Transcript
Speaker: So i had a patient tell me recently that she has slept terribly for the last five years and that she's just been trying to suck it up. And I just felt like that was so awful. She was so miserable. And I know how miserable I feel when I don't have a good night's rest. Having that for Five years is unimaginable, especially when there's treatment available. We've got science behind sleep. We've got medications. We have non-medication treatment. There's so much out there. And that's why I'm excited to have you join today. Sometimes I don't know if anybody's listening.
Speaker: Is anybody out there? But then I hear that people are enjoying the podcast episodes I'm putting together. If you are one of those people, please like and subscribe. So I know that there are people out there listening that keeps me continuing on. And then you'll get notifications when there's a new episode. Also, if you know someone who could use the information that I'm putting out there,
Speaker: Please feel free to share and forward. I love your support. Thank you. Dr. Andrea Matsumura is a double board certified sleep medicine physician and nationally recognized expert in sleep and menopause. She's the creator of the dream sleep method and the sleep goddess archetype frameworks that help women understand the biological drivers of sleep disruption in midlife.
Speaker: She serves as chief of sleep services for Monarch MD and focuses on evidence-based hormone informed and behavior driven approaches to sleep. A frequent speaker and media expert, Dr. Matsumara has been featured in the New York times, CNN, Shape, Alloy Health, and appears regularly on podcasts and national television. Please join me in welcoming Dr. Matsumara. Okay, so as I've just mentioned, I have Dr. Matsumura with us. She is an expert in this area of sleep. And if you are not getting sleep, you need an expert to help you with it because it is such an important part of your quality of life and of your health. So thank you so much for being here with us. Thanks for having me. This is going to be fun.
Speaker: Yeah, I want to just dive right in. So can you tell us about the science and how the science translates to our middle of the night waking up? i know there are hormones involved. We see this happening in perimenopause and menopause. But what is happening in our body that's disrupting our sleep beyond just sort of the hot flashes or night sweats?
Speaker: Well, it's really about how progesterone and estrogen support sleep in many different ways. The big one that i see a lot happening when women particularly will have reduction in their progesterone is that they suddenly are having some trouble getting to sleep and getting into the right stages of sleep. Secondly, estrogen really supports sustaining sleep and it actually does support REM sleep.
Speaker: And when you have this fluctuation in estrogen and then a significant reduction in estrogen, that also then affects the vasomotor area in the brain. So then you have these hot flashes, you have the middle the night awakening, but in in turn, it is also affecting sleep architecture.
Speaker: And what I mean by sleep architecture is that these stages of sleep that we need to be getting into can be affected. And it can continue to be problematic for women even when they start on menopause hormone therapy because we're not replacing what we have lost. We're simply reducing symptoms.
Speaker: There isn't enough data out there to say, are we replacing, are we providing women with enough to actually make every symptom disappear. You know, we have so many estrogen receptors all over the body.
Speaker: I don't think that's ever going to be a reality that we can replace everything that we have lost. We're just trying to mitigate symptoms. Yeah. Yeah. I mean, that's so validating for people out there who are listening and wondering, you know, I started hormone therapy and I'm still not sleeping. And I think that's that's really helpful to know, although a little bit disappointing too. It is disappointing. I mean, the other piece is that estrogen does actually modulate melatonin and melatonin and cortisol also have this relationship.
Speaker: And what we don't learn in sleep medicine and fellowship is that we are actually losing the production of melatonin as we age. And for some, it can be as high as 50% by age 50. I want to let out the audience know that melatonin is not a food supplement. It is an actual hormone. We have 50 hormones in our body. And when we lose a hormone, we typically replace it. You know, when you need insulin, we replace it. When you need thyroid, we replace it. Estrogen, progesterone, we're replacing hormones. And there just hasn't been any data or real research in the United States because in 1994, it was deemed as a food supplement. And so we don't have high quality data. So we have this disconnect around melatonin, melatonin signaling gets weakened and then cortisol is doing what it's supposed to do. It starts to rise in the middle of the night and then peaks when we're waking up.
Speaker: However, when you don't have any buffering system for it, it may be waking people up too early and then you wake up and you fire off your sympathetic response, right?
