304. Urogynecology Exists For Things We Don't Want To Talk About

Summary

You Are Not Broken – Episode 304

"Urogynecology Exists For Things We Don’t Want To Talk About"
Host: Dr. Kelly Casperson
Guest: Dr. Jocelyn Fitzgerald, Urogynecologist
Release Date: February 16, 2025

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Episode Overview

In this engaging and candid episode, Dr. Kelly Casperson invites Dr. Jocelyn Fitzgerald, a prominent urogynecologist, to discuss pelvic floor health, prolapse, the reality of childbirth’s effects on women’s bodies, and why the field of urogynecology remains under-recognized. The conversation dives deep into medical taboos, systemic challenges in women’s healthcare, the power of straightforward communication, and the urgency of informed, empowered patient choices.

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Key Discussion Points & Insights

1. Introducing Dr. Fitzgerald and Her Approach

• Dr. Fitzgerald shares how her direct, accessible, and witty communication style—honed partly through family banter and literary roots—brought her to social media advocacy ([01:03]-[02:56]).
• The COVID-19 pandemic intensified her resolve to "say the things I really think on the internet."

  "When Covid hit, it's like, are we all going to die or I'm going to say the things I really think on the Internet." – Dr. Fitzgerald [01:39]

2. Barriers to Talking About Pelvic Health

• Widespread taboo around discussing prolapse and other pelvic floor injuries: "Nobody can say the word vagina." – Dr. Casperson [04:01]
• Clear language matters: "Prolapse is when your vagina falls out...that is what it is, dude." – Dr. Fitzgerald [03:42]
• Many patients mistake prolapse for cancer or other pathologies out of fear and lack of knowledge.

  "I had a patient once actually come and think that she was delivering some, like, twin that was left behind…she thought it was, like, the head of a baby." – Dr. Fitzgerald [08:55]

3. Birth Is Not a ‘Health Neutral’ Event

• Both hosts underscore the myth that pregnancy is risk-free, noting a lack of informed consent about long-term pelvic consequences ([06:00]-[07:32]).
• Dr. Fitzgerald's forceful point:

  "Women have been collectively convinced that pregnancy is a health neutral event. And I'm here to tell you that this is a tactic used to suppress freedom of informed choice." – Dr. Casperson citing Fitzgerald [06:04]

• Informed education reduces, not increases, anxiety about birth outcomes ([06:39]-[07:32]).

4. Preventative Advice: Vaginal Estrogen and Weightlifting

• "Best advice for aging women? Vaginal estrogen and weightlifting." – Dr. Casperson quoting Fitzgerald [09:27]
• These interventions can help avoid UTIs, prevent frailty, and decrease risk for falls and dementia, says Dr. Fitzgerald:

  "You could prevent almost all of it with both of these things." [09:38]

5. Pain (and Sexism) in Basic Women’s Health Care

• The duo tackles the issue of minimal pain management for IUD placements ([11:01]-[13:55]):
  • OB/GYN reimbursement structure discourages optimal care and anesthetics.
  • Men's office procedures are 5-10x better reimbursed and always numb.

  "If men got IUDs, it would be, you know, lots of anesthesia." – Dr. Fitzgerald [13:49]

6. Urogynecology: Why the Specialty Exists, and Why So Few Know About It

• The field often deals with consequences of childbirth that are not openly discussed.
• Major risk factors for prolapse and incontinence are vaginal and particularly operative deliveries ([14:22]-[15:19]).
• "If we would just admit to ourselves…why we need a whole entire field of medicine... a whole lot of it is due to childbirth." – Dr. Fitzgerald [14:22]

7. OB and GYN Should Be Separate Specialties

• The U.S. system currently expects OB and GYN to be covered in a single four-year residency, resulting in suboptimal depth in both ([17:05]-[21:31]).
• Economic and historical context for why the specialties were combined—traced to interdepartmental rivalry at Johns Hopkins and driven by male egos ([18:12]-[21:31]).
• Reimbursement inequities impact patient care, e.g., rural labor and delivery units closing.

8. Underrepresentation and Workforce Crisis

• Only 1,000 urogynecologists in the U.S.; about 1 per 100,000 women.
• By 2050, 54.9 million women projected with symptomatic vaginal prolapse; 15% of women will have prolapse surgery ([25:18]-[25:43]).
• Less than 50% of urologists perform prolapse/incontinence surgery; female urologists remain rare.

9. Lack of Training and Awareness

• Most patients arrive at surgeons having not tried vaginal estrogen or pelvic floor physical therapy ([28:39]-[29:39]).
• Overlapping turf with urology and gynecology creates gaps and misunderstandings among providers and patients alike.

10. Feminist Perspective on Urogynecology & Women’s Health Funding

• The field is "a radical feminist act in a society that abandons and discards women after they've given birth." – Dr. Casperson quoting Fitzgerald [31:31]
• NIH women's health funding is <10% of total, and 80% of that focuses on pregnancy, not long-term health ([31:41]-[32:39]).
• Keeping women continent and healthy impacts not just individuals but also economies and families.

11. Systemic and Political Challenges

• OB/GYN residency spots are shifting in response to reproductive rights legislation, but still fill in most states ([34:04]-[35:19]).
• The impact of abortion bans on medical training and patient care is highlighted.

12. What Can Listeners Do?

• Get politically and economically engaged: “Follow the money.”

  "Vote like your life depends on it, because it does." – Dr. Fitzgerald [36:42]

• Be educated, have a reproductive contingency plan, and choose partners wisely.
• The hosts speculate on the transformative potential of reliable, reversible male birth control ([37:38]-[38:29]).

