The Sleep Crisis in Menopause: Insomnia, Sleep Apnea & Solutions

最后我是远程看的。

And at the end, I watched it remotely.

我特别惊讶，他居然说——可能我记错原话了——总之他最后的意思是，别用孕酮来助眠。

And I was very surprised to hear him say, and I may be quoting him incorrectly, at the end of the day, was like, Do not recommend progesterone for sleep.

你对此感到意外吗？

Were you surprised by that?

现在的研究证据怎么说？

What is the evidence saying?

是的。

Yes.

我也觉得挺意外的。

So I was surprised by that.

我觉得他可能是想表达，我先假设他本意没那么绝对，毕竟我也没来得及找他当面确认一下。

I think what he was trying to say, and I'm giving him the benefit of the doubt because I didn't get a chance to snag him and

嘿，

say, Hey,

这到底是怎么回事？

what's going on here?

根本没有数据表明孕酮能治愈阻塞性睡眠呼吸暂停，对吧？

There isn't any data that says that progesterone is curative for, let's say, obstructive sleep apnea, right?

但我们都清楚，它确实能帮女性入睡，让人平静下来。

But we all know that it can help with getting women to sleep and calming.

我有个

I have a

一千个患者现在就能站出来作证。

thousand patients who will testify right now.

百分之百有效。

Hundred percent.

如果科学都没意识到孕酮对某些患者有帮助，那我们问的问题可能根本就不是重点，没错。

I'm like, we're not asking the right questions if, you know, science isn't recognizing how progesterone is helpful for some patients Yes.

对于

For

而且我们还没有任何研究能证明，补充孕激素和雌激素是否对睡眠呼吸暂停有帮助。

And we don't have any studies showing whether or not we add progesterone and estrogen if that helps with sleep apnea.

这个问题我经常被问到。

And I get asked that question a lot.

女性一遍又一遍地问我：如果我开始接受更年期激素治疗，会不会改善我的睡眠呼吸暂停？

Women will ask me over and over again, Hey, if I start on menopause hormone therapy, will this help me with my sleep apnea?

但我们目前还没有

And we don't

那样活着太危险了。

dangerous to live that.

比过着B-或C+的生活还要危险，因为当你过着B或B+的生活时，你会觉得已经够好了。

More dangerous than a B minus or a C plus life because when you're living a B or B plus life, you don't change it.

你觉得已经够好了，对吧？

You think it's good enough.

真的够好了吗？

Is it?

我是苏西·威尔奇。

I'm Susie Welch.

我主持一档叫《成为你自己》的播客。

I host a podcast called Becoming You.

很多人觉得，优秀的人生离我太远，但其实是有办法的。

People think, okay, an A plus life is not available to me, but there is a way.

我们每个人都在不断成为更好的自己。

We are all in the process of becoming ourselves.

欢迎在你常用的播客平台收听《成为你自己》。

Listen to Becoming You wherever you get your podcasts.

让我们先把话题拉得更广一点，聊聊睡眠，确保听众们都能明白。

So let's let's go back a little broader about sleep and make sure our listeners understand.

当我们从整体上看睡眠障碍或失眠的主要原因时，有一类患者是入睡困难。

When we look at the major causes of sleep disruption or insomnia as umbrella term, we have patients who struggle to fall asleep.

还有一类患者是睡着后容易醒，难以持续睡眠。

We have patients who struggle to stay asleep.

是的

Yeah.

那我们来聊聊那些难以入睡的人。

So let's talk about the fall asleep crowd.

为什么有些人，尤其是女性，会难以入睡呢？

Why would any patient, especially a woman, struggle to fall asleep?

大致有哪些原因呢？

What are the broad categories of of causes?

你刚才说有七十种，对吧？

Because this is you said there's 70 different Right.

失眠的原因有七十种之多。

Causes of insomnia.

对

Right.

有七十种不同的睡眠障碍。

70 different sleep disorders.

睡眠障碍。

Sleep disorders.

好的。

Okay.

主要的类型之一是呼吸异常。

So the big ones are you have a breathing abnormality.

也可能出现运动异常。

You might have a movement abnormality.

比如哪些？

Such as?

运动方面的具体是指什么？

What is a movement So

不宁腿综合征。

restless leg syndrome.

不宁腿综合征在绝经后女性中的发病率可高达百分之三十。

So restless leg syndrome can affect up to thirty percent of women in the postmenopausal state.

女性比男性更多吗？

Is that more than men?

远高于男性。

And that is way more than men.

我之前还真不知道。

So didn't know that.

这病经常被漏诊。

Underdiagnosed.

就在前几天我参加一个聚会时，有个人特意过来跟我说，你刚才讲的不宁腿综合征，

And it I just had somebody the day I was at a party actually, and somebody pulled me aside and said, You know, you were talking about restless leg.

说的就是我。

That is me.

我根本没意识到，原来就是这个让我睡不着觉。

And I didn't realize that that is actually what was causing me to have insomnia.

那对于听众朋友们来说，不宁腿综合征到底是什么？

So for our listeners, what is restless leg syndrome?

所以，按定义来说，这是一种清醒状态下的体验，也就是说，你得是醒着的，明白吗？

So it is what I call so by definition, it is a conscious phenomenon, meaning you have to be awake, Okay?

不安腿综合征表现为身体任何部位的不自主运动

So restless leg syndrome is this movement in any limb

非得是腿不可吗？

really Does it have to be your legs?

不一定非得是腿。

Doesn't have to be your legs.

也可能是躯干。

It could be in your torso.

手臂、腿，哪儿都可能。

It can be in your arms, your legs.

就是一种越来越强的不适感，逼得你非得动一动，动完舒服点了，可没多久又回来了，根本没法安心睡觉。

And it's basically this uncomfortable feeling that builds, and you have to move, it dissipates, and then it builds right back up, and it is preventing you from getting to sleep.

等你睡着了，那情况就有点不一样了。

And then when you're asleep, it's a little bit semantics.

