385. 500k on IG Celebration - Ask Me Anything

0:00Dr. Morgan Francis: This podcast is sponsored by Explore Worldwide. One of the themes that keeps coming up in my conversations is that it's okay to want more. More joy, more connection, a better experience. And thanks to our sponsor, Explore Worldwide, you can get so much more when you travel. All of Explore's adventures are 100 % human-made. Their tour leaders have actually stayed at that family-run guest house that isn't even online. They've eaten at the neighborhood restaurant the locals love and know the trail you'd never find on your own. Your vacation should feel uniquely yours, not like it was generated from the same prompt everyone else entered.

0:37Dr. Morgan Francis: That's the difference a human touch makes. Explore Worldwide's trips are created by real destination experts and led by tour leaders who actually know the places they recommend. They handle everything so you can relax, stay curious, and experience something genuinely memorable. This is your time. Demand more. Visit ExploreWorldwide.com and don't just travel, explore.

1:05Dr. Morgan Francis: Welcome to You Are Not Broken, the podcast that challenges everything we've been taught about midlife, hormones, and sexuality. I'm Dr. Kelly Kasperson, board-certified urologist, author, and a leading voice in women's sexual and hormone health. Enjoy the show. Hello, everybody. This is so exciting. This is our 500K Ask Me Anything Q &A. 500k on Instagram. I have balloons in my office. It's adorable. Everything has, nothing's felt kind of big. Like 80k kind of felt big. 250 kind of felt big. But half a million feels big. So Instagram even sent me, you know, AI generated. I don't think it was a human, but it was like, congratulations on 500k.

1:46And I don't think they've ever sent me congratulations for anything, which is pretty fun. So we are recording, but I don't know, like I might cut this into reels, but I think, I think this is, Super fun and private and happy that you guys are here and we're just gonna have a chat. I'm so excited about it. So where's everybody from? I love seeing where people are from. Send it over. Let's see where everybody's from. Quebec. I need to get to Quebec. Los Angeles, Vancouver, Boston, New York, Scottsdale, San Francisco, Tucson, Brazil. Calgary, Louisiana, Illinois, Tallahassee, Australia, Croatia. Croatia is so beautiful.

2:23Florida, Ontario, Annapolis, Kansas, Seattle, yay, Palm Desert, California. Sunny in California. So I'm in Washington State. I am Dr. Kelly Kasperson. You found me here. The only people who got this link are Instagram people. So you are all the Instagram people. Very exciting. We've got about 100 of you on here right now, which is really great. So there's, we have the, I'm going to see if we have the questions section. Okay, we've got a Q &A box, which is super fun. And if you want to type your questions either in the webinar chat or in the Q &A, I will try to get to them all. Hello, Dallas, UK, New Brunswick, Canada.

3:03So beautiful. Alberta, Los Angeles, Florida. Very exciting. How do I feel about HRT using an estrogen patch and positive factor 2 diagnosis. So let me, just in case, just in case I need an introduction, I'm Dr. Kelly Kasperson, and I am a urologist, and I started a podcast called You Are Not Broken. I hesitate to ask how many of you guys don't know I have a podcast. See what happens. I have a podcast called You Are Not Broken. I started my podcast seven and a half years ago, and I started Instagram seven years ago. Instagram happened six months after I started my podcast. And mostly to get people to listen to the podcast.

3:43People were like, you should get on Instagram to get people to listen to your podcast. So, okay, good. People know I have a podcast. And podcast is very different than Instagram. You can have conversations with people, like long, complex conversations. For example, the conversation I had last week with Dr. Horowitz on deprescribing SSRIs. You can't do that in short form on Instagram. So I started out the podcast because of female sex med and the lack thereof. And I'm a urologist, so I give Viagra and testosterone to men all the time. That's what we were trained about. We were trained that quality of life matters.

4:24We were trained that hormones matter. We were trained that sexual health matters for the men. And then I had a woman who had a sexless marriage, and I didn't know how to help her. And that was why I'm here now, basically. Like, that was the, like, fork in the road, choose the red pill of the Matrix. That was it. And I was like, who knows anything about female sexual health? And I started going to the IshWish conferences and reading the books and talking to the experts and reading the research. And I was like, I can't make a big enough difference in the suffering of the world. just by seeing people in clinic.

5:07So I need to talk. And so I started the podcast. And then everybody kept saying, well, you know what happens to your sex life with menopause? And I'm like, I don't know what happens to your sex life with menopause. So let's figure that out. So I started going into the data on estrogen and testosterone with menopause and how that changes and how that changes your sex life. And then I was like, wait, why is everybody afraid of hormones? because they seem to be very good for you. And I think like the summary of like what I like to do is I like to get people talking. I love talking about topics that people don't want to talk about.

5:45So like the whole hormone thing, first it was like female sex med and then it was hormones. I'm like, why does everybody think this is bad? Where did that come from? What the hell was the WHI? Where's all this misinformation coming from? Like rabbit hole of menopause. And so I wrote my first book called You Are Not Broken, podcast and book, same name, You Are Not Broken. And that was about female sex ed. And a publisher called and was like, will you write another book about sex? And I was like, yes, but I think I want to write another book about menopause or a book about menopause. And they're like, great, do that.

6:18And so that came out. That's called The Menopause Moment. That came out. And I did not get the title I wanted. For anybody who knows anything about publishing, you don't always get what you want. but Amazon search terms need it to have menopause in. So I wanted to name my second book Aging in Captivity, because we are aging in captivity. We have civilization, and we have clean drinking water, and we have health care, and we have great infectious disease treatment, and now we're living longer than ever, but frail. So I'm like, when you choose to age in captivity, and everybody, I'm going off on a tangent, but I think it's fascinating.

