Kim (00:02.734)
All right, we're ready. You can go ahead, carry on.
Ardelle (00:52.081)
So I think the answer to your question has two parts. I think the reason why menopause is exploding now is partially because women of the age group that are hitting perimenopause and menopause are more willing to talk about the fact that they're getting older. They're not really wanting to hide it as much anymore. All of us who are growing, letting our silver hair go, I think is, you know, a very superficial, but I think sometimes a really deeply kind of like psychological, you know, journey that women go through, you know, as part of their acceptance of that they're aging.
And when you have women who've had hysterectomies or one after the other IUDs or have chosen not to have children, then I think that those are also a group of women who see their self -worth in a different way. And so when they're coming up to menopause and now they have these symptoms about their reproductive phases changing that are really impacting on their own quality of life, their ability to do their work, things that have been really important to them.
They're looking for medical solutions and they're realizing that accepting that they're going through menopause is part of it And so they're really they're you know wanting answers that are pro -age that aren't anti -aging but that are like honest and open right and I think on the flip side of that the medical community had to come around to realizing that that interpretation of the WHI in 2002 was exaggerated and for the most part inaccurate when you're looking at women who are going through menopause acutely, right?
The WHO was a prevention study where they intentionally enrolled women in their 60s and even 70s who for the most part were not having symptoms. Because if you randomize people to hormone therapy or not who are having symptoms, you're going to have everybody dropping out who's on a placebo. So that study was actually designed to try to bring in women who were at higher risk of cardiovascular disease to look at their long -term health outcomes if they were put on to hormone therapy, whether they were having symptoms or not.
And so, you know, that study should have never caused the pandemonium that it did. And so it took so many years of, you know, finding the long -term results of that and for other studies to come out, you know, to start walking that back and looking at it again. And as a gynecologist, I actually have had these moments of going, how is it possible? I went through, you know, an evidence -based residency program. And I remember reviewing the WHI back in 2012, 13, when I was studying for my exams.
Kim (03:09.036)
And what do you think will happen now with going forward? So what I still hear from so many people is there's, they're learning from doctors on TikTok or influencers on TikTok, whatever they're learning that the women's health initiative was inaccurately portrayed. Now we're knowing what the true evidence is, but there are still many medical professionals, not even just medical, but many care providers who are not yet informed, haven't done
Ardelle (03:13.133)
And feeling like the most important thing I needed to know about menopause was the difference in breast cancer rates and thrombosis in people who are using hormone therapy or not. A little bit maybe about osteoporosis, but not really from a perspective of this is our responsibility as gynecologists. It was more like osteoporosis happens to women and I guess for the most part they go on to internal medicine and family doctors to manage all that. Women were just, menopause of women just sort of dropped like a hot potato. Who's supposed to be taking care of them?
Kim (03:38.412)
haven't read the up -to -date research and they are denying access to hormone therapy. And so I look at that as, I'm not a medical doctor, but I have always heard the term first do no harm. And I think, is it doing harm by denying access to hormone therapy for many people? So what do you suggest people until the medical community catches up, until training, until it's, you know, that's part of the training for doctors going forward, but for people
Ardelle (03:42.573)
And so I think both of those things happening at the same time has really opened up the conversation and made it now arguably the loudest one out there in women's health.
Kim (04:08.396)
in this moment, working with a medical practitioner, what do you recommend they do so they can get access if they are facing that resistance?
Ardelle (05:03.566)
I think it's really important for us to sort of embrace this reality now that medicine is no longer a hierarchy, right?
We really are trying to have shared decision making with our clients. People are more educated now than they were before. Now granted, the general public health education overall sucks. And so of course, women and what they understand about their body has been also not well addressed in our general population, whether you're looking at high school or you're looking at university or whether you're looking at just the quality of resources that have been for women to help them learn about their continued women's health as their
going through their decades, right? So that's been a problem, but women are intelligent and hungry and want to learn that. And so I think we now have a situation where a lot of women know more about their menopause than their doctor does, right? And so there are going to be doctors who are defensive about that. And that's why I'm always encouraging women to realize, look, this is kind of a team effort right now, right? This is actually a situation where...
you need to be able to go in with good resources from societies that have banners across them, right? You know, that come from menopause societies and you know, the menopause guidelines, come in and realize that this is potentially a teaching moment as well for your doctor, give them the benefit of the doubt, come in well -prepared and then go from there, right? Because, you know, I think, I do believe that the number of family doctors who just back up and say, I don't know anything about menopause, that's not my thing, that is drastically declining.
It's going to take a while for us to address that with all family doctors. And I think a lot of them now are moving into the gray zone of saying, okay, so I realize this is a thing and that you truly are suffering and I want to help you, but I don't know how at all. And so then that is meaning then that the referrals to menopause specialists and menopause clinics and anyone who will provide any sort of menopause care, and that includes nurse practitioner clinics, you know, any...
Ardelle (06:58.44)
all of it now is just getting flooded with people who are going there and being referred there looking for their answers, right? So I do think that it will hopefully rapidly change in the next number of years that, you know, it's not difficult to read, you know, the Canadian Menopause Society guideline about menopausal care. It's one guideline. You can read the summaries. There are, you know, weekend courses. You can access things like North American Menopause Society meeting this last year that was in Philadelphia, the whole thing.
you can pay a couple hundred bucks for it and view it and get NAMS, get CME credits for that, right? So the educational opportunities are out there and I think the more women are coming in and asking, asking, asking and pushing, the more it then becomes relevant for those doctors to go, wow, I need to actually pick it up on this. Maybe that will be what I do this year for my CME, right? So I think it has to be that we look to collaborate rather than go, these doctors are so useless.
Kim (07:40.458)
I have other questions up, but I feel like that will be a whole other podcast episode, but I'm going to stick, I'm going to stay here and let's, so I know the, the overriding conversation really, I want to talk about menopause and GSM, but you've mentioned the term perimenopause, menopause. So from a definition perspective for people who don't yet know the definitions, what is perimenopause? What is menopause is
Ardelle (07:57.479)
And I think that's sometimes been the message, especially by women who've seriously gone to nine different doctors until finally someone figures out that it's perimenopause and menopause. I have no doubt that that is extremely frustrating and that that undermines people's belief in that the medical system is actually looking out for them and can help them. So it's such a tangled up mess right now, but I do believe that there's an optimistic way out of it.
Kim (08:09.61)
postmenopause an accurate term. Can you give us a little bit of guidance there?
Ardelle (08:31.591)
Well, we can always do two, Kim.
Ardelle (08:59.877)
Yep. So average menopause happens to women somewhere around 51, 52. That number wiggles around a little bit depending on your ethnicity, where you live in the world. There's some interesting things like, hey, living in higher elevations might lead to you having menopause a shred earlier. And of course, you know, different things in your life, you know, smokers, you know, if you've had chronic medical conditions, you know, there are lots of things that will potentially be associated with your menopause being a little bit earlier. And that's why we say that the average or the normal
is for your final menstrual period to happen between 45 and 55. Well, a lot of people, just kind of, a lot of women in our age group have just thought that women, you know, menopause happens when you're old somehow and not really thought about the process of how you get there. And that's when they get into the categories of, well, what is early menopause? If your final menstrual period comes between 40 and 45, that's where we truly consider early. So I do have women being referred to me who are having their final menstrual period at 47 and their family doctor is like honestly saying, you know,
Premature ovarian insufficiency, they're still using an old term like that. And it's like, no, no, no. Premature ovarian insufficiency is when you have your final menstrual cycle before the age of 40. And surgical menopause fits into that too, right? So anytime you've had your ovaries removed or maybe they've been damaged by chemotherapy, or if you just spontaneously don't have enough eggs to have menstruations up until that average age, anything that happens underneath the age of 40 falls into that umbrella of premature or early, too early.
