Kim Vopni (00:00.287)
Dr. Kelly has person I probably say your name. I don't know 15 times a day and I've been wanting to have you on the podcast for a really long time and we're now we're it's like we're here. Thank you. It was. Thank you so much for taking the time. I guess I always start with people's story. So what brought you to the world of first of all urology but then
Dr. Casperson (00:12.504)
happening. Dude, this was years in the making, so good on us, finally.
Kim Vopni (00:27.803)
Now there's this other passion with regards to women's health, hormone health, that type of thing that is a big part of your mission. So tell us a little bit about your story.
Dr. Casperson (00:37.346)
Yeah, well, I should probably just buy a lottery ticket because I keep predicting future trends pretty accurately. That's what the tea leaves say. So in America, only 10 % of urologists are women. So to be a medical student in the early 2000s and be like, I think I want to do that, is pretty rare. I trained in Minnesota. There was one practicing female urologist in the entire state of Minnesota. I've never met her.
So that's how rare it was and that's like 5 million people. So what I liked about urology is I never had problems with genitals. I was never turned off by it. Urologists tend to have really good senses of humor so I kind of liked the personality. All surgeons and medical people kind of have, I always think like the sorting hat in Harry Potter. We've all got a type. I really liked instant gratification.
Kim Vopni (01:06.953)
Wow.
Dr. Casperson (01:36.31)
I liked, you you had a kidney stone, it's gone. You have a bladder tumor, it's gone. You can't pee, now you can. You leak, now you don't. Like I love the fact that because I showed up, stuff got done and like lives were changed. So love urology to this day. was absolutely the right sorting hat for me. Fast forward seven years into my career, you get kind of bored. The seven year itch, you get kind of.
good at your job, it gets a little repetitive. You're like, what did I do all this training for to just see your current UTIs all day long? And like the universe was like, okay, you're ready and brought in the form of a patient to me, a female sexual dysfunction. And I was told in training and do a fellowship so you don't have to deal with women. Women take too long. They complain. I'm not making any of this up. This is like legit what we were told. And you're the students. So you're like, okay, women are difficult. don't, we haven't figured them out. And
So all of that training kind of came back at that point with that patient to be like, are the gynecologists helping? Because the urologists stereotypically were the penis doctors, were very comfortable getting penises hard, making men function, serving that need. And then you're like, wait, okay, 90 % of men are heterosexual. Who's taking care of the women? And so that was probably about
Kim Vopni (02:51.666)
about the women.
Dr. Casperson (02:58.336)
Six to seven years ago, I was like, what's up with female sexual dysfunction? Is it true they're too difficult? Is it true we don't have any research? Is it true the gynecologists are taking care of them? And just kind of started digging into that, started a pod. Once I learned enough, I was like, I can't keep this to myself. The need is too big. So started a podcast a little over five years ago, wrote the book, You Are Not Broken. Stop shooting all over your sex life. Basically, my whole theory is if adults had decent sex education,
Many, many, problems would be fixed. So it's really a lot of it always goes back to you. just didn't get education. We got a disease and pregnancy prevention plan, but we didn't get a like, this is how bodies function. This is how orgasms happen. Communication is number one, two, and three, right? We didn't get taught any of that. so through sex, I got into menopause because everybody was like, well, you know what happens with menopause and your sex life. And I'm like,
No, blah, blah, blah. But people kept saying that over and over and I'm like, fine, what happened to your sex life with menopause? And learning about the role of hormones. Why is everybody so afraid of hormones? What actually happens with hormones? How safe are hormones? my God, hormones actually make you live longer? Okay. Why don't women know this? Why don't women know what menopause is? Why do they just think it's no periods? Why do they just think it's a hot flash? That's not menopause. That's just what happens when you don't have hormones.
And so really diving into why are women so afraid? And at the end of the day, I'm always like, I don't care if you're on hormones. I'm not living your life. I do not care. But you better make a decision based upon education, not based upon fear. And that's why I'm here.
Kim Vopni (04:43.731)
Yeah, well, you do an exceptional job. So 10 % of urologists are women, or at least that was what the stat at the time before we started recording, you said that there is one Euro gynecologist per 100,000 women in the United States. So I guess, do you know the stat for urologists? But also I want to distinguish between what is a urologist and how does that compare to a Euro gynecologist?
Dr. Casperson (04:51.256)
Yes.
Dr. Casperson (05:13.23)
Yeah, good question. So urologist is surgical training in the genital urinary system, kidneys, bladder, male genitalia, female genitalia, but not all urologists do female. I do a lot of incontinence work, prolapse work, female sexual dysfunction work, clitoral atrophy, know, a lot of female pelvic structures, not all urologists do. So there's 10,000 urologists in America.
and percent of them are female, which means we've got a thousand female urologists, but not all of them actually specialize in female. A lot of people will be like, well, I just need to find a urologist and they can give me hormones and it's like, no, no, no, no, no, no. This is specialty stuff. So, urogynecologists are ob-gynes. So, they did obstetrics and gynecology residency, learned how to deliver babies, C-sections, hysterectomies.
and then did advanced training in surgery of the pelvis. Usually two to three more years of surgery training after OB-GYN. So you can get into, if you're talking about surgeons for bladder leakage, bladder prolapse, you can get there via urology or a urogyne. But there's not enough. I was like, women are 50 % of America or the world. And at least in America, we have 80 million women over the age of 40. 80 million.
Kim Vopni (06:21.535)
Okay. Is, yeah, yeah.
Kim Vopni (06:35.347)
Wow. So the again, before we started recording, we were talking about the differences between Canada, the US second opinions versus not in Canada, it would probably take you 10 to 15 years to get a second third opinion with regards to something about your pelvic health. So if there is also a lack of those people who are trained in the United States, what are the wait times like there to see a specialist, a specialist?
