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- [00:00]
A
Hey friends, it's Dr. Kelly Casperson. For those of you who don't know me, I want to tell you about two things that are super cool. Number one, Instagram. I'm on there a lot. I do tons of reels doing short short things about hormones, midlife, some sexuality stuff. But really the podcast is where I do a lot of sexuality because I don't want to get kicked off of Instagram. So check out the Instagram Kelly Caspers and md. It is blowing up and doing really well. Number two is these podcasts if you're interested. A lot of people listen to video podcasts on YouTube now, so we're putting up a lot of these episodes. YouTube. Head over to Kelly Casperson MD on YouTube for that. And last but not least is pre order the book you are not broken. Stop shooting all over your sex life on Amazon and Barnes and Noble. Now it is being re released September 10th. So if you already have the book from the pre the previous, you know, iteration, thank you so much. We sold enough of it that it got pot. Sorry. Bought by a major publisher and is being republished to go more international September 10th. So go do your pre orders. Means a lot to me and that's how they know people are interested. So love you so much. We got some exciting stuff today. Hope you enjoy the show. Hey friends, I want to tell you about a podcast that I've been listening to, hello Menopause. A podcast that explores the physical, emotional and mental changes that we experience during this transformative stage of life. It's hosted by the fabulous Stacy London and is produced by the national nonprofit let's Talk Menopause. Recent guests include yours truly, as well as Dr. Mary Claire Haver, Carla Hall, Naomi Watts, Dr. Sharon Malone, and so many other incredible women. These are conversations you don't want to miss. Listen and subscribe to hello Menopause wherever you get your podcasts. And as an exciting bonus, the episode I did with Stacy Lunden on that podcast is on this podcast. You are Not Broken today. So I hope you enjoy welcome to the youe 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.
- [02:09]
B
Hey friends, the views of our guests do not necessarily reflect the views of let's Talk Menopause. Let's Talk Menopause does not provide medical advice. The content in this podcast is not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified Healthcare provider with any questions that you may have. Hello? Menopause is changing the conversation around menopause. And in every episode we explore the physical, emotional and mental changes that women experience during this transformative stage in Life. Menopause has 34 symptoms and we cover all of them, from brain fog to panic attacks to heart palpitations and urinary issues. For that last one, we're thankful that this episode is sponsored by Always Discreet, makers of liners, pads, and underwear for bladder leaks. Always Discreet is available at Target. Dr. Kelly Casperson is a urologist, author, TEDx speaker, and the host of the youe Are Not Broken podcast. Combining the power of mind, work, body, science and relationships, she joyously breaks down the cultural barriers that are keeping us from living our best intimate lives. Just to talk about the fact that, you know, I feel like we're not getting through to the entire country. What I really mean when I say that about menopause is that I think that one, people still don't know that they're in it. They are still not getting like enough factual information to understand the way physical symptoms and emotional issues could be related to each other. But the discussion around menopause is happening. But when I, you know, I did that, I did a menopause retreat, right? And I brought in doctors and all sorts of things. We talked about pelvic health, which obviously I want to talk to you about as well. None of the people knew that there were any particular treatments for menopause or that there were products for menopause. And that concerns me because those women were, you know, white women of privilege and, and they have access to the best healthcare. And still there was this, like menopause is still shrouded in this weird mystery.
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A
It's clearly insane. Women, I always tell a joke and I'm like, did you know women are 50% of the population? This is insane.
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B
Insane.
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A
This is not some like rare genetic disorder. This is 50% of the population, right?
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B
And so underfunded. And I was just. Earlier today I was talking to Jen Gunter, cause her new book Blood is coming out. And we were just talking about the fact that like, you know, women are screwed. I mean, like systemic, like all medicine has been through the lens of men and then sort of, you know, guessed at when it comes to female physiology. And that there's not enough research really done about female physiology, however you identify gender wise. And it is so frustrating to me that we are in this position that we are in 2024 and sort of banging around in the dark, begging for funding for things that, you know, I mean, 1993 is when they started using women, you know, in tests. Give me a break. Like, all of this stuff makes me so angry.
- [05:25]
A
You're absolutely right. It's completely insane. People are like, we need more funding for women's research. And, like, I'm at the radical point of this of like, we need more funding for human research. We are humans. We need research. As soon as we need to actually stop being a niche and saying we need more women, like, make a little bucket over here for us, it's like, no, no, no. We get us in the bucket. Stop putting us in this, you know, 5% women's bucket over here. Like, we are humans. This is human research data, all that stuff. And the other, like, the other thing about, like, the lack of education, because I'm kind of. I came into menopause from the sex med world because, you know, again, horrifically underfunded. Doctors don't know a darn thing about it. Everybody feels broken. So, like, that was the original podcast. Like, that was what it was for. Right. And then the myth, your menopause, which is my podcast. Yeah, my podcast.
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B
Yes. Which is called you are not broken. I just, you know, I want to talk about that as well.
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A
And. And it was because women were like, well, you know, because of menopause. Well, you know, because of menopause. And I'm like, what? Because I'm like, looking down the train tracks, it's. It's hurling at me too. Right? So I'm like, what's coming? And they're like, well, you know what happens to sex with menopause? And I'm like, no. And then I really got into like, oh, my gosh, the fear of estrogen, the whi, what that has done. We have two decades of physicians that have not been trained because of the whi.
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B
Yes, exactly.
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A
It's absolutely insane.
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B
It's insane. And also that the SWAN study, it was bad data to begin with. It hurts so many people on so many levels. And the idea that there is no medical training in that 20 year gap for. For menopause at all, again, it's like, how can you overlook us? This idea that menopause is also associated with ageism and you're being put out to pasture is really reinforced medically and culturally. But medically, that's insanity. Right? We're still fighting it culturally. So let's get into this, because what you're talking about is you got into menopause through sex med. I want to discuss the fact that you are urologist. And I thought urologists only saw men and only saw penises.
