The Megyn Kelly Show - Menopause, Libido, and Childbirth: Deep Dive on Women's Sexual Health, with Dr. Mary Jane Minkin | Ep. 609

Episode Date: August 16, 2023

Megyn Kelly brings listeners and viewers a deep dive on women's sexual health, with Dr. Mary Jane Minkin, OBGYN and clinical professor at Yale School of Medicine, and expert on the issue. They discuss women's libido issues, the difference between desire and arousal, how medical conditions could affect sexual drive, how relationships could affect a woman's libido, why women don't talk about their sexual health enough, the medical options to increase women's libido, how testosterone works for women, how various medications could decrease libido in women and men, the effect of antidepressants on women’s sexual desire, how age affects libido, how the birth control pill can affect women's libido, causes of pain during sex, challenges related to orgasm, HPV vaccine, sexual health after vaginal births, the benefits of kegel exercises and "pelvic floor physical therapy," when to know when you are in menopause and notable treatments for symptoms, the “erratic period” and how to regulate it, and more.Find out more: http://madameovary.com Follow The Megyn Kelly Show on all social platforms: YouTube: https://www.youtube.com/MegynKellyTwitter: http://Twitter.com/MegynKellyShowInstagram: http://Instagram.com/MegynKellyShowFacebook: http://Facebook.com/MegynKellyShow Find out more information at: https://www.devilmaycaremedia.com/megynkellyshow

Welcome to The Megyn Kelly Show, your home for open, honest, and provocative conversations. Hey everyone, I'm Megyn Kelly. Welcome to The Megyn Kelly Show. Are you tired of hearing about the indictments? Me too. I'm sick of it. Plus we have the next year and a half, probably two years, maybe two and a half, maybe three to discuss them. So today we are doing a show that I've really been looking forward to, and that is all things related to women's sexual health and function. We talked about the men's sexual health last week, last Wednesday, for those of you wanting to hear that one, got a lot of great feedback on it. And today we dive into all the topics for the ladies. Menopause, fertility, sexual dysfunction, all of it. Plus, we're going

to be answering some of your questions too. And let me tell you, I did a call out for questions. You ladies did not hold back. My God, gave me things to think about I had never even considered. So tip of the hat to you for being honest about your issues, and we'll get into it all with our guest today. Here with us to help us through this discussion, Dr. Mary Jane Minkin. She's a clinical professor at the Yale University School of Medicine who's been in private practice for more than 40 years. In 2018, she was named Educator of the Year by the North American Menopause Society, and she has been named a top doc by Connecticut Magazine numerous times, among her many, many other honors. Dr. Minkin, welcome to the show. Megan, thank you so much, and thank you for the very kind words.

Too kind, but thank you. Oh, well, no, we're honored to talk to you. There's so much to go over, and I guess there's no better place to kick it off probably than just, I've heard you say that there's a difference between libido issues and sexual dysfunction issues. And I don't understand what are the differences? Could you help us define those? Sure. Well, we could probably spend the next couple of hours on that question alone. So it's an excellent question. So thanks. So as far as libido, that's really a desire to have sex, you know, where some women decide, women wanting to want, I know it sounds crazy, but wanting to want to want to have sex. And that's a very important thing. However, there are some people who don't have much desire to have sex, but it doesn't bother them in the

slightest. And, you know, God bless them. that's fine. So the major issue that we're concerned about with libido is women who have decreased libido and are concerned by it. It produces significant bother or concern, and they're not happy with the situation. Okay. And then, of course, there are all sorts of performance issues going on. And the issues with libido are so multifaceted, because, of course, there's some hormonal issues, to be sure. Okay. And that's, I'm sure what many of our listeners are interested in, but there are also other things in our lives, which are not strictly hormonal. And one of the things my med students, my residents ask me, how do you figure out what's what? And the answer is, it's really hard because, you know, particularly of course, one of my special hobbies is, of course, menopausal women. And but if you look

at any woman's life, there's so many things going on in her life, besides just hormonal activities. And there are relationship issues, of course, which are primary, you know, if you don't really like your partner, you're probably not going to want to have sex with him or with her. It's just something that you're not going to be interested in. You have to really, you know, be happy and liking your partner there. If you're talking about sex with somebody else. her. It's just something that you're not going to be interested in. You have to really be happy and liking your partner there if you're talking about sex with somebody else. There are also issues in your life. Are you tired? If we get into, for example, a new mother, oftentimes women who've just had babies will talk to me about their decreased sexual desire, decreased libido. Well, they're exhausted. They've been up feeding this kid

every night. They're not getting a decent night's sleep. And then they're thinking about having to go back to work. I mean, so that those are issues that might overwhelm her desire to have sex. Or if somebody is having pain, okay. There are women who have painful pelvic conditions or significant medical conditions, which just are really debilitating for them. And it's like, you know, well, who would want to have sex if it's going to hurt. And that, again, is particularly important, we get to talking about our menopausal ladies who may be suffering from vaginal dryness. So it's discomfort issues. And then there are also, you know, for many people, you know, we're looking at our partners, we're looking at our kids. But in our population, we have, you know, a significant aging population,

people are living a lot longer. So for many of my patients, they're taking care of their mother or their father. Or as I when I give a talk, I get a laugh on this one, I'll say, yeah, and even worse, you have to take care of your mother in law. That was one of my patients yesterday. So you got all these responsibilities going on. And all of those can be dampening your desire to have sex. So there are many, many things at play besides just the hormonal issues intrinsically going on for a woman. And there's also a difference between desire and arousal, right? So it's like you could get aroused, but the desire is lacking in some of these women who you just talked about because they're tired, they're mad. This is why

they say the men should help with the housework, right? Because it's like, yep, it relieves the burden on the wife. It makes you feel closer to him. It makes you feel a little bit more pep in your step. It could refire your desire. You may have no problem getting aroused when you actually get down to it, but the desire can be a problem for some women. Absolutely. And it's very difficult to dissect that out. And as far as what they're concerned about. What's the end result? Do I really want to have sex? And is it going to be fun for me? And it's going to be fun for the relationship. And the other thing that's out there, and this is, I'm probably jumping six steps ahead, but there have been some reframing of issues, desire. And one of the women who's done the most in this area is a revered professor from British Columbia, whose name is Rosemary Besson. And she actually has formulated what she calls a circular issue on women's libido and desire, that basically, it's not strictly like, you know,

a guy can just, you know, and guys got, we'll talk about testosterone in a minute, they have a lot of testosterone, that's certainly one of the hormones significantly involved, we think, in desire. And so a guy, oh, I want to have sex and that's it. But for women, there may be many other issues than just the hormonal issues at play. It may be she knows that if she does have an intimate relationship with her partner, that that will improve the relationship and improving the relationship will further lead to increasing her desire because the relationship is better. So it's more of a circular issue rather than just a linear model for wanting to have, you know, okay, I'm aroused. I want to have sex. I have sex. I'm done. That's good. Whereas for women,

it's oftentimes, and Professor Bassan has talked about this a lot, is that it's because of the desire and the closeness and the intimacy that will happen in the relationship, which will further improve the relationships will then will help involve, you know, improving libido overall. So very, very complex stuff in us. Is that is that true for men, too? Because I mean, I think of them more as simple beings who just they want to get after it. And they're not as focused on whether the relationship is in tip-top shape. You've read Dr. Besson clearly. The answer is yes. Most people think that the male model is much more of a linear model than a circular model for women. So if you're a man wanting to have sex

with your wife or your partner, it would behoove you to work on the relationship, whether that's important to you or not, if you just want more sex, because you need a willing partner and your partner is going to be more willing if she feels emotionally closer to you. Absolutely. Absolutely. And I can throw in a quote, which I think is interesting from somebody who I've had the honor of working with on certain occasions. And I've worked with Dr. Ruth Westheimer. And one of the lines that she uses, which I borrow regularly, you know, if the guy wants to have sex and stuff like that in this relationship, and she'll look and she'll say, and if he hasn't taken the garbage out in the last five days, well, she's not going to be very interested. So yes, improving the relationship can be very, improving the life at home can be very helpful to

having the woman want to get closer in this relationship. Yes. Yes, that's right. I mean, it's not that it's like hot to see your husband take out the trash. It's that you want shared burdens on the things that are no fun around the house. You do not want to be the one doing way more than your share. And then, because I will say this, I'll say to Doug, like, I'm not doing all like, I'm not cooking the dinner and cleaning up the dinner and cleaning up the house. And then, you know, you want to cuddle up to me because at that point it feels like another chore.

You don't want it to feel like something I'm just giving you, right? It needs to be more balanced. Absolutely. Definitely needs to be more balanced. And, you know, and in a relationship that's good because if the guy figures it out, that'd be great because he'll end up getting more of what he wants to. It'll make the relationship much stronger for the couple. Most men would be thrilled to realize the ticket to getting more sex is unloading the dishwasher and taking out the garbage. Great. I got the keys. Terrific. It helps. That's great. I'm an empiricist. It works. That's terrific. Right. Right. It's like, it's not that hard. You know, you, and then, you know, tell us like, we look hot or whatever. Just show us that you're attracted to us. Even if we've gained a little

weight or we got a little older or, you know, we had a bad day, especially when you're nursing your babies and you feel like your body's from another planet, all those things, like just a good reminder that you still find us attractive and, you know, we still are desirable. All those things. Those are little my tips for men. But is it true that because I read that 43 percent of women report some degree of sexual dysfunction. And I also read that most women don't report like most women don't want to discuss this at all with their doctors or anyone else. So that means a lot, a lot of women, maybe the majority of women are having some form of sexual dysfunction. A lot of women are having sexual dysfunction and you're absolutely right. And there are many things

that can hinder the discussion of this with your medical provider. One of the things that we try to teach, I think most of us try to teach in the business to our students, is to ask patients, you know, just ask is one of the mottos and things like that. Just ask that we can, you know, are sexual issues, you know, going on and are they bothersome for you? That's very important. And, you know, because and many people, and there are a whole bunch of reasons, there's a lot of literature on this, you know, why don't providers and women have these discussions? And there are anxieties on both sides. One of, of course, the major issues out there, and again, we can spend many hours talking about this, is the brevity of the typical medical visit these days.

You know, an average medical visit may go on for seven minutes and you're talking about your whole health history. And, you know, by the way, doctor, I haven't really, I don't have any interest to have sex. So that's, but that's a problem. And women have to, you know, raise these issues because sometimes the provider isn't, even though we try to teach these folks

to be asking that question. So just to say, yeah, this is going on, don't be afraid. Some patients are actually, and these, we've studied these things. Some women are actually anxious about asking their provider, not so much for embarrassment for themselves, but they're afraid they're going to embarrass the doctor. Well, don't be afraid to embarrass the doctor. If this doctor doesn't know how to talk about sex, teach him or teach her to ask about it

because you're going to be doing them a great favor. So we want our providers and we try to teach our providers not to be embarrassed. Sometimes a provider will find, particularly if it's an older woman, then the provider is, oh, you know, it's like asking my mom, you know, well, no, I mean, this is your patient and this is somebody, you know, you're taking care of, and this is an important issue for her. So ask her about these things. A lot of women also think, well, there's nothing that can be done about this. So why should I bother wasting time that, you know, valuable time in an office visit if there's nothing that can be done? You know, I'm having pain, but oh, I'm just getting older and there's nothing that can be done about it. No,

there's a lot of things that can be done. So don't be afraid to ask, bring it up. It's a totally legitimate topic. It's an important issue for wellbeing. And there are a lot of things that can be done for many of the issues that are bothering you. So there's embarrassment and time issues on both sides. How many things can be done? I mean, I have to be honest. Before I studied for today, I thought it was basically like the KY jelly was your options. But like there are so many things that women can do if they're having, you know, dryness or any of the things that come along with it can be menopause or it can be other issues that cause those things. The market's getting a little better.

It has a long way to go, but it's definitely getting a lot better than it used to be for women. So, okay. So you've got to talk to your doctor, be your own best advocate. This is by the way, why I could never personally have a male OBGYN. I just couldn't do it. I just, for me, I don't think I'd feel comfortable talking to a man about any of this stuff. I don't know if you're like me, consider whether you do better with a female GYN because I don't think it's easier. All right. So let's talk about libido because last week when we had the show on male sexual health, our doctor told us that there are actually now, he said, if you go to the drugstore and you ask for like a drug that will help a man with his libido, you'll get two dozen options. If you ask for a women's libido drug, you might get one. So what are the options in terms of drugs for women's libido and desire?