Dr. Casperson (06:59.982)
Yeah. I think it really depends upon where you live. Yeah. So like, you know, for my group, you can get in to see me usually within like, I was booked out because I'm pretty public at this point. But before that happened, you can see me within like six weeks. But even though you have access to the surgeon, you know, a couple of things. Number one, the average woman waits seven years with bladder leakage before ever seeing anybody.
Kim Vopni (07:05.183)
state. Yeah.
Kim Vopni (07:14.719)
You're popular now.
Dr. Casperson (07:30.124)
And then the second thing that always struck me is like, why are you seeing a surgeon as the first person you're seeing for this? You know, to me, I'm like, surgery is there for when physical therapy hasn't helped, when vaginal estrogen hasn't helped. Primary care doctors can give you vaginal estrogen, refer to physical therapists. So it was always very bizarre, but I would say probably the most common that primary care just refers to me. They've never seen physical therapy. They've never been started on that. They've tried nothing and they've
And most of them don't even want surgery. Right? So I'm like, why are you here? Why am I the gateway to all of the options for female pelvic health?
Kim Vopni (08:09.609)
Yeah, yeah. So what sort of conditions from a female perspective? I know you treat both male and female. What are that you've mentioned incontinence, you've mentioned prolapse, what are the recurrent UTIs? Would that be kind of your three main buckets that you deal with?
Dr. Casperson (08:23.97)
Yeah, pelvic pain. And pelvic pain is a very broad differential, right? Pain with sex, pain with sitting, just sitting there, you know? And so pelvic pain is complex. But I would say, and I want your opinion just from Canada, but I would say we have a paucity of well-trained clinicians who can actually know what they're looking at when they look at a vault.
Kim Vopni (08:51.049)
Yeah, yeah, I would say the same.
Dr. Casperson (08:53.004)
You know, like the amount of women I see who are like, three gynecologists have told me, because we can get second opinions in America, but it's like, three gynecologists have told me that it's normal down there. And I'm like, girlfriend, there's nothing normal about your vulva. Like, obviously you have pain with sex, right? So it's like, even if they can look at the structures, the amount of people who can actually find like the pelvic floor trigger points and be like, feel that, that's a muscle. That means your muscle hurts because in, we're very organ centric.
Kim Vopni (09:06.409)
Yeah, yeah.
Dr. Casperson (09:22.37)
Right, so people will be like, it's my bladder. And it's like, no, no, that's a muscle that hurts when you have somebody who can do a good exam.
Kim Vopni (09:29.853)
Yeah. Yeah. And that's, that is the same thing happening here. You, you, you go to your primary care doctor. If you're lucky to have a primary care doctor, you may have to go to a walk-in clinic for that referral because again, they've suffered for a long time. Then they're finally like, okay, I got to go see a doctor. The doctors there it's medical training and I don't fault them. It's a fault of the system. So they know to refer on to a colleague in the medical system. And that is typically the surgical route. But the
I hope at some point in my life that it becomes standard of care like it is in Europe where pelvic floor physical therapy is part of all postpartum. I would say argue just like once a year, go get a check. It's gonna save the healthcare billions of dollars. It's gonna save marriages. It's gonna save all the things which you know I'm preaching to the choir. So if somebody has come to you and I'm going to assume you are then referring on to pelvic floor physical therapy or giving them vaginal estrogen or.
telling them to do pelvic floor exercise that that's happening there. But if they then have tried all the things and they're coming to you, what sort of treatments does a urologist offer from it from a like a non surgical perspective before you even got to like bulk commit, let's say something like that.
Dr. Casperson (10:43.438)
Yeah, so I would say it depends upon what they're coming to me with and what their complaints are and what their goals are. The two most common types of bladder leakage are stress incontinence and urge incontinence. So stress incontinence is leakage with cough, sneeze, laugh, trampoline. If I had a mini trampoline in my office and I made you jump on it, would you leak? It cough, sneeze, things like that. So that's stress incontinence. It doesn't mean you're stressed. It means there's a force on the pelvis.
The bread and butter, if pelvic floor physical therapy didn't help, was slings. And I would say still in a lot of the country, it's slings. We had older bulking agents. They'd been around for a while. They were just crappy. They didn't work. They're foreign bodies, so you could get foreign body reactions. most urologists didn't like the bulking agents. Slings became the bread and butter because they're durable. A lot of surgeries need to be redone.
Whether that's like a knee or a breast implant or you know, but slings by and large, if they work for you, they can keep working for you. So that's really nice. It's a more permanent solution, but it's invasive. It's a piece of mesh in the pelvis. That's not without zero risks. I always say happy people don't go on the internet to say how happy they are with their slings. It's only the unhappy people. And that's not zero. You have to accept the risk of that. But if you're...
Kim Vopni (12:02.303)
Yeah.
Dr. Casperson (12:10.92)
I see this a lot and I think it's under discussed, but if you're limiting your cardio because of significant leakage, you're literally limiting your VO2 max, which is a marker of longevity. There becomes a level of leakage where it's probably you're losing physical strength because you just can't exercise. Slings are a powerhouse, especially for high volume stress incontinence.
Bulkamid has come in America, I think it's been around for about three years in America. It's been in Europe much longer, like seven to 10 years in Europe. And it's basically like filler. If people think about filler for your lips, right? Usually like a, it's not permanent. You'll probably have to get it reinjected at some point, but it's very safe. You don't tend to have much foreign body reaction to it. It's basically like a hydro gel. So it's mostly like, it's like a matrix of.
