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- [00:01]
Dr. Kelly Casperson
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- [00:31]
Commercial Narrator
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- [01:04]
Dr. Kelly Casperson
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, welcome back. I'm so excited today because we have Dr. Maria Sophocles on again. You were on like a long time ago. One of the very first. One of the very first. I don't even know how that happened. We're like four years in and you're back because you did an exciting thing. So thank you for coming back to talk about it.
- [01:37]
Dr. Maria Sophocles
I'm excited to be here.
- [01:39]
Dr. Kelly Casperson
You did a TED Talk on the last TED women's conference that they had. October 2023.
- [01:47]
Dr. Maria Sophocles
Right, exactly. The last talk of the conference.
- [01:50]
Dr. Kelly Casperson
Last talk of the conference. So the talk was titled what happens to sex in midlife? Tell me, because I've done this before, so I know how it works. But tell me what was, was that, how was that always the idea or tell me the evolution of the idea until it got to the TED stage.
- [02:07]
Dr. Maria Sophocles
Yeah. So I had. The short answer is I had written a book about sex in midlife and then Covid hit pre Covid and I didn't really do anything with it. I just threw it on a shelf. And then I got Covid in December of 20. Whatever. What was that? 2022. And I've had a week to sit around thinking about, should I do something with this book? And I said, yeah, I think I'll try to get it published. And then I said, maybe I could also talk about it. And so I submitted an application to ted. And I had submitted this application about four years before and it came down to me and one other person and they gave the slot to the other person and she Talked about periods and diarrhea and it was fine. But I thought. I thought it wasn't as important as my topic. So I was salty for a few years, like, oh, well. And then I thought, no, if it made it to really close to being accepted, let me try again. So I threw it back in the mix. And the guy emailed me within an hour and said, where have you been? I've been waiting for you to send this back to me. I love this topic. I love this topic. It has to be on the TED stage. And I thought, oh, great, I guess I'm in. But it doesn't mean you're in. They have to go to their committee and convince the other curators that this topic and this lens and this person are the right person. So that was in Christmas time. And it was really June before they called me, very beginning of June, and they said, yep, we want you to do it. We have only one request. And I was like, what's that? And I was praying it wasn't like, delve into data and science and math, because those aren't really my things. My thing is humor. And I was like, what are they gonna ask? And they said, just bring humor to it. Just let it rip and let it be humorous. Because it's a topic that can be intimate, difficult, sad, and we need you to find a way to make it serious but humorous. That's long winded. Long, long winded answer.
- [04:11]
Dr. Kelly Casperson
Awesome. I think where we are with education and midlife and menopause is, you know, we could just spend the rest of our lives saying menopause is not just a hot flash.
- [04:21]
Commercial Narrator
Right?
- [04:21]
Dr. Kelly Casperson
And where people are with that education, it's shocking, you know, that they don't think the changes for vulva owners has to do with changes of hormones. So talk to us briefly about how the vulva and the vagina change in midlife and how that can affect your sex life.
- [04:39]
Dr. Maria Sophocles
Right? So agree with you a hundred percent. People, most people know that menopause is gonna mean hot flashes. And after that, they get kind of murky about a lot of the brain things. The joint aches, the, you know, ha. And skin changes. But they really are in the dark about genitourinary changes, which you and I have talked about ad nauseam on air and to our patients. And they still aren't aware that when the ovary makes less estrogen and less testosterone and less progesterone, especially estrogen and testosterone, these have massive changes on the bladder, the vagina, the urethra, the vulva. And when there's less estrogen, there's simply a lower quality of collagen that is made and that affects the elasticity and youthfulness of all that tissue. And we need elasticity for comfortable sex. So it's not a shocker that if we make less collagen and it's shoddier quality collagen, that just riding a horse or riding a bike or sitting around can be uncomfortable on the vulva and having sex. You know, the vagina is one tough organ. I mean, we go through periods, we go through childbirth, we have penetration by penises and vibrators and you know, it's over the millennia become incredibly resilient. But when you make the collagen different quality, it's actually a different type and a different structure that's going to affect your ability to have comfortable sex. Ditto for blood vessels. Less estrogen means few fewer blood vessels are made. And you and I can see this when we examine a patient. The vagina of a 25 year old is different color and elasticity and moisture than that of a 45 or 65 or 85 year old. And unlike hot flashes, which can come and go, and I hope they come and go quickly for people, yes, they can last for several years. But ultimately most menopausal changes sort themselves out. Even brain effects, even the brain fog will resolve after a while. But bladder and vaginal changes are chronic and progressive. And this is bad news. This means that if it feels a little dry and uncomfortable at 57, you're not going to feel better at 67 or 77, it's going to feel worse. And this is why clinicians like you and I are so urgently adamant about helping women, you know, as early as possible get ahead of that curve and stay ahead of it by reversing these changes, which we know we can do safely with vaginal estrogen and other things too.
- [07:20]
Dr. Kelly Casperson
Yep. Where are you with vaginal estrogen being a preventative medicine?
- [07:25]
Dr. Maria Sophocles
I would, I mean, you know, they say for the statins, put it in water. Right. I feel like I would like. Remember in Covid everyone got a check. I'd like everyone at full 47 to be given, sent by the government a prescription. Not a prescription, like four tubes of vaginal estrogen. And then I'd love that to be just part of your Social Security benefits or something. I just feel like there's not, it's really hard to find women that this will not benefit. Now, certainly if you have active estrogen receptor positive cancer, I think you're not gonna wanna Take it. Your oncologist isn't gonna want you to take it. What's your feeling, Kelly? Like, would you even give it to someone with that or. That's a hard sell, right?
- [08:08]
Dr. Kelly Casperson
Yeah, well. But, you know, things. You can sell things easier when people are educated, so they just need education, you know, fear. Fear is not facts. And we can work with fear by giving people facts.
- [08:17]
Dr. Maria Sophocles
That's true. So that's. There's almost no woman.
