On the Mones
On the Mones is where pharmacist, menopause myth-buster, and accidental midlife icon Kate Thomas breaks down the chaos of hormones, perimenopause, aging, wellness woo, and the medical misinformation flooding your feed.
Equal parts science and sass, Kate gives you evidence-based clarity with zero judgement and just the right amount of swearing.
Featuring:
🔬 Prescribe or Pass Deep Dives — real evidence, made simple
🔥 Woo of the Week — the latest miracle cure getting roasted
😂 Honest stories from midlife, pharmacy, and motherhood
🤷♀️ Peri or Petty — the viral quick-fire segment with Kate’s kids
🔧 The Tradie Brother-in-Law — asking the bloke questions all men are dying to ask
Smart, funny, heartfelt, and refreshingly human, On the Mones is the women’s health podcast you’ll actually look forward to each week.
Facts you can trust. Conversations you’ll replay. Validation you didn’t know you needed.
On the Mones
Breast Awareness, Vaginal Dryness & GSM: Menopause Screening and Treatment Explained
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In Episode 11 of On the Mones, pharmacist Kate Thomas sits down with Dr Sarah Farrell, GP and principal of Sydney Women's Wellness, to tackle two major midlife health topics that do not get nearly enough honest airtime: breast awareness and genitourinary syndrome of menopause (GSM).
On breast awareness, Kate and Dr Farrell cover:
- What breast awareness actually means today and how it differs from formal breast cancer screening
- How to know when to see your GP about a breast change or lump
- Breast density, mammograms and why midlife breast changes can feel alarming
- The difference between normal hormonal breast changes and symptoms that need review
On genitourinary syndrome of menopause (GSM), they cover:
- Vaginal dryness in menopause and why it is so common and so under-treated
- Pain with sex and the impact on relationships and quality of life
- Recurrent UTIs after menopause and the link to estrogen decline
- Bladder symptoms and what is driving them hormonally
The full GSM treatment ladder is covered clearly and practically:
- Vaginal moisturisers versus lubricants and when to use each
- Vaginal estrogen and how it works
- Prasterone as a treatment option
- When hormonal treatment is appropriate
- Where non-hormonal options like hyaluronic acid vaginal preparations may fit
This evidence-based conversation helps women understand the difference between normal hormonal changes and symptoms that need medical review, without panic or misinformation.
Whether you are in perimenopause, approaching menopause, or simply trying to understand your hormones, I've got you.
Read more about this episode at Medication Clarity Clinic, Kate's own medication education and telehealth consulting site: https://medicationclarity.com.au
You're listening to On the Moons, where we have conversations about hormones, midlife, and the moments that make us wonder, is it just me? I'm Kate. I'm a 48-year-old pharmacist and newly minted perimenopausal oversharer. This is where we talk openly about the changes we aren't prepared for, so we never have to feel alone in them again. I acknowledge the Camaragle people of the Eora Nation, the traditional custodians of the land which I am recording today. I pay my respects to elders past and present, and I extend that respect to all Aboriginal and Torres Strait Islander peoples listening. Always was, always will be, Aboriginal land. Hello friends, welcome to On the Moans. This is a conversation I've really been looking forward to because we are talking about two body parts that women spend a lifetime either worrying about or pretending they don't exist. Boobs and vaginas. Specifically, breast awareness in midlife, what you should actually be doing, what's normal and what isn't. And genitor urinary syndrome of menopause, which is a very long medical phrase for something that affects an enormous number of women and yet is still whispered about. Dryness, irritation, recurrent UTIs, phantom UTIs, pain with sex, bladder changes. The stuff that quietly erodes confidence. And I have the very great privilege of talking with Dr. Sarah Farrell, GP and principal of Sydney Women's Wellness. She spends her days actually sitting in the room with women, so this isn't theoretical. This is real clinic, real bodies, real lives, real conversations. We talk about what breast awareness actually means in 2026 because it's not the same message we grew up with. What should prompt a review and how to reduce panic without reducing vigilance? Then we move to vaginal health, specifically GSM, what it is, why it happens, and what the treatment ladder looks like. We discuss lubricants, moisturizers, vaginal estrogen, prasterone, and where newer non-hormonal options like hyaluronic acid preparations may fit. As always on the moans, we are interested in mechanism, risk versus benefit, clarity, and realistic expectations. Because vaginas deserve the same clinical rigour we give to knees and cholesterol. So whether you're here for the boobs, the vaginas, or both, here with my conversation with Dr. Sarah Farrell. Hello lovely friends. I am so excited today. I am here with my beautiful friend and amazing GP, Dr. Sarah Farrell. Dr. Sarah Farrell is the principal at Sydney Women's Wellness, but actually, maybe I won't tell you where she's from because I don't want everybody to go and see her and for her to have no time for me. So just forget where she works at Sydney Women's Wellness. So Dr. Farrell is a specialist GP in menopause and women's health, but I will let her introduce herself to you.