And you inject that with a needle in the urethra. Usually, 90 % of Americans, you're giving a little bit of sedation for it because it's a needle in the urethra, but it literally takes two minutes. It's so fast. And I went in, I mean, I'm a sling trained surgeon. So I went in very skeptical because I'm like, bulking has failed before. I know slings are invasive with downtime, but like people do really well in good hands, right? So I went in cautious on bulkamid and
It's a game changer for the average bread and butter leakage with cough sneeze laugh. It's a game changer and women love that there's no downtime. You can exercise the next day. You can have sex the next day. Yes, you might have to get it reinjected, but a lot of women would rather do that than have a permanent piece of mesh in their pelvis. And I ask them, like, would you rather re-inject this or get a sling? And they're like, just re-inject it. It's so easy. Re-inject it. Insurance covers it.
So I'd say bulk of it again, not all urologists do that or urogynecologists do that and find somebody that does it lot. But it's really a game changer. I love it. And with my stats, probably I've done like 300, I've probably put slings in like four or five of those people, meaning I keep mesh out of a lot of pelvises. So I'm a convert and to be like, I went in skeptical with like the surgeon's mind of like,
Dr. Casperson (14:36.398)
If this doesn't work, we're not going to do it. And now I'm like, yeah, bulk omit is probably first line for stress incontinence. And then when we move on and talk about overactive bladder, urge incontinence, that's urgency, frequency, leak on the way to the toilet, leak without warning, leak when you're in the grocery store line out of nowhere. About a third of women will have mixed incontinence, which is stress and urge. And if you ask them, if you say, okay, there's no right answer,
Kim Vopni (14:44.157)
Yeah.
Dr. Casperson (15:04.556)
Out of those two, which one bothers you the most, urge does because it's like you know when you're going to cough and sneeze, right? But the leak without warning with the urge is very, it's just distressing because you don't know when it's going to happen, right? Much more embarrassing because you can't predict it. Vaginal estrogen works well. Most urologists don't know that. Most people don't know that the bladder has estrogen receptors. You put the vaginal estrogen in the vagina.
Vagina and bladder are condomates, they share a wall. Estrogen gets into the bladder, helps calm down the trigone or the muscle in the bladder that has, it just gets a little spastic when it doesn't have the hormones it needs to function. So does vaginal estrogen help everybody with urgent condense and overactive bladder? No, but it does make a huge difference.
You me and the uroganic colleague, we joke, we're like, you don't leave our office without a referral for pelvic floor physical therapy and vaginal estrogen. Like that's just 101. So failing that we have some medications, they're not great. They're not always covered by insurance. What I do really love for overactive bladder, again, who's failed the first line therapies, I love Botox. Like Botox for overactive bladder is a game changer. So it just decreases spasticity of the muscles.
Kim Vopni (16:01.98)
video.
Dr. Casperson (16:23.202)
We use Botox, the generic is onybotylinum toxin. We use Botox not just cosmetically for face, but for many different medical conditions like spasticity for people who have muscular issues, migraines. Right, so lots of medical uses for Botox and overactive bladder game changer. Usually just have to get reinjected once to twice a year. Let's women leave their house. They say, just have more time to get to the bathroom. So there's also some neuro stimulators.
which we could talk about if you want. But I love Botox for how non-invasive it is. We just do local numbing medicine in the bladder. So you're awake, you can drive, you can have lunch, right? It doesn't give you that like big surgery requirement like other things do.
Kim Vopni (17:09.053)
And are you injecting the bladder or the pelvic floor muscles or both? Bladder.
Dr. Casperson (17:13.176)
Bladder. Bladder. There is off label use for Botox for pelvic floor muscle spasticity. Insurance in America, least insurance doesn't cover it because it's not FDA approved for that indication. If cash Botox is pretty pricey. So really when you start getting into like pelvic floor, pelvic pain centers of excellence and they identify, yes, this is the muscle that's spastic. Those are the right people to give you a trial of Botox for muscles.
But overactive bladder is the bladder, it's the trigonal bladder.
Kim Vopni (17:44.616)
With overactive bladder, there's a lot of people who, again, they finally go and seek help and sometimes it could be their first line care provider or sometimes they've been referred to a specialist who then is like, you go to the bathroom all the time, you have overactive bladder and they might use that terminology and give them medication. But potentially people who aren't prescribing the pelvic PT and vaginal estrogen, potentially it's tight muscles, potentially it's dehydration, potentially it's constipation.
How do you differentiate between true medical overactive bladder versus all of the other things if you're not doing that root cause investigation.
Dr. Casperson (18:17.102)
the other things. Yeah. Send them to physical therapy. Who cleans up? They clean all that up, right? It's are you pooping? It's crazy in urology. Pediatric urology knows how much the bowel influences the bladder. They know. There's books written on it, right? Then, magically, once you turn 18, nobody cares about your bowels and how it influences your bladder. I always say the colon is the bully.
Kim Vopni (18:21.469)
Yeah
Dr. Casperson (18:47.018)
of the bladder. It's just bigger. If it's got tons of stuff in there, it's going to be more bacteria for a UTI risk or it's pushing as a mass effect on the bladder. The bladder doesn't have room to do its job. So colon, 100%, but physical therapists, they have time to be like, how are you pooping? How was your posture? How was your muscle strength? How are you sleeping?
all these things that go into bladder function. How much fluids? I had a guy who was getting up at night to pee. It turns out he was drinking a six pack of beer before he went to bed. And it's like, well, that's good to know. See what happens when you don't. And it's like things that I think would be simple and obvious, but he wasn't thinking, oh, I'm going to have to get up to pee more. I always say, if you're feeding your kidneys, your kidneys are giving your bladder a job to do.
Kim Vopni (19:25.556)
Yeah.
Kim Vopni (19:36.285)
Yeah, yeah. So where does Eurodynamics testing, who would you give Eurodynamics testing to? What is Eurodynamics testing and like what's involved with that and what is it used for?
