Latest / The Dr Louise Newson Podcast / 35 - How vaginal hormones can transform the health of women

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35 - How vaginal hormones can transform the health of women · The Dr Louise Newson Podcast

• 0:00
  Today it's a great podcast because I'm talking to Rachel
• 0:03
  Rubin. She's a urologist and a sexual
• 0:05
  health specialist in US. She's also a great friend and a
• 0:10
  really big ambassador for the health of women.
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  We talk a lot about how so many women are neglected when they
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  have urinary tract infections, how we're not thinking about
• 0:18
  reducing the incidence of them and the harms that can have.
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  We're talking about the inaccurate labelling of vaginal
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  hormones and how the FDA are going to change that, and we
• 0:29
  should change that over here. It's quite a meaty bit political
• 0:33
  conversation, but I hope you enjoy it.
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  So, Rachel Rubin, I want you in my studio.
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  You're nearly here. You're remote.
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  You're in US. And you, it is brilliant because
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  you understand probably as much more than me about how hard it
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  is for women to be listened to, to be treated properly, the
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  safety and the efficacy of hormones, especially when it
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  comes to even just vaginal hormones, right?
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  They're really very safe and people can't access them.
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  Yeah, I mean, holy, holy, holy mother of God.
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  And I'm a urologist. I know you're married to
• 1:11
  urologist. We curse a lot.
• 1:13
  So I'm going to try to be appropriate here because I know
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  on the other side of the pond you guys are are much more
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  proper than we are. But I have a lot of bad words to
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  say about this. And I think it really comes from
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  my frustration on the men's health side because we do not do
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  what we do to women, we don't do to men.
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  We don't have the same level of you can't do this, you can't
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  have this. I saw a woman this week in my
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  busy clinic. I have one day a week of a busy
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  clinic. And she was a picture perfect
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  candidate for hormone therapy. Picture perfect.
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  She had all the symptoms. She was very healthy.
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  She had no medical problems, no family history.
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  I mean, it was a home run as if I were to give a lecture on the
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  the perfect patient to easy give easy hormone therapy too.
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  And she said to me, she said, but doctor ribbon, my my doctor
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  said I wasn't a good candidate for hormones.
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  And I said, what are you talking about?
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  You're a perfect candidate for hormones.
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  And this poor patient is now stuck between a Doctor Who truly
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  doesn't know the data and doesn't know what she's talking
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  about, but confidently told her, no, you know, and me who is
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  like, yeah, no, this is a no brainer.
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  You should go on, you know, you know, this is what I would
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  recommend for you. And our patients are really
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  stuck in this. Well, who should I believe?
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  And so actually, I'm grateful for you because I give your
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  information and all these other people's information.
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  Don't just trust me, listen to others.
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  Yeah, and it's really hard. In fact, when I was waiting for
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  you to just join, I was just looking at my Instagram and I
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  got Adm from it. Lovely.
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  That sounds lovely, lady. She's just had her ovaries
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  removed and went to ask her GP for some HRT.
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  Not unreasonable because as you know, the ovaries produced
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  progesterone, estudiol, testosterone.
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  So she just asked for some hoe wins and her GPI could, you
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  know, said you were just jumping on the HRT bandwagon because
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  menopause is talked about everywhere like it's like a
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  fashion drug, right? It's.
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  Like a cool thing to do. But I in my e-mail this, I was
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  just getting my hair done, which is why I was late to come do
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  this. And I was looking at my e-mail
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  and a new article came out in the Menopause Journal that says
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  people who have a hysterectomy and have their ovaries removed
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  are at a higher risk of stroke. And yet people think hormones
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  cause strokes, which we know is not true.
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  And more data is coming out showing that that's not true.
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  And yet people's brains are flipped.
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  Like this is no longer a cool thing to do people.
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  This is called life saving, you know, lifestyle.
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  Absolutely. And I think this is the whole
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  thing. It's the risks of not having
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  hormones are more than any risks of having hormones, especially
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  when we talk about the natural body, identical hormones.
