You’re Not Broken: Low Libido & Vaginal Dryness After 40 with Dr. Betsy Greenleaf

🎙️ Welcome to Fit in Your 40s Podcast

If intimacy feels different than it used to — low libido, vaginal dryness, discomfort during sex, or a disconnect you don’t recognize — this episode is for you.

So many women in their 40s and beyond assume these changes are just part of aging. Our mothers stayed silent. Our grandmothers stayed silent. And many women today are still suffering quietly, believing there’s nothing they can do.

That stops here.

In today’s conversation, Doucky is joined by Dr. Betsy A.B. Greenleaf, a board-certified urogynecologist and internationally recognized expert in menopause, pelvic health, and sexual wellness.

Together, we break the silence around sexual health in perimenopause and menopause — and explain why low libido and vaginal dryness are common, treatable, and not something you have to live with.

This episode blends medical insight with a holistic lens, helping women understand what’s really happening in their bodies — and how hormones, stress, nervous system overload, gut health, and lifestyle all intersect when it comes to desire and comfort.

🎧 In This Episode, You’ll Learn:

• Why so many women experience low libido and vaginal dryness in perimenopause — and assume it’s just aging
• Why women believe they’re “the only one” struggling, even though these issues are incredibly common
• How hormone shifts after 40 affect desire, arousal, and vaginal health
• Why libido is not just about testosterone
• How chronic stress and cortisol suppress sex hormones
• Why sex and stress can’t coexist in the body
• Why simply adding hormones doesn’t work if the nervous system is overwhelmed
• How lifestyle stressors (work, kids, aging parents, poor sleep, under-fueling) impact desire
• Why cortisol patterns matter more than cortisol levels
• How gut health and inflammation influence hormones and libido
• What a true whole-body approach to sexual wellness looks like in midlife

📲 Links & Resources:

📸 Follow Dr. Betsy Greenleaf on Instagram
👉https://www.instagram.com/drbetsygreenleaf/?hl=en

🛍️ Get 10% Off The Pelvic Floor Store
Use code BFF at checkout
👉 https://pelvicfloorstore.com/discount/BFF

📘 Learn About the BFF Method
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(Plus free resources to get started)

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Transcript

Doucky 0:23

Hi, this is Coach Ducey and you are listening to Get Fit in your forties, where we have honest conversations about women's health in midlife and what actually works during perimenopause. This podcast exist because so many women are struggling in silence with hormones, energy, confidence, and changes in their bodies that no one really prepared them for. Here, we talk about it openly and give you real practical solutions. Today's episode is important one. I'm joined by Dr. Betsy Greenleaf, a renowned menopause expert and a true pioneer in women's health. She made history as the first female board certified U gynecologist, and has spent over two decades helping women reclaim comfort, confidence, and quality of life. Dr. Greenleaf is the founder of the International Pause Institute, the CEO of the Pelvic Floor store, and the founder of Fem Verity. Her approach is holistic. Empowering and refreshingly honest, bringing clarity and compassion to conversations many women have been told to ignore. Today we're talking about sexual health in midlife, including low libido, vaginal dryness, and why these changes are not something you have to just live with. Let's dive in.

Dr. Betsy Greenleaf 1:40

Thank you so much, Dukey. I'm so excited to be having this conversation with you.

Doucky 1:44

Finally, we're gonna talk about these taboo topics that, we don't want them to be taboo anymore.

Dr. Betsy Greenleaf 1:50

Exactly.

Doucky 1:51

why don't we just start by, talking about why do so many women in perimenopause experience low libido? Or vaginal dryness, but assume it's just aging and stay silent about it. I know my mom did. I know my grandma did. I know my aunt did. And we don't wanna continue that pattern. So why don't you just start talking about that.

Dr. Betsy Greenleaf 2:13

it's so important, and it's funny because in my practice I can't tell you how many times women come into the office and they'll tell me these stories and the things that they're struggling with, and then the next words out of their mouth is, I must be the only one with this because my friends aren't talking about it. Like you said, my family hasn't talked about it. I didn't know this was a thing, and I'm like. the funny thing about that is they think they're the only one, but yet my whole schedule is filled with people that think that they're the only one. I think part of it is, we're still like a little bit embarrassed to talk about sexual wellness. and I think too many. Women think oh, this is just a normal part of aging. And they just chalk it up as that and they go, all right, you know what, this is, I had a good time in my twenties or whatever, and that this is just part of aging and then this is something I need to put up with. And unfortunately, like life is not over. there's so many different. Treatment options and ways to support this pelvic health that women don't have to live with this anymore, and it's not just part of aging.

