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Hey, everybody. Happy New Year. This is like New Year's Eve. Eve, Eve. So this is a big deal because January 1st of 2025 will be five years of the podcast. And if you would have told me five years ago when I literally, like, plugged a microphone into my iPhone and like recorded this on my own, without a computer, without any guests, when I just recorded this by myself, saying, listen, I think I need to talk. I think I need to share the information that I have about the pelvis and female hormones and female sexuality and why everybody feels broken. If you would have told me, hey, hey, Kelly. Five years in, you will have one of the top podcasts in medicine, consistently ranked in the top 50, an apple of health and fitness. If you'll have written a book that did very well, so well in fact, that a publisher bought it and then you had a deal for a second book, you did a TEDx talk. You are being flown to Australia to speak at the Sydney Opera House in March 2025. And you would be retiring from traditional insurance based medicine because seeing 27 patients a day breaks you. And you're going to be opening up a concierge medical practice where you no longer have insurance as your boss. And you can spend hours with people and really get to know them and really listen to them and really help them with this midlife thing. Oh, and you'd also become one of the foremost experts in female hormones because you're obsessed with the topic and you're going to add that in to your female sexuality niche. So now you have two of the biggest niches in the world. If you would have told me that five years ago, I would have been like, I am all in. Absolutely. Bring that on. That sounds like the dream life. Five years from now, I'd be like, I don't know how I'm going to do that. I don't know how that's going to be possible. But five years ago, if you told me that that would be my life now, I'd be like, fuck, yeah. So to all the people who have a voice in their head, a dream in their hearts that you want to create something, that you want to build something, that you want to do something, go do it. The amount of shit that you can get done in five years is absolutely astronomical. And this is with me having a full time job, more than a full time job. Two kids now, two dogs. You can do it. You can do it. And you can still sleep eight hours a night and you can still work out. It's not easy. You need Support you need to find a community. Whatever you need, you can do it. It's not easy, but my God, talk about living your dream life. So in celebration of year five, I had my editor put together just a compilation. This is not the best of. This is a highlight reel. Just kind of walking through the past five years of the podcast. And it starts with my first podcast episode. I'm going to play all of it because it's only five minutes long
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and
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you'll see that the sound quality is lacking. But we, we start, we gotta start somewhere, right? So, but even that like you can hear the passion in my voice and like the fact that I have a plan and like what I want to do, it's all very clear in this first five minute episode. So I'm just going to tell you right now what all these, these compilations are and then we're just going to mash them together in the celebrating five years of the you are not broken podcast. So thank you to all of the women that I've helped and for those who've listened and for those who've shared. Thank you to all the men who love their women and want to help them. And hey, I've got some episodes in this, these podcasts for the men too. If you, if you know, you know, for anybody who is new to the podcast, start back at number one. Just go. I sound really good at 1.5 speed. And you're gonna learn a lot, you're gonna see the podcast grow as and me get a little more polished as the years go on. We are almost at 300 episodes, so pretty cool that the five year mark and the 300 episodes are. This is episode 297. So pretty exciting that they're all kind of hitting at the same time. So thank you to all the women and the men that this platform has helped. Thank you to all of the prescribers that help the women. Thank you to everybody who supports Ishwish. It's probably my most mentioned resource in these 297 episodes. Thank you to everybody who treats women for sexual health issues. I just did a course about sex, female sexual health and prescribing testosterone and go into the decades of safety and the data that we do have on testosterone for females. It the link is going to be in the show notes. That's with the Dr. Heather Hirsch Academy. So you can go sign up for that and get CME for 2025. So in honor of this milestone, let's revisit some of the highlights and wisdom shared by the Brilliant minds who've graced this podcast. The first clip again will be me doing my, like, first episode, which is five minutes long, kind of talking about my vision. Then we follow that up with Dr. Mary Claire Haver. This is an April 2023 episode, number 208, for anybody who wants to go back. So this is long before her new menopause book and long before the buzz around the medications like Ozempic started hitting the sound waves. She joined me to drop her timeless advice. She's been on my podcast at least three times now, and her message actually resonates pretty well during this holiday season when I know I'm eating tons of sweets. Um, her tips are eat more fiber, get enough vitamin D, prioritize magnesium. These small yet powerful habits are a reminder that taking care of ourselves does. Start with the basics and get you can get right back on track. If any of you guys got off in the holiday season like me, okay, episode, then the third bit is going to be me and Dr. Sari Van Anders and the Science of desire. This was March 2022, episode 147. She is a researcher in Canada and she reshapes how we think about desire. Her research challenges the heteronormative theory of low desire in women partnered with men, emphasizing that desire is far more complex than we often assume. She explains how sexual thoughts and behaviors can influence our hormones and shows us that thinking sexy thoughts can actually increase testosterone levels. So the idea that our mind and body are deeply connected, it's inspired so many listeners to explore what turns them on and why. So number three will be me talking to Dr. Avram blooming talking about the hormone window. This is episode 222 from July 2023. So we talk about his book Estrogen Matters. If