transcript

Speaker 1:
[00:02] In our last episode of unPAUSED, Dr. Kelly Casperson and I began unpacking the myths and medical blind spots that shape women's sexual health. We covered desire, pain, orgasm, and the pathways that restore function and confidence. But we were just getting started. Dr. Casperson is a urologist, surgeon, podcaster, and author who has become one of the most trusted voices in women's sexual health. Through her podcast, You Are Not Broken, and her books, You Are Not Broken, and The Menopause Moment, she has helped thousands of women understand their bodies with science instead of shame, clarity instead of confusion, and permission instead of fear. In this episode, we go deeper on testosterone, how it works in the female body, why it affects libido, energy, and brain health, and why every woman will experience declining levels over time. Yet, there are no FDA-approved testosterone products for women while men have more than a dozen. We also explore the genital urinary syndrome of menopause, the underuse of vaginal estrogen, pelvic floor dysfunction, vaginismus, and the role of vibration and blood flow in restoring sexual function. And we examine medications, SSRIs, hormonal contraceptives, and GLP-1 therapies that can quietly interfere with sexual health. This episode is about more than hormones. It's about equity in medicine. It's about rewriting the sexual script for midlife and beyond. And it's about giving women the information they need to protect their pleasure, their health, and their autonomy. If you haven't listened to part one, start there. Now let's continue. I'm Dr. Mary Claire Haver, a board-certified obstetrician and gynecologist and certified menopause practitioner. I'm also an adjunct professor of obstetrics and gynecology at the University of Texas Medical Branch. Welcome to unPAUSED, the podcast where we cut through the silence and talk about what it really takes for women to thrive in the second half of life. The views and opinions expressed on unPAUSED are those of the talent and guests alone, and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis or treatment.

Speaker 2:
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Speaker 1:
[04:36] What is the most misunderstood hormone in women's sexual health? I think so. Absolutely nothing. I didn't even know it was female hormone. I don't think I was aware.

Speaker 4:
[04:46] I didn't know it either.

Speaker 1:
[04:46] Well, I had Polycystic Ovarian Syndrome. Testosterone was bad, right?

Speaker 4:
[04:50] In PCOS too, they tend to blame testosterone instead of saying the ovarian dysfunction because of the insulin resistance drives break.

Speaker 1:
[04:59] I remember tracking my testosterone level and it was always bad. I only thought of testosterone as a bad hormone for women. It was a problem because it was elevated. I knew I had ovarian dysfunction that was leading with this high testosterone. We had to get it down and that was how we treated to bring the testosterone down. It's a huge topic right now and you have done so much education. You've taught me about it. You taught me how to prescribe it. You and Ishwesh, you may be not scared of it, but I want you to do your Testosterone 101 for our listeners.

Speaker 4:
[05:33] I want to be very clear. I didn't learn this either. I didn't learn this in med school.

Speaker 1:
[05:37] As a urologist.

Speaker 4:
[05:38] I'm a urologist. I remember the guidance were taking care of the women. So, we had to learn some things. So, ovaries make testosterone. I always start there.

Speaker 1:
[05:47] Anywhere else in the body?

Speaker 4:
[05:49] Actually, peripheral conversion and adrenals.

Speaker 1:
[05:52] All right. So, start with the precursors. So, like, take me through the factory, start with cholesterol, and walk me through how our body makes testosterone and roughly where that happened.

Speaker 4:
[06:01] So, roughly, cholesterol converts into progesterone, testosterone goes to estradiol. You can't go backwards, people think, because you're cleaving carbons off, right? So, you can't be like, oh, just give yourself enough estrogen and it'll convert to testosterone. You can't go backwards on the pathway. It's a one-way cutting carbons off pathway. So, you need testosterone to actually make estrogen, but you can't just give somebody estrogen and expect a carbon to be added on it to get testosterone, right? So, it's a one-way stream. And people, and then another, I'm telling you all the myths at the same time. One myth will be like, I can't give you testosterone because you'll just convert it all to estrogen. What's the point? No. In normal menstruating women without PCOS, without menopause, in our bodies, we have four times the amount of testosterone than estrogen. It's not all converting to estrogen. For people to be like, well, testosterone just made you feel better because it all converted to estrogen. No, that's not how it works even in healthy, young, normally cycling people. I actually did this with my labs. You can, in somebody who's not in perimenopause, postmenopause, check a testosterone, check an estradiol. You have to convert the units because they're in nanograms per deciliter versus picograms per milliliter. You have to convert your units, but there's online calculators for that. Then you can actually look and be like, I do have more testosterone in my body than estrogen.

Speaker 1:
[07:21] They're in different units because there's so much less estradiol.

Speaker 4:
[07:23] Because there's so much less estradiol.

Speaker 1:
[07:25] They have to use different units to actually measure it.

Speaker 4:
[07:27] Totally.

Speaker 1:
[07:28] We cleave off a bunch of carbons and we go through this process. We have some in the periphery, so some in the ovaries, some in the periphery. Where are there testosterone receptors in the body?

Speaker 4:
[07:38] Everywhere. Brain, bone, muscle, clitoris, vulva, vagina, eye, tear ducts. This is my new one because some of the zeitgeist on the Internet says testosterone is only for libido. Furthermore, even if it does work for libido, we can't use it because it's not FDA approved. But what about the ophthalmologists who use testosterone for dry eyes? What? I'm sorry, what? The eye doctors know that tear ducts have testosterone receptors and so they give people drops of testosterone to help with tear duct production? That's off-label. That's not libido. This stereotype of this narrow window for testosterone falls apart so quickly. It's the classic absence of evidence does not mean evidence of absence. What do I mean by that? We stereotype testosterone as the male hormone. And it's a generic medication. There's no money in the research, there's nothing.

Speaker 1:
[08:40] Just like estradiol.

Speaker 4:
[08:42] Yeah, just like, there's nothing happening. Furthermore, nobody's going to make any money from it, but we use absence of evidence to say it's pointless, you can't, it's dangerous, vulnerable.

Speaker 1:
[08:52] So what do we know? What does the evidence say clearly testosterone, giving a woman testosterone can be helpful for?

Speaker 4:
[08:58] Every single domain of sexual health. And I will say that because, again, the stereotype is it's just libido. Desire, decreasing distress about sex, blood flow, so arousal, helps with orgasm. The only domain of female sexual health that it doesn't help with is in the domain of pain. So if a woman has pain, it doesn't always help with that. But sometimes people will still use a little bit of compounded testosterone on the vulva for vulvodynia. So even that, there is a role for it. But it irritates me when people are like, it's only for libido. Well, it helps people orgasm more, helps arousal, decreases people's distress over their sexual health. None of that's libido, right? So that's just pelvic health. So now we have blood flow to the clitoris, moisture, orgasm, desire, that's a brain one. Because testosterone helps nerves. It helps the myelin sheaths. It helps glial cells. Now I'm dating myself as a neuroscience undergrad. Glial cells are the supporting cells of the neurons. Testosterones play a role in supporting glial cells. Testosterone works in the brain. Why does it help libido? Because it helps the dopamine pathway. People say it only helps libido. Is there a libido corner to your brain, that one square centimeter on the left that the testosterone goes to? You put testosterone in a woman, put her in an fMRI, her whole brain lights up. There are receptors everywhere for this. The other interesting thing about testosterone is we can study blood pressure meds in men and then give them to women. We can study statins in men and give them to women. We can study antidepressants and sleep meds in men and then give them to women. Perfectly fine, we're not studying women. Worked in men, give them to women.

Speaker 1:
[10:37] Do it all the time.

Speaker 4:
[10:38] But these decades of data on the safety and efficacy of testosterone in men, we can't use that in women. To go even further, what if we had five decades of safety data in women at 10 times the physiologic testosterone dose? What if we had that? We do. We have that. It's called trans men data. They're not dying because we gave them testosterone.

Speaker 1:
[11:02] At 10 times the dose, that we-

Speaker 4:
[11:03] 10 times the female dose because they want it, because it's a quality of life issue. Doctors say, yes, your quality of life is worth treating. Let's give you 10 times the dose because you want it. We have a 30-year paper and a 50-year paper. No increased risk of death, cancer, breast cancer, anything because of testosterone. What other drug do you study at 10 times the dose for 50 years? Then tell women, sorry, you can't have your dose because it might be unsafe.

Speaker 1:
[11:31] Where does testosterone stand right now with the Food and Drug Administration? What's for men? What's for women? What do we have?

Speaker 4:
[11:37] About 20 percent of men will have low testosterone. Probably more have it than are diagnosed with it.

Speaker 1:
[11:42] What does that mean?

Speaker 4:
[11:43] Low testosterone is basically your body's not producing testosterone. Might be from multiple reasons. Maybe you have a health condition, maybe you're living longer than your testosterone production, the testicles. Some men are born with low testosterone. So a couple of different reasons. What's interesting though, is male testosterone is FDA approved for primary hypogonadism. What does that mean? Your testicles never made enough testosterone in the first place. Most men take testosterone off-label.

