140. Dr. Kelly Casperson: The Hormone Truth About Women's Longevity

Summary

Extend Podcast with Darshan Shah, MD

Episode 140: Dr. Kelly Casperson - The Hormone Truth About Women’s Longevity
Date: February 19, 2026
Guest: Dr. Kelly Casperson, MD (Urologist, Sex Educator, Author)
Host: Dr. Darshan Shah, MD

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Episode Overview

This episode tackles the largely misunderstood and often stigmatized topic of women's hormones and their central role in longevity, sexual health, aging, and general well-being. Dr. Kelly Casperson—a rare female urologist, best-selling author, and international speaker—joins Dr. Shah to unravel truths about perimenopause, menopause, hormone replacement therapy (HRT), and the societal narratives holding back women’s long-term health. Packed with expert insight, memorable anecdotes, myth-busting moments, and practical recommendations, this conversation is an essential listen for women and anyone invested in their health.

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Key Discussion Points & Insights

1. Rewriting the Narrative of Aging for Women

• Redefining Midlife:

  • Jane Fonda’s inspiration—starting a revolutionary fitness business in her late 40s—counteracts the stereotype of decline after 40.
    • “We have a ton of time...You’re not too old.” — Dr. Casperson, quoting Jane Fonda [02:32]
  • Mindset and muscle/hormone preservation are paramount.
    • “A lot of it is mindset, and a little bit of hormones, and a little bit of muscle.” — Dr. Casperson [05:19]

• Youth-Centric Society:

  • Cultural pressure equating youth with value leads to age shame and early self-limiting beliefs—even as life expectancy rises.
    • “Our society puts a lot of weight on youth…there’s a lot of like, age shame happening.” — Dr. Casperson [04:11]

2. Dr. Casperson’s Journey & Mission

• From Surgery to Sexual Health:

  • Seven years into practice, a patient’s despair over a sexless marriage motivated Dr. Casperson to pivot and self-educate in women’s sexual health and hormones, windowing into a major gap in care.
    • “One patient...changed my life.” — Dr. Casperson [14:28]
  • Overcoming medical gaslighting and system bias:
    • Female sexual health patients were often dismissed or handed off due to the system's lack of support.
      • “Women aren’t the problem. The system’s not set up for them.” — Dr. Casperson [10:32]

• Public Education:

  • Starting her podcast, “You Are Not Broken,” to fill a void in public and professional women’s health education.
    • “The only permission you need is your own.” — Dr. Casperson [12:36]

3. The Myths and Realities of Hormone Replacement Therapy (HRT)

• Perpetuated Myths:

  • Outdated fears about HRT, especially the flawed interpretation of the Women’s Health Initiative (WHI) study, still dominate culture and med school curriculums.
    • “The fear...is so ingrained. I ask women, 'Where did you hear that from?' They don’t know. It just is.” — Dr. Casperson [18:22]
    • “You might get sued if you give someone hormone replacement therapy...so it’s probably in your best interest not to do this.” — Dr. Shah [16:53]

• Truth and Safety:

  • Data show transdermal (patch) estradiol is safe and does not carry the same risks as oral synthetic hormones (WHI's main studied drugs).
    • “Transdermal estradiol doesn’t do any of those things…no increased risk of blood clot, no increased risk of stroke. It’s incredibly safe.” — Dr. Casperson [49:44]
  • HRT should often be a default consideration:
    • “For most people, we almost have to find a reason not to put them on hormone replacement therapy.” — Dr. Shah [19:26]

4. Holistic Approach to Perimenopause & Menopause

• Fundamentals First:

  • Assess basics: sleep, exercise, diet, substance use, and overall wellness before layering on hormones.
    • “If you don’t do the basics, you’re going to be like, these hormones don’t work.” — Dr. Casperson [35:26]
  • Exercise and strength are especially critical as muscle and bone loss accelerate with menopause.
    • “Women should be adding strength...You have to undo this societal beauty perfection culture.” — Dr. Casperson [37:53]

• Personalized HRT Protocols:

  • Selection and titration should be symptom-led: progesterone for sleep, testosterone for low libido/energy, then estrogen as needed.
    • “What are her goals, what are her symptoms? This is not cookie cutter.” — Dr. Casperson [43:08]
  • Emphasizes necessity of vaginal estrogen for most menopausal women, for sexual function and prevention of atrophy and UTIs.
    • “Genitals need hormones. Hormones go away...Even if you have no symptoms, should you be on it to preserve sexual health?” — Dr. Casperson [44:34]

5. Systemic Problems in Women’s Healthcare

• Too Few Specialists:
  • Only 35,000 OB-GYNs in the US, many focused on labor/delivery, are expected to serve 80 million+ women over 40.
    • “The numbers don’t math. We need ‘mass transit.’” — Dr. Casperson [22:07]
• Structural Dismissal:
  • Many women are misdiagnosed or not even offered evidence-based treatment like vaginal estrogen.
    • “If you went to a doctor and got the proper diagnosis…7% got a treatment.” — Dr. Casperson [46:30]

6. The Role of Technology & Data Empowerment

• Paradigm Shift:
  • Patients can now access and interpret their own lab results and wearable data, pushing doctors into guidance and partnership roles.
    • “Doctors are going to now be held to a higher standard because patients know what this data means.” — Dr. Shah [25:40]
  • Wearable tech and continuous monitors (CGMs, soon hormone sensors) promise ongoing insight for personalized protocols.
    • “Hormones are coming [to continuous monitors]. The data’s in your hands.” — Dr. Casperson [32:22]

7. Sexual Health, Blood Flow, and the ‘Orgasm Gap’

• Blood Flow is Central:

  • Exercise, sleep, nitric oxide (leafy greens, beets), and possibly safe medications (Viagra, Cialis) all enhance sexual function via blood flow—often more research is needed for women.
    • “Women who exercise more have more satisfying sex lives up to a point.” — Dr. Casperson [58:12]

• Orgasm Gap and Sex Ed:

  • Heterosexual women orgasm far less than men (60% vs 97%); same-sex couples have narrower gap. Hookup culture dramatically widens the gap for women (7%).
    • “They’re literally having different meals.” — Dr. Casperson [79:19]
    • “Men are eating five-star Italian restaurants. Women have Chef Boyardee in a can…and you don’t wonder why they like Italian food less.” — Dr. Casperson [81:41]

• Social and Mindset Factors:

  • Mindset, communication, and defining “desire” are crucial. Responsive desire (which arises during/after sex) is normal and not a pathology.
    • “Desire for sex happens during sex when I’m in the sexual context or after sex…So many women don’t have desire. Of course you don’t!” — Dr. Casperson [76:29]

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Notable Quotes & Memorable Moments

• On Mindset and Aging:

  • “Life expectancy’s never been longer...why do we act like it’s over?” — Dr. Casperson [04:05]

• On Systemic Sexism:

  • “I was told to do a fellowship so I didn’t have to deal with women.” — Dr. Casperson [10:05]

• On Dismissal in Clinical Medicine:

  • “Lab values are not written in stone. That was Tuesday at 10am, that is not the whole week.” — Dr. Casperson [33:59]

• On Overcoming Medical Myths:

  • “The only permission you need is your own.” — Dr. Casperson [12:36]
  • “SSRIs are more risky [in older women] than estrogen therapy.” — Dr. Casperson [55:19]

• On Sexual Education & Communication:

  • “Did she actually ever have good sex in the first place?” — Dr. Casperson [67:31]
  • “Communication, communication, communication. Especially if you want sex with another human.” — Dr. Casperson [75:04]
  • “Let your partner take you to the party. Desire for sex might happen during or after sex.” — Dr. Casperson [75:54]

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Timestamps for Important Topics

• [02:32] — Jane Fonda's Midlife Reinvention; Mindset and Exercise
• [05:19] — Mindset, Muscle, and Hormones Drive Aging
• [07:56] — Dr. Casperson’s Path from Urology to Women’s Sexual Health
• [10:09] — Dr. Casperson Confronts Systemic Attitudes Toward Female Sexual Health
• [14:28] — “One Patient Changed My Life”
• [18:22] — Cultural Fear of HRT; Lingering Myths from WHI
• [22:07] — Stats: 80 Million Women, 35,000 OB-GYNs—A Numbers Game Failing Women
• [35:26] — Exercise, Movement, and the Foundation for Midlife Health
• [43:08] — How to Choose Hormones: Individualized Approach
• [44:34] — Vital Importance of Vaginal Estrogen
• [49:44] — Why Transdermal Estradiol is the Gold Standard
• [55:19] — “SSRIs are more risky…”: Reframing Drug Risks
• [58:12] — Exercise and Sleep are Pillars for Sexual Health
• [75:04] — “Communication, communication, communication.”
• [76:29] — Defining Desire—Responsive vs. Spontaneous
• [79:19] — The Orgasm Gap in Heterosexual Couples
• [81:41] — “Men are eating five-star Italian...Women have Chef Boyardee...”

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Practical Takeaways/Action Steps

• Women in perimenopause/menopause should:
  • Seek education about their bodies and symptoms
  • Prioritize sleep, exercise (especially strength training), and nutrition
  • Advocate for personalized HRT—don’t just accept “no” or fear-based advice
  • Strongly consider vaginal estrogen for urogenital health and sexual function
  • Track personal health and hormone data with wearables and labs
  • Expect an ongoing, relationship-based adjustment process when starting HRT
• Open communication and regular sexual education support lifelong sexual health
• Healthcare systems and technology must shift from gatekeeping to guiding and supporting—women deserve empowered, informed care

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Resources & How to Learn More

• Podcast & Books:
  • You Are Not Broken (podcast and first book)
  • The Menopause Moment (second book)
• Website & Social:
  • kellycaspersonmd.com
  • Instagram: @kellycaspersonmd
  • YouTube, Substack

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Summary Tone

Candid, evidence-based, empowering, and deeply practical. Dr. Casperson and Dr. Shah deliver the facts, bust myths, and encourage listeners—especially women—to claim agency over their health, hormones, and longevity.

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If you’re a woman in midlife, know someone who is, or simply want to age vibrantly, this episode is a high-yield, science-backed guide to thriving, not just surviving, in your second half of life.

Transcript

[A]

Welcome to Xtend with me, Dr. Darshan Shah. A podcast dedicated to cutting edge science research tools and protocols designed to help you extend your health span. Having become one of the youngest doctors in the country at the age of 21 and trained and board certified at the Mayo Clinic, I've accumulated three decades of practice as a board certified surgeon and longevity expert. Over that time, I've discovered that a mere 20% of health knowledge yields 80% of the results. When it comes to your health span, we are living in a new era where we are creating a new healthcare system no longer focused on disease management, but achieving optimal health and vitality. Join me as I interview world renowned experts offering you a step by step guide to proactively avoid disease and most importantly, extend your health span. What if your low libido isn't a problem to fix, but your body is sending you an important signal about your hormones and your health? For decades, women have been told that loss of desire is all in their heads, or worse, just part of getting older. But what if the real issue is biological and completely curable? In this episode of Xtend, I'm going to be sitting down with Dr. Kelly Caspersen. She's an MD urologist, a sex educator, and author of you are Not Broken and the upcoming book the Menopause Moment. As one of only 10% of urologists who are female, Dr. Kelly brings a rare perspective on female sexual health and hormones. We break down why perimenopause and menopause are hormone crises affecting brain, bone, heart and sexual function. You'll learn why estrogen loss causes physical changes that make sex painful and how testosterone drives desire and energy. We'll learn why vaginal estrogen and HRT are evidence based treatments and. And how to talk to your doctor without getting dismissed. If you've ever felt broken or blamed about your sex life or body in midlife, this conversation will change how you understand what's really happening and give you the tools you need to take action. Kelly, so excited to have you on the podcast.

[B]

Thanks for having me.

[A]

Yeah. This is amazing. So you just got off the stage with Jane Fonda.

[B]

I just got off the stage with Jane Fonda.

[A]

What was that like, surreal.

[B]

Like, Like I knew she was an icon. Yeah, right. Like I knew. And then I was there and I was like, oh no.

[A]

The.

