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Beyond the Prescription
Let’s Talk About Sex
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Let’s Talk About Sex

An interview with "sexpert" Dr. Kelly Casperson

You can also listen to this episode on Apple Podcasts or Spotify!


Kelly Casperson, MD, is a urologist, sexual medicine expert, and best-selling author. She is on a mission to empower women to live their best love lives.

In her wildly popular book, You Are Not Broken, Dr. Casperson breaks down the common narratives that women have been told about their bodies such as “I shouldn't enjoy sex,” “I can't get any better at sex,” and “It is my partner's job to give me pleasure,” in order to help women play, explore, and normalize their sex lives.

Combining the power of mind, body and relationships, she breaks down the societal barriers that keep women from fully embracing their sexuality and intimate experiences.

On this episode of Beyond the Prescription, Dr. McBride and Dr. Casperson discuss desire mismatch, relationship communication, and tools to help put women back in charge of their health and sex life.

It is time to normalize healthy, enjoyable sex worth desiring, and Dr. Casperson is here to help!

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The transcript of the show is here!

[00:00:00] Dr. McBride: Hello and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my Dr. Caspersons like I do my patients, pulling the curtain back on what it means to be healthy and redefining health as more than the absence of disease. As a primary care doctor, I've realized that patients are more than their cholesterol and their weight.

[00:00:31] We are the integrated sum of complex parts. Our stories live in our bodies. I'm here to help people tell their stories and for you to imagine and potentially get healthier from the inside out. You can subscribe to my free weekly newsletter at lucymcbride.substack.com and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts.

[00:00:57] So let's get into it and go Beyond the Prescription. Today on the podcast I have the honor of speaking with my friend who's also a doctor, a urologist, and a sexpert: Dr. Kelly Casperson. Last year, Kelly published the wildly popular book You Are Not Broken: Stop shoulding all over your sex life. It's a combination of real stories, conversation starters, and journaling prompts about how to have a better sex life. Kelly and I agree that mental health is health, that sexual health is health, and that women and men are unstoppable when we're armed with tools, facts, and the agency to be healthier from the inside out. Kelly, I'm thrilled to have you on the podcast today. Thank you so much for joining me.

[00:01:53] Dr. Casperson:  Thanks for having me.

[00:01:54] Dr. McBride: So let's get right after it. You are someone like me who believes that health includes many of the invisible components of our everyday life, including sexual health, mental health, a sense of agency over our everyday thoughts, feelings, and behaviors. You're someone who was trained in urology, which is a surgical field. And when people think about urologists, they typically think about male doctors treating male genitalia.

[00:02:27] Dr. Casperson: That's right.

[00:02:27] Dr. McBride: So, talk to me about what it's like to be a urologist in a male dominated field that people consider as a male dominated field, and then tell me how you came to understand Sexual health as a sort of a moral imperative to dispense more information about. 

[00:02:44] Dr. Casperson: Well, currently practicing urologists in America, 9% are female. We’re getting there. We're about 30% of the residency slots. There's only like 200 residency slots a year. So it's not like we're going to change the 9% much quickly. It's been great. I kind of… It was challenging to get into urology.

[00:03:01] I loved that. I loved the instant gratification of urology. And people are still surprised, you know, that there's women in urology and it's like I've been out of residency for 10 years now. So I don't know if that's gonna change in my career at this point. It's not changing fast. But the superpower that being a urologist brings to this whole sex medicine discussion is that I treat men.

[00:03:22] And so I get to see every single day how men are treated, and I see how women are treated, and it just becomes so glaringly obvious that we treat these two people very differently, and I get to have a voice because of that. In contrast to the gynecologists who don't see that we don't downplay men's complaints, and we don't say, well, that's just a quality of life issue, or yeah, you're just getting old.

[00:03:42] We don't treat men the same way we're treating women. And the sex meds and… I met a patient who was crying in my office, and the more I opened my eyes to what was going on, the more I said, I thought, “this is a huge problem, an absolute huge problem,” which I hadn't really seen before because I was not taking care of women's sexual health before I kind of got awakened to it. It's going to be lifelong work because we've got a lot of work to do.

[00:04:11] Dr. McBride: Let's, so let's talk about that for a second. I think what I'm hearing you say is what I experience myself as a doctor and as a person is that we countenance men's sexual dysfunction with ease and there's a whole specialty built around men's sexual health. It's urology. But in reality, urology encompasses everyone's pelvic floor, everyone's sexual health.

[00:04:37] It's just that men tend to go into the surgical field, men tend to treat men, and then the narrative is that it's really for men. So, it sounds like that was your professional path, and then you began noticing, like I do, that, hey, guess what? Women have sexual health as well. Women have pain with intercourse, low libido, pelvic floor dysfunction, vaginal dryness. And like men, women are entitled to pleasure, the absence of pain, and most importantly, in my mind, is access to nuanced information about their own bodies.

