Good Sleep Requires Good Habits: Interview with Dr. Hadine Joffe

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Another wonderful interview from the North American Menopause conference in Orlando last month. Dr Hadine Joffe, MD, MSc, is an Associate Professor at the Harvard Medical School and an Associate Professor atBrigham and Women’s Hospital as well as the Director of Psycho-Oncology Research, Dana-Farber Cancer Institute; Director of Research Development, Psychiatry, Brigham and Women’s Hospital; Director of the Women’s Hormones and Aging Research Program, Psychiatry, Brigham and Women’s Hospital; and the Director of the Division of Women’s Mental Health, Psychiatry, Brigham and Women’s Hospital
Madeleine Burnside: What drew you to this subject as a specialty?

Hadine Jaffe: There aren’t a lot psychiatrists who’ve come into the menopause space, it’s mostly been gynecologists. When I was training in the mid-1990s there were very few women in psychiatry, and our models of care were quite different back then. I had many patients who wanted to see a woman who said to me why is it that the first time I ever got depressed was when they took my ovaries out or when I went through menopause? So I dutifully went to my supervisors and asked what do we know? And the answer was we don’t really know at all. It was a time when the whole understanding of the brain and how hormones affect the brain outside of the reproductive axis in regions that could influence cognition, mood, and sleep was just starting to take off. There was animal biological evidence that hormones as they change in the brain might manifest in women with some of these symptoms. I started as a psychiatrist working in depression, but when you work in depression in the estrogen- or hormone-based mood disturbance you really can’t look at mood changes without also looking at sleep and hot flashes, so I’ve spent most of my time since then working on what causes these symptoms, how do they cluster, how do they interrelate, what can we do to treat them, and how do we provide some kind of structure to help people think about them because they can be so nebulous and overwhelming and scary. Then I started working in my clinical practice in menopause in medical and surgical and breast cancer settings, and I’ve felt a compelling case to validate people’s symptoms and to provide biological explanations, whether it’s for symptom experience and anticipation about course and factors or to identify priorities for communicative clinicians and for treatment. I start off where people come in to me and say they feel like they’re going crazy, they don’t feel like themselves, don’t know what’s wrong or how to describe it because it’s so nebulous. We know a lot more now to be able to say what we think is happening, what we think is attributable to hormonal changes or not—oftentimes I’m in a position to say hormones aren’t the right place to focus, because a number of other things happen when people go through menopause and midlife changes. So it’s not all biological, but at least we try and provide some kind of framework to say if it is a biological component this is the conceptual approach and this is the evidence that supports why this might be happening. It’s important in both women who can take hormones and in women who have natural experience of menopause, but at the cancer center where I work it’s more in the cancer survivorship realm, which in some ways is much more complicated because of the nature of symptoms often being abrupt onset related to cancer therapies, along with baseline health problems that are acute, and so I work in both spheres. That’s the long answer about something that is very near and dear to my heart.

MB I wanted to ask you about sleep, and why you think menopause has such an impact on sleep.

HJ There are several factors here. One is we’re always trying to separate out what could be age related or life-situation related and then maybe some inflection point having to do with a period of exposure relating to hormones in the brain, if that’s where we think the basis of it is. That might be temporally linked to the transition, because it’s helpful to say to people this is a period of susceptibility but it’s not forever. I think that’s an important message for people to know, because many, many menopause symptoms are temporally linked. Sleep complaints are very common and can mean many things—a stressful family situation or the illness of a relative—so the first thing we do is to make sure it is related to menopause. When it is related to menopause it presents in distinctive ways, mainly being that it’s a sleep-maintenance or waking-up problem. In the classic insomnia situation there’s a great deal of worry and anticipation about being able to fall asleep and actually falling asleep, whereas in my clinical experience with menopause you don’t get a lot of worrying about or difficulty with those aspects so much as being annoyed or uncomfortable, being sweaty or hot and having to get up and cool down, and for some people it’s not as much the heat but the interruption and not being able to get back asleep. I’m skipping to making the assumption that the sleep-maintenance problem is triggered by hot flashes, so depending on what is bothersome to them, if they’re awake for a long time or frequently, many people don’t have the reserve they normally would and it’s not so much sleepiness as it is fatigue and lethargy– they feel as if they haven’t had a restful sleep. And we know in some of the other work I’ve done that people have hot flashes at night and some wake them up and some don’t, but actually there are many more sleep disruptions which are micro-intrusions on periods of deep consolidated sleep shifting from light to deep sleep, and that kind of what we call fragmentation and those awakenings are far in excess of the hot flashes that people have. If somebody says to me what’s the big deal, you’re awake once or twice, but it is a big deal because that person often has other sleep problems that mean she doesn’t get good consolidated restorative sleep. It’s obviously a feed-forward problem because there are low energy and mood changes and cognitive changes and issues with engagement in the world around them—people tolerate sleep deprivation differently. That is the classic menopause-related sleep problem, but it’s not always hot flashes, and one of the things we’re finding is that the changing hormone dynamics, independent of hot flashes, also contribute to some of the sleep disruption. And then one important factor that doesn’t always get remembered is that sleep apnea, which is upper-airway collapse, increases in risk two- to three-fold in women in the transition, for reasons we don’t fully understand but might be related to some of the hormonal changes. There’s also the emergence of this kicking syndrome called periodic limb movement that is also disruptive. It’s complex, but one important message is that I see a lot of women who think this is normal, that they should just tough it out, they expect that menopausal sleep problems are the same as having to take care of a newborn baby and that it’s something they have to live with, and I tell them it doesn’t have to be that way. If they want to pursue an intervention, not necessarily medicine, it can really make a difference in their quality of life and it’s not a forever treatment.

