Demystifying Menopause Kelly Casperson
S2, E19
April 24, 2024

Dr. Kelly Casperson is a urologist, author, TEDx speaker, and host of the You Are Not Broken podcast. Combining the power of mind work, body-science and relationships, she joyously breaks down the societal barriers that are keeping us from living our best intimate lives.

Dr. Casperson joins Stacy to talk about the connection between urology and menopause, sexual health, and the role of testosterone for women. The two discuss the changing perspectives on aging, and Dr. Casperson busts some myths about treatment that will help women as they go through menopause.

Follow Dr. Kelly Casperson - Kelly Casperson MD.

Follow Stacy London @stacylondonreal

Hello Menopause is a podcast from the national nonprofit Let’s Talk Menopause. Produced in partnership with Studio Kairos. Supervising Producer: Kirsten Cluthe. Edited and mixed by Justin Thomas. Artwork by Stacey Geller.

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Stacy: Dr. Kelly Casperson is a urologist, author, TEDx speaker, and the host of the You Are Not Broken podcast.

Just to talk about the fact that, you know, I feel like we're not getting through to the entire country. What I really mean when I say that about menopause is that I think that one, people still don't know that they're in it. They are still not getting like enough factual information to understand the way, uh, physical symptoms and emotional issues could be related to each other.

Um, but the discussion around menopause is happening. But when I, you know, I did that, I did a menopause retreat, right? And. I brought in doctors and all sorts of things. We talked about pelvic health, which obviously I want to talk to you about as well. Um, none of the people knew that there were. any particular treatments for menopause or that there were products for menopause.

And that concerns me because those women were, you know, white women of privilege, and they have access to the best health care. And still there was this like, Menopause is still shrouded in this weird mystery.

Kelly: It's clearly insane. Women, I always tell a joke and I'm like, did you know women are 50 percent of the population? This is insane.

Stacy: Insane.

Kelly: This is not some like rare genetic disorder. This is 50 percent of the population.

Stacy: Right. And so underfunded. And, um, I was just, I earlier today, I was talking to Jen Gunter cause her new book Blood is coming out. And we were just talking about the fact that like, you know, Women are screwed.

I mean, like, systemic, like, all medicine has been through the lens of men, and then sort of, you know, guessed at when it comes to female physiology, and that there's not enough research really done about, um, female physiology, however you identify gender wise. Um, And it is so frustrating to me that we are in this position, that we are in 2024 and sort of banging around in the dark, begging for funding for things that, you know, I mean, 1993 is when they started using women, you know, in tests.

Give me a break. Like all of this stuff makes me so angry.

Kelly: You're absolutely right. It's completely insane. People are like, we need more funding for women's research. And like, I'm at the radical point of this of like, we need more funding for human research. We are humans. We need research. As soon as, we need to actually stop being a niche and saying we need more women, like, make a little bucket over here for us.

It's like, no, no, no. Get us in the bucket. Stop putting us in this, you know, 5 percent women's bucket over here. Like, we are humans. This is human research data, all that stuff. And the other, like, the other thing about, like, the lack of education, because I'm kind of, I came into menopause from the sex med world, because, you know, again, horrifically underfunded.

Doctors don't know a darn thing about it. Everybody feels broken. So, like, that was the original plan for the podcast, which is called You Are Not Broken because women are like, well, you know, because of menopause And I'm like, what? Cause I'm like looking down the train tracks. It's, it's hurling at me too. Right. So I'm like, what's coming. And they're like, well, you know, what happens to sex? And I'm like, no. And then I really got into like, oh my gosh, the fear of estrogen, the WHi, what that has done. We have two decades of physicians that have not been trained because of the WHI. It's absolutely insane.

Stacy: It's insane. And also that the SWAN study did so, was so, it was bad data to begin with. It hurts so many people on so many levels, and the idea that there is no medical training in that 20 year gap for menopause at all, again, it's like you, how can you overlook us?

This idea that menopause is also, you know, um, associated with ageism and you're being put out to pasture is really reinforced medically and culturally. Like, I mean, but medically, that's insanity, right? We're, we're still fighting it. Um, so let's get into this because you, you know, what you're talking about is you got into menopause through sex med. I want to discuss the fact that you are a urologist and I thought urologists only saw men and only saw penises.

Kelly: We see a lot of penises, Stacy. We do see a lot of penises, that is very true.

Stacy: Is it less than 10 percent women? 10 percent are women.

Kelly: Yeah. Like 9. 6. We're gonna round up. About 10 percent are women. So I went to, I went to this school, I went to med school at the University of Minnesota. When I was in medical school, there was one female urologist in the state of Minnesota and I've still never met her. I mean, now I'm friends with a lot of female urologists, but I mean, the unique lens that the female urologist lends to both sex med and hormone menopause is that the gynecologists don't have is I take care of dudes all the time.

I see how we treat them. I see gender disparity every single day. It's like, a guy doesn't come in with erectile dysfunction and low testosterone, and we say, that's just how it is now. Have you considered yoga and wine? Like, we do not talk to them that way. And so we shouldn't talk to women that way. Like, yoga and wine are fine. But that is not the treatment for me. I just had a woman in LA. She's in Los Angeles. Perimenopause goes to a doctor for bad hot flashes. The recommendation was less social media.