还有一种情况叫周期性肢体运动障碍，就是肢体不自主运动频繁引发觉醒，让你无法进入正常的睡眠阶段。

There is a condition called periodic limb movement disorder, and that is when limb movements are causing constant arousals and preventing you from getting into the right stages of sleep.

真的吗。

Wow.

这是两种不同的情况，但它们其实密切相关，机制上差不多。

They're two separate things, but they're actually on the same They share like the same Yeah.

你说什么？

What

这到底是什么原因引起的？

causes this?

为什么有人会得不宁腿综合征？

Why would someone develop bristless leg syndrome?

其中一个常见原因是体内铁储备不足。

So, yeah, one common reason is having low iron stores.

而且，别让我展开讲这个，因为我之前

And, well, let's not get me started on that because I had

有一位怀孕的病人，是病理科医生，深受不宁腿综合征的折磨。

a pregnant patient who was a pathologist and had horrible LRS.

正是她让我了解了铁蛋白的重要性。

And she's the one who taught me about the ferritin.

是的。

Yes.

我们在她孕期给她输铁，防止她贫血，虽然她的铁蛋白水平很低，但治疗效果非常好。

And we were getting her iron transfusions in the pregnancy so that she wasn't anemic, but her low ferritin, and it worked beautifully for her.

我们往往太低估了静脉补铁的作用，因为口服补铁见效太慢，你是说口服药吗？

And we underutilize iron infusions because sometimes, you know, it takes a long time with iron replacement to feel You mean oral?

对，我铁蛋白长期偏低，还有肠胃问题。

Yeah, I had low ferritin for a long time, and I had GI stuff.

那时候真的很难受，最后只好决定去接受铁剂输注。

So, very difficult for me And to finally, was like, fine, I'll go get the iron transfusion.

简直是改变了我的生活。

Life changing.

真的改变人生。

Life Yeah.

太有用了。

Changing.

我现在经常推荐给那些吸收有问题的患者。

I recommend them all the time now for patients who are struggling with absorption.

没错， definitely。

Yeah, definitely.

正常值对有不宁腿综合征的人来说根本不算正常。

And the normal values are not normal if you have restless leg syndrome.

你的铁蛋白水平是多少？

What ferritin level are you?

我今天刚发了一篇关于这个的帖子。

I just did a whole post on this today.

真是有意思。

It's so funny.

你觉得 ferritin 到什么水平才算够高？

At what level are you like, we need to get this higher?

如果你有不宁腿综合征，ferritin 应该保持在 100 左右。

So if you have restless leg syndrome, your ferritin should be around 100.

明白了。

Okay.

ferritin 是储存铁的蛋白，它在你还没贫血之前就会先下降。

So ferritin is the iron storage protein, and it drops way before you become anemic.

没错。

That's right.

对。

Right.

在我们诊所，如果患者有慢性炎症，比如 CRP 偏高，或者有其他炎症迹象，我们不会用 60 作为标准，而是用 100，因为 ferritin 是急性期反应物。

And in our clinic, if they have chronic inflammation, so if their set rate's high or, you know, we have signs of chronic inflammation, we're not using 60, we're using 100 because it's an acute phase reactant.

炎症一来，ferritin 就会异常升高。

The keratin will rise abnormally in response to inflammation.

所以得为患者调整这个标准。

So, have to move that goalpost for patients.

对。

Right.

完全正确。

100%.

而且它能穿过血脑屏障。

And also, it crosses the blood brain barrier.

你之所以有不宁腿综合征，是因为它影响多巴胺的释放。

That's why you have restless leg syndrome because it has a role in how dopamine gets released.

太神奇了。

Amazing.

这就是它在大脑中起作用的方式。

And so that's how it works in the brain.

所以你才会出现不宁腿综合征。

That's why you will have restless leg syndrome.

我们以前用的那些正常值标准，现在都调整了。

And we've had these levels that are standard that are now changing, right, for normal.

但即便如此，这些所谓的正常值对患有不宁腿综合征的人来说还是偏低的。

But even then, those normal levels are not normal if you have restless leg syndrome.

现在正常的范围已经提到了45。

So now the normal range is like 45.

45。

45.

以前是15。

It was 15.

他们之前的标准太离谱了。

They tripping Terrible.

确实太离谱了。

It was terrible.

那时候常有女性患者来，铁蛋白水平只有10左右。

So you'd have these women coming in who had like a ferritin level of, you know, 10.

你就会说，哦，你只是 borderline（临界值）。

You're like, Oh, you're borderline.

对。

Right.

其实也没那么低。

It's not really that low.

这些女性其实早就该接受铁剂输注了。

And these people probably, these women should have had iron infusions.

明白了。

Okay.

我们刚才聊了运动障碍。

So we talked about movement disorders.

咱们继续吧。

Let's keep going.

那剩下的就是慢性失眠了。

So then you're left with chronic insomnia.

慢性失眠就是说，没什么其他原因能解释你为什么就是睡不着。

Chronic insomnia is when there's not really anything else that could be causing you to not be able to fall asleep.

另一个主要原因是生物钟紊乱。

So the other big one is circadian rhythm abnormalities.

比如说你是个夜猫子，但你得早起，因为工作要早到，或者得送孩子上学，或者要照顾别人，反正就是这么回事。

So let's say you're a night owl, but you really have to get up early because you have to go to work earlier or you've got to get your kids to school or you're taking care of somebody, whatever.

关键是你的作息和生物钟对不上，而这些控制生物钟的基因就在大脑里，根本改不了。

The point is that you're not in sync with your circadian rhythm, which, again, those clock genes are in the brain, you can't really change them.

这就像眼睛的颜色，生下来就定了。

It's kind of like eye color, you're born with them.

你可以骗骗它，让它暂时配合一下。

You can fake them out.

我们想办法调整人的生物钟，这就叫生物钟重置。

So that's called circadian realignment when we try to adjust somebody's circadian rhythm.

还有其他很多原因会导致人长期睡不着觉。

And the other one is, you know, there's lots of reasons why people will have chronic insomnia.

其中一个可能是荷尔蒙变化。

One can be your change in hormones.

另一个可能是创伤。

One can be trauma.

