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Foreign.
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Welcome to the you are not broken podcast. I'm your host, Dr. Kelly Casperson, a board certified urologist, thought leader and conversation starter on midlife living, hormones and sexuality. Enjoy the show. Hey, everybody. Welcome back to the you are not broken podcast. I have my good friend Dr. Carrie Cashel. She likes to swear, but it's in a beautiful quasi Australian accent. So welcome to the podcast.
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Thank you for having me, Kelly.
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We're going to talk about a bunch of different things. We're going to talk about the number one killer of Australians in 2026. We're going to talk about testosterone in Australia. We're going to talk about why so many Australians are on DHEA and Americans aren't. And what happens when your body says no thanks in midlife. So welcome. I'm so excited you're here.
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A
Yeah, it's so nice to see you actually chat to you again. It's been too long.
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B
So good. For people who don't know Dr. Cashel's like at least half of the reason, if not more than half the reason, of how I got to Sydney in March of 2025 and now on Instagram, my number one city of followers is Melbourne.
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A
Yeah, I think the Australians absolutely love you. So we. Oh, I was following you then in the menopausy chat group together on WhatsApp, that lovely. That thing that I go in and just suddenly I'm an hour late for work. And then I think you might have said something about wanting to come to Australia and make it so.
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B
Oh, did I manifest you?
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A
Maybe, Maybe. And yeah, I think you definitely have some role in. Yeah, definitely igniting that idea. And then I started to look at a way to bring you to Australia. And of course, the only place to host such a fabulous lineup like yourself and Dr. Louise Newson and Dr. Marie Claire and Dr. Von de Right. And Professor Jashi Kulkarni.
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B
Kulkarni was there. So my favorite. Do tell me if you have a different favorite Sydney, Australia story. This is my favorite. It was an amazing trip. I got to pet a koala butt. It was fantastic. But the night of the Sydney Opera House event, it went off. It was fabulous. It was like such an iconic place and a wonderful event. We're in the car going to dinner the night of the event happened and I'm poo pooing the standing ovation that we got because I'm like, yes, people stand all the time. Time because like, we help them feel seen and it's a very important topic. And I'm kind of like yeah, yeah, yeah. We get standing ovations, like, all the time. It's fine. And somebody said, kelly, you don't understand. Australians don't stand. And the host, she's like, I've been MCing in. In Sydney for 30 years and this is my third standing ovation.
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A
Yeah. So it was huge. Yeah. Australians are not, you know, they're pretty out there. Like, everything's pretty good. Pretty exciting. But prayers. Yeah, you gotta earn it. So to have two and a half thousand women stand up and applaud, that was something I've never. I've never experienced anything like that in an Australian theater before.
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B
No, here the Americans are like, we congratulate people for graduating kindergarten.
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That's true. Yeah, that's true. Actually, I've watched your graduation ceremonies just for leaving school. No, it's not like that in Australia. Yeah, it's big.
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B
Absolutely fantastic. What was your favorite part of that whole event?
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I think just looking out at that audience when you guys were on the stage through the curtain and just seeing all these women just wrapped and just this palpable joy, there was just such an amazing feeling just being able to bring all those women together and know that each of those women was going to go and speak to another hundred women. Like, the ripple effect from an event like that is just mind blowing. So I think that was beautiful. I think the joy and, yeah, the empowerment that you could pulpate.
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B
That's so good. You know, it's so big and then it's so micro at the exact same time, like you said, like, there is. There was a woman there who brought her mother, her older mother, and she's like, afterwards, she was like, kelly, because of you, she finally agrees to go in and get vaginal estrogen. And it's like, well, that's what we do. Like, it's a big macro. Like, to change the culture on a macro level really does mean many, many individual lives are being changed. Yeah.
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A
And I think, you know, the things that were said on that stage are things that we all say day to day in our clinical practice. But to say it to a group of women, not only are you delivering it to this much bigger group of women, this connection that is created when women are sitting together and supporting each other, it just makes. It amplifies the message in ways that you can't really imagine. And that event gives so many women the confidence to go and speak to their. Their doctor and say, I think there's more that we could do for how I'm feeling and how I'm going to be for the next 40 years.
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B
I love it. I mean, Australia is unique worldwide because of the female dose testosterone product that you guys have for prescription. And it's. How long have you guys had this? It's, it's called Androfem. And how long have you guys had Androfen?
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I think I actually haven't checked the dates. I think it's about nearly 10 years. It's been around. It was in Western Australia and not in the rest of Australia for a long time. We've been able to get it in and so we were able to get it into New south Wales from 2020. So I think that's when it went on to our tga, which is the equivalent of the FDA in the States and then. But still, you know, so it's, it's been there for a while. Made in Australia, only country in the world, as you say, that makes it, it's licensed for the treatment of hypoactive sexual desire disorder in women, which is, is a very long way of saying distressing low libido. So you want to, want to have sex. It's not that we're trying to make everybody want to have sex. And we think that probably affects about 1 million Australian women. So there's good data showing that about a third of women aged over 40, up to about 65 experience distressing low libido. So that's about 1 million Australian women. So it's a lot of women and less than 15,000 get a testosterone.
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B
Yeah, I mean that was shocking to me when I went over there and was talking to women of how I would use the word underutilized. Andrephem still is in a nation that's had it for years and years and years. The other big thing I heard a lot of Australian women is the doctors ask them if they're partnered and if they're not partnered, they don't get access to testosterone. And to me that's a big problem.
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A
Yeah, I mean, libido, you know, if we're trying to stick to exactly the licensed indication it is about sexual function. But you and I have had plenty of chats that libido is, is so much more than just a desire to have sex. It's just a desire to be alive and do stuff, you know, and I. And if you're single, you mean even if we just stick to sexual desire, you know, it's absolutely fine if you just want to be able to enjoy sex by yourself. You know, it can be a one person sport. It doesn't have to Be doesn't have to be too. So even if we just stick to sex, like women should be allowed to have pleasure by themselves. And I actually love. That's one of the things. I've got my little clitoris sitting on my desk now. And the conversations that I have with older women, you know, when we're talking about gender urinary syndrome of the menopause or just sexual health, that clitoris and then suddenly I'm going, well, you know, buy yourself a vibrator. You can buy your first vibrator aged 85. That's fine. Just go online. We've got small ones, we've got ones made by women. You know, you've got. I had Lara from Elixir.
