Latest / What The Peri? - With Kirsten Cooke / Dry, Sore and Dreading Sex? Perimenopause and Your Vagina — Part 1 (Ep 14)

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Dry, Sore and Dreading Sex? Perimenopause and Your Vagina — Part 1 (Ep 14) · What The Peri? - With Kirsten Cooke

0:07
SPEAKER_00: Welcome to What the Perry.
0:09
SPEAKER_00: I'm your host Kirsten Cook, personal trainer, menopause coach, and a woman living it right alongside you.
0:16
SPEAKER_00: This is the podcast for women navigating perimenopause and menopause.
0:20
SPEAKER_00: The change you didn't ask for, but the conversations you need.
0:24
SPEAKER_00: Let's get into it.
0:34
SPEAKER_00: Picture an ordinary week.
0:36
SPEAKER_00: On Monday, there's an itch you can't quite settle.
0:39
SPEAKER_00: A low, raw sort of sting down there.
0:42
SPEAKER_00: And you put it down to thrush or to the new undies you bought on sale.
0:46
SPEAKER_00: By Wednesday afternoon, your jeans feel unbearable and you're shifting in your chair at work, trying not to look like you're shifting.
0:53
SPEAKER_00: There's a sting when you eat too, sharp enough that you brace for it every time.
0:58
SPEAKER_00: So you start putting a panty liner in every morning just in case, and you tell yourself it'll settle down by the weekend.
1:05
SPEAKER_00: But it doesn't settle.
1:07
SPEAKER_00: You buy a thrush cream from the chemist and it doesn't do much at all.
1:10
SPEAKER_00: You stop wearing the jeans and you live in loose pants or leggings instead.
1:15
SPEAKER_00: And even on the couch at night you can't quite get comfortable.
1:18
SPEAKER_00: None of it feels like an emergency, and that's part of the problem.
1:22
SPEAKER_00: It's just there all day, humming away in the background, and it's wearing you down in a way you'd struggle to explain to anyone.
1:30
SPEAKER_00: Then one night after the kids are finally in bed and the kitchen's all cleaned up, your partner slides in close and reaches for you.
1:38
SPEAKER_00: And you freeze because the last time you had sex, it felt like sandpaper, and you bled a little afterwards.
1:44
SPEAKER_00: You didn't say anything at the time, you just lay there feeling sore and confused, quietly hoping it was a one-off.
1:52
SPEAKER_00: So tonight you say you're exhausted, or you've got a headache, or there's an early start tomorrow, and you roll over to your side of the bed.
2:00
SPEAKER_00: Afterwards, you lie awake.
2:02
SPEAKER_00: Your partner's asleep within minutes, but your mind won't switch off.
2:06
SPEAKER_00: You're wondering what's wrong with you, whether something's damaged, and whether this is just what getting older means.
2:12
SPEAKER_00: Eventually you pick up your phone, turn the brightness right down, and start typing your symptoms into Google in the dark.
2:19
SPEAKER_00: The results either frighten you or tell you nothing useful, and you finally drift off feeling either more worried or confused than when you started.
2:28
SPEAKER_00: I want to tell you why I'm starting here.
2:30
SPEAKER_00: I've heard many versions of this story from many women, and it's very common.
2:35
SPEAKER_00: So many women are living it quietly, putting up with the itch and the sting and the sex they've started to dread because they think it's just how things are now.
2:45
SPEAKER_00: They don't mention it to their GP and they don't mention it to their friends.
2:49
SPEAKER_00: Some of them haven't even said it out loud to their partner.
2:52
SPEAKER_00: They carry it on their own and hope it goes away by itself.
2:56
SPEAKER_00: Or worse, they try to talk to their partner about it and are dismissed or misunderstood, and then feel more alone in all of it.
3:04
SPEAKER_00: So today I want to talk about it plainly and without any embarrassment.
3:09
SPEAKER_00: This is the first of two episodes on sexual health, and today is all about your body, what's changing down there in perimenopause, and why.
3:18
SPEAKER_00: And here's the promise I want to make you right at the start.
3:21
SPEAKER_00: There's a lot that helps with this, and much of it is simple.
3:24
SPEAKER_00: You don't have to put up with it, and by the end of this episode, I hope you'll know exactly where to begin.
3:30
SPEAKER_00: Welcome back to What the Perry, I'm Kirsten Cook.
3:33
SPEAKER_00: Last week I talked about alcohol, so if you haven't caught it yet, you can go back to it anytime.
3:39
SPEAKER_00: Back in episode 12, the pelvic floor and the bladder episode, I promised you a whole episode on sexual health.
3:46
SPEAKER_00: There's so much to cover that it's actually turned into two episodes.
3:51
SPEAKER_00: Today is part one, and it's all about the body.
3:54
SPEAKER_00: Next week is part two, and that one is about desire.
3:58
SPEAKER_00: So here's how I've laid today out for you.
4:00
SPEAKER_00: First, I'll talk about what this feels like to live with both day to day and in the bedroom.
4:06
SPEAKER_00: Then I'll explain what's happening in your body, which has a name.
