Season 2 Episode 3 GSM and Pelvic Floor with Nurse Practitioner Gisele Thissen

This episode features expert insights on GSM and pelvic floor health, addressing taboo topics like vaginal atrophy, hormone therapy, and pelvic exercises. Learn about the latest treatments, misconceptions, and practical tips for improving women's health during menopause. This episode covers vital topics in women's health, including pelvic floor health, safe lubricants, hormonal treatments, and the importance of physical therapy. Gisele offers practical advice and debunks common misconceptions.

Disclaimer: This is general information and education. This is not therapeutic or medical advice. 

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Transcript

SPEAKER_02 0:00

Hey everyone, and welcome to Take a Pause with Minute Fals, where we will talk about the pause and all of her glory, and not so glory, but the conversations will be real, honest, and funny because Lord knows we have to laugh during this time. I mean, there's a there's a lot going on. And today's topic is another conversation that always seems to be a little silence around it. It's the um GSM and your pelvic floor. Now, we have an expert here that will say GSM because in my jersey tone, I will just mess it all up. So I'm glad to have Debbie here, my other uh partner in Amenopause. Hello, Debbie.

SPEAKER_03 0:42

Hello, happy to be here. I'm excited to learn.

SPEAKER_02 0:46

Excited to learn. And we have Giselle, our favorite nurse practitioner, who is going to make sense of how when you want to sneeze, it's sometimes a good decision and sometimes a bad decision. And girls, we all know what we're talking about when I say that. So we say welcome to Giselle. How are you?

SPEAKER_00 1:11

Good. I I missed your faces, so I'm glad to be back.

SPEAKER_02 1:15

Same. Same, same. We missed you.

SPEAKER_00 1:18

Thank you.

SPEAKER_02 1:19

Yes, so this is uh we figured, you know, it's a hot topic that nobody really talks about, also. So it's you know, I I know we talked about the tea with you, and we learned so much. How about it, Debbie? Like two episodes, so we're like, if we can bring knowledge and awareness to the tea, think about what we could do with this.

SPEAKER_00 1:45

Yes, ma'am. Which you know for the V.

SPEAKER_03 1:48

I was gonna say I was ready to say that, but you know, this is such a I don't know, what would you say, like a a taboo, or I don't know, what's the word like where nobody really wants to talk about it, and growing up nobody really talked about it, and like you know, I'm still learning how to talk about the V, but I always tell people, hey, what's going on down there? And I feel like we growing up, nobody talked about it. Like the par my parents didn't say, hey, what's happening down there when I go to a doctor? It was so silent, and it's caused a lot of us to have a lot of issues because if we would have known what was happening down there, yeah, and been observant of what was happening down there, we wouldn't be where we are right now.

SPEAKER_02 2:30

Or even just how to describe what's happening, you know, like it's everybody laughs when oh, you sneeze and you're like, oh everybody know like you lock eyes with another woman, like they'll watch you sneeze and you're like, Yeah, okay. Okay, we're good.

SPEAKER_03 2:45

Yes, but I do want to I want you um with Giselle to actually say what GSM stands for. Because I know I can't pronounce it now. I'm not gonna.

SPEAKER_00 2:55

And what does it mean too? Right, it's it's well, so the term changed in 2014. It used to be vulval vaginal atrophy, which isn't that wonderful. I've heard that, yeah. So, I mean, we still to this day say vaginal atrophy, and it's like, oh, that's great. My vagina is atrophying, you know, like what does that mean, right? And um it's there's a lot that's still taboo. I mean, just hormone therapy in general. I mean, over the past couple years, few years, we've really um made strides on um talking about hormone replacement therapy, talking about sexual health, um, testosterone, just everything woman's health, right? Um, but so GSM stands for genito-urinary syndrome and menopause. And so it's really kind of like that umbrella term that we use for so many things that can be changing down there. Um, and so what it really means is that there's a decline in estrogen that's affecting the health of the of the um of the vagina and the and the vaginal tissue and urinary tissue. Um you know, we're we're talking about thinning of the tissue. I I talk to patients all the time and they're like, I don't know what's happening, but man, having sex, I feel like I have little tears, or when I wipe, it hurts. Um, so you know, the the tissue is thinning, um, there's decrease in elasticity, um, natural lubrication seems to be just non existent, non-existent, right? It's literally when women say, I feel like the Sahara Desert down there, well, yeah, because we have no estrogen. Um, and it really, when we have that lack of estrogen, um, the the vagina, the vaginal tissue in the vagina really has its own little ecosystem, if you think about it, right? And so when we have those shifts, um, it it changes the vaginal microbiome and the pH. And so when that happens, we're more susceptible um to burning, irritation, pain with intimacy, recurrent UTIs, um urinary frequency that we never had, or urgency. So that shift really does change everything. Um and it's just not, you know, it's not just the vaginal issues that we're dealing with because it's it's the quality of life and the issues that how it impacts us too. You know, how many times do you hear a woman say, Okay, where's the closest bathroom? Or I gotta go on a trip, or I have to, you know what I mean? So it's like we're mapping things out. Um, or like Deb uh, like um, like Mare said, sorry, um, okay, we sneeze or we cough, and it's like Oh, it is like you feel like coming on, yeah. Yeah, and so um it impacts everything, it impacts our confidence, especially. Okay, how many times have you guys been in a group of people or presenting and you're like, oh god, please, please don't do this. I don't, I can't, I can't cough or sneeze right now because I can't cross my legs. Because if I cross my legs, I'm trying to hold in the pee, you know.

SPEAKER_01 6:27

So and then everybody will know that that's a telltale sign.

SPEAKER_02 6:31

Like you see, you're like, oh yeah, just no, I'm not crossing my legs to, you know, be secure.

SPEAKER_00 6:38

We're not doing that. Um, and so you know, it affects everything, sleep and well-being. Um the biggest the biggest take-home is I want women to know that this is common, this does happen. There's so many things that impact GSM and the pelvic floor. Like we always, when we talk about GSM, we can't just talk about gentry-urinary syndrome menopause, the changes that happen. We also have to talk about the pelvic floor and the health of the pelvic floor.

SPEAKER_04 7:06

Yeah.

