Decoding Women’s Sleep: The Brain, Hormones, and Health Impact

Are you like Erin, who needs at least eight solid hours of sleep to function? Or are you like Gillian, who secretly wishes humans didn’t have to sleep at all? In this episode of The Savvy Patient, hosts Dr. Gillian Goddard and Erin Stein take a deep dive into one of our body's most crucial daily functions: sleep. We talk all things rest, snooze, and sleep routines—and how two best friends can have totally opposite sleep habits. We discuss the science of what happens in our brains when we turn off the lights, from circadian rhythms and natural sleep preferences to the sneaky ways hormones disrupt women’s rest. Plus, we dive into the dark side of sleep deprivation, its impact on long-term health, and what’s really going on with insomnia and sleep apnea, and the simple sleep hygiene habits that can help you wake up feeling rested. 

We take a moment to remind you that while this is a medical discussion, it is not providing a diagnosis or treatment or any medical advice. The only way to get a diagnosis, treatment or medical advice for your particular condition is through a discussion with your doctor.

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This episode was produced and edited by Erin Stein. Music: “All We Live For (instrumental)” by Wolfclub licensed through Audiio.com. Intro and outro edited, and video created, by Ian Mayer. The Savvy Patient logo by Amanda Spielman.

TRANSCRIPT

00:33 The Importance of Sleep

02:25 Understanding Sleep Across Species

05:11 The Human Brain During Sleep

07:15 Hormonal Influences on Sleep

09:57 Age and Sleep Resilience

12:18 Sleep Needs and Patterns

14:36 Circadian Rhythms and Sleep Preferences

17:02 Sleep Disruptions in Women

19:40 Consequences of Sleep Deprivation

20:25 The Impact of Sleep Deprivation on Health

24:46 Understanding Insomnia and Sleep Disorders

31:53 Diagnosing Sleep Apnea and Its Effects

40:48 The Importance of Sleep Hygiene and Routine

Gillian Goddard: Hello and welcome to The Savvy Patient.

Erin Stein: We always say, helloooooo!

Gillian Goddard: Like the belly button on Seinfeld.

Erin Stein: Yep, we're definitely popping in lot of Seinfeld references.

Gillian Goddard: [laughs]

Erin Stein: Today we will talk about sleep, my favorite thing to do.

Gillian Goddard: I wish we didn't have to sleep.

Erin Stein: Yeah, I know, because you're extremely high-functioning individual. I like a lot of sleep.

Gillian Goddard: Well, I think this is interesting because you and I could not be more different in our sleeping.

Erin Stein: Correct.

Gillian Goddard: We sleep at different times. We have different sleep needs.

Erin Stein: Different times, different amounts.

Gillian Goddard: Yep. And yet we're both normal.

Erin Stein: Well, I suppose that's debatable.

Gillian Goddard: Okay, well, our sleep is normal.

Erin Stein: Our sleep falls within some sort of spectrum that is considered normal. Typical, yes, typical. It's better than normal.

Gillian Goddard: There we go.

Erin Stein: But no one knows why we sleep, apparently.

Gillian Goddard: No one knows for sure why we sleep. There are some theories. They are difficult to prove. However, one thing we do know is humans must sleep. 

Erin Stein: Must.

Gillian Goddard: It will actually kill you to not sleep. Not sleeping is a form of torture.

Erin Stein: Yes, and while I don't want to know the answer to this question, I do want to know how long it would take to kill you just by not sleeping. I hope no one has tested this theory, although probably some horrible person has.

Gillian Goddard: ‘There is no precisely defined duration of total sleep deprivation that is lethal in humans as ethical constraints prevent such experiments.’

Erin Stein: I think that's a good answer.

Gillian Goddard: However, we have animal data and data from people who have a disease called fatal familial insomnia. Rats can live two to three weeks without sleep. Dogs die after nine to seventeen days. 

Erin Stein: Ugh, I wish we didn't know that.

Gillian Goddard: Sorry. mice can go four days.

Erin Stein: Aww, that's not very long, poor little mouse. One thing is that animals do sleep, but not all animals sleep. 

