S2 Episode 4 - Kathryn Pinkham - Night sweats and insomnia - is the menopause to blame?



Kathryn on her journey to how she got to where she is today and her background:

My background was working in psychological services in the NHS. I worked with mild to moderate anxiety, depression and panic. I did some training in CBT for insomnia and I loved it; it was so black and white. I started taking on all of the insomnia patients. At the time, there was a movement to think that insomnia wasn't just a secondary condition and can be your main problem. Other things could be exacerbating it, but insomnia is the thing that you really want to fix. I was made redundant on maternity leave and I set up a clinic and did one to one appointments and that just took off. But it was limited to how many hours I could do and so I trained a network of therapists. About four years ago, to increase access to this material, I recorded videos and put together an online course. That's been the main focus of my business and with COVID it was good timing. 

CBT is a very effective method of treatment for insomnia. But the access is terrible, GPs have nowhere to send anyone and it's not covered by private health. One of my priorities has been helping as many people as possible access material in an affordable way and so the focus has been the online course. Over time, I started seeing ladies with menopausal issues and so I started to focus on this as there wasn’t much actual evidence based research for women in that situation.


Kathryn on seeing perimenopausal and menopausal women and whether this is the first time they have experienced sleep issues? 

It’s a mixture. Some people have had sleep problems, and then are exacerbated by symptoms around menopause. Equally, there are people who say I've never had a problem sleeping but as soon as they've gone into menopause, and perimenopause, it's triggered. Whatever the trigger is, once it's happened, you start to feel anxious and stressed and it starts to spiral. So there's many different parts that play a problem in poor sleep and menopause is a perfect storm of all of those things happening.


Kathryn on the science behind the most common reasons that people start to experience sleep problems during menopause:

Women struggle during this time because as estrogen drops, we are more likely to have hot flushes. Estrogen is one of the hormones which controls temperature. Hormones control all these different elements of our body, our wellbeing and our mood and good sleep helps to balance those hormones. So the better we sleep, the more balanced we are. But at nighttime, when we are woken up by hot flushes, it then becomes a habit and people then start to worry during the day about the lack of sleep. So the other elements as well as being perimenopausal or menopausal, are going to start playing a role. It's triggered by the hormones, but we tackle what's maintaining it long term with treatments.


Kathryn on cognitive behavioral therapy on how it works:

Cognitive behavioural therapy for insomnia is a treatment which focuses on the behaviors and thoughts; we look at what feeds insomnia. 

Let's say that you're a normal sleeper, and for whatever reason, you go to bed, and have a poor night's sleep. It can begin from a hot flush, or a bereavement, a triggering event. Some people are aware of what that is, some people aren't sure when it started. Your sleep becomes disrupted and we are pretty intolerant to poor sleep. If I went to bed every day for a week and didn't sleep well, by the weekend, I'd be really aware of it. I’d look tired, I'd think about it during the day wondering what I should do. As time goes on, if I still haven't slept well, I’ll start to Google it, buy spray, buy lavender and hope it helps. Cut to another month, it still hasn't worked, my stress is getting higher. I speak to the doctor, the doctor has given me sleeping pills. I start changing things in my life, I'm not going out in the evenings anymore. As I'm not sleeping well, I’m spending more time awake in bed. The trigger is no longer that important, it’s the cycle we get into and it puts great pressure on sleep. The more we think about sleep, the harder it becomes to do. We're getting into bed, we're thinking and worrying about sleep. The problem triggers our internal fight or flight system; our brain believes there's something wrong and this is not a good place to be. We're flooded with adrenaline and for women in menopause, it's particularly important to understand the adrenaline response, your heart is racing, you can feel sick, you're sweating, hot; it's no wonder it's difficult to get back to sleep because we're not designed to sleep when we feel like that. CBT tackles behaviorally, what can I do to improve my chances of sleeping? How can I restructure my body clock? And cognitively, what do I need to do to take some of this pressure off?


