The Megyn Kelly Show - Menopause, Libido, and Childbirth： Deep Dive on Women's Sexual Health, with Dr. Mary Jane Minkin

00:00:00.520 Welcome to The Megyn Kelly Show, your home for open, honest, and provocative conversations.

00:00:12.260 Hey everyone, I'm Megyn Kelly. Welcome to The Megyn Kelly Show.

00:00:15.560 Are you tired of hearing about the indictments?

00:00:18.980 Me too.

00:00:21.260 I'm sick of it.

00:00:22.700 Plus we have the next year and a half, probably two years, maybe two and a half, maybe three to discuss them.

00:00:27.240 So today we are doing a show that I've really been looking forward to, and that is all things related to women's sexual health and function.

00:00:36.440 We talked about the men's sexual health last week, last Wednesday, for those of you wanting to hear that one, got a lot of great feedback on it.

00:00:42.860 And today we dive into all the topics for the ladies, menopause, fertility, sexual dysfunction, all of it.

00:00:50.380 Plus, we're going to be answering some of your questions too.

00:00:52.540 And let me tell you, I did a call out for questions.

00:00:55.380 You ladies did not hold back.

00:00:56.580 My God, it gave me things to think about I had never even considered.

00:01:01.160 So tip of the hat to you for, you know, being honest about your issues, and we'll get into it all with our guest today.

00:01:08.180 Here with us to help us through this discussion, Dr. Mary Jane Minkin.

00:01:12.180 She's a clinical professor at the Yale University School of Medicine who's been in private practice for more than 40 years.

00:01:18.140 In 2018, she was named Educator of the Year by the North American Menopause Society, and she has been named a top doc by Connecticut Magazine numerous times, among her many, many other honors.

00:01:30.260 Dr. Minkin, welcome to the show.

00:01:32.680 Megan, thank you so much, and thank you for the very kind words.

00:01:35.540 Too kind, but thank you.

00:01:36.660 Oh, well, no, we're honored to talk to you.

00:01:38.740 There's so much to go over.

00:01:40.440 And I guess there's no better place to kick it off probably than just, I've heard you say that there's a difference between libido issues and sexual dysfunction issues.

00:01:52.720 And I don't understand what is, what are the differences?

00:01:56.680 What, like, could you help us define those?

00:01:59.820 Sure.

00:02:00.260 Well, we could probably spend the next couple of hours on those, that question alone, so it's an excellent question, so thanks.

00:02:05.620 So, as far as libido, that's really a desire to have sex, you know, where some women decide, women wanting to want.

00:02:13.540 I know it sounds crazy, but wanting to want to have sex, and that's a very important thing.

00:02:19.000 However, there are some people who don't have much desire to have sex, but it doesn't bother them in the slightest, and, you know, God bless them, that's fine.

00:02:26.480 So, the major issue that we're concerned about with libido is women who have decreased libido and are concerned by it.

00:02:32.300 It produces significant bother or concern, and they're not happy with the situation, okay?

00:02:37.160 And then, of course, there are all sorts of performance, you know, issues going on.

00:02:41.300 And the issues with libido are so multifaceted, because, of course, there's some hormonal issues, to be sure.

00:02:48.480 Okay, and that's, I'm sure, what many of our, you know, listeners are interested in.

00:02:52.500 But there are also other things in our lives which are not strictly hormonal.

00:02:56.520 And, you know, one of the things my med students, my residents ask me, you know, how do you figure out what's what?

00:03:01.180 And the answer is it's really hard, because, you know, particularly, of course, one of my special hobbies is, of course, menopausal women.

00:03:07.740 And, but if you look at any woman's life, there's so many things going on in her life besides just hormonal activities.

00:03:13.580 And there are relationship issues, of course, which are primary.

00:03:17.420 You know, if you don't really like your partner, you're probably not going to want to have sex with him or with her.

00:03:21.160 It's just something that you're not going to be interested in.

00:03:23.040 You have to really, you know, be happy and liking your partner there if you're talking about sex with somebody else.

00:03:28.920 There are also issues in your life.

00:03:30.380 Are you tired?

00:03:31.320 If we get into, for example, a new mother, okay, oftentimes women who've just had babies, you know, will talk to me about their decreased, you know, sexual desire, decreased libido.

00:03:40.700 Well, they're exhausted.

00:03:41.920 They've been up, you know, feeding this kid every night.

00:03:44.620 They're not getting a decent night's sleep and then they're thinking about having to go back to work.

00:03:48.160 I mean, so that those are issues that might overwhelm her desire to have sex.

00:03:53.200 Or if somebody's having pain, okay, there are women who have painful pelvic conditions or significant medical conditions.

00:04:00.740 Which just are really debilitating for them.

00:04:03.200 And it's like, you know, well, who would want to have sex if it's going to hurt?

00:04:06.020 And that, again, is particularly important.

00:04:07.740 We get to talking about our menopausal ladies who may be suffering from vaginal dryness.

00:04:11.720 So it's discomfort issues.

00:04:13.440 And then there are also, you know, for many people, you know, we're looking at our partners, we're looking at our kids.

00:04:19.060 But in our population, we have, you know, a significant aging population.

00:04:23.140 People are living a lot longer.

00:04:24.560 So for many of my patients, they're taking care of their mother or their father.

00:04:29.780 Or when I give a talk, I get a laugh on this one.

00:04:32.300 I'll say, yeah, and even worse, you have to take care of your mother-in-law.

00:04:34.800 That was one of my patients yesterday.

00:04:36.920 So you've got all these responsibilities going on.

00:04:39.600 And all of those can be dampening your desire to have sex.

00:04:42.360 So there are many, many things at play besides just the hormonal issues intrinsically going on for a woman.

00:04:49.340 And there's also a difference between desire and arousal, right?

00:04:54.540 So it's like you could get aroused, but the desire is lacking in some of these women who you just talked about because they're tired.

00:05:02.740 They're mad.

00:05:04.040 This is why they say the men should help with the housework, right?

00:05:06.260 Because it's like it relieves a burden on the wife.

00:05:09.280 It makes you feel closer to him.

00:05:10.540 It makes you feel a little bit more pep in your step.

00:05:12.240 It could refire your desire.

00:05:13.880 You may have no problem getting aroused when you actually get down to it, but the desire can be a problem for some women.

00:05:20.160 Absolutely.

00:05:20.780 And it's very difficult to dissect that out as far as what they're concerned about.

00:05:24.640 What's the end result?

00:05:25.700 You know, do I really want to have sex?

00:05:27.280 And is it going to be fun for me?

00:05:28.640 And it's going to be fun for the relationship.

00:05:30.720 And the other thing that's out there, and this is, you know, I'm probably jumping six steps ahead.

00:05:34.960 But there have been some reframing of issues involving, you know, desire.

00:05:41.420 And one of the women who's done the most in this area is a revered professor from British Columbia whose name is Rosemary Bassan.

00:05:49.560 And she actually has formulated what she calls a circular issue on women's libido and desire.

00:05:57.300 That basically it's not strictly like, you know, a guy can just, you know, and a guy's got, we'll talk about testosterone in a minute.

00:06:03.620 They have a lot of testosterone.

00:06:04.980 That's certainly one of the hormones significantly involved, we think, in desire.

00:06:09.460 And so a guy, oh, I want to have sex and that's it.

00:06:13.120 But for women, there may be many other issues than just the hormonal issues at play.

00:06:17.320 It may be she knows that if she does have an intimate relationship with her partner, that that will improve the relationship.

00:06:24.200 And improving the relationship will further lead to increasing her desire because the relationship is better.

00:06:28.860 So it's more of a circular issue rather than just a linear model for wanting to have, you know, okay, I'm aroused.

00:06:34.140 I want to have sex.

00:06:34.820 I have sex.

00:06:35.360 I'm done.

00:06:35.720 That's good.

00:06:36.180 Whereas for women, it's oftentimes, and Professor Bassan has talked about this a lot, is that it's because of the desire and the closeness and the intimacy that will happen in the relationship, which will further improve the relationships, will then will help involve, you know, improving libido overall.

00:06:51.360 So very, very complex stuff in us.

00:06:54.680 Is that true for men too?

00:06:56.760 Because, I mean, I think of them more as simple beings who just, they want to get after it and they're not as focused on whether the relationship is in tip-top shape.

00:07:06.880 You've read Dr. Bassan clearly.

00:07:08.960 The answer is yes.

00:07:10.440 Most people think that the male model is much more of a linear model than a circular model for women.

00:07:16.500 So if you're a man wanting to have sex with your wife or your partner, it would behoove you to work on the relationship, whether that's important to you or not, if you just want more sex, because you need a willing partner.

00:07:29.560 And your partner is going to be more willing if she feels emotionally closer to you.

00:07:32.920 Absolutely, absolutely.

00:07:35.200 And I can throw in a quote, which I think is interesting from somebody who I've had the honor of working with on certain occasions.

00:07:41.940 And I've worked with Dr. Ruth Westheimer.

00:07:44.080 And one of the lines that she uses, which I borrow regularly, you know, if the guy wants to have sex and stuff like that in this relationship.

00:07:50.780 And she'll look and she'll say, and if he hasn't taken the garbage out in the last five days, well, she's not going to be very interesting.

00:07:57.520 So, yes, improving the relationship can be very improving the life at home can be very helpful to having the woman want to get closer in this relationship.

00:08:06.620 Yes. Yes, that's right.

00:08:08.260 I mean, it's not it's not that it's like hot to see your husband take out the trash.

00:08:11.840 It's that you want shared burdens on the things that are no fun around the house.

00:08:17.680 You do not want to be the one doing way more than your share.

00:08:20.900 And then because I will say this, I'll say to Doug, like, I'm not doing all like I'm not cooking the dinner and cleaning up the dinner and cleaning up the house.

00:08:28.360 And then, you know, you want to cuddle up to me at that point.

00:08:31.920 It feels like another chore.

00:08:33.560 You don't want it to feel like something I'm just giving you.

00:08:36.040 Right. It needs to be more balanced.

00:08:38.400 Absolutely. Definitely needs to be more balanced.

00:08:40.720 And, you know, and in a relationship, that's good, because if the guy figures it out, that's great, because he'll end up getting more of what he wants to make the relationship much stronger for the couple.

00:08:52.280 Most men would be thrilled to realize the ticket to getting more sex is unloading the dishwasher and taking out the garbage.

00:08:58.620 Great. I got the keys.

00:09:01.040 Terrific. It helps. That's great.

00:09:02.760 I'm an empiricist that works. That's terrific.

00:09:05.300 Right. Right. It's like it's not that hard.

00:09:06.860 You know, you and then, you know, tell us, like, we look hot or whatever.

00:09:10.280 Just show us that you're attracted to us, even if we've gained a little weight or we got a little older or, you know, we had a bad day, especially when you're nursing your babies and you feel like your body's from another planet.

00:09:20.660 All those things like just a good reminder that you still find us attractive and, you know, we still are desirable.

00:09:25.820 All those things. Those are little my tips for men.

00:09:28.240 But is it true that because I read that 43 percent of women report some degree of sexual dysfunction?

00:09:35.300 And I also read that most women don't report like most women don't want to discuss this at all with their doctors or anyone else.

00:09:43.280 So that means a lot, a lot of women, maybe the majority of women are having some form of sexual dysfunction.

00:09:49.720 A lot of women are having sexual dysfunction.

00:09:53.060 And you're absolutely right. And there are many things that can hinder the discussion of this with your medical provider.

00:09:58.320 One of the things that we try to teach, I think most of us try to teach in the business to our students, is to ask patients, you know, just just ask is one of the mottos and things like that.

00:10:10.460 Just ask that we can, you know, are sexual issues going on and are they bothersome for you?

00:10:16.260 That's very important.

00:10:17.320 And, you know, because and many people and there are a whole bunch of reasons.

00:10:21.200 There's a lot of literature on this.

00:10:22.780 You know, why don't providers and women have these discussions?

00:10:28.200 And there are anxieties on both sides.

00:10:30.300 One of, of course, the major issues out there, and again, we can spend many hours talking about this, is the brevity of the typical medical visit these days.

00:10:37.580 You know, an average medical visit may go on for seven minutes and you're talking about your whole health history.

00:10:41.900 And, you know, by the way, doctor, I haven't really had any interest to have sex.

00:10:44.820 So that's but that's a problem.

00:10:47.220 And women have to raise these issues.

00:10:49.020 Sometimes the provider isn't, even though we try to teach these folks to be asking that question.

00:10:53.540 So just to say, yeah, this is going on.

00:10:55.480 Don't be afraid.

00:10:56.420 Some patients are actually in these.

00:10:58.140 We've studied these things.

00:10:59.280 Some women are actually anxious about asking their provider, not so much for embarrassment for themselves, but they're afraid they're going to embarrass the doctor.

00:11:07.200 Well, don't be afraid to embarrass the doctor.

00:11:08.960 If this doctor doesn't know how to talk about sex, teach him or teach her to ask about it because you're going to be doing them a great favor.

00:11:14.820 So we want our providers and we try to teach our providers not to be embarrassed.

00:11:18.960 Sometimes a provider will find, particularly if it's an older woman than the provider is.

00:11:23.720 Oh, you know, it's like asking my mom, you know.

00:11:26.160 Well, no, I mean, this is your patient and this is somebody you know you're taking care of.

00:11:29.960 And this is an important issue for her.

00:11:31.600 So ask her about these things.

00:11:33.660 A lot of women also think, well, there's nothing that can be done about this.

00:11:37.620 So why should I bother wasting time, you know, valuable time in an office visit if there's nothing that can be done?

00:11:43.200 You know, I'm having pain, but oh, I'm just getting older and there's nothing that can be done about it.

00:11:46.960 No, there's a lot of things that can be done.

00:11:49.040 So don't be afraid to ask.

00:11:50.860 Bring it up.

00:11:51.380 It's a totally legitimate topic.

00:11:52.940 It's an important issue for well-being.

00:11:55.180 And there are a lot of things that can be done for many of the issues that are bothering you.

00:12:00.040 So there's embarrassment and time issues on both sides.

00:12:03.900 How many things can be done?

00:12:05.360 I mean, I have to be honest.

00:12:06.720 Before I studied for today, I thought it was basically like the KY jelly was your options.

00:12:11.240 But like there are so many things that women can do if they're having, you know, dryness or any of the things that come along with.

00:12:18.680 It can be menopause or it can be other issues that cause those things.

00:12:21.580 The market's getting a little better.

00:12:22.880 It has a long way to go, but it's definitely getting a lot better than it used to be for women.

00:12:28.600 So, OK, so you've got to talk to your doctor.

00:12:30.580 Be your own best advocate.

00:12:31.560 This is, by the way, why I could never personally have a male OBGYN.

00:12:35.540 I just couldn't do it.

00:12:36.680 I just for me, I don't think I'd feel comfortable talking to a man about any of this stuff.

00:12:42.320 I don't know if you're like me.

00:12:44.360 Consider whether you do better with a female GYN because I don't think it's easier.

00:12:49.640 All right.

00:12:50.620 So let's talk about libido, because last week when we had the show on male sexual health, our doctor told us that there are actually now he said, if you go to the drugstore and you ask for like a drug that will help a man with his libido, you'll get two dozen options.

00:13:07.360 If you ask for a women's libido drug, you might get one.

00:13:11.500 So what are the options in terms of drugs for women's libido and desire?

00:13:18.780 So let's say we're isolating it to everything else is, you know, we're really hunky dory in life and everything's great.

00:13:24.140 And I'm just I still could care less.

00:13:25.800 You know, everything's fine, but I just could care less.

00:13:28.280 And we have to divide this first into premenopausal women and postmenopausal women because the remedies are actually different.

00:13:34.780 OK, and there are as far as medications, basically two medications out there for premenopausal women.

00:13:42.800 There is a medication that basically women and when it came out a few years ago, people called it the pink Viagra.

00:13:50.100 And the technical name is flibanserin, but the trade name is Adi.

00:13:54.360 And this is a medication.

00:13:56.140 I think the pill is still pink.

00:13:58.320 It's a pill you take every day.

00:14:00.040 OK, and it was actually a drug that was discovered in doing research on antidepressants.

00:14:05.440 And this drug really didn't do much for depression, but it seemed to increase libido.

00:14:09.180 It's one of these drugs that acts in the central nervous system and a pill you take every day.

00:14:13.540 And yes, there are, you know, prospective randomized double blind trials, the scientific trials out there to say, yes, this medication does work.

00:14:20.540 So it's not like, oh, my God, it's going to turn you into sex maniac or anything like that.

00:14:24.880 But it does statistically significantly have women have more desire to have sex.

00:14:29.420 And the end point, I know that it sounds crazy, but then how do they study these things?

00:14:33.040 They measure what they call sexually satisfying events.

00:14:36.040 And the drugs have been shown to increase sexually satisfying events statistically significantly.

00:14:41.500 The other thing about this medication that some of our listeners may have heard about is when the drug first came out, there was a concern about having any alcohol with it.

00:14:49.680 You know, if you're going to have a glass of wine, you can't take this drug.

00:14:52.180 Well, people have sort of debunked that right now.

00:14:54.240 So there are ways to take it safely and have a glass of wine.

00:14:56.780 Don't worry about that.

00:14:58.140 And it does help.

00:14:59.760 And again, it's for premenopausal women.

00:15:01.640 There is some data in women who are postmenopausal, but it unfortunately has not gotten the FDA's approval for that as a medication in postmenopausal women.

00:15:10.740 But there is some data to show it helps.

00:15:12.800 So that's one possibility there.

00:15:14.780 The other possibility there is a, and some people are going to get grossed out by this.

00:15:18.680 It's actually an injection that you use.

00:15:21.700 But it's like an EpiPen.

00:15:23.160 It's not like a major, major shot or anything like that.

00:15:25.900 And you take it basically 45 minutes, an hour before you want to have sex.

00:15:30.120 So this is one of those drugs.