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Memorable Quotes

• On honest language:

  "Prolapse is when your vagina falls out...that is what it is, dude." – Dr. Fitzgerald [03:42]

• On under-representation:

  "There is one urogynecologist for every 100,000 women in the United States." – Dr. Fitzgerald [25:43]

• On medical culture:

  "Being a urogynecologist is a radical feminist act in a society that abandons and discards women after they have given birth." – Dr. Fitzgerald [31:31]

• On prevention:

  "Best advice for aging women. Vaginal estrogen and weightlifting." – Dr. Casperson quoting Fitzgerald [09:27]

• On the impact of undervaluing women's health:

  "You get a woman who's incontinent, has prolapse, like out of the house, back to her job, back to her church, back to her community, back to her sex life…all these things that like, are literally tied to the economy…" – Dr. Fitzgerald [32:43]

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Key Timestamps

• [01:03] – Dr. Fitzgerald’s journey to public advocacy
• [03:42] – “Prolapse is when your vagina falls out…”
• [06:00] – The myth of pregnancy as a health-neutral event
• [09:27] – Vaginal estrogen and weightlifting for aging women
• [11:01] – The IUD pain management controversy
• [14:22] – Why urogynecology exists and is so little known
• [17:05] – Why OB and GYN should be separate specialties
• [25:18] – Scope and shortage of urogynecology providers
• [28:39] – Concerns over lack of conservative treatment trials before surgery
• [31:31] – Framing urogynecology as feminist medical care
• [36:42] – How listeners can drive change

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Tone and Style

The conversation is unflinchingly honest, at times humorous, and always empowering. Both doctors champion clear, accurate, and stigma-busting language. They combine medical expertise with passionate advocacy, weaving personal anecdotes, system-level critique, and supportive encouragement for listeners throughout.

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Takeaways

• You are not alone. Pelvic floor disorders are common, treatable, and nothing to be ashamed of.
• Informed care matters. Demand language and care that honestly reflects women’s bodies and experiences.
• Preventative actions save lives. Vaginal estrogen and strength training are simple, vital tools.
• Advocate and educate. Change happens when women (and their allies) speak up—for themselves, for each other, and for systemic reform.

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For Further Learning

Follow Dr. Fitzgerald on social media (Instagram/Twitter) for more direct, witty educational content on women’s health and urogynecology. To take action or connect with advocacy, consider writing to your representatives, and support equitable funding and access in women’s healthcare.

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This summary covers all major themes and insights from the episode, with quotes and timestamps for those seeking deeper engagement or specific highlights.

Transcript

[A]

Welcome to the youe Are Not Broken podcast. I'm your host, Dr. Kelly Casperson, a

[B]

board certified urologist, thought leader and conversation

[A]

starter on midlife living, hormones and sexuality. Enjoy the show.

[B]

Hey everybody. Welcome back to the youe're Not Broken podcast. I am so excited to have Dr. Jocelyn Fitzgerald on today. She is a urogynecologist who focuses on pelvic floor disorders and. And I'm most interested in having her on the podcast because I love reading her writing on Instagram. It's like so awesome. So welcome to the podcast.

[C]

Thank you so much for having me. This is such an honor. I'm a huge fan.

[B]

When did you start speaking out? What to explain to the people? Like, you're very direct. Like I won't say like cutting, but it's like, it's like you get to the fricking point so clearly and sharply that it's just like beautiful writing. And I'm like, okay, I like how she thinks and writes and I need her on my podcast. So like when did you start being like, I think I should share this with the world?

[C]

Yeah, I will say probably my third year of fellowship I got really into Twitter and that was in Twitter's.

[B]

Wait, you had a three year fellowship?

[C]

I did, yes. Eurogyn on the gyne side is three years.

[B]

Okay, so four years. So for all the people who are mathing who think doctors don't get paid enough, four years of college, four years of medical school, four years of OB GYN residency and then three years of fellowship to take care of surgical prolapse and incontinence.

[C]

Correct. Pelvic pain, all of those things. I did have a co fellow who was urology trained, so she was with me for two years. But I did three because I came out of OB GYN. So it's like either five and two or four and three. So it's about the same. But yeah, my third year of Uruguayn Fellowship I was at Georgetown MedStar in D.C. very like political climate. So that was sort of helpful and, and had very supportive people who are leading my department who really encouraged me to basically take the things I was talking about all the time. And they were like, that is so quippy. Like what you said makes so much sense. You should put that online. And I come from a very sort of literary family. I have immediate family members in politics. Not anymore, but so just kind of like grew up also in a non medical family for the most part. And you kind of think, how can I explain this to somebody who does not understand who isn't from medicine and wouldn't get how big of a problem this is or just how do you explain it? Succinctly, but also in a way that will catch their attention. And I'm the oldest also, I'll add this. Of eight children, my siblings are. None of them are in medicine. So we have lots of very quippy conversations. The banter in my family is very strong. So that's when it started. And I was year fellow in 2019, 2020. And then when Covid hit, it's like, are we all going to die or I'm going to say the things I really think on the Internet. And that's how it began.

[B]

I love it. What kind of feedback have you gotten back from it?

[C]

Overall, extremely positive. I mean, the Internet obviously has shifted and it's levels of dumpster fireness over time. So occasionally I'll step in it a little bit or I'll. One time I criticized Harrison Bucker for being super sexist and saying that women should get back in the kitchen. And a lot of conservatives found me and that was not a super fun day. But besides that, I get incredible feedback from so many women. I talk about a lot of the same things you talk about. The very basics, like how to treat UTIs, how to prevent UTIs, what prolapse is. Without beating around the bush, you know, we kind of like come up with all these, I don't know, pseudonyms for prolapse. And you're like, prolapse is when your vagina falls out. Like, you just gotta say it. And then people are like, what? Your vagina can fall out? I'm like, I know no one wants to say it that way, but that is what it is, dude.

