Introduction and Guest Background

Hi everyone, and welcome back to the Sleep Deep Summit. New approaches for treating insomnia and sleep apnea. I'm your host, Dr. Audrey Wells. I'm a sleep medicine physician.

And today I'm super excited to be joined by Dr. Val Cacho. She is also a sleep medicine physician with an integrative approach. She has a telehealth practice where she does sleep medicine.

It's called Sleep Life Med, and she has Sleep Fauria, which is a wellness brand that she originated. And I'm so happy to have her here. Dr. Val, welcome.

Thank you. Dr. Wells, happy to be here as well. To talk up my favorite topic, how women sleep. That's so great. I wonder if you can maybe give some background on how this is kind of on the tip of your tongue and I'm sure at the forefront of what you do in clinical practice.

Yeah. Thank you so much. So for about six and a half, seven years, I practiced with a hospital based program in Hawaii. And so I was a medical director there, running pretty busy sleep department, doing consultations and running their sleep lab.

And what I came to found out was, you know, there was a lot of women coming to my practice who are really tired, who are exhausted. They didn't really know what was going on.

They had their thyroid checked. Maybe they were started on some sleeping pills, but really just weren't feeling well. And so I dug deeper into this and really looked into the relationship between underlying medical conditions, which I'm sure we'll touch on.

But like what is really happening as women get older and as we go through midlife and some of the hormonal shifts? And certainly that is a glimpse into what can be happening.

But I think part of it, too, is that, you know, there's so much that is expected for women. You know, we work full time. You know, most of us I would say we're managing our household.

We have kids now. Daughters are also the people who typically you know, I did a lot of before I went into full sleep medicine. Obviously, we knocked earnest work and hospitalist work and you would see the daughters there at the bedside.

So, you know, we're sort of burning the candle on both ends. We're working, we're taking care of our family, were taking care of our elderly parents. And it's just a combination of factors that can impact one's sleep.

And so I practice holistically. I practice integrative early because pills can only do so much. Right. And when I take a look at my patient who comes in, certainly all all my patients, because I do see men and women now, I take the whole mind, body and soul approach, you know, what's going on in their head that's keeping them from sleeping.

Is it anxiety's? It stress? They have a past history of trauma when they're asleep, their body, you know, do they have underlying medical conditions like obstructive sleep apnea?

Do they have like a restless leg issue? Is it a movement disorder and then soul? You know, sometimes we get older in life and we get to this sort of plateau phase and we start to ask ourselves maybe deeper questions, you know, is this the life I want to live?

Maybe. I've been in this career for 20, 30 plus years. You know, I've maybe plateaued. I've maybe I've reached my peak and is this all there is? And so sometimes those questions are in a way in our mind and can impact the quality of sleep that we have.

So I really like practicing integrative holistically because it touches on all those points and I like to see the person as a whole. Definitely. And I think people like to be seen as a whole.

You know, you never want to be labeled as a medical condition or that label kind of summing up a person because it's way too simplistic. Yeah. You know, I want to read something that you said that really resonated for me as I'm a champion for women.

You said a well-rested woman has the energy, clarity and the drive to change the world, but they can't do that unless they've got a good, solid night's sleep behind them.

Now, I want to go to hormones. And to me, you know, hormones is kind of this term that's tossed around. It sort of covers everything. Oh, it's my hormones.

And it's true that women take several pivots during their life with their hormones. So I wonder if you can start with the menopause and even go a little bit back with perimenopause.

What sort of hormonal changes are taking place that affect sleep?

Why Womenu2019s Sleep Is Often Overlooked

Yeah, great question. Dr. Wells. And so sure, as we both know, in medical school, hormones are really just messengers. And I feel like in today's day and age with your social media, it's almost like, I don't know, I think they're blamed for a lot of our ills, but they're really just messages that our brain is sending to different parts of our body and vice versa.

So the hormones specifically that we're talking about during perimenopause, which is a time before you stop having your periods. So menopause so you know do the definitions is 12 months without having your period.

Typical age in the U. S. is 51. For perimenopause, it's 47. However, you can actually start to have symptoms even 4 to 7 years before you stop having your periods.

So early forties, even some people. Unfortunately in their late thirties can have symptoms of perimenopause. And what are those? Well, insomnia, you know, for big one or two sleep doctors here, mood fluctuations, decreased libido, dry skin pain on intercourse, anxiety.