So let's say we're isolating it to everything else is, you know, we're really hunky dory in life and everything's great. And I'm just, I still could care less, you know, everything's fine, but I just could care less. And we have to divide this first into premenopausal women and postmenopausal women, because the remedies are actually different. Okay. And there are, as far as medications, basically two medications out there for premenopausal women. There is a medication that basically women, and when it came out a few years ago, people called it the pink Viagra. And the technical name is flibanserin, but the trade name is Adee. And this is a medication, and I think the pill is still pink.

It's a pill you take every day, okay? And it was actually a drug that was discovered in doing research on antidepressants. And this drug really didn't do much for depression, but it seemed to increase libido. It's one of these drugs that acts in the central nervous system. And pill you take every day. And yes, there are prospective randomized double-blind trials, the scientific trials out there to say, yes, this medication does work. It's not like, oh my God, it's going to turn you into sex maniac or anything like that.

But it does statistically significantly have women have more desire to have sex. And the end point, I know that it sounds crazy, but then how do they study these things? They measure what they call sexually satisfying events. And the drugs have been shown to increase sexually satisfying events statistically significantly. The other thing about this medication that some of our listeners may have heard about is when the drug first came out, there was a concern about having any alcohol with it. You know, if you're going to have a glass of wine, you can't take this drug. Well, people have sort of debunked that right now. So there are ways to take it safely and have a glass of wine. Don't worry about that. And it does help. And again, it's for premenopausal women. There is some data

in women who are postmenopausal, but it unfortunately has not gotten the FDA's approval for that as a medication in postmenopausal women. But there's some data to show it helps. So that's one possibility there. The other possibility there is a, and some people are going to get grossed out by this. It's actually an injection that you use. So something, but it's like an EpiPen. It's not like a major, major shot or anything like

that. And you take it basically 45 minutes, an hour before you want to have sex. So this is one of those drugs, the flubanserin, you take it every day, a D, you take it every day. This injection, which is called Vileci, is a shot that you sort of self-administer 45 minutes, an hour before you want to have sex. It hangs around basically for half a day. So you can go at it more than once if you'd like to, it should give you that arousal. And again, scientifically data's out there and it is approved for increasing libido for women, for premenopausal women. Again, there is some data in postmenopausal women, but it's not officially approved for postmenopausal women, but it does, you know, again, increase sexually satisfying

events. So that's our premenopausal ladies. When we go over our postmenopausal women, and again, there are some herbal preparations out there which may be helpful. You know, there's some data on some of them. They don't have as big trials as they do about the FDA approved medications. For women, for postmenopausal women, there is a fair amount of data on testosterone. And many of my patients get grossed out when I start talking about testosterone. They'll say, oh my goodness,

that's the male hormone. And the answer is there are very few hormones in life which are sex exclusively. Only men have, only women have. For example, if we have some male listeners, they may get scared when I say this, but men have a lot of estrogen in them too under normal conditions. So you really do have some estrogen. And women have testosterone. And what's interesting is our testosterone levels in women go down. They do start declining from the, and the ovary makes testosterone as do the adrenal glands.

But the ovarian production of testosterone does start going down around our time of menopause. But it lingers a while. It takes, it's a longer time to drop, but it does start going down around our time of menopause, but it lingers a while. It takes a longer time to drop, but it does start going down. And there is very nice data that shows that women who supplement with testosterone do increase their libido. So there's very nice data. And the Menopause Society in the United States, the International Menopause Society, all these organizations have officially endorsed testosterone

for libido for women. Now, a couple of things about it. Some folks are going to get nervous and say, oh, I'm going to turn hairy and I'm going to get acne and my voice is going to go down. No, it's not going to happen. I want to stay a woman. So we monitor levels and things like that. And these things do not really happen with the low doses we use. We use doses much, much lower than the guys' doses. And just to clarify, and way, way lower than a woman who actually is trying to, quote, transition. There's no comparison between what you would give a woman in terms of testosterone versus somebody who's actually trying to look like a man. Absolutely. Way lower than those doses, way lower than these doses.

They're very low doses that we use. There's only one real problem in the United States about getting the testosterone is that there is no officially FDA approved testosterone product for women in the United States. There are plenty of products for guys, which are much higher doses, much stronger doses, But there is no officially approved low dose testosterone for women. Now, that doesn't mean it's illegal and you're not going to go to jail for using the medicine. But you can either use a very, very small dose of the guys formulation, which many doctors will prescribe. The other possibility is to get from a compounding pharmacy testosterone. And many prescribers use compounding pharmacies for

getting testosterone. So those are both possibilities. The other thing about testosterone for women, I just want to clarify it for our listeners, is, and we'll obviously get into another drug that I'm sure you talked about last week. I'm sure you talked about sildenafil or Viagra for men. But the issue is that's a drug that you, and that's really not a libido drug. That's really a performance drug that lets the guy perform sex better. But the issue with that is you take it when you want to have sex. As far as the testosterone for women, that's something you need to take on an ongoing basis. So it's not that you're going to say, oh, I want to have sex on

Saturday. I'm going to use my testosterone on Saturday and be able to have more libido. No, it's a product that you use on an ongoing basis, ideally every day. Now, as I tell my patients, you know, if you skip a day, don't worry, it's not going to be ruined, but it is a drug you use on an ongoing basis and then will improve your libido, you know, over the course of time. So come Saturday night, if you've used it every day, it hopefully will be helping you want to have sex on Saturday night. Oh, there's so much to go over there. Okay. Let's go through a few of the things that you said and some questions I had when you say these drugs,

like Addy or Addy, how do you pronounce it? I call it a D, but I don't know. Some people call it Addy. Okay. That, well, that one and the other one, you say that they will increase, yes, your desire for sex, but also your sexually satisfying events. Does that mean, are you talking about orgasm or are you just talking about like you're just going to have sex more? Going to have sex more. They don't qualify that as far as orgasmic response. It really encompasses the sexual act. Okay, good to know. And then what about, before we get to testosterone, are there any side effects to those first two drugs

that increase arousal or desire for the women? It's going to be fairly minimal. They're pretty well tolerated, you know, in general. So it's not problematic. And now I know from preparing for today that a lot of antidepressants can have the effect of lowering your sexual desire, whether you're a woman or a man. Can these drugs you mentioned be taken with an antidepressant?

That's an excellent question. And the answer is there are some cautionings about it, but they can be flipped. The shot is probably less of a controversy than the D because again, it is a centrally acting drug. So there are some questions about it. Okay. So you want to talk to your prescriber about using it. You definitely want to have that conversation with your prescriber. Yeah. Cause I mean, I can see if you're depressed and your doctor puts you on an antidepressant and then your desire for sex goes away, then you're more depressed because having regular and healthy sex life is part of being a healthy person.

And it does add to joy and intimacy and connection with your partner, all that stuff. But the answer isn't necessarily just get rid of the antidepressant because that could cause problems too. Well, that's absolutely correct. However, there are things, and if you find your antidepressant, you know, you've started on antidepressant or you are taking antidepressant, you're noticing your libido is down. Again, please talk with your provider about this. Very important because there are certain antidepressants, not all antidepressants affect everybody the same way. Okay. So there are certain people who will get a downer on one antidepressant, not on another. So it's certainly quite reasonable to try different antidepressants. Obviously you want to work with your prescriber as

far as what might be a suitable alternative for you to try. Some are known to be more of a depressant than others. The other possibility, and these are the SSRIs and somewhat of an extent to the SNRIs. There is one antidepressant that does not have a decreased effect on libido, and that's what's called bupropion or Welbutrin. Okay. Oh yeah. Our male doctors said that too. Yeah. Welbutrin is not an SSRI. It's not an SNRI. Actually, we don't really know exactly how it works, but it does not have the sex depressant activities. And what some, some psychiatrists will do or other prescribers will actually add a little bit of Welbutrin to whatever you're taking. You can take Welbutrin, bupropion with certainropion with most antidepressants of the SSRIs. So that may enhance things a little bit for you. So that's

something that can be done. Trying a different SSRI or adding some Welbutrin or just switching over to Welbutrin can be helpful. So there are options to get work with your prescriber, say, listen, my libido is down. Now, the other thing to remember, and it's great, it's great that Megan, that you did recommend looking at the antidepressants. There are other medications that can depress libido too. Okay. And I want our listeners to understand that, for example, some blood pressure medications can have a downing effect on libido. And given the fact that we've got tons, yeah, some blood pressure meds can do it. And it can be for the guys too. And sometimes some of the antidepressants can actually affect their erectile issues and stuff too. So that certainly can be the case. But if

you're on an antihypertensive medication and you say, gee, my libido is not too terrific, you may want to speak with your provider about, gee, could this antidepressant do it? And might there be something else that's suitable to get my blood pressure under, gee, could this antidepressant do it? And might there be something else that's suitable to get my blood pressure under control and not do this to my libido? A couple other things that are out there, and the list is very long. But for example, people who are taking certain pain medications, certain opioids, that's another bad thing about opioids, they can decrease libido too. So again, what you really, if you're talking with your provider about my libido really is not good. You know, okay.

That, you know, make a list of your medications, bring your list of medications with you and say, and I'm taking, you know, I'm, I'm taking Prozac and I'm taking metapropyl, I'm taking this, and to try to figure out which of the medications might be problematic. And as far as can we do better or try different medications? Sure, we can. I mean, I think that's one of the things I hope people take away from this show and the one we did last Wednesday, which is sexual health is a part of health and you don't have to settle for less. You don't have to just sort of slide into, well, I'm getting older or I gained some weight or we've been married now 20 years and this is just how things go. No, no, you should fight for a very positive, good, uplifting sex life. And there are all sorts of aids that can help you get back to, you know,

feeling like I'm looking forward to it. Maybe you could get maybe you're not going to be like the 20 year old version of you, but you could be like the 34 year old version of you. Although I do have plenty of 75 year olds who are pretty sexually active too. Women, women realize that can be. Oh, I love this story. Cause I actually, I'm afraid to ask, cause I have an 82 year old mother, but, uh, like, like when does, when does it stop? Does it ever stop? I mean, are there people who are going at it in their nineties? Yeah. I've had some of those. One of my loveliest patients comes to mind and I've taken care of her for many, many years and she just turned 80 and she and her

significant other have their time reserved. And they've been doing this for at least 20 some years that I know about that they have been reserving Sunday morning as their official sex time that they look forward to it and stuff like that. And we've we've worked on maximizing everything for them. And they're doing great. And they haven't changed the ritual for over 20 some years as far as that's their dedicated time. No, it reminds me of a joke that I, that I heard, which goes, um, there's an old man, he's 95 and he, and he marries a 25 year old. And, uh, he goes to see the doctor before the wedding night and he says, you know, what do you, what do you think doc? Like, what do I need to know? And the doc says, you know, I got to tell you, you know, sex, it could be fatal. You know, it's somewhat dangerous. And the 95-year-old man says, she dies, she dies. Right. Right. Absolutely. It's possible not just for the men. It's possible

for the women to keep it rolling well into your later years. Now, I want to get into testosterone because that's a big one. The pros, the cons, the options, like what actually it's going to do besides, if anything, arousal. But I'll squeeze in a quick break before we do that, because that's a that's a good topic to tee up when we come right back with Dr. Minkin right after this quick break. All right, let's talk about the big T, testosterone. Who should be thinking, maybe this is right for me? Excellent question.

