More Than Hormones: Menopause & Women’s Sexual Health with Kelly Casperson, MD

[00:00:00] Dr. Kelly Casperson: The grand question is, how do you know who it's going to work in? Well, you don't unless you try it. But I think it's our job—again, informed risk, benefit discussion—to say this helps some people profoundly with libido, but not everybody. And I think it's a fool's errand to say it's only testosterone and it's a fool's errand to say it's only sex therapy. This is all a big yes-and.

[00:00:22] Dr. Melinda Ring: This is Next Level Health. I'm your host, Dr. Melinda Ring, director of the Osher Center for Integrative Health at Northwestern University. On this show, we explore ways to take actionable steps toward optimizing our health with leaders in the integrative, functional, and lifestyle medicine fields who believe in science-backed and time-tested approaches to well-being. Let's take your health to the next level.

[00:00:50] Dr. Melinda Ring: Menopause is often talked about as a hormonal transition, but hormones are only part of the story. The changes women experience in midlife can affect their physical health, but also mood, relationships, sexuality, and sense of self. And too often women are left to navigate these changes without the information or support they need. My guest today is Dr. Kelly Casperson, a board-certified urologist, sexual health educator, and outspoken advocate for women's health. She's the author of the bestselling You Are Not Broken and her newest book, The Menopause Moment: Mindset, Hormones, and Science for Optimal Longevity, as well as host of the popular You Are Not Broken podcast. Kelly has been challenging long-held misconceptions about women's hormones and sexual health, and she's an influential voice in this national conversation about improving women's health and menopause care. She's also the co-author of a newly published scientific review examining the role of testosterone in women's health that goes beyond sexual function. Today we'll explore why menopause deserves a whole-person approach, what we're learning about testosterone, where medicine may be falling short, and how women can take a more informed, active role in their health. Kelly, welcome to Next Level Health.

[00:02:13] Dr. Kelly Casperson: Thanks for having me.

[00:02:15] Dr. Melinda Ring: I just wanted to jump into your past or how you got into the work that you're doing now, because you started your career—you still are a urologic surgeon—and over time you became a passionate educator and advocate for women's sexual and hormonal health. So I know you talk about this a bit in your books, but can you share a little bit about what led you to make that transition from maybe a more traditional urology specialist into what you're doing now?

[00:02:45] Dr. Kelly Casperson: So for people who don't know, urology is the surgery of the genitourinary organs. So from top down, that's adrenal glands, kidneys, ureters, bladder, scrotum, urethra, penis—usually stereotypically the male pelvic structures, although we are also excellent at female, but that's kind of newer. I mean, I don't know if I was ever traditional because as of right now, and I've been out of training for 15 years, only 11% of American urologists are female. So I was always kind of the outlier, and when you are a female practicing urology, you do see a lot of female patients. And so I was very heavy in the bladder leakage, prolapse, pelvic health, and seven years into private practice, a woman was crying in my office because of sexual dysfunction concerns, and I didn't know how to help her. But at the same time, I know how to help the men. I prescribe Viagra, I give testosterone, we fix crooked penises. We do all the things to improve their quality of life in the sexual health domain. And so it was basically the beginning of my advocacy work, which now is basically gender equality in medicine. And you know, I give keynotes and get standing ovations by basically saying something that shouldn't be all that profound, which is: When women are treated the same way that men are in the healthcare system, I will be done working.

[00:04:14] Dr. Melinda Ring: I have a similar phrase in integrative medicine, which is, you know what, when what we do is just medicine, then I can retire. Same thing.

[00:04:23] Dr. Kelly Casperson: Yeah, same thing. Perfect.

[00:04:24] Dr. Melinda Ring: Same thing. Same thing. Obviously menopause is having its menopause moment. But how do you think that your background as a urologist flavors your approach to maybe some of the other menopause specialists, influencer doctors out there?

[00:04:40] Dr. Kelly Casperson: I almost feel silly for saying it because it's like, most doctors take care of all genders, right? But OB-GYNs don't, and by and large, like the grand ruse and sadness in this country is that we've taken 50% of the population and said this one subspecialty takes care of everything, right? Like that is actually insane when you think about it. And we have maybe 35,000 OB-GYNs for 80 million women over the age of 40, let alone all the ones that have babies and are young. The fact that we put 50% of our population onto a subspecialty is insane in medicine, but through that lens, they don't take care of men. They don't see how we treat men. And everything we say about women, when you hold it up to the lens of men, falls apart. An example would be, "Menopause is just natural," or "A declining sex drive when you get older is just natural." And I'm like, well, we don't dismiss men in medicine by saying testicular decline is natural, infertility is natural, erectile dysfunction is natural so you shouldn't treat it, crooked penises are natural so we shouldn't treat it. When you realize the lens is dismissal under the ruse of being natural, and then we don't "natural" all over men, that is the gender bias lens that I think gives especially female urologists so much power in this space, because as soon as you say something to a woman, if you wouldn't say that to a man, it no longer makes sense.

