Today, I am over the moon to share this conversation with Dr. Sara Nowakowski on the podcast.
Sara is an associate professor at Baylor College of Medicine, and she treats patients with insomnia and other sleep disorders at the Baylor Sleep Medicine Clinic. She is also a research health scientist at the Houston VA where she conducts research on sleep and women’s health.
Sara recently completed a study examining a cognitive behavioral therapy (also known as CBT) intervention for insomnia and nocturnal hot flashes in midlife women. Her current NIH-funded research aims to assess the efficacy of CBT for insomnia in patients undergoing hip or knee replacement on functional recovery.
There is really no one better to talk to us about sleep, fertility and the correlations between the two. I hope you get as much out of this conversation as I did!
Dr. Aimee: I have special guest Dr. Sara Nowakowski on today’s show to talk to us about sleep and your fertility. Welcome, Sara.
Dr. Sara Nowakowski: Thank you for having me.
Dr. Aimee: After getting a degree in clinical psychology, what drew you to study sleep?
Dr. Sara Nowakowski: Actually, I was studying sleep before I went to graduate school. Like a lot of people in sleep, I fell into it. I was an overnight sleep technician, so I worked overnight and did the little hookups that we do on people to diagnose sleep disorders. That got me really interested in sleep and I started pursuing it more, and I decided to go to graduate school really looking at sleep and women’s health. So, from the get-go, for about the past 20 years, I’ve been studying sleep and women’s health.
Dr. Aimee: We know sleep is so important. In fact, when I talk to my patients, one of the things that I always bring up in my new patient consultation is I want you to sleep well. That’s why I wanted you to come on and talk to us about what that actually means, because we obviously live in a society that puts a lot of value on people being very busy and skipping sleep. Now that I have an expert to answer this question, I want to ask you. How much sleep is good for us to get each night?
Dr. Sara Nowakowski: There are a couple of studies that have looked at epidemiology, national based data, such as The National Sleep Foundation, American Academy of Sleep Medicine. Two different publications came out around the same time a few years ago, and both really concluded that younger healthy adults need somewhere between 7 to 9 hours. And as we age, actually when you hit 65 and above, it goes down to about 7 to 8 hours. Children, obviously, need a lot more than that, so it goes down with age.
Dr. Aimee: What are some of the reasons why people should prioritize sleep?
Dr. Sara Nowakowski: There are a lot of reasons. Sleep is one of those interesting things that we study, and as sleep deprived healthy adults, we’ll see more and more of what happens. There are some theories and we’re starting to see links, associations and correlations, between sleep and health.
We kind of hypothesize and think it’s related to immune functioning and helping us recover from illness and rebound from life’s challenges. It also seems to help with mood regulation and helps with decreasing depression, anxiety, and things like that. It also has been shown to help memory consolidation when we’ve looked at sleep deprivation and recovery nights, and we can see that there is some memory and learning that is related to getting a good night’s sleep.
Dr. Aimee: I’m an all the time person, I’m a morning person and I’m a nighttime person. My husband is definitely a night owl. He doesn’t have insomnia, but how is insomnia different from a situation where someone is willfully staying up late?
Dr. Sara Nowakowski: You almost have three things there. You have a person that could be sleep depriving themselves that’s very busy. That could be on either end, the night or the morning. It could be insomnia. Or it could be like you’re describing as a night owl, what we call circadian rhythm and circadian disturbance, so there’s a phase delay for some people that just their body clock is out of tune and out of sync with society, life challenges, and social cues.
The biggest differences are your opportunity and your ability. With insomnia, it’s an ability issue. You could lay in bed and, typically, my patients will lay in bed 10 hours or extend the time, and they’re just not able to get the good night’s sleep that they want to get. Versus a person burning the midnight oil, they’re typically sleep depriving themselves, they’re not allotting themselves the opportunity to sleep. Given that chance, if I put them in a dark room, chances are they could catch up because they’re more than able, they’re just not giving themselves the chance.
Dr. Aimee: Is fertility and the way our reproductive system functions tied to sleep? If so, how?
Dr. Sara Nowakowski: This is a very good question. I think it’s still developing. We’re still in the infancy, no pun intended, for this line of research. We’re starting to study it in terms of sleep and menstrual health and then sleep and fertility.
