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Ep. 514 Exhausted But Can’t Sleep? – The Best Fixes for Insomnia, Sleep Apnea & Night-Time Anxiety with Dr. Andrea Matsumura

  • Cynthia Thurlow
  • 1 day ago
  • 34 min read

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I am delighted to connect with Dr. Andrea Matsumura today. Dr. Matsumura, affectionately known as the Sleep Goddess, is a board-certified sleep medicine physician, menopause expert, speaker, and the founder of the Dream Sleep Method. 


In our conversation today, we explore how different life stages impact our sleep quality. We discuss the effects of wearable technology, orthosomnia, and sleep stages, and explain why sleep quality is more important than its quantity. Dr. Matsumura highlights the red flags for sleep, breaks down how sleep deprivation affects our health, and examines specific sleep issues, including sleep-disordered breathing, Upper Airway Resistance Syndrome, chronic insomnia, and the challenges of shift work. She explains why sleep apnea is seen more commonly in menopause, and how it occurs in 67% of menopausal women, yet most fail to realize that they have it. We also tackle the risks of untreated sleep apnea and the sleep syndrome of menopause, sharing ways to address sleep issues with appliances, technology, medications, cognitive behavioral therapy, and ACT therapy, and pointing out those that have proven to be ineffective. 


This conversation with Dr. Matsumura is truly invaluable, and I look forward to reconnecting once her new book is published.


IN THIS EPISODE, YOU WILL LEARN:

  • How hormone changes in menopause impact airway function and sleep quality.

  • Why sleep apnea in women often goes undiagnosed 

  • How fragmented sleep affects brain function and mood

  • Why even mild sleep apnea can have significant health consequences

  • How different hormones influence specific stages of sleep.

  • How hormone therapy can improve sleep quality without curing sleep apnea

  • The value of oral devices and positional strategies for supporting breathing at night

  • How CPAP therapy can transform sleep and improve cardiovascular health

  • The benefits of cognitive behavioral therapy for addressing insomnia 

  • Why prescription medications and supplements seldom solve long-term sleep problems

“Moderate or severe sleep apnea increases cardiovascular risk up to fourfold.”


– Dr. Andrea Matsumura

Connect with Cynthia Thurlow  


Connect with Dr. Andrea Matsumura


Transcript:

Cynthia Thurlow: [00:00:02] Welcome to Everyday Wellness Podcast. I'm your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.


[00:00:27] Today, I had the honor of connecting with Dr. Andrea Matsumura. She's a board-certified sleep medicine physician, menopause expert, speaker, and founder of the Dream Sleep Method and affectionately known as the Sleep Goddess.


[00:00:44] Today we spoke about how different life stages impact our sleep quality, the impact of wearable technology and orthosomnia, the role of specific sleep stages and why quality is more important than quantity, specific red flags for sleep, the impact of sleep deprivation on our health, specific sleep issues including sleep-disordered breathing, upper airway resistance syndrome which is a phenotype of obstructive sleep apnea, chronic insomnia, and particular challenges of shift workers, why sleep apnea is more commonly seen in menopause and occurs in 67% of women in menopause, but most do not realize that they actually have it, what untreated sleep apnea puts us at risk for, the sleep syndrome of menopause, how to address sleep issues both with appliances, technology, medications, cognitive behavioral therapy, as well as ACT therapy and what isn't effective.


[00:01:50] This is a truly invaluable conversation with Dr. Matsumura. I look forward to connecting with her after publication of her new book.


[00:02:02] Welcome. I'm so excited to have you on the podcast and have this conversation that is really dedicated to women and sleep, which everyone knows how important sleep is or I hope they do, and certainly after this conversation, they will be able to appreciate it even more.


Dr. Andrea Matsumura: [00:02:20] Thank you for having me. This is going to be a great conversation.


Cynthia Thurlow: [00:02:23] Absolutely. We were speaking earlier about how you moved into this space and how frustrating it was as a physician, as a female, as a middle-aged woman because many patients experience some degree of normalization of suffering in perimenopause and menopause and it has to be from well-meaning providers. I don't think it's done in a way that there's any malice behind it. But let's discuss how our sleep changes throughout our lifetime. I know pregnancy can be a big pain point for many women and then we move into perimenopause. For so many of us, it probably makes us appreciate how sleep was so much easier when were younger. What is changing physiologically that's contributing to some of these changes that you see as a clinician in your patients?


Dr. Andrea Matsumura: [00:03:13] Yes. When we have those changes in the levels of progesterone, estrogen, and testosterone, the quality and the character of your sleep changes. We rely on progesterone to help us get to sleep. That is our relaxation hormone. It's a GABA potentiator. Then, we might have trouble getting to sleep when we have dips in our progesterone. Estrogen helps us stay asleep. Most people will think of it as the vasomotor controller, the one that is helping us with the temperature because our temperature dips as we get more hours of sleep. There's a nadir that your temperature reaches and it starts to rise again as we are going to wake up. That mechanism, that regulation is faulty when we have these dips in estrogen. Estrogen also helps us potentiate REM sleep.


[00:04:18] When we have these dips in estrogen, we also have changes in the quality and quantity of our REM sleep. Testosterone is really helping us maintain our slow wave sleep or deep sleep. I'm going to interject here and say, a lot of people use some sort of wearable to determine their sleep.


