How To Navigate Sleep During (Peri)Menopause

Valerie Cacho, MD

Thank you. Dr. Wells is happy to be here as well. To bring up my favorite topic, how women sleep,

Audrey Wells, MD

That is great. I wonder if you can maybe give some background on how this is on the tip of your tongue, and I am sure you are at the forefront of what you do in clinical practice.

Valerie Cacho, MD

Yes. Thank you so much. For about six and a half to seven years, I practiced with a hospital-based program in Hawaii. I was a medical director there, running a pretty busy Sleep Department, doing consultations, and running their sleep lab. What I came to find out was that there were a lot of women coming to my practice who were tired, who were exhausted. They did not know what was going on. They had their thyroids checked. Maybe they were started on some sleeping pills, but they were just not feeling well. I dug deeper into this and looked into the relationship between underlying medical sleep conditions, which I am sure we will touch on. But what is happening as women get older and as we go through midlife and some of the hormonal shifts?

 Certainly, that is a glimpse into what can be happening. But I think part of it, too, is that there is so much that is expected of women. We work full-time. Most of us, I would say, are managing our household. We have kids. Now, daughters are also the people who, typically, I did a lot of before I went into full-sleep medicine. I did nocturnist work and hospitalist work, and you would see the daughters there at the bedside. We are burning the candle on both ends. We are working, we are taking care of our family, and we are taking care of our elderly parents. It is just a combination of factors that can impact one’s sleep. I practice holistically. I practice integratively. Because pills can only do so much. When I take a look at my patients who come in, certainly all my patients, because I do see men and women. Now, I take the whole mind, body, and soul approach. What is going on in their head that is keeping them from sleeping? Is it anxiety? Is it stress? Do they have a past issue of trauma when they are asleep? Their body, do have underlying medical conditions, such as obstructive sleep apnea? Do they have a restless leg issue? Is it a movement disorder and then a soul?

Sometimes when we get older in life and we get to this plateau phase, we start to ask ourselves, maybe deeper questions, is this the life I want to live? Maybe I have been in this career for 20–30+ years. Maybe I have plateaued. Maybe I have reached my peak, and is this all there is? Sometimes those questions are in our minds and can impact the quality of sleep that we have. I like practicing integratively and holistically because it touches on all those points, and I see the person as a whole.

Audrey Wells, MD

Definitely. I think people should be seen as a whole. You never want to be labeled as having a medical condition or that label summing up a person because it is way too simplistic. 

Valerie Cacho, MD

Yes. 

Audey Wells, MD

I want to read something that you said that resonated for me, as I am a champion for women. You said a well-rested woman has the energy, clarity, and drive to change the world, but they cannot do that unless they have a good, solid night’s sleep behind them. Now, I want to go to hormones. To me, hormones are a term that is tossed around. It covers everything. It is my hormones. It is true, that women take several pivots in their lives with their hormones. I wonder if you can start with menopause and even go a little bit back with perimenopause. What hormonal changes are taking place that affect sleep?

Valerie Cacho, MD

Yes, great question. Dr. Wells. Sure, as we both know, in medical school, hormones are just messengers. I feel that in today’s day and age, with your social media, it is almost, I do not know, blamed for a lot of our ills, but they are just messages that our brain is sending to different parts of our body and vice versa. The hormones specifically that we are talking about during perimenopause, which is a time before you stop having your periods. Menopause, so the definition is 12 months without having your period. The typical age in the U.S. is 51. For perimenopause, it is 47. 

