Ep. 529 The Medical Gaslighting Epidemic – Why Women Deserve a Better Healthcare Model with Dr. Sameena Rahman
- Cynthia Thurlow
- 1 day ago
- 40 min read
Today, I am delighted to connect with Dr. Sameena Rahman, a board-certified OBGYN and certified menopause practitioner with over a decade of expertise in midlife sexual medicine and concierge gynecology. Dr. Rahman founded the GSM Collective in downtown Chicago to deliver a more personalized patient-first model of health care for women.
In our conversation, we explore how cultural and racial factors influence care for women, particularly during the menopausal transition. We discuss the heart disease risk of women with a baseline of inflammation and insulin resistance, the effects of allostatic load on minority women, why cognitive health is crucial, the impact of alcohol, and why the current medical model is a systemic failure that gaslights women. We also examine the impact of pelvic floor therapy, appropriate pelvic examinations, specific autoimmune vulvar conditions, and how oral contraceptives affect sexual health, and Dr. Rahman shares her recommendations for preventing frailty and loss of independence.
I am a big admirer of Dr. Rahman’s work and look forward to having her join us again after her new book is published.
IN THIS EPISODE, YOU WILL LEARN:
Why Hormone Replacement Therapy alone might not solve all menopausal genital issues
How pelvic floor issues can even affect women who have not given vaginal births
What a routine Pap smear can miss, regarding vulvar and vestibular health
What a simple Q-tip test can reveal about vulvar pain
How untreated pain can create a cycle of pelvic floor problems
How local hormone therapy can target vulvar and vestibular pain where systemic hormones may fall short
The benefits of trauma-informed exams
The value of integrating pelvic floor therapy with local hormone treatment
How long-term birth control use might affect vulvar tissue
What to consider for balancing contraception with sexual health
Bio: Dr. Sameena Rahman
Dr. Sameena Rahman is a board-certified OB/GYN, sex-med gynecologist, menopause specialist, and a clinical assistant professor of OB/GYN at the Northwestern Feinberg School of Medicine. She is the founder of the GYN & Sexual Medicine Collective, a successful concierge practice that emphasizes evidence-based medicine, and an affiliate of Ms. Medicine. Dr. Rahman is dedicated to evaluating and treating each patient with compassion, trauma-informed care, and an awareness of personal bias. Additionally, she hosts the podcast Gyno Girl Presents: Sex, Drugs & Hormones and will release her first book, Brown Girls Disease? A Guide To Sexual Health and Empowerment through a South Asian Lens in 2026.
“Every woman can benefit from seeing a pelvic floor specialist at some point.”
– Dr. Sameena Rahman
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Connect with Dr. Sameena Rahman
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 have the honor of connecting with Dr. Sameena Rahman. She's a board-certified OB/GYN and certified menopause practitioner with over a decade of expertise in midlife, sexual medicine and concierge gynecology. She founded the GSM Collective in downtown Chicago to deliver a more personalized patient first model of women's health care.
[00:00:53] Today we spoke about cultural and racial differences with regard to care for women, especially in the menopausal transition, the impact of heart disease risks in women with a baseline of inflammation and insulin resistance, and the impact of allostatic load on minority women, the things she recommends to her patients to avoid a loss of independence and frailty, why cognitive health is so paramount and the impact of alcohol intake, why the current medical model is set up as a systemic failure to gaslight women, the impact of pelvic floor therapy and appropriate pelvic examination, specific autoimmune vulvar conditions, the impact of oral contraceptives on sexual health, and so much more.
[00:01:44] I'm a huge fan of Dr. Rahman's work and I look forward to bringing her back after her new book is published.
[00:01:52] Dr. Rahman, such a pleasure to have you on the podcast. I'm a huge fan of your work. Welcome.
Dr. Sameena Rahman: [00:01:57] Thank you so much for having me. I'm honored to be on your podcast. Thank you so much.
Cynthia Thurlow: [00:02:01] Absolutely. I think a really important consideration when we're thinking about perimenopause and menopause care in particular is being sensitive to cultural and racial differences between patients. I know this is a particular interest of yours. Talk to us about how you approach this with your patients being sensitive to different cultural expectations, even awareness and discussions around the menopausal transition.
Dr. Sameena Rahman: [00:02:28] I think it was just interesting to see how different societies treat women as they age. Right? One thing I'll say is there's a lot more ageism in the western societies than there is in other societies. If you look at others, I think that feeds into how we treat our elders, which then feeds into how we've historically been treating menopausal and perimenopausal women, right? They become invisible, that they're not, you know, as important and I think the narrative is being reclaimed at this juncture in our life. But I have to say that looking at the Japanese culture, our own South Asian culture, there's so many cultures that women become the matriarchs of their family as they-- It's almost like a rite of passage.
[00:03:10] Like, you get past menopause, you're not no longer childbearing, and it's great because you're finally like, you're the one people come to like, get all that questions answered and the one that people have the most respect for. It's like the women have a lot of power in these societies and it's just not the case here.
[00:03:27] I think that so many times a lot of women won't even realize they're going through what they're going through in these cultures because they don't have not only the awareness, but also, like, they have other things happening to them and other powerful things going on that they may not even consider it an important factor. But we know that this transition is such an important transition from our cardiovascular health, our metabolic health, our bone health, and so, to just discount that above all would not be something that we should do.
[00:03:57] So, when I talk to my patients, whether or not they're African-Americans, South Asian, Latino, whatever. I first talk to them about how we women of color tend to experience menopause early, right? The average age of menopause for Caucasian woman is 51, 51 and a half in the United States. Certain ethnicities experience it earlier, maybe two to three years earlier. Some South Asians will have menopause at 48, 47. There's some statistics about how South Asian women can actually experience menopause or early menopause earlier. And sometimes the symptoms are worse, right? The night-- night sweats, hot flashes, the vasomotor symptoms, which we know are not benign. So, we can't ignore it.
[00:04:34] Just giving them awareness that you might experience it earlier, so this is something we want to be on top of. Just because someone didn't talk to you about it because it was so much taboo around menstruation or so much taboo about women's health issues are down there, as we call it, because we don't-- Again, the taboo around even saying the words aren't even there. Just because there's so much taboo around it in most cultures. I think, you know, that we should still address it head on, that we should know what's happening to our bodies so that we can feel empowered.