00:15:31.320 The fluvancerin is you take it every day.

00:15:32.960 You take it every day.

00:15:34.240 This injection, which is called Vilesi, is a shot that you sort of self-administer 45 minutes, an hour before you want to have sex.

00:15:42.860 It hangs around basically for half a day.

00:15:44.740 So you can go at it more than once if you'd like to.

00:15:47.040 It should give you that arousal.

00:15:48.320 And again, scientifically, data is out there and it is approved for increasing libido for women, for premenopausal women.

00:15:55.080 Again, there is some data in postmenopausal women, but it's not officially approved for postmenopausal women.

00:15:59.980 But it does, you know, again, increase sexually satisfying events.

00:16:04.060 So that's our premenopausal ladies.

00:16:05.640 When we go to our postmenopausal women, and again, there are some herbal preparations out there which may be helpful.

00:16:12.460 You know, there's some data on some of them.

00:16:14.320 They don't have as big trials as they do about the FDA-approved medications.

00:16:18.140 For women, for postmenopausal women, there is a fair amount of data on testosterone.

00:16:24.520 And many of my patients get grossed out when I start talking about testosterone.

00:16:27.980 They'll say, oh, my goodness, that's the male hormone.

00:16:30.020 And the answer is there are very few hormones in life which are sex-exclusive, like only men have, only women have.

00:16:35.920 For example, if we have some male listeners, they may get scared when I say this, but men have a lot of estrogen in them, too, under normal conditions.

00:16:43.660 So, you know, you really do have some estrogen.

00:16:46.140 And women have testosterone.

00:16:47.920 And what's interesting is our testosterone levels in women go down.

00:16:52.700 They do start declining, and the ovary makes testosterone, as do the adrenal glands.

00:16:57.920 But the ovarian production of testosterone does start going down around our time of menopause.

00:17:03.920 But it lingers a while.

00:17:05.320 It takes a longer time to drop, but it does start going down.

00:17:09.320 And there is very nice data that shows that women who supplement with testosterone do increase their libido.

00:17:16.120 So there's very nice data.

00:17:17.660 And the Menopause Society of the United States, the International Menopause Society, all these organizations have officially endorsed testosterone for libido for women.

00:17:26.660 Now, a couple of things about it.

00:17:28.820 Some folks are going to get nervous and say, oh, I'm going to turn hairy, and I'm going to get acne, and my voice is going to go down.

00:17:35.200 No, it's not going to happen.

00:17:36.760 I want to stay a woman.

00:17:37.380 So we monitor levels and things like that.

00:17:42.600 And these things do not really happen with the low doses we use.

00:17:45.880 We use doses much, much lower than the guy's doses.

00:17:49.180 And just to clarify, and way, way lower than a woman who actually is trying to, quote, transition.

00:17:54.660 Like, there's no comparison between what you would give a woman in terms of testosterone versus somebody who's actually trying to look like a man.

00:18:01.100 Absolutely, way lower than those doses, way lower than these doses.

00:18:04.840 They're very low doses that we use.

00:18:06.640 There's only one real problem in the United States about getting the testosterone is that there is no officially FDA-approved testosterone product for women in the United States.

00:18:19.620 There are plenty of products for guys, which are much higher doses, much stronger doses.

00:18:23.900 But there is no officially approved low-dose testosterone for women.

00:18:27.480 Now, that doesn't mean it's illegal and you're not going to go to jail for using the medicine, but you can either use a very, very small dose of the guy's formulation, which many doctors will prescribe.

00:18:37.720 The other possibility is to get from a compounding pharmacy testosterone, and many prescribers use compounding pharmacies for getting testosterone.

00:18:47.360 So those are both possibilities.

00:18:48.820 The other thing about testosterone for women, I just want to clarify it for our listeners, is, and we'll obviously get into another drug that I'm sure you talked about last week.

00:18:57.340 I'm sure you talked about sildenafil or Viagra for men.

00:19:01.480 But the issue is that's a drug that you, and that's really not a libido drug.

00:19:05.520 That's really a performance drug that lets the guy perform sex better.

00:19:10.160 But the issue with that is you take it when you want to have sex.

00:19:14.620 As far as the testosterone for women, that's something you need to take on an ongoing basis.

00:19:19.480 So it's not that you're going to say, oh, I want to have sex on Saturday.

00:19:22.360 I'm going to use my testosterone on Saturday and be able to have more libido.

00:19:25.880 No, it's a product that you use on an ongoing basis, ideally every day.

00:19:30.440 Now, as I tell my patients, you know, if you skip a day, don't worry.

00:19:33.200 It's not going to be ruined.

00:19:34.460 But it is a drug you use on an ongoing basis, and then will improve your libido, you know, over the course of time.

00:19:40.480 So come Saturday night, if you've used it every day, it hopefully will be helping you want to have sex on Saturday night.

00:19:45.260 Hmm. Oh, there's so much to go over there.

00:19:47.280 Okay, let's go through a few of the things that you said and some questions I had.

00:19:50.980 When you say these drugs like Adi or Adi, how do you pronounce it?

00:19:57.080 I call it a D, but I don't know.

00:19:58.840 Some people call it Adi.

00:20:00.340 Okay, well, that one and the other one, you say that they will increase, yes, your desire for sex, but also your sexually satisfying events.

00:20:09.040 Does that mean, are you talking about orgasm or are you just talking about like you're just going to have sex more?

00:20:13.480 You're going to have sex more.

00:20:15.340 They don't qualify that as far as orgasmic response.

00:20:17.900 It really encompasses the sexual act.

00:20:20.820 Okay, good to know.

00:20:21.860 And then what about, before we get to testosterone, are there any side effects to those first two drugs that increase arousal or desire for the women?

00:20:30.780 It's going to be fairly minimal.

00:20:32.420 They're pretty well tolerated, you know, in general.

00:20:35.120 So it's not problematic.

00:20:36.840 And now I know from preparing for today that a lot of antidepressants can have the effect of lowering your sexual desire, whether you're a woman or a man.

00:20:47.300 Can these drugs you mentioned be taken with an antidepressant?

00:20:50.800 That's an excellent question.

00:20:53.060 And the answer is there are some cautionings about it, but they can be, the shot is probably less of a controversy than the D because, again, it is a centrally acting drug.

00:21:03.620 So there are some questions about it.

00:21:05.960 Okay.

00:21:06.380 So you want to talk to your prescriber about using it.

00:21:09.340 You definitely want to have that conversation with your prescriber.

00:21:11.620 Yeah, because, I mean, I can see if you're depressed and your doctor puts you on an antidepressant and then your desire for sex goes away, then you're more depressed because having a regular and healthy sex life is part of being a healthy person.

00:21:25.260 And it does add to joy and intimacy and connection with your part, all that stuff.

00:21:29.480 But the answer isn't necessarily just get rid of the antidepressant because that could cause problems, too.

00:21:35.320 Well, that's absolutely correct.

00:21:36.580 However, there are things, and if you find your antidepressant, you know, you've started on antidepressant or you are taking antidepressant and you're noticing your libido is down.

00:21:45.100 Again, please talk with your provider about this.

00:21:48.220 Very important.

00:21:49.100 Because there are certain antidepressants, not all antidepressants affect everybody the same way.

00:21:53.800 Okay.

00:21:54.280 So there are certain people who will get a downer on one antidepressant, not on another.

00:21:58.820 So it's certainly quite reasonable to try different antidepressants.

00:22:02.500 Obviously, you want to work with your prescriber as far as what might be a suitable alternative for you to try.

00:22:07.520 Some are known to be more of a depressant than others.

00:22:10.320 The other possibility, and these are the SSRIs and somewhat of an extent to the SNRIs.

00:22:15.760 There is one antidepressant that does not have a decreased effect on libido, and that's what's called bupropion or Welbutrin.

00:22:23.200 Okay.

00:22:23.980 Oh, yeah.

00:22:24.320 Our male doctor said that, too.

00:22:26.700 Yeah.

00:22:26.960 Welbutrin is not an SSRI.

00:22:28.900 It's not an SNRI.

00:22:29.820 Actually, we don't really know exactly how it works, but it does not have the sex-depressant activities.

00:22:35.380 And what some psychiatrists will do or other prescribers will actually add a little bit of Welbutrin to whatever you're taking.

00:22:42.120 You can take Welbutrin, bupropion, with most antidepressants of the SSRIs.

00:22:47.780 So that may enhance things a little bit for you.

00:22:50.020 So that's something that can be done.

00:22:52.480 Trying to difference SSRI or adding some Welbutrin or just switching over to Welbutrin can be helpful.

00:22:58.200 So there are options to, again, work with your prescriber and say, listen, my libido is down.

00:23:02.780 Now, the other thing to remember, and it's great, Megan, that you did recommend looking at the antidepressants.

00:23:10.320 There are other medications that can depress libido, too.

00:23:13.960 Okay.

00:23:14.360 And I want our listeners to understand that, for example, some blood pressure medications can have a downing effect on libido.

00:23:22.180 And given the fact that we've got tons, yeah, some blood pressure meds can do it.

00:23:26.220 And it can be for the guys, too.

00:23:27.720 And sometimes some of the antidepressants can actually affect their erectile issues and stuff, too.

00:23:32.560 So that certainly can be the case.

00:23:34.160 But if you're on an antihypertensive medication and you say, gee, my libido is not too terrific, you may want to speak with your provider about, gee, could this antidepressant do it?

00:23:44.380 And might there be something else that's suitable to get my blood pressure under control and not do this to my libido?

00:23:51.780 A couple other things that are out there.

00:23:53.520 And, you know, the list is very long.

00:23:54.940 But, for example, people who are taking certain pain medications, certain opioids, that's another bad thing about opioids, they can decrease libido, too.

00:24:04.480 So, again, what you really, if you're talking with your provider about my libido really is not good, you know, okay, that, you know, make a list of your medications.

00:24:14.080 Bring your list of medications with you and say, and I'm taking, you know, I'm taking Prozac and I'm taking metapropyl.

00:24:20.580 I'm taking this and to try to figure out which of the medications might be problematic.

00:24:25.920 And as far as can we do better or try different medications?

00:24:29.180 Sure, we can.

00:24:30.640 I mean, I think that's one of the things I hope people take away from this show and the one we did last Wednesday, which is sexual health is a part of health and you don't have to settle for less.

00:24:39.060 You know, you don't have to just sort of slide into, well, I'm getting older or I gain some weight or we've been married now 20 years and this is just how things go.

00:24:47.160 No, no, you should fight for a very positive, good, uplifting sex life.

00:24:53.880 And there are all sorts of aids that can help you get back to, you know, feeling like I'm looking forward to it.

00:25:02.020 Maybe you could get maybe you're not going to be like the 20 year old version of you, but you could be like the 34 year old version of you.

00:25:07.300 Although I do have plenty of 75 year olds who are pretty sexually active too, so I want to make sure that people realize that can be.

00:25:17.120 I love this story because I actually, I'm afraid to ask because I have an 82 year old mother, but like, when does it stop?

00:25:24.800 Does it ever stop?

00:25:25.680 I mean, are there people who are going at it in their 90s?

00:25:27.840 Yeah, I've had some of those.

00:25:31.980 One of my loveliest patients comes to mind and I've taken care of her for many, many years and she just turned 80 and she and her significant other have their time reserved.

00:25:43.300 And they've been doing this for at least 20 some years that I know about that they have been reserving Sunday morning as their official sex time that they look forward to it and stuff like that.

00:25:53.500 And we've, we've worked on maximizing everything for them and they're doing great and they haven't changed the ritual for over 20 some years as far as that's their dedicated time.

00:26:04.880 No, it reminds me of a joke that I, that I heard, which goes, there's an old man, he's 95 and he, and he marries a 25 year old and he goes to see the doctor before the wedding night.

00:26:14.920 And he says, you know, what do you, what do you think doc?

00:26:17.240 Like, what do I need to know?

00:26:18.440 And the doc says, you know, I got to tell you, you know, sex, it could be fatal.

00:26:23.140 You know, it's, it's somewhat dangerous.

00:26:26.420 And the 95 year old man says, she dies, she dies.

00:26:33.700 Right.

00:26:34.440 But it's good to know it's possible, not just for the men, it's possible for the women to keep it rolling well into your later years.

00:26:42.100 Now I want to get into testosterone because that's a big one, the pros, the cons, the options, like what actually it's going to do besides if anything arousal, but I'll, I'll squeeze in a quick break before we do that.

00:26:53.340 Cause that's a, that's a good topic to, to tee up when we come right back with Dr. Minkin right after this quick break.

00:27:02.220 All right, let's talk about the big T testosterone.

00:27:06.780 Who should be thinking maybe this is right for me?

00:27:10.280 Excellent question.

00:27:11.760 And the answer is the first category that we just want to mention is of course, this is not officially recommended for premenopausal or, or perimenopausal women.

00:27:20.960 Even the official recommendation is for postmenopausal women, um, because we do understand that postmenopausally testosterone levels do decline for most women, pretty much for all women.

00:27:31.260 And again, we can measure levels.

00:27:32.640 It's easy enough to do so.

00:27:34.140 And there is very good data again, and recognized by the North American menopause society, menopause society, the international.

00:27:40.280 And again, the major hangup in this country is just getting ahold of it as far as not being officially, uh, a form officially approved by the FDA.

00:27:50.020 Um, there are several ways to do the medication.

00:27:52.800 The most commonly used method of using testosterone is a cream or a gel.

00:27:58.220 Okay.

00:27:58.660 So it's applied and rubbed into the skin.

00:28:01.240 Uh, people can rub it into their bellies.

00:28:03.180 They can rub it into the thighs.

00:28:04.840 I mean, all over the places that can be used.

00:28:06.960 Um, and again, um, it is advocated that women have levels measured, you know, after being on it for several months to see if they're on a good dose of it, you know, see how they're doing.

00:28:15.900 Uh, when I have my patients taking it, I always tell them, you know, obviously, um, any masculinizing type side effects.

00:28:23.040 Let me know, you know, headache, and that based far as hair, facial hair, um, acne, deepening of the voice.

00:28:28.240 Give me a holler.

00:28:28.900 Let's check and we'll see what's going on.

00:28:30.600 Okay.

00:28:31.060 As far as safety, it's really quite safe.

00:28:33.860 There are some concerns.

00:28:35.180 And the people who've looked at this with administration of testosterone to women, uh, one of the concerns about, well, guys have more heart disease than women.

00:28:42.640 Does it seem to increase the risk of heart disease?

00:28:44.620 And the answer is no, it does not.

00:28:46.320 Okay.

00:28:47.160 Another concern is, oh, gee, um, you know, maybe this is going to make my blood thicker.

00:28:52.260 You know, does it increase the hematocrit and stuff like that?

00:28:54.980 No, it doesn't seem to do that.

00:28:56.340 So as far as the safety parameters, yes, you should be monitored medically, but you should not, um, you know, should not, uh, worry about, you know, too many side effects really have, as far as health issues and stuff like that.

00:29:08.520 Um, the other issue, as far as administration, one method that has become popular, uh, in this country for many hormones, not just testosterone are the implantation of pellets.

00:29:20.260 You know, basically some doctors out there, uh, will basically stick you with a pellet that goes under your skin and take you an injection and stick this pellet under the skin.

00:29:28.720 Several problems with that.

00:29:30.420 Um, number one, again, this is not an FDA approved route of administration for women.

00:29:34.760 And the other issue is not approved by the FDA period, but certainly not this route of administration.

00:29:39.480 The problem is that once the pellet is on board, it's on board, you can't take it out.

00:29:45.160 So it's going to be there for two, three months.

00:29:47.240 However it is, it's going to stay active in you.

00:29:49.080 Um, and if it's giving you too high a level, that's too bad.

00:29:52.040 It's there.

00:29:52.860 Um, so in general, we don't recommend pellets.

00:29:55.560 They're, they're, they're not part of the armamentarium that we recommend people using.

00:29:59.100 The transdermal method is a safe way to do it.

00:30:01.720 And you don't have to stick it under the skin and not know how, you know, how long this thing is going to last on you.

00:30:05.980 So that's one thing as far as safety.

00:30:07.640 And you want to go to somebody who's familiar with using it as far as, uh, side effects, et cetera.

00:30:12.300 So, but is it reasonable to do it?

00:30:14.140 Yeah.

00:30:14.320 And again, the other thing just to be aware of is that because it's not approved by the FDA for use in women, your insurance company is unlikely to cover it for you because they'll say, well, it's a good excuse for them.

00:30:26.840 It's not approved by the FDA for use in women.

00:30:29.000 Therefore, we're not going to cover it for you.

00:30:30.480 And fortunately, the good news is testosterone is not too expensive.

00:30:34.600 So most people can't.

00:30:36.460 Right.

00:30:36.820 It's ridiculous.

00:30:37.200 Sorry, folks.

00:30:38.020 Right to the FDA, please.

00:30:40.080 What's the matter with American, you know, the health insurance and the health business for women?

00:30:44.740 It's like we're half the population.

00:30:46.020 What good does it do these guys if their drive's intact and their ability to perform is intact?

00:30:50.840 And we're like, not interested.

00:30:53.000 Go do your research.

00:30:54.560 Get some FDA approved options for the ladies, fellas.

00:30:57.240 Write, write to your folks in Washington, please tell them they need they need to be covering this.

00:31:02.820 Thank you.

00:31:03.820 I mean, yeah, because that's truly it's like maybe you can afford it.

00:31:07.340 Maybe you can't.

00:31:07.840 But if you can't, it'd be very nice to have some help from the insurance companies.

00:31:11.680 I want to say this.

00:31:12.640 So you said this, this you might have scared people with the call me if you start to grow a bunch of facial hair, your voice lowers and all that stuff.

00:31:19.220 But I will say the thing that interests me about testosterone, two of my friends are on it and they look amazing.

00:31:27.040 They say they feel amazing.

00:31:29.060 They were big recommenders of the testosterone regime and they aren't having any of these problems.

