The Testosterone Conversation with Dr. Kelly Casperson: Beyond Libido

In this episode of unPAUSED, Dr. Mary Claire Haver continues her conversation with Dr. Kelly Casperson, urologist, author, and host of the podcast "You Are Not Broken." Part 2 goes deep on testosterone therapy for women, the most misunderstood hormone in women's health, and covers the full range of what it actually does in the female body, why every woman will experience declining levels over time, and why there are still zero FDA approved testosterone products for women while men have more than a dozen. Dr. Casperson opens with the basics: ovaries make testosterone, the hormone pathway runs one way from cholesterol through progesterone to testosterone to estradiol, and women in normal cycling years carry four times more testosterone than estrogen in their bodies. She explains where testosterone receptors are found, which is everywhere from the brain to bone to muscle to the clitoris to the tear ducts, and why reducing testosterone in women to a libido drug misses the full picture entirely. Guest links: Kelly Casperson, MD https://kellycaspersonmd.com/ Kelly Casperson https://www.instagram.com/kellycaspersonmd/ (Instagram) Kelly Casperson https://www.youtube.com/@kellycaspersonmd (YouTube) You Are Not Broken https://podcasts.apple.com/us/podcast/you-are-not-broken/id1495710329 (Apple Podcasts) Books: “You Are Not Broken,” https://www.amazon.com/You-Are-Not-Broken-Should-ing/dp/1399813609/ by Kelly Casperson, MD "The Menopause Moment," https://www.amazon.com/Midlife-Matters-Stronger-Through-Menopause/dp/1399813633/ref=pd_bxgy_d_sccl_1/130-3437294-1658909?pd_rd_w=c4gj7&content-id=amzn1.sym.dcf559c6-d374-405e-a13e-133e852d81e1&pf_rd_p=dcf559c6-d374-405e-a13e-133e852d81e1&pf_rd_r=PGRAVXQPS7V1280H12D2&pd_rd_wg=B4VUY&pd_rd_r=ed485f65-4835-45bd-a1a7-e121f227d398&pd_rd_i=1399813633&psc=1 by Kelly Casperson, MD “The New Perimenopause,” https://thepauselife.com/pages/the-new-perimenopause-book by Dr. Mary Claire Haver “The New Menopause,” https://www.amazon.com/New-Menopause-Mary-Claire-Haver/dp/1785045547 by Dr. Mary Claire Haver "Sexual Behavior in the Human Female," https://archive.org/details/sexualbehaviorin0000alfr_p8y6? by Alfred Kinsey https://thepauselife.com/blogs/the-unpaused-podcast/the-testosterone-conversation-with-dr-kelly-casperson-beyond-libido

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

• 0:02Dr. Mary Claire Haver?

  In our last episode of UnPaused, Dr. Kelly Casperson and I began unpacking the myths and medical blind spots that shape women's sexual health. We covered desire, pain, orgasm, and the pathways that restore function and confidence. But we were just getting started. Dr. Casperson is a urologist, surgeon, podcaster, and author who has become one of the most trusted voices in women's sexual health. Through her podcast, You Are Not Broken, and her books, You Are Not Broken and The Menopause Moment, she has helped thousands of women understand their bodies with science instead

• 0:42Dr. Mary Claire Haver?

  of shame, clarity instead of confusion, and permission instead of fear. In this episode, we go deeper on testosterone, how it works in the female body, why it affects libido, energy, and brain health, and why every woman will experience declining levels over time. Yet, there are no FDA-approved testosterone products for women, while men have more than a dozen. We also explore the genital urinary syndrome of menopause, the underuse of vaginal estrogen, pelvic floor dysfunction, vaginismus, and the role of vibration and blood flow in restoring sexual function.

• 1:23Dr. Mary Claire Haver?

  And we examine medications, SSRIs, hormonal contraceptives, and GLP-1 therapies that can quietly interfere with sexual health. This episode is about more than hormones. It's about equity in medicine. It's about rewriting the sexual script for midlife and beyond. And it's about giving women the information they need to protect their pleasure, their health, and their autonomy. If you haven't listened to Part 1, start there. Now let's continue. 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.

• 2:06Dr. 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.

• 2:24Dr. 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.

• 2:45Dr. Mary Claire Haver?

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• 3:30Dr. Mary Claire Haver?

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• 3:58Dr. Mary Claire Haver?

  Talk about testosterone. This is most misunderstood hormone, I think, in women's sexual health.

• 4:04Speaker 01

  I think so.

• 4:05Dr. Mary Claire Haver?

  I learned absolutely nothing. I didn't even know it was a female hormone. I don't think I was aware.

• 4:10Speaker 01

  I didn't know it either.

• 4:10Dr. Mary Claire Haver?

  Well, I had polycystic ovarian syndrome. Testosterone was bad, right?

• 4:14Speaker 01

  In PCOS, too, they tend to blame testosterone, instead of saying the ovarian dysfunction because of the insulin resistance drives...

• 4:22Dr. Mary Claire Haver?

  I remember tracking my testosterone level, and it was always bad. Like, I only thought of testosterone as a bad hormone.

• 4:29Speaker 01

  It was the problem.

• 4:29Dr. Mary Claire Haver?

  For women. It was a problem because it was elevated. I mean, I knew I had ovarian dysfunction that was leading, but this high testosterone, like, we had to get it down, and that was how we treated it, to bring the testosterone down. It's a huge topic right now, and you have done so much education. You've taught me about it. You taught me how to prescribe it, you and Ishwish. You may be not scared of it, you know, but I want you to do your testosterone 101.

• 4:55Speaker 01

  Yeah.

• 4:56Dr. Mary Claire Haver?

  For our listeners.

• 4:57Speaker 01

  And I want to be very clear, I didn't learn this either. I didn't learn this in med school.

• 5:01Dr. Mary Claire Haver?

  As a urologist.

• 5:02Speaker 01

  I'm a urologist. I remember the gyns were taking care of the women. So I, we had to learn some things. So ovaries make testosterone. Like I always start there.

• 5:11Dr. Mary Claire Haver?

  Anywhere else in the body?

• 5:12Speaker 01

  Actually peripheral conversion and adrenals.

• 5:16Dr. Mary Claire Haver?

  All right. So start with the precursors. So like take me through the factory, start with cholesterol.

• 5:20Speaker 01

  Yep.

• 5:21Dr. Mary Claire Haver?

  And walk me through how our body makes testosterone and roughly where that happens.

• 5:24Speaker 01

  Yep. So roughly, roughly cholesterol converts into progesterone, testosterone goes to estradiol. You can't go backwards. People think, because you're cleaving carbons off, right? So you can't, people are like, ah, just give yourself enough estrogen and it'll convert to testosterone. You can't go backwards on the pathway. It's a one-way cutting carbons off pathway. So you need testosterone to actually make estrogen, but you can't just give somebody estrogen and expect a carbon to be added on it to get testosterone, right? So it's a one-way stream. And people, and then the another, I'm telling you all the myths at the same time. One myth will be like, I can't give you testosterone because you'll just convert it all to estrogen. And what's the point? No. In normal menstruating women without PCOS, without menopause,

• 6:08Speaker 01

  in our bodies, we have four times the amount of testosterone than estrogen. It's not all converting to estrogen. And so for people to be like, oh, well, testosterone just made you feel better because it all converted to estrogen. No, that's not how it works, even in healthy, young, normally cycling people. I actually did this with my labs. So you can, in somebody who's not in, you know, perimenopause, postmenopause, check it testosterone, check an estradiol. You have to convert the units because they're in nanograms per deciliter versus picograms per milliliter. You have to convert your units, but there's online calculators for that. And then you can actually look and be like, I do have more testosterone in my body than estrogen.

• 6:44Dr. Mary Claire Haver?

  And they're in different units because there's so much less estradiol.

• 6:47Speaker 01

  Because there's so much less estradiol.

• 6:49Dr. Mary Claire Haver?

  They have to use different units to actually measure it.

• 6:51Speaker 01

  Totally.

• 6:51Dr. Mary Claire Haver?

  So we cleave off a bunch of carbons and we go through this process. We have some in the periphery. So some in the ovaries, some in the periphery.

• 6:59Speaker 01

  Yep.

• 6:59Dr. Mary Claire Haver?

  Where are their testosterone receptors in the body?

• 7:01Speaker 01

  Everywhere. Everywhere. Brain, bone, muscle, clitoris, vulva, vagina, eye, tear ducts. And this is my, this is my new one because some of the zeitgeist on the internet says testosterone's only for libido. And furthermore, even if it does work for libido, we can't use it because it's not FDA approved. Okay, but what about the ophthalmologists who use testosterone for dry eyes?

• 7:28Speaker 01

  What? I'm sorry, what? The, the eye doctors know that, that tear ducts have testosterone receptors and so they give people drops of testosterone to help with tear duct production? That's off-label. That's not libido. Right? And so like this, this stereotype of this narrow window for testosterone like falls apart so quickly. And it's the classic like, absence of evidence does not mean evidence of absence. What do I mean by that? We stereotype testosterone as the male hormone. There is, and it's a generic medication. There's no money in the research. There's nothing-

• 8:04Dr. Mary Claire Haver?

  Just like estradiol.

• 8:05Speaker 01

  Yeah, just like, like, there's nothing happening. Furthermore, nobody's going to make any money from it, but we use absence of evidence to say it's pointless, you can't, it's dangerous.

• 8:15Dr. Mary Claire Haver?

  So what do we know? What does the evidence say clearly testosterone, giving a woman testosterone can be helpful for?

• 8:21Speaker 01

  Every single domain of sexual health. And I will say that because again, the stereotype is-

• 8:26Dr. Mary Claire Haver?

  And what are those domains?

• 8:27Speaker 01

  Just libido, desire, decreasing distress about sex, blood flow. So arousal helps with orgasm. The only domain of female sexual health that it doesn't help with is in the domain of pain. So if a woman has pain, it doesn't always help with that. But sometimes people will still use a little bit of compounded testosterone on the vulva for vulvodynia. So even that, there is a role for it. But it irritates me when people are like, it's only for libido. Well, it helps people orgasm more, helps arousal, decreases people's distress over their sexual health. None of that's libido. Right. And so that's just pelvic health. So now we have blood flow to the clitoris,

• 9:06Speaker 01

  moisture, orgasm, desire. That's a brain one because testosterone helps nerves. It helps the myelin sheaths. It helps glial cells. Now I'm dating myself as a neuroscience undergrad. Glial cells are the supporting cells of the neurons. Testosterones play a role in supporting glial cells. Testosterone works in the brain. Why does it help libido? Because it helps the dopamine pathway, right? And people say it only helps libido. Oh, is there a libido corner to your brain, that one square centimeter on the left that like the testosterone goes to? You put testosterone in a woman, put her in an FMRI, her whole brain lights up. There are receptors everywhere for this. The other interesting thing about testosterone is we can study blood pressure meds in men

• 9:50Speaker 01

  and then give them to women. We can study statins in men and give them to women. We can study antidepressants and sleep meds in men and then give them to women. Perfectly fine. We're not studying women. Worked in men, give them to women.

