390. Vulvar Dermatology, Red Angry Vulvas, and Why Exams Matter

0:03Welcome 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. Hey, everybody. Welcome back to the You Are Not Broken podcast. Today, I have vulvar dermatologist Dr. Melissa Mauskar on from UT Southwestern, yeah? Yep. Very exciting. And we were both neuroscience undergrads, which is so satisfying. Well, I went to the University of Minnesota and there were like 12 neuroscience undergrads. It was like a niche and now it's like a bigger thing.

0:37Yeah, I was at UT Austin and there was like so many people there that I, who knows, like, you know, lost in the sea of... I was the only one who went to med school. Oh, look at you. Everybody else went and got PhDs. I was the only one who went to med school. Cool, right? Yeah, love it. I know. So we're going to talk about vulvar dermatology today. And before we do that, first of all, on the You Are Not Broken podcast, we're allowed to say anatomically correct body parts. Which is a very nice thing. And oh, look at your beautiful vulva. Your mom made you do that? My mom made it for me. She's the best.

1:09What a supportive person. I mean, you know this because you're on Instagram. Like you can get kicked off for saying what you do in your job, basically. You can. And that's probably why I'm just like living in my own space. You know, they like decide not to send any of my shit out because that's how it works. Yeah. So for people who don't know and want to get pissed about it, Meta says that us saying clitoris, sex, vulva, vagina violates terms and conditions of their community standards. Yeah. So my five-year-old can say vulva, you know, and she says it when we're on like, you know, when we're at a vacation and the guy's like, well, what do you do?

1:45And I'm like, I'm a dermatologist. And my five-year-old's like, my mommy looks at women's vulvas. And he was just like, uh, I was like, yes, I do. People have itching and pain. That's what we do. Well, It might have like, you know, when something hurts or itches or is bothering her, I'm like, is it your anus or is it your vulva? Because I know like so many women, just me as a physician, when they go to the doctor, they say down there. Yeah. And then an exam doesn't happen. And then an antibiotic gets prescribed. And then nothing got better. When women come to see you, how many doctors have they already been to before they find you?

2:19Like five or six. You know, it really depends. It's crazy. and I will say how many doctors, A, didn't look at them or are dermatologists that were like, I don't really do that. Yeah, yeah, yeah. This is the one area. But I mean, in all fairness to gender equality, derms are also uncomfortable with penises and scrotums. Yeah, they are. But, you know, they're hanging out there. And so I feel like it's like more approachable. The patient can at least see it a little bit. Yes, yeah. And so I also think that like, just the fact of like separating the labia majora, so many doctors, not just derms, but like, you know, a lot of doctors but find that invasive, you know?

2:54And so it's learning the language, how to, you know, and so I work with a lot of residents and medical students and just kind of showing them how we do those exams and people are grateful to have those exams is super important. Rachel Rubin tells a story about when she, well, she was a medical student or something, but she was told by one of her attendings that don't touch the clitoris because that'll make people uncomfortable. And she's like, and we don't teach medical students that about the penis. Yeah. Okay, so back it up for people. what is a vulva and what is a dermatologist? Yeah, so vulva is everything on the outside.

3:25So you can see it, the outside lips, inside lips, just not the canal that goes inside your body. And dermatologists look at skin. And so really the vulva is skin and you can get any skin condition that you have on your body on your vulva too. So things like eczema, 50 % of people with eczema have it on their vulva. Psoriasis, over 65 % of people with psoriasis actually have it impair their sexual health in their relationships. It's huge. It's very high. That may even be lower than it actually is. But the problem is most people don't think of going to their dermatologist when they have itching or burning on their vulva because they're used to seeing their gynecologist, family practice doctor.

4:07Who didn't get trained. I'm overgeneralizing. I'm overgeneralizing. We have very good doctors in every single specialty. We didn't get trained how to examine the vulva. Yeah, and it's a very like, systematic thing. And so I also tell my residents, because I have some residents that come rotate with me because they want to do women's health. They're gynecologists, they're dermatologists, they're urologists. And they spend two to four weeks with me. We go over a whole bunch of things. They're also dermatologists that are never going to specialize in this, but I want to show them during a skin exam, how you can look for a big cancer that's sitting there that could be missed for 20 years.

4:41And those exams are different. So it's not me inspecting for five minutes, It's every nook and cranny that I'm seeing. It's them doing a quick open and shut, making sure there's not a big melanoma or squamous cell carcinoma jumping out at them that maybe isn't symptomatic for the patient yet. Yeah. Okay, so is there a dermatology specialist for other body parts or is it kind of unique? You know what I'm saying? Is there like a back dermatologist? Is there a face dermatologist? Well, we have scalp experts. Nail? We have nails. Nail experts. I mean, there's some breast clinics, I guess, of like, you know, mastitis.

5:16There's some pregnancy specialists. So I mean, there's a lot. But the vulva's a thing. Pregnancy derm? That's wild. Okay, cool. Go back to your neuroscience undergrad. Did you know like vulva dermatology or did you like fumble into it and was like, oh yeah, this is it? Like all of us, right? Like all of us are like, how did we get here? And I actually, when I was applying to med school, I thought family practice, psychiatry or derm. And derm at that point was the most competitive. So I spent my first summer shadowing a dermatologist. I absolutely loved it, but I loved all the rotations going through.

