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Amanda: So this interview is going to be so amazing. I was just blown away. I’m so excited for you to hear this. A lot of times I get responses from women that the reason that their libido is down or they’re struggling with sex is because their hormones are off. And while I think that is sometimes the case, and we’re going to talk about a lot of that in the interview, very much your sex drive, if you want to call it a drive, it’s not really a drive, but just, you know, for simplicity’s sake or libido or whatever you want, your desire levels are really biopsychological/social.

So we have to look at the biological component because yeah, if your hormones are off, it can definitely affect things, but it’s not going to just affect your libido. There’s going to be other symptoms that you’re having, um, that will make it apparent to you. But if those are off, we definitely want to work on those. 

And then, you know, the psychological, like your mindset, your conditioning is really important and social, what’s going on in your life and your relationship dynamics. Those are all really important and play into the whole dynamic in the sexual relationship.  

So what we’re focusing on in this interview is hormones and what that looks like for women and especially, uh, women in perimenopause and postmenopausal. 

And you may not think that you need this information right now if you’re younger than that, or if you’ve already gone through menopause. You absolutely do. We do not have a lot of education when it comes to what happens for women when we are perimenopausal or menopausal and postmenopausal. We just don’t have a lot of information.

We have a lot of information about puberty, right? And perimenopause is kind of the reverse of puberty. So we really need more information about this as women. I am so, it’s so important to me to empower women in this area. And I have been learning a ton from Dr. Kelly Casperson, and I cannot wait for you to learn more from her too.

Just so you know. And she talks a little bit about this in the episode, but the average age for menopause in women is 51. Okay. And perimenopause can start 10, sometimes even 15 years before that. So if you’re. If you’re 36 or older you absolutely need this information right now. If you’re younger than 36, you still need this information because it is going to affect you eventually, I promise you.

And so I really want to empower women to know more about their bodies and about their sexuality. And this is a missing piece. And so I’m really happy to bring you this episode. So here we go. 

I am so excited to have Dr. Kelly Casperson on the Sex for Saints podcast today. Kelly is not only a fellow sex coach, but a board certified urologist. She has written an amazing book called You Are Not Broken and has an awesome podcast by the same name (find that here). I have been following her for quite a while and I’ve learned so much from her about female sexual health, especially when it comes to perimenopause and hormones. So welcome Dr. Kelly Hasperson.  

Kelly: Thanks for having me.

Amanda: So happy to have you here. So I think it would be really helpful for my audience to hear a little background of how you as a urologist really got into the space of female sexual health.  

Kelly: Yeah it’s a cool journey because everybody thinks like we learn all we need to learn in training, right? 

Amanda: Yeah, no.

Kelly: I was a urologist doing lots, I was doing lots of female urology, prolapse, incontinence, you know, stuff like that. But, I really had a patient change my life. She had some sexual health issues and I realized, you know, urologists get trained in men and their body parts and their erections and all of their issues. And we just kind of always assumed the women were being taken care of by the gynecologist. That was my assumption. 

And then I had this patient come into my office, she basically changed my life because I was very bonded with her and I realized I didn’t know how to help her and I was taught in training that women were difficult, they were challenging, furthermore, they took too long in the doctor’s office and it’s best to just, you know, avoid that and the more I researched on female sexual health, the more I realized there’s decent research, it just doesn’t trickle down. And certainly Hollywood doesn’t help us. Mainstream media doesn’t help us. And you know, ask any gynecologist who’s worth their salt and truth, and they’re like, yeah, we don’t really get trained either.  

So it really became a gender bias issue to me in how we treat men and women very differently as far as what we think about their quality of life, what we think about if sex should be important to them. And it got to the point where I’m like, why are we bothering treating erectile dysfunction issues if nobody’s addressing their partners. Um, and then I really got into midlife and menopause and hormones because of sex. 

It was mostly Instagram that did it for two reasons. Number one, Instagram kind of frowns upon us talking about sex and sex education, which is a barrier. Um, and they know how I feel about that. Um, but really so many people are interested in hormones and it’s just a kind of a safer thing to talk about on Instagram, you know, podcasts, that’s why podcasts are so great, right? Because you can actually have sex on the podcast and not get blocked. 

So women are like, well, you know what happens because of menopause? And well, you know what happens to your sex life because of menopause? And I’m like, I don’t, and I’m staring down the barrel of this, right? Like maybe I should learn.

And so really from there, it drove into like, is estrogen important? What about testosterone? What happens in perimenopause? Why don’t people know what happens to their body? Which is insanely ridiculous because we know what happens with puberty, right? Everybody big heads up of puberty is coming. Nobody gets a head up that like puberty is basically reversing and stays that way.

So I just really got into hormones. Why are we afraid of them? Is that fear based in science? You know, what’s new since that fear based study came out 22 years ago. It’s a fascinating topic. And for me, I’ll always have work because for me, this is a quality. It is correcting the gender bias that’s inherent in medicine. And, it’s a very fascinating topic and it involves everybody like this is everybody’s health. This is everybody’s health!

Amanda: Yes. Well, and that’s why I love your work so much because you’re not only addressing some of the issues that other doctors aren’t addressing, but you’re also empowering other doctors to start learning and talking about it. And so that more and more women can get the help that they need, which I think is so, so important. 

