All Things Vaginal Estrogen (And Why to Stop Freaking Out About Health Care Worries) with Dr. Shieva Ghofrany
Show Snapshot:
Getting to midlife means facing the fact that health and wellness changes, challenges, and even *gasp* disease are coming your way, like it or not. OB/GYN Dr. Shieva Ghofrany helps us manage our mindset around midlife must-dos—mammograms, colonoscopies, Pap smears, menopause management—and advocates trading fear for “intentional anxiety”—where we take a proactive approach to tackling wellness challenges head-on. Plus, everything you want to know about vaginal estrogen but were afraid to ask. Sheiva helps us decode which choice (vaginal creams, tablets, rings, suppositories) is the best fit. Your dry vagina will thank you!
Show Links:
Follow Dr. Ghofrany
Quotable:
Life is fraught with issues because we have concrete bodies that are just going to crap out sometimes. Let's accept that these things will happen. Let's find the beauty within the suck.
Transcript:
Katie Fogarty 0:03
Welcome to a certain age a show for women who are unafraid to age out loud. Beauties a certain age has listeners in over 118 countries across 8000 cities, we may not share the same zip code, country or language. But there is no doubt in my mind that we share the same desire to look and feel our best to have our bodies and our sex lives keep humming for the long haul. But we don't get to midlife without running into body and health changes and challenges both big and small. My guest today is a woman who helps other women manage the peaks and valleys of women's health and Gynecology, and who knows firsthand what it takes to live through major health challenges while remaining committed to optimal health. Dr. Shiva go fronte is an OB GYN of 24 years and is the founder of a tribe called V A virtual platform offering resources and Education for All Things D from pregnancy to postpartum fertility, Gynecology, menopause, hormonal health and overall well being. If you're navigating uncertainty around gynecological or Hormonal Health if you're tackling a biggie like cancer, if you want to set aside fear, anxiety or avoidance when it comes to managing midlife health care, musts, colonoscopies and mammograms looking at you, stick around this show is for you. Plus, we're going to do a deep dive into vaginal estrogen. So excited to cover this all welcome, Shiva.
Speaker 1 1:33
Hi, thank you for having me. I love talking about all things vagina vulva nev word.
Katie Fogarty 1:39
We're here for we will i am V word very, very excited to dive into this with you. I follow you on Instagram, you bring such a, like, refreshing, open, you know, just honest conversation around this. I'm not surprised at all. You've been an OBGYN For 24 years. You're deeply trained, deeply experienced. But I know that your work is also rooted in your time spent as a patient. So I would love it just as a sort of a quick intro as a starting off point. Can you share a little bit of your own personal story with a certain age listeners?
Speaker 1 2:11
Yes. And the truth is, I say this very openly and publicly frequently that I wish for all of us as women and people with vaginas involve us that we could all be much more open with each other, if not, not publicly necessarily, but just with each other with our small groups and little tribes so that we feel better about the human condition because once we start sharing our stories, we realize how much all the stories overlap and we're not alone. And so in my case, besides being a physician, being a wife, being a doctor, being a mother, I also have been through so many different gynecological and obstetrical health issues, which sounds ironic as a doctor who deals with these everyday for my patients, but it's really helped inform me so you know, a joke. It's like a little laundry list. I've had six miscarriages, I've had three babies, and my first one had an intra uterine stroke. My second one was born with a clubfoot. My third one was a surprise pregnancy, which sounds strange for someone who considers herself to be a good gynecologist. But surprise pregnancy at age 40. I had endometriosis that was undiagnosed, like it is for many women for much of my life until I was 29 and ended up with a 17 centimeter ovarian cyst. I've dealt with weight my entire life up and down, had bariatric surgery for it. And I would say it still is a big battle. And it all culminated in me having ovarian cancer when I was 46. And now I'm 53 and kind of in the throes of being a postmenopausal person forever. And so all of these experiences were both like everything in life I joke miserable and magical, they sucked. And yet each one presented opportunities for me to learn about myself and to really learn how to help women with the anxieties associated with all of their health issues that we never get to learn about. Yeah, that is something I feel strongly about Yeah,
Katie Fogarty 4:04
what a what an incredible you know, journey you've been through thank you so much for sharing it so candidly, like, not only with my listeners, but on your Instagram, I really feel like I agree with you. You know, when we share our stories, we feel less alone. Creating this podcast has taught me that so many women are sort of suffering in silence I've I've featured urologist on the show who tells me that women come to them 10 years too late after suffering from, you know, sort of life changing bladder issues. I talked to women who are, you know, like you her gynecologist, who helped women who deal with painful sex and, you know, sort of other taboo topics all the time. And when when when we sort of strip away the taboo, we can get women the resources that they need. So, you know, thank you for being a guest and for sharing your story and for the work that you do with your patients and I love that you're bringing it to a bigger audience. And I know that you talk frequently Chuba managing physical health often requires managing our mindset. So you you listed all the challenges that you went through, you know, do you do you feel that going through those challenges helped you? counsel patients on mindset walk us through a little bit about how you how you manage your own challenges.