Gillian Goddard: Correct.

Erin Stein: Most have some sort of rest that we would consider sleep or some sort of sleep. Like, one-celled organisms don't sleep. And I don't know that we know that all insects sleep, but part of it is we don't know how to study whether they're sleeping or not. So, we've only studied some animals.

Gillian Goddard: That's true. Right, right. So, sleep is really a phenomenon in the brain that is both a change in the electrical signaling in the brain and in the neurotransmitter levels in the brain.

Gillian Goddard: And without the ability to study those things, it's difficult for us to know, if electrically and from a neurotransmitter point of view, if certain types of animals sleep. But my favorite factoid about animal sleep is about dolphins.

Erin Stein: The coolest animals ever.

Gillian Goddard: The coolest animals. I mean, they're incredibly intelligent, they communicate with one another, they have language, they're so fascinating. And they do sleep, but they sleep in the most unique way. And I have to tell you, if I could sleep like this, I totally would. Half of their brain sleeps at a time, and the other half is awake, and then it switches. And it's not like one half is always asleep and one half is always awake. There are times when their whole brain is awake. But that is how they sleep. One hemisphere of their brain at a time.

Erin Stein: Save the dolphins. How are they not running the planet? Or maybe they secretly are, and we just don't know.

Gillian Goddard: Maybe they are and we just don't know it.

Erin Stein: Other fun facts that I've looked up is that even a jellyfish that doesn't have a brain enters periods of inactivity to conserve energy, which you might call sleep. And that birds sleep and there's one bird who micro sleeps while flying just for like a second at a time!

Gillian Goddard: No!

Erin Stein: Yes. So cool.

Gillian Goddard: That is pretty amazing.

Erin Stein: What is the human brain doing while we are sleeping? Because while we've studied it, we still don't know for sure, but there are some assumptions about what's happening.

Gillian Goddard: Yeah. A lot of it is related to information processing. We think that sleep allows us to do things like consolidate memories, and to lay down types of neuropathways that are important for our memory and learning. This makes a lot of sense when you think about how sleep needs change over the course of our lives. You know, newborns sometimes sleep 20 hours a day, and when you think about the amount of new information that their brains are taking in, the amount of new neural pathways that they have to lay down to go from a newborn to a walking, talking one year old in twelve months, it makes sense that it takes a lot of sleep in order to do that. It's a time for the brain to clean up, like, the janitorial crew comes in. It resets our thinking and optimization. It's not an accident that we might go to sleep on something and wake up with an “aha” moment in the morning.

Erin Stein: Mm-hmm. Mm-hmm.

Gillian Goddard: I think we've all had that experience. It definitely helps with energy. We would need to consume a lot more energy to stay awake, and anyone who's pulled an all-nighter knows that.

Erin Stein: I recently took a red-eye [flight], and it was awful and horrible and I barely survived. So, it rests your metabolic system and gives you some more energy.

Gillian Goddard: Yes, it does.

Erin Stein: And the other thing that I think is cool is it's repairing muscle cells. You're growing. The other reason babies sleep is they're growing.

Gillian Goddard: A ton, right? And anybody who's cared for a baby or a toddler or a teenager will recognize the experience of putting that baby to bed and going in the morning and being like, that kid grew overnight.

Erin Stein: Yes, yes, my niece is growing by leaps and bounds and one of your children recently doubled in size as far as I can tell.

Gillian Goddard: Yes, teens going through their prepubertal growth spurt are another group that seem to go to bed one size and wake up another noticeably different size. Definitely, one of my kids is in the midst of that process right now. And actually, we know that growth hormone in growing children is high and pulsatile more at night than during the day.

Erin Stein: Pulsatile, that's new word.

Gillian Goddard: So, growth hormone gets secreted in pulses.

Erin Stein: Gross.

Gillian Goddard: It’s the truth.

Erin Stein: I mean, squirting?

Gillian Goddard: I don't know that it exactly squirts out of the pituitary gland. 

Erin Stein: But it might. I don't know, have you watched it?