4:13
SPEAKER_00: After that, I'll talk about painful sex and the part your pelvic floor plays in it.
4:18
SPEAKER_00: Then I'll get practical about what helps from vaginal estrogen to lubricants and moisturizers, and a good pelvic floor physio.
4:26
SPEAKER_00: And I'll finish with three things that you can do this week.
4:30
SPEAKER_00: And just a quick heads up before I go any further.
4:33
SPEAKER_00: This is going to be a frank conversation, and I'll be using the proper words for every part of your body, because I think you deserve plain language.
4:40
SPEAKER_00: So if you're listening in the car with the kids in the back seat, you might want to save this one for later.
4:46
SPEAKER_00: I want to begin with what this is like to live with because I don't think it's always obvious that the things you're feeling are connected.
4:53
SPEAKER_00: The first one is dryness, and I don't only mean during sex.
4:57
SPEAKER_00: For many women, it's there all day.
5:00
SPEAKER_00: It's a dry, uncomfortable feeling in your vagina and around your vulva that you notice when you're walking, when you're sitting at your desk, or when you're just standing at the kitchen bench.
5:10
SPEAKER_00: It can be so constant that you stop noticing how much it's bothering you.
5:14
SPEAKER_00: Alongside the dryness, there can be itching, burning, stinging, and a raw feeling, as if the skin down there has been rubbed.
5:22
SPEAKER_00: Sitting for long periods can become uncomfortable, whether that's a long drive, a long meeting, or a long afternoon on the sidelines at the kids' sport.
5:31
SPEAKER_00: Tight jeans can suddenly feel unbearable, and if you love a spin class or a bike ride, you might find the seat that used to be fine is now the part you dread.
5:41
SPEAKER_00: And because it all comes on slowly, you might not connect any of it to perimenopause.
5:46
SPEAKER_00: Then there's your bladder.
5:48
SPEAKER_00: You might feel a sting when you wee or find you need to wee more often than you used to.
5:52
SPEAKER_00: And you might be dealing with UTIs that keep coming back.
5:56
SPEAKER_00: I talked about this in the pelvic floor and bladder episode, so I won't go over it all again.
6:02
SPEAKER_00: But I want you to know it belongs in the same picture.
6:05
SPEAKER_00: Your bladder and your vagina sit right next to each other and they're affected by the same changes, which I'll explain in a moment.
6:12
SPEAKER_00: And then there's sex, which is often where this becomes impossible to ignore.
6:17
SPEAKER_00: Sex can start to hurt with a friction that feels rough instead of comfortable, or a burning or even tearing feeling during penetration.
6:26
SPEAKER_00: You might notice bleeding or spotting afterwards, which can be really frightening when you don't know why it's happening.
6:32
SPEAKER_00: And once sex has hurt, it's very natural to feel nervous about the next time.
6:37
SPEAKER_00: I'll explain later why that nervousness matters so much, because it's a big part of the picture.
6:43
SPEAKER_00: So I can understand why women start avoiding it.
6:46
SPEAKER_00: You might find yourself making excuses, going to bed early, or staying up late so you don't have to have the conversation.
6:53
SPEAKER_00: You might dread being touched at all, even a cuddle on the couch in case it leads somewhere.
6:59
SPEAKER_00: Some women flinch when their partner reaches for them and then feel terrible about the flinching.
7:04
SPEAKER_00: And all the while you're carrying the worry of it on your own, wondering whether this is how it's going to be from now on.
7:11
SPEAKER_00: Underneath all of that, there are the feelings, and they can be the heaviest part.
7:16
SPEAKER_00: You might feel broken or old or as if your body has quietly moved on without you.
7:21
SPEAKER_00: You might think this is just age or something you simply have to put up with.
7:25
SPEAKER_00: And because it's so personal, embarrassment can stop you raising it with your doctor.
7:30
SPEAKER_00: It's one thing to mention hot flushes at an appointment.
7:33
SPEAKER_00: It's quite another to say that your vagina hurts and sex has become painful.
7:38
SPEAKER_00: Or worse, you go to your GP about the recurrent UTIs and discomfort, and then they just send you on your way with a script for a thrush treatment.
7:47
SPEAKER_00: Now I want to say something important here.
7:49
SPEAKER_00: This matters whether or not you're having sex at all.
7:53
SPEAKER_00: You might be single or separated or widowed, or you might simply not be interested in sex right now, and that's completely fine.
8:01
SPEAKER_00: Comfort in your own body matters on its own.
8:04
SPEAKER_00: You deserve to be able to sit through a meeting or go for a walk or wear the jeans you like and we without stinging, whether there's a partner in the picture or not.
8:13
SPEAKER_00: This isn't only a bed dream problem, and it isn't only about anyone else.
8:18
SPEAKER_00: So if any of this sounds like you, please hear this.
8:22
SPEAKER_00: It's very common, it has a name, and there is a lot that helps.
8:26
SPEAKER_00: And none of it is a failing on your part.
8:28
SPEAKER_00: Your body is going through a real physical change, and once you understand what that change is, it becomes much easier to do something about it.
8:37
SPEAKER_00: So let me explain what's happening.