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A
We see a lot of penises, Stacey. We do see a lot of penises. That is very true.
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B
Is it less than 10% are women.
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A
10% are women? Yeah.
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B
Wow.
- [07:48]
A
Like, 9.6. We're gonna round up about 10% are women. So I went to this school. I went to med school at the University of Minnesota. When I was in medical school, there was one female urologist in the state of Minnesota, and I've still never met her. I mean, now I'm friends with a lot of female urologists, but, I mean, the unique lens that the female urologist lends to both sex med and hormone menopause is that the gynecologists don't have is. I take care of dudes all the time. I see how we treat them. I see gender disparity every single day. It's like a guy doesn't come in with erectile dysfunction and low testosterone, and we say, that's just how it is. Now, have you considered yoga and wine? Like, we do not talk to them that way, and so we shouldn't talk to women that way. Like, yoga and wine are fine, but that is not the treatment for. I just had a woman in la. She's in Los Angeles. Perimenopause goes to a doctor for bad hot flashes. The recommendation was less social media.
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B
Okay. That. That. That makes me want to blow my brains out. I mean, honestly.
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A
Yeah. Like, that is not. And. And, like, part of it is we don't know what menopause is. Right? Like, women are like, it's a couple of hot flashes, and then hot flashes are done. So then menopause is done, and you're like, no, no. It is a profound hormone deficiency. Which is funny because people will even fight about that. They'll be like, don't call it a deficiency. It sounds bad. And I'm like, when you're 58, pick a number. You have less estrogen in your body than the man next to you. The man has an estrogen of 30 to 40. He's got more estrogen than you do. Don't tell me this is a deficiency. That's what it is. It's less than what other people are functioning with.
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B
I want to go back to this thing about actually treating men and the way that they are treated. Right? Obviously, when somebody comes in and says they have low libido or hair loss, you're like, well, here's some Viagra and here's some Minoxidil. Or whatever. Why do you think? I mean, now we do have options for women. Why are we still in that mode of yoga, red wine, you know, get off social media. Why do we talk to women that way when we know that there are things that we should be doing?
- [10:02]
A
Yeah, I think they're in, in medicine, which I think I get to speak to because I've been through the training, right. I pay, I paid to be able to critic medicine. We have a. We dismiss pain, we dismiss female pain, we dismiss suffering, we call them names. We being the culture of medicine, right. Of like they're, they're, they just complain, Stacy. So let's just get them out of the clinic. But I mean, I tell you, like, I could, I could just go do regular urology, right? I've got plenty of people to help. There is nothing more rewarding than helping a woman with her sex life and her hormones. She comes back like she's taking higher power jobs. Her relationship is the best it's ever been. She's back in the gym, she's sleeping. Like, these are the most grateful people in the entire world. I don't understand why everybody doesn't want to help them.
- [10:53]
B
So you came to this because people started telling you that they were perimenopausal or menopausal and that their sex lives were falling apart. Right. Or their sexual health was a disaster. How did you really start helping women? I mean, you know, because that's like, if you didn't know this was coming for you and you started talking to all these women who it was coming for, what was your way in? Was it the sexual health? Was it mht? What were the things that really sort of guided you as principals into finding these people and helping them and making them so grateful?
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A
Right.
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B
I mean, that's all we want, is to improve our lives, especially as we age, not in. Despite that we're aging 100%.
- [11:37]
A
Yeah. I mean, I truly got into it because of sex med and really diving down for my own personal interest of like, is it a myth that your sex life goes away after menopause? I would say now, yes, it's a myth. Women in their 60s and 70s are having the best sex lives that they've ever had. We've got plenty of data on that. But so I was like, okay, estrogen, estrogen. Why is it, why is everybody scared? What's the role of testosterone in libido? And so I just kind of like started picking away at it and being like, estrogen is one of the safest Medications you can actually prescribe to people. We give people unsafe medications every single day, and we don't think twice about it. Yeah. And if you want to take a close example, birth control pills are less air quotes, less safe than hormone replacement, estrogen therapy. And we just think. We don't. We don't give it a second thought to give somebody a birth control pill. Right. And so it's like, to really understand, like, the fear is unfounded and people. But the fear is so embedded, people can't tell me where it comes from. I know it comes from the whi, right? But they're just like, I don't know. My sister told me, you know, this fear of estrogen.
- [12:41]
B
But that's the problem, right? That scare tactic, the whi, and that scare tactic is so systemic now in our society. I had a friend actually ask me the other day. She was like, I'm tearing my hair out. I'm going crazy. I can't sleep. I can't sleep. I can't slee. Feel nuts. I forget words, all of this stuff. And I said, have you talked to anybody about mht? And she said, no, I don't want cancer. And I said, well, does it run in your family? And she said, no, not at all. And I was like, go see a doctor. I mean, the idea that that is what is pervasive in terms of belief, as opposed to all the things that you're saying about how much richer our lives could be and how less invasive and truly difficult menopause can be. Right. I mean, my experience in perimenopause was disastrous. I mean, I had every symptom known to mankind. I thought I was absolutely insane. And culturally, I started to feel useless, and I felt hopeless, and I felt lonely. And it's. That's the reason I started to talk about it was because I was like, why is this happening? And why does everybody feel this way? So when you give me this kind of positive information, right. I want to know what that means to you. It's not just estrogen, Right. I mean, most people who are on MHT are taking some if they have a uterus, right. Estrogen and progesterone. Right. Or progestin. Talk to me about testosterone, because I feel like that is still a kind of taboo topic, even though we're breaking through a little bit, even though we're trying to get people less scared of estrogen. Right. Testosterone. It's like, oh, my God, I'm gonna grow a beard. What does the role of estrogen, excuse me, of testosterone, play during this experience, during this stage of life. And how can it help us?
