00:00 – Dr. Rubin: Your vulva, your urethra,
00:02 – your bladder, your vagina are rich hormone receptors.
00:05 – When you take birth control pills,
00:07 – it’s going to change the health and the microbiome of your tissue.
00:11 – Hi. Welcome back to the channel.
00:13 – I’m Melissa,
00:13 – and today at Live UTI Free, we’re talking about UTI and hormones.
00:17 – We have another amazing guest, Dr. Rachel Rubin,
00:19 – and we’re going to cover things like oestrogen therapy,
00:23 – contraceptives and hormone replacement therapy
00:26 – at any stage of life.
00:27 – We also have many other resources
00:30 – for patient experiencing recurrent and chronic UTI
00:32 – and we’ve linked some of those in the video description below.
00:35 – Lastly, if you enjoyed the video, think they’re important
00:38 – and wanna support us,
00:39 – make sure you hit subscribe and tick the bell
00:41 – so you’ll be notified our videos when we post them.
00:43 – Other than that,
00:45 – thanks again for joining us on this journey to making change in women’s health.
01:01 – I’d love to jump into some of the pre-menopausal hormone support
01:05 – and then contraception, because we did get some questions about that
01:08 – The first was about the bladder lining
01:10 – and whether it changes during the menstrual cycle
01:12 – Dr. Rubin: We don’t have that data
01:14 – but I would absolutely love that data!
01:17 – I don’t know exactly how you would easily study it,
01:20 – It would probably force a lot of women to get cystoscopy
01:24 – and bladder biopsis, which would probably hurt them.
01:26 – and so it might be difficult to get done.
01:28 – But I’ve actually really wanted to do a study
01:31 – of cystoscopic changes like
01:34 – like what it looks like
01:35 – Bladders between pre-menopause and post-menopause
01:38 – and can you spot. Cause I can spot a vulva
01:41 – that’s hormonaly healthy
01:43 – Can you do the same with bladder. And I don’t know if we know that answer.
01:47 – Melissa: We’re so many people in our community to report the UTI symptoms change with their cycle
01:53 – and can’t get a good explanation of that.
01:55 – Do you have something to offer there?
01:58 – Dr. Rubin: Again that’s like
02:00 – getting the right hormone status
02:02 – and figuring out what the best thing is.
02:04 – And again I,
02:06 – In my practise I play,
02:08 – like when you have data, great,
02:10 – but sometimes you have to play around with it
02:12 – and I say what’s the worst thing that could happen here, what are we fearing?
02:15 – You know what can we tinker with
02:17 – especially in peri-menopause, we see a lot of hormone change
02:21 – Even though you’re getting period, the testosteron might be dropping
02:24 – so I think testosteron needs to be played with a bit more int his space
02:29 – Am I think oestrogen, progesteron,
02:32 – I think, and the problem is nobody wants to study it
02:35 – because of the fluxuations and the complexity
02:38 – whereas I say
02:39 – Well why not play around and see what works
02:42 – You know, and I don’t think I’m gonna hurt someone, and so,
02:46 – I think there is definite truth to this, but we have a lot of work to do.
02:50 – Melissa: There are questions from people who’ve had partial hysterectomy with their ovaries remained
02:54 – they wanted to know if they would still experience a normal cycle minus
02:58 – the menstrual bleeding and if that could still impact their bladder.
03:01 – Dr. Rubin: Absolutely.
03:02 – if they felt that their hormones or fluxuations affected their bladder.
03:06 – The question is…
03:08 – I spend a lot of time just looking at pictures of the mestrual cycle with patients
03:13 – and we look at it together,
03:14 – again, birth control changes everything,
03:17 – so it’s going to change the hormone level
03:19 – so you can look at it, you, if you’re on birth control.
03:22 – But,
03:23 – For people who ovulate you know, looking at that picture
03:27 – and figuring out when are my symptomes the worst?
03:29 – Is it when you’re progesteron is high?
03:31 – Is it when your oestrogen is dropping? Is it when your progesterone is dropping?
03:35 – We look at it and it’s not like a perfect picture
03:38 – It’s not a perfect situation, but it gives us this idea of can we plays
03:43 – in the space, can we add some progesteron, can we add some oestrogen?
