Latest / Clearly Hormonal / Ep 14: How to Sleep Better with Dr. Andrea Matsumura

Transcript

Ep 14: How to Sleep Better with Dr. Andrea Matsumura · Clearly Hormonal

• 0:01
  Dr. Komal Patil-Sisodia: Welcome to the Reset Recharge podcast with your host, Dr.
• 0:05
  Dr. Komal Patil-Sisodia: Komal Patil Sisodia, a board certified endocrinologist, internist, and obesity medicine specialist.
• 0:11
  Dr. Komal Patil-Sisodia: This podcast is focused on empowering women's health and aims to help you reset your understanding of your metabolic health And recharge the conversations you are having with your health care providers.
• 0:22
  Dr. Komal Patil-Sisodia: While I am a physician, this podcast is purely for educational purposes.
• 0:26
  Dr. Komal Patil-Sisodia: No individualized medical advice is being given on this podcast.
• 0:30
  Dr. Komal Patil-Sisodia: If you do find information that is helpful, please discuss it with your health care provider at your next visit.
• 0:39
  Dr. Komal Patil-Sisodia: Welcome back everyone to Reset Recharge.
• 0:41
  Dr. Komal Patil-Sisodia: I'm really excited to have my friend and colleague Dr.
• 0:44
  Dr. Komal Patil-Sisodia: Andrea Matsumura here today.
• 0:46
  Dr. Komal Patil-Sisodia: She is board certified in sleep medicine and internal medicine.
• 0:50
  Dr. Komal Patil-Sisodia: She's a fellow of the American College of Physicians in the American Sleep Association.
• 0:57
  Dr. Komal Patil-Sisodia: Okay.
• 0:57
  Dr. Komal Patil-Sisodia: All right.
• 0:58
  Dr. Komal Patil-Sisodia: Association of sleep medicine.
• 0:59
  Dr. Komal Patil-Sisodia: Got it.
• 1:00
  Dr. Komal Patil-Sisodia: So I was close.
• 1:01
  Dr. Komal Patil-Sisodia: She is also the director of primary care services at Cascadia health and sits on the board for the Oregon medical association.
• 1:10
  Dr. Komal Patil-Sisodia: So she's very accomplished, but first and foremost, just an amazing sleep doc and is really.
• 1:16
  Dr. Komal Patil-Sisodia: Focused on women who are going through perimenopause and menopause and the types of sleep disorders that they are dealing with.
• 1:22
  Dr. Komal Patil-Sisodia: So welcome today.
• 1:23
  Dr. Komal Patil-Sisodia: I'm so excited to have you.
• 1:25
  Dr. Komal Patil-Sisodia: Thank you.
• 1:26
  Dr. Komal Patil-Sisodia: Thank you
• 1:26
  Dr. Andrea Matsumura: so much for having me on the, on this podcast.
• 1:29
  Dr. Andrea Matsumura: And I'm really looking forward to our discussion.
• 1:32
  Dr. Komal Patil-Sisodia: I am too.
• 1:33
  Dr. Komal Patil-Sisodia: I am too.
• 1:34
  Dr. Komal Patil-Sisodia: I think sleep is one of those things that becomes more elusive.
• 1:38
  Dr. Komal Patil-Sisodia: The older we get, I remember I could sleep anywhere.
• 1:42
  Dr. Komal Patil-Sisodia: I could sleep on a rock in my twenties and not have any problems.
• 1:47
  Dr. Komal Patil-Sisodia: I actually, when I was in college, I was a, an RA in the dorms and they had to put a heavy sleeper sticker on my door because I would sleep through the fire alarms.
• 1:55
  Dr. Komal Patil-Sisodia: Right.
• 1:56
  Dr. Komal Patil-Sisodia: And then as I've gotten older, unfortunately.
• 2:00
  Dr. Komal Patil-Sisodia: It is so much harder to fall asleep and it is so much harder to stay asleep.
• 2:04
  Dr. Komal Patil-Sisodia: So I'm really excited you're here.
• 2:05
  Dr. Komal Patil-Sisodia: I'd love to hear why you went into sleep medicine, what your journey was to getting there.
• 2:11
  Dr. Andrea Matsumura: Yes.
• 2:12
  Dr. Andrea Matsumura: So I was an internal medicine doc, a primary care doctor, and a hospitalist for the first part of my career.
• 2:19
  Dr. Andrea Matsumura: And around Year 13 of practicing outpatient primary care medicine I realized that I was trying to manage all of these chronic medical conditions.
• 2:33
  Dr. Andrea Matsumura: And what I was finding is that a lot of people were having trouble with sleep.
• 2:37
  Dr. Andrea Matsumura: So I started digging and doing some research around how is sleep affecting chronic medical conditions.
• 2:45
  Dr. Andrea Matsumura: And I realized, well, Sleep is the hint, the juggernaut.
• 2:49
  Dr. Andrea Matsumura: It's what controls and helps all of the other chronic medical conditions.
• 2:56
  Dr. Andrea Matsumura: be maintained and managed better.
• 2:59
  Dr. Andrea Matsumura: And so if you're not getting good sleep, then it is more difficult to control diabetes.
• 3:04
  Dr. Andrea Matsumura: It is more difficult to control high blood pressure.
• 3:07
  Dr. Andrea Matsumura: It is more difficult to control pain.
• 3:09
  Dr. Andrea Matsumura: And then it's got a cascading effect in your daily life.
• 3:14
  Dr. Andrea Matsumura: And so I went back and studied sleep.
• 3:17
  Dr. Andrea Matsumura: I call it my mini midlife crisis.
