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Queen Carvania stood haloed by the morning sun. An army hung on her every word. My champions, I have sold my chariot on Carvana. Twas a lovely suv, an inexplicably queenly offer. They're even coming to the castle to collect it. Tonight we feast. An offer you can feast on. Sell your car today on Carvana. Pick up fees may apply. Welcome to the you are Not Broken podcast. I'm your host, Dr. Kelly Casperson, a board certified urologist, thought leader and conversation starter on midlife living, hormones and sexuality. Enjoy the show. Hey, Everybody, it is Dr. Caspersen. Welcome back to the youe're Not Broken podcast. We are doing a live stream on Instagram today and we are going to talk about gsm, genital urinary syndrome of menopause. And I'm super excited. So big, big news that we now have GSM guidelines. This is multiple societies started really heralded by the American Urologic association, but also, also with the Menopause Society, it says endorsed by the International Society for the Study of Women's Sexual Health. So that's ishwish, you know, I love it. And the Menopause Society. So guideline panel is many amazing people. Urologists, not urologists. First author, Dr. Melissa Kaufman. Last author, Dr. Una Lee. Other amazing people that are on here, Dr. Ackerman, Ammon Coffey, Fabian Hardart Goldstein, Irwin Goldstein. Irwin Goldstein is the person who said put the urinary in GSM. Ippolito Northington, Dr. Powell, Dr. Rubin, Dr. Westney, Dr. Wilson and Dr. Lee. So many, many, many people. You guys, do you get some guidelines? Take a long time. They're a working document. The level of evidence is considered, right? So they'll say, we have a lot of data for this. We don't have a lot of data for this. And it takes a long time to make guidelines. They don't just poof. It's like I was hanging out with Dr. Rubin in New York City like year, year and a half ago, God, maybe even two years ago. And she was like taking a call for these guidelines at that time. So it takes a long time for the podcast for the guidelines to come out. Now we're gonna do a podcast on it, which we're super excited about. So GSM is genital urinary syndrome of men, previously known as vaginal atrophy, previously known prior to that as the senile vagina, which is a horrific, horrific thing to call it. So the summary of this, genital urinary syndrome of menopause, or gsm Describes the spectrum of symptoms and physical changes resulting from declining estrogen and androgens concentrations in the genital urinary tract during the menopausal transition. Strategies defined in this document were derived from evidence based and consensus based processes. However, shared decision making is the optimal strategy to individualize, level of impact and ultimate interventions. Outreach to the marginalized and underserved GSM populations is essential. This guideline will give clinicians across a multitude of disciplines the tools to evaluate, manage and treat GSM patients. So this is free online. If you just type in 2025 genital urinary syndrome of menopause guidelines, you can type in AUA for American Urologic Association. You can print it out, you can bring it in, you can circle what applies to you and we. Somebody just said senile, penile. That's awesome. And you can get the help that you want. So hormones decline with menopause if you've been living under a rock. And hormones in female bodies include androgens, which were just called androgens because we decided to make up that term and call them male. But all bodies have them. So. So, and I just did a blog post on called what the fuck is an androgen? Because like, it's a made up word which means nothing. They're just like, let's put these four hormones in a blue box. We'll call them androgens because they were discovered in the rooster testicle. All right, so this is a systematic reviewed guideline statement number one, shared decision making. Clinicians and patients should engage in shared decision making taking into consideration the best available evidence and the patients express values, preferences and goals of GSM care. Put. Somebody said they need to put vaginal estrogen in gumball machines. Yes, get it for a quarter. So many people say, I went to my doctor, my doctor said, no, that's not shared decision making. That's authoritative or patriarchal imbalance of power. Shared decision making is. I know you might not be studied up on this and I know you think there's risks, but I think the benefits outweigh the risks for me. And I would like to be involved in shared decision making and give this a try. So I need to do, I need to do a podcast episode on how to talk to doctors because we always come back to body autonomy shared decision making. They're