you haven't read that book yet, you're living under a rock. And in this clip we talk about the 10 year window and the window of opportunity when it comes to hormone therapy. Because more and more and more we're realizing that for many women, it is quite safe to start a low dose transdermal systemic estrogen at any age. And certainly you can start vaginal estrogen at any age. So he reminds us of the crucial role hormones play in bone health as hip fractures kill as many people each year as breast cancer. And let's not forget the importance of elasticity and how estrogen helps our tendons, collagen, cartilage, even the discs. This is what's so interesting to me. The discs between our vertebrae are incredibly important and get squished with age and low estrogen. And all of the osteoporosis drugs that work by improving density of the bone don't actually help the discs, which are very responsive to estrogen. So nobody talks about the freaking discs in the spine. They only talk about the vertebrae. The discs are incredibly important. So I digress. He doesn't talk about the discs, but to me I'm like, keep in mind, estrogen plays so much more role in the mobility of our body. Not just the bones, but the cartilage, the ligaments, the tendons, the discs, the disc, spongy tissue in our back. So Dr. Blooming's insights are a call to action. We can't afford to wait when it comes to our health. Okay. The fifth clip is the Lancet rebuttal. Are we over treating menopause? This was super fun. This was April of this year, 2024. This is episode 259 for people who want to go back. And this was a very powerful panel discussion. Me and the menopause just all got on a zoom one day to basically say what this Lancet article was that basically told women they just need to try harder and get therapy for their menopause symptoms and also accuse the medical system of over treating menopause. So the people you might recognize some voices on here, but from, from there's a lot more people in the whole episode. But in this clip we have Dr. Lauren Stryker, Dr. Ifa, Dr. Ifa O', Sullivan, Dr. Heather Quayle, Dr. Heidi Flag, and Dr. Mary Claire Haver. Together we explored whether menopause is being over treated in 2024. Spoiler the answer is no. The conversation highlighted the need for individualized care and reminded us that treating menopause is improving quality of life, not just ticking boxes and telling women to try harder. And then number five, we're going to end it with Dr. Marty Klein and the complexities of sexual fantasies. This is episode 169, July 2022. He, he wrote, he's written some really great books and this book that we talk about in this episode is called his porn, Her Pain, which sparked a fascinating conversation about the nature of fantasy. He explained why porn isn't real and that why most of us know that and why including your partner in your fantasies isn't always the best approach. His insights challenge us to think deeply about what fantasy means for us as individuals and how it can shape our relationships. So in celebration of year five, I want to celebrate. I want to celebrate me. That's Snoop Dogg, that new like I'd like to thank myself. An episode a week for five years is huge. Good job self, way to show up and create your best life. And in addition, I want to thank everyone who listens, shares and prescribes hormones and takes care of sex med for women. Your support fuels this mission to empower and educate. Here's to another year of breaking myths, sharing stories and embracing the science of of living our best lives. Happy New Year. All my loves. Kelly Casperson 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.
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Enjoy the show.
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Hi everyone, My name is Dr. Caspersen. I'm a board certified urologist living in Washington State. Over the past year I've started listening to podcasts a lot and started getting an idea in my head that I I should have a podcast. Because the more and more I listen to women, the more and more I realize that feeling broken about sexual function and misk or lack of education about their pelvis is a common recurring theme and I see it every single day in my practice. So the other thing I noticed is that when I tend to talk to people about my job or what I do, they're really curious and they want to know more about what I do in the pelvis. And people are inherently interested in anything sex related. They say that good lovers are made, not born. So that's a good motivation to keep learning. So as the new year starts and it's 2020 and happy new Year to everybody. If you're listening to this on January 1st, I thought, well, why not give this podcasting thing a try. So part of my passion project within urology and being a urologist is to help educate women about the fact that they are not broken.
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So I would love it if you
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followed me if you think this is a good ide and give me some feedback on what topics that you guys want to hear as far as your pelvis and urology and sex and relationships. Because it's my life and I live it and I think it's pretty interesting. So I'd love to share it with you guys. My mission is to empower women to live their best love life. To combine the power of the mind through self work and mind work and the body to learn about how the body heals and moves and lives and loves and works. Of course, the relationships that we're in and our history and the way we were taught and the religions that we came from, they all enter the bedroom with us. So I hope to break down the society barriers that keep us from living our best intimate lives. So whether you're young or past menopause, single or in a long term relationship, it's never too late or too early to realize that you are not broken. So I hope to get to know you as the weeks go on and use some candor and some straight talk and some humor and hopefully share some stories with you so that you can learn about this topic through hearing the stories of others. And most importantly is to start paying attention to our own stories, to listen to the stories that society has told us and Hollywood's told us and maybe past lovers or even teachers have told us about sexuality. And I want us to become more playful and to know it's okay to learn and explore and that sex is a normal part of life. And we're celebrating and getting better at. So join me in this podcast, you are Not Broken. To celebrate and learn and love and thanks for listening.
