347. Unraveling the Myths of Vaginal Hormones

Summary

Podcast Summary: You Are Not Broken – Episode 347

Title: Unraveling the Myths of Vaginal Hormones
Host: Dr. Kelly Casperson
Guest: Dr. Maddie
Date: November 30, 2025

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Episode Overview

In this dynamic, myth-busting episode, Dr. Kelly Casperson and Dr. Maddie tackle the persistent misconceptions and clinical hesitancy around prescribing vaginal hormones, particularly vaginal estrogen. Their conversation—laced with both frustration and humor—aims to empower listeners (especially women navigating perimenopause, menopause, or cancer survivorship) with up-to-date, practical knowledge on Genitourinary Syndrome of Menopause (GSM) and its treatment. They bust outdated practices, spotlight gendered medical inequities, and passionately argue for science-based care for women at every age and health status.

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Key Discussion Points & Insights

1. Prevalence of Misinformation & Frustration in Women’s Healthcare

• Both hosts express anger at ongoing clinical resistance to prescribing vaginal estrogen despite decades of evidence of its safety and efficacy.
• Dr. Maddie recounts a story of a breast cancer survivor being told to use coconut oil instead of vaginal estrogen (00:51), underscoring the absurdity and harm of such recommendations.
  • “Cooking oils are not GSM treatments.” – Dr. Maddie (01:57)
  • “The American Urologic Association has published in 2025 GSM guidelines. Nowhere in there is Crisco.” – Dr. Kelly Casperson (02:41)

2. Best Practices for Vaginal Hormone Application

• Applicators vs. fingers: Both recommend ditching applicators for finger application—citing ease, comfort, and the reality that vaginas are not sterile.
  • “Use your finger. Don’t be afraid of your own body.” – Dr. Maddie (03:11)
  • “We put not clean things in our vaginas, AKA partners.” – Dr. Kelly Casperson (03:14)
• Application technique matters: The cream should be rubbed where needed, not just applied internally with an applicator (04:31).
  • “Do we put our face cream on our forehead and hope that it, like, drips down our face?...No, we rub our cream in where it needs to go. So rub the cream in, up inside and then outside, right?” – Dr. Maddie (04:29)

3. Vaginal Hormones During Cancer Treatment

• They challenge the reluctance to offer vaginal estrogen to women undergoing chemotherapy or radiation, arguing that symptom management and tolerability of treatment should be prioritized (04:46–06:33).
  • “You want your patient to tolerate her treatment? Give her the vaginal hormones up front.” – Dr. Maddie (05:24)

4. Dosing and Forms of Vaginal Estrogen: Customization Is Key

• Twice-weekly dosing is maintenance for some but insufficient for women with severe atrophy (06:33–07:45).
• Creams vs. tablets: Cream is often preferred for external/genital involvement (i.e., the “six o’clock spot”), while tablets are less effective for external tissue.
  • “Put estrogen cream on it. Like you’re in Texas in August and you’re trying not to get sunburned. You want to rub it in.” – Dr. Kelly Casperson (07:45)

5. Impact on Sexual Function & Partner Safety

• Vaginal estrogen can restore desire and sexual comfort by rehabilitating tissue health, flexibility, and sensitivity (08:18–09:07).
  • “Some women, they’ll start on vaginal estrogen and they’ll be like, my desire is back because sex is great again.” – Dr. Kelly Casperson (08:58)
• Exposure risk to partners is negligible: Study shows even with double-dose cream, male partner’s estradiol remains within normal (11:43–12:05).
  • “Don’t use it as a sexual lubricant…but if you happen to put in your vaginal estrogen cream and the moment arises, you don’t have to say no, you’re not going to hurt anybody.” – Dr. Kelly Casperson (12:05)

6. Vaginal Estrogen and Yeast Infections: Managing Microbiome Changes

• Starting vaginal estrogen may temporarily disrupt the vaginal microbiome, increasing susceptibility to yeast infections for some (13:01–13:48).
  • “Vaginal estrogen changes the microbiome…in doing so, it can disrupt your microbiome and make you more susceptible to a yeast infection. So…don’t stop, just lower the dose, get treated for the yeast infection, and introduce the vaginal estrogen cream more slowly.” – Dr. Kelly Casperson (13:01–13:48)

7. Combinatorial and Tailored Therapy

• Combining different formulations (e.g., vaginal tablets inside and cream outside) is often effective and should be individualized (14:14–14:59).
• Insurance and cost barriers persist, and lower-dose options (e.g., Estring, Intrarosa/DHEA, and compounded estriol) can sometimes help in negotiations with hesitant prescribers or oncologists.

8. Addressing Common Myths & Pharmacy/Insurance Barriers

• There is no evidence that local vaginal estrogen should be withheld in women on systemic hormone therapy, in elderly women, or that external-only application is needed in cancer survivors (15:30–17:30).
• Pharmacy red flags about combined use (e.g., with Vioza) are systemic/hormonal class warnings and do not apply to low-dose, local preparations (18:37–19:15).

9. Debunking Limitations Based on Age, Medical Conditions, or Cancer Types

• No upper age limits or most medical contraindications for vaginal hormone use (19:40–21:43).
  • “There’s zero age limitations for local vaginal hormones. Zero. Start your 91-year-old on it.” – Dr. Kelly Casperson (20:32)
• Vaginal estrogen reduces risk of urinary tract infections, incontinence, and related complications—key for elderly and frail women (22:48–23:43), and is “as good as anticholinergics for overactive bladder.”
• All gynecologic cancers (except rare uterine sarcoma) and endometriosis are not contraindications except in extremely rare cases (36:09–36:47).

10. Controversy Around Breast Cancer Survivors & Aromatase Inhibitors

• Danish Study & Practice Guidelines: The oft-cited Danish study is flawed; higher-dose, non-comparable regimens, high-risk populations, and rebuttal statements from experts (27:13–29:39).
  • “The Menopause Society made it a practice alert…that Danish study should not be used to deny breast cancer survivors who are on aromatase inhibitors access to vaginal hormones and it should not be practice changing.” – Dr. Maddie (29:11)
• For women on aromatase inhibitors, DHEA (Intrarosa) or estriol may be favored with highly hesitant teams, though evidence supports safety for low-dose local estrogen overall (32:01–34:27).