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You have an amazing Australian product made by women. Elixir Play. We'll plug them. They're very high end, they're very soft and comfortable to hold. So, yeah, vibrators made by women.
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Yeah. My patients draw hightalk. It's a Sydney woman and she makes it. So you're supporting local business and even if you don't want to buy a vibrator, it's good for. It's good for female economy.
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B
Totally, yeah. Are you surprised that doctors are requiring or asking women if they're partnered in order to give them testosterone?
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Yeah, I would find that really offensive. It's something I have.
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B
Do we ask men if they're partnered to give them Viagra? Is that ever asked?
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No, and we don't ever ask them. As you've said before, like, does your wife want to have sex with you? You know, so. Or would your wife like some vaginal estrogen if you want to have sex with your wife? You know, so we don't have a page of whether you meet these criteria for this low libido for men, which we have, which HSDD is like a 20 question questionnaire to assess are you distressed enough for long enough.
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There was an insurance. I know you guys don't have Adiflibanserin yet, but there's talk. But. So we have that drug for HSDD in America and an insurance company was requiring a woman to fail marriage therapy first before filling this prescription. And we basically went off and we're like, do you require men to fail marriage therapy before you prescribe them Viagra? And if not, then don't do that for the woman.
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A
Yeah, I mean it's. The gender bias, particularly in sexual health, is shocking. We have nine testosterone products on the PBS for men and we have none for women.
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B
So let's talk about that because we were here to address something that could be exciting explain to the world because we're not, sadly, not all Australians. But. So your, your PBS is basically like America's Medicare.
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Yeah.
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So it's basically like what, there's a list of medications that the government will cover?
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Yeah, they cover, they cover. They come to an arrangement with the drug company and then they cover the gap. And so a patient, if they get a PBS drug, the most they'll pay is $31, which is about US$18 a month.
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B
Nice. So men have nine testosterone products on your PBS and although Australia has a female dose testosterone product, it's not covered by the PBS. So it's much more expensive.
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Correct. Over $100 per tube.
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Over $100. Does anybody give women the male dose? Do you guys, does that happen in Australia?
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Yeah, well, it doesn't happen a lot because if you look at how many testosterone, female testosterone prescriptions are used, there's not a lot of male testosterone products used for women. But yeah, we do for cost reasons. So we can use, test it on, but it's not as good.
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So what are you doing right now that's timely in petitioning the PBS to cover testosterone? How's that going? What's the plan?
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Yeah, so we've, we decided we would show that testosterone for women on the PBS actually matters to Australian women because there's, you know, everybody's talking in their own groups and complaining about the cost. But that information has to get to the higher level so you can make the decision. So as a result of our menopause inquiry last year, the government waived the huge application fee that companies have to pay to get, to apply to get onto the PBS with no guarantee that they're going to get on. So they waived that for the companies that make 2 of our body identical hormones, Estrogel and Prometrium, which is the estradiol gel and the micronized progesterone. So that got waived. So that was great. And they're now on our PBS. So our standard estrogen and progesterone HRT is now cost women on average about 16 Australian dollars a month, which is US$10 a month, which is awesome. And they also waived the fee for another big company who makes a couple of the combined oral contraceptive pills. So we know that they can do that. So we are petitioning the government to waive the fee because our androfen product is made by quite a small pharmaceutical company and these fees are usually prohibitive and that's why a lot of drugs don't even a lot of companies don't even apply, so. So we want the government to waive the fee and then we want them to encourage the committee who makes the decision about what drugs get listed to really consider this as an important drug. So really using their discretionary influence and power to make the process to make it happen. Because they can. This is something they can actually do. The drug's made, the drug is licensed. It just needs to be affordable. So that's really. Yeah. And that's something that the government can do. So we've petitioned. So we've sent this petition now, which is nearly 11,000 signatures, thanks to people like you sharing it.
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B
Don't whisper. It's a podcast. Thank you to people like Heaven Audio. This is a real good story about Bronx and his dad, Ryan.
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Real United Airlines customers.
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B
We were returning home and one of the flight attendants asked Bronx if he wanted to see the flight deck and.
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Meet Kath and Andrew.
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I got to sit in the driver's seat. I grew up in an aviation family and seeing Bronx kind of reminded me of myself when I was that age. That's Andrew, a real United pilot. These small interactions can shape a kid's future. It felt like I was the captain. Allowing my son to see the flight deck will stick with us forever. That's how good leads the way.
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A
So thanks to people like Kelly for sharing it. And yeah, so the government now are interested. They know the petition exists. We're now lobbying local. We're getting people to lobby their local MPs to really add that political voice in Canberra, which is where our government sits, to say that this is a really great opportunity for Australia to be a world leader in sexual health equity. We would be then the only country with testosterone product made for women, licensed for women and affordable for women. So that would be, you know, Australians are quite patriotic.
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B
Would like that is Viagra, etc on the pbs.
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It is not. No. It is only cheap for our veterans. So it is still expensive for men, but it's not as expensive.
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B
But testosterone's on the PBS for men, correct?
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Correct.
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And we're going to put the link in the show notes. Can anybody sign this petition?
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Well, I think if you feel that Australian women deserve it, I think you can sign. Yeah, absolutely.
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B
Yeah, I love that. Yeah. I actually saw the paperwork of the reason why New Zealand and this is public. I'm allowed to say this. I saw the paperwork of why New Zealand turned down their PBS equivalent for covering testosterone because now they have Andr as well. And one of their reasons is not everybody would want this product, so we're not going to cover this product. And I'm like, that's literally true of any medication. Like, should we not approve a seizure medication? Because not everybody's going to need treatment for seizure medications. Like, the reasons for turning it down are laughable. When you can actually read it, you're like, are you effing with me?
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Like, what other drugs? I mean, there's very few drugs that might help a third of the female population. It's basically hormones.
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It'll be interesting to see when we get a testosterone in America what it's going to be licensed for, because I think. I think low libido is problematic, number one, because doctors are freaking asking women if their partner has access to get this or not. And it's like sex is already so stigmatized that I think it's a bummer indication. Even though, yes, it does help libido, and we have studies for that. But it's like the softer things that are hard to measure. Not that libido is not hard, but, like, one of the biggest. I always joke, like, women don't come back. And they're like, testosterone only helps me with libido. It's a brain neurochemical. I feel more like myself is absolutely huge. You'll never get an indication for that. But it helps for more than just libido.