Dr. Casperson (19:46.126)
So, urodynamics is basically like an EKG of the bladder. You know, if you're like, doctor, my heart's like skipping a beat every once in a while, but then it goes like boom, boom, boom, boom, and you're like, I don't know, just get an EKG, right? Like, it actually helps understand the kind of the electrical muscle function of the heart. We have that for the bladder, it's called urodynamics. It's an annoying test because it's a catheter in the bladder and then it's a catheter in the rectum.
And the reason that they're the catheter and the rectum, I'm not saying this to scare people. Education is key. If somebody's prescribed this test, you should know what's going to happen. Otherwise, to not be surprised is a nice thing. You need a catheter and the rectum because it measures intra-abdominal pressure. And then you can basically subtract out so you actually can see what is the bladder versus what's your abdominal muscles. Some people use their abdominal muscles to urinate.
And so you can see all that when you have two catheters to use it. So how well does the bladder hold? Does it have a normal capacity? How well does it empty? Does it just get spastic and want to leak every time you fill it to a half a cup? Right? So it tells us all of that. A good urologist or urogynecologist, like we don't need to use it that much because we're pretty good at hearing your story, seeing what bothers you and going down that line.
But somebody who they're like, I'm in seven diapers a day. have no idea why I leak. Somebody who like just doesn't have insight to it. Maybe they have an ultrasound showing the bladder's kind of full. So we're thinking maybe does this even empty all the way? So it's somebody who's a little more complex. Certainly somebody who's maybe had a car accident. They've got had a stroke. So we think there's more of a neurologic condition affecting the bladder function. not, not your.
Bread and but for bread and butter, stress incontinence or overactive bladder, aerodynamics usually doesn't add very much.
Kim Vopni (21:42.761)
Yeah. Is there, like is, when people say I have a small bladder, how many people truly have a small bladder?
Dr. Casperson (21:53.774)
small, a small amount of people. I don't want to say zero, but this is what people mean when they say I have a small bladder. What they mean is it doesn't take much of it to fill for me to have to pee. That's what they mean by small bladder. Now what medical people think of a small bladder is like a structurally smaller capacity bladder. That's a very different thing than a little bit of urine triggers me to have to pee. So when people say I have a small bladder, I'm usually like, yeah, yeah, yeah.
Kim Vopni (21:56.703)
You
Dr. Casperson (22:22.83)
Like, I know what you mean, but it's not that you actually have a small shoe size, right? Yeah.
Kim Vopni (22:29.065)
Yeah. And so that it's not common that there is structurally somebody has a smaller bladder. No.
Dr. Casperson (22:34.67)
No, no, no. The average adult human bladder can hold between 400 and 500 milliliters. And if you have spastic bladder, overactive bladder urge going on, you can still have that bladder capacity, but you're getting a trigger that I want to pee at a much smaller volume. Doesn't mean that your bladder's only 200 cc's. Now there are some radiation, neurologic conditions.
There are some cases where you actually do have a contracted bladder. But most people have a normal human-sized bladder. It's just that they get a trigger to pee or a leak before it can fill up.
Kim Vopni (23:16.669)
Yeah. And then what about the opposite where people have urinary retention? What are some of the reasons why people would have urinary retention and what would the treatments offered be?
Dr. Casperson (23:26.828)
Yeah, the big one in men is prostate. So the prostate, basically you have a bladder and you pee through a tube called the urethra. Well, the prostate is around that tube and as the prostate enlarges with age, it compresses the tube. So now you just have more resistance to try to get pee through. And that's the most common reason that men don't empty their bladder all the way, which can lead to kidney dysfunction if it's really bad or urinary tract infections or getting up more at night.
because your glass is always half full, right? So you're just going to experience having to pee more frequently because you can't get it all the way empty. So it can present in lots of different ways. Addressing the prostate issue is the most common thing to do in men. You wouldn't jump just to Botox and a guy because you got to address prostate issues. In females, we don't have a huge prostate and most commonly would be pelvic floor dysfunction, a neurologic issue, multiple sclerosis, I've had a stroke.
diabetes that's untreated can affect bladder neurologic function. So bladder, so it's much more rare for a female to have urinary retention simply because they don't have prostates.
Kim Vopni (24:38.057)
Yeah, yeah. Okay, so I'm moving on to the topic that I'm usually referring to when I'm talking about you, just vaginal estrogen. Vaginal estrogen, you said nobody leaves your office without pelvic floor PT and vaginal estrogen like a prescription for and a referral. Who can prescribe, I know you're in the States and I can explain from a Canadian perspective, but who can prescribe vaginal estrogen as my first question?
Dr. Casperson (25:07.874)
Doctors, nurse practitioners, so doctors meaning D, O, or D, natural pass could also do that. DAs, nurse practitioners, some, it's state dependent, but a lot of midwives are actually getting into like menopause care and stuff like that. So some midwives can prescribe an amount of medication. So.
Kim Vopni (25:28.351)
which would make sense because the new terminology, genitourinary syndrome of lactation is really mimicking genitourinary syndrome menopause. So that would make sense. Yeah.
Dr. Casperson (25:36.91)
Yep, yep. Everybody's super happy that GSM is a thing until they realize it actually excludes some low hormone states, which include lactation, perimenopause. So there's no age where you're like, you can't have vaginal estrogen because you're 49 and you still have a period of like, no, no, no, you can still have low hormone states and still be menstruating.
Kim Vopni (25:48.755)
Yep. Yep.
Kim Vopni (26:00.799)
Yeah, yeah, okay. well, let's go down that path first. So low hormone states, which you just said, it can happen for a variety of reasons. What is it about that low hormone state that contributes to an increase in urinary symptoms, sexual dysfunction, genital symptoms?
