Dr Zoe Schaedel on Sleep and Menopause
Over on the Middling Along podcast we speak to a wide range of experts to bring you the best advice out there.
We curate a selection of these here as transcripts, to give you another way of accessing the information and advice.
This time we speak to Dr Zoe Schaedel, GP, founder of the Good Sleep Clinic, and accredited British Menopause Society specialist and do a deep dive on sleep…
If you don’t have time to read the full interview, Zoe’s top 5 tips for sleeping well are:
1) keeping our bedroom cool / taking a shower or bath before bed
2) avoiding caffeine after midday and limiting alcohol as far as possible
3) getting outside first thing to expose our bodies to daylight and getting some form of movement in during each day to help raise adenosine levels and increase sleep drive
4) winding down in the hour before bed, no food, drinks, or adrenaline-spiking TV shows!
5) ‘putting the day to bed’ - creating a brain dump on paper to stop our busy minds from running though the mental To Do list in the early hours…
But for the full interview, let’s dive in!
Emma Thomas: Alright, so I guess I am, I'm ‘lucky’… inverted commas, I'm doing air inverted commas, but no one can see me. In that sleep hasn't been a huge issue for me, and I caveat that saying ‘yet’… in perimenopause, but sleep disturbances are one of the most common symptoms for people going through perimenopause with somewhere between 50 to 60% reporting difficulties, either staying asleep or waking up more during the the nighttime.
So should we kick off by sort of trying to, to explain to people why that can be such a persistent problem?
Zoe Schaedel: Sure. So you are right. It is really quite common for sleep to be disturbed in the perimenopause and menopause. And it's definitely more than half of women report some difficulties. The most common kind of problem is, like you said, waking up in the middle of the night, so difficulty kind of staying asleep. Often people manage to fall asleep OK at the beginning of the night, and then at 2 or 3:00 am they're just awake. Sometimes it's obvious why, but sometimes it really isn't. It just feels like it's out of the blue, and this can be quite a sudden change.
So even women who've slept really well or have been really good sleepers, when they hit the perimenopause, it can change, and sometimes it can be really hard to know what's caused that. It can be one of the quite early symptoms of perimenopause and there's lots of reasons why…
So a bit like everything else in the menopause, it could be hormones. So our reproductive hormones are oestrogen and progesterone. As we know, they do an awful lot of other things other than just keep our reproductive system going, and they are useful for sleep. So we know that as soon as oestrogen starts to vary and fall, this can start to affect sleep.
So, as oestrogen drops, we tend to sleep a little bit shorter time. We tend to wake up more, and it's the same with progesterone. Progesterone can be quite a sedating, calming hormone, and when that starts to drop in the perimenopause, that will sometimes lead to disturbed sleep for some women. But it's not just those kind of background hormone changes, it's also the symptoms.
So if you are having hot flushes and night sweats, you are very likely to wake up. So, you know, we need our temperature to stay quite stable, to remain quite low actually throughout the night to keep us asleep. And if we get a huge surge in a hot temperature or you know, sweating or shivering or any of those things, it's very likely to wake us up.
Sometimes that's really obvious. Women will wake in the middle of the night, they'll feel absolutely drenched, have to get up, change, all those sorts of things, but sometimes you don't know about it. It's actually, it's kind of those subtle background changes.
Emma: So even if it's not enough to kind of say, oh, I'm completely drenched from head to toe…it doesn't have to be that dramatic to wake you up?
Zoe: Absolutely. And I think also, we all wake through the night at various times. We have these sleep cycles and every 90 minutes you often just come back up to waking. And usually we don't remember that we just fall straight back to sleep going to the next sleep cycle.
But if you are having, you know, your temperature changing or you're having any kind of symptom, you are more likely to stay awake and you're more likely to remember it and know about it. Often the mood changes in the perimenopause or menopause can contribute. So if you've got a low mood, you are more likely to wake up in the night or find it difficult to go to sleep at the beginning of the night.
Even getting up to urinate more in the night. So we see that more in the menopause and obviously that can disturb the sleep as well. And there is also just getting older. So a bit like everything else in the body as we age, things stop working so well.
I think it's good to know it's also just part of that natural aging. So even men, as they age, their sleep changes. You get a little bit less, what we call slow wave sleep or deep sleep as you get older. And so that's quite natural as well. And I also think it's worth mentioning that menopause often happens at a time, as you know, when lots is going on in life and women are really overloaded and stressed and overwhelmed, and all of those things can trigger bad sleep as well. So it's kind of this cocktail of things. Well, there's definitely that thing of, you know, the two, three or four, and you wake up and then suddenly you've got this really busy brain and all the things like what's my sort of shopping list of things that I'm worrying about right now?
