The Genitourinary Syndrome of Menopause: Care and Prevention

Podcast Intro and Guest Introduction 0:00

always thought this vaginal dryness and pain with intercourse is something we see as the women are longer in postmenopause. But it's really not true clinically. It's some of the earliest signs to start to get urinary tract infections. And they don't even have that pain-with-intercourse yet, but this is often for me the early sign. Out of blue, they get Urinary Tract Infections where they didn't use to have them. You're listening to the Lifestyle Medicine podcast with Dr. Ivan Rusilko, brought to you by Access Lab, where we explore new perspectives at the forefront of personalized healthcare.

Welcome back to the Lifestyle Medicine Podcast. I'm Dr. Ivan Rosilke, your host, and we're powered by Access Labs. If your doctor's not checking your labs, they're not a doctor. And today, do I have a treat for you. We have Dr Christina Ensman, who is fabulous. She's coming to us from Germany. she's awesome. we are talking about GSM, something that's super, super unique. i'll let her get into it. Uh, she does have book coming out called, Nobody Told Me. It's about nutrition during perimenopause.

So I am super excited to hear about that as well. uh, so Dr Kristina, thank you so much for coming by today. Well, thanks, Ivan. I'm very excited too. Thanks for letting me talk about the vagina. This is going to be fun. Definitely. So, I am very curious. What kind of got you started on the whole GSM angle? And again, that's genitourinary syndrome and menopause, correct? Just want to make sure I get it right. That is correct. Genitourinary syndrome of menopause. Yes. So, you know, I was a young gynecologist.

I'm originally from Germany, as everyone can hear. In the U.S. since 20 years, however, but that just doesn't go away. As we all, actually I know the story when I was really, you know, I started out and I realized everyone, trips over this very strong accent. I asked my boss, and was like, should I take a class to get rid of this accent? And he looked at me and he was, like why would you want that? I made peace with it. Well, he wasn't a New England guy. He felt this was a bonus, that accent, so he.

My goodness. So anyhow, so I was a young gynecologist, you know, trained in the U.S., first in Germany, then I, family reasons ended up in U S.

What GSM Is and Why It Matters 2:12

And as many of us gynaecologists, we don't really learn much about, not about menopause, and we learn about the vaginal conditions in depth. We know about okay, this is yeast and this VV and be treated every time with antibiotics. However, I actually have in Germany, a PhD on my doctoral thesis was actually in dermatology. So I was really used to looking at skin very closely, like I would love to just take out my microscope and look at it. And so I, you know, skin and the microbials, it took this very, very serious.

This was my natural inclination. actually that doctoral thesis was, it was dermatology, but actually the microbiome. So here's how everything really started, right? So it wasn't about bacteria, about skin, how important that is. When these patients came early on with first these dysbacteriosis, so infections of the vagina, not STDs, vaccine symptoms no one could treat, and pain with intercourse, many of my midlife women. This was immediately, I was like, there needs to be a better answer than we give you more antibiotics or sex has to painful.

So both of these were just not good answers for me and that's how it started. Okay. Very, very unique. And again, so is this a very prevalent issue when it comes to women of this age or is it something that you've seen on the uprise over the past 10 years? No. So this genitourinary syndrome of menopause, we used to call it vaginal atrophy, right? So it was a typical disease. Let's think about diagnosis codes from the postmenopausal women. Usually it's still in the textbooks that it is something that happens later on in post-menopus like several years in.

And it basically happens because vaginal tissue thrives on estrogen, has estrogen receptors. And as you know, the tissue gets longer and longer not exposed to estrogen. As we are longer in postmenopause, many women get symptoms, you which are associated with vagina dryness, then the vagina, however, also gets I mean, you know, usually it has this big folds, this you see these pinkish moist folds so the vagina can stretch. When the penis goes in, it can't stretch for the baby. That's how it's made.

