Loving the Menopausal Insomniac

Leila Turner, ND EndoANP 2018 Sleep Quality ~ Overall Health

A good night's sleep is vital for every human being to survive. Given that an average a person sleeps for 8 hours in a day, that means that an average person will sleep for 229,961 hours in their lifetime or basically one third of their life. For the love of sleep • Sleep provides an opportunity for the body to repair and rejuvenate itself. • Many of the major restorative functions in the body like muscle growth, tissue repair, protein synthesis, and growth hormone release occur mostly • Most people don’t get enough sleep. We are a society that burns the candle at both ends, a nation where people stay up all night to study, work, or have fun. • However, going without adequate sleep carries with it both short- and long-term consequences. During Sleep • Heart rate and BP slows • Cells recover & detoxification occurs, fasting • Memory improves – long term memories settle, decisive processes often reconcile, perspective has time to become clear • Disconnect from surroundings • Cravings are curbed/cured • Brain gets a break • Take a break from stressors • Doesn’t it make sense that the more productive and busier we are… the MORE important quality sleep Lack of adequate sleep affects

• Judgment & mood • Ability to learn and retain information • Perception and judgment • Efficiency, productivity, error • Increases the risk of serious accidents and injury • Chronic sleep deprivation à obesity, diabetes, cardiovascular disease, and even early mortality The Restoration of Sleep

• This restoration takes place mostly during slow-wave sleep, during which body temperature, heart rate, and brain oxygen consumption decrease. • The brain, especially, requires sleep for restoration • Synthesis of molecules that help repair and protect the brain are generated during sleep. • Anabolic hormones such as growth hormones are secreted preferentially during sleep. • Sleep has also been theorized to effectively combat the accumulation of free radicals in the brain, by increasing the efficiency of endogenous antioxidant mechanisms. • Wound healing has been shown to be affected by sleep The Restoration of Sleep

• It has been shown that sleep deprivation affects the immune system • sleep loss… impairs immune function • sleep increases white blood cell counts. Insomnia

• According to the U.S. Centers for Disease Control and Prevention, more than 80 million American adults are chronically sleep deprived, meaning they sleep less than the recommended minimum of seven hours a night.

• Fatigue contributes to more than a million auto accidents each year, as well as to a significant number of medical errors. Even small adjustments in sleep can be problematic. The Monday after a daylight saving time change in the U.S., there’s a 24 percent increase in heart attacks, compared with other Mondays, and a jump in fatal car crashes too.

• During our lifetimes, about a third of us will suffer from at least one diagnosable sleep disorder. They range from chronic insomnia to sleep apnea to restless leg syndrome to much rarer and stranger conditions The Cost of Insomnia

• 1 in 3 adults suffer with insomnia • Consumers speak over $32 billion on sleep aid products

Sleep Stages Sleep Stages

• These five stages of sleep must be achieved in order for restorative sleep to occur, in which the brain repairs itself by achieving brain wave regulation and creating needed connections through the brain. • Restorative sleep consists of the completion of all five stages of sleep, and also the chemical changes that occur within a twenty- four-hour period that allow the brain and body systems to be repaired, heal, and grow. • The fluctuation from Non-Rem to Rem is called the circadian rhythm, which is the sleep/wake cycle within twenty-four hours. Sleep Stages

• Non-REM (75%) • N1 (1-7 min) • light sleep, sudden noises may wake, people often feel they are awake in this stage, muscle jerks • N2 (10-25 min) • Signifies the onset of sleep, eye movement stops, HR and RR slows, Temp drops • Disengaged from our surroundings • Slower brain waves with occasional bursts of rapid activity • Spontaneous periods of muslce tension are interspersed with periods of muscle relaxation • 40-50% of your sleep, • N3 & N4 (20-40 min) • “Deep Sleep” ~ “Slow Wave” ~ “Delta Waves” • The deepest and most restorative sleep. The hardest stage to wake someone from. • Associated with cellular recovery, memory, GH release, tissue repair, hormone release • Majority of N3 happens in the first half of the night – less N3 is each subsequent sleep cycle • Amount of N3 decreases with age • The longer someone has been awake – the more N3 they need • REM (25%) • Typically occurs 90 min after falling to sleep and recurs every 90 minutes. Brain activity is similar to when we are awake • Muscles are quiet and not moving (only the eyes move) • Dreams • engorgement of sexual organs

REM

• “Every time we experience REM sleep, we literally go mad. By definition, psychosis is a condition characterized by hallucinations and delusions.“

• Dreaming, some sleep scientists say, is a psychotic state—we fully believe that we see what is not there, and we accept that time, location, and people themselves can morph and disappear without warning.