[00:05:13] Dr. Casperson: Yeah, we do a very interesting thing… to stereotype what we do, we say all of men's problems are biological and all of women's problems are psychological. And so like, you know, he's got erections issues. That's a blood flow viagra problem. We've totally forgotten it could be anxiety, depression, all that stuff going on.

[00:05:30] And conversely with a woman, we're like, oh, she's just depressed. She’s just too uptight. We're like, no, she can have a hormone problem. Women are allowed to have biological issues also. And we really put them in these little containers and then forget about the humanness of everybody.

[00:05:47] Dr. McBride: Yeah, I think, you know, we can walk and chew gum at the same time. We can have anxiety about performance, and that can be rooted in an experience that was traumatic. It can also just be rooted in low self esteem, or... Body image issues. You can also have low libido from not having enough estrogen because you're going through menopause.

[00:06:08] In other words, human beings are the complex sum of different parts. So to assume that women have sexual dysfunction because it's all “in their heads” and to assume that men have sexual dysfunction because it's all just a blood flow problem is to reduce people to these very simple parts and then assign them by gender. And that is not our job as doctors. It's also just completely inappropriate. It's really depriving people of the deep understanding of how their body and minds work in tandem.

[00:06:40] Dr. Casperson: That's right. Absolutely.

[00:06:42] Dr. McBride: Okay, so you are sitting there with a patient who's crying. Who's and by the way, I tell my patients when they cry in my office, like, you know, they're sort of apologizing or “oh, sorry. I'm just emotional.” And I'm like, oh my gosh. I mean, it’s not that I want you to cry. It’s a sign that we're getting somewhere that we have something to talk about. Let's peel back the curtain on what that is. It doesn't always mean you're depressed, it doesn't mean you're a hot mess. It just means there's something that's going on that we need to connect to your body.

[00:07:10] So what are you finding women come to you to complain about vis a vis sexual health, sexual dysfunction? What are the main issues they present to you with?

[00:07:19] Dr. Casperson: The two main ones in my office would be vaginal dryness/general urinary syndrome/menopause. Right. So low estrogen in the pelvis causing pain with sex, burning, tearing, low lubrication, decreased arousal. It's kind of this umbrella cause. And then the second one is I don't really want to have sex, or a.k.a low libido. Oftentimes, that one's so fascinating, because it's often times not a low libido problem. They don't know what it is. They come in and they say, “I have low desire,” and you talk to them and you're like, that's not what's going on at all. And a lot of times with sex, they think it's about sex, but it's just a couple's communication problem. 

[00:07:56] You’re assuming what he's thinking, he's not talking to you about what he's thinking, you think this is a sex problem. You're like, no, no, no, this is just a relationship communication problem. But like sex gets involved and like, it just all goes haywire.

[00:08:09] Dr. McBride: Yeah, I think you're right. I think sex can be the final common pathway for a lot of personal and then relationship challenges. I was talking to one of my patients who is actually a family lawyer, like she helps people get divorced or helps people not get divorced. And she, not surprisingly, said the three things that people commonly fight about or have troubles with in their relationships are kids, money, and sex.

[00:08:33] Those are three very vulnerable touch points in our lives. And so I think you're right, that sex can be kind of a symptom of other issues. But in and of itself, it's important. It's part of how we connect with our partners. It's how we experience pleasure. It's a part of the human experience. So to deny someone a conversation about what it is, whether it's truly like a body parts malfunctioning problem or it's an emotional challenge is really not okay.

[00:09:02] And your book, We Are Not Broken, speaks to this notion. That having trouble with sex, whether it's desire or the parts not working isn't a personal failure or a commentary on your ability to perform as a human. It's—the diagnosis here is human. It's common. I've, I mean, patients come into me all the time, I'd say of all ages, but often in their middle age and they'll sheepishly say to me, “I'm really embarrassed to say this, but I just don't want to have sex. I love my partner, but I'm just not interested.” And they act like they're the only person who's ever thought that before. And I'll say, “Oh my gosh, I could feel in an auditorium full of women who feel the same way.”

[00:09:47] They feel ashamed. They feel guilty. It's not a lack of love for their spouse. Sometimes it is, or their partner. It's simply that they are struggling to connect the body and mind and they need some support and they need to be given permission to have that conversation.

[00:10:04] Dr. Casperson: Yeah. Or they've just been having crappy sex their whole life.

[00:10:06] Dr. McBride: Well, that's also true.

[00:10:08] Dr. Casperson: And I don't want to downplay… there is now an actual medical condition called hypoactive sexual desire disorder because they have to DSM this stuff to get FDA approved for meds, like the entire thing that medicine is, but a lot of this “low libido,” I never believe them anymore because it's there's oftentimes something else and so I'm like, “well, what about sex? Is sex good? Do you like it?” And either the answer is “yes, I love it.” And then I say, “well, you don't have a problem. Stop worrying about low libido. Just go prioritize that amazing sex you're having.”

