Vanishing Vulvas & Menopause: What's Really Happening with Dr. Karen Tang

0:00Dr. Mary Claire Haver:Menopause hormone therapy is a microdose compared to what your body was making in your premenopausal years. It is unreasonable to think that for the next 30 years, this microdose is going to be enough to penetrate that general urinary system. You are better off treating both areas at the same time. And maybe we can prevent any of these problems. The prevention is so huge because, again, so much of the menopause and women's health in general is you're sort of like reacting. you're like waiting until you can't tolerate it anymore until you're just like I can't deal with this anymore and then you finally treat it that was definitely the way that we thought of women's health for so long the views and opinions expressed on unpaused are those of the talent and guests alone and are provided for informational and entertainment purposes only.

0:54Dr. Mary Claire Haver:No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment. In part one of my conversation with Dr. Karen Tang, she walked us through what happens when common gynecologic conditions like endometriosis and fibroids collide with the menopause transition. But there's another category of symptoms that affects millions of women and is still surrounded by confusion, stigma, and far too much suffering and silence. In this episode, we turn our attention to one of the most common complaints women bring into midlife, pain in the vulva and vagina.

1:34Dr. Mary Claire Haver:Dr. Tang, a board-certified gynecologist, minimally invasive gynecologic surgeon, and the author of It's Not Hysteria, explains why itching, burning, dryness, and painful sex are so often dismissed or misdiagnosed, and what women should know about the conditions that might be causing these symptoms. We also tackle the persistent myth that that painful sex is simply something women should expect as they age. And because so much of women's health care still requires self-advocacy, we close with a practical conversation about treatment options, vaginal estrogen, surgical decision-making, and how to find the right specialist when you're not getting answers.

2:15Dr. Mary Claire Haver:because we both firmly believe that while suffering may be common, it is never something women should have to accept. I'm Dr. Mary Claire Haver, a board-certified obstetrician and gynecologist and certified menopause practitioner. I'm also an adjunct professor of obstetrics and gynecology at the University of Texas Medical Branch. Welcome to Unpaused, the podcast where we cut through the silence and talk about what it really takes for women to thrive in the second half of life.

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3:56Dr. Mary Claire Haver:So let's move on to the vulva. All right. Vulvar pain, itching, burning, and skin changes. How common are these vulvar conditions? They're extremely common. I think like almost everyone probably at some point has had some sort of vulva vaginal itch. Like that's just a fact. Like if you have a vulva and you have a vagina, it's been itchy and irritated at some point. And especially in menopause. Like it's rare that someone - It's worse in menopause. Absolutely. Yeah. Just the low estrogen, tissue quality, like you get dryness, you get like kind of delicacy of the tissue. And the vulva under the best of circumstances is very sensitive.

4:29I always tell people it's among the most sensitive parts of the skin on your body. and it will react to soaps, to, you know, fragrances.

4:38Dr. Mary Claire Haver:I liken it to the mouth. Yes, yeah. I try to tell them your vulva, the mucosa on the vulva is the same. You would not put what you're trying to put in your vagina into your mouth. No. So like, that's like, would you put this in your mouth? Yeah, I say the eye. I always tell people like, if you wouldn't rub this on your eye, like you shouldn't put it on your vulva. And there's such an industry now of like the feminine washes and like scented stuff. And what you're supposed to smell like. Oh my God, you just smell like flowers or like a pina colada, I always say. Or a lot of these like essential oil products, which are irritating.

5:11There's like tea tree oil that can like burn your vulva. I had a patient who had like basically secondary burns. Like her skin was sloughing off because she did this dilute tea tree oil stuff. So it's very common, especially perimenopause, menopause, because of the low estrogen changes.

5:25Dr. Mary Claire Haver:A lot of patients will call in and they're like, well, that sounds like a yeast infection. And send in Diflucan or go get them to, or they'll go over the counter and get the antifungals. how often is it really yeast? Is all vaginal itching a yeast infection? No, you know what's funny? The chapter on vulvovaginal stuff in my book, I literally almost did the title, It's Not a Yeast Infection, because so much itching gets chalked up for yeast infections, and a lot of times it's not. Now, I actually don't know the statistic of how often it is a yeast infection, but we literally say it could be skin problems.