So I’m totally ready to dive into this, if you are, I’m so excited. So let’s start with perimenopause. What is it? And what should we be on the lookout for when it comes to our health as women and specifically our sexual health? 

Kelly: Yeah. I mean, it’s incredibly important to start there because so many people, if we don’t define our words, it’s hard for us to get on the same page with anything. So menopause is a year without natural periods. Average age of menopause in America is 51. It’s a difficult definition because so many people have IUDs or hysterectomies or, you know, whatever other reason that they don’t have a natural period ending point.

But that’s what the medical establishment gives us for the definition of menopause.  Perimenopause, it’s not a laboratory value, it’s not a year of your life. It’s really just the years leading up to menopause. And by definition they say about the 10 years leading up or so peri, peri means surrounding, right? So surrounding menopause. I actually saw a woman a couple weeks ago and she was kind of obsessed about if she was in perimenopause or not. She was 43. And she’s like, but am I in perimenopause? And my doctors won’t do any tests to find out if I’m in perimenopause. And I’m like, what are you asking? What do you actually want to know by answering this question? 

And she’s like, I need to know if I can take hormones or not. And I’m like, that’s a very different question in perimenopause. Right? So I mean, my advice to clinicians out there are doctors is like, really understand what people are asking. And yeah, you know, if you’re asking the question, why does it matter? 

And she was like, obsessed about it. I’m like, listen, you’re 43. That’s within 10 years of the average age of 51. By definition, you’re in perimenopause. Completely separate issue to if hormones are right for you or not.

So I think just our lack of education and people’s resistance, I don’t want to be in perimenopause. It’s like, well, honey, you’re living long. Right. Like my grandma was 96 and she always said there’s only one alternative. Yeah. And I’ll. Like use it till the day I die is like, it’s just what it is. It’s like puberty, right? Like it’s going to happen if you live long enough. So it’s not something to be afraid of, but lack of education creates fear.  

Amanda: Absolutely. Well, I know I am fully in perimenopause. I’ll be turning 45 this year. And so I am really, I mean, so much I’ve learned from you. I am trying to educate all of my peers as much as possible because I mean, most of my peers, you know, about my same age and they’re all in it too. And I know more information than they do, so I’m telling all of them. And one of the things that they’re so scared about is hormones, right?

Kelly: I know it’s, well, the interesting thing about fear of hormones too, and you can ask them this, cause if you want to be like a little sassy, you can be like..

Amanda: Which I love being sassy.

Kelly: Nine out of 10, 10 of them cannot tell you why they’re afraid, they just know to be afraid. It’s like literally a dogma that is not being challenged. Cause I’m like, Wait, you know, they’re like, Oh, my mom’s sister’s newspaper delivery man in the 1973 told her to hormones, blah, blah, blah.

It’s like, dude, update your hardware. Like we’ve got some new info. Like doctors used to use leeches. We don’t. Update the memos.  

Amanda: Yes. But I think the reason they are so scared is from the Women’s Health Initiative from 2000. 

Kelly: They don’t know that. 

Amanda: Yeah. They don’t know that. I know that. But that’s why this attitude of fear. 

So let’s talk about that a little bit. What was that? Where is all this fear coming from that they actually don’t know where it’s coming from? 

Kelly: Yeah. So the Women’s Health Initiative was a billion dollar study started in the eighties and nineties by the government.

And this was like the feminists, like wet dream, right? We’re like, we’re finally going to study women on a very large scale to see, and the question specifically was, does giving women hormones post menopause  decrease their risk of heart disease?  That was like specifically the question because we had tons of studies showing that it did. This was basically going to prove it because we didn’t have a randomized controlled placebo blinded study, right, which in the medicine world is considered creme de la creme. Except for the Women’s Health Initiative, which is not the creme de la creme. 

So what they did is they randomized women, average age, significantly post menopause. This is very important when you get down to who benefits the most from being on hormones, right? The answer is not the people who’ve already been without hormones for 20 years, but what they did is they threw these older people with significant risk factors, smokers, overweight, um, on hormones and hormones that we don’t even use anymore. So oral conjugated equine estrogens, uh, synthetic progestin. So medications we don’t even use anymore, to women who are significantly older than the people who we think can benefit from the hormones.  And they did show some adverse events the older you were, as far as cardiovascular disease, stroke, heart attack. 

That’s not why people are even afraid of hormones though. What happened was before they even published the data, so doctors couldn’t even go and read it for themselves to interpret, they went to the media and they said, we’re stopping this study prematurely, which is always a big, you know, attention getter. Because we think in the estrogen progestin arm, you have to be on a progestin if you have a uterus when you take estrogen. So in the women with uteruses who were on combined estrogen progestin, there was a possibility of higher breast cancer risk, not statistically significant. Media went nuts. And this was before social media, just mainstream media went nuts.

Eighty percent of women in this country were taking off their hormones. We now know that the placebo arm, so they said increased risk of breast cancer compared to placebo. These were not randomized to risk of breast cancer. And the placebo arm, actually, some of those women had previously been on estrogen which decreases your risk of breast cancer.  So, compared to placebo, which was a flawed placebo arm, estrogen progestin wasn’t even statistically significant, but looked like there might be higher breast cancer. 

