Ep. 230 All the Things You Want to Ask Your Doctor About Vaginal and Pelvic Health, but Are Afraid to Ask

Cynthia Thurlow: Welcome to Everyday Wellness Podcast. I’m your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.

Today I have the honor of connecting with Dr. Betsy Greenleaf. She’s a premier women’s health expert, bestselling author and specializes in female pelvic medicine and reconstructive surgery. She is the first female in the United States to become board certified in urogynecology. Today I asked her all the questions that so many of my listeners have privately shared with me. We talked about her background in surgery, we spent a great deal of time talking about the vaginal and gut microbiome, the impact of urinary incontinence, which is a $20 billion a year industry, risk factors, ways to address this as well as chronic urinary tract infections, interstitial cystitis, uterine prolapse, vulva vaginal conditions, changes that happen to our vulvas in perimenopause and menopause. And this includes changes in loss of muscle, loss of elasticity, loss of estrogen, which has a significant impact on the vaginal microbiome. The impact at Women’s Health Initiative and therapies to address all of these, I hope you will enjoy this conversation as much as I did. I have no doubt Dr. Greenleaf will be back to have a second round too.

Dr. Betsy, it’s a pleasure to connect with you outside of our normal avenues. So nice to have you on the podcast today.

Betsy Greenleaf: Yay.

Cynthia Thurlow: I’d love for you to share with listeners a little bit about your background, because you started as a general surgeon and then you ended up going into gynecology and then urology, and so you have this very important distinction. I believe you’re the first female urogynecologist.

Betsy Greenleaf: Yeah, the first board certified. So, which is interesting, because urogynecology wasn’t a specialty until the late 1970s. And it didn’t actually become a board-certified specialty until 2014, I think it is, I should actually look at the actual year. I went to medical school and was one of those people, I wasn’t exactly sure what I wanted to do. I just wanted to help everybody, I wanted to save the world. And so, I went through my rotations and I’d be like “Oh, I like this. I don’t like that.” And I found myself drawn to the surgical subspecialties. When I started off in general surgery, though, there was something that was really lacking was– and let me tell you, I love general surgeons. If your appendix burst, you want a general surgeon. So, but I found them to be very body mechanics, like get in there, get the job down, get out.

When I was rotating during general surgery, I was the one who was seeing the patients, like, “So how are you feeling today? How are things going? How do you feel now that your gallbladder is gone?” I wanted to know that emotional kind of connection and you don’t get that in general surgery. I got halfway through and I was like, “Well,

what I want to do,” and I couldn’t decide between OB-GYN and general surgery anyway, so I went with general surgery first and then I switched into OB-GYN, and obstetrics and gynecology. Though I love delivering the babies, I was missing the surgery aspect of it. So now I had the relationship with the patient, but it wasn’t getting as much surgery as I wanted.

And it wasn’t until my senior year in residency that topic of urogynecology came up. And I’m like, “What in the world is that?” I remember actually, when I first got a fellowship in urogynecology, I told my mom and she thought it was like Euro Disney, like European, like it was some kind of fancy gynecology. I’m like, “No, it’s ‘uro’ like urology. Having to do with the bladder and urinary system in gynecology. So, it’s a combination.” I did a residency and then a fellowship in the urogynecology. And then here we are.

Cynthia Thurlow: I would imagine this kind of burgeoning specialty is really important because women want to be treated by other women, we all share the same parts. And I think there’s something about that shared experience that allows women to perhaps put their guard down. Now, when you’re in clinical practice, what are some of the common things that women will come to you for, and part of this conversation is to really destigmatize talking about pelvic floor health, to destigmatize talking about painful sex, to destigmatize urinary incontinence, because if you live long enough, you may or may not experience one or more of those issues.

Betsy Greenleaf: Well, unfortunately 50% of women experience prolapse and you might not even know you have one. And somebody’s like, “What is a prolapse?” Well, I’ll tell you when people have them, and it’s not something that’s often talked about, they freak out, because all of a sudden, something’s bulging out of their vagina. And people are like, “Oh, my God, do I have a tumor? What is happening? Am I turning inside out?” Really what happens to a 50% of women is that as we age, and it could be from childbirth, or lifting heavy objects, or bearing down too hard to have a bowel movement, we damage the ligaments that hold the uterus and the vagina and the bladder and the rectum up. And so our pelvic floors are just really just open to gravity. We really don’t have anything other than those ligaments holding everything in place. And everything kind of droops and drops and sags and other parts of our body as we age. But when things are coming out of the vagina, because people don’t talk about it, a lot of patients are panicking. Often too, which will go along with that incontinence.

There’s a number of different types of incontinence. There’s stress incontinence when you cough, laughs, sneeze, or more commonly, there’s overactive bladder. This is something that urogynecologist take care of. This is where like, all of a sudden, you’re fine, and then you’re like, “Make way, I got to get to the bathroom.” Where your bladder just really spasms and it’s trying to push out the urine before you’re ready to pee, and then there’s this sudden urge to have to go or maybe you’re going 10 bazillion times in the day or 10 bazillion times at night. The interesting fact is, this is something that can start as early as in your 20s. And this is for men and women, by time we reach our 70s, there are more people walking around at any given time with an overactive bladder that has the common cold. Except we don’t talk about it. And the pad and diaper industry is a multibillion-dollar industry.

Lot of people just look at this as, “Oh, it’s just a happens when you get older and they blow it off.” Really just because it’s common doesn’t mean that there isn’t things that can be done. And there’s tons of different treatments for that. So typically, most your urogynecologist deal with prolapse and incontinence. Those are the two biggies. Recurrent urinary tract infections, even sometimes fecal incontinence has difficulty holding in stool, and pooping yourself, that happens. And then I had a special interest in recurrent vaginal infections and pelvic pain. So, those were things that we took care of.