Speaker 1:
[12:14] Really?

Speaker 4:
[12:15] Because they have secondary hypogonadism. Because it's from age, or it's from a medical condition, or cancer treatment is for something else.

Speaker 1:
[12:24] Is this secondary hypogonadism or andropause?

Speaker 4:
[12:27] People will argue. People will say it's more common as we collect metabolic dysfunction, obesity, poor sleep, alcohol, lack of exercise, right? So we kind of collect comorbidities as we age and men's testosterone will go down. So some people will say there's no such thing as andropause. And some people say, yes, it decreased by 2% a year.

Speaker 1:
[12:49] Now what happens in women? Does it fall off a cliff like menopause?

Speaker 4:
[12:52] No, it does not fall off a cliff, which is used again. It's used against women, right? They're like, testosterone doesn't fall off a cliff in menopause. So this is why you can't have testosterone. It's like, that makes no sense. Testosterone naturally starts decreasing after our 20s. We don't really know why. Again, nothing's been studied, but that's a used against women. They're like, it doesn't fall off a cliff with menopause. What's interesting is normal physiology, testosterone, slow linear decline after age 20. No testosterone is FDA approved for low libido or hypoactive sexual desire disorder, but the guidelines say it's for post-menopausal women. Why did we draw a line in the sand if there's no cliff?

Speaker 1:
[13:34] No idea.

Speaker 4:
[13:35] One possible idea is because they're worried that testosterone is teratogenic. And can you be trusted to take testosterone and not get pregnant? Because you're a woman and can you be trusted to do that? So that's one theory of like, why do we draw a line in the sand with menopause if testosterone doesn't fall off a cliff with menopause? Tratagenic. We're worried about the fetus more than we're worried about the female quality of life.

Speaker 1:
[13:59] Right. Always.

Speaker 4:
[14:01] Yeah, always. But okay, fair, testosterone's category, pregnancy category X.

Speaker 1:
[14:05] And it should be.

Speaker 4:
[14:06] Fair.

Speaker 1:
[14:08] For a female fetus.

Speaker 4:
[14:08] But we're just replacing your testosterone to how it was in your 20s when you would have gotten pregnant anyways.

Speaker 1:
[14:14] Okay. So what do we have on the market?

Speaker 4:
[14:16] Okay. So right now in America, there's zero FDA approved testosterone products for females. Let's just note.

Speaker 1:
[14:22] Why?

Speaker 4:
[14:23] Because if you don't study it, and then you do go up in front of the FDA, but it happens to be 2004. And what happened in 2002?

Speaker 1:
[14:32] The Women's Health Initiative.

Speaker 4:
[14:33] The Women's Health Initiative. And that made hormones dangerous. So now a company, the Intrinsipatch, went up to the FDA in 2004 and said, we've got a patch, we've got safety data, we've got efficacy data. What does the FDA need? Safety data, efficacy data. They said, we don't have enough safety data yet. We need years more safety data before we can FDA approve this, because the Women's Health Initiative just happened. We don't know what hormones do to women, right? Keep in mind, men's testosterone got FDA approved with six months safety data. Intrinsipatch had years of safety data, not enough safety data. So the bar is higher for a woman to get an FDA approved product than a man. See also what Adi Flavansferin has had to do to get FDA approved versus what Viagra has to do. There is a gender disparity in the FDA approval process.

Speaker 1:
[15:25] They felt that there was such an unmet need of men needing to have erections and have a high quality of their sex life that they fast-tracked Viagra.

Speaker 4:
[15:35] The fastest, most successful pharmaceutical sales that had ever happened ever before. Nobody went around saying, we can't profit off of helping men. Men just need more therapy. We don't. Adi, or testosterone, we're like recent menopause conference for sexual health. Somebody said, women don't need testosterone, they need better body image.

Speaker 1:
[15:58] Nice.

Speaker 4:
[15:59] It's like when we have products, the bias against women being biologic and deserving of medical treatment is so much different than what a man has.

Speaker 1:
[16:12] You saw it. You're on the front, you treat men and women for sexual dysfunction.

Speaker 4:
[16:17] So 20 percent of men will have low testosterone. They have about a dozen products. Would you like a pill? Would you like injections? Would you like a gel? We got pellets. Men's testosterone pellets are FDA approved. What does that mean? Insurance will cover it. That's huge. So 20 percent of men will have low testosterone, about 12 products. A hundred percent of women will have low testosterone, zero products. To me, I make it make sense.

Speaker 1:
[16:44] What is testosterone not fix?

Speaker 4:
[16:46] I'd say relationship problems.

Speaker 1:
[16:50] Yeah. That's one of the, when I'm screening our patients, I'm like, how is your relationship? Well, I hate him. I'm like, okay. This conversation needs to go a different direction because offering you testosterone to Patty or Vilece is not going to fix a relationship issue. That's really good.

Speaker 4:
[17:06] You can even break into it more. You can be like, is the relationship issue because of the sex? Then it's like, okay, well, that might be different than the relationship issues because you're an asshole. Right? So it's like, is it a sex-related relationship issue? Okay, well, let's treat the sex problem. Maybe that will help the relationship issue versus he's just a jerk. He's never around. He blames you for everything. No medication is going to make that better.

Speaker 1:
[17:28] Right. So we've established that testosterone helps with blood flow, so it helps with arousal. It helps locally with the vestibule. So that's the tissue. Where is the vestibule?

Speaker 4:
[17:41] Vestibule is basically the entrance of the vagina.

Speaker 1:
[17:44] Okay.

Speaker 4:
[17:44] So the vulva is what you look at. If you were to open up the labia majora and you're headed into the vagina, you must pass, it's like the church, you must pass through the vestibule.

Speaker 1:
[17:53] It helps with desire, which is in the brain. We have great studies in post-menopausal women showing it helps with dry eyes. My patients say it helps with energy, but man, do we get pushed back when we talk about this.

Speaker 4:
[18:07] Oh my God. Let's talk about that. So where does energy come from? Metabolic function, mitochondria, right? Mitochondria is super hot and sexy right now. Guess what helps mitochondria? Testosterone and estrogen, right? Dopamine, the pursuit of something. Testosterone helps drive the dopamine pathway. So do we have a physiologic reason that hormones help energy? Yes. Helps neurons function, helps mitochondria function, helps the dopamine pathway, helps serotonin pathway. Luis Newsom's group showed that getting women on estrogen, some of them were able to get off their antidepressants. You add testosterone, much bigger amount were able to get off their antidepressants. On the combination. Estrogen and testosterone. Why? Serotonin pathway. That's the theory, right? So I think of testosterone not as so much a libido drug, which what is libido? Libido is the pursuit of, it's the motivation of something. Testosterone is not just a libido medication, it's a motivation medication. Libido being one part of motivation. Saw a patient, she had surgical menopause, struggled for years, finally got on estrogen.

Speaker 1:
[19:17] Meaning her ovaries were surgically removed.

Speaker 4:
[19:19] Ovaries were surgically removed. This is a physician. She was a physician, had emergency surgical menopause because they were worried it was a mass. It was not, she was fine. It wasn't put on anything. She was like 50 or 51. Boom, surgical menopause. She had to quit her job because her side effects from being immediately castrated without help were so profound.

Speaker 1:
[19:40] Stop for a second. When we remove the testicles in men, when we castrate men for medical reasons, I'm assuming for medical reasons.

Speaker 4:
[19:46] Testicular cancer is the most common, if not trauma.

Speaker 1:
[19:48] What would be the post-op? Do you talk about what's going to happen? Their sexual function? What is standard counseling?

Speaker 4:
[19:54] It would be malpractice to not do it. If there was a urologist who removed testicles, who didn't talk about testosterone replacement, that's malpractice until proven otherwise.

Speaker 1:
[20:04] Okay.

Speaker 4:
[20:05] Let that sink in. Also very interesting, there's no female word for castration. Castration is by definition the removal of a male mammal's gonads. So that's also very weird of how new surgical menopause is, that we don't actually have a word for removing ovaries.

Speaker 1:
[20:21] Oophorectomy.

Speaker 4:
[20:22] Oophorectomy.

Speaker 1:
[20:22] Yeah.

Speaker 4:
[20:22] But as far as a lay person, we call it castration, but it actually means male mammal. So she gets on estrogen. She comes to see me. She's like, let's try testosterone. Okay. Try testosterone. And so we do a telemed follow-up. And she turns her laptop and she's like, I want you to see what's out this window. Great. What's that? That's my testosterone deck. Your testosterone deck? Tell me about your testosterone deck. And she's like, I have been planning on a deck for years. Started on testosterone. I have motivation to finish a product. That's the energy. That's the drive towards. So yes, it does help libido because that's a motivation towards something. It also helps you get your job done and do things. And the amount of people that come to me, I actually did a very informal social media poll. I'm like, hey, any woman who's started a business since starting on testosterone, just let me know. I'm up to like eight now. I haven't asked in a while. Motivation to do something. Why? It works in the brain. Dopamine pathway, serotonin pathway, mitochondria, nerves. We know this and we know in men. Let's go even farther on how little...