Once you break that down and you realize Oh my god, we’re actually afraid of something that is a medication we don’t use in women that we don’t use them in a placebo arm that was flawed because they’d already been on a drug that decreases your risk of estrogen. That all of this fear was unfounded. I mean, it’s pretty blockbuster story when you break it down. 

Amanda: Yeah, yeah. And so many women who should have been on hormones are not on hormones now because it’s still not trickling down to the medical community at large, correct? 

Kelly: Well, we have two decades, so that was 2002, now it’s 2024, right?

So we have 22 years, or two decades of medical schools not teaching physicians, of residencies not teaching physicians, of the mom passing it on to the daughter that the doctor said I couldn’t be on hormones because it was unsafe. And so it’s really going to be a culture shift. The good news is the culture shift is happening.

Um, and I think, you know, it’s the educated women who have access who are going to be able to get on those hormones first. So again, there’s a big disparity problem, right? But you’re going to start seeing health disparities between the women who are being proactive and the women who don’t have access yet. 

Amanda: So what are those health disparities?  Because I’ve heard you talk about like lower risk of heart disease. Correct?

Kelly: Yeah. And again, you know, I didn’t even put this in the definition of menopause cause this is not in the definition of menopause. Definition of menopause is no periods, no natural periods for one year. 

Yeah. Well, that’s a problem because that doesn’t actually tell you that, Oh, by the way, your estrogen, your progesterone and your testosterone are low, low, low. How low?  Your estrogen postmenopausal is lower than your male partner’s estrogen. A man has about an estrogen level of 30 to 40.  Yeah, a woman postmenopause has an estrogen level lower than a man’s. 

And I point that out to be like, what’s the big deal? Right? Well, estrogen is incredibly important in that man for his bone health, for his sexual desire, for his erections, for his heart health. Estrogen is important in all bodies.  So what you see in women who take hormones after menopause, decreased risk of heart disease, we are thinking there’s more and more data, decreased risk of neurodegenerative disorders, Parkinson’s, Alzheimer’s,  uh, you know, any sort of neurologic issues. Decreased risk of musculoskeletal issues, frozen shoulder. It’s a huge problem. Nobody talks about that, but I guarantee you, your listeners have frozen shoulder right now and they have no idea the association to estrogen with this. It’s literally called the 51 year old shoulder. 

Amanda: Oh jeez.

Kelly: By like, physical therapists. Right? Decreased risk of osteoporosis, significant decreased risk of fracture, which nobody thinks about. But if you end up with a hip fracture in your old age, it is a horrific way to die. Decreased risk of colon cancer, decreased risk of insulin resistance, decreased risk of diabetes. 

So many benefits, mood disorders, the rate of depression, anxiety skyrockets in our forties.

The tide is turning to say, Hey, pay attention to hormones first before antidepressants. Certainly, I would argue if you are on the natural bent of things and antidepressant is much less natural than taking a hormone, which your body always made and just has less of now.

I mean, the other goofy thing about hormones is like vitamin D is a hormone. Insulin is a hormone. Thyroid is a hormone. You don’t have anybody going around saying we shouldn’t get those people who are low in those three hormones back up to normal.  

Amanda: No one. Yeah. So if we’re hitting perimenopause, you know, 41ish, right. When should we be starting hormones? 

Kelly: There’s no, yeah, it’s a very interesting question. And I think the perimenopause question is kind of the newest question in this. Cause certainly, I mean, we’re getting to the point where like menopause hormones, people are kind of getting comfortable getting there.

Perimenopause is the reverse puberty, right? So it’s kind of coming offline. Your hormones are fluctuating. That’s why the periods are wonky. Wonky. That’s why your moods are wonky. That’s why you’ll have trouble sleeping and then you won’t have trouble sleeping, right? It’s because we’re kind of reverse puberty down to that, you know, below the man’s estrogen level. 

So the question is who, when, what hormones first, right? Give everybody a little bit of testosterone because testosterone converts to estrogen. You know, that’s a whole nother bag of worms. There’s so many, there’s so many questions and it, I mean, I hate to frustrate all your listeners for not having it be easy, but it’s like, that’s why really a good relationship with a doctor who cares, who’s not just trying to sell you one hormone product, by the way, people who are like pellets are the highway, no. We can do this cheaply. We can get your insurance to cover this. You should not have to remortgage your house to be on hormones. But the United States Physician Task Services did make a statement  saying, as a preventative medicine in all people, we’re not there. We can’t say, hey, everybody just start hormones when you’re 43. Like we, we do not have that data. Certainly there are risks to taking any medications. They’re very low with hormones, but you’re never going to get like, well, you’re 18. You can vote like you’re never going to get a, you’re 43, you can start on hormones. It’s really finding a provider who’s knowledgeable, who can listen. Certainly me. I put perimenopausal people on hormones all the time. 

Amanda: Yeah, well, that’s a really good question. Yeah, there’s like, how do we even find a provider? Because I mean, I have people coming to me all the time. They’re like, I talked to my OBGYN. Well, one, they’re like, No, you know, this causes breast cancer.