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And that is exactly it. And it doesn't work for everybody, for libido, and it doesn't work for everybody, full stop. But, you know, for. I would say it's a third of women, it's a game changer. A third of women icing them on the cake. And a third of women just go, nah, after six months, I am no different. But we do have, like, we have a randomized controlled trial showing that it improves verbal recall. So. And that's that word finding difficulty, you know, and that's what probably the thing I noticed the most for myself. And that's what women really complain about who've had surgical menopause. So I presented at meetings where women have had their ovaries removed before the time of natural menopause. Some of them have managed to get estrogen and progesterone, not all of them. And none of them were on testosterone. And the one thing they all complained about was being able to find their words.
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B
Yeah, what's the name for that one thing? Yeah, like that thing. Louise Newsom's clinic just published a paper looking at testosterone for mood energy being treated for, like, depression. It works in the brain we have dementia studies for men. We don't have any for women that I've seen, because it's just nobody thinks that testosterone is even in female bodies. But I'm like, brains are brains. And what struck me that when I was in Australia, I read. I don't know where I was where I read this in Australia. And then I asked several people, like, is this true that in 2026, dementia is going to be the number one killer of Australians?
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A
I think it already is. This year it's surpassed heart disease. So, no, it is already our main killer. And there is a study that shows for women at high risk of dementia, the APOE 4 carriers, that low testosterone is associated with increased rate of dementia.
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B
Same with estrogen for the apoes.
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Yeah. So there's data there for low testosterone. And so we've got data showing that low testosterone in women is associated with heart disease, it's associated with osteoporosis and an increased risk of dementia. And these are the main causes of death and disability in women. So I think we can do more research. We can. We can measure bone density. That's another thing that is easy to do on testosterone, dude.
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B
When I was in Australia, you know, we think it's so awful that our screening for osteoporosis in the US is 65, though I was in Australia, and they're like, it's 70 here. And I'm like, good Lord, can you call it screening at that point or just diagnosing osteoporosis?
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A
Well, what you've done is you've made sure you've diagnosed the osteopenia or the osteoporosis at a time when most doctors won't use it, hormone replacement therapy, or mht. So the only drug you're going to use is. Well, most. The only drug most people will use is a specific osteoporosis drug. You have to wonder who decided on 75 years after 65, when we have guidelines in Australia to use hormones for osteoporosis up to the age of 65.
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B
Interesting. Very interesting. I mean, that's the. What. That's one of a big, like, talk about splitting hairs, first of all. But, like, in America, estrogen is FDA approved for the prevention of osteoporosis. So people kind of get all bunchy about like, yeah, but we can't use it to treat. But if you get a DEXA that says one, you know, left hip has osteoporosis, why can't you protect the rest of your bones with estrogen? Nobody ever seems to think of that logic. And then, number two, in Australia and the uk, it's actually indicated for treatment of osteoporosis. And then people will be like, yeah, but the osteoporosis drugs work better. And I'm like, yeah, but we actually have data that says both of them together work better than either alone. We're getting, like, too focused on, like, that. We don't have an indication for it. Instead of thinking like, estrogen will always have a benefit on bones.
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A
I love. We've got a brilliant professor in Australia who is. Her osteoporosis and menopause is her big area. And she describes estrogen as nature's gift to bones. And there just isn't something. I just love that. And it's true, you know, and also because it's supporting everything around the bone. So our bone drugs work on our bones, but they're doing nothing for our tendons, our ligaments, our muscle, our hearts, our brains. But, you know, so we've got the whole musculoskeletal systems benefiting from hormones.
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B
Dude, back up for a second and tell us how you got into menopause, because you're basically the. I'll make her blush if I say the one of the menopause gurus in Australia. Everybody goes to you. How'd that happen?
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Testosterone.
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B
Testosterone turned you into a menopause expert. Tell me everything. That's a good story. I'm surprised I don't know it.
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A
Yeah. So that's. And that's really why I am particularly passionate about the third female sex hormone, or maybe we should call it the first one, because it's the one that converts to estrogen.
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In my new book, Testosterone Comes First.
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I like it.
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B
Like, I'm sick of. I'm sick of estrogen being like. Which we have less of than testosterone. Sick of it being the female hormone because it's technically incorrect.
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A
Exactly. It's just too shiny. Let's bring testosterone in. Solid and supportive. Yeah. So about four years ago, lovely patient came in. I've obviously not been arrogant and paternalistic enough because she came in to ask me for testosterone and I said, I have. That's not a female hormone. Don't be ridiculous. And she said, yes, it is.
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B
You had Androfem available in Australia. A woman came in asking for Androfem and you said, no.
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A
Yeah, I said, I have no idea how to prescribe it. And she said, well, I'm on it, and it's absolutely amazing. It has changed my life and you need to know how to prescribe it so that you can change other women's lives.
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B
She was like the fairy godmother.
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A
She was my patient zero. And she's awesome, Jules. So she's a. She's a trained nurse and, like, I work in a village, so I know everybody, so I'm, you know, I'm connected to a lot of my patients. So I did the course that she told me about, which was by some random GP in the uk, Louise Newson or something. So, yes, I did Louise's confidence in the menopause course and actually listening to her podcast, my brain just exploded each time. I'm like, oh, my God, that's. And I'd be going into work the next day and phoning five patients and saying, you don't need to be on all of these antipsychotics and antidepressants and, you know, really. And from that one interaction, you know, I've just then been on this learning journey into menopause. So testosterone was the. Was the window and I've always prescribed it. I've always prescribed hormones. You know, I had some pretty good education as a GP trainee. I had maybe two lectures or two to two tutorials on hormones. So, yeah, I was very well educated compared to other. Still shocking. And. But that really then changed. Just look at hormones as sort of the central to health and then to use that as a framework and then you can see how it impacts. You know, I look after teenagers, I look after women in their 90s. So just really seeing it as a way of understanding how female health is different to male health. So, yes, so that was. So. And since then, all I do is read menopause stuff. And then I started to lobby, to try and get. I wanted to get progesterone onto the pbs. So as a. As a result of making contact. Contact with people, at that point, I got connected into our Australian menopausy and got involved in the Senate inquiry and presented at that. And then, you know, really tried to make some from. I bet these are the things I think you guys can do. And I was really excited because actually, the things I asked them to do, they. They did. I like to think that was me. It wasn't. It was. There was hundreds of submissions, but they did some pretty cool stuff out of that. They still haven't addressed some of the big things, like really poor education in menopause. That's huge. And, yeah, so since then, I've just connected. So Louise. And then I got Louise to come and present at a event in 2023, just locally. And that really started, made me think I could do these bigger things. And then we started our Healthy hormones community, which is our online menopause community of clinicians in Australia. We have some Americans. We don't have any Canadians, and we've got people from Europe. So we've got this community of clinicians all talking about menopause and what they do and how they think we do it better. And we've got a community for the general public, for women who are struggling to access care and who are not sure what they should do when X, Y and Z happens. So really trying to provide that reliable information because there's so much misinformation out there.
