Well, I was practicing as a primary care doctor, and at the end of every appointment, people would say, "Oh, I'm having trouble sleeping. Can I get something for that? As like an after thought? Yeah, you know, as I'm walking out. And I was being a you know, a good primary care doctor and saying, "Yeah, certainly I can help you with that.Let me give you a little sleep aid." And the more I got to learn about sleep and realized gosh, everybody is having trouble sleeping and everybody's having trouble taking care of all their other chronic medical conditions, I started focus more on sleep, realized that there was a fellowship, went to school to study sleep medicine. When I got out of my sleep medicine fellowship, I was in perimenopause and didn't even know it. So, I started seeing a lot of women and I was working in an all male practice and everybody right away said, "Oh, can you see the ladies for us?" All the women that were going through perimenopause and menopause? Can you see all the ladies for us? We we really think that you they'd be better served.Yeah. And so, I started to see all of these patterns and then I realized it kind of hit me in the face, these patterns are the same that I'm experiencing and you know, I quickly became the women's expert for sleep. And then I started to dive into perimenopause and menopause, had my own menopause story where I went to four different physicians before I finally was started on menopause hormone therapy. That sounds familiar. Yeah.
So, [gasps] unbelievable, right? Even the experts. And I I do have to say though, every time I have a doctor come in here and say that they went through the same thing, I think it makes all of us feel a little bit better. Whether it's about sleep or hormone therapy or menopause or whatever it is. So, let me ask you this.
For women who feel like their sleep has suddenly like fallen off the charts and they're not able to do it anymore once they hit perimenopause, what do you say to them? What's happening to our bodies during that time? You know, so the changes between estrogen, progesterone, testosterone and melatonin, they really they completely destroy the circadian rhythm of our sleep. So, what does that mean? And the [clears throat] circadian rhythm is really your pacemaker for sleep.
So, we have clock genes in our brain that is what controls the circadian rhythm of every person, whether or not you're an early bird or a night owl. And then we also then in the hypothalamus, that is that is where they're housed, but then the pineal gland also houses melatonin. Then you have estrogen feeding receptors in the brain. You also then have progesterone that prepares us for sleep, testosterone which really helps us with deep sleep. And when all of those levels start to change, it it really just changes how we fall asleep, how we stay asleep, how deep of a sleep we can get into, and that's when we start having those middle of the night awakenings.
Yeah, I feel like you I checked the box for every one of those things, especially when I went into perimenopause unbeknownst to me. I didn't know what was going on, and the harder I tried, the worse it got. I mean, I really I really felt that cycle back and forth. So, beyond being tired and feeling crappy the next day, what happens when we don't get enough sleep? So, you can't clean the waste products out of the brain.
That's really the long and the short of it. And we do that during slow wave sleep or our the deep sleep. And that's kind of like a dishwasher for all of the brain cells. And if you are not able to get enough of that sleep, then you wake up with the brain fog. You feel like you're slogging through the day.
Mhm. What are the waste products? What what does that mean? So, all the chemical reactions that are happening in the brain, that's the easiest way to say it. We everything that we're doing, every process that we do, every movement that we do, every thought, those are all chemical reactions in the brain that are happening.
And then we have these waste products that develop throughout the day, and we need to clean the brain out. And if we're not getting into the right stages of sleep, then we're kind of there's this dysregulation. And we we certainly see that. So I guess I think about this like, you know, not being able to fall asleep is one thing and that's like completely annoying and I don't know if you you I know you have advice for what to do when you can't do that. Waking up in the middle of the night, I don't know if that's worse or not, but somehow I feel like it's worse.
Because I feel like I can't I know that that moment that that happens, I don't know that I'm going back to sleep at all and it's always 2:00 or 3:00 in the morning. What is happening when we wake up at 2:00 or 3:00 in the morning wide awake and can't get back to sleep? So for many of us, especially in midlife, that's when we have those fluctuations in estrogen and that affects then our cortisol. So for a lot of women, cortisol starts to spike earlier and then you have these middle-of-the-night awakenings. And then we we start we tend to catastrophize sleep, you know, so or wakefulness rather.
So then you get up in the middle of the night and you're thinking, "Oh my gosh, I'm going to have a terrible day. I've got a big day tomorrow. I have a presentation or whatever it is that you have to be doing." And I like to give women a plan. So when you wake up, say, "Okay, I'm going to do A, I'm going to do B, I'm going to do C to help myself get back to sleep." So that you don't wake up and you start to panic. What do you do as a I always want the doctors to tell me what they do.