5:54There's something called lichen sclerosis, which is a chronic inflammatory condition, causes horrible itching. It can cause scarring. You can lose, we say lose the architecture where people have heard this on social media, like your vulva disappear. That's one of the things can make your vulva disappear. Like your lips, like the labia minora can literally like go away with lichen sclerosis. Like it just kind of fuses to the labia majora, which are the fleshy parts of the vulva. And there's also like in simplex, which is just eczema. Like those of you with eczema out there, you can get eczema of your vulva.

6:26Scratch itch cycle. It gets a little bit dry and irritated. you scratch it itches more you scratch it itches more and then there's even like kind of pre-cancer which is rare like we always tell people you know vulvar cancer and pre-cancer is definitely rare but in postmenopausal patient absolutely we postmenopausal patient with persistent itch or something that's not going away like a little lesion got to biopsy it because it could be something that's more concerning you just save someone's life i've definitely had a patient i can't remember when this was who literally she was in like a nursing home so these poor patients Like they are in the nursing home and they're like, well, she's been complaining of itching, but she's incontinent.

7:04She wears a diaper. So maybe it's just like irritation. And literally like you would take the thing that it was like a vulvar cancer. And they just been sitting on it because they're like, oh, just like older women just have itchy vulvas. So you always have to look at it. You always have to have a low threshold to kind of consider non yeast things. And then there's just called, you know, genital urinary syndrome menopause. I'm sure you've covered it a million times where it's literally just the low estrogen causing the itching, the burning, the pain with sex, the tissue quality changes that can improve significantly and go away totally with vaginal estrogen.

7:34What about lichen planus?

7:35Dr. Mary Claire Haver:That's much more rare. I honestly have not diagnosed lichen planus. I've seen it about three or four times, but I was like a referral center for the vulvar stuff. So I did see, you know, people who'd wandered around to several clinicians who didn't know what to do with them. They sent them over. And I worked really closely with a dermatologist. like a derm path. And so we were, we kind of, I was on that train. So I've seen like, yeah, it's purple plaques. It is unbelievable when you see it, you know, like, like your attention is immediately raised. So it's not like, is this subtle thing? You're like, this is like the world's on fire.

8:08Dr. Mary Claire Haver:You know, the house is on fire and we need to get a biopsy immediately. Yeah. It's an autoimmune condition for our listeners and it causes ulcerations and plaques on the vulva and it's very, very, very painful. And so. So speaking of that, like people can get like psoriasis of the vulva. If you have skin conditions elsewhere on your body, like eczema, like psoriasis, you can get it in the vulva as well. And so I've had patients who are co-managed with dermatology being treating their little plaque psoriasis of the vulva. And then just to throw it out there, also like herpes, like sometimes people will be like, I'm burning.

8:42I don't know what this is. I kind of scratched. I feel like there's a little sore there. You know, maybe I just kind of broke it with my fingernail because I was scratching and it's a herpes outbreak. And so common things being common, that's a super common one. There's no shame to it. It's basically like a cold sore of your vulva, very normal and common. So just to be aware that, again, if it's burning, if it's itching, it's definitely not always just a yeast infection.

9:03Dr. Mary Claire Haver:And it often comes with a prodrome if they're used to it before they actually have the ulceration. Yeah, feel like a tingling or burn. It's like something's not right. And I'll be like, take your Valtrex. You'll learn when you have that signal to start taking your Valtrex and hopefully we can head off the ulceration before it comes. What is vulvodynia? Vulvodynia, it's kind of, the way I explain it, it's like a catchphrase. It's vulvar pain that we're not exactly sure it could be from something else. But the way to think of it is just vulvar pain that's not from a specific thing, not from herpes, not from an actual like lichen sclerosis.

9:39And it's basically when you think of the nerves that, you know, control like the sensation of your vulva, it's getting like really irritated by something, usually something, you know, inflammatory. A lot of times it could be from something like endometriosis that just then spiraled, your nerves got really sensitized. And then even though the endometriosis is physically not near the vulva, it then leads to vulvar pain because the nerves in that whole region get so irritated that they feel pain no matter what you do. So just touching the vulva actually burns and stings, even if your actual vulvar skin is normal looking.

