The Testosterone Conversation with Dr. Kelly Casperson: Beyond Libido

22:48And it looks as if there's about 30 % decreased risk of breast cancer in women taking the testosterone. Now, the critics will say this is not a randomized placebo-controlled trial. They will say it's pellet data. The critics will pull this apart. I say, if there is a hint and a whisper of anything that could remotely decrease the risk of breast cancer in women, why aren't we pouring money into looking at this? When we get a medication that decreases our risk of breast cancer by 5%, it will have a Super Bowl ad because 5 % is meaningful. Her data suggests testosterone might be more than that. More than that.

23:27And we know, again, is it physiologically plausible? Yes, testosterone appears to be breast protective. In addition, the oncology community is looking at terms, testosterone receptor modulators. Terms for estrogen, terms for testosterone. They're looking at terms, so they're actually creating medications to sit in the testosterone receptors that seem to help breast cancer. In fact, before we had modern breast cancer treatment, we gave women testosterone. So for me, when people say, when they dismiss this data, to me, I'm like, why aren't we profoundly curious with how afraid we are of breast cancer and how miraculous something would be that decreased our risk?

24:06Why is there silence on this?

24:08Dr. Mary Claire Haver:If I gave you, and this is one of my favorite questions to ask the scientists on this pod, if I gave you a blank check for research, what's your study? Can I have infinite time? Yes. Anything you want. All right. I'm Melinda Gates right now. Perfect. I want a randomized placebo-controlled trial looking at dementia prevention with testosterone. Oh, damn. I'm putting together the puzzle pieces. We've got basic science. We've got physiologic plausibility. We've got male data. We've got all these pieces. Testosterone might be dementia prevention. It might be. And people will poo-poo that because we don't have this damn 20-year, billion-dollar study on a generic drug that nobody's going to make profit off of.

24:52Right. Right? And so it's like, when it's the number one killer in Australia, why aren't we looking at everything that could be neuroprotective? But until we get that study that I want the billion dollars for...

25:03Dr. Mary Claire Haver:And until we value women's cognition as they age. Yes. I tell women, on that horrible day that you were diagnosed with dementia, on that horrible Tuesday, it started 20 years ago. We have to do something now to try to move the needle 20 years from now. But I believe, I'm like, if you wait for that study, you're going to be dead. We have to use the data we have now to make the best decisions we have now. And if testosterone is moving the needle even a little bit on breast cancer and dementia, why aren't we pounding down the doors studying this? Why aren't we? There's no money in it. You can't patent it.

25:38There's no money in women's research right now. No. In the U.S. We're actually seeing studies come out of other countries. What it costs to do a 20-year randomized placebo-controlled trial? I mean, look at the WHI, right? One billion. Billion dollars, which will never be replicated. And so to me, I'm like, that would be my dream study. It's never going to happen. And even if we started it now, we're not going to know for 25 years. I don't know. We have to make the best.

26:04Dr. Mary Claire Haver:We can measure the plaques. I think we could have enough markers for people who are at risk or start with like the high-risk people with APO. Well, so we, I mean, we have a pretty strong argument with APO4E that they should strongly consider hormones. Yeah. Like, we know that. And there's also, there's cadaver data, because I can't cut open your brain and look at testosterone in it, right? And your serum testosterone doesn't correlate with your brain levels. Whoa. So that's a problem, too, to study it. We have cadaver studies. Cadavers with a higher level of testosterone in their brain had less dementia.

26:33So it's like, we got to put together all the pieces to say, we've got this study, we've got this study, we know how it works on nerves, we know how it helps protect myelin sheaths, all of this, and we have to just, keep drowning out the naysayers who say it's only for libido, and even that is not that important.

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29:31Dr. Mary Claire Haver:like, Dr. Kelly, I just, I don't, I don't know what's wrong. I don't feel like myself anymore. Where do you start? I get the story first. What's going on? What do you mean by that? Because that might, that's a very different thing for different people. Yeah. Right. They give kind of seven domains. Yeah. So what, what do you mean? What are your goals? Like I hear the story and then we're going to check some labs. How's your thyroid? You know, do we have metabolic dysfunction going on? What are you checking? What are your labs? I check thyroid, full thyroid panel, A1C. I do fasting insulin now and everybody complete metabolic profile uh i do estrogen testosterone sex hormone binding globulin fs ferritin do you do iron studies yep yep i do those i've i've been checking oh my lord i just had a huge win with vitamin b12 the other day oh wow holy moly vitamin d vitamin d vitamin b12 i've been getting the omega check just to check people's omega-3 levels because it's nice to look at that are you doing the ratio quest has like an omega check panel And so it checks it all.

30:27So I had a woman come in, side note, vitamin B12. A woman came in, really bad chronic neck pain. She banged her head, basically. Was doing all the right things. Seeing PT, seeing a massage, seeing acupuncture, stretching, all the things. And she came to me and she's like, I'm going to quit my job because very high-functioning person. I'm going to quit my job because my pain is so bad and nothing's helping. And so we tweaked her estrogen a little bit. I checked my panel. B12 was in the toilet. like in the toilet. Reflated her B12. She came in, literally adjusted her estrogen, got her B12 up. She came in.

31:01She's like, I have zero pain. I'm like, zero pain? I'm like, six weeks ago, you were going to quit your job because of pain. And she's like, well, now I want to quit my job just to tell everybody that they should, you know, get help for and check some things. And so she went back. She's a feisty East Coaster. So she went back to her PCP and was basically like, what the hell? Why aren't we looking into this? Again, what are we talking about? Women can have biologic reasons to their health issues. I adjusted a woman's hormones. I got her to stop vaping and got her off her ADHD meds. I know we can't do that in everybody, but it was like this light switch in me of like, what if women being miserable and complaining and having these issues is not just how things are.

