Exploring the unseen impact breathing has on midlife health with Dr. Louise Oliver

Healthy breathing is one of the lifestyle factors women need to live a healthy life. Problem is, it’s not mainstream yet.

Welcome to my Midlife Strong interview series where I delve into the minds of experts making strides in midlife women's health. I'm shedding light on crucial information that goes unnoticed. And that’s certainly true for our expert and topic today.

Dr. Louise Oliver has worked as a general practitioner (GP) in the NHS since 2003. Throughout that time, she has developed an interest in women's health, including providing coil and contraceptive implant procedures. With over 20 years of experience working in the NHS, she has developed skills to assist people throughout their lives. As a Functional Breathing Practitioner and Therapeutic Life Coach, she helps people, especially midlife women, learn to breathe efficiently to maximize their health and well-being. She is a recovering midlife snorer who discovered the power of retraining her own breathing.

I’m working to keep these interviews at 30 minutes. So take some time to watch and listen or read the transcripts below. And sorry for the bad lighting on my part, I’ll get better.

Links from the interview:

Louise Oliver’s website

How to assess if your breathing efficiently (Youtube)

Louise Oliver’s Instagram

Oxygen Advantage (Patrick McKeown) Youtube

Resperate blood pressure lowering

The following transcript was edited for clarity. This information is not intended to replace medical advice but to educate you about breathing’s effect on health.

Transcripts of interview with Louise Oliver

Maryann: Welcome Louise. I'm just really excited to have you here because you're one of the few people I know that really focuses on breathing for midlife women. I’ve taken a big interest in breathing and I'm going to really point it out in my book and I talk about it on my Substack. So maybe we could just get started by you telling my readers how you got into this because you're a doctor too, right.

Louise: I'm a GP in England and I've been a GP over 20 years now and developed a bit of an interest in women's health. Right from the beginning of my career and sort of I've sort of looked after women all the way through contraception and then HRT. In more recent years I became a perimenopausal snorer and really struggled to function because my sleep was affected. And then I started to look into what I could do to improve that and then I essentially now am a functional breathing practitioner. So I still work as a GP but as a functional breathing practitioner helping people breathe efficiently to try and set their basic foundation of life so that then they hopefully can sleep better and exercise with greater ease and feel calmer.

Maryann: So you work with midlife women or mostly midlife women?

Louise: I mean anyone can see me but my main cohort is is women around the perimenopause and menopause.

Maryann: So you you weren't a snorer before, right? Did you all of sudden start snoring or did someone tell you that?

Louise: Correct, and it was my husband who told me.

Maryann: I see these articles about how couples are sleeping separately. But I think it's important to sleep together so you can give each other feedback.

We know sleep disordered breathing increases around midlife around perimenopause and menopause. Can you explain why that is?

Louise: One thing I should highlight is at any age, there's always more men than women have sleep disordered breathing. When women transition from perimenopause to menopause, there's a steep rise in sleep disorder breathing. By that I mean there is a spectrum. It can be anywhere through just increased resistance to the air coming in and out, to heavy snoring, to where you and block off your airway sort of obstructive sleep apnea so it is a spectrum but there's a steep rise as women transition through menopause.

And when the scientists remove confounding factors such as weight there is still this steep rise. So it clearly has to do with the change in hormones. It's still not completely clear why. It's thought that the female hormones have a protective effect on the upper airway. And when we're transitioning through to postmenopause it means we're more likely to have a partially blocked airway which causes vibrations (snoring) or collapsed airway which could lead to sleep apnea.

Also women are set up to breathe differently than men. So even generally our lungs are smaller and our diaphragms shorter. And even the way our ribs are hung onto our spine is different compared to men. So It predisposes us to be more upper chest breathers rather than a diaphragmatic breather. It means men are more likely to breathe with their diaphragms compared to women. There's lots of different factors in there and and I do think, and this is my personal opinion, women are taught to hold our stomachs to look flat but you potentially then make you more likely to upper chest breathe which sort of sets you up to breathe differently.

Maryann: Okay, so we know hormonal changes play a role in the increased risk of sleep disordered breathing but most people don't realize we have airway muscles including the throat and tongue.

In addition to hormones, these muscles also weaken with aging, right?

Louise: Yes, we know if we're not actively exercising muscles then those muscles will get weaker and that includes the tongue and the throat and all those muscles are important to keeping the airways open. Obviously there’s collagen around the voice box, we’re going to lose some with age. There was a study that looked at breathing in women and as they transitioned through to post-menopause, it was more difficult for them to breathe in. Exactly like you're saying is that because we are not training our breathing in muscles they become weaker. If we exercise with nasal breathing, we will be strengthening up those inhale muscles, those Inspiratory muscles. But if we don't know the importance of nasal breathing with say exercise and we don't know that, potentially those muscles get weaker and it gets more difficult than to breathe with ease.