- [08:20]
Dr. Kelly Casperson
There's almost no woman. Now, there is a little data that. That says, hey, if you're on an aromatase inhibitor, there might be a negligible. Probably negligible, but slightly higher increase in basically bringing in that estrogen into your body. Whether that's clinically significant or not, we don't know. One retrospective Danish study was interesting. I'm going off on a massive tangent, but people need this education. Retrospective Danish study saying, hey, women who had breast cancer who were on aromatase inhibitors and took vaginal estrogen had a slightly higher rate of recurrence but not mortality. But the women who were on systemic hormones after breast cancer did not have a higher recurrence or mortality. Now, you know science and data. How is that even possible? It just tells you. It tells you this data wasn't clean.
- [09:07]
Dr. Maria Sophocles
We need more data.
- [09:08]
Dr. Kelly Casperson
Yeah. So some people will take that paper to say, you shouldn't be on vaginal estrogen with aromatase inhibitors. And I argue, yeah, but the systemic people didn't have a higher recurrence. I think it's messy data, and I
- [09:19]
Dr. Maria Sophocles
think the aromatase inhibitor is going to suck up any estrogen it can detect in your bloodstream. And what about intrarosa? Would you put those women on intrarosa? Right.
- [09:28]
Dr. Kelly Casperson
Love it. And there's data.
- [09:30]
Dr. Maria Sophocles
Yeah, exactly.
- [09:31]
Dr. Kelly Casperson
Yeah. But, you know, so to me, if you're currently being treated for breast cancer, just get your buy in of your oncologist. An oncologist. Who knows.
- [09:39]
Dr. Maria Sophocles
Mm.
- [09:40]
Dr. Kelly Casperson
I recently put a metastatic breast cancer patient who had been sold a bill of goods on lasers and magical potions for the tune of thousands of dollars. I simply picked up the phone, called the oncologist, and said, what's the reason that I can't give her vaginal estrogen? And he's like, give her vaginal estrogen? And then I got pissed because I'm like, you're telling me a $20 solution? This woman spent thousands of dollars on lasers and potions.
- [10:04]
Dr. Maria Sophocles
They don't preemptively tell the patients. That's my fantasy, is that you and I could get a Oncologist in the country that treats breast cancer survivors and says, look, first of all, the hormone negative cancers, could you please not worry, because there's no way this can do anything. And see if they can at least preemptively give them peace of mind so they can come in our office saying, my oncologist is okay with it. That would be a fancy world.
- [10:33]
Dr. Kelly Casperson
You cannot be a urologist who treats prostate cancer without telling a man up front that erectile dysfunction is a consequence of this treatment and what we're going to do about it if it happens. That is standard of care in prostate cancer.
- [10:47]
Dr. Maria Sophocles
Yeah, but they don't get the same. They walk into my office and say, my oncologist said, I'm so lucky to be alive, and la, la, la. And aromatase inhibitor will keep me alive, but told me nothing about the genital effects of it. Nothing.
- [11:01]
Dr. Kelly Casperson
Well, I learned from an oncology nurse the rate of divorce after breast cancer.
- [11:06]
Dr. Maria Sophocles
Oh, that's sad. My gosh, that's terrible.
- [11:09]
Dr. Kelly Casperson
It's terrible. So we're letting people suffer and we're traumatizing relationships, and we're not giving anybody help. The other thing that I thought was awesome in your talk is you, because you're well trained, because I say this to my patients all the time. I'm like, I can tell you what your hormones are, roughly. I can't give you a lab value, but I can tell you by looking at your vulva, if you're very well trained, you can tell that there's been no hormones for a while. And. But I don't think a lot of clinicians are well trained. And you can have symptoms and still have a vulva, look normal. So the water is muddied a little bit. How many women do you see? And they're like, they told me I don't have atrophy, so they didn't give me vaginal estrogen. Like, if you have dryness, if you have pain, if you have recurrent UTIs, there's no reason not to start you on vaginal estrogen.
- [11:59]
Dr. Maria Sophocles
Right? It's a zero risk, all positive, all upside thing. And it's the same, you know, so many patients just say the word. I didn't feel listened. And any, I think, good clinician knows that, number one, they have to be able to tell you care. That's actually the beginning. Right? And once they tell you care, you have to give them permission to talk, give them space. And number three is listen, if they're in pain, they're not drug seeking, they're not Looking for opioids. They want to feel better when they have sex or they want to stop having recurrent UTIs. And we know that vaginal estrogen will do that for them. So just because it looks kind of pink to you, I don't think you should override their complaints.
- [12:42]
Dr. Kelly Casperson
Yes.
- [12:42]
Dr. Maria Sophocles
And then the flip side is easy. If you put a speculum in and the vagina is bone dry and the pH is super high, and it's yellowish white and pale, pale pink, and there's no rugae. I mean, that's like vaginal atrophy 101, right? We all call it GSM now, but plenty of clinicians still call it vaginal atrophy. I hate both the terms. So they both make us sound like we're one foot in the casket.
- [13:06]
Dr. Kelly Casperson
In the 80s, it was the senile vagina.
- [13:09]
Dr. Maria Sophocles
Okay, so even worse.
- [13:11]
Dr. Kelly Casperson
Even worse.
- [13:12]
Dr. Maria Sophocles
I didn't think we had worse, but we did.
- [13:13]
Dr. Kelly Casperson
Yeah, we did. We did. 1980s. So tell us what the bedroom gap is.
- [13:18]
Dr. Maria Sophocles
The bedroom gap is a term that I coined just to explain or try to have a term for the difference in sexual expectations and in some cases, abilities between men and women. It also is something, you know, that gay couples experience, especially couples of different ages. So it can be heterosexual or homosexual. It can affect abled disabled. It can affect pretty much any socioeconomic group, any religious group, any geographic location. It's universal and ubiquitous. And it's based on the physiologic changes that we just spoke about, the collagen and blood vessel lack that leads to changes that make sex uncomfortable for women. Now men age too. We know. I'm not going to tell a urologist about the male reproductive system, aging, and the experience erectile dysfunction. But for 25 years, we have had reliable and available meds for erectile dysfunction. I'm not saying they're perfect. Sometimes they're very expensive. Sometimes people can have side effects. But overall, the ED meds have been a global phenomenon that have helped. Can we say millions? Probably millions of men?