SPEAKER_00Here she is. Hello and thank you so much for having me on. I love to spend my first afternoons not with my children and doing a podcast with you. I'm Dr. Sarah Farrell. Yes, I am the principal GP and founder of Sydney Women's Wellness. We are a GP clinic in Greenwich. We um focus on women's health across all the life stages, including perimenopause and menopause, but also any stage in which women's health needs a little bit of extra attention, that's what we are here for. We have our dietitians and lactation consultants, psychologists, and we really look at the whole woman and everything that she might need. Today, Dr.
SPEAKER_01Sarah and I are going to talk about boobs and vaginas, our favourite topics. First question to you, Dr. Sarah, is what does modern breast awareness actually mean in real life for actual real people?
SPEAKER_00We all know that breast cancer is an incredibly important and common cancer in women, and it really does have such amazing advocacy and awareness all around it. But I do worry that despite all the spotlight that's out there, a lot of women don't actually even understand the basics about their own breast health, breast awareness, and their breast risk. I actually had a patient recently who, when I asked her about her breast awareness, she was very embarrassed to admit that she'd actually probably been to more breast cancer functions than she'd done her own breast checks this year. What breast awareness is, is actually just getting to know your own breasts. We're not checking for cancer, we're not looking for cancer. It's just about knowing you're normal. So when changes happen, you are going to be right onto it. 50% of cancers are actually found by patients or their doctors, and that's between their screening mammograms. And it's important to know that the five-year survival for stage one breast cancer is 100%. So finding cancers early, not just waiting for screening, can actually be life-saving.
SPEAKER_01That is so reassuring. So stage one breast cancer is 100% treatable. Incredible. What should women in their 40s and 50s be doing differently? If anything, maybe we're doing it perfectly.
SPEAKER_00Well, you will be doing it perfectly, I hope. Um and if you're not, we will talk later. First off, if you haven't started screening and you are 40, you absolutely can and you absolutely should. So this is your sign to book in. If you don't know your risk, that's the other really important aspect that a lot of women in their 40s and 50s and maybe later don't appreciate. Understanding your risk is relatively simple. First off, we've got our obvious family history, making sure you understand who in your family had breast cancer, who may have had ovarian cancer, even prostate and bowel cancer is important to know about. And then log on to IPrevent. It's an online calculator at the Peter McMillan Center and it's free. It takes about 20 minutes, but you put all your history in there, plus your other lifestyle factors: alcohol, weight, exercise, when you had your first period, when you've gone through menopause, hormonal therapy, everything. And then it will spit out your risk. And with that, I want you to go and speak to your GP to talk about a personalized screening program with your risk in mind.
SPEAKER_01How does breast density affect screening and risk conversations?