Maryann: Yeah, so you mentioned nasal breathing and I think a lot of people have heard about taping your mouth during sleep. I know one study showed that after 40 people are 5 times more likely to breathe out of your mouth at night and usually it's a combination right? It's not like people just breathe out of their mouthes. So what role does that play in the risk of sleep disordered breathing at midlife?

Louise: Oh definitely. I mean the the only role the mouth has in breathing is to make it inefficient so you know if you look at a newborn baby, he or she is designed to breathe in and out of the nose. Just for various reasons like living in a modern day society and I personally suspect wearing masks during covid converted some of us to to mouth breathing and if if you're carrying excess weight sometimes that that can predispose to breathing out the mouth. But as soon as we are mouth breathing, we're set up differently than we've been designed so we'll use the wrong muscles. We don't get as good oxygen delivery we're drying out our airways. But we're more likely to get nasal congestion because we're not using the nose and the cold air from mouth breathing irritates the the airway. So there's all these factors that just essentially shows we are more inefficient at breathing when we're mouth breathing. When you’re mouth breathing, you’re over breathing. There was a study in a small group of people that showed that as soon as you switched to mouth breathing you were breathing an extra eight hundred milliliters of air a minute.

But from a sleep point of view, as soon as you open your mouth, your tongue's in the wrong position and it's narrowing the airway. So you're automatically making it difficult to breathe. So perhaps tonight when you're in bed and open your mouth and notice how the tongue comes away from the roof of the mouth and it's too far back and if you breathe in you'll hear a sort of obstruction or feel an obstruction. But if you close the mouth but keep the tongue in the wrong position it’s a bit less noisy but you still feel it. If you then put the tongue in the correct position which is up on the roof of the mouth and the tip of the tongue is just above the back of the front teeth, and your lips are sealed but not clenched, it's a little bit freer at the back.

Well, it's important to train yourself during the day to have a correct tongue position, so it remembers that at night. So the mouth is closed and the tongue is in the correct position. The muscles around the area being strong is absolutely crucial but that's that's one part of it. That's the sort of anatomy, the structure part of it but then the other part of it is how much air someone's breathing in and out of that airway. If you someone is breathing more air in and out, it's more likely to vibrate you know which would be snoring.

So you've got to look at how someone's breathing in the day and if they're overbreathing in the day, if they’re mouth breathing in the day, or even talking you know people who talk a lot for a living breathe in a volume in excess of what they need to and then that translates into how they breathe whilst asleep at night. So all aspects are important but definitely mouth breathing but by definition the tongue's in the wrong position and you now are in the airway.

Maryann: I'm amazed that sleep is such a big topic in midlife because a lot of women have trouble sleeping. But we talk very little about how we're breathing at night.

If someone is having trouble sleeping, what are the signs that it could be their breathing? It could be the increase sympathetic tone, right? Where heart rate goes up and they're just going to be less likely to be able to get a good night's sleep right.

Louise: Oh definitely. So obviously if you have a sleeping partner you could ask them how’s your breathing at night and if you're snoring very loudly or have gaps in breathing. Well, obviously there's an issue there. You could use a sleep app that records your breathing and listen to it. If you’re waking up with a very dry mouth that would that would be a sign. If you're waking up with nasal congestion or headache and you feel unrefreshed that’s a symptom. Another symptom is getting up frequently to pass urine at night and feeling tired during the day and nightmares. There can be other reasons for bad dreams but but nightmares sometimes can be related to sleep disorder breathing.

Maryann: Do do recommend getting tested for sleep apnea? I know a lot of people think oh if I don't have sleep apnea it's not a problem but I think as you said it's a continuum and even if you're just snoring it’s having effects. Let's say you don't have sleep apnea which is where the airway either closes or you have gaps in breathing 5 or more times an hour. Yet you can still constrict your breathing but also it's a risk factor eventually, you may develop sleep apnea is that right?

Louise: I know I've worked with individuals who've seen significant improvements with with sleep working on day breathing. A group of experts who actually prescribed cpap had quite clear messages that nasal Cpap works more efficiently and is more likely to be used long term by people. Obviously if you're a mouth breather, you have to have the full face mask. Which according to them and certainly my experience of working with others is less effective and not as well tolerated long term. So I would say it makes sense first to try and reestablish nasal breathing during the day. So someone can improve the efficiency of day breathing maybe for three months because three months is what it takes to make an unconscious habit.