Right. And so bone pain actually is part of it, too. And muscle aches. So there's a whole host of basically symptoms. And the thing about perimenopause and menopause and, you know, my own medical education, we didn't learn a lot about it.

Now, when you take a look at women's health, a big chunk of it is about pregnancy. You know, OB guys in rotation, you know, it's really all about, okay, how do we help the mom stay healthy?

You know, when the baby's in utero and then go through a good pregnancy. But then as women get older, you know, maybe we talk about p-series, you know, maybe we talk about recurrent UTI eyes, or if your bladder starts double, then, you know, they can do some surgery for that.

But not a lot is put into how we can really support a woman as they go through menopause. And menopause certainly is not a disease. It's just a normal part of Mother Nature.

And what perimenopause is and we start to have those fluctuations of progesterone and estrogen, right? So progesterone is pro gestation. So when we start to go through this process are basically biological clock, say, okay, you don't need to have babies anymore.

And so the progesterone levels are triple and then estrogen levels also start to fall and actually fluctuate. And so sometimes that's why we can have really bad hot flashes, right?

The estrogen levels have to fall. Sometimes we can have problems with insomnia because progesterone, the hormone that supports gestation, is also known as a relaxation hormone.

It actually works on the Gaba system and the gap system is also like the sleep promoting system, the same system that some sleep supplements and some sleeping pills like Z drugs work on.

So it's really interesting how as we go through that change, it disrupts our sleep. And then once we go through menopause, right then the levels of progesterone and estradiol and estrogen are very, very low.

And then your episodes settle, start to rise. So if you're someone who's having some symptoms of perimenopause and you go to your doctor and you ask for a blood test for your hormones, and they say everything is normal, that doesn't necessarily mean that you're not in perimenopause, right?

Because it's fluctuating levels. So sometimes it can be helpful to do different blood tests at different time. You know for sure, when you're in menopause, when the episode levels are high and the estrogen progesterone levels are low, what can be really tricky is that sometimes people have their uterus taken out at an early age.

We don't know if they stop having their periods or they have an IUD in place or they're already on, you know, hormone replacement therapy or just birth control for heavy periods.

And so that can sort of muddy the picture and make it hard to diagnose based on lab tests. But I would say it's really a clinical situation. Right. Taking a look at the whole person.

What are they going through? Are you fitting sort of the normal ages? And because these are just clues and how we can support you? Yeah, I think that's great.

And I think when women are concerned and there's always an element of complexity. Now, you mentioned before that women are the CEO of their homes typically.

And, you know, whether they have an employer job or not, they're typically just working all the time. And I think that, you know, sometimes stress, sometimes caffeine, sometimes alcohol.

These are all sleep disruptors. Sometimes it's the bed partner. Oh, yes. Next to them that is disrupting a woman's sleep, which is so not fair. But all of these things can kind of culminate into disrupted sleep on any given night and over time.

So for someone who's sort of looking for help with their sleep and maybe they're in that perimenopausal range, how do you advise them? Yeah, great question.

So, Dr. Wells, I always talk about obstructive sleep apnea. The reason for that is that it's such a common condition. One in five adults can have at least mild sleep apnea.

And then as we get older, the hormone related changes. So when you lose estrogen progesterone, it actually makes your upper airway more floppy. So going back, I'm sure, hopefully all the audience members already know what obstructive sleep apnea is, but it's a physical blockage of your upper airway when you sleep.

So typically what happens when you sleep, your muscles relax.

Perimenopause, Menopause, and Hormonal Sleep Changes

Sometimes it relaxes a little bit too much, especially in the posterior or pharynx and the back of the tongue, and it can fall back. So age can lead to more of this because as we get older, unfortunately, our muscles atrophy.

They're just not as strong. So that's one thing as we get older. The second is losing that estrogen and progesterone had actually is supportive for our tissues.

And so rates of snoring and obstructive sleep apnea I say along the spectrum because snoring is partial collapse of the air and an apt is more complete collapse, it could happen double to triple the rates as compared to pre perimenopause or pre menopause.

Yeah. So that's number one. And the thing about the difference between men and women, there is some older studies that showed if a man is overweight or obese who comes into his PCP, his primary care physician or provider and says, you know, I'm really tired, you know, I think I snore pretty much right away, will get checks sent for a sleep sleep apnea test.