However, you can start to have symptoms even 4 to 7 years before you stop having your periods. Early forties, even some people. Unfortunately, in their late 30s can have symptoms of perimenopause. What are those? Well, insomnia, for big one or two sleep doctors here, mood fluctuations, decreased libido, dry skin, pain on intercourse, anxiety. Bone pain is part of it, too. muscle aches. There is a whole host of symptoms. The thing about perimenopause and menopause and, in my medical education, we did not learn a lot about them. Now, when you take a look at women’s health, a big chunk of it is about pregnancy. OB-GYN vocation, is all about, okay, how do we help the mom stay healthy? When the baby’s in utero and then goes through a good pregnancy. But then, as women get older, maybe we talk about Pessaries, maybe we talk about recurrent UTIs, or if your bladder gets a hole, then they can do some surgery for that. But not a lot is put into how we can support a woman as they go through menopause. Menopause is certainly not a disease.

It is just a normal part of Mother Nature. What is perimenopause, and when do we start to have those fluctuations of progesterone and estrogen? Progesterone is pro-gestation. When we start to go through this process, our biological clock says, You do not need to have babies anymore. The progesterone levels start to fall, and then the estrogen levels also start to fall and fluctuate. Sometimes that is why we can have bad hot flashes. The estrogen levels start to fall. Sometimes we can have problems with insomnia because progesterone, the hormone that supports gestation, is also known as a relaxation hormone. It works on the GABA system, and the GABA system is also the sleep-promoting system, the same system that some sleep supplements and some sleeping pills work on.

 It is interesting how, as we go through that change, it disrupts our sleep. Then, once we go through menopause, the levels of progesterone, estradiol, and estrogen are very low. Then your FSH levels start to rise. If you are someone who is 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 does not necessarily mean that you are not in perimenopause. Because it is fluctuating level. Sometimes, they can be helpful to do different blood tests at different times. 

You will know for sure when you are in menopause when FSH levels are high and the estrogen and progesterone levels are low, what can be tricky is that sometimes people have their uterus taken out at an early age. We do not know if they stop having their periods. Or if they have an IUD in place, or if they are already on hormone replacement therapy or just birth control for heavy periods. That can muddy the picture and make it hard to diagnose based on lab tests. But I would say it is a clinical situation. By taking a look at the whole person. What are they going through? Are you fitting the normal age range? because these are just clues, and how can we support you?

Audrey Wells, MD

Yes, I think that is great. I think when women are concerned, there is always an element of complexity. Now, you mentioned before that women are typically the CEOs of their homes. Whether they have an employer job or not, they are typically just working all the time. I think that sometimes stress, sometimes caffeine, and sometimes alcohol. These are all sleep disruptors. Sometimes it is the bed partner.

Valerie Cacho, MD

Oh, yes.

Audrey Wells, MD

Next to them is disrupting a woman’s sleep, which is so not fair. But all of these things can culminate into disrupted sleep on any given night and over time. For someone who is looking for help with their sleep, and maybe they are not in that perimenopausal range, how do you advise them?

Valerie Cacho, MD

Yes, great question. Dr. Wells, I always talk about obstructive sleep apnea. The reason for that is that it is such a common condition. One in five adults can have at least mild sleep apnea. Then, as we get older, the hormone-related changes. When you lose estrogen and progesterone, it makes your upper airway more floppy. Going back, I am sure that hopefully all the audience members already know what obstructive sleep apnea is, but it is a physical blockage of your upper airway when you sleep. Typically what happens when you sleep: your muscles relax. Sometimes it relaxes a little bit too much, especially in the posterior oropharynx at the back of the tongue, and it can fall back. Age can lead to more of this because, as we get older, unfortunately, our muscles atrophy. They are just not as strong. That is one thing as we get older.

 The second is losing estrogen and progesterone, which are supportive for our tissues. The rates of snoring and obstructive sleep apnea, I say along the spectrum, because snoring is a partial collapse of the air, and an apt is a more complete collapse, it could happen double to triple the rates as compared to pre-perimenopause or pre-menopause. Yes. That is number one. The thing about the difference between men and women is that some older studies show that if a man is overweight or obese and comes into his PCP, his primary care physician or provider, and says, I am tired, I think I snore pretty much right away, will get checked and sent for a sleep apnea test. 