[B]

The icons. For real.

[A]

There's a reason she's an icon.

[B]

There's a reason she's an icon. And you hear the story and like the thing. The one thing that struck me the most is she's like, yeah, when I started my fitness business company, I was like 45, or maybe I was 48. And I was like, that's right. We have a ton of time. And you've. And she's like, you're not too old.

[A]

Yeah.

[B]

Right. Like, you don't even remember when you, like, changed the world with your fitness company. Right. Like, and it's not because her memory's poor. Her memory is very sharp.

[A]

Yeah, she's super sharp.

[B]

Right. But you're like, that was one of those things that happened that decade. And she's like, in the 70s, in the 60s, in the 80s. And you're just like, wow.

[A]

And I, I went to medical school, you know, in the 80s. And I. I remember, like, growing up with Jane Fonda, like, there she was always. She was one of the first fitness influencers. Right?

[B]

Yeah.

[A]

Everywhere. On tv, videos, tapes, when those was a thing, people probably listening, don't even know what a videotape is.

[B]

Yeah, totally. No, totally iconic. Very funny.

[A]

Yeah, very sharp.

[B]

And we had a great talk and I did like an hour long panel with her. And then when I gave my keynote, I followed her and I'm like, I am following Jane Fonda.

[A]

Yeah.

[B]

On stage.

[A]

Pretty incredible.

[B]

It's like, incredible.

[A]

Well, you deserve it. I mean, you are also an icon in the field of women's health.

[B]

Thank you.

[A]

And so excited to have you here. So she is 88 years old.

[B]

She's 88 years old.

[A]

Yeah.

[B]

Her Wikipedia page takes about 45 minutes to read. I know from experience, it's. It's a long life.

[A]

And you know what's really cool about that too is like, she was in her 40s when she started her fitness company. And like, a lot of people I meet right now in their 40s, they feel like now they're on the decline. Isn't that people like Jane? And it's like, you're just. You can't be just getting started.

[B]

Life expectancy is never been longer.

[A]

Right.

[B]

And we're like, well, it's over.

[A]

You know, I know. Why? Why do we do that?

[B]

I don't know. Well, our society puts a lot of weight on youth.

[A]

Yeah, right.

[B]

And a lot of weight of, like, a lot of weight on, like, well, you weren't first and other people did it before. Like, there's a lot of like, age shame happening. Right. Like, I saw, I saw a patient. I see a lot of people for sexual health and hormone health. And I saw this couple and they're in their 70s and they're having the Best sex of their lives. Been married for four years. They needed some help, they had some pharmaceutical help. But like, they're like, this is the best, right? Literally, like that same morning, a married couple in their 40s came in and they're like, well, Doc, if you just tell us that we're too old for this to be good anymore. Like, I. So we'll just, we'll believe that. We'll take that. Like, do we just. And I was like, I had some 73 year olds in here earlier today who are having the best sex of their life.

[A]

Right.

[B]

And I'm like, I've got 40 year olds who are like, well, if you say it's over, I guess it's over.

[A]

Oh my God.

[B]

Yeah, yeah. It's like the perspective, right? It's like you have Jane Fonda who's at 88, is like exercise every day. I know that's the key to my success. Like, keep learning new things. Have it surround yourself with people who love you. Right. I'm like taking notes before I go on stage. It's like a lot of it's mindset.

[A]

Yeah, a lot of it. I mean, I would venture to say it's almost all.

[B]

It might all be mindset and a little bit of hormones and a little bit of muscle.

[A]

Yeah, exactly. Like, if you really boil it down, like, you know, you and I have been doing this stuff for a long time and you look at age related decline, it really is just a decline in muscle and decline in hormones. Yeah, right. I mean, I think everything else is. Comes from that. Like all the other aging, the frailty, the bone, you know, Vonda is. And we're very good friends with Vonda, Right, too. Like in. We were just talking to Luisa, who talks about the brain. All of it, all of that sequela, I would say, of aging comes from loss of muscle and loss of hormones.

[B]

Yeah, I completely agree. And you know, and especially in medicine, we're so organ centric. Like, these are the liver guys, that's the brain lady. This is the glucose person. And it's like, you guys, it's all a unit, right? And the unit affects each other, right. It's like hormones, you know, hormones get so stereotyped. Like they're just for hot flashes or they're just for libido. And it's like it goes everywhere and it affects everything.

[A]

It really, really does. So I'm so curious about you though, as a person. You know, you're. You and I both trained in Minnesota at some points in our lives. And when you Go through medical training in Minnesota. Like, you really put your time in because it is not.

[B]

Minnesota is a land of overachievers.

[A]

Exactly.

[B]

And it also has the weather, overachieving, because, like, what else are you going to do in. In January? It's like, unless you play ice hockey.

[A]

Yeah.

[B]

Like, you're in the library studying, you know, so, like, it's like the most educated or the most advanced degree state in the nation.

[A]

Yeah.

[B]

And it's like you're. You're competing with, like, very smart people in Minnesota.

[A]

Exactly. You know, I trained in the Mayo Clinic, and when I first got there, my first day of training, I'm like, why is this massive, incredible hospital the smartest people in the world out here? And then my first winter, I figured out why. It's because during the winter there's nothing else to do except for learn and work and just be in it to win it. And so I get it.

[B]

Yeah, yeah, yeah. There's. And there's a work ethic, I think, in the Minnesota people as well, of, like, it's just expected of you.

[A]

Yeah.

[B]

I actually interviewed for residency on the east coast at a place and they're like, oh, you're from Minnesota. And they said, you will find we don't work as hard here. And I was like, oh, the reputation. The reputation travels.

[A]

Yeah, it definitely does. Definitely. So you're a urologist. I mean, that's intense training, a lot of surgical training. And I'm just wondering, when was the moment that you decided to just really hone in and focus in on women's sexual health and hormone health? Yeah. Because, you know, I mean, you, you. You'd spend a lot of time learning how to do urological surgery, et cetera, et cetera. So was there a defining moment or like a career path change? Yeah, tell us about that.

[B]

Totally. So as a general urologist, for any listener that doesn't know, urologist is a surgical subspecialty of the genital urinary organs. So starting from the top, adrenals, kidneys, ureter, bladder, urethra, and stereotypically male genitalia and male quality of life. Right. Testosterone, Viagra, etc. So that's the urologist. And so I fell in love with urology. Nothing beat urology. Urology. Urologists are funny.

[A]

Yeah.

[B]

You have to not take things too seriously when you work in the pelvis. Right. So I was a general urologist, tended to see more women because there are so few female urologists. So the patients just gravitate towards me. Some really liked female Urology, bladder leakage, pelvic organ prolapse is a lot of my work. Still nothing better than a distal ureteroscopy, though. That's my favorite surgery.

[A]

I love it.

[B]

So in residency, I had an attending tell me, watch out for the seven year itch. Whether that's your marriage or your job, something happens at seven years, you get a little bored, you might get a little complacent. Seven year itch. And at seven years, I was kind of bored. And I was like, why did I do all this training to just see recurrent urinary tract infections 27 times a day and say the exact same thing? Right. And am I. Am I making a difference? And I actually told one of my partners, I'm like, I'm bored.

[A]

Yeah.

[B]

And so I now believe, looking back, I'm like, I now believe the universe was like, she's ready. And the universe delivered to me one of my patients who I was already very bonded with and very much I loved her. We had treated her for invasive bladder cancer. Very big surgery got her through that. Got to know her family, know her husband. And that day in clinic, seven years into my private practice career, she was crying in my office. She was crying in my office because of her sexless marriage. And I'm handing her a box of Kleenex. And everything from residency that I was told came up. Women are difficult. They take too much time.

[A]

Oh, my gosh.

[B]

We don't know about. They're too complex. We don't know how to help them. And don't worry, the gynecologists are taking care of them anyways. These are things. I'm like, people are blown away by it, but, like, you know, the indoctrination of medicine, like, absolutely. I was young. I was told that. And you're like, okay, like, that's. I was told to do a fellowship so I didn't have to deal with women.

[A]

Oh, my God.

[B]

That is what I was told. Wow. Yeah. So all that came up.

[A]

So much gaslighting in the medical.

[B]

It's wild. Like, I tell this story and I'm like, no, no. That was my reality. Like, that was the era we grew up in.

[A]

You know, I corroborate that because I remember doing my OB GYN fellowship and talking to some of the attendings, and they're like, you don't want to do this if you can't deal with hormonal emotional issues. Like, what do you mean? And, you know, it's the same kind of thing.

[B]

It's like, prepare yourself For I'm much older and wiser now. What I think they're saying now, if I look at it in a kind way, our system isn't set up for women. So women became the problem. Right. It's like, women aren't the problem. The system's not set up for them. So here's my patient. Everything's going through my brain. I'm handing her the box of Kleenex and I thought, I don't know how to help her.

[A]

Wow.

[B]

But I take care of men with sexual health problems. Which begs the question, who's taking care of the people who are supposed to be sleeping with? The people that I'm giving testosterone and Viagra to?

[A]

Yes.

[B]

And that started basically a year long educational journey for me. Great opportunity because I was bored.

[A]

Right.

[B]

Fantastic. Time to learn something new. So started going to the conferences. Ishwish Conference, International Society for the Study of Women's Sexual Health for people who don't know what that is. Started reading the journals, started talking to all the sex therapists, started figuring out, you know, hormones. And then I was like, I can't change the world. I was starting to realize how big of a problem this was. I can't change the world just by being in my clinic and seeing people in my town. This is too big now. Like, I realized it. And so a voice in my head was like, you need to talk. You need to talk. You need to share your knowledge. You need to talk. And I was like, this voice is very annoying, but it wouldn't go away. And this was, you know, seven years ago now, and I was starting to listen to podcasts, and I was like, well, I like podcasts. Maybe we should do a podcast about women's sexual health and I'll teach adults about women's sexual health. And I was like, ah. But I didn't do a fellowship in this. There's one. At the time, there was one fellowship. One spot in America.

[A]

You're kidding.

[B]

One spot. Now there's two spots. It's still only two spots for female sexual health. Yeah. Wow. One's by a gynecologist, one's by a urologist. And so I'm like, I didn't do the fellowship, though. Maybe I don't know enough. And so I was wait. I was actually waiting for somebody to give me permission to be like, kelly, you know, enough now. Right?

[A]

Yeah.

[B]

And I got out of the shower one day and like, lightning strikes and the only permission you need is your own.

[A]

Yes.

[B]

And I was like, okay, start the podcast.

[A]

Right.

[B]

So I started the podcast. It's called you'd are not broken. And the reason it's called you'd are not broken is because women kept coming in and being like, I don't have an orgasm with penetration. And I'm like, well, you're not broken. Only 30% of women do. The clitoris is actually the organ of pleasure. Another woman would come in and be like, I've never had an orgasm. And I'm like, well, you're not broken. 10% of women have never had an orgasm. Not because our bodies don't work, but because the way we shame women about touching their body. Learning about their body. Boys get to learn about their body. They have to hold their penis to pee.

[A]

Yeah.

[B]

Right?

[A]

Yeah.

[B]

So boys get to touch their genitals in a very socially acceptable way. They understand their body more. Women are told not to touch their body. Right. So you're not broken. You just didn't get the education. And I think so much can be fixed by just a little bit of education.

[A]

Absolutely.

[B]

And so the podcast started for sexual health and then morphed also into hormones, because they're like, you know what happens to your sex life with menopause? And I'm like, no, moving on. And then the next one, you know what happens to your sex life with menopause? You know what happens to your sex life with menopause? And I'm like, what the heck happens to your sex life with menopause? Let's go down that. Yeah, let's go down that aisle. Right? And I'm like, I'm staring down the barrel, like, let's learn about this. Right? And so I'm like, oh. Estrogen is essential for blood flow and moisture and to decrease pain. Oh, testosterone. We've got international guidelines on female testosterone for low desire. Oh, my gosh. Plus, I give 10 times the dose to men every day. I'm not afraid of testosterone. Right? And so started learning about hormones and, oh, my gosh, why are we afraid of them? What the heck was the whi. And just kept peeling off the layers of the onion at a time when this was getting really big, Right? So to me, I'm like, man, I caught the wave of sexual health. I caught the wave of menopause, you know? And now I'm like, oh, yeah, International. International expert on this. Because a patient changed my life.