• 3:20
  Dr. Andrea Matsumura: And I went back and did a fellowship in sleep medicine and have been really focusing on women and sleep and sleep issues that really pertain to women's health.
• 3:32
  Dr. Komal Patil-Sisodia: That is, that's really fantastic.
• 3:34
  Dr. Komal Patil-Sisodia: I'm an endocrinologist by background and everything you said just resonated with me because I don't think I realized until I went and got my board certification in obesity medicine, how much sleep apnea and other sleep disorders are related to obesity.
• 3:50
  Dr. Komal Patil-Sisodia: I think I read a stat that 83 percent of people with type 2 diabetes, which I see every day, has Sleep disorders, right?
• 3:57
  Dr. Komal Patil-Sisodia: And then you think about all of the metabolic shifts that women are going through in perimenopause and menopause.
• 4:03
  Dr. Komal Patil-Sisodia: How many people are we not catching, right?
• 4:06
  Dr. Komal Patil-Sisodia: So I'd love to hear from you.
• 4:08
  Dr. Komal Patil-Sisodia: What is your kind of starting point?
• 4:10
  Dr. Komal Patil-Sisodia: If somebody is coming in to see you for a sleep issue or for a woman who's coming in to see you, what are the things that you are thinking about?
• 4:18
  Dr. Komal Patil-Sisodia: What are the things that you're asking her in order to get a better idea of where she's at?
• 4:25
  Dr. Andrea Matsumura: Yeah, so first I, I really dive deep into a person's routine.
• 4:31
  Dr. Andrea Matsumura: So I get down to the nitty gritty of what time do you actually get into bed versus what time do you actually fall asleep.
• 4:40
  Dr. Andrea Matsumura: So a lot of people, Don't really think about that.
• 4:43
  Dr. Andrea Matsumura: And at first blush, they'll say, Oh, well, I get into bed at 10, but I'm sleeping five hours.
• 4:48
  Dr. Andrea Matsumura: So then when are you really falling asleep?
• 4:50
  Dr. Andrea Matsumura: And when do you have to wake up?
• 4:52
  Dr. Andrea Matsumura: How many times do you wake up in the middle of the night?
• 4:56
  Dr. Andrea Matsumura: And do you feel refreshed?
• 4:58
  Dr. Andrea Matsumura: The other piece I ask is, What are you doing to prepare yourself for sleep?
• 5:04
  Dr. Andrea Matsumura: So we live in this digital age and whether or not we like it, it has actually contributed significantly to sleep reduction
• 5:13
  Dr. Komal Patil-Sisodia: and
• 5:13
  Dr. Andrea Matsumura: we are all hooked on phones, tablets, TVs, computers, what have you, and there is too much light in our life.
• 5:23
  Dr. Andrea Matsumura: Now,
• 5:24
  Dr. Komal Patil-Sisodia: yeah.
• 5:24
  Dr. Andrea Matsumura: So those are the pieces that I start with.
• 5:27
  Dr. Andrea Matsumura: I also start with the medical history.
• 5:30
  Dr. Andrea Matsumura: What's going on with somebody right now.
• 5:33
  Dr. Andrea Matsumura: And we go from there.
• 5:35
  Dr. Andrea Matsumura: You know, historically, women have been socialized, if you will, to think that they do not need medical care.
• 5:42
  Dr. Andrea Matsumura: a lot of sleep or that it's normal.
• 5:44
  Dr. Andrea Matsumura: We've normalized women not getting good sleep.
• 5:48
  Dr. Andrea Matsumura: There's always an excuse.
• 5:49
  Dr. Andrea Matsumura: It starts with menstruation.
• 5:52
  Dr. Andrea Matsumura: So if you may have some insomnia right before your cycle starts or you have a lot of pain, well, it's, that's an excuse.
• 6:01
  Dr. Andrea Matsumura: Then you get into pregnancy.
• 6:03
  Dr. Andrea Matsumura: Well, you know, you're pregnant.
• 6:04
  Dr. Andrea Matsumura: You're going to be uncomfortable.
• 6:06
  Dr. Andrea Matsumura: You might acquire restless leg syndrome during pregnancy.
• 6:10
  Dr. Andrea Matsumura: Or, we have conditions that are not easily diagnosed like endometriosis that cause significant impairment in women's lives.
• 6:20
  Dr. Andrea Matsumura: And then you move on and.
• 6:22
  Dr. Andrea Matsumura: Then the excuse is, well, you have little kids or you're taking care of a partner or you're taking care of parents, all of these reasons that explain away why women are not getting good sleep or don't deserve good sleep,
• 6:38
  Dr. Komal Patil-Sisodia: right?
• 6:39
  Dr. Komal Patil-Sisodia: Ah, yeah, that is, um, I, one, guilty as charged from the tech to the making excuses for myself.
• 6:48
  Dr. Komal Patil-Sisodia: But I guess for me, what I'm wondering is how many hours of sleep do you think are appropriate for somebody to get or that they need to get to feel refreshed?
• 6:57
  Dr. Komal Patil-Sisodia: Because you hear everything from like, Oh, some 10 is really the right number and everything in between.
• 7:05
  Dr. Komal Patil-Sisodia: So what are your recommendations?
• 7:08
  Dr. Andrea Matsumura: So I fall in line with the recommendations by the American Academy of Sleep Medicine, and that is seven to nine hours, and people who say that they need less sleep are compensating actually, because there's actually, there's data that has been, that has shown that if people get less than seven hours of sleep routinely, that their reaction time is slower, their ability to consolidate memory, is hampered.