Speaker: So then it goes up even higher. Right. Yeah. ortisol ah Okay. And so that's why women are waking up at 3 a.m. I mean, that's what I hear over and over and over. It's always 3 a.m. Yeah.
Speaker: Yeah. It's a variety of issues. The other piece, the elephant in the room, if you will, is that estrogen and progesterone really support airway structure and ventilation. And you know what we're trying to catch up on is the fact that women in midlife are at high risk for sleep apnea and The literature that is out there reports anywhere between mid 40% to up to 60% in some of the studies. And nine out of 10 women don't know that they have it because we do not present the same way. When you think about those numbers, that means one in two women may have sleep apnea. They don't know that they have it.
Speaker: Progesterone really helps with ventilation. Estrogen actually helps with oxygenation. how Our airway is supported by estrogen.
Speaker: And when we lose these two, even with replacement, so there is some preliminary, you know, emerging data coming out that shows that menopause hormone therapy is not going to fix that issue. And we need to pay attention. It needs to be front and center. That women are at risk for sleep apnea, which poses a potential risk for heart attacks, strokes, neurocognitive issues, memory loss, lower quality of life.
Speaker: Yeah. Yeah. That is really, i mean, that's so huge. And I want to ask you as follow-up, you mentioned that women don't present the same way with sleep apnea. So well patients use, you know, use snore and they're like, no, no, no, I couldn't have sleep apnea. I don't know. But what is it for women? Right.
Speaker: Well, you know, first of all, the thought of being diagnosed with sleep apnea and potentially using the treatment that is most common and has the most evidence around it, which is a form of positive airway pressure, which is continuous positive airway pressure stops women from even getting tested. Another take home point in this conversation is please, please.
Speaker: get the test. Information is valuable. What you do with that information is really up to you and your provider, but at least get the test. I present typically for a midlife woman.
Speaker: However, the literature is not giving us that information. All the data, all the studies were are really focused on a male model. So the typical loud snoring The witnessed apneas, the waking up with a dry mouth, that's seen in men. And in fact, all the screening tools are gender biased.
Speaker: When we think about the stop bang, the G stands for gender. You're losing a point right there. Women present with insomnia, daytime fatigue. that I hear women say all of the time, I don't know if I'm depressed because I'm sleepy or I'm sleepy because I'm depressed. Interesting. And they may have migraines or wake up with occasional morning headaches.
Speaker: So these symptoms are part of the sleep disordered breathing issue, but they also are not specific symptoms. And I have a pretty low threshold for testing women for sleep apnea simply because of the data that's coming out showing that virtually when we think about those numbers, one and two women, I mean, that's a lot. Yeah.
Speaker: Yeah. Yeah. And it's so much easier to test now, right? I was pretty convinced with my last pregnancy that I had sleep apnea because I was like, my body's changing and I don't feel refreshed when I wake up. And I talked to my doctor about it and she ordered me a sleep study and I was actually lowered the threshold of me being willing to do it because I could do a sleep study at home.
Speaker: I got all the gear set up and all of that, which it still said I didn't have sleep apnea. And I'm like, i sure But, but. Well, so that's the thing. You just brought up a really good point is that when women have a lot of symptoms, the studies themselves were tested mostly on male models.
Speaker: Not a parent woman. Right. Or in midlife. or and one ah Yes. And home sleep testing is by and large used in people who have low risk for other comorbidities, but may have a high pretest probability for sleep apnea. So the notion and idea of I don't have to go into a sleep lab, it's akin to...
Speaker: saying, I need to get that MRI. And in fact, you need a plain film first, right? I would say that the type of testing is not a check the box choice. It's about the clinical indication. Is there a clinical indication for an in-lab versus a home study? And for women who have symptoms and they have a negative home study, I want to get those women into a sleep lab.
Speaker: Okay. All right. Well, I'm learning so much. and i'm like I'll help my patients more as well. What's really the difference between insomnia that you see with the hormonal shifts of menopause? You know, I have ah i have a large menopause, perimenopause practice. And so most of the time I do feel like we're getting huge improvements with hormone therapy. And I don't know, I don't have an accurate number, but I feel like 70% of the time it's kind of yeah depends Right. But there are other types of insomnia. And even apart from sleep apnea, how can a woman know if this is from the hormonal shifts or like you mentioned, mood changes or mental health issues? This is also a time where there's so much stress put on women, whether it's because of caregiving or work. We see anxiety show up for women. And that's what I hear from my patients. Like they wake up with all this anxiety.