00:31:36.560 So just so ladies know, it's not you're not necessary.

00:31:40.180 This is not like a real like I'm going to get facial hair and I'm going to look like a man and it can be down.

00:31:46.660 It's a it's a it really doesn't happen very commonly.

00:31:50.340 And so I don't want people being afraid of it for that reason.

00:31:53.300 The other thing and I will make a plug for this probably a couple more times during our time together.

00:31:57.740 If you are having trouble finding a doc who's familiar or a nurse practitioner or nurse or APRN who's who knows about menopause.

00:32:07.340 OK, I can find you one easily.

00:32:09.480 You go to the website menopause.org, which is the website of the Menopause Society, the North American Menopause Society as it used to be known.

00:32:17.600 And if you go to the website menopause.org, you can plug in your zip code.

00:32:22.140 OK, and the North American Menopause Society will find you providers in your area who are menopause focused and menopause experts.

00:32:29.660 So if you if your provider doesn't seem to know much about what you're going through, go to menopause.org.

00:32:34.500 This is huge. They will find you somebody.

00:32:36.900 Just because you have a GYN does not mean she or he is an expert in menopause.

00:32:41.040 This is a newly sort of more specialized field, I think, within OBGYN.

00:32:46.120 No, or maybe it's not new, but not every doctor has this expertise level that you're talking about.

00:32:50.660 Well, that's unfortunately true.

00:32:53.560 And I can make a little diversion here as far as how that came about.

00:32:57.140 And we can divert over talking about the menopausal practice and stuff like that.

00:33:01.440 But we're definitely going to get into that later.

00:33:03.580 About 20 some years ago, a publication came out that got women very scared, overwhelmingly much, much, much too scared about the use of hormone therapy.

00:33:12.680 And what happened is that basically, unfortunately, most residency programs in obstetrics and gynecology basically decided to stop teaching menopause.

00:33:23.240 It's like, well, if people aren't going to take hormones, why bother teaching folks about it?

00:33:26.740 So, unfortunately, that the house officers who have been trained in the last 20 years, who are many of your practitioners out there, are these youngins, and it's not their fault.

00:33:36.640 They didn't get the menopause education because it wasn't being offered, really didn't learn a lot about hormones and hormone usage, including testosterone.

00:33:43.580 So, again, if you've got somebody who doesn't seem to be knowing it or wanting to communicate these issues with you, you can, again, you can always go to menopause.org and find somebody who knows something about these issues.

00:33:55.200 That is so helpful.

00:33:56.660 And we will take a deep dive on menopause in our second hour.

00:34:00.080 But I do want to say this.

00:34:01.680 So a personal story that may be helpful to some of the women listening.

00:34:05.300 So I've been on the low-dose birth control pill for most of the past, most of my life, most of my childbearing years.

00:34:13.820 Even though, I already told the audience, I had my fallopian tubes removed, like, eight or nine years ago.

00:34:19.840 I had an ovarian cyst.

00:34:21.420 It was benign.

00:34:22.060 But they were taking that out.

00:34:22.980 And the doctor was like, might as well take your fallopian tubes if you're not going to use them, if you're done having your kids, given the fact that most or all ovarian cancers begin in the tubes.

00:34:33.240 I'm like, go for it.

00:34:34.120 It was laparoscopic.

00:34:35.300 It was like that.

00:34:36.340 I felt no pain.

00:34:37.400 I have no scar.

00:34:38.340 I don't even know where he went in.

00:34:39.940 I truly, like, someplace in my belly, but there's no mark.

00:34:43.580 Anyway.

00:34:44.220 Good job.

00:34:45.340 Yeah.

00:34:45.700 So the reason I was on the low birth control pills is because my whole life I have had acne.

00:34:52.280 And, you know, being on camera, I didn't want to deal with it.

00:34:54.780 And it seemed like a nice, easy way to keep the skin under control.

00:34:57.200 And it worked.

00:34:57.760 But now I'm 52, right?

00:35:00.480 And I was noticing a change, I'll confess, in my own sex drive.

00:35:05.620 Everything was okay.

00:35:06.500 It was good.

00:35:07.020 But it was, like, not quite as robust as it had been.

00:35:09.820 And all with my friends on testosterone.

00:35:11.600 So I'm like, maybe I'm getting to be that age.

00:35:13.180 Maybe I need to consider this.

00:35:14.320 And, you know, I had a very good doctor say, go off the pill.

00:35:18.620 Go off those, that low, low, low estrogen, whatever it was, and see what happens.

00:35:24.340 And I did.

00:35:25.620 And the problem was totally solved.

00:35:28.120 The drive came back 100%.

00:35:30.460 And I didn't go on testosterone or anything like that.

00:35:33.000 But apparently, this is pretty common, that sometimes birth control can affect sex drive.

00:35:42.720 Yes, that's absolutely correct.

00:35:44.680 And can I bore our listeners with a basic physiology lecture?

00:35:48.100 But I always think that if you understand what's going on, it really makes much more sense to you.

00:35:52.060 Birth control pills work by suppressing ovarian activity.

00:35:56.080 It stops you from ovulating.

00:35:57.440 And that's good.

00:35:58.020 It keeps you from getting pregnant.

00:35:59.000 That's good.

00:35:59.480 And it also controls your hormones, which is why a lot of people like it for skin conditions and stuff like that.

00:36:04.780 And the thing to remember is that the ovaries do make estrogen and progesterone, no question about it.

00:36:09.820 But they also make testosterone.

00:36:12.620 And so what happens is when you take a birth control pill, it suppresses ovarian action, okay, including testosterone production.

00:36:20.920 Okay.

00:36:21.520 So now, of course, the key thing is you say, well, I take birth control pills.

00:36:25.480 I have libido.

00:36:25.960 Many people do.

00:36:26.760 And they're not a problem with it.

00:36:28.740 But for some women, it is.

00:36:30.300 And it suppresses things low enough that they really don't feel they don't feel they have much libido.

00:36:35.880 So for some women, going off the pill, because it lets the ovaries wake up and do their thing, will allow them to ovulate, presumably they're premenopausal, and also allow their ovaries to make some testosterone.

00:36:47.560 And even that small amount that our ovaries make will be enough for many women to give them the good libido they were looking for.

00:36:54.040 So that's indeed what was going on.

00:36:56.120 And not crazy, not silly.

00:36:57.700 These things happen.

00:36:58.900 Absolutely.

00:36:59.200 And it can switch, right?

00:37:00.120 Because I had many years of not having any issue on the low birth control.

00:37:03.940 And then now I get a little older.

00:37:05.460 I'm like, well, I wouldn't have even thought to consider the birth control pill as an option of the source.

00:37:11.840 Well, I think us getting older has something to do with it, too, because I think I mentioned earlier that not only can the ovaries or do the ovaries make testosterone, the adrenal glands make testosterone-type hormones, too.

00:37:24.540 And as we get older, and this is in men and women, the production of androgens, testosterone-like chemicals by the adrenal glands goes down, too.

00:37:33.500 And that starts in our mid-30s, unfortunately.

00:37:35.660 So I think you were getting sort of a double effect going on from the adrenal glands kicking in less, and the ovaries not kicking in much at all.

00:37:43.500 So I think you had both of those processes happening.

00:37:45.700 And here's a related story.

00:37:46.680 Here's a related story.

00:37:47.420 You have to be your own best advocate, right?

00:37:49.240 Because like we were saying before, talk to your provider.

00:37:51.840 Make sure it's somebody who's got some expertise.

00:37:53.460 If you're dealing with menopausal issues, make sure she knows or he knows a lot about menopause, not just like dabbles, but like actually is educated like Dr. Minkin.

00:38:01.460 And the other thing is, so I will confess to you, this one doctor I had who I really like, but, you know, I raised it just as like, well, you know, there's been this slight change.

00:38:09.980 And what she said to me was, go away on a trip with your husband.

00:38:15.820 Now, I happen to have an amazing marriage.

00:38:18.040 I'm very lucky.

00:38:18.800 I have a great marriage.

00:38:19.560 I have a gorgeous husband.

00:38:20.940 Like, it wasn't that, right?

00:38:23.000 Like, it could be that it could be that for a lot of women.

00:38:26.220 But I think you need to like fight for yourself.

00:38:29.120 You know, it's not the fact that my relationship is having problems.

00:38:32.240 I'm not having problems.

00:38:33.740 Ask somebody else.

00:38:34.800 Go to somebody like get get a second opinion, which is what I did.

00:38:37.740 And I always said that the doctor said, consider going off those pills.

00:38:40.640 And everything was 100 percent fine.

00:38:42.400 I I'll take the trip, too.

00:38:44.260 But I'm just saying you got to be your own best advocate.

00:38:46.640 Yeah, right.

00:38:49.340 Very important.

00:38:50.920 Well, don't you think that there's a like like there's a shortage of.

00:38:54.160 I don't know.

00:38:54.920 Is it deep thought in the field or is it just willingness to spend time with a patient exploring

00:38:58.780 these things?

00:38:59.420 Like, what is it?

00:39:01.040 Well, I think the time issue is a crucial issue that indeed, unfortunately, medical care

00:39:06.420 visits have gotten shorter and shorter.

00:39:08.120 And that these are issues that tend to come up with a longer visit and longer time to

00:39:13.260 chat about these issues, which are very important issues.

00:39:16.080 And one of the other things that I will also want to mention, you know, to our listeners,

00:39:19.720 I'm sure many of you have figured this out that I mean, I love the medical profession.

00:39:24.420 Don't get me wrong.

00:39:25.400 But sometimes, you know, that MDs are so hassled as far as doing this, doing that, doing the

00:39:31.740 other thing, that if you have a nurse practitioner who's in the practice, a nurse midwife, a PA,

00:39:38.200 many of these people will sometimes have more time to sit and discuss these very important

00:39:42.800 issues with you.

00:39:44.080 So and again, many of them are affiliated with, you know, a doc in the group.

00:39:47.920 They work together.

00:39:49.100 And so sometimes you're sitting down if you if you have like a nurse midwife help deliver

00:39:52.620 you, you know, took care of you during pregnancy.

00:39:54.540 You may want to sit down with her or with him.

00:39:56.760 They're male midwives.

00:39:57.540 I've worked with several excellent ones that just to sit down and talk to you about these

00:40:02.160 issues because they are important and you need to spend the time talking about them.

00:40:06.340 Do they go by midwife or do they go by like mid husband?

00:40:09.580 No, midwives.

00:40:10.480 I think it's from the German mit vibe with a woman.

00:40:13.360 So they spend time with the woman.

00:40:14.920 They're midwives, but male.

00:40:16.080 All right.

00:40:17.740 So on the subject of testosterone, Dr. Sharon Parrish went on with our friend Peter Atiyah on his

00:40:23.940 podcast.

00:40:24.440 They had a very interesting discussion.

00:40:26.020 It was next level.

00:40:26.760 So it's like a lot of terms I didn't understand, but also very user friendly in it's in other

00:40:31.260 ways.

00:40:31.600 And she was saying there's a drug in Australia that is made for women called Androfem.

00:40:38.820 I think it's P-H-E-M that it's a testosterone.

00:40:43.160 Yeah.

00:40:43.320 And it was why are the Australians doing all this work for women and the Americans aren't?

00:40:48.460 Sharon is a good friend of mine, a wonderful person.

00:40:50.920 But I think it's just regular testosterone that they actually allow in Australia.

00:40:55.740 And it's regulatory.

00:40:57.580 It, you know, it's, is testosterone safe for women?

00:40:59.780 Yeah, that's safe.

00:41:00.340 And we've got pretty good data on that.

00:41:03.120 But if we can motivate people, this would be very nice.

00:41:07.340 She was saying on that podcast that it's for some of her patients who don't want to go to

00:41:11.260 Australia or, you know, go whatever, order their drugs from Australia.

00:41:14.360 If you want to testosterone now as a woman, you've got to get like maybe a vial from, from

00:41:21.060 your, your pharmacist.

00:41:22.860 And then you got to like pour some out.

00:41:24.300 You got to apportion it.

00:41:25.400 You got to be like a little chemist in your own bathroom to figure some of this stuff out.

00:41:29.680 Yeah.

00:41:29.920 Yeah.

00:41:30.080 As I mentioned before, you can get the male variety and just use a tiny portion of it,

00:41:34.140 which is certainly many folks do that.

00:41:35.960 Um, or you can get it from the compounding pharmacies, you know, and you just want to

00:41:39.740 make sure you're dealing with a good compounding pharmacy.

00:41:42.260 All right.

00:41:42.800 Now, have you heard of a nasal spray of testosterone?

00:41:46.560 Cause I will say I was at a party not long ago and the wives were talking about how there's

00:41:51.360 some testosterone nasal spray, some sort of nasal spray that would increase libido.

00:41:55.700 And all I could think was, Oh my God, all the husbands in America, I'd be shooting this

00:41:58.640 up their wives' nose while they're asleep.

00:42:00.020 Like, Hey, honey, it could be happening.

00:42:03.380 I must confess in our area, nobody's using a nasal spray.

00:42:06.300 So I don't know much about, I mean, with a compounding pharmacy, they could make up just

00:42:10.060 about everything I think.

00:42:11.400 But the other thing that you have to be aware of with any medication is what we call the

00:42:15.440 pharmacokinetics or the absorption issues and stuff like that.

00:42:18.760 And so some of the problems with some of the topical therapies is, you know, how are they

00:42:23.240 absorbed?

00:42:23.700 How fast are they absorbed?

00:42:24.860 How long do they live for as far as are they, you know, going to have a good shelf life and

00:42:29.100 things like that.

00:42:29.700 And I don't know much about nasal spray varieties.

00:42:32.500 Now, how long could you stay on drugs like this, whether it's testosterone or the Addy

00:42:37.600 or the, like, is there a, you know, okay, you can, they can get you over the next five

00:42:41.680 years, but then you got to get off of it.

00:42:44.060 No, they're not time limited.

00:42:45.940 So if you're doing well and you're in your, and the really are minimal side effects, you're

00:42:49.540 doing well with it and there's no cumulative.

00:42:51.320 Now, do we have, now, this is something we have to be very careful of with almost any medication.

00:42:56.120 Most of the drug trials to get a drug approved by the FDA go on for a year or two years at

00:43:03.040 most, something like that.

00:43:04.280 There are very few drugs that we have five or 10 years of experience with in a drug trial.

00:43:08.660 I mean, we have clinical experience and there are adverse event reporting and things like

00:43:12.660 that that folks have.

00:43:14.140 But there's no, to the best of my knowledge, there's really, there's no clinical trials

00:43:17.540 going on for that long to say, oh yes, it's great for five years or 10 years.

00:43:20.840 But there are no signals to say you should stop it after five or 10 years.

00:43:23.980 Not that I know of, how do you know whether you need one of these drugs or you need the

00:43:30.540 trip to the Caribbean?

00:43:31.700 You know, like, how do you know whether you need to see a sex therapist or maybe a couple's

00:43:36.820 therapist or something versus medical intervention?

00:43:41.140 That's an excellent question.

00:43:42.460 And the answer is, it's hard to tell.

00:43:44.200 Um, and certainly it's always reasonable to, it's, it's reasonable to explore both, you

00:43:48.620 know, is my life stressed?

00:43:49.860 Um, you know, am I dealing with, you know, an ailing parent in law, kid misbehaving, uh,

00:43:56.220 kid coming back from college with six dogs, um, you know, that I've got to take care of

00:44:00.080 things of that nature, which are stressful.

00:44:02.100 Um, but it's also quite reasonable to explore the hormonal issue to say, could there be some

00:44:06.020 hormonal component?

00:44:06.940 And I think it's totally reasonable to explore both.

00:44:09.580 Hmm.

00:44:10.440 Now there's a, on the subject of sexual dysfunction, pain, pain during sex is all too common.

00:44:18.280 I mean, I know a young woman who complains about this to me and I, you wouldn't expect

00:44:23.020 somebody of this age to have this issue necessarily, but she does.

00:44:26.520 So it's not a menopausal thing for her.

00:44:28.420 And I know she's not alone.

00:44:29.920 There's some, what, one third of women who may have pain during sex.

00:44:33.540 So what, what should they be thinking about?

00:44:35.960 What are their options?

00:44:37.380 Okay.

00:44:37.680 Well, the key thing is, again, I hate to sound like an advertisement for the medical profession,

00:44:42.080 but you do want to talk with a medical provider.

00:44:44.660 For example, a very common entity, um, that's getting more, more, you know, time on, on news

00:44:51.160 and stuff like that is endometriosis, which is a condition of younger women.

00:44:54.780 By definition, it's a premenopausal condition, not a postmenopausal condition.

00:44:58.400 It almost always gets better after menopause, but women can have, and the pain that they experience

00:45:03.160 is usually deep pelvic pain and oftentimes pain with intercourse.

00:45:07.120 Oftentimes they'll have lousy periods.

00:45:09.020 They may have bladder issues, all sorts of stuff.

00:45:11.020 Um, and endometriosis is fairly common.

00:45:13.860 It's estimated that anywhere from six to 10% of women have endometriosis.

00:45:17.540 So it's not unheard of.

00:45:19.420 And it also can occur in very young women.

00:45:21.680 Now, some people say, oh, endometriosis is because the career woman, she's put off having

00:45:25.420 her children and that's why she's got endometriosis.

00:45:27.620 We've got 18 year olds who have endometriosis.

00:45:29.720 So it's not an age exclusive entity.

00:45:32.080 And this is sometimes it's hard to diagnose.

00:45:34.720 Okay.

00:45:35.100 The good news is we've got a lot of therapies.

00:45:36.980 We've got a lot more therapies than we used to have.

00:45:38.740 I mean, when I was a kid starting in this business, we didn't have a lot of options.

00:45:41.960 We have a lot more now, um, that we can use.