Stacy: That makes me want to blow my brains out.

Kelly: I mean, honestly. Part of it is we don't know what menopause is, right? Like, women are like, it's a couple of hot flashes and then hot flashes are done, so then menopause is done. And you're like, no, it is a profound hormone deficiency. Which is funny, because people will even fight about that. They'll be like, don't call it a deficiency, it sounds bad. And I'm like, when you're 58, pick a number, you have less estrogen in your body than the man next to you.

The man has an estrogen of 30 to 40. He's got more estrogen than you do. Don't tell me this is a deficiency. That's what it is. It's less than what other people are functioning with.

Stacy: I want to go back to this thing about actually treating men and the way that they are treated, right? Obviously, when somebody comes in and says they have low libido or hair loss, you're like, well, here's some Viagra and here's some minoxidil or whatever.

Why do you think, I mean, now we do have options for women. Why are we still in that mode of yoga, red wine, you know, get off social media. Why do we talk to women that way when we know that there are things that we should be doing?

Kelly: Yeah, I think they're in, in medicine, which I think I get to speak to because I've been through the training. I paid to be able to criticize medicine. We have a, we dismiss pain. We dismiss female pain. We dismiss suffering. We call them names. We being the culture of medicine, right? Of like, they're, they just complain, Stacy, so let's just get them out of the clinic. But I mean, I tell you, like, I could, I could just go do regular urology, right?

I've got plenty of people to help. There is nothing more rewarding than helping a woman with her sex life and her hormones. She comes back, like, she's taking higher power jobs, her relationship is the best it's ever been, she's back in the gym, she's sleeping, like, these are the most grateful people in the entire world. I don't understand why everybody doesn't want to help them.

Stacy: You came to this because people started telling you that they were perimenopausal or menopausal, and that their sex lives were falling apart, right, or their sexual health was a disaster. Um, How did you really start helping women? I mean, you know, cause that, that, that's like, if you didn't know this was coming for you and you started talking to all these women who it was coming for, what was your way in? Was it the sexual health? Was it MHT? What were the things that really sort of guided you as principals into finding these people, uh, and helping them and, and making them so grateful, right? I mean, that's all we want is to improve our lives as Especially as we age, not in, in despite that we're aging.

Kelly: A hundred percent. I mean, I truly got into it because of sex med and really diving down for my own personal interest of like, is it a myth that your sex life goes away after menopause? I would say now, yes, it's a myth. Women in their sixties and seventies are having the best sex lives that they've ever had. We've got plenty of data on that.

But, uh, so I was like, okay. Estrogen. Estrogen. Why are, why is everybody scared? Uh, what's the role of testosterone in libido? And so I just kind of like started picking away at it and being like, estrogen is one of the safest medications you can actually prescribe to people. We give people unsafe medications every single day.

All the time. And we don't think twice about it. Yeah. And if you want to take a close example, birth control pills are less, air quotes, less safe than hormone replacement estrogen therapy. And we just think we don't, we don't give it a second thought to give somebody a birth control pill. Right? And so it's like, to really understand, like, the fear is unfounded. And people, but the fear is so embedded, people can't tell me where it comes from. I know it comes from the WHI, right? But they're just like, I don't know. My sister told me, you know, this fear of estrogen.

Stacy: But that's the problem, right? That scare tactic, the WHI, and that scare tactic is so systemic now in our society.

I had a friend actually ask me the other day, she was like, I'm tearing my hair out. I'm going crazy. I can't sleep. I feel nuts. You know, I forget words, all of this stuff. And I said, you know, have you talked to anybody about MHT? And she said, no, I don't want cancer. And I said, well, does it run in your family? And she said, no, not at all. And I was like, go see a doctor. You know, I mean, like the idea that that is what is pervasive in terms of belief, as opposed to all the things that we're, you're saying about how much richer our lives could be and how Less invasive and, and truly, you know, difficult menopause can be, right?

I mean, my experience in perimenopause was disastrous. I mean, I had every symptom known to mankind. I thought I was absolutely insane and culturally, you know, I started to feel useless and I felt hopeless and I felt lonely and it's, you know, that's the reason I started to talk about it was because I was like, Why, why is this happening?

And why does everybody feel this way? So when you give me this kind of positive information, right, I want to know what that means to you. It's not just estrogen, right? I mean, most people who are on MHT are taking some, if they have a uterus, right? Estrogen and progesterone, right? Or progestin. Talk to me about testosterone because I feel like that is.

Still a kind of taboo topic, even though we're, we're breaking through a little bit, even though we're trying to get people less scared of estrogen, right? Testosterone, it's like, Oh my God, I'm going to grow a beard. What does the role of estrogen, excuse me, of testosterone play during this experience, during this stage of life? And how can it help us?

Kelly: Yeah, it's a great question. I mean, I'm a urologist, right? So I give 10 times the dose of testosterone to the other humans all the time. So the urologists aren't afraid of testosterone. Um, gynecologists stereotypically, again, are a little more air quote afraid because they didn't get trained in it, right?

But education, let's step back for one second with education so people understand because otherwise it sounds crazy if you're like, why are you giving women testosterone if you don't understand that women's bodies make testosterone. Your ovaries make testosterone, your adrenal glands make testosterone. We just make one tenth the dose of the males. So the other thing we didn't know, and I did not get taught this in medical school, women's bodies have more testosterone in them than estrogen. in your 20s and 30s, right? So we've got to start there because now you understand, okay, this is a normal hormone in our bodies, functioning everywhere in our bodies, and just like estrogen, it starts to decline perimenopause, postmenopause.