Looking at shift workers, there is a nice study that looks at nurses who were shift work, and that is tied to fertility and infertility. We hypothesize a few things are going on. One is the sleep itself could be related to if you’re not getting good sleep or getting short sleep, or very long sleep, it might relate to hormones, things like follicle stimulating hormone, luteinizing hormone, estrogen, and progesterone. We can see that there is a relationship between sleep and hormonal functioning, so that’s one thing.
Another thing is sleep has been shown to be related to the HPA access, cortisol and our stress hormones, and that itself could have an indirect link on fertility. Sleep has been related with immune functioning. I’ve done some of that work myself. Getting less sleep, short or disturbed sleep, is related to higher inflammatory cytokines, things like CRP or IL6, these pro-inflammatory markers that seem to be elevated when we’re not getting enough sleep, and that could also have an impact on fertility.
Then just the circadian rhythm, that body clock and melatonin seem to be also related. So, there are multiple areas, but still those causal mechanisms and empirically studying it has been a slow process for us, so we’re still working on it.
Dr. Aimee: A few years ago, you did a sleep study with the Department of OBGYN at University of Texas Medical Branch to look at the impact of sleep on women. What were the findings that you reported for women in general?
Dr. Sara Nowakowski: We generally find that during these reproductive hormonal fluctuations, whether that’s the onset of menses for younger girls, for pregnancy postpartum, menopause, those seem to be chimes of hormonal shifts and women are at higher risk for insomnia and sleep disruption during those particular periods. Given what I do with the intervention, which we’ll get into a little bit more, there are ways to intervene and treat that in these different periods of life.
Dr. Aimee: During pregnancy, things can change. How do sleep patterns change during that time, and what is the effect?
Dr. Sara Nowakowski: During pregnancy, by trimester, the first trimester is when hormones are big time starting to change, even though we might not see anatomical changes. We do find, when we’ve looked at both self-report and polysomnography where we study the brain waves in their sleep, that people tend to have poorer, more disrupted sleep. Sometimes they actually get more because across a 24-hour day, they may be napping and things like that and feeling the fatigue.
It tends to settle in the second trimester. We tend to get the golden period and sleep tends to improve during that time, and women report they feel better. Then that third trimester you’re starting to get bigger anatomically, you might be getting anxious about delivering, and the stress related to that, so all of those things negatively impact sleep. So, it’s kind of trimester based.
We have seen a couple of studies that if you can get better sleep, short and disrupted sleep were associated with longer labors and increased odds of cesarean section, so it does seem to have things related to health and obstetrics.
Dr. Aimee: Very interesting. That’s our goal always, as fertility doctors and as OBGYNs, educating of the healthiest birth outcomes. Now, I’m 46. I know you can’t tell, but I am.
Dr. Sara Nowakowski: I’m a similar age, so I’ll just leave it at that.
Dr. Aimee: I keep the office really cold, and my employees that are in their 20s are shivering. Anyway, we know hot flashes are a well-known side effect of perimenopause and menopause. How do things change for sleep during this time?
Dr. Sara Nowakowski: A lot of times, you have these hormonal shifts and the hot flashes. Typically, the median age in the US is about 52 where people hit menopause. Perimenopause, that transition, the definition is 12 months without a period. You could have years and years of being in peri, so that can last a while.
What we find is very interesting, is that sleep is one of the top symptoms that’s reported as a menopausal transition, however it’s one of the symptoms that doesn’t abate, it doesn’t spontaneously always relieve itself. Sometimes hot flashes will eventually stop, thankfully. Sleep or insomnia, it takes on a life of its own, so it’s how you stress about it and how you react to getting it.
Sleep is very behavioral. I think of it like diet and exercise, so what you do consequently impacts that. The menopause itself and that transition and the hormones and the hot flashes may have brought it on, but it’s how the women react to it that can have more people actually complaining post-menopause, even after the hot flashes are gone. It’s pretty interesting.
Dr. Aimee: I would love to hear what your tips are. What are your tips for women who are transitioning? I have patients who are trying to get pregnant that are in that situation as well.
Dr. Sara Nowakowski: This is probably my favorite piece. I enjoy being a clinician helping people because it’s actually, I wouldn’t say easy… It’s like diet and exercise, starting a regimen, it’s behavioral change, but there are things we can do to turn it around.
The biggest take home message for all of my patients is you can’t force it. You can change things, but it’s like putting a square peg in a round hole. The more you worry and stress about your sleep and work to make it better, “count sheep, clear my head, don’t think,” that’s going to make it worse. It’s not until you give in to what’s going to happen and accept where your body is at.
