Vanishing Vulvas & Menopause: What's Really Happening with Dr. Karen Tang

Guest links Karen Tang, MD https://www.instagram.com/karentangmd/ (Instagram) Karen Tang, MD https://www.facebook.com/karentangmd/ (Facebook) Karen Tang, MD https://www.youtube.com/c/karentangmd (YouTube) Karen Tang, MD https://www.linkedin.com/in/karen-tang-md-mph-412b0995 (LinkedIn) Karen Tang, MD https://www.tiktok.com/@karentangmd (TikTok) GynoMight with Karen Tang, MD https://karentangmd.substack.com/?utm_source=ig&utm_medium=social&utm_content=link_in_bio&fbclid=PAZXh0bgNhZW0CMTEAc3J0YwZhcHBfaWQMMjU2MjgxMDQwNTU4AAGnmQbf91crO8-OomNRWLIuzF6PE3U57lQ56vPpl1yl-QGv7xtq1F-CokK-R2U_aem_Y2dRIhFbRxfsXdrqJLi8Qw&utm_id=97760_v0_s00_e0_tv3_a1dennhaawmhw6 (Substack) Thrive Gynecology https://thrivegyn.com/about-us/ Books “It's Not Hysteria: Everything You Need to Know About Your Reproductive Health (but Were Never Told) https://www.amazon.com/Its-Not-Hysteria-Everything-Reproductive/dp/1250894158,” by Dr. Karen Tang “The New Perimenopause: An Evidence-Based Guide to Surviving the Zone of Chaos and Feeling Like Yourself Again https://www.amazon.com/New-Perimenopause-Evidence-Based-Surviving-Yourself/dp/0593736613,” by Dr. Mary Claire Haver “The New Menopause"⁠ https://www.amazon.com/New-Menopause-Navigating-Through-Hormonal/dp/B0CKBZ4K1Z/ref=sr_1_3?crid=10GNBSGVPDFJZ&dib=eyJ2IjoiMSJ9.djG88jtefTqLpTg36Li8QIefDxRPHA-WKVyCC9DQ7X71Ad734j96bPWX-yewnsv9Pqm7WCali5P5-h2eixUH_yHkbz1DHy2rQFoQSh7O92HNwttIL_ZBgXVor81D-Z3sbsfBh7JOJXDQwUuhWNnA5LHbsuI1CyhIyjtRm6_DXYJFaWrkYTjJeqJyFBnBZfgTprhlgJe_RZoWH9pOY6S9XzRapnMjnZgOq7PBA7Wy2KM. ZfI9WXwN58225D-i3qDhw4ZlXZO4pt8rPX1nAKiBNHM&dib_tag=se&keywords=perimenopause+book+mary+claire&qid=1775810714&sprefix=perimenopause+book+mary+claire%2Caps%2C511&sr=8-3 by Dr. Mary Claire Haver For a list of full show notes, please click here https://thepauselife.com/blogs/the-unpaused-podcast/vanishing-vulvas-menopause-whats-really-happening-with-dr-karen-tang.

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:00Dr. Mary Claire Haver?

  Menopause hormone therapy is a microdose compared to what your body was making in your pre-menopausal years. It is unreasonable to think that for the next 30 years, this microdose is going to be enough to penetrate that genital urinary system. You are better off treating both areas at the same time, and maybe we can prevent any of these problems.

• 0:18Speaker 01

  Yes. The prevention is so huge because, again, so much of the menopause and women's health in general is you're sort of like reacting. You're like waiting until you can't tolerate it anymore, until you're just like, I can't deal with this anymore. And then you finally treat it. That was definitely the way that we thought of women's health for so long.

• 0:46Dr. Mary Claire Haver?

  The views and opinions expressed on UnPaused are those of the talent and guests alone, and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment.

• 1:04Dr. Mary Claire Haver?

  In part one of my conversation with Dr. Karen Tang, she walked us through what happens when common gynecologic conditions like endometriosis and fibroids collide with the menopause transition. But there's another category of symptoms that affects millions of women and is still surrounded by confusion, stigma, and far too much suffering and silence. In this episode, we turn our attention to one of the most common complaints women bring into midlife: pain in the vulva and vagina. Dr. Tang, a board-certified gynecologist, minimally invasive gynecologic surgeon, and the author of It's Not Hysteria, explains why itching, burning, dryness, and painful sex are so often dismissed or misdiagnosed,

• 1:49Dr. Mary Claire Haver?

  and what women should know about the conditions that might be causing these symptoms. We also tackle the persistent myth that that painful sex is simply something women should expect as they age. And because so much of women's healthcare still requires self-advocacy, we close with a practical conversation about treatment options, vaginal ester Estrogen, surgical decision making, and how to find the right specialist when you're not getting answers. Because we both firmly believe that while suffering may be common, it is never something women should have to accept. I'm Dr. Mary Claire Haver, a board certified obstetrician and gynecologist and certified menopause practitioner. I'm also an adjunct professor of obstetrics and gynecology at the University of Texas Medical Branch.

• 2:34Dr. Mary Claire Haver?

  Welcome to UnPaused, the podcast where we cut through the silence and talk about what it really takes for women to thrive in the second half of life.

• 2:51Dr. Mary Claire Haver?

  So let's move on to the vulva.

• 2:53Speaker 01

  All right.

