January 2007: Sleep Well: Healthy Habits for Good Rest

Still can't sleep after diagnosis?

Question from Chris UK: Since breast cancer diagnosis in 2003, my sleep has been progressively more difficult. I have tried everything I can think of but am regularly awake still at 5 in the morning. I then sleep for 1-2 hours. Sleeping tablets offer respite from this but leave me feeling tight-headed. What can I do?

Answers —Helena Schotland, M.D.: I think the place to start is what we call sleep hygiene: basically, some common sense tips. Things like trying to avoid caffeine after noon. Another thing is, bed is for sleeping or sex. Period. It's not for reading a book, watching TV, paying the bills, or talking on the telephone.

Editor's Note: Sleep hygiene includes the following:

• Maintaining a regular sleep/wake schedule
• Maintaining a healthy diet
• Maintaining a regular exercise schedule
• Avoiding or minimizing the use of caffeine
• Avoiding alcohol
• Avoiding smoking
  

Helena Schotland, M.D.: When you go to bed, turn your clock toward the wall. You don't need to see what time it is. It doesn't help you fall asleep. A lot of people are clock watchers. They'll see it's 12:03, 12:07, and get very frustrated. The other thing to do is not to go to bed until you're actually sleepy. If it's 11:30 and you're completely awake and you know you're not going to fall asleep, there's no point in going to bed. So if you go to bed, try and relax. Think of pleasant imagery, like lying on a beach in Bermuda.

Marisa Weiss, M.D., president and founder: Alone or with someone else?

Helena Schotland, M.D.: Whatever floats your boat! If you're lying there and you can't fall asleep in, say, 20 minutes (you don't know exactly because the clock is facing the wall), don't stay there. Remember bed is for sleeping and sex, nothing else. So don't just lie there. Get up, go somewhere else. Go to a different room. Do something you find relaxing: read a book, watch TV. Don't do something stressful like getting on the Internet and typing, paying bills, rehashing things in your head. Do something you find pleasant, and then when you're drowsy, go back to bed.

Marisa Weiss, M.D., president and founder: I have a great job for that—matching socks!

Helena Schotland, M.D.: You don't want to do housework. You want to do something pleasant that's not related to work or housework. You want to do something for yourself a little bit. So matching socks, even though it's a dull task, is still a little too much related to what we need to do during the day. Then when you're drowsy, go back to bed. If it happens again, do it again. Sometimes when people have trouble falling asleep in their room, they try somewhere else, like a guest room or a sofa in the living room, because some people have associations with their own bed. "Here I am in my own bedroom, not falling asleep again." So sometimes when they just change their setting—go to a different room or a different bed—they do better. I have some insomnia patients who actually sleep better on vacation then they do at home.

Marisa Weiss, M.D., president and founder: Is there a danger in seeking another sleeping place on a regular basis, if this disrupts your intimate relationship with your partner?

Helena Schotland, M.D.: I think it's nice to do once in a while in a pinch. But obviously you want to try and establish good habits. Optimally, you want to sleep in your own bedroom all night with your bed partner. You want to go to bed and get up at around the same time every morning. One cup of coffee or one cup of caffeine in the morning is okay, but I try to limit it to just one. The big thing during the day is no naps. Naps are fine for people who don't have difficulty falling asleep and staying asleep. But if you are having difficulty, you want to avoid naps because your ultimate goal is to sleep in one big chunk at night; not to sleep a few hours in the day here, a few more hours there.

There's almost a sleep pressure that builds on us during the day that makes us want to go to sleep. And if you take a nap, you reduce that pressure. So you want to stay up for the entire day so you can take advantage of that natural drowsiness in the evening, so you can fall asleep and stay asleep. You want to avoid cigarettes, because nicotine is a stimulant. A stimulant is going to make you more alert, wake your brain up, and make it much harder to fall asleep. Some of my patients who are smokers and who may have insomnia wake up at 3 a.m. and have a cigarette, which is really the last thing they should be doing. Another thing to avoid in the evening is alcohol.

