Richard G. Petty, MD

Hot Flashes and High Blood Pressure

Many women experiencing hot flashes do feel as if their blood pressure is going up.

Well, there is some new research linking hot flashes and hypertension.

A hot flash (sometimes also referred to as a “hot flush” or, incorrectly a “night sweat”) is a symptom of changing hormone levels considered characteristic of menopause.

Hot flashes are typically experienced as a feeling of intense heat with sweating and rapid heartbeat,
and typically last from two to thirty minutes on each occasion. The event may be repeated a few times each week or up to a
dozen times a day, with the frequency reducing over time. Excessive
flushing can lead to the skin problem rosacea.

The study from Weill Cornell Medical College was published in the March/April issue of Menopause: The Journal of the North American Menopause Society.

The researchers used portable monitors to record the blood pressure of 154 New York City women, aged 18 to 65 (mean age of 46). The women had no previous cardiovascular disease and either mild hypertension or normal blood pressure. Fifty-one women reported experiencing hot flashes. These women were found to have an age-adjusted mean systolic awake blood pressure of 141 and a mean systolic sleep blood pressure of 129 — compared to 132 and 119, respectively, for women not reporting hot flashes. The results were highly significant. For people whose lives are not complete without a little “p,” the values were: p=0.004 and 0.007. The group differences for systolic blood pressure remained statistically significant after controlling for conventional hypertension risk factors, race/ethnicity, age and body mass index (BMI).

This is important research: High blood pressure is a major risk factor for heart disease, with the latter being responsible for half of all deaths among American women 50 and older.

We need to understand more about the mechanism linking blood pressure and hot flashes, but this research already suggests that women with flashes are at especially high risk. So if you know someone who ishaving them, make sure that they are having their blood pressure monitored on a regular basis.

Hormone Replacement Therapy, Breast Cancer and Causality

It seems a remarkable "coincidence" that they very day after writing about breast cancer screening, we should hear the news about a sudden fall in the rates of breast cancer amongst a certain proportion of the population.

Researchers from the M.D. Anderson Cancer center in Houston presented their data at a meeting of the San Antonio Breast Cancer Symposium. They recorded a 7% drop in new breast cancer cases in the US in 2003, ad an even bigger fall – 12% – in cases of hormone-dependent breast cancer among women aged 50-69. This is the first time that breast can cancer rates have fallen since 1945.

The decrease was most striking for women with so-called estrogen-positive tumors, which account for 70% of all breast cancers. It is the growth of these tumors that may be fueled by estrogen.

The scientists believe that the fall could be linked to the fact that millions of women gave up hormone replacement therapy (HRT) following reports questioning its safety. Around 14,000 fewer US women were diagnosed with breast cancer in 2003, compared with the previous year. The number of American women on HRT had halved by the end of 2002 in the wake of a large study was halted in 2002 after evidence emerged indicating that the therapy was associated with an increased risk of developing breast cancer.

The data are striking, but they need to be confirmed. That being said, there was a different type of study in last month’s issue of the Journal of Clinical Oncology. Researchers found an even larger drop in breast cancers in some parts of the State of California where there had been some of the highest rates of HRT use in the nation.

If the figures are correct – and they will have to confirmed – they could be explained by existing tumors stopping growing, shrinking or disappearing so that they could not be detected.

When I was a full time endocrinologist I saw a great many women who suffered terribly with menopausal symptoms, but I always declined to use HRT because of my take on the research data. I used dozens of alternatives, and if they failed, I had plenty of colleagues who were happy to use HRT, but I was always uneasy about using it.

There is also another important point: epidemiology can never prove causality. We have a plausible link, but no direct proof that a fall in the use of HRT is responsible for the fall in breast cancer.

Let me give you another example. Few people doubt the link between cigarette smoking and lung cancer, but no causality has ever been proven. Typhoid can cause a horrible illness, but all that the epidemiologist can do is to suggest an association between the bug and the pattern of an outbreak. It requires a microbiologist to prove that the bacterium Salmonella Typhi is the cause of the symptoms.

A number of years ago I became involved with the Oxford Causality project. It was fascinating, because not only did we call into question the issue of uni-causality in medicine – one cause for one illness – but some scientists and philosophers – such as Roy Bhaskar and Rom Harre even went so far as to suggest that “laws” of nature are better thought of as “habits” of nature. Clearly there are laws and there is causality. I throw a stone into a pond and there should be a plopping noise and then the ripples spread out. If there were no laws, then atoms could disintegrate. But at the deepest levels of nature, it no longer appears that we live in a clockwork universe in which free will is an illusion.

