363. Mesh, Vaginal Estrogen, Female Urology and More with Dr. Una Lee

Summary

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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

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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.

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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.

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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.

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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.

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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.”

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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.

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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!”

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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.

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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.”

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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.

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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.

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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.

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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.

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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.”

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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

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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.

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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.

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

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Transcript

[A]

Welcome to youo Are Not Broken, the

[B]

podcast that challenges everything we've been taught

[A]

about midlife hormones and sexuality. I'm Dr. Kelly Casperson, board certified urologist, author, and a leading voice in women's sexual and hormone health.

[B]

Enjoy the show. Hey, everybody. Welcome back to the youe're Not Broken podcast. I have my good friend Dr. Una Lee on today, another female urologist. Yay. Thank you for coming.

[C]

Hello. Hello, everyone. Thanks for having me. It's actually my first time. We've talked about it before, but I'm. I'm taking the lead.

[B]

Been talking about you getting on this podcast for, like, years.

[C]

I'm a little.

[B]

Not that I'm shy.

[C]

I'm not shy, and I'm not introverted, but I'm reserved, I'll say that. And I have a lot to say. But I feel very strongly that it should be said in a way that's meaningful and authentic and in the right space, in the right time.

[B]

Oh, well, thank you for picking my podcast as the right space for all of your knowledge. This is fantastic. When did we meet? I feel like. Have we met before? Sufu, which is the Society for Urodynamics and Female Urology 2000. We met before the pandemic was happening. Maybe I, like, you're just imprinted in my brain at that moment. Cause that's when, like, the shit went down with the pandemic. And we were all in Scottsdale, Arizona, at a SUFU meeting.

[C]

Yeah, we definitely met before that. We've been in parallel circles.

[B]

Do you remember that, though? Because, like, CNN was like this nursing home in Seattle.

[A]

Mm.

[B]

That was the beginning of the pandemic.

[C]

Yeah. Well, how many years have you been in practice?

[B]

Have you been out of 14 this year?

[A]

15.

[B]

I graduated from residency 2012. Yeah.

[C]

So we're in the same cohort. I was. I've been in practice 15 plus years. Yeah.

[B]

Yay. How long have you been in Seattle?

[C]

Same amount of time.

[B]

We're even more alike in this podcast.

[C]

We are basically the parallel.

[B]

Oh. We're the same cohorts. I love it. So you've been in academics this whole time at Virginia Mason?

[C]

Yes.

[B]

And you are now. I'm going to put it into your mouth.

[C]

You are now the program director, section head, physician lead. So I don't lead the residency and the fellowship, but I do help lead the fellowship. I lead the department, and I lead urologists across the system of Virginia Mason Franciscan Health.

[B]

That's big. The cool thing most recently is that I quoted your paper when I was talking at HHS to catch anybody up who has been under a wooden box. I was at Health and Human Services. So FDA is underneath the umbrella of hhs, right? So HHS announced the box warning coming off of estrogen products November 2025. And I was one of the five speakers on stage. And so they were like, we want a five minute speech. Great. Wrote the five minute speech. They then they were like, it's a two minute speech. Now we're like, okay. So it's not easy to do to cut a five into a two. But I did it. And what I got to keep in the speech was your data showing if a woman is lucky enough to see a doctor get properly diagnosed with genital urinary syndrome of menopause and receive a tube of vaginal estrogen or vaginal estrogen product, when she goes home and reads the boxed warning, 30% of women did not use it because of the warning label, which we all know now was incorrect and has been removed. And that was your paper that you published in the publicity journalist section of the arena. Somebody's like, who was that? Like, they called me on it. They're like, what was that paper?

[C]

Yeah, they said, how do you know that that black box warning was a barrier? And you were like, because Una Lee's study showed that it was a barrier. And that was the point of the paper, was that fear, misinformation and cost were barriers to women receiving treatment for GSM genital urinary menopause. And we surveyed 1,500 women across the country, and that was some of the findings. And sometimes we do research to demonstrate what we know. We know that you know that, right? You see that all the time in your practice. But we needed to have the statistics to show it. And so that's why we did that, that survey, to show. Because we wanted to document what we experience in our practices and what we see. So, yeah, that was cool.

[B]

Well, I mean, it made a world of difference. And, like, even so, I was like, literally on stage quoting your paper to the dude who was like, right. And in my head, I'm like, hold on, why don't we have more of this for the systemic hormones? How many people don't use it? Like, and to think of actually how unique your paper was because they were like, what? It's not been published? How many women don't use these medications because of the box warning? Like, it was a very unique data point. And to me, I'm like, it takes these intersections, right? Of, like, the fact that I'm a Urologist. I read urology journals. I have urology friends. So I knew about that paper. And at the same time, I'm in the menopause advocacy hormone world to. It takes those. The Venn diagrams to be able to pull it all together.

[C]

Right. And I kind of remember when that journalist raised his hand, everyone kind of looked at each other like, well, I don't know. And you were like, I know these are the facts that have been in our literature that the fear of side effects that are promoted in that are a barrier to women not only actually using the treatment, getting the treatment. There are access barriers. Right. But there's actually. They have to actually put it onto their tissues.