Speaker 1:
[21:32] What does the male data say about things outside of sexual function? What do we know about men?

Speaker 4:
[21:36] Men with low testosterone have higher risk of depression, have higher risk of dementia. Also correlated, we think, with Parkinson's, multiple sclerosis, all nerve function issues, right? A higher risk of diabetes. So why is it that we can research all these things in men and apply them to women, but we completely ignore the role of testosterone outside of sex in men and we're like, we don't know in women, haven't studied it. But testosterone helps the brain, it helps neurons, it helps them function. In a world where in Australia now, the number one killer of women is dementia. And America would be headed that way, but we're pretty good at dying of other things as well. But the UK is right behind Australia. In a world where it's incurable, no great treatment, any number one killer, are we not curious about things that help support neurons? It's absolutely insane to me.

Speaker 1:
[22:30] What else about testosterone?

Speaker 4:
[22:32] So there's some really interesting data and this is pellet data. This is Dr. Rebecca Glazer's work. So what she did is she has many, many people on testosterone pellets and she compared their rate of breast cancer with the rate of breast cancer in the SEER database or the general population. It looks as if there's about 30 percent decreased risk of breast cancer in women taking the testosterone. Now, the critics will say this is not a randomized placebo-controlled trial. They will say it's pellet data. The critics will pull this apart. I say, if there is a hint and a whisper of anything that could remotely decrease the risk of breast cancer in women, why aren't we pouring money into looking at this? When we get a medication that decreases the risk of breast cancer by five percent, it will have a Super Bowl ad because five percent is meaningful. Her data suggests testosterone might be more than that. We know again, is it physiologically plausible? Yes, testosterone appears to be breast protective. In addition, the oncology community is looking at terms, testosterone receptor modulators, terms for estrogen, terms for testosterone. They're looking at terms, so they're actually creating medications to sit in the testosterone receptors that seem to help breast cancer. In fact, before we had modern breast cancer treatment, we gave women testosterone. So for me, when people say, when they dismiss this data, to me, I'm like, why aren't we profoundly curious with how afraid we are of breast cancer and how miraculous something would be that decreased our risk? Why is there silence on this?

Speaker 1:
[24:07] If I gave you, and this is one of my favorite questions to ask, I'm the scientist on this pod. If I gave you a blank check for research, what's your study?

Speaker 4:
[24:16] Can I have infinite time?

Speaker 1:
[24:18] Yes, anything you want. That's the limit. I'm Melinda Gates right now.

Speaker 4:
[24:22] Perfect. I want a randomized placebo-controlled trial looking at dementia prevention with testosterone. I'm putting together the puzzle pieces. We've got basic science. We've got physiologic plausibility. We've got male data. We've got all these pieces. Testosterone might be dementia prevention. It might be. People will poo-poo that because we don't have this damn 20-year billion-dollar study on a generic drug that nobody's going to make profit off of. Right? And so it's like, when it's the number one killer in Australia, why aren't we looking at everything that could be neuroprotective? But until we get that study that I want the billion-dollar for-

Speaker 1:
[25:02] And until we value women's cognition as they age.

Speaker 4:
[25:04] Yes. I tell women, on that horrible day that you were diagnosed with dementia, on that horrible Tuesday, it started 20 years ago. We have to do something now to try to move the needle 20 years from now. But I believe, I'm like, if you wait for that study, you're going to be dead. We have to use the data we have now to make the best decisions we have now. And if testosterone is moving the needle even a little bit on breast cancer and dementia, why aren't we pounding down the doors studying this? Why aren't we? There's no money in it, you can't patent it. There's no money in women's research right now. And truthfully, in the US.

Speaker 1:
[25:41] We're actually seeing studies come out of other countries, but.

Speaker 4:
[25:45] What it costs to do a 20-year randomized placebo-controlled trial. I mean, look at the WHO, right?

Speaker 1:
[25:50] One billion.

Speaker 4:
[25:51] A billion dollars, which will never be replicated. And so to me, I'm like, that would be my dream study. It's never going to happen. And even if we started it now, we're not going to know for 25 years. I don't know.

Speaker 1:
[26:03] We can measure the plaques. I think we could have enough markers for people who are at risk or start with the high-risk people with APO.

Speaker 4:
[26:10] Well, so we have a pretty strong argument with APO-4E that they should strongly consider hormones. Yeah. We know that. And there's also there's cadaver data, because I can't cut open your brain and look at testosterone in it, right? And your serum testosterone doesn't correlate with your brain levels. So that's a problem too, to study it. We have cadaver studies, cadavers with a higher level of testosterone in their brain had less dementia. So it's like, we got to put together all the pieces to say, we've got this study, we've got this study, we know how it works on nerves, we know how it helps protect myelin sheaths, all of this. And we have to just keep drowning out the naysayers who say it's only for libido. And even that is not that important.

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Speaker 5:
[27:47] Hi, my name is Lloyd Lockridge, and I'm the host of a new podcast from Audacy called Family Lore. In this podcast, I'm going to have people on to tell unusual and sometimes far-fetched stories about their families.

Speaker 4:
[27:58] I've heard my whole life that she invented the margarita.

Speaker 5:
[28:01] And then we're going to investigate those stories and find out how much of it is true.

Speaker 6:
[28:05] He gets a patent one month before the Wright brothers. Oh my God.

Speaker 5:
[28:09] Please follow and listen to Family Lore, an Audacy podcast available now on Apple Podcasts, Spotify, or wherever you get your shows.

Speaker 1:
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Speaker 4:
[28:52] Thank God for that paper.

Speaker 1:
[28:54] Recognized complaint that is actually medical and not psychological.

Speaker 4:
[28:58] NFLM.

Speaker 1:
[28:59] NFLM. Suspect that maybe testosterone is part of this picture. I come in, I'm 42, I'm still having regular periods, and I'm like, Dr. Kelly, I don't know what's wrong, I don't feel like myself anymore. Where do you start?

Speaker 4:
[29:14] I get the story first. What's going on? What do you mean by that? Because that's a very different thing for different people.

Speaker 1:
[29:20] They get kind of seven domains of what that might be.

Speaker 4:
[29:21] So what do you mean? What are your goals? Like I hear the story, and then we're going to check some labs. How's your thyroid? Do we have metabolic dysfunction going on? What's your blood pressure?

Speaker 1:
[29:30] What are you checking? What are your labs?

Speaker 4:
[29:31] I check thyroid, full thyroid panel, A1C. I do fasting insulin now and everybody complete metabolic profile. I do estrogen, testosterone, sexual hormone binding, globulin, FSS.

Speaker 1:
[29:44] Baritone. Do you do iron studies? Yep.

Speaker 4:
[29:47] I do those. I've been checking. Oh my Lord. I just had a huge win with vitamin B12 the other day. Oh wow. Holy moly.

Speaker 1:
[29:52] Vitamin D.

Speaker 4:
[29:53] Vitamin D. Vitamin B12. I've been getting the omega check just to check people's omega 3 levels because it's nice to look at that.

Speaker 1:
[30:00] Are you doing the ratio?

Speaker 4:
[30:01] Quest has like an omega check panel.

Speaker 1:
[30:03] Okay.

Speaker 4:
[30:03] And so it checks it all. So I had a woman come in, side note, vitamin B12. Woman came in, really bad chronic neck pain. She banged her head basically, was doing all the right things. CNPT, CNMassage, CNAcupuncture, stretching, all the things. She came to me and she's like, I'm going to quit my job because very high functioning person. I'm going to quit my job because my pain is so bad and nothing's helping. And so we tweaked her estrogen a little bit. I checked my panel. B12 was in the toilet, like in the toilet. Related to B12, she came in, literally adjusted her estrogen, got her B12 up. She came in. She's like, I have zero pain. I'm like, zero pain? I'm like, six weeks ago, you're going to quit your job because of pain. And she's like, well, now I want to quit my job just to tell everybody that they should get help and check some things. And so she went back. She's a feisty East coaster. So she went back to her PCP and was basically like, what the hell? Why aren't we looking into this? Again, what are we talking about? Women can have biologic reasons to their health issues. I adjusted a woman's hormones. I got her to stop vaping and got her off her ADHD meds. I know we can't do that in everybody. But it was like this light switch in me of like, what if women being miserable and complaining and having these issues is not just how things are? What if we can try things and adjust things and they feel better?

Speaker 1:
[31:29] She's like, the best part of my practice is literally a woman in that 15 minute box and the way I was forced to practice would not allow me to investigate these things. And now that I can like have exploded what I can do for a woman, it is like giving women their lives back. They're just like getting back to who they were and so grateful. And now they're, you know, they are quitting jobs because they didn't like the damn job because they've got something else in mind or they're getting a divorce or really like diving back into their relationships and you know, but they're like literally building these lives that they felt that they were meant to live and they couldn't live. They were limping along.

