Ep. 500 Why Women Are Being Gaslit by Medicine – The Bold Truth About Hormones, SSRIs & Social Media Censorship with Dr. Kelly Casperson

Today, I am thrilled to reconnect with Dr. Kelly Caspersen, a urologist who empowers women to live their best love lives. She is a two-time author, with her latest being The Menopause Moment.

In our conversation, we cover a wide range of topics, from navigating UTI purgatory and understanding the vaginal microbiome to how vaginal estrogen can dramatically reduce the risk of sepsis and death in the ICU. We unpack the evolving language of hormones- specifically progesterone, estrogen, and testosterone and we examine censorship and bias on social media, and the differences between prescribers and non-prescribers. We explore the effects of SSRIs on bone and brain health, changes in self-perception in middle age, and the effects of the baby boomer generation and the Women’s Health Initiative, exposing the medical gaslighting behind the use it or lose it narrative. We also offer practical options for women who cannot take hormones, and Dr. Kelly shares her go-to supplements and those she avoids.

This conversation is one of my recent favorites. Dr. Kelly’s enthusiasm is contagious, and her straightforward approach makes complex topics clear, practical, and unforgettable.

IN THIS EPISODE, YOU WILL LEARN:

• Why recurrent UTIs can feel like UTI purgatory

• How hormone terminology is evolving, and what that means for women in midlife

• The value of vaginal estrogen, and the potential it holds for saving women’s lives

• How the approaches of prescribers and non-prescribers differ

• How SSRIs can raise the risk of bone fractures 

• The brain health and self-perception shifts that often occur in midlife 

• Why the use it or lose it belief is misleading, and how it veers into medical gaslighting

• How the baby boomer generation and the Women’s Health Initiative still influence women’s healthcare today

• Some alternative options for women who cannot take hormones

• Dr. Kelly shares her preferred supplements and those she avoids

Bio: 

Dr. Kelly Casperson, MD

Urologist • Author • Podcaster • Women's Health Thought Leader

Dr. Kelly Casperson is a board-certified urologist, best-selling author, and top-ranked international podcaster empowering women to take control of their health, hormones, and sexuality. Known for blending science with storytelling, she transforms complex medical topics into relatable and actionable insights that help women live fully and fearlessly—especially in midlife.

With her signature candor and evidence-based clarity, Dr. Casperson dismantles long-held myths around sex, menopause, and desire. Her acclaimed podcast, You Are Not Broken, has become a go-to resource for hundreds of thousands of women seeking real answers about their bodies and brains. Her groundbreaking work integrates urology, neuroscience, and mindset coaching to drive lasting change in intimacy, confidence, and overall well-being.

As a keynote speaker and educator, Dr. Casperson challenges outdated norms in medicine while offering bold, science-backed solutions. She’s on a mission to build a world where women are educated, empowered, and no longer afraid of their own bodies.

Whether she’s on stage, in a clinic, or behind the mic, Dr. Casperson is leading a health revolution—one smart, honest conversation at a time.

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“If you’re stuck in UTI purgatory, you need to look at the vaginal microbiome first.”

– Kelly Casperson

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Connect with Cynthia Thurlow  

• Follow on⁠ X⁠,⁠ Instagram⁠ &⁠ LinkedIn⁠

• Check out Cynthia’s⁠ website⁠

• Submit your questions to ⁠support@cynthiathurlow.com⁠

Connect with Dr. Kelly Casperson

• On her website

• On Instagram

• You Are Not Broken (Podcast)

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 reconnecting with Dr. Kelly Casperson. She's a urologist who empowers women to live their best love lives. She's also a two-time author and most recently of The Menopause Moment.

[00:00:45] Today, we spoke about UTI purgatory and the vaginal microbiome, how vaginal estrogen reduces our risk of sepsis and death in the ICU, changing and evolving terminology for hormones, specifically progesterone, estrogen and testosterone and censorship and bias on social media, the impact of prescribers versus non-prescribers and messaging across social media, how the antidepressant drug class SSRIs impact bone health and the impact on bone fractures, how brain health changes in middle age and how we have changes in perceptions of ourselves, the impact of the Baby Boomer generation and the Women's Health Initiative, the impact of the midlife awakening, why use it or lose it is false and medical gaslighting. And last but not least, options for those that are unable to take hormones, which isn't many people, and supplements and things she strongly dislikes.

[00:01:50] This is one of my favorite recent conversations on the podcast. Dr. Kelly's enthusiasm is infectious and she has a no nonsense, very straightforward way of communicating. I know this will be a conversation you'll want to listen to more than once.

[00:02:10] Dr. Kelly, so good to have you back on the podcast. Really enjoyed reading your most recent book. 

Dr. Kelly Casperson: [00:02:15] Thanks for having me. 

Cynthia Thurlow: [00:02:17] Absolutely. Before we started recording, we were talking quite a bit about things that we can do to improve our quality of life. And we were laughing about VO2 max testing and in the same breath talking about vaginal estrogen. Talk to me about UTIs being a form of purgatory, which is something that I think for listeners is really important because every woman listening, with probably no exceptions, will benefit from replacing estrogen in her vaginal vault. 

Dr. Kelly Casperson: [00:02:52] Yeah. So, I tell women like, you're in the pit of despair-- You're in the recurrent UTI pit of despair and my job is to help you get out of it. Because they're like, “I'm here. It's awful. I'm going to be here forever.” And I'm like, you just need to know that there's a lot of women who are like, “Oh, yeah, two years ago I had that problem and I don't have it anymore.” You have to give them the light at the end of the tunnel because they really feel like this is my lot. My lot is recurrent UTIs. And I think what's missing both in the physicians and in the patients is a fundamental understanding of why it's happening in the first place. And I'm a urologist. I live in the pelvis, I trained in the pelvis and I was trained, we don't know why, right? 

[00:03:29] So, I've come a long way. So, we do know why, our microbiome changes when our hormones change. And a lot of people think menopause is a hot flash and no periods, but those are actually symptoms that happen because of what actually happens, which is declining hormones to the point of zero for estradiol. So, we need hormones everywhere. We have receptors everywhere. Our pelvis is no different. Clitoris, vulva, vagina, bladder, urethra, all of the genitourinary structures. And when estrogen goes away, we lose our microbiome and microbiome's hot right now. So, now people are paying attention. 

[00:04:04] So, when your microbiome changes, you're more susceptible to the nasty poop bugs crawling up to the bladder area because the vagina acts as a moat or a barrier because of its acidification. Poop bugs hate the acid environment that's created by Lactobacillus, which likes estrogen. So, kill off the estrogen because of menopause, kill off the lactobacillus. Now the E. coli and the poop bugs can walk across the moat and get to the bladder. And people say, “I don't know why it's happening,” because you don't have a good microbiome. So, you actually have to rebuild your microbiome by using a low-dose vaginal estrogen product, incredibly safe, incredibly cheap and now we have 2025 genitourinary syndrome of menopause guidelines published by the American Urologic Association, free online, you can print them out, you can go in. And there is no drug that helps prevent urinary tract infections like vaginal hormones, decreases them by 50%. There's nothing better than that.

Cynthia Thurlow: [00:05:03] And it's not even the pesky, urinary frequency, urgency, feeling like you have a urinary tract infection. We're talking about prevention of the sequelae of what comes when older women develop urinary tract infections. And I know you've seen this, I've seen this. In fact, how many patients. And it sometimes also happens to men, but more commonly in women, they actually will get a blood infection. So, they get a urinary tract infection, they become septic, they get a blood infection and then in many instances they get so sick they end up in the ICU. They end up dealing with whole sequelae of other issues related to that. I have a family member, God bless her, she got septic and she couldn't tell anyone that she had a visual change. 

[00:05:52] She ended up having a retinal infarct and lost a substantial amount of her vision. And I recall when she was in the hospital, my husband called me and said, “This is what she's reporting” and I said she needs to have a stat head scan and asked them to call the physician immediately. And she ended up having this retinal infarct. And so, I think about how many women that I took care of in cardiology that were either in the hospital or in my office and they were all on chronic low-dose antibiotics to help prevent something that you and I both know now could have been remedied or even never dealt with again if they had been offered vaginal estrogen products. 

