121. After Dark, Part 2 — Hormones, Desire, and What Actually Helps

In Part 2 of the Sugar-Free MD After Dark series, Dr. Stacy continues the honest, no-fluff conversation about sex, desire, and hormones as women age.

This episode goes beyond the hype and misinformation online and breaks down what hormones actually do, what they don’t do, and how to use them safely—especially when it comes to painful sex, low desire, perimenopause, and menopause.

You’ll learn why dryness and discomfort are normal anatomical changes, how estrogen, progesterone, and testosterone each play different roles, and why “more hormones” is not better. This is educational, candid, and meant to help you feel informed, empowered, and confident having conversations with your partner and your doctor.

⚠️ Not rated G. Real anatomy, real talk.

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This episode was produced by The Podcast Teacher: www.ThePodcastTeacher.com.

Transcript

Hey everybody, welcome back to the podcast. This is part two of our Sugar-Free MD After Dark series, where I am trying to give you all the information I wish I had had in my thirties about our aging desire and about how desire and arousal and our anatomy change as we get older. So this episode is not rated G. So if you've got littles in the car or wherever you're listening, just be aware of that.

It will not be X either, but it is an adult topic and I will be using real anatomical terms. So just be warned. This is educational, and I'm hoping really just to arm you to have open conversations with your partner and your doctors, your treating physicians. So for anyone outside of Louisiana, that cannot be me. But I want everyone to be able to have this information.

So today, what I wanted to do—and if you didn't listen to last week's, I would definitely start there because I do think there was some information that will help for this part of the conversation—the first thing I want to talk about today is how our anatomy changes as we get older.

The term, the acronym, is GSM. It's genitourinary syndrome of menopause. And what does that mean?

So I can't really show you an anatomy picture on the podcast, but your urethra, which is your urinary tract, which is how urine comes out of your body, is very intimately related to your vagina. Just so if you are looking like north to south, the south is the vagina, then we have our urethra where the urine comes out, then we have our clitoris on top of that. So that's sort of your little three parts of the trail there.

And so that's what we're talking about, that entire area. So it's kind of covered by some other tissues that, when we are young and have tons of estrogen, are fluffy and they help keep bacteria from getting into the urinary tract and they moisturize easily. And all of that changes a little bit as we age. And so all of that tissue can get a little bit thinner. It can get a lot drier, and it can become much more easily irritated.

Okay, so that is the sort of anatomical change that I want to talk about a little bit. This is important because if we are having pain with intercourse because everything is very dry and we are having moisture issues, that is a normal change of our anatomy and our tissues, but there are tons of things we can do to help.

Okay, so there are hormonal treatments like estrogen, yes, estrogen. We can use topical estrogen in that area, in our vaginal vault, and that will help very much replump those tissues. Okay, so if you are looking at stuff on TikTok and you see people using estradiol cream or estrogen cream on their face, it's to plump the tissues, just like it will do for our lady parts. Okay?

So vaginal estrogen or topical estrogen can help plump up all of our parts. Now, for moisture issues, we’ll go through what all of the hormones do, and they can all help a little bit. But I want to stop briefly and talk about the difference between a vaginal moisturizer and a lubricant.

Okay, because we hear “lube,” and I think these things can get interchanged, and they are not interchangeable. Lube is short acting, in the moment. We use it during sex to reduce friction. That is a lubricant or lube. That is during sex, in the moment, as needed.

A vaginal moisturizer is like skincare for your face, but we are doing it for our vagina. And that is something that we have to do to maintain. So that is going to be something like an estrogen cream, like Intrarosa, which is estrogen and DHEA, and there are a couple of others. And those are things we put on two to three times a week, and that sort of maintains a healthier tissue balance.

So I do not have all the brand names of things, and I'm not advertising any of them. So I'm just going to use them in their general terms. But it is something to ask your doctor about if you are interested in those things, because they will have ones that they specifically recommend. And there are different ones that have different pHs and different osmolality, and things that, depending on your medical history, might be better for you.

So I just want you to understand for the purposes of this podcast today that there is a difference between lube and vaginal moisturizer. Moisturizer is a maintenance therapy two to three times a week, and lube is for in-the-moment sex to reduce friction.

Okay, so hopefully that is helpful.

The other thing I just want to briefly say is that our clitoris is not just the little button on the top that we see or that is visible. It is actually a very, very large structure, and it engorges with blood flow just like a penis, similar tissue.

So when I said last week that it might take a little bit longer to get aroused, that's part of it. We need that blood flow to start to plump up our clitoris so that we can have a more pleasurable experience. So rushing—let's get her done—while appropriate sometimes depending on time, if you want to have a fulfilling experience and have an orgasm, you might need a little extra time to get that blood flow to the clitoris. That's all I'm saying. Take it for however you want.

Comfort matters. Okay?

So this vaginal moisturizer and lubricant, those are important because if we are having pain, remember our brain is going to shut down the system. So if it hurts to have sex, our brain is not going to want to have sex. Makes sense, right? Of course, it's trying to protect us.

So I want you to know the difference between those two things.

Okay, let's move into the hormones, because I want to talk about what they do and what they don't do. Because I want you to be wary if TikTok is prescribing you medication. I'm going to give you real education. I'm going to tell you what we know they do and what we know they do not do.

