00:00 – Dr. Rubin: So the data shows it helps frequency it helps urinary urgency, it helps all interstitial cystitis symptoms,
00:06 – and pelvic pain and pain with sex. If you have a weak orgasm that should get better as well.
00:11 – Hi, welcome back to the channel. My name is Melissa and today at Live UTI Free we’ll talk about UTI and Hormones.
00:17 – We have another amazing guess, Dr. Rachel Rubin and in that conversation we’re going to cover things like oestrogen therapy,
00:23 – contraceptance and the Hormone Replacement Therapy at any stage of life I also want to mention that we have many other resources
00:30 – for patients experiencing recurrent UTI, and we linked some of those in the video description.
00:35 – Lastly, if you enjoyed the video, think they’re important and wanna support what we do, Make sure you click Subscribe and tick the bell
00:41 – so you’ll be notified a videos when we post them. Other than that, Thanks again for joining us on this journey to making change in women’s health.
01:02 – Melissa: Today we’re lucky to have Dr. Rachel Rubin with us who’s both certified urologist and sexual medicine specialist
01:07 – among many others things. She also shares that passion for patient education. Thanks for joining me today to answer our community’s questions
01:15 – Dr. Rubin: I am so thrilled to be here, thank you for having me. Melissa: Amazing! Could you first give us more information about your background
01:22 – and how you came to specialize in sexual medicine? Dr. Rubin: Absolutely, so I’m a urologist
01:27 – which, in the US, is four years of medical school. It’s five years of training as a urologist
01:33 – which is surgical training in kidneys, bladders, prostates and urethras and I wish more vulvas but that’s another story.
01:40 – and then after my five years of training I did a one year fellowship it’s called “Sexual Medicine” So we take care of all genders
01:47 – and I deal with issues like Pelvic pain, hormonal issues libido, orgasms, arrosal.
01:52 – And I always joke I would see the weird and the wacky the things nobody else really quite sees very much of,
01:58 – the medication in sexual dysfunctions the things people don’t like to talk about.
02:04 – Yeah and so I started my own practise about eight months ago in the Washington DC area in the US.
02:10 – Melissa: That’s great. You’re the perfect person to answer the questions we get a lot of questions about different symptoms that many people don’t experience
02:17 – we have a whole bunch of questions on hormones but I want to start with a few on anatom that came up which could provide a good foundation to some of the questions coming
02:26 – So the first question was: Are there similarities between the lining of the bladder and the uterus?
02:32 – Dr. Rubin: That’s a great question. And so it’s different. The lining of the bladder
02:37 – is endo.. actually it’s a good question, I don’t know if I know the answer the lining of the bladder is endoderm
02:43 – the lining of the vigina is mysoderm. The lining of the uterus hum…
02:50 – endometrium which I don’t know… it’s different tissue because the endometrium tissue is very special.
02:57 – So I’m not a gynecologist but I don’t believe they are the same tissue
03:03 – But that is a good question. Melissa: I thought it was a good one too. The second one was about the bladder itself
03:08 – and what the term triconitis means and what it means in association with UTI
03:14 – Yeah. So the bladder trigone is where and the bad… So if you think of the bladder like a bowl
03:20 – when you’re standing up it’s like a bowl the bottom of the bowl is where all the urine pools and then there’s two holes at the bottom where the urine then
03:29 – where the urine comes into from the ureter and goes out to the urethra so it sets that bottom where the urine is coming in
03:36 – and it’s leaving where everything is happening that we call the trigone, so sort of like the bottom area
03:43 – And so it can look inflamed and irritated and we often call that trigonitis.
03:49 – Sometimes they can have little lesions on it when we look, visually that can be called cystitis cystica.
03:55 – There’s things like Squamous Metaplasia, there’s all sorts of visuals and biopsy proven
04:01 – uritins chronic inflammation ulcerations, infectious, things when you have a UTI
04:08 – what it looks like on scoping. Hum, yeah.