6:54So if you look at animals, all the animals, from fruit flies to yeast to mice to harbor seals to orangutans, when you look at all the animals and you put them in a captivity, aka a zoo, and you protect them from predators and you give them good food and you give them clean drinking water and you treat infections, they all live longer than their reproductive potential. I will say that again. They all live longer than their reproductive potential. So all this like, well, you know, menopause is very special and only humans. So we were meant to do it because God wanted us to be grandbabies and not have other babies and blah, blah, blah.

7:37It's like take any animal, age them in captivity. They all live longer than their reproductive potential, meaning there's an evolutionary preservation to actually existing longer than reproductive potential. Therefore, aging in captivity is what I want the book to be. because if it is true that now, because antibiotics alone have increased human life expectancy by 26 years. So the whole like, we were meant to live 40 years with no hormones. No, no, we've never lived 40 years without hormones on a societal level ever before. And it ends poorly for a lot of people. Dementia, recurrent urinary tract infections, fractures, all the things, frailty.

8:17So I wanted to name my book, Aging in Captivity. And they said no, because Amazon search terms so it's called the menopause moment and really talking about the role of hormones in preventing health issues because we live in a very reactive strap for time strap for cash healthcare environment where you're not sick enough yet come back when you're more sick but that's not how hormones work hormones help you preserve health and help you from not getting disease so it's a different way of thinking than like, are you suffering enough to earn your hormones? So there we go. I'm going to start at the top of the Q &A to be fair to everybody.

8:58I'll go from there. Okay, so if you have a factor two diagnosis, which I am assuming means a blood clotting disorder, transdermal estrogen does not increase risk of clot. Your clot risk is still higher than that of the general population, but It doesn't go higher than if, because you're on transdermal estradiol. So that's well established. You can find that data online and present it to a doctor if anybody's giving you crap about that. Somebody says testosterone cream is nearly as effective as injections. Do you feel that way for women and men? Great question. Effective is not the right word. I think what we might be looking for there to be a little more clear is the dosing.

9:45So for a lot of people, it's hard to get a high enough dose with a transdermal product, especially in men because they just need a much higher dose. So it's more rare in women that they're not absorbing. So injections bypass the need for absorption through skin. But to oversimplify that and to call one more effective, no. You're able to push the levels up better when you take absorption out of the picture. It's very normal for men to inject testosterone because they actually need, like, if you look at an Androgel product, it's actually a decent amount of product. And it doesn't push a lot of men very high.

10:24And injectables are cheap, again, for men. because men have FDA-approved testosterone doses. So effective is the wrong word. Efficacious to get you to a higher level might be a more accurate way of saying that. When do I choose injections? If somebody just is not absorbing on transdermal products. But injections for women are tricky because you either have to compound it or you have to use a male injectable dose and draw up a very, very small amount of it, and it's a little onerous, but some people love it. But to say that there is one route that for everybody is better is way oversimplifying things.

11:07What can be done to lower a high level of SHBG so there is more testosterone? We don't know, but let's back up for other people. SHBG is sex hormone binding globulin. It's a protein. It is made by the liver. It goes up when you take oral birth control pills. And it isn't something that we know how to lower. There's not like a medication for it. And oftentimes it's just used as a marker to be like your hormones are more bound than free. And so you just might need a higher dose of hormones to get you the same efficacy as somebody with a lower SHBG. But it's not something we go around like saying you need to take something for to lower it.

11:46We just use it as a marker to be like, hey, if you have a high SHBG, we might just need to give you more hormones to kind of get some that is unbound by your SHBG. That's a very common question. What's your thoughts on testosterone injections? I've been on testosterone cream for three years and my total has been dropping. Was 75, now 34. I'm 57. Well, I think I just answered that a little bit with the above question. But remember, this is what we always have to go back too. I could just say this on Instagram every single day and like still do well. Labs are the third thing we care about. What do we care about with testosterone in people?

12:23Three things. How do you feel? Do you have side effects? What's your lab value? Lab values are there to inform us. They're not there to use without the first two questions being answered. Testosterone lab values bounce around a lot? When did you dose last? Did you change your product? How much is getting into your tissues? How much is bound up by SHBG? All that to say, testosterone lab values are not law. How do you feel? Do you have side effects? Without answering those two questions, I would not answer the question, should I get on injections to push this higher? Because I don't know the first two.

13:01Labs are third. Third, third, third of importance. And that will, that's what I taught at Harvard. That will lead people on the correct path way more than chasing a lab value, which is influenced by many, many different things. And they're like some people will have a testosterone of 40 and be like, I am great. I'm fantastic. Other people, I need to push their testosterone much higher, mid 100s. I'm talking females here. Way above what normal is on lab values, right? So individual, individual risk benefits. All right, great question. Why do some of us hate progesterone? If I take it more than 100 milligrams at a time, it increases anxiety and keeps me awake.

13:44I'm so jealous of everyone who loves it for calming and sleep. I know. I know. I get it. Some people just don't tolerate progesterone. I mean, it is insane to me that we have one prescription, oral micronized progesterone, and it only comes in two doses. I would love an extended release version.

14:03Dr. Morgan Francis: This podcast is sponsored by Explore Worldwide. One of the themes that keeps coming up in my conversations is that it's okay to want more. More joy, more connection, a better experience. And thanks to our sponsor, Explore Worldwide, you can get so much more when you travel. All of Explore's adventures are 100 % human-made. Their tour leaders have actually stayed at that family-run guest house that isn't even online. They've eaten at the neighborhood restaurant the locals love and know the trail you'd never find on your own. Your vacation should feel uniquely yours, not like it was generated from the same prompt everyone else entered.