This is not just of theoretical importance, I recently received some interesting correspondence after I mad some comments about how self-cutting, if ignored, could lead to the development of borderline personality disorder. One correspondent thought that this implied causality, but I do not think so. “Disorders” are best viewed as deviations from a norm and they usually appear in bits and pieces. For example, some people with bipolar disorder may have had problems years before the illness had declared itself. The first signs were there, but they could have evolved along a dozen different pathways. Some people with borderline personality disorder have had varying degrees of distress since childhood, but back then it was impossible to say for sure what was wrong.

It is usually a mistake to try to find one cause for a problem. It is equally a mistake to try and diagnose a problem prematurely. We sometimes need to wait and see how things will evolve.

Conflicts of Interest

Last week I made some comments about the claims made in the new book by Suzanne Somers.

As expected, I had a good many people who said, “About time somebody said something,” and a few others who just felt that her publisher should have arranged for more fact checking.

To the people who agreed with me, thank you.

To those who did not, I respect your various positions, and I think that we have to look at this problem in a bit more detail.

By “this problem,” it is not simply about whether Suzanne needs to have some facts checked. I think that there is a very real problem with someone who has no medical training giving medical advice.

The more so if that person or persons is unable to undertake a critical review of published research.

This is much the same as the monstrous comments made by Tom Cruise earlier this year. He abused his position to make comments that made no sense. I saw several people who were weeping and distressed by what he had said. Many were saying things along the lines of “These medicines have saved my life, how can he say something so terrible?”

This is similar to the recent problem with Kevin Trudeau, who has made a great deal of money out of peddling highly questionable advice. He can do so in the United States because of the First Amendment. Nobody would want to change a constitutional right, but I get very worried about people saying anything that they want about health, and if anyone gets harmed, they say that it’s not their fault.

Some don’t even seem to have the wit to understand that their recommendations may cause harm. Harm that can come not just from commission – taking something harmful or being given a harmful treatment – but also of omission: not getting a treatment with proven efficacy. Trudeau claims that he is fighting on behalf of the American public. In which case, why has he not contributed the entire proceeds from the sales of his books to an independent central fund to educate the public about health?

I certainly do not think that people with an MD, DO or ND have all the answers: none of us does. But when we are talking about people’s health, I think that we all have to be extremely careful about dishing out advice.

I am also very aware that there are millions of people – mainly, but not exclusively women – who have severe problems with hormonal imbalances, and that they have not always been well-served by the medical professions. Giving unsubstantiated advice to people who are suffering is so unfair.

A number of people who are known for their work in hormone replacement have published an open letter that they have written to Suzanne Somers’ publisher, Crown House, expressing their dismay over some of the claims in her book. The signatories include Christiane Northrup and Diana Schwarzbein. Neither of whom would be called pillars of the establishment.

The Endocrine Society has just published a position paper about bioidentical hormones that I would urge you to read if you want further clarification about the whole issue of hormone replacement.

The front cover of the magazine Life Extension gleefully proclaims “Suzanne Somers Versus the Medical Establishment.” Life Extension is a fine looking glossy publication that looks like a peer reviewed Journal. It seems, though, to be a medium for disseminating information about supplements. Some of the articles are really quite good, but there is always the subtext that they are written in order to promote products.

The Journal uses a familiar tactic in some of these magazines that are selling products. This tactic is that they are letting you in on A Secret. A secret that is being kept from you by those terrible doctors or, shock horror, pharmaceutical companies that are trying to keep you sick. I’ve worked with countless pharmaceutical companies, and I’m well known for speaking my mind. But I have to tell you that in every company that I’ve worked with on five continents, the vast majority of the people involved have had a genuine concern for human welfare. Yes, they have a business to run, but pretty much all the people that I’ve known in the industry have been in that particular industry because it meshes with their own life goals of helping humanity. And as I pointed out a moment ago, the open letter to the publishers was not penned by pharmaceutical company lackeys.

Is Suzanne Somers making money out of her claims? Well, of course she is. She is using her celebrity and her extravagant claims to sell books. I’m quite sure that far fewer people would be interested in reading her material ff she just stuck to the facts.

That in itself presents some important ethical issues. Clearly, if she stuck to the data and gave a clear account of the pros and cons of what she is suggesting, she’s not likely to sell so many books.