8:40
SPEAKER_00: What's going on in your body?
8:42
SPEAKER_00: Back in episode one, I mentioned a name that I want to explain properly today.
8:46
SPEAKER_00: It's genitourinary syndrome of menopause, or GSM.
8:50
SPEAKER_00: I know that's a mouthful.
8:52
SPEAKER_00: It used to be called vaginal atrophy, and you might still come across that term online or in a doctor's notes.
8:59
SPEAKER_00: The newer name is better because it isn't only about your vagina.
9:03
SPEAKER_00: It covers your vulva, your urethra, and your bladder too, which is why your bladder symptoms belong in the same conversation.
9:11
SPEAKER_00: Here's why it happens.
9:13
SPEAKER_00: Your vulva, your vagina, your urethra, which is the tube you eat through, and your bladder are full of receptors for estrogen and for testosterone too.
9:23
SPEAKER_00: You can think of those receptors as little docking points where the hormone plugs in and tells the tissues what to do.
9:30
SPEAKER_00: But as estrogen falls through perimenopause and beyond, those tissues stop getting the same message and they start to change.
9:38
SPEAKER_00: In your vagina, the lining gets thinner, paler, and drier.
9:43
SPEAKER_00: It becomes less stretchy and it's more easily damaged, especially during penetrative sex.
9:49
SPEAKER_00: That's why it can tear a little and bleed, and that can be the bleeding or spotting you notice afterwards.
9:55
SPEAKER_00: You also make less of your own natural lubrication, and arousal can be slower than it used to be.
10:01
SPEAKER_00: So if you've noticed your body taking longer to be ready, that's part of this too.
10:06
SPEAKER_00: I want to be clear that you're not doing anything wrong.
10:09
SPEAKER_00: It's the tissue responding to having less estrogen.
10:12
SPEAKER_00: It's not only the inside that changes.
10:15
SPEAKER_00: On your vulva, which is the outside part, the skin gets thinner and paler as well.
10:21
SPEAKER_00: The inner lips, which are called the labia menorah, can get smaller and the entrance to your vagina can narrow.
10:28
SPEAKER_00: Because those changes happen slowly, they can be easy to miss, but they're part of why things can feel tight, tender, or sore, and why something that used to be comfortable now isn't.
10:39
SPEAKER_00: Now the next part might surprise you.
10:42
SPEAKER_00: Your clitoris can get smaller too, and the Australasian Menopause Society says the labia menorah and the clitoris may appear smaller.
10:50
SPEAKER_00: So I want to bring in Dr.
10:52
SPEAKER_00: Rachel Rubin here.
10:53
SPEAKER_00: She's a US urologist who works in sexual medicine.
10:57
SPEAKER_00: She says it very plainly.
10:58
SPEAKER_00: The clitoris is how most women orgasm and penetration is not how most women orgasm.
11:04
SPEAKER_00: So the health of your clitoris matters and it deserves the same care and attention as the rest of you.
11:10
SPEAKER_00: Dr.
11:11
SPEAKER_00: Rubin also talks about something called clitoral adhesions.
11:14
SPEAKER_00: That's where the hood of the clitoris, the little fold of skin that covers it, gets stuck to the head of it.
11:20
SPEAKER_00: In the women coming to her clinic, it was about one in four.
11:24
SPEAKER_00: Doctors can check for this, but most women have not had anyone look.
11:28
SPEAKER_00: And Dr.
11:29
SPEAKER_00: Rubin says that in the US, the word clitoris isn't even on the checklist of what a gynecologist has to learn.
11:36
SPEAKER_00: Can you believe that?
11:38
SPEAKER_00: One of the most important parts of a woman's anatomy down there, and it's not even acknowledged in a gynecologist's training.
11:45
SPEAKER_00: This tells you how easily this part of your body gets overlooked.
11:49
SPEAKER_00: Then there's another change, and it's about the balance inside your vagina.
11:53
SPEAKER_00: In the pelvic floor and bladder episode, I explained how estrogen feeds the good bacteria that keep your vagina slightly acidic, and how that protects you from UTIs.
12:04
SPEAKER_00: As your estrogen falls, that balance can change.
12:07
SPEAKER_00: Some women notice more discharge or a discharge that's irritating or a different smell, and some find they're getting more infections.
12:15
SPEAKER_00: If you've been reaching for the thrush cream over and over and it keeps coming back, I'd ask your doctor whether this could be part of it.
12:23
SPEAKER_00: Your bladder is part of this too, which is exactly why the name changed.
12:27
SPEAKER_00: Urgency needing to go more often, stinging when you wee, and UTIs that keep coming back can all be part of GSM.
12:36
SPEAKER_00: I covered that in detail in episode 12, so if your bladder is your biggest worry, I'd go back and have a listen to that one.
12:43
SPEAKER_00: For today, I want you to see that it's all connected and that it's all coming from the same drop in estrogen.
12:49
SPEAKER_00: Now, here's something I really want you to know because it's easy to miss.
12:53
SPEAKER_00: This isn't something that only starts after your periods have stopped.
12:57
SPEAKER_00: It can start in perimenopause.