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E
I would say. What do you find is the biggest hurdle for people to like, eat healthy? I think it was time.
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One, I think that we get away with stuff when we're younger and we build our lives around convenience. And I certainly did it for myself, for my children. And that you found this kind of system that works for you and you felt healthy and you look good and you checked all the boxes and then it stops working in midlife. And you go through, through this era of frustration of what is wrong with me where you're aging. Not only are you aging chronologically, but our endocrine system, you know, our ovaries are aging at an accelerated rate and suddenly what you were doing before is no longer working. And it's hitting that brick wall when everything in society, everything in medicine, every, not every personal trainer but you know, is saying this has to work and it's getting over that frustration. We build our lives around the convenience of food. You know, we over schedule ourselves and then when that convenience is no longer working, we're not healthy. It's like, wait, I don't understand, I don't understand what's going on.
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E
Yeah, I mean, I think another thing is like, we set up our palates. I get super used to caramel lattes and I've been doing it since college and blah, blah, blah. And then you're like, I really like it. And it's like, well, of course you like this junk you've been feeding yourself, right? You've been giving it to yourself for decades and like coming off and rethinking about food as like really medicine or support or fuel. Thinking about it in a different way instead of thinking about it as like a reward or a treat or it's just fast. All these things that end up not serving us.
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F
And not to say that there's not room for an occasional latte or an occasional, you know, something packed. We get in a rush or, you know, but it's like building your life so that 85% of the time you're not relying on that convenient stuff so that that just becomes emergency food or a treat or something that, you know, or celebration or you're just stuck in a social situation you can't get out of. That doesn't become what is normal to you. And every day, because it's not going to serve you.
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Yeah, like 2pm Every day is your soy caramel latte. You're like, ah, might be a pattern.
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Candy was mine when I was in clinic. 2pm candy, 100%.
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I had some peanut M&Ms. Yesterday. I mean, I think that we have so much data now that, like, eating well, getting sleep, exercising, feeling good in your body, being confident, all of that leads to a better sex life, can't negate the importance of our lifestyle in our sex life.
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F
So when I start breaking down sexual function, all of which I learned from you, by the way, and not from my OBGYN residency, a lot of my patients are absolutely honest with themselves and say I am struggling with desire and I don't know how much of it is a part of. I don't like the way I feel in my body right now. I don't feel confident, I don't feel beautiful. And that is not making me feel desirable. So that part of my brain can't go on. And so we have discussions around that, and that's a huge part of it. And then, you know, they're coming in months later after making all these changes, adopting new habits. They're feeling so good, they're sleeping all the things. And I'm like, do you still feel like we could try some medication here? And she's like, no, no, I'm good. Not to say there's not a place for medication or other interventions, but sometimes it is just getting the sleep, getting the stress reduction, eating the foods, and you feel better. And then therefore, that part of your mind opens up again.
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E
I love it. I mean, it's so wonderful that you shared in your book, your story, because I think, you know, if people look at you now, and I met you now, not then, right. Of like, you truly had to figure this out on your own because it wasn't working. Can you share your story and kind of talk about your journey on getting to the point where you're like, the proof's in the pudding. People like, if it worked for me, I'm not special.
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It's going to work.
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It's going to work for other people.
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So here's what I learned in my nutrition studies. The head professor said nobody ever got fat eating fruits and vegetables. This was like his pearl, his first pearl. The second was, you can't supplement your way out of poor nutrition. You can't swallow a handful of pills and think it's gonna undo nutritional choices that are not serving you. That's not how it works. You supplement a healthy diet. The end. And so there are people who cannot get what they need from food because of location, because of cost, because food deserts, because of allergies, you know, intolerances. Fine. Now you need to work hard to get everything you need from food. But it's not always possible or practical. And we can supplement the gaps. So the average American woman right now in the US is getting about 12 grams of fiber in her diet per day.
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Recommended is 20, 25.
