Ep #224: Your Body is Changing, Not Failing with Dr. Komal Patil-Sisodia

You are listening to the Midlife Sex Coach for Women podcast episode 224. Hello, hello, hello, my diamonds. How are you doing today? It’s so good to be here. Welcome back to the Midlife Sex Coach for Women podcast, where we’re talking about intimacy, desire, pleasure, and what it truly means to thrive in midlife. And today, diamonds, we’re diving into a conversation that is so important, so needed.

and honestly so long overdue. Because when women move through perimenopause and menopause, so much begins to shift. Hormones shift, energy shifts, libido shifts, the body shifts. And for so many women, nobody is really explaining what is happening. Instead, they’re often being told, it’s just your age, it’s just hormones. This is normal. This is just what you’re gonna have to put up with. Just deal with it. No.

No, no, not my diamonds, not any woman. No, we’re not doing that here. Today, I’m so excited to be joined by the incredible Dr. Dr. Komal Patil-Sisodia

And I’m so excited for you to hear this conversation. Dr. Patil-Sisodia is a board certified internist, endocrinologist, obesity medicine specialist, and menopause society certified practitioner. She helps women understand the connection between hormones, metabolism, menopause, and long-term health so that they can be informed, empowered, and supported in their bodies.

In this episode, we’ll talk about what is actually happening with estrogen, progesterone, testosterone during perimenopause and menopause and how those changes can affect libido, desire, vaginal and vulvar health, pelvic comfort, and overall wellbeing and why women deserve far more information support and

that they’re currently been given in many situations. We’re also gonna talk about self-advocacy, about paying attention to the signals in your body that you’re sending out, and also about this season of life that it’s not an end to anything. It actually can be the beginning of a deeper, wiser, more empowered relationship with yourself. So good. So diamonds, get ready. This is a powerful conversation.

at the intersection of hormones, health, and intimacy. Let’s get into it.

Dr. Sonia (03:19)
Hello, hello, hello, my beautiful diamonds. I am so excited today. I can’t even tell you how excited I am. Okay, but first of all, welcome to the Midlife Sex Coach for Women So I have been trying to get…

this doctor, this woman onto my podcast forever. And we finally just connected and reached out and said, we’re going to do it. So today I want to introduce you to Dr. Komal Patil-Sisodia And she is a board certified internist, endocrinologist, obesity medicine specialist, like it even gets better, and menopause society certified practitioner who’s changing the conversation around women’s midlife health.

I can’t believe, like, I feel like I’ve scored, like, like, it’s like, yes, like, I have found the gold mine in one human being. Does it get better than this? Okay, so with over 15 years of experience, she helps women understand the powerful links between hormones, metabolism, and long-term health, areas too often overlooked in traditional care, which is so true. She’s also the founder of the Eastside Menopause and Metabolism and the voice behind the Reset Recharge podcast.

Komal Patil-Sisodia (04:07)
Thank

Dr. Sonia (04:33)
and we will connect in so many different ways. But first of all, I just want to say thank you so much for being here today. And why don’t you kind of, know I’ve given you an introduction, but at the same time for listeners who may not know you as well, just say a little bit more about who you are and why you chose to get into this type of work.

Komal Patil-Sisodia (04:53)
Well, first and foremost, thank you so much. I think I need to hire you as my personal hype woman because I don’t think I’ve ever had such a lovely intro. So thank you. ⁓ And I just, you know, I want to, I would say that I…

am all the things that you said. I’m a board certified endocrinologist, internist, obesity medicine specialist. And then a few years ago, I decided that I was going to sit for my menopause society certified practitioner exam. And a lot of that kind of stems from my own personal journey, watching my mom go through a bunch of health issues after she had a hysterectomy very early in her life and didn’t get the care that she needed and where she is today. And then just seeing those patterns in my patients. So for me, it was one of those things like,

this is kind of the stuff that brings it all together, these midlife hormonal shifts. And I just really want women of all ages to be aware of what’s happening in their bodies and understand that what we’re told is, it’s just your hormones or, this is normal for women. Actually, these are kind of metabolic turning points in your life where your health changes over time. I always tell my patients, like women go through so many different eras of their lives, right?

childhood, we have puberty, we have our reproductive years if you’re choosing to have children, we have perimenopause and postmenopause, and every single era you’re changing a little bit and that’s like the only constant for women is the change, right? So and we I’d yeah.

Dr. Sonia (06:19)
It’s true. I’m going

to change and people are like, but which one?

Komal Patil-Sisodia (06:25)
That part,

that part, exactly, right? really since like childhood is really the most stable our hormones were, right? And that’s when you’re like living your best life and finger painting and, you know, doing all those things. And then, you know, puberty comes on. And I think we are hopefully now doing a better job of educating our girls about their bodies and what it means to, you know, have these hormonal changes happen. But I remember when I was a kid, ⁓ well, my upbringing was

a little atypical. I lived in Arizona and so oddly enough I had sex ed in second grade because we lived not too far from the border and apparently the teen pregnancy rate was really high. But I remember my mom was not equipped to have those conversations with me, right? Like she just went on whatever was in school and then ⁓ gave me a book called My Body is My Own. And that was it. It really is. Yeah.

Dr. Sonia (07:18)
She is actually more than a lot of parents. So I am applauding your mom. I’m like,

she knew she didn’t have it all, but she was gonna make sure she had something for her daughter. So that’s pretty amazing. That’s pretty good.