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  And I can't think of any other area of medicine where there's
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  just so much debate and fear and fear among our colleagues as
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  well. And, you know, the risks that
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  women are exposed to are huge. And as a urologist, obviously
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  you see lots of people with urinary tract symptoms, but
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  generally genital urinary syndrome with menopause, which
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  is such a long last thought, but it basically means vaginal
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  symptoms, symptoms affecting the bulb of the perineum and
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  symptoms. And they're so common, aren't
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  they? I think it's a nightmare
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  actually, because these are so common.
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  And the problem is, is we, we have a marketing problem, as you
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  know, right, menopause is actually a marketing problem.
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  It is, we are, yes, there is information we don't have and
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  data that we need. And I'm so grateful actually,
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  your team is always publishing amazing work to help us learn
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  more. But the reality is, is we're not
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  using the data that we do have and we're ignoring all of the
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  data that we do have and we need to market that data better.
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  And part of this marketing problem is this idea that
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  menopause is a moment in time. Oh, I had it, I went through it.
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  I'm OK on the other side or this is happening.
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  But when you are 80 years old, you have horrible menopause
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  symptoms. You have osteoporosis, you have
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  a genital and urinary syndrome of menopause, which means you
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  have urinary frequency, urinary urgency, leakage.
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  And if you're sexually active or not, you have an increased risk
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  of getting urinary tract in infections.
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  And that's all from menopause, That's all from a lack of
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  estrogen and testosterone in your body.
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  And yet our doctors, our clinicians do not know this.
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  And our patients definitely don't know this.
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  So they just give out antibiotics like their candy,
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  which has a whole host of very big problems when you're doing
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  that. And there's no discussion of
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  prevention or the reason why you have these.
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  And so we were instrumental in advocating for new guidelines to
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  say, hey, we should be screening, diagnosing, examining
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  and offering vaginal hormones to every human on earth who has a
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  hormone issue. But again, a marketing problem.
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  It doesn't matter that we wrote the guidelines.
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  If nobody reads them or changes their practice pattern, it does
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  nothing. So I'm so grateful.
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  Honestly, I do so much of my yelling and screaming because
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  I've watched you and how much progress you've made.
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  Truly, I know, you know, I'm, I'm, I'm playing cool right now,
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  but I am, you know, one of your the biggest fans in the sense of
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  like, I watch how you change the conversation.
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  And it hasn't been easy and it hasn't been straightforward, but
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  it has made real impact in, in people's lives.
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  Because as we know, if you can, if you can help women feel
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  better, that actually helps their partners and it actually
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  keeps men alive longer. So you're helping everybody or
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  we're helping everybody. So the genital and urinary
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  symptoms will kill you. The UTI's will kill you.
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  You will wake up in the middle of the night to go pee and fall
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  and break your hip and you will die.
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  Right? Like this is not a little
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  vaginal dryness or just a little bit of a lifestyle medication.
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  This is life saving therapy. And that's really, really
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  important because you know, my, my daughter, my middle daughter
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  had sepsis when she was 12. And it was horrendous to watch
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  her so poorly. And that was from an infection
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  in her bones. But about 30% of sepsis is due
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  to urine retract infections. And the majority of that is in
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  women. And I agree with you, Rachel,
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  the majority of those could be prevented by vaginal hormones.
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  And when we talk about vaginal hormones, that's just something
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  that is inserted in the vagina. It could be a cream, it could be
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  a gel, it could be a pessary. There's even a little silicon
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  ring and it doesn't even go into the system.
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  So it's really, really low dose. So anybody can use them, but not
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  just menopausal women, women who are perimenopausal, women who
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  are on contraceptives, women who are young.
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  It doesn't, there's no breastfeeding.
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  Breastfeeding really important. And, and I wish I'd known that I
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  feel so embarrassed because I didn't think about it when I was
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  AGP and I on a Monday morning, I'd get to work and there'd be
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  literally six or seven women lining outside to come in with
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  their little urine pots. And these receptionists would
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  dip them to see if they had a dipstick and they'd go, Oh no,
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  this 1A dipstick, it's negative. This one we're going to send off
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  for to the laps. And I never ever thought about
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  what do they need for child or hormones and and we've got data
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  from the 80s from 1980s showing us that incidence of recurrent
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  urinary tract infections reduces with vaginal hallway.
