บทถอดความฉบับเต็มของ The Mind-Body Connection: Optimizing Wellness with Dr. Christine Vaccaro

problem until it's 68 00:04:17,056 --> 00:04:21,048 a problem. But these muscles are either able 69 00:04:21,104 --> 00:04:24,568 to relax and accommodate penetration. 70 00:04:24,744 --> 00:04:28,216 So if we're thinking, you know, cisgender, heterosexual partnerships 71 00:04:28,248 --> 00:04:30,968 here able to accommodate penetration, 72 00:04:31,064 --> 00:04:34,552 or they're not if they're too tight. So again, muscles that are 73 00:04:34,576 --> 00:04:37,784 too tight or painful, it's difficult to accommodate 74 00:04:37,832 --> 00:04:42,040 penetration. And then they also have to contract appropriately 75 00:04:42,120 --> 00:04:44,984 to allow for blood flow and engorgement, 76 00:04:45,112 --> 00:04:49,046 more sensation with penetration. So if these muscles 77 00:04:49,078 --> 00:04:52,490 are not having a full range of motion, and sometimes I use the analogy, 78 00:04:53,070 --> 00:04:56,662 you might do this as well, of a bicep. Right. A full range of motion. 79 00:04:56,726 --> 00:05:00,422 So women can, like, understand if the pelvic floor is 80 00:05:00,606 --> 00:05:03,846 chronically in a contracted state, it's hard for it to do what it's 81 00:05:03,878 --> 00:05:07,286 supposed to do, or if it's too relaxed and doesn't have any muscle strength, 82 00:05:07,318 --> 00:05:10,566 then it's hard for it to work, too. So sometimes use that analogy 83 00:05:10,598 --> 00:05:14,426 when I'm talking about the pelvic floor and how it functions, and it supports 84 00:05:14,458 --> 00:05:17,338 our bowel and our bladder and vagina and all the. 85 00:05:17,394 --> 00:05:20,906 All the things it needs to do to have the pelvic floor function properly. 86 00:05:20,938 --> 00:05:23,914 So I often, when I'm talking about that, I'm also trying to get them to 87 00:05:23,922 --> 00:05:27,690 see A pelvic floor physical therapist who are magicians in the pelvic floor for 88 00:05:27,730 --> 00:05:30,150 any pain disorder or just again, 89 00:05:31,010 --> 00:05:34,794 poor musculature. Because it's really hard to teach a woman in a 90 00:05:34,802 --> 00:05:38,058 really short visit how to contract their pelvic floor to make sure they're doing 91 00:05:38,114 --> 00:05:41,710 proper Kegels or pelvic floor muscle exercises. But they're 92 00:05:41,870 --> 00:05:45,130 super important muscle group. And I think 93 00:05:46,470 --> 00:05:49,934 we don't, again, focus enough on, in general, the pelvic, 94 00:05:50,062 --> 00:05:53,742 the pelvis and women or the pelvic floor. And then of course, we could talk 95 00:05:53,766 --> 00:05:57,246 about how, you know, bladder leakage and bowel 96 00:05:57,278 --> 00:06:01,070 leakage and other dysfunctions of the pelvic floor 97 00:06:01,230 --> 00:06:04,926 organs themselves can affect negatively sexual 98 00:06:04,958 --> 00:06:08,222 function. Of course, if a woman's having any sort of leakage, 99 00:06:08,366 --> 00:06:11,502 that's going to usually negatively affect their feeling 100 00:06:11,566 --> 00:06:14,814 sexy. And again, if there's 101 00:06:14,862 --> 00:06:17,330 any problems with the vagina, either vaginal dryness, 102 00:06:18,310 --> 00:06:21,710 you know, or fear of recurrent UTI because of 103 00:06:21,750 --> 00:06:25,358 sex. Again, these. All these concerns are always brought 104 00:06:25,374 --> 00:06:28,942 up in my patients about, you know, anything related to their 105 00:06:28,966 --> 00:06:32,910 pelvis and pelvic floor. Right, Absolutely. And, you know, 106 00:06:32,950 --> 00:06:36,420 leaking urine women are not happy with, in general, 107 00:06:36,540 --> 00:06:40,724 general leaking during intercourse is really distressing 108 00:06:40,772 --> 00:06:44,324 to them. Yes, yes. Nothing, nothing less sexy. 109 00:06:44,372 --> 00:06:47,764 You know, unless we're talking about squirting, which is a whole nother 110 00:06:47,812 --> 00:06:51,604 podcast, I'm sure. Not that. 111 00:06:51,772 --> 00:06:55,492 That is not the topic. Right. But you 112 00:06:55,516 --> 00:06:58,868 know, and fear of leaking, if they feel like they leaked once 113 00:06:58,924 --> 00:07:02,068 during a sexual activity, then they're going to have that 114 00:07:02,124 --> 00:07:05,700 worry, which unfortunately is gonna lead to them to tighten their 115 00:07:05,740 --> 00:07:09,012 pelvic floor, which now causes secondary issues of 116 00:07:09,036 --> 00:07:12,340 pain during sex. So it really. Not to 117 00:07:12,380 --> 00:07:16,212 mention getting. Not being in the right headspace of pleasure. And then 118 00:07:16,236 --> 00:07:19,860 they're in a headspace of fear, which just means you're not enjoying the experience, 119 00:07:19,980 --> 00:07:24,356 which is really hard for women to get out of the fear of 120 00:07:24,508 --> 00:07:28,292 either they're gonna leak or something's not right or their body image 121 00:07:28,356 --> 00:07:31,794 or et cetera, et cetera. Right. So a lot of women, unfortunately, 122 00:07:31,842 --> 00:07:35,954 aren't in that pleasure zone. They're in the worry zone or pain 123 00:07:36,002 --> 00:07:39,538 zone, which is not a good place to be. Right. 124 00:07:39,674 --> 00:07:43,362 And our muscles natural response to worry or history of 125 00:07:43,386 --> 00:07:47,314 pain or is to tighten up, which is the opposite effect 126 00:07:47,402 --> 00:07:50,754 of what we want happening for them during a positive sexual 127 00:07:50,802 --> 00:07:54,870 encounter. Totally. And again, I love analogies and stories. 128 00:07:55,530 --> 00:07:58,738 It's like the pelvic floor. I get on it. Use another analogy of just like 129 00:07:58,874 --> 00:08:02,754 if there was a neck injury, Right. And then the muscles just Start lifting 130 00:08:02,802 --> 00:08:06,018 and guarding. And then over time, it's like the muscles themselves 131 00:08:06,114 --> 00:08:09,634 become the pain source. And it's like, how do we get those 132 00:08:09,722 --> 00:08:13,522 muscles to relax again? By fragmented breathing, getting

them to 133 00:08:13,546 --> 00:08:15,986 pelvic floor pt. But all these things are a lot of work and effort. 134 00:08:16,018 --> 00:08:18,914 There's no really quick fix. 135 00:08:19,042 --> 00:08:22,434 Maybe pelvic floor Botox, but that's again, for another maybe discussion. 136 00:08:22,482 --> 00:08:25,714 But how do we get these muscles 137 00:08:25,762 --> 00:08:29,026 to relax? And then how do we get them to contract appropriately 138 00:08:29,058 --> 00:08:32,974 and have a good range of motion? And I think it's a 139 00:08:32,982 --> 00:08:36,222 lot of work for women to do. Right. Is. Yeah. And I 140 00:08:36,246 --> 00:08:39,774 think, you know, everyone wants a quick fix or just give me a quick pill 141 00:08:39,822 --> 00:08:42,942 and it will take care of it. But many times by the time 142 00:08:42,966 --> 00:08:46,702 we see women, they've had not just days or weeks of 143 00:08:46,726 --> 00:08:50,302 pain, they've had years of pain. So it's such 144 00:08:50,326 --> 00:08:53,726 a great analogy. The neck pain and the shoulders coming up to protect it. 145 00:08:53,798 --> 00:08:56,590 Well, if those shoulders have been up for years, they're not just going to drop 146 00:08:56,670 --> 00:09:00,746 in a day or two. It's going to take a lot of work. And partnering 147 00:09:00,778 --> 00:09:04,074 with your patient and getting her to understand this is a journey, and I'm going 148 00:09:04,082 --> 00:09:06,506 to take it with you. And it's not going to be a short journey, 149 00:09:06,538 --> 00:09:09,914 but that's okay. I think even just letting them know that they have a partner 150 00:09:09,962 --> 00:09:12,682 on that journey is reassuring. Oh, my gosh. 151 00:09:12,746 --> 00:09:16,634 100%. I think these days, I think medicine is a 152 00:09:16,642 --> 00:09:20,170 little bit failing women, and they feel like they don't have 153 00:09:20,210 --> 00:09:23,114 a good partner. Right. They need to have that, like, provider that's going to, 154 00:09:23,122 --> 00:09:27,246 like, continue to follow them and help them through this journey. So I appreciate 155 00:09:27,278 --> 00:09:29,902 you saying that. I think that's a huge. A huge thing for women to feel 156 00:09:29,926 --> 00:09:33,550 like, you know what, Someone's listening, someone's validating my concerns, and someone 157 00:09:33,590 --> 00:09:37,246 is helping me on this journey. And I think as urogynecologists, 158 00:09:37,278 --> 00:09:40,702 we. We know that really well because we're all about quality of life. 159 00:09:40,806 --> 00:09:44,830 I find that a lot of women are getting gaslit in 160 00:09:44,870 --> 00:09:48,462 various different ways these days, and it's nice to have 161 00:09:48,486 --> 00:09:52,206 a doctor in your corner. So it is. And that's something I 162 00:09:52,278 --> 00:09:55,182 tend to say at the end of a visit. You know, 163 00:09:55,286 --> 00:09:58,338 this is the next step we're going to take. And there might be a lot 164 00:09:58,454 --> 00:10:02,186 steps, but we're in it together. And it's just really, 165 00:10:02,258 --> 00:10:05,850 really reassuring. And you can just see their faces relax and, 166 00:10:05,890 --> 00:10:09,082 like. And then they become much more open to the fact that 167 00:10:09,106 --> 00:10:12,122 it is a journey. And it's okay that it takes a long time or it 168 00:10:12,146 --> 00:10:15,402 may take many interventions to get them to where they 169 00:10:15,426 --> 00:10:18,186 want to be because they know you're not going to leave them along the way. 170 00:10:18,338 --> 00:10:21,578 Yeah, 100% right. Yeah. 171 00:10:21,674 --> 00:10:25,194 So, of course, it's not just the pelvic floor, but the pelvic floor works in 172 00:10:25,202 --> 00:10:28,762 our body, where we have hormones and blood flow and nerves, and it's a 173 00:10:28,786 --> 00:10:32,390 whole complex. And certainly not every patient 174 00:10:32,470 --> 00:10:35,734 needs to be have each of those pieces of the network 175 00:10:35,822 --> 00:10:39,110 addressed. But we know that hormones are a huge part 176 00:10:39,150 --> 00:10:42,582 of that network. So let's talk a little bit about hormones or 177 00:10:42,606 --> 00:10:45,142 testosterone specifically, because hormones is way too general. 178 00:10:45,246 --> 00:10:49,254 Testosterone specifically affects sexual function 179 00:10:49,302 --> 00:10:52,742 and the pelvic floor. Yeah. Oh, my gosh. This topic I think 180 00:10:52,766 --> 00:10:56,432 we could focus on for forever. But a 181 00:10:56,456 --> 00:11:00,016 few just to set the stage about testosterone, because I think there's 182 00:11:00,048 --> 00:11:03,760 so much misperception about it. I think 183 00:11:03,880 --> 00:11:07,568 people are fearful, even men sometimes are fearful of testosterone. They think it's 184 00:11:07,584 --> 00:11:10,192 like, you know, only for bodybuilders, 185 00:11:10,256 --> 00:11:13,900 or there's this negative connotation with it. 186 00:11:14,600 --> 00:11:18,000 It's a controlled medication. So there's this fear of, like, 187 00:11:18,040 --> 00:11:21,360 why is it controlled? It must be dangerous. Somehow we have 188 00:11:21,400 --> 00:11:25,014 made men and women afraid of something their body naturally makes. 189 00:11:25,152 --> 00:11:28,026 Which is, like, what, you know, we're all born with. 190 00:11:28,178 --> 00:11:31,786 Right. And the crazy thing that I actually didn't 191 00:11:31,818 --> 00:11:35,674 even learn until a few years ago with when talking with other urologists 192 00:11:35,722 --> 00:11:39,130 who deal with testosterone all the time is women have more 193 00:11:39,170 --> 00:11:42,938 testosterone than estrogen. And it's like, like, literally my 194 00:11:42,994 --> 00:11:46,234 mind wanted to just explode. I was like, 195 00:11:46,322 --> 00:11:49,754 what do you mean? Like, I was never taught that. That's like a foreign concept 196 00:11:49,802 --> 00:11:53,588 to me. And I think what's

