Dr Moira Junge, CEO, Sleep Health Foundation (00:00:04):
Hello, everyone. Welcome. Welcome to a very important webinar, The Sleep Menopause Connection. Let’s talk about Sleep in Midlife. So I’m absolutely delighted that you’ve joined us. I’m going to stop sharing the screen so you can actually see all of our panellists a bit more now. I’m just going to give us just another couple of seconds as I see a whole lot of you pouring in. We are so, so delighted that there’s been an exceptional amount of people coming today, so we know just how important this is. And this webinar is Marking World Menopause Month. We’re very thrilled to have you here for this important discussion. So my name is Moira Junge. I’m a health psychologist and I’m the proud CEO of the Sleep Health Foundation. Before I introduce the panel, I’d like to acknowledge the traditional owners of the land on which we meet today.
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I’m on the land of the Wurundjeri Wai Wurrung people of the Kulin Nation, and I pay my respects to their elders past and present, and also extend that respect to Aboriginal and Torres Strait Islander people on the land on which you are calling in from and any First Nations people here today or watching this later.
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So as I said, this webinar has broken all the records of attendance for us, many, many hundreds more than any other previous topic. So we know that this sleep in midlife is a topic we need to focus on and we need to unpack. The overall objective for this webinar was to raise awareness, dispel myths, provide an exploration of practical strategies and discussion of systemic solutions to improve sleep during perimenopause and menopausal transition time and provision of resources and advice about pathways to treatment and support. And probably even more importantly, I’d like to think that we might even provide some reassurance. So first of all though, I’d like to launch, before I do get into the panel, I’ve got a couple of polls I wanted to launch because I wanted to know a little bit more about you, the audience here. So I’m going to launch, I don’t know what order it is, I’m just going to launch this one.
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The question on your screen, they’re anonymous and they’re optional to jump in. And I’d like to just, this question is, do you identify as female just simply yes or no? And this is, I’ll just keep it opened for a little bit. I presumed we’re going to have mostly people who identify as a female audience, but it’s just really nice for us to check in a bit with who we’re talking with. So we can see that at this stage it’s 98%. I’ll close the poll now, even though some of you hadn’t had a chance to do that. And I’ll share the results with you that you will see that 98% of you identify as female. I’m going to launch the next poll. Sorry, let me go back to polls. I’ve got another couple of questions for you.
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Where did it go? Okay. So the next poll you’ll see on your screen, I’m just asking you whether you are a health professional, a researcher, or just someone who’s here for your own personal experience, nothing to do with your own profession. And that’s just interesting for us as well to see who you are. And I can see, I’ll keep it open for another 30 seconds or so. And at the moment, the vast majority of you are people who we were hoping actually, just the general public who are here just for your own general personal experience and not necessarily for your professional, but very welcome to have our colleagues and health professionals and researchers as well. So I’ll end that poll and I’ll share those results. You can see that on the screen that the vast majority of you, 74% are here just for your own sort of personal information.
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And I’ll find, go back to the final poll and launch that because I wanted to just get a sense of your age group. And I’ve asked you, are you under 35? Are you between 36 and 49, 50 and 59 or 60 plus? And I’ll keep that open for another 30 seconds and we’ll just see who we are speaking with. And as suspected, I thought it might be the vast majority of this point between 50 and 59, more than half of you. So that’s good. That’s really great for us. Thank you for participating. It’s really great just to know who we’re speaking with. So I’ll share results on the screen and then going back to where I was. So just a second.
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Okay. So I wanted to just give you a couple of brief words just really briefly about the Sleep Health Foundation, but some of you wouldn’t know who we are. We’re a community-facing health promotion not- for-profit organisation that seeks to raise awareness of the importance of sleep and provide evidence-based resources and information out directly to the public. We’re proud to partner with Jean Hailes for Women’s Health today and in general as well with our information partners. And Jean Hailes for Women’s Health is a national not- for-profit organisation dedicated to improving women’s health across Australia through every life stage. They were founded in 1992 in honour of the late Dr. Jean Hales, who was credited with being the pioneer of menopause management in Australia. So I’ll briefly introduce our panel now. Today we have Dr. Sarah White from the CEO of Jean Hailes for Women’s Health.
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Sarah has a PhD and a hugely interesting background ranging from cancer research to communications and other leadership roles. We also welcome Dr. Bianca Cannon, who was a GP in Sydney. Give us a wave Bianca. Bianca has been a GP for over 20 years and has a special interest in women’s health, mental health, and preventative health, including insomnia management. She also works part-time as a lecturer in general practise for the University of Sydney. We also welcome Dr. Giselle Withers. Giselle is a clinical psychologist and a mindfulness teacher with over 20 years experience helping people overcome a range of mental health and chronic health problems. She’s a pioneer of mindfulness in Australia, has developed a digital sleep programme called A Mindful Way. And Giselle has tailored this for a perimenopause and menopause audience. So we’ll hear soon from Bianca and Giselle, but I’d like to first start with asking Sarah some questions if you don’t mind, Sarah.
Dr Sarah White, CEO, Jean Hailes for Women’s Healt (00:06:44):
Not at all.
Dr Moira Junge, CEO, Sleep Health Foundation (00:06:45):
So welcome. Even though I’ve introduced briefly what Jean Hales and a bit about you, could you tell us a little bit more about your organisation and you? And Susie, what’s the ethos and what’s the main focus in a nutshell about what you’re doing at the moment with women’s health?
Dr Sarah White, CEO, Jean Hailes for Women’s Healt (00:06:58):
Sure. Well, I think Jean Hales, the organisation, started off trying to continue that tradition from Dr. Jean Hailes, the woman, where she was really firmly of the belief that if a woman understands her health, then not only is she well, but the community and family around her is also well. She also did a lot in training healthcare professionals around menopause. Started only the second menopause clinic in the world, can you believe about 50 years ago. So it was a very long time coming. And today, Jean Hales, the organisation, we’re really looking at information for women, credible, evidence-based, accessible, trustworthy information, a lot of which comes through our own clinic here in Melbourne. We hear a lot from women and clinicians about that. We also provide education for healthcare professionals for menopause. The government funds us to do some of that work. And then I think the third part is really systems change.
