Listen in to Dr. Val Cacho to understand the reasons for sleeplessness in menopause or perimenopause

Are you sleepless in perimenopause or menopause?

Laying awake at night, or experiencing full blown insomnia in perimenopause can be stressful. There are many reasons and theories for midlife sleeplessness, including worry, stress, blood sugar and even hunger.

Medical sleep expert Dr. Val Cacho joins me in talking about the reasons we lay awake at night in perimenopause including:

• anxiety

• gut health

• hormone changes

• lifestyle choices

• sleep apnea

Dr. Valerie Cacho is an integrative sleep physician, speaker, writer, and sleep wellness consultant. She is passionate about inspiring her patients to obtain optimal sleep health and wellness through integrative, holistic and lifestyle medicine approaches. Grab her Exhaustion Checklist here!

She is an expert in women's sleep health and founded the wellness brand Sleephoria, that believes a well-rested woman has the energy, clarity, and drive to change the world.

Her leadership roles include being the President for the Hawaii Sleep Society and the former medical director of sleep at Hawaii Pacific Health.  Additionally she has been rated as a Castle Connolly's Top Sleep Doctor and Exceptional Women in Medicine in Hawaii for the past several years. 

Why DO we struggle with sleep in perimenopause?

Tanya:
I'm excited to talk to you, and I know this will be fun to put on the podcast as well.
I would love for you to tell us about yourself!

Dr. Val:
Sure. Thank you so much Tanya for having me here. I'm Dr. Val Cacho. I'm an integrative sleep medicine physician and I am a women's sleep specialist. I met Tanya through a Facebook group that we are both experts in, the Perimenopause Hub, and we just really connected.

We want to share our information with everybody out there in the world, who is open to listen.

Tanya:
I know you have a sleep guide for perimenopause and menopause. A lot of women struggle with disrupted sleep!

Dr. Val:
Why women struggle with sleep as they go through perimenopause? There are actually a lot of factors, but I would probably start with the change in hormones as we get older. Our bodies say we don't need to have babies anymore, and so when that happens, we lose estrogen and progesterone.

Those hormones actually can help improve our sleep. Progesterone is also known as like the restful hormone. And you know, when we lose estrogen, we actually have changes in our body temperatures, right? So we can have more problems with hot flashes. So I would say related changes in hormones can lead to disruptive sleep.

If you've ever had a hot flash, it's really hard to stay asleep when your face is flushed! Sometimes people even have night sweats, where they have to change their clothes. But other than that, women as we get older, also develop something called obstructive sleep apnea.

And that happens when the muscles of the upper airway, generally the tongue can fall back, and choke us when we breathe. That can keep us from falling asleep.

Hormone related changes lead to that as well. Those are some of the physical changes, and then you think about the other changes, as we get older.

A lot of changes in our body can be really anxiety provoking.

Fluctuations in hormones can affect our mood and sleep occurs when our brainwaves relax. If there's funny things that happen in our body, I say funny things because there can be like dry skin, itchiness, having to wake up to urinate, having bone pain, breast tenderness …

There's a lot of different physical symptoms that come up through perimenopause and menopause. A lot of us don't recognize it. Although, maybe we do because we're running in those circles, and maybe you haven't talked to your friends about this. Even some doctors aren't super clear on perimenopause as a condition.

It can be really frightening to not understand what's going on in your body.

And then we worry at night when it's dark and it's quiet. I think we're a culture that thinks, “It's dark, you should be asleep!” When you're not asleep, you tend to self judge yourself. If you already have a lot of anxiety, because of the changes going on in your body, it can really make things worse.

A couple of reasons why women can have difficulty sleeping during perimenopause or menopause are emotional and mood changes as well.

Tanya:
That's a lot.

Dr. Cacho:
And that's like one sliver of it! What specific things do you have questions on or want me to elaborate on?

Tanya:
When you say anxiety, a lot of us are working, we're still, we're in the sandwich generation. We have kids at home, and when I couldn't sleep, especially on Sunday night, there was something about the Sunday night, right?

