How does Ovesse work?

Ovesse contains oestriol, which is a type of oestrogen made naturally in your ovaries. The hormone oestrogen keeps your vagina healthy by acting as a natural lubricant. When levels of oestriol decline in perimenopause and menopause, the tissue lining your vagina can thin and become drier, which can cause symptoms such as itching, burning and soreness, and lead to painful sex.

When you apply Ovesse, the oestriol is released where it is needed most, helping to relieve soreness and irritation.

RELATED: Vaginal dryness: why you don’t need to suffer

When and how do I use Ovesse?

Ovesse cream is applied directly to your vagina using a reusable applicator but some women apply it without using the applicator. Fill the applicator up to the red ring mark with Ovesse, then apply as you would a tampon. A good time to do this often is before going to bed.

For the first two weeks, you apply it once a day. After that, you can usually move to a maintenance dose of one application twice a week, leaving three or four days between each dose.

RELATED: Vaginal hormones: what you need to know

What doses does Ovesse come in?

Ovesse contains 1mg of oestriol per 1g of cream.

What are the benefits?

Ovesse is the only vaginal oestriol cream that’s available to some women to buy over the counter in pharmacies in the UK without a prescription (you can also buy it online), which makes it convenient for those women who it’s deemed suitable for.

By replacing lost oestriol, symptoms should begin to resolve – it can take up to a few months – natural elasticity and moisture are restored.

RELATED: More than a little vaginal dryness: how vaginal hormones can transform lives

Who is Ovesse suitable for?

Ovesse can be bought by women aged 50 and above who have not had a period for at least a year.

As Ovesse is available over the counter, the pharmacist will need to ask you a few questions from a checklist to make sure that it’s suitable for you under the criteria they use for it to be bought over the counter. You can expect to be asked about your symptoms, your age, how long it has been since your last period and if you are taking any other medications. If you would rather not answer these questions at the counter, you can ask to speak with the pharmacist in their consultation room.

Some women may still need a prescription of this preparation from a healthcare professional. This includes women who have had breast, endometrial or ovarian cancer, blood clots, heart disease, liver disease or stroke. Also, younger women will need a prescription.

Ovesse can be used in addition to HRT patches, gels, sprays or tablets and testosterone or it can be used on its own.

Can I expect any side effects?

Like all medicines, Ovesse can cause some side effects – but not everyone is affected. At first you may notice some irritation and discharge, but this usually settles. Speak to your healthcare professional if you experience side effects.

If your symptoms do not improve or worsen then you should see your doctor.

Resources

Ovesse

EMC: Ovesse

NHS: About vaginal oestrogen

The post What is Ovesse and how do I use it? appeared first on Balance Menopause & Hormones.

How does Gina work?

Gina releases a low dose of oestradiol directly to your vaginal wall to help relieve symptoms such as itching, burning, soreness, dryness and painful sex. These occur when there is a drop in oestradiol (and testosterone) levels during perimenopause and menopause, which can cause your vaginal walls to become thin, dry and inflamed. Gina contains oestradiol, which is the same type of oestrogen naturally produced by your ovaries.

RELATED: UTIs and menopause: what’s the link?

When and how do I use Gina?

You insert Gina into your vagina using a pre-loaded, single-use applicator. For the first two weeks, you use one tablet each day. After that, you usually move to a maintenance dose of one tablet twice per week, leaving three or four days between each dose.

What doses does Gina come in?

Each vaginal tablet contains 10 micrograms of oestradiol.

What are the benefits?

Gina works by replacing lost oestradiol, which starts to decline during perimenopause. Within two weeks of use, the pH levels in your vagina should start to rebalance, and symptoms should begin to resolve after eight weeks as natural elasticity and moisture are usually restored.

RELATED: More than a little vaginal dryness: how vaginal hormones can transform lives

Who is Gina suitable for?

Gina can be bought by those aged 50 and over, who haven’t had a period for at least a year. There are rules that apply when buying Gina. The pharmacist will need to ask you a few questions from a checklist to make sure that it can be bought under the criteria. You can expect to be asked about your symptoms, your age, how long it has been since your last period and if you are taking any other medications. If you would rather not answer these questions at the counter, you can ask to speak with the pharmacist in their consultation room.

RELATED: Gina vaginal oestrogen available over the counter: what you need to know

Some women will still need a prescription of this preparation from a healthcare professional. This includes those who have had breast, endometrial or ovarian cancer, blood clots, heart disease, liver disease or stroke. Also, younger women will need a prescription.

Gina can be used in addition to HRT patches, gels, sprays or tablets and testosterone or it can be used on its own.

RELATED: Vaginal hormones: what you need to know

Can I expect any side effects?

Like all medicines, Gina can cause some side effects – but not everyone is affected. At first you may notice some irritation and discharge, but this usually settles.

If your symptoms do not settle or worsen then you should see a doctor.

Resources

Gina

NHS: About vaginal oestrogen

BNF: Estradiol

The post What is Gina and how do I use it? appeared first on Balance Menopause & Hormones.

• Falling hormone levels can cause the tissues around your vulva and vagina to thin and become more sensitive
• Applying local oestrogen is effective at relieving symptoms
• Numerous preparations are available – your healthcare professional can help determine what’s best for you

Vaginal dryness is a well-recognised symptom of perimenopause and menopause but despite this, its impact has sometimes been underestimated. Oestrogen and testosterone are natural lubricants and cells that respond to these hormones are present in your vulva, vagina, urinary tract, pelvic floor muscles and surrounding tissues. Falling hormone levels during perimenopause and menopause can leave the tissues around your vulva and vagina more dry and less flexible.

While this used to be referred to as vaginal atrophy or atrophic vaginitis, this term only refers to vaginal and vulval changes. In fact, the lack of oestrogen and testosterone can also affect your bladder and the tube running from it (urethra) – they thin and become weaker, which can cause you to need the toilet more often and feel very desperate to go, without much notice. Oestrogen helps cells to fight off harmful bacteria, so a lack of this hormone can make you more prone to urinary tract infections, such as cystitis.

The term genitourinary syndrome of the menopause (GSM) now tends to be used to acknowledge that vaginal and vulval changes can also be associated with urinary symptoms.

RELATED: Managing genitourinary syndrome of the menopause (GSM)

What problems does vaginal dryness cause?

A lack of oestrogen to your vagina and vulva can cause symptoms that, although very common, are often not mentioned due to embarrassment. In a survey of women in the UK aged 55 and over, 33% did not seek professional advice for their symptoms of vaginal dryness and/or painful sex, while 36% resorted to an over-the-counter remedy [1].

Symptoms can present in the earlier years of perimenopause or may not occur at all until years after your last period. Around 65%-84% of women experience some of these symptoms after their menopause [2].

It is not just a problem for women who are sexually active – in more severe cases, discomfort can be present all the time and affect normal everyday activities, such as what clothing you wear or how long you can sit down for.

As mentioned, a common feature of vaginal dryness is for the tissue to thin and become more sensitive. This often feel sores and itchy, and can become red and inflamed. Scratching leads to more soreness, redness and inflammation, further exacerbating the problem. There may also be more frequent episodes of thrush.

You might experience intermittent, or even constant, pain at any time of the day, regardless of what you are doing. Or you may only feel discomfort when your vaginal tissue is stretched, such as during sex or when using tampons. This is because, as well as being drier, the tissue around your vagina has become less flexible and doesn’t expand as easily as it did before.

The good news is that there are effective treatments for vaginal dryness, which can be taken alongside HRT if necessary, and some remedies are available over the counter.

RELATED: UTIs and menopause: what’s the link?

What are the treatments for vaginal dryness?

Local oestrogen

Because these symptoms are due to a lack of oestrogen, a very effective solution is to put oestrogen directly on the affected area. This is known as ‘local’ or ‘topical’ oestrogen. It is not the same as the oestrogen you take as part of your HRT.

Local oestrogen is available via a prescription and­ your healthcare professional can advise which type would be best for you. There are two types of oestrogen used – oestradiol and oestriol – and three main ways to absorb the oestrogen directly from the vagina and surrounding area:

Pessary 

The most common choice of vaginal oestrogen is to use a pessary. This is a small tablet you insert into your vagina. Women usually insert the pessary at nighttime so it can stay in place for several hours. Your healthcare professional will advise you on how best to use it, but it’s commonly used daily for the first two or three weeks, then twice a week after that.

There is another type of pessary that is different to other preparations -­ Intrarosa contains DHEA (also known as prasterone), a hormone that your body naturally produces. Once positioned in the vagina, the DHEA is converted to both oestrogen and testosterone. It can be used with or without an applicator and the usual dose is one pessary every night.

RELATED: More than a little vaginal dryness: how vaginal hormones can transform lives

Cream or Gel

Oestrogen creams are inserted inside your vagina, usually on a daily basis for the first fortnight, and then twice weekly after that. An applicator can be used to insert the cream in your vagina and it can be applied with your fingertips on and around your vulva area, which can be useful if you are experiencing itching or soreness of your external genitalia too.

Blissel gel is a newer product – it contains a lower dose of oestrogen and has an applicator to insert the gel inside your vagina. It is used every night for three weeks, then twice a week after that. Some women prefer the gel formula as it is less messy than cream.

Ring

This is a soft, flexible, silicon ring you insert inside your vagina, called an Estring. The ring’s centre releases a slow and steady dose of oestradiol over 90 days, and it needs to be replaced every three months. A health professional can insert the ring if you do not feel confident or able to do so. You can leave the ring in position to have sex, or you can remove and reinsert it yourself, if preferred.

RELATED: Vaginal hormones: what you need to know

Vaginal moisturisers and lubricants

As well as vaginal oestrogen treatments, there are non-hormonal moisturisers and lubricants that act to keep the tissues well ­hydrated and feeling less sore. Moisturisers such as YESTM VM, Sylk Intimate, and Regelle are longer lasting, so you might only need to use it every two or three days.

Lubricants are for using just before having sex. Sylk moisturiser can also be used as a lubricant and YES has lubricants known as YES OB or YES WB. If you are using condoms for contraception, and use a lubricant when having sex, make sure it is a water­-based lubricant as this type will not dissolve the latex in the condom.

RELATED: How does menopause affect my sex drive?

HRT

Many women find that using the right type and dose of HRT can really improve their symptoms. It is quite safe to take HRT with the other treatments mentioned in this article.

How long does it take to improve vaginal dryness?

Your symptoms of vaginal dryness and discomfort should improve after about three months of using vaginal hormone treatments or moisturisers. Some women see significant improvement using products containing oestradiol­ and not with oestriol – for other women, it is vice versa. Some women see good results with either type of oestrogen or with prasterone. Many women experience more improvements with prasterone as the cells in this area respond to oestrogen as well as testosterone with this preparation. It can also be very beneficial for women with recurrent UTIs and urinary symptoms [3].

It can be a case of trying a few preparations before finding the one most suitable for you. On occasion, it may be necessary to use one type inside your vagina and a different type for your external genitalia. While some symptoms of menopause become less severe as you get older, vaginal dryness is unlikely to resolve by itself – most women will benefit from continuing a maintenance dose of vaginal oestrogen or vaginal moisturisers.

If you have still not had an improvement after three months, you should see your doctor, as sometimes these symptoms can be due to other conditions or medications, for example the contraceptive pill and antidepressants. It is also very important to see your doctor if you have any unusual bleeding from your vagina.

These treatments are usually continued for ever as if they are stopped then symptoms usually return. It is quite safe to continue using them.

RELATED: Gaslighting of genitourinary symptoms of the menopause

References

1. Barlow D.H., Cardozo L.D., Francis R.M. et al. (1997), ‘Urogenital ageing and its effect on sexual health in older British women’, Br J Obstet Gynaecol 104(1) pp87-91. Doi: 10.1111/j.1471-0528.1997.tb10655.x
2. Palma, F. et al. Vaginal atrophy of women in postmenopause. (2016), ‘Results from a multicentric observational study: The AGATA study’, Maturitas, 83, pp40-44. Doi: 10.1016/j.maturitas.2015.09.001
3. Rubin R., Sanaee M., Yee A., Moyneur E., Dea K., Dury A.Y. (2025), ‘Prevalence of urinary tract infections in women with vulvovaginal atrophy and the impact of vaginal prasterone on the rate of urinary tract infections’, Menopause, Jan 7, doi: 10.1097/GME.0000000000002485

The post Vaginal dryness: why you don’t need to suffer appeared first on Balance Menopause & Hormones.

• Vaginal hormones include oestrogen and prasterone
• They are available in cream, gel, pessary and silicone ring formats
• Your healthcare professional can help to determine the right dose and type to manage your symptoms

Around 80% of menopausal women vulvovaginal symptoms and lower urinary tract symptoms related to low hormone levels [1]. Genitourinary Syndrome of the Menopause (GSM) is a collective term to describe symptoms, which can include vaginal dryness, discomfort or pain during sex, irritation or burning of the vulva or vagina, needing to go to the toilet more often and feeling very desperate to go, without much notice, and urinary tract infections such as cystitis.

RELATED: Managing genitourinary syndrome of the menopause (GSM)

NICE menopause guidelines recommend vaginal oestrogen to help manage GSM in menopausal and postmenopausal women [2]. Vaginal DHEA (prasterone) can also help to alleviate symptoms. You don’t need to have all the symptoms to be prescribed vaginal hormones – some women may be prescribed them to treat recurrent UTIs and not suffer from vaginal dryness, for example. 

It’s important to note that it’s not just menopausal women who can benefit from using vaginal hormones if they are experiencing these symptoms. Younger women, especially those taking contraceptives, and some women with diseases such as diabetes and inflammatory bowel disease, can also experience these symptoms, which often improve with vaginal hormones. 

RELATED: More than a little vaginal dryness: how vaginal hormones can transform lives

Most vaginal hormones are prescribed by a healthcare professional, and they will be able to advise you on how to take them. However, there are two over-the-counter preparations – Gina, a vaginal oestrogen tablet, and Ovesse, a vaginal oestrogen cream – that are available to some women without a prescription.

If you have been prescribed vaginal hormones to treat or manage your symptoms, it can be confusing to see all the different brands available, and the different hormones and formulations available. This overview can help.

Vaginal creams

In the UK there are two brands of vaginal oestrogen cream available – Estriol and Ovesse. Both contain oestriol, which is a type of oestrogen made naturally in your ovaries. While Estriol is a prescription-only cream, Ovesse is available over the counter – it can be bought by women aged 50 and above who have not had a period for at least a year. A pharmacist will ask you a few questions from a checklist to make sure that it’s suitable and some women may still need a prescription from a healthcare professional. This includes women who have had breast, endometrial or ovarian cancer, blood clots, heart disease, liver disease or stroke. Also, younger women will need a prescription.