- [23:41]
B
This episode is brought to you by Progressive Insurance. Do you ever find yourself playing the budgeting game? Well, with the name your price tool.
- [23:49]
A
From Progressive, you can find options that.
- [23:51]
B
Fit your budget and potentially lower your bills. Try it@progressive.com Progressive Casualty Insurance Company and affiliates Price and coverage match limited by state law. Not available in all states. Nice. So Healthy hormones has two arms, basically, like a clinician support arm and then a lay population support arm, Correct?
- [24:15]
A
Yeah.
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B
Nice. And tell me what was. So after the. After the Sydney Opera House, was it the next day we did the menopause course. She ran us ragged, but we were there for it all. And that had what, 300 people at it?
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A
Yeah, 300 people came and I think 500 people online.
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B
500 people online. This was in Sydney. The best thing about it is, compared to an American conference, you guys actually had, like, nice espresso makers. Like, I literally probably had three cappuccinos.
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A
No, that was key. That was the thing that we spent the most time organizing, was making sure there was decent coffee and. And decent food. Emma, my partner, Emma Harvey, is very passionate about good coffee and good food.
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B
A step above an American conference as far as the coffee goes. And in Australia, they don't f around with paper cups for coffee. You have coffee in a nice mug with a dish saucer, and it's very fancy feeling and I'm obsessed about it.
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A
But it was great. Yeah, that conference was amazing. We had such a. The feedback was phenomenal.
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B
What was your takeaway like after it happened? Were people happy with it? Do they want more? Like, how did you guys feel when that conference was done?
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A
Well, apart from overwhelming relief because we were broken after several days of events. Yeah, just like, when can we do this again? Because people just said, that's the kind of conference I want to go to. Like, we weren't being talked down to even just the setup, the way we had the stage and the audience, it was much more interactive than a lot of conferences.
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B
I'm completely biased because I was on stage. But, like, you had Mary, Dr. Mary Claire Haver, you had Lise Newsom, you had Dr. Vonda Wright. You had me. Like, these are people who know how to speak, right? And it's like, dude, now that once you've had that, when you go to other medical conferences or scientific conferences, if they're not keeping you, like, active and engaged, social media has wrecked bad speakers for us. You know, all of the speakers, like, are telling you their why of, like, why they're passionate about this. And, like, everybody else is just, like, being lifted up to be like, we can all do this. That was my takeaway, is, like, everybody was, like, in it for the right reason.
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A
Yeah, that's such a good point. And I hadn't actually thought of it like that because I realized when you go, like, an event like that, you hear what people are saying because they know how to speak. Whereas so much of our medical education is delivered or has been delivered in this dry, flat way. No humor. So you're not open. So as soon as you've engaged your audience, you've brought them in, as you say, you've told them your why, and there's some humor, there's some compassion, there's some real human energy in it, then everybody opens up and they can listen and learn. And you remind, I think, really, all of those lectures. I don't want to call them lectures. They weren't. They were, I don't know. Manifestos.
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B
Yeah, yeah. Like storytelling manifestos.
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A
So, like, people, really, that was. That's why we do medicine or why we take care of patients, is to make them feel better and to live better lives. That's why we do it. So I think that's really. It was. It's a reminder of why we're in our profession.
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B
It's very different than being like. I mean, it's good to have guidelines, don't get me wrong. But, like, if you're sitting there just going through this is what the current guidelines are. You lose perspective of, like, what are we actually trying to do? We're. We're trying to help people live productive, fruitful, healthy lives.
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A
They're maps, aren't they? You know, and you're gonna miss all of the amazing stuff that's off to the side or on new routes. Like, we. Like, this is like, we know so little. We have to keep evolving. Like, we're so, like, there's so much we don't know.
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B
Yeah, totally. I mean, I remember Dr. Lise Newsom on stage and she was telling a story about a woman, and her talk was like, the evolution of this woman trying to get care. And, like, at some point I was like, oh, God, I see where this story's going and it's not gonna end well. And she actually told a absolutely heartbreaking story about a woman not being treated optimally for menopause and ending up losing her life over it. And it's like, if that didn't hook every single person in there to be like, I've gotta watch out for these women and help them, because it can be dire. I think I had tears in the back row.
- [28:35]
A
Yeah, No, I think that's. And that is really tragic, I have to say. I think I'm really lucky that I haven't lost any patients. I look, because I've been in the same general practice now for 12 years. I see the patients that I missed, you know, in the first seven years of that job. And, you know, and I have got a patient who did try and take her life. Thankfully, she wasn't successful and it was a menopausal depression. You know, she's living her best life on hrt. So I think. I think it's terrifying, you know, to look back and a lot of us have a lot of guilt. No. Women that probably, although they haven't died, they lost. I have several patients who lost years of their lives, and I put them on hormone therapy and, you know, within a few months, they were back to themselves as much as they can. Because, you know, there's obviously a lot happens when you have six to 10 years of having, you know, a poorly treated psychiatric illness that's actually a hormonal psychiatric illness. So I think there's. There are so many women out there where nobody has thought about hormones as part of their treatment. And it can be. I've never seen medicine that's so transformative.
- [29:43]
B
Yeah. I mean, going back to, like, a woman getting brave enough to ask for testosterone and then the physician asking them, are you sexually active with a partner? And declining her hormone that her ovaries naturally make because she doesn't have a partner. Like, it reeks so badly of, I won't give you a checking account or a mortgage because it's the 1950s because you don't have a man involved in your life. Like, it reeks of that. And it really bothers me.
- [30:06]
A
Yeah. I think you couldn't get a Mortgage in Northern Ireland until the 80s without a husband, actually. It's horrific.
- [30:13]
B
Credit card in America was 80s.
- [30:16]
A
It's just shocking. We still have that in medicine, where we are, right?