31:47What if we can try things and adjust things and they feel better? That is the best part of my practice.

31:54Dr. Mary Claire Haver:Is literally a woman in that 15 minute box and the way I was forced to practice would not allow me to investigate these things. And now that I can like have exploded what I can do for a woman, it is like giving women their lives back. They're just like getting back to who they were. Yeah. And so grateful. And now they're, you know, they are quitting jobs because they didn't like the damn job because they've got something else in mind or they're getting a divorce or are really like diving back into their, you know, relationships. And, you know, but they're like literally building these lives that they felt that they were meant to live and they couldn't live.

32:30Dr. Mary Claire Haver:They were limping along. Yeah. What if women feeling miserable isn't a default? And it's not just always hormones. I mean, no one checked a vitamin D. No one checked a ferritin. No one checked all these things, you know. And it's just the most beautiful medicine I've ever practiced. I gave up surgery for it. Like getting women to feel like they're themselves again is the best job on the planet. Hands down, the best job. I say, I help strong, smart women go out and change the world. They change the world. They go change the world. Yeah. Yeah. They are literally setting the world on fire once you give them their lives back.

33:03I was doing a book club with a CEO in Seattle. And she's like, I think menopausal women are going to take over the world. And I'm like, that's fantastic. They will never take over the world when they feel shitty. We must get them feeling better in order to get them out doing things. So when people, when they poo-poo testosterone, they're like, we don't have any data to say it helps energy or motivation. I'm like, first of all, we have a physiologic, biologic, plausible reason that it happens. Like, it's just basic physiology. You want to study it? Fine, that's your problem. But we have basic physiology of why this helps.

33:38there is nothing more satisfying than a woman saying, I feel like myself again. Why don't we try it? So to answer your question of how do you counsel a woman when they're like, I'm not feeling like myself, should I try testosterone or not? I say, okay, what are the things I need to think about to answer that question? Is it cheap? Yeah, it's cheap. It's a cheap. I'm not asking you to remortgage your house to try something. Is it safe? Yeah, we've got decades of safety data at 10 times the dose, female dose, very safe. Okay, it's cheap. It's safe. at normal physiologic doses? Do we have a big risk of side effects?

34:11No. We don't. Does it work in everybody? No, it doesn't work in everybody. But those are my bar. I'm like, hey, it's cheap. It's safe. Women will know if it helps them or not. And I usually say, just try it. You'll know. After about four months or so, maybe we have to go up on the dose. Maybe we don't. You'll know if it's worth it or not. So the bar to try it is so low that it's like you only have yourself to gain. Has anything else been working?

34:39Dr. Mary Claire Haver:But there's so many women out there. Like if only 4 % of women right now, at least the latest data that we had from 2023, are on FDA approved estrogen therapy, you know, plus or minus the progestogen. Do we even have any idea of how many of those women are also being offered testosterone? It's a good question. And I mean, I need receipts. Like I'm like publicly, I need receipts. So 98 % of women will never have the opportunity to even explore this. That's right. So FDA approval will have a huge validation. But here's the problem. Pellets? Can't measure those. Private company. Compounded testosterone?

35:17Can't measure it. Individualized. To the best data, and this is like chasing paper references, like the best of our knowledge, as many women in America are on testosterone as men. Wow. Wow. Now, when you add in compounded pellets. You got to add in the, so hormones are the top five compounded things, right? So we got to add in compounded. We've got to add in the pellets, which is kind of guessing based upon profitability data. They're not going to tell us. They don't tell us anything. They don't want any competition and say, this is a huge market. It's a huge market. Billions. 100 % of women will have low testosterone.

35:53Does that mean everybody's going to be helped by taking testosterone? No.

35:56Dr. Mary Claire Haver:No. But shouldn't you have the opportunity? So to me, I'm like, it's such low-hanging fruit to me. But I realize I know a lot at this point. Like, I know the male data. I know the female data. It's just so obvious to me, but I'm fully aware it's not obvious to everybody else yet. Right. We weren't taught. The vast majority. Me, OB-GYN, supposed to be the women's sexual health person. Yep. Not zero sex med. I got a message today on Instagram. I asked my doctor for testosterone, and they said, what, do you want to grow whiskers? And what do you want to grow whiskers? If that's the response your doctor gives you to that question, when ovaries make testosterone, we have a big learning gap.

36:36Big learning gap in the medical community. And you brought some testosterone with you. I brought some testosterone. So this is just one type of testosterone. This is a FDA-approved male testum, or generic testosterone gel, 1%. A male-dose testosterone, this is one a day. So this comes in that whole day. It's a lot of product. Yeah. Right? So this is one day for a man, and he's usually going to put it on his upper chest.

37:03Dr. Mary Claire Haver:So what does safe evidence-based prescription look like for a woman? So you have to take this packet and you have to say, use one-tenth of this. How are you going to do it? So you can draw it up in a syringe. You can get some syringes off of Amazon. You can kind of spitball it. I have some women who are, they like being very accurate. They actually weigh it out. Or you can say, you know what? Ten days from now, make this last until ten days from now. so you can kind of spitball it. I spitball it. But because we do not have an FDA-approved product, we're asking women to bootstrap, pay out of their own pocket.

37:37Insurance doesn't cover things that aren't FDA-approved. And they have to micro-dose. It's completely inaccurate. Very inaccurate. Or they're pushed to some people who only give you one type of testosterone. That tends to be pellets because that's the most profitable type of testosterone. Why don't you use pellets? Pellets are the highest dose. Stereotypically, it tends to be the highest dose.