Dr. Kelly Casperson: [00:06:42] Yeah, yeah, absolutely. And the other problem with the chronic low-dose antibiotics is you're more likely to be antibiotic resistant. Because the bugs will learn to survive in addition to those antibiotics. So, there is an abstract this year. This was not a published paper yet, but abstract, I think it was at a urology meeting. So, women with recurrent UTI on vaginal estrogen, decreased risk of sepsis, decreased risk of ICU admission, decreased risk of death. So, now we actually have data that says vaginal estrogen decreases your risk of death if you are a person with recurrent UTIs. So, between recurrent UTIs and bladder leakage, bladder leakage falling when you get up at night to pee, these are the number one reason that people end up in nursing homes. So, it's like low-hanging fruit. 

[00:07:31] Vaginal estrogen has been around forever. The most expensive part of that product is the tube it comes in. So, get it for cheap. Mark Cuban Cost Plus Drugs is a wonderful online pharmacy where you can get it very, very cost effectively. Do not be paying more than $60 for your vaginal estrogen because it is a chronic medication. If you stop using it, I think that's something I see commonly is people are like, “I use the tube.” I'm like, “No, no, no.”

Cynthia Thurlow: [00:07:58] Forever.

Dr. Kelly Casperson: [00:07:59] You don't understand that after menopause your hormones are always low unless you give yourself hormones. So, you have to educate people to be like, “You'll go back to how it was if you don't keep using this stuff.” But the biggest barrier still is the FDA box warning, which says stroke, heart attack, liver failure, blood clot, probable dementia. 

[00:08:22] A physician just texted me this week that a woman came in with a stroke. The ER doctor blamed the vaginal estrogen for the stroke. And you're like, “Physiologically it's impossible that causing a stroke,” it's low-dose skin care, it does not increase clotting factors or bleeding. But because there's a boxed warning that says it does, people who aren't educated, they don't know. They don't know what's wrong. They don't know that the data has disproven all of this. So that's part of our advocacy and why went to the FDA in July to just say, “Hey, FDA, you actually have a chance to make a difference. And 30% of women, if a woman's lucky enough to get a prescription, 30% will then not use it because of what's written on the box warning that's a published study that some urologists did.

Cynthia Thurlow: [00:09:12] That's incredible. So first and foremost, thank you for the work that you're doing. I have made sure that I shared the actual meeting with our entire list and shared it across social media because I think this work is so vital and essential. But the unfortunate thing that many people are still deterred from taking vaginal estrogen because of the black box warning, which as you astutely stated, is completely incorrect. And then the other piece of that is, there's been this meeting of the minds, many in the menopause, perimenopause space talking about changes in terminology because we have boiled down estrogen, progesterone and testosterone to “sex hormones.” And there's so much more than that. Why is the terminology so important not just for listeners, but also for other clinicians as well? 

[00:10:01] Like I am catching myself before I even say, “Oh, sex hormones, no,” it is so much more than that. That terminology is boiling things down that it's just about sex. And it really is so much more than that. 

Dr. Kelly Casperson: [00:10:13] Yeah, totally. I mean, just because we discovered these in rooster testicles and bull ovaries doesn't mean we have to keep calling them these things. So, historically, that's where they came from because that's where we found them. I just got pissed off because I'm like, “I can't say sex on Instagram.” Like, they'll ban me, they'll kick me off. They'll let somebody be completely effing naked. But I can't say sex hormones. [Cynthia laughs] I just got so pissed off with the bias on there and the fact of, like, “Oh, my God, I just can't say sex at this point.” So, we need to really stop calling them this. So, I got feisty about that. 

[00:10:46] And then another person's like, “Let's not call them menopause hormones,” because that excludes the perimenopause people, the breastfeeding people, the people who are 75 and they forgot that they're post-menopause because their periods were 20 years ago. So, even the word menopause really is exclusionary when you get into it. Okay, don't call it sex. Don't call it menopause. And so, we had a meeting of 22 of us, and we're like, “What should we call these things? What should we call it?” Because we're like, HRT. But even HRT, when people think that, they think estrogen. 

Cynthia Thurlow: [00:11:19] Yep.

Dr. Kelly Casperson: [00:11:19] Right. And we're like, “No, no, testosterone is a legitimate discussion, should be a legitimate discussion for everybody. There is no reason why not. Ovaries make four times the amount of testosterone than estrogen. We should talk about that and progesterone, especially the people who are like, they told me I can't have progesterone because I had a hysterectomy.

Cynthia Thurlow: [00:11:33] Oh.

Dr. Kelly Casperson: [00:11:34] Progesterone works in the effing brain. [Cynthia laughs] So, just calling it HRT makes you think estrogen and the WHI. So, we're like, “Okay, don't call it sex. Don't call it menopause. Don't call it HRT. What should we call it?” And we basically met for like an hour and a half, and we came up with PET therapy, which I think is still divided. Either precision endocrine therapy or progesterone estrogen testosterone therapy, because it's inclusive. It describes what you're using and we can't think of anything better at this point. Well, and that's where we are. 

Cynthia Thurlow: [00:12:06] Yeah. And then you can then use that terminology without concern for censorship bias, etc. And to me, it seems so silly that healthcare professionals are having a degree of censorship. It's fascinating. I think Rachel Rubin's quote, which I want to make sure I give her credit for what she said, because I even included it in my notes. And of course, now I'm looking for it in said notes. “If men's testicles fell off at age 51, there'd be a national vaccine for it.”

Dr. Kelly Casperson: [00:12:36] Yeah, that's true. 

Cynthia Thurlow: [00:12:37] Yeah. I mean-- [crosstalk] 

Dr. Kelly Casperson: [00:12:39] You could get a shot of testosterone at the 7-Eleven. Like, I'm being flip, but it matters. This was actually a man who said this this week on Instagram. I can't remember his name, but he's like, “If a man's risk of heart attack tripled in one day, we would have a task force on that.” And he's like, “And it's called menopause.”

Cynthia Thurlow: [00:12:59] Yeah. And I am so grateful that it's our generation that is helping to shift this narrative. 

Dr. Kelly Casperson: [00:13:06] Yeah. 

Cynthia Thurlow: [00:13:07] You did a great podcast and you talk about this in the book. And I think that it's our mother's generation. They call it boomers, the baby boomers. They should be mad because they took the bulk of the hit of the WHI's impact. And so, let's talk about some of the statistics around this. It made me angry to read them, quite honestly, when you started to realize the impact of-- [crosstalk] 

Dr. Kelly Casperson: [00:13:30] [laughs] It's working. 

Cynthia Thurlow: [00:13:32] Yeah.

Dr. Kelly Casperson: [00:13:32] I mean, that's what's so crazy, is like, we have data. What drives me nuts is I always agree when people say, “Hey, we need more research on women's health.” Yes, absolutely, I agree. But to say we don't have enough to actively act on it and prescribe wisely at this point is you just not understanding the data we have. And that's what I really wanted in this book of, like, let me dump it enough to you to be like, “Look at everything we have at this point. Use it.” And, yeah, anger's a good-- Heather Hirsch says it best, like, “Anger's the first stage.” 

[laughter]

[00:14:01] Once you're like, “The anger is where we start.” Yes. Because you're like, “Oh, my God, how do we know all of this? And yet we do nothing.”

Cynthia Thurlow: [00:14:09] Well, isn't it a degree of cognitive dissonance? It's like, “Oh, we've been doing this for so long. Why would we question it?” I feel like in so many ways I finished my NP program, God, in December of 2000. So, like I really, in 2001 was a baby nurse practitioner. And then in 2002 the WHI came out. I was neatly tucked away in cardiology where I was told to stay in my lane. How many of my patients were in the office or in clinic or in the hospital telling me that all of a sudden, they had been on hormone replacement therapy and all of a sudden everything was stopped abruptly. They had terrible pain. They had vasomotor symptoms so many of them would talk about.

[00:14:49] I feel like I was a safe person to talk to about sexual-related issues and I would have to refer them back to their GYN or their internist because in cardiology they're like, “We don't want us touch any hormones whatsoever.”

