Episode 73
The Truth About Sleep: Why Women Aren't Getting the Rest They Deserve | Dr. Andrea Matsumura
You’re doing everything right. You're on hormones, you’ve cut the caffeine, maybe you’ve even bought one of those expensive sleep trackers. So why are you still waking up at 3am, wired and restless?
In this episode, I sit down with Dr. Andrea Matsumura—board-certified sleep physician and women’s health specialist—to finally unpack why sleep is such a persistent struggle for women, especially during perimenopause and menopause. Andrea breaks down the biological, psychological, and cultural reasons why women are conditioned to expect poor sleep—and why it doesn’t have to be that way.
We talk melatonin myths (the dose matters), the silent epidemic of undiagnosed sleep apnea in women, and why most wearables are only telling part of the story. Andrea also explains why cannabis, supplements, and even hormone therapy may help—but won’t fix the root cause for many women.
Plus, we get into the real reason cognitive behavioral therapy for insomnia (CBT-I) actually works—if you’re willing to do the work—and how the entire medical system is failing women by ignoring gender-specific data in sleep studies and diagnostics.
If you’re tired of being tired and want real, practical answers—not just another supplement or influencer sleep hack—this conversation is for you.
Highlights
- Why hormone therapy helps some women sleep—but not all.
- How sleep apnea presents differently in women and often goes undiagnosed.
- The truth about melatonin: why most people take the wrong dose at the wrong time.
- Cannabis and sleep: what the research really shows.
- Why CBT-I is the gold standard for insomnia (and why apps alone aren’t enough).
Do you like what you heard? Don’t forget to subscribe, like, and leave a comment on Apple Podcasts your support helps us reach more listeners who deserve better answers.
Guest Bio:
Dr. Andrea Matsumura MD MS FACP FAASM is a board certified sleep specialist and menopause expert, event and corporate speaker, group facilitator, co-founder of the Portland Menopause Collective, and creator of the Sleep Goddess MD D.R.E.A.M. Sleep Method™ and Sleep Goddess Archetype™.
Dr. Matsumura attended medical school at The University of Texas Health Science Center in San Antonio. She moved to Portland, Oregon for her residency in Internal Medicine and was an Internal Medicine Physician with Northwest Permanente for 13 years before entering her fellowship in Sleep Medicine. She attended Oregon Health and Science University as a fellow in Sleep Medicine. She became a partner at The Oregon Clinic in Pulmonary, Critical Care, and Sleep Medicine after completing her fellowship. During her tenure there she focused on women’s health and became a sought-after expert on women and sleep. She is currently the Medical Director of primary care services and medical home development for Cascadia Health in Portland, Oregon and has plans to develop sleep services.
Get in Touch with Dr. Matsumura
Get in Touch with Dr. Rahman:
Transcript
After I'm done with you, then I'll say, I'll do the intro for you and everything. So, but, well, let's get started and then we can talk about how you got into the space. And then I have like a hundred questions that people ask me like, you're gonna talk to a sleep doctor, ask her this, this and this. Cause you know, everyone's obsessed with their sleep. So, again, hi everyone. It's Dr. Smeena Rahman, Gyno Girl. Welcome back to another episode of Gyno Girl Presents, Sex, Drugs and Hormones.
Andrea Matsumura (:Okay.
Andrea Matsumura (:Yeah. Yeah.
Andrea Matsumura (:I'm excited, I'm excited.
Yes.
Dr Sameena Rahman (:I'm Dr. Samina Rahman and you guys asked for it and I'm bringing it to you. Like you guys heard my intro. I'm super excited to have this amazing professional sleep doctor. Sorry. I'm so excited to have this amazing physician who was an expert in sleep medicine, the sleep goddess herself, Dr. Andrea Matsumura. Like I don't like overnights.
Andrea Matsumura (:Sorry.
Andrea Matsumura (:I love it. Thank you. Thank you, Samina. Yes, because we, it's part of that whole suffering syndrome, right? That we've all been told that we shouldn't get enough sleep. So yes, I'm a board certified sleep physician and then kind of turned women's health specialist and
Dr Sameena Rahman (:Cool.
Dr Sameena Rahman (:Yeah.
Andrea Matsumura (:you know, really focusing on menopause, perimenopause, and for some pregnancy as well, because your sleep definitely changes during pregnancy as well.
Dr Sameena Rahman (:yeah, I need to all this.
Absolutely, well we're gonna touch on all that because I have listeners from all arenas. mean, a lot of them are midlife, but I feel like I have a lot of, I deal with a lot of general pelvic pain patients and so they have their own sleep issues and they're on all these medications, which I feel like we need to talk about. The meds used, we need to talk about what's good, what's not, and who deserves a sleep study and maybe a little bit about obstructive sleep apnea if you can throw it in there.
Andrea Matsumura (:Yeah.
Andrea Matsumura (:Yes, 100%.
Dr Sameena Rahman (:But let's talk a little bit about your journey because like we were about to talk. I was like, let's just record this. Tell us like the way that you kind of came in because none of us, know, probably people graduating now will be able to go into menopause in this way. But most of us have come into it and really had to teach it to ourselves through the menopause society and other mechanisms because we either had patients that were having the problem or we ourselves suffered and then we had to go figure it out ourselves, right? So, and it might be both because I...
Andrea Matsumura (:Yeah. Yeah.
Andrea Matsumura (:Mm-hmm.