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It’s thinking about a woman living not just in terms of making her own decisions and having the information to make those informed decisions and choices about her health and wellbeing, but we know that women live in a social and cultural context. And so a lot of what we’re doing now is knowledge generation from our big national women’s health survey that tells us not just about the things that women perhaps need to know or aren’t sure about when it comes to their own health, but also those things around her that affect her life. And I think sleep is a perfect example of this, tying into health, but also having that terrible virtual or virtuous cycle or non-virtuous cycle of how it affects work and relationships. So it’s a really important issue for us. And we love working with the SleepHealth Foundation.
Dr Moira Junge, CEO, Sleep Health Foundation (00:08:47):
Yeah, fantastic. And I know that often with menopause, or actually probably pregnancy and postnatal, and then again, peri and menopausal stage is the first time sometimes that women have experienced inadequate sleep or frustrating, challenging sleep.
Dr Sarah White, CEO, Jean Hailes for Women’s Healt (00:09:02):
Absolutely.
Dr Moira Junge, CEO, Sleep Health Foundation (00:09:03):
Yeah. And I know I’ve heard you speak about the midlife collision. Can you tell us what is that exactly? And I’d love to know some more about that from-
Dr Sarah White, CEO, Jean Hailes for Women’s Healt (00:09:14):
It’s really interesting. For a long time, we’ve been doing these really big surveys asking women about their experiences of menopause. And we heard about the hot flushes and the night sweats and the insomnia and all these sorts of things, but always women hooked it into things that were happening in life as well. And we didn’t coin the term midlife collision.That comes from a researcher in the UK who spoke to the challenge of any woman these days in midlife is not just facing menopause or perimenopause symptoms. It’s also about being part of the sandwich generation. So we’re often caring for kids, we’re caring for elderly parents.
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We’re at the top of our financial burden, if you like. We have the most bills coming in and we’re starting to feel those effects of that gender pay equity over our years. Retirement, I’m a bit the same. It’s no longer some sort of abstract thing. I’m looking at my superannuation balances. For a lot of women, those balances aren’t where we’d like them to be. And so all of this caring burden, domestic load, emotional load, who’s organising the kids to go to soccer plus organising mom’s medical appointment falls on a woman and oftentimes it’s at midlife. So that’s the concept of the midlife collision.
Dr Moira Junge, CEO, Sleep Health Foundation (00:10:34):
So you’re saying that yes, there’s physiological and hormonal changes, but there’s also a whole lot of other stuff going on outside of the physiology.
Dr Sarah White, CEO, Jean Hailes for Women’s Healt (00:10:46):
So sleep disturbance is one of the most common symptoms we hear, and I’m sure Giselle and Bianca will speak to that some more, but actually we also know that menopause hormone therapy, which is our first line indication for health challenges during the menopause transition don’t help every woman. It’s not the silver bullet. So that midlife collision, the stresses, the challenges that we are facing are things we also have to address. Unfortunately, we can’t just put a patch on our backside and it fixes everything. We have to look at some of those other life challenges as well.
Dr Moira Junge, CEO, Sleep Health Foundation (00:11:24):
Yeah, absolutely. What about, is there other health issues besides the … Well, obviously we’re talking about sleep, but there are other emerging other health issues and I guess the caring responsibilities as well. Do you focus specifically on carers in any of Jean Hailes projects or is it more-
Dr Sarah White, CEO, Jean Hailes for Women’s Healt (00:11:51):
Yeah, well, we talk a bit about how we can help change those structural considerations around that burden falling on women. So we’re working with lots of other different groups around how we change that up. That’s social change, cultural change, that’s going to take a long time, but we’re getting people really aware of how menopause and the midlife collision affect women in the workplace, for example, how it can make it challenging to stay in the workplace, how it can affect relationships and certainly how it can affect mental health. So it’s really hard to pull these things apart. And there was a big study published just earlier this year from the US where it’s a terrific, what’s called a longitudinal study. So they follow individual women and track how they’re going over time. And they really found that these sleep issues could not untangle that from caregiving, workplace demands, stress and anxiety.
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They were just all inextricably linked with these sleep disturbances and menopause symptoms.
Dr Moira Junge, CEO, Sleep Health Foundation (00:12:55):
So lovely. And it’s so important that we know that and the research telling us that. And in my clinical days, I’ve known that too, and I think Bianca and Giselle will probably speak to this too, that it is hard sometimes to pick out what’s what.
Dr Sarah White, CEO, Jean Hailes for Women’s Healt (00:13:06):
Yeah, but I think it can help to know that there’s not necessarily a silver bullet, even though we’d all love there to be that silver bullet, the one thing that fixes it, it may not be the case. And I think it’s okay to know that because it really does help with things like mindfulness that I know Giselle will speak to later.
Dr Moira Junge, CEO, Sleep Health Foundation (00:13:24):
Yeah, fantastic. And yeah, I just know it’s so wonderful. I really applaud your organisation. I think it’s inspiration for us. So you are many few decades ahead of us and you’ve got the ear of the government. I think you get government funding, I’ve watched your progress, I’ve watched the great work and the expansion that you’re doing. So it’s good for all of us. So great to have you here. Thank you, Moira. I appreciate that. I’ll move on to Bianca. And unless, was there anything else at this point you wanted to add, Sarah, just before I move on to Bianca?
Dr Sarah White, CEO, Jean Hailes for Women’s Healt (00:13:54):
No, I don’t think so. I’m really looking forward to hearing from Giselle and Bianca.