Gillian Goddard: I think it just gets released from the cells into the circulation, but in pulses.

Erin Stein: All right, fine. Okay. So, your growth hormone’s pulsing. What other hormones are doing things or not doing things in your sleep?

Gillian Goddard: So, cortisol is really important for sleep. We talked a lot about cortisol a few episodes ago. Cortisol helps maintain our circadian rhythms. So adult humans are designed to have one long sleep at night, plus or minus a short nap typically in the early afternoon. 

Erin Stein: Ugh. I would love plus a nap every day. 

Gillian Goddard: You gotta move to Spain. Or somewhere else in the Latin world where they observe siesta.

Erin Stein: I know. I'm up for it. I'm up for it.

Gillian Goddard: Yes. We have a diurnal variation in our cortisol levels. We are more alert when cortisol is high. So, cortisol levels are high in the morning, we wake up, they're low after lunch, they nadir out around three in the afternoon, which is why we are all looking for a nap or a cup of coffee or something sweet to eat. And then they rise again in the early evening and they're low overnight. If you've ever tried to be awake at a time when you are usually asleep and you feel nauseated and like you can barely hold your head up, that is because your cortisol levels are low.

Erin Stein: Again, this happened to me. I took the red-eye and I was so nauseous. I'm like, oh my god, my cortisol is missing in action.

Gillian Goddard: So, I remember feeling like this as a as a resident when I would be on call overnight and you know, the evening would be pretty busy and if we weren't busy, we had all these things that we would do. We would go at two o'clock in the morning to this place where they had milkshakes and we would get sugar and then, at five, all of a sudden everyone would be slumped over, waiting for the morning crew to come in at six. And I just remember sitting there thinking, “my cortisol levels are so low right now.”  Which probably should have been an indication that I was going to be an endocrinologist. But it's true. that feeling is low cortisol. And it's supposed to be low at night. And anyone who's taken steroids like prednisone will know what it feels like to have cortisol levels that are still high at night. The sleep can be really disrupted. There are other neurotransmitters that change, and neuroendocrine hormones that change overnight. But cortisol is one of the key hormonal modulators of our sleep and our sleep pattern.

Erin Stein: Why is it that as we get older, it's harder to bounce back from the all-nighter?

Gillian Goddard: I think this is really just a difference in the resilience of our systems—of our endocrine system, of our cardiovascular system. When we're young, those systems tend to tolerate a lot of abuse and still be able to function well as we get older. 

Erin Stein: We become delicate flowers.

Gillian Goddard: Something like that. Something like that. No, but there were times as a resident where I was doing an all night shift every four days and I had babies at home that were waking up in the middle of the night. And so, I must have gone three years—more than that—without ever sleeping through the night and not having my sleep disrupted.

Erin Stein: It is interesting. Maybe it is related to procreation because when you have a baby, you need to function on very little sleep. And in that way, it is a young person's game. Although I often think only older, more mature people should be raising children, for other reasons. 

Gillian Goddard: For other reasons. And for women, actually, their sleep changes and the depth of their sleep changes when they have a newborn so that they can listen for the newborn. Which is why even when your husband is supposedly going to get up with the baby, you're the one that hears the baby and has to nudge him to get out of bed to get up with the baby. That doesn't mean he shouldn't do it, it just means there is a biological reason why.

Erin Stein: He should do it. I feel like I have that, but it applies to my cats. “What have they broken downstairs?” Is really what wakes me up, or they coughed up a hairball. Cat owners know what I'm talking about. So, what is typical for how much sleep you are getting at night, which will cover our opposite ends of the spectrum?

Gillian Goddard: Yes. So, the typical adult, over the age of eighteen or twenty, needs seven to nine hours of sleep a night. Teenagers need a little bit more. Children need a lot more. But the typical adult needs seven to nine hours of sleep a night. Sleep needs exist on a bell curve. So, there are people who live in either tail of the bell curve. Either they can get by with five or six hours of sleep. These are people who are quote unquote short sleepers. But most of us cannot, and most of us who are trying to get by on five to six hours of sleep a night are just sleep-deprived all the time. And there are long sleepers who need beyond nine hours of sleep. They may need, ten hours of sleep or even more to function well. And I think the challenge there is that our particular society is not set up well for those people.