• The body doesn’t thermoregulate in REM sleep; our internal temperature remains at its lowest setting. We are truly out cold.

• Our heart rate increases compared with other sleep stages, and our breathing is irregular.

• Our muscles, with a few exceptions—eyes, ears, heart, diaphragm—are immobilized.

• Sadly, this doesn’t keep some of us from snoring (caused when turbulent airflow vibrates the relaxed tissues of the throat or nose. It’s common in stages 3 and 4 too.

• In REM sleep, whether snoring or not, we’re completely incapable of physical response, slack- jawed, unable to regulate even our blood pressure.

• Yet our brain is able to convince us that we’re surfing on clouds, slaying dragons.

Sleep Stages & Aging

• As you age your sleep cycles changes • The Deeper stages of N3 slows down in frequently while the lighter stages of N1 increases • This accounts for why many older people find they wake up easily during the night. • Seniors still need plenty of quality sleep Treatments ~ TLC

• The first is behavioral and/or environmental intervention: • Chronotherapy, or stabilized time of waking. It is important to go to bed and wake up at the same time each day. • Reduction of or avoidance of caffeine and alcohol. • Elimination of tobacco. • Eating a higher protein diet while eliminating sugar, artificial sweeteners, and processed foods. • Phototherapy, or careful use of and exposure to light. • Environmental controls such as turning off lights and minimizing background noises. • Regular exercise; however, do not work out within four hours of your bedtime. • Limited time in bed by not watching TV in the bedroom. • Selection of the proper bed, pillow, and mattress for the promotion of restorative sleep. • Psychotherapy; specifically, Cognitive Behavioral Therapy to learn new cognitive approaches to sleeping and daily living and/or Trauma Therapy to minimize the effect of PTSD. Treatments ~ Medications

• The following substances can help if taken on a limited, short- term basis and under your doctor’s supervision: • Desyrel (Trazodone) and some other low-dose antidepressants may help sleeping problems, though their side effects may worsen such symptoms as daytime fatigue and memory difficulties. • Nonbenzodiazepines such as: Zolpidem (Ambien), Zaleplon (Sonata), and Eszopiclone (Lunesta). • Acetylcholinesterase Inhibitors (Aricept, Reminyl, and Exelon) and wake-promoting agents that increase vigilance while increasing verbal and visuospatial memory. Medications

• Sedative hypnotics include benzodiazepines, barbiturates, and various hypnotics. • Benzodiazepines such as Xanax, Valium, Ativan, and Librium are anti-anxiety medications. While these drugs may be useful short-term, all benzodiazepines are potentially addictive and can cause problems with memory and attention. • Barbiturates, another drug in this sedative-hypnotic class, depress the central nervous system and can cause sedation. They can be fatal in overdose. • Newer medications help reduce the time it takes to fall asleep. • Some of these sleep-inducing drugs, which bind to the same receptors in the brain as do benzodiazepines, include Lunesta, Sonata, and Ambien. • They are somewhat less likely than benzodiazepines to be habit-forming, but over time can still sometimes cause physical dependence. • They can work quickly to increase drowsiness and sleep. Another sleep aid, called Rozerem, acts differently from other sleep medicines by affecting a brain hormone called melatonin, and is not habit-forming. • Belsomra is another unique sleep aid that affects a brain chemical called orexin, and is not addictive or habit-forming. Another sleep medicine that is not habit-forming, Silenor, is a low-dose form of the tricyclic antidepressant doxepin. Medications ~ SE

• Side effects: • Headache • Burning or tingling in the • Heartburn hands, arms, feet, or legs • Impairment the next day • Changes in appetite • Mental slowing or problems • Constipation with attention or memory • Diarrhea • Stomach pain or tenderness • Difficulty keeping balance • Uncontrollable shaking of a • Dizziness part of the body • • Daytime drowsiness Unusual dreams • • Dry mouth or throat Weakness • Gas TOLLE CAUSUM Tolle Causum: Melatonin • â Melatonin • The main causes of melatonin deficiency are a lack of sleep or anything that disrupts sleep e.g. shift work, late nights, jet lag, alcohol, caffeine, blood sugar imbalances, stress, exposure to light (particularly blue light), electromagnetic waves and age (some older adults produce no melatonin at all). • Measurable in some urine tests Tolle Causum: Melatonin Tolle Causum: Melatonin • Melatonin Supplementation • .3-5mg • Alternating doses • Cofactors: SAMe, Vitamin C, Copper, B6, Iron