03:46 – Like where can we supplement to see if you feel better
03:50 – we don’t know what is the optimal dose
03:52 – what is the right timing
03:53 – I have patients you said “Gosh, when I was pregnant I felt great.”
03:56 – Or “When I was pregnant, I felt horrible?”
03:58 – And that gives us a sense of the level on that can your oestrogen back to 3000.
04:02 – but you know what can we, is there room to play with this?
04:05 – Melissa: So when someone still has their menstrual cycle
04:08 – but might need hormonal support because they are experiencing symptoms in certain times
04:11 – do you only provide that support at those time?
04:14 – Or will they need to be on something…
04:16 – Dr. Rubin: Depends on the patient and the situation.
04:19 – And again,
04:20 – in the discussion of here’s what we know, here’s what we don’t know,
04:24 – what could we try,
04:25 – so for me, I like to try and play around with FDA-approved hum…
04:30 – hormones as opposed to birth control pills.
04:33 – You know of course if you need,
04:35 – because I see a lot of the other side effects
04:37 – a lot of women don’t like birth control pills for the other side effects
04:40 – so we see if we can play around with progesterone or estradiol
04:44 – and all sorts of thing. So again, there’s a lot of…
04:49 – It’s not a one size fits all.
04:50 – And someone who has PMDD or PCOS
04:53 – It is different than someone who is a runner who doesn’t menstruate
04:57 – because there is such an amazing athlete,
04:59 – and they also have like no hormones in their body.
05:02 – You have to find the right thing for the person.
05:05 – Melissa: You just mentioned PMDD, which was one of the question,
05:08 – what is the difference between PMS and PMDD,
05:10 – and other symptoms that could help someone differentiate it.
05:14 – Dr. Rubin: That’s a gynaecology question.
05:16 – I don’t know the definitions, the difference and the definitions
05:19 – I think there are specific difference in definitions.
05:22 – I just know I work with patients
05:24 – in looking at their menstrual cycle, and saying “Ok,”
05:27 – “when do you feel awful? Let’s look at it.”
05:29 – “What days do you feel awful?”
05:31 – I don’t know if it’s your because your body hates progesterone
05:33 – or you body hates when progesteron is dropping.
05:36 – Or it could be that your body hates that your oestrogen is dropping.
05:38 – So can we help minimise that dropping
05:41 – or can we tinker with the system a little bit
05:44 – It’s not a perfect, hum…
05:47 – Again, when people are doing research
05:49 – and creating medication and drugs.
05:52 – Big picture thing is they need this works for everybody,
05:55 – they lump everybody together and that becomes challenging in this type of situation.
06:01 – Melissa: How accurate are tests for reproductive hormones
06:04 – People often have one snapshot test during the cycle and be told they are fine.
06:08 – How do you pick what is going wrong…
06:10 – Dr. Rubin: This is super…
06:11 – You know I don’t know if anyone has watched the Hulu documentary about
06:16 – The Ranelagh Square
06:17 – the lady got in trouble, she was trying to
06:20 – She scammed everybody, and it was controversial but,
06:23 – The reason I bring it up is I wished
06:25 – that the technology was there for us to put your finger on a little button
06:29 – and then every day we can see what’s going on and do all these tests and monitor
06:33 – and maybe that’s the future.
06:34 – Maybe it was just a little too soon, or maybe that’s the future
06:38 – There’s so much
06:40 – in this space,
06:41 – testing has gone
06:43 – light years ahead
06:44 – of where we are in our understanding of what the testing means.
06:48 – And that frustrates the crap out of the patients as it should.
06:51 – So all of these saliva tests,
06:53 – and these like very expensive things.
06:57 – give you numbers
06:58 – and give you always cool things that tell you all these things.
07:02 – But when you look at the research and the data and what’s published
07:05 – Well, you don’t see saliva test on there.
07:07 – and you don’t see, you know, you just don’t see, and so,
07:10 – Could saliva testing for hormones one day be accurate and be the gold standard?
07:14 – Absolutely, I’m not saying they can’t be.
07:17 – These companies should then do the work
07:20 – to then actually publish data
07:22 – to say “Oh my god look how accurate this is.”
07:25 – You should be the gold standard but they don’t.
07:27 – Because they’d rather take your money and run with it.