Komal Patil-Sisodia (07:26)
Correct. Yeah, yeah.

Yes,

which, you know, if you think about my cultural background being the daughter of Indian immigrants like that, that’s actually very progressive and very forward thinking. And I have to credit both my parents with that because they had three daughters and they were like, oh, this is going to be interesting to raise three women in a country that we don’t know. And so I feel like they gave us a really nice foundation with that. They’re yeah, we’re very blessed that way. So yeah.

Dr. Sonia (07:53)
Yeah.

And I’m saying

thank you to mom and dad right now. So thank you.

Komal Patil-Sisodia (07:59)
Yes, yes, thank you, thank you. They’re the best. yeah,

so I, you know, that’s kind of my background and I wanted to make sure I pull all this information together for women. And I love being able to connect with people like you who are doing such critical work because I think women are not taught about their own bodies and their own pleasure and what that means in terms of intimacy and how to have a fulfilling sex life as they, you know, navigate these eras and they’re getting ready for that part

their lives. So honored to be here excited that I get to know you and get to work with you.

Dr. Sonia (08:35)
I think it’s so important like the coming together of the both of things that we do, right? Because we do have to have an understanding of what’s going on with the hormones in our body and the shifts that are going on in our body and also understanding. And I like to say this a lot that we, our bodies are shifting and changing all the time. Like who we are in our twenties is not who we are in our forties and fifties. And we need to like with each transition, with each phase, as you talk about, we have to relearn the body that we’re in and we have to relearn

how it responds to sexual stimulation, how we feel about ourselves as a sexual being, how hormones relate to all of that. It’s all interconnected. So I think that this conversation is so important. What is it that you wish that more women understood about perimenopause and menopause?

Komal Patil-Sisodia (09:26)
Well, I will actually take it back to something you told me. we, for the listeners, Dr. Sonia and I met when we were at a conference. Gosh, was it last year? No, two years ago at Ali Novitski’s conference, Dr. Ali Novitski’s conference in the Berkshires. And I gave a talk called Mother Nature is Not a Feminist, right? And at that point, when I had written the talk, I think when I started my podcast, I was feeling some kind of way.

Dr. Sonia (09:40)
Yes, it was not.

Komal Patil-Sisodia (09:56)
all these changes in my body, despite like my best efforts at lifestyle changes. And I was like, my gosh, this is terrible. And so I think initially when I started these things, it was with a lens of a little bit of negativity. And you came up to me and you were like, you know, that was a great talk, but I have to disagree. I think mother nature is the biggest feminist of all. And you said that to me. And honestly, those words have been like burned in my brain. And since that point in time, I don’t think you understand like the impact you’ve

on like even my conversations with my patients have taken a more positive spin because I think here in the US we look at things as like a big like we need 20 is the new 40 we need to feel 20 or 30 forever and you know I everything is about anti-aging and none of it is actually about accepting the changes that come with your body and trying to find the power in each of those changes right and the more that I thought about it and the more that I

⁓

sat and journaled about it and looked back at all my notes and the way that I practice, I realized that you’re so right, right? With all of that constant change that we have in each era of our lives, we build this incredible resilience to be able to adapt, right? And that adaptability is our superpower. So if we lean into those changes and we lean into understanding how our bodies are changing, that is such an empowered place to come from as opposed to, my gosh, my body.

changing. I feel terrible all the time. Aging sucks, this that and the other. And that’s kind of where I was like two years ago, right? Because you have to go through the mental work of processing that for yourself. And now…

I’m excited to age. Am I excited that my joints are a little more creaky? Not really. But I know that with that, I have to change how I move my body, how I am taking care of myself. And that having to slow down a little bit actually gives you a little bit more time for thought. So I just want to introduce to women the concept that you can be powerful at any age.

Dr. Sonia (11:44)
You

at any age, this is so

true. So thank you for mirroring back the words. Right? And I didn’t realize how much of an impact I had, right? But as I’m about to hit 60, right? I’m in this place, I’m a little, I know I’m ahead of you in terms of the age and things like that. And you realize like, I loved my forties, but I don’t want to go back there. You know, and as I’m…

Komal Patil-Sisodia (12:06)
There’s a lady over here.

Yeah.

See, that’s how I feel about my 20s.

Dr. Sonia (12:28)
Like there’s so much, there’s so much wisdom that we gain and we take that wisdom and, and if we take the message that society is giving us, that aging is bad and our bodies because they’re aging are bad and all this stuff, that’s a lot to have on your shoulders, especially for women. Cause it’s interesting as men age, they get more distinguished, right? And as women age, are

Komal Patil-Sisodia (12:52)
Thank you, the language is so different.

Dr. Sonia (12:55)
wiser and everything like that, but people don’t focus on that. They focus on how do I get rid of this wrinkle? How can I keep everything the way it was in my 20s? I don’t really want it to be the way it was in my 20s.

Komal Patil-Sisodia (13:08)
Yeah, I mean, if I could have my knees from my 20s, I’d take those. you know, but otherwise, otherwise, like my confidence, my personality, like all of these things that have been evolving over the years, like, I feel like each year you get better. But unfortunately, society teaches us that because we don’t look

Dr. Sonia (13:11)
Okay, I’ll talk to these, I’ll talk to these.

Komal Patil-Sisodia (13:29)
certain way or we can’t do all the things that we used to do, our value decreases. And I think that’s so wrong to tell women, right?

