Ep #65: Sex and Menopause with Dr. Kelly Casperson

You are listening to The Midlife Sex Coach for Women™ Podcast episode 65.

Welcome to The Midlife Sex Coach for Women™ Podcast, the only show that combines a fun personality, medical knowledge, sexual counseling, and life coaching together. To create unique sex coaching that helps busy women awaken their libidos, address intimacy issues, and learn how to express their sexuality for the rest of their days. Here is your host, certified life coach and sexual counselor, Dr. Sonia Wright.

Hello everybody. I am so excited for my next question and answer session. And this guest is just so amazing. I don’t even know what to say. I’m going to have her introduce herself but let’s just say that she’s fabulous in every way. And she has an amazing podcast. If you haven’t listened to it, you’ll have to listen to it. But I’m going to have Dr. Kelly Casperson introduce herself, tell us all about the things. And today we are going to be talking about sex and menopause. Okay, Dr. Kelly Casperson, take it away. Who are you? Tell everybody about you.

Kelly: Thanks for having me. I love every opportunity to chat with you. I’m Kelly Casperson, I’m a board certified urologist. I practice in Washington state, been out for going on 10 years, finished up nine years, going on 10 years out of residency. And I started getting into female sex med a couple of years ago after a very kind of monumental ground shaking patient that came into my office. And I realized I didn’t know anything. So I kind of dove deep, started a podcast, writing a book.

And a thing that keeps coming up is menopause. And how we kind of take care of our bodies and is it true that we stop having sex after menopause? Or is that a rumor? So I kind of dug down into what the research says about it. And here’s our talk today on menopause, sex and GSM.

Sonia: I love it. This is so good. Menopause, sex and GSM. What is GSM for everybody that may not know?

Kelly: GSM is the new title of vulva vaginal atrophy. So it used to be called vulva vaginal atrophy, and people said they didn’t like the atrophy word.

Sonia: Yeah, that sounds so pleasant, doesn’t it?

Kelly: Yeah, right.

Sonia: Vulva vaginal atrophy.

Kelly: And it doesn’t explain why it’s happening. So genital urinary symptoms or syndrome of menopause is what it’s called now, GSM. And it really encompasses all the pelvic changes that happen because of the low status of estrogen which can also include urinary frequency, burning with urination because the bladder and urethra is also affected by low estrogen. So genital urinary syndrome of menopause is an entire mouthful but it was created to replace vulva vaginal atrophy.

Sonia: Fabulous. Okay. So when your clients come to see you, when your patients come to see you, what are the main complaints that they’re concerned about when it comes to menopause?

Kelly: Well, they usually don’t come to see me because of your typical menopause symptoms. Everybody just thinks menopause is your periods stop and you have some hot flushes and then it’s over. I’d say that’s the overgeneralization of where the knowledge is in America. So people don’t even know that my burning with urination, my frequent recurrent urinary tract infections, my vaginal dryness, maybe it’s more difficult to be aroused or have an orgasm, or pain with sex, or tightness of the vagina. All those things are because of low estrogen.

So a lot of it’s just education and I’ll say, “Did you know that this is a symptom of menopause?” And universally they’ll say, “No, I didn’t know that.” Or they’ll listen to my podcast, they might be like, “I heard that on your podcast.” So at least I’m doing something to get some knowledge out there.

Sonia: Yeah. We’re not taught about this. And I don’t know about you but there’s so many clients that come to me as a sex coach and they are mad. They’re mad that nobody has told them about this. And they come to me and they’re like, “Why has no one ever talked to me about this? I didn’t know this was going to happen to me. I didn’t know what this was about. Why wouldn’t anyone tell me?” And then they’re like, “Why don’t my doctors tell me that this is going to happen?”

Why is that when we’re perimenopause, maybe we’re taught about the hormone and the emotional fluctuations and things like that. But we don’t really talk about the full spectrum of what goes on and what is to be concerned about. And if we could start talking to our clients in their 40s and help them have an understanding of what they may experience in the future. I think that this would be much better, if we could educate ourselves and our clients, I think that this would be really important.

Kelly: I agree. I think a lot of western medicine, we’re very good at treating disease. We’re not so great at preventing it. And I think GSM is a thing that happens because of untreated menopause. And so it’s like to switch the pendulum into, hey, maybe at the start of these symptoms we get you on just local vaginal estrogen to try to prevent these recurrent UTIs, this overactive bladder. Because I see a lot of women right now, they stopped having sex 10 years ago because of this.