What is your What do you do when you wake up? Or do you? Maybe you don't. Maybe you sleep soundly. I I get to.
Okay, what do you do when you wake up at 2:00 in the morning? What is your go-to? First, you know, well, it doesn't happen all that often, but I remember when it started happening to me because I was known as a person who could sleep anytime, anyplace, anywhere. And then it started happen to happening to me and I would say, "Why is this happening to me?" And I would get so But then I I immediately put on something calming, like some sort of meditation. I get out of bed.
So, you do not want to stay in bed. If you are in bed, and you know, okay, I'm having trouble getting back to sleep. I know I'm not going to get back to sleep. You have to get out of bed because you your brain needs to associate the bed with sleep or intimacy only. It feels counterproductive though to get out of bed because you think, I'm just going to lay here 5 minutes more.
Maybe I'll be able to fall back to sleep. It feels painful to actually get out of bed. It doesn't feel good. Painful. And then you also feel like I'm going to wake myself up even more.
But that really doesn't happen. I I usually tell women, you know, pick an insomnia chair or a couch or someplace that you know that you can get to. We don't want people cooking, cleaning, working, exercising, and then either read a really boring book, maybe write a list of the thoughts that are racing through your mind, do some meditation, and when you feel sleepy enough, then you can get back into bed. And again, also give yourself some grace. Like maybe you're not going to be firing on all cylinders tomorrow, but you're still going to make it through the day.
Yeah, cuz that brings me to all those other questions, like what happens when you don't get enough sleep. So, you wake up in the middle of the night, find a know where you're going to go, right? Find a chair, a sofa, a blanket, whatever it is. Get a book and read it. Don't try to do any Don't try to be you know, declutter the closet right that night.
Okay? All right, that's good advice. A lot of people that you know, we've we've done sleep episodes before, and and it is the top topic. Like people want to talk about sleep, which is why I was so excited that you said yes to come on here. A lot of people complaining about they have to get up in the middle of the night and pee, which is is different than just waking up at 2:00 in the morning, and then they can't go back to sleep.
Yes. What do we do there? Well, so the first question I ask people is, are you getting up and going to the bathroom because you're waking up to go to because your body's saying oh I have to go to the bathroom are you awake and then you say well I think I have to pee so I might as well just get up. Two different things. Different things but for for people who are actually waking up and having to go to the bathroom repeatedly especially for women it may be a sign of sleep apnea.
That might be a symptom. You could also have genitourinary syndrome of menopause. There are all of these factors that suddenly play a role into why you might be waking up in the middle of the night and having to go to the bathroom. So if someone's listening to this right now and says okay I'm in my early 40s late 30s early 40s yes I have a stressful job I get that. I don't know if [clears throat] I'm in perimenopause or not or maybe I am but sleep is just not working for me.
What do you suggest they do do you suggest they right away go talk to a sleep specialist or can you start with your general practitioner or OBGYN where do you begin? I think any one of those. So anybody who has some idea about sleep is where you need to start and that's hard. Sometimes general practitioners don't know sometimes OBGYNs don't know and sometimes sleep clinicians they only focus on sleep apnea and that's it. So you know I jokingly say that I carry around a box of tissues when I see my patients because they've already been to see another sleep specialist most of them and they finally are getting some answers after like 7 to 10 years of not getting enough sleep but you know women do not present the same way that men do when it comes to sleep apnea and many many women they're not overweight they're doing all the right things and they have sleep apnea.
Do you think there's a lot more people walking around with sleep apnea than we than they even know at this point. 100% so there in midlife up to 50% of women will have sleep apnea. Nine out of 10, 90% of them do not know that they have it. How dangerous is sleep apnea? So it can be pretty dangerous. If you've got moderate or severe obstructive sleep apnea, you have up to a 25% increased risk of having a heart attack or a stroke.
In your sleep? Just generally speaking, it increases your overall cardiovascular and neurocognitive risk. So brain health and heart health basically is at risk. Can you explain sleep apnea and what it is? Sure.
