Ep036: Menopause, how to sleep better?--with Dr. Kin Yuen

deepintosleep.co

Dr. Kin Yuen

with Dr. Yishan Xu

 

TODAY’S GUEST

Dr. Kin Yuen is a sleep medicine specialist who provides a range of services and treatments for patients with sleep disorders.

Dr. Yuen's current research focuses on a medical device that treats sleep apnea. In the past, she has conducted research on sleep disorders in patients with Parkinson's disease as well as on other medical devices for sleep disorders.

Dr. Yuen earned her medical degree at the Albert Einstein College of Medicine, where she completed a residency in internal medicine. She completed a fellowship in sleep disorders at Stanford Medicine, where she also earned a master of science degree in health research and policy.

Dr. Yuen is a member of the American Academy of Sleep Medicine and American College of Physicians. She has presented her research findings at conferences around the country and abroad, and has appeared on various local media outlets to discuss topics related to sleep.

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Dr. Kin Yuen’s information can be found here.

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Transcript

- 0:00  

When your family members or friends went through menopause period, have you noticed any shift in their sleep patterns or mood? I remember when I was younger. When my mom went through menopause, she was so unhappy and she could not sleep nights after nights, which later I learned was very common among women who are going through menopause. Up to today, I could still remember the pain that I witnessed such a struggle of someone I loved, but I did not know what to do to help her at all. Sometime. I'm wondering if I could go back to help my mom to sleep better back then, would that be helpful to reduce her emotional suffering? Today, I'm very happy to invited Dr. Kin Yuen from UCSF sleep center. To talk about the ins and outs of menopause, how that impacts sleep, and what are some common strategies to deal with it?

- 1:13  

Hi, Dr. Yuen. Welcome.

- 1:15  

Oh, thank you so much for inviting me.

- 1:18  

So I really want to talk to you about menopause and sleep. I know this is a topic a lot of friends of my a lot of clients keep on asking about. So what are some common sleep difficulties or challenges we face when women are going through menopause period?

- 1:42  

Yeah, it's a very important topic and in the United States before dwelve into the symptomatology. We have found that women surprisingly are going through some very early onset of menopause. So simple terms. So when they come to the sleep clinic, typically we hear about hot flashes, for instance, night sweats. And when that feeling of warmth happens at night, very often it's hard to stay asleep or they get abruptly awakened from one of these episodes. And the symptoms can vary from Woman to Woman, for the, you know, the American population, American women. Usually the onset of menstrual irregularities, can begin perhaps six months, perhaps a year, perhaps several years before they stopped menstruating. And it can vary depending on ethnicity as well. So, proportionally Caucasian women are more likely to have some of these symptoms a lot more to the extreme version. For instance, some women can have hot flashes up to one per hour, you know, and she may have 10 episodes per night, versus others may have less frequent episodes of night sweats. They may come in clusters, you know, one woman may have two or three per hour versus others may have two or three per night. And not all the night's hot weather can, of course, exacerbate these symptoms. And if one's not sleeping, well definitely the next day's function is going to be affected. Right. So some women felt that they couldn't really concentrate as well pay attention to the conversation. Or they may have some short term memory like remembering perhaps sometimes names or people or why they intended to go into the room. So that can happen as we mature and grow older. But again, being excessively by having poor night's sleep.

- 3:57  

Do people start experiencing the difficulties of sleep during menopause or before?