04:13 – Melissa: So that means trigonitis It’s ok ski information and it could be caused by a UTI or by a number of other things
04:20 – Dr. Rubin: Yeah, and there is a lot of non-specificness to it. which frustrate the hell out of everyone in your group, as it should,
04:27 – because there is so much… Gosh, I was speaking with a pathologist on the phone yesterday
04:33 – I have a patient who has this horrific vulva lesions that we cannot figure out, I biopsy her, biopsy her, biopsy her
04:39 – and it keeps coming back as chronic inflammation, and to the pathologist I said “there has to be something”
04:45 – well it’s just chronic inflammation, I’m gonna offer you thoughts and prayers and I was like “I can’t”, thoughts and prayers are not gonna help my patient figure this out.
04:54 – Melissa: That’s a source of frustration among our groupe, definitely the topic of Trigonitis has come up recently,
05:01 – and it’s sort of giving us a diagnosis but it really means that you should be looking for the root cause it seems.
05:07 – And so one of the questions associated with that is Are there symptoms that would indicate that the information could be in the trigone area
05:14 – instead of somewhere else in the bladder Dr. Rubin: Yeah, It’s certainly… all actions are on the table, right?
05:20 – in terms of what is causing it and so that’s what we think about. Is the information in the tissue level?
05:26 – Is there a bacteria in the urine that’s causing it? Is it in a lining of the of the walls of the bladder?
05:32 – Is it coming from somewhere else? Is the vigina microbiome linked to it? Is it even an infection at all?
05:38 – which even that is a huge controversial topic that I’m sure at some point today I’ll have tomatoes thrown at me
05:43 – because there’s so much… we’re just not sure about. And so sometimes our testing
05:48 – and our terminology is beyond our ability to treat it and wave our magic wands to make everybody feel better.
05:54 – and that’s where so much frustration lies. Melissa: Yeah, it would be great to be able to get some more answers
06:00 – But the main topic we wanna cover today is about oestrogen therapy. So we can move into those questions
06:06 – I thought it would be helpful to start with an explanation of the link between estrogen and bladder health.
06:11 – Dr. rubin: This is my favorite topic. so this one I can handle. So this is really important, and could explain some of the trigonitis stuff
06:19 – I really believe that. So if everyone can think about a baby girl
06:25 – anyone who’s ever changed the diaper of a baby girl, right? Baby girl have teeny tiny labias,
06:31 – their vulvas are red raw and irritated they pee in their diapers constantly. No they don’t complain of bladder pain or UTIs,
06:38 – but they’re also not putting anything in their vaginas, they’re not… or not hum…
06:43 – poking and prodding at the zero very much to introduce bacteria and so we would put cream all over it
06:50 – because it looks so raw and painful. Babies have no hormones in their bodies no oestrogen no testosteron
06:56 – the tissue is very hormone sensitive We are rich in a oestrogen receptors and androgen receptors
07:03 – both in the urethra in the bladder in the vulva, in the vulva vestibule
07:08 – and without hormones the tissue is very raw thin and irritated So then baby girls go through puberty
07:15 – they become mean to their mothers as I like to say. But then the bodies literally change and transform.
07:22 – The tissue gets thicker It gets pink, it get healthy. The vagina acidify so that it can fight infection.
07:30 – And so it’s an hormonal response, the tissue is very hormonal. And as I like to say, when you play with hormones there are consequences.
07:38 – Sometimes they’re very good and sometimes they’re very bad, but there are consequences. And so for things like birth control pills,
07:45 – Or breast feeding or breast cancer medication, or of course menopause, which is the thing we see the most.
07:53 – What happens if you lose hormones, so the tissue start to thin, it starts to involud it starts to get dry and cracks.
08:01 – and gets irritated. and it can’t mount a healthy response to bacteria the way healthy tissue would.
08:08 – EAnd so in my opinion and when I’m trying to change the…
08:13 – the narrative on all of this, is hormones are the baseline hormones are the foundantion,
08:19 – hormones are a must for everybody. And if you don’t have that, I think all the treatments are
08:26 – third-line therapy compared to first and second-line therapy being hormones And so your groups, you can’t have one who’d say
08:34 – I failed vaginal hormones and nothing’s working for me. they must be on vaginal hormones,
08:39 – and not every type of a right for every person. but they must be on that therapy as a baseline.
