The Sleep Crisis in Menopause: Insomnia, Sleep Apnea & Solutions

17:22Dr. Mary Claire Haver:So let's go big picture. Yeah. Why is sleep such a critical piece here for overall health?

17:29Dr. Andrea Matsumura:It's like your CEO. It's for your body. So everything hinges on our ability to get into those sleep stages. So we need to have deep sleep. We need to have REM sleep in order for us to kind of clean all the waste products out of our brain, for all of our hormones to function in the pattern that it needs to function in, to continue to support our circadian rhythm because every single cell runs on a circadian rhythm. And the master one is the clock genes that are in the brain. The what genes? Clock genes. What are those? We've got clock genes in the hypothalamus of the brain. We're born with them, and they are the pacemaker of the circadian rhythm for all of the other cells in our body to function.

18:21Dr. Mary Claire Haver:We know that data is showing that poor sleep is increasing the risk, as you said, depression, cardiovascular disease, diabetes. But talk to me about the women. Why is this so important for them?

18:34Dr. Andrea Matsumura:Well, because we have the same risk factors once we hit midlife when we're in menopause. And we have this delay in our diagnosis. And that sets us up for, we know that cardiovascular health is so important. That's the number one issue.

18:54Dr. Mary Claire Haver:You know, most women think if you ask them on the street that the number one killer of women is breast cancer. What is the number one killer of women?

19:01Dr. Andrea Matsumura:It is heart attacks. And they just feel like that's bad luck. I know, it's not. And it's so intimately involved in our ability to get good sleep because we know that when people have chronic insomnia and it goes untreated and we don't try to treat it, that you have higher cardiovascular risk.

19:22Dr. Mary Claire Haver:So you've quoted that sleep is foundational. But before we talk about fixing it, which we will, can you tell me what restorative sleep is? You know, there's different kinds of sleep. And you briefly talked about sleep stages. I'd love to dig in here as well. Okay.

19:36Dr. Andrea Matsumura:Restorative sleep is when you wake up feeling refreshed. You wake up and you can remember words, connect the dots. You don't have brain fog. I call it the rainbow and the birds chirping. You don't feel dysregulated. You're looking forward to your day. That's what good sleep feels like, as opposed to when you wake up and you say, oh my gosh, I only slept a few hours. I don't know if I'm going to make it through the day. So what are the sleep stages you briefly talked about? So there's four sleep stages. So stage one is that light sleep. A lot of people will think that they didn't get any sleep at all, but they may have been hovering in stage one and stage two.

20:17Dr. Andrea Matsumura:Stage two is when your body's more or less preparing for the deeper stages of sleep. And fun fact, stage two is what we spend the most time in. So a little word about wearables or tracking devices, that light sleep is, stage two is in that light sleep. So a lot of people will think, gosh, I have so much light sleep, but you're supposed to have a lot of stage two sleep. And then there's stage three sleep, which is our deep sleep or slow wave sleep. And that's really the big stage where you have all of the body restoring itself, all the physical restoration. And then REM sleep is when we're dreaming.

20:59Dr. Andrea Matsumura:And dream sleep is really important because that is when we're doing a lot of emotional consolidation. That's that emotional regulation piece. Some memory consolidation also happens during REM sleep.

21:12Dr. Mary Claire Haver:So I wear a tracker. And, you know, I used to be obsessed. Yes, my husband and I will, you know, Chris and I will wake up in the morning and be like, what'd you get, you know, for our scores? Because not like I'm so competitive. And so I, according to Aura, I'm a much better sleeper than my husband. But, you know, what I never understood were the different phases and how much time. I spend most of my deep sleep is early in the night, in the first half of my sleep. Is that normal? That is normal.

21:38Dr. Andrea Matsumura:So that deep sleep or slow wave sleep, we're supposed to get in that first one third of the night. And then REM sleep is usually in the last half of the night. So we, you know, there's a whole method to the madness, if you will. And we're fluctuating in and out. Why? Yeah, we're cycling. Why? Your brain goes through these different cycles to kind of clean the brain out. And it's kind of like a dishwasher, right? So it keeps cycling through so that it's cleaning out all the waste products of the brain and developing and setting the stage, kind of cleaning the slate so that you can wake up refreshed in the morning.

22:18Dr. Mary Claire Haver:We had Louisa Nicola on and she talked about the microglia, the small cells, and they shrink during deep sleep and the fluids start pumping through because they can get around and that's cleaning. That's cleaning it out. That's usually in slow wave sleep.

22:34Dr. Andrea Matsumura:What is the recommended time? So the American Academy of Sleep Medicine says that everybody should sleep seven to nine hours. And everybody kind of knows their sweet spot, but there is some data coming out that all is not lost if you're not sleeping seven hours. That really, let's focus on the quality and not just the quantity. What does that mean? So quality - So if you're not wearing a tracker, how would you know? So we know ourselves better than any tracker. So I always tell folks, please ask yourself first, before you wake up, how you feel before you start looking at your data, because it primes people.

23:13Dr. Andrea Matsumura:So you, if you're not thinking about it, or you might say, hey, I got pretty good sleep. And then you look at your data and you say, oh my gosh, I got horrible sleep. And then you really wake up for the rest of the day with this perception that you're not getting good sleep. And that's not always true. The trackers are, they're good, but they're not diagnostic tools. So really trust yourself first.

23:39Dr. Mary Claire Haver:Has anybody come to your office, you know, because of a tracker?

23:43Dr. Andrea Matsumura:All the time.

23:44Dr. Mary Claire Haver:Good and bad. Like what would be a positive outcome of a tracker for you?

23:48Dr. Andrea Matsumura:Positive outcome of a tracker is when somebody notices a trend that something has shifted and it's consistently shifted. And then that's a window for us to then use some diagnostics to kind of figure out like a sleep study or kind of dig deeper. Hey, what's really going on with your sleep? But most people come in because they say, you know, my oxygen saturation is going down for five seconds here or there, you know, great. newsflash, that's not abnormal, you know.

24:22Dr. Mary Claire Haver:When should you be concerned about, because your oxygen saturation, should you be concerned about that ever?

24:27Dr. Andrea Matsumura:If it's consistently low. And again, these are not as accurate. So if it's consistently low and you notice that it's firing off a whole bunch and it's telling you, hey, I think something's going on here, then that's when you should go in to get evaluated. But even my tracker will say that occasionally I have low oxygen saturations, but I know that I don't have sleep apnea because I test myself. And it's very intermittent. But if you see like a sustained window, and for women, this is important because women will often have REM-related sleep abnormal breathing. So they will have REM-related obstructive sleep apnea, meaning that they pretty much don't have what we call obstructive sleep apnea and all of the other stages of sleep.