SPEAKER_00Breast density is excitingly now part of the breast conversation. And in my clinic, we've actually already found one stage one breast cancer and one pre-cancer, DCIS, after making changes to screening plans using these women's density in mind. What breast density means is essentially how much white shows up on a mammogram. Breasts are made of two types of tissue. We've got our fibroglandular tissue, and that comes out white on mammography, and fat, which is black. The more fibroglandular tissue we have, the more density you have, and the more white your mammogram is. The three most important things women need to know about density is one, you can only know your density from a mammogram report. It has absolutely nothing to do with the feel of your breasts, the size, or the perkiness. Two, if you have dense breasts, it can make cancers harder to see. As I said, on a 2D mammogram, you are going to have white breast tissue. If you are in that top 10% of density, that mammogram is going to be incredibly white, and finding a little white cancer in the background is very difficult. These top 10% of women, the D density, we can actually miss 40% of breast cancers in these women using just 2D mammogram. And then finally, the most important thing to know is that breast density can actually increase your risk of breast cancer in and of itself. Understanding that if you're in the bottom 10% of women with A-density breasts versus the top 10%, there's a fourfold difference in breast cancers. So knowing your breast density is really important. And so for women, it's really important. One, to find out your breast density, two, to put it into your risk calculator to see how that affects your risk. And three, talk to your doctor about what imaging is best as a screening option for your density. As we have multiple great options for breast imaging. We've got ultrasound, contrast enhanced, mammogram, and MRI, which can all be really helpful for our more dense breasted women.
SPEAKER_01Dr. Sarah and I are sitting around the living room. We've got a glass of wine, but we now also have been joined by the little fat dog. So you can probably hear him padding around in the background and wanting to have his head rubbed and be in on the conversation. What symptoms should prompt an urgent review?
SPEAKER_00Any changes to your breasts at all? We want to hear about it. So any changes to the feel of them, to the look of them, to the shape of them. Mainly things like lumps, little changes to the feel of your breast tissue when you put your fingers across it, any changes to the skin, so any dryness, flakiness, little redness, new breast pain. Or when you look at your breasts and they look different to each other, so change in symmetry or change in shape, maybe a dimple, maybe some tethering nipples. So don't forget nipple changes, inversion, any dryness, pain in the nipples, or any nipple discharge is also worth a conversation. That's all worth us knowing about. Amazing.
SPEAKER_01So really the idea is to get to know your breasts as well as you know, well, I guess you're the the spots on your skin. It's a similar conversation, isn't it? If you know what spots on your skin are always there, then you can pick up new ones and it's a similar conversation with your breasts. What are the limitations? I mean, maybe there aren't new limitations of a breast screen program.
SPEAKER_00This is really important to understand, and it's it's not breast screen itself or any of the screening programs, but it's important to know that it's not a one-size-fits-all program, which is not a criticism of breast screen. It really is just the reality of a screening program. So screening programs are designed to detect as many cancers as possible while not causing too many false positives, leading to extra tests and anxiety, but while also being financially sustainable because it is a publicly funded program. It is not designed to pick up every cancer in every breast. So this takes us back to our risk assessment and our density and determining what imaging and what timing is best for your particular risk and your particular density.
SPEAKER_01Amazing. Thank you. Thank you. So that's boobs pretty well covered. Can we go south now? Let's talk about vaginas. That's my favorite topic at the moment. Can you explain what genitourinary syndrome of menopause actually is? Because that is getting bandied about online. And I wonder if women really know what that means.
SPEAKER_00So, what that means is doctors like to have fancy terms for things. Genetourinary syndrome of menopause, GSM, really is us saying that in the menopause, something happens to the genetourinary system. And we call it a syndrome because we love to call things syndromes. What happens is when our estrogen declines, all of the tissues and organs in our body notice a change. And what that looks like in the vagina and the vulva is change in the lubrication of the skin, in the thickness of the skin, the flexibility and the fragility of the skin, and also sensation. So ability to enjoy touch and also to orgasm. And that's the genetic urinary syndrome of menopause. It also can um affect the urethra and the bladder too. So it's kind of everything down there.