08:46 – And then the additional therapy can be, that doesn’t mean that’s the only one but it’s like the foundation of the house, without it
08:53 – nothing else is going to work very well, does that make sense? Melissa: Definitely makes sense. and it kinda lays a base for
09:00 – most of the question later, which is great! You talked about vaginal health, why is that important for bladder health and reducing UTI?
09:08 – Dr. Rubin: Absolutely. So it’s it’s all one microbiome kind of a thing. and there’s lots we need to learn about the microbiome
09:14 – but the only thing in the world that is shown to make a healthy microbiome and acidify the vagina to prevent UTI.
09:21 – is vaginal hormones. So vaginal oestrogen and actually vaginal DHEA we have a paper, it’s in my email after review it.
09:29 – But we looked at a paper where also did vaginal DHEA which does decrease the incidence of UTIs as well.
09:35 – And so, what happens is the vagina has receptors for oestrogen and androgen.
09:42 – Without the hormones, you lose the acidity of the vagina, the lactobacilli,
09:48 – all the good bacteria and so the bad bacteria start to overgrow. And remember the urethra is right in that vulva
09:55 – so it’s only four centimeters long, so the bacteria can crawl into it. and then all the antibiotic can lead to antibiotic resistance
10:02 – and I don’t have to tell your listeners all of the difficulties of just getting more and more antibiotics.
10:09 – And so, The vaginal hormones are not a treatment for a UTI but they’re preventative and a protector, so that your body
10:16 – can now mount the response. so if you use vaginal hormones that acidify the tissue th vagina becomes healthier,
10:22 – able to fight infection, and it’s not just for the vagina, that little bit of hormones,
10:28 – Also it will heal the urethra And also it will lead to bladder health as well. So the data show that it helps frequency,
10:35 – it helps urinary urgency, it helps all interstitial cystitis, and pelvic pain and pain with sex,
10:41 – if you have a weak orgasm, that should get better as well. And so it helps so many thing
10:47 – but the most important thing vaginal hormones do is prevent UTIs. And I cannot stress enough
10:52 – I need your eighty-nine-year-old grandmother on vaginal hormones, I need your 98 year-old great grandmother on vaginal hormones.
10:59 – It is so safe. It is safe for all patient, there is really… The only patient on earth I would even have an extra conversation with
11:08 – is someone who has active breast cancer An aromatase inhibitor specifically actually any Tamoxifen is fine.
11:16 – And that patient and I would have a discussion But I would convince that patient why it was safe and why UTIs are way more dangerous than
11:23 – the no risk of any kind of breast cancer issues. Those are the only patient when it’s even a conversations
11:30 – if you have blood clots, if you have a family history of cancer, if you have any none of it matters, vaginal hormones are safe.
11:38 – Melissa: That was a question that was gonna come up later but let’s address it now, Why are there so many feels around the use of oestrogen
11:44 – If you have breast cancer or a family history of breast cancer. Dr. Rubin: Politics, politics, politics
11:50 – and it’s so infuriating. So basically, at least in America,
11:56 – we have a box labeling on our vaginal hormones products that are the same box labelling…
12:02 – that’s essentially what on birth control style pills that we give to women in menopause
12:07 – They’re different products, they don’t do the same thing. but they have the same warning labels on them.
12:12 – That warning label is not actually based in up to date data the warning label says it causes stroke,
12:18 – heart attack, blood clots, dementia, breast cancer, you have to use it with progesterone. There is no data to go with that box
12:25 – and yet the FDA if the FDA is listening or someone at the FDA or someone that is married to someone at the FDA
12:31 – please let them listen. They’re not interested in nuance. It would be like saying that condom wrappers should have a warning risk of blood clots.
12:40 – Right, everyone knows birth control pills have a slight increase risk of blood clots So that should mean that every contraception
12:47 – should have a box labelling that says “cause blood clots”. So your IUD, your diaphragm
12:52 – your condoms should all say that they cause blood clots. That doesn’t make any sense! Neither doesn’t make
12:58 – that a hormone therapy is not all the same thing in menopause Local Low dose vaginal oestrogen or DHEA
13:05 – had zero risk of bad things happening to you. The politics are huge here
13:11 – but the data, there is no. And I have been screaming on social media, on Twitter
13:17 – on Instagram, on LinkedIn, screaming about this for 5 years
13:23 – actually 6 years now, and no one’s been able to present me with one piece of data to show that they should be fair with vaginal hormones.
