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
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 They bust outdated practices, spotlight gendered medical inequities, and passionately argue for science-based care for women at every age and health status.
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)
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)
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
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.
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.
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."