SPEAKER_01And that makes sense, doesn't it? Because your skin, I mean, you notice your skin gets less moisturized and you can take heavier, heavier creams as you get older than you could when you were in your 20s. So it makes sense that the skin in your vagina, which I understand is a mucous membrane, would suffer the same kind of thinness and drying as as the skin on your body. So I have a friend, and she I mentioned to her that I had started using the Avestan cream and that it was wonderful and it had made a really big difference, and she very confidently said to me, I've got no symptoms down there whatsoever. So, how common is GSM really?
SPEAKER_00So, in my experience, it is super common, and those that think they don't have GSM is probably because they just don't understand what GSM is. The major guideline summaries, and these are based on studies of which there are not many great ones, so welcome to public uh sorry, welcome to women's health. Um, but it puts GSM roughly at 27% to 84% of postmenopausal women. My experience definitely fits with the 84% here in some way or another.
SPEAKER_01And I would say that that fits in with my experience. I didn't really know I was having any symptoms until I started the Eveston cream, and then I was like, oh, that was this is so much better now. So I wonder why more people aren't seeking treatment and maybe the common symptoms that you see in the clinic they're not recognizing as GSM.
SPEAKER_00GSM I really feel is the bottom of the women's health pile. And I it's just exactly how I think how women's health ends up getting treated by the public, by culture, but also by us ourselves as women. Why don't women seek more treatment? Because we have to book the kids' dentists, take the doctor to the vet, get the uniform to the go to the uniform shop to buy the fifth new school hat for the term, drop the car for the service, then go to work. We are so busy in our midlife, there is just not even a second to think about ourselves to realise that something might need attention. And even if we do realize that something needs attention, it often goes to the bottom of a very long list of things to do. And then we add the cultural layer in. We have decades of training that anything below the belt is embarrassing, abnormal, it's just aging. So women quietly downgrade their symptoms. They put painful sex in the relationship problem category, recurrent UTIs as bad luck or a microbiome problem, and then dryness is the I just should drink more water, it's my fault. So instead of understanding that it's actually a recognized and treatable medical condition. And then finally, it's also a marketing problem. Nobody has taught women that menacopause can affect the bladder and the vagina. It's always been a focus on temperature regulation or mood swings. So women don't really seek treatment because they didn't even realize there was a treatment. So they assume the options are just to tolerate it, avoid sex, or secretly randomly buy some female hygiene product from R12 and just hope for the best.
SPEAKER_01Yeah, I think that that is so true. I think that not only do women have all of those jobs that they need to do before they go to their full-time job, but often women in middle age have aging parents as well. So they're not only thinking about what their children need, but they're also thinking about potentially what their elderly or aging parents need. Would you say that GSM affects relationships, confidence, continence? And is this something that just happens with aging, or can can we treat it somehow?
SPEAKER_00Yeah, look, it it affects everything. Um relationships, confidence, continence, and UTIs. And when you're just talking about the mother that you're looking after who might be in a nursing home, who may have gone to the loo in the middle of the night and had a fall, maybe broken a hip, maybe that was preventable with some estrogen for her because vaginal estrogen should and can and should be used for all women till the end of time because it can affect everything. So UTIs, yes, it increases your risk of UTIs, changing your microbiome, and also just the health of your urethra continence. It is involved in urge incontinence and stress incontinence. Confidence, of course, if you don't feel great down there, if you feel like you are going to lose your bladder, if you don't feel like you're enjoying your sex with your partner, goodbye confidence. And then your relationships, of course, they're under strain in our midlife anyway, from systemic hormonal change, not only localized hormone change, and we blame a lot of our libido change on systemic hormones, but also just life stressors. But then we reinforce that by having bad sex, painful sex, and if we could improve that, we may be able to self-reinforce that actually sex is pretty good if it feels good and is lubricated. So yeah, it's all-encompassing.
