Speaking of Women's Health
The Speaking of Women's Health Podcast is excited to bring you credible women's health information from host and Executive Director, Dr. Holly L. Thacker. Dr. Thacker will interview guest clinicians discussing relevant women's health topics and the latest news and tips.
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Speaking of Women's Health
Improving Sleep Quality in Midlife Women
Join us for this podcast episode as Host Holly Thacker, MD tackles the often-ignored issue of midlife sleep disturbances in women with guest James Simon, MD, a leading expert in women's health.
Stress and anxiety can wreak havoc on sleep quality, but stabilizing hormone levels may offer some relief. From effective bladder habits to the novel idea of a "sleep divorce," they cover a range of strategies to improve sleep.
Dr. Thacker and Dr. Simon guide us through how to improve sleep during the menopausal transition, including non-medication approaches like cognitive behavioral therapy, melatonin and magnesium. They also highlight good sleep hygiene practices and the careful use of prescription medications.
*As of September 2024, the FDA has updated the prescribing information for Veozah (fezolinetant) to include new guidelines for liver function testing:
- Before starting Veozah: Healthcare professionals should perform a baseline liver function test.
- During the first three months: Patients should have their liver function tested every month.
- After the first three months: Patients should have their liver function tested at months 6 and 9.
- If liver function tests are elevated: Patients should stop taking Veozah immediately and contact their healthcare provider.
Welcome to the Fit, Healthy and Happy Podcast hosted by Josh and Kyle from Colossus...
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Welcome to the Speaking of Women's Health podcast. I'm your host, dr Holly Thacker, and I'm back in the Sunflower House with a new episode with such a great friend and such an esteemed physician. Joining me on this episode is Dr James Simon, who I've known since he was the president of the Menopause Society. He is a clinical professor of reproductive endocrinology and infertility in the OBGYN department at George Washington University School of Medicine and he is board certified in obstetrics and gynecology by the American Board of OBGYN and he has an excellent practice in women's health and research consultants at our heart of our country, washington DC. He provides care for women across the reproductive life cycle, from adolescence to childbirth and through the menopause transition.
Speaker 1:He earned his undergraduate degree from Washington University and his medical degree from Rush Medical College. He then went on and did an internship and a residency in OBGYN at George Washington University Hospital, followed by a fellowship in both endocrinology and infertility at UCLA. He is a fellow of the American College of OBGYN. He is president-elect and board of directors and a member in the International Society for the Study of Women's Sexual Health, and he's a past president of the North American Menopause Society, renamed the Menopause Society and the Washington Gynecologic Society. And no surprise, dr Simon has been named a top Washington physician, one of America's top OBGYNs, a super doctor of Washington DC, baltimore, northern Virginia and one of the best physicians in America. And he also earned the Doctor's Choice Award for Washington DC and the prestigious Leon Spiroff Outstanding Educational Award. And anybody in the OBGYN field knows who Dr Leon Spiroff is. Welcome, dr Simon.
Speaker 2:Thanks a lot, holly, and it's really great to be here with you and to share some time with you and your audience on a subject women's health and that I'm very excited about, even after having practiced in this space for close to 50 years.
Speaker 1:Wow.
Speaker 1:Well, you have been such an inspiration and you've certainly networked and educated several of my Speaking of Women's Health and Specialized Women's Health fellows who have graduated and gone on, and I understand you have a fourth year top-notch medical student with you right now learning and the fact that you're giving back and you're educating women across the country, as well as other physicians and physicians in training and those aspiring physicians, is so important because we've got to really complete that circle, to empower women to be strong, be healthy and be in charge, which is our motto, and this is your second appearance in our podcast.
Speaker 1:You were one of the first physicians I interviewed at the very beginning of this podcast in season one, when we were interviewing and doing continuing medical education for physicians and APPs in the field of menopause and hot flashes and the exciting candy neuron inhibitors and before we get into today's topic on sleep and menopause and that's such a big, big issue. I just had a couple of questions. I wanted to follow up from our original podcast because when we were doing those CMEs and the lectures which we have on menopauselearningcom for any physicians, nurses, clinicians listening or just any savvy woman in the audience who wants to go and listen to the science and the biochemistry of this exciting class of medicines we weren't able to prescribe them. But now we've had them on the market for about a year and we have Fezolinatant or Vioza 45 milligrams a day as a non-hormonal treatment for hot flashes and I just wonder what your experience has been. Do you have trouble getting coverage? I've had some of the most trouble, but it seems like it's just now getting a little bit easier to prescribe.