And I’m like, if I can get to the 47 year old who’s having a great sex life. And I’m like, “Hey, maybe you want to think about this prophylactically?” Why do we have to get them to suffer before we get them treatment and kind of have to reverse some stuff? Instead of like, “Hey, I’m so glad it’s great. Things to think about to keep it this.”

Sonia: Yeah. And I think also the fact that every woman’s experience of menopause is a little different or could be a lot different. So doctors don’t know exactly. And we love things that have a nice formula, this and this is going to happen. And we treat it with this and this and boom, it’s done, everybody’s happy. But when people have different varying levels of symptoms or they don’t have a symptom and somebody else has a symptom or it’s not something that can be easily diagnosed or figured out as to what’s going on.

Then we don’t exactly know what to do with it so that’s maybe part of the reason why we don’t address it ahead of time or we don’t really talk about it much.

Kelly: Yeah. And the other thing to add on that. Menopause happens differently for everybody and at different ages. What drives me nuts is all these women in their late 40s who are just like, all their symptoms get, “Oh no, that’s not menopause.” And well, the average age is 51, 52, that means 50% are having symptoms beforehand, let alone perimenopause which is by definition the 10 years surrounding menopause. You don’t even know when that starts because menopause is a thing in the future.

So it’s all these women who get ignored because they’re ‘too young’ for menopause. No, you’re actually not too young when you’re in your mid-40s.

Sonia: Yeah. So what do we do? What do we have to offer women?

Kelly: Well, for the genital urinary syndrome of menopause, the bread and butter, certainly they always say, non-prescription, non-hormonal first. But a lot of people actually believe that it’s kind of like a band-aid, add more lube, add more moisturizers, hyaluronic acid, suppositories can be really nice to keep the skin healthy. But if you really want to prevent the recurrent UTIs, the burning with peeing, the frequency or urination, the dry painful vulva vagina.

The atrophy or loss of labia minora, clitoral phimosis, where the clitoris kind of shrinks and the clitoral hood kind of comes over and gets almost scarred down. That’s vaginal estrogen. I always say, estrogen was the reason these structures became the structures they are. And now they’re kind of sliding back and atrophying because they don’t have their vital nutrients that made them thrive as much as they did. So vaginal estrogen comes in creams, pills and rings. It’s getting cheaper. I want to see $4 cream at Walmart. I’m manifesting that into the universe.

Sonia: I’m going to be right there with you. We’re going to manifest this together definitely.

Kelly: Being at $4 or anything else at Walmart, you get $4 vaginal estrogen. Because the thing is we need to be on it for the rest of our life.

Sonia: You see, this is the thing, the rest of our lives. So talk to us a little bit about that. This is like vitamin E for your vagina and vulva region.

Kelly: Yeah. I mean I always just say it’s like sunscreen and seatbelts. If you stop using the sunscreen and the seatbelt it doesn’t work anymore. So if you stop using the vaginal estrogen, you’re just going to go back to how it was without any estrogen.

Sonia: Yeah. And it’s something so important. And we do need to get that across that this is something that you’re going to be dealing with for life. Now, it does bring up questions about can this cause cancer? If you have a history of breast cancer or some other cancer, can you go on estrogen? Those type of questions start coming up.

Kelly: Yeah. So we’re really been scared about estrogen. We did a very wonderful job of scaring both doctors and women, and people who love women, starting in the early 2000s with the Women’s Health Initiative. Basically we stopped learning about it because we just thought it was bad and it caused cancer. And that’s kind of a longer podcast to go into those studies but it’s interesting. But vaginal estrogen does not cause cancer. They’ve looked at this. There’s many, many, many studies.

Now, here’s the downside of that. Your package insert says this might cause stroke, this might cause cancer. So I tell a woman it’s very safe, there’s lots of studies saying that it’s wonderfully safe. We actually can treat vaginal atrophy in women who have been treated with breast cancer. So I usually get their oncologist involved. But we know that this helps quality of life in women who have already been treated with breast cancer and there’s no risk of recurrence.

And I say, “You’re going to go home. And if you’re a package insert reader, you’re going to read stuff that disagrees with me.” We know in the American College of Infections and Gynecologists, know that that package insert is wrong and it has not been changed. They’ve been petitioning it for over 10 years. You have to really trust your doctor who says this is safe, to go against the FDA package insert. But there’s many, many studies saying that vaginal – and I spend so much time educating the difference between systemic estrogen and vaginal estrogen.