confusing for 197 00:11:53,644 --> 00:11:56,692 practitioners as well is testosterone. 198 00:11:56,756 --> 00:12:00,660 The units that are given back on a lab report are 199 00:12:00,700 --> 00:12:04,052 in not the same units as estrogen. So if you just look at 200 00:12:04,076 --> 00:12:07,684 the numbers, it looks like testosterone is lower. But then if you convert 201 00:12:07,732 --> 00:12:11,780 the units, it's like, oh, my gosh. No, it's actually like by tenfold, 202 00:12:11,860 --> 00:12:16,324 100 fold different. So it makes testosterone actually our more dominant 203 00:12:16,372 --> 00:12:20,130 hormone throughout our lifespan. Men have 10 times 204 00:12:20,170 --> 00:12:23,186 more than we do. So it's kind of like, okay, no, it's a male hormone, 205 00:12:23,218 --> 00:12:26,882 but really, no, it's a human hormone, and we have it, 206 00:12:26,906 --> 00:12:30,354 too. I sometimes tell my patients, like, estrogen is also a male 207 00:12:30,402 --> 00:12:33,714 hormone, meaning men have more estrogen than women 208 00:12:33,802 --> 00:12:37,330 after menopause, when women make zero almost. So it just 209 00:12:37,370 --> 00:12:40,178 kind of helps them realize that these are all human hormones. 210 00:12:40,274 --> 00:12:43,870 And they're not just for one gender or another. So to your question, 211 00:12:44,170 --> 00:12:47,650 testosterone receptors are all throughout the pelvis. So just like 212 00:12:47,690 --> 00:12:52,310 in men, the pelvic floor, the genitals are very androgen sensitive. 213 00:12:52,970 --> 00:12:56,994 In fact, the area of really heightened androgen 214 00:12:57,042 --> 00:13:00,866 receptors is right around the opening of the vagina called the vulvar vestibule, 215 00:13:00,898 --> 00:13:04,770 which another just kind of weird, interesting thing is 216 00:13:04,890 --> 00:13:08,034 that is the same as the male urethra. So if 217 00:13:08,042 --> 00:13:12,122 you look at embryology, which again, is like so crazy how 218 00:13:12,146 --> 00:13:16,266 our genitals are all sort of the same, just look differently, a little bit rearranged, 219 00:13:16,298 --> 00:13:20,202 but they're all the same tissue. It's the 220 00:13:20,226 --> 00:13:23,850 same tissue. So it's very, very androgen sensitive 221 00:13:23,930 --> 00:13:27,306 right around the opening of the vagina. Which is why we know 222 00:13:27,458 --> 00:13:30,602 that women that have taken oral birth control pills or 223 00:13:30,626 --> 00:13:34,282 oral hormones for pregnancy prevention a lot of times have 224 00:13:34,306 --> 00:13:36,986 a high risk factor having pain right around the vestibule, 225 00:13:37,018 --> 00:13:40,512 because birth control pills lower 226 00:13:40,576 --> 00:13:44,080 testosterone by a complex mechanism. So it makes sense because again, 227 00:13:44,120 --> 00:13:47,392 that's like starving the tissue of the hormone it needs. 228 00:13:47,576 --> 00:13:51,024 So women, again, will need either 229 00:13:51,072 --> 00:13:53,780 topical or full body replacement to help heal that tissue. 230 00:13:55,080 --> 00:13:58,704 There's also testosterone receptors in the vagina. There's testosterone receptors in 231 00:13:58,712 --> 00:14:02,064 the clitoris. Again, we could talk forever about the clitoris too. 232 00:14:02,232 --> 00:14:05,914 But again, these areas are very hormone responsive. 233 00:14:05,962 --> 00:14:09,882 Testosterone and estrogen is all 234 00:14:09,906 --> 00:14:13,898 over the pelvic floor in the genitals. So when 235 00:14:13,954 --> 00:14:17,962 women and men age in the late 20s, 236 00:14:18,026 --> 00:14:22,010 even testosterone starts dropping off and it just 237 00:14:22,050 --> 00:14:25,610 continues to decline. Takes a pretty big hit in the 30s, 238 00:14:25,690 --> 00:14:29,434 too. And that's when libido starts declining 239 00:14:29,482 --> 00:14:32,754 a little bit. But it's not until most women hit menopause 240 00:14:32,802 --> 00:14:36,114 that things get really wonky. And then we have this intersection of, like, 241 00:14:36,282 --> 00:14:39,842 both hormones declining at the same time that it's just like, 242 00:14:40,026 --> 00:14:44,002 you know, a crazy hit to usually for women and libido and 243 00:14:44,106 --> 00:14:47,586 other changes that are happening to their body. And that's generally when women 244 00:14:47,658 --> 00:14:51,538 come in seeking treatment for low libido arousal, 245 00:14:51,714 --> 00:14:55,410 orgasm concerns, because again, they're just not getting 246 00:14:55,450 --> 00:14:58,946 the hormones that their body is naturally making anymore 247 00:14:58,978 --> 00:15:02,054 to support their genitals and their brain, meaning, 248 00:15:02,102 --> 00:15:05,766 you know, how we feel. You know, libido is a thought, you know, 249 00:15:05,838 --> 00:15:09,126 more than a genital tissue issue. 250 00:15:09,198 --> 00:15:12,614 So hopefully that puts it a little bit in perspective. 251 00:15:12,662 --> 00:15:15,610 Certainly it's all about blood flow and supporting the tissue, 252 00:15:16,270 --> 00:15:19,750 the nerves, et cetera, just to make sure everything is functioning properly. 253 00:15:19,910 --> 00:15:23,366 Oh, yeah. Oh, my gosh, that's so much to unpack. And that's something, 254 00:15:23,518 --> 00:15:26,662 you know, imagine trying to go through all of that with your patient 255 00:15:26,726 --> 00:15:30,546 in a very short visit. You're never going to hit all that. But your first 256 00:15:30,618 --> 00:15:34,690 point, that both testosterone and estrogen are human hormones and they are 257 00:15:34,730 --> 00:15:38,290 not gender specific is so critical. And I think that 258 00:15:38,330 --> 00:15:41,730 message is trying to get out there. But I 259 00:15:41,770 --> 00:15:45,490 agree. I think until you start to really take extra 260 00:15:45,570 --> 00:15:49,218 time outside of traditional medical training and study this field, 261 00:15:49,354 --> 00:15:53,186 you don't see those