Speaker 2:So I've had very good results. Once we get the patient on the therapy on Vioza, it seems to work extremely well, very quickly. It seems to work extremely well, very quickly. And I find that there are two main barriers to getting access for the patient.
Speaker 2:The first, and I think it's the most common one, was the issue that you alluded to, namely that insurance coverage was somewhat spotty. The cost of the medication was somewhat expensive and that was a limiting factor for many of my patients, even though I see quite a wealthy, if not a privileged group of women in my practice. The other was more a fear issue, because this product requires some laboratory testing of liver function tests before giving it to patients. Many patients make their own judgment that it must be dangerous or it must be problematic or for them it's going to be an issue, and turn to alternative therapies or shy away from this one, and they need a lot of reassurance and I haven't seen any problems in that regard. But it is in the label and does require some additional testing in order to get the patient through the insurance story and get the medication to them.
Speaker 1:Yes, have you used it in conjunction with women who still have persistent vasomotor symptoms hot flashes, night sweats, sleep disturbance in women already on adequate doses of hormone therapy?
Speaker 2:I haven't used it in exactly that circumstance, but I have used it in women who have residual hot flashes on what you and I would probably say is a low dose or a or an inadequate dose of hormone therapy, where adding Vioza to that circumstance seems to knock out the residual symptoms so they can satisfy themselves that they're on a very, very low dose of estrogen and still have the results that they'd like. I haven't tried it on those that maybe the results that they'd like. I haven't tried it on those that maybe, to your and my thinking, are on the highest dose or the highest safe dose or the one, the maximum dose that they can use and then add it in for any residual symptoms. I haven't tried that.
Speaker 1:And and I don't yet have anyone on it for a full year because it's taken quite a while I kind of keep a list of patients and I'm wondering, like when I start seeing them back after a year, because we do the liver functions every three months for nine months but then they come back for their yearly check. If they have no symptoms, at what point would it be reasonable to wonder if that thermostat is stabilized and they don't have to keep taking the medication?
Speaker 2:I think it's unknown. I certainly don't know. I have one patient who I should see again soon, who has been on it right from the get-go, as soon as it was available. She is a professional person who reads a lot and she was on the phone with me the minute the FDA approved it because she had been watching all along to see how it was going to sail through or not and she started on it right away breast cancer survivor and she's done extremely well. But I don't have that one-year follow-up yet.
Speaker 1:Well, we'll do another podcast again in season three. Now I know you've done some interesting research too on the NK1 and NK3 antagonists, whereas fezolinatant is an NK3. Any updates on research on that, or will we get other?
Speaker 2:agents that we can prescribe. So there is some good news there. Our colleague, dr Joanne Pinkerton from the University of Virginia, not but three hours away from me, and I presented the pivotal efficacy data about a few weeks ago only at the American College of Obstetricians and Gynecologists annual meeting in San Francisco, the ACOG meeting and we were the two coordinating investigators for the two FDA approval trials for efficacy and showed the data very pointedly in a variety of presentations and it seems to work extremely well, very rapidly on hot flashes, with no no liver effects that were found and we've been discussing, but it works extremely well. The side effect profile is a little different. Most common side effect from L-enzanatant was headache, as opposed to gastrointestinal side effects with fezolinotant or Vioza. But the answer is these are not head-to-head studies and in both cases the prevalence of side effects was extremely low.
Speaker 1:Boy. That really is encouraging, and it seems like it is a very clean molecule.
Speaker 2:Looks like it so far and I'm hopeful that it continues to look that way and looks that way to the FDA, and then we'll have some competition for the current two FDA approved products for hot flashes that are non-hormonal, namely Vioza or Fesolinatant, and Paroxetine Mesylate or Brisdel, both of those agents FDA approved for this common symptom.
