00:00:17
Speaker 1: Pushkin. On every episode of Decoding Women's Health, we talk about the science behind women's bodies and share stories from leading researchers and clinicians. But now I want to hear your stories and your questions. No question is too complex, awkward, or small. So tell me what kindacologic questions have been on your mind lately. We'll get into everything from entimetriosis to fibroids, pms, pcos and more. We really want to hear from you, so please send your questions to us at Decoding Women's Health at Pushkin dot fm. That's Decoding Women's Health at Pushkin dot fm, or feel free to leave us a voicemail at four FI five two oh one, three three eight five.
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Speaker 2: This show is not a substitute for professional medical advice, diagnosis, or treatment. It is for informational purposes. Please consult your healthcare professional with any medical questions. Also in this show, we use women as shorthand for people with XX chromosomes. We understand sex and gender are more complex and acknowledge the experiences we describe reach beyond that word.
00:01:48
Speaker 1: Doctor Jade Wu has been fascinated by sleep since she was a toddler. Growing up, she lived at the China National Space Administration base, where her father studied. House Space travel impacted the sleep of the country's first space team.
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Speaker 3: That was my first introduction to sleep when I was, you know, three four years old, just toddling around the sleep lads with the astronaut.
00:02:11
Speaker 4: So, you know, it made an impression.
00:02:13
Speaker 1: So much so that doctor Wu has devoted her entire adult life to the study of sleep. Today, she's a Board certified behavioral sleep medicine specialist on the faculty of Sunny Upstate Medical School, and she's the founder of the Thrive Sleep Clinic in Durham, North Carolina, which treats people in most states through telehealth appointments. She's also the author of Hello Sleep, The Science and Art of Overcoming Insomnia Without Medications. One of my patients shared doctor Wu's book with me a while back. I was instantly drawn in by her concept of treating sleep as a friend instead of like a problem that needs to be fixed. I knew I wanted to have doctor Wu on the show because we all put so much pressure on ourselves. We fixate on questions like am I getting enough sleep? What about deep sleep? And is it okay to take a nap. Doctor Wu has answers to all these questions, and I find her perspective on sleep to be so refreshing. Her approach is grounded in reality and in science. So today we'll be talking about what you actually need to be focusing on so that we can get to when I think we all want at the end of the day, better sleep. When you're assessing an individual's overall sleep pattern, what do you do? How do you determine if somebody's lacking in sleep? Like where do you start with them?
00:03:48
Speaker 3: So there are a couple of things we want to know. One is are you sleepy during the day? Like are you able to stay awake when you should be staying awake? That's really the most important question to ask because if you have no problems staying awake and you are energetic during the day, you're alert when you need to be alert, then probably you're sleeping. If you're not getting enough good quality sleep, you will be sleepy during the day. Because you know, sleep is kind of like food or water. You know, your body really craves it. Your body really wants to sleep, just like it really wants food and water. So the most important thing to know is are you sleepy during the day.
00:04:29
Speaker 1: What are some of the common misconceptions that you hear from individuals about sleep, Like, for example, I hear that you know everybody needs at least seven hours of sleep? Is that a misconception? Can some of us get by on less sleep if we feel well?
00:04:45
Speaker 4: Yeah, so you nailed.
00:04:46
Speaker 3: One of the most common ones is that you know eight hours of sleep is the magic number and everyone should get that. Some people need more, some people need less, and even within one person. How much sleep you need and the shape like your sleep, the pattern of you your sleep is going to change throughout your life, depending on your current lifestyle, what your body's needs are. So, for example, when you're a teenager, maybe you need an and a half hours of sleep. Most teenagers are not getting nearly that, so most teenagers are actually sleep deprived. But as you get older, as you get into mid age, you're not going to need that much anymore. And as you get into even older age, like retirement age, you're not going to need that much anymore. Part of it is determined by our genes, and part of it is determined by our life stage and our lifestyle. How much sleep you need varies across people and varies within ourselves.
00:05:38
Speaker 1: So why do we need more sleep when we're younger and less sleep when we're older. What's going on?
00:05:43
Speaker 3: Well, think about what sleep really is, right. Sleep is really just recovery from what the body needs to do, and it's also time for the body to do something behind the scenes work.
00:05:54
Speaker 4: Right.
00:05:55
Speaker 3: So, when we're younger, when we're go through puberty, for example, our bodies are physically growing at a pretty rapid pace, and we're releasing sex.
00:06:04
Speaker 4: Hormones and growth hormones.
00:06:05
Speaker 3: We're learning all kinds of new things about the world, you know, the pace at which we're absorbing new information and learning new skills, and you know, learning to learning the hard way of how to relate to people and how to figure out ourselves who we are. All those things are happening so quickly and at such an intense level that we need a lot of recovery at night, and we need a lot of opportunity for behind the scenes work to happen. Whereas once we're adults, there's still a lot of maintenance work going on. But we're not going through puberty. We're not at our reproductive prime anymore like eighteen year olds are. So we just need to recover from less, so we need less sleep.
00:06:47
Speaker 1: There must be a difference between I don't sleep and I feel really tired, and I don't sleep and I feel great. But are we doing harm if we feel great and we don't sleep that much.
00:06:56
Speaker 3: That's the exact right question to ask, because how well you feel is the better marker of whether you're getting enough sleep than some arbitrary number. Some people do only need five or six hours of sleep, but not common, so it's probably better to err on the side of could I get a little more sleep, you know, could I feel a little bit better? But if you can't get more, and you really only can get five or six hours and you feel good, then that's all you need. If you only get five hours of sleep and you feel great during the day, but that's because you're pounding five espressos before ten am, that does not count ups.
00:07:37
Speaker 4: That's bad. YEP.
00:07:39
Speaker 1: Talk to us about sleep deprivation. Why is sleep deprivation not the same as insomnia? Or maybe it is? And if you are have sleep debt, can you make it up if you sleep on the weekends.
00:07:50
Speaker 3: Well, sleep deprivation in insomnia are very very different things. If you imagine a ven diagram with two circles. They are two separate circles with a little bit of overlap. And this is probably surprising to most people. They're like, well, if I haven't samnia, if I can't fall asleep, doesn't that mean I'm sleep deprived. But sleep deprivation is when you don't have enough opportunity to sleep. That's like, if you're working three jobs and you only have five hours to lie down to be horizontal, you're sleep deprived. If you're a prisoner of war and they are throwing cold water on you every hour, you are sleep deprived. If you're sleep deprived, you know it. If you hit the pillow and you're out like a light, that means you're sleep deprived because your body was so desperate to get to sleep. Whereas insomnia is when you have enough opportunity to sleep, but you're struggling to fall asleep or stay asleep, or you're just not happy with your pattern of sleep. So I want to reassure people even if you have insomn yet, that does not mean you're sleep deprived. Can you make up sleep debt on the short term? Yes, ish. So, for example, if I pulled an all night or last night for some important reason, and I'm pushing through today. I can go to bed really early tonight, I can sleep in tomorrow, and more or less, I'll be Okay, that's not a big deal. But if I do that night after night after night, there's no such thing as catching up on a whole week's or a whole months, or whole decades worth of sleep debt. That just simply can't happen. The damage is done. It's never too late to improve your sleep, but you're not going to catch up on ten years of sleep debt.
00:09:23
Speaker 1: What kind of damage does sleep deprivation do? What is it doing to our brain? What is it doing to our body?
00:09:29
Speaker 3: It's not just about sleep deprivation. It's also about disruption to our sleep consistency and our sleep schedules. But let's all lump that together and say sleep disruption basically causes chronic inflammation. It's basically chronic stress to our bodies on a cellular level, on a molecular level, of our mood, of our metabolism, of our brain functioning.
00:09:53
Speaker 4: It's like saying, you know what.
00:09:55
Speaker 3: Happens if we're chronically food it deprived, or chronically water deprived or chronically oxygen deprived. You know, it's something so essential to every aspect of our functioning, on every level of our biology.
00:10:07
Speaker 1: Do our bodies ever adjust? Do we ever get used to it?
00:10:10
Speaker 3: No, we can sort of fool ourselves into thinking that we're getting used to it, but that doesn't mean it's not doing damage.
00:10:16
Speaker 1: I want to get into a little bit about sleep architecture. Can you tell us what sleep architecture is and the different phases of sleep?