And so then that's POI and that's surgical menopause and all those medically induced menopause. Post -menopause is everything after. Menopause as a defined term is, again, it's almost starting to become a bit archaic because in order to have the classic definition of menopause, 12 months with no menstrual cycle, well, you need to have a uterus that can show you it's having menstrual cycle. So any woman who's had a hysterectomy, any woman who has a progestin IUD, had an endometrial ablation.
or is on a continuous birth control pill, you can't use that definition. That's getting to be a big proportion of the population, right? But left to your own devices, the classic definition of 12 months with no menstrual cycle is a sign that your brain has been using follicle stimulating hormone and all of its willpower, all of the tools that it has to tell your ovaries to ovulate, and for 12 months, nothing has been able to happen. So it's a clinical diagnosis that at that point is like, okay, well, I guess
Ardelle (11:23.203)
if your brain's been trying this hard for the last 12 months and you haven't been able to have a period, you're in menopause. Boom. Everything after that is now post -menopause, right? But sometimes people think about the symptoms as being their menopause and their perimenopause, right? So perimenopause is all of it around that. So as soon as you start having less feedback loop of your ovaries talking to your brain, and so now all of a sudden...
You're not necessarily dropping menstrual cycles, but they're getting more intense. Your PMS is getting worse. You're getting worse breast tenderness. You're getting more ups and downs in your mood. You can't track it well on blood work because it's a moving target. It's up and down and all over the place. But as soon as people start noticing those symptoms, and that can be in your late 30s, again, if you're on average menopause time zone, timeframe of your final menstrual period coming sometime after 45, well, those symptoms of your eggs reducing in quality and quantity,
can start happening in your 30s. They can present as heavier periods. Of course, when people are trying to get pregnant, it can present as infertility and difficulty getting pregnant. Of course, it can then eventually start showing up as dropping your periods entirely. And it goes all the way through. Perimenopause starts with them and goes all the way through to when you can say menopause has been declared. So again, even that perimenopause definition is not really an easy one for a lot of people. And so I think that's where a lot of the frustration has happened is that
because of misinterpretation again of the WHI and a feeling that menopausal hormone therapy is a risk. And then also just the starting up complications of hormone therapy. It's not uncommon to have some spottings and breast tenderness, et cetera. And so, if you wait until people have reached that menopause diagnosis, well then you're pretty certain that their menstrual cycles are done. And so if they have any bleeding after that point, whether on hormone therapy or not, you investigate it differently. But that has become, again, I think,
misinterpreted as nobody gets hormone therapy until they've hit 12 months of no period and menopause diagnosis. Again, that's just because we haven't been doing it. It's not because it's written in stone anywhere. So more people are needing access to symptom management options, whether it's hormone therapy or others, way before they hit that final menstrual period diagnosis. And post -menopause has huge implications for us for the next number of decades. We're gonna spend, you know...
Kim (13:38.602)
Yeah, that was super comprehensive. And a couple of things that came up for me was many people think that if they have a hysterectomy where just the uterus has been removed and the ovaries are spared, some people still use the term surgical menopause. So yes, you are not bleeding, but technically you still have ovaries. But as I understand it, most people who have still have their ovaries, but do not have a uterus will reach their natural menopause earlier. Is that accurate?
Ardelle (13:43.327)
at least a third, hopefully, if not more, of our life in post -menopause. So how does that shift then in your reproductive hormones affect your bone health, your dementia risk, your cardiovascular health, the attention that's being paid now to nutrition and to exercise and to muscle mass and to bladder health and to sexual health? All these things are really important to post -menopausal women and it shouldn't just be dropped from the gynecology community that those things are important.
So now this ends up being a really wide swath of women if you're talking about early or premature or POI, perimenopause, menopause, postmenopause. So that includes women from somewhere around mid 30s for the rest of their lives.
Ardelle (14:54.653)
Possibly. If you have your uterus removed and your ovaries are left, ovaries get a small amount of blood flow from the uterus coming out. But a lot of their blood flow actually comes from the abdominal walls to the ovaries. So if it's an uncomplicated hysterectomy and the blood flow to your ovaries is quite healthy from the side walls, then we have every reason to think that your menopause will be at similar ages it would have been if you hadn't had your uterus removed.
If you take it down to one ovary, so like one ovary maybe has cysts on it or something and needs to go, is scarred, and you're left with one, hmm, probably then, you know, that has you a little bit earlier, like maybe by a year or so. But you're exactly right in that, you know, women, as soon as their bleeding is gone, if they haven't had horrible PMS to track and still go, whoa, I still can tell that's going on in the background, if they aren't women who are struggling with fibrocystic, you know, breasts that are flaring every single month and horrible mood that their life is just crashing in on them,
that a lot of women just kind of then are free of the horrendous bleeding and just cruise on into the rest of their life. And it's not until perimenopause starts to hit and you don't have a bleeding pattern that they start to go, wow, man, like my mood and my sleep and my this and it takes a long time for people to put the pieces together and go, I'm in my 40s. Maybe this has something to do with my, no, it can't possibly, right? And so that's, and that's what women have been told. Nah, nah, nah, you're too young, you know? And so the physician community is guilty of that too, that we haven't.
Kim (15:53.226)
Yeah. I want to kind of shelve the uterus and ovary conversation from a menopause hormone therapy perspective, but I'm going to come back to the comment you made about many current medical providers will often say, you can't start your menopause hormone therapy until you have reached that 12 consecutive months. So let's have the population here that hasn't had a hysterectomy
Ardelle (16:18.427)
really understood perimenopause enough, haven't taught it well enough. I learned about perimenopause probably not even as much in my menopause fellowship 10 years ago as I have in my clinical practice and because of all of that, you know, the newer research that's been coming out about that now, right? So it's constantly moving where we need to put our attention.
Kim (16:22.346)
They have ovaries, have uterus, we're waiting for that final bleed. But there can be benefit to starting much earlier in some cases as it pertains to the symptoms that people are experiencing. Progesterone being the one that is usually the one that we intervene with first. So can you tell us somebody coming in, let's say they're 42 and they're experiencing some irregularities and might be experiencing some mood swings or some of the kind of earlier symptoms.
What would your approach be? And as a tag along, and maybe if you can kind of weave it into your conversation, the difference between bioidentical versus non -bioidentical and where you sit with that recommendation.
Ardelle (17:36.241)
Mm -hmm. Mm -hmm.
Ardelle (17:52.345)
Yeah, so perimenopause is truly different for everybody. So there isn't one size fits all. And I know that the hormone conversation out there is loud. But when you are a menopause practitioner, it's not difficult for any menopause specialist to be able to list off multiple people that you've tried hormone therapy on in perimenopause and it hasn't helped. Right. So yes, when you're going through perimenopause, and actually there is a visual that you'll eventually use with this. Right. I've got a graph here that I use when I try to explain this to clients.