Cynthia Thurlow: It’s really interesting because I was an ER nurse in Inner City Baltimore. I probably have not told this story on the podcast before. When I was precepting a student, I sent my student in, we’re going to put a Foley catheter. For anyone who’s listening, this when you put a tube into the urethra to help someone debulk their bladder. And this is a woman who came in with congestive heart failure and was going to get diuretics, which are going to make her pee. And my student who was very, very innocent, came back out and said there’s something obstructing her vagina. I was like, “Okay. Can you describe it to me?” She was like, “I think it’s a potato with sprouts.” I went back in with my student, I identified that, yes, indeed, there was a sprouted potato. And I said to my patient, I was like “Mrs. Smith,” her name wasn’t Smith, but for argument’s sake, “Mrs. Smith, I believe that you have a potato in your vagina.” And she said, “Yes. That helps my inside stay inside.” Pessaries are oftentimes a way that we deal with uterine prolapses, and this is a woman who had had seven children, vaginally, and so I’ve never been able to share the potato pessary story, but now I’ve shared it. And needless to say that was a source of interesting conversation for my student probably for years to come.

When we talk about urinary incontinence, I feel nearly everyone I talked to, even my grandmother who was a retired nurse, she used to talk about this all the time. She just said, “We just assume that we have to start wearing pads, once we get north of like 55 years old.” And as you mentioned, it’s a $20 billion dollar industry. Even like Lisa Renner, who’s one of The Real Housewives of Beverly Hills pedals, depends and talks about how she wears them underneath her evening gowns, which I can’t imagine. But let’s talk a little bit about some of the things that set us up for developing these pelvic floor issues. I know you mentioned vaginal delivery. For a lot of people, they go through a protracted labors, long labors, maybe they do hours and hours and hours of laboring and then they end up getting a C-section. But I think about things that for me were surprising to learn about can be risk factors for developing urinary incontinence, including chronic constipation. But as you mentioned, it’s that chronic pressure in our abdominal cavity that will wreak havoc on the pelvic floor muscles.

Betsy Greenleaf: Yeah, so unfortunately– I wish I could say that that potato story was not the only time that’s ever happened. But interesting, back in ancient Egypt, they used to use pomegranates. In ancient Rome, they used to use rocks. I advise against all those. But the idea with a pessary is it’s a support device that you put in the vagina, wedges in place and holds things up. They do make medical grade ones that are actually made out of silicone. So, I’d recommend that. Or, there is a product over the counter called the Impressa, which is almost like a tampon that can be bought– It’s made by Poise. It’s almost like a tampon that can be used to hold things up like that. But you’re right, people want to be like, “Well, how do I prevent this to begin with, so I don’t even get to that point?”

Well, unfortunately, any woman who’s had children is at risk. So, and you don’t have to have had a vaginal delivery. Like I know too much, so I had elective C-sections, which they don’t really allow them much anymore, but to try to save my pelvic floor, and I still ended up having a prolapse, because the weight of the pregnancy can damage those ligaments. So, anything that’s going to put pressure on the pelvis, like if you’re somebody who has asthma or chronic bronchitis, chronic coughing can do that. A lot of women, just try to be tough, and we do everything ourselves. And so, if that means like lifting something heavy, we’re like, “Hey, I’m superwoman, I can do it”. Well, if you lift things heavy and you’re not lifting properly, which means blow out as you lift, what if you’re holding your breath and straining as

you lift, that pressure is going to build up in your abdomen. It’s got to go someplace, and a lot of times it’s toward your pelvic floor. So, you can damage the ligaments in your pelvic floor because of that.

That’s why when we see weightlifters, they’re like blowing out, because they’re lifting because they’re trying to give themselves a hernia. And a prolapse is just a pelvic hernia. I can’t tell you how many, like people in the United States are chronically constipated. I mean, our poor diets, unfortunately, we’re not getting enough fiber, not getting enough water. 75% of Americans are chronically dehydrated. So, the combination being dehydrated and not enough fiber in our diets, and makes it hard for us to pass our bowels. And sitting on a toilet and straining and straining is going to damage those ligaments also. So, trying to keep the bowels as normally as possible. I love doing microbiome testing of the stool, which is a way for us to look if the bacterial, the gut is imbalanced, which can also add to constipation. All these things play in together for pelvic floor strength. But something that’s really interesting is in France, as you have a baby, you immediately go into a pelvic floor physical therapy program.

In the United States, if you have orthopedic surgery, what do you do afterwards? They put you through physical therapy. But they don’t put you through pelvic physical therapy in the United States if you have a baby. So, this is something like these pelvic damage happens in our earlier years. It’s not showing up until years and years later. So, we need to be doing our Kegels, and unfortunately, a lot of people don’t do Kegels correctly, a lot of people are bearing down instead of thinking about lifting up. But I had someone explain it to me. I like this explanation like picture having a straw in your vagina and you’re trying to like suck up fluid through a straw, that you’re going to be doing a lifting motion when you’re doing your Kegel exercises, not bearing down and not doing them when you’re trying to pee.

The only reason they tell you to do it, when you’re trying to pee is to figure out what muscles you use to stop the flow of urine. But a lot of women will be like, “Oh, I’m doing it every time I pee.” No, because what happens with that is, if the pee is not coming out, and your bladder is trying to push, the urine is going to a go where the least amount of pressure is and that could be back up to the kidneys.

So, you don’t want to be doing it at that point in time. But the same muscles holding in gas, holding in stool, holding in urine, it’s all the same. So, keeping those muscles strong, because we start losing 8% of our muscle mass every decade after the age of 30. So, by time we reach our 60s, there are people can actually develop what’s called pelvic atrophy, where the muscles in our pelvic floor, they’re so thin, they can’t do anything. So, this will help protect the pelvic floor help keep things up, help with incontinence, help with sexual function. And a lot of people don’t think of that not having an– like, women will complain sometimes that their orgasm as they get older is not as strong as it used to be, that’s because those muscles aren’t as strong. So, you need to actually keep doing those exercises to strengthen the pelvic floor. I’m trying other things.