The beginning of the week perpetuated the anxious thoughts in my head. For things like anxiety related sleep issues, do you have suggestions as a doctor? If I come to you as this perimenopausal woman and I can't sleep, what are your suggestions?

Dr. Val:
That's a good question. I like to really take the whole mind, body, and soul approach, because it's not a one size fits all. If you wanted the short answer, a lot of docs just will give you a sleeping pill and call it a day and you know, call back when you need a refill.

But I feel like that's doing people a disservice.

If we can figure out why you're having a hard time sleeping, certainly, you know, for a lot of women during perimenopause, it can be an emotional state. That sandwich generation is really something to think about.

You know, taking care of kids that are getting older, maybe they're going to college, and there’s elderly parents.

If you're working a full-time job, maybe you're at a point in your career where you're thinking, well, you know, do I wanna stay in this job? If my kids are gonna be out of the house, I'm gonna have more time for myself.

Do I really want to stay in this job?

DO I want to pursue my passion project? Things of the soul can also play a role in the quality of sleep that we have. Some things like that keep patients up at night.

It really just depends.

Definitely as a medical sleep doctor, I'm going to rule out any underlying medical conditions. I’m talking about obstructive sleep apnea, but also restless leg syndrome can be something that can keep someone from falling asleep at night.

Taking a look at their lifestyle, you know, as a nutritionist, talking about what are you eating, when are you eating it? Sometimes we don't necessarily make the connections between our caffeine intake, our alcohol intake, and how that contributes to our sleep, especially if it's something that you've been doing for a long time.

I probably started drinking coffee maybe in college or even in med school. Having to stay up. Sometimes it just could be a habituated pattern.

As we get older, there are changes to our gut, and changes to how we absorb certain substances. For me, I'm very sensitive to caffeine and that can really disrupt when I fall asleep at night.

Bringing light to the different changes that happen during this time and just helping someone through that, that's really my approach. Trying to figure out what's going on, whether or not you have a hard time falling asleep versus staying asleep, and then there's different recommendations based on what we find out together.

Tanya:
I love how you're touching on all these things too. Obstructive sleep apnea is huge, as dental hygienist for 24 years, I've done lots of sleep disorder training, but there was never any connection between perimenopause and maybe the onset of sleep apnea. Is there a connection?

Dr. Val:
Yes, definitely. This is something that we don't talk about enough. Yes, as we get older, age in and of itself could lead to increased floppiness or decreased muscle tone.

Think of your throat like walls in a room. As you get older the walls aren't as strong, so they're more likely to relax and close, but also, the hormone changes. Estrogen and progesterone help make the muscles stronger. You know what happens as we get older, when we lose that, everything starts to sag.

Our breasts start to sag, even our muscles of the upper airway. Sad to say, it's just part of Mother Nature's things that happen with time, and so rates of obstructive sleep apnea are higher as we get older, as we go through menopause.

Two to even up to three times higher. The thing about this is, women aren't always diagnosed with it.

If you go and talk to your doctor about feeling fatigued, having some emotional upset, maybe can't sleep, guess what? You're more than likely to have your thyroid test done or sent to a therapist to talk about your depression and anxiety, rather than a man comes in who says he is fatigued.

More likely than not, he will get a sleep study.

Tanya:
That's so interesting. From what I remember from some of the sleep training, and maybe you could, debunk all of this, it was told to me that the level of diagnosis, like you're “number” wherever you're gonna hit, where you're gonna be, you're apneic, or you're not, it's really just like an arbitrary decision.

(It was a “tongue in cheek” statement said by a doctor at a lecture. He said that it was a committeee going out to dinner and then choosing like this, ”Let's just pick that number, that's where you're gonna be if you have apnea. Whether or not that's true, I don’t know.

When you have someone who's not really hitting that diagnosis and yet they still have lots of sleep disordered issues, whether it's breathing, waking, how do you suss that out?

Dr. Val:
I like data. A lot of insurance companies and the way healthcare works is that doctors have to follow their policies. So we start off with home sleep studies, but women have a different phenotype, meaning that the way they present is a little bit different than men. So we can have a lower severity of sleep apnea.