Doucky 3:16

So do you think like all these. High divorce rates have to be where that there is not intimacy that you don't feel attracted anymore. So what is happening there? And if it's, of course it has to be with the perimenopause, hormonal changes,

Dr. Betsy Greenleaf 3:31

Yeah, so what's happening exactly and right around 40, like 40 is the key is right around the age 40. In both men and women, our testosterone is starting to go down. meanwhile, we can't say like testosterone is the only. Factor when it comes to libido, because with libido there's so many different factors. But you also have around the age of 40, you have a lot of women, and men, we're talking specifically about women. Not only is it testosterone starting to decrease, we're starting to get shifts in all the other hormones But then you also add the life stressors because here's our brain is our actually most. Important sex organ. And if we don't stimulate the brain or if the brain is under stress, like sex is not just not gonna happen. So this is why even I could give somebody testosterone and fix that problem, but if they're under a lot of stress, and so what we're seeing like around. Forties is that people are starting to like, have a lot more career stress if they're working, if they've been parents, they're starting to have like stress from the kids, are they going off to college? Are they not going off to college? what is going on? Kids getting older is gonna get easier, but it tends to get harder. Also, around that time period, you have a lot of people that are dealing with older parents and So this is all kind of happening all at once, right? As the hormones are starting to shift. And so if we're not dealing with the stressors. testosterone, like all the testosterone in the world is not gonna work. And from an interesting standpoint, if we actually go to the processes in the body, that what actually physically happening is we have to be in a relaxed state. For testosterone to be made because there's two tracks that our hormones go down. It's either it's going down the sex hormone track or it's going down the stress hormone track. And I'm always saying, sex and stress can't coexist, so the body doesn't understand that you want to have fun maybe with your partner or with yourself or whatever. just looks at it from a reproductive standpoint, and so the body goes well if there's any stress going on, whether that's mental stress or then there's also physical stress, like what are the things that we're doing to our bodies? this could be poor diet, not enough sleep, not enough fluids, not enough hydration, like the body looks at stress and inflammation, all as stress. All is the same. And it will go, okay, you know what, it's not the time to reproduce. So we're gonna convert all those hormones into cortisol and so that's gonna go down into stress hormone. I see. And especially, I just had a friend the other day who is getting like a testosterone pellet and she was telling me, first of all, the level of testosterone they were putting in her was ridiculous. It was almost that of a man and even her. Like testosterone levels were like close to a man and she was still telling me like, I don't get it. I don't have a sex drive. And I'm like, the problem isn't the hormones. It is, it's one of the factors. But I'm like, you need to look, at the stress in your life and try to change that so that the hormones will work properly.

Doucky 6:31

that is actually one question that I had. How can you differentiate that is just your hormones versus that, I don't know, maybe I'm not attracted to my husband or there is something else off, so. how can we differentiate that? So I guess it's like, well, you have to have all your dogs in a row checking that you are not, I mean, like trying to manage your stress from work, hydrating properly, eating, properly, exercising, taking some breaks, delegating some of the stuff and then saying, okay, so well, I love my husband. And then it's like, oh, maybe it's the testosterone. So what do we do when we have everything? Organized

Dr. Betsy Greenleaf 7:10

Yes.

Doucky 7:11

taking care of ourself, which is not the majority. how do we know that is a testosterone? What is the first step? Where do I go? Who do I talk to?

Dr. Betsy Greenleaf 7:19

Yeah. from my standpoint, what I like to do, and you don't necessarily have to do all the fancy testing, but as a physician, I like to do the tests to show people like, this is what's happening. really, you can actually just take a true inventory of your life and realize and look at what are you doing? So total wellness is like a three-legged stool, and it has to be body, mind, spirit equally. So if you're doing all the things right for your body, you gotta go and be like, okay, what am I doing for my spiritual health? What am I doing for my mental health? And that may be, am I spending time with friends or family? Do I have a support system like. Do, am I doing things for relaxation, like meditating or breath work or like really taking it full inventory of your life. Are you eating non-inflammatory foods? Because here's the thing, processed foods and when you're on the go, I realize it's a lot easier to go grab fast food than to eat whole foods. But is, are those inflammatory? Food's throwing off your gut microbiome, which will also throw off your hormones and your sex drive. But like from my standpoint, what I like to do is, as a, I think as a doctor and a physician I wanna look at the, what are the levels? Yeah, so the problem getting blood work though, here's the problem, like a lot of people will get blood work because the insurance tends to cover blood work, but the blood work ranges are so broad that it's really hard to figure out what's going on unless you follow them over time They're really not telling me like, what's going on in your tissue. It's really what was your levels at the time you were in the laboratory? And like you walk outta the lab and your levels can change. So some of the more advanced testing, like saliva testing or what's called dried urine testing, like the Dutch test, will actually look at it more closely and it gives us a better idea of what's actually going on in your tissue. But it's not enough to get the sex hormones. We also have to get a four times a day cortisol level. Because it's not so much the levels of the cortisol cortisone, which is their stress hormone. It's the pattern. Because naturally what should happen when you're in a relaxed state is your cortisol should peak in the morning. That's what helps you wake up, and then as the day goes on, it starts to decrease. And so if there's any kind of changes in that. Pattern, then we know it's sucking away your sex hormones. And like sometimes you can tell this just by someone's symptoms. Like someone might say alright, you know what, when I wake up in the morning, even though I slept eight hours, they don't feel rested. But yet at night. They get this like second wind and they're like doing tons of things at night. I can almost tell you when they're telling me that, and I get their cortisol levels that we're actually seeing a, inversion or a flip of their cortisol curve. And so even then we have to go and look at what From an exercise, standpoint or from a stress standpoint, what can we do to get their cortisol back in range and that it's in a normal pattern so that it's not drawing away the sex hormones. then I also particularly like to do gut microbiome testing. So microbiome is the bacteria that lives on our body, in our body, and the microbiome is different in each part of our body. So I find that unfortunately.'cause of stress, environmental toxins, the standard American diet. We tend to throw off our gut microbiome. And a lot of people will say to me like, oh, but I eat healthy and I'm eating probiotics, or eating probiotic foods. nothing wrong with my gut. And then we do the testing and I go, oh really? look at this.