07:30 – because they don’t need to do that because you’re going to pay them
07:32 – regardless of whether it’s real or not.
07:35 – And that is why I cringe
07:37 – and I get so frustrated I get tomatoes thrown at me
07:39 – and I’m sure that your people be so mad at me by saying these things.
07:42 – But that’s the truth, we have to demand better science,
07:46 – better evidence,
07:47 – And we must demand that it gets done.
07:49 – because these companies are taking advantage of women in the space.
07:52 – at very large levels.
07:54 – Melissa: In the meantime how do you identify where the problem is in someone’s cycle?
07:59 – Yeah so it’s a lot of the story,
08:01 – and I do like Snapshots but I understand the data,
08:05 – I do blood testing,
08:07 – through people’s insurance but I do go testing any this is Snapchat.
08:11 – Is it the full story, is it the full picture
08:14 – I have a patient right now who feels awful at a certain time of
08:17 – of month and so we actually got 3 Snapshots
08:20 – where we got her test you know,
08:22 – at the baseline at day 2 to 3, where her hormones are at the lowest,
08:25 – we got some testing in ovulation
08:27 – and some testing in the ludial phase.
08:28 – and it’s not perfect, and she understands that this is a snapshot
08:32 – and we’re being detectives.
08:34 – That means we may go down the wrong road
08:36 – and we may have to walk backwards and go down another road.
08:40 – And so, I am not of the mind of like
08:42 – again your body, your choice.
08:44 – No testing ever for anyone you don’t need it.
08:47 – I think again it’s not a one size fits all on proach.
08:50 – What’s right for one patient is not necessary correct for another one.
08:55 – I also think patients like basslines
08:57 – and they like to look at the change
08:59 – So if you’re in menopause and you’ll see that you’re oestrogen is zero,
09:03 – and then we search through a batch and then you’ll see that your oestrogen is now 50
09:07 – and you’re feeling better, and
09:09 – you’re doing fine and your hot flashes are gone.
09:11 – Technically you didn’t need to see it go from 0 to 50
09:14 – But that is a very valuable visual, for patients to actually see the change.
09:20 – Similar to vaginal PH, I have a little PH paper in my office.
09:23 – and they see the pH go from 7 and a half
09:26 – to 4 and a half
09:27 – and they see that their hard work is paying off and they see the change.
09:30 – So they’re gonna use their vaginal hormone twice a week forever.
09:34 – So I do that in my practice, it’s not really the gold standard of care.
09:38 – And so his is where we push
09:40 – the gold standard further,
09:42 – and we research it and we publish it.
09:45 – We keep moving forward and we question
09:47 – the standard, we question it, it’s great to question things,
09:51 – and to prad and to pock and disrupt.
09:53 – But we have to also hold everybody accountable for doing the work.
09:58 – Melissa: Do you think it’s worth patients monitoring their vaginal pH
10:01 – with stripes like that?
10:03 – Dr. Rubin: I don’t want people to go crazy and test it every day.
10:07 – I do think if you’re on vaginal hormones
10:09 – and you still getting UTIs,
10:10 – sure, put a pH paper in there and if it’s not acidic
10:13 – well your vaginal hormones’ not working or there’s something going on
10:16 – and maybe we need to change the modality, it’s super helpfull.
10:19 – I have patient who use a hormone therapy on their skin,
10:23 – and they’re like “I don’t feel any better”.
10:25 – “I’m using this high dose hormone therapy”
10:27 – check their levels, the oestrogen is still O.
10:28 – Well m’am you’re using a fancy hormone lotion
10:32 – that’s charging a lot of money,
10:33 – but it’s not actually absorbing into your skin and making any difference
10:36 – that where I think the numbers and the pH can be very helpful
10:40 – Melissa: Ok.
10:41 – You mention contraception and how people are not afraid to take them
10:44 – but a lot of people in our community report that
10:46 – it is when their UTI started that they got a IUD or started a contraception,
10:50 – do you see that in your own practice a lot ?
10:52 – Dr. Rubin: Yes. When you play with hormones, there are consequences,
10:55 – sometimes good, sometimes bad.
10:57 – So there are no,
10:59 – there are risks to everything.
11:02 – Good lord, there are risks to supplements,
11:03 – one of the number one reasons of liver failure right now.