So sleep apnea is really an oxygen deprivation state. So for the most part people will have obstructive sleep apnea and there's central sleep apnea but that's a whole different thing. So obstruction is happening at the back of the throat so the soft tissues collapse too much and then you have an oxygen deprivation state. So it's pretty technical when I interpret a sleep study. You know, so many seconds you have to have below your baseline of oxygen level, you have to have respiratory depression, you may have an arousal.
There's all of these components to a sleep study. But we then quantify all of that and if you have five or more abnormal breathing events an hour, that is sleep apnea. If 90% of the women that are in perimenopause or menopause have sleep apnea and don't don't really know it or don't know what's going on. If someone's listening right now, how can they decipher whether or not nah, I don't have great sleep or oh my gosh, I need to be really concerned that that's a possibility. Yeah, that's a great question and it's not easy because all of the screening tools are really gender biased.
They are all focusing on men's symptoms more than women's symptoms. So there's one that I that's notorious for me at least is called the STOP-BANG And the G at the end of this screening tool stands for your gender. So, already STOP-BANG? STOP-BANG. So, already, if you are a woman, you don't get that point.
And And so, and women do not have loud snoring, they don't have witnessed apneas, they typically will have insomnia. They kind of just have general they malaise, they don't feel well. They might have more migraine headaches, they might have more depression. That's the symptoms. I've tried a lot of skin care over the years, and what keeps me coming back to with code Tamsen.
After you purchase, they'll ask where you heard about them. Please support The Tamsen Show and tell them we sent you. Migraines have been coming up a lot lately for for me, just in conversation, and a lot of women saying it's happening during this perimenopause and menopause stage, and I know it's one of the symptoms. Is it because of sleep apnea? You know, it's hard to say if it's only because of sleep apnea, but I I'm We do know that there's a hormonal component to migraine headaches.
But, if you're having them and you've already kind of started on some sort of hormone therapy and you've you're continuing to have middle of the night awakenings, because starting on hormone therapy doesn't cure everybody's sleep. Mhm. They're still up to 50% of those women who will continue to have problems with sleep. All right. So, if somebody's listening and says like maybe that's me, what is the first step that a woman should do if she thinks she might have sleep apnea?
Yeah. You know, start having a conversation with your doctor or your your provider. Really, that's the first step is start asking questions. Have a have a road map, because like I said, the awareness of sleep apnea or sleep disorders like restless leg syndrome, chronic insomnia, which I I feel as a as a complex medical condition. That's not at the at the forefront of your primary care provider's mind most of the time.
So, go in there with, you know, a set a list of symptoms that you're having. Hey, I'm going to bed at this time, but I'm not falling asleep until this time. So, that's one of the questions I will ask. How many hours are you actually sleeping? Because you might be in bed for 9 hours, but you're only getting five And is that a signal that That's huge.
Okay. A huge red red flag. If you're consistently waking up in the middle of the night, if you're waking up and you feel unrefreshed. So, some people will wake up and say, I feel worse Right? I'm more tired after I sleep.
Tired than I did when I was going to bed. But, all those are signs to you that you need to go and see somebody. And do you recommend a sleep specialist then right away? You know, for the most part I do because you have to tease out all the nuances. It's not that simple and a lot of women will have a home sleep study performed, but there's a pretty high rate anecdotally, at least in my experience, that women will have negative home sleep studies, but if you do a different type of sleep study, which is either in a sleep lab or what we call a type two home sleep study, you tend to catch more mild obstructive sleep apnea.
And what we know about mild obstructive sleep apnea is that maybe the cardiovascular risk isn't there as it's not as prominent. However, if you're having trouble sleeping because you have mild obstructive sleep apnea, then that chronic sleep deprivation holds the same risk. I mean, when you go night after night and week after week, we've heard you 8 hours is how you how long you should sleep, but how how long should be you be sleeping and how long should that be, I guess, deep sleep? Yeah. So, you know, the the American Academy of Sleep Medicine recommends 7 to 9 hours of sleep.
What I tell women and everybody is really focus on quality, not quantity, because if you're in bed for 10 hours, but the quality is poor, that's that's not helpful. What you want to focus on is the quality of sleep. So, I don't want people thinking, "Oh my gosh, I'm only getting 6 hours. I'm destined for dementia." Right? That's that's not what I want women to walk away with.
