Vaginal Health Deep Dive

Show Intro and Menopause Overview 0:00

It's that thing, I always say, that's the hormone, it's made. So we women, when we are in a reproductive age, making an egg every month is difficult. You know, going through child raising is hard, so I really see, like, basically, wherever there's inflammation, you know. It is like a fire extinguisher, calming the inflammation. it is soothing your nervous system, otherwise you might just kill some people. so it really is just keeping you into this calm mode. Do you feel like your hormones have turned against you?

Trust us, you're not alone. We're Dr. Serena and Dr Heidi and on Hormone Heroines we explore all the root causes that are behind hormone imbalances and we teach you how to thrive through them. Join us for real talk, expert tips and even a few laughs. Hello and welcome back to Hormone Heroins. We are going to be speaking with Dr. Christina Ensman, a board-certified obstetrician and gynecologist and a menopause specialist, who we're going talk to her about why menoppause is a metabolic and stress event, but we are also going go over the genitourinary symptoms of menompause as well, because I don't feel like enough people talk about it, and we really need to get into the whole heart of it.

And part of Menopaus is that that no one talks about. So welcome to today's show, Dr. Christina Ensman. Yeah, thanks for having me. You already made me all excited. Like in our little pre talk, I'm like, are we going to talk about vagina? Like, yes, let's go for it. Yes, absolutely. So let us get right into it, Let us kind of let our listeners know who you are a little bit first. you work at the intersection of gynecology and functional medicine. How did that combination come about and why does it matter for your patients?

Like for most of us, it was my own life experience, right? So I'm from Germany, just because everyone is going to wonder, they're going, where's this accent from? I am German, been in the US for 20 years, accent didn't go away. So anyhow, so I started as a gynecologist in The US and then, you know, we don't get good training in menopause. And, I immediately had all the midlife women and it fascinated me.

Dr. Christina Ensmanu2019s Background 1:58

I got my training there right away, And it was conventional medicine already created with the Menopause Society. And then, of course, with all the stress and moving to the ass and being a midlife mom and whatever, menopausal hit me early, and suddenly I had to eat my own advice. With conventional medical medicine, we have hard data and sometimes, yes, you're going to gain some weight, not so bad. It was happening to me and I was like, excuse me, why this doesn't work for me. And then the only stat issues I'd see my patients where there was no conventional medical explanation, right?

And my rage and all of that. So this is how I actually really went from academic medicine. I was like, no people, there must be more answers. This is why I started to deploy the toolbox of functional medicine, I want to call it, and have been better for myself since then and for my patient. That was a big benefit. Nice. Wonderful. So I think we should dive into the urogenital symptoms of menopause first. Because that's one of the big things that hit women really hard, but nobody talks about it. Yeah, no one wants to talk about.

Let's just talk. What is it? Can you start there? Yes. So, genitourinary syndrome of menopause. In the past, we just called it vaginal atrophy. And I really didn't like, or actually, even the Menopausal Society didn´t like it because that kind of made this problem like all stuff, the vagina is dry and you can't have sex. This was kind these niche problems. So that's why then this term was expanded and it was like, no, actually that lack, long-term lack of estrogen, once you have been longer in postmenopause, we're going to talk about it, it's actually also affecting your bladder symptom, your blood and the urogenital system.

And with this actually comes, you know, also urinary urgency, frequency, or recurrent bladder infections. And this now brought this, all this is a sex topic more to know. This is the general health topic. I think this was a really important renaming of that. As I said, it's dryness of the vagina, pain with intercourse, and then urinary frequency, urgency, recurrent tract infections. And usually or classically, its labeled as a symptom of late postmenopause. So once you have been a couple of years into post menopausal, the reason for that is that then these tissues of vagina and part of bladder are very estrogen dependent.

Then after a while, these tissue thin out to a point when you get basically symptoms.

What GSM Is and Why It Matters 4:27

However, it's really not, that's what I see in my clinic. So yes, there does exist. Me either. Yes, thank you. I know, however, women, particularly the ones I seed often as one of the earliest signs of perimenopausal transition against all writing and Particularly what I see a lot is urinary tract infections. Suddenly out of the blue, you know, women who have no new sexual partners, everything is the same, suddenly they get UTIs in their early 40s. And the women will get hit the hardest also with painful sex are the ones who had C-sections.

or no children at all. So the ones who never had like, you know, the vagina stretched. That's how I say it. With these ones, we see really early 40s, right? And then the gynecologists tell them, no, they don't even think about it, but they're like no this is something else. It can't be because you still have regular cycles. But even then I see. And the third one, let's see if you'll know these one too. These are the young girls who had been on birth control pills since they are- Oh my gosh, it's me.