A woman who comes in and says she is tired—or maybe she says fatigued—because women are not always necessarily, sleepy, or tired. Because we push through. I feel fatigued; maybe, I wake up with a little bit of a headache. I do not know if I snore. My partner’s out, and he is fast asleep. He does not know anything at night. She will get sent for a TSH. She will have her thyroid checked. Then guess what? Either put on an antidepressant or sent to a therapist. Older studies, I think it was in the early 2000s, show that up to 90%, or even greater, of women, have obstructive sleep apnea, and they are just undiagnosed because there is such a gender bias in medicine. On the whole, I think we still say it, snores like a man. 

There is even some research out there that shows that women do not think that they start as loud as men. That was a clinical question. Do women snore just as loudly as men in terms of decibel level? Researchers are, Well, let us go test it out. They brought people into the lab. Yes, women snore just as loudly as men. But, 30% of women did not even think that they snored and they snored. Interesting how it happens. It is a common reason why people have a hard time maintaining sleep. We do not necessarily know. Sometimes we just have those early morning awakenings, and in that early morning show, Dr. Wells, as we have our REM periods, there is rapid eye movement, and women have higher rates of apnea-related REM. The reason for that is that when you are in REM, your body’s paralyzed except for your diaphragm so you do not act out your dreams. When your body is paralyzed, your muscles get more floppy. You can have higher rates of obstructive sleep apnea during that time. 

Yes, if your partner is fast asleep or if you do not have a partner, then you have no idea that this could potentially be happening. I always start with, Okay, do you have any little signs and symptoms of sleep apnea? Another thing too, is that the symptoms are a little bit more subtle. Women can have a milder disease but have a great amount of sleepiness. Moodiness is one of the things that is complained about. Morning headaches and mood mobility, more so than like snoring. You do not have the snore to have sleep apnea, which is interesting. I read the study, and I am like, There is no snoring, but that airway is collapsing. They had severe sleep apnea. That is why I would say it is often missed. That is why I always think everybody should get a sleep study, to be honest. But I am biased because that is what I see regularly. I think I was talking to someone on the podcast, and who said, What? Do you think everybody should get their sleep studied? I say, Yes, it is so easy to do now. You can just go home. There is a little one that you can stick on your finger. I am more traditional. I like the one with a flow inside your nose and the belt around your waist. But, technology the way it is, I keep telling my patients that one day it is going to be so great. You are just going to hit a button on the app, and we can diagnose whether or not you have sleep apnea. I feel we are not too far away from that.

Audrey Wells, MD

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. I think something worth noting for women is that you mentioned that the snoring is not present or may be perceived by a bed partner or roommate. I also think women tend to consider snoring very unladylike since they tend to go to doctor’s appointments alone more frequently, whereas men are typically with their partners.

Valerie Cacho, MD

That is a good point.

Audrey Wells, MD

I think that oftentimes the symptoms get minimized. Unless you are sitting across from an astute clinician, it can be easily missed. It is such a shame because it can go on for a long time without being addressed. Testing is so common these days. I think, 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 can underestimate the severity of sleep apnea or even yield a false negative result. I always say it is inconclusive, not necessarily negative. Can you speak more about that now?

Valerie Cacho, MD

That is a great point. Inconclusive. I think the word I have on my report is non-diagnostic. If we suspect this is sleep apnea, go to the lab. The difference between the in-lab and the polysomnogram in the home sleep apnea test is 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, there is a great difference. The question is, what is your pretest probability? I do not want to get too much into the statistics here, but if you have someone where traditional primary care physicians know about the STOP-bang screening. Snoring, you stop breathing. Wait, what is T now?

Audrey Wells, MD

Tired. Blood Pressure.

