I am excited to share AMA number eight with all our listeners today, where we dive deep into listener questions concerning sleep and HRV.
In today's AMA episode, we investigate the physiology of sleep, also looking at changes that occur with perimenopause and menopause. We discuss supplements for better sleep, explore sleep hygiene and metrics for REM and deep sleep, examine melatonin and glycine, touch on heart rate variability, and review various gadgets beyond the Aura that can enhance sleep quality.
Join me for a comprehensive exploration of HRV and the benefits of better sleep.
IN THIS EPISODE YOU WILL LEARN:
Why middle-aged women experience poor sleep during perimenopause
Why sleep hygiene is essential, particularly during perimenopause and menopause
Which supplements help with better sleep?
The benefits of a low-carb or ketogenic diet for improving sleep quality
How HRT helps to induce better sleep
The benefits of melatonin for improving sleep quality
Why deep sleep is essential for memory consolidation, improving the immune system, and overall health
Factors that could impact heart rate variability (HRV)
How to improve your heart rate variability (HRV)
Gadgets I have found helpful for sleep
Tips for improving sleep quality
“Sleep hygiene means having consistent bedtime schedules, knowing that when you get closer to bedtime, you don't want to drink alcohol or something caffeinated. You want to dim the lights, wear blue blockers in front of electronics, and do something restorative and calming.”
-Cynthia Thurlow
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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.
[00:00:29] This is AMA #8 diving deep into all of your questions related to sleep and HRV. We talk about the physiology of sleep and how things change in perimenopause and menopause. We spoke at great length about supplements that help with sleep, sleep hygiene, metrics for REM and deep sleep, melatonin and glycine, HRV/heart rate variability, and lastly, talking about gadgets beyond the Oura that can be helpful for sleep quality.
[00:01:03] Hey, we are back for AMA #8. This one is going to be sleep and HRV centric. We got a lot of questions surrounding these particular two topics. First question is from Caroline. “Why is my sleep so bad in middle age? I'm perimenopausal and I cannot believe how much my sleep quality has devolved over the last several years.” There's lots of reasons why this happens, and I know for many of us who maybe have never had issues with sleep before, it can be a tremendous source of frustration. Number one, we get changes in our circadian rhythm due to shifts in estrogen. And maybe some people in the community don't realize that actually estrogen is responsible for helping to coordinate our circadian clock. So, as we have fluctuating levels of estrogen in the beginning and midpart of perimenopause, latter stages, less estrogen that's circulating, that can exacerbate insomnia issues.
[00:02:04] There's also less circulating melatonin. I talk a lot about melatonin. It is not just a sleep hormone, it is a master antioxidant and our bodies are making less endogenous melatonin as we're getting older. So, for many people this is another layer that contributes to why we struggle with sleep. We're less able to deal with stress. It doesn't mean that we are incapable. It just means that as we are having all these hormonal fluctuations, as we have less circulating progesterone, our adrenal glands are stepping in to help provide further support. And in many instances, women, whether it's due to chronic stress, overtraining, not getting enough sleep, eating highly inflammatory foods, maybe being in a toxic relationship or toxic job, or just being unhappy at a stage of life that they're in we become less stress resilient, that can also impact sleep.
[00:02:59] And even for myself, even at the stage I'm at, when I have something that's acutely stressful, the first place that shows up is waking me up at night. And so, that's always my tell. Normally, I sleep pretty well, but for me, when I'm dealing with acute stress, it will oftentimes show up in my sleep quality. There was a narrative review I went through and did some research that nearly 90% of women in menopause experience nocturia, which is waking at night to urinate, relative specifically to the loss of estradiol, which is this predominant form of estrogens our bodies make in perimenopause and during our peak cycling years, which directly impacts bladder capacity. We use the term nocturnal polyuria.