[A]

One patient.

[B]

Yeah, one patient.

[A]

Incredible story.

[B]

Changed my life.

[A]

Well, I mean, kudos to you, too, because you actually listened and you did more than what? You know, unfortunately, like, we only have sometimes 1520 minutes with our patients. So, yeah, it's really easy. Just move on to the next thing. Write a referral to somebody. Like, you should talk to your OBGYN about this. And you actually paid attention and you listened and you didn't know something and you realized it and you admitted it to yourself and you went out there and learned about it.

[B]

Yes.

[A]

And I think that's critical. And I wish so many more physicians would do this, because so many physicians are stuck in the mentality of hormone replacement therapy is something that you have to protect yourself against more than anything, you know?

[B]

Yeah. I mean, I think two things. I think the traditional medical system, curiosity is not available anymore. You need time for curiosity. You need space for curiosity to learn things. Right. So I'm like, the traditional medical system's not set up for people to be like, I don't know, let's figure this out. And then number two, what I was taught in medical school is 50% of what we teach you will be wrong.

[A]

Yeah.

[B]

But we don't know what that 50% is. Right. And in that sense of like, stay humble, man. Yeah, like, stay humble. We don't know. Things are always changing. And I see that a lot of, like, tell me exactly the dose and exactly the lab and exactly this. Like, we're still figuring it out.

[A]

Right.

[B]

But a lot has happened between you learning in med school that hormones are dangerous and 20, 26.

[A]

Yeah, exactly. In, you know, to compound the problem, too. The speed of dispersion of medical knowledge is so slow.

[B]

Yeah. And the speed of new knowledge, it's like. Do you read about this? It's like the rate of change or knowledge gained right now in medical publications alone is like a whole new textbook.

[A]

Exactly.

[B]

Like yearly, like, it's insane. The knowledge to stay up on top of it.

[A]

Right.

[B]

Yeah.

[A]

Right. And so it's so hard for the average physician to keep up with it. And then it's so, you know, medical schools are still stuck back in what they were teaching people maybe 20 years ago. And so you have all these new physicians that are going out there. And I just talked to a brand new physician, like, I think this was like six months ago, just graduated from a family practice residency. Okay. Going out there talking about hormone replacement therapy. And even this new physician told me that hormone replacement therapy, there's a risk of cancer, so you have to be very careful. Bummer. I was so sad.

[B]

Bummer. I was so sad to hear this. Exactly. Bummer.

[A]

I was so sad to hear this. And, you know, the prevailing kind of thought process There is. You might get sued if you give someone hormone placement therapy if they develop a cancer. So it's probably in your best interest not to do this or to send them to an endocrinologist.

[B]

Yeah. Which there's plenty of endocrinologists sitting around with nothing to do, waiting to take care of 50% of the population. If you look at female hormones, the other thing that's crazy about it in me, kind of learning. And to me, I'm like, listen, I'll admit that maybe I. Maybe I am weird. Maybe it is weird that I like reading medical journals and. But, like, I'm obsessed with this topic now.

[A]

Right.

[B]

Like, there's. I'm obsessed with it. And what's so crazy is the initial WHI study from 2002 published in Jamaica is open access and free on the Internet.

[A]

It is. Right.

[B]

Anybody can read that the cancer was not statistically significant. You can read that at any time right now. Right, Right. So to me, for people just to be like, it's in the zeitgeist. It's just in the ether.

[A]

Yeah.

[B]

But it's that fear. And truthfully, when I talk to women, I was talking to women today about it. I was like, what's the best way to control a woman?

[A]

Yeah. Fear.

[B]

Keep her afraid.

[A]

Keep her afraid.

[B]

Keep her afraid. What better way than to keep her afraid of something her body naturally makes?

[A]

Right. Right.

[B]

And once you see that, you're like, oh, my Lord.

[A]

Wow.

[B]

Right. And it's like that fear that we're trying now that we're 20 some years past the whis, like, that fear, we're still. It's so ingrained. It's so in the zeitgeist, it's so in the ether, that I asked women, like, where did you hear that from? Like, are they going to quote me a 2002 jama paper?

[A]

Right, right.

[B]

Where do you hear that from? They don't know. It's just. It just is.

[A]

It's just. There's just.

[B]

There's gravity and there's one moan, and it just is.

[A]

Exactly.

[B]

And to me, I'm like, is nobody curious about where that came from?

[A]

Right, Right. Exactly. I wonder that, too. And, you know, just this year now, we're finally living in a time where there's mainstream media attention to that not being a study that we should be hanging our hat on anymore. And, you know, finally, there's some momentum, especially with podcasts, the work you're doing.

[B]

Yep.

[A]

But it's just my. You know, I speak all over the nation, and I Just got back from Tulsa, Oklahoma, and someone asked me in the audience. I heard estrogen replacement therapy causes cancer. Is that not true? And, you know, it made me boil up a little bit inside because I was like, oh, no, it's not true. And explained to whi the misinterpretation of it, et cetera, the new studies. And I think, you know, we just gotta do the best we can, which is what you're doing, spreading this knowledge to. To me, it's almost like any man or woman that comes to our clinic, we have to almost find a reason to not put them on hormone replacement therapy. Right.

[B]

Yep.

[A]

There's. It is. And you and I were talking about this earlier, is that aging really is due to two things is loss of muscle and loss of hormones, for the most part. Right. And if you can mitigate both of those, there's a chance that you're gonna age like Jane Fonda did.

[B]

Yes.

[A]

88 years old and still sharper and stronger than people half her age, probably.

[B]

Yeah, yeah, yeah. And I think, you know, people. People don't understand their own power.

[A]

Yeah.

[B]

In the control of the health. And. And there's probably many reasons to blame for that, but I think one of them giving. Give me your opinion. But it's like this. This gene theory kind of messed us up because we're like, well, you know, it's just your genes.

[A]

Yeah.

[B]

It's just your genes. You can't pick your parents. And it kind of took away this agency of like. And now the experts know, like, genes are really not everything. You can have genes. You can have genes for cancer and never get cancer. And people do not know that. Right. And it's like you. There's this lack of agency because we're like, well, you know, it's just genetics.

[A]

Yeah. I am so with you on that. And it was another one of those media frenzies that turned out to be nothing, but it turned out to be worse than nothing because like you said, it gave people an excuse, but it also took their power away too. Like, obesity became a genetic thing for many, many years. And obviously there's components to it, but you can fight through that. And to your also, to your point there, Alzheimer's disease, this APOE gene, and how if my mom had it and I have family members with it, I'm probably gonna get it. It just is what it is. And the reality is, we know that's not the truth. You can't protect against it.

[B]

Yeah, totally. And genes aren't everything. But I think the, like Genes, you know, Remember. I remember the couch I was sitting on when the news announced, we have mapped the human genome. Like it was such a big deal. Like we're gonna cure everything now. We know everything now. And here genes aren't everything. Like it's. I'm glad we are doing all this work, but it's not everything. But so many people are like, well, it's just my genes.

[A]

Yeah. How do you feel about the current kind of sphere of knowledge out there in medicine right now? How's. How are you feeling about it? Like what we're learning now, what we know now. Do you feel optimistic?

[B]

Yeah. I mean, it's a wild, crazy time right now. Right? Because I mean, just. Let's just do the math for a second. In America alone, we have 80 million women over the age of 40, 1 million physicians of those. Because again, this is the other damning thing we did. There's one type of doctor that takes care of women.

[A]

Yeah. Yeah.

[B]

And there's 35,000 of them. Right. OB gyns for anybody wasn't tracking that. But to tell 50% of the population there's one type of doctor for you to go to for everything is immense.

[A]

Yeah.

[B]

Like the numbers don't matter. So because everybody's so upset at the ob gyns of like, they don't know anything about hormones. They don't. I'm like, why are you putting all of, why are you putting 50% of the population on one type of doctor?

[A]

And there's only 35,000 and. But half of them are delivering babies.

[B]

As I said on stage today, I'm like, babies cause bleeding. They get stuck in vaginal canals. Like OB gynes are busy. Give them space. Right. And we, and we know we do not have enough OB gyns for our population. And it is getting more dire. So this basic math, you're like, okay, 80 million women over the age of 40, 100% of them will outlive their hormones. What are we going to do? Right. The math doesn't math. And so I think all of these things that are happening of like, I call it mass transit, which is the online telehealth company of like, we need mass transit. The numbers can't math even if you just do 10 minute appointments. We need mass transit. So. And AI.

[A]

Exactly.

[B]

And how do you scale a brain? How do we scale your brain? With your knowledge of longevity and what's fresh and what's new. How do we scale. Scale that. Right. Because we. You how many people can only one person see Absolutely. Right. So it's AI, it's mass transit, and there's something that we've lost that I think is precious. And it's called the doctor patient relationship.

[A]

Yes.

[B]

And there will always be a role for caring, compassion, the expert who helps interpret. But I think the role, and you're seeing it right now like the role of the doctor as the person with all the information that's going away. Because the doctor used to have the medical library. Right. That's all they had. But nobody else had that.

[A]

Exactly.

[B]

Everybody has AI.

[A]

Right.

[B]

Everybody has a cell phone. Right. Not everything on. That's true. But doctor, how do I navigate all of this?

[A]

Right now? I have the information.

[B]

I can get all the information. I can go home in a relaxed environment and do tons of research on this. And so it's a power dynamic that's shifting. And I think some physicians are like, what's our role? Oh, my gosh. Elon Musk, I think, said we don't need to go to medical school anymore.

[A]

Couple weeks ago.

[B]

Yep.

[A]

Yeah.

[B]

But my God, do you want somebody to hold your hand through all this when. When shit's hitting the fan? Yeah. So I think there is a role for that and there will always be, you know, we call them normal Barbies and, and weird Barbies of like, normal Barbie. You don't need as much if you're a weird Barbie. You might need a different level of care. Right. And so, like, to me, I don't think it's all doom and gloom.

[A]

No.

[B]

I mean, I'm having the time of my life as a physician right now.

[A]

I agree.

[B]

Like, I am so glad I went to medical school. I'm so glad I knew what I. What I know now. And so it's changing, but it's not gonna be one size fits all.

[A]

I agree with you. And you know, the other thing, other component of this that I think is really transformative is people finally are not gatekept from the data of their own body.

[B]

Yes.

[A]

Right. They can get their own blood biomarkers done. They can do it themselves without even having to request a doctor to order them. That's how it was 10 years ago. You had to ask your doctor for this.

[B]

I think it's fascinating.

[A]

I do.

[B]

So I was talking again. I was talking to very intelligent, well connected women. And I'm like, okay, there's a company. We don't need to name names. But there's a company. All it does is labs. It won't interpret them for you. It won't help. You know what to do with them. It just checks labs. It's worth $2 billion. Right, right. Like, that's the. That's what's been missing. Because people go to their doctor and they say, can I check my labs? Can I check apob. Can I check? Blah, blah, blah. And the doctor says, no. And we. There's. They're not gatekeepers anymore. And I'm like, that's your health. That's your body. You should have access to that. You might want somebody to help you interpret it.

[A]

Right, right. Or hold your hand through. What do you prioritize? What's the.

[B]

Yeah.

[A]

What should you be looking out for? What is optimal then? You know, I think, like, with the access that we have to our own data right now, doctors are going to now be held to a higher standard because the patients know what this data means.

[B]

Yes.

[A]

But I love it because all of my patients have their data. Right. And they hold me to a higher standard, and then I can be more of a guide and a confidant and like you said, an empatic ear to listen to them. And I love my role so much better now, you know?

[B]

Yeah.

[A]

So I. I don't know. I'm excited about it as well.