Doucky 10:54

Yeah.

Dr. Betsy Greenleaf 10:54

you also don't necessarily have to do the testing, but if you've tried everything else and nothing's working, that's where really doing the testing to look further into the problem is gonna help. 90% of our happy hormone is made in our gut. So if our gut is off, we're more prone to anxiety and depression, which often gets blamed. On perimenopause. And then the question is it a perimenopausal hormonal issue, which it could be, or is it a gut issue? 80% of our immune system is made in our gut. So if our gut is off and we're getting sick all the time, is it because we're stressed or is it because there's something going on with the bacteria levels, imbalance in the gut?

Doucky 11:36

To see it holistically, right?

Dr. Betsy Greenleaf 11:38

Yeah. So this is where it's, I'm getting a little frustrated because we see a lot of these hormone companies that are popping up online where people just put in their information and for a couple bucks a month, they're getting hormones sent to their house without. Anyone actually looking at the person, because it is so much more than just hormone levels. It's looking at the whole bigger picture. And I keep hearing from people, even just talking to friends and being out and about and when I speak and I teach and I hear from people and they like, oh, hormones didn't work on me. It's not that the hormones didn't work, it's that was your body prepared to accept them in a proper way, because was there something else going on that was preventing you from using them properly?

Doucky 12:22

Okay. So then we have to check everything holistically. See, depending on the person, what are the levels that they should have? There is like a number, if I go and test my testosterone that women at this age should be, or that also depends on the person.

Dr. Betsy Greenleaf 12:38

it depends on the person. a normal serum level of testosterone, is usually around 75 for a woman. But this also depends on a couple things. First of all, people don't follow. Textbooks because my normal testosterone level may be completely different than your normal testosterone. and I've seen this with patients, like I had a woman years ago where we were replacing our hormones and. She looked like on the laboratory, she looked laboratory low, but every time we actually tried to adjust her hormones to make her look normal on a laboratory level, she started to have worsening of symptoms. Because one of the, especially with testosterone, one of the problems can be like anger or losing your hair, growing a mustache, getting acne, kinda. All the like male, features. but yet when we got her in a level that her, she felt better and her symptoms were better, then we were able to look and be like, okay, look, your normal falls in this range where, so that's actually what I tell people is if you're getting hormones done by somebody else and they're, let's say they are not doing the advanced. Testing or say you don't have the extra money to do the advanced testing. At least graph your results over time. make a spreadsheet, put your levels, and then put your symptoms. if you follow it over time and you follow the symptoms and the levels, you can start figuring out like what is your normal

Doucky 14:04

And they should be testing like every three months or so, right?

Dr. Betsy Greenleaf 14:07

Yeah, at the beginning until you're stabilized, like I say, three to four months until you're stabilized and then figure out like, oh, then you see the full picture and you're like, okay, when I'm around this level, I feel great. because also we have to look at what is a laboratory normal? A lab normal, and this is why it varies from let's say you get a lab from Quest, but then you go into LabCorp the next time. Like your levels might look totally different because the laboratory normals are what that lab is reporting based on the average of what they see. So it's who's coming in and using that lab. So we don't have. A hundred percent like human levels, like what is normal for a person. And then again, each person, their normal may be different.

Doucky 14:52

Yes.

Dr. Betsy Greenleaf 14:52

I remember back in medical school, my mentors always said, treat the person, not the lab. The lab just gives you an idea of where to go. It helps with direction, but it. It doesn't really tell you what's going on with that person. You gotta treat like their symptoms, so

Doucky 15:08

Yeah, and I think it's important also that. It doesn't react immediately. We, in this society, we're so anxious and we want, you know, fast results. But yeah, it, you know, like doctor, are no magicians and you need to be testing every certain amount of time to kind of like see the patterns and then to adjust the levels until you feel comfortable. So it takes time. All of these things takes time. Okay. So. In which form? we subscribe. Testosterone. I know that answer, but I want you to explain our listeners, because I think it's like very abstract, right? Like hormones and people all the time ask me like, how do you take it? Do you inject it?