Speaker 4:
[32:09] What if women feeling miserable isn't a default?

Speaker 1:
[32:11] And it's not just always hormones. I mean, no one checked a vitamin D, no one checked a ferritin, no one checked all these things, you know? And it's just the most beautiful medicine I've ever practiced.

Speaker 4:
[32:21] I gave up surgery for it. Like getting women to feel like they're themselves again is the best job on the planet. Hands down. The best job. I say, I help strong, smart women go out and change the world. They change the world. They could change the world. Yeah.

Speaker 1:
[32:37] They are literally setting the world on fire once you give them their lives back.

Speaker 4:
[32:40] I was doing a book club with a CEO in Seattle and she's like, I think menopausal women are going to take over the world. And I'm like, that's fantastic. They will never take over the world when they feel shitty. We must get them feeling better in order to get them out doing things. So when people, when they poo poo testosterone and they're like, we don't have any data to say it helps energy or motivation. I'm like, first of all, we have a physiologic, biologic plausible reason that it happens. It's just basic physiology. You want to study it? Fine, that's your problem. But we have basic physiology of why this helps. There is nothing more satisfying than a woman saying, I feel like myself again. Why don't we try it? So you answer your question of how do you counsel a woman when they're like, I'm not feeling like myself. Should I try testosterone or not? I say, okay, what are the things I need to think about to answer that question? Is it cheap? Yeah, it's cheap. It's cheap. I'm not asking you to remortgage your house to try something. Is it safe? Yeah, we've got decades of safety data at 10 times the dose. Female dose, very safe. Okay, it's cheap. It's safe. At normal physiologic doses, do we have a lot of big risk side effects? No, we don't. Does it work in everybody? No, it doesn't work in everybody. But those are my bar. I'm like, hey, it's cheap, it's safe. Women will know if it helps them or not. I usually say just try it, you'll know after about four months or so. Maybe we have to go up on the dose, maybe we don't, you'll know if it's worth it or not. The bar to try it is so low that it's like, you only have yourself to gain. Has anything else been working?

Speaker 1:
[34:17] But there's so many women out there. If only 4 percent of women right now, at least the latest data that we had from 2023, are on FDA-approved estrogen therapy, plus or minus the progesterone. Do we even have any idea of how many of those women are also being offered testosterone?

Speaker 4:
[34:35] It's a good question. And I mean, I need receipts. I'm like, publicly, I need receipts.

Speaker 1:
[34:40] I would say 2 percent or 98 percent of women will never have the opportunity to even explore this.

Speaker 4:
[34:45] That's right. So FDA approval will have a huge validation, but here's the problem. Pellets? Can't measure those. Private company. Compounded testosterone? Can't measure it. Individualized. To the best data, and this is like chasing paper references, like the best of our knowledge, as many women in America are on testosterone as men. Wow.

Speaker 1:
[35:09] When you add in compounded in pellets.

Speaker 4:
[35:11] You got to add in the, so hormones are the top five compounded things, right? So we got to add in compounded, we've got to add in the pellets, which is kind of guessing based upon profitability data. They're not going to tell us anything. They don't want any competition and say this is a huge market. It's a huge market. A hundred percent of women will have low testosterone. Does that mean everybody's going to be helped by taking testosterone? No. But shouldn't you have the opportunity? So to me, I'm like, it's such low hanging fruit to me, but I realize I know a lot at this point. Like I know the male data. I know the female data. It's just so obvious to me, but I'm fully aware it's not obvious to everybody else yet.

Speaker 1:
[35:51] Right. We weren't taught. The vast majority, me, OB-GEN, supposed to be the women's sexual health person.

Speaker 4:
[35:56] Yeah. I got a message today on Instagram. I asked my doctor for testosterone and they said, what do you want to grow whiskers? And what do you want to grow whiskers? If that's the response your doctor gives you to that question, when ovaries make testosterone, we have a big learning gap, a big learning gap in the medical community.

Speaker 1:
[36:16] And you brought some testosterone with you.

Speaker 4:
[36:18] I brought some testosterone. So this is just one type of testosterone. This is a FDA approved male testum or generic testosterone gel, 1%. A male dose testosterone, this is one a day. So this comes in at whole two. It's a lot of product, right? So this is one day for a man and he's usually going to put it on his upper chest.

Speaker 1:
[36:40] So what is safe evidence-based prescription look like for a woman?

Speaker 4:
[36:44] So you have to take this packet and you have to say, use one-tenth of this. How are you going to do it? So you can draw it up in a syringe, you can get some syringes off of Amazon, you can spit ball it. I have some women who they like being very accurate, they actually weigh it out. Or you can say, you know what, 10 days from now, make this last until 10 days from now. So you can spit ball it. I spit ball it. But because we do not have an FDA approved product, we're asking women to bootstrap, pay out of their own pocket, insurance doesn't cover things that aren't FDA approved, and they have to microdose. It's completely inaccurate, very inaccurate. Or they're pushed to some people who only give you one type of testosterone, that tends to be pellets, because that's the most profitable type of testosterone.

Speaker 1:
[37:28] Why don't you use pellets?

Speaker 4:
[37:29] Pellets are the highest dose, stereotypically, it tends to be the highest dose.

Speaker 1:
[37:33] I've never had a patient who came to me after, within three months of a pellet, insertion, who was in a female physiologic range.

Speaker 4:
[37:40] Yeah, it's high. It's high. My analogy is if you're at sea level, and you go to Everest Base Camp that day, it can feel kind of crappy. The body doesn't like to be shocked. Hair follicles don't like to be shocked. We actually have pretty decent data saying testosterone doesn't cause more hair loss than placebo. I believe that data. I also believe women who say, I tried testosterone and I lost hair. I believe them. So how do I reconcile these two different things? Do not go from sea level to ever a space camp. It shocks the hair. So it's not so much the testosterone as the drastic change, right? You'll lose hair with rapid weight loss, thyroid storm, having a baby, surgical menopause, having a baby. It's all a shock to the body. So I think that's, and again, that's why pellets give testosterone a bad name, because women don't make a woman lose her hair. That's not good. That's very bad optics. So it tends to be the highest dose. You can't take it out. You have to wait for it to wear off. It also tends to be the most expensive dose. So what I say, and there are women who are very happy on pellets. They do not want their pellets taken away. So there's a camp that's like, ban pellets. And I'm like, well, we have FDA approved male pellets. Maybe we could actually do...

Speaker 1:
[38:52] I don't want to demonize. It's a method of delivery to the system, of putting something in your body. We have injections, we have pills, we have pellets, we have creams and gels. But the problem, I think, is with marketing around a certain company or a couple of companies. I have someone in Houston who I think practices very responsible medicine, who has the pellets compounded herself and really closely monitors the dose and her patients like it. And she doesn't super physiologically dose and all as well. And she offers them all the options. They can do the T-stem or the pump or whatever. But, you know, so I think there's a responsible way. I don't want to demonize a pellet.

Speaker 4:
[39:30] I agree.

Speaker 1:
[39:30] But there is some questionable ethics around, at least for us.

Speaker 4:
[39:34] If it's the only item on the menu, that's concerning. Yeah, and if it's your first menu item, right? So what I say is earn your pellet. What does that mean? That you tolerate a higher dose, that you've been on it for a while, you don't have side effects at a higher dose. Now, maybe I don't want to do this daily. I want something more sustained. Okay, you've earned your pellet, right? Versus like, I had no idea there was any other options.

Speaker 1:
[39:55] Yeah, and I see that because I see the post pellet people did not have a good outcome, right? All right, so now you've found a doctor who is happy to write your prescription. They're comfortable doing it. They have education. They've counseled you about the side effects. So you get this little tube. Where do you put it? Do you eat it? Do you put it on your vagina? Do you...

Speaker 4:
[40:15] So this goes on. Any place you put testosterone can have a side effect of hair growth, right? So some people do forearms.

Speaker 1:
[40:22] I do forearms.

Speaker 4:
[40:23] Yep, so some people do forearms, fine. Just know that hair growth might be a side effect of that. Quickly checks wrist. I do outer lateral thigh. Why? It's easy to reach. Bending over to do my calf, that's just farther to go. So I like lateral thigh. Lateral thigh has less hair follicles than inner thigh. You might get more hair if you do inner thigh. There's a subset of people who have been taught to apply it to their genitals. First of all, with a gel that can sting.

Speaker 1:
[40:48] Yeah, alcohol-based.