13:30 – I encourage you all to try And I will meet you at debate stage on the internet
13:36 – because it doesn’t exist! Melissa: Is there any chance those guidelines or labels will be changed ?
13:42 – Dr. Rubin: I absolutely think we have to keep trying the advocacy work that you’re all doing is actually even more important
13:48 – I believe it is patient advocates that get shit changed, excuse mu language, in this world.
13:55 – Because we’re doing a terrible job. A group of doctors did of the FTA a couple of years ago
14:00 – And sent a citizens petition And at the FDA changed the conversation,
14:06 – made it about systemic hormones and said “no we’re not changing the box labelling”. And it was infuriating.
14:11 – And so we need a few motivated folks to go out there and really get angry
14:17 – and make this the issue. So I would love to join all of you in marching down on on Washington
14:23 – because I tell you, people are not marching for vaginas! They’re not matching fro that!
14:29 – The vaginal oestrogen is never anyone’s number one priority but it should be because the number of people who are dying of UTI or urosepsis
14:38 – or antibiotic resistance we would save the Healthcare system so much money
14:43 – by investing in vaginal hormone products every nursing home patient. It’s so important
14:50 – And it’s so easy which is why it’s totally ignored Melissa: Yeah we find the same thing
14:56 – I’m sure we can get a few people together if you want to organize that. Dr. Rubin: Let’s do it, that sounds fun!
15:01 – Melissa: The topic of oestrogen comes up a little, what about other hormones? Is there a link between progesterone or testosterone in bladder health.
15:09 – Dr. Rubin: Absolutely, and we need more data. So just like I said I have a paper sitting in my email
15:14 – that shows that vaginal DHEA promotes UTIs. What I love about vaginal DHEA
15:20 – it’s the only FDA product in the US that has an androgen in it. And so we know that there are androgen receptors there
15:27 – I’d love to see more research on testosterone specifically for bladder health Because I am certain there is a role.
15:35 – And we just, the problem is again politics we don’t have FDA-approved testosteron for women in the US
15:41 – and so it becomes more difficult to do studies to know what doses to play around with and to get companies to buy into this and understand the important link here.
15:50 – Vaginal DHEA is a wonderful product that’s hard to get into patients vaginas because the expensive with insurrance companies
15:57 – and so it’s very frustrating. I think progesterone isn’t even more a known topic.
16:04 – I saw a recent abstract that there are progesterone receptors in the vulva vestibule
16:09 – which to me means there’s probably progesterone receptors in the urethra and the bladder So as far as I know,
16:16 – and I don’t know everything, it hasn’t been looked at with any significant degree. But for all those women in your group
16:22 – who said “Man, my bladder symptoms really fluctuate with my cycle.” Of course it’s hormonally related
16:29 – it has to have some hormone connection. And so I couldn’t agree more that that’s an exciting
16:35 – future place of research. Melissa: Is that the same case- a few people mention progesterone pellets not being FDA-approved
16:42 – but finding beneficial, is it the same thing, just a lack of data? Dr. Rubin: Pellet in general are a controversial topic
16:49 – because there aren’t FDA-approved products, you know. And my frustration with them is if the pellets are so great,
16:55 – and the companies are so proud of their safety, their advocacy and I’m not saying it doesn’t work! But if they’re so proud and the patients are so happy,
17:03 – why not do the work? To do scientific studies to a high standard
17:09 – and get your products approved by the FDA. Other companies do it. Why do you think- like, and so that’s where my problem with it is.
17:16 – Is why don’t we hold, and so, you could have dangerous things put in there because there’s no oversight
17:22 – And so that’s my issue with it. We have a FDA-approved male testosteron pellet! It’s fabulous, if I could get it in more patients I would!