A woman who comes in who says she's tired or maybe she says fatigued because women are not always necessary, sleepy or tight. Right. Because we push through.

I elevate fatigued, maybe, you know, I wake up a little bit of a headache. I don't know if I snore. You know, my my partner's out, you know, he's fast asleep.

You know, he doesn't know anything. At night. She'll get sent for a test, so have her thyroid checked. And then guess what? Either put on an antidepressant or sent to a therapist.

And so older studies, I think it was in the early 2000 show that up to 90%, even greater of women have obstructive sleep apnea and they're just undiagnosed because there's such a gender bias in medicine, you know, the whole I think we still say it's not like a man.

There's even some research out there that shows that women didn't think that they start as loud as men. That was a clinical question. Do women snore just as loud as men in terms of decibel level?

And so researchers are like, well, let's go test it out. So they brought people in the lab. And yes, in fact, women snore just as loud as men. And but it was like 30% of women didn't even think that they actually snored and they snored. So really interesting how it happens.

And it's a common reason why people have a hard time maintaining sleep. And we don't necessarily know. Sometimes we just have those early morning awakenings and in that early morning show, you know, Dr.

Wells, as we have our REM periods and so there is rapid eye movement and women have higher rates of apnea related, you know, REM, the reason for that is because when you're in REM, your body's paralyzed except for your diaphragm. So you don't act out your dreams.

And so when your body's paralyzed, your muscles get more floppy. So you can have higher rates of obstructive sleep apnea during that time. And yeah, if your partner is fast asleep or if you don't have a partner, then you have no idea that this could potentially be happening.

So I always start out with, okay, do you have any little bit signs and symptoms or sleep apnea? And another thing too is that the symptoms are a little bit more subtle, so women can have more mild disease but have a great amount of sleepiness.

You know, moodiness is actually one of the things that it's complained about morning headaches and mood lability, more so than like snoring. You know, you don't have the snore to have sleep apnea, which is really interesting.

I read the study and I'm like, Oh, there's no snoring, but you know, that airway is collapsing. They got severe sleep apnea. So that's why I would say it's often missed.

And that's why I'm always like, I think everybody should get a sleep study, to be honest. But, you know, I'm biased because that's what I see on a regular basis.

I think I was talking to someone on the podcast and you're like, What? You think everybody should get to sleep study? I'm like, Yeah, it's so easy to do now, you know, you can just go home.

There's a little one that you can stick on your finger. I mean, I'm I'm more traditional. I like the ones with a flow inside your nose and the belt around your waist.

But, you know, technology the way it is, you know, I keep telling my patients one day it's going to be so great. You're just going to hit a button on the app and we can diagnose whether or not you have sleep apnea.

I feel like we're not too far away from that. I agree with you. I think that sleep is so important and the test is so easy that it almost makes sense to screen everybody for obstructive sleep apnea.

And I think something that's worth noting for women is that you mentioned the snoring not being present or may be perceived by a bed partner or roommate.

I think also women have a tendency to consider snoring very unladylike. And, you know, since they tend to women tend to go to doctor's appointments alone more frequently, whereas men are typically with their partner.

Oh, that's a good point. You know, I think that oftentimes the symptoms get minimized. And so unless you're sitting across from an astute clinician, it can be easily missed.

And it's such a shame because it can go on for a long time without being addressed, you know, testing is so common these days. I think that's one of the benefits of the pandemic, was that these remote tests, the home sleep apnea tests, came up to be more popular and more accessible.

But the truth is they actually can underestimate severity of sleep apnea or even yield a false negative result. I always like to say it's inconclusive, not necessarily negative.

Can you speak more about that now? That's a great point. Inconclusive. I think the word I have on my report, it's non diagnostic, you know, here if we suspect is this suspect sleep apnea, go to the lab.

So the difference between the in lab or the police on the ground in the home sleep apnea test are a lot. Now, if you take a look at the number of sensors that you can potentially add to an in lab test versus the sensors you have at home, it's a great difference.

And the question is, is what is your pretest probability? So, you know, I don't want to get too much into the statistics here, but if you have someone where, you know, traditional primary care physicians know about the stop bank screening.