11:06 – People taking too many supplements,
11:08 – and the liver goes nuts because it doesn’t know how to process all of it.
11:11 – So, there are risks to everything that we do.
11:15 – And hormones of any kind, in any way,
11:17 – they are going to be benefits and risks.
11:20 – So yes,
11:22 – hromones can change the- remember your vulva
11:25 – your urethra, your bladder, your vagina are rich in hormones receptors.
11:29 – When you take birth control pills,
11:31 – it’s going to change
11:32 – your ovaries are no longer gonna produce their own hormones
11:35 – and any testosterone that you do produce is going to get cobbled up
11:40 – by a protein called sex hormone binding globulin
11:43 – which dicreases you have circulating
11:46 – which is going to affect the health and the microbiome of your tissue.
11:50 – IUDs don’t tend to do that as much.
11:52 – But that doesn’t mean that they cause any problem ever.
11:56 – Remember you asked about progesteron, I said “we don’t know”.
11:58 – There’s definitely,
12:00 – I have patients with hormonal IUDs who say “my vagina is so dry now”
12:04 – it’s rare but I do see people complaining of it.
12:07 – I’ve seen patients with things
12:10 – on the string of the IUD
12:12 – and we take the IUD out and their infections get better.
12:15 – There is so much we don’t know, right?
12:17 – And it really is not a one-size-fits-all.
12:19 – I love IUDs, that doesn’t mean IUDs don’t have complication, right?
12:23 – So I think the vilifying birth control and IUDs is not the correct answer either.
12:29 – We must demand
12:30 – More birth control options, more vasectomies for male patients,
12:34 – more reversible non-hormonal birth control options.
12:38 – We must like, birth control hasn’t evolved in it’s research in decades,
12:43 – because we’re not forcing the scientists to do that.
12:45 – And so we have so much work to do.
12:47 – And I just don’t know how to start any-
12:49 – there’s so much to do that it’s sometimes hard to get up in the morning.
12:52 – ’cause you’re like “where we start?”
12:54 – Unless you have one issue that you’re working on
12:56 – it gets very watered down.
12:58 – Melissa: Yeah I have the same feeling.
13:00 – There was another question about DM as a supplement.
13:03 – and what that is and whether it might be beneficial.
13:06 – Dr. rubin: I have absolutely no idea.
13:09 – When it comes to supplements my take is always this:
13:12 – At least in the US there is absolutely no
13:16 – oversight into the supplement industry.
13:18 – So we can argue and debate supplements as much as you want,
13:22 – but at the end of the day,
13:24 – I don’t even know that Dim,
13:26 – whatever that is, is even in the bottle, right?
13:29 – So if you present me a study on DIM that shows that it’s the best thing ever to prevent UTI
13:33 – well, what company do I get it from?
13:35 – Which bottle do I use? How do I know that actually in there?
13:38 – So I can even start a conversation about supplements.
13:41 – because until someone gives me some assurance
13:44 – that what’s in it is actually what’s in it,
13:46 – that you have studies to show that that is actually helpful.
13:49 – So that’s why I get frustrated.
13:51 – So in the UTI space listen, I don’t have anything new to present.
13:54 – We know that D-Mannose maybe hopefully,
13:57 – we know cranberry might be helpful, we know…
14:00 – My biggest problem with the AUA guidelines on UTI,
14:03 – is that they can’t they give you all these options,
14:06 – and then the last one is “and you should use vaginal oestrogen”.
14:09 – And I was like, guys, come on you got it wrong it should be “everyone uses vaginal oestrogen”
14:14 – and then you can add and sprinkle in these other things which might help.
14:17 – They sort of made them all seem like they were equal and benefit,
14:21 – whereas we have so much data on vaginal hormones,
14:25 – which is why I’ve lobbied
14:26 – the Urology Association to do a guidelines
14:28 – specifically on genitourinary syndrome of menopause
14:31 – so that we can just like say it loud and clear, of like,
14:34 – urologists should be treating patients
14:36 – with any urinary symptoms with vaginal hormones, period.
14:40 – And it forces, if you have guidelines
14:42 – it’s going to force insurance companies to pay attention, god willing,
14:45 – it’s gonna force the urologist to say “this is our space, we should be doing this”
14:49 – we can’t just expect our gynecology colleagues to deal with vaginas.