5:49And it actually wasn't until I came down here to Southwestern to give grand rounds. And I was actually interviewing to be an inpatient dermatologist, which is also like a rare thing that you never see. Right. And I came down and I interviewed here to be an inpatient derm, like SJS, all the scary shit that people die from in the hospital on their skin. And during my grand rounds, three out of my six cases were actually genital cases. And so they're like, oh, hey, we don't have a vulvar derm or a genital derm here. We also don't have like acne or psoriasis. I was like, well, no. I was like, I really like talking about uncomfortable things and making comfortable people uncomfortable.

6:27That is like one of my favorite things in the world. You know when you're like, just know you're going to be friends with people? I like talking about shit that people don't like talking about. Yes. And I'm like, if we don't talk about it, what's going to happen? And so now in my job, I get to carry on a vulva puppet. I get to have all this like vulva swag everywhere. And I just love it. You know, when you find what you love, you become a great, amazing physician. You take better care of your patients and you do it because you enjoy it. And people gravitate towards you because they love the energy.

6:56Yes. And it's amazing. And we're changing the world. I mean, now we have, you know, I have like trained at least eight people that are now attending vulvar dermatologists that have their own clinics. There's so many residents and medical students. We actually, I founded a vulvar dermatoses research consortium. It's a nonprofit. We have over 200 members, gynecologists, dermatologists, you know, that are like putting our, all of our smart heads together to think about how we can change the dialogue around these conditions. Oh my God. Yeah. This is the coolest thing. This is the part of the podcast where I just like have my jaw open and I'm like, oh my God, this is the coolest.

7:3451 % of the world has a vulva. Yes. Very big market. And maybe have more because sometimes, you know, people get vulvas made, right? So maybe it's actually more than 51%. Oh, that's a niche. There are people that do it. My friends, Shola Vaughan. Yeah. Yeah, totally. Okay. What is the worst thing to put on your vulva? Like, what do you see over and over again where you're like, just stop it? Yes. Benzocaine. That is my nemesis. Benzocaine. And that's a numbing agent? It is a numbing agent. It is in Vagisil and so many other different products, but they also make, you know, some things that maybe are okay, but the benzocaine, it's typically 20%.

8:09It's over the counter. And for a lot of patients, it's the only thing that makes their itching or burning better, but it becomes an irritant and an allergen. So then they come in, they get these huge, horrific ulcers. And all the time I get sent patients that have refractory lichen planus, lichen sclerosis, psoriasis. I look at their vulva and I'm like, what else are you putting on? Did you go, you know, are you doing anything else? And they're like, well, this is the, I'm like, benzocaine, my nemesis. It is my nemesis, but it's the only thing that makes them better. So then we remove that and then we do like a washout period.

8:43And I call those, some of those patients red angry vulva, like I have a whole handout for red angry vulva, but yeah, it's the worst. 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.

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10:40When I want to look put together without overthinking it or overdoing it. 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. it's the worst i see so many red angry volvois incontinence severe incontinence sitting in a diaper with yeast overgrowth yes and it's always more than one thing right and so uh two weeks ago we went to a retirement community independent and assisted living we had 80 women out there um you know 70 to 90 and we did like a 15 minute powerpoint with a geriatrician and then one of my residents and some medical students and we're like listen just because you have incontinence or you have pain with sex or you get to UTIs, you know, it's common, but it doesn't mean you can't do something about it.

11:46And so trying to empower that generation to say, hey, listen, we know that, you know, it's hard to talk about, but Viva La Vulva, it's called Real Talk Viva La Vulva. And we gave out swag, like lube and vibrators. That's the most fun job ever. That's like the best Tuesday. It was the best, yeah. That's awesome. Barrier creams for like incontinence and diaper products. What's your favorite? I'm not going to come up with the name off the top of my head because I can't remember it. But it's kind of like a thick... Like any of the diaper stuff, like the butt tastes, like the legitimate barrier stuff, which is...

12:21It's hard to wash off. It is. And that's the whole point, right? So that's what I tell patients. So I am 40 % zinc oxide. There's three different brands that have 40 % zinc in it. Boudreaux, Desitin, and Aquaphor. But it's not the Aquaphor that's clear. It's an Aquaphor that has a 40 % zinc oxide. It's like baby care or something. but basically you put it on and I tell patients put it on at nighttime, right? Um, it's a cream. So it's soothing and then overnight it dries. And so the next morning when you wake up, it'll keep you protected the whole next day. Right. But when you shower in the morning, you don't want to rub and scrub it off because when I started, people were getting, I'm like, what am I doing wrong?

12:59What is the communication? But they're all trying to get all the white shit off. Right. And so I was like, leave it alone in the summer in Texas, everyone gets inner try out. Everyone gets irritation, right? And so we just do that a couple times a week. Moisture, yeah. Wet, sweat, urine, whatever, you know? Yeah. Barrier cream is fantastic. Yeast overgrowth. I want to talk about two things. Number one, it being underdiagnosed, especially in the case of red pissed off vulva. Yes. And then I want to switch gears to over-the-counter yeast treatments, which a study showed like 40 % of those women don't actually have yeast.