Stacy: As a hormone, what is its role and function in the, in the, in female physiology?

Kelly: Yeah. And again, our research is horrific. We have, because if, if we do have, we, all we did is we gendered our hormones. And since we gendered our hormones, we erased them from being necessary in 50 percent of bodies, right? So we do not have a lot of research with things other than sexual desire. And as my brother had to point out to me, why is the only legitimate reason for a woman to be on testosterone is to sleep with somebody? Like it is kind of insane, but so we have a lot of data on desire, the role of desire, the way it works in the brain, the way it modulates dopamine, things like that. But the data coming out on mood, depression, anxiety, and these are things that are vague and you can't research.

How am I supposed to do a research study on whether testosterone improves your overall sense of wellness? Right? It's like, it's too vague, but I would say one of the most important things, I mean, how many women do we hear in perimenopause and menopause are like, I just don't feel like myself. How do you study that?

How do you study feeling like myself? Right? But that's what hormones are, who you are, right? Like who you are once you went through puberty was different than before puberty. Hormones matter incredibly much. The other interesting thing about testosterone, you can't make estrogen. You cannot make estrogen without it going through testosterone. That's how we make estrogen in our bodies. But if we don't have that knowledge, people are, they think you're crazy. Cause you're like, what are you giving the male hormone to women for? It's like, 'cause it's everybody's hormone. Um, bone health. Uh, yeah, I was just gonna add bone health, cardiovascular health. There's some, there's some decent data looking at that too.

Stacy: Well, I mean, I definitely, I want to go back to that in one second. I, you know, what, but it's so interesting the way you say, you know, hormones, when people say they don't feel like themselves and you're like, what hormones are you? Right? That makes me laugh because I, it really took me a long time to understand that my feelings were We're actually like hormones in my body doing something, right?

I'm like, I'm sad. I don't think of that as, uh, physiological. I don't think of what's going on in my brain. I'm just sad. Stacy is sad and, you know, or depressed or whatever it is. I don't know that my brain is firing or that I don't have enough dopamine or whatever it is. I don't, you know, I don't have enough testosterone or estrogen.

And when you start to realize that, You know, people say feelings aren't facts. I'm like, well, they kind of are scientific facts. We just don't talk about them that way. And you know, the minute we get to perimenopause, there is this, like, it feels, I think for a lot of people, like there's some havoc being wreaked. And we know that it's not the same for everybody, which is also why it's so hard to study. And also why treatment is is so individualized, right? But it never occurred to me that testosterone played a role in my feelings. Like, I, I, I had never heard that. Um, so to me, it's very interesting, particularly coming from urology and not gynecology, that you are able to see the benefits of not, not gendering hormones for the 51 percent of us who, uh, might need them.

Kelly: Yeah, I mean, just, just, you know, because people, I think, I, you can tell people, give people facts, but when you give them stories, it starts to connect more. Two stories with me and my women with testosterone, one of them weaned off antidepressants. She said, how do you study this? I feel like I can math better. Is something somebody told me you can't you can't study that but like that mental sharpness is back, right? I had another woman. She was 58 got her started on her estrogen first. She was happy with that. No side effects good She's like I'm ready for testosterone now put her on testosterone. See her back in three months She's like I feel like I felt when I was 28 I have that energy back again.

Stacy: And we start slow. So what do we do? What do we do with that? What do we do with anecdotal information? It's true, it's real, right? And you can't, you can't, just what you're saying, how do you test for that? How do you study that? So how do we know what's safe and what isn't depending on the person? How does that, how does that work scientifically?

Kelly: The good, like these are not brand new medications. We've been giving women testosterone and estrogen since like the 1940s in many different doses and formulations and stuff like that. So it, my rules for testosterone, for example, is like we start low and we slowly bring you back up because if you go from, let's make up some numbers, let's go from you're at a testosterone zero and you take a pellet, right?

Pellets are very high dose and they get you a high dose in a day. That's where you get like, um, all my hair fell out. I felt horrible. Like, titrate up slowly. You're going to have a lot less side effects. You're going to avoid that hair loss problem. Like, but you need somebody who understands hormones. It isn't just going to try to sell you a pellet.

Right? So we do not have an FDA approved product. That's absolutely a problem in this country. But testosterone can be given safely, effectively. And slowly over time, people will be like, It was subtle. It was subtle. But I can tell that my life is better with it. Those people are a heck of a lot happier than the like, I had to remortgage my house for these darn pellets and all my hair fell out, right? Like there's bad ways to give hormones.

Stacy: What are the delivery mechanisms that you believe in, that you prescribe, that you have seen results for people in menopause or post menopause? Um, you know, what, what is FDA approved and, and how do you get that done? What does that look like?

Kelly: Well, I just made a viral reel from this conference I was at in New York, and it hit like 300, 000 people in 48 hours. It was basically a snippet of me saying, Bioidentical is a marketing term. I saw it! I saw it! You saw it! You saw my viral reel. I did not say bioidentical is a scam. Bioidentical just means it's the same hormone that your body makes. That's all it means. There's FD approved products that are bioidentical that your insurance pays for.