10:16So basically we rule out other stuff. And if you're having vulvar pain, like it burns or stings, if someone just examining you and just kind of touches your skin, we call it vulvodynia. There's kind of variations or something called like, you know, vulvar vestibulitis, like that's sort of in that kind of opening area of the vulva, if that particular area is painful, but oftentimes it's secondary to something else. So meaning that it wasn't that there's something literally wrong with your vulva, but something is causing it to experience pain. Okay.

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11:23Dr. Mary Claire Haver:So estrogen decline, the GSM picture, it can cause this vulvovaginal atrophy, which is a terrible word. I'm glad that we don't say that. We used to say that all the time until recent years when GSM kind of was introduced. And thank God, because this makes it sound like it's just like all like crumbling, shriveling away. And then one of the most viral videos in this area is the one where Rachel Rubin is talking about losing the architecture. Yeah. All the disappears. Disappears. And like, for whatever reason, the entire internet took a pause and gasped collectively and was like, 23 million views or something.

11:59Dr. Mary Claire Haver:What? I made a video responding to that and that got millions of views. Like people couldn't get over it. There's so many, you know, just to pause, there's so many funny responses to that. They're like, they snap on like Legos and they're like deer antlers, they fell off. It's not like that. So what's actually happening? And Rachel obviously has a great explanation for this. I kind of think of it like picture like the vulva when you have like a baby or a child, it doesn't look the same as a woman who is, you know, adult. So an infantile vulva. Yeah. So you have like very little of the lips, the labia minora, which are like the lips that kind of stick out.

12:32You sort of have just like an opening and then labia majora, which are like the fleshy parts of the vulva on the outside. So under the influence of estrogen and probably other things like testosterone, like you get like these more like elongated lips. And then as you go into menopause and the hormones are dropping, like everything kind of almost goes in reverse a little bit, like the labia shrink back. And then again, it's a little bit overlapping with things like lichen sclerosis where things are getting really fused. So there are some times that, you know, you'll look at somebody who is postmenopausal and they're older, like they're 80, and they'll have like very minimal to no labia minora.

13:09Like it'll basically just be this little opening, everything's sort of shrunken back. So we say it's not like it fell off. Like the videos, like people responded, made it sound like labia were like literally detaching from your body and like falling off of you. It's not like that. It just sort of like they start to kind of almost go in reverse, like you would picture the way that the labia looks when you have like a child or a baby.

13:30Dr. Mary Claire Haver:I always say I can tell your age better by looking at your vulva if you're untreated in menopause than by looking at your face. Yeah. Yeah. And it's not going to lie. Yeah. And this is not even including like the inside of the vagina where like, you know, normally it's like pink and like it's moist and there's like bruguay, which are folds that allow it to stretch for sex and for childbirth, like you start to lose those. It gets really like kind of like pale and flat, like really kind of stretched thin. And the introitus, the opening of the vagina gets really, really, really small. Yeah. So those, all those changes.

14:03And that's why we love vaginal estrogen, which can help prevent some of those changes. I say we almost look for an excuse to give it.

14:10Dr. Mary Claire Haver:So I give it prophylactically. Oh my gosh. I, if anybody has like a whisper, I'm like, we're giving it. Yes. Yeah. I'm just like, because when you think about even with your, and a lot of people misunderstand this, menopause hormone therapy is a microdose compared to what your body was making in your pre-menopausal years. It is unreasonable to think that for the next 30 years, this microdose is going to be enough to penetrate that general urinary system. You are better off treating both areas at the same time. And maybe we can prevent any of these problems. The prevention is so huge because again, so much of the menopause and women's health in general is you're sort of like reacting.

14:45You're like waiting until you can't tolerate it anymore until you're just like, I can't deal with this anymore. And then you finally treat it. That was definitely the way that we thought of women's health for so long. Like up until recent years, there was so little kind of thought about, well, let's like do something preventatively rather than like, let's just wait to react until you're just like, you cannot take it anymore. So now again, I love the sea change where we're like, we can prevent the narrowing and the pain with sex and like the bladder stuff, the UTIs, like women getting septic because they're so infected by these bladder infections.