Dr Moira Junge, CEO, Sleep Health Foundation (00:13:57):
Great. I’ll come back to you anyway when there’s Q&A. So I probably should have said the structure to you here, the audience that we’re going to talk to the three panellists for a little while. And then by about 4:30 or so, we’re going to go to the Q&A. You’ll notice that the chat function doesn’t work for you, but you do have the Q&A function, and I’d love you to think about putting questions in already and we’ll get to as many as we can and we’ll curate them, the ones that we … More popular or we’ll make a bit of a decision about how we can get through as many as possible when that time comes. But I’m going to move on to Bianca and welcome you very warmly. We know that you’re involved in research as well, Bianca. And before we get into your clinical stuff, but can you tell me a bit about the clinician-guided research you’re doing into digital CBTI and tell me also how you became interested in sleep and women’s health.
Dr Bianca Cannon, GP and lecturer (00:14:51):
Thanks, Moira. Look, I’ve worked at a women’s health practise in the Northwest of Sydney for 18 years now, so I became interested because I’m seeing women every day at work and sleep is a common concern. And then when I started working as an academic, there was the opportunity to do some research into actually digital CBT for insomnia. And in particular, our project is studying whether clinician guidance and clinician support through that digital CBTI makes a difference. So I think it’s good to say that upfront that I’ve obviously got that leaning towards CBTI, but also that I think that the role of the regular GP is an important one in terms of supporting women through what they’re going through.
Dr Moira Junge, CEO, Sleep Health Foundation (00:15:49):
Great. And for the audience, I should have unpacked that CBTI is cognitive behavioural therapy for insomnia. We’ll talk a bit about that today because it is the gold standard. The most amount of evidence for insomnia is from this modality of cognitive behavioural therapy for insomnia. And one of the issues we have here in Australia, and actually worldwide, is that there’s not a lot of practitioners that are trained in it. So it’s wonderful, A, that you are thinking you are in the digital space, which is going to be a big part of the solution. And it’s just so great too to have multidisciplinary people. Digital CBTI can be guided by a range of different clinicians, including the medical profession. I want to get into some of the questions I have for you, Bianca. So I wanted to talk about what are some of the factors impacting … Sorry, what are some of the factors impacting on women’s sleep during peri and perimenopause and menopause?
Dr Bianca Cannon, GP and lecturer (00:16:51):
Look, I think that Sarah explained it well when she discussed that complexity of there being so many different factors. I mean, I guess the first one that we’re all aware of is that there are these hormonal changes at that period of life, and you have both initially fluctuating levels of oestrogen and progesterone and then declining. And these hormones have impacts on those neural circuits that are related not only to reproduction, but also to sleep and mood and temperature regulation. And I guess along with that, we know that up to 80% of women get vasomotor symptoms. And by vasomotor symptoms, I mean hot flushes and night sweats, and these definitely can be associated with nighttime awakenings and cause a direct impact on sleep. We also know that there’s mood changes at this time of life, so anxiety, depression, or one symptom that women commonly report to me is irritability.
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And we know that there’s two-way relationships between mood and sleep, in that having a low mood can make sleep worse and having poor sleep can make mood worse. So it becomes a bit of a vicious cycle. And the other thing is that there’s actually two-way relationships between those other factors I mentioned, like the vasomotor symptoms as well. And I guess the other thing at this time, there are the psychosocial factors, which Sarah described women often have a lot of work responsibilities as well as balancing caregiving responsibilities for our teenage children and elderly parents. I feel like I’m at that stage myself. So yes, and then we also have the effects of ageing and other medical conditions that are becoming more common. So things like osteoarthritis, for example, or obesity or sleep apnea. So there’s a whole lot of different things going on more, but one of the reasons I like treating perimenopause is that there’s also a lot we can offer women to help with them.
Dr Moira Junge, CEO, Sleep Health Foundation (00:19:27):
That’s good news. I think everyone will be sitting up in their chairs saying that’s good to hear that there are some solutions out there. I’m sure there’s not one size fits all with what your women in your clinic tell you about their sleep. Can you tell me a bit about, is there sometimes just mild and quite extreme sleep disturbances and other type of sleep problems too?
Dr Bianca Cannon, GP and lecturer (00:19:50):
Yep. So we know from trials that up to 69% of midlife women experience sleep disturbances. And one of the commonest ones that women report to me is that nighttime awakening, and sometimes they wake and can’t always get back to sleep. Some women have difficulty getting to sleep. Some women wake up early, some are worried about the overall number of hours of sleep they’re getting, but they’re also finding that they wake up not feeling as refreshed, and then it’s potentially having those daytime impacts on their quality of life and probably their subjective feeling of productivity. So I guess there is a range from a mild sleep disturbance right up to chronic insomnia, and chronic insomnia does happen at a higher frequency in this age group. There’s also an increase in the rates of other conditions like sleep apnea and restless leg syndrome. And the other thing, Moira, is that a lot of my patients are very educated and they’re reading and they’re now coming in with concerns also about the long-term health effects of their poor sleep.
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So they’re addressing that as well.
Dr Moira Junge, CEO, Sleep Health Foundation (00:21:19):
Which is really tricky too. And I’ve often say this publicly that, I mean, why I do this job is that I think sleep’s hugely important, but there’s a real balance of not wanting to cause increased anxiety about the importance of sleep, and then people aren’t sleeping well, then it’s going to make them more anxious, and therefore get into this bit more of a cycle of not worry. So it’s a really hard thing is that you don’t want to say don’t worry about your sleep, but you’re also, because you have to address if it’s becoming really problematic on quality of life, et cetera. So I’ve got so many questions I’ll just keep going with … I’m wondering, and I think a lot of people would be wondering, we hear that it’s this hormonal disruption as well as psychosocial things happening around this time in midlife. Do the sleep problems resolve when a pause settles and there’s more stability, do we find that it resolves after menopause, the sleep issues?