There are a couple of tips to help it along. We have things like not doing a lot of activities in bed. The big one is if you’re laying there and you’re unable to sleep, greater than about 15 or 20 minutes, and I do this myself, whatever wakes me up, if I’m stressed about work or something, I may not be able to get back to sleep, my brain is actively working. Don’t just lay there frustrated, staring at the ceiling or counting sheep. Get out of bed and go do something really relaxing and sleep-promoting. I’ll watch old repeats of Golden Girls. I don’t read the news because that stresses me out, but I do like to look at interior design, so I look at articles about that. Things that are relaxing and that’s clearing your brain. Then when you feel sleepy again, get back into bed at that point.
Keep the same rise time no matter what, good day or bad day. Keep your good body clock and rhythm. People are often afraid. We do things with sleep deprived people to build their sleep pressure and their sleep appetite. If you don’t get a good night’s sleep tonight, don’t worry about it, don’t stress about it. It’s not about tonight, it’s about this bigger picture. Chances are tomorrow night is going to be better for you. It might take a couple of days for your body to get with the program, but not stressing and actually decreasing the amount to what your body is able is really the magic of it.
Dr. Aimee: Let’s say you don’t get a good night’s sleep and now you’re dealing with insomnia. What do you recommend for people who are now dealing with the negative effects of not getting a good night’s sleep the night before?
Dr. Sara Nowakowski: People tend to habituate it over time. When we do neuro psych test studies, testing memory and things, we really very rarely can see the difference because people can rarely compensate for a bad night’s sleep. Knowing about that yourself, you can probably push through, mitigate with breaks. It’s hard.
For me, I sleep pretty decently. I follow these rules and guidelines, but there are nights. Chances are it’s the night where I have to catch a flight early or I have a very special meeting. Your body is telling you that something important is happening. That’s fine, realizing that. I still try to push through. I tell myself, “You can perform anyway. No one is going to know. I can probably trick most people.”
Push though, but keep your same routine. Don’t react in a negative way. I know it’s easier said than done, but try not to stress about and try not to be reactive. Compensating for a poor night’s sleep by sleeping in, irregular sleep schedule, or napping are the opposite of what’s going to help you.
Dr. Aimee: Got it. I just put up fingers in my office to say I’m on five hours, or I’m on four hours, because they know when I’m at five the tiniest little sounds, like even clicking of a pen, it’s like someone has been playing drums in my ears or crashing cymbals in my ears. I’m super sensitive to sound. I can rally and push through, but those are the little things I just have to warn people around me.
Dr. Sara Nowakowski: I have trouble making decisions when I get that way. There are so many different ways it can creep up when you’ve had a poor night’s sleep.
Dr. Aimee: You’ve done a lot of research on CBT interventions. How can that help, and how does that play a role when you’re on your period or in pregnancy, or dealing with perimenopause and menopause?
Dr. Sara Nowakowski: Some of these tips are part of the CBT. Getting out of bed if you can’t sleep. We actually tend to restrict sleep for a couple of weeks to the amount of time your body gives you. If you’re only able to sleep six hours, only stay in bed six hours for a couple of weeks and see if that helps you reset. Those are the behavioral adjustments in CBT.
The C stands for cognitive, which is where I help people try to figure out how to quiet their mind. If you’re tired, but wired, and your brain is just going, we do things like mindfulness meditation, or trying to bring closure to your day, a relaxing unwinding period, and things that can help with the thought process. The behavior I already told you, get out of bed if you can’t sleep and get up at the same time. Those are behaviors that are going to help.
The book that we put out this year for providers was about adapting CBT for these different conditions. I wrote the chapter on menopause, and a good colleague wrote the chapter on pregnancy postpartum.
We do think about, for postpartum, if women are being disrupted by childcare and things like that, how do we adapt for that? We tend to allot more time than you would in bed because you don’t want it to be the time that you’re taking care of feeding.
For myself, I did the study at UTMB that looked at it for menopausal hot flashes. We gave a lot of education around what the hot flash looks like. For instance, it spikes within 30 seconds, and the whole hot flash itself will be five minutes, so it takes about 20 minutes for the body to cool. Realizing those things, and some sleep hygiene things of ice water by the bed and sweat-wicking pajamas or maybe a towel, or things to mitigate what’s going on.
So, there are ways we tweak it for different conditions that are going on with women and what’s going on developmentally in their lifespan at that point in time.
