389. Vaginal Estrogen and DHEA: What Works, Who It Helps, and Why the Myths Need to Die

0:03Laura Berman: 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. I'm so excited that you're here. We're doing a live webinar on vaginal estrogen and DHEA. And I'm so excited if you're here live. It's going to be great. We're definitely taking time for Q &A. So options for Q &A, you can either put it in the chat box or you can, sometimes there's like a separate Q &A thing. I don't see it right now.

0:38But as you guys are coming

0:39Laura Berman: in, I want to say hi. I've got a little bit of a PowerPoint, kind of an overview 101 because everybody's coming in at a different level of education. Some people are prescribing clinicians. Some people are what the hell is a vagina. So given the state of meta and TikTok and the fact that you can't say vagina on those things I love doing these webinars because we can actually say body parts how freaking refreshing is that so um I did I posted a real real equivalent whatever a TikTok on TikTok and it was a clip from my podcast with Dr. Andrew Goldstein about vulvar health research and all of the like emerging uh treatment options coming out for vulvodynia like in sclerosis vulvar cancer gsm all that stuff it's a great podcast episode go back and listen to it it was in 2026 anyways I posted a reel basically it was vulvar cancer awareness like letting people know like exams are important and get an exam manage lichen sclerosis so basically like health education cancer awareness posted that on tiktok tiktok said it violated terms and conditions and I'm like I'm freaking done with these platforms at this point like it's insulting embarrassing wrong not supportive of medical education all of the things so let's make sure that you guys can hear me enter into the webinar chat hello maybe tell me where you're from we'll do a quick rundown of locations and where you are so I hear a hi everybody let me know you can hear me that we're okay there see I love it okay we got Mexico Ontario Vancouver Island Tacoma Fort Worth Florida Carlsbad New York Tampa Sweden Colorado Melbourne Illinois California Michigan Maryland upstate Mississippi Puerto Rico Las Vegas okay fantastic it's working all right very good so we are recording we will have this out for the people who are missing it live but if you want to get things live two things number one be on the email list kelly casper send md.com number two i post most of my stuff for live events on instagram i know not everybody's on there that's okay you can't say vulva on instagram and definitely can't say clitoris on instagram and then uh i do have another live webinar in the future about my vibrator so my vibrator is called the explorer it's made at elixirplay.com use code not broken for 20 off not broken 20 for 20 off but today we're going to talk about vaginal estrogen and dhea i'm seeing if there's like i'm trying to find if there's a q yeah okay there's a q a button which i'll also look in the webinar but questions for when we do Q &A we'll put in there so we're very excited let's see if I can share my screen I've got a little who doesn't love a good PowerPoint so we're going to share screen so that you guys can see all of that and we'll answer some questions so vaginal estrogen and DHEA this is what we are here to talk about and this is under treated under recognized under supported underrated uh all the things so vaginal estrogen and dhea this is an introduction um oh somebody said that oh two people said they love the vibrator i'm telling you it's pretty good all right so understanding genital urinary syndrome of menopause and our local hormone therapy options i am a urologist i practice in the united states i tend to use U.S.

4:43prescription names because that's what I'm familiar with and I fully understand that other countries have other brands other doses etc etc so by and large I'm most familiar with the United States products but I know I know a little bit about a lot about other countries at this point so this is not individual medical advice this is for education and entertainment purposes only

5:08Laura Berman: that said my podcast you can get for any clinicians you can get CME continuing medical education to the pinnacle network you just need their app and my podcast is on their podcasts of things you can get continuing medical education for so I would encourage you especially if you just listen to the podcast anyways like oh my lord that's 52 CMEs a year goodness gracious how awesome is that So this is not individual medical advice. Please discuss your own care plan with your own clinician. I'm a clinician and you know handle that proper properly when you go in and you're like I listen to a webinar and X Y & Z.

5:50Clinicians like it when you cite resources or cite sources etc etc. They don't like it as much when you say I saw on the internet just giving you style

6:00Laura Berman: points for talking to clinicians. Alright so I am a board-certified urologist. Urologists take care of genitourinary system from the top down that's adrenal glands, kidneys, ureter, bladder, urethra, prostate, vulva, vagina, clitoris, testicles scrotum penis clitoris what did I miss so genital urinary organs is our wheelhouse um oh somebody said I cannot wait for your DHEA product to be available me too I'm excited uh best way to know about that is to be on the email list so we're not going to talk too much about that today but I'll plug it because somebody commented on it. All right so You Are Not Broken podcast seven and a half years in at that this point which means seven years in on Instagram.

6:58Instagram's always a half a year younger than my podcast is. The podcast right now is nearing 400 episodes which is amazing. I've also written two books the You Are Not Broken book and the Menopause Moment book. So if you want more of a sex ed 101 One, you're going to read The You Are Not Broken. It is coming in Spanish this year. Menopause Moment's actually being translated into French. So both are very exciting. Both of them have chapters on GSM and genital urinary syndrome and menopause. So check them out. Oh, somebody, Angela. Angela says both books are excellent. Thank you, Angela.