But it becomes like more a stiff tube under estrogen, under estrogens lack. And that's when women become, many of them. Not all, and we get to that, but many, you know, get like this pain with intercourse or, so again, initially we called it vaginal atrophy, just saying, well, this is just problem with sex. But then we realized, oh no. And then it came this new name because we realize, part of the bladder actually also have estrogen receptors. So the same syndrome is actually when the women now start to have urinary frequency, urinery urgency, or a stress incontinence.

So we have to pee, you have two pee. This is part of that estrogen lack and can be treated with the intervention. That's when this new name came, genitourinary syndrome on menopause. To make clear, no, this is not just a sex problem because that's what many general physicians just don't feel this was worthwhile intervening. But no it's actually genito-urinary. problem, and I like that. Okay. Very, very unique. Now, so when it comes to, obviously hormones play a gigantic role. Estrogen, I'm guessing, being probably one of the most important ones there.

When it come to like, let's say a woman comes in, you know, obvious symptoms of it, are you testing for things like estradiol, estriol esterone, all the different types of estrogens, as well as progesterones, testosterone, free in total and things that? Are you just focusing specifically on estrdiol? The big one. No. So it depends what the woman comes in for. If she, if you're talking, you know, in terms of genital urination, the menopause if she's like six years into postmenopausal and doesn't want to be on hormones and systemic hormones, I don't need to check a hormone level.

Hormone Testing and Vaginal Estrogen Treatment 6:12

I know they're going to below and I'm not pushing hormones systemic, hormones on anyone. However, this lady in that case, I would give her vaginal estrogen and we can talk about that later, which is not systemic estrogen. It's just local giving estrogen, however, women in perimenopause with all kinds of symptoms, yes. I do depending progesterone to be honest, don't test a lot in my permenopausal woman because it's not, you know, whenever you test it, it is going to, be wherever, but I, and it you, know it doesn't matter if she's 45 I know she is in, peri-menopus.

estradiol, testosterone, sex hormone binding, clobolin, DHEA. So this is when I do regular labs, it's in an insurance-based frame. If we talk about someone really wants functional medicine services and we really want to dig deep, we want know how do people metabolize their estrogens, I like to do, you know. tests, so dried urine tests of comprehensive hormones based on urine metabolites. And then we look at all these things. Then I want to know how do we metabolize these estrogens so I can give a patient a risk assessment or explain how simple.

Okay, it makes total sense. When it comes to the actual estrogen itself, or I should say the difference between estriol, estrone and estradiol. when you're saying it's more of a systemic versus a localized one, are you using estrdiol or estrriole once you start to treat somebody vaginal? So for treating someone vaginally, I really do not need no estrogen levels. So that's what I'm trying to say. Because again, these people are going to be in periopostmenopause and I do check hormone levels if we are talking about hormone replacement therapy.

If someone has hot flashes, then of course I want to check these levels, But for treating the vaginal symptoms, that's when I look at the vagina and I can tell this is a vagina that lacks estrogen. And then, you know, we don't want to make care more complicated. Particularly in that for the genitourinary syndrome of menopause, I keep it simple. This is also mostly my insurance-based practice. So I don' t overcomplicate things. Estrogen levels don t help me because I'm not trying to get the estrogen level anywhere.

I m trying get as much estrogen or DHEA that vaginal mucosa and it's barely absorbed, there are some formulations for the vagina that act like systemic hormones. So, you know, we have to be careful. There are different preparations out there, like the fem ring, just saying it is a ring that goes in the vagina that helps the version atrophy, but it has enough hormones to actually help with vasomotor symptoms and we can actually measure the estrogen levels in blood. These are always two things that really have to be very carefully distinguished and causes lots of confusion.

Also, in my colleagues, I literally sometimes have my gynecologist colleagues like, no, this is not a systemic hormone. This is just vaginal estrogen. And that woman can take that, really, until the end of her days. Makes total sense. When it comes to environmental factors like UTIs and things like that changes in pH balance, does that accelerate the process of vaginotrophy much faster? And if so, how do you kind of treat that with patients? Okay. So here's what I see, what are really contributing factors.

