00:00 – Dr. Hlavinka: An increased risk of infections tend to happen at the time of the first menstrual
00:03 – period, the time of becoming first sexually active, the first pregnancy,
00:08 – obviously perimenopause and the menopause. There’s always a spike in infections at that time.
00:26 – Melissa: Today we’re talking with Dr. Tim Hlavinka, and I wanted to ask you first if you can give us a
00:30 – little background about your professional career and how you became interested in women’s health?
00:37 – Dr. Hlavinka: Thank you, Melissa and welcome. I began my urology career 30 years ago. Board certified in urology
00:46 – in the U.S. since then. I’ve always had an interest in urinary tract infections just because I
00:51 – had an interest in microbiology in my undergraduate and graduate studies.
00:57 – I’ve always been fascinated by infections and microbes so it was natural for me to be
01:03 – able to select this as part of a subspecialty when I got into urology. And secondarily I did
01:09 – reconstructive surgery and urology for about 20 years, doing over 200 major reconstructive cases.
01:16 – All of those patients, almost all have complicated urinary tract infections. And indeed
01:23 – with that population starting out as young as age nine when I operated on them, now my oldest patient
01:30 – in that practice is 31 and has had a baby. I needed some answers for infections. I was
01:37 – the go-to person for complicated infections since all of my patients had complicated infections.
01:44 – Then that started encompassing pelvic floor issues, incontinence, hormone related
01:51 – urinary tract infections. When I saw the fact that we couldn’t help most women prevent infections
01:58 – and it was simply a hormonal deficiency then I began to become interested in women’s health
02:04 – and women’s sexual health because of the frequency of sexually related infections in women. So I
02:11 – started my career as a female sexual health and women’s health specialist in 2003 and I’m a
02:18 – member of the International Society for Women’s Sexual Health and a fellow of that organization.
02:24 – It’s a very good organization that’s multi-disciplinary and absolutely non-biased
02:31 – non-biased by pharma and unbiased by patients. So it’s a very good resource for information,
02:38 – much like the North American Menopause Society and I believe it’s called the European Menopause Society
02:43 – that version of that. So because of that specialty and subspecialty, pretty much infections have been
02:53 – a big part of my practice forever. And the frustration at not being able to eradicate
03:00 – an infection and lately the frustration at not being able to even identify if something, a given
03:08 – set of symptoms, came from an infection, has been a part of the sort of chronic irritation in my
03:15 – white doctor’s collar for forever. And so because of that I have always explored new ways of
03:23 – detecting and treating infections and have been open. When you’re the buck stops here type doctor
03:29 – you don’t get to say well go see somebody else. You’ve got to look at alternative therapies, you’ve
03:34 – got to look at contributing factors, you’ve got to look at any information that’s going to give
03:38 – you an answer for your patient. And that’s why I’ve evolved to where I am now with the next generation sequencing testing.
03:47 – Melissa: Well that’s excellent because we’ve collected a couple of hundred questions from
03:49 – our audience and I thought we could just start with the hormones and hormone replacement therapy
03:53 – angle of recurrent UTI. And so if you don’t mind I’ll just start asking you some of the questions that our audience submitted.
03:59 – Dr. Hlavinka: Absolutely.
03:59 – Melissa: First maybe you can talk about whether there is a link between hormones in recurrent UTI in premenopausal and post-menopausal women?
04:10 – Dr. Hlavinka: Yes, there is definitely a link there is a link at all,
04:15 – all the spectrum of the hormone life of a woman. We know that infections tend to happen, I should
04:21 – say an increased risk of infections tend to happen at those milestones hormonally in women. At
04:27 – the time of the first menstrual period, the time of becoming first sexually active, the first pregnancy,
04:32 – obviously perimenopause and the menopause. There’s always a spike in infections at that time.
04:38 – So clearly the observation that hormone fluctuations has something to do with a woman’s
04:43 – susceptibility to infections has been information we’ve known for 70 years. But we really didn’t have
04:49 – a means of treating it. And that sometimes is not a deficiency as much as it is a fluctuation in the
04:58 – hormone level, particularly when a woman is cycling or coming off a pregnancy when she has
05:04 – estradiol levels of 5000 and they drop down to 30 for instance if she is breastfeeding. So
05:11 – these are the kinds of things that we see. And so I would answer the question,
05:15 – is there a link between HRT and I should say between hormones and those phases of a woman’s
05:22 – hormonal life? Absolutely. absolutely. And we can get into all the details of why that happens later on.