11. Individualized Dosing and Refills

• Many women require more frequent application than twice per week, and prescriptions should match actual use to avoid refill headaches and unnecessary suffering (35:23–35:50).
  • “Titrate. Use it as frequently as you need to to treat your symptoms.” – Dr. Maddie (35:20)
• Progesterone is not required for local (vaginal) hormone use at any dose (34:36–35:20).

12. Advocacy and Access

• Online menopause platforms can be a resource when local access is blocked (41:44).
• Permission from a medical oncologist is not required to prescribe vaginal estrogen. Informing them is responsible, but medical gatekeeping that denies evidence-based care is inappropriate (42:16–43:04).
  • “You do not need permission from your medical oncologist. I’m going to just say this boldly. You don’t need permission. They are not the ruler of your life to get a vaginal hormone.” – Dr. Maddie (42:16)
  • “Do you call your oncologist every time you take a drink? That’s like way more risky than vaginal estrogen.” – Dr. Kelly Casperson (43:04)

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Notable Quotes & Memorable Moments

• On absurd GSM advice:
  “Cooking oils are not GSM treatments.”
  – Dr. Maddie (01:57)

• On the finger vs applicator “debate”:
  “Use your finger. Don’t be afraid of your own body.”
  – Dr. Maddie (03:11)

• On caring about partners over women’s health:
  “We’ve cared zero for the woman so far, but now let’s worry about the penis.”
  – Dr. Kelly Casperson (09:48)

• On gender bias:
  “Why do women get the age limits? Why do men not get age limits for Viagra or blood pressure medications?”
  – Dr. Kelly Casperson (20:32)

• On lack of informed consent for aromatase inhibitors:
  “First and foremost informed consent is not there. I would like to add that to the toolkit…. That’s what we should do with any medication.”
  – Dr. Kelly Casperson (30:55)

• On gatekeeping and agency:
  “You don’t need permission from your medical oncologist…. They are not the ruler of your life to get a vaginal hormone.”
  – Dr. Maddie (42:16)

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Important Timestamps

• 00:51 – The coconut oil/Crisco anecdote
• 03:10–03:44 – Applicators and vaginal hormone application myths
• 04:46–06:33 – Vaginal hormone use during cancer treatment
• 07:45 – Importance of treating external tissues with cream
• 11:43–12:05 – Partner safety with vaginal estrogen exposure
• 13:01–13:48 – Managing yeast infections when starting vaginal estrogen
• 14:14–14:59 – Using cream and tablet combinations
• 19:40–21:43 – No age or major medical limits for vaginal estrogen
• 27:01–29:39 – The Danish (Dutch) study and practice guidelines for breast cancer
• 35:23–35:50 – Frequency of dosing, refills, and insurance issues
• 41:44–42:16 – Online pharmacy solutions and advocacy
• 42:16–43:04 – Empowerment: Oncologist permission not required

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Tone & Language

• The episode balances medical authority and fact-sharing with humor, sarcasm, and passionate advocacy. Both hosts use plain language for clarity and are direct in challenging medical inertia and systemic sexism in health care.

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Summary Takeaways

• Vaginal hormones are safe, effective, and underutilized—most restrictions stem from outdated, flawed studies and misunderstood guidelines.
• No age, most comorbidities, or even a history of most cancers are contraindications for local vaginal estrogen.
• Women deserve informed, individualized care—not gatekeeping, gendered ageism, or non-evidence-based barriers.
• Advocacy, education, and sometimes tenacity are needed to overcome outdated clinical practices.

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For anyone experiencing GSM or caring for someone who is: This episode arms you with science, practical strategies, and a strong dose of validation to seek and insist on the care you need. And remember:
"You are not broken."

Transcript

[Dr. Kelly Casperson]

Welcome to the youe Are Not Broken podcast. I'm your host, Dr. Kelly Casperson, a board certified urologist, thought leader and conversation starter on midlife living, hormones and sexuality. Enjoy the show.

[Dr. Maddie]

We're going to make like fast fire. So I'm going to say the question and we can both. You can chime in and chime in. We're just going to go through as many as possible and I just think we're both always really fired up about this and I just think it's appalling. We think of this, you and I, as low hanging fruit because we talk a lot about other more complicated uses of hormones. Well, not really complicated, but to the average doctor it seems complicated. So we think vaginal hormones, this should be easy, but it's still not. We joke. We could just have Instagram accounts where all we do is answer questions about vaginal estrogen.

[Dr. Kelly Casperson]

Right, I know, totally. No, I think the anger is appropriate. I was out to dinner last night and I'm like, I'm kind of angry today. And. Yeah. And they're like, why are you angry? And I'm like, I'm so angry that we know all of this.

[Dr. Maddie]

Yeah.

[Dr. Kelly Casperson]

We've been doing this for a very, like longer than I've been doing it. Right. Like medicine has been doing this. We know it's safe, we know it's good. And it's just beating a head against the wall because it's whack. A mole.

[Dr. Maddie]

Yeah. And so the reason why I texted you yesterday and then we'll get into the questions and what I was saying when we were trying the live earlier was that I saw a patient Yesterday who was 10 years from an early stage breast cancer diagnosis, totally doing great, is in menopause and has terrible GSM and has not been able to have sex for two years. She is literally living your book. You are not broken. Like she, her and her husband are great communicators. They have an incredible relationship. They just went on a beautiful special trip, the two of them, and we had she. Like, we had the best time, but we didn't. We weren't able to have sex once because it's so painful. And she just was seen at the survivorship clinic at a famous world class breast cancer center, which won't be named, but you can guess, they recommend coconut oil. It's like, yeah, we just try to avoid estrogen. And Dr. Sadaf, our friend, she just posted something. She had a patient and Sadaf is also in the New York area whose doctor told her to use crisco So I think you and I see this. Like, cooking oils are not GSM treatments.

[Dr. Kelly Casperson]

That's an Instagram post for sure.

[Advertisement Voice]

No, that's.