Andrea Matsumura (:Yes. I think for me, definitely it was both. So, you know, I started out as a general internal medicine doc and then around 13 years into my career, I really needed to make a shift and I went back to school to study sleep, did a fellowship in sleep medicine. And then, so then I started practicing with this big group, mostly guys. And so then I was the only woman available, right?
Dr Sameena Rahman (:for some of us as well.
Dr Sameena Rahman (:Mm-hmm.
Dr Sameena Rahman (:Yeah.
Andrea Matsumura (:So then all these women started to come and see me and what I started to notice was this pattern of this, first of all, generally speaking that biopsychosocial model, know, women are just conditioned to say that they should never get good sleep. So socially, we are told that we shouldn't get sleep because we're always taking care of somebody or we've had a past trauma psychologically.
Dr Sameena Rahman (:Yes.
Andrea Matsumura (:Then there's a lot of general anxiety sometimes around our, know, depending on what's going on in your life. Also past trauma. I one in three people will have some trauma. One in three women rather will have some sort of trauma. And then the medical, like we weren't even, you know, included in studies until 1993, right? It's crazy. And so then we're kind of behind the, I know.
Dr Sameena Rahman (:Mm-hmm.
Dr Sameena Rahman (:I I mind-blowing. It's crazy. At this rate, we won't be included anymore, at this rate.
Andrea Matsumura (:Right? And so, you know, we're just behind the eight ball and really understanding sleep, the physiology of sleep for women and the stuff that's out there right now, the sleep gurus that are out there right now, outside of myself have really simply talked about the general public and really haven't focused on women. then I got into this space. Then I hit perimenopause, menopause. I have my own terrible menopause story.
But fast forward to, started to really incorporate that all into my work about seven years ago. And so now I've really focused on menopause, perimenopause, pregnancy, you know, just women's issues and sleep. So lots of women would come to me that are in my stage of life. I'm in my mid fifties. I would recognize that they needed hormone therapy.
Many of those women would get on hormone therapy and about half of them in my practice were still having trouble sleeping even after all of the addition of hormone replacement, hormone therapy that they were receiving. So we still have a lot of work to do.
Dr Sameena Rahman (:Yeah, absolutely. I mean, we always, there's plenty of women who wake up because of their hot flashes or are drenched in their sweat at night or get up because they have to pre-frequently. So there are these symptoms that we can kind of treat and I feel like they're helpful. And I would say probably a third to a fourth of women when they take oral micronized progesterone because of the GABA effect might have some benefit. Would you agree with that?
Andrea Matsumura (:Right. Yes. that's where, if 100 % of the women came to me saying, I have trouble sleeping, I would say 50 % of them with the addition of hormone treatment, mostly progesterone, but also estrogen. Estrogen does play a role in how it can help regulate sleep, melatonin, some of these other pieces that are key for our sleep. But another
Dr Sameena Rahman (:Yeah.
Dr Sameena Rahman (:Yeah.
Andrea Matsumura (:still out of that 100 % only half were getting the sleep that they needed after hormone therapy.
Dr Sameena Rahman (:Absolutely. And I think, you know, that's attributed to, again, whether or not they have the sort of the gab effect from the micro north progesterone or getting those night sweats under control that are not waking them up necessarily or.
Andrea Matsumura (:you
or other things. So lots of other things that can affect sleep. So one of the things that is, yeah, yeah.
Dr Sameena Rahman (:Can we do a little mention melatonin? Do you mind talking about that for a minute? Because that feels like everyone's like, no, melatonin doesn't work for me. And I feel like it has a lot to do what's available and how they're taking it. And yeah, maybe it doesn't work for everyone, even when they're optimized.
Andrea Matsumura (:You are right. It is the kind and when you take it. So melatonin is released from our pineal gland about four hours before we actually fall asleep. It is released in picograms. It's sold in milligrams. It is sold as a sleep aid. It is a clock starter in our brain. So it doesn't really work the way that we think it is supposed to work in our body. Not only that, we have a reduction in melatonin production.
by the time we're 50, it's pretty much reduced by almost 50%. So that, and melatonin is our circadian rhythm, our timing hormone that is used. GABA helps to induce relaxation. It really helps to calm the body and prepare it for sleep. So even though people are taking micronized progesterone, that's helping to increase that GABA.
use if you have an issue with your circadian rhythm your melatonin production the timing then you're still going to have issues with sleep not only that but the of the women who have sleep apnea nine out of ten of those women do not know that they have it because the symptoms are different in women than they are in men.
Dr Sameena Rahman (:That's wonderful. Before we talk about sleep apnea, what do you recommend for melatonin when, but I do want to go to sleep apnea after that.
Andrea Matsumura (:Yeah. Yeah. So for melatonin, I there is some data coming out. We've always poo-pooed sustained release melatonin, but now there's some newer data coming out that a really tiny dose of sustained release melatonin taken a couple of hours before bed might in fact help you with your what we call sleep architecture. So that is achieving all of the stages of sleep.
and then increasing sleep efficiency. That is the total amount of sleep time that you're having in one night. So with that reduction of melatonin production in our body, I think I am now convinced that we should be taking a small dose of melatonin. So when I say small, I think of anywhere between 0.3 milligrams to one milligram of melatonin sustained release.
a couple of hours before we go to bed. Now, some people are very sensitive to it. That's why I have this range. But one milligram generally is going to be okay for most people. hard to find the point three. It's hard to find the point five. Now, having said that, there are studies that have been done that show that there's just, you know, we don't have any regulation of supplements. So we want to, we want to go with someone that we know is doing third party testing that is tried and true. And
Dr Sameena Rahman (:Yeah.