Speaker 1 5:23
Yeah, I think I was very lucky, obviously, right when you go through anything, but you have a little bit more information. preemptively. I mean, one of the words I love is pre emptive knowledge, when you have pre emptive knowledge about something that helps you right, because you have that little bit of the pre emptive, the anxiety that is associated with it, but you also have the knowledge to know that you will likely get through this issue. I think that's an important topic to continue to delve into. Because I say to people all the time, we do not as humans, concretely intentionally remind ourselves that we have each been through a lot of hard challenging things like without even knowing you. Well, I know you yourself have been through a million things, I'm sure. And if we all took the time to remind ourselves and say, I went through miscarriages, I went through cancer, I went through my father being diagnosed with Alzheimer's, whatever it is that I've been through, and yet I'm still here, it would help us so much the minute the next big thing comes around. And so early in my kind of career, when I was just a fresh attending, I had already had two miscarriages. And this was 22 years ago now. And so that really started the ball rolling for me to realize, yes, this sucks. Yes, this is anxiety provoking, and I have to allow myself to sit in it and not sugarcoat it and not have any toxic positivity about it. But I can also recognize that I will be on the other side of it. And so when I then had my first baby after the two miscarriages, I was able to say, oh, okay, here are the reasons that I can find within what happened. I don't think things happen for a reason. But I always say I can find reason within it. And the reason within it was that concretely miscarriages happen, they're very common, they're very sad. But then I was able to have this beautiful, healthy, you know, challenging pregnancy with a child who then ultimately also had had an inter uterine stroke. And yet again, he was still alive, and a person that is now 19 years old. So all those little journeys, reminded me each time to intentionally put that thought into my mind that I will go through things as a joke, I'll swear, and we can bleep it out. But
Katie Fogarty 7:27
you can swear as much as you like, this is a show. This is a show about grown up women, we can do this,
Speaker 1 7:32
I say this to my children, I'm not going to sugarcoat it kids, it is going to happen in your life, the sooner you accept that fact, without being negative about it, right? I think it doesn't have to be, oh my god, bad things are gonna happen. It has to be a listen, life realistically is fraught with issues because we have concrete bodies that are just going to crap out sometimes, let's accept that these things will happen. Let's find the beauty within the sock, let's be able to cry and be upset about it when we need to be. And let's each time it happens intentionally placed that thought in your mind that you have now overcome something and you will be able to do it again. Because all too often, what I find with my patients is they'll say things like, I'm so scared that I'm going to have an abnormal mammogram or an abnormal pap smear or I live in fear that I'm gonna have a miscarriage, right? Like, these are the three common things I hear from women. And when I kind of, I don't want to say gently, aggressively remind them, that those things are common, that those things still suck and are sad, but that they will probably have one, if not all three of those things at some point in their lifetime, and they will still be okay. And that they have shown themselves that they've been okay. In the past when they've overcome other things. Many of them kind of stop and go, Oh, I didn't even think about it. You're right. I already had XYZ happened. And it was terrible. And here I am. And I'm okay. So why am I engaging in fear over the next thing that might happen? Yeah. So I think a lot of it is that we just have to be very explicit. I think we all I realized as as adults, especially I think many people will say to me, Well, you live by example, right? And I always say no, no, I don't think it's I think it's necessary, but not sufficient to lead by example, I think we actually do best when we hear concrete ideologies and verbiage as to what we need to teach our brain. And so what I want to teach my children and other women is to reflect on what you've been through, tell yourself that you've been through these things, and that you've come out on the other side to help prepare you for the next thing, because every single one of us on this panel and anyone who's listening will go through something big again, if not 10 more big things.
Katie Fogarty 9:36
You're absolutely I totally agree with you Shiva because nobody gets nobody I joke sometimes, like nobody gets to the north side of 40. But you probably don't get to the north side of 30. Without having gone through something hard. You know, we every single person who's listening to this conversation today went through, like a life changing global pandemic. And we made it through you know, and we go through things like the loss of loved ones. and healthcare challenges and and I love that you share with your patients that reminder that you can have done hard things and you will again. But I also think that you know, there's when you when you were talking about how you have patients who worry about certain things, too, I think that I am going to say this, at least for myself, I have wasted a lot of time pre worrying about things that have never come to pass. And I honestly feel that getting to midlife has somewhat cured me of that. Because I realized I have a little less time to waste and I'm no longer spending it on stuff that may never happen. And you know, we worry about a lot of things that that that never come to pass. What's your test? I love that it's
Speaker 1 10:42
cured you of it. But I think you should take some credit because I will tell you having taken care of and continuing take care of women in midlife, many women still, again, and some of these women are people who have been through big things, they've already proven to themselves that they can survive big things, right? And yet, they still somehow want to attach to that notion of pre emptive fear, instead of pre emptive knowledge of I might have an abnormal mammogram. Why will I bother worrying about it yet, when I haven't even had it yet is the first prong right. And then the second layer to that I keep trying to remind people, if we keep using mammograms as an example, you can be anxious about your mammogram. But to be fearful is silly. First of all, because the odds of it being abnormal are not so small, it might come back abnormal, the odds of an abnormal mammogram, then becoming fine or very high. And the second prong to again, don't bother worrying about until it happens is even in the worst case scenario where you go in for a mammogram, it turns out to be abnormal, and you have a biopsy. And it turns out to be cancer, the vast, vast, vast majority of the time that cancer will have been found early, you'll get either surgical or chemo treatment for it. And you will be okay. And so I think that's where I really want people to be more realistic and mature. I think people want to be anxious about little thing like anxious that just the abnormal mammogram when in fact that abnormal mammogram was common. Instead, what we should really intentionally be anxious about is missing the opportunities to find and fix the things that we can find and fix.
