Menopause & Your Vagina: Here’s Everything You Need to Know From Dr. Kelly Casperson

Kelly Casperson, MD, is a urologist, mom, and wife, empowering women to live their best love lives. She hosts the popular podcast You are Not Broken, and is the author of the book You Are Not Broken - Stop “Should-ing” All Over Your Sex Life. Kelly had her life changed by a patient with low desire and identified the need for better resources and education on topics like sexual health, intimacy, hormones, neuroscience, and the science of desire. We were lucky enough to have her chat with Alloy co-founder Monica Molenaar on a recent webinar about the changes that happen to your vagina and vulva during menopause, and how they affect pretty much everything. Below is some of the interview, which has been edited for brevity and clarity. Watch the whole interview on our YouTube channel.

Monica Molenaar:

Hello and welcome, Dr. Casperson. Thank you so much for joining us.

Dr. Kelly Casperson:

Thanks for having me.

Monica Molenaar:

I would love for you just to start out and introduce yourself. Most of us think about going to an OB-GYN for menopause, but you’re a urologist. How did you get excited about menopause? How did you start making it a part of your practice?

Dr. Kelly Casperson:

It’s fun. It totally happened organically. I started the podcast a little over three years ago after a life-changing patient opened my eyes to the fact that we're really under-serving women in sexual health. You know, urologists are the ones who are like, the owners of Viagra. We're helping all the penises get erections. And I just assumed gynecologists were taking care of the women. And my mind was opened to the fact that they're not. So the more I started to learn, the more I was like, I can't keep this information to myself. I need to talk. And that's where the podcast and Instagram came from. 

I wanted to know what the science said about sex as you age, so I did a deep dive. It’s not true that your sex life goes away after menopause. In fact, some of the people having the best sex are in their fifties, sixties, and seventies. I have sexually active people in their seventies and eighties in my practice. 

And then I started to wonder about hormones. Why are we so afraid of them? Where is this coming from? Why don’t we treat women the same way we treat men when it comes to feeling good, having the best quality of life? We’ve got a lot of work to do. 

Monica Molenaar:

Yeah, it's amazing actually. And hearing you talk about that has been a real eye opener for me. Let’s start at the beginning. Can we talk about the GSM, or the genitourinary syndrome of menopause? 

Dr. Kelly Casperson:

Yeah. But before that, let’s back up even more. A lot of people don’t have a great definition of what menopause is. They think it’s just hot flashes. Our education around what happens is really poor. And, you’re not technically in menopause until you’ve gone a year without a natural period, but the symptoms start before that. So let’s talk about GSM. Vaginal atrophy is what it used to be called. And we actually also used to call them senile vaginas, which is worse. 

The genitourinary syndrome of menopause includes symptoms like vaginal dryness and itching, and also bladder stuff, like frequency, urgency, and frequent urinary tract infections. 

Monica Molenaar:

Yeah. And actually, you know, as I said, a lot of what we do at Alloy has sort of come from my own personal experience. So, for example, I suffered from genitourinary symptoms of menopause, which more than 80% of women will experience. And without estrogen, it doesn’t get better. 

Dr. Kelly Casperson:

I love vaginal estrogen. I just got a t-shirt made that says estrogen fairy.

Monica Molenaar:

Nice!

Dr. Kelly Casperson:

So, there are two different types of estrogen you can take. There’s systemic, which comes as a patch or pill. And then there’s local estrogen, also known as low-dose estrogen, also known as vaginal estrogen. 

Vaginal estrogen is incredibly low-dose. It doesn’t go into your bloodstream. You can literally measure your blood estrogen levels, and they won't go up after being on vaginal estrogen. And there are a few different options. You can use a ring, you can use tabs, or you can use a cream. I have a cream bias. I get feisty with all the people who say it's too messy. I'm like, “Did you meet your 21 year old vagina? Do you remember her? She was messy. She was doing stuff right. That's a healthy vagina.” But that’s my bias. If people don’t want cream, there are options.

Monica Molenaar:

Will using the cream solve your hot flashes or other symptoms?

Dr. Kelly Casperson:

No. It’s an incredibly low dose. One year’s worth of vaginal estrogen is the equivalent of one oral estrogen pill. It’s not systemic. 

Monica Molenaar:

Wow. That's amazing. I hope everybody heard that. 