- [30:22]
B
We still have that in medicine. Like, you can't get this without a man. It's absolutely insane. My mom, and this is public. It was on my podcast. My mom, when she was a younger woman, was declined. She was married and declined birth control because the physician knew her last name and that the family was Catholic.
- [30:40]
A
Awesome.
- [30:41]
B
Exactly. I'm like, that was the late 70s. And now we're like, that's ridiculous. And it's like, no, no, no, we're still doing that. We're still doing that with hormones our ovaries make. We're not letting a woman replace them unless she has a partner in her life.
- [30:53]
A
With testosterone, though. I actually saw a letter this week of a woman who'd had her ovaries removed, I think before the time of natural menopause. And so it's quite an old letter. And she was sent home with a testosterone. Testosterone pellet, you know, back. So this would have been in the 90s, so in Australia, and I don't know whether it was similar in the States, but a lot of gynecologists, when they did remove ovaries, sent their patients home with estrogen and testosterone implants. They're like, they knew. This knowledge is not new.
- [31:21]
B
We lost the medicine.
- [31:23]
A
I know.
- [31:23]
B
That's what I always joke about. You're like, I don't. I don't know about. You just want everybody on hormones. And I'm like, Listen, in America, 5% of women are on hormones. In the 1990s, 40% of women were on hormones. Like, I'm just trying to get back to the 90s on that one.
- [31:35]
A
Yeah, totally. Like, that was. I always say that was a great decade for music, and it was a great decade for hormones. I'm sure the two are connected.
- [31:43]
B
Let's shift gears and talk about mast cells, because I need to be educated on mast cells, which means everybody else needs to be educated on mast cells. So tell me about your CFS and how you kind of got into this.
- [31:58]
A
So this is. This is recent. So this is really, like, the epiphany that has followed hormones. I just love the curiosity that I find in my job again. And that's. Yeah. I just say to anybody who's in medicine or looking after, just keep. Stay curious. Because there is so much cool. So much cool stuff out there. So. Yeah. So mast cells is part of your fault. It was a podcast, I'm pretty sure that you did with one of the Dr. Goldstein's.
- [32:25]
B
Ah, yeah, okay. Yeah. My podcast with Andrew Goldstein.
- [32:28]
A
Yeah. And he was talking about pelvic pain and vestibular pain and vulvodynia and how some of those women were hypermob. And it was the hypermobile bit that I went, oh. And I think. I'm not sure if he mentioned mast cells at that point. I can't remember.
- [32:42]
B
He was doing work and researching at that time, so I think he did. But that's probably a year ago on the podcast now, at least.
- [32:49]
A
Yeah, so that was sort of there. And then I was chatting to, oh, she doesn't mind my hairdresser, who's hypermobile. And I was going, I think this is part of your menopause thing, that you're hypermobile. And there's something there with hypermobility and linking to other conditions. And I've just slowly been working my way through mainly podcasts. And then somebody in the menopausal group, Samina Raymond, linked to. Is it Samina? Gyno girl? Is she gyno girl?
- [33:19]
B
Yep. Gyno girl is Dr. Samina.
- [33:22]
A
So she. She did a brilliant podcast with Dr. Tanya Dempsey, who I think is one of the world's gurus on mast cells. And since then, I've been just working my way through all of these podcasts. So mast cells are one of our immune cells, and they exist in every tissue in our body, and they're really like our first line of defense to invaders. So they should be there trying to fight off viruses, bacteria, and they also react to toxins and probably react to toxic people. So they're there. And if. So if you think of, like, scratching your skin, it gets itchy. But we've got them in our brain, we've got them in our gut, we've got them in our uterus, we've got them in our limbs. So there's between hypermobility, mast cells, overacting, trauma in early life. So I have this group of patients who have lucked out, and I say that heavily, sarcastically, in terms of they've got a history of pmdd, probably adhd, they've got endometriosis or adenomyosis or at least really heavy periods, they've got allergies, and then they hit perimenopause, and it is a train wreck. So they're happy with my new diagnosis, cfs, which is clusterfuck syndrome. And that is literally. So CFS would traditionally being chronic fatigue syndrome, and actually A lot of those women would have been diagnosed or are diagnosed with chronic fatigue syndrome. And it's really where everything. So you've got hormonal chaos of perimenopause, and that is another big sort of dysregulating effect on this immune system that is already hypervigilant, a nervous system that is hypervigilant. So you hit perimenopause, and you get the brain fog. You're starting to get allergies, itchy skin. You're developing autoimmune disease. We're getting our Hashimoto's thyroid issues. We're getting women developing inflammatory bowel disease like Crohn's. And they're in the mast cells in the brain and the nervous system when the hormones go off, that really can cause some quite significant mood changes. And I do wonder if the women that really struggle in perimenopause have got a lot of this mast cell activation going on, and a lot of them were ballerinas and gymnasts in their childhood. So the hypermobility is a big. Is a big marker. So really interesting. So it's a whole other area of medicine where you've got doctors pushing the boundaries, talking to each other from different specialties, cardiology, psychiatry, immunology, going, hang on a second. There's something here. And it largely affects women. So I think it's like another. It's the master cell posse version of the menopause and another really exciting area of female health that can help us understand what's going on.
- [36:11]
B
So is it a clinical diagnosis? Are you running tests to check for inflammation or mast cell activation? If. If there's a physician who's listening, who's like, how do I even know if this is happening? Like, what. What advice would you say for, like, picking up on these people? And then we'll go into, like, treatment options.
- [36:28]
A
So I think to pick it up, you really, again, like menopause, you need to be listening to symptoms. And there are sy. I don't think there's an agreed symptom score sheet for mast cell activation. There's mast cell activation syndrome as well. But a lot of people probably don't meet the full criteria. And the only easily accessible blood test that we would have would be a blood called Tryptase. But it requires special conditions to take it, and it's not always positive. I think it's only positive in a certain percentage of people. So there are people in the States who know far much more. Like, I'm really on the beginning of this journey. So I'm not setting myself up in any way as somebody that knows much about it. It's just I'm starting to explore it.
- [37:09]
B
Next year, Sydney Opera House will be Mast cell activation syndrome. Because you'll be the Australian expert by then.