05:27 – Melissa: Okay. So you said there is a link between hormones and UTI and then you mentioned
05:33 – briefly HRT and UTI. Maybe you can explain that link a little more?
05:37 – Dr. Hlavinka: So you can see someone getting better with hormone replacement therapy. Alternatively, a rare woman will get worse
05:48 – simply because the microbiome is upset by a different set of hormones that her tissues are
05:55 – used to seeing. And so I try to tell patients that when you’re coming in with hormonal issues, let’s
05:57 – say the most common one would be the perimenopause. A woman’s 49, starting to have irregular periods,
06:08 – starting to have maybe some other symptoms of menopause like hot flashes or sleep disturbance,
06:14 – low libido, all sorts of things like that. Vaginal dryness, well that’s a sign. That’s
06:19 – the canary in the coal mine that menopause is imminent. My problem is that my colleagues
06:24 – wait until somebody’s had their last period for 12 months to call them menopausal. Well, it’s
06:30 – an epidemic now, Melissa, of early perimenopause. I just started a 39 year old on full hormone
06:38 – replacement therapy. She has both ovaries, never had any other kind of issues, no sickness, chemo, nothing
06:45 – and she’s full-blown menopause at 39. It is not uncommon at all and we will get
06:51 – I think the question – I may as well take it right now because there’s a form about the contraception.
06:56 – It is not at all uncommon for very young women when they’re taking strong and even lower dose
07:04 – oral contraceptive agents to have a profound diminishment in their estrogen. The
07:08 – contraceptive gives your body enough estrogen to fool it into not ovulating but not enough to have
07:15 – nearly what you need for estradiol replacement and progesterone replacement at that phase of
07:20 – your life. And so the common practice in the United States and throughout the world I’m so
07:28 – told is to give these low-dose oral hormones (and we’ll get into detail why that’s really bad) at the
07:34 – time of the perimenopause just to kind of calm down symptoms. It’s the worst possible thing you
07:39 – could do because the oral hormones are the worst form and they actually exacerbate
07:45 – many of the problems of the perimenopause. So my youngest who came in on oral contraceptives
07:52 – since age 14 was 21. Full-blown menopause at age 21. I mean, not just vaginal dryness but she
07:59 – had vaginal atrophy that you couldn’t get even a pinky finger in her vagina at age 21.
08:06 – It took me 18 months of aggressive hormone replacement therapy and vaginal dilation
08:11 – and stimulating her ovaries to get her back. And she did call me and tell me
08:15 – that she had a healthy baby at age 27 so I’m really satisfied with her, but it is not at
08:20 – all uncommon to see full-blown menopause at age 35. Mark my words, take this to your providers – if
08:26 – they’re not aware of this, they need to be. There are seven percent of women – in one out of 14
08:32 – there is actually a genetic alteration on the androgen, the male hormone receptor, that
08:39 – makes you susceptible to premature menopause from as short as
08:45 – six months on the pill, all right. And it doesn’t matter if it’s low dose, high dose.
08:50 – So there’s that group of women that are going to be on the pill for six months and they’ll never
08:55 – be the same. Their hormonal trajectory throughout life will be downward and they will be the ones
09:01 – that come in at age 35 already complaining of menopause.
09:04 – Melissa: Is it possible to look for that gene before going on birth control?
09:08 – Dr. Hlavinka: I keep trying to get my colleagues with how inexpensive it is to create genes these days, why hasn’t someone? That should be a panel of
09:16 – every woman who comes in for her first pap smear or first pregnancy test, so yes i will bring that up
09:24 – again. I’m glad you said that because if it’s patient driven sometimes they’ll listen.
09:29 – It can’t be a cost factor anymore. So that is something I think that women
09:35 – need to be recognized and be proactive because so many women’s health providers are so happy
09:42 – that women have control over their reproductive processes that they’re willing to take
09:48 – the side effects so to speak. And in the past when that was predominantly male providers,
09:53 – I can see how awful that is, but that is across the gender spectrum in medicine providers, I just
09:59 – believe it’s just so easy to give a woman a pill and not worry about it and not worry about the
10:03 – detritus that may happen afterwards genetically, or physiologically. So that’s my take on that.