Erin Stein: It's really not and if you're one of those people and you're a night owl you're really screwed.

Gillian Goddard: Yeah. So, there are differences in people's circadian rhythms as far as when they like to sleep, and we've alluded to this a little bit. I would definitely be categorized as a true lark. If I sleep till 7 AM, it's sleeping in.

Erin Stein: Ridiculous.

Gillian Goddard: Yes, but I want to be in bed asleep by ten PM. And Erin, you're the exact opposite. You're a true night owl. I think you would be nocturnal if you could.

Erin Stein: I am. I would be if I could for sure. The later the better and I used to be able to sleep till like noon or one o'clock even in adulthood and now I would say in my old age I sleep till about 10. That's early for me which I know sounds ridiculous but it's true. There are actual syndromes which I don't remember the names of because they're not as catchy as Lark and Night Owl. 

Gillian Goddard: No, they're not.

Erin Stein: These are real things. Being a night owl is a real legitimate thing and being an early bird is a real legitimate thing. Not that your boss cares.

Gillian Goddard: No, that is true. That is true. And there is a real shift in circadian rhythms in adolescence during puberty. That desire that kids start to show to stay up later and later, and sleep later and later, is definitely a real thing. There's lots of theories on why it developed in adolescence. nobody knows for sure. But I can tell you I have a couple of people in my house right now—it's July—who are desperately trying to become nocturnal.

Erin Stein: Does anything like that happen in the perimenopause-menopause transition? Do they adjust again or...?

Gillian Goddard: Not as much. I think the biggest phenomenon during perimenopause and menopause is sleep disruption. So, not connecting sleep cycles. One thing that is a big misunderstanding about sleep is that we should go into our room, put our head on the pillow, instantly fall asleep, stay dead to the world for eight hours, and then our eyes should pop open eight hours later, and we should be wide awake.

Erin Stein: Yep.

Gillian Goddard: That is not how sleep works. the average time of sleep latency, which is how long it takes from the time you put your head on the pillow and decide to go to sleep till you actually fall asleep is fifteen minutes and that's considered normal. Up to half an hour is actually considered normal. And it is normal to wake up one time in the middle of the night to get up, go to the bathroom, come back, settle in. What's abnormal is if you're awake for many hours in the middle of the night struggling to get back to sleep. And I think that kind of disruption and disrupted sleep is more common as women are going through perimenopause and menopause. A big factor there though is vasomotor symptoms. So as part of the study of women's health across the nation or SWAN, if you will.

Erin Stein: SWAN.

Gillian Goddard: One subset of participants in SWAN had sleep studies. So, they both answered questionnaires about their sleep and had sleep studies longitudinally over time. And they actually showed that a lot of the waking that women experience in the middle of the night during perimenopause is related to night sweats. Which makes sense. If you're suddenly hot and uncomfortable or cold and clammy, it's going to wake you up. Environmental factors are huge when it comes to affecting our sleep.

Erin Stein: We touched on that in the perimenopause episode and there's just a combination of factors, right? Like, you might be having those symptoms. You might have children in the home who are waking you up more frequently. If you've had children, you're a lighter sleeper as we discussed, so you're waking up more often. Maybe your partner has started snoring in middle age and that is a problem.

Gillian Goddard: Hmm, maybe. Yes, perhaps that could be why. Also, if you have anxiety or depression, which can increase during perimenopause, the biochemical changes in the brain can affect your sleep as well.

Erin Stein: My brain will not shut the f@ck up when I'm trying to go to sleep sometimes. 

Gillian Goddard:  Yes, yes, yes. This is a phenomenon many women experience in midlife.

Erin Stein: Many of us do and it's quite annoying. So let's get into what happens when you're sleep deprived. So, we discussed, I felt nauseous and exhausted and I didn't feel like eating anything just because I took a red-eye. What else happens when you're deprived of sleep for a day or two?