12:59
SPEAKER_00: One study found it in about one in five women aged 40 to 45.
13:05
SPEAKER_00: That's a lot of you listening right now.
13:07
SPEAKER_00: So if you've been telling yourself you're far too young for this, you might not be.
13:12
SPEAKER_00: But there's another thing that makes this different from a lot of perimenopause symptoms.
13:16
SPEAKER_00: It usually doesn't go away on its own.
13:19
SPEAKER_00: Hot flushes for most women ease over time, but the Australasian Menopause Society says these symptoms often persist and tend to worsen as we get older.
13:29
SPEAKER_00: So waiting it out isn't much of a plan here.
13:32
SPEAKER_00: I'm not saying that to frighten you, I'd just much rather you do something about it now than hope that it will pass.
13:39
SPEAKER_00: Yet so few women are getting help for it.
13:42
SPEAKER_00: Fewer than one in ten Australian women in perimenopause and after are using vaginal estrogen, which is the treatment I'll talk you through later.
13:51
SPEAKER_00: I think there are a few reasons for that.
13:53
SPEAKER_00: Embarrassment is a big one, and so is the belief that this is just part of getting older, or that nothing can be done about it.
14:00
SPEAKER_00: Ideally, your doctor would ask you about it directly, but many don't, so you need to be the one to bring it up.
14:06
SPEAKER_00: And I'd go one step further.
14:08
SPEAKER_00: A lot of the women I'd talk to don't even know that vaginal estrogen exists, let alone what it's for.
14:14
SPEAKER_00: Over the last few years, on my own challenging journey to find a good hormone doctor and get onto a protocol that's actually working for me, not once was vaginal estrogen mentioned as an option.
14:26
SPEAKER_00: Even though I'd talked about my symptoms many times, including what felt like recurrent thrush and tearing.
14:33
SPEAKER_00: And every one of those doctors called themselves a hormone or women's health specialist.
14:38
SPEAKER_00: So I can only imagine the challenge so many women are having with a regular GP.
14:43
SPEAKER_00: I have a friend who just turned 40 and was getting recurrent UTIs.
14:47
SPEAKER_00: When she went to her trusted family GP, she was basically laughed at.
15:02
SPEAKER_00: Yet, as I said a moment ago, this can start in perimenopause, in up to one in five women aged 40 to 45.
15:11
SPEAKER_00: So if this is the first time you've heard any of this, I understand.
15:15
SPEAKER_00: In this series, I've talked about how nobody said the word perimenopause to so many women.
15:21
SPEAKER_00: It's the same story here.
15:23
SPEAKER_00: Nobody may have mentioned GSM to you either.
15:26
SPEAKER_00: Not your GP, not your friends, not anyone.
15:29
SPEAKER_00: That isn't something you've done wrong and it doesn't mean you've missed your chance.
15:33
SPEAKER_00: But now you know the name, and that means you can walk into any appointment, say it out loud, and ask what can be done.
15:40
SPEAKER_00: So now I want to talk about painful sex because it's one of the hardest parts of this to say out loud, and it's often the part that hurts the most.
15:48
SPEAKER_00: Dr.
15:48
SPEAKER_00: Rubin puts it very simply.
15:50
SPEAKER_00: Sex is not supposed to be painful.
15:53
SPEAKER_00: I want you to sit with that for a second because it's easy to start accepting pain as normal.
15:58
SPEAKER_00: If it's been hurting for a while, you might have even stopped questioning it altogether and started thinking that this is just how it is now.
16:06
SPEAKER_00: Dr.
16:06
SPEAKER_00: Rubin has a good way of explaining it to partners too.
16:09
SPEAKER_00: She says it's like a sunburn.
16:12
SPEAKER_00: If you had sunburnt skin, you wouldn't keep rubbing it and expect it to feel good.
16:17
SPEAKER_00: You'd be gentle with it and you'd treat it.
16:19
SPEAKER_00: Tissue that's thin, dry, and sore needs that same care, and pushing on regardless doesn't make it better.
16:27
SPEAKER_00: If you've been struggling to explain it to your partner, that's a picture you could borrow.
16:31
SPEAKER_00: Now, painful sex can have more than just one cause, and they often feed into each other.
16:37
SPEAKER_00: The first is what I've just talked about, the thin, dry tissue that comes with GSM.
16:42
SPEAKER_00: The second is a pelvic floor that's too tight, and for a lot of women, it's both at once.
16:48
SPEAKER_00: There's a third piece as well, which is arousal.
16:51
SPEAKER_00: Your body makes its own lubrication when you're aroused, so if you're not really in the mood, which is very common in perimenopause because of everything you're already going through, or things are rushed, you'll be drier and on top of thinner tissue, that can really hurt.
17:07
SPEAKER_00: Arousal and desire are a big part of next week's episode, so I'll go into that properly then.
17:13
SPEAKER_00: For today though, it helps to understand how the tissue and the pelvic floor connect, because if you only look at one of them, you might miss the other.
17:22
SPEAKER_00: That's why I want to spend a bit of time on your pelvic floor before I get into what helps.