Dr Sameena Rahman (:best of them.
Andrea Matsumura (:You might, because a lot of the stuff that's sold over the counter, when you go to like the major supermarkets, the studies show that it could be antihistamine, that it could be, it says on the bottle, three milligrams, but it's really eight. And so we want to be careful with melatonin because if you take too much, then you start having problems. You have nightmares. It can...
Dr Sameena Rahman (:Yeah.
Dr Sameena Rahman (:There's no regulation.
Andrea Matsumura (:make people have like a hangover effect the next day. So then you're not sure am I tired because I'm not getting enough sleep or am I tired because I'm taking too much melatonin or is there some other sleep issue going on?
Dr Sameena Rahman (:Yes.
Dr Sameena Rahman (:Is there a third party, is there a group or a company that you found to be significantly helpful for your patients? I know you don't usually recommend like, I'm just saying like, if there's something that you think has worked or any study that they do third party testing, is there one like particularly?
Andrea Matsumura (:Yeah. I know. Yeah.
Andrea Matsumura (:Yeah, pure encapsulations and I get, I have no affiliation with them, but they're actually made in Canada and they do a really good job of their third party testing, know, Thorin pharmaceuticals also. So some of those over, you can't find those in a drug store. You have to buy them online. those.
Dr Sameena Rahman (:Let's see.
Andrea Matsumura (:and they produce the lower doses. What's sold I find in supermarkets or at drugstores is that the doses are too high and they're usually combined with other things. And so then you want to be careful. What are those other things that are combined? There's some things that I would say, yeah, but then if it's just loaded with a bunch of stuff, then you don't know what's working.
Dr Sameena Rahman (:you
Yeah, absolutely. Speaking of like this unregulated sort of supplement industry, I always give the example because so many women turn to cannabis, you know, for sleep aids and other things. And I think I read a study like up to a fourth of women or a third of women would turn into cannabis to help them sleep in the midlife. And so I was, you know, it's just like when people say they don't feel anything when they take gummies, it's just as unregulated, right? You could take one that tastes like a gummy bear and the other one is like puts you out or makes you high and all the things. Is there one particular
Andrea Matsumura (:Mm-hmm.
Andrea Matsumura (:All
Dr Sameena Rahman (:particularly cannibinoid that you would reckon or cannabis. I mean, that's.
Andrea Matsumura (:Yeah, know, cannabinoids, CBN, it has been shown to help increase your ability to get to sleep, but there isn't really good data that says that it is helping you get into all the right stages of sleep. And I still am not a fan of cannabinoids or cannabis to be used for sleep. At the end of the day, it is it to me, it is similar to
some of the other agents that are prescribed for sleep where it gives you the perception that you're getting sleep, but you're not really getting the right kind of sleep, the right stages.
Dr Sameena Rahman (:Yes.
Dr Sameena Rahman (:Okay, the right stages. Do you mind going over those stages for the listening?
Andrea Matsumura (:Yeah. Okay, so there are three stages of sleep. There's, we call them N1, N2, and N3, and then there's REM sleep. So in total four. So N1 is kind of that very light sleep. A lot of people will think that they were awake all night, but they were probably going between N1 and N2. N2 is what we actually get the most of in a night. N2 is that
mid stage of sleep and then N3 is what we call deep sleep or our deep stage of sleep and that's when growth hormone is released and we actually naturally reduce N3 levels as we age which is part of kind of also how we age because we're getting less N3 so we're getting less time to repair so then as we age we have reduction of N3 which makes sense then our cells you know more oxidative stress.
Dr Sameena Rahman (:Yes.
Andrea Matsumura (:And then REM sleep is when we're actually cleaning the products out of the waste products out of our brain. That is kind of when the washing machine for the brain turns on and we absolutely need REM sleep to live. So a lot of people will say, well, I'm I can never dream. I don't remember any of my dreams. The fact that you're sitting there talking to me tells me that you're dreaming because we simply cannot survive if we're not getting REM sleep.
Dr Sameena Rahman (:Right, no, absolutely. On another side note, do you recommend any of these products, like the ones that measure your sleep? Do you think that any of them are reliably looked at in the literature in terms of the Oura Ring or your Apple Watch and all the things? Yeah.
Andrea Matsumura (:Yeah.
Andrea Matsumura (:Yeah.
Now, so those are called wearables. the things I have a whole talk on wearables. I've got two on right now. So this is one called the EV ring. It's a little tiny startup company, but it's really made just for women. Of course, the ORA ring is like the big brother to it. So the ORA ring's been out for a really long time. It's got the most population data, but the data that is being used is really focused on general population.
Dr Sameena Rahman (:wonderful.
Dr Sameena Rahman (:Andrea Matsumura (14:36.64)
women are then kind of lumped in and you know women and especially postmenopausal women have different values. So what I would say to that is that wearables are great adjuncts to helping you identify patterns but they are not diagnostic. So I would not I would always tell people or I tell people right now first wake up and ask yourself how you feel.
Dr Sameena Rahman (:Yeah.