Estriol

Estriol cream is available as a 1mg/g cream preparation and each applicator contains 0.5g of cream, which is 0.5mg oestriol. You screw the clear plastic applicator onto the neck of the tube, which makes it easy to squeeze the cream into the applicator up to the red ring mark. To dispense the cream, it’s best to lie down, put the applicator into your vagina and slowly push the plunger all the way in.

Ovesse

Ovesse contains 1mg of oestriol per 1g of cream. Like with Estriol, you apply the cream directly in your vagina using a reusable applicator. Fill the applicator up to the red ring mark with Ovesse, then apply as you would a tampon. Again, usually a good time to do this is before going to bed.

Vaginal Gel

Blissel

Blissel is a clear, water-based gel. It contains a lower dose of oestriol than most other creams or pessaries (50 micrograms of oestriol per gram of gel). This makes it a gentler option – it is less likely to cause irritation and can be used to treat external soreness.  

It comes with an applicator that you can screw onto the neck of the tube of gel. You squeeze the tube to fill the applicator up to the filling mark. To apply the gel, simply lie down, insert the applicator into your vagina, and push the plunger all the way in to release the gel. It’s usually best to do this before you go to bed. Alternatively, you may be recommended to use the gel externally on your vulva or other areas in which case you gently apply with your fingertips.

As it’s water based, Blissel is not as thick and sticky as creams so is often less messy to use. The water-based formulation means it’s safe to use if you rely on latex condoms or a diaphragm for contraception.

RELATED: Contraception during the menopause and perimenopause

Vaginal Pessaries

In the UK, there are numerous brands of vaginal hormonal pessaries. Most of these contain the hormone oestrogen (which will appear on the leaflet as either oestriol or oestradiol), but pessaries containing prasterone are also available.

Imvaggis

Imvaggis pessaries contain 30 micrograms of oestriol, which makes it the lowest-dose topical oestrogen product available in the UK. The pessaries are small, waxy and bullet shaped. Unlike other pessaries, Imvaggis doesn’t come with a plastic applicator – it’s designed to be inserted with your finger, which reduces plastic waste. The waxy texture makes it easy to insert, and adds some extra moisture to your vagina as it melts. As Imvaggis is oil-based, it shouldn’t be used alongside condoms or a diaphragm as it could damage the latex.

Vagifem

Each dose of Vagifem, which contains 10 micrograms of oestradiol, comes in a foil-wrapped, pre-dosed, single-use applicator, which looks similar to a tampon applicator. You can insert it when you’re standing up or lying down, and it’s best to use it before you go to bed. As Vagifem pessaries stick well to the vaginal walls, they aren’t as messy to use as some other creams and pessaries and don’t leave a sticky residue.

The main downside is that Vagifem can only be used internally, unlike creams and gels which can be used around the vaginal opening and vulva. You should avoid having sex straight after using Vagifem as your partner will be exposed to the oestrogen from the pessary.

Vagirux

Vagirux is a similar product to Vagifem. Each pessary contains 10 micrograms of oestradiol but unlike Vagifem, it comes with a single reusable applicator in each pack, which should be cleaned after each use. Simply load the pessary into the applicator before use, then insert it in the same way that you would when using a tampon, either standing up or lying down.

It’s best to use Vagirux before you go to bed, so the pessary stays in place for several hours and you should avoid having sex straight after using Vagirux as your partner will be exposed to the oestrogen from the pessary.

Vagirux pessaries aren’t as messy to use and don’t leave a sticky residue. However, it can only be used internally, unlike creams and gels that can be used around the vaginal opening and vulva.

RELATED: Vaginal dryness: why you don’t need to suffer

Intrarosa

Intrarosa is one of the newest treatments available in the UK and is the only vaginal non-oestrogen treatment available. It contains plant-derived form of the hormone dehydroepiandrosterone (DHEA, also known as prasterone), which your body produces naturally. Each pessary contains 6.5mg of prasterone, and once inserted into your vagina, this hormone is released and converted to both oestrogen and testosterone. These hormones lubricate and improve the condition of affected vaginal and surrounding tissues, and research has shown that women using Intrarosa have a lower future risk of developing urinary tract infections and symptoms too [3].

RELATED: UTIs and menopause: what’s the link?

Vaginal tablet

Gina

Gina is a small vaginal tablet that contains 10 micrograms of oestradiol, and you insert it into your vagina using a pre-loaded, single-use applicator. This is the same as Vagifem. Gina is available without a prescription in the UK to women aged 50 and over, who haven’t had a period for at least a year. As it’s available over the counter, stricter rules apply when buying Gina. The pharmacist will need to ask you a few questions to make sure that it’s suitable, and some women will still need a prescription of this preparation from a healthcare professional.

RELATED: Gina vaginal oestrogen available over the counter: what you need to know

Vaginal silicone ring

Estring

Estring is a soft, flexible, silicon ring that contains 2mg of oestradiol. Once inserted into the upper third of your vagina, Estring slowly and continuously releases oestradiol (at an average amount of 7.5micrograms per 24 hours) directly to the area where it’s needed most to relieve symptoms. It works for three months, at which point it needs to be replaced.

You shouldn’t be able to feel Estring once it’s in place – if you can, this means it’s too low in your vagina and needs to be inserted a little higher up. If you’re not confident about inserting Estring yourself, a healthcare professional can do it for you.

There’s no need to remove it before sex. If you prefer to take it out, it should be rinsed in lukewarm water and reinserted as soon as possible. If you rely on barrier forms of contraception such as condoms or a diaphragm, there’s no risk of Estring damaging the latex, unlike oil-based creams and pessaries.

Some people prefer Estring to creams, gels and pessaries, which can be messy to use as they leave a sticky residue when they leak out of your vagina.

What other vaginal treatments are there?

Women with vaginal dryness can also use non-hormonal vaginal moisturisers and lubricants alone or in addition to vaginal oestrogen.

Are vaginal hormones safe?

Vaginal hormones are different to HRT as they are very low dose and do not get absorbed into your body. Vaginal oestrogen is safe to use and can usually safely be prescribed for women who have had any type of breast cancer [4,5,6,7].

Vaginal hormones are safe to use alongside other forms of HRT, including gels, sprays and patches.

RELATED: Gaslighting of genitourinary symptoms of the menopause

Resources

NHS: About vaginal oestrogen

BNF: Estradiol

BNF: Estriol

BNF: Prasterone

References

1. Genitourinary Syndrome of Menopause: Epidemiology, Physiopathology, Clinical Manifestation and Diagnostic. Sarmento ACA, Costa APF, Vieira-Baptista P, Giraldo PC, Eleutério J Jr, Gonçalves AK. 2021, Front Reprod Health., p.15; 3:779398. doi: 10.3389/frph.2021.779398. PMID: 36304000; PMCID: PMC9580828.
2. NICE: Menopause: identification and management (ng23)
3. Rubin R., Sanaee M., Yee A., Moyneur E., Dea K., Dury A.Y. (2025), ‘Prevalence of urinary tract infections in women with vulvovaginal atrophy and the impact of vaginal prasterone on the rate of urinary tract infections. Menopause. doi: 10.1097/GME.0000000000002485. Epub ahead of print. PMID: 39774900.
4. Agrawal P. et al. (2023), ‘Safety of vaginal estrogen therapy for genitourinary syndrome of menopause in women with a history of breast cancer’, Obstet Gynecol,142(3):660-668. doi: 10.1097/AOG.0000000000005294
5. McVicker L. et al (2024), ‘Vaginal estrogen therapy use and survival in females with breast cancer’, JAMA Oncol, 10(1):103-108. doi: 10.1001/jamaoncol.2023.4508
6. The 2022 hormone therapy position statement of the North American Menopause Society advisory panel (2022), ‘the 2022 hormone therapy position statement of The North American Menopause Society’, Menopause, 29(7):767-794. doi: 10.1097/GME.0000000000002028
7. Hussain I., Talaulikar V.S. (2023), ‘A systematic review of randomised clinical trials – the safety of vaginal hormones and selective estrogen receptor modulators for the treatment of genitourinary menopausal symptoms in breast cancer survivors’, Post Reprod Health, 29(4):222-231. doi: 10.1177/20533691231208473

The post Vaginal hormones: what you need to know appeared first on Balance Menopause & Hormones.

Vulval lichen sclerosus (vulval LS) is a chronic condition that can make the skin of your vulva sore, itchy and fragile.

It’s most common in postmenopausal women, aged over 50, but can occur at any age and is under recognised and under diagnosed [1, 2]. Vulval LS can be a distressing condition that can have a big impact on your life. Find out here the causes of the condition, symptoms to look out for and advice on how to manage it.

What symptoms can vulval LS cause?

This inflammatory condition affects the skin on your vulva – this is the area on the outside of your genitals, including your clitoris and your labia, which consists of two folds of skin or ‘lips’.

Vulval LS can cause a number of distressing and uncomfortable symptoms on your vulva, including:

• Itching and soreness, which may get worse at night
• Your skin may change colour and may have patches known as plaques, that are pale, white or silvery. If you have darker skin, LS may initially look like vitiligo (a condition in which the skin loses its pigment, causing white patches)
• Small areas of bruising may appear, which look like blood blisters
• Your skin may become fragile, and could split or tear
• Over time, the skin of your vulva may scar and shrink. This can cause your vaginal opening to narrow, which may make sex or other vaginal penetration uncomfortable.

Not everyone will experience all of these symptoms, and the condition can go into remission, which means that your symptoms may not be present all the time. And it’s worth pointing out that vulval LS does not affect your vagina, nor cause any discharge.

Can vulval LS be missed?

Symptoms can sometimes be confused with thrush or vaginal dryness to speak to a healthcare professional if symptoms persist.

Don’t rely on over-the-counter treatments, it’s important you get the right diagnosis and treatment. Early treatment can avoid the more advanced symptoms, when the skin of your vulva can scar and shrink [2].

‘Early diagnosis and appropriate treatment of vulval lichen sclerosus are crucial to prevent the progression of symptoms and permanent scarring,’ says Consultant Dermatologist Dr Sajjad Rajpar.

‘Patients should not hesitate to consult a healthcare professional if they notice any changes in their vulva, as prompt intervention can significantly improve their quality of life.’

What causes vulval LS?

The cause of vulval LS are still not fully understood. It is not sexually transmitted, infectious or caused by an allergic reaction.

LS is increasingly thought by researchers to be caused by an autoimmune condition, where the some cells in your body increase inflammation.

Almost a third of women with vulval LS have another autoimmune condition, when compared to 10% without LS, but it is not clear why this is the case. Thyroid disease and the skin condition vitiligo are those most frequently experienced with people with LS [2]. It sometimes runs in families, so may be caused by an inherited altered gene [2].

RELATED: Thyroid health and menopause

How do I get a diagnosis?

Usually, diagnosis is made by taking a medical history and examining your vulva.

Your GP is often able to make the diagnosis, but you may be referred to a gynaecologist or a dermatologist for more specialist care.

Rarely, a biopsy (a small piece of skin that can be analysed under the microscope) is required to make the diagnosis but if this is needed, it will be done using local anaesthetic.

How is vulval LS treated?

While there is no cure for vulval LS, it can generally be well managed with treatment.

“Managing vulval lichen sclerosus effectively involves a combination of potent topical steroids and regular use of emollients,’ Dr Sajjad says.

‘Around the perimenopause and menopausal, incorporating vaginal hormones is also beneficial.’

The main treatment is a strong steroid ointment which you apply to your vulva. This can sometimes cause burning or stinging when you first apply it, but this usually settles within a week or two and should not stop you using it [3].

The ointment is normally used daily but this can usually be reduced once the condition is well controlled. You should not worry about using topical steroids with LS; they are very safe to use with this condition and will not cause thinning of the skin.

Using emollients or moisturisers to soften and protect the skin is also recommended [3].

Increasingly in the Newson Health clinic, we finding vulval LS improves in women who are using vaginal and/or vaginal hormones. There are cells that respond to oestrogen, progesterone and testosterone throughout your vulva, vagina and surrounding tissues so low levels can affect the these tissues and exacerbate or worsen LS.

RELATED: I’m 27 and perimenopausal: how testosterone helped my symptoms

Vulval LS and genitourinary syndrome of menopause (GSM)

If you are perimenopausal or menopausal, you may be experiencing genitourinary syndrome of menopause (GSM) alongside vulval LS.

GSM is an umbrella term which is a common group of symptoms caused by dropping levels of hormones that can lead to dryness, soreness and itching of the skin on your vulva and surrounding tissues. It can be experienced by up to 70% of women during and after menopause.

Some women find that vaginal hormones, which helps thicken and restore the delicate skin of your vaginal area, relieves itching and soreness, according to the British Society for the Study of Vulval Disease [4].

RELATED: More than ‘a little vaginal dryness’: how vaginal hormones can transform lives

Vaginal hormones can be prescribed as a cream, gel, pessary or flexible ring that sits inside your vagina. These often contain oestrogen and there also pessaries containing prasterone which is a hormone called DHEA that converts to both oestrogen and testosterone. These can be used on their own or with HRT.

Surgery is rarely used to treat vulval LS, unless scarring has caused problems such as a narrowed vaginal opening, which is impacting on your sex life, for example.

You should have regular follow-up appointments until your symptoms are well managed.

RELATED: Read more articles about vaginal dryness and GSM here

What else can I do to manage symptoms?

To help manage the pain and discomfort caused by a flare-up, you can:

• Use an emulsifying ointment or moisturiser, like Dermol 500, instead of soap. These creams can be as a barrier before using the toilet, to reduce stinging and irritation
• Avoid potential irritants like soap, bubble bath, talcum powder, feminine wipes, panty liners, perfumed products or tight trousers
• Use a peri bottle (a simple bottle for washing the perineal area) filled with warm water when passing urine. Spraying warm water around the vulva will dilute the urine and reduce stinging and burning

Does vulval LS bring any other risks?

A small number of women who have vulval LS may develop vulval cancer, but this is very rare when symptoms are well controlled [5].

Regular self-examination is very important. If you notice a change in your symptoms or appearance, particularly any ulcers or lumps, it’s important to talk to your doctor about this.

Dr Sajjad Rajpar is a Consultant Dermatologist and medical director of Midland Skin. Follow him on Instagram @dr.rajpar_dermatologist.

References

1. Wallace H.J. (1971). Lichen sclerosus et atrophicus. Trans St Johns Hosp Dermatol Soc. 57(1):9-30.

2. Popa, A. et al (2024). ‘Vulvar lichen sclerosus: navigating sex hormone dynamics and pioneering personalized treatment paradigm’, J Pers Med. 14(1):76. doi: 10.3390/jpm14010076.