[00:10:38] It's not normal to have a spontaneous desire in a long term relationship. And number two, if they're like, yeah, I could take it or leave it. I'm like, well, that's how dopamine works. You're never going to desire something you could take or leave, right? Like anchovies on my pizza. I'm whatever, right? Like I don't desire it.

[00:10:54] And then it's just like, go have the sex worth desiring, which is very stuck in depth. That's easier said than done for a lot of people. They've spent how many years having the exact same unsatisfying sex because they're having sex the other person's desiring. And really prioritizing desire equality and pleasure equality within a relationship. It's like, you don't actually have a low libido problem. You have a sexist man problem.

[00:11:18] Dr. McBride: interesting. So to break that down a little bit, and I'm assuming you're talking more about women, are sort of subjugating their needs and not allowing themselves to experience pleasure as much as men are. And therefore they are just having bad sex, which of course they don't desire because why would you desire something that's not that great.

[00:11:38] Dr. Casperson: I'm stereotyping, you know, a heterosexual relationship here. Within any partnered relationship, you're going to have somebody who wants sex more than the other person. That's just, that's desire mismatch, and it's completely normal. And we need to normalize that. Like you, you want to, you know, drink seltzer water way more than I do.

[00:11:54] Why is there so much seltzer water in our house? Between two people, there's always different things going on. So just normalizing desire mismatch, normalizing it. The other thing to normalize is it's not the lower desire person's job to come up to the higher desire person's level. It's to work within the relationship, to be like, what does our relationship need sex wise to keep everybody happy?

[00:12:14] You can fulfill some of your needs outside of my vagina, right? Now, I can say that very easily because I've been talking about sex for years, and you have to be a little more nuanced in a relationship where you've maybe never talked about sex before. Because couples don't talk about sex, and then there's a problem with it.

[00:12:31] Well, I don't have the basics of how to talk about sex when it was good. Now it's broken and I really don't know how to talk about it. So even just communication skills about sex is important. But yeah, I think a lot of women and there's we do not have much research on this…We've got decent studies in like college students, which are not long term committed relationships of “well, that's what he wanted. He wanted to do it. I did it to keep him happy.” Kind of this like mercy sex to control another person's behavior. I don't want him to get grumpy. I don't want him to get mad. And so you're having sex for that reason instead of connection and pleasure. And then you come in thinking you're the problem for having low libido. It's not a low libido problem.

[00:13:13] Dr. McBride: Well, and there's nothing like shame or guilt to crush a libido that's already low, right? If your relationship with your partner is rooted in shoulds, then… 

[00:13:24] Dr. Casperson: You need to have sex with me more is the least sexy thing you can say to somebody. The partner is telling the low desire person that they're broken and they need to up their game. Like it's worked zero out of one million times to approach it that way.

[00:13:38] Dr. McBride: Well, it's also, it's probably less than zero of a million times in the sense that the telling someone how to feel and then promoting the sort of shame narrative is like the ultimate libido crusher.

[00:13:50] Dr. Casperson: Yep. I'm inadequate and I'm supposed to love this thing that I don't love more. 

[00:13:54] Dr. McBride: So I think you're right, Kelly. I think at the end of the day, it's about communication. It's about shared responsibility for meeting each other's needs. And I think that's hard in the modern era. I mean, who has time to sit down and have a nuanced conversation about sex? But I think we have to.

[00:14:11] Dr. Casperson: Right. And even I, I live, I work in a very traditional medical 15 minute visit, right? And now through my years of work, I have the podcast and the book because I cannot explain this to anybody in a 10 minute visit and undo the years of socialization that women are passive and women's pleasure doesn't matter as much.

[00:14:30] Male orgasm is what we prioritize—penis and vagina sex for heterosexual people. That's the only sex you should be having. All of this stuff. And they come in with low libido, and then somebody's gonna slap them on a drug. And not undo all this biopsychosocial stuff. I saw a woman literally yesterday. She had a painful vulva and vagina from menopause. Painful to the touch, like even her just touching herself hurt. Somebody threw her on testosterone for low desire. And she's like, “well, what do you think about the testosterone?” And I'm like, “I'm a urologist. I love testosterone. I'm very comfortable with testosterone.”

[00:15:06] But putting somebody on testosterone who has a painful vulva, who's never going to want to be touched in the first place, you're completely missing the boat on this. We have to address the pain before we can address the desire. And so it is complex, which is why I love this topic. And I get to keep talking about it for years.

[00:15:22] Dr. McBride: Yeah, I think it's treating people from the inside out, right? It's like not band-aiding them with prescriptions and referrals and drugs before we understand the patient. We are not just a set of organs. We are thinking, feeling people who absorb the public narratives, who have been raised perhaps in our own families to think about pleasure and desire and sex itself in a certain way. I think deconstructing those narratives in our own lives, and then being comfortable talking about those things is key. And I think having people like you, Kelly, out there talking about these things in a very matter of fact way is gradually changing the narrative and hopefully empowering women to ask the right questions and give themselves permission to feel.