So right. Snoring, you stop breathing. Okay. What's tired? Snoring. Are you tired? Your blood pressure, age, BMI, male gender. Right. And then your neck circumference.

And so based on that, you can have a woman with maybe like a score of one, you know, based on age and they're not qualified for the test. So, you know, when you take a look at any type of diagnostic tool, the sensitivity and specificity really depends on their pretest probability.

So someone that comes into your waiting room, you know, at a practice telehealth. So my virtual reading room, who is, let's say a trucker, right, is just like what I think of where a football player there's high rates of sleep apnea in football players. Right.

Their necks are quite big. Maybe they have really big tongues or BMI is high. Maybe they already have some high blood pressure. And so high risk for sleep apnea doing a home sleep apnea test in that case.

Right. I had a gentleman who came in was falling asleep. I kid you not, Dr. Wells, when you were doing his blood pressure and that thing squeezes your arm pretty tight.

And I'm like, I don't know, sleep. I mean, pretty close. That's sleep apnea, but potentially narcolepsy as well. We already know pretty much the diagnosis.

So doing a home sleep apnea test is really just like a check off for insurance. But for women, right? If the symptoms are a little bit more subtle, it really is better to go to the lab.

And the reason for that is in the lab, you get the EEG, you actually can look at their brainwaves, the electro and type LOCKERBY. And so that's really helpful because women have a type of sleep apnea.

And I always say because women are smarter, because I'm so biased. I had a dentist that said, is it because they're smarter or are women more anxious when your airway will partially collapsed and your brain will wake you up before it completely collapses?

And so that's one of the problematic parts with these home sleep apnea tests where it doesn't measure measure arousal. And so arousal is really important because if you're constantly waking up because your airway's partially collapsing, that could be a big reason why you're tired.

And so when you take a look at the commercially available sleep tests, you know, there's a wide range, some monitor flow, some monitor arterial tone. The sensitivity and specificity can vary really on the test probability, but also on the type of sensor you're using.

Some of the ones that just go on your finger are the rings. You know, they say it's about 70%, you know, high eighties.

Sleep Apnea in Women: Symptoms and Testing

The one that I like to use is the more traditional one with the flow sensor in your nose, plus the belts, plus a monitor, snoring and body position, plus accelerometers and pulse oximetry.

So those tests could see how many more sensors are on it. Have a higher sensitivity and specificity. So higher in the, you know, I'd say eighties and nineties.

And that's what I'm more comfortable with. Yeah. But if you do have a sleep apnea test at home and it's negative, I say don't stop there. Right? It's inconclusive.

It's not diagnostic, especially if you're feeling really tired. Try it. Especially if you're waking up with those headaches. And I think more so if your blood pressure is starting to creep up.

Right, if you are having some symptoms of the metabolic syndrome. Right. And another thing to to talk about is if you're waking up to urinate at night, nocturnal TIA is a symptom of untreated obstructive sleep apnea.

I mean, if it's not from diabetes, if you've already subjecting, you know, water at 6:00, which some people do and some women are already on some of the medications, the anticholinergic medications to stop, you know, having to wake up and pee.

And they're still peeing at night. Yeah. So that clues me. And there's, you know, there's got to be more to it. And the connection we have time to discuss is when I was thinking of, like, plumbing.

So if there's a narrowing in your pipe in your house, right, what happens downstream? There's more pressure. So if there's a narrowing in your pipe here, your lungs are taking deeper breaths.

Right. So when you have more pressure in your lungs, your lungs are in the same cavity. And so the pressure gets transmitted in the top part of your heart will actually stretch and signal down to your kidneys that tell you to wake up on your knee.

So happens in men and in women sometimes. I have some patients wake up every hour and they're used to it when fortunately I used to have them get diagnosed and treated for sleep apnea.

Now they wake up once and they're so happy. Yeah. So nocturnal and obstructive. Sleep apnea, our our colleagues or friends. Yeah. I can get better, right?

Yeah. Yeah, totally. And next area or going to the bathroom frequently at night I think also happens when somebody is having frequent nighttime awakenings and they kind of feel like, well, I'm awake, I might as well go.

And, you know, there's a couple of issues there. One is that, you know, you're getting up out of bed, which is going to, you know, potentially increase your level of alertness.