3. Lewis F.M. et al (2018), ‘British Association of Dermatologists guidelines for the management of lichen sclerosus’, British Journal of Dermatology, 178 (4): pp.839-53. doi.org/10.1111/bjd.16241.

4. British Society for the Study of Vulval Disease, ‘What to do at a lichen sclerosus follow-up visit’

5. Halonen P. et al (2017), ‘Lichen sclerosus and risk of cancer’, Int J Cancer, 1;140(9):1998-2002. doi: 10.1002/ijc.30621.

The post Vulval lichen sclerosus and menopause appeared first on Balance Menopause & Hormones.

• What signs to look out for that suggest you are dehydrated
• How to check you are drinking the right amount
• Tips on drinking enough through the day to keep hydrated

More than half of your body is water and, as the weather starts to get warmer, it is essential you keep your hydration levels topped up.

But how do you make sure you are drinking enough, can the perimenopause and menopause affect your hydration needs, and should you really be aiming for eight glasses of water a day?

Here, we look at the issues.

RELATED: How to cope with hot flushes in warm weather

What is hydration and dehydration?

Water is essential for life and has many critical roles in your body. Water transports nutrients and compounds in blood, removes waste products through urine, helps to regulate body temperature through sweating and acts as a lubricant and shock absorber in joints, according to the British Dietetic Association (BDA) [1].

Being hydrated means drinking enough so that fluid levels are at the optimum level for your body.

When you don’t drink enough you can become dehydrated, and this has an impact even when your hydration dips only slightly. Headaches, tiredness, confusion, lack of concentration, constipation and urinary tract infections can all be signs of dehydration.

How much water should I be drinking?

You have probably heard before the often-repeated recommendation that adults should drink six to eight glasses of water a day. This is also backed by the NHS and included in its healthy eating guidance [2].

But where did this idea originate?  This is a source of some debate, with a number of researchers pointing towards a 1945 document from the US Food and Nutrition Board of the National Research Council [3]. The document advised 2.5 litres of water was suitable for most people and, while it also states most of this fluid will be obtained from food, the message has stuck.

The BDA says that women need about 1600ml a day, although this will vary depending on temperature, humidity levels and exercise. About 20 to 30% of this is likely to come from food [1].

Rather than worrying about how many glasses you have drunk, monitor the colour of your urine. If your urine is pale straw coloured, that means you are well hydrated, while a darker yellow colour means you are likely dehydrated.

Thirst is a less reliable indicator as we often stop feeling thirsty before we are fully hydrated.

Should I be avoiding tea, coffee and caffeinated drinks?

Drinking water remains the best option, as it has no calories or sugar, but there are other good choices.  While caffeine has a small dehydrating effect, the amount of water in a mug of tea or coffee means that there is usually an overall benefit from the fluid consumed, so unsweetened tea and coffee can help maintain hydration. Herbal teas are also a good alternative to caffeinated drinks.

Caffeinated drinks such as cola are often best to avoid especially as they often contain sugars, sweeteners and other chemicals which can be detrimental to health too.

Milk (or plant-based alternatives) is also an option. You should limit other drinks containing sugars and sweeteners, such as fizzy drinks and juices.

Is dehydration more of an issue during perimenopause and menopause?

Oestrogen and progesterone, which fluctuate and decline as you approach menopause, play a role in the complex pathways which control hydration. They are involved in several different systems in your body which control thirst, how much you drink, the regulation of levels of sodium and kidney function [4].

Oestrogen can help to increase the amount of water your body holds, while progesterone has an important role in helping you get rid of excess fluid through urine. When levels of these hormones fluctuate and fall, it can impact your internal fluid balance.

In addition, some perimenopause and menopause symptoms can also impact your ability to stay well hydrated.

If you experience night sweats, you lose water through sweating and may wake up dehydrated. You may also be having an increased urge and frequency to pass urine. As a result, you may be tempted to drink less to reduce your trips to the toilet, however this should be avoided as can affect your overall hydration.

RELATED: Urinary incontinence in menopause: are you ignoring the symptoms?

What else can affect my hydration levels?

Independent of your changing hormones, increasing age also affects your ability to stay hydrated. As you age, you feel less thirsty when exercising or when you haven’t drunk enough, and your body takes in fluid more slowly, probably due to the kidneys not working as effectively [4].

This means it becomes harder to stay hydrated as you get older.

Independent of your changing hormones, increasing age also affects your ability to stay hydrated. As you age, you may feel less thirsty when exercising or when you haven’t drunk enough fluids, and your body absorbs fluid more slowly, probably due to the kidneys not working as effectively [4]. This means it can become harder to stay hydrated as you get older.

How should I keep hydrated?

It can be easy to forget to drink enough, so here are some tips to keep fluid levels high:

• Drinking little and often is best to keep hydrated
• Keep a bottle water on your desk, carry one with you and put a jug of water on the dinner table
• Drink more fluids if you have been exercising or are somewhere hot or humid
• Keep an eye on the colour of your urine to see if you’re drinking enough
• Remember food is a valuable source of water, especially fruit and vegetables, soups and stews
• Monitor how much alcohol you’re drinking. Alcohol is a diuretic, which means it promotes water loss from the body. Consider swapping some alcoholic drinks for water or non-alcoholic alternatives.

References

1. British Dietetics Association ‘Fluid (water and drinks) and hydration’
2. NHS.uk ‘The Eatwell Guide’
3. Valtin H. (2002), ‘”Drink at least eight glasses of water a day”. Really? Is there scientific evidence for 8 × 8?’ Am J Physiol Regul Integr Comp Physiol, 283(5):993-1004. doi: 10.1152/ajpregu.00365.2002
4. Stachenfeld N.S. (2014), Hormonal changes during menopause and the impact on fluid regulation, Reprod Sci. 21(5):555-61. doi: 10.1177/1933719113518992

The post How to keep hydrated during perimenopause and menopause appeared first on Balance Menopause & Hormones.

This week on the podcast, Dr Louise is joined by Elin Sullivan, a young woman who suffered a myriad of symptoms for years before getting the right treatment.

Elin first experienced recurring urinary tract infections at 19 years old, and twice required hospitalisation. She also suffered from sweats, sleep disruption and fatigue, shaking and lichen sclerosus. After a chance encounter with Louise, she tried local hormones, which was transformative, and now takes testosterone to balance her low levels.

Elin talks about how hard it can be to experience perimenopausal symptoms at a young age and shares her tips for other younger women experiencing issues that they think might be down to their hormones:  

1. Although it can feel really hard, don’t stop advocating for yourself. You may have self-doubt or worry that you’re wrong but keep pushing. My doctor was sick of seeing me, I was there probably every week, but don’t give up.
2. Rather than just giving your doctor a list of your symptoms, show them when they were happening as well. Have a log of symptoms and anything that might have affected them on that day. This will help your doctor rule out things but also show if your diet, etc, has an influence.
3. Don’t be scared to try medications or suggestions. It might help but if it doesn’t it can potentially help your doctor decide the next step. I never believed local HRT could make such a big difference but am so glad I tried it.

Click here to find out more about Newson Health.

Transcript

Dr Louise: [00:00:11] Hello, I’m Doctor Louise Newson, I’m a GP and menopause specialist, and I’m also the founder of the Newson Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. I’m also the founder of the free balance app. Each week on my podcast, join me and my special guests where we discuss all things perimenopause and menopause. We talk about the latest research, bust myths on menopause symptoms and treatments, and often share moving and always inspirational personal stories. This podcast is brought to you by the Newson Health Group, which has clinics across the UK dedicated to providing individualised perimenopause and menopause care for all women. So today on my podcast, I’m delighted to introduce to you someone called Elin, who is young actually, she’s only 27 and I recently met her in a weird way. I meet all sorts of people in things that I do, and I’ll explain more in a minute. But firstly, I’m just going to welcome Elin to the podcast. So thanks ever so much for joining me today. [00:01:20][69.2]

Elin: [00:01:21] Ah, thank you for having me. [00:01:22][1.0]

Dr Louise: [00:01:23] So I really believe in connections happen for a reason. And it’s really, really weird actually. So I am very conventional. I’m very traditional. I’m not very artistic at all. And when one of my children a couple of years ago now had some piercings done in her ear, I was really like shocked because she, they had a cartilage. And then my middle daughter’s had all sorts of piercings, and I thought I’d be one of these mums where my children maybe have doubles, and that’s about it. Clearly not. So I shocked them a few, a couple of years ago and had my conch pierced, which they thought I would never do, and I did it as a bit of a rebellious thing so people could realise that I’m not quite as conventional and conformist as maybe I have been in the past. And it was really painful, and it took ages to heal, and the wind blowing in my ear was awful. And then my oldest daughter and I Jess decided to go and get another piercing done, and I wanted to get my cartilage done. So we went to a different place and we met you. I don’t know if you remember, Elin. We both came in… [00:02:20][56.9]

Elin: [00:02:20] Yeah, I do. [00:02:20][0.0]

Dr Louise: [00:02:20] And Jessica went first and we chose and it was such an amazing experience because you were so calm and you explained everything, and you put me at ease. And I didn’t feel like I was far too old to be sitting in a tattoo parlour, like having my ear pierced and like, I walked out and we walked through London, Jess and I, and my ear the wind didn’t hurt on my piercing and it’s just been incredible. I’ve really enjoyed having it. And I remember you saying when you were piercing my ear that you were feeling quite tired and you had some sort of condition. And obviously I think everything’s related to hormones, but it wasn’t appropriate because I was nervous to ask you any questions. And then Jess, my eldest daughter, then had her eyebrow done and something went wrong with it. I think there was a one of the bits came out, so she went back to see you, didn’t she? [00:03:11][50.6]

Elin: [00:03:11] Yeah, she did a couple of days later. [00:03:12][1.3]

Dr Louise: [00:03:13] Yeah. And she came to talk to you and you can explain what you said to her. But then she came out and phoned me and she said, Mummy, I’m really worried about Elin. And I said, who? I’m sorry. And she explained, she said, I’ve just gone in back into the piercer and I think some of it’s related to her hormones. And I told her to listen to your podcast and find out more about what you’re doing. But I feel really sad for her because she’s really struggling. So then I said, just give her my details and I’ll talk to her. And that’s what happened. So what happened with Jess? What did you say to her or what happened for her to think about your hormones? [00:03:48][35.3]

Elin: [00:03:49] We just got chatting quite very organically. Like none of it was forced but just chatting about how our day’s been, turned on to how are week’s been? And then just saying, I’m tired. And it turned into a question of oh, how long have you been tired? Like, gosh, when I think about it, it’s been months. And then it’s like, but doctors don’t seem to find anything wrong. And then I think that piqued Jess’s interest to be like, oh, have you, have you tried this? Have you tried that? Yeah. Nothing’s really flagged anything up with the doctors. And then we both said, oh, I think it might be hormonal. She said funnily enough you should mention that, my mum actually knows all about this and said, have you ever heard of this podcast? Have you ever heard of my mum? And I was like just when I met her when I pierced her a couple of weeks ago. And I went home and well, she came back later on that day and said she’d spoken to and I think we spoke very quickly after that. But she was very, very knowledgeable, explaining she basically reeled off every symptom I had, just like, do you suffer from this, do you suffer from that? And she said that she’d experienced it too. And it was really just refreshing knowing it wasn’t, I’m not the only young person that felt like that. It made me feel like I wasn’t crazy. So she just helped me feel like I wasn’t the crazy one. [00:05:11][82.0]

Dr Louise: [00:05:12] And isn’t that important? You know, in medicine, we don’t always have answers. We absolutely don’t. And I learned as a GP many years ago to deal with uncertainty and share uncertainty with patients. And often I say, I don’t know. Or I say it could be this, but if it’s not this, we can try something else or we can think about something else. So you’re 27 now, but you’ve had years of symptoms in different ways, haven’t you? [00:05:37][25.8]

Elin: [00:05:38] It probably started when I was about 19. It all started with urinary tract infections I just couldn’t shake. And that was going on up until probably about a year ago. And then starting on some steroids and everything seemed to get a little bit easier. Realising my skin was quite dry and everything I’ve read into the doctors they were kind of shocked that they couldn’t figure out what exactly was causing it. They couldn’t figure out why I wasn’t able to shake the infection. I’d be chatting to Harley Street, chatting to my urologist. And I tried everything and every diet, every drink, every tablet, every plant I could have tried and nothing helped. So it just escalated from there to the point where my body just didn’t feel like my body anymore. [00:06:28][50.3]

Dr Louise: [00:06:29] No and did you have sepsis at one stage with your, one of your urinary tract infections? [00:06:33][4.3]

Elin: [00:06:34] Yeah, it turned into a brief trip to A&E, probably twice I’d say I think, if I look back. Once when I was 20, once when I was 23, that would have been in lockdown. [00:06:49][15.1]

Dr Louise: [00:06:51] So very scary. [00:06:51][0.5]

Elin: [00:06:52] Yeah. It almost felt normal by that point, which is sad. And no-one really seemed to take it seriously. When I went back to the doctors and just getting those three days of antibiotics, it almost wasn’t made out to be a big deal. And then you would start reading into it. And sadly that’s how my grandma passed away, was from a result of urosepsis. So you realise the full extent of it then. [00:07:15][22.3]

Dr Louise: [00:07:16] Absolutely. So you had urinary symptoms. You had recurrent urinary tract infections, under urologists for many years, but then you had other symptoms as well, didn’t you? [00:07:26][10.3]

Elin: [00:07:27] The more recent ones where when I couldn’t sleep, I couldn’t sleep through the night, always waking up covered in sweat to the point where you just know it’s not normal. I’ve never had issues with that before, unless I did have like a urinary tract infection that was normal at the time, but constant shaking, like not being able to walk far distances without shaking and feeling like I was going to pass out, or having to lie on the floor with my legs in the air. And doctors just telling you to eat more, to sleep more to, oh if you exercise and push through it it will pass, but it never passed. It just kept getting worse and worse. And I, I loved going to the gym. I loved going on long walks, and I couldn’t even walk up a hill without sitting to try and catch my breath. I mean, the gym was just almost like, I started to think I was getting something like Parkinson’s in the end. I had really got into my own head with it but thankfully it wasn’t. I’m very glad to be… [00:08:23][55.8]

Dr Louise: [00:08:24] But it’s very scary, isn’t it? Because, you know, you want to exercise, you’ve got the motivation, you go, your stamina is not there. And, and you were saying that you were falling asleep on the Tube before going to work or coming back from work. [00:08:35][11.4]

Elin: [00:08:36] And I’m not a napper. I’m not a napper at all. I’m very strict with my bedtime. I wake up and go to sleep the same time every day and night. But yeah, that’s how I knew it was bad is missing my stops on the way to work, or missing my stops on the way home and yeah, it wasn’t good, I was falling asleep on the sofa before I’d even finished my dinner sometimes as well. [00:08:56][19.9]