[00:16:09] So it's interesting because you and I both know that doctors are hurried, doctors are rushed. No one has time anymore with their doctor, unfortunately. You've got the field of gynecology, which is tasked with doing your pap test, writing your mammogram order, you know, checking your pelvic exam, and how can they possibly fit into a 10 minute or even 5 minute visit a conversation about pleasure, desire, feelings, behaviors, your relationship. It's just a tall order for a single specialty, right?

[00:16:45] Dr. Casperson: they can't. I mean, the other thing that we completely forget in this narrative is that women are 50% of the population, that we've completely ignored in this arena, talking about both menopause and sexual health. 50% of the population, there's not enough gynecologists. Even if they could spend 15 minutes, there's not enough of them.

[00:17:02] This is primary care, internal medicine, psychiatry. We really all have to get on board, because, like, we're not a minority recessive gene problem. This is 50% of the world.

[00:17:16] Dr. McBride: Right? Yeah, so one of the things I try to help patients navigate is the medical system, given that we have needs the medical system cannot meet. Arm people with the questions to bring to their gynecologists. Instead of being a passive recipient of like the pap test and the referral to the mammogram, make sure you're bringing your needs to them and asking for their advice and then making a separate appointment just for a conversation if needed because it's not the doctor's fault necessarily that they don't have time to talk about sexual desire.

[00:17:49] Patients are conditioned not to ask about it. Doctors don't have time. It takes a whole lot more time to counsel someone on the nuances of behavioral health and pelvic floor and the nuances of hormone replacement therapy, which we'll talk about in a minute, than it does to hand someone a referral for a mammogram and say, you look great, see you next year.

[00:18:07] Dr. Casperson: Totally. And that's where good resources like your podcast, my podcast, the book is like what you read it, you can consume it. And then our podcast will give you better resources. So you come in with the current menopause guidelines. You come in saying, “I've already talked to my partner about this.”

[00:18:22] Dr. Casperson: You're telling us what you've already done. You're an engaged person. We actually want to help, right? And so it's like setting that person up to be successful in the doctor's office and to ask why so many, like, you know, the hormone thing. So many women will come to me and they'll be like, well, they took me off my hormones.

[00:18:38] And I'm like, “why?” Why is a very natural question for me, right? And they're like, oh, I don't know. I didn't ask. So it's very okay to just ask why in a non threatening way to your doctor. Like that's my other doctor pro tip and how to talk to…

[00:18:51] Dr. McBride: Ask why.

[00:18:52] Dr. Casperson: Ask why so you understand!

[00:18:53] Dr. McBride: This is your body. This is your life. So let's talk about hormone… it used to be called hormone replacement therapy, HRT, now it's called menopause hormone therapy, MHT. Whatever the acronym, what I want to talk about, the conversation every woman should be entitled to about hormones and using hormone replacement therapy to offset the symptoms of menopause and to prevent the myriad potential downstream effects of the absence of hormones.

[00:19:25] Just to frame the question and to give listeners a little bit of a sense of what I'm talking about, what is menopause? Menopause is defined as the absence of a menstrual period for a full year. The average age in the U.S. of menopause is 51 and a half years. That stretch of time of not having a menstrual cycle can occur in the mid 40s, it can occur in the mid 50s, there's a range.

[00:19:46] And during the lead up to menopause, people can experience a variety of symptoms. As a result of our ovaries no longer making robust amounts of estrogen, progesterone, and some testosterone. That can be hot flashes, night sweats, vaginal dryness, urinary tract infections. Pelvic floor, pain with intercourse, mood instability, rage, although maybe the rage is just that we're pissed off, but yes, rage.

[00:20:15] And then, of course, there are the less immediate and the long term effects of not having estrogen and progesterone in our bodies, which can be downstream osteoporosis, accelerated cognitive decline, cardiovascular disease, risk of heart attack and stroke, and then the accumulated... downsides of having painful sex or having urinary tract infections.

[00:20:41] How many women do I see in their 80s, for example, who end up having recurrent urinary tract infections? They're not even sexually active, necessarily. And that could have been ameliorated with hormone therapy from the get go, when they went through menopause at age 50, for example. So, the question I want to ask you is rooted in the reality that since June 2002, when the Women's Health Initiative study was halted prematurely and the headlines read, “hormone replacement therapy is bad for you.” We really took a hard right turn in the public square on the narratives around hormones. People, patients, doctors included, have been loath to prescribe estrogen and progesterone for menopausal symptoms.

[00:21:30] Because the narrative that came out of that 2002 press release was that we're doing harm to women. And that wasn't the narrative before 2002. In fact, hormone replacement therapy was almost standard of care. So you probably read the same article I did, the Susan Dominus article in the New York Times.

