Permission for Pleasure
A podcast to educate and equip women with the information and confidence they need to express, experience and enjoy their sexuality. Cindy Scharkey RN, BSN, brings her 35+ years of experience as a healthcare professional to open the doors to healthy conversations about sex. This is a community where you can listen and learn to give yourself permission for pleasure. Visit www.cindyscharkey.com for educational blogs and newsletter.
Permission for Pleasure
Perimenopause 101: Treatment Options
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There are many options available to treat your symptoms during the menopause transition. I continue my conversation with Dr. Shyama Mathews, a Board Certified OB/GYN, and NAMS Certified Menopause Specialist about perimenopause. We discuss non-hormonal prescriptions, systemic hormonal therapy, vaginal estrogen, moisturizers, and lubricants for sex. Dr. Shyama also shares how to find qualified menopause clinicians and why we should all ask for a pelvic floor physical therapy referral.
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Learn more about Dr. Shyama Mathews
More on these topics:
Find a menopause practitioner through NAMS
Midlife & Menopause: Let's Go Girls with Heather
Sexual Reset for Midlife Women
Do you ever think your sex life is broken with Dr. Kelly Casperson
Tips for speeding up arousal
Pain and Sex
Guide to Lube
Pelvic Health
How to talk to a provider about sexual health
ORDER my Book: Permission for Pleasure: Tending Your Sexual Garden
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There are options out there. It's very individualized. It is not ever a one size fits all when it comes to treatments. Some women don't need anything, some women need something more minor, and some people need some real help with this.
SPEAKER_01Welcome to Permission for Pleasure. I'm Cindy Sharkey, your host. This episode is part two of my discussion with Dr. Shawma Matthews, a board-certified OBGYN, minimally invasive gynecologic surgeon, and a NAMS or North American Menopause Society certified menopause specialist. Perfect person to talk to about this big topic of the menopause transition. If you missed part one, I hope you'll go back and listen, and it will give you a good framework for the transition, the symptoms, what that feels like, looks like for many women before you jump into this episode about treatment options, which is what we're going to zero in on. I have heard from quite a few listeners after last episode messaging saying how helpful it was to understand the relationship between lack of lubrication due to decreasing hormones and why then penetrative sex has become so painful. This is such important information for everyone to know. And so I'm delighted that the message is getting across in these episodes about the need for using quality lube for sex, especially during the menopause transition and beyond. So, friends, you know I am a big fan of Uber lube. It's my favorite silicone lube. So what are you waiting for? Now is the time. And did you know that when you go to uberlube.com and use my code Cindy, you can get your favorite lube for less. Less than Amazon and you support the podcast. There's no kickback to me, friends. All the savings goes to you. But please know that Uberlube is a huge friend to the podcast. So when you use my code on their website, it lets them know you heard about it right here on permission for pleasure. So go to uberlube.com. The link is in the show notes, and use my code Cindy to get my favorite silicone lube. You do not have to have painful sex. Painful sex is not normal. And especially in this stage when our lubrication is down, Uberlube is your friend. So let's jump in now and continue this conversation with Dr. Shawma Matthews. Dr. Shawma, welcome back to the show.
SPEAKER_00Thank you. So glad to be here.
SPEAKER_01We were talking about all the symptoms of the menopause transition, why the hormones, last episode, and now we want to say what are my options for all of these things? Let's talk about some treatment options with this stage. And again, reminding people to weigh the risks and benefits with their own health history as you listen to these things that we're going to talk about. You are the best person to know your own body. So listen to what she's saying and pay attention. And then weigh the risks and benefits. You're smart. Tell women, you're smart. You know what's going on. You know, pay attention so you can talk to a provider. So I'm so glad Dr. Shalom could be back with us and talk about some treatment things because no, you don't need to just gut it out.