14:41Dr. Morgan Francis: That's the difference a human touch makes. Explore Worldwide's trips are created by real destination experts and led by tour leaders who actually know the places they recommend. They handle everything so you can relax, stay curious, and experience something genuinely memorable. This is your time. Demand more. Visit exploreworldwide.com and don't just travel, explore. This podcast is sponsored by Jones Road. I like to take care of my skin, but I don't like the whole cover-up makeup routine. I like things fast and fresh. So when I found Jones Road Beauty's Miracle Balm, it genuinely fit the bill for my lifestyle and skin.

15:23Dr. Morgan Francis: You see, it doesn't mask your skin, it enhances it. No brushes, no complicated steps, just your fingers and go. And it's a total multitasker too. You can use it as a highlighter, a blush, even a lip tint. One product, several jobs. And the best part, it's actually good for your skin. No phthalates, sulfates, petrolatum, cyclic silicones, EDTA, or BPA. Clean and high performing. It looks like your skin, but better. This is why I reach for it on busy mornings, before work or the gym, or even before getting on social media. when I want to look put together without overthinking it or overdoing it.

15:58Dr. Morgan Francis: Modern day makeup that's clean, strategic, and multifunctional for effortless routines. For a limited time, our listeners are getting a free full-size mascara on their first purchase when they use code YANB at checkout. Just head to jonesroadbeauty.com and use code YANB at checkout. After you purchase, they will ask you where you heard about them. Please support our show and tell them that our show sent you. So some people will say if you're getting that with progesterone, it's too much of a dose all at once. And so it's like it's like a peak and a trough. So a lot of people will do a sustained release progesterone SR.

16:36You have to get that compounded. In other countries, that is a medication. But sustained release progesterone is not a prescription in America unless you compound it. But that is an option. So talk to your prescribing clinician. Vaginal estradiol is supposed to help a lot with UTIs, but I've been on vaginal estradiol for two years and still have chronic UTIs about every three months. I started transdermal estrogen patches with progesterone in January, 2026. Okay, so what do I think about as a urologist with that question? What's your exam? Do we have significant atrophy? How much are you drinking a day?

17:10How much do you pee a day? Have you had a kidney, bladder, ultrasound? Remember, we can get UTIs for lots of reasons. Vaginal estrogen decreases UTIs by helping the microbiome of the vagina because a healthy microbiome prevents that type of UTI. But if you're still getting UTIs, how much are you drinking? How much are you peeing? Do you have a negative kidney bladder ultrasound? So the urologist wants you to think more comprehensively about that. And then what's your pelvic exam show? Do you still have atrophy? You're probably under treating your GSM then. Great question. Question, can you gain weight after starting estrogen and progesterone?

17:44I'm being told that it isn't a side effect. Weight has been stable for 15 plus years, menopause at 47. Started T a year ago, no weight gain. Started E &P six months ago and gained 10 % of my body weight within six weeks. No change in diet, workouts, etc. Yeah. So everybody's different. If you pool everybody and you look at all the data, people don't gain weight on hormones. But that's the mean. That's the average. That doesn't mean individual people don't gain weight. At the same time, we're aging. Our bodies are changing. metabolism might be changing like so there's there is a lot of other things still going on like you don't stop aging when you start hormones you're still aging right people are like and now i'm losing hair it's like you might have anyways but by and large hormones aren't a weight loss drug they're not a weight gain drug but so to you i'd look into it and be like what's your body composition what's your a1c what's your insulin how much protein are you eating so get a lot more granular on it versus just should i stop my hormones what's your estrogen level is it too hi.

18:43All the things. Okay, great question. Any info about HRT post-endometrial cancer? I don't know what to ask my doctors about. So the most important thing with endometrial cancer is what type, what stage, and then what type of hormones do you want? So there are published papers on hormones after endometrial cancer. I would recommend meeting with a hormone specialist who can look that up and give you risks and benefits. The big concern being recurrence rate on it. And there's a big difference between stage one versus stage three, uterine sarcoma versus endometrial adenocarcinoma, right? So there's a lot of details there.

19:20So know your data, know your pathology, know what your goals are, and bring that into your hormone specialist. So it's not an absolute yes, it's not an absolute no, but the best thing you can do is know your data on it. What are your thoughts on DHEA supplements as testosterone support 500 milligrams a day. So first of all, DHEA is a supplement in this country. In America, it's not a prescription. 500 milligrams a day is actually very high for DHEA. They say 50 milligrams is high. They sell it in 100 milligrams. 500 milligrams a day seems like a womper dose. I was just talking to a patient in clinic about this today.

19:56DHEA orally, it has excellent safety data. It's been around for a long time. It shows more benefit in people with profound low hormones like hypopituitary, a low adrenal surgical menopause. But for by and large, for the average woman, oral DHEA doesn't seem to move the needle significantly on anything. The biggest side effect I tend to see is like greasy skin. So rest assured that it's relatively safe, but not in the guidelines of what you need to be doing because it's just the data on efficacy isn't there. Now, oral DHEA and vaginal DHEA are very different things. And I want to show you something, but I like literally just gave it away to somebody.

20:39I'm making a vaginal, a vulvar DHEA for aging skin. It helps, you know, DHEA converts into both testosterone and estrogen. So vaginal or vulva DHEA is the chef's kiss. It is the chef's kiss. It makes beautiful skin. And that's going to be over the counter. The best way for you guys to be first on that is to make sure you're on my email list, which you can get to on my website. That DHEA will be available on the market this fall is the current plan. So it's great, great, great for vulva vagina. Is there an end in sight for the estrogen patch shortage? I'm now using two of my old 0.375 patches to make my 0.75 dosage.