- [37:14]
A
I'm certainly interested. There's some great people in Australia already who've done quite a lot of work in this and who've connected to Americans. So the blood, blood tests again, are not that useful. Just like perimenopause, a lot of the chemicals that are probably changing are not easily accessible and these are things that are rapidly changing in your bloodstream and in your urine. So probably do require, you know, sort of these longer tests and, you know, really understanding. And I think it's at the minute in Australia we don't have easy access to testing. I think in the States you've got quite a lot of mast cell experts who know what they're, what they're on about.
- [37:47]
B
So you have a woman, you're like, maybe we've got some mast cell stuff going on here. What do you advise her to do as far as like, lifestyle changes to try to mellow this out? And then what can we try as far as like immunomodulators, anti inflammatory, what's the role of hormones? How do you start to try to help these people?
- [38:06]
A
Again, a lot of it isn't rocket science. It's very much what we would say to our perimenopause and menopause patients is always going back to those beautiful pillars of health. So you want to eat a real food diet. So probably the rise of ultra processed foods is one of the reasons why we are seeing so many more people with allergies and possibly adhd because we're.
- [38:27]
B
Putting fake stuff in and our body's reacting to it and then it builds up to a point over time that it's going to start looking like irritable bowel syndrome or arthritis or gut issues, skin issues.
- [38:39]
A
Yeah. So I would say like ultra processed food is another, like, you know, it's another toxin. So it's just, you know, and over time your body's like, that's not what I want to eat, you know, so, so it's reactant, so ultra processed food. So we're trying to get back to real, real food diet. For people who are mast cell activated, it is a good idea to look at a low histamine diet because once you're on the real foods, there probably are foods that are more triggering than others. There's things like avocados, kiwis, tomatoes and leftovers. Reheated. Left leftovers. For all of us who work in busy lives who like to reheat, it really increases the histamine content of food.
- [39:13]
B
Really?
- [39:14]
A
Yeah. So that's, that's an interesting one.
- [39:17]
B
This sucks. Are you telling me that. That we have to create fresh food every day? Like that's a huge burden on people?
- [39:22]
A
Yeah. You could have a salad.
- [39:25]
B
Yeah. You're like, sorry, sorry. That's what we did for all of evolution, Kelly. Okay, got it.
- [39:30]
A
Yeah. Yeah. So we didn't have fridges or freezers or microwaves. So a lot of it is just going back to basics. And you need to have a good night's sleep. Again, not rocket science. You need to move. So sitting still is not good for you because your muscle obviously produces a lot of anti inflammatory chemicals. So weightlifting. And Tanya Dempsey, I didn't realize, is a professional. I don't know if she's a professional weightlifter, but she's certainly a serious weightlifter.
- [39:54]
B
Is she? Your arms show off that you're a serious weightlifter. Sorry, audio only podcast people. Carrie's got envy. This woman wears tank tops proudly.
- [40:04]
A
Yeah, that's. It's the only good bit of me left. Your arms, like just arms. The rest of me is like a blob.
- [40:14]
B
So what about, what about like antihistamines? People talk about Benadryl, which like Benadryl is like a bad thing to do, but now people are like, no Benadryl. Cause it's antihistamine. What are people doing in. In addition to kind of tone down the mast cell activation?
- [40:29]
A
So one other really important thing in terms it's not drug is like looking at heart rate variability, training breath work, breathing through your nose. So these are things that are again excellent for perimenopause and menopause. So nasal breathing and controlled breathing is a way of controlling your nervous system, which is a big part of mast cell. So really underused breathe through your nose. So drug wise, you can use antihistamines and then we've got two types of antihistamines. We've got H1 blockers and we've got H2 blockers. So H1 blockers are the drugs like loratadine or fexofenadine. So these are our traditional antihistamines people would use for hay fever or an itch. You try one at a time. So you just do one and maybe try it for a week and see if it makes a difference. And if it makes a difference, then you could add on what's called an H2 blocker. And those traditionally would be ones that we use to suppress acid secretion like famotidine. I can't remember what famotidine is called in the States. Pepcid. So then you can add that on top and this combination of those two antihistamines can make a big difference for people. And then you can add in some supplements. So vitamin C, which is obviously just supporting that real food diet. Magnesium can help people, making sure your vitamin D is optimized. Again, these are all the things we do for perimenopause and zinc. A lot of things are deplete in our soil because we over farm. So again, these are all things we would have just gotten naturally. And there's specific supplements that seem to act like mast cell stabilizers. There's luteolin and quercetin, which again people can find, I think ludiolan, particularly people find really helpful. But you have to find the right dose. And that's supplement. Yeah. So you can buy that.
- [42:10]
B
Do you have like a. Is there a patient story that comes to mind that you've had success with as far as like catching the mast cells and having their quality of life be better now?
- [42:19]
A
Yeah, so I've got some young patients who are really, who really come with all the things. And so they've got pmdd, you know, which is an early marker of that. You're going to have a bad perimenopause, urticaria and heavy periods and starting them on the H1 blocker. I've used fexofenadine and then adding in famotidine on top and suddenly their mood is better and calmer across the month, you know, And I do use hormones as well for pmdd, but the. It's just not enough. So hormones are part of the package, but adding in the antihistamine as well has been a game changer. Urticaria is gone. You know, that itchy skin, just feeling uncomfortable in yourself. And the gut symptoms will settle as well.
- [43:03]
B
I mean, I think the big thing for people to hear. And I just finished Dr. Elizabeth Komen's it's all in Her Head book. So I'm like acutely sensitive to this right now. But. But these women are labeled as crazy because they've got everything wrong with them. The tests all come back, you know, air quotes, normal. And we're like, dude, they're just complaining of everything. They're just like complainy people. And to be like, you know, I listen to a podcast I think it's like the Mass Cell podcast or something like that. Is that. That's one of the big ones.
- [43:30]
A
Mail matters.
- [43:31]
B
Yeah, Mass cell matters. I was listening to an episode with the Expert and I'm like, what if this is not all in her Head? These are like literally inflammatory cells that are creating all of this. And it's just this, like, you know, what we said is like, you gotta stay curious and not just assume. And again, for anybody who is under a rock and hasn't heard of Dr. Elizabeth Komen's book All in Her Head, read it. It basically says, like, we've gotta be real careful that we're not gaslighting women because we have such a strong culture of saying biologic things are psychological. Like we have centuries of historical context that that's what we do to women. And so for this is like, oh my God, are we unroofing a biological reason for yet another thing? We are just saying women are crazy or overreactive or super sensitive or. You know how we're dismissing this and be like, no, no, this could be like a dysregulated nervous system inflammatory issue.