• 7:33
  Dr. Andrea Matsumura: Executive functioning is impaired on some level.
• 7:37
  Dr. Andrea Matsumura: And so we compensate.
• 7:39
  Dr. Andrea Matsumura: And typically what happens is when I see somebody in my office, it's because those compensatory mechanisms are failing them.
• 7:48
  Dr. Andrea Matsumura: So for the most, yeah, for the most part, it's when somebody says, I'm having trouble sleeping and they may have had trouble sleeping for decades, but they were compensating and then something shifted in their body that then does not allow them to compensate any longer.
• 8:08
  Dr. Andrea Matsumura: And then their daytime.
• 8:10
  Dr. Andrea Matsumura: is impaired or their nighttime is impairing their day, their
• 8:14
  Dr. Komal Patil-Sisodia: daytime.
• 8:14
  Dr. Komal Patil-Sisodia: Yeah, that makes sense.
• 8:15
  Dr. Komal Patil-Sisodia: So what kind of compensatory mechanisms are we talking about?
• 8:18
  Dr. Komal Patil-Sisodia: Is it just caffeine or are there more things that people are doing to kind of muscle through a day?
• 8:24
  Dr. Andrea Matsumura: The first and foremost, it is caffeine.
• 8:27
  Dr. Andrea Matsumura: So people are using stimulants also.
• 8:30
  Dr. Andrea Matsumura: So people get misdiagnosed with ADHD when they really don't have it.
• 8:36
  Dr. Andrea Matsumura: And now there's lots of research that has come out around the misdiagnosis of women.
• 8:43
  Dr. Andrea Matsumura: So women have had less that the diagnosis has been delayed for women.
• 8:51
  Dr. Andrea Matsumura: So you need to be really careful and that's the whole piece around obtaining that history is if women really have ADHD, we do need to focus on that.
• 9:00
  Dr. Andrea Matsumura: Okay.
• 9:01
  Dr. Andrea Matsumura: But by and large, when I see people, I'd say about 50 percent of those who are on stimulant therapy, they're not really treating ADHD, they're treating symptoms of sleepiness and lack of concentration secondary to sleepiness.
• 9:18
  Dr. Andrea Matsumura: So those things also weight gain is an issue, but going back to the compensatory mechanisms, it's just kind of plowing through and being told that you should only, you know, that it's normal to only get five or six hours of sleep a night.
• 9:35
  Dr. Andrea Matsumura: So then people feel themselves with caffeine or they get this diagnosis of ADHD and they are on stimulant therapy.
• 9:44
  Dr. Andrea Matsumura: All types of stimulants.
• 9:45
  Dr. Andrea Matsumura: So we, you know, there's modafinil, armodafinil, and then there's the classic stimulants that people know about, like Adderall or Ritalin.
• 9:55
  Dr. Andrea Matsumura: Those are all out there.
• 9:56
  Dr. Andrea Matsumura: Sometimes people are placed on medications that are historically used for narcolepsy that, And when you really get down to the core of what the driver is, they never really got the official diagnosis of narcolepsy, but somehow they were placed on a medication for it.
• 10:14
  Dr. Komal Patil-Sisodia: Yeah.
• 10:16
  Dr. Komal Patil-Sisodia: That's scary.
• 10:17
  Dr. Komal Patil-Sisodia: That is scary.
• 10:18
  Dr. Komal Patil-Sisodia: So I can't underscore the importance of going to see a sleep specialist enough to help.
• 10:24
  Dr. Komal Patil-Sisodia: Kind of navigate through all of those different pieces.
• 10:28
  Dr. Komal Patil-Sisodia: So let's talk, let's shift gears and talk a little bit about women and sleep specifically, right?
• 10:32
  Dr. Komal Patil-Sisodia: Because we are in this era right now where perimenopause and menopause are finally getting their due.
• 10:39
  Dr. Komal Patil-Sisodia: And we are talking about all of the different things that women's bodies go through as our estrogen levels are declining.
• 10:46
  Dr. Komal Patil-Sisodia: I started to really wonder about it when I was seeing women coming into my office in their.
• 10:51
  Dr. Komal Patil-Sisodia: You know, late thirties, early forties and their metabolic diseases like PCOS, prediabetes, diabetes, everything was starting to get worse, even though they'd been doing exactly the same thing.
• 11:01
  Dr. Komal Patil-Sisodia: And I imagine it's much the same for sleep.
• 11:04
  Dr. Komal Patil-Sisodia: So I'd love to hear about that.
• 11:06
  Dr. Komal Patil-Sisodia: And I'm sure the listeners would as well.
• 11:08
  Dr. Komal Patil-Sisodia: Yeah.
• 11:09
  Dr. Komal Patil-Sisodia: Yeah.
• 11:10
  Dr. Andrea Matsumura: So when people start, so the awareness around menopause is fantastic because as we all know, And we've heard plenty now that perimenopause can start much earlier than we thought.
• 11:24
  Dr. Andrea Matsumura: And then what happens is that the brain begins to learn a pattern of wakefulness in the middle of the night.
• 11:30
  Dr. Andrea Matsumura: And so perimenopause and menopause is.
• 11:35
  Dr. Andrea Matsumura: The sleep is really affected because there's these declining levels of estrogen that then cause all of these Effects in and women and kind of show up in the middle of the night But the other piece is that if you're not then getting enough sleep It's this cascading effect as you know growth hormone then is affected cortisol And growth hormone is really important for Muscle development and I repair muscle repair rather.
• 12:01
  Dr. Andrea Matsumura: And cortisol levels are then artificially elevated.