And if you flip on the bathroom light, you get that bright light exposure that can prevent a person from getting back to sleep very easily. So really good to look out for that and maybe use a nightlight or even a red bulb light.

Somebody had suggested to me a party bulb. And it actually is is quite effective. I've got one in my bedside lamp and it and it works really well to reduce that light exposure at night.

Makes sense. I want to go back to nighttime awakenings with hot flashes so, so frustrating in the perimenopausal phase. And there are some things that you can do to reduce the chances of waking up with hot flash.

So can you review some of those and tell me what your success rate has been in advising these things to women? Yeah. So good. Yeah. So honestly, the reason for the hot flashes are fluctuations in your estrogen levels.

The acute drop can lead to that flash. Right. So with that said, being on hormones, hormone replacement therapy, I think they call it now menopausal therapy helps.

So but not everybody is a candidate for it. You know, if you have a history, personal history of like breast cancer or things like that, or sometimes you think of cardiac disease or strokes, but always talk to your health care provider about that.

So hormonal therapy can help if you don't want that. Okay. What are plant based therapies? Right. So the whole integrative model, what are the supplements that could help that are basically that basically have estrogen like properties?

So something is like red clover, right? Black cohosh, you know, is commonly recommended. But, you know, the studies are actually pretty mixed around that I'm a big fan of food as medicine.

So soy based products phyto. So tofu soy milk. If you take a look at sort of the Asian diet versus the traditional American diet, you know, women in Asia report less hotspot rashes potentially because they have a lot of soy products as well.

So their estrogen levels are a little bit more stable as they get older. And what else, you know, integrative therapies, clinical hypnotherapy is actually really huge for if the hot flushes are causing insomnia, some research actually shows as compared to menopausal education.

Cognitive behavioral therapy for insomnia, not specifically for hot flashes, can improve hot flash frequency. Melatonin actually may have some properties to help.

Another hormone there. Yeah, melatonin natural sleep hormone helps regulate our sleep stages, but there's benefits beyond sleep, which is so interesting.

It can improve bone health, it may improve our blood sugars, but melatonin actually can have a property that can help lower our core body temperature.

And so I'm sure any woman who has had a hot flash before I had them during pregnancy, which was uncomfortable, just like, you know, a taste for the future.

But, you know, turning down your thermostat can help. And so I think I even saw a TikTok hack where, you know, if you're if you don't have a C or if your partner doesn't like the AC to cold, you can just put a little fan like a desk fan with ice water bottles and then just have that.

AC There's alternate techniques and tricks that you can do, but yeah, there are supplements, there are medications now that certainly can help mind body therapies.

Yoga actually has been associate to to help improve hot flashes. And the way I like to think about is when I used to work as an apprentice, I was only in the hospital.

Psych on the air and off the air was clear. The was quiet. You know, I could get some sleep at night, but sometimes it was really hard because you never know when that pager is going to go off.

You never know when a nurse is going to call you for a medication or the air is going to call you and it's going to be code. So it's almost like that anticipation.

So women who have really severe hot flashes, they call the super flashers and sometimes even before even have the hot flash, that anticipation that the hot flashes coming can even trigger to the hot flash.

So that's something to consider. So that's how I think the mind body therapy's really work. And then food, you know, alcohol or spicy food, avoiding the triggers for caffeine.

I think that makes flashes worse. Yeah. I've had the most success with recommending women cut out alcohol in order to improve their hot flashes. That seems to be really worthwhile.

And, you know about the temperature fluctuation. I think that putting the cold pack on your upper face, on your forehead and over your eyes has such a nice sort of calming rest and digest response.

And sometimes that can help get a woman back to sleep, which, you know, it's very easy to try. And there's products out there like the chili pad. Have you heard of this?

Yeah, I have. I have. Them. So they all help to regulate or stabilize or manipulate temperature, which can promote sleeping through the night. I wonder if the the cognitive behavioral therapy is kind of using that sleep restriction to make sleep more deep, make arousal less likely.

What are your thoughts on that? Yeah, well, I think a lot of it helps reduce anxiety. Right. So you take a look at that. I the triad of sleep you have your homeostatic sleep drive, circadian rhythm and then your arousal state.

So exactly what you're saying is how can we reduce those anxious thoughts, those ruminating thoughts? You know, am I going to be able to sleep tonight?