And I want to distinguish between the premenopausal women and the older women. As I said, traditionally, we always thought this vaginal dryness and pain with intercourse is something we see as the women are longer in postmenopus, but it's really not true clinically. It's really some of the earliest signs, particularly suddenly women in their early 40s or mid 40's start to get urinary tract infections. And they don't even have that pain with intercourse yet, but this is often for me the early sign.

Out of blue, they get Urinary Tract Infections where they didn't use to them. and then women who never had their vagina stretched. And I just have it to say this way. So basically they never have born a baby vaginally, either because they have no children or they had C-sections. These women actually feel that effect of the vaginal tightness much earlier than other women. Women who had vagin babies, we kind of feel this tight-ness effect a little later, but the women had the C section or no-children, this is also often interestingly the first sign.

even before they get hot flashes, they often suddenly have pain with intercourse. So this is something what I want to clarify. And then they tell, oh, no, you're fine. Often they read and they bring it up to their doctor and the doctor dismisses them because they're too young. That is actually not true. This can indeed be an early sign. What is, I also would like to tell our listeners because many people don't know that. And now I'm talking about the young women. If you have been a long time on oral contraceptive pills, and I have nothing against that, you know, they have their place in medicine.

However, many women are started very early because they've painful cycles or endometriosis, whatever the reason is. In my observation, when these women started early, let's say around 14 to 16 years old, often once they reach in their mid 20s,

Early Symptoms, UTIs, and Oral Contraceptives 11:30

they literally start to get pain with intercourse and no one can figure it out. And what it is, it's genitourinary syndrome of not menopause, but estrogen deficiency. People throw all kinds of things at these women and they get all kind of treatments. While the only treatment would be just stop that birth control pill, at least for a while to prove the concept because that tissue estrogenizes really fast again and they're going to feel better. So this is what I really want everyone to know. The other thing that is really important, so, you know, apart from yes, we can give estrogen and that that's really going help that vaginal discomfort, the tissue is going up estrogenize again.

And many women now say, well, I have got an estrogen for my doctor. I didn't do a thing. This is really because usually they don't get enough. So often they're told, you know, take a pea-full amount and just put it a little bit outside. That's not going to do nothing if you have severe vaginal atrophy or severe syndromes. You really need to use whatever they give you. Usually it's cream or a tablet. I usually say three weeks every night. that is really to up estrogenize these tissues. And then, you know, then you can taper down to two to three times a week and then see how much that individual woman is going to need.

Some things are cellular genetics. You know, you mentioned earlier, estradiol, estriol and estrone on the DHEA on vaginal tissue levels. No one has examined that, but I do know and trust this is also important to know. Not every woman gets skinny to urinary syndrome of menopause or pain with intercourse. You know, because we always say, oh, everyone gets it. It's not true. And I've seen plenty of very, you know vaginas, I would call atrophic, like the mucosa looks thin and pale. These women look at me and like, no problems with intercourse.

So they are, also having regular inter course helps to stretch these tissues. Even if there is not much estrogen, they have good blood supply. Just for everyone to know. We get this everyone, we are still very individual. Just many of us are going to, you know, it's likely that there are some type of symptoms from it. What is super important is that I see my practice is. Feminine hygiene products. This is also, you know, we are bombarded at all ages, young and old with, these colorful products in our supermarket.

And, the feeling is conveyed like this vagina needs to smell like roses, is dirty, needs, to be cleaned, it needs be sanitized. Maybe we also if something itches, would give you like local anesthetic. This is, so my practice is really full of patients that have literally chronic irritation from over the counter cleansing and feminine hygiene products. Okay. My number one is really talking about vaginal microbiome, bath soaps. And this is something, I don't know, in Germany, we don' use much bath soap for body hygiene.

