Sleep is the bedrock of health and lack of it can lead to poor food choices, weight gain, and increased risk of cardiovascular issues. For women in midlife, sleep issues during perimenopause and menopause are especially disruptive. In this conversation, Dr. Shelby Harris, a leading expert in the field of Behavioral Sleep Medicine, joins Stacy to talk about why women have trouble sleeping during this stage in life, what can be done to improve our sleep, and our health. Dr. Harris explains the principles of Cognitive Behavioral Therapy for Insomnia (CBT-I), as well as the benefits of exercise and the role of nutrition in promoting better sleep.
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Stacy: Welcome to Hello Menopause, I'm Stacy London. Dr. Shelby Harris is the author of The Women's Guide to Overcoming Insomnia. She is a clinical psychologist who specializes in behavioral sleep medicine and a specialist in cognitive behavioral therapy. She's here to tell us why we can't sleep during menopause and what we can do about Please welcome Dr.
Shelby Harris to Hello Menopause.
Now we're going to talk about the fact that 60 percent of American women have sleep issues and that, , we really start dealing with them throughout our lives starting as early as menstruation. So, I guess, what is going on that more than half of the, you know, you know, born as female population Has trouble with sleeping from the jp almost, you know, from like 11 or 12 years old.
Shelby: So there's a perfect firestorm. I always say like a trifecta of three areas that factor in. So the first one that most women will realize are the hormones. I mean, hormonal changes. So, we actually see in girls versus boys, there isn't a change in, there's no difference in sleep problems until women or girls start to hit puberty.
And then once they get their period, that's when actually we see a higher rate of insomnia, especially before you get your period for some of the, some of the women, young women. And then, there's hormone changes all throughout the lifespan. So, it could be every month I have, I have a lot of patients that will say every month right before I get my period, I have four days of just really bad sleep, or they just have it more routinely.
Then pregnancy, and a lot of women nowadays when they're going through certain things like IVF, other hormonal treatments, things to try and help them get pregnant, that can also cause, , some sleep disruption in some people. And then having the baby, perimenopause, menopause, it's just like throughout life, it's kind of on and off.
Stacy: Is it hormonal changes or is it that we're getting more of one, , hormone than another or loss of hormone? Like, is estrogen the, the, the kind of key factor here when we're talking
Shelby: about hormones? It's the balance between estrogen and progesterone a lot of times. So there's a lot, and especially like if you're thinking about your period, there's big drops in estrogen that will happen.
So it's the shifts, and that's what we see happen, for example, in perimenopause. It's the shifts in progesterone and estrogen that tend to be the bigger culprit. , but that, so that's one major area is hormonal changes. The other big thing is that we have more psychological stressors, so we tend to have a bit more anxiety and depression and that can definitely be for a lot of people and just a busy brain and worry can increase the risk of insomnia.
And then the third area that I think people don't often consider as much are more social stressors. So women are busier than ever before. So there, it's not like just taking care of your kids and then doing stuff at home and then going to bed. A lot of women are working or they're doing a bunch of things outside of the house.
Even if they don't have kids, they're just busier and our phones are on 24 seven. And a lot of people are having kids at a later time in life. So they're working, they have kids, they're further in their careers, they're older. older and a lot of women are dealing with having kids who are getting into their teenage years and having aging parents.
So they're kind of stretched in way too many directions. So you put the social, the psychological and the physical together and it's like that firestorm I was saying.
Stacy: Yeah. And I was going to say that it really does intersect in some ways, mostly it may be, Uh, you know, in perimenopause because we are not kids.
So it's not like we're menstruating and somebody is paying our bills, right? We are, you know, absolutely responsible financially. And I think they bring up this kind of intersection, like that firestorm is, you know, uh, also, you know, it's financial. I know that I read in Scientific American that the highest rate of depression for women is between 45 and 55, highest rate of divorce and highest rate of decreased earning potential.
And those things alone, just to hear those stats, I was, I was terrified, right? I was stressed out. So I wonder if, , if it does get worse, if that kind of, if you see, uh, almost insomnia getting worse as we age more because of social stressors, not just physical stressors.
Shelby: Yeah. Oh, a hundred percent. I'm definitely seeing that. But interestingly, I don't know if it's just my practice, if it was the pandemic, I am seeing more and more. People in their twenties, mid twenties coming to me in my practice, which I had not seen routinely before. I don't know if it's also because we're talking about sleep more and people are coming for treatment. , but I am seeing that and that's a big, like, there's a lot of stress on that, that generation as well.