Dr. Casperson (26:23.052)
Yeah, so what people don't know is that hormones are basically messengers of the body and hormones help cells thrive from a mitochondrial level. So it's like hormones are basically for lack of a better term, food. Like it just, it's nutrients for the cell. just helps the cell be the best cell it can be. Right. And then people don't know that.
So you have to know that to be like, well, when you take that away from the cells, the cells will not be the best they can be. So what does that look like in the pelvis? It looks like thin skin because we're losing our blood flow. We're losing our collagen. We're losing our elasticity, right? So tightness, the notorious one for sex for GSM is pain and I call it pain at the six o'clock. So it's the bottom.
entrance of the vulva and on exam this will look very thinned. It won't look like robust healthy skin. I love putting vaginal estrogen cream there. That's the notorious when I try to put something in my vagina, that's where it hurts. With the bladder you get more spasticity. So urgency, frequency, getting up at night to pee, having to pee before you can have that whole bladder capacity, right? Leakage. So more
bladder leakage because your urethra is losing its collagen. It's losing its blood flow. And that's what you have to explain that to people because they have no idea what hormones are for. So they have no idea why they might not have hormones or that why giving a hormone back will help. The baseline body literacy is low.
Kim Vopni (28:03.593)
Yeah, I, this is a sidebar, I think about, I feel like school really needs to catch up with modern day. And I feel like a lot of changes need to happen in school. I, with, with how much I have learned about my body that I had no idea and spent, you know, 40 ish years in my life without knowing, I feel like school really should have a major component to, you just use the term that I love body literacy.
It's not just about here's a couple of STDs that you need to avoid, wear a condom, don't get pregnant. know, that's really the education we got. and this is called a menstrual cycle and you'll bleed after 28 days. Like we didn't really go into, I learned more about my menstrual cycle and perimenopause when I hadn't even heard the term perimenopause at that stage of life. But I feel like we need a lot more education much earlier in life so that when these, we know how to navigate along the way. We know who to see, we know what trouble signs are.
Anyway, coming back now. from a genitourinary syndrome of menopause, that terminology has indirectly spiked awareness about pelvic health. I've been doing this for almost 21 years and social media came along and social media played a huge role in increasing awareness. But I would say the explosion of the conversation of menopause is really what tipped the needle in favor of more people talking about
pelvis, the vagina, the vulva, all the things. Amazing, yeah.
Dr. Casperson (29:31.636)
amazing. It's made it less, I mean, I think especially for the pelvis, there's such a stigma and a shame of like, there's something wrong with me instead of like, no, no. We're talking about menopause now. Pelvis is part of menopause. Like it just kind of normalizes it because it's so shameful for some, because they didn't get any education.
Kim Vopni (29:54.099)
Yeah, the other part and you sort of alluded to it at the beginning where you've worked very hard at the beginning of making penises hard and those penises would like to often enter a vagina and if that vagina is dry and if it hurts then that's not going to work very well and it's been fine to even in the subways have posters of Viagra have stuff all over TV but yet I haven't I took me years to be able to say the word vagina without without having my account.
shut down. And you know, so there's a whole discrepancy there from the male versus female as it also from a study research perspective. So anyway, where I'm kind of going, I'm coming down to now vaginal estrogen is being offered yet we have the shame and taboo plus we have the hangover from the women's health initiative and everybody is even if they find out about it, they're like, no, no.
No, it's hormones, I can't take it. I have a history of breast cancer. So how are you helping? I know how you're helping, but share how you help with that conversation.
Dr. Casperson (30:59.374)
Yelling, yelling into my phone daily. We're actually doing some very cool advocacy on a national level, which is really an international level because Canada's got the same warning label, Australia's got the same warning label. Like when it falls, multiple cards will fall, which is wonderful. So the FDA, long story short, the Women's Health Initiative came out and said something that wasn't true.
It's a much bigger story than that. But the very short story is they said something that wasn't true and what got perpetuated via the media and in your doctor's office was that something your body naturally makes is trying to kill you. That thing was called estrogen. That's not true at all. And people like they don't even like they don't like it when I make it a short story but it's like we need to understand that I've got multiple podcasts on it. We have to move on. Estrogen doesn't hurt you. But what happened is the FDA said we need to put warning labels on
hormones no matter if they're natural or synthetic or they're super low dose or they're high dose we don't care it's a hormone it gets a warning label and the warning label says this will cause probable dementia not possible probable probable dementia blood clots heart attack stroke cancer and especially in vaginal estrogen which is skincare skincare for down there
You're not swallowing it. not going, it's not being processed by your liver. If you drew your blood, you would not be above postmenopausal levels. We don't make you not menopausal. It's so low dose that it's the lowest hanging fruit to get the boxed warning off. We have a study, the study was done in Seattle, at Virginia Mason. And they said of the women who receive a prescription, so it's hard enough to go to your doctor, get a proper exam, get properly diagnosed, get a prescription for vaginal estrogen.
If you make it through the gauntlet and you have a prescription for vaginal estrogen, 20 % of women will then not use it because of the warning label. So the savvy clinicians will say, and this is what I say in clinic is, okay, I'm telling you this is perfectly safe. If you read labels, you will read that it causes X, Y, and Z. Now you have the wonderful option of deciding if I'm wrong or if the FDA is wrong. And that's a horrible position to put you in.
Dr. Casperson (33:23.202)
But you have to know that I know the data more than the FDA knows the data at this point. We have years of safety data on vaginal estrogen, thousands of people, including breast cancer survivors. So it's the lowest hanging fruit. The FDA just took a warning off of testosterone. So we know they're at their desks. We know that they're working. We know that they are actually very interested in truth and accuracy in government warning labels.
