Menopause and the 3AM Wake Up: What Light, Meal Timing and Hormones Do with Dr. Kristen Holmes

23:19And then we've got non-photic sidekeepers, time givers, right? That also inform our clocks. Okay. Feeding, time-restricted eating. I want to get into that too, because this is an underutilized lever for women in midlife. And I really want to hammer this. So time-restricted eating and insulin doesn't have, it's a hormone, of course. It doesn't have a circadian rhythm per se, but it's circadian patterned in the sense that it responds to the timing of your food. We are more insulin sensitive in the morning. We get more insulin resistant out of the day goes on.

23:52Dr. Mary Claire Haver:Okay. Right. So eating later in the day. Yeah. This is the first I hear this. Let's go back. Okay. We are more insulin sensitive in the morning. So if I did a home IR first thing in the morning when we're fasting and it looks great, but I repeated that. Fasting in the evening, it would change. Yes. Yes. I know. There's some really good studies. So how should we be eating? Well, we want to bias our calories. We want to distribute our macronutrients across the day. Yeah. Right. And I think we want to fuel, and this is something I talk about in my book in terms of just a mindset around food, we want to fuel for activity, right?

24:30We want to make sure that we have enough calories to engage in the activities that we're taking on throughout the day. And so when we know from the data that, you know, in the morning and you want to eat like a princess and a queen, I'm going to use the women versions for breakfast and lunch, and then a popper at night. Okay. Please explain what that means. Okay. So we want to eat a most nutrient dense, you know, as most, the most calories, you know, that, that we can earlier in the day, because we're more primed to metabolize that.

25:00Dr. Mary Claire Haver:So fasting in the morning is not, is not. No, No, not for men or women. Yeah, men or women, no one, right? Because we're more insulin sensitive in the morning. So prior to 3 p.m., right, we want to be eating a bulk of our calories. Okay. Okay? And there's a great study that literally did this exact experiment. They looked at people who were preferentially eating a bulk of their calories, Mediterranean diet, both groups. One was eating before 3 p.m., the other group, and this is quite a big study. We'll link to it in the notes. And then the other group was eating after 3 p.m. And the earlier eaters had better metabolic outcomes, better sleep, better sleep.

25:40Every parameter they were measuring was better. And it just is the reality of the situation. It gets more egregious as we age, right? We become less sensitive, insulin sensitive at night, right? As we age.

25:51Dr. Mary Claire Haver:And menopause takes another chunk out of it. It exactly does. And that's why this notion of aligning our circadian rhythms, aligning our behavior with our rhythms is so, I think it was really powerful.

26:05Dr. Mary Claire Haver:Taking the first step towards getting help for your mental health isn't always easy. Whether you're dealing with anxiety, depression, ADHD, or you're simply trying to understand what you're experiencing, knowing where to start can feel like the hardest part. While therapy is an important piece of mental health care, sometimes you need a psychiatric evaluation and a personalized treatment plan from a medical provider. That's where talkiatry comes in. Talkiatry is a 100 % online psychiatry practice that makes it easier to connect with licensed psychiatrists for comprehensive evaluations, diagnoses, and ongoing medication management.

26:46Dr. Mary Claire Haver:With a network of more than 800 clinicians, talkiatry matches patients with a psychiatrist they will continue to see over time. This allows them to build a relationship with a provider who knows their history instead instead of starting over at every appointment. The best part? Psychiatry accepts major insurers, so you can use your existing coverage instead of worrying about high out-of-network costs or monthly subscription fees. Whenever you're ready, psychiatry makes it easier to take that next step, with first appointments often available within days. Head to talkiatry.com slash unpaused to complete the short assessment and get matched with an in-network psychiatrist in just a few minutes.

27:30Dr. Mary Claire Haver:That's talkiatry.com slash unpaused to get matched in minutes. Talkiatry.com slash unpaused. Let's talk about something every woman knows. Your body changes. And sometimes the things that used to work perfectly suddenly don't. The bra you've worn for years starts digging in. The underwire feels like it's fighting against you. The cute, comfortable options don't always give you the support you actually want. And honestly, finding something that checks every box, comfort, lift, support, and confidence can feel impossible. That's where Honey Love comes in. They're a female-founded brand focused on creating supportive, thoughtfully designed essentials for real women and real bodies.

28:17Dr. Mary Claire Haver:Their Cloud Embrace bra is designed to feel incredibly soft and lightweight while still providing the support and shape you're looking for. And their new crossover Contour bra takes comfort and structure even further, using innovative bonding technology and molded foam cups to create a smooth, lifted silhouette without the discomfort of traditional underwires. Because the goal isn't to change your body. It's to find pieces that work with your body, support you through every season and help you feel confident in the skin you're in. Treat yourself to the most advanced bras and shapewear on the market.

28:55Dr. Mary Claire Haver:Use our exclusive link to save 20 % off Honey Love at honeylove.com slash unpaused. That's honeylove.com slash unpaused. After you check out, they'll ask you where you heard about them. Please support our show and tell them we sent you. Experience the new standard and comfort and support with Honey Love.

29:21Dr. Mary Claire Haver:i for 10 years fasted in the morning based on the early intermittent fasting data i know i know i would do that completely you know i know better now i've read yeah but at the time that was kind of what the prevailing data said but now i break my fast almost you know i know i'm i get to the gym by eight or nine yeah so i know i want to get at least 10 grams of protein in before i start lifting. And so I make my shake, which is a lot of calories, a lot of protein, a lot of fiber, a lot of stuff. And I start drinking it and I try to get a good 20 % of it down and I take it to the gym and I sip at it for the next three hours.

