In this episode, Dr. Rena Malik, MD discusses the significant changes that the vulva undergoes during menopause with her guest, ...

painful-sex-amp-shrinking-labia-what-menopause-really-does-to-your-body-ft-dr-haver

Painful Sex &amp; Shrinking Labia? What Menopause Really Does to Your Body ft Dr. Haver

what happens to the vulva during menopause like there are actual physiologic changes right the tissue between the pubic bone all the way to the sacrum in the female so we've got the vulva the labia majora the labia manora the vagina the urethra and then the perineum which is kind of the area between the the anus and the rectum I mean sorry the anus and the vagina and then um and kind of everything out you know out to the side of that all of that tissue is very highly estrogenized and has testosterone receptors as well and when we go through menopause we have loss of those sex hormones dramatically we go to down to less than 1% of our estradiol levels and we drop to 50% or less of our previously healthy testosterone levels so what you know physiologically what's happening the tissue all in all that area becomes thinner we lose a lot of collagen we lose elastin so the elasticity of the tissues changes we lose mucus production so if you did a biopsy of a premenopausal woman of her vulva vagina labia you'll have this multiple layers of thick gorgeous velvety looking tissue under the microscope with all these goblet cells and lots of mucous production it's just absolutely beautiful and then you look then you biopsy her postmen several years postmenopause and that tissue is just thin it's loot it's down about 10% of its former thickness and there is no mucous production so that tissue becomes easily irritated Frable you know sex can be the vagina becomes contracted sex can be extremely painful you know you can actually tear the skin from from from sex if it gets you know towards the end stages of GSM the other things that start happening are the health of the urethra the ability to resist the normal bacteria that is just living on our skin at all times you're much more prone to have an opportunistic infection through the urethra and we see recurrent UTI and then Euros sepsis and all the problems ensuing from that yeah it's pretty dramatic I mean I think what what people don't realize is like how much it changed first of all people don't ever look so I always tell my patients like like one I show them their vulva when I do an exam but I think people should look at their vulva and know what it looks like and it will actually change like those laia will shrink the tissues will become thinner I mean these things are pretty remarkable like imagine your penis just shriveled up like you would you would see it you would notice and you'd be horrified and it become painful every time you try to have sex and then you would you know you you usually will have some difficulty with erection with age you know but not being able to get erect at all like like all of that and your sex hormone levels which also help to control your mood and how you see the world and your muscle mass and your bone density you know it's as if your testicle sheveled up and died at the age of 51 and all all the downfall that would happen I mean and that's what's happening to her you know it's amazing I think that hormones are have so many receptors all over our bodies they have so many use cases and I I wonder why people have such resist I know the Whi did some damage and I want to talk about that but why do you think people are so resistant even if they are eligible to take hormones to benefit their I think the misinformation campaign around you know the demonization of estrogen is somehow being bad when it is the most safe natural thing in our body that we have it keeps us healthy and when we lose it not only do all the things we talked about happen but your cholesterol goes up your blood pressure goes up your you know risk of cardiovascular disease start accelerating your A1C climbs like if your partners out there all of a sudden with no changes in diet and exercise have elevated A1C elevated blood glucose levels a high om IR score their cholesterol's up and their docks like take a stat and here's your blood pressure meds when no one talked you know we're not teaching the clinicians to connect the dots that all these things are related so I think we've undersold the benefits of estrogen dramatically and only assigned it to this kind of selfish like get your get your sexy back or something and and we're not talking about the cardio vascular benefits that you're going to live longer that you're going to have a lower increase risk of heart attack and that the younger you are when you go through menopause the higher your risk is for chronic disease that's all related to estrogen yeah and you're you'll have a less risk of dying of all cause all CA mortality yeah any cause of death yeah so we are underselling the protective benefits even the US preventative task force where we know estrogen will decrease your risk of a fracture you know from osteoporosis by 50% will not recommend it for preven primary prevention of any disease and it is just ridiculous because we have this and I think it's how we treat women I think how women have been treated through history in Medicine of stay in your place just get through it and we are like rewarded for suffering and suffering quietly and I don't think these the the people who are loud about this now are going to back down and so the medical establishment has got to wake up and realize they're not serving females past reproduction yeah it's amazing the difference right so when you have a woman that goes to a clinic asking for hormones she's very often told oh you don't need that