I was like I want to talk about this. breath control pill because they're endometri, you know, all valid reasons. I'm not, and these ladies really in their early 20s, I really already see them, they come with painful sex and they are diagnosed with rubidinia, yeah, kind of symptoms. And I am like, well, let's just stop the birth control pills. Nothing bad against the birth control pill, right? But you have to know, we always think of the hormones, so there are lots of hormones around. It's like, no, these little daily hormones are overriding your own natural up and down.

So overall, you're getting very little hormones over time. That's why it works so great if you endometriosis or painful cycles. And the only thing these young women really need instead of giving them then estrogen cream, you know, just stop the birth control pill for a couple of months and really, it usually resolves within like three months. So just, and then you can decide what you're going to do when there are reasons for the Birth Control Pill. But it's just this proof of concept instead of giving them a thousand greens and giving then compounded, all kinds of things.

And then they end up with... Make them think it is in their head. In their heads. indeed in the warmer right so so yes so that's yes i think we agree i can see in your faces you're like no i mean i i'm suffering from that personally because i was on birth control for a pretty extended period of my life but i the one that i noticed it the worst with was when i nuva ring or the vaginal estrogen ring and that one I ended up with like atrophic vaginitis and I had to like argue with my doctor being like no I know it's atrophy like it s not just this and they like did not believe me and then so I just stopped taking it and you're right I did improve but The other time I would point out that I feel like what I've seen people be susceptible to is a lot of vaginal atrophy postpartum from breastfeeding.

I personally just had a baby and it was happening. So I started using some vaginol estrogen cream even though I'm still breast feeding, but because it's local, it still okay and I am still able to breastfeed. Yeah, but it helped a lot because it helps everything heal faster because the first time around, I didn't do that. And it took like a year for the tissue to heal because I breastfed for over a years. It was a problem. Yeah. Estrogen is our healing hormone. We need estrogen to heel that tissue for sure.

Yeah, I always say it's the fire extinguisher. It doesn't mean we can't live without it. I'm not someone who puts hormones on people in postmenopause. No, but it's that thing. I always say that's the hormone. It's made. So we women, when we are in a reproductive age, because childbearing is hard, making an egg every month is difficult. Going through child raising is hot. This hormone, I really see, it basically, wherever there's inflammation, fire extinguisher, It's calming the inflammation, it's soothing your nervous system, otherwise you might just kill some people occasionally.

So it is just keeping you into this calm mode. And my other argument is that that's why sometimes we postmenopausal women, we just don't go for so much nonsense anymore, because we don´t have this moving estrogen around anymore.

Early Symptoms, UTIs, and Vaginal Atrophy 9:08

We don' have the veil of estrogen calming you and keeping everything there. Don't talk to me, this makes no sense. Yes, exactly. I'm done with your bull crap, just leave me alone. Yes. Yeah. Exactly. Um, I know in our practice we see this a lot, but in your practice, what have you seen? We've seen like UTIs that are completely different types of bacteria that aren't even run on regular cultures. Um so we're having to run specialty cultures to get our tcr testing to find out what actually is causing the uti's because we'll have a lot of women come and they're Having all the symptoms and then they are having some blood in their urine and stuff but then you know like the regular like urine dip and microscopy doesn't show anything with the the normal bacteria that it looks for and so we're running you specialty labs trying to find the infections that are different bugs that is not just on or like a bladder dysbiosis that started because those tissues aren't keeping it out as much as it used to.

Yeah, interesting. So you're saying on the urine dip or also on regular urine culture, you don't grow it? Both. Okay. Basically, on a culture it doesn't show up, but they are having all the symptoms of a UTI besides maybe pain, yes or no, depending on age, because it's common for it to not be there. and then we do like a PCR functional medicine lab for the urine and it shows all the different bacteria or potentially even like candida in the bladder and treating it for that and suddenly it gets better.