Dr. Betsy Greenleaf 15:47

And then that's the other thing is a lot of people think, women, they don't get testosterone because that's a male hormone, but yet women have it, and in the body, testosterone will convert also into estrogen. So if you're getting testosterone as a woman, some of it's gonna convert into estrogen. One thing I definitely have to point out though, if you have a uterus, it's really important to also be on progesterone.'cause progesterone is a hormone that protects the lining of the uterus from overgrowing. And so some practitioners don't put two and two together for whatever reason.'cause they've always been trained like, oh, if you give a woman with hormones. estrogen, we have to give them progesterone, but they don't think about the same thing with testosterone. And so sometimes I see people that have been put on testosterone and not given progesterone to protect the uterus, but so we gotta realize that testosterone will also convert in the body into estrogen. So you, if you have a uterus, you definitely need progesterone. If you don't have a uterus, I still like progesterone'cause there are some, neurotransmitter effects. So there's effects on the brain that it's really good for. But when it comes to how to. Give testosterone. There's a couple different ways and you can take it orally. You can take it as an injection, you can do it topically or you can do a pellet. Now I will start off with saying I would not recommend oral testosterone. when I teach practitioners how to do this for a couple different companies. I say, don't even bother doing that because you have to give such high levels of these hormones because they have to be absorbed and they have to be processed by the liver before the body even sees it. So it's hard on the liver. cause of gut absorption is variable. You don't actually know exactly how much you're getting. So then that leaves us with topical injections or pellets. And really there's advantages and disadvantages of all of'em. So the topical is nice in that you put it on every day. The body gets this nice up and down of your receptors are being exposed to it. the problem with topicals is that it has to be put in a place on the body, which. It's not gonna be exposed to other people because if you, let's say you put it on your arm and you're hugging your dog or your kids like that hormone can rub off on other people and pets. And there

Doucky 17:56

problematic. Yes.

Dr. Betsy Greenleaf 17:57

have been reports of kids and pets having side effects of hormonal exposure. a lot of times I will tell women just apply it to the vulva or the vagina. because you're getting, you're killing two birds, one stone. You're like absorbing it very easily. And then you're also. it has an effect on that tissue in the vulva and vagina. So with regeneration. so putting it on thin skin, it works better. Even sometimes I'll have people use emu oil, which I absolutely love emu oils and is a anti-inflammatory type of, it is animal based oil. It's a great carrier oil. So if you put emu oil on first and then put your hormones, it'll absorb through the skin better. So that's one thing. Then there's injections, and so the disadvantage of injections is you have to inject yourself. And then the injections, there's injections where you have to do it every day, or there's long acting injections where they're done every 12 weeks. But usually, most of the time we end up using an injection that lasts a week or two. So the disadvantage, like I said, is you have to inject yourself.

Doucky 18:58

Yes.

Dr. Betsy Greenleaf 18:58

and then lastly is pellets, where it's a little, it's like a little tablet that's been like made and it's implanted underneath the skin and pellets. Typically last for about three months. they are considered a minor surgical procedure. So you have all the risks of a minor surgery, meaning bleeding, bruising, infection. But the problem with pellets is once they're in, they're very difficult to get out. In fact, I would not even. Tell anybody to get them out because you have to really do a big incision and try to, it's like trying to find a needle in a haystack. So if they're in and you have a side effect, let's say it's too much testosterone, you have to wait out the three months for it to wear off. but people, and the other thing I'm not, even though I do pellets, I'm not a big fan of them, is because anything in the body that stays at a steady state for long periods of time, the body starts to tune out and it's, I give the example of I walked into the room and I had a big cow bell and I'm ringing this cow ball and I'm like, ring. Ring. You'd be like, stop that. That's annoying. But if I kept doing it over time, you would just tune me out. You wouldn't even hear it. So like a more real life example is if you have teenage kids and you tell them, clean your room, and you're telling them that all the time, they don't even hear you. They don't even know you said that because they've tuned you out. one of the potential problems with pellets is. Over time, sometimes the body won't respond to it anymore, so people will say it was working and now it's not working. And it's not that you're not getting the testosterone or hormone levels from the pellet, it's just your body has tuned it out. the way to overcome that is just take a break and you can bridge it with shorter acting like topicals or shorting acting injectables. if you're using a topical or injectable, you're not gonna get that receptor tuning out as much because you get like an every day up and down, depending on, with the injectables, if they're longer acting injectables, that can happen.

Doucky 20:53

Okay, great information there. Now let's talk about pelvic floor. You're a specialist on pelvic floor as well, and how can that help in our pleasure? Because let's say, my libido increased, but I'm not finding pleasure when I'm having sex with my partner.