And it's just, just seems really, really hard to, to turn that off. And I think the longer that kind of creeps in towards your wake up time, the harder it is too, because you know you haven't got much longer and you have to get up. And you can see that time, time disappearing. And I think also in, in life, when women are really busy, they don't take much time to sort of reflect and think and just have that kind of downtime.
And so if you do wake up in the middle of the night, your brain is sort of yearning for a bit of thinking time and it's the worst time to be thinking, you know, we really don't want to be thinking in the middle of the night about all the things we've got to do the next day. But often there hasn't been that much other space in life to do that.
Emma: Your brain's like…right…Yes. Great. A clean slate. So I'm just, just gonna run through the list. Won’t take long. Maybe an hour! So …probably a lot of people have heard of sleep hygiene, but if they haven't come across that term before, can you talk us through some of the strategies, some of the things that we can do to kind of help us sleep better, get to sleep better and stay asleep?
Zoe: So sleep hygiene is a term that describes really good common sense habits to help your sleep. There's no definition of what sleep hygiene is. It's just a sort of collection of things that make good sense. And most sleep hygiene advice is based on trying to kind of emphasize and strengthen your body's own sleep regulation systems.
So actually, although it doesn't feel like it, our body is designed to sleep well and it's designed to put us to sleep every night and get, you know, reasonable sleep and then wake us up. And there are different mechanisms that go into that, but one of those is our natural body clock, our circadian rhythm.
And the idea with that is that every kind of 24 hours we move through this rhythm. And in the morning, you know, we wake and we feel alert, we can get on with the day and do all sorts of activities. And at night we are prompted by our body clock to wind down and go to sleep and sleep through the night.
And there's various things we can do that will really help to emphasize this circadian rhythm. And in particular, it's things to do with light and temperature and routine. So in terms of light, we know that actually we do have very light lives, so we have lots of artificial light. It wasn't exactly how we were designed.
We had much darker evenings before the invention of the electric light bulb. People slept better. So our sleep time has gradually reduced since we've had electric lighting and things like that. So it's just really tapping into that, if you can have some time before bed where the lights are dimmer, you're not in this really bright artificial light, it allows more release of a hormone called melatonin.
So we release melatonin in our brains in the pineal glands. And the darker it is, the more that release is encouraged. And so you really want melatonin. Melatonin is kind of setting the scene for sleep and naturally we release it about an hour before we go to sleep, and if we can kind of emphasize that by just dimming the lights a little bit, that can be really helpful and you can do the kind of opposite in the morning when you wake, you can try and expose yourself to some natural lights and daylight to say, this is the time to shut off that melatonin. And, and this is the kind of cycle that we're in, day awake and the light, nighttime, dark kind of release that melatonin and get you ready for sleep.
Emma: And you were saying that the melatonin, our bodies release that an hour before sleep. So is that part of that why it's good to have that routine that your body kind of almost, it knows when it needs to sort of kick that process off?
Zoe: You are absolutely right because it's a bit like coming off a motorway, isn't it? You can be driving along quite fast. You don't just suddenly turn off onto the slip road. You have to slow down. You have to brake, you have to give yourself some time. And it's the same with going to sleep. So you do get that release of melatonin and also your body is set up that it doesn't particularly want to be doing other things. So for instance, we don't really want to be eating much or drinking much the hour before we go to bed. Because we don't want our body to be active, you know, our gut to be working. We want everything, all of that to be on the low down. And so you are absolutely right. Having a bit of time where the lights are dim, we are not eating, we're getting into that kind of more sleepy mindset. Our brains aren't really active.
Emma: It's almost like we need to need to baby ourselves and kind of do the bath, not quite bath, bed, pajamas, story…
Zoe: I mean, you've literally summed it up and the thing is, it makes perfect sense with children, right? You can see, you can actually see you've got this kind of wired child in front of you and you know, you couldn't just say, I'm gonna stick you right in bed now and go to sleep, click your fingers.
They do need a little bit of wind down and for some reason, when we are adults, we just think we don't need it and it's fine. But actually, we would probably benefit from a bedtime story. I mean, I know that sounds ridiculous, but sleeping before bed, you know, just switching our mind from the day to something where we are just not you know, we are not running at that speed is really helpful.
And it, some people do really love, you know, there are different apps and things like that and you can get sleep. Yeah.