Dr Louise: [00:08:56] Which is hard. And I know you’ve got a partner, and it’s hard when you’ve got a partner as well, because it involves them too, doesn’t it? [00:09:03][6.9]

Elin: [00:09:03] Yeah, yeah. But he helped me realise there was something wrong as well and kept pushing me to go to the doctors. And as soon as your name came up, it was like, you have to talk to her. Please talk to her. You’re not yourself anymore. [00:09:16][12.9]

Dr Louise: [00:09:17] Yeah, and it’s difficult because you were still having, you’ve still been having periods, haven’t you although they’ve changed and became quite sort of painful and heavy at times hadn’t they? [00:09:26][8.4]

Elin: [00:09:27] Yeah. Sometimes they didn’t even come at all. [00:09:28][1.8]

Dr Louise: [00:09:30] And so, you know, when we talk, and I’ve spoken before in this podcast about premature ovarian insufficiency or POI, it’s called, which is common. It affects at least 1 in 30 women. But that’s when periods have stopped. But we also know that perimenopause can last for ten years or so before periods stop. And so in medicine, I think it’s cruel and wrong to wait for something to happen if, as in the menopause, which is a year since your last period, if you’re getting symptoms. And so there’s no diagnostic test for the perimenopause at all. And then that makes it quite difficult. And obviously I felt quite guilty almost that I’ve hoicked you out of, you know, from piercing my ear to saying, let me try and help you. And I’m sure I said to you when I saw you and I often say to patients, I have no idea how much is related to your hormones. I can take a really thorough history and let’s see, and certainly I was worried because you had recurrent urinary tract infections and you told me you had lichen sclerosus as well, and your skin in your perineum was breaking down. You were using steroid cream, and that was a real problem. So you had these, I hope you don’t mind me saying, these local symptoms that were really and I remember you saying you saw someone and they had never seen someone so young with such severe lichen sclerosus. [00:10:48][78.6]

Elin: [00:10:50] Yeah, just explaining, oh, it’s an older woman’s problem. It’s an older person’s problem, it shouldn’t be affecting you. And they never explained with how I looked, they weren’t sure if I’d gain any colour back or if any of the sort of tearing would heal, and I couldn’t find any information online about it. There were no pictures to compare to, there were no, there was no-one else my age I could find information from. So I found a couple of groups, and was chatting to people on there, trying to get their experiences. But everyone, there’s maybe a couple that are under 30 in there but same. We’re all looking for the same answers. And since starting the local HRT, it was almost like a gamechanger. Like my skin. You wouldn’t even guess now, it looks normal. [00:11:38][48.1]

Dr Louise: [00:11:39] It’s amazing, isn’t it? And so for those people listening, and Elin’s given me full consent to share, but I started just giving you some local hormones. So that’s vaginal hormones. And I decided to give you Intrarosa, which is prasterone, which is DHEA, and it converts to oestrogen and testosterone in the vulva, but it helps all the tissues surrounding. And because you’re young, I didn’t want to just start giving you systemic hormone therapy without thinking what else could be going on, getting to know you more. And we also, I did some blood tests as a guide. We can’t do a blood test to make the diagnosis, but I wanted to see if your testosterone level and oestrogen level was on the low side, because it would help sort of build this picture in my mind that something was going wrong with your hormones. But the first thing I did was give you vaginal hormones. And actually they’re very safe. They’re very safe for everybody. And although people think that they can only be used in the menopause, we can give them in the perimenopause, but we can also give them to younger women. There are a lot of young women who maybe have had a baby or who are using contraception, or who are just prone to urinary tract infections. And so I knew it was safe. And I knew with vaginal hormones, if you stop using them, they wear off so they don’t build up in the system or anything. And your localised symptoms were so severe I just wanted to see because in my mind, also, if your skin and that area of your body improved with local hormones, it was more likely your rest of your body would improve with hormones as well. But I didn’t expect you to respond quite so quickly because your symptoms were so severe. But that area is very forgiving. You know, we know that if people have a baby, sometimes they have tears and awful, you know, just the whole stretching and everything, having a baby. And then, you know, the body heals itself very quickly. But it’s very reassuring. And just for those people listening who might have lichen sclerosus, it often can be a reversible condition with the right treatment. But often people are given steroids, which can reduce inflammation, of course. But one of the side effects of steroids is that it can thin the skin. And if your skin’s thin already, you have to, it’s a really fine balance, isn’t it, when you use local steroids. [00:13:49][130.2]

Elin: [00:13:50] Yeah, thankfully I haven’t experienced issues with that as it was all very quick diagnosis. Only on steroids for about a year and a half, maybe a year, just between a year to a year and a half before we started the local HRT and yeah, it’s so much better because it’s a lot easier. It quicker. You don’t have to wait for it to dry before you get dressed. It gives you all that time in the morning or the evening again that you wouldn’t normally have just sat on the bed just waiting for it to dry. [00:14:17][27.2]

Dr Louise: [00:14:18] It does make a difference. You know, I think as much as possible we want to just be normal. We don’t want to be labelled. We don’t want to sort of think about treatment that we’re using. So anything that’s easy and quick and also we’re more likely to do it. So this is a daily pessary once it’s, you know, been used often people don’t really realise that they’re having it because they feel well. And it’s a long-term treatment. Often people, once they start it, continue it forever and it’s fine, it’s safe to do that. So then you did that and then I did some hormone tests. And your testosterone level was very low. And testosterone levels are only a guide. And a low level doesn’t mean that’s the cause of your symptoms, of course, but you know, you’re otherwise super healthy. You look after yourself, you eat well. You tried, as you say, so many things before so I decided to give you some hormones systemically to try, thinking I’m sure most of it is related to testosterone, maybe oestrogen as well. But I don’t know how you felt, like a stranger from the street giving you hormones. Did it feel strange or did it feel the right thing to do? [00:15:20][61.7]

Elin: [00:15:21] Well, I’d just gotten to a point where I will try anything and after the local HRT reducing all of that tearing, my skin had gone from white to pink. I was able to wear certain clothes again I thought I wouldn’t be able to wear, just because the discomfort of clothing against my skin. So I was like, I’ll try it. I’d say HRT helped me feel about 40-50% better, the local one. And then I just feel like that last little bit was what I needed to get me back to how I felt when I was 17, 18, everything. It did feel a little bit strange, like the first time you’re putting it on, you’re like, I was never taught about this in school. Doctor never mentioned any of, the GP was very much pushing towards the coil route, which I’d already tried and didn’t want to try again. So I was just glad there was something else I could try. But yeah, I did feel a bit weird, but it’s a lot nicer than I’d say what my other options were that I’d been offered. [00:16:18][57.5]

Dr Louise: [00:16:20] Yes. And I think, you know, we were very clear that it might or might not help. It’s completely reversible. It’s worth trying. And having the blood test is reassuring I think as well to know that there was something that was, you know, low and hopefully treatable. And then I remember, usually when we start HRT often I arrange a blood test before someone comes back to the clinic. And again, blood tests are only a guide, but it helps guide sometimes the absorption to see if levels had improved. And I saw your results and they were significantly better. And I emailed you actually before I saw you, because I was so desperate to hear how you were getting on. And it’s just so lovely. I mean, I’m very privileged in my clinical job because the stories that I hear are dreadful initially, but it is the most transformational medicine I’ve ever practiced. You know, I’ve done a lot of diabetes care and asthma care and raised blood pressure care and, you know, I’ve obviously treated people with infections and all sorts, but the difference is incredible. And so you sent me this lovely email and then we had a consultation a few days later. But even if I all I could see were your eyes, I could see there’s such a difference in you. It’s just wonderful. [00:17:29][69.0]

Elin: [00:17:30] Yeah, my bags aren’t down to here anymore, down to my chin. [00:17:33][3.2]

Dr Louise: [00:17:35] But you tell me you’re working longer hours as well, which is good. [00:17:37][2.5]

Elin: [00:17:37] Yeah, I’ve picked up extra days. I’m back into a sleep routine which I hadn’t had for a while. So it’s always bed around midnight, wake up about eight, half eight, which felt impossible before. I’m back in the gym. I’m stronger than I was probably before I even started to get unwell. So everything is complete U-turn to how it was when we first met. [00:18:00][22.5]

Dr Louise: [00:18:01] It’s amazing, isn’t it? And, I, with your permission, told Jessica as well, my daughter, who’s obviously been instrumental in joining us together, and she’s done that a lot for quite a few other people. But she also says, which I feel as well, very sad for two reasons. Firstly, if I’d not had my ear pierced we’d never have met. And you’re only 27, so would you have carried on for 20 years before you reached the average age of the perimenopause, you know, into your 40s? And how would your life have been? [00:18:34][32.1]

Elin: [00:18:34] Yeah, because I would just never have even heard your name. My GP was, although they did what they could have done, they weren’t taking it as seriously as you did. So yeah, I think I’d still be going. [00:18:46][12.0]

Dr Louise: [00:18:47] So yeah and so your individual life would have been affected, but there are still lots of people out there who are affected. And, you know, we can’t reach everybody through our clinic. And globally there’s a lot of people who are really struggling, and there are people in other countries where it’s less easy to talk about the symptoms and they end up not talking about them because they’ll be judged incorrectly and seen as a failure as a woman, which I find really sad. But I know that if I’d met you ten years ago, before I started my menopause clinic and doing as much work as I do, I would have been the same as your GP. I would not have known what to do because no one taught me about menopause. But more importantly, no one really taught me about testosterone and how important it is throughout our body. And even now the guidelines are, you start HRT, you add in testosterone later if people have reduced sexual desire. But actually testosterone is a biologically active hormone that goes throughout our body, affects every single cell. And increasingly we learn through patients. That’s often what we do in medicine anyway. But we learn that stamina improves, strength of muscles improve because we have testosterone receptors in our muscles, in our bones, and even in our joints. But also energy and sleep improve, which are really important to help us function. That mood, motivation can improve, and also urinary symptoms often improve with testosterone in addition to oestrogen and testosterone’s very anti-inflammatory as well. It reduces inflammation. So there’s lots of reasons why it can help. But no one’s really done any research properly in women looking at testosterone deficiency on its own. You know, you’re still having periods, you’re still producing some oestrogen and progesterone, probably less than you would have done compared to other 27 year olds. But actually, for you, a lot of it was the testosterone that was really low. And we don’t know why some women have lower testosterone sooner than others. And that’s something that is really important because it’s an independent hormone, if you like, that is crucially important for many people, but they’re not, it’s not being diagnosed, it’s not been recognised and then the people are not having the treatment. So, you’ve been discharged from your urologist, haven’t you? Which is great. [00:21:11][143.5]

Elin: [00:21:11] I have, I thought that wouldn’t, I’d never see the day. [00:21:14][2.3]

Dr Louise: [00:21:14] And what did your urologist say? Was he. Well, I’m saying he could be she, were they pleased? [00:21:19][4.3]

Elin: [00:21:20] There was a group of students there as well. We’d done my last cystoscopy, and we’d done my last I can’t remember what it was called… the amount of urine that you can hold and pass. [00:21:32][12.5]

Dr Louise: [00:21:32] Was it urodynamics? [00:21:32][0.0]

Elin: [00:21:34] Yeah. That’s the one. They were really shocked to see that I didn’t have a problem with my urodynamics. That’s what they’d had their money on from the start. Even though I’ve had all these tests a few years prior and no-one could find anything wrong. And they said, so what’s changed? You’ve gone eight months now without… What’s changed? And I gave them your name. I told them about your podcast. I explained about the hormone insufficiency and everything and they were just shocked. They were like, oh, we heard it could affect things. But again, not on someone so young. So it just felt a little bit like, well, I’m here and I’m telling you, and I’d already met so many other young people in the waiting areas in the past that I know haven’t had access to information yet. So again, I’m super happy for myself but then it does make me very angry that there are so many people without the knowledge that you’re spreading. [00:22:25][51.6]

Dr Louise: [00:22:28] It’s really important. And certainly my, I don’t know if you know, my husband is a urologist, and last year I lectured at the British Association of Urological Surgeons, and it was really great because they’re a very dynamic group of people, and they really wanted to learn. There’s a lot of sort of scepticism when I talk to some groups of doctors, but actually they see it already, they see that local oestrogen pessaries can make a real difference for some women with urinary tract infections, but they didn’t know about testosterone, and they don’t often give systemic hormones the same. But they’re really keen to learn. And I think that’s the most important thing in medicine. Certainly, I’ve always been taught to have a really open mind and try, you know, as long as something’s safe, like, I would never try, there’s lots of new drugs that come on all the time that I’m really cautious of starting a new drug if we don’t have data. Some people say we don’t have enough data about testosterone. But then if you look how it works physiologically in the body, you know our natural testosterone. And if people have good understanding of how it works in our body, then that’s very easy, because all I’m doing is giving testosterone. I’m not giving you a testosterone-like substance. There’s lots of, young men in various gyms that are taking testosterone analogues and having all sorts of problems because they’re like testosterone, they’ll help build their muscle, but they have problems as well. But I’m not doing any of that. So it’s quite simplistic medicine. But the problem is, is that no-one’s been taught. And then a lot of people say, well, we need to wait for the studies. Well, the studies won’t be done because there’s never or hardly ever any funding for female studies or studies involving women. But in the meantime, what I would hate to do is have said to you, well Elin, we haven’t got any studies, it might help you, but let’s wait for the studies to be done. Come back in 20 years’ time, because that’s not right and not fair, is it to have that approach, I don’t think? [00:24:23][115.4]

Elin: [00:24:24] I think I’d have cried. [00:24:24][0.3]

Dr Louise: [00:24:25] Yeah, yeah. So we’re hoping, testosterone at the moment is only licensed for women in Australia. It’s not licensed in other countries. And we’re not really sure why. I think it’s just because there’s so much misogyny really that goes on. And it’s never been a priority thinking about female hormones in the same way. There’s always a fear that people will abuse and use it wrongly, and I think that’s why it’s actually labelled as an anabolic steroid, because if you use too much, it can build your muscles too much. But actually, I’m not aware of any women that abuse a natural hormone. And they’re so relieved, like you are that you’re feeling better. But as long as it’s been given in the right way and people are monitored. So always in the clinic, we monitor everyone. Every year they have a blood test to make sure the levels within normal ranges and make sure they don’t have any systemic side effects. But very few people have side effects when it’s used in the right way, because you’re just topping up what’s missing, and your testosterone level is probably still lower than other people’s who are 27, and it might be higher than others. But it’s right for you. And everyone’s different. And so that’s the most important thing, is monitoring and making sure that you’re feeling better. And sometimes in medicine it’s very hard to measure feeling better. You know that you can do these studies looking at blood pressure or weight or, you know, sort of objective measurements. But feeling better can be quite hard to quantify. But just being able to increase your hours at work, to not fall asleep on the tube on the way home, to be able to go to the gym, to be able to sleep at night, in my mind are really good measurements that things are going in the right direction for you. [00:26:08][103.0]