there. Doctors are there to help partner with you, so don't put them in the God status. They're not God, they're partners. So they can tell you what they know. They might know a lot or they Might not know a lot, but at the end of the day, shared decision making. All right, so screening and diagnosis, clinical principle. Patients with symptoms of GSM should undergo a genital urinary examination. I agree with this. The problem with this statement is not all clinicians know how to do a good pelvic exam. And women can have symptoms of GSM and have an air quotes normal looking pelvic exam. So I would never want anybody to invalidate your symptoms because they thought your exam looked normal. I've seen many, many vulvas that people are like three OB GYNs have told me that this is a normal exam. And I'm like, you have no labia, your clitoris is shrunken, you have tearing at the six o' clock posterior fourchette. There's nothing normal about this. But other people's opinion about the normalcy of their vulva exam is what prevented them from getting care. So the, the other statement I will make about this guideline statement is that telemedicine is good, it is effective, but you cannot do a pelvic exam on it. Please don't do a pelvic exam on telemedicine. If your symptoms, I don't think it's a reason not to treat GSM via telemedicine. I think many people will. But if your symptoms persist, you at some point should get an exam by a talented clinician. Clinicians should educate patients with GSM about genital urinary signs and symptoms that result from decreased sex steroid hormones. One of the biggest things I saw, I see is that because we don't know what menopause is, we meaning society, women don't know they don't have hormones. They don't know that. They think menopause is no periods. So they don't know they don't have any hormones. And then you're like, well, this is because of no hormones. And they're like, what? Because they don't even know that that's what the postmenopause state is, is a state of profound low hormones. Hypogonadism is a term for that. Women postmenopause have less estradiol in their bodies than men do. Men have estradiol levels around 30 to 40. Postmenopausal women have estradiol blood levels less than 10. You have less estrogen than a man and your labia and your clitoris and your bladder and your vagina became the functioning adults that they became because of estrogen and androgens. And then you decided to live past the lifespan of your ovaries and not replace what your ovary function is. And this is what happens. So education, education, education to educate women. And the other thing, because they don't get that education is like, how long do I have to keep taking these vaginal hormones? And it's like you have to keep taking them forever unless you plan on like an ovary transplant or something where your hormones are coming back. So that's something to think about. In patients with GSM and psychosocial and or sexual health concerns, clinicians may refer to a credentialed therapist. Pain hurts and will mess with you. Need I say more? So therapy is very, very good to help you process through changing bodies, medical trauma, possibly past pelvic trauma. So therapy is not the only treatment for gsm, but I love that they can. They brought in the biopsychosocial aspect of healthcare and bring that up in patients with GSM and pelvic floor dysfunction. Clinicians may refer to a physical therapist in specializing in pelvic floor conditions. Love that when the skin gets tight and dry and painful, muscles will tense up and get tight in response. Muscles are there to protect us, right? So many times we can have both GSM and pelvic floor pain. Pelvic floor muscle spasm, vaginal estrogen and fixing the hormones will help the skin and the tissues in the bladder, but won't help the muscles. And that's why oftentimes we must also see pelvic floor physical therapy in addition to getting on vaginal estrogen. And when people say like, I still have pain with sex and I've been on vaginal estrogen, then I usually think, is it muscles? Do we need to see pelvic floor PT or do you also need androgens or a testosterone? Somebody asked, can vaginal estrogen help with urinary frequency and urgency? Yes, absolutely. It's as effective in the studies we have. It's as effective as the traditional overactive bladder medications which are called anticholinergics and have a whole host of side effects. Estrogen has way less side effects than the overactive bladder medications. All right. Hormonal interventions. Clinicians should offer the option of low dose vaginal estrogen to patients with GSM to improve volovaginal discomfort, irritation, dryness or dyspareunia. Should offer the option of vaginal dhea. DHEA converts to testosterone