[00:03:42] So, getting up multiple times a night, it may actually induce anatomy and physiologic changes in the bladder, and it'll actually impact a reduction in functional bladder capacity. So, what all of that is saying is, in menopause, that loss of estrogen, if we're not doing HRT, it'll just exacerbate and magnify these issues. So, it is not in your head that you feel like you have to wake at night to urinate. Your body is working against some of these normal physiologic mechanisms. And there's another article that I looked at that was not statistically significant in terms of quantity of participants, but still interesting. It was looking at just using estrogen only increases the ability to concentrate our urine versus if you're using both estrogen and progesterone, it allows us to concentrate our urine.
[00:04:37] So, again kind of a smaller study, but showing that hormone replacement therapy can help with that. And interestingly enough, this research also looked at. This will be in the show notes everyone can look at if they have a desire to do so. We can also get shifts in our ability to concentrate our urine just in our menstrual cycles. So, I thought that was really interesting. Other things that impact sleep quality, vasomotor symptoms, hot flashes, you don't even necessarily have to have hot flashes. I think that many women just sleep warmer in general in perimenopause and menopause, and that can be sleep disruptive. Many people are dealing with sleep apnea. Many people don't even realize they have sleep apnea.
[00:05:17] So, many of my colleagues that are doing internal medicine, whether it's functional, integrative, or otherwise, they're doing a lot of screening for women in perimenopause and menopause if they're really struggling with insomnia. Because if you have untreated obstructive sleep apnea, not only can that fuel sleep quality, but can also predispose you to specific heart arrhythmias, hypertension or high blood pressure, and then lastly or secondary to lastly, issues related to histamine. So, I do see a lot of women in these wildly fluctuating periods of time in the beginning and middle of perimenopause that have very high levels of estrogen. They will also get some histamine intolerances. They will get mast cell degranulation that in and of itself can disrupt sleep.
[00:06:03] I myself had some issues with hives during my book launch, probably in relationship to being on too much hormone replacement therapy for where I was. So, high estrogen driving that high histamine mast cell to granulation and sleep quality. And then lastly, we know that we get direct disruption of sleep centers in the brain relative to this loss of estradiol and progesterone. So, I would say that insomnia and trouble sleeping is complicated business, but doesn't need to be. I think this is where and you'll hear reoccurring themes in this episode. Sleep hygiene becomes critically important. I jokingly say that sleep has become a second job.
[00:06:46] Maybe it doesn't feel that way anymore, but when I had to start thinking more thoughtfully about my sleep hygiene in order to make sure I could sleep, it started to really hone in on why this is so important.
[00:06:56] Next is a question from Kim. “What are some supplements that help with sleep?” Now, I would be remiss if I said the sleep hygiene piece, we have to focus in on first. It's not going to benefit you to take supplements or sleep if you are not practicing the good sleep hygiene. So, what does that mean? It means that you try to have a consistent bedtime. Maybe it's an hour or 30 minutes off on the weekends, but having consistent bedtime schedules, getting in touch with the fact that when you're getting closer to bedtime, you don't want to be eating, you don't want to be drinking alcohol. You don't want to be drinking something caffeinated. You want to dim the lights. You want to make sure if you are in front of electronics, you're wearing blue blockers. Maybe you're reading a book. Maybe you are practicing meditation, legs up the wall, doing something that's restorative and calming.
[00:07:46] Obviously when we sleep, we want to be in a cold dark room. I do really well with a face mask. I have a Blissy, no affiliation with them, but I wear one of their silk sleep masks. It doesn't mess up my hair and as soon as I put that on, I'm out at night. But I'm very light sensitive, so for a lot of people they are. So good sleep hygiene but we usually start with magnesium. We know that magnesium helps upregulate GABA, which is this inhibitory neurotransmitter and helps to suppress glutamate, which is this excitatory neurotransmitter. And obviously when you go to bed, you want to be gearing down, not gearing up. I think that when we talk about types of magnesium, magnesium L-threonate gets quite a bit of focus because it crosses the blood brain barrier. I do have an upcoming podcast coming out diving deep into magnesium that I think everyone will really enjoy. I will save some of the pearls that I got out of that podcast, but magnesium L-threonate is really a nice option. It does cross the blood brain barrier, tends to be a little bit more expensive because its proprietary. You can also think about magnesium glycinate, bisglycinate. Those are also reasonable. If you struggle with constipation, they can be very helpful for that. They will help with relaxation.