Stacy: That makes so much sense. I mean, you know, obviously, there's like, I, you know, I know we're four years out from the actual beginning of the, of the pandemic. But to me, I feel like we have COVID hangover.
It's almost like everybody is sort of so determined to get back to normal that we are sort of ignoring some of the, you know. The, the, the ripple effect and the impact that this had on us psychologically. I mean, you know, a lot of people weren't sleeping at all right during the pandemic just because it was terrifying.
Shelby: Oh my gosh. There was one study, I totally forgot the exact stat, but it looked at people who were Googling at the beginning of the pandemic, people who Googled the word insomnia at about two in the morning and the rates went up like 60%. It was beyond.
Stacy: That is so funny because that's what I found out during COVID that the Googling the word menopause was 300% higher. So, you know, having all this time on our hands obviously made us a little bit more aware of like something not right in our bodies. And I'm curious, like when you think about, well, I mean, now we understand there's this trifecta, right? The physical, the psychological, the social. Are there any sleep disorders that you would define specifically to perimenopause or, or menopause or things that you see?
Shelby: Oh, for sure. So, the biggest one, I would say insomnia is the one that I see the most. I mean, that's what made me write my book a few years ago, because it's like, why is it all these women in the SAGE range? Tell us the name of your book. Oh, The Women's Guide to Overcoming Insomnia.
Get a good night's sleep without relying on Medication. There you go. See? Okay. Very important for people to know. Thank you. So that was because I was thinking about the population. This was before everyone was talking about menopause. It was kind of crazy that it just came out. It was timed well without my planning it.
, but the other thing that we see a lot that people don't talk about enough, and I think we've talked about it a little bit before, is sleep apnea. So people often think of sleep apnea as the older male who's overweight, who has that really loud snoring. Women, the rates are going up and they get about even once you hit perimenopause because the airway is loosening as we get older.
So that makes us tend to snore and it doesn't have to be that really loud, obnoxious snoring. It can be much quieter. It could be pauses in your breathing. Little things like that could be happening. So anything like that needs to be evaluated. A lot of times we see it in women and they're not doing anything about it because people are like, Oh, you're thin.
You're, you're in your, you know, 40s or 50s. You don't have sleep apnea. You don't snore really loud. So that gets missed all the time. So women might fix their insomnia, but still feel tired during the day because they might have sleep apnea. That's causing them not to breathe well.
Stacy: I just want to go a little bit deeper into that for people who don't really understand sleep apnea.
We've all heard of like sort of the overweight man who like snores too much, you know, but what does sleep apnea when you talk about the loosening, , in the throat, what that means and sort of what are the, uh, what are, what are some of the, uh, ramifications of untreated sleep apnea?
Shelby: Great question. So there's different types of sleep apnea. The most common one that we have is called obstructive sleep apnea. So that's what most people would have. So what that is, is you have this airway in your neck. When you fall asleep, it tends to loosen for everyone. It always loosens. And that's when you start to, your muscles relax as you go to sleep. And when you have apnea, it loosens so much that you either have a full or a partial closing of the actual airway.
So that's a kind of noise that happens. It's actually air that's having resistance getting through the airway. So when you have an apnea, if it's a full apnea, your airway actually closes fully. Your brain has a signal that says, I need oxygen. You wake up right away and you go right back to sleep because everything kind of gets more tense and taut when you wake up and then you're fine and you go right back to sleep.
And that can happen. Multiple times an hour. So even mild is five to 15 times an hour. Wow. I mean, I've seen patients 50 to a hundred times an hour that they're stopping breathing and they have no idea. So it's about how often you're stopping breathing, but then also what happens is how often your oxygen is dropping and how significant it drops.
So think about it. You're. literally not, you're starving your body and your brain of oxygen multiple times an hour. And most people have zero clue. Some women with insomnia will say, Oh, I wake up at night and I don't know why, and I can't get back to sleep. You have the insomnia part because you can't get back to sleep, but oftentimes the apnea can be waking you up.
So if you're, and the other thing to consider that people don't consider all the time is that if you have any apnea, that's not treated. And you're taking meds for, let's say, anxiety that relax your body, or you're taking like a sleeping pill that could relax your airway, alcohol does this too, you're worsening your airway, and worsening your apnea, and things are getting loosened, and you feel worse during the day, but you don't know why, because you're actually worsening your apnea.