Gillian Goddard: Yeah. So, if you don't sleep for a full twenty-four to forty-eight hours, you start to experience distortions in perception and you can become anxious and irritable.

Erin Stein: So irritable.

Gillian Goddard: So irritable. Your reaction time goes down. So not having slept for 24 to 48 hours can affect reaction time in the same way that being drunk can affect reaction time, which is important when you think about driving while sleep deprived. Which is an experience I remember so well from my residency, driving home after an overnight call, especially one where there was very little sleep involved and trying to be so cognizant of the fact that I was sleep deprived and driving and doing my best to do so safely.

Erin Stein: We should talk about this in another episode: How We Torture Medical Students.

Gillian Goddard: Many of these things have now changed, and we can talk about whether that's for better or for worse, but I trained at a time when the longest shift you could work was twenty-seven hours.

Erin Stein: Oh my god. That doesn't seem safe.

Gillian Goddard: Well, a topic for another day. It affects your appetite, as we talked about, coordination, but also raises your blood sugar and your blood pressure. So, your body is trying to keep you alert and awake and it does that by increasing blood sugar and blood pressure to keep fuel going to your brain to keep it going. If you are doing this over and over and over again, we know that sleep deprivation long-term can affect your cardiovascular health, it can affect your blood pressure, it can affect insulin resistance. We know that when people with diabetes are chronically sleep deprived, their insulin needs go up. That happens to those of us who don't have diabetes too. Our pancreas just handles the increased demand. And depression and anxiety are increased in people who are chronically sleep deprived. However, this is a little bit of a tricky causal relationship to sort out. Depression and anxiety definitely change brain chemistry, which can affect sleep and wake. And so, the question is: Is somebody becoming sleep deprived because they're depressed and anxious? Or is somebody becoming depressed and/or anxious because they're sleep deprived? And it's probably a little bit of both.

Erin Stein: Yes, I was gonna say, yes. The answer is yes.

Gillian Goddard: Yes.

Erin Stein: Some chicken or egg. And when we're talking about long-term sleep deprivation, like you're not getting enough sleep every night, not that you're staying awake for two weeks, because then you might be dead. We don't know.

Gillian Goddard: Yeah. Yes, yes, yes. We're talking about people who are getting, four or five hours of sleep night after night, on an ongoing basis for weeks, months, years even.

Erin Stein: And so, can you catch up? We call it a sleep deficit if you didn't get enough sleep. Again, I had a red-eye. I was exhausted. I did catch up. I slept for 14 hours the next night.

Gillian Goddard: I think we intuitively know this, right? if you have a bad night of sleep, if you take a red-eye, if your baby was up all night or your partner was snoring all night long and you have a string even of bad nights, we intuitively know that when we get back on our regular sleep cycle and even if we can do things like nap—you know, a lot of parents of infants and young kids appreciate getting a little extra nap time during the day—we can return to the feeling of being well slept so in that way yes we can catch up. What I think we can't do is necessarily make up for years and years of bad sleep from a long-term health perspective. So, I think when they say you can't catch up, of course you're not going to feel sleep deprived for the rest of your life and only feel more and more sleep deprived as you go through life. But where the damage can be done, especially when catching up and feeling good again takes longer, if we're having chronic sleep deprivation in those times, the health implications of that chronic sleep deprivation still exist.

Erin Stein: So, there are environmental factors, there's work, there's children, all of these things, but what are some of the medical conditions you might have, i.e. insomnia?

Gillian Goddard: Yes.

Erin Stein: What is the difference between I just am anxious and can't get to sleep and true insomnia?

Gillian Goddard: Yeah, it can be difficult to tease that apart. So, insomnia can take a few different forms. Insomnia can be difficulty falling asleep. It can be difficulty staying asleep, so waking up more than once a night.

Erin Stein: Mm-hmm.