• 2:54Dr. Mary Claire Haver?

  Vulvas pain, itching, burning, and skin changes. How common are these vulvar conditions?

• 2:59Speaker 01

  They're extremely common. I think like, almost everyone probably at some point has had some sort of vulva vaginal itch. Like, that's just a fact. Like, if you have a vulva and you have a vagina, it's been itching irritated at some point. And especially in menopause. Like, it's rare that someone-

• 3:14Dr. Mary Claire Haver?

  It's worse in menopause.

• 3:14Speaker 01

  Absolutely, yeah. Just the low estrogen, tissue quality, like, you get dryness, you get like, kind of delicacy of the tissue. And the vulva, under the best of circumstances, is very sensitive. I always tell people, it's among the most sensitive parts of the skin on your body. And it will react to soaps, to, you know, fragrances.

• 3:33Dr. Mary Claire Haver?

  I liken it to the mouth.

• 3:36Speaker 01

  Yes, yeah.

• 3:37Dr. Mary Claire Haver?

  I try to tell them, your vulva, the mucosa-

• 3:38Speaker 01

  Or the eye, the eyelid.

• 3:39Dr. Mary Claire Haver?

  It's the same, and you would not put what you're trying to put in your vagina into your mouth.

• 3:43Speaker 01

  No.

• 3:43Dr. Mary Claire Haver?

  So like, that's like, would you put this in your mouth?

• 3:45Speaker 01

  Yeah. I say the eye. I always tell people, like, if you wouldn't rub this on your eye, like, you shouldn't have put it on your vulva. And there's such an industry now of, like, the feminine washes and, like, scented stuff-

• 3:57Dr. Mary Claire Haver?

  And what you're supposed to smell like.

• 3:58Speaker 01

  Oh my god, you just smell like flowers, or like a pina colada, I always say. Or a lot of these, like, essential oil products, which are irritating. There's like, tea tree oil, that can like, burn your vulva. I had a patient who had, like, basically secondary burns. Like, her skin was sloughing off, because she did this dilute tea tree oil stuff. So, it's very common, especially perimenopause, menopause, because of the low estrogen changes.

• 4:20Dr. Mary Claire Haver?

  A lot of patients will call in and they're like, well, that sounds like a yeast infection and send in di-flucan or go get them to, or they'll go over the counter and get the antifungals. How often is it really yeast? Is all vaginal itching a yeast infection?

• 4:32Speaker 01

  No, you know what's funny? The chapter on vulvovaginal stuff in my book, I literally almost did the title, "It's not a yeast infection" because so much itching gets chalked up for yeast infections and a lot of times it's not. Now, I actually don't know the statistic of how often it is a yeast infection, but we literally say it could be skin problems. There's something called lichen sclerosus, which is a chronic inflammatory condition, causes horrible itching, it can cause scarring, you can lose, we say lose the architecture, where people have heard this on social media, like your vulva disappear. That's one of the things can make your vulva disappear, like your lips, like the labia minora can literally like go away with lichen sclerosus, like it just kind of fuses to the labia majora, which are the fleshy parts of the vulva.

• 5:14Speaker 01

  And there's also lichen simplex, which is just eczema, like those of you with eczema out there, you can get eczema of your vulva, scratch itch cycle, it gets a little bit dry and irritated, you scratch it, it itches more, you scratch it, itches more. And then there's even like kind of precancers of vulva, which is rare. Like we always tell people, you know, vulvar cancer and precancer is definitely rare, but in postmenopausal patient, absolutely. Postmenopausal patient with persistent itch or something that's not going away, like a little lesion, you gotta biopsy it because it could be something that's more concerning.

• 5:45Dr. Mary Claire Haver?

  You just saved someone's life.

• 5:47Speaker 01

  I've definitely had a patient, I can't remember when this was, who literally, she was in like a nursing home. So these poor patients, like they are, you know, in the nursing home and they're like, well, she's been complaining of itching, but she's incontinent, she wears a diaper, so maybe it's just like irritation. And literally like you would take the thing that it was like a vulvar cancer. And they've just been sitting on it because they're like, oh, just like older women just have itchy vulvas. So you always have to look at it. You always have to have a low threshold to kind of consider non-yeast things. And then there's just called, you know, genitourinary syndrome of menopause, I'm sure you've covered it a million times, where it's literally just the low estrogen causing the itching, the burning, the pain, the sacs, the tissue quality changes that can improve significantly and go away totally with vaginal estrogen.

• 6:28Dr. Mary Claire Haver?

  What about lichen planus?

• 6:30Speaker 01

  That much, much more rare. I honestly have not diagnosed lichen planus.

• 6:33Dr. Mary Claire Haver?

  I've seen it about three or four times, but I was like a referral center for

• 6:37Speaker 01

  Oh, vulvar.

• 6:38Dr. Mary Claire Haver?

  the vulvar stuff. So I did see, you know, people who'd wandered around to several clinicians who didn't know what to do with them. They'd send them over and I worked really closely with a dermatologist, like a derm path.

• 6:48Speaker 01

  Yeah.

• 6:48Dr. Mary Claire Haver?

  And so we were, we kind of, I was on that train.

• 6:50Speaker 01

  Interesting.

• 6:51Dr. Mary Claire Haver?

  I've seen lichen planus.

• 6:52Speaker 01

  Yeah, it's purple plaques. It's sort of the, yeah.