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25, 25 minimum. I pushed for 35 with my own diet because of family history and stuff like that. And it makes me feel better. So I'm a big fan to make sure you're getting enough fiber and supplementing a gap that you can't hit consistently. Second thing is vitamin D. 80% of my patients are deficient, severely deficient in vitamin D. That is a tough one to get. We're not getting enough sun because we're protecting our skin. Understandably, we absorb less as we get older. And it is such an important hormone. Vitamin D is a hormone, you know, in the body that has multiple organ systems, everything from hair loss to weight gain to brain function to sexual function, all of it. And so I'm a big fan of supplementing vitamin D. Everybody asks how much you know you can safely probably take four to 5,000 a day without becoming toxic. This is a fat storage vitamin hormone. And so it is something that we can become toxic. K, A, D and E are vitamins that are stored in fat cells, so you can build up a lot of them. But that being said, magnesium, about 50% of us are not getting enough mag and it is crucial to brain function. And so everyone's like, what? Magnesium is the best? And I'm like, it depends on what you're treating. And so some are better to treat constipation poor bioavailability, stays in the gu, makes you poop, you know, others are great at raising low levels. Magnesium, glycinate, citrate, those are all great for that. If you're treating something in the brain, most of those studies are done with magnesium L serenate, called Neuromag or magtine commercially. And that's the one that seems to cross the blood brain barrier the best. So when I'm recommending it to help with sleep, to help with depression, to help with anything in the brain, I'll usually recommend that one. Now right now, the Internet is blowing up. At least my for you page. And all my ads are all about these miracle cures for menopause. These marketers are smart. They know that this is a hot topic. They know that there are multiple pain points. And you'll see. I saw a woman crawling across the floor in pain, holding up a bottle of X saying, it's gonna. This has changed my life. It's cured me.
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I'm like, look.
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And it's a probiotic. I'm like, I like probiotics. I take em myself. Cause I'm not getting enough in my diet, okay? But I know it is not curing all my menopausal symptoms. Okay? It might make my gut a little bit better. I'm a fan. But you don't need to pay all this money and get this thing on subscription. It's amazing the, the audacity that these companies and I can't believe the FDA is not like hot on this because they're making medical claim. You cannot make a medical claim on a supplement. FDA will come after you, you know, and take it off the market.
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You can't call something a lube without the FDA getting on you. I'm always like, save your money, people. Save your money.
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Spend it on healthy, good quality food.
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If it seems too good to be true, it probably is.
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E
This is the first time I had actually like thought of this, but it makes so much sense to me. You talk about the blurring of the roles of partner and mother, and they do such a beautiful job of. It's not that mothers aren't sexual. It's that the relationship between mothers and those they mother is not a sexual one. And so if we take our intimate partner, our husband or spouse, and we mother them, we might be lowering our desire as a happenstance to that.
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Yeah, exactly. And you know, our culture has a story that mothers aren't sexy. And you know, there's the acronym in pornography that many people will know which is about sort of, I won't spell it out, but mothers who are seen as sexual, which stands against the norm, right? That's why that's a category.
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That's why if you have to point it out, it means that we think that they're not. Yeah, okay.
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But I think really we have it quite opposite in that it's not that, you know, mothers can be sexual and sexy, so can anyone. It's more the act of mothering is not a sexual act with the people you're mothering. So as you sort of paraphrase, that's what we talk about, that it's not that mothers aren't sexy or that being a mother can't be sexual with someone else, but that obviously we're not sexual to the people we mother. And because of these inequities, if you're in charge of making sure your 6 year old has socks and then your partner has socks, it's hard not to make the connection that you're sort of doing the same roles. And we argue that especially right now in our culture there's this norm of interdependence. So it's like, I'll rely on you for some things, you rely on me for some things, and we support each other. It's not I take care of you and you get taken care of. There's more back and forth. And we have, as relationship partners, we offer something to all the people who are part of that relationship. But the idea that having to kind of parent your partner when really in our culture your partner shouldn't, it's not that they shouldn't need help, it's that it shouldn't be a one way helping, it shouldn't be a one way relationship like that. We argue like, you know, probably we're not set up to have sexual desire for people. We are parenting and for good reason, right?
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E
Are we not supposed to have sexual desire for people?
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A
We nag also?
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That's a big.
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We talk about that too. And you know, we talk about the way that nagging is really this powerful thing. No one wants to be a nag, right? No cool girl is a nag, no fun mom is a nag. But one of the things we talk about is that nagging is a word given to someone asking someone else to do their job, to do something they've agreed to. So it's a really powerful way to shut down someone's request for something reasonable that they shouldn't even have to request. So if you've agreed to do whatever is your chore the laundry, the cooking, the driving, and you have to be nagged for it. You're the one who's not fulfilling your role or doing what you agreed to do. If you don't agree to it, you should renegotiate the agreements in your house, but not just not do the thing. And so, yeah, like, obviously someone who isn't accountable, someone who doesn't take responsibility, is not an equitable co partner. That reminds us of, for those of us who have kids, that reminds us of our kids. And I think one of the great things about queer sexualities is that there's so much more negotiation and discussion about what people want. That's one of the things about heteronormativity. The assumption that all sex is penetrative sex, penis, vagina sex means that, like, you can't just say, hey, like, today I just feel like touching each other's genitals. I know the word genitals is not the most sexual word, or, hey, let's do oral sex, or things like that. Like, there's such a norm to not be able to communicate about these things. And that is if everyone's on the same page, that sex means this. But what if that's not what you want? But what if you still want sex, just not that part of it?