Katie Fogarty 12:18
Without Scott, we're gonna cover next Shiva, this intentional anxiety, which I love, we're heading into a break. And when we come back, I want to talk about sort of intentional anxiety and planning versus pre worrying. We'll be right back. Shiva, we're back from the break, when we went into it, we talked about what how pre worrying is a total waste of time. But that planning, you know, which sometimes is informed by what you I think you were calling intentional anxiety is a good idea, right? Because when we like work, a health care plan, when we are proactive, we can sometimes prevent these worries. So I want to hear from you, you know, you're counseling patients all the time that are worried about mammograms and might be worried about like, you know, doing things they don't want to do like nobody wants to do colonoscopy is how do you counsel a listener who might be avoiding these midlife must is
Speaker 1 13:08
so so many different layers and layers to discuss this two things I'll say, like as broad categories. So first is that I really like one of my many isms is let's be proactive, not paranoid, right? In other words, paranoia would be I'm so scared of my mammogram, I'm so scared of my colonoscopy. I'm so fearful of whatever. Whereas proactive is, I don't really want to do my mammogram, but I'm going to do it because I would, I would rather find something early. So that's one aspect is being proactive, not paranoid, because when we're paranoid, what happens is most patients end up being so paranoid that at some point, they practice avoidance. And that's the real concern I have with the paranoia or the fear, fear of the mammogram or colonoscopy or PAP smear or fear of a miscarriage or fear over whatever is going to lead to an unnecessary angst, right? There's something that unnecessary angst and there's unnecessary, but also it's going to lead to avoidance. So that's one part of it. The second part is that I think people really need to be like I said before, the segments are more mature about how we approach it. If someone comes to me and says, I'm just so scared, I'm going to have an abnormal mammogram and find out if cancer I mean, I hear about cancer every day. It's just so scary. My response is often well, actually, because you hear about it so frequently, that shouldn't be an indication that maybe you shouldn't be scared that instead, let's be mature, let's accept that. The reality is that it is not so uncommon for people nowadays to find out they have breast cancer, but that again, the vast majority, if they do their screening mammograms once every I would still advocate for once every year, then they will likely find it early and it will be fixed. Which doesn't mean that the journey to finding and fixing it is easy or not fraught with like crap, right? But it means that there's no reason to fear it. We should really put the fear basket in the things that are truly truly detrimental to our ultimate ability to stay on this earth. Right and those are relatively small things, most of us are going to get through these things and be okay on the other side. And so again, that common theme of realistically accept that something is going to happen without it being Doomsday, so that it doesn't lead you to avoiding the tests and ideas that will help you get through that and be able to fix things is that's something that I think is so important. And again, it's not explicitly discussed enough. And so that's why I say like, leading by example isn't enough. Because if you say to 10, women, you know, one or two of you are gonna die with breast cancer in the next, whatever. They'll all be like, This is scary. When in reality, we should say, no, no, in fact, this offers us the opportunity to be proactive. Let's figure it out. Let's find it soon. Let's fix it. So you can be on the other side. Yeah, absolutely. That can be calming. Yeah. And I
Katie Fogarty 15:45
also think it gives you so much mental peace. And I you know, I will say that I just recently booked my mammogram, I'm having it in a week or two. And by doctor wrote me the script in December, and so this show is coming out in July, and it literally took me six months to you know, move it off the desk, you know, pile and pick up the phone and make the call. And I when I called being busy, or because of it Yeah, no, I wouldn't say it was anxiety, but it's more like it just felt like an onerous to do and I kind of forgot, like time had sped by so much. When I called. I had a you know, it was like the call of shame. I'm like, can I still use my old prescription from six months ago, and the woman laughed, and she said, I hope so because mine's about that add a date to this is the receptionist. So I'm saying to everyone who's listening, don't be me and the receptionist, you know, pick up the phone and call for the screenings that you need. Because it takes a while sometimes to get these appointment I yeah, I just saw my cardiologist and it took me 10 weeks to get that appointment because he was busy. And I feel so much better for having done it. And it wasn't anxiety or fear. But it was more like just not prioritizing something that felt like one of those adulting to dues that you never want to do. So
Speaker 1 17:03
I want to tell you a little tip that i is not easy in every practice, because not everyone will do this. But I used to have my patients when they walked out of their annual exam with me, I had my staff open up my schedule a year out every single two, they would walk out and they would schedule their annual a year, right then in there. Because I knew what would happen if I said, Okay, you're going to be back in a year, a couple months go by they'd forget, then they'd end up calling like three months ahead of time, I would get booked out for months, they wouldn't you know, and it would be a mess. Now, some practices won't open up the schedule a month a year ahead of time, they'll only open up about six months ahead of time. So if you're with a practice like that, for your gynecologist for your internist, or for your mammogram, then my other tip is marking your calendar that day when you've had your mammogram for six months later, and six months later, you call ahead to get your next mammogram six months after that
Katie Fogarty 17:51
I love I love that tip. By the way I'm going to achieve this is embarrassing, but I do that when I get my hair colored. I am not leaving that salon without booking the next appointment. Because I'm like I am not going to have these roots for one day longer than I need to. Yet here I am like twiddling my thumbs about doing these other things. So I bet a lot of listeners can relate to that. So I love your advice of just like prioritize it like your your hair color appointment ladies, because it will absolutely get done. So what are some of the what are the some of the screens that you really I know this is sort of broad and we're but what's what are must use screens that you want to see women doing in midlife that they may or may not be I just did a DEXA bone scan a couple of months ago. Is that one of them? What do you recommend to your patients?
