00:00 – Dr. Kumar: A lot of the the urinary symptoms, or even some of the systemic symptoms like
00:05 – lack of sleep, irritability, may start happening during perimenopause.
00:24 – Melissa: Maybe you can explain what we should expect, hormonal change-wise, as we age. What is healthy and what isn’t healthy?
00:30 – Dr. Kumar: Well, I think that most women don’t appreciate the fact that in the 10
00:38 – years prior to menopause you go through something called perimenopause and during that time
00:44 – you may have periods of time where your estrogen levels surge and you may have periods of
00:48 – time where your estrogen levels are much lower. And so a lot of the urinary symptoms or
00:55 – even some of the systemic symptoms like lack of sleep, irritability, may start happening
01:01 – during perimenopause. I see a lot of women who never got urinary tract infections
01:07 – and then suddenly around age 45 they’re getting post-coital UTIs and they’re saying, well
01:13 – this never happened to me before. And I think that those changes are actually
01:19 – starting before you go through that menopause transition, which is defined by
01:25 – when you don’t have a period for one year. And so a lot of women aren’t expecting that
01:32 – before they actually go through menopause, they may start experiencing some of the manifestations
01:38 – of the fluctuations in estrogen. The other thing when it comes to genitourinary syndrome of
01:45 – menopause is that a lot of women will say, oh but you know I went through menopause 10 years ago.
01:51 – The transition is what we associate with things like hot flashes or
01:57 – irritability or those other systemic symptoms but when it comes to the genitourinary syndrome of
02:04 – menopause, that actually progresses over time. So the vaginal dryness, the vaginal irritation,
02:12 – some women feel itching, some women notice severe pain with intercourse like
02:19 – razor blades. Intimacy is very difficult
02:23 – and so I think it’s important to recognize that the vagina needs estrogen. And
02:33 – unfortunately, when the women’s health initiative study came out in 2002 everyone became really
02:38 – afraid of estrogen and it’s so important to recognize that using local estrogen, I mean this is
02:45 – like your multivitamin for the vagina. Using local estrogen is not the same as taking
02:54 – hormone replacement therapy. When you take hormone replacement therapy you’re really
02:59 – increasing your blood levels of estrogen, basically back to like a pre-menopausal woman.
03:06 – Hormone replacement therapy is beneficial in many ways for appropriately
03:10 – selected people but using vaginal estrogen is extremely safe. It’s not raising your
03:18 – blood levels of estrogen back to a pre-menopausal state and and there’s very few people
03:26 – who can’t use it. Even in women who are breast cancer
03:32 – survivors we’ll use a very low dose like Yuvafem twice a week if they’re
03:38 – having symptoms. In many women the benefits outweigh any potential risk.
03:46 – Melissa: Given those kind of symptoms start in perimenopause and it can be 10 years earlier, is that the time when you
03:52 – should start using some kind of estrogen therapy or do you wait until it’s kind of a definite issue?
04:00 – Dr. Kumar: I mean, I think that if you’re noticing that you’re starting to
04:07 – get urinary tract infections after intercourse or you never really had them in your
04:12 – life and now in a year you’ve had one or two, or you’re noticing that intercourse is
04:18 – slightly painful, you’re not lubricating as well, you feel any sort of increased awareness
04:26 – of your bladder or urethra. I do think that it’s beneficial to start it early. And you know
04:34 – if you have none of those symptoms then no, then it’s fine but I would sort of
04:40 – have a low threshold, like at the subtlest of symptoms I would say, okay start using it.
04:47 – Melissa: Is the dosage different depending on what the issue is that you’re trying to address? So if it’s
04:51 – for recurrent UTI is it different to if it’s just for dryness or itching?
04:57 – Dr. Kumar: Not really. What we’re sort of taught to recommend is like for example, if you’re using estrogen
05:04 – cream like estrase, that you use one gram every day for two weeks and then after that twice a week,
05:12 – I think that tends to be confusing for some people. And so in my patients I have them
05:18 – use it three times a week. In some women where I’m not seeing enough of an improvement,
05:24 – if a woman has really severe atrophic vaginitis I’ll say use it every day or every other day until
05:30 – I re-examine you. So I mean, I might change it based on what the exam looks
05:37 – like or how they’re responding but I usually start out with, I would say like a standard
05:42 – template of three times a week and that works really well for most people. There’s
05:47 – a lot of women where they’ll get prescribed estrogen cream by their gynecologist or
05:54 – urologist and they don’t have a sufficient conversation about it so when they
06:00 – get the tube it comes with the same warnings as systemic estrogen, so it’ll say like,
06:08 – may cause heart attacks, stroke, all this stuff, breast cancer, uterine cancer, and it’s really scary.
06:13 – So I think it’s really important to recognize that local estrogen is very safe um and
06:19 – there are no studies that show that it increases your risk of cancer or thromboembolic events
06:26 – and then I think you use it to the extent that it works. So some women
06:34 – might need to use it a little more often and some women use it two or three times a week, and that’s it and they’re fine.
06:40 – Melissa: How soon should you experience benefits from it if it is going to work?
06:44 – Dr. Kumar: That’s a great question and I think that that’s a reason why a lot of women stop using it.