• 12:05
  Dr. Andrea Matsumura: And then you have the imbalance at a high level because we know that when we're talking about hunger and satiety, that you know, it's not just leptin and ghrelin, but those are the Big ones that pop up that are imbalanced when you're not getting enough sleep.
• 12:23
  Dr. Andrea Matsumura: Thyroid can be affected.
• 12:25
  Dr. Andrea Matsumura: You know, all of these things can be affected.
• 12:27
  Dr. Andrea Matsumura: And so then this cascading effect of the body's imbalance really surfaces.
• 12:36
  Dr. Andrea Matsumura: And again, that's why I call sleep your superpower, because if you're getting enough sleep, that seven to nine hours, all of these things.
• 12:46
  Dr. Andrea Matsumura: Should be in balance.
• 12:49
  Dr. Komal Patil-Sisodia: That's really fantastic to hear because I don't think that people realize what a widespread effect it has so, I have noticed, a lot of these metabolic changes and some of my female patients as early as mid 30s really, but really, most of them in their 40s.
• 13:06
  Dr. Komal Patil-Sisodia: So how does estrogen play a role, we know that estrogen levels peak at 35 and they start to come down.
• 13:12
  Dr. Komal Patil-Sisodia: Yeah.
• 13:13
  Dr. Komal Patil-Sisodia: Yeah.
• 13:13
  Dr. Komal Patil-Sisodia: What role does estrogen play in us being able to get good sleep?
• 13:17
  Dr. Komal Patil-Sisodia: And is there a role for progesterone and testosterone?
• 13:20
  Dr. Komal Patil-Sisodia: I know everybody is reading and hearing about all of these different things.
• 13:23
  Dr. Komal Patil-Sisodia: And so I'd love to hear from the expert.
• 13:26
  Dr. Andrea Matsumura: Yeah.
• 13:26
  Dr. Andrea Matsumura: With the declining levels of estrogen, when you replace estrogen, then you're, it's because really the hot flashes tend to promote that wakefulness in the middle of the night.
• 13:36
  Dr. Andrea Matsumura: The core body temperature.
• 13:38
  Dr. Andrea Matsumura: People don't realize also that that is affected by declining levels of estrogen.
• 13:44
  Dr. Andrea Matsumura: We know that progesterone can be helpful in inducing some sleep, but it is not like a slam dunk.
• 13:52
  Dr. Andrea Matsumura: It's all about the fine balance between estrogen and progesterone.
• 13:56
  Dr. Andrea Matsumura: So, like all of this data that's coming out when when we used to just provide people with estrogen thinking that they didn't need progesterone in patients who have had hysterectomies, right?
• 14:08
  Dr. Andrea Matsumura: But that's no longer true.
• 14:11
  Dr. Andrea Matsumura: So we really need to focus on one, if you're having these symptoms, we want to eliminate Or address rather all the causes that potentially could be affecting your sleep.
• 14:27
  Dr. Andrea Matsumura: So I always draw a circle for people and I write sleep in the center of that circle and then all these little arrows around it.
• 14:35
  Dr. Andrea Matsumura: Is it Breathing abnormality.
• 14:38
  Dr. Andrea Matsumura: Is it a movement abnormality?
• 14:39
  Dr. Andrea Matsumura: Is it medications affecting sleep?
• 14:42
  Dr. Andrea Matsumura: Is it hormones affecting sleep?
• 14:44
  Dr. Andrea Matsumura: Is it pain affecting sleep?
• 14:46
  Dr. Andrea Matsumura: Is it your environment?
• 14:48
  Dr. Andrea Matsumura: So we, that's what I address in a sleep medicine consult.
• 14:51
  Dr. Andrea Matsumura: I look at all of the things that can be affecting one's sleep.
• 14:56
  Dr. Andrea Matsumura: Now, replacement of estrogen and progesterone really helps to promote people getting back to their sleep cycle.
• 15:03
  Dr. Andrea Matsumura: But oftentimes, if somebody has been struggling with sleep long term, they have developed a comorbid condition, which is chronic insomnia, in addition to maybe needing replacement of hormone therapy, hormone therapy replacement.
• 15:19
  Dr. Andrea Matsumura: So you want to treat both of them at the same time.
• 15:23
  Dr. Komal Patil-Sisodia: That makes good sense.
• 15:24
  Dr. Komal Patil-Sisodia: And so for people who do have chronic insomnia, because to your point, as women you know, those of us who are moms, those of us who aren't, those of us who are in stressful careers or are running their household 24 7 to your point, we've learned to compensate over time so I'm guessing chronic insomnia is a pretty common complaint that you see How do you address that?
• 15:47
  Dr. Komal Patil-Sisodia: How do people get back on track with their sleep?
• 15:51
  Dr. Komal Patil-Sisodia: Because it's taken years to build up and get to that point.
• 15:54
  Dr. Komal Patil-Sisodia: I can't imagine that it's an easy fix, but there's got to be some steps we can take to hopefully get back to baseline.
• 16:01
  Dr. Andrea Matsumura: Yes, it is.
• 16:02
  Dr. Andrea Matsumura: Like I, I will liken it to weight loss or training for a marathon.
• 16:07
  Dr. Andrea Matsumura: We don't do couch to marathons, right?
• 16:10
  Dr. Andrea Matsumura: We can do a couch to 5k.
• 16:13
  Dr. Andrea Matsumura: The process is largely behavioral, so the tried and true evidence based method is cognitive behavioral therapy for insomnia.
• 16:23
  Dr. Andrea Matsumura: So cognitive behavioral therapy is this umbrella term, and there's different types of protocols based on what you're treating.