SPEAKER_01And that is such a good point because we know that couples who have sex have better relationships, and we know that having sex is good for you. We know it's a good marker of your overall health, but we know it's good for you cardiovascularly, and we know it's good for you mentally. So have trying to have good sex in an environment, I mean, for the men it's it's it's unchanged, right? They they get an erection and nothing, nothing much changes. But for the for the women, if if that environment has become well, as our friend, as our friend Georgina would have said, less juicy, then of course it's not going to feel as good. And then of course you're not going to want to do it, and then of course that's gonna build resentment, and you can imagine the flow-on effects from that. Do vaginal moisturizers, where do they sit compared to lubricants?
SPEAKER_00Vaginal moisturizers are great for day-to-day symptom management, just the same way I guess you'd use them for all your other skin to make you just feel more comfortable down there. They don't do nearly enough for sex, so that's where you'll need a lubricant. And as we tend to get older and we have less of our own natural lubrication, we're really needing to use a good quality, often silicon-based lubricant. Um, obviously, we need to be sensible about condoms and toys if we're using those, but we need to use it every time we need to use it liberally, and we need to try them to see which one works best for us. But also knowing that these are just band-aids for something that actually needs a treatment. So that's where we need to really be talking about our vaginal estrogens, um, of which we've got a few different options, all worth talking to your doctor about, but that actually fixes the root cause of what's going on down there, which is loss of these hormones. So if we re-establish the estrogen in the vagina, then the tissue can repair and then we can use it for maintenance, still needing lubricants, but not having the problem in the first place.
SPEAKER_01Where does prasterone fit in? Prasterone is topical DHEA, and how do you fit that into your practice?
SPEAKER_00With presterone, topical DHEA, in guidelines it sits as a second-line therapy once we've tried estrogen-based therapy, like estrogen-alone therapy, and we are not getting benefit from that alone. Uh, that's what the guidelines say. What I like to use presterone for is for women that tend to have a little bit more sexual dysfunction than those that tend towards the more common types of GSM symptoms because presterone breaks down into an estrogen, progesterone, testosterone, so all of the receptors are activated in the vagina, and that's where we see a lot of improvement in sexual touch and orgasm rates and just enjoyment of sex. GSM isn't purely a sex problem, and I really want people to appreciate that if you're not having sex, you still need to look after your vagina. But if sex is the problem, then it's really important that we treat it as optimally as we can.
SPEAKER_01Prosterone actually is a little uh pessary, it's like a little oily pessary, and it it sits in the vagina and there's no discharge, so it sort of just gets absorbed into the tissue, and that conversion in the tissue, so it's as Dr. Sarah said, it's localized, it's not systemic, and that's called intracyne therapy, and the the little cells in there they just convert the DHEA into, as she said, testosterone, estrogen, and progesterone, which is incredible. How clever is that? Are there women who should avoid local hormonal options?
SPEAKER_00There are a lot less women that you would think that should avoid it. Um, I hear way too often, oh, I can't take vaginal estrogen. The only women that cannot take vaginal estrogen is those with an active hormonal breast cancer or those with unexplained vaginal bleeding. Other women can nearly all of them can use it, and those who have had breast cancer and are on treatment for that should talk to their oncologists about their option because it is an option for a lot of our breast cancer patients.
SPEAKER_01Is local estrogen the same as systemic HRT? Because I hear a lot of women say, you know, I'm on HRT and they take the pill and maybe they use a Vestin.
SPEAKER_00It's a little bit complicated because MHT is actually quite complicated. There are so many different types. So when we're talking about systemic, natural estradiol and progesterone, then we are talking about the body getting back through their whole system. Estradiol and the progesterone that we're missing, and that works for the vagina too, but it's not the best way to deliver it. You can absolutely take vaginal estrogen as well as systemic MHT, and I often encourage people to do that. The question about people being on the pill, when we take oral estrogen, we actually go via the liver, and it can increase something called the sex hormone binding globulin. And that in itself, so women who take the pill can actually decrease the sort of can cause issues in the vagina. And those women definitely need their own vaginal estrogen because the pill is not doing anything there.