13:34They're trying to treat something else with an over-the-counter yeast product. So let's go into both of those. Let's go with like, I guess, over diagnosis happens often, but there are medicines too, like some of the new SGLT2 medicines, right? Diabetes. Yes, for diabetes. Diabetes medication. Because it dumped sugar in the urine. Is that those? Yes, exactly. And so a lot of those patients actually do have yeast, right? And it's horrible. And unless you stop that medicine, there's not a lot you can do. Thankfully, we have a ton of really good diabetes medicines now. Yeah, I was going to say, I feel like they're falling, like they got big maybe like 10 years ago or something and they are kind of quieted down because they're not like the new go-to diabetes drug anymore.

14:16Yeah. And like the risk of Fournier's gangrene is real with these things because of all the sugar it puts in the urine. But yeah, the over-the-counter stuff, I agree. Like a lot of patients will try it because they're like, well, the burning or the itching must be yeast when actually, say it's psoriasis, like in sclerosis, you know, something else going on there and irritant to the actual product or the vehicle. that they're using. But then the misdiagnosis, you know, I think there are a lot of conditions on the vulva that may mimic yeast for a while. So lichen sclerosis is one of them. And really, it's because you get these linear fissures.

14:47And so where all the skin folds are, so the anterior commissure, interlabial sulcus, that perineum, you can get these chronic linear, people call them paper cuts. You can get that with irritant, allergic contact dermatitis. You can get it from yeast. And then you can also get it from LS and psoriasis. So anytime the epidermis is a little And GSM, you see with GSM? Yeah, I see it sometimes with GSM. I do. But like a lot of times, it's just the friction of the skin rubbing together, you know? So a lot of people will say, oh, it must be yeast because you have these tears. But a lot of times, maybe they do have chronic yeast, right?

15:21And they actually have to put on oral diflucan for three months to get the yeast to go down. So yeast is tricky. And I've been humbled many times, you know? I actually learned that from a gynecologist at one of my retreats. She's like, those fissures, if they don't get better, And you've treated for the other thing. She's like, yeast. And I've done it since then because of a tip from her. And I was like, ah, it worked. Sometimes you just have to like have it in your differential. You know, it's like, if you're not thinking about it, you're not thinking about it. Talk about soaps, douches, vulvar washes.

15:53So I'm not like, I don't know. I feel like, and I think you're probably on the same page. Like there are so many things targeted to get their vulva smelling like clementines. I mean, seriously, the teen products too. I mean, there's just so much out there, right? But you don't need anything fancy. I mean, I honestly, a lot of my colleagues just say water. I tell patients, you know, if you have that just dove sensitive bar soap or anything that's eczema approved, but put it where the hair is or was, because some people, I don't tell people how to wear their hair, you know, whatever, do what you want.

16:26But, you know, rub your hands, put the suds there and let the water rinse down. My patients rub and scrub and get in every nook and cranny and they're over cleaning. Because people think, I mean, the cultural dogma is women's genitals are dirty. Dirty. And if it's itching, it must be because you're dirty and unclean. And you have all the shame around it. And also the toilet paper pieces, like the toilet paper pieces, right? I don't know if you, like a lot of my patients will come in and like, they want to be clean for me. They're like, I worked really extra hard to clean. I'm like, you're here because something's wrong.

16:55I want to help. Like, I don't care what, you know, I don't care what you look like. And we're more sensitive to our smells. I don't want to go to the dentist smelling like coffee breath. but like they probably don't care. That's true. I mean, a bunch of dentists being like, I actually do care. I hate coffee smell. We do not care if you've shaved or not. Do not wax for us. Do not do any of that for the doctor. Nowhere in our training where we like judge a woman for hygiene. Never. Yeah, but I think we put those pressures on ourselves, right? Like totally. Yeah, even myself, like I'm thinking about when I'm getting ready to go to the doctor, you know?

17:29Totally, but we didn't like, I didn't get trained that way. The other thing here, So this, again, this is N of one. I do not have a paper on this. Recurrent urinary tract infections, association with waxing. I'll preface this by saying any age, this is not just premenopausal, postmenopausal. Let's say their GSM's been adequately treated if that's a condition going on. Because I've had the experience of a woman with recurrent UTIs and then she waxed and then she went camping and got all natural and there's probably a lot of things she like switched off of, but then never got a UTI again. And I think waxing specifically, it's microtrauma and hair is a protective barrier.

18:13That's what I tell patients all the time. There's hair there for a reason. Hair there for a reason. So, and so like since that experience and having had that work for some people, I'm like, I'm not here to judge. I even say like, my mom owned a waxing studio. Like I'm not here to judge, but hair is protection and you're ripping it out. So I'm like, trim it, clippers, don't shave, don't whack. So just try to avoid micro trauma. But then the hair is a protective barrier to the entrance of the vulva and the urethra. And I'm like, if you're just at wit's end and you want to try it, and I'm like, and the hair keeps in natural oils.

18:47Yes. Yeah, that's a good point. Right? So to me, I'm like, there'll never be a study done. It's kind of expert opinion. But I'm like, when you've run out of ideas, is go back to mother nature. No, I love, I tell people, you know, if you really, if that's how you like your hair, you know, laser hair removal is actually much cheaper now than it was 10 or 15 years ago. So one treatment for laser hair removal, specifically for like the vulva, especially the inguinal folds or other things, is the same as a waxing session. So, I mean, and it's like a permanent removal, you know, so that would be another option for people without the micro trauma.