还有可能是心理健康问题。

Another one can be mental health.

原因多种多样。

There's all sorts of reasons.

很有共鸣。

Resonating.

焦虑、抑郁。

Anxiety, depression.

各种情况都有可能。

I mean, all kinds of things.

明白了。

All right.

那那些人晚上一开始睡得好好的，可到了凌晨两点、三点就醒了，这是怎么回事？

So what about the patients who go to sleep fine, but then two a.

那那些人晚上一开始睡得好好的，可到了凌晨两点、三点就醒了，这是怎么回事？

M, three a.

那那些人晚上一开始睡得好好的，可到了凌晨两点、三点就醒了，这是怎么回事？

M?

这到底是怎么回事？

What is happening?

对。

Yeah.

这是习得性的过度警觉。

That's learned hypervigilance.

尤其是中年阶段，这跟神经内分泌和神经类固醇的变化有关，对吧？

Especially in midlife, this is a neuroendocrine, neurosteroid change, right?

所以体内的皮质醇水平也会发生变化。

And so we have a change in cortisol.

有时候，皮质醇的激增会提前发生，导致人早早醒来。

And sometimes that cortisol spike starts to happen earlier, which causes early morning awakenings.

然后，你大脑中负责睡眠的神经通路就会发生变化。

Then your brain, basically, neuro pathway for sleep, it changes.

你的大脑会默认，好吧，我们得走一条新路了。

Your brain just says, Okay, we're going to learn a new path.

于是你就形成了睡眠中的过度警觉和过度兴奋，这是一种行为上的改变。

And so you develop this hypervigilance, this hyperarousal in your sleep, and that is a behavioral change.

这就是为什么治疗失眠需要时间，通常不是靠处方药、药物或补充剂就能解决的。

This is why it takes time to treat insomnia, and it is not typically fixed with any sort of prescription, medication, or supplement.

那该怎么改善呢？

How do we fix it?

最有效的治疗方法是认知行为疗法，专门针对失眠的。

So the number one treatment is cognitive behavioral therapy for insomnia.

那是什么？

What is that?

其实就是重新训练大脑。

So it is basically retraining the brain.

关键在于行为上的改变。

It's all about behavioral change.

要解决并理解导致过度警觉的原因，然后重新训练大脑，就像锻炼肌肉一样。

It's about addressing and understanding what is causing that hypervigilance and retraining the brain, kind of like building muscle.

我常跟人说，你不可能一进健身房就直接举起50磅的重量。

You know, I always tell folks, you don't just go to the gym and pick up 50 pounds.

这办不到，对吧？

You can't, right?

得从慢开始，保持规律，慢慢才能举得起那50磅。

You have to start slow, you have to be consistent, and then you can eventually pick up that 50 pound weight.

我还跟人说，这不是从沙发到五公里，而是从沙发到马拉松。

I also tell people it is not a couch to five ks, it is a couch to marathon.

这事儿急不得。

It doesn't happen fast.

如果你真逼自己一把，跑个三英里或许能做到，但没经过训练，想在一周两周内轻松跑完马拉松根本不可能。

If you were really pressed, you could probably three miles, but you can't run a marathon really easily in a week or two without training.

这关乎改变一个人的思维方式，也要给他们一些方法，让他们能允许自己重新回到睡眠中。

This is about changing somebody's way of thinking and also giving them some ideas on how they can kind of give themselves permission to go back to sleep.

那具体是怎么做的呢？

How does that look?

我的意思是，你通常会怎么做？

Like, what would you Okay.

比如我。

So me.

好的。

All right.

我总是在凌晨三点醒来。

I'm waking up at three a.

M.

M.

每天晚上都这样，我们已经排除了医学方面的原因。

Every night, and we've ruled out medical causes.

我没有睡眠呼吸暂停。

I don't have sleep apnea.

我的荷尔蒙已经补充了。

My hormones are replaced.

说真的，我们还没找到真正的原因。

You know, we haven't put a finger on it.

你会建议我怎么做？有什么App可以用吗？

How would you counsel me to do Is there an app?

我该去找心理咨询师吗？

Do I go to a counselor?

是的。

Yeah.

有好多不同的方法可以尝试。

There's so many different avenues.

现在市面上有不少睡眠类应用。

So there are apps out there.

也有专门研究睡眠的心理学家。

There are sleep psychologists out there.

还有在线的治疗项目。

There are online programs.

书也很多。

There are books.

关键是坚持。

The key is consistency.

你得把认知行为疗法里的各个要素都照顾到。

And you really have to address all of the components that are in cognitive behavioral therapy.

这就像是一个三条腿的凳子。

So it's kind of what we call a three legged stool.

第一条腿，大多数人做得还不错，就是睡眠习惯。

So the first one, most people do a pretty good job at, which is sleep hygiene.

但其实，比我们想的更多人，睡觉和起床的时间并不固定。

But more people than we think don't always go to bed at the same time or wake up at the same time.

他们日常生活中的一些习惯可能影响了入睡，自己却根本没意识到。

Maybe they're doing things in their daily life that is affecting their ability to get to sleep and they don't even realize it.

也许他们临睡前吃了特别油腻的大餐。

Maybe they're eating a really heavy meal right before bed.

也许他们锻炼得太晚了。

Maybe they're exercising too late.

也许他们一整天都压力山大，却没意识到这会让他们很难放松下来入睡。

Maybe they are super stressed all day and don't realize that that is going to affect their ability to kind of shut down and get to sleep.

这就是睡眠卫生的那部分。

So there's that sleep hygiene component.

还有，卧室温度可能不够合适。

And also, maybe bedroom is not Too cold.

太热、太冷、太吵，都不行。

Too hot, too cold, too loud.

太亮了。

Too bright.

另一个问题是应对过度警觉和外界刺激，也就是导致半夜醒来的真正原因。

And then the other one is addressing the hypervigilance, the stimulus, like what is causing that middle of the night awakening?

我会告诉人们，咱们来制定一个计划吧。

And I will tell people, you know, let's develop a plan.