[B]

Totally. I think a lot of people think that labs are. I say God, but labs are God. Labs are the commandments. Labs are the bible, whatever you want to call it. Because they're like, what exact lab value should this be? What exact lab value should that be? And I'm like, what are your goals? And do you have side effects when you're trying to get those goals? Right. And they're like, oh, yeah. And so especially when it comes to testosterone, for example, what exactly should the right testosterone be for a woman? And I'm like, three things matter to me and my patients. What are your goals? How do you feel on it? Do you have any side effects? And what are your lab values? In that order? Right. And they're like, oh, because, you know, people are learning on the Internet and we like concrete things. Right. But you need that expert to be like, some people have side effects when they're at that level.

[A]

100%.

[B]

The labs aren't everything. Help interpreting them is what our role is going to be now.

[A]

Yeah.

[B]

But not access to them. Those companies have been created. They're doing very well.

[A]

Exactly. And guess what? Every individual's biology is completely different. So what's the best testosterone level for you is going to be different than your own sister? There's going to be different than what your mother's testosterone Was Right. And so it's different for every individual completely. And so we don't know what is the optimal one for you. And we have to use what are your goals, what are the side effects, and then what is the level? As kind of like our guiding principle to optimizing any piece of blood work. Right. So, yeah, I love that model. The other thing that we have now is wearable devices, too, which are giving you constant feedback.

[B]

I have a loop on.

[A]

Exactly.

[B]

So it's very interesting. When I do public speaking, I'm like, zone four, zone five. I'm working out on the stage, and they actually have a thing. You can record your activity. And there's a public speaking thing.

[A]

There is. I didn't know that.

[B]

Yeah. So now I'm like, public speaking.

[A]

I just got a whoop band. I also wear an OURA ring. I'm gonna wear both. I feel like they're both such great pieces of. First of all, they're great to wear. So you have your own data, but they're also. I think the companies have done a really good job of really getting the data as accurate as possible.

[B]

I want to see a little bit more female focus.

[A]

Yes.

[B]

We can't just take male data and tell a woman that this is how things are supposed to be. So I would like them to be. And I think they're headed in that direction. But I call mine my gentle parent. Because I'm like, I know I should go to bed. I should go to bed. Right. Like, it just, like, gently guides me to be like, I know that I should put in a little bit more extra couple more steps. So to me, it doesn't stress me out. It's more a guide. Like, don't forget that stuff. Right. Especially when you're traveling.

[A]

Exactly right.

[B]

Of like, get your sleep, otherwise it will mess with you.

[A]

The travels are really kills me, and I really use the guide when I'm traveling. So can you kind of push you on that a little bit? How should wearable companies think about women and how to use the data a little bit differently? Like, what are you having specific examples for us?

[B]

I mean, this is just talking to friends who are in the space and are trying to design this stuff of, like, how does heart rate variability change when you throw on an estrogen patch versus not having an estrogen patch on estrogen? Estrogen influences heart rate variability. Right. That would be fantastic data to have. How does sleep change? What do. What do women need to sleep versus men need to sleep? So to me, I'm like, we're not all Toyotas that came out of the same factory. So it's like if we tried to put everybody's factory settings to the Toyota is, well, we've got some Ferraris over here.

[A]

Right.

[B]

But we should probably pay attention to the Ferraris and Ferraris on hormones, Ferraris off hormones. Women are the Ferraris in the scenario in case anybody. Because we create life. Exactly. So yeah, to me the experts are like a lot of the data for the whoop and the oura ring are built on male.

[A]

Right, Absolutely.

[B]

And so to me I'm like the people who will start. And to me I'm like, the market's huge. Like you start saying you've got female data to track and like you've done that, that's good for your brand.

[A]

Yeah. And also there's probably an opportunity in how the data changes throughout the cycle of the month as well. Right. And so HRV should probably be interpreted differently at some weeks of the month versus other weeks.

[B]

Right. Are you stressed or do you have low U.S. estrogen?

[A]

Yeah, exactly.

[B]

We don't know. And can we, can we figure that out? What else can we use? Respiratory rate, like, I don't know, depths, how well you're sleeping. So.

[A]

Hi, Dr. Shah here. I want to take a minute to talk to you about cellular health. So in my clinics I've actually seen 30 year old people with cells that look like they're pushing retirement. And I've also seen 60 year olds with cells that look like they're 40 years old. So what's the difference? It's really about how fast their telomeres are breaking down. Your cells you see are like phones and they have limited cell phone battery, poor sleep, stress, processed foods, all of these things can drain that battery way faster than it should. So this is the reason why I partnered with ima. IMA powers that cellular battery. It's not just another multivitamin. It's a comprehensive 92 ingredient formula designed specifically for cellular health and longevity. I'm talking 900 milligrams of vitamin C. That's like 20 oranges worth of DNA protection, the clinical dose of CoQ10 that you need to power your cellular engine. You also get zinc, selenium, vitamin E, alpha lipoic acid. All of these work synergistically for cellular repair and protecting your telomeres. So instead of taking a handful of pills every day and all these supplements, IMAID actually gives you everything that you need in one scientifically formulated system. And this isn't just a theory anymore. IMAID had partnered with Oxford University, the International Space Station, San Francisco Research Institute. And they've done studies and they've gotten this NSF certified to truly power your health. Most people are aging twice as fast as they should. Unfortunately, you don't have to be one of them. Try im8. I actually have a discount secured for you if you go to DrShaw.com IMA or go to ImaidHealth.com discount DrShaw. And you can get 20% off with my discount code DrShaw. You can also find the link below. I'm really also excited about these continuous monitors that put a filament in through our skin, like the continuous glucose monitor. There's a lot coming out. I'm talking to some of the CEOs and the researchers of these companies that they're going to be adding cortisol, they're going to be adding lactate, maybe hormones.

[B]

I think hormones are coming. I think hormones are coming.

[A]

I mean, that's going to be a game changer.

[B]

Yeah, yeah. The data's in your hands. I mean, especially for the perimenopausal women, because it's zone of chaos.

[A]

Yes. Right.

[B]

And to know, like, oh, wow, okay, estradiol's 350 right now. Let's prioritize sleep. Maybe do I need to exercise? Like, what do I need to do? Or even just a validation of like, oh, that's why I'm off. Right. Like, all of that is just, it's again, gentle parent. Right. Like, hey, you might, you might have a loop cycle right now. Like, what do we need to do to make you feel better?

[A]

Right, right, right. Yeah. And we're such an incredible time with all these converging technologies and AI being there as well.

[B]

Yeah.

[A]

I'm super excited about it.

[B]

Yeah.

[A]

So let's go. You know, you're one of the foremost hormone experts in the world. Right. And so I'm sure you synthesized thousands of patients worth of data and your experience and the conversations that you've had. And so if a woman were to come to you today on 2026, and she is right now perimenopausal, what should she do? Like, she's experiencing some symptoms, maybe hot flashes, maybe brain fog.

[B]

Yeah.

[A]

Weight gain. Give her some advice from that she. That she can then take and put into her own protocol moving forward.

[B]

Yeah.

[A]

How should she. Where should she go?

[B]

So the first thing is basic education, because body literacy is crappy for everybody. So what is perimenopause? Do you know what it is? Right. What's happening to you? And validating that our symptoms are real. So many people get dismissed, right? Of, like, I think I'm the crazy one because they said, especially the. All my lab values are fine in air quotes, right? Like, those people get very dismissed. And again, lab values are not written in stone, right? That was Tuesday at 10:00am that is not the whole week.

[A]

Exactly.

[B]

Right? So it's really validating. What's your understanding of this? Do you know what's going on? Do you know anything about your mom? Did that go well? Do you know when she went through menopause? Just to kind of get the story of it and then what's your goal? Right? Because again, I don't. This is not cookie cutter. This is not one side. Some people hot flashes, some people sleep, some people sex drive, Some people I want to preserve bone mass because my mom just broke her hip, right? So what's everybody's priority? And then the basics of, like, are you sleeping? Do you exercise? Are you drinking every day?

[A]

Why are we.

[B]

Why are we still drinking every day? We drink ounces of water, not alcohol, right? And so I had a perimenopausal woman. She came in, had a bladder cancer scare. Low grade, non invasive, cured the bladder cancer. And I'm like, well, of course you don't smoke cigarettes. Like, I'm kind of assuming, right? Because I'm like. And she's like, does a bong every day count? And I'm like, honey, we count ounces of protein, grams of protein, ounces of water. At this stage, we don't do bong hits anymore. And her husband's like, thank you. Right? So they go back to the basics of how are you treating the Ferrari, right? Are you hitting it up against the curve every day? Right? And that really does move the needle on how you feel, right? Exercise is fantastic for helping out vasomotor symptoms and perimenopausal symptoms and all that stuff. So to answer your question is like, basics first, right? We're Americans. We want quick, fast fixes, right? Just give me the right testosterone level of like, if you don't do the basics, you're gonna be like, these hormones don't work.

[A]

Yeah, yeah, exactly. I say that all the time. Like, you know, it's a pyramid and you have to build the base first. Otherwise the rest of it just comes crashing down every time you try to do anything.

[B]

Yeah.

[A]

And so those bases are exactly what you said. Exercise, nutrition as an intervention and sleep as an intervention. How should a woman in their 40s think about an exercise routine? What would be the Optimal exercise routine for that woman.

[B]

Yeah. What do you like to do?

[A]

Right?

[B]

Because you're like, I've done all the research and this is exactly what you do. You like doing it. I think you can learn to like things. Like, I was like, I need some more zone 5, 4, 5. Let's start spinning. And I was like, I did not like this for a while, but now I'm like, I like it. So I truly believe you can start to like things that you, I haven't done before, but it's like just move the body, I think. Mobility, like yoga, stretching, mobility, range of motion exercises. Nobody talks about that. I'm sure Dr. Wright does because she's amazing. But it's like just the feeling of your body moving. And to me I'm like getting out all those like cracks and kinks and everything every day, like feels very good.

[A]

Yes.

[B]

And just kind of getting into your body. So to me I'm like, are you exercising at all? Because if she's not, you're not going to be like, okay, you need zone four and five and this much zone two and lift heavy. Like if she hasn't done that, it's very overwhelming and it's not sustainable.

[A]

Sure.

[B]

I mean, low hanging fruit is walking. Yeah, walk, walk, walk, walk. Like get the steps in. So you got to meet people where they are. You can give them data. But if they're not going to do it.

[A]

Right, right, exactly. You know, in my practice, what I find when I talk to specifically women, let's just focus on women, is that there is a huge percentage of them, maybe 40% that are not doing any exercise. You know, I look at their phone and they're getting two to 3,000 steps in a day. And all of this advice is absolutely critical. Gotta get moving. Right. But then I also have a big percentage of women, I would say 30, 40% of women are also going to the gym. And they, you know, they're not overweight, they're going to the gym. They're spending three to four hours in the gym a week just on the treadmill. All they do is run and they really focus on calories and maintaining their weight. And the running feels good. It's like an endorphin hit to them.

[B]

It can be a stress relief.

[A]

Yeah, it is a stress relief for them too. And so, you know, I, I, one of the things I try to prioritize with those particular women is changing it up a little bit though, adding some strength training in, adding some yoga, mobility exercises and as well. Is that something that you believe in.

[B]

Oh, my God. Yeah.

[A]

Women should be adding strength.

[B]

Women in their 40s and 50s, we grew up in the 90s.

[A]

Yes.

[B]

Skinny is best. No, skinnier is better. Not eating is good. Right. And so it's like, to explain to people we exist within a culture.

[A]

Yes.

[B]

And if the culture tells women and we. We're seeing this again, women are getting skinny again. Right. If we exist in a culture that says thin is beautiful. Well, I've been told, like, muscles make me bulky. I don't even know what does bulky look like. And frankly, the guys are like, we wish. We wish lifting weights made us bulky. Right. The guys are like, I wish.

[A]

Yeah.

[B]

And so you. But you have to, like, undo this societal beauty perfection culture. Like, there's so much. Let alone your women in their 70s, they had it worse, man. They didn't. They didn't have sports.

[A]

Yeah, right, Right.

[B]

And so I see my 70 year old, I call them my pissed. My pissed advocacy boomers. Because they're like, we didn't get hormones. Our friends are breaking their hip. I want mine. I'm a little upset about it. Like, I have a large, large practice of them. I love taking care of them because there's so many myths about who. What's allowed in their 70s.