Speaker 1 18:37
Okay, and let me preface by saying because I'm an OB GYN, this is my lens a little bit. In other words, you should still be making sure that you are seeing your primary care doctor, I would personally tell you that I would love for patients to see their primary care doctor once a year, whether or not they have the need for it because at least their annual exam each year will ideally be a boring screening test where they just get everything done and chit chat with their doctor, and you want it that way. I've had patients every year just go and everything's the same. The answer is yes, it's supposed to be the same and good. And the bigger purpose to me of going once a year and consistently doing it is so you have a relationship with your primary care. So that if or more likely, when, as we discussed before something happens you already know them well enough that you can call, pick up the phone, go in and see them if you don't have a relationship with them or you haven't seen them in three or four years. The honest answer is it's sometimes hard to get into a primary care right away. So I think it's very valuable to see your your regular primary care once a year and your gynecologist once a year. Even though to touch upon screening tests. Many people equate seeing their gynecologist with just a pap smear. And they might know that the Pap smear guidelines now are that you really only need your Pap smear every three to five years, sometimes even sometimes once a year, but depending on your risk factors previous pap smears. Pap smears are something that you will get it anywhere from one to five year intervals and many people unfortunately conflate the fact that they don't need a pap smear more than once. Let's see every three years to not go into the gynecologist as well. And that's not really the case you should see your gynecologist every year because besides your Pap smear, they do other exams, your breast exam, they look at your vulva, they do an exam of your pelvis, and they talk to you about screening tools. And again, just like with your primary care, they then have a relationship with you so that if your mammogram comes back abnormal, you can call your gynecologist and get in to see them to have the discussion. Yeah, so those are two kind of general screenings. And then with regard to tests, I would say, keep up with your Pap smear and make sure you keep track of it, having the doctors be the only ones keeping track of it sounds great. But we all know doctors are very busy. It doesn't always transmit with regard to like how often you need it and how when you had your last one, so I would keep that kind of stuff in your phone, like keep it on your calendar, when you've had it done. But a pap smears anyone anywhere from one to five years. Again, depending on various risk factors, you have to ask them each time when you should do it. And when you should repeat it. I still advocate for a mammogram starting at least at 40. And doing it every year. And I say that because there are varying guidelines, some of which will start you later and have you do it every two years. But most of the guidelines nowadays they at least start at 40. Not later, some people start at 35 or even earlier based on other risk factors. Colonoscopy now we should absolutely start at 45, not 50, like we used to say. And that's regardless of any risk factors or family history, that is a screening colonoscopy at 45. And then bone density is where the guidelines are a little bit fuzzy, like you would set a desk DEXA scan, which is a bone density. I think it really depends on a lot of different risk factors. So it's not as easy as slam dunk. And the reason I think many of us are a little more cautious about kind of advocating for that all the time is that the treatment for osteoporosis and osteopenia, which is where your bone densities change. And it leads you to have more of a risk of fracturing, especially your hip or your spine. The treatments for it are not kind of as straightforward as treatment, for example, for breast cancer. And so that's why I think many of us if we're going to be a little bit fuzzy about guidelines, that's where I and many gynecologist probably feel a little bit fuzzier. But it is a good idea to discuss your bone density or what's called DEXA scan with your primary care and gynecologist and started anywhere in your late 40s to mid 60s, just depending on various risk factors like when you went through menopause, whether or not for example, you're on thyroid medication, if you've had a long history of steroid use if you're very lean and fair skin because your frame your bones might be a little bit less dense. So there's a lot of different ways to approach that.
Katie Fogarty 22:29
Yes, such great advice I was actually I was I did not have fear around colonoscopy is it's honestly it's like the prep snowfall. It's the world's best nap. I you know mammograms, I don't dread those either, even though he's lazy about getting it done. But I was a little bit nervous about the DEXA scan because I am like small framed and fair and I you know, had a past life as a smoker when I was in high school in college, I was really worried I had done some, you know, irreparable damage to my bones. And I felt amazing to hear that, you know, the fact that I quit smoking and that I like you know, do a lot of exercise and do a lot of you know, bone friendly sports like, you know, high impact sports like racquet sports, that got a clean bill of health and it did feel amazing. So you know, I recommend people to you know, get those scans done that she just outlined. I want to switch gears for a minute though and ask you a little bit about me you share that you had ovarian cancer. You're a gynecologist. I'm curious if we could just sort of touch quickly on on HRT, and and whether or not you know, for any of the listeners who are not choosing HRT now actively without consultation with their doctor because of concerns about cancer? Do you recommend them having a conversation with their doctors? Can you do anything to alleviate people's fear around the HRT cancer link?