So I use an FDA approved product and most commonly that's going to be your estrogen, your progestin. We've got a couple of good options on those. Testosterone is a challenge because we do not have an FDA approved testosterone for women. Frankly, I want there to be one, but I'm worried they're going to charge 500 and put it in a pink box and I I wouldn't vote for that.

Like, these should be cheap. Um, so we can use an FDA approved male product, dose it at one tenth the dose. That's easy to do. I've had a lot of issues with my pharmacists. They've been a little obstructionist. They ask my women very uncomfortable questions when they try to pick up the FDA approved male testosterone.

So I have gone to a compounding cream. Because the pharmacists were being too obstructionist with my women and frankly, it's inappropriate. You can also compound estrogen, or sorry, a testosterone injection. That's less like, you know, people are less interested in injecting, but it works great usually once a week.

What we're trying to do is we're trying to get your testosterone to where it was, let's 30s. Right? I'm not trying to get you to, you know, to grow a beard or if you don't want to transition to a male, don't take testosterone doses that are male doses, right? Dose it to a female dose. Now some people do better at a little bit of a higher dose, but I want to get you there slowly.

I want to get you there so it's not a shock to your system. So you're not losing your hair or kind of all of those like horrible high testosterone. You know, when women write to me and they're like, this is what happened when I took a testosterone pellet. And I'm like, because you went from, you know, zero to three hundred overnight. Body doesn't like that. So safe, cheap, effective, go slow, check in with your patient. Like, you know, menopause is really customized, but it's not rocket science.

Stacy: Well, let's talk about this a little bit because I mean, it's customized, you know, it's individualized because what you're saying, and I, at the end, I want to go through this because one of the things that is very important to me about this podcast is that there are, there is an action item list at the end of this.

If you feel like crap. You know, listening to you is going to make the difference between feeling like crap and getting your agency back to do something about it. So when, um, when we're talking about, uh, uh, you got into this because of sex health, right? And this was about libido and desire. And there's lots of data about, um, uh, cognitive behavioral therapy.

There are pharmaceutical options for female libido now. What are other reasons that people want to take testosterone? Is it energy? Is it strength training? You know, what are some of the other benefits? Because I think it's really important that people understand if we've always had testosterone in our bodies, what, what, what good does it do us, right? It can't just be libido.

Kelly: Yeah, and this is really where that anecdotal evidence comes in, because I, again, we have no FDA approved indication that even sexual desire is not an FDA approved indication, right? Which means your insurance won't cover it, you know, and it's the legitimacy of it. I mean, just telling you of the women that come in, my lean body mass is up.

This is one I see a lot. I'm recovering better from my workouts. I see that a lot with women who are on testosterone. Mental health, sharpness, and clarity. We’ve got data for bone health, women who really care, they're like, I want to keep fit and keep my bones strong. We've got some data on cardiovascular health, both in men and women. We kind of take the men's studies and extrapolate, right? If testosterone works for their bodies for this, probably works in our bodies too.

Stacy: But that just pisses me off that we don't have those studies that are specific. It should piss you off.

Kelly: Right? Yeah, it does. It should piss you off. Absolutely. I mean, can I give you one more thing to be really pissed off about? So, for testosterone, you can go to any provider and get a prescription for estrogen. Testosterone is a regulated drug on the level of a narcotic. You do not have a physiologic level of fentanyl and oxycodone in your body, Stacy. But you do have a physiologic level of testosterone. Why are those two medications both restricted? Now, what does this mean? Why is this important? Two reasons. Number one, telemedicine struggles with giving, with offering testosterone because telemedicine, it's, it's harder to give a scheduled drug telemedicine. And a doctor I can go get a license in Texas. I got to get a separate license in California. Great. But now I have to get a separate DEA license in Texas, a separate DEA lease on the tune of about a thousand bucks per state, just to give you physiologic testosterone. It is absolutely insane. And I'm like, it, it, it kind of happened today. I think it happened because of the worry of males abusing testosterone and an anabolic steroid sort of. You know, bodybuilding sort of world.

But to me, the fact that it's so restrictive to give you a physiologic dose of something your body makes already, and, Just to add a little bit more, this is all made up, Stacy. You can go to Mexico, and in the airport, you can buy testosterone. Over the counter. With your latte and your cheeseburger.

Stacy: Love this country.

Kelly: Right. Which country is the free country, Stacy?

Stacy: So this is why I get so confused, because, again, it's so restrictive in some ways. But particularly for those people who happen to have uteruses, that we seem to be the ones who are suffering the most and, and are under the most restrictive laws around hormones specifically.

Um, and I wonder, what would be your dream? What does it look like, for you as a doctor, to be able to treat any of your patients the way you want to? Is it that the FDA approves testosterone and has testosterone that is made for women instead of having to do this one tenth of a male dose? What would be the dream?

Kelly: Definitely acts, I, I want the DEA restriction off of testosterone, it is not a narcotic, it will not kill you. We just want to dose it, you know, physiologically. So get the DEA off. I want 20 FDA approved testosterone medications for women. Why 20? Because the men have more than 20, and that's just a quality.