I want people to know that there's always something you can do for your sleep and that every 15 minutes counts. You bring up dementia. Let's talk a little bit about that. Are those some of the things that you see if somebody's not sleeping or do you see that as something that could be a problematic down the line? So, the good news is that you could have trouble sleeping for decades, but if we can help you get higher quality sleep, then you're more likely than not able to to kind of not have to make you won't have there's no guarantee that oh my gosh, you're destined for a dementia.
I really think that it's multifactorial. I think that women carry a huge mental load that is not really factored in quite yet. Then we have all of these hormonal changes. Then we may have a delayed diagnosis if we have obstructive sleep apnea or restless leg syndrome or treatment for chronic insomnia. Does a lack of sleep cause dementia?
Is that one of the causes of it? Well, if you're chronically sleep deprived, then you're not able to get into all the right stages of sleep. You asked about the percentages and it's really about your total sleep time. So based on your total sleep time, you should have certain percentages of each stage of sleep. And fun fact, really your staying in stage two sleep.
There's four stages of sleep the most time. So trackers I've got a tracker on. They're not all they're cracked up to be and there are way more advanced ways of identifying stages of sleep. These are surrogates and and they prime people. So I feel like a lot of people really worry about their stages of sleep when it it's really still just an estimate and we can't focus too much on this when it's not diagnostic.
I guess it just makes me happy when it tells me to go to bed or start winding. Tamsen, you've got to start winding up for sleep. All right, I know you're big on solutions. So I want to talk about some of these solutions. When it comes to sleep, first let's talk about where hormone therapy fits in and what types of hormone therapy that we're talking about.
So you know, first of all, if somebody is in perimenopause or menopause and they really are having a lot of trouble with sleep. That is one of the many symptoms around perimenopause or menopause. And it may be worthwhile if you meet criteria and it's not There's no contraindication to start on hormone therapy. Now, for a lot of women, it helps their sleep. Estrogen, progesterone progesterone is really that hormone that helps us relax, get ready for sleep.
Estrogen really helps with sustaining sleep. Okay. And then testosterone really helps with deep sleep. It's interesting though, most of the time if you ask you think progesterone is the magic pill, but it really is the estrogen and progesterone. And then you're saying also added testosterone.Yes, for some women. Okay. So So not everybody needs testosterone, but we're also not reaching for it as an option as often as we should. So for everyone, you really should start on estrogen and progesterone if you can. And then reassess.And then you may consider starting on testosterone. I have a lot of women who will say, "That was the missing link for me." Mhm. But then even after most women will start on that, there's still up to 50% of those women who will continue to have problems with sleep. I had to increase my dosage. It went up a bit by bit, but I'm at 200 mg right now, which I I'm like, "Oh my gosh, how much bigger can the pill be?" But But I'm sleeping most of the time.Yeah. Talk about the role alcohol plays because I think my life since 2020 I [snorts] mean, 2018 I thought I was still kind of cool and I could have drinks before I go to bed or go out for margaritas. Then 2020, COVID hit. Then 2021 I was still kind of like, "Okay." And then 2023, 4, 5 Mhm. Nothing.Mhm. A glass of wine Yeah. I can't go to sleep or I wake up. It's just It's really remarkably different for me. Is that perimenopause?Is that age? Is that What is it? But it really does impact sleep. It does, and I'm sad too I'm sad with you. Maybe we just have a drink during the podcast and not wait until bed.I don't know. I don't know. I'll think about that. I mean, we have we change the way when we metabolize alcohol. So, we're just not as good at metabolizing it.And then it really affects your REM sleep. Okay. And what what stage is REM sleep? So, REM sleep is when you're dreaming. And you tend to have your dream sleep in the second half of your night.So, stereotypically, that is when a person starts to cycle through REM. And you know, textbook says that you should have three to four REM cycles and with each cycle it's supposed to get a little bit longer. Mhm. So, if alcohol is disrupting your REM sleep, then you really don't That's where you're doing all of your emotional processing, some memory consolidation. That's where the emotional regulation happens.So, you feel like crap when you wake up in the morning if you've had a little too much to drink. And you basically are just you feel like a zombie. And then when you go to bed the next night, typically your body does what we call REM rebound. So, it makes up for losing the night before. And it gives you more opportunity to capture REM sleep the next night.So, if you have a drink the second night you're better maybe? I don't know. Is it Is it that you've had too much of I mean, I think even a glass of wine right now impacts me. Right, because we we do not metabolize it as well. And when we don't metabolize it as well, then it's half-life is right around the time if we drink it really close to bedtime, right around the time that you should be getting into REM sleep.So, that half-life. And And really what we're doing is we're just medicating ourselves to kind of pass ourselves out, but it really doesn't allow us to get into those stages of sleep that we need. So, if you're going to have a drink or a glass of wine, Dr. Andrea, you know I'm trying. If you If you're Just know Should you do it over I don't know.Treat it like caffeine. What do you do? Do you do it earlier in the day? It you Everybody knows themselves. Like I I think if you can get away with one drink, great, but for most people they usually start to complain if they have two or more.If you know that it's even one drink, then you have it earlier during the day. I mean, there is this big business of mocktails nowadays, right? Still haven't found a non-alcoholic wine I like, but you know. Okay. All right.Well, we'll we'll work on it. My dad has something he used at over Thanksgiving and it's like It's like a filter and he mixes it around in the drink. It's like it You know, it's like a little filter and it takes us the sulfites out of it, I guess, of the wines. I don't Is that helpful? Does that help the wine?