The other thing that happens as we age is our estrogen levels start to go down. When our estrogen levels go down, our vaginal tissue starts to thin out, and we do get some support from that tissue when it’s thicker and healthier. All of a sudden, we’re in our 50s and 60s and we have thin mucosa, thin muscles and weakened or damaged ligaments. And now this is when for the majority people, these conditions are starting to show up. Even though it can show up in younger ages, or it can show up later, majority people in their 50s are going to start seeing these problems. I have to say I know better. And I

was so mad the other day, I went to go lift something really heavy, and I know better not to, and all of a sudden, I was like, “Damn it, if I didn’t pee a little bit in my pants. Gosh. Darn it. I know better not to do that.”

Cynthia Thurlow: Well, but I think it goes without saying that with awareness and education, we can think about these things, even as an NP, because I had two breech kids, I had two C-sections, I kind of assumed I was safe from the pelvic floor issues. So, you’re absolutely correct. I had two big kids, not being a very big person. And even though I didn’t go through pushing babies out of my vagina, you’re right, over nine months of caring pregnancies, that alone can weaken the pelvic floor muscles. One thing that I thought was really interesting, and I got some questions specific to interstitial cystitis, which I promise is we’re doing a segue, people who say that they’ve got these bladder irritants, and that can exacerbate the incontinence symptoms. So, I started thinking about things that seem pretty benign. Like, coffee, tomatoes, citrus fruits, alcohol, chocolate, and how that can underline this urge incontinence.

When you feel like you have to go, you have to go. I jokingly say to my husband, I drink a lot of water during the day, and I have to be very careful how much I drink relative to how much walking around and talking and podcasting and those kinds of things. If I keep thinking about needing to go, it almost becomes like I’m definitively going to have a little bit of spill of urine. The other thing that I thought was really interesting, because I had a couple questions about interstitial cystitis, which we’ll talk about was the foods I eat I know can worse than that. And I was explained that it can also worsen this urge incontinence. So, just being careful and conscientious. If you’re prone to that, don’t wait until your bladder is totally full, like try to be more regular and diligent about emptying your bladder. So, you’re not getting to this point of no return. I think back to when I was pregnant, and you would have that like I have to go right now. Sometimes you still get that sensation, you’re not pregnant. But as you mentioned, the muscles are not as strong. It’s important to do Kegels, probably many of us aren’t doing them at all or doing them improperly. And how all of these changes with age, including the hormonal fluctuations can exacerbate these symptoms.

Betsy Greenleaf: Yeah. Interstitial cystitis is a really interesting condition, and it was discovered in the late 1800s, and we still don’t know much more about it. It’s an inflammatory condition of the bladder. I have my own opinions after treating it for many, many years. There are foods that can aggravate it. There has been this theory in the past that there’s this gut relationship to it, and I have seen that over the years that gut imbalances will make people more sensitive to these foods were histamine intolerances. People who can’t tolerate foods that are high in histamine, but foods are also very high in acid, like the ones you mentioned will also irritate the bladder. What happens with interstitial cystitis is you get microscopic cracks in the lining of the tissue.

It’s almost like a paper cut in the bladder. When the urine gets into a paper cut, it burns. If you had saltwater and you poured it on your finger and your finger was normal, you’d be like, “Eh, whatever.” But if you had a paper cut and you poured some saltwater on your finger, you’d be like, “Oh, my God, this hurts,” or it would cause some irritation. So that’s what interstitial cystitis usually is. Also, foods that are high in artificial sweeteners and artificial dyes can be very irritating. I myself years ago was dieting and I wasn’t drinking enough fluids. And so to try to drink more fluids, I was drinking Crystal Light. And

all of a sudden, I developed this, felt I had Tabasco in my bladder. This is what I do for a living, and I’m like, “There’s no way I have interstitial cystitis,” and I had to go to somebody else to scope me. Sometimes they can pick it up on a scope, sometimes they can’t. There’s no definitive test for it. When I had big ulcers in my bladder from the artificial sweeteners in the Crystal Light, so that can be very, very irritating.

Any things that are bladder irritants, like the foods that you mentioned, anything’s a very acidic, they can also aggravate, not only interstitial cystitis, but also overactive bladder symptoms. There’s so many other causes. Sometimes there are causes that are not related to the bladder for these kinds of conditions. If you have something wrong with the spinal cord of herniated discs, that can sometimes cause inflammation downstream of where the back injury is. And so that’s going to affect all those organs that are downstream. And that could be the vagina, that could be the vulva, that could be the bladder. So, a lot of times when we’re looking at these pelvic symptoms, sometimes the body’s screaming for help. And there’s another problem elsewhere. Surprisingly, I have found women who’ve had tears in their hips, whether they’re like doing lots of sports or even during childbirth and straining, they’ve torn a ligament in their hip, and they don’t feel the pain in the hip, they feel the pain in the pelvis, and now their pelvic floor becomes spasm, or their bladder becomes inflamed or the vulva becomes inflamed because that’s those downstream nerves are going, “Okay, you got to start looking for the pain elsewhere.”

It’s difficult, because anytime people hear the word vagina or pelvis, there’s a lot of shame and embarrassment around those organs, and really, they’re just other body parts, really should just normalize the conversation about those areas. But I see it even in the medical community is if you go to a doctor– I’ll send patients to the orthopedic because I’m like, “I think I want them having checked the back or check the hip.” And they’re like, “No, it’s vagina, it’s yours.” If they hear vagina or bladder, like, “No, that’s your parts, go back to the urogynecologist.” I’m like, “No, no, no, it could be these other areas.” You almost are like a detective trying to uncover what areas are causing the problems. I said even diet and inflammation in the gut can lead to some of these issues.

Cynthia Thurlow: It’s really being a detective, and you’re talking about referred pain, meaning, that you injure your hip, injure your back, and then you’re having genital urinary pain and discomfort. Thank you for being such a huge advocate for women, because let’s be clear, the traditional allopathic model is very laser focused on your organ system. If you’re an orthopedic surgeon, you treat joints and bone issues. If you’re a cardiologist, you focus on the heart, and maybe other major blood vessels. So important to be thinking root cause systemic manifestations of things that can happen.