Emma: My son uses Headspace, the sleepcasts, so he's twelve and a half and that just kind of is that little wind down for his busy brain sort of 45 minutes I think they are. So generally he's out for the count by the time it's finished.
Zoe: Exactly. And honestly I think we can totally see it with kids, but adults would really benefit from that as well. And the other thing is temperature. So I think this is more powerful than we think. We naturally need to drop our body temperature. Before we go to sleep, you have to actually drop it a little bit to sleep.
And we can kind of, we often have the heating on, we're in quite warm places. And actually keeping our bedroom nice and cool can really help to generate sleep. And you can kind of enhance it by having a hot bath or shower. So exactly as you said with that pre-bedtime routine for kids.
If we have a hot bath or shower, we encourage heat out of our bodies to our skin. We drop our core temperature, and that again, that helps us get to sleep. So they're all good ideas.
Emma: The other thing that I've noticed more so now in perimenopause, is that any kind of amount of alcohol really will probably wake up because of you know, getting hotter and I think one of my other guests was saying, you get the sugar rebound, the blood sugar really, really dips and that can wake you up as well. So yeah, I think that's definitely another thing that I'm kind of much more aware of the sort of poor sleep on the occasions that I do have more than one.
Zoe: Alcohol is really interesting as well because you can see that really clear link. You know, you kind of know if you have some alcohol, you're gonna have a worse night's sleep. But I think what's tricky is that for some people, it's actually one of things they turn to when they're not sleeping well because it can make you a bit more drowsy at the beginning of the night. And if you struggle to fall asleep, we've probably all experienced having a bit of alcohol and then feeling quite drowsy.
And so what I sometimes see is that people increase their alcohol using it more regularly because they're struggling with sleep. And the problem with that is the sleep that you have with alcohol just isn't good quality, even if you don't find you’re waking up. What's happening in the background is that you are not getting that same kind of rapid eye movement sleep, the kind of quality sleep that we need.
And you do get these little micro wakings as well that you might not even remember, but it, you will tend to wake up feeling much worse if you've had alcohol the night before. And actually, the closer you have alcohol to bedtime, the worse it is. So, you know, if you are drinking, it's much better to have it earlier in the day.
Perhaps not at breakfast, but you know, a bit earlier in the day! And again, it's just really saying like in menopause, in midlife, alcohol tolerance often does drop and it's the same with the sleep becomes more sensitive and we've just got to be really careful. I think alcohol's quite a powerful sleep disruptor.
Emma: While I was doing a bit of research on your website, before we spoke, I learned a new term, which is sleep drive. Not something I've come across before. Can you explain, what it is, how it works, how does it impact on our ability to get back to sleep? If we got that classic kind of 2, 3, 4 am wake up.
Zoe: So, you know, I said with the sleep hygiene habits, they're all designed around our own mechanisms that are there anyway to help us sleep. And one of them is the body clock, the circadian rhythm. But the other one that's really powerful is this idea of sleep drive. And what happens is from the moment that you wake up in the morning, your brain produces this substance called adenosine.
From waking, it starts to build up and the levels get higher and higher throughout the day. And as these levels increase, so does what we call your sleep drive or sleep pressure is another word for it, and it's almost like stretching an elastic band. As that increases throughout the day, you get closer and closer to your bedtime.
And this adenosine, when it's at high levels, creates that sense of sleepiness. So it's what will help you fall asleep at the beginning of the night. So you've got the body clock that prepares your body and your mind for sleep. And then you've got the kind of sleep drive, the sleep pressure, the adenosine levels ready to make you feel sleepy and fall asleep.
And the more adenosine you have, the easier it is to go to sleep, but also the longer you stay asleep for. So what we find in people that haven't been sleeping well, Is that quite often they've got quite weak sleep drive. And we really need to enhance this sleep drive, really see what we can do to build it up to make falling asleep easy but also keep them, keep them asleep for as long as possible. And there are things you can do to try and increase the sleep drive. So you build up more adenosine with exercise and with activity and people who make sure they do daily exercise, daily activity do tend to find day sleep a bit better. So that's a really good one.
But also just cognitive activity, you know, talking with people, thinking, working, all those things contribute to having a good sleep drive. The other thing that really, really matters is how long you've been asleep for. And often I speak to women, particularly in the perimenopause or menopause, who are just so exhausted that they're getting into bed quite early.