What we look at is how many times an hour during a sleep study are you holding your breath, for at least 10 seconds, five times an hour, or greater?

Home sleep studies don’t measure your brain activity. I like to always say women are smarter. Sorry to the men out there. I'm very biased.

Our brains are a little bit more sensitive. We can have a type of sleep apnea where our airway partially collapses, but our brain wakes us up before it completely collapses.

The home sleep apnea test may miss that. If you do have a home sleep apnea test and it was normal, please don't stop there.

Go to the lab, make sure that they put the EEG leads on your brain, because we need to know if you're asleep. We do see some women who have more arousals because they have subtle changes in their tongue relaxing and difficulty breathing at night. So that's how I would really try to suss out what's going on.

That's a big part, getting a good quality test.

The problem about this is that sometimes people don't sleep well in the lab, right? What if it's not sleep apnea?
What if you have a hard time sleeping in different environment?
We need to take in the reasons for that. Is it anxiety? Is it those ruminating thoughts? The list of things to do, or the regrets that you didn't do.

That can keep you up at night.

Honestly, one of my fantastic recommendations is to write it down. It sounds so simple, but journal.

Sometimes journaling could be a trigger word for some people. They don't like to journal and okay, if you don't like to journal, use your smartphone if you have one. . Hit the button and then just talk. Let all the verbal diarrhea come out, all the things that are bothering you.

No judgment. Just get it all out.

You can delete it if you want, but it's almost like that release.

You release the gates. Let all the thoughts go and guess what? The more you practice this, the easier it gets. Sometimes I like to say set aside a worry time.

Not everybody who has difficulty sleeping at night, worries, though.

Some people definitely have worries, but sometimes it's just the busy mind. It's not a negative experience, it's just that we're really busy. We have information at our fingertips. There's just a lot of stimuli coming in 24/7, if we allow it.

• How do we make healthy boundaries around that?

• How do we protect our time for ourselves?

• How do we be mindful right of our time?

Instead of just running from one thing to the next, (and I'm sure there's a lot of analogies between how we eat and how we sleep) when you go in to eat a meal, do you just start off like scarfing down your food?

Think of the main course. Do you eat a little bit slowly? Do you take time to enjoy that whole process? Maybe start off with little appetizer, have a bigger meal, because if we're going throughout our day and then say, “Okay, it's time to go to bed. I gotta put my head on my pillow” that might not work.

If you didn't have that little wind down, if you didn't really have that warmup to sleep, how would you expect to sleep instantly? Some people do, but at the end of the day, people who have a hard time sleeping, sleep is when your brain waves slow down.

Are you allowing your brain to slow down at least the half an hour before your desired bedtime? Ideally about an hour.

We have that warmup phase.

Tanya:
That's a great analogy, what you just said. It made me think of that cliche, how you do one thing is how you do everything.

Some of us necessarily have to power through life. We are in a very busy modern society. It's almost like a badge of honor to go, go, go all the time.

To have that wind down time, whatever that means to you, makes so much sense. I can just feel you as a physician, and I'm sure that's something you talk about to your patient.

Dr. Val:
It's a lot of self setting boundaries. One of my primary messages is always to prioritize sleep. If you take a look at things that keep us alive, drinking water, eating healthy food, getting fresh air., why has sleep been brushed under the rug?

Why is it we wait until we're retired to sleep? Why is it that we're going to wait until the weekend to catch up on sleep?

Can we incorporate it as a non-negotiable?

My thing is like, yes, you need to, because of all the health benefits.
If you don't get enough sleep, you could have problems with your blood sugar. If you have problems with your blood pressure, if you know problems with dementia,

There's so many health consequences of not getting enough sleep. It's available to all of us. What I do is teach people about sleep, about the importance of sleep and help them, guide them through healthy habits. Have people think about some of the barriers that are keeping them from sleep.

Tanya:
You say something very important, the benefits of sleep. Being in the health space, sometimes we're so down the road of other things, that some people may not know the benefits of sleep and the risks of not having sleep.

Is that in your guide?

