Ep. 498 Chronic Stress Is Aging Your Ovaries – The Shocking Link Between Trauma, Hormones & Menopause with Dr. Heather Quaile

Today, I am delighted to connect with Dr. Heather Quaile, a double board-certified women's health nurse practitioner and advanced forensic nurse with specialty training in female sexual medicine. Her training focused on integrative gynecology.

Today, we dive into trauma-informed care, defining big and little T trauma, examining how adverse childhood events impact gynecologic care, and clarifying how chronic stress and trauma affect ovarian aging. We discuss the role of recalibration of the nervous and autonomic nervous systems during perimenopause and menopause, and explore the importance of estrogen in supporting serotonin, dopamine, and adrenal health in middle age. We cover GLP-1s, reframing packaging around vaginal estrogen, FDA approval for testosterone, the new terminology of PET, and holistic management of low libido, and we also tackle the genitourinary syndrome of menopause, new terminology, barriers, self-advocacy, and the significance of pelvic floor Health. 

This conversation with Dr. Quaile is truly invaluable. She is a most helpful resource on everything related to integrative gynecology, sexual medicine, and self-advocacy.

IN THIS EPISODE, YOU WILL LEARN:

• How big and little T trauma differ

• What trauma-informed care is, and why it is particularly relevant for women in perimenopause and menopause

• Symptoms and behaviors that indicate trauma in women

• How the interrelationship between estradiol and serotonin affects our worldview, self-perception, sleep, and relationships 

• The benefits of addressing any hormonal imbalances before using GLP-1s for weight loss

• The pros and cons of gaining FDA approval for testosterone and commercializing it  

• Factors that could cause decreased libido in middle-aged women

• The genitourinary changes that occur in different life phases of women, or with cancer, or when going through gender reassignment

• How PET (progesterone, estrogen, and testosterone) terminology is evolving to include women outside of perimenopause and menopause 

• The five questions Dr. Quaile has in her DSDS (decreased sexual desire screener) for clinicians, to get to the root cause of hypoactive sexual desire disorder in patients

• The importance of women being comfortable about advocating for themselves

  
  

Bio: Heather Quaile

Dr. Heather Quaile (she/her) is a renowned clinical and academic leader and entrepreneur. She is a double board-certified women’s and gender health nurse practitioner and advanced forensic nurse specializing in human trafficking and female sexual health. She is a thought leader and creator of the Just Ask podcast. Dr. Quaile is also trained and certified as a Menopause Society Certified Practitioner, AASECT sex counselor, and sexual assault nurse examiner, providing sexual health education, trauma-informed care, and information to patients of all ages. She created and implemented a medical program for emergency stabilization for the commercial sexual exploitation of youth in Georgia. Dr. Quaile has been working in all aspects of women’s healthcare for over 24 years, caring for women of all ages across the health-illness continuum. She recognized the lack of sexual health awareness not just in her community but in its clinicians. She founded, developed, and implemented her private practice, The Sexual Health Optimization and Wellness (SHOW) Center. Her goal is to help guide patients through their healthcare journey and provide a range of services that address the biopsychosocial aspects of health, wellness, optimization, and sexuality. She is passionate about changing the systems and beliefs that have stigmatized women’s health and female sexuality through a non-judgmental, trauma-informed, empathic approach grounded in evidence-based research. She is a Fellow of the International Society for the Study of Women’s Sexual Health (ISSWSH) and a Fellow of the American Academy of Nurse Practitioners. She is the treasurer of ISSWSH, past chair of the ISSWSH scientific committee, and past Treasurer of the National Association of Nurse Practitioners in Women’s Health. She is on the National Menopause Foundation medical advisory committee as well as the Governor’s Task Force on human trafficking and sex offenders. She is widely published in the field of women’s health and trauma-informed care, and is a highly sought-after speaker for lectures to international and national audiences.

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"“It is important to acknowledge that healthcare providers need to have trauma-informed care.”

– Dr. Heather Quaile

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Connect with Cynthia Thurlow  

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Connect with Dr. Heather Quaile

• On her website 

• On Instagram

Transcript:

Cynthia Thurlow: [00:00:02] Welcome to Everyday Wellness Podcast. I'm your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives. 

[00:00:29] Today, I had the honor of connecting with friend and colleague Dr. Heather Quaile. She's a double board-certified women's health nurse practitioner and advanced forensic nurse with specialty training in female sexual medicine. She has focused her training specifically in integrative gynecology. 

[00:00:46] Today, we spoke about trauma informed care and helping to define big and little T trauma, the impact of adverse childhood events and evaluation on how this impacts gynecologic care, the impact of chronic stress and trauma on ovarian aging, the role of recalibration of our nervous system and autonomic nervous system in perimenopause and menopause and the importance of estrogen's role in serotonin and dopamine supporting adrenal health in middle age, the impact of the GLP-1s, the importance of reframing packaging around vaginal estrogen, FDA approval on testosterone and the new terminology of PET which incorporates progesterone, estrogen and testosterone, holistic management of low libido, the genitourinary syndrome of menopause and new terminology, barriers and self-advocacy and the importance of pelvic floor health. 