And the answer is the first category that we just want to mention is, of course, this is not officially recommended for premenopausal or perimenopausal women even. The official recommendation is for postmenopausal women because we do understand that postmenopausally testosterone levels do decline for most women, pretty much for all women. And again, we can measure levels. It's easy enough to do so. And there is very good data, again, and recognized by the North American Menopause Society, the Menopause Society, the International Menopause Society saying this works. And again, the major hangup in this country is just getting a hold of it as far as not being officially, a form officially approved by the FDA. There are several ways to do the medication. The most commonly used method of using testosterone

is a cream or a gel, okay, so it's applied and rubbed into the skin. People can rub it into their bellies, they can rub it into thighs, I mean, all over the places that can be used. And again, it is advocated that women have levels measured, you know, after being on it for several months to see if they're on a good dose of it, you know, see how they're doing. When I have my patients taking it, I always tell them, you know, obviously any masculinizing type side effects, let me know. Headache, as far as hair, facial hair, acne, deepening of the voice, give me a holler. Let's check and we'll see what's going on. As far as safety, it's really quite safe. There are some concerns and the people who've looked at this with the administration of testosterone to women. One of the concerns about, well,

guys have more heart disease than women. Does it seem to increase the risk of heart disease? And the answer is no, it does not. Another concern is, oh, gee, maybe this is going to make my blood thicker. Does it increase the hematocrit and stuff like that? No, it doesn't seem to do that. So as far as the safety parameters, yes, you should be monitored medically, but you should not worry about too you know, too many side effects really have as far as health issues and stuff like that. The other issue as far as administration, one method that has become popular in this country for many hormones, not just testosterone, are the implantation of pellets, you know, basically, some doctors out there will basically stick you with a pellet that goes under your skin and take you an injection and stick this pellet under the skin. Several problems with that. Number one, again, this is not an FDA approved route of administration for women. And the other issue is not approved by it's on board. You can't take it out. So it's going to

be there for two, three months, however it is, it's going to stay active in you. And if it's giving you too high a level, that's too bad. It's there. So in general, we don't recommend pellets. They're not part of the armamentarium that we recommend people using. The transdermal method is a safe way to do it. And you don't have to stick it under the skin and not know how, you know, how long this thing is going to last on you. So that's one thing as far as safety. And you want to go to somebody who's familiar with using it as far as side effects, etc. So but is it reasonable to do it? Yeah. And again, the other thing just to be aware of is that because it's not approved by the FDA for use in women, your insurance company is unlikely to cover it for you. Because they'll say, well, it's a good excuse for him. It's not approved by the FDA for use in women, your insurance company is unlikely to cover it for you because they'll say,

well, it's a good excuse for them. It's not improved by the FDA for use in women. Therefore, we're not going to cover it for you. Fortunately, the good news is testosterone is not too expensive. So most people can't afford it. It's ridiculous. Right? It's ridiculous. Sorry, folks. Right to the FDA, please. What's the matter with American, you know, the health insurance and the health business for women? It's like we're half the population. What good does it do these guys if their drive's intact and their ability to perform is intact? And we're like, not interested. Go do your research.

Get some FDA approved options for the ladies, fellas. Write to your folks in Washington, please. Tell them they need to be covering this. Thank you. I mean, he's got it approved first. maybe you can afford it. Maybe you can't. But if you can't, it'd be very nice to have some help from the insurance companies. I want to say this. So you said this, you might have scared people with the call me if you start to grow a bunch of facial hair, your voice lowers and all that stuff. But I will say the thing that interests me about testosterone,

two of my friends are on it and they look amazing. They say they feel amazing. They were big recommenders of the testosterone regime and they aren't having any of these problems. So just so ladies know, it's not, you're not necessarily, this is not like a real, like I'm going to get facial hair and I'm going to look like a man and it can be titrated down. It really doesn't happen very commonly. And so I don't want people being afraid of it for that reason. The other thing, and I will make a plug for this probably a couple more times during our time together.

If you are having trouble finding a doc who's familiar or a nurse practitioner or a nurse or APRN who knows about menopause. Okay. I can find you one easily. You go to the website menopause.org, which is the website of the menopause society, the North American menopause societies that used to be known. And if you go to the website menopause.org, you can plug in your zip code. Okay. And the North American menopause society will find you providers in your area who are menopause focused and menopause experts. So if your provider doesn't seem to know much about what you're going through, go to menopause.org. This is huge.

And they will find you somebody. Just because you have a GYN does not mean she or he is an expert in menopause. This is a newly sort of more specialized field, I think, within OBGYN. No, or maybe it's not new, but not every doctor has this expertise level that you're talking about. That's unfortunately true. And I can make a little diversion here as far as how that came about. And we can divert over talking about the menopausal practice and stuff like that. But about 20 some years ago, a publication came out that got women very scared, overwhelmingly much, much, much too scared about the use of hormone therapy.

And what happened is that basically, unfortunately, most residency programs in obstetrics and gynecology basically decided to stop teaching menopause. It's like, well, if people aren't going to take hormones, why bother teaching folks about it? So unfortunately, that the house officers who've been trained in the last 20 years, who are many of your practitioners out there, are these youngins, and it's not their fault. They didn't get the menopause education because it wasn't being offered, really didn't learn a lot about hormones and hormone usage, including testosterone. So again, if you've got somebody who doesn't seem to be knowing it or wanting to communicate these issues with you, you can, again, you can always go to menopause.org and find somebody

who knows something about these issues. That is so helpful. And we will take a deep dive on menopause in our second hour. But I do want to say this. So a personal story that may be helpful to some of the women listening. So I've been on the low dose birth control pill for most of the past, most of my life, most of my childbearing years, even though I already told the audience I had my fallopian tubes removed. It was benign, but they were taking that out. And the doctor's like, might as well take your fallopian tubes if you're not going to use them. If you're done having your kids, given the fact that most or all ovarian cancers begin in the tubes. I'm like, go for it. It was laparoscopic. It was like that. I felt no pain. I have no scar. I don't even know where he went in. I truly like someplace in my belly, but there's no mark anyway. Good job.

Yeah. So the reason I was on the low birth control pills is because my whole life I have had acne and, you know, being on camera, I didn't want to deal with it. And it seemed like a nice, easy way to keep the skin under control. And it worked. But now I'm 52. Right. And I was noticing a change, I'll confess, in my own sex drive. Everything was OK. It was good, but it was like not quite as robust as it had been. And all with my friends on testosterone.

So I'm like, maybe I'm getting to be that age. Maybe I need to consider this. And, you know, I had a very good doctor say, go off the pill, go off those that low, low, low Western, whatever it was, and see what happens. And I did. And the problem was totally solved. The drive came back a hundred percent and I didn't go on testosterone or anything like that. But apparently this is pretty common that sometimes birth control can affect sex drive. Yes, that's absolutely correct. And can I bore our listeners with a basic physiology lecture? But I always think that if you understand what's going on, it really makes much more sense to you. Birth control pills work by suppressing ovarian activity. It stops you from

ovulating and that's good. It keeps you from getting pregnant. That's good. And it also controls your hormones, which is why a lot of people like it for skin conditions and stuff like that. And the thing to remember is that the ovaries do make estrogen and progesterone, no question about it, but they also make testosterone. And so what happens is when you take a birth control pill, it suppresses ovarian action, okay, including testosterone production. Okay. So now, of course, the key thing is you say, well, I take birth control pills. I have libido. Many people do, and they're not a problem with it. But for some women it is, and it suppresses things low enough that they really don't feel they have much libido.

So for some women going off the pill, because it lets the ovaries wake up and do their thing, will allow them to ovulate, presuming they're premenopausal, and also allow their ovaries to make some testosterone. And even that small amount that our ovaries make will be enough for many women to give them the good libido they were looking for. So that's indeed what was going on. And not crazy, not silly. These things happen. Absolutely. And it can switch, right? Because I had many years of not having any issue on the low birth control. And then they now get a little older. I'm like, well, I wouldn't have even thought to consider the birth control pill as an option of the source. Well, I think us getting older has something to do with it too, because I think I mentioned earlier that not only can the ovaries or do

the ovaries make testosterone, the adrenal glands make testosterone type hormones too. And as we get older, and this is in men and women, the production of androgens, testosterone-like chemicals by the adrenal glands goes down too. And that starts in our mid thirties, unfortunately. So I think you were getting a sort of a double effect going on from the adrenal glands kicking in less and the ovaries not kicking in much at all. So I think you had both of those processes happening. And here's a related story. Here's a related story. You have to be your own best advocate, right? Because like we were saying before, talk to your provider, make sure it's somebody who's got some expertise. If you're dealing with menopausal issues, make sure she knows, or he knows a lot about menopause, not just like dabbles, but like actually is educated like

Dr. Mencken. And the other thing is, so I will confess to you this one doctor I had who I really like, but, you know, I raised it just as like, well, you know, there's been this slight change. And what she said to me was, go away on a trip with your husband. Now, I happen to have an amazing marriage. I'm very lucky. I have a great marriage. I have a gorgeous husband. Like it wasn't that right. Like it could be that it could be that for a lot of women. But I think you need to like fight for yourself. You know, it's not the fact that my relationship is having problems. I'm not having problems. Ask somebody else. Go to somebody like get a second opinion, which is what I did. And I was the doctor said, consider going off those

pills. And everything was 100 percent fine. I'll take the trip too, but I'm just saying you got to be your own best advocate. Right. Very important. Well, don't you think that there's a shortage of, I don't know, is it deep thought in the field or is it just willingness to spend time with the patient exploring these things? What is it? Well, I think the time issue is a crucial issue that indeed, unfortunately, medical care visits have gotten shorter and shorter. And that these are issues that tend to come up with a longer visit and longer time to chat about these issues, which are very important issues. And one of the other things that I will also want to mention, you know, to our listeners, I'm sure many of you have figured this out that, I mean, I love the medical profession, don't get me wrong, but sometimes, you know, that MDs are so hassled as far as doing this, doing that, doing the other

thing, that if you have a nurse practitioner who's in the practice, a nurse midwife, a PA, many of these people will sometimes have more time to sit and discuss these very important issues with you. So, and again, many of them are affiliated with, you know, a doc in the group, they work together. And so sometimes just sitting down, if you, if you have like a nurse midwife helped deliver you, you know, took care of you during pregnancy, you may want to sit down with her or with him. There are male midwives. I've worked with several excellent ones that just to sit down and talk to you about these issues, because they are important and you need to spend the time talking about them.

Do they go by midwife or do they go by like midhusband? No, midwives, I think it's from the German mitweib, with a woman. So they spend time with the woman, they're midwives, but male. Okay. All right. So on the subject of testosterone, Dr. Sharon Parrish went on with our friend Peter Attia on his podcast. They had a very interesting discussion. It was next level. So it was like a lot of terms I didn't understand, but also very user friendly in other ways. And she was saying there's a drug in Australia that is made for women called Androfem.

I think it's P-H-E-M. Yeah, it's a testosterone. Yeah. And it was. Why are the Australians doing all this work for women and the Americans aren't? Sharon is a good friend of mine, a wonderful person, but I think it's just regular testosterone that they actually allow in Australia. And it's regulatory. Is testosterone safe for women? Yeah, it's safe for women. And we've got pretty good

data on that. But if we can motivate people, this would be very nice. She was saying on that podcast that for some of her patients who don't want to go to Australia or whatever, order their drugs from Australia, that if you want a testosterone now as a woman, you've got to get like maybe a vial from your pharmacist. And then you got to like pour some out. You got to portion it. You got to be like a little chemist in your own bathroom to figure some of this stuff out. Yeah. Yeah. As I mentioned before, you can get the male variety and just use a tiny portion of it, which is certainly many folks do that. Or you can get it from the compounding pharmacies.

You know, you just want to make sure you're dealing with a good compounding pharmacy. All right. Now, have you heard of a nasal spray of testosterone? Because I will say I was at a party not long ago, and the wives were talking about how there's some testosterone nasal spray, some sort of nasal spray that would increase libido. And all I could think was, oh my God, all the husbands in America, I'd be shooting this up their wives' nose while they're asleep. Like, hey, honey. It could be happening. I must confess, in our area, nobody's using a nasal spray. So I don't know much about that.