Dr. Sonia (13:38)
And it is so wrong in every way and our value is just increasing with time. I mean, we’re more amazing, we’re more beautiful, we’re more sexy, we’re more into ourselves, we’re more in like, what can this body do? You know, like we are more, we just get better and better. And so like, as we do this, like I think that it’s important to understand about our hormones and what’s happening.

Komal Patil-Sisodia (13:44)
Yeah.

Yeah.

to

your person.

Dr. Sonia (14:07)
so that we’re not like against our body and acting like it’s our enemy, but we can understand. So when we’re shifting into perimenopause and menopause, give me the straight information. What’s happening with estrogen? What’s happening with the progesterone? What’s happening with the testosterone? What’s happening with all that stuff? We need to know.

Komal Patil-Sisodia (14:18)
Yeah.

Yeah.

Yes, so I’m gonna actually take it back a few steps, right? So childhood, like we don’t have any sexual development. We hit puberty, our estrogen, progesterone and testosterone levels rise, right? And they’re doing that because women are born with a set number of eggs in their ovaries. And if you look at it from a reproductive process, right? If you look at all of us from purely biologic perspective, like we are supposed to reproduce during that era of our lives. Now, free will and all that, you don’t have to if you don’t want to. ⁓

Dr. Sonia (14:30)
Wow.

Komal Patil-Sisodia (14:57)
but that’s how our bodies work. And so every month we’re having a cycle with ovulation and the uterus is building up the lining so that we can potentially have a pregnancy. If a fertilized egg attaches, that’s great. If not, you reset again and go for it again the next month. And those are our menstrual periods, right? And that actually is pretty smooth sailing up until about your late 30s, early 40s, right? And that’s where the number of eggs and the ovaries have declined to the point that the hormone levels are starting to come.

down, right? And ovulation gets more erratic, right? And as the ovaries are shutting down, which they are supposed to do, right? Like that’s how our bodies are built. We’re not meant to reproduce forever. I don’t think I’d want to be pregnant at 45 or 60 or anything like that. There are some people who do it. Not for me. But they’re, you know, what we see is that because we don’t need the hormones to

Dr. Sonia (15:40)
What?

Komal Patil-Sisodia (15:51)
induce that ovulation, right? There’s an entire pattern to how it happens. Like in the first half of your cycle, which is day one of your period, estrogen levels start increasing, progesterone levels are low. Then your brain, your pituitary gland in your brain, which I call the remote control of all the hormones in your bodies because it controls your thyroid, your adrenals, your ovaries, or testes if you’re a man, it’s sending signals for the estrogen to start increasing. Then two signals from the pituitary

spike up and that releases an egg from the ovaries. And then if the egg stays fertilized, then the estrogen level remains high. The progesterone level, which has kind of been increasing, maybe studies out. But if nothing happens during that time, the progesterone level rises and then we shed the lining and we start the cycle again. In perimenopause, because things are fluctuating so much and ovulation becomes unpredictable, we start having these cycles that are kind of on top of each other, which are called

called

loop events, that’s where periods can shorten, they can lengthen, they become very unpredictable. And when we talk about early perimenopause, usually periods will start varying from like seven-ish days or so, right? That phase can last five to seven years. And then what we call late perimenopause is where the period starts spacing out by 60 days or more. And we call that ⁓ the one to two years prior to your period stopping.

Menopause is actually just a single point in time where your periods stop. That’s your last menstrual period. And you can call it menopause only a year later when you haven’t had a cycle for 12 months, right? And then after that, everything is post menopause. So menopause is just that discrete point in time. And really the hormone levels fluctuate a lot in perimenopause. it’s, because you’re having a cycle, it’s very hard to measure and know what your hormone levels are at that time. So a lot of doctors will say, you know, there’s no point in measuring hormones.

And I think we’re such a data-driven society. A lot of women feel like, but I want to know where my levels are at. They’re changing. Every day they’re changing, right? So there’s not really a steady point. A lot of this comes down to symptoms and paying attention to our bodies. And a lot of times, because we’re so busy with everything else, we are not tuned into what’s actually happening inside of our bodies. We’re not paying attention to ourselves. And again, that goes to, put everything and everyone first before we actually take

care of ourselves, right? Because of what society tells us.

Dr. Sonia (18:24)
So we’ve got a lot going on here. And how is that relating to like differences in libido and a shift in sexual energy and interest and desire? How is that playing out?

Komal Patil-Sisodia (18:27)
and

Yeah.

That’s a great question. So, you know, when we talk about each of these hormones, estrogen and progesterone are the ones that are driving your cycles, right? They also maintain your pelvic floor, estrogen specifically, and they hold on to the musculature in your pelvic floor. So in perimenopause, when these levels are kind of fluctuating, but then declining, what women see is weakening of their pelvic floor. They will see the thinning out of the tissue in the labia and the vagina. And what happens is a

of vaginal dryness, and that can lead to pain within our course. It can lead to an increased frequency of UTIs, especially after sex. so those physiologic changes actually will decrease libido. Because as you and I know, libido is a very ⁓ complicated thing in that there can be external factors such as what might be happening in your relationship or what stress you might have in your life that’s

affecting your mental ability to get into the mood. We have this hormonal piece. And then there’s also testosterone, which has been approved for use in hyposexual desire disorder, because when testosterone levels are low, libido in women tanks, right? So the estrogen is really affecting the pelvic floor musculature and how things feel. Testosterone as it declines can affect the libido. And where this gets a little complicated is that testosterone hasn’t really been