00:10:25
Speaker 3: Sleep architecture refers to the shape of your sleep over the course of one night, and it specifically refers to the transitions and the proportions of different types of sleep that you're getting. So usually we refer to these as stages of sleep. I don't love the worst stages because that implies that you know, some are better than others, or you're trying to pass through levels like through video game, you're trying to get to later stages. But it's actually really more like different types of nutrition. You know, a balanced plate is the best most nutritious meal, right, A balanced sleep architecture is also the best healthiest night of sleep. So, for example, we have rem sleep and we have non rem sleep, So I'll do non rem sleep first, because that happens in the first half of the night. Non run sleep is generally broken up into three different types. We have what we call stage one or light sleep, Stage two or light sleep, and stage three or slow wave sleep, deep sleep, delta sleep. There's lots of names for deep sleep, and these stages all are important. Stage one is really basically a transition between wakefulness and a sleep. So that's kind of like the gateway where you're starting to get relaxed. You know, your body is starting to slow down and get calm, and your brain is starting to lose track of your environment. Stage two, that's where you're fully asleep now, but you're still easy to wake up from your sleep, so that's why it's still called light sleep. The important thing to know about stage two light sleep is that it's supposed to take up about half the night. Usually people say, oh, I want to get more deep sleep, I don't want light sleep, you know, get me as much deep sleep as possible. But actually, in healthy sleep, fifty percent of your night should be light sleep. And during light sleep there's memory consolidation going on. Your brain is practicing skills that you learn during the day. It is really important. And then there's deep sleep that's a stage three sleep, slow wave sleep, delta sleep that should take up about fifteen ish percent of the night fifteen and if you're younger, maybe about twenty percent. So if you're in your twenties, maybe twenty percent. But in midlife people, older people, ten fifteen percent is perfectly fine because remember, at different stages of our lives, our bodies have different jobs. And then rem sleep rem sleep is really fun. This is where dreaming happens, and it happens mostly during the second half of the night. Emotion regulation sort of nighttime therapy is happening. Rem sleep is doing memory consolidation, and that should take up about twenty five ish percent of the night twenty to twenty five percent overall, And we're sort of cycling through these different types of sleep throughout the night. But mostly non remsleep happens in the first half. Remsleep mostly happens in the second half.
00:13:28
Speaker 1: So I always say that if you go through Manhattan, you're going to see lights on at three o'clock in the morning, right two o'clock, three o'clock in the morning, Like every midlife woman is like this, awakening pattern is somewhere between two o'clock and three o'clock. I find when I speak with women, why is that? Why did midlife women just wake up all of a sudden at two o'clock or three o'clock and then can't fall back asleep.
00:13:48
Speaker 3: So it's not just midlife women. Everybody wakes up during the night, everybody. So a healthy night of sleep for a healthy person in there, let's say forties, involves about over a dozen awakenings. They're just so brief that you usually don't remember. The brain doesn't log that in its long term memory because of it wasn't important. It's just a quick awakening to see, okay, any tigers you know in the camp?
00:14:16
Speaker 4: No, okay? Back to sleep, And.
00:14:18
Speaker 3: Usually there is a little bit of a longer awakening that most people do not remember anyway, because again, it's not going to be that important. It's going to be so brief that happens at about two or three am, that one tends to be a little bit longer because it's the dropping of the baton between the non rem sleep that happens for the first half of the night and the rem sleep that happens in the second half. These two halves of the night are so qualitatively different that it's like a relay race run in two halves, and non realm sleep is passing the baton to rem sleep, and sometimes that baton is dropped, and that's okay because we're supposed to have that intermission. In pre industrial times, people used to get up for like a couple of hours at about two am three am, to sing songs, rise bread, visit their neighbors, do chores. They actually had a whole chunk of their life lived in that middle of the night, and then they will go back for their second sleep. This is what we call bi phasic sleep, as in sleep that happens in two phases. It's just that in recent you know, one hundred or so years, we've come to expect that sleep should be squeezed into one chunk, and then we're really surprised in midlife when our sleep is you know, a little bit more prone to being lighter, or our sleep is you know, tends to be a little bit more fragmented. We're suddenly noticing this natural biological pattern that, oh, we always do wake up at two or three am.
00:15:49
Speaker 4: That's natural.
00:15:52
Speaker 1: Still to come. Are you an early bird or a night owl. We'll discuss the body's natural preference to sleep and wake at certain times of the day, also known as chronotypes. Plus, doctor Wu tells us all about what it means to nap responsibly more in just a moment. So, you're a sleep psychologist, which means you study sleep and you treat various sleep disorders. What are some of the more common issues that you come across in your work, and especially with women and midlife women.
00:16:37
Speaker 3: Yes, the most common sleep problem I come across is insomnia, which should be no surprise to most midlife women. It's just such a common experience. In fact, our best estimates are that about thirty seven percent or up to fifty percent of perimen apostle women or postmon apostle women have some sort of significant sleep problem. They might feel irritable, they might feel like blood, they feel.
00:17:03
Speaker 4: You know, not at their best.
00:17:06
Speaker 3: They might feel exhausted even but they can't fall asleep during the day even if they tried. So that's a tricky thing about insomnia is that it's a twenty four hour disorder. It's not just about trouble falling or staying asleep at night. It's about all these experiences of hyper arousal, this wiredness during the day while also feeling really tired. So it's a little bit of a tricky disorder in that sense.
00:17:31
Speaker 1: So you can kind of say it's a lived experience, how You're that's right.
00:17:35
Speaker 4: Insomnia is not just one thing.
00:17:38
Speaker 3: It's not just hot flashes, especially if we're talking about midlife women.
00:17:43
Speaker 4: It's not just hot flashes.
00:17:44
Speaker 3: It's not just a little bit more back pain. It's not just some weighting. It is everything. Hormones impact everything. So for example, estrogen, Estrogen is not just a sex hormone. It is the CEO of the brain. It manages so many systems in the brain. It manages your muscle tone and manages your decision making. It manages the level of anxiety that you feel, the amount of attention that you pay two different things. Even within one day, your estrogen levels can go up and down and up and down, and that roller coaster is what really messes with all these other systems that then impact sleep. But alongside that, I also see circadian rhythm issues. So that's where someone's body clock, the timing of their sleep wake patterns, and the timing of their other biological processes are inconsistent or just off in some way, and that really impacts their energy, their health, their mood.
00:18:45
Speaker 1: And where does progesterone fit into this picture.
00:18:48
Speaker 3: Yes, progesterone is an important hormone as well that is also more than just a sex hormone. It tends to calm the whole system down. It works on the gava system, and the gava system is the system in the brain that is the breaks as opposed to the gas, So it sort of keeps everything more calm, post the brakes on things when they go out of control. When progesterone is less reliable, then the gava system is less reliable. We also get more fluctuation in things like your cognition and your mood.
00:19:25
Speaker 1: What we try to do many times is we say, okay, we'll add some progesterone to help mid life women's sleep, maybe estrogen also, if estrogen levels are really starting to fluctuate. But it's often multifectorial. Correct. Am I wrong in that? Because I rarely you just take a hormone and everything rights itself. It gets better maybe, but doesn't go away completely.
00:19:45
Speaker 4: That is totally correct.
00:19:46
Speaker 3: I hate to say it, but they're even progesterone is not a magic pill for solving sleep because the other problems are going on are you know, during midlife, we are more likely to have other sleep disorders like sleep apna. For example, sleep apnea is when we completely or partially cease breathing for a longer period than we should when we sleep, you know, up to ten seconds or even much longer than that. And when we stop breathing when we're sleeping, the CO two is building up in our blood and on our brain, and if that goes on for too long, then the brain goes, oh my gosh, crisis mode, what's going on?
00:20:28
Speaker 4: Why is there? Why are we not breathing? Are we dying?
00:20:30
Speaker 3: And it suddenly, you know, wakes you up to force you to breathe. You can imagine if that happens many times over the course of even just one hour, you know, severe sleep apnea is like thirty times per hour or more that that's happening. Then you can imagine how much that is fragmenting your sleep so that you can't ever get into deep sleep. You're always sort of floating on a surface, you're always getting interrupted. And also how much that's contributing to the amount of cortisol that is in your system. Cortisol is basically the stress hormone. You know, we should have it to sort of kick our butt into gear if there is if there are problems in the environment, if there's danger. But if that danger is you yourself stopping breathing every two minutes, that corto isola is going to be high all night long, and of course that's going to be problematic for our sleep. We also have a lot of you know, psychological factors during mide age, this is the age where we are taking care of kids and taking care.
00:21:27
Speaker 4: Of our parents.
00:21:28
Speaker 3: We're probably at a point in our careers or we have more responsibility, so we're multitasking, you know, if we live in a society where gender roles have not quite caught up to the realities of you know, women who have high level careers.
00:21:42
Speaker 4: We're also managing households.
00:21:44
Speaker 3: We're remembering whose birthday it is, whose shoes eyes, you know, is about to change. We're managing all these things, all these tabs in our brains that we can't close, and that makes it really hard to just quiet the brain down when it's time to go to bed.
00:21:59
Speaker 1: We need jill down on sleep apnea for just a moment, What causes sleep apnea and how do you know if you have it?