Dr. Kelly Casperson:

I get this all the time on Instagram: “I can't use vaginal estrogen because I've had a blood clot.” Not true. “I can't use vaginal estrogen because I've a family history of breast cancer.” Not true. “I can't use vaginal estrogen because I've had an abnormal mammogram.” Not true. If you’ve had breast cancer, run it by your oncologist. But we do have ACOG (American College of Obstetricians and Gynecologists) guidelines. And multiple countries have it over the counter. Vaginal estrogen is safe.

Monica Molenaar:

I think it also increases sensation, which, you know, I've noticed is lost otherwise. Which brings us to Viagra. It’s been FDA-approved for the last 25 years for men, but it hasn’t been available for women readily until now. Alloy is selling a topical cream, we're calling it the O-mazing Cream™, to give women a female dose of Viagra. But it’s topical, not oral. 

Can you talk a little bit about another total revelation I had recently, which is that the clitoris is basically the same organ as the penis? And that’s why Viagra is a good tool for women, in terms of improving their arousal. 

Dr. Kelly Casperson:

My pleasure. How much time do you have? Just kidding. So, the clitoris is the organ of orgasm. There's nuances to that, but that's beyond the scope of this talk. So, the clitoris is just like the penis. It needs blood flow, it has erectile tissue, it needs to get aroused and engorged. And that's how we promote an orgasm. 

Monica Molenaar:

Are there any contraindications? 

Dr. Kelly Casperson:

We don't have tons of studies, but I have not seen any big risks with topical, low-dose sildenafil. 

Monica Molenaar:

I think it's a great tool. It's not gonna change your whole life. Women's sexual arousal is a combination of lots of things, right? It's your head and your body. So if your head’s not there, it won’t help.

Dr. Kelly Casperson:

Yeah, I mean I think the power of it is, it really draws awareness to your vulva, to your clitoris, to your body. So I like it as a focusing tool. 

Monica Molenaar:

I want to get to audience questions. One woman emailed in advance, and I promised that I would ask this question. “For those in surgical menopause who have cancers or blood clot risks that preclude them from using Hormone Replacement Therapy, can they use vaginal estrogen?” Actually, can they use hormone replacement therapy? What’s your feeling?

Dr. Kelly Casperson:

Vaginal estrogen? Absolutely, yes. 

For blood clots, you should talk to a hematologist about systemic estrogen, and they will likely recommend that you choose transdermal estrogen over oral estrogen, because it doesn’t pass through your liver. 

Monica Molenaar:

One woman asked, “Why are doctors so against estrogen?” 

Dr. Kelly Casperson:

This treatment was developed in the forties, and until the nineties, lots of women were on estrogen. Until the Women’s Health Initiative (WHI). It was a huge study that was stopped prematurely, and the media ate it up and said estrogen causes breast cancer. So medical schools stopped teaching it, residencies stopped training doctors, and because of that, we have about two decades of untrained physicians. 

Now, we have so much data saying that hormones are safe. And it's really on the medical community to catch up. 

Monica Molenaar:

Another question: “Can you address surgical menopause and the bladder?”

Dr. Kelly Casperson:

See a physical therapist and start on vaginal estrogen. Why wait? 50-80% of the time, she’s going to need vaginal estrogen, so she should just go on it. It’s like preventative skincare. There’s a study that shows vaginal estrogen is equivalent to anticholinergics, which are medications used for overactive bladder. I also don’t want to downplay the importance of a great pelvic floor physical therapist.  

Monica Molenaar: 

Here’s a question that I think I know the answer to. “My mom, 74, has to pee four to five times per night but her doctor refuses to give her estrogen vaginal cream. Does she need a new doctor?”

Dr. Kelly Casperson:

Yes.

Monica Molenaar:

Is there an age that you need to stop using it?

Dr. Kelly Casperson:

No. 

This is safe, safe stuff. 

You basically can't leave my clinic without getting a vaginal estrogen prescription.

Monica Molenaar:

And Alloy has it!

We could go on and on forever. I forgot to mention that you recently joined the Alloy family as a medical advisor, which we’re so excited about. And thank you so much for joining today.

Dr. Kelly Casperson:

Thank you. Happy to be here!

A huge thank you to Dr. Kelly Casperson for sitting down with us. There’s so, so much we couldn’t include in this one blog post. To watch the whole interview, head over to our YouTube channel!