I mean, with a compounding pharmacy, they could make up just about everything, I think. But the other thing that you have to be aware of with any medication is what we call the pharmacokinetics or the absorption issues and stuff like that. And so some of the problems with some of the topical therapies is, you know, how are they absorbed? How fast are they absorbed? How long do they live for as far as are they, you know, going to have a good shelf life and things like that? And I don't know much about nasal spray varieties. Now, how long could you

stay on drugs like this, whether it's testosterone or the Addy or the like, is there a, you know, okay, they can get you over the next five years, but then you got to get off of it. No, they're not time limited. So if you're doing well and you're in your, and they're really your minimal side effects, you're doing well with it. And there's no cumulative. Now, do we have, now this is something we have to be very careful of with almost any medication. Most of the drug trials to get a drug approved by the FDA go on for a year or two years at most, something like that. There are very few drugs that we have five or 10 years of experience with in a drug trial. I mean, we have clinical

experience and there are adverse event reporting and things like that that folks have. But to the best of my knowledge, there's no clinical trials going on for that long to say, oh yes, it's great for five years or 10 years. But there are no signals to say you should stop it after five or 10 years. Not that I know of. How do you know whether you need one of these drugs or you need the trip to the Caribbean? You know, like how do you know whether you need to see a sex therapist or maybe a couples therapist, something versus medical intervention? That's an excellent question. And the answer is it's hard to tell. And certainly it's always reasonable to, it's reasonable to explore both, you know, is my life stressed? You know, am I dealing with, you know, an ailing parent, in-law, kid misbehaving, a kid coming back from college

with six dogs, you know, that I've got to take care of, things of that nature, which are stressful. But it's also quite reasonable to explore the hormonal issue to say, could there be some hormonal component? And I think it's totally reasonable to explore both. Now, on the subject of sexual dysfunction, pain, pain during sex is all too common. I mean, I know a young woman who complains about this to me, and you wouldn't expect somebody of this age to have this issue necessarily, but she does. So it's not a menopausal thing for her. And I know she's not alone. There's somewhat one third of women who may have pain during sex. So what should they be thinking about? What are their options? Okay. Well, the key thing is, again, I hate to sound like an advertisement for the medical profession. You do want to talk with a medical provider. Okay.

For example, a very common entity that's getting more, more, you know, time on news and stuff like that is endometriosis, which is a condition of younger women. By definition, it's a premenopausal condition, not a postmenopausal condition. It almost always gets better after menopause, but women can have, and the pain that they experience is usually deep pelvic pain and oftentimes pain with intercourse. Oftentimes they'll have lousy periods. They may have bladder issues, all sorts of stuff. And endometriosis is fairly common. It's estimated that anywhere from six to 10% of women have endometriosis. So it's not unheard of. And it also can occur in very young women. Now, some people say, oh, endometriosis is because the career woman,

she's put off having her children and that's why she oh, endometriosis is because the career woman, she's put off having her children and that's why she's got endometriosis. We've got 18 year olds who have endometriosis. So it's not an age exclusive entity. And this is sometimes it's hard to diagnose. Okay. The good news is we've got a lot of therapies. We've got a lot more therapies than we used to have.

I mean, when I was a kid starting in this business, we didn't have a lot of options. We have a lot more now that we can use. So if you're having pain with deep penetration, deep in the pelvis and stuff like that, and you have crummy periods, you don't have to have crummy periods, but if you do, you know, do talk to your provider, preferably, I mean, you know, a primary care person should know stuff about this, but certainly a GYN should know about this, that they can help you with. So these are things that can be helpful there. There are also women

who have things, there's an entity called vestibular vulvitis, which can be seen in young women or older women, which is pain around the opening of the vagina. And it was actually a Sex in the City episode on this, so it must be very, very important. But it's estimated that up to 9% of women will have vestibular pain. And again, this is something we can help with. But again, talk to your provider. That's more pain with penetration, oftentimes pain with putting in a tampon, pain with even wiping yourself at the bathroom, things like that. So there are many different entities that can cause pain. And you want to try to figure out when am I having this pain? Where is it hurting? Are my periods crummy? And talk to your provider because there are're going to talk about the young women. We're going to talk about the old women, all of us. So stand by for more with Dr. Mary Jane Menken. And then we will take your calls just a little bit later in the show. And you can find

the show live on Sirius XM Triumph Channel, 111 every weekday at noon east. The full video show and clips by subscribing to our YouTube channel, youtube.com slash Megyn Kelly, and an audio podcast available for free wherever you get your podcasts. Check it out. All right, Doc, let's talk lube. There are options. There are options. Like I said, it's not just the KY. You got all sorts of options now. You betcha. Absolutely. So if I can take the liberty of going into some basics again here, I'd like to explain to our listeners the difference between lubricants and moisturizers. Okay. And there actually is a difference. Moisturizers are things that we can place

in our vaginas, mostly two or three times a week, depends on what particular product you're using, which will give you ongoing moisture in the vagina. Okay. And some people can have discomfort from dryness without ever having sex. So sometimes a moisturizer can be helpful. Sometimes people who, you know, ride bikes, run, ride horses, can have vaginal dryness discomfort. So a moisturizer can be very helpful along those lines. Lubricants were products that we tend to use for sexual activity, you know, for self-sexual activity, for partnered sexual activity. And they can be very helpful as far as, and again, the other key thing when I talk about a lubricant is I always tell my patients never buy for the first time with a product a giant economy size. Because there are, in different lubricants, there can be a scent or there can be something that the product is dissolved in that can be irritative. And don't forget the vulvar and vaginal tissue

is the most sensitive tissue in the body. So if somebody's going to bother you, it's going to bother you there. So make sure you buy a small amount first, see if you like it, if you're comfortable with it, and then you can get the giant economy size and try to get something that doesn't bother you. And many, many women will use both a moisturizer and a lubricant at the time of intercourse. So there's nothing harmful or shameful about using them. Now, of course, they shouldn't basically stop the need for foreplay because basically that women get moisturized, develop lubrication when they're sexually aroused. Okay. The fluid flows into the vagina. And so we don't want to say, oh, just use lubricant and no foreplay. You want that too. But some women will need an adjunct to the foreplay to get things going and to be comfortably

moisturized and lubricated. I hate to ask, but like the all coconut oil is all the rage on your skin, potentially on your hair. Is that like, there a natural remedy for down south in Rio or no? Don't don't be putting any food products down there. Well, a lot of my folks use coconut oil. And if it works for you, great. God bless them. That's terrific. Some people have told me they develop yeast infections, you know, because, again, you've got a product with a little bit of sugar around there.

You know, they can develop that if it does stop using it. But if it's working for you, I don't develop that if it does stop using it. But if it's working for you, I don't think there's anything tragic about using it, but it doesn't work for everybody. I mean, there's gotta be, it can't be like spraying Pam up there before. Well, actually, if I do, I hate to say this, but there is a body of literature from some gynecology groups about women who really have dry vulvar tissue, particularly as well as vaginal tissue. And they actually have some work using things like Crisco and other shortenings to coat the vulvar area. Yeah. I would talk to your provider about it, but there is some

provider do not, do not spray the olive oil Pam there without consulting. Probably not. Probably not. Yeah. Okay. And then, so there's like, in terms of the options for moisturizers, like what are they, what are women looking at? You say it's like two, three times a week. Is it like a, is it like an insert? Like what is it? Yeah. Yeah. Most of the time they're, they're inserts for the vagina. They're gels that come in like prepackaged things, applicators that you can squirt inside the vagina again, two, three times a week. There are suppositories and there are different agents that are used as the moisturizers. One product that's gotten to be very popular these days, and people laugh at me when I

tell them about it, is there are some products out there that have hyaluronic acid. You know how some ladies use it on their face? Well, there's a couple of several hyaluronic acid products for the vagina, which are pretty nice for a lot of people. It doesn't hurt? It doesn't hurt to put in. No, people like it. In other words, acid, you know.

No, yeah, acid. Now, that brings up a very interesting topic, which we'll address in one minute, if I may. So basically, no, it does not hurt and it's fine. So there are moisturizers there. Now, of course, the other thing is if somebody is in a hypoestrogenic state, because estrogen promotes moisturizing the vagina. And if you're in a low estrogen state, adding some vaginal estrogen can be very helpful for moisture.

And yes, the most commonly thought of group for this are women who are after menopause or perimenopausal and their estrogen levels are going down. But there's actually one group of very young women that gets vaginal dryness for low estrogen, and that's breastfeeding moms. That when you're breastfeeding, you don't make much estrogen. And so the vagina can get very dry. So my poor patients who are breastfeeding, you know, they're exhausted anyway from the breastfeeding. Oh, damn it, it's dry now.

That's awful. So they may also need a moisturizer. So would the estrogen be, it wouldn't be something you take orally, it would be like an insert? No, in general, now oral estrogen for a postmenopausal woman, you wouldn't do this for a breastfeeding mom, but a postmenopausal woman can take oral estrogen and get results vaginally, that is correct. However, there are plenty of vaginal estrogen products, which you can put in, they are prescription, anything with estrogen is a prescription, but you can put these vaginal estrogen products in there and there are creams and there are rings and there are tablets, all sorts of good stuff that we use

to pop into the vagina. And they, again, you use those things two, three times a week, most of the time, and they work. And some people use some non-hormonal stuff with some hormonal stuff. So it's absolutely fine. What is a ring? What do you mean vaginal ring? What's that? There's actually, it looks like the rim part. Now this is for our young folks. They won't be able to think about this, but the old contraceptive diaphragms that had a rim, and then they had a cup sort of with it. These rings look like the rim part of a diaphragm, but no cup in there. And you pop it in the vagina and it sits there and you can leave them in place for three months at a time. And it's cool. And they moisturize the inner part of the vagina.

Now, the other thing just to remember is if you are using a product for inside the vagina for moisture, which is great, that's terrific, that many women will benefit by the addition of some cream or some topical therapy to use around the opening to the vagina, because that area can be very uncomfortable, particularly with penetration. I mean, obviously, again, you want good foreplay and some stretching, but that some women will, many women will benefit by the addition of a topical cream to rub around the opening of the vagina. Does your partner feel the ring? Nope. Nope. I basically, I had maybe one person in my career, it's very long, who's told me that the partner felt the ring and I was like, well, God bless them., it's very long, who told me that their partner felt the ring.

And I was like, well, God bless them. But it's mostly not felt there, very rarely. Fascinating. Okay. And now what about, this may be a far field, but are there like lasers? As somebody who is, I don't like face fillers, but I do like some of these lasers. They can do wonders, at least on your face. Can they do wonders down

on your Mary Jane? Well, that's a very interesting question that you ask. And the answer is there certainly is some data and some of my buddies are experts on lasers and they do a very good job. But the problem with lasers, and by the way, it's never made much sense to me how you can destroy tissue and get more moisture. Just conceptually, it doesn't make sense to me, but whatever. But there are some of my buddies who are very good and there's literature showing it does work. The problem with laser technology is that there's really no licensing to go to say, okay, this is a board certified laserologist or something like that. So anybody can just buy themselves a machine and hold themselves out to be a laserologist. And there are in the literature case reports of people who've had really bad stuff done to their vaginas from a laser.

So if you really are interested in a laser, please, again, talk to your provider, somebody you know and trust, and make sure they send you to somebody. Or if they happen to be a licensed, you know, certified laserologist, that's fine. But as I said, I wouldn't just go to some, you know, Jane Doe or Joe Schmo, who holds him or herself out as a laserologist without knowing if they're skilled at it. All right. While we're on the subject of the laser, because we use it on our facial skin to like tighten things up or to stimulate collagen. A lot of women who have had vaginal births who are worried about, you know, blowing things out down south and they, you know, they don't want the hot dog in the hallway. They want things a little bit snugger. Is there any remedy on that? Or does the things just settle down? Like do women even need to

worry about this? Like after you have a vaginal delivery, will things tighten up after a time? The answer is yes. Most women after vaginal deliveries are just fine. You know? Okay. And one thing that I, now this is a personal belief of mine. I, I, but I, I would be bad if I didn't mention my personal belief. There are folks who elect to have cesarean sections for what I consider no good reason, because we really, you don't destroy your vagina by having a bad vaginal birth. And there are many, many, many potential complications to having a cesarean section. I mean, if you need to get the kid out safely, and that's the only way to do it, by all means, it's appropriate. But to just have

a cesarean section because you're worried about your vagina, don't worry, it's really much safer to have a vaginal birth if you can. So anyway, but after vaginal delivery, there are some women who, you know, have some stretching and stuff like that. And one thing that I always encourage people to do is Kegel exercises. I'm a big fan of Kegels. And I think Kegels are great for everybody. So and the thing I tell my patients, so I always think of the musical cats that they used to advertise cats now and forever. Well, I tell my patients Kegels now and forever, it's a good thing to do. And that actually does help. Another thing that can be associated with the stretching of the vagina, some people do have some bladder issues, leakage issues and things like that, which can be very annoying

for folks to be sure. I mean, yes, there are surgeries that can be done, but Kegels help. And the other thing is, this is another, and I find this is an excellent motivation to people, that as far as like leakage of urine, if you look at all the literature on bladder leakage, that there's a 5% body weight loss translates in this literature to a 50% improvement in leakage. So if you're way over your body, yeah, yeah. If you're really overweight or not even really, really overweight, but somewhat overweight, that if you lose 5% of your body weight, you have a 50% improvement in leakage

of urine. That's amazing. And many of us are. If you're a leaker. That's awesome. I got that's very good news for a lot of women who worry about this issue. So that's good to know. Okay.