[Dr. Maddie]

Yeah, cooking up. I was gonna. I was gonna wait till after this, and then I was gonna. I figured we come up with some snarky things. But that's my next thread post. Cooking oil is not a prescription for gsm.

[Dr. Kelly Casperson]

And you can. Then you can link like we. We.

Now.

The American Urologic association has published in 2025 GSM guidelines. Nowhere in there is Crisco.

[Dr. Maddie]

It's a nice moist dress you want to moisturize.

[Dr. Kelly Casperson]

Fudge.

[Dr. Maddie]

It is not going to fix your gsm. Full stop. Anyways, let's move on to all these questions. All right, so in no particular order, ladies. They're just reading as they come in. So is there a brand with a better applicator that is easy to clean? Not like the ones that I get. So I tell patients to ditch the applicator. Thoughts on applicator?

[Dr. Kelly Casperson]

Use your finger.

[Dr. Maddie]

Use your finger. Don't be afraid of your own body.

[Dr. Kelly Casperson]

And then when I feel like being snarky, I'm like, we put not clean things in our vaginas, AKA partners.

[Dr. Maddie]

Yeah.

[Dr. Kelly Casperson]

Like, the applicator is not the dirtiest thing in the world. It's fine. Wash it. Like, some people will buy. You can go on Amazon and you can buy a boatload of applicators if you want to destroy the earth and throw a bunch away all the time. So, like, there's tons of options, like, deal with the applicator and just don't worry about sterility in your vagina because it's not a sterile environment.

[Dr. Maddie]

Yeah.

[Dr. Kelly Casperson]

Number two, use your finger, which is also not sterile. Number three, go on Amazon and buy a whole bunch of applicators. But there is, to answer the question specifically, there is not a brand with the best applicator out there.

[Dr. Maddie]

And the other problem with the applicator, because I've used it myself all different ways. Right. The applicator. Yes. Will deliver the vaginal hormone up into, you know, higher up into the vagina. So if you're concerned about pain and atrophy further up in the vagina, that's great to get it up there. But your finger can get it up there, too. But when you put it in, it just leaks out. You wake up in the morning, you've got white vaginal estrogen cream sitting in your underwear, and it's messy. And so then people are not compliant with using it. So this is why. And I Kind of said it recently on a real. Do we put our face cream on our forehead and hope that it, like drips down our face?

[Dr. Kelly Casperson]

No, I'm good.

[Dr. Maddie]

No, no, we rub our cream in where it needs to go. So rub the cream in, up inside and then outside, right?

[Dr. Kelly Casperson]

Yep.

[Dr. Maddie]

Is it safe during chemotherapy and radiation? Can we use vaginal hormones during cancer treatments?

[Dr. Kelly Casperson]

I think we should. I mean, people put this thing on their hair so they don't lose their hair. Like it's called pre treatment, right? Yes. Like, I don't, I do not understand why it's not pre treatment for women.

[Dr. Maddie]

Well, so this is a big thing that. I totally agree with you. And when I was going through chemotherapy, I was given a whole bunch of prescriptions so that I could tolerate my treatment. I was giving medications to keep my white blood cell counts up. I was giving anti nausea medications, anti anxiety medications, anti inflammatory medications. I was given prednisone so I could tolerate the therapy. You know, do you want your patient to tolerate her treatment? Give her the vaginal hormones up front.

[Dr. Kelly Casperson]

And that is a good substack for you.

[Dr. Maddie]

Oh, it's, it's on my list. And I don't really understand the idea of giving a medication that you know is going to cause severe estrogen deprivation, not just menopause, but severe deprivation like an aromatase inhibitor. So everyone understands making it almost zero and then saying. And this is our beef with the guidelines, the guidelines still from the Menopause Society and ACOG say in breast cancer patients start, start with a non hormonal moisturizer, again, not a treatment for gsm.

[Dr. Kelly Casperson]

And then start with ginger for nausea. Or do you go straight to odansadrone?

[Dr. Maddie]

Yeah. Or do you start with like a sling when you have like a hip fracture or something? Or do you go to the actual treatment? So I feel that's a very strange double standard. And so, yeah, chemotherapy, radiation. And now your thought here. I have very strong feelings about this idea of someone who has very severe atrophy and gsm, who was prescribed just twice a week, a little dry vagifem tablet. Nothing against vagifem for mild or maintenance. But what are your feelings and your experience on that?

[Dr. Kelly Casperson]

Yeah. So twice a week is by and large a maintenance dose. If it's the run of the mill average person, I usually don't do a loading dose because I don't like them to have a big hormone rush at the beginning because they're super atrophic. They'll get side effects. They won't like it. So I tend to start there just to get them going. And if they're not better in six to eight weeks, you adjust the dose. And I think a lot of women need a lot more hormone than just twice a week. And it's very safe. The more you use it, the more risk you have that the dose goes up, but the twice a week. And that's all you can do is a one size fits all. That does not fit all.

[Dr. Maddie]

Yeah. And not just the twice a week, but this idea of when you have severe atrophy and you use a little dry vag tablet. So to me, I have. Yeah. As a gynecologist for years, I would see patients literally for their routine Pap smears who were using, and I would look inside, I was just like, the tablet's not even dissolved because the atrophy was so bad that it was a little dry tablet sitting there. And not to say that it doesn't work for some women. Some women that works fine. But I think that sometimes we need a little bit more.

[Dr. Kelly Casperson]

That's why I love the cream, because the cream can get on the vulva. And so if this is the entrance of the vagina, this is the posterior fourchette, and I call it the six o' clock spot on a clock. This notoriously gets thinned tight, pinched, torn. This is pain with insertion right here. And a vagufin tab up in the vagina does not target this location because it's way up here. Put estrogen cream on it. Like you're in Texas in August and you're trying not to get sunburned. You want to rub it in.

[Dr. Maddie]

I like that analogy. This is a good one for you, actually. This vaginal estrogen help to have more fun in sex, like to be more sensitive and feel more. And this kind of brings back to what Rachel Rubin always loves to say, is that vaginal estrogen is Viagra for women. So can you just explain that to the audience?

