Podcast Summary

Podcast: You Are Not Broken
Host: Dr. Kelly Casperson, MD
Episode: 363 – Mesh, Vaginal Estrogen, Female Urology, and More with Dr. Una Lee
Date: March 22, 2026

Episode Overview

This episode features an in-depth, candid, and highly practical discussion between Dr. Kelly Casperson and Dr. Una Lee, both leading female urologists, on pivotal issues facing women’s pelvic health. They explore the impact of vaginal estrogen guidelines, the lived experiences of women navigating Genitourinary Syndrome of Menopause (GSM), the saga of pelvic floor mesh, and the evolving workforce and multidisciplinary solutions for female pelvic floor disorders. Their conversation blends science, patient-centered care, professional insight, and a dash of humor—delivering truth bombs and actionable information to help women advocate for their health.

Main Discussion Points & Insights

1. Personal Introductions & Shared Career Paths

[00:25–01:55]

• Dr. Casperson and Dr. Lee reflect on their parallel careers:
  • Both have over 14 years in practice.
  • Both are academic urologists in Seattle, with Dr. Lee as department lead at Virginia Mason Franciscan Health.
• They reminisce about meeting pre-pandemic, illustrating their close professional network.

2. Vaginal Estrogen, HHS/FDA Boxed Warning, and Dr. Lee's Impactful Research

[02:12–07:38]

• Dr. Casperson shares her advocacy at HHS leading to the removal of the black box warning on vaginal estrogen in November 2025.
• She highlights Dr. Lee's study: Of women prescribed vaginal estrogen, 30% did not use it because of the boxed warning, demonstrating the harm of misinformation and regulatory obstacles.
  • Dr. Casperson [03:06]:
    “When she goes home and reads the boxed warning, 30% did not use it because of the warning label... That was your paper.”
• Dr. Lee discusses grounding research in patient experiences—using both quantitative surveys and a qualitative Reddit analysis to capture real barriers and fears.
  • Fear of side effects and cancer remains prevalent, despite safety data.
  • Patients ask highly practical questions about medication use and sexual activity.

3. GSM: Stigma, Suffering, and Balancing Harms

[07:40–10:39]

• The conversation pivots to the lack of information about GSM and its long-term effects:
  • Many women aren’t informed that untreated GSM leads to pain, tissue atrophy, reduced sexual function.
  • Dr. Casperson [09:05]: “Nobody told me my vulva was gonna disappear. Nobody told me my orgasms were gonna change.”
• Dr. Lee underscores the disconnect between the fear of medication and the real harm from not treating pelvic atrophy.
  • Even supplement-heavy patients hesitate with prescription estrogen due to stigma.

4. Disseminating Guidelines and Improving Education

[11:32–14:54]

• Dr. Lee explains how qualitative research led to quantitative studies (e.g., about barriers to GSM care).
• Dr. Casperson calls for similar studies on women’s experiences with testosterone, and for better tracking (“receipts”) of female testosterone prescriptions.
• Discussion on spreading the GSM guidelines:
  • Successes after black box removal, but ongoing need for education for primary care, gynecology, urology.
  • Dr. Lee: “It’s absolutely education, awareness... lots of specialties could take this on and embrace it.”

5. Shocking Data on GSM Under-Treatment

[14:54–16:41]

• Key stat: Only 9% of women with a diagnosis of GSM received a prescription for vaginal estrogen within 18 months [14:54].
• “Third highest group of prescribers was urologists—despite there being so few!”
• GSM is extremely prevalent (50–80% of women), yet massively undertreated.

6. Widening the Knowledge Network

[17:04–17:53]

• There’s a gap between specialties: seminal papers about vaginal estrogen may be published in menopause journals but missed by urologists.
  • Dr. Casperson [17:04]: “Who sees overactive bladder patients? Pelvic floor people. Think vaginal estrogen!”

7. Patient Impact & The Value of Listening

[17:53–19:17]

• Both highlight life-changing improvements with proper hormone therapy, compared to the distress of untreated pelvic issues.
• Patient-centered research is the evolving priority—shifting academic focus to what truly matters for patient quality of life.

8. The Mesh Saga: History, Complications, and Lessons Learned

[19:48–32:18]

• Background: Both trained during the rise and fall of vaginal mesh kits for pelvic organ prolapse.
  • Mesh was introduced based on success with male hernia repairs, but vaginal mesh for prolapse and incontinence surgery led to high complication rates (20–40% for some products).
  • Dr. Lee: “The informed consent process and the surgeon-patient relationship is paramount. You have to know what you're getting into.”
  • Complications include pain, erosion, obstruction, and difficulty urinating—especially severe in women with untreated vaginal atrophy from menopause.
  • Dr. Casperson [28:04]: “If you have mesh in your pelvis, you have vaginal estrogen until death do you part.”
• Gender disparity: Men’s prosthesis complications don’t result in device bans, but women’s mesh complications led to class-action suits and bans in many countries.
  • Dr. Casperson [29:26]: “The level of risk tolerance in men versus women is different. The rules are not applied equally.”

