the foundation. It's the core. We could be chasing our tail with high blood pressure if somebody is not getting enough sleep. We could be chasing our till. If somebody has untreated sleep apnea, and we didn't realize that they were spending eight hours in bed, but they were only getting five hours of sleep.

[A]

What gives you hope right now in the field of women's sleep medicine?

[B]

This increased awareness and me just kind of ringing that bell over and over again. And people like yourself and all of us out there who are taking notice and giving women agency and knowledge to have these types of conversations with their provider.

[A]

How can someone find a sleep medicine specialist?

[B]

So you can look online on the American Academy of Sleep Medicine has a list of providers. There are sleep providers in just about every city. And I, you know, I think that that's a good place to start.

[A]

So you developed something called the dream sleep method.

[B]

Yes.

[A]

Am I saying that correctly?

[B]

Yeah. What is it? So it is an acronym to cover all of the different bases that could be affecting your sleep. What I hear a lot from women is that they got told that they didn't have sleep apnea because they had a home sleep study and that there was nothing else that could be done. So, you know, gotta figure something else out. So they come to my office in appointments feeling pretty hopeless. So what I realized is that there's all of these other factors that could be affecting people's sleep that are not really getting addressed. So the dream sleep method is basically an acronym for all of those bases to cover. So D is your daytime activities. So what are you doing during the day that could be affecting your ability to get to sleep? Are you running around? Are you feeding yourself correctly? Are you giving yourself enough water? Are you stressed out all day long and then bringing that into the bedroom? So that's daily activities. That's the D. R is the resting environment. Is your bedroom too cold, too hot? Is the mattress uncomfortable? Do you have a TV that you have to have on all night? Is there too much light coming into your bedroom? So you wanna make sure that the bedroom is dark, cool and quiet and that you're optimizing that resting environment for sleep. And then e are the emotions. So, you know, are you struggling with depression? Are you struggling with anxiety? Are you struggling with trauma that is affecting your ability to get to sleep and stay asleep? And then a is archetype or your chronotype. So are you an early bird, but you work a night shift. Are you a night owl or what I call an Aphrodite. So I call Artemis is your early bird. Aphrodite is your night owl. But you have to wake up really early to get to work or you've got to take kids to school or you've got some other commitment and you can't follow your true circadian rhythm. Or are you an Athena, which is basically somewhere in between. And. And you're able to kind of fit into the norm, the societal norm, which we have here in the United States, which is like 10pm to 6pm but knowing what your circadian rhythm is is really important to understand how you get into the right stages of sleep and then the last one. Are medical conditions. Do you have untreated sleep apnea, restless leg syndrome, a neuromedical condition, a cardiovascular condition, menopause, all of these things.

[A]

Having to get up to pee. Yeah, yeah. Multiple times at night.

[B]

That's right. That's actually a risk factor. I have so many urologists refer patients to me because getting up to go to the bathroom in the middle of the night can be a risk factor.

[A]

Amazing. Is there anything else you want to tell our audience?

[B]

Well, I'll just kind of leave again with. There is always something you can do to help yourself get better. Sleep. All is not lost and that nothing is. Nothing is wrong with you. There is something that we can do to help you feel better about your sleep, feel confident again about your sleep.

[A]

Amazing. Thank you so much for joining us on paused. You're menopausal now.

[B]

I'm post. Yeah. Post menopausal.

[A]

You're done.

[B]

I am done.

[A]

So menopause for a lot of our listeners. Not me anymore. I feel like I am my absolute most badass self now. Feels like that the world wants us to hit pause. The world wants us. You know, we tend to be invisible. Women really, really feel invisible. But what are you doing to unpause for yourself?

[B]

I reinvented myself. This was my reset. And that's. That is the one thing I want to leave people with, is that even if you've had years of bad sleep, you can still. Still reset and enjoy the rest of the decades that you have left to live. And with menopause, my f jar got empty and I said I am over this. I am not going to be invisible. I'm going to be heard and I'm going to raise awareness and I'm going to help other people know that they have power in themselves. There's a group of other people that want to promote health and that we have a whole nother second half of our life to live even bigger and better.

[A]

Awesome. Thank you so much for joining us on on pause.

[B]

Thank you.

[A]

You can find Andrea on Instagram rndreamatsumura and through her website sleepgoddessmd.com youm can find full episodes of Unpaused on YouTube at Dr. Maryclair. I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram @Doctor Maryclair and get honest, accurate information on health, fitness and navigating [e-mail] My upcoming book, the New Perimenopause is available for pre order on Amazon. If you're loving this podcast, I have an important request. Please take a moment to follow Unpause on your favorite podcast app. Following and listening is what pushes this information to more women who need it. So if this podcast has helped you feel seen, understood or supported, hit follow right now so you never miss an episode. Thank you for being here with me. Let's keep going. Unpaused Unpaused is presented by Odysee in conjunction with pod people. I'm your host, Dr. Mary Claire Haver. The views and opinions expressed on Unpaused are those of the talent and guests alone and are provided for information, informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis or treatment.

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