21:24I'm so over calling pharmacies every month and putting together old doses to equal new doses. Yes. And the other thing that's super irritating, yes, and it's worse, is people, people, the pharmacies will swap out brands of patches and people will be like, it's all equivalent. Not always. I just saw some, I had a woman check her estradiol level on her, I think it was a Dottie patch. I don't remember. And then on the new generic one that her pharmacy switched to her and it was like her estradiol went from like 70 to 30 on the same dose, I'm air quoting, same dose, but different brand. So different brands aren't always equal with each other, even if it's the same dose.

22:03So that's happening a lot more now that we have a shortage. So a group of people just met with the FDA and the too long didn't read as the shortage is going to be around for at least three years. ballpark-ish. So it's not good. Here's the thing. There isn't a shortage everywhere. And the shortages come and go. In personal opinion, CVS is the worst, followed by Walgreens right now. Like CVS in Los Angeles is like literally out of progesterone at this point, which is the second biggest city in America. That's a problem. HRT Club has not yet had a shortage. So they're wonderful. Mark Cuban comes and goes as far as shortages, but Mark Cuban just ran out of vaginal estrogen, which is a big problem.

22:45So I don't know. Hang in there. Might not be the best platitudes to give you. You can always switch to gel. If you just don't want to deal, switch to gel. Gel's pretty cheap, especially at HRT Club. And oral, for people who are low risk, oral estrodial is very cheap. So I think we're going to see a lot more of people switching to orals and gels because of the patch shortage because it's not like, oh yeah, September, it's going to be fine. I've been married for 45 years. In the past five years, I've had a hard time having an orgasm. I feel like my clitoris shrank or doesn't work like it used to.

23:18I love my husband and we enjoy sex, but I don't know what to do to get my orgasm back. Or so orgasm is very hormone sensitive, estrogen and testosterone. So what are your hormones doing? what's your exam? What's your clitoris look like? Do you have untreated atrophy? Do you have clitoral phimosis? Do you have lichen sclerosis? Think about orgasm as like, we got to figure out all the pieces. So the first thing I have to say is what's your hormones doing and who's done a good exam on you? So, and not all doctors are good at exams or sexual health, but we're working on it. So that's what I would say is like, you are not broken.

23:55There's probably something going on. go get it. I just had a patient very recently. She's like, I didn't really know that my orgasm was being affected. But now that we've got her on estrogen and testosterone, she's like, whoa, the orgasm is so much better. I think a lot of like we spend so much time talking about libido. We do not spend a lot of time talking about orgasm, but orgasm is like quite linked to hormones. What is a good level of blood test of estrogen for a postmenopausal woman? What is your best recommendation for dosage and method. Okay, so remember, labs are not God, labs are not gold, labs are not law.

24:32What can you tolerate? What are your goals? Do you have bone loss we want to try to rebuild, or do we have bone loss we're trying to protect? We know, so postmenopausal in America is an estradiol of 30 or less, bones specifically. There's a big difference in risk of fracture between somebody who's 0 and 10, and now they're both considered postmenopausal estradiol levels. But even a little bit of estrogen helps bones. And for bones, the more, the better. And that's well studied. That is patch data. We have studies on that. I need you guys to know that things that come out of my mouth are because I'm extensively obsessive about this topic.

25:12You could call that a diagnosis of something if you'd like to. But it's like, everything I say is, if it's my opinion, I will say this is my opinion. Otherwise, it is backed up by studies that I have read. Susie, you're adorable. Is that a quince sweater? Yes, this is a quince cashmere sweater. And it is the time of the year where I can wear short sleeve sweaters. And I'm very excited about it. So yeah, I am wearing quince. I recommend them. I'm very happy. I have another one. It's a dolman sleeve short sleeve that's all black. It's not cashmere. I love it. I'm like, I literally told my husband, this is not an ad for quince.

25:47I am not being paid at this exact moment, although they are an advertiser to the podcast. I am wearing my Dolman sleeve, short sleeve, all black, quince sweater with a pair of kind of like khaki green baggy shorts that kind of cut right above the knee and some necklaces. I literally told my husband this week, I'm like, if I can wear this outfit for the entire summer and just this outfit, I'm like the happiest. Going back to me saying there could be a diagnosis here. I'm like, I could wear this outfit for the whole summer and I would be incredibly, incredibly happy. Yeah, Susie says, I have them in several colors.

26:25I know. I'm telling you. I have a friend in Seattle who like the second to the last time I saw her in person, I was like, this outfit. And she's like, quince. And I'm like, stop it. I know. Somebody said I like their, there could be a diagnosis. I know. I'm just saying. Get their leisure wear too, just like Biori. I didn't know that, Lori. glory says their leisure wear is just like the lori that rhymes fantastic okay oh this is a good one how do you approach the subject of sexual health with clients menopause coach i see approximately 60 women a week fantastic shelly thank you for your work slow slow slow sex is a very big topic like how do you eat an elephant one bite at a time and they're coming to you and i especially see this with like not newer people but like people who are like i have all the information This is how amazing sex is.

27:17It's like too much for people because they've got layers of heavy blankets of like dogma, trauma, religion, first fucking boyfriend, like stonewalling husband, right? Like erectile dysfunction. Like they've got heavy blankets on them. And if we come in being like, there's five million different things we have to evaluate when we talk about orgasm and blah, blah, blah, blah. It's like, it's too much. So my best advice is like, know where your resources are in town, know who your sex therapists are, know who can do a good pelvic exam, know where you can get hormones for genital urinary syndrome and menopause, know the good books, aka you are not broken, know the good podcasts, aka you are not broken.