Speaker 1:And this whole arena of hot flashes, vasomotor symptoms, night sweats, sometimes it's just fatigue, brain fog, not functioning well has a lot of overlap with what today's podcast is going to be, which is on sleep and, according to the National Sleep Foundation, women in their perimenopause, through the postmenopausal years, report experiencing menopausal insomnia, and I, for some of my patients, this is so devastating that some of them can't even function or work. It's really a critical problem. So a lot of people ask me is menopause causing my sleep problems? Maybe, maybe not. Sometimes they can occur and disrupt sleep. Sometimes people wake up and then they flash.
Speaker 1:It seems like there's been a lot of progression in research and sleep disorders. And then, of course, there's this whole overlap of anxiety and the stresses of the day. I always tell my patients have your 10 minute worry period in the morning and then they say I worry all day. I'm like no, no, just at the beginning, not right before bedtime. And obviously when something bad happens right before you would go to sleep. Like we just got some bad news of a horrible murder of a friend's in-laws. I couldn't sleep the whole night, like when something terrible happens. Your brain just won't shut off. But we have everyday stresses in life and that can intensify in midlife for a variety of reasons, and it's really important to try to chew through that, those thought processes at the beginning of the day and have a regular cycle. So talk to our listeners in over 80 countries. We're so thankful for all those folks tuning in. What treatments are available to help women who are experiencing sleep issues related to menopause?
Speaker 2:So let me dial it back first before going forward. And there is some very interesting scientific information looking at women in the SWAN study study of women across the nation. And in the SWAN study it's quite clear that sleep begins to be disturbed in a pretty substantial group of women and across different ethnic groups in the perimenopause, in women who are just starting into this transition but are still having their menstrual cycles, and there's an uptick in disturbed sleep. But there's also a larger uptick after menopause and a larger uptake than that if the menopause is surgical or induced, like from a hysterectomy and oophorectomy or from some other damage, like radiation etc. To the ovaries. So it would seem that, at least statistically, that the perimenopause and menopause are a key factor in disturbed sleep as women traverse this age group or hormonally related sleep disturbance Because, as you alluded to, there are a number of women who even have their hot flashes taken care of.
Speaker 2:They're not waking up from their night sweats, they're not waking up from hot flashes or to empty their bladders, but they're still waking up or having difficulty falling asleep and then also staying asleep. And we don't really know for sure what the cause is. But there is clearly some overlap with stress and anxiety and anxiety, and so, as a gynecologist, my initial approach would be to make sure that they have unique but stable levels of hormones, if they're willing to take them. So we want to knock out their hot flashes, either with hormones or maybe with Vioza or paroxetine. But knock down or knock out their hot flashes so that's not a factor in their going to sleep or staying asleep.
Speaker 2:Sometimes they need bladder retraining or just good bladder habits. Make sure they empty their bladders fully and completely before they get in bed at night. It might sound stupid or silly or trivial, but it's a real issue. And then, if they still have early morning waking or disturbed sleep where they're waking up multiple times, I have two approaches. The first is to make sure that their bed partners are not waking them. Now, that may seem trivial, but the answer is it happens all the time, and I have saved many marriages with what I call a sleep divorce. A sleep divorce, it's not a divorce. It just means you kiss each other good night, but you go and sleep in different rooms.
Speaker 1:That's important. I think I've also saved some of my patients' partners in terms of longevity, because a lot of our female patients have partners who may have untreated sleep apnea or sleep disorder breathing which can shave like eight years off your life.
Speaker 2:So Absolutely, and apnea occurs in women also. Yes, and we, the medical profession, need to be much more on top of that and aggressive in how we approach those women or their partners to. You know, for the sake of the couple, get treated, get their sleep under control, et cetera. And I don't think we're doing a good enough job or being forceful enough, maybe, to help those women.