7:39Laura Berman: I've been a speaker at the FDA. big conferences teaching at Harvard last year I have oh this year this year next year 2027 I'm going to be teaching at Harvard twice plugs for them one will be in and all of these are you know you can do these remotely too these are clinician level talks one is in Florida in January it's their testosterone course and then I think March will be their third annual women's health and menopause wham conference how to get on my email list go to kellycaspersonmd.com and anywhere it says like sign up blah blah blah put your put your info in all right i think what i do which is educating the general population gen pop for people in the know um that's the third to me that's the third pillar of academic medicine it's not enough to do research and to teach the next generation of clinicians we must also educate people because I think we're in the pickle we're in because we do research and we put it behind a paywall and then the culture of research is well don't be don't be too proud and promote what your work is just let it stand on its own well it's standing on its own behind an effing paywall so I think we're in the pickle that we are in with loss of funding for research because nobody actually knows of the research and I think the other big argument I just did a reel on this on Instagram.

9:06There's people like, we need more research. We need more research. I 100 % agree. And we're not using the research that we have.

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11:09Laura Berman: 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 Y-A-N-B 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. Exclamation point, exclamation point, exclamation point. So I think the third pillar of academia is to communicate the research, to communicate the knowledge to the general population. because a lot of what I see and we'll talk about this today is the myths persist.

11:56Dr. Jim Simon who's an amazing person in this world talks about zombie zombie myths meaning you try to keep killing them but they keep on living it's like they do not die. One of the big ones with vaginal estrogen and GSM is that people who've had a history of breast cancer can't use it. It's absolutely not true and there's like so much data against it but these zombie myths will keep popping up and you'll you'll see it people will eek in doubt they'll be like yeah but do we really

12:27Laura Berman: know do we really have long enough studies do we really have proof do you events and they these doubts keep eking in because people don't know we have meta-analyses looking at over 50 000 women years after breast cancer and vaginal estrogen that it's freaking safe. So and at the end of the day I think women should have body autonomy and be allowed to make their decision with informed consent. So that's that's the point. It's the third pillar of academics. It's very very important. Not just direct patient care. Not just clinician education but educating the general population and that is why I am here my friends.

13:06All right so a very common patient that a doctor

13:10Laura Berman: might see in clinic is a 78 year old female with urinary frequency urgency getting maybe she's getting up at night to urinate a couple of times that's called nocturia. She's tried her the classic overactive bladder meds a common generic is called oxybutynin. By the way these overactive bladder meds are actually contraindicated in people age greater than 65. They're associated with dementia. So clearly if there was something that was equivalent, aka vaginal estrogen, it would be safer for them, right? She gets urinary tract infection symptoms, burning with urination a couple of times a year. They get better with antibiotics.

13:48And she stopped having sex years ago because it started hurting and never talked to anybody about that. the um the data says the average woman waits seven to eight years before going to her doctor to discuss bladder leakage I have not seen data on how long women go with pain with sex before seeing a doctor um and I get it most doctors are not trained in pain with sex the advice some women are given is abysmal that's why I wrote the book you are not broken but I would guess my wager would be it's equally seven to eight years, if not longer. All right. Before seeking help with pain with sex. A lot of people just think it's like normal or that they don't think there's something you can do about it.

14:33So this is our stereotypical post-menopausal woman going in with what you think might be a whole bunch of different things. Overactive bladder, pain with sex, recurrent urinary tract infection. Should we give her three different problems? or is there one unifying problem that nails it all? So genital urinary syndrome of menopause, which is a mouthful, we call it GSM for short, describes the symptoms and signs resulting from low hormones. It's important, both estrogen and testosterone. So deficiency, meaning you used to have hormones and now hormones are low. Because your hormones are low, tissues change, cells change.

15:17the changing tissue is what's giving you the symptoms this term was developed at a 2014 consensus conference and the Erwin Goldstein a male urologist was at the table and said we need to add urinary into what this is before this it was called vaginal atrophy which didn't describe the urinary tract infections or the pain with sex part or the bladder stuff and then before that it was called the senile vagina so we've come a long way since the senile vagina but I get a laugh every time I say that when I'm doing a talk so with adequate estrogen and testosterone the vaginal lining that vagina vulva is thickened rugated well vascularized GSM is what happens as that support falls away somebody said um ditrapan was a no-go for me same with gemtessa so you started on overactive bladder stuff first the journey's been hard femring pessary and testum win i am 50 i hate the word atrophy perfect nobody likes the word atrophy um i finally have a clinician she couldn't prescribe me vaginal estrogen fast enough fantastic i love hearing about people's wins so gsm is the syndrome it describes that patient instead of having three separate things she has recurrent urinary tract infections, sexual pain and urinary issues.

16:45And she has GSM, previously known as bubble vaginal atrophy, previously, previously known as senile vagina.

16:52Laura Berman: So we like GSM, but some people don't like GSM because they actually think it's too narrow. And the reason for that is it can happen in perimenopause. So the fact that your periods have to end to call it menopause, you know, General Urinary Syndrome of Menopause is kind of a, it's actually very arbitrary. People's hormones go down well before periods stop. You actually need a very small amount of hormones to make a period. So the people who don't like GSM are the people who are like, you can actually get this stuff for many reasons of having low hormones, whether that's oral birth control can cause low hormones in the genitals, perimenopause, breastfeeding, cancer treatments, all of the things.

17:39So anybody who is here again and has questions, there is a question box and we will do questions and answers at the end. I'll also look in the webinar, but there's a lot of you in the webinar chat. Okay, so GSM, incredibly common.