• 10:00Dr. Mary Claire Haver?

  Do it all the time.

• 10:02Speaker 01

  But you know, these decades of data on the safety and efficacy of testosterone in men, we can't use that in women. To go even further, what if we had five decades of safety data in women at 10 times the physiologic testosterone dose? What if we had that? Oh, we do. We have that. It's called trans men data. They're not dying because we gave them testosterone.

• 10:25Dr. Mary Claire Haver?

  At 10 times the dose.

• 10:26Speaker 01

  Times the female dose because they want it, because it's a quality of life issue. And doctors say, yes, your quality of life is worth treating. Let's give you 10 times the dose because you want it. 50 year, we have a 30 year paper and a 50 year paper. No increased risk of death, cancer, breast cancer, anything because of testosterone. And like, what other drug do you study at 10 times the dose for 50 years and then tell women, sorry, you can't have your dose because it might be unsafe?

• 10:54Dr. Mary Claire Haver?

  Where does testosterone stand right now with the Food and Drug Administration? What's for men? What's for women? What do we have?

• 11:01Speaker 01

  About 20% of men will have low testosterone, probably more have it than are diagnosed with it.

• 11:06Dr. Mary Claire Haver?

  What does that mean?

• 11:07Speaker 01

  Low testosterone is basically your body's not producing testosterone. Might be from multiple reasons. Maybe you have a health condition, maybe you're just, again, you're living longer than your testosterone production, the testicles. Some men are born with low testosterone. So a couple of different reasons. What's interesting though, is male testosterone is FDA approved for primary hypogonadism. What does that mean? Your testicles never made enough testosterone in the first place. Most men take testosterone off-label. Really? Because they have secondary hypogonadism. Because it's because it's from age, or it's from a medical condition, or cancer treatment is for something else. Is this menopause or andropause? People will argue.

• 11:52Speaker 01

  People will say it's more common as we we collect metabolic dysfunction, obesity, poor sleep, alcohol, lack of exercise. Right? So we kind of collect comorbidities as we age and men's testosterone will go down. So some people will say there's no such thing as andropause. And some people say, yes, it decreased by 2% a year. Now, what happens in women? Does it fall off a cliff like menopause? No, it does not fall off a cliff, which is used again. It's used against women, right? They're like, testosterone doesn't fall off a cliff in menopause. So this is why you can't have testosterone. It's like, that makes no sense. Testosterone naturally starts decreasing after our 20s. We don't really know why. Again, nothing's been studied. But that's a used against women. They're like, it doesn't fall off a cliff with menopause.

• 12:35Speaker 01

  What's interesting is normal physiology, testosterone, slow, linear decline after age 20. No testosterone is FDA-approved for low libido or hypoactive sexual desire disorder. But the guidelines say it's for post-menopausal women. Why did we draw a line in the sand? I don't know. If there's no cliff? No idea. One possible idea is because they're worried that testosterone is teratogenic. And can you be trusted to take testosterone? Oh, my God. And not get pregnant? Because you're a woman and can you be trusted to do that? So that's one theory of like, why do we draw a line in the sand with menopause? If testosterone doesn't fall off a cliff with menopause?

• 13:19Speaker 01

  Teratogenic, we're worried about the fetus more than we're worried about the female quality of life. Right, always. Yeah, always. But, okay, fair testosterone's category, pregnancy category X. And it should be. Fair. But we're just

• 13:31Dr. Mary Claire Haver?

  For a female fetus.

• 13:32Speaker 01

  But we're just replacing your testosterone to how it was in your twenties when you would have gotten pregnant anyways.

• 13:37Dr. Mary Claire Haver?

  Okay, so what do we have on the market?

• 13:40Speaker 01

  Okay, so right now in America, there's zero FDA approved testosterone products for females. Let's just note

• 13:46Dr. Mary Claire Haver?

  Why?

• 13:47Speaker 01

  Because if you don't study it, and then you do go up in front of the FDA, but it happens to be 2004. And what happened in 2002?

• 13:56Dr. Mary Claire Haver?

  The Women's Health Initiative.

• 13:56Speaker 01

  The Women's Health Initiative. And that made hormones dangerous. So now a company, the Intrinsic Patch, went up to the FDA in 2004 and said, we've got a patch, we've got safety data, we've got efficacy data. What does the FDA need? Safety data, efficacy data. They said, we don't have enough safety data yet. We need years more safety data before we can FDA approve this. Because the Women's Health Initiative just happened. We don't know what hormones do to women, right? Keep in mind, men's testosterone got FDA approved with six month safety data. Intrinsic Patch had years of safety data. Not enough safety data. So the bar is higher for a woman to get an FDA approved product

• 14:37Speaker 01

  than a man. See also what Addi, Flavon Srinath has had to do to get FDA approved versus what Viagra has to do. There is a gender disparity in the FDA approval, in the FDA approval process.

• 14:49Dr. Mary Claire Haver?

  They felt that there was such an unmet need of men needing to have erections and have a high quality of their sex life that they fast-tracked Viagra.

• 14:58Speaker 01

  The fastest, most successful pharmaceutical sales that had ever happened ever before. And nobody went around saying, oh, we can't profit off of helping men. Oh, men just need more therapy. Like, we don't, Addi, or testosterone, we're like, recent menopause conference for sexual health. So they said, women don't need testosterone, they need better body image.

• 15:22Dr. Mary Claire Haver?

  Nice.

• 15:23Speaker 01

  So it's like, when we have products, the bias against women being biologic and deserving of medical treatment is so much different than what a man has.

• 15:36Dr. Mary Claire Haver?

  And you saw it. You're on the front, you know, you treat men and women for sexual dysfunction.

• 15:41Speaker 01

  Yeah, so 20% of men will have low testosterone. They have about a dozen products. Would you like a pill? Would you like injections? Would you like a gel? We got pellets. Men's testosterone pellets are FDA approved.

• 15:51Dr. Mary Claire Haver?

  Mm-hmm.

• 15:52Speaker 01

  What does that mean? Insurance will cover it. That's huge, right? So 20% of men will have low testosterone, about 12 products. 100% of women will have low testosterone, zero products. Like, to me, I'm like, make it make sense.

• 16:07Dr. Mary Claire Haver?

  What is testosterone not fix?

• 16:10Speaker 01

  I'd say, relationship problems.

• 16:12Dr. Mary Claire Haver?

  Yeah. Yeah, that's one of the, when I'm screening our patients, I'm like, how is your relationship? Well, I hate him. I'm like, okay.

• 16:19Speaker 01

  Yeah.

• 16:19Dr. Mary Claire Haver?

  That, you know, this conversation needs to go a different direction because offering you testosterone or Addy or Valisi is not going to fix a relationship issue. That's really good.

• 16:29Speaker 01

  And you can even break into it more. You can be like, is the relationship issue because of the sex? And then it's like, okay, well, that might be different than the relationship issue is because you're an asshole, right? So it's like, is it a sex-related relationship issue? Okay, well, let's treat the sex problem. Maybe that will help the relationship issue. Versus, he's just a jerk, he's never around, he blames you for everything. No medication's going to make that better.

• 16:51Dr. Mary Claire Haver?

  Right. So we've established that testosterone helps with blood flow, so it helps with arousal. It helps locally with the vestibule. So that's the tissue. Where is the vestibule?

• 17:04Speaker 01

  Vestibule is basically the entrance of the vagina.

• 17:07Dr. Mary Claire Haver?

  Okay.

• 17:07Speaker 01

  So the vulva is what you look at. If you were to open up the labia majora and you're headed into the vagina, the vestibule, you must pass, it's like the church, you must pass through the vestibule.

• 17:17Dr. Mary Claire Haver?

  It helps with desire, which is in the brain.

• 17:19Speaker 01

  Helps with dry eyes.

• 17:21Dr. Mary Claire Haver?

  We have great studies in postmenopausal women showing it helps with dry eyes. My patients say it helps with energy, but man, do we get pushed back when we talk about this.

• 17:31Speaker 01

  Oh, my God, let's talk about that. So where does energy come from? Metabolic function? Mitochondria, right? Mitochondria is super hot and sexy right now. Guess what helps mitochondria? Testosterone and estrogen, right? Dopamine.

• 17:44Speaker 01

  The pursuit of something. Testosterone helps drive the dopamine pathway. So do we have a physiologic reason that hormones help energy? Yes, helps neurons function, helps mitochondria function, helps the dopamine pathway, helps serotonin pathway. Louise Newsom's group showed that getting women on estrogen, some of them were able to get off their antidepressants. You add testosterone, much bigger amount were able to get off their antidepressants.

• 18:12Dr. Mary Claire Haver?

  On the combination.

• 18:12Speaker 01

  Estrogen and testosterone. Why? Serotonin pathway. That's the, that's the theory. Right? So I think of testosterone not as so much a libido drug, which what is libido? Libido is the pursuit of. It's the motivation of something. Testosterone is not just a libido medication. It's a motivation medication. Libido being one part of motivation. Saw a patient, she had surgical menopause, struggled for years, finally got on estrogen.

• 18:41Dr. Mary Claire Haver?

  Meaning her ovaries were surgically removed.

• 18:43Speaker 01

  Ovaries were surgically removed. This is a physician. She was a physician, had emergency surgical menopause because they were worried it was a mass. It was not, she was fine. Wasn't put on anything. She was like 50 or 51. Boom, surgical menopause. She had to quit her job because her side effects from being immediately castrated without help were so profound.

• 19:03Dr. Mary Claire Haver?

  Stop for a second. When we remove the testicles in men, when we castrate men for medical reasons, I'm assuming for medical reasons.

• 19:09Speaker 01

  Piscocer is the most common, if not trauma.

• 19:12Dr. Mary Claire Haver?

  What would be the post-op? Like, do you talk about what's going to happen? Their sexual function? Like, like what is standard counseling?

• 19:18Speaker 01

  It would be malpractice to not do it. If there was a urologist who removed testicles, who didn't talk about testosterone replacement, that's malpractice until proven otherwise.