10:09 – Melissa: Okay, when it comes to people who are menstruating and are not on birth control, can
10:14 – you explain more the mechanism of infection that happens at certain times of the cycle?
10:20 – Dr. Hlavinka? So you have your peaks and valleys during the menstrual cycle. You have your phase where
10:27 – the uterine lining is being built up. You have your pre-ovulatory phase where there’s a surge
10:33 – of testosterone and estrogen, and that of course is when there’s less susceptibility to infections,
10:40 – simply because everything’s all protected. But of course that’s when the woman has intercourse,
10:44 – and so sometimes that’s when she does get them because she may be ovulating or periovulatory.
10:49 – And then you have a rapid decline with the menses and the menstrual bleeding
10:54 – and you get a low ebb of the hormones at that time before you build back up. So at both of those
11:00 – time frames, just because she’s more likely to be having intercourse because of the higher libido
11:09 – associated with ovulation, and at the other part of the cycle where the hormones are low.
11:11 – And you can actually have subtle changes in the physical chemistry of the vagina.
11:16 – The microbiome changes over the menstrual cycle and thus the susceptibility to infections does.
11:22 – Same thing with the vaginal epithelial layer. The vaginal lining layer
11:26 – undergoes profound changes throughout the cycle, becoming more sensitive and susceptible
11:33 – at the low ebb and less sensitive and susceptible at the higher. But again you have that confounding factor of if she’s having intercourse, okay?
11:41 – Melissa: We do hear from a lot of people that say they experience UTI symptoms right before their period.
11:47 – Is there anything that you can do to kind of stop that from happening?
11:51 – Dr. Hlavinka: It is possible to prevent the infections or the
11:54 – bladder irritation that happens right before a woman begins her cycle. I tend to do non-hormonal
12:01 – approaches to that and more practical ones. To take more aggressive doses of probiotics
12:06 – during the three or four days before your menstrual cycle will happen – the bleeding
12:13 – portion of the menstrual cycle. Sometimes you can take some of the urinary antiseptics and
12:18 – things like Cystex or Mandelamine to kind of prep the bladder to not get
12:25 – infected. Also, being very careful about avoiding any sort of irritants, vaginal irritants
12:33 – and things like that. You know things like spermicides or any sort of douching or something
12:40 – like that. Be very careful about the cyclical changes that happen, to prevent the irritation that might happen at that time.
12:47 – Melissa: One other question on that topic then: If it is a cycle of hormones that is causing this irritation is it necessary to treat those symptoms or will it cycle back up?
12:56 – Dr. Hlavinka: I would say that it is not necessary, it just depends on the bother. That’s a difficult one to
13:02 – categorically answer, Melissa. I would say if it’s really bothersome and a woman’s worried that she
13:08 – may have urinary tract infection and feels like running to the provider to check a urine every
13:13 – time and that becomes an issue, then I would be more aggressive. Otherwise, in my opinion, we say
13:22 – in urology the solution to pollution is dilution – lots of water and things like that.
13:27 – Melissa: What are some of the indications in perimenopause and menopause that hormone replacement therapy may be beneficial?
13:35 – Dr. Hlavinka: My opinion is that symptoms are the most important thing. And I cannot get my colleagues to understand
13:46 – how in depth a hormone deficiency may be and how much risk that puts a patient in,
13:58 – because it is not treated and not treated aggressively
14:03 – So when it’s something like recurrent urinary tract infections and we have options,
14:08 – it’s easy to kick the can down the road and put a woman off
14:13 – when the background may simply be hormone replacement therapy. I should say, the background
14:18 – therapy should be hormone replacement therapy. Much like if you’re trying to paint a wall. If you
14:24 – don’t put a primer layer on you’re not going to get the paint to stick. And then none of the
14:28 – other therapies will be effective. So having said that, I am constantly almost universally surprised
14:36 – at how little in depth my providers, my colleagues that do women’s health go into detail about what
14:43 – might be menopausal symptoms. For instance, unless they’re just having full-blown hot flashes
14:49 – and miserable night sweats, they ignore them. Well, for me a loss of vertebral, a loss
14:56 – of a half an inch, well she’s probably got osteoporosis and nobody’s done a DEXA scan.