Speaker 1:We pretty much screen almost all of the women with the stop bang questions who present, because most midlife women have some sort of constellation of weight gain, fatigue, irritability, brain fog and so many different things going on that some of it is hormonal, some of it can be lifestyle, some of it can be external stressors, some of it can be vitamin deficiencies. But we certainly diagnose a lot of sleep disorders and I've certainly seen sleep clinics around the country rapidly, you know, proliferate clinics around the country rapidly proliferate.
Speaker 2:Yeah, I think that you're doing a better job than many other primary care practitioners and certainly more as I would like my OBGYN colleagues to do. I don't think we're doing enough to test people or assess people or screen people for sleep problems or even mandate, to the degree you can mandate, that the patient and I only see, primarily see women mandate that they get their partners to be assessed and it could be a female partner, for that matter, but whoever's in their bed disturbing them get assessed, not only for their own sleep hygiene but also for the potential to save my patient.
Speaker 1:And it may not be even another human. We have some furry creatures that do lots of disturbing of my patient's sleep and they really have to separate from that little cute furry creature at night that's disturbing their sleep.
Speaker 2:Absolutely, and the furry creatures also frequently get up early in the morning and they'll wake that person too early in the morning and for my OBGYN colleagues, they may have been up delivering a baby and the last thing they want to do is get up and walk the dog at 4.30 or 5 in the morning. So, yes, well stated, very important point, and one that's really under assessed, and I wasn't thinking about it, but you're absolutely right.
Speaker 1:Well, I was watching one of my friends cute little Boston Terriers that she's named Napoleon Bonaparte. Actually, he's made a guest appearance on this podcast when I was interviewing his dog mother, who's a divorce attorney on one of our earlier podcasts, and so he was crated in my bedroom when his parents were away on a trip. And this dog snores. So I guess animals can have sleep apnea too, but that was like disturbing my sleep, the dog snoring.
Speaker 2:Yeah, I think it happens more than we appreciate. And then, finally, there are some relatively easy sleep disorders that patients can tell us about if they or their bed partner have them. You mentioned sleep apnea. The other is restless leg syndrome. That is not uncommon, where one of the partners have these uncontrolled leg movements while they are sleeping, have these uncontrolled leg movements while they are sleeping and they commonly kick their bed partner, waking them up, or kick and disturb both the person with the leg movements and whoever's there with them.
Speaker 2:So just questioning about these sleep disorders apnea, snoring sleep disorders, apnea, snoring, restless leg, et cetera can go a long way to eliminating easily treatable causes of sleep disturbance.
Speaker 2:And then for me, my approach is if we haven't figured it out by then, or treating your hot flashes hasn't improved it by then, then I think a really good history to focus on depression, anxiety and possible primary sleep problems that you had before or that a woman had before and that are now raising their ugly head again, where they may have disappeared for months, weeks, years, decades, but now they're back in the perimenopause, helps me to put that person in one bucket or another, and the three buckets for me are depression or anxiety or a primary sleep problem, and we have really very good, safe, effective medications for all of those. Most gynecologists do not prescribe them, but as a menopause person and there are many others or obviously you were trained in primary care medicine at one point. Clearly you've been trained to take care of some of those problems, as are many other primary care practitioners, and I think we need to be more aggressive about taking care of women's sleep, because no one's particularly good at their next day if they haven't slept.
Speaker 1:Well, you have been listening to the Speaking of Women's Health podcast. I'm your host, dr Holly Thacker, the executive director of speakingofwomenshealthcom, and our guest is OB-GYN Dr James Simon, who practices advanced midlife menopausal women's health and also conducts research into leading problems in women, and we've been talking about sleep disorders and hot flashes and the differential diagnosis of sleep disorders, and we're going to talk about some natural tips and things that people can do, probably both men and women, because women's sleep is going to be affected if their family members aren't sleeping well, for whatever reason as well. So can you talk to us about that, dr Simon?
Speaker 2:Sure. So you know, many men and women with sleep problems don't want to take medication and I think we, the practicing public, if we're going to prescribe, we'd prefer not to use the typical anti-anxiety and sedative hypnotic medications that are associated with habituation, like the benzodiazepines. While they work and I'm not averse to giving patients them I do worry that they may have carryover sedative hypnotic effects the next morning, where you know they're rushing off to drive the kids or the grandkids to school and they're really not quite awake because they've been sedated with these medications, and I also worry about the possibility that they'll become habituated to using them In lieu of those agents. I've come to do basically a variety of approaches, and I'll try and make this simple and not get into the weeds too much.
