Listener Q&A: GYN Concerns and Menopause Insights

Oct 13
5 min read

I'm Cynthia Thurlow, NP, and I had the joy of talking with my dear friend Dr. Anna Cabeca about the real-life questions women bring about perimenopause, menopause, vaginal health, hormones, and sexual function. Dr. Anna and I dug into practical, clinical, and compassionate guidance—because while menopause is mandatory, suffering is optional.

"Menopause is mandatory; suffering is optional."

Menopause is mandatory; suffering is optional.

Why mindset matters: refining, not fighting, midlife

One of the first themes we emphasized is mindset. Midlife—and the transition through perimenopause into menopause—is not a punishment. Think of it as a period of refinement, not a problem to simply power through. Small, consistent shifts in sleep, stress management, nutrition, and self-care change how you experience this decade and beyond.

Early signs of perimenopause to watch for

Perimenopausal changes can begin in your mid-30s to 40s. If you're wondering when to start paying attention, note these red flags:

Changes in your menstrual cycles (frequency, flow, color)
New or worsening mood swings or cyclical irritability
Sleep disturbances or insomnia that weren't previously present
New brain fog or forgetfulness that follows a cycle
Shifts in energy patterns across your cycle (when you feel called to rest vs. be active)

Use your period as a report card—if you're not on hormonal contraception, it’s one of the best signals you have about your reproductive and hormonal health.

Foundations before hormones: what to do first

Hormone therapy can be transformative, but it rarely fixes everything on its own. The first line of work is always the terrain—your diet, sleep, stress, detox pathways, gut health, and metabolic fitness.

Improve insulin sensitivity: intermittent fasting and targeted strategies (like the keto green 16 approach) often help rapidly.
Support adrenals and hormone production: adaptogens (Dr. Anna’s Mighty MAA+ is an example) can improve day‑21 progesterone in some people.
Heal the gut: a healthy estrobolome supports estrogen metabolism and systemic balance.
Detox and liver support: optimize sulfation and P450 pathways so your body can metabolize hormones effectively.
Sleep and stress: prioritize rest; chronic stress shunts precursors toward cortisol rather than sex hormones.

Testing: look beyond standard labs

Lab evaluation needs to be individualized. Key assessments include:

Detailed glucose/insulin testing (2-hour OGTT with insulin draws can reveal early insulin resistance missed by fasting glucose alone)
Serum hormones: total and free testosterone, estradiol, DHEA-S, progesterone
Thyroid panel and other longevity markers
Specialized testing: DUTCH (urine steroid metabolite testing) or salivary profiles depending on the route of hormone delivery

Importantly: treat the patient—not just the numbers. Bioindividuality means similar labs can require different treatments depending on symptoms and context.

Hormone strategy: replenish, don't rush to replace

My practical sequencing with symptomatic patients typically looks like this:

Start with foundational lifestyle changes and adaptogens.
Support progesterone/pregnenolone (these are "mother" hormones) — often the first topical combination I use.
Then address DHEA, testosterone, and estradiol in a top-down manner.

Why start with progesterone? Statistically, women lose a large proportion of progesterone between ages 35–55 (estimates often quoted around 75%), and replenishing it can relieve many symptoms. Estrogen declines too (around 50% in that timeframe), but when to add estrogen depends on symptom patterns, insulin sensitivity, and individual metabolism.

Delivery methods: pros and cons

Topicals (creams/gels): flexible and often favored, but absorption can vary—gut and skin health matter.
Patches: inexpensive and accessible; good option for many.
Oral hormones: convenient but oral estradiol can increase risk of blood clots and stroke in older or inflamed patients.
Injectables and subcutaneous: useful when transdermal absorption is poor or when precise dosing is needed.
Compounded preparations: allow customization but require a knowledgeable prescriber.

Genetics, stress, and progesterone dosing

Some patients don't tolerate progesterone well—oral progesterone can be shunted into cortisol production under high stress, causing weight gain and other issues. Genetic differences in metabolism and detoxification (sulfation, P450 enzymes) also influence dosing and modality choices. Monitoring symptoms and targeted testing (including genetics when appropriate) helps guide adjustments.