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  It's so true, right? We have had data for decades.
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  It's been in the New England Journal of Medicine.
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  There have been guidelines since 2019.
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  The recurrent urinary tract infection guidelines clearly
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  state we should be giving vaginal hormones. 2025.
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  We've published the guidelines on genital urinary syndrome of
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  menopause. So it's actually not a research
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  question or a research problem. This isn't, oh, we need more
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  data to see that it's safe. In fact, there was a study came
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  out recently that said if you have a urinary tract infection,
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  you are at much higher risk of stroke and heart attack.
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  And there is a paper from a few years ago, I think it was 2018
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  that showed people who use vaginal estrogen have a
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  decreased risk of stroke and heart attack compared to those
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  who don't. So we have so much data to show
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  that these are life saving safe and 0 papers to show harm, 0
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  papers show any problems with vaginal hormones.
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  You may get a yeast infection initially, but just keep going
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  and treat the yeast infection. You'll get, you'll be OK.
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  But the benefits outweigh the risk more than any other thing
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  that I can think of in this world, like truly more than any
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  other thing I can think of. And we published that we would
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  save our Medicare system, our government healthcare system,
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  between 6 and $22 billion a year if women were given vaginal
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  hormones. So Can you imagine how much
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  money the NHS would save if every woman over fourty, I would
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  say 35, was literally just handed vaginal hormones and
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  explained why they must take it for life?
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  It's a lifelong therapy. Can you imagine how much money
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  they would save as a system? It's just a new brainer but I've
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  also changed my practice the last probably 3 or 4 years in
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  that I don't actually prescribe vagina or estrogen first line
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  anymore. I prescribe something called
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  Prasterone, which is DHEA, so it converts to Estrada and
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  testosterone. And you've got some really key
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  papers and research on that because you've had it in the US
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  longer than we've had it in the UK.
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  We've had it in the UK for a few years now.
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  But can you just summarize your data, especially the ones with
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  people with diabetes? Yeah.
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  Is it easy for you to get for your patients in the UK because
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  you have some? It's a post code lottery and,
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  and in fact, yes, it's available on the NHS, it's got MHO
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  approval, but a lot of doctors refused to prescribe it.
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  And one of my patients I spoke to on Monday actually has been
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  trying to get it. And she went to a specialist
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  clinic and I, I read the letter. I, I normally nearly cried with
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  her because it says that you cannot have this pastoral, you
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  need to try four different preparations of vaginal estrogen
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  for at least six months each. So she has to try the the
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  vaginal gel, the vaginal cream, the vaginal in the vaginal ring,
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  the six months each and then, and only then, if she's still
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  having symptoms, she can come back and talk.
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  So that's two years of inappropriate treatment.
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  It's wild. So, so when it comes to hormone
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  therapy, right, we have further approved options.
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  We have estradiol in the United States and we have DHEA and both
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  are fabulous. All are fabulous products that
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  are going to acidify the tissue. We want your pH to be 4 1/2 so
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  that it can have a healthy microbiome and fight infections
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  like urinary tract infections. And so we know that both vaginal
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  estrogen and vaginal DHEA do this.
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  Now, just like we said, we've had data going back to the 90s
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  and before that vaginal estrogen prevents urinary tract
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  infection. Well, we hypothesized that
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  vaginal DHEA does the same thing.
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  And we published on this a couple years ago, actually last
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  year, that vaginal DHEA also decreases urinary tract
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  infections by more than half. And it doesn't matter if you
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  have a history of diabetes, which we know in infections are
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  worse and it doesn't matter sort of any medical problems that it
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  really is effective at decreasing your risk of urinary
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  tract infections. We have it is it is we
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  hypothesize that it is a fabulous mechanism of action
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  because it's not just estrogen, but it is the precursor to both
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  estrogen and androgens or testosterone, which the tissue
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  is rich with. And So what is actually quite
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  revolutionary about these new guidelines in the genital
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  urinary syndrome of menopause, which have been endorsed by the
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  urologist, by the urogynecologist, by the
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  Menopause Society is an in the women's sexual health societies,
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  is that the word androgen is all over these paper, this guideline
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  and that it really does say that this is not just an estrogen
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  problem, but this is an androgen problem as well.