28:00know your resources and don't overwhelm. I say very commonly, I see a woman with low libido. Here's my other advice for that. When somebody tells you they have low libido and you understand low libido, what they think low libido is and what you think low libido is are two different things. So what do you mean by low libido? And then it might be like, I don't trust my husband. Like, that'll come up, right? And then you're like, okay, well, obviously, you don't want to have sex with people you don't trust. But when I think low libido, I think about something different than a trust issue. And a lot of information can come up when you're like, what do you mean by low libido?

28:42Because we're both saying the same words, but we mean different things. So that's my other advice, is like, get specific and just be comfortable asking those questions and then know where to refer to. So thank you, Shelly. Oh, Shelly says, I'm so gentle. Thank you. Yeah, do that. And just be like, we're totally here. And encourage people to be like, people get better. Like, people have amazing sex lives. Like, to me, like, I have so many wins that I'm like, you know, in six months, it's quite possible that you could be coming back here having the most amazing sex of your life. And they're like, really?

29:14And I'm like, oh, yeah, happens all the time. But not without legitimate work. legitimate work to work on trust, to work on body image, to work on your own pleasure is okay, to see somebody for clitoral issues. Like, yeah, do some work. It's like, I will not become a master's champion pickleball player by like sitting on a chair and being like, I wish I was really, really good at pickleball. That's not how you get good at pickleball. And that's not how you get good at sex. You have to go on the pickleball court, aka bed, and figure out where the weak backhand is because sometimes you're never going to find out where the weak backhand is sitting on the chair.

29:54You got to get on the court. So how do you approach a woman in her 50s who has little to no libido for decades and says she's not concerned about it? Such a... Oh, who asked that? Anne. Good job. Do you leave it alone since she's not distressed or do you explore whether she's simply accepted something and could potentially be improved? Where do you draw the line between respecting autonomy and educating patients about options for sexual well-being? And I love it. Such a good question. I think this is such an important question, and this is the reason. We spend a lot of time talking about women who want to want and don't currently want, but I want to want.

30:30We call that in the medical world HSDD, hypoactive sexual desire disorder, which in that definition says distressed by low libido. Whole other subject, group of people, and I'm saying women because that tends to be my target audience, but this is also men. It's all people, all genders. I don't want, I don't want, and I don't want to want. Different group. That's technically not HSDD. Not distressed by not wanting, right? And so I always say, I'm not here to tell everybody they need to or they should have an amazing sex life. It is available should they want to. And feel out, like, do you want to explore that?

31:04Do you feel like that's in a good place? Are you sad about not wanting and not giving a fuck about it? And are you partnered? Because I think that's where, when you were saying like, where do we draw the line, right? Of like, if you're in a partnership that started out sexual and now you're like, I'm good. Pickleball court is closed. Don't want to play. Don't want to become an expert. But you're married to somebody who thinks pickleball should be happening. That is a conversation that needs to happen lest that conversation doesn't happen. And then we're surprised that there's a big fallout because you got a pickleball player who started playing pickleball with you and now you don't want to play pickleball.

31:43So I think in a partnered relationship where it was sexual, if both people aren't on board with not wanting to want and not caring about it, that's worthy of a discussion because we can't just ignore the other person's needs and hope that they agreed with the plan of retirement from pickleball without a discussion about that. So I hope that that I hope that that helps.

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32:46Dr. Morgan Francis: Addy is not for men or to enhance sexual performance. Addy can cause severe low blood pressure and fainting. Your risk is higher if you drink alcohol close to your dose. Don't take Addy if you have liver problems, take certain medicines, or are allergic to any of its ingredients. Before taking Addy, tell your doctor about all the medicines you take if you have had any mental health conditions, are pregnant, planning pregnancy, or breastfeeding. Side effects may include dizziness, nausea, tiredness, trouble sleeping, and dry mouth. Learn more at addyi.com, including important warnings. Visit addy.com and complete an online telehealth visit today.

33:20Dr. Morgan Francis: With commercial insurance coverage, Addy is as little as$20 a month, eligible patients only. Restrictions apply. Visit adi.com, A-D-D-Y-I.com.

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34:16Dr. Morgan Francis: Now, when I need something, my first thought is, I wonder what Quince has. Find the fall pieces you'll reach for most at Quince. Download the Quince app for app exclusive offers or go to quince.com. Get free shipping on your order and 365 day returns. Now available in Canada and the UK too. And when Quince asks where you heard about them, let them know it was You Are Not Broken. It's the best way to support the show. All right. Well, yay, Mellie. I'm a menopause coach and these are such great questions learning a lot. Amazing. My kid has that, doesn't care about having a libido and isn't partnered.

34:53So I'm like, whatever works for you. But made sure to say they can get assistance with it if things change. I love it. Somebody said, I'm so calling sex pickleball now. I will never play pickleball the same way again. If you think of me while playing pickleball, it's better than thinking of me when you're having sex. So could be worse. All right. I love it. Can you please make your DHEA available in New Zealand? Okay, so here's the deal. DHEA isn't over the counter in every country. It's the great grandness of America that our DHEA is over the counter. In the UK, it's a prescription. In Canada, it's a prescription.

35:28So my default is it's probably a prescription in most countries, but it's not in America. So my DHEA serum is going to be for sale in America because that's where it's over the counter. And here's my why. There was a paper just published, the end of 2025, by Stanford. And I need to have this person on my podcast. It just hasn't worked out yet. And she looked at Medicare database. And if a woman went to her doctor and she got diagnosed with genital urinary syndrome of menopause, so pelvic issues because of low hormones. So you got to a doctor and you got the right diagnosis. You're already winning compared to women out there.