Valerie Cacho, MD

Snoring. Are you tired? Your blood pressure, age, BMI, and male gender. Then your neck circumference. Based on that, you can have a woman with maybe a score of one, based on age, and they are not qualified for the test. When you take a look at any type of diagnostic tool, the sensitivity and specificity depend on its pretest probability. Someone who comes into your waiting room at a practice telehealth. My virtual waiting room, who is, let us say, a trucker, is just what I think of as a football player. There is a high rate of sleep apnea in football players. Their necks are quite big. Maybe they have big tongues or their BMI is high. Maybe they already have high blood pressure. High risk for sleep apnea. Doing a home sleep apnea test in that case. 

I had a gentleman who came in and was falling asleep. I kid you not, Dr. Wells, when you were taking his blood pressure and that thing squeezed your arm pretty tight. I am, I do not know, sleep apnea is pretty close. That is sleep apnea, but potentially narcolepsy as well. We already know pretty much the diagnosis. Doing a home sleep apnea test is just a check-off for insurance. But for women, If the symptoms are a little bit more subtle, it is better to go to the lab. The reason for that is that in the lab, you get the EEG, you can look at their brainwaves, the electroencephalography. That is helpful because women have a type of sleep apnea. I always say that women are smarter because I am so biased. I had a dentist ask, Is it because they are smarter? Or are women more anxious when your airway will partially collapse and your brain will wake them up before it completely collapses? That is one of the problematic parts of these home sleep apnea tests, where it does not measure arousal. 

Arousal is important because if you are constantly waking up because your airway’s partially collapsing, that could be a big reason why you are tired. When you take a look at the commercially available sleep tests, there is a wide range; some monitor flow, and some monitor arterial tone. The sensitivity and specificity can vary depending not only on the test probability but also on the type of sensor you are using. One of the ones that just go on your finger is the OURA ring. They say it is about 70% in the high 80s. The one that I use is the more traditional one with the flow sensor in your nose, plus the belts, a monitor, snoring, and body position, plus accelerometers and pulse oximetry. Those tests could see how many more sensors are on it. Have a higher sensitivity and specificity. Higher in the, I would say, the 80s and 90s. That is what I am more comfortable with. Yes. But if you do have a sleep apnea test at home and it is negative, I say do not stop there. It is inconclusive. It is not diagnostic, especially if you are feeling tired. Especially if you are waking up with those headaches. 

I think more so if your blood pressure is starting to creep up. If you are having some symptoms of metabolic syndrome. Another thing to talk about is that if you are waking up to urinate at night, nocturia is a symptom of untreated obstructive sleep apnea. If it is not from diabetes if you have already taken water at 6 o’clock, which some people do and some women are already on some of the medications, the anticholinergic medications to stop, and having to wake up and pee and they are still peeing at night. 

Audrey Wells, MD

Yes.

Valerie Cacho, MD

That clues me endlessly. There is got to be more to it. The connection we have time to discuss is when I was thinking of plumbing. If there is a narrowing in your pipe in your house, what happens downstream? There is more pressure. If there is a narrowing in your pipe here, your lungs are taking deeper breaths. When you have more pressure in your lungs, your lungs and your heart are in the same cavity. The pressure gets transmitted to the top part of your heart where it will stretch and signal down to your kidneys that tell you to wake up and urinate. It happens in men and women. Sometimes I have some patients who wake up every hour, and they are used to it, unfortunately. I used to have them get diagnosed and treated for sleep apnea. Now they wake up once, and they are so happy. Yes. nocturia and obstructive sleep apnea, are our colleagues or friends.

Audrey Wells, MD

Yes.

Valerie Cacho, MD

I can get better.

Audrey Wells, MD

Yes, totally. Nocturia or going to the bathroom frequently at night. I think this also happens when somebody is having frequent nighttime awakenings and they feel, Well, I am awake, I might as well go. There are a couple of issues there. One is that you are getting out of bed, which is going to potentially increase your level of alertness. 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. It is good to look out for that and maybe use a nightlight or even a red bulb light. Someone had suggested to me a party bulb. It is quite effective. I have one in my bedside lamp, and it works well to reduce that light exposure at night. 