[B]

Yeah. You know what I'm seeing, I'm seeing right now, and so I need to create more content about this is women are getting the prescriptions now. And it's been an explosion since the hhs and the box warning are coming off like, which is crazy in and of itself because you're like, estrogen actually didn't become safe on a Monday. It was actually always safe. But now doctors are like, and I get it, we're busy, blah, blah, blah. But it didn't become safe on that Monday. It's been safe for decades. But because of that Monday and the social media and the CNN and like, the knowledge explosion from that Monday, estrogen's safe again. And so the prescriptions are happening, but the barrier now is a doctor does not have time in their office to educate on how to use this product. And this product requires some troubleshooting. For example, do you know what your vulva is? Right. Like, it's. There's a lot of knowledge barrier toward it. So on my Instagram, I get a lot of people being like, I got a prescription. What do I do with this thing? Right. And it's like, we don't have time in the clinic to teach on this.

[C]

Yeah. So that was actually one of the first papers that we did on GSM is that we went on Reddit and reread every single post that patients, users talked about gsm. It was fascinating. And then we did a qualitative analysis, which is like a. Basically reading and looking for themes and quotes.

[B]

I call it Brene Brown Research.

[C]

I love it. It's like, to me, it is patient centric.

[B]

Yeah. It's her whole shtick is like, let's listen to a bunch of stories and see what we learned from it.

[C]

Yes. And that's what it is. And honestly, that's the kind of research I'm leaning into. Right. Now, because I want to better understand the patient human lived experience so that we can meet your needs better, so that we can help you, so that I can. So there's not a gap in understanding and that we can meet that gap.

[B]

So what'd you learn from the Reddit gsm?

[C]

The Reddit gsm. It wasn't a GSM thing, but we searched for everything they wrote about it. Number one, they were engaged and passionate and knowledgeable, but they had a lot of questions about the medication uses, the alternatives, the fear of side effects, the fear of cancer. Right. All the things that we kind of hear from our patients. But it was over and over and over and, you know, just a lot of practical things like how do I do this and have sex? Right. Do I have to take a break? Da, da, da.

[B]

Like, very practical things, big questions about how does it affect the man? And there's a paper on that. They studied it. They studied men's for. Just for anybody who wants to know that answer to that question. They took men's blood levels before and then eight, like eight hours after having sex with somebody who had vaginal estrogen product in their vagina. And it does subtly raise the man's estradiol level, but not above a man's normal estradiol range. And then people are like, men have estrogen. And you're like, yes, men have estrogen. So I always say, don't use it as a sexual lubricant.

[C]

And if you can't avoid it that evening, don't use it that evening. Right. But it would be fine. It's not going to harm anyone. And so what I learned from that was just again, that patients had a big fear of the side effects and the fear of cancer. And I think that's a very real and deep seated emotion in women is that they don't want to cause any harm to their bodies. And because they felt like this was causing harm, they were like, I'm not touching it. And we know that's not true.

[B]

That's a very interesting one side of the coin, because the corollary is there is harm done to the pelvis and the vagina and the vulva because of low hormones, whichever way you have hormones, right? So there's harm by not treating. And yes, there are always risks with any medication. But what I hear over and over and over on social media is nobody told me my vulva was gonna disappear. Nobody told me my labia 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. Nobody told me about that either. So then you're in a balance. You're like, well, which harm would you like?

[C]

Right. And we know that the benefits outweigh by far 100,000 times. But I don't think people realize that your vaginal. Because I do vaginal exams every day, 20, 30 times a day. And the tissues look and probably feel terrible to that person. Right. Pale red, fragile, bleeding, uncomfortable. That's what happens untreated. And we have great treatments. So it's interesting that a woman would rather suffer with that than apply a product that is safe and effective.

[B]

And I think even the stigma, the stigma that it's a prescription met a woman in Texas who built a special cupboard in her kitchen for her supplements. That's how many supplements she buys but would not do vaginal estrogen because it was a prescription. And having that conversation of what are you making it be a prescription mean?

[C]

Yeah, I mean just the stigma of hormones.

[A]

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[C]

But anyway, so that study was helpful to just really get deep into that patient perspective. And then actually the study that was quoted that you quoted in the HSS presentation was the follow up study. Because I was like, oh, this is fascinating and I want to document it in a more quantitative way. So that study was take a big sample and ask these questions that were generated from that study. So that's kind of you can. Each study generates the next study.

[B]

I love it. Okay, so this is what I need. This is what I need from your team. Delegate as your time allows. I need a quantitative study on women's opinions about taking testosterone because they want to talk, and nobody's listened and done a Brene Brown on that. Can you do a Brene Brown on women's experiences taking testosterone? Because there's lots of fascinating things going on there. The other thing I need is so I now can talk to HHS people. And so I was having a meeting after that Monday, and I was like, we need a female dose testosterone. It is ridiculous that we're microdosing and we're pelleting and we're compounding. And he's like, yeah, but is there really actually a need for it? I don't have any receipts, but to the best of the expert's knowledge, there's as many women in America on testosterone as men are on testosterone, but we do not have receipts on that.