Marisa Weiss, M.D., president and founder: Are you suggesting we should drink in the morning? :-)

Helena Schotland, M.D.: No, one should not have an eye-opener. I think a glass of wine—one—at dinner is fine. But you don't want to use a nightcap. And you certainly don't want to use alcohol to excess. Alcohol is a central nervous system depressant, so it makes us kind of sleepy. Initially you fall asleep more easily with alcohol than without, but as the alcohol wears off, your brain starts to wake up, so that sedative effect goes away and your brain starts to become more active. You can have a lot of sleep disruption as a result. Of course, you can have a full bladder as a result of the alcohol, and oftentimes a headache or dry mouth, and that's not exactly going to keep you sleeping well either.

Possible to develop dependence on Ambien?

Question from Dale: Is Ambien too habit-forming to take nightly?

Answers —Helena Schotland, M.D.: That's actually a very good question. Ambien (chemical name: zolpidem tartrate) is a sedative-hypnotic medication, so it makes us fall asleep more easily, and hopefully stay asleep. The problem with all of the sedative-hypnotic medications is that you can develop dependence on them.

Editor's Note: Sedative-hypnotics are medications that cause drowsiness, triggers the onset of sleep, and/or helps you sleep through the night.

Marisa Weiss, M.D., president and founder: How long does it take to develop dependence?

Helena Schotland, M.D.: It really depends on the person. The general recommendations are that people should not be given more than 2 weeks of Ambien at a time, unless they're being followed by a sleep physician, because of the issues with dependence. Usually a few weeks continuously (once a night). The other issue with some of the sedative-hypnotics is the issue of tolerance: after a period of time, the medication can stop working (although this isn't the case for all of the sedative-hypnotics). So you basically never want to use a sedative-hypnotic all by itself.

There are a number of approaches to insomnia. Sleep hygiene is one, which we were just discussing. Medications play a role, but have to be used judiciously. The third is something called cognitive-behavioral therapy, which is typically done by a psychologist. These are relaxation techniques, techniques to help you figure out what is contributing to your insomnia, self-awareness. That is a very useful adjunct for insomnia therapy. So with my patients, I usually use anywhere from 1 to 3 of these approaches at one time.

Marisa Weiss, M.D., president and founder: Are these interventions covered by most insurance policies?

Helena Schotland, M.D.: It depends on the insurance. My patients have had a lot of success having the cognitive-behavioral therapy covered by their insurance.

Okay to take trazodone every night?

Question from HDGIRL51: I am a 2-year survivor of IDC. However, in November 2006 I had a bilateral mastectomy because I had developed malignant fibrous histiocytoma sarcoma in the same side that I had my lumpectomy on. I have had trouble sleeping since chemo. It takes forever to get to sleep; then when I do, I have to force myself out of bed in the mornings. I have been taking trazodone, but don't want to become dependent. Is it better that I take it every night so I can rest?

Answer —Helena Schotland, M.D.: This is someone who should use the sleep hygiene techniques. That's good for every single one of us, no matter why you're having insomnia. One of the other issues—what are you thinking about when you're trying to go to sleep? Is there a role for cognitive-behavioral therapy? In many patients there is. Trazodone (brand name: Desyrel) has been around for a long time and has been used successfully in the treatment of insomnia. For a patient who has been going through chemotherapy and having a lot of medical issues, it does make sense to use something, at least temporarily, to get a good night's sleep. However, at some point in time, you might want to have a night without the trazodone, just to see what happens. If there's a night when you feel drowsy and relaxed, just skip the trazodone that night and see what happens. You may be able to start using the trazodone on an as-needed basis once things get better in terms of your insomnia.

Switch from Arimidex to fix insomnia?

Question from Silvergirl: I have been switched from Arimidex to Femara due to side effects such as joint pain and insomnia. How long does it take to determine if the new medication is effective in reducing these side effects or if there is no difference?