I'm trying here for anybody who Anybody who is going to say, like, "Why didn't you ask this?" I mean, it's worth It's worth a try. Okay. Okay. It's worth a try. I actually saw that and it piqued my interest, so then I looked it up online and you some.
He was so funny. We were We were at the table and everyone's like, "What is he doing?" And I go, "I don't know. My dad is like he's a trans- He's the king of Yeah, DIY hacks." [gasps] So, you created something called the DREAM method. And when I interviewed you back in October, we had an event together here in New York. We talked about it.
And it's a method to help women understand why they're not sleeping so well and then what to [clears throat] do about it. So, can you walk us through the DREAM method that you have in terms of real life? Yeah, definitely. So, I developed the DREAM sleep method because women were coming to me saying, "Hey, I got told I didn't have sleep apnea, but I still can't sleep." And what I found is that there's so many different components to helping you get to sleep. And if we're only touching on one, we're only going to get halfway.
Okay. So, the D stands for daily habits. What are we doing during the day that could be contributing to our inability to get to sleep or stay asleep? So, are we feeding ourselves correctly, you know, providing ourselves with the right nutrition, right hydration, down time, are we totally stressed out all day? So, all of those pieces actually play a role in getting ourselves to sleep.
R is for your resting environment. So, I mean, if you've got a bad bed, you got to change it. If your pillow doesn't feel good, change it. If it's too hot, too cold, you know, you have to make your environment ideal. What's an ideal temperature to sleep in?
This is for my husband, I'm just asking. Well, so, you know, it's different for everybody. I I I typically don't like to say, "Oh, it should be, you know, 65° or whatever." I tell folks because typically with partners, one is cold and one is hot. Yes. Right?
So, then there's a whole market for beds beds and blankets to individualized temperature control. But, generally, you want your room dark, cool, and quiet. So, cool is Cool is better. What's cool? Better. 65.
Oh, I love you. All right, I like that. Thank you. I just wanted evidence of it to take back to Ira. Okay, what's the E stand for?
So, the E stands for emotions. We all know that anxiety, depression can certainly rear its ugly head in the bedroom when you're not distracted by anything else. And we need to address those. Those are real issues and someone's ability to get to sleep. Mhm.
And then the A is archetype. It's really it's my way of describing your circadian rhythm. Are you an early bird? Are you a night owl? Are you somewhere in between?
Because if you don't know and you're fighting against your circadian rhythm, then that's going to be really difficult to get you into all of the right stages of sleep. Does that mean what time you go to bed and And time you wake up? Yeah. So, if you're an early bird, typically those folks they like to go to bed at 8:00, wake up at 4:00, go to bed at 9:00, wake up at 5:00. Someone who's a night owl, by definition, it's 12:00 a.m.
Waking up at 8:00. Oh, yeah. 1:00 a.m. Waking up at 9:00. Is there an ideal if you're not Well, like I worked a night shift and I worked an early morning shift, so I've kind of been all over the I've been all over the board with that. I did 2:00 in the morning, I did 2:00, you know, I did I've done all of it.
Is there an ideal kind of, you know, wind it down that you think would be as good as getting up? I mean, do you have rules like that? I don't know. You know, I I think that if you can follow your circadian rhythm Yeah. Because again, we have clock genes that we're born with.