• 16:30
  Dr. Andrea Matsumura: And the one that has been studied is cognitive behavioral therapy for insomnia that should be, used alongside anything else.
• 16:41
  Dr. Andrea Matsumura: If there is a comorbid condition, if there isn't, then we focus only on the chronic insomnia, but by and large, people develop anticipatory anxiety.
• 16:52
  Dr. Andrea Matsumura: They develop sleep anxiety because you start not looking forward to going to sleep.
• 16:58
  Dr. Andrea Matsumura: You start.
• 16:59
  Dr. Andrea Matsumura: Fearing the bedtime because you know, you're going to have trouble going to sleep.
• 17:05
  Dr. Andrea Matsumura: So then you don't know if you're anxious because you're not sleeping or you're not sleeping because you're anxious.
• 17:12
  Dr. Andrea Matsumura: Oh, that's such a verbal catch 22.
• 17:16
  Dr. Komal Patil-Sisodia: I could see myself spiraling in that.
• 17:19
  Dr. Andrea Matsumura: Right?
• 17:19
  Dr. Komal Patil-Sisodia: Yeah.
• 17:20
  Dr. Andrea Matsumura: So that's a real additional problem that you kind of have to unpack.
• 17:26
  Dr. Andrea Matsumura: So that's why in many forums, people will say, Oh, just take this medication.
• 17:30
  Dr. Andrea Matsumura: Oh, just take that.
• 17:32
  Dr. Andrea Matsumura: And then on the other hand, you hear the general population say, Oh, doctors are just pill pushers.
• 17:37
  Dr. Andrea Matsumura: No, no.
• 17:39
  Dr. Andrea Matsumura: A lot of it has to do with education.
• 17:41
  Dr. Andrea Matsumura: Like We should really be upset with the patriarchal nature of medicine, medical education.
• 17:47
  Dr. Andrea Matsumura: We were not.
• 17:49
  Dr. Andrea Matsumura: Taught.
• 17:49
  Dr. Andrea Matsumura: We weren't taught about menopause, and we were not taught about sleep.
• 17:54
  Dr. Komal Patil-Sisodia: I agree with you.
• 17:55
  Dr. Komal Patil-Sisodia: It's it's mind boggling to me, and I feel so bad when I look back on the early parts of my career for all of the people that I told that I couldn't do anything
• 18:05
  Dr. Andrea Matsumura: for.
• 18:05
  Dr. Andrea Matsumura: Right.
• 18:06
  Dr. Komal Patil-Sisodia: But I totally agree with you.
• 18:07
  Dr. Komal Patil-Sisodia: And nowadays, there's so much distrust in medicine because we were not properly trained.
• 18:13
  Dr. Komal Patil-Sisodia: How do we start reclaiming that trust?
• 18:15
  Dr. Komal Patil-Sisodia: I think that's going to be a long term process, right?
• 18:18
  Dr. Komal Patil-Sisodia: But I'd love to hear from your perspective as somebody who's board certified in sleep medicine and the expert.
• 18:24
  Dr. Komal Patil-Sisodia: We hear everything like, Oh, take melatonin, Take Benadryl, take Unisom, take this, take that try these herbs stay away from, oh gosh, what is it called, the one that Tiger Woods took, Ambien, right?
• 18:36
  Dr. Komal Patil-Sisodia: Ambien, right.
• 18:37
  Dr. Komal Patil-Sisodia: Stay away from that, because that can be bad for you.
• 18:40
  Dr. Komal Patil-Sisodia: I mean, there's just, There's so much out there and there's so much bad information on the internet.
• 18:45
  Dr. Komal Patil-Sisodia: I would love for our listeners to hear what is good from your perspective in terms of let's talk supplements and pills, and then we can talk habits and all of those other things that, that you think are important for somebody to get back on track with their sleep.
• 19:01
  Dr. Andrea Matsumura: It all goes back to treating the root cause.
• 19:04
  Dr. Komal Patil-Sisodia: Yeah.
• 19:04
  Dr. Andrea Matsumura: And that's what it goes back to.
• 19:06
  Dr. Andrea Matsumura: So, if the root cause is sleep apnea, and by the way, I'm bringing up sleep apnea because 90 percent of women who have it are not diagnosed.
• 19:15
  Dr. Andrea Matsumura: Yes.
• 19:19
  Dr. Andrea Matsumura: And that's again, because it goes back to that normalization that women shouldn't be getting good sleep.
• 19:24
  Dr. Andrea Matsumura: And there is data out there that shows that if a woman has a partner that is male, they're not seeing the abnormal sleep.
• 19:34
  Dr. Andrea Matsumura: They're not great observers of abnormal sleep versus we know that.
• 19:39
  Dr. Andrea Matsumura: Historically, men are coming into the office because their female partner is saying something is wrong with their sleep.
• 19:48
  Dr. Andrea Matsumura: So there's that, there's lack of awareness, and then there's normalization of getting bad sleep.
• 19:56
  Dr. Andrea Matsumura: And so then women have a delay in diagnosis.
• 19:59
  Dr. Andrea Matsumura: And in fact, again, it goes back to the education.
• 20:02
  Dr. Andrea Matsumura: Let's not forget that women were not included in its studies until 1983.
• 20:08
  Dr. Andrea Matsumura: Right.
• 20:09
  Dr. Andrea Matsumura: There was that time when women were included, but then what happened is that we had women who were affected, their children were affected by thalidomide, right?
• 20:19
  Dr. Andrea Matsumura: So that's what stopped all of the research.