Gillian Goddard: And it can be early waking, so you know, waking at three, four in the morning and then not going back to sleep. All those things fall under the category of insomnia and really at this point we're talking about in situations where all those other environmental factors have been removed. This is when a sleep study, for example, can be helpful where they monitor your breathing, they monitor your brain, and they monitor your oxygen saturation, and they can figure out is there something happening in your brain or in your airway like sleep apnea, that is preventing you from sleeping normally? And then hopefully intervene.

Erin Stein: Right, so you might have insomnia. You might have narcolepsy,

Gillian Goddard: Mm, where you just fall asleep. Yeah, it's a neurological disorder of the brain where the electrical system switches into a sleep electrical system all at once.

Erin Stein: Mm-hmm. And sleep apnea, which you just mentioned, is another kind of major thing you might have that is not just environmental.

Gillian Goddard: Yes. Most people have what's called peripheral sleep apnea, so it's related to their airway, to their nose, the back part of their mouth, and what's called their oropharynx, which is the back of your nose and mouth going down toward your trachea and esophagus. In the most common type of sleep apnea somewhere in that anatomy, the airway is getting shut down. So, you stop breathing. and when you stop breathing you wake up and start breathing again. Sometimes that apneic episode and waking is not something that you're aware of and people with severe sleep apnea can be having apneic episodes many, many, many, many, many times a night. As you can imagine, if you're constantly waking up, you're not getting deep sleep, you will feel very tired in the morning even if you were in bed and thought you had slept for, you know, seven, eight hours.

Erin Stein: Right.

Gillian Goddard: The biggest risk factor for sleep apnea is having obesity, but again, a little bit of a which came first, because we know that having sleep apnea raises cortisol levels, high cortisol makes you insulin resistant, and insulin resistance makes you gain weight. And so, did the sleep apnea cause the weight gain? Or did the weight gain cause the sleep apnea? Again, it's probably a little bit of both. We know that losing weight can improve sleep apnea, and we know that treating sleep apnea can help people lose weight. There is probably a both/and component to sleep apnea as well. There's also a much more rare type of sleep apnea called central sleep apnea, where the brain is not properly signaling you to breathe while sleeping. And that is much harder to treat and requires a neurologist specialist to diagnose and treat.

Erin Stein: That sounds more serious. So, if you may or may not be aware that you're doing it, how would you know if you have sleep apnea or how would you diagnose the person sleeping next to you and tell them to go get it checked out?

Gillian Goddard: So, bed partners are a great source of information when it comes to sleep apnea. If you've ever been in bed with someone who's snoring and then all of a sudden like snorts and seems to wake up and change position, that is sleep apnea. Snoring is a definite symptom, and bed partners can be a great source of information. But there's different types of tests you can do. You can actually do a home test for sleep apnea that comes in like a little carrying case and you get it from your doctor, and you set it up. Most of them I think you do three nights in a row, and you put on a pulse oximeter to measure your oxygenation and a heart rate monitor and some of them involve like a little probe that you put like right next to your nose. Some of them don't.

Erin Stein: That sounds like a recipe for a great night's sleep.

Gillian Goddard: You can do it at home and you get a zip-up little thing and take it back to your doctor and they read all the information off of the little computer and they count the apneic episodes, etcetera. The other thing you can do is a sleep study in a sleep center. Obviously, waits for sleep studies and sleep centers are much longer because you're need a bed in a sleep center and those are limited. But people actually sleep really, really well when they go to sleep centers for sleep studies. And it was explained to me once by one of my attendings when I was a resident that it's sort of like when you go on vacation and you think that the bed at the hotel is so comfortable that you want to buy the mattress and then you buy the mattress and you get it home and it's not the same. When people go in to do sleep studies, they know that all they have to do is lay there and sleep and they don't have to worry about getting up in the morning. And so, a lot of the anxiety around sleeping goes away and people actually reduce their sleep latency when they're in for sleep studies. I always thought that was kind of fascinating. That said, I do have a patient who had a sleep study who was told that they had a totally normal sleep and they were like, I literally was awake the entire night. So, you know.

Erin Stein: I feel like that would be me. Sleepwalking…we didn't talk about that.

Gillian Goddard: More common in children. Most people outgrow it.