• 19:27Dr. Mary Claire Haver?

  Okay.

• 19:28Speaker 01

  Like, let that sink in. Also, very interesting, there's no female word for castration. Castration is by definition, the removal of a male mammal's gonads. So that's also very weird of like, how new surgical menopause is, that we don't actually have a word for removing ovaries.

• 19:45Dr. Mary Claire Haver?

  Oovrectomy.

• 19:46Speaker 01

  Oovrectomy, yeah, but like as far as a layperson, it's like, we call it castration, but it actually means male mammal. So she gets on estrogen. She comes to see me. She's like, let's try testosterone. Okay, try testosterone. And so we do a telemed follow up. And she turns her laptop and she's like, I want you to see what's out this window. Great. What's that? That's my testosterone deck. Your testosterone deck? Tell me about your testosterone deck. And she's like, I have been planning on a deck for years. Started on testosterone. I have motivation to finish a product. That's the energy. That's the drive towards. So yes, it does help libido because that's a motivation towards something. It also helps you get your job done and do things.

• 20:31Speaker 01

  And the amount of people that come to me, I actually did a very informal social media poll. I'm like, hey, any woman who started a business since starting on testosterone, just let me know. I'm up to like eight now and I haven't asked in a while. Motivation to do something. Why? It works in the brain. Dopamine pathway, serotonin pathway, mitochondria, nerves. We know this and we know in men, let's go even farther on how little-

• 20:56Dr. Mary Claire Haver?

  What does the male data say about things outside of sexual function? What do we know about men?

• 21:00Speaker 01

  Men with low testosterone have higher risk of depression, have higher risk of dementia. Also correlated, we think with Parkinson's, multiple sclerosis, all nerve function issues, right? Higher risk of diabetes. So why is it that we can research all these things in men and apply them to women? But we completely ignore the role of testosterone outside of sex in men. And we're like, we don't know in women, haven't studied it. But testosterone helps the brain. It helps neurons. It helps them function. In a world where in Australia now, the number one killer of women is dementia. And America would be headed that way, but we're pretty good at dying of other things as well. But the UK is right behind Australia.

• 21:42Speaker 01

  In a world where it's incurable, no great treatment, any number one killer? Are we not curious about things that help support neurons? It's absolutely insane to me.

• 21:54Dr. Mary Claire Haver?

  What else about testosterone?

• 21:55Speaker 01

  So there's some really interesting data and this is pellet data. And this is Dr. Rebecca Glazer's work. So what she did is she has many, many people on testosterone pellets. And she compared their rate of breast cancer with the rate of breast cancer in the SEER database or the general population. And it looks as if- There's about 30% decreased risk of breast cancer in women taking the testosterone. Now, the critics will say this is not a randomized placebo-controlled trial. They will say it's pellet data. The critics will pull this apart. I say, if there is a hint and a whisper of anything that could remotely decrease the risk of breast cancer in women, why aren't we pouring money into looking at this?

• 22:39Speaker 01

  When we get a medication that decreases our risk of breast cancer by 5%, it will have a Super Bowl ad because 5% is meaningful. Her data suggests testosterone is, might be more than that.

• 22:49Dr. Mary Claire Haver?

  More than that.

• 22:50Speaker 01

  And we know, again, is it physiologically plausible? Yes, testosterone appears to be breast protective. In addition, the oncology community is looking at THERMS, testosterone receptor modulators.

• 23:02Dr. Mary Claire Haver?

  THERMS for estrogen?

• 23:03Speaker 01

  Oh, yeah. Terms for testosterone. They're looking at THERMS, so they're actually creating medications to sit in the testosterone receptors that seem to help breast cancer. In fact, before we had modern breast cancer treatment, we gave women testosterone. So for me, when people say, when they dismiss this data, to me, I'm like, why aren't we profoundly curious with how afraid we are of breast cancer and how miraculous something would be that decreased our risk? Why is there silence on this?

• 23:31Dr. Mary Claire Haver?

  If I gave you, and this is one of my favorite questions to ask the scientists on this pod, if I gave you a blank check for research, what's your study?

• 23:40Speaker 01

  Can I have infinite time?

• 23:42Dr. Mary Claire Haver?

  Yes, anything you want.

• 23:43Speaker 01

  All right.

• 23:43Dr. Mary Claire Haver?

  Size of the limit.

• 23:44Speaker 01

  I want.

• 23:44Dr. Mary Claire Haver?

  I am Melinda Gates right now.

• 23:45Speaker 01

  Perfect. I want a randomized placebo-controlled trial.

• 23:49Dr. Mary Claire Haver?

  Okay.

• 23:50Speaker 01

  Looking at dementia prevention with testosterone.

• 23:53Dr. Mary Claire Haver?

  Oh, damn.

• 23:53Speaker 01

  I'm putting together the puzzle pieces. We've got basic science. We've got physiologic plausibility. We've got male data. We've got all these pieces. Testosterone might be dementia prevention. It might be. And people will poo-poo that because we don't have this damn 20-year, billion-dollar study on a generic drug that nobody's going to make profit off of.

• 24:15Dr. Mary Claire Haver?

  Right.

• 24:15Speaker 01

  Right? And so it's like, when it's the number one killer in Australia, why aren't we looking at everything that could be neuroprotective? But until we get that study that I want the billion dollars for.

• 24:26Dr. Mary Claire Haver?

  And until we value women's cognition as they age.

• 24:28Speaker 01

  Yes. I tell women, on that horrible day that you were diagnosed with dementia, on that horrible Tuesday, it started 20 years ago. We have to do something now. To try to move the needle 20 years from now. But I believe, I'm like, if you wait for that study, you're gonna be dead. We have to use the data we have now to make the best decisions we have now. And if testosterone is moving the needle even a little bit on breast cancer and dementia, why aren't we pounding down the doors studying this?

• 24:58Dr. Mary Claire Haver?

  Why aren't we?

• 24:59Speaker 01

  There's no money in it. You can't patent it. There's no money in women's research right now.

• 25:03Dr. Mary Claire Haver?

  No.

• 25:04Speaker 01

  And truthfully-

• 25:04Dr. Mary Claire Haver?

  In the US.

• 25:05Speaker 01

  In the US-

• 25:06Dr. Mary Claire Haver?

  We're actually seeing studies come out of other countries, but-

• 25:08Speaker 01

  What it costs to do a 20-year randomized placebo-controlled trial, I mean, look at the WHO, right?

• 25:14Dr. Mary Claire Haver?

  One billion.

• 25:14Speaker 01

  Billion dollars, which will never be replicated. And so to me, I'm like, that would be my dream study. It's never gonna happen. And even if, even if we started it now, we're not gonna know for 25 years.

• 25:25Dr. Mary Claire Haver?

  I don't know.

• 25:26Speaker 01

  We have to make the best-

• 25:27Dr. Mary Claire Haver?

  We can measure the plaques. I think we could have enough markers for people who are at risk or start with like the high-risk people with APo-

• 25:34Speaker 01

  Well, so we, I mean, we have a pretty strong argument with April 4E that they should strongly consider hormones.

• 25:39Dr. Mary Claire Haver?

  Yeah.

• 25:40Speaker 01

  Like, we know that. And there's also, there's cadaver data, because I can't cut open your brain and look at testosterone in it, right? And your serum testosterone doesn't correlate with your brain levels.

• 25:48Dr. Mary Claire Haver?

  Whoa.

• 25:48Speaker 01

  So that's a problem, too, to study it. We have cadaver studies. Cadavers with a higher level of testosterone in their brain had less dementia. So it's like, we gotta put together all the pieces to say, we've got this study, we've got this study, we know how it works on nerves, we know how it helps protect myelin sheaths, all of this, and we have to just keep drowning out the naysayers who say it's only for libido, and even that is not that important.

• 26:20Dr. Mary Claire Haver?

  How do you counsel women who come in and say, I just don't feel like myself anymore? Which is now, thank God for that paper.

• 26:27Speaker 01

  Thank God for that paper.

• 26:28Dr. Mary Claire Haver?

  Recognized complaint that is actually medical and not psychological.

• 26:32Speaker 01

  NFLM.

• 26:33Dr. Mary Claire Haver?

  NFLM. And suspect that maybe testosterone is part of this picture. Like, like, how's you, you know, I come in, I'm 42, I'm still having regular periods, and I'm like, Dr. Kelly, I just, I don't, I don't know what's wrong. I don't feel like myself anymore. Where do you start?

• 26:48Speaker 01

  I get the story first. What's going on? What do you mean by that? Because that might, that's a very different thing for different people.

• 26:53Dr. Mary Claire Haver?

  Yeah.

• 26:54Speaker 01

  Right?

• 26:54Dr. Mary Claire Haver?

  They, they get kind of seven domains of what that might be.

• 26:56Speaker 01

  Yeah, so what, what do you mean? What are your goals? Like, I hear the story, and then we're gonna check some labs. How's your thyroid? You know, do we have metabolic dysfunction going on? Was your blood pressure-

• 27:04Dr. Mary Claire Haver?

  What are you checking? What are your labs?

• 27:06Speaker 01

  I check- Thyroid, full thyroid panel, A1C. I do fasting insulin now in everybody. Complete metabolic profile. I do estrogen, testosterone, sex hormone binding globulin.

• 27:18Dr. Mary Claire Haver?

  Feritin, do you do iron studies?

• 27:20Speaker 01

  Yep. Yep. I do those. I've been checking, oh my Lord, I just had a huge win with vitamin B12 the other day.

• 27:26Dr. Mary Claire Haver?

  Oh wow. Vitamin D.

• 27:28Speaker 01

  Vitamin D, vitamin B12. I've been getting the omega check, just to check people's omega 3 levels because it's nice to look at that.

• 27:34Dr. Mary Claire Haver?

  Are you doing the ratio?

• 27:35Speaker 01

  Quest has like an omega check panel.

• 27:37Dr. Mary Claire Haver?

  Okay.