00:45:44.540 So if you're having pain with, with deep penetration, deep in the pelvis and stuff like that, and

00:45:49.100 you have crummy periods, you don't have to have crummy periods, but if you do, you know,

00:45:52.580 do talk to your provider, uh, preferably, I mean, you know, a primary care person should

00:45:57.140 know stuff about this, but certainly a GYN should know about this, um, that they can help

00:46:01.640 you with.

00:46:02.180 So these are things that can be helpful there.

00:46:04.280 There are also women who have things, there's an entity called vestibular vulvitis, which

00:46:09.380 can be seen in young women or older women, which is pain around the opening of the vagina.

00:46:14.180 Um, and it was actually a sex in the city episode on this.

00:46:17.380 So it must be very, very important.

00:46:18.940 Um, but it's estimated that up to 9% of women will have vestibular pain.

00:46:22.600 And again, this is something we can help with, but again, talk to your provider and that's

00:46:26.440 more pain with penetration.

00:46:27.800 Oftentimes pain with putting in a tampon, pain with even wiping yourself at the bathroom,

00:46:32.800 um, things like that.

00:46:33.940 So there are many different entities that can cause pain and you want to try to figure

00:46:38.320 out when am I having this pain?

00:46:40.200 Where is it hurting?

00:46:41.440 Are my periods crummy?

00:46:43.280 And talk to your provider because there are a lot of things that we can do.

00:46:47.100 Okay.

00:46:47.640 And then there's the issue of vaginal dryness, which we'll take up next as we delve deep into

00:46:52.220 menopause.

00:46:53.920 That's coming up.

00:46:54.620 We're going to talk about birth control and its effect potentially.

00:46:57.280 I know a lot of our young staffers worry about fertility issues.

00:47:00.460 Are they linked?

00:47:01.280 What do they need to know?

00:47:02.060 We're going to talk about the young women.

00:47:03.300 We're going to talk about the old women, uh, all of us.

00:47:06.720 So stand by for more with Dr. Mary Jane Menken, and then we will take your calls just a little

00:47:11.120 bit later in the show.

00:47:11.920 And you can find the show live on Sirius XM Triumph channel, 111 every weekday at noon

00:47:16.580 east, the full video show and clips by subscribing to our YouTube channel, youtube.com slash

00:47:20.600 Megan Kelly and an audio podcast available for free, wherever you get your podcasts.

00:47:25.580 Check it out.

00:47:29.640 All right, doc, let's talk lube.

00:47:32.280 There are options.

00:47:34.800 There are options.

00:47:36.120 Like I said, it's not just the KY.

00:47:37.800 You got all sorts of options now.

00:47:40.180 You betcha.

00:47:41.000 Absolutely.

00:47:41.560 So, um, if I, if I can take the liberty of going into some basics again here, um, I'd

00:47:47.560 like to explain to our listeners the difference between lubricants and moisturizers, okay?

00:47:52.740 And there actually is a difference.

00:47:55.000 Moisturizers are things that we can place in our vaginas, mostly two or three times a

00:47:59.500 week, depends on what particular product you're using, which will give you ongoing moisture

00:48:03.760 in the vagina, okay?

00:48:05.340 And some people can have discomfort from dryness without ever having sex.

00:48:08.900 So sometimes a moisturizer can be helpful.

00:48:10.780 Sometimes people who, you know, ride bikes, run, ride horses, um, can have vaginal dryness

00:48:16.560 discomfort.

00:48:17.180 So a moisturizer can be very helpful along those lines.

00:48:20.540 Lubricants were products that we tend to use for sexual activity, you know, for self-sexual

00:48:25.600 activity, for partnered sexual activity.

00:48:27.840 Um, and they can be very helpful, um, as far as, and again, the other key thing when I talk

00:48:32.600 about a lubricant is I always tell my patients never buy for the first time with a product,

00:48:38.340 the giant economy size, because there are in different lubricants, there can be a scent

00:48:43.220 or there can be something that the product is dissolved in that can be irritative.

00:48:47.360 And don't forget the vulvar and vaginal tissue is the most sensitive tissue in the body.

00:48:52.700 So if something's going to bother you, it's going to bother you there.

00:48:55.180 So make sure you buy a small amount first.

00:48:57.240 See if you like it, if you're comfortable with it, and then you can get the giant economy

00:49:00.460 size.

00:49:00.920 Try to get something that doesn't bother you.

00:49:03.660 And many, many women will use both a moisturizer and a lubricant at the time of intercourse.

00:49:08.480 So there's nothing harmful or shameful about using them.

00:49:11.320 Now, of course, they shouldn't basically stop the need for foreplay because basically that

00:49:17.140 women get moisturized, develop lubrication when they're sexually aroused.

00:49:22.760 Okay.

00:49:23.080 The fluid flows into the vagina.

00:49:24.800 And so we don't want to say, oh, just use lubricant and no foreplay.

00:49:28.740 You want that too.

00:49:29.740 But some women will need an adjunct to the foreplay to get things going and to be comfortably

00:49:34.500 moisturized and lubricated.

00:49:37.000 Hmm.

00:49:37.800 I hate to ask, but like the coconut oil is all the rage on your skin, potentially on your

00:49:43.480 hair.

00:49:44.040 Is that like, is there a natural remedy for down south in Rio or no?

00:49:47.240 Don't don't be putting any food products down there.

00:49:49.480 Well, a lot of my folks use coconut oil.

00:49:52.120 And if it works for you, great.

00:49:53.660 God bless them.

00:49:54.180 And that's terrific.

00:49:54.860 Some people have told me they develop yeast infections, you know, because again, you've

00:49:58.280 got some product with a little bit of sugar around there, you know, they can develop that

00:50:02.720 if it does stop using it.

00:50:04.500 But if it's working for you, I don't think there's anything tragic about using it, but

00:50:08.340 it doesn't work.

00:50:08.960 It's like, I mean, there's got to be, it can't be like spraying Pam up there before

00:50:12.040 you, well, actually, if I, I hate to say this, but there is a body of literature from

00:50:20.280 some gynecology groups about women who really have dry vulvar tissue, particularly as well

00:50:25.360 as vaginal tissue.

00:50:26.540 And they actually have some work using things like Crisco and other shortenings to coat the

00:50:31.300 vulvar area.

00:50:32.300 Yeah.

00:50:32.540 I would talk to your provider about it, but there is some other.

00:50:34.840 Talk to your provider.

00:50:36.040 Do not, do not spray the olive oil Pam there without consulting a doctor.

00:50:39.740 Probably not, probably not.

00:50:41.200 Yeah.

00:50:42.180 Okay.

00:50:42.660 And then, so there's like, in terms of the options for moisturizers, like, what are they?

00:50:48.000 What are women looking at?

00:50:49.000 You say it was like two, three times a week.

00:50:50.400 Is it like a, is it like an insert?

00:50:52.600 Like, what is it?

00:50:53.520 Yeah.

00:50:53.920 Yeah.

00:50:54.260 Most of the time they're, they're inserts for the vagina.

00:50:57.160 They're gels that come in like pre-packaged things, applicators that you can squirt inside

00:51:01.200 the vagina again, two, three times a week.

00:51:03.360 There are suppositories and there are different agents that are used as the moisturizers.

00:51:08.700 There's one product that's gotten to be very popular these days.

00:51:11.320 And people laugh at me when I tell them about it is there are some products out there that

00:51:15.080 have hyaluronic acid.

00:51:16.680 You know how some ladies use it on their face?

00:51:18.540 Well, there's a hyaluronic, a couple of several hyaluronic acid products for the vagina, which

00:51:22.320 are pretty nice for a lot of people.

00:51:24.180 It doesn't hurt?

00:51:25.880 It doesn't hurt to put in.

00:51:27.160 No, people like it.

00:51:27.660 In other words, acid, you know.

00:51:29.560 No, yeah.

00:51:30.040 Acid.

00:51:30.360 No, that's good.

00:51:30.860 Now that brings up a very interesting topic, which we'll address in one minute if I may.

00:51:35.540 But so basically, no, it does not hurt and it's fine.

00:51:38.700 So there are moisturizers there.

00:51:40.100 Now, of course, the other thing is if somebody is in a hypoestrogenic state, because estrogen

00:51:44.760 promotes moisturizing the vagina.

00:51:47.040 And if you're in a low estrogen state, adding some vaginal estrogen can be very helpful for

00:51:51.640 moisture.

00:51:52.660 And yes, the most commonly thought of group for this are women who are after menopause

00:51:56.780 or perimenopause when their estrogen levels are going down.

00:51:59.520 Um, but there's actually one group of very young women that gets vaginal dryness for

00:52:04.200 low estrogen and that's breastfeeding moms that when you're breastfeeding, you don't

00:52:08.520 make much estrogen.

00:52:09.620 And so the vagina can get very dry.

00:52:11.780 So my poor patients who are breastfeeding, you know, they're exhausted anyway.

00:52:15.040 The breastfeeding, oh, damn it.

00:52:16.540 It's dry now.

00:52:17.240 That's awful.

00:52:17.780 Um, so they may also need a moisturizer.

00:52:21.160 Um, and so wait, so with the, would the estrogen be, it wouldn't be something you take orally.

00:52:25.980 It would be like an insert in general.

00:52:28.060 Now you, now oral estrogen for a postmenopausal woman, you wouldn't do this for a breastfeeding

00:52:32.300 mom, but a postmenopausal woman can take oral estrogen and get results vaginally.

00:52:36.960 That is correct.

00:52:38.020 Um, however, there are plenty of vaginal estrogen products, which you can put in, they are prescription

00:52:43.040 anything with estrogen and it is a prescription, but you can put these vaginal estrogen products

00:52:46.960 in there and there are creams and there are rings and there are tablets, all sorts of

00:52:50.680 good stuff that we use, uh, to pop into the vagina.

00:52:53.780 Um, and they, again, you use those things two, three times a week, most of the time and

00:52:57.320 they work.

00:52:57.700 And some people use some non-hormonal stuff with some hormonal stuff.

00:53:01.400 So it's absolutely fine.

00:53:02.180 What is a ring?

00:53:03.060 What do you mean vaginal ring?

00:53:04.400 What's that?

00:53:04.840 There's actually, it looks like the rim part.

00:53:07.060 Now this is for our young folks, they won't be able to think about this, but the old contraceptive

00:53:11.220 diaphragms that had a rim and then they had a cup sort of with it.

00:53:14.060 Um, these rings look like the rim part of a diaphragm, but no cup in there and you pop

00:53:19.260 it in the vagina and it sits there and you can leave them in place for three months at

00:53:22.460 a time.

00:53:22.940 And it's cool.

00:53:24.080 Um, and they moisturize the inner part of the vagina.

00:53:26.680 Now, the other thing just to remember is if you are using a product for inside the vagina

00:53:31.940 for moisture, which is great, that's terrific.

00:53:34.260 That many women will benefit by the addition of some cream or some topical therapy to use

00:53:39.780 around the opening to the vagina, because that area can be very uncomfortable, particularly

00:53:44.520 with penetration.

00:53:45.500 I mean, obviously, again, you want good foreplay and some stretching, but that some women will,

00:53:49.880 many women will benefit by the addition of a topical cream to rub around the opening

00:53:53.840 of the vagina.

00:53:55.240 Does your partner feel the ring?

00:53:57.420 Nope.

00:53:58.320 Nope.

00:53:58.800 I basically, I had maybe one, one person in my career and it's very long who's told me

00:54:03.840 that the partner felt the ring.

00:54:05.020 And I was like, well, God bless them, but it's, you know, it's mostly not healthier.

00:54:09.020 Very real.

00:54:09.820 Fascinating.

00:54:10.400 Okay.

00:54:10.700 And now what about, I, this may be a far field, but are there like lasers, you know, like as

00:54:16.860 somebody who is, uh, I don't like face fillers, but I do like some of these lasers.

00:54:21.140 They can do wonders, at least on your face.

00:54:23.800 Can they do wonders down on your Mary Jane?

00:54:27.160 Well, that's a very interesting question that you ask.

00:54:30.340 And the answer is there certainly is some data and some of my buddies are experts on

00:54:35.340 lasers and they do a very good job.

00:54:37.760 Um, but the problem with the lasers, and by the way, it's never made much sense to me

00:54:41.420 how you can destroy tissue and get more moisture just conceptually.

00:54:44.360 It doesn't make sense to me, but whatever.

00:54:46.060 But there are some of my buddies who are very good and there's literature showing it does

00:54:49.500 work.

00:54:49.740 The problem with laser technology is that there's really no licensing to go to say, okay, this

00:54:56.680 is a board certified laserologist or something like that.

00:54:59.480 So anybody can just buy themselves a machine and hold themselves out to be a laserologist.

00:55:04.660 And there are in the literature case reports of people who've had really bad stuff done

00:55:08.840 to their vaginas from a laser.

00:55:10.280 So if you really are interested in a laser, please again, talk to your provider, somebody

00:55:15.480 you know and trust and make sure they send you to somebody, or if they happen to be a licensed,

00:55:19.980 you know, certified laserologist, that's fine.

00:55:22.040 Um, but as I said, I wouldn't just go to some, you know, Jane Doe or Joe Schmo, um, who holds

00:55:28.480 him or herself out as a laserologist without knowing if they're skilled at it.

00:55:32.180 All right.

00:55:32.700 Well, while we're on the subject of the laser, cause we use it on our facial skin to like

00:55:35.940 tighten things up or to stimulate collagen.

00:55:38.380 Um, there are a lot of women who have had vaginal births who are worried about, you know,

00:55:43.260 blowing things out down South and they, you know, they don't want the hot dog in the

00:55:46.680 hallway.

00:55:47.160 They want things a little bit snugger.

00:55:48.940 Is there any remedy on that?

00:55:50.780 Or does the things just settle down?

00:55:52.220 Like do women even need to worry about this?

00:55:53.760 Like after you have a vaginal delivery, will things tighten up after a time?

00:55:58.080 The answer is yes.

00:55:59.820 Most women after vaginal deliveries are just fine.

00:56:02.320 You know, okay.

00:56:02.820 And one thing that I, now this is a personal belief of mine.

00:56:06.060 I, I, but I, I would be bad if I didn't mention my personal belief.

00:56:09.720 There are folks who elect to have cesarean sections for what I consider no good reason, because

00:56:15.080 we really, you don't destroy your vagina by having a bad vaginal birth.

00:56:18.920 And there are many, many, many potential complications to having a cesarean section.

00:56:22.700 I mean, if you need to get the kid out safely and that's the only way to do it by all means,

00:56:26.540 it's appropriate, but to just have a cesarean section, cause you're worried about your vagina.

00:56:30.920 Don't worry.

00:56:31.720 It's really much safer to have a vaginal birth if you can.

00:56:35.260 So anyway, but after vaginal delivery, there are some women who, you know, have some stretching

00:56:40.600 and stuff like that.

00:56:41.500 And one thing that I always encourage people to do is Kegel exercises.

00:56:45.900 I'm a big fan of Kegels.

00:56:47.780 And I think Kegels are great for everybody.

00:56:50.500 So, and I'm like, yeah, the thing I tell my patients, so I always think of the musical

00:56:53.960 cats that they used to advertise cats now and forever.

00:56:57.160 Well, I tell my patients Kegels now and forever.

00:57:00.040 It's a good thing to do.

00:57:01.200 And that actually does help.

00:57:03.160 Another thing that can be associated with the stretching of the vagina.

00:57:06.840 Some people do have some bladder issues, leakage issues and things like that, which can

00:57:10.240 be very annoying for folks to be sure.

00:57:12.560 I mean, yes, there are surgeries that can be done, but Kegels help.

00:57:16.100 And the other thing is, this is another, and I find this is an excellent motivation to people

00:57:20.480 that as far as like leakage of urine, if you look at all the literature on bladder leakage,

00:57:26.200 that there's a 5% body weight loss translates in this literature to a 50% improvement in leakage.

00:57:33.360 So if you're way over your body, yeah, yeah.

00:57:36.620 If you're really overweight, or not even really, really overweight, but somewhat overweight,

00:57:40.480 that if you lose 5% of your body weight, you have a 50% improvement in leakage of urine.

00:57:47.060 If you're a urine leaker.

00:57:48.260 And many of us are.

00:57:49.580 If you're a leaker.

00:57:50.220 So that's awesome.

00:57:52.600 I got, that's very good news for a lot of women who, who worry about this issue.

00:57:55.660 So that's good to know.

00:57:56.820 Okay.

00:57:57.280 What is that the same thing?

00:57:58.580 The Kegels, we've all been told what the Kegels are, but is that the same thing?

00:58:01.780 Cause we had Sarah and Michelle both wrote in about pelvic floor physical therapy, pelvic

00:58:08.280 floor PT.

00:58:10.120 Is that a Kegel or is this, does it involve more than Kegels?

00:58:13.500 They do more than Kegels.

00:58:14.720 They do more than Kegels.

00:58:15.740 And if you need more than that, pelvic floor PT is great.

00:58:19.420 And that's really blossomed in the last 10 years or so.

00:58:22.440 What is it?

00:58:22.680 And there are many, many people who've been now trained in pelvic floor physical therapy.

00:58:26.940 It can be a terrific option.

00:58:28.540 And again, Hey, I love operating.

00:58:31.360 Don't get me wrong.

00:58:32.360 It's a lot of fun.

00:58:33.740 But if you don't have to have an operation, that's great.

00:58:36.500 And don't let those surgeons stay in business.

00:58:38.760 But the key thing is if you can do it through, you know, Kegeling, through pelvic floor PT,

00:58:43.320 through weight loss, if you, you know, you could use a loose few pounds, all of these

00:58:47.720 things can be helpful.

00:58:48.820 And, you know, if you need surgery, we've got surgery, but these things are really very

00:58:52.080 good to do non-surgically if you can.

00:58:54.660 What is pelvic floor PT?

00:58:57.200 I don't understand.

00:58:58.480 Like, and who would I go to for it?

00:58:59.740 Like, are you, do you call like the same guy who works on your knee?

00:59:02.660 The answer is these days, most of the physical therapy places have people who are subspecialists

00:59:08.580 in areas.