I made this for a presentation that I do for family doctors now all the time. When you are in your premenopausal area of your life, you know, you're up and down of your estrogen and your progesterone. It's happening every month. Now that in itself for some people is no big deal and for other people is misery, right? PMS, PMDD, endometriosis, you know, horrible bleeding, all these things go up and down and fluctuate if your periods are left to their own devices, right? So when people start coming in with the earliest stages of perimenopause, they're not dropping a period yet. That's what these stars are.
their brain is actually trying harder to get their follicles to respond. And so sometimes you might have more of these little follicles making estrogen, but none of them, they're all sitting on the bench, they're all warmed up for the game, but none of them feels like getting off the bench and going up to bat, right? And that's when you start actually then like losing that progesterone component of your up and down menstrual cycle. And so yes, it can be that in here when you're making thicker, heavier lining.
but you're not bleeding it off, you're not making progesterone, you're not ovulating as well. It can be that cyclic progesterone in here can help a little bit to bring back sort of a predictable bleed so that you're not missing one entirely and now having a horrendous flooding period two months later, right? But for some people, again, that progesterone they can be very sensitive to. Remember, progesterone is not made in your follicular phase at the beginning of your month. For two weeks you're making estrogen and many people feel pretty darn good in their follicular phase when they're making nothing but estrogen.
PMS and such comes in your luteal phase when you are making progesterone. So some people have been exquisitely sensitive to progesterone from the beginning, right? And so if you give people who are very progesterone sensitive more progesterone, they often don't necessarily feel better. I've had people come back and say that they felt suicidal, like on micronized bioidentical progesterone, and we'll get to that. So it doesn't always work for everybody, but it can be that, say, putting a progestin IUD in will help to reduce the bleeding and such. It can be.
Ardelle (20:14.261)
that even though the antidepressants that we talk about, the SSRIs and the SNRIs, they've been kind of thrown under the bus because when doctors have been afraid to do hormone therapy, they've just gone to those. And they are second line, right? Hormone therapy for people who don't have contraindications is the gold standard and is first line. But that doesn't mean we don't have evidence that the SSRIs and the SNRIs can help. They can. There's a list of them that can help pretty much equivalent to some of the lowest doses of menopausal hormone therapy. And for some people where
their hormones are already up and down, adding more hormones to the situation, for some people doesn't make them feel better. For some it does, right? And so it ends up being that perimenopause, you really have to kind of troubleshoot a little bit more, figure out what people's main problem is, be willing to try something and then try something else. And what I always say to people in perimenopause is say, look, we can make the best plan today, but six months from now, you're gonna be moved further along in your perimenopause. It might not work, it might work great for three months.
And then the next three months it won't because now you've moved into a different phase, right? And so, you know, that being willing to sort of like change it up and not see it as, you know, either you as the client, you know, something's wrong with you. Something's, you know, we don't got this balance right. There isn't just, you know, perfect, you know, resolution of all symptoms in perimenopause. And as a provider too, you have to be willing to kind of have that, you know, more rich conversation and say, we might have to change up the plan. It's not that I, that we chose the wrong thing. We had to choose something somewhere.
and then we change it up as we go, right? So for some people, perimenopause, particularly when they move along a little bit further and into here and they're actually dropping a period, then it can be helpful to use cyclic micronized progesterone because then that can mimic a luteal phase or a corpus luteum that you make whenever you ovulate. And then when you take it for like about two weeks or so and then stop it, it mimics your corpus luteum making progesterone and then failing.
Progesterone falls, that triggers then all of the pathways that then have your lining shed. So for some people, it can start with cyclic progesterone. Other people in their perimenopause, they start having vaginal dryness and hot flushes, but it comes and goes with their periods up and down. So again, if people have a contraindication, sometimes in perimenopause, it makes sense to put people on a birth control pill if they don't have a reason to avoid it, especially if they've had one in the past and they've realized that they felt well on it.
Ardelle (22:35.826)
low dose pills, you know, there's one pill that actually does have a bioidentical estrogen in it. There are options that will calm the storm, so to speak, if your problem is your ups and downs of your hormones. And then they are, you know, SSRI, the SNRI, sometimes people with chronic pain. Gabapentin can be helpful for people who have had fibromyalgia or different things. If you take it at night, it can help with your sleep and your heart pressures and your pain. You know, there's just a whole list of different things that we can go through one by one.
But everyone is coming now wanting bioidenticals, right? Bioidenticals. So the term bioidentical really took off, I think, because the Women's Health Initiative used non -bioidentical therapy. Well, it's bioidentical to horses. It's actually a natural product, right? It is made by another mammal, and it's collected, it's purified, et cetera. And that's how we have Premarin as an oral tablet for systemic hormone therapy. And Premarin has always also been available as a cream for genitourinary syndrome and menopause.
So that was the most popular hormone therapy in the 90s. And so that's the one that they studied or that's the one that was in Women's Health Initiative, that and a progestin called hydroxyprogesterone acetate, which again is also an oral progestin. So that was the combo. And so when the WHI again was overblown in what it said the risks and the harms were to people by using even Premarin and MPA,
That turned everybody away from those ones that are more traditional or they were at the time more traditional and had them then going over to people who were compounding and saying, well, the problem was those nasty prescribed hormones. You should be on bioidentical. Bioidentical estrogen is estradiol. That's the one that you make for the most part in your ovaries. It's made also in other areas of your body. You make estrone in your fat. You make estriol from the placenta. There are different types of estrogens, but estradiol is the main one.
So that became then really tempting for people to then say, well, I'll go over here then and I'll try compounding and bioidenticals because they're safe, they're natural, they're plant -based, they're aren't going to harm me. Well, estradiol is just estradiol. It's actually also the active ingredient in pretty much every other menopausal hormone therapy except for Premrin. So every gel, every patch, every oral tablet of menopausal hormone therapy in Canada, there's only two exceptions to that, has estradiol in it, which is bioidentical.
Ardelle (24:54.415)
bioidentical as attempting to just be a description of the chemical formula, you know, has been unfortunately a little bit kind of twisted around into women then thinking that it's like the natural and the safest and you have to get it in some sort of special formulation, you have to get it compounded. And compounding is actually where we don't want to see people go unless they really have to, right? Like if people have allergies,
Kim (25:17.822)
So what, like, when I think of, when I look at the research and back at bioident, sorry, the Women's Health Initiative, and, you know, it was grossly exaggerated, yet there still was small increased risk, blood clots and cancers and that type of thing with the non -bioidentical and small.
Ardelle (25:17.87)
you know, we shouldn't be shutting down the compounding pharmacies. Again, people get these knee -jerk reactions to be like, well, why does the government not allow for compounding? Because we do still need compounding for formulations and medications that aren't available in current doses, right? And so compounders still need to be out there, but the vast majority of women can get bioidentical hormone therapy. You know, as in the physician community, we just call it menopausal hormone therapy.
But if it's estradiol in it, that's what it is. And if it's micronized progesterone that you take at bedtime, technically that's what it is. And that is prescribable by all doctors, right? And so I think that has also become, or that has been a problem that has obstructed women from getting hormone therapy as well because of that mystique and that misunderstanding around the term bioidentical.
Kim (25:51.549)
Yes.
Kim (25:57.309)
Yes.
