Pain, Dryness, and UTIs: The Truth About Menopause and Vaginal Health

Introduction to Menopausal Genitourinary Symptoms 0:00

These women get literally vaginal symptoms way before they enter perimenopause. Early 40s, literally. That's how early this can happen. Interesting. And they're usually really dismissed because again, these women are often even still cycling, but they start to get these symptoms really early. So having said this, regardless when they show up, I definitely encourage everyone to bring that up with their gynecologist, and regardless how young you are, how old you, no one has the right to tell you you shouldn't be able to use your vagina comfortably.

apart from the urinary tract infections. Have you made it past menopause or are you going through it now? I'm Dr. Pat McShane and on the Women's Health Span Voices podcast, I'll guide you through the menoppausal transition and beyond. helping you to thrive in this powerful time of your womanhood. Hello and welcome. I'm Dr. Pat McShane and this is Women's Health Span Voices. i'm delighted to have a wonderful voice with us today, Dr Christina Entzman, and she is a gynecologist and trained in functional medicine with an emphasis on nutritional endocrinology as well.

She has specialized her practice in menopausal issues. And today we're going to be talking about the genital urinary symptoms of menipause, which is a pretty big topic that impacts so many of us. So Dr. Christina, wonderful to have you with us today. Thank you. Yeah, thanks for having me. I'm very excited talking. Dr. Christina, besides her other activities, has a book coming out that is already published in the German literature where she is originally from, but it will be coming in English literature, and it's called Somebody Told Me, it is about menopausal issues, I presume.

Is that correct, Christina? Yes, heavy focus on nutrition and really how to eat your way out of most of your symptoms. Okay, wonderful. Well, a lot of our audience may not be familiar with the term genital symptoms of menopause. It's kind of a specialty name anyway, but probably many of listeners and audience have actually experienced some of these symptoms, and they include things like vaginal dryness, frequent urinary tract infections, urinarian continence, and so on. And that's a pretty broad umbrella.

Maybe you could start off by telling us a little bit about the difference between just vaginal dryness and some of the more specific genital symptoms of menopause.

What GSM Means and Why Vaginal Estrogen Matters 2:51

Yeah, absolutely. So I think it's important to understand the evolution of that term. We really used to call it just vaginal atrophy, right? And it basically said, well, the woman has a dry vagina and pain with sex. And you know, it was a little marginized problem, not really well addressed by most physicians because as well this woman basically can't have sex and she's in midlife. Unfortunately the general consensus was this might not be too important. Although treatment for impotence in males is very advanced.

We know all of that. But then basically, the menopause society and really the women's advocate, they were like, hey, This is that estrogen in the vagina is not just causing, you know, painful sex and drier vaginal tissues. It's actually affecting also the part of the bladder. So, and then, with the extension of this term, the genitourinary symptom of menopause, it was also a move to make this not-just focused on sex and make this less dismissible. But say this is actually something, this a condition that has real value.

Of course sex has values too, but you know, I'm just telling you how life is out there. So this basically said this was something that needs to be publicly addressed. And the urinary symptoms are the Urinary Frequency Urgency or Recurrent Urine Tract Infections. And all of this can be addressed with vaginal estrogen. For example, there are other treatments, but it's also important to know, I always like to tell people, it is not that everyone is going to get that. And this is, you know really my clinical experience.

very mature women and might look in the vagina and, you know, the mucosa, so the skin in vagina does look very pale and doesn't have so much moisture. However, not everyone reports really problems with sex. also the ones who have sex. So it's a multifactorial thing. And I want to just tell people not everyone is going to have these issues. It has to do with estrogen, but also how stretchy is the vagina? How often do you use it? Maybe there are factors that have to how do women metabolize estrogen on the tissue level in the vagina?

So many things feeding in that And historically, going back to your discussion about how did we get here where we are currently, the Women's Health Initiative and the whole idea that estrogen replacement was dangerous for people, hormone replacement, not just estrogen, kind of muddied the waters for many years, and there's been with the new FDA labeling a new focus on women actually benefiting from using hormone replacement therapy. So that's been part of this whole story as well. And if you wish to comment, please jump in.

Yeah, I'm glad that you mentioned that because this was actually from early on a big confusion. So the topical estrogens we call them, so the ones you put in the vagina has never been systemic hormone therapy. This has nothing to do, but it's not systemic home on therapy that we give for hot flashes or osteoporosis prevention. It's really only local estrogen that helps that vaginal skin to plump up. It doesn't create no blood hormone level. So studies have been done. Actually, the vaginal estrogens, even after the Women's Health Initiative study, were actually never part of that scare of the risk equation.