Dr. Aimee: I sometimes, unfortunately, have to induce these kinds of symptoms in women. I call it Devil Lupron, but it’s actually called Depot Lupron, and hot flashes are one of the side effects. Hearing these little tricks that you’ve suggested, I think I might be using those in the future.
Dr. Sara Nowakowski: There are actually studies, especially at Harvard they’ve done a lot, that they actually give it to people on purpose to study their sleep and hot flashes and see what happens. Yeah, that’s kind of evil.
Dr. Aimee: You have another fascinating study that looked at how insomnia may be tied to the risk of a pregnancy miscarrying. Can you explain a little bit about that study and what you learned?
Dr. Sara Nowakowski: That study was very interesting. One of my dreams of different areas to study is to actually just partner with fertility and endocrine and do what we call prospectively, or collect sleep data while we’re collecting these other hormones. For that, the best we were doing was looking at epidemiology data. We used this data set called Unhaint from the CDC. They collect all of this information, and part of it in their survey every year is they have sleep questions in there. So, we were looking at sleep and what are other women’s health questions in there.
The best we could come up with that was related to fertility was actually pregnancies that didn’t result in a live birth. That could have been that they chose to electively end the pregnancy, so it’s not exactly one-to-one of fertility, but we did find that people with shorter sleep, less than 6 hours, and self-reporting disrupted sleep, it was related to higher levels of pregnancies that didn’t result in a live birth.
It just gives us what we call hypothesis generating, that then we would like to do these bigger studies to look at “is there something there and is it meaningful and should women be paying attention to this.” That it’s as important as their diet, or stress, or other things that we tell people about.
Dr. Aimee: If I have a patient that works a graveyard shift, especially a woman who has had a history of miscarriage, I’m going to often ask her to change her work schedule and do what she can to get a healthy amount of sleep. Thank you for doing this work.
I also see that you’ve looked at acupuncture as a way to help people who suffer from insomnia, specifically around menopause. I actually recommend that my patients consider acupuncture as well. How can acupuncture help someone with insomnia?
Dr. Sara Nowakowski: There have been several trials. There are actually studies that even analyze all of the trials or do these systematic reviews and meta-analysis. It does show that acupuncture seems to help people with insomnia. They would like to collect more data and do bigger trials, but there is definitely something there, a signal that it’s helpful for people with insomnia to treat it. And women… We’ve done it in menopausal women and in different groups.
There are different thoughts on the mechanisms of why. We know acupuncture can impact neuroendocrine function and things like GABA in the brain, or serotonin, or potentially melatonin. By impacting those things, it may be bringing down stress and the whole process of that. I could see it being very helpful for sleep and then also for fertility. It just seems like a generally good guideline.
We kind of weigh these studies. When we don’t have quite enough data, I tell people for some things we just haven’t done the trials, especially for things like herbal supplements. We just haven’t done all of the trials to know if it’s going to be helpful or not. Use your best judgement, be an educated consumer, and you may consider them. We know the power of placebo is super strong, so that alone, if that is changing your mindset somehow and helping things, that’s great. I tell people I don’t really poo-poo what anyone is taking when they tell me what they are taking.
Dr. Aimee: Right. I think what you’re referring to is probably melatonin, CBD, or THC.
Dr. Sara Nowakowski: Correct. Yes. I didn’t mean to imply that acupuncture was in that group, but particularly things like CBD that we just don’t have much data yet at all.
Melatonin, we actually have a little bit more, but we have found it’s very good as a chronotherapy. You described your husband as being a night owl. If you take it, it’s not as much the dose, it’s kind of a micro-dose, like half-milligram to one-and-a-half milligrams, taken about five hours before sleep onset, so a good period before, you can pull your rhythm and your body clock. That’s one that we tend to therapeutically recommend.
There are certainly some ties to fertility with melatonin as well. Still a lot needs to be studied so that we can get some definitive answers, but all very interesting.
Dr. Aimee: We’ve gone through so many specifics, but I’m very curious. If someone is wondering if lack of sleep or insomnia could be impacting their ability to conceive, how can they get a diagnosis and then also treatment?
Dr. Sara Nowakowski: I do like that you said educating doctors, because I think that is a big thing, not just for fertility.
Insomnia and poor sleep tends to be underreported by patients, and it tends not to be asked a lot, so it doesn’t receive the proper diagnosis it should receive just because there are so many other things to cover. Yet here we are seeing it, at least kind of a lifestyle factor. At the very least, we might as well be improving women’s quality of life. At best, perhaps we could be improving fertility by doing these things, physicians asking about it, patients knowing about it and telling their doctors when they’re having these issues.