Speaker 1 23:53
Yes, I mean, Lord, we could do an entire we could do 10 episodes on this and still not even get to the root of everything. But in a nutshell, many people probably have heard that the guidance and knowledge about hormones has changed dramatically, even just in the last, I mean, a couple of years. And our ability to talk about a very, very frequently and openly has also changed in the last year I'd say even. And just to give you a teeny bit of background, I know you know this, but for your listeners, the W H AI, the Women's Health Initiative study, which was back in the early 2000s came out really saying that hormones were bad. And women got ripped off their hormones literally overnight. And it said that basically it increases the risk of breast cancer, therefore everyone should be off of it. And that was coming off of decades of us saying it's good for you. It's good for your bones, it's good for your health, it's good to decrease all things like cardiovascular risk, with maybe a small increased risk of breast cancer. And again, that study basically made it seem as if breast cancer is the biggest risk, take off your take you off hormones immediately. And so now we've had essentially two decades of women being scared of hormones. Luckily, the pendulum has swung to where all the data has really isn't completed yet but Allah Have great data that shows that that study was flawed for many different reasons. We were using formulations that we don't use regularly anymore. We're really using much more what are called bioidentical formulations which not bioidentical necessarily in the compounded form from independent pharmacies, but bioidentical formulations that are mimicking the hormones that we have in our body that are very safe, that are used from commercial pharmacies and FDA approved formulations. And so, because of that new guidance and understanding that many of us kind of knew from the beginning, but now it's being more publicly discussed in social media, and in all of the news, conferences and everything, I think women are starting to learn about it. So I urge any person who is not only gone through menopause, but as Peri menopausal, meaning in that stretch anywhere from their mid to late 30s, into their 50s, where they're still getting their period, but their hormones are starting to change. I urge them to talk to their doctors about it, because the doctors might not always bring it up for a lot of different reasons, not the least of which is they don't always have the time. But talk about it because we know much more. And we know that using estrogen and progesterone, depending on whether or not you need both can really impact not only how you feel going through perimenopause and being postmenopausal, but absolutely can impactfully help your body and especially your brain, we're finding out so much more about dementia, we know it can protect your bones, we know it can decrease the risk of colon cancer. So there's a lot of value in considering hormones. And that doesn't mean that every single woman needs to be on it or should be on it. And there are certainly some risk factors. But the obvious risk factors that people thought like, Oh, my God, I can't go on it, because it increases the risk of breast cancer is really not, I don't want to say it's completely untrue. But it was very much overblown, and we really need to do a lot of work, to, to go back in time and try to fix that fear that women have. Yeah, because it's that if they don't get the help they need with hormones, because it can be so impactful. No, absolutely.
Katie Fogarty 26:52
And I, you know, I learned this from from creating this podcast, you know, honestly, having so many experts like yourself on the show, who've educated me about the, you know, HRT and all that can do to help, you know, with your, your vaginal health, with your bones, with your cardiac health with dementia, it's just something that I started to explore myself and my doctor, and I, you know, brought it up. And I said, Tell me about what you think are the risks? Here's my, you know, risk factors, what do you think, and we came up with a plan together. And I'm thrilled, you know, I'm so happy that I sort of took control of this. And I think that I didn't have that the concern about cancer, and I know, you've you've, you've gone through that. So I just want to make sure it's clear for our listeners. So if somebody has had had cancer has a concern about breast cancer, do you recommend that they bring that up with their counselor? Doctor? Do you recommend they bring it up their gynecologist you know, what, what's the? Is it both? What do you recommend to help them alleviate this fear?
Speaker 1 27:52
Here's the set of The honest answer. And then we should touch on vaginal estrogen quickly. But sadly, my answer is you should bring it up with both your oncologist and your gynecologist and your primary care only if they happen to have a big interest in it. But to be honest, the primary care doctors have so many other things to address that they're probably not going to be as knowledgeable about about hormones. And so you should bring it up with both. And the answer should be if they both summarily say, Absolutely not you had breast cancer, therefore, you cannot be on hormone replacement. And even if they say because you are estrogen receptor positive, meaning your tumor had estrogen receptors on it, you cannot be on it. Then I personally would say maybe also talk to someone who has really learned the much more up to date information because many doctors are still unfortunately quoting the whi study because they have not had time on their own to research the newest data. And that's not doctors fault. Again, there's so much we have to look into all the time that some just aren't as steeped in what's updated in this part because they've learned other things. And so if you really want to know more, or you think you need hormones, or want to be on them, then you should talk to both oncologist gynecologist and if they both say no, then I'd never want to say doctor shop to seek out a third opinion because you can always find an opinion that's going to agree with you. But find someone who is really well versed and there are some doctors out there who really know this stuff very well and they've been very intimately involved in all of the data and studies
Katie Fogarty 29:15
yeah, great advice. You need to educate yourself and then advocate for yourself and you know, potentially find a doctor I know the national names and National Association of menopause specialists has doctors who have continued to get training and menopause and could be a great starting place. So that's that's terrific advice, Shiva. So let's switch gears and talk about vaginal estrogen. I believe you say this is a midlife mass, right for any person who's got a vulva and that you share three things with patients to help them you know, when they consider whether or not they want to add vaginal estrogen to their weekly care routines. So what are those three factors?
