Own Your Vaginal and Sexual Health through Perimenopause, Menopause & Beyond

For our most recent webinar, we were thrilled to welcome Dr. Maria Uloko! Dr. Uloko is a urologist who specializes in comprehensive sexual health, which includes the medical and surgical management of vulvar sexual dysfunction, vulvar sexual pain, low libido/desire, regenerative ED treatments, advanced erectile dysfunction, symptomatic menopause, atrophic vaginitis, urologic prosthetic surgery, Peyronie’s disease, and hormone replacement therapy. She provides care for all genders from all over the spectrum. She is one of six urologists in the world able to provide this level of evidence-based care. 

Dr. Uloko is also a strong advocate for improving the quality of life of her patients by providing a comprehensive, compassionate, and inclusive approach to often stigmatized subjects. She believes in empowering her patients to take ownership of their sexual health by providing a shame-free space to ask questions and share their stories. She seeks to close gaps in disparities of care and implement systems that promote diversity and inclusivity.

She spoke with Alloy’s community manager Rachel Hughes about perimenopause, menopause, and sexual and urinary health. The conversation has been edited for brevity and clarity, but we highly recommend you watch the whole thing on our YouTube!

Here are the highlights.

Rachel Hughes:

Today we are so lucky to be joined by Dr. Maria Uloko, a urologist who specializes in comprehensive sexual health. She believes in empowering her patients to take ownership of their sexual health by providing a shame-free space to ask questions and share their stories. She seeks to close gaps in disparities of care and implement systems that promote diversity and inclusivity. 

Dr. Maria Uloko:

Thank you so much for having me. I'm so happy to be here talking about a topic I love. Menopause is one of those things that, like taxes, is inevitable. If you live long enough, you have to go through it. But despite the inevitability of it, there are very limited resources for people to actually access not only the appropriate care, but also the appropriate information about menopause. 

As a urologist that treats all genders, I get to literally compare how people with penises and people with vulvas are treated in the medical system. For people with penises, we hold them to quite a standard, which has become my standard. We try to save their lives, but we also make sure their quality of life is going to be good. With people with vulvas, there is a lot of permissive suffering. And there’s so much fear surrounding hormones, which is not the case with men. With men, we support them, we celebrate them. In women’s health, hormones are vilified. And fear mongering prevents us from getting to the science. 

Rachel Hughes:

Thank you. Let’s start with the idea that sexual health equates to overall health.

Dr. Maria Uloko:

So, one of the pillars of sexual health is understanding how it connects to overall health. And I learned this in treating men. So when Viagra came out in 1997, there was this huge push by doctors to say that when people with penises start experiencing erectile dysfunction, it is actually potentially a cardiac issue. 

And when it’s your heart, we care. It’s actually in our clinical guidelines for urologists that if someone comes in with new erectile dysfunction, we have them get a cardiac workup. With men, when it comes to sexual health, of course it relates to overall health. But in women, we see a lot of sexual dysfunction that comes with the decrease in hormones due to menopause, and we don’t have that same reverence. We see it as a frivolous thing of, Oh, they’re not having sex, it’s not a big deal. 

We need to elevate it to, Oh, they’re not having sex, they’re unhappy, and potentially it’s also the marker of a bigger medical problem. We need to add to the validity of it. Sex is oftentimes dismissed. But I want to make it so your sexual health isn’t a secondary part of you, it’s a primary part of your life and your health. 

Rachel Hughes:

Thank you. So, the first line of defense is the hormone piece. I would love for you to discuss the role of hormone therapy in managing urological symptoms during menopause. 

Dr. Maria Uloko:

So, two things that many people experience when they go through menopause are urinary urgency and frequency. A lot of people also experience something called pelvic organ prolapse, where their actual pelvic organs are coming out of their vaginas, and it’s a terrifying thing. These things affect your quality of life. I’m a big believer in preventative care. I just want people to be healthy. And it’s interesting how societally we have been conditioned to just ignore a huge part of our bodies. I care so much about health. I just want people to be healthy. And it's an interesting thing how societally we have been conditioned to just ignore a huge part of our bodies. 

When it comes to hormones, I'm a big believer in both estrogen and testosterone.

Rachel Hughes:

Great. Thank you. Can you talk a bit about effective strategies for improving sexual health and intimacy for menopausal individuals?

Dr. Maria Uloko:

I think about sex from a biopsychosocial place. If we think about it like sports, sexual health is a team sport. What I do is I make sure your vulva is healthy, and that any disease is gone. If you think about it like tennis, I’m giving you the racquet. And then, you need to learn how to play. I work with pelvic floor physical therapists, sex therapists, sexological body workers.

And one of the things we need to work on is how much shame we have around the topic of sex. If you can’t even talk about sex and your relationship to sex, it’s going to be so much harder. You need to get comfortable with sex and with your relationship to sex. 

Rachel Hughes:

Could you just take a few minutes to sort of walk through what that might look like in your practice?