[00:01:45] Dr. Quaile is an invaluable resource on all things related to integrative gynecology, sexual medicine and self-advocacy. I know you will find this to be a truly invaluable conversation and one you will likely listen to more than once. 

[00:02:03] Well Heather, I've been so looking forward to this conversation. Welcome to Everyday Wellness. 

Heather Quaile: [00:02:07] Thank you so much for having me. I'm so excited to be here. 

Cynthia Thurlow: [00:02:10] Absolutely. I really made an intent this year to bring on as many nurse practitioners and other advanced practice nurses because we are seeing so many patients and yet I felt like we weren't being properly represented on the podcast. So, this is part of the rectification of this. I respect your area of focus and I feel like trauma-informed care is something that you speak about with great frequency. Why is this particularly relevant in perimenopause and menopause and how do we create and build a safe environment for our patients? 

Heather Quaile: [00:02:48] So, I think we need to start a little bit at the basics and say, like, “What's trauma?” I think we've done a really poor job in society defining trauma. Because I think when we think of trauma, we think of it as this big-- I like to call it big T trauma and little t trauma. So, big T traumas, like a lot of the things we know, maybe in war and seeing people killed, sexual violence, physical violence, but then there's also this like little t trauma that exists and that could be lots of different things. It could be that maybe there's like racial and systemic oppression or that you've had things that have happened to you. Maybe you go into your doctor's office and you say, “Hey, I'm having these symptoms” and they're like, “Oh, it's in your head.” 

[00:03:33] That's like real true medical gaslighting. And those can cause some what we call little t traumas. And for some it could be big T trauma. So, I think it's really important to come at it that. Trauma doesn't have to be this big, huge, life altering, oh my gosh, it was a sexual assault or it was war or something that it can stem from these little things and then it retriggers. And I think that if we come to the approach, especially as healthcare providers, that trauma exists for every single person. So, you've had trauma, I've had trauma. How we define it, again, may not be like a sexual abuse or anything, but there's other things that could cause that. Maybe how we were parented or something we experienced in our childhood. 

[00:04:16] And so if we came into every interaction knowing that every person experiences trauma in different ways, I think that's the first way to start. And then I think it's an important thing to acknowledge that as healthcare providers we need to have what's called this trauma-informed care. And what that means is it's an approach that really acknowledges like, “Okay, there's this prevalence of trauma. We understand that there are like these physiological psychological impacts. And then what do we do when we're giving this type of care?” And that really goes into a lot of those different aspects of creating safety, trust, empowerment and those things. So, now getting back to your question of why does it matter in peri and menopause, I think it comes down to that a lot of women are dismissed. 

[00:05:04] I think there's a lot of medical gaslighting that happens. We are seeing peri and menopause get such a big stage now. So, more people are open to talking about it, even if they are dismissed. But I think the most important piece is that there are just these profound neuroendocrine changes that happen and what that can do is it can totally reactivate these trauma symptoms or worsen that dysregulation of that stress response. 

Cynthia Thurlow: [00:05:31] And for patients that are perhaps listening, what are some of the symptoms that you will either see patients reporting or objectively observe behaviors when you're interacting with them before you even got into the physical exam piece. But when you're onboarding them or looking through paperwork, what are some things as a clinician that will slant your direction and how you're going to approach these kinds of topics?

Heather Quaile: [00:05:57] So, one of the things that I always will tell clinicians and you may not get the answer from day one. Oftentimes, it's why I like the concierge membership cash-based model. Yes, I know it's expensive. Yes, I know it doesn't take insurance. But what it allows us to do is develop this relationship with the patient. So, when a patient comes in to see me, they usually have a pretty big intake form. And I directly ask in there, like, “Has there been a history of sexual assault?” I'll even have some ACE score questions. ACE stands for adverse childhood experiences. I think every single patient should do an ACE score and answer these 10 questions because a score above 4 shows that there is a history of trauma. 

[00:06:42] But these are things where I'm going is that you can put it on your intake form so that a patient knows that you are generally interested in knowing what kind of trauma they come to. They may not tell you. They may not feel comfortable telling you on your intake form. But if they do and you read that intake form and it's on there, it already gives you that lens. The other thing is that if they don't answer it and you feel that maybe they're guarded or that they are maybe not answering the questions or they're not making good eye contact, you can start bringing in those little underpinnings like, “Is there anything you want to talk to me about? Could there be a past trauma history in it?” 

[00:07:21] It may not happen on that first visit. It may take three or four visits. But that's the parts and pieces that I have. I also think during perimenopause time, one of the biggest questions that I start with in my visits is, “Tell me your story. What brought you to my clinic today?” And a lot of times they'll say, “I decided not to use my insurance because I wasn't being seen, I wasn't being heard. I was saying that I had hot flashes or night sweats or I was just totally unstable. I wasn't feeling like myself,” that token word. And I was made to feel like, I'm sorry, you can either go on an SSRI or here's a statin for you. You can't do hormones. You haven't stopped your periods yet.” 