[00:21:51] I cheered. I also was sort of pissed off reading it, thinking where has the New York Times been for 20 years, but we'll take it better late than never. Her article was a very beautiful explanation of why we deprive women of conversations around hormone replacement therapy. It's easier to not talk about hormone replacement therapy because it's a long conversation in the doctor's office.

[00:22:18] There are risks of hormone replacement therapy, potential risks, but there are potential risks of not being on hormone replacement therapy. And you and I both know, and even the expert society for menopause has said that if given within the first 10 years of a woman's last menstrual cycle, hormone replacement therapy in most women does more good than harm.

[00:22:47] In other words, protecting you from long term downsides of not having estrogen, osteoporosis, heart disease, stroke, etc., and treating the menopause related symptoms that you have right now, arguably is better for most women than it is to not be on hormones. Now, of course, there's nuance. If you have a personal history of estrogen sensitive breast cancer, that's going to be a different conversation.

[00:23:15] To deprive women of that conversation and the choice, given that risk is everywhere and there's risks of hormones and there are risks of not being on hormones, that is where we need to start. Empowering women with facts and rooting their decisions. In their risk tolerance, not ours.

[00:23:32] Dr. Casperson: Yeah, I mean, I'm to the point now in my journey of like you want to control women? I got a good idea. Make them afraid. Now you have complete control out of them.

[00:23:41] Dr. McBride: Oh my gosh, Kelly, amen, hallelujah. And I'm not a conspiracy theorist, but sometimes I think I am.

[00:23:46] Dr. Casperson: Well, you start, I mean, you just do this long enough and you're like, I see what's going on because you know what you do when you empower women and you take their fear away, you give them agency and you give them the ability to choose what they want to do with their body—you give them a hell of a lot more power. So, that’s my whole thing now—I'm here to get rid of fear.

[00:24:04] Dr. McBride: It's very simple. If you have fear and shame in the driver's seat… 

[00:24:07] Dr. Casperson: Boom. Control.

[00:24:08] Dr. McBride: We are castrated, literally. If you have fearlessness and facts in the driver's seat and a good guide, like a Kelly Casperson or some other doctor who knows the data and is focused on you, not risk aversion for their own protection, liability wise, reputation.

[00:24:29] I don't know what doctors are doing when they're depriving women of the conversation or gatekeeping on hormone replacement therapy. But when you put women in charge of their own health and give them tools and information, watch out world. 

[00:24:42] Dr. Casperson: Yeah. Totally. I mean, the other thing, the other piece I think that Western medicine's very bad at is preventative health care.

[00:24:49] Dr. McBride: A hundred percent

[00:24:49] Dr. Casperson: And if we look at menopause hormone therapy as preventative health care because what we're doing is we're preventing heart disease We're preventing dementia. We're preventing osteoporosis. We're preventing genital urinary syndrome of menopause. We're preventing diabetes. And you can't see that—you can't measure that especially on an individual scale. And so you're like well just come in when you've got osteoporosis and diabetes and heart disease. We know how to treat you; we've got tons of meds for those problems. But to change the paradigm and be like, I would like to actually not need to be treated for those things, so I want to choose hormones. Hormones aren't perfect, but they will certainly help prevent to a decent amount.

[00:25:27] Dr. McBride: Right, I mean people get strokes, people get heart attacks, people get dementia for other reasons, age related, genetics, environment. But certainly the data are clear that again starting hormone replacement therapy within the 10 years of the last period tends to decrease those risks. I think what you're touching on, Kelly, is a really important point that Western medicine does a very poor job—arguably abysmal job—at countenancing things we cannot see, we cannot measure.

[00:25:56] So, we can measure cholesterol, we can measure your pap test, we can look at your mammogram result. We can hold it in our hands and look at the number on the computer screen. It is less easy—it takes more time, it takes more conversation and it takes an appreciation of the invisible components of the human condition—to weave in the invisible components of life.

[00:26:20] If you live to your 105 and you have perfect cholesterol and no stroke and you're, that's great. But if you are suffering for 50 years from pelvic pain, the absence of a healthy sex life, depression, anxiety, that's not necessarily a good thing we've done for this person. We can help them live long, but what about living well?

[00:26:43] And by the way, they're not mutually exclusive, right? It's not like I'm saying, oh, let's knock 10 years off your life to give you a good sex life. I'm saying, let's give you both. Let's be greedy. Let's give you quantity of life and quality.

[00:26:53] Dr. Casperson: I think the other thing is menopause is 30 years of your life. Right? Like, maybe you aren't going to decide to go on hormones this year, but go learn some more. You can start them next year, if you want to. Who do you want to be? What do you want your health to be? What do you want to be doing when you're 70?