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So, yeah, yeah. And I think I really like that because I like to. I mean, I think there's such a lack of understanding how to communicate about this. And I think both the queer area and then the, like, bdsm, the emphasis placed on consent, talking about it up front, talking about it afterwards. How was that? Was it okay? What, you know, what do you think about next time? Like, it's a culture that's very different than, you know, your heterosexual, but let's just all assume we're assuming the same thoughts and, like, there's no talking about it.
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G
Yeah, exactly. And so stepping outside, you know, doing a different kind of sex can be a nice way. From what I understand from, like, what you're saying from BDSM folks, from queer folks, from therapists. It can be such a powerful way to step outside the assumptions. And you have to communicate because it's like, it's not obvious, but of course it's never obvious. And one thing I want to add is there's really brilliant work by Sarah, Hunter Marie on men that they want to be communicating too. So there's these stereotypes about what men want, and there's stereotypes that men don't want to communicate and so on. But, you know, most men do want to be having sex that their partners enjoy. But our cultural norms are so strong and tend to advantage the things that men do enjoy more that it means that they're also conditioned and socialized not to ask these questions and not to check in.
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E
Talk about in your research of like testosterone and oxytocin, like these behaviors, whether it's the mothering behavior or the nagging or having more work than the other person, how does it affect testosterone and then like oxytocin and kind of break it down into like how this actually affects. Because I think it's a leap for some people to think like the water you're swimming in affects like your biochemistry.
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G
Yeah, well, and you know, we're so used to thinking of our bodies as driving our behavior and that's. People call that biologism or biological determinism, the idea that our hormones drive our behavior. But for humans, actually, if anything, the reverse relationship is stronger. Our behavior influences our hormones more strongly than our hormones influence our behavior. So one of the things we found, for example, is even thinking sexual thoughts can change testosterone levels.
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No joke.
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Yeah.
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E
So can you tell me how you did that research?
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So we, you know, it's. We're sex researchers. So we have people take saliva samples at sort of the pre activity standpoint time point. Then we have people in different conditions. One of them is a sexual thoughts condition. And we ask them to. We call this imagine sexual situation exercise. And this was with former grad student Katie Goldie, who's now a professor. And it's kind of a guided imagery thing. So we ask them to think of a sexual situation, describe who you're with and so on. We don't really care so much what they say. We're just trying to guide them through thinking sexual thoughts. Then we take another saliva sample a little bit after that, and we compare the change in testosterone and that condition to a control condition where they're not thinking sexual thoughts. And we have them think sort of like other things, like social things that aren't sexual to really control for what's going on. And we find that it does increase testosterone. There's other people too. We found that various kinds of social situations change hormone levels, which makes sense because our hormones are released at the end of a whole long physiological stream that starts with the brain, the brain monitoring amount of hormones in the body and the brain monitoring our outside environment.
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E
So it's like a two way street. But yeah, I think this whole idea of our body exists in a bubble that's not influenced by anything else is not understanding the whole picture.
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G
That's right. And I mean, even things like you think your body gets sick and reacts to sickness and illness, like with COVID but that comes from outside your body. Stress often comes from outside your body. Your body changes what it's doing depending on whether it's hot or cold. And that's influencing stimuli from outside our bodies. And it's the same with hormones. It responds to things in our bodies and they respond to things outside our bodies.
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E
I posted something this week and I said, why aren't boomers more pissed because they missed the safety window. And I got tons of replies saying, like, we are pissed.
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A
What do we do about it?
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Right?
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E
So my question is, the more we say, yes, estrogen safe. There's like that hard cutoff of 10 years, which the experts know is not a hard cutoff. How would you approach that 63 year old, that 65 year old, maybe she has symptoms, maybe she doesn't. Do you do a calcium score, work her up for cardiovascular disease first? Or do you really say like, at some point, sorry, it's too late?
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I
Why is that 10 year window felt to be important? It's felt to be important because the increased risk, although it was small, the increased risk of stroke, for example, is seen, or heart attack is seen more often among women who are more than 10 years post menopausal. And the question is why? And the best answer that I've been able to find is young blood vessels. Young arteries are distensible. As arteries get older, and this is true for all of us, they get narrowed and less distensible. So that if you take a drug like estrogen, which has the potential for taking platelets in the blood, these are small, normal corks that circulate in the blood and help prevent bleeding. If they form a platelet plug, they can block an already narrowed artery. And it is thought that this increased risk of, say, stroke or coronary artery disease seen among women who were more than 10 years postmenopausal, May be due to further blockage of one of these vital arteries. This problem, which I think we have to take very seriously, was not seen uniformly. It was seen in a minority of people, and it was seen primarily during the first year of starting hormones and rapidly diminished as a problem once a woman was on the hormones for more than a year. What that presents us with is a benefit risk calculation that could be part of the discussion. How miserable are you? How much at risk are you of other serious problems? And is it worth the extra risk of taking it? If you are more than 10 years postmenopausal.