differences where women's Testosterone 262 00:15:53,218 --> 00:15:56,578 levels are 100 times higher than estrogen at any given day 263 00:15:56,634 --> 00:16:00,274 in their life. And imagine if we took this hormone 264 00:16:00,322 --> 00:16:03,842 that is present throughout our entire adult life and start, you know, 265 00:16:03,866 --> 00:16:06,914 taking it away. When you look at the receptors from head to toe, 266 00:16:06,962 --> 00:16:10,630 that means women are going to feel changes from head to toe. 267 00:16:12,970 --> 00:16:16,802 And then the second thing I think that you said is that declining testosterone that 268 00:16:16,826 --> 00:16:20,210 even starts before menopause in again, both men and 269 00:16:20,250 --> 00:16:23,746 women. One of my favorite things to say is a lot of the symptoms 270 00:16:23,778 --> 00:16:27,800 that people attribute to aging are 271 00:16:27,840 --> 00:16:31,128 really waning hormone symptoms. Oh, 100%. 272 00:16:31,184 --> 00:16:34,456 Like the Menno belly. Like, all the changes, the shifting. And, 273 00:16:34,528 --> 00:16:37,656 you know, women are constantly telling me, like, I'm crashing at the gym. 274 00:16:37,688 --> 00:16:41,096 I'm like, weight training like crazy. I'm like, why can't 275 00:16:41,128 --> 00:16:44,184 I keep muscle in my body? Why do I keep getting more fat in the 276 00:16:44,192 --> 00:16:48,072 midsection? And it's just like, you know, again, we have this, like, collision of, 277 00:16:48,096 --> 00:16:51,192 like, lowering testosterone and then also the, 278 00:16:51,296 --> 00:16:54,888 you know, terrible sleep with perimenopause symptoms and all these things, right? And it's 279 00:16:54,904 --> 00:16:58,536 just this, like, really nasty, like, switch cheese. 280 00:16:58,568 --> 00:17:02,060 All the holes are just lining up perfectly where it's just like women are feeling 281 00:17:02,560 --> 00:17:05,608 miserable. And it's from, you know, 282 00:17:05,664 --> 00:17:08,740 it's from hormonal causes, right? 283 00:17:09,200 --> 00:17:13,352 We can help with, you know, if they're open to consideration. 284 00:17:13,416 --> 00:17:16,376 I think that's the. I think that's the biggest leap, right? 285 00:17:16,448 --> 00:17:20,246 It's like, what are women afraid of? How do we address their fears so that 286 00:17:20,408 --> 00:17:23,610 we can get them the help they want? Because I have so many patients coming 287 00:17:23,650 --> 00:17:27,130 in seeking treatment, but they're afraid. 288 00:17:27,210 --> 00:17:30,698 You know, they're like, they've been told hormones are scary. You know, there's still this 289 00:17:30,754 --> 00:17:33,930 prevalent fear of hormones. And it's just really, again, I feel 290 00:17:33,970 --> 00:17:37,226 shameful that we've made women afraid of something their body naturally produces. 291 00:17:37,258 --> 00:17:41,002 It's like, you know, we're not afraid of giving back thyroid hormone. 292 00:17:41,066 --> 00:17:44,650 It's a human hormone. We're going to give it back to women and 293 00:17:44,690 --> 00:17:48,002 men forever. Because again, like, if they're low in 294 00:17:48,026 --> 00:17:51,858 thyroid, we're going to give them back what their body's making to support their body. 295 00:17:51,994 --> 00:17:55,250 But for some reason when we talk about sex hormones, it's like, 296 00:17:55,370 --> 00:17:58,946 well, no, we can't do that. That's like, you know, kind of crazy 297 00:17:58,978 --> 00:18:02,690 and dangerous. And again, we've made people afraid of their own biology. And it's, 298 00:18:02,850 --> 00:18:06,830 it literally blows my mind every time I think about it, how we 299 00:18:07,610 --> 00:18:12,034 just treated this biologic 300 00:18:12,082 --> 00:18:15,410 function. No, I agree. And it, I love that 301 00:18:15,450 --> 00:18:18,674 thyroid analogy as well. I use that a lot, 302 00:18:18,762 --> 00:18:22,194 that if you had a thyroidectomy, you would be getting thyroid replacement in 303 00:18:22,202 --> 00:18:25,586 the post op recovery. We would say, we don't want you to be without thyroid 304 00:18:25,618 --> 00:18:29,330 hormone for one moment. Or if you look at the flip side of that 305 00:18:29,370 --> 00:18:33,266 coin, you could live without your thyroid and without those attendant thyroid 306 00:18:33,298 --> 00:18:37,122 hormones, but you would have a horrible quality and 307 00:18:37,146 --> 00:18:41,012 in shortened lifespan due to the lack of that critical 308 00:18:41,076 --> 00:18:44,884 hormone. And yet we let the entire population live horrible 309 00:18:44,932 --> 00:18:48,212 lives and lifespans because of the lack of their normal 310 00:18:48,276 --> 00:18:52,932 hormones. And Kristen, I don't know what it is. I've been, I obviously 311 00:18:53,076 --> 00:18:56,644 been thinking a lot about this lately. What is it 312 00:18:56,652 --> 00:18:59,860 with women and suffering? I feel like again, society is just 313 00:18:59,900 --> 00:19:02,760 like, we love women to suffer. 314 00:19:03,260 --> 00:19:06,212 Suffering is supposed to be just a part of the life. It's like pain with 315 00:19:06,236 --> 00:19:10,238 periods, heavy periods, you know, pain, pain, pain. And then with procedures 316 00:19:10,334 --> 00:19:13,758 like again, we've traditionally not given women 317 00:19:13,814 --> 00:19:16,878 adequate anesthesia and pain control during procedures. 318 00:19:16,974 --> 00:19:20,398 And then it's like menopause, it's like, nope, like, let's just suffer. So I don't 319 00:19:20,414 --> 00:19:24,142 know what this, you know, we need to change as a society this idea that 320 00:19:24,166 --> 00:19:27,326 women are supposed to suffer. And then again, also, 321 00:19:27,398 --> 00:19:30,686 like, how much suffering does a woman need to have 322 00:19:30,758 --> 00:19:34,192 until she can have a treatment? And again, I've, 323 00:19:34,326 --> 00:19:38,460 this has just recently clicked for me because I now have urology partners 324

00:19:38,540 --> 00:19:41,960 in my practice. And you know, 325 00:19:42,820 --> 00:19:46,268 a man comes in for a kidney stone, they ask 326 00:19:46,324 --> 00:19:50,040 about the kidney stone and they're like, well, how are your erections? How's sex? 327 00:19:51,780 --> 00:19:54,956 Like, they're not even coming in for these questions, these things. 328 00:19:55,028 --> 00:19:58,412 And they're like, you know, validating anything that 329 00:19:58,436 --> 00:20:01,926 could potentially happen to a man in the sexual realm. And we, 330 00:20:02,078 --> 00:20:06,070 you know, hardly ever talk to women about their sexual function or 331 00:20:06,110 --> 00:20:09,410 ask about it. And then if it comes up, you know, 332 00:20:09,790 --> 00:20:13,606 we usually, and I'm just generalizing here, dismiss it 333 00:20:13,678 --> 00:20:16,770 or under treat it. So I think again, 334 00:20:17,390 --> 00:20:21,462 in medicine, I'm actually giving another talk to my medical school later today where 335 00:20:21,486 --> 00:20:24,038 I'm going to talk about all these things. I mean, we need to change it 336 00:20:24,094 --> 00:20:28,000 from the ground level, from the medical school school, and stop 337 00:20:28,860 --> 00:20:33,524 being okay with just women suffering. Like, let's validate 338 00:20:33,572 --> 00:20:37,092 their symptoms. Let's offer treatments that are effective and 339 00:20:37,116 --> 00:20:40,372 also not just effective for their quality, but also, like, improve their 340 00:20:40,396 --> 00:20:43,652 quality of life, reduce their need of, you know, 341 00:20:43,836 --> 00:20:47,972 cardiac stents and other treatments for dementia and osteoporosis, 342 00:20:48,036 --> 00:20:52,302 fractures. Like all the things that we could actually help 343 00:20:52,406 --> 00:20:56,206 them prevent if we were considering menopause hormone 344 00:20:56,238 --> 00:20:58,890 therapy. So I think we're just really missing the ball. 345 00:20:59,910 --> 00:21:03,230 Yeah, I, Oh, I couldn't agree more. 346 00:21:03,270 --> 00:21:06,670 I think that's so prevalent in all fields of medicine where 347 00:21:06,710 --> 00:21:11,022 if a man presents with a pain symptom, it's immediately 348 00:21:11,086 --> 00:21:14,654 validated. Okay, you have pain, let's take the next step to treat that pain. 349 00:21:14,782 --> 00:21:18,030 And women get asked questions, well, how bad is it and 350 00:21:18,070 --> 00:21:21,314 are you able to work and is it disrupting your life? 351 00:21:21,462 --> 00:21:24,790 Well, she's in the doctor's office, so it must be doing something. 352 00:21:25,490 --> 00:21:28,650 It's clinically relevant. She's here. She made the appointment. 353 00:21:28,730 --> 00:21:31,994 That's right. She's here to talk about it. And she doesn't want to just discuss 354 00:21:32,082 --> 00:21:35,754 her pain. She wants to resolve her pain. She wants treatment 355 00:21:35,802 --> 00:21:39,226 options, please. Yes, she wants to get rid of her pain, get

to the source 356 00:21:39,258 --> 00:21:43,034 of it and improve her life and then the sexual 357 00:21:43,082 --> 00:21:47,018 function as well. I actually accompanied a family 358 00:21:47,074 --> 00:21:51,428 member to a urology appointment, again talking about prostate, 359 00:21:51,524 --> 00:21:55,172 where the male patient was steered away from surgery. They said, 360 00:21:55,196 --> 00:22:00,132 no, you don't want to consider surgery because it might decrease your erections immediately. 361 00:22:00,276 --> 00:22:03,732 Sexual function was the first thing. Number one, you don't want this because it could 362 00:22:03,756 --> 00:22:07,012 negatively affect your sexual function. And I thought, when have 363 00:22:07,036 --> 00:22:10,052 we ever talked to a woman and said, hey, we're going to give you this 364 00:22:10,076 --> 00:22:13,380 antidepressant, but it might kill your libido. Do they ever 365 00:22:13,420 --> 00:22:17,156 even hear that, oh, Kristen. Or, or they're 366 00:22:17,188 --> 00:22:20,720 coming in for menopause symptoms and they get an antidepressant because, 367 00:22:22,380 --> 00:22:25,988 like, yes, there it is, an FDA approved 368 00:22:26,164 --> 00:22:29,780 therapy. But it shouldn't be the first thing that we reach for. It's just, 369 00:22:29,820 --> 00:22:33,124 to me, that just tells women you're crazy and we're going to 370 00:22:33,132 --> 00:22:36,580 give you the crazy medicine. And I'm sorry that you're now 371 00:22:36,620 --> 00:22:40,166 in the crazy zone. It just, it really frustrates me because again, 372 00:22:40,308 --> 00:22:44,082 this is just biology. It's just we need to support or at least offer and 373 00:22:44,106 --> 00:22:48,098 consider hormones as first line, not as the 374 00:22:48,154 --> 00:22:51,634 last possible option. Right. And I 375 00:22:51,642 --> 00:22:54,770 think it's the same fear of those hormones. I always 376 00:22:54,810 --> 00:22:58,690 think it's kind of hysterical when people are fearful of hormones. They'll say, 377 00:22:58,730 --> 00:23:02,194 well, don't take too much because it might cause 378 00:23:02,242 --> 00:23:05,330 cancer or it might cause stroke. And my feeling is, 379 00:23:05,370 --> 00:23:08,582 wait a minute, you think something causes cancer? So instead of 380 00:23:08,606 --> 00:23:11,942 giving them a lot, you'll just give them a little of something that causes 381 00:23:12,006 --> 00:23:15,494 cancer. Like, I'm sorry, do we give them a little arsenic or. 382 00:23:15,582 --> 00:23:19,286 No, none at all. If something is harmful, we shouldn't 383 00:23:19,318 --> 00:23:22,822 give it at all, but is not harmful, then we 384 00:23:22,846 --> 00:23:26,022 should use it properly. Absolutely. But that's kind 385 00:23:26,046 --> 00:23:29,382 of that underlying message that you get. Just use 386 00:23:29,406 --> 00:23:32,806 a little. Because I don't want to increase your cancer risk a lot. 387 00:23:32,878 --> 00:23:35,930 I just want to. I just want to get you out of my office by 388 00:23:35,970 --> 00:23:40,202 having you stop complaining about what you're talking about. No, totally. Or the corollary 389 00:23:40,266 --> 00:23:42,442 is like, well, we might give it to you for. In a little bit, 390 00:23:42,466 --> 00:23:45,642 and then we're going to take it away, even if it works really well in 391 00:23:45,666 --> 00:23:49,402 a few years, because we don't want to. It's like, 392 00:23:49,586 --> 00:23:53,034 so that at least some of those changes have fallen by the 393 00:23:53,042 --> 00:23:56,266 wayside. I think the menopause society now has some pretty 394 00:23:56,298 --> 00:23:59,994 strong statements about no need to discontinue hormone 395 00:24:00,042 --> 00:24:03,674 therapy now after a certain age. Again, this was like, all arbitrary 396 00:24:03,722 --> 00:24:07,286 anyway, so at least there's been some headway. But, man, 397 00:24:07,438 --> 00:24:09,250 and I'm sure you were there too, 398 00:24:09,870 --> 00:24:13,462 when this Women's Health Initiative study came 399 00:24:13,486 --> 00:24:17,158 out in the early 2000s, and it was just like a terrifying time for women 400 00:24:17,294 --> 00:24:20,950 and providers. It was like, what's going on? And so many 401 00:24:20,990 --> 00:24:24,182 women were taken off of their hormone therapy because 402 00:24:24,206 --> 00:24:28,086 of a study that, of course now we all know has been debunked, 403 00:24:28,118 --> 00:24:31,884 but it was still wreaking havoc. And still, I think that prevalent fear 404 00:24:31,932 --> 00:24:35,400 of hormones, that's still there, sort of like mesh, you know, 405 00:24:36,180 --> 00:24:39,100 that's like, oh, there's a. It's a fear. And then we have to, like, 406 00:24:39,140 --> 00:24:42,332 talk through all the nuanced nuances of 407 00:24:42,356 --> 00:24:46,316 that. So hard. It's hard in society to take a thought 408 00:24:46,388 --> 00:24:49,532 out of collective consciousness once 409 00:24:49,556 --> 00:24:53,324 it's there. Right. It's true, but. And I. 410 00:24:53,412 --> 00:24:56,812 I think some of it will be newer generations 411 00:24:56,876 --> 00:25:00,718 of women who are not going to be accepting they're. 412 00:25:00,734 --> 00:25:04,782 Not going to suffer. Right. Of the suffering that their generations in 413 00:25:04,806 --> 00:25:08,174 front of them did. So, you know, our grandmothers and mothers suffered 414 00:25:08,222 --> 00:25:11,710 quite a bit. And I think our generation is starting to Say, wait, 415 00:25:11,790 --> 00:25:15,294 do we have to deal with this and feel horrible all the time? No, 416 00:25:15,382 --> 00:25:18,622 but I feel like the generations behind us are going to be like, no way. 417 00:25:18,726 --> 00:25:22,366 I'm going to demand the proper care. And I'm so glad that 418 00:25:22,438 --> 00:25:26,282 menopause certified providers are there and hopefully continuing to 419 00:25:26,306 --> 00:25:30,042 grow and get this message out and