- [14:35]
Dr. Kelly Casperson
Golly, can we say billions yet? Like,
- [14:39]
Dr. Maria Sophocles
something they cut from my talk for time, But I went on a vacation to a little tiny island in Mexico. Like, I tried to find the place that's the most opposite of Cancun as possible, like, nothing but jungle. And one little pharmacy and a bicycle. That's where I went for a vacation. And I was walking around the town, which was like a restaurant and a pharmacy. That was it. I go in the pharmacy just for kicks, and they have like, a diabetes med and a blood Pressure med and tons of Viagra. Like cases and cases of it and nothing else. Like, they don't have anything. I think one antibiotic. So it is so ubiquitous. And I'm happy, I'm happy that men have that, you know, men didn't cause this bedroom gap, this difference in ability and expectations. But having Viagra just widens the gap. Because if you're 62 and, you know, have a way to have an erection over and over again on demand, and your wife is literally bleeding or in pain and the, you know, someday I'm going to make a mural of all the terms that I have heard over 30 years. Razor blades, cactus. Feels like the desert. You know, I mean, one woman told me I need invisalign for my vagina. It's more out of whack than my teenager's teeth. You know, they just, just. It's misery. And honestly, Kelly, I feel like it's an uneven playing field. So it's a call to action. The talk is a call to action for our medical community to get educated, right? 4 out of 5 OBGYNs are not educated on menopause. Probably more than that, are not educated on sex. Sexual health is not really considered like a medical thing, right? Don't you find that it's like this awkward. We're a weird country.
- [16:29]
Dr. Kelly Casperson
It's extraordinary. I mean, even insurances, right? Because, you know, I think a lot of women in their anger and desperation, they're like, but insurance covers Viagra. And I'm like, technically, no, a lot of insurance doesn't cover Viagra. A lot of insurances just say, none of, we don't cover anything sexual health related. Which is kind of bizarre. Like, who made that up? What Puritan wrote that 20 years ago and it stuck around, right?
- [16:54]
Dr. Maria Sophocles
And then I think doctors bring that into their exam room. If you're a little squeamish talking about sex and you're not you, and you only had one lecture in med school and you're time pressed, you're going to focus on their thyroid and blood pressure, or if you're an OBGYN or urologist, you're going to focus on other stuff and maybe hope to gosh they don't bring it up and you can get out without having to talk about it. Like, the little researchy stuff I've done has looked at that and how physicians themselves, many have their own puritanical squeamishness from their upbringing or their church or their mother or their own awkwardness about their body. There's so many factors that come into whether a clinician or a provider just even brings it up. And if they don't bring it up, so many women are loathe to initiate. They feel embarrassed or awkward.
- [17:48]
Dr. Kelly Casperson
100%. Like, women are shamed forever talking about sex, let alone, like, to a professional who might judge them, it is a big barrier for to be like, oh, just go talk to your doctor about sex. It's like, you try that, man. They're like, they're gonna fail.
- [18:05]
Dr. Maria Sophocles
Yeah. I think the one little sunshine ray of sunshine good news is that with the advent of online dating, this has been a mixed bag. By the way, it's also been a mess for people because suddenly they're thrust into. I can have three dates in a week, and three men ask me to have sex. And oh, my gosh, all I've ever done is had sex with my ex husband. For. It's a little overwhelming and scary. But the other thing is, it's brought women into my office saying, I'm divorced or I'm widowed or I'm single and I'm menopausal, and I'm having more sex than I ever had, and I need help. I can't just put my husband off anymore. And I want to be vibrant. I want to be in the game. I love those visits is like, they want help. And so I'm also a sex therapist. And so the good thing is it's fun to be able to help them as a gyno physiologically and then to say, so what do you. What do you want? Or what's scaring you? Or what. What be awkward, you know? Or what are you getting asked that you're not comfortable with? Or how do we get you comfortable with that? How do we talk about self pleasure and how does that factor in? You know? So it does open a good can of wor. It's an opportunity.
- [19:18]
Dr. Kelly Casperson
I love it. How many gynecologists are also sex therapists?
- [19:22]
Dr. Maria Sophocles
I don't know any others, actually. I'm sure there are. I'm sure there are, but I. I
- [19:27]
Dr. Kelly Casperson
think there's one urologist who's also a sex therapist. I'm blanking in my head right now.
- [19:34]
Dr. Maria Sophocles
Well, I did it, Kelly, because I felt ignorant. I felt like I couldn't help them beyond the tissue. And then I would send them to pelvic floor physical therapists to help the pelvic floor muscles. But then they would say, you know, this guy's into this. Or my. I have a lot of trans patients as well, and I just start feeling Like, I just didn't get trained well enough to really be of any help to people unless I could be a good listener and have something intelligent to say. So I did it for my own comfort. You know, in a way, I mean,
- [20:07]
Dr. Kelly Casperson
I think that a hugely common one, I'd be want your opinion on what you think is the most common, but just empowering your patient to talk to their partner about their sex life. There's so many assumptions that people make about what they think their partner's thinking about them and their sex life because they have no freaking idea, because they don't know how to talk about sex. I'd say that's the most common.
- [20:31]
Dr. Maria Sophocles
And think of how crazy it is that you'd share a bed with someone for 42 years. You go through kids, college, homeownership, death of relatives, like a hundred thousand things in your marriage, and yet you slide into bed, you have some sex, you go to sleep, and so few couples really talk about it.
- [20:50]
Dr. Kelly Casperson
I mean, it's crazy, right?
- [20:52]
Dr. Maria Sophocles
Yeah, but it's actually crazy. If we can empower that too, then we could maybe empower a closing of the bedroom gap, right in. In the couple where you don't. Do you know what I mean? And then that woman will come to us saying, you know what? I'm not comfortable. I'm uncomfortable. And we decided as a couple that my pleasure counts too. So help me, Dr. Caspersen, give me something for that.
- [21:14]
Dr. Kelly Casperson
Yeah, I think, you know, I've seen urologists turn on this pretty quickly because I think even just a couple of years ago, the urologists were like, I'm just taking care of the patient in my office. Man wants an erection, going to give him an erection. And really, this conversation of like, listen, you are doing a massive disservice to this relationship. There's actually a paper talking about the destabilization of relationships when you bring Viagra home in a brown paper baggie.