Dr. Betsy Greenleaf 21:09

Yeah, so there's a couple things. So number one, if you don't use it, you lose it. So this happens to men and women. So if the vagina is not being used or the vulva, the clitoris, or in a man a penis. will lose it. It is actually something like, think of it as your pelvic physical therapy. The more you use it, the better it's going to work. It's if you had a car and you stuck it in your garage and it was there for months to years and then you go to try to start that car, it's not gonna run as well as if you were running it all the time. So this is where, I know this gets a little uncomfortable for some people, but it's a touchy subject. But if you're not having sex with a partner. From a purely medical standpoint, thinking about incorporating self pleasure as part of your pelvic physical therapy to keep things in working order, because one of the problems we see as we age is we don't get as much blood flow into the genitals unless we're using it all the time. Postmenopausal women, will actually start to get retraction of the blood vessels in that tissue. So by using it more frequently, it encourages more blood flow to that tissue so that it's more responsive. You can get it back. Things, or you found yourself where you're like, I've seen many women in their forties who are like, because the sex drive has gone down, they get annoyed with their partners and then they don't wanna do stuff. Now they're like, okay, now I gotta try to do this again. And that actually goes very well with, I love the Rosemary Bassan model of female sexuality, which if you can look up Rosemary Bassan online, because if we go back to the Masters and Johnson model, people may think of, it was a very linear model. And so some people always think I have to be in the mood to have sex. Because the Master and Johnson's, model was there was a start and a stop. Like you were in the mood, you had sex. Maybe there was an orgasm and then there's a resolution it's start and stop. Where Rosemary Bisan was a sex researcher, in the nineties who re mapped out female sexuality. And what she said was, you can still have spontaneous desire, but it gets a little harder as we get older because number one, there's more stressors, there's more responsibilities. And the longer you're in a relationship, you become desensitized to that person.'cause remember you're being, same thing with the hormones. If you're being exposed to the same person all the time, like when you're first with that person, it's all like fireworks. And that's dopamine getting, like in your brain. So like you see that person, you get excited, but. It's not that you can't still have that, but the longer you're with that person, there's a process called habituation makes it a little bit more work maybe to get those dopamine hits and get that excitement in the brain.'cause the brain likes novelty and I'm not necessarily saying go get a new partner, We do see this in women who get divorced though all of a sudden, like they have a new partner and their sex drive is fine, So Rosemary Bean okay, starting out with willingness so you can have spontaneous desire. Okay, we'll put that aside'cause we know that can happen, but it isn't happening, starting with willingness. So set like you said. a date night, with the intention of having communication with that partner that if, hey, if this doesn't work, don't you don't wanna force yourself through something because then it creates a negative feedback and it makes it unenjoyable. But having the willingness to go through the steps can sometimes trigger blood flow and then sensitivity and then. After the fact, you go, oh, wait a minute. This is fun. And then you continue to it on, and hopefully you have a satisfying sexual event that makes you go, oh wait, why don't we do this more So a lot of times when I show people the Rosemary Bassan model, sometimes just looking at the model, Fixes people's libido.'cause they're like, okay, I'm gonna set a date night. I'm gonna try to do something with my partner. Or if you're not partner, this is something like setting time aside for yourself. and then they go through the steps and they go, okay, like that worked. the funny thing is there's actually some products out there that. Are geared for women's libido. there's a couple different like arousal oils, and if you actually look at the ingredients, some of them are actually very stimulating.

Doucky 25:21

Okay.

Dr. Betsy Greenleaf 25:22

or the instructions will say rub this into the vulva for 10 minutes before sex. And I'm like, that's so funny, because they're actually just using the Rosemary bassan model, like just stimulating the tissue.

Doucky 25:35

be having the willingness,

Dr. Betsy Greenleaf 25:36

Yeah, so this is where to fix things with long-term relationships. It's actually all about communication and trying to figure out how to improve novelty in the relationship, how to make things new And that's gonna look different for everybody. This is why sometimes women get really frustrated, especially like they come in and they say to me, it's not fair. Men have Viagra. We don't have anything. And I'm gonna be really blunt. But what I say is, Viagra is not a horny pill. It doesn't put you in the mood. It's a blood flow pill. All it does is when the brain is stimulated, it will increase blood to the pelvic floor and that's how men get erections. So actually Viagra works on women. it just increases sensitivity and lubrication when the brain is stimulated.'cause if the brain is not stimulated and you take a Viagra, it doesn't do anything. So, um, you know, and this is why we, I don't think we'll ever see a pill that's gonna put. People in the mood because everybody's brain is different. So it's really having a conversation with yourself and figure out like, what are the things that turn me on? And then communicating that with a partner. some people, this may be fantasies, some people it might be incorporating devices and toys. sometimes it's being in a different place. This is where like sometimes when I talk to people and I'm like, how is the sex when you're on vacation? And they're like, oh, when we're on vacation, it's so much better than when we're at home. And I'm like, number one, you're in a new place, but you're also not being exposed to all the stressors that you would normally be having if you were home. So take out the stressors, throw in something new, and there you go.

Doucky 27:10

That is so true, and what you're telling me is basically that we also need a new strategy for this age in life. Exactly what we said in our program is like you cannot pretend just starving and just going on a treadmill to lose weight as you did in your twenties. Now you need to focus on other stuff and it is another type of a strategy. So same thing when it comes to. with your partner or sex with yourself, as you just said, right? Because if you don't have a partner, you also have the right to enjoy yourself and to feel pleasure. And we are using the same strategy. It's oh, I wanna be surprised by my husband. Your husband is working, he's coming coughing and stressed, and there is no surprise,

Dr. Betsy Greenleaf 27:51

Yeah.