Is that the same thing? The Kegels, we've all been told what the Kegels are. But is that the same thing? Because we had Sarah and Michelle both wrote in about pelvic floor, physical therapy, pelvic floor PT. Is that a Kegel or is this, does it involve more than Kegels? They do more than Kegels. They do more than Kegels. And if you need more than that, pelvic floor PT is great. Um, and that's really blossomed in the last 10 years or so. And there are many, many people who've been now trained in pelvic floor physical therapy. It can be a terrific option.

And again, hey, I love operating. Don't get me wrong. It's a lot of fun. But if you don't have to have an operation, that's great. And don't let those surgeons stay in business. But the key thing is if you can do it through, you know, kegeling, through pelvic floor PT, through weight loss, if you know, you could use a loose few pounds, all of these things can be helpful. And you know,

if you need surgery, we got surgery. But these things are really very good to do non surgically if you can. What is pelvic floor? PT? I don't understand like, and who would I go to for like, do you call like the same guy who works on your knee? The answer is these days, most of the physical therapy places have people who are subspecialists in areas. So you go, you call up your pelvic, your PT place and say, who's doing your pelvic floor stuff? And is this somebody who's had special training in pelvic floor PT? And most of your gynecology folks will know folks to go to.

I have some really terrific pelvic floor physical therapists that I refer my patients to. Okay. This is like we had this Michelle writes in a pelvic floor physical therapist was a game changer for me and my husband, our sex life and our marriage. I had no idea until after my third baby in 2021, this is even an option, but I had pain and discomfort during sex for years, making it a chore, something I generally did not look forward to. After PFPT, the pain is basically gone. The incontinence issues, sneezing, coughing, et cetera, are so much better and so on. So I heard about this from a couple of different viewers and just wanted to share that with the audience. Look into

it. That's another potential option. Okay. And we're going to get to some other questions in just a second. So that covers another piece of sexual dysfunction, but we have to spend a minute on orgasms. Last week, you talked about men who are not able to have one. Like there are men who, of course, have problems getting an erection, but actually men who cannot have an orgasm, believe it or not. And I think it's probably an even greater number of women who have difficulty achieving orgasm, which, you know, may not make it pointless, but it makes it less enjoyable if you can't. So is that a dysfunction? What is that? Well, it's not necessarily a dysfunction. I think a lot of it is expectation. Many women expect that they're going to have an orgasm from strictly vaginal intercourse. Okay. And there aren't that many women who really do achieve orgasm without

some clitoral stimulation. Okay. Many women can have a clitoral orgasm without any vaginal activity, but there's not much, there aren't too many women who can have a vaginal orgasm, you know, achieve orgasm without some clitoral stimulation. So don't forget the clitoris. It's very important. Okay. And again, if you're having pain dealing with it, you know, talk to your provider to see if we can get things better for you. And so clitoral stimulation is pain dealing with it, you know, talk to your provider to see if we can get things better for you. And so clitoral stimulation is important. Again, avoiding pain, making sure there's good lubrication for sex is very important. And we are a big most most of us in the gynecology business. And I'm sure you're interviewing Sharon. She probably discussed this, too.

Many of us are big advocates for things like vibrators and other sex toys and things like that, which can liven things up. And the other good thing about a vibrator besides emphasizing stimulation is that also vibrators increase pelvic blood flow. So anything that increases pelvic blood flow is good for moisture. So if you're having dryness problems, vibrators can do many things for you. So we encourage people to use that. And we encourage people to explore and try them in different manners. So those are all very good things to use.

And again, many, many women can have orgasms, you know, which is the appropriate clitoral stimulation. Now, one thing that I am going to mention, okay, and I may get people, some of my buddies may get mad at me for saying this, but that's okay. People get mad at me a lot. That there are women, and we get back to the SSRI issue. There are women who take SSRIs that blocks their orgasmic response. Okay. And that is a real issue. And again, we get back to the issue of, could you change, you know, SSRIs, could you change to a different medication? Could your depression be ameliorated with, you know, Welbutrin as opposed to an SSRI? Things of that nature. However,

there is a very small, and this is not an official indication, folks. This is not an official indication. Don't feel badly if your gynecologist says, no, that's stupid. There's no official indication for this drug. But there is one use of Viagra in women, Sildenafil. And that is for women who have a blunted orgasmic response from SSRIs. And there is a very limited body of information showing that Sildenafil, Viagra can help those women achieve orgasm. So again, limited body of data, talk to your gynecologist, think if this person, if she or he thinks it's a reasonable option. Again, in people, and you see all the advertisements on TV for the guys, if you have heart disease and stuff like that, same thing goes for women. But if you're basically in good

health and you're in good shape and your heart's in good shape, most people can take it. So it's something that is something that's possible to use. It's not widely known, but it is something that is a possibility. Well, do not forget the clitoris. Good advice for men and women. Absolutely. Please, please. An important part of your body. Yes, I think we know that.

That's for sure. All right. Now, a quick question for you on the youngins, because we had a long debate on the show one day about the HPV vaccine. A lot of us, a lot of my friends have daughters right around this age where their pediatricians are recommending it. And we had somebody who was, you know, arguing it's, it's a good idea. And we had somebody who said, maybe more caution is in order on that one. And I recently saw one of my closest, I love this woman.

She delivered all three of my babies, miss my OBGYN in New York. And she was like, all of your kids are getting the HPV vaccine. I don't care what you talked about on your show. Give it to your boys. Give it to your daughter. Shut up. That she was like, just stop. She was hardcore. She's one of my friends. I'll tell her your name later. Anyway. So let me get your opinion on that while I have you. It's very good advice. And the key thing is, I mean, I'm a very, very lucky person. I've been in my same practice basically for 44 years.

So I know these people. I've delivered their kids. I'm sometimes taking care of their kids. You know, I haven't had any grandchildren this way. But anyway, plenty of honorary grandchildren, but not great-grandchildren. Anyway, but the key thing is many mothers will say, oh, no, no, but my daughter, and the reason we immunize them early is not that we think they're necessarily going to have sex at nine or 10. We hope they aren't. But the key thing is it's easier to get them when they're nine or

10 to give them their shots and make sure they get them before they get to be 15 and 16. And we may have trouble corralling them to get the shots. So it is a good idea. There really are no side effects to the shot. Yeah, I've seen a few kids get lightheaded. So we make the kids, after we give them the shots, sit in the office for 15 minutes to make sure they're not getting lightheaded, but they'll be fine. But there really are no known bad complications. And we are seeing, we actually have literature showing this, that in populations where you're getting immunizations, that we have seen the rate of cervical cancer start to really decline.

And the thing to remember is with the new vaccine, the new one called the non-available, it gets nine strains of the HPV virus, because there are a lot of strains of the virus out there, that you can prevent about 90% of cases of cervical cancer. I mean, if somebody says to me, there's this, that, or the other, you can do to present 90% cases of lung cancer, pancreatic cancer. I'd say that's fabulous. That's terrific. But this is a disease that if the kids get the shots. Now, the other thing though, and we have literature to support this as well. A lot of my patients are concerned, oh, but if my kid gets the shot, they're going to become promiscuous, okay, and'm helping to prevent your risk of cervical cancer, but I'm not helping to prevent your risk of chlamydia, gonorrhea, syphilis, HIV. Should I keep going? So the issue is, yes, I am helping to prevent cervical cancer.

Show them a couple of pictures on the internet if they're thinking about not using a condom and that'll shake things up. For people who are interested, that debate was held in episode 565. If you want to go back and hear both sides of it. But I always like getting, you know, everybody. I like to hear from everybody. And, you know, it's like people have to make up their own minds on these things. But I was personally, it made me feel better to have the woman who I've trusted for 15 years with all my babies just be so blunt about it.

And that may bring others comfort to hear you talking about it, too. OK, let's jump to a little bit older. And that is the age of most of my producers on this show. Women in their late 20s, early 30s, who are like strong and fierce and professional, who probably aren't going to have babies until like maybe 35, you know, maybe mid 30s. And they're already worried. You know, they've been on birth control pills for, you know, whatever, how many years. And they're concerned about whether waiting until your mid to late 30s, how high does it drive up your infertility numbers, right? Like how much does it lower your chances of conceiving and how do birth control pills play into those risks, if at all?

Interesting questions. And the answer is waiting. The time is the issue, not the birth control pill usage. Okay. The birth control pills do not lead to long-term infertility. And if you look at resumption of fertility after stopping the pill, it should be pretty quick. Now, that doesn't mean something can be happening in your belly that you might not be aware of, you know, because the birth control pill is giving you nice limited cycles and things like that. But indeed, actually, birth control pills are one of the therapies we use to help treat or prevent endometriosis. So it's actually good to help prevent it, not bad or anything like that.

So the pill I'm not worried about as far as keeping them infertile. As far as age issues, though, themselves, there are issues that the older we get, the less fertile we get. Until 35, you don't see a huge diminution. Okay. After 35, you do start seeing some, you know, levels of fertility going down. And I sort of break it into like 35 to 38. Yeah, it's down, but it's not awful down. Once you get beyond 38 to 40, you start seeing some pretty significant diminutions. Now, again, it doesn't mean people 40 don't get pregnant, hell no. But it does lead to some diminutions. And again, one other thing to get back to the STI, STD question, okay, is one thing you can prevent is STI. So don't, chlamydia is a terrible disease. Chlamydia you can get without knowing it's being transmitted to you.

And again, people who are using birth control pills for their contraception oftentimes aren't using a condom to help prevent them getting chlamydia, which they may be being transmitted. So keep yourself as free as you can from STIs because that hinders you getting pregnant. What's an STI versus an STD? It's basically the same thing. Some people use the term, the old term, like an old person like myself often uses STD, sexually transmitted disease. The current terminology is sexually transmitted infection, but we're talking about the same thing.

The old term is venereal disease, right? That's like way back when we were grown up. Well, you know where the term venereal disease comes from? You know what the origin of the word venereal is? No. I like Latin scholars. It's from the Latin word Venus or Venus veneris. So it means of love of the goddess of love. So that's where venereal comes from.

Anyway, so that's something to keep in mind. But you know, goddess of love, notwithstanding, use a condom. Very important. Or make sure your partner's been tested recently. So those are all important things to do. Now, of course, the question then comes up because obviously, you know, many of us don't want to have kids that, I mean, you know, docs are out there. I mean, my kids were born when I was 36 and 38. So, you know, many of us are working and training, training and working for a number of years before we have our kids. So obviously one of the issues that's come up that what about egg freezing?

Is egg freezing a good thing to do? And it's certainly quite reasonable. And again, the last 10 years, the technology has come along very nicely. It is expensive. It's not cheap. And the process of getting the eggs and then maintaining the eggs, keeping them in a good freezer and things like that in a good supervised facility. These are expenses. But many people choose to do it. And I think it's certainly fine. The only concern I have with egg freezing is don't count on it. Because there are some times you'll freeze a fair number of eggs, and it won't work. So it's not like a guarantee to say, oh, if I freeze my eggs, okay, I can wait till I'm 47 or 50 to have my family. The answer is- No, can I just say, I can speak to this because till I'm 47 or 50 to have my family. The answer is no. Can I say I can speak to this because I had IVF for all three of my kids. And, you know, you you like when they unfreeze the eggs, they can not like take they can they can sort of completely unfreeze to where they're not usable.