Ardelle (26:25.965)
It's small. The truth is, we have to be honest, that even the long -term results of the WHI showed those numbers to be extremely small with the hormone therapy that now everyone wants to throw under the bus. And when people now like to talk about the long -term results of the Women's Health Initiative, they keep on saying estrogen as if they're talking about bioidentical estradiol. It's like the long -term results of the WHI that actually showed that it wasn't so worth demonizing is still the Premarin.
and the MPA. So chill out guys like like menopausal hormone therapy if it improves your symptoms that's the benefit that's why we should be offering hormone therapy whether it's bioidentical I have clients who've been on primarin for 30 years and they are fine and you try to I've tried to switch them sometimes off to a transdermal and such and they can't tolerate it right so there are people who benefit from non -bioidentical menopausal hormone therapy so
The take home message is that if you have symptoms, we should treat them. If you want to start with a bioidentical gel or a patch, well, that's fine because that's actually the majority of what we have available. But if you feel that an oral tablet is going to fit into your schedule better, there's a list of things that might make you a little bit higher risk for clot. But again, people have overblown as well the risk associated with an oral estrogen in menopausal hormone therapy. It's extremely small.
Kim (27:49.498)
Got it. Yeah, I was going to say, do you think that it will go like it's been, it's been, it's been more accepted. The term bioidentical is now more accepted. Now there's more people searching for it. Do you feel like based on what you said, there will be, I still think a place for non -bi identical and bioidentical and people can make their choice and work collaboratively with their physician and see which one is going to work best for them. But to the, the overriding message is
Ardelle (27:51.915)
Most women don't have contraindications to oral hormone therapy either. But again, that kind of gets wrapped up in this bioidentical thing that you need to have your hormone therapy custom compounded, you know, adjusted every couple of months, that it has to be absorbed through your skin, you know, that there's all these have to have to have tos about it. And it's like, well, again, as soon as you work in the menopause field for a while, you realize that there isn't a one size fits all. And it is a problem when there are menopause specialists out there who say,
Kim (28:18.523)
non -bioidentical has been demonized and unjustly and don't throw it right under the bus, it still could stay there as an option.
Ardelle (28:20.234)
that they will never prescribe anything except for transdermal estrogen and micronized progesterone. Because that's just a sign that you haven't learned enough and you haven't met enough people. Because there are people who need to have their symptoms controlled and that bioidentical route doesn't work.
Ardelle (28:51.497)
Yeah.
Ardelle (28:56.521)
set.
Ardelle (29:00.297)
Yep. Yep.
Ardelle (29:12.969)
Yep, yep, yep. Because people who are on it are now afraid. They're like, should I come off it? You're 75. You've been on Premarin for 30 years. No one should tell you you have to come off of it. If you're doing well and you have osteoporosis and it's one of your indications to stay on it for your bone health, no. No one should tell you that you have to come off of it. Again, unless you've accumulated a bunch of other risk factors. There are people who, if you place them on bioidentical therapy, they get all of their mood and their PMS and their et cetera back again.
So there are people who specifically should not be given bioidentical hormone therapy out of the gates. They should be given some of these alternates. There's one that's called Tibolone, which is neither estrogen or progesterone. It's a steroid precursor molecule that your body has the ability to do a bunch of chops here and there and modifications, and you get an estrogen and a progesterone and a bit of an androgen effect from it. There's one that's called Duaviv that has primarin in it with basaldoxamine. Basaldoxamine is a serum.
which means it's not gonna have as much when it comes to spotting and breast stimulation and such, right? So there are benefits of these ones that are non -bioidentical by design. They are intentionally not bioidentical because they can have different advantages to them and they are the right thing for a good number of people. And as more people get access to hormone therapy, it's important that we have good options that are non -bioidentical as well. Like the stats are still extremely low, right?
Kim (30:27.64)
Yeah. The conversation around systemic meaning body. I want to bring it down into the pelvis and into the vagina, but a kind of a question that I want to lead there is with the delivery. So you've mentioned oral, you've mentioned transdermal, you've mentioned the patch. Transdermal is a delivery. It's a place of delivery, basically.
Ardelle (30:35.111)
I don't think in Canada, if we're saying that 80 % of women have menopausal symptoms of one type or another, I'd be surprised if 15 % of women are getting menopausal hormone therapy. So as we are opening that up and realizing that hormone therapy has true benefits for a lot of people, that the risks are small, the benefits are great, then there are going to be more people who need all of the different products. Some people need the gel, some people need the patch. They'll react to the glue in the patch, so then these people need to move over to the oral.
Kim (30:56.215)
Transdermal estrogen usually means you put a patch on or you rub a cream or a gel on your skin somewhere. But local vaginal estrogen, you could technically still say is transdermal on the outside, correct?
Ardelle (31:04.614)
when the oral mixes with this and that and then maybe they gotta switch back again to the gel and then maybe they gotta try bioidentical. We need to have all of them available to us.
Kim (31:14.679)
Yeah. Yeah.
Ardelle (31:19.302)
Yes. Yes.
Ardelle (31:38.898)
Yes. Yes. Yes.
Ardelle (31:47.61)
Yep.
Ardelle (31:57.0)
Yeah, and you know, sometimes these terms again, you know, they get mixed, they get confusing when they're so close, right? So like local therapy or topical therapy, you know, is typically the terms that we try to use for the products that are intentionally designed to be placed on a skin surface and make their benefit on the skin surface where they make contact compared to systemic therapy, where yes, you are applying it, you know,
topically, yes you are applying a topical gel or a patch to your skin, but it's absorbing through your skin with the intent of getting a measurable blood serum level. From your blood is where it makes it up to your brain for your hot flushes and night sweats, to your bones if that's one of your indications. And from your blood, some people will notice on their systemic hormone therapy that their genitourinary syndrome and menopause will improve because it's getting from your blood out to your tissues.
That is not the same as a local therapy that you apply to the skin and you need to think about it more like sunscreen. You put sunscreen on your face, it doesn't protect your shoulders and it doesn't get into your bloodstream in amounts, right? So that it can then give you sunscreen elsewhere. It doesn't. So a local product, a cream or a tablet or a ring or any of these products that we do that are marketed and designed specifically for genitourinary syndrome and menopause are specifically studied to be a dose and a formulation that is meant to stay local.
So sometimes when people start them, when their tissues are so thin and so dry and so fragile, some people can notice that they have a little bit of change in their hot flushes or night sweats or a breast tenderness or something. That is a sign of how thin and fragile the skin of your vagina and your vulva is that it can't even keep it in the area. But as you use it and as you push through that, all of a sudden those other side effects, and they are side effects.
Kim (33:34.677)
Is there ever a place for using the vagina as the delivery mode for systemic if it was at a higher dose?
Ardelle (33:44.643)
Those are initiation side effects and they go away because your tissue becomes thicker and healthier and then it keeps it again local, which is what its intention is. And that's where then the data is very clear that the amount of systemic absorption that you get from local therapies over the course of an entire year is a fraction of a birth control pill. This is why local therapies are now being offered to people who are breast cancer survivors, right? Because they are designed, if you use them according to directions,
They are designed to be so low dose that they are treating a skin surface. They are not a systemic therapy, so they don't impact them on all those other body systems.