14:52 – We also have to talk to women, so…
14:57 – This is the mountain that I’ve lived on.
15:00 – Melissa: I hope you’re successfull because those guidelines make a huge difference
15:03 – A lot of patient say that doctors can’t help them because there aren’t guidelines.
15:08 – So…
15:09 – Dr. Rubin: But there are. I would say in the UTI guideline,
15:12 – very specifically says it and I believe, it’s number 18 on the guideline it says:
15:16 – “if you are par”- this is a really important sentence,
15:19 – “if you are peri or post-menopausal with UTI”
15:23 – “vaginal hormones will prevent UTIs”.
15:25 – I’ve seen a lot of patients online
15:27 – who say “my doctor will not give me vaginal hormones because I still get period”.
15:31 – That sentence, you can bring that sentence into the doctor and say
15:35 – “See? this is why you should give me vaginal hormones”.
15:38 – You should follow Dr Rubin on Instagram or Twitter
15:41 – because she’s not affraid to do it, so this is the prescription you should give me.
15:46 – Melissa: That’s really good advice.
15:48 – There was one more question a supplement,
15:50 – which was around vaginal probiotics and whether you think they might be helpful.
15:54 – Dr. Rubin: The only probiotic on Earth
15:57 – that is prooven to fix your microbiome and make it perfect
16:01 – is vaginal hormones.
16:02 – Vaginal oestrogen or DHEA will make your pH 4.5
16:07 – will reproduce your lactobacilli
16:08 – will take 2 to 3 months and only keep working if you keep using it.
16:12 – There is no probiotic on the market that has any proof
16:15 – that it does anything to the level of vaginal hormones.
16:18 – And so yes,
16:20 – the idea of maximising our microbiome, the idea of a vaccine, or a,
16:25 – a supplement or something that fixes everything, but
16:28 – we have something it’s been around since the seventies, it works amazing!
16:32 – There are many different types.
16:34 – And yet, no one is using it.
16:35 – I can’t figure out it’s because the…
16:38 – It’s the fear of the word hormone,
16:41 – which is so strange because no one fears that when it’s birth control for reproductive rights
16:45 – nobody fears hormones when they’re young and taking birth control
16:49 – they may have side effects, they may not agree with them,
16:52 – but they don’t fear it.
16:53 – And yet, as soon as you turn 50, the word hormones all of a sudden make you terrified.
16:58 – I had a patient with
17:01 – What is podcast
17:02 – I had a patient who had lichen sclerosus, and I was on the phone with her,
17:06 – She said “oh I can’t use this”
17:07 – she has horrible lichen sclerosus she has pain, she is itching she is miserable.
17:11 – They started her on a very heavy medication
17:15 – I said “I see you have vaginal oestrogen on your med list, do you take it?”
17:18 – “Oh no I can’t take that, it causes cancer”.
17:20 – And I said “Oh my god, Lady.”
17:22 – “Your out of control lichen sclerosus”
17:24 – “actually causes vulva cancer”.
17:26 – This actually causes cancer.
17:28 – Vaginal hormones has never caused anyone cancer.
17:31 – So that’s what we’re working with is
17:34 – she had the correct prescription
17:36 – and still she wouldn’t use it.
17:38 – And so we have so much work to do
17:40 – And you’re doing such an important work, Melissa,
17:42 – because we have to just educate women
17:45 – to understand it because unless they understand it,
17:47 – they won’t put it in their vagina, they won’t use it.
17:50 – they’ll buy some supplement on the internet that has no research behind it
17:53 – because it feels safer, but it is not safer.
18:00 – Melissa: I have 2 quick questions about UTI after sex, before we finish.
18:02 – I first one is for UTIs triggered after sex,
18:03 – Is it usually a reinfection or could it be caused by a persistent infection
18:07 – that had just been cleared-up.
18:09 – Dr. Rubin: Ok, I have a very controversial take on this.
18:12 – And again I’m gonna get a lot of tomatoes thrown at me.
18:16 – I don’t think…
18:17 – So right at sex, if you are having pain, right at sex,
18:21 – and sex is painful or sex is painful after and you say “Oh my gosh I got a UTI!”
18:26 – I don’t think bacteria work that fast, in my opinion.