• 20:23
  Dr. Andrea Matsumura: Oh, we can't include women.
• 20:25
  Dr. Andrea Matsumura: They're too complex.
• 20:28
  Dr. Andrea Matsumura: until 1993.
• 20:30
  Dr. Andrea Matsumura: Fast forward 1993.
• 20:32
  Dr. Andrea Matsumura: So a lot of what we were trained to do and what is still being trained in medicine is from a male's perspective.
• 20:40
  Dr. Andrea Matsumura: So we all have to do our own homework.
• 20:43
  Dr. Andrea Matsumura: But having said all of that it's really about getting down to the root cause.
• 20:47
  Dr. Andrea Matsumura: And with supplements and medications, those are not things that I typically go to unless there's a very specific indication for a medication, because like I said, we have to get back.
• 21:00
  Dr. Andrea Matsumura: Is it a movement issue, which Oftentimes, if it's a restless leg syndrome issue or a periodic limb movement issue, then we need to look at ferritin levels because ferritin is part of making of iron stores and that movement issue is related to low iron stores.
• 21:21
  Dr. Andrea Matsumura: We have to look at breathing abnormality.
• 21:23
  Dr. Andrea Matsumura: Sometimes medications that we are prescribing for people that are, we know, are reducing morbidity and mortality, meaning heart attacks and strokes, sometimes cause insomnia.
• 21:34
  Dr. Andrea Matsumura: And if we just move them around or change them, It fixes people's insomnia and then clearly menopause, right?
• 21:41
  Dr. Andrea Matsumura: We know sometimes we need to have hormone therapy so that we can help people get back to sleep, but if that doesn't cure it all, then we need to go to behavioral.
• 21:54
  Dr. Andrea Matsumura: So up to 60 percent of patients who have.
• 21:57
  Dr. Andrea Matsumura: Obstructive sleep apnea have the condition called comesa, which is comorbid insomnia with obstructive sleep apnea.
• 22:06
  Dr. Komal Patil-Sisodia: Oh, interesting.
• 22:07
  Dr. Komal Patil-Sisodia: That's a lot of people.
• 22:08
  Dr. Komal Patil-Sisodia: Yeah, that is a lot of people.
• 22:10
  Dr. Komal Patil-Sisodia: That is a huge amount.
• 22:12
  Dr. Komal Patil-Sisodia: So that's interesting.
• 22:13
  Dr. Komal Patil-Sisodia: So what are things that I guess you see in the menopause space outside of the hot flashes that are causing sleep impairment?
• 22:21
  Dr. Komal Patil-Sisodia: I know we had touched on pain.
• 22:23
  Dr. Komal Patil-Sisodia: Is there anything else that we should be aware of?
• 22:25
  Dr. Komal Patil-Sisodia: I know there's been a lot of talk about musculoskeletal syndrome of menopause and that great paper by Dr.
• 22:31
  Dr. Komal Patil-Sisodia: Vonda Wright.
• 22:31
  Dr. Komal Patil-Sisodia: So love to hear your thoughts on that.
• 22:34
  Dr. Andrea Matsumura: So yes, people will come in and they'll say, I get up every two hours because I have to change positions because I'm in pain and then you realize that the core issue here is that maybe they do need hormone therapy.
• 22:45
  Dr. Andrea Matsumura: So more people than not probably should be evaluated if they're having symptoms around menopause, which we know is.
• 22:53
  Dr. Andrea Matsumura: a long list because it affects itself.
• 22:56
  Dr. Andrea Matsumura: Yeah, it affects everything.
• 22:58
  Dr. Andrea Matsumura: It's worthwhile to get that evaluation to see whether or not hormone therapy is going to make a difference.
• 23:04
  Dr. Andrea Matsumura: That would be my first pass and need an indication for hormones.
• 23:08
  Dr. Andrea Matsumura: And we know that the supplements just fall short in really treating those symptoms.
• 23:15
  Dr. Andrea Matsumura: So this is that indication.
• 23:19
  Dr. Andrea Matsumura: For using a prescription medication.
• 23:21
  Dr. Andrea Matsumura: Now the data is really far out on test on testosterone.
• 23:26
  Dr. Andrea Matsumura: There is no data out there that correlates any better sleep with testosterone.
• 23:31
  Dr. Andrea Matsumura: But we do know that there's data around estrogen and progesterone that it does correlate with improved sleep, but if that's not hitting the mark in the slam dunk, then you need to think about behavioral.
• 23:42
  Dr. Andrea Matsumura: We don't, I do not move to medicine or supplements.
• 23:45
  Dr. Komal Patil-Sisodia: Okay.
• 23:46
  Dr. Komal Patil-Sisodia: And how long would you give somebody on hormone replacement when they're starting?
• 23:50
  Dr. Komal Patil-Sisodia: Right.
• 23:50
  Dr. Komal Patil-Sisodia: I know I've had some patients who like in a week, they're like, my life is better.
• 23:54
  Dr. Komal Patil-Sisodia: But, sometimes it takes a while.
• 23:57
  Dr. Komal Patil-Sisodia: What do you think is a reasonable observation period once you start a therapy before you shift gears?
• 24:02
  Dr. Andrea Matsumura: Yeah, since there is no data, right, when we as physicians don't have evidence out there or data we go by, you know, anecdotes and experience.
• 24:14
  Dr. Andrea Matsumura: And what I find is that if things haven't shifted after a month, that we probably need to do something then.