想办法帮助自己重新入睡，别一醒来就往最坏的方向想。

Let's figure out how to help yourself get back to sleep and not catastrophize when we wake up.

很多人半夜醒来，第一反应就是：天哪，我再也睡不着了。

So a lot of us, right, wake up in the middle of the night and go, Oh my gosh, I'm not going to get back to sleep.

接下来会怎么样？

What's going to happen?

相反，你要提前想好应对方案。

Instead, have a plan.

好吧，我醒了，也知道短时间内不可能马上睡着，那我就起床，去别的地方做点特别无聊的事，比如看书，或者冥想——越枯燥越好，这样反而更容易催眠。

Okay, I'm awake, and I know I'm not falling asleep, falling back to sleep anytime soon, so I'm going to get out of bed, and I'm going to go sit somewhere and do the most god awful boring thing I can do, like reading a book or doing some sort of meditation, something that will help induce sleep.

所以如果睡不着，千万别在床里做饭、打扫、工作或者锻炼。

So we don't want people cooking, cleaning, working, exercising if they cannot fall back to sleep.

我们希望他们干脆下床。

And we do want them to get out of bed.

这叫刺激控制，说白了就是让大脑把床和睡觉、亲密行为联系起来，别的都别想。

That is called stimulus control, fancy word for making sure that your brain associates the bed with sleep or intimacy and nothing else.

因为你如果老赖在床上，大脑就会觉得床跟沙发、餐桌没什么两样。

Because if you stay in there for a long time, then your brain starts to think that the bed is like the sofa or the kitchen table.

它就不会把床和……

It doesn't associate it with

所以你得起来。

So you should get up.

你真得起来。

So you got to get up.

这确实挺难受的。

It's painful.

找把专门用来失眠的椅子，叫什么名字都行，就做点特别放松又无聊的事，让自己慢慢犯困。

Pick something like an insomnia chair, whatever you want to call it, and just do something really relaxing and boring to help yourself get sleepy enough.

等真困了，再回床上去。

And when you're sleepy enough, you go back to bed.

最后这一条最难，但效果特别好，叫睡眠限制法。

The last one is the hardest, but it actually works really well, which is sleep restriction.

如果你觉得自己每晚只睡五个半小时，那你就只给自己安排这么多时间。

So if you think you're only getting five and a half hours of sleep, then that's how much time you should give yourself.

别一到十点就上床，翻来覆去两小时，睡着了又半夜醒，再折腾两小时，最后六点爬起来，这样不行。

So instead of trying to get into bed at ten tossing and turning for two hours or falling asleep and then waking up at one and tossing and turning for two hours or whatever, and then getting up at six.

我们会建议：既然你每晚只睡五个半小时，那就先从这个时间开始，慢慢压缩你的睡眠时间，等效率上去了，再逐渐延长。

We tell people, well, if you are only getting five and a half hours of sleep, then let's slowly we don't just say only get five and a half hours, but we start to help people kind of compress their sleep so that they can then expand their sleep.

我把这叫‘手风琴效应’。

So I call this the accordion effect.

你想想，手风琴一压紧，唯一的出路就是往外拉开。

So you know how you have to The only way, if you push an accordion in, the only way for it to go is out.

所以道理是一样的，得先压缩睡眠时间，才能慢慢延长睡眠。

So that's the same concept, is that you kind of have to compress the sleep in order to expand the sleep.

关于失眠的认知行为疗法，我想说的是，这方面的研究数据挺多的。

So, you know, what I will say about connotative behavioral therapy for insomnia is that there's a lot of data around it.

效果是有的，但要求特别严格。

It is successful, but it is pretty rigid.

你得把所有步骤都做到位，不然效果就会打折扣。

And you do have to follow all of the components or you have a lower success rate.

我发现，专门针对女性慢性失眠的研究其实很少，对吧？

And what I find is that there hasn't been a lot of studies on chronic insomnia only in women, right?

这反而让很多人更加焦虑了。

And so I think it drives a lot of people's anxiety.

你本来就已经为睡不着感到紧张，这下又把睡眠焦虑推得更高了。

So you already have some anxiety about getting to sleep, and then it revs up this sleep anxiety even more.

所以我喜欢把接纳与承诺疗法结合起来，那是另一种完全不同的疗法，关键是要对自己温柔一点，给自己一些空间，这样第二天就算没睡好，也不会觉得天塌下来了。

So I like to combine acceptance and commitment therapy with it, which is a different type of therapy altogether, where you give yourself, you know, love and grace so that you can actually get up the next day and maybe feel like it's not going to be the end of the world.

所以你可能半夜就是睡不着。

So maybe you can't fall asleep in the middle of the night.

别一想‘明天肯定完蛋了’就慌了。

And instead of saying, oh my gosh, I'm not going to do well tomorrow.

你有演讲要开，要照顾孩子，诸如此类，不如换个想法：你知道吗？

I've got a presentation or I have to do these things for my children or what have you, that you say, You know what?

今晚我就醒着九十分钟，绝不让它毁了我一整天。

I'm going to be awake for ninety minutes tonight, and I'm not going to let it ruin my day.

也许我没法全速运转，但我能尽量把明天过好。

Maybe I'm not going to fire off on all cylinders, but I'm going to make it the best that I can for the next day.

你开始对自己温柔一点。

And you start to be kind to yourself.

我把认知行为疗法叫作‘韧性’，而接纳与承诺疗法叫作‘慈悲’。

So I call CBTI the GRIT and Acceptance and Commitment Therapy, or ACT, the GRACE.

如果能把这两者结合起来，我觉得效果会更好。

So if you can combine those two, I think you have a higher success rate.

关于这一点，公开发表的研究非常少，专门从事这种综合疗法的睡眠心理学家也寥寥无几。

There are very few published studies on this, and there are very few sleep psychologists who practice this in combined therapy.

但我的做法就是这样的。

But that's what how I practice it.

我帮助失眠患者时，重点就放在这些方面。

That's what I focus on when I help people with insomnia.