[C]

What do you mean by receipts? Like data info?

[B]

Yeah. You can count in a Medicare database how many people take Ozempic, but when Ozempic's compounded, you can't measure that. Mm, I see. Right. So when you're taking a male dose testosterone or you're compounding or you're pelleting, there's no database. Right. So I can tell you how many men are on a testosterone prescription, but I can't tell you how many women are on a testosterone prescription, and that's a disservice to the women. I put that in your brain to think about.

[C]

I'm going to ponder that one. We did debate it highly, very vigorously at the GSM guidelines panel, and the data was reviewed. I don't think it made it into the guidelines, but it is. It is. The data is accumulating and will be followed very closely. Vaginal testosterone, testosterone in general.

[B]

Okay, well, because vaginal testosterone is different than systemic testosterone, just like vaginal estrogen is different than systemic. So I'm like, what are these? What's the GSM guideline people doing with systemic testosterone? Great. Great. If they are.

[C]

Yeah. I'll think about it. I'll have to look back.

[B]

So now that. I mean, people. I think people who listen to me know that there's GSM guidelines. I've had Dr. Rachel Rubin on talking about it. She's very vocal about it. It's phenomenal. Just in the validation of how women can advocate for themselves when they go to the doctor. So now I say print out the GSM guidelines and bring it into your doctor. How do you see it best, that information shared so that the primary care doctors know that there's guidelines, that this is legitimate and very effective and very safe? Like, once it's Written. How do you spread it? Because it does no good to just sit on the AUA website if nobody knows to read it.

[C]

Well, I think the black box warning coming off helped a lot because it was in the lay press. And so primary care is now reaching out to me on education and they want to embrace it and they feel like they can. And so I think it's definitely education, awareness, absolutely. Primary care, general gynecology, general urology. I mean lots of specialties could take this on and embrace it and see and manage women with this issue.

[B]

Have you. I do not mean to put you on the spot, but there was a recent paper just published in JAMA out of Stanford looking at Medicare databases up to 2018 and a couple of takeaways from it. Number one, if you were lucky enough to be properly diagnosed with gsm. So these are like, think of all the suffering women and how many actually go to the doctor? Okay, so there's a fraction, right, but and then you go to the doctor, did you get properly diagnosed with GSM or not? That's another fraction of the people with a GSM diagnosis. What percentage of them got a prescription within 18 months of vaginal estrogen? 9%. So think of that funnel. Think about this is how under treated GSM is of like you actually went to the doctor, you actually got the right diagnosis. So this is diagnosed with GSM. 9% got a prescription for vaginal estrogen. Now one can hope that it's better now than 2018. One can hope that. The other shocking thing about that paper was guess what? The third top group of prescribers was urologists. So it's like, and you know, there's not a lot of us. So you're like, if we were the, like you had to get to a specialist to get your vaginal estrogen, right? Like that's how undertreated. And we know GSM, 50 to 80% of women will experience it.

[C]

Oh yeah, the prevalence is high. It's almost like you have to assume you have it. It's a combination, right, of the signs and symptoms.

[B]

How are some women not getting it? Right? Like I think some people just have a little bit more estrogen in it in them. It's funneled to their pelvic structures. But like in a state of no to very minimal hormones. How do some people not have gsm?

[C]

The appearance of GSM on exam and no or less symptoms. There are people who look healthy and have symptoms and there's every combination in between, right? And the symptoms are a constellation. But I would Say if someone's walking into my office, 50 plus, 45 plus, I assume that that's a factor in their situation, especially cause they're walking to my office. So they have something going on.

[B]

Well, for any urologist or any pelvic floor person, urogynecologist, et cetera. And this is again going into the Venn diagram of knowledge, because where is the paper published that vaginal estrogen is equivalent to anticholinergics? Where's that paper published? The Journal of Menopause. How many urologists are reading that journal? Five maybe. Which is five more than five years ago. So it's like that overlap of. They didn't publish the anticholinergics equivalent to vaginal estrogen in the urology journal. But who sees the overactive bladder patients? So we just have to get like, you know, if you're a pelvic floor person, think vaginal estrogen. When women come in with recurrent UTIs, overactive bladder, bladder urgency, dysuria, all of the things microhematuria.

[C]

And think about all the women who get treated and they come back amazingly better, right? Like it's such a rewarding part of a clinical practice or as a patient to have some of these symptoms going on and then you get treatment and one, two, three months later, you're like, I'm so much better. That was life changing.