15:01 – Vaginal dryness, well, that means that she’s had a hormone deficiency
15:05 – in her vagina that’s going to put her at risk for trauma during intercourse and
15:09 – recurrent urinary tract infections for at least a year once you first start noticing dryness.
15:13 – The other thing, it’s just a change in skin. Estrogen is, I should say, a woman’s skin is so
15:20 – sensitive to estrogen levels and just coming in and saying my skin is dry doctor it really
15:26 – just doesn’t look the same to me. Those are the subtle signs I’ve seen over the years.
15:31 – At least measure. And sure you can say you’re perimenopausal, there’s nothing we can do. That’s
15:37 – the most incorrect thing that’s possible. It’s just hard to treat a woman when she’s perimenopausal
15:42 – and so nobody wants to do it. Or they want to give them the pellets that we’re doing so
15:48 – much in the United States here, where you know everybody’s getting these pellets in their rear
15:52 – ends and they’ve got super physiologic hormone levels and they’re happy but nobody is looking
15:59 – at the long term. Now that may be a good thing. Maybe these women are going to be better off as
16:05 – they age with the higher levels but we just don’t know that and so individualizing
16:12 – a woman’s evaluation and individualizing a woman’s therapy are the absolute essentials if you’re
16:20 – going to do women’s health. You just can’t do it any other way and to think you can
16:25 – do it effectively, to do it ‘my way’? That doesn’t work because almost always ‘my way’ isn’t her way.
16:31 – Melissa: I 100% agree with that. So is it possible to reduce or eliminate all symptoms of menopause and should you even aim for that?
16:40 – Dr. Hlavinka: It’s a very good question. Well, I would say that depends on the woman, because some of them absolutely insist
16:46 – on that and others are okay with changing the sheets every night because they sweat through them.
16:55 – I believe that a woman should not suffer with the symptoms of menopause. That is an indication
17:00 – that the estrogen deficiency is too profound.
17:04 – And again unless we’re doing things like bone mineral density and looking at subtle
17:09 – signs of estrogen deficiency, you don’t know the long-term impact. But my opinion is also that what
17:12 – if vaginal dryness and pain on intercourse and recurrent urinary tract infections is a trigger
17:21 – and a canary in the coal mine, as I said, for estrogen deficiency elsewhere that you don’t see.
17:28 – Maybe that’s brain and protection for cognitive decline. Maybe that’s bones, maybe that’s skin, maybe
17:34 – that’s all sorts of other tissues that have more need for estrogen. Because I can tell you I had
17:42 – women come in at age 38 and have osteoporosis and they look 28, and that’s the only part of
17:48 – their body that needs more estrogen. The rest of it isn’t going to need estrogen for 20 years or more.
17:53 – And so if we don’t look at those women we’re not going to find the kind of key components of the
17:59 – menopause transition that may need to be treated 10 years before menopause for instance now. And in
18:05 – fairness, we don’t have a lot of markers for that. We we need more work in that area to
18:10 – look at some biomarkers and things like that would help us to predict in these women – much like that
18:15 – androgen receptor for use of the pill. Those are the kinds of things we need to have developed.
18:21 – Melissa: Can you explain a little bit more what hormone replacement therapy typically looks like? Is it a balance of hormones or is it a single hormone? is it different for everybody?
18:31 – Dr. Hlavinka: It should be different for everybody because not every woman needs the same. To be specific we should go into
18:37 – pre-menopausal, full-blown menopausal and with and without a uterus because those are four major
18:44 – categories of therapy. And the easiest woman to treat is a post-menopausal woman who
18:50 – has had a hysterectomy because then there really is not a need for progesterone. That’s very,
18:56 – very controversial. There are some that find that progesterone is essential for things such as
19:03 – mental health. For instance, a woman that has post-menopausal headaches, I almost always include
19:12 – progesterone because it does have sort of a neural calming effect. There are women who
19:17 – have sleep disturbances that the progesterone helps for. Certainly there are women who
19:24 – need progesterone but to say, like a lot of my colleagues, that every woman needs progesterone
19:28 – no matter what I think, that’s treating them their way and not the way the patient needs it.