Am I going to have a hot flash? So the more we can help someone with cognitive restructuring to help get them into a Zen, more relaxed type mindset, then they're able to go into a deeper state.

And maybe if their body temperature does rise, it's not going to wake them up as much. Or, you know, like a clinical hypnotherapy type term is, you know, maybe you're going to have a hot flash, but it's not going to bother you like it used to.

And tell me more about clinical hypnotherapy. I love it. It's just so fascinating tool. It's got a lot of maybe some negative bias to it because there's stage hypnotherapy or stage hypnotists.

Or, you know, like a carnival situation. Yeah, you go to Vegas and, you know, your friends up there are cooking like a chicken or, you know, doing a funny dance.

But, you know, it's been around for you know, hundreds and hundreds of years in psychology. A lot of dentists use it for people who, you know, are really anxious coming in for procedures, the time, even like surgeries without anesthesia, like appendectomies on people who have clinical hypnotherapy.

So what is clinical hypnotherapy? Well, if you are going to work with someone, I recommend going to the ASH websites this American Society of clinical hypnotherapy dot net and look up a licensed professional so when you see someone for whatever type of reason.

So for me, either it's claustrophobia with their CPAP mask, typically more it's insomnia. Having a hard time getting to relax will say you want to see someone who already trained in their field.

Meaning if you go to a dentist, right, you want to have, you know, the dentist clinical hypnotherapy because you're going to get your teeth done. If you if you go to there's actually an interesting case of a pediatrician who healed a case of works in one of her or her patients who was playing volleyball.

So it's almost like you want to go to a practitioner who's already well versed in treating the thing that you're going for. So I would say that's like step number one.

Step number two is what is clinical hypnotherapy? So have you ever been in a situation say kids are amazing at this, you think they're ignoring you, but they're actually so focused.

So when my kids are watching Netflix or, you know, watching TV, they come in the room. I'm like, you know, one last time, every three old is awesome. You use the restroom or you know, how to drink cool water.

And this is like nothing and it's not intentional. I would say that he's ignoring me. His brain is so focused on what he's watching that things around the environment are there, but he's not paying attention to it.

So it's laser focused attention. Another good example is if you're driving down the highway and you're, you know, you're you need to go stop at the market before you go home.

And then a song on the radio comes on. Or, you know, I guess I'm aging myself, a song on your M. P.

Managing Hot Flashes and Nighttime Awakenings

three player. And it brings you back to, like, high school. And it was like, Oh yeah, I remember hanging out with my girlfriend. We first heard this song and you're driving down the road and then you end up at home.

You're like, Oh, shoot, I was supposed to go to the market. Your brain, basically, it was so focused on that that your attention was diverted from other things.

So when you're in a highly focused state of awareness, we add a lot of post hypnotic cues which are just positive psychology. You're a great sleeper. You can sleep as long as deep as you need to, any time you need to.

You know you deserve sleep. Sleep is she comes easy for you. And so with these positive cues, basically it's a reprograming of the subconscious mind because I'm sure if you were to work with anyone who has insomnia, I'm a bad sleeper.

My mom's a bad sleeper. My aunts have had sleeper. But is anyone really a bad sleeper? So it's reframing the mindset. Sometimes I call it aging myself again, the tape players, right?

You know, I used to have my first car, I had a tape player and I remember putting a tape in. And, you know, if if it doesn't, it doesn't work. Well, the tape gets all tangled.

And sometimes that just happens with our sleep. Right. You know, you have that tape, it really wants to work. And maybe it's the CD that scratched and it's just skipping a bit.

So how do we unwind that tape? How do we clean the scratches off of it? It's reprograming your mind. So what are the thoughts that we can implant or program?

And doing it through clinical hypnotherapy is great because when someone's in that really relaxed state, the way I like to do it is, you know, what's your perfect day?

You know, there's no time restrictions. You can have a private jet, you can be on your own island and just paint this really beautiful, perfect day. And at the end of the day, you're so exhausted because you have so much fun that you're either at home or you're in a hotel and you're just sleeping as deep as you need to do as long as you need to sleep.

And then we recorded it and I just had to listen to it over and over again. It's fantastic. I had a lady who had insomnia for over 20 years, and fortunately there was a traumatic incident that, you know, pre-dated her insomnia but on medications.