[B]

That's what I say. Because people come to me and they're like, my bladder's falling out. I'm like, your bladder's not falling out, that's your vagina turning inside out. And then they're like, why did my X, Y and Z, primary care doctor whatever tell me it's my bladder falling out? And I'm like, because nobody can say the word vagina.

[C]

They don't want to say the word vagina. And they want to make it into a polite thing. You can tell your daughter or son who's going to drive you to the hospital for your surgery, like, oh, my mom's having bladder surgery.

[B]

Bladder lift, bladder tuck, bladder tack. They're not things. And to me, I'm always like, the bladder to me is my favorite organ. It's like the kindergartner the kindergartner's a good kid. It just lives in a crappy house so it can act up. It's not your bladder's fault. Your bladder is not trying to leave your body.

[C]

No, it's not. It would like to stay where it is. It really is a canary in a coal mine for things that are going on in your body. I agree.

[B]

They're like, my bladder. I'm going off on bladders now. But they're like, will my bladder get better after my prolapse surgery? And I'm like, listen, bladders like living in the penthouse. They don't like living in the basement. You move them up to the penthouse, they might behave better, but they might not. But we gotta put it back where it likes to live.

[C]

I love that. It's very similar to what I say, but I'm gonna steal that and say the penthouse thing they do. They're like, oh, is this prolapse surgery going to fix all my problems? And I'm like, well, we will see. It may.

[B]

Yep. The goal of prolapse surgery is to fix the prolapse. Other things might get better, but you can have overactive bladder without prolapse. All the things.

[C]

But I try to tell people on the Internet, I'm like, I cannot let one more generation go by without knowing this can happen to you. That just makes me so mad. Like, when patients come in, they're in their 40s. Like, no one ever told me this could happen. I would never have maybe had that vaginal delivery after my C section. Maybe I would have never said yes to forceps. Like, no one could. No one told me that this was a thing. And I'm like, it just makes me so mad that we don't tell women thing. It's, like, so taboo to be like, oh, birth might not be perfect, and there are things that might happen to your body as a result. I can't let millennial women be like women 25, 30 years older than them who are coming in a little bit. I don't want to say too late,

[B]

but, yeah, I had this lady, she had three kids. Yeah, she's young, and she had prolapse. She's effing devastated by it. And you, you said something. One of your quips was, women have been collectively convinced that pregnancy is a health neutral event. And I'm here to tell you that this is a tactic used to suppress freedom of informed choice. And my question, I mean, there's so many ways we can go with that, but my question is do you think if a woman was actually should. AKA should we use this as. As a sex ed thing? Do you think a woman would choose to not have children because of the risk of prolapse, though, or. I don't think they would. I think they'd still have kids. They'd just be better informed.

[C]

Exactly. I feel so strongly about this. I talk about this all the time because that is the kind of post that gets me some pushback from like the mommies of the world who are like, I would never change anything. My children are worth it. It's like, that's not what I was tweeting about. That is you feeling defensive. People who want to become parents are going to become parents no matter what, and they will go into parenthood with more information. And in fact, there is good research that shows when you educate people about the pelvic floor outcomes of birth, it actually decreases their anxiety rather than increases it, which is what everyone thinks. And I will say this, that if learning about prolapse is all it takes for you to say, you know what, I don't know. If I think parenthood is for me, then probably you shouldn't have been a parent in the first place. If that's all it takes to deter you, I've probably done you an enormous favor.

[B]

Yeah, I mean, education's not bad. And it's like, we're not here to scare people. It's like prolapse is a legitimate, like, dude. Jocelyn, I had like a close to 10 pound baby to me. I'm like, I better stay on the hormones, stay with the muscle strengthening, keep everything going. Because I'm like, I'm staring down the barrel. My mom had a prolapse, right? So I'm like, I'm staring down the barrel of prolapse. If I don't maintain.

[C]

Yeah, absolutely. You need to pay attention.

[B]

Don't get a chronic cough. Don't start smoking cigarettes.

[C]

Yeah, exactly. Avoid constipation at all costs.

[B]

Poop smoothly.

[C]

No, it's true. It's really, really is true. And exactly if you know that it's something that runs in your family. Sorry, hopefully no one listening, that I'm adjusting my headphones. Hopefully doesn't create weird noises. But if it runs in your family or you had a big baby or you had forceps, knowing these things can help you take preventive measures. Also, it will teach you what a urogynecologist is or a female urologist who treats prolapse, so that if and when you feel a certain type of way, you don't just live with those symptoms for years and years and years while things get worse. You can go see someone sooner. And we know the sooner you see anyone for any medical problem, the better your outcomes will will be.

[B]

The amount of women who come to my office after having gone to the emergency department thinking it was a tumor.

[C]

Yes. Thinking they had cancer, having a total panic, having no idea. I had a patient once actually come and think that she was delivering some, like, twin that was left behind. I mean, I'm not laughing at this. Like, her literacy was obviously not great, but she thought it was, like, the head of a baby.

[B]

Sure. What else are you gonna think it is?

[C]

Yeah, like something a ball is coming out. So that's why, you know, I think social media is super important. Cause we cannot continue in this way. Like, women cannot be going to the emergency room thinking they have cancer when, in fact, they have prolapse.

[B]

Yeah, totally. One of your tweets was best advice for aging women. Vaginal estrogen and weightlifting.