[00:08:04] And it's like all those things I give them the opportunity to tell their story and that really helps guide my process and a lot of times they've been dismissed. And that is that little t trauma. 

Cynthia Thurlow: [00:08:18] Yeah, absolutely. And I think for so many of us, especially healthcare providers, I was led to believe that trauma is the big T trauma. And, now we have this burgeoning awareness, not only on a systemic level, but just even as clinicians, we're talking more about the impact of little t traumas. And I love that you brought up the ACE scores because that's something that we do definitely talk about on the podcast with some regularity. And for so many women--and this is an easy-- accessible. You can go online. It was a joint venture between Kaiser and the CDC, if I recall properly. But what I think is really significant about high ACE scores-- and mine is 7, high ACE scores-- When I was looking at the research and writing my book, for a lot of these women, that chronic underlying stress that started in childhood, that probably very likely persisted in their 20s, 30s, and beyond could have the potentiality of leading to an earlier menopause. 

Heather Quaile: [00:09:14] 100%

Cynthia Thurlow: [00:09:13] And for these women, I think this is not discussed often enough and it's certainly not building enough awareness. So, younger women hearing this or their family members, helping them understand that chronic long-term stress can hasten ovarian senescence, ovarian aging. Our ovaries were born with a finite amount of eggs. By the time, we hit our 40s, we have a lot less eggs than were actually born with, but we know that stress over time can exacerbate this.

Heather Quaile: [00:09:43] I think a lot of hormonal shifts interact with that stress response. So, for example, vasomotor symptoms, you got your hot flashes, your night sweats, which we're all really familiar with. I think we know that's tied to this hypothalamic thermoregulatory instability that's going on, and those also to interact with those stress pathways. We know that during this time frame, like there's that decline in that estrogen and progesterone, and that really affects that hypothalamic pituitary access and our autonomic nervous system, it's all intertwined in there. So, when that's all going on, it increases our invulnerability, it increases our sympathetic overdrive, that fight flight response and if you live in this constant state of fight flight, you're releasing lots of cortisol. I don't love the word adrenal fatigue.

[00:10:34] And I actually was listening to McCall talk about this on your podcast a couple weeks ago, that we either have this, you're fine or adrenal failure, and there's nothing in between. And I don't love adrenal fatigue. We need a better word for between nothing and failure. Because there is this middle ground, but in Western medicine, no one wants to accept that. And I think when you're in this huge sympathetic overdrive and that increased fight flight, of course you're in this middle ground, you're not in failure, but you're certainly not normal. 

Cynthia Thurlow: [00:11:06] Yeah. And certainly not optimal. I think that's really ultimately what it comes down to. And I think for the benefit of listeners, when we're talking about these changes in the autonomic nervous system that are driven by changes in sex hormones, let's talk about the interrelationship between estradiol, or the predominant form of estrogen and our serotonin levels, which can impact, how we view the world, how we perceive ourselves, how we sleep, how do we interact with loved ones. 

Heather Quaile: [00:11:35] Absolutely. And what I think is super interesting, when we think about that, we know it's declining. We know that estrogen is more than just this reproductive hormone. I think that that's one of the most important things to point out. My colleague, as we all know, Dr. Mary Claire Haver, always says, “Like this estrogen decline and perimenopause is a state of total chaos that's going on in the body because estrogen acts more than reproductive. It is this neuro-steroid in the brain. We know it's in the brain. The research is there. We also know that it works with serotonin, it works with dopamine. And as it starts to decline, why are we seeing insulin resistance, metabolic syndrome, all the things? 

[00:12:17] So, we know that estrogen is really important for that serotonin synthesis, decreasing that serotonin breakdown. And then we know that it's really important to even acting in that the way I like to think of it, almost like when we think of the little pink pill that's called Flibanserin. It's what we call this 5-HT2A receptor agonist antagonist. Estrogen almost acts in that way where it can increase some of those receptor responses and decrease in that prefrontal cortex, hippocampus-type of things. And I think it's really important to see like this whole neuroregulatory thing that estrogen's doing because a lot of times we think of it as, “Oh, it's just a sex hormone, it's just in your ovaries.” But it's so much more than that. 

Cynthia Thurlow: [00:13:06] Yeah, I think in many ways, Tom Dayspring called it bikini medicine, that for a lot of providers, they think of estrogen, progesterone, testosterone as these bikini medicine-related hormones. And he said, it affects every system in the body. Every cell in the body is impacted by these sex hormones. So, is it any surprise that as women are navigating this hormonal chaotic environment in perimenopause, that they start to not feel like themselves? They start to feel like they view the world very differently, that they don't understand why their sleep has suddenly gotten very poor. They become less stress resilient, their body seems, like, they're like I'm outside my body looking in and saying I'm doing everything I used to do and nothing is now working.