Elin: [00:26:08] And there’s lots of other weird symptoms as well, like you’d have like weird reactions to certain things. I’ve not had that since starting and then weird nightmares, weird dreams and things, there’s so much more than just those little top ones that I feel like are really common for everyone. Just those little ones that affect your day-to-day life have all gone. And like you said, it’s such a tiny amount I’m using, when I actually put it on to my leg you think that’s not going do anything. It’s such a tiny amount and, like, such a big difference. [00:26:37][28.5]

Dr Louise: [00:26:37] Yeah. No. It’s amazing. It really is such a joy to listen to you and hear. And I’m really grateful for you sharing your story as well, because we all learn from other people’s stories. And obviously it’s not going to be as transformational for everybody. But certainly it’s something to consider for people who are having similar symptoms. So I’m very grateful. But before we end Elin, I always end with three take-home tips in the end of my podcast so people can just reflect a bit more. So I’m really thinking about younger audiences, you know, people like you who are in their 20s. What are the three things that you would say to women, girls, you know, who are in their teens and 20s, who think they might have some hormonal changes, but they’re either not being listened to or they’re too scared to go and ask for help. [00:27:25][47.3]

Elin: [00:27:26] The top one thing is it’s really hard at times, but just don’t stop advocating for yourself. There are times where you do have a lot of self-doubt, and you do feel like you’re battling yourself. You feel like you’re wrong but you’re not. Keep pushing. My doctor was sick of seeing me, I was there probably every week. Just don’t give up on that side. And I found what was really helpful to finally get the blood tests on the NHS or to start that discussion with a doctor that actually listened to me was to not just list your symptoms but list when they were happening as well. So having a almost like a log of what happened on what days, just to make sure everything they want to quickly rule out so they’re not ruling it out. So for example, if you’ve not eaten very well for that day, you’ll know if it’s affected by food or if it is affected by hormones and things like that. So if they say, you need to eat better you can say no, I’ve eaten really well this week. I think the other one will be, don’t be scared to try medications. Don’t be scared to take suggestions. And whether it’s to just see if it helps or whether it is just to keep the doctor happy to potentially to get to the next step. So if it is potentially try some hormonal contraception and see if that helps. Or try the local HRT because I’m shocked at how much that helped. I thought that would be completely wasted when we discussed it, I was like, I’m happy to try it, but I don’t know how that’s going to help and if I hadn’t have felt it and hadn’t have done it, i wouldn’t have believed you that was such a big difference it made for me. So just don’t be scared to try things as well. [00:29:05][99.5]

Dr Louise: [00:29:06] Brilliant. Great advice and thank you so much for your time tonight because it’s late at night, you’ve had a long day at work, and I hoicked you in to do this, because I just felt your story is so important to share with others, and I’m sure it will resonate either to people directly or people who have children or know people who are young. So thanks again Elin for your time. It’s been great. [00:29:28][22.1]

Elin: [00:29:29] Thank you for having me. [00:29:30][0.8]

Dr Louise: [00:29:35] You can find out more about Newson Health Group by visiting www.newsonhealth.co.uk. And you can download the free balance app on the App Store or Google Play. [00:29:35][0.0]

ENDS

The post I’m 27 and perimenopausal: how testosterone helped my symptoms appeared first on Balance Menopause & Hormones.

The post Managing genitourinary syndrome of the menopause (GSM) appeared first on Balance Menopause & Hormones.

This week on the podcast Dr Louise speaks to Dr Ashley Winter, a urologist and sexual medicine specialist, based in Los Angeles.

Dr Ashley has seen the transformative effects of vaginal hormones on women – not only those who are menopausal, but also women who experience cyclical symptoms of bladder pain, UTIs and painful sex.

She shares her frustration on the situation in the US, where inaccurate and harmful warnings are included in every oestrogen product available, and her hopes of dispelling the fearmongering by talking, looking at the evidence and sharing her clinical experience.

Finally, Dr Ashley gives three reasons why women should use vaginal hormones:

1. It’s extraordinarily safe. No risk of any cancer or blood clots, 100% safe.
2. It can prevent you from needing so many other unnecessary treatments that don’t address root causes, and so you will probably save money.
3. It is not just a vaginal treatment. It is a bladder treatment, a urethral treatment, a vulva treatment. The medication acts locally, but acts locally throughout the pelvis.

Follow Ashley on X and Instagram @ashleygwinter

Transcript

Dr Louise Newson: [00:00:11] Hello. I’m Dr Louise Newson. I’m a GP and menopause specialist, and I’m also the founder of the Newson Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. I’m also the founder of the free balance app. Each week on my podcast, join me and my special guests where we discuss all things perimenopause and menopause. We talk about the latest research, bust myths on menopause symptoms and treatments, and often share moving and always inspirational personal stories. This podcast is brought to you by the Newson Health Group, which has clinics across the UK dedicated to providing individualised perimenopause and menopause care for all women. Today on the podcast, I’m super excited actually, to introduce to you Ashley Winter, who is a Los Angeles board-certified urologist, but she also has a fellowship in sexual health for men and women. And I’ve been avidly stalking her on social media for a little while now, and I love her robustness and gobbiness and just getting it all out there, really. So I’m delighted that she’s taking some time away from her ten-month-old daughter to record the podcast today. So welcome Ashley. [00:01:34][83.0]

Dr Ashley Winter: [00:01:35] Thank you so much. I am so happy to be here and honoured that you reached out and asked to have me on. So, yeah, thank you for having me on. My husband is desperately trying to keep up with our ten month old right now. She has far too much energy for him. [00:01:50][14.8]

Dr Louise Newson: [00:01:52] So it’s really interesting because the more work I do, the more frustrated I get, actually, because there’s just suffering wherever you look. And obviously, the menopause affects 51% of the population. And it was interesting, actually, I’ve just come back from Australia and a report came out at the time that I was there saying that 70% of women don’t suffer severe symptoms. And it was almost stating that we’re overexaggerating, especially on social media, actually how women are suffering. Now, in my mind, that was just ridiculous. And there were lots of people in Australia were really cross with this report because it still meant that 30% of women have severe symptoms. Now, symptoms, as you know, can really vary. And for many years it’s always been about hot flushes, night sweats and some vaginal dryness. And that’s where it goes on and on and on. Now, if we look at vaginal dryness, I don’t like the word dryness. I think it’s a weird adjective for someone’s anatomy, but the symptoms around the area of the vagina, so we’re talking about the vulva, the vagina, but also the urinary tract, which sits, as you know, just next to it, are very, very common, actually, more common than the flushes and the sweats. And as many of you might know, it used to be called vulvovaginal atrophy. And if you look up the definition of atrophy, it means withering or wasting away. Now, I don’t want to be thinking of any of my anatomy withering or wasting away. So it was changed a few years ago to GSM genitourinary syndrome of the menopause, which is quite a mouthful. And I still think that’s confusing because it can occur in the perimenopause in younger women. And so we don’t have to wait till we’re menopausal to have GSM. But it does encompass the urinary symptoms. And living with a urologist who is now converted into the importance of female hormones, it’s really interesting to reach out to other urologists because for too long, I think, and I certainly see so many women in my clinic who have been investigated by gynaecologists and urologists for bladder symptoms, for recurrent urinary tract infections. They’ve had all sorts of weird and wonderful treatments, and no one has ever spoken to them about the role of hormones in their causation of their symptoms, but also treatment as well. So you’re a urologist Ashley, just before we start talking too much in depth, tell me why you decided to be a urologist. [00:04:21][149.6]

Dr Ashley Winter: [00:04:22] Oh, gosh. The very honest answer, which is not a very sexy answer, is I was in college undergrad, and I was actually studying engineering, which is my undergrad degree, and I decided that I didn’t want to do that as a profession. And at the time, a family member of mine came home from a doctor’s appointment and they had seen a urologist and they had had a cystoscopy, which is where you put a camera inside the bladder and they were suffering with bladder pain, you know, something that is commonly called interstitial cystitis and was frustrated that people weren’t really understanding their concerns and resolving the issue. And I said, that sounds like a very interesting thing to do. I’m going to go become a urologist. And then I went to med school to become a urologist. That’s a very weird… and then I would say, going through all my training, you know, all my rotations in medical school and whatnot, that just reinforced that my preconceived notion of being a urologist was a great idea. So, yeah, that’s the basic thing behind it. [00:05:27][64.8]

Dr Louise Newson: [00:05:28] Well, that’s fair enough. You would have seen lots of people with interstitial cystitis, presumably as part of your training and now, you know, in your day to day practice, presumably. [00:05:37][9.0]

Dr Ashley Winter: [00:05:37] Yes. Well, this is a very interesting question, because I do believe that what is called interstitial cystitis is most commonly either genitourinary syndrome of menopause or changes related to perimenopause. So genitourinary syndrome of perimenopause, if you will, and then in a younger population oftentimes it’s actually related to use of combined oral contraceptives, which we know, you know, suppress the bioavailable testosterone and can cause atrophic changes in the genitalia. And, you know, there’s a fascinating, since we’re nerding out on the GSM, there’s a really fascinating study that was published in 2003 in the European Journal of Urology, which happens to be the highest impact factor urology journal in the world. So that means, you know, kind of the best journal. And they took a bunch of women who are actually having recurrent UTIs and they were in their early 20s and they were on oral contraceptives and they had signs of genital atrophy on exam and they gave them even just one month of low dose, topical vaginal oestrogen. And all those women had a tremendous amount of inflammation in their bladder. And after treatment with the hormone, the inflammation resolved and their urinary tract infections resolved and their pain resolved. And I can say in my practice as a urologist, you know, so much of what we just kind of lump into this diagnosis of interstitial cystitis, which is, you know, people manifesting with essentially chronic bladder pain related to filling and other activities. A tremendous amount of the time I use low dose topical hormones, which are incredibly safe and the symptoms are resolved entirely. And I just, kind of it circles back to, you know, you talking about only 30% of women having symptomatic menopause. I mean, how many people out there are being diagnosed with interstitial cystitis, which was does not fall necessarily under the basket of menopause. And that diagnosis may be a direct consequence of the physiology of, you know, a lack of hormones in the body. [00:07:44][126.9]

Dr Louise Newson: [00:07:45] Yeah, and it’s so interesting, actually. So, when I eventually did some menopause training, which was only a few years ago now compared to being decades as a doctor, I was taught this sort of criteria about symptoms and it was always that people have vasomotor symptoms, flushes, sweats. They might then get the psychological symptoms and then the symptoms related to GSM occur later. And so there’s sort of this path. Now in my clinical experience, that just doesn’t happen at all. I’ve seen a lot of women whose presenting complaint has been either pain and discomfort in the genital area or urinary symptoms. And I’ve known that it’s been related because by the time they see me, it’s sort of five, ten years later. And they then started to have some muscle and joint pain, some headaches and other symptoms suggestive of their hormones. But that’s been their presenting complaint. And so is that the same in your practice? [00:08:44][59.5]

Dr Ashley Winter: [00:08:45] Absolutely. Absolutely. And I think this comes to some extent to the gaslighting of the symptoms that women feel, because we say that the genitourinary syndromes come later, in part because this profound anatomic changes associated with low oestrogen state, such as labial thinning, prolapse of the urethra, narrowing of the introitus, visible anatomic changes often come later and are delayed by a number of years. But that doesn’t mean that in the perimenopause period we are not experiencing pain related to low oestrogen levels, bladder urgency and frequency related to low oestrogen levels. Small amounts of blood in the urine related to low oestrogen levels, recurrent UTIs. And it is fascinating to me because I have had a number of women who are in their, let’s say, early, mid-40s and they have cyclical onset of these symptoms, bladder pain, urgency frequency, UTIs, painful sex. And oftentimes it’s right around the time of menses, right, when oestrogen is lowest in the cycle. And they get told it couldn’t possibly be related to their hormones because they’re still menstruating and because they’re not menopausal, right. Even times I’ve had women manifesting with these symptoms and their last menstrual period was ten months ago, but because it wasn’t a year ago, they don’t classically fit this strict definition of menopause and they’re told it couldn’t be related to their hormones. And they feel like they’re going crazy because they notice a relationship. And when I finally give them the low dose vaginal oestrogen, their symptoms will completely, completely resolve. I had a woman recently who is in her early 40s, and she was getting such bad urinary infections around the time of her menses that she ended up hospitalised with sepsis of urinary origin. And we put her on vaginal oestrogen and she said, You have saved my life. It’s just wild. So I 100% agree with you that those symptoms begin much earlier than we recognise. And just because the anatomy hasn’t made these drastic changes doesn’t mean the physiology isn’t changing. [00:11:05][139.6]

Dr Louise Newson: [00:11:05] Absolutely. And certainly what people’s vulva, vagina looks like, doesn’t correlate with symptoms as well. And that’s really important for people to be aware. And, and actually, my one of my children had a piercing on her eyebrow, as you do when you are 20. But she.. the piercer was talking about, well they were just having a general conversation and she said, oh, I’m really struggling with my health. And Jessica said, Oh, what’s going on? Do you mind me asking? And she said, Oh, well. She said, I’ve been having so many urinary tract infections, I’ve got this thing called interstitial cystitis. I’ve been under the top urologist. I’ve had this treatment, that treatment, this investigation. And I’ve had sepsis a few times. And I’m also incredibly tired. I get night sweats. I used to work out in the gym and now I don’t, I have a rest every day. And my boyfriend is really kind and I’ve had all these blood tests, everything’s normal. So when Jessica left, she said, Oh, you might want to just look up my mum. She does a lot of work in this area. And then she came out of the building and phoned me. And she said oh Mummy I’m feel really sorry for this woman. And I actually had her piercing in my ear, and I’ve got a few sort of rebellion piercings in my ear…so I had my cartilage done by her a few months ago, so. And she was a lovely, lovely lady, or she still is. So I said to Jessica, Do you know what? She probably just needs some really simple treatment, but I’m sure she’s got no money. So I said, Look, why don’t you just go back, get her email address and I’ll just give her a quick ring. I won’t do a full on consultation, but I’ll just give her a ring and some advice. So she went running back in and she came out crying. Jessica, my daughter said, Mummy, she was so emotional, she couldn’t believe it. And then the next day I spoke to her and she said she’d stayed up all night, downloading balance, listening to podcasts. And she said, Everything you say makes sense. But I’ve been asking for years for some treatment, thinking it’s my hormones. People in my family have had an early menopause, yet no one will give me even any vaginal hormones. And of course I recommended her to have some vaginal hormones and I spoke to her recently to see how she was. And she’s still having systemic symptoms. But I arranged a blood test. Her oestrogen is very low. Her testosterone is very low. But her local symptoms, she said, I am not getting up in the night anymore. She said that whole irritation has calmed down. You have, even if this is as good as I’m going to get, this has been transformational for me. Now she’s only 31. You know, it’s just shocking, actually, because vaginal hormones, so we’ve got vaginal oestrogen and we’ve also got this other vaginal DHEA, which is prasterone which converts to oestrogen and testosterone, but it’s only localised. So I can’t think of many things that are safer than vaginal hormones that we prescribe. Can you? [00:13:52][166.6]