So, I want multiple safe, I don't want to have to compound stuff. I don't want women to have to remortgage their house for pellets. I want this to be cheap. It's fine if it's not over the counter, you know, that's fine, maybe, you know, physician oversight is probably good to make sure you don't have other health issues going on, but the access is absolutely insane. We've got, we've got a big problem.

Stacy: Yeah. I mean, and that's access. I'm, I'm assuming you're talking about people who have access to the best healthcare in the world, right? I mean, if we're talking about the most privileged people, and this is still impossible. Um, you know, obviously when you start talking about the more marginalized of us, this is, it's, it's even more impossible. It's like a pipe dream.

Kelly: Yeah. My other wish is if any middle aged woman goes in for depression or anxiety symptoms, her hormones are addressed before she's given an SSRI and anti anxiety meds.

Stacy: Ah, now that is so fascinating to me when we talk about the mental health aspect of this. Because when I started to not feel like myself, I did, I felt depressed. I felt anxious. I had an incredible rage. I had droid rage without the droid. And I went to my doctor and I said that and the first thing she offered me was an SSRI. The first thing, not any discussion about where I was in my life, uh, any, you know, external, like, reality factors that may be playing into this, and nothing about hormones. Absolutely nothing. Not one discussion.

Kelly: We were doing it wrong. 25 percent of middle aged women are on an SSRI in this country. One in four. Are any of those women? Are any of those women told that SSRIs are associated with increased risk of bone fracture? We have multiple studies showing that the risks of these, let alone coming off, and don't get me wrong, like I will back up and say, depression needs to be treated appropriately, but a lot of times it's hormones. A lot of times it's hormones. And we just throw an antidepressant on these women, and they're still miserable because we didn't fix the problem.

Stacy: And it is interesting to me also that you say that, especially when it is about bone density. Because here we are saying now, you know, menopause is, I love to say that it's the last exit on the highway, right? For you to start really taking care of what longevity, your health span is going to look like. It's not that you want to live to be a hundred if you're not going to be able to stay in And I think that it's so interesting to me that that is not something, I mean, you know, obviously maybe, maybe it's on the, you know, box or whatever of an SSRI. But that is, particularly for middle aged women when bone density is at its most important and building bone density and strength training and all of these conversations that we're having about how you're taking better care of yourself could be undermined by that, by medication. To me, that makes no sense. That's contradictory and confusing to a patient.

Kelly: Yeah. Well, it's insane. It's like, you know, we don't offer hormones, which are some of the safest meds. Why? Because our body makes them naturally. Right. It's kind of like giving people insulin and thyroid is like, they're, they're pretty safe because it's just what our body makes.

Right. Let alone an anti anxiety medication. Um, but I started when I started reading about this, when I started learning that 25 percent of midlife women are on an SSRI, when I started learning that we have meta analyses, which is like an analysis of the data. We have meta analyses showing the correlation between an SSRI and fracture because we have all of these nerves, you know, the, the, the, sorry, the receptors for the, are in the bones.

There's something going on with SSRIs that increase a woman's risk of a fracture. So I texted my orthopedic surgeon and I said, did you know that SSRIs are associated with fracture? And he's like, no, but, but everybody's on them and nobody's on estrogen. Cause he sees the 80 year old fractures all the time, right?

He's picking people out of the river downstream. And then I texted a primary care physician friend and I'm like, did you know SSRIs are associated with bone fracture? And she's like, no, we've known this for over 10 years. The papers started coming out years ago. And so I'm like, oh my gosh, we're treating menopause symptoms with SSRIs. Instead of estrogen, and we're actually hurting, risking, hurting the bones, but it's insane, the data is there.

Stacy: What's interesting to me now is, you know, amongst uh, menopause advocates and doctors like yourself, you know, we are talking about hormones as the gold standard, and even though you're a urologist, what it sounds to me is like you're actually like a hormone doctor. You understand how hormones need to be, um, you know, fine tuned in the body and that if we understood menopause to be a hormonal change, like puberty or something else, then wouldn't hormones be the first thing that we would reach for in order to, you know, sort of make it as smooth as possible? Like, I used to say, look, you know, menopause is, you can feel hopeless, but you aren't helpless. And that's more and more the case, the more we understand how hormones play a significant role here. We get away from the idea that they're completely dangerous and that, you know, there is a way to fine tune them for individuals, let's say for right now, right, because there's no blanket way to do it. Um, it's just so interesting to me.

I mean, like that, it's not endocrinology exactly, but it's so interesting that you're coming at this from a, a, your logic. viewpoint. Like to me, it's like listening to you, it's like, duh.

Kelly: Well, yeah. I mean, urologists see it, I mean, every single day, overactive bladder, urinary tract infections, bladder leakage, pain with sex, all over and over.

That's all low estrogen. It's all low estrogen. Right? And so it's like, I really started paying attention early on like why are we giving people overactive bladder drugs, which by the way are contraindicated over age 65, instead of putting these women on vaginal estrogen. The bladder has estrogen receptors. The bladder gets better. This is what I tell women. Like we're at a time, we've never aged like this before. I mean, I tell women I'm because they're like, why do I have to take hormones, blah, blah. And I'm like, well, cause you have to floss and you have to wear sunscreen and we have to wear a seat belt.

Like we've, we have the insane privilege of aging. Insane privilege. I've looked at the data. We did not make it past 50 in great numbers ever before. And we're learning how to do it. We're, we're the, we're the babies. We're like the first generation learning how to age on a global massive scale.