So, but even many gynecologists didn't understand that sometimes I was reading other notes and they were basically counseling patients about the risk of blood clots if they give vaginal estrogen. So this was always nonsense. Sometimes these products overlap so people, you know, it's often difficult to understand, but no, vaginal estrogens have always been, that's not going to help your hot flashes. It helps your vagina. What was confusing is FDA labeling. since they were still hormones, even they weren't absorbed, they still came with the same FDA labeling.

So indeed, the vaginal cream would say increased risk of breast cancer, blood clots, et cetera. This took a lot of talking of us gynecologists to convince patients who really needed that, that this is still safe in their condition, so whatever it was. The vagal estrogens really always say can be taken until the end of our days, no problem. And one additional feature here is that while the typical symptoms of the menopause transition, hot flashes is number one,

Early Symptoms, Misdiagnosis, and Treatment Approaches 7:51

sleep disturbances, mood changes, and so on, tend to get better. Often it takes many, many years, but they do typically improve. The vaginal and genital urinary symptoms tend get worse with our aging not better, so that's something to tell us about when you might consider initiating therapy even in someone in their 60s, 70s or 80s if clinically relevant. Yeah. First, I always want to initiate therapy whenever they have symptoms, but it's correct. So traditionally we think, you know, that genitourinary symptom of menopause is more a syndrome of the late post-menopausal because when really these tissues haven't been exposed to estrogen for a long while.

This is traditional teaching. And here I want to add something out of my clinical experience, because interestingly in my practice, the genitourinary syndromes can often be one of the earlier signs. I see it as early as in the early 40s. So suddenly a woman gets urinary tract infection, never had that before. And it's really, I even see these symptoms before I can even can see on the vaginal tissue. Also women who, let's say, who had C-section for their children or haven't had children born vaginally, basically nothing stretched the vagina ever.

These women get literally vaginal symptoms way before they enter perimenopause. Early 40s, literally, that's how early this can happen. And they're usually really dismissed because again, these women are often even still cycling, but they start to get these symptoms really early. So having said this, regardless when they show up, I definitely encourage everyone to bring that up with their gynecologist, and regardless how young you are, how old you, no one has the right to tell you you shouldn't be able to use your vagina comfortably.

apart from the urinary tract infections. So I start vaginal estrogen really right away and there is the vagin estrogen. It comes in a cream, it comes and tablets. it Comes in little suppositories. Insurance usually pays for the nice cheap vagina tablet, which I really have nothing against because the good thing really is it has no other ingredients that can really bother the vagina. So while it's a tiny tablet that has to be inserted, I really like that and insurances pay for it. And then there are more sophisticated formulations, more capsules that, again, everyone can choose what they like.

Then there's vaginal testosterone or type of testosterone that has additionally the benefit even also actually barely absorbed. Studies have shown it adds a little bit to some sexual function parameters. So why not? For the younger woman, there is one thing I really want to mention. Sometimes women when they started very early on on birth control pills, let's say they were started at age 16 because they had dysmenorrhea, pain with cycles. We always think we give birth-control pills and there is an extra hormone level, but what's really happening instead of the woman having her own high hormones up and down, that hormone levels stabilize on a very low level.

And indeed, vaginal tissue suffer from that. So these women often present in their mid-twenties and they have, guess what? They have pain with intercourse and, you know, they get all kinds of diagnoses when really the one thing that they should do first thing is stop the birth control pill, if possible. And usually after three to six months, that vaginotissue just recovers. That's something I wanted to mention here because that is really a very common thing. That's very interesting. I haven't heard that before or experienced it clinically, but my practice was not in general gynecology.

So why do you think women are so often either dismissed or misdiagnosed with these symptoms, which is what I've been reading about on the social media especially? Well, you know, I think not many physicians really have interest in that. And I don't know why. I thinks sometimes we just want, a woman get in and out of, it has to do with our healthcare structure and how it's paid and physicians just, and we don' have much time, which is terrible. So if someone has more complex symptoms like, you know, pain with intercourse, and now we have to figure out what is it, right?

Because there are other reasons why that woman might have pain within their course. You know it can be, yes, it could be vaginal atrophy. It can pelvic floor disorders. it Can be vestal lipidemia, other inflammation, inflammatory skin conditions. There's just so many things and it's complex. So that is not something, where you can, if we can't just prescribe something quickly and get, patient out of the door, it gets complicated, right? And then these patients tend to come back. And often, you know, the first line solution is, doesn't even work.