17:30 – it’s sometimes not easy with insurrance. And so I love the idea of pellet bu no one’s studying it at a rigorous level
17:37 – and these companies have so much money and are doing such a great job and they think they are doing such a great thing. Then we should hold onto the highest standard of saying
17:45 – “why don’t we go through the process and actually do the same for women. That’s my issue with it. Melissa: We would love that if more research was done in this space
17:53 – Definitely. What what are the indicators that might prompt you to investigate oestrogen therapy for patient
17:59 – Dr. Rubin: If it is a patient that has a vagina. Hum, that’s it! Right. You need must to have a vagina.
18:04 – So anybody over forty-five, so if you’re anyone over forty-five, And you have any symptoms so,
18:11 – I’m very aggressive. Because it doesn’t hurt anyone. Vaginal hormones has never hurt a fly.
18:17 – Occasionally when you start it, as your microbiome acidifies you can get a yeast infection or a thrash infection, you treat it
18:24 – It goes away it’s not something that creates a chronic yeast situation
18:29 – that is the worst thing that can happen with vaginal hormones. If you don’t like the cream, switch to a tablet.
18:36 – If you don’t like the tablet switch to a ring if you don’t like the Rings which to DHEA. There are different forms
18:41 – and sometimes the base, or was it in or the modality is not right for you. You have to find a product that’s right for you.
18:48 – Anyone over forty-five, I believe, should be on preventative care. But that’s very aggresive, that’s a very aggressive statement.
18:55 – that I know not everybody agrees with. But what I think is I don’t want you to have urinary frequency and urgency.
19:00 – and I don’t want you to get a UTI and I don’t want sex to become painful And I don’t want to treat you once you orgasm has already become muted
19:07 – I want to prevent all of those things from happening. So I believe that early in perimenopause
19:13 – we should all be encourage vaginal hormones therapy. Now we need more data when it comes to premenopausal women
19:20 – Vaginal hormones won’t hurt you, they won’t change your cycle, they will not hurt your partner, they will only help locally.
19:28 – If you’re on birth control pills, I don’t have much data and my impression is it’s
19:33 – it’s sometimes we can a balance each other and so it’s hard to fully help that microbiome.
19:39 – So I tend to like IUDs for that reason, it seems to be a little less caustic on the microbiome and on the tissue.
19:47 – We’re still learning. We you more data. We treat young babies
19:52 – with labial adhesions with vaginal oestrogen. We give this stuff to babies. Is it is so safe for everybody
19:59 – And yet it is so under-discussed because we hate the word vagina, and we cannot handle the terminology.
20:07 – I actually think the terminology “vaginal dryness” is killing women because we minimize, vaginal dryness doesn’t sound like a big deal
20:14 – “Oh just suck it up, lady!” You got vaginal dryness, just take that. I saw a woman in my office yesterday
20:19 – She couldn’t sit, she could not sit. She could not wear pants. She was miserable, she is so miserable!
20:27 – She’s had inpatient psychiatric care because of how much pain she has in her vulva.
20:34 – This is vaginal dryness, people. This is horrific and it’s hormonaly mediated.
20:40 – It’s all seem from our perspective that the quality of life in not taken seriously If it doesn’t kill you then, just deal with it
20:47 – it’s kind of the message we’re getting from many people in this sphere. But quality of life is so important to our community, that’s everything
20:55 – And there were a couple question about you said that there aren’t really side effects to this. But a few people said they have experienced burning or pain.
21:03 – Is that because of the oestrogen or the type they’re using? Dr. Rubin: It’s typically the type they’re using,
21:08 – a couple of things there. And so, if you’re using a cream, and I don’t love creams.
21:13 – The reason I don’t love cream is a couple reasons. One they’re messy and goopy and glopy
21:19 – and this is something that you’ll have to do forever. So you hate putting goopy creams in your vagina
21:24 – it’s hard for me to say “do this twice a week ’til death tear you ‘part” And so the cream also sometimes have
21:32 – chemicals in them that can be very irritating and caustic to the tissue. Premarin cream which I don’t even think is available in Europe
21:38 – but for some unknown reasons we still have it in the US, and so many people prescribe it, has alcohol in it,
21:45 – it has chemicals that are raw, that irritate. And also hum, it’s…
21:50 – they like, tortured horses to make it happen. But I don’t love those creams. If the creams are the only option you get,
21:56 – the only affordable choice that you have, then yes, use the cream. They are so much better than the using nothing.