Systemic means your body, so you’re either taking a pill or a patch, cream that goes in your body. So every place in your body sees that estrogen. Vaginal estrogen is local, it’s very low dose. I actually just read and I think this is very useful, one pill of hormone therapy estrogen is the same as an entire year of vaginal estrogen cream usage. That’s a low dose vaginal estrogen, one oral pill.

Sonia: Okay, well, that’s good to know. Can you repeat that again?

Kelly: Yes. So if people say, “Is vaginal estrogen too much?” Vaginal estrogen is so low it’s not enough to get into your body. And a year’s worth of vaginal estrogen is equivalent to taking one pill of what we call hormone replacement therapy or hormone therapy of estrogen, which is still very low dose. It’s a lot lower dose than birth control.

Sonia: Really? So it’s really a lot lower dose. Why is that if you’re doing systemic estrogen that you have to take progesterone with it?

Kelly: To protect your uterus. So if you still have a uterus, you have to protect the uterine lining from unopposed estrogen. Unopposed estrogen has about a five to ten percent increased risk of uterine cancer if we don’t protect the uterine lining with taking progesterone. So if you’ve had a hysterectomy then you don’t have to worry about progesterone and if you want to be on systemic estrogen. Again, vaginal estrogen, you don’t need to be on any progesterone because it’s not systemic. It’s so low dose that that uterus isn’t seeing it.

Sonia: And then since you’re a urologist, and so how does this lack of estrogen play into the situation where you end up having urinary frequency, and urgency, and increased urinary tract infections, how is that a thing?

Kelly: So the bladder has estrogen receptors in it, what I call the bladder and the vagina condo mates, they share a wall. So I tell a lot of people, “We’re putting estrogen in your vagina but it’s actually for your bladder.” That’s how I kind of get them over like, “Why am I putting this here for that?” I’m like, “Shares the same wall, the bladder gets the estrogen.” The bladder again loves having estrogen around and it misbehaves, it gets a little overactive. And then also the outside the urethra and that skin around the vulva can get thin. And it’s very sensitive.

Urine is an acid so if you pour acid on unhealthy skin it’ll burn. So treating that skin nice, it’s just skin care really helps those bladder symptoms.

Sonia: Okay. Alright, that’s a good way to look at it. And I have to say that earlier when you were talking about phimosis and the clitoris shrinking. I was shedding a tear, the thought of a clitoris shrinking was just making me so sad. You know it’s my best friend. I always have my little 3D model of the clitoris, Goldie, she’s just so important to me. So tell me a little bit more about the estrogen and menopause and why is my clitoris shrinking?

Kelly: Well, just like all the other structures down there, it became a clitoris because it saw estrogen and it thrives with estrogen around it. And the tissues just kind of atrophy, they lose some collagen, they lose some blood supply. So there’s skin, just like foreskin on a penis, there is foreskin of the clitoris, we call it the clitoral hood. And it can kind of become adherent or attached to the top of the clitoris. I always have to use my hands on my head when I describe this.

Sonia: Well, that is one big clitoris. And this is the glan, your head is the gland.

Kelly: Oh my God, it’s always the clitoral phimosis. But somebody in low estrogen states, again that skin can become tight or adherent and it just doesn’t move as clearly. And you can on exam, by somebody who’s skilled at looking at the head of the glans of the clitoris you can see how much phimosis that that clitoris has.

Sonia: Fabulous. Thank you. This is such good information. Now, what else do you want us to know about this?

Kelly: Yeah. I want people to know it’s not dangerous. It’s okay to ask for it. A lot of your doctors might not know about it because they didn’t get taught either. So it’s okay if you bring it up and they’re like, “I don’t know about this.” I have a lot of people refer their doctor to my podcast for the vaginal atrophy ones or for this episode would be great too. Just educate the doctors because again, we’re not so great at preventative measures, especially preventative measures of the pelvis.

So your doctor actually might need to get some education. But it’s very safe. The cream is generic now. Some of the tabs are generic now. So the cost is coming down because this is a lifelong medication.