• 24:22
  Dr. Komal Patil-Sisodia: That's really good to hear because I know some people will wait as long as like three to six months before they're willing to make another change and I think a lot of that is fear based right in terms of not wanting to try something else that might be a medication or some other type of treatment outside of what they deem is possibly safe for themselves
• 24:45
  Dr. Andrea Matsumura: yeah.
• 24:45
  Dr. Andrea Matsumura: And so what I'm talking about is if somebody starts on hormones and a month later, there's no change, do they need a change in dose of their hormone or are all of those symptoms that they were coming to the office with?
• 25:02
  Dr. Andrea Matsumura: alleviated except for sleep.
• 25:05
  Dr. Andrea Matsumura: So if there's other symptoms around that for instance, like we talked about the musculoskeletal pain hot flashes, still vaginal dryness, all these things, right?
• 25:16
  Dr. Andrea Matsumura: If there's still all of that, then maybe We need to make adjustments to the hormone therapy, but if everything feels like it's calmed down, but the sleep abnormality is still present, then we need to focus on behavioral
• 25:29
  Dr. Komal Patil-Sisodia: changes.
• 25:30
  Dr. Komal Patil-Sisodia: Okay, and that makes perfect sense.
• 25:32
  Dr. Komal Patil-Sisodia: How often do you see women dealing with genitourinary syndrome having to get up in the middle of the night to use the bathroom?
• 25:40
  Dr. Komal Patil-Sisodia: How often do you see that as part of this perimenopausal menopausal population?
• 25:46
  Dr. Andrea Matsumura: It is it is moderately frequent.
• 25:48
  Dr. Andrea Matsumura: I do have a lot of urologists that refer to me for anyone who's getting up in the middle of the night to go to the bathroom because we know that when you have sleep apnea, you have an increase in urine production.
• 26:02
  Dr. Andrea Matsumura: So you want to eliminate a breathing abnormality.
• 26:06
  Dr. Andrea Matsumura: And if that breathing abnormality is not there, then you want to focus on that genital urinary tract.
• 26:12
  Dr. Andrea Matsumura: You know, the syndrome from perimenopause and menopause and that often because that is very disrupting to sleep, having to get up in the middle of the night.
• 26:24
  Dr. Andrea Matsumura: And so then we want to focus on treating that.
• 26:27
  Dr. Andrea Matsumura: But for many people, I will see many women, I will do the workup and they may not have sleep apnea, but they just need hormone therapy.
• 26:36
  Dr. Komal Patil-Sisodia: Yeah, that's fascinating.
• 26:39
  Dr. Komal Patil-Sisodia: I see it in my patients with diabetes as well, right?
• 26:42
  Dr. Komal Patil-Sisodia: When the diabetes is not well controlled, they're up in the middle of the night and getting up and doing whatever, you know, using the restroom as many times as they need to, which then worse, sleep means worse blood sugars the next day.
• 26:53
  Dr. Komal Patil-Sisodia: So it's this never ending cycle.
• 26:55
  Dr. Komal Patil-Sisodia: So I think we see that probably with a lot of different a lot of different.
• 26:59
  Dr. Komal Patil-Sisodia: Conditions.
• 27:00
  Dr. Komal Patil-Sisodia: In terms of setting up a good sleep routine for yourself, what are your general recommendations for people to try?
• 27:06
  Dr. Komal Patil-Sisodia: Is this something you recommend doing along with cognitive behavioral therapy?
• 27:10
  Dr. Komal Patil-Sisodia: Or do you give people a period of time to try these things on their own before moving down the path towards CBT?
• 27:17
  Dr. Andrea Matsumura: So chronic insomnia by definition is when you cannot get to sleep and or stay asleep greater than three times a week for greater than three months.
• 27:26
  Dr. Andrea Matsumura: So then you, so that means that there's a new neurological pathway that your brain decided to take.
• 27:32
  Dr. Andrea Matsumura: So you do need that cognitive behavioral therapy for insomnia if you meet that criteria.
• 27:39
  Dr. Andrea Matsumura: If it's less than three months, Then you could potentially try working on sleep hygiene, but I really want to make clear for folks.
• 27:48
  Dr. Andrea Matsumura: It's not just sleep hygiene, how you prepare yourself for sleep when you have developed that new neurological pathway.
• 27:55
  Dr. Andrea Matsumura: It is about addressing the behavior that is causing hyper arousal.
• 28:01
  Dr. Andrea Matsumura: Okay.
• 28:02
  Dr. Komal Patil-Sisodia: A KAR phones,
• 28:04
  Dr. Andrea Matsumura: phone phones or anxiety.
• 28:07
  Dr. Andrea Matsumura: You have to focus on the hyper arousal state and the hyper vigilance that is learned.
• 28:13
  Dr. Andrea Matsumura: That's so, so it's not, it's not just, yeah.
• 28:16
  Dr. Andrea Matsumura: Well, you know, just stop using electronics, you know, that is.
• 28:20
  Dr. Andrea Matsumura: That is all about sleep hygiene.
• 28:22
  Dr. Andrea Matsumura: What we don't want people to do is when they wake up in the middle of the night, you have to have a plan for yourself to help yourself get back to sleep.
• 28:29
  Dr. Andrea Matsumura: And most of us reach for that phone, which is the absolute opposite of what we should be doing.
• 28:35
  Dr. Andrea Matsumura: I'm guilty.
• 28:36
  Dr. Andrea Matsumura: I do that.
• 28:36
  Dr. Komal Patil-Sisodia: Okay, so what do you recommend in terms of a sleep plan?
• 28:41
  Dr. Komal Patil-Sisodia: If somebody finds themselves waking up in the middle of the night, what are things you can try?