Testosterone: why "a little" matters—and when pellets can go wrong

Testosterone is important for female health, libido, bone and muscle—but it must be dosed within a female-appropriate, functional range. Some cautionary points:

Pellet therapy can create sustained superphysiologic levels. That can suppress natural glandular production and lead to withdrawal symptoms (mood changes, depression) when levels fall.
Chronically high testosterone can change behavior, mood, and even voice; some changes (like deepening of the voice) may be irreversible.
If absorption or transference to partners is a concern, injectable or low-dose oral options can be preferable to topical gels with transfer risk.

Bottom line: don’t assume “more is better.” Work with an experienced clinician who understands dosing, monitoring, and the underlying drivers of low testosterone (HPA axis dysfunction, toxicity, insulin resistance).

Vaginal health and genitourinary syndrome of menopause (GSM)

As estrogen declines, vaginal tissues thin, pH shifts, and lactobacilli decrease—leading to dryness, painful sex, recurrent UTIs, and incontinence. Important clinical points:

Vaginal estrogen improves mucosal lining but does not restore underlying connective tissue elasticity.
DHEA (vaginal) and vaginal testosterone are superior at improving tissue elasticity and muscle function compared with estrogen alone in many cases.
Vaginal estrogen products can transfer to male partners and can remain active for many hours; be mindful of timing if that’s a concern.
Local hormones (DHEA/testosterone) are generally minimally systemically absorbed when used at appropriate doses.

Sexual health and low libido: it's rarely just hormones

Libido is complex—biological, psychological, relational, and environmental factors all play a role. Essentials to consider:

Evaluate hormones (testosterone, DHEA, thyroid), but also screen for toxic burdens, medications, mood disorders, relationship dynamics, and sleep quality.
Address histamine and neurotransmitter mediators—antihistamines and some medications can blunt desire and orgasm.
Behavioral and therapeutic interventions matter. Dr. Anna built a "Sexual CPR" program to assess all contributors comprehensively.

Incontinence: types and practical treatments

Know your type—treatment depends on the mechanism:

Stress incontinence (leak with cough/sneeze): target structure and support—pelvic floor therapy, hormonal optimization (DHEA/testosterone locally), and, when needed, surgical options.
Urge incontinence (sudden uncontrollable urge): bladder retraining, dietary modification (caffeine and irritants often trigger symptoms), pelvic floor therapy, and careful use of medications when indicated.
Overflow and post-void dribbling: evaluate urinary emptying mechanics and possible anatomical contributors.

Avoid chronic anticholinergic agents if possible (e.g., oxybutynin) because they exacerbate dryness and cognitive burden; often hormonal and lifestyle approaches help markedly.

Vaginal rejuvenation: lasers, RF, and the role of hormones

Energy devices (lasers, radiofrequency, red light) can help when the vagina has been properly conditioned hormonally. Key points:

Laser/RF works better on conditioned tissues—use local hormonal therapy first (DHEA/testosterone ± estrogen) to improve thickness and elasticity.
Red light and RF are less traumatic alternatives to older laser technologies.
Maintenance is important—simple at-home measures (vibrators combined with topical hormones) may support long-term outcomes.

Practical, clinician-friendly takeaways

Start with lifestyle foundations—sleep, insulin sensitivity, gut health, and detox pathways—before expecting hormones to be a panacea.
Bioindividualize therapy: symptoms guide decisions more than a single lab value.
Begin with progesterone/pregnenolone support, then layer DHEA, testosterone, and estrogen as needed and monitored.
Use local DHEA/testosterone for severe genitourinary symptoms—they improve elasticity and function more reliably than estrogen alone.
Be cautious with pellets and long-term superphysiologic testosterone; consider injections or tailored compounded dosing when appropriate.
When in doubt, assess insulin resistance—improving insulin sensitivity often dramatically improves hot flashes, mood, and overall response to hormones.

When to seek a provider and where to look

If you're symptomatic and your provider only offers a single, one-size-fits-all solution, seek a clinician who understands bioidentical, bioindividual approaches and looks at hormones in the context of lifestyle and labs. Ask about their experience with:

Detailed hormone testing (DUTCH, serum panels, insulin/glucose challenges)
Pelvic health, vaginal therapies, and sexual medicine
Comprehensive lifestyle interventions, not only prescriptions

Resources & Next Steps:

To learn more about Dr. Anna Cabeca’s work and programs, visit DrAnna.com (referenced during our conversation). For more from me, Cynthia Thurlow, visit https://cynthiathurlow.com/.