[00:04:43] REM sleep and deep sleep or slow wave sleep are lumped into the deep sleep category. Light sleep is stage 1 and stage 2. A lot of people will have some anxiety around the levels, but we actually spend the most time in stage 2 sleep. I want to allay people's fears and not hang so much on the percentages, but really rely on your perception how you feel. That is the most important thing.


[00:05:18] Make no mistake, these hormones definitely affect your sleep quality and quantity, but I want us to focus on how are we feeling because we know our bodies the best. A wearable is going to be a great adjunct and indicator to help you notice different patterns, but it's not really going to be diagnostic.


Cynthia Thurlow: [00:05:42] I think this is so important because I know Oura changed our algorithm for deep sleep maybe a year and a half ago and so many of my patients were reporting, "I was getting two hours of deep sleep. Now if I'm lucky, I'm getting an hour." To your point, there's some degree of variability or variance in these wearable technology. I think for a lot of patients, it's trusting how you feel and what your perception of your experience with sleep. I know for me, it's interesting when I look at my metrics, how much I've been awake, even if I've been imperceptible of it, is oftentimes a better reflection for me personally of how good my sleep is.


[00:06:27] Because you have nights where you hopefully don't toss and turn very much, but if I'm getting up early for a flight or I'm traveling, my sleep may be impacted, but it’s usually for me personally, how much I've been awake, even if it's imperceptible. I think reassuring women how important it is to be checking in with yourself. Don't allow the Oura Ring, the readiness score or the percentages of breakdown between REM and non-REM sleep to be the primary driver of how you view yourself during the course of your day.


Dr. Andrea Matsumura: [00:06:59] Absolutely. All of the wearables are priming people. I always tell folks, “Before you look at any of that data, ask yourself how you feel before you look at the data because it will change your perception.” You might wake up thinking, "I slept great." Then you look at your data and it says that you slept terrible. Then you're thinking, "Did I sleep terribly? I don't know." That's just my caveat with all of the wearables. Apple just came out with this new algorithm for measuring sleep apnea. Of course, I know we'll get into that. Most women have mild-to-moderate sleep apnea and it's really focused on severe sleep apnea. It's not that helpful for women. [laughs] 


Cynthia Thurlow: [00:07:43] Absolutely, absolutely. There's even something called orthosomnia. There are some people can get-- I don’t want to say that-- again not sounding pejorative, but I think people can get overly fixated with the quality of their sleep to their own detriment. Do you have many patients that come to you where you have these concerns? It's just kind of orthorexia, people can be so fixated on eating perfectly. There can be individuals as well who get fixated on having sleep perfection 100% of the time?


Dr. Andrea Matsumura: [00:08:14] I think that we have a society that is relying on the wearables too much and there is a rise in orthosomnia. What I tell folks, because we know that. Typically when I'm in front of an audience of women, I can safely say that half of you are having trouble sleeping because in midlife, perimenopause, and menopause up to 55% to 56% of women will have trouble sleeping. I tell my women that come to see me all of the time, “every 15 minutes count.” Don't hang all of your sleep quality worth on getting the seven to nine hours. If you've been able to accomplish an extra 15 minutes every night, you multiply that by seven, you multiply that by 30, and you multiply that by 12 months. That's a whole lot more time you accomplished.


Cynthia Thurlow: [00:09:10] I love that perspective because that's doable for everyone. I know sometimes when I encourage women to go to bed 30 minutes earlier or give yourself an additional 30 minutes of sleep, that seems overwhelming whereas 15 minutes is something all of us can do to improve our sleep quality. I would love to just briefly touch on the sleep stages because I think there's a lot of misinformation about REM versus non-REM sleep. You mentioned stage 1 and stage 2 sleep. We spend most of our sleeping hours in stage 2 sleep. What are the important characteristics of REM versus non-REM sleep that are important for listeners to really understand?


Dr. Andrea Matsumura: [00:09:49] Yes. There are different mechanisms at play in the brain around clearing out the waste products of the brain, around regenerating-- the repair of your body, the emotional regulation. Stage 1 is that light sleep. That’s when a lot of people might think that they didn't sleep at all, but they were probably in stage 1. That's the phase where you're starting to relax. The body is getting into sleep mode. It is preparing the body for the other stages of sleep. Stage 2 is a deeper form of stage 1, but it is really where we just have all of these mechanisms for relaxation and letting the brain sleep if you will.


[00:10:39] Stage 3 and 4 is really REM sleep-- the old terminology is stage 4. Those are the pieces that are most active. But you don't need a lot-- That's not the majority of your sleep. It's stage M2. So, stage N3 or slow wave sleep is when we're doing all of our repair. That's the most restorative part of our sleep and we do have less of it as we age. There's a debate whether or not that's just the norm, healthy aging-- that's normal aging and I will say to people, well, between normal aging and healthy aging, we don't have to suffer as we're aging. The stereotype is an older person coming in or a person who is 50+. Let's just say that because I'm 50+ and I don't consider myself old. [laughs] 


[00:11:34] But they'll come in and say, "I'm supposed to get bad sleep now because I'm older." That's not necessarily true, yes? That might be part of the aging process. But do we have to suffer in the second half of our life? REM sleep, the last stage of sleep is really around emotional regulation, consolidation of memory, that is, when we're dreaming. Those two are the most important stages of sleep, but we don't have high percentages. We have smaller percentages of those compared to stage 2 of sleep. A lot of people will get very upset that they don't have that much deep sleep. Again, we don't really need-- there are norm values and they do get reduced as we age.


