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Dr. Christine Vaccaro, a double board certified urogynecologist, provides crucial insights about the often-overlooked challenges of surgical menopause and comprehensive hormone replacement therapy. She explains why the abrupt hormonal changes after ovary removal create a “rude awakening” for the body, unlike the gradual transition of natural menopause.
• The difference between natural menopause and surgical menopause (removing ovaries)
• Why all three hormones matter: estrogen, progesterone and testosterone
• The specific roles each hormone plays in overall health and wellbeing
• How quickly bone loss occurs without hormone replacement
• Why local vaginal hormone treatment is necessary even with systemic hormone therapy
• Options for vaginal hormone treatments including creams, tablets, rings and suppositories
• The importance of addressing pelvic floor muscles after surgery
• Why some women still have pain after hysterectomy
• How mental health support, particularly sex therapy, aids in recovery
• The value of education before surgery to make informed choices
Don’t underestimate the impact of surgical menopause. Find doctors who will discuss comprehensive hormone replacement before surgery and create personalized treatment plans to support your quality of life afterward.
general email: info@rachelrubinmd.com
appointments: office@rachelrubinmd.com
website: rachelrubinmd.com
instagram: @drchristinevaccaro
youtube: youtube.com/@DrRachelRubin
Website endobattery.com
Introduction to EndoBattery
Speaker 1
0:02
Welcome
to
EndoBattery
,
where
I
share
my
journey
with
endometriosis
and
chronic
illness
,
while
learning
and
growing
along
the
way
.
This
podcast
is
not
a
substitute
for
medical
advice
,
but
a
supportive
space
to
provide
community
and
valuable
information
so
you
never
have
to
face
this
journey
alone
.
We
embrace
a
range
of
perspectives
that
may
not
always
align
with
our
own
.
Believing
that
open
dialogue
helps
us
grow
and
gain
new
tools
always
align
with
our
own
believing
that
open
dialogue
helps
us
grow
and
gain
new
tools
.
Join
me
as
I
share
stories
of
strength
,
resilience
and
hope
,
from
personal
experiences
to
expert
insights
.
I'm
your
host
,
alana
,
and
this
is
EndoBattery
charging
our
lives
when
endometriosis
Welcoming Dr. Christine Ficarro
Speaker 1
0:38
drains
us
.
Welcome
back
to
EndoBattery
.
Grab
your
cup
of
coffee
or
your
cup
of
tea
and
join
me
at
the
table
.
Speaker 1
0:47
Today
we're
joined
by
Dr
Christine
Ficarro
,
a
double
board
certified
and
fellowship
trained
urogynecologist
and
reconstructive
pelvic
surgeon
with
advanced
training
in
sexual
medicine
.
Dr
Ficarro
is
deeply
passionate
about
women's
pelvic
health
and
the
role
it
plays
in
overall
well-being
.
She's
compassionate
,
dedicated
and
truly
takes
the
time
to
create
the
best
care
plans
for
her
patients
.
And
when
she's
not
in
the
clinic
or
in
the
OR
,
you
can
find
her
cheering
on
her
kids
at
their
sports
events
,
walking
her
labradoodle
or
powering
through
a
hot
yoga
session
.
Please
help
me
in
welcoming
Dr
Christine
Vaccaro
to
the
table
.
Thank
you
,
dr
Vaccaro
,
so
much
for
joining
me
at
the
table
.
I
am
excited
for
this
conversation
.
It
is
long
awaited
,
so
thank
you
for
taking
the
time
out
of
your
busy
schedule
to
join
me
today
.
Speaker 2
1:40
Alana
,
it
is
my
absolute
pleasure
,
as
you
and
I
have
spoken
before
,
it
fills
my
cup
to
educate
women
so
they
have
good
education
to
empower
themselves
to
make
excellent
healthcare
decisions
.
So
I
can't
wait
to
start
this
conversation
.
Understanding Surgical Menopause
Speaker 1
1:47
I
know
and
we
need
more
education
surrounding
the
topic
that
we're
going
to
cover
today
,
and
this
is
something
that
is
near
and
dear
to
my
heart
as
someone
who
has
had
a
hysterectomy
and
a
nephrectomy
and
trying
to
navigate
this
convoluted
world
of
hormone
replacement
therapy
and
what's
right
and
what's
wrong
,
and
I
think
that
something
that
you
and
I
had
talked
about
before
is
that
there
is
a
lot
of
talk
surrounding
perimenopause
and
normal
menopause
,
but
what
gets
a
little
bit
challenging
is
when
you
go
into
surgical
menopause
.