SPEAKER_00You're 100% correct. And that's my big thing too. I just like people to know that they have options. There are options out there. And it really, you're right, it's very individualized. It is not ever a one size fits all when it comes to treatments. Some women don't need anything, some women need something more minor, and some people need some real help with this, right? So you really have to pay attention to what's going on with your body. Again, like we talked about before, you know, making note of the different symptoms, how often they're happening, how disruptive they are, are they affecting your quality of life? Like that's really the key question. Because if it is, then we really should be talking about what kind of treatments are available. So, in general, the treatments for menopause vary. So there's, I start with sort of the most conservative, non-hormonal, over-the-counter options. There are herbals, there's supplements. Again, we talked about mindfulness, we talked about cognitive behavioral therapy, is actually shown to be helpful. There's yoga, there's acupuncture. I mean, there's a whole wealth of options that are there. Now, what I caveat that with is that it doesn't work for everyone. And the data is a little bit not quite there because the big studies haven't really been done for all of these things, right? Because I think there are so many variables that it's really hard to do a big study. The data that has been there has been reviewed, and there are, you know, again, not a lot of data that says all of these things help everyone. But I often say if it's something you want to try, try it. Do it. Let's do it for some time, commit to it. It may take several weeks, it may take, you know, two, three months to really know if it's gonna work. But there isn't any harm if you think that's gonna help you. And if it does, amazing, right? It's done its job. And if it doesn't, back to the drawing board, we have other options.
SPEAKER_01So for supplements and natural remedies and botanicals, all those things. Do you hear what Dr. Shauma's saying here? If you think it's gonna work for you and you give it a go, and it for some people, some of these things, like I'm not gonna say it doesn't help you. And I have women day in and day out who are like, this is what is helping me. Whether the study and the data is there or not, it works for them. And it could be their first line of something to try.
SPEAKER_00Absolutely. That's exactly what I say too. I know people that it helped, so you want to give it a shot, go for it. But there's also people it doesn't help. So again, don't just sit quiet about it, try it, come back, let's talk about it.
SPEAKER_01Yes, and also keep in mind who's selling you what and who makes the money. I have to say this because it is so pervasive out there, right, Dr. Shama. I mean, who's making money off you and is it is your money well spent? It's always a factor to consider.
SPEAKER_00Absolutely. I agree with that. And that's kind of where it's a little bit difficult with supplements and botanicals because there really isn't a lot of regulation around it. So we don't have things that say that, you know, A is equal to B is equal to C. We don't have that kind of metric or way to tell. So that's also part of the reason why it's a bit difficult to gauge, you know, and compare and really talk about it that way. So, yes, absolutely keep those things in mind. You know, the supplements that I'm sure people are wondering which ones, the ones that often come to mind, and people have mentioned to me as well, and and most of the studies I've looked at surrounding are things like black kohosh, evening primrose oil, sometimes ashwagandha. So there's a few different ones out there. There may be mixtures of them, components of them, and many of them are directed towards obviously this category, right? This group of women that are going through menopause transition. So pay attention to that.
SPEAKER_01So let's get into the menopausal hormone therapy and talk about systemic, non-systemic. Start into your whole spiel on this because people want the they want the education on this.
SPEAKER_00You know, I have a spiel.
SPEAKER_01I hope, I know you do. That's why I have you on.
SPEAKER_00Hormone therapies include systemic and local. And I like to keep those separate when we're talking about it because the risks associated with them, who is a good candidate for them, very different. So when we talk about systemic hormone replacement therapy, that's where we're talking about estrogen and progesterone through either oral tablets or through the skin, typically with a patch or a gel. And estrogen and progesterone function for two different reasons. The estrogen is really what's correcting the symptoms and are going to help with things like hop lashes, night sweats, even some of the sleep disturbance, mood stuff. That's the estrogen levels. The progesterone is really for women who, if they have a uterus and they have not had a hysterectomy, they need the progesterone to protect the uterus from the estrogen. So that's really important. Now, some women also do see benefit with progesterone. They see that it can help them with sleep, it can help them sometimes with like keeping things more even, the fluctuations, and that often is helpful as well. But keep in mind that that's the real purpose. So if you have a uterus, you gotta take both, can't just take one, can't just take the estrogen. So that's systemic use, and this is where it got a real bad reputation a few decades back, and that was because the media decided to take like one line from a giant study and splash it all over. And that's basically that became everyone's take-home message. Hormones are bad. But then when actual scientists sifted through all of this data from thousands of women, they realized, well, no, that's actually not true. It's not bad for everyone. There are some risks associated with certain populations, but in general, for most women that are not at any increased risk for any reason, in the early stages of menopause, it can actually be protective and helpful. In addition to helping the symptoms, it can actually protect your heart and your bones in those initial years. So there's a real reason that it should be on the table as an option for all women. And then considering their risks and what you know other concerns that they may have, then you know, rule in or rule out whether or not you're a good candidate for it. So that's systemic hormone replacement therapy. Now, why I put local in a different category is because local vaginal estrogen you can use to treat the vaginal mucosa and really help with that genitourinary syndrome of menopause that we talked about to help replenish estrogen locally to the vaginal cells, and that really helps them strengthen and you know thicken up again and become a little more elastic again and provide a little bit of their own lubrication. It can help prevent UTIs, it can help prevent vaginal infections, pain with inner course is often resolved. And it's usually a local vaginal cream or ovule that you do twice a week, and that's a maintenance therapy. So once you stop, it will regress. But if you keep it up and you can do this for indefinitely with very little risk associated with it, because it's very safe, it's very locally absorbed. It doesn't change your systemic levels at all. So it doesn't change our blood levels by much at all for it to be a concern. So that's why I put them in different categories.