Doucky 27:51

there is. maybe a turn off on thinking that you have to plan it, because before it was more spontaneous. But

Dr. Betsy Greenleaf 27:58

Yeah.

Doucky 27:58

this time also that has to be in the agenda. We have a list of things to do, to think about and things to solve,

Dr. Betsy Greenleaf 28:05

Oh yeah. And sex is definitely, women unfortunately tend to multitask and we're very proud about multitasking. But sex is the worst time to be multitasking.'cause you can't be there and go, okay, who's picking up the kids? Like laundry. Okay, food. what's for dinner? Like you need to figure out how to turn the brain off and like just do the one thing. Oh, the other thing I was thinking about when it comes to sex is, in the pelvic floor is muscles. And this is where a lot of times we lose about 8% of our muscle mass for every decade that we live after the age of 30. And so that works out to be almost 1% a year. And people think about exercising their arms and the legs and they don't think about exercising the pelvic floor. So if our pelvic floor muscles start to become too weak, that can affect. Our response to sex. So this is where doing your Kegel exercises gonna be really important. And unfortunately, I see too many women not doing them properly. they're like, where are those muscles? Like how sometimes they're pushing down like they're having a bowel movement where Kegels are more like a lifting and like almost. I steal this from a friend of mine. I can't take credit for this, but my friend says, who's another urogynecologist? He's pretend there's a giant straw coming out of your vagina and you're trying to suck in a thick milkshake. you're like, if you were sucking in a thick milkshake with your mouth, you'd be like, really sucking and lifting and, but in the vagina, you'd just think about Kind of like lifting and pulling up and that's your key goals. So, and if you still don't know what you're doing, which is fine because not everybody does, is there's pelvic physical therapists that can show you how to do it. Your gynecologist can show you, there are tons of different devices out there that you kind of like. Put in the vagina and you get feedback. And then some of'em work with, just like every time you squeeze it, there's a little light that comes on. Some of them, there's a little app where you play games like every time you squeeze, you like score points. So there are different ways

Doucky 29:59

Oh my

Dr. Betsy Greenleaf 30:00

Yeah.

Doucky 30:00

And like we want all those names. We're gonna put it in the notes for everyone to get, so everyone is gonna be exercising that muscle, at least in my group is gonna do it. And also for the listeners as well. So we talk about pelvic floor and how useful is to get those muscles, worked out. now let's talk about the vaginal dryness. So when do we start experiencing the dryness? How do you feel it? What to do about it?

Dr. Betsy Greenleaf 30:26

Yeah. So what happens is as estrogen is starting to come down in the body, the vaginal tissue starts to thin out because in our reproductive years under control of estrogen, the vaginal tissue is actively growing cell by cell, and it's many cell levels thick. So there's a couple things that end up happening. Number one, that supports the elasticity of That tissue, it makes that tissue moist, but it also from A microbiome standpoint, supports the healthy bacteria in a vagina because as that tissue is actively growing, the old cells are being pushed out. They die off, they slough off, and they contain a chemical called glycogen, which is the. Food source for lactobacillus, which is the healthy bacteria that keeps our vagina in order. It prevents us from getting urinary tract infections and bladder infections and vaginal infections because the lactobacillus keeps the vagina very acidic. So as we get older. it can actually happen on birth control too. You can get a thinning of the vaginal tissue and birth control and pregnancy, but more so as we age, because as our estrogen levels going down, that tissue's not actively growing. So the tissue becomes thin, it becomes dry, it's not as elastic. So any pressure that's put on the area can cause that tissue to rip and tear. And then we also lose the lactobacillus that is keeping us healthy, and now we're prone to more. Vaginal infections and more urinary tract infections. So we're like, great, you don't get pregnant anymore. But things don't feel good down there. It's dry, it's uncomfortable, it's painful. It feels like it's being ripped open, like you don't wanna have sex. So it's, it's, and there's actually interesting enough, there is this vagina brain connection. And so when there's a change in the microbiome of the vagina, there's a feedback loop that also decreases libido. So now we gotta go, alright, what can we do? And giving up and being like, oh, that's, it is really not an option anymore. we're living much longer. And we go, you know what? There has to be options. And so there's a lot of different options. there's anything from using lubricants. Lubricants are not gonna actually change the structure of the tissue, but they're just gonna make it more comfortable Some people are fine with using lubricants, but there's some women that are like, they look at it as like it's bad because, or I guess there's this misconception on both their PO standpoint and the partners that the level of wetness is equal to the level of excitement and desire, and that's not true because there are so many different things that can cause. Like natural lubrication and na natural lubrication is actually a blood product. So when the blood is flowing to the vagina and the vulva and it's under pressure, you actually get plasma coming through the walls of the vagina. And that's really what that. Lubrication is, so any, if you're dehydrated, that can affect your level of wetness. If you're on medications, there are certain medical conditions, especially autoimmune diseases, so that's why lubricants exist.