Kim Vopni (33:43.217)
You
Dr. Casperson (33:51.212)
So I do believe it is a matter of time before we get the boxed warning off of vaginal estrogen. The next thing will be getting the boxed warning off of systemic estrogen. So that's to answer your questions. I'm involved in many advocacy activities because there's a lot we need the government to do. But it's like until the government warning label is correct. And we're like, we're not asking.
for moon here, we're asking you to be medically accurate based upon the decades of data that there is. Like that is low hanging fruit. If people want to help, I would love it if they went to letstalkmenopause.org. You can also Google unboxing estrogen. That's like a subset of the letstalkmenopause.org. That is the nonprofit.
That's really pushing. So there's two letters you can sign. If you're a clinician, sign that one. It'll go to the FDA. If you're a lay person and you're like, I just want truth in government labeling, they have one for that. So it's really helping show the FDA does listen to people. But I would argue they listen to people more than they listen to doctors from the doctors have met with the FDA twice already and they haven't taken the black box warning off. So.
Kim Vopni (34:59.846)
really?
Kim Vopni (35:03.668)
Wow.
Kim Vopni (35:07.155)
What about with it being available over the counter at some point, like it is in the UK? Is that do you?
Dr. Casperson (35:12.46)
Yeah. So the UK, one product is available over the counter in the UK. You have to be 50, which is a little arbitrary as 50 % of people are menopausal before the age of 51. But so they, did an age cutoff, which is a little arbitrary, but, I don't see it happening. And it's not just the FDA that makes that decision, but it's the pharmaceutical companies. I mean, to me, I'm like, it's a no brainer.
Kim Vopni (35:21.993)
Yeah.
Dr. Casperson (35:42.262)
We got 80 million women over the age of 40, 50 to 80 % of them will have GSM. It's hard to access doctors, right? So to me, I'm like, and it's so stinking safe. So would I like to see it over the counter? Absolutely. It'll improve access a lot. Interesting thing, has to do with health systems. So interesting thing in the UK, their health system actually saves money by putting it over the counter because then you don't have to access a doctor to get it.
When you have a prescription from a doctor, it's free. So what they did is they actually took the cost and put it on the woman instead. So like, they're actually kind of pissed that it's over the counter because now they're like, I have to pay for it now. Medications are free when you get it through a doctor. And then you look at the American system where it's like, well, it's expensive whether or not we have insurance or buy it at, you know, over the counter. So if there's a lot, it's not as easy as being like, Hey, just put this over the counter. There's a lot of players.
Kim Vopni (36:17.075)
Got it, yeah.
Dr. Casperson (36:40.65)
involved in that. But with the doctor shortage, I'm like, women are horribly undertreated. It would only increase access and it's so safe.
Kim Vopni (36:49.939)
Yep. What is better, Estriol or Estradil for the vagina and the vulva?
Dr. Casperson (36:55.0)
Well, yeah, we don't really have head-to-head studies. It's more like what country are you living in? So Europe tends to have more of the vaginal Estriol product. America doesn't have a vaginal Estriol product. We tend to be either primarin conjugated equine estrogen or estradiol. Estriol is a lower potency estrogen, but we don't have any head-to-head trials. We never will. Nobody's ever going to look at two different types of generic vaginal estrogen to see which one works better.
So to me, I'm like, they're both good, they're both effective. It really depends upon what country you're living in. I think it's splitting hairs at this point. To me, I'm like, just get some help. You know, what's available in your country? Let's try to help you out.
Kim Vopni (37:32.98)
Yeah.
And what about testosterone specific to the vulva and vagina? there's now again back to there's oodles of data, testosterone, men zero. Well, I actually don't know if there's zero studies, but there's zero products available for women. The recent change. So they've removed some of the warning, thankfully. And again, that's kind of what you're saying is hopefully going to happen with estrogen. But is there benefit to
testosterone applied via the labia or intervaginally.
Dr. Casperson (38:06.702)
Yeah, it's a really good question. this tends to confuse people. Which doesn't mean we shouldn't talk about it. It's just I want to be very careful that I'm clear and please ask questions. So I think the first place you have to start is testosterone is in all bodies. Ovaries make testosterone. Ovaries make four times the amount of testosterone than estrogen. The only way you can get estrogen is by converting it from testosterone. Okay.
So have to back up because otherwise women are like, why are you trying to give a male hormone to your vulva? And like, you're crazy, right? So it's like, okay, that health literacy has to be there. And then we can say, all right, if it's true that hormones help cells, and if it's true that receptors are everywhere in our body, it's also true that your testosterone lowers with age and that our pelvic structures are wildly testosterone dependent.
We've got studies looking at testosterone for stress incontinence horribly understudied. Probably has to do with the testosterone helping skeletal muscle and just having a stronger pelvis. two different things when we talk about testosterone, same with estrogen, is systemic, meaning I'm putting it on my thigh to increase my blood levels so it goes everywhere in my body. That's the most common type of testosterone for women. Again, there's no product.
You either have to microdose a male product or you have to get it compounded. And again, Canada is difficult to access this as well as any country. And you can do a lower dose on the vulva, again, compounded, because there isn't a cream, there isn't a product that's, you are FDA approved. The most well-known reason for using testosterone on the vulva is for...
congenital neuroproliferative vestibulodynia, what that means in English is I have a painful vulva. I've always had it. It hurts. And we really kind of push the hormones into it that seem to really make that vulva less ouchy. I see a lot of people getting their systemic testosterone and being told put it on your vulva to make it go into your body.
Dr. Casperson (40:25.058)
There's no data that that's the best route. It kind of comes from the original testosterone studies in men where put the testosterone on your scrotum. And the reason is we have tons of receptors. So they actually at one point had a patch that you put a patch on your scrotum. We don't do that anymore. Like ripping a patch off a scrotum might not be the most pleasant thing in the world. But so it's not a huge leap to see why people are putting their systemic testosterone on their vulva. But I'm like, you don't have to touch your vulva. It's systemic dosing. Like put it on your thigh. It's fine.