• 28:45
  Dr. Andrea Matsumura: Yeah.
• 28:46
  Dr. Andrea Matsumura: So, first of all, you want to make sure that you are preparing yourself for sleep so that you, everybody needs a wind down period.
• 28:54
  Dr. Andrea Matsumura: I give the analogy of eating.
• 28:55
  Dr. Andrea Matsumura: We don't just go, go, go, go, go and then open the refrigerator and shove food in our mouth, right?
• 29:00
  Dr. Andrea Matsumura: We prepare.
• 29:01
  Dr. Andrea Matsumura: Food to eat.
• 29:03
  Dr. Andrea Matsumura: It's the same for sleep.
• 29:05
  Dr. Andrea Matsumura: Sleep is food for your brain.
• 29:07
  Dr. Andrea Matsumura: So yeah, so you prepare yourself.
• 29:11
  Dr. Andrea Matsumura: You don't just go, go, go, go, go, go, go, and then plop into bed, right?
• 29:15
  Dr. Andrea Matsumura: You got, you've got to give yourself a little wind down period to tell your brain that it's time for sleep.
• 29:22
  Dr. Andrea Matsumura: Now, if you wake up in the middle of the night, you want to have a plan.
• 29:25
  Dr. Andrea Matsumura: The plan is Part of what we call stimulus control, meaning it's a fancy word for saying, what am I going to do to help get my brain to shut down?
• 29:37
  Dr. Andrea Matsumura: Because it's awake.
• 29:39
  Dr. Andrea Matsumura: First off, never look, never have phones.
• 29:42
  Dr. Andrea Matsumura: Don't look at clocks.
• 29:44
  Dr. Andrea Matsumura: At the clock, if you wake up in the middle of the night, because that drives wakefulness.
• 29:48
  Dr. Andrea Matsumura: So you kind of guesstimate your sit, you're probably lying there and you're thinking, all right, it's been about 15 minutes.
• 29:53
  Dr. Andrea Matsumura: I know I'm not getting back to sleep.
• 29:56
  Dr. Andrea Matsumura: The ideal thing to do is to develop a plan, like have a chair or an area in your home that you are going to go to.
• 30:05
  Dr. Andrea Matsumura: And then you can do things like imagery work.
• 30:08
  Dr. Andrea Matsumura: meditation reading the most boring book.
• 30:12
  Dr. Andrea Matsumura: You don't want to read an exciting book.
• 30:14
  Dr. Andrea Matsumura: You want to read the most boring thing with indirect light.
• 30:17
  Dr. Andrea Matsumura: So a lot of people have electronic readers and I say, those are all marketing ploys that all of those types of, light, Changing mechanisms that really is not working.
• 30:29
  Dr. Andrea Matsumura: And you want to, you don't want to cook clean work exercise.
• 30:34
  Dr. Andrea Matsumura: You don't want to be doing any of that when you wake up.
• 30:37
  Dr. Andrea Matsumura: And so the key is to.
• 30:40
  Dr. Andrea Matsumura: I know that you're not going to fall back to sleep easily.
• 30:46
  Dr. Andrea Matsumura: Get out of the bed, do something extremely boring and relaxing, reset yourself, and then try, when you feel sleepy, get back into bed.
• 30:57
  Dr. Andrea Matsumura: And over time it shortens.
• 31:00
  Dr. Andrea Matsumura: And that's where that piece of it's a couch to marathon comes in.
• 31:04
  Dr. Komal Patil-Sisodia: Yeah.
• 31:04
  Dr. Andrea Matsumura: Because this is a process just like weight loss.
• 31:07
  Dr. Andrea Matsumura: It took A long time to gain the weight.
• 31:10
  Dr. Andrea Matsumura: It's not going to take a week to lose it all.
• 31:13
  Dr. Komal Patil-Sisodia: That's true.
• 31:14
  Dr. Komal Patil-Sisodia: That's very, very true.
• 31:15
  Dr. Komal Patil-Sisodia: So, those are fantastic tips.
• 31:18
  Dr. Komal Patil-Sisodia: I know I'm going to try a few of them.
• 31:21
  Dr. Komal Patil-Sisodia: I did I did do the boring reading thing.
• 31:23
  Dr. Komal Patil-Sisodia: I have a stack of journal articles I've been meaning to, you know, Sometimes they're fascinating, but late at night, they can be a great set of tips.
• 31:33
  Dr. Komal Patil-Sisodia: But thank you so much for for being here today.
• 31:36
  Dr. Komal Patil-Sisodia: I really appreciate your time, everyone.
• 31:39
  Dr. Komal Patil-Sisodia: This is again, Dr.
• 31:40
  Dr. Komal Patil-Sisodia: Andrea Matsumura, who's joined us.
• 31:42
  Dr. Komal Patil-Sisodia: Where do you practice, Andrew, just in case some of our listeners want to come find you.
• 31:47
  Dr. Komal Patil-Sisodia: So I practice at
• 31:48
  Dr. Andrea Matsumura: Cascadia Health in Portland, Oregon.
• 31:52
  Dr. Andrea Matsumura: Yeah.
• 31:52
  Dr. Komal Patil-Sisodia: Wonderful.
• 31:53
  Dr. Komal Patil-Sisodia: Well, we will link all of your information at the bottom of the podcast and thank you again for taking the time today.
• 32:00
  Dr. Komal Patil-Sisodia: I really appreciate you being here and this was a great conversation.
• 32:04
  Dr. Andrea Matsumura: Oh, well, thank you for having me.
• 32:05
  Dr. Komal Patil-Sisodia: My pleasure.