They're like eye color. We can't really change them. We can fake them out. We can we can adjust a person's circadian rhythm with melatonin. But you know, I I always cringe when I see one of the major papers talk about being an early bird because up to 20% of the population globally is a night owl.
And there are Interesting. There are you know, different countries who work later. Like if you go to Spain and try to go to dinner at 7:00, they think you're silly. Yes. Right?
So, I think if you can follow your natural circadian rhythm, you're better off. Okay. But, you know that you you do need to figure out what your what your circadian rhythm is. Your best time of going to sleep, your best time of waking up, and trying to be consistent. Right.
Okay. Consistency. And then, yeah. What is the Keep going. What was the other one?
Oh, M. Oh, M. Yeah, what's the M for? Yeah. So, that's medical conditions.
So, perimenopause, menopause, sleep apnea, restless leg syndrome, any sort of neurological condition, any type of rheumatologic condition. So, you know, if you've got an autoimmune disorder, these are all things that can affect your sleep. And we need to be able to evaluate and figure out how it's affecting your sleep because if we ignore that, then again, we're only getting halfway. So, I think I had restless leg syndrome for a while, but I didn't have a word for it, but I found magnesium spray. Is that Am I just my father's daughter like finding solutions for things or is it or you know, restless leg syndrome is real?
Restless leg syndrome is real. It can affect up to 30% of women in midlife. That's a lot of people and that has to do with our iron stores. And so, there's all this talk right now around iron stores in women and the changes that we're making in terms of the normal iron levels and that marker is ferritin. So, ferritin is what we call an acute phase reactant.
It gets complex, but the point is that the normal ranges were really low and now there's all this new data coming out that they should be higher, but if you have restless leg syndrome, your ferritin level should be above 70 and really closer to 100. That's huge. Does that mean your iron is low? Is that what that means? It means the iron stores are low.
So, you might have a normal blood count, but your ferritin level is going to be low. I've never heard of ferritin level. Yeah. Where do you get tested for that? Is that just a blood draw.
A blood draw? Okay. It you know, like you're getting your electrolytes, your kidney function, your blood count, you get a ferritin level. And then you can find out if that's what's going on and it could be causing that restless leg syndrome. Right.
That's the first thing is to give somebody iron supplement. Okay. And then if that it you still have symptoms, then let's discuss prescription medications. Okay. Let's go to supplements because I think there's a lot of question about that.
There's there are a lot of things out there and and I want to go through them and I know that you're a fan of certain supplements and have one. Can you go into supplements and let's talk about that and what you think research says about supplements for sleep and I guess there's magnesium, there's my spray magnesium, there's melatonin. Can you talk a little bit about that? Yeah. So, supplements are really big market, there's no doubt about that.
I tend to be pretty judicious around supplements. Okay. So, I try to use as little as possible because a lot of supplements out there are a combination of too many things in my mind and so then you don't know what's really working for you. And for the most part they don't they're not sleep aids. So, supplements are in my mind I define those as things that are already going to that are going to support the good sleep that you already have.
They are not going to fill a hole. They're not going to cure something. So, a supplement for sleep is not going to fix chronic insomnia. A supplement's not going to fix sleep apnea. You know, when I talk about a supplement for restless legs syndrome, that's really iron replacement.
So, what will a supplement do? Will it help you go into a deeper sleep? Well, it [snorts] just depends on what it is, right? There's a whole market, there's valerian, there's lemon balm, there's hops, there's melatonin, there's magnesium, there's L-theanine. They all have a specific mechanism of action, if you will, and so that's why I'm not a fan of things that have like 10 or 12 things in them because you don't really know what's what's working and what's not working.
Ideally, I know melatonin confuses a lot of people, right? And then I I didn't even realize that there was a you know, level that you should be taking or not taking or how long. Can you explain melatonin? Sure. So, melatonin is made in the pineal gland of the brain.
It does a lot of different things, but it's really our marker for starting the cascade of sleep. So, first and foremost, melatonin is a hormone. It is not a sleep aid. It is a clock starter. So, it starts the cascade of sleep.
So, taking it right at bedtime is not typically recommended. And we really don't need a whole lot if we're going to use it for what I call circadian support. So, again, circadian is basically Circadian rhythm is the mechanism that allows you to get to sleep, stay asleep, get into the stages of sleep that you need to get into. What I didn't even learn in my fellowship is that we lose melatonin production as we age and that we lose up to 50% by age 50. So, should we be all taking melatonin?