37:55Dr. Mary Claire Haver:Yeah, I've never had a patient who came to me after within three months of a pellet insertion who was in a female physiologic range. Yeah, it's high. It's high. My analogy is if you're at sea level and you go to Everest Base Camp that day, it can feel kind of crappy. The body doesn't like to be shocked. Hair follicles don't like to be shocked. We actually have pretty decent data saying testosterone doesn't cause more hair loss than placebo. I believe that data. I also believe women who say, I tried testosterone and I lost hair. I believe them. So how do I reconcile these two different things? Do not go from sea level to Everest base camp.

38:34It shocks the hair. So it's not so much the testosterone as the drastic change, right? You'll lose hair with rapid weight loss, thyroid storm, surgical menopause, having a baby. It's all a shock to the body. So I think that's, and again, that's why pellets give testosterone a bad name because women are, don't make a woman lose her hair. That's not good. That's, it's very bad optics. So it tends to be the highest dose. You can't take it out. You have to wait for it to wear off. Also tends to be the most expensive dose. So what I say, and there are women who are very happy on pellets. They do not want their pellets taken away.

39:09So there's a camp that's like, ban pellets. And I'm like, well, we have FDA approved male pellets. Maybe we could actually do.

39:15Dr. Mary Claire Haver:I don't want to demonize. It's a method of delivery to the system. Yes. To, you know, of putting something in your body. We have injections. We have pills. We have pellets. We have, you know, creams and gels. But the problem, I think, is with marketing around a certain company or a couple of companies. I have someone in Houston who I think practices very responsible medicine who has the pellets compounded herself and really closely monitors the dose. And her patients like it. And she doesn't super physiologically dose and all as well. And she offers them all the options. You know, they can do the T-stem or the pump or whatever.

39:48Dr. Mary Claire Haver:But, you know, so I think there's a responsible way. I don't want to demonize a pellet. I agree. But there is some questionable ethics around, at least for us. If it's the only item on the menu, that's concerning. Yeah, very concerning. And if it's your first menu item, right? So what I say is earn your pellet. What does that mean? That you tolerate a higher dose, that you've been on it for a while. You don't have side effects at a higher dose. Now, maybe I don't want to do this daily. I want something more sustained. Okay, you've earned your pellet, right? Versus like, I had no idea there was any other options.

40:18Dr. Mary Claire Haver:Yeah, and I see that. Because I see the post pellet people who did not have a good outcome, right? All right. So now you've found a doctor who is happy to write you a prescription. They're comfortable doing it. They have education. They counsel you about the side effects. So you get this little tube. Where do you put it? Do you eat it? Do you put it on your vagina? Do you? So this goes on. Any place you put testosterone can have a side effect of hair growth, right? So some people do forearms. I do forearms. Yep. So some people do forearms. Fine. Just know that hair growth might be a side effect of that.

40:49quickly checks wrist. I do outer lateral thigh. Why? It's easy to reach. Bending over to do my calf, that's just farther to go. So I like lateral thigh. Lateral thigh has less hair follicles than inner thigh. You might get more hair if you do inner thigh. There's a subset of people who've been taught to apply it to their genitals. First of all, with a gel, that can sting. Yeah, alcohol-based. Yeah, alcohol-based. Don't do that. The genitals are very interesting. A very original male testosterone patch. was for the scrotum. Ouch. Who wants to take that patch off? But why? Because the genitals have a much higher density of testosterone receptors.

41:29So it was a very good way to push testosterone into the male body using a patch on the scrotum. So that's the theory. But no, if you take a systemic dose testosterone and you put it on your genitals, check your levels. You might have a much higher systemic level than if you're going to put it on your skin.

41:46Dr. Mary Claire Haver:Oh, wow. So I don't advocate for genital aposom like why do you need to touch your labia to do your daily hormone dosing you don't have to now you can compound a lower dose usually with estradiol for the vulva that tends to be for a provoked vulvodynia a very specific vulvar pain issue because vulvas have testosterone receptors clitoris has testosterone receptors i would love to see more research looking at clitoral phimosis prevention. What is clitoral phimosis? Right. So if you think of a penis and you think of the foreskin of the penis for uncircumcised people, it's the skin that covers the glands.

42:24Clitoris has the same thing. We call it the clitoral hood. And that can kind of get stuck. Adhesions. Adhesions. Little baby scars. Little baby scars because of low hormones. So things we don't have data on. If we just start women in perimenopause on hormones, will they have less vulvar atrophy? We don't know. We've never studied it. If you have clitoral adhesions, can we reverse that reliably with a testosterone cream? We don't know. We haven't studied it. Right. And only to make people realize there's so many unanswered questions that the field really is wide open. It tends to be a funding problem.

42:57But Rachel Rubin did the research on clitoral adhesions. It's actually pretty common, which why, you know, if you have sexual health issues, I see this all the time on the internet is like, get a good pelvic exam. Does somebody know what they're looking at who can give you a good pelvic exam? Because pain down there is never normal. No, it's never normal. And it could be like 30 different things. Where does it hurt? Right. Do you have diminished orgasm because of low hormones? Do you have diminished orgasm because you have severe clitoral phimosis that nobody knows about? Right. So I love telemedicine.

43:30I think telemedicine is here to stay. I don't think telemedicine will ever replace a good pelvic physical exam. Yeah.

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47:25Dr. Mary Claire Haver:So let's talk about general urinary syndrome of menopause, GSM. And I hope our listeners realize you were really critical to this final round of approval that the FDA finally, finally had the black box warning removed. and then the GSM guidelines Dr. Rubin you know was really critical and then we all kind of pitched in to like get it out on social media it really was a grassroots effort yeah guidelines do no good in a box yeah to get these guidelines out there so people know about them but what is GSM what is genital urinary syndrome of menopause genital urinary syndrome of menopause is a complete mouthful we say GSM for short but it's a better name than vaginal atrophy because vaginal atrophy Or my favorite.

48:12Your favorite. Senile vagina. Senile vagina. Brought to you by the 1980s. Yeah. So it was a senile vagina. Then it was a vaginal atrophic vagina. And now the vagina is in the pelvis along with the genital urinary organs, which include labia, urethra, bladder, vagina, vulva, clitoris. And so the big mouthful is genital urinary. So lots of different structures can be affected. Syndrome, meaning a constellation of issues. of menopause, meaning it should really mean low hormones. It's probably a better title. Yeah. But we're getting there. Incredibly common. 50 to 80 percent. Some people will argue 90 percent.

48:49The other people will argue, why don't we just say it's 100 percent. If you live long enough, it's 100 percent.

48:53Dr. Mary Claire Haver:I, you know, hormones go away. The tissue atrophies, you know. The better question, which, again, hasn't been researched to my knowledge, Why does a small amount of women make it to 75 without GSM? I looked at vaginas in their 70s and 80s. They had it. They just weren't symptomatic. Yes. I can look at a vagina and tell you how old the patient is. Or at the vulva, really. My talk tomorrow is your vagina can tell your age better than your driver's license. For sure. If she's not treated. Yeah, yeah. If she's not on hormones. I can tell how old you are. Mm-hmm. Yeah. But unless if that vulva is on DHEA.

49:31oh she's beautiful oh juicy delicious yeah dhea makes vulvas beautiful again yeah agree so for your listeners dhea is a precursor hormone that converts into both testosterone and estrogen there right now there's one fda approved product that goes in the vagina called intrarosa or prasterone it's a made-up word it's dhea um but the reason why we say it makes vulvas beautiful again is because it gives you a little bit of the estrogen and the androgen. And that's why it's so beautiful.

50:01Dr. Mary Claire Haver:You mentioned GSM and this new data, the Medicare data that came out with GSM. So a paper just got published out of Stanford looking at Medicare recipients. Now, the caveat is it was only up to 2018. So God can hope it's better than this right now. So this was looking around up to 2018. These women, Medicare recipients in America, went to a doctor, got a diagnosis of gsm which might include recurrent urinary tract infections overactive bladder pain with sex so you you got a gsm worthy diagnosis because there's a laundry list of things that are associated with gsm yep so let's look at let's look at they made a point they put it in the chart they wrote it down they clicked on a diagnosis code like she has been diagnosed with something to do with gsm yes within 18 months of that diagnosis seven percent of women were given vaginal estrogen which is the bread and butter treatment for GSM.

50:55Highly safe, highly effective, highly cost efficient. And saves lives. And saves lives. So God, I just hope we're better than that right now. So that's 2018 data. But to me, I think about the unmet need, which is why I'm interested in the DHEA over-the-counter solutions because medicine can't help this amount of women. These were the women who had insurance, got to a doctor, made the right diagnosis. So you got through how many hoops and you still didn't get treatment? Now think of all the women in the pond that are suffering that didn't get through those hoops.

51:34Dr. Mary Claire Haver:Yeah. Right? So I think, oh my gosh, 7 % of those got treatment. New paper out of Canada, same scenario, 71 % didn't get treatment. So they had 30 % were treated. So Canada's winning over Medicare. but the profound amount of suffering and we're and doctors are getting more educated we've got gsm guidelines now i just talked to dr una lee who was a co-author with rachel rubin and i'm like where's your patient facing one page handout because i go to tell patients print out the gsm guidelines bring this to your doctor doctors do not like 25 page stapled together things i want a patient facing one page document that they can print out and bring to their doctor so dr lee says they're working on it.

52:18You can go free online, print out your GSM guidelines, bring them to your doctor. Oh, lovely. Yeah. What is vaginismus? Vaginismus is a not purposeful, so I'm not sitting here trying to clench my pelvis tight. So it's not purposeful tightness of the pelvis that prevents penetration of the vagina. Painful, painful penetration. How common is it? Oh, it's probably way undertreated. I couldn't give it to you. What's the classical history?

52:44Dr. Mary Claire Haver:Do you know Yeah. That's in the bitches be crazy school of medicine, like vaginismus. Well, you know, people used to think it was because of your, it was probably your mom's fault. You know, like all these, again, social reasons for your biologic health issue. It is a lot more acknowledged now of like, can you just relax? No, when you have vaginismus, you can't just relax. You can't treat this with a glass of wine, right? It is a medical issue with tight muscles that prevent non-painful intimacy. I mean, I've seen it. they can't even insert a tampon. Yeah, yeah. Nothing. You know, finger, nothing.

53:21Dr. Mary Claire Haver:Mm-hmm. Why is there a cultural obsession so, so, so about tightness of the vagina? Oh, God. Oh, Lord. I don't know. Do we care about tightness of penises? Do penises become flabby the more they have sex? Like, there's so much stigma in trying to make you the right woman. Am I tight enough? Am I too tight? Am I too loose? and we're marketing and we're making money off of this. And again, a lot of it stems from the fact that women don't know. Where do you go online to figure out if your vulva is normal or not? Porn. That's not normal vulvas. That's, you know, the F1 races. And now that we've stripped all the hair, you know, this generation doesn't like hair in the area.

54:09Dr. Mary Claire Haver:Like they see more, you know? Yeah, totally. And they're like, oh, my labia don't look like her labia. Therefore, there must be. There's like the uptick in women who, young women, healthy women who come in requesting labioplasty. Yeah, yeah. And some people think it is because we have a lot more access to video. A lot of augmented video, right? And performative video. Yeah. Right? Even the sexual dysfunctions of like, I'm kind of watching myself have sex, which is called spectatoring, of like, am I performing this properly? the sex therapists who have been around for a long time are like, that didn't used to happen before you could watch people have sex on video.

54:47And so now like things are changing because we have access to video and this whole like labial needing to look a certain way. This is what gets me. Many things about this get me. Women make less money than men. Women have less net worth than men. Women get paid less for having the same jobs as men. Now we're taking 10 ,000 of their dollars to cut their labia off. They're already down economically. We've given them a new problem to separate them from their cash. I just want people to think about the craziness of this sometimes, of like, how many, I was talking to a woman, should I get it? How many people do you plan on showing your labia too?

55:24Like, is this going to be an income source for you? Like, then maybe make the investment. But if you're with somebody who is supposed to love you and you're supposed to be in a trusting, loving relationship who loves you, Like, oh, I have such a great relationship because her labia is nice. We just need to step back and be like, what are we obsessing over? And is this the point? And we look back, you know, Elizabeth Komen, Dr. Komen wrote this amazing book all in her head. All in her head. About look at all the foolish things we used to do to women. Yeah, I think we're still in the bloodletting phase for pelvic health.

55:56Yes. I'm like, we tried to move the clitoris closer to the vagina in Freud's era. Guess what we're doing now? we're cutting off your sexual organs to make you look a certain way. Are we any better? And I will asterisk all of this. There are some medical conditions where the labia does need a little bit of help. Absolutely. Same with penises, same with scrotums. Asterisk. Yeah. But we are separating hard-earned cash from women because we're telling them they need to perform a certain way, look a certain way for the approval of their partners. And it's absolutely shameful.

56:29Dr. Mary Claire Haver:What I see advertised is as the smell. The vagina should smell a certain way. If you eat the... Did you see the pineapple videos? You drink the pineapple juice or whatever. Not asparagus. It was mega viral. Yeah, crazy. Again, it's a pure... And once you learn, you're like, where is it? Should we have a smell? Yes, yes, we smell. Like, we have a sweat glands. And the other thing about women who aren't on hormones and then they take hormones, some of them will say, my sweat smells again. Mm-hmm. Yes, it does. Because hormones help the sweat glands be sweat glands, right? Like your sense, your smell actually goes away when your hormones are low enough, which is fascinating.

57:08Wow. But yes, there is a certain musk to things. If there isn't a, if there isn't an infection and there isn't something else going on, we all get a little bit musky. Where does it come from? Purity culture, right? Be clean. You're never, we're never clean enough. No. In our society.

57:22Dr. Mary Claire Haver:No, I mean, and Komen talked about the shame in the exam room. I can't myself. I'm like folding up my underwear and, you know, that women are always apologizing in the exam room. And I'm like almost a hundred percent. And it doesn't matter her socioeconomic status. I've treated royalty. I've treated, you know, and anytime a patient gets undressed, she tends to apologize for something on her body, which is completely normal. Let's talk about vibrators. Yay. You like vibrators? Oh God, I love vibrators. People, you know, the whole like, it's not natural. I did. So this got flagged on the internet.

57:59I did a cheeky video saying, you guys, I have a new vibrator and I'm going to show it to you. And out of the bottom of the screen, I brought up my electric flosser that I got. And the joke is I have three vibrators for my mouth now. Like I have an electric toothbrush, an electric flosser and a water pick, right? Like this has never looked so good. And so I'm like, we're using technology to improve upon what we had before we had technology. You can buy it in Costco. Right. Normal. But when you improve technology down there, same stuff, vibration technology, we're like only certain women. Oh, but you shouldn't need that because you've got a partner like all of this.

58:36I'm like, why is the pelvis the only area that we're like, but not technology there?

58:41Dr. Mary Claire Haver:Yeah. Like in this technology, this technology is good. And I would say this technology, like some of the vibrators they have, especially the clitoral air pulse ones. Yeah. There's lots of different brands, but like it works so well. Too well. I agree. It's too well. It's like, I didn't want this to be a light switch. For science, I have to try them all out, right? So that I can adequately cancel my patients because science. I'm a scientist. You're a scientist. And the vibrator companies love to ship these things to my house, which may or may not freak out my children. My husband gets very excited.

59:10Dr. Mary Claire Haver:So let's talk about categories of vibrators. So there's the external, and I'm just going to vibrate ones. There's the ones that have a little suction cup over the clitoris. Those are newer. They're newer. There's lots of stuff. And then there are some that have an internal component, you know, some just for the inside. The combo ones. So there's ones that are clitoral suction that actually can curve in. And so it can be internal and external. Turns out I do not have the right anatomy for that. I do. But I find the little suction cups to be too much. It's too fast, too furious. But for some people, that can be the right thing.

59:49I just need a little bit more intensity, especially as I'm getting older. Right. So why is that? Why do we need more intensity? Wear and tear on our bodies.

59:56Dr. Mary Claire Haver:Nerve changes. And I read that the nerves that innervate the vibration, the vibratory nerves, right, are the last ones to go as far as loss of the myelin sheath. Ooh, interesting. With age. Someone taught me that. Fascinating. That is why, like, if, you know, using your fingers isn't doing it, get a vibrator that, and there's a certain hertz that they measure 30 or something. Some of these vibrator companies, like engineers are in there, But my patients are like, look, I can't see anymore. I don't want to put on glasses to have an orgasm. I don't want to turn on the lights to have an orgasm. I don't want to, you know, I just want to reach over, grab, turn it on and go.

1:00:34Dr. Mary Claire Haver:And the simple is better. What do you see? Because some of them are very complicated and they cycle through multiple different... Oh, I know. To me, I don't know, it's a privacy issue, but I'm like, I'm never going to put something on my phone that's an app that's going to control this. Like, I have no interest in that. I'm like, I want analog, not digital for these. But I think simple is better. I had asked, I don't know if it was a vibrator company. I asked somebody, I was like, why are there 10 settings for every vibrator? Like, is three not enough? Is there any science to that? No, it's just that the factories in China all make them the same way.

1:01:08And so like, they made one that way, they just make them all that way. That's like the simple answer to it. They're like, women want different things. And I'm like, I don't know if they do. I don't know anybody who goes,

1:01:18Dr. Mary Claire Haver:you know, they're frustrated having to go. go through all of the different, you know, cadences of vibration. So, and they just want to just turn it on and go. Can we talk about my vibrator? Yes. Mm. Mm. So, I have a - You have a favorite? No, I have a vibrator coming out. Stop it. Do you know that? I did not know. I know you have the DHEA serum, which I love. That'll be coming. That'll be coming. And I do not have any affiliation, but it is absolutely, it is just the best. I love the texture of it. Yeah. It's like, It's important. So lubralicious. Yeah. So like products on the vulva cannot, in my opinion, they shouldn't be cold.

1:01:57I hate being cold probably because I grew up in northern Minnesota. Don't put cold stuff on my vulva. It's not pleasing to me. So I like, I don't like lube that's cold. I don't like any product that's cold. So the DHA serum is like skin temperature, which makes a big deal.

1:02:10Dr. Mary Claire Haver:So what is it? It is a external only because you cannot take a woman who hasn't had penetrative sex in a while or might have untreated GSM. GSM is horribly undertreated. We should get into that recent Medicare data on that. You can't take that woman and say, here's a vibrator, put this in your vagina. You cannot do that to her. It hurts, right? But blood flow, blood flow, blood flow, blood flow. Blood flow, number one, prelim data might help signs and symptoms of atrophy. That's super exciting. Needs to be researched more. Same with lichen sclerosis. Needs to be researched more. Blood flow matters.

1:02:45I just want blood flow. Just experience blood flow in your pelvis. External only vibrator. Just goes on the outside. So you can use it with a partner, without a partner. You can flip it. There's a little ridge on it. You can put in between your labia minora, get a little bit of vibration right in the vestibule, but no pressure to put anything on the inside. I just want you to experience pleasure and blood flow. If orgasms happen, awesome. If they're with a partner, awesome. But I wanted to create something that didn't cause more harm. And that was kind of like an intro. Like I want in my grand scheme, I want like intro, intermediate, advanced, right?

1:03:24Like, because women are like, just tell me what to do. There's so much out there, right? Like, start with the intro. Start with like low pressure, nothing's going on the inside. So she is called the explorer. Stay tuned.

1:03:37Dr. Mary Claire Haver:What is one thing every woman should keep in on her nightstand? Oh, Kleenex. I mean, I think lube, like never have lube too far away. We know lube helps people have orgasms better. And I always say like when people, because people get judgy and I've seen women judged by men on this. I've seen young women. I've in one week, this is a couple of years ago, in one week I had two 24 year olds come in for pain with sex. And I never, you learn this in med school. You don't say, you know, do you take your blood pressure medications? You say, when do you forget to take your blood pressure medications? Right.

1:04:13So I say, what lube do you use instead of do you use lube? Right. So what lube do you use? They said, my boyfriend told me that I shouldn't need lube. And I'm like, you're taking sex advice from a 24 year old dude who has no lubrication in his pelvis at all. And you're putting all the pressure on a vagina and you're starting to wait.

1:04:34Dr. Mary Claire Haver:So all of these spicy books, you know, so I've read a few for science. There's millions of them. And literally there's a sentence in there. You're so wet for me. You know, it's like this, this positive thing that they're, you know, yeah, that, that, that like, Oh, he's all excited because she is so moist. So moist is a word I don't love. But there's like a lot of liquid in the area. Yeah. Talk about that. Ability to produce moisture is not directly correlated to interest in having sex with a partner. Well, can you talk to all these authors out there who are writing this shit and making women feel like they're crazy and they're all having simultaneous orgasm?

1:05:15I want to write a adult fiction book. I will help you. with an adult fiction book established writer who can write, but I want to make it medically accurate. Oh my God. Let's manifest. Like that, give me that job. I will spend a year. That would be amazing. I want that book.

1:05:32Dr. Mary Claire Haver:That would be amazing. So where do these young men learn things from? Stories like that, porn, blah, blah, blah. And so, and there's no arousal for her. Her pelvis doesn't know if this is a tampon or a penis, right? So you're putting a hard penis in a dry vagina. She comes to the doctor for pain. And she needs sex ed. Get warmed up first. Connect. Relax. Vibration. Vulvar massage. All the other things. Nipples. Shoulders. Back. Get your body into the touch. Let it know what to expect. The arousal will come. But don't just come by the guy's ready and hard. Put it in. It will hurt. That's trauma.

1:06:14So it's like, again, going back to like, there's so much low-hanging fruit just because we do not have a good sex ed and poor education yeah and these young women are on birth control pills birth control pills tend to block okay so great segue

1:06:30Dr. Mary Claire Haver:because we've talked about medications that can improve sexual function therefore there must be medications that hurt sexual yes so many many about birth control pills what do they do what can they do because it doesn't happen to everyone but it definitely could happen yes and some birth control pills are worse than others. But the layman's way of saying it is a birth control pill kind of blocks hormones and blocks the hormones in the pelvis. So you can actually get a vulva that looks atrophic. It looks menopausal. And I always want to asterisk, birth control is amazing. It's changed our world.

1:07:05It's incredibly safe. It's incredibly effective. But you're not getting an accurate informed consent if you aren't told how it works and what possible side effects might be. I just think that that's good medical practice. I'm not here to scare people off of birth control pills.

1:07:21Dr. Mary Claire Haver:So how can a birth control pill affect sexual function? What happens? It blocks your testosterone. How? In a perfect world, we would just add a little bit of testosterone into the birth control pill. How does it? It increases your sex hormone binding globulin through the liver. And so then the testosterone is not as free to go do its job. Other medications like antidepressants. Antidepressants. Again, did you get a fully informed conversation? Of course you didn't. We have 10-minute doctor visits, right? But when 60 to 80 percent of people have sexual side effects from antidepressants, and in America, 25 percent of women are on one of these.

1:07:56Over the age of 45. Yes. Do you have an informed consent? This might happen, right? But again, we blow off sex, and it's not important, and it's a quality-of-life issue of, like, yes, it's profoundly important. It's profoundly important to relationships. It's profoundly important to your sense of who you are. And these medications can blunt orgasm, decrease desire. High blood pressure medications are another one. Any of the antipsychotics can be some of them. So anything that kind of can dry out things can affect lubrication, anticholinergics for overactive bladder. So the list of things that might affect sexual function is actually quite long.

1:08:31Dr. Mary Claire Haver:And then there's some new emerging information about GLP-1 medications. Yeah, it's going to be very exciting to see what happens with looking at sexual function in GLP-1s. So some of the data in men, when men lose body fat, their testosterone goes up because they're not converting it via aromatase, via their adipose tissues to estrogen. So their testosterone goes up when they're on a GLP-1 increased in sexual desire for men. It will improve their sexual function. In women, it might be a mixed bag. A lot of women with GLP-1s, they're postmenopause. They're not on any hormones. Their hormones won't go up because they're on a GLP-1.

1:09:07So are we seeing some decreased desire? Yes, because GLP-1s affect the dopamine pathway of what's rewarding. So that's what we're seeing. Gambling go down. Drinking go down. Eating go down. Sexual desire go down. So I don't think we don't have a big enough jury out to say blanket statement it does this, but to say, hey, it is improving. It could. Yeah, it could decrease sexual function. It can increase sexual function. Body image. I like how I look now. I have more energy. Right? Right. So again, sex is biopsychosocial. GLP-1s can affect that in different ways. What do you want every woman listening right now to know about her body?

1:09:45You are not broken. You are not broken. You are undereducated. You are likely undercared for. But this is not a personality flaw. This is biology.

1:09:55Dr. Mary Claire Haver:How does she find a partner in this care? Because she, most likely her OBGYN is undereducated. Yeah. So some online companies are good that do hormone care. Interlude, for example, all it does is vaginal estrogen. So that's a great company for just for vaginal estrogen. I think the Ishwish website is good to find a doctor because Ishwish has this nice Venn diagram overlap of sex med plus hormones. Because sex med doctors know the role of testosterone for libido. We know the role of estrogen for lubrication and moisture. So it's that Ishwish just, you know, is in the middle of the Venn diagram of sexual health and hormones.

1:10:31and I think that's probably my best go-to. I mean, you have an excellent list on your website as well. So it's like the other good option is, do you have a friend who got help? Who are they seeing? Who are they seeing? Yeah.

1:10:44Dr. Mary Claire Haver:You brought vaginal estrogen as well. All right. I do want to talk about that. So say she finds the right partner in care. They give her the vaginal estrogen. She gets home and doesn't know how to use it. Is vaginal estrogen absorbed systemically? Teeny, tiny, teeny amount, more so in people who are very atrophic in the beginning until they get healed up. Until they get healed. But then once you have nice, healthy skin down there, absorption is minimal. It stops absorbing. And it's always below... Right. If you have raw tissue and I rub something on it, you're more likely to absorb the medication.

1:11:13Dr. Mary Claire Haver:Yeah. That's why I don't do a loading dose. So the common prescription for vaginal estrogen is every day times two weeks, then twice a week. Multiple problems with that. Number one, the loading dose isn't based in any sort of science or paper that I could ever find. Probably to just get it working faster, but it backfires because in people who are really atrophic, really thin tissue, it can burn or you can absorb a lot. Doctor, I thought you told me this wasn't going to go in my body. My breasts are tender. Well, you have really atrophic skin and it sucked up a lot of product. Skin is supposed to be a barrier.

1:11:45Yeah.

1:11:46Dr. Mary Claire Haver:And when it's atrophic, it's not a good barrier. How long does it take to grow that mucosa back? Six to eight weeks. Okay, I'm going to tell people. So I tell people... You have to grow it back and it's going to take six weeks. And if you stop using this, It goes right back to where you are. You go back to the low hormones. So how do you explain to people how to apply this? If they're not on video, so walk them through. Yeah. Okay. So what was in my box of Estradiol Vaginal Cream, 0.01%, which is the generic product available in America. How much did that cost? This should cost no more than$20.

1:12:16Dr. Mary Claire Haver:Yeah. And I tell all my patients that. I'm like, if you can't get this for less than$20, you let me know. I will change your prescription to Mark Cuban, cost plus drugs, No affiliation. I hope to meet Mark Cuban someday and give him a very big kiss and a hug. But it's a generic product. Your insurance company shouldn't make money off of this. So at Mark Cuban, I think you can get it for$13 plus$5 shipping. So I haven't seen it cheaper than that. That's the best deal that I've found. So it comes in a tube and it comes with an applicator. And I can take this off to actually show it if you want. But two ways to do this.

1:12:48You can fill up the applicator to the one gram on here and then put it in kind of like a tampon. or you can put it from the tip of your finger. I was like. To the second knuckle.

1:13:00Dr. Mary Claire Haver:Where now? How do they put it? Where do they put it? I would put your finger comfortably in, but you don't need to go to the top of the vagina. I do like it middle of the vagina because the bladder and the vagina share a wall and that's how it helps the bladder out. Decreases urinary tract infections, decreases urgency, frequency, getting up at night to pee. But again, I always say I have a cream bias. Why do I have a cream bias? Cost. Cost. Big one. You should not remortgage your house for this. And hey, if we're lucky, menopause is going to last 40 years. You need this to be cheap. The other reason I have a cream bias is because you can put some on your face.

1:13:32Kidding, not kidding. But people do put a little bit. You know that Egypt sold out of vaginal estrogen because all the women were putting it on their faces? On their face. An Egyptian dermatologist told me that. But anyways, I like the cream because you can put it on the vulva.

1:13:46Dr. Mary Claire Haver:Yeah. Put it on the clitoris. 100 % of patients, I tell them. Put it on the clitoris. Clitoris down the labia minora. Yes, in that six o 'clock spot. that tight spot, pain with entry. The classic, where do you have pain with sex? Pain with entry. It's at six o 'clock that gets tight and painful, especially if you had an episiotomy. Side effect. Let's talk about the side effects of this. One of the most common side effects of starting on vaginal estrogen is your microbiome changes because your microbiome is different with estrogen than without estrogen. So a side effect can be a yeast infection is one of the most common ones.

1:14:17I tend to say lower your dose or back off on your dose. You don't have to stop. treat the yeast infection. As your microbiome changes, that will happen less.

1:14:26Dr. Mary Claire Haver:What is the number one treatment for the prevention of recurrent UTIs? Vaginal estrogen. Not FDA approved for that, but it is the most effective. And Rachel Rubin, our good friend, did a Medicare analysis paper that if Medicare basically shipped everybody on Medicare with a vagina, vaginal estrogen, and they used it, it would save Medicare$13 billion a year just in decreased urinary tract infection costs. Anything else you want to share with our audience? This decreases death. So there was an abstract, I think, at a urology conference. Yeah, was it? There was an abstract, and it was women with recurrent UTIs who are on vaginal estrogen, decreased risk of admission to ICU, decreased risk of admission, and decreased risk of death from sepsis.

1:15:11Dr. Mary Claire Haver:When they looked at the breast cancer data, they saw women who were given vaginal estrogen, zero increase in recurrence. That's right. And they lived longer. Yeah, they lived longer. They lived longer. And there's a new paper, women on vaginal estrogen seem to have a decreased risk of rectal cancer. Maybe it's healthier tissue. Maybe you get less, you know, trauma to the tissue. Maybe it's a microbiome thing. We don't know. That's newer data. How can our listeners find you? I hang out. I hang out on Instagram at kellykaspersonmd. And I have a sub stack, kellykaspersonmd. You still take a patient?

1:15:46I still take patients. I practice currently in Washington State. Getting a California license takes forever. So maybe some decade I'll have a California license. And my podcast is called You Are Not Broken. Book's called You Are Not Broken. Second book's called Menopause Moment. You brought that too. This is her latest baby. So when I was writing this, I was feeling like I was bold. I was like, I'm going to say the big, bold things. And the exciting thing about it is it's kind of all come to fruition. What are the bold things you say? Testosterone exists in female bodies. We should consider using this for health span, longevity.

1:16:22Dr. Mary Claire Haver:Where is testosterone approved in the world? Australia, New Zealand, South Africa, and the UK. They're having trouble getting their governments to cover it, but it is available with cash. But this is already outdated because the boxed warning has come off. So my brand new baby book, we've already outdated it. So that's exciting. That's very exciting. Well, Dr. Kasperson, Kelly, the OG of the menopause, thank you so much for coming to share all your wisdom and knowledge to our listeners. And I talk to her every day. So it's so good to see you in person. Thanks for having me. You can find Kelly through her website at kellykaspersonmd.com, where you can listen to her podcast, You Are Not Broken, and find links to all her books, as well as to more information on her clinic, the Casperson Clinic.

1:17:14Dr. Mary Claire Haver:You can find full episodes of Unpaused on YouTube at Dr. Mary Claire. I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram at Dr. Mary Claire and get honest, accurate information on health, fitness, and navigating midlife at thepawselife.com. My new book, The New Perimenopause, is available everywhere you buy books. If you're loving this podcast, I have an important request. Please take a moment to follow Unpaused on your favorite podcast app. Following and listening is what pushes this information to more women who need it. So if this podcast has helped you feel seen, understood, or supported, hit follow right now so you never miss an episode.

1:17:59Dr. Mary Claire Haver:Thank you for being here with me. Let's keep going Unpaused. Unpaused is presented by Odyssey in conjunction with Pod People. I'm your host, Dr. Mary Claire Haver. The views and opinions expressed on Unpaused are those of the talent and guests alone and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment. Perimenopause is not early menopause. It is its own distinct biological phase, and it has been largely ignored. My new book, The New Perimenopause, is about the 7 to 10 years before periods stop, a transition that is anything but gentle.

1:18:46Dr. Mary Claire Haver:Hormones fluctuate wildly, and for many women, this is when anxiety, brain fog, sleep disruption, weight changes, mood shifts, joint pain, and that unsettling feeling of, I don't feel like myself anymore, begin. Long before anyone says the word menopause, perimenopause often starts quietly. It shows up in the brain first. then the body, then everywhere else. And all too often, women are told nothing is wrong. I wrote the new perimenopause because you deserve answers before things spiral. You deserve care before burnout. And you deserve a clear roadmap for a transition that medicine has ignored for far too long.

1:19:28Dr. Mary Claire Haver:The new perimenopause is now available everywhere books are sold. Learn more and order your copy at thepawslife.com.