Valerie Cacho, MD

Makes sense.

Audrey Wells, MD

I want to go back to nighttime awakenings with hot flashes, which is so frustrating in the perimenopausal phase. There are some things that you can do to reduce the chances of waking up with a hot flash. Can you review some of those and tell me what your success rate has been in advising these things to women? 

Valerie Cacho, MD

Yes. Honestly, the reason for the hot flashes is fluctuations in your estrogen levels. The acute drop can lead to a hot flash. With that said, being on hormones, and hormone replacement therapy—I think they call it now, menopausal therapy—helps. But not everybody is a candidate for it. If you have a history or personal history of 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. Hormonal therapy can help if you do not want that. What are plant-based therapies? 

In the whole integrative model, what are the supplements that could help that have estrogen-like properties? Something like Red Clover, or Black Cohosh is commonly recommended. But the studies are pretty mixed around the fact that I am a big fan of food as medicine. Soy-based products phytoestrogen. Tofu, Soy milk. If you take a look at the Asian diet versus the traditional American diet, women in Asia report fewer hotspot flashes, potentially because they have a lot of soy products as well. Their estrogen levels are a little bit more stable as they get older. What else? Integrative therapies and clinical hypnotherapy are huge for if the hot flushes are causing insomnia, some research shows as compared to menopausal education. Cognitive behavioral therapy for insomnia, not specifically for hot flashes, can improve hot flash frequency. Melatonin may have some properties to help.

Audrey Wells, MD

Another hormone there.

Valerie Cacho, MD

Yes, melatonin, is a natural sleep hormone. Helps regulate our sleep stages, but there are benefits beyond sleep, which is so interesting. It can improve bone health; it may improve our blood sugars; but melatonin can have a property that can help lower our core body temperature. I am sure any woman who has had a hot flash before I had them during pregnancy, which was uncomfortable, just has a taste for the future. But turning down your thermostat can help. I think I even saw a TikTok hack where, if you do not have an AC or if your partner does not have the AC too cold, you can just put a little desk fan with ice water bottles and then just have that as your AC. 

Audrey Wells, MD

That is right.

Valerie Cacho, MD

There are alternate techniques and tricks that you can do, but yes, there are supplements and medications now that certainly can help with mind-body therapies. Yoga has been associated with helping improve hot flashes. The way I think about it is that when I used to work as a nocturnist, I was the only doctor in the hospital in the E.R. The E.R. was quiet. I could not get some sleep at night, but sometimes it was 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 medication or when the E.R. is going to call you and it is going to be coded. It is almost like anticipation. Women who have severe hot flashes, call them super flashers, and sometimes even before they even have the hot flash, that anticipation that the hot flashes are coming can even trigger the hot flash. That is something to consider. That is how I think mind-body therapy works. Then food, alcohol, or spicy food, avoiding the triggers.

Audrey Wells, MD

Caffeine, I think makes flashes worse. Yes. I have had the most success with recommending women cut out alcohol. 

Valerie Cacho, MD

Okay. 

Audrey Wells, MD

To improve their hot flashes. That seems to be worthwhile. 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 calming, rest, and digest response. Sometimes that can help get a woman back to sleep, which is very easy to try. There is a product out there called the Chilipad. Have you heard of this?

Valerie Cacho, MD

Yes, I have.

Audrey Wells, MD

They all help to regulate, stabilize, or manipulate temperature, which can promote sleeping through the night. I wonder if cognitive behavioral therapy is using that sleep restriction to make sleep more deep and make arousal less likely. What are your thoughts on that?