00:59:09.060 So you go, you call up your pelvic, your, your PT place and say, who's doing your pelvic

00:59:12.660 floor stuff.

00:59:13.460 And is this somebody who's had special training in pelvic floor PT?

00:59:16.560 And most of your gynecology folks will know folks to go to.

00:59:19.920 I have some really terrific pelvic floor physical therapists that I refer my patients to.

00:59:24.080 Okay.

00:59:24.980 This is like we, we had this, Michelle writes in a pelvic floor physical therapist was

00:59:28.780 a game changer for me and my husband, our sex life and our marriage.

00:59:32.320 I had no idea until after my third baby in 2021, this is even an option, but I had pain

00:59:36.680 and discomfort during sex for years, making it a chore, something I generally did not

00:59:41.020 look forward to after PFPT.

00:59:43.080 The pain is basically gone.

00:59:44.920 The incontinence issues, sneezing, coughing, et cetera, are so much better and so on.

00:59:49.480 So I heard about this from a couple of different viewers and just wanted to share that with

00:59:53.680 the audience.

00:59:54.480 Look into it.

00:59:55.160 That's another potential option.

00:59:57.320 Okay.

00:59:57.720 And we're going to get to some other questions in just a second.

00:59:59.660 So that's, that covers another piece of sexual dysfunction, but we have to spend a minute

01:00:05.100 on orgasms.

01:00:06.680 Last week, you talked about men who are not able to have one.

01:00:09.600 Like there are men who of course have problems getting an erection, but actually men who cannot

01:00:14.320 have an orgasm, believe it or not.

01:00:15.600 And I think it's probably an even greater number of women who have difficulty achieving orgasm,

01:00:21.000 which, you know, may not make it pointless, but it makes it less enjoyable if you can't.

01:00:26.120 So is that a dysfunction?

01:00:28.260 What is that?

01:00:28.760 Well, it's not necessarily a dysfunction.

01:00:32.100 I think a lot of it is expectation.

01:00:34.640 Many women expect that they're going to have an orgasm from strictly vaginal intercourse.

01:00:39.940 Okay.

01:00:40.660 And there aren't that many women who really do achieve orgasm without some clitoral stimulation.

01:00:46.320 Okay.

01:00:46.980 Many women can have a clitoral orgasm without any vaginal activity, but there's not much

01:00:50.960 many, there aren't too many women who can have a vaginal orgasm, you know, achieve orgasm

01:00:55.360 without some clitoral stimulation.

01:00:56.780 So don't forget the clitoris.

01:00:58.760 It's very important.

01:00:59.820 You know, okay.

01:01:00.360 And again, if you're having pain dealing with it, you know, talk to your provider to see

01:01:03.480 if we can get things better for you.

01:01:05.300 And so clitoral stimulation is important.

01:01:07.460 Again, avoiding pain, making sure there's good lubrication for sex is very important.

01:01:11.400 And we are a big, most of us in the gynecology business, and I'm sure when you were interviewing

01:01:17.720 Sharon, she probably discussed this too.

01:01:20.020 Many of us are big advocates for things like vibrators and other sex toys and things like

01:01:24.940 that, which can liven things up.

01:01:26.340 And the other good thing about a vibrator besides emphasizing stimulation is that also vibrators

01:01:34.240 increase pelvic blood flow.

01:01:36.480 So anything that increases pelvic blood flow is good for moisture.

01:01:40.140 So if you're having dryness problems, vibrators can do many things for you.

01:01:44.140 So we encourage people to use that and we encourage people to explore and try them in different

01:01:48.120 manners.

01:01:48.460 So those are all very good things to use.

01:01:51.500 And again, many, many women can have orgasms, you know, that with just the appropriate clitoral

01:01:56.140 stimulation.

01:01:57.020 Now, one thing that I am going to mention, okay.

01:02:00.120 And I may get people, some of my buddies may get mad at me for saying this, but that's okay.

01:02:05.080 People get mad at me a lot that there are women, and we get back to the SSRI issue.

01:02:11.000 There are women who take SSRIs that blocks their orgasmic response.

01:02:16.240 Okay.

01:02:16.880 And that is a real issue.

01:02:18.160 And again, we get back to the issue of, could you change, you know, SSRIs?

01:02:21.940 Could you change to a different medication?

01:02:23.520 Could your depression be ameliorated with, you know, Wellbutrin as opposed to an SSRI?

01:02:28.200 Things of that nature.

01:02:29.480 However, there is a very small, and this is not an official indication, folks.

01:02:34.320 This is not an official indication.

01:02:35.760 Don't feel badly if your gynecologist says, no, that's stupid.

01:02:38.700 There's no official indication for this drug.

01:02:41.080 But there is one use of Viagra in women, sildenafil.

01:02:45.800 And that is for women who have a blunted orgasmic response from SSRIs.

01:02:50.780 And there is a very limited body of information showing that sildenafil, Viagra can help those women achieve orgasm.

01:02:58.400 So again, limited body of data.

01:03:00.720 Talk to your gynecologist.

01:03:02.140 Think if this person, if she or he thinks it's a reasonable option.

01:03:06.060 And again, in people, and you see all the advertisements on TV for the guys, if you have heart disease and stuff like that, same thing goes for women.

01:03:12.160 But if you're basically in good health and you're in good shape and your heart's in good shape, most people can take it.

01:03:16.760 So it's something that is something that is possible to use.

01:03:19.640 It's not widely known, but it is something that is a possibility.

01:03:23.520 Well, do not forget the clitoris.

01:03:25.840 Good advice for men and women.

01:03:28.420 Absolutely.

01:03:29.180 Please, please.

01:03:30.200 An important part of your body.

01:03:31.780 Yes, I think we know that.

01:03:34.520 That's for sure.

01:03:35.320 All right.

01:03:35.480 Now, quick question for you on the youngins, because we had a long debate on the show one day about the HPV vaccine.

01:03:44.180 A lot of us, a lot of my friends have daughters right around this age where their pediatricians are recommending it.

01:03:50.880 And we had somebody who was, you know, arguing it's a good idea.

01:03:54.700 And we had somebody who said, maybe more caution is in order on that one.

01:03:59.240 And I recently saw one of my closest.

01:04:02.320 I love this woman.

01:04:03.500 She delivered all three of my babies, my OBGYN in New York.

01:04:07.140 And she was like, all of your kids are getting the HPV vaccine.

01:04:11.100 I don't care what you talked about on your show.

01:04:13.640 Give it to your boys.

01:04:15.060 Give it to your daughter.

01:04:16.580 Shut up.

01:04:17.460 That's she was like, just stop.

01:04:19.960 She's one of my friends.

01:04:21.940 I'll tell her name later.

01:04:23.200 Anyway, she.

01:04:24.260 Yes.

01:04:24.740 So let me get your opinion on that while I have you.

01:04:27.540 It's very good advice.

01:04:29.260 And the key thing is, I mean, I'm a very, very lucky person.

01:04:32.960 I've been in my same practice basically for 44 years.

01:04:36.000 So I know these people.

01:04:37.600 I've delivered their kids.

01:04:38.620 I'm sometimes taking care of their kids.

01:04:40.760 You know, I haven't had any grandchildren this way.

01:04:43.800 But anyway, plenty of honorary grandchildren, but not great-grandchildren.

01:04:48.820 Anyway, but the key thing is many mothers will say, oh, no, no, but my daughter.

01:04:54.000 And the reason we immunize them early is not that we think they're necessarily going to

01:04:57.080 have sex at 9 or 10.

01:04:58.420 We hope they aren't.

01:04:59.700 But the key thing is, it's easier to get them when they're 9 or 10 to give them their

01:05:03.360 shots and make sure they get them before they get to be 15 and 16.

01:05:06.920 And we may have trouble corralling them to get the shots.

01:05:10.160 So it is a good idea.

01:05:11.480 There really are no side effects to the shot.

01:05:13.920 Yeah, I've seen a few kids get lightheaded.

01:05:15.720 So we make the kids, after we give them the shots, sit in the office for 15 minutes to

01:05:19.420 make sure they're not getting lightheaded, but they'll be fine.

01:05:21.420 But there really are no known bad complications.

01:05:24.980 And we are seeing, we actually have literature showing this, that in populations where you're

01:05:29.980 getting immunizations, that we have seen the rate of cervical cancer start to really decline.

01:05:35.400 And the thing to remember is with the new vaccine, the new what they're called, the non-availant,

01:05:39.680 it gets nine strains of the HPV virus, because there are a lot of strains of the virus out

01:05:44.120 there, that you can prevent about 90% of cases of cervical cancer.

01:05:48.440 I mean, if somebody says to me, there's this, that, or the other, you can do to present 90%

01:05:53.080 cases of lung cancer, pancreatic cancer.

01:05:55.300 I'd say, that's fabulous.

01:05:56.600 That's terrific.

01:05:57.740 But this is a disease that if the kids get the shots.

01:06:00.280 Now, the other thing though, and we have literature to support this as well.

01:06:04.240 A lot of my patients are concerned.

01:06:06.300 Oh, but if my kid gets the shot, they're going to become promiscuous.

01:06:09.480 Okay.

01:06:09.880 They're going to have sex with everybody.

01:06:11.500 And the thing that I tell people in any shot that I give, I give them the shot and they get

01:06:15.260 to talk at the same time, you still want to use condoms, condoms, condoms, no substitute

01:06:20.160 for condoms, because yes, I'm helping to prevent your risk of cervical cancer, but I'm not helping

01:06:25.120 to prevent your risk of chlamydia, gonorrhea, syphilis, HIV.

01:06:30.360 Should I keep going?

01:06:31.560 So the issue is, yes, I am helping to prevent cervical cancer.

01:06:33.260 Show them a couple of pictures on the internet if they're thinking about not using a condom and

01:06:36.820 that'll shape things up.

01:06:38.760 For people who are interested, that debate was held in episode 565.

01:06:43.060 If you want to go back and hear both sides of it, but I always like getting, you know,

01:06:46.140 everybody, I like to hear from everybody and you know, it's like people have to make up

01:06:48.980 their own minds on these things.

01:06:50.480 But I was personally, it made me feel better to have the woman who I've trusted for 15 years

01:06:54.760 with all my babies just be so blunt about it.

01:06:57.520 And that may bring others comfort to hear you talking about it too.

01:07:01.060 Okay.

01:07:01.420 Let's jump to a little bit older.

01:07:03.000 And that is the age of most of my producers on this show, women in their late twenties,

01:07:08.400 early thirties who are like strong and fierce and professional who probably aren't going

01:07:13.840 to have babies until like maybe 35, you know, maybe mid thirties.

01:07:18.700 And they're already worried.

01:07:20.040 You know, they've been on birth control pills for, you know, whatever, how many years.

01:07:24.040 And they're concerned about whether waiting until you're mid to late thirties, how high

01:07:30.520 does it drive up your infertility numbers, right?

01:07:32.740 Like your, your, how much does it lower your chances of conceiving and how to birth control

01:07:36.700 pills that play into those risks, if at all.

01:07:41.000 Interesting questions.

01:07:42.100 And the answer is waiting.

01:07:44.580 The time is the issue, not the birth control pill usage.

01:07:47.600 Okay.

01:07:47.820 The birth control pills do not lead to long-term infertility.

01:07:51.260 And if you look at the resumption of fertility after stopping the pill, it should be pretty quick.

01:07:56.000 Now that doesn't mean something can be happening in your belly that you might not be aware of,

01:08:00.660 you know, because the birth control pill is giving you nice limited cycles and things

01:08:04.320 like that.

01:08:05.120 But indeed, actually birth control pills are one of the therapies we use to help treat

01:08:09.160 or prevent endometriosis.

01:08:10.520 So it's actually good to help prevent it, not, not bad or anything like that.

01:08:14.680 So the pill I'm not worried about as far as keeping them infertile.

01:08:18.180 As far as age issues though themselves, there are issues that the older we get, the less

01:08:23.800 fertile we get until 35, you don't see a huge diminution.

01:08:28.140 Okay.

01:08:28.440 After 35, you do start seeing some, you know, levels of fertility going down.

01:08:33.700 And I sort of break it into like 35 to 38.

01:08:36.660 Yeah, it's down, but it's, it's not awful down.

01:08:39.140 Once you get beyond 38 to 40, you start seeing some pretty significant diminutions.

01:08:43.680 Now, again, it doesn't mean people 40 don't get pregnant.

01:08:45.820 Hell no.

01:08:46.860 But it does lead to some diminutions.

01:08:49.320 And again, one other thing to get back to the STI, STD question.

01:08:53.000 Okay.

01:08:53.980 Is one thing you can prevent is STI.

01:08:57.160 So don't, chlamydia is a terrible disease.

01:09:00.220 Chlamydia you can get without knowing it's being transmitted to you.

01:09:03.620 And again, people who are using birth control pills for their contraception, oftentimes aren't

01:09:07.900 using a condom to help prevent them getting chlamydia, which they may be being transmitted.

01:09:12.040 So, you know, keep yourself as free as you can from STIs because that hinders you getting

01:09:16.480 pregnant too.

01:09:16.760 What's an STI versus an STD?

01:09:19.540 Oh, it's basically the same thing.

01:09:20.980 Some people use the term, the old term, like an old person like myself often uses STD,

01:09:25.520 sexually transmitted disease.

01:09:26.820 The current terminology is sexually transmitted infection, but we're talking about the same

01:09:31.160 thing.

01:09:31.680 The old term is venereal disease, right?

01:09:34.360 That's like way back when we were growing up.

01:09:35.800 Well, you know where, you know where the term venereal disease comes from?

01:09:39.000 You know what the origin of the word venereal is?

01:09:41.540 Uh-uh.

01:09:42.080 No.

01:09:42.560 I like Latin scholars.

01:09:43.980 It's from the Latin word Venus or Venus Veneris.

01:09:47.900 So it means of love, of the goddess of love.

01:09:50.460 So that's where venereal comes from.

01:09:52.580 Anyway, so that's something to keep in mind.

01:09:55.140 But, you know, goddess of love, notwithstanding use a condom.

01:09:58.900 Very important.

01:09:59.800 Or make sure your partner's been tested recently.

01:10:02.320 So those are all important things to do.

01:10:04.000 Now, of course, the question then comes up because obviously, you know, many of us don't

01:10:08.400 want to have kids.

01:10:09.280 I mean, you know, my docs are out there.

01:10:11.320 I mean, my kids were born when I was 36 and 38.

01:10:14.740 So, you know, many of us are working and training, training and working for a number of years

01:10:18.480 before we have our kids.

01:10:20.160 So obviously, one of the issues that's come up that what about egg freezing?

01:10:23.920 Is egg freezing a good thing to do?

01:10:25.760 And it's certainly quite reasonable.

01:10:27.420 And again, the last 10 years, the technology has come along very nicely.

01:10:31.180 It is expensive.

01:10:32.000 You know, it's not cheap.

01:10:34.000 And, you know, the process of getting the eggs and then maintaining the eggs, keeping

01:10:37.980 them in a good frozen, a good freezer and things like that in a good supervised facility.

01:10:42.740 These are expenses.

01:10:44.580 But many people choose to do it.

01:10:46.520 And I think it's certainly fine.

01:10:47.780 The only concern I have with, you know, egg freezing is don't count on it.

01:10:53.600 Okay.

01:10:53.940 Because there are some times you'll freeze a fair number of eggs and it won't work.

01:10:57.960 So it's not like a guarantee to say, oh, if I freeze my eggs, okay, I can wait till I'm

01:11:02.000 47 or 50 to have my family.

01:11:04.180 The answer is, no, I can speak to this because I had IVF for all three of my kids.

01:11:09.520 And, you know, you like when they unfreeze the eggs, they can not like take, they can

01:11:17.620 they can sort of completely unfreeze to where they're not usable.

01:11:21.380 Some can be if you have genetic testing, you can find out, you know, some are not able

01:11:25.480 to, like, you know, develop into an actual fetus.

01:11:28.720 So it's like there's also if you just like freeze 10 eggs and think I'm good, you are

01:11:33.320 not necessarily good.

01:11:34.220 No, no, you aren't.

01:11:36.640 And that's the key thing that I think that many women are in a sense, they're either

01:11:41.160 they're being sold a bill of goods or convincing themselves that they're guaranteeing that they're

01:11:45.160 going to have, you know, well, I'll have a kid because I have frozen eggs.

01:11:47.820 I mean, there's a good chance you will, but there's also a significant possibility you

01:11:51.060 won't.

01:11:51.520 And the thing I always say is, God forbid, how would you feel if, you know, that you couldn't?

01:11:56.440 So these are things to take into account.

01:11:58.280 And I don't think, you know, the gynecology folks can answer that for anybody.

01:12:01.620 I think that's something that you independently have to ask yourself.

01:12:05.580 And listen, I have a couple of friends of mine who are lesbians in a marriage.

01:12:10.820 And of course, they used donor sperm and they have amazing children.

01:12:14.880 Their kids are absolutely gorgeous, beautiful, smart, you know, fun, strong.

01:12:19.440 You know, it's there are all sorts of ways, like if the biological clock is ticking and

01:12:23.280 you really want to be a mother in modern day America to to take care of it, you could

01:12:29.020 freeze eggs, you could get donor sperm, you could do a bunch of different

01:12:31.560 things and get on those damn dating websites.

01:12:35.240 Ideally, you have a friend set you up.

01:12:37.740 I think that's the best way to meet your future partner for nobody asked me, but that's

01:12:41.340 what that's what I think.

01:12:42.600 OK, let's get into menopause.

01:12:44.760 The big pause, the big pause.

01:12:47.160 First of all, how do you know when you are actually in menopause versus being periomenopausal

01:12:56.240 versus being postmenopausal?

01:12:57.920 Like, what is menopause?

01:13:00.800 OK, menopause, as I define it for my patients, is the pooping out of the ovaries.

01:13:04.920 That's what it's about.