Dr. Kelly Casperson: [00:15:02] Yeah, I know, it's crazy. Even in cardio-- the cardiologist, if you read papers in the 1990s, the cardiologists are like, “Hey, this is preventative. Hey, should we just be putting it like they were having the conversation of should we put people on this as prevention?” Like that's where they were they, the WHI so wrongly misinterpreted. But we can actually use the WHI data now when we look at the boomers to say, is it safe to start greater than 10 years post which by the way, no medical society says it isn't safe. Everybody says you can't. And I'm like, “Where's that written?” [Cynthia laughs] It's not. They say the best benefit is early because these hormones work best by prevention.

Cynthia Thurlow: [00:15:42] Yeah, absolutely. 

Dr. Kelly Casperson: [00:15:43] We can't change that. But the cardiologists, they were the ones seeing this group of women on hormones are having way less heart attacks, way less congestive heart failure, lower blood pressures, lower cholesterol. So, the cardiologists were at the forefront and then they're like, “Well, let's prove it with a randomized placebo-controlled trial in a way that didn't pan out well for people.” But if you look at the 18-year follow up of the WHI, because I think we spend a lot of time poo pooing the WHI and not using what we actually can to use that data.

[00:16:15] So, if you look at 18-year follow up published in 2018 or 2019, Rossouw, who did the first WHI paper, so that's the WHI researchers almost a decade on, no increased incidence of cardiovascular disease between the placebo arm and the treatment arm at 18 years follow up. So, here we are like, “Oh, we can't start the 70-year-olds on hormones because it's going to give them heart disease.”  Really? The oral synthetics didn't and now this is transdermal, which is way safer. So, it's like, “Use the data we have man,” challenge, status quo.

Cynthia Thurlow: [00:16:46] Yeah. Isn't it important of shared decision making, talking to the patient and saying, “Yes, you're 10, 15 years into the menopausal transition and let's do some risk assessment, let's talk about your symptoms that you're experiencing.” And I think for many women, because they are not experiencing terrible vasomotor symptoms, they're not having terrible hot flashes, maybe their bones are still healthy, they're like, I don't need hormones. And I'm like, that's the unfortunate thing, is that brewing beneath the surface is this evolving endothelial dysfunction. We know the number one killer of women is heart disease. And certainly, when I retrospectively think back to some of the things that we used to say to female patients, oh, it's normal to see some left ventricular remodeling, it's normal to have more atrial fibrillation in the menopausal time frame.

Dr. Kelly Casperson: [00:17:39] Now you're like, oh, God. Number one visit to a cardiologist of women in their 50s is heart palpitations. 

Cynthia Thurlow: [00:17:45] Yep. How many event monitors and Holter monitors did we place? And you just pray you wouldn't catch a-fib, atrial fibrillation. 

Dr. Kelly Casperson: [00:17:52] Well, so many women, they're like, “It was normal and then they're dismissed but they're still having heart palpitations.

Cynthia Thurlow: [00:17:58] Courtesy of low estrogen. 

Dr. Kelly Casperson: [00:18:00] Yeah. So, I write about that in my book, “Estrogen literally acts on the sinoatrial node in the heart. You take estrogen away, it gets a little wonky in there.” So, it all like, once you understand, you're like, “Oh my God, it all makes sense.” 

Cynthia Thurlow: [00:18:13] Yeah, yeah.

Dr. Kelly Casperson: [00:18:14] It all makes sense.

Cynthia Thurlow: [00:18:15] There's a statistic that you mentioned in that chapter. You say somewhere between 19,000 and 90,000 women have died due to being denied hormones. I mean, that is-- [crosstalk]

Dr. Kelly Casperson: [00:18:23] That's the [unintelligible [00:18:22] Sarrel paper. 

Cynthia Thurlow: [00:18:25] Yeah.

Dr. Kelly Casperson: [00:18:26] That's multiple years old at this point. And so, it's like, that's not even updated. That's only heart disease. That's a heart disease specific factor that's not looking at suicides, death from hip fracture. So, I talked to Dr. Vonda Wright recently, I'm like, “You need to do a Sarrel [unintelligible [00:18:45] paper on death from bone fracture since the WHI. 

Cynthia Thurlow: [00:18:50] Yeah. 

Dr. Kelly Casperson: [00:18:50] And she's like, ‘My team is on it.” Because I'm like, “Where is that” to understand and you brought this point up is like when that 73-year-old in your office, people are like, “Oh, it's too risky.” Okay, challenge that. It's actually not, but there's a benefit to it. And that's what-- And I think people are like, “Oh, you're that far past menopause, you don't have any symptoms.” It's like, “The average woman will say she doesn't have symptoms.” Then you educate her what symptoms are. She's like, “Oh, yeah, I haven't slept great in 20 years. Oh, my anxiety is way worse. Oh, I thought it was just a warm human.” No, those are hot flashes. You start educating them or you just do a trial of hormone therapy and they're like, “Oh my God, I think I've been like this for 20 years and didn't know it was menopause.” And you're like, “Uh-huh.”

Cynthia Thurlow: [00:19:35] Yeah. 

Dr. Kelly Casperson: [00:19:36] I tell people like, I sailed through menopause. And then you talk to them and they're like, “I don't sleep, I sleep shitty.” Like, “Huh.” Like they don't know that that's a low hormone thing. 

Cynthia Thurlow: [00:19:45] Yeah. Well, how many nurses have I taken care of over the years that have said things like, I haven't slept in 10 years. I thought I had new-onset ADD, ADHD. And so, you start examining that maybe they're not having a lot of other symptoms, but it's like the mood piece, they're more irritable, they're more anxious, they have more lability to their moods. And that can all be a byproduct of estrogens, declines, alterations in serotonin and dopamine. And I think that this is why these conversations are so critically important. Because to your point, a lot of women are just thinking, “Oh, I'm sailing through really beautifully, quietly. There's no need for me to take hormones.” 

[00:20:30] And yet, when you do buffer their hormones, all of a sudden, they feel so much differently and are able to interact with not just their friends, their family, their loved ones, occupationally. Otherwise, they're like, “Oh, I feel like I'm myself again.” 

Dr. Kelly Casperson: [00:19:45] Huge. And the problem with feeling like yourself, number one, it's massively common in perimenopause they're like 40% to 60% of women don't feel like themselves. But the problem with that in the medical world is I can't measure what Cynthia feels like and how that's different than what Cynthia used to feel like. Like, it's not objective. I don't know how to believe you on that. I can't like touch it. I can't x-ray it. I can't draw a lab. I can't be like, “Great, we got you feeling like yourself again. Can't you see this data?” And so, it's really not tangible thing that-- I would argue one of the most important things to help people with, but is very, I don't say woo-woo, but it's just very like-- it's in the ether. 

[00:21:26] And so, there's no ICD10 code for feeling more like myself. [Cynthia laughs] So it's this very completely neglected. But when a woman gets it and she's like, “I feel like myself now.” I just had one, I just had a perimenopause patient. She'd literally seen five other doctors. She's being worked up for obscure autoimmune stuff, which is frightening. But would be happy to have answer. So, I started her on a low-dose patch and some progesterone at night and she's like, “I get what feeling like myself feels like. I get what it means when people say that now because I'm back.”

Cynthia Thurlow: [00:22:01] So, important. 

Dr. Kelly Casperson: [00:22:02] Yeah, once you don't feel like yourself and then you feel like yourself, you're like, “Aha, I got that.” But until that happens, I don't know what does Cynthia feel like? I don’t know. It's incredibly important but not objective. So, I think it gets invalidated in medicine. 

Cynthia Thurlow: [00:22:18] Yeah, no, absolutely. Because we like numbers, we like data, we like quantification, and sometimes in circumstances like this, we can't per se quantify. We just don't have some discernible like, “Oh, here's a test we're going to give you.” And if you score X, it means this worked, and if you score Y, it means it doesn't. I think this is certainly the beauty of practicing medicine is it's an art and a science. And I think sometimes people forget about that. I think that we've gotten so pigeonholed into thinking, like, everything has to be quantified in order for it to be correct. 

Dr. Kelly Casperson: [00:22:54] Yeah, well, I get this all the time, like, what's your ideal estrogen level, testosterone level, blah, blah. And I'm like, “Ask the woman how she feels.” 

Cynthia Thurlow: [00:23:03] This is huge.

Dr. Kelly Casperson: [00:23:04] And it's also like, lab values are not everything. They're not the ten commandments. [Cynthia laughs] They change throughout the day. 