22:03 – The other side effects, again, is that you have a yeast infection that can pop up If you use the cream, you want to make sure you dose it properly
22:11 – This is a very common mistake. That’s not your fault. It is all the doctor’s to tell you- I tried working on educating all of the doctors
22:18 – because they say “take a pea size of the cream, and rub it on your urethra.” Just a tiny bit of cream on the outside.
22:25 – It’s not enough to acidify the vagina. So if you really wanna know if it’s working get a pH paper and see if your vagina is a 4 and a half pH
22:33 – You got to get the pH of the vagina to 4 and a half. That’s really important because the urologist, and the urogynecologist
22:41 – and the gynecologist will say “just take a little pea size” and it’s wrong, it’s not enough. So that’s why I like the vaginal oestrogen tablets.
22:49 – Tablet insert the ten micrograms. I like the rings that stay in for three months at a time
22:54 – I like the DHEA insert ’cause you don’t have to think about it or dose anything out And wonder “am I using enough?”
23:01 – and they’re not goopy and messy, does that make sense? Melissa: Definitely. Would you use the tablets everyday,
23:06 – or twice a week? Dr. Rubin: You use them- So everyday for two weeks and then twice a week. The DHEA are written for everyday,
23:13 – although I certainly do have patients who do it 2 or 3 times a week and think that’s enough. They were studied as everyday.
23:19 – Occasionally you’ll see a woman who has breast tinderness and that is not breast cancer it does that mean you have breast cancer
23:24 – Think of when, if you’ve ever been pregnant, the very first sign of “oh my gosh, I’m pregnant!”
23:30 – is breast tinderness. And you say you don’t run to say “oh my god I have breast cancer, i must get a mamogram right away.”
23:35 – You run to the drugstore, and you get a pregnancy test. And you say “is this it, is this the time I’m pregnant?”
23:41 – That typically goes away. What happens is that your tissues are so thin, they’re so raw, so cracked, that the littlest bit of oestrogen
23:51 – you know goes in the bloodstream and your nipple get stimulated, but as it builds up in the tissue,
23:59 – as the tissue builds up, It no longer goes into your bloodstream and you don’t get the nipple tenderness anymore.
24:05 – It’s rare but I have seen patients happen. Melissa: Ok so once you do start on therapy how long does it typically take to alleviate symptoms?
24:12 – Dr. Rubin: This is the best question because people well women were used to an antibiotic for a week
24:18 – for UTIs or one day diaflucant for a yeast infection. Rome was not built in a day.
24:25 – It takes two to three months to build up the tissue two to three months to make it strong and healthy
24:30 – two to three months to acidify to make sex not painful again And that step one, you’re not going to see benefit for two to three months
24:38 – so don’t expect it. You gotta refill it, you gotta take it forever, it will stop working if you stop using it.
24:44 – The other thing to know is that… It takes two to three months to start working up.
24:52 – If you still have pain, that doesn’t mean it’s not working. It means that you may need an additional androgen to the tissue,
24:59 – because remember it’s not just an oestrogen story. It may mean that you need a pelvic floor physiotherapist to work on your muscles
25:05 – because nderneath that angry tissue is thick muscles that really get tight and tinder
25:10 – like if you put your hand on a hot stove your muscles are gonna pull away So you need often a physiotherapist
25:16 – to really help you work on those muscles and do rehab, it’s rehab. And we don’t think of it like that.
25:22 – Melissa: Yeah it makes sense so. A lot of people in our community are seeing a physical therapist. So that’s something that a lot of people… Dr. Rubin: YEAH!
25:30 – Melissa: And we also have interviewed a few of them our channel. There are a few questions around whether people who are oestrogen dominant
25:37 – or have endometriosis, can you still oestrogen therapy Dr. Rubin: Absolutely it’s a great question.