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  And so again, I hope that this gets, you know, you all just had
• 13:06
  even more testosterone approvals in your system.
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  You know, we're very far behind. And so I hope that companies are
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  starting to look at more preparations for for GSM
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  therapies, therapies for genital urinary syndrome of menopause
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  that have androgens in them because we see right if I'll
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  give you an example of why this is so important.
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  It's important in menopause, but in the women on birth control
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  pills, birth control basically shuts down your ovaries and it
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  adds back fake estrogen and fake progestin, but it doesn't add
• 13:38
  back testosterone. And so we actually see a
• 13:41
  significant genital and urinary syndrome in the these women that
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  they have increased UTI's pain with sex, dryness, irritation,
• 13:49
  low libido because of the lack of androgens.
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  We think right on this tissue. So it is what an incredible
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  thing to think about. First.
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  We should be thinking about birth control that adds back
• 14:00
  testosterone. We should be thinking about more
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  bioidentical types of birth control if they exist or ones
• 14:05
  that don't shut your ovaries off.
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  But we should be what if we added testosterone to birth
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  control? No one is anyone studying this,
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  right? This, these are the things that
• 14:14
  that I need people's brains on. And you know, everyone in the
• 14:17
  United States, everyone kicks and screams and says, oh, we
• 14:19
  need more research. Oh, we need more research.
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  Nobody's going to be doing research.
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  There's no money for research and to do research requires, as
• 14:27
  you know, because you do research requires funding and
• 14:29
  planning and, and brains and participants and people.
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  And so it it, we have so much work to do right to advance
• 14:37
  Women's Health. But in the meantime, we need to
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  use common sense every, Rachel, because, you know, we've got
• 14:42
  androgen receptors around our vulva, our vagina, our perineum,
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  and a yearly tract. So why would we not give
• 14:50
  replacement when we know that it's low?
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  You know, it's so simplistic. It's so logical, right?
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  And I think that's, you know, one of the things I do a lot of
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  teaching, I have, like you, I have, I, I, I have a course
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  where I try to teach clinicians how to prescribe hormone
• 15:03
  therapy. And my big push is, is what are
• 15:07
  you afraid of, right? What are you afraid of here?
• 15:10
  Because, you know, when I think the problem is so many people
• 15:13
  have these fears that actually aren't based in any data or
• 15:16
  logic. And so when you have something
• 15:19
  you're afraid of, the question becomes, are you afraid because
• 15:22
  there is data that says you should be afraid?
• 15:25
  Are you afraid because there's, there's no data or are you
• 15:27
  afraid because that like they're, they're like, you don't
• 15:29
  know the data. And so my whole thing is like
• 15:32
  when you're talking about genital hormones, vaginal and
• 15:35
  genital hormones, like, like there's, I'm not afraid of
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  anything, right? I, I am afraid of nothing.
• 15:39
  No stroke, no blood clots, no heart attacks.
• 15:41
  Why would dementia happen? It doesn't make any logical
• 15:44
  sense. So I love your, your point is
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  that you have to use logic. You have to use data and logic
• 15:51
  and compassion and, and, and education, right?
• 15:54
  That is our pathway to helping get women the information so
• 15:58
  that they can make decisions about what's right with for
• 16:00
  them. As our hormones change
• 16:04
  throughout our lives, especially during perimenopause and
• 16:07
  menopause, looking after our bones, muscles, and balance
• 16:11
  becomes even more important. That's why I love Vivo Barefoot.
• 16:16
  Their shoes are designed to let your feet move more naturally,
• 16:19
  helping you build strength and stability from the ground up.
• 16:23
  That natural movement can support not just your physical
• 16:27
  house, but your sense of well-being too.