17:27
SPEAKER_00: In episode 12, I talked about your pelvic floor and how those muscles contract when you orgasm.
17:33
SPEAKER_00: I told you that pelvic floor training improved arousal and orgasm in women past menopause, and that a pelvic floor that's too tight can make sex painful.
17:43
SPEAKER_00: I also shared what Dr.
17:44
SPEAKER_00: Kelly Kasperson says.
17:46
SPEAKER_00: She's the US urologist who hosts the You Are Not Broken podcast.
17:51
SPEAKER_00: You can have weak muscles and tight muscles at the same time.
17:55
SPEAKER_00: Kegels aren't right for everyone and can make pain worse, and she's a big believer in a good pelvic floor physio.
18:01
SPEAKER_00: What I want to add today is something pelvic floor physios describe, and it's called the guarding cycle.
18:08
SPEAKER_00: When sex hurts, your body learns to brace for it.
18:11
SPEAKER_00: It's a bit like flinching before someone touches a bruise.
18:14
SPEAKER_00: So the next time sex is on the cards, your pelvic floor tightens up in anticipation, often without you even realizing it's happening.
18:22
SPEAKER_00: And a tight pelvic floor makes penetration hurt more.
18:26
SPEAKER_00: So it hurts, you brace, the muscles tighten, it hurts even more, and the cycle continues.
18:33
SPEAKER_00: And that's why pushing through painful sex can make it worse, not better.
18:37
SPEAKER_00: I understand why you might push through, because you don't want to disappoint your partner, or because you hope it'll ease up if you just keep going.
18:45
SPEAKER_00: But each painful time teaches your body to brace a little harder the next time.
18:50
SPEAKER_00: So stopping isn't giving up and it isn't failing anyone.
18:54
SPEAKER_00: It's how you break the loop and it gives your body the chance to learn that it's safe again.
18:59
SPEAKER_00: Now I want to explain the difference between a weak pelvic floor and a tight one because they need very different things.
19:06
SPEAKER_00: A weak pelvic floor may need strengthening, and that's where exercises can help.
19:11
SPEAKER_00: But a tight pelvic floor needs to learn to relax and let go first.
19:16
SPEAKER_00: And many women have a mix of both, which is why it can get confusing.
19:20
SPEAKER_00: The tricky part is that you can't tell which one you have on your own.
19:24
SPEAKER_00: You need a proper assessment.
19:25
SPEAKER_00: So that's where a pelvic floor physio comes in, and I mean one who works in pelvic health.
19:31
SPEAKER_00: A pelvic health physio can assess what your muscles are actually doing, whether they're weak, tight, or both, and they can teach your muscles how to release.
19:40
SPEAKER_00: If you don't know where to find one, the National Continents Helpline, which I gave you in episode 12, can point you to one.
19:47
SPEAKER_00: The number is 1-800-3306.
19:52
SPEAKER_00: I want to say this clearly before I move on.
19:55
SPEAKER_00: You don't have to push through pain and you can stop at any point.
19:59
SPEAKER_00: If something hurts, that's your body telling you something and it deserves to be listened to.
20:04
SPEAKER_00: Sex can also include lots of things that aren't penetration, so stepping back from one thing doesn't mean having to step back from all closeness.
20:13
SPEAKER_00: I'll talk much more about pleasure next week, but for now I just want you to know that stopping is always an option.
20:20
SPEAKER_00: So let's get to the good part, which is what helps.
20:23
SPEAKER_00: There's a lot, and I'm going to take you through the options one at a time.
20:26
SPEAKER_00: First, I'll explain vaginal estrogen, which is the treatment that works on the tissue itself.
20:32
SPEAKER_00: Then I'll touch on a couple of other options, including one I'd encourage you to save your money on for now.
20:37
SPEAKER_00: And then I'll cover lubricants and moisturizers and how they look after skin down there day-to-day, which you can start on right away.
20:45
SPEAKER_00: I want to start with vaginal estrogen because it's the one that restores the tissue.
20:50
SPEAKER_00: It's a low dose of estrogen that you put directly into your vagina where it works on the tissue right there.
20:56
SPEAKER_00: In Australia, it comes as a small vaginal tablet which contains estradyol, or as a cream or pesseries, which contain estriole.
21:05
SPEAKER_00: Both are body identical, meaning they're the same estrogen your own body makes.
21:10
SPEAKER_00: Estriol is one of the three types of estrogen I talked about in episode two.
21:15
SPEAKER_00: Whenever HRT comes up, I recommend bioidentical hormones, so I'm glad these fit with that.
21:21
SPEAKER_00: They're on the PBS and you'll need a prescription from your GP or menopause doctor.
21:27
SPEAKER_00: Now, this next point matters a lot to me because I think it's where much of the worry comes from.
21:32
SPEAKER_00: Vaginal estrogen works locally, not across your whole body.
21:37
SPEAKER_00: HRT tablets, patches, and gels are designed to get estrogen into your bloodstream so it can reach your whole body.
21:44
SPEAKER_00: Tablets also go through your liver first, as I explained in episode three.
21:49
SPEAKER_00: Vaginal estrogen is different because it's designed to stay where you put it.