36:07You got to the doctor. You got a diagnosis for GSM. what percentage of those women got a prescription for vaginal estrogen or vaginal DHEA because they're both options oh wait I'll see what people say somebody said 0.0002 percent it was better than that thankfully um let's see if anybody else has anything else about them so the answer is nine percent so when I think about how I want to change the world I can help educate the doctors And I am. In 2027, I'm doing two Harvard CME courses. The first one is in Florida. That's Dr. Morgan Teller's course in Orlando. That's testosterone and sex med. And then the other one is the Harvard CME course in Boston.

36:52So you can change the doctors and the nurse practitioners and the PAs. Or you can make solutions available that are over-the-counter that we have access to. So that's my too-long-didn't-read of why I'm making a vulvar DHEA serum. and why you can get it in America and you probably can't get it in New Zealand unless you guys allow DHEA to be over the counter. Because when you go to the doctor right now, only 9 % of people will be able to get on hormones when properly diagnosed with genital urinary syndrome of menopause. Properly diagnosed, still only 9 % of people got vaginal DHEA or vaginal estrogen.

37:28It ain't good enough. It's not changing fast enough. That's why I'm like, I got to create a solution that works and is available over the counter. And so how DHEA works is DHEA converts in the cells to both estrogen and testosterone, and it works locally. It doesn't go into your bloodstream. Yes, over-the-counter is great. What will it be called? I don't know, you guys. We haven't named it yet. Currently, I would show it to you right now, but it's not in my office. Currently, I think it's called like Kaspersen Vulva DHEA. Very generic. But it's going to go, we're going to name it. Probably the end of the summer or in September, we're going to name it.

38:06Vulvar serum. I know. If you are a pro at naming things, send some names my way. Somebody said vulvar serum. Yes. V serum. Name it pickleball. You think that's trademarked? We should just do that. We should just name it pickleball and say it's for when you play pickleball and it's for when you don't play pickleball. It's just it's for the pickleball court, basically. I love it. Do the vaginal gels, creams change your natural scent? Well, a lot of people say natural scent changes when hormones go down because, again, your microbiome is changing. So I have a lot of women say like their discharge and their smell gets better after getting back on the vaginal hormones because it changes the microbiome back to where it was.

38:48The V effect. All right. I don't hate it. I don't love it. B power. Don't hate it. Don't love it. I don't know. I'm going to do something that's not flowery, that's not a f***ing orange slice with dripping things on it like all the people do. All right. I can't figure out my progesterone. I'm on a 0.075E patch. Use progesterone rectally and believe 100 milligrams is working for me. No bleeding, no brain fog. Doctor is pushing for 200 milligrams but wouldn't do a blood test. I can't find any studies except the levels on fertility treatments that 100 rectally is enough. And she's very by the book.

39:22Any suggestions? I do have vaginal sonograms scheduled for July, so we'll check out the lining. Any studies would be helpful. Thank you for the knowledge I got from you in addition to other sources. Fantastic question. Fantastic question. So the party line is the higher your estrogen dose, the higher your progesterone dose should be. That is not, That's expert opinion. That is not based on decades and decades of study. And it's a flawed opinion because we have multiple studies saying if I give Susie a 0.05 estrogen patch and I give Rhonda a 0.05 estrogen patch and I give Elizabeth a 0.05 estrogen patch, their bodies are going to actually see different levels of estrogen with the same patch dose.

40:05I want you guys to follow me, so I'm speaking slowly. What that means is the party line of if the patch dose goes up, your progesterone needs to go up is only true if your patch dose going up actually means you have more estrogen in your body, which isn't true for many people. So, and in addition, pelvic progesterone is like closer to the uterus and is considered like likely more uterine coverage than oral progesterone because oral progesterone is broken down into multiple metabolites. But again, we do not have a study to say that. I am pedantic about if there is a good reason for me to be absolute on something, I will tell you.

40:47And if there isn't, I will tell you. But to be absolute about something where there isn't good data on it is cutting corners, in my opinion. So that was Nora who asked that question. So Nora, thank you for answering that question. And I don't know what to tell you. My level of knowledge on this is like, I don't expect everybody, like, how do you get your doctor to know all this? I don't think you can. They also, like, they need to care about moles and high blood pressure and, like, pink eye and, like, things I don't have to think about. So is the short answer. But, like, if you were, like, show me the data that says why you need 200 rectally, like, rectally is completely off-label.

41:25Very poorly studied. Not saying don't do it. I'm just saying you don't have a strong argument that you have to shove 200 up there instead of 100, especially since I don't know what your estradiol blood level is. Like maybe your 0.075 patch is giving you an estradiol level of like 25. Like maybe your loaves are over, right? Like we don't know. So again, this lovely call is not for individual medical advice, but if I can, again, the things I could say on Instagram every single day on repeat would be like, everybody's an individual here and individual risk benefits. And I think, you know, to like, this is why women in my clinic gets so much better so fast is because I see them every six to eight weeks and we dial them in.

42:05And they're all on very different things. Not because it's complicated, but because it's individualized. So I hope that helps. Individuality is what makes this so hard. Yes. And also so interesting and also so fun. Right. And by and large, the wind, like the winds are so big. I just make people feel better. I make people feel like themselves. It is the best effing job on the entire effing planet. And I am all in. And I hate insurance companies. Side note. Hate insurance companies. All right. So, please tell us why Intrarosa is considered a controlled drug. I was at my pharmacy and thought I would pick up my prescription, denied, as I was six days early and was told it was a controlled drug.