- [21:38]
Dr. Maria Sophocles
Oh, I'd love you to send me that. Could you send me that?
- [21:41]
Dr. Kelly Casperson
Yeah, it's in my pile of something somewhere, but we can Google it. But really in empowering the physician to be like, what's your plans with this? Right. And so, you know, I've started doing it, but I've seen a lot more urologists do it. I would love to tell you that some of the guys are like, well, I talked with my wife, so I'm here today to get some Viagra. Nine out of 10 have not talked to their partner about it.
- [22:03]
Dr. Maria Sophocles
Yeah, I know it's shady.
- [22:05]
Dr. Kelly Casperson
You know, I don't know. So I'm like, okay, so you're in my office to get a harder penis. You haven't had sex in eight years and you haven't thought about what the plan is when you bring the Viagra home, right?
- [22:17]
Dr. Maria Sophocles
And you're gonna come home with this rock hard erection and be like, okay, I'm ready to go now. Where does that leave her? And that's the kind of story, you know, I've been in practice 29 and a half years. That's the kind of story that you hear that story a hundred times and you start thinking, this needs to be a thing people need to know about this bedroom gap so that they're not just suffering silently as a woman or being clueless as a man. Because neither one wants that. The men don't want that. They want better sex. They want communication. I do think they do. But think about it. Do we ever get taught to communicate about sex? Do we ever get trained? Do we ever get taught, even as teens, to talk about sexual pleasure? Our sex ed is putting a condom on a banana is. What was that movie where he goes, just don't ever have sex or you'll die of chlamydia. Mean girls, of course, right? It's classic. And it's like, not so far from the truth, really. And we know that telling teens not to have sex doesn't work. And I don't think you're ever too young as a man or a woman to think about your own pleasure or someone else's pleasure. You know, in the Netherlands, sex ed talks about both parties, sexual pleasure. When teens in the Netherlands have sex ed, sexual pleasure itself is a topic and male and female. And I learned this from two Dutch guys on a subway in Tokyo. Somehow, you know, it was more than a five minute subway ride. So we start talking about the bedroom gap. And they were like, that's really cool. But in the Netherlands, we learn this as teens. You know how the Dutch are totally straight, right? They don't like, everything they deliver is straight up. And they're like, oh, we are taught this as teens. It's part of our national curriculum. And I was like, oh my gosh, game changer. I was born in the wrong country. That is cool, right?
- [24:08]
Dr. Kelly Casperson
The Europe still has challenges getting hormones, though. I wouldn't say they're ahead of us in the whole menopause. Taking care of.
- [24:14]
Dr. Maria Sophocles
No, I just sex stuff.
- [24:16]
Dr. Kelly Casperson
Oh, yeah, for sex is fine.
- [24:17]
Dr. Maria Sophocles
I think sexually they're more open, to be honest, you know, Whereas we're a little more prudish. But then, I don't know, I just would love, I'd love to see Americans embrace talking to their clinicians more easily. And I love clinicians. I love the training to get a reset for sure in OB gyn, but even primary care, I mean, who says as a primary care you can't bring it up and you can say, look, we're out of time, but this is important. Your sexual health is part of your mental health, your physical health. We know it. If you stay sexually active, you will reduce depression, anxiety, cardiovascular disease, all kinds of crazy stuff.
- [24:56]
Dr. Kelly Casperson
There's data in men that sexually active men live longer. We don't have that data in women. And you can say it's a healthy bias, it's a healthy user bias. Right? If you're healthy enough to have sex, you're living longer than the people who aren't healthy enough to have sex. But it's like, like, wait, we've got some longevity data. It's not, it's not horrible.
- [25:11]
Dr. Maria Sophocles
I think said no man ever. Oh, I only want to have sex if it keeps me alive longer. I'm pretty sure, I'm pretty sure that one isn't actually what's pushing them to do it. I'm pretty sure it's about something that feels good. But I'd like that for women too. I'd like women to know their bodies better and that includes self pleasure. And one thing I tell women when they're first, when we first talk about self pleasure, I keep vibrators in every exam room in big glass cases and we take them out and touch them and talk about them. And some women are so like terrified and skeeved out, grossed out. But the trend in sex toys is not things that look like a penis. More and more are designed by women and so more and more are just vibration or heat or something that you can use anywhere on your body. Kelly. And so I start with, I call it G rated masturbation. And I say just bring this in the shower and put it on your arms. Feels really good or on the side of your breast or wherever it might feel good to you. And we sort of baby step in to just things that feel good because I think a lot of women feel that masturbation has to be this big multi orgasmic screaming thing with penetration. And as you know, most of them don't even know that most orgasms in women don't necessarily happen from penetration. So there's a lot of reeducating, right?
- [26:30]
Dr. Kelly Casperson
Totally. Well, I think, you know another, just pile on another Societal pressure is like, are you doing it perfect enough? Are you doing it correct enough? Are you doing it right? Like, this whole, like, performance to sex, which is like, just literally wrecks sex. Your brain. If you have your frontal lobe on, the orgasm can't happen.
- [26:49]
Dr. Maria Sophocles
Yeah. I mean, right is what feels better. Right is what feels good, not better. So right is. Feels good. And if what feels good is just putting a little vibrating egg or tulip or something, you know, they all look like. They don't look like penises anymore on your bre.
- [27:05]
Dr. Kelly Casperson
Tulips at south by Southwest.
- [27:07]
Dr. Maria Sophocles
Exactly. That's why I said tulip plus one.
- [27:09]
Dr. Kelly Casperson
I was going to plug that brand plus one gave us all tulip vibrators at south by Southwest. Yes.
- [27:15]
Dr. Maria Sophocles
They gave me a bunch. I actually gave them away to the got people I was staying with at south by Southwest and to airline people. I had so many. I was like, do you guys want one of these? They're great. They were like, oh, my God, just gave me a vibrating tulip. But I'm not. Yeah, it was easy, you know.