Answers —Marisa Weiss, M.D., president and founder: The two medications you mention are very similar from a chemical point of view. But for each individual person you may be able to tolerate one better than the other. I would give the new medication about 2 months at least, before deciding its associated side effects are more acceptable to you. Helena, how much does anxiety about staying awake and being unable to go to sleep contribute to insomnia?

Helena Schotland, M.D.: Anxiety plays an enormous role, for exactly that reason. I see that in a good 40-50% of my insomnia patients. And once you start thinking in that manner, it becomes a self-fulfilling prophecy. So a lot of times I tell my patients not to put sleep on a pedestal, don't spend a lot of time chasing sleep. Sleep will happen. You're probably sleeping more than you actually think you are. For patients who have anxiety about their lack of sleep, that's where cognitive-behavioral therapy can be essential, along with sleep hygiene.

Marisa Weiss, M.D., president and founder: I often get anxious about possibly oversleeping, and I handle that by setting at least 2 alarms. Relieving myself of that anxiety has been very helpful to me.

Exercise, herbs to help sleep?

Question from Seg0354: I'm having trouble balancing pain medications, hot flashes, and stress and that's affecting my sleep. Is there some exercise routine or herbal aid that might help?

Answers —Helena Schotland, M.D.: Exercise is actually good for all of us. Period. But you don't want to exercise too close to bed time. Exercise tends to make people wake up, so you don't want to go to the gym at 9 at night. But exercise at some point during the day, preferably earlier, would be extremely beneficial.

Marisa Weiss, M.D., president and founder: What about vigorous sexual activity close to sleep? For some people it may make you relax and go to sleep, but for other people it may be a "wake me up."

Helena Schotland, M.D.: It really depends on the person. If you find it pleasurable and relaxing, something that makes you drowsy, then take advantage of it.

What's the right amount of sleep to get?

Question from CecilleS: Good day, thank you for giving me a chance to ask this question. Is 6 hours of sleep without a nap enough for a breast cancer patient?

Answers —Helena Schotland, M.D.: It's interesting, everyone asks me what is the right amount to sleep. The answer is really dependent on the person. A typical range is from usually 7 to 9 hours. Some people can get by on less sleep, and some people need 10 or even 12 hours of sleep every day to feel refreshed. The right amount of sleep is whatever you need to feel rested and on top of your game. I suspect 6 hours of sleep for you is probably not sufficient.

Marisa Weiss, M.D., president and founder: What happens if you get a good night sleep but you still "crash" after lunch each day? And your body is DEMANDING a time out? What do you do? And how do you manage that if you have a lot of work to do?

Helena Schotland, M.D.: That's actually a well-known phenomena, feeling sleepy after lunch. It's actually called the circadian dip. It's the time of day when we feel most drowsy. The only other time when we're more drowsy than this is when we fall asleep at night. I suspect the circadian dip is the reason that siestas came into existence. I think if you have the luxury or opportunity to take a nap at that time and you don't have difficulties with insomnia, take advantage of it.

Possible causes for waking frequently?

Question from CindyH: I am a 56-year-old post-menopausal woman who has a lot of problems sleeping. I take 1 Flexeril and 1 melatonin at bedtime. I take the Flexeril for a bladder condition. I do not have caffeine after 1 p.m. and try to do some exercise. Is there anything else? I am up at least 3 times per night. I forgot to mention my husband snores. Ha.

Answers —Helena Schotland, M.D.: You raise a lot of different issues. One thing that we could discuss first is the issue of melatonin. Melatonin is a hormone produced in our brain by the pineal gland and melatonin causes us to be sleepy. People have been taking samples of melatonin that you can buy at health food stores. However, melatonin from a health food store is not a drug regulated by the Food and Drug Administration (FDA), so we cannot assess its purity, effectiveness, or safety. So in general, I don't like to prescribe melatonin for my patients for those reasons. There is a new medication called Rozerem (chemical name: ramelteon), which is a melatonin agonist, so it works like melatonin and this one is a drug approved by the FDA.