- 4:06  

Yeah, that also can vary quite a bit. So in the extremes or more extreme spectrum, some women may begin to have mental irregularities in their 30s even Wow. Yeah. Which is really surprising because, and that's an unfortunate trend that I have observed in the clinical population. I myself was very surprised until I read the data and found that there is increasing risk of premature ovarian failure when the ovaries start producing sex hormones, causing some of the menstrual irregularities or abrupt stoppages. And so in terms of onset of symptoms can vary quite a bit. So some women may begin to have some hot flashes before their menstrual periods, become, you know, come to a complete stop versus other ones. Women may still be menstruating failing regularly, but the periods may get a little bit heavier some months, a little bit lighter of a month, they may have spotty between periods. And so this so call perimenopausal lack of about word period can can vary in like I says For some, it could be quite short for others it could be extended for a certain number of years you know it's not uncommon to have onset these pennant pyramid Walsall sweats and so forth for a year. And so it depends also on whether there is surgery, right. So some women may have physical reasons that they require hysterectomy to remove the the uterus, and sometimes the surgeon will offer as an option depending on what the reasons are behind the surgery to remove the ovaries together with the uterus, depending on whether it's For instance, some women have so called fibroid tumors, which are benign tumors, but they take up a lot of space can cause irregular bleeding from the uterus, in which case maybe just taking out the uterus alone would be sufficient if it's causing other compression problems for the individual. For others that may be close to menopausal age, you know, close to 50 or slightly older. Sometimes the surgeons will also remove the ovaries. So if it's done for surgical reasons, and it's quite abrupt, then that woman may feel a lot more. abrupt onset of symptoms in the hot flashes tend to be a lot more severe. And in that kind of situation. With the ovaries removed 90% of the women that have undergone this kind of operation will feel hot flashes is almost always a given. And not all the women are candidates. For hormone replacement, right? So some women or they have the bracha gene for breast cancer, for instance, or for other reasons they may have ovarian cancer and a family has a strong history. And so these women usually are not going to be candidates for hormone replacement.

- 7:21  

Hmm. So for hormonal replacement therapy, I think there are some data showing it helps with the symptom of menopause. Will that help with any sleep related symptoms during that period?

- 7:37  

Yeah, the controversy came in that there was a well publicized Women's Health Initiative study with 10s and thousands of women being study a while back. And unfortunately, you know, the study that originally was published, involve failing high dose because it was sponsored by one Most manufacturers, and at that time the outcome showed that so there were a few outcomes they were looking at whether it actually reduce the so called cardiac events in women having heart attacks in helping women potentially who might be a risk of having dementia. So they were looking into whether that could be helped by hormone replacement. And the data show that it did not. But the problem is the women that were enrolled in the study were older. So they were about 6061 at the time when this study began. And so the outcome showed that more women were harmed by the higher dose of hormonal replacement, although it did help with some of the sleep issues in regards to menopause. And so, because of the report of that study, it has taken A lot more motivation and also persistence in research in figuring out, you know whether it is really helpful for women to go on hormone replacement. So for a couple of decades, there's really not a lot of research after that study was published. So but in terms of helping sleep having what we call the vasomotor symptoms, which are the hot flashes, and night sweats, hormonal replacement at lower dose, which is currently what's being recommended, either in a form of a patch, which is preferable, they're a combination patches were both the estrogen component, and then the progesterone component of combined into one. So women that have intact uterus are recommended to have a combination to protect your uterus so that we don't develop bleeding and or risk of cancer for women that deliver Have a uterus typically they will go on estrogen alone. So it can be estrogen patch alone without the progesterone component to it. And so, either alone or together, they have been at low dose known to reduce substantially, the number of night sweats the number of awakenings and the number of hot flashes that a woman experiences. Now, the two hormones presumably have different function a lot of that has to be looked into further. So a lot of the data that we have are from rodents or rats and mice and along with human subjects, and so what we have found is that the estrogen so one of the reasons that we have these acute onset right as I said earlier, the spectrum presentation can be highly variable. Some women experience a lot more symptoms, some women not so much. And some women can also tell you that no all you know my periods stuff, everything's okay. And I continue to function as normal. So we consider those women incredibly lucky.