Kathryn on the behavior and the cognitive tips that she gives to people:

People are often buying a lot of different things to improve their sleep, because we're desperate. There’s not a lot of evidence for those things and they can start making the problem worse. 

What we actually need to control our sleep is a really strong appetite for sleep. If you think of an elastic band, when you wake up in the morning, you start stretching that elastic band, it gets tighter and tighter as the day goes on. The ideal scenario is that if your elastic band is really tight, then your appetite for sleep is going to be brilliant, fall asleep quicker, you wake less in the night, you wake up in the morning and you feel good. So your sleep appetite is really important. Things that would affect your sleep appetite is if you nap before bed, that would take the edge off that appetite; spending too long in bed. 

The second thing that matters is our body clock. Our body clock controls not just sleep and weight, but also temperature, hunger, and thirst. When we get into the habit of waking up at 2, 3, 4 in the morning, your body clock alters and our body expects to wake up. Your body gets used to being more fractured in terms of your body clock. You wake up regularly through the night, the more of a pattern it becomes, the more that your body will keep it going. We need your sleep drive to be high, but we also need your body to understand what it is you want it to do and where we want to sleep in that 24 hour period. We have to teach ourselves how to sleep properly in the right window. 

The third thing is our connection with our bed. If you're spending 50% of the time in bed, stressed and hot then your connection with your bed is very weak and the bed becomes a  trigger for stress. 

For our sleep appetite, the first thing most of us do is go to bed earlier. I always advise people to spend less time in bed, which sounds counterintuitive. But actually if your sleep drive is higher, your quality of sleep is going to be improved. Sleep quality, not quantity, is more important. Eight hours of broken sleep, is not is not better than six hours of pure quality sleep. If you can remain consistent with that routine for a few days, what will happen is you'll start to not only increase your sleep drive, you're also teaching your body what to do. You're saying I won't go to bed any earlier, I'm not going to get up any later, I'm not going to sleep in the afternoon, here's the window, here's your six hours, I'm training you to sleep within that period. 


Kathryn on resetting your body clock:

One of the first things that people do, when they wake up in the night, is check the time. The problem with checking the time is you're resetting your internal body clock every time to wake you up again. If I set my alarm for 3am, for a week, by next week, I would probably wake up at 3am without the alarm.  If you wake up at two in the morning, and you're ruminating and you're worrying about something, you look at the time, the next night, you look at the time again, we are teaching our body, well done, you woke up at the right time. So turn your clock to the wall and don’t have your phone as your alarm. The second thing is if you can't sleep, if you wake up, if you're really wound up, leave the bedroom, get up and go downstairs. There's no benefit staying in bed. We tend to think at least I’m resting, you're not resting when you're in that state of feeling awful. Go downstairs, put the telly on, read a book, calm down, change your state of mind. You're far more likely to fall asleep when you get back into bed. What you're doing by staying there is creating a negative connection with your bed. And that's what we want to avoid. Don't lie there feeling terrible.

Kathryn on tips for women experiencing hot flushes: 

If that happens during the day, this hot flush racing into a panic attack, we tend to stop it as fast as we can because it's such an unpleasant feeling and we want to stop it. We have a glass of water, we take a deep breath, we go outside, we get out of the situation. The problem with doing that is that if you don't allow your body to see what happens, you're teaching it that you can't cope with the outcome. Therefore the fear continues to build. With hot flashes, I would recommend, if you wake up, just stay with it, lying in bed and start labeling everything - my heart's racing, really sweaty. Allow it to be safe. It feels awful, but we know it's safe, you're not going to die, you're not going to pass out, none of the bad things that you feel are going to happen, are going to happen. But we need to see it in practice. Let that adrenaline response be there, because it has to come back down, you can't stay in that state forever. Your adrenaline will start to reduce and what you've done is taught your brain, actually, although this is incredibly unpleasant, it's not any worse than this, this is the bad bit, and I dealt with it. It was horrible but I'm okay. If you keep doing that, you'll start to be less bothered by them. You'll wake up at the hot flush, but it won't have the same impact because your body will no longer associate a hot flush with you're in danger.