[Dr. Kelly Casperson]

Yeah. So estrogen helps these tissues be adult tissues. Right. Like, these issues needed estrogen. They also need androgens and testosterone. And we can get into dhea, but it helps flexibility of the tissue, like stretching, elasticity, blood flow, which is arousal in the sex word, blood flows arousal.

[Dr. Maddie]

Right.

[Dr. Kelly Casperson]

Nerve sensitivity in a good way, not in a pain way. It's not every woman, but. But some women, they'll start on vaginal estrogen and they'll be like, my desire is back because sex is great again. Yes.

[Dr. Maddie]

Well, I learned this language from your book, which you're not broken, is something I literally prescribe is a prescription for my patients. I tell them, this is your homework and we're going to follow up in three months and you're going to tell me that you and your partner read it.

[Dr. Kelly Casperson]

It won an award. So now I get to say it's award winning.

[Dr. Maddie]

Oh, I love it. Well, I always knew it was award winning, but this idea that, yeah, your brain will have negative biofeedback if it hurts. Your brain doesn't want to desire something that's causing you harm. Yeah. Well, vaginal estrogen makes sex more fun. Or you'll be more interested. Yeah. Because you'll be interested in something that's not shards of glass. Good one. Does it affect my partner if he comes in contact with it?

[Dr. Kelly Casperson]

I love this question. Just because I'm like, we've cared zero for the woman so far, but now let's worry about the penis.

[Dr. Maddie]

Yes.

[Dr. Kelly Casperson]

So I get a little snarky because we're like, we're not taking care of you at all and now you're worried about another person. And it's like the bane of women's problems in society. But we could step back and we could be like, they actually did a study on this. So they A woman put double the dose of a vaginal cream. So very high. Two grams, two grams in her vagina had penis and vagina intercourse measured his estradiol levels. Remember, men have estrogen. Men have more estrogen than a postmenopausal woman. Their estradiolabs are on 30 to 40.

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[Dr. Kelly Casperson]

So she puts in a really high dose. They have sex, they measure his labs. They measure his labs eight hours later. And it raises his labs, but not above normal estradiol levels. So this is what I tell people. I say, don't use it as a, as a sexual lubricant. We've got lubes for that. But if you happen to put in your vaginal estrogen cream and the moment arises, you don't have to say, no, you're not going to hurt anybody.

[Dr. Maddie]

Yeah. And this is where I. Getting back to the cream and ditching the applicator. I've told women and I actually use it myself this way. I put my vaginal estrogen cream in in the morning. I'm doing. I brush my teeth, my face, and.

[Dr. Kelly Casperson]

I pair on the morning person.

[Dr. Maddie]

Well, because I rub it in with my finger so there's no messy dripping out. It's already absorbed. So if the mood arises later on, my husband's already at work. I'm not going to do anything with him in the morning. And so then that solves that question, if you're really that worried. But I tell women, don't care, don't. I wouldn't worry about it. This is a really, really common one that we always get from patients. So patient who just started vaginal estrogen and she's experiencing itching and irritation, or another common question along this line is that I just started vaginal estrogen and now I got a yeast infection that I never had before, so I have to stop the vaginal estrogen. You want to, right?

[Dr. Kelly Casperson]

Yeah. So vaginal estrogen changes the microbiome of the vagina back to how you were when you had estrogen. Right. So it creates more lactobacillus, which then in turn acidify the vagina and that's how you prevent urinary tract infection. But in doing so, it can disrupt your microbiome and make you more susceptible to a yeast infection. So if anybody. Temporarily.

[Dr. Maddie]

Temporarily, yeah.

[Dr. Kelly Casperson]

While you're adjusting your microbiome. Yeah. And so, like when people say, what's the risk of vaginal estrogen? I'm like, rare, but yeast infections for some people. So what I tell people to do is lower the dose. Don't stop, just lower the dose, get treated for the yeast infection. And we're just going to introduce the vaginal estrogen cream more slowly as you develop a more estrogenized microbiome, the risk of that yeast infection goes away again.

[Dr. Maddie]

Yeah, yeah, that's what I see, too.

[Dr. Kelly Casperson]

If you're on an estrogen cream product or something, maybe I'll switch to the lower dose tabs for a little bit just to, like, slowly get that microbiome to change. And once you kind of. Because women won't trust it then, because they'll be like, it gave me a yeast infection. So we got to build back the trust. And once we can build back the trust, then we'll be like, okay, now do you want to go back to the cream? What do you want to do? I have a lot of women who use the tabs in the vagina and the cream on the vulva.

[Dr. Maddie]

That was another question that comes up. I do that a lot with my patients, too, especially people who I know have a lot of bladder problems and urinary frequency and urgency. And I really want to make sure that they're getting vaginal hormones up inside the vagina because then that's what gets absorbed into the bladder wall. But they have that pain on the outside. So that's where the. So there was a bunch of questions about that, too. Can we use both? This is called the art of medicine. And being an expert, like, knowing that you can use not only vagifem, you can use E string, let's remind people the little ring that goes up inside, which is really, really low, steady dose. The medical oncologists actually who get it love that because they know it's a very low dose and it's very steady, and it really works wonders for women. Insurance coverage is a problem.

[Dr. Kelly Casperson]

The other thing just to note on Eastering, it's made for three months, and a lot of people will say it wears off before then. So I'll have people use Easter drink for, like, two months, and then they need some cream. So it doesn't always last three months for some people. But I like to tell people that because they kind of feel like they're like, am I crazy? That this kind of feels like it's going away after a while?

[Dr. Maddie]

Like, no, no, no, you're not crazy. And this is why, like, having a tube of vaginal estrogen cream is just like a great little add on. If you want to just use it locally and do something on the inside.

[Advertisement Voice]

All right.

[Dr. Maddie]

Most common question that we always hear is that my gyn told me that she will only give me the estrogen patch, not also vaginal estrogen, because it's too much estrogen, or the patch is Going to totally treat my GSM bullocks. Nonsense. That's not true. At least 50% of women need vaginal hormones.