01:13:06.800 When somebody has is having periods, in other words, she hasn't had a hysterectomy or she

01:13:11.420 doesn't have an IUD and it keeps her from having periods or something like that.

01:13:14.520 You can say you are menopausal when you go a full year without having a period.

01:13:19.900 Any bleeding or a period?

01:13:22.840 No bleeding, no bleeding at all, no bleeding, even a little bit of light bleeding counts

01:13:25.960 and you got to reset that clock.

01:13:27.360 So even a little bit of light bleeding counts, doesn't have to be a full period.

01:13:30.420 OK, so you go that year without a period or significant bleeding.

01:13:34.120 You can say, yep, I am fully menopausal.

01:13:36.320 OK, until then, if you and but the key thing is you can have all the fabulous symptoms of

01:13:42.520 menopause, the hot flashes, the night sweats, the insomnia, the achiness, vaginal dryness.

01:13:48.100 We can keep going.

01:13:49.500 You can have all those fabulous symptoms even before you skip period, let alone start getting

01:13:54.220 erratic periods.

01:13:55.440 And the erratic periods can go on for quite a while, unfortunately.

01:13:59.880 And the problem is, let's say you go six months without a period and you say, oh, I'm getting

01:14:03.740 there, I'm getting there, bingo, you get a period.

01:14:06.500 Well, it's not another six months to put in the clock.

01:14:09.040 It's a full year.

01:14:09.860 You have to say, OK, I have to wait another full year to say I'm fully menopausal.

01:14:13.800 OK, now, the key thing is that doesn't mean that you have to wait until you've got a full

01:14:18.860 year without seeking intervention.

01:14:21.280 You know, if you haven't slept the night, I don't care whether you're having skipped

01:14:24.260 periods or not had to skip periods.

01:14:26.000 We got to help you.

01:14:26.840 We got to make you get some sleep so that, you know, intervention is certainly fine, but we

01:14:32.100 just can't say you're technically fully menopausal.

01:14:34.280 And the other thing that I always like when we talked about fertility in older folks, well,

01:14:38.400 the thing to remember is that until you go that magic year without having a period, without

01:14:43.660 anybody else keeping you from having a period, that you can't say to somebody, she's not

01:14:48.020 going to get pregnant.

01:14:49.000 And in my personal experience here, I personally have delivered three women at the age of 47 who

01:14:56.680 were not in vitro patients.

01:14:59.560 They were people who were like, oops, pregnancy.

01:15:01.220 So I've delivered three 47.

01:15:02.840 It can happen.

01:15:03.760 Now, when you say the erratic period, that sounds terrifying.

01:15:06.820 That's basically going back to when you're 12 or 13 and you don't know when the period's

01:15:10.280 coming and you haven't figured out, you know, like how to prepare for it.

01:15:13.300 The next thing you know, you have an embarrassing moment in gym.

01:15:15.260 Like, what's the erratic period?

01:15:17.780 They can go from two weeks.

01:15:19.520 They can go to six weeks or 12 weeks or eight weeks.

01:15:22.260 You know, it's they're all over the place.

01:15:24.240 Well, that's a nightmare.

01:15:25.320 And how do you regulate that?

01:15:26.660 Well, we can do this.

01:15:29.220 You know, okay.

01:15:29.860 Because the key thing that's going on is that actually the erratic periods are more of a

01:15:35.660 problem of less progesterone.

01:15:37.840 Progesterone is the hormone our ovaries make when we ovulate.

01:15:41.680 And one of my buddies, Dr. Nanette Centoro always says, oh, I just tell my patients that

01:15:46.500 the lining of the uterus is like a lawn.

01:15:48.880 And estrogen is like fertilizer.

01:15:50.740 And progesterone is the lawnmower.

01:15:52.600 And I think that's a pretty good analogy is about what's going on.

01:15:55.480 So estrogen feeds the growth of the lining of the uterus.

01:15:58.160 And the progesterone goes in there and regulates it and cleans it out.

01:16:01.100 And so we can oftentimes take these women who are having crazy bleeding all over the place

01:16:05.580 and give them some progesterone in a manner to regulate their cycle.

01:16:09.060 So we can do that without using estrogen.

01:16:11.680 However, a lot of times when people are getting their wacky periods, they are also

01:16:15.980 junk that people get that makes them uncomfortable.

01:16:21.320 And there are a couple of tricks that we can do very nicely for folks to get them through

01:16:26.240 perimenopause.

01:16:27.680 And for example, a low dose, you mentioned being on the low dose birth control there,

01:16:32.280 Megan.

01:16:32.820 And so that can be a friend of yours for controlling crap, crazy cycles.

01:16:37.660 And a low dose pill can be very, very helpful.

01:16:40.080 And the nice thing about a low dose pill, besides having a progesterone, a synthetic progesterone

01:16:44.380 in it to keep the bleeding under control, it also has estrogen there.

01:16:48.360 So if you're getting hot flashes, night sweats, sleep craziness, that will help take care

01:16:52.920 of the crazy sleep and the crazy periods.

01:16:56.020 So low dose birth control pills can be a real blessing in the perimenopausal time frame.

01:17:00.740 How long can you stay on them?

01:17:02.320 If you're not a smoker, if you're a smoker, you don't want to be on them.

01:17:05.720 You cannot be on them.

01:17:06.880 Beyond the age of 35, smokers should not be on the pill.

01:17:10.060 Now, of course, I tell people, let me help you to stop smoking, then I can give you the

01:17:12.800 pill.

01:17:12.960 Um, because I really am an advocate for stopping smoking if we can.

01:17:16.840 So the key thing is that you can stay on them forever, to be honest, well, not forever.

01:17:21.540 Um, and, um, there are patients that I put on the pill and this, and I always tell this

01:17:26.060 to somebody that I'm putting on the pill for perimenopausal control.

01:17:29.060 I will not know when your ovaries have officially pooped because the pill will keep giving you

01:17:34.680 periods.

01:17:35.420 Okay.

01:17:35.780 So I don't know whether they're, you know, what your own ovaries are doing because it's

01:17:39.600 masking them.

01:17:40.340 But my usual statement to my patient, but do you really care if you know exactly when you're

01:17:44.400 stopping your periods?

01:17:45.400 You don't care.

01:17:46.100 You want to be comfortable and you don't want to bleed.

01:17:47.960 I thought that once you hit like right around my age, 50, 52, 53, that you couldn't stay on

01:17:53.700 the birth control pill anymore because of the risk of blood clots and or heart attack.

01:17:59.500 And there was something to the effect that you mentioned synthetic, like that's a, that's an

01:18:03.540 issue of taking the synthetic.

01:18:05.060 I don't even remember whether it's the estrogen or the progesterone, but can you talk about

01:18:08.880 that?

01:18:09.740 Sure.

01:18:10.300 Sure.

01:18:10.600 The issue is that there, you're absolutely right.

01:18:12.780 There is an increased risk of blood clotting the older we get, which is why we tend to

01:18:16.120 like to use very low dose pills rather than using a high dose pill and in general, try

01:18:20.280 to minimize that risk of clotting.

01:18:22.200 Um, however, there is no one age to say, okay, you were 54, you should go off.

01:18:26.520 Okay.

01:18:27.400 What I will often do though, because the key question is we don't know if you're fully menopausal

01:18:31.400 and the key thing that most women don't realize is that birth control pills actually have much

01:18:37.220 more estrogen than quote unquote hormone replacement therapy or hormone therapy, that

01:18:41.920 the pill is actually more estrogen.

01:18:43.900 So if somebody is having is on the birth control pill, and we really don't know whether she's

01:18:48.780 menopausal or not, what I will often do, and I will use like, for example, family history.

01:18:53.960 If she has, everybody in my family went through menopause at age 48.

01:18:56.820 Okay.

01:18:57.440 Okay.

01:18:58.320 I mean, that doesn't guarantee that she's going to be menopausal age 48, but that's a

01:19:01.660 guide.

01:19:02.140 So we may stop her at 48 or 49 and say, okay, are you menopausal?

01:19:06.400 If you go off the pill, see what your hormones are doing on your own.

01:19:09.280 If she says, everybody in my family went through menopause at 57, you know, we may try at about

01:19:14.400 age 55, if it was only she's totally happy and see where she is.

01:19:18.020 But if she's not, we can put her back on the pill if she wants to be back on the pill.

01:19:21.020 Is hormone replacement therapy, like it's estrogen and progesterone, right?

01:19:26.240 But is that just a lower dose of what's in the pill?

01:19:30.180 It's a much lower dose.

01:19:31.420 Yeah, it is a lower dose.

01:19:32.820 Now, the one thing that we can say is that with the birth control pills, there's a slightly

01:19:37.860 different estrogen in general in the pills than what's in the hormone therapy.

01:19:42.120 Not dramatically different.

01:19:43.440 I mean, accomplishes the same thing.

01:19:45.460 And then hormone replacement therapy, hormone therapy view of using progesterone, there are

01:19:50.000 some naturally natural progesterones that we can use for hormone replacement therapy.

01:19:56.060 And some people do prefer them to the synthetic progestins.

01:19:59.260 So again, we can come up with a nice friendly combination for low dose hormone therapy.

01:20:04.680 If somebody says, I really like my estrogen and my progestin, but, you know, if you don't

01:20:08.660 need it, then by all means, you don't need to take it.

01:20:11.520 Is that a same question on that as we did on the testosterone?

01:20:15.580 Is there a shelf life for how long you can take HRT?

01:20:21.180 No, the honest answer is no.

01:20:25.100 Basically, the key thing is, again, you want to revisit, you know, these things with your

01:20:30.160 provider and you want to talk to a provider who knows something about menopause.

01:20:33.560 Okay.

01:20:34.420 For a while, back after the Women's Health Initiative came back in 2002, a lot of people

01:20:41.500 have raised all the concerns about HRT that led people to say, I'm not doing that.

01:20:45.400 And basically now women got screwed for 20 years, not even being offered HRT.

01:20:50.580 Yeah.

01:20:51.040 Well, we can talk more about that too.

01:20:52.720 But anyway, around that time that folks realized that the increased risk of breast cancer seemed

01:20:58.780 to manifest itself, you know, in this study after about five years of use, okay, in women

01:21:04.640 who were taking estrogen plus progestin.

01:21:07.300 And so there are a thought arose among many providers.

01:21:10.960 Okay.

01:21:11.220 It's okay to take it for five years, but then you want to stop because that's where you have

01:21:15.020 your increased risk of breast cancer.

01:21:16.900 Well, the answer is it was a very, very minuscule increased risk of breast cancer.

01:21:21.160 And there are ways we can minimize those risks so that really, I think the, this five-year

01:21:25.660 mark has now sort of become passe.

01:21:27.240 And the official, um, the official mantra of the menopause society, the former North American

01:21:32.820 menopause society is basically to take, it used to be take the lowest dose for the shortest

01:21:37.340 duration of time.

01:21:38.340 That was the official mantra.

01:21:39.660 The official mantra now from the menopause society is use the appropriate dose for the

01:21:45.040 appropriate duration.

01:21:46.000 And so the key thing is you need to be visiting, you know, with a provider who knows something

01:21:51.520 about menopausal therapy, menopausal hormone therapy.

01:21:54.400 And if people are doing well and they really seem to be, be doing thriving and everything's

01:21:59.480 to be fine, um, they may stay on it.

01:22:02.200 So it's really, it's really an independent thought.

01:22:04.520 Like why, why would you take it?

01:22:06.380 Is it just, just for hot flashes and sleepless nights?

01:22:09.760 And, uh, I don't know.

01:22:11.880 I can't remember the other symptoms, but is it just to address symptoms or is it like I

01:22:16.540 talk about my two friends who I have in Connecticut who are like totally vibrant and they're in

01:22:21.840 their later, you know, like they're in their mid to late fifties and like, I don't know if

01:22:27.040 that's HRT or testosterone or like, why, why would you take HRT is I guess what I'm asking?

01:22:32.700 Well, it's an excellent question.

01:22:34.680 And certainly symptomatology is important.

01:22:37.140 And the key thing is like, some people think hot flashes, well, they're only going to occur

01:22:40.520 around menopause, you know, the first couple of years.

01:22:43.780 Well, about 10% of women will have significant hot flashes for more than 10 years.

01:22:49.580 Okay.

01:22:50.120 Unfortunately.

01:22:50.920 Now I don't greet my patients saying, guess what?

01:22:53.420 You know, you have those lousy hot flashes now and about 10% of you are going to have persistent

01:22:57.540 hot flashes.

01:22:58.140 They're going to last for a while.

01:22:59.300 No, I mean, I try and they do get better over the course of time.

01:23:01.720 But the other thing that I reaffirmed for them is that we got plenty of therapies that

01:23:05.520 can help.

01:23:05.960 So we don't sit there and suffer and be miserable.

01:23:07.980 We're not going to let that happen to you.

01:23:09.280 So they do help symptoms, but what else does it help?

01:23:12.260 Well, and again, the other thing to remember is vaginal dryness.

01:23:15.500 The hot flashes tend to get better.

01:23:17.280 Vaginal dryness, unfortunately, in general does not get better.

01:23:20.860 It tends to get worse over the course of time.

01:23:23.000 Now, of course, there are vaginal therapies that one can use, but systemic therapy does help,

01:23:28.240 you know, as far as the vaginal tissue as well.

01:23:30.240 Now, however, in a sense of vibrancy, the question is, well, are these ladies sleeping

01:23:34.880 better?

01:23:35.300 Is that why they're more vibrant?

01:23:36.880 Certainly, again, skin dryness occurs.

01:23:39.920 Are they looking vibrant because they have much more moisture in their skin?

01:23:42.980 Well, estrogen therapy helps that too, although it is not an official indication for that.

01:23:47.700 The official health, if there are health indications, estrogen therapy is very protective

01:23:52.660 for bone loss, protective against bone loss.

01:23:55.160 And so if somebody has a very strong family history of osteoporosis, and she herself is

01:24:00.100 a very slim woman, and this is the only, osteoporosis is the only entity that is worse if you're

01:24:06.920 slim.

01:24:07.480 That's a terrible thing.

01:24:08.760 But slim women have a higher risk of a fracture than women who are heavier, unfortunately.

01:24:14.000 So that's out there.

01:24:15.060 Um, so, but dementia, right?

01:24:17.740 Doesn't it help prevent if you start HRT, um, like early in your menopause, like not,

01:24:24.400 not until you're 10, 10 years post menopausal, it can help prevent dementia.

01:24:29.440 Not clear.

01:24:30.620 Unfortunately, the dementia data is not clear and we don't have the formal answer on it.

01:24:35.720 Um, certainly we have data that says if you have dementia, don't give estrogen.

01:24:39.260 It's not going to make a difference.

01:24:40.380 There is certainly some literature that suggests if you take, uh, estrogen early on, it will

01:24:46.240 help prevent dementia, but that's not, that's not written in stone and we don't have unequivocal

01:24:50.460 data.

01:24:51.180 The major question that's out there is does estrogen help prevent heart disease?

01:24:56.420 And this is actually the reason the women's health initiative was actually launched was

01:25:00.960 to answer that question.

01:25:02.480 Does estrogen help prevent heart disease?

01:25:04.880 And if you just think about it, you know, I think about your, your friends and your family,

01:25:08.220 do you have a guy that you know who had a heart attack in his thirties or forties?

01:25:13.120 Yeah.

01:25:13.240 Most of us know guys that have had heart attacks in their thirties or forties.

01:25:16.160 Now think about women and women, friends, family, how many women do you know that had a heart

01:25:20.400 attack in their thirties or forties?

01:25:21.620 And the answer is not many.

01:25:22.620 So that sort of started the thinking about this, gee, maybe there is something in estrogen

01:25:26.920 that helps protect the heart.

01:25:28.720 And there were some studies out that showed that women who were taking estrogen as they went

01:25:32.880 through menopause seemed to have a substantial reduction in heart disease.

01:25:35.880 So that led to the WHI study to answer that question.

01:25:40.220 Now, the key thing about the WHI study is that it didn't show protection against heart

01:25:46.940 disease, but the problem with the WHI study is it was studying primarily older women.

01:25:52.980 The average age of women in the women's health initiative starting the estrogen was about

01:25:56.840 age 63.

01:25:58.140 Whereas the average age of women going through menopause is about 51.

01:26:01.980 And that was the typical age around then that people were starting their estrogen for relief

01:26:06.820 of symptoms.

01:26:07.360 They were getting hot flashes.

01:26:08.460 They were getting night sweats.

01:26:09.480 They were given estrogen.

01:26:10.740 And for those women, it seemed to help protect against heart disease too.

01:26:14.460 So the problem is the WHI did not show any degree of heart protection.

01:26:19.200 And people started asking the question, why?

01:26:21.160 And then folks started doing some smaller trials, looking at women actually going through

01:26:25.640 menopause and getting estrogen shortly thereafter.

01:26:28.540 And in those trials, it did seem to help prevent heart disease.

01:26:32.320 However, they were not huge trials and stuff like that.

01:26:36.340 And the official recommendation is, although estrogen certainly when given early seems to

01:26:40.980 have a protective event, we are not officially supposed to recommend it for women as a protection

01:26:46.140 against heart disease.

01:26:47.120 Now, do I say it doesn't exist?

01:26:49.840 No, but it's not an official indication.

01:26:51.780 Now, the one group though that I really, if we have some listeners in this category, if you

01:26:56.600 are one of these folks going through menopause at 35 or 40, you're going through menopause

01:27:00.880 really early.

01:27:01.760 And unfortunately, 1% of women are menopausal by age 40, that 5% to 7% of women are menopausal,

01:27:08.280 fully menopausal by the age of 45.

01:27:11.240 That's young.

01:27:12.020 I mean, that's really young.

01:27:13.100 If you are in one of those young categories, you know, particularly if you're 38, 40,

01:27:17.420 something like that, and you're going through menopause and you go to a gynecologist who

01:27:21.360 says, no, you're not having any symptoms.