- [14:38]
A
Yeah, it's a great question. I loved. I mean, I'm a urologist, right? So I give 10 times the dose of testosterone to the other humans all the time. So the urologists aren't afraid of testosterone. Gynecologists stereotypically, again, are a little more air quote afraid because they didn't get trained in it. Right? But education, let's step back for one second with education so people understand because otherwise it sounds crazy if you're like, why are you giving women testosterone for. If you don't understand that women's bodies make testosterone, your ovaries make testosterone, your adrenal glands make testosterone, we just make 1/10 the dose of the males. So the other thing we didn't know, and I did not get taught this in medical school, women's bodies have more testosterone in them than estrogen in your 20s and 30s. Right. So we've got to start there because. Because now you understand, okay, this is a normal hormone in our bodies, functioning everywhere in our bodies. And just like estrogen, it starts to decline perimenopause post menopause as a hormone.
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B
What is its role and function in the. In the. In female physiology?
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A
Yeah. And again, our research is horrific. We have. Because if, if we do have, all we did is we gendered our hormones. And since we gendered our hormones, we erased them from being necessary in 50% of bodies, right? So we do not have a lot of research with things other than sexual desire. And as my brother had to point out to me, why is the only legitimate reason for a woman to be on testosterone is to sleep with somebody? Like, it is kind of insane. But. So we have a lot of data on desire, the role of desire, the way it works in the brain, the way it modulates dopamine, things like that. But the data coming out on mood, depression, anxiety, and these are things that are vague and you can't research. How am I supposed to do a research study on does testosterone improve your overall sense of wellness? Right. It's like, it's too vague. But I would say one of the most important things, I mean, how many women do we hear in perimenopause and menopause are like, I just don't feel like myself. How do you study that? How do you study feeling like myself? Right, but that's what hormones are, who you are. Right? Like who you are. Once you went through puberty was different than before puberty. Hormones matter incredibly a much the other. The Other interesting thing about testosterone, you can't make estrogen. You cannot make estrogen without it going through testosterone. That's how we make estrogen in our bodies. But if we don't have that knowledge, people are. They think you're crazy. You're like, what are you giving the male hormone to women for? It's like, because it's everybody's hormone. Bone health. Yeah, I was just going to add bone health, cardiovascular health. There are some. There's some decent data looking at that, too.
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B
Well, I mean, I def. I want to go back to that in one second. I. You know, but it's so interesting the way you say, you know, hormones, when people say they don't feel like themselves. And you're like, but hormones are you. Right? That makes me laugh because it really took me a long time to understand that my feelings were actually, like, hormones in my body doing something right. I'm like, I'm sad. I don't think of that as physiological. I don't think of what's going on in my brain. I'm just sad. Stacy is sad or depressed or whatever it is. I don't know that my brain is firing or that I don't have enough dopamine or whatever it is. I don't have enough testosterone or estrogen. And when you start to realize that, you know, people say feelings aren't facts, I'm like, well, they kind of are scientific facts. We just don't talk about them that way. And, you know, the minute we get to perimenopause, there is this, like, it feels, I think, for a lot of people, like, there's some havoc being wreaked. And we know that it's not the same for everybody, which is also why it's so hard to study and also why treatment is so individualized. Right. But it never occurred to me that testosterone played a role in my feelings. Like, I had never heard that. So to me, it's very interesting, particularly coming from urology and not gynecology, that you are able to see the benefits of not. Not gendering hormones for the 51% of us who might need them.
- [18:47]
A
Yeah. I mean, just. Just, you know, because people. I think you can tell people, give people facts, but when you give them stories, it starts to connect more. Two stories with me and my women with testosterone. One of them weaned off antidepressants. She says, how do you study this? I feel like I can math better. Is something somebody told me you, how do you can't study that? But, like, that mental sharpness is back, right? I had another woman, she was 58, got her started on her estrogen first. She was happy with that, no side effects. Good. She's like, I'm ready for testosterone now. Put her on testosterone, see her back in three months. She's like, I feel like I felt when I was 28. I have that energy back again. And we start.
- [19:27]
B
So what do we do? What do we do with that? What do we do with anecdotal information? It's true, it's real, right? And you can't, you can't just. What you're saying, how do you test for that? How do you study that? So how do we know what's safe and what isn't? Depending on the person. How does that, I mean, how does that work scientifically?
- [19:45]
A
The good news, like, these are not brand new medications. We've been giving women testosterone and estrogen since like the 1940s in many different doses and formulations and stuff like that. So it's my rules for testosterone, for example, is like, we start low and we slowly bring you back up. Because if you go from, let's make up some numbers, let's go from, you're at a testosterone a zero and you take a pellet, right? Pellets are very high dose and they get you a high dose in a day. That's where you get like, oh, all my hair fell out. I felt horrible. Like, titrate up slowly, you're gonna have a lot less side effects. You're gonna avoid that hair loss problem. Like, but you need somebody who's understands hormones, isn't just going to try to sell you a pellet, right? So we, we do not have an FDA approved product that's absolutely a problem in this country. But testosterone can be given safely, effectively, and like, slowly over time, people will be like, it was subtle, it was subtle. But I can tell that, that my life is better with it. Those people are a heck of a lot happier than the, like, I had to remortgage my house for these darn pellets and all my hair fell out, right? Like, there's bad ways for bad ways to give hormones.