- [44:30]
A
Yeah. And we know that. So we know that people who have these adverse childhood events have a much higher incidence of chronic disease in later life. So this is what connects those things. That early life trauma in a genetically vulnerable person and trauma, as I said, can be so many different things. But we've activated a nervous system, we've activated an immune system to be on high alert all the time. And that chronic low grade inflammation drives disease, it drives cancer, it drives obesity, you know, and it drives a lot of mental health.
- [45:01]
B
It's like the how behind the knowing that we already have.
- [45:06]
A
Yeah. So it really makes sense. And we need to be intervening so much earlier. You know, these teenage girls that I see who all. I think this has really increased and it's increased post Covid for whatever, for probably a multitude of reasons. But we need to be looking after this, this population, our younger population, so that they. We don't have 30 years until finally it's a train wreck at perimenopause. I think there's things that we could do and it is largely women. I think the hormones coming in at puberty are the first thing that sets this off. So that's why women are hugely overrepresented in this clusterfuck syndrome. Men are affected, but not in the same way. And endometriosis probably as a huge. Probably sits in this, this, in this syndrome somewhere. So endometriosis covered in mast cells. And this is a. And this is something we think. And we do think endometriosis is on the rise as well.
- [45:59]
B
Very interesting. God, how it all, like, ties together. Of like, you heard Andrew, Dr. Andrew Goldstein, on my podcast, you got, as a compliment, obsessed about this topic. And, like, the amount of women you're now helping in your town because of that and, like, how this just continues, like, that's just the coolest thing ever.
- [46:18]
A
And I think that's the thing that's just. If you. But if you don't, if you're not curious, are you ever going to ask the questions?
- [46:24]
B
Current medical is like, you need the right code, you need the right diagnosis, you need to write the correct test. Like, none of that is curiosity.
- [46:32]
A
Yeah. I think we traumatize. I think we traumatize our doctors in training. You know, it's like, it's hard. And I think when you're traumatized, your curiosity dies. I think it took a long time for mine to come back and go, actually, you know, I know enough that I can start to. To look outside of my little box.
- [46:48]
B
Yeah. And then it keeps. And then, like, learning's fun again. Like, we went to medical school because we like to learn, you know, and like, my story is like, seven years in, I was bored at the seven year itch being like, what the f. Am I doing? I'm saying the same thing over and over. What did I do all this training for? Like, I know the day that my curiosity came back, Right. Like, I had a patient that brought my curiosity back. And now that's just like. Like, you know, put me on the Sydney Opera House stage, apparently.
- [47:16]
A
Yeah, that's it. That's where curiosity gets you.
- [47:18]
B
That's what happened. One more question on the Mass syndrome. I was listening to the podcast, and she was talking about women who are on SSRIs because we know God, in America, it's like 40% of midlife women are on SSRIs now being. Being medicated for things that SSRIs aren't the best things for, like, menopause. But she says women who have trouble getting off of the SSRIs, they just can't. Can't get off of these things. And they have to do, like, the slow wean. She's like, consider mast cell activation syndrome because the SSRIs are actually, like, tamping down the mast cells. And every time they try to get off the SSRIs, they have a flare. And that's why they react so poorly to trying to get off these meds. Talk to me about that.
- [48:00]
A
Yeah, so that is again. And I've got a couple of patients in that group who had the worst menopause ever and were missed and went on to antidepressants. And it's taking years to come off. And it is trying to take. And trying to use the antihistamines alongside that is another way of doing it. But ultimately, I have found that you just have to do this extremely slow taper. And our drugs are not made. Antidepressant drugs are not made to be tapered. You know, there's one. I think maybe Sweden has got a tapering. You know, you can get tapering drugs, but we have got a program out of the University of Queensland in Australia which has tapering protocols for multiple antidepressants and teaching telling you how to do it with your patient, because so many patients will, you know, you'll tell them just to go to alternate days and then stop. And people who are mast cell activated because the SSRI seems to have an antihistamine effect, they just can't do it. So we have to go really, really slowly and supplement them with other things that can help their mast cells, but very difficult.
- [49:01]
B
I love that. I mean, I, like, I literally, I'm like. I remember I was walking, listening to this podcast episode and being like, what? And realizing, like, how much we don't know. But super exciting for people to start thinking about stuff like this, especially when we're like, you know, SSRIs are associated independently associated with bone fracture. Like, I really think we're at the beginning of being brave enough to talk about how do we get 40% of the population maybe not on these drugs. Not to say everybody it can should stop them, but. But we know some people were put on them for reasons that didn't require SSRIs, and now they can't get off of them.
- [49:42]
A
Yeah, I think we just really need to be putting, you know, instead of just putting people on an ssri and as you say, absolutely needed for some people. But we need to look at all of the tools in the toolkit like we do for perimenopause, hormones, lifestyle, nutrition, supplements. I think all of these things are so key. You know, we've really. Medicine has trained a lot of us to look at one specific drug for each distressing symptom or each disability, when really we need to look at the person as a whole person, look at the root cause, and look at the things that are largely common sense and very safe, you know, and then start to build out from that. That takes time. And I think your system and our system doesn't encourage or doesn't support physician time with the patient. It's hard to do that. Good medicine in 10 minutes, I would.
- [50:32]
B
Say damn near impossible. So the people that do it, we see you. But there is something to being able to spend more time with people. Like, it's truly like the relationship itself is healing, you know, and we've taken that away as well. One more thing I want to talk about before we wrap it up. When I was in Australia, seemed like everybody was on vaginal dhea. You guys have intrarosa or prosterone, just like we do. But. But unlike America, you guys are actually on this product. And so, like, at some point I was like, why is everybody on vaginal DHEA here? And they're like, because it's only $40 a month here in America. At best, it's $80 a month.
- [51:09]
A
Yeah. So, I mean, that's a good thing. A lot of our drugs, you're not supposed to tell anybody because Trump, I think, is having a wee party at the minute about how much you guys pay for drugs. And Australia, I think, has been very effective at negotiating good price points with pharmaceutical companies. So, yeah, we do, we do have dhea. I think you were lucky who you met, to be honest.
- [51:31]
B
Like, I had a curated group of women who had access. That's who I was talking to. Yeah, yeah, fair enough.