Doucky 33:27

Please use lubricants. It doesn't have anything to be on how much you love your partner.

Dr. Betsy Greenleaf 33:32

yes.

Doucky 33:33

key in this conversation because it's true.

Dr. Betsy Greenleaf 33:36

And the getting the right lubricant is now the science behind lubricate the lubricants that you can buy on the market is so crazy. They realize that if it, the lubricants are not pH balanced. So if they're not acid balanced for the vagina, If they're not osmolarity balance, which means if they're not balanced for salt concentration, that they can actually damage the vagina. So there are a few companies that make them that are specifically for vaginal health. the ones that I know offhand are ones called like. Good, clean love, Uber, lube, or I, yes. unfortunately, KY Jelly unfortunately is probably one of the worst ones you can use because it specifically dries up the vagina. So you have to use more to get that lubrication. but if there's something you're using and you're not having any problems with, like stick with it, it's fine. But if you're having problems, think about, looking for one that's more. healthy for the vagina. Then there's options for prescriptions. So there's prescriptions, anywhere from topical hormones that can be placed in the vagina from creams to tablets to rings. there is an oral medication that's not hormonal, but the body perceives it as a hormone. It's called, O PAF or osphena. some people like that's an option. you can use, there's anywhere from estrogen creams, testosterone creams, DHEA, which is a precursor to testosterone and estrogen. Those all can be used in the vagina. to help regenerate that tissue.

Doucky 35:01

Okay.

Dr. Betsy Greenleaf 35:02

there's those options, and that was all that was on the market for a very long time. And beginning in the early two thousands, we started to see the science change where more products came on the market. And then in the United States in 2014, the first vaginal laser came out on the market, and that was brilliant. And I wish I had come up with that because lasers have been used in aesthetic medicine for years and they know that how do lasers work is, it's using light energy to. Basically create micro channels in the tissue. It's actually a very controlled microtrauma and so that sounds terrible, but it's, the light is penetrating the tissue and just poking a little hole in the tissue and the body responds to that. It goes, oh gosh, something injured me. I need to flood that area with growth factors. So when we do it to our faces, we actually stimulate the collagen to regrow in our tissue. So people use it for skin tightening and make their skin look younger. And then somebody goes, wait a minute, if we can do it to a face, why can't we do it to do it without hormones, which is really nice. And usually you do it where you come in, once every four to eight weeks for three treatments, usually on average, three treatments total, It's minimally three treatments, and that will usually rejuvenate the vagina for a full year. And then every year you just have to come in for one treatment to keep it going. in fact, I gotta put up a video. I have a video of me getting it done, which you don't see, you see it from the top. You don't actually see the details. But, you can see that I'm having it done and it's not very uncomfortable. if it's done on the outside, you do have to get numbing medicine, but internally you don't really feel much other than some pressure. we are doing laser removal, like the hair laser removal. We're doing buttocks, we're doing fillers. So if that is for our health benefit, our sexual health benefit, I'm sure that is not gonna be a problem. So we have three things. We have the lubricants, we have the hormones, treatments, and we have the laser. Yeah, so the laser industry opened like a whole can of worms because people went, wait a minute, if lasers work, what about any of the other things that we do aesthetically? So literally overnight, like we went from like lasers to like everything you can do to your face. You can do below. So anything from using different energy sources like sound waves to regenerate the tissue shock waves to regenerate the tissue. there's home versions of red light therapy. There's red light wands that can be placed in the vagina, so you can do it at home. And red light stimulates mitochondria, which is very anti-aging, and that'll stimulate the tissue. there's something called carboxy therapy where it's using a carbon dioxide gel and you place it internally and that oxygenates the tissue, pulls oxygen into the tissue and it can get it to regrow. You can do platelet rich plasma, you can do exosomes. Exosomes are just like signaling. compounds to get the tissue to regrow. So all the things that we see being done now to people's faces, all can be done below. So there are so many different options, that can be done to rejuvenate the vaginal tissue, that it's just absolutely amazing. So you could get like a whole makeover done.

Doucky 38:18

That is excellent news because we have two years talking about perimenopausal menopause and finally women are getting, heard. I mean it sucks in some way, but now we have all these, solutions and we are talking about it and more solutions are to come. I just learned about even more solutions, so it's a good time to to be

Dr. Betsy Greenleaf 38:39

Yes, and here's the thing. What people are realizing is in your forties when these changes are starting to happen, it's actually better to start the treatments now because it prevents it from. Going on because if I have a woman that comes in and her, she's in her eighties, it's a lot harder to reverse the tissue. We can still do it. It just takes a lot more time and energy and effort and a lot more treatments than if we go and look at it from a prevention standpoint. So if we're preventing it. It's so much easier to keep it functional and working the way it's supposed to be than trying to reverse something.

Doucky 39:17

Exactly.

Dr. Betsy Greenleaf 39:18

Yeah.

Doucky 39:18

no. So thank God we have practitioners like you who are helping us, What to do when the sexual health is not even asked. And when you are being dismissed, what should you do?