Right. Even though you think you're sleeping. Exactly. So you said, why do you, what are some of the ramifications of it? So think about it. You're not getting oxygen. So that's the cardiovascular stuff that we often will see. We see, , metabolic issues. We see higher risk of diabetes. We see higher risk of, like I was saying, stroke, heart attack, , even sometimes it's a little debated, but mood issues, depression, higher risk of, I mean, it can impact so many things.
And if you have really bad sleep apnea, you're really sleepy during the day. So falls, accidents while driving, it really can impact so many areas. And headaches, blood pressure.
Stacy: I think that that's so interesting. I don't think I ever realized how major the ramifications were. It's like, okay, you know.
Stop snoring or, you know, whatever. Get a better night's sleep. It might make you sleepy, but to understand that the deprivation of oxygen actually has an effect on your body in so many ways.
Shelby: A lot of people are treating blood pressure and they're struggling with getting it treated, but you know what, if you have high blood pressure, if you're, you don't have to be overweight to have apnea at all.
It could just be how your, uh, your airway is built, but if you are overweight, you have high blood pressure and you're snoring, you 100 percent need to get your, uh, self evaluated because you likely have apnea.
Stacy: And also, I mean, what do you think about people who are perimenopausal or let's say postmenopausal who are noticing that kind of, that kind of exhaustion that you're talking about during the day, like they get a good night's rest, seven hours, eight hours, and they still feel cloudy.
Is that worse than going to see somebody like you and just say, Hey, I just want to check, like sleep apnea could be a potential. Yeah. Yeah. Potentially.
Shelby: And so like I, because I'm a PhD and I'd mostly treat insomnia, nightmares, like night owl syndrome, that sort of stuff. I can totally like to evaluate someone and if I think they need a sleep study, I'll refer them to someone who will do a sleep study.
If you think you're snoring, if there's any pauses, then just go to your doctor and you can ask them to potentially do a home sleep study or they'll send you to someone who can, but you can always reach out to me too. And I will be able to tell you whether I think you should do it. But if you're. There's a lot of reasons for fatigue, and I think, you know, as much as I love M.H. T. and that we're using it for many things, there can still be other reasons why you might be fatigued, and that's one thing to be considering.
Stacy: And is that something that you find, is that when a lot of people are talking about M. H. T., one of the things that they, Uh, recognizes that they're tired, brain fog, but there's a lot of overlap with sleep issues there too. So that's interesting to me because I feel like I, I, I, I am now on MHT and I was sleeping for seven years. I was sleeping four hours a night until the point where I was like, I'm literally going to jp off a bridge. And now I sleep seven to eight hours a night, mostly. And it's changed my life. I'm a nice person.
Shelby: It's so interesting. You know, MHT, it's like, it's a, it really, when it works, It works, but I do caution people because there are some people that it just either it's not indicated for some reason or they just don't respond fully or enough to it that if you're still tired, if you're sleepy during the day especially, you're dozing, you can't keep your eyes open, if you still feel like you're having broken sleep at night, maybe you're sleeping more but it's not the best quality, I would definitely still see a sleep doc just to make sure that there's nothing else going on for sure.
Stacy: And let's just talk about some sleep hygiene generally, because, you know, I'm sure that these are practices that we should start thinking about ahead of menopause, especially if we know that during perimenopause, we may start to see sleep issues of some kind. , so let's talk about hygiene a little bit.
Like what are the things, you know, when should you have that last glass of wine if you're going to have it? How, you know, I, I will spend nights doom scrolling for sure, which I don't think helps my sleep or my sanity. , but you know, what are some of the things to be thinking about in terms of, uh, you know, I don't know. Sheets, the temperature of the room, watching TV.
Shelby: Yeah, so the thing I always, the blanket statement I always give about sleep hygiene is it's just like my colleague used to always say this, that it's like dental hygiene. So it's a sort of thing where it helps to prevent sleep issues for a lot of people.
Just like brushing and flossing helps to prevent a cavity. But that being said, once you get a cavity, brushing and flossing is not going to stop. It's not going to cure the cavity. You still have to get treatment for it. So that's how you have to think about sleep hygiene. So it's good as a buffer initially, and if you did develop insomnia, it might not be as severe, but it's not going to fix a sleep problem once it happens.