SPEAKER_00 7:06

So when um I'm gonna totally just probably embarrass my daughter. Well, you guys don't know my daughter, but anyways, um, when she was little, I'm gonna embarrass myself. When she was little, she um she sneezed a couple times and like she crossed her legs, and I was all for like for a little girl to do that. So I'm like, I I like brought her aside and I said, Um, is everything okay? You know, what's going on? Does it does it burn when you go potty? Like, what's happening? And she goes, What are you talking about, mom? And I'm like, maybe you're like crossing your legs when you sneeze. I said, What's going on? And she goes, Nothing. And I said, Then why are you doing that? And she goes, Because I see you do it. So I think you have to do it.

SPEAKER_03 7:53

And I'm like, Oh how oh my gosh.

SPEAKER_00 7:56

Yes, I gotta go see the pelvic floor therapist because uh Oh my gosh.

SPEAKER_01 8:02

And so um, you know, it's just such a sweet, funny, and I think it's very moment all in all in one, you know, like I see you do it.

SPEAKER_00 8:11

It's like, oh yes, that's so good. Yeah. So so you know, we have to talk about the pelvic floor and all its glory too, because that's part of everything. And I have my model with me. It's not this, isn't my favorite model because I can't tear it apart. I love models.

SPEAKER_03 8:28

I well, I really need a model because I don't ever look down there. So it's okay.

SPEAKER_00 8:34

I am going to tell you the number one thing that I tell my patients all the time. You need to know what your tissue looks like. I you need to know. I well, listen, if you don't want to do it, invite your husband or your partner to do it and say, what does it look like? Uh, because it's really important as women, we are never taught when we're talking about the anatomy of the vagina, right? We have this is again not my favorite model, you guys. You can't really see, I'm not gonna use this model. Um, we have the introitus, which is the vaginal opening, we have the inner lips and then the outer lips. Well, in between the inner lips, up to the clitoral hood or up to the clitoris is the vestibule, right? The clitoris, which has 10,000 nerves, um right? It it is. It has it has the clitoral hood, which is synonymous with foreskin, right? As women, we are never taught that we need to pull that back and clean, right? Yeah, just like with a little boy, for those of us who have had boys in the past, before if they've ever been circumcised or whatnot, we were always taught you gotta push it back, you gotta clean it, let it dry, and then put it back. As women, we need to know what our tissue looked like.

SPEAKER_03 9:47

I know, right? You're all I've I've never even, I didn't even know that existed. I had no idea. Like, seriously.

SPEAKER_00 9:54

It totally exists. And so when I talk to women and they're like, I can't orgasm or I can't do this, I'm like, listen, that that little clitoris has 10,000 nerves. Something's going on. We need to figure out what's going on. Is it hormonal? Yeah, right. Is it hormonal? Do we have cl do we have um do we have adhesions that are blocking that? Is there discharge? Is there um keratin pearls? What is going on? And what's kerat what's that? So a keratin pearl is basically um it's I mean it sounds pretty, but I don't really think it I don't think it is. Did you know what it was? I didn't know what it is. Okay, good. I had to ask. Anytime, anytime we uh hear the word pearl, we're like, ooh, that sounds so nice, yeah. But um it's it's not with some of the stuff that you can maybe you can turn it into earrings. I suggest not. But um yeah, so it's it's just a bunch of um it's a bunch of like discharge and keratinized junk that gets stuck underneath um the clitoral hood that kind of causes an adhesion. And so that can cause that can cause um get that. Yeah, yeah, that can cause issues with with orgasm.

SPEAKER_02 11:20

Right, because it would decrease the sensation.

SPEAKER_00 11:23

Absolutely. Yeah, and it can cause um it can cause discomfort. Um, there's just a lot of different things that that that can come up with this, right? So when we talk about genitor urinary syndrome and menopause, uh, we really need to talk about the public floor as well and all of the things that can that can impact this. Um but truly when we talk about GSM, um we are also discussing the vestibule, which is the the we're talking about the introitus, which is the vaginal opening, the vestibule, which is in between the um the inner lips, up to the clitoral hood, the vagina. We're talking about all that because that those that tissue has estrogen and testosterone receptor sites. There it's very rich with estrogen and testosterone receptor sites. And so when our estrogen decreases, testosterone decreases, then we start to have a lot of those symptoms. Um in the urethra itself, right? Women may say, Man, I just have this sensation of urgency or I have to pee. Well, it that there's issues that can happen with that, right? So um it's it's very much a topic that we need to talk about. Um, it needs to, as providers, providers really need to um hone in on recurrent UTIs. A lot of women who come in and they're like, Oh, I got a UTI again. I don't truly think it's um a UTI, it's the inflammation that is happening.

SPEAKER_04 13:01

Oh, I see, yeah.

SPEAKER_00 13:03

You see what I'm saying? So it's the inflammation that's happening that's causing that sensation, right? And so we as providers are over prescribing on antibiotics. Well, now what does that do? It's the whole down like slippery slope, right? So um we really need to get better. Hey, let's get some vaginal estrogen cream, let's let's get some good stuff on board.

SPEAKER_02 13:28

I didn't even know that there was um testosterone receptors down there because Oh yeah, yeah, I didn't either. Yeah, yeah, that's another miss thing. Like I I just thought it was like all just estrogen because they talk about like just putting like the estrogen creams you know that that would help down in the vaginal area, but I know that's very interesting.

SPEAKER_00 13:48

It is, and so you know, when when speaking when speaking to patients about um optional treatments, um everybody goes for estrogen, which is fine. A lot of times, a lot of times estrogen works. What type of estrogen delivery system? We have we have an estrogen cream, we have an estrogen tablet, we have the little um invexy uh suppositories. Um truly my favorite is Intrarosa. Um an intra- you showed us that it's a syringe. Um it's it's a suppository.

SPEAKER_02 14:27

But it's is it in a tube?

SPEAKER_00 14:29

So it's this little guy. It comes with an applicator.

SPEAKER_02 14:32

Applicator, yeah.

SPEAKER_00 14:33

Yep.

SPEAKER_02 14:33

That's it. Yeah, yeah, yeah.