- [20:56]
B
What are the delivery mechanisms that you believe in that you prescribe, that you have seen results for people in menopause or post menopause. You know what, what is FDA approved and how do you get that done? What does that look like?
- [21:11]
A
Well, I just made a viral reel from this conference I was at in New York. It hit like 300,000 people in 48 hours. It was basically A snippet of me saying bioidentical is a marketing term.
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B
I saw it.
- [21:24]
A
I saw it. You saw it? You saw my viral reel? I did not say bioidentical is a scam. Bioidentical just means it's the same hormone that your body makes. That's all it means. There's FDA approved products that are bioidentical that your insurance pays for. So I use an FDA approved product, and most commonly that's gonna be your estrogen, your progestin. We've got a couple of good options on those. Testosterone's a challenge. Cause we do not have an FDA approved testosterone for women. Frankly, I want there to be one, but I'm worried they're gonna charge $500 and put it in a pink box. And I wouldn't vote for that. These should be cheap. So we can use an FDA approved male product. Dose it at one tenth the dose. That's easy to do. I've had a lot of issues with my pharmacist. They've been a little obstructionist. They ask my women very uncomfortable questions when they try to pick up the FDA approved male testosterone. So I have gone to a compounding cream because the pharmacists were being too obstructionist with my women. And frankly, it's inappropriate. You can also compound estrogen or, sorry, a testosterone injection that's less like, you know, people are less interested in injecting, but it works great, usually once a week. What we're trying to do is we're trying to get your testosterone to where it was, let's say in your 30s, right? I'm not trying to get you to, you know, to grow a beard or to, if you don't want to transition to a male, don't take testosterone doses that are male doses, right? Dose it to a female dose. Now, some people do do better at a little bit of a higher dose. But I want to get you there slowly. I want to get you there so it's not a shock to your system so you're not losing your hair or kind of all of those, like, horrible high testosterone. You know, when women write me and they're like, this is what happened when I took a testosterone pellet. And I'm like, cause you went from 0 to 300 overnight. Your body doesn't like that. So safe, cheap, effective, go slow, check in with your patients. Like, you know, menopause is really customized, but it's not rocket science.
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B
Well, let's talk about this a little bit because, I mean, it's customized. You Know, it's individualized because what you're saying. And I, at the end, I want to go through this because one of the things that is very important to me about this podcast is that there are. There is an action item list at the end of this. If you feel like crap, listening to you is going to make the difference between feeling like crap and getting your agency back to do something about it. So when we're talking about, you got into this because of sex health, and this was about libido and desire, and there's lots of data about cognitive behavioral therapy. There are pharmaceutical options for female libido. Now, what are other reasons that people want to take testosterone? Is it energy? Is it strength training? You know, what are some of the other benefits? Because I think it's really important that people understand, if we've had testosterone in our bodies always, what good does it do us? Right. It can't just be libido.
- [24:25]
A
Yeah. And this is really where that anecdotal evidence comes in. Because again, we have no FDA approved indication that even sexual desire is not an FDA approved indication. Right. Which means your insurance won't cover it. You know, and it's the legitimacy of it. But, I mean, just telling you of the women that come in, my lean body mass is up. This is one I see a lot. I'm recovering better from my workouts. I see that a lot with women who are on testosterone. Mental health, a sharpness, a clarity. We've got data for bone health, women who really care. They're like, I want to keep fit and keep my bones strong. We've got some data on cardiovascular health both in men and women. We kind of take the men's studies and extrapolate. Right. If testosterone works for their bodies, for this probably works in our bodies, too.
- [25:11]
B
But that just pisses me off that we don't have those studies that are. It should piss you off, right?
- [25:16]
A
It should piss you off. Absolutely. I mean, can I give you one more thing to be really pissed off about?
- [25:21]
B
Please.
- [25:21]
A
Okay. So fort, if so estrogen, you can go to any provider, get a prescription for estrogen. Testosterone is a regulated drug on the level of a narcotic. You do not have a physiologic level of fentanyl and oxycodone in your body, Stacy, but you do have a physiologic level of testosterone. Why are those two medications both restricted? Well, now, what does this mean? Why is this important? Two reasons. Number one, telemedicine struggles with offering testosterone because telemedicine, it's harder to give a scheduled drug. Telemedicine and a doctor doctor. I can go get a license in Texas. I got to get a separate license in California. Great. But now I have to get a separate DEA license in Texas. A separate DEA lease on the tune of about a thousand bucks per state just to give you physiologic testosterone. It is absolutely insane. And I'm like, it kind of happened. I think it happened because of the worry of males abusing testosterone and an anabolic steroid sort of, you know, bodybuilding sort of world.
- [26:28]
B
Right. Where does the myth come from?
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A
That's where the rule comes from.
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B
Is that the roid rage that people talk about?
- [26:35]
A
Yeah.
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B
Okay. All right.
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A
But to me, I'm like, the fact that it's so restrictive to give you a physiologic dose of something your body makes already. And just to add a little bit more. This is all made up, Stacy. You can go to Mexico and in the airport, you can buy testosterone over the counter with your latte and your cheeseburger. Right. Which country is the free country, Stacey?
- [26:59]
B
So this is why I get so confused. Because again, it's so restrictive in some ways, but particularly for those people who happen to have uteruses, that we seem to be the ones who are suffering the most and are under the most restrictive laws around hormones specifically. And I wonder, what would be your dream? What does it look like for you as a doctor to be able to treat any of your patients the way you want to? Is it that the FDA approves testosterone and has testosterone that is made for women instead of having to do this one tenth of a male dose? What would be the dream?