Speaker 1 29:50
Well, and let me just say they're probably more than three but yeah, well, there's a couple but in the discussion of how challenging it is to to discuss perimenopausal and postman puzzle hormones. The so when it's when we're discussing systemic hormones, which would be patches, pills, ring, things like that. That is such a complicated topic. In contrast, I would actually say vaginal estrogen is not as complicated, thank God. So I think if every single person with a vulva and vagina hears about it, they will gain a lot. So if that's all we could ever touch upon, it would be great. But basically as you go through perimenopause, and then become postmenopausal and your estrogen levels change and decrease your vagina, which is the inside part and the vulva, which is the outside part will be less elastic, a lot of people use the word dry, I don't like the word dry, because then it implies that just lubricating is enough. And that's not enough. Many women use lubrication, it still hurts when they have sex, or when they ride a bike or when they even just have underwear hitting it. And that's because the tissue is less elastic from the lack of estrogen. So that's just the background to understand what's happening. And when I prescribe vaginal estrogen, I typically try to start with the cream because I think it provides the most coverage. And so it really can get on the vulva and in the vagina, as opposed to using the vaginal tablet, the vaginal ring, or vaginal suppositories, all of which are good, but I think the cream works best. They patients need to know a couple of things. One is that this is not systemic hormones. So even if you've had breast cancer, this is very safe. This is not getting into your system. So the risk of blood clots, stroke, heart attack, breast cancer is not there. And unfortunately, many practicing physicians who I love and value and trust, but they are still scaring women by saying oh, you had cancer, you can't use vaginal estrogen. And that's really just too bad. Because it can help in so many ways, not only improving sex and sexual relations, but also decreasing urinary tract infections. So one is you need to know that it's safe to is you need to know that Unfortunately, despite being safe, the package insert is literally going to say this can cause breast cancer. And it's wrong. It is really that is the package insert that was for the systemic hormone replacement. And even that needs to change. But the FDA put it in the package insert for vaginal estrogen. So in my younger years, I would prescribe it and then patients would call and be like, I can't take it you said it doesn't cause cancer, but the package insert says it does. So I now preemptively tell patients packages or will say breast cancer ignore it. I also tell them the insurance may or may not cover it because your insurance company does not care about your inelastic vagina, you should write because there'll be saving on urinary tract infection medications and things like that. You also need to know that if they don't cover it, you can get it now from pharmacies like not to advocate for anyone pharmacy. But there are now commercial pharmacies that are offering things to patients at much lower prices. So if you can't go to like your regular CVS, Walgreens, places like that, because your insurance won't cover it, there are mail order pharmacies, that will make it much cheaper. And then the last thing is you have to know that you have to use it regularly for it to work. So when patiently will How long do I need to use this for? My answer is as long as you want to use your vault on your vagina.
Katie Fogarty 32:52
You're like, this is an end of time situation, you're going to be using this till the end of your days. How so? How often do you use it during a week? Is this once or twice?
Speaker 1 33:01
Yeah, well, it depends. And again, I'm not always gonna say listen to your doctor or nurse practitioner or PA who prescribed it. But for the most part, the formula like the vaginal cream, which let me reiterate is actually a bio identical cream, meaning it is mimicking the hormone that we have in our own body. So it's extra dial cream, that typically is used twice a week. So some people will start it every night for two weeks and then switch to twice a week. The easier way for most of us is to just prescribe it twice a week, twice a week, twice a week, twice a week, meaning Monday and Thursday or Tuesday and Friday. So kind of three or four days apart. And it comes with an applicator the applicator is quite annoying, I actually often will tell my patients use the applicator at the beginning so you know the dose that you're going to be using, it's typically most of us start with one half gram twice a week. But after a while, you'll notice that that amount is kind of like the strip of it of toothpaste. And it's easier to just not use the applicator put it on your finger and rub it on the outside and push it up on the inside. It's just so it's such a simple thing to do that I really wish we could get that word out to every single person who's perimenopausal or postmenopausal even women who are breastfeeding will have benefits from using vaginal estrogen because any state where you are low on estrogen,
Katie Fogarty 34:20
well I'm happy to help get the word out because I you know, I do but it's and also thank you for educating me that I should stop saying Dr. Vagina because I say that a lot on the show. And I sometimes joke that if like you know if I can help cure Dr. Vagina my work is done. But I guess doctors say to ease but now we're gonna say if I can help cure inelastic vaginas, my work is done. But people should not be suffering and I know that urinary tract infections are you know, very consequential as you age and that women wind up in hospitals when they're older. Because of this and you do need to take care of yourself. One of the things I'm going to be honest here and I do use the extra dial cream but I find it to be more So so I'm not as consistent as they should be. And I'm curious about the suppositories and supplements. I know you know, that's, you prefer the cream but talk to us a little bit about what is a supplement and the suppository look like what is the tablet look like? How do they work? Yep.
Speaker 1 35:15
Okay, so there's the tablet that the brand name was badger femme. There's a generic called UNIFEM, it's a tiny little tablet. Ironically, it comes with like 30 applicators, or however many years, you know, because you're using that twice a week as well. On one hand, it's so much easier to place it's a little tablet, you use the applicator, or you just use your finger put it all the way in, and it liquefies. And it definitely causes I would say less of a thicker discharge, but a little bit more of a watery discharge. And the downside is it's really it's getting into your vagina. It's not helping you evolve as much. I mean, theoretically, it is, it is targeting your vagina and part of your vulva. But it just won't get all over. And so that's the downside, right? Because when you think about it, when we were younger, and we had our hormones in that normal up and down cycle, we had more discharge and does discharges, I mean, we can have a whole conversation about discharge and how how triggering discharges for women, and then we hate our discharge. But the discharge is a normal physiological process that keeps our everything lubricated. And it's a reflection that our tissue is lubricated and elastic. So again, the tablets twice a week, which makes it easier I just personally have found with myself and my patients that it didn't seem to help, especially with the vulva as much. The other form is there's a vaginal ring that is nice and that you put it in and it stays in for three months. Most of the time, you can put it in and out yourself. Sometimes you have to go to the doctor because it's a little bit more rigid than a birth control ring, for example. And so you might have trouble putting it in and out. But again, the nice part is it just sits there, you don't have to worry. And even though it mostly affects your vagina more than your vulva, I would say anecdotally, I think it helps a little bit better than the tablet still. But again, in contrast, doesn't help as well as the cream. And then there is an entirely different class of d h e a s suppositories, very easy to put in, that's formulated to use actually, every single night though most patients find that they don't need it every single night, they could probably get away with, you know, four to five times a week. And DHEA s which is a different hormone will then in the cells convert into estrogen and testosterone. So that's nice in that it's not a cream, you don't have to slather it all over. I do find that because people are using it regularly, they don't forget. And then it does seem to help the vagina and the vulva. But still, you'll get a discharge. I mean, it's kind of like one of those good news, bad news. You don't you know, like we it would be great if we could find a way to elasticized, the vulva and the vagina without discharge. But if you think about the skin on your face, there's no way to use various products that help keep it elastic that don't make it feel a little bit almost oily. Right? It's hard to feel dry and elastic at the same time.