29:59Dr. Mary Claire Haver:That's great. And I think we know that it's okay to train fasted. That's okay, right? As long as you're getting food at some point relatively soon after your training, right? Like that seems clear in the data that because we have glycogen stored in our muscles, it's okay to, if you prefer to train on an empty stomach, you can do that. You just want to make sure that you're getting a nice hearty meal in the morning when we are most primed to utilize those nutrients and you likely need those nutrients. And I think for women who are really hungry before bed, you know, generally, that generally means you haven't probably eaten enough calories during the daylight hours.

30:36But there's something really powerful about this 12 on 12 off, 11 on 13 off.

30:42Dr. Mary Claire Haver:So we don't need to do 16 hours? No, I don't think so. I think I naturally do 12 without trying. Yeah. I think we are designed to have a consolidated fasting period. And that's really what time-restricted eating is, is a consolidated fasting period where you're biasing a majority of your calories during the daylight hours. Once the sun goes down, you know, it's your body is ready to just wind down. Okay. So what did the princess, queen, and popper mean? Yeah. So they'd say eat like a prince and a king in the morning and lunch. So I just kind of, you know, use the female versions. So princess for breakfast, a queen.

31:19Princess for breakfast, queen. So have a big, yeah, nice hearty meal with all your, you know, micro-nosed, macronosed. Yeah. Queen at lunch. And then, yeah. And then a popper, you know, just a lighter meal at night. Again, making sure that you're getting in total, like the amount of calories you need relative to your resting metabolic rate to make sure that, you know, you're obviously not in a deficit unless of course you're trying to lose weight. But yeah, that's one of the other non-photic time givers that's really powerful and an important lever. And then just your activity patterns. Okay. You know, you really, again - I'm like terrified.

31:51Dr. Mary Claire Haver:Okay. When should I be working out? I know, no, I know. And you know, it's not, I don't want to overthink it too much, but there's really good data on - And let's preface this with all exercise is good. All exercise is good. There's no question about it. And nothing's better than - Nothing's worse than sedentary. Yeah. But if you have all the time in the day to exercise for your security and rhythm, what would be the best times? I think after the sun goes down, and there's really, and actually our team at Woo published a beautiful paper, and I think Nature Comms, that basically showed the closer you exercise to bed in the higher intensity, the more it compromise your sleep architecture.

32:25I can see that. Which seems obvious, right? But I think it's just a good reminder, you know, that's an inactive phase of our circadian rhythm. So if we're applying a lot of intensity and effort, it just makes us wired, right? And we are basically flooding our system with all sorts of, yeah, yeah, adrenaline and cortisol. And so it just makes it harder to wind down and fall asleep and potentially stay asleep. So and that's what we see in the data. Zone two appears to not have an impact. So the lower thresholds, you know. So your walk after dinner is fine. Oh, that encouraged. That is, I think, a beautiful strategy, especially if you've had a bigger meal or a carb heavy meal potentially.

33:05That's a great way to just kind of get your blood sugar back under control. And there's lots of good data around that as well. But yeah, activity, we want to, again, try to be active during the day. And the other thing that we see in the data is this activity rest pattern. And again, following this logic of amplitude, we want a lot of activity during the day, during the daylight hours. That is when we're primed to take on load, mental, physical, emotional, right? As the day goes on, we get less primed. And so once we move from the active phase of our circadian rhythm, which is essentially when the sun is up to the inactive phase when the sun is down, our body expects to be winding down.

33:48So when we go against that, we again, we confuse those cells in our body. And I think it's important to say that the confusion, the cellular confusion is the basis of aging and disease, to be clear, right? So we want to create as much synchronicity, as much beautiful communication internally as possible. And a big piece of that puzzle is maintaining this synchrony with the natural light dark cycle. So time for sure to eating and then sleep-wake timing. So sleep-wake consistency or sleep-wake regularity. Another well-known in trainer, right? And so when we have really high, lots of variability in our sleep-wake consistency.

34:35Dr. Mary Claire Haver:And what she means is like going to bed at a certain time, waking up at a certain time and being as consistent as possible. Exactly. Yeah. Yeah. So we want to try to maintain sleep consistency as much as we can. And I think one of the things that's important about sleep consistency and Andrea, your amazing sleep scientist, you know, touched on this in her episode. So, but I want to double down on it. Sure. Because I think we talk about the lead up to bed, right? And we talk about hygiene, both very important. And Andrea covered that beautifully, right? So we want to make sure that we're winding down.

35:09We want to make sure that we leave a nice two to three hour buffer between our last calorie when we intend to sleep. Cold, dark, quiet, very important. But sleep consistency, and I see this in the data, okay? The path to sleep consistency actually starts the moment you wake up. Okay. If I were to tell women to stabilize one thing, it would be sleep-wake timing, sleep-wake consistency. Really? Yes. Okay. And this is, again, being inside the data that I am, it bubbles up in every single piece of research as being predictive. And this was my PhD thesis was circadian alignment. Sleep-wake consistency is a proxy for circadian alignment, predicted both physiological and psychological resilience in humans.

35:53Okay.

35:54Dr. Mary Claire Haver:this is the what does but it's not easy exactly and i'm so when we look at if i'm going to maximize my circadian rhythm and start waking up at three in the morning you know without hot flight like take menopause i'm 25 yes and so for my best chance to have the absolute recovery during sleep nutrition what does that look like yep time restricted eating we want to eat a bulk of our calories during the daylight hours and give ourselves a nice big buffer at least a three-hour window. I think from last meal, two to three hour window, two head on the pillow. Yep. If women find themselves really hungry or maybe didn't get the calories that they needed during the day, and gosh, they're hungry before sleep, a yogurt, 130 calorie yogurt is going to be just fine.