I would say if someone's willing to put the effort, work on your breathing to improve the breathing efficiency for three months and then at that point if you still think you've got sleep apnea speak to your health professional to see whether you need a study. Even if you’re diagnosed at that point with sleep apnea, I don't think you've lost anything because hopefully if you've re-established nasal breathing and you'd be able to have the the nasal cpap.

I've certainly worked with individuals that have not had a sleep study before my work and after their breathing is at a state where they don't feel they need the the tests anymore. But obviously there are some that feel like they do need it. But at least then you're in a better position because your basic foundation is efficient and then you can have the the sleep test on top of that.

Maryann: Yeah, and isn’t any midlife women going to benefit from becoming more efficient at breathing?

So when you say “breathing efficiently,” what does that look like during the daytime when we're conscious?

Louise: I have a theory and this is based on my my own clinical experience of working with people rather than looking at papers. But I will put a caveat in that I see people who obviously don't feel well and they've already recognized there's a problem with their breathing. I think there's something about the hormonal effects that women become more intolerant to the buildup of carbon dioxide. What I mean by that is we breathe in oxygen and we blow out carbon dioxide and so carbon dioxide is a waste gas but it has a role in helping release oxygen from the blood cells. When we exercise or go upstairs or whatever and carbon dioxide goes up, it gives us that feeling of air hunger or suffocation. And then obviously when we feel like that we don't like it and then we often end up mouth breathing. But the trouble is if you become less and less tolerant to carbon dioxide there's less and less activity.

But you can train your body to be more tolerant to carbon dioxide and as a result of that you would then actually get improved oxygen delivery around the body which then makes it easier to exercise. But the wonderful thing with sleep is when you're more tolerant to carbon dioxide your breathing becomes slower and gentler. From a sleep point of view that is exactly what you want when you're asleep. You want your breathing to be as slow and gentle and soft as you can because you're less likely to obstruct or rattle the airway. But also it makes the body feel safe, putting it in that parasympathetic response. So your body can then do all the repair processes it needs to do at night. So, to answer your question. Well, how do I know how how efficiently I'm breathing? Well it's a bit complicated because we don't really have a gold standard of assessing that.

I have a video on my Youtube on how to assess if you're breathing efficiently where I go in a bit more detail. But just observe your breathing over the next week and just really be honest with yourself about how much mouth breathing you're doing because generally people are mouth breathing a lot more than they realize. If you wake up with a dry mouth that would suggest your mouth breathing at night. Are you mouth breathing when you're just walking to the car or going up the stairs? That's the first one and there's also you you can do an assessment with a breath hold and asking a few questions. But again, that's on the video. If you sigh in a lot or if you're yawning a lot those are also signs. And if you're feeling significant air hunger that feeling of suffocation with very minimum activity.

Do you recognize upper chest breathing? So you might even feel your shoulders lifting up realizing that you're not using your your diaphragm. Or your lower ribs aren't moving when breathing and you're using your chest. All these things are sort of suggestive that you've perhaps not breathing as efficiently as maybe you could be.

Maryann: Patrick McKeown from Oxygen Advantage talks a lot about how your breathing should be really quiet throughout the day. So maybe the first step, like you say, is just notice your breathing for a few days and it might be different when you're sitting versus when you get up.

What about sleep disordered breathing in general. How many midlife women do you think it affects and is it more in post menopause?

Louise: There's not been enough studies on it to be completely honest. The Wisconsin sleep cohort study showed that as women transitioned through from perimenopause to post-menopause, there is a three times increase in risk of moderate to severe sleep apnea. So that's huge and I've seen many studies and they vary in such wide amount. I think there's one that thought that 40% of women had obstructive sleep so it's huge but I do think it’s difficult to put a figure on it. There's something that happens around around this transition phase in our life.

Maryann: Let’s talk about the health consequences. I don't think most people realize that your blood pressure and breathing are very much so linked. And they may not know there are options like the FDA cleared option called Resperate. And it's a device that people can do I think 4 to 5 times a week and it slows the breathing to six or less breaths and has been proven to lower blood pressure. But if you go to your doctor and your blood pressure is up, they're probably going to offer medication. I’m not saying don’t take medication but don't you think in particular people with higher blood pressure should look into their breathing? What are some other health consequences?

Louise: I always say that I signed the hippocratic oath when I graduated from medical school. You know, do no harm. You know what? What's the most basic foundation of life? The most basic foundation of life is breathing. Even the best divers in the world can't last more than a few minutes without breathing. So it really is utterly crucial and so your body still get oxygen in and carbon dioxide out if it's not breathing efficiently. But what you're doing is then you're asking the rest of your body to make adjustments so that the body can still maintain that. So you're setting your basic foundation on an inefficient, unstable basis and then you're not then setting the basic foundation for everything else to work well. So I definitely think you're completely right that we need to look at breathing.