Cynthia Thurlow: [00:23:11] Yep. 

Dr. Kelly Casperson: [00:23:12] Right. And so, but people, like, they just want something that's very tangible and there's also a decent amount of like, “Am I doing it right? Is this good enough? Does Cynthia have a lab value that I need to know so I can be optimized? There's all of that, like, comparison shopping happening, but at the end of the day it's like, “Are you sleeping? Do you feel like yourself?” 

Cynthia Thurlow: [00:23:32] Well, I think that I've learned this through you, especially about testosterone, because for me personally, I know that my provider, as open minded as he is, he has like a range that he wants his testosterone levels to be within. And I had to explain to him, like, I feel better when my free and my total are here. And that's a little outside your comfortable range, but I'm not having like untoward symptoms. I'm not having acne. My voice has been deep my entire life. It has not changed. Thank God. All the things that are showing, like androgen excess are not an issue. 

[00:24:06] And I actually pointed him to one of your podcasts and said, “I really think we have to personalize our patient’s experiences” because if we certainly-- if we just say it has to between X and Y, that might not be optimal. 

Dr. Kelly Casperson: [00:24:19] You're giving so much power to the lab. 

Cynthia Thurlow: [00:24:20] Yep. 

Dr. Kelly Casperson: [00:24:21] First of all is like, you do not understand how many testosterone receptors do you have? How many CAG repeats on the end of the-- To me, I'm like, there's so much going on in your body that to use one serum lab from one timeframe, from one day to be like, this is how it is in there is like blind. So, how many receptors do you have? How sensitive are your receptors to testosterone? What does your serum level have to before enough gets in your brain? Brain testosterone levels are different than serum testosterone levels. So, it's like, once you learn all of that, then you can comfortably be like, “Okay, the labs are a weak tool to make sure we're not underdosing or overdosing or blah, blah, blah, blah.” 

[00:25:03] But it's like one woman's 80 is and another woman at 80 is like, “Oh my God, I hate this.” She might be super sensitive to it or super absorber of the product. Maybe she needs to go down because she just, like, sucks it all in because her dermis is different. So, it's like, the more that you learn, the more you realize, those tools are not God, do not go by them. There's too much going on underneath the surface that, that tool can't measure. 

Cynthia Thurlow: [00:25:27] I think that's really important. I know when my testosterone is where it needs to be. Number one, my executive function, which is pretty good on a good day, is even stronger and I think about sex like, I'll be totally transparent. That's how I know. Like, that is my litmus test, because my body is much more sensitive to alterations in testosterone than maybe someone else. And that's my tell. That's like, okay, we're at the right level for you, might be a different level than my neighbor or you or someone else. I think on the flipside, Kelly, I want to talk about something that I find really frustrating on social media. Individuals who are not prescribers- [crosstalk].

Dr. Kelly Casperson: [00:26:08] Preach. 

Cynthia Thurlow: -who try to mansplain women not needing hormones.

Dr. Kelly Casperson: [00:26:16] Jesus Christ. [Cynthia laughs] Amen. Say it louder and slowly for the people in the back. If you do not give women hormones, if you do not prescribe, you are not allowed to say with any sort of authority what it is. Now you can say, “In my experience in the gym, X, Y, and Z. In my experience on the chiropractor table, X, Y, and Z.” But if you do not prescribe hormones, you are not allowed to say things such as, -“Hormones are band aids,” Hormones are not band-aids. If you say hormones are band-aids, you do not understand how hormones work. They literally go inside your cell, into the mitochondria and help the efficiency of the engine function better. That is, by definition, not a band-aid. You're not allowed to say that. 

[00:26:57] Like, to me, I'm like, it's such ignorance to say that a hormone is a band-aid, because it's literally not what a hormone is. But it sounds authoritative when you say it on Instagram. And so, literally this week, I was like, “Oh, my God, this person's saying hormones are band-aid. They don't prescribe. They didn't go to a school that teaches hormones to my knowledge.” And you're not allowed to say that. It sounds authoritative, but I can't make them not say that. All I can do is go on podcasts and write books and be like, this is how hormones work. So that a woman can think for herself. Is that how a band-aid works? No, that's not how a band-aid works. 

Cynthia Thurlow: [00:27:31] Yeah, no, I. And I think it's important because typically, I try to rise above the nonsense on social media, but every once in a while, I have to stop. My husband came to me one day and he said, “Oh, this individual on social media saying, X, Y, and Z.” And to your point, I was like, this is someone who cannot legally prescribe, who is shaming women, which drives me crazy because I'm so protective of my community and the women I interact with. I'm like, “How dare you shame people into thinking that hormones are a band-aid or a crutch as they indicated.” I was like, “You cannot do yoga or pray to replace hormones.” Like, it doesn't work that way. Is it important to manage your stress? Absolutely. 

[00:28:16] But I think if you were taking your ability to communicate with the social media realm, like, you should use your talents for good and not evil. Like, I think, they do a lot and this is women then come to you, to me, to other people, and they start doubting themselves. 

Dr. Kelly Casperson: [00:28:34] Right. Yeah. Well, and I think that's where we get to do the fun job of empowerment, to be like, “What's that person's degree? Are they qualified to say that? Okay, all right, we've decided they're not now.” Okay, so why are you giving them that power? Because I think women will they'll throw up their hands and be like, “I'm so confused.” And I'm like, “Not if you have critical analysis and thinking skills.” Because you're like, that person did not go to a place where they learned about hormones. Plus, they don't prescribe hormones. How many women have come back to my clinic with X, Y, and Z I'm better because of hormones. And I'm like, “Yeah, but it's just a band-aid. I just gave you band-aid.” [Cynthia laughs] 

[00:29:08] No, I'm fundamentally changing the health of their cells on a molecular structure. And you can biochemically understand that by definition, not a band-aid. So, it's like, critical thinking skills will get you out of there, but a lot of women, they don't have or they just think everybody on Instagram's an expert. It's like, “Dude, I'm not an expert in a lot of things, but I can share my opinion on things.” But I don't go around saying that the Big Bang theory isn't true, because I've got a better idea. [Cynthia laughs] Like, I didn't get trained in that. So, it's like, use your critical thinking skills. Because people are like, “Who do you know how to trust?” And I'm like, “Well, see what their credentials are.” And yeah, it takes some work.

[00:29:51] But like, “Hey, if you're going to listen to their advice, you might as well put in the work of realizing if it's legitimate or not.” I think that's fair. 

Cynthia Thurlow: [00:29:57] Absolutely. And I think it doesn't mean that we aren't entitled to have different opinions. It just means if you're going to take medical advice, be conscientious and careful about who you take it from. 

Dr. Kelly Casperson: [00:30:09] Yeah. And medicine's complex we're not all Toyotas. 60 seconds on a reel is actually not the best place. Like, that's why podcasts are so great. Because you can actually listen and explain and clarify and get a much deeper understanding of it than like. Because, I'll do a reel and then people will be like, “But you didn't explain.” And I'm like, it's a 60-second Instagram reel. [laughs] Like, you can't literally explain. 

Cynthia Thurlow: [00:30:33] You're like, that's why I have a great podcast and that's why I write on Substack. 

Dr. Kelly Casperson: Yeah, exactly. Because you can actually get into stuff. But I think the other thing just for to go on what you said is, people are like, “Why can't everybody agree?” I'm like, “Well, that's not how the world works.” There is literally some people who still think the earth is flat, which is like nuts. Like, didn't we settle that one? But we still are-- Some people still disagree on that. [Cynthia laughs] But it's like, even within what thought leadership is and in the menopause world is like, we agree on a lot of things. We can easily do top 20 things that are just true at this point. Birth control is not the only thing to do for perimenopause. Yes, you can take progesterone when you've had a hysterectomy. Testosterone is a hormone that the ovaries make. 

[00:31:17] Like, there are some vaginal estrogen and systemic estrogen, both reasonable to take at the same time. Like, we could do a top 20 of things all the experts actually do agree on, because we agree on a lot. And then there's the nuances because we all have a little bit of expertise on this and we're a thought leader more on that and blah, blah, blah. It's like there's stuff we don't agree on, but by and large, we agree on a lot of stuff. 