[00:13:50] I think for so many women it's frustrating to navigate in the medical system where a lot of providers are actually never trained in what women are going to experience in perimenopause and menopause. And a big thank you to you and so many others that are building greater awareness around this. When you're talking to your patients just to back up and talk about the adrenals and I agree with you, adrenal fatigue is not an appropriate term at all. What is one of the most important things that you like to emphasize with your patients to help support their adrenals as they are navigating this middle age timeframe?

[00:14:28] So, one of the big things, and we've been hearing it from other people talk about it as well. One of the first questions I ask them is what does exercise look like for you? Because we also have to flip the mindset. All the GLP drugs that are out there, they're wonderful. There's a lot of anti-inflammatory things that they do, forgive the word, but microdosing, I don't love the word because again, it falls in that adrenal fatigue category. But there are true benefits of it. But then it also has now shifted that mindset of oh, GLPs, I can get skinny. It's the Hollywood drug. And it's still all that implication of people taking these drugs to be skinny. 

[00:15:06] And so, it maybe it's gotten away from this crazy exercise phenomenon, but where I'm going with this is that back in the day it was like, “Eat less, exercise more, you'll lose the weight.” Now it's like, “Okay, shoot yourself with the injections, maybe you don't have to exercise.” So, that is a whole other day's discussion. But with the exercise, it's one of the most important things I talk about on my midlife women because they get on this hamster wheel like, I'm not losing weight, I'm having more middle abdominal belly adiposity. They don't really understand this whole insulin resistance that happens when our estrogen declines, the metabolic syndrome.

[00:15:41] And so, they're exercising more, they're doing tons of HIIT or more cardio. I think that we're seeing more and more that people like us that are going in and trying to give knowledgeable, evidence-based advice is that we're coming at it from, no, you don't need to be doing crazy cardio, you need to be lifting more, you need to be taking rest. You need to be focusing in that Zone 2 where you can have a conversation and not feel winded because that's super taxing on their adrenals and on their stress response and I think that a lot of women when they come in and hear that are like, “Oh, I haven't really ever heard that before.” 

Cynthia Thurlow: [00:16:19] Yeah, I did an intake on a discovery call with a lovely middle aged, 55-year-old female who unfortunately had gotten a pellet and then felt terrible and gained a bunch of weight and was listing off all the things that were going on for her. And she said to me, “I do 05:00 A.M. bootcamp five days a week.” And I heard that and I said, “Has anyone talked to you about moderation in terms of your physical activity?” What you can do at 35 is very different than what your body can tolerate at 55. And I think for a lot of individuals, they've probably never been told that they should be strength training. 

[00:16:55] They have never been told that you need to manage your stress or I jokingly will say to patients that if I can't get you to sleep through the night. That is a foundational element that that is the first thing we need to worry about. Because once I can get you to sleep through the night, you're going to make better food choices, you're going to have more energy to be able to do the right types of exercise. You're probably going to be able to manage your stress better. Now, in terms of GLP-1s, I hear what you're saying and I think it's important to kind of qualify that there are definitely people out there that certainly patients I've spoken to that have said it's the first time in their adult life that food noise has been quiet. 

[00:17:32] Especially those on the that tirzepatide and those kind of drugs that have not just the GLP-1 but also have that GIP which helps support cravings in the brain. But when we're looking at longitudinally long term, do you feel like that GLP-1s are-- I proverbially call them, the icing on the cake. There's a lot of other foundational work to focus in on first. I do think that there are a lot of people that benefit from the GLP-1s. Do you think that we're navigating this environment now where people are more open minded to using them for purposes beyond just weight loss for the autoimmune piece, for the anti-inflammatory benefits, which I know there's a lot of people out there that and we won't use the term microdosing, we'll just say we're personalized dosing, we'll use it that way.

[00:18:20] Personalized dosing, depending on the individual, are using them kind of off label for other reasons or are you staying pretty straightforward with your GLP-1 use in terms of weight loss primarily. 

Heather Quaile: [00:18:33] So, in terms of weight loss, I'll be honest, I try to take an approach. Let's fix your thyroid, your gut, your hormones first and then the GLPs will work nicely synergistically with it. There has been really good data in the evidence-based literature that hormones and GLPs work better synergistically together. I feel like if I could get all my patients to go that route instead of just taking the GLPs they would be doing even better. I think that I very much customize my doses. So, if they're using it particularly for weight loss and they have a decent amount of weight to lose, I want them on average to be losing a 0.5 pound to 1 pound, 1.5 pounds a week. I use a body composition scale. I have an InBody in my office.

[00:19:16] So, I make sure they're not using too much skeletal muscle mass. But my reality is if you're losing on the lowest doses and you're maintaining, I do not escalate every four weeks. So, that's technically personalized dosing. But of course, if they're in it for long-term weight loss, they likely will have to escalate. If they hit a set point and they're comfortable with it, then we work on what that looks like, maybe reducing their set point, can we go lower? But yes, I've been using it a lot off label because what I'm finding-- I want more data on it because I'm a data-driven person and we need more. But I'm finding that it really is helping a lot of my patients with joint pain. 