That's
a
whole
nother
ball
game
,
and
one
that
I
didn't
know
that
I
was
signing
up
for
,
necessarily
,
in
the
sense
that
I
was
in
so
much
pain
.
I
just
wanted
my
uterus
and
ovaries
out
,
but
I
didn't
know
what
was
going
to
come
,
and
there's
a
problem
with
that
.
Speaker 2
2:39
Absolutely
,
and
I'm
going
to
just
shape
this
response
in
my
lens
so
that
your
listeners
know
who
I
am
,
so
they
understand
my
lens
.
So
I
am
a
double
board
certified
,
fellowship
trained
gynecologist
,
which
basically
just
means
I
am
a
specialty
gynecologist
in
women's
quality
life
conditions
and
that's
like
pelvic
floor
symptoms
,
urinary
leakage
,
pelvic
floor
pull
ups
,
menopause
,
sexual
health
,
pelvic
pain
,
so
basically
anything
in
that
realm
is
what
I
deal
with
on
a
daily
basis
and
I
think
sometimes
when
patients
have
a
diagnosis
of
either
pain
or
cancer
,
right
,
we're
really
good
at
like
treating
those
conditions
,
but
then
we
forget
about
the
quality
of
life
aftermath
.
So
for
you
specifically
,
it's
like
all
right
,
alana
,
we're
going
to
do
the
definitive
procedure
for
you
,
we're
going
to
take
out
the
uterus
which
is
producing
the
implants
outside
your
uterus
causing
pain
,
and
we're
going
to
take
out
your
ovaries
.
But
we
might
not
get
to
then
talk
about
like
how
catastrophic
that
is
for
the
rest
of
your
body
to
go
from
a
natural
hormone
level
to
zero
hormones
,
meaning
estrogen
,
progesterone
,
testosterone
those
are
the
three
hormones
that
are
all
critically
important
,
that
are
made
by
our
ovaries
to
help
our
body
be
functioning
optimally
.
So
,
basically
,
women
that
have
a
slow
decline
of
estrogen
,
progesterone
,
testosterone
.
As
we
approach
midlife
,
have
a
little
bit
more
of
a
gentler
but
still
not
great
gentler
approach
to
perimenopause
,
menopause
.
Speaker 2
4:09
But
again
,
surgical
menopause
is
an
abrupt
,
almost
rude
awakening
.
It's
like
running
,
it's
like
you
know
,
going
1000
miles
an
hour
and
slamming
into
a
wall
.
Right
.
It's
like
the
body
is
all
of
a
sudden
completely
,
not
completely
,
not
prepared
to
deal
with
.
And
again
,
you
can
tell
me
what
your
symptoms
were
if
you'd
like
.
But
generally
,
again
,
severe
hot
flashes
,
night
sweats
,
brain
fog
,
memory
loss
,
word
finding
,
zero
libido
and
then
usually
musculoskeletal
aches
and
pains
,
chest
heart
palpitations
,
musculoskeletal
aches
and
pains
,
chest
heart
palpitations
,
and
then
again
,
the
longer
from
hormone
support
,
the
genitourinary
syndrome
of
menopause
,
like
recurrent
UTIs
and
going
to
the
bathroom
all
the
time
,
getting
up
at
night
,
vaginal
dryness
,
difficulty
with
arousal
and
orgasm
.
So
all
these
things
start
happening
,
very
detrimental
to
women's
quality
of
life
.
And
I
forgot
to
mention
anxiety
,
depression
.
Those
are
also
extremely
common
.
And
not
because
you're
going
crazy
,
it's
because
your
hormones
are
low
.
Speaker 1
5:11
Which
is
hard
to
differentiate
that
when
you're
in
the
midst
of
it
.
You
know
,
I
think
for
me
.
I
woke
up
and
I
craved
chocolate
first
thing
,
which
I
had
not
done
before
.
You
know
.
I
was
like
give
me
that
cookie
and
don't
take
it
from
me
,
because
I
will
chop
your
arms
off
,
Right
.
It
just
was
like
this
visceral
response
to
my
body
changing
,
and
then
it
went
from
that
to
.
I
was
in
so
much
pain
prior
that
I
was
like
certainly
it's
got
to
The Three Essential Hormones Explained
Speaker 1
5:36
be
better
.