[00:12:27] But again, I try to focus on the quality as opposed to the quantity. Really what we need to focus on is how high quality your sleep is, not necessarily how many hours you're getting of sleep. If you feel pretty good when you wake up in the morning and you got five and a half hours of sleep, that's a win.


Cynthia Thurlow: [00:12:51] I think this is an important distinction because we've been conditioned by a lot of the male biohackers [Dr. Matsumura laughs] that we need this much time in deep sleep and we need this much time in REM sleep, and if we're not getting that much, then somehow we're messing with our glymphatic system. We're not able to clear waste. The glymphatic system is like a toilet in the brain. There's no other way to visualize it. It's just very important for cleaning out debris and waste that we don't need. It takes so much energy we need to be doing it while we're sleeping because our body is utilizing so much energy to do that.


[00:13:26] When you're doing an intake on a new patient, what are some of the red flags about sleep that for you set you into a different frame of mindset? I know that a lot of your patients are--you're going to be thinking about diagnostic testing to evaluate their sleep quality. But before we get to some of the problems that will happen when we're not getting high quality sleep, what are red flags to you as a clinician? Things that will set in motion that there's more going on than just perimenopause, menopause, too much stress, not enough sleep hygiene, etc.


Dr. Andrea Matsumura: [00:14:04] When people spend a lot of time in bed versus the amount of time they're sleeping. That's a big red flag. That doesn't get asked unless you're seeing a sleep clinician [Cynthia laughs] most of the time. People will say, "Oh, yeah. I get eight hours." Then I will dive deeper and say, "Well, what time do you get into bed versus what time do you fall asleep?" Somebody will say, "Oh, it takes me two hours to fall asleep." That's a red flag. Or they don't get asked how many times they wake up. We have arousals throughout the night, they last seconds. But if you wake up and then you wonder when you're going to get back to sleep, that's very different.


[00:14:45] When you start diving deep and asking people how many times do you wake up and how long does it take you to fall back to sleep and then you start hearing, "It takes me about 30 minutes" or "I just get up and go to the bathroom and then I come back and it takes me 15 to 20 minutes." That's actually a long time to fall back to sleep. Those are some really big red flags. The last one is when people say, “I wake up in the morning and I feel like I could sleep for another three hours” or “I feel worse than when I was going to sleep”, that's another big red flag.


Cynthia Thurlow: [00:15:21] Thank you for sharing those because I feel like there's sometimes not an appreciation for those nuances and if someone's listening and let's say once a week you wake up and it takes you 15 or 20 minutes, that's not what we're talking about. We're saying a consistent pattern or spending a lot of time in bed and being unable to fall asleep for hours, that is not something we want to see happening all the time.


[00:15:44] What are some of the greater concerns if we are sleep-deprived? If we perceive we're not getting enough sleep and on paper we're not getting enough sleep, what is the research demonstrating in terms of-- what are the long-term effects when we are missing out on high-quality sleep over time?


Dr. Andrea Matsumura: [00:16:00] There are studies that were done on people who are chronically sleep-deprived and it's basically similar to somebody who is inebriated. Your reaction time is slowed, your memory consolidation is hampered, and then your executive functioning is not up to speed. Those are the three big areas when you are chronically sleep-deprived.


[00:16:24] There's newer data that is coming out that clearly-- we know that there is higher cardiovascular risk when you are chronically sleep deprived. In addition, there's a correlation, not causation, but a correlation around an increase in cancer. The last one is a correlation around the increase in dementia.


[00:16:46] That's really what has sparked my interest and why I've started to take a deep dive in melatonin research because we lose melatonin production as we age. I thought to myself, “Why wasn't I taught this in my sleep medicine fellowship? I was taught that melatonin is only a circadian rhythm regulator, but I was not taught that the pineal gland is the first gland in the body to calcify and that by age 50, we lose up to 50% of our melatonin production. That's a lot and that has a lot to do with why we start having fragmented sleep, why it contributes to the brain fog. Then I started to read some of the work that Lisa Mosconi has done around the fact that two-thirds of all dementia cases are in women, and that led me down the path of realizing that when we lose estrogen, estrogen modulates the production of serotonin. Serotonin modulates the production of melatonin.


[00:17:56]  I think women get two hits. We have the natural-- In the general population, we have a natural reduction of melatonin. Then women have this secondary reduction when they have a loss of estrogen. Speaking of the male biohackers out there, some of them have villainized melatonin, but it's a hormone. If our thyroid stops working, we replace the hormone. If our pancreas stops working, we replace the hormone. If our ovaries stop producing estrogen, we replace it. Right? So why aren't we thinking about replacing melatonin? Not as a sleep fix. It's not going to be the silver bullet that suddenly your sleep is all fixed because typically sleep issues are multifactorial. But it is part of your longevity solution. It's part of the healthy aging. Because what we want to do is not necessarily extend life and have it be poor quality. I want to have the highest quality I can have for the time that I'm here on the planet.


Cynthia Thurlow: [00:19:09] I am so excited and I knew-- [Dr. Matsumura laughs] based on my research I knew we're going to talk about melatonin. I've been talking about this for years as a master antioxidant and how important it is. It was always the male biohackers that would poo-poo melatonin. "You shouldn't be taking it." I said, "This doesn't make sense to me." If we make less of it as we get older, we know that it has so many functions in the body beyond just helping with sleep. It seems to make sense to me intellectually. You mentioned that we have this estrogen piece as well. We have this duality that impacts melatonin secretion just by virtue of changes in estradiol signaling as we are getting older and it is all about optimization.