00:22:05
Speaker 3: Sleep Apnea is also multifactorial, so at the actual level of the apnea, it's basically a collapse of something in the airway, So that could be somewhere in your nasal passage that's usually more like in the back of your throat or even you know, more pressure on your chest. So one of the factors that increases the risk for having sleep apnia is excessive weight. For example, Another time that women can are more likely to have sleep apnia is during pregnancy, so there's more pressure more weight that you know, rapid weight gain during pro pregnancy. Of course that happens, but that ads more pressure to the airway and that makes it more likely to collapse and block the airway. Another reason is that as we get older and as estrogen goes down, we have less muscle tone, so there's basically less firmness in our muscles to keep that airway open. So with less of that firmness in our airways, we're more likely to happen in apnea. And also there are other factors that we don't quite understand yet, factors that also, people may not have control over So for example, East Asians are more likely to have sleep apnia because of our or facial bat structure. So I'm of East Asian descent, i am not overweight, and I am not in menopause yet, but I am more likely to have sleep apnia than my peers because of my rifacial bone structure. For women, it's hard to tell if you have it, harder than for men. In men, it's basically like if you snore, if you have high blood pressure, you know, if you're sleepy during the day, boom you pretty much we know you've got sleep apnia. For women, we tend to have more subtle signs. So instead of snoring like a freight train, we're more likely to hold our breath while we sleep.
00:23:57
Speaker 4: And not really snore loudly.
00:24:00
Speaker 3: We're more likely to have a morning headache or a tight jaw or dry mouth, and we might be more fatigued during the day rather than so sleepy that we fall asleep, you know, at the steering wheel. And that's why I really urge my women patients, especially in my midlife or older women patients, to air on the side of caution if they're not sure if they have sleep apia, just go ahead and ask for an at home sleep test from your doctor.
00:24:30
Speaker 1: And you can even order those online yourself, right, you can do like a telehealth and order yes.
00:24:35
Speaker 4: Yeah.
00:24:36
Speaker 1: My understanding and please correct me if I'm wrong, is that they have a really pretty good specificity, meaning if they're positive, they're usually positive, and you get to a sleep specialist. Right, And that's important to realize. I think that women and men presentlessleep atany a little bit differently. Can you see sleep apne on a sleep tracker, like on your device that you use to track your heart rate variability and sleep? Can you see sleep apnea?
00:24:57
Speaker 3: Not necessarily, that would not be a reliable screening. I have heard of people saying, like, my, you know, my heart rate variability is really off, it's or even my body temperature is high during the night, and that has led them to ask for a sleep study that then found sleep apnea. But it's not reliable to just look at your own sleep track of data and say I have it or I don't.
00:25:23
Speaker 1: It's really important to keep in mind, I think when we start to look at how women are sleeping in midlife, and to always remember to think about a sleep study and sleep apnea. Let's talk about chronotypes because a lot of us, again not to personalize all of this, but a lot of us are night owls. Right, we get jacked up at night, we're ready to go, but we live in a daytime world. Can you tell us are these chronotypes real?
00:25:46
Speaker 4: That's a fabulous question.
00:25:48
Speaker 3: So chronotypes are genetically predisposed, but they're also factors. But let's say, for now, genetically predisposed tendencies to sleep and wake at certain times of day. So this is just a natural variation diversity in our species. Just like height, some people are tall, some people are short. Most of us are somewhere in the middle. Right, Some people are night some people are extreme morning larks. Most of us are somewhere in the middle. And there is nothing inherently wrong with being a night all or a morning lark. I mean, imagine us being on the savannah alltogether. Let's say there's one hundred of us in the group in the tribe. I mean, some of us have to get up early to string the bows, but some of us also have to be awake late at night to look out for the tigers. Right, So it's good to have variation in our chronotype and chronotype is about fifty percent heritable, so like about half of it is from our genes and the other half is from like lifestyle habit of bringing environments things like that. It's tough because our current society really does expect everybody to function during the same chunk of time. So a lot of us have a hard time performing our best when we show up to work first thing in the morning because we're night owls, we naturally are just not at our best first thing in the morning. We're still trying to do ren sleep, you know, in our brain during that time, whereas our creativity and our productivity comes out at ten pm eleven pm midnight. So you know, it's it really is a waste of talent, I think to expect everybody to function at the same time.
00:27:32
Speaker 4: It's also a little bit risky.
00:27:34
Speaker 3: It's a safety thing too, because I don't know, I don't want to drive my kids to school at seven thirty am with people who are driving to work at that time who really should be sleeping. Right.
00:27:47
Speaker 1: I'm a huge fan of the power nap and what's happening when we nap, And is it reasonable for somebody who maybe is a night out that they're a little sleepier during the day. Maybe they take a power nap and they wake up. Tell us a little bit about the science of napping.
00:28:01
Speaker 4: I love naps.
00:28:03
Speaker 3: I highly recommend naps, But you have to nap responsibly because I love that nap responsibly responsible, y'all. Uh, naps are a double edged sword. So on the one hand, we do know from plenty of research that naps are really beneficial. Napping is also a natural biological pattern we evolve to have, maybe to avoid the hottest part of the day, or to catch up on energy. Whatever the reason is, we are naturally wired to nap in the early afternoon. And when we do listen to our bodies and nap in the early afternoon, we wake up with better energy, better mood, better cognition. So like faster reaction times, better decision making, you know, all sorts of benefits. Even athletes perform just a little bit better when they have napped, you know, And if you're swimmer, just the tiny little bit better is silver metal versus gold medal, Right, so you know, napping is super beneficial. However, if you nap at the wrong times, or if you nap too long or or if your napping is haphazard, then that's going to interfere with a nighttime sleep and it's going to make your daytime functioning worse. So the ideal nap is like midday or early afternoon, depending on your chronotype. If you're a super late morning riser and super late night owl, then obviously adjust accordingly. But for people who have conventional prototypes, midday or early afternoon is your best time to nap. And about a half hour nap is good because then you get enough of a refresher to get the benefits of napping without getting into deep sleep during your nap. And we don't want to get into deep sleep during our nap because then you're going to wake up feeling more groggy, and that's going to take away from your sleep appetite, so to speak, for your nighttime sleep. So we don't want a super long nap and we don't want a late nap.
00:30:10
Speaker 1: Yeah, that was so funny. The in medical school always like, don't nap more than a half an hour, and that was really true, right.
00:30:16
Speaker 3: Yeah, And you know there are people who say, oh, yeah, I try really hard to nap, but I just can't fall asleep for a nap.
00:30:22
Speaker 4: That's okay. You don't have to fall asleep.
00:30:25
Speaker 3: To get the benefits of a sort of pseudo nap, you know, if you lay down, close your eyes, don't look at your phone, you know, just actually like.
00:30:33
Speaker 4: Your body rest for half an hour.
00:30:35
Speaker 3: Research has shown that even just a twenty minute meditation has similar benefits as to napping.
00:30:43
Speaker 1: So let's talk a little bit about how we manage sleep disorders or insomnia, especially in mid life women. Can you talk about the term a little bit sleep hygiene?
00:30:52
Speaker 3: Sure, The sleep hygiene is kind of like dental hygiene, Like, yes, it's a good baseline set of habits to have, but if you already have a cavity, brushing or flossing is not going to get rid of that cavity, right, So, if you already have insomnia or sleep at meal or another significant sleep problem, sleep hygiene is also not going to help. Is too little, too late, And in fact, in our clinical trials for insomnia, we use sleep hygiene education as the control condition, as in it's like it's literally the placebo sugar pill, you know, of our of our trials because we know it's.
00:31:33
Speaker 4: Not going to solve insomnia. In fact, a lot.
00:31:37
Speaker 3: Of the work I do with my patients is to kind of walk back their sleep hygiene. Sometimes people do too much sleep hygiene. They try so hard to optimize their sleep environment. They're so caffeine celibate or alcohol celibate, or they're so hard on themselves to be perfect that it backfires because then now they're like really anxious about it. They put a big spotlight on their sleep, they're dreading bedtime, and that actually makes sleep worse. So sleep hygiene is like a good general sort of baseline, like yeah, brush your teeth every day, and like, you know, don't drink too much caffeine. Like those are good general kind of things to follow, but don't overdo it. And it's also not enough. I do not like the fact that as a society, sleep hygiene is like the first go to and often the only go to that we have for midlife women with insomnia. So instead, what actually works is cognitive behavioral therapy for insomnia CBTI for short. So this is a treatment where we change people's behaviors and their thoughts about sleep, their attitudes and their beliefs about sleep, how they structure their days, what they do around sleep, you know what they do when they haven't slept well. All of these things really matter and setting you up for sustainable, resilient good sleep and CBTI, you know, as opposed to sleep medications. CBTI you do it once, you know, it's usually like four or five or six sessions, and then that's pretty much it. You don't have to keep doing it for the rest of your life to keep insomnia at bay. Also, it's very safe and there tends to be no side effects compared to sleep medications that you know, if you take them long term, you gain tolerance, you might gain dependency. You know, if you stop taking them, it stops working. Cognitive behavioral therapy CBTI is the safer and more effective.
00:33:37
Speaker 1: Option, and that's done with the psychologist.
00:33:39
Speaker 3: Right usually as psychologists, but there are other people who do CBTI too, sometimes social workers, sometimes nurses, Doctors sometimes do CBTI. We're trying to spread the good word and train as many people as we can on CBTI.