Some can be if you have genetic testing, you can find out, you know, some are not able to like, you know, develop into an actual fetus. So it's like there's also if you just like freeze 10 eggs and think I'm good, you are not necessarily good. No, no, you aren't. And that's the key thing that I think that many women are in a sense, they're either they're being sold a bill of goods or convincing themselves that they're guaranteeing that they're going to have, well, I'll have a kid because I have frozen eggs. I mean, there's a good chance you will, but there's also a significant possibility you won't. And the thing I always say is, God forbid, how would you feel if that you couldn't?

So these are things to take into account. And I don't think the gynecology folks can answer that for anybody. I think that's something that you independently have to ask yourself. And listen, I have a couple of friends of mine who are lesbians in a marriage. And of course, they used donor sperm and they have amazing children. Their kids are absolutely gorgeous, beautiful, smart, you know, fun, strong. You know, it's there are all sorts of ways, like if the biological clock is ticking and you really want to be a mother in modern day America to to take care of it. You could freeze eggs. You could get donor sperm. You could do a bunch of different things and get on those damn dating websites. Ideally, you have a friend set you up. I think that's the best way to meet your future partner.

Nobody asked me, but that's what that's what I think. Okay. Let's get into menopause. The big pause. The big pause. First of all, how do you know when you are actually in menopause versus being perimenopausal versus being postmenopausal? What is menopause? Okay. Menopause, as I define it for my patients, is the pooping out of the ovaries. That's what it's about. When somebody has, is having periods, in other words, she hasn't had a hysterectomy or she doesn't have an IUD and it keeps her from having periods or something like that. You can say you are menopausal when you go a full year without having a period. Okay. Any bleeding or a period? No bleeding, no bleeding at all. No bleeding, even a little bit of light bleeding counts

and you got to reset that clock. So even a little bit of light bleeding counts, doesn't have to be a full period, okay? So you go that year without a period or significant bleeding, you can say, yep, I am fully menopausal, okay? Until then, if you, but the key thing is you can have all the fabulous symptoms of menopause,

the hot flashes, the night sweats, the insomnia, the achiness, vaginal dryness, we can keep going. You can have all those fabulous symptoms even before you skip period, let alone start getting erratic periods. And the erratic periods can go on for quite a while, unfortunately. And the problem is, let's say you go six months without a period and you say, oh, I'm getting there. I'm getting there. Bingo. You get a period. Well, it's not another six months to put in the clock. It's a full year.

You have to say, okay, I have to wait another full year to say I'm fully menopausal. Okay. Now, the key thing is that doesn't mean that you have to wait until you've got a full year without seeking intervention. You know, if you haven't slept the night, I don't care whether you're having skip periods or not having skip periods. We got to help you. We got to make you get some sleep. So that, you know, intervention is certainly fine, but we just can't say you're technically fully menopausal. And the other thing that I always like, we talked about fertility in older folks. Well, the thing to remember is that until you go that magic year without having a

period, without anybody else keeping you from having a period, that you can't say to somebody, she's not going to get pregnant. And in my personal experience here, I personally have delivered three women at the age of 47 who were not in vitro patients. They were people who were like, oops, pregnancy. So I've delivered three 47. It can happen. Now when you say the erratic period, that sounds terrifying. That's basically going back to when you're 12 or 13 and you don't know when the period's coming and you haven't figured out, you know, like how to prepare for it. The next thing you know, you have an embarrassing moment in gym. Like what's the erratic period? They can go from two weeks. They can go to six weeks or 12 weeks or eight weeks.

You know, it's, they're all over the place. Well, that's a nightmare. How do you regulate that? Well, we can do this. Because the key thing that's going on is that actually the erratic periods are more of a problem of less progesterone. Progesterone is the hormone our ovaries make when we ovulate. And one of my buddies, Dr. Nanette Centoro always says, oh, I just tell my patients that the lining of the uterus is like a lawn and estrogen is like fertilizer and progesterone is the lawnmower. And I think that's a pretty good analogy as about what's going on. So estrogen feeds the growth of the lining of the uterus and the progesterone goes in there and regulates it and cleans it out. And so we can oftentimes take these women who

are having crazy bleeding all over the place and give them some progesterone in a manner to regulate their cycle. So we can do that without using estrogen. However, a lot of times when people are getting their wacky periods, they are junk that people get that makes them uncomfortable. And there are a couple of tricks that we can do very nicely for folks to get them through perimenopause. And for example, a low dose, you mentioned being on the low dose birth control there, Megan. And so that can be a friend of yours for controlling crazy cycles. And a low dose pill can be very, very helpful. And the nice thing about a low dose pill, besides having a progestin, a synthetic progesterone in it to keep the bleeding under control, it also has estrogen there. So if you're getting hot

flashes, night sweats, sleep craziness, that will help take care of the crazy sleep and the crazy periods. So low dose birth control pills can be a real blessing in the- How long can you stay on them though? How long can you stay on them? If you're not a smoker, if you're a smoker, you don't want to be on them. You cannot be on them. Beyond the age of 35, smokers should not be on the pill. Now, of course, I tell people, let me help you to stop smoking, then I can give you the pill because I really am an advocate for stopping smoking if we can. So the key thing is that you can stay on them forever, to be honest, well, not forever. And there are patients that I put on the pill, and I always tell this there are patients that I put on the pill and this,

and I always tell this to somebody that I'm putting on the pill for perimenopausal control. I will not know when your ovaries have officially pooped because the pill will keep giving you periods. Okay. So I don't know whether they're, you know, what your own ovaries are doing, because it's masking them. But my usual statement to my patient, but do you really care if you know exactly when you're stopping your periods? You don't care. You want to be comfortable. I thought that once you hit like right around my age, 52, 53, that you couldn't stand the birth control pill anymore because of the risk of blood clots and or heart attack. And there was something to the effect that you mentioned synthetic, like that's an's an issue taking synthetic i don't

even remember whether it's the estrogen or the progesterone but can you talk about that sure sure the issue is that you're absolutely right there is an increased risk of blood clotting the older we get which is why we tend to like to use very low dose pills rather than using a high dose pill and in general try to minimize that risk of clotting um however there is no one age to say okay you were 54, you should go off. Okay. What I will often do though, because the key question is we don't know if you're fully menopausal. And the key thing that most women don't realize is that birth control pills actually have much more estrogen than quote unquote hormone replacement therapy

or hormone therapy, that the pill is actually more estrogen. So if somebody is having, is on the birth control pill, and we really don't know whether she's menopausal or not, what I will often do, and I will use like, for example, family history. If she says, everybody in my family went through menopause at age 48. Okay. I mean, that doesn't guarantee that she's going to be menopausal age 48, but that's a guide. So we may stop her at 48 or 49 and say, okay, are you menopausal? If you go off's a guide. So we may stop her at 48 or 49 and say, okay, are you menopausal? If you go off the pill, see what your hormones are doing on your own. If she says, everybody in my family went through menopause at 57, we may try it about age 55,

presuming she's totally happy and see where she is. But if she's not, we can put her back on the pill if she wants to be back on the pill. Is hormone replacement therapy, it's estrogen and progesterone, right? But is that just a lower dose of what's in the pill? It's a much lower dose. Yeah, it is a lower dose. Now, the one thing that we can say is that with the birth control pills, there's a slightly different estrogen in general in the pills than what's in the hormone therapy. Not dramatically different. I mean, it accomplishes the same thing. And then hormone replacement therapy, hormone therapy. I'm not dramatically different. I mean, it accomplishes the same thing. And then hormone replacement therapy,

hormone therapy view of using progesterone, there are some natural progesterones that we can use for hormone replacement therapy. And some people do prefer them to the synthetic progesters. So again, we can come up with a nice friendly combination for low dose hormone therapy. If somebody says, I really like my estrogen and my progestin, but you know, if you don't need it, then by all means, you don't need to take it. Is that a same question on that as we did on the testosterone? Is there a

shelf life for how long you can take HRT? No, the honest answer is no. Basically, the key thing is, again, you want to revisit, you know, these things with your provider and you want to talk to a provider who knows something about menopause. Okay. For a while back after the Women's Health Initiative came back in 2002. That's the thing that raised all the concerns about HRT that led people to say, I'm not doing that. And basically now women got screwed for 20 years, not even being offered HRT. Yeah. Well, we can talk more about that too. But anyway, around that time that folks realized that the increased risk of breast cancer seemed to manifest itself in this study after about five years of use in women who were taking estrogen plus progestin.

And so a thought arose among many providers, okay, it's okay to take it for five years, but then you want to stop because that's where you have your increased risk of breast cancer. Well, the answer is it was a very, very minuscule increased risk of breast cancer. And there are ways we can minimize those risks. So that really, I think the this five year mark has now sort of become passe. And the official, the official mantra of the menopause society, the former North American menopause society is basically to take, it used to be take the lowest dose for the shortest duration of time. That was the official mantra. The official mantra now from the menopause society is use the appropriate dose for the appropriate duration.

And so the key thing is you need to be visiting, you know, with a provider who knows something about menopausal therapy, menopausal hormone therapy. And if people are doing well and they really seem to be doing thriving and everything's to be fine, they may stay on it. So it's really, it's really an independent thought. Why would you take HRT? Like, why would you take it? they may stay on it. So it's really, it's really an independent point. Like why, why would you take it? Is it just, just for hot flashes and sleepless nights? And I don't know, I can't remember the other symptoms, but is it just to address symptoms? Or is it like

I talk about my two friends who I have in Connecticut who are like totally vibrant and they're in their later, you know, like they're in their mid to late fifties. And like, I don't know if that's HRT or testosterone or like, why, why would you take HRT is I guess what I'm asking. Well, it's an excellent question. And certainly symptomatology is important. And the key thing is like, some people think hot flashes, well, they're only going to occur around menopause, you know, the first couple of years. Well, about 10% of women will have significant hot flashes for more than 10 years. Okay. Unfortunately, now I don't greet my patients saying, guess what? You know, you have those lousy hot flashes now, and about 10%

of you are going to have persistent hot flashes are going to last for a while. No, I mean, I try, and they do get better over the course of time. But the other thing that I reaffirm for them is that we got plenty of therapies that can help. So we don't sit there and suffer and be miserable. We're not going to let that happen to you. So they do help symptoms. But what else does it help?

Well, and again, the other thing to remember is vaginal dryness. The hot flashes tend to get better. Vaginal dryness, unfortunately, in general, does not get better. It tends to get worse over the course of time. Now, of course, there are vaginal therapies that one can use, but systemic therapy does help, you know, as far as the vaginal tissue as well. Now, however, and the sense of vibrancy, the question is, well, are these ladies sleeping better? Is that why they're more vibrant? Certainly again, skin dryness occurs. Are they looking vibrant because they have much more moisture in their skin? Well, estrogen therapy

helps that too, although it is not an official indication for that. The official health, there are health indications. Estrogen therapy is very protective for bone loss, protective against bone loss. And so if somebody has a very strong family history of osteoporosis and she herself is a very slim woman, and this is the only, osteoporosis is the only entity that is worse. If you're slim, that's a terrible thing, but slim women have a higher risk of a fracture than women who are heavier, unfortunately. Um, so that's out there. Um, so, but dementia, right. Doesn't it help prevent if you start HRT, um, like early in your menopause, likeause, not until you're 10 years post-menopausal, it can help prevent

dementia? Not clear. Unfortunately, the dementia data is not clear and we don't have the formal answer on it. Certainly we have data that says if you have dementia, don't give estrogen, it's not going to make a difference. There is certainly some literature that suggests if you take estrogen early on, it will help prevent dementia, but that's not written in stone and we don't have unequivocal data. The major question that's out there is does estrogen help prevent heart disease? And this is actually the reason the Women's Health Initiative was actually launched was to answer that question. Does estrogen help prevent heart disease? And if you just think about it, you know, I think about your friends and your family.

Do you have a guy that you know who had a heart attack in his 30s or 40s? Yeah, most of us know guys that have had heart attacks in their 30s or 40s. Now think about women, women, friends, family. How many women do you know that had a heart attack in their 30s or 40s? And the answer is not many. So that sort of started the thinking about this, gee, maybe there is something in estrogen that helps protect the heart. And there were some studies out that showed that women who were taking estrogen as they went through menopause seemed to have a substantial reduction in heart disease. So that led to the WHI study to answer that question. Now, the key thing about the WHI study is that it didn't show protection against heart disease. But the problem with the WHI study is it was studying primarily older women.