So then they won’t, right? Or they don’t know enough about it. Or they tell me I’m normal, when I know that I’m not in, I might fit in the normal range, but I don’t feel Yeah. Like my normal self. 

Kelly: Yeah. Well, I think the other common thing, if I’m just going to stereotype, especially in the OBGYN world, or even the doctor world, is like, for a perimenopausal woman, is putting her on birth control pills first.

Amanda: Yes!  

Kelly: Versus hormone replacement therapy, which, they’re two very different things. Now, I always say, in perimenopause, you can still get pregnant. So, if you have sperm in your life and you need to not get pregnant, you’ve got to figure that part out. Because if you just throw yourself on an estradiol patch, you could get pregnant. As opposed to a full year without natural periods, you’re basically not going to get pregnant anymore. So perimenopause has that unique other thing we got to figure out. Um, and what do I say? And, or birth control pills can help some people, but I certainly would say birth control pills by and large have more side effects than hormone replacement therapy does.

They’re a synthetic hormone. They’re, they’re made to mimic, but they’re not exactly like, you know, hormones. Um, so you got to be with, you know, somebody who can figure that out. First and foremost, do we have to figure out pregnancy? Okay. We don’t. Okay. We can, you have a vasectomy in your life or you’re, you know, not sexually active. Great. Let’s just deal with putting you on some hormones. 

I think it now it takes advocacy, it takes bringing in, you know, I think it takes a relationship. Like you can’t go to an urgent care and expect somebody to put you on hormones, right? Like it’s a relationship. What I find helps is to say, Hey, I’ve been reading a lot about this. I’m curious. Can I just try XYZ, whatever, some estrogen and progesterone for three months, I will come back, I will adjust the dose, and if it doesn’t work, I will stop. Like, that is the power move in the doctor’s office. You say, I’m going to partner with you, we’re just going to try, and I promise I’ll come back. 

That is a, that will get you farther than like being antagonistic or why won’t you, or, you know, or like not kind of  can keeping the conversation going when somebody tells you no. 

Amanda: Yeah, well, and so should they be asking their OBGYN, should they find a urologist should they find just their general practitioner?

I mean, I hear a lot that like functional medicine doctors do better at this, but a lot of that’s not covered by insurance. So people are more reluctant to go there. What do you suggest?

Kelly: I mean, uh, yes to all of that. Um, not all urology. I mean, I’m kind of a unique urologist for a smart female. That’s a low percent of urologists.

Uh, and I really got into hormones again because of gender bias, right? Like a man comes to my clinic with low testosterone and poor erections. I’m not telling him to drink a glass of wine and do yoga and that he’s just getting old and to deal with it, right? And once you see how we treat men and women differently, I couldn’t help but start helping the women the way we help the men. 

Amanda: So many women get told like just deal with it, deal with all these symptoms This is just part of being a woman and that’s not true.

Kelly: No, it’s not true And and so what if it is? Dry eyes are part of life? We treat it. Cavities are part of life, we treat them. Painful childbirth is a thing. We treat it. Like to me, I’m like, it just doesn’t hold up to anywhere else in medicine. Getting cancer is a natural part of life. We’ve been getting cancer for thousands of years, as do other organisms. We don’t say it’s natural and just live with it, right? Like you can’t, that it just doesn’t apply when you hold it to anything else. 

Amanda: It’s so true. That’s so true. So I heard you talk about vaginal estrogen and it literally changed my life. I have been having chronic UTIs for years, gone on multiple medications, you know, a daily antibiotic. I have not had a single one since I started vaginal estrogen, but I went to my urologist and she told me that I was too young. I was 43 at the time and she told me that I was too young and I had to advocate for myself. I said, no, this is what I want. I want you to put me on it. I will come back if it’s not helping, but I want you to put me on it. So talk to me about vaginal estrogen and how important it is for women. 

Kelly: Yeah. I mean, sometimes I joke, but not really like God put me on the earth to tell people to use vaginal estrogen. 

I’m like, can God have such a specific niche? Because it seems to have really niched down on me. 

So vaginal estrogen is amazing. It is local estrogen only. What that means is it’s very different than systemic hormones when you think of like pills and patches and things where you’re all your body gets the estrogen.

Vaginal estrogen is just for your pelvis and it works great on the vulva in the vagina. It really helps the bladder out. And I tell people the bladder and the vagina share a wall. So we’re just putting the medicine in the vagina. That’s how it’s helping the bladder and most importantly, how it also helps reduce UTIs is it rebuilds your natural microbiome. So the vagina loves being acidic. Estrogen helps it be acidic. When it’s acidic, it can promote lactobacillus, which helps make it acidic. And when you have an acidic environment, it acts as a massive infection preventer between the poop and the pee. So really a healthy vagina really decreases the rate of urinary tract infections. 

Um, in some countries it’s over the counter, which is awesome. 

Amanda: Right? Oh, I wish it was here!