hopefully to younger patients so that 420 00:25:30,066 --> 00:25:33,690 they will know as they approach their 30s, 40s and beyond 421 00:25:33,850 --> 00:25:36,778 this is not the way life needs to be. And you can make it better 422 00:25:36,834 --> 00:25:40,362 with something very natural. Yes. And very safe. The most 423 00:25:40,386 --> 00:25:44,714 natural. Yes. The most natural, exactly. Yes. Which identical. 424 00:25:44,842 --> 00:25:48,362 The most natural. Yes. Right. But I mean, then we of 425 00:25:48,386 --> 00:25:51,866 course do need more research and data on it. Oh, for sure. 426 00:25:52,018 --> 00:25:55,578 Give patients actual information and evidence based 427 00:25:55,634 --> 00:25:59,002 information. I mean, I know that you and I use these medications all the 428 00:25:59,026 --> 00:26:02,842 time and we know there is a huge volume of information we can give 429 00:26:02,866 --> 00:26:05,690 to patients, but there's still a lot lacking yo. 430 00:26:05,770 --> 00:26:08,874 100%. 100%. I agree. So when 431 00:26:08,882 --> 00:26:12,698 you're approaching testosterone treatment with the patient, how do you 432 00:26:12,754 --> 00:26:15,674 talk to her about the safety and the benefits? 433 00:26:15,802 --> 00:26:19,402 Yeah, that's a great question, certainly. Right. I want to. 434 00:26:19,426 --> 00:26:22,682 The first thing I want to tell her is I don't want to get 435 00:26:22,706 --> 00:26:26,634 you in the male zone. Right. We're using, I want to use testosterone to 436 00:26:26,642 --> 00:26:29,962 keep you in the female physiologic zone. When you were like, 437 00:26:30,066 --> 00:26:33,722 you know, early 30s, feeling wonderfully vibrant, 438 00:26:33,786 --> 00:26:37,162 had a lot of energy, had great libido, it was easy to 439 00:26:37,186 --> 00:26:41,658 work out, you felt strong, all those things that you were feeling right earlier 440 00:26:41,714 --> 00:26:45,290 in your life, that's where I want to get you back. So I do 441 00:26:45,410 --> 00:26:48,550 follow the clinical practice guidelines from ISSWISH about 442 00:26:49,010 --> 00:26:52,272 checking a baseline testosterone level and 443 00:26:52,296 --> 00:26:55,904 I check a total testosterone, I check a sex hormone binding globulin and 444 00:26:55,912 --> 00:26:59,728 I calculate the free androgen index just to like give me a starting place 445 00:26:59,864 --> 00:27:03,536 to make sure we know that we're treating women 446 00:27:03,608 --> 00:27:07,088 actually has low testosterone and have a baseline. 447 00:27:07,264 --> 00:27:10,272 And then of course I follow those levels usually like six to eight weeks later, 448 00:27:10,296 --> 00:27:13,584 just to make sure, again, we're keeping her in the female physiologic 449 00:27:13,632 --> 00:27:16,720 range. So I explained this to her. 450 00:27:16,760 --> 00:27:19,552 So she, I think women want to know, like, I'm not going to turn into 451 00:27:19,576 --> 00:27:22,688 a man. Right. I'm not going to like

start having a ton of facial hair 452 00:27:22,704 --> 00:27:25,100 and changes and like, you know, 453 00:27:25,480 --> 00:27:29,312 none of that. Right. So we talk over that. I do let them know 454 00:27:29,336 --> 00:27:32,976 though, for women that are starting on testosterone, it is really 455 00:27:33,048 --> 00:27:37,440 common to start getting a little bit oilier skin and 456 00:27:37,480 --> 00:27:41,120 Potentially a pimple or two. Right. And when they're starting because again, 457 00:27:41,240 --> 00:27:44,848 their body has been depleted of these hormones and it's 458 00:27:44,864 --> 00:27:47,440 like the body's a little bit waking up and it's like, oh, I'm doing that 459 00:27:47,480 --> 00:27:50,602 again. It's like oil production and like a little bit 460 00:27:50,626 --> 00:27:54,282 of clogged pores and I just let them know, like it's okay if it 461 00:27:54,306 --> 00:27:58,630 happens. Generally that goes away. Your receptors are just kind of waking up and 462 00:27:59,010 --> 00:28:03,034 usually that settles once we get you kind of receptors saturated, 463 00:28:03,082 --> 00:28:06,506 etc. Women, I think are always concerned 464 00:28:06,538 --> 00:28:10,138 about their hair. You know, like, oh my gosh, please, I can't have any hair 465 00:28:10,154 --> 00:28:14,330 loss. Because again, generally in this time frame women might be having been 466 00:28:14,370 --> 00:28:18,028 huge swings in estrogen and having hair loss. So we talk through that 467 00:28:18,084 --> 00:28:20,892 and generally what I say is, as long as we're keeping you again in the 468 00:28:20,916 --> 00:28:24,636 physiologic female range, we're not going to cause any sort of 469 00:28:24,708 --> 00:28:28,732 hair loss that's related to like again, male pattern baldness, et cetera. That's like 470 00:28:28,836 --> 00:28:32,012 again, really high levels of testosterone. But again, I always let them know, like, 471 00:28:32,036 --> 00:28:35,452 it's always a possibility, especially if you're using way too 472 00:28:35,476 --> 00:28:37,644 much, you know, that's why I want to keep you in the physiologic range. 473 00:28:37,692 --> 00:28:40,444 So if there's any concerns, I just, I do have them reach out to me. 474 00:28:40,452 --> 00:28:44,766 But in general. Right. This is a physiologic body 475 00:28:44,838 --> 00:28:48,638 identical hormone. So generally there's not any 476 00:28:48,694 --> 00:28:52,398 side effects above what I mentioned, oily skin and a pimple 477 00:28:52,414 --> 00:28:56,046 or two. Kind of like, you know, think like a corny teenager sort of 478 00:28:56,198 --> 00:28:59,950 concept. That's basically what we're starting to recreate once. 479 00:28:59,990 --> 00:29:03,438 And then again once we get saturated and it levels out to a steady state 480 00:29:03,494 --> 00:29:07,086 that those things go away in general, four months later, 481 00:29:07,158 --> 00:29:10,830 libido comes back. It does take a while though. I think that's another thing 482 00:29:10,870 --> 00:29:14,156 with testosterone is it's not like, you know, just flipping 483 00:29:14,188 --> 00:29:17,820 on a switch. It takes a little while for the receptors, 484 00:29:17,900 --> 00:29:21,132 especially in the brain, to kind of wake up and those thoughts and fantasies come 485 00:29:21,156 --> 00:29:24,268 back. So I tell them to stick with it. 486 00:29:24,324 --> 00:29:28,172 Like just stick with it. There is 487 00:29:28,196 --> 00:29:32,092 no FDA approved product for testosterone in the us. There is 488 00:29:32,116 --> 00:29:35,852 one in Australia. So again, it's not a safety issue. And in 489 00:29:35,876 --> 00:29:39,162 fact, that study I mentioned when I in my fellowship, 490 00:29:39,316 --> 00:29:43,310 we had five years of excellent safety data on women using testosterone in these 491 00:29:43,350 --> 00:29:46,610 clinical studies. And the FDA said, I'm sorry, 492 00:29:47,030 --> 00:29:51,210 I think we need five more years because we don't have Quite enough data. 493 00:29:51,830 --> 00:29:56,126 We're talking about women here. We need it to be really safe, so whatever. 494 00:29:56,238 --> 00:29:59,230 So it didn't come to market, but we had great safety data and again, 495 00:29:59,270 --> 00:30:03,290 it was very effective. We need to 496 00:30:03,910 --> 00:30:07,390 appreciate that there is not an FDA approved product for 497 00:30:07,430 --> 00:30:10,786 women, but that doesn't mean we can't use male FDA approved 498 00:30:10,818 --> 00:30:14,322 products. So in my practice we use a male 499 00:30:14,386 --> 00:30:16,930 FDA approved product, we just dose it for a female. 500 00:30:17,010 --> 00:30:20,162 So we use generic testosterone, 501 00:30:20,226 --> 00:30:23,650 1% in the, in the tubes and have a woman 502 00:30:23,690 --> 00:30:27,586 use a tenth of the amount a man would use the whole entire tube 503 00:30:27,618 --> 00:30:31,122 per day. Sometimes a little tricky to dose that out. So we 504 00:30:31,146 --> 00:30:34,610 have them use a 5ml syringe if it's, you know, very tricky. And again, 505 00:30:34,650 --> 00:30:37,760 this is like a topical gel, not an injection. 506 00:30:39,060 --> 00:30:42,252 And most women do great with that. And again, 507 00:30:42,356 --> 00:30:45,772 the nice thing is it's also very inexpensive to get 508 00:30:45,956 --> 00:30:49,532 testosterone gel generic. So that's also a 509 00:30:49,556 --> 00:30:52,684 nice benefit. But then of course there's compounded creams, 510 00:30:52,732 --> 00:30:56,316 right. If there's no FDA approved product for women, this is where compounding 511 00:30:56,348 --> 00:30:59,676 is also a nice way to do it. So compounded 512 00:30:59,708 --> 00:31:03,088 creams, again, still important 513 00:31:03,144 --> 00:31:07,152 to follow the blood levels to make sure again, they're staying in the right and 514 00:31:07,176 --> 00:31:10,352 the right zone. You know, I'm not 515 00:31:10,376 --> 00:31:13,568 a huge fan of pellets,