and estrogen. That's why it's beautiful. It makes I. It's the chef's kiss for a beautiful, beautiful vulva. I love the DHEA prescription. It's a prescription. Prescription product. Clinicians may offer the option of ospemifeme to patients with gsm. Ospemifeme is the oral medication for gsm and it works by working in the pelvis. It is a selective estrogen receptor modulator. That class of drugs includes tamoxifen and is can also help your bones. So that's good. DHEA is intrarosa. The other name for intrarosa is prastirone. Ospemafeme. The other word for that is osphena is the brand name. Somebody just said, I'm not telling women all about you, Kelly Casperson. Maybe that's a typo. Maybe you're telling all women about me. I don't know. Thank you for keeping me a secret. I don't know. Is DHEA safe? Yeah, absolutely it's safe. DHEA is what our body makes oral. DHEA does not seem to help like vaginal DHEA is. So clinician should recommend the use of vaginal moisturizers and lubricants, either alone or in combination with other therapies to help improve dryness or dyspareunia in patients with gsm. Remember, dyspareunia means pain with sexual moisturizers and lubricants. They're great. They're wonderful. They are band aids. They don't fix the problem of low hormones. So of course we love them, but we no longer need to use them. First, we have GSM guidelines. Now clinicians should counsel patients to avoid vulvovaginal irritants or cleansers which may exasperate the signs and symptoms of gsm. Save your money. You're. You're showering, you got soapy water. You're just going to rub a little. And I don't mean rub like harsh. I just mean, like, separate the labia. Clean in there a little bit with your hand and some soapy water. But no washcloths, no harsh chemicals. Chemicals. No. Wipes, for the love of God. The wipes are really bad for your microbiome and to dry out your skin. Never in the millions of years of human history have we needed vulvar wipes. So don't start now. Somebody just said, I just started estradiol cream. And it's a game changer. Thank you. Yay. We love it. Can you use both vaginal estrogen along with dhea? I think some people need to. They. Some people need higher levels. That's an individualized question that you're going to ask your clinician about. So Have I, have I done that in my practice? Yes. Energy based interventions. Clinicians should counsel patients that the evidence does not support the use of CO2 laser or ERG YAG laser or radio frequency in the treatment of GSM related vulvovaginal dryness, vulvovaginal discomfort, irritation, dysuria, quality of life, change in bothersome symptoms or satisfaction with treatment. Save your money or do it as part of a trial, which most people don't. Here's the deal. Many people who do lasers, et cetera, aren't trained in the pelvis. They aren't trained in anatomy, they're not trained in sexual function. They are looking to take your money. If you're gonna do a laser or one of those things like by the love of God, also be on vaginal estrogen. So lasers help skin, but we don't have enough data to say that they are as helpful as hormones. They're like a thousand times more expensive than hormones. So it's hard, I'm hard pressed to say the average woman needs to spend her money that way. Let's see next page. Clinicians should inform patients of the absence of evidence linking low dose vaginal estrogen to the development of breast cancer. This is where the FDA black box warning is wrong. There is no evidence to say that vaginal estrogen is linked to breast cancer. So knock it off. That's not a reason to not be on vaginal estrogen. Somebody asked with physical changes to labia and clitoris, will this be permanent and is treatment localized or does non vaginal hormone therapy treat this? A great question. Get enough hormones on board, you should be able to reverse it. Don't have great studies to back that up. That's my clinical opinion in treating this. I don't think systemic hormones work as great as pelvic hormones in both GSM and in restoring function. And you might need a higher dose to restore function, not just like maintenance level doses. Standard doses for vaginal estrogen is twice a week. If you're coming to me and we're trying to improve sexual function, clitoral blood flow, et cetera, et cetera, we're probably going to use more than just maintenance doses. That said, systemic testosterone does help clitoral blood flow. So there you go. Clinicians should counsel patients with GSM that local low dose vaginal estrogen does not increase the risk for endometrial hyperplasia or endometrial cancer. So basically too long didn't read vaginal estrogen safe. After initiation of treatment, clinicians should reassess patients with GSM to monitor response. We need to know that you're doing better and if you're not doing better, you need an exam or you need to see somebody for options. Clinicians should counsel patients receiving therapy for GSM that long term treatment and follow up may be required to manage signs and symptoms. Exactly. Your hormones are coming back. Somebody asked me today I was down in Seattle doing a talk at Women and Work and it was awesome. And somebody's like, can I take these forever? And I'm like, yeah, do you want to? How are you going to be buried? Are you going to be buried? Are you going to be cremated? What's your plan? She's like, probably cremated. I'm like, great, take them to the urn. There you go.