Erin Stein: My husband does it occasionally. Only when he's over tired. It’s yielded some pretty good stories. What kind of doctor should you go to if you are concerned about your lack of sleep?

Gillian Goddard: As I often say, start with your primary doctor. Most primary doctors are set up to do things like at-home sleep studies and so you can do a lot starting with your primary doctor. And then if it looks like you have something more severe, there are sleep specialists. They are typically a subset of pulmonology. Usually, pulmonologists will study sleep as part of their training and there is a sleep specialty. So that is where I would start. The other thing is there are things that you can do on your own even before you go to the doctor that the doctor is going to tell you to do as you're thinking about improving your sleep. Things like a set bedtime routine, not looking at screens in the hour or two before you go to sleep. Some people need to cut back liquids at night if part of the problem is needing to get up to go to the bathroom. Make sure you're sleeping in a dark room. Many people do better, especially if there's ambient noise, which there's going to be with a white noise machine. Make sure that your pillow and your mattress are comfortable and that ideally your room is cool. Most people sleep better in a cool room than an overly warm one. I know my sleep has been disrupted the last couple of nights because we are having a heat wave this week and our air conditioner can't always keep up. These are all things that you can do. Darkness is a big one. Some people need complete darkness.

Erin Stein: This is what some people call sleep hygiene, which I think is a weird term.

Gillian Goddard: That's correct.

Erin Stein: Because it's not about soap. It's about making sure you have the right conditions for maximum sleep. You know, limiting caffeine and alcohol before bed and any fluids if you tend to pee a lot. And another factor might be the other person. Sometimes you might need two blankets or two beds or two bedrooms.

Gillian Goddard: That's very Lucy and Ricky.

Erin Stein: I think it made sense.

Gillian Goddard: Very 1950s TV.

Erin Stein: I understand it now. My grandparents had two separate beds and I'm like; I get it now.

Gillian Goddard: I know a lot of couples who don't sleep in the same room. And not to make another, Seinfeldian reference, but just because you don't sleep in the same room doesn't mean that you can't do other activities together that are often done in a bed, although not always.

Erin Stein: Not always.

Gillian Goddard: And how sleep and sex got all mixed up with one another, you know, one never knows.

Erin Stein: Well, watching The Crown, how the Queen has her bedroom suite and the King has his bedroom suite across the hall from each other.

Gillian Goddard: That's aspirational for me.

Erin Stein: The queen needs her sleep. Yeah, no, agreed. Okay, so we talked about sleep hygiene making your environment comfortable. But what about medications? What about sleep spray on your feet with magnesium?

Gillian Goddard: There are some things that have been shown to reduce sleep latency. A lot of the things that we think of as being sort of home remedies or supplements for sleep have been shown to best reduce sleep latency. So, if you're lying in bed for a long time before falling asleep. Melatonin and magnesium and valerian root have all been shown to reduce sleep latency. Magnesium has only been studied for sleep if you take it by mouth. It does not get well absorbed through the skin and so spraying it on your feet at night is not going to affect your sleep or anything else about your internal function in any way, shape, or form. So, you do not need magnesium sleep spray for your feet.

Erin Stein: Sorry, New York Magazine, I think it was placebo effect.

Gillian Goddard: Yes. And look, placebo effect is strong. It works. Placebo effect works. We again know that managing vasomotor symptoms can be helpful. So, hormone therapy can be helpful for sleep if you are a woman in perimenopause or menopause. Progesterone has been shown specifically to be helpful with sleep, although you need big doses of progesterone, 300 milligrams a night, and usually those doses cause other side effects like constipation, bloating, and breast tenderness. Although I do have patients who anecdotally report that just their regular 100 milligram dose helps them sleep. And it might, especially if it comes in combination with some estrogen. And if you are not someone who can take hormone therapy, treating your hot flushes and night sweats with a non-hormonal treatment. So Veozah and specifically Lynkuet reduced sleep disruption from vasomotor symptoms. Lynkuet causes some somnolence on its own. It's recommended that women take it half an hour or so before bed to avoid being groggy when they wake up. The other thing that's been shown to be really helpful for sleep is a specific type of cognitive behavioral therapy for insomnia. So cognitive behavioral therapy is a type of talk therapy that is very structured and you have to do it with someone who specifically was trained to do CBTI, cognitive behavioral therapy for insomnia. The challenge there is finding a practitioner.