And then after we did the clinical hypnotherapy session, I saw her two weeks later, she was sleeping 8 hours and she was only sleeping like 3 to 4 hours before that.

And I was almost like shocked how long how well it record is it just one case? But, you know, she really believed that she could get help. And so, you know, just having that door open and then now planting that programing where you actually are a good sleeper, there's nothing wrong with your brain or your body.

You can sleep as long as you need to as deep as you need to. She was able to sleep. That's pretty phenomenal. That's fantastic. You know, I love reminding people that sleep is a biological need.

Everybody knows how to sleep. Your brain knows how to sleep. Sometimes it takes a little bit of uncovering to re access that ability and the stories that we tell ourselves matter so much that internal dialog of how we're processing our world.

I call it a scary bedtime story when people are. Really it's a good one. Yeah. You know, they almost make a self-fulfilling prophecy sometimes and just a little bit of a change to their perspective, to their mindset, can open up a whole world of sleep with ease, which is something that they may not have remembered having.

Having been so long since they slept well. So I totally endorse that. And I want to clarify, is it a s h dot net or ac h. SDH Start ac dot net. That's where you find it.

In that room. Nicole Hypnotherapy. Yeah. Fantastic. There's a directory there that you can look at. Good deal. Now it seems that at least half of women are going to struggle in the perimenopausal menopausal state.

And you mentioned before that hormones in the form of pills or patches are not for everybody, but do they eliminate the sleep problem if somebody were to go forward with hormone supplement?

Yeah, definitely. Specifically progesterone. Um, a lot of women who and I think just as one caveat, I don't start women on hormone therapy, typically they come in already on it or I suggest that they go talk to the gynecologist or is because I don't do it too often.

I just prefer to discuss it and have them follow up with their provider for that. But it certainly can help. Literature shows it. I've seen in clinical practice, but I've also seen on the other side where maybe the trigger for someone's insomnia was a hot flashes.

And now it's a lot better because it's been five years ago, they're on, you know, hormone therapy, but they still can't sleep. And so I would say those are the patients that I typically get where, you know, my doctor has tried Ambien, I've tried CBD, I've gone through, you know, my local herbal store and just tried everything there and nothing works.

And so then it's like, okay, we'll have you done CBT II, right? You know, taking a look at their thoughts they have in interim around sleep. And like you were saying, I basically think of myself as someone who helps reinstate their confidence in that sleep is a natural ability.

Yeah. Yeah. And I'm wondering in your hands, how long does that usually take? It sounds like there's probably a time investment. Yeah. And you have to approach it with an open mind.

So, you know, for most people, what are they looking at in terms of sessions with you or what timeframe there is to get relief? So honestly, Dr. Wells, I'd say for the motivated person within a month, I'd say after that initial visit, they can start to feel better.

Typically to pick up my schedule, they do another visit two weeks later and then if I see them after a whole month, the good one I say the good ones, the good students, the ones who follow the recommendations and actually really believe in improvements that they certainly can.

Yeah, but you know, part of this is just working with a patient and where they're at, you know, especially if they're at a state where I had some people saying, you know, my dentist doesn't want me to take my Xanax at night because it's bad for me and I'm getting older and it's like, yeah, that's definitely true.

But then it was almost like, like a stab in the heart because it's like, well, my brother gets to take something, you know, my daughter takes something.

Clinical Hypnotherapy for Insomnia

Why can't I take something? And it's almost like reframing that, like, well, why do you feel like you need to take something? And I think that's where our health care system has sort of I, I don't know, put people, like, in the wrong direction.

Like we've been really misguided. A lot of people saying that can't sleep. Take this right. And I think that's true for so many things. High blood pressure, take this, have diabetes, take this.

It's almost like, okay, well, let's step back in. Like what's going on in your life? Well, where does the sleep come from? And it's so interesting because yeah, maybe it was from perimenopause, but ten years down the line, you know, all that hot flashes are gone away and your mood is stabilized.

But, you know, maybe you're in a relationship that is just a little bit sour and you can't stand that person that is in their bedroom every night. Or maybe, you know, that person that you had your partner's like on and they're actually seeing a lot of people who can't sleep because they're lonely.

And there's really no supplement, no pill for that. And so it's it's taking the time giving someone the space and holding space for them to be able to talk about what potentially could be leading to their sleep disturbance.

