Ep. 299 What is Sexual Wellness? with Dr. Kelly Casperson

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Connect with Dr. Kelly Casperson

On her website

TEDx talk: Why We Need Adult Sex Ed

Podcast: You Are Not Broken 

Book: You Are Not Broken- Stop “Should-ing” All Over Your Sex Life

Transcript

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 had the honor of connecting with Dr. Kelly Casperson. She is a urologist. She is committed to empowering women to live their best love lives. She is a TEDx speaker and she is the author of You Are Not Broken podcast as well as book. Today, we dove deep into the influence of Hollywood on the lack of education regarding bad and good sex, the role of parenting, why sex ed isn’t taught in schools, the impact on the paradigm around female physiology, the lack of education about sexuality in med school and in her education, the role of hormones, hormone replacement therapy, why boomers should be pissed, oral contraceptives versus HRT, bridging behavior in the bedroom to lead to better sex, changes to the genitourinary system with age and so much more. This has absolutely been one of my favorite recent podcasts. Dr. Casperson is an incredible resource. She also has an incredible podcast as well as recent TEDx Talk.

Talking about how do we actually define good sex versus bad sex, because in the book, you did such a beautiful job of talking about some of the research that’s been done and the psychology around this. I think for a lot of people, they’re on autopilot, they don’t even recognize that what is their norm, doesn’t have to be that way. So, as a clinician, having the opportunity to speak to men and women, what do you think actually defines good sex or bad sex? What is it? Is it heavily influenced, I would imagine by societal norms, by what people see in the movies, by what they see if they engage in watching pornographic material or just in conversations with their peers when they’re younger. What are some of the things that influence our perceptions around good versus bad sex? 

Kelly Casperson: Yeah, so much to unpack there. It’s awesome that you’re providing a platform where people can’t even think about this. Because I think Hollywood is status quo. We’ve been doing it for how many decades now of, boy meets girl, boy pursues girl, girls blindlessly in love, and just swept away and then an instant simultaneous orgasm in like one minute. [Cynthia laughs] Like, rinse and repeat. It’s just what it is. So, the state of sex education in our country, in the world is so bad, we’ve basically got like a “don’t get pregnant, don’t get a disease plan”, that’s nice if we are lucky enough to even get that. But our education is so bad, we have to look to Hollywood and top 10 country hits and now more and more porn. We’re looking for education. We’re just looking for it in the wrong places.

Or we’re assuming that’s an education when that’s really an entertainment. That’s a product that we consume and purchase, and it’s not an education and it’s a crappy education. I think going back to what’s good and bad, what’s bad tends to have some universal themes like pain is not good, coercion is not good. We’re clear of what bad is. Good is very individualized I think, it’s very unique. Really, that’s for an individual to seek out of what does good mean to you? Does it mean it’s the same every time? Does it have to be different all the time? Does it have to feel a certain way? Do you have to be connected a certain way? Is there a little bit of surprise involved in it for you? Good, I think, is not a universal. I think trying to live up to what Hollywood looks like as that’s what’s good or that’s what’s to be obtained only leads to disappointment.

Cynthia Thurlow: Yeah, I couldn’t agree more. It was interesting. I was having a conversation with my husband last night, the teenagers were upstairs because I’m at this stage of life where my teenagers think any discussions around sexuality, anything related to a lot of what I talk about on the podcast, everything is embarrassing. I embarrass them endlessly and constantly and that just becomes–

Dr. Kelly Casperson: Good job mom.

Cynthia Thurlow: Exactly. I’m like, “I’m just doing my job.” But I was saying to my husband, I was like, when I was reading your book, 17 states mandate sex ed, 17 out of 50. If most kids aren’t having a discussion with their parents and they’re not getting any, even perfunctory information at school, it means they’re very likely not getting good information or even factual information and leading to these concerns and I don’t want to unpack this in a way that we’re down a rabbit hole talking about Roe v. Wade but helping people understand that if we’re going to have children, part of what I think is so important is to have conversations with our children, starting at a young age, about their bodies and about the changes that will be coming. 

I have all boys. So, we’ve been having those all the way along and now it’s talking about every time you have sex, you have the opportunity to either contract a sexually transmitted disease or get someone pregnant. So, you have to be thinking about these things. Of course, they’re still maturing and I don’t think either of them are sexually active. But the point of why I’m sharing this is we have to be having these conversations with our kids because if we’re not having it, someone else will and it very likely may not be someone who’s giving them good information that they can utilize in order to make good decisions. When I say good decisions, if the average age for marriage right now, I think, according to The Knot, was 31 for women and 33 for men. They’re very likely going to have premarital sex. So, we have to be having these conversations. We can’t dig our heads in the sand and pretend that this is an inevitability.

Dr. Kelly Casperson: Yeah. To me, I’m like, “Congratulations, parents, it’s on you because it’s coming in crappy otherwise.” Our school systems are not stepping up. I think it’s fraught with, “How to do it, how to say this, should you say that?” So, I think I don’t see that getting better anytime soon. It’s interesting to the gendering of this that so many people are like, “Oh, well, girls didn’t get an education, so they rely on the guy to tell them what sex is.” It’s like they didn’t get an education either to assume that men have more education than us and know how to pleasure us more or know how to protect us more or to have our interests better than we do. We’re giving way too much power to a group that also didn’t get any education. I have a university in my town and the health clinic has these college age guys come in feeling horrifically broken because their bodies don’t perform like what they’re watching on porn, because that’s where they’re getting their education from. It’s just a dramatic story to be like, nobody’s getting a good education, so we mostly just feel broken about it.