Speaker 2:The first is there is a subgroup of cognitive behavioral therapy, a particular type of psychological training that's focused on sleep, not on depression, not on anxiety, but on sleep, and if you can find one of those experts in your community, that's a very straightforward way of getting a patient a non-medicine approach to improving sleep or sleep hygiene. If obviously they have restless leg or apnea or are known to have a sleep problem. I would try and find someone who's an expert on sleep in your community to intervene with them, but if there is no such person, there are well-documented approaches that really go beyond what we're talking about here today. And then there's a group of antidepressants and anti-anxiety agents that can also be utilized. That can also be utilized, but before I start them, I will typically allow patients to try things like melatonin and magnesium both of which have mild sedating and anti-anxiety effects with little or no adverse effect at standard doses.
Speaker 2:And I think that's, you know, very tolerable to patients to try something that they can get over the internet or in the drugstore without prescription, and if it's good enough for them and it's commonly good enough for many then they can avoid prescription medications altogether. If, however, we're going into the prescription medication regimen, then I try to tease them apart in terms of my understanding of the problem Are they depressed or are they anxious, or are they both and because of my personal interest in people's sexual functioning. Menopause and sex is a really important subject beyond our, you know, focus here today, but it's very important and commonly goes by the wayside, I might add. But there are some medications that fall into the antidepressant or the sedative, hypnotic realm which tend to preserve, not interfere with, normal sexual desire and orgasmic function in women, and I'll try and lean on those rather than picking even more commonly used anti-anxiety or anti-depression aids.
Speaker 1:So you must be talking about flamanserine, addy, the little pink pill. I find that so helpful for sleep and mood and sexual function and no weight gain, maybe a little weight loss. It's a great thing that we have in our pocket to prescribe that's one option.
Speaker 2:the other, uh, that I would include in that group would be low doses of trazodone, which is also pro-sexual and has generally weight neutral at very low doses and can help with sleep. And then there are certain antidepressants that have very good anti-anxiety effects as well, and we can talk about those if you'd like, but I think it's a little in the weeds for most of your listeners.
Speaker 1:I would say my most commonly prescribed after cognitive behavioral therapy sleep hygiene. Using the bed just for sex and sleep, keeping it dark and cool, getting your exercise and caffeine earlier in the day and alcohol even one glass of alcohol in the evening can really ruin sleep for a lot of women who are already putting on weight and having higher blood pressure, and certainly I understand it's fun to have a cocktail, but it really does interfere with sleep. So, after magnesium, trazodone is my go-to prescription in low dose. It's not addictive, I tell my patients. Psychiatrists studied it as an antidepressant but they found their patients slept really well but were still depressed. So we non-psychiatrists who have patients that don't fit the criteria for major depression but have crappy sleep and may become depressed and non-functional if they can't get sleep, trazodone is a great go-to generic, safe, inexpensive medication.
Speaker 1:I was talking to a friend of mine who is telling me that her husband has always been a bad sleeper and it's just gotten worse and he doesn't want to take prescription medicines but took Trazodone one time and had such intense dreams that he's like forget it, I'm not doing it again. And I I said, if you're sleep deprived and then you finally get to sleep, you have this rebound of so much REM sleep that I try to warn my patients that, regardless if we're going to do a pharmacologic agent, something that's going to knock you out, you may have very vivid dreams, and it's not because of what we gave you or something wrong. It's your brain is trying to recover and make up for all that lost sleep. I don't know if you've had that experience with your patients.
Speaker 2:Many, many times, and I think it's very good advice. Stick with it, it'll pay off in the longer run. One other thing that I think both of us would want to include in that list of sleep hygiene using the bed only for sex and sleep, getting in bed early and making sure that your critter or your dog or cat doesn't sleep in the bed with you, et cetera. Keep it cool in your bedroom. All the things that you mentioned, but one that maybe you forgot. That's very important stay off your electronic screen. Oh yes, and even if you have to check your email before you go to bed, make sure your screen is not blue and is turned to night vision, so it's yellow or orange in its base color, but I think, more importantly, stay off. That's very helpful and quite important.