17:54Laura Berman: When we talk, when doctors talk about prevention, when we say, should we be on vaginal estrogen to prevent this? These are the things we have to talk about. Is it common enough to have Gen Pop do some treatment? So GSM is actually quite common. Is the treatment cheap enough, right? And does it prevent something that would be harmful or otherwise costly? So I would say, yes, this fits all three criteria. Common 50 to 90 % of women at time of menopause or after. The biggest issue I see, and this might be the generation I'm not sure what this is but like many women that I see who are in their 70s or 80s who had come in with GSM they're like well but menopause was like decades ago or I'm over menopause honey there's no over low hormones you you have low hormones until you die unless you give yourself hormones so there's that disconnect right because they think they're over menopause or past that or they don't know that menopause means low hormones right so there's this this education that needs to happen before you can just be like here's some vaginal estrogen right so the gsm is incredibly common and gets worse over time and is more common the longer you are without hormones and certainly can start while you're still having periods.

19:29There was a study that came out of Stanford at the end of 2025. Dr. Day is a name on the, was it Dr. Day's paper? No, Dr. Day's paper just got published. She needs to be on the podcast. Basically saying women on vaginal estrogen had decreased risk of hospitalization, admission to the ICU and death compared to women with recurrent UTIs who weren't on vaginal estrogen. This is so this is looking at women with recurrent UTIs on vaginal estrogen versus not on vaginal estrogen, a large U.S. database. And this improvement in disability, including death, went down to age 20 meaning there might be a role for vaginal estrogen with recurrent UTI certainly before menopause and I think there's a role in like reestablishing your vaginal microbiome after being on antibiotics for a while so an amazing paper basically showing I'll say it again slowly huge database women with recurrent UTI on vaginal estrogen versus off vaginal estrogen women on vaginal estrogen statistically significant decreased risk of death admission to the hospital admission to the ICU and sepsis death so I mean it makes you die less if you have a recurrent UTIs that's a good reason And also just less UTIs, which is nice.

21:09So the other study that I had started saying, but then got distracted by Dr. Day's study, came out of Stanford, published at the end of 2025, was a Medicare database. So this is women 65 and older in America. These women went to a doctor and got the proper diagnosis of GSM. Now understand all the women that didn't make it to a doctor and didn't get the proper diagnosis. But let's say you've got, you've passed those two hurdles. You've got a doctor. You got a diagnosis of GSM. Only 9 % of them actually got a prescription for vaginal estrogen. Embarrassing. Embarrassing. So it's bad. It's bad out there, ladies.

21:56Laura Berman: But the more I can educate you as a general population and educate clinicians, it hopefully won't be such a hurdle when you get to the doctor because you can say, I've heard vaginal estrogen decreases urinary tract infections by 50%. True, it does. What's the definition of a recurrent urinary tract infection? The medical definition of recurrent urinary tract infection is two UTIs, urinary tract infections, within six months or three within a year. There you go. My 26-year-old daughter has recurring UTI. I wanted her to ask her doctor if she was too young for estradiol. Remember, age isn't a, knock it off, age is not a reason that you can or cannot have something and I would actually quote the Dr.

22:40Day's paper about down to age 20 women with recurrent UTIs did much better when they were on vaginal estrogen remember what every time you take an antibiotic you wipe out your microbiome so it might not always be low hormones for these people I think the vaginal estrogen helps microbiome we've got some data we don't have enough data in really young women but that's my my uh theory all right let's keep going vaginal estrogen prevention many papers on this basically the too long didn't read is decreases recurrent urinary tract infections by 50 very exciting big deal very big deal and there's nothing like there's nothing cheaper than vaginal estrogen It's like$14 at Mark Cuban's cost plus drugs right now.

23:30Know that. Know that if you're paying$100 for your vaginal estrogen, you're paying too much. So vaginal discomfort with GSM, the closer survey of 58 % of women avoided intimacy, 64 % said it contributed to their low libido. I always say when women come to me and they say, I have pain with sex and low libido, I say, you have one thing, you have pain with sex. Nobody wants to have sex with pain with sex. You have to fix the pain with sex first before you can expect the libido to get better.

24:24Laura Berman: Adi, Flabanserin, is a prescription medication for women under 65 with hypoactive low sexual desire disorder that is distressing to them, known as HSDD. Adi is for low desire that happens in all situations and is not caused by a medical condition, relationship issues, or medicines. Adi is not for men or to enhance sexual performance. Adi can cause severe low blood pressure and fainting. Your risk is higher if you drink alcohol close to your dose. Don't take Adi 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.

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26:35Laura Berman: It's the best way to support the show.

26:41Laura Berman: Somebody said so many UTIs when I was on birth control. So yeah, oral birth control can block hormones, especially in the pelvis. I have labial atrophy and wish I knew about vaginal estrogen before now. Yes. I mean, that's the other big argument. If you knew you had a chance of your clitoris and your labia atrophying to the point of disappearing after menopause, would you want to keep them? In addition, so labia minora, in addition to being sexual arousal structures and important for blood flow, help protect the urethra and the vagina. So the urethra becomes more pronounced, more susceptible to microtrauma, likely infections, right?

27:28So hormones matter and vaginal hormones help the pelvis. to clear up. I haven't seen this question come in yet, but many people who are on systemic, meaning full body hormone therapy, it's not a lot of hormones and they might still have GSM and it is very standard, safe, acceptable to be on both systemic hormones and vaginal hormones. So I wanted to make sure that you knew about that. I wish my mom's doctor would put her on vaginal estrogen? You can ask because he thinks she doesn't need it. Ask why? Why does he think she doesn't need it? I mean we're kind of in the prevention camp over here so.