Sleep disordered breathing is associated with increased risk of high blood pressure, increased risk of heart attack, stroke, arrhythmia in particular atrial fibrillation. So when the upper chambers of the heart don't beat regularly there's a condition called atrial fibrillation. There's definitely an association with that and also an association with dementia, probably related to the drop in oxygen levels. There's an increased risk of death because people fall asleep at the wheel or fall asleep when they're working machinery. So it's It's really quite concerning. And people also have fatigue which obviously then makes it difficult to function from a from a work point of view. There's a higher risk of weight gain and and diabetes because it affects our hormones. Exactly like you're saying when we're asleep that sympathetic drive should come down and the cortisol and hunger hormones should stay low when we're asleep. But when people have sleep disordered breathing that doesn't seem to happen. Adrenaline and cortisol are elevated which then can fuel that that risk of diabetes and weight gain which may make the obstructive sleep apnea even worse. So it is like a bit of a vicious circle which is such a shame.

Maryann:

Do you know of any studies that show that hormone therapy can alleviate, prevent or delay sleep disordered breathing?

Louise: The data is mixed. It seems to help some women but makes it worse in others, which matches my clinical experience. I've definitely had some women that snore and then they go on Hrt and it helps, but I've had women whose it's made no difference. For me personally I did go on Hrt and it helped certainly some of my symptoms but it made no difference at all to my snoring. So I think I think it's really complicated. Obviously we need to separate out was it estrogen only was it was it in a combined Hrt.

The other thing that we often forget with with studies with breathing is what's the efficiency of breathing. You know you can breathe efficiently or inefficiently or anywhere in between and what happens how you react to something will be very different dependent on your breathing efficiency. So I just I think that's why it’s a mixed bag. We need studies to separate these factors out.

Maryann: I always say that midlife women are also aging. So even if hormone therapy can help it’s eventually going to be a problem with our muscle tone. As I see it, regardless of whether women take hormone therapy, they still need to be conscious of their breathing.

I know you see clients. What could a woman expect working with you? What are your sessions like?

Louise: I do individual or group programs. They generally run over 5 sessions and I work on ensuring that we reestablish nasal breathing whilst awake, asleep, and moving. But I work on all three dimensions of breathing. I definitely work on improving carbon dioxide tolerance to improve air hunger. The client starts to naturally breathe slower and gentler but also make sure they’re breathing with the correct muscles. Encouraging that body to breathe slower as well. So sort of looking at all those aspects of breathing. It's not a passive process obviously because what you're trying to do is work with someone to work consciously on their breathing to improve their breathing pattern. They get homework every day to work on it and then over time then that just becomes unconscious and then that's where you've changed their underlying breathing and that's where the power of it is I think.

I think what's so empowering particularly for women when transition through menopause is they understand that you have some control over your body. It’s so important to know you can change how you breathe. You can control the autonomic nervous system. You can direct whether it's more sympathetically fight or fight driven or whether it's more parasympathetic relaxation driven and I think that's really powerful particularly at this stage in life.

Maryann: I think it's huge. I know for myself I'm lucky I was never a mouth breather. Some people have had allergies from young ages, making breathing difficult. So they naturally breathe out of their mouth more so it's going to be different for everyone.

And there are some studies showing breathing exercises help with hot flashes and because part of the reason for hot flashes [vasomotor symptoms] have to do with our nervous system. So breathing should be included as part of a healthy lifestyle for midlife women. I'll be happy someday when that instead of just exercise and diet, we have breathing too.

We're finishing up our time. So for the women watching or listening what is one small thing they can do to put them in the right direction for breathing.

Louise: Well I think I think as we've just said having an awareness that breathing is really important and actually observe your breathing and and maybe even watch that video on my Youtube channel about how to assess how efficient your breathing is. Then you can consciously make a decision - Am I breathing efficiently or am I not and then if you're not breathing efficiently then you can start to. I’ve got lots of stuff on my website Patrick McKeown’s got some great stuff on his Youtube channel. And you can start to think how can I make changes and and reestablishing nasal breathing is definitely the first thing to do. But as you've said, how you deal with someone who's been inefficiently breathing for fifty years and I've definitely worked with people who recognize that. Obviously is going to take longer and there might be a lot more entrenched habits so that might be more difficult but it's certainly possible. But I think just bringing awareness to your breathing is important.

If you recognize you're not breathing efficiently, trying to improve that a little bit and working towards improving because it will set that system up to work more efficiently.

Maryann: Yeah, well, that's so great. I'll make sure that we have those links on Substack. At the beginning of this article we have Dr Louise Oliver’s website, youtube channel and instagram.