• 27:38Speaker 01

  And so it checks it all. So I had a woman come in, side note, vitamin B12. Woman came in, really bad chronic neck pain. She banged her head, basically, was doing all the right things. CMPT, seeing a massage, seeing acupuncture, stretching, all the things. And she came to me and she's like, I'm going to quit my job because, very high functioning person, I'm going to quit my job because my pain is so bad and nothing's helping. And so we tweaked her estrogen a little bit. I checked my panel. B12 was in the toilet, like in the toilet. Reflected her B12. She came in, literally adjusted her estrogen, got her B12 up. She came in, she's like, I have zero pain. I'm like, zero pain? I'm like, six weeks ago, you were going to quit your job because of pain. And she's like,

• 28:22Speaker 01

  well, now I want to quit my job just to tell everybody that they should, you know, get help for and check some things. And so she went back, she's a feisty East Coaster. So she went back to her PCP and was basically like, what the hell? Why aren't we looking into this? Again, what are we talking about? Women can have biologic reasons to their health issues. I adjusted a woman's hormones. I got her to stop vaping and got her off her ADHD meds. I know we can't do that in everybody, but it's, it was like this light switch in me of like, what if women being miserable and complaining and having these issues is not just how things are? What if we can try things and adjust things and they feel better?

• 29:03Dr. Mary Claire Haver?

  That is the best part of my practice.

• 29:06Speaker 01

  I gave it a yeah.

• 29:07Dr. Mary Claire Haver?

  A woman in that 15 minute box and the way I was forced to practice would not allow me to investigate these things. And now that I can like have exploded what I can do for a woman. It is like giving women their lives back.

• 29:21Speaker 01

  Yeah.

• 29:21Dr. Mary Claire Haver?

  They're just like getting back to who they were.

• 29:24Speaker 01

  Yeah.

• 29:24Dr. Mary Claire Haver?

  And so grateful. And now they're, you know, they are quitting jobs because they didn't like the damn job because they've got something else in mind, or they're getting a divorce, or are really like diving back into their, you know, relationships and, you know, but they're like literally building these lives that they felt that they were meant to live and they couldn't live. They were limping along.

• 29:43Speaker 01

  Yeah. What if women feeling miserable isn't a default?

• 29:45Dr. Mary Claire Haver?

  And it's not just always hormones. I mean, no one checked a vitamin D, no one checked a ferritin, no one checked all these things, you know? And it's just the most beautiful medicine I've ever practiced.

• 29:56Speaker 01

  I gave up surgery for it. Like

• 29:58Dr. Mary Claire Haver?

  Same.

• 29:58Speaker 01

  Getting women to feel like they're themselves again is the best job on the planet. Hands down, the best job. I say, I help strong, smart women go out and change the world.

• 30:09Dr. Mary Claire Haver?

  They change the world.

• 30:10Speaker 01

  They go change the world.

• 30:11Dr. Mary Claire Haver?

  Yeah, yeah. They are literally setting the world on fire. Once you give them their lives back.

• 30:15Speaker 01

  I was doing a book club with a CEO in Seattle and she's like, I think menopausal women are going to take over the world. And I'm like, that's fantastic. They will never take over the world when they feel shitty. We must get them feeling better in order to get them out doing things. So when people, when they poo poo testosterone and they're like, we don't have any data to say it helps energy or motivation. I'm like, first of all, we have a physiologic, biologic plausible reason that it happens. Like it's just basic physiology. You want to study it? Fine. That's your problem. But we have basic physiology of why this helps. There is nothing more satisfying than a woman saying, I feel like myself again. Why don't we try it? So you answer your question of how do you counsel a woman when

• 30:59Speaker 01

  they're like, and I'm not feeling like myself. Should I try testosterone or not? I say, okay, what are the things I need to think about to answer that question? Is it cheap? Yeah, it's cheap. It's a cheap. I'm not asking you to remortgage your house to try something. Is it safe? Yeah, we've got decades of safety data at 10 times the dose, female dose, very safe. Okay, it's cheap. It's safe. At normal physiologic doses, do we have a big risk of side effects?

• 31:23Dr. Mary Claire Haver?

  No.

• 31:23Speaker 01

  We don't. Doesn't work in everybody. No, it doesn't work in everybody. But those are my bar. I'm like, hey, it's cheap, it's safe. Women will know if it helps them or not. And I usually say, just try it. You'll know. After about four months or so, maybe we have to go up on the dose, maybe we don't. You'll know if it's worth it or not. So like, the bar to try it is so low that it's like, you only have yourself to gain. Has anything else been working?

• 31:51Dr. Mary Claire Haver?

  But there's, there's so many women out there. Like, if only 4% of women right now, or at least the latest data that we had from 2023, are on FDA-approved estrogen therapy.

• 32:02Speaker 01

  Yep.

• 32:03Dr. Mary Claire Haver?

  You know, plus or minus a progestin. What percent, do we even have any idea of how many of those women are also being offered testosterone?

• 32:11Speaker 01

  And I mean, I need receipts. Like, I'm like, publicly, I'm like, I need receipts.

• 32:15Dr. Mary Claire Haver?

  98% of women will never have the opportunity to even explore this.

• 32:19Speaker 01

  That's right. So FDA approval will have a huge validation. But here's the problem. Pellets? Can't measure those. Private company. Compounded testosterone? Can't measure it. Individualized. To the best data, and this is like chasing paper references, like the best of our knowledge, as many women in America are on testosterone as men.

• 32:42Dr. Mary Claire Haver?

  Wow.

• 32:43Speaker 01

  Now, that's-

• 32:44Dr. Mary Claire Haver?

  When you add in compounded and pellets.

• 32:46Speaker 01

  You gotta add in the, so hormones are the top five compounded things, right? So we gotta add in compounded, we've gotta add in the pellets, which is kind of guessing based upon profitability data. They're not gonna tell us.

• 32:57Dr. Mary Claire Haver?

  They don't tell us anything.

• 32:58Speaker 01

  They don't want any competition and say, this is a huge market. It's a huge market.

• 33:01Dr. Mary Claire Haver?

  Billions.

• 33:02Speaker 01

  100% of women will have low testosterone. Does that mean everybody's gonna be helped by taking testosterone? No.

• 33:08Dr. Mary Claire Haver?

  No.

• 33:09Speaker 01

  But shouldn't you have the opportunity? So, to me, I'm like, it's such low-hanging fruit to me. But I realize I know a lot at this point. Like, I know the male data. I know the female data. It's just so obvious to me, but I'm fully aware it's not obvious to everybody else yet.

• 33:25Dr. Mary Claire Haver?

  Right. We weren't taught. The vast majority. Me, OB-GYN, supposed to be the women's sexual health person.

• 33:31Speaker 01

  Yep.

• 33:31Dr. Mary Claire Haver?

  That zero sex med.

• 33:32Speaker 01

  I got a message today on Instagram. I asked my doctor for testosterone and they said, what? Do you wanna grow whiskers? And what do you want to grow whiskers? If that's the response your doctor gives you to that question, when ovaries make testosterone, we have a big learning gap. Big learning gap in the medical community.

• 33:50Dr. Mary Claire Haver?

  And you brought some testosterone with you?

• 33:52Speaker 01

  I brought some testosterone. So this is just one type of testosterone. This is a FDA approved male testem or generic testosterone gel 1%. A male dose testosterone, this is one a day. So this comes in.

• 34:07Dr. Mary Claire Haver?

  That whole.

• 34:07Speaker 01

  This whole day. It's a lot of product.

• 34:09Dr. Mary Claire Haver?

  Yeah.

• 34:09Speaker 01

  Right? So this is one day for a man and he's usually going to put it on his upper chest, something like that.

• 34:15Dr. Mary Claire Haver?

  What does safe evidence-based prescription look like for a woman?

• 34:19Speaker 01

  So you have to take this packet and you have to say, use a one tenth of this. How are you going to do it? Right? So you can draw it up in a syringe. You can get some syringes off of Amazon. You can kind of spitball it, right? I have some, I have some women who are, they like being very accurate. They actually weigh it out. Or you can say, you know what? 10 days from now, make this last until 10 days from now. So you can kind of spitball it. I spitball it. But because we do not have an FDA approved product, we're asking women to bootstrap, pay out of their own pocket. Insurance doesn't cover things that aren't FDA approved. And they have to microdose. It's completely inaccurate, very inaccurate. Or they're pushed to some people who only give you one type of testosterone. That tends to be pellets because that's the most profitable type of testosterone.

• 35:02Dr. Mary Claire Haver?

  Why don't you use pellets?

• 35:04Speaker 01

  Pellets are the highest dose. Stereotypically it tends to be the highest dose.

• 35:07Dr. Mary Claire Haver?

  Yeah, I've never had a patient who came to me after, within three months of a pellet insertion, who was in a female physiologic range.

• 35:15Speaker 01

  Yeah, it's high. My analogy is if you're at sea level and you go to Everest Base Camp that day, it can feel kind of crappy. The body doesn't like to be shocked. Hair follicles don't like to be shocked. We actually have pretty decent data saying testosterone doesn't cause more hair loss than placebo. I believe that data. I also believe women who say, I tried testosterone and I lost hair. I believe them. So how do I reconcile these two different things? Do not go from sea level to Everest Base Camp. It shocks the hair. So it's not so much the testosterone as the drastic change, right? You'll lose hair with rapid weight loss, thyroid storm,

• 35:55Dr. Mary Claire Haver?

  Having a baby.

• 35:55Speaker 01

  Surgical menopause, having a baby. It's all a shock to the body. So I think that's, and again, that's why pellets give testosterone a bad name because women are, don't make a woman lose her hair. That's not good. That's, it's very bad optics. So it tends to be the highest dose. You can't take it out. You have to wait for it to wear off. It also tends to be the most expensive dose. So what I say, and there are women who are very happy on pellets. They do not want their pellets taken away. So there's a camp that's like, ban pellets. And I'm like, well, we have FDA approved male pellets. Maybe we could actually

• 36:26Dr. Mary Claire Haver?

  I don't want to demonize. It's a method of delivery to the system.

• 36:29Speaker 01

  Yes.

• 36:30Dr. Mary Claire Haver?

  To, you know, of putting something in your body. We have injections. We have pills. We have pellets. We have, you know, creams and gels, but the problem I think is with marketing around a certain company or a couple of companies. I have someone in Houston who I think practices very responsible medicine, who has the pellets compounded herself and really closely monitors the dose and her patients like it. And she doesn't super physiologically dose and all as well. And she offers them all the options. You know, they can do the T stem or the pump or whatever. But, you know, so I think there's a responsible way. I don't want to demonize a pellet.

• 37:04Speaker 01

  I agree.

• 37:05Dr. Mary Claire Haver?

  But there is some questionable ethics around, at least for us.

• 37:09Speaker 01

  If it's the only item on the menu, that's concerning.

• 37:12Dr. Mary Claire Haver?

  Yeah.

• 37:12Speaker 01

  And if it's your first menu item, right? So what I say is earn your pellet. What does that mean? That you tolerate a higher dose, that you've been on it for a while? You don't have side effects at a higher dose. Now maybe I don't want to do this daily. I want something more sustained. Okay. You've earned your pellet, right? Versus like, I had no idea there was any other options.