- [27:34]
Dr. Kelly Casperson
Totally. One of the things I love that you brought up is gender roles being etched in stone and our sexual dogma. And you said, a woman's role in the bedroom is to please and serve and not impede the sexual pleasure a man is entitled to. And I think this is both a written and an unwritten rule. Like, how many women said, my mom said, I just have to. Once I'm married, I just have to give it to them. So I think it's written and then I think it's unwritten that like, a lot of women, they were never told that explicitly, but they're like, well, cause I'm married, I just need to, like, you know, suffer, take it, blah, blah, blah. And it's like, it's this gray world of, like, it's not. Not consensual, but it's not consensual. And it's just. I think it's a river of misery. It leads to a lot of resentment. And a lot of people don't know how to get out of that when they find themselves in it.
- [28:24]
Dr. Maria Sophocles
Yeah, they don't even think they can. They. They come in and they say, I really have to do this for him. And sometimes I never meet him, but sometimes I do. And the men are often. It's lack of communication. They're not bad people. But I think this is the sociocultural ethos we inherit. And I think it's been literally so many generations, and I think there's been A lot written about women as pleasers, givers, nurturers. And this is why it's been expressed in the bedroom. It's been expressed in the boardroom why women are more likely to back down. Okay, you take the CEO role. I'll be the vice president. And women are speaking up, speaking out. I mean, they're saying they're pushing against the glass ceiling. And I would say it's time to kind of push against the glass mattress. Right. And say, I'm happy. I love you, but I need pleasure too. And until I can have comfortable sex, we're just gonna kiss, you know, and we're just gonna. And I've had women say, well, he's not gonna like that. He's not. We have sex every Friday night. And I'll say, it's gonna take me, us about three months to rehabilitate this tissue and these muscles, and we're gonna come up with something else. For three months, you're gonna work on intimacy or cuddling. I give them homework. I give them other homework. Because I think you're right. There's this pressure that I have to do it for him, you know?
- [29:49]
Dr. Kelly Casperson
Yeah, I agree with you. The majority of people want their partner to be enthusiastic. Like, a lot of guys are like, hey, would you wanna still have sex with her if you knew she was kind of just, you know, rolling over? They're nice people who care about their partners. They'd love their partner to have a good time. They don't know how to communicate either. But I think especially in heterosexual relationships, women give away their power.
- [30:11]
Dr. Maria Sophocles
Totally. But this brings us back to another menopause issue, which is libido and the loss of libido. And so many women come in for menopause consult, and the libido is almost what's crushing them more than the hot flashes or whatever, because they can't get out of it. They can't. They don't think there's anything they can do. And it's almost like a depression where they're like. It's there every day. They climb in bed and they think, I'd rather turn on Netflix than be intimate with my husband. I just would. It's more interesting to me to rewatch the Handmaid's Tale or whatever.
- [30:44]
Dr. Kelly Casperson
Yeah. I mean, because, number one, there's no fricking data on this. But I've talked to several divorce lawyers now who kind of specialize in gray divorces. Right. Kids are out of the house. Maybe you're retired, maybe. And they're pulling people out of the stream way downstream, right? The relationship's already ruined. He's already have gender stereotyping. He's already found another lover. She's devastated. She still could take or leave sex, Right? But the relationship is shattered. And so they cut. The divorce lawyers come to me and they're like, we're pulling the people out way down at the bottom of the river. And the divorce lawyers say, hormones save marriages.
- [31:25]
Dr. Maria Sophocles
Amazing. Amazing to hear a divorce lawyer say that. I mean, I never thought I'd hear that.
- [31:30]
Dr. Kelly Casperson
Yeah. And we can't give you data on it, but. But it's such a, for lack of a better word, juicy topic. Because how. How do you take that? And you say, okay, you guys started as a sexual. This was a sexual relationship. At least one of you still wants it to be. What are you gonna do about that? And again, I think it comes down to communication and I never want it to be. We are blaming the woman for not taking hormones to not have libido, right?
- [31:57]
Dr. Maria Sophocles
Like, he feels the blame. He already feels the blame. How can you not feel the blame when it's not mutual? When he wants it and you don't, you're gonna feel the blame. Like if I make a cake and you love it and I don't eat it, I feel guilty at the birthday party. I just do. I think that's one of the biggest challenges and we don't have great options for it. We have okay options. And this is why I put time into the sex therapy training that I have, because I felt like, okay, I have Addi, FDA approved for female sexual dysfunction. And I have Vylisi an injection, which is sort of on demand dopamine release woo hoo for 15 hours, you wanna have sex. But I think much more important than an on demand band aid is to build the libido from the ground up again. And I find that that takes. Takes a combo usually of like a. Like some testosterone and then what we call bibliotherapy, which is just a term for bringing erotic content into the brain through apps like Quinn or other audio porn. There's a whole industry now called audio porn, which is a terrible term because everyone goes, oh, porn, I don't like porn. And that's bad for women. This is not that. This is largely made for women, produced by women and stories. You know, you can put headphones on and climb in bed at night and listen to some of these stories. And yeah, some are silly and corny, but we know that the female brain, especially when primed with a little testosterone Stores that erotic imagery and it's like a savings account and we lie on our partner's shoulder and it, it feels more masculine to us. It feels more physical and sexual and male to us. And again, I don't want to imply that gay couples don't have this. They have these issues and we really. It's wrong of us to think they don't have issues. But for the majority of couples who are heterosexual, I think that actually, I think the therapy works for gay couples just as well. Testosterone and bibliotherapy. But bibliotherapy could be renting movies with erotic content and it doesn't have to be like, like crazy porn. Women screaming. It can be something romantic that has a sort of sexual tension. Many women find that super erotic and they will store big British show that
- [34:25]
Dr. Kelly Casperson
everybody was talking about how sexual it was.
- [34:27]
Dr. Maria Sophocles
Oh, Bridgerton, Bridgerton, Bridgerton.
- [34:29]
Dr. Kelly Casperson
I, I never saw it.
- [34:31]
Dr. Maria Sophocles
I hear it was very stimulating, very, very steamy.
- [34:35]
Dr. Kelly Casperson
You're like, makes you warm.
