The Dr Louise Newson Podcast - 233 - Gaslighting of genitourinary symptoms of the menopause

Episode Date: December 5, 2023

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: It's extraordinarily safe. No risk of any cancer or blood clots, 100% safe. It can prevent you from needing so many other unnecessary treatments that don't address root causes, and so you will probably save money. 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

Hello, I'm Dr Louise Newsom. I'm a GP and menopause specialist and I'm also the founder of the Newsom Health Menopause and Wellbeing Centre here in Stratford-Pon-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, and always inspirational personal stories. This podcast is brought to you by the Newsome 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 10-month-old daughter to record the podcast today. So welcome, Ashley. Thank you so much. I am so happy to be here and honour 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 10-month-old right now. Very good. She's far too much energy for him. 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 over exaggerating, 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's 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 unitary 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 Volvo vaginal 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 to wear menopausal to have GSM. But it does encompass a 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 gynecologists and urologists for bladder symptoms, for recurrent urinary tracts, 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. Oh, gosh. The very honest answer, which is not 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 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 and just did. That is, it'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. Yeah. So yeah, that's the basic thing behind it. Well, fair enough. So you would have seen lots of people with interstitial cystitis, presumably, as part of your and now, you know, in your day-to-day practice, presumably. Yes. And, well, this is a very interesting question because I do believe that what is called interstitial cystitis is most commonly either genitoneary syndrome of menopause or changes related to perimenopause. So genitonear 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 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 were 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 estrogen. 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 resolve entirely.

And I just kind of, it circles back to, you know, you talking about only things. 30% of women having symptomatic menopause. I mean, how many people out there are being diagnosed with interstitial cystitis, which 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. 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 unary 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. I'm sure. Is that the same in your practice? Absolutely. Absolutely. And I think this comes to some extent to the gaslighting of the symptoms that women feel, because we say, that the genitohirinary syndromes come later, in part because this profound anatomic changes

associated with low estrogen states, such as labial thinning, prolapse of the urethra, narrowing of the entreatis, 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 in. experiencing pain related to low estrogen levels, bladder urgency and frequency related to low estrogen levels, small amounts of blood in the urine related to low estrogen 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, urtie eyes, painful sex.

And oftentimes it's right around the time of mencies, right, when estrogen is lowest in the cycle. And they get told they 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 10 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 estrogen,

their symptoms will completely, completely resolve. I had a woman recently who's in her early 40s, and she was getting such bad urinary infections around the time of her mencies that she ended up hospitalized with substance of urinary origin. And we put her on vaginal estrogen, 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 recognize.

And just because the anatomy hasn't made these drastic changes doesn't mean that physiology isn't changing. 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 actually one of my children had a piercing on her eyebrow. you do when you're 20, but she, the piercer was talking about, they're 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 have a rest every day and my boyfriend's 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, Mommy, I feel really sorry for this woman. And I actually had her piercing in my ear. I've got a few sort of rebellion piercings in my ear when I've got, 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. 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-long 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, Mommy, she was so emotional.

She couldn't believe it. And then the next day I spoke to her and she said she 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 estrogen's 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 estrogen and we've also got this other vaginal DHA, which is prasteroom, which converts to estrogen and testosterone. But it's only localized. So I can't think of many things that are safer than vaginal hormones that we prescribe. Can you? Oh, absolutely not. I mean, it's safer than acetaminopin, which I, what is that called in the UK?

Paracetamol. Yeah, I mean, it's so safe. I mean, I say this all the time. I think vaginal hormones should be over the counter. Yes. 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 do you think we can't have them over the counter? Yeah, this is a great question. So at least in the US, we have something called class labeling on all hormones. So what that means is that every single estrogen product in the US has a very scary black box

warning on it, saying that the women's health initiative study showed that. that estrogen 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 estrogen alone causes breast cancer or blood clots or any of that. 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 estrogen.

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 a, you know, attending physician in the United States, unless I spent so much time unraveling 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 labeling. 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 estrogen does not cause any of these problems whatsoever, and they won't do it. And I do not know why. It is incredibly harmful. 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 exma on your hand or arm and I gave you a low dose hydrochortisone 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 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,

with 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. Transformation and safe. And I think, for example, in the case of genitory urinary 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 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, right? And they've done in animal studies and showed that as estrogen 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, right, filling with urine when estrogen levels go down. So this is

an innate fact of our bladder is that you can develop overactive bladder when your estrogen levels go down. And if you take a low-dose vaginal estrogen that will permeate 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 mechanico receptors and not just put a match on your overactive bladder, but you could cure, right? You could cure your overactive bladder. But because of our fearmongering 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. I know. And it's just, it's mind-boggling, right? And this is why I have to talk about it all the time. Well, you're totally right. My oldest daughter has asthma, actually, and she was given one of her inhalers was an anti-mascarinic, so it's the same as having one of these acetylcholine drugs, like oxibutin. And very frustrating, it really affected her memory. So it was quite quick that it worked or had these side effects, but she was a trombonist, so she was finding it really difficult to read music because she couldn't remember the notes. 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 mint, you need some onions. She goes, well, where do I look for those? I'm like, Jessica, well, you're right? And she doesn't drink alcohol. I knew there was nothing else. Yeah.

And then I said, just tell me again, which inhaling you've been given recently. And she told me. And I was like, oh, my gosh, you've got to stop. But 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 there are all these anti-masculinic 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 flashes, actually, is this drug. And it has the same side effects as the asthma inhaling you had.

especially when women have 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. I'm actually a study in the British Medical Journal last week showed it increased 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, 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 talked to a lot of women who their urinary symptoms are the really main symptoms of their, you know, their menopause or perimenopause. And they're being told, oh, just be lucky that you're still alive. 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 localized hormones to these women. Oh, 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 estrogen in the tissue of the bladder and the urethra and the vagina and estrogen 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 urinary cancer. You do not have to check blood levels of anything to take this.

And it can prevent overactive bladder, recurrent uti, is painful sex, vaginal dryness. 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, multi-drug 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 do we do that?

No, where else is it? 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's 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 in 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 three to six 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 realize how disabling they are. I've had quite a few recurrent urinary tract infections. I wish I'd 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 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 horrid, it ruins their lives. 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, feeling all's extreme urethral pain, extreme urethral burning, frequency, severe pain. And their, you know, GP or whoever's 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 a regulation of pain receptors, of sensitivity, of friable tissue, burning, that that can all be a direct consequence of their low hormonal sting 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. Absolutely. So anybody who's been having any urinary symptoms and is listening to this really needs to talk to the healthcare provider about the possibility of vaginal hormones. 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.

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 might prevent you from taking antibiotics, anticholinergics. I mean, maybe you won't need vaginal moisturizers. I mean, who knows? You will probably save money.

So that's number two and number three. Oh, gosh, I don't know. I mean, 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 vulvar treatment. The medication acts locally, but it 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 yeah. Very good. Excellent. in this podcast. And I'm very grateful for your time again, Ashley. So thank you very much.

Yeah. So thank you so much for having me on. You can find out more about Newsome Health Group by visiting www.org.com. And you can download the free balance app on the App Store or Google Play.