We started talking a little bit about some of the changes that are occurring in the genital urinary system. We call it the GU system. As we’re transitioning into perimenopause and menopause. And you talked about this loss of estrogen and how that impacts the vagina. And I think this is really important for people to understand. This is why the pH of vagina changes, the microbiome, we have a vaginal microbiome and an oral microbiome and a gut microbiome, and they’re all interrelated. So, if one is unhealthy, very likely the rest of them are not healthy either. But let’s talk a little bit about what’s starting to change in the vagina or vulva. It seems to be now like it’s more in vogue to say vulva. What is your preference?

Betsy Greenleaf: No, I always say vagina only because that’s what most people will say. But vulva is really the outer part, and vagina is the tube inside. So proper would be the vulva, but we’re getting changes as we eat in both areas. And so, you’re getting extending of that tissue. Where that comes into play is that now as we age, we are more at risk of recurrent vaginal infections and urinary tract infections. More issues with odor. Some people are always like, “Well, I have a bladder infection.” “I have vaginal infection.” They just know the symptoms. So, this may be like itching, this may be burning, and this may be an odor, whether it’s in the bladder or the vulva or the vagina. And so what ends up happening is when we’re young and our hormones are going crazy, we have this nice thick vaginal tissue that’s actively growing. And as it actively grows, the new tissues are pushing out the old cells, and old cells slough off. When they slough off, they contain a chemical called glycogen. That’s actually the food source of lactobacillus. The lactobacillus is a bacteria and there’s many different strains of lactobacillus. But that’s the healthy bacteria that we can’t live without.

It keeps our vagina healthy, keeps our bladder healthy. And so how it does that is it eats the glycogen in these cells. And in return, it produces hydrogen peroxide. And that hydrogen peroxide chases away the bad bacteria, chases away the yeast and also balances the pH of the vagina. So, it keeps the vagina very acidic, so everything stays in balance. Now what ends up happening is, as we get older and that estrogen level starts to go down, we’re essentially starving the lactobacillus to death. And so, once the lactobacillus is no longer there, now bacteria from the rectum, because the rectum and the vagina are so close together, no matter how clean you are, like, people always think like, “Oh, I’m very clean. Why am I having these problems?” It has nothing to do with cleanliness. It has to do with the anus is very close to the vagina. And just by proximity, bacteria will transfer back and forth.

Of course, proper wiping and hygiene does play a factor, but even in the cleanest people, you can still get recurrent infections. So, the bacteria from the gut now gets into the vagina. And that’s one step closer to the bladder. And so that’s usually where the bladder infections are coming from, as the vagina is acting as a reservoir for the bacteria that’s now getting into the bladder, causing urinary tract infections, bacteria that’s getting into the vagina and the vulva area causing odor and itching and burning and discharge. And so unfortunately, these things all get thrown out of whack. Even worse is that when the basic bacteria is out of balance, it actually increases our risk of sexually transmitted diseases, because now we get inflammation in the vagina and microscopic, like cracks in that tissue.

And that’s actually puts us at higher risk if we are with a partner that might have had some other infection, it puts us at a higher risk for sexually transmitted infections, HIV and other bacterial infections. So, it becomes very difficult. And in the past, all we had to treat the vagina was topical hormones. And a lot of people get nervous about the hormones, and

themselves are not evil. It’s the synthetic hormones that were really on the market that were the problem. But now there’s a lot of bioidentical options that are even prescription based that can be used, or if you don’t want to use hormones at all, then the regenerative therapies, which are fascinating.

A lot of the regenerative therapies have been around since the 1980s, early 90s. They’ve been used for cosmetic purpose. Lasers been used on people’s faces since the 80s for skin rejuvenation. I wish I came up with it, decided, “Well, wait a minute, I turn that into a one that can be placed in the vagina,

can we rejuvenate the vaginal tissue?” And lo and behold, you can and that kind of birth the industry of using, things are used cosmetically for the vagina. So that’s now lasers, that’s radiofrequency using sound waves to generate heat. When you heat tissue to a certain temperature, it will cause regeneration of the tissue.

Using red light ones, red light therapy can also cause regeneration of the tissue. There’s something called carboxytherapy. And that’s actually applying a topical carbon dioxide gel to the tissue that will actually attract oxygen into the tissue would recall regeneration. And those are two things that can be done at home where the red light and the carboxy where the other things have to be done by a health practitioner, or even platelet-rich plasma. Using the growth factors in your own blood and having them injected in and around the vulva and vaginal area to cause that tissue to regenerate. So, there’s really some fascinating things that are on the market now.

Cynthia Thurlow: Yeah, it’s really interesting. I know we have a mutual friend who has tried all of these things, Susan Bratton, who’s actually been a guest twice, and talks about all things related to sexual health. Now, when we’re talking about these changes that are happening in the vaginal microbiome, the vulva, etc. We would be remiss if we don’t also mention like testosterone. And for a lot of women, they get the combination of the ligamentous changes, to their orgasms aren’t as strong, exacerbated by this loss of testosterone. Then for some women, they are using both bioidentical estradiol, progesterone and also testosterone to help with that.

Now, I would love your take on the Women’s Health Initiative. I always love asking my GYN colleagues and friends. I talk a lot about this on the podcast that I think we have a whole generation of clinicians, as well as women that are paranoid about taking hormones. Thankfully, I’ve had a lot of guests on that have talked about how this has really disrupted entire generation. I look at my mom’s generation, and it actually– for me, I was finishing my NP program in 2000 into 2001. So right at the time when the Women’s Health Initiative data was released, I feel like in many ways, it’s done a lot of detrimental things to not just women and women’s health, but their sexuality, their cognitive function, their bone and brain health. What is your take on that in your position?