Andrea Matsumura (:because these wearables tend to prime people. in other words, you might feel like you slept really well and then you look at your date and you say, oh my gosh, I didn't sleep well at all. Oh, I didn't sleep. And then it gets in your head, right? And the most accurate device on the market is likely the Oar ring. We're right behind it, this EV ring, because I sit on the board. And that's at 75 % accuracy. So Apple watches,
Dr Sameena Rahman (:And then I guess I'm done.
Andrea Matsumura (:are trying really hard to get their Garmin, let's see, the Wahoo. I mean, there's so many. And then all the rings are the devices that are out there. They're all, anything that you put on your body is called a wearable. Anything that you put beside you is called a nearable. And those are less accurate. So bottom line, they're great to help you identify something that might be abnormal, but they are not.
Dr Sameena Rahman (:Yeah.
Andrea Matsumura (:diagnostic tools and I think that is really lost on the general public that we don't want to diagnose you with something that's only 75 % correct.
Dr Sameena Rahman (:And what world of that would be okay?
Andrea Matsumura (:Right, like you don't want to be diagnosed with a sleep disorder that is a fourth incorrect half the time. I mean, you know, a fourth incorrect a fourth of the time.
Dr Sameena Rahman (:Right, right, That the positive predictive value, you know, all the sensitivity basically of the test. Really not that great.
Andrea Matsumura (:Right.
Dr Sameena Rahman (:Well, so that's really helpful actually, because people are always asking, which one should I get and da da. And so I'm always like, well, I don't even have to take on that. So that's very helpful. Okay, let's go back to what you were saying about obstructive sleep apnea, because I feel like that is something that we see a lot in our office, or I mean, most people probably see and don't even realize that it's not the typical patient that you would think of, right? That might have it, because women don't have, just like in cardiovascular disease, we don't always present with the typical symptoms.
Andrea Matsumura (:Yeah.
Andrea Matsumura (:Right?
Dr Sameena Rahman (:maybe by calling, and I interviewed Dr. Jane Morgan and she was like, you by calling them atypical, we're already othering it and making it harder for patients to get the right diagnosis because we're not making it a normal, this is normal for women. You know, because we don't even have the good data to say this is normal for women, but we're delaying diagnosis and treatments in lives. But let's talk about, you know, what obstructive sleep apnea is and how do we diagnose it and how is it different in women?
Andrea Matsumura (:huh.
Andrea Matsumura (:Right.
Andrea Matsumura (:Mm-hmm.
Andrea Matsumura (:Yeah, so obstructive sleep apnea, the one that everybody knows about is simple obstructive sleep apnea. People do not realize that there are many different phenotypes. So that word for the general public means that they're different, they're just different subtypes of sleep apnea. The one that everybody knows about, that hears about, that reads about online and social media is simple obstructive sleep apnea. And that means that this part of your
the neck area where the tongue falls back and the soft tissues close together, it closes off too much, which then reduces oxygen saturation. And that is actually how you get diagnosed. It is not, yes, one of the symptoms is snoring, but when we take a look at a sleep study, I am looking at reductions of oxygen saturations for a certain amount of time. It's actually very technical. So,
People don't realize that I am looking at a lot of different what we call channels. We're looking at three channels of breathing. We're looking at multiple channels of brain activity. We're looking at movement. All of these things play a role into whether or not somebody has what we call an apnea. Then there are calculations that are made to determine how many times you're having apnea per hour. That's when we get the apnea hypopnea index.
and five or more of those events is sleep apnea. And women tend to have REM-related sleep apnea, meaning that most of their abnormal breathing is happening when we're dreaming. So it's harder to capture. So just to your point about, let's not talk about atypical, let's just talk about how women present, right? So women will have more fragmentation of sleep. They might have more depressive symptoms.
They rarely are told or come in saying that they have loud snoring. They will say that they toss and turn. They might wake up with some headaches, but it's again, not specific symptoms. And sometimes women will say, I just don't feel good when I wake up and I'm giving myself seven hours of sleep and something just doesn't feel right. So I have a lower threshold of testing women
Dr Sameena Rahman (:Right.
Andrea Matsumura (:because we simply haven't developed great screening tools for them. Screening tools are gender biased, so we don't capture the women. And we have the same heart attack and stroke risk as men do when we're postmenopausal.
Dr Sameena Rahman (:Absolutely.
Dr Sameena Rahman (:Absolutely, absolutely.
Andrea Matsumura (:So that, I was just gonna say that is key. People need to realize that moderate or severe sleep apnea actually has an increased risk for heart attacks and strokes.
Dr Sameena Rahman (:That's wonderful to say. also, any, can you talk a little bit about how abnormalities in your sleep cycle can affect metabolic function a little bit, or the amount you're sleeping with?
Andrea Matsumura (:Right. you know, when we think about if somebody is having to wake up all of the time because their brain wakes them up to breathe, if you have sleep apnea, that's one reason why people will have then a metabolic dysregulation because everything, your body is this, how I explain it to patients is that all of your organs, it's like a metropolis, you know, it's a city.
Dr Sameena Rahman (:Yeah.
Andrea Matsumura (:and certain things have to open up and certain things have to close. And when you're going to sleep, the anchor stores are kind of sleeping. The anchor stores are like your heart, your lungs, your brain. Those big organs need to kind of get into sleep mode. And then all of these other little organs, the little boutiques, they're opening up. And if we are not getting into the right stages of sleep, then all of that hormonal
Dr Sameena Rahman (:Right.