Cynthia Thurlow: Yeah. And, I think the title of your book and your podcast is so telling because I would imagine that most people, if they are looking at either Hollywood or social media or they’re looking at pornography, no one can live up to that idea. Like, that’s not realistic in terms of just the physiology. Maybe a male can have an orgasm faster than a female, but women, it’s not necessarily, as you say, “PIV sex,” penis-in- the-vagina. And I said to my husband, “Have you ever heard that? He’s like, “PIV. What does that mean?” [laughs] We had this whole conversation. I was like, this terminology that I think is so descriptive but also very appropriate. Because if we’re not helping young adults and children learn about their bodies as they’re getting older, we want to have at least some accurate control over information that they’re getting so that they then feel comfortable about having conversations with their partner, whomever that might be, and with their physicians or their nurse practitioners so that they can advocate for themselves. 

Because unfortunately, I think most people figure this out, like stumbling and fumbling along until maybe they figure out, what was it? The Seinfeld episode like, I’m really dating myself, Seinfeld, the master of your domain. It was all the characters figuring out how quickly or how frequently they could figure out what works for them. But it’s like even the concept of talking around masturbation is so stigmatized and yet it shouldn’t be. It’s just a very natural reflection of human sexuality, but also something that most people aren’t comfortable talking about. Maybe they are in a physician-patient relationship, but certainly not amongst friends. I mean, I can’t think ever of having a conversation with a girlfriend about surrounding these kinds of things.

Dr. Kelly Casperson: Yeah, I mean, the good news is I think it’s getting better. But again, it might be the circles I hang out in. [laughs] I went out to dinner, people are– I have a podcast about sex. The two girlfriends were talking about their travel vibrator and this one’s just for their suitcase. [Cynthia laughs] I’m like, “Okay, we’re having this conversation now.” So, I do think it’s getting better. I do like that we’ve labelled PIV sex and given it a name because when you do that, then you realize, “Oh, maybe there are other things that are PIV sex that could equally be as valid of something to do or something to have.” It’s like when we just defaulted penis and vagina as what sex is. It’s like, no, no, no, it’s one card. That’s one card. You can do all these other things, really can open things up for people well. 

Cynthia Thurlow: It’s interesting. Friends of mine that are educators that are dealing with middle school or high school students have talked about how in certain cultures, if you don’t have PIV, then you’re still a virgin. That the thought process is, that’s the holy grail and if you haven’t done PIV, then you’re still a virgin. So, when they shared this with me, I was like, “Really?” I was like, “That’s so interesting how that’s in the hierarchy of sexual activity, PIV is considered to be that is what determines whether or not you are still a virgin” which I thought was fascinating. 

Dr. Kelly Casperson: Yeah, and I mean, I put this in my book too. I hadn’t questioned this until I started down just studying what I have of like, “How can putting something in your vagina change who you are as a person? How can it change a label? Why is that a label? Why did that become invented.” Just starting to question the whole label of what a virgin is and how it can be changed by somebody else putting something in your body is like, “Blew my mind.” Wasn’t something that I ever questioned growing up. Lord knows I’m going to be talking to my daughters about it. You’re saying somebody can change your inherent worth by putting something in your vagina? That’s goofy. It’s goofy when you break it down. You’re like the amount of control put over women and shame and when you get down to it, you’re like, you put a body part in a body part. 

Why are we doing that to people? Why don’t men have a name change when they put their body part in something? Why is that not as equally shameful as it’s the same activity? I think that’s the power of being a urologist versus somebody who just cares for women is like, “I care for the men too. Why aren’t we shaming them equally? Not that we should shame anybody. But it’s not fair once you start looking at that.

Cynthia Thurlow: Well, and it’s interesting. I’m in a unique time in my children’s development where they are both in high school and I’m very fortunate they still share a lot. And we have moments where they will share or talk about circumstances. There was an unfortunate situation at school. There was a young woman who– and I’m going to say that it involved several men and herself consensually. Now many people in school know about it. So, my kids were talking around it and talking to my husband and I about it. I said, well, why is the woman being shamed when they all seemingly, from what you’ve shared with me, this was all willing participants. They just said, “Oh, it’s different for girls.” I said, “But does that make sense if they were all consensual and all chose to do these things together? Does that make sense?” 

I said, “Let’s kind of unpack that.” Because one thing that I have done with having teenagers is impressing upon them that they have a tremendous need to be very clear, whatever they are doing with a partner, that they have complete consent and being very direct and open about that. But I thought it was very telling that even for these individuals who were teenagers that there’s this hierarchy still. This kind of very paternalistic, “Well, guys can get away with anything.” But if you do that as a woman, then there’re certain terms that they use which I don’t like, not them, but I’m just saying, as a society, they will use to describe women who either are choosing to be sexually active or have multiple partners and they’re labeling them and I just, “It’s not that fair though.” Does that make sense?

Dr. Kelly Casperson: Yeah, it’s not fair at all. 

Cynthia Thurlow: So, kind of challenging them, mm-hmm.

Dr. Kelly Casperson: Dude, your boys are so lucky to have you because–

Cynthia Thurlow: [Laughs] They might not feel that way.

Dr. Kelly Casperson: Even if they’re like, whatever mom, they’re just soaking in. Like, to be able to see and there is a sex educator who was saying, using Hollywood films as a backdrop of, isn’t it interesting how she needs to be this certain way to get his interest? Isn’t it so just like using it as a conversation to call out the inequalities in our society.” There’s a very famous superstar who apparently is with a boyfriend and he was married or something and that she was getting all this crap for breaking up his marriage. I’m like, “Where’s the crap for him? He was the one who was in a relationship and nobody was picking on the dude.” It’s like, “Dude, it’s left and right inequality for sex all over the place.” Then we wonder why we’re in this predicament. It’s because we need to start questioning equality in people’s behavior.

Cynthia Thurlow: Absolutely. It’s interesting, I was trying to keep the door open, as they were, because it has now turned into three days’ worth of conversation because they’re still talking about it. I just said, first of all, language is important and that’s something that I think how you choose to frame or reframe what has happened and understanding that both this young woman and these young men, they all chose to engage in this behavior together. But let’s leave the judgment out of it because I think that’s so important. I don’t know if it’s because I’m the only female in my house. I almost feel like I have to really make sure they reaffirm for them, that it’s important to understand. If you’re going to judge her, then you should be judging them as well and no one should be judged.