Speaker 4:
[40:49] Yeah, alcohol-based. Don't do that. The genitals are very interesting. A very original male testosterone patch was for the scrotum. Ouch, who wants to take that patch off? Ooh. Ooh. But why? Because the genitals have a much higher density of testosterone receptors. It was a very good way to push testosterone into the male body using a patch on the scrotum. That's the theory, but no, if you take a systemic dose testosterone and you put it on your genitals, check your levels, you might have a much higher systemic level than if you're going to put it on your skin. So I don't advocate for genital applism. Why do you need to touch your labia to do your daily hormone dosing? You don't have to. Now, you can compound a lower dose, usually with estradiol, for the vulva, that tends to be for a provoked vulvodynia, a very specific vulvar pain issue, because vulvas have testosterone receptors, clitoris has testosterone receptors. I would love to see more research looking at clorophymosis, what is clitoral phimosis? Right. So if you think of a penis, and you think of the foreskin of the penis for uncircumcised people, it's the skin that covers the glands. Clitoris has the same thing, we call it the clitoral hood, and that can get stuck.

Speaker 1:
[42:06] Adhesions, little baby scars.

Speaker 4:
[42:08] Little baby scars because of low hormones. So things we don't have data on. If we just start women in perimenopause on hormones, will they have less vulvar atrophy? We don't know, we've never studied it. If you have clitoral adhesions, can we reverse that reliably with a testosterone cream? We don't know, we haven't studied it. Only to make people realize, there's so many unanswered questions, that the field really is wide open. It tends to be a funding problem. But Rachel Rubin did the research on clitoral adhesions. It's actually pretty common. Which why, if you have sexual health issues, I see this all the time on the Internet, is like get a good pelvic exam. Does somebody know what they're looking at, can give you a good pelvic exam? Because pain down there is never normal. No, it's never normal and it could be like 30 different things. Where does it hurt? Do you have diminished orgasm because of low hormones? Do you have diminished orgasm because you have severe clitoral phimosis that nobody knows about? I love telemedicine. I think telemedicine is here to stay. I don't think telemedicine will ever replace a good pelvic physical exam.

Speaker 1:
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Speaker 6:
[45:59] Eczema is unpredictable, but you can flare less with EbGlyce, a once monthly treatment for moderate to severe eczema. After an initial four-month or longer dosing phase, about four in 10 people taking EbGlyce achieved itch relief and clear or almost clear skin at 16 weeks, and most of those people maintain skin that's still more clear at one year with monthly dosing.

Speaker 7:
[46:18] EbGlyce, Lebrichizumab LBKZ, a 250 milligram per two milliliter injection is a prescription medicine used to treat adults and children 12 years of age and older who weigh at least 88 pounds or 40 kilograms with moderate to severe eczema. Also called atopic dermatitis that is not well controlled with prescription therapies used on the skin or topicals or who cannot use topical therapies. EbGlyce can be used with or without topical corticosteroids. Don't use if you're allergic to EbGlyce. Allergic reactions can occur that can be severe. Eye problems can occur. Tell your doctor if you have new or worsening eye problems. You should not receive a live vaccine when treated with EbGlyce. Before starting EbGlyce, tell your doctor if you have a parasitic infection.

Speaker 6:
[46:52] Ask your doctor about EbGlyce Visit ebglyce.lily.com or call 1-800-LILY-RX or 1-800-545-5979.

Speaker 1:
[47:03] So let's talk about General Urinary Syndrome of Menopause, GSM. And I hope our listeners realize you were really critical to this final round of approval that the FDA finally, finally had the black box warning removed. And then the GSM guidelines, Dr. Rubin, you know, was really critical. And then we all kind of pitched in to like get it out on social media. It really was a grassroots effort.

Speaker 4:
[47:31] Yeah. Guidelines do no good in a box.

Speaker 1:
[47:34] Yeah. To get these guidelines out there so people know about them. But what is GSM? What is General Urinary Syndrome of Menopause?

Speaker 4:
[47:40] General Urinary Syndrome of Menopause is a complete mouthful. We say GSM for short, but it's a better name than vaginal atrophy, because vaginal atrophy only...

Speaker 1:
[47:48] Or my favorite.

Speaker 4:
[47:49] Your favorite.

Speaker 1:
[47:50] Senile. Senile Vagina.

Speaker 4:
[47:52] Senile Vagina, brought to you by the 1980s. Yeah. So it was a senile vagina, then it was a vaginal atrophic vagina, and now the vagina is in the pelvis along with the genital urinary organs, which include labia, urethra, bladder, vagina, vulva, clitoris. And so the big mouthful is genital urinary. So lots of different structures can be affected. Syndrome, meaning a constellation of issues of menopause, meaning it should really mean low hormones is probably a better title. But we're getting there. Incredibly common. 50 to 80 percent. Some people will argue 90 percent. The other people will argue, why don't we just say it's 100 percent? If you live long enough, it's 100 percent.

Speaker 1:
[48:32] I, you know, hormones go away. The tissue atrophies, you know.

Speaker 4:
[48:36] The better question, which again, hasn't been researched to my knowledge, why does a small amount of women make it to 75 without GSM?

Speaker 1:
[48:45] I looked at vaginas in their 70s and 80s. They had it. They just weren't symptomatic.

Speaker 4:
[48:50] Yes.

Speaker 1:
[48:50] I can look at a vagina and tell you how old the patient is. Or at the vulva, really.

Speaker 4:
[48:55] My talk tomorrow is your vagina can tell your age better than your driver's license. For sure.

Speaker 1:
[49:00] If she's not treated, you know. If she's not on hormones, I can tell how old you are.

Speaker 4:
[49:05] Yeah. Unless if that vulva is on DHEA.

Speaker 1:
[49:09] Oh, she's beautiful. Juicy, delicious.

Speaker 4:
[49:12] Yeah. DHEA makes vulvas beautiful again.

Speaker 1:
[49:15] Yeah. Agree.

Speaker 4:
[49:17] For your listeners, DHEA is a precursor hormone that converts into both testosterone and estrogen. Right now, there's one FDA-approved product that goes in the vagina called Intra-Rosa or Prasterone. It's a made-up word. It's DHEA. But the reason why we say it makes vulvas beautiful again, is because it gives you a little bit of the estrogen and the androgen, and that's why it's so beautiful.

Speaker 1:
[49:39] You mentioned GSM and this new data, the Medicare data that came out with GSM.

Speaker 4:
[49:44] A paper just got published out of Stanford looking at Medicare recipients. Now, the caveat is it was only up to 2018, so God can hope it's better than this right now. This was looking around up to 2018. These women, Medicare recipients in America, went to a doctor, got a diagnosis of GSM, which might include recurrent urinary tract infections, overactive bladder, pain with sex. You got a GSM-worthy diagnosis.

Speaker 1:
[50:11] Because there's a laundry list of things that are associated with GSM.

Speaker 4:
[50:14] So let's look at this.

Speaker 1:
[50:16] They put it in the chart. They wrote it down. They clicked on a diagnosis code. Like she has been diagnosed with something to do with GSM.

Speaker 4:
[50:23] Yes, within 18 months of that diagnosis, 7% of women were given vaginal estrogen, which is the bread and butter treatment for GSM. Highly safe, highly effective, highly cost efficient.

Speaker 1:
[50:35] And saves lives.

Speaker 4:
[50:37] And saves lives. So, God, I just hope we're better than that right now. So, 20 has 2018 data. But to me, I think about the unmet need, which is why I'm interested in the DHEA over-the-counter solutions because medicine can't help this amount of women. These were the women who had insurance, got to a doctor, made the right diagnosis. So you got through how many hoops and you still didn't get treatment. Now think of all the women in the pond that are suffering that didn't get through those hoops. Yeah. So I think, oh my gosh, seven percent of those got treatment. New paper out of Canada, same scenario, 71 percent didn't get treatment. So they had 30 percent were treated. So Canada is winning over Medicare. But the profound amount of suffering, and doctors are getting more educated. We've got GSM guidelines now. I just talked to Dr. Una Lee, who was a co-author with Rachel Rubin, and I'm like, where's your patient facing one-page handout? Because I go to tell patients, print out the GSM guidelines, bring this to your doctor. Doctors do not like 25 page stapled together things. I want a patient facing one-page document that they can print out and bring to their doctor. So Dr. Lee says they're working on it. You can go free online, print out your GSM guidelines, bring them to your doctor. A lovely idea.

Speaker 1:
[52:01] What is vaginismus?

Speaker 4:
[52:03] Vaginismus is a not-purposeful, so I'm not sitting here trying to clench my pelvis tight. So it's not purposeful, tightness of the pelvis that prevents penetration of the vagina. Painful, painful penetration.

Speaker 1:
[52:15] How common is it?

Speaker 4:
[52:16] Oh, it's probably way under-treated. I couldn't give it to you.

Speaker 1:
[52:19] What's the classical history?

Speaker 4:
[52:21] Five percent?

Speaker 1:
[52:22] We barely touched the surface and she was kind of crazy.

Speaker 4:
[52:25] Yeah.

Speaker 1:
[52:26] That's in the Bitches Be Crazy School of Medicine, like vaginismus.