[Dr. Kelly Casperson]

Yeah, all the time. I just want to address. Somebody had put a fem ring price in there. Fem ring, Systemic hormones. We're not talking about systemic hormones. We're talking about estring, which is the local ring. So there's two vaginal rings, fem ring, estring. We're talking about estring because we're talking about local pelvic hormones right now. Yeah. So this is my math equation. And I'm like, I'm sorry for anybody who listens to me a lot and effing hates my math equation at this point. But if systemic hormones, AKA a patch, raises your estradiol levels to X and pelvic hormones raise your estradiol 0. X +0 is x, meaning you can be on a patch and vaginal estrogen and not raise your hormone levels. Somebody was like, I was at a Ishwish conference last year. They're like, you need to do a study proving that. And I'm like, we have a million studies showing that low dose vaginal estrogen doesn't raise hormone levels. We already have the studies. That's why I have this equation. Right. Like, we don't need more. This is one area where we don't need more research.

[Dr. Maddie]

No, no. Yeah. It's Maddie. The other thing that I really. This is again where I kind of push back on. You know, I still think the guidelines are too conserved when it comes to this. And this idea of, like, well, a woman presents with menopausal symptoms, hot flashes, night sweats, and some GSM symptoms, and you say, well, let's start with a patch of progesterone, say, and then if it doesn't help in three or four months, then we could start the vaginal hormones. I'm like, no, she has the symptoms. Both treat her. Why are you perpetuating and prolonging suffering? I don't get it.

[Dr. Kelly Casperson]

Wasn't that just a question in, like, the endocrine boards or something?

[Dr. Maddie]

Oh, you know Dr. Solace Whelan, right? I think it was Rocio.

[Dr. Kelly Casperson]

Yeah.

[Dr. Maddie]

She said in her endocrine boards, the question was for a breast cancer survivor who presents with hot flashes and painful sex. And it gave the option only take one and vioza or the answer, which then is, we're going to. We'll come back to general vaginal estrogen questions, but we're going to get heavy into the breast cancer questions because there's such extreme Suffering in this community. So the first one is I had my own patient come to me with this question. This came up in our thread yesterday. A pharmacist would not prescribe or would not dispense the vaginal estrogen to me because I'm on vioza. And so the thing is, when you put. Well, so this is a little. This is a thing that people don't realize. So when you prescribe vioza and you try to put an estrogen prescription in, not systemic estrogen, but a local vaginal estrogen, it flags in the pharmacy system because systemic estrogen has a potential to potentiate the impact of vioza. Impact on the liver. We know Vioza. The has a warning about liver.

[Dr. Kelly Casperson]

Oral, systemic.

[Dr. Maddie]

Oral, systemic estrogen. Again, this is where class labeling of estrogens causes harm. So this is the second question I've had where a breast cancer patient on vioza and it's effectively treating her hot flashes, is now being told by either a doctor or her pharmacist that she can't take vaginal estrogen because in the pharmacy system, she gets a red flag.

[Dr. Kelly Casperson]

Bummer.

[Dr. Maddie]

Yeah. And so totally not true. Fiozza Fennian. You absolutely can use that along with vaginal hormones, right?

[Dr. Kelly Casperson]

Dr. Man, is. Is there a medication with which you cannot use a vaginal hormone product? No, I can't think of one.

[Dr. Maddie]

No, there's none. So. Because there's a bunch of like, random questions about like, other medical contraindications outside of the breast cancer stuff, which we're going to dig into in a second. I don't care if your 80 and had a str. A massive heart attack. I don't care if you have some complicated autoimmune disease. I mean, I care about those things, but I don't care about them when it comes to vaginal estrogen. Do you feel the same?

[Dr. Kelly Casperson]

Yeah, I agree. I mean, especially since there's nothing that decreases urinary tract infections more successfully than a healthy vagina and a well estrogenized vagina, AKA vaginal estrogen. And these women, these frail women with medical comorbidities, they're at the highest risk of hospitalization, sepsis, and death from urinary tract infections. Why would you not treat them? And I think that before we get into the breast cancer stuff, just to dispel the myth that there's an age limit. I effing hate age limits. Why do women get the age limits? Why do men not get age limits for Viagra or blood pressure medications? Women get these like, oh, 72. I don't understand the age limits that society is putting on women for these medications. So there's zero age limitations for local vaginal hormones. Zero. Start, start your 91 year old on it.

[Dr. Maddie]

Yeah. And for all the ladies listening, you probably have an aunt, a grandmother, a mom, or a friend who is older who might be elderly. This is an uncomfortable conversation to have with them. Sometimes they don't want to bring it up. Vaginal pain, dryness, and even if they're not sexually active. Because people write off older elderly women or women in a nursing home saying, oh, well, she's not having sex. Why would she need vaginal estrogen? Well, first of all, a lot of nursing home patients are having just so you know, and it should be pleasurable for them if they want it. But it's because of urosepsis UTIs, the risks of going to the emergency room with a urinary tract infection. Right. That's just why we should want our elderly women in our lives to have access to vaginal hormones.

[Dr. Kelly Casperson]

Yeah. And you have to explain to them, I have, and that's a stereotype generation. But I have a lot of older women, they don't understand that their vagina is theirs and it's theirs to take care of. And it can actually help them reduce the, you know, I'll say vaginal estrogen for UTIs and they'll be like, but my husband's dead. And so it's like, you do have to educate people that like, vaginal health is bladder health is pelvic health and it's all related.

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[Dr. Maddie]

Yeah, yeah, absolutely. I actually had a friend's mom. Chronic UTIs not on vaginal estrogen. Getting up every night to go to the bathroom. Elderly. And she fell and she broke her hip. So I actually think vaginal estrogen would have prevented her hip fracture.

[Dr. Kelly Casperson]

Yeah. Vaginal estrogen is as good as anticholinergics for overactive bladder. So getting up at night to pee, huge risk of falls, urinary incontinence. Number one reason people end up in a nursing home. Right. So these aren't small problems and people will be like, oh, I get to sleep through the night or only get up one time to pee now instead of four or five, which they just thought was normal, not realizing that this is a low hormone problem. The bladder gets spastic when it has low hormones. The trigone muscle of the bladder gets spastic. We've got the studies. So you put the hormones back, the bladder can function better.