- [27:41]
A
Definitely I want the DEA restriction off of testosterone. It is not a narcotic. It will not kill you. We just want to dose it, you know, physiologically. So get the DEA off. I want 20 FDA approved testosterone medications for women. Why 20? Because the men have more than 20, and that's just equality. So I want multiple safe. I don't. I don't want to have to compound stuff. I don't want women to have to go remortgage their house for pellets. I want this to be cheap. It's fine if it's not over the counter. You know that. That's fine. Maybe, you know, physician oversight is probably good to make sure you don't have other health issues going on. But the access is absolutely insane. We've got a big problem.
- [28:24]
B
Yeah, I mean, and that's access. I'm assuming you're talking about people who have access to the best healthcare in the world. Right. I mean, if we're talking about the most privileged people and this is still impossible, you know, obviously when you start talking about the more marginalized of us, this is, it's even more impossible. It's like a pipe dream.
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A
Yeah. My other wish is if any middle aged woman goes in for depression or anxiety symptoms, her hormones are addressed before she's given an SSR and anti anxiety meds.
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B
Ah, now that is so fascinating to me when we talk about the mental health aspect of this, because when I started to feel not like myself, I did, I felt depressed, I felt anxious, I had like incredible rage, I had roid rage without the roid. And I went to my doctor and I said that and the first thing she offered me was an ssri. The first thing. Not any discussion about where I was in my life, any external like reality factors that may be playing into this. And nothing about hormones. Absolutely nothing. Not one discussion.
- [29:28]
A
We were doing it wrong. 25% of middle aged women are on an SSRI in this country. 1 in 4 are any of those women. Are any of those women told that SSRIs are associated with increased risk of bone fracture? We have multiple studies showing that the risks of these, let alone coming off. And don't get me wrong, like I will back up and say depression needs to be treated appropriately, but a lot of times it's hormones, A lot of times it's hormones and we just throw an antidepressant on these women and they're still miserable because we didn't fix the problem.
- [30:01]
B
And it is interesting to me also that you say that, especially when it is about bone density. Because here we are saying now, you know, menopause is, I love to say that it's the last exit on the highway. Right. For you to start really taking care of what the longevity your health span is going to look like. It's not that you want to live to be 100 if you're not going to be able to stand at 100. We want to be able to be strong and like take care of ourselves. And I think that it's so interesting to me that that is not something, I mean, you know, obviously maybe, maybe it's on the box or whatever of an ssri, but that particularly for middle aged women, when bone density is at its most important and building bone density and strength training and all of these conversations that we're having about how you're taking better care of yourself could be undermined by that medication. To me that makes no sense. That's contradictory and confusing to a patient.
- [30:55]
A
Yeah, well, it's insane. It's like, you know, we don't offer hormones, which are some of the safest meds. Why? Because our body makes them naturally, right? It's kind of like giving people insulin and thyroid is like, they're pretty safe because it's just what our body makes, right? Let alone an anti anxiety medication. But I started when I started reading about this, when I started learning that 25% of midlife women are on an SSRI, when I started learning that we have meta analyses, which is like an analysis of the data. We have meta analysis showing the correlation between SSRI and fracture because we have all of these nerves, you know, the, the, the, sorry, the receptors for the are in the bones. There's something going on with SSRIs that increase a woman's risk of a fracture. So I texted my orthopedic surgeon and I said, did you know that SSRIs were associated with fracture? And he's like, like, no, but, but everybody's on him and nobody's on estrogen because he sees the 80 year old fractures all the time, right? He's, he's picking people out of the river downstream. And then I texted a primary care physician friend and I'm like, did you know SSRIs are associated with bone fracture? And she's like, no, we've known this for over 10 years. The papers have started coming out years ago. And so I'm like, oh my gosh, we're treating menopause symptoms with SSRIs instead of estrogen and we're actually hurting the bones. But it's insane. The data's there.
- [32:19]
B
What's interesting to me now is amongst menopause advocates and doctors like yourself, we are talking about hormones as the gold standard. And even though you're a urologist, what it sounds to me is like you're actually like a hormone doctor. You understand how hormones need to be, you know, fine tuned in the body. And that if we understood menopause to be a hormonal change, like puberty or something else, then wouldn't hormones be the first thing that we would reach for in order to, you know, sort of make it as smooth as possible? Like I used to say, look, you know, menopause is, can feel hopeless, but you aren't helpless. And that's more and more the case. The more we understand how hormones play a significant role here, we get away from the idea that they're completely dangerous and that you know, there is a way to fine tune them for individuals, let's say for right now, Right. Because there's no blanket way to do it. It's just so interesting to me. I mean like that it's not endocrinology exactly, but it's so interesting that you're coming at this from a urologic viewpoint. Like to me it's like listening to you, it's like, duh.
- [33:30]
A
Well, yeah, I mean, urologists see it, I mean every single day, overactive bladder, urinary tract infections, bladder leakage, pain with sex all over and over. That's all low estrogen. It's all low estrogen, right. And so it's like I really started paying attention early on of like, why are we giving people overactive bladder drugs? Which by the way are contraindicated over age 65 instead of putting these women on vaginal estrogen, the bladder has estrogen receptors. They, the bladder gets better. This is what I tell women. Like we are at a time, we've never aged like this before. I mean I tell women because they're like, why do I have to take hormones? Blah, blah. And I'm like, well, because you have to floss and you have to wear sunscreen and we, you have to wear a seatbelt. Like we've, we have the insane privilege of aging. Insane privilege. I've looked at the data. We did not make it past 50 in great numbers ever before. And we're learning how to do it. We're, we're the, we're the babies. We're like the first generation learning how to age on a global massive scale.