studied well in women. fact, the Endocrine Society, one of my major professional societies, did not advocate for any testosterone use in women until very recently. And now they are saying what the Menopause Society has been saying, which is in women with hyposexual desire disorder who have low testosterone levels, testosterone is a reasonable therapy. And I think a lot of that comes from the fact that we treat a lot of PCOS, or polycystic ovarian syndrome. And in that subgroup of women, testosterone level

actually are high for most of their lives. And so we see all the bad effects of high testosterone in women. So I think endocrinologists for years have just been like, no, I don’t think we should do that to women. Right? So that’s kind of where we are. And that’s how each of the hormones play into libido and desire and at how a woman is feeling in terms of her sexuality.

Dr. Sonia (21:00)
just wondering and this is just a side question. ⁓ So people with PCOSF tend to have a higher level of testosterone. Do they have issues with libido? does their body get used to this high level of testosterone so it doesn’t show itself as higher libido or do they tend to have higher libido? was just wondering.

Komal Patil-Sisodia (21:03)
Yeah.

That’s an excellent question.

So if you look at the data, I think it shows that women tend to have a higher libido. But what I find interesting is in perimenopause, it’s kind of a mixed bag, right? Because ⁓ one of our big treatments for PCOS to drive down those testosterone levels is to give people more estrogen. And usually we do that in the form of birth control, or there’s a blood pressure medication called spironolactone. And that increases your body’s ⁓ endogenous production of estrogen. So what your ovaries are making

the the spironolactone kind of helps amplify that and that drives down the testosterone level. So a lot of my patients as they go through PCOS treatment with the decline in the androgens they feel a lower libido right because you’re right their body is used to that higher amount and the same thing happens when we start them on hormone therapy in in perimenopause or menopause is that hormone therapy will then drive down that testosterone level and a lot of times what I see with my

PCOS patients is even when we normalize their testosterone levels, they so they’re not high, they’re in the normal range, they’re not frankly low, they feel symptoms of low libido. And it’s such a tricky thing to manage, right? Because they’ve been dealing all their lives with facial hair, irregular periods, all sorts of other things. And we fixed that, but there’s this newer issue, right? And for some people, it takes them a while and they adjust and they do okay. But for others, they never really feel that again. And then there’s

this complicated, well do I give somebody with PCOS testosterone? I just spent like a few years trying to lower it. I don’t know what to do. So that’s where a really goal-directed conversation with your doctor is important.

Dr. Sonia (23:05)
And that’s why I always think of like an endocrinologist is such a balancing act. Like the work that you do is so amazing because you’re always looking, okay, I’m going to do this and it’s going to have this type of effect and now I have to watch out for this and we’ve got to make sure this and obviously taking your ⁓ patients in as the partner with the treatment and stuff. So I’m going to say this, we are both doctors, but we’re not specifically your doctor, Diamond.

Komal Patil-Sisodia (23:10)
Yeah.

Yeah.

Yes, yes.

Dr. Sonia (23:30)
So that’s very clear.

And now I’m going to ask some questions around medication. But if you have any specific questions that relate to your situation, please go talk to your provider. So having said that, now I’m going to ask some questions. So when you have ⁓ a woman that’s coming to you and she’s dealing with like perimenopause, postmenopause time, and her libido has been impacted, and she’s also dealing with thinning,

Komal Patil-Sisodia (23:35)
Yeah.

Dr. Sonia (23:57)
in the vulva area or pain and things like that. What type of treatments are available? What type of things are the options that are available for local and systemic?

Komal Patil-Sisodia (24:09)
Great question. So local treatment, if you’re having that thinning, if you’re having that pain, vaginal estrogen, vaginal estradiol specifically is such a great tool. It’s inexpensive or should be. You can get it, I think, cost plus drugs for $13 a tube, which lasts you a few months, is probably the easiest way to start treating that, right? There are some people who can’t have hormonal therapy for whatever cancer they may have. There’s recent data that actually

actually

shows breast cancer survivors can have vaginal estrogen. And so that’s been really nice. ⁓ I think it’s a little less clear around people who’ve had endometrial cancer or some sort of gynecologic cancer that’s in that pelvic area. But with that type of hormonal treatment, you can see that the tissue improves significantly, right? It’s been shown ⁓ to reduce the incidence of UTIs. It’s been shown to improve the vaginal dryness and improve the

flow to the genitalia so that women can actually have more comfortable intercourse, right? And it decreases that pain with intercourse. For people who can’t have, ⁓ and this is a very small group of people, vaginal estrogen, you can also use vaginal moisturizers and lubricants, right? Those are great tools. And I think even if you’re on vaginal estrogen, it’s a good idea because it makes sex more pleasurable. And there’s no reason why we shouldn’t be doing that, right? There’s no reason to be embarrassed about

about that because these are physiologic changes that are happening to our body and everybody wants to have a good time, right? It should just be one of the two partners. Yeah. Yeah.

Dr. Sonia (25:44)
Yes, yes, yes, we all deserve to have a good time. Now I have a couple of quick questions

around this. So when we’re talking about ⁓ like the cheap tubes that you can get and do we need prescriptions for these?

Komal Patil-Sisodia (26:01)
Yes,

for vaginal estrogen you need prescriptions, Correct, yeah.