Erin Stein: Mm-hmm. And what about more serious medications? The Ambien and like. Or people just take Benadryl to go to sleep?

Gillian Goddard: Benadryl is diphenhydramine. if you are a young person who just needs to fall asleep like one night, Benadryl is probably okay. If you are using it chronically and/or you are an older person, it has been shown to not be safe. And so, you really want to be careful. Things like Unisom over the counter can be helpful but again you want to be a little careful. All of these medicines are really intended for short-term use. They're not intended to be used chronically night after night after night. Same with like Ambien, Lunesta, but with Ambien and Lunesta, you want to be especially careful. They have some wild side effects, including a kind of sleepwalking and sleep eating, actually, is really common. You do have to be cautious with these medications.

Erin Stein: I have a story about this that thankfully did not happen to me personally. You may be someone who has a serious problem and maybe you do need to take this medication at some point. So, I don't want to freak people out too much, but someone took it on a plane, obviously to get through the plane ride and to try and sleep on the plane but instead of sleeping they got up and were walking around in the aisle and they thought they had gone into the bathroom but they were not in the bathroom, they were in the aisle. And they did their business.

Gillian Goddard: That is really unfortunate for everyone on that plane.

Erin Stein: Yes, exactly.

Gillian Goddard: I know someone who consumed an entire bottle of red wine while asleep after having taken Ambien.

Erin Stein: Hmm. So, they partied all by themselves.

Gillian Goddard: She did not feel great when she got up in the morning. All this to say, yes, these medications can be helpful, but we want to use them with a great deal of caution.

Erin Stein: Caution, and perhaps some supervision the first time you take it.

Gillian Goddard: And some supervision. And maybe not on a plane.

Erin Stein: Some people take it and are fine, but some people are not.

Gillian Goddard: Yes. but what most of us really need and what most of us really need to hear about sleep is that it needs to be a priority for our health. I am very disciplined about my sleep. I've given myself a bedtime to make sure that I am getting an adequate amount of sleep. 

Erin Stein: You're bragging right now.

Gillian Goddard: Now, I am an adult, and I can make the decision to not honor that bedtime. It makes a difference to consciously sit down and think about when you need to go to bed to get an adequate amount of sleep to get up when you need to get up the next day. My friend Laura Vanderkam always talks about how giving yourself a bedtime and going to sleep early is the adult way of sleeping in.

Erin Stein: Yeah, that works for some people, not for all of us. 

Gillian Goddard: Yes, agreed. Agreed.

Erin Stein: I do think it is a goal to work toward for some of us who are not as disciplined to try to have a regular routine of some kind. And for some of us that's reading before we go to bed. 

Gillian Goddard: Mm-hmm. Yeah.

Erin Stein: I like to read. I stay up later than my husband and so he's falling asleep and I'm reading and on the best nights I start to fall asleep while I'm reading and then I just put it down and go to sleep.

Gillian Goddard: Yep. Reading is a great way to wind down.

Erin Stein: But you need sleep. That's the message: you need it.

Gillian Goddard: You need it. You need it to be in good health. Most of us need seven to nine hours. I'm sure someone is going to tell us they only need six.

Erin Stein: God bless you.

Gillian Goddard: If you only need six hours of sleep, I would really do some investigation to see if you aren't chronically sleep deprived, although you might just be one of those lucky people who lives in the tail of the bell curve.

Erin Stein: You might be lucky. You might be functioning, but you might not be functioning well.

Gillian Goddard: Exactly.

Erin Stein: But there's probably a couple of you out there. Okay well I need a nap now. get your sleep, go to sleep.

Gillian Goddard: Get your sleep, people.

Erin Stein: Good night.

Gillian Goddard: Good night.