So that's really like what a case usually looks like for us. Yeah, interesting. So I have not thought about that they wouldn't grow the rattle up stuff, but I always, in my previous life back in Germany, I did traditional Chinese medicine. And what they used to say is like antibiotics treat kind of the heat. or they treat the bacteria, but they don't really get rid of that heat or the inflammation, right? So I always tell my patients, you know, when they get a UTI and we, we have to treat because it's really bad.

And I tell them, I was warned them. I'm saying there might be some, small recurrence, But I am not gonna throw immediately antibiotic at you. We are just gonna do it, some herbals, warm water bottles, just to see if your body is able to calm this down. because whatever is happening, you're right. It creates this propensity or this vulnerability of the bladder. Either we get different bacteria, maybe we pick up bacteria that are not even causing the symptoms, or for sure we're getting this bladder irritation.

That's what I see a lot. Bladder, vagina is kind of combined. So that's when I go a little with soothing medications, But same idea, basically strengthening the normal environment, the mucosa, and really working towards that the vagina and bladder can defend themselves. Because the next thing we see is then, you know, painful bladder syndrome that can then, you know, when suddenly everything hurts and it gets wilder and wild. And I also see this in the vagina, like if we treat like we over vigorously, because we think we, every time there's a slight recurrence, we're giving more antibiotics and then women get so focused on it, but because they think it's an infection, right?

I'm like, no, it is a bacterial over shift, so let's think about this a little different. sometimes I call it leaky vagina. It's not, you know, like not in the leeky gut. I have to find a better term for it. No, I love it! It makes sense, think about it, yeah. We have this mucosal breakdown, it's like suddenly that muccose on the vagina that's really supposed to keep things out is suddenly breaking down, so everything, every green we put in there is burning and then, patients think this is still yeast or it can be meat, but it is not.

I'm done. My skin needs to heal back off. So, and I think these are all, you know, similar concepts. As we see it in the gut, we seed in, why not seed it the bladder? Why not have it get in to the vagina? And I seed clinically, I am going to give it a proper word one day. A proper name. I don't know I like leaky vagina I think that works great. I feel like that term might be used for other things though. Well yeah but it makes sense to us because we talk about leaki gut all the time too. Uh I've had to describe it to patients because what I usually say is like maybe why we're seeing more UTIs is because the skin that's supposed to keep the vagina separate is now thinner so maybe it's maybe its thin vagina maybe that is the term.

Yeah, but I see this also in young women. You know, once we have over-treated them with topical antibiotics, and you know they get that too.

Treating BV, Yeast, and Vaginal Irritation 14:06

And then you, know it goes into Volvodinia, even that's not really, anyhow, it's a lot of things we still need to learn about the vagina, that for sure. What are you using to treat those, like let's say BV or Candida, what are using instead of antibiotics? I do, so let's say straightforward, you know, my regular office, they just have a BV, okay, first time or let say it's a recurrence and they came from somewhere else. So I don't give them oral antibiotics. That's the first thing, but I want to clarify because many women are like, I didn't want deal with my vagina.

I done want put nothing in there, right? I just need me to have the doctor. And that's when I'm like no. It's just, I'm not your doctor then, because that just means we're killing the entire microbiome every time. We don't want that. I don' want to affect your bladder and your gut. So I do straightforward MetroGel, like literally. This is well tolerated, covered by insurance. What I have do, however, if I know they had recurrences, is I give them what I call eradication protocol. They really get this every month.

for six months, but only five days. Because then between this and the next treatment, I want the vagina to recover, to get their own bacteria going. And that's when I use lactic acid gel. I like to use from Good Clean Love, the Restore, because I knew the research actually created that. Oh, really? Yes. So I really like that approach. And even that gel itself, we actually tried, it's still in study to see if itself it is marketed as a sex loop currently. But really, actually we have pretty good data that it helps to eradicate BV long term.

So basically I make this, I bonk the bacteria I wanna go away and at the same time I'm strengthening the vagina. So that's what I do with that. And yeast, it really depends, okay? And it can go both ways there. Sometimes I oral because some women come, they had so repeated treatments, the vagina is on fire. I don't wanna put any more tropical antifungal cream in there and these women I actually do give them oral antifungals. I do draw sensitivities, you know, because there are more and more resistencies of the current Candida against Diflucan, which we like to give.