Speaker: How can people tell if it's, you know, because of the hormonal treatment or something more or Sometimes it's difficult to decipher. You're right. And anecdotally, that is the number that I see. I see around 30 to 34% of women who are started on menopause hormone therapy, they continue to have symptoms. And that insomnia may be due to sleep apnea, may be due to restless leg syndrome. which can present as anxiety because you're waking up and your body reflexively may be telling you, hey, wake up, breathe. And then you have this knee-jerk, sympathetic, you know, release. And then you wake up feeling like you're anxious. Other times, again, that when we think about the systems in place that help to bring balance to the body metabolically. When we lose the estrogen and the progesterone, and we're also losing or have a weakening signal of the melatonin, then you do have this kind of lower threshold or anxiety because that sympathetic part is not buffered with these systems.
Speaker: And so it's not only about potential past trauma, maybe current trauma that's happening to your body physiologically, right? It is just kind of a new norm. And then your brain is trying to compensate and it basically learns a new pathway for sleep, which is hyperarousal,
Speaker: It may be sleep onset insomnia. It may be sleep maintenance insomnia. It may be what we call terminal insomnia, meaning that you wake up earlier than than you want to an hour or two before your alarm. Or it may be just unrefreshing sleep and mixed insomnia. So a number of things occurring. And then there's also an entity called co-misa, which is the combination of obstructive sleep apnea and insomnia. And you have both things together.
Speaker: Oh, my gosh. So basically, they need to come see a sleep expert. I mean, I'm beyond the scope of myself as a gynecologist. Yeah, you know, zog diations to sleep ex totally. I mean, here's the thing. Sleep is one of is sleepy. I mean, it's a fairly new subspecialty. It's only about I don't know the exact. I lost track. I want to say it's under 60 years old. It's not older than that. And, you know, again, when we couple that with women finally being included in studies in 1993, then move forward to the general thinking that.
Speaker: sleep problems were a man's disease. We're woefully behind in treating, diagnosing, and helping women develop a path to good sleep. And my mission in the work that I do is to really stop the normalization of the suffering of women through every stage of life. And in part, it is due to lack of sleep. I feel like sleep is the OG longevity tool.
Speaker: we don't we We don't need supplements. We don't need to hack our way into anything. We need the core foundation of sleep or else it's harder to exercise.
Speaker: It's harder to get that nutrition. Your pain is worse. Medications don't work as well. Your emotional regulation is off. I mean, everything is off. Yeah, you're so right. Okay, so for that woman who's waiting to have her an appointment go with a sleep expert and she's waking up at 3 What should she or should she not do? oh yeah. Unpopular opinion is that there is actual evidence around it.
Speaker: When you cannot get back to sleep, you really should try to help yourself by getting out of bed and doing really something that's very relaxing. That is an intervention called stimulus control. it is one of the core components of cognitive behavioral therapy for insomnia. That is the gold standard treatment treatment. for chronic insomnia and all of its forms. Your sympathetic is firing. you You're yeah trying to calm yourself down. Is that the idea?
Speaker: Well, the reason why it's called it stimulus control is because we want the brain to recognize that your bed is only for sleep or intimacy. And it's not for ruminating,
Speaker: thinking it's not for working in bed. It's not for eating in bed. Our brains are like those Pavlovian dogs. You know, if if we spend time in bed doing other things, it's going to be like, well, I guess this is like the kitchen table or the sofa. I'm not sure what I'm supposed to be doing. But it's an unpopular opinion because it is not comfortable when you have to make yourself get out of your bed. And it sounds counterintuitive. And again, this is a general recommendation.
Speaker: Cognitive behavioral therapy is not cookie cutter. It needs to be personalized for every patient. Yeah, that makes sense. And what about for women who are having a hard time falling asleep? I feel like I see that less often. Most of my patients say like, I'm so tired, I can fall asleep, but it's staying asleep. But I do have the occasional patient who can't fall asleep. That is around, you know, the general, again, general recommendations would be pick a time that you wake up and stick to it.