The average age of women in the Women's Health Initiative starting the estrogen was about age 63. Whereas the average age of women going through menopause is about 51. And that was the typical age around then that people were starting their estrogen for relief of symptoms. They were getting hot flashes, they were getting night sweats, they were given estrogen. And for those women, it seemed to help protect against heart disease too. So the problem is the WHI did not show any degree of heart protection. And people started asking the question, why? And then folks started doing some smaller trials,

looking at women actually going through menopause and getting estrogen shortly thereafter. And in those trials, it did seem to help prevent heart disease. However, they were not huge trials and stuff like that. And the official recommendation is although estrogen certainly when given early seems to have a protective event, we are not officially supposed to recommend it for women as a protection against heart disease. Now, do I say it doesn't exist? No, but it's not an official indication. Now, the one group though, that I really, if we have some listeners in this category, if you are one of these folks going through menopause at 35 or 40, you're going through menopause really early. And unfortunately, 1% of women are menopausal by age 40.

About 5% to 7% of women are menopausal, fully menopausal by the age of 45. That's young. I mean, that's really young. If you are in one of those young categories, you know, particularly if you're 38, 40, something like that, and you're going through menopause, and you go to a gynecologist who says, no, you're not having any symptoms. You don't need estrogen. Please find yourself another gynecologist who says, no, you're not having any symptoms. You don't need estrogen. Please find yourself another gynecologist, go to the NAMS website and find the gynecologist who

will give you estrogen. Because unless there's an absolute contraindication to taking estrogen as a very young woman, like a 40 year old going through menopause, you should be taking some estrogen unless you have a contraindication because you're at very high risk. And those people are at high risk if they don't take it for dementia. And if you look at women under the age of 45 who have their ovaries taken out and don't get estrogen, there's about a threefold increased risk of getting dementia. We have good data on that. Very, very good to know. Dr. Menken, we've got a call from Maria in Connecticut, who's got a question for you. Maria, what's your question for the good doctor?

Hi, thanks for taking my call. My question is, I'm almost 50 years old. I'm having menopausal symptoms, night sweats, hot flashes. I have a younger sister who had hormone positive breast cancer two years ago. So I'm not, I've been told I am not a candidate for hormone replacement because of that. So I'm just curious what my options are for symptoms. Good question. Well, Maria, I don't mean to disagree with an eminent doctor who might have told you this, but it's okay for you to take hormones.

It really is. Family history does,, a family history does increase your native risk of getting breast cancer, unfortunately. And I don't know if she's had genetic testing or anything like that, because if she has a genetic issue, you do want to be tested to see if you've got a genetic issue. So keep that in mind. But particularly if you know that she's genetics negative and it's not a BRCA type situation or one of those diseases, you may take estrogen therapy. Now, there are plenty of other options out there. What if she had had the breast cancer? Some of our viewers said, I have had breast cancer.

Exactly. If you yourself have had breast cancer, most oncologists do not want women taking hormone replacement therapy. That's absolutely correct. Family history does not preclude the use of it. However, we have a lot of other options for people who do have breast cancer. And we have some other medications, many medications. We have a brand new medication that's out there that's very good for hot flashes. Just came out about three months ago. So there are plenty of options there. And I'll take the chance of saying you may go to my website.

I have an exciting website called madamovary.com. And I've got on Madam Overy a lot of information about the other options that you can use for hot flashes. There are some herbal remedies that do help. We have plenty of other medications that can be helpful for you. Not to worry. Very good. Let's go to Colleen in Michigan. Hi, Colleen. What's your question? And thank you for taking my call. I'm a 63-year-old female and I feel terrific. I've been taking HRT, estrogen, progesterone, and testosterone for a decade now. My question for the doctor, I'm considering the DIVA vaginal laser technique. I want it to treat some urinary incontinence, and I understand it's also good for regeneration of the vagina.

Your thoughts? The diva. I love the names of these things. You know, the key thing is I would say you want to go to somebody who knows how to do it. You know, are there some people who seem to get excellent results with it? Yes, there are. Okay, so I wouldn't preclude it. If you go to somebody who really knows what they're doing, I think it's reasonable.

But I just wouldn't get any random name, you know, somebody who's advertising that they're a laserologist. You want to go through your gynecologist who knows some people who can do it for you well. You know, speaking of like procedures down on the vag, all these people are getting like a vag facelift. Like what is that? What is that? Just like a nip and tuck, like pulsing. What does it do? I think the facelift, I think some of these people are talking about using various insunging creams and, and, uh, potentially toxic. No, no. There's some surgical thing you can get. It's like a lift. If what they're doing is that again, some of these people are doing stuff with laser and some of these people are doing surgical interventions. And again, if it's just to do something for cosmetics, I wouldn't do it. Because again, there are always potential

complications to any surgical procedure and any laser procedure. If it's something that's really got a problem, you know, other than just the cosmetic issue, again, I think it's worthwhile talking to your provider to get somebody who knows what they're doing with it. And if you want to consider it, it's totally reasonable with somebody who knows what they're doing. Let me get another caller in. Kim in North Carolina has been waiting for a while. Kim, what's your question?

Quickly. My daughter was experiencing jealousy after she switched from the main brand birth control to the generic. Our doctor said she was just extremely sensitive to the minute difference in the brands. I was wondering how many other emotional side effects get chalked up to just PMS instead of it actually being a side effect of the birth control? That's an excellent question. And indeed, there are women who do have emotional issues with birth control pills. Most of the mood issues on the birth control pills are not related to the estrogen on the birth control pills are not related to the

estrogen in the pill, but they are related to the progestin, the synthetic hormone component of the progesterone. And there are many different varieties of pills out there with different progestins. So if I have somebody who's experiencing some moodiness, but otherwise likes the pill as a method of contraception, what we will do is to try a pill that has a different progestin, different synthetic progesterone in there to see if that agrees with her better. And there are certain pills that will do better for people who have bad PMS, so-called PMDD, because they have a more favorable progestin in there for them. So indeed, that's a good thing to think about. If at first you don't succeed. Okay. Geneva in Florida has a question for you, Dr. Micken. Go ahead, Geneva.

Thank you for taking my call. I am calling regarding some of the information provided today regarding estrogen, first of all. I don't know that many women understand that there's three types of estrogens. There's E1, E2, and E3. You've got the bad. What's your question, Geneva? Sorry, we don't have a lot of time. Well, you're getting progesterone from your OBGYN, and it's usually an E1 or an E2, which attracts and repels cancer. Well, is there any use for E3 in that application? My understanding is it repels cancer cells. Thank you. Go ahead, Doc. Unfortunately, it doesn't repel cancer cells. That is one thing it definitely doesn't do. E3 is called estriol. It's a very weak estrogen. And it certainly has uses as far as vaginal therapy. As far as systemic therapy, there's

not really any significant advantage over estriol versus estradiol or estrone. So as I said, and they all interconvert in the body. So there really isn't much to that issue as far as it's just the fact that it's a weaker estrogen. That's all. Pat in Ohio. Pat, you have a question that I think I share. What's your question for the good doctor? So I wanted to know if she has any opinion or information on HRT pellet therapy. Oh, I have an opinion on everything. The answer is yes and the answer is no. Don't do pellets. What are they? The problem with pellets is, first of all, they are made by compounding pharmacies the answer is no, don't do pellets. The problem with pellets is first of all, they are made by compounding pharmacies. There is no FDA approved pellet out there.

And the problem with compounding pharmacies, some are really terrific. There's no question about it, but you don't know. And there's really very little quality control. So some people out there are really crazy and they don't put out a quality product and there's really very little supervision. The other problem with a pellet is that once it's in, it's in. Nobody's getting it out of you. So if you get a reaction to it or it's really too strong for you, it's going to be on board for another two, three months and you can't do anything about it. So in general, we have some, and a lot of people who are like bio-identical therapies. Well, the key thing is we have a lot of really fabulous bio-identical FDA approved therapies that we can use. So for example, you can get commercially available transdermal patches or gels, which are exactly

the same as the estrogen your body makes, truly bio-identical. We can get natural progesterone. We can get basically the same progesterone our ovaries make, and you can get it in an FDA approved form. So there's really no need to go to a compounding pharmacy for anything except testosterone. Testosterone. So we don't have the approved dosage available for women in an FDA approved product. So in general, I would steer clear of pellets. But can I ask you, so the benefit of the estrogen patch, as I understand it, is if you're not taking it like in a pill, you have to worry less, like it doesn't go through your whole system, you know, I guess.

I don't know. Never mind. Forget what I said. What is the advantage of the patch over the pill? No, you're on the right track. No question about it. The key thing is everything gets into your bloodstream. Not vaginal. Vaginal, you don't. The amount that's absorbed from vaginal estrus is minuscule. I won't say zero, but it's minuscule. However, if you're wearing a patch or something like that on your regular skin, it's going to get

into your bloodstream. But the key thing is it gets to your liver in a very dilute form. When you take a pill, the pill goes into your esophagus, over to your liver very quickly, through the duodenum, and it gets over to your liver. And what's made in the liver? Things like clotting factors. So you have an increased risk of blood clots when you use oral estrogen. It's not huge, but it's increased. Whereas if you use a transdermal patch, it gets to the liver in a very dilute form and it does not increase the risk of blood clotting. So for somebody who's worried about blood clots, which many of us are, that you can avoid that risk in general by using a, what we call a transdermal form of a patch or a gel.

So if that's, I mean, who, who doesn't worry about blood clotting? Like no one wants a blood clot, but why wouldn't you then? Cause earlier you were saying you could stay on the pill, you know, for who knows, you know, for the indefinite future. But if I want to lower, like if I can get the things that are in the pill via this transdermal patch, and I will talk about how you ingest progesterone, why wouldn't I just do that? Megan, you're too good a lawyer. That's your problem. You're asking good lawyer questions. The key thing is that you're absolutely right that there is a lower risk of clotting with the transdermal patches. No question about it. The problem is when you are premenopausal, okay, that to control your cycle, to control your bleeding and things like that, you need a much higher dose of estrogen. Okay. So that the pill is going to deliver that much more effectively in general than a patch. And if you, and if you do use, because there are

birth control patches, you're absolutely right. Cause you've got to say that to be next. The problem with the birth control pill patches is they are a much higher dose of estrogen than the hormone replacement therapy patches. And those actually sort of override the fact that it's a transdermal thing. And the patches for contraception do increase your risk of clotting because it's such a high dose of estrogen in them. They'll go visit your liver potentially. Okay, Got it. That's, that's very interesting. All right. Another question, um, on, let's see, this one's okay. Lynn in Georgia has got a question for you. Hi Lynn. What's your question for the doctor? My question is I had been on both, uh,

HRT and testosterone injections and the pellet, which I just heard you say, but they took me off the injections. And when I did the pellet, which I just heard you say, but they took me out the injections. And when I did the pellets, I got nothing. And there's no, no libido, no nothing. And I just want to know where to go from here. Okay. Question. It's miserable. Well, have you tried any of the transdermal gels for the testosterone i did the gel in the first time um no no they did not they be for the estrogen they did but not for the testosterone now and the pharmacist would argue with me about giving me my testosterone like they didn't want to feel it and they would try to tell me what to do. And I just want to be normal again. Sounds like a reasonable request. But again, I would talk to,

I would talk to a gynecologist. And if you have somebody, if you don't have somebody who knows a fair amount about menopause, go to that menopause.org website, find a menopause certified practitioner near you. And basically almost all menopause practitioners would know about testosterone and they would know about compounding pharmacies that could get you transdermal gels of testosterone. And that there are some national pharmacies that we use. And so they can get you some transdermal gel and you could try it and see what it does. And the other thing is you can always measure levels, you know, to make sure that you're getting a good amount. Okay. So, you know, if you're not, if one part of your body doesn't seem to absorb it, you could try it on a different part of your body. Um, if

you get better absorption, but there should be a way to get you an adequate level of testosterone into your body to see if that helps. Good. Um, Lynn, thank you for calling in and being brave enough to answer to ask the questions. You have to self-advocate. There aren't enough experts in the menopausal field and your pharmacist does not have the final say over your life. So go to menopause.org, check it out. All right, let's get to Amanda in California. Hi, Amanda, what's your question? Hi. Well, I just wanted to let you know that I tried and really liked the Mona Lisa Touch laser. I had it done at UCLA by a gyno urologist and it really helped. It really helped with a lot of stuff. What does it help with? It helped with dryness.