Kim Vopni (40:39.347)
Whoa.
I know.
Dr. Casperson (40:55.226)
so I tend to frown on that because I don't see why it's necessary, except for you can use a lower dose because you have a lot more receptors to suck it up. So watch your levels if you are doing it that way, because I think a lot of people aren't appropriately dosing it and checking levels and just like any medication, if you push the levels high, you will get side effects. and that said testosterone at the right dose is incredibly safe.
Kim Vopni (41:16.563)
Yeah.
Kim Vopni (41:22.323)
Okay, I have three final questions. estrogen, when do you think it's appropriate to give somebody the loading dose versus just starting them with twice a week?
Dr. Casperson (41:31.852)
I never do the loading dose. For a couple of reasons. Three reasons maybe if I can remember them all. Number one, there's no data to say why a loading dose is at all necessary. Do those people do better? Do they do just the same? We don't know. There's no data. So I'm like, so that's the first reason. No data to say a loading dose. It's just a thing that from what I could tell a pharmaceutical company made up. Number two, it's confusing. So every day one gram and then after two weeks, then twice a week and then how long does that?
Kim Vopni (41:33.886)
and why not.
Dr. Casperson (41:59.534)
It's confusing. People are, you need to be very simple when you're in a doctor's office because it's a stressful environment. Just say twice a week till you're dead. Great. So I like the simplicity of it. Number three, many women because they've been undertreated for so long are incredibly atrophic. And if you push a daily estrogen product on their vulva, they will absorb some of it. Now that's safe. It's not that it's unsafe, but they'll say, I've I'm getting headaches. I'm getting breast tenderness. I got.
I'm crying at this commercial, right? You're pushing them systemic and they have side effects and now they're freaked out because you told them this was low dose and they weren't supposed to have any side effects and now they do. But it's because when your skin is so thin and you have no hormones down there, you'll suck it all up because you don't have a good skin barrier. so for that, like, doctor, we don't want to get phone calls that you're having side effects. So don't push their estrogen up high.
Now, to add to that, the traditional vaginal estrogen dose is twice a week. That's maintenance dose. Many women who come in with severe pain with sex, severe atrophy symptoms, it hurts when I sit, whatever it might be, they need more than the standard maintenance dose. Right? So I would think about that, but I would get them started on twice a week just for simplicity, to not have them absorb a lot, get them tolerated on it, and then I would
see them back six to eight weeks, how's the exam? How are you feeling? Do you feel like you need more? And women are smart. They'll be like, I feel like the day before my next dose is due, I have symptoms again. Right? You're like, that person is gonna need more. So this whole like, it's only twice a week is like, no, that's maintenance if you're doing well. And a lot of women do need more, I think.
Kim Vopni (43:39.657)
Yeah. Yeah.
Kim Vopni (43:52.147)
Yeah. So we have there's tablets, there's creams, there's the ring. I know that you're favorite you favor the cream as do I because it can go inside and outside. There's some recommendations that it only needs to go within the first two thirds of the vagina and not all the way is is that accurate from a medical perspective? Is there some reason why we shouldn't like with a tablet? Usually it'll go up a little bit higher and kind of melt down cream or fingers may not be able to get up quite as high is there do we really have to
Dr. Casperson (44:17.687)
Yep.
Kim Vopni (44:21.948)
pay attention to how high or how far into the vagina it goes.
Dr. Casperson (44:25.974)
I don't think so. But again, I like simple. think women because they like they've never done it before. It's foreign to them. Like they get freaked out. I do it. It's just so much for people is like I'm like get it halfway up. We need to get it up high enough so we can get it into the bladder. Right. Like putting it on your urethra will not help your bladder. You got to like get it into the bladder. But like you need to put it around your cervix. There's no data. So I think it just stresses people out more than anything.
Kim Vopni (44:51.497)
Yeah, okay.
Yeah, yeah. Final question, DHEA. there's Interrosa in the United States, Dr. Annika Becker has Jalva, Karine has DHEA. So DHEA is helping basically with the conversion. It's not a hormone itself, it's helping us, it's helping our bodies make the conversion. Is that how you would best describe it?
Dr. Casperson (45:04.11)
Mm-hmm.
Dr. Casperson (45:16.11)
It's a hormone. Not good. Everybody can be here. We're so afraid of hormones. Let's not call it a hormone so that people feel better about it. So the other thing people will call it, they'll call it a precursor hormone, which makes it sound, I don't know if that makes it sound, it's a effing hormone. Like get over our fear of hormones already. Vitamin D is a hormone, right? Like everybody has to get over their fear of hormones. So.
Kim Vopni (45:21.447)
Yes, I know.
Kim Vopni (45:33.117)
Okay. When would you use that versus estrogen? Yeah.
Dr. Casperson (45:43.822)
I love DHEA and Intra Rosa. The biggest problem is it's just in America, it's expensive. I was just in Australia speaking at the Sydney Opera House and they can get Intra Rosa DHEA for 40 bucks a month and like many people are using the product. And I'm like, that's amazing. That's incredible. Here it's like 80 to a hundred bucks a month. So.
Kim Vopni (46:05.363)
Yeah. And it's daily use, correct? Yeah.