Dr. Kelly Casperson: Right. 

Cynthia Thurlow: So, shifting gears because I think that you bring up so many good points in your book. I can’t think of a time that ever in my entire medical education, we ever talked about the clitoris other than in a passing description, like, checkbox, here’s a clitoris. Why do you think physicians, NPs, nurses, PAs aren’t taught enough about female physiology in terms of sexuality? Because I can’t think of any book. I actually pulled out my old book from undergrad and then one from grad school, and there’s a little description with a line like, “Here’s the clitoris.” There was very little information, maybe a sentence or two, but yet it’s such an important organ, and it’s completely negated in the conversation or even in the educational exchange.

Dr. Kelly Casperson: Yeah, because it’s not necessary to produce a baby. I am not an expert on everything, but I read a lot. That’s one theory that’s thrown out as to why it’s not important in the medical paradigm is that because it’s not, actually– a couple of hundred years ago, we thought that you had to have simultaneous orgasm in order to actually produce a pregnancy. Turns out you don’t. You only need the penis to ejaculate to get the sperm out. So, the clitoris is not important in reproduction per se. Now what you can argue, be like, “Yeah, well, if that person doesn’t want to be involved in the sexual activity,” it’s actually quite important and isn’t it interesting that it’s put on the outside that perhaps her pleasure is so important it has to happen first before she lets anybody in? We don’t know. God and evolution isn’t sharing the design. Pigs have clitorises in their vagina.

Cynthia Thurlow: That’s interesting. 

Dr. Kelly Casperson: So, all animals are different. [Cynthia laughs] But the answer I’ve read as to why the medical paradigm doesn’t talk about it is because it’s not a reproductive necessity. 

Cynthia Thurlow: But yet it’s something that is so categorically important for those that are sexually active that it’s this pleasure aspect of our sexuality that is not talked about. I mean, I think as a female, taking ownership of our bodies is so important, but yet I grew up in a household where– I grew up Roman Catholic, and my parents, when I went off to college, honest to God, both my parents who were divorced said the same thing, “Whatever you do, don’t get pregnant.” That was their resounding concern, was do not get pregnant. Nothing else. No other words of wisdom. But don’t get pregnant when you’re in college. I just recall thinking, when my kids are going off to college and I have one that will go off next year, what are the conversations that we’re going to have? And very likely will not be surrounding that. It’ll be something larger kind of life lesson.

But when we’re talking about this lack of information in textbooks, this lack of emphasis, I think you mentioned in the book you had one classroom session devoted to talking about sexuality, not even about the clitoris, but just about sexuality in general. Do you think it’s the discomfort within our culture? Because I look at other cultures, friends of mine that grew up in Europe or other parts of the country where they’re much more, I guess, comfortable having these discussions. They’re done at younger ages. There’s less shame around sexual habits. I try to think about it from a bigger perspective, what contributes to us as a society being really uncomfortable talking about our sexuality like as a culture, we can create all these Hollywood romances and all this “onscreen romance” and pornography, which is a whole separate conversation and very explicit magazines and books and things like this. But yet we can’t have the conversation. Somehow that’s a whole much harder discussion to be had and what does that really say about us as a culture?

Dr. Kelly Casperson: I know it’s this weird paradigm of a culture where sexuality is literally in your face but not talked about. It’s very weird. [laughs] When you step back and look at it, you’re like, “How do we sell hamburgers?” [Cynthia laughs] There was that Super Bowl ad for whatever hamburger company with this woman completely in a bikini. It’s like, we sell cars and hamburgers and everything else, we use sex as a sales tactic, but we can’t talk about it, let alone a female’s pleasure. One of my big aha’s was like, “Viagra is one of the most recognized pharmaceuticals on the planet.” Not many drugs are recognized by the shape and color of the pill. Blockbuster drug for Pfizer when it came out. It’s like, “Who’s taking care of the people who are supposed to be sleeping with the people we’re all giving Viagra to?” 

Let’s assume 90% of the men taking Viagra are heterosexual. Who’s taking care of all their partners? Who are supposed to instantaneously want to now have sex with these people who maybe they have not been sexual with in a long time. That was my big aha equality. The other interesting thing with equality, I mean, there’s so many you could write multiple books on inequality of– I was talking to a friend about hormone replacement therapy and in women right now, hormone replacement therapy is only if your symptoms are severe and bothersome enough, and sex is never talked about as a reason to be on hormone replacement therapy. What are two reasons that men can be on testosterone for symptoms? Low libido and erectile dysfunction. So, even when we talk about hormone replacement therapy, sexual wellness is very important in talking about a reason for a man to go on hormones. It’s hardly mentioned at all for estrogen patches, the inequality is everywhere.

Cynthia Thurlow: Yeah. It’s interesting. So, I was a new nurse practitioner in 2001 and so my whole background was in cardiology until I left. I did that for 16 years, saw a lot of Viagra. The Viagra heyday was back in the early 2000s. I recall that the male physicians would take all the samples. So, it became this running joke. I would go to hand out a sample, and I’m like, “We have no samples, so I’d have to call my Pfizer rep.” He was like, “I just dropped off samples a couple days ago.” I said, “This is what I think. I don’t know, but this is what I think.” I think the male physicians are trying it out at home.