• 16:32
  I'm really thrilled to share with you that I'm doing my UK
• 16:35
  theatre tour next year. It starts the 14th of April and
• 16:39
  goes on for two months. I'm coming to lots of places all
• 16:43
  over the UK and I'm going to be talking a lot about hormones, a
• 16:47
  lot about the history, what's happened and what's gone wrong
• 16:50
  for so many women and how we can change this.
• 16:53
  It's going to be uplifting, it's going to be sad, it's going to
• 16:57
  be happy and there's a lot of opportunity to ask questions as
• 17:00
  well. I'm just so excited about
• 17:03
  meeting so many of you. So head to the show notes and
• 17:06
  you can book tickets. I have had so many urinary tract
• 17:12
  infections despite being married to lovely Paul, the urologist.
• 17:16
  He's watched me swim. He's watched me in pain.
• 17:18
  He's watched me, you know, have hematura blood in my ear and
• 17:22
  he's he's watched me with low in pain.
• 17:24
  He's and I've had numerous antibiotics and then after I had
• 17:28
  a hysterectory a few years ago, they became a lot worse and I,
• 17:33
  no one really spoke to me about vaginal hormones.
• 17:36
  And then I thought, actually I'm already on HRT.
• 17:38
  Do I need vaginal hormones? And of course they do.
• 17:40
  And my knife has been transformed with presterone.
• 17:43
  But every day I use presterone. Whenever I open the box of my
• 17:47
  presterone, there's a lovely patient information leaflets and
• 17:50
  I'm a very good patient and I open it and I read it and it
• 17:54
  tells me that pastorinis has an increased risk of heart attack
• 17:58
  strokes blot breast cancer. I'm a migraine sufferer.
• 18:01
  So if I'm a migraine sufferer, I shouldn't really take it and and
• 18:04
  and that you know, the list is as long as the book sort of
• 18:06
  Prostorin that your patients or silly as well.
• 18:10
  So I know your FDA have been looking at this and you did the
• 18:14
  most amazing presentation, which I was so proud and tingly when I
• 18:18
  watched it. I thought it was amazing.
• 18:20
  It was a panel discussion and and everybody was listening and
• 18:23
  it's part of starting a conversation because when they
• 18:27
  inaccurately labeled all hormones as carcinogens in the
• 18:30
  1980s because they realized there was an association with
• 18:34
  ethanol estradiol, which is a synthetic estrogen, the
• 18:37
  synthetic progestins and also and they conjugated equine
• 18:42
  students pregnant losses you it. They just made every single
• 18:45
  hormone A carcinogen, which is so wrong because how can our
• 18:50
  natural hormones cause cancer? Like, you know, our bodies are
• 18:53
  really clever. They're not going to come
• 18:55
  against us and turn against us and cause cancer.
• 18:58
  We know that. But it's it's something in the
• 19:00
  evidence because I was reading a paper recently and it was
• 19:03
  looking at people's let you say healthcare professionals are
• 19:06
  often very scared of prescribing cormones.
• 19:08
  And it was looking at urologists and they were saying one of the
• 19:11
  big factors for not prescribing vaginal hormones isn't because
• 19:15
  they don't know the evidence is because of the perceived risks.
• 19:19
  And this insert, because our, I don't know what it's like for
• 19:23
  yours, is linked with those inserts.
• 19:25
  So the inserts, the warnings are exactly the same.
• 19:28
  That's what what's on our computer screens.
• 19:30
  So you have to be quite confident to click override to
• 19:33
  actually prescribe it. Totally.
• 19:34
  And so it's we have, I sort of think of this as we are at war
• 19:40
  and the enemy is on multiple fronts, right?
• 19:43
  Like, this is a battle and we have a lot of enemies.
• 19:46
  One of our enemies is the system, right?
• 19:49
  The system, the labeling that is harming us, that is telling us
• 19:52
  this is dangerous when it's actually not.
• 19:54
  It's false. It's lies.