As a spin off, she is also getting large numbers of people to visit her website, where they may buy products that may not contain bioidentical hormones, but ARE touted as being “anti-aging.” In other words the products on sale make some of the same claims that are associated with the hormones. This is a well-known marketing tactic. She claims to have one million people in her database, though we have not been able to confirm those numbers.

People all over the Internet are trying to find out if she is receiving any payments for endorsing products. I know that because several have contacted me. Of course she can do any kind of business deals that she wants, but there are ever-evolving rules about conflict of interest. Some new rules have just been proposed in the medical literature, and it would be excellent if the same standards were applied in all publications, whether print, online, in infomercials, interviews or any other kinds of medium of communication.

An important article on conflict of interest and full disclosure has just been published in the American Journal of Psychiatry.

Most major scientific journals now require that authors fully disclose ALL sources of funding. There are also strong, and I believe welcome moves to ensure that when patients receive medications, that they are fully informed if the prescriber has any relationships with drug companies. I have seen some people suggest that there should be a complete separation of pharmaceutical industry and the medical professions. A moment’s thought shows that would not be an answer to anything. If we can do this in conventional medicine, why not in every area of healthcare?

(As I’ve said before, my own list of disclosures is available to anyone who wants them, and they get updated every time that I do any work for which I get compensated. And not just me, any members of our staff. We are determined to remain squeaky clean.)

So what to do about the people who make wild claims about health, without disclosing their conflicts of interest?

Since we’ve just been through an election we’ve all seen how the squeaky wheel gets the grease!

People who say things loudly and repeatedly and appear to be saying something novel, do get attention. There’s no question about it, and there’s a good reason: Our brains are hard wired to notice and respond to loud noises and novelty. But when we are dealing with outrageous medical claims, the soft whispers of good data will ultimately drown the foghorns of dogma and opinion, however loudly they are blasted from the rooftops.

Some of the claim makers retire behind the fig leaf of saying, “Well there isn’t any data but if there were any, it would prove what I’m saying.”

Believe it or not, I’ve had that said to me on several occasions by several different people.

All of whom managed to keep a straight face…

Hormones, Pseudoscience and Self-Deception

A few months ago I saw a letter in Time magazine from the actress Suzanne Somers. She roundly and quite unfairly criticized Andrew Weil for not talking about hormone replacement therapy using what are known as “bio-identical hormones.”

I didn’t say anything at the time. Andrew Weil is well able to take care of himself and treated the letter quite correctly: by not responding. Suzanne did not reveal in the letter that she has a commercial interest in the bio-identical hormones. I assume that she did tell the editors of Time magazine, to have not done so would obviously have been unethical.

Her comments were a bit silly. But why respond to her now? After all the world’s full of silly things, and most of the time we can just move on. But now she’s promoting a new book and I am afraid misleading people. It may be that these bio-identical hormones are the answer to a maiden’s prayer and maybe they are not. My worry is that she does not discuss the pros and cons of using these products. Just lots of pros, implying that almost every woman of a certain age should be taking them. She claims that there is some research to back her up. In fact there are some very big holes in the research.

Now we see the recommendation to measure sex hormone binding globulin (SHBG), because “if that number’s not right, it doesn’t matter how high your testosterone is.”

I am an endocrinologist, but this advice is so mind bogglingly absurd that I still thought that I might perhaps have missed something. SHBG is not a single entity carrying sex hormones like some molecular equivalent of the number 9 bus.

It is a complex of proteins and glycoproteins that has many jobs, only one of which is the transport of some sex hormones to tissues that need them. Measuring the SHBG is complex: there are many genetic variations in SHBG and each has a different capacity for carrying estrogen and testosterone. You, your brother, sister, and spouse may all have different types of SHBG, with varying numbers of recognition sites geared toward testosterone or estrogen transport. Some vary if you have inflammation or liver trouble, and the amount of abdominal fat impacts SHBG but subcutaneous fat does not. You see that is it quite a complex topic!

It is simply absurd to make pronouncements based on “Levels” of this group of proteins and glycoproteins. There is no such thing as a “normal” level: when we measure hormones or their carriers, we use “reference ranges,” because the levels “refer” to numbers obtained from large panels of apparently healthy people.

I’ve carefully examined all the papers that she cites in support of her line of bio-identical hormones, and they certainly do not say the things claimed. This worries me: pulling bits of half-understood studies does not help us to advance health care or quality of life. Suzanne can tell us about as many cases as she likes, but she is using pseudoscience to buttress her position.

Yes, it is possible that she is correct, but why oh why isn’t there some proper research to say so?