- 11:11  

And so what we have learned is how rapidly the estrogen part drops. So the faster wishes the biologically active component we call extra dial in the blood that's measurable. But there's a very big range of what's normal. So of the women that tend to have more severe symptoms, we tend to see a more abrupt drop in their estrogen levels. But not all women, of course, need to have their blood drawn to see if the estrogen is really low. Again, just because the range of normal was so big. So if it's within the normal level, but this is much lower compared to where her levels were before, then she's much more likely to have symptoms. So the women that have more abrupt onset more severe symptoms, of course, seem to be helped more with hormone replacement. women that have milder symptoms or less frequent symptoms, may not wish to consider hormone replacement because they're not without risks. And one of the risks is having blood clots, there is a much higher risk of having blood clots, you know whether we're taking a low dose hormone replacement, either transdermal Lee through patches or through pills. And we've seen that even with women who are on oral contraceptives of any kind. So, this is not a risk to be taken lightly. It has to be weighted, you know, against all the other risk factors that one may be feeling. The progesterone level is an interesting thing, because experiments have been done to look at Well, you know, what are the effects not just on women, but let's look at how it affects men. So the research was done, and we found that the more Or are higher dose that we give to women and men, the more sedated they may feel, and the better their sleep is. So it creates this so-called dose-dependent effect, the more we give to sleep you one can become, it's not always good, right? Because we want to make sure that our sleep is high enough dose to sustain sleep that we don't wake up as frequently. But we don't want to wake up feeling like we're kind of drugged the next day and can function. So the current thinking with hormone replacement is to keep it as low as possible to mitigate against the risk of having blood clots, and also of course, irregular bleeding, which can also be a quality of life issue. And make sure that there are other medications if or behavioral approaches. So very often, fan works we know because when we have hot flashes, We have so-called visa dilation the blood vessels get bigger similar to you know, we have a couple of drinks very often the skin may turn slightly red and we turned that the Asian glow. So particularly for Asians were a few alcoholic beverages we may turn red bright red, so that that's because the blood vessels are getting bigger try to dissipate heat.

- 14:31  

So we know by wearing clothing, for instance, linen silk actually is not as helpful as silk tend to retain heat on although, yeah, so natural fabrics, you know, like cotton and linen may be helpful. There's also some this I don't think I've looked into research as much. Some of the athletic fabrics that are moisture-wicking, in that it, you know, takes the moisture away from the body can be somewhat helpful, although I don't think studies have been done to specifically look at that and really depends on how it's constructed right so for instance, it was a loose-fitting tank top, then it may be helpful more so than a long sleeve shirt. And and then the weight of the Comforter and the other fabrics that one may use. So there is some combination fabrics that's kind of cotton mixed in with other fabric may be able to, again get the moisture away from the body. That may be more helpful compared to let's say, you know, heavier cotton comforter. So some of these combination fabrics. Again, this the woman herself, we may have to kind of test it out a little bit before committing to obviously changing our bed linens or comforters right because what works for some people may not work for others. And an interesting thing that again, has not been looked into the so-called weighted blankets. Because we know for insomnia work, some of the patients actually like these weighted blankets either 15 or more pounds. So, for Metapod also transition, I don't think that has been looked into whether they're helpful or not. Just because even though they wait a bit, very often, the fabric itself is lighter weight compared to a comforter. So I don't really have an opinion on that, except it's still going to be trial and error process. Whether it works for some women versus others.

- 16:37  

Yeah, but sounds like what we wear what we use on bed that possibly can help us somehow.

- 16:46  

Oh, yes, yeah, I would totally agree with that. temperature. We also knows, we also know makes a difference right? So most often in women that are experienced in hot flash. We feel more comfortable in cooler environment. So for our sleep purposes, there's also a high range of what's comfortable for some women. Certainly, if we were experiencing hot flashes, we don't want the temperature to be like, you know, 74 or 78 degrees Fahrenheit, we probably want to dial it down to closer to mid or high 60s that will make one more comfortable. But the other thing that's interesting and you're hearing women talk about, oh, you know, I felt warm, I took off the covers, and then I feel cold, right? Because when we go into so REM sleep, rapid eye movement sleep, and we go through those four to six periods, hopefully during the night, each one getting longer. And so when we're in REM sleep, we don't have temperature regulation. We are actually like a lot of the nonmammals. That we take on the room temperature. So if we had dialed down the thermostat before the night starts and then all sudden you know we feel warm where we're not comfortable but then we go through a dreaming cycle, then we may feel chilly then we can feel cold again. So that pan with some women up as well. So I guess you know we just have to find a balance that will allow us to feel comfortable and up and not shivering as the night progresses.