So what are different types of sleep hygiene? So there's always the rule of like three hours that I always think about for certain things. So one is three hours before bed, you want to limit alcohol. Now, I'm also, I say this all the time, I'm a realist, like I'm not going to tell someone never go out and have that drink.
Right? Because you will. Once in a while. Because people get a little too, I think also people get sometimes too rigid about stuff. And I think sleep is a very important thing, but I think if you let it rule your life, then you're losing a little bit of perspective overall. Sleep is supposed to help inform how you feel.
So if you go out once in a while. a week, every two weeks and you have a glass of wine. Fine. Just accept you might not sleep as well. So limit it within three hours of bed most nights. , then other things, three hours of bed would be limiting vigorous exercise. So don't get too warm, too sweaty.
You can do light yoga, stretching, go for a light walk. That's fine. , you want to limit liquids, a lot of liquids within three hours of bed. A lot of women will wake up to pee at night and not realize it was all that stuff they drank two hours before bed. So limiting that, if you have to take medication, eight ounces max, that's it.
So really a little bit of liquid is really the key. , and then when you think about things like caffeine, the rule of thb is typically eight hours, but as you get older, it can take longer for caffeine to leave your body and there's research showing that some people metabolize caffeine faster than others, but we don't have like a test at home to do.
So the rule of thb is to just say like eight to 12 hours, limited and you kind of play around with it yourself and see, , and caffeine can make you have trouble with awakening in the middle of the night and have to go to the bathroom more. So it's not just trouble falling asleep. It can do middle of the night problems too, because it's a diuretic.
Right. Exactly. Exactly. So people will not put that together that the coffee they had six hours before might be impacting it. Then there's things like winding down before bed. , I think that's really important. I think if you can get some time to get a buffer between the day and the night to help your brain know that bedtime is coming.
Super important light exposure is interesting when you were talking about things like the doom scrolling and stuff. I mean, I've gotten sucked into that stuff many times myself. It's the sort of thing where it's interesting blue light. There's some research coming out that blue light is not the devil that everyone makes it out to be.
So it's really more about bright light and the screen and what you're looking at and the brighter the screen is a problem too. So if you're like, I mean, many people don't even have TVs in the room. They're just like on their iPad or their phone, like in their face. So give it some distance. Turn the screen brightness down.
Stacy: Yeah, turn the screen brightness down. I was going to say, I wear blue blockers because I'm like, I wear, I just want, right? I mean, we spent four years on screens in front of everything. But I also keep the dimness on my phone screen down all the time. Yeah, most people don't think about that. Yeah, I know. I mean, it took me forever to realize I could fix that.
I think my girlfriend had to show me. But more importantly, when you talk about this buffer between day and night, right, there are a lot of, , societal cues. I think that we've grown up with over the years. It's that five o'clock cocktail. Five o'clock somewhere, right? That's the buffer between work and evening, or it's watching your favorite television show, or maybe it's reading a book.
Are there, when you talk about that buffer that we're trying to create between sort of a work day or taking care of the kids or, you know, cleaning up or whatever you've done to kind of give yourself a buffer into sleep. Is there something that you recommend in particular that's more helpful than something else?
Like I've been stretching lately and I wonder, you know, that seems to help me a lot more than doom scrolling, psychologically and physically, right?
Shelby: I think a lot of it's trial and error. It's funny. People ask me all the time in interviews, like, what's your rindown routine? Like I have some magic routine and I really don't.
, there's, it's a lot, cause what I would do, someone else might hate. So it's really trial and error of what you do. Find relaxing, enjoyable and kind of quiets your brain down. So the key is to find it something that's somewhat enjoyable. If it's not enjoyable to you're going to start resenting it and resenting bedtime.
So I personally, , when the pandemic hit, I started because, like I said, I'm a runner. I was so tight. It was like, I need to stretch, which runners never do. So I started doing some nighttime stretching and I would do it. Actually, I did it with a screen just on the, just until I got the kind of routine down and I would do that next to my bed.
And I'm a big fan of skin care and have a routine there. And that to me is just very soothing. And then I get in bed and I listen to sometimes a meditation, but I don't fall asleep to them. , and I read a book or a magazine. If I have one, I'll read that for maybe 10, 15 minutes and then I go to sleep.
It’s not a lot. I don't really have an over, like an over kind of pulled out, drawn out routine, but there are other people who love to read for a while beforehand. Other people love to listen to, sometimes I'll listen to a podcast. It's really finding what works for you. The, uh, there are some people who really are like, I love to watch The Office or Friends or something like that.