I'm very American, that's what I had to find. So, you know this foaming three times a day. The soap scum really disrupts the microbiome, not just from the vaginal skin or the vulva skin, from entire body. And what it really does, it feeds, particularly for women who have recurrent BV, chiral vaginosis. Everyone who has had that knows exactly what I'm talking about. So the soap scum is going to accumulate on the skin and feed the wrong bacteria. So exactly this anaerobic bacteria that love that soap's scums, and that's what's then going cause this reinfection or recolonization of the vagina.

And that causes this fishy, gray odor, smell, irritation. Then the patient comes back and says, yeah, Dr. Anspann, I have stopped using it vaginally. I just use it for the rest of my body. And then I'm looking and I was like, yes, no, that's not going to help because our body is a continuum. And it, you know, then they're trying to explain me, but no it doesn't run down there. I like it. Doesn't matter. So SOPSCOM is very bad, really bacterial disruptor. If we can't stop that, I literally can get rid of bacterial vaginosis.

This is an important thing. What's the right way to clean it then? I am curious. Yeah. So basically, I was just going to say also disrupt cell to cell adhesion barriers. If you're really like a vigorous scrubber, you have a rag and you clean yourself very well in your private area, it's you also going be more prone to yeast infections because you literally, will weaken the defense of your cells in the genital area. Yeah, so what do you use? I always say, just to be generic, an organic shower gel.

So first, no bar soap. Go for gel, don't go for an Organic bar Soap. Don't come in with, you know, the, what is it called? Like the Castile soap, like I'm like, Hey, in Germany, we clean our floors with that. Literally. This is very organic, but it's not for your skin. Organic shower gel that's paraben and sulfate free. I'm not saying it's enough. If it has some essential oils in there for some subtle nice fragrance, I don't think that is bad as long as it is not an artificial fragrance with phthalates.

Hygiene Habits, Microbiome, and Irritation 17:00

That is good. Personally, the company Good Clean Love. They helped me a lot starting to support me to look closely at these things. We're doing studies together. So they have a product that is a pH balancer. But again, none of this is supposed to be applied in big amounts on a wash rack. It's all gentle on your fingertips, applied outside, rinsed off. This is how you maintain that balance. But again, if you want one product, just get an organic shower gel that you can apply. Then also just to the stinky areas, your armpits and where else you wanted.

And very sparingly, no wash rack needed. That's really all we need. I always say, well, sure, our grandparents, they were working hard all day. They were maybe on the fields. Yes, they would take like a shower or bath with real soap, you know, bath soap once a week. Well, that was okay. Our skin would recover. But now that we like, all of us, well, how often do you take a show? Like two to three times a day. That's what my patients are telling me. And then every time you do this foaming soap scum ritual, this is what you get.

You're going to get chronic skin irritation and other bacteria are going take advantage of that. There were studies that showed basically the bath soap use is really associated with a pre-selection of propionibacteria, which are associated was boils and acne. So more is not more if it comes to... to our washing hygiene in 2026. Okay. It might've been different like a hundred years ago. Now here we are. How important when it comes to, because whenever I'm testing anything, cause I also deal a lot with perimenopause, menopausal, things like that.

how important are androgens when I, when, it, comes with the actual vaginal, I guess, pH and how everything works lubrication wise. I mean, thanks like testosterone, DHEA, even cortisol. Even though that's not an androgen, are these things also playing into like the vagal floor and everything else that goes on? You know, I'm sure they do. I don't think we have really big data on it. So we do know some women, if they don t respond to estrogen, vaginal estrogen. We do give them testosterone compounded in creams.

And for some vulva vagin pain symptoms, that can actually be helpful. If you're talking about DHEA, we have been using that a long time in the functional medicine space for more libido, but also vaginal sensation. And it was actually FDA approved. I would say like 10 years ago, the product is called IntraRosa. So the doctor can prescribe that. It's one of my favorite ones. it's a very nice formulation, if you ask me. It's a suppository on a paraffin base, which I like because it doesn't irritate the vagina at all and you use it every night.