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C
And that was oral estrogen too, because
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E
it was WHI data where most experts would say, okay, well, even if they're over 10 years, if they're a great candidate, you're going to start on a transdermal to decrease that clot risk.
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I
Let's talk about the clot risk for a minute. First of all, the risk I just spoke about was a platelet plug induced formation because of estrogen. That is true regardless of how the estrogen is administered. But that compromises arteries, not veins. The increased clot risk that you're talking about is a clot in a vein. And that is seen more often among women who take estrogen orally than women who take it transdermally. The clot in the vein carries the risk of breaking off in the vein and traveling to the lung and causing a pulmonary embolus that is rare. And by the way, follow up of the Women's Health Initiative 20 years looking at the risk of pulmonary emboli, found that there was no increased risk seen when the two groups, those taking hormones and those who didn't take hormones, were compared. The difference in risk of clots in the vein between the transdermal approach and the oral approach, which is real, is also very small. It might be about 5%. And among the women who develop a complication, the 5% is irrelevant. They develop the complication, but it shouldn't overwhelm a decision that is forced to look at many different factors going into the use of hormones.
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E
Beautiful. Yeah. I think so many people take that 10 year as an absolute concrete wall instead of a risk benefit discussion.
- [33:42]
I
I didn't answer your question specifically about hip fracture. And yes, it's important to note that the number of people who die within one year of a hip fracture is comparable to the number who die each year of breast cancer. Hip fracture, even if it doesn't result in death, is debilitating and can affect quality of life. And the best preventive treatment for osteoporotic hip fracture is perimenopausal and menopausal estrogen therapy. It is better than the bisphosphonates. It's much better than calcium and vitamin D. It works, and it works indefinitely as long as a woman continues to take it. Once a woman stops taking estrogen, her bone starts to lose elasticity so that by four or five years after she stops, it has lost any benefit that it might have gained during the years that she was taking it. And it's the best Treatment, it reduces that risk by up to 50%.
- [34:55]
E
But if we're not even screening for osteoporosis until age 65.
- [34:59]
I
See, that's the other part of your question. I said there were so many parts. How do we screen for osteoporosis? We get a bone mineral density study. Is that a good screening test? No, it is not. Because what you lose in osteoporosis is not only bone density. You lose the elasticity of the collagen fibers within the bone. It's that elasticity that allows bone to stretch without breaking. Bone mineral density while we use it, correlates very poorly with bone fracture, especially with hip fracture over time.
- [35:44]
E
Yeah, I think you explained that really well in your book of why calcium, although makes it denser, doesn't make it stronger.
- [35:52]
I
Right.
- [35:53]
E
You know, the urologists are taking it all the way to the bank because in the 70s, women had one eighth the amount of kidney stones as mentioned. And my. And I have not seen great papers on this, but we took everybody off estrogen, we scared them about osteoporosis. We did a huge calcium publicity thing with milk, et cetera. We threw them all on calcium supplements. They are equal to men in their rate of kidney stones. Now, I think it's because, you know, when diet calcium is best, but when you take it in supplement form, it just goes straight through your kidneys and then makes nice little stones. But the boomers are pissed. At first, there's fear, Then you get educated. Then I think there's the anger and, like, the evolution of watching people through this.
- [36:36]
J
To me, the biggest, like, dirty bandaid of this is the statement that we're over medicalizing menopause. And part of that is I don't even think the people, these authors understand what menopause is, that it is a decline in hormones. It is an endocrine opathy. It is the ovaries running out on their timeline.
- [36:58]
E
Right.
- [36:58]
J
And just saying, like, oh, it's just a hot flash. And not understanding the pathophysiology behind what happens. Let's start a conversation about your thoughts on are we in 2024 over medicalizing menopause and what that means to you.
- [37:13]
K
I think we're under medicalizing menopause, quite frankly. You know, here we have this going on at the same time that Drew Barrymore puts out this nonsense of supplements that are supposedly gonna help with your brain fog sleep hot flashes again, ignoring the consequences of all these things. And this is an exact example of, no, these women don't need to take Worthless, unproven herbs and spices. They need people who are going to give proven, effective, safe hormonal and non hormonal options. And I think we would all agree that if men stopped making testosterone at age 50 and couldn't sleep and couldn't think and were having all day and all night hot flashes, nobody would talk about over medicalizing the fact that they would be getting testosterone supplementation. So this is offensive and sexist on every level.