[00:05:02] So, I always start with that like, you may be experiencing it worse than some and we have to take into account that, for instance, if I have another South Asian woman in the room with me and I tell her we are 25% of the world population, but 60% of the world’s heart disease and we're number one in diabetes. Like these parameters are so important because as we learned from the Menopause Society meeting last week, the majority of women still don't know that heart disease will kill them earlier than breast cancer. I think that used to be like 60% of women knew that in the 90s or something that heart disease was their number one killer. Now it's something like 40%. So, even the awareness of what's going to kill us isn't there for the majority.
[00:05:43] So, just having this understanding that like this is a time of accelerated risks, that we have to be on top of it if we want to not end up in a nursing home like so many women end up in. What are we going to do to make sure that-- I find so many midlife women are coming to me like all of a sudden, all the burden of the world on their shoulders, right? Dealing with aging parents, dealing with teenage kids or college bound kids. I swear, every woman coming to my office right now has a senior applying for college. [giggles] It's really stressful, right? Like I just hear and I'm a few years away, but like it sounds so stressful to be going through that with your child.
[00:06:20] So, the culmination of all of this just adds more stress to your system that we know contributes to heart disease. Like these things are facts. So, even navigating, how are you going to deal with your in laws or your parents as they age, which is something that that generation maybe didn't have to think about as much, right? We want to age better. We want to not be like, a significant burden on the kids that we're raising if you have kids.
[00:06:46] And so, it's really about keeping mobility, keeping your brain working, not peeing on yourself. Like the things that would improve your quality of life. Sex span is so important, keeping good quality of life with your partner. So, I just think knowing that awareness of how we might experience things differently and how it's not talked about. “Oh, my mom didn't go through menopause.” Oh, she absolutely did. But she probably just suffered through it. Do you remember when Sue Dominus did that huge article in 2023? I think that women have been misled about menopause. I remember hearing her speak at the Menopause Society and her saying that, like, “As a society, we accept women suffering. We accept women suffering.”
[00:07:26] It's a badge of honor not to have an epidural when you go in labor. Like, I went right back to work postpartum. Like, these are not that-- This is not something that other societies do. Like, people take care of postpartum women like nothing else in other cultures. People take care of their moms, dads and elderly patients in a way that we probably neglect here in this society. I think that we can learn a lot from these cultures and still retain a lot of that, but also be proactive about what's happening.
Cynthia Thurlow: [00:07:55] I love that you're bringing this up because I think that we can take a bit from so many cultures and apply it to our own circumstances and I do think a great deal. I'm in that sandwich generation, aging parents. One of my parents passed away last year. I've got one in college, one who's applying to college right now. That is a shared experience across the board for so many people, and yet may be my mother’s generation, certainly they didn’t talk about menstruation, contraception, perimenopause or menopause and I think that when I look at my mom and her sisters and my other aunts, all of whom have given me permission to give some broad level perspectives, that generation lost out on the ability to utilize hormonal replacement therapy because they came in the wake of the WHI and listeners are very familiarized with when this came out in 2002 and the net impact that it had and I know that some practitioners were still prescribing hormones, but the vast majority were not.
[00:09:08] I was safely tucked away in Cardiology, where I was told to stay in my lane and refer people back to their GYN or their internist if they had questions or concerns about being taken off of medication. But your points about heart disease, and very astutely, we just finished the month of October, which is Breast Cancer Awareness Month. It's very important to be talking about awareness and screenings. But by the same token, one in three women will die of cardiovascular disease.
[00:09:24] And I think the other piece of it is, yes, menopause is this vulnerable time in a woman's life. But it's also like, who are the women we know are at greater risk heading into perimenopause? The women that have gestational diabetes, the women that have PCOS, women that have had hypertensive urgency.
[00:09:42] When you're doing an intake on a patient or talking to patients, what are some of the, like, red flags for you, the things that get you concerned, like, “oh, this is a patient that I need to be talking to them earlier rather than later about their increased risk of developing heart disease?
Dr. Sameena Rahman: [00:09:58] Yeah, I think all the things that you mentioned. When we talk to patients, sometimes they're coming in for the perimenopausal symptoms, but I ask them, “Let's go back to what your menstruation has been like. Tell me what you experienced. Do you think that you had symptoms of endometriosis? Because it didn't say on your intake. Do you think that those periods of time where you lost your menstrual cycle and you gained weight, was that actually PCOS that didn't get diagnosed?”
[00:10:21] Because we know that a lot of these things takes up to what, eight to 10 providers before someone gets diagnosed with some of these conditions. So, we're leaving these hugely inflammatory conditions untreated for so long, which then we know can precipitate or put you more at risk for cardiovascular disease.
[00:10:38] Of course, like you said, let's talk to me about your pregnancies. Like, “What were your pregnancies like, did you develop-- “Oh, I had to watch my sugars” or “Oh, they did induce me because of my blood pressure.” People just put it off and like, it was no big deal or that they had really bad postpartum depression and they're now struggling with all this ADHD symptoms, perimenopausal symptoms, PMDD got worse. All the things that are happening at once and colliding and no one's putting two and two together. Like, this should have been like a discussion for you your 30-year-old self, that like, “Hey, you what, you had these babies, maybe you're still having babies, I don't know. But let's consider the fact that we should optimize your health now. We're a reactive society. We're always reacting to your blood pressure, what's happening with your lipids. But why don't we talk about, like, let's be proactive. Let's say, like, okay, this is something that you experienced. We know as a result you're at risk.” You see a South Asian woman, a black woman in your office, you know that they are more at risk for cardiovascular disease because of just the concept of what's known as allostatic load.
[00:11:37] The systemic injustices that are placed on minority women that as a result, the systemic issues that result in this epigenetic change in their microvasculature, basically, like your blood vessels are learning from the genes of the people before you, right? It's really a matter of understanding that these are your risks.