Andrea Matsumura (:balance becomes imbalanced. And so then that's why people have abnormal cortisol levels, secondary to sleep, not the cortisol levels that we think about with other medical conditions, just it's a little off. Sometimes people have elevated blood counts. So the red blood cell level is elevated because your body is trying to make more red blood cells to carry oxygen.
People will, you know, so those are the big ones that we talk about. That metabolically people will just have everything will be off. then all of the, you know, all of your other hormones that regulate blood sugar, that regulate sex, you know, hormones, your libido, all of these things get affected when you're not getting into the right stages of sleep.
Dr Sameena Rahman (:Absolutely, that's great to hear. I mean, not great to hear, but that's great for you to say so that people will know. Okay, so you feel like you have a patient in front of you that you think, you know, I should test her for sleep apnea. Walk me through what a sleep test looks like for that patient.
Andrea Matsumura (:Sure. So that's another thing that I think social media has not done sleep any favors. People really say, well, they'll come in and say, I think I need a home sleep study. It's kind of like saying, I think I need, you know, an MRI, right? You just don't really know. I need to make that assessment, right? So by and large, home sleep studies, particular home sleep studies do a better job than others, especially when we're testing women.
And again, that goes back to that REM-related sleep apnea. If you can't capture the REM sleep accurately, sometimes you can't capture the abnormal breathing. So home studies are a good first pass. There's a different type of home study that kind of acts like an in-the-sleep center sleep study. That is called a type two home sleep study. And that can capture more of the stages of sleep.
but sometimes women just simply need to be in the sleep center. That's where we actually look at all of the sleep stages the most comprehensively. It also has the most sensitivity for breathing abnormalities. And again, women fall into this category where they will have mild sleep apnea overall, but then these little clusters of significant abnormal breathing, and that is during REM sleep.
Dr Sameena Rahman (:Yes.
Dr Sameena Rahman (:Yeah.
Andrea Matsumura (:And if you're sleeping in a weird place or maybe you're not getting good sleep, sometimes we don't capture enough REM sleep. So then, you know, women are told, well, you don't have sleep apnea with a home study. And home studies have a higher false negative rate for women than they do for men. So it's complex. So a home study, have to go back to, you know, what's the difference? A home study is where you have a few connections on your body.
Dr Sameena Rahman (:Yeah.
Dr Sameena Rahman (:so interesting. Yeah, it works.
Andrea Matsumura (:some key ones which are measuring oxygen saturation, heart rate, sometimes heart rhythm, and maybe one electrode that's measuring your sleep stages. And then type two has a couple of more additions for measuring oxygen and more sleep stages. And then an in the sleep center sleep study is the full meal deal. Yeah. So.
Dr Sameena Rahman (:Gold standard, yeah. The gold standard, And what happens to a patient when they find, because I feel like when I send patients to sleep centers, sometimes it's hard for them to get appointments, there's long wait lists, you all the things. And then they finally get one, but they're very grateful that they actually got, because sometimes they'll get this diagnosis, well, I didn't think I had obstetric sleep. So tell me what a patient will experience when they come to a sleep center. How does that work?
Andrea Matsumura (:Yes.
Andrea Matsumura (:Yeah, so I'm going to address that point that you just made that people have a hard time getting we don't have enough sleep doctors in the country. And we definitely don't have enough sleep doctors in the country that understand women's health. So a lot of women will go and be told that they don't need a study. Okay, so, so I'm actually
In the process of opening up my private practice, I do live in the state of Oregon. I don't know if I'm going to, you know, acquire a license outside of the state, but I feel this calling and this need to open up a practice for women. So what they expect is, you know, you're going to sleep in this bed. You have a lot of attachments and it is there's a whole lot of little stickies on your head. There's something that's
Dr Sameena Rahman (:Yes. Yes.
Andrea Matsumura (:put in your nose that looks like it's giving you oxygen, but it's not. It's measuring pressure and temperature changes of the work of breathing. You have two like bungee cord style belts that are measuring the effort of breathing in your chest and abdomen because we use that to help us sleep. Something that's measuring heart rate, heart rhythm, and oxygen saturations, and then attachments that are looking for movement in your legs and sometimes your arms. It's a lot.
Dr Sameena Rahman (:Okay, gotcha. And then it's a lot. And so you just have them sleep for the night and then all this.
Andrea Matsumura (:Then you have them sleep for the night. And we, you know, I always laugh thinking, okay, now we've put you in this weird place. We have all these attachments. Now I need you to sleep at least six hours.
Dr Sameena Rahman (:I can't speak.
Yeah. It's kind of like when you make someone, you know, peer to ejaculate in a cup and they have all this performance anxiety around it. Yeah.
Andrea Matsumura (:Yeah, yeah. So, I mean, this is why home studies, generally speaking, are a good first pass, especially if you don't have other medical conditions that really indicate that you need to go into a sleep center first. But I think it really depends on the person interpreting. So sleep doctors are the only people that can interpret a sleep study. And we really need to kind of tailor how we want people to use the home study.
Dr Sameena Rahman (:See then.
Dr Sameena Rahman (:Yeah.
Andrea Matsumura (:to capture the data that we really need, especially for women. So.
Dr Sameena Rahman (:And so you have someone either in any of these studies that comes back and they have now general OSA. What would you, so what's the first line treatment for them? Because most people are really intimidated by the devices, you know.