00:33:56
Speaker 1: Coming in next is scheduling a sleep a good idea. We'll also talk about the benefits and drawbacks of using a sleep tracker. I find that as my day goes on, like there's just not enough hours in the day, and I've come to the point where I kind of schedule sleep for myself. I'm like, Okay, at ten o'clock, I have to be in bed, or you know, I have to be getting my eyes closed by eleven whatever.
00:34:31
Speaker 4: Is that a good.
00:34:32
Speaker 1: Thing to schedule sleep for yourself so it becomes a little more active and not just passive in your day.
00:34:38
Speaker 3: I think that's actually a good idea for people who tend to be busy or there tends to be always one more thing you could do, like one more email you could check, or one more show you could binge. You know, it's good to have a reminder or some boundaries rather, But I would maybe tweak that just a tiny little bit and say, instead of saying scheduling sleep, I would say scheduling wind down or scheduling a protected time and space for sleep to come to you. So it's not that at ten o'clock I have to hit the pillow and fall asleep.
00:35:13
Speaker 4: You can't control that.
00:35:14
Speaker 3: I mean, like, sleep is an involuntary phenomenon, right, So you can't make sleep come to you, but you can create the conditions that make sleep want to come to you more right, so you can put your emails away, put your tasks and strategic thinking to do lists away for the day. You can take a hot shower or a warm bath. You can you know what I like to call, get out of your head and into your body, so you know, cuddle your partner and your kids and your dogs. Do some light stretching, do some deep breathing, Get really into your body so that your body has a chance to switch gears and really start to get into the zone that gets you readier for sleep.
00:36:01
Speaker 1: How much time do you need to get into the zone? Do you wind up for? Twenty minutes, thirty minutes?
00:36:05
Speaker 3: I mean, if possible, I really love at least protecting an hour before bedtime to get out of heading into your body. I mean, if that's literally not possible for you, don't sweat it. It's okay, you don't have to.
00:36:17
Speaker 4: Have an hour.
00:36:18
Speaker 3: But I think in our modern life we really do sort of push the envelope too far.
00:36:24
Speaker 1: So sleep trackers fan are not a fan fan.
00:36:28
Speaker 3: As a researcher and scientist, not necessarily a fan as a clinician, because as a researcher, more data is always better, right, Like, yeah, this is an unprecedented amount of data and real life, real time at home, in people's environment kind of data that is just like amazing. Clinically, I think it can sometimes be helpful for people who really need to see data to realize, oh my, like two beers after dinner really do make my sleep more fragmented, and they otherwise wouldn't believe it. Then yes, I want data to show them. Also, sometimes I want data to show people you know, so, yes, you have insomnia. It felt like you struggle so hard to fall asleep or to stay asleep last night, but you know what, you felt like you got four hours of sleep.
00:37:18
Speaker 4: You actually got six and a half.
00:37:20
Speaker 3: I also like it for that purpose because for most people with insomnia, they're getting more sleep than they think they are. But I don't love sleep trackers when people are really paying so much attention to them, putting them on such a pedestal, like they live and die by their sleep data and their their readiness score. I don't like that at all because then that really puts a lot of pressure on people to sleep. When sleep is again not a voluntary phenomenon, and people pay so much attention to their sleep score that is actually backfiring and causing more insomnia, more anxiety.
00:37:54
Speaker 1: Talk to us a little bit about supplements. You know, we hear that melatonin can help. What type of supplements actually do you recommend for sleep if any, and talk a little bit about melatonin.
00:38:06
Speaker 3: So, as a non prescribing clinician, I'm going to not say any specifix but generally, let me say that supplements are neither necessary nor sufficient to cure something like insomnia or insufficient sleep or sleep apnea. So sometimes some supplements can be helpful for people in general to help regulate their nervous system or to you know, do something else that downstream could be beneficial for sleep, but usually it's not going to be the answer to your sleep problem. Specifically when it comes to melatonin. Did you know that melatonin is actually not approved to treat insomnia?
00:38:46
Speaker 4: Like at all?
00:38:47
Speaker 3: Most people's first go to for insomnia is melatonin, but it is not even for insomnia. Melatonin is for shifting your circadian rhythm for jet lag, and even when people use it for that purpose, they're usually using it wrong. And the dosages that are sold over the counter are not evidence based. They are ten twenty thirty times high than it should be based on research.
00:39:14
Speaker 4: And also we know that the amount.
00:39:15
Speaker 3: Of melotonin that are in those pills or gummies, especially gummies sold over the counter, can be up to five times as much as what is said on label, or down to almost zero percent of what is said on the label. So if you think you're getting three milligrams, you might be getting zero, or you might be getting fifteen. It's just not well regulated. So talk to your doctor about melotonin. Just because is over the counter does not mean you should be taking it on your own without guidance.
00:39:44
Speaker 1: And in sleep medications, right, what about pulsatali use. We have people who may say, you know, I'm traveling and I'm going to flip into a different time zone. I need to rest on the plane. Doesn't sound like a bad idea to use a sleep medication then, but probably shouldn't be used chronically. Is that correct?
00:40:01
Speaker 3: Yes, that's exactly what for example, ambien is used for. Is like you're going on a trip to Europe for a week. That's what ambient is for, you know. But as everyone can see, if you actually read the labels on those medications, they're not meant to be used long term because they actually lose effectiveness over the long term, and they can actually make insomnia worse by creating psychological or chemical dependency.
00:40:25
Speaker 1: I'm going to take myself back a few years and say I'm a midlife woman and I just can't fall asleep. In my mind is racing, and I've got the list in my head that won't go away, and I'm not getting good sleep. Give me three action points. What should I do?
00:40:41
Speaker 3: Exercise more than you think you need, so not just cardio. Especially strength training is going to be your good friend because that puts the type of strain on your muscles that deep sleep is going to.
00:40:55
Speaker 4: Be required to repair.
00:40:57
Speaker 3: So strength training, get outside during the day to get light exposure, at least thirty minutes of bright light exposure, and also just get out of your head and into your body.
00:41:09
Speaker 1: The strength training is music to my ear.
00:41:11
Speaker 3: Let's do at least one more, which is to hold your rise time steady. You don't have to go to bed at exactly the same time every night because again you can't control when you fall asleep, but get up at the same time every day, including weekends days off of work.
00:41:26
Speaker 4: That is going to be super important.
00:41:29
Speaker 3: Here's what I'll say on a philosophical note, treat sleep accordingly. Okay, it's your friend, is your lifelong companion, and that means you have to nurture it, give it TLC, give it priority. At the same time, don't overdo it. Don't be overbearing. Don't be that friend who's like, you have to show up on my schedule, my way or the highway.
00:41:52
Speaker 4: That's not fair to sleep.
00:41:53
Speaker 3: Allow sleep to change over your lifetime, just like friendships change sleep changes. Allow that to naturally happen. Be flexible, be forgiving. Treat sleep like a friend, and it will take good care of you.
00:42:10
Speaker 1: There's a lot of noise around sleep trackers, supplements, and bedtime routines. Doctor Wu offers something simpler and honestly more useful, a way to stop fighting. The real measure of whether you're sleeping well isn't a number. It's whether you can stay alert during the day. If you're reaching for melatonin, it's worth knowing it's a circadian rhythm tool, and the doses sold over the counter are not well regulated. Research suggest the actual amount in a pill or gummy can differ significantly from what's listed on the label, so talk to your doctor before you use it. While sleep hygiene practices like the screen curfews, the dark rooms, the caffeine rules can help. They likely, however, won't resolve insomnia. What does work is CBTI, Cognitive behavioral therapy for insomnia. It's typically forty six week sessions, not ongoing, and can make a big difference for a lot of people. And if you're waking up exhausted regardless of how much sleep you get, don't assume it's hormones alone. Postman apostal women develop sleep apnea at roughly the same rate as men, around twenty percent. Women just tend to present differently. Sometimes this shows up as morning headaches, jaw attention, dry mouth, or daytime fatigue rather than obvious signs like loud snoring and at home sleep test is a reasonable place to start. If you want some concrete tips for better sleep, here's what doctor Wu recommends. Strength training, morning light exposure, get out of your head and into your body, and hold onto your rise time, including weekends. Notice she said rise time, not bedtime. That's because we just can't control when we fall asleep. Your rise time is your anchor. Dacoding Women's Health is a production of Pushkin Industries and the Atria Health and Research Institute. This episode was produced by Kalalah. It was edited by Amy Gaines McQuaid, mastering by Sarah Buguer. Our associate producer is Sonia Gerwit. Our executive producer is Alexander Garretton. Our theme song was composed by Hannas Brown. Concept and creative development by Shaban O'Connor. Special thanks to Vicki Merrick, Alan Tish, David Saltzman, doctor David Dodick, Sarah Nix, Jacob Goldstein, Leah Rose, Jordan McMillan, Morgan Ratner, Owen Miller, Eric Sandler, and Greta Cone. I'm doctor Elizabeth Pointer. Thanks for listening and until next time.