[00:19:52] I'm so glad that you mentioned that because we field a lot of questions about melatonin. I'm very pro-melatonin, obviously in an appropriate dose. We're not talking about massive doses, but I do think for most patients, they do see an improvement. Again, multiple things impact our sleep quality. The melatonin can absolutely be part of that.


[00:20:11] When you're talking to patients or you're doing an intake and you're trying to get a sense of whether or not there are specific issues related to narcolepsy or people that are shift workers and certainly as healthcare providers, we've all experienced the challenges of sleep issues related to shifts. Help us understand the differences between sleep apnea versus sleep fragmentation versus narcolepsy. We got a lot of questions that came in around here and something new to me that I want to admit as I was doing my due diligence, upper airway resistance syndrome being a phenotype of obstructive sleep apnea more commonly seen in women.


Dr. Andrea Matsumura: [00:20:56] Yes, so let's talk about what sleep apnea is. Sleep apnea is basically obstructive sleep apnea as being the most common. That's when the back of the throat, the soft tissue at the back of the throat closes off too much and then your brain has to wake up and tell your body to breathe. You might not know it. You just don't feel good when you wake up. Many women have different symptoms. All of the screening tools that we use to me are fairly gender-biased. [Cynthia laughs] One in particular that I don't want to use ever is the STOP-BANG, that G stands for gender. So if you're a woman, you don't get the point. We don't snore loudly most of the time.


[00:21:44] We don't have a bed partner that's witnessing apneas and we wake up. We tend to come in and present with insomnia, with feeling like you have fragmented sleep, with brain fog, with depression. I will say that many women will come in and say, "I don't know if I'm depressed because I'm not sleeping or I'm not sleeping because I'm depressed. I don't know which one it is.” We don't have great screening tools for women. Five or more abnormal breathing events an hour is sleep apnea. It's technical.


[00:22:26] An apnea or a hypopnea, those are very specific changes that we see in the respiratory breathing curves. When we think about upper airway resistance syndrome, that is a change in the amplitude of your breathing curve, but not necessarily a change in your oxygen saturation. They're based on respiratory effort-related arousals. You have a lot of arousals, but you don't necessarily have deep dips in your oxygen. Then that's affecting sleep architecture because then you're less likely to get in all the stages of sleep, you're having a lot of fragmentation of sleep, and that affects your ability then to have high-quality sleep.


[00:23:14] You're right, more women will present that way. Guess what? Insurance doesn't cover upper airway resistance syndrome treatment because it hasn't been studied. Insurance companies hang their hat on evidence-based medicine. That again is gender biased because lots of studies are done mostly on men. Yes, we have started to include women. Especially in the world of cardiology, there's been more research done on women presenting with angina and acute coronary syndromes. We haven't done that though in the sleep world. Then it's less likely to be diagnosed and it's less likely to be treated. You can't diagnose upper airway resistance syndrome with a traditional Type 3 home sleep study. Most insurance companies cover a home sleep study first. You need a Type 1 or a Type 2 sleep study to start to dive deeper into respiratory effort-related arousals. It's because you have to measure the arousal and you can't really do that with a Type 3 home sleep study. We're missing lots of women.


Cynthia Thurlow: [00:24:30] Yes. It's interesting [Dr. Matsumura laughs] because I'm realizing I have done a home sleep study and I can appreciate why, maybe not for the lay public, if I'm wearing a little band and a clip on my finger, that is very different than being in a formal polysomnography environment where you're sleeping in a bed and there's someone that's watching you sleep overnight. You're hooked up to multiple ways that your body, breathing, respiratory rate, blood pressure, everything is being monitored very closely. You can appreciate why you can't do those things at home. Unfortunately, as much as we prefer sleeping in our own bed, if they really are concerned about the presence of sleep apnea, it has to be, and correct me if I'm wrong, it was certainly my understanding previously, you have to be in like a formal sleep study evaluation.


Dr. Andrea Matsumura: [00:25:17] You do. You need an in-lab sleep study. There is some data that shows that type 2 because type 2 sleep studies use a couple of electrodes for an encephalogram and then you can measure the arousal. You can use a type 2 to pick up respiratory effort-related arousals. But, type 3 sleep studies, there are different kinds of type 3 sleep studies. The one that you were mentioning is likely one that is using arterial tone, which is a surrogate for your respiratory breathing curves. And then changes-- arterial tone changes with your changes in hormone levels, and of course I'm never going to do any of this data or research showing that this isn't a great study or a great tool for women. I think that we're missing a lot of women using arterial tonometry for measuring sleep apnea.


Cynthia Thurlow: [00:26:22] It makes so much sense. What are some of the common challenges in your patients? I think most people listening would probably guess.  If you're working shifts and it's probably in your 20s when you're in training. Certainly in my 20s I could weather flip-flopping between nights and days and somehow I managed to sleep, but as I got older, it was a whole lot harder to do overnight shifts or be on call.


[00:26:47] For the shift workers that are listening to the podcast, what are some of the suggestions as a sleep expert for them to continue or at least attempting to continue to get as high quality sleep as they can on their days off or if they're trying to flip flop between days and nights which happen so often? It's like we're really cruel to one another in healthcare that flipping between days and nights can be very challenging.