What I liked about it, it causes very nice moisture. And then the nice thing about, if a woman asked me, so what about if I have sex? So how do I, let's say they want to take estrogen, and it's like, when do i place this in my vagina? You know, I'm like, yeah, you don't necessarily want to get estrogen cream on your partner's penis on a regular basis. But that's where I really like then the intravaginal DHEA, which is a type of testosterone. And you can actually use it as a lubricant. You can insert it prior to bedtime or to intercourse.

It dissolves really quickly. it gives, very nice moisture. All insurances are paying for it, so it's not my first line, but I like to offer it to patients. What is usually covered by insurance, which I always say is dirt cheap and this is perfectly fine, is the vaginal estrogen tablets. Okay. There are some women who are really sensitive to ingredients in pharmaceuticals. So let's say a cream, they're like, Oh, I can't do estrogen cream. And I'm like I I mean, allergic to estrogen. I was like no, no I don't think you're allergic estrogen, you are allergic something in that preparation and you know, and then it can irritate them and we just don' know what it's or they just on like moisture from it.

so for these patients that very. very cheap, small, dry estrogen tablet that you insert with an applicator is fantastic. Usually I'm like, well, it doesn't really create so much moisture, but it does matter. This is just very boiled down formulation of estradiol, nothing else to irritate the vagina. So it really depends always a lot on the patient, what they need, and what is their situation. But there are lots of products out there. So it's always good to have a physician who is willing to explore the different option with someone and not just give up if one of them doesn't work.

Now, are there any other types of issues or diseases or symptoms that can mask what this is or actually be confused with it? So somebody might say, oh, this might be this, but it is actually this. Well, yeah, you're talking about the genitourinary syndrome of menopause, which can cause pelvic pain or pain with endocourses, urinary frequency, all of that. However, we always, when someone has suddenly pained with an endocrine, often I see pelvic floor muscular disorders. People often don't think about that.

If there was, you know, even from childbirth, muscles were always a little tighter after that, and now comes the postmenopause and things just get a bit tighter. And now suddenly, maybe there were a couple of uncomfortable intercourses and there is a muscle spasm reflex. Now these muscles in the pelvic area become even tighter and suddenly intercourse is painful.

Androgens, DHEA, and Treatment Options 23:00

Then people are saying, well you have vaginismus. Yes, but this is just a term, right? But the underlying problem is really that the muscles are too tight. And for this, we have a perfect profession. There are the physical therapists, they are specialized in pelvic floor physical therapy. I mean, there are really miracle workers, if you ask me. They are like so good in figuring out, does this woman need pelvic force strengthening or does she need help with, how do I relax my pelvic floor? Because you know, we always hear Kegel exercise.

So someone tells you, you have something wrong with your pelvic, floor muscles. Then they start to do Kekel exercises, which is all the wrong thing because they actually need to learn. Someone needs to teach them relaxation exercises. Yes. Pelvic floor disorders, then we have vestibulotinia. This is now something that It's an area in the vagina, right, where the penis goes in, that is the vestibule, so the entry hall, if you want so, and that can be chronically irritated. And as a gynecologist, we can't even see nothing, but it's really when we touch that area, there is a pain sensation or a sensation that's disproportionate to what we do.

Basically, I put my finger there very gently and the patient feels severe burning. So this is what's called like a dysesthesia. So the nerves are feeling something that is really not there. Why does that happen? I think chronic irritants, sometimes we see it after repeated STD treatment or treatment of like BV, like, you know, the things like which, bacterial vaginosis and yeast infections are not STDS. overgrowth of other bacteria in the vagina. So this was often mindlessly treated repeatedly without thinking what might be underlying, or if it's even that.

People get irritation again, they go to the urgent care center, and they just want to get rid of you fast, so they give you the same prescription like to 10th time. And this is when I then often see these, I call it the post-treatment inflammatory mucosa. We don't really see much, but it adds like the skin in the vagina is angry. Is that a term yet? I called it leaky vagina. It's a terrible term. Like we know from leaki gut. I'm like trying to tell you. the same symptom exists in the vagina. It's not about bacteria only, it's about the mucous layer, the salt content.