28:21Laura Berman: How much can vaginal estrogen help with clitoral atrophy? We think it can help a lot but maybe put the hormones on the clitoris not the vagina. They're somewhat neighbors but they're not the same structure that's why I like the cream because the cream can go on the vulva again vulva external genitalia vagina the part on the inside that you can't see right so you need hormones in the vagina to help with the bladder because the bladder and the vagina are condo mates another thing just for people here I have an older podcast you literally like literally google this you can literally google the you are not broken podcast in any topic and it'll pull up an episode for you the internet's amazing um but it's uh gsm 101 or vaginal atrophy 101 is a is a much older podcast episode if people want to have podcasts to refer to people i get vaginal estrogen through mark cuban for 13 thanks to you yeah i know plus shipping It's more expensive in Ontario, Canada, but Premarin is covered so that's why I use it.

29:33Yeah, Canada tends to favor price-wise Premarin. I don't know why. Estradiol is the body identical one. Premarin is actually conjugated equine estrogens that they make from pregnant horses. Some people have a problem with that, some people do not. They are likely equivalent. Europe tends to use an Estriol. Published data on that too. Estradiol works nice. We're never going to get a head-to-head of all three. They're all, I would say they're all better than nothing. The Premarin, at least in America, is a smaller package than the Estradiol. So dollar for dollar you're getting more with the Estradiol, but Estradiol is generic in America.

30:12That tends to be often the most cheap compared to the Premarin in America. I think Premarin is owned by Pfizer at this point and is not generic. So some health insurances do cover Premarin better in America. But in America, by and large, estradiol 0.01 % is the generic commercially available. And on Mark Cuban, it's like$14 plus shipping. All right.

30:47Laura Berman: If I feel okay with all my HRT plus T, do I also need vaginal estrogen or only if I have issues? Depends upon what your belief is, meaning, hey, maybe it's good enough. If you have issues, start it. Versus I would like to preserve vulvar structures and I would like to preserve vaginal health and I want to be on this preventatively. Ideally, in a perfect world, you're going to have a vulvar exam by a trained clinician to start noticing atrophy, resorption of labia minora, if you can't see that yourself. And then that clinician is going to be like, you know what? Even though you're feeling fine, you're having signs of GSM.

31:23Do you want to get on top of this? So in a perfect world, trained clinician genital exam. I know that's not available to everybody.

31:35Laura Berman: Went years with discomfort and pain. I was told I was eating too much carbs, causing severe bloat. turns out you had prolapse vagina collapsed vagina is always collapsed my friends vagina is a potential space it's a closed sock what you're talking about with prolapse is that it's basically herniated so the vagina is kind of turning inside out or looks like a hernia not that it's collapsed technically speaking the vagina is always collapsed except they're like when a baby is coming out of it or a penis or a vibrator is in it vagina is a potential space can't things you can't say on meta okay so then you had robotic sacral copal pexy good job way to get it treated fantastic difference between primer and estradiol we just answered that they're by and large pretty similar but they are different products I applied exterior as I did not want to do the tampon applicator and everything is going very well good for you I like the cream because I like it on the outside and the inside a lot of people will use their finger instead of the applicator perfectly fine can attribute atrophy be reversed yes absolutely but likely the dose might be higher or you might need not just estrogen but an androgen ideally you're gonna see a trained specialist who can help you on that I think the DHEA and we'll get into the DHEA a little bit more here but I think the DHEA is more effective if we're trying to reverse atrophy versus prevent something because it has the androgen component to it and really does make vulvas beautiful again.

33:17Chef's kiss. All right. Are vaginal tablets as effective as cream for the bladder and urethral health? They're never going to do a head-to-head, but they are effective. You can't put your tablet on your vulva, so I worry about targeting sexual organs if you're just gonna do the tablet but for people who can afford the tablets they tend to be more expensive for people who can afford the tablets or for people who don't care about vulvar health tablets are fine but I never I mean again I'm biased people don't come to me and they're like everything's perfect I'm on my vaginal tablets I usually see people who are like it still hurts I'm on vaginal tablets and it's not enough so individual results may vary.

34:03Can systemic estrogen be given when perimenopause begins? Yes, absolutely. Somebody said, I smear it everywhere. You can put it on your finger and insert instead of applicator. Absolutely. All right. Oh, somebody's sending love to Dr. Louise Newsome. I love her. She's fantastic. Can DHEA be used with vaginal estradiol? Yes, but you're going to see somebody trained clinician to be like why do you want that what are your goals x y and z um this is a good question do you suggest that a woman go off of her current testosterone dosage if she decides to use intra rosa so intra rosa is vaginal dhea it is not systemic you are talking about apples and oranges marcia you're talking about should i stop eating apples because i decided to eat an orange.

34:55Two separate things. Systemic testosterone is not vaginal DHEA. Separate things. Alright.

35:08Somebody said, Evalon is Estreol brand available in India. Good to know. Somebody just said Premarin was$250. Yeah, that's insane. You're gonna use 250 a month for 40 years like stop it right somebody said Primarin is free on my drug benefits all right yeah now you from Canada

35:31Laura Berman: Primarin is covered in Canada a lot what specific vaginal cream brand prescription would I ask my doctor to help with dryness asking from British Columbia. British Columbia, lovingly, covers a lot of hormone therapies. So I would first of all like what's covered? Use the free stuff first. Only if it doesn't get better, you then need an exam and you might want to talk about other options. I have absolutely no clitoral sensation despite estradiol patch, vaginal estrogen, and testosterone cream. I have never had an issue with that until menopause. I'm 51. Several doctors and gynecologists have not been able to help you need an exam 100 % you need an exam you have clitoral phimosis do you have lichen sclerosis you guys the amount of times I hear people say stuff on the internet and I'm like you need an effing exam you need an exam what can online doctors never do pelvic exams like AI cannot replace us all my friends.