Speaker 4:
[52:29] Well, people used to think it was probably your mom's fault. All these, again, social reasons for your biologic health issue. It is a lot more acknowledged now of like, can you just relax? No, when you have vaginismus, you can't just relax. You can't treat this with a glass of wine. It is a medical issue with tight muscles that prevent non-painful intimacy.

Speaker 1:
[52:54] I've seen it. They can't even insert a tampon. Nothing. Finger, nothing. Why is there a cultural obsession about tightness of the vagina?

Speaker 4:
[53:06] Oh, Lord. I don't know. Do we care about tightness of penises? Do penises become flabby the more they have sex? There's so much stigma in trying to make you the right woman. Am I tight enough? Am I too tight? Am I too loose? And we're marketing, and we're making money off of this. And again, a lot of it stems from the fact that women don't know. Where do you go online to figure out if your vulva is normal or not? Porn. That's not normal vulvas. Mm-mm. That's, you know, the F1 races.

Speaker 1:
[53:41] And now that we've stripped all the hair, you know, this generation doesn't like hair in the area. Like, they see more, you know?

Speaker 4:
[53:48] Yeah, totally.

Speaker 1:
[53:49] And they're like, oh, my labia don't look like her labia. Therefore, there must be, there's like the uptick in women who, young women, healthy women, who come in requesting labiaplasty.

Speaker 4:
[54:00] Yeah, yeah. And some people think it is because we have a lot more access to video, a lot of augmented video, right? And performative video, right? Even the sexual dysfunctions of like, I'm kind of watching myself have sex, which is called spectatoring, of like, am I performing this properly? The sex therapists who have been around for a long time are like, that didn't used to happen before you could watch people have sex on video. And so now like things are changing because we have access to video and this whole like labial needing to look a certain way. This is what gets me, many things about this get me. Women make less money than men. Women have less net worth than men. Women get paid less for having the same jobs as men. Now we're taking 10,000 of their dollars to cut their labia off? They're already down economically. We've given them a new problem to separate them from their cash? I just want people to think about the craziness of this sometimes. Of like, how many, I was talking to a woman, should I give, blah, blah, blah. How many people do you plan on showing your labia to? Like, is this going to be an income source for you? Like, then maybe make the investment. But if you're with somebody who is supposed to love you, and you're supposed to be in a trusting, loving relationship, who loves you, like, oh, I have such a great relationship with a woman who loves her labia is nice. We just need to step back and be like, what are we obsessing over? And is this the point? And we look back, you know, Elizabeth Komen, Dr. Komen wrote this amazing book, All in Her Head, about, look at all the foolish things we used to do to women.

Speaker 1:
[55:31] Yeah, I think we're still in the bloodletting phase for public health.

Speaker 4:
[55:33] Yes, I'm like, we tried to move the clitoris closer to the vagina in Freud's era. Guess what we're doing now? We're cutting off your sexual organs to make you look a certain way. Are we any better? And I will asterisk all of this. There are some medical conditions where the labia does need a little bit of help. Absolutely. Same with penises, same with scrotums, asterisks.

Speaker 1:
[55:54] Yeah.

Speaker 4:
[55:54] But we are separating hard earned cash from women because we're telling them they need to perform a certain way, look a certain way for the approval of their partners. And it's absolutely shameful.

Speaker 1:
[56:07] What I see advertised is the smell. The vagina should smell a certain way. If you eat the pie, did you see the pineapple videos? You drink the pineapple juice or whatever.

Speaker 4:
[56:18] Not asparagus.

Speaker 1:
[56:19] It was mega viral.

Speaker 4:
[56:20] Yeah, crazy. Again, it's a pure, once you learn, you're like, where is it?

Speaker 1:
[56:24] Should we have a smell?

Speaker 4:
[56:26] Yes, yes, we smell like we have a sweat glands. And the other thing about women who aren't on hormones and then they take hormones, some of them will say, my sweat smells again. Yes, it does, because hormones help the sweat glands be sweat glands, right? Like your sense, your smell actually goes away when your hormones are low enough, which is fascinating.

Speaker 1:
[56:45] Wow.

Speaker 4:
[56:46] But yes, there is a certain musk to things. If there isn't an infection and there isn't something else going on, we all get a little bit musky. Where does it come from? Purity culture, right? Be clean. We're never clean enough.

Speaker 1:
[56:59] No.

Speaker 4:
[56:59] In our society.

Speaker 1:
[57:00] And Komen talked about the shame in the exam room. I can't... Myself, I'm folding up my underwear and that women are always apologizing in the exam room. And I'm almost 100%. And it doesn't matter her socioeconomic status. I've treated royalty. I've treated... And anytime a patient gets undressed, she tends to apologize for something on her body, which is completely normal. Let's talk about vibrators.

Speaker 4:
[57:29] Yay.

Speaker 1:
[57:30] You like vibrators?

Speaker 4:
[57:31] Oh, God, I love vibrators. People are, you know, the whole like, it's not natural. I did... So this got flagged on the Internet. I did a cheeky video saying, you guys, I have a new vibrator and I'm going to show it to you. And out of the bottom of the screen, I brought up my electric flosser that I got. And the joke is I have three vibrators for my mouth now. Like I have an electric toothbrush, an electric flosser and a water pick, right? Like this has never looked so good. And so I'm like, we're using technology to improve upon what we had before we had technology. You can buy it in Costco, right? Normal. But when you improve technology down there, same stuff, vibration technology, we're like, only certain women. Oh, but you shouldn't need that because you've got a partner. Like all of this, I'm like, why is the pelvis the only area that we're like, but not technology there?

Speaker 1:
[58:19] Yeah.

Speaker 4:
[58:19] Like in this technology, this technology is good. And I would say this technology, like some of the vibrators they have, especially the clitoral air pulse ones.

Speaker 1:
[58:27] Yeah.

Speaker 4:
[58:27] There's lots of different brands, but like it works so well.

Speaker 1:
[58:31] Too well.

Speaker 4:
[58:31] I agree. It's too well. It's like, I didn't want this to be a light switch.

Speaker 1:
[58:34] For science, I have to try them all out, right? So that I can adequately cancel my patients because science, I'm a scientist.

Speaker 4:
[58:40] You're a scientist.

Speaker 1:
[58:40] And the vibrator companies love to ship these things to my house and which may or may not freak out my children. My husband gets very excited. So let's talk about like categories of vibrators. So there's the external and I'm just going to vibrate ones. There's the ones that have like a little suction cup over the clitoris. Those are new, there's lots of stuff. And then there are some that have an internal component, you know, some just for the inside.

Speaker 4:
[59:07] So the combo ones. So there's ones that are clitoral suction that actually can curve in and so it can be internal and neutral.

Speaker 1:
[59:15] It turns out I do not have the right anatomy for that.

Speaker 4:
[59:17] I do.

Speaker 1:
[59:20] But I find the little suction cups to be too much.

Speaker 4:
[59:23] It's too fast, too furious. But for some people, that can be the right thing. I just need a little bit more intensity, especially as I'm getting older, right?

Speaker 1:
[59:30] So why is that? Why do we need more intensity?

Speaker 4:
[59:32] Wear and tear on our bodies, nerve changes.

Speaker 1:
[59:35] And I read that the nerves that innervate the vibration, the vibratory nerves, right? So the last ones to go, as far as loss of the myelin sheath with age. Someone taught me that. That is why, if using your fingers isn't doing it, get a vibrator that... And there's a certain Hertz that they measure 30 or something.

Speaker 4:
[59:57] Some of these vibrator companies, like engineers are in there and they're...

Speaker 1:
[60:01] My patients are like, look, I can't see anymore. I don't want to put on glasses to have an orgasm. I don't want to turn on the lights to have an orgasm. I just want to reach over, grab, turn it on and go. And the simple is better. What do you see? Because some of them are very complicated and they cycle through multiple different... Oh, I know.

Speaker 4:
[60:20] To me, I know it's a privacy issue, but I'm like, I'm never going to put something on my phone that's an app that's going to control this. Like, I have no interest in that. I'm like, I want analog, not digital for these. But I think simple is better. I had asked, I don't know if it was a vibrator company, I had asked somebody, I was like, why are there 10 settings for every vibrator? Like, is there science?

Speaker 1:
[60:41] Are there any science to that?

Speaker 4:
[60:42] No, it's just that the factories in China all make them the same way. And so like they made one that way, they just make them all that way. That's like the simple answer to it. They're like, women want different things. And I'm like, I don't know if they do.

Speaker 1:
[60:54] I don't know anybody who goes, you know, they're frustrated having to go through all of the different, you know, cadences of vibration. So they just want to just turn it on and go.

Speaker 4:
[61:05] Can we talk about my vibrator?

Speaker 1:
[61:07] Yes.

Speaker 4:
[61:10] So I have a vibrator coming out.

Speaker 1:
[61:13] Stop it.