19:21And the repetitive pain, you mean I can have pain once versus pain all the time for the rest of my life. Kind of a good sell. Yeah, I think the over-reliance on being too clean and then letting the like, people don't understand the microbiome and the role of the microbiome in preventing urinary tract infections and how estrogen helps the natural. Like we have a natural microbiome. We do things to disrupt it, which then can cause pathologies. Yeah, and I literally talk to every single dermatology resident. And when I give lectures all around, I'm like, listen, You are a dermatologist. We are experts in the skin.

19:57There's a huge system that needs your help, right? If you have patients that are getting recurrent UTIs, give them vaginal estrogen. This is in your purview. I tell them how to do it. It's great. There's multiple meta-analyses in the dermatology literature. This is my go-to Instagram spiel. There's multiple meta-analyses in the dermatology literature showing the benefits of estrogen on skin. Yes. I mean, and I will say that most of those studies were done in the 90s and they were done before WHI came out or whatever. But there's actually several studies that looked at benefits for sun-protected skin instead of sun-exposed skin.

20:36So more collagen was built in sun-protective sites. The sun does a lot of damage to our keratinocytes and aging and all that stuff. So this is why your butt still looks so good no matter what you're eating. There you go. There you go. I mean, I've gone like this way and that way and this way, but like right now, I think I'm still tried and true like retinoid topical for face and sunscreen. And then honestly, if you ask any dermatologist, the reason why they look so good is because they get laser resurfacing done every five years. I haven't done mine yet, but I will be doing mine soon. Okay, well, I'm getting close.

21:06So maybe I'll get your cell phones. I can be like, which one is best and which one should we avoid? Mine is, so I went to my dermatologist and she's like, what are you doing? And I'm like, tretinoin, sunscreen, and estrogen on my face. And she's like, yep, keep going. Yeah, your skin looks great. Also, Instagram filters. Everybody on Instagram is like, your skin's so amazing. I'm like, goddamn Instagram filters. And bronzer. They don't need a tan. Tans are bad. Yeah. I can't condone a tan. I feel like they're coming back like smoking cigarettes. Like cigarettes are coming back. I spoke in women's world this week talking about like derm skin tips and how you can get melanoma down there.

21:47That means on your vulva or in your vagina. and that if you do have itching, bring it up to your dermatologist. Because melanoma, as opposed to like, you know, tanning is terrible for your skin. It does increase melanoma. At five years, 80 % of patients with melanoma on their skin are still living. In five years, like a large majority of people with vulval vaginal melanoma are not living. And it's because we catch it so much later. A delay in diagnosis. Yeah, it's really sad. And so it's something that we're working on. This podcast is sponsored by Addy. Let's stop pretending low libido isn't a big deal.

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24:56I was like, is melanoma discovered at a later stage in the shame areas? Yeah, exactly. And there was a patient that came in. she saw one of my colleagues, um, she came in to her gynecologist. She was getting regular skin checks by a very good person, but they didn't look at their, they didn't talk about the vulva. She went to her gynecologist for postmenopausal bleeding and she had a huge tumor, you know? And so, I mean, it's just, and again, patients, if they're not used to having their vulva looked at, or if dermatologists aren't used to that in their practice, then there's things that are missed.

25:28And so again, that's why we're trying to like, I have like, just like, I mean, I have lots the soapboxes, right? They're like stashed so high. Give us all the soapboxes. I know. That's one of them. I should just start asking that on podcasts. Like, what's your soapbox? I think that's a concern amongst my friends who are gynecologists with the changing pap smear diagnoses. Yes. Who's going to be looking at vulvas? Who's going to be looking at vulvas? And even if it wasn't a great vulva exam, it was... Someone was looking, right? They were still there. They would have seen a giant thing, right? Like, so yeah, so no, that I have like an op-ed written for one of our derm journals that like, I'm just waiting to send out to the world.

26:07So it's like, hey, home pap tests are FDA approved and they're doing them in Canada, I think in some sites too. And this is something that is important. And you know, the dermatologists, we need to look. That's one of my soapboxes because people are like, oh, telehealth for menopause, telehealth for sex med, telehealth for blah, blah. And I'm like, pelvic exams, man. Pelvic exams. Well, that was my opening when I talked at Menopause Society last year. There was like three of us up there and it was really like the vulva comedy show. I had the best time. But I started with like, hey, you're seeing a patient.

26:40You're on telehealth. And it sounds like GSM. You give her estrogen, but she's not doing better, right? And it's because she looks like this. And I showed this. And everyone was like, I was like, that's why we need exams if they're not getting better. And GSM, you know, they get better. It takes six weeks, right? But if they're not getting better, you need to reevaluate. I think the AUA GSM guidelines did an excellent job with that because in the guidelines, it says, if you're not better, reassess and exam. That's an important part instead of like, I don't know why your vaginal estrogen is not working.

27:15And I see, I mean, how many times do I see this on Instagram every day of like, I've been on vaginal estrogen for six weeks, for eight weeks, I still have X, Y, and Z. And I'm always like, if I could just clap on Instagram in people's faces and be like, go get an exam. This question cannot be answered by talking. And it's hard because I know people, and one of my colleagues, one of my chief residents who'll be joining me in October, I'm so excited to have a partner. She did a study looking at barriers, right? And one of the barriers is that patients don't know who to go to. and they've been misdiagnosed before.