So suddenly this protective layer is breaking down and everything we put now in there or touch it is reacting out of proportion. Okay, so this was the vestibulotinia. There is, you know, I probably have a different approach than other people to treat that. That's when I actually, pack out my functional medicine toolbox. And that's what I would actually do a gut health test, right? I also do then food sensitivity testing because, yeah, because I'm like, now look, what's going on in your gut is going in the vagina probably too and vice versa.

So let's just have look. So I do that usually, you know, and there are certainly some compounded creams that help, like a band-aid solution to let this area rest. There are some old fashioned surgical procedures, but again, that's where I become very, I put my functional medicine hat on when I'm really like, no, not just going to put for like band aid solution. That must be a reason that is happening. And so I have seen indeed women with just food sensitivities. You know, and they get, you know histamine reaction.

They are often sensitive to, to oxalates to histamines. So I try to talk to them about the things that they're eating. We do have something that I think is often related. It's the painful bladder syndrome, right?

Other Conditions That Mimic GSM 27:00

interstitial cystitis. I think that's also something you always have to keep in mind when someone comes with vaginal and urinary symptoms, like something hurts, the bladder hurts maybe, pain, sex hurts. Definitely something to be, you know, has to considered. And what else? Yes, there are a couple of other definitely vaginals symptoms. STDs, please, Mike. I just assume we are testing you for STDs, please, right? We want to make sure. But sometimes, you know, we get, again, it was, often when the women are older, they didn't really expect that.

And now, when we treat the STDS, and that's often, some of these more vaccine symptoms start. We are just more fragile. as a system, as the body system. I think as we get older, then when we do, you know, multiple antibiotic treatments, sometimes the vagina reacts in an unexpected way. That makes total sense. So I'm curious, if you could give the advice to any two women out there, I am sorry, to, any woman out right now, the two most important things that they could do on their own at home to kind of perfect their vaginal perfection, If you will, what were the top two things a woman could just to make sure that she's in tip top shape?

All right, remove bar soaps. They may have a very simple feminine hygiene procedure. Please don't annoy your vagina. Less is really more. And then if you are in midlife and you have pain with intercourse, dryness, all of this, go to your gynecologist. Everyone can prescribe vaginal estrogen. So this is for the mid-life woman. For the younger one, I really want to say whatever you see or read on TikTok or social media, don´t put it in your vagina. That's really my first recommendation. I think that's the quote of lifestyle medicine right there.

That was a great, great one. Really, that is, I mean, really I could have a whole business just from fixing these women. And so, and then vaginas are not supposed to smell like roses. So there is just, you know, penis don't smell roses either. so this is not necessary. You did no spray, none of these, colorful things you should really buy. Then many things, You can even buy in the supermarket, like the antifungals and the anti-itch with lidocaine. This is the most. common topical allergy that I really see is really from lidocaine from these creams.

And the other thing, sorry, for the young woman, you need to know perineal pads. So I'm not sure if I am allowed to mention some brands, but there are some that really stand out causing like a severe allergic reaction in the perinatal area. What? So that's definitely not an area that needs to be inflamed. That's for sure. Yes. So, you know, some of the big brands out there who cause, perineal pads, very fancy. This is like the most common toxic skin eruptions I see. If you feel after you've had your mensis, your peroneum is inflamed, look at the pad you're using and go for something simple, organic, plastic-free, perfume- free.

Many brands actually, they emit toxic fumes and you have no idea what kind of rashes I They are blistering, they are red. So, you know, ask me what to use. Use something else, use something more organic. I personally like menstrual cups. There's nothing wrong with them. They're made of silicone. You can put them in the dishwasher if you like. Anyhow, so yes. So really, I think many things we see are really caused by modern feelings about how we have to clean and to wash and how things to have, to look like, or what we to do.