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provider hasn't wanted to prescribe vaginal estrogen because I'm still cycling. That's a good one. You do not need to stop, have your period stopped to be on vaginal estrogen. Periods are not magic. There's nothing magic about periods. You could be cycling and take vaginal estrogen. So we need to get over the period as a marker for anything besides the need to, like, wear pads. All right, vaginal estradiol versus vaginal dhea. I love both of them. I think vaginal DHEA in my opinion, makes better tissue, but it's way more expensive. So I like to start with vaginal estradiol and if it's not working, then kick it over to vaginal DHEA. Let's see. GSM term got coined in 2014. Volvo. Vaginal symptoms associated with menopause include dryness, burning and irritation. Urinary symptoms include urgency frequency, dysuria and recurrent urinary tract infection. Infections. The vulvovaginal and urinary effects of menopause are often considered the cause of sexual symptoms of gsm, including dyspareunia and bleeding during intercourse, as well as broader impacts on sexual functions such as reduced libido, arousal and orgasm. Physical changes associated with GSM include labia atrophy, reduced moisture, introidal stenosis, meaning it gets tight, and clitoral atrophy again. What are hormones? Hormones are chemicals that are made somewhere in the body that communicate with cells elsewhere in the body to help cells function. That's all hormones are. If you take away the communicators that help cells function, you get dysfunction of cells. That's how it works. This isn't magic. There's a reason for all of this. Objective measures of postmenopausal vaginal changes include the vaginal maturation index, which is a shift from superficial cells to parabasal cells as the vaginal epithelium thins. And vaginal ph then rises as fewer superficial epithelial cells exfoliate and break down to release glycogen and glucose, which would typically be broken down into lactic acid by lactobacilli in an estrogenized vagina. That's how it works. That's why you get more UTIs. Your lactobacillus dies off because it doesn't have the cells that it needs to live because your estrogen went away. All. It all makes sense. Okay. GSM prevalence estimates in postmenopausal patients vary widely, from 13 to 87%. It's crazy. Despite the potentially disruptive nature of GSM, only half of individuals with GSM symptoms report discussing their symptoms with their clinicians. And of those who did, most said the clinician did not initiate the conversation. So there you go. Traditional therapies are vaginal estrogen moisturizers and lubricants. They restore, alleviate symptoms and avoid friction, respectively. All right, what type of physician do we see for this? My doctor or guy would have no clue. You don't need them to have a clue. Print out the guidelines and bring it in and say this is super common. It's an easy treatment which is very cheap and very safe. Estrogen binds to receptors in the vagina, vulva, urethra, bladder and pelvic floor. Shifts the vaginal cytology towards superficial cells away from parabasal cells and red the vaginal ph. Vaginal moisturizers increase the fluid content in the endothelium and reduce the vaginal ph. Personal lubricants can be water, silicone or oil based and are primarily used to provide short term lubrication during sexual activity. So lube, Lube, lube. Always premenopausal. Post menopausal. The clitoris doesn't self lubricate, the penis doesn't self lubricate. Don't. That's an unequal distribution of labor to make the vagina do all of that. Always use lube and Use more lube when your skin gets dry. Okay, so DHEA is a precursor to both androgens and estrogens that is transformed into estradiol and testosterone within the vaginal cells. Any recommendations for lubricants? I love stripes oil based lubricant. I love uber lube. I don't love spit. I don't love. Oh, what's the basic bitch of lube? Help me out, somebody, quick. Basic bitch Astroglide. I don't like Astroglide. I don't really like water based. But if you