But what I do recall and at that time, I oversaw a heart failure clinic. I had this wonderful patient, and I’ll never forget this. I gave him with permission, talked it over with his cardiologist. I was like, “I’m going to give him a little bit of Viagra.” He was so happy, he went home. Two days later, I get a call from our ER department, “I need you to come down and see one of your patient’s spouses. She wants to talk to you. So, they hadn’t had sex in 15 years. He took his Viagra, went home, was so excited, had been married to his wife forever, and she was this little itty-bitty thing, osteoporotic. Well, I guess he was so overcome by passion that he, I guess, during sex, fractured two ribs. She was so mad at me that when I walked in the room, the ER doc was like, “Go talk to her.” I mean, she yelled and screamed at me and she said, “I didn’t ask for this. I didn’t want this.” 

She was like, “You need to have a conversation with the spouse’s significant others, before you prescribe these medications and that stayed with me forever. Because very much in her mind, she was like, “Lights are out. I’m done. I’m in my 70s. I’ve done my duty. We have a bunch of grandkids and kids. I’m done. I didn’t want to do that.” I mean, I will never forget that. That was right at the heyday of when Viagra was really starting to take off. And to your point, we’re not thinking about what’s happening to those partners, but to the point about we’re always thinking about the men. Well, even at that time, thinking about the men, and there weren’t options for women. If women had low libido, it was like, “Oh, it’s in your head,” not realizing that the constellation of hormonal fluctuations that are happening for women and perimenopause and menopause can play a huge role.

And I know that you’re very outspoken, for which I’m grateful, talking about, why aren’t we prescribing more intravaginal estrogen? Why are women having to deal with the constellations used to be called, I think you mentioned senile–

Dr. Kelly Casperson: The senile vagina. 

Cynthia Thurlow: Senile vagina. I was like, that is the saddest thing ever. Senile vaginas, the genitourinary symptoms of menopause, which is equally equally unpleasant to hear, but understanding that if you’re not taking care of your vagina, there are a lot of things that will happen that will make sex nearly impossible unless you are working with someone that is helping you find a solution to the problems you’re experiencing.

Dr. Kelly Casperson: Yeah. I mean, I love pelvic hormones. They’re over-the-counter in multiple countries, which I just love saying, because it’s that’s how you just go into a grocery store and buy some vaginal estrogen. It’s that safe, which is a whole another conversation. But yeah, the problem is women were taught over the last 20 years that something your body naturally makes kills you, which is a hell of a way to oppress people and get them scared. What if we told men that testosterone causes their prostate cancer?

Cynthia Thurlow: They don’t stop it immediately.

Dr. Kelly Casperson: Yeah, but it doesn’t cause their prostate cancer. So, we don’t call it that. I think the big one right now is women are like, “I’m estrogen-positive breast cancer.” That does not mean estrogen caused your breast cancer. It just means your breast cancer has some estrogen receptors on it. Really mislabeling that to make people so afraid of estrogen then again, lack of education. Like, “Menopause is not just a hot flash.” Some people don’t have hot flashes, but they’re going to have horrific vaginal dryness, recurrent urinary tract infections, overactive bladder, pain with sex, decreased arousal, clitoral phimosis, going into– nobody was taught anything about the clitoris. I see clitoral phimosis a lot in clinic because I do a lot of exams and I’m like, “Are orgasms trickier? Do they take longer? Are they more elusive?” They’re like, yeah. Why? Because, your clitoris is covered up by your clitoral hood. We don’t talk about that stuff. So, she’s like, “I just thought that you know.” I’m like, “No, you have, like, a skin condition.” So, women are biologic beings just like men are. It’s not all in our heads. But erections were psychologic until Viagra came out.

Cynthia Thurlow: Yep. Well, and what I find fascinating is and this used to make me so angry. Viagra would get covered by insurance, but oral contraceptives were not and I’m sure at that time if people were still prescribing HRT, it probably wasn’t covered. I said, “No, I don’t know if this bothers you, but it bothers me.” Something to help women decide when they want to have children and something that supports women in terms of hormonal fluctuations that are happening throughout perimenopause into menopause. It’s a quality-of-life metric. If women spend 40% of their lifetime in menopause, why in the world would they want to have a lower quality of life? And that for me, having gone through this transition myself a little earlier than I expected, I read your book with great interest because my mother’s generation was all taken off of hormones after WHI came out. 

All of my aunts, I have five aunts, all of them were taken off of HRT. Something that I feel so passionate about is making sure women understand that they have options, that if they’re working with someone that still is fear mongering, the hormones are going to cause cancer. There are many many talented physicians and other healthcare practitioners that would love to be able to help you. That does not have to be your destiny. That quality-of-life piece is huge. I mean, I talk to girlfriends all the time, some of which are not on HRT. They want to be on HRT and they’re terrified of it. I remind them, if you just understand the physiology of what changes in your vagina as you’re making that transition, as you are losing estrogen, you lose off the lactobacilli, you have all these changes within the vagina.

For many of these younger, late 40s, early 50s, they’re like, “Oh, this explains why I have overactive bladder, why I have chronic itching, why I have three urinary tract infections in a year, I’ve never experienced that.” I would say there are so many relatively easy fixes to these problems, but we still have this narrative that is so focused on making women fearful instead of educating them about their options. And to your point, hot flashes isn’t just the only thing that happens. If people understood that menopause is this de facto disease state, all the inflammation that’s going on below the surface, like, how many thin women I see that are like, “Oh, I don’t need HRT,” I’m going to do this naturally. I’m like, “Okay, that’s fine, but understand what’s going on below the surface because and I’m talking more openly about this now.” 

There was about a six month stretch where I was off of HRT because I was in between providers. And when we drew labs and this is someone I have this strong cardiology background. I was like, I want all these lipids done. I have this strong family history of elevated lipids and we were doing the ApoB and Lp(a), and looking at particle size. My functional medicine doc looked at me and said, “Holy cow, I would never know.” Looking at you, I’d never know. And I said, “This is why we have to talk about this,” because without HRT, I am going to have so much inflammation and oxidative stress, and I’m going to end up having something happen that I don’t want to have happen. So, let’s be proactive and now that I’m back on things, I feel 1000% better. I actually said the other day I’m dreaming again. 