[00:11:58] “We got to look at your BMI a little closer. Like, I'm sorry, 23 is your cut off, versus like, 25, 27.” So, these are things that we should getting aggressive about. But the reality is what happens to women, like as we're getting into this childbearing ages and raising children and your life gets so busy, you don't think about yourself. You and I both know, I preach really well, but I don't take my own advice half the time, [giggles]
[00:12:25] It's like where there are worst patients, I'm like, you should really work on your stress. My stress is 10 out of 10. I think the reality is this is what happens to women that are constantly being caretakers, that are constantly looking after other people.
[00:12:39] The majority of people that I know in my life, and this is the majority of the patients that I take care of, saying, like, “Listen, this self-care is really you trying to figure out what your risks are of dying and how to prevent them.” Like, we can't-- No one can say, “I can't prevent you from dying from an accident, but we want to preserve your quality of life, but improve your lifespan too and make sure that you're living your best life.” That's all we want. No one wants to live the last decade of their life in miserable condition, but we should hope that we can get on top of it.
[00:13:11] I think that's why even the Menopause Society, when this last week or last month was saying that we should really be having these discussions to women when they're in mid-30s, right? We should be discussing this, like-- I always say we give great puberty talks to like preteens, but like who's talking to the 30 plus year olds in the office? It's a Catch-22, because a lot of my 30-plus-year-old patients haven't even like settled down or haven't even started childbearing because we're all having later childbearing. Some are like, “What are you telling me about metabol-- So they get really like-- But the others are like, “Wow, I didn't realize this would happen to me.” And so, they're appreciative of the fact that like, you're addressing this and I'm like, “I'm not saying this is happening to you, but I'm giving you a heads up.” I think that's really important.
Cynthia Thurlow: [00:13:58] No, I agree. I think about, even as a Nurse Practitioner, I don't recall ever having a conversation with my GYN, not once about perimenopause until I was in the throes of it. I know every person listening to this podcast is on that perimenopause to menopause transition, whether they're pre perimenopausal or they're postmenopausal. I'm sure everyone has their own story of, maybe you had a very proactive GYN or midwife or NP or PA that talked to you about these things, but the vast majority of women have shared that they just really weren't prepared and I think sometimes you're in the flux of perimenopause before you realize it and I think some of it's the normalization. You're like, “I don't feel my age, so I'm not-- I couldn't possibly be old enough to be looking at the end of my fertility.” I would imagine most 30-year-olds are probably thinking about either preventing pregnancy or trying to get pregnant. They're not even thinking about 15 years down the road. You mentioned that a lot of the theme around the recent menopause societies content was the things that improve our quality of life, the things that keep us out of the nursing home, the things that are very important. I know Peter Attia talks about the marginal decade. Women live longer, but they generally don't have a good quality of life the last 10 years of their lives.
[00:15:18] What are the things that you talk to your patients about that are really important for avoiding frailty, for-- ever getting to that point where they are falling, they are breaking hips, which we know is a poor prognostic indicator, or they're having worse injuries that are occurring. But what are the things you're thinking of for your perimenopause to menopausal women that help them just build awareness around the things that contribute to frailty as an example?
Dr. Sameena Rahman: [00:15:45] I'm a big advocate of looking at your lifestyle parameters first of course. I think hormones definitely play into it, and we have this discussion, but I always first ask about “What you're doing and what a day looks like for you. Like, let's talk about it. Let's break that down.” Because I do think that looking at how much you move in a day. I have a walking treadmill in my office, so that when I'm writing my notes, I can walk a little bit.
[00:16:14] The movement is so important. We want to continue to be able to move all throughout our life. Nobody wants to be wheelchair bound one day. I think that talking about movement, talking about strength building. We know how important muscle is these days for not only preventing injury and frailty, but even promoting that longevity, that health span that everybody's looking for. So, looking at those-- looking at--. I'm a big-- having dealt with people in my life that have had, like, dementia and cognitive decline, that's another thing that I'm always looking at, like, how can we incorporate cognitive fitness in our life? What does cognitive fitness look like?
[00:16:52] To me, I look at, of course, this movement we know. We have to look at-- What other things are you doing in your life? Are you drinking alcohol? Are you smoking? Are you doing any kind of recreational drugs? Let's see how this plays into everything that you're doing. Obviously, looking at your diet. Like, the diet, I think is one of our hardest things to tackle. What do we hear from our midlife women so much? “I've been on a perfect diet. I watch my macros, and I'm still getting this midsection visceral fat, the midsection accumulation.” We know that there's that transitional metabolic changes that happen. Just being on top of that, what are we doing? Are you doing anything differently with your protein intake? What does your fiber intake look like? Are you on sort of a Mediterranean diet? These are the things that I'm really looking at.
[00:17:36] And then, of course, sleep. How many times do we forget to like, really discuss how important sleep is to prevent metabolic dysfunction, to prevent cardiovascular disease, obesity, all the things that we know it can really help to maintain. And I feel like we, every other woman in my office has sleep disruption. They're getting up at 3 am the mid-- The nighttime awakenings, they're real. Whether or not it's from hormonal dysregulation or from urinary frequency, urgency, drinking too much at night, stimulating your bladder too much, whatever the case may be, people are getting up. If you're getting up in the middle of the night and you trip on something and you fall-- these are big risks that we talk about. I even talk to patients about what does it look like when you retire and like, you decide your big house that you're in or whatever you're living in has too many stairs. These are things you have to start thinking about because those fall risks are huge as we get older.
[00:18:30] I think looking at those kinds of things and then social community, that kind of stuff that we know is important for our cognitive health. [unintelligible 00:18:37] keep community, what do you do? Which I think is so wonderful about what's happening with menopause right now. It's a community that's being built. The events that are happening all over the country all the time, women feel like heard and they feel fed. I think they feel this connection with other women. I love that is happening at this day and age because I think it's just going to help promote better aging for all the people involved.
Cynthia Thurlow: [00:19:02] Absolutely.
Dr. Sameena Rahman: [00:19:03] I think it's really important that every event that I attend is, “Wow, there's so many women here who are-- I'm so glad it's not me.” We live in these silos where we think everyone knows about what we're talking about. But every event, I see someone or hear someone and they're like, “Oh, I didn't even realize this.” You're like, “Oh, okay, we still have a lot of work to do.”