Dr. Andrea Matsumura: [00:27:14] It can. I always say, “The ugly truth is that you can't really flip-flop there.” I know that people want to be present in their social life. They're losing out on family time. You have to balance that piece. But truly, if you're a shift worker, you really need to stay on the same schedule or really get involved with graduating the sleep schedule if you have the ability to do that. But when people have these schedules where it's very random-- At the very least, that's what I say is do what you can with your employer to stop the random night shifts.


[00:28:01] Lump the night shifts together if you can. So then you have more opportunity to phase back into a couple of daytime activities before you go back into a night shift. Also, people will say, "Well, I get home and I go to sleep." But then again, when you dive deeper, people will tend to do things when they get home. You absolutely need to shut down. You have to get into bed, lights out, blackout shades, eye mask. You have to force your body into thinking that it is nighttime when it is daylight and that's hard to do. If you're spending too much time in the sunlight when you get out of your night shift, then that is problematic because that's our biggest cue. It's called a zeitgeber, it's an external cue.


[00:28:57] The biggest and strongest cue for our body to align our circadian rhythm is light because we have nerve cells in our eye that directly connect to the wake center and fire off the circadian wake rhythm. If you're leaving your night shift, put sunglasses on while you're driving back home or taking public transportation to get back to your home. The minute you get there, you need to employ your nighttime routine. Whatever that routine would be that you like to help yourself get to sleep, you got to do it right away. Then you have to force your brain into thinking it's nighttime.


[00:29:38] The other piece is that people drink caffeine too late in their shift. You really want to drink it at the beginning of your shift. If you start drinking it too late in the shift, that's going to affect your sleep quality. You want to stop that.


[00:29:54] There is evidence also that if you take a little tiny nap, like a 30-minute nap before you start your shift, you're more apt to stay awake throughout the night or at least have less problems if you have to stay awake throughout the night. It's a real gift if you have a night shift where you can take a little tiny 20-minute nap in between the shift, that's helpful. A 20-minute nap is not going to affect the quality of your long sleep.


Cynthia Thurlow: [00:30:20] I think it's so interesting, what we ask EMS workers, police officers, healthcare professionals to do and to go without sleep for such long period of time. There were many times I left the ER as a nurse after doing my third night shift in a row because that's what I did. Because I was also in graduate school and I would sometimes say I don't remember how I got home. It's terrifying to me now when I think about that. But that is the norm for a lot of people that they're so tired by the time they get into their car, by the time they get home, they don't even recall what they were doing in between. Those kinds of tips are really invaluable.


[00:30:57] Let's talk about why sleep apnea is more common to see in menopause. What is happening physiologically that puts us at greater risk and what are the things we need to be looking for as individuals?


Dr. Andrea Matsumura: [00:31:13] Sleep apnea in menopause really takes a huge-- you get this huge uptick in sleep apnea for women who are menopausal and postmenopausal. Up to 67% of women in menopause will end up having sleep apnea. 90% do not know that they have sleep apnea. 90% of women, 9/10 women do not know that they have sleep apnea. What happens is that estrogen, progesterone and testosterone all play a role. Testosterone to a little bit of a lesser extent, estrogen to a lesser extent. It's really progesterone that helps with the support structures of the soft tissue at the back of the throat. They all play a role, but the biggie is progesterone.


[00:32:00] When we lose the progesterone, the estrogen and testosterone is declining over the decades of life, then we have more collapsibility of those soft tissues at the back of the throat. We have this rise in obstructive sleep apnea. Again, women tend to not have that big, severe obstructive sleep apnea. They tend to have simple mild or moderate obstructive sleep apnea which again, it either gets missed because we don't present with the loud snoring, the witnessed apneas, or daytime sleepiness because we're wired differently. We override that daytime sleepiness because of other societal factors around needing to be awake for others most of the time. Those are not the typical symptoms. It's more of the brain fog, the insomnia, the fragmented sleep, depression. Those are really common for women. Then that’s a challenge because insurance companies don't typically cover studies. I have to really tease out, so you purr in your sleep. [laughs]


Cynthia Thurlow: [00:33:20] Purr. [laughs] 


Dr. Andrea Matsumura: [00:33:21] That's snoring for women. Because there's this stigma, “I can't snore. I'm a woman.” Right? Even if you are having some mild snoring, women will say, "It's like a purr. My partner says it's a little hum."


[laughter]


Cynthia Thurlow: [00:33:40] That's so interesting. I hadn't thought about the purring, but I think that even as I reflect back of all those years working in Cardiology, I was sharing with you before we started recording. We would walk into our patient's room and one of the first things I would do if I saw a male patient with a very large neck, I would say, "What shirt size do you wear?" and if it was 17 inches or greater, I was like, “Oh, this is someone we need to work up for sleep apnea.” You don't necessarily have to have a larger neck as a female. It is a byproduct of this loss of particularly progesterone, this progesterone signaling that impacts our ability to breathe properly and maintain muscle tone.


[00:34:18] I find it really interesting that this is a nuance where I think it's really important to work with a provider who's looking a little more deeply because they could easily say, "Oh, the brain fog is related to the lack of estrogen. You have less circulating estrogen. So is it any surprise or blood sugar dysregulation?" when in fact it could be this latent sleep apnea that has not been addressed.


[00:34:40] I think what's really interesting is we reflect on what happens if we don't treat sleep apnea. I think this is the bigger issue, beyond the purring or the humming that we're doing unknowingly. As a clinician, what are some of the bigger picture things that maybe is important for patients to understand if we don't treat the sleep apnea? Number one, we have to diagnose it, but number two, if we don't treat it, what are some of the sequelae that patients can be at risk for?