- [34:31]
B
Well, that's what I find so interesting. I really do believe this is sort of the legacy of Gen X, is that we are the generation that learns. Stop sitting all the time, stop smoking, don't drink as much or drink at all. Right? 10,000 steps, all of that stuff has orgasmic equality. Right? But this is all in our lifetime, that these are the things that we're recognizing. And I do think, obviously that does mean that our chances of having a stronger health span and being able not to fall at 85 are much more realistic. And I think, I remember when my grandmother went to one grandmother fell and wound up in a nursing home and just never got out of bed and was clear as a bell brain wise, which I just thought was heartbreaking. And another, my other grandmother, when her husband died, she moved to Florida and just waited to die. And I think that was this kind of old school thinking of you get to a certain age and, you know, you move to Florida, like, that was that, you know, and you found a community in Florida. And I don't think that that is the way that we look at aging now. Right. And we are looking at what is coming for us in a way that is so much more proactive. And. And what you're saying is exactly that, Right? If we're. If we're told we have to floss, if we're told we have to wear seatbelts, why aren't we told that this is something that, you know, hormonal treatment is something that is essential to our well being as we age.
- [36:02]
A
Yeah. And I get it. I mean, you know, there's so many women our age, they've never been on medications before. Right. Or they pride themselves in. Like, I'd one woman be like, I'm the natural friend in my friend group. I'm the natural one. I don't take meds. And I'm like, it's very possible. And we have some data on this, that by taking hormones, you're actually decreasing the risk of you needing other medications.
- [36:24]
B
Yeah. Wow.
- [36:26]
A
Yeah. You're decreasing your heart disease, you're decreasing your insulin resistance, you're decreasing your osteoporosis. Like, by taking a hormone, you're decreasing the chance you're gonna need other meds.
- [36:36]
B
And it's funny because I had a doctor say to me, when you get to a certain age, like, you know, postmenopause, just expect a new pill a year.
- [36:43]
A
Ooh.
- [36:44]
B
And I was like, I reject that. I reject that philosophy with all of my being. I reject it.
- [36:50]
A
You should. And to me, I'm like, what if falling and breaking your hip at 80 wasn't the default? What?
- [36:58]
B
And I really believe our generation is actually not. That is not going to be our default. But I'm also curious as a urologist, because this is so fascinating to me. You were talking about overactive bladder and how after 65, these are contraindicated for actually working. What are the five top issues that people come to you with? I'm curious. And what is your response for each of them? Because I want people to understand the difference between what you do and gynecology.
- [37:27]
A
Yeah. Yeah. I basically do not deal with the cervix and I do not deal with ovaries. And I do. So I'm like external female genitalia and external male genitalia. All of men have external genitalia. Right. But so, yeah, people, they wanted. They want me to talk about fibroids. And I'm like, no. I will not. Right. But kidney stones, enlarged prostate, bladder leakage, prolapse is quite common and very shameful. Still, recurrent urinary tract infections, pain with sex, erectile dysfunction. That's kind of the urologist's wheelhouse. And then, you know, any kidney issues, stuff like that. But I don't do. I don't do big kidney surgeries anymore.
- [38:09]
B
And I'm curious, for women who come to you, what are they usually talking about? The same kinds of things.
- [38:16]
A
Bladder, kidney, recurring uti, which, you know, just to get dramatic, to get people to pay attention. Recurring kidney that recurrent urinary tract infections kill people. And I tell women, if you had a medication that decreased urinary tract infections by 50 to 60%, would you want to be on it? And they're like, yes, I would want to be on that. And I'm like, great. It's called vaginal estrogen, you know, because the myth of vaginal estrogen, women will be like, well, I'm not sexually active, so I don't need that. And I'm like, why is your vagina for somebody else? First of all, why is caring for your vagina only valid if somebody else is using it? Like, it drives me absolutely insane. So we have to talk about that first.
- [38:59]
B
Now let's talk about this, right? Maybe I'm sort of asking the wrong set of questions, and I want to make sure I really get this right. That, you know, you're seeing resistance to things that you know are going to be helpful. Like, vaginal estrogen is not just about painful sex. This is about just having, like, a healthy, comfortable vagina that doesn't get recurring UTIs that could then eventually kill you. And we know that UTIs can, as we age, right. Don't always feel like painful peeing. It can be all sorts of other symptoms. Am I right about that?
- [39:30]
A
The most classic bladder infection is a sudden onset. I feel like I'm peeing razor blades. Right? That's your classic bladder infection. But it can also look like I'm leaking a lot more now, or I have to go to the bathroom a lot more frequently now. It can be confusion in older people. You know, they don't have the classic symptoms. You know, it's interesting in my. In my group of friends, because we're the urologists who want to prevent this. Western medicine is so good at treating disease. You come to me when you have a problem. I don't want to wait for my labia to go away. I don't want for my way to wait for my clitoris to atrophy. I don't want to wait for a urinary tract infection. I don't want to wait till I. Till I'm getting up three times at night to pee. What can I do to. To prevent that? Right. So the. The role of vaginal estrogen as a preventative medicine. I think I'm on the forefront of that discussion. But to me, I'm like, if genital urinary syndrome of menopause, which is a mouthful, but that's what it is. If that's in 50 to 80% of women, that's not rare.
- [40:33]
B
Exactly.
- [40:34]
A
And if we have a medication that's safe and cheap, why wouldn't we want to use it at least once a week to, like, just keep things healthy? I floss. I'm not going to wait till my teeth get rotten.
- [40:44]
B
Well, I mean, all of this is. It's kind of. The logic is almost stupid. It's so easy.
- [40:49]
A
Thank you. Thank you for seeing that. I try to point that out. Like, this makes sense to me.