[C]

That's it. I mean, I told tell my mom, my grandma. I'm like, if you can do these two things, you will avoid UTIs and you will avoid frailty. And with it, like, risk. Both of those things are risk factors for falls, dementia, cognitive decline. I mean, you could prevent so many heinous things that happen that people are scared of. These are the things that scare women. Like, I don't want to end up like my mother or my grandmother. I'm like, you could prevent almost all of it with both of these things.

[B]

Yeah, you. You might. You. I'm sure you get this, too, unless your people are very different than my people. But it's like, I don't want that bad shit to happen to me. But at the same time, I can't believe I actually have to do. Do something. I know this attitude of like. And I'm like, you put a seat belt on every day. You floss, you put on sunscreen.

[C]

Right?

[B]

Like, we do preventative things every day without thinking about it. And so it's like, we could just start incorporating these other things in too.

[C]

No question. And it doesn't need to be such an overwhelming task. I mean, I don't know how you tell your patients to put their estrogen on, but I'm like, put it on your sink, like, next to your toothpaste. Put it on at night before you go to bed or 20 minutes of weightlifting. I mean, it doesn't need to be this whole thing. Get some weights online, have them shipped to your house. You don't have to go pick them up and then find a video on YouTube. It doesn't need to be expensive.

[B]

So easy at this point. Yeah, absolutely. Let's talk quickly about the insanity of no pain medications for IUD placement.

[C]

Yeah. Okay. So this is very interesting, and I do, in some sense, want to defend ob gyns a little bit on this one.

[B]

Defend ob gyns for all of this shit. They didn't create this world.

[C]

People don't know who to blame a lot of times for, like, all of women's health's failings and ob gyns really, I think, take the brunt of it. Like, we have been set up to fail in so many ways with our training with, like, the deeply patriarchal structure with which we are, like, taught and again, again, trained. And it has a lot to do with reimbursement. So the thing that people don't always know is that IUDs reimburse basically nothing. And in general, OB GYN services, especially procedures. Procedures. Actually, I'm going to not pick on urologists, but use them as a counterpoint that, like, urologic procedures that are done in the office on men and their genitalia are reimbursed at almost five to ten times.

[B]

Vasectomies are a nice gig, man. And we use numbing medication and we anesthetize it.

[C]

Yes, exactly. Because the billing justifies the cost of the anesthesia. In women's health, that is not always the case. And you have so many patients to see in the office, and the anesthesia is not always covered by insurance, and the anesthesia or the anesthesia is more expensive than the reimbursement for the IUD itself. I'm not saying anyone's doing this on purpose, but that ends up being, like, insidiously over time, how practices get set up. And then you get taught this, like, patriarchal nonsense that the cervix doesn't have nerve endings, so it's fine. You can just, like, grab it with a tenaculum. And that's not true.

[B]

Right. And then the cognitive dissonance of if a woman does experience pain, that must be a problem with her, because usually it shouldn't be painful 100%.

[C]

And there's plenty of patients for whom it's not painful. I thought my IUDs were, like, the most painful things I've ever experienced.

[B]

Oh, my God. My. My pre baby IUD was very painful. My post baby iud, I'm like, true.

[C]

Everyone says it's so much better, but I took my, like, milliparous, you know, 19 year old sister to get an IUD. I was like, we're gonna pre med you with ibuprofen, all these things. It's gonna hurt, but it's worth it. I do love my iud. Like now that it's in, she felt nothing. So she's like one of those people, she's like, I don't know why you hyped me up for this so much. It didn't hurt. But there's still so many people that have so much pain. I'm one of them. So that's like a big thing is like, it is ridiculous. And it's also, you have to think, you're like, oh, is the paracervical block like the big needle I need to give the block, is it going to take longer and actually hurt more than the IUD itself. So in that sense, like a lot of OB GYNs I think are trying to spare women the pain of the block because the block is almost just as bad as the procedure. Also, like recently, insurance, many insurances have literally stopped paying for IUDs under anesthesia. So.

[B]

Yeah, that's bullshit and a half.

[C]

Yeah, if men got IUDs, it would be, you know, lots of anesthesia.

[B]

Yeah, it'd be. They'd throw super bowl parties and then knock em out. Okay. Women have never heard of urogynecology because first we'd have to admit why urogynecology exists. Tell me more.

[C]

I mean, I do, I feel this is so fun.

[B]

I'm like, I'm like reading you to you and then being like, here's your stage.

[C]

I know if I. This is like narcissist paradise is just being read your own words and then told.

[B]

And then being told like, you're amazing. Please tell me more.

[C]

I really feel this way. I really feel like we would all know what a urogynecologist is if we would just admit to ourselves, like why we need a whole entire field of medicine basically to. I mean not everything we treat, of course is due to childbirth, but a whole lot of it is. I mean, the incontinence and the prolapse. The biggest risk factor, modifiable risk factor for both of those things is having a vaginal delivery, particularly having an operative vaginal delivery. And so when people are like, oh, it happens every day. You're a urogynecologist, what is that? I tell them what I do and they're like, oh my God, I did not know. Like, how do those things happen? Having a baby Makes them happen. Like, oh, my God, I had no idea. I had no idea. So we would have to. Yeah. Admit to ourselves that birth is not a health neutral event. That birth from minor to major almost always causes some type of complication in every single person. Some of them, again, very minor, very worth it. I'm not saying it's not for like.

[B]

Yeah, you're just saying. You're saying pull back the fricking curtain of perfectionism. So what do you see? These Hollywood people, and they're like, bounced back in six weeks and blah, blah. Like, does your brain explode in anger when you see that? Because you're like, dude, they're perpetuating the myth of nothing just happened to this body.