• 6:55Dr. Mary Claire Haver?

  It's unbelievable when you see it, you know, like, like your attention is immediately raised.

• 6:59Speaker 01

  Yeah.

• 6:59Dr. Mary Claire Haver?

  So it's not like, is it something? You're like, this is like, the world's on fire.

• 7:03Speaker 01

  Yeah.

• 7:03Dr. Mary Claire Haver?

  You know, the house is on fire and we need to, you know, get a biopsy immediately.

• 7:06Speaker 01

  Yeah.

• 7:07Dr. Mary Claire Haver?

  It's an autoimmune condition for our listeners and it causes ulcerations and plaques.

• 7:11Speaker 01

  Exactly.

• 7:12Dr. Mary Claire Haver?

  On the vulva and it's very, very, very painful. And so.

• 7:16Speaker 01

  So speaking of that, like people can get like psoriasis of the vulva. If you have skin conditions elsewhere on your body, like eczema, like psoriasis, you can get it in the vulva as well. And so I've had patients who are co-managed with dermatology, being treating their little plaque psoriasis of the, you know, vulva.

• 7:32Dr. Mary Claire Haver?

  Okay.

• 7:33Speaker 01

  And then just to throw it out there, also like herpes, like sometimes people will be like, I'm burning. I don't know what this is. I kind of scratched. I feel like there's a little sore there. You know, maybe I just kind of broke it with my fingernail because I was scratching and it's a herpes outbreak. And so common things being common, that's a super common one. There's no shame to it. It's, it's basically like a cold sore of your vulva, very normal and common. Uh, so just to be aware that again, if it's burning, if it's itching, it's definitely not always just an easy infection.

• 7:58Dr. Mary Claire Haver?

  And it often comes with a prodrome.

• 8:00Speaker 01

  Yes.

• 8:00Dr. Mary Claire Haver?

  If they're used to it before they actually have the ulceration.

• 8:04Speaker 01

  Feel like a tingling or a burn.

• 8:05Dr. Mary Claire Haver?

  Or some, it's like something's not right. And I'll be like, take your Valtrex.

• 8:09Speaker 01

  Yeah.

• 8:09Dr. Mary Claire Haver?

  You know, you'll learn when you have that signal to start taking your Valtrex and hopefully we can head off the ulceration before it comes. What is vulvodinia?

• 8:17Speaker 01

  Vulvodinia, it's kind of, the way I explain it, it's like a catchphrase. It's vulvar pain that we're not exactly sure it could be from something else. But the way to think of it is just vulvar pain that's not from a specific thing, not from herpes, not from an actual like, lichen sclerosus. And it's basically, when you think of the nerves that, you know, control like the sensation of your vulva, it's getting like really irritated by something. Usually something, you know, inflammatory. Uh, a lot of times it could be from something like endometriosis that just then spiraled, your nerves got really sensitized. And then even though the endometriosis is physically not near the vulva.

• 8:57Speaker 01

  It then leads to vulvar pain because the nerves in that whole region gets so irritated that they feel pain no matter what you do. So just touching the vulva actually burns and stings, even if your actual vulvar skin is normal looking. So basically, we rule out other stuff. And if you're having vulvar pain, like it burns or stings, if someone's just examining you and just kind of touches your skin, we call it vulvodynia. There's kind of variations or something called like vulvar vestibulitis, like that's sort of in that kind of opening area of the vulva, if that particular area is painful. But oftentimes, it's secondary to something else. So meaning that it wasn't that there's something literally wrong with your vulva, but something is causing it to experience pain.

• 9:39Dr. Mary Claire Haver?

  Okay.

• 9:48Dr. Mary Claire Haver?

  So estrogen decline, the GSM picture, it can cause this vulva vaginal atrophy, which is a terrible name.

• 9:55Speaker 01

  A horrible word. I'm glad that we know what to say. We used to say that all the time until recent years when GSM kind of was introduced. And thank God, because it just makes it sound like it's just like all like crumbling, shriveling away.

• 10:07Dr. Mary Claire Haver?

  And then one of the most viral videos in this area is the one where Rachel Rubin is talking about losing the architecture.

• 10:14Speaker 01

  Yeah, your vulva disappears, your labia disappears.

• 10:17Dr. Mary Claire Haver?

  For whatever reason, the entire internet took a pause and gasped collectively and was like 23 million views or something. What?

• 10:24Speaker 01

  I made a video responding to that and that got millions of views. Like people couldn't get over it. There's so many, you know, just a pause. There's so many funny responses to that. They're like, they snap on like Legos and they're like deer antlers they fell off. It's not like that. So what's actually happening? And Rachel obviously has a great explanation for this. I kind of think of it like picture like the vulva when you have like a baby or a child. It doesn't look the same as a woman who is, you know, adult.

• 10:50Dr. Mary Claire Haver?

  So an infantile vulva.

• 10:51Speaker 01

  Yeah. So you have like very little of the lips, the labia minora, which are like the lips that kind of stick out. You sort of have just like an opening and then labia majora, which are like the fleshy parts of the vulva on the outside. So under the influence of estrogen and probably other things like testosterone, like You get like these more like elongated lips. And then as you go into menopause and the hormones are dropping, like everything kind of almost goes in reverse a little bit. Like the labia shrink back. And then again, it's a little bit overlapping with things like lichen sclerosus where things are getting really fused. So there are some times that, you know, you'll look at somebody who is postmenopausal and they're older, like they're 80. And they'll have like very minimal to no labia minora. Like it'll basically just be this little opening.