01:27:23.100 You don't need estrogen, please find yourself another gynecologist, go to the NAMS website

01:27:29.080 and find the gynecologist who will give you estrogen.

01:27:31.980 Because unless there's an absolute contraindication to taking estrogen as a very young woman, like

01:27:37.220 a 40 year old going through menopause, you should be taking some estrogen unless you have

01:27:41.300 a contraindication because you're at very high risk.

01:27:44.220 And those people are at high risk if they don't take it for dementia.

01:27:47.280 And if you look at women under the age of 45 who have their ovaries taken out and don't

01:27:53.820 get estrogen, there's about a threefold increased risk of getting dementia.

01:27:57.760 We have good data on that.

01:27:59.540 Very, very good to know.

01:28:04.360 Dr. Minkin, we've got a call from Maria in Connecticut who's got a question for you.

01:28:08.960 Maria, what's your question for the good doctor?

01:28:10.940 Hi, thanks for taking my call.

01:28:12.240 My question is, I'm almost 50 years old.

01:28:15.280 I'm having menopausal symptoms, night sweats, hot flashes.

01:28:19.520 I have a younger sister who had hormone positive breast cancer two years ago.

01:28:24.540 So I'm not, I've been told I am not a candidate for hormone replacement because of that.

01:28:30.560 So I'm just curious what my options are for symptoms.

01:28:34.060 Good question.

01:28:34.680 Okay.

01:28:35.220 Well, Maria, I don't mean to disagree with an eminent doctor who might have told you this,

01:28:40.540 but it's okay for you to take hormones.

01:28:42.160 It really is.

01:28:43.320 Family history does, now a family history does increase your native risk of getting breast

01:28:48.680 cancer, unfortunately.

01:28:50.040 Okay.

01:28:50.800 And I don't know if she's had genetic testing or anything like that, you know, because if

01:28:54.240 she, if she has a genetic issue, you do want to be tested to see if you've got a genetic

01:28:58.080 issue.

01:28:58.460 So keep that in mind.

01:28:59.700 But if you, particularly if you know that she's genetics negative and, you know, she's, it's

01:29:03.600 not a bracket type situation or one of those diseases, you may take estrogen therapy.

01:29:08.280 So you can, now there are plenty of other options out there.

01:29:12.680 And if I may, Doc, what if she had had the breast cancer?

01:29:15.440 Some of our viewers said, I have had breast cancer.

01:29:17.380 Exactly.

01:29:18.200 If you yourself have had breast cancer, most oncologists do not want women taking hormone

01:29:22.620 replacement therapy.

01:29:23.480 That's absolutely correct.

01:29:24.520 Family history does not preclude the use of it.

01:29:27.120 However, we have a lot of other options for people who do have breast cancer.

01:29:30.920 And we have some other medications, many medications.

01:29:35.000 We have a brand new medication that's out there.

01:29:36.740 That's very good for hot flashes.

01:29:38.000 Just came out about three months ago.

01:29:39.500 So there are plenty of options there.

01:29:41.040 And I'll take the chance of saying, you may go to my website.

01:29:44.400 I have an exciting website called madamovary.com.

01:29:47.860 And I've got on Madam Ovary, a lot of information about the other options that you can use for hot

01:29:53.020 flashes.

01:29:53.520 There are some herbal remedies that do help.

01:29:55.400 We have plenty of other medications that can be helpful for you.

01:29:57.960 Not to worry.

01:29:58.620 Very good.

01:29:58.960 Let's go to Colleen in Michigan.

01:30:00.960 Hi, Colleen.

01:30:01.440 What's your question?

01:30:03.640 And thank you for taking my call.

01:30:05.140 I'm a 63-year-old female, and I feel terrific.

01:30:07.820 I've been taking HRT, estrogen, progesterone, and testosterone for a decade now.

01:30:12.840 My question for the doctor, considering the DIVA vaginal laser technique, I wanted to treat

01:30:21.740 some urinary incontinence, and I understand it's also good for regeneration of the vagina.

01:30:27.280 Your thoughts?

01:30:27.860 The DIVA.

01:30:29.140 I love the names of these things.

01:30:32.720 You know, the key thing is, I would say you want to go to somebody who knows how to do

01:30:36.040 it.

01:30:36.440 You know, are there some people who seem to get excellent results with it?

01:30:39.200 Yes, there are.

01:30:40.080 You know, okay, so I wouldn't preclude it.

01:30:41.460 If you go to somebody who really knows what they're doing, I think it's reasonable.

01:30:45.020 But I just wouldn't get any random name, you know, somebody who's advertising that they're

01:30:49.160 a laserologist.

01:30:50.220 You want to go through your gynecologist who knows some people who, you know, can do it for

01:30:53.900 you very well.

01:30:55.080 You know, speaking of like procedures down on the vag, all these people are getting like

01:30:59.700 a vag facelift.

01:31:01.620 Like, what is that?

01:31:02.460 What is that?

01:31:02.880 Just like a nip and tuck, like pulse thing?

01:31:04.640 What does it do?

01:31:06.020 I think the facelift, I think some of these people are talking about using various and

01:31:09.840 sunji creams and potentially toxic agents.

01:31:13.940 No, no, there's some surgical thing you can get.

01:31:15.820 It's like a lift.

01:31:16.280 Oh, if what they're doing is that, again, some of these people are doing stuff with laser

01:31:20.560 and some of these people are doing surgical interventions.

01:31:23.820 And again, if it's just to do something for cosmetics, I wouldn't do it because, again,

01:31:28.940 there are always potential complications to any surgical procedure and any laser procedure.

01:31:33.660 If it's something that's really, you've got a problem, you know, other than just the

01:31:37.580 cosmetic issue, again, I think it's worthwhile talking to your provider to get somebody who

01:31:41.760 knows what they're doing with it.

01:31:43.200 And if you want to consider it, it's totally reasonable with somebody who knows what they're

01:31:46.080 doing.

01:31:46.620 Let me get another caller in.

01:31:47.960 Kim in North Carolina has been waiting for a while.

01:31:49.780 Kim, what's your question quickly?

01:31:53.200 My daughter was experiencing jealousy after she switched from the main brand birth control

01:31:58.400 to the generic.

01:31:59.220 Our doctor said she was just extremely sensitive to the minute difference in the brands.

01:32:04.600 I was wondering how many other emotional side effects get chalked up to just PMS instead

01:32:10.700 of it actually being a side effect of the birth control?

01:32:15.000 That's an excellent question.

01:32:16.780 And indeed, there are women who do have emotional issues with birth control pills.

01:32:21.460 Most of the mood issues on the birth control pills are not related to the estrogen in the

01:32:25.800 pill, but they are related to the progestin, the synthetic hormone component of the progesterone.

01:32:31.620 And there are many different varieties of pills out there with different progestins.

01:32:35.840 So if I have somebody who's experiencing some moodiness, but otherwise likes the pill as a

01:32:40.140 method of contraception, what we will do is to try a pill that has a different progestin,

01:32:44.840 different synthetic progesterone in there to see if that agrees with her better.

01:32:48.340 And there are certain pills that will do better for people who have bad PMS, so-called PMDD,

01:32:52.740 because they have a more favorable progestin in there for them.

01:32:57.000 So indeed, that's a good thought to think about.

01:32:58.860 If at first you don't succeed.

01:33:00.580 Okay.

01:33:01.060 Geneva in Florida has a question for you, Dr. Micken.

01:33:03.800 Go ahead, Geneva.

01:33:06.400 Thank you for taking my call.

01:33:10.160 I am calling regarding some of the information provided today regarding estrogen, first of all.

01:33:17.460 I don't know that many women understand that there's three types of estrogens.

01:33:24.100 There's E1, E2, and E3.

01:33:27.180 You've got the bad.

01:33:30.300 What's your question, Geneva?

01:33:31.660 Sorry, we don't have a lot of time.

01:33:32.960 The good.

01:33:33.580 Well, you're getting progesterone from your OBGYN, and it's usually an E1 or an E2,

01:33:43.920 which attracts and retails cancer.

01:33:46.400 Well, is there any use for E3 in that application?

01:33:52.660 My understanding is it repels cancer cells.

01:33:56.540 Thank you.

01:33:57.480 Go ahead, Dr.

01:33:58.040 Unfortunately, it doesn't repel cancer cells.

01:34:00.540 That is one thing it definitely doesn't do.

01:34:02.580 E3 is called estriol.

01:34:04.140 It's a very weak estrogen, and it certainly has uses as far as vaginal therapy.

01:34:09.080 As far as systemic therapy, there's not really any significant advantage over estriol versus

01:34:13.480 etrodial or estrone.

01:34:14.860 So, as I said, and they all interconvert in the body.

01:34:18.000 So, there really isn't much to that issue as far as it's just the fact that it's a weaker

01:34:22.280 estrogen.

01:34:22.940 That's all.

01:34:24.060 Pat in Ohio.

01:34:25.560 Pat, you have a question that I think I share.

01:34:28.960 What's your question for the good doctor?

01:34:30.620 So, I wanted to know if she has any opinion or information on HRT pellet therapy.

01:34:35.460 Oh, I have an opinion on everything.

01:34:39.360 The answer is yes, and the answer is no.

01:34:41.380 Don't do pellets.

01:34:42.600 What are they?

01:34:43.300 The problem with pellets is, first of all, they are made by compounding pharmacies.

01:34:47.960 There is no FDA-approved pellet out there.

01:34:50.600 And the problem with compounding pharmacies, some are really terrific.

01:34:53.480 There's no question about it, but you don't know.

01:34:55.460 And there's really very little quality control.

01:34:57.820 So, some people out there are really crazy, and they don't put out a quality product.

01:35:03.460 And there's really very little supervision.

01:35:05.300 The other problem with a pellet is that once it's in, it's in.

01:35:09.600 Nobody's getting it out of you.

01:35:11.060 So, if you get a reaction to it, or it's really too strong for you, it's going to be on board

01:35:15.400 for another two, three months, and you can't do anything about it.

01:35:18.200 So, in general, we have some, and a lot of people are like bioidentical therapies.

01:35:24.520 Well, the key thing is, we have a lot of really fabulous bioidentical FDA-approved therapies

01:35:30.200 that we can use.

01:35:32.060 So, for example, you can get commercially available transdermal patches or gels, which

01:35:37.400 are exactly the same as the estrogen your body makes, truly bioidentical.

01:35:41.920 We can get natural progesterone.

01:35:43.640 We can get basically the same progesterone our ovaries make, and you can get it in an

01:35:47.240 FDA-approved form.

01:35:48.580 So, there's really no need to go to a compounding pharmacy for anything except testosterone.

01:35:53.500 So, we don't have the approved dosage available for women in an FDA-approved product.

01:36:00.040 So, in general, I would steer clear of pellets.

01:36:03.060 But can I ask you, so the benefit of the estrogen patch, as I understand it, is if you're not

01:36:11.140 taking it like in a pill, you have to worry less.

01:36:15.100 Like, it doesn't go through your whole system, you know?

01:36:17.020 I guess.

01:36:17.660 I don't know.

01:36:17.940 Never mind.

01:36:18.540 Forget what I said.

01:36:19.180 What is the advantage of the patch over the pill?

01:36:23.000 No, you're on the right track.

01:36:25.060 No question about it.

01:36:26.380 The key thing is everything gets into your bloodstream, okay?

01:36:29.900 There's not vaginal.

01:36:31.160 Vaginal, you don't, okay?

01:36:32.440 The amount that's absorbed from vaginal estrogen is minuscule.

01:36:35.400 I won't say zero, but it's minuscule.

01:36:37.460 However, if you're wearing a patch or something like that on your regular skin, it's going to

01:36:41.840 get into your bloodstream.

01:36:43.400 But the key thing is it gets to your liver in a very dilute form.

01:36:48.140 When you take a pill, the pill goes into your, you know, esophagus over to your liver very

01:36:53.060 quickly, okay, through your, you know, through the duodenum.

01:36:55.900 And it gets over to your liver.

01:36:57.620 And what's made in the liver?

01:36:59.160 Things like clotting factors, okay?

01:37:01.400 So, you have an increased risk of blood clots when you use oral estrogen.

01:37:06.020 It's not huge, but it's increased.

01:37:07.500 Whereas if you use a transdermal patch, it gets to the liver in a very dilute form.

01:37:12.140 And it does not increase the risk of blood clotting.

01:37:15.040 So, for somebody who's worried about blood clots, which many of us are, that you can avoid

01:37:19.980 that risk in general by using a, what we call a transdermal form of a patch or a gel.

01:37:25.080 So, if that's, I mean, who doesn't worry about blood clotting?

01:37:28.760 Like, no one wants a blood clot.

01:37:30.420 But why wouldn't you then?

01:37:32.200 Because earlier you were saying you could stay on the pill, you know, for who knows, you

01:37:35.860 know, for the indefinite future.

01:37:37.380 But if I want to lower, like, if I can get the things that are in the pill via this transdermal

01:37:43.780 patch, and we'll talk about how you ingest progesterone, why wouldn't I just do that?

01:37:48.760 Megan, you're too good a lawyer.

01:37:50.200 That's your problem.

01:37:52.600 You're asking good lawyer questions.

01:37:54.900 The key thing is that you're absolutely right that there is a lower risk of clotting with

01:38:01.040 the transdermal patches.

01:38:02.120 No question about it.

01:38:02.880 The problem is, when you are premenopausal, okay, that to control your cycle, to control

01:38:10.180 your bleeding and things like that, you need a much higher dose of estrogen, okay?

01:38:15.500 So, that the pill is going to deliver that much more effectively in general than a patch.

01:38:20.220 And if you do use, because there are birth control patches, you're absolutely right,

01:38:24.480 because you've got to say that to be next.

01:38:26.060 The problem with the birth control pill patches is they are a much higher dose of estrogen

01:38:30.640 than the hormone replacement therapy patches, and those actually sort of override the fact

01:38:37.440 that it's a transdermal thing, and the patches for contraception do increase your risk of

01:38:42.720 clotting, because it's such a high dose of estrogen in them.

01:38:45.120 They'll go visit your liver, potentially.

01:38:46.800 Okay, got it.

01:38:47.420 That's very interesting.

01:38:48.520 All right, another question on, let's see.

01:38:53.140 This one's, okay.

01:38:54.060 Lynn in Georgia has got a question for you.

01:38:55.560 Hi, Lynn.

01:38:55.960 What's your question for the doctor?

01:38:56.900 My question is, I have been on both HRT and testosterone injections and the pellet, which

01:39:03.720 I just heard you say, but they took me out the injections, and when I did the pellet, I

01:39:08.500 got nothing.

01:39:10.420 And there's no libido, no nothing, and I just want to know where to go from here.

01:39:18.600 Okay.

01:39:20.260 Question.

01:39:20.860 It's miserable.

01:39:22.460 Well, have you tried any of the transdermal gels for the testosterone?

01:39:26.900 I did the gel in the first time.

01:39:29.800 No, no, they did not.

01:39:31.440 For the estrogen, they did, but not for the testosterone, no.

01:39:35.320 And the pharmacist would argue with me about giving me my testosterone.

01:39:42.500 Like, they didn't want to fill it, and they would try to tell me what to do, and I just

01:39:47.180 want to be normal again.

01:39:48.140 Sounds like a reasonable request, but again, I would talk to a gynecologist, and if you

01:39:55.060 have somebody, if you don't have somebody who knows a fair amount about menopause, go

01:39:58.320 to that menopause.org website, find a menopause-certified practitioner near you, and basically almost all

01:40:04.840 menopause practitioners would know about testosterone, and they would know about compounding pharmacies

01:40:10.080 that could get you transdermal gels of testosterone, and that there are some national pharmacies

01:40:16.000 that we use, and so that they could get you some transdermal gel, and you could try it and

01:40:20.800 see what it does.

01:40:21.640 And the other thing is you can always measure levels, you know, to make sure that you're

01:40:25.500 getting a good amount, okay?

01:40:27.160 So, you know, if one part of your body doesn't seem to absorb it, you could try it on a different

01:40:32.060 part of your body, if you get better absorption, but there should be a way to get you an adequate

01:40:37.160 level of testosterone into your body to see if that helps.

01:40:41.780 Good.

01:40:43.320 Lynn, thank you for calling in and being brave enough to ask the questions.

01:40:47.560 You have to self-advocate.

01:40:48.960 There aren't enough experts in the menopausal field, and your pharmacist does not have the

01:40:54.560 final say over your life.

01:40:55.580 So go to menopause.org, check it out.

01:40:58.220 All right, let's get to Amanda in California.

01:41:01.860 Hi, Amanda.

01:41:02.340 What's your question?

01:41:04.440 Hi.

01:41:05.180 Well, I just wanted to let you know that I tried and really liked the Mona Lisa touch laser.

01:41:14.120 I had it done at UCLA by a gyno-urologist, and it really helped.

01:41:23.300 It really helped with a lot of stuff.

01:41:25.020 What does it help with?

01:41:27.460 It helped with dryness.

01:41:30.700 It stopped me looking like a dead fish down there, and it sort of brought a bit of life

01:41:35.820 back to it.

01:41:37.180 That's good.

01:41:39.120 Yeah.

01:41:39.820 Yeah.

01:41:40.440 I'm 58.

01:41:42.340 My husband still thinks he's 14.

01:41:44.440 So, you know, he wants way more sex.

01:41:49.380 I would love to be closed for repairs indefinitely, but, you know, I've got to give in.

01:41:55.640 So, I tried the patch, you know, the low-dose patch.

01:42:03.720 I tried the Estradol.

01:42:05.540 None of them worked.

01:42:07.000 The Mona Lisa really, really worked for me.

01:42:09.360 It really helped.

01:42:10.280 It helped to stop me feeling so sore, irritated, UTIs, and all the rest of it.

01:42:17.440 I mean, it was good for me.

01:42:21.000 Insurance doesn't cover it, you know, but it's a three-part session.