Stacy: Well, that's what I find so interesting. I really do believe this is sort of the legacy of Gen X, is that we are the generation that learned to stop sitting all the time, stop smoking, don't drink as much, or drink at all, right? 10, 000 steps. All of that stuff has happened in our life. Orgasmic equality. Right. But, but, you know, this is all in our lifetime. That these are the things that we're recognizing. And I do think, obviously, that does mean that, you know, our chances of having a stronger healthspan and being able not to fall at 85 are, are much more realistic. And, you know, I think, I, I remember when my grandmother went to, one grandmother, um, fell. and wound up in a nursing home and just never got out of bed and was clear as a bell brain wise, which I just thought was heartbreaking.

And another, my other grandmother, when her husband died, she moved to Florida and just waited to die. And I think that was this kind of old school thinking of you get to a certain age and, you know, you move to Florida. Like that's, that was that, you know, and you found a community in Florida. Um, and I don't think that that is the way that we look at aging now, right?

And we are looking at what is coming for us in a way that is so much more proactive. And, um, and what you're saying is exactly that, right? If we're, if we're told we have to floss, if we're told we have to wear seatbelts, why aren't we told that this is something that, you know, hormonal treatment is something that is essential to our well being as we age?

Kelly: And I get it. I mean, you know, there's so many women our age, they've never been on medications before, right? Or they pride themselves in like, I had one woman be like, I'm the natural friend in my friend group. I'm a natural one. I don't take meds. And I'm like, it's very possible, and we have some data on this, that by taking hormones, You're actually decreasing the risk of you needing other medications.

Stacy: Wow.

Kelly: Yeah. You're decreasing your heart disease. You're decreasing your insulin resistance. You're decreasing your osteoporosis. Like by taking a hormone, you're decreasing the chance you're going to need other meds.

Stacy: And it's funny because I had a doctor say to me, when you get to a certain age, like, you know, post menopause, just expect a new pill a year. And I was like, I reject that. I reject that philosophy with all of my being. I reject it.

Kelly: You should. And to me, I'm like, what if falling and breaking your hip at 80 wasn't the default?

Stacy: Right? And I, I really believe our generation is actually not, that is not going to be our default. But I'm also curious as a urologist, because this is so fascinating to me. You were talking about overactive bladder and how, you know, after 65, these are, you What are the five top issues that people come to you with? I'm curious. And, and what is your response for each of them? Because I want people to understand the difference between what you do and gynecology.

Kelly: Yeah. Yeah. I basically do not deal with the cervix and I do not deal with ovaries and I do, so I'm like external female genitalia and external male genitalia. All men have external genitalia. So people want me to talk about fibroids and I'm like no. Right. I will not. Right. But, uh, kidney stones, enlarged prostate, bladder leakage, prolapse is quite common and very shameful still, recurrent urinary tract infections, pain with sex, erect, erectile dysfunction. That's kind of the urologist's wheelhouse. And then, you know, any kidney issues, stuff like that, but I don't do big kidney surgeries anymore.

Stacy: I'm curious for women who come to you, what are, what are, are they usually talking about? The same kinds of things, bladder, kidney, recurrent UTI.

Kelly: Which, you know, just to get dramatic, to get people to pay attention, recurrent kidney eye, uh, recurrent urinary tract infections kill people. And I tell women, if you had a medication that decreased urinary tract infections by 50 to 60 percent, would you want to be on it? And they're like, yes, I would want to be on that. And I'm like, great. It's called vaginal estrogen. You know, cause the myth of vaginal estrogen, women will be like, well, I'm not sexually active so I don't need that. And I'm like, why is your vagina for somebody else, first of all? Why is caring for your vagina? only valid if somebody else is using it. Like it drives me absolutely insane. So we have to talk about that first.

Stacy: Now let's talk about this, right? I, maybe I'm, I'm sort of asking the wrong set of questions and I want to make sure I really get this right. You know, you're seeing resistance to things that you know are going to be helpful. Like, vaginal estrogen is not just about painful sex. This is about just having, like, a healthy, comfortable vagina that doesn't get recurring UTIs that could then eventually kill you. And we know that UTIs, as we age, don't always feel like painful peeing. It can have all sorts of other symptoms. Am I right about that?

Kelly: Well, the most classic bladder infection is a sudden onset, I feel like I'm peeing razor blades. That's your classic bladder infection. But it can also look like I'm leaking a lot more now, or, you know, I have to go to the bathroom a lot more frequently now. Um, it can be confusing for older people, you know, they don't have the classic symptoms. Uh, you know, it's interesting to me, in my group of friends, because we're the urologists who want to prevent this. Western medicine is so good at treating disease. You come to me when you have a problem. I don't want to wait for my labia to go away. I don't want to wait for my clitoris to atrophy. I don't want to wait for a urinary tract infection. I don't want to wait till I, till I'm getting up three times at night to pee. What can I do to prevent that, right? So, the role of vaginal estrogen as a preventative medicine, I think I'm on the forefront of that discussion. Um, but to me, I'm like, if genital urinary syndrome of menopause, which is a mouthful, but that's what it is. If that's in 50 to 80 percent of women, that's not rare.