Hormones, whether naturally occurring or bio-identical, are powerful chemical mediators. Used judiciously they have a role in the care and treatment of some women, whose lives would otherwise be miserable. But you also need to remember that some tumors may be promoted by bioactive hormones, whether they are synthesized or derived from plants or animals. And there are other potential health risks.

Caveat emptor!

Black Cohosh and Liver Damage

After discovering that some of the Black Cohosh sold in the United States contains precious little of the active ingredient, we now learn that that may not have been such a bad thing.

In 2004, a Conference sponsored by National Center for Complementary and Alternative Medicine and Office of Dietary Supplements, National Institutes of Health indicated that Black Cohosh appeared to be safe. However, earlier this year, the regulatory authorities in Australia issued a policy statement about adding warnings about liver toxicity to all herbal products containing Black Cohosh. The European and British regulatory authorities followed suit.

This highlights a problem with which we’ve struggled before: are the reports of hepatotoxicity due to a “bad batch?” Adulterated perhaps, or collected incorrectly? Yet that highlights both the strength of natural remedies and also their Achilles’ heel. We have so little information about the purity of individual products.

The standardization of herbal medicines is difficult, particularly since herbals usually contain complex mixtures of constituents, some of which are active, and some not. We often do not know exactly which component of an herbal medicine is responsible for clinical effects. There are often also differences in the composition of herbal preparations among manufacturers and lots. There are also enormous variations in the identification of plants by the manufacturers, how they are handled and the presence of other chemicals. Just think of the variations in the taste of different types of coffee, and you will see the point.

This variation has important consequences in clinical trials, many of which have failed to address the question of whether the herbs that they were using were of high quality.

The information on the label does not always reflect the actual content of the preparation and it is difficult to give one standard dose for an herbal medicine.

I thought that I should give you the wording from The European Medicines Agency (EMEA) and the Committee on Herbal Medicinal Products (HMPC)”

“Following review of all available data, the HMPC considered that there is a potential connection between herbal medicinal products containing Cimicifugae racemosae rhizoma (Black Cohosh, root) and hepatotoxicity.

The EMEA therefore wishes to give the following advice to patients and healthcare professionals:

Advice to patients:

— Patients should stop taking Cimicifugae racemosae rhizoma (Black Cohosh, root) and consult their doctor immediately if they develop signs and symptoms suggestive of liver injury (tiredness, loss of appetite, yellowing of the skin and eyes or severe upper stomach pain with nausea and vomiting or dark urine).

— Patients using herbal medicinal products should tell their doctor about it

— Advice to healthcare professionals:

— Health care professionals are encouraged to ask patients about use of products containing Cimicifugae racemosae rhizoma (Black Cohosh, root).

— Suspected hepatic reactions should be reported to the national adverse reaction reporting schemes."

What is Your Risk of Developing Breast Cancer?

When I was first practicing in the United States I was stunned when a research coordinator – who was with me as I examined a young woman – complained that it embarrassed her that I asked the patient about breast cancer screening. I had been trained and then practiced for many years in the United Kingdom, where it would have been deemed negligent if I had not asked the question. As I was taught a long time ago, “When you see a patient, man, woman or child, that may be their only contact with a doctor, so take the opportunity to do as much screening and education as you can.” I still take that to be good advice. We have good data that if women did regular breast self-examination and men checked their testicles, that we would each year catch many cancers at the stage when they are still easily treatable.

I was reminded about all this as I read the shocking results of a study that will be coming out in the European Cancer Journal this month.

In a survey of over 10,000 female students from 23 countries, hardly any knew about any of the major risk factors for developing breast cancer. We have obviously done a lousy job a teaching young people about a disease that may in large part be preventable.

This is desperately important. About 30% of illnesses you cannot help: they are the result of genetic mutations, accidents and so on. But 70% of all illnesses are thought to be the result of lifestyle choices.

Breast cancer is a good example. Yes, there are undoubtedly some cases that are largely genetic: genes have been identified in some families that strongly predispose women – and some men – to the disease. But they are uncommon: probably no more than 5-10% of cases. It is likely that the majority of people with the illness do have a genetic predisposition. But the impact of family history is usually small. And remember that biology is not destiny. Lifestyle modification may indeed significantly reduce your risk.

These are the Major Breast Cancer Risk Factors:
1.    Age
2.    Family history (slight risk)
3.    Starting periods at a younger age
4.    Late menopause
5.    Using hormone replacement therapy
6.    Using the contraceptive pill (small)
7.    Alcohol
8.    Obesity

Please do note that this is not the whole list of risk factors. Perhaps the most comprehensive list is here.