Andrea Matsumura (:Uh-huh.
Andrea Matsumura (:So the, so CPAP, there are different types of what we call positive airway pressure. That's what the PAP stands for. CPAP stands for continuous positive airway pressure, but there are other types of positive airway pressure. So again, the one that everybody hears about is CPAP. And so then that's a mask. Yes, most masks are made for men's faces. So that's already barrier one for women.
And then two insurance companies typically will only cover one or two types of masks. So then, you know, you're kind of already set up to fail because maybe one particular mask works really well for you, but your insurance doesn't cover it. So then you have to pay a hundred dollars for that mask. So masks can come in many different forms. Some of them come just under the nose. Some of them are just right over the nose. Some of them are under the nose and over the mouth.
Dr Sameena Rahman (:Yes.
Andrea Matsumura (:Some of them are over the nose and over the mouth. But most often I will have people just do the little one that's either under the nose or just a little tiny one that's over the nose. So CPAP is our first line of treatment because that's what we have the most data on. However, for women, if women have mild sleep apnea that's severe during REM sleep, they had some desaturations but they did not have
Dr Sameena Rahman (:sure.
Andrea Matsumura (:hypoventilation, meaning they didn't spend all this time with low oxygen and we didn't see that they were having a hard time moving air. Sometimes an oral appliance or what we call a mandibular advancement device or oral apnea therapy, you know, there's many different ways to say it. Some of these devices work really well for women. The caveat is that you do have to spend some dollars again because insurance may only cover
Dr Sameena Rahman (:Mm-hmm.
Andrea Matsumura (:one type of oral appliance with your dentist. There's over 17 on the market. Okay. So it gets complex, right? And, and yes, it's new. That's, I think what I am trying to say loud and clear that sleep is nuanced. It is not cut and dry. And so people, yes. So people will say, well, I just need an oral appliance. I'm just going to buy one online. No, please don't do that. Right. Because
Dr Sameena Rahman (:Right.
Dr Sameena Rahman (:Yeah, very nuanced.
Dr Sameena Rahman (:Right, just like men also care,
Dr Sameena Rahman (:Yeah.
Andrea Matsumura (:An oral appliance that you buy online is not fit for precision for your mouth and you have to wake up in the morning and talk and eat and drink.
Dr Sameena Rahman (:Yes, yes, exactly.
So important, actually. And I think that's one of the issues is that we're so used to just like going on Amazon and clicking and buying something that we don't have to like, you know, but the reality is most of what you're saying is so true that insurance is really and I say this on many of my podcasts that they set women up for failure when it comes to menopause, when it comes to sexual medicine and all the things because the systems aren't really made for that. We don't have, you know, FDA approved products that are, you know, for women and a lot of these arenas, you know, especially like
You know some of that post post menopausal low libido issues that we talk about so I think these are you know some setups that Systemically as a structure as a medical structure as a medical system that are really set up to fail women So you can't always just order something online and think it's gonna cure you and make you sleep better You do have to
Andrea Matsumura (:100%. I would spend the dollars because the fact of the matter is now that if you want to get good care, your insurance typically isn't going to cover it for you anymore, right? So I would spend the dollars if you had sleep apnea and you saw someone who said it's simple, obstructive sleep apnea, I would probably get an oral appliance and see a dentist who understands sleep apnea and
then get fitted for the right type of oral appliance that you can use. You know, I think that that's probably the way to go for most women. The other thing that we haven't even touched on, and that's a whole nother topic, is that some women will have upper airway resistance syndrome. So that is, again, phenotype of sleep apnea. That's not even recognized as a treatable disease for insurance companies.
Who gets that? Who gets upper area resistance syndrome? Women.
Dr Sameena Rahman (:Yes, yeah. That's so fun.
Andrea Matsumura (:Treatment for insomnia, because we haven't talked about that yet, is cognitive behavioral therapy for insomnia. That is the number one treatment. Typically not approved for treatment by most insurance companies. Or there's one person that you can see and you have a nine month waiting list. And who disproportionately gets insomnia, chronic insomnia? Women.
Dr Sameena Rahman (:Yes.
Dr Sameena Rahman (:Yes.
Dr Sameena Rahman (:It's so frustrating actually. think, and then, you know, most people want the quick fix. I feel like I take care of lot of patients and as physicians and as a former obstetrician, you know, there are times I had, you get the ins, you do, you work a bunch of nights in a row and you get insomnia. And like, feel like my sleep depth from residency is so huge that like you just never, you know, and I remember these periods of time where I just, you know, you couldn't sleep. And then the thought of not being able to sleep make you more anxious about not sleeping. And it became a really circular thing.
Andrea Matsumura (:Dr Sameena Rahman (33:46.07)
Can we talk a little bit about insomnia before we wrap things up?
Andrea Matsumura (:Yeah. So going back to that whole discussion where we were talking about hormone treatment and that in my world, would treat, I would start women on hormone therapy. We'd get to a good place for reducing most of their symptoms, but they were still having trouble sleeping. So then I have to evaluate, I evaluate them. have this actual method that I developed called the dream sleep method, which goes over each component.
Dr Sameena Rahman (:Mm-hmm.
Dr Sameena Rahman (:yeah, that's right.