- [34:38]
Dr. Maria Sophocles
I had patients that were having like Bridgerton, not parties, but like they and all their girlfriends were watching it, you know, and kind of forcing themselves, but not forcing, but anyway, long winded way of saying the lack of libido is part of the bedroom gap. It is. The bedroom gap is certainly physiologic, it's certainly worsened by all the erectile dysfunction meds. But the lack of libido is a psychological part of the bedroom gap of a woman climbing into bed and wanting literally to do anything else but have sex. Or as many women tell me, never have sex again. They say, I'd be fine. I'm not a weird person, but I'd be fine if I never had it again. What about your husband? Oh, he would like it four times a week. So we compromise. We do it once a month and I just get through it. That's the gap. That's the bedroom gap.
- [35:29]
Dr. Kelly Casperson
That's the gap. Yeah. Well, it's, it's wonderfully complicated. It is biopsychosocial. Don't forget the importance of estrogen on libido. Gendered these hormones. We said testosterone is the libido hormone. That's not true.
- [35:40]
Dr. Maria Sophocles
I didn't mean to. I just wanted to bring it into the top.
- [35:43]
Dr. Kelly Casperson
No, to me I'm like, hormones are key and if you weren't having great sex to begin with, now you have low hormones on top of it, Forget it. But you, you know, you'll see these women, they're like, I had an amazing sex life. Life. We were great. We're great together, I love my husband, blah, blah, blah. And then it just got gray. It was a gourmet meal I love showing up to. And now it's mushy broccoli, right? Then you're like, okay, that might be more of a hormonal than like, I never liked it like Kelly.
- [36:13]
Dr. Maria Sophocles
And you know, I'm a hormone fan just like you. But I want to repeat, sometimes hormones are not enough. That sometimes you, me, or a sex therapist, and we can talk about how they can get to a good sex therapist, even online. Need to peel back some layers of the onion. Is there a sick child at home, A sick elderly parent at home? Are they losing their business? Are there financial stresses? You know, all these things impact too.
- [36:38]
Dr. Kelly Casperson
So loss, resentment's a big one.
- [36:42]
Dr. Maria Sophocles
True, that's true. But there are so many factors that. And if you do not take the time as a clinician, you may miss the fact that there was an affair two years ago. So they just don't feel comfy. She doesn't feel comfortable yet. Or how does she feel about how she looks when we do studies, when we look at studies of couples with a massively overweight female partner, three to 400 pounds. Okay, not talking about 160. I'm talking massive. Almost 100% of their partners find them sexually attractive, gorgeous, and they don't even know what you're talking about when you bring up the weight. But women don't necessarily feel that we all have weights, that we're comfortable. And whether it's our stretch mark or our mole or our lumpectomy scar, there's something that may make us feel self conscious and not feel like society says we have to look like, you know, Julia Roberts getting into bed. So there's a lot of pressure on women to stay young, stay young looking, stay thin, get implants, get your butt lift, whatever it is. I mean, I had a woman come in today asking for injections of fillers into the labia. She said, I'm just too self conscious to have sex because my labia have sagged and I need them puffy. So she said, will you inject fillers in and then I'll feel better? And I said, no, I won't. I can't say someone else won't. I certainly could send you to a plastic surgeon and if that's what you need, do that. But I said, but you have really severe loss of estrogen, estrogen deficiency in the vagina. So let me work on that. And you talk to the plastic surgeon because shame on me, to say, no, you can't have that. I mean, if that's what she needs, that's what she needs. If you need Botox and you want Botox, it's not for me to judge and say, kelly, your skin looks great. I don't think you need Botox. Right. I mean you do have beautiful skin. But we're allowed to make our own decisions about what we need aesthetically. But I just think the lack of libido can be quite a multifactorial thing. And if you are suffering from lack of libido, I hope you'll get find a clinician who will take the time to sort of look at all the angles. And if your physician doesn't, if they give you vaginal estrogen, good, you got better than most. But if they don't have the time or expertise to talk to you about the other issues that might be impacting this, you can find a sex therapist. You can go to a or.org that's the American Academy of Sex Educators and certified Therapists and you can put your zip code in and an ASEC trained therapist can, you know, I'm sure now since COVID many more of them do online stuff and I have great names of great ones around the country, so anyone can find me on Maria sophoclesmd.com or princetongyn.com Just to say, hey, I live in Iowa and I need someone. So I just, I want people to feel that's not a shameful or crazy thing. You know, sometimes you go once and you get some key unlocked and that's all you need.
- [39:48]
Dr. Kelly Casperson
Yeah, a little bit of education goes a hell of a long way.
- [39:52]
Dr. Maria Sophocles
Yeah.
- [39:53]
Dr. Kelly Casperson
Like, oh, most women don't have an orgasm just by putting something in their vagina. Oh, okay. So I'm not normal that I need my clitoris stimulated, thank you very much. Right. Like it's like a little bit of education goes such a long way. Like people are like, this is how it's gonna be forever. And like they see a sex therapist once and they're like, oh, turns out I'm normal. I just needed to know that.
- [40:15]
Dr. Maria Sophocles
Yeah, I had a very, very progressive mother in law. She just passed away. But my husband and I got married 29 years ago and she literally took him aside before the wedding and was like, I don't know what your father ever told you, but your father, eh, he's kind of conservative. He might not have really told you what need to know. So I'm just going to do it, you know. And she just launched into how women have orgasms, what makes them happy, what you need to do, how she has to come first. Like all this stuff. My poor husband was like, oh my God, my mother just told me all this. But good for her, right?
- [40:52]
Dr. Kelly Casperson
That's a big deal. That's very, very cool.
- [40:55]
Dr. Maria Sophocles
Wasn't that huge?
- [40:56]
Dr. Kelly Casperson
I mean, it comes from love.
- [40:58]
Dr. Maria Sophocles
Oh yeah.
- [40:58]
Dr. Kelly Casperson
She wants her husband, her son to have a successful pair bonding.
- [41:02]
Dr. Maria Sophocles
Yeah, yeah.
- [41:03]
Dr. Kelly Casperson
I mean you, you know, you talk to these people when they're like the people who are like, yeah, my mom usually mom. But dads do it too. Like my mom told me everything. Nobody's like, I wish she didn't do that.
- [41:15]
Dr. Maria Sophocles
Right.
- [41:15]
Dr. Kelly Casperson
Like, everybody's so grateful about the parent who like gave them the heads up.
- [41:21]
Dr. Maria Sophocles
Yeah. But actually many parents don't. They really can't. They just can't talk about it because their parents didn't talk to them. So they have no.