You know, you are so tired. You know, once you get in, you're gonna drop off. But if you go to bed too early, you haven't given yourself the chance to really build up these high levels. So sometimes I actually say, look, do you think you could stay up another half an hour or an hour? Just really emphasize that adenosine, give it a chance to build up because as soon as you fall asleep, it starts to drain away. And by the morning, It's zero and you don't have any,
Emma: it's a vicious circle! You wake up early. So you're even more tired that evening. Or you think you're more tired…
Zoe: Exactly. So whatever you can do to kind of enhance it. And I think also when people are tired, so you know, not sleeping makes you feel exhausted and tired. You do start to drop things in life. You start to do less exercise commonly and people often drop their social lives and become a bit more withdrawn. Same as with menopause symptoms. You know, you often find that people just don't do the things that they know would be good for them or nurture them or, and the problem is, when you stop doing those things, you have a less good sleep drive. And it is, it's exactly as you say, it's a vicious cycle.
Emma: Thinking about things like the exercise, is there a minimum amount, if somebody was really struggling…15-20 minute walk. Would that be enough?
Zoe: There's evidence that almost anything, almost any activity, just moving your body for a short time can be helpful.
And if you can do that outside, even better because you are then getting the natural light into the eyes in the daytime. Being active, even for a short time can really help just to give us that light, that signal that then when you move to the dark at night, you are then more ready for sleep.
So I think just we have to start somewhere, don't we? It's much, much better to start small just with, you know, simple things that can make a bit of a difference.
Emma: Yeah, definitely something sustainable and it doesn't feel too overwhelming. Having said that, I am one of those people who, who kind of continually sort of says, oh, I'll go for a walk at lunchtime, and then, you know, just, it doesn't happen.
But, yeah, I get my exercise in first thing in the morning, otherwise. Generally if it doesn't happen, then it's, it's not gonna happen.
Zoe: Well, you've got to do what works for you. And actually probably the earlier in the day the better. For some people who exercise late night, there is some evidence that late night exercise isn't great for sleep actually. So you are doing it the right way around For sure.
Emma: Anything else that, that we haven't sort of covered in terms of sort of sleep hygiene, sleep drive, we're all pretty much guilty of, of looking at our, our phones… well, so I definitely am anyway…too late at night. You were talking about that sort of, that hour before sleep is, that's the kind of the critical window really. Are we including things like TV screens as well as phones? I think, you know, again, there's that temptation that you kind of, you get everything done, clear up after dinner sort of flop on the sofa and watch TV for that last hour before bed.
Zoe: I think it really depends. So I actually, I'm not that strict on the advice about screens because actually the most important thing for me is that you're relaxing before bed. And I also think we have to be really realistic, right?
Like the idea that you have this clear hour of your day before bedtime where you can't do anything but lie there. I mean, who has that time? It's really hard and I certainly don't. And so I think we have to just be really careful. What we want to do is, for you to be in a situation at bedtime where you are feeling fairly relaxed and your mind isn't full of the day. Whatever works for you really. So a bit of TV before bed, if you enjoy it, it's relaxing. It's absolutely fine. I think where screens can become more problematic is that kind of screen activity that really draws you in and gets you a little bit, kind of very stimulated, particularly social media, to be honest.
Even Netflix, you know, the whole, you know, do you want to go onto the next episode and it automatically takes you there? It just means we are not so in control of our timings. In the evening you can easily sit there for another episode or another episode.
But the screen itself, I think we have to be relaxed. Lots of people find a bit of TV helpful, and I think that's absolutely fine. And again, I don't think it needs to be an hour full of relaxation activities. It's whatever you can kind of fit in that just brings you down from that kind of daytime, just to transition a little bit between day and nighttime. Often it can be quite quick. It could be 20 minutes before you switch things off, have a shower, read something, listen to something on an app, and then that's it, you know, but whatever kind of gives you the chance to wind down a bit. So often women during this time have got very busy minds and if they struggle to fall asleep or if they wake up with racing mind, which is really, really common, it can be helpful to do a little bit of a brain dump before bed…
Emma: So, funnily enough I was going to ask you about that…
Zoe: I really love it. So we call it ‘putting the day to rest’, just getting some time and I think it takes about 10-15 minutes maximum, and just writing down everything that's kind of, near to the surface.
Emma: What are the things that you meant to do, but you didn't get round to that, you know you're gonna have to do tomorrow, the things that are gonna be kind of popping up at three in the morning if you are suddenly wide awake. If you can get it all out on paper…
Zoe: So I think it's a great exercise to do, because again, like you said, if it's not on paper, it's gonna be right on the mind and it's gonna come out at three in the morning, you know? So I think that's really lovely. There was one other sleep hygiene or habit tip we didn't mention that's important, which is related to that sleep drive idea, which is caffeine. And that's super interesting because the way that caffeine actually works is to block the adenosine receptors, so all of that sleepiness chemical that you have in your brain, so you're kind of holding it back for when the caffeine runs out, and then it makes you even more, you have this kind of crash afterwards. So, It is really important to try and limit caffeine to the morning because caffeine does hang around for quite a while. It's got quite a long half life, so if you are feeling exhausted and you need something in the afternoon to wake you up, try to avoid having a caffeinated drink, because it can really be disruptive.