SPEAKER_01So you touched on it briefly, but I'll just ask you how you counsel women who have had breast cancer. So these, so not women who are on active treatment, but for women who perhaps have had a lumpy, a lump ectomy or a mastectomy.
SPEAKER_00Yeah, so if you are post-treatment and you have no ongoing treatment at all, then you are safe to use vaginal estrogen. Vaginal estrogen does not increase your serum estradiol level. It does not travel to the breast. So even if you had an estrogen-positive breast cancer, it is safe to use vaginal estrogen. I would always chat with your oncologist about this, but it is something that is misunderstood out there, and a lot of women are suffering. It also leads us into the non-hormonal option that is available, which is hyaluronic acid. We have very excitingly in March coming to the market a hyaluronic acid pessary, which is inserted vaginally just like our other vaginal pessaries. It's non-hormonal, and in the studies, it's actually equally as effective on the lubrication and the moisture levels in the vagina.
SPEAKER_01That's amazing. So for women who either can't or for whatever reason don't want ovestine or prasterone, there is going to be a TGA-approved hyaluronic acid product. I think what people don't know is that anything that is inserted is considered by the TGA to be a medical device and therefore it needs to be listed with the TGA. So the TGA has a governance over products and they have listed products. So for example, sunscreens are listed products. If you look on your sunscreen, you'll see an L Ost number, and that means it's been listed with the TGA. Medications that are prescription only are registered, so they're on the ARTG, that's the Australian Register of Therapeutic Goods. But something that is inserted, like a pessary, is considered a medical device and needs to go through the TGA. So it just gives you confidence that it's had all it's jumped through all of those regulatory hoops. What are the most common symptoms you see women complaining about in your clinic?
SPEAKER_00I would say it would be painful sex and then phantom UTIs. So you definitely see an increase in actual UTIs, but I also commonly see women who swear they've got a UTI. They swear they had one last week and they swear they had one the week before, and they've been to a GP and nothing comes up. That isn't one of my most like red flag. Here's some GSM.
SPEAKER_01Lovely Dr. Sarah, thank you for coming and speaking to me after your very busy clinic. And hopefully we can get you back and we can talk about ooh, what could we talk about? We could talk about so many things. We could talk about testosterone replacement, or we could talk about starting HRT in later life. Would you be up for that? If you'll have me back, I would love to. There is non-hormonal moisturization, highlyuronic acid preparations, vaginal estrogen, presterone, pelvic floor support, clinical follow-up when needed. And the right choice depends on your history, your risk profile, your comfort, your symptoms, and sometimes your stage of readiness. I also want to normalise something. We spend hundreds of dollars on serums for the skin on our face, and yet the tissue of the vulva and vagina, which is hormonally dynamic, highly vascular, and deeply connected to continence, intimacy and quality of life, is often treated as an afterthought. That deserves to change. If this episode has prompted questions, talk to your GP, talk to your pharmacist, start the conversation. Midlife isn't about decline, it's about recalibration. And if you found this useful, share it with a friend, the one who's Googling, why does sex hurt now at eleven forty seven PM? So many of the messages I get really aren't comments, they're confessions. Women whispering into my DMs, is it normal that I think I'm the only one who I feel ridiculous asking this, but So what if we made space for those voices properly? Here's what I want to try. If you have a question or a worry or a confession or a thing you've never quite said out loud, record it, just a little voice memo on your phone and send it to me on themoans at gmail.com. Let me know your name and where in the world you are. You don't have to be polished or clever, just honest. And then in a future episode we can answer them together. Because I have a feeling a lot of us are carrying the same questions just quietly. Thank you again to the brilliant Dr. Sarah Farrell of Sydney Women's Wellness for sharing her expert knowledge on all things boobs and vaginas. I'll look forward to your company the next time we get on the moans. Bye bye.