SPEAKER_01Love it. Because I just get so sad for women who are going through, like we talked a lot about GSM, about these vulvo vaginal changes with dryness and itching and painful sex and burning and more, you know, urgency. And then they don't understand that they have this option that has very few side effects and is pretty safe for most women, as an option that works beautifully and for long term. Yes. So I appreciate you talking it out like that, and also for people to say, hey, go to my provider and say, I'm experiencing this, this, and this. I've heard that vaginal estrogen is an option for someone like me. And can we talk about that? Because how many providers don't have a lot of education around the menopause transition? Could we just insert that right here?
SPEAKER_00Yes, too many. So this is where I will tell you how to find those clinicians. Menopause.org. It's the menopause society website. The reason I like it is because they have a provider database of certified menopause practitioners. Now, these are physicians, nurse practitioners, nurses that take an exam to become certified in managing menopause, and then they have to maintain that certification with either continuing education specifically about menopause or by retaking the exam every two years. So you know they have to be on top of the latest information, which means they have to study it, they have to care, they have to keep re-educating themselves, and they're going to be ones willing to talk about these options with you. So if we want to hope that who you have with you now is able to have these conversations, but if they're not, if they're limited because their training was limited, and remember, there was a whole, you know, time, there's a decades where we weren't teaching any of this stuff because it had just been written off as, you know, unsafe. So a lot of doctors, unfortunately, a lot of clinicians are not well educated. I mean, I'll tell you it myself, my OBGYN residency, we spent what, one or two lectures a year, maybe on menopause. That was it. We didn't talk about it more than that. And we didn't know what options to give patients. So we didn't really get a lot of training in it. I learned all that afterwards, and by getting the certification, I really sort of, you know, honed in on this as um as something I was interested in. So find people that are are willing to talk to you about it.
SPEAKER_01Love that. Thanks for the resource there. And also let's kind of differentiate between vaginal moisturizers and what we're talking about as far as vaginal estrogen therapy. These are two separate things.
SPEAKER_00Yes. And they don't work against each other. So, you know, we already talked about lubricant. Lubricant, every time, all the time, definitely have it. It should be like, you know, like you have a cleanser for your face and you have moisturizers for your face. You need a lubricant, just have it there. Second is vaginal moisturizers, which are pH balancing, is sort of the way that it works, and it's meant to be maintenance. So not just lubricant at the time of intercourse, it's a moisturizer that you use regularly, twice a week, and it's supposed to help balance the pH. You keep that sort of steady. And then vaginal estrogen also twice a week, but again, it has that hormone component in it. So it can be anywhere within that. Some people are not ready or don't want to do something like uh, you know, an estrogen therapy or a cream or anything like that. So there they may just want to do something more that they can kind of control on their own and they can use when they need it, etc. And that's fine. But if that's not working for you, and this is what's key like if the moisturizer is not getting you completely there where sex is pain-free, then the conversation about estrogen should definitely happen.
SPEAKER_01Okay. And I'm going to insert right here, because of the questions I frequently get. Your vaginal moisturizer helps you with moisturizing the tissue. So it's a I always keep the word moisturizer because your lubricants for sex are a completely different thing. So and I'm always encouraging you to try lubricant for sex, you know, try my the Uber lube that I like as your silicone option. That's for pain-free, less friction sex with the lowering of our the moisturizers and the lubricating that we do on our own because our hormones are going down. Your vaginal moisturizer is to keep those tissues moisturized, right? People ask about bioidentical. There's so much misinformation about this. I'd love for you to speak to that.