• 11:36Speaker 01

  Everything's sort of shrunken back. So we say it's not like it fell off, like the videos, like people responded, made it sound like labia were like literally detaching from your body and like falling off of you. It's not like that. It's just sort of like, they start to kind of almost go in reverse, like, like you would picture the way that the labia looks when you have like a child or a baby.

• 11:55Dr. Mary Claire Haver?

  I always say I can tell your age better by looking at your vulva. If you're untreated in menopause than by looking at your face.

• 12:02Speaker 01

  Yeah, yeah.

• 12:03Dr. Mary Claire Haver?

  Like it's not gonna lie.

• 12:04Speaker 01

  Yeah. And this is not even including like the inside of the vagina where like, you know, normally it's like pink and like it's moist and there's like there's brugae which are folds that allow it to stretch for sex and for childbirth. Like you start to lose those. It gets really like kind of like pale and flat, like really kind of stretched thin.

• 12:23Dr. Mary Claire Haver?

  And our, the entroidus, the opening of the vagina gets really, really, really small.

• 12:27Speaker 01

  So those, all those changes, and that's why we love vaginal estrogen, which can help prevent some of those changes. I say we almost look for an excuse to give it.

• 12:35Dr. Mary Claire Haver?

  So I give it prophylactically.

• 12:36Speaker 01

  Oh my gosh, I, if anybody has like a whisper, I'm like, we're giving it. Yes.

• 12:40Dr. Mary Claire Haver?

  Yeah.

• 12:40Speaker 01

  Yeah, bladder stuff.

• 12:41Dr. Mary Claire Haver?

  Cause when you think about, even with your, and a lot of people misunderstand this. Menopause hormone therapy is a microdose compared to what your body was making in your pre-menopausal years. It is unreasonable to think that for the next 30 years, this microdose is going to be enough to penetrate that genital urinary system. You are better off treating both areas at the same time. And maybe we can prevent any of these problems.

• 13:04Speaker 01

  The prevention is so huge because again, so much of the menopause and women's health in general is you're sort of like reacting. You're like waiting until you can't tolerate it anymore. Until you're just like, I can't deal with this anymore. Then you finally treat it. That was definitely the way that we thought of women's health for so long. Like up until recent years, there was so little kind of thought about, well, let's like do something preventatively, rather than like, let's just wait to react until you're just like, you cannot take it anymore. So now, again, I love the sea change where we're like, we can prevent the narrowing and the pain with sex and like the bladder stuff, the UTIs, like women getting septic because they're so infected by these bladder infections. It's so easy. It's

• 13:45Speaker 01

  like this medication that like everyone can use. There's almost no risk to it. There's generic versions covered by insurance.

• 13:52Dr. Mary Claire Haver?

  There's a push to make it over the counter.

• 13:54Speaker 01

  Yes, in UK, it's over the counter.

• 13:55Dr. Mary Claire Haver?

  Yeah.

• 13:56Speaker 01

  A friend of mine was.

• 13:56Dr. Mary Claire Haver?

  So we have a precedent in a, in a first world country. And so, you know, it's not that hard once somebody else did it for us to say, hey, they have it over the counter.

• 14:06Speaker 01

  UK does it. Yeah.

• 14:07Dr. Mary Claire Haver?

  You and I can get on social media and teach people how to use it.

• 14:10Speaker 01

  Yeah.

• 14:10Dr. Mary Claire Haver?

  You know, it's so safe and we will prevent, we will save the United States billions in Medicare for our elder population. And there's other, you know, talk about the other low estrogenic states outside of menopause.

• 14:22Speaker 01

  Yes. So lactation and breastfeeding, birth control, like there are all these things where our estrogen levels are suppressed. People don't think of it because I think, you know, in menopause, at least those of us who had formal training, we're like, yeah, we were taught to ask about the vagina and sometimes the bladder. But we never ask about the vagina when someone is on birth control or, you know, not often when they're breastfeeding. But those are very low estrogen states as well because your ovaries are being suppressed. You know, just when you're breastfeeding, people know like you oftentimes aren't having your period for a long time. So they have what's it called? Like the genital urinary syndrome of lactation. Dr. Rachel Rubin, I think, was spearheading the use of that term, which is a great way to phrase it because it is physiologically so similar to menopause.

• 15:07Dr. Mary Claire Haver?

  Low estrogen.

• 15:07Speaker 01

  Yeah, low estrogen, burning, pain with sex, bladder problems, UTIs.

• 15:12Dr. Mary Claire Haver?

  Yeah.

• 15:12Speaker 01

  All very similar. And just to throw it out there, because a lot of people don't realize that the birth controls, you know, they are suppressing your ovaries. A lot of times people will feel like some low estrogen symptoms, including sometimes pain with sex or vaginal dryness.

• 15:24Dr. Mary Claire Haver?

  So let's talk about pain with sex because it's a. Huge complaint.

• 15:28Speaker 01

  Big one.

• 15:28Dr. Mary Claire Haver?

  What is the workup of really, you know, where do you go from there? Patient comes in, chief complaint, I'm having painful sex.