[C]

It's so insane. It really is so insane. And I mean, yeah, stuff happens. Your vagina, while it does bounce back in many ways, will never be the same. And that's okay. And there are people that can help you. And that's it. That's just. It doesn't need to be a thing. It just is what it is. That's life. That's the reality of pushing a watermelon out of a very small hole. And there are things we can do. You just need to know about it so that people don't feel ashamed or alone when it happens. Probably once per clinic, someone says, have you ever seen this before?

[B]

Right. Yeah. Yeah. What do you mean?

[C]

Like this morning? Yeah, because of course I have.

[B]

Let me clutch my pearls. You're my first. Except for I trained for a decade to see you today. Well, yeah, I mean, it's so shameful, right? Because it's like people feel so broken. And I usually. I used to say, like, you know, we're unique because we're on two legs and gravity and our vagina points of the ground. And then somebody sent me a picture of a cow having prolapse and I'm like, okay, four legged animals can get this too.

[C]

Yes, they can. That is true. That's true. People love to tell me about cows with prolapse. Like, did you know when cows and prolapse, you just have to, like, punch it back in? And I'm like, okay, let's not maybe compare women to cows.

[B]

But yeah, it is a. It happens to many, many different mothers. Okay, here we go. Women deserve better than OB and gyne being crushed into one specialty.

[C]

I feel very strongly about this. This should be a podcast unto itself. I feel very strongly that OB and GYN should be two separate specialties. And not because I have, like, an axe to grind against ob. Just because all of women's health cannot be contained into one four year residency, like the surgical and medical management of all of female reproductive biology cannot be four years. It just does not make sense. Obstetrics is now like such an advanced practice. Also, women in the United States are so sick, they have so many conditions before they get pregnant. I mean, the riskiness of pregnancy. And I know there's gonna be people who say like, oh, pregnancy is over medicalized in this country. Like women used to die in childbirth.

[B]

Actually one in eight for the people in the back, natural is one in eight.

[C]

It's so unhinged. I hate when people say stuff like that. I'm like, oh, so what about like, if you can't see and you need glasses that not natural. You would have been eaten by a bear like before glasses exist.

[B]

Yeah, Shoes aren't. I always say shoes aren't natural. What are you gonna do?

[C]

Shoes aren't natural.

[B]

Like air conditioning. But childbirth is natural and death is 1 in 8.

[C]

I know, it's so crazy and there's like so much good public health data that once we started like intervening on things that used to kill women with medical evidence that they started to live like praise. And so obstetrics is like a huge field. It's very, very complicated. And it needs. It's not only its own. I speak from this, from like with a medical, but also an economics perspective. Like, not to jump all around, but like, I do consider myself to be an expert in OB GYN reimbursement and the way that we decide in this country how much money gets allotted to each different procedure and each different like, medical problem is this committee called the RUC Committee, which is appointed by the American Medical association to decide like how many monopoly money relative value units everything gets allotted. And OB GYN only has one representative for all of its specialties, like all of its high risk OB infertility, urogynecology, GYN oncology, and all of like the endometriosis. Surgeons are represented by one person. And many people may not know that when the Social Security act put forth this thing called a budget neutrality clause, which means there's a finite number of dollars that can be spent on all of health care every single year. And you can't really shift them around without like a real act of Congress practically. So OB GYN was like, given this very small sliver in the early 90s and has never been able to overcome that. So OB and GYN are like fighting each other over this really small amount of reimbursements and if they had, like, separate representation from being two different fields of medicine, we would be able to fix a lot of public health problems, like labor and delivery units closing all over the country. Only one in two counties in the United States has a labor and delivery unit, which is so insane. I mean, women. It's just crazy how far women have to travel to deliver a baby. But, like, we can't really fix that problem because of how little they're paid to keep those units open. So anyway, economically, we need to have representation, two separate people on this committee. But also to take all of ob, GYN and be like, there's not enough room in modern medicine for two fields of medicine that deal with women. We're going to have one. And that happened where I did residency at Johns Hopkins over 100 years ago. There was this cat fight basically between the chief of gynecologic surgery and the chief obstetrics and the chief of obstetrics. His name is John Williams. He writes like that. Our major textbook in OB is still named after him. And he didn't want to be called a man midwife anymore. People were making fun of him and being like, you're a man midwife. You're a man midwife. So in order to give himself, like, more legitimacy, he felt surgically, he became the chair and then took over the gyne department. But till this day at Johns Hopkins, fun fact, it's called the gynecology and obstetrics department because that was like, the deal they brokered to put them together is that gynecology still had to be first. Whatever. It was just like a bunch of men, like, fighting over nothing. And they basically decided so that Williams didn't have to be called a man midwife anymore, that OB and GYN were going to be the same field, which is wild. And so then women get this, like, subpar care. We're expected to learn all of obstetrics, then all of gynecology, and all of, like, menopause medicine and all this stuff. It really is a full body condition.

[B]

And all the cancers, uterine cancer, ovarian cancer, breast cancer screenings, cervical cancer screening, vulvar cancer screening, lichen sclerosis expert. And don't forget all of the hormones that happens to 100% of women around age 51.

[C]

And all of the sexual medicine.

[B]

Oh, yeah. Also you're supposed to be taking care of all the sexual medicine.

[C]

Correct. It's nuts. And then women, understandably, are, like, very angry at us. They're like, why? Are like, why aren't you fixing all my problems? It's like, well, first of all, there's only like, at best nine of us per residency per year, and we get split nine different ways into nine different specialties. And there is no, like, fellowship in sexual medicine and there really is no, like, special training in menopause medicine. No one really owns that. OB GYNs aren't walking around going, oh, yeah, I know all about, like, musculoskeletal syndrome of menopause. Like, they have no idea, like, why your shoulder hurts all of a sudden. But it's estrogen driven. But we're not taught that and neither is ortho, so no one knows, right?