Exactly. And if we have a medication that's safe and cheap, Why wouldn't we want to use it at least once a week to, like, just keep things healthy? I floss. I'm not gonna wait till my teeth get rotten.

Stacy: The logic is almost stupid. It's so easy. Thank you. Thank you for seeing that.

Kelly: I try to point that out. Like, this makes sense to me.

Stacy: Listening to you say this, I'm like, well, this makes perfect sense and, and I agree with you. I think that, um, uh, you know, people who have uteruses tend to actually believe more in preventative medicine than those that don't. And that, you know, um, just some of the studies that I've done on men's health, just to use that phrase for what it is at the moment, um, uh, they wait until something is wrong. And that, uh, their chances of, uh, living past retirement age are raised if they have a woman in their life, right, or a partner in their life that's like, you gotta go to the doctor. But what I was saying before about, um, UTIs becoming like confusion in older people is that if you were taking, you're saying if you were taking vaginal estrogen as a preventative measure, then the chances of you getting UTIs that would then, again, be more serious over time lessen. Because you're just not getting UTIs.

Kelly: Yeah. Now, we don't have a study to show that preventative, they haven't done a study looking at preventative vaginal estrogen. I would love for them to do that. Like bring it on. Um, the other myth of vaginal estrogen is that you can't start it once you're 10 years post menopause, right? Because there's, which again, I'd love to talk about systemic in that rule because it's not a rule. It does not mean 10, I'm like, why does it make any sense? Again, going with the Kaspers and the logic bombs, why 10 years in one day? Postmenopause, you can no longer take hormones. Like, that's not what it says.

It just says the best benefit is, is earlier. But going back to vaginal estrogen, which is only pelvic, You can start that. A non systemic. Non systemic. I put 92 year olds on that. You know, I tell them, well, you're 40 years overdue. Let's get you on this medication. Right? I put 83. So many people, can I put my mom on this?

Stacy: Absolutely. First of all, obviously, you know, this is the type of thing that we want. We want research done. We want those studies so you can say, see, I was right. I mean, that's sort of the first thing.

Kelly: This is an easy study. You take two nursing homes. This nursing home, everybody gets vaginal estrogen. This nursing home, nobody does. See how many urinary tract infections happen. This is a pretty easy study.

Stacy: Exactly. And then I'd be so curious about people who are sexually active as well. Um, you know, what, what does that look like? Because again, those are the two populations that are going to benefit the most from this. Um, and what I was going to say And everybody with bladders. Yes, and everybody with a bladder, exactly. So it's interesting because I remember a doctor said to me, you know, cause I was like, what about this thing that you can't take hormones after 10 years? What does that mean? And she gave me the analogy of, think about it this way, you know, if you were putting money into a bank account, a savings account, you would have more money if you started at 20 than if you started at 60, but it doesn't mean you wouldn't have any money saved if you started at 60. Might as well not save.

Kelly: Oh, that is so good. I am going to use that from now on. That is a fantastic metaphor.

Stacy: Susan Hardwick Smith, I give her credit where credit is due. And it was, you know, again, the logic and these analogies that you make are very helpful to lay people like me who want to advocate for things that we know are going to help us, but don't have medical degrees, right? We need these analogies to say, okay, this is how we explain this. When we're in a doctor's office, this is why we can advocate for ourselves. Um, let's talk a little bit about your podcast as well, because clearly this started out of what you saw happening, uh, with your patients. So when did you start it? Let's talk about it a little bit.

Kelly: Yeah, thank you. So my podcast is called You Are Not Broken. It's named You Are Not Broken because once I learned a lot about female sexuality, I just kept telling women, don't worry, you're not broken. Don't worry, you're not broken. And I'm like, obviously there, that's the podcast title.

I started it four years ago. It's currently number seven in the medicine category and like in the top 100 of Apple health and fitness, it's doing phenomenally like the word of mouth on this because this is evidence based, practical, Midlife, hormone, sex, like it's what everybody needs to listen to.

Partners listen to it and discuss it together. The men are insanely interested about what's going on with women's bodies, right? They don't know either. Um, but the reason I started it is because a woman changed my life. I was in clinic, she was crying, sexless marriage, distraught. I had no idea how to help her.

And I handed her the box of Kleenex and like lightning hit my brain and was like, You, you don't know how to help her. And I was like, let's, let's start learning. And because of her, and she knows who she is. She changed my life. I, you know, I'm on stages now. I did a TEDx. I wrote the book. I'm on my second book. I got the podcast because this woman changed my life as much as I changed hers.

Stacy: And I'm, I'm, I'm thrilled to hear, I mean, you know, whether heteronormative or not, right, that, um, all people are interested in this conversation. Because I do feel, and I, I say this all the time, Scientific American did a study years ago, they said the lowest point of happiness in a person with a uterus life is 45 to 55. Because of the highest Perimenopause. Right? Highest rate of divorce, highest rate of depression, highest rate of decreased earning potential. And I was like, that can't be by accident, right? I mean, if we were talking about perimenopause.

Kelly: There's no doubt in me it's the big black, you know, elephant in the room.It's like your estrogen is plummeting, perimenopause. progesterone and your testosterone. Like, I think we're going to look back and you know we have a lot of hormones in our bodies that we just don't know how to measure and we don't have drugs for, right? Like, there's other stuff going on too. We just talk about three hormones but there's way more hormones in our body.