I didn’t realize I wasn’t dreaming. I didn’t realize I wasn’t dreaming for this period of time that I was off of estrogen. So, for me, I love your message and I love the fact that you’re opening up these conversations because we have to continue helping women understand what their options are, helping to find practitioners that are going to be able to support what they desire to be the case. Maybe someone starts, maybe intravaginal estrogen is the gateway to HRT and progesterone. If appropriate, whether it’s a patch or compounded estradiol or estrone or depending on what the formulation might be, or even progesterone, all can be very very helpful. But to think that you have to suffer in silence, I think those days are gone. Because I look at my mom’s generation, osteoporotic, their lipids look terrible, none of them sleep, they look fragile. A lot of it is just a byproduct of the aging process without the benefit of these sex hormones.

Dr. Kelly Casperson: Yeah, absolutely. My podcast two weeks ago, the title was Boomers Should Be Pissed. [Cynthia [laughs] Because I’m like, “Oh, my God, you guys should be pissed.” I get a lot of messages of like, “We’re pissed?” I’m like, “Get more vocal then, where is the like oops, we messed up a generation.” My mom’s got horrific vertigo. My grandma had macular degeneration. Otherwise very healthy people. My great grandma, multiple osteoporotic fractures. In my research because as a physician, I have the power. I can go behind the paywalls. I can interpret the journals. I’ve got all this skill that I can share with people. I’m like, “Oh, my gosh. HRT decreases macular degeneration risk.” I didn’t know that. HRT decreases risk of vertigo. Have you ever had vertigo? It’s horrific. I talked to the 50-year-olds, which is like, the perfect time to get on HRT is safest window.

And they’re like, “I don’t know. I want to be all natural.” And I’m like, “What do you want to be doing when you’re 72? Who do you want to be when you’re 72?” Think about that, because it’s like, “What you’re doing now will pave that way.” Listen, if men had a drug that decreased all-cause mortality by 30%, decreased risk of cardiovascular disease and events by 30%, decreased risk of colon cancer by 30% between the ages of 50 and 60, they would all be on this drug. This drug is called estrogen. No, not everybody can take it. I see the social media people of like, “But the people who can’t take it, they’re having FOMO. I’m like, some drugs have side effects, and not everybody can take every drug.” That’s how it is. But that doesn’t mean we shouldn’t talk to the 97% of women where it’s safe. 

It’s like, we don’t want to hurt one person’s feelings, so we got to not talk about it to everybody. It just doesn’t land well with me. It’s like, “No not everybody can, but about 97% of people can. So, let’s keep talking about it. Right now, in America depends upon the data, about maybe 4% of people are on hormones. 

Cynthia Thurlow: Is it that low? 

Dr. Kelly Casperson: It’s very low. It’s very low.

Cynthia Thurlow: Wow.

Dr. Kelly Casperson: Before the WHI, estrogen was the fourth highest prescribed drug in the country. So, we took about 70% of people off their hormones.

Cynthia Thurlow: That’s unbelievable. I mean, I remember because in cardiology, you can imagine you see a cross section of the population, and I remember all these women saying to me, “Cynthia, I can’t sleep any more” Back then being a baby nurse practitioner, I was like, “Oh, write your prescription for Ambien.” 

Dr. Kelly Casperson: Which kills people. Ambien kills people.

Cynthia Thurlow: Exactly. It’s like, you think about–

Dr. Kelly Casperson: We know that now. But Ambien wasn’t studied on women. Turns out women need a much lower dose of Ambien if they’re going to use it. But why not just replace the hormone that helps you sleep,

Cynthia Thurlow: Yeah, and it’s interesting to me because one thing that I’ve started seeing emerging, and occasionally I’ll do these AMA episodes on Everyday Wellness, and women will share, “Oh, yeah, my GYN prescribed.” I’m like, “That’s not HRT. That’s actually the pill.” So, I’m curious to know if you’re seeing that and these are not people who need contraception. Let me be clear. They are in menopause. There are been prescribed oral contraceptives. I’m like, “Well, I hate to say this, but that’s not actually hormone replacement therapy. That’s not actually helping you.: Are you seeing that clinically? Are there women that are coming to you? Are you hearing about this on the podcast from other practitioners? Because for me, when I saw that and it wasn’t just one or two, it was more like 20 or 30 that were asking the same question, I was like, “Well, that’s not actually HRT.”

Dr. Kelly Casperson: I am like, what is happening? I think it’s a couple of things. I think gynecologists, primary care doctors in general, are more comfortable with birth control because it’s a much more common medication that they’re comfortable with. So, I’m like, “Okay, I can see that.” Also, the risks of HRT have been grossly overblown, so we think that’s way scarier. But dude, “There’re risks to birth control pills like known risks.” Some will argue, “The risks are higher than with HRT,” which is actually a bioidentical and much lower dose. The experts really say around age 50, start switching off of your birth control pills and switch over to HRT. Yes, the younger people do need pregnancy prevention. So, I always ask people, I’m like, “What’s your pregnancy prevention plan? Do you have one? Need one?” [Cynthia laughs] Because you can get pregnant on HRT because it’s not birth control. It is a different chemical formula. But yeah, around age 50, because the risks of being on oral contraceptives do go up with age, clotting risk, stuff like that. So, I think a lot of it’s just the miseducation of how to switch people from your birth control to your hormone replacement therapy because it is individualized. 

Cynthia Thurlow: Yes. Oh, absolutely. It’s interesting because my best friend from high school who never wanted to have kids, so she has been on oral contraceptives, called me one day recently and has debilitating vertigo. I was explaining to her, I said, “Well, now you’re 52, you’re almost 53. It could very well be that you’re in a low estrogen state because you’re on the pill that might be exacerbating things. So, she brought that to her primary, who said, “Oh, that’s nonsense.” [Cynthia laughs] I said, “Maybe it’s time to think about doing some testing and maybe seeing a different provider, and maybe it’s time to make that transition to your point, going from the oral contraceptive pill, maybe going over to some HRT.” I said, “Because it sounds like from some of the things you’re telling me, your estrogen is probably pretty low and that might be exacerbating some of the symptoms you’re experiencing, which you don’t need to experience.” 