Andrea Matsumura (:Right? And if we exhaust all of that, you don't have any other medical condition outside of chronic insomnia, then cognitive behavioral therapy for insomnia is the way to go. And that is retraining your brain. And I always tell people that is a marathon, that is not a 5K. however, if we talk to people about
the rest of their life, right? So it's maybe three to four months of hard work, uncomfortable work to set yourself up for the next decades of better sleep. And people come to me and they'll say, well, I don't want to do cognitive behavioral therapy for insomnia. I tried it. It doesn't work. You have to do every component of it for it to be successful. And the other piece is that people will come to me and
I'll say, but you haven't been sleeping well for 10 years. So three months of to four months of being uncomfortable so that you can set yourself up for the rest of your life of getting better sleep is a small price to pay because what's happening right now isn't working.
Dr Sameena Rahman (:not sustainable. Absolutely. And can you talk a little bit about the apps that say they do the CBTI? Like how, you know, helpful do you think those are?
Andrea Matsumura (:You know, they vary. what people, think what happens with those apps is that people end up picking and choosing what they want to do with the Cognitive Behavioral Therapy for Insomnia. And it's not focused at the very beginning that you need to actually follow all of the components of Cognitive Behavioral Therapy for Insomnia. It's similar to, you know, I'll tell people if you have high blood pressure, do you take your blood pressure medication three times a week?
Dr Sameena Rahman (:Nyeh.
Andrea Matsumura (:No, right? It's the same for like treating sleep apnea. People will say, well, I use my CPAP machine four times a week. I'm like, well, do you take your diabetic medication four times a week or do you take it every day? So, right, so with cognitive behavioral therapy for insomnia, those apps, if you are all in and you focus on doing everything, it's gonna be successful.
Dr Sameena Rahman (:All right. All right. Exactly.
Dr Sameena Rahman (:Right. I think that's the big issue is really, you know, that dedication because it's similar to anxiety and some of these other things where you have these ruminations and you have to actually face. you know, we talk about this in pelvic floor issues and like vaginismus and some of these conditions where you have to desensitize your your brain. You have to reshape it. You have to restructure and reconfigure, you know, everything so that you don't continue in the same sort of loophole.
And I think that so many patients don't, it brings them so much anxiety to face all of those things at once that they run from it, right? And so it's only until they almost hit rock bottom that they're like, okay, fine, I'll do the dilators, I'll do the sex therapy, I'll do the cognitive behavioral therapy. Because most people want a quick fix with the medication, which doesn't always work.
Andrea Matsumura (:Yes, so with sleep, there's no quick fix. Sleep is sleepy. That's what I like to say. And yeah, but if you, know, I'm here for people for if you want to start that journey, I am there to walk it with you. And I can guarantee that if we work together and we follow the tried and true methods, and we also think outside of the box too, like I, I will say,
Dr Sameena Rahman (:Yes, yes. There's so many places.
Andrea Matsumura (:It's a all hands on deck approach. There's not one thing, there's not one silver bullet that's going to work.
Dr Sameena Rahman (:That's like most of what we're doing these days. Can you just touch a little bit on the medications that are supposedly FDA approved for sleep and then why they can be so dangerous for some conditions?
Andrea Matsumura (:Ha
Yes. So the medications that are FDA approved for sleep are really FDA approved for acute insomnia. So acute insomnia is when somebody has a really defined period of time that is affecting their sleep. You are getting a divorce, someone dies, you move to a different part of of the world or you have a new job.
And they're really the fine print of all of those medications, say, not to use for more than two weeks at a time. So they're not generally habit forming. It's more of the notion that you need it to get to sleep. they don't really, the data is pretty weak on them. They're not really increasing.
Dr Sameena Rahman (:just singing.
Andrea Matsumura (:hours of sleep, the best is it increases it by like 40 minutes. So it's, it's, and then most people who have chronic insomnia need an escalating dose because the power of the brain overrides what any medication you're going to take. And that's the key with kana tippe behavioral therapy for insomnia is re it's, it's reframing and addressing the neurological pathway.
Whereas medication is filling receptors. But if you have a hypervigilance, it doesn't matter how much medicine you take, you're not gonna get to sleep.
Dr Sameena Rahman (:That's so true. Can you walk through the best forms of sleep hygiene? Like what would you recommend for patients? I mean, we're all addicted to our little phone in front of us. And so I'm always like, you we got to, you know, you don't take your own advice sometimes when it comes to that stuff. I'm always like, okay. I don't know why I can't sleep, but.
Andrea Matsumura (:Sure.
Andrea Matsumura (:I don't take my own advice. I get it. Yeah. It's pretty.
Andrea Matsumura (:I know it's kind of getting back to the basics. you know, so my general path, you know, plan for sleep hygiene or that's how do I prepare myself for sleep is wind down, like give yourself that hour before you want to go to sleep to start winding down all the sensory, all the light in our life is not good for us. So yeah, put your phone down.
an hour before you're going to sleep. Don't put it in your bedroom. People will say, but I use it as my alarm clock. Okay. Put it across the room. You can hear it. It's loud. If you'll need it right next to you, put it in the, in the drawer of your nightstand. Just don't use it an hour before you go to sleep. We have nerve cells in our eye that connect directly to our wake center in our brain where we have too much light in our life. So it's not allowing us to actually
excuse me, shut down. So that's the biggest piece. The other piece is, you know, watch your caffeine intake. Caffeine's half-life is five to seven hours. That means 50 % of caffeine is still in your body after five to seven hours. So studies have shown that if you take, drink caffeine too close to bedtime, it actually reduces your total sleep time by at least 30 minutes. Okay. You know, your bedroom should be dark.
cool and quiet. I'm a big proponent of eye masks, like reduce the sensory component. If you need earplugs, I recommend earplugs. If you need blackout shades, you know, don't let that light come in too early because then you will have a hard time getting back to sleep. But generally speaking, you know, wear comfortable clothes. Have a routine. Just it.