[B]

I gave up surgery for hormones, Una. Like that's how life changing it is. And pulling out a distal kidney stone is pretty damn rewarding in my opinion. And I was talking to somebody about this yesterday of like the thousand little cuts that like made me become. What I do now is this woman came in, she had bladder cancer. It was low risk, superficial bladder cancer, took it out, was doing her surveillance cysto, you know, this fine bladder cancer won't come back. It was super low, minimally invasive. And she's like, that's nice that you cured my bladder cancer. Like, thank you. But that's not what changed my life. You gave me vaginal estrogen. I had seen two nurse practitioners, another doctor for my recurrent UTIs, the absolute pain with sex. They just kept throwing antibiotics at me. Nobody helped me. You gave me vaginal estrogen and my life has changed. Like, I'm all, I'm all better. And I'm like, here I am curing bladder cancer. And that wasn't the most important thing to her, right? It's like those stories are the stories that like change your career.

[C]

Well, that's also again, all my research has evolved over the years to Be patient centered. Because what really matters is not what a scientist thinks, not what a researcher thinks, not what a doctor thinks, what we think. The research questions are, the outcomes are, the studies are. There's tons of amazing scientific literature, but what really matters is what patients need and want. And it's been mind blowing in a great way to change the paradigm. And so it actually all started with mesh.

[B]

Let's talk about it. Because that was mesh and the mesh paper was the reason I wanted you on the podcast to begin with, like years ago. So both of us trained. Now that we know that we trained at the same age, both of us trained in the world of pelvic mesh kits for pelvic organ prolapse. It was an extension of hernias, right? So male inguinal hernias, they use mesh because it's stronger than your body. And they thought, well, let's put this down in the structures surrounding the vagina and see if it makes prolapse, which is a descent of the pelvic organs through the vaginal canal. Let's see if that makes that come back less. Because if you get a surgery for pelvic organ prolapse, recurrence rate is around 10% plus or minus. Now we have robotic sacral copepexies, which are a little. Which are even better. But putting mesh in via the vagina, so that's via the pelvic vaginal approach, was probably the standard of care for a while. So we brought it in and then we took it back out. That's my little history lesson. Please add or correct as needed.

[C]

Okay, so yes, we saw mesh rise and mesh decline right in the use in the pelvic floor. It's used for stress during incontinence, a midurethral sling. And it was used for prolapse in two directions. Either put in vaginally through the vagina with big sheets, or put in abdominally to support things.

[A]

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[C]

So three different uses and we kind of think of it as one bucket, but it's really three buckets.

[B]

We just say mesh, but it's best to specify when we're talking about risks. Yeah, yeah.

[C]

So it started with slings. 1997, 98. The midurethral sling was brought on the market after some study and it revolutionized the care of women who leaked. Right. It really was more durable, more effective than the prior procedures, which was the Birch procedure, which is a suture based stabilization of the urethra. And millions of women benefited and continue to benefit from this. The problem was twofold, was that these mesh kits got introduced under the same process. Like saying, oh, they're just like slings, just let us do them. And they got put in willy nilly into probably poor candidate people or lots of different reasons they were put in. And the complications rates were too high. 20, 30, 40%. That's way too high. Eroding through the walls. Pain, pain with intercourse, bad problems with the mesh in that category for pelvic

[B]

organ prolapse, vaginal mesh specifically. Yep.

[C]

And what happened is millions of women who had mythrethral slings successfully. A portion of those 2 to 6% had problems with mesh slings too. And unfortunate. But you can have a complication anytime. You're putting polypropylene mesh, which is essentially plastic, for all the benefits and all the great things it does. There's also a subset who's not going to do well and it's going to have complications. When you take on surgery, and I don't know if patients really realize it is you take on all the good, the best case scenario and you take on the worst case scenario too. You consent to that, you consent to the 90% success rate, but you also consent to the 2% complication rate. And so what we saw was women who did great with slings. But you also said women who had horrific pain, horrific erosions, horrific obstruction, can't pee difficulties. And so I trained at places where we saw a lot of these complications and managed them. And then I moved to Washington State and I continued to help women with this problem. And I just had such a heart for these women. I really believe them. I really listened to them. I could really help them. And they often couldn't find help other places. Right. People didn't believe them. People didn't listen to them. People didn't want to help them. People didn't have the skills to help them. So I get it. It's not like a judgment. It was just. It's a difficult situation. Some of the women had slings who didn't even need a sling right there. Was there something called a prophylactic sling or preventative sling?

[B]

Like, we did that for a while. There were studies on this of like, if you put in a midurethral sling at the same time as prolapse, they were less likely to have stress incontinence after what we unmasked stress incontinence after the prolapse was fixed. So sorry. For. For anybody who needs Intro 101 on pelvic organ prolapse, I do have a previous podcast. This is. We kind of brought everybody in at the 301 level today. But. But for the people who are already educated, they can handle this. I got a lot of smart people. So they did that for a while. They just put in midurethral slings at the time of pelvic organ prolapse because a risk of fixing especially severe pelvic organ prolapse is that you unmask stress incontinence because you're kind of not kinking it off with the prolapse. So anyways, they did that for a while and then it kind of got to the like, well, you know, if you leak afterwards, then we'll think about doing a sling. Not that the surgery failed, but it unmasked this other issue that you had. Right.