25:42 – they can certainly try and it will not… Remember when you use local oestrogen or DHEA therapy,
25:48 – it doesn’t go to your bloodstream. let’s talk numbers, people, cause I think numbers make people less scared.
25:53 – If you draw my blood right now depending on where I am in my cycle we’re going to talk pocigrams per mililiter
26:01 – Picograms is still what we do in the US. My oestragen level is going to be between fifty and a hundred and fifty.
26:08 – Just to give you an idea, fifty and a hundred and fifty. My husband oestrogen level is twenty-five.
26:13 – Ok? When I was pregnant with my kids my oestrogen level was about three thousand
26:18 – That’s pretty damn high, right? Like really high.
26:23 – When I go into menopause, my oestrogen level will be zero. zero, right?
26:29 – my husband will get to keep having more oestrogen than I will. Although, I doubt I’ll ever have my oestrogen get to zero, let’s be real.
26:35 – I’ll put a patch on myself but, but with endometriosis when you use vaginal hormones
26:42 – your oestrogen level stays zero in your bloodstream. You can check your labs, it stays zero. It stays in menopausal level.
26:48 – So if you’re oestrogen, if you have endometriosis and your oestrogen’s fluxuating between fifty and a hundred and fifty, if you add vaginal hormone
26:55 – it stays between fifty and a hundred and fifty it doesn’t change your oestrogen levels there is no reason to believe it will grow endometriosis
27:02 – or it will change endometriosis in any way. People with endometriosis trying to get pregnant, and their oestrogen are three thousand and it happens all the time.
27:10 – So I think there’s a fear of the word “oestrogen”, a fear of the word “hormones”. And you must understand that hormones are not all the same thing
27:18 – they’re not all good, they’re not all bad. If you’ve done badly with birth control pills that doesn’t mean you will do badly with vaginal oestrogen
27:25 – cause they’re very different. If an IUD wasn’t right for you, that has nothing to do with vaginal hormones.
27:30 – You have to understand that there’s a lot of nuance here. Melissa: There’s also a lot of misinformation around endometriosis
27:37 – which is part of the problem. Dr. Rubin: Yes, there’s a tone of misinformation but it’s 2022 and we have crap research, right ?
27:45 – Like we don’t have it figured out yet, PCOS. Endometriosis. So there’s so many people trying to make these giant claims
27:53 – without the data to back it up. And we must hold, we must hold our scientists accountable,
27:59 – and say we need good data, because there’s a lot of people pedalling not real stuff out there.
28:04 – Melissa: That’s definitely true. For people that don’t want to use oestrogen therapy are there non-hormonal produced
28:11 – to vaginal dryness that you can suggest? Dr. Rubin: I would try to convince them, I will always try to convince them that vaginal hormones are good for them
28:17 – because they can’t find a data point to tell me that they’re dangerous I always incourage them follow my social media,
28:23 – watch what other eople are saying, there is no give it a try and change the modality,
28:29 – vaginal DHEA is a great choice. DHEA, you can get it at any supplement center
28:36 – you can see DHEA it’s a quote-on-quote supplement, right? We have an FDA-approved option, which is just called a supplement
28:43 – put it in your vagina, it’s a precursor hormone, right? It’s the precursor to estrogen and testosterone. so DHEA would be great option for that person
28:50 – who’s afraid of the word “oestrogen”. Now moisturiser with hyaluronic acid has been looked at in the breast cancer community
28:57 – Their data is pretty good I haven’t seen any data to say that it prevents UTIs,
29:03 – but I’d love to see that data. I haven’t seen your perfect pH data to stay that it comes down
29:08 – Maybe it exists. So moisturisers and lubricants are nice band-aids.
29:14 – I like to fix the problem with vaginal hormones, but the band-aids are acceptable as well
29:19 – if you’re really unwilling. But I ‘m not sure if it’s gonna fix the problem. Melissa: Ok.
29:24 – Does hormone replacement therapy address the vaginal dryness? Or is that kind of… Dr. Rubin: You’re asking the best questions ever.