42:44I felt I was asking for narcotics from Canada. Okay, well, I don't know Canada as much as I know America. In America, DHEA is not a controlled drug. Controlled meaning DEA-restricted American term for it. But like testosterone is a controlled drug, narcotics, ketamine, Tylenol with codeine, Adderall, right? A higher risk of abuse. The only abuse happening with Intrarosa is people fighting if somebody's going to take it away from them because it works out damn well. But in America, Intrarosa, which is intravaginal DHEA, is not a controlled medication. Somebody Dale said, who said? Colleen said, same.

43:21I hate insurance companies. Does vaginal progesterone work to protect the uterine lining? And can you use the oral prometrium tablet vaginally? So yes to the second question. Yes to the first question. It is an off-label indication, but it's been very well tested and been used that way for a very long time. All right. Name for your cream, CDH, Kaspersen DEH helper. Love it. Who said that? Thanks, Nora. That's a good one. Does it often make sense to use both DHEA and vaginal estrogen? It depends. Again, what are your goals? How effective is the vaginal estrogen alone? What are we trying to treat?

44:00Do you want to do vaginal estrogen in the vagina and DHEA? There's so many different ways, but by and large, yeah, you can be on both. You don't need to be on both. Some people are just trying to prevent UTIs. Some people are trying to have the most amazing mind-blowing sex of their lives. Those people might require different vulvar vaginal products. Goal is reduced bladder leakage. Okay, well, I would say optimize your hormones as much as you can in pelvic floor physical therapy. Hormones alone doesn't always help all bladder leakage. In Quebec, intra-rosa is not restricted but needs prescription.

44:34Yeah, it's a prescription. Okay. And DHEA, by and large, in Canada is a prescription. I knew that. Okay. Please talk about postmenopause and depression. I'm 57, and now I'm with lots of medicines with my neuropsychiatrist because he says I need antidepressants, and he doesn't talk about feminine hormone replacement. I'm so desperate. I guess my last chance is$13 ,000 ibogaine treatment. I don't know about ibogaine treatment. I've never heard of that. So the data suggests right now, And this is in the, let me asterisk this with, we need way more studies on this. But current data, depression in perimenopause seems to be more responsive to hormones than postmenopause.

45:14That doesn't mean you can't try it. It just means the brain's more responsive to hormones in perimenopause for depression. We actually have, this is like, raise your hand if you actually knew this. You probably knew this if you read my second book. In perimenopause, they did a randomized placebo-controlled trial looking at depression. And nine of you raised your hands before I said the fact. I don't know if that counts. So perimenopause, estrogen patch versus placebo patch. Who got more depression in one year? The placebo patch. Estrogen is protective of depression in perimenopause, according to that study.

45:46So now there's one person with their hand remaining up. Good job. I put that in my book. So it's like hormones help brains. Hormones help serotonin. Hormones help dopamine. Now there isn't an ICD-10 code for perimenopausal depression. Like we don't have a code for it, but it's very real. And to me, I'm like, I've heard too many stories of people feeling better on hormones than to not give it a chance. Hormones are, by and large, incredibly safe. I started HRT 13 years ago post-menopause and had some side effects, so got on a Facebook group for menopause and HRT to see if these are common. I was surprised to see how many women posting that their HRT made them blow up with their weight.

46:30Also, huge stomach blowups that look like they are pregnant. Menno belly. You know that happens not on hormones, too. Belly fat and visceral fat go up not on hormones. So to say it is all the hormones is not fair to the natural aging process. That's what I was saying before. I'm not, I am not saying women don't gain weight on hormones. I'm not saying that. I'm just saying midlife people gain weight, whether they're on hormones or not, not all people. So to me, I'm like, if you are, you choose the word blowing up. My medical training doesn't allow me to say that word. It sounds very dramatic. Experiencing belly fat.

47:03Again, what dose of hormones are you on? Is it too much? Is it too low? What is your metabolic health? What's your A1C? What's your fasting insulin? What's your body composition? Like, to blame hormones for everything is so oversimplified and, like, you know that, like, this is some, this is some, what's the story? Parable. It's a parable of, like, four blind people feeling an elephant from different sides and being like, this one is around big this must be a tree this is a they felt the tusk they felt the tail but nobody knew it was an effing elephant right of like if you just blame everything on hormones you're missing like the entire rest of the human and to me i'd be like is your hormones too high if so many people are put on like very very low doses of hormones that aren't actually optimized for them and then they gain weight and they're like it's on the hormones and vice versa with being on too high of hormones let's see what do you recommend for a 70 year old female who misses sex with her husband who now is Parkinson's and no longer interested in sex, despite this very happily married, any clitoral toys that work.

48:05I like the clitoral air pulse devices. I love the Womanizer by WeVibe. I love the Explorer. That's my vibrator. You can get that at Elixir Play. Use code NOTBROKEN for 20 % off. That's a nice vulvar massager. So neither one of those vibrators penetrate, which I think is nice for multiple reasons. So that's what I would recommend. Those are my top two favorite vibrators. But if you're not like a pro or used to incredible high-level stimulation, the clitoral pulse devices can be very intense to people. I'm on my fifth listen of the menopause moment. You guys, that's incredible. That's like me and heated rivalry.

48:46I've listened to You're Not Broken as well. I've recommended it to so many. I feel like I've learned the most from it. Thank you. I tell all of my women friends, you don't know how bad off you feel until you start feeling better. Yes. So I was just seeing a patient today and this is her second follow-up. So her third visit and we've like, we're pretty dialed. She's pretty happy. She doesn't want to adjust anything. And she's like, you know, you said like women just know when like they're back. And it sounds very like woo. I was like, nah, women know. Women know. And she's like, I know what you mean now.

