Podcast Summary: BETTER! with Dr. Stephanie Estima

Episode: Your Guide to Estrogen Down There: Pelvic Health & Hormones for Menopause with Dr. Kelly Casperson
Date: November 3, 2025
Guest: Dr. Kelly Casperson – Board-certified urologist specializing in women’s sexual health and hormone therapy

Episode Overview

This episode is a deep dive into menopause, hormones—particularly estrogen and testosterone—and pelvic health. Dr. Stephanie and Dr. Kelly Casperson discuss evidence-backed approaches to hormone therapy, debunk common misconceptions, and stress the importance of informed consent and individualized decision-making for women approaching or in menopause. Topics span cardiovascular and bone health, the physiology and safety of hormone therapy, pelvic and sexual health, and the cultural “naturalistic fallacy” that influences women's health choices.

Key Discussion Points & Insights

1. The "Naturalistic Fallacy" & Social Context

• Naturalistic Fallacy: The widespread but incorrect belief that “natural” is always better—especially in menopause and hormone therapy.
  • Dr. Casperson: “Living 40 years past your ovarian function is not actually natural…this conversation about, like, do you want to be on hormones? Because we got 40 years, ideally, you're going to be without ovarian function.” (44:42)
• The modern dilemma is unprecedented. Women now live decades beyond natural ovarian function, which ancient or even 20th-century women did not.

2. Purpose & Approach of Dr. Casperson’s New Book

• Book: “The Menopause Moment: Mindset, Hormones, and Science for Optimal Longevity”
• Focus on informed consent and body autonomy.
  • “I much more happy when people are like, I feel pretty confident that the risk benefit is in my favor, and I want to choose to be on this for me. And thanks, Dr. Casperson, for the education.” (07:36)
• Emphasis that education is paramount—patients do not have to be on hormones but must know their options.

3. Hormones Are the "Bricks" of Health

• Hormones support cellular health, mitochondrial function, and biomechanics.
• Lifestyle factors (weights, sleep, alcohol, protein, mindset) remain essential; hormones are foundational, but not the whole house.
  • “If you slap an estrogen patch on and you still hate yourself… I haven’t helped everything.” (09:12)

4. Menopause Myths and Critical Timing

• Biggest Myth: Lack of understanding that menopause and its symptoms are due to hormonal decline—not the end of periods itself.
• The timing hypothesis (from cardiology and neurology data): Early hormone replacement is most effective for prevention, especially for cardiovascular health.
  • “Estrogen works best to prevent [cardiovascular issues]. And in order to prevent, you have to keep it in before it ages without it.” (13:43)
• Most bone loss occurs in the two years before menstruation ends, suggesting perimenopause may be optimal for intervention.

5. Reappraising the Women’s Health Initiative (WHI)

• The 2002 WHI study incited mass fear due to misreported increased breast cancer risk. Actual findings were not statistically significant for most women—fear persists decades later.
  • “If you read it, it said, came close but did not reach statistical significance. And I liken that to be like, you're kind of pregnant.” (18:23)
• In the estrogen-only arm: breast cancer incidence decreased. Cardiovascular disease remains the far more significant killer in women.

6. Cardiovascular & Bone Health: The Estrogen Advantage

• Estrogen and nitric oxide: Estrogen keeps arteries supple, improves endothelial function, and mitigates heart disease risk if started early.
• Estrogen and osteoclasts: Declining estrogen increases bone resorption and fracture risk. Testosterone also aids bone health via osteoblasts.
  • “Testosterone helps the osteoblasts… Anabolic simply means to build.” (42:54)

7. Hormone Therapy Nuance: Who, When, and How

• Systemic vs. Local Hormone Therapy:
  • Systemic (patches, pills, gels): Affects whole body
  • Local/Vaginal (creams, suppositories): Targets pelvic tissues without raising systemic estrogen levels.
  • “Vaginal estrogen… just stays in the pelvis… systemic level of estrogen will raise your blood levels, X. Vaginal estrogen… raises your blood levels zero. What's X plus zero? X.” (35:09)
• Vaginal Estrogen & DHEA: Essential for genitourinary syndrome of menopause (GSM), improving comfort, sexual function, and urinary tract health.

8. DHEA—A Forgotten Player

• DHEA: Hormone precursor produced by adrenals, declining with age. Vaginal DHEA (e.g., Intrarosa) converts locally to both estrogen and androgens, supporting both tissue health and sexual function.
  • “Dollar for dollar, I would choose vaginal DHEA, but… it's individualized.” (60:42)
• Oral DHEA has mixed and less clear evidence—potential benefits but also dosage uncertainty due to supplement regulation.