So my analogy is when we're hungry, we don't just go, go, go, go, go, go, go, the refrigerator and then start shoveling food in our mouth, right? We prepare ourselves to eat by preparing a meal or going to a restaurant, sitting down, relaxing, looking at the food in front of us, being mindful about our food intake. It's the same with sleep. We have to be mindful about how we prepare ourselves for sleep.
Andrea Matsumura (:Most people will say things like, you know, I can drink caffeine until, you know, 30 minutes before I go to sleep and then I fall right to sleep and I will tell people, that's just confirmation that you're chronically sleep deprived. Because again, it is a drug, so to speak, and your brain is overriding it because you're so tired.
Dr Sameena Rahman (:Yes.
Dr Sameena Rahman (:Absolutely. What about exercise? Some people are swearing that they exercise late in the day, they're good, and other people are like, can't exercise past this point.
Andrea Matsumura (:Yeah, we used to not recommend heavy exercise at night, but there is a subset of people that will say that heavy exercise helps them feel sleepy. I also tell people, you know yourself the best. If you know that exercise keeps you awake, like for me it does, I really cannot exercise after a certain hour, then please don't do it at night, right? If you...
Dr Sameena Rahman (:YouTube.
you
Andrea Matsumura (:are the person who I exercise and then I feel super relaxed, hey, then do it at night.
Dr Sameena Rahman (:Yeah.
Yeah, that makes sense. Well, this has been so great, Andrea. Like, I feel like, you know, these are some of the basic questions that people are always like trying to, you know, navigate when it comes to sleep. And we know how important sleep is. Everyone is obsessed with their sleep patterns. When looking for someone to help, you know, navigate their sleep disruptions, like, are there sources for finding a good therapist for that does CBTI? there other resources?
for other sleep doctors like yourself.
Andrea Matsumura (:You know, so there's, know that there are sleep doctors all over the country, right? About a third of sleep doctors are women. I would say that you want to focus on somebody who isn't only looking at sleep apnea, but is looking at the entire picture because I think that there has been this tendency for sleep doctors to really only focus on sleep apnea.
And that's not really going up to 60 % of people who have sleep apnea have insomnia. There's actually a name for it. It's called co Mesa. So we, you want a holistic approach to your sleep. so that's the first thing. So in most big cities, you're going to have some sleep doctors, right? Now, if you're looking for somebody to really focus on insomnia, you really want them to be trained.
Dr Sameena Rahman (:Yeah.
Andrea Matsumura (:in cognitive behavioral therapy for insomnia. Because time and time again, I've had many people come to me over the years and tell me that they saw a psychologist who helped them with sleep and they only focused on sleep hygiene, getting ready for bed. That's not it. It's really about understanding the hyper arousal, hyper vigilance in your sleep that is preventing you from staying asleep or getting to sleep.
Dr Sameena Rahman (:Is there like any, like you know how you can go to the Menopause Society and find a certified Menopause practitioner? Can you do that?
Andrea Matsumura (:Yeah.
So the American Academy of Sleep Medicine does have a list of sleep clinicians. The American Psychological Association has a list of cognitive behavioral therapy trained for insomnia trained. So you wanna just make sure that you search for that. That person is CBT-I trained.
And there's a book actually, again, I have no affiliation. It's just, I often will say to people, this is the best, like 40 bucks you're gonna spend. It is called Overcoming Insomnia, A Cognitive Behavioral Therapy Approach. It's a workbook and it really takes you through the steps for self-help. Sometimes I think getting the book over an app helps people. It's little, it's thin, it's not very big. It's totally doable.
And it is a game changer if you actually follow it 100%.
Dr Sameena Rahman (:that's great. That's great to hear. Well, we love to have those resources, so we'll put them into our discussion notes in this podcast as well. But thank you so much, Andrea. This has been great. know, like sleep is so important for so many people and your knowledge is amazing. And I feel like, you know, more people should follow you and everything that you're talking about on all of your platforms. And, you know, we'd love to hear about your practice. Are you in the process of evolving into a practice or?
Andrea Matsumura (:Mmm!
Andrea Matsumura (:Yes, so I'm in the process of developing my own private practice. You can also follow me on Instagram, sleep goddess MD. I have a website as well and I do have a fair amount of blogs on my website that focus on sleep in general, but then also sleep and menopause.
Dr Sameena Rahman (:Well we'll keep up with that so anyone in the area that wants to come see you as a patient they'll be able to and if you ever expand beyond that I'm sure we'll find out from your website. Awesome. Well thank you so much for joining me today on GynaGurl Presents Sex Drugs and Hormones. I'm Dr. Smita Rahman. Remember I'm here to educate so you can advocate for yourself. Please join me on next week's episode. Yay! Andre that was great!
Andrea Matsumura (:Yeah, thank you.
Andrea Matsumura (:Bye. Thank you.