SPEAKER_00 14:35

Yep. So Intrarosa is DHEA. And so it um it's non, it's it's not estrogen, it's not testosterone, it's DH, uh presterone. And this medication is truly the only medication that at the cellular level changes to what your body needs. Remember those estrogen and testosterone receptor sites I told you about? Yeah, it this will occupy both of those. And it is originally this was made for um painful intercourse, and it really is not so it's it's not a true hormone like estrogen or testosterone, right? Right. It's PHEA, which is a precursor. Um so when it changes to what our body needs, those estrogen and testosterone receptor sites are occupied and it's magical. Um, it truly is.

SPEAKER_02 15:30

And that's amazing.

SPEAKER_00 15:32

Out of I have been prescribing this for probably 15 no um 13 years. A lot, I've been using from when it first came out, I have been prescribing it. And I can probably tell you that on one on a on one full hand, I had have probably five patients who have said, I don't like it. All the other patients have liked it. Their husbands have come in and said, I love you, thank you. You know, and it it truly makes a difference. Um I've had patients who have said that about estrogen, right?

SPEAKER_04 16:07

Right.

SPEAKER_00 16:07

Um now depending, we can also compound a special cream to put on the vestibule if we're having you know issues with pain or discomfort with estrogen and testosterone.

SPEAKER_03 16:20

So that would uh that would actually that would be super cool. I just know that putting that, I mean, is it messy? Is it like does it absorb easy? No, I mean the the tablet thing though that you just talked about, the DHEA.

SPEAKER_00 16:35

So this one, that's I love that you brought that up because this is something that we talk to patients about all the time. Well, I talk to patients about all the time. So with the vaginal estrogen cream, it truly is the suppository. You put the you put the tube, right, you like fill this up, right? Yeah, what goes up must come down.

SPEAKER_03 16:54

Right, yeah.

SPEAKER_00 16:55

So with and with the cream, that's one of the biggest things that patients are like, I don't like it. It's messy, it's gross, it just feels ugh. So a lot of times when patients use the cream, I tell the patients and I invite them, I'm like, look, insert it. You have to put your finger in the vagina, rub it into the rolls. Yeah, put it, put it in the vestibule, right? Um, so that's how you can get the effectiveness of the S one way, right? To really get it to absorb in. Um the the DHEA actually is amazing. It's again, it's one of my favorites. I have like no no uh obligation to to the pharmacy or to the manufacturer who makes it, but I love it because it's made of a derivative of coconut oil. So it's very soothing for the skin or for the tissue. Um it's silky. Yes, sometimes when you put it in, you'll have a little bit of residue on like on your panty or on a panty liner, but nothing compared to what vaginal estrogen does. Right. Especially if you don't rub in the cream, right? If you put it in, sometimes it's like it just pumps up.

SPEAKER_04 18:05

Yeah.

SPEAKER_00 18:05

Um one thing that I love to tell patients to do with this is you this with the DHEA, the intra rosa, typically is every night. You use it every night. Um I tell patients you can break it in half, put half inside the vagina, take the other half, and just rub it on the vestibule because it's gonna, those receptor sites are really gonna just take this in. Um last year, 2025, I believe, um the American Urology Association said that used intrarosa as a form or or accepted intrarosa as a form of um treatment for GSM, which is great because originally it was just for dysparunia, which is painful intercourse. That was the indication for it. But now we know because the Urology Association has said nope, we can use it for GSM as well. Um still, it's kind of a little bit hard to get it covered by insurance, but not too bad.

SPEAKER_02 19:07

I was waiting, I was I was I was gonna ask, what's the catch? This is too good. That people are saying it's good, it's really good. What is stopping women from getting it who need it?

SPEAKER_00 19:18

It's it's insurance. It's insurance. Always, I hate to say this, and I'm not um, you know, we're very sometimes we're very limited by insurance, or we have to jump through all these hoops to do prior authorization.

SPEAKER_03 19:30

We totally know that.

SPEAKER_00 19:32

Yeah, you guys, you we we get that, right? Um, and then there's other there's other methods like um UVAFem or Vagifem, which is a um tablet of estrogen, right? So it comes with a suppository, you use it every night for the it's similar to the to the cream on how you use it. So if you're getting started on it, it's typically a loading dose. So every night for the first two weeks and then twice weekly thereafter. So that goes the same for the vaginal estrogen cream, the UVFem, um, or even Invexy, which Invexy is the capsule that um that you use vaginally as well. So um, I would probably say the messiest is the cream.

SPEAKER_02 20:18

Yeah. But it's I mean, girls, it's we've all used monostat, right?

SPEAKER_03 20:23

Oh, exactly.

SPEAKER_02 20:25

Like it's it's just I grew up on that.

SPEAKER_03 20:27

It's like every month I had it, it's like no fair.

SPEAKER_02 20:30

It seems like the same, the same concept. Like, yes, it's we all know it. You put the tube in there, but it's like you need it, it works. So you sort of like put that like, okay, I know this may be messy, but it is something that we all need. So absolutely.

SPEAKER_03 20:46

Yeah. Can can you use both oh, sorry. Go ahead, go ahead. No, can you use both the D A G A and the estradiol? Estradiol.

SPEAKER_00 20:54

You you absolutely can if you do like the estrogen cream for the outside vestibule. Yeah, you can, and then you can use the inside of the sclerosa for the inside for the vagina. Um, you know, and one thing that I tell patients all the time, um, what I like about the vaginal estrogen cream, which is really important, as we get older, um, the urethra, where the urine comes out of, can prolapse essentially, right? So you can have what's called a carbonocle, carbon knuckle, excuse me.

SPEAKER_04 21:25

Yeah.

SPEAKER_00 21:26

Um, and so, and so that tissue um is susceptible to bacteria, right? Um, it gets it can get inflamed, it can just be uncomfortable. So I tell patients all the time, I'm like, you get that estrogen cream, you put it on your finger, and you rub that urethra really good, and you get that in there to help prevent any types of UTI or um, because that's a lot of times that's what we're feeling, right? We're feeling that that discomfort. Right.

SPEAKER_02 21:57

And you think it's a UTI because you remember, oh, they Is what it feels like, but it's just really from the irritation and from the exposure and dryness.