need to use them because of condoms, use them because of condoms. But you can also use silicone with condoms. Just don't use oil based with condoms. But oil based is like luxurious and it's not cold. Silicone's not sticky. So I don't like the water based ones. But again, water based are kind of the basic. The basic b. Oh, KY jelly. Yeah. God. KY jelly is awful. Vomit sign. That's like the one ply toilet paper of lubes. Okay, dhea, we already talked about how that works. They've researched vaginal oxytocin gel, but that doesn't seem to have great data. And then we did talk about ospemafeme has unique estrogen receptor agonist activity in vaginal tissue. So they're talking about the research. Placebo effect is high, particularly in studies using a vaginal lubricating gel. And like their argument is like, vaginal lubricating gel is not actually a placebo. You're actually like making tissues feel better with that. So to compare the studies comparing like vaginal estrogen to a gel that has no estrogen in it, it's not a fair comparison because like the gel in and of itself is soothing and can help dryness. So it's not really a placebo, it's just placebo estrogen. Good Clean love is a nice lube brand. Yes. Coconut oil, not my favorite. I don't love using food. Don't love using food as a lube. Just seems like there are other things for that job. But some people like coconut oil can be super greasy and super messy. But you do you boo. Some people like olive oil. I just don't like food down there. Personal preference. Most experts are like, you know, you should put down there for lube food. Nobody says that. So I don't know where this. The coconut. Like the coconut oil is nice. It's nice on your skin, but like man, it's greasy. Safe to have sex after applying vaginal estradiol. Yes, it's Safe, it will rise. If you're having sex with a man, it'll make their estradiol increase slightly, but not above man levels. And then it goes away. Remember, men have estrogen. This is. Here's the thing. It's nice that we care about the dudes. It's very nice. But let's do some basic math. Vaginal estrogen doesn't. If you're doing a loading dose, it can increase your estradiol blood levels, but by and large, it doesn't increase your blood estrogen levels at all. More than placebo? No. So if it doesn't raise your vaginal estrogen levels, why would it make sense that it would affect somebody else's vaginal estrogen levels? It's more on you than it is on them. So there you go. What else do we have in these guidelines? These guidelines are so good, clinicians and patients should engage in shared decision making. Again, a no is not a no. That's not shared decision making. Understand their why. If their why is because it causes cancer, bring them the guidelines. Because the all the data. In breast cancer survivors alone, we have studies on over 55,000 women who have used vaginal estrogen. That said, we know that we are under treating the breast cancer population. What about oral sex and estradiol? Don't use it as a lube for oral sex.
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Remember, vaginal estrogen is twice a week. So like, it is quite possible that you could be spontaneous and like, you know, forget that. But like, usually not so just space it out, it's fine. And you know, it's not fun to eat, it's not a food. But like, you're not going to hurt anybody by having oral, oral sex with that. Where can we print these guidelines? Go Online. Type in 2025 AUA GSM guidelines and it'll pop up. All right. It says the clinician should engage patients in their decision making early and often by letting them know that their goals and preferences are an important part of the treatment decision. One robust method is simply asking what matters most to you when making this decision? Love that. A clinician should screen patients at risk or presenting with signs of GSM for sexual and urinary symptoms. Women can be using medications that cause gsm. The most common would be oral contraceptives and chemotherapy. What else are we on? These guidelines are in depth. They're pretty awesome, right? Many pages. This is the understatement of the guideline of the year. Many patients do not have a complete understanding of the vulvar vestibular vaginal and lower urinary tract changes associated with with decreased levels of sex steroid hormones, including atrophy, or that GSM represents a chronic condition. This ain't getting better. If you've outlived your ovaries, it's not getting better. It'll get worse. The more years that you have low hormones, the more issues that happen. All right, Clinicians should identify potential medications that might cause vaginal dryness. Oral contraceptives, Spironal, lactone, antihistamines, anti androgens. The clinicians should