[A]

My mom is like 8 inches than she was when I met her.

[B]

8 inches.

[A]

She's so tiny.

[B]

Poor thing. Wow.

[A]

Yeah. She's had many, many joints replaced. I can't even. I lost count of all the joints that have been replaced.

[B]

Yeah.

[A]

You know, it's just unbelievable.

[B]

We have that generation, like, they didn't have girl sports. This is before title IX.

[A]

Right.

[B]

So it's like, at least we have the 40 year olds on a treadmill. Yeah. Right. But it's the culture you grew up.

[A]

In that is so true.

[B]

And the education that we give does have to acknowledge, like, we're asking them to do something that we told them, don't do that.

[A]

Right, Right.

[B]

And then they get. And they're like, things are always changing. And we're like, of course they are. Because 50% of the things we learned in med school are wrong. Yeah.

[A]

Things will change. Right?

[B]

Things will change.

[A]

It's really good to update your knowledge base and kind of understand where we need to be right now with our exercise, our thoughts around exercise.

[B]

Right.

[A]

Especially. And so, okay, so say they're exercising and they're coming to you. They're still struggling with symptoms and you want to talk to them about hormone replacement therapy. How does that conversation go? Where should they start? What should they Be looking. How do you pick the hormones they should be on, et cetera.

[B]

So I always ask them what they know about hormones.

[A]

Okay.

[B]

Because if you have a woman and in their head, hormones cause cancer, and you're like, let's get you started on estrogen, then we'll do blah, blah, blah. You're like, my doctor's trying to kill me.

[A]

Right.

[B]

So what do you know about hormones? What have you heard about hormones? Do you have any questions about hormones? Do you think hormones would play a role in your plan? Right. So it's like, I want her to give me the download of what she knows, because I'm here to help. I'm not here to tell her what to do. That's butting up against her beliefs.

[A]

Right, Right, Right.

[B]

So, I mean, luckily, I joke that I've worked very, very hard to have very, very educated patients. Yes. I'm like, I have a seven year podcast. I have two books. Most of my patients know that and have read them. So by the time they get to me, they're like, give me the things. I'm good to go. I know. I know all the things. Right. Which is a super fun way to practice because you're like, I've got educated.

[A]

People who know I'm not starting at square one every time.

[B]

We're not starting at square run anymore. Yeah. So really, why do you want, you know, what do you want? What do you know about this? What's. What would you like? And then I like to tell them, this takes adjusting.

[A]

Yeah.

[B]

You know, and I think that's why if you hear women say, like, hormones didn't work for me, one type of hormones with one dose maybe didn't work for you. Right, Right. But in our traditional healthcare system, see you in six months. Right. Or you're lucky to see you in three months. And so, so many people think they failed hormones.

[A]

Right.

[B]

And I'm like, different formulations, different types, different doses.

[A]

Right.

[B]

Like, it's all individualized. Amazing paper just got published looking at transdermal estradiol. And that if I give you a.05 patch and you have 0.05 patch, your symptoms might get better and you might not because you absorbed them and you didn't. It's like, we're not Toyotas.

[A]

Yeah.

[B]

Right. So I tell people that up front so that they have the expectation of, like, sometimes we hit it out of the park right away, but not always. Sometimes.

[A]

How often are you following their hormone levels and talking to them?

[B]

So in my clinic now, because I run a concierge Clinic now, because I was like 27 patients a day, plus three add on surgery cases plus on call.

[A]

Like, was crazy.

[B]

I only think had we had the AURA ring or the whoop in training.

[A]

Oh, my God, it would be like.

[B]

Can we please call 911 for you? Like, is your supervisor aware that you're dying?

[A]

Someone at the AURA headquarters would be like, yeah, yeah, yeah, this person is in big trouble.

[B]

Totally, like, barely surviving. So to me, I now have that concierge. And what did women and men, anybody, what did they want from me in the traditional medical system? Time.

[A]

Right. Absolutely.

[B]

Time. Right. And so now I have time. So I see them every six to eight weeks to change things, dial things in. Usually get people dialed in around four to six months.

[A]

Got it.

[B]

Yep.

[A]

So, and that's. I think that's a very realistic expectation. Like, you're not gonna get dialed in before four to eight months. Like, you gotta, like, have. Have that time period in your head. So you don't think that you're failing if things aren't perfect one month into it. Right.

[B]

And if it's perimenopause, I'm like, that's a moving target. You know, that's a moving target. Things will change.

[A]

Absolutely.

[B]

And it's just so, yeah, like, post menopause is easy. You don't have any hormones.

[A]

Right?

[B]

Right. Let's add something.

[A]

Exactly, exactly. So in the perimenopausal woman, are you starting with estrogen, progesterone? What are you starting with testosterone?

[B]

Yeah. What are her goals? What are her symptoms?

[A]

Okay, got it.

[B]

Right.

[A]

So it changes.

[B]

It changes based on if it. I'm not sleeping. Let's start with progesterone. Right, Right. Low libido, low energy, blah, blah. Let's start with testosterone. So estrogen, and this is. Again, I'm stereotyping. We're not all Toyotas. Estrogen tends to come last because estrogen seems to be the hanger honor. Right. And the brain and the ovaries are doing everything they can to try to get enough estrogen to get a follicle and an egg out. And so that tends to be the last one out. But we're not all created equal.

[A]

Right.

[B]

But yeah, I mean, people are like, what are the guidelines for perimenopause? It's like, there's no guidelines for perimenopause. And people are like, there should be. And I'm like, have you treated perimenopausal people? Like, it's all different. Right. Like, you make up a guideline for that but if there was gonna be a guideline, it would probably be progesterone, testosterone first.

[A]

Right.

[B]

Followed by estrogen, plus or minus vaginal either, to get on it for prevention.

[A]

Yes.

[B]

Because why are we waiting for. If 50 to 80% of women will have genital urinary syndrome and menopause, why are we waiting for them to suffer?

[A]

Right, right.

[B]

So plus or minus vaginal estrogen at any time.

[A]

Got it. Yeah. I think the vaginal estrogen piece of this is really important to mention and highlight because almost universally, when I see a patient that's coming from, like a primary care doctor that's treating the person's, you know, in air, quote, treating their menopause, they're never on vaginal estrogen. And so whether or not you're on any form of estrogen, do you feel that vaginal estrogen should be added to that mix?

[B]

Yeah, unless you're completely asymptomatic. But even that, like, you want to break the Internet, Right. Tell people that their labia minora goes away after menopause. And so there's two groups of people, the people who don't know what a labia minora is, and then the other group of people are the people who are horrified by this. They're like, are you joking? Like, no, no. Genitals need hormones. Hormones go away. Because a lot of people just think. I mean, people don't understand even what menopause is. So it's not a hot flash or the end of periods. It's profound. Gonadal hypofunction. You are outliving it. Right. So that's why the labia goes away. But so even if you're. I mean, the argument is, even if you have no symptoms, should you be on it to preserve sexual health? Right. Like, do you want to wait for your clitoris to get phymotic?

[A]

Right.

[B]

Like, that's 20% of people, as far as we know. Not that there's a lot of research, but the best research we have. But here's what's super exciting, and this is brand new. Our president, two days ago, just announced his healthcare plan.

[A]

Yeah, right, Saw that.

[B]

And one of them is taking safe, effective medications that could be over the counter. Over the counter. So we've already talked as high as we can in the administration because vaginal estrogen is the lowest hanging fruit.

[A]

Agreed.

[B]

For over the counter medications should be over the counter.

[A]

For.

[B]

Should be over the counter, over the counter in multiple countries. And here's some damning studies. So there was just a study published out of Stanford looking at Medicare recipients. So age 65 plus, again, 50 to 80% of these women have GSM Medicare. And this study ended in 2018. So I'm hoping it's better now than 2018. But if you went to a doctor and got the proper diagnosis. So these are women diagnosed with gsm, either recurrent uti, pain with sex, any sort of GSM symptom.

[A]

Right.

[B]

Lucky enough to see a doctor, lucky enough to get the proper diagnosis. What percentage of those women had a prescription for vaginal estrogen within 18 months of that diagnosis?

[A]

Oh, my gosh. I know, I know. It's going to be a depressing number. Is it like 40%?

[B]

7.

[A]

7% with symptoms.

[B]

So these women with symptoms saw a doctor, got the proper diagnosis, 7% got a treatment. 7 to 9%. Another paper just came out of Canada looking at the exact same thing. 71% didn't get treatment. So 30% got treatment.

[A]

Oh my gosh.

[B]

So when I think about that, I think about, okay, what about all the women who aren't seeing the doctor who doesn't know that this could be helped? Right. And it's like, okay, we're not treating. The doctor is. The doctor is the problem. Right. It's like they went to the doctor, they got the right diagnosis and they still didn't get the right treatment.

[A]

Exactly.

[B]

All right, let's move that vaginal estrogen over the counter.

[A]

That needs to go over the counter.

[B]

Yeah, it's a no brainer. We're like, make that your first medication over the counter.

[A]

Because the risk of side effects is incredibly low. And the potential benefit, like getting rid of recurring UTIs, for example, for the loss of sexual function through the atrophy of the labia minora.

[B]

Yeah.

[A]

Like this is why the vagina looks so different as you get older, is because of the lack of estrogen.

[B]

Right.

[A]

And you can maintain the even just the function and the anatomy just by using vaginal estrogen. Yeah, there's so many benefits. The strength of the pelvic floor as well.

[B]

Oh, totally. Bladderly gets bladder leakage. There you go. So Rachel Rubin did this study. Dr. Rubin did this study. If Medicare gave every Medicare recipient with a vagina vaginal estrogen and they used it, it would save Medicare 13 billion a year just in reduced urinary tract infections.

[A]

There you go.

[B]

And in the, and this was an abstract from last year of women with recurrent UTIs, the ones on vaginal estrogen. Decreased admission to the hospital, decreased admission to the ICU with sepsis, decreased risk of death.

[A]

Yeah. It's massive.

[B]

You know, a tube of generic vaginal estradiol at Mark Cuban. Cost plus drugs is $13.

[A]

Yeah.

[B]

You know, so you look at what, what should a preventative medicine be? It should be safe, it should be cost effective, and it should, it should prevent something that's common within the population. Right, right. Vaginal estrogen checks all the boxes.

[A]

It does, yeah. Okay, so good. So I'm so glad we, we talked in depth about this because I do believe that's foundational. Right. But let's move on to just estrogen. Your favorite form of estrogen is estrogen patch. Orally. What do you.

[B]

I would say right now, in 2026, a transdermal estrodial patch is probably the gold standard starting. Somebody asked a question today, actually, they were like, is bioidentical better? Blah, blah, blah, blah, blah. I like to have a different conversation and say hormones are under a tent, and it's a very big tent and there's lots of different options. And if we say bioidentical, meaning what your ovaries naturally make, if we say that that's better, it makes people who can't take that feel like they're really missing out or they're broken or blah, blah, blah. Because some of us need different formulations.

[A]

Sure.

[B]

We just do. Especially when it comes to progesterone and progestins. Right. And so I want to change the language away, but at the same time saying the estrogen your ovary naturally makes in transdermal form, so you're decreased or eliminated first pass hepatic metabolism, so no increased risk of blood clot, no increased risk of stroke. It's incredibly safe.

[A]

Right?

[B]

Yeah.

[A]

And safe and effective for reducing symptoms, but also effective for long term chronic disease prevention as well.

[B]

Let's talk about that.

[A]

Let's please, let's talk about that.

[B]

So the, the, the counter to us, because we're, our view is let's keep healthy people healthy.

[A]

Exactly.

[B]

That's our view. Right. So the counter to that is hormones shouldn't be used for primary prevention of any disease. All right, well, let's look into that data. So the United States Preventative Services Task Force, Independent task force, which urologists don't like anyways because they told us not to screen for prostate cancer and that backfired bad. Like more people with metastatic prostate cancer now.

[A]

Right.