SPEAKER_00 22:06

Yeah, yeah. Um, so we want to be careful uh with that, right? So um, and that helps that does that definitely does help um with prevention too, right? Women um women are are women are more susceptible to UTIs and to sepsis as they get older. And a lot of times, um a lot of times that can be prevented.

SPEAKER_02 22:43

I know, like what is the correlation? Because I've heard people say, you know, if you you know, women when they break a hip, then you get the UTI and then you die. I was like, Yeah, it's kind of scary. Where the hell did that, where did you go from being like upright and normal, you break a hip, you tie like, but is it just because of the estrogen and everything is just all like it's all breaking?

SPEAKER_00 23:05

It's a combination of things, right? So one common um, and I I of of course, Mary, you know how we go down rabbit holes and everything. Oh yeah, I love it. I know, right? It's just one thing after another. Um, so especially in elderly patients, uh they may not not that they can't communicate it or say it, right? But we may not know.

SPEAKER_04 23:31

Right.

SPEAKER_00 23:31

But a lot of times what can be a tip-off for for our loved ones who may be taking care of an elderly parent or you know, somebody who's advanced in age, is they change like all of this, not not it sometimes it's a drastic change, sometimes it can be a subtle change, right? I always tell I always tell patients or their caretakers, listen, go get a urine culture. Yeah, let's see what's going on. Because if they're having these this this change in cognition or mental status, what what is if do we have an underlying infection that's going on? That needs to be treated, right? Um, and for women who are getting older in age, there is nothing wrong with using vaginal estrogen cream or you know um intrarosa or even uvifem, right? A localized estrogen is gonna help that tissue stay healthy and prevent a lot of the the you know the bad things that can happen with uh um you know with the decline in estrogen.

SPEAKER_02 24:44

I know, and I think that too, it's like because there is still, even though like we all know the black label came off, but I I still think there's still such a stigma that nobody wants to give the estrogen, yet alone tell you, oh, use the cream on your vaginal area, use the patch, use it's very hard to it's sort of like one or the other, is what I've heard, like talking with other friends that are like they're oh I can't do both. And I'm like, Yeah, yeah, you can.

SPEAKER_00 25:12

Um absolutely you can.

SPEAKER_02 25:15

Yeah.

SPEAKER_00 25:15

Um, absolutely you can.

SPEAKER_02 25:17

And I have a they're not.

SPEAKER_00 25:20

I have a lot of patients who um, or you know, vice versa, right? So I've had a lot of patients who have told me, my provider's not gonna put me on systemic, um, on systemic estrogen. I'm just getting vaginal estrogen. Yeah. And it's doing nothing for my hot flashes. Well, of course I'm not gonna do it for hot flashes because that's systemic. Kudos for being on or or localized estrogen, kudos for her putting you on that, but now we gotta do something about this, right? About the systemic symptoms that you have. Um, but localized estrogen, right? I mean, you can absolutely be on systemic therapy and localized and and as and be covered and be okay. It's not a lot of estrogen, right? Um, you know, it's it's every a lot of providers and even patients, right, are like, well, my symptoms aren't that bad. I'm talking about systemic therapy now. Yeah, um, they're not that bad, so I may not need that. HRT is not just about symptoms, right? Like nobody wants to walk around feeling like shit, right? Like, right? But we need we need to also talk about the health benefits of it. We need to talk about cardiovascular prevention, bone health, brain health, right? Um, I have had a lot of patients who are like, listen, I got started on systemic therapy and all my GSM symptoms went away. That's great. That doesn't happen for most people, right? Sometimes it does, sometimes it doesn't. So for them, I have the conversation. Okay, if you start feeling like we're having recurrent infections or you're feeling kind of um just different, then at that point we can start a vaginal treatment, right? The earlier we address it, the better outcomes we have, yeah, right? If we're waiting, then that means that we've gone over some time and now we're starting to have those symptoms. So let's address it, let's get this stuff done, right? Um, yeah.

SPEAKER_02 27:30

So what can because I know there's and and I learned from you that there's more than just keggles to help with your floor, like, but I had no idea before talking with you about it. I think it was Debbie. We were on here and I was like, Well, they say keggles, keggles, keggles, and you're like, Yeah, that's good.

SPEAKER_00 27:50

Yeah, but you're you're absolutely correct, right? So there's a group of muscles that help support's coming out again, Debbie. Here comes the model, I know. The model's coming out, but it's not the good model, so I can't really differentiate. This is your pelvic floor from the inside, that's looking this is the pelvic floor from the outside, right? So we have a group of muscles that it's like a hammock, right? Okay. Now, when we do kaggles, I mean, so these muscles, just like any other muscles, they need to be exercised, right? Because that's gonna help support the organs that are that are in that area. Uterus, bladder, you know, rectum, all of that. Um, so yes, those need to be exercised. But when everybody says keggles, keggles, keggles, if we're not doing them right, we can kind of overshoot, right? So we can actually cause a symptom called hyperpelvic floor dysfunction, where we've engaged muscles up here but have done absolutely nothing for these muscles, right? For the bottom muscles. And so um interesting.

SPEAKER_02 28:58

If you look at it like a hammock, so your whole it's too tight up here and still just flopping.

SPEAKER_00 29:04

Too loose, yeah. So um the hammock. Love the hammock, we gotta have the hammock, right? So, you know, during perimenopause and menopause, those hormonal changes can affect, you know, the the muscles. Childbirth, number one cause, right? Can affect can affect the muscles, um, chronic stress. Um, there's a lot of different things that that affect the pelvic floor. Um and so, you know, I always, it's not just weakness that may happen that's that's going on with those muscles. I always tell patients, and I think we've had this um discussion on another podcast, you should always have phone a friend, remember? So you should always have a sexual therapist, a pelvic floor therapist, and a and a colleague, a good colleague that you can run things by. Um, but you know, over act being overactive or or tight muscles can cause issues, right? So it's really, it's really impressive when you go in and um I've counseled patients on this, I've done exams, and I'm I'm going in and I'm feeling their muscles, and I'm like, oh my God, no wonder. It's like it is tight. Those muscles are so tight. So no wonder you have painful intercourse, or you know, your your bladder, you feel like you have to pee every five seconds. Well, up here, these muscles are great, but down here you've got nothing. Um, so really um, really getting into a pelvic floor therapist to have to have them do a good assessment and really help the patient engage those muscles and teach them exercises at home that they can do um is really beneficial. And a lot of times um I encourage patients too to have their partner go with them. I know sometimes it can be embarrassing, but guess what? If you have a partner who can listen and say, okay, well, we need to engage this muscle, okay. Well, if a woman, there's tools that you can use, and the and PT's um pelvic floor therapists are amazing with explaining that. But sometimes it's like, okay, well, I need I need somebody else to help me here. Okay, well, engage your partner. And and then, you know, another good, another good um pelvic floor therapy, exercise, sex. You engage those muscles, right? So if you're doing those exercises and it and you happen to if one thing leads to another, guess what? You're engaging those muscles, so everything's good.