[00:06:12] Dr. Melinda Ring: Is that framing what brought you to the name of your podcast and your first book?

[00:06:17] Dr. Kelly Casperson: Yeah, so the podcast is called You Are Not Broken. The first book's called You Are Not Broken, and it was a very natural name because I just kept telling women they weren't broken. So the woman who was crying in my office, I was like, let me see what the gynecologists know. My gynecology friends are like, "Oh no, we didn't get trained in female sexual health either." And so then the question was, do we know anything about female sexual health or do we frankly not know? And I spent a whole year going to conferences, reading the journals, reading the books, being like, oh no, we actually know a lot. It's just not translating to the general population. And then things work against it, like Hollywood, which is fake intimacy, and it's not real. Right, and so the more I learned, the more I was like, oh, 70% of women do not have an orgasm by putting something in their vagina. You're not broken—that's the design, right? 10% of women have never had an orgasm, not because their body's broken, but because from a very young age they were discouraged from even touching themselves. Whereas men are encouraged to touch their penises starting at age 2—why, they've got to potty train, right, as they get directed at the toilet. So we're socialized so differently. But once you know the facts of like, putting something in the vagina to have an orgasm, it's kind of like rubbing a scrotum. You're like, it's really close, but we're not surprised when rubbing a scrotum doesn't give you an orgasm, right? And so the more I educated people to be like, "No, you're not broken, you just didn't get educated, or even worse, you got educated incorrectly."

[00:07:46] Dr. Melinda Ring: It's interesting the way you're talking about this, because you are also bringing in something that struck me right away when I was reading this book, which is the larger lens, like the context of what a woman's life is. And so I was thrilled when you started your book out with a look through the biopsychosocial lens, looking beyond hormones to the psychological and the social dimensions of women's experiences, because, you know, again, that's similar to how we approach health in integrative medicine, is saying like, we have to treat the whole woman, the whole person. So why was it important for you to start the book there and what do you think we miss when we look at menopause through just a hormonal lens?

[00:08:34] Dr. Kelly Casperson: Well, we don't realize that what we're doing to women is dismissing them. I think, again, I love your 10,000-foot view because we keep yelling—or what you hear people yelling on social media and at the academic conferences and blah, blah, blah, is we keep yelling, "We need more research, we need more research, we need more research, we need more funding, blah, blah, blah." Agree 100%. And why aren't we using the research and the funding that we already have? Because when we yell into the void that women haven't been researched—you know, we didn't even start researching women until 1993 and blah, blah—people actually believe that that's true. They don't understand why that is and they don't understand. Like, there's amazing studies from the 1980s, amazing studies like the work looking at testosterone in post-surgical menopause, amazing studies done in the 1980s. But when we say we don't have enough research or we've never been researched, people actually think that's true, and we don't use the research that we have. So I don't think it's actually about needing more research. I think it's about fundamentally viewing women as—yeah, we might not have all the research we want, but we need to start now, because we're stopping and holding off until we get more research, which means there will never be enough. There will never be enough to actually move on women's health.

[00:09:56] Dr. Melinda Ring: Now to this idea about us being whole people and hormones only being a part of the picture, because you know, yes, it's wonderful. Like, I think ACOG just came out with their latest position statement, you know, saying, "Yay, we should be on hormones." You know, it's on the news, we're all talking about hormones, but in many ways.Now I think women start to feel like, okay, I just need to fix my hormones, and then that's going to take care of everything. When you're talking to your patients, are you talking to them about, you know, stress and relationships and cultural expectations and what it means to be at this stage of life? How do you prioritize everything when you're talking hormones versus everything else?

[00:10:44] Dr. Kelly Casperson: I describe—and this is my metaphor and it's imperfect—but hormones are bricks. They help build walls. They help healthy cells stay healthy, but bricks and walls make a house, not a home, and everything else makes the home, right? But if you don't have strong walls, you can't have a home, right? So it's like it's all integral and it's all part of it, but one thing I like to say is don't give hormones more power than what they actually do. You'll see this a lot, especially in the testosterone world, of like, people think testosterone's a miracle, it fixes everything, blah, blah, blah. It's like, testosterone is a hormone that moves through your body, attaches onto a cell, goes into the cell membrane, affects mitochondrial health. Do not give it more power than what it actually is. I think social media feeds into this, that there's a perfect, there's a best, there's a balance, there's this like "always," and that goes into the perfectionism culture that we put on women, right? You're never enough, including your hormones, right? And so they get in this cycle of "If I just get the hormones dialed in enough..." and it's like, zoom out, stop drinking alcohol, go to bed at the same time, right? Like put down the phone, right? Zoom out. Hormones are important, but don't give them all of the power.