27:48And so they feel like they have to take treatment into their own hands. But if things aren't getting better, you need to talk to us because we're here to help, right? We want to help you get better. How many people even know what the vulva is though? Do you have that data? So Amanda, was it Amanda Silk? Or it was, there was a study that they took, I think it was Amanda. And they did a picture and they brought it out into the wild for people. And like, how did you correctly like - Identify it. I think I know this. And clitoris was actually the most identified. one. Yeah. But it was very, it was like, I don't know.

28:20It was not good. It's really low. That's why I'm like, even if you hang the biggest shingle on the highway and you say vulvar dermatologist, it's not going to break through. No. I mean, that's why my billboard would have like a picture of me with the big puppet and some of our clinical trials. I'm like, Hey, just smother purple puppet with like cream and like show it getting better. You know, I don't know. We need something like, you know, like all the campaign. And one of my patients actually said that breast cancer, we talk about, everyone talks about breast cancer, but it wasn't until Nancy Reagan had breast cancer a long time ago.

28:55And she said that that's what she had. Did people feel comfortable starting to talk about these things? Right. Because, you know, you make it mainstream. If someone says something like that and says that word, like what about vulva cancer? What about, you know, all the work that you and Rachel have done and all everyone with estrogen and, you know, hormones and everything. So I think more communication, more dialogue, you know, hopefully in five or 10 years, things will be better. Well, I mean, I think, again, I think social media has done so much for the general population understanding things, but we're still hamstrung by the terms and conditions on our anatomical body parts on these big platforms.

29:35Okay. So a lot of women are told itching, burning, irritation, or pain is normal or just hormones. When do you tell people to seek? Like every once in a while, things can pinch and itch. But like, at what point if you were to give like very broad generic guidelines, like greater than four weeks, two weeks? Two weeks? I think two to four weeks. And if it's an everyday thing, something's not right. Because your genitals aren't supposed to hurt. Yeah, exactly. I mean, you're not supposed to be aware constantly of your vulva, right? And I tell like, I don't want your vulva running a show. And so many times people come in, they've seen so many different doctors, and it's very frustrating.

30:09They've been on these horrific journeys. And I'm like, your vulva is running the show. It's calling the shots. You're like, we need to figure out what's going on. So, so it's not, so you can use it how you want to use it, but you're not aware of it 24 seven. And you're not, I mean, I have some patients that spend three hours a day caring for their vulva. And I'm like, I have three kids. Who knows how many, you know, I mean, there's so many other responsibilities all of us have. There's no way I could spend that much time. I'm thankful that I, right now, I'm sure, you know, we're all going to get something in the future.

30:37but it's just a lot that patients go through. I think it's like, you know, the slowly boiling pot analogy of like, it doesn't start out at three hours and it just gets there slowly, slowly. Like if somebody says that it's been going on for a very long time because it doesn't go from zero hours to three hours overnight, right? You're just like slowly figuring out how you need to cope. So do you see tons of GSM or is your community pretty well trained where like you don't see that? or is it like coming in, is GSM coming in more than ever? Yeah, 50 % of my people or more have GSM. I'd say this year in 2026, I'm seeing so many more people that are on estrogen than when I started this clinic in 2015.

31:20So it's been wonderful. It's been so nice. It's like, we've come a long way, baby. But I joke about it because I'm like, oh, now I get the really hard shit because like low-hanging fruits, the low-hanging fruits being treated, which is wonderful because we need all hands on deck because there's a lot of vulvas. And I mean, GSM is like nearly ubiquitous. You know, the data is 50 to 90%, but we're like, yeah, the other 10 % just don't tell us. Or they're just asymptomatic waiting for a UTI. Did you see this paper out of Stanford at the end of 2025? I love quoting it. Medicare database looking at, you went to a doctor, you got a correct diagnosis of GSM or GSM adjacent recurrent UTI, dysuria, blah, blah, blah.

32:02What percentage of those Medicare women who made it to a doctor and got a correct diagnosis, what percentage of them got vaginal estrogen as a prescription? Wasn't it like less than 5 % or something? I know, and you think like that's a privileged population. I got to a doctor and I got a correct diagnosis. Like they put in an ICD-10 code. Yeah. And still didn't get vaginal estrogen. Now, was it that they didn't prescribe it or that it wasn't picked up? I don't think it was not picked up. That's a good question. But Una Lee has the paper, and I quoted this paper when I was at HHS taking the boxed warning off.

32:37I quoted Una Lee's paper that of women who got a vaginal estrogen prescription, 30 % didn't use it because of the boxed warning. That's gold research. Thank God that was published. It completely helped us. I'm so, because I mean, honestly, I can't tell you how many patients, you know, we have that conversation all the time. I'm like, listen, you know, you're going to see this. I'm telling you it's okay. Here are the old studies showing that even if you had active breast cancer, I'm okay with you being on this very low dose. You know, I mean, I think most of the papers were done with the 10 MCG Vagifem or estradiol tablet, but still I'm like, I'm okay with this.

33:14And now I can actually point patients to all the advocacy work that y 'all, you know, everyone has done to try to get this going. So 50 ,000 patient years, post-breast cancer survivor, safety vaginal estrogen. Like it's, so it irritates me to know anyone. People are like, well, yeah, yeah, but you know, we won't really know. And I'm like, what else has 50 ,000 patient years and we question if that's enough? Yeah, and I mean, the other thing with that is that, you know, compared to 20 or 30 years ago, right? Women are living so much longer and having more robust sex lives than they did earlier on.