Betsy Greenleaf: Yeah, I was doing my residency when that came out. Prior to the Women’s Health Initiative, it was like, “

hormones, it’s going to keep you young, it’s going to keep you healthy.” And then the Women’s Health Initiative came out. This was a study that looked at estrogen and progesterone in women. And they stopped the study because there were women who developed breast cancer, estrogen related cancers and heart disease. And so, it all of a sudden came to a screeching halt. And then what was taken out of that is doctors panicked, because first thing we do is do no harm. So, we’ll just take away [unintelligible 00:30:00] hormones, we won’t harm them. Well, instead of actually looking at this study. And so now looking back, we go, “Wait a minute,” this study was done. number one, an older population that probably based on their age, and lifestyle alone were at higher risk for these conditions. And then the biggest problem was it was done with synthetic hormones.

And so we know that synthetic hormones when the body metabolizes them, it doesn’t break it down in the same way as natural hormones. Synthetic hormones have toxic metabolites that is known to damage DNA. When you damage DNA, when the DNA repairs, you can sometimes turn on cancer

genes. It was in the estrogen progesterone arm of the study, whereas probably more so the synthetic progesterone than anything else, that was the issue. We know that with synthetic progesterone, there’s increased risk of anxiety, depression, problems, sleeping weight gain. But when you give someone natural progesterone, they have improvement in mood, they have improvement in sleep, they decreases their risk of all these cancers, it increases–

An estrogen and progesterone are also– we think of them as hormones, we think of them having to deal with what makes us feminine and have sex. And they’re also neurotransmitters, and they protect our brain. And they have to be taken in conjunction with each other to get that neurotransmitter protection. The WHI studied did a great in service to women, because even the estrogen alone harm, even though it was synthetic, which I’m not a big fan of synthetic hormones, there was protection against colon cancer, and there was protection against osteoporosis. So, there were more benefits and there was harm in the estrogen alone. But the problem with bioidentical, and I like to call them bioequivalent, because I think bioidentical has been overused and sometimes gets a bad rap. But bioequivalent, which are naturally occurring types of hormones, is that there’s really not a big pharmaceutical company market for them, because you can’t patent something that’s natural. And because of that, unfortunately, we’re not going to see giant studies looking at these hormones, because there’s not any money to do a giant study.

Now, with that being said, everyone thinks you got to get your hormones have to be compounded to get them as bioidenticals. There are some prescription bioidenticals on that market, too. There are some really good options with that. There was a recent saying, I’ve been looking for this because I teach this course on this and can’t find an article. But there was an article that showed that if you don’t get on hormones within five years or three years of going through menopause, and you go on, like hormones later, you’ve lost the brain protection. So, actually we need to be getting on the hormones when we’re younger for brain protection than after protection, you can actually lose that.

I had a hysterectomy when I was 41. And at the time, I didn’t know a lot about integrative and functional medicine. Even as an OB-GYN, I was scared of hormones. So, I was stubborn, I’m like, “I’m not going on hormones. I’m not doing it. I’m not doing it.” Well, after five years of hot flashes and just side effects, I was like, “I don’t care if it causes cancer, give me the hormones.” Well, I’m really upset about is that looking back, I wish that study about the brain protection was out because now it doesn’t matter that I’m on hormones, I’ve already lost that brain protection of the neurons for the brain because I didn’t get on it within three years of my hysterectomy. So, luckily, there are newer studies that are coming out. But unfortunately, there’s still this great fear of hormones.

Personally, if it was up to me, I would take synthetic hormones completely off the market because I just think they’re dangerous, and that’s my opinion. I also wish we had, there are no bioidentical birth control methods out there. I wish somebody would come up with a bioidentical birth control because we know even with birth control, not only you’re getting synthetic hormones, but those hormones affect the gut. And the same thing, if you’re taking hormone replacement with synthetic hormones, it’s affecting your gut microbiome, which is leading to other inflammation and leading to vitamin disruptions. So, we’re getting vitamin deficiencies from those synthetic hormones.

Cynthia Thurlow: Well, probably most people listening were on oral contraceptives for a period of their youth not realizing that they were not giving full consent. I certainly would have thought very differently about oral contraceptives had I been fully informed. It impacts the gut microbiome. You mentioned the B vitamins. We know that your pheromone sensitivity is different when you’re on oral contraceptives, so you might not even pick the same partner. A lot of women probably come off of contraceptive. At some point, they’re like, “Well, wait a minute, this is probably not the person I should be with.” But I think it’s important to bring that out that we’re hopeful that they will– they meaning, Big Pharma is going to be looking into options beyond synthetic oral contraceptives, etc.

Now, one thing that, I, in my research and listening in on other podcasts you have done here, you were talking about ingredients in some of the hormonal replacement therapies, specifically estradiol that sometimes women will use because they’re having predominant vaginal symptoms related to hormone loss. And so, there’s an ingredient called propylene glycol.

Betsy Greenleaf: Oh, yes. [laughs]

Cynthia Thurlow: Which I know you are not a fan of. I’d love to talk about why, because there may be women listening that are maybe not on a patch, maybe they’re using this in lieu of systemic absorption of estradiol, which is the predominant form of estrogen prior to going through menopause. And so let’s talk a little bit about what this does, along with the parabens. There’s a lot of parabens and propylene glycol that are in these estradiol preparations that we’re using in our vaginas.

Betsy Greenleaf: Yeah. And also, it’s found in a lot of lubricants. And it’s actually found in the cream yeast medications or the bacterial vaginosis medications. So, propylene glycol is a thickening agent, it’s also used as a preservative. It’s actually considered food safe when you look at it from any of the websites when it comes to how the FDA clears these products. I actually found it in some hot sauce recently, which was a little annoying to me, because my kids wanted to eat something and I’m like, “What are those ingredients?” And it was in some food products, but what it can do is it can be a mucosal irritant, so can actually irritate that delicate tissue in the vulvar area. Once again, this was not something I was taught in medical school. It’s something I found out years later, and I would see patients where you’d give them a prescription and are like, “Here, I’m going to give you this, this medication for your vagina.” And they would be like, “It burns, it burns, it burns.” “It’s burning, it’s supposed to be helping.” And like, “Okay, we’ll switch it to a different one,” and it burns, and you’re like, “What is going on?”