36:37Right. So I wouldn't stress about that. It's what we don't want to be eating is like three donuts and, you know, a cup of coffee or something, right? Like that's not good. So time-restricted eating is one way to help. And I saw this in a study that I published called Core 4, published last May, I basically ran this challenge where I looked at these kind of four core circadian behaviors. And I just wanted to see if people engaged in these behaviors, what would happen to these metrics? And these circadian behaviors actually stabilize sleep-wake consistency. And one of those behaviors that stabilize sleep-wake consistency was time-restricted eating.

37:14That also actually had a direct effect on cardiorespiratory fitness. So cardiorespiratory fitness improved, but it was mediated through sleep-wake consistency. So basically engaging in these circadian behaviors, people stabilize their sleep-wake consistency, which then improved markers of cardio-wake fitness, which is so cool. But yeah, time-resurated eating. All right.

37:37Dr. Mary Claire Haver:Now, movement. When would she be doing her exercise? I'm going to do what? Okay. Let me talk about light first because this is really, so then we'll go to movement. In this challenge that we were able to publish, light behavior was the second so i encouraged that big bolus of morning light so i gave them a little protocol very simple um and they just reported whether they did what was the protocol quickly just basically 20 minutes of morning light okay go outside go outside window okay no the window actually cuts down a lot of that photon energy um so you want to get outside all right it's raining it's cloudy go outside and even uncloudy skies it's not going to have the same luxe, that same intensity of light, but it still is going to tell your system that it's daytime and it's going to tell it what it needs to do.

38:22Okay. So there's nothing more powerful than the sky in terms of entraining our circadian system. Do we have substitutes for that?

38:28Dr. Mary Claire Haver:Can I go buy what you put in the lizard's cage or whatever, the UV? Yeah, I have a circadian lamp. So Amazon, I think I got it for 30 bucks or whatever. Amazon sells these. And definitely in the winter, I use kind of a sad lamp, seasonal affect disorder lamp. So I have that on my desk. And so, yeah, I'm trying to, again, preserve the amplitude, create as much contrast between my day and my night. So, yeah, I really try to bathe myself in light throughout the day. But specifically in the morning prior to 10 a.m., that light is particularly impactful on our circadian system. After that, there's less of a circadian impact.

39:06Red light therapy does not, that light does not change. It's neutral, right? It's not bad, but it's not going to shift your circadian rhythm. Got it. And that's why it can be useful at night and actually kind of make you a little lethargic, which is good for sleep. So I do red light at night, but that won't help you in the morning, I guess is what I'm saying. Okay. So, but some of these other lights that have these really super heavy blue rich light can help wake up the system and be a good, you know, fail safe if you can't get outside in the way that you want to.

39:35Dr. Mary Claire Haver:Okay. But that morning pulse of light is just, I can't underscore it enough, is so, so critical to basically, because basically that tells your system 12, 14 hours later, it's time to produce melatonin. Yeah. Right. So all of this is just orchestrated super, super tightly. And these cues are basically telling the system when to do what it needs to do. So we just want to be mindful, you know, of ensuring that we're building in these behaviors intentionally so we can create this really high amplitude during the day. Okay. Third. Okay. And then movement. And I think just the other thing in our study, we tested zone two, which doesn't sound like a circadian behavior, but the thesis was based on all the other data that I've seen, zone two is highly recovery promoting.

40:22Dr. Mary Claire Haver:What is zone two for our listeners who don't know? Yeah. So zone two is basically the best way to do it. The simplest way, if you don't have any technology or whatever, is just literally to walk briskly, or for some people, it's jogging briskly on a treadmill or you can be on a bike, whatever, where you can comfortably talk. So if you're with a girlfriend, you're just kind of talking. It's not like perfectly comfortable, but you could talk easily. It's a little bit of a struggle. Yeah, a little bit of a struggle. Zone two is a heart rate, basically. Yeah, it's basically a heart rate zone. So, you know, 60 % of your max heart rate is usually kind of in that zone two threshold.

40:56And what we control for all these other recovery detractors and sleep detractors, okay, like alcohol and irregular sleep-wake consistency, all of that, we see that zone two actually helps you with markers of recovery. So you will have a better chance of maximizing your recovery and potential for sleep when you engage in zone two. Okay. How much? How long? Yeah. So really 30 minutes to an hour in this kind of zone two seems to be really protective for recovery or really help facilitate recovery. And I think that's where a lot of the conversations out there about zone two, I get a little frustrated because I'm, gosh, I see the data and I'm like, wow, for men and women across the entire lifespan, zone two is so recovery supportive and sleep enhancing.

41:48So, and that's what we saw in terms of movement, that zone two helped stabilize sleep-away consistency, which then again, improved cardiorespiratory fitness. So I love zone two. Obviously we need to be training at intensity a couple of times a week. We need to be strength training. I'm not saying we're not, we shouldn't be doing those things, but zone two is really recovery enhancing. And in my book, I kind of put it more in the recovery bucket than I do the training bucket because of just what I've observed in the data.

42:14Dr. Mary Claire Haver:I like thinking of it that way. This is going to enhance recovery and sleep. This is not, you know, I'm not training my heart to like grow old. I'm not training my muscles and bones to be strong. I am literally recovering with zone two. Yeah. And you just get your podcast on, whatever it is, go with your girlfriends, your partner, whatever it is. I think it's just a different way of thinking about moving your body. And then side benefit, it helps with your sleep-wake consistency, right? Kind of this idea that how do we back into a stable sleep-wake time? Zone two promotes it. And then breath work was the fourth one.

42:50Yeah.