One of the questions you may want to ask yourself is what's causing you to wake up at night. Is it some physical sensation, like having to go to the bathroom? It could be very possible that your bladder is causing you to wake up at night. Other patients with asthma wake up wheezing at night. Other patients with chronic pain may wake up with back or extremities pain. There are certainly common conditions that can result in people waking up multiple times at night. One of the most common is obstructive sleep apnea, which is a disorder characterized by periods where you stop breathing or have shallow breathing during sleep. It's interesting that you mention your husband who snores. Snoring is one of the red flags for sleep apnea. Exercise may help, but again I would recommend it earlier in the day. And it's just good for general health and wellbeing.

My favorite solution, at least temporarily, is silicone earplugs. These are little balls of silicone that you put over the opening of your ears. They don't go inside your ear; they're external. They're very comfortable. They reduce noise. You can get them at the pharmacy. I like Mack's brand. Position therapy: I always say there's nothing like the elbow of a good wife, so you want him to sleep on his side rather than on his back. And then obviously, you don't want to ignore snoring if it could be associated with sleep apnea, so you may want to take him in for an evaluation.

Marisa Weiss, M.D., president and founder: I had to kick my Labrador retriever out of the bedroom because of lip smacking and snoring.

Helena Schotland, M.D.: Sleep hygiene is basically common sense tips on getting a good night's sleep. It doesn't mean Lysol. It means lights off, not Lysol. Things like making sure to go to bed and wake up at a regular bedtime, and that bed is for sleeping and sex only. A more complete and examples of sleep hygiene will be posted in the transcript from an earlier answer.

Danger of regularly using sleeping pills?

Question from Carole: After 3 years of Arimidex and increasingly impaired sleep (sweating 10 times per night), I am now resorting to sleeping pills and am concerned about doing so. I exercise (walk 30 km a week), eat exceptionally well, do not smoke, drink moderately, have 1 coffee a day and mainly drink herbal teas. What else can I do? I have reached a point of considerable distress.

Answers —Helena Schotland, M.D.: It's basically a lot of things we've already discussed.

Marisa Weiss, M.D., president and founder: What's the danger of using sleeping pills regularly and depending on them if you get the benefit of a good night's sleep every night?

Helena Schotland, M.D.: There is a trade-off of dependence versus a good night's sleep, and it's different for every person. For some people, the benefits greatly outweigh the risks. And in going through cancer therapy, it is imperative to get a good night's sleep.

Marisa Weiss, M.D., president and founder: As you move through life, does the average person's sleep requirement increase or decrease?

Helena Schotland, M.D.: That's an interesting question. There have been a lot of studies on sleep all the way from infancy to old age. As we age, the total amount of sleep may stay the same; however, people's sleep becomes more disrupted. They may sleep the same amount, just over smaller chunks during the day. Some elderly people may go to sleep very early in the evening, wake up early in the morning and nap during the day, so your sleep can become less consolidated. There are a lot of medical issues that contribute to sleep consolidation (being able to sleep in 1 large chunk at night).

Depression and other side effects of insomnia?

Question from Kathleen: I've been taking zopiclone 7.5 mg for 3 years since cancer. I get depressed when I try to stop. I'm 71. Is there any great harm in staying on it forever? If so, what is the method to get off?

Answer —Helena Schotland, M.D.: It really depends on the underlying insomnia, whether it has been fully evaluated. There are some people who require long-term therapy, but most people do not. Insomnia is often transient, and may ebb and flow over time. I like to give patients an opportunity periodically to see if there's a night they can do without the sleeping medication, with the goal of transitioning them to using sleeping medications only as needed, rather than nightly. And in fact, I've had some patients where I prescribed sleeping medications for their insomnia. When they come back to see me, their insomnia is cured and they never took the sleeping medication. But knowing that they had it in their medicine cabinet was enough to make them relax and sleep on their own. Depression and anxiety can play a large role in insomnia, and cognitive-behavioral therapy can be useful in those situations. Patients may also need to have their depression or insomnia addressed directly by a psychiatrist, as insomnia may be a symptom but not necessarily the underlying issue.