Dr. Andrea Matsumura: [00:35:09] In moderate or severe obstructive sleep apnea, so moderate is 15 or more abnormal breathing events an hour and severe is 30 or more abnormal breathing events an hour. Then you have up to a fourfold increased risk of cardiovascular events. Then you also have this increase in potential memory loss. Everything is harder to manage. If you have diabetes, it's going to be more difficult to manage. If you have pain, it's more difficult to manage. If you have high blood pressure, more difficult to manage, which all leads to cardiovascular and neurocognitive risk. Now, in the mild setting there isn't solid evidence that says that there is an increased risk in cardiovascular events or neurocognitive issues.


[00:35:58] However, if you have mild obstructive sleep apnea and you have this fragmentation of sleep and you're not getting the quality of sleep that you need, then it leads to the same endpoint. So that hasn't been thoroughly investigated. There is evidence out there, but I don't think it's at the forefront of a lot of other sleep providers, mind that the quality is as important as the objectives around the severity.


[00:36:36] If somebody has mild obstructive sleep apnea and they have really poor quality sleep, that is going to give them some of those same risk factors. I think that we're missing--it's a phenotype. Right? It's on the spectrum of obstructive sleep apnea. But if you have obstructive sleep apnea and really poor quality sleep, then that's problematic. I think we're missing a lot of opportunity to treat folks who are in that mild obstructive sleep apnea range that would benefit from some form of treatment.


Cynthia Thurlow: [00:37:10] This is why I think your work is so important because it's influencing clinicians like myself and others to just be thinking about this more thoughtfully and to understand that the traditional body habitus that we see in men may not be the same case for women. I think for so many of us, it's the realization that as I'm getting older and I'm getting wiser, as I always say, I think it's realizing missed opportunities with some patients. I think that bringing greater awareness will have listeners asking more questions of their own providers or looking for providers that are more sleep savvy.


[00:37:47] Let's talk about the sleep syndrome of menopause, which I know you have a lot of beautiful content around this and specifically, we've touched on some of these hormones. But let's talk about what this syndrome looks like because it is a real syndrome. Obviously, most of us are living through it and have lived through it. But for a lot of individuals, understanding that it is both reassuring and also frustrating. These are things that most people will likely experience, but there is ways that we can address it.


Dr. Andrea Matsumura: [00:38:15] So, the sleep syndrome of menopause, I break it down into four different areas. It's getting to sleep, that's how that is affected by progesterone. It is then staying asleep and that is the melatonin reduction. It's getting into the right stages of sleep. Your REM sleep then is affected by estrogen levels and then testosterone affects your slow wave sleep or M3 sleep.


[00:38:45] All of these hormones play a role in helping you achieve high-quality sustained sleep and instead of fragmented sleep. I think that if we can help address what it is that you're really struggling with, then we have more opportunity to help treat the sleep overall. There's also alternatives to help women who cannot take hormone therapy to help them achieve high-quality sleep as well.


Cynthia Thurlow: [00:39:21] In terms of how we address sleep apnea, because I know inevitably this question will come up a lot because we haven't tackled sleep apnea on the podcast before. Walk us through from most benign all the way up to machines and then even your cognitive behavioral therapy, which I have learned a lot about prepping for a talk I'm giving at A4M, walk us through the options that are available for patients beyond hormone replacement therapy, as you appropriately stated, that is appropriate for certain individuals. But when we're looking at addressing sleep apnea specifically, walk us through how you approach that.


Dr. Andrea Matsumura: [00:39:58] Yeah. That's a really good point that you just made. Hormone replacement therapy or menopause hormone therapy that is not necessarily going to be curative for obstructive sleep apnea. It certainly is going to help with quality of sleep, but up to a third of women who start on menopause hormone therapy still have trouble sleeping. That's a lot of people.


[00:40:24] When we think about treatment options for obstructive sleep apnea, there is a whole host of them. I will talk about CPAP or positive airway pressure last. One option is using an oral appliance and there are a lot of different oral appliances is out there. People will find that they are told about one that's typically-- if your insurance covers that they have partnered with one particular type. There's a whole bunch out there and they're not all gigantic. They look different than an Invisalign retainer. They’re not as big as a mouth guard, but they're designed to help pull the lower jaw forward to open the back of the airway in millimeters. The things to really focus on with an oral appliance is fit the precision and working with a dentist who understands sleep apnea. Please do not buy one over-the-counter or off the internet unless you want to have it fitted for you because when you take this appliance out, you have to eat, drink, and talk the whole day and that really relies on precision around how your jaw is sitting. A lot of the over-the-counter or you can buy them online, oral appliances aren't going to be fitted to your precision.


[00:41:47] Then you also want to work with somebody who what we call titrates it, so advances it to fit the needs of the sleep apnea to resolve the sleep apnea. You do want to get a sleep study most of the time to see if it's truly working for your sleep apnea. In mild sleep apnea, you may not need to do that, but if you have moderate or severe sleep apnea, you definitely want to repeat the study to see if it's really made a difference in the amount of apnea that you're having.


[00:42:19] There are these positional therapy, different types of-- There's physical, like a bolster that you can wear, like a shirt that has tennis ball. [Cynthia laughs] There's rolls, there's all these kinds of things. There is also a little device that is being made that you can stick in your ear that sends you a little signal to help you shift position. If you have positional obstructive sleep apnea that's a good option. If you don't have positional obstructive sleep apnea, that's not going to be an option for you.