In 2016, the American College of Physicians actually recommended the CBTI as the first line of treatment for insomnia above and beyond medications because it tended to work in trials in the short term, and in the long term it actually worked better to learn the behavioral skills. People like me that are trained in it, I do behavioral sleep medicine, we can be hard to find, there’s not a ton of us out there, but there are definitely resources out there.
In fact, one that I like to give patients a lot that’s free that any of your listeners or viewers could take is if you Google ‘VA insomnia workbook,’ there’s a beautiful self-management workbook that was created based on empirical data by the experts in the field for veterans returning home from war. However, it’s not very specifically tied to the VA or to veterans, so really anybody that is looking and wants a self-management program to get some more tips about sleep, I think that might be a good place to start.
Dr. Aimee: When does someone need to see a sleep specialist?
Dr. Sara Nowakowski: If it becomes big and problematic. The diagnosis for insomnia disorder is it occurs three nights a week for a period of at least three months, so if it’s ongoing and becomes this chronic problem of sleep disruption and you just can’t get a handle on it, that might be a time.
Any sort of loud snoring, partner jabbing you, or waking yourself like that. It tends to go up during pregnancy, too, because we’re changing anatomically. It’s good to get it checked out.
Another big symptom is excessive daytime sleepiness, so that daytime if you’re just wiped out, unrefreshing sleep, and you just can’t get a handle on things, that might be a good time to see someone, or at least bring it up to your regular provider.
Dr. Aimee: What do you wish fertility doctors knew about the relationship between sleep and fertility?
Dr. Sara Nowakowski: Looking at correlations, it seems like there is a relationship. It would probably be smart to ask about it and make referrals if needed, and maybe learn a few of these tips themselves that they could provide to patients or some of the free online resources that we have. Just try to recommend people get a good 7 to 9 hours of sleep as what you’re aiming for.
We’re not fully sure that, if we treat it, that we get better sleep. It’s probably not going to be this magic panacea that is going to cure all unknown fertility or other things. We don’t expect it to cure everything, but it certainly could help quality of life and potentially have some benefit there.
Dr. Aimee: I know as a fertility doctor I have my own special supplements that I like to recommend or a diet. As a sleep specialist, especially with all of the studies that you’ve done, do you have a sleep monitor that you tell your patients to use or a special eye cover to wear, or special curtains that they can get to darken the room?
Dr. Sara Nowakowski: I don’t think I have. I’m not tied to any specific products. It’s really what works for them. The big things are for the CBT of just not staying in bed if you’re not asleep, don’t torture yourself. Other than that, those other things can be kind of like icing on the cake and can help or hurt.
I use all kinds of things. I use aromatherapy at night. I have a little tinnitus, so I listen to white noise. I have blackout curtains. I have a weighted blanket. I think those things can help.
Those things are kind of sleep hygiene. I think of sleep hygiene like I think of dental hygiene. You brush your teeth every night to prevent cavities. If you have a big cavity in your molar, brushing your teeth for 24 hours a day is not going to get rid of it, you need to go see the dentist. It’s kind of the same with this. Those things can be very helpful, but it may not solve all of the problems if we have insomnia disorder going on, or something bigger.
Dr. Aimee: Thank you so much for all of the work that you’re doing. If someone lives in your area, or I’m not sure if you can see people out of state, where can people find you and learn more about your work and even work with you?
Dr. Sara Nowakowski: I do not practice out of state. I’m in Houston, Texas. But I can practice pretty much anywhere in Texas since thanks to COVID we’re doing video visits, just like this really. I can do all of the interventions via video, so that’s lovely.
I’m at Baylor College of Medicine. If people just Google my name, Sara Nowakowski, they’ll be able to find all of my information on that. My Twitter handle is @Sara_Sleep, so they could follow me there.
If they want to see my work, I think the best place I tell the community to do it would be to look under Google Scholar. Type “Scholar” into Google, and then that pops up, and then if you write my name in there, you’ll see all of my articles. They’re all public access now. I get my funding through NIH, so we’re accountable to the taxpayers, so all of that information is available to look at.
Dr. Aimee: That’s wonderful. Thank you again, Sara. Thank you for your time today. I appreciate you and your work so much.
Dr. Sara Nowakowski: Sure. Thank you for having me. It’s been a pleasure.
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