• 37:30Dr. Mary Claire Haver?

  Yeah. And I see that. Cause I see the post pellet people who did not have a good outcome.

• 37:34Speaker 01

  Yeah.

• 37:35Dr. Mary Claire Haver?

  All right. So now you, you've found a doctor who is happy to write you a prescription. They're comfortable doing it. They have education. They, they've counseled you about the side effects. So you get this little tube. Where do you put it? Do you eat it? Do you put it on your vagina? Do you?

• 37:49Speaker 01

  So this goes on. If any place you put testosterone can have a side effect of hair growth.

• 37:54Dr. Mary Claire Haver?

  Mm hmm.

• 37:55Speaker 01

  Right? So some people do forearms.

• 37:57Dr. Mary Claire Haver?

  I do forearms.

• 37:57Speaker 01

  Yep. So some people do forearms. Fine. Just know that hair growth might be a side effect of that. Quickly checks wrist. Um, I do outer lateral thigh.

• 38:05Dr. Mary Claire Haver?

  Mm hmm.

• 38:06Speaker 01

  Why? It's easy to reach, bending over to do my calf, that's just farther to go. So I like lateral thigh. Lateral thigh has less hair follicles than inner thigh. You might get more hair if you do inner thigh. There's a subset of people who've been taught to apply it to their genitals. First of all, with a gel, that can sting. Yeah, alcohol based. Yeah, alcohol based. Don't do that. The genitals are very interesting. A very original male testosterone patch was for the scrotum. Ouch, who wants to take that patch off? Ooh. But why? Because the genitals have a much higher density of testosterone receptors. So it was a very good way to push testosterone into the male body, using a patch on the scrotum.

• 38:46Speaker 01

  So that's the theory, but no, if you take a systemic dose testosterone and you put it on your genitals, check your levels, you might have a much higher systemic level than if you're going to put it on your skin. Oh, wow. So I don't advocate for genital app. Plus, I'm like, why do you need to touch your labia to do your daily hormone dosing? You don't have to. Now, you can compound a lower dose, usually with estradiol for the vulva. That tends to be for a provoked vulvodynia, a very specific vulvar pain issue because vulvas have testosterone receptors. Clitoris has testosterone receptors. I would love to see more research looking at clitoral phimosis prevention. What is clitoral phimosis?

• 39:28Speaker 01

  Right. So if you think of a penis and you think of the foreskin of the penis for uncircumcised people, it's the skin that covers the glands. Clitoris has the same thing. We call it the clitoral hood. And that can kind of get stuck. Adhesions. Adhesions. Little baby scars. Little baby scars because of low hormones. So things we don't have data on. If we just start women in perimenopause on hormones, will they have less vulvar atrophy? We don't know. We've never studied it. If you have clitoral adhesions, can we reverse that reliably with a testosterone cream? We don't know. We haven't studied it, right? And only to make people realize there's so many unanswered questions that the field really is wide open. Tends to be a funding problem, but Rachel Rubin did the research on clitoral adhesions.

• 40:12Speaker 01

  It's actually pretty common, which why, you know, if you have sexual health issues, I see this all the time on, on the internet is like, get a good pelvic exam. Does somebody know what they're looking at who can give you a good pelvic exam? Because pain down there.

• 40:27Dr. Mary Claire Haver?

  Is never normal.

• 40:28Speaker 01

  No, it's never normal. And it could be like 30 different things. Where does it hurt? Right? Do you have diminished orgasm because of low hormones? Do you have diminished orgasm because you have severe clitoral phimosis that nobody knows about? Right? So I love telemedicine. I think telemedicine is here to stay. I don't think telemedicine will ever replace a good pelvic physical exam.

• 40:48Dr. Mary Claire Haver?

  Yeah.

• 40:57Dr. Mary Claire Haver?

  So let's talk about genital urinary syndrome of menopause, GSM. And I hope our listeners realize you were really critical to this final round of approval that the FDA finally, finally had the black box warning removed. And then the GSM guidelines, Dr. Rubin, you know, was really critical. And then we all kind of pitched in to like, get it out on social media. It really was a grassroots effort.

• 41:25Speaker 01

  Yeah. Guidelines do no good in a box.

• 41:27Dr. Mary Claire Haver?

  Yeah, to get these guidelines out there so people know about them. But what is GSM? What is genital urinary syndrome of menopause?

• 41:33Speaker 01

  General urinary syndrome of menopause is a complete mouthful. We say GSM for short, but it's a better name than vaginal atrophy because vaginal atrophy only talks-

• 41:42Dr. Mary Claire Haver?

  Or my favorite.

• 41:43Speaker 01

  Your favorite.

• 41:43Dr. Mary Claire Haver?

  Senile vagina.

• 41:45Speaker 01

  Senile vagina, brought to you by the 1980s.

• 41:48Dr. Mary Claire Haver?

  Yeah.

• 41:48Speaker 01

  So it was a senile vagina, then it was a vaginal atrophic vagina. And now the vagina is in the pelvis along with the genital urinary organs, which include labia, urethra, bladder, vagina, vulva, clitoris. And so the big mouthful is genital urinary. So lots of different structures can be affected. Syndrome, meaning a constellation of issues of menopause, meaning it should really mean low hormones. It's probably a better title.

• 42:14Dr. Mary Claire Haver?

  Yeah.

• 42:14Speaker 01

  But we're getting there. Incredibly common, 50 to 80%. Some people will argue 90%. The other people will argue, why don't we just say it's a hundred?

• 42:22Dr. Mary Claire Haver?

  If you live long enough, it's a hundred percent. I, I, you know, hormones go away, the tissue atrophies. You know.

• 42:30Speaker 01

  The better question, which again, hasn't been researched to my knowledge. Why does a small amount of women make it to 75 without GSM?

• 42:39Dr. Mary Claire Haver?

  I looked at vaginas in their seventies and eighties. They had it, they just weren't symptomatic.

• 42:43Speaker 01

  Yes.

• 42:44Dr. Mary Claire Haver?

  I can look at a vagina and tell you how old the patient is. Or at the vulva, really.

• 42:48Speaker 01

  My talk tomorrow is your vagina can tell your age better than your driver's license.

• 42:52Dr. Mary Claire Haver?

  For sure. If she's not treated.

• 42:54Speaker 01

  Yeah.

• 42:55Dr. Mary Claire Haver?

  If she's not on hormones, I can tell how old you are.

• 42:58Speaker 01

  Yeah. But unless if that vulva is on DHEA.

• 43:02Dr. Mary Claire Haver?

  Oh, she's beautiful.

• 43:03Speaker 01

  Oh.

• 43:04Dr. Mary Claire Haver?

  Juicy, delicious.

• 43:06Speaker 01

  Yeah. DHEA makes vulvas beautiful again.

• 43:08Dr. Mary Claire Haver?

  Yeah. Agree.

• 43:09Speaker 01

  So for your listeners, DHEA is a precursor hormone that converts into both testosterone and estrogen. There, right now, there's one FDA approved product that goes in the vagina called Intra Rosa or Prosterone. It's a made up word, it's DHEA. But the reason why we say it makes vulvas beautiful again is because it gives you a little bit of the estrogen and the androgen. And that's why it's so.

• 43:32Dr. Mary Claire Haver?

  You mentioned GSM in this new data, the Medicare data that came out with GSM.

• 43:37Speaker 01

  So a paper just got published out of Stanford looking at Medicare recipients. Now, the caveat is it was only up to 2018, so God can hope it's better than this right now. So this was looking around up to 2018. These women, Medicare recipients in America, went to a doctor, got a diagnosis of GSM, which might include recurrent urinary tract infections, overactive bladder, pain with sex. So you, you got a GSM worthy diagnosis.

• 44:04Dr. Mary Claire Haver?

  Right, because there's a laundry list of things that are associated with GSM.

• 44:07Speaker 01

  Yep. So let's look at, let's look at this.

• 44:10Dr. Mary Claire Haver?

  They put it in the chart, they wrote it down, they clicked on a diagnosis code, like she has been diagnosed with something to do with GSM.

• 44:16Speaker 01

  Yes, within 18 months of that diagnosis, 7% of women were given vaginal estrogen, which is the bread and butter treatment for GSM, highly safe, highly effective, highly cost efficient.

• 44:29Dr. Mary Claire Haver?

  And saves lives.

• 44:30Speaker 01

  And saves lives. So. God, I just hope we're better than that right now. So 2018 data. But to me, I think about the unmet need, which is why I'm, you know, interested in the DHEA over the counter solutions because medicine can't help this amount of women. These were the women who had insurance, got to a doctor, made the right diagnosis. So you got through how many hoops and you still didn't get treatment. Now, think of all the women in the pond that are suffering that didn't get through those hoops.

• 45:05Dr. Mary Claire Haver?

  Yeah.

• 45:05Speaker 01

  Right. So I think, oh, my gosh, 7% of those got treatment. New paper out of Canada, same scenario, 71% didn't get treatment. So they had 30% were treated. So Canada's winning over Medicare. But the profound amount of suffering and we're, and doctors are getting more educated. We've got GSM guidelines now. I just talked to Dr. Una Lee, who was a co-author with Rachel Rubin. And I'm like, where's your patient facing one-page handout? Because I go to tell patients, print out the GSM guidelines, bring this to your doctor. Doctors do not like 25-page stapled together things. I want a patient facing one-page document that they can print out and bring to their doctor.

• 45:47Dr. Mary Claire Haver?

  And hand to their doctor.

• 45:48Speaker 01

  So Dr. Lee says they're working on it. You can go free online, print out your GSM guidelines, bring them to your doctor.

• 45:53Dr. Mary Claire Haver?

  So lovely. What is vaginismus?

• 45:56Speaker 01

  Vaginismus is a not purposeful, so I'm not sitting here trying to clench my pelvis tight. So it's not purposeful tightness of the pelvis that prevents penetration of the vagina. Painful, painful penetration.

• 46:08Dr. Mary Claire Haver?

  How common is it?

• 46:09Speaker 01

  Oh, it's probably way undertreated. I couldn't give it to you.

• 46:12Dr. Mary Claire Haver?

  What's a classical history?

• 46:14Speaker 01

  5%.

• 46:15Dr. Mary Claire Haver?

  We barely touched the surface and she was kind of crazy.

• 46:18Speaker 01

  Yeah.

• 46:19Dr. Mary Claire Haver?

  So, you know, that's in the bitch is be crazy school of medicine, like vaginismus.