also seek to identify medical comorbidities, Lichen, sclerosis, malignancy, gender affirming hormone treatments, endocrine disorders that are known to cause GSM symptoms in some patients. Shout out to trans men. High levels of testosterone can cause basically an inhibitory or blockade in the vagina. Looking like atrophy. Trans men will have more urinary tract infections, more burning with urination, more urinary urgency, frequency pain with intimacy. So very common actually for trans men to be on vaginal estrogen. Even if they don't want to call that vaginal estrogen, they call it pelvic estrogen because it really helps because higher doses of testosterone can cause an atrophy in the pelvis. Super interesting, right? Super interesting. Okay. Trauma informed care is an approach that a clinician may use to recognize the impact of past traumas, psychosocial or physical, on individuals. All right. Careful examination of the clitoris and prepuce should be performed to determine the presence of phimosis, lesions or tenderness. Pelvic exam is important. You guys in my clinic. Pelvic exam. Any sexual health issue. Pelvic exam. I don't care about the cervix. That's not my job. I'm not a gynecologist. I don't do pap smears. I care about how hormones have affected your external genitalia. Any reason to go for Premarin over estrace? Self pay price difference is 750 versus $20. Yeah, why not use a generic whenever you have an option? Anybody who's paying $720 for vaginal estrogen, they're being ripped off. Most expensive. Most expensive thing about a tube of vaginal estrogen? The tube. This is cheap. People are making money off of you. Don't do that. Okay? Go cheap. Use the Mark Cuban cost plus drugs pharmacy or use your good Rx app or make sure that you're getting the generic. This is for estrogen cream that I'm talking about. And then as far as exam goes, you don't need an exam that looks like GSM to be treated for gsm. So many women like they're still like looking like normal labia, etc. But still have symptoms. So treat them both. Androgens and estrogens are critical physiologic modulators for development and maintenance of genital tissue structure and function. Androgens are necessary precursors for biosynthesis of estrogens. It's important to educate patients that documentation of hormone levels is neither necessary nor helpful for the treatment of GSM. I agree 100%. You don't need your labs drawn to get GSM treated. People with pre existing anxiety and depression may be at risk for more bothersome GSM symptoms. Patients who have experienced sexual abuse or sexual violence are at a higher risk for experiencing bothersome GSM symptoms. In a sample of perimenopausal and postmenopausal women veterans, vaginal symptoms associated with GSM were more common in participants with a history of military sexual trauma. Very, very interesting. Don't forget the physical therapists. Whenever I do a pelvic health talk, the physical therapists are always like, don't forget about us. I'm like, I never effing forget about you. But thank you for always constantly reminding me not to forget about you. It's helpful because pelvic floor muscle tightness needs to be addressed if you're having pain with sex, urinary frequency pain with sitting, all of the pain things. Hey, it's your ceiling vent. So I'm dripping. Could be the rain, could be the upstairs bathroom room. Yikes. You could hire the guy your neighbor recommended, but I'm pretty sure that's just his cousin. Do we know if he's licensed or does he just own a ladder? Listen to your home, go with thumbtack. Upload a photo or voice note and we'll diagnose your project and match you with the right pro for the job. Thumbtack. We know homes hire the right pro today. All right. Myofascial pelvic floor muscle training performed by physical therapists who have additional training and clinical expertise in the muscles, ligaments, joints and connective tissues of the pelvis and adjacent structures has been shown to be an effective treatment for urinary incontinence and pelvic floor dysfunction. One question I get frequently people are like, what if I started vaginal estrogen and I still have bladder issues? It's like, you're allowed to have bladder issues without it being a hormone problem. There's many Many reasons for bladder issues. That's what urologists are for. Go, go see a pelvic floor physical therapist or a urologist. Okay. How long should vaginal estrogen treatment take to see a benefit? Eight weeks, six to 12 weeks. Remember, you actually have to like regrow healthier tissue and get the tissues functioning better again with estrogen. So this is not an overnight thing. There is insufficient evidence to compare the efficacy of all the hormone interventions against one another. I get