[00:09:01] I think about melatonin. We've gotten several questions about melatonin, which I'll get to, but starting with as low a dose as possible, 0.5 mg or 1 mg I think is really reasonable. Again, it's a master antioxidant. It is not just about sleep, and we make less endogenous melatonin as we're getting older. So, for a lot of people, this is something that can be instrumental in conjunction with other things that I'm going to talk about.
[00:09:27] Myo-Inositol, now obviously I have my own supplement, but one of the reasons why I opted to do that was that I saw profound changes in the quality of my sleep with Myo-Inositol. Now you can start with 1 g before bedtime. It will not break a fast. It also has other attributes that can help with insulin sensitivity. It's a really multifunctional sleep support, helps with sleep architecture. I obviously take more than 1 g because I'm always tweaking things, sometimes they take 2 to 3 g. One day out of the week. I don't take progesterone and I will increase my Myo-Inositol to help cover the effects of that. If you're someone that is low carb, and for a lot of people that are intermittent fasting, they may be following a ketogenic diet. Maybe they're cycling their carbs, maybe they're not.
[00:10:14] I find for some people, their sleep quality will devolve or worsen when they go low carb, and that could be very different for everyone. We know the average American is consuming 200 to 300 g of carbs a day. So, if you get under 100, maybe under 75, maybe under 50, maybe if you're really restrictive, you're under 30 g of carbs. For some people, that can impact their sleep. Now, if it's a one-night situation, I don't think it's a big deal. But I have met some women who need to increase their consumption of high-quality carbohydrates to buffer their sleep quality. So, if you are new to a ketogenic lifestyle or new to low carb and you're noticing that you're having some issues with sleep, I might experiment to see where you are.
[00:10:58] Obviously, I think most perimenopausal/menopausal females do best with having some degree of conscientiousness around carbohydrate consumption. Typically, no more than 30 g per meal. Having said that, I've been doing a great deal of experimentation with carbohydrates, which I will probably do a separate AMA episode talking about things that I'm doing differently because there are a lot of questions with people wanting to know what I specifically am doing. But low carb is definitely something to consider. And then beyond those things, I think a great deal about hormone replacement therapy. Now, progesterone is one of these wonderful sleep induction hormones. So, it'll help with having you fall asleep, depending on the type of formulation of progesterone. If you have the generic progesterone that you can get inexpensively, it is immediate release. It is not a delayed release formulation.
[00:11:51] If it's compounded, you may have the benefit of delayed and immediate release, and that can sometimes be helpful for sleep coverage. I also think about estrogen. Estrogen can be very beneficial for helping you stay asleep. Remember we talked about those circadian clocks and how estrogen is really involved in regulating our master clocks. And so, I think that it's important to first dial in on the sleep hygiene, layering some supplements and then consideration given to HRT. And you don't have to be in menopause to consider HRT. Many women are starting HRT, even just progesterone during their luteal phase and perimenopause. And there's a lot of research to suggest women do best when HRT has started prior to menopause. So, if you're out there and you're curious about that, just know that that's the shift that is starting.
[00:12:44] Also, for women that are more than five years into menopause, you are not a candidate for HRT. It is something worth discussing with your healthcare practitioner. It's all about risk stratification. It's all about determining your personal risk stratification and whether or not that's appropriate. I've met many women, have walked many women through initiating HRT, even 10 years into menopause, appropriately, safely, etc. Okay.