Well, some people they’re very sensitive to this propylene glycol. I tried to find products that don’t have it. There still are some that I will recommend that have it, because I’m like, “All right, well, the other ingredients kind of outweigh.” But for the most part, I try to stay away from it, because it can be an irritant. Well, the whole science of lubricants. When we think of lubricant, you think about K-Y Jelly. And when you’re in a medical office, we’d have big tubes of surgery lube. But if you look at the ingredients on it, they contain a lot of propylene glycol. And even worse, we now know that those products are not only not pH balanced for the vagina, but their osmolarity is not right for the vagina. So, osmolarity has to do with the amount of particles and solutes in this material. And if there’s too many solutes, what it

does is, it’s almost putting salt on a slug. It’s going to just shrivel up the tissue. K-Y, purposely, and they know this, it purposely dries the tissue, so that you have to use more–

Cynthia Thurlow: More.

Betsy Greenleaf: They’d have to keep buying more, but it’s horrible. Years ago, we actually switched the lubricants in our office to being more vaginal friendly products, like Good Clean Love is a great company, they make ones that are pH balance and very closely related to the actual osmolarity of the vagina. There’s another company called Uberlube that makes one. There’s this whole science now behind vaginal lubrication. These products are now, thank God, because people are becoming more aware, are demanding that these are balanced for our parts.

Cynthia Thurlow: It’s interesting, because I think the assumption is made if it’s in a store, or if it’s my doctor’s office, from my NP’s office, then evidently, it’s good for me. And I’m the first person to say that, parabens alone, which can be these estrogen disrupting [crosstalk] chemicals you’re putting it right into a very vascular part of your body. And we have to as consumers really be advocating and asking and demanding for these things. I know, anytime I go to my local GYN’s office, and I’m sure this is not a criticism, but any woman who’s had a GYN exam, they over lubricate everything and you feel like it’s a slip and slide. You’re like, “Oh, my gosh, how can I get the stuff off of me?” There’s just so much of it to make sure that the speculum examination all goes kind of effortlessly.

This is a good tangential jump into talking about some of these painful conditions. These are the ones that women sent me DM’s, they sent me messages, they didn’t want to talk about it openly. Let’s talk about painful intercourse. Let’s talk about lichen sclerosis, vulvodynia and even rectal itching. These were like each one of these were touched on. I think it was on Sex and the City years ago that Charlotte thought she had vulvodynia or she was diagnosed with vulvodynia. And so trying to destigmatize these things that do happen to otherwise healthy people, so that they understand there’s ways to address these proactively.

Betsy Greenleaf: And these conditions are very difficult because I always tell patients, “These are not cookbook conditions.” It’s not like, “Oh, you have vulvodynia, we’re going to do this, this and this, and you’re going to be better.” No, because vulvodynia just means pain of the vulva. Okay, you have pain, you have burning, you have itching, they all fall in the same category. We now going to go back and find what’s the root cause.

Now I will tell you, one of the things that happens is the rates of vulvodynia go up every January, every single January because people are trying to do their New Year’s resolutions. They’re trying to lose weight. What do I see the two biggest culprits are, they got a peloton for the holidays, and now they’re sitting on their stationary bike and they’re compressing their pudendal nerve because those seats are pushing on the pudendal nerve, the nerves that are right where your sit bones are, are come in contact, and now they’re irritating those nerves. And now they get pelvic pain, they can get worsening of bladder symptoms, they get worsening of the vulvar pain and inflammation. So, that’s number one.

The other thing is they start eating a lot more kale and spinach, because they’re like, “Oh, I’m going to eat healthy,” and they start eating more kale and spinach. And we see the rates of kidney stones go up, but also vulvodynia because those vegetables are very high in oxalates. And oxalates, when they build up in the tissue and they tend to go towards mucosal membranes, and now cause inflammation. So, every January. I’m not saying like, “Don’t do your peloton or stop eating kale. It’s just if you’re having those problems, stop those two things first. And then we need to kind of look into what’s going on, because vulvodynia can be anything from there’s an infection. There’s a food allergy that’s now being– when someone with an allergy and their face blows up, it’s because their mucosal membranes are blowing up. Well, sometimes you see those allergies just being expressed in the vulvar tissue. I see patients with seasonal allergies. I had one woman who she had ragweed sensitivity. Every fall she would get some stuffiness, but her vulva would become so inflamed, and we would have to address that.

Other thing is sometimes there can be from emotional trauma, or even some sort of physical trauma. So, one of the things that can happen is, let’s say, sex is painful. Well, our bodies and our minds don’t want to keep doing something that’s painful. So now the next time you’re in the position where you might be having sex, even though you’re like, “Yeah, yeah, I want to do this,” your brain is going, “No, no, no, it hurt last time.” So, what’s going to happen, your body’s going to splint against that pain, and you’re going to tighten the muscles in your pelvic floor. What happens with that? It makes sex painful because there’s muscles are tight. And so now the tissue feels like it’s getting ripped when you’re having sex. So, then this just sets up this vicious cycle.

Sometimes that’s triggered initially by emotional trauma or something physical trauma, like maybe you injured yourself or– I had pelvic floor spasms after I had my hysterectomy. It took a long time for those muscles to relax. And the problem is once those muscles tighten, they themselves now cause pain, because now when the muscles are tight, the blood flow can’t get into those muscles. And it can oxygenate that tissue to get those muscles to relax, and now it causes more pain and they tighten even more. Sometimes we need to do like pelvic physical therapy. And there are some amazing pelvic physical therapists around the country that can help with getting those muscles to relax. Or we say like, if your leg was spasming, you eat, stretch and massage. Well, for the vagina, you get a little more creative with that. So, maybe soaking in a bathtub, or putting a hot, warm pack on your bottom, not too long, you don’t want to burn your skin. So, something to try to get those muscles relaxed, or even using a device to help stretch out the tissue or even you having a partner taking their fingers and trying to relax and gently pull on those muscles, because you want blood flow and you want those muscles to be relaxed so that sex will be enjoyable.