[00:12:06] Dr. Melinda Ring: And do you think—I mean, it sounds like some of this is coming from medicine, some from social media and other places—but then I think some also is the way that women have been taught to interpret those changes that are happening in their body, the narrative around a woman aging and what is—

[00:12:28] Dr. Kelly Casperson: That's the biopsychosocial of it, right?

[00:12:30] Dr. Melinda Ring: Right.

[00:12:31] Dr. Kelly Casperson: If we tell women that being natural, doing it right, being perfect... We never tell men like, "Well, you know, Mother Nature didn't want you to reproduce, that's why she made your dick soft at 45," right? We never explain male medical issues like this. Like, "Mother Nature designed you to have a soft penis after 50," right? Like we never do that. That would be insane. That's an insane thing for me to say. But we do that for women.

[00:13:05] Dr. Melinda Ring: So how do you think we can actually help women shift the mindset without dismissing real symptoms?

[00:13:13] Dr. Kelly Casperson: We call out the gender bias in it.

[00:13:16] Dr. Melinda Ring: Okay.

[00:13:17] Dr. Kelly Casperson: I have an 89-year-old male patient whom I give testosterone and Viagra to, because his quality of life matters.

[00:13:26] Dr. Melinda Ring: Mm-hmm.

[00:13:27] Dr. Kelly Casperson: The way we dismiss older women in this culture is absolutely insane, insane. So it is cultural, right? What worth is an older person? And in the United States of America, we've decided that they're not wise, and they're not experienced, and they're not worth the same healthcare that a 3-year-old gets. Other cultures, it's different. In other cultures, menopause is like, these are the wise people, these are the people you seek counsel from, these are the people who have time to shape their communities. Right? And so once you understand the cultural lens through all of this, you're like, well, if you want to participate in your own importance in society, like listen to everybody, but this is an incredibly powerful time. And I think Gen X has gone a long way, because never has society aged like we're aging right now, unnaturally. By the way, society living to 84 is not natural. We've never done it before. It's brand new. And Gen X is saying, "What if we don't go frail? What if we continue to travel and write and play pickleball and drive our grandkids around, whatever it might be?" Because we're watching the first generation age into frailty, and now we have the opportunity to say, what if we do this a different way? But you can't decide to act when you're 74. You can, but it's better if you act when you're 50.

[00:14:55] Dr. Melinda Ring: Yeah, or—

[00:14:55] Dr. Kelly Casperson: Preservation of function is much better than trying to fix it once it's broken.

[00:15:02] Dr. Melinda Ring: We talk a lot about that, you know, healthspan versus lifespan, you know, if you want to be able to put your suitcase above the bin and all those kinds of things. As we age, on the one hand, the sooner we start with changing those behaviors—I mean, childhood, you could go even earlier, but childhood, teenagers... I mean, I see it with my own kids who are in their 20s, that luckily they absorb things from me, but they and all their friends, you know, they don't necessarily know how to adult in a healthy way. That does have an impact as we age. And then on the other side of things, we're seeing, you know, even if we go back to the hormone conversation, there is like this cutoff, like, "Oh, if you're over 60, you missed your window," where you can't do it. It's not like there's some line that has to be drawn at a certain age. So I think women are feeling that they missed the boat. This whole generation of women who were not allowed to take hormones now feel like they missed the boat. So how are you helping those women, or what is your advice to those women who are 60-plus, maybe not having major hot flashes, but are still dealing with a lot of the things that hormones could potentially help? What's your advice to those women?