36:34Pelvic exam is incredibly important. All right.

36:43Can you use estrogen and DHEA if penetration is still painful with the use of estrogen? You need an exam, Sue. So other things that can hurt with sex include muscles, include other skin conditions, right? So we have to think about the whole person and all the reasons for pain with sex don't just add another hormone without getting a comprehensive evaluation oh somebody said you had no idea we could reverse atrophy sarah think about this logically if atrophy happens because of low hormones and you add hormones back you can reverse atrophy it's so exciting i reverse atrophy twice on tuesdays all right does it help with incontinence yes it can.

37:26So both systemic hormones and local hormones. There's some very interesting, not enough data, interesting data on testosterone systemic and stress incontinence, likely because of core and pelvic muscle improvement. And then vaginal estrogen can help a lot both with urgency leakage, what we call overactive bladder, and then stress incontinence. So leaking with cough, sneeze, and laugh. I've got many bladder leakage podcasts. If you go back, I haven't had anything recently, but great. Both prolapse. I got a prolapse 101 that I highly recommend. And then I've got several bladder leakage ones with some great female urologists that you guys should listen to.

38:10I use vaginal tablets and it's not enough. See, Donna, Donna said what I said. It works for some people. It's not enough for some people. is burning and vaginal discharge a normal side effect with estradiol I'm assuming you're talking about the estradiol cream but you didn't say burning can happen in the beginning especially if you're very atrophic because your skin is just so thin and irritated but it shouldn't be a long it should get better as your skin gets healthier discharge yes cream discharge and then sometimes just this is what I tell people do you remember your vagina when you were 23 it was juicy a healthy vagina is juicy it has discharge so sometimes you can see that if it smells that's a different matter get a workup but if it's just juicy it's juicy because it's being a vagina again people people who've had atrophy for so long they forget that their vagina like discharged in their underwear for like their entire teenage years and 20s as long as it's not foul foul smelling that's a vagina being a lubricated vagina things you didn't learn in sex ed man let me tell you okay let us what's the organization that sounds like it wish that's a good one ish wish International Society for the Study of Women's Sexual Health ish wish org find a provider is on their website I highly recommend these people

39:52Laura Berman: Can you use tablets for inside and cream on the outside? Oh, sure. If you want multiple products. Yes. Two people asked that. Can you take tablets and the vaginal cream together? Yes.

40:14Oh my gosh. You're all asking this question. Can you use the internal tablet and then the cream on the exterior at the same time? Yes, totally.

40:21Laura Berman: Okay.

40:24Laura Berman: Am I applying the vaginal cream incorrectly? I feel like I pee it out the morning after applying it. If you put it in at night and it all comes out in the morning, you might just be using too much of it. I like people to make things as... It has to be enough to be effective, but the least amount to not be messy so that you don't stop using it. That's how I think about it.

40:49Laura Berman: I'm 64 using vaginal extra dial but going to the toilet twice in the night what do you advise pelvic floor physical therapy also work on your sleep are you waking up because you have to pee or are you waking up and they're like I'm awake I'll go pee right is it a sleep issue versus a bladder issue also no drinking three hours prior to bedtime that's bladder health 101 stay hydrated during the day if you're prone to getting up at night to pee stop three hours before bed always pee right before bed and they the urologist physical therapist getting up one time a night to pee is normal i can never tell anybody i'm going to get them to zero times a night and after 65 getting up twice a night is considered normal the reason for this is your kidneys stop concentrating urine as they get older so all the more important to do the behavioral stuff of fluid limitation at night.

41:45Recommend only using vaginal estrogen twice a week. So the standard, it depends upon what product you're using, right? But number two is the standard doses twice a week. That's maintenance, not treatment dose. So some people just need more. Talk to your individual provider.

42:09is a urologist the best person to see for the exam Andrea fantastic question the best person to see for an exam is somebody who's trained in female genitals that can be primary care that can be an OB-GYN that can be a urogynecologist that can be a urologist that can be many people and not all of those people see what I'm saying um not all urologists no not all gynecologists I see women and they're like I've seen four gynecologists they all told me my vulva is normal I'm like there ain't a damn thing normal about this vulva Stephanie so meaning just because you had a certain uh credential doesn't mean you're qualified or not qualified all right great great great question that was from Andrea Good question, Andrea.

43:00Is vaginal cream and vaginal pessaries okay for people on kidney dialysis? Fantastic question. Why wouldn't it be? It doesn't go in your body. It does not be, it is not filtered by your kidneys. Again, your dialysis team should know all the medications you're on. But this is local, local vaginal estrogen. It does not go in your bloodstream by and a large.

43:27Jane asks, can you review bladder leakage in 50 year olds? I think we all have been told it is because we held our bladder. That's not why Jane. Genital urinary syndrome of menopause meaning bladders change. Bladders are profoundly responsive to hormones. You take hormones away, bladders get turned to be like crazy kindergartners. so bladders love estrogen but it's not because you held your if anything like the holders which i would say teachers doctors surgeons nurses border patrol people anybody who has to postman mail delivery anybody who has to hold a lot if anything they we encourage them to urinate more because and that's one of my top questions when i see people for recurrent utis how many times a day do you pee?