19:33 – Because let’s face it, progesterone is the one that kind of makes you bloat and gain
19:37 – weight. And the fluid retention and the kind of lousy symptoms, that sort of premenstrual
19:43 – syndrome symptoms of you know feeling bad and the mood changes – progesterone is all part of that.
19:48 – Melissa: How safe is it to be on HRT? Can you take it long term or should you try to taper it off at some point?
19:55 – Dr. Hlavinka: So the whole notion that the shortest amount for the, I should say, the lowest amount for the
20:02 – shortest time to treat symptoms, that was once again – and hopefully we have learned
20:09 – in the modern post-COVID era that scientists and doctors are full of policies – they like
20:17 – to parade them as science but they’re full of policies and that was a policy by the North
20:22 – American Menopause Society based on a study. The women’s health initiative that scared the heck
20:26 – out of everybody. That study was preeminently flawed. It was one of the most profoundly
20:34 – damaging events that happened in the long history of sordid issues and treatment of women and
20:43 – women’s health. So to undo the damage, that’s taken about 15 years. So I have 88 year olds
20:51 – who wring me by the neck if I don’t refill their hormone replacement therapy and I have younger women
20:56 – who have difficulty with HRT. Perhaps there’s a side effect that’s bothersome
21:01 – or we just can’t quite get the levels right and they elect not to have it. But what is known and
21:08 – what is clear is that within the first two years of menopause and for 10 years, and again if you
21:14 – have menopause at age 42 this is not the same as a woman’s average menopause at age 51, you need
21:21 – to continue that for 10 years afterwards. There’s clear data that the hormones are physiologically
21:26 – protective during that time frame. And again, let’s look at medical studies. Medical studies don’t take
21:31 – a woman across the spectrum. They cut you off at 49, at 59, at 69, at 79. So the whole data is
21:41 – linked to decades of life, but you don’t have a magical change between 49 and
21:48 – 364 days, and you know, 50 and one day, all right? That doesn’t change that fast. So
21:55 – we have to think. And we have to think about that, and so for a lot of women
21:59 – I think it’s lifelong and it should be because there’s going to be a good
22:03 – cardio protective event – there’s going to be cardio protective aspects of it. There’s going to
22:09 – be bone density, mental capacity, muscle maintenance, all of these things for a woman. I think it’s
22:16 – important to continue that on. And we don’t really have an answer. We do know that in the first decade
22:21 – afterwards for instance, that it is protective. There is actually a lower incidence of breast cancer
22:25 – in women who took it – lower. I didn’t say equal, I said lower. And again, you can’t say that
22:33 – hormones are safe and you’re not going to get breast cancer. It takes me 20 minutes of history,
22:40 – just history, (and that doesn’t involve laboratory exam) and discussion. My appointments for a woman
22:46 – to start hormone replacement therapy are twofold. The original one to get the information for 45
22:51 – minutes and the second one for an hour and 15 minutes, to be able to decide what therapy she
22:55 – needs safely and to discuss the side effects. So I take two hours with these women to find out
23:01 – what they need and you can’t do it in any shorter than that.
23:04 – Melissa: We did receive a question about newer types of hormone replacement therapy, so bioidentical hormones, patches and creams and
23:12 – other things that are coming onto the market. Do you see that those are actually safer or more effective than more conventional types?
23:18 – Dr. Hlavinka: In my lectures on hormone replacement therapy
23:23 – I have a big slide that says all these terms and basically attacks them.
23:34 – The most important thing is to have a bioidentical hormone. The closer that little molecule,
23:43 – that estradiol, that progesterone, and that testosterone, the closer that is physical
23:48 – chemistry wise to a woman’s own hormones, the safer and the better and the more effective it is.
23:54 – And the reason is, is that all hormones get changed in the body. They get metabolized primarily in the
24:00 – liver and the breakdown products are some of these. For instance Premarin.
24:04 – Premarin is the worst possible one we could possibly have and you know where that came from?
24:09 – Pregnant mare urine. Wasn’t that real clever? That’s where Premarin comes from – pregnant mare urine.
24:14 – So that in and of itself is such a sexist term. Oral Premarin is the scourge of my existence
24:22 – and makes my job very hard. But to say bioidentical, okay, how do you get bio-identical?