[Dr. Maddie]

Totally. So let's get into the breast cancer patients and the suffering. So I'm just going to read these things. Breast cancer survivor. I was told not to use the estrogen on the inside. Sex is excruciating and I've avoided it for five years. So let's bust the myth that vaginal hormone should not be used on the inside of the canal in breast cancer survivors. So because I hear this a lot, they finally beg, barter and steal. They get this prescription and then they're told by the the survivorship NP or the medical oncologist or the ill informed GYN to put a dot, a pea sized amount and just rub it a little bit on the outside. You can use it for six weeks, just for a short period of time. It like literally makes no sense. Right, right.

[Dr. Kelly Casperson]

So yeah, I explain that to people because they think a tube is the treatment course. Instead of this, you will go back to how you were when the hormones go away.

[Dr. Maddie]

Yeah. So there is no data to say that breast cancer patients should only be using it on the outside. Correct, Kelly?

[Dr. Kelly Casperson]

Correct.

[Dr. Maddie]

Yes. Okay. All right, so let's just talk about tamoxifen and aromatase inhibitors. All right. So is vaginal estrogen safe for women who are on ovarian suppression or already menopausal and are using tamoxifen? Let's say it together, Kelly. Yes. Yes. And it's really interesting. Tamoxifen impact on the vaginal canal. The outside of the tissues is different than the impact on was an aromatase inhibitor. Tamoxifen itself doesn't cause Severe vaginal atrophy in premenopausal women. But it can cause like irritation and inflammation. But once you're menopausal, it can accelerate those changes, but not to the degree as an aromatase inhibitor. Why don't you explain to people what an aromatase inhibitor means to vaginal tissue? And what's the degree of estrogen deprivation, Kelly?

[Dr. Kelly Casperson]

Yeah, so aromatase inhibitors. And correct me if I'm wrong, but so aromatase inhibitors, our bodies make testosterone. Testosterone converts to estrogen, estradiol, because of the aromatase enzyme. That's the machine that takes our testosterone and makes it estrogen. So when you put an aromatase inhibitor in, your estrogen levels plummet. There's no machine making any estradiol because you blocked that machine. So in the genitals, become adult because of testosterone and estrogen. And so you're really going down to very, very low levels of estrogen.

[Dr. Maddie]

Yeah. And so. So this is the case that like we were referring to before that, when we know we're going to be initiating medications like aromatase inhibitors and these women are not on them for just a few months, they're on them for generally five to ten years. This is severe deprivation, hormones everywhere. And our conversation is not about that. We're talking literally about the local effect of these hormones. And we have no studies that show an increase in mortality or recurrence with these low dose local vaginal hormone products, even if you are using aromatase inhibitors. Correct.

[Dr. Kelly Casperson]

Well, there's the Dutch study which caused the big kerfuffle.

[Dr. Maddie]

Yeah, the Danish study. The Danes of the Dutch, they always get themselves. I have like a huge beef with that. To me, the Danish study is like the whi. Well, no, the wh.

[Dr. Kelly Casperson]

I was a study talk about it because people will say that that's the study that use it. So we should talk about that study.

[Dr. Maddie]

Yeah, so let's get. There's. There's. So what's really interesting about that study is, and it was published fairly recently about like three or four years ago, and it is literally held as well. But if you're on an aromatase inhibitor, we have this study, but actually nobody. It's kind of like your point about the whi. The doctors who are using that study to deny vaginal hormones to people on aromatase inhibitors. Actually, I don't think they ever read the study. Kelly. Number one, these are retrospective reviews, right? So these studies were looking back and interesting. In the study, one of the big points were only women who were at the most high risk of having breast cancer recurrence were being put on aromatase inhibitors. Basically the practice patterns in that study were not modern day practice patterns. Basically a minority of the survive or the breast cancer patients were being given aromatase inhibitors. So already the group who were being given aromatase inhibitors were already by definition at a higher risk of having recurrence. And it's basically not modern practice, meaning, like, you know, basically low and high risk patients now are all put on them. So this study, like already was setting up the patients who were on aromatase inhibitors to already have a high risk of recurrence. Number one, they were using much higher levels of vaginal estrogen than what we do in contemporary practice. Right. So those were the two kind of biggest points of why the data is not actually applicable to modern practice. And they actually showed no increased risk of mortality either. Right. To the point where Sherry Goldfarb, who is a medical breast oncologist at Memorial Stone Kettering, along with other leaders from the Menopause Society, actually issued a rebuttal and a practice statement from the Menopause Society that that Danish study should not be used to deny breast cancer survivors who are on aromatase inhibitors access to vaginal hormones and it should not be practice changing. They actually published that in the Journal of Clinical Oncology and the Menopause Society made it a practice alert to go out to all of their members. But that's something that nobody ever brings up with these patients.

[Dr. Kelly Casperson]

I love that. And isn't it also true that breast cancer survivors in this study who are on systemic hormones didn't have any increased risk of recurrence? Yeah, that's the other big red flag is like, how is it biologically possible that the vaginal estrogen would, but the systemic ones wouldn't?

[Dr. Maddie]

There's so many flaws with the study. And so the problem is, is that if you're going to deny patients access to a medication that can be life changing, life saving, and you don't really know the details of why you're denying it, then you have no business to be advising that patient. Right. You can't just tell patients no and you can't really back up why you're saying no. So I think, I don't know today or tomorrow I'll put up a link to that rebuttal that Dr. Goldfarb, who is a breast medical oncologist, highly respected, wrote. So we'll give the details. So let's talk about how we can. Because it's a huge problem. The women on aromatase inhibitors, it's increasingly more Common that more and more women are being put on these rheumatism inhibitors. So I have my ideal cocktail of like what I would use for these women, but would like to kind of hear. Do you have any thoughts about that before? I kind of spiel on. Yeah.

[Dr. Kelly Casperson]

I mean, first of all, I'm concerned that the informed consent is not there. I don't know if I've heard a woman say they told me what's going to happen when I take this aromatase inhibitor. So I think first and foremost informed consent is not there. I would like to add that to the toolkit of like, this is how this medication works. As a consequence of how this medication works. This is what you might experience. Yes, because you might experience these things. This is what we're going to do to help you. I did not just ask to go to the moon right there. I told you what standard medical practice should be. That's what we should do with any medication. So certainly vaginal estrogen, low hanging fruit, vaginal estradiol creams, the cheapest. I think some women do a lot better with dhea, especially if we're talking like profound gsm because.