42:50Dr. Mary Claire Haver:I've learned how to do that finally, but walk our listeners through. I know. I did it last night when I woke up. Oh my God, I love it. It puts me right back down. And I will say, you mentioned in your podcast with Andrea that you suffered trauma as a child. You know, same. I know, I know. And I think for trauma survivors, regaining control of the autonomic nervous system, I devote a whole chapter on this in my book because it can keep you from living a life of joy and energy and it can keep you from sleeping and what a beautiful path to regaining control of your autonomic nervous system is through the breath and i think a path to sleep is learning how to breathe which i also talk about in my book you know really understanding how to breathe properly how to breathe through the nose and putting resources into that i think is really important so so walk what how do you practice this so i do a couple different types of breathing techniques i I do TUMO, which is super oxygenated breathing.

43:50Never heard of it. Okay. Yeah. And then I do physiological sigh. So I kind of toggle between these two. Physiological sigh I engage in during the day just a few times.

44:00Dr. Mary Claire Haver:I do it without thinking. Well, that's good. Yeah. I mean, it's a natural reflex. Why are you huffing? I'm like, it just happens. I'm like, yeah, no. I'm like, I just call it this autonomic cleansing breath. I cannot help it. Oh, I love that. And I just, I cleanse breath all day. I used to sit in a small office with Jesse, if you're listening, I love you, a nurse I worked with for years in clinic, and we became concomitant deep breathers. And she's like, are you okay? I'm like, I'm fine. I'm just taking my cleansing breath. And then she would start doing it. I love that. Yeah. It's so good. And I didn't know I was doing it.

44:34And we definitely know there's a really great study published in 2023 at a Stanford that looked at the physiological sigh against some other breathing modalities and meditation as well. sorry mindfulness meditation so there are four different modalities and the physiological sigh emerged as the most efficacious in reducing anxiety not just in the moment but five hours after the session wow and it was just a five minute and this is the protocol that we put in the study is just a five minute slow paced breathing which is a little different than the physiological side but just this idea of a longer more extended exhale was really as simple as we said.

45:11So just breathe through your nose and you can breathe out through your nose or your mouth and just prioritize a longer exhale than inhale. That was kind of it. It was very simple and just try to do it for five minutes a day. And the people who engaged in this modality, again, saw improved sleep-wake consistency. So it's one of those things where, you know, a big bulk of my background is in psychology, not on the clinical side, but just a lot of the theory and applied side of sports psychology and psychology. And, you know, there's no question that this negative stress accumulation that can happen over the course of the day is going to rear its head when we try to fall asleep at night.

45:45We all know this, but yet we run ragged throughout the day and we don't take these many moments of rest. And you're taking them naturally. You've built in that muscle almost, right? Or almost just by, like, I find like I have to, or I'm just going to explode, right? Like I find like I have to breathe, right? But I think for a lot of folks, It's just before attaching it to something else that you do, like maybe lunch or breakfast. I always try to breathe before and after, just even a few times. I'll just do some soul place breathing. And it's definitely a part of when I lay in bed every night, I take one, two really big inhales, long exhale, and then I shut my mouth, I breathe through my nose, and I picture myself in a field holding the hand of someone I love, whether it's one of my kids, my partner, and I just feel the sunshine.

46:39I'm in a field. I'm joyful. I'm at peace. I breathe through my nose. And then before I know it, I'm asleep. You're out. And that has just been my routine for just coming to center, telling my body I'm safe. It's okay to sleep. And I think sometimes we feel like we don't deserve it almost, you know? And creating these little routines, I don't know, for me, like makes me, I'm like, I deserve it. You know, like I deserve this peace. You know, I deserve this beautiful consolidated rest.

47:12Dr. Mary Claire Haver:A little off topic, but it just bubbled up in my head. So I can't push it back down. What about the position we sleep in? I am a stomach sleeper. Oh yeah. Inside sleeper. Okay. It's very hard for me to sleep on my back. I think because I feel vulnerable because I was I had so much sexual trauma and I can't sleep without underwear on you know because I don't feel safe and I it took me years to figure that out like what's you know like after intimacy I will go put my underwear back on because it's hard for me to sleep and I'm like why would this be I'm totally safe in my house you know whatever my husband is next to me I know and I that's the only thing that makes sense to me like is the position important Is it mean something?

47:54It's communicating to your nervous system. Trauma is an injury to the nervous system. It embeds every fiber and cell in your body. Wow. So, okay. Yeah. So we have a paper that's in review right now that looked at individuals who say they have sleep anxiety. We looked at all the different modalities that they tried. And this is a huge sample size. So they're doing all sorts of different types of things like melatonin and a weighted blanket. Weighted blanket for people with sleep anxiety. And again, trauma, sleep anxiety, highly, highly linked, right? Associated. Weighted blanket was the number one modality.

48:32I don't know if you've ever tried that.

48:33Dr. Mary Claire Haver:My daughter has one and she swears by it. Wow, yeah. I mean, people who have suffered trauma really love the weighted blanket. I don't know if you've ever tried it. I haven't tried it yet. I mean, I always sleep with a blanket. Yeah. Like a sheet is not enough. The weighted might allow you, if you want to try to sleep on your back, that might help you feel more cocooned and safer.

48:59Dr. Mary Claire Haver:Let's talk about makeup for a second. Have you noticed that what worked for your skin five or ten years ago just doesn't anymore? Foundation settles into places you didn't even know existed. Blush seems to disappear by lunchtime. and somehow your makeup leaves you looking more tired instead of more refreshed. Here's the thing. Your skin has changed, so your makeup should change too. That's where OG comes in. OG is a certified organic beauty brand that combines luxury makeup with skin care inspired ingredients. Their crystal contour collection is made with nearly 90 % skin-loving ingredients like green coffee oil, elderberry extract, and cold-pressed jojoba.