Kelly: I know. I don’t see that happening. Believe me, I’ll be the first person to announce it. The two big problems in the United States of America is cost. A lot of insurances are making money off of this. This product is generic. It’s been around since the 70s or earlier. It should be no more than $20 a tube. Um, really quick. Three tips for that: Amazon Pharmacy, Mark Cuban’s Cost Plus Drugs, Online Pharmacy, and the GoodRx Coupon. I went in to get my vaginal estrogen and I think I have Blue Cross Blue Shield, you know, the generic big insurer. And they’re like, that’ll be $260. I’m like, you know who I am and how much vaginal estrogen I put through this place. And so I just pulled up my app on my phone, pulled up the GoodRx coupon, made it that pharmacy and it was $27. And they’re like, oh, okay, here it is for $27. And you’re like, women shouldn’t have to know the loopholes to get, you know, affordable healthcare, but that’s the way it is.

So number one, cost is a problem. Number two, the FDA put a black box warning on all estrogen products because of the WHI, which we’ve now debunked, right?  And they don’t care if it’s vaginal estrogen or systemic estrogen. And the black box warning says probable dementia, stroke, heart attack, cancer, et cetera, et cetera.

So if a woman doesn’t know that that’s actually wrong, she’ll get her prescription from her doctor and then she’ll think the doctor’s trying to kill her. We’re actually petitioning the FDA to get the black box warning off. ACOG petitioned in 2018 and failed. We now believe we have more and more better data saying this stuff is so safe. 

It does not cause all these problems. 

Amanda: Yeah. Is there anyone who shouldn’t be on it? 

Kelly: No. 

Amanda: Okay. Good to know.

Kelly: If you’re currently being treated for breast cancer, get an okay from your oncologist. But most oncologists who know the modern data know that it’s okay. So I’m not saying they can’t, I’m just saying make sure everybody on your team knows everything that you’re taking. In case you have some weird case where you just can’t. 

But we actually have the ACOG statement. You can get that online. American College of Obstetricians and Gynecologists that says vaginal estrogen, multiple studies showing safety in cured breast cancer, active currently being treated breast cancer, because these women have significant pelvic issues with the estrogen blockers.

Right. Um, pain with sex, burning when they pee, recurrent UTIs, severe pain, cracking skin. Yeah. Like, you know, all these things where we say we can help that. We can do something about it. 

Amanda: And the vaginal estrogen, correct me if I’m wrong, can also help with the dryness, like even clitoral atrophy?

Kelly: Yep. I mean, that’s the big question. You know, like I was saying before, like, should we just start all perimenopausal women on estrogen? Well, we don’t have enough data to say we just give everybody this. But when it comes to vaginal estrogen, you know, we’re, and this is how I like to think about medicine, medicine in America right now, come to me when you have a problem.

Like what if I don’t want to get clitoral atrophy? What if I don’t want to wait for my orgasms to be a problem? What if I don’t want to wait for burning, itching, dryness, recurrent UTIs? Right? Like, so to me, I’m like, I think if, if there’s a preventative role of any hormone, it’s really the local vaginal estrogen, because I tell you, I’m not going to wait around to have a problem down there.

Is most of it reversible? Yes. But clitoral atrophy can be, not only does it, it can cause pain, right, but it can also diminish orgasm, diminish pleasure, really can affect your relationship. Not only with yourself, but with your partner. And sometimes we do have to do a minor surgical procedure if you’ve got clitoral thymosis, which is where the skin over the clitoris becomes adherent and kind of covers the clitoral head in order to get those tissues kind of exposed and healthy again. 

And I wish I could tell you that happens in 75 year olds, but you know, I just helped out a 52 year old with complete clitoral thymosis.

Amanda: Yeah. Well, I reached out to you a few months ago with, um, a follower of mine that had, she’s my same age and she is had significant clitoral atrophy and she was devastated by it and who she could go to in her area.

And you gave me a few names to pass on to her. And I mean, she’s 44, 45, like. It’s happening in all different ages. It’s not just happening when you’re 75.

Kelly: Yeah. And I mean, shout out to my friend, Dr. Rachel Rubin, who’s sex med in Washington, DC who’s really starting to publish the papers on clitoral atrophy and, you know, license of clitoral adhesions because it’s not much in the medical literature, right?

I would argue that most physicians don’t know how to examine a vulva. Which just, if anybody doesn’t know what that is, it’s the external structures. Vagina is the tube that the tampon and the babies are in. The vulvas are the outside stuff. 

Amanda: Yes. Good. So I recently saw a reel that you did from the sexual health conference in New York City, where you said that bioidentical hormones is a marketing scheme. Tell me about that.

Kelly: Yeah. Mike Drell. Talk about breaking the internet on like things you wouldn’t break the internet on, right? So, this is what happened. Like, it’s really good for people to under, that’s why I love podcasts. You can actually like explain yourself. You know, 82 seconds long. Um, because of the WHI, we said hormones are scary. And remember, those were the synthetic hormones that we used, right? Which we don’t even use anymore. But we said they were scary. We took all the hormones away. None of the doctors would prescribe anything. And women were suffering.  So how did the people help the women who needed some help? They said, don’t worry. Come over here. I’ve got safer stuff. It’s called bioidentical. 

By the way, also give me thousands of dollars for, you know, the pellets or the compounds or the blah, blah, blah, because it’s not the pharmaceutical industry, so it’s safer. And I get it. I get it all. We were afraid, women needed help. This was the way to make everybody feel safe.