[B]

Yeah, totally. I mean, when I. So when I started this journey the 6ish years ago, you know, talking on social media or something, a gynecologist called me out and said, she's just getting into menopause. And it was a fuel under my fire of, excuse me, everybody needs to get into menopause. You guys can't do it. And for anybody to put the burden on ob gyn for hormones is insane. You can't do it. I'm like, we need neurologists, cardiologists, GI people, oncologists, the ortho people, primary care everywhere. Internal medicine everywhere. The endocrinologists. The endocrinologists in my town. Don't see air quotes. Sex hormones.

[C]

Yeah, no, neither do they in Pittsburgh. I don't know any.

[B]

Yeah, but to me, I'm like, listen, Gyne, if you want, if you, you, you need to share the load. And to me, I like, I still

[A]

have a chip on my shoulder.

[B]

I'm like, it was a gynecologist who said, I'm getting into. And I'm like, damn straight I'm getting into. We all need to get into. Okay, here we go. To all the firstborn. This one particularly hit home to all the firstborn daughters. How's your career in healthcare going?

[C]

Are you a firstborn daughter? You have big first daughter energy.

[B]

Do I have big first daughter energy?

[C]

You do.

[B]

My energy is like, don't fuck with me and don't fuck with my tribe.

[C]

Yeah, exactly. I told you at the beginning. I'm the oldest of eight kids. I don't know. My mom's pelvic floor is doing really well, which is shocking. But my youngest brother is only 10 years younger than me, so we're all really close names.

[B]

Holy bananas.

[C]

I know, but my nickname growing up was bossy Jossy. And that is just.

[B]

Yeah, you needed to maintain order.

[C]

I did so, yeah, we're caregivers, but we're also very. We have leadership potential. And I've been tasked with. We're very type A. We're very organized.

[B]

Yeah, I see it. I see it in my firstborn daughter. I'm just like, damn, I'm raising myself. No, I love it. But on the dark side, note of that, I think because of how toxic healthcare is and the burden. Somebody was asking me today about it, and I was like, listen, current healthcare will eat you up until you die or leave from getting sick. And I'm like, I needed to get out before I got sick. Thank God I left healthy. Right. Of, like, health care at this point is fraught with harm.

[C]

Yeah, it's really hard to be a doctor if you don't have good boundaries and, like, happen to work in a place with people who are protecting you or in the positions where they can do that. But nothing is perfect, like, every day. I mean, I have issues with so many things. Insurance, sexism, women's health problems.

[B]

Like, yeah, insurance not covering shit. Okay, here we go. By 20, 54.9 million women will have symptomatic vaginal prolapse. 15% of women will have prolapse surgery in their lifetimes. There are currently 1,000 urogynecologists in the United States.

[C]

Yeah, it's not good. It's pretty dire. There's one urogynecologist for every 100,000 women in the United States.

[B]

Do you know the percentage of urologists who perform prolapse and incontinence surgeries?

[C]

I do not know that number, but

[B]

it's less than 50%.

[C]

It's disturbingly low.

[B]

I mean, I probably 20% or less of urologists. There's 10,000 urologists in the country. There's 1,000 female urologists ballpark in the country.

[C]

Yeah. There has been a study that came out recently where they compared basically procedural counts between, like, urology focused urogyne fellowship fellowships and then gyne focused urogyne fellowships, and the urology focused urogyne fellowships, unsurprisingly, maybe did a lot less prolapse surgery. They did a lot more, like, complex neuromodulation, a lot more neuro urology, a lot more like complex urethral reconstruction, like diverticulums and buccal grafts and that kind of stuff. So it's, I think, decreasing. And I think that's also a big reason. I remember being told. I was very torn between urology and.

[B]

You act like a urologist. I'm like, how did how did the sorting hat put over there?

[C]

It's very interesting that you ask. I was very, very torn. I did my research here in a urology lab, and I never wanted to do ob. I, like, not Pregnancy is not for me. I knew I wanted to urogyne. I asked some urologists, like a female urologist, this woman named Liz Sagan. She was, I think, a pretty legendary female urologist in Pittsburgh. And I was like, what do I do? Do I do go to urology residency or ob GYN residency? And she told me to go to ob GYN residency if I wanted to take care of women. Just because she didn't feel like she got great training in how to take care of women. But she did also say, like, you'll get paid less. You'll have to deal with, like, some misconceptions about your surgical skills, perhaps, like, some other things that I really had to sort of come up against and still sort of try to fight against those misconceptions on online. But, I mean, yeah, it's a tough road to hoe. There's very few. There's not very many of us. And we do the number one surgery that women get over the age of 65 in the United States.

[B]

Prolife. Before it used to be hysterectomy, as the most common surgery is that. Has that changed?

[C]

I believe that hysterectomy still is the most common surgery that women get. And then followed by a C section is the second most common surgery that women get.

[B]

Fair enough. I wasn't thinking about it.

[C]

I know people don't think of it that way, but it's a laparotomy. I mean, it's a big. Women often forget. I'm like, have you had any surgeries before? Do you have any scars in your abdomen? They're like, no. And I look in their chart. I'm like, well, you've had three C sections. And they're like, I didn't think of it that way. But I'm like, I still got to get through those adhesions, right?