Speaker 4:
[61:13] Do you know that?

Speaker 1:
[61:14] I did not know. I know you have the DHEA serum, which I love.

Speaker 4:
[61:17] That'll be coming.

Speaker 1:
[61:18] And I do not have any affiliation, but it is absolutely, it is just the best. I love the texture of it. Yeah. It's like, so lubricant.

Speaker 4:
[61:29] Yeah. So like products on the vulva cannot, in my opinion, they shouldn't be cold. I hate being cold, probably because I grew up in Northern Minnesota. Don't put cold stuff on my vulva. It's not pleasing to me. So I like, I don't like lube that's cold. I don't like any product that's cold. So the DHEA serum is like skin temperature, which makes a big deal. So what is it? It is an external only, because you cannot take a woman who hasn't had penetrative sex in a while, or might have untreated GSM. GSM is horribly undertreated. We should get into that recent Medicare data on that. You can't take that woman and say, here's a vibrator, put this in your vagina. You cannot do that to her. It hurts. But blood flow, number one, prelim data might help signs and symptoms of atrophy. That's super exciting, needs to be researched more. Same with lichen sclerosis, needs to be researched more. Blood flow matters. I just want blood flow. Just experience blood flow in your pelvis. External only vibrator, just goes on the outside. So you can use it with a partner, without a partner. You can flip it, there's a little ridge on it. You can put in between your labia minora, get a little bit of vibration right in the vestibule, but no pressure to put anything on the inside. I just want you to experience pleasure in blood flow. If orgasms happen, awesome. If they're with a partner, awesome. But I wanted to create something that didn't cause more harm, and that was like an intro. In my grand scheme, I want intro, intermediate, advanced. Because women are like, just tell me what to do. There's so much out there. Start with the intro. Start with low pressure, nothing's going on the inside. She is called the Explorer. Stay tuned.

Speaker 1:
[63:15] What is one thing every woman should keep in on her nightstand?

Speaker 4:
[63:20] Kleenex. I mean, I think lube, never have lube too far away. We know lube helps people have orgasms better. And I always say when people, because people get judgy. And I've seen women judged by men on this. I've seen young women. In one week, this is a couple of years ago, in one week, I had two 24 year olds come in for pain with sex. And I never, you know, you learn this in med school. You don't say, you know, do you take your blood pressure medications? You say, when do you forget to take your blood pressure medications? Right. So I say, what lube do you use instead of do you use lube? Right. So what lube do you use? They said, my boyfriend told me that I shouldn't need lube. And I'm like, you're taking sex advice from a 24 year old dude who has no lubrication in his pelvis at all. And you're putting all the pressure on a vagina. And you're starting just by-

Speaker 1:
[64:10] Oh wait. So all of these spicy books, so I've read a few for science.

Speaker 4:
[64:16] There's millions of them.

Speaker 1:
[64:17] And literally, there's a sentence in there. You're so wet for me. It's like this positive thing that they're-

Speaker 4:
[64:27] It's bad sex ed.

Speaker 1:
[64:28] Yeah. That like, oh, he's all excited because she is so moist. So moist is a word I don't love. But there's a lot of liquid in the area.

Speaker 4:
[64:37] Yeah.

Speaker 1:
[64:38] Talk about that.

Speaker 4:
[64:39] Ability to produce moisture is not directly correlated to interest in having sex with a partner.

Speaker 1:
[64:43] Well, can you talk to all these authors out there who are writing this shit? And making women feel like they're crazy? And they're all having simultaneous orgasm.

Speaker 4:
[64:52] I want to write an adult fiction book.

Speaker 1:
[64:56] I will help you.

Speaker 4:
[64:58] With an adult fiction book, established writer who can write, but I want to make it medically accurate.

Speaker 1:
[65:04] Oh my God.

Speaker 4:
[65:05] Let's manifest. Like that, give me that job. I will spend a year. I want that book.

Speaker 1:
[65:10] That would be amazing.

Speaker 4:
[65:11] So where do these young men learn things from? Stories like that, porn, blah, blah, blah. And there's no arousal for her. Her pelvis doesn't know if this is a tampon or a penis, right? So you're putting a hard penis in a dry vagina. She comes to the doctor for pain and she needs sex ed. Get warmed up first, connect, relax, vibration, vulvar massage, all the other things, nipples, shoulders, back. Get your body into the touch. Let it know what to expect. The arousal will come, but don't just come by the guy's ready and hard, put it in. It will hurt. That's trauma. So it's like, again, going back to like, there's so much low-hanging fruit just because we do not have a good sex ed.

Speaker 1:
[66:00] And poor education.

Speaker 4:
[66:02] And these young women are on birth control pills. Birth control pills tend to block.

Speaker 1:
[66:05] Okay. So great segue, because we've talked about medications that can improve sexual function. Therefore, there must be medications that hurt sexual function.

Speaker 4:
[66:15] Yes.

Speaker 1:
[66:16] So talk to me about birth control pills. What do they do? What can they do? Because it doesn't happen to everyone, but it definitely could happen.

Speaker 4:
[66:22] Yes. And some birth control pills are worse than others.

Speaker 1:
[66:26] Yeah.

Speaker 4:
[66:27] But the layman's way of saying it is a birth control pill kind of blocks hormones and blocks the hormones in the pelvis. So you can actually get a vulva that looks atrophic. It looks menopausal. And I always want to asterisk, birth control is amazing. It's changed our world. It's incredibly safe. It's incredibly effective. But you're not getting an accurate, informed consent if you aren't told how it works and what possible side effects might be. I just think that that's good medical practice. Then I'm not here to scare people off of birth control pills.

Speaker 1:
[66:58] So how can a birth control pill affect sexual function?

Speaker 4:
[67:02] It blocks your testosterone.

Speaker 1:
[67:04] How?

Speaker 4:
[67:04] In a perfect world, we would just add a little bit of testosterone into the birth control pill. How does it? It increases your sex hormone binding globulin through the liver. And so then the testosterone is not as free to go do its job.

Speaker 1:
[67:14] Other medications like antidepressants.

Speaker 4:
[67:17] Antidepressants. Again, did you get a fully informed conversation? Of course you didn't. We have 10 minute doctor visits, right? But when 60 to 80% of people have sexual side effects from antidepressants, and in America, 25% of women are on one of these.

Speaker 1:
[67:33] Over the age of 45.

Speaker 4:
[67:36] Yes. Do you have an informed consent? This might happen, right? But again, we blow off sex and it's not important. It's a quality of life issue of like, yes, it's profoundly important. It's profoundly important to relationships. It's profoundly important to your sense of who you are. And these medications can blunt orgasm, decreased desire, high blood pressure medications are another one. Any of the antipsychotics can be some of them. So anything that kind of can dry out things, can dry, affect lubrication, anticholinergics for overactive bladder. So the list of things that might affect sexual function is actually quite long.

Speaker 1:
[68:09] And then there's some new emerging information about GLP-1 medications.

Speaker 4:
[68:12] Yeah. It's going to be very exciting to see what happens with looking at sexual function in GLP-1s. So some of the data in men, when men lose body fat, their testosterone goes up because they're not converting it via aromatase via their adipose tissues to estrogen. So their testosterone goes up when they're on a GLP-1, increased in sexual desire for men. It will improve their sexual function. In women, it might be a mixed bag. A lot of women with GLP-1s, they're postmenopause. They're not on any hormones. Their hormones won't go up because they're on a GLP-1. So are we seeing some decreased desire? Yes, because GLP-1s affect the dopamine pathway of what's rewarding. So we're seeing gambling go down, drinking go down, eating go down, sexual desire go down. So I don't think we don't have a big enough jury out to say, blanket statement, it does this. But to say, hey, it is improving.

Speaker 1:
[69:04] It could.

Speaker 4:
[69:05] Yeah, it could decrease sexual function. It can increase sexual function.

Speaker 1:
[69:08] Body image.

Speaker 4:
[69:09] I like how I look now. I have more energy, right? So again, sex is biopsychosocial. GLP ones can affect that in different ways.

Speaker 1:
[69:19] What do you want every woman listening right now to know about her body?

Speaker 4:
[69:22] You are not broken. You are not broken. You are under-educated. You are likely under-cared for. But this is not a personality flaw. This is biology.

Speaker 1:
[69:33] How does she find a partner in this care? Because she most likely her OBGYN is under-educated.

Speaker 4:
[69:39] So some online companies are good that do hormone care. Interlude, for example, all it does is vaginal estrogen. So that's a great company for vaginal estrogen. I think the Ishwish website is good to find a doctor, because Ishwish has this nice Venn diagram overlap of sex med plus hormones. Because sex med doctors know the role of testosterone for libido. We know the role of estrogen for lubrication and moisture. So Ishwish is in the middle of the Venn diagram of sexual health and hormones. And I think that's probably my best go-to. I mean, you have an excellent list on your website as well. So it's like, the other good option is, do you have a friend who got help? Who are they seeing?