It needs a little detective work, and I think that is often so complex. Many women still get just this cookie cutter solution. Often they get prescribed, actually, estrogen these days. vaginal estrogen, but then it's not enough. They get like, because again, even physicians are still scared because they don't know this stuff is really not absorbed. Then they get told, hey, take a pee full of estrogen cream, apply to your vulva like twice a week. That's of course not gonna be enough to really get that tissue estrogenized so she can have comfortable intercourse again.

So that's the one thing I find, it's just not given it. Usually I say, hey, three weeks every night to really up estrogen like that tissue, and then you can taper down. So I think this is just, you know, complex. It's a woman issue. You cannot just say okay, great, here, take this. except if it's a yeast infection or bacterial vaginosis. We always like to overdiagnose that because that's an easy thing. For a physician, they can just prescribe another course of antibiotics and they think they have done something good, but often they actually didn't because things get worse.

Now, on top of the vaginal atrophy, we get chemical sensitivities and, you know, the mucosa really gets irritated. So yes, so then we add really one problem to the next and suddenly this patient has a very complex condition, which before probably wasn't even so complex, if it would have been diagnosed correctly, what it actually is. Yeah, many of us with regard to hormone replacement therapy are following the start low, go slow protocol. And that's the opposite of what you just described for women with genital urinary symptoms and who are in need to get their atrophy.

topped up again, so. And the other thing that's going on, I think, why women may be misdiagnosed or dismissed, is that most of us are fired by our gynecologist at some point, and it's like, okay, no more reproduction, No more cycles, you don't need birth control anymore, You're not going to have any more babies. So adios, amiga, that was my experience. She was very nice about it, but that is what happened. And then we land in our primary care or internal medicine office with our other list of things.

Maybe our blood pressure is a little high, maybe our glucose is little, you know, et cetera, and the vaginal symptoms fall to the bottom of the list. And I think it's very easy to be dismissed or just even forget about it by the time you've talked about all those other symptoms and issues that you might have. So. And that is so rude, right? You know, sometimes I'm even wondering if just often physicians are not comfortable talking about it. So this is why, you know they just don't want to talk about vagina and sex.

They're themselves uncomfortable with it, but that doesn't help that, that you, know. No, it doesn´t help. You know, you shouldn't get fired by a gynecologist. You really still should have, perhaps it really stops at age 65 if there are no other risk factors. But I always tell my patients, don't forget, every two years you still have a pelvic exam. And mostly it's really, for me, the most important part is having a look at the vaginal tissue, address problems with urinary frequency, urgency. People pee on themselves, they don' want to get out of the house anymore, and they do not know that there is help for that.

estrogen doesn't fix all of this. However, this is like a point of contact with your gynecologist to see maybe you need a referral to a urogynechologist when things get more complex with

Finding Menopause-Savvy Care and Certified Specialists 17:00

pelvic organ prolapse, any of these things. So first of that, and then I think the most important thing is to inspect the vulva. right? The outer genitalia. So this is where, you know, we can get contact dermatitis, the vulva itches, women just start buying stuff over the counter. Then they get, again, even more contact allergies. And sometimes there are, vulvas, skin, cancerous preconditions, everything easy to detect and to treat, but someone needs to have a look. And if the primary care physician just says, oh yeah, this itches here, take this cortisone cream, then I see these patients back like five years later, chronically cortison use, and then they have like a vulva cancer.

And it's like, well, why didn't no one have a look at that? So that's what I've seen in my practice. This is what would like to tell people. If you go every three years, that is fine. But don't just abandon that area because you think one physician indicated they're not interested in that anymore. So let someone have a look, please. And tell us a little bit about the menopause certification that you have. If a woman is unhappy with either the gynecologist kind of ignoring her symptoms or saying goodbye to her, or her internal medicine doc just doesn't want to go there, how would she go about finding someone who's really interested and adept at menoppause care?

Yeah, so there is actually so, you know, there's so much stuff on social media and I'm glad that you're asking this question because, all these influencers, they have all kinds of motivations and, not everyone really understands the real guidelines. If you really want to know. What is real, there's a website, it's called menopause.org. And that's really the website from the, used to be called North American Menopausal Society. Now they're just called Menopus Society because they really taking on the entire world if you want.

So they are like, we are going to educate the women. It's not, you know, some of the German guidelines in Germany, they all like more for physician caters. this website is really meant to educate physician and to education the patient. So you really know what is the current data, what are the guidelines, and they are super women friendly. Menopause societies, these were really the ones that right after the women's health literature study came out, they were immediately raising the flag and saying, you did something wrong with this data.