SPEAKER_00So bioidentic are tough because, again, we're gonna go down that path of things that we don't really have a lot of regulation around. And that's the difficulty. I'm not opposed to bioidenticals. You know, I work with some great compounding pharmacies that will do some, you know, formulations of bioidenticals for patients, hormone levels. And it doesn't mean that they don't work. It's just that we don't have as much reliability around them unless you know what you're working with, unless you know, you know, you've got a trusted compounding pharmacy and a, you know, or a provider that's very versed in it. So it's not that it won't work, it's not that it's a bad option. It's just that when we have things that we know, right? And I know what an FDA approved estrogen pill is gonna deliver, an estrogen patch is gonna deliver, and I know how to work with that, then we know that that's uniform. And it's a much easier thing to manage the levels and to figure out what it is that a person needs. Because again, that's unique, how much they need. So biodentticals isn't always that easy. And so that's where it's a little bit difficult to really counsel patients that this is a better option for them.
SPEAKER_01Yes. And could I just insert the questions around pellets as well?
SPEAKER_00Yeah, so pellet therapy too. I same thing, I'm not opposed to them. It's a different method of management. Pellet therapy is basically you go to a provider that injects pellets under the skin and they slow release hormones typically over the course of three to six months, depends on you know the dosing in the pellets. They have a different method of management. So remember, I was focusing very much on symptoms. And if the symptoms, you know, are relieved by what we're doing, great, that's all we need. We don't need to treat to a number. When they do pellet therapy, the therapists are using numbers to help guide them. And they'll check hormone levels and they'll be, you know, they'll be kind of tailoring the approach. And it doesn't mean that it's there's not a place for it. I actually think there are some people who need that level of replacement and they do better with that. But you also have to, again, be mindful, it's not going to be the same across the board. The absorption is going to be different from person to person. So that too, you really do have to be monitored and you have to manage and make sure you're not getting, you know, unnecessarily high levels, which can be detrimental to your health. So you have to be real careful about that.
SPEAKER_01Yes, thanks for speaking to that. What about some non-hormonal prescriptions?
SPEAKER_00That's another important one that I also want to dispel myths around. So there are a few non-hormonals. There's actually a new one that just came out on the market, just starting to use and get patient feedback on it. That's uh the ZOA, I think I'm saying it right. Uh and then there's the one I actually often go to because it's been around a long time and it's had a lot of data surrounding it. Are medications that are traditionally we use for anxiety and depression therapy can actually be used often at even lower doses than what would typically treat anxiety or depression to manage menopause symptoms, vasomotor symptoms, and they work very well. They have no hormone in them, they work very well. Again, it's not necessarily something you would need to be on forever, but it could help you through that transition very well. And again, there's a lot of data surrounding it. And it's not surprising because remember, we talked about this last time about how the hormone levels do seem to affect our brain chemistry, and vice versa. There's an interplay there that if you correct that brain chemistry piece of it, so these medications they affect the serotonin and neuropinephrine levels of our brains. They can actually translate into these improvements in the vasomotor symptoms and sleep.
SPEAKER_01Vasomotor symptoms, meaning your hot flashes, people, and then also sleep. Okay. Okay.
SPEAKER_00And mood, right? Because we talked about anxiety and depression. Yep.
SPEAKER_01Great. Okay. We kind of glossed over last time pelvic floor physical therapy, but I am a huge proponent of pelvic floor PT. She's written Dr. Sean's raising her hand over there, too. Why is this such an important piece for people at this phase and stage? Well, any phase or stage, I think.
SPEAKER_00Pelvic PT is helpful at any stage in one's life. So pelvic floor physical therapy is a type of physical therapy with a therapist who is trained in the pelvic floor, which are all the muscles and ligaments and bones surrounding our vaginas, our urethras, and our rectum, our GI system. So it's kind of like if you think about your hips as sort of a basket, it's everything within that basket, all that network of muscles. So they are there to support each of these organs in to keep them where they are supposed to be. After menopause, does the hormone level shift? That can affect the strength and the tightness of these muscles and ligaments. And so many times we'll develop, especially if we have some other risk factors like having had children, you may develop uh weakening of the pelvic floor as we age, and that can lead to, you know, leakage of urine. It could lead to uh prolapse, which is where the the or the uterus, vaginal walls, etc. start to kind of come down a bit, and also issues with constipation. So a lot of different issues related to those systems are supported by our pelvic floor muscles. So therapy is really geared towards addressing those concerns. So therapy can work both ways. It can help with strengthening those muscles, which is where in this area that helps. But we mentioned painful sex before, and so sometimes patients who have painful sex will notice that they have tightening of those muscles and they can actually help neutralize the tightening as well. So it's pretty amazing.