Ardelle (34:28.737)
Yeah, yeah. Also, yeah, exactly. This is why the research is important, right? Because yeah, you can place micronized progesterone in your vagina instead of swallowing it, right? People who have problems with a lot of gastrointestinal upset from taking micronized progesterone, if they place it in their vagina, they can absorb it and then get the uterine benefit from that, but they often have less than of a sleepy side effect from it, right? So it's a different route of getting into your system.
Yeah, like there are products like say the the new ring is is a silicon ring that is a birth control pill method Well, you place that medical grade silicon ring in your vagina. It has enough of the active ingredients that it will Get into your bloodstream and provide you with trustworthy contraception because the dose is higher where if you're using the East ring the East ring dose is designed to be lower and slower absorption and so that is a local therapy even though both of them are
a medical grade silicon ring that you place in your vagina. So this is why science and evidence -based and health candidate approval and everything is important because the doses and the research and the absorption matters. And there is also actually, to add even more confusion for people in the state, there is one that's called the Fem Ring, which is systemic estrogen therapy that is in a silicon ring that is a high enough dose that it will absorb from your vagina.
In Canada, we have only the E -string, right? We have only this one called the E -string, which has the dose, you know, and that's been health kind of approved for genital urinary syndrome menopause. But yeah, you're exactly right, right? Like I've had clients who misread the directions and are using, you know, a huge amount of the creams on a daily basis. And so, yeah, they're treating their hot flashes and their night sweats inadvertently. And they're not getting uterine protection. If you have a uterus,
Kim (35:56.371)
Okay. Kind of backtracking a little bit, but just for clarity, we've said the term GSM, genitourinary syndrome of menopause. Can you please define that for us?
Ardelle (36:22.239)
and you are absorbing estrogen systemically, then you need to have something that will protect your lining. And so if people have been at inadvertently because the directions that were given to them have been wrong sometimes, sometimes they've interpreted it wrong, but you can get systemic estrogen levels from the vagina if you don't dose it right.
Ardelle (36:51.871)
Yes. So genitourinary syndrome of menopause is the new, better, and more appropriate term for what used to be called vaginal atrophy. Vaginal atrophy was very singular, right, in that you have atrophy and a shrinking down of your vagina. What horrible messaging that is, right? And so when the medical community started listening to women and realizing that they actually are kind of emotionally triggered by someone telling them that their vagina has dried up and died,
it was realized that it's probably more important to actually accurately describe what's going on. So genitourinary means your genital area and your bladder system. Syndrome, because it really impacts on your personal wellness, your relationships, your ability to function of menopause because it's the low estrogen problem, right? So GSM is kind of the acronym for that now and it's meant to encompass that there are signs, so things that doctors can see. So that might be that the skin is thinner.
paler, if you are getting a speculum exam done, the doctor can see that there's less vaginal secretions, that the cervix looks very smooth and fragile, that it's got little blood vessels on the surface because it's so, you know, you bump it with the speculum and it wants to bleed. The vaginal walls are flat and thin and pale. Those are signs, and we can see them on the vulva too, right? That the labia are thinner, that the clitoral hood and everything is smaller. There are things that we can see those are signs.
Kim (38:08.145)
Yeah. I have been based on evidence from many other practitioners, medical providers that I follow with research, knowing how many people are affected, you know, upwards of 80%. It's not something that gets better with time. Symptoms come back again if you stop using it. So I, I recommend people around the start of their menopause sooner if they have symptoms, ask their provider for
Ardelle (38:15.708)
but there are also symptoms. So symptoms can be that you feel itching and burning and scratching, that you feel dryness and pain with intimacy. So genitourinary syndrome of menopause should now be appropriately discussed and diagnosed by both signs and symptoms. Because again, I've had clients refer to me where their letter from the doctor says, well, I didn't see any atrophy. And it's like, yeah, but if the client says that they're having symptoms of GSM, then they have symptoms and we need to treat them.
Kim (38:37.136)
vaginal estrogen that they will stay on for the rest of their life. Dose might change, the delivery method may change, but it's a lifelong therapy. Do you agree with that?
Ardelle (38:45.147)
So that's the bigger umbrella term now, GSM. I think it's kind of an awkward, long, big term, but it is more accurate.
Kim (39:24.528)
Hallelujah, yes.
Ardelle (39:31.962)
Absolutely, absolutely. Because again, there have been people who have been afraid. They don't realize that their symptoms are part of their menopause. And of course, there are people who, if they didn't have a whole lot of hot flushes and light sweats and they kind of made it through their menopause without accessing their doctor, they don't realize that years later, the problems that they're having with their bladder and their recurrent yeast infections and their discomfort and now their sexual pain, they're not linking that back to something that happened five, 10 years ago. So, you know, women need to be better informed. Their partners need to be better informed.
All doctors who are prescribing Viagra to males should be asking them if they are in a heterosexual relationship and if so, you know, is their partner menopausal and deceased, right? That needs to be part of it. You can't just treat one member of the couple. So all of the, and doctors need to initiate the conversation, right? Because again, you know, if we're realizing that a lot of other people out there in the general public aren't connecting the dots, we need to connect the dots and we need to offer it before it becomes a problem.
because otherwise, you know how it is, you see it in your clients, people suffer and they have horrible giants and they try this and they try that and they try over the counter things and they try supplements and then they've got lubricants and moisturizers. Finally, sometimes they make it to pelvic floor physio. Sometimes they just like grit their teeth and make it through painful intimacy until finally their relationship is just about on the brink. And now they're coming to their doctor saying they have a lola beetle. Well, we missed the train when it left the station long time ago, right?
Kim (40:37.137)
None of them.
Kim (40:45.521)
Yeah, yeah.
Ardelle (40:59.544)
We could avoid so many of those problems if we were not afraid to have a conversation and offer local therapies, particularly when we know that they don't absorb systemically. So they're like what women shouldn't be offered a local therapy when it's when it's a local skin treatment, right? It's few people that I have who will say, no, no, no, I don't have any of those symptoms. And I'll I'll repeat the list. I'll be like, really? Do you really not have that? Because again, I think a lot of women don't think that they have.
Kim (41:04.307)
So a couple of questions with regards to the differences between vaginal DHA and estrogen. And then I also want to ask the question on the testosterone. But before I go there, the estrogen cream in Canada is estrogine, which is estrone, correct? So the estrone being the one that is primarily
Ardelle (41:29.144)
that problem because they don't know what all the different symptoms might be. So sometimes once you can like outline really what GSM is, someone they'll come up with some symptom right and that's not phishing. That's being accurate to realize that it can present differently in different people and have different amounts of severity but the local therapies are so safe and beneficial we should offer them to virtually everyone.
Kim (41:30.61)
produced in fat later on in life. And many people talk about it as being more inflammatory. So is there like, what's the reason first of all, why don't we have a bio identical vaginal estrogen cream that is estradiol in Canada? Do you think we ever would? And is this one still equally as effective for people in your practice?
Yeah, yes.
Ardelle (41:57.207)
Boom.
Kim (41:57.298)
Yes.
Ardelle (42:11.607)
Yep. Yep.
Ardelle (42:38.103)
Well, we have vaginal products that are estradiol. It's just that the cream, this specific cream is the Estrone, right? But if you're not going to be using that, then the Mvexie little capsules, these are estradiol. The Vagifem is estradiol. The Estring is the estradiol. So it's a good question. Why did they choose to put Estrone in the cream instead? These things come from other countries. There is an Estriol government approved vaginal product in Australia.
But again, Estriol is the weakest of all of the estrogens and up from that is Estrone and then up from that is Estrodial. So again, sometimes when people have come to me and they've been on the Estriol compounded vaginal creams, they're still having symptoms of GSM and it's because it's such a weak estrogen, it's less effective. So you do have to have good manufacturing and reliable dosing in order to know that the Estriol products are gonna help you. So I think in the last...
couple years, man, like the products are just increasing. It used to be that it was, you know, the ring, which hardly anyone knew about. It was the Premarin cream and the Estregine cream and then Vagifem, these little Vagifem tablets that have been around, you know, for decades. Well, the Vexi is new, that's been released this year. The DHEA that you alluded to, the DHEA is a little capsule that is on, that has like oils as part of its sort of inactive ingredients, but they're not inactive. Moisturizing is good for your vagina, right?
So the benefit of doing the DHEA, which is a daily dose where most of these other ones will get back off to a couple of times a week. As a daily dose, you're getting your moisturizer in there and your DHEA. DHEA is being created by your adrenal glands on a daily basis. It's in your bloodstream. It can be measured. But it's not really impacting on your vaginal health. If you place DHEA directly into the vagina, it's called intracranology, where inside the cells of the vaginal walls,
you have the enzymes to make that into both estrogen and androgen. The vulva is full of androgen receptors. So again, I'm not pulling all of my people who are doing very well on estrogen creams and tablets off and saying they must go on to this, but I offer it now as part of the menu of all the different things that are available, right? And particularly for people who maybe have tried a few of the different estrogen only type of vaginal products and just maybe not kind of gotten all of the benefits that they should.
Kim (44:45.678)
Is there a place for somebody to use estrogen and DHEA? So on the twice a week, they're using their estrogen. The other days of the week, they would be using their DHEA.
Ardelle (45:01.01)
then it makes sense to then try a different active ingredient, you know, no different than bioidenticals, you know, go through your body. If the gel or the patch doesn't work, well then maybe you should try one of the non -bioidenticals, right? So DHEA, again, if you're going to use the term bioidentical, you know, then obviously DHEA should fit into that category, but it's not about the bioidentical ingredients that makes it safe. It's the approval process, it's the manufacturing, it's the reliability, it's the recalls if they need them.
That's what makes the product safe.
Ardelle (45:40.946)
That hasn't been studied as far as I know because the products seem to be kind of exclusive. It's one or the other. So when the Intra Rosa was approved, it was being in comparison to the estrogen products. So I don't know of anyone who would be doing one or the other. I do know a few clients who just plain forget. They just don't remember to do it on a daily basis. That can be a reason why they might prefer a tablet or a cream or something that is intentionally.
Kim (45:45.838)
From a testosterone perspective, you mentioned that we have androgens, like it's part of us and part of the tissue support. And yet, so just big overriding conversation, no approved testosterone replacement therapies for women. It's all approved for men.
Ardelle (46:10.289)
meant to be two, three times a week. Or they might find that once they've gotten up to improve tissue quality, maybe they can miss a dose here and there and maybe only be taking it three, four times a week and they still have the benefit. Again, that's not published and that's not well studied, but clinically that's what we're starting to see now that we've been able to prescribe this product for more often.
Kim (46:12.622)
Yeah. Yeah.
Ardelle (46:49.648)
There is one that's called Androfem. It's been manufactured in Australia. It is available in the UK and people can pay cash for it, but it hasn't come here to Canada yet. I hope that it will soon. The benefit of a product like Androfem is that it is the smaller appropriate doses that people can use it on a daily basis. It isn't difficult for us to use the ones that are available. For my clients who do need to be on testosterone,
then I just simply prescribe for them the pump of Androgel that is designed for male clients. But then they're just using one pump of it a couple times a week, right? Which if they're switching their patch a couple times a week or they're doing their vaginal cream a couple times a week, it's not a big deal, right? And usually that's a sufficient dose. It's been rare that I've had clients who need to be using multiple pumps or every single day because you got to watch people's blood levels, right?
And if their blood levels start going high and super physiologic, we don't have any evidence to say that that's okay. Then you're potentially getting into like anabolic steroids, right? Yes, you can get anyone to build muscle and have an amazing libido with high enough levels of testosterone, but that's not the goal of when we're doing it for women. And even the blood levels, right? Like we're testing blood levels to make sure that your levels on your own are low, not because that's a diagnosis.
But because that tells us that your levels are low so that if you are having symptoms that could be benefited by a trial of testosterone therapy, then we know we have room to bump you up and still keep you in what we know to be women's physiologic range. And there's all sorts of problems with it. There are problems with testing testosterone levels on the bottom end of the spectrum, where the test is designed really to be testing higher levels.
Kim (48:37.964)
Would you give somebody, if you're working with somebody who they would benefit from testosterone, how would you deliver it? Would it be transdermal on the skin? Would it be topical on the vagina? A lot of people say you don't want to put it close to the clitoris because the clitoris is going to get too enlarged. And I'm sure that's also dose dependent.
Ardelle (48:40.078)
There are problems that with both estrogen and testosterone, what you measure in the bloodstream isn't necessarily a straight correlate with how people's bodies are taking it up, right? This isn't an antacid or a Tylenol. Hormones are very elegant. So we can put hormones into your system, but how quickly and how easily your body takes them up into the cells, that's where they're doing their activity. So even blood levels are just kind of like a blunt indicator of whether or not you're absorbing and making sure that we're not.
you know, out of what we think are relatively normal ranges. But that doesn't mean that everyone sees the benefit that they want to on testosterone therapy or even on estrogen therapy, right? Like hormones are really elegant and complex and we shouldn't try to simplify them.
Ardelle (49:46.028)
Yep, yep. You know, right now, again, we don't have any health counter approved products that are testosterone that you would apply to the vagina or the vulva. But for people who do want to kind of experiment with that benefit, that's where the DHEA vaginally is a good option. I would prefer that for people rather than them getting to compounded testosterone. Because again, you don't know if the dose is going to be something that over time is going to contribute to them having cloromegaly or whether or not the formulation is getting absorbed into their bloodstream and then you are getting systemic.
you know, absorption from it, right? So if people are going to be doing it systemically, there is an issue or guideline about this. The International Society for the Study of Women's Sexual Health, they collaborated with the International Menopause Society, the IMS, and I think the AMS from Australia. So it's a joint collaborative statement where they do say, look, like, first off, we need way more research in this area, right? But they have tried to go through the literature that there is and, you know, and there are studies here and there, but the problem is that they're
they're small or they're too short or they're in this particular population. And so like we just really need more of this research to be done so that we can, you know, be more clear as to who can benefit from it. But people who don't have a current indication and do have, you know, reasonable reason to think that a testosterone trial is something that they should pursue, then the guidance is to do those baseline blood levels, make sure that there is room, wiggle room to move up, make sure cholesterol is fine.
Kim (50:53.387)
Yeah, yeah. Amazing. I'm trying to think if I have any other questions that I want before I know we've gone, we've gone very deep and a long time, but I guess.
Kim (51:09.739)
I actually do have a question on that. Yeah, thank you for highlighting that. So it used to be and I shouldn't say it used to be. Maybe it did used to be but there was often a loading dose for vaginal estrogen once a day for two weeks and then twice a week thereafter. And other practitioners who I follow have now said actually I don't do the loading dose because especially somebody who's been in that low estrogen state for a really long time
Ardelle (51:12.362)
Of course, there's often a psychosocial component when it comes to people's libido and desire and energy and different things. Don't just medicalize it and say, everything's going to get fixed with you being on testosterone. But again, most people have gone through that psychosocial approach before they've been able to finally get an opportunity to try testosterone. And then the guidance is for doing transdermal over oral. And so that's why for people in Canada who I'm prescribing it for, I choose the gel.
Kim (51:40.043)
too much too soon can sometimes create those, you know, yeast infection reactions that it goes systemic, it doesn't stay in act locally. So we just start out with twice a week. So where do you fall in that? And again, I understand it's individualized, but what's the general consensus there?
Ardelle (51:50.421)
We talked about vaginal estrogen products, we didn't really talk much about dosing them, but again, that could be something that is just in a guideline.
Ardelle (52:38.569)
Right. Yep.
Ardelle (52:43.528)
For me, it depends on the context in which we're starting it up. If someone is already on systemic hormone therapy and they're finding that their GSM is still there, well then they already have estrogen going through their bloodstream. Even with your loading dose initially, and even if the vagina is thin and fragile, their bloodstream and their breasts and everything have already come in contact again with estrogen. So less problems, it seems, to be that way.
but I also then often don't find that it's as necessary to do a loading dose in those situations. Because again, they might have gotten some small benefit from the systemic. So sometimes then you can just go right into the products that are two or three times a week. If people are not on systemic hormone therapy, but they have a lot of concerns about this, then again, you want to minimize anything that's going to give them those breast effects. Because even if it is an initiation side effect and it's a very small window of time,
because the fears about estrogen and breast cancer have been so intertwined. As soon as people have a benign side effect of initiation of estrogen, such as breast tenderness, boom, they're afraid and they're backing off, right? So it's a matter of, sometimes I just even just have that as an open conversation with someone and say, look, we can start you off with a loading dose where you're doing some of this every single day. You might have some breast tenderness and some systemic feelings from that.
Kim (53:38.472)
Yep. Yep.
Ardelle (54:02.599)
but the intention is that it will fast track improving the quality of the tissue in your vagina so that we're gonna get to homeostasis a bit faster. But you don't have to do that. If that ends up giving you too many side effects, then you can back off, but it just might take us then a little bit longer to get up to then, you know, true mechanism of action has been achieved that we now have your vagina and your vulva and everywhere, you know, healthier and we can maintain that, right?
Kim (54:17.192)
Yep.
Ardelle (54:27.462)
So, you know, the principle was always, you know, meant to be altruistic, right? Like, let's get people feeling better faster. But you need to have a conversation then about, you know, which way is better. And of course, some products like the ring, there is no loading dose, right? You place this in, it starts giving you constant secretion from day one. So if you pull this out every once in a while for intimacy and you pop it back in again and you miss a day, it's not a big deal. Like you've got rather steady state. You know, they might show that there is a little bit more of a blip in your...
Kim (54:38.984)
Right, right, yeah.
Kim (54:48.712)
Yeah. Yeah.
Ardelle (54:56.325)
blood serum levels when you first put in a fresh ring. But again, over the course of 365 days of the year, it makes no difference. I often find that the Vagifem tablets, as they are prescribed, one of these teeny tiny 10 microgram tablets twice a week is not enough for most people. So the number of times I have people refer to me saying that they've tried vaginal estrogens and it didn't help. Well, they typically prescribe Vagifem twice a week and we're forgetting the dose half of the time.
Kim (55:04.136)
Totally, yeah.
Kim (55:14.504)
Yeah.
Ardelle (55:26.725)
So again, you got to think about whether or not people are really dosing things right because again, sometimes people, if you don't address concerns about breast cancer, then there are people who are intentionally using less cream, using less tablets, trying to see if they can make do with less. And that's a, again, that's a sign that we've then missed an opportunity to educate people to say, if you under dose and you haven't fixed the problem, then there's no point.
Kim (55:29.832)
Yeah, yeah, good point.
Hang on one second. I just heard my doorbell go. I just want to go, but I want to, I want to kind of wrap it up with one more question. So you can just hang on for one sec. I apologize.
Ardelle (55:51.491)
The point is to get people feeling better, whether it's with your systemic hormone therapy or with your local therapy. So if you haven't gotten to the point of your symptoms going away, then we're not there, right? And there isn't risk. There isn't risk to using the dose that will improve your symptoms. If anything, if you're underdosing it, so then whenever you are trying to use a little tablet, then you are getting breast tenderness, then you're never getting the tissue down there healthy again.
Ardelle (56:26.082)
Yep.
Yes sir.
Kim (56:40.584)
Okay, sorry.
Kim (56:45.672)
Okay, one final question before we wrap up is what you just said with regards to the ring taking it out for sexual activity. So many people also, do we need to protect our partners from it? Should we make sure that all sexual activity has happened? And you're saying we do need to remove the E string for insertion, correct or no?
Okay.
Ardelle (57:28.354)
Yeah, no problem. My doorbell, your doorbell.
Okay, so what's next?
Ardelle (57:56.521)
Actually, no, some people do, some people don't, right? So again, if you think about the fact that the vagina is not a rigid tube that is exactly the size of your partner or your sex toy or whatever, right? Like the vagina is a roomy area that is not just a tube, right? And so some people do have their E string in there and they completely forget that it's in there. And maybe they thought they were going to take it out for intimacy, but then they forget.
and they do and then they're like, that was okay. Other people do. Some people, of course, have a pestery. So they have a pestery and they have their E -string right behind it in order to give them that estrogen to reduce their chance of getting erosions from their pestery. And so those people don't tend to take it out, right? Because those people tend to come into their doctor and have it rinsed and washed with other pestery and then have a new E -string placed. But for your average person who is sexually active,
Some people will remove it, some people will not. It's really just based on your comfort level, but it doesn't have to be. And the other products, again, sometimes that interferes with people's spontaneity. So creams and such tend to be dosed at bedtime so that then they're just kind of like hanging around in the area and not just falling out into the toilet if you're doing them first thing in the morning. So most people tend to place their creams in their tablets at nighttime. But what I like to say to women is, you know what?
Most women should not be surprised when intimacy comes a -knockin'. Right? Most women in most relationships should be able to tell that there's been some flirtation, there's been some suggestion that they're planning for it. Too often, I see that there are many, many women who are still stuck in a rote pattern with their partner of doing their daily business, getting the job done, you know, paying the bills, cleaning up the house, blah, blah. And they finally hit the pillow and then it's like,
Kim (59:29.0)
Yeah.
Ardelle (59:52.734)
pink pink pink, how about now? That is not foreplay. That does not appreciate that many, many people have a responsive libido, which is completely normal, but it does require a little bit of brain engagement before the actual activity, right? So most women should not be, you know, over and over and over again, inconvenienced by they've placed their vaginal product and now lights are supposed to go on, right? So that I, you know, often just try to have just a...
Kim (01:00:08.936)
Yeah. And just as a final little note, estrogen or DHA is not your lubricant. We still benefit from lubricant. It's also not your moisturizer. We still benefit from moisturizer. They're all, yeah.