This is not right. Just so you know, it just took them a long time until they started to be heard. So yes. And then that website has a list of all physicians who are actually certified. That's a certification. So you, you know, to go basically train with them and then you get a certificate as a menopause certified... And pass a test, right? There's the test. Yes. Back to testing, even in your 40s, 50s and 60s. You thought you were done with all those times. This is not a one time and done. I think every two years or so you have to do that again.

Great. Let's switch gears and talk about the vaginal microbiome, which again is starting to get a little bit of interest in the medical literature and I'm sure in social media as well. And of what importance would you say that is in menopausal years?

Vaginal Microbiome, Hygiene, and Irritation 20:30

super important because, you know, as the vagina still has all this estrogen, then that vaginal tissue, we call it mucosa, is plump and it's moist. It's like this has, all these folds and its pink and lovely, right? And it can stretch either because of the penis or for the baby, who knows? It is ready and protective, it is this interface between outside and inside. So it, very well, calibrated to kind of keep the bad things out and keep you know, and stay as a protective barrier. And you, know of course and help to conceive the baby and all of that.

So that is the vagina under estrogen. Now when that estrogen falls away, that tissue just becomes very thin and there's less moisture so it gets easier irritated. And so there's like this vicious cycle that I see a lot that, you know, women get older and maybe there are some urinary issues. Their tasks, they continue to rub and scrub this area. And that really causes so many problems that often these are really self-made problems. The vagina basically and the vulva is so much more easily irritated.

So the microbiome is not as stable as it's before to defend itself. So if we are now coming with bar soaps and whatever we buy over the counter that from Procter & Gamble and Johnson & Johnson that has all these colorful and mix, I think the vulva and vagina has to smell like flowers. And so we start now to apply all of these things. And this is when I see in my practice then really tremendous contact dermatitis and yeast infections. So these products now break down the skin to skin adhesion barrier faster.

There is yeast infection or what's called the bacterial vaginosis. Even there is a change in a microbiome as we get older. So, as the estrogen goes away, which usually feeds the lactobacillus in the vagina, right? And it makes this environment nice and acidic. So with the estrogens moving out slowly, these lacto-bacilla also move out. The vagina of the more mature woman doesn't have that many lactopacillas, if at all, anymore. It becomes a different microbiome. Similar what happens to the gut, by the way.

Many people have heard this at this point, that the estrobolome, the gut microbiome changes as we get through perian postmenopause. And you can actually see that's happening very similar in the vagina. So the pH raises naturally, it has just to do with the different bacteria. That's why also in my opinion, like the BV in post menopausal is tremendously overdiagnosed because we measure pH and then we say it's Bv. And I'm like, well, no, this is not BV. This is just an atrophic vagina. If you give this vagina some estrogen, that Bv is actually also gone away.

So I think there's just many people who don't think that really properly through what's happening through that vagina in transition. Microbiome changes. It's not bad. it's a different microbiome, but the vagina becomes much more sensitive. soap scum from bath soaps. And then there is, you know, the dove and the dials. Women love it. However, that the problem really is that that lotion effect, right? Like it's actually stripping the natural oils off the skin and puts this soap, scums or this, basically artificial mineral fatty acids back on the skincare.

That feeds the wrong bacteria. And really, like, it's this BV, particularly also in younger women, we are going to be unable to get ever rid of that as long as that woman engages in this two to three times a day shower ritual with her wash rack and works up this big lather and it is not going go away. And even, you know, then they come back, no, I'm not using it on the wool bar anymore, just anywhere else. I am like it not gonna help. because this is the continuum of our skin. But yes, so there are so many things that really are important for maintenance, but maintenance meaning less is much more.

So really just leave the vagina and the vulva in peace, get an organic shower gel, just apply gently to your hands, apply it outside to the volva, let it be. I have cured so may women just by telling them that. It's not even funny, it's terrible, really. Yeah, so what I'm hearing you say is that we shouldn't be putting anything in our vagina except estrogen replacement, essentially. Once we are in at least perimenopause, if not full menopaus, and anything with vaginal washing or even vulvar washing is to be avoided or to as gentle as possible with the vulva.

Okay, that all makes perfect sense. Yes, and also wipes, right? This was like the other one. I have not found one wipe, even from some companies I really like, the wipes this moist wipes is really unnecessary, literally. Everything they put in there is always going to sit on the skin, on this very delicate vulva skin and it's going be absorbed. Perfectly unnecessary. Just don't do it, please. Okay. Thank you. Anything else that we should be mentioning that haven't covered yet? We've covered a lot of ground here today.