[00:16:21] Dr. Kelly Casperson: Number one, first of all, there's no line in the sand. You know, the 2022 menopause guidelines are on our side with this. And just for your listeners, after age 60 or 10 years post-menopause, an individual risk-benefit discussion is warranted, which is the exact same advice given to anything else in medicine. Statins: risk-benefit advice; high blood pressure medication: risk-benefit advice; birth control: risk-benefit discussion, right? People are like, "Oh, there's a line in the sand and you can't have it." It's like, no, no, no, it says greater than 10 years post-menopause or age greater than 60, risk-benefit discussion is warranted. Guess what? Men—Viagra, testosterone, risk-benefit analysis is warranted. What we say about surgery: risk-benefit analysis is warranted, right? Like, this is not a crazy statement, but people have taken it and put it into "You can't start hormones." And then how do you combat that? You just educate them. Be like, the guidelines are free online. What's more meaningful about these guidelines that I think the general population and even the doctors don't realize is they say within 10 years of menopause, benefit outweighs risk. Now, you're a doctor and I'm a doctor, and we know "benefit outweighs risk" is an incredibly powerful statement, not said for many things in medicine. Incredibly powerful statement. And then they say risk-benefit discussion greater than 10 years, age greater than 60. So first is that education. And then the second piece of education—and this is how I describe it—hormones are a very big tent. Within that tent, we have testosterone, no age contraindication. We have oral micronized progesterone, no age contraindication. We have vaginal products, both DHEA and estrogen, no age contraindication. We've got oral estradiol products. We've got transdermal estradiol products. So for you to say "no hormones" is a fundamental lack of understanding that there's a whole bunch of stuff inside the tent. Individual risk-benefit discussion is warranted, and within 10 years, benefit outweighs risk. And that's where, like, hormones will always help the cells stay healthy, but they won't prevent disease if the disease is already there. And that's where the preventative benefits of starting it early come from. It's like, I can't tell you that we have any data to say I'm going to prevent heart disease or dementia starting hormones in a 75-year-old. But it'll always help you sleep, it'll always protect your bones. So, risk-benefit discussion, and to realize that's all of medicine. Why are we using that to scare women off hormones? I think the baby boomers are pissed. A third of my practice is women greater than 70. We could open entire clinics in the 10 major metropolitan cities in America that just took care of pissed boomers. And the last thing I would add to that is do not take away your power. When women say, "Oh, I missed the boat," yeah, you better not be drinking, you better be lifting weights two to three times a week, you better be managing your stress, you better be going to bed on time, right? Like people, again, it's not all about the hormones. Hormones help healthy cells stay healthy; they don't make a home. Women throw in the towel because they're like, "Well, I can't have hormones." No, no, no, no, no. There is so much that's within your control. Do not give away your power.

[00:19:42] Dr. Melinda Ring: Now speaking about education, you just co-authored this review that was titled "Beyond Libido: The Multifaceted Role of Testosterone in Women." But before we talk about those different aspects that testosterone could potentially help with, let's talk about it itself, because I love what you say in your book. This is, again, one of those things about where you're breaking down the differences. But as you, as you know, like most women have been taught to think, well, testosterone is a male hormone and

[00:20:16] Dr. Kelly Casperson: What andro- means. That's what an androgen in Greek means: male-like. The word is wrong.

[00:20:24] Dr. Melinda Ring: So even the word... so the androgens, you don't even like "androgens"? You think we should get rid of that?

[00:20:29] Dr. Kelly Casperson: It means male.

[00:20:30] Dr. Melinda Ring: Yes. Okay, great. Well, so tell, so tell me about that framing. So why is labeling testosterone as a male hormone just plain inaccurate?

[00:20:39] Dr. Kelly Casperson: So this started because we found testosterone in rooster testicles, and we found estrogen in cow ovaries, and forevermore we put one in a blue box and we put one in a pink box, right? So it came from the historic discovery of the sex of the animal we discovered these things in, so we understand. But doctors have known for a very long time: We've been giving women testosterone since the 1940s, right? But nobody knows that because we tell everybody we've never studied anything on women. We've been giving women testosterone since the 1940s! So yeah, ovaries make testosterone, and testosterone gets one carbon cleaved off and it becomes an estrogen. So it's like Mother Nature... these things are actually very close, very similar molecules, like biosimilar molecules. There is a one-carbon difference. They're both carbon steroid compounds, right? It's humans that made the dichotomy and made them separate things. They're actually incredibly close to each other. Just one has 19 carbons and the other one's missing one. So to go back, it's like, they all belong in all bodies. Testicles make estrogen, right? And I think when going into it, it's very bio-psychosocial, right? Our FDA and our pharma system creates one molecule to do one thing, to treat one disease, to get one FDA approval, to get insurance to cover it for one disease. That's not how hormones work. Hormones help healthy cells stay healthy. They work in every cell. Every organ has receptors. So once you know that, you're like, it's actually very silly to say it's just for libido. Because Melinda, you went to medical school—where's the libido box? Is it on the left side of the brain or the right side of the brain? Is the libido box in the temporal lobe or the occipital lobe of the brain? There is no libido box, right? Okay. So now that we know all of that, we can break down to be like, I'm not here to fight to say, oh, it should be 20 different things, or 30 different things. It should be like: This is a hormone, it doesn't act like a chemotherapy drug on one cell doing one thing. It's a hormone, so it should have every indication. But that's—again, it works on mitochondria. What do mitochondria do? They're the energy producers of the cells. So when people say, "These hormones help me with energy," they get dismissed because they're like, "Well, that's not an ICD-10 code. How do you measure energy?" You're like, no, no, but legitimately they help mitochondria. They legitimately help energy. How else do you want to define that? But again, it's very poo-pooed in Western medicine because there's no ICD-10 code for "wants energy up."