06:51 – Because it’s actually changing the architecture of the cells in the vagina and
06:58 – the vaginal cells need to be rich in a substance called glycogen in order to promote
07:03 – the growth of healthy bacteria which is lactobacillus. And it actually takes about
07:10 – three months to change the architecture of the cells and if you stop using it then the
07:15 – effects go away. And I think a lot of women start those, they’ll use it for the first
07:21 – couple of weeks and they’ll say, oh this isn’t doing anything, and so they stopped using it. Or
07:26 – I see a lot of women who were told to use it because they’re getting
07:30 – recurrent urinary tract infections and then they say, yeah I stopped using it because I got a
07:36 – UTI, it didn’t work. And I think you have to really think of it, literally it’s the
07:43 – multivitamin for your vagina. It’s what you’re just going to use every day to keep the tissue healthy, to
07:48 – help promote a healthy vaginal microbiome. And you know it’s not something that’s like
07:54 – taking Advil or Tylenol, where you’re going to feel this immediate relief of symptoms. You have to use it over the long term.
08:02 – Melissa: And long term, does that mean basically for the rest of your life?
08:06 – Dr. Kumar: I think so, yeah, because I think where our guidelines tell us, use it for
08:11 – the shortest duration possible, but I see women where when they stop using it
08:15 – they develop atrophic vaginitis again and their symptoms come back. So I recommend
08:21 – continuing to use it. I tell my patients, look if you go on vacation or something and
08:25 – you don’t have the tube with you or there’s a lag between getting your
08:30 – script, like you go a few weeks or a month and you stop using it, it’s okay. But
08:36 – in general, once you stop using it over a long period of time, the same issue that you had
08:43 – before is probably going to come back. So it’s best to just continue using it with reasonable consistency.
08:50 – Melissa: Is the advice you give to women at this point of life different depending on
08:57 – whether they are or are not still sexually active?
09:01 – Dr. Kumar: Yes, because there are some women who I examine who have signs of atrophic vaginitis but they’re not sexually
09:14 – active, they don’t have symptoms from it. And if they have no complaints or issues
09:22 – then yeah, I would leave it alone. But if I see a patient where they
09:26 – are having irritative symptoms, they’re getting recurrent UTIs, or even in women who have stress
09:31 – incontinence and their problem is not necessarily pain, their problem is more like leakage of urine,
09:39 – I still use it because it really helps to boost a healthy collagen and vasculature
09:48 – around the urethra which helps support the urethra. So I think for female lower urinary tract conditions it’s important.
09:59 – Melissa: Okay. Are there circumstances where you would use testosterone or progesterone as a local treatment?
10:04 – Dr. Kumar: Testosterone yes. I think, you know we talked
10:09 – about women with skene’s gland irritation, I’ve actually seen a couple of cases of clitoral
10:17 – phimosis where I’ll use a combined estrogen testosterone with that and topical progesterone
10:27 – in the vaginal area. I use progesterone orally for women who are having
10:34 – issues with menopause and progesterone is really wonderful to help with sleep so
10:41 – I’ll prescribe it to take at bedtime in women who are having issues with sleep during or
10:46 – after menopause. And then the other thing that I like intravaginally is Intrarosa which is
10:54 – called prasterone, which is intravaginal DGEA and that’s like the steroid precursor to
11:01 – estrogen and progesterone. And that’s something that you use once a night for three months
11:07 – and I find that it works well. So it’s a suppository and the suppository also has
11:14 – a nice emollient, you know, the way they’ve formulated the suppository it actually acts as a
11:20 – nice moisturizer as well. So yeah, there are cases where I’ll use a little testosterone,
11:27 – and that’s something I have to have compounded. And then there are cases where I’ll also use the DHEA.
11:33 – Melissa: Okay. Another question on hormones, not so much to do with therapy,
11:38 – but a question comes up a lot – is it possible that this certain stage of my menstrual cycle
11:43 – is causing my UTI? Some people explain that they get a UTI every time they menstruate
11:48 – or every time just before or after, and some people say it happens only when they ovulate.
11:53 – Can you explain the link there and what might be happening with those people?
12:00 – Dr. Kumar: Well it’s interesting because I think that a lot of women develop urinary symptoms which are cyclical.
12:06 – And I think if it’s actually a urinary tract infection it may have to do with changes in the
12:13 – microbiome. Some women during menstruation, if they’re using a tampon or something like that,
12:21 – you can certainly get BV, bacterial vaginosis. You can get
12:28 – overgrowth of bacteria when there’s a lot of blood which is nutrient-rich in the vagina.
12:34 – And so I think symptoms, bladder symptoms can certainly be cyclical and if it turns out that it
12:41 – actually is a urinary tract infection then it most likely has to do with changes in the vaginal
12:48 – microbiome at that time that are making you more susceptible.
12:54 – Melissa: Are there certain symptoms that you look for that might indicate something else is the cause when it is cyclical
13:00 – like this, like endometriosis or another pelvic condition?
13:05 – Dr. Kumar: That’s a great question. So certainly yes, women who tend to have more pelvic pain urinary symptoms, and we
13:12 – talk about the fact that the culture, our urine cultures aren’t necessarily sensitive
13:18 – enough, but if you’re seeing for example, no white blood cells as well, on the urinalysis,
13:25 – then I think that’s an indication that it’s not necessarily an infection, that it could
13:31 – be something like endometriosis. The patient’s history, so for example,
13:38 – somebody who has an extensive smoking history, I’m very concerned that we
13:45 – have to do a cystoscopy and we have to rule out bladder cancer or carcinoma in situ,
13:51 – which can be the cause for irritative symptoms. And then of course, patients who have
13:57 – interstitial cystitis can also complain that their symptoms are worse based on where they are in
14:02 – their cycle. And also, I have a very low threshold to do a cystoscopy and
14:10 – see if there are any specific bladder findings. The other thing is when
14:19 – patients are having those symptoms, a big thing for me is, like one of the
14:25 – first questions I’ll ask is, well when you take antibiotics are your symptoms getting
14:30 – better? I think that’s a big clue as to whether this is an actual infection versus something else.