• 15:35Speaker 01

  Yeah, a lot of it you can tell even before we examine someone. Obviously, we're going to examine them and all the things that can be hurting. But we ask very detailed questions and sometimes when people come in with this concern, one, they may not even bring it up. Like, just to say that a lot of times it's because we're asking specifically, like, if you're coming in for a perimenopause consult, I'll ask about sex and like, are you having any sort of pain?

• 15:56Dr. Mary Claire Haver?

  It's on our intake paperwork. We have a whole disparunia.

• 15:59Speaker 01

  Yeah, a lot of people don't come in being like, hey, I need a consult for pain with sex. Like, they're often coming in for something else and it sort of comes out in the conversation.

• 16:07Dr. Mary Claire Haver?

  Is pain with sex ever normal?

• 16:08Speaker 01

  No, never.

• 16:09Dr. Mary Claire Haver?

  It's common, but should we ever accept this?

• 16:11Speaker 01

  Make a T-shirt. Yeah, common does not mean normal. You don't have to suffer from it.

• 16:16Dr. Mary Claire Haver?

  You should not suffer.

• 16:17Speaker 01

  You shouldn't suffer. And again, there's sort of this myth that at some point, sex is always painful. That's not the case. Even though things are common, doesn't mean it's normal. So.

• 16:26Dr. Mary Claire Haver?

  Can I tell you something?

• 16:27Speaker 01

  Yeah.

• 16:27Dr. Mary Claire Haver?

  I'm having the best sex of my life.

• 16:29Speaker 01

  Absolutely, absolutely.

• 16:30Dr. Mary Claire Haver?

  I'm 57.

• 16:31Speaker 01

  Oh, my God.

• 16:32Dr. Mary Claire Haver?

  Hi.

• 16:32Speaker 01

  Same? Yeah, I think a lot of people, perimenopause, menopause, like, one, you have the confidence. Number two, you can ask what you want.

• 16:39Dr. Mary Claire Haver?

  Not afraid to ask for what I want.

• 16:40Speaker 01

  You know what you want. You can communicate it. You don't feel like you have to hold back to like, you know, to be like cool or whatever. You can feel like, I need this, I need the stimulation. But back to the pain with sex thing is that we can get a lot of information just by asking you, where does it hurt? When does it hurt? And are there certain things, like positions, that make it more or less painful? Is that the opening of the vagina when you're first having, you know, penetration? Is it deep inside with thrusting? Is it certain positions and angles? And that kind of gives us a sense, well, we think it's the vulva. We think it's the pelvic floor. We think it's fibroids or endometriosis. It could be muscle spasm, like something called vaginismus, which you have, the muscles kind of seize up because, you know, you're having pain. It's a big cycle. It hurts. Your muscles want to protect you. They seize up. It hurts more.

• 17:24Speaker 01

  So that happens a lot sometimes with, you know, everything that can cause pain with sex. And then, obviously, doing an exam, checking the skin, checking the vagina, seeing what hurts. Like, if you touch here, is it painful? Does your muscle? Muscle kind of cramp up if you push on it. Do you have a big mass? Like, do we feel a huge fibroid in there that's getting pushed on when you have intercourse? So, and then sometimes we'll do an ultrasound if we're like, oh, we wonder if there's something kind of deep inside that's hurting when you have deep penetration. And I always tell people, we can almost always fix it. Like, there is not, I don't think I've ever had a situation where a patient had pain with sex that we couldn't at least get it almost all under control, so they could have satisfying sex. So, a lot of times people think, oh, God, this is something I just have to kind of deal with now.

• 18:06Speaker 01

  Like, I'm 60, I guess it's always going to be painful, and that's not the case. Between the vaginal estrogen, pelvic physical therapy, I send everyone for pelvic PT. I think it can only help, and, oh, my God. And then, especially with pain with sex, almost 100% of the time, they can help in some way. Between, like, muscle stuff, but also, like, dilators. It's very hard to use a dilator on your own if the vagina's narrow. People don't know what to do or how to insert it. The physical therapists help guide you, and they help to, you know, retrain the nerves. Like, they do all sorts of amazing things. So, there's hope out there. If you're experiencing pain with sex, believe that you can get relief and, and everything will be improved.

• 18:45Dr. Mary Claire Haver?

  So, we have vaginal estrogen, but we also have vaginal DHEA. So, do you, how often are you using that in your practice?

• 18:51Speaker 01

  You know what's funny? I actually, because almost always, I, the patients like the vaginal estrogen. Like, I usually start with the vaginal estrogen, and then, you know, like, I can't even remember the last time I've done the DHEA. But it is, it's obviously an option. How about you? Like, what role do you use that for?

• 19:05Dr. Mary Claire Haver?

  Person came out, like, I haven't, we prescribed it a couple of times. Like, some patients come in asking for it. They saw something, they read something, and they want that, that two-one hit of testosterone and estrogen. Because for our listeners, the DHEA in the tissues will convert to both estradiol and testosterone. We do have androgen receptors in the vulva. And so, the sex med people are really, they're on it, so they will have watched a podcast.

• 19:28Speaker 01

  Got it, got it.

• 19:29Dr. Mary Claire Haver?

  Rachel Rubin talked a lot about it. So, they'll come in asking. It's not generic.

• 19:33Speaker 01

  I was about to say, it's branded.

• 19:35Dr. Mary Claire Haver?