Dr. Sonia (26:05)
So creams, pills, rings, whatever, needs some sort of prescription. So that’s the

first thing. Then the second thing is ⁓ a lot of times we put so much focus on the vagina. Now, you know, I love the vagina just like anybody else, but the vulva is where it’s at as far as I’m concerned. Like everything, like that is the place. So I always make sure that people have an understanding that yes, we wanna make sure, cause sometimes we spend all this time putting estrogen in our vagina and it’s like the…

Komal Patil-Sisodia (26:15)
Yeah.

Fair. Yeah, yeah, yeah.

Dr. Sonia (26:34)
cozy as warm as moist place the velvet is known.

Komal Patil-Sisodia (26:35)
And everything else is dry. Yeah. I actually have

my patients spread it all over because that’s the way, that’s the right way to do it. And that’s why I like the cream better than the tablet or the ring, because you actually have control over how you apply it. And you will get enhanced blood flow then not just to the vaginal walls, but to your point also to the vulva. Yeah.

Dr. Sonia (26:40)
Exactly. just want to make sure that people are aware of that. Exactly. Yes.

right.

Please, thank you. So that’s something that’s very important because

not everybody talks about this. So if it were the case, because some people don’t necessarily want to put the creams up in the vagina. They prefer a pill or a ring or something like that. So if that’s the case, do you prescribe like a cream for the vulva area and then ⁓ a tablet for the vagina or do you just basically suggest that they try the cream?

Komal Patil-Sisodia (27:11)
Yeah.

start with a cream. they’re very anti-cream, I’ll start with a tablet and then tell them, you know, if you’re not seeing vulvar improvements, let me know. And then maybe we can alternate. Like you do a tablet, alternate with the cream and maybe something like that works, works better for you. But generally vaginal estrogen is considered topical, which is a very important distinction from transdermal. I learned this from this amazing woman on TikTok. She calls herself the menopause pharmacist. If you, if you don’t follow her, you should, but

Dr. Sonia (27:51)
great.

Komal Patil-Sisodia (27:54)
she did a really great breakdown of the difference between topical and transdermal. And sometimes we use the words interchangeably, but topical is really what’s happening. The preparations that you’re applying to the pelvic floor. Transdermal estradiol is something that we use that is more systemic, right? Like those are the patch formulations, gel, sprays, creams like that, you apply it to the skin surface and it absorbs into your bloodstream and is through your whole system.

The topical estradiol is really just what you’re applying and stays in your pelvis. There’s very little systemic uptake. Very little amount of that actually gets into your bloodstream, if any.

Dr. Sonia (28:34)
So that’s also a good question. Now, what about reverse? Have you seen that there’s people that will use transdermal, the systemic oxygen, and then they need the localized because they’re still having issues? Could you talk about that a little bit, please?

Komal Patil-Sisodia (28:42)
Yeah.

Yes. Yes.

Absolutely, absolutely. So I will always offer both upfront to my patients, right? Because I think that it’s important to treat both areas, especially if they’re having significant pelvic symptoms, right? Some women come to me and they’re like, I don’t have any problems. You know, my sex life is great. I don’t have any issues. And so what we do is we’ll start them with a transdermal preparation. So a patch, a cream, a gel, spray, something like that, where they’re applying it to their skin surface to be absorbed in.

But for the women who come in and tell me that, you know, I have these pelvic symptoms as well, I will tell them that they need to do both. And everybody’s always a little hesitant about it because I think, you know, we haven’t normalized people actually being comfortable with their entire body or their genitalia. So some people are very like anti, I don’t want to put anything down there. I don’t want to touch anything down there. Right. It’s kind of an interesting mixed bag there. The other thing that I counsel my women who don’t have any pelvic symptoms and are only on like

the transdermal preparation is that if you start to notice those changes that is a sign that your systemic therapy is not taking care of your pelvis and we then need to give you the vaginal preparation of the estradiol so that you can be comfortable in that way and you know vaginal estradiol is one and like we talked about there is the vaginal moisturizers and then the lubricants the difference between the moisturizers and the lubricants is the moisturizer is for daily

replenishment of moisture, whereas the lubricants are used during intercourse, right? So to make intercourse more comfortable. Sometimes people don’t know the difference between the two. The daily vaginal moisturizers, actually the data shows that that improves symptoms in more women ⁓ overall in terms, ⁓ compared to just using the lubricants during sex. So you know that daily replenishment of moisture is more important. There’s more high quality evidence around that if you look in the data and the lubricants do help a significant

Dr. Sonia (30:37)
it.

Komal Patil-Sisodia (30:45)
amount of women, but sometimes if you’re just doing that during that time and you haven’t maintained, right? It’s like, like get the skin on your face, right? Like if you’re not applying moisturizer every day, but then one day you do like a really hydrating mask, it feels fine on that day, but it still won’t feel as good as if you did the moisturizer every day and then did the mask, right? Once a week. So that’s kind of a weird analogy, but that we have to maintain the skin down there as well. Yeah.

Dr. Sonia (31:10)
Exactly, that’s

definitely something that’s important. Now, are the moisturizers, are those prescription as well or is that kind of over the counter?

Komal Patil-Sisodia (31:16)
out.

That’s

all over the counter because they’re non hormonal. So those are really great options for people to just be able to go to like if you go to your local drug store or you know, big box store, I think they even have them in the grocery stores now when you go to the feminine product style and it will say on there whether it is a lubricant versus a moisturizer. So you’ll be able to tell the difference. And then the other thing that we didn’t really talk about is vaginal DHEA, which is the, my gosh, I can’t remember the, I’m an endocrinologist.