[00:23:40] Dr. Melinda Ring: There's a good fatigue code—I end up using that one a lot—but yeah.

[00:23:43] Dr. Kelly Casperson: Hormones will never get FDA-approved for fatigue, and you know...

[00:23:46] Dr. Melinda Ring: No, absolutely not. Absolutely not. And actually, I think I learned from you that women at certain times in our cycles, we have more testosterone than our female, technically female, the estrogen hormone. But then when we look at the data. Again, it's, you know, it gets associated with hypoactive sexual desire disorder, low libido, but the data on how much it actually improves, it isn't as dramatic as I think. Even that, you know, that claim turns out like to me, I think some of some

[00:24:19] Dr. Kelly Casperson: Who's the boss of what's a meaningful improvement? Don't be so confident that we know what the right amount of libido is on a given Tuesday morning when you've decided to do a research program on this. Right? Don't give hormones more power than they actually have. But that's why testosterone gets poo-pooed, is like, well, yeah, libido's incredibly complex. And who gets to say what a significant improvement is?

[00:24:48] Dr. Melinda Ring: I bring it up because, you know, I've been prescribing testosterone like you, you know, for two decades at this point. A lot of women I see start it and, you know, their levels will go up, they'll notice, but I think their expectation of what's going to happen is maybe not as robust as the buzz might say. And so a lot of them end up saying, "You know what, it's not worth it to me," or "I'm not getting enough benefit from it." So while I do feel like the pendulum right now is like... not every woman should be on testosterone, but there are all of these benefits. I would say that in my own practice, I haven't seen it be as dramatic as maybe some of those claims are saying or the research is showing. So I don't know what your take is on this, Kelly. Do you feel like it should be estrogen, progesterone, and testosterone for every woman? Is there a rationale for that?

[00:25:46] Dr. Kelly Casperson: There is nothing that on a public health level we say everybody should do. We never did that with baby aspirin, right? We won't do it with statins. You'd be hard-pressed to do that with vaccines, right? So for anybody to say all people should is like, no, we don't do that with anything. Clean drinking water is like... everybody should, but that's about it. It's like public health measures that everybody should. But my stance has always been: I want women to have the education and the tools to advocate so that if they choose, they should be able to have access to that. And again, what does that do? Think of that energy—that puts her on her front foot, that puts her in the driver's seat instead of sitting around saying, "We don't have enough research yet to say everybody should." Of course we don't. We don't even give everybody baby aspirin, right? This is insane. And I think going back to your "don't give hormones more power than what they do" is your sex life is within the context of a home, not within the context of walls that are strong, right? So if you don't have energy and testosterone gives that back, you're more likely to then be interested in sex. But if your relationship stinks and you have untreated genitourinary syndrome of menopause, no amount of testosterone's going to get you a good sex life, right? So sex life is incredibly complex, and this is how I educate my women with testosterone, because it demonstrates a point and it gets a laugh: There are two types of women on testosterone. The first type feels benefits within a couple of weeks. It's as if a light switch has gone on, many things are better, and she notices immediately and she tells all of her friends and she tells social media and she tells her sister and she tells everybody about it. nd the second group of women on testosterone hate that first group of women. Now, what does that illustrate? That illustrates that hormones work differently in everybody, and for some people it is true—it's as if their world is now in color. We must not dismiss them, but do not think that's how it works in everybody, right? So the grand question is, how do you know who it's going to work in? Well, you don't unless you try it. But I think it's our job—again, informed risk, benefit discussion—to say this helps some people profoundly with libido, but not everybody. Not everybody, but you know, sex is biopsychosocial, but it's a layer of the onion, and I think it's a fool's errand to say it's only testosterone and it's a fool's errand to say it's only sex therapy. This is all a big yes. And.

[00:28:26] Dr. Melinda Ring: You talked about access being the issue—we don't have an FDA-approved testosterone formulation in the United States. And you've been really active in this national conversation about getting women access, and in discussions with the FDA and on Capitol Hill. That's a whole different part of education and work, working toward advocacy. Can you share a little bit about that—maybe what are some of the things that you've found to be barriers? What's standing in the way of this moving forward?