[B]

So we're already like not sure. Not sure about this group. But okay, so what they did is they published this thing like two or three years old now. They published Grade D recommendation, which means do not recommend hormones for the primary prevention of any disease. Now, if you actually read their analysis, their biggest study that they weighted, because we talk about waiting studies, like the big study was the whi. All right, let's talk about that. Oral synthetics.

[A]

Yes.

[B]

Increased risk of gallbladder disease. Increased risk of blood clot. Blood clot, then suggesting stroke risk and cardiovascular risk. Okay. Transdermal estradiol doesn't do any of those things.

[A]

Exactly.

[B]

So you're taking an oral synthetic and taking a national statement to say, don't use that for primary prevention of any disease. And we're like, it's apples and oranges.

[A]

Yeah, right.

[B]

It's apples and oranges. But most people don't read into that data.

[A]

No.

[B]

Right. But the majority of that data is oral synthetics.

[A]

Yeah. Yeah. And then that's. That's the key fallacy of the whi, is that it was an oral synthetic. We can't draw any conclusions from that is because it's just basically what people don't really even use anymore.

[B]

Right.

[A]

And so.

[B]

And the good news from it. There's good. I mean, there's plenty of good news out of the whi, but the good news from it is, okay, if we gave you an oral synthetic, it actually isn't that. That's not that bad of a drug. It actually did a lot of great things.

[A]

Yeah, it still did great things with.

[B]

Risks, but now we have something that even has less risks. Right. So people are like, oh, oral synthetics. And you're like, they weren't actually that bad. This is a powerful study. So the HERS study.

[A]

The HERS study, right.

[B]

Looked at subset of. It looked at oral synthetics. So the Prempro as secondary prevention after cardiovascular event. This is an important study. So women who've already had heart attacks, oral placebo versus oral prempro. Oral oral synthetics, no increased risk compared to placebo. So don't use it for secondary prevention because it didn't make you have less second heart attacks. But it was no worse. It was no worse follow up greater than four years. That's an important study because now what we're talking about, we got the pissed boomers and this whole, we can't take. You can't start hormones after 10 years. Like, we need to talk about this. So the guidelines, 2022 menopause guidelines, say within the first 10 years, benefit outweighs risk in medicine. You know, that is a very strong statement.

[A]

A very strong statement. Right?

[B]

That is an incredibly strong statement. I say that to him like I hope you understand what I mean when that's an incredibly strong statement. Benefit outweighs Risk. Right. Ten years after or age greater than 60, individual risk. Benefit discussion should happen.

[A]

That's what it says.

[B]

That's what it says.

[A]

Right.

[B]

And you can go read it. It's free online.

[A]

Yeah.

[B]

People have taken that to say, you can't start, it's too late. It's too late. Is it true? What are the risks? 18 year follow up of WHI women up to the age of 70, started on oral Prempro, did fine, no significant risk. And the dementia risk was self reported or family reported. This was not even a physician diagnosis of dementia risk. So when you say increased risk of dementia, you're like, we don't really know.

[A]

Yeah, right.

[B]

And so that kind of falls away. And I've done, you know, webinars, I have these classes available on my, on my website of like, let's talk about it. Am I too old for hormones? Hormones is a big tent. You're never too late for vaginal.

[A]

Right?

[B]

Right, right. And so the big question is, are you too late for transdermal estradiol? You're never too late for oral progesterone. You're never too late for testosterone.

[A]

It's just a transdermal estradiol.

[B]

That's the right. But, but let's look at transdermal estradiol. Right. You. So you can't tell me the WHI risks are transdermal estradiol. Apples and oranges.

[A]

Right.

[B]

So they're like, oh, the increased risk of heart disease or stroke or dementia. No, show me the data. Now, do we want more studies in older people and. Absolutely, we want more studies. But there's actually a very old, old study and this was transdermal versus placebo in women who'd already had a heart attack. No worse than placebo.

[A]

Right.

[B]

So you're telling me a 71 year old because of her age who has never had heart disease can't start a transdermal estradiol when the women who've already had a heart attack, even if we gave them oral Prempro or a transdermal estradiol, did no less than, no worse than placebo. We have those studies and we have the WHI and you don't get a transdermal estradiol patch. And this is like, this is my 2026 soapbox, is like the older women give me the data on why they can't start because I have so much data to say, you can.

[A]

That's great.

[B]

Right. We have multiple Placebo controlled trials looking at really low dose patches in older women, specifically for women, bone improvement. Right. So we have those studies.

[A]

Yeah.

[B]

Risks no worse than placebo.

[A]

Right.

[B]

Right. So to me, I'm like, why do people keep telling a woman she can't start a hormone? That is an excellent safety profile.

[A]

Right.

[B]

SSRIs are more risky.

[A]

Yeah, absolutely.

[B]

Overactive bladder medications are more risky. Right. And so to me, I'm like, and again, this is me being obsessed with this topic that I actually went and like read all of these things. But I'm like, God darn it, tell me why they can't start this.

[A]

Yeah.

[B]

And my other argument is at, if at age 75, a woman can't say what she wants to do with her body after being informed with a risk benefit thing, what age is she able to say what she wants to do with her body? Right. This is like quality of life too. And a lot of people are like, oh, the symptoms are gone though. Menopause symptoms only last for seven years. And she like, these people aren't suffering. These people are suffering profoundly.

[A]

Yeah.

[B]

They don't sleep, they've got negative moods, they've got osteopenia or osteoporosis. Like they're profoundly suffering and we are not taking care of them properly.

[A]

Exactly. Yeah. I think there's a Great Soapbox for 2026 for you because all these boomers are coming up to this now. And like my mom, again, perfect example, she should be on hormone placement therapy right now, you know, and it would protect what joint she has left and her bones and her mood, all of it. And so I think this is an important, very important topic. And I'm really looking forward towards the narrative on hormone replacement therapy completely changing. And so, you know, I also think that a lot of women, they also think of their sexual health as something that it's supposed to decline as you age. And we talked about this with a 70 year old couple and a lot of what's going on with their sexual health also is very tied into like their pelvic floor as well. And so we know, like, we talked a lot about vaginal estrogen and how it, how it helps the pelvic floor to be stronger. But what else can a woman do to maintain their sexual health into older age?

[B]

Exercise. Exercise. It's blood flow. Like nobody thinks about female sexual health in terms of blood flow. But erections are obviously blood flow.

[A]

Right, Right.

[B]

And clitorises or penises, they're the exact, they're exact same is a stretch. But Incredibly similar anatomy. Right. And then. But people again, going back to what. What's my why? Right. Of like, we did. You got a disease and pregnancy prevention plan, probably, if you were lucky.

[A]

Yes. Right.

[B]

You did not get a. Like, how does this work? How do we get both people equally interested in going to the party? Right, Right. We didn't get. Did any of us learn about the clitoris?

[A]

Right.

[B]

Or the fact that women get erections? We get blood flow best way. This is the same for penis owners. Exercise, like, get the blood flow is good for everything. Absolutely right. And they have. And we've studied it. Women who exercise more have more satisfying sex lives up to a point. The over exercisers, their sexual function drops. What do I mean by over exercising? You're exhausting yourself. Right. Or you're using exercise as a coping mechanism for other things. So the more you exercise, the better your sex life is. Except for the very top. There's the over exercises where you're like, you're stressing yourself out. And nobody. Nobody has a great sex life when they're horribly stressed out.

[A]

Yeah.

[B]

So I would say if I had to pick one, exercise number two would be sleep. We have this data. Shift workers, worse sex lives. Night workers, less. Less. Sex life is like all domains of sexual function, when measured, diminish.

[A]

Right, Right. Right.

[B]

So you. Your body prioritizes things.

[A]

Right.

[B]

And if it's not sleeping, it doesn't want to reproduce. Right. It doesn't want to have pleasure. So sleep and exercise are key.

[A]

Got it. And then, you know, just like, like you said, like, when you go through medical school, you do days and hours and hours of studying the man's penis, but the clitoris is like, here it is. That's it. It's like five minutes.

[B]

Yeah. I can't remember. I can't remember. On my cadaver, I had a female cadaver. I know that. Did we dissect the clitoris? I don't know. And the other crazy thing is I'm a pelvic surgeon.

[A]

Yeah.

[B]

I put mesh around clitoris.

[A]

Right.

[B]

That's what. That's what a sling is.

[A]

Yeah.

[B]

I didn't understand the full anatomy of the clitoris.

[A]

Wow.

[B]

I had a sex therapist have a clitoris model. She is a clitoris model. And I'm like, what? So I mean, that's like. Only to be very humble, to be like, I got through surgical pelvic training. Right. And then I learned all the places the clitoris goes.

[A]

Yeah. This episode was brought to you by Next Health, a health optimization and longevity clinic. Located in Los Angeles, Manhattan and soon to be opening in Montecito, Nashville, Miami and many other cities in the United states and Canada, NextHealth is the Apple store of wellness where you can optimize your health span and lifespan using cutting edge technology. I actually founded NextHealth eight years ago to give my patients a place to go, get extensive biomarker testing done and provide them with all the tools that I used to get my health in order. The longevity circuit in NextHealth using hyperbaric oxygen, sauna, cryotherapy and LED light, is a game changer. In addition, the doctors at NextHealth measure thousands of biomarkers and put into place a longevity optimization plan using advanced tools like ozone plasma exchange and peptides. Go to www.next.health to check it out. So what about some pharmaceutical therapy for sexual health? You know, men have Viagra. Is this effective for women as well?

[B]

Yeah. So Viagra is a blood flow drug. Right. Fascinating stuff in the longevity world. Looks like people who take Viagra or Cialis or I call them the cousins. Right. The cousins of the PDE5 inhibitors. Less dementia.

[A]

Right.

[B]

Why? Blood flow drug blood for the brain. So I. It'll be interesting to see where we are with PDE5 inhibitors in about 5 years now. Interesting thing about, there's a lot of.

[A]

People taking it for like longevity.

[B]

Yeah.

[A]

Like they take a daily 2.5 milligrams.

[B]

Right. It's safe. Right. And in a world, and I will argue this with, with hormones too, in a world where dementia is deadly, costly.

[A]

Yeah.

[B]

Impossible to treat or at least very expensive, why aren't we doing everything we can to prevent it?

[A]

Right.

[B]

Number one killer of women in Australia now this year is dementia. Is dementia. UK is right behind heart disease. Yep.

[A]

Wow.

[B]

Just massive. It's massive. UK is right behind. I joke it's not something to be joking about, but like America, not quite there yet. Because we're really good at killing. Killing off people for other reasons.

[A]

Yeah, exactly.

[B]

But yeah, no, the. The developed countries where people are living longer. Dementia is now the number one killer in Australia.

[A]

Wow.

[B]

So it's like if it's cheap, if it's safe, it's effective. Why aren't we doing everything we can to prevent this from happening? It's not inevitable.

[A]

Right, right. So do you think there's a world in the future where men and women would be taking PD5 PDE5 inhibitors, like low dose Cialis or Viagra? Preventatively? Possibly.

[B]

I mean, I would hate to say. Oh, Casperson said this is what we should do. No, but what do we need for a good preventative medication? Safe, cheap.

[A]

Sure.

[B]

And it's something big, like a large part of the population to prevent it. And like, it checks the boxes.

[A]

It does, yeah.

[B]

It also helps overactive bladder in women.

[A]

Right.

[B]

Why? Blood flow to the bladder.

[A]

Absolutely.

[B]

And blood flow to the pelvis. So to go back to the initial question, when a man gets an erection, so I improve blood flow. So you have an erection, your brain is linked and it's like, oh, I'm interested in sex now. Right. They've done these studies in women because you're like, Viagra can help in women, but not all women. You make a woman have blood flow to her pelvis. She doesn't always want to have sex. She needs other things. Am I safe right now? Is this a socially acceptable place to have sex? So just because she has blood flow doesn't mean she's interested in sex. Right. So just a little bit different. We're just hooked up in a little bit different ways. So people. That's the argument of, like, Viagra does work, Viagar doesn't work. Viagar improves blood flow.

[A]

Right.

[B]

But that doesn't always mean you want to have sex.