Speaker 1:Very important and some people like lavender spray. Other people don't absorb magnesium as well orally, but they absorb it through the skin. So I know my husband loves to take Epsom salts, which is magnesium sulfate. Relaxing baths and certainly I always did that with my children and having that sleep routine I think is very important, and trying to keep the room dark if possible. I know I have trouble when it's a full moon. I have this big celestial window in my bedroom, so sometimes of the year it's really much brighter and that makes it difficult. Do you want to talk about the metabolism and mood and how all that gets affected if sleep goes to pot?
Speaker 2:So once you're not sleeping, once a person man or woman is not sleeping well, we feel tired, and when we feel tired we tend to reach for foods that give us a big burst of energy, like sugary and sweet foods, simple carbohydrate foods and those that provide a big boost of sugar in our bloodstream, and particularly in women, and both men and women who are relatively sedentary these big rises in sugar go directly to stored fat and increase our risks of metabolic syndrome, which is extremely bad for one's health, increasing both inflammation and fat, and I mean unhealthy fat stores around the organs, what we call truncal weight gain or truncal obesity, and that can become a vicious cycle where more weight, more sleep apnea, more disturbed sleep, more hunger, less well-functioning.
Speaker 2:The next day you're tired, so you don't exercise, and so you reach for again sugary, sweet, simple carbohydrates, eats for again sugary, sweet, simple carbohydrates, and then the cycle perpetuates itself. So this is extremely important to break the cycle, to get exercise, to eat properly, even if you're tired, and try very, very hard to figure out why you're not sleeping and get a good night's sleep.
Speaker 1:So before we end this podcast, Dr Simon, I understand you have an Ohio license.
Speaker 2:I do. I got an Ohio license and I'm happy about that. I have several other licenses, but I also just recently within the last week in fact got my Ohio license. So I can now do video visits for anyone who would be interested in the state of Ohio and prescribe for them as necessary or refer them to someone in Ohio and, if they're close to you, dr Thacker at the clinic happy to send them your way as well. I'm located in Washington DC, five blocks from the White House, so if you're in the tri-state area Virginia DC, which is not a state, or Maryland, I'm some unscrupulous companies out there that promote estrogen cream on the face, not worrying about the uterus and not even checking for drug-drug interactions or serious medical problems.
Speaker 1:So I really encourage all of our listeners wherever you're at, you don't want to see a charlatan. You want to see someone who is an expert, who's going to put your health and your well-being first and foremost, and I would certainly strongly endorse seeing such an expert with such an incredible credentials and experience as you. Dr Simon, and how can our listeners follow you on social media or contact you? Or do you have a website or Facebook or Instagram?
Speaker 2:Yes, so we have all of those things. My social media presence is pretty small, but I think patients can get to know me and there's a lot of well-adjudicated information on the website for my practice. The practice is called Intim Medicine Specialists Intim Medicine, i-n-t-i-m Medicine Specialists and we're in Washington DC and we have a website loaded with all kinds of videos, peer-reviewed articles and other information appropriate for patients, and then, obviously, you can make a secure appointment through the website or pick up the phone the old fashioned way. I actually have a human being that answers the phone without a phone tree and so happy to talk to anyone following an appointment in that way.
Speaker 1:Well, that is such excellent advice and thank you so much, dr Simon, for joining us on this Speaking of Women's Health podcast, and I want to have you on for season three, just so you know, because there's so many great things to talk to you about and I love to catch up with you, and I'd like to thank our listeners for tuning in, and we're so grateful for your support and hope that you'll consider supporting the podcast, share it with others, give us a five-star rating and to catch all the latest from Speaking of Women's Health, you can hit, follow or subscribe. Wherever you listen to podcasts Apple, spotify, tune in and, if you'd like to watch, we're also on Rumble and YouTube and it's all free and we'll catch you next time in the Sunflower House.