[00:29:02] Dr. Kelly Casperson: The big barrier again for the FDA is it's incredibly expensive. Companies have gone out of business trying to provide enough data for the FDA, right? We're talking hundreds of millions of dollars to get things through the FDA, and then people will use that barrier to say women can't try something. That's insane. Those are two completely different issues: having a big enough business to pay the bills to get something FDA-approved versus telling women that they could try something. And the other thing—and you know, the FDA has said this—the FDA is not in the business of practicing medicine. They say that, yet we have insurance companies in this country only covering what's FDA-approved. You see this in your integrative practice all the time. It's like we have the tail wagging the dog on this one, where now the doctors won't do what insurance doesn't cover, which won't do what FDA doesn't cover. And here we have a generic, naturally occurring hormone that is unpatentable. It's unpatentable, and you want a company to make enough money to recoup the expense of getting that through the FDA? But once you know all of that, now you can say, "I understand why we don't have an FDA-approved product." Now, the game that the GLP-1s are playing is a different game than what a naturally occurring hormone is playing. I have a woman in front of me who is suffering. I understand what her goals are. I understand the risks and benefits of hormones, and I'm willing to give it a try. And because of the power of social media and women speaking up and women being advocates and doctors being in this space, we are going to get an FDA-approved testosterone. The FDA—here's a secret—the FDA does not hold a daylong meeting on something that they're not going to do anything about. The FDA has heard, HHS has heard. I truly feel like doctors have brought this to the top, women's voices have been heard at the top, we now need the companies and the FDA to agree on a plan to get this across the line.

[00:31:10] Dr. Melinda Ring: The whole idea of women trying to fractionate one-tenth of a male dose that's FDA-approved is... I mean, to me that creates more potential for risk and harm. For me, I prefer compounded from a good company, or like you said, ultimately getting FDA approval is going to be the best way to go.

[00:31:31] Dr. Kelly Casperson: You know, people come to me and they're like, "What do you think we should have? Do you think we should have an oral, or an injectable, or a gel, or a cream, or a ring? What do you think we should have?" And I'm like, men have all of it. I expect the same for women. And again, going back to gender equality, right? It's like, why would you think that we should have one type of testosterone for women? Don't think so narrowly, right? Only 20% of men have hypogonadism and they've got about 20 FDA-approved products.

[00:32:00] Dr. Melinda Ring: And you didn't mention one, which is pellets, so I'm curious what your feeling is.

[00:32:05] Dr. Kelly Casperson: Yeah, so men have FDA-approved pellets. A lot of people don't know this because it's just one of their many menu options, right? Men have FDA-approved pellets. Why do women not have FDA-approved pellets? A company hasn't gone to get FDA approval, so...

[00:32:23] Dr. Melinda Ring: Do you feel like they fit in there as a safe and preferred option? Because I always have concern with pellets, you know? These hormone pellets are put in—I see major spikes and then troughs. What I've seen in some women who have gone and gotten hormone pellets is, I mean, they feel awesome because their levels get really high.

[00:32:44] Dr. Kelly Casperson: They get a steroid high.

[00:32:45] Dr. Melinda Ring: They get a—yes. And then they crash, and it can't be removed easily. So for me it's always been a little bit like, yeah, you know, I'd rather have something that's a little more consistent, that's a little more reversible. Do you feel like there is a place for pellets for women?

[00:33:03] Dr. Kelly Casperson: Absolutely there's a place—men have a place. Are you going to take pellets away from men, right? But what have we created for women because of the failure of the FDA and the medical system to treat low testosterone or libido? Except pick a lane: sexual health or hormones. Because of the failure of the medical system to do that, women are pushed out to people who are going to help them. But when your only trick is a pellet, your only trick is a pellet. So here we are blaming pellet companies. It's like, no, no. Do not dismiss the fact that traditional healthcare has dismissed women completely and has not taken on any of this. They won't compound, they won't male-microdose, so women think their only option is a pellet. So pellets should be on your menu. I think you should earn a pellet. What does that mean? Start low, go slow with likely a daily dosing first. Get to the point where you're like, "I'm a person who needs and tolerates a higher testosterone, and I'd like this in a sustained-release product." Pellets are an option, but I don't think pellets should be your first option. They shouldn't be. Going from sea level to Mount Everest base camp shocks the system, right? And I think that's what a lot of people are doing with pellets. Does that mean pellets are inherently bad? No. We have FDA-approved pellets for men, right? But how they're used—as "my way or the highway" only... like, there are many people giving very mild pellet doses, but the super high shock to the system, you can't get it out. It ruins the reputation of testosterone for sure. You're like, that's high-dose testosterone—that is a legitimately different conversation than low-dose transdermal daily application. But it should be... it's like, your first car probably shouldn't be a Ferrari. You cannot handle that engine. Should we ban Ferraris? No. Some people like the Ferrari, but you shouldn't get.