49:17Cause that's where I am. And she's like, sometimes you just don't know until you know. And I'm like, I know sometimes you just don't know until you know. But if you're feeling bad, sometimes you have to borrow other people's belief that feeling good is possible and feeling good feels effing phenomenal. And you just have to like go and be like, where is that? Have you noticed having to adjust HRT levels when patients go on a GLP-1? Fantastic question. Oh, fantastic question, Lori. I have many people on both GLP-1s and hormones and we aren't doing a lot of adjusting. But I'm not having anybody, most of my people aren't losing like 50 pounds, 60 pounds.

49:55Maybe there's a difference between like significant weight loss and like, I'm not saying 20 pounds isn't significant. They feel like a million bucks. But I haven't needed to adjust anything yet. Doesn't mean I'm not going to have to. Finding the balance of what we each need of all these hormones is a real trial and error that's frustrating. Absolutely. Absolutely. But you You got to know like you'll get there and you'll get it. And like, thank God you took the time to adjust. It's just that our health care system, our health care system is a Honda dealership. And women are Ferraris. I like to use the word fucking Ferraris.

50:31Women are fucking Ferraris. We create life. We have very dialed in, expensive, life-giving machinery. And so what we're doing is we're bringing our Ferrari to the Honda dealership. And then everybody whines because we're not Hondas. And I'm like, yeah, because we're fucking Ferraris. Stop being grumpy. when you take the Ferrari to the Honda dealership. It's not equipped to service us. That doesn't mean that the Ferrari's the problem. I'm so bummed I got a Ferrari. Yeah, you create life. Whether you choose to or not, you create a motherfucking life. And the equipment is a little technical. We don't know where the goddamn owner's manual is, that's for sure.

51:09But you're not a Honda. And stop thinking that not being a Honda is a problem. Because you're a fucking Ferrari. Sometimes it's just a little bit more technical. Cool. All right. Thank you for all your work and having this Q &A. So happy you reached 500 followers. I love it. How often do I recommend lab follow-ups? Is it different based upon hormone administration? I'm in the pro-lab camp. As much as I will yell at you and say there isn't an optimal lab for anybody, I am in the pro-lab camp. After we adjust hormone doses, I'll check labs. If you are noticing a change in symptoms on something, I'll check labs.

51:44Perimenopause, that's a moving effing target uh i like labs every once in a while to tell a story we are coming close to home hormone testing and it's going to be fascinating one of my patients is actually doing a home hormone piece stick if anybody wants to check it out the company's called mira and we are learning a lot about her symptoms and how it fluctuates with fsh so i'm very excited about that. So I'm in the pro-checking labs camp, and I don't think labs are law. They inform us, and they tell us a story, but they're not law. I had somebody today who had a crazy estrogen level, but like no symptoms of high estrogen.

52:25And I'm like, that lab is just not right. We're rechecking it. So I'm a therapist working with women who are navigating peri and post-menopause. I recommend your podcast and your book all the time. I've gotten so many thank yous for the wrecks. My clients say they feel seen, understood, informed, and empowered. Thank you, Kim. And Michelle says, love that analogy. We're fucking Ferraris, Lori. Have you read Reviving Ophelia by Mary Pfeiffer? If not, you should, as it talks about how unfairly our girls and women are treated in our culture. Carol, I'm writing that down right now. Reviving Ophelia.

52:59Book club to follow. All right. Yeah, I think what I'm going to do, because this is so good, I'm going to put this out on my podcast. Like this is a really good Q &A and I'm having fun, which means other people will have fun. All right. Do you find DiviGel is roughly as equal to transdermal patches, which are almost impossible to find? I think, I think in my experience, you may have to fiddle. So I tell people when I'm transferring them from like a patch to a gel is like this might take an adjustment or two because there is like a grid that says this patch is equal to this gel. but I don't find that, again, perfectly reliable, and we might have to adjust a dose or not, but people tend to do really well with it.

53:40Your thoughts on bioidentical hormone replacement therapy as compared to regular hormone replacement therapy? Doctors here in Australia reject it, saying the dose is not regulated. Thank you. Don't confuse bioidentical hormone therapy with compounded hormones. Very, very different. Very different. And I explain that all in my book. If you want to read more, I would recommend that because we're running into the hour right now. But in America, bioidentical hormones, which is just what your ovaries make, are FDA approved product. The estrogen patch is a bioidentical hormone. Divagel is a bioidentical hormone.

54:13Vaginal estrogen is a bioidentical hormone. They're all FDA approved and heavily regulated. So don't confuse compounded with bioidentical, which is maybe my best guess on this, but if you want to find out more on that, Menopause Moment book talks about it. All right. Very good. Love these lives. I know I should do lives more. Here's what I'm thinking. You're seeing a work in progress. I'm thinking when the DHEA serum comes out, I will probably do, for people who are like subscribers to the DHEA serum, I really want to do a smut book club. Maybe we should do a Reviving Ophelia book club. Like I want to do a book club in there.

54:52I want to do lives in there. So that'll probably be stepping that up when the DHEA serum comes out. And anybody who wants to name, help me name that DHEA serum. Feel free to keep it coming. All right, everybody. I love you so much. I got like, I literally got to 8 % of these questions. 8%. So I know that the interest is huge. And I know that I could just do this every day and probably have a hell of a fun time doing it. I just remember like at the end of the day, like you're a goddamn Ferrari. You are not broken. Like feeling good is possible. Reading books is awesome. So is lifting weights. And I like my job is making women feel more like themselves so they can go out into the world and change the world.

55:36Like that's what I do. And I absolutely love it. I love it. Goddamn Ferraris. Absolutely. All right. Until next time. I love you guys. Thanks so much.

56:13Dr. Morgan Francis: 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.