SPEAKER_02 31:41

Everything, listen, that's yes, that is a good day. When that I mean, that is I took a um there was on I have uh Peloton, and there was they have like exercises that you can do that's just not on the bike, and they have this series, and it's a menopause series, and I love it. And they were doing pelvic floor exercises, and what we did was like you do a bridge, right? Like an inverted bridge, right? And you lift one leg up and just go up and down.

SPEAKER_03 32:12

Oh, I see, yeah.

SPEAKER_02 32:13

So I was doing that, and I was like, I've done this before, but nobody ever says it was pelvic. That's what it was. I'm doing it, I'm like, am I really like, but you are holding everything tight. Like you your core, it is tight, and you're so going up and down so that you don't fall over, it is it was great. I was like, well, that was cool, and I never knew that that helped the pelvic floor. So I think sometimes people don't know the exercises and they think, Oh, I can't do that. How am I gonna engage? We've all done the bridge. Like you went to any class Pilates, you've done the bridge.

SPEAKER_00 32:47

And and another interesting fact is your core, if you have a strong core, that helps your back, it helps your pelvic floor, it helps all of that. So having a strong core is really important as well. Yeah, um, one thing that you mentioned, so I had a patient, she had reached out to me, um, and she she had been to numerous providers. Now, granted, remember, I'm virtual, so I can't get my hands on her. Right. Um, I'm still virtual, I don't have my brick and mortar yet. But so she came to me with PGAD, which is persistent genital arousal disorder or dysfunction, discomfort. Um, and it's basically I don't have any idea.

SPEAKER_02 33:31

I don't know, those were a lot of initials.

SPEAKER_00 33:36

I threw a lot of stuff out there, sorry. So basically, it's having sexual arousal without being aroused, right? Or having spontaneous orgasms. It's a misfire of things I had no idea that could ever happen. Oh, yeah. And for some, like some patients are like, oh my god, sign me up. That's amazing. Yeah. But the for those patients, they're like, no, it's absolutely horrible. And some patients, truth be told, and it's very sad, have actually taken their life because nobody has been at all. Um, and so that is truly a thing. It is a thing. And so, anyway, she had reached out to me and she said, Um, she said, you know, I want to know if you have any experience in treating PGAD, you know, and I and I told her up front in my email, I said, Look, I'm virtual, but I take a very detailed history. I can talk through all of this with you. And so um we were able to do that. And I said, first and foremost, um, and it was classic, classic signs. Um, so I was able to get her into a pelvic floor therapist. I was able to get imaging done that we needed to just to make sure there wasn't anything going on with any of the nerves that can innervate. Um, and so the pelvic floor therapist called me and she's like, Oh my god, you like hit the nail on the head. And I said, But I'm not quite convinced that it's actually nerve. And she goes, No, which led her to our discussion. Um, it was actually stemmed from her core, from her diaphragm. So it's pretty impressive, right? So there's the you're all of this, all of these muscles work together, right? And and everything is interconnected. I always make the joke, well, you know, the hip bones connected to the knee bone, right? Like I remember that and it all works together. So um, so yeah, so so pretty, pretty impressive for sure. Um again, phone a friend, have a pelvic floor therapist on hand or or know of one that you can refer to for sure.

SPEAKER_03 35:47

I have another question. Can't believe I'm asking this question.

SPEAKER_00 35:52

Okay, wait, did you just say I can't believe I'm asking this question? So it's gonna be a good question.

SPEAKER_01 35:56

We're all we're all coming in. Yes.

SPEAKER_03 35:58

How do you know like what's the best lubricant to use and what's safe and what isn't safe? Because isn't there like probably lots of ingredients that may not be good for you? Is there one that's healthier?

SPEAKER_02 36:13

Uh that would irritate it, that stuff would irritate if you had stuff.

SPEAKER_03 36:17

Like if you're very sensitive, so you know, like I mean, you you can see all these different ones where it said this makes you hot, this makes you cold, this is the guys, this is the girls. I mean, probably lots of that that kind of lubricant was probably not very safe, I would think, because they're probably putting stuff in it that you shouldn't even have on you. Like how would you know what to start with if you were having painful intercourse?

SPEAKER_00 36:40

That's a fair question. And so, and I love that you asked that because there are um there are a lot of products out there, right? Um, and especially when we have somebody who's whose vestibule is already just angry or inflamed. Yeah, um, we want to be careful with that, right? So we really want to be careful with that. Um, we don't want anything that causes burning or and and it's so there's a lot of scream creams that people are selling, right? That may have an ingredient that makes things hot. And so um I couldn't even imagine.

SPEAKER_02 37:24

Uh I'm like, what? Why would you want it hot?

SPEAKER_00 37:27

Of course, my of course for me, I'm like, well, have we done a good exam to see what's going on? But yeah, um, so to answer your question, there's a lot of you know, water-based, silicone, all of those lubricants that are out there. What I can tell you is some of my favorite ones that I like. Um, my ultimate favorite is Uber lube. Um and it is an amazing lubricant. Um, and you're gonna, I can't believe I'm gonna say this on video. I cannot recall if that's silicone based or not.

SPEAKER_03 38:01

But um uh My OB told me that was when I I did ask that question, and he said it was Uberloop. Was his Uber lube is it was his go-to. That was his go-to.