49:43Dr. Mary Claire Haver:It's also NSF-certified organic, meaning it's formulated without synthetic fragrances or unnecessary additives. You don't need a drawer full of products or a complicated routine. Just three easy-to-use sticks that work together to add warmth, color, and glow, leaving you with makeup that feels light, looks natural, and moves with your skin throughout the day. If you're ready to raise your beauty standards, OG's got you covered. Go to og.com slash unpaused and use code unpaused for 20 % off. That's ogee.com slash unpaused and enter code unpaused to get 20 % off. Did you know that your oral health is directly connected to your overall health, especially as you navigate the different stages of womanhood?

50:30Whether you're going through puberty, planning a family, or navigating menopause, your body goes through constant changes, and your oral health changes right along with it. We hear a lot about tracking our hormones for our general health, but did you know those same hormones can affect your gums, teeth, and saliva? It's true. Oral health is whole body health, which is why preventative dental care is such a vital part of your wellness routine. Don't wait for symptoms to appear. Many oral health issues begin quietly, so regular visits help you detect changes early. Your dentist is a crucial partner in your health journey, often the one you didn't know you needed.

51:08To learn more about the connection between oral health and overall wellness, visit smilegeneration.com slash unpaused. That's smilegeneration.com slash unpaused to learn more about the mouth-body connection and find a trusted provider near you.

51:24Dr. Mary Claire Haver:This podcast is sponsored by MidiHealth. Have you noticed the conversation around menopause is suddenly everywhere? It's trending on social media, celebrities are opening up about their symptoms, and conversations that used to happen in whispers are finally out in the open. And honestly, it's about time. For decades, women were dismissed, ignored, or told their symptoms were just part of aging. And while I'm glad the conversation is happening, here's the truth. Menopause care isn't a trend. It's long overdue medical care that women have always deserved. If you've been listening to me, you know this isn't new territory for me.

52:05Dr. Mary Claire Haver:This is my life's work, helping women navigate perimenopause and menopause with real science. That's why I want to tell you about MidiHealth. MIDI is a virtual menopause clinic staffed by clinicians who listen, who take your symptoms seriously, and never utter the words, it's all in your head. Like me, MIDI focuses on your health span, not just your lifespan. That means taking a comprehensive look at your metabolic health, bone density, cardiovascular risk, and cognitive function, because all of it matters. MIDI delivers the kind of proactive, evidence-based care I've always believed women deserve.

52:43Dr. Mary Claire Haver:And the best part? Women in all 50 states can access personalized care, and it's almost always covered by insurance. So yes, I'm glad menopause is finally getting attention. But don't settle for noise. Get care from clinicians who are in this with you for the long haul. Book your virtual visit today at joinmidi.com. That's joinmidi.com.

53:14Dr. Mary Claire Haver:You know, as a former shift worker, so I was OBGYN. I was delivering babies. I loved that part of my job. Yeah. Like, talk about one of the most beautiful moments to be present with people. You know, this incredible. And then you get this present. And then you get to hand the present to the parents, you know, and their loved ones. Oh, my God. But Jesus, God, can they just come between 8 and 5? I know. You know. I know. It's not going to happen. I was rapidly losing my resilience in my 40s. Now I know it was perimenopause. I did fine. I could compensate. Like I was, you know, doing it no problem.

53:55Dr. Mary Claire Haver:I signed up for this. This was my job. You know, I did this on purpose. And I'm not a napper. So I have napped, but I cannot nap on command. And my husband can sleep anywhere. I know. Every movie, every plane. I was realizing I was playing games with sleep. I was like negotiating my sleep with myself over all of this call and being up late at night and just not being able. So my 50th birthday present to myself was to give up that part of my medical practice. Because I knew I was shaving years off of my life. I didn't know the data. I didn't know the science. I didn't know the research. But I knew I cannot continue like this because I am not a human that is going to be able to stay married or be the mom that I need to be and negotiate this life that I built if I keep doing.

54:40Dr. Mary Claire Haver:When I read the data around shift workers, I was shocked. Circadian misalignment. So let's talk about that. Yeah. So when you are operating outside the natural light dark cycle, one of the consequences of shift work is you end up with really misaligned circadian rhythms. And this is kind of everything that we're talking about, right? We're trying to get back to a place where we're engaging in behaviors that align our circadian rhythms, right? Well, shift workers don't have that luxury, right? It's almost like I feel like we owe it to the shift workers to do everything that we can to be as robust for society so we can help them through it.

55:16Circadian misalignment. When we look at the shift work data, I've done a lot of research with frontline healthcare physicians, published a paper in Annals of Surgery in 2023 with Drs. Mitch Cohen and Jamie Coleman, both acute care surgeons. 27 different centers across the country, 270 acute care surgeons. We observed them over the course of a year. Lots of really good demographic information. We did burnout questions. We knew when they lost patients. When they didn't lose patients, we knew exactly what their shift work looked like. The mean age in the study was 43. Every single one of these surgeons had at least 10 years of on-call where they were on-call at least two times per month.

55:58Okay. On average, some more. Their resting physiology looks like that of a 60-year-old. 17 years older. And we know that shift workers have a reduced lifespan of 10 years. And it's because of this circadian misalignment operating outside the natural light dark cycle. It just comes at a cost, right? A lot of, you know, one of the things that I'm studying right now is, you know, are the things that we can do to mitigate the cost of shift work, right? Definitely exercise. We have to have shift workers. We have to, right? So trying to eat a bulk of the calories while you wake up, so when it's actually so light.

56:36So if you wake up at 3 p.m. for your shift or 4 p.m., yeah, 4 p.m., 5 p.m. for your 7 p.m. shift, try to get a really big, your densest meal in at that point, right?