Valerie Cacho, MD

Yes, well, I think a lot of it helps reduce anxiety. You should take a look at that. In the triad of sleep, you have your homeostatic sleep drive, your circadian rhythm, and then your arousal state. Exactly what you are saying is: How can we reduce those anxious thoughts, those ruminating thoughts? Am I going to be able to sleep tonight? Am I going to have a hot flash? The more we can help someone with cognitive restructuring to help get them into a Zen, more relaxed type of mindset, the more they can go into a deeper state. Maybe if their body temperature does rise, it is not going to wake them up as much. Or, a clinical hypnotherapy-type. Maybe you are going to have a hot flash, but it is not going to bother you like it used to.

Audrey Wells, MD

Tell me more about clinical hypnotherapy.

Valerie Cacho, MD

I love it. It is just a fascinating tool. It has a lot of, maybe, some negative biases to it because there are stage hypnotherapy or stage hypnotists.

Audrey Wells, MD

Like a carnival situation.

Valerie Cacho, MD

Yes, you go to Vegas, and your friends up there are clucking like a chicken or doing a funny dance. But it has been around for hundreds and hundreds of years in psychology. A lot of dentists use it for people who are anxious about coming in for procedures. They have done it even in surgeries without anesthesia, like appendectomy, and people who have clinical hypnotherapy. What is clinical hypnotherapy? Well, if you are going to work with someone, I recommend going to the ASCH website. American Society of Clinical Hypnotherapy, asch.net, and look up a licensed professional so when you see someone for whatever type of reason. For me, either it is claustrophobia with their CPAP mask or, typically, it is insomnia. Having a hard time getting to relax. I will say you want to see someone who has already been trained in their field.

 Meaning if you go to a dentist, you want to have a dentist’s clinical hypnotherapy because you are going to get your teeth done. If you go, there is an interesting case of a pediatrician who healed a case of work in one of her or her patients who was playing volleyball. It is almost like you want to go to a practitioner who is already well-versed in treating the thing that you are going for. I would say that is step number one. Step number two: What is clinical hypnotherapy? Have you ever been in a situation where kids are amazing at this? You think they are ignoring you, but they are so focused. When my kids are watching Netflix or TV, then I come into the room. I asked when was the last time you used the restroom or had a drink of water. It seems like nothing and it is not intentional. I would say that he is ignoring me. His brain is so focused on what he is watching that things around the environment are there, but he is not paying attention to them. It is laser-focused attention. 

Another good example is if you are driving down the highway and you are, you need to stop at the market before you go home. Then a song on the radio comes on. Or, I guess I am aging myself—a song on your MP3 player. It brings you back to high school. It was, Yes, I remember hanging out with my girlfriend. We first heard this song: You are driving down the road, and then you end up at home. You are, Shoot, I was supposed to go to the market. Your brain was so focused on that, that your attention was diverted from other things. When you are in a highly focused state of awareness, we add a lot of post-hypnotic cues, which are just positive 

psychology. You are a great sleeper. You can sleep as long as you need to, any time you need to. You deserve sleep. Sleep is what comes easy for you. So with these positive cues, it is a reprogramming of the subconscious mind, because I am sure if you were to work with anyone who has insomnia, I am a bad sleeper. My mom is a bad sleeper. My aunts have bad sleepers. But is anyone a bad sleeper? It is reframing the mindset.

 Sometimes I call it, aging myself again, the tape players. I used to have my first car; I had a tape player, and I remember putting the tape in. If it does not work. Well, the tape gets all tangled. Sometimes that just happens with our sleep. You have that tape; it wants to work. Maybe it was the CD that scratched, and it is just skipping a bit. How do we unwind that tape? How do we clean the scratches off of it? It reprograms your mind. What are the thoughts that we can implant or program? Doing it through clinical hypnotherapy is great because when someone is in that relaxed state, the way I do it is, What is your perfect day? There is no time restriction. You can have a private jet, you can be on your island, and you can just paint this beautiful, perfect day. At the end of the day, you are so exhausted because you have so much fun that you are either at home or in a hotel, and you are just sleeping as deep as you need to for as long as you need to sleep. Then we recorded it, and I just had to listen to it over and over again. It is fantastic. 