Sonia: Yeah, definitely, it’s lifelong medication. I love that, I love that. I think that we can’t repeat that too often. I think it’s something that we have to be aware of that this is something that we’re going to be taking for an extended period of time and that’s okay. There’s nothing necessarily wrong with that. I mean basically if we go back a million years, or 100,000, or whatever. Humans, most of us were dead in our 30s or 40s. So we didn’t really go into postmenopausal times.

And if we think about the fact, I know that I advocate and I believe that you also advocate for the fact of sex and sexual intimacy throughout the lifespan and pleasure, especially for women throughout their lifespan. And this is part of it. This is ensuring that your vulva and your vagina is healthy enough to engage in pleasurable intimacy.

Kelly: Yeah, absolutely, even for people who aren’t currently vaginally sexually active. Because I’ll get a lot of women, and like I said, I meet them, they stopped having sex 10 years ago because it was painful. And now I’m trying to convince them to be on vaginal estrogen for bladder symptoms or recurrent UTIs, or pain and dryness. And they tell me, they say, “I don’t need to be on that because I’m not sexually active, I don’t have a partner.” And it irritates me because I’m like, “I’m not doing anything for your partner. This is for you, whether you have a partner or not, this is for you.”

So a lot of people defer, “I don’t need to put something in my vagina because I don’t have a partner.” And it’s like, “No, no, this is about you and taking care of you.”

Sonia: Yeah. I think that that’s such an important thought, is just that in our society, it’s almost like the vagina is not a part of a woman’s body, it’s like it’s out for rent or something like that. And this concept that we don’t necessarily, if we’re not utilizing it then we don’t need to necessarily keep the maintenance up because there’s not somebody else that needs to utilize the vagina. As opposed to it’s about us, it’s about our health, it’s about our pleasure, whether we’re going to have penetrative sex or whatever. If we’re having self-pleasure or whatever it is.

There’s women that like to just stimulate their clitoris, but there’s also women that will also penetrate and stimulate themselves at the same time, so whatever it is. But what you’re telling us is that just for your overall health, just in general we do need to take into consideration that we need the estrogen onboard?

Kelly: Yeah. And I think part of that too is women don’t know or we’re not taught the importance of the vagina in pelvic health. That the vagina actually it plays a role in preventing infections of the bladder. When it’s healthy, it’s acidic, it prevents the gut bacteria, the E. coli from the rectum from going up into the bladder. It actually works as a barrier, a fortress but women don’t know that. And so it’s like the vaginal estrogen keeps the vagina healthy. It keeps that lactobacillus there. There are fighters that prevent infection.

How many women say, “I get more UTIs, more yeast infections after menopause?” That’s why, because your pH is off because of lower estrogen. But women don’t get taught that important function of the vagina. We just think it’s for somebody else. And since there isn’t somebody else, I don’t need to do anything about it.

Sonia: Yeah. So that’s so important, that it’s really about our health. And that our vagina plays a role in our overall health just in general. And can you talk a little bit more about urinary tract infections? And as we get older, what actually that means in our lives if we’re having chronic urinary tract infections?

Kelly: Yeah. I think it’s one of the top eight reasons that people go to the doctor. Recurrent UTIs is incredibly common, it becomes more common with age. Even me, I don’t remember in urology residency learning that estrogen was a treatment for it. We really didn’t have the studies then. But a new study just came out that vaginal estrogen decreases the chance of a recurrent UTI by 68%. Again, normalizing our microbiome and acidifying. Who wouldn’t want to take something that decreases a chance of this happening again by 68%? It’s great.

Don’t forget to drink water though. You’ve got to drink water. You’ve got to pee. But yeah, incredibly important, it’s just such a common, common thing that happens to women as they age.

Sonia: So the use of estrogen is directly linked to reducing urinary tract infections by, did you say 68%?

Kelly: Yeah.

Sonia: Right there. For all my Diamonds that are listening, for everybody that is listening to this in any way, shape or form, please understand that estrogen replacement is about you and for you and your health. And yes, everything else is a bonus. But we’re really talking about the health of your body. And urinary tract infections is something that can also be under the radar, symptomatic ones, they’ll come to you.

But there’s a lot of women, probably a lot more women out there that are having urinary tract infections, are not necessarily aware of it and then it could become septic. Or we could have more problems with that.

Kelly: It can. I mean the old school was that urine was sterile. New school thought is about 10% of people are walking around with bugs in their urine, it’s just not bothering them so we don’t search for them. We don’t treat them. We don’t advocate checking asymptomatic people. But I think like you said, people jump, some people just are prone to, I get a UTI and I go to sepsis.