Katie Fogarty 37:49
Yeah, absolutely. Absolutely. It's so funny. You've convinced me like with a dry skin thing too, because I love I use a wonderful face oil that I learned from having a woman named Cara grin on the show, I adore her face oil. And it does make me feel like, you know, not dry. And I'm happy about that. So I need to just sort of reframe my mindset and just, you know, be less less upset about the astronaut oil, but I really I do use it. But I do find myself sometimes thinking, you know, it's depending on where I'm going when I'm wearing like when I want to put it in, and I'm not quite as good about using it. But you've you've you've further motivated me, which is why I have these shows. i This is why I have these conversations. Because when I talk to women like you, I get excited about doing the things that I know I need to do to take care of myself, and I hope our listeners are excited as well. It's particularly because you've outlined at least four different options that women can use to make vaginal estrogen a part of your life, you know, right, we've got that. So I would
Speaker 1 38:46
urge them to try the different formulations. If they don't like for you as well, if you don't like the district, try the other ones. Because you might have a different experience and what I've anecdotally seen, right, and so I really, I never want to act like there's only one right way to do any of these things. There are multiple ways to it. Most importantly, what I think you and I both want is for women to recognize that they can talk about it with their doctor that they should talk about it with their doctor that they shouldn't be embarrassed that it's very common for this to happen. It's actually borders on what I would call normal, right? It's normal for us to have lose the the elasticity over time. And if we just made this one important, impactful difference, it would be so great for our health.
Katie Fogarty 39:20
Yeah, absolutely. So when for Well listen, because my listeners range in age, you know, it's kind of 40 to 65 or so. Do you recommend people start using this in perimenopause, right when you start to experience some of the symptoms of like slowing periods? Is this something that you you do when you're fully in menopause? What's the timing?
Speaker 1 39:41
It depends. And so just to reiterate for your listeners who I hope know, but they might not because many of my most educated friends don't even realize that perimenopause again can start mid to late 30s If not early 40s Because it can last 10 plus years and it's just that time your hormones are starting to shift and change may be evidenced by irregular period But maybe it's just subtle things like, I feel a little more hot at night I feel a little bit more moody, I feel a little bit more weight around my middle like subtle things can be a sign of perimenopause. And so when patients come in and have those subtle signs, and I say to them, oh, you might be Peri menopausal. And I joke that, I always call it the other P word. Because they're like, what? I won't tell them that they should start the cream yet, it really depends on them. Meaning if they say, No, I'm actually not having any trouble when I have sex. If I even still feel like having sex, it doesn't hurt, it doesn't feel I don't have any trouble. Or I use a lubricant. And that's good enough because I'm not in pain, then they don't need to start it. In other words, it's not as though like you should start to preemptively because you've, you've lost the battle. If you haven't started it, you can start once you start to notice discomfort either with intercourse with again, if you spin a lot, and you notice that when you're when everything's rubbing against the bike seat, it hurts, or you're having recurrent urinary tract infections, those are the times where I would say, start it. And certainly, even if you don't have any of those things, recognize that once you become postmenopausal, your hot flashes, night sweats, things like that might abate over time and go down. But your vaginal in elasticity will only potentially get more and more and more.
Katie Fogarty 41:11
Right. And that's such an important distinction to say that this is not just when you're suffering from some of the symptoms, this is an ongoing maintenance that you need to do to keep these tissues healthy for the long run. Because, you know, even at some point, if you're not having an intimate or sex life, you know, maybe you're single, but you still want your tissues to protect you from things like urinary tract infections taking hold. And I love your bike example, right? Yeah, you need to take care of this body part for your healthy living and a vibrant aging. It's not simply about making your sex life less painful,
Speaker 1 41:49
right. And many people don't have sex with a partner. But even on their own, if they're using a vibrator or something like that, they might need to make sure that that tissue still feels really elastic, because many women will say I used a lubricant, but it's still burned and hurt. And that is because that tissue is what we need when we actually are having intercourse or if we're doing anything with ourselves, we need that transition where the tissue becomes more lubricated and more elastic and the vagina and vulva actually kind of lengthen and thicken and do a lot of different things. So merely putting a lubricant on it, which is what we've been told for decades, right as women like, oh, just lubricate. That's not enough. So yeah, I think that I think we've made it clear.
Katie Fogarty 42:28
I think we've made it clear vaginal estrogen all the way figure out what works for you. I love it. Thank you so much. We're gonna head into our speed round in a few minutes, because we're nearing the end of our time. But before we do I have a question. I know. I said at the top of the show, you've got a fabulous Instagram you share like really helpful, frank advice on a range of topics. I definitely recommend everyone check it out. It's called at Big Love fierce Juju. But my question is, why big love fierce Juju? What does that mean to you?