Like that looking because, it works mostly well. It has a low side effect profile. it's well tolerated. We can give it for longer. So, but then again, for the vagina itself, I work again. i like, to do this lactic acid gel. to just really try to strengthen the vagina again. However, some women, they have such an irritated vagina. When I put the lactic acid gel in there, it burns. And this is then for me a sign. This is really very irritated and broken down vaginal mucosa. Then we have to tread very carefully to get that restored.

So I have several layers I go through there. Okay, so I'm going a little bit into treatment. So we talked about BV and yeast, but what about if you're just having the genital urinary syndrome, the treatment for that protocol for them. Let's talk about this. You know, many physicians also primary care, they know about that already and they're willing to prescribe that they don't give enough. So, you know, many women are like, oh yeah, I have been on estrogen. You know I took like a pea size, three times a week, but that's not going to do nothing, right?

And I'm like well, this is no wonder this doesn't help. So when they really have severe pain, like penis goes in hurts and once the penis is in hurt. That's the inside and outside. cream for a couple of weeks every night, or usually I say three weeks, every and really a lot of that stuff inside and outside. This is really, I call it up estrogenizing the vagina. Once we are there, then we can taper down to do it two to three times a week. And then I offer other formulations, right? The cream can be kind of messy.

So then, well, let's do a vaginal estrogen tablet. Then there is also an alternative to estrogen, which is DHEA. type of testosterone, which has been used in functional medicine for a long time. We used it for the vagina in the past. It helps a little bit with libido, very subtle. However, it was FDA approved about 10 years ago for genitourinary syndrome of menopause. And the manufacturer, they have some data that it helps with sexual satisfaction. I don't understand net powdery because it's not really absorbed in any higher levels, but well, who knows?

I know this is a very, I love that DHEA. It's a vaginal suppository and I like it because its nice, its moist, it kind of looks serious. And then there's another point why I really like. even though I thought about it. But if you put estrogen in your vagina, you know, every night, people sometimes ask, so can I get this on my husband? And, matter of fact, I don't think it's particularly good for your husband's penis, estrogen. However, if use a little bit vaginal DHEA, and you can even use this prior to sex because it is kind of a great lubricant, well, it perfect for you husband too, because of some type of testosterone.

So that's why I like the DHA. It does help with blood flow to the clitoris too, so the DHEA helps with the blood flows. So I think that's why it helps for sexual pleasure too. Yeah, and I that how we used it in the past, right?

Vaginal Estrogen and DHEA Options 19:38

You compound it and apply. And there are some, you know, over-the-counter and some people produce that. Yes, some women really have that effect if applied to their cliteris, like with regular testosterone. But the effect, I thing, is very individual. It always depends. Yeah. I did want to ask you, just because so many people do ask, what do you tell women? Like how long after you use the vaginal estrogen before you would have sex? Yeah, it's safe to have with a male partner. I don't think we have any.

So if you are, you know, I always say, well, it's kind of unsexy to think about that, but I would always, say well if use the vaginal tablet, i would probably apply this after you have sex that night, if that is possible. And then on the other hand, if you have sex and you've already applied it, wash it off after sex. It's not deadly. You shouldn't have this on your partner all the time. He can also use it on them if that's a thing. I wouldn't worry too much about it. But we are all sexually active at a different rate.

And if someone has sex twice a month, it might not be a big issue compared to someone who has like sex every night or every second night. So then that might be more a concern. And the FDA doesn't give no guideline there, unfortunately. I'm also sometimes wondering like, come on guys. Yeah. Okay. So the other thing I wanted to ask you about going back to the vagina, not just the genitourinary symptoms. Well, it is, but we've found a lot of postmenopausal women having a of mycoplasma and urea plasma infections as well.

And what we kind of postulate, we haven't done a lot of deep dives into it or anything, but we postulated because when you lose all that estrogen and the tissue is thinning and you've got the leaky vagina, your pH is going to be different. Different things are going be able to grow. And so have you seen that a little bit in your practice too? Yeah, I have a test for microplasma and urea plasma, but I wouldn't say I test against my older patients that much. However, what you're saying makes perfect sense, because we do know as our estrogen gets lower, the vaginal microbiome changes.