25:18Dr. Andrea Matsumura:But during dream sleep is when they actually start to have low oxygen saturation, some hypoventilation where you cannot oxygenate well. And that could show up on a tracker where you have a little window of time where you were consistently having low oxygen saturations. Okay.

25:41Dr. Mary Claire Haver:Talk about hormones and their role in sleep regulation. So we're talking about sex hormones or the PET hormones.

25:49Dr. Andrea Matsumura:Yep. When we think about estrogen, progesterone, testosterone, so estrogen is really helping us with our thermoregulation, with our temperature control. It also helps with sleep spindle production, which is part of stage two of sleep. It also then helps with REM sleep. Progesterone is really about, it's got a lot of what we call GABA, GABAergic potential. So it really helps calm the brain. It also helps to support the structures at the back of the throat. So progesterone helps with supporting the airway while we're sleeping. And then testosterone is really helping with that deep sleep and sustaining sleep.

26:32Dr. Andrea Matsumura:So those are kind of the big components of how these sex steroids really affect sleep.

26:40Dr. Mary Claire Haver:This year at the Menopause Society, you were there, right? And the incoming president is a psychiatrist, and he did a presentation on sleep. And at the end, I watched it remotely. And I was very surprised to hear him say, and I may be quoting him incorrectly, at the end of the day, it was like, do not recommend progesterone for sleep. Were you surprised by that?

27:03Dr. Andrea Matsumura:What does the evidence say? Yes. So I was surprised by that. I think what he was trying to say, and I'm giving him the benefit of the doubt because I didn't get a chance to snag him and say, hey, what's going on here? There isn't any data that says that progesterone is curative for, let's say, obstructive sleep apnea. Right. Right. But we all know that it can help with getting women to sleep and calming.

27:30Dr. Mary Claire Haver:I have a thousand patients who will testify right now. 100%. I'm like, we're not asking the right questions if, you know, science isn't recognizing how progesterone is helpful for some patients for sleep.

27:43Dr. Andrea Matsumura:And we don't have any studies showing whether or not we add progesterone and estrogen if that helps with sleep apnea. And I get asked that question a lot. women will ask me over and over again, hey, if I start on menopause hormone therapy, will this help me with my sleep apnea? And we don't know.

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31:04Dr. Mary Claire Haver:So let's go back a little broader about sleep and make sure our listeners understand. When we look at the major causes of sleep disruption or insomnia as an umbrella term, We have patients who struggle to fall asleep. We have patients who struggle to stay asleep. So let's talk about the fall asleep crowd. Why would any patient, especially a woman, struggle to fall asleep? What are the broad categories of causes? Because this is— You said there's 70 different causes of insomnia. Right.

31:34Dr. Andrea Matsumura:So 70 different sleep disorders. Sleep disorders. Okay. So the big ones are you have a breathing abnormality. You might have a movement abnormality. Such as? What is a movement abnormality? Restless leg syndrome. So restless leg syndrome can affect up to 30 % of women in the postmenopausal state. Is that more than men? And that is way more than men. And so... I did not know this. And it is underdiagnosed. I just had somebody the day I was at a party, actually. And somebody pulled me aside and said, you know, you were talking about restless leg. That is me. And I didn't realize that that is actually what was causing me to have insomnia.

32:17Dr. Mary Claire Haver:So for our listeners, what is restless leg syndrome?

32:20Dr. Andrea Matsumura:So it is what I call it. So by definition, it is a conscious phenomenon, meaning you have to be awake. OK, so restless leg syndrome is the this movement in any limb really. Does it have to be your leg? Doesn't have to be your legs. Could be in your torso. It can be in your arms, your legs. And it's basically this uncomfortable feeling that builds and you have to move. It dissipates and then it builds right back up and it is preventing you from getting to sleep. And then when you're asleep, it's a little bit semantics. There is a condition called periodic limb movement disorder. And that is when limb movements are causing constant arousals and preventing you from getting into the right stages of sleep.

33:07Dr. Andrea Matsumura:Like, wow, they're two separate things, but they're actually on the same. They share like the same loci. Yeah. What causes this?

33:16Dr. Mary Claire Haver:Why would someone develop restless legs?

33:18Dr. Andrea Matsumura:So, yeah, one common reason is having low iron stores. And well, let's not get me started on that.

33:24Dr. Mary Claire Haver:I had a pregnant patient who was a pathologist and had a horrible RLS. And she's the one who taught me about the ferritin. Yes. And we were getting her iron transfusions in the pregnancy. Yep. So that she wasn't anemic. But her low ferritin, and it worked beautifully for her.

33:40Dr. Andrea Matsumura:And we underutilize iron infusions because sometimes, you know, it takes a long time with iron replacement to feel oral. You mean oral.

33:50Dr. Mary Claire Haver:I had low ferritin for a long time. And I had GI stuff. So very difficult for me to absorb. And finally, I was like, fine, I'll go get the iron transfusion. Life-changing. Yeah. Life-changing. I recommend them all the time now for patients who are struggling with absorption. Yeah, definitely. And the normal values are not normal if you have restless leg syndrome. What ferritin level are you? I just did a whole post on this today. It's so funny. At what level are you like, we need to get this higher?

34:21Dr. Andrea Matsumura:So if you have restless leg syndrome, your ferritin should be around 100.

34:27Dr. Mary Claire Haver:So ferritin is the iron storage protein, and it drops way before you become anemic. That's right. Right. And in our clinic, if they have chronic inflammation, so if they're set rates high or, you know, we have signs of chronic inflammation. Right. We're not using 60. We're using 100 because it's an acute phase reactant. Right. The ferritin will rise, you know, abnormally in response to inflammation. So we have to move that goalpost for the patients.

34:56Dr. Andrea Matsumura:Right. 100%. And also it crosses a blood-brain barrier. That's why you have restless leg syndrome because it has a role in how dopamine gets released. And so that's how it works in the brain. That's why you will have restless leg syndrome. And we've had these levels that are standard that are now changing, right, for normal. But even then, those normal levels are not normal if you have restless leg syndrome. So now the normal range is like 45. 45. It was 15. They tripped it. Terrible. It was terrible. Yeah. So you'd have these women coming in who had like a ferritin level of, you know, 10. You're like, oh, you're borderline.