but pellets are another option. Again, 516 00:31:13,624 --> 00:31:16,832 I think women are so in need of just any hormones that 517 00:31:16,856 --> 00:31:21,136 they'll go anywhere they can get help. And certainly pellets are convenient 518 00:31:21,168 --> 00:31:23,740 because it's like they work for several months at a time. 519 00:31:24,680 --> 00:31:27,786 I wish they were FDA approved for women, they're approved for men. 520 00:31:27,968 --> 00:31:31,734 So I just wish that we had a little, a little. I wish we 521 00:31:31,742 --> 00:31:34,998 had a better option for women. Right now we're still kind of in between 522 00:31:35,054 --> 00:31:38,934 using a female dose, female dosing 523 00:31:38,982 --> 00:31:42,970 for an FDA approved product for men, compounding or pellets. 524 00:31:43,470 --> 00:31:47,094 Hopefully one day we'll get somewhere. 525 00:31:47,222 --> 00:31:50,470 Yeah, I definitely hope so. For sure. And it's, 526 00:31:50,630 --> 00:31:53,920 I think one thing that a lot of people may not know is 527 00:31:54,070 --> 00:31:57,160 you can't patent a natural product. 528 00:31:57,460 --> 00:32:01,676 So body identical testosterone, body identical estrogen. No pharmaceutical 529 00:32:01,708 --> 00:32:04,908 company can own the patent for those because it's already in 530 00:32:04,964 --> 00:32:08,908 nature. And in order to own a patent, they have to change 531 00:32:08,964 --> 00:32:12,700 it or make it unique. But what the lesson has 532 00:32:12,740 --> 00:32:16,844 taught us from whi and on is when we start changing hormones, 533 00:32:16,972 --> 00:32:20,618 they do some of the things that the body hormone does, 534 00:32:20,674 --> 00:32:24,298 but then we get potentially things we don't want or things 535 00:32:24,354 --> 00:32:28,298 we aren't even aware of. So that's where when we get into the synthetic version 536 00:32:28,314 --> 00:32:31,690 of hormones, we have to be cautious because those 537 00:32:31,730 --> 00:32:35,610 are not comparing apples to apples, bioidentical hormones and synthetic, 538 00:32:35,770 --> 00:32:39,162 even though there are synthetic versions of estrogen at least. 539 00:32:39,186 --> 00:32:42,250 And, you know, that women can take. And I, 540 00:32:42,290 --> 00:32:46,594 and I love that you said that. I think again, everyone lumps estrogen, 541 00:32:46,642 --> 00:32:50,642 especially, right. All in one bucket when there's synthetic 542 00:32:50,706 --> 00:32:54,082 and there's, you know, there's literally bio 543 00:32:54,146 --> 00:32:57,938 body identical hormones available and then there's, you know, 544 00:32:57,994 --> 00:33:00,994 slightly modified hormones again. And it's, 545 00:33:01,042 --> 00:33:04,338 it's very confusing for women to know what they're getting. 546 00:33:04,394 --> 00:33:07,954 It's like all estrogens aren't the same. Just like, you know, all fruits 547 00:33:08,002 --> 00:33:10,914 aren't the same. You know, there's apples and bananas and, you know, but we lump 548 00:33:10,962 --> 00:33:14,538 them all together in one bucket and they're totally not 549 00:33:14,594 --> 00:33:17,350 one thing. So, again, 550 00:33:17,730 --> 00:33:20,906 the FDA insert for vaginal estrogen, 551 00:33:20,938 --> 00:33:24,954 which is a very, very, very safe product, has a black box warning 552 00:33:25,002 --> 00:33:28,650 for, you know, when women pick it up from the pharmacy that talks all about, 553 00:33:28,770 --> 00:33:32,970 you know, cancer and dementia and stroke. And it's really 554 00:33:33,010 --> 00:33:36,250 scary. And there's never been any evidence for that. But again, it's a 555 00:33:36,290 --> 00:33:39,802 class labeling where every estrogen product got this warning put 556 00:33:39,826 --> 00:33:43,498 on it. And, and they're not all the same. And it is hard, 557 00:33:43,554 --> 00:33:47,050 though, for patients to understand all this. 558 00:33:47,090 --> 00:33:49,946 Right? It's. Right. Very difficult, challenging. 559 00:33:50,058 --> 00:33:53,322 It's a lot to sift through. And that's why we need specialists, 560 00:33:53,386 --> 00:33:56,954 because you need to keep up with all of the information on all the 561 00:33:56,962 --> 00:34:00,410 different products. I mean, even in my training, I did not. When I 562 00:34:00,450 --> 00:34:04,522 graduated medical school and started practicing, I absolutely did not know all 563 00:34:04,546 --> 00:34:07,942 these differences between the hormones. And I 564 00:34:07,966 --> 00:34:11,542 just kind of thought, hey, this is the main one we prescribe. Premarin certainly was 565 00:34:11,566 --> 00:34:14,902 very popular. There was a patch called Prempro, 566 00:34:14,966 --> 00:34:18,454 and that was more convenient. So I was thinking about convenience 567 00:34:18,502 --> 00:34:21,846 for my patient and not about the molecule I was putting 568 00:34:21,878 --> 00:34:25,414 in their body. And now, 20 years later, we know 569 00:34:25,502 --> 00:34:28,982 so much more. And that's the point. Medicine advances, science advances, 570 00:34:29,046 --> 00:34:32,374 and we know more than we did 20 years ago. Yeah. And Kristen, I think 571 00:34:32,382 --> 00:34:36,054 that's another great point you brought up is, you know, as physicians, 572 00:34:36,102 --> 00:34:39,750 we don't just stop learning after medical school or residency. You have to keep 573 00:34:39,790 --> 00:34:43,050 learning and keep being curious and keep getting extra training. 574 00:34:43,950 --> 00:34:47,718 But unfortunately, because menopause has been like, no one 575 00:34:47,774 --> 00:34:51,510 has owned this midlife health section is kind 576 00:34:51,550 --> 00:34:54,838 of very random. Who decides that 577 00:34:54,894 --> 00:34:57,958 I, you know, wants to get more information or wants to be menopause, 578 00:34:58,054 --> 00:35:01,552 certified provider, etc. There was a study that came 579 00:35:01,576 --> 00:35:05,360 out that only 7% of physicians felt comfortable 580

00:35:05,520 --> 00:35:08,976 addressing any sort of menopause midlife care for women. 581 00:35:09,128 --> 00:35:12,160 And that is really shameful when we have a population of, you know, 582 00:35:12,200 --> 00:35:16,128 50% of, you know, of our population is eventually going to get 583 00:35:16,264 --> 00:35:19,440 to menopause if they live, you know, to that age. And, 584 00:35:19,560 --> 00:35:22,300 you know, we need to, we need to again, 585 00:35:23,080 --> 00:35:26,854 reanalyze how we are treating midlife women 586 00:35:26,942 --> 00:35:30,742 and prioritize their health. Right. And I 587 00:35:30,766 --> 00:35:34,806 think that it's okay if physicians don't know how 588 00:35:34,878 --> 00:35:39,398 to practice menopause medicine. I don't know how to practice cardiology 589 00:35:39,494 --> 00:35:42,854 or neurology, and I don't think of that as shameful. 590 00:35:42,902 --> 00:35:45,958 I just tell my patients that's not my area of expertise. 591 00:35:46,054 --> 00:35:49,446 Yes, I have a little more general medical knowledge about 592 00:35:49,518 --> 00:35:53,360 those conditions than you do, but I'm going to send you to someone who has 593 00:35:53,400 --> 00:35:57,120 dedicated their life to learning about that. Exactly. So I would 594 00:35:57,160 --> 00:36:01,184 just hope, kind of the same respect from our colleagues. 595 00:36:01,312 --> 00:36:05,136 If a menopausal woman says, hey, I'm suffering and I'm having all of these symptoms 596 00:36:05,168 --> 00:36:08,864 that we know are so related to menopausal transition, for that 597 00:36:08,952 --> 00:36:12,512 physician to say, you know, this is outside my area of expertise, I'm not 598 00:36:12,536 --> 00:36:16,160 going to weigh in on the benefit or risk of hormones because 599 00:36:16,280 --> 00:36:20,048 I don't have the knowledge. That's a much more fair statement than just 600 00:36:20,104 --> 00:36:23,680 saying, maybe you shouldn't take them. They might be risky. I'm not 601 00:36:23,720 --> 00:36:27,620 sure. Well, if you're not sure, get them to someone who is very confident. 602 00:36:28,120 --> 00:36:31,872 Because planting that little seed, even with the 603 00:36:31,896 --> 00:36:36,016 word might, is like, for a woman, like, nope, it's dangerous. 604 00:36:36,128 --> 00:36:39,312 Right. And I say this often when 605 00:36:39,336 --> 00:36:42,896 I'm teaching is the things that physicians say to patients are really 606 00:36:42,968 --> 00:36:46,630 important. They will hang on to your words forever. 607 00:36:47,130 --> 00:36:51,282 So make sure what you are saying is founded in evidence and, 608 00:36:51,386 --> 00:36:55,698 you know, not like these mights and maybes. And especially 609 00:36:55,754 --> 00:36:59,390 again, when it's not your area of expertise, just like you said. 610 00:37:00,410 --> 00:37:03,826 I think also medicine, we could use a little humility, like we don't know everything, 611 00:37:03,898 --> 00:37:07,730 and that's okay. But each