So a follow up to that question, because I always like to ask two questions at the end. If you're a physician who's speaking to a patient who has these actual type of symptoms, what's the best way you can kind of approach that, bring it up and kind, you know, the, best, I guess, formulation of action to actually treat this for a woman who is painful sex? Okay, so for the mid-life woman with painful sex, and if we really, I would always do a good trial, enough of estrogen, because even if you have other things underlying and there are some other diseases that can happen, i always treat that vagina first with estrogen because everything, every treatment you're going to do is going work better once the vagina has enough estrogen.

What's common is a lot. condition called lichen sclerosis, that is an autoimmune condition of the vulva skin that can also come with itching, irritation, pain with intercourse. But also these women, you know, there's always a double therapy. We do some cortisone if we need to, but at the same time, estrogen. And for the younger women Here you have to really advocate for yourself, get rid of all the unnecessary feminine hygiene products.

At-Home Tips and Clinical Advice 32:00

And then if you to be treated for BV, which sometimes is necessary, here I really recommend try to go with a vaginal treatment. So there is always the oral treatment, clindamycin or metronidazole, with which many women are like, I just want to take it orally because I don't want deal with my vagina. However, I really don't want you guys to do that because that's really disrupting every time the entire microbiome of your entire body, right? And you swallow this tablet, it's going to disrupt the gut, It's gonna disrupt your microbiomes in your ears and in you nose, everywhere.

So you don' want that, because BV is not an infection. It's a bacterial overgrowth. So that's where I'm a big fan. If your vagina is otherwise okay and it's not complaining about topical products, I like the gel form for the vagina and this you can also do repeatedly. Sometimes I call it an eradication protocol. while you basically change your feminine hygiene habits, we actually give you like a brief course of this vaginal gel every month. I always say to bump the bad bacteria away, but then in the meantime, you have to give this vagina a chance to regrow the healthy bacteria.

Then in between, use a lactic acid gel to see if you can get the vagina back in balance. And the same applies for yeast infections. Sometimes, you know, the vagina is very irritated. I'm like, take an oral tablet. It's okay. However, if there are chronic vaginal yeast colonization, some of them are kind of resistant to normal doses of the oral antifungals, then often vaginotreatments work actually much better. And sometimes you have to do them longer, but they are still, good at in controlling the vaginally yeast overgrowth.

Yeast is okay. It's our microbiome. So it's really the fungium. Okay. We all have bacteria in our vagina and our gut. Just, it is a problem when the guys take over the place because we have cost balance. Not like I have to eradicate every single yeast. No, It is part of our micro biome make up really. Makes total sense. Well, Dr. Christine, I got to say, you've never made me more relieved that I'm a man for certain reasons. Not going to lie. That seems like there's a lot of women got a deal with.

So God bless you guys, but it's been an absolute treat. You know, so for everybody who would like to learn more about you and everything else that you do, how can they find you? Where are they going get a hold of you. Well, I have a website, drchristinaentzmann.com, where I do most of my functional medicine work. I actually have the microbiome program there too. So I've found actually many things I can fix without really seeing the vagina. If you are in Maryland, you do have an office here. But if you have other vaccine vaginal microbiomes issues that you really would like someone to have looked at, who really have dealt a lot with it, check out my website.

Fantastic. Well, again, thank you so much. It's been a very informative day for me, at least, so I can't appreciate that much I'm Dr. Ivan Russoco. This is the Lifestyle Medicine Podcast. We're powered by Access Labs. If your doctor's not checking your labs, they're not a doctor. Dr Christina, Thank you. So much for everything. Every innovation we pursue is driven by one bold purpose, making personalized medicine more practical and accessible for patients and providers. If this episode sparked new ideas or challenged how you think about patient care, awesome.

Follow the show and share it with a colleague who's ready to level up their practice. Head over to our website at accesslabs.com and register your practitioner account today. You'll get access to over a thousand routine and advanced biomarkers. with 24-hour results. When signing up, select Lifestyle Medicine Podcast as how you heard about us and score 10% off your first invoice. Oh, and don't forget, drop us a review. It helps more practitioners like you find us. We'll see you next time.