Cynthia Thurlow: [00:19:23] Absolutely. I think I was talking to someone on my street who's maybe 10 years older, and she said, “Oh, I missed that window of being able to have a conversation around hormones.” and I said, “No,” they really have to do a workup and determine the appropriateness. But I said, “To think that just because you're eight years into menopause that for some reason it's not at all appropriate.” I said “You deserve to have an informed conversation with someone that is savvy with hormonal replacement therapy and at least talk about your options.”
[00:19:55] Where does alcohol fit into the conversation with you and your patients? Because I feel like, there's growing awareness around alcohol not being, per se, a benign entity. I used to tell my Cardiology patients and this is 20 years ago, so let me just put that-- put that little dovetail in there and say, red wine, 20 years ago, “Have that glass of red wine every night.” We used to encourage patients not realizing you need, like gallons of resveratrol for you to get the benefits far more than you would be able to consume. But is alcohol part of the conversation that you're having with women, especially given the mommy drinking culture that I think most of us have existed into one extreme or another during the trajectory of our child rearing years.
Dr. Sameena Rahman: [00:20:38] Remember about that a lot so-- When we talk about sleep and sleep disruption, it's like, you know, how does alcohol play into this? When we talk about people who are scared to go on hormones because of their breast cancer risk, “You know what, your breast cancer risk is just as much when you're drinking that much alcohol.” Having an understanding how it impacts your cognitive decline, metabolic dysfunction, all of that stuff, like having an understanding of how it can have a negative impact and for some people, it's really hard for them to give it up. But I have to be honest. I think the majority of my patients are like one a week at the--
[00:21:11] They've really cut down on their own because metabolically they can't handle it like they used to. So, I think that people are realizing that on their own a lot of times. Every once in a while, you'll have a patient [unintelligible 00:21:22] we own a winery-- They have investments in certain things that they feel like they can't separate from or they're very cautious of what they're doing and when they're doing it. But I don't think I have that many patients anymore that are really actively-- This is different than during COVID I feel like a lot [crosstalk] bottle, so to what extent that's impacted what the health consequences we're seeing now is something that we have to worry about.
[00:21:49] We know it's a carcinogen. We know cancer rates are up in most cancers these days. And so, to what extent is that contributing to? What extent is obesity, some of these other things? Some people are like, “I'll just pick my poison.” You have to actually-- I always say you have to meet a patient where they are. If they're not willing to do certain things, which in my mind would optimize their overall health, “I'm like, I get it. You can't give that up” or “I get it. You can't use the vaginal estrogen twice a week like I want you to, because you're too busy or you can't think about everything all at once.” Sometimes the to-do list that we give patients, especially midlife women, is hard because I'm sure both of us probably don't follow our to-do.
Cynthia Thurlow: [00:22:36] No, no. In fact, I will oftentimes say to my internist, like, “I can do these three things, but not these three. Realistically, I think I can tackle these three.” This is where I think this shared decision making conversations are so important to your point. Really tailoring recommendations based on what a patient is willing to do or is capable of doing at that time, and certainly I think that a lot of the content that I really appreciate, obviously all of your content, but you are such an expert in the sexual medicine space.
[00:23:11] I'm looking behind you and you've got uterus and fallopian tubes and then the giant vagina vulva that I'm sure you probably use with your patients for education. Where does the conversation around sexual medicine start? Because I feel like even as a healthcare provider myself, I know that discussions around sexual health are generally at the comfort level of the provider just to initiate the conversation and I know some of this is cultural and some of it is-- people have differing comfort levels discussing private matters. But I do think sexual medicine is really important and I find that the vast majority of my patients will say things to me like, “That's just no longer part of what I do.” They're like, “It's painful, therefore I don't want to do it, therefore I'm not interested.” How do you initiate those conversations to help patients bring greater awareness to sexual medicine and health?
Dr. Sameena Rahman: [00:24:07] I think it's all about understanding the commonality of what's happening, normalizing that it is something that women experience, but you don't have to suffer through it. I do think one point I wanted to make is-- one of the biggest problems we have in healthcare is the ability to take care of these patients and have an understanding. So back when I was in a huge practice where I saw 30 or 40 patients a day, if someone came to me as I was leaving for their annual and says, “Hey, by the way, I have painful sex.” I would say, “Oh my God, what am I going to do?” Like, because you have five other patients waiting. I always say our healthcare system is set up to fail women.
[00:24:44] Because at the end of the day, if you have 15 minutes to see a patient to really get an understanding of what's happening, their perimenopausal, menopausal symptoms or sexual symptoms, you need time, you need to understand the story, which will give you like 90% of your diagnosis right there. When I worked with Dr. Irwin Goldstein for a short period, that's one of the things I learned from him is like, you have to just listen. You have to listen to the patient so that you can understand what's happening with them. Most of our systems don't have that in place. I think that's where women feel gaslit a lot.
[00:25:14] I always tell patients, when they tell me stories that you always hear the craziest things that they get told by other clinicians, “Oh, relax and have a glass of wine” or “You should try something more impressive took for your significant other or your body was made for pain. Look at labor.” You hear all these things that your patients tell you. It's like, I think the majority of people that go into medicine want to help people. I don't think that this comes from a malicious place. I also think probably the last 15 years is when we've got a grasp on what happens with our sexual medicine understanding of women's health.
[00:25:49] There's two factors, like lack of research, lack of knowledge, but there's also like lack of time and lack of insurance coverage for this area of medicine. When I was an insurance-based clinician, if I code an F code, which is a psych code, and that's what hypoactive sexual desire is, that's what peak at is that's what all of these sub codes for sexual medicine are. You don't get reimbursed by insurances for F codes because they're psych codes, right? They're DSM4 psych codes. Of course, like, then what's, how do you even keep a practice or sustain a practice? It becomes difficult. My point was really that we have a system set up to fail women in this arena.