MB What kinds of interventions are you talking about here?

HJ Well, one of the non-medication treatments people should be aware of is called sleep hygiene that involves good habits. There are some resources on the Internet, including the American Sleep Foundation, that provide extremely good information. Everybody thinks that they know it, because they understand not to have coffee at night and so forth, but for a sleep maintenance problem that information isn’t as widely known. One key thing is to cover the clock, because as soon as you know that it’s three o’clock in the morning part of you gets more annoyed and more alert and it gets harder to fall back asleep. Covering the clock is an iPhone/Samsung problem because everybody now has a phone next to or near their bed, so putting that out of sight is profoundly effective. The other common sleep hygiene practice for people who can’t get back to sleep within ten or fifteen minutes is to get out of bed—low lighting, no video screens or TVs or monitors, do something to distract yourself from what you’re thinking about—it can be some craft work or a junk magazine, but don’t get engrossed for an hour and don’t do things like emptying the dishwasher—and that’s hugely effective. Getting the bedroom environment comfortable for sleep is important, so using lighter pajamas and bedcovers, fans, open windows, all those make a difference.

There’s a structured behavioral treatment for insomnia called CBTI (cognitive behavioral treatment for insomnia) that is a very widely proved effective treatment for all kinds of insomnia, but recently it’s been proven for insomnia for women with hot flashes. That’s available through therapists and there are some online options. It takes time and structure and prioritization.

Medicine-wise there are two different approaches. One is target the hot flashes because anything that treats hot flashes has been shown to have secondary benefits on sleep problems. That can either be hormones or non-hormonal prescribed treatments that have been shown to be effective for hot flashes, like off-label SSRIs and SNRIs, even though people worry because those are medicines that can sometimes worsen sleep in people who take them for depression; but in women without depression with hot flashes they improve sleep. Gabapentin is another one we use for hot flashes, which is a pain and seizure medicine, and also for sleep. Those are all off-label, and there’s one FDA-approved serotonin-based treatment called Paroxetine that in low doses is also shown to improve sleep. There are hormone options that combine hormones and SERMS (selective estrogen receptor modulators) where as soon as you add selective estrogen to the SERMS you get sleep benefits. Those are good options for people.

When we don’t have the option of controlling hot flashes with hormones we may decide to try what are called the Z drugs designed to sedate, and those of course we’re going to minimize the duration of use. Anything that’s designed to sedate we want to be careful that there are no morning hangover effects and that people are functioning at their best when they get up for the day.

MB I know we should be talking to our own doctors about this, but what kinds of things can we do beyond that? While there are a thousand people who’ve gone through the NAMS menopause training, there are about a million who haven’t.