How to find a sleep psychologist?

Question from CJ-3: How do I go about finding a sleep psychologist?

Answers —Helena Schotland, M.D.: The first thing I would do is look for a sleep center, accredited by the American Academy of Sleep Medicine. The American Academy of Sleep Medicine has a website, which is www.aasmnet.org. Another place to look is the National Sleep Foundation. They should have links to accredited sites.

Marisa Weiss, M.D., president and founder: Are there sleep support groups?

Helena Schotland, M.D.: There are many sleep support groups around the country. Some meet at hospitals, some meet more in community centers, and some of them meet in actual sleep centers. You can find out about them probably in the same places.

Self-help books for sleep problems?

Question from Ina: Can you recommend a self-help book about sleep problems?

Answer —Helena Schotland, M.D.: I haven't read the self-help books myself, so there isn't one that I would be able to recommend.

Sleep-onset insomnia vs. sleep-maintenance?

Question from SMT: Hi, I'm a 2-year IDC survivor, 49 years old. I had radiation but no chemo. I'm on tamoxifen and also taking Effexor for hot flashes and night sweats. The night sweats are now almost non-existent but the hot flashes still occur 4 to 10 times daily. The real problem is that I seem to be getting less and less sleep—sometimes my husband says I toss and turn all night. Other times I spend 1 to 2 hours trying to fall asleep at bedtime.

Answer —Helena Schotland, M.D.: Insomnia comes in a couple of different flavors. One is sleep-onset insomnia, where you may have difficulty initially falling asleep. The other is sleep-maintenance insomnia, where you may have difficulty staying asleep. Techniques for sleep-onset insomnia we've discussed. Sleep-maintenance insomnia needs to be evaluated a little bit more closely from a medical standpoint, to see if there are underlying medical issues causing you to wake up. In some patients, this may require a sleep study to further evaluate the sleep disruption.

Later bedtime better for sleeping?

Question from KTucker: When I go to sleep at 11:00 p.m. or earlier, I sleep for an hour or so, then wake up and can't go back to sleep. If I go to sleep at 1 a.m. or later, I usually sleep better. How can I remedy this?

Answers —Helena Schotland, M.D.: Many people wake up in the middle of the night and fall back asleep fairly easily. If that's the case, I wouldn't be too worried about the situation. Some folks have a much harder time going back to sleep, which can obviously impact them in a negative way. Some people just have a naturally later bedtime than others. And if you find that you're able to fall asleep and stay asleep without any issues when your bedtime is somewhat later, I would just gravitate toward that natural bedtime. As long as you're getting a sufficient duration of total sleep, and you feel refreshed the next day.

Marisa Weiss, M.D., president and founder: What about variable bedtimes throughout the week, for people who have to work at night or travel at night to get to their jobs?

Helena Schotland, M.D.: It's really best if you can stick to a schedule as much as humanly possible. Little kids like schedules, and so do big kids. I find that people who tend to work late at night have a hard time shutting it all off and immediately going to sleep. I used to work evening shifts in an emergency room and got home at 12:30 in the morning. I found it very difficult to immediately go to sleep. So it's best not to work in an evening shift in an emergency room if one can. It's best to give one downtime before you go to sleep. Little kids need a bath or a book before they go to bed, and adults need some downtime as well. It's very hard to shut everything off and expect yourself to go to sleep as if you were a machine.

Stress about illness affecting sleep?

Question from Michelle: If it's hard to sleep because of anxiety due to the illness, would you recommend doing physical activity a few hours before going to bed? What can you do to take your mind off stressing about the illness while in bed trying to sleep?