Cynthia Thurlow: [00:31:41] Well, and I think it's really important because everyone's coming to these conversations from a different perspective. You're a urologist, you're also a surgeon. Someone else may be doing internal medicine, someone else is a neurologist, someone else works in primary care. And so, everyone has their differing perspectives. But I agree with you there's a lot of commonality and then there's nuance. And again, it goes back to medicine is both an art and a science. And probably when you were a newbie resident and when I was a newbie nurse practitioner a million years ago, it was all more like, I made decisions based on facts all the time. And then it became this art and the science of a gestalt. You walk into a patient's room, you hear a conversation, you're like, “Oh, I'm thinking this.”

[00:32:23] Although I don't yet have enough information to support that, that is the direction we're moving in. And I think for listeners to understand that this is where experience and our differing backgrounds can have a large impact on our perspectives. And it's not that one is right and one is wrong. It's that we're all evolving in different ways. And I think our generation is shifting the narrative. I think our parent’s generation really, in many instances, literally the floor was ripped out underneath them and they were told, “Just deal with it.” So, we're going to put you on antidepressants, we're going to prescribe medications that address other symptoms. We're just not going to replace your hormones. And that's just the way things are. 

[00:33:03] And one thing that we were talking about before we started recording that I think is really important to identify and just talk about is a lot of women have been prescribed antidepressants. And there's one class of antidepressants, the selective serotonin reuptake inhibitors, that have a negative net impact on bone health. And why is this important? Because again, we have this whole generation of women that, for the most part, taken off of their hormones, were probably prescribed an SSRI. And it's not a question of if, but when. There is a negative net impact on bone health if you are taking one of these drugs. And I think this is significant in a population of women that are also concurrently not on hormones.

Dr. Kelly Casperson: [00:33:45] Yeah, thank you for talking about it. Because I would argue most people don't know that. And there's multiple meta-analyses on this. So, this isn't like, “Oh, we saw this once over here.” It's like, “No, no. There is enough papers that multiple meta papers about papers have been written on this, which is a whole another level of, there's enough going on that, we get to do a consensus on this, basically. And so, when I started seeing that, I was like, “Oh, my God, do we know about this?” Because, again, I'm a urologist. I don't prescribe SSRIs. And so, I texted my primary care doctor friend and I'm like, “Do you know about the rate of independent risk of bone fracture on SSRI?” And they're like, “No.” And then I texted my orthopedic surgeon friend. Because he sees hips for fractures all the time.

[00:34:31] And I'm like, “Do you know about this independent risk factor for bone fracture with SSRIs?” And he's like, “No.” And I'm like, “Okay, we've got 25% of midlife women in this country on SSRIs. One in four-- one in four people on SSRIs with a double hit for bone fracture. Because now you're not on hormones, and you're on something that independently increases your risk.” And they're like, “It's not from osteoporosis.” They think there's serotonin receptors in the bone. And so, it's an actual different mechanism than just osteoporosis and low hormones that's influencing the risk factor. And so, it's like, “Dude, talk about informed consent.”

Cynthia Thurlow: [00:35:07] Absolutely. 

Dr. Kelly Casperson: [00:35:08] We're so “afraid” of what our body naturally makes. So, we put you on these other things to treat the symptoms. And many will argue, especially in perimenopause SSRIs are used inappropriately for mood, that they're not getting an informed consent, let alone how difficult it is for people to get themselves off of these medications if they so choose to try.

Cynthia Thurlow: Yeah, I think that's significant. And for listeners, if you're on this drug, we're not saying to stop, Paxil, Prozac, Zoloft, Lexapro, etc. Just bringing greater awareness to the fact that you may need to have a DEXA scan earlier. I think it's criminal that—[crosstalk]

Dr. Kelly Casperson: [00:35:43] Yeah, DEXA won't pick up the SSRI risk because it's a different mechanism. But what you're saying is like, “Yeah, make sure you're keeping your bones as strong as you can.”

Cynthia Thurlow: [00:35:53] Yeah and I put this in my book. There is a randomized placebo-controlled trial of women in perimenopause. And they gave them estrogen patches versus a placebo patch. And these were not depressed women, they just said, what if we start these people on estrogen and these people on placebo and see who has more depression in a year because perimenopause is a huge risk factor for depression because of fluctuating hormones, which nobody knows. And at one year, 17% on the estrogen arm had depression and like 32% in the placebo arm statistically significant decrease in risk of depression at one year. 

Dr. Kelly Casperson: [00:36:30] And you're like, “Dude, nobody knows about that study.” But you're like, “Dude, perimenopause is this huge risk factor for it because of fluctuating hormones.” And you give people safe, just transdermal estrogen patch, just a safe, very low dose keeps you from bottoming out like just a nice little perimenopause estrogen patch. And it statistically significantly decreases your risk of depression at one year compared to placebo. 

Cynthia Thurlow: [00:36:57] I think this is important because I believe that a lot of what women hear about perimenopause is you have 20% to 30% greater fluctuations of estrogen in perimenopause and do it any other time in your life. So, they're thinking they're always high. But the point that you're making is you could have high-high and also low-lows and this can drive and exacerbate a lot of the symptoms that women are experiencing so much so that, we see these mood-related issues and I jokingly said to someone, “Oh my gosh, like, why aren't we starting women on progesterone replacement way earlier?” Like, “Why are we waiting until they're in the late stages of perimenopause when things are really magnified.”

Dr. Kelly Casperson: [00:37:40] Why then we do the whole like, are you suffering enough? 

Cynthia Thurlow: [00:37:42] Yeah, exactly. 

Dr. Kelly Casperson: [00:37:43] Is it enough? Is it enough suffering? And I think talk about things you hate on the Instagram. Like, I had a woman the other day, she's like, “I'm estrogen dominant.” And I'm like, “The problem with that is you are now going to carry that label with you until you're dead.” And post menopause, you won't be estrogen dominant. And most of perimenopause, you won't be estrogen dominant. But on that day, you got your labs tested, you had some high estrogen compared to some other things. And you literally have to explain to them because, again, you don't understand what perimenopause is. It is like you're not just riding high estrogen all the time until you're dead at 94. But they take that label that somebody gave them and then they wear it like a name tag, like, “I'm estrogen dominant.” 

[00:38:24] I'm like, “On that Tuesday, you were.” [Cynthia laughs] You might not be today. But it's a way to validate what people are feeling. And I understand why it happens. It's just not the whole picture. Especially, if you take a label and you hang onto it like a woobie, and you're like, woobie, have you met me?-- [crosstalk]

Cynthia Thurlow: [00:38:41] Like a labubu. 

Dr. Kelly Casperson: [00:38:42] Yeah, like my labubo. Like, this is me and my estrogen dominance is like, “No, it's not how ovaries work.” Like, no. But I understand again, on Instagram, it's catchy. 

Cynthia Thurlow: [00:38:53] Yeah. I've actually used the term relative. Like, progesterone and estrogen are like a seesaw. Up until you go into perimenopause, their job is to balance each other out. And yes, as you are making less progesterone, you may have relative more estrogen to progesterone, which can drive a lot of symptoms. But you're right, the day you have your hormones tested, they may be completely different two days later. And I think we, as a society, like labels, we like to say, like, I'm PCOS or I'm perimenopause, or I'm menopause, or I'm estrogen dominant or I'm progesterone deficient or testosterone deficient. I think we love labels because labels make us feel like we have power, we have information. 

Dr. Kelly Casperson: [00:39:35] Yeah, egos. Egos love labels. [Cynthia laughs] It's identity. We love being in, like, that's just the human nature. 

Cynthia Thurlow: [00:39:43] Why do we care a lot less in perimenopause and menopause, as you put, giving less fucks, which I love. 

Dr. Kelly Casperson: [00:39:50] I think there's multiple reasons. Truthfully, I think there's multiple reasons. People want to really peg it on lower estrogen. And there might be some truth to that and there's great trans data on this. If you give trans women high-dose estrogen. They're like, “Oh, my God, I'm crying. My orgasms are different.” Like, literally, your body experiences the world different when your estrogen's high versus estrogen low. And we learn a lot from trans dating with that. And so, yes, your estrogen is going down that nurturing, that caring for others, like, is everybody okay? How's everybody doing? Like, hormones change. And I don't think that's everything. I think wisdom, I think experience, I think laps around the planet. I think putting up with enough bullshit.