It stopped me looking like a dead fish down there. And it sort of brought a bit of life back to it. That's good. Yeah, yeah. I'm 58. And my husband still thinks he's 14. So, you know, he wants way more sex. Yeah, I'm 58 and my husband still thinks he's 14. So, you know, he wants way more sex.

I would love to be closed for repairs indefinitely. But, you know, I've got to give in. So I tried the patch, you know, the low dose patch. I tried the Estrador. None of them worked the mona lisa really really worked for me it really helped helped to stop me feeling so sore irritated utis and all the rest of it i mean it it was good for me and insurance doesn't cover it you know but it's a three-part session and for me it really helped and I've got to say my doctor recommended it and I went to somebody who did it and uh yeah I've got to say I'm very happy. Was it painful? No not at all. Did you have any and i'm not painful no not at all it takes like three minutes they

numb it with some cream down there and he said to me it's going to feel like an elastic band but i couldn't feel anything so i think it just inside it just sort of i don't know like revived it let's put it that way. That's amazing. Brings a bit of color back to it. So Dr. Megan, now we've heard about the Mona Lisa and the Diva. These names are amazing. Do you have any thoughts on those? No, I mean, they're all basically varieties of the same approach. I mean, there's different kinds of laser therapy. And again, people who are laser savvy and stuff like that

have been appropriately trained, will know the differences if there are certain ones that would work better for you or otherwise, you know, that they can advise you along those lines. I think I would encourage, again, that many women will get relief from vaginal estrogens, and there are a lot of different preparations out there. So I wouldn't say, if you are experiencing dryness, what I would certainly say, talk to your provider and it doesn't have to be an OBGYN, but again, somebody who knows something about vaginal estrogens and other, there are other products out there besides vaginal estrogens. There's actually a product which has DHEA, dehydroepiandrosterone, which can be very helpful. There are different things that you can use vaginally. There are also a couple of oral

medications, which are good for the vagina too. So, but somebody who's an experienced menopause doc can help you. And we can usually take care of discomfort with a medication rather than having to go to laser. But as I said, that certainly if you haven't had good results with the vaginal, you know, therapies, or, you know, it hasn't worked well for you. Again, it's reasonable to talk to your gynecologist, find somebody who's good at doing them and, and talk to an expert at doing them. Sure. That's awesome. Thank you for calling Amanda. Um, I want to say, uh, Shannon called, but dropped Shannon's in Florida and said that her OBGYN said she's at high risk for hormone replacement therapy. So maybe she's got, you know, cancer history of her own, but there are quite a few

people who wrote in saying that they had, they had survived breast cancer and yet they were having menopausal symptoms and just wondered if there's, if they can't do HRT, like what can they do? Lots and lots of things. And again, I'm going to encourage anybody listening to go to madamovary.com. I've got lots of information about the other therapies that are out there. I have a couple of videos on menopause for cancer survivors, which is a special interest of mine. So as far as for the cancer survivor folks or people that can't take estrogen, for example, SSRI antidepressants, SNRI antidepressants can be helpful.

Certain herbal products can be helpful. There are also gabapentin is another therapy that can be helpful. So all of these have been around for a number of years, which can help with hot flashes and other symptoms. However, this new medication that's out there, which is something referred to as fezolinatant, it's been available now for about three months. And it really gets to a novel mechanism of action for hot flashes. It's called Veoza is the trade name. And it's really quite effective against hot flashes. Again, any menopause doc would know about it. And it has no, you know, unfortunately was not tested extensively in breast cancer survivors, but it is not, it is not a hormonal therapy. So there

is no reason they can't take it. And it's pretty effective. So we have a lot of options out there. Somebody who's a cancer survivor should not say, well, this is my lot in life. I just have to sit and suffer with high flashes. Not at all. We've got a lot of therapies for you. Please, again, go to madamovary.com and look at some of the information I have for you there, please. My information was that HRT might potentially raise the risk of breast cancer by a negligible amount. And that was sort of the information that was missing from really telling women that. So, you know, you say, you're going to increase your risk of breast cancer. Women are like, oh, forget it, I'm out. But if it's going like from a two to a 3%, and you can tell me what the actual percentages are, that's probably not going to move a lot of hearts and minds.

They probably do it anyway to get the relief and get all these other benefits. Well, again, Megan, you're a very good lawyer. The answer is you're looking at the data. However, the key thing is American women hear the word breast cancer and they flip out. They oftentimes will do that. And the increased risk was minuscule in the WHI. It was really tiny. And if you look at the long-term data, we have very nice long-term data now that shows no increased risk of mortality from breast cancer in women taking HRT.

We have even in the WHI data. So we have that data there. And the other thing to remember is that not all estrogens and progestins are created equal, that there are progestins or progesterone compounds that do not seem to have an effect on increasing the risk of breast cancer. And we can use those. So, you know, if you say, gee, I really want to use this, but I'm really concerned about breast cancer risk, well, look at my website, read about the breast cancer issues with some of the different progestin

options, and talk to a knowledgeable menopause practitioner who can give you that data to talk to you about ways that we can minimize a very minimal risk to begin with. Now, I have a friend who's on HRT and she said she hates the progesterone. She hates the progesterone. She said it is making her bloated. She has all sorts of issues with the breasts. So what's the story there? I have something for her. Now, okay, that there is a product out on the market, which actually does, it protects them because the progesterone is there to protect the lining of your uterus. That's what it's there for. It's not to do anything else other than to protect the lining of the uterus from overgrowth. However,

If you just do estrogen, you get uterine cancer. Is that the story? Very, again, very, very slight increased risk, but it's there. So we basically always provide something to protect the lining when we give estrogen. And somebody who has a uterus, if you've had a hysterectomy, you don't have to use progesterone. No reason you have to use progesterone. However, there is a new product out there called basodoxafine. Or it actually protects the lining of your uterus. And it is not a progesterone. And it really has no evil effects on mood.

And so if I have somebody who's getting mood and irritability, I put them on this base of oxyphene combination and they do very well with it in general. And the trade name of this is called Duavee, D-U-A-V-E-E. And it's at your pharmacy and you can get it. It's a prescription, but your gynecologist or your primary care person or your nurse practitioner can prescribe it for you. But that's an oral pill. So are you back to the liver blood clot risks? It is not available in a transdermal form. Unfortunately, that is true. But again, your risk, and again, the key thing when we talk about blood clots, the baseline risk of somebody in this age ballpark is if you wanted a thousand, if you look at oral

estrogens, the risk goes to two in a thousand. So yeah, it's doubles the risk, but it's a very, very, very rare event still. So, you know, I wouldn't want somebody to say I can't use it because of that. What about when women have sleep difficulties during a, during menopause, what is it in HRT that is solving it? Is it the estrogen or the progesterone? What's helping them? What's helping them primarily is the estrogen. And the mechanism of action is now under question. There are several different theories as far as what's helping it to calm the hypothalamus down, which is where these changes are going on. But so it's the estrogens, the major actor, however, micronized natural progesterone, okay, which is basically

the same same progesterone that our ovaries make actually has an effect on sleep. It actually tends to make people sleepy. So if somebody is having a really problem sleeping, I almost always would recommend they take estrogen with micronized natural progesterone before they go to bed, and they'll have a much nicer night's sleep. Okay. And does it matter? Because progesterone, too, you can't get that in a patch, right? But you can do a pill. You can get it in a patch, but that's not an issue with clotting.

So it's not a problem there. But I know you can also get it in an IUD form, right? So that would mean bypassing the rest of the body. Is there an advantage to that? Well, the answer is yes, because you can use now some of it does get absorbed systemically. There's no question about it, but it's a minimal absorption, you know? Okay. So that basically most women will, who have problems with some progestins will do well with an IUD because they get a very limited level. Now, I have had patients who've gotten, even though it's a small amount of stuff that's absorbed systemically, they get headaches,

they feel miserable. I've had to yank out the IUD, but that's like two women. The vast majority of folks do well with it. Then you could do the new medication you just talked about. And then the new medication is very nice. As I said, the Duovir is a very nice combination. And if that doesn't have progesterone in it, do you have to worry about uterine cancer? Nope, because the basodoxafine takes care of that. It prevents the growth of the lining of the uterus, but it's just not progesterone. It's another compound that prevents the growth of the lining of the uterus. Oh, my God. Thank God. Some people are making investments in women's health. All right. I want to get to Bob. Bob in North Carolina. You've been so patient, Bob. Thank you so much for waiting. What's your question for Dr. Minkin? This is Bob from Delpo. Are we waiting for Bob for North Carolina?

Just you, Bob. You go. You're my man. What's your question? So, Megan, I want to thank you very much for having the good doctor on. I've learned so much from this. My wife is 56. I'm 63.

There was a time when we had a wonderful life, sex life, and then one day, gone. No part of her body, nothing, just gone. You touch it before she would get excited, dead. Her current doctor said that she hasn't had sex in 23 years, so what's the big problem? I said, get away from that gynecologist because she doesn't care. She wants you to be in the same disaster relationship that she's in. My question to you, for the men out there, what can we do to help support our wives? Sorry. To support our wives, to help them understand that there's hope for them and hope for us.

A couple of things. I really need this podcast or whatever recorded so my wife can watch it. I've been trying to record parts of it off the phone. It is recorded. It'll release today

and you can share it with her and it'll be on YouTube as well. And thank you for being so honest and raw about the issue. Aw, Dr. Winkert, this is like, but doesn't he make a good point of like how painful these issues can be? Absolutely. Absolutely. And again, I hate to keep harping back to

go to menopause.org and find a certified menopause practitioner near you who should be able to help. The other website that's out there is there's a group called ISHWISH, I-S-S-W-S-H, and Sharon Parrish is a former president of it. It's the International Society for the Study of Women's Sexual Health, okay? And there are licensed, they have a list of ISHWSH trained physicians who are specialists in women's sexual health on the ISHWSH website, website okay and they have trained people who are trained in women's sexual health as a special sexual certification and find an ishwish provider there and there should be somebody close by you guys either from the menopause society or from the ishwish folks to get you somebody that can help you because there is really no reason that you know people

shouldn't have sex i mean i saw a patient yesterday who's, you know, somebody had told her 20 years ago, she shouldn't be having sex and she's only 74. And it's like, this is ridiculous. And she was like crying at the end of the visit. It's like, I can do this. I said, watch this. You know, somebody told her her vagina was too small to have sex. So I used some dilators, vaginal dilators, great gadgets. And I said, look at this. And we put, you know, we use the little Novocaine at the entrance of her vagina. We took away her pain and she was great. You know, she's going to use some vaginal estrogen to get it rejuvenated.

So there really is no reason she should be suffering and that you guys can't have sex. And you, it's like, don't underestimate the value of a healthy sex life in a relationship. It's just, it can lead to so much, so much good stuff. Like good intimacy, better connection, more willingness to share your emotional issues with one another. You know, it's all this great cycle if you can get into it and an unhealthy one, if you can't. Yeah, absolutely.

Well, listen, what were you going to say? Were you going to add something else? No, no. I was just going to say, I think those folks were looking to see if I could chat with them here. So I think I may have to go. Oh yeah. Yeah. No, I'll let you go. Thank you for staying late. I'm very grateful. You've been amazing. What a great font of information. And we'll check out menopause.com, but also, um, dot org you said, um, and also Madam Bovary. That's amazing. Madam Ovary, Madam Ovary, M-A-D-A-M-E-O-V-A-R-Y.com. That's my website. All the best.

Thank you for all you do. Thank you much. Thank you for your educating the folks. It's lovely. Oh, talk again soon. And I want to tell you that tomorrow we have an exclusive interview with Sage Steele. She just left ESPN and has a lot to say. Thanks for listening to The Megyn Kelly Show. No BS, no agenda, and no fear.