Speaker 1: Pushkin. On every episode of Decoding Women's Health, we talk about the science behind women's bodies and share stories from leading researchers and clinicians. But now I want to hear your stories and your questions. No question is too complex, awkward, or small. So tell me what kindacologic questions have been on your mind lately. We'll get into everything from entimetriosis to fibroids, pms, pcos and more. We really want to hear from you, so please send your questions to us at Decoding Women's Health at Pushkin dot fm. That's Decoding Women's Health at Pushkin dot fm, or feel free to leave us a voicemail at four FI five two oh one, three three eight five.
00:01:18
Speaker 2: This show is not a substitute for professional medical advice, diagnosis, or treatment. It is for informational purposes. Please consult your healthcare professional with any medical questions. Also in this show, we use women as shorthand for people with XX chromosomes. We understand sex and gender are more complex and acknowledge the experiences we describe reach beyond that word.
00:01:48
Speaker 1: Doctor Jade Wu has been fascinated by sleep since she was a toddler. Growing up, she lived at the China National Space Administration base, where her father studied. House Space travel impacted the sleep of the country's first space team.
00:02:04
Speaker 3: That was my first introduction to sleep when I was, you know, three four years old, just toddling around the sleep lads with the astronaut.
00:02:11
Speaker 4: So, you know, it made an impression.
00:02:13
Speaker 1: So much so that doctor Wu has devoted her entire adult life to the study of sleep. Today, she's a Board certified behavioral sleep medicine specialist on the faculty of Sunny Upstate Medical School, and she's the founder of the Thrive Sleep Clinic in Durham, North Carolina, which treats people in most states through telehealth appointments. She's also the author of Hello Sleep, The Science and Art of Overcoming Insomnia Without Medications. One of my patients shared doctor Wu's book with me a while back. I was instantly drawn in by her concept of treating sleep as a friend instead of like a problem that needs to be fixed. I knew I wanted to have doctor Wu on the show because we all put so much pressure on ourselves. We fixate on questions like am I getting enough sleep? What about deep sleep? And is it okay to take a nap. Doctor Wu has answers to all these questions, and I find her perspective on sleep to be so refreshing. Her approach is grounded in reality and in science. So today we'll be talking about what you actually need to be focusing on so that we can get to when I think we all want at the end of the day, better sleep. When you're assessing an individual's overall sleep pattern, what do you do? How do you determine if somebody's lacking in sleep? Like where do you start with them?
00:03:48
Speaker 3: So there are a couple of things we want to know. One is are you sleepy during the day? Like are you able to stay awake when you should be staying awake? That's really the most important question to ask because if you have no problems staying awake and you are energetic during the day, you're alert when you need to be alert, then probably you're sleeping. If you're not getting enough good quality sleep, you will be sleepy during the day. Because you know, sleep is kind of like food or water. You know, your body really craves it. Your body really wants to sleep, just like it really wants food and water. So the most important thing to know is are you sleepy during the day.
00:04:29
Speaker 1: What are some of the common misconceptions that you hear from individuals about sleep, Like, for example, I hear that you know everybody needs at least seven hours of sleep? Is that a misconception? Can some of us get by on less sleep if we feel well?
00:04:45
Speaker 4: Yeah, so you nailed.
00:04:46
Speaker 3: One of the most common ones is that you know eight hours of sleep is the magic number and everyone should get that. Some people need more, some people need less, and even within one person. How much sleep you need and the shape like your sleep, the pattern of you your sleep is going to change throughout your life, depending on your current lifestyle, what your body's needs are. So, for example, when you're a teenager, maybe you need an and a half hours of sleep. Most teenagers are not getting nearly that, so most teenagers are actually sleep deprived. But as you get older, as you get into mid age, you're not going to need that much anymore. And as you get into even older age, like retirement age, you're not going to need that much anymore. Part of it is determined by our genes, and part of it is determined by our life stage and our lifestyle. How much sleep you need varies across people and varies within ourselves.
00:05:38
Speaker 1: So why do we need more sleep when we're younger and less sleep when we're older. What's going on?
00:05:43
Speaker 3: Well, think about what sleep really is, right. Sleep is really just recovery from what the body needs to do, and it's also time for the body to do something behind the scenes work.
00:05:54
Speaker 4: Right.
00:05:55
Speaker 3: So, when we're younger, when we're go through puberty, for example, our bodies are physically growing at a pretty rapid pace, and we're releasing sex.
00:06:04
Speaker 4: Hormones and growth hormones.
00:06:05
Speaker 3: We're learning all kinds of new things about the world, you know, the pace at which we're absorbing new information and learning new skills, and you know, learning to learning the hard way of how to relate to people and how to figure out ourselves who we are. All those things are happening so quickly and at such an intense level that we need a lot of recovery at night, and we need a lot of opportunity for behind the scenes work to happen. Whereas once we're adults, there's still a lot of maintenance work going on. But we're not going through puberty. We're not at our reproductive prime anymore like eighteen year olds are. So we just need to recover from less, so we need less sleep.
00:06:47
Speaker 1: There must be a difference between I don't sleep and I feel really tired, and I don't sleep and I feel great. But are we doing harm if we feel great and we don't sleep that much.
00:06:56
Speaker 3: That's the exact right question to ask, because how well you feel is the better marker of whether you're getting enough sleep than some arbitrary number. Some people do only need five or six hours of sleep, but not common, so it's probably better to err on the side of could I get a little more sleep, you know, could I feel a little bit better? But if you can't get more, and you really only can get five or six hours and you feel good, then that's all you need. If you only get five hours of sleep and you feel great during the day, but that's because you're pounding five espressos before ten am, that does not count ups.
00:07:37
Speaker 4: That's bad. YEP.
00:07:39
Speaker 1: Talk to us about sleep deprivation. Why is sleep deprivation not the same as insomnia? Or maybe it is? And if you are have sleep debt, can you make it up if you sleep on the weekends.
00:07:50
Speaker 3: Well, sleep deprivation in insomnia are very very different things. If you imagine a ven diagram with two circles. They are two separate circles with a little bit of overlap. And this is probably surprising to most people. They're like, well, if I haven't samnia, if I can't fall asleep, doesn't that mean I'm sleep deprived. But sleep deprivation is when you don't have enough opportunity to sleep. That's like, if you're working three jobs and you only have five hours to lie down to be horizontal, you're sleep deprived. If you're a prisoner of war and they are throwing cold water on you every hour, you are sleep deprived. If you're sleep deprived, you know it. If you hit the pillow and you're out like a light, that means you're sleep deprived because your body was so desperate to get to sleep. Whereas insomnia is when you have enough opportunity to sleep, but you're struggling to fall asleep or stay asleep, or you're just not happy with your pattern of sleep. So I want to reassure people even if you have insomn yet, that does not mean you're sleep deprived. Can you make up sleep debt on the short term? Yes, ish. So, for example, if I pulled an all night or last night for some important reason, and I'm pushing through today. I can go to bed really early tonight, I can sleep in tomorrow, and more or less, I'll be Okay, that's not a big deal. But if I do that night after night after night, there's no such thing as catching up on a whole week's or a whole months, or whole decades worth of sleep debt. That just simply can't happen. The damage is done. It's never too late to improve your sleep, but you're not going to catch up on ten years of sleep debt.
00:09:23
Speaker 1: What kind of damage does sleep deprivation do? What is it doing to our brain? What is it doing to our body?
00:09:29
Speaker 3: It's not just about sleep deprivation. It's also about disruption to our sleep consistency and our sleep schedules. But let's all lump that together and say sleep disruption basically causes chronic inflammation. It's basically chronic stress to our bodies on a cellular level, on a molecular level, of our mood, of our metabolism, of our brain functioning.
00:09:53
Speaker 4: It's like saying, you know what.
00:09:55
Speaker 3: Happens if we're chronically food it deprived, or chronically water deprived or chronically oxygen deprived. You know, it's something so essential to every aspect of our functioning, on every level of our biology.
00:10:07
Speaker 1: Do our bodies ever adjust? Do we ever get used to it?
00:10:10
Speaker 3: No, we can sort of fool ourselves into thinking that we're getting used to it, but that doesn't mean it's not doing damage.
00:10:16
Speaker 1: I want to get into a little bit about sleep architecture. Can you tell us what sleep architecture is and the different phases of sleep?