yet or you don't need that or you're fine or it's too late for you or too early or too early or too late or you really don't need your symptoms aren't severe enough right whereas a man if he comes in at the very least he'll get a test at the very least if he says I want to get a test for low testosterone he'll get a test and then if he wants testosterone a lot of people will you know if he if he meets the criteria and has symptoms people will be like okay and it's not as I mean there's still definitely stigmas in men as well but I think it's definitely easier for men to obtain testosterone than it is for women to accept and obtain hormonal therapy yeah and well part of the other problem is these Antiquated blackbox mornings that are on even vaginal estrogen you know they they finally get their prescription they're so excited they get home they open up the paperwork and it's like giant bold letters this will kill you yeah you will get cancer you will have a a stroke you will have a blood clot and it's like not possible and then they freak out and call me there is zero evidence not one smidgen of data to suggest that local estrogen vaginal topical you know in the dose for topical application like for the face or for the vagina Velva has ever been systemically absorbed enough to do any of the things that they quote you know yeah so these are part of the problems like you open up your prescription your FDA approved prescription with giant scary warning that has really no proof yeah that these things will actually happen to you absolutely and they won't change it Le they will eventually but it's been a while we have to sue the FDA but it'll happen let's talk about the the women's health initiative and what were the flaws with that first of all what that study was what the flaws were so the the Women's Health Initiative was really exciting at the time so it it started like first time I heard about it was I think med school I want to say 1995 they started recruiting patients so the NIH agreed we need to study women so we had known for decades that women on hormone therapy so at the time of the Whi 40% of women in the US who were eligible were on hormone therapy so a little less than half okay just to give you perspective right now we're about 4% so and some people say six or seven but like way less than 10% that's crazy 40% 4% so you know what tripled was SSRI use like anti-depressants yeah go figure so anyway so we have this study we we know that from observational data that women are living longer and they're having less heart attacks who are on HT versus those who aren't so the the whole purpose of the Women's Health Initiative was to prove that point because some thought that this is observational data maybe it's just because they're healthier and wealthier those are the women who tend to go to the doctor and get on HRT and this is just an artifact because of their socioeconomic status not unreasonable so let's study it to a randomized control Place control style so they set up the study they have I think 30 something ,000 patients between two arms first arm you have a hysterctomy you don't need progesterone you're getting estrogen only the estrogen they chose was primin not unreasonable that was the number one prescribed estrogen at the time okay the other arm women still had their uteruses they got estrogen and progesterone a progestogen called proa very specific synthetic progesterone which again number one prescribed in the us at the time because they were looking for heart disease as an outcome the average age of the patient was 63 she was much older so that's kind of thought flaw and I don't say a flaw but that's they designed the study to look for heart disease doesn't happen till we're older in general so they had to start with an older population okay so these women had not had estrogen in their bodies for 10 to 13 years on average right because average age of menopause is 51 and so time away from estrogen is when the disease starts right what percentage of those women already had plaques in her kateed arteries already had plaqu in her pericard yeah coronary artery sorry and so what percentage had already had high cholesterol and you know all the risk factors for cardiovascular disease they put them on meds they start measuring and a few years and they noticed that the group who was on estrogen and the progestogen had a slight increased risk of breast cancer and they reported they called a a press conference I believe at the Watergate Hotel had not published the study no one could see the data and said estrogen causes breast cancer we have stopped this arm of the steddy okay the estrogen arm still going they had a 30% decrease risk of breast cancer everyone's like okay oh my God because the relative risk is different than the absolute risk but all was reported what and and most lay people don't understand so relative risk is more of a population risk so it went from four out of a thousand women per year to five out of a thousand women per year you know so the placebo you know women get breast cancer because they have breasts okay and so four was the Baseline it went up to five so they stopped the study the absolute risk for you and me year was 8% but that's not what they reported so the estrogen only arm kept going they stopped it a few years after that because they noticed a small but not statistically um significant rise in Strokes so that was after s years of therapy so they stopped that arm those Studies have been walked back multiple times but in 2002 when all that got announced it was the number one medical news story of 2002 every magazine cover every news show every morning show there was no internet at the time but everyone knew this in 80% of of women