SPEAKER_01Yeah. So you can hear both of us, we're cheering you on towards asking for that kind of referral and get an evaluation and see if it's something that can help you, right?
unknownYeah.
SPEAKER_00Absolutely. It will teach you so much about that part of your body and how much you engage it and use it on a day-to-day basis.
SPEAKER_01And that's good for your lifetime. Yes. Wow, I could probably talk to you for an hour. I have a whole other hour of questions. I'm so bummed our time is almost over. But I do want to say there's one more thing about keeping your genitals healthy, and that's blood flow. And so before we wrap up, keeping the blood flow to your genitals helps your genitals stay healthy.
SPEAKER_00I agree. So, you know, if you don't use it, you can potentially lose it. So I would say make sure you're paying attention to those body parts. So whether that's on your own or with a partner or whatever, like don't ignore it because it it actually is helpful to improve blood flow and improve those sensations of intimacy, all of those things, you know, arousal, it's more, all of these things are more possible if you are engaging those muscles and, you know, uh promoting that blood flow to that area.
SPEAKER_01And I'm gonna reference in the show notes my tips for speeding up arousal, which are exercise increases your blood flow, right? You can read the blog, I'll link to it, because I think sometimes we forget the natural, normal things we can do to increase our own blood flow and then also increase blood flow to our genitals, which is super helpful for great sex. Absolutely. Yeah. I'm so thrilled that we could talk about all these things and educate people about this transition. I really think we're gonna need a few more episodes on this. So tell people how they can find you, Dr. Shama, and your work.
SPEAKER_00Sure. So my website is dr drmatthewsgyn.com. Um I'm also on Instagram as well at the same handle, Dr. Matthews G Y.
SPEAKER_01Yes, and I will link to the way you can find a provider that is educated on menopause. And Dr. Sean referred all to that, but I'll link it in the show notes. And on this podcast, we like to share something that delights us day to day because I think that when we find pleasure day to day, we can also bring that practice into our bedrooms. So something just delighting you day to day that you would share.
SPEAKER_00Wow, delighting me day to day. I have a lot of gratitude for what I have in my life. So my family, my career, the fact this is where I am in my career. So that delights me that I've somehow my path has brought me to this, having a conversation like this with you and you know, with the patients I get to meet every day and the family I get to go home every day. I I feel a lot of gratitude for that.
SPEAKER_01Gratitude is a beautiful thing. Thanks for sharing that. And we appreciate you being with us and your work in the world on behalf of women everywhere. Thank you. Thank you.
SPEAKER_00Thank you so much for having me.
SPEAKER_01Well, listeners, I do realize this is a huge topic. And in many ways, we just scratched the surface. Like I said, I could have talked another hour easily with Dr. Shamma. So look for more episodes about this topic or let me know if you want to hear more. I always enjoy hearing from you. You can contact me through the link in the show notes. But I do hope you will continue the conversation within yourself and with your body, with a partner if you're partnered, and with your provider. The menopause phase is an ongoing stage of life, and so these conversations are not one and done. Before we wrap up, I want to offer one conversation prompt to use if you're partnered. But before that, I want to remind you that in the show notes I provide links to information and topics we discuss in the episode or reference. As well, you'll find your link for Uber lube and my discount code Cindy to try my favorite silicone lube for sex. You know what? A couple things I love about Uber lube. One is it comes in a pretty glass bottle. It's just pretty, it's pretty to have out. And it has a metered pump. Meaning you press the pump and it gives you an exact amount, like almost some not a dosage, but just the right amount. And it makes it so easy during the flow of intimate moments to give it a pump. Or two if you need it. And speaking about those intimate moments, my conversation prompt for couples is this I'll educate you about my body and you educate me about yours. Or perhaps you want to word it this way. Will you please educate me about changes that are happening with your body? And I'd love to share some of what I'm finding out about my own body. Let's normalize our stages and evolving bodies and their changes. And for sure talk and tell a partner what those are. Let's not assume a partner knows what's changing within our bodies, our genitals. Let's educate one another. This kind of communication, hmm, it is part of giving ourselves permission for pleasure.