[00:40:34] I think enough years of living in a society where you see the bias and you see how gender differences really do drive how you experience your life. Like, that's not all just hormones going down. There's a certain level of like, “I do not stand for this anymore.” 

Cynthia Thurlow: [00:40:55] Well, I even think back, I left traditional allopathic medicine nine years ago and started my own practice. And when I worked for this very large cardiology group, there were a lot of great physicians and that I worked with who were super supportive. And it was a very collegial environment. And then there were a couple outliers because cardiology attracts some people with strong egos. And I recall I got along really well with those people and it was because I was so accommodating. I was such a people pleaser. People would say, “Oh, we're going to let you work with doctor so and so, because they're really difficult and they love working with you.” And I was like, “I just was such a people pleaser.” And I think about that now, and I cringe because I'm like, I couldn't do it. 

[00:41:37] Like, I can't not talk about how I feel about things like that Cynthia is a totally different version than where I am now. And to your point, whether it's aging wisdom, a combination of perhaps a little less circulating estrogen, that makes you a little less accommodating. I think it's really fascinating to me how our brain recalibrates itself as we're navigating this perimenopause to menopause transition. 

Dr. Kelly Casperson: [00:42:04] Yeah. I think another one is, like, maybe you're not seeing where the finish line is, but you get an understanding of, like, I got this many years left. What's my plan? What's my life? What's my integrity? What do I get to say no to now? Because it's not in alignment. And I'm like, “It's not all hormones,” but I think we can't deny that hormones change. And I'm not saying it's not hormones. I'm just saying you can't discount years on the planet wisdom, putting in the reps. Like these difficult people, you don't need them anymore for your job. Like, of course you're not going to put up with them as much anymore, and so it's like there's so many different reasons and I think the overall takeaway is like, embrace it, man. 

[00:42:43] Like we, nature changes by definition and we're in this really weird society where we think everything should be the same or we should actually be getting younger. Like, it's like trying to change the laws of physics and-- but you don't get to-- you don't get to, change is what this earth is. And I think there's this fear of change, but man embracing it is like, this is what nature is. Nature's changing. Nature is getting older. You get to be a different you than you were when you were 22, because your survival needs are different, right? There's so much beauty in it that I think people, once they see that and get it, they're like, “Oh yeah, fuck it, let's bring it on.” What do I want to do? And then you get a little bit of hormones back and they're like, “I decided to start a business.”

Cynthia Thurlow: [00:43:36] Yeah.

Dr. Kelly Casperson: [00:43:37] Right. Amazing things happen. 

Cynthia Thurlow: [00:43:38] Yeah, absolutely. You have the emotional bandwidth to be able to be creative. Like I feel like I have a 20-year-old and an almost 18-year-old and I've loved every stage of parenting. Let me be really clear. I could not be more excited about where my boys are at this stage of life. But 20 years ago, I did not have the emotional bandwidth to be able to like contemplate reading books because I was so tired all the time. And now I'm like, you can create and do all these dynamic things and I think middle-aged women have the ability to be more creative and that could manifest in different ways. 

[00:44:10] But we have the bandwidth to be able to do more and to contribute maybe more to society as opposed to just focusing on like our family unit or maybe occupationally. It's like we're just thinking broader.

Dr. Kelly Casperson: [00:44:21] Yep. Yeah. To me, I'm like, “Dude, embrace the wisdom of the years, embrace the wisdom of you having done this enough that it's not new anymore.” We know how to tie our shoes now. What else do you want to do? There's just so much cool stuff and such an amazing world to explore. And you talk to the women who have those midlife crises or whatever you want to call them, like, these big awakening moments. It's hard, it's painful, it's disruptive. But on the other end of it, they're all like, “Oh, my God, I'm myself.” Like, you find yourself and you just need enough years to discover who you are at some point. 

[00:45:03] But then you realize, like, maybe I was not in integrity for survival or for whatever reason. And you get to this point of like, “Dude, what does Kelly want? What does she want?” And to become the most you of you is freaking awesome. And so, to me, that's like, the mindset part of the book is like, “Dude, this is a gift. But you got to see it as that.” Because if you truly believe that you shouldn't get older or you shouldn't decline or you shouldn't age or society should treat you better just because they should but they're not. Like, you're going to be stuck in this less creative integrity spot, which is a bummer, because it's pretty cool to watch women become the best themselves that they can be. 

Cynthia Thurlow: [00:45:48] Yeah. I jokingly tell my teenagers I was like, with the exception of marrying my husband and the boys, I'm like, the work I'm doing right now is the work that I knew I was put on this earth to do. 

Dr. Kelly Casperson: [00:46:00] Yep. 

Cynthia Thurlow: [00:46:01] And that's pretty cool. And I think for everyone listening, it could be some different variation of what you were supposed to be doing. And so, finding that reframe, I think, is so important. 

Dr. Kelly Casperson: [00:46:12] A couple years ago, I was like, “Oh, my God. I think I was put on earth just to tell people to use vaginal estrogen.” [Cynthia laughs] And I'm like, is it possible to have that narrow of a niche? [laughs] Yep, that's what I'm here for. 

Cynthia Thurlow: [00:46:25] Yeah. Well, when I think about some of the terminology that you and I probably both were exposed to in the beginning, senile vaginas, demented vaginas. How things have evolved in terms of suffering with silence for you, why is the kind of use it or lose it terminology? Why is that intrinsically false? Because I was taught that, you should continue having sex even in menopause, even if it hurts, because if you don't, then you're literally going to lose the ability-- [crosstalk]

Dr. Kelly Casperson: [00:46:57] Because it's going to hurt worse. It's so awful, it's so patriarchal. It's so the woman's role in a marriage is to be a vessel. It's so you, got to do something or else life gets worse. It's really bad. And it also takes the joy and the goodness and the transcendence and the spiritual and the amazingness of what sex is, and makes it a chore of, like, eat fruits and vegetables, five minutes of Zone 5 cardio. 

[laughter]

[00:47:26] Sex, it turns sex into a chore. And it's also rooted in no data. So, the original use it-- And I got my bee in a bonnet, it's an old podcast episode of mine now, and it was called Stop Gaslighting My Vagina. And it was my original use it or lose it rant. He was a physician online who basically was saying that you should have sex because it'll help. And I'm like, “Where's this coming from?” And so, I dove deep and even some guidelines that say that don't cite their sources. And so, it's like the ether. It's the zeitgeist with no data. So, you're like, “Where is this?”  So, I dug in, I dug in, I dug in and I actually have an amazing librarian who can access paper. They can go to the copier and actually copy journal articles that aren't online. So, it's a 1983 paper where it's called Senile Vagina Gynecology Clinic. Basically, physical exams on women saying, “Yep, atrophy or no atrophy.” What we call GSM now. And do you have sex? Nope, you don’t have sex.

[00:48:33] Okay, so there's a correlation study. The correlation study showed that women with more GSM have less sex. Yep. Could have told you that, but they validated that. Problem is, there was a new paper just this year published out of Japan doing the exact same thing. Come in, tell me if you have sex or not. Let's do an exam. Let's see who has GSM. Oh, turns out that the people with GSM have less sex, correlation study, not a causation study. So, let's take these painful, atrophic people and force them to have sex to see if their atrophy gets better. They didn't do that. But the media, in the beautiful way that media does, just like they did with the WHI said have sex to prevent atrophy. It's like, that's not what the studies show. 

[00:49:12] It's not what-- you took the study and you bastardized it and that gave women a chore. And so, I'm like, until there's data and the exciting thing-- and so first of all, women assume that sex means putting something uncomfortable in their vagina. It's not what sex is. That's one form of sex. So, like we've got massive problems in understanding what sex is in the first place, but there is compelling data. So, this is the use it or lose it asterisks that using a vibrator externally, we're not putting anything inside. We're not doing anything that hurts. We're just laying a vibrator on the external vulva for five to ten minutes, two to three times a week. That’s all we're doing. In preliminary studies, decreases GSM and lichen sclerosis and it also increases sexual function. So that's vibrator therapy, which means blood flow. And it can help with pain too.