33:53And so I, all the time I'm like, yeah, you survived your breast cancer. I am so glad, but now we need to make sure your quality of life is how you want it. And you're not going back to the hospital for UTIs too, right? So, I mean, there's so many things. Even if you're not having sex, like we don't want you in the hospital for UTIs. Totally. I mean, just getting up at night to pee. Just pick nocturia. Yes, exactly. Yeah. People don't know vaginal estrogen helps so much. I mean, I can get people, not all people, bladder is complicated. That's why we have urologists. But the role of vaginal estrogen in knocking down getting up at night to pee is like, I don't talk about it enough for like how life-changing it is.

34:34And even the incontinence, I think that there's so many patients that have adapted to their incontinence, right? And so I'm like, when you walk into the store, do you immediately look around and see where the bathroom is? And if they say yes, I'm like, you have found a ways to adapt, but if this is really impairing, like, are you leaving your home, right? Are you doing the social things you want to do? There are things that I have colleagues I can send you to that we can figure out more about what's going on. Let's start this cream first. And if you're still having problems, like see one of my friends, see my colleagues, we can get you better, you know?

35:05Totally. I mean, it's pretty crazy that urology guidelines for overactive bladder doesn't have vaginal estrogen in it yet, but it's such a game changer and it's such a low hanging fruit. Let's talk about, and this is expert opinion. I know this isn't guidelines. Prevention. So dermatologists love talking about prevention, sunscreen, hats, Right? Like, neurotologists talk about prevention all the time. It's the perfect opportunity to talk about prevention for what if I don't want to have pain with sex? What if I don't want to have atrophy? Everybody always asks, what if I don't want to lose my clitoris and my labia minora?

35:36You know, the million-dollar question is like, vaginal estrogen tube at 45 and say once a week? Like, we don't know because we don't have the data. But in your opinion, when do we start to prevent GSM? I would probably think in perimenopause. like, you know, when you start seeing those hormonal fluctuations and stuff. But I think that would be a really interesting study to look at because obviously, you know, when patients are in their 90s... How do we do that study? Like, seriously. Yeah, no, that's what I'm thinking about because I think there's so many factors, right? It'd be a long longitudinal study.

36:09It would. But like, again, I have a lot of residents that come down. They're like, hey, if you have an 80-year-old, how do you tell the difference between LS and GSM? Because a lot of times you get clorofimosis, you get miniaturization of the labia minora, but there's not that like overlying texture change that you get with LS and stuff. But yeah, I think perimenopause and maybe just like once a week or something. But yeah, I think that would be interesting to look at. Because you don't, I mean, to me, I'm like, when you take vulvar health and you just make it skin, right, like if you take the whole like vulva out of it and you're like, we don't tell somebody to start using sunscreen once they've gotten a sunburn.

36:47Yeah, no, I love that perspective, actually. I think it's a really good point. And knowing how safe vaginal estrogen is, and until now, cheap and available, right? Which is changing fast, sadly. But to me, I'm like, we downplay... Because the second question is, okay, now you've got GSM and atrophy. What is the right combo to reverse it? And I will argue the twice a week estradiol, which is baseline maintenance, is not enough to reverse atrophy. And to my knowledge, nobody's investigated that from like a research standpoint. Yeah, I'm trying to think about the reversal aspect. And I mean, I think there's a lot of different parts of that question because, you know, is it impairing you functionally?

37:35Because if it's not having any functional problem, I mean, I tell patients all the time, my face sags, my breasts sag, right? Everything in the vulva gets pushed up, which is why Rachel Pope wrote a poem, why I wish my vulva was my face. Because over time, all your wrinkles of your vulva go away and you get them all on your face, right? And so I think that our bodies change. And I am personally embracing aging. Just, you know, I don't want to look like a 20 year old right now. I'm 43. I'm content. I'm so happy. But you're using sunscreen and retinoid. I didn't start using my retinoids as regularly until like about 40.

38:10Okay, but sunscreen, yes. I love sunscreen. I don't think we'll ever tell women you should or you need to prevent GSM. But it's like, if you want to. Yeah. But again, I think it's the symptomatic part. It's the symptomatic part because I don't know if we'll be able to, like if your lips get a little bit smaller, right? And as long as you're able to have orgasms, but again, I mean, maybe when I'm 60 or 70, I'll think differently. I think that, yeah. I mean, I think there's a androgen component to needing to reverse it. And we just haven't, like there's certainly no protocol. Like we've got somebody now who's like, let's say orgasms have changed or they notice their clitoris is smaller and it's bothersome.

38:48Yeah. X, Y, and Z, what's the protocol to reverse? And I would argue 10 micrograms of a vaginal estrogen insert is not going to touch the vulva. We need vulvar hormones, likely DHEA, testosterone compounded to bring back atrophy once we have it. That end of that conversation versus prevention in the first place. Yeah, I agree. And I mean, I think at least for my patients, for instance, for lichen sclerosis in the 80s and 90s, they thought treatment was testosterone, topical testosterone. If you pull up the original papers, I give a couple of lectures about this. The white color change, the hyperkeratosis, all of that stays exactly the same.