Dr Bianca Cannon, GP and lecturer (00:22:13):
Well, that’s a good question, Moira. I mean, the vasomotor symptoms can range between one and six or seven years on average, but we know that in 10 to 15% of women, they’re still getting hot flashes 10 years after menopause. And I guess the other way I think of it is that even though at menopause, the hormonal changes and the vasomotor symptoms might be part of what triggers the insomnia, there are also those perpetuating factors such as women do start to worry more about their sleep then, and that can actually perpetuate the problem or they might make some changes which seem intuitive, but actually don’t help like going to bed earlier and earlier or perhaps having-
Dr Moira Junge, CEO, Sleep Health Foundation (00:23:12):
Watching the clock too much and those-
Dr Bianca Cannon, GP and lecturer (00:23:14):
Exactly all of that. So I think the answer to your question is that for some women, the sleep disturbances do definitely resolve, but for some women they keep going.
Dr Moira Junge, CEO, Sleep Health Foundation (00:23:28):
And when should someone see their GP as a GP experience? Because not all women do probably need any kind of medical intervention for starters, but they might need some psychological just support and chat. Well, we know from our studies, a recent study, so 34% of women in this age bracket said their sleep wasn’t disturbed, but you said 69, 70% often are reporting sleep disturbance. Can you tell us a bit about how and when and what options a GP can offer?
Dr Bianca Cannon, GP and lecturer (00:24:02):
Yeah, sure. Well, I mean, I guess first to say you don’t only see a GP if you need a prescription, even if you’ve only got mild or moderate perimenopausal symptoms, see your GP for an assessment. And for all those preventative health things, we know that this is a good time of life to start to address things like bone health, looking at maintaining strong muscles because women are living a long time. So I really feel that this is the stage to start that preventative health stuff. So go and talk to your GP about that. Also get your blood pressure checked, they can assess your cardiovascular risk. But I guess also in terms of specifically sleep, if you are getting symptoms and you’ve tried some self-help strategies and they’re not working, then go and talk to your GP. And yeah, there are a wide variety of options and it doesn’t have to involve a prescription if that’s not what the patient is looking for.
Dr Moira Junge, CEO, Sleep Health Foundation (00:25:18):
That’s great. Is there anything else you wanted to add at this stage? We’ll come back to you, of course, Bianca, but anything else you want to add before I move on to Giselle?
Dr Bianca Cannon, GP and lecturer (00:25:27):
I guess probably just to say one of the options that the GP is well-placed to discuss with you is the option of HRT hormone replacement therapy or menopause or hormone therapy. And I’m happy to talk more about that later if you want to. But I do think that as Sarah said, we know that HRT is not the answer for all sleep problems. And so I think Giselle will be well-placed to tell us about the psychological strategies, which I think can be really helpful for everyone.
Dr Moira Junge, CEO, Sleep Health Foundation (00:26:09):
Absolutely. And just a note, so it’s definitely true that HRT and MHT is interchangeable terms?
Dr Bianca Cannon, GP and lecturer (00:26:17):
Sort of. So we now call HRT MHT, menopausal hormone therapy. I get into the habit of saying HRT because that’s mostly what my patients say. We now call it HRT more if it’s early menopause, so before age 45, or if it’s premature menopause before age 40. And I guess that’s a good point just to mention that there are women who experience menopause much younger, and they definitely should go and see their GP for an assessment because there’s particular things to take into account in those women.
Dr Moira Junge, CEO, Sleep Health Foundation (00:26:56):
A quick definition of peri, we should have done that upfront really, which is just the difference or just for a general definition of perimenopause as opposed to the term menopause.
Dr Bianca Cannon, GP and lecturer (00:27:09):
The definitions, yes. Okay. So I mean, perimenopause is really generally thought of as the years leading up to menopause when the periods become less regular, the ovarian follicles are decreasing in number and you’re starting to get those hormonal changes. Menopause is your last period, but generally we don’t call it your last period until you’ve been 12 months without a period. So most people use peri to refer to those years leading up to menopause and that final 12 months after. And then after 12 months, we’d say that a woman is postmenopausal.
Dr Moira Junge, CEO, Sleep Health Foundation (00:27:56):
Interesting. Thank you so much. Thanks. And I’m welcoming Giselle now. Fantastic to have you, Giselle. Even I’ve introduced you, can you tell us a little bit about yourself and particularly how you came to be so interested and have this specialisation with particularly women menopause and sleep and mindfulness?
Dr Giselle Withers, Clinical Psychologist (00:28:16):
Yeah. Hi, everybody. So as you did say in the introduction, I have been working as a clinical psychologist for the past 20 years and seeing people across the full gamut of the life’s challenges, but I’ve always had an interest in sleep and chronic health conditions. So chronic insomnia included and have done some research in sleep in my undergraduate and postgraduate days. There’s always been that interest, and I’ve always seen that improvements in sleep can really benefit people in terms of improvements in mood and chronic pain and so many other factors. If you can improve sleep, it really helps people. It goes a long way in terms of helping the other symptoms. Of course, we still need to address that too, but because of that bidirectional relationship that Bianca spoke about, actually having sleep as an intervention as part of a broader psychological treatment approach is I think really important and always something I’ve done.
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So I was fortunate to work at the Melbourne Sleep Disorders Centre, and I ran CBTI and mindfulness groups there. I’ve always had an interest in mindfulness-based therapy as well, so that combination just worked beautifully. I found that was a really effective approach. I think it enhances the benefits of CBTI when people can practise mindfulness as well. And so it was just also the way we were moving in the digital age, it was just a natural process really to have that programme that I was running face-to-face and live groups fully recorded in video format so that people could access that from home if they couldn’t attend them in person. So then we have the full CBTI mindfulness programme in a digital format that people can undergo. That’s the mindful way way to healthy sleep programme. And we’ve had a couple of research studies on that programme with Monash University.