44:20Two times a day is not a normal time to pee. You should be peeing every two to three hours while you're awake not around the clock. So if anything the holders have trained themselves to hold but that's not why they're bleaking urine now. Alright I wish I'd been told to use the cream sooner. I'm 42 and was just diagnosed with IC and atrophy just started the cream but not tolerating it very well. See a clinician if you if you have severe atrophy the the again in America the estradiol it tends to be irritating to very sensitive skin so you might need to start slower. Wow Danielle. Hi Dr. C. I'm so so very glad I found you.

45:06Ah thank you. Any age to stop Stop the estrogen. Remember, if I have to browbeat people at this point, what does Kasperson say about age? There is not an age. Your driver's license doesn't tell you if you're too young or too old for vaginal estrogen. Knock it off. Stop thinking about... Where do people effing get this age shit from anyways? Like WTF, seriously. And in all seriousness, stop vaginal estrogen when you're dead. because like shit won't bother you when you're dead uh i'm 66 and never get up to pee at night

45:42Laura Berman: oh nancy's bragging you guys all right what else you got

45:52my pcp and gano won't prescribe me hrt because dense breasts uh dense breasts are not a contraindication to HRT my friends just saying I see a lot Stephanie I see a lot of patients who come to me with symptoms of perimenopause menopause and when they tell me they've had a hysterectomy one of my first thoughts is why weren't they offered hormone therapy after surgery I know Stephanie I mean here's the deal I'm a urologist I know how I know how to surgically remove testicles for testicle cancer, etc., etc. If a urologist ever removed testicles and did not replace testosterone in a man, that's malpractice.

46:30Use that information how you will. Louise Newsome's group did this research in the UK that of all the women who've had their ovaries removed for benign reasons, meaning not cancer, 5 % were offered hormone therapy. Can you imagine if urologists only offered men testosterone five percent of the time we cut their testicles off that would be insanity insanity use that information how you will

47:06Laura Berman: 77 in small uterine fibroid does that mean i can't use any local estrogen no it does not mean that what should the examination for gsm diagnosis include excellent question nancy uh Pain, any pain on palpation in the pelvis, skin, labia majora, labia minora, clitoris. Does the clitoral hood retract from the clitoral head or do we have phimosis? Any issues with the skin like sores, bleeding, cracking, lichen sclerosis? Anything that looks thinned, irritated? I call it chapped lips. the urethra does the urethra have prolapse does the vagina have prolapse does the vagina is the vagina narrowed do the pelvic floor muscles hurt on palpation muscles tend to hurt like one side right like one muscle on one side will hurt more than the muscle on the other side vagina is it narrowed is it well lubricated healthy skin or not okay there we go sarah says no age limit lol dr caskerson you've got it

48:24you're amazing dr kelly have totally changed things for me things are so much better what are your thoughts about vaginal estrogen on the face yes skin is skin you guys like literally if you like just think logically if that's if vaginal estrogen helps skin because the vulva and the vagina are basically skin it's kind of specialized skin but skin why would it not help the face um some people don't like using their vaginal products on their face some people will get face stuff compounded um estriol is a lower potency estrogen so people tend to use that on their face. It's well described in the dermatology literature.

49:05I've actually done several podcasts on it. Look up my podcast with Dr. Ellen Gendler, who is a New York City dermatologist. We talk a lot about it. Yeah, it's lovely. It's absolutely lovely. Okay. My estrogen cream and I have a commitment till death do we part. That's how much it has changed my life. Oh, that's so awesome.

49:2980-year-old mom started vaginal estrogen and her issues have all stopped. Oh, my Lord. Winner, winner. Chicken dinner. Did I miss the talk about estrogen and bone density? Well, Kate, this is about local vaginal estrogen, not systemic estrogen. And local vaginal estrogen, as you know, is local. Meaning it doesn't go into your bloodstream, which means it doesn't go into your bones. Which means there's no conversation about vaginal estrogen and bone density. Because by and large, it's nuanced. People who come to my clinic, I'll tell you the actual story about that. But by and large, local estrogen therapy does not help bones.

50:05I'll keep it simple for today.

50:11Laura Berman: This podcast is sponsored by Joy and Blokes. One thing I've always believed, if I'm helping one person with their sexual health, I always have to think about who's on the other side of that relationship. Because intimacy doesn't happen in isolation. And I've said this for years. If I'm prescribing a blue pill for a man, what about his partner? Are they dealing with pain during sex, low libido, hormonal changes? Are they both healthy enough to enjoy the relationship they're trying to build together? I see it with women and their health all the time too. She starts optimizing her hormones, more energy, better sleep, the brain fog lifts, libido comes back, and the next thing I hear is, now my husband needs help too.

50:49Laura Berman: That's one of the reasons I like Joy and Blokes. They care for both women and men, connecting patients with licensed clinicians for personalized hormone optimization when it's clinically appropriate. And they publish peer-reviewed research on outcomes, real improvements in energy, mood, mental clarity, sexual function, and quality of life. Whether you're navigating perimenopause, menopause, low testosterone, or simply wondering why you don't feel like yourself anymore, the first step is understanding what's going on with your body. If you started feeling better because you've taken care of your own health, maybe it's worth asking whether your partner could benefit from doing the same.

51:27Laura Berman: If you've been wondering whether your hormones could be contributing to the way you feel, visit joyandblokes.com slash not broken and use code not broken for 65 % off labs and 20 % off treatment. That's J O I and B L O K E S.com backslash not broken code not broken.

51:54Laura Berman: My primary consulted with oncologists who feel it's not recommended for me to get the patch only estradiol cream. I'm 65, 22 years, breast cancer survivor, estrogen positive, any other options I would see a specialist did you just read go to Oprah daily I wrote an article on it I did we discussed the habits trial the Stockholm trial like you should be educated on your actual risk and everybody's risk is different based upon cancer type what treatment all the things and then you should be able to make a decision this is not a binary this is complex medicine and everybody should be given a risk benefit discussion also listen to my podcast episode with Dr.