- [51:36]
A
You got the lucky ones. We know in Australia, our prescribing of vaginal hormones is abominable. So it's still about less than 10% of post menopausal women are on. On vaginal hormones. I would counter it's probably less than. Yeah, probably less than 1% are on vaginal DHEA, which is intrarosa in Australia. And that's my other thing that I could pitch if any Australian clinicians are listening. I've just launched my survey into clinicians attitudes to GSM and prescribing. So I want to use this as a research product project that I'm doing with the University of New South Wales to see why doctors don't ask about GSM and why we aren't prescribing. Hopefully we will get more, more women over time.
- [52:18]
B
Tell me those results when you have them. I bet. I'm guessing it's time knowledge and like the stigma of sex, but maybe it's something else and we'll learn something.
- [52:27]
A
Yeah, but it's really just to get the conversation.
- [52:30]
B
Yeah. Get this conversation going. Yeah, absolutely. Anything else we missed?
- [52:34]
A
Testosterone for a woman we Deserve it. We deserve to be able to try it.
- [52:39]
B
Just try it. I know, that's the thing. It's like one more plug on dementia. Do you guys have PBS approved dementia medications? Do you have what we have?
- [52:51]
A
I can't remember if the new one's just been TGA approved. The monoclonal antibody, the one that causes brain bleeds.
- [52:57]
B
Yeah, the brain bleed one. Yeah, perfect. I mean, my big plug is with especially in Australia, because I'm like, if you guys. Your number one killer now is not shark bites or tarantula bites, it's dementia. We have crap. There's no cure. The treatments are expensive and crappy. Side effects include brain hemorrhage. That's the other thing people don't know. On that tragic Tuesday that you're diagnosed with dementia, this started 20 years prior, right? And like the tragic in lack of curiosity of like, we don't need a 20 year randomized controlled placebo controlled trial that costs a billion dollars. We don't have time. We do not have time for that. You're dying. That's your number one killer. Now why aren't we saying, you know what? We don't know fully, but we know these hormones are cheap and we know that they will help some things, they might prevent dementia. And we've got nothing else. Why aren't we using them 100%?
- [53:51]
A
And we know that osteoporosis and dementia are connected. So if you've got osteoporosis, you're much more likely to have dementia. We know that. And I know you can't say that because HRT prevents osteoporosis. It's going to prevent dementia. But you have to wonder, anything that supports mitochondrial function, which estrogen does, our mitochondria are covered in estrogen receptors, probably progesterone receptors and testosterone receptors too. Mitochondrial health is the key to longevity. It's the key to healthspan. It makes basic scientific sense that supporting hormones and all the other things, like none of us as people suggest that menopause doctors just say, take HRT and you'll be fine. Take your hormones, lift your weights, keep moving, eat well, all of sleep enough. All of those things support mitochondrial health. And that's what's dying or what has been dying when dementia hits 20 years later.
- [54:48]
B
So I mean like glial cells. So testosterone specifically supports glial cells, which are the supporting cells to the neurons. And so like we have all this basic science and I'm like, I'm to the point of like the basic science researchers have to be like. Like rolling over in their beds, being like, what the f. Are we doing all this basic science for if you're not going to use it in clinical practice of, like, every piece of basic science says estrogen and testosterone protect nerves.
- [55:15]
A
Yeah, we've got all that, all the data. If you've got more hot flushes, you're going to have more what we call white matter changes on your brain scan. And that's because of loss of myelin, as you said. Like the estrogen, testosterone, progesterone, all stimulate the little oligodendrocytes, which are the brain cells and that produce myelin. So we've got, as you say, the basic science is there. We've got, like, there's no other sort of drug or medicine that can stimulate nerve growth. Exercise, yes, does it as well. But in terms of drugs, we don't have another drug that will build brain, build bone, properly build muscle. You know, it's just obvious, really.
- [55:57]
B
I know it's. To quote our very good, lovely friend, Dr. Lise Newsome. It's just so obvious. Kelly, she's like, it's just so. It's just so obvious, isn't it? It's just so obvious. Okay, so when are you coming to America? Are you coming to Ishwish 2026?
- [56:11]
A
Yes, I'd love to. I'm just slightly scared. Will I have to clear my social media account to get into the country? I desperately want to come to Iswish.
- [56:18]
B
I mean, I live close to the Canadian border and I'm like, the Canadians are very afraid now, and they're like, kelly, can you promise me that I won't have to pledge allegiance to. To, you know, Trump when I cross the border? And I'm like, first of all, that sounds crazy, but again, I'm a child of the 90s and our biggest problem was, like, a blue dress and blowjobs. So, like, I can't imagine this is going on, but I'm like, I can't promise you that. I have. I. Nobody put me in charge of the border.
- [56:39]
A
I'll come in through Canada. My dad lives in Vancouver, so that's just over the border.
- [56:43]
B
There you go. We want you coming through Canada. We'll travel to California together.
- [56:46]
A
Yeah, sounds good. Yes. Road trip. Yeah.
- [56:49]
B
Everybody signed the petition for Australia to get. Get testosterone on the pbs. We must support this company because it's now in South Africa, New Zealand, uk, Australia. It's in four countries now, desperately need it in America, and we need to help out the Australian women. So that we decrease the stigma to testosterone. You don't need to be partnered to get a prescription for testosterone. It's insane. And check out healthy hormones if you're a clinician or a layperson for menopause and perimenopause support.
- [57:19]
A
Yeah, awesome. Please do. We want you on there. We need to learn so much. Thank you for having me. It's so nice to chat.
- [57:26]
B
So nice to chat. Until next time.
- [57:28]
A
Bye.
- [57:31]
B
Thank you for listening to this week's episode of you 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. Concerns. If you want the Adult Sex Education Masterclass for free, join my monthly membership for more in depth exclusive content, more time with yours truly. A private podcast, coaching and educational empowerment and you can watch my interviews live and get them immediately without advertising. Head over to www.kellycaspersonmd.com for the membership and adult Sex Ed Masterclass members. Get the master class for free. This podcast is presented solely for educational, entertainment and informational purposes only. I am a doctor, but not your doctor in this format and all of my platforms and guests including on this podcast are not giving individual medical advice or practicing medicine. See in Consult with your own care team for your individual needs and concerns. This podcast is not intended as a substitute for the care and advice of a physician, therapist or other qualified professional. This podcast does not constitute the practice of medicine, in case you were curious about that and no doctor patient relationship is formed. But I still love you. Using the information on this podcast or any of my platforms is at your own risk. Until next time. Remember you are not broken.