[00:35:14] Dr. Melinda Ring: ...wasn't the first car they got when...

[00:35:16] Dr. Kelly Casperson: It was not the car they learned on, right? Yes. But I think, you know, we're so quick to blame the pellet people, and we're so slow to blame the traditional medical system for creating the need to have to go outside the medical system for healthcare.

[00:35:33] Dr. Melinda Ring: Some of these issues that we're talking about for GSM, or genitourinary syndrome of menopause, are so undertreated. Is it, do you think, women being hesitant to use it—maybe due to some of what you were talking about, not feeling comfortable with that part of their body—or do you think it's that doctors are not bringing up the conversation?

[00:35:56] Dr. Kelly Casperson: All of it. We need everybody on board. Hey, you know what? We need to be able to say "vulva" and "vagina" on Meta.

[00:36:03] Dr. Melinda Ring: Yeah.

[00:36:05] Dr. Kelly Casperson: Like all of it. All of it is a problem. Insurance—insurance making you fail a birth control pill in order to get your vaginal estrogen prescription, right? Insurance practicing medicine— that makes absolutely no sense. That's a problem, right? Like, it's all a problem, but slowly, I mean, how are advocates like you and me changing this? Two ways: bottom-up and top-down. So bottom-up is educating women—podcasts, books: What's actually happening in your body with menopause? Menopause means no periods. No periods is not the problem here, my friends, right? This is a profound low-hormone state. Women don't even know that. They don't even know that! Well, here you come waving your vaginal estrogen at them—they're 70, they haven't had a period in 15 years, and you're telling them it has to do with, you know, menopause. They don't know what that means. So, bottom-up education: how to advocate, how to ask for a doctor, how to ask for a prescription—that's ground-up. And then top-down: things like the Harvard Menopause and Women's Health course that we teach at. We've got to get clinicians to be able to serve and understand and not dismiss the women that we've now taught how to educate and advocate and get into the system. So the system changes two ways. Bottom up and top down. And I think we're doing both.

[00:37:34] Dr. Melinda Ring: Do you think that there's misconceptions on both sides about the safety of the vaginal preparations relative to systemic hormones?

[00:37:43] Dr. Kelly Casperson: I think...I think people don't understand that they're, again, different things under a big tent called hormones, right? But I think that the boxed warning coming off last November helped significantly. And this is what I say: It sure did not become safe on a Monday, but the world's awareness of its safety happened on a Monday.

[00:38:04] Dr. Melinda Ring: And do you think that the controlled status is going to come off testosterone, speaking of labels changing?

[00:38:10] Dr. Kelly Casperson: Ah. We hope so—there are a lot of people working on that. And for your listeners who don't know what we're talking about, testosterone is a DEA-regulated medication like narcotics, like ketamine, like ADHD medications. And the reason that a hormone your body naturally makes is on a DEA restricted list is because of the anti-doping scandals and legislation of 1991. Because if anybody remembers the East German swimmers, they were taking some substances. But testosterone is not unsafe at normal physiologic levels, and having the DEA... I just renewed my DEA license just for Washington State—it's $880, right? Like, it is a legitimate stigma and cost to the system. The problem with undoing it: You can't just decide to undo it on a Tuesday, because this was actually a congressional law that was passed, so you can't just not do what Congress made a law against. So the undoing of that is what they're working on now.

[00:39:18] Dr. Melinda Ring: Alright. Another thing, hopefully that's gonna happen maybe on a Wednesday.

[00:39:22] Dr. Kelly Casperson: Yeah, exactly. And again, it'll be the same story, right? Testosterone didn't become safe on a Wednesday, but the awareness of the deregulation of it did.

[00:39:30] Dr. Melinda Ring: I'm going to switch gears. So you have popularized this distinction between spontaneous and responsive sexual desire, and I think that can be really liberating for women who assume that something is wrong with them or that they're broken because they don't experience desire the way that they want to. And as a woman in midlife, I'd love to hear you explain the distinction and really, how should women be thinking about intimacy in midlife?