Cutting the Risk:
1.    Breastfeed
2.    Having several children, and having them young
3.    Stay in shape
4.    Eat and drink healthily
5.    Don’t smoke

The take home message for everyone is this: lifestyle can strongly influence the risk of developing breast cancer. You cannot change everything, but stopping smoking, cutting down on alcohol, reducing weight and taking regular exercise are in the reach of almost everyone.

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Black Cohosh for Menopausal Symptoms

Black Cohosh (Actaea racemosa or Cimicifuga racemosa) is a commonly used herb also known as baneberry, black snakeroot, bugbane, squawroot, rattle root. It is most often prescribed for the treatment of symptoms related to menopause. As with many herbs, the purity and constituents of most Black Cohosh products has generally not been well established.

There are three major active constituents of Black Cohosh:
Triterpene glycosides,
Phenolic constituents, and

The May 17 issue of the Journal of Agricultural & Food Chemistry reported that of 11 Black Cohosh products analyzed for these three constituents, 3 only contained an Asian adulterant (Asian Actaea) instead of Black Cohosh, and 1 contained both genuine Black Cohosh and Asian Actaea. For the products containing only Black Cohosh, there was significant product-to-product variability in levels of the selected triterpene glycosides and phenolic constituents and no formononetin was detected at all.

The way in which Black Cohosh is thought to work is by reducing the levels of luteinizing hormone (LH) and modulating estrogen. LH is a pituitary hormone that stimulates the ovary to produce estrogen and testosterone. As estrogen levels fall, the pituitary responds by increasing its production of LH. And the increasing levels of LH are implicated in the production of some menopausal symptoms. The Black Cohosh binds to the estrogen receptor, reducing the production of LH. Therefore by reducing LH, Black Cohosh reduces the production of estrogen that is responsible for some menopausal symptoms. It is useful to know this: three days ago I was asked to consult on the treatment of a woman who had her ovaries removed, was on hormone replacement therapy, but was taking Black Cohosh for menopausal symptoms. It had not helped her, which was not surprising: the evidence shows that you need at least one ovary for it to work.

I would also like to mention a program for professionals that I wrote late last year. It is available here. Although designed for health care professionals, it is one of the most comprehensive and up to date reviews on the uses, side effects and interactions of over twenty of the most commonly used herbal remedies. There is also a detailed discussion of how to work out if a remedy is likely to interact with prescription medicines and a comprehensive set of resources: scientific references, books and websites, together with advice on obtaining effective herbs.

Oh yes, and some really nice pictures of all the herbs that I discussed!

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Some Suggestions for Dealing with Insomnia

I have received an interesting question from a 50-year-old professional woman, who has had sleep problems that are especially severe during times of stress. As she says:
“I seem not to have the shut down switch in my brain.” She is worried about taking medications, and wonders if there is anything else that she can do to help herself.

It is always unwise to make specific recommendations about someone without seeing them face-to-face, and the evaluation of a problem like this will normally take several hours. But the points that she raises have a great deal of relevance for so many people that I thought that a few comments would be helpful and equip everyone reading this with some information to discuss with their healthcare providers.

As usual, I think that it is a good idea to look at the question from the multiple dimensions of physical, psychological, social, subtle and spiritual. They are all inter-related, so dividing them up is simply a convenient way to help us think through the problem.

Before we do anything, we have to try and find out why someone has problems with sleep, and that may need investigations up to and including a sleep study.

The first thing is that my correspondent is female and likely either menopausal or perimenopausal. That is important, because as most women know, hormones have potent effects on sleep. It is not just that uncomfortable hot flashes can wake a person; it is also a direct effect of estrogen and probably of some of the releasing hormones in the hypothalamus. Hormone replacement therapy alone, does help some women but by no means all. Even at the physical level we see the general principle that there is rarely one cause for one problem. Typical menopausal sleep disturbances include a difficulty in falling asleep, and around 20% of menopausal women report that they sleep less than six hours a night. There is also some degradation in what we call sleep efficacy and an increase in deep slow wave sleep. Estrogen has effects on nasal mucosa, and when estrogen levels fall obstructive sleep apnea is more likely to occur. A major physical and psychological issue is that insomnia may become a learned habit that can persist even in the face of the best treatments.