Do you find that testosterone for women is gaining popularity? We’ve talked about it in the context around men, but this is something that I still feel like is taboo. I don’t think people understand that testosterone is very potent in our bodies, but it is very important for us and it’s not just about libido. Unfortunately, people think about it just in that context and there’s more to testosterone than just there.

Dr. Kelly Casperson: It’s insane. [Cynthia laughs] But I think it’s I mean, again, all of my answers are like, “It’s a lack of education, of like, all bodies have testosterone, but what did I get taught in medical school? Testosterone is the male hormone, estrogen is the female hormone. Just to go off on a man estrogen tangent for a second, there is this amazing study in the New England Journal of Medicine 10 years ago, they took healthy men. I don’t know who signed up for this study, because it was nuts. [Cynthia laughs] They took healthy men. They blocked their testosterone. They then gave them back testosterone, but blocked the conversion to estrogen. So, we got healthy men with pharmaceutical testosterone blocking the conversion to estrogen in their bodies. What happened. Their libido went down and their ability to have erections went down because the estrogen was blocked.

Cynthia Thurlow: That’s fascinating. 

Dr. Kelly Casperson: Boom, mic drop. Men need estrogen for bones and sexual health. Women need testosterone because all bodies have all of these things. Because of our lack of education, we try to oversimplify it. But my brother was the one who pointed this out to me. Again, I go along clueless until I get all these insights. My brother’s like, “Why is the only acceptable reason for women to be on testosterone is to sleep with a man?” I’m like, “Fascinating realization, brother. Thank you.” But really, the only guidelines for testosterone, is for hypoactive sexual desire disorder or low libido. We say that’s the legit reason to give you testosterone is your sexual function, which is insane. We know testosterone is really important for brain. I’ve got a woman on testosterone, and she was– we got her on her regular “hormones.”

Then I’m like, “Do you trust me? Let’s just try this. Let’s just see how you go with this.” She’s like, “Not only is my libido better,” she’s like, “I’m thinking faster. I can math better.” She’s like, “My brain loves this stuff.” I just think we’ve done a huge disservice in not studying the role of testosterone in women bodies. It depends upon where you are in your cycle. But women have more testosterone in our bodies than estrogen, which is insane. I put the little conversion in my book of picograms per deciliter converts to– so estrogen and testosterone are measured in different things. For my menopausal women now, if they come in with a male partner, I point to the guy, and I’m like, “You know, he has more estrogen in his body than you do right now.” They’re like, “What?” I’m like, “Yeah, his estrogen is probably around 40. Your estrogen is 0.” I’m like, “I’m just trying to get you to 40. I’m just trying to get you to match his, you’ll probably feel a lot better.” It’s almost a way of like, “Okay, well, if that much estrogen is safe in his body, it’s probably safe in my body.” 

Cynthia Thurlow: Yeah. 

Dr. Kelly Casperson: Which again, we’re catering to the male as the default, which rubs me the wrong way, but it works for some people.

Cynthia Thurlow: Yeah. No, and I think it also like I’m looking at my very athletic 50ish husband, and we’re starting to have these conversations about whether or not even at his age and stage, that he may be in a position, even though he’s insulin sensitive and he exercises. But I was saying, you’re probably in conjunction with his urologist. He has a male urologist who’s great and talking to him about testosterone replacement therapy. So, my teenagers, if you can imagine, because they don’t understand all the complex physiology, they’re like, “Can’t we get more?” I was like, “You all have plenty. You both have grown really tall. You’re in this massive anabolic phase. You got all these muscles.”

Dr. Kelly Casperson: A level of 900 is enough, honey.

Cynthia Thurlow: Correct? They’re like, “We just need more.” I’m like, “No, you don’t.” So having these conversations about it, it’s different as you’re getting older, it’s like the tires wear out on the car. You got to replace the tires to get more longevity. I said, sometimes people do benefit including men with some hormone replacement therapy. And I said, I think there should be no shame, because they were asking, “Mom’s on it, why do you need to be on it?” I said, “Well, if you’re optimizing things” and that’s what I think many of us are looking to do, is optimization where you feel good, you sleep well, you have plenty of energy, you have an interest in sex. I always say it’s one thing when people will say, “I just had a baby. I’m exhausted. I don’t want to think about sex.” 

But when your kids are older, if you have no interest or desire or you don’t even think about sex anymore, and I have girlfriends that will say to me, “I don’t even think about sex.” It’s not that they don’t love their partner, and so helping to find that disconnect. So, when you’re working with your patients and you’re working with a couple, and they’re saying, like, “I love my partner. I want to desire my partner, there’s just a disconnect.” Where do you start from? Are you looking at hormones as a starting point? Are you talking to them more about connection and taking time for arousal? What are the things that you’re usually working on? 

Dr. Kelly Casperson: Yeah, I think it’s a very good point, and it’s so hard in the traditional western medical system of 15 minutes, fix my desire. [Cynthia laughs] You’re like, “Especially, if I’m stereotyping,” men have low desire too, but if a man brings a woman in and he’s like, “She’s broken, fix her desire.” I’m like, “Well, you’re the first problem.” [Cynthia laughs] That’s not sexy at all. But thank God I wrote a book and have a podcast now, because again, going back to how little sex ed we get. Like, “Are you involving the clitoris? How aroused are you before you put something in your vagina? How much are you guys prioritizing everybody’s pleasure as equally important? Are you in marital counseling?” Maybe this is your body saying, don’t sleep with this person right now. There’re so many different, is she doing more of a share of the household work than he is? Is there inequality in the relationship? Is she carrying more of the cognitive stress burden than he is? He’s all relaxed and ready to have sex. She is not relaxed at all.