I always say when people are having painful sex, they need to go have that looked at because there’s could be so many different causes. We want to make sure there’s nothing more serious going on. It’s all serious because it’s affecting your life but you want to make sure there’s not something like an infection or something that can get elsewhere in the body. But that can be very disruptive. And here’s one of the other problems is, the vagina, if you don’t use it, you lose it. And this is true, because what’ll happen is, if you’re not sexually active, and even if you don’t have a partner not sexually active with yourself, you’re not getting the blood flow into that tissue to keep that tissue healthy, and the blood vessels will

actually start to retract. And that will make the tissue even more brittle. Vagina can shrink if it’s not being used.

When I’ve had women who lost their partners, they were older women who maybe their partners died and hadn’t had sex in years, and now they come in for a pelvic exam, you can barely get a pinky inside of them, because that tissue is shrinking up. So actually, we got to keep using it, whether it’s by yourself or with a partner to keep it healthy. Now, at the same time, I’m laughing because my husband always loves to use like, “Hey, we’re going to do our physical therapy.” And I’m like, look at him, “You’re crazy.”

[laughter]

Cynthia Thurlow: Once those changes happen, are they permanent? Meaning, if you don’t use it and you lose it, does that mean the vagina length shortens, and you can agglutinate out of the tissues can stick together, I’m presuming that’s probably a permanent.

Betsy Greenleaf: No, it can easily be reversed. It can be reversed with either using topical hormones or laser, and combination of physical therapy, or sometimes even using dilators to stretch things back out, because the vagina was made to be able to stretch and go back because you can pass a 10-pound baby through that. So, if it just was stretched and stayed, that would not be great. So, it will go back. Same thing, if it shrinks, you can get it back to normal, which also brings up, we see a lot of these problems with lichen sclerosis. Lichen sclerosis is an inflammatory condition of the vulva. And that becomes incredibly itchy. Unfortunately, the mainstream treatment for that type of condition is steroids. And so topical steroids can help for a short period of time, but over a long period of time, they can actually worsen that condition. They can thin out the tissue more. So, I actually have found that there’s a big dietary component to that condition.

We make sure we get people off inflammatory foods, maybe test for food sensitivities, or tests gut health that they tend to do better because it’s like an autoimmune disease of the vulva. That tissue becomes very white, very thin, very friable, cracks very easily. I love emu oil. And some people don’t like the idea of emu oil because it is from an animal and it’s not like the animal has to be killed to use it. But emu oils is very anti-inflammatory that works great for vulva for lichen sclerosis, even CBD oil. I actually been using more CBD oil on patients where you can just get any CBD oil and apply it to the vulva vaginal area, because it has anti-inflammatory properties to it. Hit or miss with coconut oil. A lot of people always ask about coconut. I have seen research either way with coconut. Some people find it very soothing, and I say, “If you don’t have any problems, go ahead use it.” But coconut oil can be antibacterial. And so it can affect the microbiome. So, if you’re getting recurrent infections, and I’d say stay away from the coconut, but if you’re not having problems, then add the coconut.

Recently, somebody told me another one of my colleagues said that they see great improvement in tissue with sesame oil. And that doesn’t have as much of an anti-microbial side effect. And I’m like, “Oh, I’ll have to try that out with people.” But something to keep the tissue oiled and moist in that you want to keep it like moisturize, like something that’s going to kind of get deeper. And this is where also the laser technology. I’ve been able to reverse like in sclerosis with laser technology, microneedling and platelet rich plasma. To some of the regenerative therapies, you can actually reverse it. I say reverse, and put

air quotes around the word reverse. Same thing when we’re using those therapies to rejuvenate the vagina. We can’t stop you from aging. The aging process is going to still happen. But we can rewind back things up with these regenerative therapies. And then there is like a maintenance, usually it’s something we may have to do it every six months to a year to keep that tissue healthy.

I had one patient where she had horrible, lichen sclerosis, like the vulva all the way down and around the anus. And we were able to get the tissue back to normal with the laser. But then everyone gets busy and then the pandemic happened. And so she disappeared for a while and then all of a sudden, she came back three years later and it would all come back. And so, it just meant having to do the laser a little bit more, get it back healthy and then keeping on a maintenance therapy schedule with that.

Cynthia Thurlow: I guess those internal therapies, microneedling sounds painful in a sensitive body part. I would imagine that there’s some degree of downtime with these lasers and PRP. How does that work? I’m fascinated.

Betsy Greenleaf: Yeah. I’m thinking of somebody coming at you with a needle that they’re going to stick in your vagina does not sound like a good idea. But interesting enough, when you do it the outside, the vulva area, you do have to put numbing medicine on there. Surprising enough, when you do things inside the vagina, if it’s just like laser, and you’re not actually penetrating with a needle, you don’t even have to numb up, because the way the nerve endings are, you don’t really feel. It just feels crampy.

I will tell you, I myself have had laser, and usually cramping for about 24 hours. And then most people don’t complain of any discomfort after that. The vaginal area is so vascular, this is why we were meant to heal very quickly, because in childbirth, we get rips and tears and it heals very, very quickly. I always warn people when it comes to those treatments, that you may feel like you have a sunburn for up to a week, and because the tissue is raw for about a week afterwards, there are protective to use, protective creams to create a barrier in the skin so that you’re not getting any kind of infections from other bacteria that are in and around that area. But for the most time, and usually there’s no– if you do the outside, there’s no sex for a week. If you just laser or treat or do radiofrequency in the inside of the vagina, usually no sex for about two days if that, most of the time people are going back to their normal activities.

Cynthia Thurlow: That’s really encouraging that there’s so many options. Now I want to touch on rectal itching before we briefly touch on, the gut microbiome and how that’s interrelated with the vaginal microbiome and what type of testing you like to use.