[00:42:53] If you have any type of micrognathia or retrognathia, meaning that the chin is either tiny or back and you don't really have a chin, then you can actually have maxillofacial surgery done to help bring the jaw forward and that can resolve people's sleep apnea.


[00:43:15]  Then there's other types of interventions, laser therapy to help increase the tone. They tend to work for a short period of time, but they don't have long-lasting curative effects. Then there is surgery to remove the tissue at the back of the throat. That's really invasive and what I have found is that it works for some people, but doesn't work for everybody. As we age, I always say we get floppier on the inside like we do on the outside.


[laughter]


Cynthia Thurlow: [00:43:51] Yep.


Dr. Andrea Matsumura: [00:43:52] You may end up needing positive airway pressure as we age. These types of interventions, you need to have a relationship with someone to check in periodically to make sure that those are still working. What I tell folks is that “I'm treating your sleep apnea, but it's not like a one and done, see you later. It's like anything else. I'll go back to those bread-and-butter diagnoses.” Like if you have high blood pressure, we don't give you a medication and say, "Okay, never come back again." No, we have to check it every once in a while. We have to maybe change therapy. That's the same for sleep apnea. Sleep apnea is a chronic medical condition that needs chronic management. Those are the biggies.


Cynthia Thurlow: [00:44:40] No, no. Thank you for walking us through all of those. It's interesting, over-- I've been in the medical field for now almost 30 years. It's interesting to see what has been in vogue because those surgeries for a long time were like mainstay. We were referring patients all the time to sleep specialists. I recall patients coming back to me, some of which it was helpful, some of which it was not.


[00:45:03] The main takeaway from this conversation about interventions is work with someone who's actually a sleep specialist, whether it's a dentist, a physician like yourself, someone who you're not buying a fly-by-night product because to your point, especially if we're talking about augmenting breathing, there's so many things that can become problematic. You're fixing one and creating multiple others and those positional therapies.


[00:45:28] I have a wonderful husband who's a healthy weight, but snores. We started with mouth tape. I think we're at the point now where mouth tape is not doing enough and I actually have been saying to him, "I think you need a sleep study." He's terrified of that because he was like, "I don't want to have a machine." You don't go from having a sleep study to necessarily qualifying for CPAP. There's probably something else. I think he probably needs one of those oral devices, but that's a whole separate conversation.


[00:45:55] Let's talk about CPAP, because I think most people don't know what that is and I think they're terrified. They see things like maybe there's a joke on a movie or in a TV program and they don't fully appreciate.


[00:46:05] For a lot of my patients in Cardiology, they would say when I finally acquiesce to using it, my sleep quality is night and day better. It reinforces using it if they have severe enough sleep apnea. In many instances, it helps their blood pressure, their diabetes, their heart disease, all of those things improve, their arrhythmias as were talking about before we started recording.


Dr. Andrea Matsumura: [00:46:25] Yes, I try to destigmatize continuous positive airway pressure. Positive airway pressure is basically room air that's compressed. All of these machines are fancy compressors. There's continuous positive airway pressure, there's auto-positive airway pressure, there's bilevel positive airway pressure, and then there's more advanced machines, and these are just all forms of non-invasive ventilation. There's one form of invasive ventilation and that's intubation.


[laughter]


Cynthia Thurlow: [00:46:59] Ventilation, yep.


Dr. Andrea Matsumura: [00:47:03] I'm just prescribing air. I'm literally prescribing room air to help you oxygenate and reduce strain on the heart, the lungs, and the brain. There are a lot of different masks. They're not all the big Darth Vader ones. [Cynthia laughs] There's some that go in the nose, under the nose, over the nose, over the mouth, and into the nose and then there are some that go over the nose and over the mouth. The caveat with this is that most masks are made for men's faces and women's faces. They're tinier, they're smaller. There is a little bit more of a challenge sometimes to find the right mask fit. There have been efforts that have been made to make smaller designed nasal masks that are more apt to fit a woman's face.


[00:47:59] Getting that room air that's compressed can be night and day, can really help people get the quality of sleep, because again, that's the focus. It's getting the quality of sleep and maintaining oxygen levels so that you offload the heart and the lungs and the brain. Because we don't want to be running a marathon at night. Right? Our heart has to get into sleep mode and if it's on alert because we're having trouble breathing, then your heart's working hard at night. It never gets into sleep mode. It never is able to have its own circadian rhythm that it needs to follow as well. That's the simplified version. That's how I usually tell folks.


Cynthia Thurlow: [00:48:43] No, no. I think it's so helpful to understand there's lots of options. Maybe women will have more fit issues because we're smaller anatomically and physiologically we're smaller. How does cognitive behavioral therapy fit into your conversations with patients? I'm knee-deep in the research because I'm doing a lifestyle lecture at A4M next week or week after next. I was amazed to see how solid the evidence is on specific cognitive behavioral therapy for insomnia, which I thought for a lot of patients that maybe they're on the HRT, they've ruled out some sleep apnea, they're still struggling with sleep, that there's other options that are available for them.