But we haven’t, again, updated the hardware of like insurance covers. What is what’s bioidentical mean? Bioidentical means it’s the exact same stuff as your body makes. Now it’s made in a lab in a pharmaceutical place, whether that’s a compounding pharmacy or, you know, Abbott Pharmaceuticals, like it’s not, people have this like idyllic, like we take the yam from the organic garden and then we mash up the yam and then it’s a plant based formula.

It’s like you guys in your organic farming. Like, no, this is pharmaceuticals on a massive grade. We don’t have enough yams, right? Like it’s, these are chemical compounds, but they’re the exact same as what you make just like insulin is and thyroid is, right?  So, going back to all of that, but bioidentical means exactly what your body makes. So if I test your blood, And then I give you some bioidentical hormones and I test your blood. Your blood will show that you put those in there because I can measure them because they’re the same as what your body makes. That’s all it means.  

Amanda: Okay. Good to know.

Kelly: But people use it as a marketing term. And the thing, you know, I liked, which was on this reel of like, if I take two candy bars and I put natural on one of those candy bars, I can charge more money for that because it’s a marketing tool and people somehow think that that’s better. But it doesn’t actually mean anything.  Because natural doesn’t mean anything in the food industry, right? It’s literally just a word. And so that’s what bioidentical is because it’s like you can go to your traditional doctor and get insurance approved bioidentical hormones because we use, by and large, hormones now are estradiol and micronized progesterone. By and large, there are, you know, you can, we can get an nichy with it, but estradiol and micronized progesterone are bioidentical and they are cheap, cheap, cheap, cheap, cheap. 

But the doctors like the average person isn’t going around being like bioidentical because we know it’s a made up word, right? That’s what everybody uses. Everybody uses bioidentical hormones. You’re just paying more for your bioidentical ones. And then hoodwinked into thinking it’s better. 

Amanda: Yeah. But it’s actually what we’re doing and not synthetic like it used to be.

Kelly: Nothing’s, yeah, no. You know what’s synthetic? Like, birth control is synthetic. How many people are on birth control? And I’m not dissing birth control. Birth control has literally changed the world. But we’re all so, you know, nose uppity about this when it comes to hormone replacement therapy. And we don’t think twice about being on birth control, for the most part, because there’s risks and there’s benefits.  But yeah, I mean, that’s my whole thing is like, you guys, it’s, it’s safe. It’s cheap.  

Amanda: Yeah. So do you think as women, we need to go on like all the hormones? I mean, the estrogen, progesterone and testosterone, because I know a lot of women are going on just testosterone or a lot of women are scared to go on testosterone because they’re afraid of side effects.

Kelly: Yeah. I mean, again, it’s so hard to give a blanket statement. Yeah. You know, and in all fairness to me or any expert who waffles on this answer is like the true expert knows this is not a one size fits all, but what I can tell you is female bodies make estrogen, testosterone and progesterone, they’re all important. You might notice benefit from some one or all of them. And this is really where, I mean, again, why healthcare is hurting us is like one 15 minute appointment a year is insufficient, especially in perimenopause when you’re like, well, last fall I couldn’t sleep, but now in March I just feel exhausted and like a little, you know, sad and like I’m not making gains in the gym.

Right. Like maybe we needed more progesterone in the fall. Now we need more testosterone because again, in perimenopause, things are changing. 

My wish on all of this is for women just to not be afraid. For women to understand you can try things and change things. And for women to understand we are not cookie cutters.

What works well for your cousin and your friend down the street might not work well for you. And that’s okay.  I think so many women are just looking for the best, like how many Instagram things, like what’s the best? What’s the best? And it’s like, that’s the wrong question. The question is, What should you try?

Amanda: Yeah, what’s the best for you? 

Kelly: For you. And until you try it, you’re not gonna know. And there’s so many different doses. And there’s so many different routes of administration. And I’m not saying this to be complex, I’m saying this to get people to understand, like you don’t know what your zone of genius is until you try something and you, you know, fiddle around with it. 

But, by and large, most of my women, they get on a plan. They’re happy with it. They’re like, no, I’m good. I don’t want to adjust anything.  And then you’re fine. You know, it’s just figuring out what you need, but if anybody says you just need a pellet or you just need these, if any, a big red flag is like truly oversimplifying this, like, this is just what everybody needs.

No. No. That’s not how it works. 

Amanda: Well, and I’ve heard you talk about pellets and kind of anti pellet, does that sound correct? Maybe I’m just reading things into it.

Kelly: Yeah. I mean, the more and more I learn, and again, here I am being nuanced, right? But it’s like, there are some women who I think do very well at a higher physiologic dose of testosterone.

Right. Which classic pellet, you get estrogen pellets, you can get, but classically it’s a testosterone pellet. And these women, their blood levels are 200 to 300 on these pellets, which is like a low male value. Again, normally women have about one 10th, the amount of testosterone that a man does. So what I see with pellets is that women go for, I use the analogy of like, you’re living at sea level. 