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One was published 2019 and found that to be effective and one underway now. And actually the one that’s underweight at the moment, we’ve just finished recruitment, so I can’t reach out for new participants, but that was for the 55 plus. So it’d be really interesting to see now how this programme helps women, most of them will be menopausal. So we’re really keen to that data analysis to
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Occur, which is very soon. So yeah, that’s my background. And then of course, how I came into the perimenopause spaces just through that personal experience, having been a good sleeper all my life, I’m lucky enough to say that suddenly in my late 40s, I was waking up at 2:00, 3:00 in the morning and wondering why suddenly my sleep was being affected and joined the dots to realise actually these are big hormonal changes happening. Also, another sleep disorder I developed, which is sleep apnea and just a lot of things I needed to address. And this is where it comes back to that biopsychosocial model and exactly all the factors that both Sarah and Bianca have spoken about in terms of that midlife collision and why a good sleeper can suddenly find themselves struggling. Even a so- called expert in sleep who knows all the tools, really, really finding that that can still be a challenge.
Dr Moira Junge, CEO, Sleep Health Foundation (00:31:37):
Yeah, absolutely. So sleep is difficult for a range of things like biological, psychological, socially. Do you feel like you need to unpack that a little bit more or do you feel like we’ve-
Dr Giselle Withers, Clinical Psychologist (00:31:50):
I think that Sarah and Bianca have just covered that beautifully. The only other things I would add to that is that when I see women who are struggling with sleep, it really is a kind of a high stakes time in life. I think we’ve already talked about this. There are so many pressures on women at this time of life and they’re wearing so many hats, so they really feel they can’t afford to be sleep deprived. There’s too many balls in the air. So that pressure to sleep well, I think is intensified at this time of life. And that really adds to that perpetuating factor that Bianca spoke about, the pressure to sleep and the worry about not sleeping, that anxiety about not sleeping is very high. And people are often doing what they can to keep their health and wellbeing in check. And so when you’re doing research on sleep and you’re finding out how important it is, it just exacerbates the pressure to sleep well.
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So a lot of work that I do is around helping people with this sleep anxiety and the worry that we can do a lot about. And yeah, that’s where I might talk a bit more about CBTI and mindfulness and how that can help those perpetuating factors.
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Sometimes there can be a trauma background too, that when you’re experiencing a life change or perhaps parents are ageing and something can often be death of parents, that can bring up some trauma if you’ve had difficult life experience with your own family of origin. Also, children can be very challenging. And if your children are at the time of life that you may have experienced some trauma, that also might remind you of how young you were at the time when you experienced that. So even later in life, even though you might’ve coped well with that early life trauma for many years, suddenly at this stage of life that can really present too. So that’s another work piece of work that a psychologist can help you with at this time.
Dr Moira Junge, CEO, Sleep Health Foundation (00:34:03):
Really, thanks so much for sharing that and highlighting those things. It’s a huge part of the psychology of sleep. And I’d love that my next question was actually a great segue anyway, because I wanted to know what are the non-medical solutions or the non-pharmacological, psychological things women can try to help improve their
Dr Giselle Withers, Clinical Psychologist (00:34:22):
Sleep. Yeah, so it is absolutely a biopsychosocial approach. So as Bianca said, and Sarah, it’s so important to address the biological factors, make sure you’re seeing a GP, seeing a menopause doctor address any of those biological factors that may be playing a big role, addressing the hot flashes, perhaps hormonal therapy. The psychological factors and the social factors are also about that life reset in terms of looking at exercise, diet, lifestyle, whether there’s delegation of tasks. If you are taking the majority of the load at home, there’s lots of lifestyle things that can be addressed and looked at at this age, and it is an opportunity for a midlife reset. So the psychological factors, yes, addressing mood, anxiety, depression, all of those, the hypervigilance that happens around sleep is important. So the two approaches that have the most evidence-based for managing sleep at this stage is the cognitive behavioural therapy for insomnia, CBTI, and mindfulness-based therapy for insomnia, which is CBTI combined with mindfulness training.
(00:35:43):
And that’s the approach that I tend to use because I find that really effective. So CBTI, it is a psychological structured therapy. It has five core pillars. Most people think of it as sleep hygiene, but that is only one component of CBTI. And sleep hygiene is around the reducing caffeine, cutting back on alcohol, and making sure your bedroom environment is a relaxing one that’s not noises outside and it’s dark enough to sleep. So it’s getting the right conditions for sleep, all important, but the other factors are really about resetting the body’s brain’s natural sleep processes. So we are working on making sure that your bedtime is actually in sync with your circadian rhythm. So as Bianca mentioned, there’s often strategies people use to try to manage not sleeping well, like going to bed early, but if that’s not matching where your circadian rhythm is, and that’s your body’s natural 24-hour sleepwake cycle.
(00:36:53):
So there’ll be a time in the day where we naturally move into sleepiness, and we need to match that time roughly with the time that we are actually going into bed to attempt to sleep. So if you’re going to bed too early and it’s not matched with that time, you might find you’re lying awake in bed for an hour or two. Having said that, there is a shift of circadian rhythm as we age. So we do tend to become more of the morning larks than the night hours as we age. So that can sometimes explain the early morning awakening at four, which might be unusual if there is quite a significant shift. So when I work with people, it really is looking individually, when are they most sleepy at nighttime and when are they waking up and have they actually had sufficient sleep? It may be that six hours or six and a half hours is enough for them to function on for a period of time, and they’re actually getting sufficient sleep.
(00:37:56):
So when you’re trying to have another two hours of deep sleep, that’s when the frustration can begin early in the morning, and instead you might look at that last hour as just a time for rest, that you’ve had a good amount of sleep, and now it’s either just resting if you are feeling relaxed and comfortable in bed. If you’re feeling agitated, it might be about getting up. So CBTI dresses all of these factors, the bedtime, the weight, the getting up time. It’s also about how we use the time in bed. We want the bed to be a place where we’re quite relaxed and resting well. So if you’ve got that hyperarousal, lots of thinking, the busy mind, then perhaps moving that agitated or stimulated state out of bed is a good way to create a better conditioned connection with bed being a place of rest.