• Tryptophan 1000-4000mgqhs • 5-HTP 100-200mg qhs Tolle Causum: Blood Sugar Imbalances

• áCarb dinner/dessert • Diabetes • Insulin Resistance • Improper macronutrient ratios • Obesity • Sleep Apnea • Sleep disruption leads to insulin resistance • Genetic tendencies towards elevated blood sugar

***Tx the Cause*** Tolle Causum: Overweight

• á Blood sugar • á Cortisol • Obesity à Sleep Apnea • à Poor quality sleep • à Less likely to get to delta waves and REM sleep

***Tx the Cause*** Tolle Causum: Nocturia

• Thirstless during the day ~ thirsty end of day • Drinking time of day • BPH • Interstitial cystitis • Muscle weakness – detrusor • Medication side effect • Pregnancy Tolle Causum: Nocturia Tx

• Water timers in first and thirds of the day • Trace minerals • Tx BPH • Tx Interstitial cystitis • Consider referral Muscle weakness – detrusor • Med Check ~ What necessary? • Pregnancy – control water intake Tolle Causum: Environmental

• Lights • Noise – snoring, neighbors, ticking • Temperature • Electronic devices - lights • Television • Allergens – air, flora, fauna • Family members Tolle Causum: Environmental Tx

• Awareness and Commitment – control what you can • Lights • Temperature • Electronic devices - lights • Television • Night mode on apps • Noise – snoring, neighbors, ticking • Allergens – air, flora, fauna • Family members Tolle Causum: Cortisol • Inversed cortisol curve • Chronic stress • Acute stress • Stress à â System Function à â Efficacy of all hormones à Inflammation à Obesity à Neurotransmitter imbalances Tolle Causum: Cortisol

• Tx the HPA • Phos-serine Tolle Causum: Hormone Fluctuations

• Perimenopause ~ Menopause • Fluctuating Estrogen (high and low) • Total Estrogens <50 • Account for cross reactivity and environmental estrogens • BiEst (50:50 – 80:20) (1.25 – 2.5mg qd-bid) • Estradiol (.25-1mg qd-bid) • Topical/ Patch/ Pellet • Fluctuating Progesterone (usually low) • P4 blocks absorption of E2 so dose separately • 300mg/cap if SR and 400mg/cap if IR • Prometrium (peanut) • Fluctuation Testosterone (usually low) Elevated E2 & Hypothyroid?

• Estrogen à Increases TBG • Estrogen à decreases T4à T3 conversion

Rudy Dragone, AZNMA Conference 2011 Progesterone ~ Estrogen

• Progesterone à Helps convert E2à E1

• So when P4 is low

à Back up of áE2

b/c the conversion from E2 to El and El to E3 won't occur

Rudy Dragone, AZNMA Conference 2011 Elevated E2 & Testosterone Deficiency?

• E2 à áSHBG • E2 à blocks androgen receptors

Rudy Dragone, AZNMA Conference 2011 Sex Hormone Receptors

• Estrogen à FORMATION of progesterone receptors • Progesterone à REGULATES estrogen receptors

ááEstrogen or ááProgesterone à âEstrogen Receptors

ááEstrogen or ááProgesterone à âProgesterone Receptors

“Therefore for proper receptor function of each hormone… both hormones are needed at a physiologic level”

Jim Paoletti, FAARFM, FIACP, Practitioner’s Guide to Physiologic Bioidentical Hormone Balance © 2015 SHBG

• Sex hormone-binding globulin (SHBG) or sex steroid- binding globulin (SSBG) is a glycoprotein that binds to sex hormones, to be specific, testosterone and estradiol.

• Other steroid hormones such as progesterone, cortisol, and other corticosteroids are bound by transcortin.

• SHBG is produced mostly by the liver and is released into the bloodstream.