- [40:56]
B
Listening to you say this, I'm like, well, this makes perfect sense. And I agree with you. I think that people who have uteruses tend to actually believe more in preventative medicine than those that don't. And that just some of the studies that I've done on men's health, just to use that phrase for what it is at the moment, they wait until something is wrong and that their chances of living past retirement age are raised if they have a woman in their life or a partner in their life. That's like, you gotta go to the doctor. But what I was saying before about UTIs becoming like confusion in older people is that if you were taking. You're saying if you were taking vaginal estrogen as a preventative measure, then the chances of you getting UTIs, that would then again be more serious over time lessen. Right. Because you're just not getting UTIs.
- [41:52]
A
Yeah. Now we don't have a study to show that preventative. They haven't done a study looking at preventative vaginal estrogen. I would love for them to do that, like, bring it on. The other myth of vaginal estrogen is that you can't start it once you're 10 years post menopause. Right. Because there's. Which, again, I'd love to talk about systemic in that rule, because it's not a rule. It does not mean 10. I'm like, why does it make any sense? Again, going with the Casper syndrogic bombs. Why 10 years in one day postmenopause, you can no longer take hormones. Like, that's not what it says. It just says the best benefit is, is earlier. But going back to vaginal estrogen, which is only pelvic, you can stay non systemic. Non Systemic. I put 92 year olds on that. You know, I tell them, well, you're 40 years overdue. Let's get you on this medication. Right. I put 83. So many people. Can I have put my mom on this? Absolutely.
- [42:44]
B
First of all, obviously, you know, this is the type of thing that we want. We want research done, we want those studies. So you can say, see, I was right. I mean, that's sort of the first thing.
- [42:54]
A
This is an easy study. You take two nursing homes. This nursing home, everybody gets vaginal estrogen. This nursing home, nobody does. See how many urinary tract infections happen. This is a pretty easy study.
- [43:04]
B
Exactly. And then I'd be so curious to people who are sexually active as well, you know, what does that look like? Because again, those are the two populations that are going to benefit the most from this. And what I was thinking.
- [43:17]
A
And everybody with bladders.
- [43:18]
B
Yes, and everybody with a bladder. Exactly. So it's interesting because I remember a doctor said to me because I was like, what about this thing that you can't take hormones after 10 years? What does that mean? And she gave me the analogy of, think about it this way. If you were putting money into a bank account, a savings account, you would have more money if you started at 20 than if you started at 60. But it doesn't mean you wouldn't have any money saved if you still have.
- [43:45]
A
That is so good. I am going to use that from now on. That is a fantastic message.
- [43:49]
B
Susan Hardwick Smith. I give her credit where credit is due. And it was, you know, again, the logic and these analogies that you make are very helpful to lay people like me who want to advocate for things that we know are going to help us but don't have medical degrees. We need these analogies to say, okay, this is how we explain this when we're in a doctor's office. And this is why we can advocate for ourselves. Let's talk a little bit about your podcast as well, because clearly this started out of what you saw happening with your patients. So when did you start it? And let's talk about it a little bit.
- [44:27]
A
Yeah. Thank you. So my podcast is called you'd are Not Broken. It's named you are Not Broken because once I learned a lot about female sexuality, I just kept telling women don't worry, you're not broken. Don't worry, you're not broken. And I'm like, obviously. That's the podcast title. I started it four years ago. It's currently number seven in the medicine category and, like, in the top 100 of Apple Health and Fitness. It's doing phenomenally, like, the word of mouth on this because this is evidence based, practical midlife hormone sex. Like, it's what everybody needs to listen to, partners listen to it and discuss it together. The men are insanely interested about what's going on with women's bodies.
- [45:06]
B
Right?
- [45:06]
A
They don't know either. But the reason I started it is because a woman changed my life. I was in clinic, she was crying, sexless marriage, distraught. I had no idea how to help her. And I handed her the box of Kleenex and like lightning hit my brain and was like, you, you don't know how to help her. And I was like, let's, let's start learning. And because of her, and she knows who she is, she changed my life. You know, I'm on stages now. I did a TedX. I wrote the book, I'm on my second book. I got the podcast because this woman changed my life as much as I changed hers.
- [45:44]
B
And I'm thrilled to hear, I mean, you know, whether heteronormative or not, right. That all people are interested in this conversation. Because I do feel, and I say this all the time, Scientific American did a study years ago, they said the, the lowest point of happiness in a person with a uterus's life is 45 to 55, right? Because of highest perimenopause.
- [46:10]
A
Right.
- [46:10]
B
Highest rate of divorce, highest rate of depression, highest rate of decreased earning potential. And I was like, that can't be by accident, right? I mean, if we were talking about
- [46:20]
A
perimenopause, there's no doubt in my. It's the big black, you know, elephant in the room is like your estrogen is plummeting, let alone your progesterone and your testosterone own. Right? Like, I think we're going to look back and let you know we have a lot of hormones in our bodies that we just don't know how to measure and we don't have drugs for. Right. Like, there's other stuff going on too. We just talk about three hormones, but there's way more hormones in our body. Like, we're going to look back on this and we're going to be like, this is like leeches and bloodletting, you know, us, us being like, you know, let's not give you a small estrogen patch. This is like, just. It's crazy.
- [46:54]
B
I mean, that's really. From your mouth to God's ears. I actually, I hope, even if it's not for our generation, but the generations that follow really do think about this as bloodletting and leeches, because we need better medicine for us. We need better medicine. Like, the fact that we just have not been included in studies only from 1993 on. It makes no sense to me. And it does seem to me like we really need a billionaire to give somebody $400 million and say, just go invest in women's health. Right. We know that we. Because even doctors who identify as female have still been taught medicine that's through this kind of patriarchal lens. And I wonder if you just took female physiology on its own and all you did was study that. All the amazing things that we would find and be able to do.