(00:38:53):
So CBTI covers all of these approaches, and there’s relaxation training, there’s also cognitive therapy. So that’s about looking at whether you might be getting into unhelpful thinking patterns that perpetuate the stress. “If I don’t sleep now, tomorrow will be a write-off or I’m going to have more health problems if I don’t sleep, “all of these unhelpful thoughts can add pressure to sleep. So by addressing those, we can have a different approach that’s actually more a healthy, calm approach to sleep. Yeah, then it’s the mindfulness factor, but I’ll wait to see whether we have time.
Dr Moira Junge, CEO, Sleep Health Foundation (00:39:39):
Yeah, I think the mindfulness part is I think that addressing those cognitions we get caught up in and all those things, it sounds like the mindfulness part of what you’re talking about helps address that with trying to … Is that right? I was wondering, Giselle, we might talk about how people can access a mindful way, the actual course, or did you want to talk more about the mindfulness principles now? A
Dr Giselle Withers, Clinical Psychologist (00:40:05):
Little bit about the mindfulness first, and then the website is amindfulway.com. Au, so that’s an easy answer to that question. So the mindfulness approach really helps to address this
(00:40:21):
Effort and the worry and the anxiety towards sleep. So when we practise mindfulness, it’s about learning how to pay attention in the present moment with a certain quality, these qualities are about acceptance and trust and patience and letting go. They all sound like wonderful qualities that in training in those qualities, we can then approach sleep differently. So for example, when there’s anxiety about sleep and a high need to sleep, we call that striving. There’s effort going in and we’re working really hard to find out the right approach to sleep well. So this sleep effort and this kind of really a strong attachment to sleep increases stress and anxiety. So when we can apply a mindful approach, which those qualities of patience, that’s about sleep will come in its own time, the letting go of striving, even that there’s a principle called non-striving, which is having no agenda and just being able to be with things as they are, even if they’re unpleasant and unwanted, then we’re actually shifting our relationship to what’s happening in the moment.
(00:41:46):
So I sense it in my body immediately when I start thinking about the letting go and the stepping back and the acceptance of things as they are. There’s a relaxation and a softening that happens in the body immediately that does have an immediate effect on reducing hyperarousal. So it takes a while to learn that, and this is where we need to practise during the day so that we can use it at night. And when I say use it, it’s not about a tool that we use to get to sleep. It’s much more about the way we approach the difficulty of wakefulness at nighttime and the not being able to sleep. So in the daytime, we’re also practising … We have two ways of practising the skills of mindfulness, and one is informal practise and the other is formal. So most people will have heard of formal practise, and that’s actually sitting with a meditation, a guided recording, and practising , even if it starts at five minutes, just each time the mind wanders off, we bring the attention back to the breath and we’re practising the acceptance and the letting go and the non-judgment.
(00:42:59):
And then you build that up and hopefully we can help people build that up to 15 minutes, even longer, sort of half an hour. And then we have informal practise, which is just any moment in the day, noticing where our thoughts are, noticing our level of awareness and just bringing it right into the moment and being with all of our sensations in the body without judgement . So that might be just if you’re walking outside, really taking in the sensations of the breeze on your skin, there’s the sun on your skin, just looking around, taking in the sounds. And when you start practising that, you notice that you’re out of that busy, always juggling lots of the to- do list and coming back into just being present in the moment. So we cultivate those skills in the daytime so that at nighttime it becomes much easier to apply the same approach when we’ve got a lot of effort or the busy mind and we are trying to let go of thoughts.
(00:44:05):
So it’s very hard to explain mindfulness in a nutshell. There are books and books and books written on mindfulness, as many of you will know. I hope I’ve captured some of the essence there with how and why it works.
Dr Moira Junge, CEO, Sleep Health Foundation (00:44:19):
Yeah, absolutely. That’s a great overview. And I think that it’s important for people to realise they can do that at home. Learn how to cultivate that as a self-help strategy doesn’t always have to be part of led by a clinician. I think that there’s resources we’ll put up a slide at the end with more information from different websites so people can find information. That’s a great overview. Is there anything else you wanted to add before we go to the gen looking at the questions and start getting stuck into the Q&A?
Dr Giselle Withers, Clinical Psychologist (00:44:52):
In terms of being able to summarise an intensive treatment approach, probably leave it at that. There are lots of ways in which people can go and access a full CBTI or mindfulness approach, so there’s much more that people can learn when they dive in a bit more.
Dr Moira Junge, CEO, Sleep Health Foundation (00:45:12):
Fantastic. That’s so good. I’m so happy that we’ve had a good chat with our three panellists and just bringing different kind of perspectives and expertise to this topic. And I think it’s a great idea to just go into the questions that are there. And some of them, I’ve answered a couple just privately and we’re doing a little bit live as we go, but I’ll start with the first question that’s there because we didn’t really talk about the menstrual cycle per se, but I think is there a correlation between the time of menstrual cycle and insomnia in those approaching perimenopause? So this is a one for Bianca, and it doesn’t matter if it’s hard to answer and it’s because you need more information, then that’s actually a really valid response as well, Bianca.
Dr Bianca Cannon, GP and lecturer (00:46:02):
Look, I think it varies. I mean, a lot of women do get premenstrual symptoms throughout their life, and I find that they’re often the same women who then get issues at perimenopause. So it can be that leading into the period is a time where there’s more symptoms, but I think it does, given the complexity and the fact that it’s not really just the hormone changes that is all those psychosocial things as well, it could be that it happens … A lot of women say to me it’s when they’ve got a big meeting or something the next day or something important. So I think certainly women, I encourage them to keep sleep diaries and track things, but then sometimes too much tracking is not good as well, Maura, because I’d be interested to hear what Giselle thinks about that. That tends to be more something I do in the diagnostic phase rather than keep women going with that.
(00:47:09):
So yeah.
Dr Moira Junge, CEO, Sleep Health Foundation (00:47:12):
Yeah. Did you want to comment at all, Giselle, with whether there’s a need for tracking too much around menstrual cycle and/or insomnia? I know sometimes too much monitoring is not necessarily a good thing from a psychological lens. Just a couple of brief comments.