[00:19:59] So, I have a lot of midlife women that have a lot of different joint pain. Estrogen, as we know, is a big factor that helps with that joint pain. But the GLPs are wonderful. As we know, the first things that we see with GLP is a reduction in an of lot of the inflammatory labs. So, cholesterol is getting back to normal, CRP is going down, insulin resistance is getting better. So, I think there are so many benefits from it. I personally myself will die on my hormones and my GLPs because they were so life changing for me with weight loss. And now I just don't want to go off of them because I feel like it helps a lot of my menopausal symptoms in a lot of good ways, like my cholesterol is perfect. It was not perfect for the last several years and I think there's a lot of good things it does. 

Cynthia Thurlow: [00:20:47] Absolutely. And I appreciate you sharing so transparently and I've even shared with my community that I've been on the milieu of an estradiol patch, testosterone and oral progesterone, which I jokingly say I will take till the day I die. But adding in a GLP-1 at a personalized dose. So, I'm going to use that personalized dose. Initially we utilize it to see if it would have a positive net effect on my Lp(a). And I think for a lot of individuals who are reluctant to go on more cholesterol medication or other modalities. I know we talk about statins a lot on the podcast and I prescribe them hundreds of thousands of prescriptions for statins while I was working in cardiology. But I appreciate the nuance around the utilization of these drugs to see if we're getting personalized effects. 

[00:21:35] And so, number one, as you stated that bioimpedance scales or body composition is very very important. So, you're making sure you're maintaining muscle, not losing it, adequate strength training, adequate protein intake, making sure someone's sleeping and then adding in these other sex hormones can be very, very helpful. Now I'm curious, I know that, I think of Kelly Casperson, Vonda Wright, Dr. Rachel Rubin, all of which have recently spoken at the FDA. What are your thoughts on testosterone therapy? Do you think in the next five or ten years we're going to get FDA approval for testosterone in women? What I find interesting, Heather, is how many people are still in my DM saying it's not FDA approved, that means we can't take it, that is not the case. 

Heather Quaile: [00:22:22] I hope that it does. I think part of it is a lot of things that we're doing. So, we're trying to unbox the box morning on vaginal estrogen so that we can explain. Okay, There's a big difference between systemic versus local. So that's first thing. Secondly, there's a bunch of us that, as you know, because you're big in the Instagram social media space, we get banned for saying so much. So, we had a meeting of the minds like two Saturdays ago where a bunch of us menopause providers got on a Zoom call and we're now trying to maybe use the word PET hormones. I don't know how well it will go, but it's more for social media spaces for banning us, which is progesterone, estrogen, testosterone. So getting that word out that these hormones need to stop being gendered. 

[00:23:06] They're not sex hormones. They do way more than what they're there for. They're banning us from using the word sex. So, to go back to your question, we know that the UK just came out with a new product that just got approved. Australia has a product for testosterone that has been approved. I am hopeful that we'll get there. But the sad reality is, and this as well as I do, Cynthia, they're going to put it in a pink box and they're going to charge #300 for a one-month supply where I can go get test them off label that a man uses a box of 30 for a $100 that's going to last my patients 300 days, to be totally honest. I hate to put that out there in the world, but that's exactly what they're going to do. 

[00:23:48] So I'm kind of in this, yes, we need testosterone. Yes, we need to get the controlled substance label off of it at least for women, because who in the hell is going dope testosterone as a female? Let's be for real. And then unfortunately, they're going to package it in a pink box and it's going to be super expensive and prevent and then have more issues around it. So, kind of on the fence about how I feel about the whole testosterone getting off label.

Cynthia Thurlow: [00:24:13] Well, and I think it's important for people to be aware because I would imagine there are people listening who don't realize the way this commercialization comes in terms of bringing new drugs, bringing, I'm going to put it in air quotes, “New drugs to market.” Anything that they market for women will end up being very expensive. And this is incredibly unfortunate because one thing I hear from patients regularly is I get pushback from my insurance company that testosterone is not FDA approved, therefore I don't have to pay for it. So, women are either going with a tenth of the male dose like you're talking about, or they have to have it compounded, which ends up being way more expensive than it should need to be. And yet this is a vital hormone for women, a very vital hormone. 

Heather Quaile: [00:24:58] Very much, very much so. And yeah, it's certainly frustrating. 

Cynthia Thurlow: [00:25:02] Yeah. Talking about testosterone, it lends itself to having a conversation around libido. I think many people's perception is low libido equates to low testosterone. It's so much more than that. What are some of the factors that most often kind of underpin low libido in middle-aged women? And how do you approach that clinically? 

Heather Quaile: [00:25:23] Well, I think since you mentioned Kelly, I love Kelly, she's a good friend of mine. Kelly Casperson puts it so well. “Libido is a mood.” [Cynthia laughs] And I hate to tell women that it's all in their head, but it is in our head. So, it's like I think libido is this mood type of thing. And so, when you're not feeling maybe great in your own skin because maybe it's some weight loss issues, maybe you're going through big T or little t trauma and all those different things. There's so many parts. And I do think testosterone absolutely can help with libido. But I think that if you just throw testosterone at libido. And you don't come at libido from a lens of biopsychosocial. Like one of the big questions I ask my patients all the time is, “Okay, how's your libido and what does orgasm look like? Are those blunted? Have those changes? What does that look like over time?”