Dr. Cacho:
In my guide, I talk about, It. It's really brief. I don't wanna make it a whole ebook! It just talks about the sleep science, what happens as we go through perimenopause, some of the hormone changes.

One of my favorite images from that is all the disruptions that can happen for women in perimenopause and sleep disruption.

We talk about the psychosocial factors, the underlying medical conditions, aging, hormonal changes.

I like to think of it as a light bulb, to help someone think of looking in at: what could potentially be going on in their own life. Start the wheels turning for yourself, and then when you're ready to have a conversation, with your doctor, with your health coach, with the sleep coach, about what you’re going through, then you’re prepared.

When you go online, in forums. you see questions like,

• “I can't sleep, what supplement are you taking?”

• “What sleeping pill are you taking?”

• Someone will chime in and say, “Oh, try this meditation app.”

I talk to a lot of people about meditation.

I help some of my patients and clients meditate, and it's so different if you have someone teaching you how to do it versus just watching a video on YouTube.

It really hits and lands differently, if you can really understand the process and reasoning behind it. Sometimes patients or people who have insomnia, are really in a fight or flight. Helping them calm down, relax, be more receptive to the information about how you can meditate makes it a little bit easier than thinking, “Oh shoot, it's another bad night. My pill isn’t working. Let me just find something on YouTube. Oh, it's too noisy. I don't like the sound of that voice.”

If you're already in that negative state of mind, a meditation may not even work. Then it turns you off to it.

If you're really interested in looking for a way to calm your mind, mind body practices, if you have the resources, go find a meditation course.
Go find a meditation teacher.

Tanya:
Do you teach that as part of your sleep coaching, your sleep practice?

Dr. Val:
I teach people about mind body practices.

It's really individualized. Oftentimes what I find one of the biggest concerns is, is the negative sleep thoughts.

“I can't sleep. I'm a poor sleeper. I've been a bad sleeper my whole life. It runs in my family. There's nothing I can do about it.”

The first step is to have someone sit, be quiet, be mindful and recognize that the thought patterns that they have. Then know that those things that they believe, they don't actually have to believe because they may not actually be true. You We don't have to believe everything our brain tells us.

Sometimes when we do, then we start to feel really hopeless.

So helping people sort of acknowledge what they're going through, teach them a little bit about self-compassion, but also give them hope.

Part of what I like to say as a coach, I help instill confidence that you can sleep. And if you don't believe in yourself yet at this moment, that's okay because I believe in you.

I've seen you and other people that I've worked with, and they have gotten better.

Tanya:
I love all what you're saying, the self-compassion component and even letting go of the perfection of meditation and understanding that there's times when it's not for you and there's times when it is.

This is speaking to people in a holistic mind-body approach.

Dr. Val:
I've been trained as a western doctor for a long time, and there's only so many resources we have. I was talking to someone recently, in the medical setting, and it was like, well … I've tried these five pills, what should I do next?

Her whole mindset was: the only way I can fix my sleep is to take another pill. There must be a better, stronger pill out there available for me.

I was reflecting on this a little bit later and I started to think, maybe a good analogy would've been okay, well what's your favorite fruit?

You like strawberries, let's just say for instance.

What if only thing that you knew were strawberries, and then you went on a vacation and you found mangoes? And now there's other options besides just this, that can help and make me feel better.

I think part of it, it's people don't realize that there's other options.

Maybe people have heard about mindfulness, maybe people have heard of breath work and breathing. They sound so simple.

What I love about them is that they're really accessible, in that right context. Sometimes when you hear about it, and hear about it, over and over, and the seed is there and someone's watering.

Within the proper environment, when you're ready, when the sun is shining just right, then you know the seed can become a seedling and really loom into a beautiful flower.

It’s helping someone along their journey.

I don’t have a hundred percent success rate. I have people that I have been working with a couple weeks and I do great. Some people … it's been a year and we're still working together. We're all on different paths in this.

Tanya:
There's different things that people are able ,or willing to change in their life. I say able or willing, sometimes it's coffee, they can't let go of the coffee?

We have to accept that is something we have to work around.