that question all the time. People are like, what's better? I'm like, nobody's done a head to head study on a lot of this. Don't hold your breath. It's not going to happen anytime soon. The greatest amount of evidence and experience exists for vaginal estrogen supplementation, much less data on DHEA and OSPEM fee. Dollar for dollar, vaginal estrogen cream is going to be the cheapest. Safety of low dose vaginal estrogen is supported by multiple studies which found significant improvement in GSN symptoms with no increase in serum estradiol levels. Remember, this is local. When we meet local hormone therapy, it means it does not go into the bloodstream. Into the bloodstream means systemic. There's been evidence of safety in breast cancer survivors using low dose vaginal estrogen. Multiple studies, enough studies on this that there's meta analyses. One study found daily utilization of vaginal estrogen CRE, significantly better at improving vaginal dryness compared to twice weekly when compared to placebo. So twice weekly is like the maintenance dose. But if you're having significant symptoms, you might need more. If you're going to use a lot, just know it might become systemic because of dosing. Dosing, dosing, dosing. People do not understand dosing. Dosing is like how much hormone is actually there. And the more product you use, the higher your doses. Somebody, side note, dermatologist has me on spironolactone. Is this affecting my testosterone? And libido is low. Yes. Spironolactone is a testosterone blocker. Basically, that's why your skin gets nice, because you're blocking your androgens. That's not rocket science, that's a Google search. But it's complicated, right? Because you're trying to balance a woman's desire for help for, for smooth skin with the benefits of androgens, which can be libido. And so that's a unique conversation that I'll have with women of like, what are your goals? What are your options? Same with, same with birth control. A lot of women are on birth control off Label for acne because it blocks your androgens. They also have low libido because your androgens are blocked. So I don't think that's a common informed consent that people get. Like, hey, you all, if you had a choice between clear skin and libido, what would you pick? And there's no right answer. And it's not always an all or none, but for some people it is right. All right. When comparing vaginal estrogen to no treatment, one randomized controlled trial found patients with vaginal estrogen had significantly more symptom resolution than those without treatment after 36 weeks. Not a lot of data looking at testosterone vaginally, but there are a couple of studies. They have found improvements in the orgasm domain. There's also studies on vaginal estrogen in women, on aromatase inhibitors. Their serum sex steroid levels did not change. So I don't. Don't hold your breath for a vaginal testosterone product that is all kind of compounded off label stuff. If and when we get a FDA approved testosterone product, it's going to be systemic. It's not going to be a vaginal product first. Can you take while on birth control? Yeah. Vaginal estrogen, yes, absolutely. What else do we got? Vaginal testosterone cream may improve sexual function, but the panel cannot recommend this treatment at this time. There's just not enough studies. Same with oxytocin, not enough studies on it to make a recommendation. Guideline number nine, clinicians should offer vaginal dhea, which is great. We've got more and more studies on vaginal DHEA, which is great. Guideline 11, this is important for people who are already on systemic estrogen. In patients with GSM who are on systemic estrogen therapy, clinicians should offer the option of local low dose vaginal estrogen or dhea. That's what you need. You need to print that out and bring it into them. When they say you can't be on both, you absolutely can be on both and the guidelines support it, which is nice. It can help with overactive bladder. Consider it in women with overactive bladder. And you. If you're a woman who comes to see me as a urologist with overactive bladder, you do not leave without a prescription for vaginal estrogen and a referral to pelvic floor physical therapy every single time. And all the experts would agree with me. All right. In patients with GSM and recurrent UTI urinary tract infection, clinicians should recommend local low dose vaginal estrogen to reduce the risk for future uti there's nothing better at reducing recurrent urinary tract infections than vaginal estrogen. Also, don't hold your pee and also be well hydrated. All right, the recurrent uncomplicated UTI guidelines, that's 2022 guidelines. Recommends the use of local low dose vaginal estrogen in both peri and postmenopausal women. Periods are not a reason to not be on vaginal estrogen. Periods are meaningless when it comes to can I be on vaginal estrogen or not? You can recommend lubes or moisturizers, but they should not be done by themselves. Like treat the hormone problem, not just lubes. Clinicians should counsel patients that the evidence does not support the use of alternative supplements in the treatment of gsm. I don't care what the Kardashians are trying to sell proprietary shit for your vaginas. We're just not there. Mixed herbal supplements are particularly unpredictable is what they say. There's a review of over 40 natural products studied in the literature. The majority had small sample sizes and they really say we can't make any big recommendations on them at this point. Avoid irritants and cleansers which may exacerbate the signs and symptoms of gsn. Common vulvovaginal irritants include urine, sweat, feces, soaps, cleaners, douches, spermicides, pads and liners. All right. Not great data on the lasers. And they're safe, they're expensive. They probably can help in addition to the hormones, but they should not be to the exclusion of hormones. Clinicians should inform patients of the absence of evidence linking low dose vaginal estrogen to the development of breast cancer. Incredibly safe family history of breast cancer. Not a reason not to be on vaginal estrogen. No. Even when women with BRCA mutation, which is the highest risk genetic mutation for breast cancer, there is data to suggest that systemic, even systemic estrogen in this group does not further increase the risk for breast cancer. So you can be on vaginal. All right. Patients with personal history of breast cancer are at a high risk for developing gsm, sexual dysfunction and issues with vaginal health. These women are being under treated who is use vaginal estrogen? No increased risk for breast cancer recurrence in the majority of studies. There's one study, I think it's a Danish, Danish or Finnish study showing increased risk of recurrence but not death with vaginal estrogen but not with systemic estrogen. Methodological flaws. With that study, the 55,000 women who are breast cancer survivors that they've studied on vaginal estrogen. They'll use that one study, which has got issues to say that that's why you can't be on vaginal estrogen. It makes no sense. All right. Also, ospemifem and DHEA don't increase the risk of breast cancer. Don't drink alcohol. Alcohol increases your risk of breast cancer. But being obese increases your risk of breast cancer. Not exercising increases your risk of breast cancer. None of those things are pelvic estrogens. All right? You don't have to survey your endometrial lining with vaginal ultrasound. If you're on pelvic hormones, that's good to know. And then, man, I think that's about it. Follow up to make sure that you're better. Otherwise think about other things. And it's a chronic condition and can get worse if left untreated. So I hope that was a nice little, what, 40 minutes of the new 2025 AUA, Ishwish and Menopause Society guidelines for GSM. You heard it here first. Go get it. It's free on the Internet. Bring it in. All the reasons that people tell you you can't be on vaginal estrogen are probably not true. You've got guidelines to back you up now. So good luck and I love you. And remember, you are not broken. Hey friends, if you love the you are Not Broken podcast, please show me your support by liking, subscribing and sharing it with someone you care about. Your support helps more people find this empowering information for courses, clinic info, and all things midlife mastery. Head over to kellycaspersonmd.com and don't forget, you can grab your copy of youf Are Not Broken. Stop shooting all over your sex life at Barnes and Noble, Amazon, or ask your local bookstore to order it for you and a friend. While you're there, make sure to pre order my upcoming book, Menopause Science, Hormones and Mindset for optimal longevity coming September 16, 2025 Medical Disclaimer the you Are Not Broken podcast, Instagram and content created by Dr. Kelly Casperson is presented solely for general information, education and entertainment purposes. The use of information on this podcast or materials linked from this podcast or website is at the user's own risk. Risk. It is not intended as a substitute for the advice of a physician, professional coach, psychotherapist, or other qualified professional. This podcast does not diagnose or treat you. Users should not disregard or delay in obtaining medical advice for any medical or mental health condition they may have and should seek the assistance of their healthcare professionals for any such conditions. And as always, I got you. I got your back, and you are not broken. Thanks for listening.