[00:26:17] And a lot of patients will tell me, I just don't feel in the mood. I feel like I'm on a hamster wheel, I'm doing 20 million things and of course that plays into it. But I think you need to take talk about this spontaneous versus responsive desire that happens and how those things change, especially in heteronormative relationships. There's a beautiful article called the Heteronormative Desire. And actually, Kelly did a podcast on it years ago, and I have it as an article that I give my patients in these relationships and how that dynamics changes. So, I think it's important to ask that. I think, number two, I always say, “Do you like your partner?”

[00:26:54] Because there's so many things I can fix with libido. But if you don't like your partner, then we need to unpack that, maybe get you in counseling. Do you want to stay with your partner? And then hormones as they start to really plummet. I think testosterone helps a lot with libido if it's truly a hormonal thing. But I think it's way beyond libido. I think I always say we only have it off label and a consensus statement for libido. But secondary gains, anecdotal evidence and things I see as a boots on ground clinician is mood, bones overall, CEO functioning overall, like just feeling like yourself. I think testosterone does a lot of things like that. 

Cynthia Thurlow: [00:27:33] Yeah. And it doesn't get enough focus. I mean, I oftentimes will say to people that again, it's a hormone that's systemic. It is not just relevant to executive function or bones or our desire to have sex or not have sex. And I think, you bring up such a good point about do you like your partner? Do you want to stay with your partner? Then that's a different conversation than part of the reason why I have zero libido is I'm not attracted to my partner. I don't like my partner. And how many women that are navigating perimenopause and menopause are also people who are determining whether or not they want to get divorced or they want to remain in a committed relationship. 

[00:28:11] I think most recently it was Dr. Sara Gottfried that was talking about how many women she sees as patients that determine in perimenopause. They're like, “I don't like my partner.” And so that then lends itself a different conversation. And they may do very fine with their libido when they're with a different partner. And I think that is something that maybe in the past we weren't discussing often enough with our patients. 

Heather Quaile: [00:28:34] There was an article or something on Instagram that actually said it was like over 50, menopausal were seeing more people like leave the relationship. I'm not saying that I'm this huge advocate of divorce, but I think women are getting more comfortable saying, “You know what? I don't feel seen, I don't feel heard, not just by my healthcare provider, but by my significant other, by my spouse, my partner, whatever that may look like for you and that I need to be getting these needs met.” And they're having a little bit more clarity as they navigate through this.

Cynthia Thurlow: [00:29:04] Absolutely. And let's do talk a little bit about the genitourinary changes that are happening as women because this is also important. Some people may not have a libido and they're not interested in their partner per se. Some people may be having painful sex, they may tear with sex. There's a lot that changes in the genitourinary system as we are navigating this hormonal decline. Let's talk about some of the changes in how you approach this as a clinician. 

Heather Quaile: [00:29:31] So, I think one of the things that I have to put out there is we actually are doing a name change on the genitourinary syndrome of menopause. So, we actually presented it at the ISSWSH scientific meeting this past February. When we think of the genitourinary changes that happen, it's not just menopause. So, like your listeners that are lactating, that are postpartum, that may be nonbinary, trans care, gone through cancer, there are genitourinary changes that happen in these different phases of life. And what we're trying to do is actually change the wording so that it's called the genitourinary symptoms of or genitourinary syndrome of. And then you tag your thing because sadly it used to be called senile vagina, then it got changed to vulvovaginal changes. 

[00:30:25] And now we have this genitourinary syndrome because it does involve the bladder. Thank God, we're talking about that now. But it involves when women are lactating, when they're going through gender reassignment, when they're in postpartum, when they have cancer, all these different things. So, it's beyond that menopause. So, I just wanted to give a little plug for that. 

Cynthia Thurlow: [00:30:44] No, I think it's important. In fact, I don't recall who was talking about this on Instagram, but they brought up the lactation piece and I said, “I breastfed two kids for a year each, and I experienced this. And my GYN, when I reported my symptoms, gave me a tube of low-potency topical steroids, when in fact what I needed was some estrogen.

Heather Quaile: [00:31:04] It was an estrogen.

Cynthia Thurlow: [00:31:05] Yes. And I mean, back then, I will say I did not know better, but now I know better and when I explained to this GYN who had made this post, she was like, “they prescribe steroids.” And I said, “Yes, but this was now like 18, 20 years ago.” And I said, “Now I think things have evolved.” But to your point, I'm glad that the terminology is evolving so that it encompasses not just women in that perimenopause to menopause transition, because it can happen to women outside that context. 