Dr Giselle Withers, Clinical Psychologist (00:47:27):
It is a little bit like sleep tracking that it’s helpful to gather information to have more awareness about what’s happening. So I will often ask people to track their menstrual cycle if we think perhaps this might be what’s contributing to sleep problems that helps people to feel a bit more prepared, understanding why it’s not anything they’re doing wrong or no, there’s nothing that’s changed that this makes sense. So then you can bring greater compassion towards yourself in that time of the month, knowing that this is having an impact on sleep and mood and so many other things. So I think that part’s important. But with sleep tracking, yes, it’s good to understand the sleep patterns and also to track when you’re feeling sleepy, what the bedtime’s like, but then too much can add to anxiety. So it is just for a short period of time for information gathering only, I would say.
Dr Moira Junge, CEO, Sleep Health Foundation (00:48:23):
Another one that’s Bianca related in terms of this one you can probably see from Lisa Taranto. Is obstructive sleep apnea and chronic pain a factor in creating sleep issues for women with menopause going in that phase?
Dr Bianca Cannon, GP and lecturer (00:48:39):
Yes. So definitely both obstructive sleep apnea and chronic pain are two of these comorbidities that tend to interact with insomnia. We know that women’s rates of obstructive sleep apnea increase by about two or three times, but from premenopause to postmenopause. And I think there’s various factors associated with that, including hormonal factors, including that one thing we haven’t mentioned is that along with the hormonal changes and the sleep changes, there often is unfortunately some weight gain as well. The evidence shows that we do gain weight in menopause, and also we have a redistribution of weight. I say to my patients, it’s very unfair. It tends to settle around the middle. So yes, definitely when I’m assessing someone with insomnia or sleep disturbance, I would always try and address that risk of sleep apnea. And there’s various tools that we use to assess for risk of sleep apnea.
(00:49:54):
And then if there is a suspicion of it, then the way to confirm that is by a sleep study. And then we have good treatments for sleep apnea as well, whether that’s CPAP, continuous positive airways pressure, or for some women, a dental splint. And even more recently, there’s been an approval for a weight loss medication, Mounjaro for treatment of sleep apnea. Chronic pain I think is a whole topic in itself, but I think once again, that’s a two-way relationship that the pain can be interfering with the sleep and that if the sleep is not good, then pain is worse. So I think it’s once again about breaking some of those cycles.
Dr Moira Junge, CEO, Sleep Health Foundation (00:50:47):
That’s great. Oh, thank you for that. There’s so much to … It’s good to just get through some of these other ones. The next two we can combine because there’s talking about correlation between exercise and diet and sleep, and another one about, is there good research on sleep and exercise in perimenopause or menopausal women? So questions really around, do we have a lot of evidence around specific types of exercise or diet and exercise? Anyone got comments on that in terms of the evidence that’s there or any helpful hints or resources for these questions, the next two from Katrina and Charlotte?
Dr Bianca Cannon, GP and lecturer (00:51:29):
I talk to all my patients about exercise because it’s beneficial for so many different things, mental health, quality of life, healthy bones, healthy muscles. I think there is good evidence that exercise is helpful for sleep. I check with Giselle, but usually I say to my patients, probably don’t exercise in the couple of hours before you go to sleep, but certainly regular exercise at other times of the day definitely is helpful. I don’t know that there’s a lot of good evidence published on which types of exercise are better than others. With my patients, I tend to say the right exercise is the one that you are going to actually do. So yeah, in terms of diet, I guess I talk to patients about having a healthy diet, something like a Mediterranean diet is good, and maintaining a healthy weight as well is helpful, but I don’t know about specific diets for helping with insomnia.
(00:52:48):
I tend to probably say just generally a healthy diet.
Dr Moira Junge, CEO, Sleep Health Foundation (00:52:55):
Before I move on to any other questions, is there anyone on the panel who has a particular one they wanted to answer that you’ve got access to the questions there, or are you happy for me to just keep going through them? We’ve got several minutes. Nothing jumping out. I’ve
Dr Sarah White, CEO, Jean Hailes for Women’s Healt (00:53:07):
Thrown in the answers I can. I’m leaving the sleep ones to the expert.
Dr Moira Junge, CEO, Sleep Health Foundation (00:53:10):
Oh, great. Thanks, Sarah. I thought you were typing away. I think
Dr Sarah White, CEO, Jean Hailes for Women’s Healt (00:53:13):
Everybody can see the answers to the questions, so I’m just going to type in as I go.
Dr Moira Junge, CEO, Sleep Health Foundation (00:53:17):
Yeah, fantastic. Thank you. I wondered, is there … Let me just get rid of that one. Sorry, just so I know which ones you’ve answered.
Dr Bianca Cannon, GP and lecturer (00:53:27):
Moira, I was interested in this question from Laura, can existing good sleep hygiene help prevent sleep issues leading into perimenopause and menopause? I think that’s a really good point because I think good sleep hygiene is a good start and it’s good for us to all be aware of it and generally following it. But I also think that you can be doing all the right things and still reach this period of life. And because of the hormones and the hot flushes and everything, I guess the point I’m trying to make is it’s not necessarily your fault. You have been doing all the right things and still end up in this situation.
Dr Moira Junge, CEO, Sleep Health Foundation (00:54:11):
Absolutely. Did you want to add to that, Giselle?
Dr Giselle Withers, Clinical Psychologist (00:54:15):
Well, I’m just smiling because I related to
Dr Moira Junge, CEO, Sleep Health Foundation (00:54:17):
That. Yeah, exactly. The sleep issue. Doing all the right things
Dr Giselle Withers, Clinical Psychologist (00:54:20):
And that’s happening. I thought we might’ve had a question come in pre the workshop around neurodivergence and sleep, so I thought I might just speak to-
Dr Moira Junge, CEO, Sleep Health Foundation (00:54:31):
Thanks for reminding me of that, yes.