[00:26:27] But when I talk to patients, I try to first tell them, especially if it's a midline patient, I'll tell them, like, “Are you having sex? What's your sex life look like for you?” A lot of them are married or recently divorced or whatever. They'll tell me that it's maybe not in the equation. What do we know? 40% of women have, like, low libido concerns that come in through some clinics. Some people with that low libido concerns are okay with their low libido because their spouse or significant other is not bothering them enough to really warrant the attention that I'm trying to give it. Sometimes it's like, “No, it's not an issue.” But other times it's like, my-- “I feel dead inside.”
[00:27:04] “I feel really bad because my husband approaches me and I'm like, shoo, shoo, you know.” So, when it becomes that low libido would bother which is usually like 1 in 10 women, probably, that's when we can do something about it, which is, I think, the most common sexual complaint for midlife women. It’s like, really, you want to want to have sex, but you don't have an internal or spontaneous drive to do it? You can look at your husband and be like, “Eh, I'm good.”
Cynthia Thurlow: [00:27:31] [laughs] Well, and I think it's very validating to know that women are not alone.
Dr. Sameena Rahman: [00:27:36] Yes.
Cynthia Thurlow: [00:27:36] I think this is the conversation, like-- whereas, when my friends and I were younger women, before were married, we would have funny conversations around these kinds of things. When people get married, people stop talking about this with their girlfriends, and then they get into perimenopause and menopause, and it's only the most daring girlfriend that will, like, bring this up. Oh, the one who's really looking for validation or some way.
Dr. Sameena Rahman: [00:28:04] Samantha's of the group, right?
Cynthia Thurlow: [00:28:05] Yes, the Samantha's of the group. I do love the reference.
Dr. Sameena Rahman: [00:28:09] It’s just age difference [unintelligible 00:28:09]
Cynthia Thurlow: [00:28:11] Sex and the City. But I think for a lot of people, it's their-- Maybe they're uncomfortable initiating, maybe their clinicians not comfortable initiating, maybe they're not comfortable having the conversation with their significant other. One of the things that patients will share with me is it's not a lack of interest. They love their significant other, but it's they can't orgasm anymore. It's-- they're dealing with painful sex. They bleed after sex. A lot of women have said, “Oh, I've heard that--” I think it might have been Dr. Rachel Rubin, who was talking about some of the vaginal changes that can occur. They were like, “What do you mean it can get stuck together?” Like, they hear that and they're like, “Oh my gosh. Does this mean that it's an inevitability that this is going to happen?”
[00:28:52] Just helping bring awareness to a lot of these things are a reflection of genitourinary syndrome of menopause, which is better than senile vagina, but still not a great name. Probably a little less stigmatizing than the senile vagina, which someone brought that up the other day. [crosstalk]
Dr. Sameena Rahman: [00:29:08] Atrophic one. [crosstalk]
Cynthia Thurlow: [00:29:10] All these very pejorative names that are certainly not how people want to describe their physiology. But I think so much of it is comfort level of patient, comfort level of provider. You astutely stated [crosstalk] if you're in the insurance model and you've got your hand on the door because you have six other women waiting for you that are sitting in paper gowns on an exam table, you're like, “I have to be thoughtful for them as well”. It's absolutely a system designed for women to suffer if they're not able to express themselves and do so in a way where it's actually helpful.
Dr. Sameena Rahman: [00:29:44] Absolutely. I think that just having that and bringing up that conversation, we know that when clinicians bring up the conversation, women are not more likely to talk about it. But to your point, they're not going to sometimes bring it up on their own because I always bring it up and tell them what women experience. “Tell me about your sex life. How long you guys been together”, let's talk about that. Sometimes I'll get into it. I always ask about their sex life too, like their husband or a significant other, like they're having sex with another woman. Because it's important to understand that 40% of men, by the time they're 40, have erectile dysfunction.
[00:30:17] So, all the same things that might be happening to them are happening-- How many people are on GLP-1s these days and how is that affecting your sex life? We're starting to learn a lot about that now. I think it's really important to ask the questions and to understand because if you have a drive to have-- your favorite food goes down and we assume for some-- Although libido is incredibly complicated, so some people might feel better in their own skin and might have more of a libido.
[00:30:43] But I think that understanding what medications they are on, what kind of conditions they're having at that time, because sexual health is health, as we say. It's the first sign that something might be happening from a microvascular perspective.
[00:30:56] All of a sudden, you're diabetic, you're hypertensive, you have cholesterol issues and can't orgasm the same. You can't bring in the blood flow to the clitoris the same. Really having that understanding is so important. Then we go from there, just normalizing that women experience this, that you're not alone, but we have solutions. There are things we can do about it. It's a complicated thing. It's biopsychosocial. It's not just like, “I can give you a medicine and you're all good.”
[00:31:22] Usually we have to work on the other factors. There's a whole heteronormative model of sexual dysfunction and how low libido is linked to heteronormative roles for people that have been in the same couple for so long.
[00:31:35] I learned this from Dr. Laurie Mintz when she spoke to us last year at ISSWSH. But just the concept of like, okay, “I work and I go home and I have to still do the dishes, feed my kids, take them to their after-school stuff, and then I get to sit down on my couch”. Whereas for some people, their husband's work, they come home and they sit on the couch waiting for other things to happen. You come home with this inequal thing that's happening, and of course you get pissed. You're like, “Why? Why do I want to have sex with that person?” That's what women say a lot of times too. Or all of a sudden they have to manage and care for their significant other in a way they never had to.
[00:32:11] Those two things feed into low libido too, and of course, there's these issues around, like, low testosterone and how much that impacts. “Are you on an antidepressant?” Because women are four times as likely to get antidepressant for some perimenopausal mood disorders than they are to get hormone therapy. Then you have all these that play in. Because the biopsychosocial is so complex, you have to address all of it. “You have to see my sex therapist friend down the street. You might have to see pelvic floor because I can give you the vaginal estrogen, but you are clenched up because you're so anxious. You got new onset anxiety in midlife.” Like every other woman tells me that they're so anxious they can't sleep or if you just open your eyes and pay attention to the dumpster fire that's happening, [giggles] it's like, you can-- If you're not clenching, then you're not paying attention.”