I can’t remember the long name of DHEA, but that’s okay. But there is one that’s called Prasterone That’s a prescription that is for vaginal use that can help with pain within our course. There’s also another medication called Ospemifene that is a selective estrogen receptor modulator that can be used for that. And that one’s an oral one. Both of those are prescriptions. So really the prescription is gonna be the

the vaginal DHEA, is called prasterone or the Ospemifene And then things you can do on your own before, like say you’re trying to find a doctor and the appointment’s like six weeks out, but you need to do something now, go grab yourself some vaginal moisturizer and some vaginal lubricant. That will help in the meantime. And then, you know, there’s also testosterone, which is the libido part of things. Some women say that they feel some improvement in their,

floor symptoms with testosterone, but the data really shows that really the maintenance of that pelvic floor is more estradiol and the testosterone helps more with decreased desire. And so that is a separate thing that we do. And then if you have a, I know we’re talking more about the pelvic floor, but if you’re taking systemic hormones and you still have your uterus, you also have to add in progesterone for that. And that’s a separate conversation, but I just want to throw that in there so people.

Dr. Sonia (33:12)
Yeah, I was going to ask about that

too, because I don’t want people rushing up and just be estrogen, estrogen, estrogen. OK, something maybe we’ll hear about testosterone without talking about progesterone and the preventative measures and why we bring that in there. So if you just have a minute to just say why that’s important.

Komal Patil-Sisodia (33:16)
Right, yeah. Yeah. Yeah. Yeah.

Yeah, I’m happy to do that.

Yeah. So when I am seeing women in perimenopause, so before their periods have stopped and even after their periods have stopped postmenopausally, right? There’s three things that I will always consider. Number one, do you have a uterus and do we need to protect it? Because if you take estrogen by itself, it’s if you think back to earlier in our conversation, it’s building up that uterine lining in order for potentially an egg to attach to it. And if you are just taking the estrogen and you don’t have any progesterone in your symptom, that lining gets thicker.

thicker and thicker and that can lead to something called endometrial hyperplasia which can then lead to endometrial cancer. So you cannot take it by itself if you have a uterus, right? It will, it has the potential to kill you if you do that and you end up with endometrial cancer. So we try to do no harm there. The progesterone will thin out that lining, right? So we’re thinking about do you have a uterus and do we need to protect it? And one of the questions I get a lot is, but I had a uterine ablation and I don’t have periods.

anymore.

It doesn’t matter. The uterus is still there. And if I’m giving you estrogen, it has the potential to build up in that lining, even though you’ve had a uterine ablation. So if your uterus is in your body, you need progesterone. The second is going to be if you’re still having your periods and you’re in that perimenopause range, you can get pregnant. So you need contraception. I’ve had to tell people in their late 40s and early 50s that they have a positive pregnancy test. And everybody looks at me like I’ve grown eight heads, but it’s very

possible, right? So if you’re still having periods and you have a uterus, you need contraception. And then the third thing is going to be, does it treat your symptoms? Right? Because our bodies are so different and we’re so genetically diverse that if we try one, and this is the sad thing, right? Like people, unfortunately nowadays are so distrustful of medicine that if they try one thing and they have a bad reaction, they’re like, Oh, I don’t want to try anything ever again. That’s not going to be the best. You have to kind of cycle through a few different options. Otherwise you’re in my

opinion, cutting off your nose to spite your face, right? That’s the same, right? I think I said that right. But yeah, you’re really limiting your options when there are other things that can be equally useful for you, right? So the micronized progesterone that we use, that is the bio identical one, right? And bio identical is this big hot button marketing term that, you know, it just means that the hormone is chemically, structurally identical to what your body makes, but doesn’t mean that it came from like a

Dr. Sonia (35:33)
Yes, yes.

Komal Patil-Sisodia (36:00)
human source, right? They actually mostly come from plant estrogens that then get changed in a lab to be identical to what our body has, right? So people are like, it’s unprocessed. That’s not true. It’s still processed in a lab. ⁓

but it’s just chemically identical to what our bodies do, right? Some of the synthetic progesterones that we’ve made are better at suppressing ovulation, but there is concern about potential increased breast cancer risk with those. And when I have gone and looked at the data, there are two synthetic progestins that don’t actually increase the risk of breast cancer in the studies so far. They have not been studied in the context of perimenopause and menopause, just for contraception, which is what they’re

used for, but they can also be used for uterine protection. And those are Drosparinone and Nomagestrol. Those two don’t have that increased risk. So a lot of times people will be like, well, the bio-idontical progesterone didn’t work for me and now my doctor won’t give me estradiol and I don’t know what to do. Go talk to them about these other two synthetic progestins. Just because it’s synthetic doesn’t mean it’s bad for you. It binds to your receptors in a different way. The Drosparinone, for example, for some of my patients who have PCOS is actually a better progesterone for them. ⁓

to help with their PCOS symptoms as well. So trial and error, you have to do trial and error, otherwise it gets really, really hard.

Dr. Sonia (37:21)
So good. So if you have somebody that’s coming to see you and they’re in that post-menopausal range and they’re talking about their libido, and we did talk in terms of like the hormones and how that affects physically, but how does it affect like just the libido and the interest in sexual intimacy and things like that? How do you address that with them?