• Also produced by the brain, uterus, testes, and placenta. Testes-produced SHBG is called androgen-binding protein. SHBG

• Conditions with low SHBG include: • Polycystic ovary syndrome • Diabetes, • Hypothyroidism

• Conditions with high SHBG: • Pregnancy • Hyperthyroidism • Anorexia nervosa THE FOLLOWING INCREASE SHBG • Thyroid Hormone à áSHBG • áEstrogen and phytoestrogens à áSHBG • Progesterone à áSHBG • Aging à áSHBG • âInsulin à áSHBG • Liver support: botanicals/ castor oil packs à áSHBG • Green tea extract: 500 mg/d à áSHBG • Soy isoflavones: 50-100 mg/d à áSHBG • Flaxseed: 1-2 tbsp./d à áSHBG • GH à áâSHBG THE FOLLOWING DECREASES SHBG

• áTestosterone à âSHBG • áDHEA à âSHBG • á Glucocorticoids à âSHBG • áInsulin à âSHBG • Fish oil à âSHBG • Avena à âSHBG • Tongkat Ali à âSHBG • Nettles root: 600 mg/d “â“SHBG • (binds SHBG à á free hormones)

Tolle Causum: Vasomotor Fluctuations

• Hot flashes / Night Sweats • Hormone fluctuations • Neurotransmitter fluctuations • Tx: • 5-HTP • Estrogen, Testosterone • Rubarb • Black cohosh, saliva • Tolle Causum: Thyroid

• Hypothyroid or Hyperthyroid • Some pts do better with thyroid dose qhs Tolle Causum: Neurotransmitters

• â Serotonin • â GABA • á Glutamate à poor sleep quality • á Dopamine à poor sleep quality • á Epinephrine à poor sleep quality • Genetic susceptibilities to neurotransmitter imbalances

***Urine testing and amino acid protocols GABA

• GABA Phenibut

• Phenibut (beta-phenyl-gamma-aminobutyric acid) – a derivative of GABA Tolle Causum: Pain

• Inflammation • Joint Pain • Muscle Pain • Charlie Horses / Cramps • Nerve Pain • Fibromyalgia • Auto-Immune • Genetic tendencies towards inflammation Tolle Causum: Pain Tx

• Tx Muscle Pain/ Charlie Horses / Cramps • Magnesium • Calcium • Potassium • Tx the Inflammation • Tx the Joint ~ collagen • Tx the Nerve Pain ~ homeopathy, LDN, PolyMVA, ALA, Homeopathic Injectable, Biopuncture • Tx Fibromyalgia ~ Mitochondria, Gut • Auto-Immune ~ LDN • Genetic tendencies towards inflammation ~ Treat the susceptibilities/ Diet/ Lifestyle • CBD Products/ Medical Marijuana • Progesterone binds GABA Tolle Causum: Anxiety ~ Depression ~ Stress • Anxiety • PTSD • Fears • Stressors • Persistent thoughts • Balanced Life Plate • Abandoned feelings? Abandoned Desires? Abandoned Dreams? Plans? • Prioritization • DELTA DELTA DELTA ~ Quality and Quantity for sufficient regeneration Tolle Causum: Anxiety ~ Depression ~ Stress

• Meditation • Nightly Brain Dump • Pineal Gland Calibration (432hz Theta meditation) • Solfeggio Harmonics (174-963 hz) à induced theta and delta • Homeopathy • Grounding ~ Nature • Spinal manipulation (NMT / Spinal Network Analysis) The Interview

• Understand your underlying causes • Night time ritual. Lights. Devices. • Time to fall asleep / What makes it difficult to fall • Time staying asleep / What makes it difficult to stay • Times they wake and time to resume sleep / What wakes them • Energy on waking • Daytime energy curve Root Causes • Melatonin ~ Amino acids ~ cofactors • Diet ~ Blood Sugar Dysregulation ~ Macronutrient Issue ~ Gut dysfunction • Overweight ~ Apnea • Nocturia • Environmental exposures • Cortisol ~ HPA Dysfunction • Hormones • E / P / T • Thyroid • Neurotransmitters • Pain • Stress ~ Anxiety ~ PTSD ~ Abandoned dreams • A Time Deficiency ~ Prioritization Thank You

Interested in getting involved? [email protected] References

• https://www.womensinternational.com/wp- content/uploads/2017/03/Hormone_Binding_Proteins.pdf • https://www.nationalgeographic.com/magazine/2018/08/science-of- sleep/?cmpid=org=ngp::mc=crm- email::src=ngp::cmp=editorial::add=sunstills_20180722::rid=18457076275&user.t estname=none