- [38:04]
D
Well said.
- [38:05]
J
Who's next?
- [38:06]
L
Yes, I mean they actually say it, Kelly. They say rather than focusing on menopause as an endocrine deficiency, we propose an empowerment model. I mean I just try to imagine myself whenever I know we've all said this now and Dr. Streger just there always try to flip it and think, would I say this to my male patients if I had a man sitting in front of me? I checked his testosterone and it was undetectable. He was in tatters as a man, couldn't sleep, had just no quality of life. Would I say to him now, rather than focusing on this as an endocrine deficiency, let me empower you? I mean it's just, it's ridiculous.
- [38:46]
K
That will help be empowered. Exactly.
- [38:50]
L
Let's try some cold plunges and some acupuncture. You know, acupuncture is great, but not for menopause. It's just laughable.
- [38:58]
H
I think when you said it on your Instagram, Dr. O', Sullivan, it cracked me up actually because you're like, you know, I decided I was gonna read this from the side of a man. So everywhere it said female, I replaced it with male.
- [39:09]
G
That was brilliant. And when you read it, it was brilliant.
- [39:12]
H
And when you read it that way, I said, what man in God's green earth would put up with?
- [39:18]
B
I think the over medicalization statement is just, it's absurd quite frankly to say that in our country where 4 to 6% of menopausal perimenopausal women are medicated. 4 to 6%. How can you possibly say that they're over medicalized in that scenario? I think maybe 6% in England are treated right.
- [39:36]
H
I always am thinking of our marginalized or the people that can't afford things. So hormone replacement therapy is affordable for most use. A Goodrx app, you can get it. Probably a six month supply for 30 to 60. 60 bucks. So not crazy. Off the charts to go into cognitive behavioral therapy. Most insurance sadly is not covering it anymore. It's a cash based business. It's 100 plus or more dollars and that's at a minimum for a 50 minute consult that's going to take six months. No one has, like you said, that kind of time for a lot of people. Especially when I again think of the marginalized who have to work. When are they going to do this? And again, it's just not an option for everybody because there's a huge barrier to cost. And that's some of the things being that boots on ground clinicians that we all are, is we have to kind of balance out what patients can do, what's feasible and what's affordable.
- [40:27]
L
One of the really infuriating things about that article, one of them was the thread the whole way through that clinicians who prescribe hormone therapy just do that. We don't think to prescribe pelvic floor therapy or cognitive behavioral therapy or to support our patients with nutrition and diet and exercise. That ran through the whole article. As if we don't. That doesn't occur to any of us. I mean, we all use all those tools.
- [40:57]
K
Well, not only was it insulting, but the other thing that ran through the entire article was the idea of and if your patient is having a hard time, it's her own fault. She just needs to buck up and do some CBT and start thinking positive thoughts and then she's gonna wish away all of these symptoms. It's interesting that they did not say she could wish away her vaginal dryness. Even they were not willing to go that far. I'm waiting for it, you know.
- [41:24]
E
Yeah.
- [41:24]
J
I think from a sheer numbers game, women are 50 to 51% of the population. Our medical system's already jam packed. Now you're gonna have, let's say 80% of them are symptomatic from perimenopause menopause. You're gonna push 50% of the population, 80% of them to a cognitive behavioral therapist. We simply can't.
- [41:45]
A
Even if we said yes, that should
- [41:46]
J
be the gold standard, we do not have enough training schools to dump out that many cognitive behavioral therapy providers to help this sheer amount of humans. This is a massive, this is, I always say this is not an autosomal recessive genetic disorder. This is 50% of the population. And to help the majority of them, we need to really follow the evidence.
- [42:11]
L
They really went out of their way. Not to mention any of the benefits of hormone therapy on bones and brain and heart. I mean, they went out of their way. There was one line that said MHT might improve sleep, memory and concentration in women taking it for vasomotor symptoms, but it is Unlikely to have any effect in women without vasomotor symptoms.
- [42:33]
B
I totally reacted to that line.
- [42:35]
J
I couldn't say,
- [42:38]
K
you know, it's just false. Simply not true. Every piece of data that we have.
- [42:43]
H
Yeah.
- [42:44]
F
So the interesting twist on that's an interesting twist on a fact. When most women navigate the menopause without the option for menopause hormone therapy, which is a very different statement than without the need that we have overwhelming evidence to support the need for menopause hormone therapy for patients not only for treatment of their vasomotor symptoms, but prevention of disease in multiple organ systems. And categorically denying a patient that. Just saying to chin up and suck it up and get through it is outrageous.
- [43:14]
A
I wonder where they even got the
- [43:15]
B
basis for that statement either, right?
- [43:17]
L
They don't.
- [43:17]
E
Yeah.