56:46Dr. Mary Claire Haver:My daughter's going into emergency medicine. Yes. So I'm like, Catherine, take notes. I know, I know. Really thinking intentionally about when you're eating a bulk of your calories. And then while you're on shift prioritizing, you know, just you got to eat as healthy as humanly possible. That's, I think, a non-negotiable for a health care worker. It's a cross that they bear, unfortunately. But I think that's a non-negotiable. Exercise is a non-negotiable. And I think high intensity exercise, you know, short, intense can go a long way. Strength training, you know, one of my dear friends, she's very thin.

57:20You know, you look at her, you'd think she's really healthy, you know, called me up. She's like, I'm pre-diabetic. I'm like, we're going to start lifting weights. Had never picked up a weight before in her life. Was able to reverse her pre-diabetic state within two months of strength training. Started taking creatine, still obviously on call and having to navigate that, but that went a long way. And she literally reversed her pre-diabetic condition in two months of starting a strength training and just being more mindful of when she's eating. So that gives me hope. And we have to do some interventional randomized control trial study to really try to isolate these effects.

57:56But given what I know of the literature, I know that that can get shift workers on a better path really quickly.

58:02Dr. Mary Claire Haver:So light, let's go back to light. I think you've said this, and if I'm misquoting, let me know. It's the most underestimated drug in the world. Yeah, it's so powerful. and if we think about perimenopause and menopause and you know one of the things that we see in the data is this idea of amplitude and again if we're going back to this principle of getting as much light during the day and getting as much darkness at night you will increase the amplitude of heart rate, of respiratory. Every metric that we know that has a circadian rhythm is going to improve just by creating more contrast, activity, rest, light, darkness, eating during the active phase of circadian rhythm, not eating during the inactive phase of circadian rhythm.

59:02If we can just start to apply these principles, we will increase our heart rate amplitude. When we increase our heart rate amplitude, which is the magnitude of change over the course of the day, and we look at measure, which is the average heart rate, okay, when we look at these two things, which help us understand amplitude, higher amplitude, lower severity of symptom of perimenopausal symptoms, okay? So this idea of preserving amplitude through circadian practices is one way, based on the data that we have, it's one way to mitigate the severity and frequency of symptoms in perimenopause. I believe it.

59:43Yeah. So we have not published these data yet, and these are kind of hot off the press, but I want to share them, and people can judge that if they want to, but we will put these through review. We will let the audience peer review. You can talk all you want. Okay. Thank you. I appreciate it. But we're really excited about these data because I think it gives hope, right? It doesn't mean that you don't need hormone replacement therapy. It does not mean that you don't need these other therapeutic strategies. Right. I talk about tools in the toolkit. Totally. This is circadian alignment is a really important foundational element to human health and functioning.

1:00:18And when we look at shift workers and we know that they were reduced health span of 10 years, we see very clearly this experiment is not working for human beings because we have not adapted to blue rich light after the sun goes down. We have not adapted to access to food 24-7. We haven't adapted to partying until three o 'clock at night, right? We haven't adapted to this modern life. So we need to be smart on average about adopting these per-circuiting practices. It doesn't mean about missing out and being perfect, right? But it's just like being more intentional, right? Knowing that misalignment comes at a huge cost.

1:00:53There's an increased risk for cardiometabolic disease. Misalignment leads to an increased risk in cardiovascular disease, not to mention mental health disorders. There is not a mental health disorder that exists that doesn't have some sort of circadian disruption element to it. So when we zoom out and we look at what is the foundation of human health and functioning, circadian alignment is a big piece of this puzzle.

1:01:17Dr. Mary Claire Haver:Okay. You sent me a graph. Yep. And here's what I love. I love so many things about this graph. And we are going to show the graph on video, but we'll have it in the show notes. but this is a graph looking at the percent of women reporting sleep problems and instead of h the axis is time around the final menstrual period so like this you were like singing music into my ears so we're looking at the center of the graph being menopause and then right before it is perimenopause and then we have postmenopause so percentage of women with any sleep problem averages 25 to 30 percent in premenopause okay by the time we're like t minus three years before you're fully menopausal so you are full-on perimenopausal yeah that number is going to climb dramatically like one and four across the transition yeah and then it is going to stabilize at the 45 percent range and it doesn't go down you have a new baseline so that is where i'm meeting people in my clinic so i'm taking care of perimenopause all the way through 60s 70s and the girls are not sleeping i know and and what i will say and what these data show is that it's happening four years to perimenopause the four years prior to your first reported symptom your sleep is getting worse well medically we still define perimenopause symptoms as a fucking hot flash okay i know so but like my patients are having sleep issues yeah well before that They're having mental health changes well before that.

1:02:53Dr. Mary Claire Haver:They're having brain fog well before that. To me, that is where in my new book, that's where perimenopause begins in the brain. Sleep disruption, mental health changes, and brain fog, you know, cognitive decline. And cognitive struggle. And so it's unbelievable. And like seeing it like, yes, this is what I'm seeing in clinic. I know. Exactly. I know. And this is what we see in the data. And so what frustrates me is I just saw like some quotes from, I think, Wall Street Journal or something. And they interviewed people who've been kind of in the menopause space and academics for a long time. And they seem to be very biased to me where they're like, no, no, no.

1:03:33Dr. Mary Claire Haver:Any sleep disruptions is simply a hot flash. If we, you know, put her on Vioza and get rid of that, she should sleep fine. Well, she's not. Yeah. She's not. The data is clear. Yeah. You know, I have I'm great at controlling hot flashes with medications. my patients were still struggling with sleep yeah why i mean i think a big piece of it is this decline in amplitude lower amplitude affects your entire profile and and so preserving amplitude from from what i understand of the literature is a path to preserving sleep so why don't doctors understand this because half of them will give this patient who is absolutely struggling.