Emma: Maybe it's a five minute walk around the block instead?
Can you explain a little bit, about the use of CBT or CBTI for insomnia? I think there have been some interesting articles recently about this. So is that something that you use in practice with patients? How does that work and does it only work for people with chronic insomnia or if people have occasional issues, do you use it?
Zoe: So it's a really useful treatment and I suppose the important thing to say is, you know, all those sleep hygiene and the sleep habits, they're fantastic things to do, but if you have got insomnia or if you've got a long-term sleep problem, they don't work. You know, you can have perfect sleep hygiene, but you can get stuck in a cycle of poor sleep and then you're gonna need some other help, something else to do. CBTI is cognitive behavioural therapy for insomnia and I don't think the name is actually that helpful.
We have CBT for lots of things, for depression, for anxiety, but CBT for insomnia is really different. It's a sort of very structured step-by-step program, and the way it works is that it talks about a lot of the things that I've talked about. How do you enhance the body clock? How do you enhance the sleep drive? It looks at some of the cognition, the thinking, the kind of anxiety around sleep. Lots of people are very anxious around sleep when they're not sleeping, and it looks at how to reduce those things. It also looks at the behaviours, particularly around the timings for sleep and what do you do when you are awake in the middle of the night. What can you do that's helpful? That's not gonna make things worse. Our brain makes really big connections with our beds, and we know that if we are lying awake for hours, we start to associate being in bed with being awake.
We need to really reverse that and spend less time awake in bed and more time asleep in bed. So that's what CBTI works on, and it does it in different ways. So you tend to have a bit of understanding how sleep works, a bit of timings change some help with your thoughts, some exercises like breathing exercises or mindfulness.
And you can do it in different ways: you can use a book; there are online programs; you can do it face-to-face; and in the Good Sleep Clinic, which is the clinic that I founded, along with my sister who's a clinical psychologist, we will often use CBTI to help treat people for their sleep.
It's got the evidence base, it’s in the NICE guidelines in the UK and also the American guidelines. This is the thing to try first if you have insomnia, it is more effective than sleeping medication in the short term and in the long term, it's much, much better than than sleeping medication.
CBTI is effective whether or not you're on HRT, but, but if you are waking up with night sweats all throughout the night, it may be that some hormonal treatment will help as well, so we have to look at the whole picture, look at it from all those different angles.
Emma: We haven't really touched on HRT, but obviously some do find that starting HRT can can help several aspects of poor sleep, so it's definitely something to, to consider if, people are struggling,
Zoe: If people are struggling and, and certainly if they have any symptoms like hot flashes and night sweats, HRT can be very effective, but even if they don't, it can sometimes help. But I think also the opposite is true is that you can be on HRT and your symptoms of menopause can get better and your sleep doesn't improve and that's where you need to do that kind of looking at the other things and try something like CBTI and actually there's lots of evidence that it's helpful in that situation.
So for women in the menopause, it's probably the most effective thing we've got to really reset sleep problems.
Emma: Obviously everyone is different, but is there a typical timeframe that, that someone can expect to see results using CBTI?
Zoe: Yeah, it's six to eight weeks: a course can be six weeks, it can be eight weeks. It's rarely much longer than eight weeks. And you know, that can feel like a long time. It can feel like hard work, but when it makes that practical difference and you really feel like your sleep is improving, particularly if you're supported through it, you usually have a weekly session with somebody and that can make it really much easier to kind of stay motivated and make the changes that you need to make.
Emma: I've come across an app I think called Sleepio - are there some parts of the NHS where that's available?
Zoe: At the moment, it's just Scotland, unfortunately. But there are two excellent digital programs. One of them is Sleepio, which is available for free in Scotland, or for people who have had cancer in the last year through the Macmillan charity. The other one is Sleep Station. And again, there are pockets of the NHS where Sleep Station is free, but it is one of those postcode things, so you have to ask your GP. They're both based on on CBT for insomnia, and they're both really effective.
You can also find Dr Zoe Schaedel at https://www.mylahealth.co.uk/ and on Instagram at https://www.instagram.com/zoemenopausedr/