Speaker: And then dial it back, you know, the seven to eight hours and then try to get into bed from there. And if you're not able to fall asleep within 20 minutes, get back out of bed and wait until you're sleepy enough to get back into sleep. Getting up out of bed. This is like, ah it's called sleep compression or sleep restriction.
Speaker: So when I always give the analogy of an accordion, you first have to press it out for it to for it to relax, right? yeah and And this type of sleep restriction, what it does is, again, it's not comfortable, but it builds the sleep pressure so that your body, you're forcing it to have to expand its sleep over time because you're going to give yourself not enough sleep by this sleep restriction.
Speaker: And then your body is going to say, oh boy, I'm tired. I got it. You need to get into bed a little bit earlier. And that is another core component of cognitive behavioral therapy for insomnia. You typically, let's say you get into bed at 10, you never go to sleep until 12 and you have to wake up at six.
Speaker: Now, this is for the person who's already been evaluated and they do not have delayed sleep phase. That's a circadian rhythm disorder. And we have to make sure that you don't have delayed sleep phase and that this is sleep onset insomnia because they're different. The whole concept is that let's say you never get to bed until 12. So you don't get into bed until like 1130 so that you can fall asleep at 12.
Speaker: And then maybe after a week, you're just struggling and you say, okay, I'm going to go to bed at 1115 and you dial it back 15 minutes and you're retraining the brain. The brain is basically, um it's our biggest muscle, you know, and it's just like this muscle.
Speaker: When we start an exercise program, we don't go and lift 50 pounds. Right. Right. We start small and it's all about small incremental change for a big change over time.
Speaker: Yeah. Oh, that makes sense. It's so interesting. I love, i love it. This is your area of expertise and I love it. There's people like you out there to to help women. And like you said,
Speaker: They should not be suffering. You know, I always start off my podcast with a bit of an anecdote. And my anecdote for this one is a patient I saw recently who told me that she's had terrible sleep in the last five years and she's just been sucking it up. and Why?
Speaker: Why are you doing that when you can get help? And I'm sure you see that a lot. Oh, I carry tissues around with me when I see patients because the delay in diagnosis, it's like eight years, 10 years, and they've been talking to folks. And the fact of the matter is that the providers out there in our communities, they're doing the best they can. We just simply weren't taught any of this. And in fact, that call to action is missing from the physician community because we have been conditioned to not to think about sleep when we are in medical school, when we are in our residency. And we learn that sleep is not priority. That's Yeah, you're right. You're right. but don't make that for ourselves You're blowing my mind here. yeah so when talk about it with other um Yeah. So that call to action is missing. And we, you know, physicians, providers, they talk about things that they feel like they know, they know that
Speaker: pain sucks. They know that not breathing sucks. They know that having a heart attack is terrible or having cancer is horrible, but it's elusive when it comes to sleep. And in fact, there's data out there, survey data on doctors and providers, and it's on the upwards of like 34% of docs don't get good sleep. Oh my gosh. Yeah. Oh my gosh. I mean, this was one of the things I was most terrified about going into OBGYN residency. It's like, how am I going to function without, you know, six hours of sleep straight? And to be honest, my intern year was the year that they changed the work restrictions. And I was like,
Speaker: phw i mean, we had more working days. So it was kind of more like a marathon, but I was able to get on most nights, six hours of sleep, which I think was, you know, met with a lot of resistance in the medical community. They're like, we don't, you know, we've got through this without work hour restrictions. Everybody should, should be doing that, but it's just not safe. Right. and the data is not. I mean, I trained.
Speaker: I started in 1999, so I missed I missed all of those changes. However, it's really important that doctors and providers take care of themselves first in order to treat others. And you are absolutely right. Your profession doesn't do itself any favors around.
Speaker: sleep as being important, the kind of call that your specialty has to take. yeah It's yeah really hard physically on your body and mentally. Yeah, you're right. It's I think the shift work, especially, you know, whether it's emergency medicine or obstetrics, that takes years off of our lives, which is awful.