- 18:31  

Yeah, it sounds like it's really an individual approach to each of individuals need to find out what really works for her.

- 18:39  

Precisely.

- 18:41  

So how about some cooling device I know for treating insomnia, there are some device right now. Still going through possibly research period that they either cool your neck, your forehead, or your whole body. You can put it below You while you're sleeping on it? Will, is there any evidence about those kind of device can help with menopause-related sleep difficulties?

- 19:09  

Yeah, so to my knowledge, number one, I think it's great to have technology. Because insomnia obviously is an area that needs a lot more research. And because again, people have different reasons why they have developed insomnia. And menopause is a big risk factor, right? Because if we do not help women get through this period, then some of either thinking or maladaptive behavior may perpetuate. And now, these women may potentially have longer-term consequences for insomnia. So these cooling devices, there are two thoughts number one is that in some of the research, what's interesting is predating that that when Some of the subjects were sleeping, and they immerse the subjects hand into different temperature water. With their permission, of course, then it actually helps improve in terms of how they feel, and how the quality of their sleep as reported by the subjects the next day. And what we know, among some people that have the so called hyperarousal response, in that, if there is a stimulus, they get awakened really quickly, and that the acceleration and heart rate, the faster heart rate, and the thinking may prevent them from falling back to sleep. So what we also know is that sleep is more likely to come if our body temperatures drop a little bit. So hence we had for a very long time, ask patients to take a warm bath if there was insomnia. So the warm bath of course raises your body temperature but they also relaxes the muscle. But the moment we step out from the warm bath, then the temperatures actually drop faster. So we're actually helping the process along for that person to feel sleepier. And so the theory goes, Well, what if we help them cool the brain, right? So we call the forebrain or at least the forehead, then will we get a stronger signal that this is a correct time to go to sleep. Um, as from what I understand these data's being getting FDA approval. So hopefully we'll know once they are able to market to a wider audience whether it's going to be helpful. But again, from what I've heard is that the research look looks promising. The only thing is when we have done some studies on patients for other reasons, let's say for obstructive sleep apnea, which also increases after menopause. When we have done studies using different types of technologies, so for instance, there are some that we put around the wrist, there are some that has a belt that goes across the chest area, there are some that are fitted over the forehead is, you know, the universal complaint is no, these are not comfortable. And that does include the device that goes across the forehead. Some of it may be the weight of it, you know, some of it could be just, we don't like things on our faces or forehead sometimes as we sleep, particularly if they become dislodged. So I think that will be a consideration. You know, if you're someone who doesn't like wearing glasses, or if you wear sunglasses and they bother you, or if you wear a hat and sometimes from the compression, some people are very sensitive to it. So if they don't like wearing hats, so if you're one of those individuals, then perhaps you know That's not gonna be the device to help you sleep, you may want to go for other alternatives.

- 23:06  

Great to know. Thank you. Oh, you also mentioned very quickly about sleep apnea that that athlete could increase among post-menopausal women and I know there's some data showing the snoring symptom could be more common among that population.