[00:27:12] And think about your future self, and think about how I can set her up. Because once you're 70, once you're 75, you can't start on hormones. The risk is… because, I mean, you can. Technically, you can. But the risk goes up if you don't start during what they call the healthy cell hypothesis. You’ve got to start on healthy cells, keep them healthy, not start hormones on unhealthy cells. So we're going to think, and I asked these 50 year old women, I'm like, what do you want to be doing when you're 72? What's your plan? And a lot of them see moms with dementia, moms with osteoporosis, they've got stiff joints, they can't get on off the ground with the grandkids.

[00:27:49] And you don't have to be that. You can choose, as best as you can, to set yourself up for great health. But it requires making decisions in your 40s, in your 50s, to eat right, sleep well, exercise, possibly use hormones. We don't think about our future selves, and then, you know, she might be kind of miserable.

[00:28:08] Dr. McBride: It's true. You know, you probably get this question, and I do too, from middle aged women. How can I age gracefully? What can I do to preserve my cognitive, mental, physical health over time? And that's a great question and oftentimes patients have gone on the internet and they've bought some supplements, they've bought some gizmos, they've bought some gadgets.

[00:28:26] They've bought into, unfortunately, the sort of worshiping at the false idols of wellness. Not that I'm anti wellness. Wellness is part of our job, right? It's just that let's be real about what is evidence based and what is woo woo in a nice package. As you can tell, I have an opinion about that.

[00:28:43] Dr. Casperson: A woman sent me on Instagram today, what do you think about this supplement? And I'm like, are you drinking alcohol? Stop. Are you exercising? Start. Are you working on love in your life and keeping your brain expanded? So many people, they get narrow in their brain and their flexibility to think as they get older.

[00:29:03] Dr. McBride: Well, I think that we think that, not that people are not smart, but I think we start to think that agency exists in a pill. That we'll have control if we can just take the right supplement or pay enough money for some guru, right? And it's not that I know everything. I certainly don't. You can ask my children. It's that there is no vitamin, supplement, or pill for quality of life. It's an integrated sum of different components, and that includes agency. And hormone replacement therapy, arguably, is one of the things we can do to help people “age gracefully.” There's a whole industry, as you know, about treating the symptoms of menopause by nibbling around the edges of the symptoms, like giving you a little eye of newt and a tincture of whatever to treat the various symptoms.

[00:29:50] And people will go, women will go to extreme lengths and extreme costs to avoid being on hormones because of the narrative. And so the industry is now promoting, look, you can do non hormonal treatment. And that's fine. I'm not saying, I don't think you are either, that every person should be on hormone therapy.

[00:30:09] Not at all. It's not appropriate for everyone. It's not even necessary for everyone. It's just that we should be honest about the data and not steer people down the path of the sort of pseudoscientific wellness industry at the expense of their actual mental and physical health.

[00:30:24] Dr. Casperson: Our good friend Rachel Rubin is quoted in that New York Times article: “menopause has the worst PR campaign in the history” of health problems which is just brilliant. 

[00:30:32] Dr. McBride: What is it about Rachel? She has these sound bites. That was such a freaking brilliant quote. I'm just cheering for her so big, like you are.

[00:30:39] Dr. Casperson: mic drops, but it's true. Like we just, we think it's a hot flash and then we think it's done. I literally saw this woman this week. She's 52. She's having heart palpitations. She's having weight gain. She's having a moodiness. Her hot flashes are so debilitating. She has to pull over her car because it's unsafe to drive during her hot flashes.

[00:30:56] She went to her provider. They're like, we'll run some tests, see what your hormones are. She's 52, hasn't had a period in two years.

[00:31:03] Dr. McBride: smells like a duck, sounds like a duck, looks like a duck.

[00:31:05] Dr. Casperson: To me, I'm like, you're in raging menopause, you need no blood work. Get this woman on some hormones. Like, it's so obvious to the people, because menopause and hormones actually isn't that hard. We just didn't get educated. It's not hard. We just didn't get educated for two decades. We've had two decades of doctors who didn't get taught how to treat menopause because of the Women's Health Initiative.

[00:31:27] Dr. McBride: Right. And so people who are listening are going to think I'm making this up to make a point, but I'm really not. I spoke to a gynecologist this week who is someone I've worked with for decades. And again, like I'm not in the business of like demonizing other doctors. In fact, I am only as strong as my community of doctors I work with, but my patient is experiencing menopausal symptoms that are hard to measure.

[00:31:49] Depression, some heart palpitations, anxiety, sleeplessness, and just feeling like she's a broken person when it's all menopause. So I call the gynecologist because I want to be a team player and ask the gynecologist, what do you think about putting her on fem ring and progesterone? This is a low risk person.

[00:32:08] And she's a year and a half out of her last menstrual cycle, this was her response. She said, “can't you just put her on Prozac for the depression?” And I said, well, I'm not sure she's actually depressed. I think she's just experiencing menopause. And I think that the Prozac would maybe help with mood, but it's not giving her the treatment that is going to actually help, in my opinion.