So, there’s so much to that and desire in a sex life again biopsychosocial. But if they’re like, “We are great. The kids are out of the house. We are chill. It’s just not how it used to be. Blah, blah, blah.” You’re like, “Maybe it’s a hormone thing.” But I always say with hormones, I’m like, “Hormones can help. Sometimes hormones are where it’s at, but hormones will not fix a lot of that biopsychosocial stuff.” So, I never want somebody to be like, “Well, I tried the hormones and they didn’t work. So now I’m super broken.” That’s always my worry of, “There’s a role, but you got to work on all this other stuff to.” 

I’m not afraid of hormones at all because I’m a urologist. We give them to men all the time for the quality of life. Do we tell men, like, “Are you suffering enough?” [Cynthia laughs] We ask women, “Are you suffering enough to get put on hormones?” We never ask a man, “Are you suffering enough?” We believe them when they tell us they’re suffering. So, more equality needs to happen with hormones for sure. 

Cynthia Thurlow: I think that’s really important and every female friend of mine I know is this way. We have the mental to do list going in our brains all the time. Our brains are designed to be able to multitask. So, my husband always says, “Anytime, anywhere, doesn’t matter what we’re doing.” He’s like, “Whereas you’re like,” Well, I have to have all these five things done first before I can cut. I just said, I think it’s because I just have this brain that’s thinking about all the things. So, to get focused one thing requires a bit more effort. I do believe fervently that if your partner is helping you out at home and my husband is the meal prep king. He’s an engineer. I mean, I asked that I need some help in the kitchen, and he is the meal prep guy, and we would otherwise not survive with two teenage boys because they eat everything.

When I say everything, I mean everything. So, for me, it is so sexy to know that he’s in there getting meal prep done so that we can at least get through four days of the week without running out of protein and vegetables. I’m like, “I appreciate that.” When you feel appreciated or you feel like someone’s helping out, all of a sudden you have more bandwidth to even consider thinking about having sex, as opposed to if you feel like you’re the only person that is burdened with the household responsibilities, you’re not going to have the bandwidth. I think most women would probably not feel like they had the bandwidth to be able to engage in anything pleasurable, because they’re like, “I got one more thing I need to do. I’m going to check the box.” No one wants their relationship to be that way. 

Dr. Kelly Casperson: Yeah, well, and especially if sex becomes another checklist. My brain was blown by this article that came out a year ago. It’s actually on my link, on my Instagram because I just love it so much. It’s called the heteronormative theory of low desire in women who are partnered with men. Sari van Anders is her name. She’s a researcher out of Canada. I read that article and it blew my freaking mind. I actually read the article as a podcast episode and then interviewed her as the next episode because I was like, women feel seen now, like you literally described what all these women are saying of like, he’s ready, and I still got all these things to do, and I’m the object of desire, not the person who gets to desire. All of these heteronormative socializations that really do affect your sex life. It’s an amazing paper.

Cynthia Thurlow: I’ll have to definitely check it out because I do find the more you understand, the more you can share with others to help them put those connections together. I would love to talk about what are some of the functions within the clitoris that impact sexual function and pleasure. The reason why I think this is important is as an example, how many women have carried pregnancies and have pelvic floor dysfunction, and because they have such significant pelvic floor dysfunction, interestingly enough, friends of mine that live in Europe, pelvic floor therapy is like, automatic. You have a baby. You go to pelvic floor therapy. Here unless you’re having horrific problems. You oftentimes– maybe you’re doing it, but I’m saying most people are not getting referred to pelvic floor therapy. Are some of the things that it can back lubrication, whether it’s where you are in your cycle, time of life, etc., that I think might be of interest to help prime the idea that time is of the essence. Meaning you have to invest a little bit of time into warming yourself up so that you can then move on to whatever type of sex you’re having, whether it’s PIV or otherwise. 

Dr. Kelly Casperson: Yeah, well, I think the big myth of, we’re just light switches. We go from this sympathetically activated state of parenting, job, commute, scheduling, dinner, go, go, go. Then we’re like, “Do you want to have sex?” You’re like, “No, I don’t want to have sex.” The experts really talk about this bridging behavior of like if you want to prioritize sex in your life and you want to get there, but right now you’re a hell no. What are the behaviors that work for you to bridge you into the sexual experience. Whether that’s connecting with a partner, relaxing, arousing behavior. I’m going to go read some erotica or going to go use the vibrator on myself for a little bit, whatever you figure and it’s going to be different for everybody. Like, yoga works awesome for me and my husband’s like, “Every time you do yoga at night, I know that it might be a good time.” [Cynthia laughs] 

Because it just gets my nervous system totally into the parasympathetic, relax, accept, enjoy. So, really, to think of it as, like, a bridging behavior and figuring out what that is to really work for some people, I think, can be a game changer. Because you’re like, “No, right now I am not interested in sex.” Then you’re like, “I’m never interested in sex.” Or maybe you didn’t learn how to bridge to doing this activity that requires a different area of your brain, a different area of your body, different skills. How do we get over to that land instead of thinking it’s like a light switch where you just need to be on all the time.

Cynthia Thurlow: Such a good analogy and one that I think many people can relate to. To kind of wrap things up, I’d love to talk about what are some of the genitourinary changes you’re seeing with women as they’re making that perimenopause to menopause shift. Then, I want to talk about your statement in the book about vaginal estrogen is like sunscreen or seatbelt ChapStick for the vulva and vagina, which I thought was hilarious.