[00:13:10] Annie asked, “How many hours of REM and deep sleep should we aim for?” So, typically, when we're talking about REM and deep sleep, I like to see 90 minutes of each. What starts to happen is as we are getting older, we start seeing less deep sleep. It's harder to stay in that deep sleep, and it's important, and we'll talk more about this, what's going on in deep sleep, why it's so restorative, why it's so important, but many times the reason why people are not hitting that sleep metric has a lot to do with lifestyle. And we'll talk more about that.
[00:13:44] Michelle asked, “How would you determine how much melatonin is required if it was working and now doesn't seem to be, would you increase the dose? Would you take it regularly or on and off to prevent your body from relying on it and not making its own?” Okay, this is depending on the x, and I'm going to say “expert” because we could all be experts, right? Depending on who you talk to, there are differing opinions on melatonin. I do not believe that there's any harm in using melatonin after the age of 40 because we are making less of it just like all our other hormones. We're just not making as much. So, since women are making less and less north of 40 years old and it's a master antioxidant, it has more roles than just helping you fall asleep. I don't believe the hype about the concerns over supplementation.
[00:14:35] Do I think that there's value in being conservative? Absolutely, I wouldn't start off with 10 mg of melatonin. I would start with 0.5 mg or 1 mg and see how you respond. Obviously, if you're someone that is struggling with jet lag, it can be very, very helpful. We know it takes about one day per hour of time change. So were just in Portugal. I can tell you that I have got it down to a science what works well. So, I avoid jet lag entirely, which drives my family crazy. But having said that, melatonin can be very helpful in those circumstances. I think a lot of it depends on your lifestyle. What's your age? Are you doing the sleep hygiene piece? Because if you're just trying to supplement with melatonin and you're not doing the sleep hygiene piece, then that can make it ineffective.
[00:15:22] And things like the DUTCH, which is a dried urine and saliva test, they do look at urinary melatonin metabolites. And more often than not, when I'm looking at those results, for most women, their melatonin levels are low in perimenopause and menopause. So, adding that can be very helpful. I also did a podcast with Dr. Deanna Minich where she was talking about plant-based melatonin, herbatonin, and that is another option as well. So, lots of great options.
[00:15:50] Krista asks, “Can you talk about glycine? I see it as a sleep support.” Okay, so I admittedly will occasionally use glycine. I think that it does have some degree of efficaciousness. I do think it can beneficial in conjunction with, again, the sleep hygiene stuff. We know it's an amino acid. It helps to maintain insulin sensitivity. It helps build collagen. It's very calming to the brain. So, when we're talking about sleep induction, things that are calming to the brain are going to be beneficial. We know it also boosts serotonin and melatonin and can actually lower core body temperature. Things that lower core body temperature can help induce sleep, which is kind of exciting. So, starting at about 3 g, I think is reasonable. I have Designs for Health product at my house. That's what I've been using. I like the powder. I'll just put it into water. It does taste a little bit sweet to me. I do consume it usually at the tail end of a feeding window prior to closing my window down.
[00:16:46] Olivia asks, “What is the optimal goal for deep sleep? Mine rarely goes beyond 30 to 40 minutes on my Oura Ring. Last night, it was only 10 minutes. What are some additional things to help improve deep sleep?” This is now on my priority list. And then she also has some questions about HRV. Okay, so again, deep sleep, went about 90 minutes this is when we have slow wave sleep. This is non-REM sleep. It supports memory consolidation, hormone regulation, it promotes release of growth hormone. Super important, enhances the immune system. Not surprisingly, when you are not getting good sleep, you are more susceptible to not only hormonal imbalances, but also dealing with making yourself more susceptible to getting sick.
[00:17:33] We know that insufficient deep sleep impacts the immune function as I mentioned. Memory, because we have a lot of memory consolidation that goes on. The glymphatic system is activated when we're in deep sleep. So, if you are getting 10 minutes of deep sleep, you're definitely not getting that restorative action of that. We know that if you don't get adequate deep sleep, you can be at greater risk for developing insulin resistance and diabetes. And so, obviously, these are things we want to avoid as much as possible. So, things that can be helpful for deep sleep are things like sunlight exposure.
[00:18:08] So, getting sunlight exposure in the morning, I'm not talking about an hour. It's 10 or 15 minutes without sunglasses can be very helpful. Being conscientious about physical activity so that you're not sitting all day long, it doesn't mean that you have to go to the gym and do strenuous workouts every single day, but physical activity is super important. It's also important to avoid alcohol and caffeine before bedtime, or if you're really susceptible to both. We know that alcohol really erodes sleep quality. And so, for most of my perimenopause/menopausal patients and clients, we talk very openly about why sleep quality is so important. And many times, when patients share with me their Oura Ring metrics, they'll say, “Oh, my deep sleep dropped by 50% when I had a glass of alcohol.” So, just kind of keeping those things in mind.
[00:18:58] Again, the sleep hygiene, cold, dark room, wearing blue blockers, wearing a sleep mask, having that consistent bedtime, and being in bed long enough, trying to get by with 6 hours of sleep is not going to cut it. Maybe you got away with that when you were 20 or 30. As you get older, you actually genuinely need the sleep. I always jokingly say, my teenagers think they don't need sleep, and so it's this constant battle in my house to try to convince them, like, you genuinely need just as much sleep as I do. Even considering, like a warm shower or a warm bath before bed, it helps with raising that core temperature and helping with sleep induction. And those are the things I think about most. I think most people, when they're conscientious about each one of those.
[00:19:42] I also noticed when I travel, when I'm on vacation, I always get better sleep metrics. When I was traveling with my family, I was getting nearly two hours a night of deep sleep, and I was still in bed about the same time. So, it just goes to show you that sometimes when we travel, we may get better quality sleep sometimes it may erode. It really depends on where you're going, whether or not you have jet lag, whether or not you're hydrated, etc.
[00:20:07] Let's get to Olivia's questions about “What's an optimal heart rate variability, and how do you improve this?” Okay, so heart rate variability is a balance between the autonomic nervous system, the sympathetic, the parasympathetic, and HRV actually calculates variations in time between heartbeats. So, if you looked at an electrocardiogram, you could also look at this information. But when you're wearing Oura or WHOOP Band, that's helping look at that. It's usually calculated during sleep in milliseconds. And there are some age-adjusted impact to this. So, there's some age-adjusted variables that are genetically mediated. Meaning you could inherit some propensity for either higher or lower HRV just based on your genetics.
[00:20:50] We know that age plays a role. preexisting medical conditions, nutrition, whether it's good or bad. If you're eating all ultra-processed food, I would assume you're probably not going to have the same HRV as someone that's eating a nutrient dense diet. Over training, I see so many women that are doing Orange Theory fitness six days a week, and they wonder what's wrong. They're over training, they're over fasting, they're over restricting.
[00:21:13] Dehydration and illness, so obviously, I'm really susceptible to dehydration at altitude. So, when I fly out west, like if I go to Denver, my HRV is going to tank, even if I'm doing all the right things. But if you're sick, that will impact HRV. Poor sleep, flying, travel in general, obviously, can be challenging. It can improve with all those same things, the opposite of all those things, like improving your sleep, improving your stress management, hydration, electrolytes, getting out in nature, meditation. And it's interesting, I was listening to Peter Attia recently, and he was talking about the fact that it's really difficult to improve your HRV by more than 50%. So, if your HRV is 20, if you get to 40, that's pretty darn good. I mean, you're not going to get to 100 and that's very unlikely and so I'll give you some metrics.
[00:22:06] We know that women have lower HRV's than men. And when we're looking at young adults and 25- to 30-year-olds that range, they could be anywhere from 55 to 105 ms. Older adults, sadly, those are people older than 45 or 50 between 25 to 45. So, I'm doing pretty well if my HRV is in the 40s. If I am in the 20s, it's usually I'm sick or I'm at altitude. So, I'm cognizant of where I am. It also is a reflection of recovery. So, if I'm more in sympathetic fight or flight, my body thinks I'm being chased by a saber-toothed tiger. My number is going to be lower than if I'm on vacation and super relaxed. So, I think all those things are super important.
[00:22:48] And then Crystal's question is about, “You talk about Oura Rings a lot. I don't have it on right now. It's charging. What are some of your favorite gadgets to help with sleep?” Okay, for full disclosure, I brought both of these gadgets downstairs so that I could show everyone what they are. First is Apollo Neuro, and there's good solid research around the Apollo Neuro. In fact, my second podcast with Dr. Dave Rabin will be out soon, probably within the next six weeks or so. And so, he is a psychiatrist and a researcher. And the Apollo Neuro looks like a bracelet. So, this is mine. Sometimes, I wear it on my wrist, sometimes I wear it on my ankle. I don't use it necessarily every day, but it's designed through touch, through vibration, it's designed to reduce your stress levels and get you out of the sympathetic into the parasympathetic.
[00:23:40] The technology was originally created for people that have PTSD and now has been extended to populations that are not that traumatized. And so, looking at the research, we know that the Apollo Neuro based on research can improve deep sleep by 19%, which is pretty significant. I mean, there's a lot of different sleep metrics, but because we've been talking a lot about deep sleep and why that's so important, and it's much more common to see that devolve with age, I thought that would be helpful.
[00:24:10] The other little goody that I have next to me, it's called Somnox. It looks like a little bean. And for full disclosure, these were gifted to me that's why I have them, and this is a bean shaped cushion designed to help people breathe more slowly. So, you hug it and it really does work. It acclimates to your breathing into the parasympathetic so that you're able to not only induce sleep, but calm the body, calm the autonomic nervous system down. It's used for sleep enhancement. There is some research that we'll link up. I think those are two gadgets that I would say I have used and found to be successful. I don't use them every night because I do so many other things to gear my body down. The other things I think about that are completely free, like meditation, box breathing. If I wake up in the middle of the night, I am box breathing. I take five breaths in, I hold for five and I exhale for five, and I do that five times, that can be very helpful. Reading a book, legs up a wall, I think all those things are very helpful.
[00:25:08] I think that, when we're talking about sleep-related issues, HRV, it's clear to me that many people are still trying to figure out what works best for them. And so, for everyone listening, it might be a different combination of strategies, supplements, etc., that can be helpful. One extra supplement I forgot to mention when I was asked what supplements help with sleep. Interestingly enough, creatine helps with jet lag and helps with sleep architecture. So, if you are taking creatine to help with muscle strength like I do, when I was traveling, I was taking about 10 g a day to help with sleep architecture and jet lag. I literally had no jet lag. When I tell you I was like, able to acclimate to being initially 4 hours and eventually 5 hours ahead and then come back and do the same. I think a great deal of it had to do with that.
[00:25:56] So, another supplement to tie in there and we'll put links to everything that's here. I do have a podcast that I've done with Dave Rabin. I have a second one coming out. I do not have a podcast with the Somnox researchers. We've tried to coordinate our calendars. Eventually that will happen.
[00:26:13] Keep the questions coming. Again, you can send them to support@cynthiathurlow.com. I also encourage people to join my free Facebook group called Intermittent Fasting Lifestyle/Cynthia Thurlow It is a drama free zone. It is designed to connect with me. I am the person that answers the questions. My team is in there to help facilitate conversation, but I answer the questions. It is a drama free environment. There are men and women. We may eventually change that name, but for now it's Intermittent Fasting Lifestyle/Cynthia Thurlow. I'd love for you to join us there. It's another way to connect. Completely free. I do a couple, maybe one or two lives in there a month answering your questions. Thanks again.
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