Patricia Yarberry Allen, M.D. is a Gynecologist, Director of the New York Menopause Center, Clinical Assistant Professor of Obstetrics and Gynecology at Weill Cornell Medical College, and Assistant Attending Obstetrician and Gynecologist at New York-Presbyterian Hospital. She is a board certified fellow of the American College of Obstetrics and Gynecology. Dr. Allen is also a member of the Faculty Advisory Board and the Women’s Health Director of The Weill Cornell Community Clinic (WCCC). Dr. Allen was the recipient of the 2014 American Medical Women’s Association Presidential Award.

Dear Dr. Pat,

For the past four years I have had an increasing problem with sleep.  My husband says that I snore and occasionally appear to stop breathing. Sometimes my snoring must be so loud that I gasp and wake up, and I often have trouble falling back to sleep. I am exhausted all the time.  When I wake up, I feel as tired as when I went to bed.

I am 60 years old and had my last period 8 years ago. I had no problem with menopausal symptoms until I began to gain weight. Over the last 6 years, I have gained 40 pounds that I cannot lose, and now weigh 170 lbs. at 5 feet 4 inches tall. I have a thick neck but don’t look unusual in other ways.  My thyroid and diabetes tests are all normal, but I have high blood pressure that is not well controlled in spite of three different medications.  My doctor just tells me to lose weight, but I don’t seem to have the will to do this.  I drink six cups of coffee a day in order to function in my job as an assistant principal. I am often agitated early in the evening, when I get home, due to the stressors of caffeine and daytime fatigue and generally have two glasses of wine with dinner. My husband gets home later than I do, and we spend time cooking and having dinner together.

I begin to get anxious even before I get into the bedroom, because I know that nighttime feels like a battleground to me.  In order to relax after getting in bed, I respond to emails, make phone calls, and watch the nightly news. Occasionally, I take Tylenol PM, which seems to help me fall asleep but doesn’t make me feel any better in the morning.

What should I do?

Irene

Dear Irene,

Questions about sleep and daytime energy and wakefulness should be part of all wellness visits to a health practitioner.  A few selected questions will direct further evaluation and treatment for a sleep disorder that has an impact on a patient’s ability to function.

You have many of the signs and symptoms of sleep apnea, which include snoring, snore/gasp, witnessed prolonged periods of no breathing, along with your complaints of unrefreshed sleep and daytime sleepiness, exhaustion, and need for stimulants in order to function at work.  In addition you are overweight with a larger neck. Obstructive sleep apnea, which your symptoms suggest, is associated with hypertension and other medical problems and is statistically associated with death at an earlier age.

Visit your doctor again and insist on an evaluation for sleep apnea.  During episodes of sleep apnea, the airway is temporarily compressed or blocked by the soft tissues around the trachea (windpipe).  Obesity, an enlarged neck, and hypertension are all associated with this diagnosis.  Your doctor should be willing to refer you to a sleep specialist who may ask you to spend a night in a sleep lab to diagnosis your sleep disorder in order to create a treatment plan.

While you will need this medical evaluation for your sleep dysfunction, there are things that you need to change now if you want to feel better. 

1. Use the bedroom only for sleep and romance.  Tell colleagues, friends, and family not to email or call after 10 pm.  Do not watch television in bed.
2. Late-night eating is a recognized factor in poor sleep.  Eat your lightest meal of the day in the evening, unless it is a special occasion. 
3. Avoid all alcohol until you have improved your sleep disorder.  Alcohol allows many patients to fall asleep more easily, but increases arousal for the rest of the night.  Alcohol also reduces REM sleep, which is necessary to a healthy sleep cycle.
4. See a therapist to work with you to decrease your negative thoughts about sleep disruption and your ruminating thoughts that you will not get back to sleep when you wake up, and to teach you meditative breathing and relaxation to help when you wake up.
5. The weight loss that you need may be difficult, due to the sleep apnea that you have described.  If you have sleep apnea it is common for a device called a CPAP (constant positive airway pressure) to be fitted to your mouth or nose and altered in the sleep lab to work best for you.  Once the sleep apnea has been addressed, then you must lose the weight that has contributed to the sleep problem and the hypertension. 
6. Set a sleep schedule that you stick to, even on the weekends. Get out of bed as soon as you wake in the morning.  This reinforces the idea that the bed is only for sleep.
7. If you wake up in the night and relaxation and meditation techniques do not work, get up and do something that is boring until you become sleepy again.

Insomnia is a condition in which difficulty sleeping at night disrupts the ability to perform during the day, causing impaired cognitive function, fatigue, mood disorders, and poor performance at work.  Insomnia is more common in women of all age groups.  About 10 to 13% of adults meet the criteria for insomnia but 30-40% of adults have some form of disturbed sleep during the year

Sleep has been described as the “mysterious one third of our existence.” Many of us are constantly in search of getting enough sleep and feel as though we are frequently not well rested when we get out of bed many days. Sleep hygiene, like all other body maintenance, is essential to improving the quality and quantity of our sleep.

Dr. Pat

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