• 46:23Speaker 01

  Well, you know, people used to think it was because of your, it was probably your mom's fault. You know, like all these, again, social reasons for your biologic health issue. It is a lot more acknowledged now of like, can you just relax? No, when you have vaginismus, you can't just relax. You can't treat this with a glass of wine. Right. It is a medical issue with tight muscles that prevent non-painful intimacy.

• 46:47Dr. Mary Claire Haver?

  I mean, I've seen it. They can't even insert a tampon.

• 46:49Speaker 01

  Yeah.

• 46:50Dr. Mary Claire Haver?

  Nothing, you know, finger, nothing. Why is there a cultural obsession so, so, so about tightness of the vagina?

• 46:59Speaker 01

  Oh, Lord. I don't know. Do we care about tightness of penises? Do penises become flabby the more they have sex? Like, there's so much stigma in trying to make you the right woman. Am I tight enough? Am I too tight? Am I too loose? And we're marketing and we're making money off of this. And again, a lot of it stems from the fact that women don't know. Where do you go online to figure out if your vulva is normal or not?

• 47:28Dr. Mary Claire Haver?

  Porn.

• 47:29Speaker 01

  That's not normal vulvas. Mm hmm. That's, that's, you know, the F1 races.

• 47:34Dr. Mary Claire Haver?

  And now that we've stripped all the hair, you know, this generation doesn't like hair in the area, like they see more.

• 47:41Speaker 01

  Yep.

• 47:41Dr. Mary Claire Haver?

  You know?

• 47:41Speaker 01

  Yeah, totally.

• 47:42Dr. Mary Claire Haver?

  And they're like, oh, my, my labia don't look like her labia. Therefore, there must be, there's like the uptick in, in women who, young women, healthy women, who come in requesting labiaplasty.

• 47:53Speaker 01

  Yeah, yeah. And some people think it is because we have a lot more access to video. A lot of augmented video, right? And performative video.

• 48:02Dr. Mary Claire Haver?

  Yeah.

• 48:02Speaker 01

  Right? Even the sexual dysfunctions of like, I'm kind of watching myself have sex, which is called spectating, of like, am I performing this properly? The, the sex therapists who have been around for a long time are like, that didn't used to happen before you could watch people have sex on video. And so now like, things are changing because we have access to video and this whole like labial needing to look a certain way. This is what gets me. Many things about this get me. Women make less money than men. Women have less net worth than men. Women get paid less for having the same jobs as men. Now we're taking 10,000 of their dollars to cut their labia off? They're already down economically. We've given them a new problem to separate them from their cash?

• 48:46Speaker 01

  I just want people to think about the craziness of this sometimes of like, how many, I was talking to a woman, should I get blah, blah, blah? How many people do you plan on showing your labia to? Like, is this going to be an income source for you? Like, then maybe make the investment. But if you're with somebody who is supposed to love you, and you're supposed to be in a trusting, loving relationship, who loves you, like, oh, I have such a great relationship because her labia is nice. We just need to step back and be like, what are we obsessing over? And is this the point? And we look back, you know, Elizabeth Coman, Dr. Coman, read this amazing book, All in Her Head, about, look at all the foolish things we used to do to women.

• 49:24Dr. Mary Claire Haver?

  Yeah, I think we're still in the bloodletting phase for public health.

• 49:27Speaker 01

  Yes, I'm like, we tried to move the clitoris closer to the vagina in Freud's era. Guess what we're doing now? We're cutting off your sexual organs to make you look a certain way. Are we any better? And I will asterix all of this. There are some medical conditions where the labia does need a little bit of help. Absolutely, same with penises, same with scrotums, asterix.

• 49:47Dr. Mary Claire Haver?

  Yeah.

• 49:47Speaker 01

  But we are separating hard-earned cash from women because we're telling them they need to perform a certain way, look a certain way for the approval of their partners, and it's absolutely shameful.

• 50:00Dr. Mary Claire Haver?

  What I see advertised is as the smell. The vagina should smell a certain way. If you eat the, did you see the pineapple videos? You drink the pineapple juice or whatever.

• 50:11Speaker 01

  Not asparagus.

• 50:12Dr. Mary Claire Haver?

  It was mega viral.

• 50:14Speaker 01

  Yeah, crazy. Again, it's a pure, and once you learn, you're like, where is it?

• 50:18Dr. Mary Claire Haver?

  Should we have smell?

• 50:19Speaker 01

  Yes, yes, we smell. Like, we have sweat glands. And the other thing about women who aren't on hormones, and then they, they take hormones, some of them will say, my sweat smells again. Yes, it does, because hormones help the sweat glands be sweat glands. Right, like, your sense, your smell actually goes away when your hormones are low enough, which is fascinating.

• 50:38Dr. Mary Claire Haver?

  Wow.

• 50:39Speaker 01

  But yes, there is a certain musk to things. If there isn't a, if there isn't an infection, and there isn't something else going on, we all get a little bit musky. Where does it come from? Purity culture? Right? Be clean. You're never, we're never clean enough.

• 50:52Dr. Mary Claire Haver?

  No.

• 50:52Speaker 01

  In our society.

• 50:53Dr. Mary Claire Haver?

  No, I mean, and, and Coman talked about the shame in the exam room. I can't, myself, I'm like folding up my underwear and you know, that women are always apologizing in the exam room. And I'm like, almost a hundred percent. And it doesn't matter her socioeconomic status. I've treated royalty. I've treated, you know, and anytime a patient gets undressed, she tends to apologize for something on her body, which is completely normal. Let's talk about vibrators. Yay. You like vibrators?

• 51:24Speaker 01

  Oh God, I love vibrators. People, you know, the whole like, it's not natural. I did. So this got flagged on the internet. I did a cheeky video saying, you guys, I have a new vibrator and I'm gonna show it to you. And out of the bottom of the screen, I brought up my electric flosser that I got. And the joke is I have three vibrators for my mouth now. Like I have an electric toothbrush, an electric flosser and a water pick, right? Like this has never looked so good. And so I'm like, we're using technology to improve upon what we had before we had technology. You can buy it in Costco, right? Normal. But when you improve technology down there, same stuff, vibration technology, we're like, only certain women, oh, but you shouldn't need that because you've got a partner. Like all of this, I'm like, why is

• 52:08Speaker 01

  the pelvis the only area that we're like, but not technology there?

• 52:12Dr. Mary Claire Haver?

  Yeah.

• 52:13Speaker 01

  Like, and this technology, this technology is good. And I would say this technology, like some of the vibrators they have, especially the clitoral air pulse ones.

• 52:20Dr. Mary Claire Haver?

  Yeah.

• 52:21Speaker 01

  There's lots of different brands, but like, it works so well.

• 52:24Dr. Mary Claire Haver?

  Too well.

• 52:24Speaker 01

  Too, I agree. It's too well. It's like, I didn't want this to be a light switch.

• 52:27Dr. Mary Claire Haver?

  For science, I have to try them all out, right? So that I can adequately cancel my patients because science, I'm a scientist.

• 52:33Speaker 01

  You're a scientist.

• 52:33Dr. Mary Claire Haver?

  And the, the vibrator companies love to ship these things to my house and which may or may not freak out my children. My husband gets very excited.

• 52:41Speaker 01

  Yep.

• 52:41Dr. Mary Claire Haver?

  So let's, let's talk about like categories of vibrator. So there's the external, and I'm just gonna vibrate ones. There's the ones that have like a little suction cup over the clitoris. Those are new, are new.

• 52:52Speaker 01

  They're newer.

• 52:53Dr. Mary Claire Haver?

  There's lots of stuff. And then there are some that have an internal component, you know, some just for the inside. So.

• 53:01Speaker 01

  The combo, the combo ones. So there's ones that are clitoral suction that actually can curve in and so it can be internal and external.

• 53:08Dr. Mary Claire Haver?

  I do not have the right anatomy for that.

• 53:10Speaker 01

  Woo, I do.

• 53:13Dr. Mary Claire Haver?

  But I find the little suction cups to be too much.

• 53:16Speaker 01

  It's too, yeah, it's too fast, too furious, but for some people, that can be the right thing. I just need a little bit more intensity, especially as I'm getting older. Right? So.

• 53:23Dr. Mary Claire Haver?

  Why is that? Why do we need more intensity?

• 53:26Speaker 01

  Wear and tear on our bodies, nerve changes.

• 53:28Dr. Mary Claire Haver?

  And I read that the, the, the nerves that innervate the vibration, the vibratory nerves, right, are the last ones to go as far as loss of the myelin sheath.

• 53:39Speaker 01

  Ooh, interesting.

• 53:40Dr. Mary Claire Haver?

  With age. Someone, someone taught me that.

• 53:41Speaker 01

  Fascinating.

• 53:42Dr. Mary Claire Haver?

  That is why, like, if, if, if, you know, using your fingers isn't doing it, get a vibrator that, and there's a certain hertz that they measure thirty or something.

• 53:50Speaker 01

  Oh, some of these vibrator companies, like engineers are in there and they're.

• 53:54Dr. Mary Claire Haver?

  My patients are like, look, I can't see anymore. I don't want to put on glasses to have an orgasm. I don't want to turn on the lights to have an orgasm. I don't want to, you know, I just want to reach over, grab, turn it on and go.

• 54:03Speaker 01

  Yep.

• 54:03Dr. Mary Claire Haver?

  And the, the simple is better.

• 54:06Speaker 01

  Yep.

• 54:07Dr. Mary Claire Haver?

  What, what do you see? Cause some of them are very complicated and they, they cycle through multiple different.

• 54:11Speaker 01

  Oh, I know. To me, I don't know, it's a, it's a privacy issue, but I'm like, I'm never going to put something on my phone that's an app that's going to control this. Like, I have no interest in that. I'm like, I want, I want analog, not digital for these, but I think simple is better. Um, I had asked, I don't know if it was a vibrator company, I had asked somebody, I was like, why are there ten settings for every vibrator? Like, is, is three not enough?

• 54:34Dr. Mary Claire Haver?

  Is there any science to that?

• 54:35Speaker 01

  No, it's just that the factories in China all make them the same way. And so like, they made one that way, they just make them all that way. That's like the simple answer to it. They're like, women, people, women want different things. And I'm like, I don't, I don't know if they do.

• 54:47Dr. Mary Claire Haver?

  I don't know anybody who goes, you know, they're frustrated having to go through.

• 54:52Speaker 01

  Right? No.

• 54:52Dr. Mary Claire Haver?

  All of the different, you know, cadences of, of vibration. So, and they just want to just turn it on and go.