35:38Dr. Andrea Matsumura:You're borderline. Right. It's not really that low. And these people probably, these women should have had iron infusions. Okay. So we talked about movement disorders. Let's keep going. So then you're left with chronic insomnia. chronic insomnia is when there's not really anything else that could be causing you to not be able to fall asleep. So the other big one is circadian rhythm abnormalities. So let's say you're a night owl, but you really have to get up early because you have to go to work earlier, or you've got to get your kids to school, or you're taking care of somebody, whatever. The point is that you're not in sync with your circadian rhythm, which again, And those clock genes are in the brain.

36:19Dr. Andrea Matsumura:You can't really change them. It's kind of like eye color. You're born with them. You can fake them out. So that's called circadian realignment when we try to adjust somebody's circadian rhythm. And the other one is, you know, there's lots of reasons why people will have chronic insomnia. One can be your change in hormones. One can be trauma. Another one can be mental health. There's all sorts of reasons. anxiety, depression, I mean, all kinds of things. All right.

36:50Dr. Mary Claire Haver:So what about the patients who go to sleep fine, but then 2 a.m., 3 a.m., what is happening?

36:55Dr. Andrea Matsumura:Yeah, that's learned hypervigilance, especially in midlife. This is a neuroendocrine, neurosteroid change, right? And so we have a change in cortisol. And sometimes that cortisol spike starts to happen earlier, which causes early morning awakenings, then your brain basically that neuro pathway for sleep, it changes. Your brain just says, okay, we're going to learn a new path. And so you develop this hypervigilance, this hyperarousal in your sleep, and that is a behavioral change. This is why it takes time to treat insomnia, and it is not typically fixed with any sort of prescription, medication, or supplement.

37:45Dr. Mary Claire Haver:How do we fix it?

37:46Dr. Andrea Matsumura:So the number one treatment is cognitive behavioral therapy for insomnia. What is that? So it is basically retraining the brain. It's all about behavioral change. It's about addressing and understanding what is causing that hypervigilance and retraining the brain, kind of like building muscle. You know, I always tell folks, you don't just go to the gym and pick up 50 pounds. You can't, right? You have to start slow. You have to be consistent. And then you can eventually pick up that 50-pound weight. Also tell people it is not a couch to 5K. It is a couch to marathon. It doesn't happen fast. You know, if you were really pressed, you could probably run, you know, three miles, but you can't run a marathon really easily in a week or two.

38:37Dr. Andrea Matsumura:without training. This is about changing somebody's way of thinking and also giving them some ideas on how they can kind of give themselves permission to go back to sleep. How does that look like? What would you? Okay. So, so me, all right.

38:53Dr. Mary Claire Haver:I'm waking up at 3 a.m. every night and we've ruled out medical causes. I don't have sleep apnea. My hormones are replaced. You know, we haven't put a finger on it. How would you counsel me to do? Is there an app? Do I go to a counselor?

39:09Dr. Andrea Matsumura:Yeah, there's so many different avenues. So there are apps out there. There are sleep psychologists out there. There are online programs. There are books. The key is consistency. And you really have to address all of the components that are in cognitive behavioral therapy. So it's kind of what we call a three-legged stool. So the first one, most people do a pretty good job at, which is sleep hygiene. But more people than we think don't always go to bed at the same time or wake up at the same time. Maybe they're doing things in their daily life that is affecting their ability to get to sleep and they don't even realize it.

39:50Dr. Andrea Matsumura:Maybe they're eating a really heavy meal right before bed. Maybe they're exercising too late. Maybe they They are super stressed all day and don't realize that that is going to affect their ability to kind of shut down and get to sleep. So there's that sleep hygiene component. And also maybe their bed, their bedroom is is not too conducive, too cold, too hot, too cold, too loud, too bright. And then the other one is addressing the hypervigilance, the the the stimulus, like what is causing that middle of the night awakening? and I will tell people, you know, let's develop a plan. Let's figure out how to help yourself get back to sleep and not catastrophize when we wake up.

40:35Dr. Andrea Matsumura:So a lot of us, right, wake up in the middle of the night and go, oh my gosh, I'm not gonna get back to sleep. What's gonna happen? Instead, have a plan. Okay, I'm awake and I know I'm not falling asleep, falling back to sleep anytime soon. So I'm gonna get out of bed and I'm going to go sit somewhere and do the most god-awful boring thing I can do, like reading a book or doing some sort of meditation, something that will help induce sleep. So we don't want people cooking, cleaning, working, exercising if they cannot fall back to sleep. And we do want them to get out of bed. That is called stimulus control, fancy word for making sure that your brain associates the bed with sleep or intimacy and nothing else.

41:18Dr. Andrea Matsumura:because if you stay in there for a long time, then your brain starts to think that the bed is like the sofa or the kitchen table. It doesn't associate it with sleep. So you should get up. So you got to get up. It's painful. Pick something like an insomnia chair or whatever you want to call it and just do something really relaxing and boring to help yourself get sleepy enough. And when you're sleepy enough, you go back to bed. The last one is the hardest, but it actually works really well, which is sleep restriction. So if you think you're only getting five and a half hours of sleep, then that's how much time you should give yourself.

41:56Dr. Andrea Matsumura:So instead of trying to get into bed at 10, tossing and turning for two hours, or falling asleep and then waking up at one and tossing and turning for two hours or whatever, and then getting up at six, we tell people, well, if you are only getting five and a half hours of sleep, then let's slowly, we don't just say only get five and a half hours, but we start to help people kind of compress their sleep so that they can then expand their sleep. So I call this the accordion effect. So you know how you have to, the only way if you push an accordion in, the only way for it to go is out. So that's the same concept is that you kind of have to compress the sleep in order to expand the sleep.

42:39Dr. Andrea Matsumura:So, you know, what I will say about cognitive behavioral therapy for insomnia is that there's a lot of data around it. It is successful, but it is pretty rigid and you do have to follow all of the components or you have a lower success rate. And what I find is that there hasn't been a lot of studies on chronic insomnia only in women, right? And so I think it drives a lot of people's anxiety. So you already have some anxiety about getting to sleep, and then it revs up this sleep anxiety even more. So I like to combine acceptance and commitment therapy with it, which is a different type of therapy altogether, where you give yourself, you know, love and grace so that you can actually get up the next day and maybe feel like it's not going to be the end of the world.