[00:32:34] She said, “can't you give her gabapentin for night sweats?” I said, absolutely. We can do the workarounds. But what are you worried about, if I may ask, about putting her on true hormone replacement therapy? Basically, the hair of the dog that bit you. And the answer was, “well, the FDA has really only approved hormone replacement therapy for vaginal dryness.”

[00:32:55] I said, “well…”

[00:32:56] Dr. Casperson: Not true.

[00:32:57] Dr. McBride: Look, I believe in our federal government. I'm a registered Democrat, but the FDA does not know my patient. The FDA, as far as I'm concerned, is a gatekeeping apparatus to deprive women of these medications. So, as her doctors, you and me, I feel obligated to offer her something that would actually help with her symptoms instead of nibbling around the edges. What do you think? And she agreed with me. But it took a long conversation. She agreed.

[00:33:24] Dr. Casperson: Well, it's the… hormones are this, it's this myth that they're so dangerous. It's like Zoloft has a black box warning for suicide. Is that the preferred drug? Besides the fact that it isn't treating the root cause, which is low hormones.

[00:33:36] Dr. McBride: Exactly! The level of scrutiny on hormone replacement therapy is beyond any degree of scrutiny I've ever seen for any medication, right? Urgent cares are prescribing Z packs for viral colds. I mean... What are we doing by not giving people a natural hormone if they need it, if they want it, and they know the potential downsides?

[00:33:57] Dr. Casperson: 100%. Like, once you, like, as you see, you see this. It's absolutely insane. If there was a drug that helped men live three years longer on average, every man would be on it. That drug is called menopause hormone therapy. Multiple studies showing decreased immortality, increased longevity, and not only living longer, but living quality of life longer.

[00:34:22] And I'm like, do you, do you think the man would be on that if he had a chance to be on that? Heck yeah. And it's like, there's no other drug. What other drug is going to give you three extra years of life? None of our drugs, to my knowledge, have that kind of longevity data.

[00:34:37] Dr. McBride: That's right.

[00:34:37] Dr. Casperson: Estrogen has that longevity data. We blow it off. We would not blow it off if that was given to men.

[00:34:43] Dr. McBride: So tell me what your advice to people listening to your audience, Kelly, is, when they are experiencing symptoms of menopause, their doctor may not be... interested, have the time or be informed with all the data to have a discussion. What do you tell patients to do? In the power dynamic in a doctor's office, patients assume that their doctor knows everything.

[00:35:06] They're making a good judgment when frankly we are experts and we do know a lot, but it is not our job to tell you what to think, tell you how to feel or to gatekeep on medications. It's really to arm you with the tools you need to manage your everyday health. So what do you tell people? In your audience as a good kind of like three or four rules of thumb to bring to your doctor when you're experiencing menopausal symptoms or want to just have the conversation.

[00:35:35] Dr. Casperson: Yeah, I would bring in the 2022 North American Menopause Guidelines. That's a great document. Doctors are going to respect that document. And it really downplays a lot of fears. It says how safe it is. So come in prepared with something that the doctor, they speak that language,

[00:35:50] Dr. McBride: Great. And I'm going to link to that document in the show notes.

[00:35:53] Dr. Casperson: Yep. And the other pro tip for talking to a doctor about something that they might not be comfortable with is to say, you know what I'd like?

[00:35:58] I would like just to try this for a couple of months and then I'll come back and I'll report back and if it didn't go well, I'll stop. Does that sound okay to you? Most doctors are going to say yes to that. Because now they've got a plan, they know you're not going to follow up, right? I'm like, I just want to try this and see if it works.

[00:36:17] Dr. Casperson: Because I think people get so bent out on hormones, they're like, “should I do hormones? Should I not? Should I? Should I not?” It's like, “just try them. You could stop. This is not an amputation. It’s all okay.” But having that sort of plan with your doctor, I truly believe in a long term doctor patient relationship. They're going to know you. That is the best case scenario. That doesn't always exist in our current culture. And when women don't get what they need, the smart ones are going to go online. And that's where these online clinics for menopause are coming from, because they see we are underserving women.

[00:36:51] Doctors do not have time. This is a nuanced conversation. And I think for better, for better or for worse, but I think for better, you can get your hormones online now, because you don't have to spend two hours on hold trying to make an appointment with somebody you might not even know anyways. The healthcare system is kind of bad.

[00:37:08] We're not set up for this, right? We're not set up for the New York Times changing, like, how many millions of women are like, maybe I can consider hormones now. We're not set up for that. We're already full, right? So, I think that's the role of where these online clinics are going to come from. I think some are doing it well.

[00:37:26] Certainly, I don't think it's as good as an inpatient, in your town doctor patient relationship. But we do not have capacity to start tackling these issues like we should. And so I think that's the new role for the online clinics.