• 54:58Speaker 01

  Um, can we talk about my vibrator?

• 55:00Dr. Mary Claire Haver?

  Yes.

• 55:00Speaker 01

  Hmm. Hmm. So I have.

• 55:03Dr. Mary Claire Haver?

  You have a favorite?

• 55:04Speaker 01

  No, I have a vibrator coming out.

• 55:06Dr. Mary Claire Haver?

  Stop it.

• 55:06Speaker 01

  Do you know that?

• 55:07Dr. Mary Claire Haver?

  I did not know. I know you have the DHEA serum, which.

• 55:10Speaker 01

  That'll be coming. That'll be coming.

• 55:11Dr. Mary Claire Haver?

  And I do not have any affiliation, um, but it is absolutely, it is just the best. I love the texture of it. Yeah, it's like,

• 55:21Speaker 01

  It's important.

• 55:22Dr. Mary Claire Haver?

  So lubricious.

• 55:23Speaker 01

  Yeah, so like, products on the vulva cannot, in my opinion, they shouldn't be cold. I hate being cold, probably because I grew up in northern Minnesota. Don't put cold stuff on my vulva. It's not pleasing to me. So I like, I don't like lube that's cold. I don't like any product that's cold. So the DHA serum is like, skin temperature, which is makes a big deal.

• 55:41Dr. Mary Claire Haver?

  So what is it?

• 55:42Speaker 01

  It is a external only, because you cannot take a woman who hasn't had penetrative sex in a while, or might have untreated GSM. GSM is horribly undertreated. We should get into that recent Medicare data on that. You can't take that woman and say, here's a vibrator, put this in your vagina. You cannot do that to her. You, it hurts. Right? But blood flow, blood flow, blood flow, blood flow, blood flow, number one, prelim data might help. Signs and symptoms of atrophy, that's super exciting, needs to be researched more. Same with lichen scerosus, needs to be researched more. Blood flow matters. I just want blood flow. Just experience blood flow in your pelvis. External only vibrator, just goes on the outside.

• 56:25Speaker 01

  So you can use it with a partner, without a partner, you can flip it, there's a little ridge on it, you can put in between your labia and menora, get a little bit of vibration right in the vestibule, but no pressure to put anything on the inside. I just want you to experience pleasure and blood flow. If orgasms happen, awesome. If they're with a partner, awesome. But I wanted to create something that didn't cause more harm, and that was kind of like an intro. Like, I want, in my grand scheme, I want like, intro, intermediate, advanced, right? Like, because women are like, just tell me what to do. There's so much out there, right? Like, start with the intro. Start with like, low pressure, nothing's going on the inside. So she is called the Explorer. Stay tuned.

• 57:08Dr. Mary Claire Haver?

  What is one thing every woman should keep in on her nightstand?

• 57:13Speaker 01

  Oh, Kleenex.

• 57:16Speaker 01

  I mean, I think lube, like never have lube too far away. We know lube helps people have orgasms better. And I always say, like, when people, because people get judgy. And I've seen women judged by men on this. I've seen young women. I've, in one week, this is a couple of years ago, in one week, I had two 24 year olds come in for pain with sex. And I never, you know, you learn this in med school. You don't say, you know, do you take your blood pressure medications? You say, when do you forget to take your blood pressure medications? Right? So I say, what lube do you use? Instead of, do you use lube?

• 57:48Dr. Mary Claire Haver?

  Yeah.

• 57:48Speaker 01

  Right? So what lube do you use? They said, my boyfriend told me that I shouldn't need lube. And I'm like, you're taking sex advice from a 24 year old dude who has no lubrication in his pelvis at all? And you're putting all the pressure on a vagina? And you're starting just by-

• 58:04Dr. Mary Claire Haver?

  Oh, wait. So all of these spicy books, you know?

• 58:07Speaker 01

  Yeah.

• 58:07Dr. Mary Claire Haver?

  So I've read a few.

• 58:08Speaker 01

  Yeah.

• 58:09Dr. Mary Claire Haver?

  For science.

• 58:09Speaker 01

  There's millions of them.

• 58:10Dr. Mary Claire Haver?

  And literally, there's a sentence in there. You're so wet for me. You know, it's like this, this positive thing that there, you know, if she-

• 58:20Speaker 01

  Bad sex ed.

• 58:21Dr. Mary Claire Haver?

  Yeah. That, that, that, like, oh, he's all excited because she is so moist. So moist is a word I don't love. Um, but there is like a lot of liquid in the area.

• 58:30Speaker 01

  Yeah.

• 58:31Dr. Mary Claire Haver?

  Talk about that.

• 58:32Speaker 01

  Ability to produce moisture is not directly correlated to interest in having sex with a partner.

• 58:37Dr. Mary Claire Haver?

  Well, can you talk to all these authors out there who are writing this shit?

• 58:41Speaker 01

  That is-

• 58:42Dr. Mary Claire Haver?

  And making women feel like they're crazy? And they're all having simultaneous orgasm.

• 58:45Speaker 01

  I want to write a adult fiction book.

• 58:50Dr. Mary Claire Haver?

  I will help you.

• 58:50Speaker 01

  With, with an adult fiction book, established writer who can write. But I want to make it medically accurate.

• 58:57Dr. Mary Claire Haver?

  Oh, my God.

• 58:58Speaker 01

  Let's manifest. Like that, give me that job. I will spend a year.

• 59:01Dr. Mary Claire Haver?

  Amazing.

• 59:01Speaker 01

  I want that book.

• 59:03Dr. Mary Claire Haver?

  That would be amazing.

• 59:04Speaker 01

  So where do these young men learn things from? Stories like that, porn, blah, blah, blah. And so, and there's no arousal for her. Her pelvis doesn't know if this is a tampon or a penis. Right? So we're putting a hard penis in a dry vagina. She comes to the doctor for pain and she needs sex ed. Get warmed up first. Connect, relax, vibration, vulvar massage, all the other things, nipples, shoulders, back. Get your body into the touch. Let it know what to expect. The arousal will come, but don't just come by the guy's ready and hard, put it in. It will hurt. That's trauma. So it's like, again, going back to like, there's so

• 59:48Speaker 01

  much low hanging fruit, just because we do not have a good sex ed.

• 59:53Dr. Mary Claire Haver?

  And poor education.

• 59:54Speaker 01

  Yeah. And these young women are on birth control pills. Birth control pills tend to block.

• 59:59Dr. Mary Claire Haver?

  Okay, so great segue, because we've talked about medications that can improve sexual function. Therefore, there must be medications that hurt sexual function.

• 1:00:09Speaker 01

  Yes.

• 1:00:09Dr. Mary Claire Haver?

  So talk to me about birth control pills. What do they do? What can they do? Because it doesn't happen to everyone, but it definitely could happen.

• 1:00:16Speaker 01

  Yes. And some birth control pills are worse than others.

• 1:00:20Dr. Mary Claire Haver?

  Yeah.

• 1:00:20Speaker 01

  But the layman's way of saying it is a birth control pill kind of blocks hormones and blocks the hormones in the pelvis. So you can actually get a vulva that looks atrophic. It looks menopausal. And I always want to asterisk, birth control is amazing. It's changed our world. It's incredibly safe. It's incredibly effective. But you're not getting an accurate, informed consent if you aren't told how it works and what possible side effects might be. I just think that that's good medical practice. And I'm not here to scare people off of birth control pills.

• 1:00:51Dr. Mary Claire Haver?

  Dan, how can a birth control pill affect sexual function? What happens?

• 1:00:56Speaker 01

  It blocks your testosterone.

• 1:00:57Dr. Mary Claire Haver?

  How?

• 1:00:57Speaker 01

  In a perfect world, we would just add a little bit of testosterone into the birth control pill. How does it? It increases your sex hormone binding globulin to the liver. And so then the testosterone's not as free to go do its job.

• 1:01:08Dr. Mary Claire Haver?

  Other medications like antidepressants.

• 1:01:10Speaker 01

  Antidepressants. Again, did you get it fully informed? Conversation, of course you didn't. We have 10 minute doctor visits, right? But when 60 to 80% of people have sexual side effects from antidepressants, and in America, 25% of women are on one of these.

• 1:01:27Dr. Mary Claire Haver?

  Over the age of 45.

• 1:01:29Speaker 01

  Yes. Do you have an informed consent? This might happen, right? But again, we blow off sex and it's not important. And it's a quality of life issue of like, yes, it's profoundly important. It's profoundly important to relationships. It's profoundly important to your sense of who you are. And these medications can blunt orgasm, decrease desire. High blood pressure medications are another one. Any of the antipsychotics can be some of them. So anything that kind of can dry out things can affect lubrication, anticholinergics for overactive bladder. So the list of things that might affect sexual function is actually quite long.

• 1:02:02Dr. Mary Claire Haver?

  And then there's some new emerging information about GLP-1 medications.

• 1:02:05Speaker 01

  Yeah, it's going to be very exciting to see what happens with looking at sexual function in GLP-1s. So some of the data in men, when men lose body fat, their testosterone goes up. Because they're not converting it via aromatase, via their adipose tissues to estrogen. So their testosterone goes up when they're on a GLP-1. Increased in sexual desire for men will improve their sexual function. In women, it might be a mixed bag. A lot of women with GLP-1s, they're post-menopause. They're not on any hormones. Their hormones won't go up because they're on a GLP-1. So are we seeing some decreased desire? Yes, because GLP-1s affect the dopamine pathway of what's rewarding. So we're seeing gambling go down, drinking go down, eating go down, sexual desire go down.

• 1:02:50Speaker 01

  So I don't think we, we don't have a big enough jury out to say blanket statement, it does this, but to say, hey, it is improving.

• 1:02:57Dr. Mary Claire Haver?

  It could.

• 1:02:58Speaker 01

  Yeah, it could decrease sexual function. It can increase sexual function. I like how I look now. I have more energy. Right? So again, sex is bio psychosocial. GLP-1s can affect that in different ways.

• 1:03:12Dr. Mary Claire Haver?

  What do you want every woman listening right now to know about her body?

• 1:03:16Speaker 01

  You are not broken. You are not broken. You are undereducated. You are likely under cared for. But this is not a personality flaw. This is biology.

• 1:03:26Dr. Mary Claire Haver?

  How does she find a partner in this care? Because she, most likely, her OB-GYN is undereducated.