43:34Dr. Andrea Matsumura:So maybe you can't fall asleep in the middle of the night, and instead of saying, oh my gosh, I'm not going to do well tomorrow. I've got a presentation or I have to do these things for my children or what have you that you say, you know what? I'm going to be awake for 90 minutes tonight and I'm not going to let it ruin my day. Maybe I'm not going to fire off on all cylinders, but I'm going to make it the best that I can for the next day. And you start to be kind to yourself. So I call CBTI the grit and acceptance and commitment therapy or act the grace. So if you can combine those two, I think you have a higher success rate.

44:13Dr. Andrea Matsumura:There are very few published studies on this and there are very few sleep psychologists who practice this and combine therapy. But that's how I practice it. That's what I focus on when I help people with insomnia. Yeah.

44:28Dr. Mary Claire Haver:You've talked a lot about how some of these common sleep conditions like sleep apnea and RLS are missed in women. I learned zero. I heard of RLS more as like this curiosity. And sleep apnea was old fat guys, you know, and men who snored. I think it's important for our listeners to understand the female presentation, the atypical sleep apnea, though we're 51 % of the population. Like talk to me about women and how they present with these. And why do we care?

45:00Dr. Andrea Matsumura:Yeah, we care because it is a cardiovascular risk factor. So if you have moderate or severe obstructive sleep apnea, we know that you have up to a 25 % increase in having a heart attack or a stroke or having a neurocognitive issue later on. And is it the hypoxia? Yeah. And inflammation? Yeah. So it's the chronic low oxygen state. that then causes all of this reflex physiology in the body that then puts you at risk. So women don't typically present with loud snoring, witnessed apneas. There's actually a study out there that talks about the fact that if women have a male partner, they're less likely to be identified as having sleep apnea because their male partner will not notice anything abnormal happening in their sleep.

45:54Dr. Andrea Matsumura:But women tend to have insomnia. They tend to have this, they call it tossing and turning. And I love it. Women never say that they snore. They say that they purr. Yeah. So I love it. Women always say, I don't really snore. I kind of purr when I sleep. That can be mild, mild snoring. That's enough. And the issue is that you don't have to, you know, be obese to have sleep apnea. And especially women, right? Especially women. You can have a normal body mass index. You don't have to have loud snoring. But if you're menopausal, you're at greater risk. So, whoa, menopause increases the risk of sleep apnea?

46:42Dr. Andrea Matsumura:Yep, it does. up to 50 % of women will have sleep apnea, not know they have it. 90 % of those women do not know that they have sleep apnea. So nine out of 10 women are not diagnosed. And then there's a delay in diagnosis because all of our screening tools are gender biased. I mean, the stop bang questionnaire, which is this acronym for these questions. The G is gender. So if you're a woman, you don't get a point.

47:14Dr. Mary Claire Haver:You get a lower score. Stop it. Because they don't recognize that women have sleep apnea. Yeah. Okay. One of my takeaways from all this is if a woman is snoring and her partner recognizes it or she's purring, she might be further along the course than her male counterpart. Yeah, exactly. So if you're snoring at all, you should go get evaluated.

47:37Dr. Andrea Matsumura:A hundred percent. I have a very low threshold for testing women because, again, women come in feeling just generally that, you know, I don't feel well. I don't know what's going on. I have brain fog. I can't seem to feel rested when I wake up. You know, I might have some mild snoring. So snoring does increase in midlife. But again, it's not caught. It's not, you know, if it's not big, bad snoring or if somebody isn't watching us have trouble breathing, then many times the connection of a woman might be at risk for sleep apnea. That connection is not made. A lot of women try to self-medicate their sleep problems.

48:21Dr. Mary Claire Haver:And the first thing they usually reach for is melatonin. Talk to me about melatonin, what it is, why it's important.

48:29Dr. Andrea Matsumura:Melatonin's a hormone. It's got a lot of different uses in our body, actually. But the one that we know about the most or the one that's talked about the most is how it starts to set the stage for sleep. So there is this whole concept called dim light melatonin onset. That means in the absence of light, that's when the pineal gland starts to release melatonin. So it's really a clock starter. It is not a sleep aid. It is starting the cascade of sleep. But it is also a circadian rhythm regulator. And what I did not get taught in my sleep medicine fellowship is that we actually lose melatonin production as we age.

49:13Dr. Andrea Matsumura:Like how much? Well, up to 50 % by age 50, which I had no idea about. And I did not realize that the pineal gland is the first gland in the body to calcify. and that the whole stereotype of the older person coming in.

49:30Dr. Mary Claire Haver:Now, the only thing I was taught about sleep is you sleep less as you get older.

49:34Dr. Andrea Matsumura:Yeah, and that is normal. That is expected. That is normal. Maybe it's expected, but should it be normal? I mean, you know, it's part of, quote unquote, normal aging. But do I have to live like that? Do I have to live with a lower quality of life?

49:50Dr. Mary Claire Haver:Why do you think women's sleep complaints are so frequently minimized?

49:55Dr. Andrea Matsumura:Well, you know, it goes back to, and this is why I do what I do. I am really tired of the normalization of women's suffering in society. That is exactly why I'm doing what I'm doing. Because we get told from a very young age that our baseline for suffering is higher. We should just suffer through those horrendous menstrual periods that we should be anemic. It's okay. Sorry, you're losing a lot of blood. If you have children, well, you're just not going to get enough sleep. Well, you have to take care of somebody else. There is mental load in the working environment, in your home environment. We are taught that we are supposed to suffer more.

50:39Dr. Andrea Matsumura:And then you hit menopause, you hit midlife, and then you become invisible. and then you you're supposed to suffer well you know you don't have hormones now it's just the way it is sleep is like horrifically disrupted yes okay so um and we'll get back to

50:56Dr. Mary Claire Haver:melatonin because i have so many more questions yeah but i chose a field of medicine that you know is a lot of shift-ish work or staying up late at night or getting up early in the morning for obstetrics to deliver babies and it was fine when i was 25 you know it was fine when i was 35 it was fine when I was 40. But man, in my 40s, it was hitting harder and harder and I was not rebounding like I should. And I would bring everything to work so I could perform. And my family was suffering. So when I was about 48, 49, I was having disrupted sleep from hot flashes when I was going through menopause or in the early stages before I realized HRT wouldn't kill me.