Answers —Helena Schotland, M.D.: Exercise is great, if you make it earlier in the day. The sleep hygiene and cognitive-behavioral therapy can play a large role here. Sometimes, I even tell patients to set aside a worry time earlier in the evening, where they think about their illness, do their research. But when it's time to go to bed, I like them to go to bed with a blank slate in their head, and preferably substitute some pleasant imagery instead. Some people are anxious about what they have to do the next day, so I tell them during their worry time to make lists of what they need to do. Again, when you go to sleep you can think about (my favorite image) lying on a beach in the Caribbean somewhere, or whatever favorite image you want to think about.

Marisa Weiss, M.D., president and founder: What's the latest you would schedule your worry time?

Helena Schotland, M.D.: I would say at least 2 to 3 hours prior to bedtime.

Marisa Weiss, M.D., president and founder: It must be important to have your place of worry far away from your bedroom?

Helena Schotland, M.D.: Exactly!

Fear causing interrupted sleep?

Question from AMS: Since my diagnosis and subsequent surgery, I can fall asleep easily, but during the night I wake up at least once an hour. I have learned meditation techniques, and can usually get back to sleep within a few minutes, but the fact that my sleep is so very interrupted means that I never feel rested. The thing that is waking me up is sheer unadulterated fear. I am not bothered by the fear during the day and can pray it away during the day.

Answers —Helena Schotland, M.D.: Some people have anxiety that manifests itself primarily at night. They may not feel particularly anxious during the day, but they can have night terrors, nightmares, and anxiety that causes them to wake up that sometimes can prevent them from falling back to sleep. The anxiety should be addressed primarily. The insomnia is a result of the anxiety.

Marisa Weiss, M.D., president and founder: At night time, you are without all the distractions during the day, and the feeling can be like an IMAX theatre playing all of the scary parts. For some people who get in a bad habit of worrying at night in their bedroom, the bedroom becomes a toxic place, heavily associated with this type of negative pattern. Sometimes it's worth trying to break the cycle by moving into another bedroom with your partner (it's not worth disrupting your closest relationship during an extended period of time by moving by yourself. Invite your partner to come with you.) Then, after a few months, you might be ready to move back into your bedroom. It's probably worth rearranging furniture, treating yourself to a fresh coat of paint on the walls, and doing a little decoration, so that your bedroom once again feels like a safe place to have some great sleep. Moving forward, how do you set rules about going to sleep or having sex at the end of the night? Setting limits, as well as creating opportunities in a way that allows you to get both done?

Helena Schotland, M.D.: Basically, it's really making time for yourself and making time for your partner. We spend our days rushing around, doing a lot of different things. When we're going through treatment for breast cancer, our days are even more complicated than they normally would be. So you want to give yourself a break. You want to give yourself the luxury of time. Do something for yourself, do something good for your partner. And again, what you really want to do is take the pressure off yourself.

Marisa Weiss, M.D., president and founder: What about kids in the bed?

Helena Schotland, M.D.: I am not at all for the family bed. It can provide a huge disruption to the parents, and kids don't learn to sleep on their own if they're sleeping with Mom and Dad every night. If a little one has a nightmare or is sick in the middle of the night, there are certainly exceptions. But those should be fairly rare.

Foods to avoid to help stay asleep?

Question from Xoot: For me, STAYING asleep is more difficult that GETTING to sleep. Are there foods that should be avoided in the evening to prevent nighttime awakenings? (I know alcohol interferes with sleep, but I am wondering specifically about food.)

Answers —Helena Schotland, M.D.: There are some folks who have reflux disease, and certain foods can trigger it. You also want to avoid foods that contain caffeine, such as chocolate, and citrus things that induce GERD (Gastroesophageal Reflux Disease).

Marisa Weiss, M.D., president and founder: Sometimes there are foods that contain caffeine, like coffee ice cream or chocolate cake, and foods that have a high alcohol content, like rum cake.

What to do for hot flashes?

Question from Farida: I am a breast cancer stage III patient on Herceptin therapy after mastectomy and chemotherapy. I wake up many times at night. During the night I am struggling with my body temperature. I feel cold and warm intermittently. When I use a blanket because I am cold, the next moment I am warm. This is going on all night and keeps me awake. What can I do for it?