And I'm like, okay, if you can do that for a little bit, but maybe give a little bit of a space between the screen and then going to bed, but whatever kind of quiets your brain.
Stacy: Yeah, what quiets your brain and also I think just the way, , trainers talk about exercise, you mentioned, you know, finding something enjoyable.
That idea of having something to look forward to before sleep, so that if you're panicky about sleep or you're worried that you won't fall asleep, that you're already setting yourself up to do something enjoyable. , I think that's really important. I was going to ask you a little bit about, , you, you talk about this in your book a little bit, like when there is a serious insomnia problem, let's just talk about, let's say in menopause, you know, how do you choose something like, , medication versus, uh, cognitive behavioral therapy, right?
Which is, uh, uh, a kind of, uh, therapy, but that's been proven to help with insomnia, correct? How do we choose between those two? Okay.
Shelby: You know, I think what we really try to do most often in the world of sleep medicine is it's kind of like a tiered approach. We really don't want to start someone on medication if we don't have to.
And what we know is that CBT, this cognitive behavioral therapy for insomnia. I mean, I see some people for two to three sessions. It doesn't have to be a long drawn out thing. It's generally four to eight sessions. So we tend to find that treatment without medication works really well in the long term for a lot of women.
So if we can get them doing that, it's not easy to do. I mean, I'll make people stay up a lot later, get up early and change some of the stuff that they're doing. But if we can do that without medication, then we're saving that road for later, if we need to go to the medication. Right. If we need to go nuclear.
Exactly, the reason we don't love medication at the outset is because as you get older, you tend to have a higher risk for falls, accidents, brain fog, memory issues. So we don't want to have someone start it and then feel like they can never sleep again unless they keep taking this medication. Or sometimes the medication will stop working and they have to move to other ones.
If that's not working, CBT for insomnia, then we move to other treatments. So we might think about if there's apnea going on, treat that a little more aggressively. Or, for example, like you were saying, , with M. H. T. earlier, sometimes M. H. T. is something that we'll use right off the bat if we need to.
And then we might think about some of the more traditional sleep aids, like Ambien, Lunesta, all those sorts of sleep aids. Sure.
Stacy: I'm curious if, you know, we were, we're not familiar with CBT for insomnia, you said that could take as little as four to eight sessions. What is it that we're, when I think of cognitive, I think of, okay, now I'm going to have to teach myself to think a different way in order to wind down. Is that, is that sort of the basis of, of CBT for insomnia?
Shelby: Okay, so there's, it's essentially what it is, is it's a bunch of different strategies, techniques that have been combined into one treatment package. I don't use all the treatment strategies with every patient. The things, the B and the CBT, the B is really, , changing your bedtimes and wake times.
What a lot of people who have insomnia do is they spend too much time in bed, so they might be in bed eight hours, but only sleeping six hours. So I'm actually going to limit the time that they're in bed, which is kind of goes against common sense and it's hard for people to do, but once you get them sleeping more efficiently throughout the night, consolidating it, we can have them start going to bed earlier.
The other thing is like, what are they doing in the middle of the night? Are they trying to force sleep to happen? So that's another thing that we have called stimulus control, maybe getting out of bed, doing something to pass the time is really helpful.
Stacy: You say this is also kind of contradictory to me in thinking is that you can't force sleep. So you would suggest that somebody get up and do some. Even if it's like meditative or passive or you know, I'm immediately thinking of needlepoint and knitting. Don't ask me why.
Shelby: My mother's a needlepoint instructor in Rhode Island, so I love it. She would be very excited to hear that.
So it's, yeah, it's one of those things where You can't force sleep. And that's the kind of, in my opinion, that's one of the biggest issues with insomnia, especially with women who can control a lot of areas of their lives. This seems like the most basic thing that we should be able to control. And then what do we do?
We end up over controlling it, that it becomes a problem. So, if you're in bed and you're chill, you're cool as a cucber, you're not thinking about anything, not worried, I don't need you to get out of bed. But nine times out of ten, people are lying there and they're saying, why am I not sleeping? What's the time on the clock?
I need to sleep because of X, Y, Z tomorrow. That's the recipe for disaster. Get out. You can't force sleep to happen. You just, aside from drugging yourself, you just can't. And I'd rather you get out past the time, and when sleeping happens, it happens. For example, so, needlepoint's a great one, knitting. I, it's kind of weird, but I collect cookbooks, and that's not weird.