If you live at sea level and I take you in a helicopter and I fly you up to Mount Everest, like, you’re gonna pass out. Like, it’s not comfortable for you at all. And that’s where I see a lot of pellets. You’re moving around like, oh, pellets and oh my god, right? And it’s like, yeah, it was too much. Like, my hair fell out. I’m like, yeah, you got out of a helicopter at Mount Everest. Like, it hurts everybody, right? But some people like living it, you know, in Denver. It’s like, if you got to figure out what elevation is right for you, I think pellets are good for some people, but even a lot of the pellet pros will say, get there slowly. Right? Like go live at Denver for a little bit before you decide Nepal’s the right elevation for you. 

Get there slowly. But again, it’s hard to do in a 15 minute appointment once a year. It really does require a little bit more, but yeah, I mean, I think the other reason in this isn’t so much anti pellet, but it’s like if anybody says there’s just a one size fits all to everything, we shouldn’t wonder why so many women give up on hormones.

Amanda: Yeah. I know that you’ve talked a little bit about how estrogen actually plays a huge part in libido. So we tend to focus on testosterone. Like if you’re, if your libido is low, take some testosterone and that might help, right? But estrogen plays a part in that as well. And from what I’ve heard you say, like it’s playing a bigger part than we thought it did. 

Kelly: Yeah, a hundred percent. Um, I’m going to use a male study just as it’s just a fascinating study. And I think it really, it helps us understand how important estrogen is in libido. Um, first of all, libido is complex. Not everybody’s libido is just a low hormone. It’s relationship issues. It’s your body. Are you sleeping? Do you have a kid that keeps you up all night? You know, like libido is basically a canary in the coal mine of how your life is by and large, but sometimes it’s quite responsive to hormones. Right. So now, so now we’ll talk about that, but yeah, so there’s this crazy study. And they took healthy younger men, they blocked their hormones with a medication, blocked their hormones, they gave them back testosterone, but they blocked the conversion to estrogen. So testosterone makes estrogen, right? So we’ve got men with, they put back their testosterone, but they blocked their ability to make estrogen.

These men had low sex desire. Low sex drive. Normal testosterone. Low desire, low libido because the estrogen was missing. I mean, so that’s like a fascinate. First of all, what man would have signed up for that study? I don’t know, but it just tells you like, estrogen is important for all libidos.

Even a little bit of estrogen in the men affected their libido. Um, and so many women I’ll start them on estrogen and they’ll come back and they’ll be like. Yep. I’m good. Like, this is great. Not even sure my partner wants me to have this much. Like this is a different part of our relationship now.

And another thing that estrogen does, even if it’s not directly affecting libido, is if you have hot flashes, if you have night sweats, if your body’s changing and you’re not happy with it, you know, body image issues, whatever, if you’ve got hormone changes that estrogen helps those things, then your libido can naturally come back because you’re just feeling better.

Amanda: Feeling better makes such a difference.

Kelly: They looked at if women stop having sex after menopause, what are the reasons for this? Right? And the two biggest reasons were availability of partner, which I always joke, I can’t help you with that one. And then number two is vasomotor symptoms of menopause, hot flashes, night sweats, anxiety, depression,  estrogen fixes, those things.

Oh. By and large, my libido came back.  So I think estrogen works in two ways. Number one, just fixing all the things that make you feel crummy. And then number two, for some people, there is a direct libido effect to it.

Amanda: Awesome. Love hearing that. Talk to me a little bit about DHEA.

Kelly: So DHEA is a pre, we call it a precursor hormone.

It basically can make itself, it can turn into testosterone and estrogen. In America, DHEA is a supplement. What that means is you can buy it at Target, at, you know, any sort of supplement store, online, Amazon. You do not need a prescription for it. In other countries, it requires a prescription. All these countries and their hormone rules are all crazy and made up.

By the way, testosterone’s over the counter in Mexico. You can buy it at the airport.

Amanda: Oh, okay.  Good to know! Next time I go to Mexico…

Kelly: I’m not telling you to go do that. I’m just telling you all of our rules are made up and they’re all different across the world. Right. Australia has a female testosterone dose. No other country in the world does.

Right. So like everything’s made up and it’s crazy. But so in America, you do not need a prescription. The problem with the supplement industry, the United States of America, in case people don’t know this, is it is unregulated. That means what’s in the bottle might not match what’s on the label and this happens at least 30 percent of the time whenever you look at a study that said, Hey, we saw it was on the label and we actually checked to see if that was in the bottle. Most of the time it’s not. So we’ve got a big trust issue, right? Do you trust that this is actually what they say it is? Placebo effect is real, especially in sexual health. But we know placebo, the placebo effect is real in regards to hot flashes. Give some people a placebo, their hot flashes get better, right?

The brain is amazingly interesting.  So does DHEA work? For some people. It can raise the estrogen and testosterone a little bit. I don’t think you’re going to get crazy high doses. You know, you’re, I don’t think you’re going to be able to get male doses by taking oral DHEA. So by and large, I say it’s pretty darn safe. And it’ll probably help a little bit. It might not help, but I’m not a big, like you have to be on DHEA or don’t be on DHEA, but if you want to look at like, who is it probably going to be most useful for? Probably perimenopause because you still have the ability, you know, you still got ovary function, you got some hormones in there, you probably have the ability to convert it a little bit more than say a um, 70 year old who hasn’t seen any hormones in a very long time.

Yeah, but I don’t have good studies to show you on that.

Amanda: Someone asked me about, um, DHEA suppositories.