29:31 – So hormone replacement therapy, so hormones for your all body. So say you’re menopaused you have hot flashespack, night sweats,
29:37 – brain fog, you just feel awful, you’re not sleeping and your doctor said “ok, hormone therapy is going to fix all of this.”
29:44 – and they give you a patch and they gave you a natural micronized progesterone a pill.
29:50 – and they say “ok, this is gonna fix all of that.” I still think that that patient should be seriously screened for and treated for
29:58 – the genital and urinary problems because often the patch is not enough to get to the vaginal tissue
30:05 – So for some people it’s enough but I’m very very quick to add the local therapy
30:10 – because it doesn’t add any extra risk or any extra harm. and I know it will prevent UTIs.
30:16 – So that is a really good question. Melissa: Do you think everyone post-menopause should be on both HRT and local oestrogen?
30:24 – I would never say everyone should be on everything. I think the reason why I love my job so much
30:31 – is because I get to spend time with people and really hear their story, their fears their histories and medical problems
30:37 – and I get to use what I know about Medicine, biology and physiology and Psychology and I get to say “ok this is what
30:44 – “with all the data that I know in 2022,” “this is what I think make sense for you, let’s talk about it,”
30:49 – “here’s data, here’s Literature and let’s decide together.” I think that’s hormone therapy in menopause
30:55 – is incredibly underused, and there is a lot of fear mongering and I think people in the UK are doing a Kick-Ass job
31:02 – of getting the word out and being angry and picking in a street I wish I could come picking with you
31:07 – I’m so proud of what people are doing in the UK because they’re getting mad and they should be.
31:13 – I would love to see this happen in the US, but it’s kinda slow.
31:18 – I think way more people should be on hormones than are currently. But do I think it’s a one size fits all?
31:25 – It is so far from one size fits all. The problem that we have in the US is our doctors are not trained how to properly do menopause care.
31:33 – There’s some data that show that 7% of doctors actually feel like they know how to do menopause care
31:40 – So I feel very lucky that I do. But there is one of me, right? We have to really do a lot of teaching and training
31:46 – because a lot of people don’t do it well and don’t know how to do. Melissa: Yeah, a lot of people report
31:51 – being taken off HRT for something, for a blood clot or for some other kind of illness
31:57 – In general would you say that people should remain on it for the rest of their lives? The type, so the answer again I can’t say that it
32:05 – this answer applies to everyone in all situations. The type of hormone matters.
32:11 – So oral oestrogen therapy is much higher risk for blood clots and strokes
32:17 – and it’s also worst for sex functions, so I’m not a big fan of oral pills for oestrogen.
32:23 – Now Transdermo products seem to be much safer for blood clots and strokes
32:28 – a patch, a ring, a gel seems to be much safer. I certainly, it’s all about counselling and it’s all about…
32:37 – Gosh, I’m a urologist! We deal with men’s sexual health all the time! Men and quality of life, it is a giving.
32:43 – When a man says “I don’t want to have this prostate cancer surgery “because I want to ejaculate”
32:49 – Our fields is “Alright cool! We’ll just watch you! Your body your choice.” “You do whatever you want and we are supportive of that.”
32:56 – That’s the world I was raised in Now I’m in the women’s health space and I see men about fifty per cent of the time
33:01 – And I do the same thing I say “Ok, here you have this history” “here’s the data we know here’s what we don’t know,”
33:07 – “certainly there is some uncertainty.” “But you know what? it’s your body your choice.” “Let’s make the best informed decision that we can together.”
33:15 – “and you get to choose.” You can never go wrong in that situation, right?
33:20 – like it is long as you’re well informed Now that we get more data, more data comes out we analyse it and then look to it and change our opinion
33:27 – Yeah, but we have to be able to adjust to new information and demand new informations, which is the most important thing.
33:34 – Thanks so much for watching. Hope you enjoyed the video. To learn more about this and related topics,
33:39 – be sure to check out our other videos or head off to liveutifree.com We have some really important articles related to this topic.
33:46 – For instance, we have one on UTI and menopause and one on UTI during pregnancy. We also dropped those in the description below.
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33:58 – thanks again for watching, And until next time, keep asking questions and pushing for better solutions.