Dr. Val:
Yeah. That's the thing about it too. It's finding what you're willing to do, balancing what feels good, feels good now in the moment versus what's best for me in the long run.

Going back to your health goals, you know, what would the ideal situation look like?

For some people it's just, you know, being able to sleep a little bit earlier, right? Or extending their total sleep by another hour. Or sometimes people realize, well, if I'm getting six hours, I'm gonna be okay with that.

I don't have to get the eight hours, like the Reader's Digest article told me. I can actually function great on six hours.

Little mind shifts to that.

Tanya:
That's actually I think a big mind shift, when you say that, because sometimes we have these like standards. I need to have 10 glasses of water a day, eight hours of sleep. If I drink nothing and I haven't hit the 10 glasses, do I give up?

Allowing it to be a little bit here, a little bit there.
What can you handle today? What fits? It's so important for all of us to keep that into perspective, I think.

Dr. Val:
Exactly. I think, you know, that all or non thinking can really lead us to setbacks, versus two steps forward, three steps back one day, maybe another day we'll do 10 steps forward.

As long as you're moving, it's okay.

As long as we're breathing too.

Tanya:
In every sense of the word. Breathing is a blessing. To be here, and breathing as diaphragmatic and getting more breath.

Dr. Val:
I was writing my gratitude journal today and number one was: I'm still alive. That's good. It's a gift just to be alive, just to be here.

Tanya:
It's true. It truly is. I love that you say that, because I went through my own period this summer. I put a podcast episode out about a midlife crisis, almost like an existential crisis. We get to these things, we ruminate at certain times in our life, and I honestly went back to that.
I have to sometimes realize what privilege I live in.

It is a gift to wake up and just have another day.

Dr. Val:
So, so true. I think sometimes when our thoughts are spiralling, as we're going through perimenopause. The social issues, the family dynamics, the body changes that just don't feel right and maybe your doctor isn't able to help you or, tell you to be on hormones. Someone told me I don't wanna be on birth control, and I'm like, well, it's not birth control, but okay.

Working through that together and taking that self-compassion, how can I speak kindly and gently to myself?

Imagine someone that you really love and care about going through something similar. How would you talk to them?

It's different than how we talk to ourselves sometimes.

Tanya:
It is. We don't realize that at times. You know, we have to get out of our minds.
You mentioned journaling.

If your next patient is a woman who's in perimenopause and the spiral starts at 10 o'clock at night, just as she lays her head down, is journaling your first suggestion?

What is your first suggestion for someone?

Dr. Val:
My first suggestion is find a practice that will calm you down.

One of the quickest ways we know from, you know, neuroscience to get out of fight or flight is by changing your breath. Can you slow down your breaths?

Because when we tend to be anxious, we tend to have shallow breathing.

I can see you do a deeper breath right now. A breathing exercise, and there's so many out there, honestly, my favorite, you know that Dr. Andrew Wild talked about all the time is the 4 7 8 breathing technique.

You inhale for four. Hold for seven. Slowly exhale for eight because as you work on slowing the exhalation, as you work on that pause. It flips the switch, right from the stress response to relaxation response.

One thing I want everyone that's listening this to know is that no one is a perfect sleeper a hundred percent of the time. Even myself. I catch myself, where my mind's racing, maybe it was the latte that I had late in the afternoon.

But I loved it because, you know, green tea is good for you, right?

At the end of the day, that little bit of caffeine can still affect me.

So sometimes, you know, I get to the point where I do two of the rounds and I'm starting to feel myself yawn.It definitely does work. Breathing exercises are definitely my, my go-to.

Tanya:
It’s so simple, and it's free for everybody.

Yes, definitely. That's important.

Tanya:
Well, this was a very enlightening conversation. I'm so glad you joined me. I hope you'll join me again.

Dr. Val:
Thanks for having me, Tanya. Happy to come back anytime.

Tanya:
Well, thank you, and anybody listening, who's popped on, feel free to leave any questions or comments for Dr. Val Cacho,

Until next time …

Dr. Valerie Cacho & Tanya Stricek

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