And they’re like, “How can I become more aware of that UTI?” And I’m like, “I can’t make you more aware of something you’re not feeling but I can work on prevention of that UTI and sepsis again by just getting everything as healthy as we can so that it doesn’t go from I’m feeling fine to super sick.” Which is how some people do present.

Sonia: Yeah. Okay, so is there anything else that we should be aware of when we’re talking about menopause and that women should have on their minds?

Kelly: Well, if you want to talk about systemic hormones and desire.

Sonia: Yeah, let’s talk about that.

Kelly: That’s important. So I would end to answer the question of do hormones help sex lives? And the data’s mixed. You’re going to find some data that says it doesn’t matter. There’s plenty of people who aren’t on hormones and they have great sex lives. And then you’re going to see some studies that say, again, this is systemic, this is not vaginal. Vaginal is more for skin care down there. Systemic is more for drive, interest, vitality, helping with night sweats and your body.

So some studies will say treat those menopause symptoms. When she’s well rested she’s feeling great, her mood swings are better. She’s going to just be interested in having sex more. So I can find data to argue any of it which I think is good news. Because it means some people who really can’t be on hormones, it doesn’t mean their sex life is doomed. But if you’ve got those symptoms and a sex life that is just not thriving like you want it to, try some hormone supplements, see if it makes a difference. But again hormones aren’t all the solution.

I always say this, hormones can’t change your social situation, your stress, your relationship problems. It can’t fix all of that, which we know is important to healthy sex lives. But it can make a big difference. And the studies come back and say, two top reasons that menopausal women stop having sex, number one, untreated menopause symptoms, whether it’s the systemic, hot flushes, night sweats, anxiety, heart palpitations. And number two, availability of a partner. Those are the two top reasons.

It’s not because they just have low hormones, it’s because they have untreated symptoms and partner availability.

Sonia: The partner availability is kind of interesting because I always talk about the fact, and this is something that I want women and people in general just to be clear. Yes, it’s wonderful if you have a partner, but I believe in solo partnering as well. You always have a partner, your first and your best partner is yourself. I will always advocate for that. So whether you have a partner, you can have a fantastic sex life. And hormones can just help improve that, improve your overall health and then also improve aspects of that with the libido and things like that.

So it sounds like it’s a win/win combination. And you get the best of both worlds when you have yourself as your own partner as well.

Kelly: Totally. And I think that’s the next step. I think about the data and it says availability of partner. And I think it’s because so many women think sex is with a partner. They don’t even think that sex is with themselves. They don’t even think sexuality is an inside job. And so they don’t even take advantage of the 24 hour a day clitoris that they’re walking around with.

Sonia: I know, seriously, which is within hand’s reach, within arm’s reach, it’s there for a reason. We can have a lot of fun with it, it’s just great. And I think I talk a lot about it. I know you talk a lot about it in terms of let’s change women’s minds about this. They get to be sexual beings their entire life. And they get to experience sex and pleasure and this is what it’s all about, sexual intimacy. So thank you so much for being here. Thank you for talking to us about this very, very, very important concept.

And of course we always say that, yes, we are doctors but we’re not specifically your doctor. So make sure to go out and check out all that we said with your doctor and see what is right and best for you. So definitely that’s an important thing, to go check in with your doctor about it. But what we’re giving you is general information and it’s just information that’s so vital and so important at this point in time.

And so thank you, Dr. Kelly Casperson, thank you so much for being here and just answering all my questions and informing my Diamonds about this very important topic around sex, sexuality and menopause. So tell us, how can we find you if we want to know more about you or reach out and follow you in some way, how exactly can we know more about Dr. Kelly Casperson?

Kelly: I’d love it if you followed me. I’m most active on Instagram, that’s my social media of choice right now, so, Kelly Casperson MD is where I am on Instagram, that’s also my website, kellycaspersonmd.com. And then the podcast is called You Are Not Broken.

Sonia: Fabulous. Okay. Alright, so everybody, all my Diamonds, now you know how to follow her and where to find her. She is just fabulous. And you do need to listen to her podcast because it is incredible. Thank you so much, Dr. Kelly Casperson for being on this program. I really appreciate you in so many ways and I really appreciate all the work that you’re doing. Thank you.

Kelly: Thanks for having me.

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