24:30 – Natural, so natural comes from natural sources. That would be the pregnant mare’s urine. All right, so
24:39 – Premarin could be natural but it is certainly not bioidentical. You can get estrogen and progesterone
24:45 – and testosterone from yams and you can get it from soy and you can get it from other products,
24:51 – but you have to go through a chemical degradation project, I should say, you have to go through
24:57 – a chemical degradation process to get it to its forms that you can make it into something that
25:02 – can actually be safely used by a woman in a cream or a pill. But by and by, the fact that
25:10 – something happens when you swallow a pill, and even the sublingual, and even the dissolve in your
25:15 – mouth troches – those have some first passage effect through the liver and creation of metabolites that
25:22 – we don’t understand and we can’t measure that are certainly behind a lot of the complications. The
25:29 – blood clots, the weight gain, the liver issues and what I’m convinced of, the higher
25:36 – incidence of breast cancer. All of those things are because of the metabolites that go there. So
25:41 – definitely in the vagina and on the skin are safe and a cream and a patch is much better. Whether or
25:46 – not pellets is okay and safer I don’t really want to get into the weeds of that one, but a lot
25:52 – of people are getting them and done by the right provider they are safe. My parent organization
25:58 – would say that’s controversial and I will say I agree with them, it’s controversial. But many people,
26:04 – many good quality providers, including myself, use them.
26:07 – Melissa: Okay, and someone did ask whether it’s safe to use an estrogen cream on a daily basis, long term?
26:14 – Dr. Hlavinka: If we’re looking at an estrogen cream in the vagina and on the external genitalia this is a good place to segue into one aspect of that.
26:24 – And one of my pet peeves and how it’s given. Yes, it’s safe to use for the lifetime. Many women
26:29 – have to. I have many women, who if they stop their estrogen cream for three weeks, UTI, incontinence,
26:36 – vaginal dryness, comes right back. So for some women they can build up their lining layers – so let’s
26:42 – talk about the vaginal creams first. And again, all are the same from the standpoint, the vaginal
26:47 – troches, vaginal suppositories, the little pills like Vagifem and things like that. Although,
26:53 – Vagifem is so weak these days. It used to be 25 micrograms, it’s now 10 micrograms, so honestly,
26:59 – you should be taking it every day. But three times a week, one gram deep in the vagina, of estrogen
27:06 – cream is the right way to do it and then a second half a gram spread on the external genitalia
27:11 – and the urethra. They’re actually are, deep in the vagina, predominantly estrogen receptors. As you get
27:19 – to the mid-vagina and even the external genitalia, testosterone, androgen receptors become more common,
27:26 – and those androgen receptors are very important. Now, most women that are getting
27:31 – testosterone replacement get enough to satisfy the receptors in the vaginal and genitalia area.
27:38 – The clitoris for instance is 100 percent testosterone sensitive, almost 100 percent
27:44 – androgen receptors. And that’s why it can be a side effect of testosterone replacement therapy in
27:50 – women, is clitoral enlargement. But I think many providers don’t realize that, and they tell them
27:54 – to smear it on the external, take a half a gram and put it on your urethra at bedtime.
27:58 – Well that’s worthless. Number one, it’s going to wash off. Number two, you’re gonna urinate the next
28:03 – time and wipe it off. If you don’t put it deep in the vagina where the estrogen receptors are, you’re
28:08 – not going to capture it and it needs to be done at least three times a week, one gram, and a half a
28:12 – gram of external genitalia. Whether or not you need a combination of estrogen and testosterone cream,
28:18 – which I use in a lot of my patients when they’re really not getting the responses.
28:23 – Again, some women are more susceptible. Some women don’t need the testosterone portion of it. Some
28:28 – of them are exquisitely sensitive to a lack of testosterone in the external genitalia. They
28:33 – need it to maintain external genitalia health.
28:35 – Melissa: Okay. So there is a question on vaginal atrophy and the rejuvenation procedures.
28:41 – Can you comment on that and maybe give us a bit more insight into how they work or don’t work?
28:46 – Dr. Hlavinka: The first thing I do for a woman when she comes to my office, because I do those treatments, is
28:52 – I do the radio frequency device. I also use the platelet-rich plasma, the so-called o-shot, which yeah, it does work. It does work for that.