[A]

But can it improve the likelihood of having an orgasm or the intensity?

[B]

Because it's blood flow.

[A]

Right, Exactly.

[B]

It's erections. So they're actually coming out now with a topical sildenafil.

[A]

Right, Right.

[B]

And so they've got some. Some funds behind it. It's going to. I think people are going to know about it. Right. And it's safe, it helps blood flow. And the big question is, especially, you know, when you look at female sexual dysfunction, there can be a lot of different reasons that you don't like sex.

[A]

Right.

[B]

So it might help especially. This is so under researched. We know the role of heart disease, high blood pressure, diabetes on erections in men.

[A]

Right.

[B]

Same. Same. Same way, less research.

[A]

That's so true.

[B]

Right. So the, the mechanism is probably there for a woman to have decreased blood flow as she ages and collects comorbidities. We just have way less data on it.

[A]

Right, right. What about nitric oxide? Like, you know as well as. Is it as important for women as is for men?

[B]

Yeah.

[A]

Erections. Right.

[B]

Vasodilator.

[A]

Exactly.

[B]

Right. Green leafy vegetables increase nitric oxide. Yeah.

[A]

And exercise and red beets, Huge nitric oxide boost with that as well. Okay. And then what about some of these peptides like Kiss, Peptin, and what are some of the other ones that are marketed?

[B]

Oxytocin.

[A]

Oxytocin is one of them.

[B]

Yeah. That people are interested in. Not as much data.

[A]

Okay.

[B]

And I think the low hanging fruit probably hasn't been addressed. So to me I'm like, don't go for the next trendy thing. How's your hormones?

[A]

Yes.

[B]

How's your relationship? How's your relationship? Are you prioritizing orgasm or does sex end when a partner has an orgasm?

[A]

Right.

[B]

Like, there's so much sex ed that's missing that to be like, kiss Pepin is going to work for everybody. Of like, probably not. But if it's a, Is it a specific arousal problem? Is it a specific orgasm problem? Right. Like, there are things for people but doctors did not get taught about sex.

[A]

Yeah.

[B]

Right.

[A]

Zero.

[B]

There's one, there's two fellowship spots in America for women's sexual health with 80 million women.

[A]

Right.

[B]

Yeah. Viagra was approved in 1998, became the fastest selling pharmaceutical ever, created record profits. Right. Was fast tracked by the fda, got approved with less than six months data because it was such an essential new medication. Yes, right.

[A]

Yes.

[B]

I got, I was part of the team, which was awesome. To get the boxed warning off of estrogen in 2025.

[A]

Nice.

[B]

What's estrogen? It's a blood flow medication.

[A]

Right, Right.

[B]

So these people got blood flow medications. These people got. This stuff's going to kill you on their blood flow medications.

[A]

Exactly.

[B]

We've been destabilizing heterosexual relationships for 27 years.

[A]

That's so true. Right? Absolutely. I mean, it's, it's, it's so. It's such a huge hill to climb when all the men had this new drug Viagra and the woman had nothing, basically. And so both going through that same sexual dysfunction at the same time period of their life. The perimenopause for men is andropause. And one group got a solution and one group didn't get a solution. And to your point, that makes complete sense.

[B]

We have to point that out to people to be like, we took care of half of that heterosexual relationship. And so most urologists, and this has moved pretty fast, but most urologists, when a man's in the office were like, oh, you want Viagra, you want testosterone? Great. Now they come to see me and knowing what I know now, to be like, what is your plan with this super penis we're gonna give you? And I thought like, it would be the rare man who like, didn't have a plan. And to me I'm like, I don't care what you do with it. Like, you do, you Great. But if your plan is to put your brand new super hard penis in a vagina, does she want that?

[A]

Right.

[B]

Has anybody been taking care of her? Is she on vaginal estrogen? Do you use lubrication? Right. And they're like, I haven't, I'm telling you, this blowed my mind. They don't have a plan.

[A]

No.

[B]

I'm like, you made an appointment with a urologist to get Viagra and you did not have a conversation with the person you haven't slept with in seven years who you now want to go home with and try to sleep with.

[A]

Yeah.

[B]

And they're like, yeah, no, we haven't talked about it yet.

[A]

He just thought she'd be ready.

[B]

She'd be ready. We actually joked in residency women would return their partners Viagra to the clinic and we would joke like, oh my God. And now I'm like, oh, that's not funny, right? I'm like, she's under treated, right? Nobody's taking care of her, Right. Nobody asked her if this was the plan, but he just assumed this would be the plan.

[A]

It should have been at least vaginal estrogen, maybe a low dose testosterone, Maybe even some PDE5 inhibitors and everyone would be on the same page.

[B]

And did she actually ever have good sex in the first place? Before you stopped, was she actually ever having good sex? Right. And this was mind blowing to me as I was going into my journey of female sexual health is one of the leading researchers in female desire is a man. And he was talking about low desire and the different types of blah, blah. And I'm like, hold on, you're assuming the woman was having good sex in the first place and she's just not desiring good sex. And he's like, well, yeah. And I'm like, that's such a male centric view of the party that that woman was at, right? I'm like, a lot of them aren't having great times at the party.

[A]

Yes.

[B]

Right. And so in the first place, so you have to back up and be like, you know, before we go to like, which vibrator, which lube, blah, blah, blah, like, did she ever have fun at the party? Right. Was she just doing this for somebody else? And again, it's the. We never got taught how to talk about sex, Right? And if we don't talk about sex when it's good, how the hell are you supposed to talk about it when it's bad?

[A]

That's so true, right? In fact, you know this. I would postulate that many women, when the husband's desire went away. That they were probably happy about it because they weren't having good sex in the first place.

[B]

Many people say that. Right. Yeah. I didn't mind.

[A]

And so for this return to sexuality, when the men got the Viagra was actually a traumatic event. Yeah. In their life. And so. And you know, you hear this story every once in a while, and then couples break up, divorces happen, et cetera, et cetera.

[B]

Yeah.

[A]

And the reality was no one really explored was the sex good the first, you know, when it was happening and now that it's returned, how can we get it to be good at this point in time?

[B]

Totally. And like, adults can learn new things.

[A]

Yes.

[B]

Right. Like, adults are capable of learning new things, but we have to want to learn new things. Right, Right. I have retreats, and a divorce lawyer came to one of my retreats and she's like, I pull people out of the river. Right. Like, I can't save anything. By the time they're in my office for a divorce, they're already drowning down the river. Right. And she's like, I am convinced these women, they're not taken care of. Like, these are untreated menopause. The relationship fractures, and by the time they get to her, like, she can't help.

[A]

Right.

[B]

But it's like when the divorce lawyers are telling you we're not taking care of the women properly, we should probably listen to him.

[A]

So true. Yeah. I mean, I think every divorce lawyer out there should have a partnership with a physician like yourself. That could be like, let's try to unwind this. Let's put some interventions in place first. Let's talk about these things.

[B]

Yeah.

[A]

But you're right. By the time you're there, it's often too late.

[B]

Yeah. There's. There's so much like, animosity and like the relationships fractured. By the time you're in a divorce lawyer's office.

[A]

Right.

[B]

Of like, you got to go 10,000ft above that, that, that awful spilled ship to like, try to right the boat.

[A]

Absolutely, absolutely. So in your big picture assessment, for a woman that has never had good sex and she's listening to this right now, what are some of the techniques that she can use to maybe rehab this or get to a point where she's actually enjoying sex the way she should be?

[B]

Yeah. So I think a lot of people jump straight to self exploration, masturbation, vibrators. I want to back it up. What are your thoughts about sex? What do you think sex is? What would you hope to get out of sex. It's the thoughts, right? We're talking about mindset of, like, if you think it's dirty, it takes too long, it's for somebody else. What's the point? Certainly, if it hurts, right? Like, what are your thoughts about sex? And let's just understand that that's what we think sex is. Because if we don't unpack that first, me being like, I designed the best vibrator for you. Pointless, right? Like, I can make blood flow.

[A]

Yes.

[B]

But if you're not on board with sex, right? And like, that's why I'm like, I'll have a podcast till I die. Because this topic is huge. How are you raised? What did your religion tell you about sex? What did your stupid first boyfriend tell you about sex? Right, right. Like, let alone any traumatic experiences that you've had. So who's allowed to desire in our culture, right? Who is sex for? Who gets sex freely, right? Who's the gatekeeper of sex? Like, it's such a huge topic.

[A]

It's a massive topic.

[B]

It's massive. You know, they say sex is biopsychosocial and like, there's no better word for it. Like, it really is. It's your biology, it's your relationships, it's the, the fishbowl you're swimming in, which is society, right? And so to me, I think people jump. They're like, you need a good lube, vaginal estrogen and a vibrator. Of course. When you're ready. When you're ready for the hardware. Let's do hardware, right? But if the software thinks that sex is like, what's the point? Or I was hurt in the past, or I don't really like my partner in the first place, right? But it's all this, like, when we just say, like, women can have great sex and should have great sex, like, yes, we gotta unpack where they're at, right, right? And be like, could it be possible that sex could be something different for you in the second half of your life compared to how it was in the first half of your life, right? And I think the stereotype is like, that the 22 year olds are having great sex. That's not what the data says. First of all, the 22 year olds are having way less sex than they've ever had, really? Because they're not hanging out anymore.

[A]

Oh, that's so true.

[B]

Right? Like Covid happened. We've got phones, all the things. And when you think of, even think, like a hundred years ago, sex was the best dopamine Besides, like, a shot of whiskey.

[A]

That's true.

[B]

Like, sex was the best.

[A]

You couldn't get it anywhere else.

[B]

What was better? Dopamine.

[A]

Exactly.

[B]

Sex was amazing, and you couldn't have it. And it was really rare. Right. Like, it was very good dopamine. And now we're like, dude, a pint of mint chocolate chip ice cream and Instagram scrolling like, I'm good.

[A]

Yeah.

[B]

Right. Like, it rings all the bells.

[A]

Yeah.

[B]

And so sex takes work.

[A]

Right.

[B]

Especially if you want to do it with somebody else. Right. How's your schedule? What's my schedule? Are you tired? Like, you've got a bum knee. Okay, well, what position? But, like, it's work to get that dopamine. Right. And so when we're like, where sex is. Plays a role in our society now, like, it's actually harder. Dopamine.

[A]

It's changed a lot. You're absolutely right. Especially in the context of all the other dopamine hits we get throughout the day.

[B]

Yes, totally. There's some crazy statistic about how many people look at their phone during sex. Like, and it's a crazy. It's way more than I would be, like, 5%. Like, super. No, it's like, I can't quote exactly what it is, but it's.

[A]

It's a surprising number.

[B]

Frightening amount of people.

[A]

That is frightening.

[B]

Who check their phone during sex. For anybody who's uncertain, don't do that.

[A]

Yeah, yeah. That's not. That's not.

[B]

It takes you out of the present moment. Yeah. So the young people aren't having that much sex, but we think they're having the best sex. But the data actually suggests the older you get, the better sex you're having, especially for women, because they're like, I'm throwing away the rules. I'm making this about me. I'm a lot less concerned about how I look, how I'm. We're less spectatory. Right. We're more experienced.

[A]

Yeah.

[B]

We might want it. We've done it enough that we're like, let's have a little bit of novelty now. Right. And so that's what people don't know. Right. Because our society's like, the sexy, beautiful young people are having. No, they're not. Right. And the other. There's an amazing book by Peggy Klein platz. She's a PhD and it's called Magnificent Sex. And what she did, she's at a university, and she's like, hey, anybody who has really great sex, like, raise your hand. Can I interview you? Right. So it was kind of A qualitative research study of, like, what does it take to like be a self admitted, like, I'm great at sex. Yes, Right. Because everybody thinks desire for sex is what allows you to have great sex life. Right. Nowhere in like the top 10 is desire. Sexual desire a necessary ingredient.

[A]

That's interesting.

[B]

Communication, prioritizing, time to be sexual.

[A]

Right.

[B]

Trying things, recorrecting, start, you know, starting and stopping. That wasn't great. How can we do it different?

[A]

Right.

[B]

So willingness to try just being involved.