21:54
SPEAKER_00: And so little of it gets into your bloodstream that you don't need to take precautionary progesterone with.
22:00
SPEAKER_00: It.
22:00
SPEAKER_00: As we discussed in episode 2, there is a link between estrogen and progesterone.
22:05
SPEAKER_00: Estrogen on its own makes the lining of the uterus grow, and progesterone keeps that lining in check, which is why women with a uterus who take estrogen as HRT are also given progesterone to protect it.
22:18
SPEAKER_00: The Australasian Menopause Society says no progesterone is needed at the recommended doses because the amount absorbed is too low to thicken the lining of the uterus.
22:29
SPEAKER_00: But I want to be really clear about what that means because I don't want it misunderstood.
22:34
SPEAKER_00: It's only about the link between vaginal estrogen and the lining of your uterus.
22:39
SPEAKER_00: It doesn't mean you shouldn't be on progesterone or that you wouldn't benefit from it.
22:43
SPEAKER_00: Progesterone does so much more than protect the uterus, and it's often the first hormone to drop in perimenopause, as I talked about back in episode two.
22:52
SPEAKER_00: And women who've had a hysterectomy can still benefit from progesterone too, which is something I've been through myself.
22:59
SPEAKER_00: It also means you can use it on top of HRT without doubling up your estrogen.
23:05
SPEAKER_00: I think that matters because plenty of women on HRT still have vaginal symptoms, and that's exactly why so many women need both, the HRT for the whole body and the vaginal estrogen for the tissue right there.
23:19
SPEAKER_00: So how do you use it?
23:21
SPEAKER_00: Usually it's every night for about two weeks to begin with, and then two to three times a week as a maintenance dose.
23:27
SPEAKER_00: Your doctor will tell you exactly how to use your particular product, so follow what they say.
23:32
SPEAKER_00: And please be patient with it.
23:34
SPEAKER_00: It can take up to about eight weeks to feel the full effect, so don't give up after the first week because you haven't noticed a difference yet.
23:42
SPEAKER_00: It keeps working for as long as you keep using it.
23:45
SPEAKER_00: On that point, Dr.
23:46
SPEAKER_00: Kasperson was asked whether a woman in her 70s should keep using vaginal estrogen long term.
23:52
SPEAKER_00: Her answer was simply yes.
23:54
SPEAKER_00: I find that reassuring because it tells you that this isn't a short course you have to stop after a few months.
23:59
SPEAKER_00: It's something you can keep using for as long as it's helping you.
24:03
SPEAKER_00: Now, I know safety is probably the first question on your mind, so let me tell you what the experts say.
24:09
SPEAKER_00: Dr.
24:09
SPEAKER_00: Rubin says vaginal hormones are safe for your great-grandmother in the nursing home.
24:14
SPEAKER_00: The Australasian Menopause Society says no studies have shown a link between vaginal estrogen and breast cancer.
24:22
SPEAKER_00: And in the US, late last year, the regulator announced it is removing the old breast cancer, heart disease, and dementia warnings from hormone therapy labels, and that includes vaginal estrogen.
24:34
SPEAKER_00: I think that's a meaningful change and a welcome one.
24:37
SPEAKER_00: But if you've had breast cancer, I want to talk to you directly for a moment.
24:42
SPEAKER_00: Your situation is different and you deserve advice that fits your history.
24:46
SPEAKER_00: The place to start is with lubricants and moisturizers, which I'll come to shortly.
24:51
SPEAKER_00: Then talk to your oncologist about vaginal estrogen because Australian clinical guidance says it can be a reasonable option after that conversation.
25:00
SPEAKER_00: So please don't rule it out on your own and please don't start it without your oncologist being part of the decision.
25:06
SPEAKER_00: There are a few myths I want to clear up quickly.
25:09
SPEAKER_00: Vaginal estrogen isn't the same as HRT, and it doesn't carry the same risks because it works locally.
25:16
SPEAKER_00: It isn't too late either, and women keep using it well into their 70s and beyond.
25:21
SPEAKER_00: And as I said, doesn't double you up if you're already on HRT.
25:25
SPEAKER_00: So if any of those worries have been holding you back, I'd encourage you to take them to your doctor, ask your questions, and have that conversation with the facts in your head.
25:35
SPEAKER_00: Now, I also made you a promise in episode 12.
25:38
SPEAKER_00: I told you that vaginal estrogen is the most effective thing for UTIs that keep coming back.
25:43
SPEAKER_00: And I said I'd explain why today.
25:45
SPEAKER_00: It helps restore the tissue and it helps to bring back the good bacteria that keep things slightly acidic, which cuts down on UTIs coming back.
25:54
SPEAKER_00: And please don't brush UTIs off.
25:57
SPEAKER_00: An untreated UTI can spread to your kidneys and into your bloodstream, which is called sepsis, and that can be life-threatening, especially as we get older.
26:06
SPEAKER_00: So if vaginal estrogen is recommended for you, not using it isn't being stoic.
26:11
SPEAKER_00: Putting up with infection after infection is costing you your health and it can put your life at risk.