After
my
hysterectomy
,
Like
it
is
,
like
I'm
in
,
I
was
desperate
at
that
point
and
I
had
severe
adenomyosis
bleeding
all
the
time
.
So
of
course
it
was
like
this
has
got
to
be
better
,
right
?
Well
,
after
my
hysterectomy
,
after
my
excision
surgery
and
everything
else
,
what
ended
up
happening
was
it
didn't
get
significantly
better
in
intercourse
.
It
didn't
get
significantly
better
with
my
brain
fog
.
My
fatigue
was
slightly
better
,
but
there
were
things
that
I
just
didn't
understand
.
Speaker 1
6:05
I
was
immediately
put
on
the
Estradiol
patch
,
which
I
was
thankful
for
,
but
I
didn't
know
why
,
I
didn't
know
why
I
was
being
put
on
that
,
and
I
remember
a
provider
it
was
a
nurse
in
the
office
who's
no
longer
there
saying
to
me
.
She
said
you
know
,
you
don't
really
need
the
estrogen
patch
if
you
don't
want
,
just
get
some
over
theounter
things
to
help
with
your
symptom
relief
.
And
I
was
like
,
no
,
that's
not
what
I
was
going
to
say
.
I
had
the
wherewithal
to
say
no
,
I
don't
think
they're
right
,
but
I
didn't
know
about
testosterone
or
anything
else
walking
into
it
,
and
so
I
think
a
lot
of
those
things
that
you
mentioned
I
dealt
with
.
And
so
when
you
talk
about
that
mental
struggle
with
thinking
that
things
were
going
to
be
better
and
it
wasn't
as
good
as
it
could
have
been
post-operatively
,
there
was
a
little
bit
of
depression
.
That
happened
after
that
.
Speaker 1
6:55
You
know
,
that
false
sense
of
hope
in
a
way
,
like
my
endo
pain
was
not
there
anymore
,
but
I
definitely
had
other
pains
and
I
still
dealt
with
the
brain
fog
and
the
muscular
skeletal
let's
not
even
go
into
that
yet
.
You
know
,
it's
kind
of
all
those
little
things
that
escalated
in
a
way
,
but
in
that
I
wish
I
would
have
had
a
pre-surgical
plan
for
hormones
.
What
should
we
do
in
that
respect
?
Speaker 2
7:25
Yeah
.
So
,
Alana
,
I
think
you
ask
a
really
important
question
.
I
love
prevention
and
I
love
proactive
women
.
I
love
when
I
see
a
patient
coming
in
for
variety
of
reasons
why
they're
having
their
uterus
out
and
their
ovaries
out
and
they
want
to
have
the
conversation
,
and
it's
like
thank
goodness
,
because
can
you
imagine
a
world
where
we're
actually
women
,
are
prepared
and
ready
and
like
know
exactly
what
they're
going
to
do
and
and
have
the
expectation
that
,
like
you
know
,
here's
what
happens
if
you
don't
supplement
your
hormones
,
that
we're
going
to
be
abruptly
ripping
from
your
body
?
You
know
,
and
make
it
obviously
a
conversation
,
shared
decision
making
,
right
,
Because
,
again
,
for
a
variety
of
reasons
,
some
women
may
not
want
hormone
therapy
.
Speaker 2
8:08
At
least
they
know
and
they
understand
the
risk
.
I
don't
think
we
also
clearly
talk
about
what
this
happens
to
your
bones
,
right
?
Just
osteoporosis
alone
kills
so
many
women
every
year
and
,
again
,
we
don't
talk
about
that
enough
either
.
So
it's
just
all
sorts
of
prevention
.
So
,
again
,
imagine
a
world
which
I
do
see
this
often
actually
,
and
I
love
it
the
woman
comes
in
,
okay
,
to
meet
with
her
surgeon
and
or
,
potentially
,
a
hormone
specialist
,
and
they
go
through
all
the
options
,
they
go
through
the
expectations
and
there's
a
plan
for
either
hormonal
or
non
hormonal
therapy
and
that
can
actually
start
the
day
of
slash
.
Before
,
after
whatever
they
agree
upon
,
you
don't
have
to
wait
until
symptoms
are
severe
and
you're
feeling
awful
and
anxiety
and
depression
and
brain
fog
sets
in
.
Like
the
point
about
prevention
is
to
prevent
feeling
terrible
,
so
catching
it
before
it
starts
.