  Compound it, and most of our patients do get symptom relief with just the estrogen, but it is something that's in the back of my mind.

• 19:41Speaker 01

  I hadn't thought about that with the testosterone. And so, this is, again, for listeners, we're learning all the time. There's no like kind of guide, you know, we're writing the guidebooks.

• 19:50Dr. Mary Claire Haver?

  Since I started the podcast, I'm a way better doctor because I have so many experts on. I'm like, I did not know this.

• 19:55Speaker 01

  I've learned so much from the other doctors I've met on social media because I'm like, oh my gosh, I didn't think about X, Y, and Z. Like Rachel Rubin taught me how to prescribe testosterone gel to get it covered. Yeah, to get it through GoodRx. Like, I didn't know about just these logistical things. So, yeah, for the listeners, we are also educating ourselves because, again, we came from sort of this world where there wasn't like kind of gold standard, like this is the algorithm, et cetera. Like, we're kind of learning as we go, too.

• 20:23Dr. Mary Claire Haver?

  Yeah.

• 20:23Speaker 01

  So the downsides have been, for my mind, just the fact that branded medication, like oftentimes the insurance coverage is kind of a pain. And because we can get generic estrogen, you know, covered and usually does the trick. So that's kind of in my mind where I had had the holdup. But it just makes sense from a physiologic point, maybe the people would improve with this testosterone as well.

• 20:51Dr. Mary Claire Haver?

  Last subject, surgery. So we want to talk about hysterectomy. And so you perform a lot. That is like part of your menu. Hysterectomies, myomectomies, endometriosis, excisions. How does surgical decision making change in a very pre-menopausal patient to a perimenopausal or postmenopausal patient?

• 21:08Speaker 01

  Yeah. So a lot of times it hinges on things like fertility. So there are many more decisions to be made if somebody is wanting to preserve their fertility. For instance, for fibroids. If a person with fibroids comes in and fertility is on their mind, there's a lot more to discuss in terms of, well, this surgery could have this impact on future fertility. You might need a C-section for this. Like, this one is the gold standard with more data behind it. Not that we don't consider other stuff if you are past kind of childbearing, but the conversation's much more straightforward. And not to say that, you know, we're like, yay, it's easier. But, but just to say that we don't have to spend like that much time being like, well, in this scenario, this could happen if you're pregnant, or this could happen if you're pregnant. We just kind of skip right over that.

• 21:51Dr. Mary Claire Haver?

  Okay.

• 21:51Speaker 01

  So a lot of times, too, decision making is a little bit more, like, people kind of know what they want a little bit more. When they know that they don't ever plan to get pregnant, either when you're younger or when you're a pair of men a puzzle and those kind of years are done for you. So I do find like people who are in that frame of mind, they come in and be like, I want to hysterectomy. They've thought about stuff, they've learned about it, they're like, I know this is for me. A lot of times, especially if people are younger, they may not have like had the opportunity to learn about a lot of these things. They may not have other friends who have kind of been through it. I feel like the hysterectomy thing, like pretty much everyone had a friend who has had a hysterectomy, maybe has been able to talk with them about it. Enematosis is getting more attention and people are connecting with each other online.

• 22:34Speaker 01

  So they are able to kind of have more of those discussions amongst themselves. But I do feel like in my experience, people kind of with the hysterectomy angle of things are like, oh, I know. Like my friend, my mom, my grandmother, I've talked to all of them. I know their experiences, like I've thought about it, blam. As opposed to, you know, I have fibroids, I'm 27, I need to learn about this option, this option, this option, this option. What can happen with this? Like if I give birth with this? But everybody's obviously different. Like I have 19 year olds come in, they know exactly what they want. They've researched everything up the wazoo. They've thought of every possible consideration. So I just tell people, we should treat everyone the same, no matter where they are in life. I never make assumptions. I literally never assume what somebody wants.

• 23:16Speaker 01

  And I present everything in a way that I say, this is why somebody might choose this option. This is why somebody would probably not want to do this option. This is a benefit, this is the drawback, here's the recovery, like this is how you should, you know, think about it and make your decision.

• 23:30Dr. Mary Claire Haver?

  When someone's trying to choose a surgeon, what are some red flags they should watch out for?

• 23:35Speaker 01

  If someone only gives you one option, I hear this all the time. So say for fibroids, that's a good example, where they literally only give them the option of a hysterectomy. They don't talk about myomectomies, assessa, there's something called fibroid embolization that's done by radiologists. Exactly. So if someone is seeing a surgeon and they literally only have one thing that they're going to give you, that's a big red flag. A good surgeon and just a doctor in general, like any doctor should give you multiple options. Because again, every person's different, their background, their goal. Their perspective on medicine and surgery, et cetera, is completely different. You should never have a doctor who's only giving you one thing, and this happens all the time. They're like, I only, I'm going to give you birth control. I'm only going to give you a hysterectomy.

• 24:18Dr. Mary Claire Haver?

  Pellets.

• 24:19Speaker 01

  Yes.

• 24:19Dr. Mary Claire Haver?

  Yeah, we're only going to do it.

• 24:19Speaker 01

  Or pellets, exactly. Something that there's, uh, literally, it's no matter who you are, they're going to offer you the same thing. I always tell patients, before you walk in, I have no idea what we're going to choose. Like, how could I? Because every person's different. So you should get that experience with whatever doctor you see, whether it's a surgeon, like a menopause specialist, whoever. They should be laying out a whole buffet of options and then helping you figure out, you as an individual, which one seems like the best fit for you.