51:41Dr. Mary Claire Haver:I reluctantly went on HRT and I, my sleep went back to normal because I didn't, wasn't having hot flashes at two in the morning. I then transitioned positions to shift work, um, away from the clinic so I could go part-time. And so I became a hospitalist and then COVID hit and I was working 24 hour shifts, three, three days a week. And I wonder how many years I took off of my life because of this. I was an absolute basket case for like the last year of that. And I've read that shift workers are at super high risk for medical conditions. Can you talk a little bit about that? Yeah.

52:21Dr. Andrea Matsumura:Well, the good news is that you can repair what you were kind of deconstructing.

52:27Dr. Mary Claire Haver:Because my 50th birthday present to myself was no more shift work.

52:31Dr. Andrea Matsumura:You know, there is good data out there that shows that, you know, if somebody has untreated sleep apnea or untreated insomnia, that once we begin to treat it, you can get yourself back to baseline. Okay. But there is data out there that does state that if you're a shift worker and let's say you are not a night owl, then, yes, you are at higher risk for dementia, for cancer. And that's because the way that our circadian rhythms work in our body, they rely on our ability to get to sleep at a particular time. It's all about timing, right? And so shift workers have this disruption. And like I said, every cell works on a circadian rhythm.

53:18Dr. Andrea Matsumura:So then it's like chaos inside the body. And so our immune system suffers. Our ability to clean all the waste products out of the brain suffers. There's so much oxidative stress on the body. And yes, that then kind of is a total setup.

53:35Dr. Mary Claire Haver:Why are so many women complaining about nightmares with melatonin? So one, you might be taking too much. How much is too much?

53:43Dr. Andrea Matsumura:So I'd say anything over three milligrams. Three milligrams is the max that I would recommend for anyone. You don't really need to take more. More is not better.

53:53Dr. Mary Claire Haver:The one I was taking when I didn't know what to do was 10. I was like, this is what is in the bottle. It's purple. It looks pretty. I associate purple with sleep. And I was having horrible nightmares. And sometimes it would help or I'd wake up completely drunk, groggy, you know.

54:09Dr. Andrea Matsumura:Like I said, more is not better. And we also don't know what's out there over the counter. There's lots of different brands. There's lots of, you know, some of them are high quality, some of them varying qualities. And there's a couple of studies that were done that showed that at least 70 % of the melatonin that is sold over the counter is not just melatonin. There's something else in it. And so we just need to be really careful. Now, when you do take melatonin, you can even take a low dose of melatonin and have nightmares or intense dreams. And that's because melatonin is what really intensifies dreaming because you're having more sustained sleep.

54:55Dr. Andrea Matsumura:So then you might have more intense dreams. And that intensity might translate into, you know, having more abnormal dreaming.

55:05Dr. Mary Claire Haver:Why do I remember some dreams and usually the scary ones versus the good dreams?

55:13Dr. Andrea Matsumura:Yeah. So, you know, it's all about how the amygdala is reacting when you're dreaming and how you're consolidating and storing the memories. I don't know exactly why somebody is going to remember a nightmare other than the fact that, you know, the way that the brain works when we're dreaming, it almost looks like we're awake. So all of the parts of the brain that are typically asleep and the other stages of sleep actually wake, you know, they wake up. The PET scans show that when you're dreaming, a whole lot of your brain is lighting up. And, you know, that might play a role in how we are consolidating the memory, how we're reliving something that might be when something that was really stressful during the day translates into a nightmare because it is subconsciously affecting our ability to get to sleep and stay asleep.

56:14Dr. Mary Claire Haver:When you want your spring break to feel like and your kids pool day to feel like and your hotel bed to feel like and room service to feel like because at Hilton hospitality feels like

56:34Dr. Andrea Matsumura:Your cabana's ready. Would you like fresh towels?

56:36Dr. Mary Claire Haver:It matters where you stay. Book now at Hilton.com. Hilton, for this day. My day kicks off with a refreshing Celsius energy drink, then straight to the gym. Pre-K pickup, back home to meal prep. Time for my fire station shift. One more Celsius, gotta keep the lights on. When the three alarm hits, I'm ready. Celsius, live, fit, go. Grab a cold refreshing Celsius at your local retailer or locate now at Celsius.com. Spring is here, and there's a whole new way to chai at Starbucks that's made perfect for you. Choose your sweetness, dial it up, or keep things light. Add a touch of pistachio, a hint of strawberry, or vanilla, or make it a spring classic with lavender.

57:23Dr. Mary Claire Haver:Because this season, there's endless ways to chai at Starbucks.

57:33Dr. Mary Claire Haver:So let's talk about solutions. Yeah. And what actually works. Hormone therapy in sleep, estrogen, progesterone.

57:40Dr. Andrea Matsumura:Right.

57:40Dr. Mary Claire Haver:and what we know.

57:41Dr. Andrea Matsumura:So we had talked about how the lack of estrogen, then, you know, you tend to have more fragmentation of sleep. It really focuses on thermoregulation. And so if you replace estrogen, then you tend to have more of that temperature regulation, which then allows you to stay asleep, which then allows you to get into all the right stages of sleep and increase your REM percentage. So that's the plus with estrogen. With progesterone, when we give progesterone to folks, that is also then calming. It helps to set the stage for sleep better. And it helps, probably helps. We don't have data with some of that airway protection, but we don't know if it's curative or not.

58:27Dr. Mary Claire Haver:Okay.

58:27Dr. Andrea Matsumura:So you're kind of like calming the brain and then you're preparing the brain to stay asleep, right? And then there are some studies that show that testosterone does help with deep sleep. And for some people, testosterone is a missing link. Like they still have trouble sleeping even after they've started on estrogen and progesterone. And they're like, okay, let's try testosterone. And that was the missing link for them. It's not as well studied, but it is a potential solution. But up to, you know, at least a third of those folks who start on hormone therapy still have trouble sleeping. Up to half of those folks still will have trouble sleeping.

59:07Dr. Andrea Matsumura:So then we have to start looking at the other organic causes, right? Like, do you have untreated sleep apnea? Do you have untreated restless leg syndrome? Do you have chronic insomnia? Let's fix that. Let's work together and treat that.

59:22Dr. Mary Claire Haver:And that's where you come in. Yes. Yeah. How do you build the perfect sleep environment? Build me a bedroom.

59:29Dr. Andrea Matsumura:Yeah. You want it to be dark, cool, and quiet. Those are your big three. So you don't want extra light. If you need blackout shades, you need an eye mask. I'm a big fan of eye masks. I love a good eye mask. You have an eye mask on your website. I do. I did this collaboration with Kailu Soak and I love it. And I made little eye, little pads, little pillows for so that if you wear eyelashes, it doesn't affect your eyelashes. But you know, that tiny little bit of pressure around the eye actually induces calming. So for some people, that can really be helpful. For other people, maybe they don't, that's not for them, but you have to figure out what's good for you.