Cynthia Thurlow: [00:33:02] Yeah, no. I think you bring up so many good points and really looking at it from a very comprehensive model and not just, “Okay, A plus B equals C”, meaning you're in perimenopause or menopause, the hormone's going to fix everything. There's so much more to it. When you are talking about genitourinary syndrome of menopause as an example and talking about replenishing of hormones as a starting point, walk us through-- Are you doing compounded topical products in addition to systemic estrogen? Are you--
[00:33:38] If you're--I'm assuming if you're referring to pelvic floor therapy, they might be doing dilators. They might be doing specific exercises to strengthen the pelvic floor, which even people who have not had vaginal deliveries, and I'm talking about people that have had C sections, appropriately or not. That's not for me to decide because I'm not an OB.
[00:33:58] But even people who've had just C sections can develop significant pelvic floor disruption and I think there's this kind of common misconception in the lay public that you just have to have had traumatic vaginal deliveries to need PT and what I've come to find is I think probably every woman would benefit from seeing a pelvic floor specialist at some point.
Dr. Sameena Rahman: [00:34:20] Absolutely. When I see someone in my office, I'm always like, “I'm going to do your pelvic.” Sometimes they're like, “Oh, I've already had my Pap.” I'm like, “Pap does not equal pelvic.” [Cynthia laughs] Pap is done for cervical but I'm actually going to look at your vulva. I'm going to look at your labia minora. Are they regressing? Are they shriveling away? I think that was Rachel's that went viral about the disappearing labia minora, which happens to--.
Cynthia Thurlow: [00:34:42] Oh, my gosh, like, the Gen Z's were like, “Oh, my God, my labia is going to disappear?” Like--
Dr. Sameena Rahman: [00:34:49] Especially when they find out it's because they're on birth control. But the disappearing labia, looking at the clitoris, retracting the clitoral hood, seeing if there's phimosis, looking if the clitoris has shrunk down, is it smaller than the Q tip? Then looking at the vulvar vestibule, the little area, inner area, between the labia minora and the hymenal remnant up to the urethra down to the perineum. Doing that little soft Q tip test with the soft part of the Q tip, like, seeing how much pain or pressure you have. Some people are like, “Are you touching me with a knife? I'm like, no, it's just the soft part of the Q tip.” You can tell if it's very red and angry.
[00:35:24] They give me a scale of 1 to 10 and we try to figure out where's most of the pain. If it's only in the bottom part of the vestibule and they have a really high tone pelvis, maybe it's the majority of it is the pelvic floor issues, which almost every one of my patients has. But if it is really something more related to the hormones, what starts as a little bit of hormone dysfunction becomes pelvic floor too because you clench because you're in pain and then all of a sudden, your floor becomes hypertonic, pelvic floor with the high tone that can't contract in coordination, just gets weaker. So, the weakness of the pelvic floor then leads to the incontinence and all this stuff.
[00:35:59] People, sometimes mistakenly, think they have UTIs when they're really having that vestibulodynia, that pain at the vestibule from the lack of hormone. What we know is that there's so many androgen receptors at the opening of the vestibule that of course estrogen's so important and we put in vaginal estrogen, but sometimes it's just not enough. Especially for people who experience pretty bad sexual pain on initial penetration, as well as the urinary frequency urgency, recurrent UTIs.
[00:36:28] I tend to go toward Intrarosa or Prasterone first which is vaginal DHEA, because you get that conversion of estrogen and testosterone locally that ends up shedding into the vestibule as well. But for some people, like if their vestibule looks really inflamed and I'm like, “You know what? This is like 10 out of 10 in pain, going to take a long time for that Intrarosa to work its magic for you.” They're just anxious about getting back to their sex life. Then I will compound an estradiol-testosterone gel or cream from a trusted compounding pharmacy since there's no FDA-approved version of that, then we have to work with what we can and then have them directly apply it to the vestibule. That in combination with pelvic floor PT-- I have a pelvic floor PT in my office, usually gets them to where they needed to go, but it just depends on where we're starting from.
[00:37:15] So getting that really full vulvar exam, even-- I do a pelvic floor assessment. I try to feel all throughout the pelvic floor, down to the levators, down deeper into the deeper pelvic floor muscles, see if I feel any knots. If I'm feeling them and they're like, “This is painful. What are you touching?” Then you know this is a high tone pelvis and they see my pelvic floor therapist. I think all of those are really important to getting-- because of course that contributes to low libido too. No one wants to experience pain over and over again.
Cynthia Thurlow: [00:37:42] No.
Dr. Sameena Rahman [00:37:46] It's so funny because sometimes I get these 70-year-old women that come to my office who are on their third marriage and have a new boyfriend and they're like, “Fix my vagina.” [Cynthia laughs] I'm like, we need some fixing. I'm like, “Let's go.” I think it's something that we have to pay more attention to. It's just not going in for the speculum exam and checking out what your cervix looks like. It's really a detailed trauma informed. I'm always like, “If any of this hurts or it's too uncomfortable for you at any time, we could stop and you're in control so that they know, because I think that's where the re-traumatization in medicine continues to happen.” It can start from the first bad Pap to like, your 70s or whatever. But like, I think people should really know that they're in control of that exam.
[00:38:29] Sometimes I've had to use like Pro-Nox for exams which is nitrous oxide I'll bring in and patients will use that to have their exam done because they have significant involuntary contraction of that pelvic floor or that vaginismus, the historical term we've always used for. It can vary, but just having that understanding of what's happening, I give them a mirror, take a look at what I'm seeing and they're like, “Whoa, where did my labia go?” No one ever does that like, looks down there for any particular reason unless they have a bump or something, but--
Cynthia Thurlow: [00:39:00] No, and I think this really speaks to physicians and other licensed medical providers that have specialized training to be able to have these conversations because I think for a lot of patients, certainly my generation, I think the way that younger GYNs have interacted with me at this point in my adult life is so different. It is all about like, they'll touch your leg before they put the specula. There's so much communication and conversation.
[00:39:28] I was laughing with my Gyn, who's young, she's early 30s, she's lovely though, and she loves middle-aged women. She's like, “You guys know exactly what you want. You're really clear. You're not as worried about like contraception or you're already done and you're in menopause.”