• 24:46Dr. Mary Claire Haver?

  Walk us through how you would counsel a patient on her ovaries, whether or not to keep or remove.

• 24:52Speaker 01

  Yeah, so nowadays, again, the default is to keep them. There was kind of a big study, uh, looking at hysterectomies and whether to take the ovaries out at the time of hysterectomy. This was sort of like a big groundbreaking study. It was like the Women's Health Initiative that then, in retrospect, they're like, oh, whoops, this isn't so pertinent anymore. We used to say that the ovaries could have like a major benefit even through age 65. If, say, you were having a big surgery, like a hysterectomy, they're like, well, let's keep them until you're 65. Like, it used to be, like, the pendulum swung in both directions. It used to be, we're like, yeah, take them out, whatever.

• 25:28Dr. Mary Claire Haver?

  We used to say, I was taught to counsel, there's a 10% chance we'll have to go back for them for something. So you might as well just remove them now.

• 25:34Speaker 01

  Yes, exactly. So I was about to say, even going farther back, uh, again, when I started residency in 2005, it was very much like, yeah, like, you're 40 something, you're not wanting to get pregnant. Like, why would we take the chance that you'll get ovarian cancer and have to come back another day? You might as well get them out. And then there was a study, and I can't remember what year it came out, but it was the pendulum swing, the exact opposite direction, where we're like, well, you should keep them until you're 65, no matter what, because they could, you know, have major, like, other health problems. And then they reanalyzed that, and they were like, well, actually, like, after about 50, when you're kind of in menopause age range, like, it probably doesn't make a huge difference. So now I just present everything to you as an individual and see what you want to do. Because

• 26:16Speaker 01

  If you have a strong family history of ovarian cancer, I'm sending you for genetic counseling. I want to know if you have a BRCA mutation. So obviously that totally changes the decision.

• 26:25Dr. Mary Claire Haver?

  Interchange the counseling, yeah.

• 26:26Speaker 01

  Absolutely. If you don't have a high risk of ovarian cancer, just taking your tubes out decreases your ovarian cancer risk. A lot of people don't know that. That's like a secret hack is that a lot of ovarian cancers come from your tubes.

• 26:36Dr. Mary Claire Haver?

  Primary period, to Neil.

• 26:37Speaker 01

  So yeah, so you can just take your tubes out, like for sterilization, and that drastically decreases your ovarian cancer risk. You don't have to go into surgical menopause. And then there are some people who are like, look, you know, I don't have like a genetic mutation, like a BRCA mutation, but I had, you know, a grandmother died of ovarian cancer, and it would just really keep me up at night. I don't want to worry about this. I'm 52. I just want them out. And of course, we take them out. So we just have to kind of talk about, you know, we balance the ovarian cancer risk with the menopause risks.

• 27:04Dr. Mary Claire Haver?

  Got it.

• 27:05Speaker 01

  And then we take into consideration, you know, your family history, your personal preferences, et cetera, when we decide. So again, like with all these pendulum swinging situations, we always say like, the pendulum has now swung to the middle where we center the patient and we call it like, you know, the shared decision-making, patient-centered care, where we present everything to you and then you let us know. So it's no longer, everyone get them out, everyone keep them forever.

• 27:30Dr. Mary Claire Haver?

  So let's get these women who are all listening, who suspect or know that they may have one of these diseases, endometriosis, fibroids, vulvar symptoms, you know, and she's, she's heading into menopause. What does she need to have prepared when she goes to her doctor?

• 27:43Speaker 01

  Yeah. So I always tell people, and I talk about in the book, the good preparation, because sometimes your doctor's visits are so short. Like, you've really got to optimize every minute of these visits. So literally write down for yourself, what is your list of things that you want to make sure you cover with your doctor? Like, and I always tell people, prioritize it from like, this is my biggest concern, my main issue, we've got to hit this hard, to the other stuff which are sort of secondary, but they are quality of life things that you want to discuss, or questions you're sort of curious about. So make your list for yourself. What am I experiencing? What are my concerns? What are my questions? And if you have specific treatments that you've been looking at, like hormone therapy or treatment for endometriosis, you know, what are your specific questions? And then you want to try

• 28:26Speaker 01

  And kind of not like kind of take over the conversation, but to guide the conversation to those things, you want to make sure by the end of your appointment that you're like, I feel satisfied. Like I was heard. My doctor is really addressing my concerns. And then if say there wasn't enough time, make another appointment, follow up, we're going to hit, you know, problem number two, we're going to get maybe an ultrasound in between, or maybe we'll try you on physical therapy, we'll try you on, you know, vulva vaginal estrogen, and then we'll see how you're doing in a month. So that's how I do it. I sort of say, let's kind of go over, you know, what are your concerns, like step by step, starting with most important, maybe we're going to do some work up, like, you know, doing imaging studies or other tests, blood tests, etc. And then let's try something, let's come back, let's see how you're doing. If you're thinking about surgery,

• 29:11Speaker 01

  rarely does somebody come in the first time you're meeting a doctor, and then say, you know, I'm ready to sign on the dotted line, I'm ready for surgery, like right this second. It's possible that people come in knowing that they are purposely there for that. But a lot of people are like, I just want to learn what five words are. Like, you know, what is endometriosis? I don't know what you're talking about. Like, I just need to understand the basics, and let's go to big surgical decisions like another day.