[C]

So your experience, my experience, we've seen lives uplifted and such benefit from treating their prolapse and their incontinence with or without mesh. We've seen lives devastated. The pain that I have firsthand walked aside. Patients with. I've taken out so much mesh surgically, and I've learned so much from it. And patients have learned, doctors have learned. We've all learned a lot from this process. But some of the things that we've learned Is that the informed consent process and the surgeon patient relationship is paramount. You really have to know what you're getting into. And patients need to be properly selected, properly counseled. Not everyone's a candidate. Some of the worst complications were in patients who I kind of thought like, you know, and I did, actually, I did a study on this high level of immunosuppression, obesity, other comorbidities, chronic pain conditions, psychiatric conditions. For whatever reason, these tissues did not like this foreign body. It's the pelvic floor, it's the urethra, it's the vagina, it's the bladder, it's the rectum. These tissues are sensitive. And to think that you could put sheets of plastic in, in a sexually active, physically active, urinary, active bowel, active organ, it's a big supposition, It's a big deal.

[B]

And I think, I mean the other thing. Just as far as violation of surgical principles, let's go back to our GSM data on how many women with genital urinary syndrome and menopause are actually getting treated for that. Right. So now we're putting in surgical mesh, creating an incision, putting in a foreign body in tissues that are substandard. Cause they've never been optimized. And we know pick an area of the body you want, as good of a surgical real estate as you can be. And how many of these really bad surgical mesh complications are in atrophic pelvises that were never given vaginal estrogen for treatment in the first place. And to me, I'm like, if you have mesh in your pelvis, you have vaginal estrogen until death do you part. You've got to keep your tissues healthy, resilient, thick, well vascularized. Like that's part of the responsibility of taking care of your pelvis post surgery.

[C]

And your tissues evolve. You maybe had a successful sling 10 years ago.

[B]

And as your tissues when you were 47. Yeah.

[C]

Lose the level of estrogen, the erosions come through the tissue. The literally fibers of the polypropylene mesh come through the wall. And it hurts. It's not pleasant, it's discharged. Bleeding, pain, uncomfortable. You know, people are kind of confused, like, what's going on. So mesh in itself isn't bad. Right. We use mesh for hernias, but that's a different part of the body. That's the abdominal wall. Is that wall having sex? Is that wall lifting groceries? Is that wall like peeing and pooping?

[B]

Pooping and peeing around it?

[C]

Yes, It's a very intimate Part of the body with a lot of sensitivity. And I'm not against mesh. I'm not, you know, I use midurethral slings, I use copepexy mesh. To fix prolapse. We just have to be judicious and careful and have such respect for those tissues. And when we're using it and how we're using it and not just willy nilly put it in people, which I don't think people really did. But at one point in that peak, it was, it was getting put in very rampantly. I think there's a lot of lessons is that you have to have the experience and stick with your patients. You know, if they have a problem, believe them, examine them, and please know

[B]

about the effects of low hormones on pelvic structures. If you're gonna be a pelvic surgeon, like, come on. You know what's very interesting about that is what's kind of an equivalent surgery in men? I would say the inflatable penile prosthesis. So it can be life changing for people. This is for severe erectile dysfunction. So it can be life changing for people. But when it goes bad, man, it goes bad. You've got plastic tubes jutting out the tip of your penis, infections removal, right? Complete impotence afterwards. Like when it goes bad, it's bad. When it goes good, it's good. Now, when a man has a bad penile prosthesis surgery, do we ban penile prosthesis surgeries for all men everywhere in multiple nations? No, we don't. When women have bad pelvic floor prolapse options, do we ban these? Do we get rid of all the kits? Yes, we do. And we got rid of the midurethral slings in multiple countries after this happened. And my thesis is the level of risk tolerance in men versus women is different. The rules are not applied equally. Because when a guy gets a plastic rod through his penis, we don't pull it out of countries because we say a man's sexual health is important. Of course that's a risk. These are the things I think about as a urologist in implying the gender disparities and how we think about risks and what's tolerable this is for a man's sex life, let alone like, you can't urinate in a woman. Right. But a man's sex life is important. We're not going to ban these surgeries. So has that ever crossed your mind, like they pulled midurethral slings out of multiple countries because of this? When the pelvic organ prolapse mesh was really the big beast.

[C]

Yeah, I mean, I have a heart for this area. And so hundreds of thousands of women's lives were devastated. And so the sheer number. Because if you think about the prevalence data, right, like, yes, penal prosthesis is a small number. Right. And so they can manage this. It's not like a public health issue. This was an FDA safety issue. Because if you think about it, millions of slings have gone in over time. And if you, my calculations are 2 to 6% have some form of complication, that's still hundreds of thousands of women. And as you know, there was litigation and all this stuff. So I do think it was just. It was real. It was real and there was real

[B]

and it was big.

[C]

It was big by the numbers. Because if you think 50% of women have incontinence, many women have prolapse and not, not as many as incontinence. Honestly, it's a smaller number, but just by the sheer number, it just mounted. It just hit a tipping point where it affected so many women that they had to pause and figure out what was going on.

[B]

But to remove midurethral slings, and they did. They didn't remove it from America. These days I'm all about quality over

[A]

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[B]

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[A]

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[B]

hear from the British ladies and the European ladies and they're like, I'm just peeing my pants. I can't exercise. This is not cosmetic. As much as I don't want to dismiss cosmesis, but like, this is a legitimate medical Problem that where options were taken away. Now, I think the silver lining of that is balcomid became a thing. They developed a better bulking agent. I know you do. Bulkhamid. I love bulkhamid. But so, like, when the gap opens, more options come in. Right. So I think that's the good thing. Well, let's talk about the workforce in 30% of women will have bladder leakage. Pelvic organ prolapse surgery is becoming. Because hysterectomy rates are going down, pelvic organ prolapse surgery is becoming one of the more common surgeries a woman will need in her life. And think of how many people are untreated. Right. We don't have a workforce to support the aging population with pelvic floor issues. And it's not getting better. I'm part of the problem.

[C]

Also, you have other gifts you're giving to the world at this moment.

[B]

I have other gifts.

[C]

I see women with prolapse and incontinence every day. Highly prevalent people don't really talk about it, and they feel a lot of validation when someone listens to them. And I think that's another theme I would talk about, is just patience. Women. I mean, I see women, a lot of women, but they want to be heard, listened to, acknowledged, and that means everything. You know, I think if you can listen more than you talk in a visit and really try to understand what their priorities are, what their problems are, what their goals are, they will really appreciate that. And I think prolapse or incontinence and GSM and mesh complications and overactive bladder, all the things that we deal with, recurring UTIs, pelvic pain, all the things we deal with are areas that have been marginalized and not hard to find good care and hard to find answers. Sometimes it's not an easy peasy thing. It's multifactorial.

[B]

It's tough. It is a tough. The pelvis is complex and so is the neck. Like, there's lots of complex parts of the body, but the pelvis is complex. And like you said, you have to have sex through it, poop through it, pee through it, not get it infected. There's a lot of players.

[C]

It is the basis of everything. Your body's resting on it, right? And so when you talk about someone being physically active, if this isn't working, how can you be physically active?

[B]

Oh, yeah. And like a hip issue will throw off the bladder. Everything can destabilize the pelvis as well. Just. I sent you a text which I have not validated but it was like the amount of urology jobs currently posted is 10% of the urology current workforce. We can't just, we have a big workforce issue. Urogyne is helping on their end. Absolutely. Pelvic floor physical therapists, God bless them, powerful, essential. I mean how many patients came to me, that's the other interesting thing. How many patients get to me, the surgeon with surgical options before they've seen a pelvic floor physical therapist. The patients don't even know these people exist. But it's like perhaps they'll referral to pelvic floor physical therapists because they fix a lot of things.

[C]

How many people could be cured with engagement with a pelvic floor physical therapist? And doing patients want that. They want the natural choices when they have the options.

[B]

Yeah, yeah. I would say in my experience they either want the quick fix, they think surgery is a quick fix. Which like you said, you got to take the wins of the quick fix with the, the not wins of sometimes it's not a quick fix at all. And it's a path, it's a road. I think that's why and I think a lot of patients don't know about pelvic floor physical therapy or they didn't get referred there before here.

[C]

That's my current research. It is a two year funded patient centered outcomes research initiative to disseminate evidence based information about efficacy of pelvic floor physical therapy for urinary incontinence in women. I know that's a lot of words but basically we are trying to get the word out there that public floor physical therapy is a valuable, I'll say first step for anyone with any women with urinary leakage.

[B]

Yes.

[C]

And so we're collab, it's a collaborative kind of project and we're working on getting the word out.

[B]

When I first moved to town so like 15 years ago, you know, like what you did, you did strange things in your past. You're like, oh really? I did that. Good job. But the pelvic floor physical therapists in town are still like, we remember when you came into town and you came around and had coffee with all of us and introduced yourself. And I'm like, I did that. But it's like it meant so much to them. But to me I was like, I knew that from training. I needed to know who these people were. I needed to get them into my team because they weren't in my building. They're part of pelvic floor health. I don't think you can have A pelvic floor health conversation without pelvic floor physical therapists. I certainly wouldn't want anybody to have that conversation without the pelvic floor physical therapist. Yeah.

[C]

When you have an orthopedic injury, you know that the options are going to be physical therapy or other options.

[B]

Right.

[C]

And they accept. People accept that, like, oh, if I do the physical therapy and I really stick to it, it's going to get better. It's the same way with the pelvic floor. And what's been mind blowing to me and very helpful to me is I've actually talked to a lot of physical therapists through this project and learning more and more about how it's advancing. It's not just Kegels. Right. There's so much more that they're offering and breathing, managing pressures, how to work with what you got. It is not just strengthening. I heard a really interesting thing. Kegels were designed like in the 1950s when women were not physically active. Well, now our generation and generation above and below us are more active. And so we don't need the strengthening. Not everyone, Right. That's why you get people who say it didn't work because they're like, the muscles are strong, but how do you use them? And how do you manage the pressure and all the sensations in there so that you don't leak or so that you don't feel the way you do. And so there's kind of a new wave of physical therapists who are pushing the boundaries. And I love it because there's much more than Kegels.

[B]

I think that's so great. I mean, everybody asks, like, people ask me all the time because there's so many pelvic floor trainers available now with like apps on your phone and they're like, what's the best one? And I'm like, I have no idea what the best one is. How could you be. Unless you own stock in one of the companies, how could you be so certain there is a best one for everybody?

[C]

No, I think it's very individualized.

[B]

Yeah.

[C]

And again, that's why you need access to these specialists. They're also in high demand and there's poor access issues. But you need to individualize it to your anatomy, your needs, you know, your goals. And sometimes I worry some of these products are. I mean, they're trying to make money on a need that is.

[B]

I was going to say predatory, but I didn't want to.

[C]

Predatory. Predatory. But there's all kinds of predatory stuff in our field. That's an Area where people can have spend a lot of money. Patients come to me and I spent this much money on this and, and then they're still coming to me, which means it didn't get. It didn't get it resolved, right? So I see a lot of predatory products around pelvic floor physical therapy and I think the theory of it is good, right? Bring it into your own home, like make it more personalized, you know, engage and gamify it or. But I got to wonder. And then the other big One is recurrent UTIs.

[B]

Yes, totally.

[C]

I worry that they're spending money on things that are not evidence based. As long as they're not doing harm, I'm okay.

[B]

If it helps you drink more water, then yes, maybe it's working, right? But you better be on the vaginal estrogen, right?

[C]

But I don't want you spend thousands of dollars or hundreds of dollars on something.

[B]

Oh God, please don't. Sides of the coin, right? Because we've got two arguments going on. We've got this one argument that says nobody's paying attention to women. We need more innovation, we need more products, we need more things geared towards women's solutions. Other side of the coin, but now we're preying on women and we're just making money off of women. And I'm like, aren't we actually trying to solve the problem of nobody paying attention to women? Right? So I'm like, I don't think you can flip to that side of the coin without some of that. I don't think it can be done perfectly. But the opposite of where we've got all these predatory solutions is we've got no solutions, right? So I think about that because I think especially the Internet is so quick to say we're not doing enough and now we're preying on you.

[C]

Another struggle is we say go see a specialist. You know, whether a specialist physical therapist, a specialist pelvic floor person, specialist hormone person. But the access is so hard, right?

[B]

Oh well, don't need a dermatologist, that's real bad.

[C]

But my wish is that people would have better access. But I can't personally do all that I want to, but so how do we create better access to high quality, safe, patient centered care?

[B]

I think you have to change the profit drivers and you have to not burn out the people. Like that's the thing is like we're trying to replace everybody with AI, we're trying to replace everybody with less trained people. Like there's flaws in that system without saying let's address the burnout. Let's address the malpractice issue. Let's address the reimbursement issue. Let's address the fact that we've got a surgeon, but we didn't provide any supports staff for that person. So they're doing it all right. Let's have them work at the top of their license. It's so multifactorial. And I think these simple solutions aren't going to actually solve it without actually looking at the culture that we've created.

[C]

Yeah, healthcare has a lot of big problems, and that's one big one.

[B]

Right.

[C]

Access. And what's doing the right thing for patients and keeping that at the center?

[B]

Well, and at the same time, like, we're getting older, we're on multiple medications, we have multiple comorbidities. I mean, people joke. They're like, the cardiologists have done such a fricking good job of keeping people alive that now we actually have people, pretty sick people who have significant pelvic floor issues or urology issues or kidney stone issues or ankle issues, whatever they have. And so it's like we weren't even trained. Were you trained? Do you remember how do we deal with somebody who's freaking complex? Like, it's like this level of complexity that I don't think any of us got that training for, but that's the world we're working in now. What do you do when they're on 14 different medications?

[C]

I do think the silver lining to bring it back is that I think there's consensus that vaginal estrogen is safe and that it's effective. Everyone agrees. That's why the black box warning came off. That's why people have energy around this.

[D]

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[C]

because there are no naysayers per se

[B]

is the lowest hanging fruit. There were naysayers. And to me, I'm like, of course I heard them because I was on stage, right? Like, that's my job. I get to hear the naysayers. And some people did want to make this political. They're like, they just decided. And I'm like, there Was no. And then to me I'm like, it's such a lack of, it's a lack of knowing, but it's also a lack of respect for all the people who tried to do this for the last two decades. And then they saw me on stage and the four other people on stage and they're like, they just decided to do this. Of like, we stood on the shoulders of giants who have been yelling this and actually doing the research, publishing the data, going to the FDA for the first time, going to the FDA for the second time. Right. So it's like I got to be super fortunate to take it over the finish line, but not without the baton being passed multiple times to finally land in my hand.

[C]

Yeah, it was definitely a huge collaboration. There's a big history this momentum, you know, had built up over time. And I think even just, I mean, if you think about the serendipity of urology taking this on, you know, actually I had a gynecologist who talked to me about this and she said, it's interesting. I've been part of the menopause society for so long and we had a hard time achieving this. But the urologist got involved and it helped. But I think what really, I thought about what she said and I think it's because gsm, the evidence was so strong and had built up over time. Not that the hr, you know, that the systemic hormone data is also very compelling. But it helped that the urologist did the guidelines that we looked at the data, that it was safe, that it's a ubiquitous problem, that people could get behind. Absolutely. There is strength behind the hormone data too, but it's a little more nuanced. Whereas I feel like the safety profile of vaginal estrogen for GSM is low hanging fruit. It's very like easy peasy. You can say it's safe, you can say it doesn't cause cancer. And that is the truth.

[B]

Yeah.

[C]

And effective. And it works 100%.

[B]

Yeah, totally. I mean, it's over the counter in multiple countries, I think. Not this year. We've got some other big advocacy projects that we're working on this year. But I think very quickly in the future there will be a push to make it over the counter because of the access issue. Like what you've been saying of like we say see a specialist, we say see a blah, blah, blah. But even Medicare known diagnosis of GSM, only 9% got vaginal estrogen. Right. And making it over the counter to say this is safer than Tylenol, this is Safer than some over the counter things. Right? This is safer than ibuprofen.

[C]

Yeah. We have to give people that responsibility. Give people the trust and responsibility.

[B]

Yeah. And to say because of an access issue, should this. And because of access issue and because it's so safe, should this be over the counter? And I think that's the case that we'll be building. One more question before we end the genital urinary syndrome menopause guidelines that people can search for on the Internet. It's free. You can print the whole multi page thing out and bring it into your doctor. Do you have a patient facing onepage?

[C]

We're working on it. Absolutely.

[B]

Yeah.

[C]

The A Way foundation is absolutely working on it. They're the patient education part of it. We need patient facing.

[B]

Yeah, it needs to be right next to the link of the GSM guidelines. There needs to be the patient facing one so that they can. Because when I say print it out, it's a lot.

[C]

It's also, it's made for, it's like dense. It's made for academics. And honestly a lot of our medical literature is like that. That was one of my about this is that we have great data on a lot of these things. But if you don't make it patient friendly, you don't make it patient facing. How are they going to absorb it?

[B]

Yeah, totally. Well, you know, my career, I'm patient facing. Like it's, it's. You can change the world by publishing, by teaching your peers. You can also change the world by educating the average person.

[C]

And they're all important, right?

[B]

It's all important. It's like you can't do one without the other one. And I mean 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 because they don't know. And so it's that what social media and podcasts have allowed doctors to do to reach many patients. I'm like, the academics should take that on as a third pillar of academics of like we don't just teach the next nurses and the next pas, but we teach the people.

[C]

Agree. I 100% agree. I think there's different ways to educate and we need it all, you know, we need it all public facing. I educate patients one on one in a clinic room and that's super valuable. But if I could amplify that and bottle it up and what the impact of that would be. We amplify things through research, we amplify things through teaching the next generation but yes, 100%. I think that education is power and I want people to be very informed about these intimate parts of their bodies so that they can lead these fabulous lives. Right. We want. You know, another thing I've learned from all my patient centered research is that it's about quality of life. Patients want to improve the quality of their lives. That's what they're seeking. And so once you realize that that's their priority, then what can I do to help you improve the quality of life? What little step can we take forward together? Can I help you? Can I guide you, Sherpa? You know, I'm your Sherpa, because are

[B]

you ever going to get any medication FDA approved for quality of life? No, that will never happen. Right. So there's a fundamental disconnect in how the system works and what people want. I think about that a lot with testosterone, Right. Like it fundamentally improves quality of life. Why do you think it's gangbusters fire on social media because it improves people's quality of life. But you will. It's hard to measure. You will never get it FDA approved for quality of life, but that's why it's so big right now. It's a quality of life improvement. Ah. We could talk for a whole nother hour.

[C]

We could talk forever.

[B]

We could talk forever. Well, whenever you ask me to do anything, I always try my very best to say yes to you. So whatever you need. Some qualitative research on women and testosterone, though I'm gonna be a bee in your bonnet on that. Now that I know you know how to do that research, if there are

[C]

people out there who would be my little army of worker bees, then we could make that happen.

[B]

Ooh, very nice. We will talk offline. We'll find some. All right, my love, until next time. Thank you for your time.

[C]

Thank you, everybody.

[A]

If you found this episode funny, helpful, insightful, please take a moment to follow rate and share the you are not broken podcast with someone who might need this conversation too. That support is how this information reaches more people. And thank you for courses, books and my monthly membership and the Caspersen clinic information. Visit KellyCaspersonMD.com this podcast and all content from Dr. Kelly Casperson is intended for educational and informational purposes only, and this is not a substitute for individual medical coaching or psychological advice, diagnosis or treatment. Always seek the guidance of your qualified healthcare professional with any questions you may have regarding your health. Never disregard or delay medical advice because of something you've heard on this or other podcasts. Thanks for being here. And remember, you are not broken.