Speaker: But yeah, It's a tough one. I don't do obstetrics anymore, but you know it is it's just a really tough thing for for people who do. And so, yeah, I'm sure you have a a lot of patients who are are medical providers or they need to be your patient because they You need to find a way to get them. oh They're the funniest because they like downplay everything. Oh, you know, I'm just not getting that I think I probably just have sleep apnea. You know, I just probably need to get it tested. When in fact, nine times out 10, every single one of my patients has more than one sleep issue going on. And we need to treat all sleep issues.
Speaker: Yep. Anywhere between two to four is the average. It's not just one thing that people come in with. Oh my goodness, that's a lot. And do you sorry, if you don't mind me asking, do you also prescribe hormone therapy as part of your treatment for people or do that in combination with people?
Speaker: Yeah, I do. i started to to do that about five years ago and then I went and got menopause certified when in fact, you know, I'm originally an internal medicine doc and then I went into sleep medicine, did a fellowship. And, you know, as a primary care doctor, i was a already kind of doing that. So I was relieved to see that the test was pretty, it's a good test, but it was things that I was already doing. So I felt good ah good confirmation on that.
Speaker: yeah The fact of the matter is yes, that's you asked me if I was prescribing it. And yes, in fact, I do when I see, because I feel like I'm living sometimes in this little bubble where everybody has heightened awareness. But then when I go out into the communities and I do presentations,
Speaker: I'm floored at the physician community. We've done a disservice to the provider community because they literally don't connect these dots because we haven't done the education that we need. Yeah, you're right. And you mentioned something earlier when we were chatting about like the sleep syndrome of menopause. Can you tell us more about that? Yeah, it's something I've come up with. I coined this term because what I found in my midlife women was these four things that kept coming up. All of a sudden, women were having trouble getting to sleep, staying asleep, that 3 a.m. wake up, waking up a couple of hours before their alarm clock or getting enough hours and simply feeling unrefreshed. And it's these four symptoms, these four things that come up for many midlife women. And it's teasing each one of those out
Speaker: and figuring out what that driver is. That is so helpful. Sometimes just having a name to name something helps to not only validate a person's experience, but then also help to get other people to recognize it and treat. So that's really great. Thank you for coining that.
Speaker: So in terms of looking forward, you know, if there's anything that you could change about how sleep is addressed in menopause care or how training is done and how to help women out there, what would you want to see? I'd want sleep to be a vital sign.
Speaker: I think that it is important because if your blood pressure is getting elevated, if your heart rate is elevated, if all of a sudden your oxygen level is changing, these are all potential signs that maybe something's going on with your sleep. And in fact, again, what I said earlier,
Speaker: about sleep. It's the core pillar. Like we are so diseased focused still in medicine and we are not really in that prevention mode. And this is all about prevention, heading things off at the pass. And if we can address the sleep issues first, then we may prevent a lot of other disease processes down the road.
Speaker: yep. You're right. I mean, that's like mic drop. That's it. That's It is so valuable. And I think people don't realize that until they don't have it. Right. And so thank you so much for sharing your expertise. You've been so enlightening. I've learned something and I'm sure that the people listening have also learned. And I think people can follow you. We've got all of your information here. We'll list out for you that, you know, you show up all the time in in different media outlets. i see your work out there. can can follow you for more information and more insight, especially as this field is growing.
Speaker: Yeah, absolutely. And thank you. Yes, you can follow me on my website. And I would encourage people to sign up for my newsletter because I give information in my newsletters. And I'm going to be having educational sessions that people can sign up for in the fall. I'm going to have a book coming out next year called When Women Stop Sleeping. It's really the first of its kind. There's no book out there that talks about women's health and sleep. Giving you agency, awareness, a roadmap. And at the same time, I'm building a course for healthcare providers because I definitely don't want all that this lovely material in women's hands. And then they go to their doctor or their provider and they're like, who's this lady who wrote this book?
Speaker: Yeah, you're right. You have to do the work on both sides. Yeah. Well, you're not alone. We support you and I'll do what I need to do to learn as well. Thanks. Yeah. But thank you so, so much for your time. I really appreciate it and look forward to the seeing your book. All right. Thank you. Thanks for having me.