Betsy Greenleaf: Rectal itching once again, so many different causes from hemorrhoids, which, unfortunately, a large number of women have hemorrhoids from either childbirth or from constipation. They’re varicose veins of the butt, that’s all they are. But they can become very inflamed, they can become very itchy. Any of the skin conditions, even anal fissures, we get little cracks in the tissue. But it’s something that I’m thinking about that I didn’t mention, which actually is not just for the rectum, but also affects the vagina and causes Itching is paper products. Toilet paper, pads, tampons, incontinence products, many of these products are bleached. So, to get that nice white color of our toilet paper, those

paper products are beached, a lot of the bleached lace stays behind in those products. When you put bleached materials against the skin, it can be very irritating. If you’re somebody who’s suffering from any of those, first of all, I would say if you’re using any paper products that are white, white, white, then stay away from them. It was so impossible in the past to find these products but now you can find them anywhere. You want to look for organic, unbleached products. There’s a lot of like bamboo toilet papers that are out there that are unbleached that are nice, and the personal pads and tampons.

The other thing that we do to ourselves all the time is what we wash our clothes in. You may have been itching because the dyes and the fragrance in our laundry detergents and our fabric softeners. This is why I tell people, wash your underwear in like a dye-free, fragrance-free. It has to be fragrance-free, not unscented, because unscented, they actually put fragrance in it to cover up the smell of the product. So, it has to be a fragrance-free, dye-free soap. And then also what we’re washing ourselves with. I mean, I always tell people, there was a company that not too long ago was marketing to teenagers and it came out with a creamsicle scented like vaginal wash. Unlike our vagina was not meant to smell like creamsicles.

And not only that, and all these harsh chemicals and soaps that you’re putting on our skin, not only do the chemicals from the fragrance, and the detergents can irritate the tissue, but they’re also stripping away our protective oils that can now make our tissues really dry and easily irritated. Honestly, just warm water is probably the best. I used to only say that was it but there are a couple of new products that are made specifically for the vulva vaginal area that I like pH-D Feminine Health is a company that just came up with a boric acid wash, foaming wash. So far, I’ve tried it, personally I like it, but I haven’t really seen any issues with it. There’s a couple other companies that have some like delicate washes in there, but honestly if you just do like warm water and that’s it, that’s all you need. We don’t need special perfumes and things down there. If you are noticing an odor, especially a fishy odor, that’s usually a sign of a bacterial imbalance. If there’s a bread ready like odor, then that’s usually from yeast. So, other than that, it’s usually the bacteria on our body that are causing lot of those odors. So, if you’re having those problems that you need to have that looked into.

Cynthia Thurlow: Absolutely. I hadn’t even thought about bleach toilet paper. That’s brilliant.

Betsy Greenleaf: Yeah.

Cynthia Thurlow: I will definitely make sure the young woman who reached out to me, I point that out in the transcript. And then just lastly, and I want to be respectful of your time. When we’re talking about the vaginal microbiome and the gut microbiome, really identifying that they are interrelated, they are not separate. What kind of testing do you personally like to do for the gut microbiome? Do you like the GI-MAP?

Betsy Greenleaf: I love the GI-MAP. There’s so many different companies that make tests to test the microbiome. I like the GI-MAP, because it’s one of the few laboratories that Medicare will cover. So usually Medicare will cover it, then the other insurance is covered. But I warn you, don’t hold your breath, because the insurance companies, I think nowadays are really looking for reasons not to cover things. But it is worth every dime to get answers and to make a difference. I mean, I myself was at one

point in my life, had anxiety, depression, and was diagnosed with a primary immune deficiency disease. And I was getting sick all the time. One day I went, “Wait a minute. What does anxiety depression and immune system have to do with each other?” And I went, “[gasps] My gut.” I was getting recurrent vaginal infections, recurrent bladder infections. So, I tested my gut, I was filled with yeast, my intestine is filled with yeast.

The reason why they’re connected is 95% of our happy hormone, serotonin is made in our gut, and 80% of our immune system is made in our gut. So, when the gut is off, that affects the brain. Even the brain, gut and vagina are connected. So, I love the GI-MAP. Just going back and talking about how the vagina is connected to the brain, this is an it really fascinating one, is researchers are finding that if the microbiome of the vagina is off, there’s a feedback loop to the brain to say it’s not the ideal time to reproduce. And so, your brain doesn’t know the difference between you just want to have sex and versus you’re trying to make a baby. So, your brain will start dampening all the processes of libido, it will squelch your sex drive, and can affect hormones fertility. So, even like our postmenopausal patients, they come in a lot of times they want hormones, because their sex drive is tanked. And it’s not always a hormone answer, and maybe a vaginal microbiome answer.

And so, from the vaginal microbiome standpoint, there are a couple over the counter tests that you can just as a patient just get them, but they’re just for informational purposes only. There’s two companies. One is Juno Bio and other ones called Evvy. And those are just information purposes only. But it’s very difficult, because you get them and you’re like, “Okay, well, things are off, now what?” So, they’re from a medical standpoint, one of the medical labs. It’s a little bit more expensive, and you got to get it usually through a health care practitioner. I really like Microgen, that’s a company. Microgen makes a really good product. And in fact, actually we are in the process of developing some courses to try to teach people how to read these products and how to naturally fix imbalance these hormones or balance these microbiomes.

Cynthia Thurlow: You’ve given me so much, and so much for my listeners to think about, please let my listeners know how to connect with you, how to connect with your amazing podcast, for which I was very grateful to be recently interviewed on? How can we connect with you outside of this podcast?

Betsy Greenleaf: Yeah. Well, first of all, follow me on Instagram. It’s @drbetsygreenleaf_ or any social media. I’m all over the place. If you look up Dr. Betsy Greenleaf, I’m in there one form or the other. I have The Pelvic Floor Store where we have a lot of the pelvic products that I mentioned, and we do put a lot of education on there. drbetsygreenleaf.com is actually in the middle of getting upgraded. So, you may or may not be able to get to me through there. And then two podcasts, one called Body, Mind, Spirit that’s done through the nonprofit organization wytv7.org. And then another one called Some of Your Parts. So, I’m everywhere. [laughs]

Cynthia Thurlow: Awesome. Thank you so much. I’ve learned so much today. I know my listeners well as well.

Betsy Greenleaf: Thank you so much for having me. This has been wonderful.

Cynthia Thurlow: If you love this podcast episode, please leave a rating and review, subscribe and tell a friend.