你提到过，像睡眠呼吸暂停和不宁腿综合征这些常见的睡眠问题，常常被漏诊，是的。

You've talked a lot about how some of these common sleep conditions like sleep apnea and RLS are missed Uh-huh.

尤其是在女性身上。

In women.

我以前对此一无所知。

I learned zero.

我听说不宁腿综合征，只觉得是个挺奇怪的现象。

I heard of RLS more as, like, this curiosity.

对。

Yeah.

人们总觉得睡眠呼吸暂停就是那些老胖男人的事。

And sleep apnea was old fat guys.

你知道的。

You know?

还有那些打呼噜的男性。

And so and men who snored.

但我们的听众得明白，女性的睡眠呼吸暂停表现很不一样，虽然女性占了人口的百分之五十一。

I think it's important for our listeners to understand the female presentation, the atypical sleep apnea, though we're fifty one percent of the population.

你能不能说说，女性出现这些症状时是什么样子？

Like, talk to me about women and how they present with these.

为什么这很重要？

And why do we care?

当然重要，因为睡眠呼吸暂停是心血管疾病的危险因素。

Yeah, we care because it is a cardiovascular risk factor.

如果你有中重度阻塞性睡眠呼吸暂停，那么你未来发生心梗、中风，或者出现认知问题、记忆力减退的风险，会高出百分之二十五。

So, if you have moderate or severe obstructive sleep apnea, we know that you have up to a twenty five percent increase in having a heart attack or a stroke or having a neurocognitive issue later on, memory loss

还是痴呆？

or dementia?

对。

Yeah.

那炎症呢？

And the inflammation?

对。

Yeah.

所以这是长期的

So it's the chronic

身体长期处于低氧状态，才会引发这一系列连锁反应，增加风险。

low oxygen state that then causes all of this reflex physiology in the body that then puts you at risk.

女性通常不会表现出打鼾剧烈或被观察到呼吸暂停。

So women don't typically present with loud snoring, witnessed apneas.

实际上有一项研究指出，如果女性有男性伴侣，她们被诊断出睡眠呼吸暂停的可能性更低，因为男性伴侣往往注意不到她们睡眠中的异常。

There's actually a study out there that talks about the fact that if women have a male partner, they're less likely to be identified as having sleep apnea because their male partner will not notice anything abnormal happening in their sleep.

但女性更容易失眠。

But women tend to have insomnia.

她们常说晚上翻来覆去睡不着。

They tend to have this they call it tossing and turning.

这说法真有意思。

And I love it.

女性从不说自己打呼噜。

Women never say that they snore.

她们会说，自己只是在发出呼噜声。

They say that they purr.

是的。

Yeah.

这说法真有意思。

I love it.

女性总说，我其实不打呼噜。

Women always say, I don't really snore.

我睡觉的时候会轻微打呼。

I kind of purr when I sleep.

这其实算是轻度打呼。

That can be mild snoring.

这就够了。

That's enough.

关键是，你不一定得肥胖才会得睡眠呼吸暂停。

And the issue is that you don't have to, you know, be obese to have sleep apnea.

尤其是女性，对吧？

And especially in- Especially women, right?

尤其是女性。

Especially women.

你的体重指数完全可以是正常的。

You can have a normal body mass index.

也不一定得打很响的呼噜。

You don't have to have loud snoring.

但如果你进入更年期，风险就会更高。

But if you're menopausal, you're at greater risk.

所以，等等，更年期会增加睡眠呼吸暂停的风险？

You know So, woah, menopause increases the risk of sleep apnea?

是的，确实如此。

Yeah, it does.

高达百分之五十的女性患有睡眠呼吸暂停，却根本不知道自己有这问题。

Up to fifty percent of women will have sleep apnea, not know they have it.

这些女性中，有百分之九十根本不知道自己得了睡眠呼吸暂停。

Ninety percent of those women do not know that they have sleep apnea.

也就是说，十个女性里有九个没被诊断出来。

So, nine out of ten women are not diagnosed.

而且诊断还会被延误，因为目前所有的筛查工具都存在性别偏差。

And then there's a delay in diagnosis because all of our screening tools are gender biased.

比如那个叫STOP BANG的问卷，是个缩写，其中的G就是指性别。

I mean, the STOP BANG questionnaire, which is this acronym for these questions, the G is gender.

所以如果你是女性，你拿不到

So if you're a woman, you don't get

更低的分数

a You lower

得分会更低。

get a lower score.

因为大家没意识到女性也会得睡眠呼吸暂停。

Stop it because they don't recognize that women have sleep apnea.

对。

Yeah.

好的。

Okay.

我从中得出的一个结论是，如果女性打呼噜，伴侣注意到了，或者她自己也有类似症状，那她的情况可能已经发展得比较久了。

One of my takeaways from all this is if a woman is snoring and her partner recognizes it or she's purring, she might be further along the course than her Yeah.

男性：没错。

Male Exactly.

所以只要你打鼾，就应该去检查一下。

So if you're snoring at all, you should go get evaluated.

完全同意。

A 100%.

我对女性做睡眠检测的门槛很低。

I have a very low threshold for testing women.

因为女性常常来就诊时只是说，我总觉得不舒服，说不清哪里出了问题，脑子昏昏沉沉的，睡醒后还是觉得没休息好。

Because, again, women come in feeling just generally that, you know, I don't feel well, I don't know what's going on, I have brain fog, I can't seem to feel rested when I wake up.

可能我只是轻微打鼾而已。

You know, I might have some mild snoring.

不过到了中年，打鼾确实更常见了。

So, snoring does increase in midlife.

但这种情况往往被忽略了。

But again, it's not caught.

如果打鼾不严重，或者没人注意到你睡觉时呼吸暂停，那医生就很难把女性的这些症状和睡眠呼吸暂停联系起来。

You know, if it's not big, bad snoring or if somebody isn't watching us have trouble breathing, then many times the connection of a woman might be at risk for sleep apnea, that connection is not made.

很多女性会自己用药来解决睡眠问题。

A lot of women try to self medicate for their sleep problems.

她们通常第一反应就是吃褪黑素。

And the first thing they usually reach for is melatonin.