[Dr. Maddie]

Yeah, well, I'm glad you brought that up. That's very, very important because. And what's interesting is vaginal DHA is a FDA approved option. The brand name is intrarosa. And interesting. In my experience with medical oncologists, they, they actually are more comfortable with DHEA because it doesn't say the word estrogen in it. Even though the way it works is that it within the cells gets converted to estrogen and to testosterone.

[Dr. Kelly Casperson]

It doesn't work DHEA receptors. It works the testosterone and estrogen receptors. Yeah.

[Dr. Maddie]

And this is not.

[Dr. Kelly Casperson]

But it doesn't have the boxed warning.

[Dr. Maddie]

Yeah. So I think it's interesting the medical oncology community seems to like, like that, which is fine. I love intrarosa and dhea. So to me, if I have a patient on an aromatase inhibitor and I know that their GSM is going to either be profound or it already is profound, I often will lean in onto intrarosa. When you have a very nervous medical oncologist who's very reluctant to prescribe it, Dr. Allison McBess in the UK, she actually just wrote a post this morning and she was smart by saying this. In Europe, estriol is the standard, their FDA approved version of vaginal hormones. Estriol does not convert to estradiol. It doesn't convert to estradiol. Estriol is extremely weak on breast tissue. So if you have a very nervous patient and a very nervous medical oncologist. Compounding in the US An Estriol vaginal cream, which you can get if you're really nervous about it. Again, I don't think this is absolutely necessary, but it's an option for women who are facing barriers. A vaginal estriol cream can be prepared and a really nice like a versa base or non irritating base. And that can be like a bridge to getting women access. And I if people are also really nervous in Vexi. The brand in Vexi, which is an estradiol insert, does come in a lower 4 microgram versus a 10 microgram do it.

[Dr. Kelly Casperson]

If it doesn't work, it it's because it's very, very low dose and you might be different.

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[Dr. Maddie]

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[Dr. Kelly Casperson]

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[Dr. Maddie]

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[Dr. Kelly Casperson]

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[Dr. Maddie]

So the only reason I bring the estriol and the very low dose in Vexi is to give women another tool to be able to communicate with their medical oncologist, to just get rid over some of the fear and the psychological barriers. We are not saying you need to use these absolute lower doses, lower potency options, but they're a bridge, right?

[Dr. Kelly Casperson]

Yeah. We're experts and we know a lot, which can be confusing to people, but it can also be that's where the gems are that can really help a lot of people.

[Dr. Maddie]

Yeah.

[Dr. Kelly Casperson]

One thing I want to make sure we hit is if you're on local vaginal estrogen only, do you need to be on a progesterone because of that?

[Dr. Maddie]

Absolutely not. You don't need progesterone. And we had multiple questions come in about that. Actually, I'm looking one right here. I'm on vaginal estrogen three times a week. If I use less than three times a week, I still suffer. My new doctor I saw said that that's way too much. And now I have to take a progesterone to protect my uterus. This is just nonsensical. So this comes back to individualization. Not every woman does great with it twice a week. Many, many women need it three times a week, five times a week. This is low dose. It's okay. I tell patients, titrate. Use it as frequently as you need to to treat your symptoms.

[Dr. Kelly Casperson]

If you're using it more than that, you do need a prescription for that amount because otherwise the pharmacist will not refill your tube early. There's sticklers on this stuff. Like it's actually harmful.

[Dr. Maddie]

Yeah, someone wanted to.

[Dr. Kelly Casperson]

It's over the counter in many countries, by the way, so it's very safe. But if you don't have the prescription written for every other day and you run out of it early, you can't get a refill if it's only written for two times a week. So that's like a tip and trick.

[Dr. Maddie]

Yes. And a patient wrote that today saying that her PA will only write it for twice a week and her co pay is very high for it. And so she's having all these increased costs. So that's just crazy nonsense. GYN cancers, endometrial cancer, ovarian cancer. Vaginal hormones are safe, right, Callie?

[Dr. Kelly Casperson]

Yes, I will. Asterisk. Very rare uterine sarcoma, which is a very rare, very rare. It's not your normal bread and butter. Endometrial adenocarcinoma. Very rare uterine sarcoma. There's like case studies or something that you can't. So the true experts will know, like that's the one thing. But it's so incredibly rare that it's a long.

[Dr. Maddie]

You have that.

[Dr. Kelly Casperson]

Yeah, it's a longer conversation versus, like, dude, by and large, everybody can be on vaginal estrogen.

[Dr. Maddie]

Yeah. Also other hormonal conditions that people think about. Hormones with endometriosis. Vaginal estrogen is safe. Systemic estrogen is also safe.

[Dr. Kelly Casperson]

Vaginal estrogen when you're breastfeeding, well, that's.

[Dr. Maddie]

The genitourinary syndrome of lactation. Because breastfeeding causes lower hormone levels, lower estrogen levels. Right. And so a lot of women have painful sex while they're breastfeeding. Very safe. With more and more women living with metastatic breast cancer, Metastatic breast cancer years ago was considered a death sentence. Now many, many women are living with metastatic breast cancer as it being a chronic disease for them. Luckily, we're blessed with more and more treatments for advanced breast cancer. But I see the metastatic breast cancer community of younger women in particular are really, really ignored that because they have metastatic cancer. They're like, well, no, you're Going to have to just give up on your sex life. We can't even give you vaginal hormones. There is no data that tells us that metastatic breast cancer patients can also use low dose vaginal hormones. These women are often on hormone blockers for the rest of their lives because they're metastatic disease. But again, we're using hormones that don't raise systemic hormone levels.

[Dr. Kelly Casperson]

Exactly. And I would add, caring about the woman's quality of life has completely gone out the door. Relationships end over this. Like it's painful to pee. Like recurring UTIs end up in a hospital to not care about her quality of life. Especially when we don't have any data that you're going to make anything worse with it. It's so myopic.