Komal Patil-Sisodia (37:39)
Yeah.

So I will

sit down with them and talk through, ⁓ you know, there’s the biopsychosocial sexual model of desire. And so we kind of try and pinpoint like, where is the issue coming from? And if they’ve been on hormone replacement therapy, menopause hormone therapy, I think is the new term that is giving them systemic therapy. One of the things that I see is you can start off with a normal testosterone level, but the hormone therapy can drive down the testosterone level. So I will always do fasting, morning

testosterone levels and there is a specific assay that I think is more accurate than others. It’s called liquid chromatography mass spectrometry mass spectrometry. That is actually a more accurate way to measure testosterone. You want to do it fasting first thing in the morning before 9 a.m. ⁓ to actually see and then you want to check another blood marker with it called sex hormone binding globulin. Sex hormone binding globulin is the protein that estrogen

progesterone and testosterone all bind to. ⁓ It’s interesting because there are studies that show they all have a different affinity to bind to it. But one of the things that I’ve seen in my practice is that when we measure total testosterone, total testosterone is all of the testosterone that’s bound to that protein plus all of the testosterone that’s circulating in your system free. And when we look at both of those things, if you have a sex hormone binding globulin that you’re born

with and is just a low level, it’s going to make your total testosterone look low, even though the free fraction, which is actually what is biologically active, is normal. You’re going to, you can’t treat just based on a low total testosterone if you don’t know what the sex hormone binding globulin is and if the free testosterone is high, right? I’ve seen that actually happen. The flip side of it is that you, some people are born with a very high level of sex hormone binding globulin. And then when you’re taking estrogen treatment,

actually further increases the sex hormone binding globulin. If the total testosterone looks high, but the free testosterone is on the lower side or the lower end of normal or what we consider low, at that point, I’ll say, you’re having these symptoms, we should give it a trial and see how you do. Then generally what I’ll recommend is a month or two into treatment, we’ll check the levels to make sure they’re going up. Then I think the current guidance is that you check the levels every six months after that to make

sure that there is not ⁓ too much of an increase in the testosterone levels ⁓ because then women will start getting acne and like aggressive mood changes, facial hair, body hair, ⁓ things like that that are not and the female pattern baldness

alopecia that ⁓ is very distressing to most women. So those are things that you have to watch out for. So you really want to

make sure that you’re clearly monitoring that. And that’s where that testosterone component comes in. And then I would say for libido desire, if you’re having physical pain with intercourse that’s where the vaginal estrogen and the systemic therapy comes in.

Dr. Sonia (40:56)
that becomes it.

Great. Thank you for that very thorough answer. I appreciate that. Now, I only have a couple more questions left. So I’m wondering about what advice you have for women in terms of advocating for themselves. Obviously, when they come to you, like you kind of put all this synthesizes all together and you’re there and you can help them. But sometimes we have providers that may not have all this information or may not be as up to date.

Komal Patil-Sisodia (41:00)
I’m sorry.

Dr. Sonia (41:24)
Or they might be like, ⁓ it’s just your age. It’s just hormones. It’s just happening now. Just suck it up. How can women advocate for themselves?

Komal Patil-Sisodia (41:28)
Yeah.

That’s a great question. I, what I have found as, my stance on this has changed a little bit, right? Like there’s a few things you can do, but I, one of the things that I have found most effective, right? Cause I’ll have patients who come see me for ⁓ diabetes, thyroid, other things, but they, they don’t necessarily want to, ⁓ you know, see me for the menopause part of it because they have a gynecologist they’ve been with long-term or something like that. And I totally respect that, right? But what I will tell them is like,

If you’re not getting anywhere and you’re just being told this is something you’re going to have to wait until your periods go away, go online and find a green climacteric scale score. ⁓ It’s a test of 21 different symptoms of menopause. You can rank them as having none, mild, moderate, to severe. The mild is you notice the symptoms, but they’re not really bothering you too much.

is

it gives you pause, but you can still keep doing what you’re doing. And severe is where it’s really impacting your quality of life to where you can’t function on a daily basis. Rank that and it will tabulate a score for you out of 63. A score of 12 to 15 out of 63 is considered symptomatic, right? Mildly symptomatic, but symptomatic. I have women who come see me whose scores are like in the 30s, 40s, and 50s, and they are clearly suffering. But when they go in and talk to their doctors, they’re like, you have to suffer more.

we can justify treatment at a scale score of 12 to 15 or higher, right, if a patient is willing. So I’ll tell them, you know, fill this out, or I’ll do it with them in my office and I’ll say, this is what your score is. So when you go talk to your gynecologist, you say, I have symptoms per the scale. I need something because I am suffering, right? I don’t want to wait till this gets worse. I need help to get it better now. So that is actually a really great way to advocate for yourself is to go in arms with information.

⁓ It’s called the Green Climacteric Scale.

Dr. Sonia (43:30)
So tell me the name of this scale again.

Komal Patil-Sisodia (43:36)
And I will send you a link so you can link it to your website. ⁓ I have a calculator that I created. I’m trying to figure out how to link it to my website that does something similar. But if you can advocate for yourself, improve, you know, because as physicians, are data driven people. Right. And if somebody comes to me and says, I filled out the survey and I feel terrible in this, you know, this medically vetted, ⁓ you know, survey that has been shown in studies to

show that women have symptoms that need to be treated. If somebody’s bringing me that that they’ve filled out, I’m not going to say no.