But I will get up in the middle of night, and I will, if I have a night here and there, I'll get up and look at all my cookbook collection, especially like my heirloom ones or family ones and kind of earmark things that I might want to make over the next few weeks or that are interesting. Mildly enjoyable and passes the time, right?
So it's mildly enjoyable. I had one mentor many years ago who would say, get up and bake a cake if you want. So what if you don't sleep that night, you'll sleep better the next night. Like just pass the time. And if you get sleepy, get back in bed. That's the key. It's the forcing it.
Stacy: It's the forcing it. And sorry, I didn't want to interrupt the rest of the strategies you were talking about BT.
Shelby: So that plus the kind of restricting the time better, the two kinds of biggest ingredients that we have that work the most powerfully and then doing some basic sleep hygiene, which doesn't fix it.
But I always say, if you drink a two liter bottle of soda before bed, good luck having anything else work. So then the next thing was the cognitive stuff that you were talking about. So this is appropriate for some people, not everyone. So some people like that, forcing it. that we were talking about. It's that idea of if I don't sleep, X, Y, Z is going to happen tomorrow.
And there are a lot of people who dread the night as it gets closer. So it's learning to teach people or teaching people ways to modify that thinking because it's not positive thinking. If I had someone who got reprimanded at work every time they had a bad night. If they had all these issues that were legitimately true, I'm not going to say to them, just think it's fine.
Like that's not helpful. We need to problem solve this issue. But if a lot of times at one, two in the morning, that, like I said, that prefrontal part of our brain's not working, the judgment, we will go to the worst possible conclusions and not be able to kind of challenge it for ourselves. So if you're able to challenge it, I have people write cards next to their beds, , with challenges just to kind of prime it a little bit.
So if you can do some of that, it actually can be really useful for people. And then there are other people where we'll do things like meditation routinely. I'm a huge believer in doing meditation because just doing it during the day helps you to be able to recognize when your brain's kind of going a little bit haywire at night to let things go easier.
Stacy: The idea of meditation during the day and being able to kind of recognize the way your brain is going, uh, out of, you know, spiraling out of control, I think is really, really important. And I wonder if it, you know, I remember, I think this was from therapy some, some many years ago. I remember somebody saying to me it was more of a visual, right?
That if you've got this monster in your head that's making you crazy, that's criticizing you or putting you down or taking you to that worst place possible, right? The worst place that you can go in the middle of the night. You've got to put somebody else in the ring. You've got to put another boxer in the ring with a different voice.
If you're going to have the, like, you know, voice of doom, you have to have like a superhero who's fighting for you in there as well, and that way, at least you've got a chance, right? That you're not going to be overtaken by these like gloomy, doomy thoughts.
Shelby: Totally. And like one of my two best questions that I ask people that I find that I have to use for myself too, would be, what would you tell a friend who's in the same situation right now?
You'd probably tell them you're overreacting to this. You're thinking too much. It's not going to likely happen. And then what's the effect of believing this thinking right now that these bad things are going to happen? It just makes you stay up more. So if you can kind of have that challenge there or those questions, it can be really useful.
Stacy: There are normal nights of insomnia, right? There are no, there are going to be people. Like, at what point does somebody come to see you? When do we know that it's time to make an appointment with Dr. Shelby? What
Shelby: I always say there's individual variation from night to night. Like, I don't sleep perfect every single night, but if you start noticing consistently three or more nights a week where you're having trouble falling asleep, staying asleep, or you're waking earlier than you'd like and it's been going on for a few weeks, you might want to seek some help.
So even a month of that is considered short term insomnia. Most women it's been going on for way longer than three months and is now in the chronic realm. So three or more nights a week, or if you're just concerned. You know, sometimes I can, uh, I'll see people and they're concerned and I'm like, you're within normal limits. You're okay. It's once every two weeks. You're okay.
Stacy: We talked a little bit about this before once when I interviewed you, but I - this is just a question completely out of left field with no scientific basis whatsoever, because we know that insomnia is one of the, uh, potential issues during the menopause experience.
Are nightmares? Because you said that you treat nightmares and I'm wondering if nightmares become more severe in middle age or if, if they pop up when you've never had them before or if there's no connection whatsoever.
Shelby: I don't think that there's much of a connection, at least I haven't seen it, but what there is a connection for is there are a lot of people who take, not a lot, but people who take melatonin, , some people actually have more vivid dreams and more nightmares on them.