[Dr. Maddie]

You can always measure an estrogen. If you're really that worried, just freaking order an estrogen level. I don't recommend people getting their estrogen levels checked when they're taking vaginal hormones alone. But if you're in some complicated medical situation, you've got a fearful medical oncologist. This patient wrote one of the questions was, I have metastatic breast cancer and I'm on Ibrance and Faslodex with recurrent UTIs. So someone who is being treated for chronic UTIs and also has cancer, we really are. We don't want their immune system to be challenged by recurrent infections. That puts them at risk for other complications. So to me, the last person, I would never want a cancer patient to have recurrent UTIs. So just for that reason alone. Right?

[Dr. Kelly Casperson]

Yeah. It's awful.

[Dr. Maddie]

It's awful. This is an interesting. I had a question from a woman who's a DES daughter. So maternal DES exposure, she has an increased risk herself of clear cell adenocarcinoma of the vagina and cervix. And her doctor refuses to give her vaginal estrogen. There is no data that DES children, patients, adult women, should not have vaginal estrogen.

[Dr. Kelly Casperson]

Well, it's apples and oranges. This is a synthetic medication that has lots of risks. Nobody uses it anymore. And we're talking about low dose estradiol, which is what your body naturally makes. And this is like the brilliant Korean men who's always like, was removing your ovaries a treatment plan for you being a DES daughter because your ovaries made estradiol? And if the answer is no, which the answer is no, why can't you give yourself a little bit of skin care that has estradiol in it? And I love that logic question, like, it's the best thing ever because it really makes people think like, oh, I'm scared of something that my ovaries been giving me for 40 years.

[Dr. Maddie]

Yeah. So yeah. And this is like the triple negative breast cancer. All breast cancer patients can use hormone therapy or local vaginal hormone therapy. But for these triple negative breast cancer patient, she has her breast cancer, she goes through her chemotherapy, her periods come back to normal, she has seven years of normal hormone production. Removing her ovaries was not part of her treatment plan. Lowering her estrogen wasn't. And then she gets to menopause either because it naturally happens or maybe she carries a BRCA mutation and she wants to lower her ovarian cancer risk. So then she has her ovaries taken out for that reason, not to lower her hormone levels for cancer. And then she's denied vaginal hormones or even a discussion on systemic. It's like sometimes I think this knee jerk reaction is not the practice of medicine. It's like doctors are giving advice and they're not even reading the literature.

[Dr. Kelly Casperson]

Yeah, it's, it's pretty flip.

[Dr. Maddie]

Imagine it's pretty flip. Yeah. I think I'm gonna end it with something that is just like. I'll just read the last one. My 75 year old woman is mother is having recurrent UTIs. She requested vaginal estrogen and her doc did not even consider it saying she's far too old to start it now.

[Dr. Kelly Casperson]

That's the age I keep telling you. Like once you see that we're using a woman's age as a marker for. Where does it say in anything that a woman becomes too old for something? We don't say that to men. We give 90 year olds Viagra. For the love of God. They're human also. Yeah, there's my, there's my Instagram post for the day. Is like 72 year olds are also humans.

[Dr. Maddie]

Yeah.

[Dr. Kelly Casperson]

So if you have trouble getting vaginal hormones from your doctor and, and you know it's safe and you have a legitimate access problem. This is where the online hormone menopause companies are. Great Interlude is one that only does vaginal estrogen. You can use the code not broken for a discount on their alloy. Ever. Now, Genev Midi, what am I missing? There's a lot of online companies now that do hormones. So know that that's an option.

[Dr. Maddie]

The other point there is that you do not need permission from your medical oncologist. I'm going to just say this boldly. You don't need permission. They are not the ruler of your life to Get a vaginal hormone. Okay. And so this is a huge problem. And so I see sometimes some doctors require the oncologist to sign off on it. I will push back on that. I think you should always inform your medical team of what you're doing. Your oncologist should be aware. But if you want to pursue this and your sexual medicine expert, your menopause doctor, whether it's an online physician or your in person doctor, is going to write the prescription for vaginal estrogen, they should not be blocked because your medical oncologist doesn't know the literature and is not up to date.

[Dr. Kelly Casperson]

I'll just go there. Because I'll go there. But alcohol is really bad and is associated with eight cancers. Do you call your oncologist every time you take a drink? Right. And that's like, way more risky than vaginal estrogen. So it's.

[Dr. Maddie]

And also, do they, Kelly, do they ask us permission to prescribe aromatase inhibitors to make sure that we're okay with the collateral damages of decades of estrogen deprivation? Do we get permission? Do we get permission?

[Dr. Kelly Casperson]

No, you should get an informed consent.

[Dr. Maddie]

But you should get an informed consent. And that's not happening. Okay, now we're feeling spicy.

[Dr. Kelly Casperson]

Okay. This is so great. I think what I will do is I'm able to pull this audio and I will. We'll keep it up on Instagram so everybody can refer your sister and your mother to this. But I'll also probably try to pull the audio and put it on the podcast later on this fall so that more people can get this knowledge because this was on fire. Good.

[Dr. Maddie]

Love it. Love you. Have fun with Bring your kids to school. Have a great day.

[Dr. Kelly Casperson]

Love you. Till next time.

[Dr. Maddie]

Bye.

[Dr. Kelly Casperson]

Bye.

Thank you for listening to this week's episode of youf Are Not Broken. If you want to dig deeper with me, sign up for my Adult Sex Education Masterclass where you learn adult things like communication skills, anatomy lessons and desire types, and how to talk to your doctor about sexual health concerns. If you want the Adult Sex Education Masterclass for free, join my monthly membership for more in depth, exclusive content, more time with yours truly. A private podcast, coaching and educational empowerment. And you can watch my interviews live and get them immediately without advertising. Head over to www.kellycaspersonmd.com for the membership and Adult Sex Ed Masterclass members get the master class for free. This podcast is presented solely for educational, entertainment and informational purposes only. I am a doctor, but not your doctor in this format and all of my platforms and guests, including on this podcast are not giving individual medical advice or practicing medicine. See 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.