So estrogen. Estrogen helps tissue. Okay, so it can help with the dryness, the irritation, pain with sex related to this GSM. One of the clinical indications for estrogen is GSM. So we know it helps the tissue.

Systemically, if we take it for our whole body, it can reduce some of the other symptoms of menopause or perimenopause. So for perimenopause, what it can do is level out your estrogen. If you are in perimenopause and your estrogen is starting to decline, your body wants to re-regulate that. So it starts spiking your estrogen, and then maybe the next month your estrogen would have been fine, then it plummets.

So lab tests for estrogen to determine if you are in perimenopause are not helpful, because at any given time of the day it can be a huge fluctuation. All right? So if someone says they need to measure estrogen to see if you're in perimenopause, they're a liar pants on fire. Or as we say in our house, you're a liar and your feet stink.

Your estrogen is going to be all over the place.

The symptoms you might feel from that might be changes in your estrogen. So things like your estrogen is really high, maybe your boobs hurt that month. Your estrogen is really low, maybe there's problems with your period. So when we start to see those period fluctuations—we used to be regular all the time, now we're not—or mood swings like, “I don't know what's going on, I'm feeling a little crazy, I'm feeling a little all over the place.”

That might be a sign that you are in perimenopause, and some systemic estrogen to level it out might help.

If you are having hot flashes, we absolutely know systemic estrogen can help.

So what does systemic mean? Systemic means we want our whole body to get it, not just our vaginal tissue. So you might be prescribed an estrogen pill or an estrogen patch. Which one's better? Well, it is a conversation for you and your doctor.

If you have blood clot risk, you probably don't want to take the pill. You might do something like the patch instead. The patch is like this little teeny sticker that you change out twice a week. Very easy.

So estrogen can come three ways, FDA-approved ways. Bioidentical might mean by a compounding pharmacy that's not FDA-approved. We have good FDA-approved estrogen. We do not need to use non–FDA-approved forms.

So if we are having GSM or genitourinary syndrome symptoms of menopause—pain with sex, dryness, recurrent UTIs because our tissue is thinning—that all can use systemic and/or topical estrogen.

So systemic either by a pill or by a little patch. Transdermal is what we call that. Or the cream. And we have a cream that is estrogen and DHEA. We can use that too.

There are also lots of non-hormonal prescription therapies that are FDA-approved for this as well. So we have hormonal and non-hormonal, and all will help this GSM, pain with intercourse, hot flashes, and night sweats.

What estrogen does not do: it does not magically fix low desire all by itself, although it will help desire some. I have patients that are just on estrogen and they say they feel spicy again. So they don't need man-level testosterone to feel in the mood again.

It’s not going to help your stress and mental load or relationship issues.

We also have a vaginal ring as an FDA-approved option. I might have forgotten other FDA-approved ones, and I apologize. I just want you to understand what it does and what it doesn't do, and that there are FDA-approved ways to get them.

If you have hot flashes, night sweats, or GU symptoms of menopause, absolutely FDA-approved. Your insurance should pay for it. You can get a prescription, go to the pharmacy—multiple routes, multiple medications, some hormonal, some non-hormonal, all very effective.

We should not have to suffer with hot flashes and night sweats. If you have those things, they actually put you at risk of cardiovascular issues later. Go get medicine for that.

If you are having painful intercourse because everything is dry and friable, go get medicine for that. We don’t want that. We don't want you to have a hundred UTIs.

Okay, progesterone. Progesterone is really used for mood and sleep support. And very important: if you have a uterus and you are taking estrogen, you have to take progesterone. You have to, because otherwise you’re going to have endometrial lining growing and growing, which puts you at risk for endometrial cancer.

So progesterone protects the uterus. It also helps with sleep and mood. And sleep is sexy.

If you're on a birth control pill and it’s working, you do not need to come off it just because you turn 45 or 50. That can be your hormone replacement therapy.

Testosterone. I am not anti-testosterone, but I want you to understand what is true and what is not true. Testosterone has a place. It can help with desire and arousal in women with hypoactive sexual desire disorder.

It can help a little with brain fog. It will not fix pain with sex. It will not help your relationship problems. It will not help you sleep. It will not build lean muscle or fix fatigue at appropriate doses.

Appropriate doses for women are much lower than men. Man-level doses are not safe long-term for women and can cause irreversible changes like clitoral enlargement, deeper voice, acne, unwanted hair growth, and weight gain.

The safest way for women to use testosterone is a daily cream. Injections and pellets are not appropriate for women.

So the way informed physicians do this is: maximize estrogen first, add progesterone if needed, fix pain with sex, address lifestyle factors, and then consider testosterone cream if needed.

Women are not tiny men. More is not better.

So if this was helpful to you, I am going to be putting together a course. I’m doing a couple of in-person events, and I would love questions from you.

What I want you to take away from these two weeks is that it is 100% normal that your spontaneous desire has plummeted. That does not mean you are broken. Hormones have a role, but they do specific things, and they need to be used safely.

If you need a menopause-certified provider, look them up. We didn’t learn this in med school. Some of us chose to learn more because there is a need.

Longevity matters, but health span matters more.

I would love to hear your questions. Email drstacey@sugarfreemd.com. Please share this with a friend or your partner if you want to talk about it and make some plans.

I’ll talk to you next week. Bye.