Heather Quaile: [00:31:30] So many chapters. I feel like anyone that goes through a cancer diagnosis really should have these conversations and literally be given that tube of vaginal estrogen, especially our breast cancer survivors, because we know that there is limited, if not any systemic absorption, it's safe for the most part. But unfortunately, they don't have these talks with patients because their number one thing is “We removed the cancer.” And that again, goes back to this whole trauma-informed care and gaslighting a lot of times. And I don't mean to call out oncologists. Their work is so vitally important to remove the cancer, but they're so narrow focused on removing the cancer that they forget that the patient sitting in front of them has a life beyond their cancer. So, what does that look like from a sexual health perspective, a getting back to work perspective, feeling like yourself again? 

Cynthia Thurlow: [00:32:22] Yeah. I have a team member who speaks very openly, and I have her permission. She's a breast cancer survivor and I think it took the two of us, like a year to find her a provider in her state that would prescribe her vaginal estrogen. Even though, I kept sharing all this literature and sharing so much good work that's being done, Dr. Corinne Men, Dr. Avrum Bluming's work, Dr. Carol Tavris. And yet there are still clinicians that were very fearful to prescribe vaginal estrogen. Beyond estrogen, what are some of the other modalities you like to utilize with your patients that are experiencing painful sex or other genitourinary symptoms that they're reporting to you in clinic?

Heather Quaile: [00:33:04] So, I do a lot of sex med in my practice, and I think getting to that proper diagnosis is super important. Is your pain coming? And we have a pathway, so we call it vestibulodynia or that vestibule. We've changed it out of that word of vulvodynia so that it may encompass most of the pain that most people experience beyond the whole vulva, it's in that vestibule, which is that area that surrounds the opening to the vaginal canal, or I like to call it like the vaginal canal foyer, if you will. [Cynthia laughs] And so I think getting to the root cause of where the pain's coming, is it coming because the pains at that vestibule, is it in the clitoris? Is it in the perineal area? It is it in that anus area? What does that look like? 

[00:33:50] And then really figuring out, is it nerve pain? Is it hormonal pain? So, let's take something more simple, basic. If it's hormonal pain in the vaginal vulvar reasons, a lot of times we go back and we give hormones. I use a lot of compounded estrogen and testosterone in a methylcellulose base or Aversa base to really work on those hormones in the vestibule. Because one of the things, and if you follow Rachel Rubin or Dr. Goldstein or any of my swish colleagues, our area of the vestibule is made up of different types of tissues. And the tissues at that vestibule are the same tissues that are in that bladder and in your urethra and they need androgens. They need that testosterone. And that's where testosterone and estrogen localized on those tissues is so important.

[00:34:40] The vaginal canal is mostly made-up tissues that need estrogen bearing. So that's why you often don't hear about testosterone necessarily in the vaginal canal. But that whole foyer and the urethra and everything does need that testosterone. So, I like to use a lot of different hormones to talk about with patients when there's sexual pain. And then it goes way beyond that. If it's pain and it's not hormonal, I use a lot of different combinations of ways to help my patients through compounded pain meds or oral pain meds, or is your pain neuroproliferative, what is it related to. Sexual medicine, I want to say is probably one of the hardest things I've ever done in gynecology practice, and it's probably why a lot of people don't do it, because it's not easy. 

Cynthia Thurlow: [00:35:24] Yeah, no, thank you for that. Because I think it was. Dr. Anna Cabeca was probably the first person that brought up to me how important androgens are in that genitourinary area. And whether it's DHEA or testosterone or both combined with estrogen. This is why estrogen therapy sometimes is not enough to be able to improve the quality and the responsiveness of that area of the body. And I think for so many women, there's still so much shame discussing these things with their providers. 

[00:35:55] When you're working with women, do you have suggestions or recommendations if someone's listening and they're having pelvic pain or they're having genitourinary pain, how to open up the conversation if perhaps-- there's nothing wrong with talking about different parts of our bodies, but for a lot of women, they were raised in a way that they felt a tremendous amount of shame about their sexuality, and that then translates into they're not advocating for themselves because there's a degree of discomfort talking about it. 

Heather Quaile: [00:36:22] So, my big thing that I tell clinicians when I teach them is if you can put things on your intake form to ask, like, “Are you having issues with your libido? What does orgasm look like for you?” Even doing what I call the DSDS, the Decreased Sexual Desire Screener. It's five questions, and it gets to the root cause of if it's Hypoactive Sexual Desire Disorder. And I think that's a really good way to put it on your intake form. And if they do put it on their intake form and it's not an area that you're comfortable with, then know who your providers are so that you can at least tell your patient, I see you. I hear you. I understand that this is a concern for you, and I want to help you find a clinician that you can see. This is the resources we have in our area that we recommend.

Cynthia Thurlow: [00:37:08] No, I think it's important to know, and I think for each clinician to know, where your comfort level is. If you've gotten to a point where that you have only so many tools in your toolbox and you feel like a patient has exceeded them knowing when to refer out. And that does not mean that you're discontinuing care. In some instances, they do need to see a subspecialist, someone who is even more nuanced, even more dialed down. And certainly, the ish-wish providers are certainly a great tool to look for that. Let's pivot and talk a little bit about pelvic floor health. I think that now there's greater awareness. I certainly have interviewed several pelvic floor specialists this year alone. Do you feel like a conversation around pelvic floor therapy is oftentimes beneficial when women are having pelvic floor pain? Is that part of the conversation for you?