Speaker 1:
[70:20] Who are they seeing? You brought vaginal estrogen as well. All right. I do want to talk about that. So say she finds the right partner in care, they give her the vaginal estrogen, she gets home. And doesn't know how to use it. Is vaginal estrogen absorbed systemically?

Speaker 4:
[70:35] Teeny, tiny, teeny amount. More so in people who are very atrophic in the beginning until they get healed up.

Speaker 1:
[70:41] Until they get healed.

Speaker 4:
[70:42] But then once you have nice, healthy skin down there, absorption is minimal. It stops absorbing. And it's always below.

Speaker 1:
[70:47] Right. If you have raw tissue and I rubbed something on it, you're more likely to absorb the medication.

Speaker 4:
[70:51] That's why I don't do a loading dose. So the common prescription for vaginal estrogen is every day times two weeks, then twice a week. Multiple problems with that. Number one, the loading dose isn't based on any sort of science or paper that I could ever find. Probably to just get it working faster, but it backfires because in people who are really atrophic, really thin tissue, it can burn or you can absorb a lot. Doctor, I thought you told me this wasn't going to go in my body, my breasts are tender. Well, you have really atrophic skin and it sucked up a lot of product. Skin is supposed to be a barrier. When it's atrophic, it's not a good barrier.

Speaker 1:
[71:25] How long does it take to grow that mucosa back?

Speaker 4:
[71:27] Six to eight weeks.

Speaker 1:
[71:28] Okay.

Speaker 4:
[71:28] That's what I tell patients.

Speaker 1:
[71:30] You have to grow it back and it's going to take six weeks.

Speaker 4:
[71:32] If you stop using this, it goes right back to where you are. You go back to the low hormones.

Speaker 1:
[71:36] How do you explain to people how to apply this? They're not on video, so walk them through.

Speaker 4:
[71:41] Okay. What was in my box of Estradial Vaginal Cream, 0.01 percent, which is the generic product available in America.

Speaker 1:
[71:50] How much did that cost?

Speaker 4:
[71:51] This should cost no more than $20. I tell all my patients that. I'm like, if you can't get this for less than $20, you let me know. I will change your prescription to Mark Cuban Cost Plus Drugs. No affiliation. I hope to meet Mark Cuban someday and give him a very big kiss and a hug. But it's a generic product. Your insurance company shouldn't make money off of this. So at Mark Cuban, I think you can get it for $13 plus $5 shipping. So I haven't seen it cheaper than that. That's the best deal that I've found. So it comes in a tube and it comes with an applicator, and I can take this off to actually show it if you want. But two ways to do this. You can fill up the applicator to the one gram on here, and then put it in like a tampon. Or you can put it from the tip of your finger to the second knuckle.

Speaker 1:
[72:38] Now, how do they put it? Where do they put it?

Speaker 4:
[72:40] I would put your finger comfortably in, but you don't need to go to the top of the vagina. I do like it in the middle of the vagina because the bladder and the vagina share a wall, and that's how it helps the bladder out. Decreases urinary tract infections, decreases urgency, frequency, getting up at night to pee. But again, I always say I have a cream bias. Why do I have a cream bias? Cost. Cost. Big one. You should not re-mortgage your house for this, and hey, if we're lucky, menopause is going to last 40 years. You need this to be cheap. The other reason I have a cream bias is because you can put some on your face. Kidding, not kidding. But people do put a little bit. You know that Egypt sold out of vaginal estrogen because all the women were putting it on their faces? An Egyptian dermatologist told me that. But anyways, I like the cream because you can put it on the vulva.

Speaker 1:
[73:23] Yeah.

Speaker 4:
[73:24] Put it on the clitoris.

Speaker 1:
[73:25] A hundred percent of patients, I tell them. Put it on the clitoris. Down the labia.

Speaker 4:
[73:28] Yes. And that six o'clock spot, that tight spot, pain with entry. The classic word, you have pain with sex, pain with entry. It's that six o'clock that gets tight and painful, especially if you had an episiotomy. Side effect. Let's talk about the side effects of this. One of the most common side effects of starting on vaginal estrogen is your microbiome changes because your microbiome is different with estrogen than without estrogen. So a side effect can be a yeast infection is one of the most common ones. I tend to say lower your dose or back off on your dose. You don't have to stop. Treat the yeast infection. As your microbiome changes, that will happen less.

Speaker 1:
[74:04] What is the number one treatment for the prevention of recurrent UTIs?

Speaker 4:
[74:08] Vaginal estrogen. Not FDA approved for that, but it is the most effective. Rachel Rubin, our good friend, did a Medicare analysis paper that if Medicare basically shipped, everybody on Medicare with a vagina, vaginal estrogen, and they used it, it would save Medicare $13 billion a year just in decreased urinary tract infection costs.

Speaker 1:
[74:29] Anything else you want to share with our audience?

Speaker 4:
[74:31] This decreases death. So there was an abstract, I think in neurology conference. Yeah. Was it? There was an abstract and it was women with recurrent UTIs who are on vaginal estrogen, decreased risk of admission to ICU, decreased risk of admission, and decreased risk of death from sepsis.

Speaker 1:
[74:49] When they looked at the breast cancer data, they saw women who were given vaginal estrogen, zero increase in recurrence.

Speaker 4:
[74:57] Multiple studies. Yeah.

Speaker 1:
[74:59] They live longer.

Speaker 4:
[75:01] There's a new paper, women on vaginal estrogen seem to have a decreased risk of rectal cancer. Healthier tissue. Maybe it's healthier tissue, maybe you get less trauma to the tissue, maybe it's a microbiome thing. We don't know. That's newer data.

Speaker 1:
[75:14] How can our listeners find you?

Speaker 4:
[75:17] I hang out on Instagram at KellyCaspersonMD. And I have a sub stack, KellyCaspersonMD.

Speaker 1:
[75:22] You still taking patience?

Speaker 4:
[75:24] I still take patience. I practice currently in Washington State. Getting a California license takes forever. So maybe some decade, I'll have a California license. And my podcast is called You Are Not Broken. Books called You Are Not Broken. Second book is called- And Menopause Moment. You brought that too.

Speaker 1:
[75:40] This is her latest baby.

Speaker 4:
[75:43] So when I was writing this, I was feeling like I was bold. I was like, I'm going to say the big bold things. And the exciting thing about it is it's kind of all come to fruition.

Speaker 1:
[75:52] What are the bold things you said?

Speaker 4:
[75:53] That testosterone exists in female bodies. We should consider using this for health span, longevity.

Speaker 1:
[75:59] Where is testosterone approved in the world?

Speaker 4:
[76:03] Australia, New Zealand, South Africa, and the UK. They're having trouble getting their governments to cover it, but it is available with cash. But this is already outdated because the box warning has come off. So my brand new baby book is all we've already outdated. So that's exciting, very exciting.

Speaker 1:
[76:21] Well, Dr. Casperson, Kelly, the OG of the menopause. Thank you so much for coming to share all your wisdom and knowledge to our listeners and I talk to her every day. So it's so good to see you in person.

Speaker 4:
[76:34] Thanks for having me.

Speaker 1:
[76:38] You can find Kelly through her website at kellycaspersonmd.com, where you can listen to her podcast, You Are Not Broken, and find links to all her books, as well as to more information on her clinic, the Casperson Clinic. You can find full episodes of unPAUSED on YouTube at Dr. Mary Claire. I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram at Dr. Mary Claire and get honest accurate information on health, fitness, and navigating midlife at thepawslife.com. My new book, The New Perimenopause, is available everywhere you buy books. If you're loving this podcast, I have an important request. Please take a moment to follow unPAUSED on your favorite podcast app. Following and listening is what pushes this information to more women who need it. So if this podcast has helped you feel seen, understood, or supported, hit follow right now so you never miss an episode. Thank you for being here with me. Let's keep going, unPAUSED. unPAUSED is presented by Odyssey in conjunction with PodPeople. I'm your host, Dr. Mary Claire Haver. The views and opinions expressed on unPAUSED are those of the talent and guests alone, and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment. Perimenopause is not early menopause. It is its own distinct biological phase, and it has been largely ignored. My new book, The New Perimenopause, is about the seven to ten years before periods stop, a transition that is anything but gentle. Hormones fluctuate wildly, and for many women, this is when anxiety, brain fog, sleep disruption, weight changes, mood shifts, joint pain, and that unsettling feeling of, I don't feel like myself anymore, begin. Long before anyone says the word menopause, perimenopause often starts quietly. It shows up in the brain first, then the body, then everywhere else, and all too often women are told nothing is wrong. I wrote the New Perimenopause because you deserve answers before things spiral. You deserve care before burnout. And you deserve a clear roadmap for a transition that medicine has ignored for far too long. The New Perimenopause is now available everywhere books are sold. Learn more and order your copy at thepawslife.com.