Kelly: Yeah, so DHEA in the vagina, there is actually a FDA approved pharmaceutical product. So again, now this is not over the counter. Uh, it’s called Intra Rosa or Prasterone, 6. 5 milligrams, if I’m recalling correctly off the top of my head.

It is an amazing product. We love it. And what it does is in the vagina, it will convert to estrogen and testosterone. The vulva and the vagina have androgen receptors. Testosterone is incredibly important for the function of the vulva and the vagina as well. So sometimes, especially if they’re like, Man, I’m really good with the estrogen. It’s just, I’m still having atrophy. I still have all these issues. You can do a DHEA, um, and get that androgen component kicking in. And it just is amazing sometimes what can happen down there. 

The problem with it being a pharmaceutical is it’s expensive because it’s brand new. Now the things you break the internet about, right, is I had a world expert on my podcast and he’s like, dude, just take an oral over the counter DHEA tab and put it in your vagina.  

Now, we don’t have a lot of studies on that. Okay. Probably quite safe because if you think of something that’s, you know, over the counter to swallow, vagina is not even swallowing. Probably pretty safe. Definitely off label. Um, 

I’m here to make people think. I don’t think it’ll hurt you. I don’t think it will kill you. Um, do I do it? No. For the aforementioned thing of I have a strong suspicion of supplement industry anyways, just because I know it’s, I can’t trust what’s in the packaging. That truly is the power of an FDA approved prescription product is what it says it is, it is.

And I think a lot of people don’t know that about the supplement industry. 

Amanda: Yeah. Well, this has been so good. Thank you so much, Dr. Kelly. Um, is there anything else you feel like we should talk about or mention before we end today?

Kelly: I think the role of communication, and the communication with partners specifically, specifically if you’re partnered with somebody who doesn’t go through menopause or perimenopause, right? Of like, women didn’t get an education on this, so by and large, you can assume that the men got less. And what you’re going through is real. What you’re going through is valid. We don’t know how to help everybody, but if you don’t communicate that well, you’re gonna, you know, you’re probably going to see a lot less compassion, more kind of like just deal with it.

Like, listen, if your partner’s testicles shriveled up and went away by 51, would you want to know about that so you could help and be as supportive as you possibly could? Yeah. And that’s inevitably what’s happening to our ovaries. You just can’t see our ovaries. So it’s harder to know that it’s, you know, air quote, real, but it’s very real and helps available. But I think people who communicate about this and kind of say, you know, what do you need? What do you need today? What’s going on? How did it go when you went to your doctor and asked about that? You know, how do you want to age all of these things of like, that’s going to be a better bond than people kind of not talking, being distant. And, and feeling not connected over, over this part of life.

Amanda: Yeah. I think that communication is so, so important. I feel like it’s not talked about enough with women when with perimenopause and menopause, let alone with our, you know, partners. And I feel like men don’t talk a lot about when they have issues with erections and different things like they don’t want to, and they don’t communicate with their spouse. And then the spouse is going, why is our sex life like stopping? They don’t understand. So there’s total, you know, it goes back and forth between two, both of them, they’re not communicating. And so that communication piece is definitely so, so important.

Kelly: A hundred percent. I just interviewed this, uh, sex coach for my podcast. And she said, assumptions are the termites of any long term relationship. 

Amanda: I love that. 

Kelly: Christine D’Angelo is her name. I’ll give her credit for that quote. But it’s like, if you don’t know why your husband’s not sleeping with you anymore, and it’s be, let’s say it’s because of erectile dysfunction. Literally, women are going to be like, he’s cheating. He thinks I’m unattractive. Like all of your assumptions are freaking the worst case scenarios to you. 

Instead of like, dude, he’s doesn’t have confidence. He’s like questioning what the definition of manhood is. Like he’s got, you know, big stuff he’s wrestling with and none of it is he wants this to end and he’s not attracted to you.

And so yeah, communication can go so far. 

Amanda: Well, I feel like I need to have you back to talk about men’s sexual health because I think you’re the expert in that too. 

Kelly: Yeah. No, I’m happy to. It’s, uh, they, everybody needs to know about that too. 

Amanda: Absolutely. Thank you so much for being here.

Kelly: Yeah. Thanks for having me.

Amanda: Okay. Wasn’t that amazing? So, so good. Was your mind just blown over and over and over? I think so much of this is just stuff we don’t talk about and stuff we don’t even talk about with our doctors and our doctors don’t talk about with us. And so it’s so, so important that we get this information and we learn this information and we share it with our peers.

So if this was helpful for you. Please share it with other women in your life. Um, we all need this information. Um, the good news is that she will be coming back to talk about men’s sexual health. Um, I’m really excited to bring that interview with you. That will be, um, in a little while because she’s kind of booked for a while, but, um, we’re going to talk about men’s sexual health and erections and, um, when men age out of erections and different things that affect men’s sexual health.

So if you have questions for her about men’s sexual health, please send me an email, amanda@amandalouder.com or send me a DM on Instagram with your questions so that I can make sure and get those answered in my next interview with her because she is just a wealth of information and I’m so, so grateful that she has been willing to come on and share that information with my audience.

So thank you so, so much for being here and we’ll see you next time. Bye. Bye.