SPEAKER_00 38:13

Uber lube by far is my is my favorite. Um, and it I can tell you it does not dry out, it's not tacky. The the key to it is so a lot of times we have women who are like, look, I am dry, it hurts to have sex, we have to use so much lubricant. What do we do, right? And so um, you know, they go to the store and they get the KY or they my favorite is the KY, non-tacky or non-drying. Okay, when you look at it, those products are made with such a high osmoolity, right? And so if you're putting that, if you're using that product in a in an environment that's already compromised, yeah, you have just sucked out whatever moisture, sucked out whatever lubricant, anything from this environment that it had. And so, yeah, you're gonna have to reapply. And women are like, oh my god, it hurts. I'm drying, I'm getting UTIs because of the inflammation. I'm getting, you know. And so um Uber lube is a good one, Silk is a good one.

SPEAKER_03 39:21

Oh, I think I've heard of that one.

SPEAKER_00 39:23

Yeah, and Wicked. Those are those are I would say three um that I would that I would recommend. It okay, I always have stories, you know. I always I always have stories. I love stories.

SPEAKER_02 39:35

Okay, because I love the name Wicked. I mean that that capital, I'm like, I'm picking that one.

SPEAKER_00 39:40

I call it like Wicked Blue. It's Wicked Good. I'm gonna go get my lubricant from the cop, because it's wicked good. Yeah, but but can you get those?

SPEAKER_03 39:49

You have to order those online, I'm sure.

SPEAKER_00 39:51

You can order them online, or you can go to this this is where my story is going.

SPEAKER_03 39:56

I get it, because you have to ask for permission to open up the cabinet. It's usually some young sales guy that has to open the cabinet at CBS or wherever.

SPEAKER_00 40:04

Well, CBS I have not seen, and I like to peruse the aisles so I can tell my patients what they can get, right? Um, it's not at CBS. Okay, anyways, so this was it's so much better. So I was this is when I was um back home still in California, working at a very busy OBGYN practice, and I'm talking to this lady, and um the subject comes up, and we're talking about sex and you know a lot of other things. And we brought up, I brought up this subject about um lubrication, and um and she's sitting there prim and proper. She's older, like not one hair out of place. She's dressed, she's dressed to the nines, like she is she's classy, right? She is just great. And so I'm talking to her, and um, and I said, Yes, there's this one lubricant um called Uber Lube, and she goes, Oh, I've heard of it. And I said, Oh, okay. I said, you know, it's not um, you can't really buy it at CBS. I I haven't seen it. Um, I think you can buy it online through CBS, but um, there are some stores that you can go to, and at the time it was really funny. So there was this one you have to, I can't, I have to just describe it. So, so in Fresno, where we lived, there was 41, Highway 41, and it kind of like went down, right? And so up were the streets, the mall, and then there was you there, it used to be an old Hofbrow, it used to be an old brewery where they they turned that into um a store called Hustlers.

SPEAKER_01 41:51

And so my god, I knew it. I knew it was I knew, I knew that.

SPEAKER_00 41:57

So I'm talking to her and I said, I said, you know, I'm sure you can buy it. And in Fresno, we had a place called um Suzy Bookstore, Susie's bookstore. Oh yeah, we we have that yeah, yeah. And so I'm like, I'm sure you can go. And she goes, she looked at me and she said, Oh, Hustler's actually has it. It's in the back. It's like and I just went, good for you. Good for you about it. You know it. And so I said, Well, have you used it? She goes, No, I was thinking about that, but I'm since you brought it up, I'm so glad. I'll make sure to go get some. And I'm like, hell yeah, you go get that Uber loom and you can use it. I'm so proud of you. But it was just so, you know, unexpected because she was I Yes, anyways, don't judge a book by its cover, but um I would definitely stay away from like the KYs and those things because a lot of times they can cause further irritation, they can cause starting like answering.

SPEAKER_02 42:55

It's like chapstick when you keep putting chapstick on too much. That's I I know I saw you put it on earlier. I know, but yes, it ha it's the same concept though, right? Yeah, like yeah.

SPEAKER_00 43:08

Absolutely now, and I'm gonna some of my colleagues may roll their eyes at me and um and say, I can't believe that she just said this, but I'm going to say it. Um, and I know, right? You know, we're like listen, I'm I am going to say it. Um coconut oil. Oh, I I get that. Yes, and there are coconut oil-based lubricants. Um I mean coconut oil, you can put it on your skin, you can use it for specs, you can cook with it, but but that's also something that you that you can use for sure.

SPEAKER_04 43:48

Yeah.

SPEAKER_00 43:49

Yeah. So I would say the three that I mentioned are are the top.

SPEAKER_03 43:54

And then the coconut oil would be the backup if you don't want to go shopping and you have somebody. your kitchen.

SPEAKER_00 44:02

Just make sure you make sure you like take off the top layer.

SPEAKER_02 44:09

Just keep it in the bathroom once you start using it. Yes.

SPEAKER_00 44:17

But anyways.

SPEAKER_02 44:26

And I think the irritation and the drying causes so many different things. Well now we have we have the we have recap we figured out the exercises. We know the lubrication, the estrogen, the testosterone also. The DHEA.

SPEAKER_03 44:46

I'm that's my biggest takeaway. That is my biggest takeaway. Is my biggest takeaway.

SPEAKER_02 44:52

Because I know when I was trying to get as we all know trying to get the testosterone here they would um give me a prescription for DHEA.

SPEAKER_00 45:00

And I'm like so that was that was oral DHEA. Correct. Oral DHEA I I have patients on I don't have patients on it because I usually take them off of it. Oral DHEA I have found in my practice is not very beneficial. Now DHEA vaginally is a completely different story right um oral DHEA is not beneficial. If you want to increase your hormones then you replace it with progesterone or testosterone.

unknown 45:33

Yeah.

SPEAKER_02 45:34

It was kind of like how you were saying earlier like with you know people think oh that I'm taking hormones just for the symptoms.

SPEAKER_00 45:40

Right.

SPEAKER_02 45:41

You're not that's not the concept the concept is you are replacing what you are actively continuing to lose. Like that's like and I think that when you realize that and get into that mindset you realize oh okay I'm taking the symptoms getting decreased and going away that's the the best part of it but it's actually you're protecting yourself for cardiovascular for bone health and and everything like that. So I think that sometimes people well I'm not having symptoms I'm not having hot fleshes so I don't need to go on it. No you do because you're still actively looking so I think that somewhere still is not people get it but they don't. Right? Do you know what I mean?