26:17
SPEAKER_00: And I'll be honest with you about where I'm at with this.
26:20
SPEAKER_00: In that episode, I told you I was talking to my hormone doctor about starting vaginal estrogen because of my frequent mini UTIs.
26:28
SPEAKER_00: I'm still waiting on that appointment and I'll let you know how I go.
26:31
SPEAKER_00: And if you're waiting on an appointment too, you can still start on the comfort side of things for now, which I'll come to in a moment.
26:38
SPEAKER_00: But first, there are a couple of other options I want to mention briefly.
26:42
SPEAKER_00: One is vaginal DHEA, which comes as a pessary called presterone.
26:48
SPEAKER_00: It's another prescription option in Australia for women after menopause, but it isn't for women who've had breast cancer.
26:54
SPEAKER_00: So if you're past menopause, it's one more thing you could ask your doctor about.
26:59
SPEAKER_00: The other is vaginal laser, and I'll say this kindly because some of you may have already paid for it.
27:05
SPEAKER_00: An Australian trial compared laser with a placebo treatment and found it didn't improve vaginal symptoms any more than the placebo over a one-year period.
27:14
SPEAKER_00: So I'd save you money until better evidence comes along.
27:17
SPEAKER_00: And if you've already had it, please don't be hard on yourself about it.
27:21
SPEAKER_00: You were looking for help with something that was making you miserable, and that's a completely reasonable thing to do.
27:27
SPEAKER_00: Now you just have better information about where to put your money and your energy next.
27:32
SPEAKER_00: Now let me get to lubricants and moisturizers because I think it's easy to mix these two up and they do different jobs.
27:38
SPEAKER_00: A vaginal moisturizer is something you use regularly, every few days, for everyday dryness and comfort.
27:45
SPEAKER_00: You don't need a prescription for one, and there are options like hyaluronic acid gels.
27:50
SPEAKER_00: It's the same kind of ingredient you'll see in face serums, but please don't reach for your face serum because those have other things added that aren't made for down there.
27:59
SPEAKER_00: Use a gel that's made for vaginal use.
28:02
SPEAKER_00: Hyaluronic acid is something your own body makes and it works by holding on to water, so in the vagina, it keeps the tissue moist.
28:10
SPEAKER_00: These gels are generally very well tolerated.
28:14
SPEAKER_00: A lubricant is something you use at the time of sex to reduce friction.
28:18
SPEAKER_00: So the moisturizer looks after you day to day, and the lubricant is there for the moment that you need it.
28:24
SPEAKER_00: Now, when it comes to lubricants, there are a few types.
28:27
SPEAKER_00: Water-based lubricants are the most common in Australia, but they soak into dry skin quite quickly, and they can lose their slipperiness partway through.
28:36
SPEAKER_00: Silicon-based ones stay slippery for longer, and in one Australian study, women preferred them.
28:42
SPEAKER_00: Oil-based ones are another option, but they can't be used with latex condoms, so keep that in mind if condoms are part of your life.
28:49
SPEAKER_00: If you're not sure where to start, I'd try a silicon-based one first, unless you're sensitive or allergic to silicon.
28:56
SPEAKER_00: But I also want to say something about how lube is seen because there can be a bit of embarrassment attached to it.
29:02
SPEAKER_00: Using lube isn't a sign that anything's wrong with you.
29:05
SPEAKER_00: It's a tool like reading glasses.
29:08
SPEAKER_00: We don't think reading glasses mean we're broken, we just pop them on so we can read the menu.
29:13
SPEAKER_00: This is exactly the same.
29:14
SPEAKER_00: Your body has changed and you're giving it what it needs to be comfortable, which is a sensible, practical thing to do for yourself.
29:21
SPEAKER_00: Looking after the skin down there can help a lot with everyday comfort too.
29:26
SPEAKER_00: The Australasian Menopause Society suggests avoiding soaps, perfume washers, washing or rinsing inside your vagina, scented panty liners, and scented toilet paper.
29:37
SPEAKER_00: Wash with plain water and patch yourself dry instead of rubbing.
29:41
SPEAKER_00: Wear natural fiber undies and don't sit around in wet swimmers or sweaty gym gear.
29:46
SPEAKER_00: Some women also find a plain barrier like petroleum jelly on the vulva also helps.
29:52
SPEAKER_00: There's small changes, but when your skin is already thin and sensitive, they add up.
29:58
SPEAKER_00: So I want to be clear about what these can and can't do.
30:01
SPEAKER_00: Lubricants, moisturizers, and good skincare all help with the comfort and they're worth doing.
30:07
SPEAKER_00: But they don't restore the tissue the way that vaginal estrogen does.
30:11
SPEAKER_00: That's why so many women use both, the moisturizer and lube for comfort and vaginal estrogen to help the tissue itself.
30:19
SPEAKER_00: You don't have to choose one or the other, and you can start on the comfort side today, even while you're still waiting to see your doctor.
30:27
SPEAKER_00: So let me bring all of this together into three things you can do this week.
30:31
SPEAKER_00: They're practical, they're doable, and each one is a step towards feeling comfortable in your own body again.