Dr Giselle Withers, Clinical Psychologist (00:54:33):
Yeah, because this really, it’s like a triple whammy for people who are neurodivergent. The stress from operating day-to-day in a world that is set up for neurotypical people, it’s a daily stress that whether it’s ADHD or autism, managing the sensory overload and running schedules and all of the stresses that can come when you’re neurodivergent, then you’ve already got a level of hyperarousal that makes sleep difficult. So neurodivergent people often have high levels of sleep problems. I think the rates are 50 to 80% in some studies, so it’s very high. So then when you reach perimenopause and you have the additional factors that we’ve spent talking about today, then that’s adding to a lot of the symptoms that can exacerbate the memory issues of brain fog for ADHD and you’re having trouble with organisation, and then the sleep deprivation itself. So if you’re sleep deprived or you’re not sleeping well, that the symptoms of poor sleep add to that, the memory issues, the cognitive issues, increased anxiety, mood.
(00:55:48):
So this triple whammy, this sort of compounding effect. So it is really, really challenging. So I have a lot of compassion for people managing these three things at this time of life. So in terms of CBTI and mindfulness, we do need to think about how that can be tailored and adapted for different ways in which people think and work. And that’s where working with the clinician. So the clinician can bring the expertise, but then you are working collaboratively. So we find out what works best for you. For some people with ADHD, having lots of schedules and routine can be really helpful to keep them organised on track. For others, that’s a nightmare. It’s already a struggle. So to have advice around keeping a regular bedtime routine and getting uptime routine just adds to the stress and demand. So it’s really about what works best for each individual person.
(00:56:48):
There’s no one size fits all. And the wind down routine is particularly important. So for ADHD, particularly, there tends to be a delay in circadian rhythm. So most people, there’s a higher proportion of people will have a later circadian rhythm time, which means they’re not sleepy until much later. And because the bedtime represents a time where there’s less stimulation, that can leave people feeling restless, and then the mind starts to wander as a way of keeping the stimulation going. So helping someone to have a focused way of relaxing, and that could be listening to music or listening to sounds, something to focus on. Some people talk about the white noise having a fan on, or something sensory that you can use like a steaming tool or even a fidget toy of some type. So it’s really about working out what works best for you to help with that wind down routine.
(00:57:53):
So again, it’s a big topic in itself. I’d love to know if Bianca or Sarah had anything to add there, but it’s important to know that everyone is different. And so it is needing a tailored approach for each individual person.
Dr Bianca Cannon, GP and lecturer (00:58:10):
Giselle, I mean, I really agree with that last comment about the tailored approach. And I guess that would be one of my main messages is that it’s great that I think all the people we’re talking to are very educated, they’re informing themselves, and I think it’s good to go to your doctor with your own questions and queries, but then also that there isn’t really a one size fits all approach at this stage of life. And it is sitting down and having that shared decision making. Your doctor will tell you the risks and benefits of various things for you. And I was just starting to type an answer in the Q&A to an anonymous person who asked, can you have good health outcomes navigating menopause without MHT? There is a big push for MHT at present. And that’s really interesting because there is because having been in general practise now 20 years ago when I first started in general practise, nobody wanted MHT, and now we’ve had a really big swing the other way, and definitely it has its benefits and its pros and cons.
(00:59:26):
But to that anonymous person, yes, I think you can navigate menopause without MHT if that’s your preference and you look at all the other options.
Dr Moira Junge, CEO, Sleep Health Foundation (00:59:41):
Yes, I’m very conscious of the time. We’ve gone five o’clock, which was our end time, and I know there’s several questions still we haven’t done. And I just noticed Belinda raised a hand. I’m not sure whether we can actually take you off mute and speak, Belinda, but we’ve actually run out of time for questions, but What I would really encourage you to do is if there were some burning questions that haven’t been answered, I’m about to put up a couple of slides. I’ve got two slides here just to finish up with the webinar that I wanted to have the website for Jean Hailes for Women’s Health (www.jeanhailes.org.au), the website for Sleep Health Foundation (www.sleephealthfoundtion.org.au) and the website for A mindful way (www.amindfulway.com.au). So you see there, you can probably just Google anyway, but you can find the websites for these organisations that have been involved today for more information.
(01:00:40):
Go to the next slide to the final slide. I would like you to contact me via the Sleep Health Foundation website if you had the questions that you really did need answered and weren’t answered, and I’ll sort that for you. This is just a few. I’m happy to do that. What I’d like to draw your attention to is the Sleep Health Foundation is consumer sleep across the whole lifespan, not just women or not just perimenopause and menopause stage. We’re trialling a tool at the moment at the front end of our website. You go straight to it, says, “Explore your sleep. What are you looking for? ” It prompts you to either go to the sleep spotlight and it’s a really important tool that you can … Because sometimes you’re sitting thinking, “I don’t know if I’ve got insomnia. I don’t know if I’ve got it sleep happening.
(01:01:17):
What are the symptoms?” And it’s something that you can actually personalise, give you a little personalised report. It’s a trial. You get directed to go to a consent form with Flinders University. So we’re trialling it on our website. I’m saying it now because I think it’d be really useful for some of you particularly to think, I don’t even know what to look for for sleep apnea, et cetera. So there’s the different ways you can find us. I wanted to thank the panel. I wanted to thank you all so much for your insights. I found it a really enriching webinar, really grateful for your time. I’m really grateful for all the audience that have come today and wish you all good sleep. I think we all agree there’s plenty of work to do too. There’s lots more work we need to do. And there will be a live recording.
(01:02:02):
All of you that have registered will get an email with the recording and also an email with some summary slides or the slides I gave you and some other resources. So yes, you’ll get all that. So I just was distracted by the other extra questions, but I think we should just stop now because I know people have to go to their next things and people sort of start dropping off. So thanks everyone. Thanks again. And I’ll end the webinar now.
Dr Bianca Cannon, GP and lecturer (01:02:35):
Thanks, Moira.
Dr Moira Junge, CEO, Sleep Health Foundation (01:02:36):
Thank you, everyone.