through their prescriptions in the trash and no one would prescribe it after that yeah you know interesting very similar thing happened to testosterone so when testosterone they did one study where they saw a risk of heart attack with and I I don't remember the specifics but they saw a higher risk of heart attack it got picked up by the media there was actually an error in the statistical analysis they took it back they did retracted it but by that time was everywhere and and those kind of things stick with the population like like the the myth that there's this dramatic association between hormone replacement therapy and breast cancer as resilient as a menopausal Chen hair like every day on the internet I'm rebutting that and showing studies and rebutting it I am doing a conference tomorrow here in LA with Aon blooming who wrote estrogen matters and really helped you know it all those had been debunked but no one had like put it together and he put it together in a book and showed really the safety of estrogen and actually the protective benefits of estrogen besides the the ridiculous notion that it has this huge association with breast cancer yeah it's pretty crazy so you did mention something SSRI us went up by 30% so one of my colleagues uh Heidi flag so she practices OB gen in New York City and she's part of our menop posi right so she did this awesome slide looking at as like the rates of SSRI use versus when HRT plummeted and then all the money that went into new ssris from Big Pharma and I hate to sound sound like it's conspiracy theorist but it's economic reality and it we saw like four new ssris come out right as HRT prescriptions went down and then even in 2023 85% of women will go into their Healthcare provider's office you know having symptoms stating the symptoms it's documented in the chart only 10% are being offered any therapy and 4 to one it is an anti-depressant that's wild so we go from 10% female anti-depressant use before menopause to to 20 so we double and then 25 after the age of 65 you know it's interesting I don't know if this has been studied in the menopause lure but in the testosterone literature it has been looked at that men who take testosterone who are depressed actually have similar responses to SSRI use now that doesn't mean you shouldn't take ssris but the point is that it may be valuable if you are if you have symptoms of low testosterone and a low testosterone that replacing that testosterone may actually improve your symptoms enough that you won't need an SSRI so the it's very clear in per menopause now and I just at the menop posium in menopause conference in Chicago like last two weeks ago there were two neuroscientists two psychiatrists and talking about what's happening on a pathophysiologic basis to women's Brains during par menopause because of the chaos you know what used to look like an EKG each month this EB and flow of hormones is now super high rises in estrogen with big plummets and the progesterone never quite gets to where it used to be and the whole timing of the amplitude of the peak pses off and that just continues until you Flatline right but that per menopause is very very uh vulnerable time for the female brain and she is more likely to respond to estrogen replacement to stabilize those levels through the transition than an SSRI especially in per menopause and if she's postmenopausal using HRT adjunctively with her SSRI has a much you know she's doing way better let's go to those Peaks and valleys so I've seen patients come in with their whole hor like their whole month mapped out like they've gotten blood draws I mean it's wild and should people be getting that I don't think so um it's not predictable and it's very expensive I mean I would love like I wear I have insulin resistance and I've had it my whole life and so I wear CGM what I would love you know would I think the most accurate thing would to have some kind of a continuous hormone monitor something with that would kind of track us through the month I think there's some application potentially with the Sleep rings we're wearing for body temperature because our basal body temperature is very much tied to ovulation and we can see at least for women who were not PCOS patients but people who had normal Cycles regular cycles that were very predictable and now you're you can use the body temperature changes to start seeing the unpredictability there's probably some value in amh but we're not there yet like like checking estrogen and progesterone and FSH and LH is not helpful it is not predictable you know five elevated fshs above 25 you're probably in late per menopause but who's coming in for five FSH draws you know but when I see I can't tell you how many times women are getting this blood work and they're like my I'm estrogen dominant my estrogen was over 400 or 300 I'm like that's per menopause you have these massive surgeries and estrogen did they check it two days later cuz I promise you it was on its way down you know like no one sustains that so I think there's just so much because we don't have we're not training our clinicians and people are it's the Wild West in per menopause and they're making stuff up I think they're trying but there's you know I don't think the it's worth it to have these very frequent hormone tests done to make the diagnosis of Perry menopause all you have to do is listen to a woman and believe her maybe rule out hypothyroidism or autoimmune disease or you know look at her symptoms rule out the other things which is what I do in clinic and then I say okay yeah I believe you let's let's let's talk about treatment that's so powerful I believe you yeah right I believe you

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