Speaker 1 42:59
So I'm going to try to make this quick. But I was diagnosed with ovarian cancer. About two weeks later, one of my friends who's also a patient who's actually a nurse at our hospital, was just diagnosed with breast cancer. And I had, we've been calling and texting back and forth. And I said, at one of my texts I ended with, okay, I'm sending you. I'm sending you my my big love. And it just didn't feel like enough. But it also just didn't feel right saying prayers, because while I'm very, very spiritual, I'm not religious. So I said, I'm sending you my big love. And then I said, and fierce juju, and it seemed to just be like the right mix of, I want to be concrete, I want to love you, I want to, you know, educate you and I just I love that little bit of whimsical like Juju and Juju to me is not evil I where I think people are casting a spell on us or looking ill on us It is that kind of indescribable little feeling of goodness, and sometimes a little bit of luck and just, you know, that folly and so that just became a tag that I thought was fun. Now we're kind of in this transition because my business partner I have our company called tribe called V which is an OBGYN platform to really help educate women on all the things that they've never learned as far as any of their health concerns. And we're in this inflection point where we're actually going to change our name and our branding and I kind of need to know if I'm going to switch to being like Dr. Shiva G or big lifters Juju and I'm really conflicted because I love the juju
Katie Fogarty 44:25
part I love it also, I don't know maybe we'll get our listeners to vote so when I when I share this and when I put it on Instagram, I will ask you guys to weigh in you can you can vote for what you think Shiva should use but big big love fierce Juju. I love it. I love that idea of just you know warm support good vibes energy and a little bit of like, I don't know maybe like steel on our spine a little bit of you know, fierceness. Alright Shiva. We are going to head into our speed round. This has been so educational. You've gotten me super excited about being more consistent with my vaginal estrogen. I appreciate that. Um, but our speed round is just the way we close. It's just one to two word answers so we can end on a high note and cover a little bit more ground before we say goodbye. Are you ready? Perfect? Yes. Okay. I could talk about this midlife health topic over and over again.
Speaker 1 45:15
Yes. Wait, what am I supposed to do? Which one which fun? Oh, I could talk about perimenopause.
Katie Fogarty 45:25
Nice Okay. A menopause or perimenopause resource, either a book a podcast, a thought leader that needs to be on our
Speaker 1 45:33
radar. NAMS the North American menopause society.
Katie Fogarty 45:37
Nice. Very good. So you share a lot of fabulous content on your Instagram. What's the topic that always resonates with your audience?
Speaker 1 45:47
I'm gonna give you five topics quick HPV herpes, perimenopause, menopause, pregnancy loss. Okay,
Katie Fogarty 45:53
those are biggies. This lifestyle choice. fuels your peace of mind.
Speaker 1 46:01
Finally, lifting weights. Ooh,
Katie Fogarty 46:04
I'm doing that too.
Unknown Speaker 46:06
Gosh, it's been a long time coming.
Katie Fogarty 46:08
Yeah, it took me it took me a couple years but I do it once a week. Now. I should probably do it more. But you know, we can't do everything. This menopause friendly food is always in my grocery cart.
Speaker 1 46:20
You're gonna laugh but organic heavy cream. Who do you want me to expand on to Yeah, why? I'm actually a fan of time restricted eating or intermittent fasting depending on how you look at it. And so when I have my coffee in the morning, I put a little scoop of the organic heavy cream in it. It doesn't break my fast it makes it yummy. And it doesn't have any sugar in it because sugar is a big trigger for hot flashes, as is caffeine and alcohol by the way, but caffeine I can get away with and so if I've kept you in a little stitch of organic heavy cream, it's really it helps me with the long term weight issues I've always had.
Katie Fogarty 46:58
I had Dr. Mary Clara Havre on the show who wrote the book Alvis and diet and she the book is a great resource for anyone who's curious about time restricted eating and, and making some different kinds of health choices. And she shared that one of the hardest things for her was saying goodbye to the sort of the sugary coffee that she loved in the morning. So this is this is a great workaround. You know, you can have coffee with this, this little scoop of cream, so that's a very nice call. Okay, finally, what's your one word answer to complete the sentence as I age I feel more at ease. worries, I love it. I love it. Three words. Mito. This is Shiva, this has been such a treat. I love following your Instagram. You share great, great advice. You get people you know it's informative. It's fun. It's it's straight talking, I encourage all of our listeners to go check it out. Before we say goodbye, though, how can our listeners find you your work and a tribe called V and your podcast which I know is coming?
Speaker 1 48:01
Yes. So I'm mostly on Instagram and they can either look up Shiva go fronte or big love fierce Juju. And our website is tried called v.com. So just try but called the v.com. The soon to be renamed but for now Chad called v.com. I would love for people to come sign up for our email list. We send out newsletters that are not spammy and not even that frequent. But they will also be able to learn about the different things that we have to offer. We have a lot of free content. And then we have different classes. We have a pregnancy class, I just gave a perimenopause zoom a couple of weeks ago and there's going to be more and more to add to that because I really know that this can be a great resource for people across their entire spectrum from their very first period all the way past their last period like into their eighth and ninth decade of life because there's so many aspects of women's health that we do not learn about and OB GYN health and people with uterus, ovary, ovaries, vaginas and pelvis. So we need to learn about all of it. Absolutely. I
Katie Fogarty 48:55
could not agree more on putting all of those in the show. No thank you so much Shiva. This wraps a certain age a show for women who are aging without apology. Want more of a certain age, sign up for our newsletter age boldly over on our website a certain age pod.com or follow us on Instagram at a certain age pod. We share bonus content, giveaways, links and mid life resources come hang out with us on Instagram. Special thanks to Michael Mann CME who composed and produced our theme music. See you next time and until then, age boldly beauties.