Speaker 2
9:03
I
think
there's
a
misperception
still
in
the
medical
community
that
transdermal
hormones
cause
or
can
contribute
to
blood
clots
.
Transdermal
estrogen
products
do
not
cause
blood
clots
.
But
I
think
again
,
sometimes
surgeons
still
have
this
sort
of
perception
and
they
don't
want
to
start
anything
in
and
around
the
perioperative
time
frame
either
.
That
you
know
before
,
right
,
immediately
after
,
etc
.
So
a
lot
of
times
women
are
in
this
,
you
know
,
six
week
zone
of
suffering
until
they
go
into
their
postdoc
visit
and
then
it's
like
,
oh
,
how
are
you
feeling
?
And
it's
like
I
feel
awful
,
like
you
know
.
But
we
have
avoided
that
six
weeks
of
awful
and
just
helped
them
through
that
with
replacing
again
what
their
body
was
already
making
.
It's
not
like
we're
giving
supra
therapeutic
doses
here
,
we're
just
giving
a
little
gas
in
the
tank
so
it
doesn't
run
on
empty
.
Speaker 1
9:55
Yeah
,
I
think
what's
hard
too
is
a
lot
of
people
coming
out
post-operatively
kind
of
associate
what
they're
going
through
as
post-op
pain
as
opposed
to
the
significant
changes
in
their
bodies
occurring
instantly
,
and
I
definitely
experienced
that
.
Are
there
risks
associated
with
holding
off
on
hormone
replacement
therapy
,
even
if
it's
a
year
or
two
?
Because
I
think
you
know
personally
for
me
I
didn't
start
testosterone
for
a
year
because
I
didn't
know
that
was
a
thing
.
But
,
I'll
tell
you
it
was
a
huge
difference
when
I
did
.
Speaker 2
10:29
Yeah
,
I
think
the
best
,
the
best
data
we
have
is
in
bone
health
.
So
for
bones
the
loss
is
pretty
significant
right
away
.
The
best
data
we
have
is
the
perimenopause
window
,
which
is
like
four
to
seven
years
before
menopause
.
During
that
just
that
transitional
time
where
again
times
estrogen
is
normal
and
sometimes
it's
really
low
,
we
lose
like
10%
of
our
bone
loss
just
in
that
up
and
down
time
.
So
if
you
can
imagine
one
year
without
hormones
completely
,
which
is
a
huge
change
,
the
bones
take
a
huge
hit
there
.
I
don't
have
a
number
to
quote
,
but
again
it
could
be
up
to
10%
.
You
know
,
you
don't
know
,
but
again
women
that
have
normal
testosterone
then
go
down
to
zero
.
That's
a
huge
change
and
the
bones
definitely
feel
that
.
Speaker 2
11:17
I
mean
,
other
things
are
going
to
be
harder
to
quantify
,
right
?
We
know
how
much
sleep
is
disrupted
during
hot
flashes
,
night
sweats
,
and
again
,
it
doesn't
even
have
to
be
a
hot
flash
of
night
sweat
.
You
can
just
wake
up
for
no
reason
at
all
,
meaning
like
you're
a
great
sleeper
,
and
then
all
of
a
sudden
you're
like
why
am
I
awake
at
2am
?
For
no
reason
,
and
then
the
mind
starts
going
and
then
things
start
happening
and
then
you
can't
fall
back
asleep
,
okay
.
So
then
you
have
,
you
know
,
months
slash
years
of
poor
sleep
,
which
poor
sleep
is
directly
related
to
chronic
illnesses
,
skeletal
pain
,
depression
,
yeah
,
et
cetera
,
et
cetera
,
right
,
so
it's
like
all
these
things
layer
on
each
other
and
only
the
patient
themselves
know
how
devastating
that
,
you
know
,
year
of
waiting
can
be
.
Speaker 2
12:03
You
know
,
again
,
I
just
hate
to
see
women
suffer
at
all
.
So
my
approach
is
that
that
timeframe
is
zero
days
,
like
I
want
them
to
start
right
away
.
I
even
have
some
patients
that
are
already
low
in
testosterone
start
testosterone
before
their
surgery
,
because
it
does
take
several
months
to
ramp
up
on
testosterone
.
So
every
patient's
a
little
bit
,
a
little
bit
different
,
based
on
their
age
,
symptoms
that
they're
already
experiencing
.