- [41:29]
Dr. Kelly Casperson
So I'm like the annoying urologist at the kids preschool. Right. So we had, we had this preschool, this is pre Covid where like the parents could actually get together and it was like the parents would have a meeting every month. It was a co op preschool. It was very cool. And they were, you know, they're like, what do you guys want to learn? Blah, blah. And I'm like, there's this amazing sex educator in my town whose specialty is educating kids. Right. She has kids, she has adolescents, she does, blah, blah. And I'm like, I would like the sex educator to come in to talk to the parents about how to talk to preschoolers about their boss bodies. So like I, I offered it up and did the blah. She came and afterwards the feedback was like, favorite talk of the whole year. Wished they had it when they were growing up. And it was the most like nervous the most there were. The parents were like, I don't know about this one. Right. Like it was like, you know, the delta change of like they went in being like not sure and then being like best thing ever. It's like how to talk to your preschoolers just about their body. Yeah.
- [42:25]
Dr. Maria Sophocles
I mean, I wish I had had that, you know, I mean I. My poor kids got baptism by fire because I.
- [42:31]
Dr. Kelly Casperson
They've got a gynecologist for a mom.
- [42:33]
Dr. Maria Sophocles
Well, not just that I had. This is like going to get me in trouble. I had a new electronic health record with this beautiful system where I could actually take pictures of the vulva. Vulvar disease so that over the course of the appointments, as it got improved, we could track it. So I Started using it and I didn't realize I had hooked it up improperly. So instead of only staying in the health record, it was also feeding to my living room TV screen. Like how this happened. Anyway, thank gosh, I fixed it right away because the first day I come home, I'm really excited about how progressive I'm being. And my three teenage sons go, mom, you've ruined sex for us forever. We don't ever, ever want to see that again. I was like, what are you talking about?
- [43:18]
Dr. Kelly Casperson
About, oh my God.
- [43:19]
Dr. Maria Sophocles
I called the IT guy. I'm like, gotta get it off this TV screen in my house. Luckily there were no names, but so my, my efforts were. Were all not always correct, but I tried. I tried. Do you have little vulvas in your office? Those little vulva puppets ever? Have you had those? Yeah.
- [43:36]
Dr. Kelly Casperson
Yep. Yeah, and mirrors. One thing you got a huge clap about on your talk was when you said a right to pleasurable sex. Why do you think this struck such a nerve with the audience?
- [43:48]
Dr. Maria Sophocles
Because I think so many women don't think it's their right. Or they do deep down, but they're not gonna go out with posters and march in Washington saying, we have a right to pleasurable sex. We've just lost our right to abortion. You know, they feel like people are dying of cancer, there's a war in Ukraine, and I mean, but deep down they just dream of actually having that right. And, and I mean, at least with Harvey Weinstein and me too, we blew the lid off of some of the horrors, right? So we've taken one step towards not being assaulted to get a job. Woo hoo. So that's how darn far we are from this, right? We've just had a movement, MeToo, that has said, you know what's not right. It's not right for a scummy, horny media exec to rape you for you to get your job. That's how low the bar is, Kelly. Okay? And we're all happy about that, that we've maybe made dents in that, by the way. That's all still happening. You know, it's just hopefully happening a little less because people are thinking, oh, she could blow the whistle. But sexual assault on campus is rampant.
- [44:59]
Dr. Kelly Casperson
Rampant.
- [45:00]
Dr. Maria Sophocles
You know, so there's still so much male entitlement to sex and to sexual pleasure and to women's bodies for their sexual pleasure. So I don't mean to get all despondent and depressing, but we are so darn far from true gender equity in the bedroom that I Think when I said, that's in my book, I have a little appendix, just women's sexual bill of rights. And the number one thing is right to comfortable sex, and the number two is right to pleasurable sex. These should be basic things no man ever said, boy, I wish I had the right to comfortable or pleasurable sexual sex. Men have had that for millennia. So that's why it struck a chord, because it was one of those. So obvious. But nobody says it right. That's what I think. Why, why do you think it struck a chord? I mean, did you. Sorry, I didn't mean to.
- [45:50]
Dr. Kelly Casperson
No, I, I think. Excellent answer. I. I think you're absolutely right. I mean, to me, like, you spend and I, I didn't show up fully developed, having a podcast and knowing a crap ton about hormones and sex. Right. Of like, like I was there too. And it's like, you get to a point though, where like, you forget the bar is so freaking low still. And it's like, you're doing a great job. I'm doing a great job. There's great people doing great jobs. But you're like, dude, we Forget this is 50% of the population. This is not an autosomal recessive disorder. Right.
- [46:25]
Dr. Maria Sophocles
Like, this is so huge, woman. You know, I mean, which. Not that I like the term, but I mean, that's a term, you know, it's not like once in a blue moon, women are standing up saying, I'd like to have pleasurable sex. It's like, I think we all would, and I think we'd all like to have comfortable sex. And I don't think that's a lot to ask.
- [46:45]
Dr. Kelly Casperson
Yeah.
- [46:45]
Dr. Maria Sophocles
You know, it's interesting.
- [46:46]
Dr. Kelly Casperson
I mean, I love. One thing I love about how you talk about this is like, your willingness to be like, dude, there is gender inequality in heterosexual relationships. And I think one way to, to level that playing field is you have to fricking talk about your sex life.
- [47:03]
Dr. Maria Sophocles
Yeah.
- [47:03]
Dr. Kelly Casperson
You have to be uncomfortable with possibly making another person a little uncomfortable.
- [47:09]
Dr. Maria Sophocles
Yeah. Your girlfriend or your clinician or your partner or all of them. And I think that until we break, you know, I think I use some term like free ourselves, emancipate ourselves. I picture women like literally smashing chains off them and saying, I'm calling Kelly and I'm going to talk to her because I'm not happy, or I'm calling my cousin because honestly, she's kind of open minded and I think she won't think I'm crazy for talking about this and how sad that women have to say, gosh, I hope someone doesn't think I'm crazy. No man ever is judged when he sits at a football game or a bar or his kitchen table with his guy friend and they talk about sex. No man ever looks at his friend talking about sex and goes, dude, you're nuts. You're talking about sex, you know, like, it's just a given. You masturbate. Duh. I've been masturbating since I was 12 in my bedroom. Yeah. Any guy has. And nobody has any shame about that, right? So can we, like, lose the shame? And I think you're right. It starts with conversation and with, you know, maybe you and I need to go do little. Host little groups where we just have open. Open table, open mic night.