This leads me to the second dimension, and that is psychological. The writer of the letter mentioned that she couldn’t turn off her thoughts. You would be amazed at how frequently I have been asked to consult on someone with a sleep problem and the individual has never been asked the question, “What is it that stops you falling asleep?” I have seen countless people prescribed sleeping tablets, when the real problem was anxiety or some other nasty problem that needed to be tackled first. In a moment I am going to make some suggestions that will try and help with both sleep and the ruminations and anxieties that may be contributing to its disturbance. Similarly, I have known a great many people whose sleep problems were the result of relationship difficulties or of something as simple as one person being a night owl and the other an early morning riser.

I always start with some simple sleep hygiene:

    1. Stress management
    2. Exercise a couple of hours before retiring
    3. Keeping mentally stimulated until it is time for bed
    4. Don’t go to bed until you are tired
    5. No caffeine, alcohol or nicotine after 6pm. (Preferably, of course, no nicotine ever!!) {Remember that many over the counter painkillers contain caffeine, as does chocolate}
    6. There are some specific dietary recommendations for helping with sleep, and I shall write about those on a future occasion
    7. Try to keep the bedroom atmosphere relaxing, and establish a sleep ritual
    8. If you cannot sleep, get up and do something relaxing: struggling to go to sleep is virtually impossible.
    9. Always get up at the same time in the morning, to try and re-set your brain, and as soon as you get up, be exposed to as much bright light as possible.
Now let me give you a few tricks that work on the five dimensions.
  1. Start by lying on your left side for 5-10 minutes and then roll onto your right side. This appears to work by exploiting the so-called nasal cycle, which I shall write more about on a future occasion.
  2. Still on the subject of the nose, one of the reasons that aromatherapy can be helpful, is because smell is unique amongst our senses, in that it is the only one that is not filtered by the thalamus. The regions of the brain that respond to smells are also directly related to some of the memory centers. The result is that smells can evoke memories extremely rapidly. You will probably have had the experience of smelling a perfume or cologne and instantly remembering someone who wore it in the past. This close linkage of smell and memory has enormous survival advantages: the smell of a predator can cause us to respond extremely rapidly. We can also use this knowledge to our advantage. Lavender has been used as a sleep aid for centuries. You can try putting a few drops of lavender oil on a cloth on your night-stand. Or you can use an electric diffuser or aromatherapy lamp. When I was growing up, we grew lavender and would put sprigs of it in the bed linens. It certainly seemed to help.
  3. Some people have found that melatonin can be very helpful, and it is readily available. Discuss it with your health care provider.
  4. Here is an old trick from traditional Chinese medicine. If you cannot sleep, soak a washcloth in cold water, lie down and put it on your abdomen for about ten minutes. I was taught that this works by pulling excess energy out of your head and neck down into the abdomen. There’s not a shred of scientific evidence that the technique works, but it does surprisingly often.
  5. If people who are good at visualization, some have reported great success by creating a picture of a warm, calm and relaxing place. And not just a picture, but also a five senses experience. It has to be personal, and perhaps even a place to go back to on a regular basis. When I first learned to do hypnotherapy I was put into a light trance by one of my teachers. To this day, more than 25 years later I can still vividly recall the experience of being told that I was drowsing on a grassy knoll on a warm summer’s day on the Downs of Southern England, and actually feeling that I was there. I can still evoke the memory at will and I’ve made it more detailed over time. If you are a visualizer, try that.
  6. Another technique that I learned from an early teacher, is to review the day backwards. Remembering what you did immediately before going to bed, and before that and so on. A simpler and often effective technique is just to start slowly counting backwards from 100.
  7. Herbs: There are three that are widely used, and for which there is some research base. There is good evidence that the herb Valerian can induce drowsiness, and it is widely used – even by doctors – in France and Germany. An important point about valerian is that it is poorly absorbed and chemically and thermally unstable. So it needs to be kept cool, and used fairly soon after it is prepared. As with all herbs, Valerian has side effects and can interact with prescription medications and alcohol, so it really is essential to discuss its use with your health care provider. The same goes for the other two widely used herbs: Hops and Passionflower.
  8. There is some evidence, though it’s not that strong, that taking a combined calcium/magnesium supplement (500mg calcium and 250-500mg magnesium) an hour before bed helps some people.
  9. I recommend massaging your facial muscles before lying down to sleep. Not only does this reduce muscle tension, but also the face is covered in acupuncture points, and so that may be another reason why it can help.
  10. Do not read or watch television in bed, but listen to a little calming music before retiring.

I do hope that will help you in your discussions with your health care provider. And I am always interested in hearing other suggestions, particularly if there is some research to back them up.

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