[B]

Yeah, yeah, it counts. Okay, here we go. If you come to my. This one. It was also speaking to me. If you come to my office, you'll be leaving with a prescription for vaginal estrogen and pelvic floor physical therapy. Yes, boss. I was just talking to somebody today about that. I'm like, I think it's messed up that people get to the surgeon having tried nothing.

[C]

Having tried nothing.

[B]

And they come to see me and they're like, but I don't want Surgery. I'm like, why are you here?

[C]

Right? They don't know that you're like a surgeon. They just know that you're a woman who sees vaginas. So, yeah, you probably face that too. It's like, oh, they probably ask you to do your. Their pap smears. Which maybe not, but I get asked all the time, like, oh, can you do my pap? I'm like, no, I'm a pelvic surgeon. I can't.

[B]

Yeah, no, I like, I mean, to me, I'm like, I trained at the very tail end of pelvic mesh kits. And then I trained. So half of it was putting pelvic mesh kits in. The second half of my residency was pulling out pelvic mesh kits. And to me, I'm like, dude, first rule of surgery is have a healthy tissue.

[C]

Right?

[B]

Nowhere was it these people needed to be on vaginal estrogen before. Nowhere was it that these people needed to be on vaginal estrogen after you put mesh in the vagina. How much would be prevented if we kept the tissues healthy in the first place instead of let them become a trophic and erode?

[C]

Yeah, that is a really good question. People have done, like, dabbled in that study. We've. They've done that study recently. Like, a pretty good RCT came out about if vaginal estrogen helps outcomes of prolapse surgery. Like if you randomize people. Turns out it actually does not.

[B]

I think it was. But my argument for that was there were very short studies. I'm like, you do that study for five years, you'll see that vaginal estrogen is going to win.

[C]

Yeah. And those are also our post op patients. That. Those are people. Like, that's hugely confounding. Like, these people already have gotten prolapse and have not done well.

[B]

I think even if you get a sling, if you get a mesh sling for incontinence, you better be on vaginal estrogen for the rest of your life. Keep those tissues healthy.

[C]

Yeah, yeah. It's very interesting. I want very much to like 100% agree with that. And I do. But. But being premenopausal when you get a sling is a risk factor for an exposure, not because I think it your tissue. It's because your tissue's almost like too healthy. If this makes sense. The argument that, like the mesh experts make is that the stiffness of the mesh is closer is more similar to like the stiffness of postmenopausal tissue. So that like you. The stress shielding forces that it Sees are like more similar than like stiff mesh on soft, well, estrogenized tissue. And that you actually like, might need to be using a different weight or a different type of sling in a premenopausal patient who is well estrogenized. And probably same thing, like for a post menopausal woman on estrogen, I wouldn't be surprised if we need to come up with a better device. But yeah, it's almost like the atrophy is good for mesh because the mesh is also like they're thin.

[B]

Oh, that's fascinating. That's super. In my experience, the, the sling mesh exposures aren't on vaginal estrogen. It's gotta be there.

[C]

And also they're so rare in general. If like they're put in by someone who knows what they're doing. They're rare. Pretty rare.

[B]

Okay. Being a urogynecologist is a radical feminist act in a society that abandons and discards women after they have given birth. That's badass. You gotta keep writing.

[C]

Thank you. I mean, I feel very strongly about that. I mean, it's true. All the money we spend on research is always on pregnancy. I mean, the NIH spends less than 10% of all of their money on women's health. But of that 10%, 80% of it, so 8 total percent is spent on pregnancy and pregnancy related disease, which leaves 1 to 2% for the rest of a woman's life. Women are only pregnant like 2 to 3% of their lifespan, depending on how many kids you have. So it's just like so insane to, you know, you spend most of your life postpartum. People think like, Postpartum is like six weeks after your baby, but I mean, 2/3 of your life is postpartum. So I do, I think it's a radical feminist act to be like, you know what? We care about women, once they're done having, being a vessel for the state, now that their baby has left their person. Like, we need to still think of women as people.

[B]

The next generation of tax revenue has been created, thank you very much.

[C]

Yeah, exactly. It's just so crazy. And yeah, it does. I mean, Eurogyn, it restores the economy because women are like the biggest drivers of the economy. You get a woman who's incontinent, has prolapse, like out of the house, back to her job, back to her church, back to her community, back to taking care of her kids, back to her sex life. Like all these things that like, are literally tied to the economy, to women's like financial independence, but also the general, like, health of their families. And the things that make economies great, like Uruguayan does, that We. We put women back where they belong intact.

[B]

That. Well, then, I mean, the number one reason for admission to nursing homes is incontinence. And why are we falling? Because we're getting up at night to pee. It's profoundly important.

[C]

Profoundly important. Profound. And we get all these UTIs.

[B]

Oh, God. Yeah. But, you know, it's. You know, Rachel Rubin says it. The best vaginal estrogen will save your life because you can die from uti.

[C]

Look at that breast cancer study that just came out. The women who were on vaginal estrogen versus the women who were not. The women with breast cancer who were on vaginal estrogen lived longer than the ones who were not on it. And I tell my patients the reason for that is probably because they weren't dying of neurosepsis.

[B]

Yeah, totally. Let's talk about the projected deficits of OBGYNs. Are residency spots even filling at this point? I know they're not filling in Texas.

[C]

My understanding is that there definitely has been a shift in the applicant numbers to red states, but that's also across all medical specialties. Any woman and many men who are partnered with women in medicine are not trying to be of reproductive age. In a state where they can't control their body and their reproductive future, ob gyn remains an incredibly competitive and popular specialty. I do think where people apply is gonna shift. But, yes, I do think that residency spots are still filling. It's just that now these programs have to ship their residents to other states to get abortion training. Because you can't be an ob GYN without abortion training. Someone comes in, like, hemorrhaging, and they're 12 weeks and their cervix is dilated, but there's still a heartbeat, but they're bleeding and they have a fever. Like, you don't know how to do an abortion. She's gonna die. Like, what are you even talking about?