1:00:09Dr. Mary Claire Haver:Catherine sees with an eye mask, my daughter. Yeah. Yeah, I don't. And I've taken him on a plane, like, you know, especially in overseas flight, but I just worry, you know, I've never slept without, and maybe because I had trauma as a kid and was assaulted, but, you know, I sleep with fear that someone's going to touch me and hurt me, you know.

1:00:30Dr. Andrea Matsumura:A hundred percent. Well, you know, you just brought up. And so being blind scares the hell out of me. Yep. You brought up trauma. And that was discussed actually at the Menopause Society. And it's something that we don't talk enough about or really bring it up in the menopause state. But those hormones are actually a little bit protective. You know, they're actually allowing us to power through the day. And when that scaffolding starts to diminish that, then you don't have the compensatory mechanisms to power through. And so trauma tends to resurface in midlife when women are going through menopause and it greatly affects their sleep.

1:01:12Dr. Mary Claire Haver:Wow.

1:01:13Dr. Andrea Matsumura:That's a big deal that we don't talk enough about. I jokingly, or maybe not so jokingly, I carry around a box of tissues with me. Because every, literally every single woman that I see will just break down in tears. Oh, me too. Once we get down to the bottom of everything. Because a lot of women will not be on hormones because, again, we still have a lot of work to do, right? So I'll say, let's start with that. And if that isn't going to help with the sleep, then let's start digging deeper.

1:01:46Dr. Mary Claire Haver:So for women who can't, for a contraindication, or choose not to use hormones, what are your top strategies for them?

1:01:56Dr. Andrea Matsumura:At the end of the day, there's no medication that's going to cure your inability to get to sleep as we talk. There's no medication.

1:02:05Dr. Mary Claire Haver:Yeah, we haven't talked at all about the sedatives.

1:02:07Dr. Andrea Matsumura:Yeah. So that's a, such a Pandora's box.

1:02:11Dr. Mary Claire Haver:I took Ambien. Yeah. I've taken Ambien when I was doing shift work. My husband, when he went overseas, but I have friends, one of my best friends who cannot sleep without it, like will not, like it is, it is non-negotiable in her life. And there's an addiction here, you know, talk, let's, let's go there.

1:02:29Dr. Andrea Matsumura:Okay. So there's, again, there's no medication that cures your sleep. And Ambien and those medications like that, the benzodiazepine-like receptor agonist is what I like to call them, they're sedative, hypnotics, and they're also amnestics, meaning they cause amnesia. Yes. You forget waking up in the middle of the night. I don't know how many people that I've reviewed their sleep study with them. And I'll say, oh, look, you were awake here for like 40, 45 minutes. And I'll say, no, I wasn't. Yes, you were. Your brainwaves are awake and they don't remember. So their perception is that they're getting good sleep.

1:03:13Dr. Andrea Matsumura:So these medications taken long-term can be pretty detrimental because if you're still not getting into the right stages of sleep, you still have all those risk factors.

1:03:22Dr. Mary Claire Haver:What about trazodone? So trazodone, oh, love

1:03:27Dr. Andrea Matsumura:Trazodone. Is that like a bless your heart comment? Like, Trazodone, bless your heart. It is used. It's overused. It is labeled as an antidepressant that was a terrible antidepressant. And at the doses that it works for depression, you're a complete zombie because you need like 300 to 400 milligrams to treat depression. But they realized that everybody was falling asleep all the time. So trazodone is one of those medications that is used widely. But you really want to get down to the root cause of your problem. Because what if that medication stops working or there's no medication that works forever?

1:04:08Dr. Andrea Matsumura:Most people need escalating doses or they need a triad or, you know, five things. It used to work and now it's not working. You

1:04:17Dr. Mary Claire Haver:increase the dose.

1:04:18Dr. Andrea Matsumura:Yeah. So really you want to get back down to those drivers, those behavioral drivers, and maybe it's masking another sleep disorder that you didn't even know you had. So up to 60 % of folks who have obstructive sleep apnea have insomnia. And that's a condition that's called comisa. So that is the comorbid condition of having sleep apnea and insomnia. And maybe you're just treating your insomnia and don't even know that you have sleep apnea in addition. What time should I go to bed? It depends on what your circadian rhythm is set at. So people are either early birds, they're night owls, or they kind of fall somewhere in between.

1:05:00Dr. Andrea Matsumura:Is that your chronotype? Yeah, that's your chronotype. Again, those are clock genes. You're born with them. Again, we can kind of help you reset them, if you will, or align them to fit your needs. I am a morning person. You're a morning person.

1:05:16Dr. Mary Claire Haver:Oh, yeah. I am a badass in the morning. I mean, I could like cure cancer in the morning. And then the minute, like by two in the afternoon, I am just really kind of just functioning. And I go to bed typically earlier than most people. So because I'm up at five.

1:05:33Dr. Andrea Matsumura:Yeah. So you go to bed like at nine-ish. Yeah.

1:05:36Dr. Mary Claire Haver:Sometimes eight-30.

1:05:38Dr. Andrea Matsumura:Yeah, 8.30.

1:05:39Dr. Mary Claire Haver:Yep.

1:05:40Dr. Andrea Matsumura:So that's an early bird. Somebody who wants to go to bed at 8, 9, wake up at 4, 5. People who are night owls, by definition, they want to go to bed at 12, wake up at 8, go to bed at 1, wake up at 9.

1:05:52Dr. Mary Claire Haver:What if you marry someone of the different, you know, what if your life partner, your bed partner is in a different chronotype? What do you do?

1:05:59Dr. Andrea Matsumura:You have to honor your own chronotype. It's better for your health. So, you know, that's interesting you say that because a lot of women will come in and they try to follow their partner's chronotype because they are people pleasers and they want to go to bed when their partner goes to bed. They want to wake up when their partner wakes up and they're just dying of chronic sleep deprivation because those folks tend to be more of an early bird and they're staying up way too late with their partner. And the other funny thing is that anecdotally, a lot of people marry the opposite chronotype.

1:06:37Dr. Mary Claire Haver:So let's talk about lifestyle outside of, we're talking exercise, nutrition, all the other pillars of health. How do these play into how we sleep?