15:19It's so easy. It's like this medication that like everyone can use. There's almost no risk to it. There's generic versions covered by insurance.

15:27Dr. Mary Claire Haver:There's a push to make it over the counter. Yes. In UK, it's over the counter. A friend of mine - So we have a precedent in a first world country. And so, you know, it's not that hard once somebody else did it for us to say, hey, they have it over the counter. does it. Yeah. You and I can get on social media and teach people how to use it. You know, it's so safe and we will prevent, we will save the United States billions in Medicare for our elder population. And there's other, you know, talk about the other low estrogenic states outside of menopause. Yes. So lactation and breastfeeding, birth control, like there are all these things where our estrogen levels are suppressed.

16:04People don't think of it because I think, you know, in menopause, at least those of us who had formal training, we're like, yeah, we were taught to ask ask about the vagina and sometimes the bladder. But we never ask about the vagina when someone is on birth control or, you know, not often when they're breastfeeding. But those are very low estrogen states as well because your ovaries are being suppressed. You know, just when you're breastfeeding, people know like you oftentimes aren't having your period for a long time. So they have what's called like the genital urinary syndrome of lactation.

16:34Dr. Rachel Rubin, I think, was spearheading the use of that term, which is a great way to phrase it because it is physiologically so similar to menopause. Yeah, it's low estrogen. Yeah, low estrogen, burning, pain with sex, bladder problems, UTIs, all very similar. And just to throw it out there, because a lot of people don't realize that the birth controls, you know, they are suppressing your ovaries. A lot of times people will feel like some low estrogen symptoms, including sometimes pain with sex or vaginal dryness.

16:59Dr. Mary Claire Haver:So let's talk about pain with sex because it's a huge complaint. What is the workup of really, you know, where do you go from there? Patient comes in, chief complaint, I'm having painful sex. Yeah. A lot of it you can tell even before we examine someone. Obviously, we're going to examine them and all the things that can be hurting. But we ask very detailed questions. And sometimes when people come in with this concern, one, they may not even bring it up. Like just to say that a lot of times it's because we're asking specifically, like if you're coming in for a perimenopause consult, I'll ask about sex.

17:30Are you having any sort of pain? It's on our intake paperwork.

17:32Dr. Mary Claire Haver:We have a whole dyspareunia. Yeah. A lot of people don't come in being like, hey, I need a consult for pain with sex. Like they're often coming in for something else and it sort of comes out in the conversation. Is pain with sex ever normal? No, never. It's common, but should we ever accept this? Make a t-shirt. Yeah, common does not mean normal and you don't have to suffer from it. You should not suffer. You shouldn't suffer. And again, there's sort of this myth that at some point sex is always painful. That's not the case. Even though things are common doesn't mean it's normal. Can I tell you something?

18:02Dr. Mary Claire Haver:Yeah. I'm having the best sex of my life. Yeah, absolutely. Absolutely. I'm 57. Oh my God. Hi. Same. Yeah, I think a lot of people, perimenopause, menopause, like one, you have the confidence. Number two, you can ask what you want. Not afraid to ask for what I want. You know what you want. You can communicate it. You don't feel like you have to hold back to like, you know, to be like cool or whatever. You can feel like I need this. I need the stimulation. But back to the pain with sex thing is that we can get a lot of information just by asking you, where does it hurt? When does it hurt? And are there certain things like positions that make it more or less painful?

18:34Is that the opening of the vagina when you're first having, you know, penetration? Is it deep inside with thrusting? Is it certain positions and angles? And that kind of gives us a sense, well, we think it's the vulva. We think it's the pelvic floor. We think it's fibroids or endometriosis. It could be muscle spasm, like something called vaginismus, which you have the muscles kind of seize up because, you know, you're having pain. It's a big cycle. It hurts. Your muscles want to protect you. They seize up. It hurts more. So that happens a lot sometimes with, you know, everything that can cause pain with sex.