provider has dedicated their 612 00:37:07,770 --> 00:37:10,962 life or their career to treating this X, Y and Z. And let's get 613 00:37:10,986 --> 00:37:15,040 you there so you get the best care you can get. 614 00:37:15,740 --> 00:37:19,540 I totally agree with you. That's such a great message for young training 615 00:37:19,620 --> 00:37:22,996 physicians or new physicians, because I'm sure we've 616 00:37:23,028 --> 00:37:26,436 both heard patients come in and tell me almost word 617 00:37:26,468 --> 00:37:29,940 for word, will my other doctor Said. And then they give me 618 00:37:29,980 --> 00:37:33,480 an entire monologue, and I'll think, oh, my gosh, 619 00:37:34,460 --> 00:37:37,892 just like you said, these patients are listening. They are hearing 620 00:37:37,956 --> 00:37:41,520 your tone. Even if it's not the words you say, 621 00:37:41,560 --> 00:37:44,912 it's how you say it. If you have a big hesitance, 622 00:37:45,056 --> 00:37:48,340 hesitancy, and you take a big pause or a big sigh, 623 00:37:48,680 --> 00:37:52,320 well, you can use them. I'm not 624 00:37:52,360 --> 00:37:55,360 saying you can use them, but, I mean, my goodness. Right, 625 00:37:55,400 --> 00:37:58,688 right. All of that body language. And it's important as 626 00:37:58,744 --> 00:38:01,952 physicians to understand that how we interact with our patients. 627 00:38:02,016 --> 00:38:05,312 Words, body language, tone. Yep. All a part 628 00:38:05,336 --> 00:38:07,907 of the care that matters. 100%. 629 00:38:08,122 --> 00:38:11,766 100%. Yeah. So. So let's. We talked 630 00:38:11,798 --> 00:38:15,174 about, obviously, if patients have issues with the pelvic floor too loose 631 00:38:15,222 --> 00:38:18,646 or too tight, they might have issues with sexual wellness. 632 00:38:18,838 --> 00:38:22,230 That needs to be improved. If they have hormone loss, which every woman 633 00:38:22,270 --> 00:38:25,798 is going to have hormone loss as we get older, that needs to be improved. 634 00:38:25,894 --> 00:38:29,670 Is there anything women can do on their own? Because I'm sure you also hear 635 00:38:29,710 --> 00:38:33,830 about, I want to be all natural and I want to do things all naturally. 636 00:38:33,910 --> 00:38:37,768 I mean, I know my answer for sure, but I love to hear everyone 637 00:38:37,824 --> 00:38:41,496 else's answer to this very question. Yes, 638 00:38:41,688 --> 00:38:45,416 I approach this with a little bit of cheekiness. 639 00:38:45,528 --> 00:38:49,304 So I asked them if they drive a car, if they wear 640 00:38:49,352 --> 00:38:52,460 clothes, if they wear glasses, if they wear shoes, 641 00:38:52,880 --> 00:38:56,440 because it would be natural to be naked and walk around with 642 00:38:56,480 --> 00:38:59,224 no clothing and no shoes and no glasses. 643 00:38:59,272 --> 00:39:02,402 And like, how natural are we talking? 644 00:39:02,466 --> 00:39:06,018 Right? We. We do things right. We have tools. 645 00:39:06,114 --> 00:39:09,058 We wear glass, like, to improve our quality of life, 646 00:39:09,114 --> 00:39:12,466 to improve our comfort. And so, 647 00:39:12,538 --> 00:39:15,106 yes, truly being completely naturally, 648 00:39:15,298 --> 00:39:18,658 suffering and feeling miserable. Right? But we take. We take 649 00:39:18,714 --> 00:39:21,746 Tylenol and Advil when we have a headache because we don't want to suffer. 650 00:39:21,778 --> 00:39:25,490 Right? And we. We do things to alleviate suffering. So I 651 00:39:25,530 --> 00:39:28,828 try to make it kind of analogies about 652 00:39:28,964 --> 00:39:32,684 being natural and kind of put it in perspective. I oftentimes 653 00:39:32,732 --> 00:39:36,560 again talk about thyroid because it just sort of clicks about other hormones. 654 00:39:37,700 --> 00:39:41,356 And then I talk about sometimes other hormones like, 655 00:39:41,428 --> 00:39:44,828 you know, vitamin D and melatonin, which are other hormones that we 656 00:39:44,884 --> 00:39:47,948 don't talk about, and those are just over the counter. Again, 657 00:39:48,084 --> 00:39:51,868 it's like there's all these other hormones that we have 658 00:39:51,924 --> 00:39:56,068 naturally in our body, but somehow, again, we've. We've just reserved these sex 659 00:39:56,124 --> 00:40:00,004 hormones as being something scary and that we should just be natural and 660 00:40:00,092 --> 00:40:03,440 suffer. So I talk a little bit about that. 661 00:40:04,620 --> 00:40:08,196 Kind of think of how else I phrase it. Of course, I Talk about 662 00:40:08,268 --> 00:40:12,212 again, I oftentimes actually show the exact chemical 663 00:40:12,276 --> 00:40:16,484 structure of estradiol, which is our main estrogen. 664 00:40:16,612 --> 00:40:20,372 And I show the chemical structure of progesterone. I show the chemical structure of 665 00:40:20,396 --> 00:40:23,674 testosterone. And I, like, tell them this is exactly 666 00:40:23,722 --> 00:40:27,990 what your body, your ovary makes. Three main things. These three main things. 667 00:40:28,290 --> 00:40:32,010 And if we're talking about being the most natural, we're talking about 668 00:40:32,050 --> 00:40:35,350 replacing exactly the same chemical that your body was making 669 00:40:36,450 --> 00:40:40,346 oftentimes. And I'm sure you get this, Kristen. Women come in with a gigantic 670 00:40:40,378 --> 00:40:41,790 bag full of supplements. 671 00:40:43,490 --> 00:40:46,906 And again, whole topic we could spend on supplements, 672 00:40:46,938 --> 00:40:51,578 but I think women are looking for a 673 00:40:51,634 --> 00:40:55,258 natural solution in supplements. But really, are those 674 00:40:55,314 --> 00:40:58,858 more natural than what your body is making? And how much money 675 00:40:58,914 --> 00:41:02,762 are you going to spend on certain supplements that are maybe going to target one 676 00:41:02,786 --> 00:41:06,602 or two areas that you're suffering? Is it your hair 677 00:41:06,666 --> 00:41:10,250 loss? How many supplements

are there for hair loss? How many 678 00:41:10,290 --> 00:41:13,618 supplements for dry skin, dry eyes, achy joints, 679 00:41:13,754 --> 00:41:16,674 sleeping better and sleeping better. Like, it's just like, 680 00:41:16,762 --> 00:41:19,906 again, the anxiety and the depression and it's like, how many 681 00:41:19,978 --> 00:41:22,658 supplements? And then, of course, 682 00:41:22,714 --> 00:41:26,242 weight changes. Right. How many supplements does a one woman need to 683 00:41:26,266 --> 00:41:29,970 take to sort of overcome what her body is. 684 00:41:30,010 --> 00:41:33,330 Was naturally missing? So I kind of try to tell them, 685 00:41:33,370 --> 00:41:37,266 like, we could. We could take a handful of medications or supplements 686 00:41:37,298 --> 00:41:40,604 to treat all of your ailments that's happening in midlife. 687 00:41:40,652 --> 00:41:44,508 Or you could replace what your natural ovary was 688 00:41:44,644 --> 00:41:47,612 doing for you and doing it perfectly, 689 00:41:47,676 --> 00:41:51,436 meaning you have estrogen and progesterone receptors all throughout 690 00:41:51,468 --> 00:41:55,340 your body. And they're really important to keep 691 00:41:55,380 --> 00:41:58,988 all of them working. The genitals usually need more, which why we 692 00:41:59,124 --> 00:42:01,440 always, of course, love talking about vaginal hormones. 693 00:42:02,180 --> 00:42:06,240 But we need to think about this more holistically 694 00:42:08,030 --> 00:42:11,894 versus again. And I'm not saying all supplements are bad. I love 695 00:42:11,982 --> 00:42:15,686 certain supplements for certain reasons. But if we're thinking 696 00:42:15,718 --> 00:42:19,446 about natural, I do tend to try to focus women 697 00:42:19,518 --> 00:42:22,742 on their natural products their 698 00:42:22,766 --> 00:42:26,262 body was making. Yeah, I agree. I mean, I know 699 00:42:26,286 --> 00:42:30,662 we both feel there's nothing more natural than maintaining 700 00:42:30,806 --> 00:42:34,696 your body's optimized hormone levels, which is 701 00:42:34,768 --> 00:42:38,488 usually when we're in our 20s and maybe early 30s, when all of our endocrine 702 00:42:38,584 --> 00:42:42,008 organs are functioning at their best and we are feeling great 703 00:42:42,064 --> 00:42:46,184 and we are generally free from chronic disease. And all of those benefits 704 00:42:46,232 --> 00:42:49,592 we get from youth are really proper hormones. 705 00:42:49,656 --> 00:42:53,688 So if we can maintain that or return to that really 706 00:42:53,744 --> 00:42:57,192 is the most natural. Right, Right. And certainly if people 707 00:42:57,216 --> 00:43:00,920 are thinking about cost, I mean, there's A huge cost in the supplement industry. 708 00:43:01,040 --> 00:43:04,510 I also use supplements and I have, yes, quality ones that I 709 00:43:04,550 --> 00:43:08,142 believe in. But you also have to think about what do 710 00:43:08,166 --> 00:43:11,630 you get for your money. And whatever you're going to choose, 711 00:43:11,710 --> 00:43:15,518 I think you get the most bang for your buck. Replacing Your proper 712 00:43:15,574 --> 00:43:19,470 hormones 100% benefit list is going to be huge. 713 00:43:19,630 --> 00:43:23,342 Now it's not going to be maybe 100% right, 714 00:43:23,446 --> 00:43:27,230 all of your symptoms, but you're going to get the biggest percentage 715 00:43:27,310 --> 00:43:30,494 improvement using something like replacing your natural hormones 716 00:43:30,542 --> 00:43:33,866 versus a supplement for sleep, a supplement for weight, a supplement for hair, 717 00:43:33,898 --> 00:43:37,498 a supplement. Right. I couldn't agree, could not agree 718 00:43:37,554 --> 00:43:40,762 more. Yeah, that's, that's really important. But you're right, 719 00:43:40,786 --> 00:43:44,538 I think patients are thinking that they're doing it all 720 00:43:44,594 --> 00:43:48,778 naturally. Right. I just, you know, mixing up this cocktail of 721 00:43:48,834 --> 00:43:51,850 supplements that are probably not harmful necessarily, 722 00:43:51,930 --> 00:43:55,610 but may not be getting the job done. And I, and I love 723 00:43:55,650 --> 00:43:59,642 when a woman says, comes in and says to me, like I'm, I'm doing meditation, 724 00:43:59,706 --> 00:44:03,248 I'm journaling, I'm doing yoga, I'm being active, like doing 725 00:44:03,304 --> 00:44:06,688 all the things that are good for just general health. Right. 726 00:44:06,744 --> 00:44:10,384 So I never want to say like, well, don't do all those things. Like we 727 00:44:10,472 --> 00:44:13,760 clearly want you to do all of those other healthy things that are just really 728 00:44:13,800 --> 00:44:17,280 good for your mind and body. But again, the foundation for 729 00:44:17,320 --> 00:44:20,320 me, after good quality sleep, 730 00:44:20,480 --> 00:44:23,856 because the ultimate foundation, I think for health and wellness 731 00:44:24,048 --> 00:44:27,152 is the layer of hormones and then again it's exercise, 732 00:44:27,216 --> 00:44:30,352 nutrition, potentially then supplements if 733 00:44:30,376 --> 00:44:33,744 there's nutritional deficiencies, et cetera. But I mean, again, I think we forget 734 00:44:33,792 --> 00:44:37,184 about the foundation, you know, and if we don't have a strong foundation, 735 00:44:37,312 --> 00:44:40,140 nothing else is going to be going well. 736 00:44:40,520 --> 00:44:43,760 Right. And there's, there's data 737 00:44:43,880 --> 00:44:48,336 showing that those things like meditation and journaling and walking in nature 738 00:44:48,528 --> 00:44:52,192 naturally increase the correct hormone balance 739 00:44:52,256 --> 00:44:55,792 in our body. So we, if you want to do something naturally, 740 00:44:55,856 --> 00:44:58,922 that can do it. But I also tell patients your 741 00:44:58,946 --> 00:45:01,190 organs can only make what they can make. 742 00:45:01,890 --> 00:45:05,610 Your 70 year old ovary is not making any 743 00:45:05,650 --> 00:45:08,550