Like, we're going to look back on this and we're going to be like, this was like leeches and bloodletting. You know, us, us being like, you know, let's not give you a small estrogen patch. This is like, it's just, it's crazy.

Stacy: I mean, that's really from your mouth to God's ears. I actually, I hope even if it's not for our generation, but the generations that follow really do think about this as bloodletting and leeches because, you know, we need better medicine for us.

We need better medicine. Like the fact that we, you know, just we're. Have not been included in studies only from 1993 on, it makes no sense to me and it does seem to me like we really need a billionaire to give somebody 400 million dollars and say just go invest in women's health, right? We, we know that we, because even doctors, um, who identify as female have still been taught medicine that's through this kind of patriarchal lens.

And I, I wonder if you just took female physiology on its own and all you did was study that, all the amazing things that we would find and be able to do.

Kelly: Yeah, you know, for people to be like, Oh, but the gynecologist. And it's like, dude, that's one's medical specialty. We need all medical specialties. I need cardiologists. I need a GI. We certainly need neurology. We definitely need urology. We need orthopedic surgeons. Like, 97 percent of orthopedic surgeons are male. Right? Frozen shoulder. Like, I'm gonna throw an estrogen patch on me if only to prevent frozen shoulder. I don't wish frozen shoulder on anybody. And this new study that came out looking at, you know, women who are taking hormones have a significantly decreased risk of frozen shoulder. That was done by a female orthopedic surgeon. Wow. Of course, of course. No, I know. That's, I'm like, we need, I mean, it's, we need everybody to care about this.

Stacy: Yeah. And so, can we talk a little bit about the book that you're working on? Are you allowed?

Kelly: Well, it was interesting because a publisher reached out after my first book and they're like, we'd like you to write another book about sex. And I'm like, that's very nice. Um, you know, my first book is about sex and uh, I'm like, I think my second book's gonna be about midlife though. And they're like, Oh yeah, write that. And I'm like, apparently I just tell people what I want to write. Like, what a gift. But really understanding, understanding the hormones. How to talk to your doctor about hormones. How to, how to know the truth. To understand the WHI. To understand, because your sister is going to come at you and tell you what you're doing is dangerous.

And I need to arm you so that you can actually tell her, No, these are the studies. I'm choosing to do this. This is a choice. And to really empower women to be like, nobody is coming to save you on this. Like, you gotta, you have to advocate for yourself.

Stacy: Most people are going to get in your way of trying to help yourself.

Kelly: Yeah. But the hard work we're doing is only gonna get easier and easier. That's my hope.

Stacy: And on the podcast, um, you were saying that, you know, men, women are listening to this, everybody is sort of interested. What would you say the top five episodes have been of the pod?

Kelly: The hormone ones. Because there's so much crap out there. But my number one biggest episode, I just looked at this, it's called The Boomers Should Be Pissed.

Stacy: Well,they should be!

Kelly: They should be pissed! They should be! And once they get it, but a lot of them aren't because they have no idea. Right, but once you give them the information like, do you know the rate of hip fracture and cardiovascular disease and death has gone up since they took hormones away from this country? Like, we have data to show how much lives have suffered because we took hormones away for two decades. And then they get pissed. And then they, then they freak out and they're like, 10 years, the 10 years. What if you're incredibly healthy 18 years on? It's very individualized. Very individualized. So not everybody can take hormones, but there's way more people who could take hormones and get benefit and who aren't because they're afraid. And it's that fear that's what I want to be like, let me just give you the data and the info. I don't care if you take hormones.

It means nothing to me. But what does mean a lot to me is I empower women to go feel better and then they go change the world. I would say that's a pretty great place to stop. It's a fun job.

Stacy: I love my job. It's an amazing job. And also, um, an amazingly caring and, uh, you know, unbelievably courageous thing to do. Because you are really in territory that has not been as studied as other things have been, and you are really working with people who are telling you that they feel better, and you know, that's the kind of data, how, how, the things that you're saying, how can we measure them? Well, what are the tests that we're going to be able to do? What are they? Like, how are we going to be able to figure this out? So the FDA says that it's fine, or that we just know that this is common practice, um, and that, you know, what we've been doing thus far is, is, is fine. Leeches and bloodletting. Great, great quote. Yeah.

Kelly: Yeah, Stacy, I was thinking about this. Because so many people are like, when are the doctors? When are the doctors? When's the FDA? And I'm like, remember the AIDS epidemic? The doctors didn't come to save them. Right? It was the lesbian women. Like, the people got loud. The people got loud, and that's how the AIDS epidemic took a turn. And I see a big correlation here, of like, we have to turn the Titanic, because it's not gonna come from, the FDA is not gonna be like, oh yeah, let's take some of our restrictions, the frickin restriction on the vaginal estrogen package that says probable dementia.

We're fighting to get that taken off again because it's not true and it scares women. But yeah, I think that this, like the AIDS epidemic, is grassroots, we're gonna get loud and we're gonna see amazing things happen.

Stacy: From your mouth to God's ears, that's all I can say. And in the meantime, thank you for doing everything that you're doing to help us all out. I mean, you know, it must be so gratifying, really, to see somebody come into your office and feel like their life has changed because of you. It's the best drug in the world.