Dr Ashley Winter: [00:13:52] Oh, absolutely not. I mean, it’s safer than acetaminophen, which is what is that called in the UK? [00:13:57][4.7]

Dr Louise Newson: [00:13:58] Paracetamol. [00:13:58][0.0]

Dr Louise Newson: [00:13:59] Yeah. I mean, it’s so safe. I mean, I see this all the time. I think vaginal hormones should be over-the-counter. [00:14:03][4.5]

Dr Louise Newson: [00:14:05] And so why aren’t they over-the-counter? I mean, how is it that men can buy Viagra, certainly in the UK over the counter, as long as they’ve got a credit card or some money they can get them? But why vaginal hormones? What is the reason other than it’s a female preparation? But why? Why do you think we can’t have them over the counter? [00:14:23][18.0]

Dr Ashley Winter: [00:14:23] Yeah, this is a great question. So at least in the US, we have something called class labelling on all hormones. So what that means is that every single oestrogen product in the US has a very scary black box warning on it, saying that the Women’s Health Initiative study showed that oestrogen and progesterone combinations can cause breast cancer, uterine cancer, blood clots and all these terrible things. Right. So, of course, what we know is that the Women’s Health Initiative never showed that oestrogen alone causes breast cancer or blood clots or any of that. So and certainly not in transdermal preparations or transvaginal preparations, but also that low-dose vaginal preparations do not enter the bloodstream, do not change the systemic levels of oestrogen. And so that black box warning is not only wrong, but it’s incredibly harmful because a patient will be prescribed this treatment and they read it and they get scared and they do not ever take it. And I found in my practice, as you know, attending physician in the United States, unless I spent so much time unravelling all this fear related to hormones, they would not take this treatment. So, you know, part of the reason I think there are no over-the-counter vaginal hormones in the United States is because even our regulatory institutions will not remove this fear mongering, inaccurate labelling. And the North American Menopause Society has asked the Federal Drug Administration, which is our medical regulatory agency, to remove that black box warning, citing large retrospective studies showing that low dose vaginal oestrogen does not cause any of these problems whatsoever and they won’t do it. And I do not know why. It is incredibly harmful. [00:16:29][125.9]

Dr Louise Newson: [00:16:30] And it’s the same. We don’t have the same warning, but we still have the same words. And it’s our MHRA, which is exactly the same. And I sort of sometimes compare it with other medication that we use systemically and topically. So for example, if you had asthma and you had a flare up of your asthma and I gave you steroid tablets to calm it down, the tablets would warn that there’s a risk of immunosuppression and various side effects, quite rightly so, because that’s absolutely accurate. If you had a bit of eczema on your hand or arm and I gave you a low dose hydrocortisone cream, so it’s still a steroid, but it’s a really, really low dose. You put it on your eczema, it doesn’t really get into the bloodstream and the bit that does is really low. So it doesn’t make any difference. It doesn’t have the same warning of immunosuppression and everything else. So it’s the exactly the same with what we’re doing with our hormones systemically and vaginally. And so it seems completely wrong that whether it’s available over the counter or not is one conversation. The other conversation is the warning of these inserts. And you’re absolutely right, we spend a lot of time in the clinic saying to people, actually, don’t read what’s in the insert because it’s not right. And that’s quite hard to… it looks like we’re making something up and we’re not. And it just doesn’t make sense that we’re trying to dissuade women from having a treatment that can be really transformational for them and we know is safe. [00:17:59][89.0]

Dr Ashley Winter: [00:17:59] Transformational and safe. And I think, for example, in the case of genitourinary syndrome of menopause, right. What is one common symptom, like overactive bladder, right? And because of the fearmongering related to the low dose topical hormones, which essentially have almost no side effects and definitely, you know, essentially no danger, we instead will put women on anticholinergic medications. Right. Which are a common medication for overactive bladder. And those medications cause dry mouth. They cause constipation. They have been linked to increased risk of dementia. Right. And they don’t work very well. They work poorly and they don’t address the root cause. Right. I was looking at an interesting study. And they’ve done in animal studies and showed that as oestrogen levels go down in the body, the bladder lining has an upregulation of mechanoreceptors. So what this means is that in the bladder itself, your bladder becomes more sensitive to distension, filling with urine when oestrogen levels go down. So this is an innate fact of our bladder is that you can develop overactive bladder when your oestrogen levels go down. And if you take a low dose vaginal oestrogen, that will permeate into the…from the vagina into the surrounding tissues, the urethra, the bladder, and you will actually address the root cause, right. You can cause downregulation of those mechanoreceptors and not just put a patch on your overactive bladder, but you could cure. Right? You could cure your overactive bladder. But because of our fear mongering around hormones and the way we gaslight menopause symptoms and the way we take symptoms that are so common and pretend they’re not related to hormonal levels, we have somebody on anticholinergics. We have women getting menopause, I mean, dementia directly from our treatments. And it’s just it’s mind boggling. And this is why I have to talk about it all the time. [00:20:06][126.3]

Dr Louise Newson: [00:20:07] So you totally you’re totally right. My oldest daughter has asthma, actually, and she was given one of her inhalers was an antimuscarinic. So it was the same as having one of these acetylcholine on drugs like Oxybutynin. And very frustratingly it really affected her memory. So it was quite quick that it worked or had these side effects. But she is a trombonist, so she was finding it really difficult to read music because she couldn’t remember the note, she couldn’t remember the position on her slides. Once she phoned me up in a supermarket and said, I’ve come to make some bolognese, but I don’t know what I need. And I was like, Oh, you need some mince, you need some onions. She goes, Well, where do I look for those? Jessica are you alright? And she doesn’t drink alcohol. I knew there was nothing else. [00:20:50][42.9]

Dr Ashley Winter: [00:20:50] Yeah. [00:20:50][0.0]

Dr Louise Newson: [00:20:51] And then I said, Just tell me again which inhaler you’ve been given recently. And she told me, Oh my gosh, you’ve got to stop it. And she was also telling me that her mouth was very dry, which is a real problem for a trombonist of course. But she said, my eyes are dry. I can’t read my screen on my phone very well. And then she also had the most horrendous vaginal soreness and itching and skin and then all these antimuscarinic side effects and actually then recently I was telling her you know when people don’t take HRT one of the treatments that sometimes are given for hot flushes actually is this drug and it has the same side effects as the asthma inhaler you had. And especially when women who have had breast cancer, they often are given this drug. And she’s not that emotional a person. But she burst into tears and she said, I cannot imagine having that drug as a tablet. What are they doing to people? And I said, well, we know it increases risk of dementia. And actually a study in the British Medical Journal last week showed it increases risk of cardiovascular disease as well. I’m not surprised. So there’s one thing not giving treatment, which I think is bad enough, but there’s another thing giving treatment that A isn’t treating the underlying cause, but B is potentially causing harm. You know, there’s always a balance of benefit versus harm for anything we do. Getting up in the morning, driving a car, whatever we eat, whatever we do. But actually hormones are the safest thing because it’s just what we naturally are producing anyway. And even vaginal hormones, you know, are usually very safe in women who choose not to take HRT or women who’ve had breast cancer. And we see a lot of women who’ve had breast cancer and talk to a lot of women who, their urinary symptoms are the really main symptoms of their, you know, their menopause or perimenopause and they’ve been told, oh, just be lucky that you’re still alive and you’ve got through cancer treatment. And, you know, I’m sure you’re the same that, you know, I’m very confident in prescribing localised hormones to these women. [00:22:52][121.4]

Dr Ashley Winter: [00:22:53] Oh, I absolutely agree with you. And I mean, if there was one thing I could accomplish in my entire career, it would be to have every, every, every single woman use vaginal hormones or at least have a discussion about vaginal hormones, be offered vaginal hormones, and not just do it in response to development of symptoms, but really do it as a preventative measure. So when you’re entering the age of perimenopause to discuss what are the signs and symptoms associated with reduction in oestrogen, in the tissue of the bladder and the urethra and the vagina and oestrogen and testosterone, to be frank, and say, you know, this is something that is safe for you to take from now until the day you die and it will not give you breast cancer. It will not give you uterine cancer. You do not have to check blood levels of anything to take this. And it can prevent overactive bladder, recurrent UTIs, painful sex, vaginal dryness. You can be offered this, right? I mean, like I say, we don’t wait for somebody to have a heart attack to be put on cholesterol medication. I mean, why do we wait for a woman to have five, six, seven urinary tract infections, be put on quite dangerous antibiotics, potentially get C. Diff colitis, antibiotic bacteria, multidrug resistant organisms in their body. Why do we wait for that to institute something that we’ve known with level one evidence for over 30 years prevents about 80% of urinary tract infections in women after menopause. I mean, why why do we do that? Nowhere else in medicine would we do that? [00:24:35][102.4]

Dr Louise Newson: [00:24:36] No, you’re absolutely right it absolutely doesn’t make sense. And I do feel, you know, we should be twisting on its head and say, why are women not on a vaginal hormonal preparation. And certainly, like you say, any woman that has had any urinary symptoms or any urinary tract infection, it should be the number one treatment really to try. And I feel very strongly also in anything we do for medicine, it’s often we give a therapeutic challenge, don’t we? We try a medicine and see if it helps. With the vaginal treatments, women are inserting them themselves. So, you know, I have to say to patients, we’ll try a treatment for 3 to 6 months, see how you feel. And if it’s not helping, you don’t need to continue with it. And usually people it’s transformational. And even women who are on HRT, there’s still a considerable proportion, probably around 20%, maybe more, who still need to use vaginal hormones. And that’s really important as well. And I think a lot of people, when they haven’t had urinary symptoms, they don’t realise how disabling they are. I’ve had quite a few recurrent urinary tract infections and I wish I had started vaginal hormones when I was a lot younger. But actually when you’ve got pain in your urethra it is the most awful pain ever. You absolutely don’t know what to do with yourself. And I think it’s underestimated. And a lot of these people, you say gaslighting a lot, but a lot of these women have a lot of psychological symptoms as well. And it’s almost like, oh, there there you’re making a bit of a fuss. Well, they should be shouting from the rooftops because it’s horrendous what they’re experiencing. It really is. And I just think it’s underestimated the symptoms and the the suffering that goes on for these women. And it’s not just a one off urinary tract infection, you know, and it’s recurrent. It’s a horror and it ruins their lives. [00:26:25][108.9]

Dr Ashley Winter: [00:26:26] You know, it’s so great you touched on this, and this is something that I did not really point out, but there is a whole other cohort of patient that ends up in my office as a urologist, who is the woman who has recurrent UTI-like symptoms without infections. So this woman, every few weeks or even constantly feels extreme urethral pain, extreme urethral burning, frequency, severe pain and their, you know, GP or whoever is taking care of them, maybe the emergency room, you know, is getting urine cultures and they’re all coming back negative. And so people say, Hey, nothing’s wrong with you because you don’t have an infection. And the problem is something is wrong because they are experiencing those symptoms. And almost always this has an onset that coincides with some reduction in hormone levels, either perimenopause, menopause, you know, starting birth control or medications specifically for hormonal related acne. And those people, when I put them when I explain to them the physiology that their urethra can have, upregulation of pain receptors, of sensitivity, of friable tissue burning, that that can all be a direct consequence of their low hormonal state. And we put them on a topical low dose hormone. It completely resolves and they are back to themselves. So that is another cohort of these, not UTI, but feel like I have a UTI, that is just tremendous and probably also not falling under that category of symptomatic menopause, but really it is part of symptomatic menopause. [00:28:11][104.4]

Dr Louise Newson: [00:28:11] Absolutely. So anybody who’s been having any urinary symptoms and is listening to this really needs to talk to their healthcare provider about the possibility of vaginal hormones. And so I’m very grateful for your time, Ashley. But I’d like to finish with your three take home tips. So I would ask you to say three reasons why the majority of women at some stage in their life should be using vaginal hormones and once they start using them, continue forever. So just three reasons for that, please. [00:28:41][30.1]

Dr Ashley Winter: [00:28:42] Okay. One, it’s extraordinarily safe. No risk of any cancer or blood clots, 100% safe. So that’s number one. Number two is that it can prevent you from needing so many other unnecessary treatments that don’t address root causes. Right. This may prevent you from taking antibiotics, anticholinergics. I mean, maybe you don’t need vaginal moisturisers. I mean, who knows? You will probably save money. I know. So that’s number two And number three. Oh, gosh, I don’t I don’t know. I mean, that’s it’s safe and it fixes everything. I just can’t even. Not everything, but it fixes so much. Yeah. And number three is that it is not just a vaginal treatment. It is a bladder treatment, a urethral treatment, a vulva treatment. The medication acts locally, but acts locally throughout the pelvis. And so oftentimes, again, we think of menopause or hormones related specifically to sex organs. But it is not just quote unquote, sex organs. It is urinary organs as well. And those are hormonally sensitive. So safety, efficacy. And it is not just a vaginal treatment. It is a urinary treatment. So. [00:30:03][80.5]

Dr Louise Newson: [00:30:03] Very good. Excellent. So lots of really valid and important information in this podcast, and I’m very grateful for your time again Ashley. So thank you very much. [00:30:14][11.1]

Dr Ashley Winter: [00:30:15] Yeah. So thank you so much for having me on. [00:30:17][1.9]

Dr Louise Newson: [00:30:22] You can find out more about Newson House group by visiting www.newsonhealth.co.uk and you can download the free balance app on the App Store or Google Play. [00:30:22][0.0]

END

The post Gaslighting of genitourinary symptoms of the menopause appeared first on Balance Menopause & Hormones.

Are you experiencing symptoms like burning and itching around your vulva and vagina, or painful sex? Or perhaps you have the urge to wee more often or are plagued by recurrent urinary tract infections?

Joining Dr Louise this week is trailblazing US urologist and sexual health doctor Dr Rachel Rubin, to address these common menopause symptoms and the relief vaginal hormones – often used alongside systemic HRT – can bring.