[00:39:41] She was having this conversation and said there's been a shift in the training for GYNs in particular about like, communication is key and making sure you're having this conversation every step of the way, much like you were mentioning, not just putting a speculum because I think the first pelvic exam I had as a teenager, I had a male, middle aged cardiologist-- gynecologist and it was like no conversation. I didn't know what to expect. I think many women of my generation, that's probably been their experience for at least the first 10, 15, 20 years of their lives, that was their experience.
[00:40:21] Now we're realizing that it's much more important to have this kind of more thoughtful approach where women feel comfortable, they're not feeling like things are being rushed along or their concerns aren't being addressed.
[00:40:34] One of the things I got a lot of questions about were the auto-immune piece related to vulvar issues. So, lichen sclerosis is one example. Help listeners understand how this is different from say, just the gen-- You can have both at the same time let me be clear. So genitourinary syndrome of menopause, it's not a question of if, but when eventually we will all have some symptoms. But how does this differ from lichen sclerosis, which is an autoimmune condition?
Dr. Sameena Rahman: [00:41:02] Yeah. So, lichen sclerosis and lichen planus are vulvar dermatologic skin conditions that are secondary to some autoimmune triggers. People that have autoimmune diseases tend to have more of these or if they have a family history. It's kind of like if you think about-- My friend Joe Kraft always talks about the layers of your skin and how the bottom layer can have this protein or this thing that your body's now looking at as an enemy. You have an inflammatory reaction that develops from something that it shouldn't have this reaction to. What happens in lichen sclerosis is you can have both thickening and thinning of skin tissue at the same time.
[00:41:40] We used to think it was a bimodal distribution, meaning like, teenage-- or pre-puberty and then postmenopausal. But what I see in my practice and what most our experts also see is that-- that's probably where people are the most symptomatic, where they're most itchy because it creates a lot of discomfort and vulvar itching. Whether that itchiness is from change in the tissue or actually like a neuropathic pain that can cause itchiness is confusing and confounding for some people.
[00:42:10] But the symptomatology-- but if you're looking at someone's vulva, like we all should be examining, sometimes you'll pick it up ahead of time, like, “Oh, why is your labia minora disappearing? You're not on birth control and you're not peri or postmenopausal” and so, being able to assess what's happening to the labia. “Why is your clitoral hood totally smashed over the clitoral glands and it won't move at all. There's no movement. No wonder you have muted orgasms or pain with orgasm because you might have all this smegma and keratinized pearls that build up under the hood.” We have all these things that we're looking at. For the lichen sclerosis, it's an inflammatory skin condition, presents differently a little bit in women of color because there's you look at the pigmented changes that happen.
[00:42:56] People with whiter skin might have more discoloration, things can look white and thick at the same time that the skin is getting thinner. These patients really do-- We usually do a biopsy to confirm for the most part, mainly because also-- if the average woman with a vulva has a 1% risk of vulvar cancer, somebody that has lichen sclerosis has a 3 to 5% risk. So, depending on which study you read. So, it's still low, but it's a lot more than the average. We want to make sure we're not missing anything precancerous. We want to make sure that we're getting the right diagnosis and we want to make sure that they're getting treatment.
[00:43:33] The standard treatment is usually like a steroid ointment, like a clobetasol potent ointment that's really going to get into the skin that you can really rub in and over time alleviate symptoms but also prevent this from turning into cancer. This is autoimmune linked, so people will-- also sometimes they can get fissuring in the opening. Some patients that I diagnosed earlier that are like reproductive age will tell me, like, “Oh, I always rip when I have sex and this bleeds.” Or they'll come in with bleeding during intercourse or after intercourse, and I'll see this fissuring that happens right at the perineum. Then their labia look a little different and there's some thickening in certain parts of their skin. It's really a matter of doing the biopsy and trying to get the results.
[00:44:15] But that along with lichen planus which has more like redness and ulcerations and can affect the vagina as well as the vulva, they both have autoimmune-mediated situations and estrogen does impact them in that, if you're in a low estrogen state, then you might be more symptomatic. We do always in those, prepubescent women, girls will oftentimes just by exam, get a diagnosis. Sometimes it'll be a patient that I see in their 20s or 30s that their mom will tell me, “You know what she was always scratching when she was 11. Like, I would find her in the corner just scratching away down there and then would never have gotten help.”
[00:44:56] There are ebbs and flows that happen in life. All of a sudden, we realize that this was happening to them early on and they'll come in with a completely fused clitoris and labia minora that are totally gone and all the things inside-- I have actually a number of patients like that. So, really it's getting them the right diagnosis, treatment. Like I was saying about lichen planus, which is like the sister to lichen sclerosis, is that the inner canal of the vagina can be affected too. That’s why it's really important for that situation for us to really see what's happening with the vaginal tissue as well as the vulvar tissue.
Cynthia Thurlow: [00:45:33] Thank you. That's the best explanation I've heard of that yet. So, thank you for that. Before we end the conversation, I do want to tie up one little point that you were making. The impact of oral contraceptives on our vulva and vagina. Can you touch on this? Because inevitably people will hear you've touched on it a couple times. I will get questions, but I would rather ask the expert.
[00:45:57] When someone is taking oral contraceptives either to prevent pregnancy and I know some patients are on oral contraceptives and think they're on menopausal hormone replacement therapy, but they're not. Talk to us about how that changes the physiology and anatomy of our vaginas and vulvas.
Dr. Sameena Rahman: [00:46:14] Yeah, sure. I want to make the point. I'm not trying to villainize birth control pills, but as a sexual medicine expert, I know that it can have an impact on our sex life. It's not every woman. If every woman had painful sex because they took birth control pills, then probably we wouldn't have this still happening. But what happens to some women, and we think it comes down to their receptors. If we think about how hormones are like a lock and key and your tissue is accepting a hormone. Some receptors have maybe a defect or something that would mean that they either need a lot more of that hormone to get into the tissue to make it work or some deficit that's happening that means that if you're not getting enough of that hormone to the tissue, it can change.