Dr. Andrea Matsumura: [00:49:24] Yes, cognitive behavioral therapy for insomnia has been studied extensively. It is a successful treatment and it really aims at the negative thoughts around sleep and the hypervigilance in sleep. A lot of people will come in and see me and still have that 3:00 AM wakeup in the middle of the night. They don't have sleep apnea. They're on menopause hormone therapy and then they're still struggling with this middle-of-the-night awakening. That's when cognitive behavioral therapy for insomnia really works. It's again aimed at the hypervigilance. It's not around just sleep hygiene. Most people who have insomnia have these amazing rituals to help themselves get to sleep, but it's about what's preventing them from getting to sleep or what's keeping them awake that cognitive behavioral therapy focuses on.


[00:50:16] Now, this workbook that I'm going to be selling on my website, I've added ACT therapy to it because I find that a lot of women struggle with sleep anxiety. Once you start having problems getting to sleep, then you don't look forward to getting to sleep, you have anxiety around sleeping and staying asleep. And CBT-I, again, it's pretty regimented. It does work. It is not comfortable. Right?


[00:50:42] For some people then, it might drive their anxiety. I did some research and started looking at combination therapies and ACT is Acceptance and Commitment Therapy and that really addresses meeting you where you're at. Another way of saying it is it's learning to be comfortable with being uncomfortable sometimes. You wake up in the middle of the night and you realize, "Okay, I'm going to be awake for an hour. It's not going to ruin my day. I'm not going to let it ruin my day. We're going to be able to get most of the things done. I'm going to be kind to myself." I like to call that combination the grit and the grace. CBT-I is the grit and ACT therapy on top of the CBT-I is the grace. The combination, I think is potentially more successful for women to accomplish achieving, resolving their insomnia.


[00:51:44] Also, the other piece going back to what we talked about at the beginning of this conversation is that every 15-minute counts. Don't focus on, “I have to get through this program to get seven hours of sleep.” If you are getting four and a half and now you're getting five and a half, it’s huge, huge win.


Cynthia Thurlow: [00:52:05] I love that perspective.


Dr. Andrea Matsumura: [00:52:07] Let's focus on the quality and not the quantity.


Cynthia Thurlow: [00:52:11] No. I think that's so important because we as women, we're so hard on ourselves all the time. I love to end the conversation talking about what is not effective. If there are listeners that are listening, there's a lot of misinformation that's out there. I hear this from patients. Sometimes it's prescription medications like benzodiazepines. We know that that's not a long-term option, but certainly there were a whole generation of women that were given benzos in lieu of [laughs] hormones to help with their sleep. When you're doing intake and talking to patients, what are some of the things that you're like, “Oh, that's definitely not effective. I would not advise that you stay on chronic benzodiazepines, Ativan, Valium. That's not a long-term solution.”?


Dr. Andrea Matsumura: [00:52:54] Medications do not work long-term for chronic insomnia. They fill receptors, they might make you sleepy, but they're not allowing you to get into the right stages of sleep. Prescription medications are a big no for long-term treatment of insomnia. That's one piece. Supplements, there's so many supplements out on the market.


[00:53:21] What I say is none of those are going to solve all of your insomnia, but think about what you're using and why you're using it. Write down what the purpose of using a supplement is for and then check yourself a few weeks later. Sometimes supplements are used just to help with their adjunct therapy, but none of them are going to be solutions. It's about the neurological pathway and retraining the brain when it comes to cognitive behavioral therapy for insomnia or ACT therapy combined.


[00:53:54] The other piece is that there's no pill or medicine for obstructive sleep apnea. It's devices-- It's medical devices that are used to treat obstructive sleep apnea. There's no lifestyle change outside of weight loss that potentially reduces obstructive sleep apnea, but there are plenty of women who are a normal body mass index, whatever that is. Right? But basically there's plenty of women who don't fit the stereotype that actually do have sleep apnea. It's not about just, “Let me change how I sleep and then I'll get rid of my sleep apnea.” That's not it. It's a medical condition just like having high blood pressure, high cholesterol, diabetes.


[00:54:41] That's pretty much-- Those are my take-homes with that. Women who cannot take hormone therapy, there are other alternatives out there that may be just as successful for you. It's not all is lost because you're not able to take estrogen, progesterone, or testosterone. There are alternatives out there. There are other things that we can do. That's really why I developed that whole Dream Sleep method because it hits all of the different components. Because again, sleep is not rocket science. That's what I always say. But it is complex and we sleep a third of our lives. We need to be sleeping. It's how we restore our entire body.


Cynthia Thurlow: [00:55:26] Well, such an important conversation. Thank you for the work that you do. Please let listeners know how to connect with you outside of this podcast. I know you mentioned there are a couple new things that are coming. You're more than welcome to share them with the community. By the time this podcast is out, I believe they will be out as well.


Dr. Andrea Matsumura: [00:55:41] Okay, so I do have a website. It's andreamatsumuramd.com or sleepgoddessmd.com. On that website, I do have a quiz where you can figure out what your circadian rhythm is or your sleep archetype. I'm also public speaking. I have an Instagram account that's @sleepgoddessmd. Soon to be released in the middle of October is my insomnia workbook and also a sleep supplement that is coming out.


[00:56:15] Then in November, I am releasing an eye mask because I'm a big believer in blocking all the light out to help you sleep and that might be something. It's just a tool for some people to be able to use that might be the thing that helps people get to sleep.


Cynthia Thurlow: [00:56:33] Thank you so much for the work that you do and thanks for your time.


Dr. Andrea Matsumura: [00:56:36] Thank you.


Cynthia Thurlow: [00:56:39] If you love this podcast episode, please leave a rating and review. Subscribe and tell a friend.



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