So from the heavy lactobacilli, it's going to be very mixed bag of goods, which is still normal. Many people then confuse that with BV, like in a 65-year-old. And that's not B-V. The BH goes up because, as you know, the lactic acid is lacking. Just give her some estrogen and most likely she's just not going to get these symptoms back. Yes, so I think it makes sense that there's more microplasma, urea plasma. You know, again, remember only the uria plasma genitalium is the one that is now considered kind of an STD since a couple of years.

But there is micro plasma hominis, there the Urea Plasma which for the longest time, you know the data really comes from fertility medicine. So we really don't know what it causes and you I know if I have some symptoms and I find it, I'm going to do something about it. But I wouldn't just look for it because as you know, we don't have a real treatment guideline and it's really hard to eradicate. So, if it doesn't cause anything, it is more commensal bacteria. And the other thing is, sure, I mean, the microplasma, urea plasma, started to do this early on, but it's really, it just picking up to be more broader use.

So I'm just wondering maybe, what do we know how long these women had that? This was not part of the standard STD panel like three to five years ago. I am relaxed there. As long as people have no symptoms, very multi-ethnic microbiomes. You just watch this. Yeah. Okay. So last more of a fun question, but to wrap up the genital urinary syndrome and menopause, is there any more fun tips or tricks that you have to increase pleasure for women outside of the treatments we already talked about? Well, I think what, you know, as women get older, it's not only that they would, the partner often, partner might have ED.

I thing what's important, everything is really allowed. If you need to get a nice vaginal stimulator and your partner is using it on it, use the freedom and the mental freedom you have as you get old to be creative

Lubricants, Pleasure, and Red Light Therapy 24:18

with sex. Whatever pleasures you, is perfectly fine. I think what is really nice, if the vagina is nice and moist and moisturized, so I'm a big fan, there is one loop that most of my post-menopausal patients love and I am not associated with them at all. They just, you know, they merit some calling up because it's good. It's the uber loop, If you've ever heard of that. because that I always tell, you know, women particularly, if you, know many of the water-based lubricants, they are great, but they feel nice initially and then they dry up as you have longer sex.

So the loop kind of remains slippery. It's kind a hybrid lubricant. That means I tell them, I'll be careful when you shower after sex because you might slip. This is how slippery it is. But I think it can You know, once you know it doesn't cause no tearing of the tissue. It really makes it, it makes them feel really nice. You can apply it to the partner's penis. So I think again, I don't think I had a one person note one who didn't like it. The other important thing about these hybrid or partly silicone based lubricants is, and you might not expect that because we are here silicone.

We are like, Oh God. I like it because it doesn't interfere with a vaginal microbiome. So if we do water-based, then we always have to watch the osmolality and not many manufacturers know that. That means most even what you might associate with good brands, water based, they feel good the first moment. And then since they're hyperosmolar, are they actually now pulling water out of the cells? So actually they are cytotoxic in the second step. and that when you get a later irritation two to three days later.

And there was actually a report from the World Health Organization from 2014. They already pointed that out and had a list of all the major lubricant manufacturers, but it just gets ignored. So if you have a water-based lubricants and they don't mention the osmolality and you can't find it, I wouldn't use it. back to the silicone base, doesn't interfere with your vaginal microbiome, sits right there. So that's my tip. Nice. I love it. Oh my gosh. One last thing. Do you like any of the vaginol red light therapy devices?

You know, I just bought myself one to try it out in the office. Do you have experience with it? I have one. I'll have experienced with the V-Fit is the one that I had experience. It's great. Like for pain and inflammation? Pain, for inflammation, moisture, everything. Okay, well, we are going to, you know, email offline, because you're running out of time, but I want to know about that. Okay. I'm all for it because, it increases collagen. My question is more like, do I have to do this in the office or does the patient has, like how often and how long you thought that would be good to get some data?

More research. I think there's one thing, if someone is listening, what I want to point out, that vaginal estrogen or vagin DHEA therapy is not the same than systemic

Closing Thoughts and Sponsor Message 27:48

hormone therapy. So it's not going to raise your hormone level, and you really can take this until the end of your days. Okay, so just to be clear, it is NOT the SAME. It's NOT going work for hot flashes, but it'S great for the vagina. Yes. Amazing. I love it. All right. Well, thank you so much for being on today. This has been a really fun conversation about all things vagina. We'll have to have you back again to talk about the metabolic aspects of menopause, but thank again. And this has another episode of Hormone Heroin, and we will see you next time.

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