[A]

Yeah.

[B]

And communication. Communication, communication. Especially if you want sex with another human.

[A]

Right. Right.

[B]

So that's a great book because everybody's like the typical male model. And this is, you know, Kinsey and Masters and Johnson and all they're like, desire first or desire was assumed.

[A]

Right.

[B]

Because like these are people in the 1950s being hooked up to electrodes in the Midwest in winter. Like by default, they had a spontaneous desire for sex. Yeah, yeah. They were like, let's do this, let's learn for science. So but then desire was assumed as coming first. And so women say, well, I don't have a desire for sex, so I don't have sex.

[A]

Right.

[B]

And a nice analogy is like, if you're full after a meal, you don't really want more food, but like the dessert table comes around and then you're like, okay, let's do it. Or it's Friday night. I don't really feel like going to the party, but when I go to the party, it's a freaking good time.

[A]

Right?

[B]

So it's like, let your partner take you to the party. And especially how women's brains work. We need a safe sexual context. So if there's kids around, if we're stressed, if we don't feel safe, you're not going to have desire for sex. You must go in a sexual context. So our role or our partner's role to bring us along or us to go there. Because in women, this is Rosemary Besson's work. Desire for sex happens during sex. Yeah, I love this. Yeah, this is good. I love this party.

[A]

Yeah.

[B]

Right. So desire happens during sex when I'm in the sexual context or desire happens after sex.

[A]

Interesting.

[B]

That was so good. I forgot how good that is. That is a great time. Will you remind me again that I liked that? Because I forget that I like that that's desire for sex after I had sex. Right. So so many women, like, don't have desire. I'm like, of course you don't. You just got off of work, you just packed the lunches. You're, you're in the living room where you don't usually have. You're not in a sexual context.

[A]

Yeah.

[B]

So it's like provide the, the avenue, be willing to go to the party. You can always stop. And I never mean have sex when you don't truly want it, if you don't feel safe and it's not good. But be willing to go to the party, see what, see what adventures at the party might be interesting because desire for sex might happen during, desire for sex might happen after.

[A]

This is such critical, great information for women that are listening, that are just, you know, they're feeling that they're not having the desire, just completely reframe that. The desire might come during, it might come after, and get yourself in the sexual context. This is great information for men too.

[B]

100%.

[A]

Right. Because I think men need to know this in order to understand why they're part of or doesn't potentially have the desire at this moment. The context might not be right or we just gotta get them into the place and then the desire will come.

[B]

And the word for that is responsive desire.

[A]

Responsive desire.

[B]

So I respond to this being in the sexual experience, but spontaneous. Again, that's what Hollywood tells us. It's just on demand, drop of a hat. Yeah, let's go anytime.

[A]

That's not the real world. Well, that's what we do, right?

[B]

Yes.

[A]

And so men need to realize that the female context around desire is different than the male complex around desire.

[B]

It can be. Men can also have response of desire. And this is also what's very interesting in a heterosexual relationship is the woman's desire is usually anchored around where the man is. So if she wants more sex than him, she has too high of a desire. And if she wants less sex than him, she has too low of the desire. We've anchored the man as the default and made her the problem. Right. And that is not what we should do. We should say desire mismatch. That's what it's called, desire mismatch. When two people want different amounts of sex, that's a couple's problem, not an individual person's problem. And that's to be navigated with the couple.

[A]

That's such critical information too.

[B]

I think the one other thing I want to make sure we cover because it's golden. Have you heard of the orgasm gap?

[A]

No.

[B]

Okay, so the orgasm gap, fascinating research, is the percentage of times that a male is going to have an orgasm in a given sexual experience compared to the percentage of time. And we're Using orgasm as a proxy for enjoyment, satisfaction. Right. Because you have to have sex worth desiring. You can't desire mushy broccoli, you can't desire boring sex. So proxy orgasm to say, right?

[A]

Yep.

[B]

And in a heterosexual relationship, man orgasms around 97% of the time. Pretty successful, pretty enjoyable sex. Heterosexual female clocks in around 60% of the time. They're literally having different meals.

[A]

Right.

[B]

When you look at same sex couples, lesbians about equal. Right. Around 86% of the time.

[A]

Really.

[B]

Heterosexual male, both clock in right around mid 90% of the time.

[A]

Right.

[B]

So the biggest gap is the heterosexual couple. What's worse is that's in a committed, loving relationship, if you do hookup sex, college campus hookup sex, he still gets the orgasm high. 90%. Her percentage of orgasm. 7%.

[A]

7.

[B]

7.

[A]

That's massive.

[B]

So to me, I'm like, why are you participating in this? Why are you participating in this situation?

[A]

Why are you in it anyway?

[B]

Why are you in it anyways?

[A]

Yeah.

[B]

Yeah.

[A]

Huh. I did not realize that that is in a committed relationship. There's a 30%, 25% mismatch. In a non committed relationship, cop sex.

[B]

It's horrific sex. Horrific sex.

[A]

It's like not even. Right. Exactly.

[B]

Yeah.

[A]

Yeah. I mean, that should completely change the mindset around the current hook up culture through these apps like Bumble or what have you. I've never used one, but I mean, it just seems like there's such a new paradigm around meeting people and then how you hook up and how quickly that goes into sex. And I'm hearing about it right now because my nephews are in college and they're living it real time and they don't use these apps because of this kind of massive mismatch. They're. They're actually feeling it like. Yeah, like it's just too easy now, I think, right?

[B]

Yeah, yeah. No, I mean, it's crazy research. The other stereotype is that women want sex less than men. That's a, that's this common stereotype. Right. And it probably stems from many places, but one study was people on a college campus, they went around, they asked men, would you like hookup sex tonight? Most. Most of the men were like, yes, that would be great. Thank you very much. They went around women, would you like hookup sex tonight? And they're like 0% said yes. They're like, no. Which begs the question. We're using a lot of alcohol to coerce or to get women's inhibitions down so they will participate in this ruse of 7% orgasm. Right. So they're like, oh well look, men like sex more than women do. And then some very smart researchers were like, I think there's different menu items here. They went up to women and they said, if we offered you shame free, non judgmental, safe, no risk of pregnancy, no risk of disease, loving, orgasmic pleasure, would you like that tonight? All the women said yes.

[A]

Right.

[B]

And so the researchers in their wisdom said, men are eating at five star Italian restaurants. Women have Chef Boyardee in a can.

[A]

Yeah.

[B]

And you don't wonder why they like Italian food less.

[A]

Right, right.

[B]

And so that's the whole stereotype. Like women just aren't as sexual. And it's like, have you seen what's on offer?

[A]

Yeah, exactly.

[B]

Like up, up, up the ante for this.

[A]

Yeah. That's such incredible information. So many great reframes that you have for us that I think empower both men and women with this knowledge and give you a different perspective of how to think about sexual relationships. And also, you know, going back to the beginning of this conversation, just getting your mindset around perimenopause and menopause and how it is a completely treatable, the symptoms can be treated away and you don't have to live in that situation state and it's safe for you.

[B]

Yeah, mindset about that too. Because we were like, why do we have to do this when we grow old? Especially if you identify as somebody who doesn't take medications.

[A]

Right, yeah.

[B]

Like, why do I do this? Why do we have to outlive our ovaries? Blah, blah. I just want to remind people we've been massively successful at extending lifespan.

[A]

Exactly.

[B]

I did this research for my book of like the wealthiest land owning males in early Britain. This is like 1400s. So like you were worth spending a pencil on to like write your birth and death date. Right. Because there were no birth and death records for like the, the peas. Yeah. So you were wealthy, you had land, you had parchment. Right. And you didn't die in childbirth. Average life expectancy 47.

[A]

47.

[B]

47. That was as good as it got.

[A]

Right, right.

[B]

So people are like, well, great grandma didn't use. And it's like, we've never aged.

[A]

She never got there.

[B]

Yeah. And going back to like how we think about aging versus like the traditional medical system is like we're seeing people age and we're like, maybe there's a different way of doing this and maybe we do actually have to start now to not have this happen when we're 80 and like, the amazing blessing it is to have we're outliving our ovaries. And if you take any animal from fruit fly to yeast to orangutan, and you age them in captivity, they all live longer than their reproductive potential because they're like only humans and whales. And I'm like, first of all, most mammals don't menstruate. They don't have periods to track. Don't say they don't do this. But if you put them in a zoo and you feed them and you give them antibiotics when they have an infection and you take away their predators, they all live longer than their reproductive potential. So I wanted to name my book Aging in Captivity, but the publishers were like, I don't think people will get it. And it seems like they're in jail. And I'm like, my fans love that name. We're aging in captivity.

[A]

Absolutely.

[B]

Do we want to do it? Well, most people say yes.

[A]

Yeah. I make this point all the time. You know, in the longevity space, there's always this fear of getting old because you imagine it as frailty. And there's also a perception that, well, you know, humans are meant to get old. It's natural to age. There's nothing natural about what we're doing. We've. We've artificially extended our lifespan by double. And our organs that were producing these hormones just were not made to last this long.

[B]

Yeah. And I tell, I tell, I'm like, once we push the lifespan even longer, more men will outlive their testicles.

[A]

Right.

[B]

Like, Like, I just, that's just how it's gonna be. Right? And we're not gonna shame them and say, like, this is mother Nature's plan to make it past your 80s. Right. We're gonna be like, oh, well, we replace eyes, we replace hips, we replace teeth, we replace shoulders, we replace heart valves, we replace insulin, we replace everything except for ovaries.

[A]

Right.

[B]

Like, what a bias.

[A]

Yeah, exactly.

[B]

And the, the interesting thing, why can't our ovaries last longer? Ovaries are built to be proportional to the size of the mammal.

[A]

Ah, right.

[B]

So a mouse has very small mice ovaries. Elephant has big elephant ovaries. Human have human sized ovaries. There's only so many follicles, so many eggs. Enough years go by, you've outlived the size of the ovary. Right. Because people want to overthink this and judge it and say, what you should do is like, if we get that health literacy and understand all of that, we're like, okay, yeah, yeah, yeah. I want to live long. Antibiotics alone increased human life expectancy by 26 years.

[A]

Oh, absolutely. Absolutely. Yeah. And we developed a whole pharmaceutical industry around antibiotics, and now, look, they're keeping us alive even longer with even more therapeutics, so there's more lifespan coming. We just got to get our heads wrapped around replacing these hormones, giving our body the things it needs that it can't make anymore. Yeah, that's the way I look at it.

[B]

In the 1990s, 40% of American women were on hormones because people are like, do you just want everybody to be on hormones? And I'm like, well, going back to the 90s would be a struggle.

[A]

They were right. Exactly. Let's just get there right now.

[B]

Let's just get. Let's get there.

[A]

7%, 8% of women are on hormones right now.

[B]

Right?

[A]

Yeah. Amazing conversation. I can't wait. I could spend hours and hours.

[B]

Well, we're going out to dinner next, so we'll get more time. We just won't have it recorded.

[A]

I love it. Yeah. So this is absolutely fantastic. You're a force of nature, and I really appreciate you being here. And where can people hear more from you directly? Tell us about your podcast, your social media handles.

[B]

So the podcast and the first book are called you are Not Broken. The I love hanging out on Instagram. That's KellyCaspersonMD. Website's KellyCaspersonMD.com Second book's called the Menopause Moment. Not Aging in Captivity because the publishers didn't like it. But those are my main ones. Yeah, I got YouTube substack, all the things.

[A]

Incredible. Well, we thank you so much for being here and can't wait to have you back on again. I'm sure we can talk a lot more about a lot more fun topics.

[B]

Thanks for having me.

[A]

Thank you. Thank you so much for listening to the podcast today. Please remember to subscribe if you like this episode and give us a good review and share a link with your friends. It really helps to support all of our efforts. I also want to remind you that the information shared on this podcast is for educational purposes only and is not intended to replace professional medical advice, diagnosis, or treatment. Please consult with your healthcare provider or physician before making any decisions or taking any action based on what you hear today, especially if you have any underlying health conditions or on any medications. Your doctor knows your personal health situation the best, and it's always important to seek their guidance.