- [43:17]
J
The data was not cited.
- [43:19]
F
It was not cited. I found citations to prove the opposite.
- [43:23]
G
Right.
- [43:26]
E
Yeah. I think the overreaching theme of your book, his porn, her pain, is that it's never about the porn. Air quotes. The porn pretty much. There's always something underneath it. I see that a lot in the work I do with, like, women coming in left and right saying they have low desire. And my argument is it's not about low desire. There's always something else. We're just calling it low desire.
- [43:46]
M
Right. And my question is low desire for what? If it's low desire for sex with someone who calls you the wrong name, hasn't taken a shower in a week, doesn't look at you during sex, and. And finishes and leaves the room without saying thank you, then I don't call that low desire. I call that common sense. Does porn dehumanize women? No, porn doesn't dehumanize women. Some people who consume porn, they dehumanize women. Just like some people who consume NASCAR racing, they dehumanize women. The mistake that a lot of people make is imagining that porn is a documentary and that when people look at porn, they think that they're looking at the way that sex really is. The data is really clear that most people who look at porn, they know that they're looking at fiction the same way that when you watch Star wars, you know that you're looking at fiction. So are there images in porn of women being treated poorly? Absolutely, yes, of course. Because porn is a library of human sexual fantasy. And human sexual fantasy is not the same thing as human sexual behavior. It's human sexual fantasy. So I see patients all the time who say, well, you know, my sexual thing is X. And I think, well, I have no problem with you getting turned on by X, but I don't get turned on by X as long as the other person is up for it. Sure. So the data is that the single most common sexual fantasy of all orientations and all genders is being coerced, is being treated roughly. That's been replicated over and over again. So when we see porn of women being treated roughly or women being coerced, not only is that a popular sexual fantasy among men, men, it's a very popular sexual fantasy among women. In fact, the data says that it's more popular among women than it is among men. So how does that translate into the way that people behave in their own bedrooms? If it doesn't lead people to treat women poorly in their bedrooms, then it doesn't matter what the imagery is. And the data on this is pretty clear. There's a small number of men who this Machiavellian, stark triad of psychological traits, when they consume porn that depicts violence against women, they're more likely to behave roughly with women. That's an extremely small number of men. Fortunately, it's a lot smaller than the number of people who consume alcohol and go out and drive drunk. Let's remember, most porn out there does not depict violence, does not depict rough sex. And there's a very simple reason for that. It's because that's not what a lot of consumers want. The same way that any consumer product responds to what people are going to want. And number one, sexual fantasy of everybody is inappropriate activities, inappropriate partners, inappropriate situations. And if you don't want to say inappropriate, we could say doing stuff that you wouldn't normally do in real life. So number one, sexual fantasy for men, typically, sex with more than one person at a time.
- [47:13]
E
Perfect. The difference between, like, it's fantasy and real life. There was a gentleman and he. I don't think the woman fully wanted to have a threesome, but he's like, that's my fantasy. And she's like, okay. So they did it and it was like, downhill ever since. And it's like, that was his fantasy. He chose to bring it into his reality. I'm not sure she was. She fully consented.
- [47:33]
G
Right.
- [47:33]
E
She's kind of like, ah, I was going to make him happy. And can you talk about, like, fantasies are okay to just keep his fantasies and buyer beware if you bring it into the real world or, like, how do you navigate that for people?
- [47:44]
M
Absolutely. You know, most people don't fantasize about the stuff that they did last Saturday night. I mean, if you can do it, why fantasize about it, right? So people typically fantasize about stuff that they don't do, either because it's illegal or because it's ill advised. And if I say to you, gee, Kelly, I heard you play tennis, next time I'm in your area, let's play tennis together, and you say, no, I don't want to do that. It's not the end of the world and we both forget about it. But if I say to you, let's have sex, me and you and your sister, you can say, no, I don't want to do that. But it doesn't go away. The question and the answer, they sort of soak into the wallpaper in the kitchen and like three months later she's still thinking about you wanted to have sex with me and my best friend. Sexual fantasy is an opportunity to have sexual experiences with no repercussions. And I think it's it's really important that people not assume that people not assume that fantasies have meaning. Sexual fantasies do not have meaning. It's a big mistake to say, oh, you have sexual fantasies about being dominated. That means you want to be dominated in real life. Or you have sexual fantasies about you and your guy and another woman. That means you feel inadequate to please him. It's a huge mistake to assign meaning to sexual fantasy. And it's a huge mistake to assign meaning to the porn that people choose to watch. Why do people choose the porn that they choose? It's one of these mysteries of human chemistry.
- [49:25]
A
Thank you for listening to this week's
- [49:27]
C
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 from 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
- [49:55]
E
and get them immediately without advertising.
- [49:58]
C
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 and 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. 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.