hormones, no matter how much meditation and journaling do. 744 00:45:09,490 --> 00:45:12,970 But certainly we make cortisol our entire lives 745 00:45:13,010 --> 00:45:17,098 and our adrenal gland works our entire lives and we can use things like meditation 746 00:45:17,194 --> 00:45:20,474 and music to keep that more healthy, but it 747 00:45:20,482 --> 00:45:23,882 can only give you what it can give you. So at some point we're going 748 00:45:23,906 --> 00:45:28,094 to have to help support those organs by replacing 749 00:45:28,142 --> 00:45:31,598 their natural hormones. 100%. Couldn't agree more. 750 00:45:31,734 --> 00:45:35,070 But and getting back to that, you know, things like meditation and all Those 751 00:45:35,110 --> 00:45:38,650 great things we talk about, they sometimes take work. I mean, 752 00:45:40,070 --> 00:45:43,998 I am definitely a person whose brain is going at 753 00:45:44,054 --> 00:45:47,614 110 miles an hour from the minute I'm up until 754 00:45:47,702 --> 00:45:50,814 I go to sleep. And I practice meditation. 755 00:45:50,862 --> 00:45:54,398 And I will say it is hard. It is hard. 756 00:45:54,454 --> 00:45:57,102 It is really hard work. Quiet your mind. 757 00:45:57,286 --> 00:46:00,526 If you are used to your mind. Always going, yes, 758 00:46:00,638 --> 00:46:03,918 yes, it's a practice. Right? I. I am still. 759 00:46:03,974 --> 00:46:07,006 I'm still trying to, trying to get there. Yes. 760 00:46:07,118 --> 00:46:10,542 Practice. Yes. Meditation. I always feel that every time my 761 00:46:10,566 --> 00:46:14,190 brain drifts off, I just have to tell myself, 762 00:46:14,270 --> 00:46:17,290 that's okay, just come back to here. Right. That's why. 763 00:46:17,830 --> 00:46:21,982 Right. That's why yoga is a practice. Not every yoga session. You're fabulous. 764 00:46:22,046 --> 00:46:25,482 Sometimes you're falling on your. That's okay. Even though you 765 00:46:25,506 --> 00:46:29,274 did those poses last week. And it's about 766 00:46:29,362 --> 00:46:32,794 just kind of getting into that zone where you can shut 767 00:46:32,842 --> 00:46:36,698 everything else down and, and really let your body be healthy. 768 00:46:36,874 --> 00:46:40,410 Totally. That's great. Oh, I love it. Thank you 769 00:46:40,450 --> 00:46:44,250 for all of your wonderful information. It's been really so 770 00:46:44,290 --> 00:46:47,994 fun. Yeah, I wish we were closer. I'd hang out with you. 771 00:46:48,082 --> 00:46:51,322 Oh, I would love that. That would be great. Yes. I'm going to send you 772 00:46:51,346 --> 00:46:54,834 my cell number. We can chat. I love it. I love it. 773 00:46:54,922 --> 00:46:58,082 Tell me about your day to day. Are you in clinic? Most days. Are you 774 00:46:58,106 --> 00:47:01,762 operating? Yeah. So because I just retired 775 00:47:01,826 --> 00:47:06,322 from the military, I'm in a new practice again with two urologists 776 00:47:06,386 --> 00:47:10,210 and our focus is mostly sexual medicine. So I would say 777 00:47:10,250 --> 00:47:13,314 before I retired I would do about 10% sexual medicine, 778 00:47:13,362 --> 00:47:16,978 90% Eurogyne. And now that is like flipped right now. So I'm building the urogyne 779 00:47:16,994 --> 00:47:21,310 side. So right now it's mostly clinic. And I do one 780 00:47:21,350 --> 00:47:25,230 little other thing just for public awareness that I feel like 781 00:47:25,270 --> 00:47:29,006 is greatly overlooked is in our practice 782 00:47:29,038 --> 00:47:32,206 we see a lot of women with muted 783 00:47:32,238 --> 00:47:35,886 orgasm, clitoral pain, delayed orgasm, 784 00:47:35,998 --> 00:47:40,046 and we find a ton of clitoral adhesions, which is 785 00:47:40,198 --> 00:47:43,010 never talked about. No one discusses. 786 00:47:43,510 --> 00:47:47,806 And so again, I'm doing a lot more procedures for clitoral 787 00:47:47,838 --> 00:47:51,610 pain and clobno in my 788 00:47:51,650 --> 00:47:55,898 practice right now it's mostly clinical building. 789 00:47:55,954 --> 00:47:59,130 The surgical side. I just spoke with 790 00:47:59,170 --> 00:48:02,842 a specialist out in Tampa. She does vulvovaginal diseases, 791 00:48:02,906 --> 00:48:06,042 lichen, sclerosis and other German. And we had 792 00:48:06,066 --> 00:48:09,594 a talk about clitoral anatomy and how 793 00:48:09,682 --> 00:48:12,826 overlooked it is once again in the routine 794 00:48:12,858 --> 00:48:16,186 GYN exam. Are you ever taught to examine the clitoris, 795 00:48:16,218 --> 00:48:19,858 push back, look at it. And I will 796 00:48:19,914 --> 00:48:24,066 be the first to say that for Many years. I also completely ignored 797 00:48:24,098 --> 00:48:27,298 the clitoris. Kind of went right to the Vegas. 798 00:48:27,394 --> 00:48:30,562 That's what we were taught. That's how we were taught. But then the 799 00:48:30,586 --> 00:48:34,386 more I talked to women and they started to have symptoms, I started looking 800 00:48:34,458 --> 00:48:38,146 on my own and then reading, you know, more research and finding these clitoral 801 00:48:38,178 --> 00:48:41,506 problems where I'm like, I can't even find your clitoris. 802 00:48:41,698 --> 00:48:45,488 It's amazing. It's. I would 803 00:48:45,544 --> 00:48:48,832 say one out of four patients that I see now has moderate to 804 00:48:48,856 --> 00:48:52,192 severe clitoral adhesions. We don't ever tell women how to take care of 805 00:48:52,216 --> 00:48:55,744 their bodies. You know, boys that have a penis are always. That have 806 00:48:55,752 --> 00:48:58,688 a foreskin. Excuse me, are always told, pull the hood back, 807 00:48:58,744 --> 00:49:02,128 pull the foreskin back. Right. Yes. We never tell women 808 00:49:02,184 --> 00:49:06,080 how to take care of their genitals. And I do believe if we did that, 809 00:49:06,120 --> 00:49:09,296 we wouldn't have so many adhesions. Certainly there's vulvar 810 00:49:09,328 --> 00:49:13,096 dermatoses that can also put women at risk for this. But in general.

811 00:49:13,248 --> 00:49:17,080 Right. Most of the women I see don't have any vulvar skin conditions. It's just 812 00:49:17,200 --> 00:49:20,904 adhesions. And I'm sure. Was it Jill Kraft, the one that you were talking with? 813 00:49:20,992 --> 00:49:24,392 Yeah, yeah, yeah. She's so great. And we talked about that 814 00:49:24,416 --> 00:49:28,376 exact thing. Right. Women don't get taught about their anatomy. We know it's eternal, 815 00:49:28,408 --> 00:49:31,672 but that doesn't mean we just ignore it. Of course, there's all 816 00:49:31,696 --> 00:49:35,544 the shame about it. And you know, keeping it hidden, that's a whole separate 817 00:49:35,672 --> 00:49:39,506 thought process. Right. When we should. I mean, I gave the. 818 00:49:39,608 --> 00:49:43,550 The point that I'll take 50 and 60 year old women and 819 00:49:43,590 --> 00:49:47,086 take a mirror out and my little Q tip and point around this clitoris. 820 00:49:47,118 --> 00:49:50,830 This is the clitoris. And they are in amazing. 821 00:49:50,910 --> 00:49:54,030 Mind blown. Right? Mind blown. Yes, I know, I. 822 00:49:54,070 --> 00:49:56,926 And they're almost embarrassed. I am 65 years old. I never, 823 00:49:56,998 --> 00:50:00,318 I never knew this. That's. That my urethra was there and that was this. 824 00:50:00,374 --> 00:50:03,054 And things that I'm sure for you and I, we feel like, okay, we look 825 00:50:03,062 --> 00:50:07,022 at it 10,000 times a day. Right. They do not look at their anatomy and 826 00:50:07,046 --> 00:50:10,780 they don't know. Or the flip side, for the very first time ever, 827 00:50:10,820 --> 00:50:14,172 they'll look at their anatomy and they're like, what is it? Has it 828 00:50:14,196 --> 00:50:15,400 always been like that? 829 00:50:17,300 --> 00:50:21,180 Yes. No. I think the power of a mirror cannot be understated. 830 00:50:21,340 --> 00:50:25,180 We also use a mirror and I'm always blown away by 831 00:50:25,220 --> 00:50:28,620 how powerful that is for women and encourage them to 832 00:50:28,660 --> 00:50:31,916 inspect often and frequent to make sure. 833 00:50:31,988 --> 00:50:35,512 Things are staying healthy. Definitely. 834 00:50:35,576 --> 00:50:39,512 Yeah. And I think we probably don't truly know 835 00:50:39,616 --> 00:50:43,080 the percentage of clitoral phimosis and adhesions because 836 00:50:43,120 --> 00:50:46,632 again, it hasn't been looked at and don't teach women to take care of their 837 00:50:46,656 --> 00:50:50,888 anatomy. So it makes sense. After a lifetime of not 838 00:50:51,024 --> 00:50:54,072 literal, hood maybe gets stuck. Yeah. 839 00:50:54,216 --> 00:50:56,820 So I'm actually really proud to say this. 840 00:50:57,440 --> 00:51:01,432 One of my prior fellows, we measured 150 841 00:51:01,536 --> 00:51:04,730 vulvar vulvas for all every single 842 00:51:05,390 --> 00:51:08,662 thing that could be potentially measured. And it's getting presented this month in 843 00:51:08,686 --> 00:51:11,862 Atlanta at