[00:37:39] Dr. McBride: Yeah, I think you're right. I mean, it's sort of like the sort of outcrop of mental health providers who are doing virtual care to kind of meet the demand. I don't think online virtual therapy is ever going to replace in person therapy, but it's better than nothing. And if they're doing good and people have managed expectations about what an online therapist can do, Great. Similarly, a lot of these outposts, these online businesses helping people with menopause and hormone replacement therapy are really doing good work, like MyAlloy, which was founded by a friend of mine, Ann Fullenweider. Their medical advisor has been Sharon Malone, who's a really well respected OBGYN in DC.

[00:38:20] She's a friend of mine as well. And they're doing really good work trying to empower women with facts and information because not every woman, A, has a primary care doctor, B, is comfortable talking about these things with that doctor, and C, has the time and the visit to even discuss these things. So I think it's a net.

[00:38:38] I just think people need to be careful about the snake oil salesmen that are telling you to just take this little eye of newton—whatever the metaphor is—because we run the risk of misinformation running rampant as it already is.

[00:38:52] Dr. Casperson: Well, yeah. And people's dollars are limited and you go online and it's this supplement, that supplement, what's the new trendy thing? And at the end of the day, I want you to save your money. Like, you really don't need a lot of that crap. And hormones are pretty darn cheap. They've been around since the 60s and 70s, right?

[00:39:08] If we came out today with a drug that made you live three years longer, you know how much that would cost? Right, and you can get that in estrogen for pretty darn cheap. So that's…

[00:39:17] Dr. McBride: The other point I'd love to make that people don't always understand is there's a lot of brand sort of marketing lingo around hormones that in my opinion is unnecessary and make people think that there's like a right way or a wrong way to take hormones. The word bioidentical is sort of having a moment and I would just say to people you don't need to buy fancy brand name hormones.

[00:39:41] CVS, Walgreens, not that I'm a big believer in chain pharmacies, but your regular pharmacy has “bioidentical hormones.” In other words, micronized progesterone, which is the safer progesterone and estrogen in the form of a tablet, a patch, a ring is as close as it can get to not being actually your tissue.

[00:40:03] So, I think that people need to be educated on the fact that it doesn't have to be fancy, formal, or brand name, and to be suspicious of anybody who says that they have the best bioidenticals and someone else doesn't, because that is just made up.

[00:40:20] Dr. Casperson: It's made up. Well, I mean bioidentical came because we were so freaking afraid of hormones That it was a way to help people stop being so afraid of hormones. So it was kind of like this lead in to safety But I tell people it's like you know when you like you have a granola bar and it says natural on it and I'm like, you know what the natural means like legally And they're like, no. And I'm like, it means nothing. It doesn't… 

[00:40:43] Dr. McBride: It's a marketing word. It's a marketing word. It's a way to deescalate fear and to make people feel like it's their own body. When... if we can just get rid of the charade and just get people what they need, we'd be a lot better off.

[00:40:55] Dr. Casperson: Yeah. And most cheap FDA approved products are “bioidentical.” They're the same. 

[00:41:00] Dr. McBride: It is funny. I mean we're all victims of sort of messaging and narratives and we're beneficiaries of it too. But it's just you have to know what the landscape is because otherwise we get tripped up and believe things that are just sort of hoo ha. I'm a victim of that too. And do I buy soap at CVS that says lavender scented calming soap?

[00:41:24] I was laughing at that the other day and I was like, as if this soap is going to calm my noisy brain down. If it did, that'd be awesome, but I'm just going to manage my expectations that this soap is just going to clean my hands.

[00:41:37] Dr. Casperson: Yeah. A hundred percent. The power of the mind, man. I mean, going back to sex, placebo gives you an erection 40% of the time. So, the mind is very powerful.

[00:41:45] Dr. McBride: It's true. So Kelly, as we come to the close of our conversation, I'd love to just thank you for helping change the narrative for arming people with facts and tools and for reaching people where they are, because this is where we need to be in the modern era. We need women to have truth, access to tools and to take shame and fear out of the driver's seat.

[00:42:12] Thank you so much for joining me.

[00:42:13] Dr. Casperson: Thanks for having me.

[00:42:15] Dr. McBride: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download, and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you liked this episode to rate and review it. And if you have a comment or question, please drop us a line at info@lucymcbride.com. The views expressed on this show are entirely my own and do not constitute medical advice for individuals. That should be obtained from your personal physician. 

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Beyond the Prescription
Each week, Dr. Lucy McBride talks with her guests like she does her patients — pulling the curtain back on what it means to be healthy, connecting the dots between mental and physical health. To Dr. McBride, health is about more than the absence of disease. Health is a process, not an outcome. It's about having awareness of our medical facts, acceptance of the things we cannot control, and agency over what we can change. To learn more about Dr. McBride, visit: https://www.lucymcbride.substack.com/about To sign up for her weekly newsletter, visit www.lucymcbride.substack.com/welcome