SPEAKER_00 46:23

Oh for sure for sure um and that's why you know being trying to trying to educate patients as much as as much as I can or as much as we can um educate the population about what's out there um is is so important and just giving them options and saying hey look there's these resources that you can go and look at you can look at the menopause society go to the Urology Association go to um uh which I need to see if I don't know if they've updated um anyways there's you know there's podcasts there's other doctors out there that are that are talking about this stuff seek them out too get all the information and weigh it out and see what works best for you but there there is um there are a lot of options out there for sure uh for patients now we talked about lubricants and we talked about hormonal treatments for for um vaginal health there's also some over the counter things for somebody who's like listen I I just don't want any hormones okay I respect that I respect that um hyaluronic acid suppositories are amazing that can help build the collagen it's now it's not estrogen I've never heard of that um but there are some things out there that can be used as well non-hormonal things if we have patients who are completely adamant about no hormones and I have a few of those and that's okay um as long as we're upfront and honest with them and say hey look you know we can use this as a moisturizer it's a vaginal moisturizer to see if that helps it may not you know it may not give us everything or it may not um prevent or um treat everything that we are hoping for but if it's giving you some sort of relief then that's okay and um there's actually a couple there's one one company that I know of that's pretty that's reputable that makes one and then there I have seen some over the counter in the pharmacies too where you can use um but that's an option as well for a moisturizer there's a difference between a loop okay that that was my my next question. That was it what is the difference my G Y N who you know um she recommended this and said and uh bona fide I think that's I've heard of that yeah bona bona fide.com that's the that's the company um but it is just it's just a moisturizer like right that's it yeah so it's not going to treat debt so so it's going to give it's like dry skin right so if we put we put lotion or moisturizer but you have to keep doing it like all the time. Exactly exactly it's not treating it's covering the symptom. Right. Well but then the same it can similarly be said with estrogen right well you got to use it all the time well yeah but you're gonna get more out of it yeah because it's the hormones that are occupying those those receptor sites right so um but definitely a difference um but again if we have if if we know patients or if we have patients who are completely adamant that don't want to use any hormone based anything that's an option for them as well.

SPEAKER_02 49:51

Yeah. So what would you say like for women out there who are like oh I I think I have this maybe not what are the signs that you're like okay now this is to the point where you really do need to see a dog like is it in regard to uh vaginal symptoms?

SPEAKER_00 50:07

Yeah so if they're having recurrent UTIs or they're having that urgency that frequency they're getting up in the middle of the night right I like to look at everything as a provider right because my training is okay well if they're getting up in the middle of the night is there something else going on like a blood sugar issue all right yeah right so um but if everything checks out and it's just look these symptoms line up with GSM let's treat GSM there's no harm or foul to sit there and say let's try some vaginal estrogen cream or hopefully intra rosa if we can get it covered by insurance um let's get these symptoms checked out first right um but if they're coming in with recurrent um inflammation or um infections you know what they think may be an infection um there's no harm or felt to try to get them started on something perfect I think that I mean just getting the conversation and and also just having somebody that you can talk this with because I think sometimes people think oh it's it is just I sneeze pee a little bit you know or they don't realize what it can continue to go into without some type of treatment. Yeah yeah um and and and that's the take home right like and I've said this from the I say this all the time I say this from the beginning we need to listen actively listen to what our patients are saying and we need to believe them because they've been in their bodies I haven't I'm I'm like give me the information I need to put my gat my MacGyver hat on to figure out what's going on with this patient right so we can't just assume that everything is just normal aging right um it can be a little difficult being virtual right um and I've had I've had some providers some providers really challenge me on that but guess what if you take a good history and you know what questions to ask yeah you're gonna get your answers exactly um yes and I that has never that has not failed me yet so um so you know making sure to get evaluated we we really want to support that tissue we want to support that tissue we want to prevent euroscepsis yes in women um you know we we need to if if a patient just wants um a moisturizer okay we can look into that but we also have to educate and say hey look we can also use hormones that like like is not systemic right it doesn't get into the system um um and we really need to phone that friend and get patients on board with pelvic therapy it's very it's becoming more and more now in the States but um for the longest time you know women are having these pelvic organ prolapse right we're having uteri come out and cervics and and and bladders and rectums and it's like why aren't we why aren't we exercising these things we need to we need to figure out how to prevent that from happening um and are they just all like not all physical therapists are pelvic health no yeah you specifically have to look for pill for pelvic floor physical therapist and I don't know if it's changing now but historically all physical therapists are physical therapists they have taken it a step further and have gone and done their own training outside of PT school because again it's not trying there it's not learned in PT school just like menopause isn't isn't in NPPA MD programs. But people like yourself who have gone the extra step and and done it right and so we they go and do their own training on on pelvic floor therapy to really get these patients treated which is amazing um which is uh it's a specialty within itself right um so really getting in and getting a good physical therapist that understands that pelvic floor and and again and I'm I'm just saying this I'm I'm gonna say this it's not just women who have issues with pelvic floor it can be men too right and so having a pelvic floor therapist is imperative I wanted to throw that in there because guys can I did not know that yeah I did not know that either that's I mean that see we just learned so much I I'm telling you and it is you know I mean I I mean I had no idea about the um testosterone receptors down there the DHEA I'm like psyched I don't know if providers will be when I go and tell them with my notes like hi hey I would like this also this yes yes and so one thing that I do tell patients is Intra Rosa has a um um and again I have like no ties to them I just love the product um I've prescribed the product for so long and when you like when I've had women tell me they can they and their partners can can feel a physical difference. I'm so excited yeah but there's a there's a manufacturer coupon and you guys need to go out there and tell the pharmacists if your if your insurance doesn't cover it print out the coupon and say you guys need to apply the manufacturer coupon for commercial insurance here it is and then they'll go through the whole rig of row oh it's not covered and then I mean this is one of the big I have I I had a patient who I prescribed it for and I used the um I always put a little love note in my prescription big block bold capital letters please use manufacture coupon for commercial insurance price reduction and so um my patient texts me and she's like look I can't they're not utilizing the coupon they're saying it's not covering and I was like what and you know in my practice my patients have my my cell phone number so they text me and I'm like are you sure and she's like listen I'm here right now and so I call the pharmacy and I call the pharmacy and I'm like hey this is you know Giselle Tyson nurse practitioner I put in this prescription for a patient intra rosa I put in there to use the manufacturer coupon and she's like it's not working and I said okay well um I'm not there so I can't tell you how to input it but it's the man you you should be able to use the manufacturer coupon. I had one of my one of my um pharmacists that I use um I love him he's awesome and I asked him one day I said why are these other pharmacies not doing it and he goes because they're lazy and I was like thank you um I don't want to say that I don't want to say that into the public but um or they don't know how to do it or it takes too much time right and it tracks all of this tracks. It does yeah so I'm on the phone with her and I said ma'am listen um I I don't just use it and she goes well you know the indication here it's it says it says to place the patch on and and I'm like what I said it's a suppository and she goes I'm looking at the prescription I said what does the prescription say she goes estradiol zero point and I said Intra rosa is D H E A. It's a vaginal suppository you're trying to apply that to a patch and she goes oh I said I said are you I said are you the pharmacist and he said yes and I said I said I didn't know I I didn't know what to say I have and literally for me to have no words is really shocking and I was like ma'am because I'm I'm in Texas right so we gotta be polite ma'am have our manners I almost said bless your heart because you know what that's and and see we all know see we all know what that thank you so I'm I'm sitting there and I'm like hmm so Intra Rosa is a vaginal suppository it's press drone it's D H E A.