You know, there's no there's no published data that says absolutely. There's a few studies out there that say that taking melatonin isn't problematic for the replacement. There are studies out there that say long-term dose long-term use of melatonin is safe. There's actually studies out there that say that it may be cardioprotective because it it's it works against oxidative stress, free scavenger, free radicals. It supports immune system.
I mean, it's a hormone. Yeah. So, in my mind, I think that we don't have enough data out there quite yet to say that everybody should be on it, but it just might be the next vitamin D. Mhm. And we just don't know enough about it like we do now about vitamin D.
I remember when vitamin D came out and everybody said, "Wait, why do we have to take this? It's a hormone." One of the other pieces is that melatonin, if you take it long-term, you're not going to ruin the production in your body. So, a lot of people think, "Oh, if I take it for too long, then I'm going to stop producing my own melatonin." That has been debunked. So, lots of studies say that that is not true. Should you take the lowest amount?
The lowest amount. So, you know, when we're and there's different reasons why we prescribe melatonin in a sleep medicine practice for our patients. So, if you're using it for jet lag, you take a a low dose. 1 mg? Wait, what do you take it for in jet lag? So, you want to adjust your circadian rhythm so that you you prevent having jet lag.
Oh. So, typically every every hour of of of change that you're going into, so let's say seven, it might take you up to seven days. So, for every hour that you're shifting is a day that you have to recover. So, of course, there's a big business in adjusting your circadian rhythm. So, yeah.
There's no quick fixes for sleep, though. No. No. No. No.
No. That's hard for people because when people they want to know like what can I do tonight? Yeah. Is there something if there's a a woman or a man listening that says, "What can I do tonight Yeah. To start figuring this out?" I know.
It You're right. It's largely behavioral when we're thinking about insomnia, getting to sleep, staying asleep. So, the first thing that I tell folks all the time is you want to get to bed at the same time and you want to wake up at the same time. And a lot of people literally I'll get some side eyes, hard eye rolls like, "I already do that." And yes, but do you? Do you really do that?
Mhm. Because if you start to to write down when you're getting into bed, people are surprised. It's it's the same thing My my analogy is is when you're trying to lose weight and you think, "I I I don't Oh, I ate perfectly today. And then you start writing everything down and you realize, "Oh, yeah. I had a piece of pizza or I had, you know, a cookie or, you know, all of those things count.
So, trying to get to bed at the same time and waking up at the same time is really, really important. Our brains like routine. That's good to know. I mean, I think that it's really important. I I did that for a while and I'm trying to do it again.
I think when I there's the time change, my body gets very confused. It's dark out, it's light out. It's so dark starting at like 4:30. I, you know, New York City. And so, you know, I feel I feel like I'm tired earlier.
Yeah. Okay. So, we we covered that there's no quick fixes, but I do know that diet and exercise are always a part of everything. No matter what we do, we always kind of drill back and say you got to go to the root. How important are diet and exercise when it comes to your sleep?
They're really important. So, there is lots of data out there that shows that exercise really helps people get to sleep, stay asleep, promotes deep sleep. So, you really want to move your body. It doesn't really matter what you're doing as long as you're increasing that heart rate, and you're giving yourself enough bursts of that increased heart rate throughout the day. So, again, there's studies that show that, you know, you don't have to go a whole hour at once.
If all you can do is fit in 5 minutes here, 10 minutes there, but you're increasing your heart rate, you're moving your body, that's going to be beneficial for sleep. Then the other piece is with nutrition and food intake. You really want to avoid eating a very heavy meal right before bed. That will affect your ability to get to sleep and and to stay asleep as well. So, you want to try to eat your heavy meal of the day a little bit earlier.
So, you know, I usually tell people 3 hours is a good window. Like, try not to eat too late right before bed. And caffeine, I didn't mention caffeine cuz I was already upset about the alcohol part. What about caffeine? What's the What's the drop dead time?
You know, you really shouldn't have any caffeine 6 hours before you go to bed. 6 hours? Because Because again it all has alerting and stimulating effects in the brain. And it has a half-life and it will keep your brain awake for about 30 The studies show that you're losing about 30 minutes of sleep if you drink caffeine too late. So when people say, "I can drink a whole cup of coffee and go right to bed." I usually tell them, "You're just proving to me that you're chronically sleep deprived." Because for a long time. This other chemical in the brain called adenosine.