So I think I couldn't. Agree with. You more. A lot of women need I mean, men as well. But I think we all just need a safe place where we can be vulnerable and have someone, you know, reflective to do some reflective listening.

Totally agree. And and with the pills, you know, I think that's a very attractive response to problems for a lot of people because it seems quick. However.

The tendency is to overestimate what pills can really do for you and, you know, in the long term they're not beneficial and not good for your brain. So the sleep skills that you've reviewed today have the advantage of being a side effect, free and durable over time.

You know, that's that's sort of a meta skill of knowing yourself better, of being able to respond to your own needs and to to comfort yourself and quiet your mind.

I think that's really fantastic. What you've described expands beyond the realm of sleep, right. You know, I imagine there is some drama at work, right?

Being able to coach yourself through that, to be able to come from a place of calm versus then reacting, you know, getting into an argument with your spouse or your kids. Right.

Being able to have that mental fortitude, just, yeah, step away, calm yourself down and then come back to the situation I think is so helpful. And then just going back to sleeping pills, you know, it's just talk is for women, you know, zolpidem, right.

Is the first FDA approved medication that actually had a dose change for gender, because what we saw is that at higher doses, women were having more side effects with complex sleep behaviors.

So interesting had a patient tell me, you know, she was on zolpidem and she somehow went to her local mini mart, bought an energy drink, came back home, did not know how she got in her car, how she paid for that drink.

And it really scared her. And she'll never take any type of sleeping pill again, which is scary. But, you know, that's not the first person has told me something like that.

Not everybody, you know, there's a complex behavior. Sometimes it's just sleep eating or sleep talking. I had not. Remembering what they say the next day.

Sleep, social media. Yes. I think going online and tagging people in pictures and their friends are like, why did you do that? You know, I didn't want to be tag.

So it's really interesting the things that your brain can do on medications. And so something very, very to consider. I mean, take a look at what the research shows, right?

You know, does it how much actually improve our sleep? You know, maybe 30 minutes, maybe 40 minutes, depending on maybe that. Yeah. And you know, they only last a couple of hours too, so.

Yeah. Did you ever hear this is kind of coming up in my brain? I believe I heard a statistic that women were not included in research studies about sleep until the early to mid nineties.

And because that too that makes. Sense. Yeah.

Hormone Therapy, Sleep Medications, and Practical Takeaways

Because they were seen as as so complex to be confounding in our research studies. And so you know when you look at it, I was born in the seventies and you know that is 20 years before I even came to be.

So just for some perspective, the sleep medicine field is quite new, right? And even studies on sleep in women is newer than that. And I suppose you could say it's still fresh if you've managed to put a positive spin on it.

But truly more more work needs to be done. And I really appreciate you bringing your wisdom and your expertize to us today. And certainly you've given us some really practical tips for improving sleep, especially with nighttime waking and and getting to sleep at night.

We talked about perimenopause and menopause, some things that you could do to increase your sleep efficiency at night, maybe even avoid hot flashes. You mentioned the you mentioned the clinical hypnotherapy with the ASCH.net And we talked about home sleep apnea testing and women not to stop at an inconclusive test.

You got to go get that confirmatory test if you've got symptoms. Yeah. Thank you so much, Dr. Val. And I wonder if you can tell everyone where they can find you if they want to work with you further.

Yeah. Fantastic. So if you are located either in the states of Hawaii or California, my clinical practice is called SleepLife Med. So if you just type sleeplifemed.com you can find me there.

I do telehealth visits and then if you're a woman looking for really more high quality education and resources about women's sleep, health and whole living, you can check out sleephoria, sleephoria.com I have a youtube where I do live mini webinars twice a month.

The last one was just talking about how to create a sleep sanctuary. I also have a blog and you can join my weekly newsletter where I will be in your inbox, giving you some sleep tips and just really giving people some support in and around this time because yes, as you mentioned, about 50% of women going through midlife do have difficulty with your sleep, but their sleep and that number is just way too high.

That just kills me. So there's a lot of things that you can do there support there. So I invite you to come join our community. Thank you so much. And everybody, take this seriously.

Sleep is so important to your well-being. Take care. Bye bye

Valerie Cacho, MD

How To Navigate Sleep During (Peri)Menopause