And I think a lot of people who are in menopause start relying on melatonin. And that's when I see the nightmares pop up more. One other thing, actually. , yeah. Yeah. Absolutely. I don't know if the rates of it necessarily go up a lot during that range, but we actually see a lot of nightmares as well in people who have sleep apnea.
So if you have a lot of sleep apnea, you might have some nightmares as well. I feel like sleep apnea, this is like the key to a lot. People can sleepwalk because of apnea, sleep talk. There's so many things. The teeth grinding can be worsened because of sleep apnea. It's like the thing that can cause so many problems yet no one treats it or even asks about it.
Stacy: So I know we said like, you know, we're talking about, , uh, you know, Ambien or, or Lunesta, kind of the nuclear option, obviously as it. You know, you don't want somebody dependent on it and potentially have issues, you know, when they're older. But when, how weird does something need to be for you to really warrant it?
Is it that you've tried everything else? Or is there a particular type of insomnia that makes you think like, we're only going to solve this with medicine? Or we need to start with medicine in order to get this person like, on a better, you know, footing if they're really exhausted from not sleeping. What are, what are some of the things that you look at?
Shelby: It's really case dependent, so I don't prescribe it myself, but I will often, I work with every provider who will, you know, like, so we'll work together a lot of times, but I think sometimes patients will come to me and just be like, I've tried this before, or usually they've failed, I wouldn't say failed, but CBT isn't working for them necessarily. So if it's not, if they're not responding to it, I can usually tell after a few sessions, if someone's not responding well, then we might need to go the medication route. There are other people that are so, like, you can still have anxiety and depression and do CBT, but if you are so anxious. Or, or have a lot of depression that it's gonna make it harder for you to do those treatments that I'm gonna recommend, like getting out of bed at the same time or going to bed later, that that's making you really anxious, then considering medications might be, , an option.
And there are some people that are just flat out like, I'm not gonna, I just can't do CPTI, it's not gonna happen. And then, I mean, then it's a discussion with the provider. Some providers like, too bad, I'm not gonna, I'm not gonna give you anything, and then other doctors will. So, it depends upon, you know, the, the individual cases.
Stacy: Have you seen where there are, like, I remember I took Ambien for a little while and then I stopped because I actually, you know, more research started to come out and I was like, Ooh, you know, this could have like a longer term effects that I want it to, but so you would, you, you, , absolutely recommend that people can use things like Ambien and Lunesta and not stay on them forever, right?
I mean, that is something that you can use also in the short term. That is 90 percent of my practice. 90 percent of your practice. And do you see the same type of nightmares or increase in nightmares that you see with melatonin? Because I never heard that about melatonin. That's fascinating. I do think that many women, particularly in menopause, are relying on melatonin.
And that may not be the right answer.
Shelby: Now, melatonin is what we like to call, it's like a phase shifter. So what it really does when it's working properly, and we use it, I use melatonin a good amount in my practice, but I use it for people who have shift work, jet lag, who can sleep a full night, but it's not on the schedule that they like, so, or they need.
So we use tiny doses and we give it at different times, not right before bed, and it actually can change the shift, it can shift their sleep wake timing. It's not really an insomnia treatment.
Stacy: Right. And that is so interesting to me. And now I'm forgetting, of course, the name of the company. And I think we talked about this before, but I think it's called, , uh, something shifter or like site shifter.
Oh, time shifter. Time shifter. Yes, we do. So, , I'm curious because how does jet lag and things like that, are we talking about sleep when we're tired or is that a circadian rhythm and how do those things interact? How do they intersect and how are they different? And I'll ask the questions after that.
Shelby: So jet lag is really a circadian, it's a disruption of your circadian rhythm. So when you're, , on one time zone and you've been for a little while, light and dark are extremely important cues for your body's sleep wake rhythm. And so we eat around the same time. We sometimes go to the bathroom at the same time.
And we have all these clocks in our body, in our cells that tell us. to secrete hormones at certain times, it's very regular. And when we're, we're not built to travel the globe in the span of a few hours, our bodies just don't catch up that fast. So jet lag is a very natural thing that happens. We try to hack it as much as we can to try and like, how can I adjust immediately?
I tell people like most people don't adjust immediately. My husband adjusts immediately, but. That's few and far between. And so, things like melatonin, certain medications, , getting light at certain times, dark at certain times, eating at certain times, caffeine, those are things that can help. And there are, I work with people on that, there are the apps like I was saying that can help.