Heather Quaile: [00:37:56] I think it's really important. The interesting thing is I think talking about this, the script has shifted. So, it used to be that patients would come in and see the healthcare provider first and then I always say, “I have two arms,” my sex therapist, my pelvic floor therapist and we would refer them. I think because patients have been so badly dismissed by healthcare providers over the years, sometimes the first access point to care is they're going direct to the pelvic floor PT, which I think is awesome. And now I think that narrative is switched where they're wanting to know who are the sexual medicine providers that I can refer to. Because I think it's so important to be talking about pelvic floor PT, I think there are more people that are actually getting trained in pelvic floor PT and I think that is really, really cool. 

Cynthia Thurlow: [00:38:43] Absolutely. I think about a conversation I had earlier this year with Dr. Sara Reardon and from the time that she finished her training, she was solely focused in on women's pelvic floor health. And she said, I'm so grateful to know that there is greater awareness that women are not taking for granted. It is not normal to have multilayered incontinence. It is not normal to have fecal incontinence, sometimes these things get normalized in the medical system. And yet I think our generation is building greater awareness so the women understand you don't have to live with urge incontinence. I was talking to a woman the other day who said she can't even put the key in the door of her house. As soon as she starts to do that, she'll start having an episode of urination because she is got to go. Dr. Malik is who I always think about where she talks about, you got to go, got to go. That as soon as you trigger that association with, “Oh, I'm home, I can finally empty my bladder.” They're actually having an accident in the garage or at their front door. 

Heather Quaile: [00:39:44] Yeah. So, I think it's so great that we're starting to talk about it more. 

Cynthia Thurlow: [00:39:48] Absolutely. If a midlife woman would remember one thing about sexual health and pelvic floor health, what would you like it to be? 

Heather Quaile: [00:39:59] Oh, that's an interesting question. I think the most important thing is that you have to be comfortable advocating for yourself. I think that self-care and having the resiliency to say something is not right and believing your intuition is probably the most important thing these days for a midlife woman. And if you're not feeling like yourself, you're not feeling optimal, then it's really important for you to advocate for yourself. Other thing that really impacted me last week when I did Mary Claire's Instagram takeover is I always say, “If you don't feel like you're being supported by your provider, it's time to find a new provider.” And someone commented on that post and said, “I understand that and it's a time to advocate for ourselves, but what is the problem with more providers not learning the skills to take care of us?” 

[00:40:49] And I thought that that was so empowering. And I think it comes back to our why. Like, why are you and I and a lot of our colleagues in the Instagram spaces giving evidence-based medicine? Why did I just launch my Q-Spot platform today? Because the why is that it's no longer okay to not go get training in women's healthcare if you are going to care for half of this population. And that really, really was very eye-opening for me last week. So, not only to advocate for yourself, but I think I'm going to shift my mentality to start saying that not only do you have to find someone that will care for you, but we need more clinicians trained to care for women properly, if that makes any sense on my whole-- That was a whole like tangent on there. [laughs] 

Cynthia Thurlow: [00:41:39] No, no, I, I loved your response and I think that it really speaks to the heart of the matter, like, “Why do we put ourselves out there? I'm an introvert.” I would imagine most of the clinicians I interview on the podcast are also introverts, but they're looking to help improve education, advocacy and awareness of women's health-related issues. Please let listeners know how to connect with you outside of social media. I'm not sure if you're still taking new patients, so I don't want to put you on the spot but. 

Heather Quaile: [00:42:04] No, I am. I am.

Cynthia Thurlow: [00:42:06] You're taking new patients and your multistate licenses, Heather would be a fantastic resource.

Heather Quaile: [00:42:11] Yeah. So, you can find me obviously on my Instagram @drquailenp. My practice address is www.theshowcenter.com stands for Sexual Health Optimization and Wellness. I'm licensed now in seven states but it soon it will be 11 states total. I'm adding in Washington, Alaska, Nevada and I'm missing one of them. I can't even remember but they're those are coming soon. And then I just launched today on August 26th, I'm five years open for my show center and it's the birth of the Q-Spot. So that's kind of my love letter to clinicians that it's time to step up. It's time that we start learning this evidence-based care.

[00:42:55] I have tons of coursing in there, downloads in there, mentorship and I want to be a space for, really truly advanced practice providers to be able to come and learn everything that they deem is important in women's care to care for women. Yeah. My new website is theqspot.net.

Cynthia Thurlow: [00:43:17] Love it. Thank you again for all the work you do Heather. 

Heather Quaile: [00:43:19] Thank you for having me. 

Cynthia Thurlow: [00:43:23] If you love this podcast episode, please leave a rating and review, subscribe and tell a friend.

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