- [48:19]
Dr. Kelly Casperson
You know, it really is how I think the world gets changed, truthfully, is like small. Small groups of women talking about things. The other thing I love. Just to wrap up. The other thing I love about your TED Talk is that you called out in the open what people's fear is about estrogen. Because if you had done that talk and just said, everybody needs vaginal estrogen and hadn't addressed that people have a bias incorrectly, a bias about estrogen causing cancer, that you would have given them information, but they wouldn't have done anything with it. And the fact that you, like, brilliantly called out that fear in your was. It was brilliant. Very well done. Anything else you'd like to say about that?
- [49:00]
Dr. Maria Sophocles
It's the elephant in the room. And I have to say, I'm a little tough sometimes with my patients, where they go, oh, I'm kind of squeamish. Like, you know, I grew up in the 90s and, you know, the fears and so lots of them, and I think I'll just skip it. And I just put my knees right up to their knees. I sit down right across from them, and I lean in and I just say, I want you to name the fear. I want you to tell me, what is the fear? Just say the name. No judgment. I want to hear, is it kidney disease? Is it acne? You know, am I getting warmer? And I know what it is, you know, and they go, well, no, it's. It's. Well, I mean, you know, breast cancer, everybody's going to get it, you know, And I think they might get it from hormones. And I go, okay, let's talk about that. Let's just talk about whether that's actually the case. And I say, thank you for telling me honestly what your fear is, but I have to bring it out of them. And. And once we name it in the room, there's the enemy. It's right in the room. And they might still be scared of it, but at least they've heard from my mouth that vaginal estrogen does not pose a cancer risk. And they can take that info and decide what they do.
- [50:09]
Dr. Kelly Casperson
Totally. Yeah. I agree with you 100%. Is you gotta name the fear. And then another step is like, where did that come from? Who told you that? The here of breast cancer and estrogen. People don't know. They will Never say the WHI in 2002 when the media took it. They don't know that. It's just in the ether.
- [50:29]
Dr. Maria Sophocles
Yeah. It's often someone in their family who got cancer and told them, I think the cancer's from the hormone. I don't know what you feel, but I hear that a lot. Well, my grandmother had cancer, so she said, never take hormones because it probably caused hers. Oh, really? What was her cancer? Colon cancer. Right.
- [50:47]
Dr. Kelly Casperson
Yeah. Our brains love to correlate things. Like our brains really, really want to blame something. And I'm like, a lot of times with cancer, we don't have anything to blame.
- [50:55]
Dr. Maria Sophocles
Yeah. And I don't want to crap on anyone's grandmother or hairdresser. And I'm clear about that. That I'm really sorry that she had that cancer. But your decision to do this now today is not impacted by that cancer in the 1970s. And I think if we can help them divorce that it helps.
- [51:14]
Dr. Kelly Casperson
Helps.
- [51:14]
Commercial Narrator
Gosh.
- [51:15]
Dr. Maria Sophocles
We covered a lot of different stuff from the talk. I'm really grateful.
- [51:18]
Dr. Kelly Casperson
It was a very good talk, my friend.
- [51:21]
Dr. Maria Sophocles
Well, yours was great, too. So we have two good talks. People have to listen.
- [51:24]
Dr. Kelly Casperson
Doctors doing TED talks.
- [51:26]
Dr. Maria Sophocles
Bring it on.
- [51:27]
Dr. Kelly Casperson
The new. The new. I mean, it's really an important. Like, you know, where do people get their education from? Right. Like the TED platform and what they stand for. Ideas were spreading. Like, I am a disciple and convert of. I love that organization for being like, but you gotta keep it short and you gotta keep it interesting because that's. We watch it on the Internet. You gotta keep it short and interesting.
- [51:51]
Dr. Maria Sophocles
They changed their thing from ideas were spreading. This week they launched a new thing is ideas change everything. And so I think that applies to you and I because we want our ideas to change behavior so that women can avail themselves of what we've spoken about and so that they can feel empowered to change their quality of life, even their longevity.
- [52:16]
Dr. Kelly Casperson
You know, I love it. All right. I'll put it all in the show notes and the link to the TED Talk. Go watch it.
- [52:22]
Dr. Maria Sophocles
All right. Let's not take four years to talk again, huh?
- [52:25]
Dr. Kelly Casperson
I know. Hey, God bless. Hopefully the podcast will still be going on.
- [52:29]
Dr. Maria Sophocles
Oh, I hope so. But you know, the TED Talk has almost a million views already and it just came out a couple weeks ago. So I think that's a good that women want to hear this and I hope men want to hear it. And you and I will continue to spread the word and spread the message and I'm really grateful. Thanks for having me on. Appreciate it.
- [52:50]
Dr. Kelly Casperson
Thank you for listening to this week's episode of youf Are Not Broken. If you want to dig deeper with me, sign up for my Adult Sex Education Masterclass where you learn adult things like communication skills, anatomy lessons and desire types, and how to talk to your doctor about sexual health concerns. If you want the Adult Sex Education Masterclass for free, join my monthly membership for more in depth exclusive content, more time with yours truly. A private podcast, coaching and educational empowerment and you can watch my interviews live and get them immediately without advertising. Head over to www.kellycaspersonmd.com for the membership and Adult Sex Ed Masterclass members. Get the Master class for free. This podcast is presented solely for educational, entertainment and informational purposes only. I am a doctor, but not your doctor in this format and all of my platforms and guests including on this podcast are not giving individual medical advice or practicing medicine. See in Consult with your own care team for your individual needs and concerns. This podcast is not intended as a substitute for the care and advice of a physician, therapist or other qualified professional. This podcast does not constitute the practice of medicine, in case you were curious about that and no doctor patient relationship is formed. But I still love you. Using the information on this podcast or any of my platforms is at your own risk. Until next time, remember you are not broken.