• 19:56
  How they can have such a strong warning label with not a single
• 20:00
  paper on earth to back it up. So it's it's actually killing
• 20:03
  women by trying to protect them. But there's no data.
• 20:07
  We think there's, there's no data.
• 20:08
  There's no data to support it. So there's that enemy.
• 20:11
  There's the enemy of the status quo, of the people who are just
• 20:14
  doing the same thing over and over again.
• 20:16
  And women are dying. So it is your clinician who was
• 20:19
  never taught this, who has no, even doesn't know how to write
• 20:22
  the prescription, doesn't know why they have to write the
• 20:24
  prescription, doesn't know how to educate the patient about it.
• 20:27
  And then we have the enemy of the patient, the uninformed
• 20:30
  patient, the patient who doesn't know that her urinary tract
• 20:33
  infections can kill her, that can be prevented, that can
• 20:37
  easily be fixed, not just treated, but fixed and
• 20:40
  prevented. And so we have this enemy on all
• 20:43
  fronts. And which is why I always joke,
• 20:46
  you know, people in this space, what I love about this space is
• 20:49
  how collaborative it's become and how we all really like each
• 20:53
  other. Because anyone who wants to do
• 20:55
  this work and wants to get loud about it, I don't need to agree
• 20:59
  with 100% of what they think. I don't even agree with 100% of
• 21:02
  what my husband thinks or what my children think.
• 21:05
  But the idea is that when you're in this fight and you see those
• 21:08
  enemies, those are the true enemies.
• 21:10
  You, you know, I need you on my team and we need to work
• 21:13
  together to get loud. And that's kind of what we've
• 21:16
  this, this group that we've created in these, these, this
• 21:18
  sort of army that we're building.
• 21:21
  And, and I just honestly, I've watched what you've all done in
• 21:24
  Britain and the Army and the collaboration and what you've
• 21:27
  done. And I've been saying for years,
• 21:29
  how do we copy that? How do we do that in America?
• 21:32
  And it's, we're a few years behind, but you feel it, you
• 21:35
  feel a sea change. You feel a little bit of more
• 21:38
  power than we had before in getting the word out.
• 21:41
  But we're also in this echo chamber.
• 21:43
  The way my algorithm works is I only see what I want to see.
• 21:47
  And so sometimes you forget how this is half the population.
• 21:51
  This is not niche boutique, a super specialized medicine.
• 21:57
  So we have to teach everybody how to do this.
• 21:59
  Yeah, it's so important and it's great because we're part of a
• 22:02
  group with lots of really inspirational doctors and we're
• 22:04
  whatsapping and different hours because we're in different time
• 22:08
  zones. But we're all supporting each
• 22:10
  other because at the end of the day, we went into medicine to
• 22:13
  help people. And sometimes this is forgotten
• 22:16
  with politics and medicine. And I think, you know, there is
• 22:19
  still a hierarchy with medicine and, you know, certain people
• 22:24
  will look at different specialities in different
• 22:26
  lights. Whereas I don't think we need to
• 22:28
  do this because hormonal changes affect every single specialty,
• 22:33
  whether you're a urologist, whether you're a family
• 22:35
  physician, whether you're a brain surgeon, whether you're a
• 22:39
  psychiatrist, it doesn't matter. The hormones get everywhere.
• 22:42
  And it's about time that we all had joined up thinking and we
• 22:45
  all thought about how to improve our patients day-to-day living
• 22:49
  and their future health as well, isn't it?
• 22:51
  I mean, I I know of no other field where people who are not
• 22:55
  in the field adamantly tell women they can't have something
• 23:00
  so confidently. I was at dinner a few like last
• 23:03
  year and it was a big dinner with, with really nice people.
• 23:07
  And I was sitting next to to a neurosurgeon and he finds out
• 23:10
  what I do for a living. And he said, oh, hormone therapy
• 23:14
  that's so dangerous. I tell all my patients not to
• 23:17
  take it because or get off it immediately because it causes
• 23:20
  meningiomas. And I looked at him and I said,
• 23:23
  huh, what's the data? Is it all hormones?