• 1:03:32Speaker 01

  Yeah. So some online companies are good that do hormone care. Interlude, for example, all it does is vaginal estrogen. So that's a great company for just for vaginal estrogen. I think the Ishwish website is good to find a doctor because Ishwish has this nice Venn diagram overlap of sex med plus hormones. Because sex med doctors know the role of testosterone for libido. We know the role of estrogen for lubrication and moisture. So it's that Ishwish just, you know, is in the middle of the Venn diagram of sexual health and hormones. And I think that's probably my best go-to. I mean, you have an excellent list on your website as well. So it's like, the other good option is, do you have a friend who got help? Who are they seeing?

• 1:04:14Dr. Mary Claire Haver?

  Who are they seeing?

• 1:04:14Speaker 01

  Yeah.

• 1:04:15Dr. Mary Claire Haver?

  You brought vaginal estrogen as well. All right. I do want to talk about that. So say she finds the right partner in care. They give her the vaginal estrogen.

• 1:04:22Speaker 01

  Vaginal estrogen.

• 1:04:24Dr. Mary Claire Haver?

  And doesn't know how to use it. Is vaginal estrogen absorbed systemically?

• 1:04:28Speaker 01

  Teeny tiny, teeny amount, more so in people who are very atrophic in the beginning until they get healed up.

• 1:04:34Dr. Mary Claire Haver?

  Until they get healed.

• 1:04:35Speaker 01

  But then, once you have nice, healthy skin down there, absorption is minimal. And it's always below.

• 1:04:40Dr. Mary Claire Haver?

  Right. If you have raw tissue and I rub something on it, you're more likely to absorb the medication.

• 1:04:44Speaker 01

  Yeah. That's why I don't do a loading dose. So the common prescription for vaginal estrogen is every day times two weeks, then twice a week. Multiple problems with that. Number one, the loading dose isn't based in any sort of science or paper that I could ever find. Probably to just get it working faster, but it backfires. Because in people who are really atrophic, really thin tissue, it can burn or you can absorb a lot. "Doctor, I thought you told me this wasn't going to go in my body. My breasts are tender." Well, you have really atrophic skin and it sucked up a lot of product. Skin is supposed to be a barrier.

• 1:05:16Dr. Mary Claire Haver?

  Yeah.

• 1:05:16Speaker 01

  And when it's atrophic, it's not a good barrier.

• 1:05:18Dr. Mary Claire Haver?

  How long does it take to grow that mucosa back?

• 1:05:21Speaker 01

  Six to eight weeks.

• 1:05:23Dr. Mary Claire Haver?

  So I tell people. You have to grow it back.

• 1:05:24Speaker 01

  Yes.

• 1:05:25Dr. Mary Claire Haver?

  It's gonna take six weeks.

• 1:05:25Speaker 01

  And if you stop using this.

• 1:05:27Dr. Mary Claire Haver?

  It goes right back to where you are.

• 1:05:28Speaker 01

  You go back to the low hormones.

• 1:05:29Dr. Mary Claire Haver?

  So how do you explain to people how to apply this? If they're not on video, so walk them through.

• 1:05:34Speaker 01

  Yeah. Okay. So what, what was in my box of estradiol vaginal cream, 0.01%, which is the generic product available in America.

• 1:05:44Dr. Mary Claire Haver?

  How much did that cost?

• 1:05:44Speaker 01

  This should cost no more than $20.

• 1:05:46Dr. Mary Claire Haver?

  Yeah.

• 1:05:47Speaker 01

  And I tell all my patients that. I'm like, if you can't get this for less than $20, you let me know. I will change your, your prescription to Mark Cuban, cost plus drugs, no affiliation. I hope to meet Mark Cuban someday and give him a very big kiss and a hug. But it's a generic product. Your insurance company shouldn't make money off of this. So at Mark Cuban, I think you can get it for $13 plus $5 shipping. So I haven't seen it cheaper than that. That's the best deal that I've found. So it comes in a tube and it comes with an applicator and I can take this off to actually show it if you want. But two ways to do this. You can fill up the applicator to the one gram on here and then put it in kind of like a tampon. Or you can put it from the tip of your finger.

• 1:06:27Dr. Mary Claire Haver?

  I was like.

• 1:06:28Speaker 01

  To the second knuckle.

• 1:06:31Dr. Mary Claire Haver?

  Where, now, how do they put it? Where do they put it?

• 1:06:33Speaker 01

  I would put your finger comfortably in, but you don't need to go to the top of the vagina. I do like it in middle of the vagina because the bladder and the vagina share a wall and that's how it helps the bladder out. Decreases urinary tract infections, decreases urgency, frequency, getting up at night to pee. But again, I always say I have a cream bias. Why do I have a cream bias?

• 1:06:51Dr. Mary Claire Haver?

  Cost?

• 1:06:52Speaker 01

  Cost. Big one. You should not re-mortgage your house for this and hey, if we're lucky, menopause is gonna last 40 years. You need this to be cheap. The other reason I have a cream bias is because you can put some on your face. Kidding, not kidding. But people do put a little bit. You know that Egypt sold out of vaginal estrogen? Cause all the women were putting it on their faces.

• 1:07:11Dr. Mary Claire Haver?

  On their face?

• 1:07:11Speaker 01

  A dermat, an Egyptian dermatologist told me that. But anyways, I like the cream because you can put it on the vulva.

• 1:07:17Dr. Mary Claire Haver?

  Yeah.

• 1:07:17Speaker 01

  Put it on the clitoris.

• 1:07:18Dr. Mary Claire Haver?

  A hundred percent of patients I tell them.

• 1:07:20Speaker 01

  Put on the clitoris.

• 1:07:21Dr. Mary Claire Haver?

  Down the labia minora.

• 1:07:21Speaker 01

  Yes, in that six o'clock spot. That tight spot, pain with entry. The classic, where do you have pain with sex? Pain with entry. It's at 6 o'clock that gets tight and painful, especially if you had an episiotomy. Side effect, let's talk about the side effects of this. One of the most common side effects of starting on vaginal estrogen is your microbiome changes. Because your microbiome is different with estrogen than without estrogen. So a side effect can be a yeast infection is one of the most common ones. I tend to say lower your dose or back off on your dose. You don't have to stop. Treat the yeast infection as your microbiome changes, that will happen less.

• 1:07:57Dr. Mary Claire Haver?

  What is the number one treatment for the prevention of recurrent UTIs?

• 1:08:01Speaker 01

  Vaginal estrogen. Not FDA approved for that, but it is the most effective. And Rachel Rubin, our good friend, did a Medicare analysis paper that if Medicare basically shipped everybody on Medicare with a vagina vaginal estrogen and they used it. It would save Medicare 13 billion a year just in decreased urinary tract infection costs.

• 1:08:23Dr. Mary Claire Haver?

  Anything else you want to share with our audience?

• 1:08:25Speaker 01

  This decreases death. So there was an abstract, I think in a neurology conference. Yeah, was it? It was, there was an abstract and it was women with recurrent UTIs who are on vaginal estrogen, decreased risk of admission to ICU, decreased risk of admission and decreased risk of death from sepsis.

• 1:08:42Dr. Mary Claire Haver?

  When they looked at the breast cancer data, they saw zero increase, women who were given vaginal estrogen, zero increase in recurrence.

• 1:08:50Speaker 01

  That's right.

• 1:08:50Dr. Mary Claire Haver?

  And they lived longer.

• 1:08:52Speaker 01

  Yeah, they live longer.

• 1:08:53Dr. Mary Claire Haver?

  Longer.

• 1:08:54Speaker 01

  And there was a new paper, women on vaginal estrogen seem to have a decreased risk of rectal cancer.

• 1:08:59Dr. Mary Claire Haver?

  Healthier tissue.

• 1:09:00Speaker 01

  Maybe it's healthier tissue, maybe you get less, you know, trauma to the tissue. Maybe it's a microbiome thing. We don't know. That's, that's newer data.

• 1:09:08Dr. Mary Claire Haver?

  How can our listeners find you?

• 1:09:09Speaker 01

  Hmm, I hang out, I hang out on Instagram at Kelly Casperson MD. And I have a Substack, Kelly Casperson MD.

• 1:09:16Dr. Mary Claire Haver?

  You still taking patients?

• 1:09:17Speaker 01

  I still take patients. I practice currently in Washington State. Getting a California license takes forever, so maybe some decade I'll have a California license. And my podcast is called You Are Not Broken. Book's called You Are Not Broken. Second book's called.

• 1:09:30Dr. Mary Claire Haver?

  And menopause moment, you brought that too.

• 1:09:33Dr. Mary Claire Haver?

  This is her latest baby.

• 1:09:36Speaker 01

  So when I was writing this, I was feeling like I was bold. I was like, I'm gonna say the big, bold things. And the exciting thing about it is it's kind of all come to fruition.

• 1:09:45Dr. Mary Claire Haver?

  What are the bold things you said?

• 1:09:47Speaker 01

  Testosterone exists in female bodies. We should consider using this for health span, longevity.

• 1:09:53Dr. Mary Claire Haver?

  Where is testosterone approved in the world?

• 1:09:56Speaker 01

  Australia, New Zealand, South Africa, and the UK. They're having trouble giving, getting their governments to cover it, but it is available with cash.

• 1:10:04Dr. Mary Claire Haver?

  Okay.

• 1:10:04Speaker 01

  But this is already outdated because the box warning has come off. So my brand new baby book is all, we've already outdated it. So that's exciting. Very exciting.

• 1:10:15Dr. Mary Claire Haver?

  Well, Dr. Casperson, Kelly, the OG of the menopause, thank you so much for coming to share all your wisdom and knowledge to our listeners. And I talk to her every day. So it's so good to see you in person.

• 1:10:28Speaker 01

  Thanks for having me.

• 1:10:31Dr. Mary Claire Haver?

  You can find Kelly through her website at kellycaspersonmd.com, where you can listen to her podcast, You Are Not Broken, and find links to all her books, as well as to more information on her clinic, The Casperson Clinic. You can find full episodes of UnPaused on YouTube at Dr. Mary Claire. I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram at Dr. Mary Claire and get honest, accurate information on health, fitness, and navigating midlife at the pausedlife.com. My new book, The New Perimenopause, is available everywhere you buy books. If you're loving this podcast, I have an important request. Please take a moment to follow UnPaused on

• 1:11:14Dr. Mary Claire Haver?

  your favorite podcast app. Following and listening is what pushes this information to more women who need it. So if this podcast has helped you feel seen, understood, or supported, hit follow right now so you never miss an episode. Thank you for being here with me. Let's keep going, UnPaused. UnPaused is presented by Odyssey in conjunction with Podpeople. I'm your host, Dr. 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.