Adenosine is what builds up all day long and makes us sleepy. So it is fighting for that same receptor. So that's why when we wake up in the morning honestly we we probably should wait a couple of hours to drink our coffee because that's when You're killing me. Adenosine is is building up just a little bit. Right.
But you know, it's also a ritual. Like I myself love having a cup of coffee. I'm going to just say Dr. Andrea does it and I'm allowed. Getting outside first thing in the morning.
Do you think that's important? I do. I do think it's important and if it's dark where you're living and you're and you can't get sunlight, that's why it's important because sun is what fires off your circadian wake. So there's there's this whole homeostasis in the brain. When you wake up and the sun hits your eyes because we've got these nerve cells in the eye that connect directly to our wake center in the brain that fires off our wake cycle.
That's that is hard when you're living somewhere and it's dark. So then I usually tell folks, "Use one of those bright lights." Mhm. And it's 10,000 lux. That's what all the studies were were done on. 10,000 lux is the intensity of the light that you should use. And so if you're turning that on, putting that on first thing in the morning.
First thing first hour. If you do it too late, you're just going to move your bedtime later because that homeostasis is sleep pressure is really low and wake cycle is really high. And then they kind of crisscross over the day so that your sleep pressure is really high when you go to bed and your wake cycle, your circadian wake is really low when you go to bed. What about those hatch alarm clocks? [sighs and gasps] Yeah. There's a People probably ask you about everything I know, right?
I know, right? I mean, you know, so here's the thing. I think that it gets There's too many gadgets and and simple is better, right? So, if you need bright light, I have a I have a light for myself. I live in the Northwest and it's dark when I wake up and it's dark when I'm going home for the day.
Put it turn it on when you So, yeah, so I tell people like if you're looking at your computer screen, if it's off to the left or to the right of your computer screen, that's probably a good distance. Okay. So, it's about 12 in away from your face. You don't want to look directly into it because it's very bright. So, it's off to the side and it's within the first hour of waking for, you know, anywhere between 10 and 20 minutes.
Okay. All right. Now, if there's anybody listening that feels very defeated about their sleep, what do you want them to know? One, it's not your fault. There are There's a lot of physiology at play here.
Mhm. Two, there's always help. There's always something we can do. It's not always comfortable, but there are solutions. And three, 15 minutes, every 15 minutes counts because let's say you're only getting 5 hours of sleep and you do all the things and you say, "I'm only getting like 5 hours and 15 minutes." But, you multiply that by seven, by 30, 31 days, 12 months, that's a lot more sleep.
It's a lot more sleep. And when you're sleep deprived, you'll you'll take you'll take 15 minutes. It feels like gold. Is there one practical thing people who are listening can do tonight to at least get started in the process of getting a better night's sleep? Make sure that you've got a routine.
So, again, one of my analogies is when we're hungry, we don't just open the refrigerator door and start shoveling food in our mouth. We owe it to ourselves to have a routine for sleep, whether or not that's I like to put on my favorite pajamas or not. I like to brush my teeth, wash my face. If you have some sort of spray that you love, you know, white noise machine, eye mask, ear plugs, whatever it takes, develop something and stick to it. I always tell parents we're so dedicated to our children's sleep cycle or if you don't have children, you always know somebody you know, that you're visiting with and is oh, we have to get, you know, our kid to bed.
Well, we owe that to ourselves. Why do we lose that when we're adults? I don't know. It's a it's a whole learning curve. Need it.
We matter. Yeah. Dr. Andrea, thank you so much. It's It's so good to see you again.
I I felt like the last time that we talked, I sat there and I went, "Wait a minute." I think we had 20 minutes and I could go on with you for, you know, hours and hours cuz I really do think if you're not getting a good night's sleep, what do you how are you even going to eat right or work out right or all the other things we talk about? So, I certainly appreciate it. Well, thanks for having me. Yeah, and thank you all for listening. If you have not left a review yet, please take a moment wherever you're listening from.
It truly helps the podcast grow and I read every single one of your comments. You can find more from Dr. Andrea across her social media and her website and be sure to check the show notes for all the links. I'll see you for the next episode.