• 23:26
  Is it certain types of hormones? And he looked at me and he said,
• 23:28
  I don't know. And I was like, I was like,
• 23:31
  well, well, that doesn't make any sense because hormones are
• 23:33
  all different. And like there's estrogen,
• 23:35
  there's progesterone, there's testosterone, there's synthetic
• 23:37
  ones, there's bioavailable. Like what?
• 23:39
  What are you talking about? And he had no idea.
• 23:41
  And he said, oh, but I tell every woman I know never to take
• 23:44
  it because of this rare benign brain thing that can happen to
• 23:48
  you. And I looked at the data and it
• 23:51
  was on Depo Provera, OK. And there's a slight increase of
• 23:55
  brain meningiomas when you take a high dose synthetic progestin
• 23:59
  birth control for young people. And that has absolutely nothing
• 24:04
  to do with hormone therapy and menopause.
• 24:06
  And so he's looking at this one thing.
• 24:10
  He's not looking at your bones, he's not looking at your urinary
• 24:12
  tract infections. He's not looking at your heart,
• 24:15
  he's not looking at your muscles.
• 24:16
  He's not looking at your mental health.
• 24:18
  He is looking at this very rare brain meningioma that has like a
• 24:22
  very low risk of ever happening to you.
• 24:25
  And yet he confidently with the most confidence you've ever
• 24:29
  seen, scares women into thinking that what they're doing is
• 24:32
  dangerous. So I, I just, I don't like it's,
• 24:36
  it's one of those moments of like what?
• 24:38
  Like it's. So again, that's the enemy.
• 24:40
  That's the art. That's the that is part of the
• 24:42
  enemy. Yeah, I was at conference
• 24:44
  recently and I was telling someone about the difference
• 24:47
  between synthetic or veins, which are chemicals in
• 24:50
  contraception, the difference between that and that natural
• 24:53
  body, identical hormones that we prescribe.
• 24:56
  And he looked at me and he's really clever.
• 24:57
  I've worked with him for many years in the past.
• 24:59
  He said, Louise, I'm sorry, you've lost me.
• 25:01
  I don't understand what you're talking about.
• 25:03
  And I said, but hang on, it's not difficult.
• 25:06
  It's really not difficult. But there's this willful
• 25:09
  blindness that has occurred and it carries on.
• 25:12
  And I, I know people have threatened to change.
• 25:14
  They don't like change. But I think what we're doing
• 25:17
  differently to previous generations of doctors who have
• 25:21
  been silenced is that we can reach people, not just our
• 25:25
  patients. We can reach bigger populations
• 25:28
  and we can allow them to decide whether they want antibiotics or
• 25:32
  vaginal hormones. And they can ask.
• 25:34
  And some people don't like it. But I'm sure you're the same as
• 25:37
  me, Rachel. There's that.
• 25:38
  I love it when patients come and ask and have a discussion about
• 25:41
  treatment choices in the consultation room.
• 25:43
  I'm with you. I an educated patient, an
• 25:47
  informed patient, a passionate patient.
• 25:50
  I, I absolutely adore. I mean, I think it's the with
• 25:53
  today, with AI, with Google, with what we have available to
• 25:57
  us, patients are smarter than we are.
• 26:00
  They are better research than we are.
• 26:02
  Some of the time when you have rare conditions and we're seeing
• 26:04
  more and more sort of these rare things pop up, I believe that it
• 26:07
  is patient advocates who change medicine because they are not
• 26:11
  messing around. So I work a lot in the pelvic
• 26:13
  pain and nobody is smarter than women who are trying to navigate
• 26:19
  pelvic pain and navigate the challenges of, of being told
• 26:24
  it's all in your head when they very clearly have a medical
• 26:27
  problem. And so I love when patients come
• 26:30
  in asking questions and I actually love when they say,
• 26:34
  Hey, I'm, you know, all the time, I'll tell them if you see
• 26:38
  a paper, if you see something that scares you, if you see
• 26:40
  something that seems wrong about what I've said, listen, we're
• 26:44
  always learning, we're always pivoting, we're always evolving.