00:10:25
Speaker 3: Sleep architecture refers to the shape of your sleep over the course of one night, and it specifically refers to the transitions and the proportions of different types of sleep that you're getting. So usually we refer to these as stages of sleep. I don't love the worst stages because that implies that you know, some are better than others, or you're trying to pass through levels like through video game, you're trying to get to later stages. But it's actually really more like different types of nutrition. You know, a balanced plate is the best most nutritious meal, right, A balanced sleep architecture is also the best healthiest night of sleep. So, for example, we have rem sleep and we have non rem sleep, So I'll do non rem sleep first, because that happens in the first half of the night. Non run sleep is generally broken up into three different types. We have what we call stage one or light sleep, Stage two or light sleep, and stage three or slow wave sleep, deep sleep, delta sleep. There's lots of names for deep sleep, and these stages all are important. Stage one is really basically a transition between wakefulness and a sleep. So that's kind of like the gateway where you're starting to get relaxed. You know, your body is starting to slow down and get calm, and your brain is starting to lose track of your environment. Stage two, that's where you're fully asleep now, but you're still easy to wake up from your sleep, so that's why it's still called light sleep. The important thing to know about stage two light sleep is that it's supposed to take up about half the night. Usually people say, oh, I want to get more deep sleep, I don't want light sleep, you know, get me as much deep sleep as possible. But actually, in healthy sleep, fifty percent of your night should be light sleep. And during light sleep there's memory consolidation going on. Your brain is practicing skills that you learn during the day. It is really important. And then there's deep sleep that's a stage three sleep, slow wave sleep, delta sleep that should take up about fifteen ish percent of the night fifteen and if you're younger, maybe about twenty percent. So if you're in your twenties, maybe twenty percent. But in midlife people, older people, ten fifteen percent is perfectly fine because remember, at different stages of our lives, our bodies have different jobs. And then rem sleep rem sleep is really fun. This is where dreaming happens, and it happens mostly during the second half of the night. Emotion regulation sort of nighttime therapy is happening. Rem sleep is doing memory consolidation, and that should take up about twenty five ish percent of the night twenty to twenty five percent overall, And we're sort of cycling through these different types of sleep throughout the night. But mostly non remsleep happens in the first half. Remsleep mostly happens in the second half.
00:13:28
Speaker 1: So I always say that if you go through Manhattan, you're going to see lights on at three o'clock in the morning, right two o'clock, three o'clock in the morning, Like every midlife woman is like this, awakening pattern is somewhere between two o'clock and three o'clock. I find when I speak with women, why is that? Why did midlife women just wake up all of a sudden at two o'clock or three o'clock and then can't fall back asleep.
00:13:48
Speaker 3: So it's not just midlife women. Everybody wakes up during the night, everybody. So a healthy night of sleep for a healthy person in there, let's say forties, involves about over a dozen awakenings. They're just so brief that you usually don't remember. The brain doesn't log that in its long term memory because of it wasn't important. It's just a quick awakening to see, okay, any tigers you know in the camp?
00:14:16
Speaker 4: No, okay? Back to sleep, And.
00:14:18
Speaker 3: Usually there is a little bit of a longer awakening that most people do not remember anyway, because again, it's not going to be that important. It's going to be so brief that happens at about two or three am, that one tends to be a little bit longer because it's the dropping of the baton between the non rem sleep that happens for the first half of the night and the rem sleep that happens in the second half. These two halves of the night are so qualitatively different that it's like a relay race run in two halves, and non realm sleep is passing the baton to rem sleep, and sometimes that baton is dropped, and that's okay because we're supposed to have that intermission. In pre industrial times, people used to get up for like a couple of hours at about two am three am, to sing songs, rise bread, visit their neighbors, do chores. They actually had a whole chunk of their life lived in that middle of the night, and then they will go back for their second sleep. This is what we call bi phasic sleep, as in sleep that happens in two phases. It's just that in recent you know, one hundred or so years, we've come to expect that sleep should be squeezed into one chunk, and then we're really surprised in midlife when our sleep is you know, a little bit more prone to being lighter, or our sleep is you know, tends to be a little bit more fragmented. We're suddenly noticing this natural biological pattern that, oh, we always do wake up at two or three am.
00:15:49
Speaker 4: That's natural.
00:15:52
Speaker 1: Still to come. Are you an early bird or a night owl. We'll discuss the body's natural preference to sleep and wake at certain times of the day, also known as chronotypes. Plus, doctor Wu tells us all about what it means to nap responsibly more in just a moment. So, you're a sleep psychologist, which means you study sleep and you treat various sleep disorders. What are some of the more common issues that you come across in your work, and especially with women and midlife women.
00:16:37
Speaker 3: Yes, the most common sleep problem I come across is insomnia, which should be no surprise to most midlife women. It's just such a common experience. In fact, our best estimates are that about thirty seven percent or up to fifty percent of perimen apostle women or postmon apostle women have some sort of significant sleep problem. They might feel irritable, they might feel like blood, they feel.
00:17:03
Speaker 4: You know, not at their best.
00:17:06
Speaker 3: They might feel exhausted even but they can't fall asleep during the day even if they tried. So that's a tricky thing about insomnia is that it's a twenty four hour disorder. It's not just about trouble falling or staying asleep at night. It's about all these experiences of hyper arousal, this wiredness during the day while also feeling really tired. So it's a little bit of a tricky disorder in that sense.
00:17:31
Speaker 1: So you can kind of say it's a lived experience, how You're that's right.
00:17:35
Speaker 4: Insomnia is not just one thing.
00:17:38
Speaker 3: It's not just hot flashes, especially if we're talking about midlife women.
00:17:43
Speaker 4: It's not just hot flashes.
00:17:44
Speaker 3: It's not just a little bit more back pain. It's not just some weighting. It is everything. Hormones impact everything. So for example, estrogen, Estrogen is not just a sex hormone. It is the CEO of the brain. It manages so many systems in the brain. It manages your muscle tone and manages your decision making. It manages the level of anxiety that you feel, the amount of attention that you pay two different things. Even within one day, your estrogen levels can go up and down and up and down, and that roller coaster is what really messes with all these other systems that then impact sleep. But alongside that, I also see circadian rhythm issues. So that's where someone's body clock, the timing of their sleep wake patterns, and the timing of their other biological processes are inconsistent or just off in some way, and that really impacts their energy, their health, their mood.
00:18:45
Speaker 1: And where does progesterone fit into this picture.
00:18:48
Speaker 3: Yes, progesterone is an important hormone as well that is also more than just a sex hormone. It tends to calm the whole system down. It works on the gava system, and the gava system is the system in the brain that is the breaks as opposed to the gas, So it sort of keeps everything more calm, post the brakes on things when they go out of control. When progesterone is less reliable, then the gava system is less reliable. We also get more fluctuation in things like your cognition and your mood.
00:19:25
Speaker 1: What we try to do many times is we say, okay, we'll add some progesterone to help mid life women's sleep, maybe estrogen also, if estrogen levels are really starting to fluctuate. But it's often multifectorial. Correct. Am I wrong in that? Because I rarely you just take a hormone and everything rights itself. It gets better maybe, but doesn't go away completely.
00:19:45
Speaker 4: That is totally correct.
00:19:46
Speaker 3: I hate to say it, but they're even progesterone is not a magic pill for solving sleep because the other problems are going on are you know, during midlife, we are more likely to have other sleep disorders like sleep apna. For example, sleep apnea is when we completely or partially cease breathing for a longer period than we should when we sleep, you know, up to ten seconds or even much longer than that. And when we stop breathing when we're sleeping, the CO two is building up in our blood and on our brain, and if that goes on for too long, then the brain goes, oh my gosh, crisis mode, what's going on?
00:20:28
Speaker 4: Why is there? Why are we not breathing? Are we dying?
00:20:30
Speaker 3: And it suddenly, you know, wakes you up to force you to breathe. You can imagine if that happens many times over the course of even just one hour, you know, severe sleep apnea is like thirty times per hour or more that that's happening. Then you can imagine how much that is fragmenting your sleep so that you can't ever get into deep sleep. You're always sort of floating on a surface, you're always getting interrupted. And also how much that's contributing to the amount of cortisol that is in your system. Cortisol is basically the stress hormone. You know, we should have it to sort of kick our butt into gear if there is if there are problems in the environment, if there's danger. But if that danger is you yourself stopping breathing every two minutes, that corto isola is going to be high all night long, and of course that's going to be problematic for our sleep. We also have a lot of you know, psychological factors during mide age, this is the age where we are taking care of kids and taking care.
00:21:27
Speaker 4: Of our parents.
00:21:28
Speaker 3: We're probably at a point in our careers or we have more responsibility, so we're multitasking, you know, if we live in a society where gender roles have not quite caught up to the realities of you know, women who have high level careers.
00:21:42
Speaker 4: We're also managing households.
00:21:44
Speaker 3: We're remembering whose birthday it is, whose shoes eyes, you know, is about to change. We're managing all these things, all these tabs in our brains that we can't close, and that makes it really hard to just quiet the brain down when it's time to go to bed.
00:21:59
Speaker 1: We need jill down on sleep apnea for just a moment, What causes sleep apnea and how do you know if you have it?