[00:46:58] And so, it does come down to your genetics to some degree. Like what is happening. We don't really know how to test for that beyond looking at the tissue and some of these things, but what we know is that there are certain women, say you're 14 years old, you got really bad acne, you get placed on birth control because-- why does it work? Birth control shuts down your ovaries by really tricking your body, thinking it's already [unintelligible 00:47:19]. It prevents ovulation at the same time and that's usually the work of the progesterone-- the progestin, but depending on the type of synthetic progestin that's in a birth control pill, it can either have like a neutral effect on your natural androgens or testosterone.
[00:47:39] It can increase it a little bit. So maybe it's a little more androgen increasing to some capacity. People will say, “Oh, I get more acne on the birth control pill.” The other generation of birth control pills reduce androgens. It's a couple different ways that it does that by binding up to the receptors for androgens, but by decreasing the testosterone in your system, you're also increasing this protein called the sex hormone binding globulin, which is a protein that your liver makes when you metabolize birth control pills orally. This SHBG goes up and then that binds up to your testosterone, so you have less testosterone available for yourself. There's some of the women that are using birth control pill, and they've been on it since they were 14.
[00:48:21] They come to me when they're 34, and they've been on it for 20 years. But for the last, I don't know, 10 years or so, they noticed they have to use a lot of lubrication when they have sex. I just thought it was because I've been with this partner for a long time. When I look at their vestibule and their vulva, I'm like, “Oh, it looks like a postmenopausal woman to me because the changes that are happening” you lose the androgens and the estrogen at the vulva, so they shrink down and there's pain on that Q tip test that I do. For that subset of women, and it's probably on the order of, I don't know, 5 to 7% or less, like maybe 3 to 5. I can't remember the statistic credit offhand, but it's not like every woman.
[00:48:59] But it is a lot of the women that I see because they come to me because of painful sex. We look at that and we say, “Okay, so maybe this birth control pill that you've been on for the last decade has contributed to your lack of hormone at the vulva where it needs it.” Sometimes patients are like, “I'm not going off the pill because I'm going to get acne.” You have to meet them where they are. Right? Because my goal would be to get them off a birth control pill, maybe put an IUD instead so they can have some form of contraception that we know shouldn't affect their androgens at the vulva as much. Then try to treat that local vestibule, the opening of the vagina with an estrogen testosterone cream or gel, so that with pelvic floor PT will get them into a pain free sex area.
[00:49:47] And so those are patients that we know are going to be susceptible to this on birth control pills. It's like again, it's not every patient. Think about the patients who have acne, PCOS, or endometriosis and they need the birth control pill to sustain their lifestyle or for them if they have a face full of acne, they're not going to want to have sex anyway. Because their self-esteem and how they feel about themselves is so intertwined with how they feel and look.
[00:50:09] I have a lot of patients who are like, “This keeps my skin clean, I'm not coming off of it.” I meet them where they are like, “Let's work on your pelvic floor. Let's get you some local cream. Maybe we can switch it to a different birth control that might be less androgen reducing.” Eventually, I would say like, they either come off of it at some point, because they want to have kids, or they want to try something else. But I do have a lot of patients who are like, “My endo pain is so bad, this is the only thing that will mitigate it.”
[00:50:39] So, I don't want to villainize birth control pills because I feel like TikTok does that enough [Cynthia laughs] and it's given women so much freedom and quality of life in so many other ways. But it is something as a sex med specialist that I look for to see if like this is contributing to your sexual pain at all.
Cynthia Thurlow: [00:50:57] Yeah, it's helpful to have your perspective. Now if someone's listening and they want to work with a sexual medicine specialist, vulvar specialist, would they go to ISSWSH? Like what is the best way to find a provider in their respective area? I know you're in Chicago, so if a listener's in Chicago they can come see you. But how do they go about locating someone that does the kind of practice that you have?
Dr. Sameena Rahman: [00:51:21] Yeah, and I think if it's specifically about their sexual concerns, it's www dot I-S-S-W-S-H dotcom. So that's ishwish.com and there are people that are members that are learning about sexual medicine and then there are people who are fellows who have been doing it for a while. You can differentiate that based on level of experience. So, depending on where you are, we have a lot of ISSWSH deserts as we call them, where we don't have anyone that really has touched base with us. There are ways to like, find-- I definitely have people that are coming in from different states sometimes to see me. But that and I think, depending if it's like vulvar pain or sexual pain, with lichen sclerosis there is ISSVD, the International Society for Vulvovaginal Diseases.
[00:52:06] A lot of us who are members, part of that. There's also for The Menopause Society we have the TMS for, I'm sure you've talked to that about. Then there's like the National Vulvodynia Association, also Tight Lipped, which is a patient driven organization. It's based on patient advocates who have experienced vulvar pain or sexual pain. They have their own list of Tight Lipped clinicians. I think that there's many available resources out there. ISSWSH has a patient facing website called Prosayla P-R-O-S-A-Y-L-A and that actually will talk to you about some of the different conditions that we treat. And so, I think those resources are great and that one is sort of an evidence-based resource that will tell you some of the more questionable stuff that you hear on the Internet.
Cynthia Thurlow: [00:52:58] Thank you so much for your time today. I've been like, I mentioned earlier, huge fan of your work. Please let listeners know how to connect with you outside of this podcast or work with you directly.
Dr. Sameena Rahman: [00:53:09] Yeah, you can-- I have a concierge practice called the GSM Collective which is Gyn and Sexual Medicine collective. We love GSM. So that's [unintelligible 00:53:17] [Cynthia laughs] www.thegsmcollective.com. I'm on Instagram as @gynogirl. I have my own podcast Gyno Girl Presents: Sex, Drugs & Hormones which I need you on by the way. I will be releasing a book next year so that'll be on all my information to [unintelligible 00:53:35]. But yeah, I think I'd love to help anyone and navigate this experience if I can, so.
Cynthia Thurlow: [00:53:41] Awesome. We'll have to have you back when published for sure.
Dr. Sameena Rahman: [00:53:43] Yeah, I would love to. Thanks so much.
Cynthia Thurlow: [00:53:47] If you love this podcast episode, please leave a rating and review, subscribe and tell a friend.