Dr Rachel explains why we need to stop using terms like vaginal dryness and vaginal atrophy, which hugely downplay the impact of declining hormones on your whole genitourinary system.

‘When we say women have vaginal dryness, we minimise their symptoms, we minimise that it’s no big deal, that you can just use a little lubricant, a little moisturiser,’ says Dr Rachel.

Plus, Dr Rachel and Dr Louise also discuss DHEA – a hormone treatment which converts to estrogen and testosterone in the vagina – and the benefits this can bring to women struggling with genitourinary syndrome of the menopause (GSM), again often alongside systemic HRT.

Dr Rachel’s three tips if you are struggling with GSM

1. Know that if you have any symptoms that affect your vagina, vulva or urinary system and you’re over the age of 45, you deserve a vaginal hormone product.

2. Talk to your healthcare professional about access to this treatment that can prevent urinary tract infections, decrease your frequency and urgency of needing to urinate, decrease your pain in intercourse and lead to better lubrication, arousal and orgasm.

3. Keep using your localised hormone replacement: it is a safe product, so can be used long term to sustain the benefits.

 Click here to visit Dr Rachel’s website, and follow her on Instagram @drrachelrubin.

Transcript

Dr Louise Newson: [00:00:09] Hello, I’m Dr Louise Newson and welcome to my podcast. I’m a GP and menopause specialist and I run the Newson Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. I’m also the founder of the Menopause Charity and the menopause support app called balance.

On the podcast, I will be joined each week by an exciting guest to help provide evidence-based information and advice about both the perimenopause and the menopause. Today. I’m actually very excited. I’m usually excited recording my podcast, but today I’m very excited because I have another very esteemed doctor from across the pond in America, who’s kindly agreed to talk today about her work and about some of her thoughts. And she’s a sexual health specialist and a urologist. And I would say that she’s probably a bit more gobby than me, but I don’t know that you’ll agree with that, Rachel. But she’s very forthright. She says it as it is. And I think that’s actually what us as women need to hear. She’s very evidence-based, very impressive. And I’m just delighted that you’re here in front of me, Rachel. So thanks for joining me today.

Dr Rachel Rubin: [00:01:26] This has been a dream come true for me to, just, even that you know who I am. And I know it’s been hard to get our time zones correct so we could do this. So I’m just thrilled to be here.

Dr Louise Newson: [00:01:36] So tell me a bit about you then. You’re a female urologist and they are still in their minority. As many listeners know, my husband’s a urologist. You specialise in different areas of urology, but there’s still not many women. So tell me about your career.

Dr Rachel Rubin: [00:01:51] I can’t believe I just found out that your husband’s a urologist. So I am a urologist, and I did a fellowship in sexual medicine. And so I take care of all genders, and I do four things. I deal with issues of libido, arousal, orgasm and pain in all genders. And that comes with a lot of menopause care. And so I’m very passionate about menopause care and also the genitourinary syndrome of menopause. Right? All the bladder and vaginal and vulval issues that happen in menopause. And I’m very outspoken. And yes, I think I’m good at this because I’m a urologist, that this is not just a gynaecologic issue, but sexual medicine is just medicine. And it’s really important that we start to talk about it. Female urologists, we’re about only 10% of practising urologists, but the last time I checked, all women had urologic organs, which include the clitoris and the urethra and the bladder and the kidneys. So we have to start taking away from that the only doctor you need is a gynaecologist.

Dr Louise Newson: [00:02:46] Absolutely. It’s so important and actually, you know, you say GSM – genitourinary syndrome of the menopause. I know it’s a bit of a mouthful. But it used to be referred to as VVA, vulval vaginal atrophy. And if you look up the word atrophy in the dictionary, it’s withering and wasting away. Well, I don’t want to think of any of my anatomy withering and wasting away. But then it does focus on the vaginal, the vulva. And then often, even now, if you Google menopause or menopausal symptoms, it will come up with vasomotor symptoms. So flushes and sweats and vaginal dryness. It’s all about the vagina being dry. And it was good that the terminology was changed to include genitourinary, so the urinary tract. But it’s not just our vagina that gets dry at the menopause, is it?

Dr Rachel Rubin: [00:03:31] So I actually lecture on this frequently and I believe the term vaginal dryness is killing women. Let me explain. Right. When we say women have vaginal dryness, we minimise their symptoms, we minimise that it’s no big deal, that you can just use a little lubricant, a little moisturiser. You’re fine. It’s just a little vaginal dryness. Suck it up, lady. You’ll be okay. But it’s not just a little vaginal dryness, it’s urinary frequency and urgency. It’s itching and burning of the vulva. It’s difficulty wearing pants. I’ve had patients say, oh, my God, Dr Rubin, I can wear pants again. It changes your vaginal pH so that the microbiome changes and the bad bacteria start to grow. And so by losing the acidity of the vagina, you get bladder infections which can kill you and do kill people. And so the term vaginal dryness is killing women because there are women, lots of women who are dying of urinary tract infections who could be prevented by being on vaginal hormones, which are essentially safe for pretty much everyone to use, which I’m sure we’ll talk about. But we’re not prescribing it because we think, oh, it’s a little vaginal dryness. Start with lubricants and moisturisers. And I just think we minimise women’s experiences. And the problem is 70 and 80 and 90 year old women don’t associate their urinary tract infections with menopause. But that is what is the cause. Over time, the tissue thins, it gets irritated, it loses the acidity, and it never gets better.

Dr Louise Newson: [00:04:57] No. And it is one of the few symptoms that really don’t get better with time, and often progress. When people talk about transitioning through the menopause, which I always find a bit weird because I’m not sure I’m transitioning at all as a menopausal woman, but some people say, well, then their hot flushes, their night sweats improve, their memory starts to come back, or their fatigue might improve. But really, once people start to have those symptoms without proper treatment, it’s very hard to get on top of them because, like you say, there are anatomical changes as well that occur because of the hormonal deficiency that’s occurring in those tissues, isn’t it?

Dr Rachel Rubin: [00:05:34] Absolutely the urethra starts to protrude, it gets red, it gets irritated at the vulva opening the labia minora shrivel up and disappear, those inner wings. When you’re a baby, you don’t have labia minora, you grow them in puberty and you lose them in menopause. Can you imagine if men’s penises shrivelled up at age 52? We would have a vaccine available. I’m sure Pfizer, because they created Viagra, I’m sure they would have made it just like they did the COVID vaccine. But the labia minora disappear and no one’s talking about it. No one warns you about it. No one tells you about it. And so you have changes. And so by us being uncomfortable with private parts is actually hurting women because we’re not doing a very good job of preventing issues. Right? We wear sunscreen to prevent skin cancer. We should be doing vaginal hormones to prevent the changing architecture, the changing microbiome and prevention of urinary tract infections.

Dr Louise Newson: [00:06:28] And you’re so right, it’s easy for men. They can just look down and see what’s happening to their penis. It’s not so easy for women, and sometimes they’re not sure what’s going on. And certainly I’ve been to a lot of menopause conferences now, and there’s a slide that they always seem to show, some people always seem to show, showing this sort of progression of symptoms with time. And it always says about early symptoms of the menopause, are flushes and sweats, and then it can be tiredness and it can be memory problems. And then further down the line, it can be urinary symptoms and symptoms related to vaginal dryness or pain or discomfort and everything else. But I have a real issue with that because I’ve seen so many young women who are perimenopausal, and the first symptom they’ve had is urinary symptoms. Or, I saw a lady recently and she said, it just feels like a blowtorch in between my legs every single day. I’ve seen gynaecologists, I’ve seen urologists, and I just can’t carry on like this. So that was the only symptom.

Dr Rachel Rubin: [00:07:25] I see this frequently in my clinic, and I believe there is a bimodal effect that you see people whose genital and urinary symptoms start before the menopause and other symptoms starts, so in their late 30s, early 40s, and they get told that is this BV [bacterial vaginosis] and yeast, and they get told that it’s stress, they get told all these things and then so now it doesn’t affect everybody, but there’s a large portion of people where they start getting symptoms in perimenopause, and then there’s the people who really start getting symptoms in their late 50s, early 60s or 70s. Right? It takes some time. And I believe I haven’t proven it yet, but I believe this is a testosterone story. This is an androgen story, because the tissue, we have lots of data to show that the vulva vestibule, the urethra, the bladder, the vagina has not just estrogen receptors, but testosterone receptors as well. And we know that a woman’s testosterone can change sort of later on in her late 30s, early 40s. We see libido drop and we do see changes in the bladder, urethra, vagina and vulva at that time as well. And so we see a real benefit for both for vaginal hormones in the either vaginal estrogen or in some cases vaginal DHEA, which is the only androgen product that we have available right now that are very beneficial. And the cool thing is, is that vaginal hormones don’t hurt anyone. There is no risk, no harm to using vaginal hormones in the perimenopause or even pre-menopausal period. Do we need more data on efficacy? Absolutely. But giving a local dose of hormones to the vagina does not increase blood levels of hormones at all.he AUA, the American Urological Association, has guidelines on recurrent urinary tract infections that came out in 2019. And the brilliant thing that it says is that peri- and post-menopausal women, peri, they put that word in there, perimenopausal women with recurrent UTIs should be given vaginal hormones. And so the problem is, is not everybody reads the AUA guidelines and they say, oh, well, you’re still getting your period, so your hormones are normal. There’s nothing to do. This is not hormonal and it’s probably not the case. It’s probably not true.

Dr Louise Newson: [00:09:28] Yeah, it’s very interesting you mention testosterone because we see a lot of women in the clinic who have symptoms more of testosterone deficiency than estrogen deficiency. And we follow the NICE guidance that say you start HRT, and if women still have reduced sexual desire, then you can add in testosterone. And a lot of women do have reduced sexual desire. But we find that so many women have other symptoms that improve, especially cognitive symptoms, muscle and joint pain, sleep, all sorts of symptoms, but also urinary symptoms. I see a lot of women who have been back and forth to urologists, all sorts of investigations, give them local, say, vaginal hormones, give them HRT, they do improve, but then you add in testosterone and they’re like, wow, this is incredible. And you’re absolutely right. We have estrogen and testosterone receptors all around our vulva, vagina, our clitoris, our urethra. And I was as at a European menopause conference a few weeks ago, and they showed this picture with the dots showing the receptors and different colours, estrogen and testosterone, and they said, oh we know why we have, why women have – it was a man, obviously lecturing, of course – saying we know why women have estrogen receptors and they can respond very well to vaginal estrogen. What we don’t know is why women have testosterone receptors around there. And I say…

Dr Rachel Rubin: [00:10:43] Why? Because they’re…

Dr Louise Newson: [00:10:44] So then I put my hand up and said absolutely fascinating. But I find in my clinical practice using Intrarosa, which is DHEA, which vaginally as you know, it converts to estrogen and testosterone in the vagina, but seeps out to all those areas. That seems to have a bigger effect on women than just estrogen alone. And they said, oh, we never prescribe it, we wouldn’t see the results and they don’t prescribe systemic testosterone. And it was around that time that your great paper came out, or your presentation, with your poster, talking about using Intrarosa. So it was brilliant.

Dr Rachel Rubin: [00:11:20] Yeah. So we looked at this because, you know, we love vaginal estrogen, right? Vaginal estrogen is wonderful because it’s the affordable option for most of our patients. And so what I always say is the best GSM therapy, the best therapy to prevent UTIs, urinary tract infections, is the one your patient can afford, and that will use forever till death does she part. And so I’m not here to say you must use vaginal DHEA, but because we know that the receptors have testosterone in them and that sometimes it’s an androgen story, We believe that vaginal DHEA and that’s why, you know, it was invented, was probably it has a really nice property to the tissue. And so we need a lot more data to show that. And the data that we did have was really to prove that vaginal DHEA also reduces urinary tract infections the same way vaginal estrogen does, which we did show that. We looked at data of 22,000 people on vaginal DHEA and compared it to 22,000 people who are matched for diabetes and age and comorbidities all. It was unbelievable. And then you looked at the year after they started this therapy and the incidence of urinary tract infections and it reduced by half. And then that was really stable with every age, especially in the over 70 crowd. And so that really showed us that we can reduce urinary tract infections with vaginal DHEA just as we can with vaginal estrogen. And so do we need more data to show why you would use one over the other? We have a little data. There’s one paper that shows that women who do vaginal estrogen, but they still have symptoms, you switch them to DHEA and you can rescue and recover. So that’s, I like it for that. And in America we can often get prior off, you know, when we have that situation, we certainly have women who will not use estrogen because of the word estrogen, and vaginal DHEA is not the word estrogen and the data shows no increase in systemic blood levels of estrogen or testosterone. We have women who really like the product because it’s palm oil and DHEA. It’s very lubricating and moisturising. So it really is a nice product. So the point being is that it adds options. As women, we need options because as you know, in your clinic, not everyone responds to the same therapies the same way. And so some women love putting creams in their vagina, some women hate putting creams in their vagina. Some women like rings, some women like tablet inserts. And so the other area of concern really is what’s called the vulva vestibule, which is the area that surrounds the urethra. And right at the opening of the entrance of the vagina is actually bladder tissue. And it’s commonly the most painful part that women have pain with penetration, pain with sitting, and its irritating tissue that can create urinary urgency. And we find that sometimes vaginal estrogen is not enough to help that tissue at that opening. And so that DHEA, and there’s a paper that just got accepted of colleagues of mine, that really does show improvement in that vulva vestibule bladder tissue that surrounds the urethra with the DHEA, which is really fabulous. So I think most of our guidelines and data for testosterone say, yes, it’s good for libido. However, we can’t ignore the fact that it’s probably good for more things than just libido. We just need more robust data. And the problem, because we don’t have products, a lot of products, we don’t have a lot of interest in studying it. We don’t have a lot of money to do big projects. And to do good research requires a lot of resources. And so guidelines change because we do more data, we get more information and they change because of people like you who see things clinically and then study them. And thank God for what you’re doing. You know that where you see changes, you see trends, you see people, and then you say, why is this happening? How do we study it? The only reason we have been able to solve really complex issues like persistent genital arousal disorder is because groups of patients work together and say, well, this worked for me and this worked for me and why? And then we look back, say, why did it work? And then we study it. And so that’s how science evolves.