9. Pelvic Floor Health: Workforce, Therapy, and Access Gaps

[32:24–40:44]

• Urologist workforce is shrinking; there is a looming crisis in providing care for an aging population with pelvic floor disorders.
• Pelvic floor physical therapy is extremely effective and underutilized:
  • Many patients see surgeons before ever being referred to pelvic floor PT, despite strong evidence and new therapies (e.g. Bulkhaamid).
  • Dr. Lee is leading funded research to disseminate information about the efficacy of PT for urinary incontinence.
• There is a surge of commercial pelvic floor trainers and “predatory” wellness products, often marketed to desperate women; evidence remains limited.
  • Emphasis on individualized care and access to qualified specialists.

10. Systemic Barriers & The Future of Access

[40:51–42:54]

• Barriers to care are multifactorial: reimbursement, burnout, specialist shortage, lack of support staff, and system design.
• Need to rethink profit drivers and physician burnout to improve patient access and care quality.

11. The SAFETY Consensus and Looking Ahead

[43:33–47:46]

• Dr. Lee: “There’s consensus that vaginal estrogen is safe and effective—everyone agrees. That’s why the black box warning came off.”
  • Black box removal was a collaborative achievement, years in the making, enabled by strong evidence and cross-specialty advocacy.
  • Urologists became leaders in GSM advocacy, supplementing traditional gynecology work.
• Making it over-the-counter: Given the safety profile, the next likely advocacy push is for OTC access to vaginal estrogen, solving persistent access barriers.

12. Patient-Facing Resources & The Future of Education

[47:46–49:46]

• A patient-friendly GSM guideline is in the works to complement the dense professional version.
• Dr. Casperson advocates for patient education as a critical third pillar of academic medicine:
  • “You can change the world by publishing... you can also change the world by educating the average person.”
• Consensus that empowering patients and raising health literacy is vital, especially for quality-of-life (QoL) interventions that don't fit the traditional FDA model.

Notable Quotes

• Dr. Casperson [03:06]: “30% of women did not use [vaginal estrogen] because of the warning label, which we all know now was incorrect and has been removed.”
• Dr. Lee [05:38]: “Women are getting the prescriptions now… but a doctor does not have time to educate on how to use this product. And this product requires some troubleshooting. For example, do you know what your vulva is?”
• Dr. Casperson [09:05]: “Nobody told me my vulva was gonna disappear. Nobody told me my orgasms were gonna change. Nobody told me that sex was Gonna be painful. Like the harm that happens from living without hormones.”
• Dr. Lee [19:56]: “The informed consent process and the surgeon-patient relationship is paramount. You really have to know what you’re getting into.”
• Dr. Casperson [28:04]: “If you have mesh in your pelvis, you have vaginal estrogen until death do you part.”
• Dr. Lee [43:33]: “There’s consensus that vaginal estrogen is safe and that it’s effective. Everyone agrees. That’s why the black box warning came off.”
• Dr. Casperson [47:58]: “I truly think patient education should be the third pillar of academics. We do the research, we take care of people, but we need to educate people.”

Timestamps for Major Segments

• [00:25–01:55] – Personal/professional introductions
• [02:12–07:38] – HHS panel, boxed warning, Dr. Lee’s estrogen research
• [07:40–10:39] – GSM, stigma, and untreated health consequences
• [11:32–14:54] – Study design, guidelines, and spreading information
• [14:54–16:41] – GSM under-treatment statistics
• [19:48–32:18] – Mesh history, complications, and informed consent lessons
• [32:24–40:44] – Urology workforce and pelvic floor therapy
• [43:33–47:46] – Vaginal estrogen safety consensus, advocacy, and OTC future
• [47:46–49:46] – Need for patient-facing resources and health literacy

Memorable Moments

• Dr. Casperson’s story of a bladder cancer patient more grateful for vaginal estrogen than her cancer cure.
• The vivid critique of gendered risk tolerance in surgical device regulation.
• Dr. Lee’s ongoing, patient-centered research—qualitative, quantitative, and the quest for better patient-facing education.
• Shared commitment to advancing education as advocacy, for both clinicians and directly to the public.

Final Takeaways

• Vaginal estrogen is safe, effective, and underused—stigma and misinformation are major barriers.
• Access to care is limited by knowledge gaps, regulatory and systemic barriers, and workforce shortages.
• A multidisciplinary, patient-centered approach—including pelvic floor physical therapy and improved education—is essential to improving quality of life for women.
• Advocacy for better guidelines, OTC access, and direct patient education continues.

For patient resources, guidelines, and more information, visit KellyCaspersonMD.com.