你能不能讲讲褪黑素是什么，为什么它这么重要？

Talk to me about melatonin, what it is, why it's important.

褪黑素是一种激素。

Melatonin's a hormone.

它在我们体内其实有多种用途。

It's got a lot of different uses in our body, actually.

但我们最熟悉、最常提到的，是它如何帮助我们准备入睡。

But the one that we know about the most or the one that's talked about the most is how it starts to set the stage for sleep.

这里有个概念叫‘暗光褪黑素分泌启动’。

So there is this whole concept called dim light melatonin onset.

意思是，没有光线的时候，松果体就开始分泌褪黑素了。

That means in the absence of light, that's when the pineal gland starts to release melatonin.

所以它更像是一个启动时钟。

So it's really a clock starter.

它并不是助眠药。

It is not a sleep aid.

它启动的是睡眠的整个过程，同时也调节生物节律。

It is starting the cascade of sleep, but it is also a circadian rhythm regulator.

我在睡眠医学培训期间从未学到过，随着年龄增长，我们体内褪黑素的分泌会减少。

And what I did not get taught in my sleep medicine fellowship is that we actually lose melatonin production as we age.

减少多少呢？

Like how much?

到50岁的时候，可能减少高达百分之五十，我以前完全不知道。

Well, up to fifty percent by age 50, which I had no idea about.

我也没想到，松果体是人体内第一个钙化的腺体，难怪常见到老年人来就诊时

And I did not realize that the pineal gland is the first gland in the body to calcify and that the whole stereotype of the older person coming in

不过，我以前学睡眠知识时，只听说人年纪越大，睡得越少。

Now, the only thing I was taught about sleep is you sleep less as you get older.

是的

Yeah.

而且这一点是

And that is

这很正常

And that is norm.

这是预期中的

That is expected.

这是普遍现象

That is normal.

也许这是预期的，但真的应该被视为正常吗？

Maybe it's expected, but should it be normal?

我的意思是，这算是所谓的正常衰老的一部分，但我非得这样生活吗？

I mean, you know, it's part of quote unquote normal aging, but do I have to live like that?

我非得接受生活质量下降吗？

Do I have to live with a lower quality of life?

为什么

Why do

你觉得女性的睡眠问题总是被轻视呢？

you think women's sleep complaints are so frequently minimized?

说到底，这正是我做这份工作的原因——我实在受够了社会对女性痛苦的习以为常。

Well, you know, it goes back to and this is why I do what I do I am really tired of the normalization of women suffering in society.

这正是我坚持做下去的原因。

That is exactly why I'm doing what I'm doing.

因为我们从小就被灌输，女性的痛苦承受阈值应该更高。

Because we get told from a very young age that our baseline for suffering is higher.

我们得忍着那些糟糕透顶的经期不适，甚至贫血也得扛着。

We should just suffer through those horrendous menstrual periods that we should be anemic.

这没什么大不了的。

It's okay.

抱歉啊，你流了这么多血。

You know, sorry, you're losing a lot of blood.

如果你有孩子，那根本别想睡够觉。

If you have children, well, you're just not going to get enough sleep.

你总得照顾别人吧。

Well, you have to take care of somebody else.

不管是工作还是家里，都有种看不见的精神负担。

There is mental load in the working environment, in your home environment.

我们从小就被灌输，得忍得更多。

We are taught that we are supposed to suffer more.

等到了更年期，到了中年，你就被当成了透明人。

And then you hit menopause, you hit midlife, and then you become invisible.

那时候，你还得继续忍着。

And then you're supposed to suffer.

你瞧，现在你没激素了嘛。

Well, you know, you don't have hormones now.

这事儿就是这么个情况。

It's just the way it is.

睡眠完全被打乱了，简直没法睡。

Sleep is, like, horrifically disrupted.

对。

Yes.

明白了。

Okay.

我们回头再聊褪黑素吧，我还有好多问题想问。

So and we'll get back to melatonin because I have so many more questions.

是的。

Yeah.

我选了妇产科，这行经常得倒班、熬夜，或者大清早就得起来接生。

But I chose a field of medicine that, you know, is a lot of shift ish work or staying up late at night or getting up early in the morning for obstetrics to deliver babies.

那时候我才25岁，还扛得住。

And it was fine when I was 25.

嗯，没错。

Uh-huh.

你懂的。

You know?

35岁的时候还行。

It was fine when I was 35.

40岁的时候也还能撑住。

It was fine when I was 40.

但到了四十多岁，情况越来越糟，我再也恢复不了以前的状态了。

But, man, in my forties, it was hitting harder and harder, and I was not rebounding like I should.

我把所有精力都带到工作上，只为了表现好，可家里却受到了影响。

And I would bring everything to work so I could perform, and my family was suffering.

大概48、49岁的时候，我更年期刚开始，夜里潮热得睡不着，那时候我还不知道激素替代疗法其实没那么可怕。

So when I was about 48, 49, I was having disrupted sleep from hot flashes when I was going through menopause or in the early stages before I, you know, realized that HRT wouldn't kill me.

我勉强接受了激素替代治疗。

I reluctantly went on HRT.

睡得好多了，因为半夜不会再被潮热惊醒了。

And my sleep went back to normal because I wasn't having hot flashes at two in the morning.

后来我换了个岗位，不再在诊所上班，这样就能只上半职了。

I then transitioned positions to shift work away from the clinic so I could go part time.

于是我成了住院医师。

And so I became a hospitalist.

接着新冠疫情来了，我每周要值三个24小时的班。

And then COVID hit, and I was working twenty four hour shifts, three days a week.

我不禁想，因为这段经历，我到底折了多少年寿命。

And I wonder how many years I took off of my life because this.

那段时间最后一年，我简直崩溃了。

I was an absolute basket case for, like, the last year of that.

我看过资料，说轮班工作的人患各种疾病的风险特别高。

And I've read that shift workers are at super high risk for medical conditions.

你能说说这方面的情况吗？

Can you talk a little bit about that?

当然可以。

Yeah.