52:33Linda Bosserman who not only is a PhD in sex therapy but she is an oncologist who specializes in hormones after cancer that is a must must must episode listen for you glory ann all right um I'm 73 and my PCP said I do not need to see a gyno anymore I think that's wrong. Yeah it's very interesting a lot of people think they just need to see gynos for a pap smear. First of all pap smear guidelines change frequently and they are age-based but remember what's right for you is not right for the general population. Meaning I'll use prostate cancer for example they said to stop screening for prostate cancer after a certain age but not all 70 year olds are created equally and not all 70 year olds have the same risk of death or otherwise.

53:28So what decisions are for the general population might be different for you but don't like primary.

53:34Laura Berman: I'm always like why do you need to go to a gynecologist and people are like well for my mammograms and pap smear and I'm like good lord they're busy enough get that done by primary care. Primary care can take care of all of that for you. So my first question is if you're 73 and you want to see a gynecologist why and is it for a reason that your primary care can't handle? Because I gynecologist has to take care of all women which the math is insane there's 80 million women over the age of 40 and at best 40 ,000 gynecologists in this country right so like I would never send you to a gynecologist for something that primary care can do so that'd be my first thought history of DVT and PE no HRT question mark see a specialist for that that is high risk we need to know you've had a workup we need to know how you're optimized we need to know if you're on blood thinners and yes you can still be on vaginal hormone therapy all right i should get out of the comment section and finish my presentation huh i kind of just jumped in because questions are so fun but we've got like 10 minutes left um wasn't the black box label about estrogen with stroke and heart attack taken off yes um

54:51Mom can't tolerate generic estradiol cream. Affordable alternatives. Nothing's as affordable as generic vaginal estrogen cream, my friends. Nothing. You can get it compounded to get the additives taken out of it though. Start with Vagifem tabs. Again, not as cheap. There's nothing cheaper, to my knowledge, correct me if I'm wrong, nothing cheaper than generic estradiol cream. But there are alternatives if you have sensitivities. I was told I can't do HRT because my mom had breast cancer. But now I understand that isn't correct. That's true, Julie. Meaning family history is not an absolute contraindication to hormone therapy.

55:31I'm 64 and healthy. Could I possibly start systemic HRT? Yes, you could possibly start that. but you need to see an expert who is trained in up-to-date risks and benefits for you. I'm having a difficult time having an orgasm. I'm on vaginal estrogen, estrogen, progesterone, and testosterone. You need an exam, Nancy. What's your clitoris look like? Do you have phimosis? Do you have lichen sclerosis? Do you have untreated atrophy? What's your testosterone level? What's your estrogen level? Nancy, you need a workup. Also, my vibrator is nice, but you still need to work on it. What does it mean for things to get compounded?

56:10That is from Sheevy Cooper. So in America, I can't say this is the entire world, in America we have compounding pharmacies. Think of it as bespoke. So they're making something specifically for you. Maybe you need a dose that isn't otherwise available. Maybe you need preservatives taken out of a cream. Maybe you need alcohol taken out of a cream. Maybe you need something formulated because you have trouble swallowing. So think of it as bespoke. That's what compounded means. It means it's not an FDA approved product because it's not mass produced. You are getting individual shoes made instead of buying shoes at a shoe store.

56:48That's a new metaphor. You might use that more. Nancy said, I use it on my face every day and have amazing skin.

57:03somebody said who's it danielle danielle says no hesitation here using on face my mom's 88 she has a uti e coli in her urine since february it's affected her so much she's been to a urologist and an infectious disease doctor they uh she asked about the cream and they don't really give me much response or think it will work oh okay just pull go to PubMed pull up go to open evidence go to clod they will literally give you medical papers to send to these people if you asking isn't enough but recurrent urinary tract infections nothing decreases urinary tract infections better than vaginal estrogen nothing and also make sure she's staying well hydrated and is urinating and is you know can you can we help with any incontinence, any risk factors, all the things.

57:53Do I need vaginal cream if I'm getting systemic estrogen? Some people, yes, some people are fine. Some people are in the, if it's not broke, don't fix it. Some people are in the, I would like my labia and clitoris not to atrophy in the first place before I try to fix it. So it really depends upon what are your goals, what are your wishes, but is it safe? Yeah, absolutely. Lots of people. Remember, your systemic hormones are not very high dose compared to how high your estrogen was when you were 24 or pregnant etc

58:34I'm a psychiatrist provider and changing many women because of you you have made my job easier oh Colleen thank you that's awesome

58:44the podcast is with Dr. Linda Bosserman oncologist we talk a lot about podcast my podcast called you are not broken Rachel says Becky says love estrogel in the face cheapest skincare ever yeah yeah yeah it's definitely cheaper than this stuff that's on the market which probably doesn't do for you what estrogen does for you is it okay for GSM with lichen sclerosis is it okay to use both vaginal estrogen cream and clobetazole on the vulva yes absolutely for people who have lichen sclerosis who are just using clobetazole i would say why are you not using vaginal estrogen if you're not using vaginal estrogen talk to your trained clinician about that link for mark cuban site yeah it's classplusdrugs.com i have hirsutism that means hair growth in the medical world is that a contraindication for using testosterone yeah you need it worked up like work that up what's going on um it's not an abs you're like you're gonna die if somebody gives you testosterone but you might be more prone to more hirsutism i would get that worked up for sure before you would just start