01:42:26.480 And for me, it really helped.

01:42:28.960 And I've got to say, my doctor recommended it, and I went to somebody who did it.

01:42:37.760 And, yeah, I've got to say, I'm very happy.

01:42:39.740 Was it painful?

01:42:41.640 No, not at all.

01:42:42.280 Did you have any?

01:42:43.140 Not painful.

01:42:44.960 No, not at all.

01:42:46.440 It takes, like, three minutes.

01:42:48.460 They numb it with some cream down there.

01:42:52.020 And he said to me, it's going to feel like an elastic band, but I couldn't feel anything.

01:42:57.660 So, I think it just, inside, it just sort of, I don't know, like, revives it.

01:43:03.720 Let's put it that way.

01:43:05.460 That's amazing.

01:43:06.460 Brings a bit of color back to it.

01:43:09.600 So, Dr. Megan, now we've heard about the Mona Lisa and the Diva.

01:43:13.240 These names are amazing.

01:43:14.840 Do you have any thoughts on those?

01:43:16.780 No, I mean, they're all basically varieties of the same approach.

01:43:19.720 I mean, there's different kinds of laser therapy.

01:43:22.120 And, again, people who are laser savvy and stuff like that have been appropriately trained,

01:43:26.380 will know the differences if there are certain ones that would work better for you or otherwise,

01:43:30.060 you know, that they can advise you along those lines.

01:43:32.660 I think I would encourage, again, that many women will get relief from vaginal estrogens.

01:43:37.720 And there are a lot of different preparations out there.

01:43:41.220 So, I wouldn't say, if you are experiencing dryness, what I would certainly say, talk to your

01:43:45.600 provider.

01:43:46.020 And it doesn't have to be an OB-GYN, but, again, somebody who knows something about vaginal

01:43:49.820 estrogens.

01:43:50.860 And there are other products out there besides vaginal estrogens.

01:43:54.780 There's actually a product which has DHEA, dehydroepi, and drosterone, which can be very

01:44:00.000 helpful.

01:44:00.500 There are different things that you can use vaginally.

01:44:02.460 There are also a couple of oral medications, which are good for the vagina, too.

01:44:06.600 But somebody who's an experienced menopause doc can help you.

01:44:09.140 And we can usually take care of discomfort with a medication rather than having to go

01:44:14.540 to laser.

01:44:15.900 But, as I said, that certainly if you haven't had good results with the vaginal therapies

01:44:20.380 or, you know, it doesn't work well for you, again, it's reasonable to talk to your gynecologist,

01:44:24.860 find somebody who's good at doing them, and talk to an expert at doing them, sure.

01:44:28.740 That's awesome.

01:44:29.420 Thank you for calling, Amanda.

01:44:30.620 I want to say Shannon called, but dropped.

01:44:34.360 Shannon's in Florida and said that her OBGYN said she's at high risk for hormone replacement

01:44:40.000 therapy.

01:44:40.580 So maybe she's got, you know, cancer, a history of her own.

01:44:44.540 But there are quite a few people who wrote in saying that they had survived breast cancer,

01:44:48.900 and yet they were having menopausal symptoms and just wondered if they can't do HRT, like,

01:44:56.460 what can they do?

01:44:58.400 Lots and lots of things.

01:44:59.640 And again, I'm going to encourage anybody listening to go to madameovry.com.

01:45:03.840 I've got lots of information about the other therapies that are out there.

01:45:07.380 I have a couple of videos on menopause for cancer survivors, which is a special interest

01:45:11.540 of mine.

01:45:12.760 So as far as for the cancer survivor folks or people that can't take estrogen, for example,

01:45:17.700 SSRI antidepressants, SNRI antidepressants can be helpful.

01:45:22.480 Certain herbal products can be helpful.

01:45:25.300 There are also gabapentin is another therapy that can be helpful.

01:45:29.120 So all of these have been around for a number of years, which can help with hot flashes

01:45:33.060 and other symptoms.

01:45:34.500 However, this new medication that's out there, which is something referred to as

01:45:38.080 Fezzolinotant, it's been available now for about three months.

01:45:41.880 And it really gets to a novel mechanism of action for hot flashes.

01:45:45.460 It's called Vioza is the trade name.

01:45:47.960 And it's really quite effective against hot flashes.

01:45:50.320 Again, any menopause doc would know about it.

01:45:53.320 And it has no, you know, it unfortunately was not tested extensively in breast cancer survivors,

01:45:57.980 but it is not a hormonal therapy.

01:46:00.900 So there is no reason they can't take it.

01:46:02.800 And it's pretty effective.

01:46:03.960 So we have a lot of options out there.

01:46:06.120 Somebody who's a cancer survivor should not say, well, this is my lot in life.

01:46:09.520 I just have to sit and suffer with hot flashes.

01:46:11.520 Not at all.

01:46:12.180 We've got a lot of therapies for you.

01:46:14.100 Please again, go to madamovary.com and, you know, look at some of the information I have

01:46:19.240 for you there, please.

01:46:20.120 My my information was that HRT might potentially raise the risk of breast cancer by a negligible

01:46:28.820 amount.

01:46:29.360 And that what like that was sort of the information that was missing from the women's initiative.

01:46:34.660 Like, yes, your risk does go up, but it's still overall very low and that they weren't

01:46:41.340 really telling women that.

01:46:43.000 So, you know, you say you're going to increase your risk of your risk of breast cancer.

01:46:47.200 Women are like, oh, forget it.

01:46:48.220 I'm out.

01:46:48.700 But if it's going like from a two to a three percent and you can tell me what the actual

01:46:53.960 percentages are, that that's probably not going to move a lot of hearts and minds.

01:46:58.180 They probably do it anyway to get the relief and get all these other benefits.

01:47:02.000 Well, again, Megan, you're a very good lawyer.

01:47:04.760 The answer is you're looking at the data.

01:47:07.260 However, the key thing is American women hear the word breast cancer and they flip out.

01:47:11.740 You know, they oftentimes will do that, even if it's and the increased risk was minuscule

01:47:16.000 in the WHI.

01:47:16.960 It was really tiny.

01:47:17.940 And if you look at the long term data, we have very nice long term data now that shows

01:47:22.740 no increased risk of mortality from breast cancer in women taking HRT.

01:47:26.920 We have even in the WHI data.

01:47:29.040 So we have that data there.

01:47:30.540 And the other thing to remember is that not all estrogens and progestins are created equal,

01:47:36.320 that there are progestins or progesterone compounds that do not seem to have an effect on increasing

01:47:42.100 the risk of breast cancer.

01:47:43.220 And we can use those.

01:47:44.900 So, you know, if you say, gee, I really want to use this, but I'm really concerned about

01:47:48.660 breast cancer risk.

01:47:49.640 Well, look at look at my website.

01:47:51.780 Read about the breast cancer issues with some of the different progestin options and talk

01:47:55.920 to a knowledgeable menopause practitioner who can give you that data to talk to you about

01:48:00.320 ways that we can minimize a very minimal risk to begin with.

01:48:03.520 Now, I have a friend who's on HRT and she said she hates the progesterone.

01:48:08.880 She hates the progesterone.

01:48:10.440 As she said, it is making her bloated and has all sorts of issues with the breasts.

01:48:14.860 So what's the story there?

01:48:17.060 I have something for her.

01:48:18.500 Now, OK, that there is a product out on the market, which actually does it protects them

01:48:24.360 because the progesterone is there to protect the lining of your uterus.

01:48:27.360 That's what it's there for.

01:48:28.200 It's not to do anything else other than to protect the lining of the uterus from overgrowth.

01:48:31.440 However, if you just do estrogen, you get uterine cancer.

01:48:35.740 Is that the story?

01:48:37.040 Very, again, very, very slight increased risk, but it's there.

01:48:39.960 So we basically always provide something to protect the lining when we give estrogen.

01:48:44.080 And somebody who has a uterus, if you've had a hysterectomy, you don't have to use progesterone.

01:48:48.260 No reason you have to use progesterone.

01:48:50.140 However, there is a new product out there called basodoxy.

01:48:55.360 And it actually protects the lining of your uterus.

01:48:58.560 And it is not a progesterone.

01:49:00.480 OK, and it really has no evil effects on mood.

01:49:04.280 And so if I have somebody who's getting mood and irritability, I put them on this basodoxy

01:49:08.740 in combination and they do very well with it in general.

01:49:11.920 And the trade name of this is called Duavee, D-U-A-V-E-E.

01:49:16.520 And it's at your pharmacy and you can get it.

01:49:19.820 It's a prescription.

01:49:20.360 But your gynecologist or your primary care person or your nurse practitioner can prescribe

01:49:25.180 it for you.

01:49:25.680 But that's an oral pill.

01:49:27.720 So are you back to the liver blood clot?

01:49:29.580 It is an oral pill.

01:49:29.940 Unfortunately, it is not available in a transdermal form.

01:49:33.820 Unfortunately, that is true.

01:49:36.200 But again, your risk.

01:49:37.480 And again, the key thing when we talk about blood clots, the baseline risk of somebody

01:49:41.260 in this age ballpark is if you wanted a thousand.

01:49:44.120 If you look at oral estrogens, the risk goes to two in a thousand.

01:49:48.100 So yeah, it doubles the risk, but it's a very, very, very rare event still.

01:49:52.400 So I wouldn't want somebody to say, I can't use it because of that.

01:49:56.340 What about when women have sleep difficulties during menopause?

01:50:01.360 What is it in HRT that is solving it?

01:50:05.400 Is it the estrogen or the progesterone?

01:50:08.280 Like, what's helping them?

01:50:11.440 What's helping them primarily is the estrogen, okay?

01:50:14.540 And the mechanism of action is now under question.

01:50:17.420 There are several different theories as far as what's helping it to calm the hypothalamus

01:50:21.300 down, which is where these changes are going on.

01:50:24.720 But so it's the estrogen is the major actor.

01:50:27.420 However, micronized natural progesterone, okay, which is basically the same progesterone

01:50:34.320 that our ovaries make, actually has an effect on sleep.

01:50:37.980 It actually tends to make people sleepy.

01:50:40.360 So if somebody is having a really problem sleeping, I almost always would recommend they

01:50:44.100 take estrogen with micronized natural progesterone before they go to bed, and they'll have a

01:50:48.440 much nicer night's sleep.

01:50:50.460 Hmm.

01:50:50.900 Okay.

01:50:51.240 So that's, and does it matter?

01:50:52.560 Because progesterone too, you can't get that in a patch, right?

01:50:55.880 But you can do a pill and you can get, you can get it in a patch, but that's not an issue

01:51:00.480 with clotting.

01:51:01.280 So it's not a problem there.

01:51:03.180 So, and, but I know you can also get it in an IUD form, right?

01:51:07.340 Yes, you can get that.

01:51:08.780 So that would mean bypassing the rest of the body.

01:51:11.240 Is there an advantage to that?

01:51:13.300 Well, the answer is yes, because you can use, now some of it does get absorbed systemically.

01:51:18.060 There's no question about it, but it's a minimal absorption, you know?

01:51:21.860 Okay.

01:51:22.580 So that basically most women will, who have problems with some progesterones will do well

01:51:28.100 with it, with an IUD because they get very limited level.

01:51:31.540 Now I have had patients who've gotten, even though it's a small amount of stuff that's

01:51:35.400 absorbed systemically, they get headaches, they feel miserable.

01:51:38.320 Oh, I've had to yank out the IUD, but that's like two women.

01:51:41.800 The vast majority of folks do well with it.

01:51:44.220 Then you could do the new, the new medication you just talked about.

01:51:46.980 Then, and then the new medication is very nice.

01:51:49.740 As I said, the Duovie is a very nice combination.

01:51:52.880 And that, if that doesn't have progesterone in it, do you have to worry about uterine cancer?

01:51:57.960 Nope.

01:51:58.320 Because the, the, the basaloxicine takes care of that.

01:52:01.180 It prevents the growth of the lining of the uterus, but it's just not progesterone.

01:52:04.320 It's another compound that prevents the growth of the lining of the uterus.

01:52:07.780 Oh, oh my God.

01:52:08.540 Sounds like a, thank God.

01:52:09.480 Some people are making investments in women's health.

01:52:11.500 All right.

01:52:11.620 I want to get to Bob, Bob in North Carolina.

01:52:13.800 You've been so patient, Bob.

01:52:14.820 Thank you so much for waiting.

01:52:16.140 What's your question for Dr. Minkin?

01:52:21.080 This is Bob from Villebo, or are we waiting for Bob for North Carolina?

01:52:25.880 Just you, Bob, you go.

01:52:27.780 Okay.

01:52:28.280 You, you're my man.

01:52:29.080 What's your question?

01:52:29.720 So, Megan, I want to thank you for very much for having the good doctor on.

01:52:34.360 I've learned so much from this.

01:52:36.860 My wife is 56.

01:52:38.580 I'm 63.

01:52:40.120 There was a time when we had a wonderful life, sex life, and then one day gone.

01:52:45.820 No part of her body, nothing, just gone.

01:52:48.720 You touch it before she would get excited, dead.

01:52:52.100 Her current doctor said that she hasn't had sex in 23 years.

01:52:56.420 So what's the big problem?

01:52:57.320 I said, get away from that gynecologist because she doesn't care.

01:53:00.200 She wants you to be in the same disaster relationship that she's in.

01:53:03.920 My question to you, for the men out there, what can we do to help support our wives?

01:53:12.800 Sorry.

01:53:14.280 To support our wives, to help them understand that there's hope for them and hope for us.

01:53:22.980 A couple of things.

01:53:24.040 I really need this podcast or whatever recorded so my wife can watch it.

01:53:28.720 I've been trying to record parts of it off the phone.

01:53:33.040 It is recorded.

01:53:34.540 It'll release today, and you can share it with her, and it'll be on YouTube as well.

01:53:38.360 And thank you for being so honest and raw about the issue.

01:53:42.540 Dr. Wink, this is like, well, doesn't he make a good point of how painful these issues can be?

01:53:46.940 Absolutely, absolutely.

01:53:49.360 And again, I hate to keep harping back to go to menopause.org and find a certified menopause

01:53:56.260 practitioner near you who should be able to help.

01:53:58.900 The other website that's out there is there's a group called ISHWISH, I-S-S-W-S-H.

01:54:06.500 And Sharon Parrish is a former president of it.

01:54:09.160 It's the International Society for the Study of Women's Sexual Health.

01:54:13.320 Okay, and there are licensed, they have a list of ISHWISH trained physicians who are

01:54:18.820 specialists in women's sexual health on the ISHWISH website.

01:54:22.800 Okay, and they have trained people who are trained in women's sexual health as a special

01:54:29.060 sexual certification and find an ISHWISH provider there.

01:54:33.380 And there should be somebody close by you guys, either from the Menopause Society or from

01:54:38.220 the ISHWISH folks to get you somebody that can help you.

01:54:40.820 Because there is really no reason that, you know, people shouldn't have sex.

01:54:44.520 I mean, I saw a patient yesterday who's, you know, somebody had told her 20 years ago,

01:54:48.280 she shouldn't be having sex.

01:54:49.260 And she's only 74.

01:54:50.460 And it's like, this is ridiculous.

01:54:52.340 And she was like crying at the end of the visit.

01:54:54.040 It's like, I can do this.

01:54:54.960 I said, watch this.

01:54:55.900 You know, somebody told her her vagina was too small to have sex.

01:54:58.640 So I used some dilators, vaginal dilators, great gadgets.

01:55:02.000 And I said, look at this.

01:55:03.020 And we put, you know, we used a little Novocaine at the entrance of her vagina.

01:55:06.460 We took away her pain.

01:55:07.340 And she was great.

01:55:08.660 You know, she's going to use some vaginal estrogen to get it rejuvenated.

01:55:11.380 So there really is no reason she should be suffering and that you guys can't have sex.

01:55:16.340 And you, it's like, don't underestimate the value of a healthy sex life in a relationship.

01:55:20.720 It's just, you can lead to so much, so much good stuff, like good intimacy, better connection,

01:55:27.200 more willingness to share your emotional issues with one another.

01:55:29.720 You know, it's all this great cycle if you can get into it and an unhealthy one if you can't.

01:55:33.740 But yeah, absolutely.

01:55:36.800 Well, listen, what were you going to say?

01:55:38.300 Were you going to add something else?

01:55:40.060 No, no.

01:55:40.600 I was just going to say, I think those folks were looking to see if I could chat with them

01:55:43.660 here.

01:55:43.920 So I think I may have to go.

01:55:45.720 Oh, yeah, yeah.

01:55:46.140 No, I'll let you go.

01:55:46.900 Thank you for staying late.

01:55:48.300 I'm very grateful.

01:55:49.600 You've been amazing.

01:55:51.260 What a great font of information.

01:55:53.200 And we'll check out menopause.com, but also dot org, you said.

01:55:57.980 And also Madam Bovary.

01:56:00.000 That's amazing.

01:56:00.460 Madam Bovary.

01:56:01.440 Madam Bovary.

01:56:01.960 Madam Bovary.

01:56:02.640 Madam Bovary.

01:56:02.840 M-A-D-A-M-E-O-V-A-R-Y dot com.

01:56:05.860 That's my website.

01:56:06.440 It's brilliant.

01:56:07.260 All the best.

01:56:07.800 Thank you for all you do.

01:56:09.460 Thank you much.

01:56:10.320 Thank you for your educating the folks.

01:56:11.860 It's lovely.

01:56:13.060 Oh, talk again soon.

01:56:14.740 And I want to tell you that tomorrow we have an exclusive interview with Sage Steele.

01:56:18.340 She just left ESPN and has a lot to say.

01:56:23.560 Thanks for listening to The Megyn Kelly Show.

01:56:25.580 No BS, no agenda, and no fear.

The Megyn Kelly Show - August 16, 2023

Menopause, Libido, and Childbirth： Deep Dive on Women's Sexual Health, with Dr. Mary Jane Minkin ｜ Ep. 609

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