Answers —Helena Schotland, M.D.: I think it's better to wear some light pajamas or a nightgown, something that can breathe, such as cotton. You don't want to smother yourself when you have a hot flash in the middle of the night; you want to be able to throw off the covers quickly. So I would probably use the lightest bed clothing I could get away with, rather than having a heavy down comforter wrapped in a heavy duvet (which is what I had when I had my hot flash last night!). Different layers of covers and clothing, and a change of clothing next to your bed.

Marisa Weiss, M.D., president and founder: There are medications that can help minimize the symptom or make it more tolerable, such as Effexor (chemical name: venlafaxine) or Paxil (chemical name: paroxetine), etc. These need to be prescribed by your doctor. There's good information at the website. See our section on hot flashes at Breastcancer.org for more information.

How long will fatigue last after treatment?

Question from Tina: Should a breast cancer patient treated with only a bilateral mastectomy feel tired 2 years after her surgeries, and if so, how long will this continue?

Answer —Marisa Weiss, M.D., president and founder: Fatigue is a very common side effect of any form of breast cancer treatment. The duration and the severity of the fatigue depends a lot on the various treatments you've received as well as your general medical condition, your emotional state, and plenty of other factors which we've touched on this evening. As we grow older, we tend to exercise less and gradually gain weight, and eat comfort food, all of which can drain some of our energy away. Alcohol may have a greater effect on you than it did before, as well as other chemicals and medicines. It may be time to pull into the "shop" and get checked out by your doctor and tune up a bunch of things that may lead to higher energy and greater strength of well-being. We have a whole section at Breastcancer.org on managing fatigue.

Over-the-counter sleep remedies?

Question from Julia: What about Benadryl for sleeping?

Answers —Helena Schotland, M.D.: I'm constantly taking my patients off of Benadryl (chemical name: diphenhydramine). The reason Benadryl is used for sleep is because it causes sleepiness, which is one of its biggest side effects. Benadryl can stay in your bloodstream many hours, thus you can awaken feeling very groggy. Benadryl can also interfere with sleep architecture, or the various stages of sleep we go through at night. People often have decreased REM (rapid eye movement) sleep with Benadryl and feel less rested as a result. Some have reported that Benadryl can lose its effectiveness fairly quickly after repeated use.

Marisa Weiss, M.D., president and founder: Is there any effective sleep remedy that is over-the-counter?

Helena Schotland, M.D.: None that I know of. So if someone needs a sleep medication, they should see a sleep physician.

Marisa Weiss, M.D., president and founder: Do you have a favorite sleep medication to start with?

Helena Schotland, M.D.: Sometimes, after doing all the sleep hygiene techniques first, I sometimes start with Rozerem, which is a melatonin agonist. The beauty of Rozerem is that it does not have any issues of dependence or tolerance (where the medication stops working over time). If that is effective, then you may not need to take further steps into a true sedative-hypnotic medication such as Ambien, Lunesta (chemical name: eszopiclone), and Sonata (chemical name: zaleplon).

Marisa Weiss, M.D., president and founder: It's not a good idea to take someone else's sleeping pills. One size does not fit all.

Helena Schotland, M.D.: Alcohol is a central nervous system depressant, as are the sedative-hypnotic medications. These are not two things that you should ever mix. Once you've taken a sedative-hypnotic medication, make sure you're ready to devote yourself to a full night's sleep. By no means should you be operating heavy machinery, such as a car, after having taken any sedative-hypnotics. You also may want to limit your activities the following morning after the first dose of a sedative-hypnotic until you see how the medication can affect you. Some people report drowsiness upon awakening in the morning. So it is important to know how you are going to react.

Marisa Weiss, M.D., president and founder: In terms of sleeping habits, if you have to wake up early during the week, is it okay to sleep late on the weekends? Or will that varied sleep schedule during the week cause a problem overall?

Helena Schotland, M.D.: If you don't have insomnia you can vary your sleep schedule without too much problem. If you have the opportunity to sleep in, by all means—enjoy! However, if insomnia is an issue for you, you may not want to deviate more than an hour each way in terms of your bedtime and your rise time.