好消息是，你还是可以修复之前造成的损伤的

Well, the good news is that you can repair what you were

某种程度上可以吧。

can kind of.

所以我给自己五十岁生日的礼物，就是彻底告别倒班工作。

Because my construct fiftieth a birthday present to myself was no more shift work.

你懂的。

You know?

有大量研究显示，如果一个人有未治疗的睡眠呼吸暂停或失眠，一旦开始治疗，身体就能恢复到原来的状态。

There is good data out there that shows that, you know, if somebody has untreated sleep apnea or untreated insomnia, that once we begin to treat it, you can get yourself back to baseline.

明白吗？

Okay?

但确实有研究指出，如果你是倒班工作者，又不是那种夜猫子类型，那患痴呆和癌症的风险会更高。

But there is data out there that does state that if you're a shift worker and let's say you are not a night owl, then yes, you are at higher risk for dementia, for cancer.

这是因为我们身体的生物钟依赖于每天固定时间入睡的能力。

That's because the way that our circadian rhythms work in our body, they rely on our ability to get to sleep at a particular time.

这全靠时间点，对吧？

It's all about timing, right?

所以轮班工作的人就会被打乱节奏。

And so shift workers have this disruption.

就像我说的，身体里的每个细胞都遵循昼夜节律。

And like I said, every cell works on a circadian rhythm.

这样一来，身体内部就乱套了。

So then it's like chaos inside the body.

我们的免疫系统受影响，大脑清除废物的能力也跟着下降。

And so our immune system suffers, our ability to clean all the waste products out of the brain suffer.

身体承受着巨大的氧化压力。

There's so much oxidative stress on the body.

没错，这简直就是为疾病铺好了路。

And yes, that then kind of is a total setup.

为什么这么多女性服用褪黑素后总做噩梦？

Why are so many women complaining about nightmares with melatonin?

首先，你可能吃太多了。

So, one, you might be taking too much.

多少算太多呢？

How much is too much?

我觉得超过三毫克就有点过了。

So I'd say anything over three milligrams.

三毫克是我建议任何人服用的上限。

Three milligrams is the max that I would recommend for anyone.

吃得多并不等于效果更好。

You don't really need to take more is not better.

我以前不知道该怎么选的时候，吃的是十毫克。

The one I was taking when I didn't know what to do was ten.

我当时就想，瓶子里写多少我就吃多少。

I was like, this is what is in the bottle.

那药是紫色的。

It's purple.

看起来挺漂亮的。

It looks pretty.

我一看到紫色就会想到睡觉。

I associate purple with sleep.

那时候我老做噩梦。

And I was having horrible nightmares.

有时候有用，但更多时候醒过来感觉像被药麻住了，昏昏沉沉的。

And sometimes it would help or I'd wake up completely drugged, groggy.

你懂的。

You know?

我之前就说了，量多不见得更好。

Like I said, more is not better.

而且我们也不知道市面上那些非处方药到底是什么成分。

And we also don't know what's out there over the counter.

牌子太多了。

There's lots of different brands.

有些质量不错，有些则参差不齐。

Some of them are high quality, some of them varying qualities.

有几项研究显示，市面上销售的褪黑素至少有七成并不只是单纯的褪黑素。

And there's a couple of studies that were done that showed that at least 70% of the melatonin that is sold over the counter is not just melatonin.

里面还混了别的东西。

There's something else in it.

所以我们得特别当心。

And so we just need to be really careful.

就算你吃的是低剂量的褪黑素，也可能会做噩梦或者做特别强烈的梦。

Now, when you do take melatonin, you could even take a low dose of melatonin and have nightmares or intense dreams.

这是因为褪黑素会让梦境变得更强烈，因为你睡得更沉、更持续了。

And that's because melatonin is what really intensifies dreaming because you're having more sustained sleep.

所以你可能会做更强烈的梦。

So then you might have more intense dreams.

而这种强烈感，可能会让你做更多奇怪的梦。

And that intensity might translate into, you know, having more abnormal dreaming.

为什么我总是记得那些梦，尤其是吓人的梦，而不是好梦呢？

Why do I remember some dreams and usually the scary ones versus the good dreams?

是的。

Yeah.

这其实跟杏仁核在你做梦时的反应有关，也跟记忆的巩固和存储方式有关。

So, you know, it's all about how the amygdala is reacting when you're draining and how you're consolidating and storing the memories.

我不确定为什么有人会特别记得噩梦，但有一点是肯定的——人在做梦时，大脑的活动几乎跟清醒时一模一样。

I don't know exactly why somebody is going to remember a nightmare other than the fact that, you know, the way that the brain works when we're dreaming, it almost looks like we're awake.

所以，通常在其他睡眠阶段处于休眠状态的大脑区域，在做梦时反而全都活跃起来了。

So all of the parts of the brain that are typically asleep in the other stages of sleep actually wake, you know, they wake up.

PET扫描显示，做梦的时候，大脑的很多区域都在强烈活跃。

The PET scans show that when you're dreaming, a whole lot of your brain is lighting up.

这可能会影响记忆的整合，让你把白天经历的高压事件在梦里重新体验一遍，因为这些压力在潜意识里干扰了你的入睡和睡眠维持。

And, you know, that might play a role in how we are consolidating the memory, how we're reliving something that might be when something that was really stressful during the day translates into a nightmare because it is subconsciously affecting our ability to get to sleep and stay asleep.

那我们来聊聊解决办法，哪些方法才是真正有效的。

So let's talk about solutions and what actually works.

关于睡眠中的激素治疗，比如雌激素和孕激素，我们现在知道些什么？

Hormone therapy in sleep, estrogen, progesterone, and what we know.

之前我们聊过，雌激素水平下降会导致睡眠碎片化更严重。

So, we had talked about how the lack of estrogen, then, you know, you tend to have more fragmentation of sleep.

主要跟体温调节有关。

Really focuses on thermoregulation.

如果你补充雌激素，体温调节就会改善，这样更容易整夜安睡，也能更好地进入各个睡眠阶段，提高REM睡眠的比例。

And so if you replace estrogen, then you tend to have more of that temperature regulation, which then allows you to stay asleep, which then allows you to get into all the right stages of sleep and increase your REM percentage.