1:06:50Dr. Andrea Matsumura:So, you know, when we think about exercise, we know that exercising actually does help you get into all the different stages of sleep better. You just have more sound sleep. So we do want to promote people moving. What kind of movement? Any kind of movement. You know, as long as you're out there raising your heart rate a little bit, that's all that counts. I mean, if you can go walk fast, you can go swim lanes fast, you can walk lanes in the swimming pool. You can do whatever it takes to help you.

1:07:21Dr. Mary Claire Haver:Dr. Mats Moore is a triathlete, so I'm like, I don't get in the pool.

1:07:26Dr. Andrea Matsumura:So, you know, whatever it takes to get that dopamine release, it really helps with sleep. And then there is some data that shows that if you eat too heavy of a meal too close to bedtime, that affects your ability to get into the right stages of sleep.

1:07:44Dr. Mary Claire Haver:What about the quality of our nutrition? Does that really play in at all?

1:07:47Dr. Andrea Matsumura:Yeah, definitely. I mean, you know, if you're eating nothing but greasy junk food, it definitely affects the other parts of your body that then affect your ability to get to sleep. So if you're eating stuff that doesn't allow your stomach to feel good, then that's going to affect your sleep. High saturated fatty food is not going to be conducive to helping you get into the right stages of sleep.

1:08:11Dr. Mary Claire Haver:Okay. Now I've seen a lot of in the wellness world, lots of talk about, you know, and I even have a few of these devices, the red light therapy, morning light, like how important is all that?

1:08:23Dr. Andrea Matsumura:There's some small studies that say that that might be helpful, but these are all new things that have come out. And what I try to do is let's get down to basics, right? Like if you try to eat the way that we're supposed to eat with, you know, lots of vegetables, fruits, good protein, some carb, and you try to honor your body with exercise and movement therapy, that's really what you need to focus on. I don't want to complicate it too much. You don't need a wearable to get better sleep. You don't need light therapy to get better sleep. This is not about all of the little accessories that we need, right?

1:09:06Dr. Andrea Matsumura:Sleep is foundational. It's a core thing. We got to eat. We have to drink water. We have to sleep.

1:09:13Dr. Mary Claire Haver:Full disclosure, Dr. Matsumura and I, and I talked about it in the intro, have developed a sleep supplement together. So let's talk about supplements with our listeners knowing that there is a commercial interest here, but let's just talk about it in general. Don't even say what's in our sleep supplement. We talked about melatonin. Yeah. So yes or no, yay or nay. You like it? Don't like it? I like it.

1:09:34Dr. Andrea Matsumura:And melatonin, I think there's something to it. We don't have enough research out there that we should absolutely 100 % replace it. But goodness, if we are losing that much of it. Can we check melatonin levels? And you can in saliva. So there's some tests that you can do to check melatonin levels. Do you check them in your patients? No, I don't. So I think that sleep support, circadian rhythm support, relaxing your body is really important. Like you've said, it's not a sleeping pill. It's not a sedative. Right. It's not a sedative. It's not a prescription sleep aid. This is about supporting mechanisms that maintain quality.

1:10:21Dr. Andrea Matsumura:So what else? Any other supplements you would consider? I don't really recommend supplements typically because it's usually really personal, right? Like something that might work, like valerian root might work for somebody but may not work well for somebody else. Lemon balm might work well for somebody but might not work well for somebody else. And it's really difficult then to say, well, you should use this. What I like to focus on are things that are evidence-based that we have a lot of data on. So we have a lot of data on the components that we put into this sleep supplement, and we know exactly what they are doing.

1:11:01Dr. Andrea Matsumura:What I find is that when people come to see me, they're having trouble sleeping, and they come with an entire shopping bag full of supplements and medications. and I start to say things like, well, I don't think we need to actually take all of these. And somebody will say, but I can't sleep without these. And I said, no, wait a minute, you're still here. You're here seeing me because you're still having trouble sleeping. So are they really helping you or what's really going on here? So you're still here because you are still not getting sleep and you're taking$150 worth of supplements.

1:11:40Dr. Mary Claire Haver:Yeah.

1:11:40Dr. Andrea Matsumura:So I don't think that they're really helping you or else you wouldn't be here.

1:11:44Dr. Mary Claire Haver:So for a woman who's been listening and who's exhausted, who's been exhausted for years, what's the first step that she, you know, because you are talking to, you know, a couple thousand people on the podcast and there's at least, I promise, 20 percent of them, at least in my pace. In yours, it's 100 percent of your patient population. But in mine, it's close to 50. and it's only menopausal women who were like, okay, I'm not sleeping. We need to fix this because I don't want to die. What is she going to do?

1:12:14Dr. Andrea Matsumura:So the first thing that I do, which is why I carry those tissues is I validate. And I say, this is not a you problem. This is not an internal problem. This is something that we can work together. It's just not that something's broken in you. We can help. These are organic. Chronic insomnia, which is talked about a lot, is an organic medical condition.

1:12:43Dr. Mary Claire Haver:Would you say that it is a predictable, expected consequence of menopause and aging?

1:12:51Dr. Andrea Matsumura:It's pretty darn common, yeah. And we need to do something about it. And we need to say to women, sorry, you don't need to, you know, you don't need to live with this. And again, that validation, that telling women that they're not broken, that this is not something inherently wrong with them, they didn't cause it, is huge. So I start there.

1:13:16Dr. Mary Claire Haver:I see in my patients, and it's happened to me occasionally, when you get that middle of the night wake up or you're struggling to fall asleep, I had trouble with falling asleep when I was younger and ended up doing CBT before I realized I was doing it, you know, and you get into that negative spiral in your head. Like you, you were describing it of, oh my God, I'm up, shit, you know, it's going to ruin everything. And why is this happening? It's horrible. You know, you were sitting there spiraling alone in a room, struggling so hard. I need sleep. I need sleep. I just have to sleep, sleep, sleep, sleep, and I can't sleep.

1:13:49Dr. Mary Claire Haver:And I think it's affecting our mental health way more than we ever expected.

1:13:53Dr. Andrea Matsumura:It takes a toll on someone's ability to maintain positivity, to feel like there's hope for them. And that's what I tell women. That's the other thing I tell women is there is always something we can do to help you get better sleep.