Dr. Casperson (46:08.97)
It's daily use. Because it's so expensive here, I'll basically get happy on it and then back off and see if maintenance for you could be every other day. See what you need. I use it for severe atrophy. A woman is air quotes failing vaginal estrogen or just not seeing an improvement with it. She might need a little more testosterone. DHEA converts to estrogen and testosterone. That's the magic of DHEA is because
We know we have receptors for testosterone and estrogen in our pelvis. Great. Let's give you one product that has both the things. Comes in a nice little suppository bullet. It makes beautiful vulvas. Like it really makes beautiful vulvas. And you know, I'll tell my, my skeptical women, they're like, imagine estrogen didn't help and blah, blah. And I'm like, listen, just pay for it. Just pay for it for two months. Do it every month. Come back, let's do an exam. like nine times out of 10, they'll be like,
Whoa. You know, so I'm like, in my perfect world, it would be $20 a month. I would love that. We're going to be waiting a while for a generic. But I mean, if you said, what's your favorite DHEA? But that's not my first go-to because vaginal estrogen cream is the cheapest. And I want it to be sustainable. Ideally, you're going to live 30 plus years after menopause, right? This isn't a one-month thing.
Kim Vopni (47:08.255)
Wow, yeah. Yeah.
Dr. Casperson (47:36.682)
So I think cost does matter.
Kim Vopni (47:38.633)
Does DHEA have the same reduction of UTIs that estrogen does?
Dr. Casperson (47:42.38)
Yeah, yeah, there's more and more data coming out on that. They, I don't think they'll ever do a head to head, but it's, it's looking like, because it's the same mechanism, right? Puts the hormones back, we get the lactobacillus back, it reacidifies the vagina, the acidification because of the lactobacillus is what literally prevents the stool bacteria from making its way up. So same exact same mechanism, you would expect it to be as effective. And that's what the data is showing.
Kim Vopni (48:09.533)
And could somebody potentially, even from a cost savings perspective, estrogen a couple, two, three times a week, DHEA on the other days?
Dr. Casperson (48:17.102)
yeah. mean, women get they like everybody kind of gets their favorite cocktail. Yeah, routine of like, you know, we, like the cream because we like to put that on our clitoris and labia minora, you know, but we don't like the cream in our vagina because it's messy. So can we do DHEA? Like, this is what I say, get with a trained clinician who's not afraid of hormones. I always tell my women, I'm like, listen, my job is to just make sure you don't do anything unsafe. And that's it. Like I fully understand.
Kim Vopni (48:21.907)
routine. Yeah.
Dr. Casperson (48:47.574)
your estrogen receptors and your testosterone receptors might be different than Suzy's. You might need a higher dose, you know? And so it's like, we are not one size fits all, but we are in our infancy of supporting women to make safe choices, but to modify it for where they see the most benefit.
Kim Vopni (49:06.719)
Yeah. Okay. I have one more question. I promise it'll be the end where, what do you think from people looking for doctors who have the knowledge that you do the training that you do? Did you take specific training or were you doing your own research? And if you were taking training, are there like, what should we be looking for in a physician? Like I know menopause.org has a directory where, would you recommend for people trying to find somebody?
Dr. Casperson (49:28.814)
Yeah, I the I'm like, how do I say this nicely? A clinician on menopause.org does not guarantee that they will even prescribe you hormones. So it's a low bar. It might be it's people who have they all taken the test? I don't know. But it's a pretty low bar as far as in it, especially when you get into people like, where can I go for testosterone, blah, blah, blah, blah, So that's a it's a starting place, but it's a low bar. I've gotten much feedback of seeing
clinicians off of there who are like they are and they can't help me with my hormones. My favorite place is isshwish.org. I-S-S-W-S-H, International Society for the Study of Women's Sexual Health dot org. And then you go on there and you find the people. And those are people who are members. They didn't particularly take a test, but they're members of isshwish. Why does that matter? They're experts in sex or they have a big interest in helping you with sex.
And then because of that interest, understand how hormones affect the pelvis and affect sex. So that's your best bet for like GSM, pain with sex, menopause hormone issues, testosterone, because we've got the most data on testosterone and sexual function and not just desire, orgasm, arousal, distress with sexual function. It helps with all domains of female sexuality.
So I'd say that's my main go-to for hormones specifically, anybody who's done Dr. Heather Hirsch's trainings, Heather Hirsch Academy, that's probably the best training in America at this point. Harvard just did a menopause course, which seemed pretty darn in-depth. But you wanna see somebody who like, I mean, for me, what did I do? I'm obsessed. Like I've read more journal articles in the past five years than I probably did in my training. And I was at the top of
you know, the class in my training. Like I'm just simply obsessed with the topic. So I can't, right? Cause I'm obsessed. But so it's hard to be like, you know, ask your clinician if they read journal articles. Like most people don't, right? Unless they're like, like me and my friends, we're all obsessed. We share journal articles with each other. But I mean, I'm 20 miles south of Vancouver, BC. So it's
Kim Vopni (51:22.547)
Yeah. Thank you.
Kim Vopni (51:32.585)
Yeah.
Kim Vopni (51:41.236)
Yeah.
Dr. Casperson (51:46.452)
It's hard even in a big metropolitan city to find people to go to for hormones. And so to me, I'm like, I live between Seattle and Vancouver, BC. It's a nice place to visit to get somebody who cares.
Kim Vopni (52:00.787)
Yeah. Where can people find you and follow along? Listen to your podcast, read your book. I know you were part of the factor documentary as well. So where would you direct people?
Dr. Casperson (52:10.091)
Yeah, so if you love Instagram, I hang out there mostly. I'm KellyCaspersonMD on Instagram. My podcast and the book are called You Are Not Broken. Website's kellycaspersonmd.com. The second book is coming out in September. It's called The Menopause Moment. It's basically, get your shit together women, you're in midlife. Let's make some wise decisions.
Kim Vopni (52:30.079)
I love it. love it. You're amazing. will still continue to refer even more. So I just I love everything you share. Thank you so much for taking the time.
Dr. Casperson (52:40.631)
thanks for having me and keep helping all the pelvises because we're not getting any younger.
Kim Vopni (52:45.983)
Thank you.