But
again
,
you
know
,
think
about
one
year
.
Think
about
a
diabetic
with
one
year
without
insulin
.
You
know
that's
a
really
important
human
hormone
.
Think
about
a
hypothyroid
patient
with
one
year
without
their
thyroid
.
They're
going
to
feel
miserable
.
And
I
don't
know
why
we
treat
sex
steroids
as
something
that
we
withhold
for
some
reason
,
just
to
allow
women
to
suffer
,
like
it
doesn't
make
any
sense
to
me
at
all
.
So
,
to
prevent
pain
and
suffering
and
also
to
prevent
chronic
disease
like
osteoporosis
,
I
don't
recommend
waiting
unless
there
is
a
concern
about
hormonal
dependent
cancers
.
Or
there's
a
concern
,
and
then
again
then
that's
a
more
of
a
detailed
discussion
with
the
patient
about
risk
benefit
.
Speaker 1
13:06
Right
,
and
I
think
something
that
maybe
we
should
address
is
what
each
of
these
hormones
do
in
the
body
,
because
I
think
that
can
be
very
confusing
for
patients
walking
through
the
various
aspects
of
trying
to
heal
their
body
or
help
their
body
.
What
?
Part
does
estrogen
play
?
What
part
does
testosterone
play
?
And
is
there
a
reason
to
take
progesterone
?
And
what
role
does
that
play
in
our
bodies
?
Speaker 2
13:31
Because
,
oh
my
gosh
,
these
are
such
that
is
very
confusing
and
these
are
such
great
questions
.
Thank
you
for
bringing
it
up
.
So
you're
right
,
each
one
does
things
that
are
unique
to
it
,
but
then
a
lot
of
times
they
,
when
layered
together
,
complement
each
other
.
So
we'll
go
through
them
one
by
one
.
So
the
main
estrogen
is
estradiol
.
The
ovary
actually
makes
several
estrogens
,
but
that's
the
main
bioidentical
most
active
estrogen
and
it's
the
most
important
for
,
again
,
supporting
our
whole
body
,
head
to
toe
.
So
when
I
think
of
estrogen
,
the
easiest
way
to
describe
it
is
it
is
a
grower
.
It
grows
things
.
It
grows
our
hair
,
it
grows
our
bones
,
it
helps
support
our
muscle
,
helps
support
elastin
and
collagen
in
our
face
.
So
,
again
,
it
helps
support
the
elastin
collagen
in
the
vagina
.
So
it
literally
grows
and
supports
our
tissue
,
whereas
progesterone
its
main
role
and
again
,
a
woman
that's
had
a
hysterectomy
,
it's
like
well
,
I
don't
need
that
because
its
main
role
is
like
stabilizing
the
uterine
lining
,
because
,
again
,
estrogen
grows
things
,
including
the
uterine
lining
,
and
for
women
that
have
a
uterus
,
we
need
to
balance
that
growth
with
progesterone
and
I
actually
want
to
do
this
research
study
.
I
really
think
that
progesterone
is
not
just
for
uterine
protection
.
We
know
,
we
have
great
data
,
that
it
helps
support
sleep
quality
and
also
initiating
sleep
and
it
also
reduces
anxiety
.
It
works
on
the
GABA
receptors
in
the
brain
to
help
kind
of
quiet
and
calm
our
mood
.
So
there's
so
many
other
additional
benefits
of
progesterone
and
I
think
sometimes
women
that
again
are
going
in
for
hysterectomy
don't
get
offered
progesterone
,
and
I
think
sometimes
women
that
again
are
going
in
for
hysterectomy
don't
get
offered
progesterone
when
that
also
might
be
something
that
they
really
would
benefit
from
.
So
I
would
like
to
see
progesterone
,
some
more
good
quality
studies
that
I
may
or
may
not
be
involved
in
creating
,
because
there
hasn't
been
a
study
showing
the
benefit
in
women
that
either
had
their
uterus
removed
or
potentially
women
that
are
using
a
Mirena
IUD
to
control
their
pain
symptoms
,
control
the
uterine
lining
.
But
again
,
could
those
women
benefit
from
oral
progesterone
for
sleep
and
anxiety
reduction
as
well
?
No
one
has
done
those
studies
yet
.
So
again
,
just
a
little
teaser
on
progesterone
.
Speaker 2
15:41
But
then
next
is
testosterone
.
So
testosterone
,
of
course
,
the
most
data
we
have
is
in
males
.