Ithwish. And we found 15% of 844 00:51:11,886 --> 00:51:16,022 women have cloidal fibromosis that's moderate to severe with all 845 00:51:16,046 --> 00:51:19,558 comers, meaning they're not coming in for a sexual complaint. They're coming in for anal 846 00:51:19,614 --> 00:51:22,970 gyn exam, they're coming in for something else. 847 00:51:23,470 --> 00:51:27,446 So there you go. Hot off the press. Getting presented 848 00:51:27,558 --> 00:51:31,136 in two weeks 15 was congratulations. 849 00:51:31,248 --> 00:51:34,864 That is real information. All women, all ages, 850 00:51:34,912 --> 00:51:38,960 all genders. A really nice diverse group of women. So that 851 00:51:39,000 --> 00:51:42,512 is great. Yeah. Because that's the kind of basic work that we need that has 852 00:51:42,536 --> 00:51:46,368 been ignored. Right. Like, how do we not know this? It's like, 853 00:51:46,424 --> 00:51:49,824 oh, my gosh. Yeah. Yeah. There's actually an old 854 00:51:49,912 --> 00:51:53,200 study, I don't know if you've seen, where they measured the. 855 00:51:53,320 --> 00:51:56,672 In many women, the distance between the clitoris and the 856 00:51:56,696 --> 00:52:00,660 anterior vaginal wall and that, you know, leading to that whole discussion of why 857 00:52:00,700 --> 00:52:04,180 women cannot reach orgasm with penetration alone or 858 00:52:04,220 --> 00:52:07,380 when women can reach orgasm, maybe they have that shorter distance. 859 00:52:07,460 --> 00:52:11,172 Yep. It's really just clitoral stimulation during penetration 860 00:52:11,236 --> 00:52:14,452 that's happening. Clitoris. The other 861 00:52:14,476 --> 00:52:17,492 thing is the big thing that I always say too, when I'm showing the genitals 862 00:52:17,556 --> 00:52:20,692 together, male and female, is they said the penis is 863 00:52:20,716 --> 00:52:23,732 the clitoris. And the clitoris complex, 864 00:52:23,796 --> 00:52:26,404 it's the same as the penis. And we kind of look at the internal structures 865 00:52:26,452 --> 00:52:30,062 because again, I think all the women, it's like, mind blown. Like what? 866 00:52:30,166 --> 00:52:33,646 You know, like, I didn't know, you know, so it's, 867 00:52:33,678 --> 00:52:36,942 it's, oh, it's just basic. It's just, it's just the basics. 868 00:52:37,006 --> 00:52:40,530 And we're just, we're missing sometimes just the basic fund of knowledge. 869 00:52:40,870 --> 00:52:44,814 Women, I think, feel shame their whole life if they can't orgasm through vaginal 870 00:52:44,862 --> 00:52:48,206 penetration. And it's because they really need clitoral stimulation. 871 00:52:48,318 --> 00:52:51,710 So. Yeah, exactly. And I, I usually teach it to women 872 00:52:51,750 --> 00:52:55,134 the other way. Say, you know, if you were just stroking 873 00:52:55,182 --> 00:52:58,784 your husband's penis on the shaft and he Never touched the 874 00:52:58,792 --> 00:53:01,872 head of the penis. Yep, totally. I mean, it would feel nice, 875 00:53:01,936 --> 00:53:05,664 but you would do nothing for him, right? For many, that's what penetration 876 00:53:05,712 --> 00:53:09,168 is. Just. And they kind of have a life moment and they're like, 877 00:53:09,224 --> 00:53:12,064 oh my gosh, you're right. And I'm like, he needs to stroke the head of 878 00:53:12,072 --> 00:53:15,696 your penis. Yeah. What needs to happen? So totally true. 879 00:53:15,808 --> 00:53:19,376 We're just the same. We're the same animal, but just with 880 00:53:19,448 --> 00:53:23,200 our parts in slightly different areas, a. Little bit 881 00:53:23,240 --> 00:53:26,672 rearranged in different sizes, a. Little rearrange for a different function. 882 00:53:26,736 --> 00:53:29,612 But, you know, we can all get there if we just had little bit of 883 00:53:29,636 --> 00:53:33,628 knowledge. And that, you know, goes even back to teaching it correctly 884 00:53:33,724 --> 00:53:36,924 to kids, right? To younger kids. Oh, totally, totally. 885 00:53:36,972 --> 00:53:40,636 Well, when my kids were young, they, you know, their school had their sex education 886 00:53:40,788 --> 00:53:43,884 time. And I called up the director and 887 00:53:43,892 --> 00:53:47,612 I said, hey, I'm a GYN and a Eurogyn. I would love to 888 00:53:47,636 --> 00:53:51,692 teach your kids about proper anatomy. I'm a huge fan of using the proper words. 889 00:53:51,756 --> 00:53:55,452 Right. And stigmatizing the proper anatomical terms. And I 890 00:53:55,476 --> 00:53:58,814 said, let me talk to them. And they, they said, no, 891 00:53:58,822 --> 00:54:02,254 we haven't, you know, this is what we're going to talk about. Right? Was asking 892 00:54:02,302 --> 00:54:05,790 the kids to write down questions they had and answering them, you know, 893 00:54:05,830 --> 00:54:09,086 And I was like, yeah, that's. They don't know what information. They don't 894 00:54:09,118 --> 00:54:12,782 know. I know. Well, I have a quick, quick story. 895 00:54:12,886 --> 00:54:16,222 So my son, fifth grade, his family life, this was 896 00:54:16,246 --> 00:54:20,238 several years ago now, the very last day, this girl raised her hand and 897 00:54:20,294 --> 00:54:23,498 said, do girl have penises? The girls have penises. 898 00:54:23,694 --> 00:54:27,602 And my son, apparently the teacher tells me, my son sheepishly raises 899 00:54:27,666 --> 00:54:31,570 his hand like, oh, God, I can't believe I'm doing this. Right? And he says 900 00:54:31,610 --> 00:54:35,426 to the teacher, well, my mom's a vagina doctor. And she 901 00:54:35,498 --> 00:54:39,122 says that women have a penis like structure called the 902 00:54:39,146 --> 00:54:42,418 clitoris. I was like, 903 00:54:42,554 --> 00:54:46,050 that's it. My job is done. My life is complete. 904 00:54:46,210 --> 00:54:49,858 My son understands. And she calls me and she's like, 905 00:54:49,914 --> 00:54:53,246 in my 30 years of teaching, I have never heard 906 00:54:53,278 --> 00:54:56,926 that before. And that was so beautiful. She

thought that was amazing. 907 00:54:57,118 --> 00:55:00,606 Thank you. You're welcome. I know. Hopefully we will have 908 00:55:00,678 --> 00:55:04,734 more of that. I'm the clerkship director for the FSU 909 00:55:04,782 --> 00:55:08,270 College of Medicine here in Florida. So I see all the third year medical 910 00:55:08,310 --> 00:55:11,534 students that come through and I, you know, I give them their weekly lectures. 911 00:55:11,582 --> 00:55:14,942 Obviously we have a syllabus. It's the same weekly lectures. And every time we get 912 00:55:14,966 --> 00:55:18,780 to the week where we talk about menopause medicine. I tell them this 913 00:55:18,820 --> 00:55:22,188 is going to be my legacy. I am educating a new 914 00:55:22,244 --> 00:55:25,468 generation of physicians. Do not be fearful. 915 00:55:25,564 --> 00:55:28,652 And just these things, you don't have to be an expert, but you need to 916 00:55:28,676 --> 00:55:32,284 send to an expert. And you have to make sure that we are giving women 917 00:55:32,372 --> 00:55:35,868 fair and balanced information and no longer fear mongering. I said that's 918 00:55:35,884 --> 00:55:39,404 going to be my med school legacy. This is my platform to get it 919 00:55:39,412 --> 00:55:43,164 done. I love that legacy. For you, for them, 920 00:55:43,252 --> 00:55:46,746 for women kind. I love it. Yeah, that's wonderful. 921 00:55:46,938 --> 00:55:50,602 You know, I started. My daughter is just turned 24 and I 922 00:55:50,626 --> 00:55:53,834 talk to her girlfriends all the time about things like this. And I just think, 923 00:55:53,922 --> 00:55:57,786 you know, I want more for them. I don't want them age exactly, 924 00:55:57,898 --> 00:56:01,786 having disease and having dementia and. And fracture or osteoporotic 925 00:56:01,818 --> 00:56:05,210 fractures. I want them to know and demand more because, I mean, 926 00:56:05,250 --> 00:56:08,602 I know that my generation didn't. And we just kind of did what we were 927 00:56:08,626 --> 00:56:11,892 told to a degree. Right. But I'm proud of 928 00:56:11,916 --> 00:56:16,004 them for pushing it, you know, and I want to contribute to that 100%. 929 00:56:16,092 --> 00:56:19,412 I couldn't agree more. Great. Thank you so 930 00:56:19,436 --> 00:56:23,268 much for taking time. This is really wonderful. We'll definitely have to do more 931 00:56:23,324 --> 00:56:26,240 about, you know, I mean, there's so many more topics to. 932 00:56:26,700 --> 00:56:30,132 We do one just completely on the clitoris. Oh, my gosh. I would love 933 00:56:30,156 --> 00:56:34,420 that. I would love that. Thanks so much for listening to today's episode. 934 00:56:34,580 --> 00:56:38,548 No information from this recording is intended as a diagnosis or treatment 935 00:56:38,644 --> 00:56:42,292 for any disease. If you are enjoying the show, please subscribe 936 00:56:42,356 --> 00:56:46,132 so you don't miss any of our exciting episodes. And we love 937 00:56:46,156 --> 00:56:49,780 to hear from our listeners and will be grateful for your positive review. We'll talk 938 00:56:49,820 --> 00:56:50,140 next time.