1:14:09Dr. Mary Claire Haver:All is not lost. What is one myth about sleep and menopause or just sleep and women and aging in general that you want to debunk? Well, one of them is

1:14:18Dr. Andrea Matsumura:that you don't have to live with it. We don't have to suffer through it, that we can work together, that every 15 minutes counts. That's the other thing. A lot of people get stuck. A lot of women come in and say, well, I'm only getting six hours of sleep or I can only get five. And I'll say, well, let's work on achieving an extra 15 minutes because if you add that extra 15 minutes times seven times 12 months, a whole year, that's a whole lot more sleep. So let's focus on the little wins and not have to think that we have to be perfect. You've described sleep as a vital sign. What do you mean by that?

1:15:02Dr. Andrea Matsumura:So, you know, why do we check vital signs? Because we know that... They're screening tools. They're screening tools. We know that there's something that we can do about them. We know that also treating somebody's high blood pressure, treating somebody who has an abnormal respiratory rate, that actually is going to help them with reduction of other medical conditions, right? And so that's why I think that sleep should be a vital sign because, again, it is the foundation, it's the core. We could be chasing our tail with high blood pressure if somebody is not getting enough sleep. We could be chasing our tail if somebody has untreated sleep apnea and we didn't realize that they were spending eight hours in bed, but they were only getting five hours of sleep.

1:15:48Dr. Mary Claire Haver:What gives you hope right now in the field of women's sleep medicine?

1:15:52Dr. Andrea Matsumura:This increased awareness and me just kind of ringing that bell over and over again and people like yourself and all of us out there who are taking notice and giving women agency and knowledge to have these types of conversations with their provider.

1:16:14Dr. Mary Claire Haver:How can someone find a sleep medicine specialist?

1:16:17Dr. Andrea Matsumura:So you can look online on the American Academy of Sleep Medicine has a list of providers. There are sleep providers in just about every city. And I, you know, I think that that's a good place to start.

1:16:32Dr. Mary Claire Haver:So you developed something called the DREAM sleep method? Yes. Am I saying that correctly? What is it?

1:16:38Dr. Andrea Matsumura:So it is an acronym to cover all the different bases that could be affecting your sleep. What I hear a lot from women is that they got told that they didn't have sleep apnea because they had a home sleep study and that there was nothing else that could be done. So, you know, got to figure something else out. So they come to my office in appointments feeling pretty hopeless. So what I realized is that there's all of these other factors that could be affecting people's sleep that are not really getting addressed. So the DREAM sleep method is basically an acronym for all of those bases to cover. So D is your daytime activity.

1:17:17Dr. Andrea Matsumura:So what are you doing during the day that could be affecting your ability to get to sleep? Are you running around? Are you feeding yourself correctly? Are you giving yourself enough water? Are you stressed out all day long and then bringing that into the bedroom? So that's daily activities. That's the D. R is the resting environment. Is your bedroom too cold, too hot? Is the mattress uncomfortable? Do you have a TV that you have to have on all night? Is there too much light coming into your bedroom? So you want to make sure that the bedroom is dark, cool, and quiet, and that you're optimizing that resting environment for sleep.

1:17:56Dr. Andrea Matsumura:And then E are the emotions. So, you know, are you struggling with depression? Are you struggling with anxiety? Are you struggling with trauma that is affecting your ability to get to sleep and stay asleep? And then A is archetype or your chronotype. So are you an early bird, but you work a night shift? Are you a night owl or what I call an Aphrodite? So I call Artemis is your early bird. Aphrodite is your night owl. But you have to wake up really early to get to work. Or you've got to take kids to school. Or you've got some other commitment and you can't follow your true circadian rhythm. Or are you an Athena, which is basically somewhere in between and you're able to kind of fit into the societal norm, which we have here in the United States, which is like 10 p.m.

1:18:52Dr. Andrea Matsumura:to 6 p.m. But knowing what your circadian rhythm is, is really important to understand how you get into the right stages of sleep. And then the last one are medical conditions. Do you have untreated sleep apnea, restless leg syndrome, a neuromedical condition, a cardiovascular condition, menopause, all of these things? Having to get up to pee. Yeah.

1:19:15Dr. Mary Claire Haver:Yeah. Multiple times at night.

1:19:17Dr. Andrea Matsumura:That's right. That's actually a risk factor. I have so many urologists refer patients to me because getting up to go to the bathroom in the middle of the night can be a risk factor.

1:19:28Dr. Mary Claire Haver:Is there anything else you want to tell our audience?

1:19:31Dr. Andrea Matsumura:Well, I'll just kind of leave again with there is always something you can do to help yourself get better sleep. All is not lost and that nothing is wrong with you. There is something that we can do to help you feel better about your sleep, feel confident again about your sleep.

1:19:54Dr. Mary Claire Haver:Amazing. Thank you so much for joining us on Unpaused. You're menopausal now? I'm post, yeah. I'm past. You're done? I am done. So menopause for a lot of our listeners, not me anymore. I feel like I am my absolute most badass self now. feels like that the world wants us to hit pause. The world wants us, you know, we tend to be invisible. Women really, really feel invisible. But what are you doing to unpause for yourself?

1:20:22Dr. Andrea Matsumura:I reinvented myself. This was my reset. And that is the one thing I want to leave people with, is that even if you've had years of bad sleep, you can still reset and enjoy the rest of the decades that you have left to live. And with menopause, my F jar got empty. And I said, I am over this. I am not going to be invisible. I'm going to be heard. And I'm going to raise awareness. And I'm going to help other people know that they have power in themselves. There's a group of other people that want to promote health. and that we have a whole another second half of our life to live even bigger and better.

1:21:12Dr. Mary Claire Haver:Awesome. Thank you so much for joining us on Unpause. Thank you. You can find Andrea on Instagram at Dr. Andrea Matsumura and through her website, sleepgoddessmd.com. You can find full episodes of Unpause on YouTube at Dr. Mary Claire. I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram at Dr. Mary Claire and get honest, accurate information on health, fitness, and navigating midlife at thepawselife.com. My upcoming book, The New Perimenopause, is available for pre-order on Amazon. If you're loving this podcast, I have an important request.

1:21:53Dr. Mary Claire Haver:Please take a moment to follow Unpaused on your favorite podcast app. Following and listening is what pushes this information to more women who need it. So if this podcast has helped you feel seen, understood, or supported, hit follow right now so you never miss an episode. Thank you for being here with me. Let's keep going Unpaused. Unpaused is presented by Odyssey in conjunction with Pod People. I'm your host, Dr. Mary Claire Haver. The views and opinions expressed on Unpaused are those of the talent and guests alone and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment.