The biggest differences are your opportunity and your ability. With insomnia, it’s an ability issue. You could lay in bed and, typically, my patients will lay in bed 10 hours or extend the time, and they’re just not able to get the good night’s sleep that they want to get. Versus a person burning the midnight oil, they’re typically sleep depriving themselves, they’re not allotting themselves the opportunity to sleep. Given that chance, if I put them in a dark room, chances are they could catch up because they’re more than able, they’re just not giving themselves the chance.
Dr. Aimee: Is fertility and the way our reproductive system functions tied to sleep? If so, how?
Dr. Sara Nowakowski: This is a very good question. I think it’s still developing. We’re still in the infancy, no pun intended, for this line of research. We’re starting to study it in terms of sleep and menstrual health and then sleep and fertility.
Looking at shift workers, there is a nice study that looks at nurses who were shift work, and that is tied to fertility and infertility. We hypothesize a few things are going on. One is the sleep itself could be related to if you’re not getting good sleep or getting short sleep, or very long sleep, it might relate to hormones, things like follicle stimulating hormone, luteinizing hormone, estrogen, and progesterone. We can see that there is a relationship between sleep and hormonal functioning, so that’s one thing.
Another thing is sleep has been shown to be related to the HPA access, cortisol and our stress hormones, and that itself could have an indirect link on fertility. Sleep has been related with immune functioning. I’ve done some of that work myself. Getting less sleep, short or disturbed sleep, is related to higher inflammatory cytokines, things like CRP or IL6, these pro-inflammatory markers that seem to be elevated when we’re not getting enough sleep, and that could also have an impact on fertility.
Then just the circadian rhythm, that body clock and melatonin seem to be also related. So, there are multiple areas, but still those causal mechanisms and empirically studying it has been a slow process for us, so we’re still working on it.
Dr. Aimee: A few years ago, you did a sleep study with the Department of OBGYN at University of Texas Medical Branch to look at the impact of sleep on women. What were the findings that you reported for women in general?
Dr. Sara Nowakowski: We generally find that during these reproductive hormonal fluctuations, whether that’s the onset of menses for younger girls, for pregnancy postpartum, menopause, those seem to be chimes of hormonal shifts and women are at higher risk for insomnia and sleep disruption during those particular periods. Given what I do with the intervention, which we’ll get into a little bit more, there are ways to intervene and treat that in these different periods of life.
Dr. Aimee: During pregnancy, things can change. How do sleep patterns change during that time, and what is the effect?
Dr. Sara Nowakowski: During pregnancy, by trimester, the first trimester is when hormones are big time starting to change, even though we might not see anatomical changes. We do find, when we’ve looked at both self-report and polysomnography where we study the brain waves in their sleep, that people tend to have poorer, more disrupted sleep. Sometimes they actually get more because across a 24-hour day, they may be napping and things like that and feeling the fatigue.
It tends to settle in the second trimester. We tend to get the golden period and sleep tends to improve during that time, and women report they feel better. Then that third trimester you’re starting to get bigger anatomically, you might be getting anxious about delivering, and the stress related to that, so all of those things negatively impact sleep. So, it’s kind of trimester based.
We have seen a couple of studies that if you can get better sleep, short and disrupted sleep were associated with longer labors and increased odds of cesarean section, so it does seem to have things related to health and obstetrics.
Dr. Aimee: Very interesting. That’s our goal always, as fertility doctors and as OBGYNs, educating of the healthiest birth outcomes. Now, I’m 46. I know you can’t tell, but I am.
Dr. Sara Nowakowski: I’m a similar age, so I’ll just leave it at that.
Dr. Aimee: I keep the office really cold, and my employees that are in their 20s are shivering. Anyway, we know hot flashes are a well-known side effect of perimenopause and menopause. How do things change for sleep during this time?
Dr. Sara Nowakowski: A lot of times, you have these hormonal shifts and the hot flashes. Typically, the median age in the US is about 52 where people hit menopause. Perimenopause, that transition, the definition is 12 months without a period. You could have years and years of being in peri, so that can last a while.
What we find is very interesting, is that sleep is one of the top symptoms that’s reported as a menopausal transition, however it’s one of the symptoms that doesn’t abate, it doesn’t spontaneously always relieve itself. Sometimes hot flashes will eventually stop, thankfully. Sleep or insomnia, it takes on a life of its own, so it’s how you stress about it and how you react to getting it.
Push though, but keep your same routine. Don’t react in a negative way. I know it’s easier said than done, but try not to stress about and try not to be reactive. Compensating for a poor night’s sleep by sleeping in, irregular sleep schedule, or napping are the opposite of what’s going to help you.
Dr. Aimee: Got it. I just put up fingers in my office to say I’m on five hours, or I’m on four hours, because they know when I’m at five the tiniest little sounds, like even clicking of a pen, it’s like someone has been playing drums in my ears or crashing cymbals in my ears. I’m super sensitive to sound. I can rally and push through, but those are the little things I just have to warn people around me.
Dr. Sara Nowakowski: I have trouble making decisions when I get that way. There are so many different ways it can creep up when you’ve had a poor night’s sleep.
Dr. Aimee: You’ve done a lot of research on CBT interventions. How can that help, and how does that play a role when you’re on your period or in pregnancy, or dealing with perimenopause and menopause?
Dr. Sara Nowakowski: Some of these tips are part of the CBT. Getting out of bed if you can’t sleep. We actually tend to restrict sleep for a couple of weeks to the amount of time your body gives you. If you’re only able to sleep six hours, only stay in bed six hours for a couple of weeks and see if that helps you reset. Those are the behavioral adjustments in CBT.
The C stands for cognitive, which is where I help people try to figure out how to quiet their mind. If you’re tired, but wired, and your brain is just going, we do things like mindfulness meditation, or trying to bring closure to your day, a relaxing unwinding period, and things that can help with the thought process. The behavior I already told you, get out of bed if you can’t sleep and get up at the same time. Those are behaviors that are going to help.
Dr. Aimee: You have another fascinating study that looked at how insomnia may be tied to the risk of a pregnancy miscarrying. Can you explain a little bit about that study and what you learned?
Dr. Sara Nowakowski: That study was very interesting. One of my dreams of different areas to study is to actually just partner with fertility and endocrine and do what we call prospectively, or collect sleep data while we’re collecting these other hormones. For that, the best we were doing was looking at epidemiology data. We used this data set called Unhaint from the CDC. They collect all of this information, and part of it in their survey every year is they have sleep questions in there. So, we were looking at sleep and what are other women’s health questions in there.
The best we could come up with that was related to fertility was actually pregnancies that didn’t result in a live birth. That could have been that they chose to electively end the pregnancy, so it’s not exactly one-to-one of fertility, but we did find that people with shorter sleep, less than 6 hours, and self-reporting disrupted sleep, it was related to higher levels of pregnancies that didn’t result in a live birth.
It just gives us what we call hypothesis generating, that then we would like to do these bigger studies to look at “is there something there and is it meaningful and should women be paying attention to this.” That it’s as important as their diet, or stress, or other things that we tell people about.
Dr. Aimee: If I have a patient that works a graveyard shift, especially a woman who has had a history of miscarriage, I’m going to often ask her to change her work schedule and do what she can to get a healthy amount of sleep. Thank you for doing this work.
I also see that you’ve looked at acupuncture as a way to help people who suffer from insomnia, specifically around menopause. I actually recommend that my patients consider acupuncture as well. How can acupuncture help someone with insomnia?
Dr. Sara Nowakowski: There have been several trials. There are actually studies that even analyze all of the trials or do these systematic reviews and meta-analysis. It does show that acupuncture seems to help people with insomnia. They would like to collect more data and do bigger trials, but there is definitely something there, a signal that it’s helpful for people with insomnia to treat it. And women… We’ve done it in menopausal women and in different groups.
There are different thoughts on the mechanisms of why. We know acupuncture can impact neuroendocrine function and things like GABA in the brain, or serotonin, or potentially melatonin. By impacting those things, it may be bringing down stress and the whole process of that. I could see it being very helpful for sleep and then also for fertility. It just seems like a generally good guideline.
We kind of weigh these studies. When we don’t have quite enough data, I tell people for some things we just haven’t done the trials, especially for things like herbal supplements. We just haven’t done all of the trials to know if it’s going to be helpful or not. Use your best judgement, be an educated consumer, and you may consider them. We know the power of placebo is super strong, so that alone, if that is changing your mindset somehow and helping things, that’s great. I tell people I don’t really poo-poo what anyone is taking when they tell me what they are taking.
Dr. Aimee: Right. I think what you’re referring to is probably melatonin, CBD, or THC.
Dr. Sara Nowakowski: Correct. Yes. I didn’t mean to imply that acupuncture was in that group, but particularly things like CBD that we just don’t have much data yet at all.
Melatonin, we actually have a little bit more, but we have found it’s very good as a chronotherapy. You described your husband as being a night owl. If you take it, it’s not as much the dose, it’s kind of a micro-dose, like half-milligram to one-and-a-half milligrams, taken about five hours before sleep onset, so a good period before, you can pull your rhythm and your body clock. That’s one that we tend to therapeutically recommend.
There are certainly some ties to fertility with melatonin as well. Still a lot needs to be studied so that we can get some definitive answers, but all very interesting.
Dr. Aimee: We’ve gone through so many specifics, but I’m very curious. If someone is wondering if lack of sleep or insomnia could be impacting their ability to conceive, how can they get a diagnosis and then also treatment?
Dr. Sara Nowakowski: I do like that you said educating doctors, because I think that is a big thing, not just for fertility.
Insomnia and poor sleep tends to be underreported by patients, and it tends not to be asked a lot, so it doesn’t receive the proper diagnosis it should receive just because there are so many other things to cover. Yet here we are seeing it, at least kind of a lifestyle factor. At the very least, we might as well be improving women’s quality of life. At best, perhaps we could be improving fertility by doing these things, physicians asking about it, patients knowing about it and telling their doctors when they’re having these issues.
In 2016, the American College of Physicians actually recommended the CBTI as the first line of treatment for insomnia above and beyond medications because it tended to work in trials in the short term, and in the long term it actually worked better to learn the behavioral skills. People like me that are trained in it, I do behavioral sleep medicine, we can be hard to find, there’s not a ton of us out there, but there are definitely resources out there.
In fact, one that I like to give patients a lot that’s free that any of your listeners or viewers could take is if you Google ‘VA insomnia workbook,’ there’s a beautiful self-management workbook that was created based on empirical data by the experts in the field for veterans returning home from war. However, it’s not very specifically tied to the VA or to veterans, so really anybody that is looking and wants a self-management program to get some more tips about sleep, I think that might be a good place to start.
Dr. Aimee: When does someone need to see a sleep specialist?
Dr. Aimee: I know as a fertility doctor I have my own special supplements that I like to recommend or a diet. As a sleep specialist, especially with all of the studies that you’ve done, do you have a sleep monitor that you tell your patients to use or a special eye cover to wear, or special curtains that they can get to darken the room?
Dr. Sara Nowakowski: I don’t think I have. I’m not tied to any specific products. It’s really what works for them. The big things are for the CBT of just not staying in bed if you’re not asleep, don’t torture yourself. Other than that, those other things can be kind of like icing on the cake and can help or hurt.
I use all kinds of things. I use aromatherapy at night. I have a little tinnitus, so I listen to white noise. I have blackout curtains. I have a weighted blanket. I think those things can help.
Those things are kind of sleep hygiene. I think of sleep hygiene like I think of dental hygiene. You brush your teeth every night to prevent cavities. If you have a big cavity in your molar, brushing your teeth for 24 hours a day is not going to get rid of it, you need to go see the dentist. It’s kind of the same with this. Those things can be very helpful, but it may not solve all of the problems if we have insomnia disorder going on, or something bigger.
Dr. Aimee: Thank you so much for all of the work that you’re doing. If someone lives in your area, or I’m not sure if you can see people out of state, where can people find you and learn more about your work and even work with you?