HJ Exercise has also been shown to improve sleep in general and in menopause, even though it doesn’t work for hot flashes. Being physically active is good for sleep too, and getting adequate light exposure during the day and avoiding screens. Being structured and regimented about sleep is helpful, not letting yourself lie in bed until eleven o’clock on a weekend and then having trouble falling asleep on Sunday night and being tired the next day can be a viscous cycle. Being careful with alcohol is important, because we know people with alcohol problems have sleep problems, and we also know that alcohol in regular non-abusive use will give people a good first half a night’s sleep and a bad second half, and that usually translates into an un-refreshing quality of sleep. Cigarettes aren’t good either. For some people who wake up and can’t get back to sleep, I’ll have them keep a little book where they write down what they would worry about or have on their to-do list, and so if they wake up in the middle of the night they’re able to realize they can stop worrying because everything they’re worrying about is in that book already. It’s surprisingly effective for some people. This is a dyadic process for people who share close spaces—ill parents down the hall, young children or grandchildren, a husband or a wife or a partner. But whatever it is, I sometimes tell people that if they can do something different consistently for a week to break the cycle they’ll have a chance to reset some of those patterns. A lot of general doctors are not going to raise the issue because it’s a complicated discussion, but saying to your doctor this is important to me is something you need to do. And again, the resources I mentioned earlier are really great.

MB I’m a meditator, and what I’ve found is that it’s like driving your car on a long trip. At first you’re getting on the highway and then once you’re in the zone of just driving on a highway all these random thoughts start coming in. And with meditation what I do is have a stack of Post-Its so instead of trying to remember something that pops into my head I simply write it down. If I’m supposed to be focused on meditation or going to sleep and I’m drifting off into the shopping list then I write it down and it’s gone.

HJ Yes, and these kinds of memory aids are actually more of a psychological strategy to try and prevent you from being distracted and worried or preoccupied. And I should mention that from an evidence-based standpoint there is not much strong evidence for the effectiveness of melatonin or acupuncture or meditation, but flipping from a regular high-energy day into a calmer state can be a routine that helps your body relax, and it does have to be a process for some people. Warm baths can be helpful, or meditation in the evening, or in the morning in order to develop a practice. You try to slow your heart rate down, you try to relax your body, you try to not be distracted by everything around you, and that’s important preparation for going to sleep.

MB Well, it also helps you get the perspective that the world’s not going to end if you didn’t finish a project fast enough or forgot to put the apples in the fridge.

Do you find that more people have sleep problems in peri-menopause or post-menopause?

HJ Data-wise it’s both, from the standpoint of milder sleep disturbance. From the standpoint of a more chronic pervasive persistent insomnia that interferes with daytime functioning, the evidence suggests that peri-menopause is more the period where that happens, and that’s consistent with the idea of an inflection point that it’s transitory and will subside. But as the menopause effects will subside the age-related effects will increase, and that is often sleep fragmentation and sleep interruption. Not everybody has sleep problems, and not everybody has sleep problems in their 50s– these age-related problems really hit much later, though a little earlier for women than for men. Menopause-related problems are circumscribed to the period of the hot flashes, which can be long—seven to eight years on average when the hormones are going through a period of change.

When I started doing this in the 1990s I read Barbara Bush’s book, and she discussed the fact that nobody talked about menopause and women suffered in silence. But we are such a resource to each other, and I think the thing for women to do is network, because this is not a pinky toe problem that .00005 percent of the population has. When people start having hot flashes they know it– they’ll say are you hot, because I’m hot– but people don’t always do that with sleep. It may be common but it doesn’t mean it’s healthy.

MB One of the things that prompted me to get involved in this was that people would say to me there was no one to talk to. I’d think what do you mean, you have a sister, but either the sister was too young and hadn’t gone through it, or she was older and had gone through it and didn’t want to talk about it. It was certainly not something that people raised, and I’d ask did you talk to your doctor and the response was usually well, yes, and that was helpful. No one has really complained about their doctor, other than the classic issue of either they were too young to know what was going on or they were a man who also wouldn’t know, but very few said that their doctor didn’t try.

HJ Women are such good networkers, and there’s all this important work about how people who make larger networks tend to have much better outcomes in midlife and feel less alone, so these are the right conversations to have. And many online resources are perfect for that.

MB Well, it’s amazing, but it certainly wasn’t available when I was going through it—blogging then was kind of a joke.

HJ And for people who don’t feel comfortable talking in person it’s good because then they realize that they aren’t alone.

MB I had one interview where a woman said that she’d get up at three o’clock in the morning and switch on her computer and scour it for what she was going through. Obviously she’s not going back to sleep and the screen isn’t helping, but that’s when she does it and it gives her some comfort to know that the information is there and to maybe read some of it, and that’s what it’s all about—sharing the information and saying things are common and you might have an unusual symptom but most of it is basically somewhere in this blog. There are those who have no symptoms and those who have crazy symptoms, but most people are in the center block and they have some depression and definitely hot flashes and maybe moderate insomnia, but it can go pretty fast—sometimes it’s gone in six months, which is astounding to me.

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