I had a lady who had insomnia for over 20 years, unfortunately, there was a traumatic incident that predated her insomnia but was on medications. Then, after we did the clinical hypnotherapy session, I saw her two weeks later; she was sleeping 8 hours, and she was only sleeping 3 to 4 hours before that. I was almost shocked at how long and how well it worked. Is it just one tape? But she believed that she could get help. Just having that door open and then now planting that program where you are a good sleeper, there is nothing wrong with your brain or your body. You can sleep as long as you need to and as deep as you need to. She was able to go to sleep. That is pretty phenomenal.

Audrey Wells, MD

That is fantastic. 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 in the internal dialog of how we are processing our world. I call it a scary bedtime story when people are.

Valerie Cacho, MD

It is a good one. Yes.

Audrey Wells, MD

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. I endorse that. I want to clarify, is it ASH.net or ASCH? 

Valerie Cacho, MD

It is ASCH.net American Society of Clinical Hypnotherapy.net

Audrey Wells, MD

ASCH.net. That is where you find it. 

Valerie Cacho, MD

American Society of Clinical Hypnotherapy.net

Audrey Wells, MD

Fantastic.

Valerie Cacho, MD

There is a directory there that you can look at.

Audrey Wells, MD

Good deal. Now it seems that at least half of women are going to struggle in the perimenopausal state. 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 supplements?

Valerie Cacho, MD

Yes, definitely. Specifically progesterone. A lot of women, and I think, just as one caveat, I do not start women on hormone therapy; typically, they come in already on it, or I suggest that they go talk to the gynecologist, or it is because I do not 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 have seen this in clinical practice, but I have also seen it on the other side, where maybe the trigger for someone’s insomnia was hot flashes. Now it is a lot better because it has been five years; they are on hormone therapy, but they still cannot sleep. 

I would say those are the patients that I typically get where my doctor has tried Ambien, I have tried CBD, I have gone through my local herbal store and just tried everything there and nothing works. Then it is, okay, we will have you do CBT II, taking a look at their thoughts they have in the interim around sleep. You were saying that I think of myself as someone who helps reinstate their confidence that sleep is a natural ability. 

Audrey Wells, MD

Yes. I am wondering, in your hands, how long does that usually take? It sounds like there is probably a time investment.

Valerie Cacho, MD

Yes.

Audrey Wells, MD

You have to approach it with an open mind. For most people, what are they looking at in terms of sessions with you, or what timeframe there is to get relief?

Valerie Cacho, MD

Honestly, Dr. Wells, I would say for the motivated person, within a month, I would 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 ones, I say the good ones, the good students, the ones who follow the recommendations and believe in improvements that they certainly can. Yes, but part of this is just working with a patient and where they are at, especially if they are in a state where I had some people saying, My dentist does not want me to take my Xanax at night because it is bad for me and I am getting older, and yes, that is true. But then it was almost a stab in the heart because, well, my brother gets to take something, and my daughter takes something. Why can’t I take something? 

It is almost reframing that, Why do you feel you need to take something? I think that is where our healthcare system has, I do not know, put people in the wrong direction. We have been misguided. A lot of people say that they cannot sleep. Take this. I think that is true for so many things. For high blood pressure, take this; if you have diabetes, take this. It is almost Okay. Well, let us step back in. What is going on in your life? Well, where does the sleep come from? It is so interesting because, yes, maybe it was from perimenopause, but 10 years down the line, all those hot flashes are gone and your mood is stabilized. 

But maybe you are in a relationship that is just a little bit sour, and you cannot stand that person who is in your bedroom every night. Or maybe that person that you had your partner’s on and they are seeing a lot of people who cannot sleep because they are lonely. There is no supplement or pill for that. It is taking the time to give someone space and hold space for them to be able to talk about what potentially could be leading to their sleep disturbance. I think.