30:36
SPEAKER_00: You just have to start with one of them, and the others will feel easier once you've begun.
30:41
SPEAKER_00: Step one is to say it out loud to your doctor.
30:44
SPEAKER_00: Book an appointment with your GP or a menopause doctor and name your symptoms clearly.
30:50
SPEAKER_00: Say the words, whether that's dryness, itching, stinging, painful sex or UTIs.
30:56
SPEAKER_00: Then ask about vaginal estrogen.
30:58
SPEAKER_00: And if you're already on HRT and you've still got symptoms, ask about adding vaginal estrogen on top.
31:04
SPEAKER_00: It can help to write your list down before you go so the embarrassment doesn't make you forget it when you're sitting in the room.
31:10
SPEAKER_00: Step two is to look after your comfort now while you wait for that appointment.
31:15
SPEAKER_00: Pick up a vaginal moisturizer for everyday use and use a good lubricant for sex.
31:20
SPEAKER_00: And I've put some fragrant-free options you can get in Australia in the show notes.
31:25
SPEAKER_00: I go for a silicon-based one if you can, because it lasts longer unless you're sensitive to silicon.
31:30
SPEAKER_00: And swap out anything perfumed down there, whether that's your body wash, your panty liners, or your toilet paper.
31:37
SPEAKER_00: None of that needs a prescription, and you can do all of it on your next trip to the chemist or the supermarket.
31:43
SPEAKER_00: Step three is for when sex hurts.
31:45
SPEAKER_00: If it does, stop pushing through.
31:48
SPEAKER_00: Then book in with a pelvic floor physio so you can find out whether your pelvic floor is weak, tight, or a mix of both.
31:55
SPEAKER_00: That one appointment can tell you a lot about what your body needs, and it means that from then on, you're working with your body instead of against it, which is exactly where I want you to be.
32:06
SPEAKER_00: If you'd like to read more, I've put the research behind this episode in the show notes, along with where to find a pelvic health physio near you.
32:13
SPEAKER_00: So if you want something to take along to your appointment, or you'd simply like to look at it in your own time, that's the place to go.
32:20
SPEAKER_00: Have a scroll through after you finish listening and then take whatever's useful to you.
32:24
SPEAKER_00: Here's where I want to leave you today.
32:26
SPEAKER_00: I want you to think back to the woman at the start of this episode, the one lying awake with her phone turned down low, googling her symptoms in the dark.
32:35
SPEAKER_00: Now picture her a few months from now.
32:38
SPEAKER_00: She sat down with her GP and said the words out loud.
32:41
SPEAKER_00: She's got a good moisturizer and a good lube in the bathroom cupboard, and the perfumed body wash is gone.
32:47
SPEAKER_00: She's seen a pelvic health physio.
32:49
SPEAKER_00: She can wear her jeans again, and she isn't lying awake googling anymore.
32:53
SPEAKER_00: So if that woman is you, here are your three steps again.
32:57
SPEAKER_00: Say it out loud to your doctor and ask about vaginal estrogen.
33:00
SPEAKER_00: Look after your comfort now with a good moisturizer, a good lube, and nothing perfumed down there.
33:06
SPEAKER_00: And, if sex hurts, stop pushing through it and see a pelvic health physio.
33:11
SPEAKER_00: None of that is complicated, and each one of those steps can bring you a little closer to feeling at home in your body again.
33:18
SPEAKER_00: And next week, I'm going to talk about the other half of this, which is desire.
33:23
SPEAKER_00: Dr.
33:23
SPEAKER_00: Kasperson says we have to address the pain before we can address the desire.
33:28
SPEAKER_00: That's exactly why I've done it in this order.
33:30
SPEAKER_00: Next week, I'll talk about why wanting sex changes at this stage of life and why so many women feel like they couldn't care less.
33:39
SPEAKER_00: And I want you to know before we even get there that feeling that way is really understandable.
33:45
SPEAKER_00: But before then, if this episode helped you, I'd really appreciate it if you sent it to a friend.
33:50
SPEAKER_00: Maybe it's the friend you walk with on a Saturday morning, the one who's mentioned she hasn't felt like herself lately.
33:55
SPEAKER_00: Or maybe it's the friend you message late at night when neither of you can sleep.
33:59
SPEAKER_00: You don't have to explain why you're sending it, just send it and let her listen to it in her own time.
34:05
SPEAKER_00: And if you haven't already, follow the show and leave a rating or a review because it helps other women find these conversations.
34:12
SPEAKER_00: I'm so glad you're here.
34:13
SPEAKER_00: Look after yourself, and I'll see you next week.
34:19
SPEAKER_00: Everything I've mentioned today is referenced in the show notes, along with all the links.
34:24
SPEAKER_00: And you can find me at Kirstencookcoaching.com.
34:28
SPEAKER_00: Just a reminder, though, this is education, not medical advice.
34:32
SPEAKER_00: So take these conversations to a practitioner who will actually listen to you.
34:37
SPEAKER_00: Thank you so much for being here and for listening to the What the Perry podcast.
34:42
SPEAKER_00: The change you didn't ask for, the conversations you need to do.