Dr. Maria Uloko: 

Absolutely. A patient will come to me and I’ll ask them, “What are you seeking?” And then they have to do the hard work of figuring out exactly what they want. I am a very goal-oriented person, and I want to help my patients reach their goals. And sometimes there’s a lot of deconstructing what society has told us. And we’ll figure out how to reach our goals by using a wide toolbox of practitioners and partners and collaborators that I work with.

Rachel Hughes:

Fantastic, thank you so much. I want everyone who comes across this conversation to walk away with a better sense of agency and a better understanding of how they can best advocate for themselves when they walk into a physician’s office. Can you speak to that a bit?

Dr. Maria Uloko:

I'm going to answer this as an intersectional feminist who is also a black woman in medicine. Urology is considered predominantly a male field, and when I started I knew we dealt with incontinence and urination in women, but that was it. And I was humbled quickly. I didn’t know a lot about hormones. We were just taught that menopause is something that happens to women. We weren’t taught anything about the ways to help. And at first I bought into that. My fellowship really opened my eyes. And I learned that the system was made to not teach you much about women. 

If we look at our medical education system, we learn very minimally about women’s bodies in general. We learn about pregnancy, barely, and that’s where it ends.  

But I want the facts. I want the knowledge. And that’s one reason I do research. And I want everyone doing research. It’s a means of advocacy. And I tell my patients too, that they are their own biggest healthcare advocate. Don’t let anyone tell you what you should and should not be doing, based on things that are not facts. So many doctors dismiss women without knowing evidence. 

And it’s also on doctors to keep doing research. It’s part of our Hippocratic oath. There is a selective ignorance when it comes to women, and I hate it because this is not happening at all in men. And I get to actually see both. I treat all genders. And it’s important because many deaths are preventable. So I tell patients to arm themselves with their own research. You are your own biggest advocate until the medical system chooses to start actually taking care of women and people with vulvas. 

Rachel Hughes: 

I'm going to pivot now to audience questions. Someone asks, “How do you deal with dryness internally and externally?”

Dr. Maria Uloko:

There are many changes that happen in the vagina, and they’re all related to hormones. So when we think about how to keep this tissue healthy, we have to think about hormones. Estrogen helps increase blood flow to the vagina, which increases lubrication. The other thing that helps with lubrication is vaginal testosterone. And you have to keep taking it, even once you’re feeling better. You can’t just stop drinking water because you’re not thirsty at the moment!

Rachel Hughes:

Thank you. Here’s another one. “I have an extremely low sex drive and my boyfriend hates it. What can I do to improve my sex drive?”

Dr. Maria Uloko:

Libido. Okay, we're going to use another analogy, and it's a little funny. Think about a plane in a cockpit. There are so many levers and dials that need to be up and down to make the plane fly. And I use this analogy when people come in for low libido. There are so many factors that go into your sex drive. How stressed are you? Does it hurt every time you have sex? Do you have decreased lubrication? Are you ashamed of your body? Do you have neurologic issues? Do you just not have a healthy relationship to sex? There are so many factors that go into it. And my job when people come to see me with low libido is figuring that out. And I love it. It's like playing detective. I can help you optimize your hormones. I can help you optimize your vaginal tissue and your vulvar tissue so that it's healthy, and you’re getting blood flow. 

And then the biopsychosocial approach, the holistic approach comes in. Because if you have low libido, and you’re feeling guilty about it, you’re probably not having great sex. It’s not necessarily a quick fix. 

Rachel Hughes:

There were a few questions that came in from different people, but they sort of had the same tone, which is about seeing a gynecologist versus a urologist. When should you see one or the other? 

Dr. Maria Uloko:

It's an interesting thing because as a urologist for men, when they have any real issues with their pelvis, they just go to a urologist, and so they just have a one-stop shop. For people with vulvas, it is so much harder, because a urologist deals with urinary issues, and not necessarily gynecological issues. So I say the distinction is whether or not it’s urinary. If it is, urologist. If not, gynecologist. 

Rachel Hughes:

Thanks so much. The next question is, “Could you use vaginal estrogen before you have symptoms?” 

Dr. Maria Uloko:

I believe in preventative care. Recurrent UTIs cost people their lives, and it costs the healthcare industry $85 billion per year. They’re easily preventable if you just start preventative care. Why do we get mammograms and colon screenings, but there’s nothing to address vaginal health? I think you should get a mammogram, you should get a colonoscopy, and at the same time you should get your first tube of vaginal hormones. 

Rachel Hughes: 

Thank you so much, Dr. Uloko. It's a pleasure always speaking with you and sharing time with you. 

Dr. Maria Uloko:

I love speaking on this. I hope I made everyone into advocates who want to burn down the system, because that's what I'm trying to do. Burn it down and build again.

Rachel Hughes:

Love it!  I'm glad you're at the helm. Thank you so much everyone. Thanks Dr. Uloko. Be well.  To watch the whole webinar, head over to our YouTube! For more information about upcoming webinars, follow us on Instagram @myalloy.