Dr. Betsy Greenleaf 39:30

So I think it's really important to, number one, feel comfortable with your practitioner and if you feel like you're not being heard, it's okay. Like I see too many women who feel obligated to stay with the same doctor? would you be staying with, would you be dating somebody who wasn't treating you right? Hopefully not. Hopefully, because it's not like they're gonna, I know like people have that conversation like, oh, they were good at the beginning and they're, maybe they'll be good again. No, like life is too short. Like you need to be heard and listened to. Break up with that practitioner, and get to somebody that you feel really comfortable. the other problem is I'm very happy that this is a conversation that's coming up, but I unfortunately am seeing practitioners that are jumping into it because they look at it as a way to make money. you are, you're the one in power, remember you have the power. You interview that practitioner, and if you don't feel comfortable with them. that's okay. They're not for you. Go find another one. But I would really be asking them how comfortable are they with treating these conditions? How long have they been doing it? And it doesn't mean that someone who just started is bad. But I would ask, I think too, like I think one of the key questions would be like. For example, if somebody came to you and their hormones looked normal, but they were still having symptoms, how would you approach that patient? that's that's a key one, because sometimes they may be like, just give them more hormones. that's not always the answer. The answer is. We need to look into what is the cause and look into, like treating the symptoms and not just the labs. what is their comfort level with reading labs? And do they use other type of labs? Do they look at other aspects of life? Do they look at the whole body, mind, spirit? and I find that. yes, there's, gynecologists are probably a great place to start. Urogynecologist are a great place to start, but even then, the traditional gynecologists don't always have the training. And I would find a practice that has more of a dedicated service to this type of, issue. Because if they're doing a little bit of everything. Are they doing every anything good? So if they're doing one thing and they're doing it all the time, then that's a place that is usually pretty good. But once again, it's still gonna come down to having a conversation with that practitioner and filling your comf, comfort level because, not everybody's gonna be for you. The more comfortable you are with a practitioner, and the more open that you feel like you can talk with that person, the more likely you're gonna get better success. So if you're going in and listen to your gut, like there is a lot of science behind that gut feeling. A lot of us dismiss the gut feeling because we're like, oh, there's no logic behind. It doesn't make sense, but let me tell you. They're finding out that if that energy behind that gut feeling really is very telling and don't dismiss it.'cause if you have this gut feeling that, this is just not right, you are, you have a lot of power, like just go find somebody else.

Doucky 42:24

Yeah.

Dr. Betsy Greenleaf 42:25

yeah.

Doucky 42:25

I had to. Interview several doctors until finally I found the one who helped me. But that gut feeling that you talk about is so true. I was always leaving the office with a bad feeling that, this is not right. I have to keep finding the solution. But hopefully now we have many practitioners like you who are helping. So there is something else you wanna add to this interview. Do you want to say something that we didn't talk about?

Dr. Betsy Greenleaf 42:51

Yeah, there's tons of things. I think really just listening to your body and not, I think a lot of us are realizing that we don't have to accept the changes that are happening. There's so much that. That we can do. also just remember things aren't instantaneous. So you know, you're having these symptoms, but they didn't show up overnight. So it can take some time and have patience and grace with your body and with your mind. It's going to get better. And just give it some time. So it's called forties Forward and we talk about all things of life and wellness after 40.'cause that's forties that, that key change when things are starting to happen. And here's the thing, I also find people misunderstand this menopause. Thing. they think it's okay, I went through menopause and it's over. you're actually going through a change that is now the rest of your life. I compare it to being a butterfly. When you're in your reproductive life, you're like caterpillar. And now during that perimenopausal period, you're in the cocoon. And if you've ever heard about what happens to a butterfly in a cocoon, the butterfly actually completely dissolves.

Doucky 44:00

Yes.

Dr. Betsy Greenleaf 44:01

cellularly. Reorganizes. And that's why this period of time can feel so crazy. You are completely changing and that's okay. So give yourself grace, like you're not expected to have it all together at this point. listen to your body, and then on the other side, you're a butterfly. And you're a butterfly for the rest of your life. So this is not the end of your life. This is just the beginning. Of something greater and you just have to change. exercise in your twenties is not gonna be the same as exercise in your forties. You gotta change for this new phase. eating in your twenties is not gonna be the same as eating in your forties. this is a new phase of life that you have to change and adjust to.

Doucky 44:40

And definitely

Dr. Betsy Greenleaf 44:40

know.

Doucky 44:41

change the speech that, we can thrive

Dr. Betsy Greenleaf 44:44

Yes.

Doucky 44:45

In menopause. Nothing is over.

Dr. Betsy Greenleaf 44:46

Yeah.

Doucky 44:46

and live our life. my God. So Doctor, thank you so much for being with us today, and you, thank you so much for tuning in. You will find Dr. Betis information in the podcast notes so you can get in touch with her. And if you wanna lose fat in your forties while easing your perimenopause symptoms, but you don't know where to start, of course, check the notes because we can have a consultation with you. Thank you so much and see you in the next episode.