There are definitely things, but don't expect perfection, because it's really a disruption of your body's natural rhythm. And then when you get on that time, you start getting more routine light exposure, eating at different times, you will start to adjust. And the rule of thb is always nber of days, or nber of time zones crossed is the average nber of days to fully adjust. So you go six time zones, it can take a full week to really fully be on that time zone. Yeah. It's crazy.
Stacy: That was the funny thing. Sometimes I think that the really fast trips are easier because you just don't get off the time that you were on, , and then there's kind of middle, you know, week or a little bit more.
Those are the ones that really get you. I know. Well, I joke around about the fact that going to the West Coast is three hours, you know, three hour time difference.
Shelby: It hits hard. It can. And as you get older, I've noticed, like, as I've been getting older, it just definitely hits harder. Rule of thb, too, that I always tell people, like, I was just running with a friend.
She was asking me about a trip that she was taking that was really fast. I said, if it's fewer than three days, three nights that you're gone, try to at least stay on your original time zone, , or halfway in between the two time zones. So that there's like a middle ground, so it's not so drastic one way or the other when you're coming back.
Stacy: Oh my god, these are great tips. We wanted to be very action oriented on the podcast, and I feel like you just gave us a ton of information. Are there, are there, this is my last question because it's just all coming out of my head, but Are there any foods that you associate with better sleep?
Like, you know, people drink valerian tea or chamomile tea. Is any of that stuff for real?
Shelby: No, not really. I mean, if it helps you and it relaxes your brain, I'm very matter of fact about that stuff. If it helps you and relaxes your brain, then go for it. There's not really any data that shows consistently that it is anything that helps insomnia, but there are things that can worsen sleep at night that we know and things that can help enhance just.
Just that routine and that kind of getting sleepy, but they're not going to solve problems. So there's things like, , things that have nuts, seeds, eggs, fish, chicken. Those are things that actually can be a bit, , better for you when it comes to actually producing your body. It will help convert eventually into melatonin, believe it or not, in your brain and serotonin.
So it can help to relax a bit. Bananas. People always ask me about tart cherry juice. I'm like, you know what? If If it helps you, great. But for a lot of people, it makes them have to pee at night because it's a liquid. Exactly. And it's for cherry juice. Look. Also, what about tryptophan? So that's, yes. So the tryptophan ends up being a precursor of the serotonin and the melatonin.
So it's all stuff that will, that's why the meat, the chicken, but what helps it to work the way it does is a carb as well. So it's the combination of ideally a complex carb or whole grain carb with that sort of, , some sort of a protein. So it could be like a banana or an apple with a little bit of peanut butter.
When I can, I do Greek yogurt at night, , sugar free Greek yogurt, and I'll put some berries in it and maybe a little bit of peanut butter. That can be useful. Oats can be really helpful too. So I'll do oats with a little bit of protein powder in it sometimes. So that mix of carb and protein.
can be really useful. And a lot of people who do intermittent, intermittent fasting will say, well, if you eat at night, it can be a problem. But there are a lot of people that do need that little snack about an hour before bed. And for me, that's a game changer because I do wake up sometimes and will have a headache if I don't eat breakfast or eat dinner or like a snack before bed.
So that can actually really be useful for some people.
Stacy: Oh, wow, that's incredible information because I think that the other thing that everybody thinks three hours is the cutoff, don't do any. So no heavy meals within three hours. Yeah. But those kinds of complex carbohydrate protein combos that are in a small amount, right, is something that can help.
Is that something that we can just eat as snacks throughout the day to help with our ability to sleep?
Shelby: I don't think it would do much for sleep at night unless you're doing it closer to bedtime. , but, you know, there's no harm in eating more complex carbs and some cleaner, some better proteins. I mean, go ahead.
But yeah, in the evening it does help a bit. And for some people it can help regulate their blood sugar a little bit. So they might actually feel better.
Stacy: Oh, that's great. Oh, Dr. Shelby, thank you so much. This is so much great information. I love that we're talking about ease of exercise. Stretching is good.
Yoga is good. Vigorous exercise is not the kinds of foods, mixed protein and complex carbohydrates. If you're going to have a snack before bed, the idea of winding down and finding something enjoyable as your buffer between daytime and nighttime. All of this is so helpful, I mean, for perimenopause, menopause, and beyond.
I want to thank you so much for your time. This was wonderful.
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