• 26:46
  Science changes come to me, teach me.
• 26:49
  So I actually like you probably learn about new articles, new
• 26:53
  things that come out because patients are very, they're
• 26:57
  interested and they're teaching me as much as I'm teaching them
• 27:00
  sometimes. And so that's part of the army
• 27:01
  that we're building educated patients.
• 27:04
  So when we dismiss patients and say, you know, I, I'm an, you
• 27:08
  actually find if you listen to me carefully and I have lots of
• 27:10
  people who listen to me carefully.
• 27:12
  I never call myself an expert. I hate, I actually hate that
• 27:15
  word very much because I, I feel Dumber than ever.
• 27:19
  I feel completely clueless in that.
• 27:22
  Like there is so much we don't know.
• 27:25
  And I'm up to date on a lot of the data, you know, and, and so
• 27:28
  because we are so far behind and we have so much work to do, I
• 27:33
  can't, you know, I'm always humble and realizing like we,
• 27:37
  you know, be curious, be interested, be curious.
• 27:40
  And then balance people's quality of life, what their
• 27:42
  goals are, what they care about with risk benefit, known risk,
• 27:46
  known benefit. And have like good conversations
• 27:50
  with people and show them you care.
• 27:52
  Could people get cancer in, in life?
• 27:54
  Of course. Are my patients going to die?
• 27:56
  Every single one of them, every single one of my patients is
• 27:59
  going to die. But how are my patients going to
• 28:01
  live? What do they want to do with
• 28:03
  their life? How do they want to age?
• 28:05
  Because I've seen a lot of ways I don't want it age right and
• 28:08
  you have two. And so it becomes, what
• 28:11
  decisions am I going to make for my body that I want to try
• 28:14
  knowing that I might get some of them right and I might get some
• 28:17
  of them wrong. But like, I'm going to do the
• 28:19
  best that I can with the information that I have.
• 28:21
  Yeah, it's such good advice so I can listen to you forever and
• 28:25
  I'm going to have to get you to come back again Rachel.
• 28:27
  But the fully ends obviously. I want to ask you 3 take home
• 28:30
  tips. But.
• 28:32
  Three things that I think people should be asking about vaginal
• 28:38
  hormones. So what are the three biggest
• 28:41
  reasons why we should all, I think, be considering vaginal
• 28:44
  hormones as women? Everyone should be on vaginal
• 28:47
  hormones because they prevent urinary tract infections which
• 28:50
  are going to kill you, OK. They help all your urinary
• 28:53
  symptoms, frequency, urgency and leakage and they make sex
• 28:58
  possible. So they can help with
• 28:59
  lubrication, arousal, orgasm and make sex not painful.
• 29:03
  So actually, you know, I'm going to put my finish with my urology
• 29:07
  hat. Vaginal hormones, estrogen or
• 29:10
  DHEA is better than Viagra or Cialis.
• 29:14
  OK, it's better than Viagra. Why Viagra helps with erections,
• 29:18
  arousal. It helps get a penis hard and
• 29:20
  helps men have sex. But it can also if you take a
• 29:24
  low dose of Cialis daily can help with urinary symptoms.
• 29:27
  So Viagrans like those kinds of meds help with arousal and
• 29:32
  urination. Vaginal hormones help with
• 29:34
  arousal for women, urination and they prevent urinary tract
• 29:39
  infections. So vaginal hormones is female
• 29:42
  Viagra times a million because they will, it will save your
• 29:46
  life. And so this is so important
• 29:49
  because it's a marketing problem.
• 29:51
  We've had vaginal hormones long before we had Viagra, and yet
• 29:55
  Viagra had great marketing and so everyone wants to use it.
• 29:58
  Vaginal hormones needs the same excitement and marketing as
• 30:02
  Viagra did for men. And it's it will actually save
• 30:06
  our governments billions of dollars.
• 30:09
  Great way to end, thank. You ever so much so we all need
• 30:13
  to be thinking about vaginal hormones.
• 30:15
  But thanks for a great conversation, Rachel.
• 30:18
  Thank you for having me.