- [47:47]
A
Yeah. You know, for people to be like, oh, but the gynecologist. Well, it's like, dude, that's one's medical specialty. We need all medical specialties. I need cardiologists, I need gi. We certainly need neurology. We definitely need urology. We need orthopedic surgeons. Like, 97% of orthopedic surgeons are male. Right. Frozen shoulder. Like, I'm going to throw an estrogen patch on me, if only to prevent frozen shoulder. I don't wish frozen shoulder on any. Anybody. And this new study that came out looking at, you know, women who are taking hormones have a significantly decreased risk of frozen shoulder. That was done by a female orthopedic surgeon.
- [48:26]
B
Wow. Of course. Of course.
- [48:27]
A
No, I know. I'm like, we need. We need everybody to care about this.
- [48:32]
B
Yeah. And so can we talk a little bit about the book that you're working on? Are you allowed?
- [48:38]
A
Oh, tell us.
- [48:39]
B
Tell me everything.
- [48:40]
A
Tell me.
- [48:40]
B
No.
- [48:41]
A
Well, it was interesting because a publisher reached out after my first book, and they're like, we'd like you to write another book about sex.
- [48:46]
B
Sex.
- [48:46]
A
And I'm like, that's very nice. You know, my first book is about sex, and I'm like, I think my second book's going to be about midlife, though. And they're like, oh, yeah, write that. And I'm like, apparently I just tell people what I want to write. Like, what a gift. But really understanding. Understanding the hormones. How to talk to your doctor about the hormones. How to. How to know the truth. To understand the whi. To understand. Because your sister is going to come at you and tell you what you're doing is dangerous, and I need to arm you so that you can actually tell her no. These are the studies. I'm choosing to do this. This is a choice. And to really empower women to be like, nobody is coming to save you on this. Like, you gotta. You have to advocate for your.
- [49:28]
B
Most people are gonna get. Yeah, most people are going. Are gonna get in your way of
- [49:32]
A
trying to save you. Most people are gonna get in your way. Yeah. But the hard work we're doing is it's only gonna get easier and easier. That's my hope.
- [49:40]
B
And on the podcast, you were saying that men, women are listening to this. Everybody is sort of interested. What would you say the top five episodes have been of the pod?
- [49:52]
A
Oh, yeah, the hormone ones. Cause there's so much crap out there. But my number one biggest episode, I just looked at this. It's called the Boomers should be Pissed.
- [50:10]
B
Well, they should be.
- [50:12]
A
They should be. And once they get. But a lot of them aren't, because they have no idea, right? But once you give them the information of, like, do you know the rate of hip fracture and cardiovascular disease and death has gone up since they took hormones away from this country? Like, we have data to show how much lives have suffered because we took hormones away for two decades. And then they get pissed, and then they. Then they freak out, and they're like, 10 years. The 10 years. And I'm like, well, what if you're 10 years in one day? What if you're incredibly healthy 18 years on? It's very individualized. Very individualized. So not everybody can take hormones, but there's way more people who could take hormones and get benefit and who aren't because they're afraid. And it's that fear that I want to be like, let me just give you the data and the info. I don't care if you take hormones. It means nothing to me. But what does mean a lot to me is I empower women to go feel better, and then they go change the world.
- [51:09]
B
I would say that's a pretty great place to stop.
- [51:11]
A
It's a fun job. I love my job.
- [51:14]
B
It's an amazing job and also an amazingly caring and unbelievably courageous thing to do, because you are really in territory that has not been as studied as other things have been. And you are really working with people who are telling you that they feel better. And, you know, that's the kind of data, the things that you're saying. How can we measure them? Well, what are the tests that we're gonna be able to do, what are they? Like, how are we going to be able to figure this out? So the FDA says that it's fine or that we just know that this is common practice and that what we've been doing thus far is leeches and bloodletting. Great, Great quote.
- [51:56]
A
Yeah, yeah, Stacey, I was thinking about this because so many people are like, when are the doctors? When are the doctors? When's the fda? And I'm like, remember the AIDS epidemic? The doctors didn't come to save them.
- [52:08]
B
Right.
- [52:08]
A
It was the lesbian women. Like, the people got loud. The people got loud. And that's how the AIDS epidemic took a turn. And I see a big correlation here of like, we have to turn the Titanic because it's not going to come from. The FDA is not going to be like, oh, yeah, let's take some of our restrictions, the fricking restriction on the vaginal estrogen package that says probable dementia. We're fighting to get that taken off again because it's not true and it scares women. But yeah, I think that this, like, the AIDS epidemic is a grassroots. We're gonna get loud and we're gonna see amazing things happen.
- [52:43]
B
From your mouth to God's ears. That's all I can say. And in the meantime, thank you for doing everything that you're doing to help us all out.
- [52:49]
A
Oh, my pleasure.
- [52:50]
B
You know, it must be so gratifying really, to see somebody come into your office and. And feel like their life has changed because of you.
- [52:57]
A
It's the best drug in the world.
- [53:02]
B
Let's talk Menopause, a national nonprofit organization is changing the conversation around menopause to make sure women get the information they need and the healthcare they deserve. Please visit letstalkmenopause.org for a wealth of menopause information, including a symptoms checklist, information about long term health risks, how to navigate menopause at work, interviews with health experts, and so much more. This episode of hello Menopause is sponsored by Always Discreet, makers of liners, pads and underwear for bladder leaks. Always Discreet because we deserve better. And you can find Always Discreet at Target in store and online. Hello Menopause is a production from let's Talk Menopause, produced in partnership with Studio Kairos. I'm your host, Stacey London. Kirsten Kluthe is our supervisor, producer, editing and mixing by Reavoice Media. Hello Menopause is available on Spotify, Apple, Google, and wherever you get your podcasts.