[00:40:04] Dr. Kelly Casperson: In order to learn new things, you first must unlearn old things. We got crappy sex ed, and we filled that in with Hollywood, with advertising, with your first stupid boyfriend, right? Your sex ed is crappy. And so you must first understand that, because otherwise you're like, "Why are you telling me something different than what Charlize Theron is doing with Tom Cruise in a Hollywood movie?" Right? So you have to kind of realize that you have to undo the bad education that you got. Then you're like, okay, well, knowing that... because I'm like, why are you pissed you don't have spontaneous desire? That is not how brains work, right? But you're like, "Well, I'm pissed because Hollywood has spontaneous desire, and that's what I watch." I listen to country music and it's all spontaneous desire. You're like, yeah, yeah, yeah. It sells. It's sexy. That's not how brains work. So your brain is habituated to things not being novel after about a year in a relationship. Okay. All right. Now, you know, now you know that. And I think the other thing that people think about desire is that, number one, the stereotype that which we should all just spontaneously want sex all the time, which good God, could you imagine? But then number two is that they feel entitled to this, like, "I'm entitled to sexy biceps and a high-fiber diet" without actually putting in the work to have fiber in my diet and go to the gym and lift weights. That's not how it works. You have to put these things in your life if you want them. The other stereotype about desire is women think they should desire things that aren't worth desiring. That's not how dopamine works—that's not how the dopamine pathway works. You can't make me like hitting my thumb with a hammer, right? If you have pain with sex, you will never desire it. And many, many, many women have pain with sex, and they think they have two problems: They have pain with sex and low desire. No, you have one problem: You have pain with sex. You will never desire that, right? So it's really undoing the layers of... if you are engaged in a sexual relationship where you only have an orgasm 20% of the time and your partner has an orgasm 95% of the time, you will desire that event less than your partner. That is a no-brainer. You should not be surprised by that. It is a less rewarding experience for you. Do not feel entitled to desire a less rewarding experience than your partner has, and that is what I'm speaking of. There is the heterosexual orgasm gap, where in best-case scenarios, women in a heterosexual relationship will orgasm 60% of the time to the man's 90% to 95% of the time. So again, this is all sex ed that you didn't get, but do not feel entitled to this made-up spontaneous desire that does not exist in the world that you live in.

[00:42:54] Dr. Melinda Ring: It takes work, like everything else, yeah.

[00:42:56] Dr. Kelly Casperson: Yeah, exactly. When you compare it to weights and fiber, I do not sit around spontaneously desiring vegetables. I just do not. But I enjoy eating them when I'm doing it, and I want them in my life, so I prioritize them. You can have an amazing sex life without sitting around on a random Tuesday desiring sex. But the more you understand sex, the more you're like, "Oh yeah, that all makes sense." But because you got such a bad sex education, you think you're entitled to sit in your Lazy Boy on a Tuesday and just have the winds of desire blow across your cheek. Like, that's

[00:43:34] Dr. Melinda Ring: Your partner walks by you and you're like, "Ah..."

[00:43:37] Dr. Kelly Casperson: That's not how it works.

[00:43:38] Dr. Melinda Ring: Yeah.

[00:43:39] Dr. Kelly Casperson: But that's fake.

[00:43:40] Dr. Melinda Ring: I'll ask one last question for you: What is a piece of advice for a woman listening who maybe feels like she's lost some connection to her body, or she's been told her symptoms are just something she has to live with? What's one step she can take to feel more informed, empowered, and return to that next level of health?

[00:44:04] Dr. Kelly Casperson: Well, I think it's... you know, this is a positive framed as a negative, but nobody's coming to save you. Nobody knows you better than you. Don't give away your power.

[00:44:15] Dr. Melinda Ring: Well, Kelly, thanks so much for joining me. I so appreciate the work you're doing to bring this attention to women's health and really challenge some of the assumptions that have shaped menopause care and sexual healthcare for so long. So for listeners, I hope today's conversation leaves you with a better understanding of the many dimensions of menopause. Thank you again so much, Kelly.

[00:44:39] Dr. Kelly Casperson: Thank you.

[00:44:39] Dr. Melinda Ring: For listeners, I hope today's conversation leaves you with a better understanding of the many dimensions of menopause, and a reminder that you deserve care and you need to advocate for your own care in a way that considers your whole health, not just your hormone levels, not just one symptom. To learn more about Dr. Casperson, explore her books, The Menopause Moment and You Are Not Broken, and her podcast, You Are Not Broken, as well. Thank you for tuning in to Next Level Health, and until next time, I'm Dr. Melinda Ring. Thank you for joining me on this episode of Next Level Health. I hope you found some inspiration and practical insights to enhance your wellness journey. Don't forget to leave a comment on YouTube or a review on Apple Podcasts. I'd love to hear your thoughts and suggestions for future topics or speakers. Be sure to follow Next Level Health with me, Dr. Melinda Ring, as we continue exploring the path to healthier, happier lives together.