1:04:17Dr. Mary Claire Haver:Yeah. Ambien or another sedative. Yeah. A benzodiazepine. Progesterone and estrogen is the path here. What's wrong with giving them a sedative? So a sedative is going to impact the depth of your sleep. You just because you're passed out doesn't mean you're actually getting into deeper stages of sleep. And that in those data are very, very clear. Well, let's talk about that. Yeah. Because a lot of our listeners if they haven't listened to the matsumura andreas episode don't understand about sleep architecture yeah you know we spend a lot of time the internet is rife with how many hours how many hours how many hours are you sleeping and not very many people are talking about the quality of your sleep so for the listener who doesn't understand sleep architecture what are sleep stages why are they important yes how much time should we be spending in each of them?

1:05:06Great questions. And just as a reminder, one of the drivers of sleep quality is sleep consistency. So if we back out, we look at, okay, what are the four pillars of sleep? We've got sleep sufficiency, so time in bed. And how much time you're spending in bed matters, right? Because you've got to run through the sleep cycle. So everyone is different, and that's what is important. Not huge variability, right? In the same way that we don't have huge variability in chronotypes, We don't have huge variability in sleep need. Now, there's obviously people on the extremes for both of those. But generally speaking, it's somewhere around seven to nine hours.

1:05:41That said, you can be sleeping less than seven hours but getting really high quality sleep, right? And in the absence of sleep debt, some folks only need six hours and four to two minutes of sleep or seven hours and five minutes of sleep, right, if they're getting really high quality of sleep. So I think it's figuring out, okay, what do you need to live your values with joy and energy, right? That's what we're trying to figure out here. And we know that stable sleep-wake time is going to help drive quality of sleep. And then the timing of sleep matters too. We know that folks who are going to bed after midnight, for example, are going to wake up with a higher fasting glucose levels than people who go to bed prior to midnight.

1:06:25So there's something about the timing of sleep that matters. We know when we look at folks who have no access to artificial light, fall asleep three and a half hours after the sun goes down. And if you've got a group of people on a mountain, this experiment has been done. Evening people, morning people, they all fall asleep within 30 minutes of each other. So we know that somewhere around 10, 9, 30, 10 p.m. is probably the sweet spot for sleep for most humans. So timing does matter, consistency, sufficiency, and then quality. So when we look at stages of sleep, you've got basically four stages of sleep.

1:07:00Your kind of first two stages of sleep are generally light stages of sleep where your body's kind of preparing for these deeper stages of sleep. And then you drop into slow sleep. And this is where a lot of the physical restoration happens. This is where you release a bolus of the human growth hormone. And again, this is where timing I think really matters, right? If you bypass your natural pressure for sleep by staying up and watching more Netflix shows or doing whatever it is that you do, when you bypass that natural pressure for sleep, you will end up releasing less, definitely less melatonin likely because you basically bypassed it, right?

1:07:35You bypassed that bolus of melatonin, and now it's starting to decline because you're up and engaging in life and potentially viewing light and all of those things. And then also you compromise that third stage of sleep, which is that deep stage of sleep. So if you're not dropping into that deeper stage of sleep, then you're obviously not going to wake up as refreshed, right? And then that fourth stage is the REM, this is the dreaming. And you basically want to cycle through this, you know, every cycle takes about 90 minutes and you want to cycle, you know, four times-ish, you know, through these various cycles of sleep.

1:08:07Dr. Mary Claire Haver:I get the bulk of my deep sleep in the first third of my night. Yeah. Is that normal? Yeah. Yeah. That's normal. Yeah. And I'm cycling, but it's like, boom, boom boom boom and then i stay in the upper upper ranges for the back half for most of it yeah yeah that's that's normal that's normal and are you waking up feeling refreshed most of the time okay yeah and i think that's that's like the danger of sleep trackers i think is that sometimes we're like wait is this you know and that's where it could be helpful but also maybe harmful if we're i have a wearable and a shareable and like nearable and a wearable so i have a mattress and i have a ring and i just pick whichever one tells me i slept the best perfect perfect yeah Yeah, there's a little bit of a placebo going on there for sure.

1:08:49But no, I mean, I think really before you look at your tracker, like let that, you know, when we wake up, we have that moment of, you know, maybe we wake up in a deeper stage of sleep. We maybe feel a little groggy, right? That's totally normal. Let yourself kind of take a, I have a huge glass of water and this is when I have my creatine and some of my other little whatever. I take my huge glass of water and then I'm like, how do I feel? And then I kind of go on my day and then I'll look at my data a little later maybe. But I definitely try not to obsess over it. And I really try to go off how I feel.

1:09:19And I think that's important for most folks. So if you're feeling refreshed and you don't feel sleepy throughout the day, you don't have to hack your way through the day with stimulants, you're probably getting enough sleep. And you put a pin in it and you're like, all right, what did I do? And you try to replicate that as much as possible. I think one of the ways to kind of create that rhythm is definitely to set a time in the morning that you can wake up reliably. And I think for us, we travel a lot, so it can be hard, right? But on average, you want to, for me, it's around 6.30 a.m. I always set my alarm.

1:09:56Sometimes I wake up a little bit before. Sometimes I want to sleep a little later. But generally speaking, I'm going to wake up at 6.30 a.m. regardless. Get my big bullets of light. Have my big glass of water. you know kind of shake off whatever and then i go about my day but um that allows again me to set my circadian rhythm and then reliably release melatonin at the same time every single night so that is again how you back into that sleep consistency which is then going to allow you to drop into those deeper more restorative stages of sleep you minimize the chances of that 3 a.m wake up right right because again amplitude amplitude amplitude right is going to prevent that 3 a.m wake up.