Ardelle (01:00:21.054)
casual conversation with women to maybe also try to empower them to move that area of their relationship a little bit if they'd like to. And then there are other tests. So for example, I asked the people specifically who make IntraRosa, the GHG product, and they said within an hour, the active ingredient has been absorbed. And not only that, but there aren't the enzymes in the skin of the penis that are going to be converting.
and it wouldn't make any difference anyways. It's such a small dose. So for the most part, the vaginal products don't have a concern to a partner. Yeah, which is good.
Ardelle (01:01:04.86)
Reading my mind. Yes, yes, that's exactly where my brain was going next. Because again, so often I ask people what they're doing for their lubricant and they will tell me prepped for plans. Right. So so many people are, again, stuck in products that have been around for forever and not reading the labels, not realizing that moisturizers are like skin moisturizers. They are meant to absorb into your skin and disappear. They are hyaluronic acid. They are vitamin E. They're meant to leave the skin surface and get into your deeper layers of your tissue. So that's good.
on a day -to -day basis, but no, when you're having intimacy, you need to have something that's a lubricant. And having a well -estrogenized and healthy vagina so you don't have dysuria and infections and such may or may not lead to better lubrication, right? Some people have used the lube since they were in their 20s. They just don't have the same kind of glandular secretory function with arousal. That doesn't mean that they're not interested and they're not turned on. It's just that we're all slightly different that way. And so again, I try to coach people and say, look, there's
because so many women are so hesitant. They worry that it's breaking the spontaneity or that their partner doesn't like it. And it's like, well, again, if your partner understood what painful sex actually feels like, then maybe this wouldn't be a problem. And yeah, this might be a skill that you have to then figure out how you're going to weave this in a little bit or use the lube applicators. Again, if you can tell that intimacy is coming, well then use one of those lube applicators that you can just load up.
and you place the lube high up just like you would with a vaginal cream or et cetera. And then it can kind of lubricate and coat the inside walls of your vagina if you feel self -conscious about placing it on your vulva or on your partner, right? Like there are ways to work around this stuff so that something as beneficial and as effective as lubricant is something that people can really benefit from. And again, people are buying still flavored ones, tingling ones, things that have all sorts of extra ingredients in them. I tell people like,
Kim (01:02:51.848)
Yeah.
Yep. Yep.
Ardelle (01:02:58.682)
This is about osmolality, and again, that's a chemistry concept that a lot of people don't really talk about. But if you have a lubricant that has a lot of extra ingredients and such in it, it has a higher osmolality and can actually draw fluid from other areas because it's a higher concentration. So high osmolality lubricants can actually dry out your skin a little bit. As well, the pH is important. So moisturizers and lubricants shouldn't have a basic pH. If in menopause,
Kim (01:02:58.984)
one more question. Should the estrogen, like a lot of people say that the predominant, like the most receptors are in that first two thirds of the vagina, so place it there, but should we plunge it all the way up? Should it be just in the first third or what's your recommendation there?
Ardelle (01:03:25.945)
We're doing everything we can to try to keep your pH in your vagina a little bit more acidic and lower. So that ends up being the reason why then I recommend certain lubes over others is because that osmolality and pH are really important factors. And you can get around that entirely with something that's like silicon, right? Because silicon is neither. Yeah.
Yeah.
Ardelle (01:04:02.009)
Again, I think sometimes that can be reflected on what people's symptoms are. So if people don't complain that they have vulva discomfort, but they do have dryness with intimacy, then I will lean them towards a product like a cream or a tablet that they do place high in their vagina. And I don't try to tell them to kind of keep it to the lower part because again, if you place a tablet or a cream high up in the vagina, it's going to coat the walls and come down.
aren't describing that that's a problem or they, you know, got lube but their vulva is really what's uncomfortable, then I'll encourage them instead to use a cream or the DHEA ovule that will liquefy and be able to cover more surface area. And sometimes there are people that were kind of walking the line between both. People who have used, you know, their teeny tiny tablet for years and that's fine, but now they actually do have pain and discomfort on their labia, around their clitoral area because that teeny tiny tablet that is placed six inches up your vagina
Kim (01:04:33.472)
Yeah, yeah.
Kim (01:04:52.16)
Mm -hmm.
Ardelle (01:04:57.655)
is not getting to the skin surface on the vulva. And so I do have some people who prefer to still stick with this because it's such a small and non -mass kind of tablet. They like it. It's worked for them for years. But then we will place a little tiny bit of an estrogen cream specifically on the vulva and the labia areas, right? So, you know, again, there is room for us to customize how we do this. Yeah. But again, sometimes, again, with this DHA one, I found that if people don't have to use the applicator,
Kim (01:04:57.696)
Right.
Right. This has been so informative. Thank you so much. You are an incredible wealth of knowledge and this could have been like a four hour podcast, but thank you so much. Where can people find you and learn more about all the amazing things that you do?
Ardelle (01:05:27.639)
And so if they use their finger, they can push it up as far as it can go. Because sometimes if they use the applicator and whether or not they push the plunger right, the question is whether or not the tablet gets dried out again, right? Where if you're just kind of pushing it with your finger, you can make sure that it gets set kind of up there nice and high. And then it's less likely to just then kind of fall out and get lost.
Ardelle (01:05:56.983)
Yeah, well, it's always a pleasure.
Ardelle (01:06:03.061)
Yeah, so I still am on my Instagram, but not as often as I'd like to be. My practice is very busy. I do practice in Ontario. And so I am available for people when it comes to telemedicine referrals. So clients being referred to me for a one -on -one conversation about this, but that as well has become very busy lately. So I'm offering a lot of what's called e -consults. So there is a telemedicine platform across the province where physicians can reach out to other physicians.
particularly specialists and upload the history and et cetera of their client and in the secure platform, ask questions. And when I sign up for that service, I try to get to those within seven days. So it's a year to wait to see me in person, but it's seven days if your nurse practitioner, gynecologist, family doctor is willing to partner with me and realize that this is a learning skill set for them.
Kim (01:06:37.024)
Yeah, yeah.
Kim (01:06:41.344)
That's awesome.
Kim (01:06:49.472)
That's really cool.
Ardelle (01:06:58.74)
So it's more like coaching for me to be able to kind of get them, you know, and I'm expository, man, like if they don't want to get a response that is this big and long with a bunch of attached, you know, PDFs and symptom score sheets, and this is the guideline, like I juice it up because I want them to see that as an educational opportunity, not only so that they have confidence now with the client that they've asked me about, but maybe also with other people, right? So I really do try to use the e -consult tool as a teaching tool.
Kim (01:07:00.416)
know. Yeah, yeah, amazing. I'll have all the links to everything in the show notes. But thank you for taking your time away. You're very busy woman and you've shared so graciously your information. I'm really grateful for that. Thank you so much.
Kim (01:07:17.088)
Thank you.
Ardelle (01:07:27.987)
And I probably see now just as I help just as many new patients on the e -consult service as I do in my day -to -day practice. But yeah, I do need to get onto my Instagram more or some sort of web -based educational online platform because the needs aren't going away anytime soon. We just need to keep on getting good resources out there.
Ardelle (01:07:59.954)
I've been looking forward to this for a long time, Kim. I'm glad we could finally connect.