9. Genitourinary Syndrome of Menopause (GSM): Epidemic but Under-Discussed

• GSM impacts up to 80% of women; includes vaginal dryness, atrophy, incontinence, UTIs, and decreased sexual function.
  • “Doctors don't know how to examine the clitoris... So... yeah, so there's that.” (57:46)
• Most women would benefit from vaginal estrogen/DHEA regardless of systemic hormone therapy status.

10. Permission, Autonomy & Culture

• Cultural expectations force women into passive health roles, waiting to be told they “need” something instead of choosing.
  • “Are you seeing how it's like an active decision versus a passive decision?” (44:28)
• There's stark contrast with men, who are often quickly offered testosterone or erectile dysfunction treatments without such social hesitation.

Notable Quotes & Memorable Moments

• About Hormones and Choice:
  • “It’s your body. I am not making any money off of that. I don’t care what you do, but I care deeply that you are educated about what’s happening to your body, and you’re able to advocate for what you want.” —Dr. Casperson (06:07)
• On Policy & Guidelines:
  • “Nobody’s going to stick their neck out and say, we should put all women on hormones.” —Dr. Casperson (29:23)
• On Individualization:
  • “Best is individualized.” —Dr. Casperson (34:44)
• Why Women Wait for Permission:
  • “You’re going to wait for some other expert to give you permission to take care of your body versus I want this, I’m choosing this.” —Dr. Casperson (44:28)
• Grandmother Hypothesis Critique:
  • “The grandmother hypothesis is absolute effing bullshit.” —Dr. Casperson (56:17)
• On the New Longevity Challenge:
  • “We’re living caged... Zoo animals live past menopause... We have shelter, we’re not freezing, I don’t have to haul food or starve—we’re immensely privileged. And then we’re like, I don’t know if hormones are natural. And I’m like, none of this is effing natural, you guys.” —Dr. Casperson (54:56)

Timestamps for Key Segments

• 00:00-01:00: The Naturalistic Fallacy and why hormone loss after menopause is an unprecedented problem
• 05:20: Dr. Casperson introduces her new book, "The Menopause Moment," and her emphasis on informed consent
• 12:03: Myths about menopause; critical windows for hormone intervention
• 14:14: Mechanisms for estrogen action in cardiovascular protection
• 18:00: Breaking down the Women's Health Initiative—what it really proved about breast cancer and hormones
• 29:19: Why guidelines will never be made to put all women on hormones (social/legal context)
• 35:09: The difference between systemic and local (vaginal) estrogen, and why both may be needed
• 36:46: Vaginal estrogen for skin (and the historical use of estrogen in skin cream)
• 42:54: How estrogen and testosterone support bone health
• 44:42: The problem of waiting for "permission" as a woman to seek hormone therapy
• 54:56: Humans living far beyond reproductive years is a new, privileged social experiment
• 56:17: Dismantling the “grandmother hypothesis;” hormone therapy as a path to better aging
• 60:41: DHEA—mechanisms, benefits, and individualization
• 64:50: Female sexual symptoms as early warning signs for cardiovascular issues
• 66:18: GSM—genitourinary syndrome of menopause—a near-universal but neglected condition
• 69:24: Advice for women who missed the early “window” for hormone therapy

Recommendations & Audience Takeaways

1. Informed Decision-making:

• Seek providers open to discussing hormone therapy.
• “You might know more than your doctor who’s well-meaning…but did not get this training.” (31:33)

2. Don’t Wait for Symptoms to be Severe:

• Early (even perimenopausal) hormone therapy offers more opportunities for prevention, especially for bones and heart.

3. Advocate for Yourself:

• Call clinics first, ask if they treat menopause/perimenopause, and remember you deserve individualized care.

4. Lifestyle Still Matters:

• Hormones are foundation ("the bricks"); lifestyle (sleep, protein, strength training) is irreplaceable for real health gains.

5. Consider Both Systemic and Local Hormones:

• Many women need both—systemic for whole-body health, vaginal for pelvic, sexual, and urinary health.

6. Don’t Buy Into the "Naturalistic Fallacy":

• Modern aging is not “natural;” interventions are simply using our privileges to maintain healthspan.

Tone & Language

The conversation is candid, approachable, and refreshingly nonjudgmental. Both Dr. Stephanie and Dr. Casperson use humor (“The side benefit [of squats] is a really nice ass.” (11:59)), analogies, and personal anecdotes to make complex science digestible and relatable while calling out medical and societal double standards.

Final Thoughts

This episode is a must-hear for women over 40, those experiencing peri/menopause, or anyone supporting them. It’s an empowering primer on hormone therapy, pelvic health, and the self-advocacy required to age with agency, not just acceptance.