18:29 – I think more often than that,
18:31 – remember that opening to the vulva, is bladder tissue,
18:35 – it’s called the vulva vestibule, very hormone sensitive.
18:38 – When anything rubs against it like a penis or anything else that might be inserted,
18:44 – right? It is raw.
18:46 – it is irritated
18:47 – and it doesn’t like to be touched.
18:49 – That’s bladder tissue the vulva vestibule
18:51 – at the opening of the vulva is bladder tissue
18:54 – So when it’s irritated like a rug burn,
18:56 – guess what your symptoms are gonna be?
18:58 – Frequency, urgency, dysuria and pain. It’s an inflammatory thing,
19:03 – not an infectious thing.
19:05 – if your body hurts,
19:07 – we are trained to think this is an infection.
19:09 – “Oh my god, I got a UTI!”
19:10 – It doesn’t work that fast, right?
19:12 – now if you’re the person,
19:13 – who a couple days later starts to have burning and pain and urgency
19:17 – yeah, get a dip, get tested, get a culture.
19:20 – I think this idea that
19:22 – a penis goes in and bacteria now are there
19:25 – and are causing this acute infection.
19:27 – What happens is that women take antibiotics
19:29 – then start to feel better.
19:31 – but what makes them feel better is that they are now not having anything rub against their vulva
19:34 – and they’re not having sex, not having anything rub against the bladder tissu
19:38 – and they get better on it’s own.
19:40 – Think about rubbing an open wound in her
19:42 – it hurts right? It’s really irritated.
19:44 – You will never take an open bladder and just rub against it,
19:47 – that would irritate the bladder.
19:49 – But you essentially bladder tissue right at the opening of your vulva.
19:52 – That’s why it’s important to keep it strong and healthy with an hormone approach
19:56 – so it doesn’t hurt to the touch,
19:58 – so it doesn’t feel like raw spicy chili pepper,
20:01 – when anything touches it. Does that make sense?
20:04 – Melissa: It does. But a lot of people do report it happening 48 to 72 hours later so…
20:08 – Dr. Rubin: And those people, I am not- that’s different, right ?
20:12 – That’s totally different. My issue’s with those who say “as soon as I have sex I get a UTI”.
20:17 – I think too often that’s an inflammatory irritant
20:20 – as opposed to an infection.
20:22 – There are no question if there’s a whole world of embedded UTI
20:27 – potential or UTI, chronic UTIs
20:29 – that we don’t quite understand.
20:30 – and that we have a lot of work to do.
20:33 – Melissa: And for those people that do get the infection later
20:36 – There was one more question which is
20:37 – could the microbiome of one partner be incompatible with the microbiome of another?
20:42 – Dr. Rubin: Sure, anything is possible. I’ll never say no doubt, right?
20:45 – I’ve seen
20:47 – I have seen things like that happen
20:50 – And it’s certanly a weird allergic reaction and all.
20:53 – It’s just, again, our testing is sometimes beyond our ability to
20:58 – know what the heck to do about it.
21:00 – So things you could try, female condom, which are totally underused.
21:05 – There are these cool things that attached to the sides of the vagina
21:09 – and the penis can go in and out.
21:10 – So it protect the walls it’s not going to be as irritated against and if semen bothers you,
21:16 – then it won’t hit the tissue.
21:17 – So you can see, is it am I allergic to my partner?
21:20 – Or is this an inflammatory, I don’t know.
21:23 – That’s why I like being a detective,
21:25 – “Did you try this, did you try that? Should we test this ?”
21:28 – It takes really getting to know someone.
21:30 – and getting to know their intimate history
21:33 – in order to understand what’s happening and what could be happening.
21:36 – Thanks so much for watching, hope you enjoyed the video
21:39 – To learn more about this and related topic,
21:41 – be sure to check out our other videos, or head over to liveutifree.com.
21:45 – We have to really important articles related to this topic
21:48 – For instance we have one on menopause and one on UTI during pregnancy.
21:52 – We’ll also drop those in the description below.
21:55 – Of course if you like what we doing,
21:56 – be sure to subscribe and tick the bell so you’ll be notified of our YouTube videos.
22:00 – Thanks again for watching and until next time,
22:02 – Keep asking questions and pushing for better solutions.