[B]

Yeah, it's so ridiculous. You had done one other thing about, like, if legislatures, senators, like, people who made the law, followed a gynecology resident around for 24 hours to actually see what happens in a hospital, see what you're making laws about.

[C]

Yeah, I did. I mean, people don't like to think of it as abortions, but I probably did one abortion per shift when I was a resident just because that is, if you're going to have sex and get pregnant, planned or unplanned, wanted or unwanted, the complication rate Is so high. The miscarriage, threatened miscarriage rate, the bleeding rate, the infection rate is so high. Pregnancy is so complicated. So many things can go wrong. And they do go wrong. All.

[B]

They go wrong all the time. Yeah, that's like, when it goes right, be like, oh, it's a miracle. It's a miracle.

[C]

It's a miracle when it. We. All of us walking around are miracles. Because something went right in, like, the fusion of this sperm and this egg that then grew into a person. Like, yeah.

[B]

And you didn't kill your mom in the process. Good job.

[C]

Correct. We didn't kill our moms. I mean, it's a miracle. But people. Yeah, you just. You would have to see the reality of it. Just, like, got another page. Oh, another lady is down in the er. She's pregnant. She's bleeding, like, again and again and again throughout the whole shift. Your pager just explodes.

[B]

I want to leave women with. Because women are like, okay, we're angry, we're pissed. We want to do something. My advice is always talk to your senators, Write to the f. Talk to the people who control the money. Because being pissed in your kitchen with your friend is. It doesn't change any of this. Would you offer up any other thoughts on action and what to do?

[C]

I really do. Like what you said about following the money. People, like, really don't like to talk about money, but unfortunately, we live in capitalism and money is the only thing that matters. So, yes, follow where money is going to decide, like, if. Whether or not your reproductive rights are being parlayed as some sort of bartering chip for another piece of legislation that people are trying to push through. Obviously, vote like your life depends on it, because it does. But, like, also be educated about reproductive biology and the laws where you live and have a contingency plan. I mean, stock up on abortion pills. I know that, like, there's some. Whether you should or shouldn't do that is, like, you don't want to gobble them all up and then not have them be available for people who need them. But I think at this point, like, we. We do have, you know, a lot of them. And then, I mean, I don't know. This isn't going to be a podcast about, like, the 4B movement, but, like, don't have sex with men who are going to, like, not support your reproductive choice.

[B]

You know, these are things I stay up at night thinking about. I'm like, and maybe this has been my urologist brain, but I'm like, tell me you've thought about this. I can't wait. I better be alive because I need to see how the world's going to change. When we finally get a reliable reversible male birth control, the world will change. I don't know how it's going to change. I just know when 100% of people are involved instead of 50% of people, the world will be different. And I want to be alive to watch it.

[C]

I know. Same. I do too. I always said, I think like the vast majority of the world's problems would go away if every time a man and a woman had sex it was a 50, 50 chance as to who would wind up pregnant. If it was just rolled the dice and it was like either 1, 50, 50 chance someday it might be the man this time might be the woman this time it would fix like all the world's ills, but unfortunately.

[B]

That's awesome. What are you gonna do with your writing? We're gonna do this for a while. You got some books, you got some speaking.

[C]

I mean, I do do a lot of speaking. Obviously the Internet though is not great. Like meta's not doing great. There's a lot of oligarchy men who are in charge of all of our social. I wish there was like a woman owned social media platform.

[B]

Dude, Instagram. Like, I'm like, you can't say body parts. That's why podcasts are so great. Because I can say vulva without being screened.

[C]

No. Yeah, maybe. I mean there's so many great podcasts. You've done such an amazing job. It's like a hard. Anyone with like a mic and an opinion, you know, there's a lot of. Not you. A lot of people have podcasts, so it's like hard to kind of crack in there. But I think if you have something important to say that people gravitate towards that. So, yeah, maybe. I've often thought about maybe writing a book someday. I mean, I'm still very busy clinician. I'm 70% clinical. I take care of a lot of patients. So yeah, I don't know. We're gonna see how social media pans out. I'm working very hard with an incredible group of people from D.C. from McKinsey, lawyers from, from BU and Harvard were really working hard on this like gynecologic surgery reimbursement thing. So I've been throwing like my heart and soul into that at the moment. But yeah, I feel like the path forward will declare itself. Yeah, I mean, I do write things all the time. I write a lot of like jam opinion pieces and have a lot of people who invite me to like you to be. I'm very grateful. Like be heard by their. Their audience and their platform. So we'll see.

[B]

Well, keep writing because it's brilliant and I support you 100%.

[C]

You're so kind. I love everything you say too. It makes me sometimes really laugh out loud.

[B]

I'm good.

[C]

So good.

[B]

That's how you get adults to learn, right? You get an adult to laugh. You got them tremendous.

[C]

I read not to shift around, but yes, humor. I read this amazing article that for a woman to seem both likable and competent, unfortunately the answer to that is humor. If you are funny, people think you're those two things.

[B]

Yeah, yeah, yeah, exactly. Well, I'll keep working on my standup routine.

[C]

Yeah, well, no, you're doing great. Can't wait for the Netflix special.

[B]

I know we're manifesting it for sure. Thanks so much for joining us today.

[C]

Yeah, thank you for having me. Anytime.

[A]

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.

[B]

I am a doctor, but not your

[A]

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 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.