Well, you know, I would say, pain with intercourse as we get older. Again, we are focusing on this Gagnito-urinary syndrome of menopause, of vaginal atrophy, but there can be many other things underlying. So one I want to mention is pelvic floor dysfunction, meaning the muscles in the pelvic area being too tight. And, this could be, It's fascinating. It can be caused by just musculoskeletal misalignment. it could be birth injuries. And again, when we're younger, that tissue is still stretchier and we can kind of balance that out.

Pelvic Floor Dysfunction and When to Reassess 26:30

But as we get older, it's not happening so well anymore. So many women had pain a little bit for a long time and then there really comes this reflex cycle that these pelvic floor muscles become very tight. And often it's both. It's vaginal atrophy together with pelvic dysfunction. So there is a specialist for that out there. The pelvic-floor physical therapist. These are real miracle workers, if you ask me. I don't even know how they do it. They have the finger in the vagina, they can figure out all these muscles and then they show them just, you know, to me, unrelated exercise that have nothing to do with the vagina and that really helps.

So again, don´t give up on your vagina and your pelvic floor. This can really, it's fantastic what can be done without surgery, with nothing. It just needs a little bit commitment on you side and give that, really a chance. This is what I see a lot, so don't forget about that. And sometimes women, you know, if they're being treated repeatedly, like for BV or vaginal treatments, again, for things that are probably not even there or have an underlying issue, really, then they get this... post-treatment vaginal inflammation.

Like literally, that's what it is. And they come then and they're like, I still have this, you know, was treated with Monistat and I, but it's still, it still there. It's, and look, there's no more yeast. Just this vaginomucosa is so angry at that point. And then again, you know, and it takes a moment, but then, we always are inclined to go to another doctor and put more and more on it. And that's often the moment when you just have to take a deep breath and really back up and find someone who doesn't just want to prescribe you something new, But really try to figure out what is actually going on, really waiting for cultures to come back.

and really trying to make sense out of it. Speaking of testing about cultures, is there any testing for hormone levels that's useful in this population where we're treating just the genital urinary symptoms, not hot flashes or anything else? No, it's not because again, we are not trying to, you know, to fix hormone levels. We are just trying give the vaginal tissue that estrogen back, but I think- Just to make it that clear. Yep. Yes. But I'm glad you're mentioning this because, so if someone is on systemic hormone, menopausal hormone therapy, right, patch, tablet, This often, depending on the dose they get, that will at some point also benefit the vagina.

However, these days often we have, it depends how high this dose of systemic hormones is and when it's going to actually reach the vagina. So many women, when I have them on a lower or medium dose systemic hormone, I still give them additionally some vaginal estrogen. On the other hand, if there are women who have such an aggravated vagina, like it doesn't tolerate nothing in the vagina anymore, that's when I'm sometimes giving systemic hormones to help the vaginas. This is actually an FDA approved indication for systemic hormone.

It's actually the genitourinary syndrome of menopause. However, If this is the only symptom, then the recommendation is to use the virginal estrogens, which come with again, minimal to no risks. And we can take them forever. So this is for clarification. That's good to clarify that. Thank you. I want to put in a plug for my video series where we have recently interviewed Dr. Nanette Santoro about systemic hormone replacement therapy, menopausal hormone, replacement, therapy in the context of the new FDA guidelines.

And also a little bit of an older episode that I did with a gynecologist and a pelvic physical therapist, exactly as you mentioned,

Hormone Testing, Systemic Therapy, and Closing Thoughts 30:30

pelvic floor dysfunction and how the approach to treatment is very, very different, but important and very often highly successful. So I would refer my listeners and viewers over to those videos as well if they want more information on all of that. Well, this has just been plethora of fabulous information with a lot of clinical experience behind it. I really appreciate that. Things beyond what you can read in the journals or on the textbooks. Does anybody read textbooks anymore? Probably not, but online or what do you see on social media postings?

Definitely. So I, really, appreciate this great information and thank you for your willingness to share it with us, Dr. Christina. Absolutely. I thank you so much. This is always my pleasure. And you know, there's one exception about the books. You know like the photo atlases about dermatology conditions? I still love to look at these because if you do this online, you never know if your really looking at the thing you're actually trying to find because they send you pictures of all kinds of things.

So yes, I have a great collection of great photoatlase about skin conditions. Good to hear that. Thank you. And for our audience, if this is the kind of information that you value, thank you for being with us. And please like us and tell your friends. That's how we reach more people. Thanks and take care and be well, everybody. Bye-bye. If this episode spoke to you, please share it with a friend ready to take charge of her health. and please leave a review. It helps more to find us