- 23:27  

Right and thank you for reminding me is a very important issue because some women may begin to realize that well while their breathing was fine pre-menopausal Lee, then there was some reports that here and there hey, you know, I, I hear you shorting or doing a hotel room that one may share with family or other friends like there are some reports of storing and so what we know That definitely with the decrease in estrogen level, which helps the soft palate which is the back of the throat and the tongue to stay in place, progesterone also plays a role in maintaining the tongue in a more forward position that postmenopausal Lee the risk of having obstructive sleep apnea when one starts breathing, or have shallower breathing repeatedly during the night, causing one to wake up, it increases by about 4% per year is additive. And so in the peak around 42, depending on how one defines sleep apnea 40 to 70% depending on which study we reading, so it increases substantially postmenopausal Lee so for comparison for menopause, in the so-called middle-age category, it could vary around 2% of women may be at risk of having sleep apnea. And then but 4% of men, but postmenopausal Lee, we are about even and part of the reason again is from the estrogen withdrawal. Literally the the soft tissues in the back of the throat become more collapsible. And the fact that the airway you know where voice boxes and some of those Cartledge to suspend the voice box become literally harder because it's taken over by the soft cartilage becomes more bony and then the vocal cords become a little bit stiffer from the stimulation for male hormones that we all have ages that postmenopausal Lee we may have a little bit more of it. And that also coincides with why you stop women will have more facial hair, you know or thicker facial hair compared to before menopause. And so this is definitely an area that just because if one stops breathing during the night, that's going to wake you up to and it's it has a lot more dire consequences in terms of you know, if we're not breathing repeatedly, and I heard the podcast that your father uses more faily loudly. Yeah, yeah. So the story is just one symptom. A lot of women don't snore, necessarily. They may have heavy breathing, or it only happens when they're on their backs. But that could be the beginning, right? Because snoring just indicates that, well, there is something that's interfering with the air going in and perhaps with the air coming out. And so we have to identify what that something is. myself being Asian Asians a little bit more risk of having sleep apnea, just because the how the jaw is structured. And so and then to position at the tongue because some agents not all maybe Have a smaller lower jaw. And it may be a little bit recessed compared to our Caucasian counterparts. So if the tongues already kind of a little bit setback, it really doesn't take a lot, particularly when we go to the dream cycles when the muscles are paralyzed, except for the diaphragm, maybe a little bit written muscles. And so for the tongue to be so relaxed, that it would just drop further back, and therefore blocking the airway. So we think that the abrupt withdrawal of estrogens or the more gradual withdrawal of estrogen, again, depending on the woman's body composition, genetic factors, and sometimes environmental factors. Again, I think one blessing if you're one can save that from COVID-19 is that we have less polluted air in general, just because we all stop going outside. And so there's a little bit less of the nasal congestion, you're feeling stuffy all the time. But now that we're going gradually back to back to work, we may see the air pollutants going up again. And so when a couple days so congestion nice stuffy nose, along with a more relaxed tongue, and if we are enjoying, you know,

- 28:22  

any alcoholic beverage and where the tongue is even more relaxed, then we have the perfect storm right? So if the tongues more relaxed muscles are more relaxed. We may have more breathing problems that night compared to other times.

- 28:39  

Yeah, wow, great, great, no all this science reasons behind what may happen and why they happen. So I think that can really help a lot of our audience going through menopause or have some symptoms of sleep difficulties. To help them understand their bodies better, and then they possibly can consider whether they need to see a sleep doctor to get more diagnose or intervention accordingly.

- 29:13  

I hope so I hope that the audience out there if they are having issues, particularly now that we're all sheltering in place Still, this is a great forum for them to try to get help. If it's not for themselves, certainly for people that they love and that they know may need some help and guidance.

- 29:34  

Yes, definitely hope so. Thank you very much, Dr. Yuen for sharing all your expertise and knowledge with us with the audience.

- 29:43  

It is my pleasure. Thank you for inviting me.

- 29:45  

If you have listened to my show before, you may know I always emphasize that sleep is an individual thing. Everyone sleep difficulties are unique to themselves. And the intervention varies Also sleep difficulties among menopause are very similarly, there is no one fit all method, we really need to understand what our body needs, what really works for us what doesn't, and then we can figure out how to intervene and how to help ourselves accordingly. Hopefully, this episode really help you to understand this phenomenon better, and gave you some ideas where to get started to find the help to get better. If this bothers you or your loved ones are wrong to you. If you want to read more about Dr. Yuen's work or read the transcript of our show, you can go to our show notes at www.deepintosleep.co/episode/036. If you want to know more about the season bt for insomnia treatment which offers you can also find information on the website at www.deepintosleep.co. Thank you very much for listening. I will see you next week.

- 31:14  

Sleep is an individual thing. We all sleep differently and there are so much we can do to improve sleep quality. Keep hope and carry on. This podcast is for general informational purpose only and does not include the practice of medicine or other health professional services. The usage of the information we share is that the listeners own risk and our content does not intend to be a substitute for any medical and professional services, diagnosis and treatment. please seek professional health services as needed.

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Dr. Yishan Xumenopause, insomnia, Menopause Hormone Therapy, sleep, sleep quality, hot flashComment