1:10:36Dr. Mary Claire Haver:Why is the 3am wake up happening? It's a lack of amplitude. It's such a common complaint. It's a lack of contrast. But my patients are feeling like they did something wrong or something's wrong with them. Well, no one is purposely trying to sabotage their sleep, right? No one's purposely trying to sabotage their health, generally speaking, right? But I think women don't know the power of these circadian practices and setting your circadian rhythm. It's because when you don't set your circadian rhythm, you have a flat, you don't, you have a flat, there's no amplitude, right? It's flat, right? And we know if you were to look at, and we can share, this is the, one of the studies that I shared with you, that circadian bundle study in the ICU patients.

1:11:15If you look at their melatonin and cortisol, it's basically like this, you know, like, right? If you look at a healthy, robust human, it's this, right? So amplitude matters. Low amplitude is predictive of it well this is what we see in the data women who have low amplitude have more severe and more frequent reported and for our perimenopause she's talking about

1:11:42Dr. Mary Claire Haver:amplitude being light dark yes not fed exactly workout heart not workout you know like like yeah it's not hacking all of the energy the activity the stuff into the daylight hours yeah to be clear Again, as I said in the outset, these are free behaviors, right? And generally democratically available to all of us who are not shift workers. Obviously, there's some complications when we have partners who want to go to bed late and we have teenagers. I have two teenagers, right? So I understand that there are aspects of our life that make it more challenging, but that's where we just have to ramp up the communication.

1:12:19That's what I tell patients. You have to triple down. You've got to triple down. You just have to talk to people like, hey, listen, I want to be available for you and all the things that I love during the day. And this means I have to do X, Y, and Z, you know?

1:12:31Dr. Mary Claire Haver:Let's talk about the curve again. Does the curve look like this for men? Yes. This is all humans. Well, I mean, is seeing this acceleration. So women are going to have lower amplitude because of the hormonal changes. Okay. Yes. So menopause is clearly here when you look at the timing of menopause and not just age. Right. Because we all go through menopause at different ages. Menopause is associated with lower amplitude. So full stop. Okay. Done, done, done. Yep. Does this curve look better if the woman is on estrogen plus or minus the progesterone? Yes. Okay. How powerful is progesterone here?

1:13:09Well, I think progesterone is particularly powerful because it puts on the brake. So I think what happens with regard to the 3am wake-ups is when you have low progesterone, the GABA signal is muted. Very, very important to make sure that that signaling is happening. And that's one of the reasons is that GABA signal starts to increase basically when it shouldn't be, and that's what's facilitating that 3am wake-up. So when you get your levels correct, I don't know if I can say back into balance, that's not the right terminology. But what would we say? What's the best way to characterize?

1:13:51Dr. Mary Claire Haver:Well, you just get these hormones, the estradiol and the progesterone no longer exist. You know, they go, we go into a zone of chaos. Right, right. Progesterone really lags in perimenopause. Estrogen goes crazy. Right, right. It's up and down. Up and down. It's just variable. It's very unpredictable. And progesterone is always just struggling to kind of keep up. so for like if i had a patient who came in and her number one symptom was sleep disruption and she was still having monthly predictable periods i would start her on progesterone okay especially just progesterone starting with progesterone um now if it was mental health and brain fog i would add in estrogen on the front end and so quite often those three things are together i have a rare patient who's just having sleep disruption without the other mental you know without the other brain changes but occasionally i'll start a patient on just progesterone and that really helps her sleep yeah when a woman when she becomes more stable hormonally and is getting treated in a way where she's able to restore sleep and is able to create more of this contrast right and is thinking about that intentionally amplitude should improve right amplitude of course being a proxy for just general health and well-being, reduced risk of neurodegenerative disease, reduced risk of mental health issue, reduced risk of cardiometabolic disease, reduced risk of cardiovascular, right?

1:15:10So it stands to reason. And I will be able to do this research because I have health history questionnaire data that has every single permutation of hormone therapy a woman has ever been on, of course, their life. I know, I know, I know. Dr. Haver, I can't wait. And what I'm going to do is look at this amplitude, how amplitude changes over the course of a woman's life, what that looks like with the physiology and how things help and hurt. And we'll be able to say something quite, I think, definitive and exciting that will, I think, empower women. But I will say that this amplitude piece is huge.

1:15:53Women need to be taking control of these circadian practices in parallel to all the other stuff that they're doing so they can preserve their sleep, right? Because we know that this is obviously the biggest complaint. And when your sleep is off, it just, everything goes south, right? We know that, right? And this is what you see in your clinic.

1:16:09Dr. Mary Claire Haver:The risk factors for chronic disease skyrocket. Right, right. And it's a circadian sleep thing that's happening. Unbelievable. I was surprised to read this, but it makes sense now after talking to you that 100 % of mental health conditions involve some level of circadian disruption. And in some cases, it's not correlation. It's It's causing it. Yeah. The only evidence that we have that it's causal is in mood disorders. Okay. Yeah. And there's a good paper that it might be a review and mood disorders bubbled up as being causal. Circadian misalignment causes mood disorders. And yeah, and I think it's the dopamine, I think, system that's really impacted how we seek reward during the day changes when our sleep-wake timing is highly variable.

1:16:57So, you know, we call this social jet lag. And we know individuals who have social jet lag are more vulnerable to all sorts of mental health issues and conditions. Wow. Okay.

1:17:12Dr. Mary Claire Haver:Dr. Holmes' new book, Aligned, the data-driven guide to performance, recovery, and human potential, is available now wherever you buy your books. You can also find her on instagram at drkristinholmes and on linkedin at drkristinholmesphd I would love to hear from you about this topic and anything else that's on your mind You can find me on instagram at drmaryclare and get honest accurate information on health fitness and navigating midlife at thepawslife.com My new book the new perimenopause is available now everywhere you buy books and through our website You can also find full episodes on YouTube.

1:17:52Dr. Mary Claire Haver:Unpaused is presented by Odyssey in collaboration with Pod People.