Audrey Wells, MD

I could not agree with you more.

Valerie Cacho, MD

A lot of women need men as well. But I think we all just need a safe place where we can be vulnerable and have someone to do some reflective listening.

Audrey Wells, MD

Agree. With the pills, I think that is a very attractive response to problems for a lot of people because it seems quick. 

Valerie Cacho, MD

Yes.

Audrey Wells, MD

However, the tendency is to overestimate what pills can do for you, and in the long term, they are not beneficial or good for your brain. The sleep skills that you have reviewed today have the advantage of being a side effect that is free and durable over time. That is a meta-skill of knowing yourself better, of being able to respond to your own needs, to comfort yourself, and to quiet your mind. I think that is fantastic what you have described.

Valerie Cacho, MD

It expands beyond the realm of sleep. I imagine there is some drama at work. Being able to coach yourself through that, being able to come from a place of calm versus then reacting, getting into an argument with your spouse or your kids. Being able to have that mental fortitude to just, step away, calm yourself down, and then come back to the situation. I think, is so helpful. Then just going back to sleeping pills, it is just talk for women, Zolpidem, this the first FDA-approved medication that has a dose change for gender. Because what we saw was that at higher doses, women were having more side effects from complex sleep behaviors. Interestingly, I had a patient tell me that she was on Zolpidem and somehow went to her local mini-mart, bought an energy drink, came back home, and did not know how she got in her car or how she paid for that drink. It scared her. She will never take any type of sleeping pill again, which is scary. But that is not the first person who has told me something like that. Not everybody in a dense and complex behavior. Sometimes it is just sleep eating or sleep talking. I had not.

Audrey Wells, MD

Or remembering what they say the next day.

Valerie Cacho, MD

Yes. Sleep and social media. I think going online and tagging people in pictures and their friends is a good idea. Why did you do that? I did not want to be tagged. It is interesting to see the things that your brain can do on medications. Something very important to consider. Take a look at what the research shows. Does it how much improve our sleep? Maybe 30 minutes, maybe 40 minutes, depending on that. 

Audrey Wells, MD

Yes. 

Valerie Cacho, MD

They only last a couple of hours too, so.

Audrey Wells, MD

Yes. Did you ever hear this 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-90s.

Valerie Cacho, MD

Makes sense.

Audrey Wells, MD

They were seen as so complex and to be confounding in research studies. When you look at it, I was born in the 70s, and that is 20 years before I even came to be. Just for some perspective, the sleep medicine field is quite new. Even studies on sleep in women are newer than that. I suppose you could say it is still fresh if you have managed to put a positive spin on it. But truly, more work needs to be done. I appreciate you bringing your wisdom and expertise to us today. Certainly, you have given us some practical tips for improving sleep, especially with nighttime waking and getting to sleep at night. We talked about perimenopause and menopause and some things that you could do to increase your sleep efficiency at night—maybe even avoid hot flashes. You mentioned the clinical hypnotherapy with the ASCH.net website. We talked about home sleep apnea testing and women not to stop, at an inconclusive test. You have to go get that confirmatory test if you have symptoms. Thank you so much, Dr. Val. I wonder if you can tell everyone where they can find you if they want to work with you further.

Valerie Cacho, MD

Yes. Fantastic. If you are located either in the states of Hawaii or California, my clinical practice is called Sleep Life Med. If you just type sleeplifemed.com. You can find me there. I do telehealth visits, and then if you are a woman looking for more high-quality education and resources about women’s sleep, health, and whole life, you can check out Sleephoria.SLEEPHORIA, sleephoria.com. 

I have a YouTube channel 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 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 their sleep, but that number is just way too high. That just kills me. There are a lot of things that you can do to support them. I invite you to come join our community.

Audrey Wells, MD

Thank you so much and everybody, take this seriously. Sleep is so important to your well-being. Take good care. Bye bye.