I’m gonna say, how can I help you? So that’s one way to do it. The other thing is if you’re still running into walls or you don’t have somebody who understands, if you go to menopause.org, you will find a Menopause Society certified practitioner. These are people who have trained in this. They’ve taken an exam. They’re committed to trying to help women through these issues. So you can find one in your area that I think is going to be probably the best resource if you’re not able to get your help in the traditional system. But that being said, I have a lot of my primary care colleagues

who are now going and doing menopause education and who are having these conversations with women. I try and have any 40 plus woman who comes into my clinic gets my TED talk about how their body is changing. They have to pay attention. I’m like, I’m really sorry. I know we’re here to talk about your thyroid, but you’re 41 and we’re gonna talk about all these other things really quickly too. And I’d say like 90 % of people are like, oh, thank you for saying that. Yeah, I haven’t been feeling great. And then other people are like.

Dr. Sonia (44:54)
you

Komal Patil-Sisodia (45:09)
I don’t want to talk about this right now, but everybody gets to talk.

Dr. Sonia (45:10)
⁓ It’s like

you thought there was only one talk and then you find out there’s just so many talks. You never stop with the talks, right?

Komal Patil-Sisodia (45:19)
Exactly. And I’m like,

hey, you didn’t think you’d get a two for today. Here we are.

Dr. Sonia (45:24)
Yeah, I really know.

⁓ So we’re going to be wrapping up at this point in time. Is there anything, and we will need to have a part two to this, obviously, but is there anything else that you would like my diamonds to know about? Anything else that you would love women to have or know about?

Komal Patil-Sisodia (45:33)
Yes. Yeah.

So two things, one, I’m gonna go back to our desire conversation. I did not mention a medication that is out there and FDA approved for people who can’t have hormonal therapy and it’s called ⁓ Flibanserin (Addyi) and that is approved for hypoactive sexual desire disorder in premenopausal women has its own pluses and minuses, but it can actually be very helpful for issues with libido if you can’t take testosterone. ⁓

And that’s something you can discuss with your doctor. So that aside to push to that. I would say that, you know, what I want women to know is that not all hope is lost because your body is changing. It’s supposed to change.

Dr. Sonia (46:13)
Thank you.

Komal Patil-Sisodia (46:25)
you know, pay attention to your bodies because we’re taught to ignore ourselves in favor of everything else. Our families, our work, our community, our friends, our, if you’re in a religious organization, your religious organization, a lot of times women are conditioned to put everything before them and you can’t.

from an empty cup, right? To say that, it sounds trite when I say that, but honestly, like if you are not paying attention to your body and talking to your doctor about all of those changes that are happening, your body is sending you signals that something needs to change, right? And for a lot of women who come into my practice, it’s also a metabolic turning point. I see blood pressure go up, I see blood sugar go up, I see cholesterol go up, I see all of the genetics that the hormones we’re keeping out of bay that may run in your family.

start to come out during that time and this is like the key opportunity to intervene on your health and hormones will fix some of it but sometimes you have to ask for help for other medical conditions and if you do that and you’re paying attention to your body we can potentially prevent heart disease or stroke or any of these things by doing hormonal and non-hormonal interventions and lifestyle interventions so you can have the best quality of life for the longest period of time.

vest in yourself. That’s it.

Dr. Sonia (47:45)
I love that, invest in yourself, that is so great. So how can my diamonds find you?

Komal Patil-Sisodia (47:50)
They can find me by going to either my practice website, is EastsideMM.com. I’m based in Washington state, but I also have a license in California and I’m seeing patients virtually from there. I also have a podcast called Reset Recharge, which if they go to ResetRecharge.com, that is where all of my podcast stuff lives, or you can find me on Apple or Spotify. And then on socials on Instagram and TikTok, I’m at Dr. Patil Sisodia So I will send you all of that information for your show notes, but thank you.

again,

having me on your podcast. I really, really enjoyed our time and yes to part two.

Dr. Sonia (48:26)
Thank you so much for coming and it’s been a joy having you here. Thank you so much.

Komal Patil-Sisodia (48:31)
Thank

you.

Sonia Wright (48:32)
Beautiful diamonds. I hope you enjoyed this conversation as much as I did. There is so much wisdom here. One of the biggest takeaways for this episode is that your body is not betraying you. Your body’s changing.

Your body is communicating, your body is asking for your attention, and you deserve support as you learn how to care for yourself in this season. But You do not have to suffer in silence and you do not have to dismiss your symptoms and you do not have to accept pain, confusion or disconnection as part of getting older. There are answers.

There are options, there is support, and most importantly, there is still so much pleasure, vitality, and possibility available to you in midlife and beyond. I always say that it gets better. This is going to get better. So a huge thank you to Dr. Komal Patil-Sisodia for joining us and for sharing her expertise so generously.

And make sure you check the show notes so that you can connect with her and learn more about what she does and her work and explore her podcasts and other resources. And if this episode spoke to you, share it with a friend, share it with a sister, share it with another woman who needs to hear that she is not broken and that she deserves real care. And as always, Diamonds, if you’re ready to go deeper into the emotional, sensual, and intimate sides of this journey,

Come join me inside the Diamond Intimacy Collective. Until next time, be kind to yourself, be curious about your body, and remember, you are worthy of amazing, pleasurable intimacy at every age. Okay, Dr. Sonia out.