39:28The clitoris breaks through and it busts open the adhesions, but it doesn't change the disease histology. It didn't do anything like that. Then when they looked at itch and symptoms, they actually did a study where they compared testosterone to just placebo Vaseline. And there was absolutely no difference between those two things on LS pathology or symptoms. But I mean, I think the photos clearly show that like clitoris like pop out. Well, that's for when we say we don't have any atrophy reversal data. I think you can extrapolate that though, if testosterone is working. But I think, you know, for libido, testosterone when they're having low libido.

40:08But I do have all the patients that are on like the pellets and have like giant... Giant clitoris. I know. I mean, I think that is again, under underreported. Again, shame, right? But it also can be useful in the figuring out how to reverse atrophy is like, we might have to do, and you know, I've floated this with friends is like, you might have to do some high dose systemic if local isn't helping and you really want to reverse somatrophy, get the side effect that other people where it's too much. I know a story of a woman East Coast came to see a friend who had one pellet dose. I don't know what her max testosterone was, but it was, it's not like, oh, I was on pellets for four years and my clitoris got big or slowly over time.

40:53It was one pellet dose. And she went back for a second one and said, things are changing down there. Nobody did an exam. And then she got a second pellet dose. It was like such a pronounced clitoris, incredibly sensitive, uncomfortably sensitive, and couldn't wear a swimsuit anymore because of the protuberance and ended up having to pay cash to get a clitoral reduction surgery. Because that doesn't go away, unfortunately. It doesn't go away and it can happen. Like I would have never told you, I don't know if it happens commonly after one pellet dose. I'm assuming it, I always assumed it was slowly over time.

41:25But now I'm like, don't mess with high testosterone doses. There are side effects. Yeah, yeah. And I'm a big testosterone proponent, but not severe, super physiologic without proper informed consent. Yeah. What else? Tell me more soapboxes. Definitely the name thing. I'm glad we actually started with that because that's, I think, one of the biggest things, right? I'm finding ways to do it. Do you get super cringy or is it just me when you see like vulva products with like fruit with shit dripping off the fruit? Yeah. But again, like there's all these products aimed at teens that get their period, right?

42:00Really? I'm not in that world. Tell me everything. Oh, yeah. And it's like all of these like confetti like things on the product about how it's like Clementine and vanilla and these wipes and that wipe. And in 2026, why is the douche market? I don't understand that. Exactly. I think it's lack of people's knowledge and not actually getting their stuff treated at the doctor and thinking that we're dirty. And it makes them tons of money. Yeah, it does. Well, yeah, people just ping pong. You know, it's like they go to the grocery store and they like ping pong back and forth. But I will say like some of, there's so much you can get in the drugstore now that when I was growing up, you couldn't.

42:39Like there's vibrators in drugstores now. You know, like it's awesome. Condoms used to only be at gas stations or something like that. And now you can actually buy them at like the grocery store, which seems reasonable. I got a vibrator that was like, it's hidden in like a blush compartment. So I brought that to like our retirement community. And that was like our grand prize for people that answered questions. So it's like concealed, you know. That's so fantastic. Do you see a lot of teenagers in your clinic? I, you know, I see a lot of 20 year olds. I do adolescents also. And I, one thing in that population, when I started, you know, in 2015, there were a lot of patients coming in for labiaplasties.

43:21And I don't know if it's, I'm hoping that there's more awareness or maybe they just found me on a list that you don't go to her if you want to lay the plastic, but they're getting better. That's why they don't come back. Right. That old thing. But, but I think a lot of people now, like I have several books that I have them flip through that like vulvas come in all shapes and sizes, right? There's not one that is supposed to look a certain way. You can have inside lips, you can have outside lips. Thankfully we are, there are more avenues for, for patients to see that as opposed to 10 or 15 years ago.

43:54I think it's predatory to not educate people on what normal body parts look like. It's very hard. It's very hard for a young person or any person to go on the internet and see if their anatomy is normal without coming across porn or negative stuff or just coming across plastic surgery websites that tell you how it could be. So it's predatory to not educate and then take people's cash because of their lack of education and security. Well, and especially like, I think that as part of, I mean, my kids are, you know, eight, six, and four. And so when we get through their like, you know, sex ed or whatever we're going to do, like, and I mean, they look at their own stuff, but I feel like I want that to be part of sex ed training, right?

44:38Is like part of sex ed, you look at your vulva, you see what it looks like so that when you're 25 or 35 or 45 and you have itching, you look down and you know that you're red. That's just, just like this is pink. Like your vulva is, has, you know, many different colors, right? But if you're looking for the first time when you have itching or pain, then you see a four dye spot, you see a epidermal inclusion cyst and you think it's cancer. And some of these patients won't come in for two or three years because they're worried they have something, you know, whereas if it was on their face, they wouldn't think another minute they'd be in to see, you know?

45:10So that is something I hope we can move in the right direction too. Do you know how many vulvar dermatologists are in the nation? So in our like vulvar derm, please don't say 10. Oh, no, no. In our vulvar derm consortium, there's at least like 45 attendings. There's tons of residents. And then we actually have like, you know, there's Ishwish and then there's also like the International Society for the ISSVD. VD. Yep. 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.