1:00:06testosterone i'm 70 started vagrafem two weeks loading was great almost all my bladder leakage went away once I started on twice a week the bladder leaks came back yeah because it's probably not enough of a dose ever we are not all Toyotas some of us need different dosing than what the standard dosing is and that's okay that doesn't mean you're the problem just talk to your clinician about it all right my sister is like in sclerosis would vaginal cream be safe for her yes absolutely

1:00:45Laura Berman: oh i've got an og fan on today connie i see you one of your earlier podcasts with dr erwin goldstein he recommended that women take over-the-counter dhea and insert the tablets into the vagina that's an old podcast taking me back i think the podcast episode is called like dr goldstein the goat or something like that for people who don't know goat stands for greatest of all time.

1:01:11I'm tested but man if it's good enough to swallow it's probably good enough to put in your vagina. I'm saying that flipply but I haven't I you know I haven't heard from a lot of people that do it but I don't think it's dangerous. I mean they're they're made to be swallowed. It's very odd. The whole supplement thing is very odd in this in this country for multiple reasons but the fact that you can swallow it but not put it in your vagina is like it's just very odd if you know if you know what I'm talking about you know what I'm talking about anyways Connie very impressed OG fan all right we have like five minutes left so I'm gonna just stop I'm having fun the next one should just be vaginal estrogen I answer all your questions because I can't get through my freaking website so just know they're available formulations in America we've got some creams we've got some insert tabs we've got a ring we also have an oral option called osphema or ospemapheme.

1:02:08For people who have older mothers who can't deal with like a vaginal cream I would use the osphena or I would use the ring which just has to be changed every three months because twice a week vaginal application is difficult for people who have cognitive limitations maybe rheumatoid arthritis of their hands they can't reach their pelvis because of body habitus or memory issues or they can't see lots of reasons so to me I'm like vaginal estrogen although the cream is the cheapest might not be the best format for my elder elderly population all right how do you find the vibrator elixirplay.com it is called the explorer use code not broken 20 for 20 off um yeah i gotta get through i gotta get through this and here's my vaginal dhea so in america i was so i went to sydney last year to speak at the sydney opera house humble brag it was amazing everybody i talked to was on dh it was on prasterum uh intra rosa and i'm like are you guys just all the privileged people like how does this work People in America are not on DHEA like you guys are on DHEA.

1:03:20And they're like, oh, well, our health insurance covers it. It's$40 a month. And I'm like, good God, we would all be on it if it was$40 a month. At best in America, we're getting it for like 80 bucks with insurance. Cash price for this stuff is like$300 a month. But it's chef's kiss for reversing atrophy. That's the medical term, chef's kiss for reversing atrophy. It's really good. and for some people with really severe atrophy I'm like just use this for like two months and then you can space it out and decide if the price is right for you but like it works so well it's just incredibly expensive and then I will beat the drum until I stop but it has been around I put this on ACOG committee opinion use of vaginal estrogen women with a history of estrogen independent breast cancer published in 2016 it's 10 years ago we're still telling people it's freaking safe 2025 asco meeting which is a american clinical oncologist local estrogen does not diminish survival among patients with breast cancer like this is the zombie myth that like this the myths just don't die like are we sure are we sure we've been saying it's safe for like over a decade please please i'll just say i'll just say please that's all i could say um i I know I'm so my next live webinar is going to be on the vibrator that'll probably do another testosterone one because you guys are hungry for testosterone help.

1:04:49What else do I have? This is me helping to remove the boxed warning. Thank you to everybody who helped that. That was over a decade in the making. All the haters are like they just decided on a Tuesday. I'm like no they didn't. They were working for over a decade to get the boxed warning off of this. so box warnings off because vaginal estrogen does not cause blood clots stroke cancer all the things so that was a very very fun and then I just wanted to end with this person my mother has been given a prescription by her doctor but she says it burns and is uncomfortable to use so if the cream burns or is uncomfortable lesser of a dose or get it compounded or switch to the non-cream for a while until you get healthy enough.

1:05:34What's the difference between DHEA and vaginal estrogen? DHEA converts to both testosterone and estrogen. So it's covering more hormonal things with the pelvis than just estrogen. Sorry, you said for elderly instead, use ring or osphina, the oral one, because some people just can't manage the vaginal as they get older for whatever health concerns. So here we go. You are not broken. If anything is broken, It's the system, the lack of sex education, the way we think about desire and our expectations. You, you are lovely. This is from Julie Jeske and I just absolutely love that quote. So instead of saving questions to the end, I just did it all in the middle.

1:06:14And that, my friends, is one hour of a webinar. Thank you for staying on. I hope you guys learned so much. Follow me at YouAreNotBroken. Get on my email list. And thank you for sharing the podcast. The podcast is my favorite baby. And until next time, I love you. Okay.

1:06:33Laura Berman: If you found this episode funny, helpful, insightful, please take a moment to follow, rate, and share the You Are Not Broken podcast with someone who might need this conversation too. That support is how this information reaches more people. And thank you. For courses, books, and my monthly membership and the Casperson Clinic information, visit kellycaspersonmd.com. This podcast and all content from Dr. Kelly Casperson is intended for educational and informational purposes only, and this is not a substitute for individual medical, coaching, or psychological advice, diagnosis, or treatment. Always seek the guidance of your qualified healthcare professional with any questions you may have regarding your health.

1:07:17Laura Berman: 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.