Marisa Weiss, M.D., president and founder: Are there certain hypnotic noises, like the waves on a beach, or soft blowing winds, or a soft train sound that help some patients go to and stay asleep?

Helena Schotland, M.D.: Some people do fall asleep to a timer and have a noise-producing machine, but I don't like people to have those run for the entire night's duration. I prefer that they are set on a timer. It's amazing to me in my practice how many of my patients use the white noise of the TV to fall asleep. That's actually a bad thing, and if people are really dependent on the TV, I have them put it on a timer. One of the nice things about using silicone ear plugs is that you can hear your heartbeat and your breathing very easily. That's an internal stimulus that can be very relaxing to some people.

Sleeping pills affect liver, other organs?

Question from JoAnn: Do prescription sleeping pills do any bad harm to the liver or other organs?

Answer —Marisa Weiss, M.D., president and founder: This is an important question to ask your own doctor, because side effects for medications depend very much on your own medical situation, as well as interactions with other medicines you may be taking.

Tamoxifen causing hot flashes, affecting sleep?

Question from Carrie: Since I have started tamoxifen, the multiple hot flashes do not allow quality sleep. It does not matter what time of day the medication is taken, the hot flashes continue. What suggestion do you have to obtain quality sleep needed for physical and emotional homeostasis?

Answers —Helena Schotland, M.D.: I think you should go to the hot flash section at Breastcancer.org because the insomnia is a result of the hot flashes.

Marisa Weiss, M.D., president and founder: Managing hot flashes while on anti-estrogen therapy is a real challenge for everyone. There are solutions, which are suggested in the hot flash section. All of them require a lot of trial and error, and a great deal of patience (not my strength!). If you cannot manage to get more comfortable with the hot flashes on tamoxifen, your doctor may try another form of effective anti-estrogen therapy that you may handle with more comfort.

Adjusting sleep patterns when traveling?

Question from Irma: Can you suggest ways to adjust sleep patterns when traveling and experiencing time changes of 5 or more hours?

Answers —Helena Schotland, M.D.: Jet lag is a well-known hassle. The best thing to do is to use social cues to acclimate to the new time, such as meals. Whenever it's time to go to bed in England, that's when you should be going to bed. You want to avoid naps if you can and just try to adapt to the time zone as quickly as possible. It doesn't help to think, "What time is it back in Philadelphia?"

Marisa Weiss, M.D., president and founder: Why bother trying to adapt to a new schedule if you're going back right away?

Helena Schotland, M.D.: Some people don't. It really depends on the length of the trip.

Suggestions for restless leg syndrome?

Question from MBJ: I get restless leg syndrome that keeps me awake. Any suggestions to help with this?

Answers —Helena Schotland, M.D.: Restless leg syndrome is an uncomfortable sensation in your legs that feels better when you move them. Restless legs can be associated with periodic limb movements of sleep, which are basically limb movements that cause someone to wake up from sleep. Restless leg syndrome occurs during the day while someone is awake. Both restless legs and/or periodic limb movements of sleep can be treated with a variety of medications. It is also important to assess whether that individual has any elements of iron-deficiency anemia, which can be associated with these disorders.

Marisa Weiss, M.D., president and founder: During this evening's program we mentioned a number of medications that you may consider with your doctor. All medicines need to be reevaluated over time, as they have benefits and side effects that can affect each person uniquely. Some of these medications may only be needed for a short period of time, and other medicines may be required over the long haul. Be sure to only take medications with your own doctor's supervision. It's really not in your best interest to borrow medications from somebody else when it comes to any issue, including sleep. Going through breast cancer disrupts so many of the rhythms and rituals in your life, and change alone can take away the quality of your sleep. Whatever you can do to reestablish a routine in your life and find regular ways to relax, enjoy yourself, and find meaning will all help to recapture a healthy sleeping pattern. Good night, and get to sleep!