SPEAKER_02 59:19

You put it in nightly like I'm going through all of this with her and I'm telling her and I'm like my pay my other patients waiting I'm like oh my god I can't believe I'm doing this right now and so anyways long story short um she didn't know what intra rosa was and so she was trying to apply a coupon oh just something that wasn't even yeah I can't you know so sometimes you really need to like stand there not be I'm not saying be rude but I'm just saying hey listen teachable moment teachable did she do you think she felt it was a teachable moment you know what hopefully hopefully she did hopefully she did I always look for the summer if she listened for she will from now on though she will she will know so thank you for being patient with her I listen it's cool I mean I know Debbie and my I know I am I am so excited because I do have these I will make all of my notes and we can always with my insurance you can just also go on like online and like text them like in the um like in an app type of thing you can you know and then they get back to you within two to three days whatever but I will be like oh can we please the coupon and do this and we'll see how far I get in PA and then when they say sure I'll be like oh good now there's a manufacturer's coupon that you will also apply.

SPEAKER_00 1:00:51

And so I always invite patients to do that right well and it's the same thing. I have patients who they can't get vaginal estrogen cream their insurance is saying that they don't want to cover it and for them it's like $238 for a tube of cream I'm like go to Mark Cubans Cost Plus sign up and get the tube for $13.

SPEAKER_04 1:01:09

Yep.

SPEAKER_02 1:01:10

But this stuff isn't this stuff isn't there unfortunately but yeah well cool well I'm glad that we always have the um go arounds that if you know the go-arounds for the insurance thank you for that way if people do ask us questions and I just think this was such a very good informative I mean it's something that has to be talked about it's starting to come out but not really but it is something that I mean think about it girls like you said in the beginning know what you look like down there. Debbie get a mirror I know I know get a mirror and just so that you know I just have to share something funny.

SPEAKER_03 1:01:49

You you'll like this one. So I'm at the OB and he was like showing me how to put some ointment on and he and I said to the girl I thought he said get a hammer I go what do you need a hammer for he goes no I meant get a mirror so he was they they wanted to show me how to get mirror and I'm like I'm not putting a hammer it was just funny I don't I don't know how I got hammered from mirror but that's what I thought he said.

SPEAKER_02 1:02:13

I'm like I know I was like uh no but he was trying to tell me that it's very important for every woman to take the time to get a mirror and to actually know so I gotta give him credit for that he was even though he knows that that's not what I'm gonna do he says I'm still gonna tell you I think that we all need to do it so that way we you can see differences because you have no idea until you know at least what it looks like starting point and then you can just keep track of it.

SPEAKER_00 1:02:42

Agreed agreed because then when a when a patient comes in and they're like look I've had this recurrent infection and it's itchy and it hurts and and I just keep on getting creams okay well what did it look like what does it look like now I don't know what it looks like I just know I have these symptoms. I can provider you know hey is it BV is it yeast is it lichen sclerosis which can cause changes to the vulva that may be a precursor to vulva cancer right like we need to know these things so that way we can really educate patients and and um and we can get some good information and and try to um come up with a diagnosis right well that is our takeaway I'm gonna say girls grab your mirrors and ask questions ask questions and yeah and don't you know the pelvic floor is very important like do not think that it's not and it's we need to do more than keggles we at the bridge find a provider that is a physical therapist that specializes in that's perfect and we are just so thankful that we have our favorite nurse practitioner who specializes in women's health and um it's just perfect. Please tell everybody where you can be found so that way they can find you virtually so uh wishhealth.net so that is www dot wish e a l t h dot net so that is one H in there. Um my web designer did that on purpose I still don't understand why she only put one H in there but that's it. Or you can always call my office which is 71389474.

SPEAKER_02 1:04:28

Perfect I thank you again we enjoy these I always feel like we get so much information to help other women out there who are struggling and just don't know what to say but at least they can and I actually know somebody that does um have one of those carbuncle things that they never knew what it was so I was so excited and I was like if we don't talk about it I will ask but we did so I can be like hey listen to this episode. Yeah and and those are the carnuncles excuse me are very common right and we happen and it's like if we can prevent those from happening and treat that and get that I mean it's it's just the whole GSM pelvic floor it's women's health we gotta we gotta we gotta take care of all that and that was yes I stand corrected Jersey will come in with carbuncle but it's carbuncle so that I did I think I did add a B in there when I was talking about it earlier so Lord knows with Jersey anything yeah so we say thank you so much um with our Giselle thank you Debbie we'd like to if you like to listen to more of this you can follow us on Spotify YouTube um Apple Podcast and we say thank you to our affiliate sponsors who are Good Day Chocolate parlor games pantry products isogenics and small picks uh magnets so thank you thank you everybody this was yes thank you again we loved it and as we like to say Debbie what do we say see you next Tuesday