[00:50:07] Just like a TENS unit on the back for back pain. Massage for pain. Like rubbing things helps pain. So that's the okay. Blood flow might be helping blood flow to tissues, just like cardiac rehab. Blood flow to the tissues helps cardiac rehab. So, that's where the use it or lose it does now have a moment of truth. But that's not a penis. That's not a vibrator inside. I want to be very clear, that the “have sex or else” is still a big piece of bullshit and not based in any science.

Cynthia Thurlow: [00:50:39] I think that's really important because I have girlfriends that will share-- They're in menopause. They're plus or minus using vaginal estrogen or vaginal DHEA or testosterone. And they'll have sex twice a year. And it's not because they don't love their partner, it's that it’s so painful that they aren't willing to go through that. So being able to say that using a vibrating device externally can help with blood flow and can be like rehab for the vagina. I think that's pretty exciting. 

Dr. Kelly Casperson: [00:51:14] I think it's awesome because it puts the woman in control. The cool thing about this paper is it wasn't you have to have an orgasm. There was no goal to it. It was just 5 minutes external vibrator therapy. It could be very nonsexual if you wanted it to be. And so that's the other thing of like, you're in control. There's no goals. We're just bringing some blood flow into the pelvis and it's just a beautiful, I think, approachable thing for women. Instead of like, you got to do it X, Y and Z or you got to have an orgasm or blah, blah, blah is like, nope, we just want some blood flow because blood flow again, if it works for the heart, works for the pelvis. 

[00:51:52] There's another study actually looking postpartum. And they did it for about a year, they did it for six months or a year and it was postpartum. And they said, “Hey, have an orgasm.” We don't care how you do that. Again, not prescriptive. Didn't have to be with the penis, didn't have to put anything in the vagina, we don't care, just have an orgasm. I think they were saying like, have an orgasm twice a week or something like that. And then it was compared to a group where they didn't tell anybody anything and they had less pain with sex at one year. And I think they actually had a better pelvic floor, like less bladder leakage or something at a year. And so again, blood flow, pelvic floor muscle contraction. But it didn't have to be with a partner, didn't have to be penetrative. It was just the sheer act of having an orgasm twice a week seemed to make the pelvis have less pain and better function at a year. 

Cynthia Thurlow: [00:52:37] That's incredible. And I think for many, many people it's reassuring to know that something that is non-penetrating can have a positive net effect. Because I know certainly when I was breastfeeding, I had the atrophic vaginitis, just like so many other women do. And I used to jokingly say, I had girlfriends they were Irish twins, they had, 11 months, nine months or maybe 13 months in between kids. And I was like, “How are they doing that?” I was like, “Oh, no,”

Dr. Kelly Casperson: [00:53:10] Right. Yeah, how did that happen?

Cynthia Thurlow: [00:53:12] Exactly. Exactly. I would love to quickly touch on options for those who cannot take hormones. And I know there are people out there that maybe that's not appropriate for them and then things that you dislike, which you talk about in the book, but I think are helpful to touch on because I think it'll be valuable for listeners.

Dr. Kelly Casperson: [00:53:31] Yeah. So, I think the number one thing, when people say, “I can't take hormones,” as I say, “Why can't you take hormones?” Because I truly believe way more people can try hormones than think they can. So, there's a lot of education that goes into that. Family history is not a contraindication, clotting factors, transdermal estradiol, not a contraindication, age for by and large most things. And remember, when we say hormone therapy, we're always thinking estrogen. But most people can take progesterone, most people can take testosterone. So again, like, just that question just opens it up to so many people. I'm seeing now in the breast cancer survivor world the biggest problem with breast cancer. There's many problems with breast cancer, but one of them is that we call 50 different things breast cancer.

[00:54:14] And so it's a very big disease. There is very many different risks for recurrence. And we just call it one thing and then try to put them all in a bucket. The other big problem with breast cancer is 50% of recurrences happen greater than 5 years. Like, that's just a bitch. So, it's like you're going to have late recurrences because of the nature of the disease, not because you started hormones. And so that's a lot of education you got to get people okay with. And then educating people on the Stockholm trial and the HABITS trial and like, what they actually need to know to say, is there actually an increased risk of breast cancer recurrence? A lot of breast cancer patients, if they don't want to do estradiol, get on testosterone, and everybody can be on vaginal estrogen, right? 

[00:54:54] Which is why we call it PET therapy. Because when you say HRT or hormone therapy, people only think of estrogen. And so, I like to expand people's knowledge on that. I'm like, who can't take testosterone besides high testosterone people, who can't be on vaginal estrogen. Way more people can be on hormones than they think they can. They just have a narrow vision of what they think a hormone is. 

Cynthia Thurlow: [00:55:13] Well, and I think a lot of people get shut down. I have a free Facebook group, and a lot of the questions that come in, I'm like, “Oh, boy, we just need to get you hooked up with a PET savvy provider because that is absolutely not the case.” There's this blanket statement of, nope, your mom had history of breast cancer, you can't be on hormones. I'm like, “No, that's kind of like the easy way out.” That provider either being unwilling or hasn't been properly educated. And I'm sure 99.9% of the providers out there, it's just a lack of education. It's not that they're unwilling to help their patients, they just are working off of old information.

Dr. Kelly Casperson: [00:55:51] Yeah, absolutely. What I tell people, 2022 menopause guidelines, print it out free online, bring it in. It says family history is not a contraindication. Like some of these are such low-hanging fruit that we actually like, just highlight that, bring it in, so that could be helpful for some people. But I think the online clinics are, we have 80 million women over the age of 40 in this country. We have about a million physicians. How many nurse practitioners are there, do you know? 

Cynthia Thurlow: [00:56:20] Oh, there's at least 500,000. It might be 700,000 now the last time I think I checked the stats. So, it's a good amount, not yet a million, but there's a lot of providers and then you know, PAs and midwives and other advanced practice providers.

Dr. Kelly Casperson: [00:56:36] But, but if you divide that by 80 million. 

Cynthia Thurlow: [00:56:39] Yeah, there's not enough of us.

Dr. Kelly Casperson: [00:56:40] Yeah, it's a huge, huge unmet need. So, I think the online asynchronous clinics are really filling a big need because right now you can't get into your primary care doctor for four to six months. 

Cynthia Thurlow: [00:56:51] Yeah. 

Dr. Kelly Casperson: Let alone like hey, something new that can I make sure you're trained on? [Cynthia laughs] So, I think the online clinics are helpful. 

Cynthia Thurlow: [00:56:59] Yeah, oh absolutely, absolutely. Things that you don't love.

Dr. Kelly Casperson: [00:57:04] Other people's opinions. That was my favorite thing to put it. So, the chapter before that is like supplements and I think are good and have good data. And I always start out with caffeine because people don't think that caffeine is a supplement. It's most widely consumed supplement on the planet. And people like so much so that people are like oh right, a non-necessary food source. But so, like oh okay, caffeine's a supplement, got it. Creatine, whey protein, like very low-hanging fruit, vitamin D, omega 3, stuff like that. I think though just the word supplement's been so bastardized as like good, bad, black, white. And it's like caffeine's a supplement, who's actually completely anti-supplement.

[laughter]

Cynthia Thurlow: [00:57:43] How many people are drinking coffee every morning? 

Dr. Kelly Casperson: [00:57:45] Yeah, exactly. And so, the just the word supplement again, it's like breast cancer. It's like way oversimplified because it means a lot of different things. And then the next chapter is called Bullshit and Bullshit Adjacent. And my favorite one in there is other people's opinions. Not necessary. I think any proprietary blend-

Cynthia Thurlow: [00:58:03] Yeah.

Dr. Kelly Casperson: [00:58:03] -those tend to by and large be pretty poo pooed by the science people. There's a lot of extra fluff. There's the safety and regulation of supplements in this country isn't where FDA-approved medications are. And to the great, great profit of pharmaceutical companies that are really in the supplement game. So, I think I’ll talk about that. It's like if you think you're doing supplements because it's not Big Pharma, let me tell you, [laughs] like Big Pharma is in the supplement game, my friends. 

Cynthia Thurlow: [00:58:30] Absolutely.

Dr. Kelly Casperson: [00:58:31] It is low-hanging fruit. So yeah, we have to understand the placebo effect. Lots of things can help symptoms temporarily. And I think people's interest, again, it's comparison-itis of like, “I want what Susie has, I want to be the best optimized longevity person and blah, blah, blah.” It's like by and large save your money on a lot of this stuff. And what people will say is like, “Nail the basics as best you can. You can always add and see if it helps.”