Dr. Kelly Casperson: I love it. Yeah, I see a lot of overactive bladder, getting up at night to urinate, which is called nocturia, urgency, frequency. But of course, I’m a urologist. So, they’re coming in for that, they’re staying for the hormones, but decreased moisture, lubrication. I always tell people, I’m like, “Do you remember your 23-year-old vagina, it was crazy town down there. It was a self-cleaning oven. We forget. We forget how naturally lubricated those tissues are with sufficient amounts of estrogen. For people who are like, “Oh, is vaginal dryness that big of a deal?” It’s like, have you ever had dry eyes? Have you ever had a dry mouth? where your tongue is sticking to the–, it’s very uncomfortable, let’s not dismiss these symptoms. So, I see a lot of that pain with sex. I see a lot of people who are like, “Well, I stopped having sex seven years ago because it started to hurt” and not ever figuring that out. 

I’m like it’s so fixable. Then going into the seatbelt thing, because people are so entitled to not having to take care of themselves. People are like, “I don’t want to have to use vaginal estrogen.” They throw a fit over it. I’m like, “Do you floss?” “Yeah, I floss.” Okay, well, flossing isn’t natural. [Cynthia laughs] You wear a seatbelt. They’re like, “Yeah.” I’m like, “Well, it’s easier to get in the car and not use a seatbelt. It’s an extra step every single time you get in the car. It is so annoying.” And I just start pointing out these things that are just like habits in our life that we do because we want to be healthy and safe and do you brush your teeth? My joke finally is, like, “I have a WaterPik and an electric toothbrush.” I’m like, “I have two vibrators for my mouth,” [Cynthia laughs] so it gives me like, “I don’t want to use a vibrator for sex because that’s unnatural.” I’m like, “I have a WaterPik.” I recharge this thing that like pounds water between my teeth because I’m so much better for having good oral hygiene. So, I just like to demystify this. Like, I don’t want to have to do this. It’s like, “Well, what are you going to do?” We do things to take care of ourselves. Let’s be glad we’re living this long. 

Cynthia Thurlow: Well and it’s finding that reframe. So, for every negative thing they’re saying, it’s like, find the reframe of, okay, let’s think about this differently so that we understand what we’re actually doing is X. We’re protecting our lives. We’re protecting our teeth. We’re being proactive so we don’t end up developing urinary tract infections. And what’s interesting to me is how many women that I reflect back on, probably 50s, 60s, 70s that I saw in cardiology, they were on multiple antibiotics. They had an allergy to every antibiotic known to man because by that point, they had chronic recurring UTIs around the clock. They got up two or three times a night. And of course, in cardiology we’re thinking, “Oh, is it because they’re in a little bit of heart failure” and now I understand, no, it’s actually this loss of estrogen which is contributing to all these other issues. 

So, for you personally when women come in and they’re having issues with fissures and friability, maybe they’re having a lot of pruritus because of tissue paper or toilet paper, how quickly do you feel like they will get resolution in the average person if they start using vaginal estrogen? So, if you’re listening to this and you’re like, oh, this all sounds very familiar, I would imagine that the reconstitution of those tissues would happen fairly quickly, that you would get resolution of symptoms pretty quickly. And yes, it involves putting something in your vagina, but if you’re not using compounded estrogen that you’re using transdermally or patches, etc., this might be a good starting point or gateway to HRT.

Dr. Kelly Casperson: Yeah, so the answer is about six to eight weeks and starting to see things improve. But I’ll see women back in two weeks sometimes and they’ll be like, “Oh my gosh, I’m better already.” It’s amazing how fast the change can be. That’s just like a total win because people love instantaneous, like, “I don’t know if it’s better or not” of like, “Yeah.” And I tell people, I’m like, “Listen, the only person who never gets a urinary tract infection is a dead person. We’re humans and we can get infections.” But we really want to space it out and we know just taking antibiotics messes with your microflora and puts you up at a risk to get another UTI just because you took an antibiotic. You killed all your helpers. I’m like, “Well, did you know there’s a drug that decreases the risk of recurring UTI by 60%?” They’re like, “No, I didn’t know that.” I’m like, “Yeah, let’s get you on that.” We put it in your vagina. [Cynthia laughs] Just share the data with them. And another amazing statistic is vaginal estrogen is basically equivalent to anticholinergics as far as controlling overactive bladder. 

It’s like, why is not restoring function the number one option over drugging function? Anticholinergics are horrifically full of side effects. They’re cheap, but they’ve got tons of side effects, so much so that they’re by the Beers Criteria not recommended in people over the age of 65. So, to me, I’m like, why wouldn’t you restore, why isn’t that part of the overactive bladder paradigm in urology? I don’t know, because these studies are published in the Menopause Journal, not the Urology Journal. But, I mean, these medications work very well.

Cynthia Thurlow: I think it’s really important for people to understand. So, if you’re suffering with chronic UTIs or you’ve got overactive bladder or you’re getting up multiple times a night to sleep, I mean, I always start with cut down on your fluids after 6 o’clock and then trying to figure this out. It’s amazing to me when women come through programs, I can tell without question, without even looking through their entire intake, who’s on HRT and who is not, just based on how well they are doing in terms of energy and sleep quality and sleeping through the night, which you don’t realize how wonderful a blessing it is to sleep through the night until you don’t sleep through the night and then you’re like, “Okay. my whole perception of the world has changed now.” This has been an invaluable conversation. I would love to have you back on the podcast again. 

Please let my listeners know how to watch your TED Talk, how to purchase your book, or listen to your amazing podcast on iTunes. 

Dr. Kelly Casperson: Absolutely. So, the TED Talk is called Why Adults Need Sex Ed. If you just Google TEDx Casperson, it pops up. It pops up for me when I just google that. The website’s kellycaspersonmd.com podcast is You Are Not Broken. The book you can get on Amazon, also called You Are Not Broken: Stop “Should-ing” All Over Your Sex Life.

Cynthia Thurlow: I love it. Thank you again. 

Dr. Kelly Casperson: Thanks for having me. 

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