• 29:36Dr. Mary Claire Haver?

  Okay.

• 29:37Speaker 01

  So everyone's different, but just make sure that you feel like you have your list. And then sometimes if people feel like, you know, like I was joking about brain fog, but I have brain fog. If you feel like you might get overwhelmed, like bring a friend, like bring a spouse, a friend, somebody who exactly support person. And I love this when when people bring a support person and they chime in, they're like, actually, she wanted to make sure we asked about recovery from surgery or time off of work or whatever, because they'll pipe up and, you know, as we're wrapping up, they'll sort of say, actually, you know, before we go, I really wanted to make sure she got a chance to ask about blah. So sometimes you need that backup, just to kind of

• 30:11Dr. Mary Claire Haver?

  Well, and you're like overwhelmed and overstimulated.

• 30:13Speaker 01

  Yeah, there's so much.

• 30:14Dr. Mary Claire Haver?

  There's so much for you to process. So I love them when they have a support person. What should she not accept as an answer?

• 30:20Speaker 01

  There's only one thing, like I said, going back to, there's never just one answer, not for cancer, not for a heart attack. There's never just one thing. They should give you a range of options. And then just deal with it is never an option.

• 30:33Dr. Mary Claire Haver?

  Yeah, unmedicated suffering is never an option.

• 30:35Speaker 01

  Just like suffer is never an option. And kind of very Experiences of that, like just relax, just drink wine. Like sadly, there was some article about vulva vaginal pain where they they polled people about what they were told at some of these visits and like something like 20%. I can't remember the exact statistic had been told, like, why don't you just try drinking alcohol of like have a glass of wine and relax? I don't know. It's still being told to women. So no version of just deal with it or just relax is okay. There should be always a next step. I always tell people there should be always what's next, a test, a treatment option, a consult with another specialist. I refer people all the time to all sorts of specialists because I'm like, this is the end of what I know about this, but let me send you to a uro-gynecologist or to pelvic

• 31:18Speaker 01

  physical therapy or to a chronic pain specialist who can do a nerve block, you know, whatever you need, as long as you are helping the person figure out their path, meaning that it shouldn't be like, well, good luck. I don't know what to do with you.

• 31:30Dr. Mary Claire Haver?

  Yeah.

• 31:30Speaker 01

  A good doctor should partner with you in figuring out the next step, even if it's not them. Like, so it could be like, I don't do endometriosis surgery, but let me refer you to somebody who does. So we always tell people, start with your local doctor. They know you, hopefully they can kind of get everything started. And then most good doctors know their limits. Like, we are very clear about like, this is not something I do or feel comfortable with. Let me help you find someone who is. And if you can't, like if your local doctor isn't, that's where you try to crowdsource. Like, you know, you have your newsletter with your list of menopause specialists or for endometriosis, there's various support groups that have surgeon lists, same thing, you know, random stuff like actually for sterilizations, there's a child free Reddit that has a surgeon list. So there are a lot of these resources now for people who are like, you know, I don't know who to go to.

• 32:14Dr. Mary Claire Haver?

  The internet's become the water cooler.

• 32:16Speaker 01

  Yeah, it's great in that way. At least people don't feel so isolated and they're like, you know, I'm struggling with this. Someone might be like, hey, you know, I was too. And here are some doctors who I saw had a good experience with. They know what they're doing. For endometriosis and fibroids, just so listeners know, there is, you know, my specialty is called minimally invasive GYN surgery or MIGS. And those are both surgical specialists and also pain specialists. So we train in diagnosis of pain and coordination of care with other specialists. So in general, if you are Not getting answers from a local gynecologist. Look up MIGS near you. A lot of them live, quote unquote, at like academic medical centers. There are definitely some of us who are private practice, but you know, we are sprinkled all over the place and people drive from all over.

• 32:59Speaker 01

  I have patients come from all different states because they know I'm a specialist in endometriosis. So it sometimes requires some traveling, which is, you know, we, we feel bad that that's the case, but it's just the reality. And we are fortunate in America at least like that we can travel. I, when I would did the UK version of my book, I had to like edit it because I was like, yeah, go see like a third, fourth, fifth opinion, wherever you want to go. And they're like, well, in the NHS, you can't exactly do that. So, you know, at least in the US, we do have the, the ability to travel and try and find a specialist outside of our geographic area.

• 33:28Dr. Mary Claire Haver?

  Well, Dr. Tang, thank you so much for coming on UnPaused.

• 33:31Speaker 01

  We could go on forever.

• 33:32Dr. Mary Claire Haver?

  We could go on for hours.

• 33:32Speaker 01

  Oh, my God.

• 33:33Dr. Mary Claire Haver?

  We're gonna have you back. That's what we need to do.

• 33:34Speaker 01

  Oh, of course. Yeah, please.

• 33:37Dr. Mary Claire Haver?

  You can watch full episodes of this podcast on YouTube at Dr. Mary Claire. You can also find me on Instagram at Dr. Mary Claire and get honest and accurate information on health, fitness, and navigating midlife at thepauselife.com. UnPaused is presented by Odyssey in conjunction with Pod People. I'm your host, Dr. Mary Claire Haver.