Cynthia Thurlow: [00:59:01] Absolutely. 

Dr. Kelly Casperson: [00:59:01] I was in Texas at South by Southwest and this woman raised her hand and she redid her kitchen to build a big enough cabinet for her supplements.

Cynthia Thurlow: [00:59:09] Wow. 

Dr. Kelly Casperson: [00:59:11] And refuses vaginal estrogen because it's a prescription. So, the supplements are better because they're not a prescription. And so, I was just like, put me in, coach, let me take this one down. [Cynthia laughs] Because I'm like, “I can attack this from like five different angles.” Like vaginal estrogen is not a prescription in other countries, like, so what's the point of that argument? Vaginal estrogen is the most natural thing because it's what your body made and put in your vagina. And so, like to me, I'm like to see her and she was suffering like such bad pain with sex, like just really challenging the relationship. And I'm like, your judgment of supplements are good and vaginal estrogen is bad, I mean it was like wrecking her life. 

[00:59:56] And so at the end of that conversation, her friend came up to me and she's like, “Thank you for being here. I think she really listened to you.” But it's this like, bias that supplements are all good. It's like, no, buyer beware. And some of them are just not helpful.

Cynthia Thurlow: [01:00:09] Yeah, well, and it could be that placebo effect. I want to ask you about vaginal rejuvenation because I got a lot of questions about it. My understanding having not utilized a laser in my vagina, but friends who have, and I was at getting a facial one day and the one very nice aesthetician mentioned, oh, we've got this vaginal laser. And I was like, “Oh, do you have a medical professional who's, nurse, PA, NP? Like, who's doing that? “Oh, I am.” And I was like, “I don't think I'd want a nonmedical person putting an energy source inside such a sensitive body part.”

Dr. Kelly Casperson: [01:00:51] There is a huge need for help. Women want help. People say they can help them. Money is exchanged. Repeat, repeat, repeat, repeat, repeat. And absolute bullshit, the absolute bullshit of like, “Your labia is starting to show its age,” [Cynthia laughs] I was talking to somebody, she's like, “Well, I just really feel like my labia is starting to show my age.” And I'm like, “When people ask you how old you are, do you say, let me check my labia.” [Cynthia laughs]

Cynthia Thurlow: [01:01:22] This is my litmus test, I check by labia.

Dr. Kelly Casperson: [01:01:24] I get the skin, I get the face. I get it. This is your calling card. It's on on social media. You want to look nice for work, hundreds of people see it a day. How many people are looking at your labia and judging you for it? There should be zero people including yourself. And so, to me, there's a lot of predatory behavior. There's also a lot of behavior happening from people who aren't trained. So, they're like, you've got a medical condition down there, but they're just zapping it, no. So, I struggle because I understand the role that body image is important to people. 

[01:01:58] But I, at the same time, like you said earlier, like, I'm fiercely protective of women and fiercely protective of the fact that most women don't have as much money as men. Yet you're giving your gobs of money away because somebody told you that your labia is showing its age, it's absolute bullshit, very, very quickly. 

Cynthia Thurlow: [01:02:17] Yeah. And this is where I think a really good physical examination is so important because there are things that occur beyond the genitourinary syndrome of menopause or vaginal atrophy that we are experiencing as we're aging relative to the hormones declining, I'm going to say hormones, not sex hormones. But I think from my perspective, not everything is attributable to genitourinary syndrome of menopause. And I think those autoimmune pieces, like lichen sclerosis, have to be ruled out because of very small-- [crosstalk] 

Dr. Kelly Casperson: [01:02:53] May be a clitoral phimosis, right, that's super common. Laser doesn't help it. So, there's a lot of low libido. Lasers don't help low libido. The amount of women I've seen who spend $8,000 on X, Y and Z injections, lasers, blah, blah plumpings, blah, blah, blah and they're like, “I still have low desire and I'm like, “Did they tell you” that it would help desire in the body image? Sort of like, I feel empowered, I feel sexy. Yes, there's that piece. But it doesn't change your hormones, it doesn't change your relationship. It doesn't teach you to prioritize your orgasms. The amount of women who've spent thousands of dollars and then come see me, because it didn't help X, Y and Z. I'm like, of course it didn't help X, Y and Z. That's not what lasers do. But they didn't know that, they just needed help and it's predatory, a lot of it. Does it help some people? Yes. In the right hands, with the right arms, with the right consent, absolutely. But that's not what it's all about, is it? 

Cynthia Thurlow: [01:03:55] Yeah. And this is again, I'll just keep saying, get a good physical exam, work with someone that's knowledgeable, that's licensed and prescribes, let me be clear-- 

Dr. Kelly Casperson: [01:04:05] Yeah, agreed. If you're going to get a laser and they do not put you on vaginal estrogen, that's a red flag. Because I think the laser works best with tissue that is being given as much health opportunities as it can. 

Cynthia Thurlow: [01:04:19] Yeah. It's like when you're on an airplane and they tell you to put your oxygen mask on first before helping others. Like really thinking about, you've got to do the foundational elements to improve the integrity of that tissue before you start adding in additional, perhaps also out of pocket expenses and treatment options.

Dr. Kelly Casperson: [01:04:42] Yeah. 

Cynthia Thurlow: [01:04:43] Anything that we didn't talk about today that you feel like is really important for women. Obviously, your book is going to be an incredible resource. It is as straightforward, no fuss, no muss, as you are. You are a fierce advocate for women. So, thank you so much for the work that you're doing. Anything that we didn't touch on that you feel like is important to touch on given the expansive nature of our conversation today.

Dr. Kelly Casperson: [01:05:08] Don't forget to loop in the men. Men need to know what's going on. They don't. And most men want to help. Most men want to understand. Don't keep them in the dark. This is not happening to their bodies. It's very simple to explain it to them. It's as if your testicles quit their job at-- This is not a hard concept to understand. When you take a man's testicles and you cut them off AKA castration, their moods change, their sleep goes rough. They're going to put on more body fat. Like, metabolically, things change because hormones help cells function. So, bring the man along on the journey. By and large, they want to help. If they don't want to help and you explain it, that might be the time where you're like, “This no longer serves me, right?”

[01:05:50] But by and large, the men want to help. Most men do not want to get divorced. 70% of divorces are initiated by the female. So, most men do-- they're kind humans. They want to get it. Don't keep them in the dark. And I have a chapter in my book, This is How to Talk to Men About this. Really, it's a paragraph long. [Cynthia laughs] Tell them that [crosstalk] you just can't see, you just can't see your testicles fall off because they're ovaries and so it's pretty simple to explain it once you understand what's going on. 

Cynthia Thurlow: [01:06:18] Well, and if they care about you and they love you, obviously they want to be supportive. They want to go the extra mile to ensure that, you're optimized, you're feeling good. Because there's nothing worse than. You add in the changes in hormones, you add in the lack of sleep, you add in the body composition changes, you add in the mood changes. It's the perfect storm for them, probably waking up one day and feeling like they don't recognize you anymore. And it's like the more they understand, the more they can support you. 

Dr. Kelly Casperson: [01:06:48] They want happy, healthy people who like sex. [laughs] And pain with sex is not a psychological problem. It's a biologic physical issue that can be treated. And a loving, supportive partner goes a long way. 

Cynthia Thurlow: [01:07:01] Absolutely. Well, Dr. Kelly, thank you again for your time today. Please let listeners know how to connect with you outside of this podcast, purchase your new book, listen to your podcast, read your Substack of which I am an avid reader and supporter. Please let them know how to connect with you. 

Dr. Kelly Casperson: I like to hang out on Instagram @kellycaspersonmd that's the website as well, kellycaspersonmd.com. The book The Menopause Moment is on Amazon, Barnes & Noble. I've got a whole list of Mom and Pops and different countries listed in the book webpage if you people want to go there. And then my podcast is called “You are not Broken.” 

Cynthia Thurlow: [01:07:33] Awesome. Thank you again. 

Dr. Kelly Casperson: [01:07:35] Thanks for having me. 

Cynthia Thurlow: [01:07:38] If you love this podcast episode, please leave a rating and review subscribe and tell a friend.

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