00:22:05
Speaker 3: Sleep Apnea is also multifactorial, so at the actual level of the apnea, it's basically a collapse of something in the airway, So that could be somewhere in your nasal passage that's usually more like in the back of your throat or even you know, more pressure on your chest. So one of the factors that increases the risk for having sleep apnia is excessive weight. For example, Another time that women can are more likely to have sleep apnia is during pregnancy, so there's more pressure more weight that you know, rapid weight gain during pro pregnancy. Of course that happens, but that ads more pressure to the airway and that makes it more likely to collapse and block the airway. Another reason is that as we get older and as estrogen goes down, we have less muscle tone, so there's basically less firmness in our muscles to keep that airway open. So with less of that firmness in our airways, we're more likely to happen in apnea. And also there are other factors that we don't quite understand yet, factors that also, people may not have control over So for example, East Asians are more likely to have sleep apnia because of our or facial bat structure. So I'm of East Asian descent, i am not overweight, and I am not in menopause yet, but I am more likely to have sleep apnia than my peers because of my rifacial bone structure. For women, it's hard to tell if you have it, harder than for men. In men, it's basically like if you snore, if you have high blood pressure, you know, if you're sleepy during the day, boom you pretty much we know you've got sleep apnia. For women, we tend to have more subtle signs. So instead of snoring like a freight train, we're more likely to hold our breath while we sleep.
00:23:57
Speaker 4: And not really snore loudly.
00:24:00
Speaker 3: We're more likely to have a morning headache or a tight jaw or dry mouth, and we might be more fatigued during the day rather than so sleepy that we fall asleep, you know, at the steering wheel. And that's why I really urge my women patients, especially in my midlife or older women patients, to air on the side of caution if they're not sure if they have sleep apia, just go ahead and ask for an at home sleep test from your doctor.
00:24:30
Speaker 1: And you can even order those online yourself, right, you can do like a telehealth and order yes.
00:24:35
Speaker 4: Yeah.
00:24:36
Speaker 1: My understanding and please correct me if I'm wrong, is that they have a really pretty good specificity, meaning if they're positive, they're usually positive, and you get to a sleep specialist. Right, And that's important to realize. I think that women and men presentlessleep atany a little bit differently. Can you see sleep apne on a sleep tracker, like on your device that you use to track your heart rate variability and sleep? Can you see sleep apnea?
00:24:57
Speaker 3: Not necessarily, that would not be a reliable screening. I have heard of people saying, like, my, you know, my heart rate variability is really off, it's or even my body temperature is high during the night, and that has led them to ask for a sleep study that then found sleep apnea. But it's not reliable to just look at your own sleep track of data and say I have it or I don't.
00:25:23
Speaker 1: It's really important to keep in mind, I think when we start to look at how women are sleeping in midlife, and to always remember to think about a sleep study and sleep apnea. Let's talk about chronotypes because a lot of us, again not to personalize all of this, but a lot of us are night owls. Right, we get jacked up at night, we're ready to go, but we live in a daytime world. Can you tell us are these chronotypes real?
00:25:46
Speaker 4: That's a fabulous question.
00:25:48
Speaker 3: So chronotypes are genetically predisposed, but they're also factors. But let's say, for now, genetically predisposed tendencies to sleep and wake at certain times of day. So this is just a natural variation diversity in our species. Just like height, some people are tall, some people are short. Most of us are somewhere in the middle. Right, Some people are night some people are extreme morning larks. Most of us are somewhere in the middle. And there is nothing inherently wrong with being a night all or a morning lark. I mean, imagine us being on the savannah alltogether. Let's say there's one hundred of us in the group in the tribe. I mean, some of us have to get up early to string the bows, but some of us also have to be awake late at night to look out for the tigers. Right, So it's good to have variation in our chronotype and chronotype is about fifty percent heritable, so like about half of it is from our genes and the other half is from like lifestyle habit of bringing environments things like that. It's tough because our current society really does expect everybody to function during the same chunk of time. So a lot of us have a hard time performing our best when we show up to work first thing in the morning because we're night owls, we naturally are just not at our best first thing in the morning. We're still trying to do ren sleep, you know, in our brain during that time, whereas our creativity and our productivity comes out at ten pm eleven pm midnight. So you know, it's it really is a waste of talent, I think to expect everybody to function at the same time.
00:27:32
Speaker 4: It's also a little bit risky.
00:27:34
Speaker 3: It's a safety thing too, because I don't know, I don't want to drive my kids to school at seven thirty am with people who are driving to work at that time who really should be sleeping. Right.
00:27:47
Speaker 1: I'm a huge fan of the power nap and what's happening when we nap, And is it reasonable for somebody who maybe is a night out that they're a little sleepier during the day. Maybe they take a power nap and they wake up. Tell us a little bit about the science of napping.
00:28:01
Speaker 4: I love naps.
00:28:03
Speaker 3: I highly recommend naps, But you have to nap responsibly because I love that nap responsibly responsible, y'all. Uh, naps are a double edged sword. So on the one hand, we do know from plenty of research that naps are really beneficial. Napping is also a natural biological pattern we evolve to have, maybe to avoid the hottest part of the day, or to catch up on energy. Whatever the reason is, we are naturally wired to nap in the early afternoon. And when we do listen to our bodies and nap in the early afternoon, we wake up with better energy, better mood, better cognition. So like faster reaction times, better decision making, you know, all sorts of benefits. Even athletes perform just a little bit better when they have napped, you know, And if you're swimmer, just the tiny little bit better is silver metal versus gold medal, Right, so you know, napping is super beneficial. However, if you nap at the wrong times, or if you nap too long or or if your napping is haphazard, then that's going to interfere with a nighttime sleep and it's going to make your daytime functioning worse. So the ideal nap is like midday or early afternoon, depending on your chronotype. If you're a super late morning riser and super late night owl, then obviously adjust accordingly. But for people who have conventional prototypes, midday or early afternoon is your best time to nap. And about a half hour nap is good because then you get enough of a refresher to get the benefits of napping without getting into deep sleep during your nap. And we don't want to get into deep sleep during our nap because then you're going to wake up feeling more groggy, and that's going to take away from your sleep appetite, so to speak, for your nighttime sleep. So we don't want a super long nap and we don't want a late nap.
00:30:10
Speaker 1: Yeah, that was so funny. The in medical school always like, don't nap more than a half an hour, and that was really true, right.
00:30:16
Speaker 3: Yeah, And you know there are people who say, oh, yeah, I try really hard to nap, but I just can't fall asleep for a nap.
00:30:22
Speaker 4: That's okay. You don't have to fall asleep.
00:30:25
Speaker 3: To get the benefits of a sort of pseudo nap, you know, if you lay down, close your eyes, don't look at your phone, you know, just actually like.
00:30:33
Speaker 4: Your body rest for half an hour.
00:30:35
Speaker 3: Research has shown that even just a twenty minute meditation has similar benefits as to napping.
00:30:43
Speaker 1: So let's talk a little bit about how we manage sleep disorders or insomnia, especially in mid life women. Can you talk about the term a little bit sleep hygiene?
00:30:52
Speaker 3: Sure, The sleep hygiene is kind of like dental hygiene, Like, yes, it's a good baseline set of habits to have, but if you already have a cavity, brushing or flossing is not going to get rid of that cavity, right, So, if you already have insomnia or sleep at meal or another significant sleep problem, sleep hygiene is also not going to help. Is too little, too late, And in fact, in our clinical trials for insomnia, we use sleep hygiene education as the control condition, as in it's like it's literally the placebo sugar pill, you know, of our of our trials because we know it's.
00:31:33
Speaker 4: Not going to solve insomnia. In fact, a lot.
00:31:37
Speaker 3: Of the work I do with my patients is to kind of walk back their sleep hygiene. Sometimes people do too much sleep hygiene. They try so hard to optimize their sleep environment. They're so caffeine celibate or alcohol celibate, or they're so hard on themselves to be perfect that it backfires because then now they're like really anxious about it. They put a big spotlight on their sleep, they're dreading bedtime, and that actually makes sleep worse. So sleep hygiene is like a good general sort of baseline, like yeah, brush your teeth every day, and like, you know, don't drink too much caffeine. Like those are good general kind of things to follow, but don't overdo it. And it's also not enough. I do not like the fact that as a society, sleep hygiene is like the first go to and often the only go to that we have for midlife women with insomnia. So instead, what actually works is cognitive behavioral therapy for insomnia CBTI for short. So this is a treatment where we change people's behaviors and their thoughts about sleep, their attitudes and their beliefs about sleep, how they structure their days, what they do around sleep, you know what they do when they haven't slept well. All of these things really matter and setting you up for sustainable, resilient good sleep and CBTI, you know, as opposed to sleep medications. CBTI you do it once, you know, it's usually like four or five or six sessions, and then that's pretty much it. You don't have to keep doing it for the rest of your life to keep insomnia at bay. Also, it's very safe and there tends to be no side effects compared to sleep medications that you know, if you take them long term, you gain tolerance, you might gain dependency. You know, if you stop taking them, it stops working. Cognitive behavioral therapy CBTI is the safer and more effective.
00:33:37
Speaker 1: Option, and that's done with the psychologist.
00:33:39
Speaker 3: Right usually as psychologists, but there are other people who do CBTI too, sometimes social workers, sometimes nurses, Doctors sometimes do CBTI. We're trying to spread the good word and train as many people as we can on CBTI.