Dr Louise Newson: [00:15:14] It’s very interesting, actually. I was reading some work by David Sackett. So in the 80s he wrote about evidence-based medicine, and he was also very clear that it’s not just about randomised control studies, it’s about clinical evidence as well. And we seem to forget that. There’s a lot of things that people are now saying if we haven’t got a randomised controlled study then it can’t be right. And actually we have to remember not everything is tested as a randomised controlled study and actually if there are trends and they make sense biologically as well, then we shouldn’t ignore the signals. And I feel with testosterone there’s a really big anti-testosterone, sort of almost not campaign, but a group of people, not just in the UK, but globally as well, who keep thinking it’s placebo. And now there are certain gynaecologists and groups in the UK are saying that women have to be severely psychologically distressed with their reduced libido before considering testosterone. And they also need to have a full bio-psychosocial assessment. And I find as a woman myself who takes testosterone, it’s quite distressing, actually. My libido changes every day, every minute of every day. You know, I’d actually say if you assessed me now doing a podcast, my libido is probably pretty low. My husband’s gone away for the weekend, so actually I’m not really thinking about sex, but does that mean I shouldn’t have testosterone now? Well, actually, we also know we’ve got testosterone receptors in other areas of our brain and our muscles and joints. I’m very scared of osteoporosis. So testosterone, we haven’t got a good RCT in women, but it probably does help strengthen our bones. And I’ve really suffered with recurrent UTI, so I really want my urinary tract to be as healthy as possible. And actually, as a woman, can’t I choose to have my own hormone back? Why is testosterone so dangerous? You know.

Dr Rachel Rubin: [00:17:05] Say that part louder. And I think, again, men get to choose, right? If their testosterone is low and they have the signs and symptoms of testosterone deficiency, the guidelines support giving men a trial of testosterone for six months to see how they feel. And 80% of my male patients feel incredibly better. Their mood is better, their energy levels are better, their drive is better. I say 80% because I think 20%, and I see this in my female patients too, 80% who take testosterone are like, oh my god, I got one last week. Who said, Rubin? That was the piece that was missing, right? You got me. You know, my estrogen, progesterone, but that testosterone now I feel like me, now I feel like me. So we actually have to be talking about gender affirming care in a broad sense. If you want breast implants and you say, I will feel more like me if I get breast implants, you can invest in your body and get breast implants. And I don’t want breast implants. That sounds not good for me, you know, and so it has to become this body autonomy thing. If a man says, I’m bothered by how big my prostate is, I am peeing all the time, I am up all night and that is not good for my mental health, I would like a surgery to open my channel, you know, has nothing to do with cancer, it’s quality of life. We say, okay, your body, your choice. If a man gets prostate cancer and it’s localised and he says, gee, I’m dragging, I don’t feel good. I have low libido and erectile dysfunction and his testosterone is low. We, with evidence based and shared decision making, we offer testosterone therapy and his body, his choice. And so all we’re saying on the female side is we do the best that we can with the knowledge that we have in 2023. We are constantly going to learn more and see more and study more. And we will always change our evidence and change our guidelines. But at the end of the day, you get to decide what you do with your body, right? You get to decide, do you have that glass of alcohol? You get to decide if you eat the French fries, you get to decide if you exercise every day. We don’t force you to do those things. And so gender affirming care, you know, and I think, again, our understanding of transgender medicine, is that when you get to choose what you do, like, you can choose. That means, you know, you can change your mind. And do we have all the evidence of what is safe and what the long-term risks are? That’s why we study it. And so we continuously have to gather data and do shared decision making with our patients. But we have to stop telling women, you can’t do this. You absolutely cannot do this. We never say that to men of like, you absolutely cannot do this. We say, well, we don’t recommend this. We don’t think this is a good idea. But like your body, your choice. It is unbelievable.

Dr Louise Newson: [00:19:40] I totally agree. I really feel very strongly that as a doctor, I could never say no to people unless it’s obviously completely unreasonable. But I would still talk about how unreasonable it is. And a lot of women want something knowing that there isn’t long term data, knowing that there could be risks, but they also know there are benefits. And I think when you think about wellbeing, it’s really difficult to actually measure in studies. So, for example, I know taking testosterone, I can sleep better, but also I can empty the dishwasher quicker, I can put a load of washing on quicker because it’s not such a big effort. Now actually that sounds really small, but, you know, when I’m busy and I’ve got three children, my husband’s on call, the dishwasher has to be emptied and if it doesn’t, then the house gets a mess. Then I get more stressed and…. but that’s very hard to put, you know, randomised controlled study: does taking testosterone improves your ability to…

Dr Rachel Rubin: [00:20:37] So we have actually you know, it’s actually very interesting and a lot of, as I said, a lot of what I do in, will see in the male sexual medicine world I actually apply to the female side. And there was a big study called the Ageing Male Study and they took older men, right, and with like not healthy guys and they gave them testosterone for a long time and they followed them and they came back. And what was improved? Well, their erections got a little better, their libidos got a little better and their quality of life got a little bit better, you know. But it wasn’t like their grip strength was so measurably better or their endurance was measurably a lot better. And so what was fascinating, Dr Newson, is the headline was testosterone doesn’t work. That was the headline. Testosterone doesn’t work. Whereas the headline should have been testosterone is not harmful for old sick men and makes them feel better sexually and makes their quality of life better. In fact, it told us that it works fabulously. And that’s the exact same story on the female side. There is no data showing major harm. There is lots of data showing benefit. And so it really becomes the discussion of do we know everything? No. But the data is overwhelmingly positive and you could try it for yourself. And once you try it, you can decide if this is something that you continue as part of your regimen.

Dr Louise Newson: [00:21:52] Absolutely. Putting patient choice is so, so crucial, but yet we sort of forget that. And with testosterone, one of the other things that a lot of people are worried about, about the risk or theoretical risk of clitoromegally, so the clitoris becoming enlarged. And I haven’t had any problems with any of my patients. But what I have had is that women can find their clitoris again, because, again, as you were saying, the anatomical changes that occur, often their clitoris becomes a lot smaller, you know, harder to arouse as well. And it doesn’t have the same sensations without hormones. So a lot of people are very grateful that they can find their clitoris as opposed to this clitoromegally which has connotations of this massive thing growing between our legs and men are being scared of it. So I don’t know what it’s like in your clinical experience, Rachel.

Dr Rachel Rubin: [00:22:37] We’ve never seen it, but there is a movement, Cosmo has written about, that women are trying to grow their clitorises, in fact, which is kind of interesting, but we know that the clitoris and the penis are exactly the same thing. They are erectile tissue that is very testosterone sensitive and that, you know, they get erect, it gets hard, it arouses, and then it’s hormone sensitive. And so, yes, we can see improvements in orgasm and arousal with the use of hormone therapy. But we have you know, when you use correct evidence-based doses, you do not see severe, you know, deepening voice or cliteromegally or anything like that. And, you know, the worst thing you can see that I’ve seen, right? Somebody says, oh, my acne, I got a little more oily skin, I’ve got some acne, you know, where I apply it on my calf. There’s a couple extra hairs that grow in and I shave them off. I mean, you’re not talking about, you know, massively harmful side effects. And we do a lot of scary things as doctors that have really severe and crazy side effects. We give chemotherapy, which is poison. We give, you know, we give you so many things that are harmful. This is one of those things like, it’s not that serious, you guys. It’s not that serious. And I think we want it to be more serious than it is. And it’s not that serious. It helps women’s sexual health. It doesn’t help everybody’s sexual health, a lot of people’s sexual health. And that matters to people. And we should listen to them and figure out what their goals are, because it’s not everybody’s goal. If improving your sexual health is not the goal, then it’s not. You don’t have to do it. But don’t deny other people from saying, this is my goal and this is something I want to do. And we really do, just it’s so wonderful when you see the benefits and you’re like, well, I didn’t do that much for you. And you can really, you know, as you see every day in your clinic. Right. It makes a huge difference.

Dr Louise Newson: [00:24:16] Absolutely. And I think it’s very frustrating and I find very frustrating is that when I do my clinic, I see and listen to stories. The transformational nature of what we do in the clinic is huge. Yet away from my clinic on social media, I feel like I’m a complete failure and then I seem to get a bit more strength. I think, I went into medicine to help people who are suffering. Not other people who hate me on social media. So it’s really important that we stay focused and put our patients in the centre. And one of the things I wanted to just pick up on before we finished, Rachel, is you were saying about the expense of vaginal hormones and obviously they depend, the cost depending on what they are and there is expense with HRT and what some of our NHS England and the government are worried about, if more women take HRT, that’s going to be a lot of money because there’s about 14 million menopausal women in the UK and currently only 16% will take HRT. But if it’s more, oh my goodness, that’s a lot of money. But even if we just look at local, say, vaginal hormones in reducing urinary tract infections, that surely must save money, doesn’t it?

Dr Rachel Rubin: [00:25:25] In fact, we are looking at this right now and we are gathering data to show if you can reduce urinary tract infections which can lead to hospitalisations, antibiotic resistance, high dose IV antibiotic, or urgent care visits for urinary tract infections. We can save our government in the United States in the billions. And I’m not talking like one or two billion, like lots of billions of dollars a year. If you do the modelling correctly. And so this is actually cost saving over time. And so especially vaginal hormones, right, for the 80-year-old, the 90-year-old, the money that is spent in the end of life for urinary tract infections is unbelievable. And so, again, vaginal dryness. The term is not only killing women, but it is costing your government an obscene amount of money. And so by using these vaginal hormones and changing the education around these are bladder medications that prevent death. Right. It becomes a whole different conversation. And so we must stop calling it vaginal atrophy. We must stop calling it a little vaginal dryness. And we must call it UTI, preventing, you know, microbiome, improving essential oil, creating magic that really will prevent urinary tract infections. There is no other medication at all ever proven to reduce urinary tract infections the way vaginal hormones is. There’s nothing. No probiotic, no cranberry pill, no antibiotic. There is nothing, no vaccine, that they’re coming out with, that’s going to surely cost your government a lot of money, that will work as well as vaginal hormones, which can be produced very inexpensively. The problem is in the United States is everyone wants money. And so they haven’t until just a couple of years ago, it’s been very expensive and unaffordable for people. And now you can get a tube of estradiol cream for $20, which lasts two and a half months. That’s the cash price without insurance. And so that has allowed our advocacy to get even louder because we have to tell women, you can afford this now. Five years ago, you couldn’t, but now you can. Thanks to some really incredible entrepreneurs and business people who see that like, okay, we need to actually change things here.

Dr Louise Newson: [00:27:31] And it’s so crucial because the money that’s saved is two-fold, I think. You’re saving money for health economies because women aren’t going into hospital with urinary tract infections. Quite a few people when they go in and then some women develop urosepsis. So they have quite long hospital admissions or they’re even just going back and forth to primary care. They’re often having inappropriate urine testing as well, being sent up to the laboratories. They’re having antibiotics, which obviously is causing or can lead to antibiotic resistance. But then it’s also the cost to the economy, because a lot of women actually, if you have got recurrent UTIs or you’re having symptoms, often can’t work to the same capacity or they’re taking time off for every hospital appointment or…

Dr Rachel Rubin: [00:28:14] They’re getting divorced because they have so much pain with any kind of intimacy. You know, the cost of divorce.

Dr Louise Newson: [00:28:21] Absolutely.

Dr Rachel Rubin: [00:28:21] And that affects their mental health and quality of life. I mean, this is not just a little vaginal dryness.

Dr Louise Newson: [00:28:27] And also there’s layers and layers of medication that is given instead. You know, you’ve already said some of the sort of alternatives that are given. Lots of people are given thrush-type treatments, lots of people are given antibiotics. But then because of the systemic effects, a lot of people have painkillers. I see a lot of people who are on amitriptyline or gabapentin or pregabalin, they’re on sleeping tablets, you know, the list sort of goes on and on and on, and yet no one’s giving them something that’s $20, you say, for a few months. It just doesn’t make sense, but it’s because it’s just a women’s problem, it shouldn’t be really spoken about and it affects the majority of women, have localised symptoms and all women become menopausal. And I think the other women where they’re saying there’s a few that don’t have symptoms, it’s because they don’t talk about it actually.

Dr Rachel Rubin: [00:29:16] The genital and urinary symptoms are just, it is everybody. I mean, I can’t say 100% of people and maybe some people’s adrenal glands are working pretty well, but it is so, so common. We just don’t associate with menopause, frequency, urgency, leakage, you know, pelvic pain. We don’t think about it as a hormone issue, but it is a hormone issue. But think of the 85-year-old woman who gets up in the middle of the night having to pee and she trips and falls and breaks a hip. Right. The amount of money that goes into that and the likelihood that that is going to kill that woman is incredibly high. And if she had been on vaginal hormones, we might get her sleeping through the night, not getting up in the middle of the night to pee, not risking that fall. And so we have to start looking at this from a different lens. And because of what you are doing, you have, you know, the entire country looking at this through a different lens. And as much as you hate being yelled at on social media, for every person who is not nice to you on social media, there is somebody like me who is watching what is happening in Britain and who is literally sitting there scheming and talking to her friends in America, saying, how do we do what Newson is doing in Britain? I say this once a week, how do we do this here? How do we gather an army? How do we change the narrative? How do we create this revolution? Because it is so important. Women are not getting this information. They lack basic education on these things. And what you are doing is motivating us to keep going. So thank you.

Dr Louise Newson: [00:30:42] Oh, you’re very kind. What a lovely way to end. I’m going to stop before you know, change your tune, but that’s really lovely to say. Thank you very much. Well, there’s a lot more we and when I say we, I include you as well, to change the world for women because it’s the future health of women that worries me, especially as I have three daughters. Just before we finish, though, I would like to ask for three take home tips, and I’m really keen to ask you just three things. So women who are listening who think they might have some symptoms related to GSM, genitourinary syndrome of the menopause, what are the three things that they should do as a priority to help themselves?

Dr Rachel Rubin: [00:31:19] If you have any symptoms, urinary symptoms, and you are past age 45, you deserve a vaginal hormone product. Talk to your doctor about it, it is safe for every human on earth to take. If you are on an aromatase inhibitor, we should have a conversation with your oncologist. But we don’t have mega data showing harm and we have unlimited amounts of data showing benefit, UTI reduction, decrease in frequency and urgency, decrease in pain with intercourse, better lubrication, better arousal, better orgasm. And number three, I know I’m going way over is that female Viagra has existed since the 70s. Vaginal hormones is female Viagra and it prevents UTIs, which Viagra doesn’t do. So here you have a safe product that improves sexual health, prevents urinary tract infection, and really should be used very widely. And you have to use it forever. Right. Till death do you part because like sunscreen it will and wearing your seatbelt, it will only work if you keep using it.

Dr Louise Newson: [00:32:20] Brilliant, very good, love it. So thank you so much for your time today. And I’m sure that you will come back at another time to be a guest again, Rachel. So thank you.

Dr Rachel Rubin: [00:32:29] Any time. Any time.

Dr Louise Newson: [00:32:33] For more information about the perimenopause and menopause, please visit my website www.balance-menopause.com. Or you can download the free balance app, which is available to download from the App Store or from Google Play.

END.

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