29:02 – And a lot of women love it, but the first thing I do when a woman comes to me for a consultation
29:07 – is I take a history about hormone replacement therapy and about menopause in her family
29:15 – history. Do women have early menopause? How about vaginal dryness? Pain on intercourse? Do you need
29:20 – lubricant? You know the problem with lubrication is that the quantity of lubricant may be fine for a
29:28 – woman, even a woman many years after menopause they are responding to the sexual response by creating
29:35 – a lubricant, but the quality of it decreases. So clearly the relationship between adequate estrogen
29:42 – levels and the quality of lubricant and therefore the protective aspect of that is as much less as
29:49 – a woman gets older. So having said that, the most important thing to recognize is that continuing to
29:57 – do that is important. It’s very important that if you’re going to have a rejuvenation procedure
30:04 – that you have adequate vaginal estrogens and unless a woman’s under 40, I pretty much give them
30:10 – six weeks to three months of vaginal estrogens and tell them to come back. Many times they’re happy
30:15 – with things, but afterwards it makes me more successful because those are healthier
30:22 – tissues and my vaginal rejuvenation is going to work on healthier tissues.
30:27 – Melissa: That makes sense and the particular one that a lot of people mention is the Mona Lisa. Can you comment on that?
30:33 – Dr. Hlavinka: Unfortunately, in the U.S. there was a moratorium put on these devices.
30:40 – There was a black box warning. Seven companies got named. The company that has my machine, that sold me
30:47 – my machine, does too and that was a real problem because it’s an extremely safe device.
30:53 – We vetted it for months. We did trials. We tried the Mona Lisa, we tried the cynosure laser.
30:59 – We tried our device. I’m not going to
31:04 – say companies. I don’t want to say who’s better or who’s not, but the bottom line is that you have
31:10 – to individualize. The problem with this, is the laser is very superficial and for women who have genital
31:17 – urinary syndrome and menopause or vaginal atrophy, it does work well for that, but in my opinion it
31:23 – did not treat the deeper layers as effectively. And indeed, the ThermiVa
31:30 – device, same thing, it just wasn’t that strong. Now, there may be devices on the market that are
31:35 – superior now, both laser and non-laser devices. The bottom line is that you need to deliver energy
31:43 – to the tissue to create the kinds of changes in the architecture and if you don’t deliver adequate
31:49 – energy deep, you’re not going to get any benefit from it. So I’m not a big fan of the Mona Lisa.
31:54 – Melissa: Before we leave the topic of hormones and hormone replacement therapy, I just wanted to ask around
31:59 – different forms of contraceptives. You’ve kind of touched on the fact that a
32:04 – hormonal contraceptive could be linked to recurrent UTIs, just because of the
32:08 – change in hormones, but what about devices like an IUD, whether it has hormones or not?
32:13 – We’ve actually heard from quite a number of people over the last few years that associate the onset
32:17 – of their recurrent UTIs with the insertion of an IUD. Do you see that, and do you have an explanation for why that could happen?
32:24 – Dr. Hlavinka: I see it weekly, at least weekly. I guess that makes it
32:29 – pretty possible if I see it weekly. I think, like I said, when there’s any changes in a woman’s
32:36 – architecture, that can change the microbiome. Perhaps there is a difference in the excretion
32:43 – from the cervix and that subtle change, I mean these are exquisitely sensitive environments,
32:50 – micro environments, and under those circumstances it doesn’t take much to change.
32:58 – I have seen that whether it’s a hormonal or non-hormonal IUD, in just the placement. I’ve also
33:04 – had a lot of women who get off the oral hormones and that’s been the best thing for them because
33:09 – they don’t have the estrogen suppression and they finally get healthy tissues. So I would say
33:15 – it again has to be tailored. There’s not a perfect solution for women, unfortunately.
33:20 – Some will have problems with the IUD, some will have, certainly many will have problems with the pill.
33:24 – And under those circumstances it’s individualization. The non-hormonal IUDs
33:29 – are preferable simply because the hormones that they elute, even though they’re safe and
33:34 – they’re absorbed into the vagina, I should say in the uterus from the vagina, I should say
33:39 – they’re directly absorbed in the uterus, they’re still a micro environment. There’s
33:42 – still a circulation around there where the pelvic circulation gets affected. And so you just can’t
33:48 – say. And there’s pretty good data to show that the Mirena can affect hormone levels too.