这就是雌激素的好处。

So that's the plus with estrogen.

而孕激素呢，给患者使用后有镇静作用，能帮助更好地入睡，也可能对气道保护有一定帮助——虽然目前还没有确凿数据证明它能根治问题。

With progesterone, when we give progesterone to folks, that is also then calming, it helps to set the stage for sleep better, and it probably helps, we don't have data, with some of that airway protection, but we don't know if it's curative or not.

所以，你其实是让大脑平静下来，为整夜安睡做好准备，对吧？

So, you're kind of like calming the brain and then you're preparing the brain to stay asleep, right?

还有一些研究显示，睾酮有助于提升深度睡眠。

And then there are some studies that show that testosterone does help with deep sleep.

对有些人来说，睾酮才是关键所在。

And for some people, testosterone's a missing link.

他们即使开始用雌激素和孕激素了，还是睡不好，于是就想：要不试试睾酮？

Like, they still have trouble sleeping even after they've started on estrogen and progesterone, and they're like, Okay, let's try testosterone.

结果发现，这正是他们缺的那块拼图。

And that was the missing link for them.

虽然研究还不多，但确实是个可能的解决方向。

It's not as well studied, but it is a potential solution.

但即便开始激素治疗，仍有至少三分之一的人睡眠问题依旧存在。

But up to, you know, at least a third of those folks who start on hormone therapy still have trouble sleeping.

甚至有一半的人，睡眠还是得不到改善。

Up to half of those folks still will have trouble sleeping.

那我们就得往别的生理原因上找了，对吧？

So then we have to start looking at the other organic causes, right?

比如，你有没有没被诊断的睡眠呼吸暂停？

Like, do you have untreated sleep apnea?

你有未经治疗的不宁腿综合征吗？

Do you have untreated restless leg syndrome?

你有慢性失眠吗？

Do you have chronic insomnia?

我们来解决这个问题。

Let's fix that.

我们一起努力，把这个问题处理好。

Let's work together and treat that.

这时候就需要你来帮忙了。

And that's where you come in.

对。

Yes.

没错。

Yeah.

你怎么打造一个完美的睡眠环境？

How do you build the perfect sleep environment?

给我布置一个卧室。

Build me a bedroom.

对。

Yeah.

你得让房间保持黑暗、凉爽和安静。

You want it to be dark, cool, and quiet.

这三点最重要。

Those are your big three.

所以别让多余的光线进来。

So you don't want extra light.

如果需要，就装遮光帘，或者戴眼罩。

If you need blackout shades, you need an eye mask.

我很喜欢用眼罩。

I'm a big fan of eye masks.

一个好的眼罩真的很棒。

I love a good eye mask.

你们网站上有眼罩卖吗？

Do you have an eye mask on your website?

有的。

I do.

我跟Kailu Silk合作推出了一款，特别喜欢。

I did this collaboration with Kailu Silk, and I love it.

我还加了小垫片和小枕头，这样戴假睫毛的人也不会受影响。

And I made little pads, little pillows so that if you wear eyelashes, it doesn't affect your eyelashes.

但你知道吗？眼睛周围那点轻微的压力其实能让人放松。

But, you know, that tiny little bit of pressure around the eye actually induces calming.

对有些人来说，这真的很有帮助。

So for some people, that can really be helpful.

对另一些人来说，可能就不适合他们。

For other people, maybe they don't, that's not for them.

但你得弄清楚什么对你最有效

But you have to figure out what's good for

凯瑟琳戴眼罩睡觉，我也是。

Katherine sees with an eye mask, my Yeah.

对，我不戴。

Yeah, I don't.

我带他坐过飞机，尤其是长途国际航班。

And I've taken him on a plane, like, you know, especially an overseas flight.

但我就是有点担心。

But I just worry.

你知道的。

You know?

我从来没试过不戴眼罩睡觉，也许是因为

I've never slept without and maybe because

我小时候经历过创伤，而且

I had trauma as a kid and and

被袭击过。

was assaulted.

但是是的。

But Yeah.

你知道的，我睡觉时总害怕有人碰我、伤害我。

You know, I sleep with fear that someone's gonna touch me and hurt me.

你懂的。

You know?

百分之百同意。

A 100%.

你知道的，你刚才提到

Well, you know, you just brought

失明真的让我非常害怕

up so being blind scares the hell

是这样吗？

out of me?

对。

Yep.

你提到了创伤问题。

You brought up trauma.

其实，更年期协会也讨论过这个话题。

And that was discussed actually at The Menopause Society.

但我们平时很少谈到，也很少在更年期的语境下主动提起它。

And it's something that we don't talk enough about or really bring it up in the menopause state.

不过，那些激素其实有一定的保护作用。

But those hormones are actually a little bit protective.

它们帮你撑过一整天。

You know, they're actually allowing us to power through the day.

一旦这种支撑开始减弱，你就失去了应对压力的缓冲能力。

And when that scaffolding starts to diminish, then you don't have the compensatory mechanisms to power through.

所以到了中年，女性经历更年期时，过去的创伤容易重新浮现，严重影响睡眠。

And so trauma tends to resurface in midlife when women are going through menopause, and it greatly affects their sleep.

真的吗。

Wow.

这确实是个大问题，我们平时讨论得太少了。

That's a big deal that we don't talk enough about.

我开玩笑说，也可能不是开玩笑，我随身都带着一盒纸巾，因为我见到的每一位女性都会突然忍不住哭出来。

Jokingly, or maybe not so jokingly, I carry around a box of tissues with me because literally every single woman that I see will just break down in tears.

我也是。

Oh, me too.

在更年期门诊里吗？

In menopause clinic?

一整天

All

都得这样。

day.

等我们把所有问题都彻底搞清楚之后。

Once we get down to the bottom of everything.

因为很多女性不会选择激素治疗，毕竟，我们在这方面还有很多工作要做，对吧？

Because a lot of women will not be on hormones because, again, we still have a lot of work to do, right?