00:33:56
Speaker 1: Coming in next is scheduling a sleep a good idea. We'll also talk about the benefits and drawbacks of using a sleep tracker. I find that as my day goes on, like there's just not enough hours in the day, and I've come to the point where I kind of schedule sleep for myself. I'm like, Okay, at ten o'clock, I have to be in bed, or you know, I have to be getting my eyes closed by eleven whatever.
00:34:31
Speaker 4: Is that a good.
00:34:32
Speaker 1: Thing to schedule sleep for yourself so it becomes a little more active and not just passive in your day.
00:34:38
Speaker 3: I think that's actually a good idea for people who tend to be busy or there tends to be always one more thing you could do, like one more email you could check, or one more show you could binge. You know, it's good to have a reminder or some boundaries rather, But I would maybe tweak that just a tiny little bit and say, instead of saying scheduling sleep, I would say scheduling wind down or scheduling a protected time and space for sleep to come to you. So it's not that at ten o'clock I have to hit the pillow and fall asleep.
00:35:13
Speaker 4: You can't control that.
00:35:14
Speaker 3: I mean, like, sleep is an involuntary phenomenon, right, So you can't make sleep come to you, but you can create the conditions that make sleep want to come to you more right, so you can put your emails away, put your tasks and strategic thinking to do lists away for the day. You can take a hot shower or a warm bath. You can you know what I like to call, get out of your head and into your body, so you know, cuddle your partner and your kids and your dogs. Do some light stretching, do some deep breathing, Get really into your body so that your body has a chance to switch gears and really start to get into the zone that gets you readier for sleep.
00:36:01
Speaker 1: How much time do you need to get into the zone? Do you wind up for? Twenty minutes, thirty minutes?
00:36:05
Speaker 3: I mean, if possible, I really love at least protecting an hour before bedtime to get out of heading into your body. I mean, if that's literally not possible for you, don't sweat it. It's okay, you don't have to.
00:36:17
Speaker 4: Have an hour.
00:36:18
Speaker 3: But I think in our modern life we really do sort of push the envelope too far.
00:36:24
Speaker 1: So sleep trackers fan are not a fan fan.
00:36:28
Speaker 3: As a researcher and scientist, not necessarily a fan as a clinician, because as a researcher, more data is always better, right, Like, yeah, this is an unprecedented amount of data and real life, real time at home, in people's environment kind of data that is just like amazing. Clinically, I think it can sometimes be helpful for people who really need to see data to realize, oh my, like two beers after dinner really do make my sleep more fragmented, and they otherwise wouldn't believe it. Then yes, I want data to show them. Also, sometimes I want data to show people you know, so, yes, you have insomnia. It felt like you struggle so hard to fall asleep or to stay asleep last night, but you know what, you felt like you got four hours of sleep.
00:37:18
Speaker 4: You actually got six and a half.
00:37:20
Speaker 3: I also like it for that purpose because for most people with insomnia, they're getting more sleep than they think they are. But I don't love sleep trackers when people are really paying so much attention to them, putting them on such a pedestal, like they live and die by their sleep data and their their readiness score. I don't like that at all because then that really puts a lot of pressure on people to sleep. When sleep is again not a voluntary phenomenon, and people pay so much attention to their sleep score that is actually backfiring and causing more insomnia, more anxiety.
00:37:54
Speaker 1: Talk to us a little bit about supplements. You know, we hear that melatonin can help. What type of supplements actually do you recommend for sleep if any, and talk a little bit about melatonin.
00:38:06
Speaker 3: So, as a non prescribing clinician, I'm going to not say any specifix but generally, let me say that supplements are neither necessary nor sufficient to cure something like insomnia or insufficient sleep or sleep apnea. So sometimes some supplements can be helpful for people in general to help regulate their nervous system or to you know, do something else that downstream could be beneficial for sleep, but usually it's not going to be the answer to your sleep problem. Specifically when it comes to melatonin. Did you know that melatonin is actually not approved to treat insomnia?
00:38:46
Speaker 4: Like at all?
00:38:47
Speaker 3: Most people's first go to for insomnia is melatonin, but it is not even for insomnia. Melatonin is for shifting your circadian rhythm for jet lag, and even when people use it for that purpose, they're usually using it wrong. And the dosages that are sold over the counter are not evidence based. They are ten twenty thirty times high than it should be based on research.
00:39:14
Speaker 4: And also we know that the amount.
00:39:15
Speaker 3: Of melotonin that are in those pills or gummies, especially gummies sold over the counter, can be up to five times as much as what is said on label, or down to almost zero percent of what is said on the label. So if you think you're getting three milligrams, you might be getting zero, or you might be getting fifteen. It's just not well regulated. So talk to your doctor about melotonin. Just because is over the counter does not mean you should be taking it on your own without guidance.
00:39:44
Speaker 1: And in sleep medications, right, what about pulsatali use. We have people who may say, you know, I'm traveling and I'm going to flip into a different time zone. I need to rest on the plane. Doesn't sound like a bad idea to use a sleep medication then, but probably shouldn't be used chronically. Is that correct?
00:40:01
Speaker 3: Yes, that's exactly what for example, ambien is used for. Is like you're going on a trip to Europe for a week. That's what ambient is for, you know. But as everyone can see, if you actually read the labels on those medications, they're not meant to be used long term because they actually lose effectiveness over the long term, and they can actually make insomnia worse by creating psychological or chemical dependency.
00:40:25
Speaker 1: I'm going to take myself back a few years and say I'm a midlife woman and I just can't fall asleep. In my mind is racing, and I've got the list in my head that won't go away, and I'm not getting good sleep. Give me three action points. What should I do?
00:40:41
Speaker 3: Exercise more than you think you need, so not just cardio. Especially strength training is going to be your good friend because that puts the type of strain on your muscles that deep sleep is going to.
00:40:55
Speaker 4: Be required to repair.
00:40:57
Speaker 3: So strength training, get outside during the day to get light exposure, at least thirty minutes of bright light exposure, and also just get out of your head and into your body.
00:41:09
Speaker 1: The strength training is music to my ear.
00:41:11
Speaker 3: Let's do at least one more, which is to hold your rise time steady. You don't have to go to bed at exactly the same time every night because again you can't control when you fall asleep, but get up at the same time every day, including weekends days off of work.
00:41:26
Speaker 4: That is going to be super important.
00:41:29
Speaker 3: Here's what I'll say on a philosophical note, treat sleep accordingly. Okay, it's your friend, is your lifelong companion, and that means you have to nurture it, give it TLC, give it priority. At the same time, don't overdo it. Don't be overbearing. Don't be that friend who's like, you have to show up on my schedule, my way or the highway.
00:41:52
Speaker 4: That's not fair to sleep.
00:41:53
Speaker 3: Allow sleep to change over your lifetime, just like friendships change sleep changes. Allow that to naturally happen. Be flexible, be forgiving. Treat sleep like a friend, and it will take good care of you.
00:42:10
Speaker 1: There's a lot of noise around sleep trackers, supplements, and bedtime routines. Doctor Wu offers something simpler and honestly more useful, a way to stop fighting. The real measure of whether you're sleeping well isn't a number. It's whether you can stay alert during the day. If you're reaching for melatonin, it's worth knowing it's a circadian rhythm tool, and the doses sold over the counter are not well regulated. Research suggest the actual amount in a pill or gummy can differ significantly from what's listed on the label, so talk to your doctor before you use it. While sleep hygiene practices like the screen curfews, the dark rooms, the caffeine rules can help. They likely, however, won't resolve insomnia. What does work is CBTI, Cognitive behavioral therapy for insomnia. It's typically forty six week sessions, not ongoing, and can make a big difference for a lot of people. And if you're waking up exhausted regardless of how much sleep you get, don't assume it's hormones alone. Postman apostal women develop sleep apnea at roughly the same rate as men, around twenty percent. Women just tend to present differently. Sometimes this shows up as morning headaches, jaw attention, dry mouth, or daytime fatigue rather than obvious signs like loud snoring and at home sleep test is a reasonable place to start. If you want some concrete tips for better sleep, here's what doctor Wu recommends. Strength training, morning light exposure, get out of your head and into your body, and hold onto your rise time, including weekends. Notice she said rise time, not bedtime. That's because we just can't control when we fall asleep. Your rise time is your anchor. Dacoding Women's Health is a production of Pushkin Industries and the Atria Health and Research Institute. This episode was produced by Kalalah. It was edited by Amy Gaines McQuaid, mastering by Sarah Buguer. Our associate producer is Sonia Gerwit. Our executive producer is Alexander Garretton. Our theme song was composed by Hannas Brown. Concept and creative development by Shaban O'Connor. Special thanks to Vicki Merrick, Alan Tish, David Saltzman, doctor David Dodick, Sarah Nix, Jacob Goldstein, Leah Rose, Jordan McMillan, Morgan Ratner, Owen Miller, Eric Sandler, and Greta Cone. I'm doctor Elizabeth Pointer. Thanks for listening and until next time.