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47:03That's J-O-I-N-D-B-L-O-K-E-S dot com backslash not broken. Code not broken. So International Society for the Study of Vulvar Disorders? Vulvovaginal Diseases, yeah. Vulvovaginal Diseases, okay. Can you find a provider on there? Not that people are searching for my vulvovaginal disease. I don't think they have the list like menopause has or like Ishwish has for members they can search. But there's gynecologists and urologists, right, that take care of vulvas. So, I mean, I don't think it necessarily has to be a dermatologist. It just has to be someone that cares about your vulva, that wants to look and know how to ask for help if they need help with like an autoimmune blistering disease, you know, severe lichen planus.

47:48Some of these things that we use big gun medicines for, I think derms can work with, you know, colleagues to help. But I'm obviously biased. I think derms are great and I love what I do. So. Of course, there's, I mean, the only problem is there's not, there's not enough of you. No, but there, you know, I think, and there's so many people that have vulvar problems, right? Like I tell the gynecologists that rotate with me, 20 % of your patients are going to have some sort of skin condition on their vulva. If you ask a woman, is everything fine down there? Anything bother you? Any troubles at all?

48:21They say no. Great. Moving on. Rest of conversation. And now we're going to do an exam because it's a bladder leakage. It's a prolapse exam. It's something like that. Right. So like my exam is intended for a different problem. I've already asked them about any concerns and they say no. Right. Then we do an exam. And then I say, does this bother you? And it's GSM. It's like in sclerosis. It's whatever it is. Yeast overgrowth, blah, blah, blah. Oh yeah, it's awful. Patients will not tell you something's a problem until you are in the exam. And then they're like, oh yeah, I know I stopped having sex six years ago.

48:54It's like, I asked you any problems down there, anything that bothers you, the answer is no until you're doing the exam. So I guess my point is like, I completely believe you when you say 20%. Yeah, and I don't know a way other than, thank you for having me on here and talking about this stuff, but to get people that feel more comfortable bringing up, right, because I do think that's a huge barrier. And even when the resident staff with me in their like resident clinics, they know if it's a psoriasis or eczema patient, it's not okay to ask, you know, do you have anything you have to specifically say, do you have psoriasis on your genitals or is it impacting your sexual relationship?

49:30And they know if they're staffing with me, I'm gonna ask them that question. So they better have already asked. But when you ask like those targeted questions, sometimes they will say yes, but still a lot of times you'll see, like I have some patients with mucous membrane pemphigoid or bullous pemphigoid, you know, and they have horrible lesions all over their body. But I'm like, does it burn when you pee? And they're like, no. I'm like, well, I'm a vulvoderm. So if I don't look, then like, it's gonna be kind of bad if someone else finds it. So let's just look. And we look and they have horrible eruptions.

49:57And like how, I don't understand. Like, and either it's just got used to the pain, right? And it's been going on so long that it's just part of like, oh, I thought it was supposed to burn, you know? Or, you know, so I do hope we can help with that. Oh my God. How much are you booked out? Don't tell me two years. A long time. Because we take insurance. I mean, I'm at UT Southwestern, you know, I have, I actually have three half days of vulva a week. and then I also have a vulvar procedure clinic twice a month. And so it's awesome. I have the derms, the gynes and then I also have PA students, medical students and the urogynecology or the female pelvic reconstructive.

50:35I know there's a lot of overlap. Urology fellows. Yeah, now rebranded as urogyne. Okay. So, cause the FMRS is too difficult for people. Yeah, I'm glad. I mean, there's so much overlap in all we do. There is a lot of overlap, right? But yeah, I am booked out a while but I am getting a partner. So I'm excited. Oh, well, I mean, cheers to UT Southwestern for seeing the need and for having this. Like the institutional support is very important, you know? Well, it is. But again, when my chairman was like, I think, again, I came here to interview for inpatient derm. And so he told me I was going to have to have an area of focus.

51:11I was like, well, inpatient, like, he's like, no, more focus. And so I think he thought SJS, calciflaxis, something, right? But I was like, uh, vulvoderm. And so it did not exist. I started with two half days a month, right? And then I went out for a couple of maternity leaves and now it's three half days a week with a crazy long waiting list. But I do like, I am very thankful for my chairman's support. And just like, I think again, if you find something you love doing, then you just do it, right? You don't ask. I mean, yes, I need to ask permission for a lot of things, but they see the joy and that I want to do research just because I am asking the questions, you know, and if you're the expert and you don't ask questions, who's going to do it?

51:53Who's going to find the answers to the questions for your patients if you don't do it, you know? Oh my God, I love it. Any final parting words for the labia, for the vulva, for the women, for the doctors? I think, honestly, at the end of the day, just do what brings you joy. And I hope more people find joy in taking care of patients with vulvar and genital concerns. A lot of it, like there's the tough cases where now I'm like, I'm glad I know you, but like the low hanging fruit on treating DSM. And you make people get better. It's so rewarding. They're so grateful. And I am so, I feel, sometimes I feel guilty because I wish all of my calling, there's a lot of burnout in medicine, a ton of burnout in medicine.

52:37But I was like, if you find something that you find rewarding and fulfilling and can make patients better, just do that. Don't feel like you have to do everything for everyone, right? Find that area what it is for you. So I love it. That is great advice. And thank you for ending with that. How can people find you? Dr. Melissa Moscar at Instagram. And yeah, I'm at UT Southwestern in Dallas. And thanks for having me on. Absolutely. My pleasure. I'm glad that you agreed to it. Thank you. 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.

53:16That 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 Kasperson 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.

53:56Thanks for being here, and remember, you are not broken.