Again
,
testosterone
is
not
a
male
only
hormone
,
it's
a
human
hormone
.
Women
have
more
testosterone
at
all
times
in
their
life
than
estrogen
.
The
only
time
where
this
may
not
be
true
is
late
in
pregnancy
,
when
estrogen
levels
are
really
really
high
.
But
other
than
that
,
we
have
more
testosterone
than
estrogen
,
which
I
think
is
a
revelation
to
some
patients
.
It's
a
revelation
to
some
doctors
because
,
again
,
we
just
don't
have
good
education
on
hormones
in
our
medical
education
.
Speaker 2
16:15
It's
true
that
men
have
a
lot
more
testosterone
than
we
do
.
They
have
10
times
more
,
but
we
still
have
a
lot
more
than
we
have
estrogen
.
So
the
symptoms
and
the
way
it
supports
a
man's
body
again
,
we're
all
human
,
so
it
works
.
Similarly
,
it
supports
libido
,
okay
,
which
is
the
main
reason
that
we
use
testosterone
in
women
.
That's
like
the
most
commonly
indicated
reason
to
use
it
,
even
though
it's
still
off
label
because
there's
no
testosterone
products
for
women
in
the
U
S
,
although
there
are
some
in
Australia
.
Speaker 2
16:43
But
it
works
for
libido
.
It
works
for
overall
muscle
building
and
muscle
strength
.
It
works
for
overall
feelings
of
wellbeing
.
There's
data
to
support
it
.
It
works
for
depression
and
anxiety
.
So
again
,
it
is
a
very
important
hormone
.
Just
again
,
feel
.
It's
kind
of
similar
in
women
not
feeling
like
yourself
.
That's
kind
of
a
similar
phrase
they
sometimes
use
for
men
with
low
libido
.
Like
not
feeling
like
yourself
Because
,
again
,
in
both
men
and
women
,
testosterone
starts
Hysterectomy Types and Terminology
Speaker 2
17:12
to
decline
in
our
late
twenties
and
just
continues
to
decline
.
So
it's
very
common
for
men
to
seek
testosterone
replacement
,
but
it
should
also
be
common
for
women
to
seek
testosterone
replacement
to
continue
to
feel
our
best
selves
.
So
in
very
short
,
estrogen
is
a
grower
.
Progesterone
stabilizes
the
lining
,
but
can
be
used
for
sleep
and
anxiety
reduction
.
And
testosterone
is
great
for
libido
but
also
probably
has
other
benefits
to
muscles
,
bones
,
brain
.
Speaker 1
17:39
I
experienced
that
tenfold
when
I
started
testosterone
.
It
was
a
huge
difference
for
me
,
huge
difference
,
and
when
you
get
it
balanced
it
makes
a
big
difference
in
your
quality
of
life
,
for
sure
.
Speaker 2
17:52
And
again
all
those
,
yeah
,
and
all
those
again
.
And
things
complement
each
other
right
.
It's
like
you
know
,
women
feel
generally
so
much
better
when
they
get
a
little
extra
on
board
if
they're
having
hot
flashes
,
night
sweats
,
because
at
least
then
they
can
sleep
right
.
And
then
you
layer
on
even
improved
sleep
quality
,
and
then
you
layer
on
a
little
bit
extra
energy
and
libido
and
it
just
again
,
it
all
just
complements
each
other
.
Speaker 1
18:13
Yeah
,
you
know
there
are
kind
of
two
different
phases
of
hysterectomy
there's
a
partial
and
then
there's
a
full
hysterectomy
.
Does
that
affect
our
hormone
,
how
we
receive
hormones
if
we
need
hormone
replacement
therapy
,
and
then
how
does
that
affect
our
sexual
function
as
well
,
Because
they
kind
of
all
go
together
?
Speaker 2
18:32
right
.
Another
great
question
,
and
I'll
tell
you
we
do
a
bad
job
at
terminology
as
well
.
Even
I'm
so
confused
sometimes
when
patients
tell
me
like
I
had
a
total
hysterectomy
or
I
had
a
partial
hysterectomy
,
because
depending
on
what
they
mean
,
it
could
be
very
different
,
Right
?
So
I'm
just
going
to
talk
about
medically
what
the
term
hysterectomy
means
.
So
sorry
,
we're
going
to
go
down
this
rabbit
hole
for
a
second
,
but
I
like
it
.
Speaker 2
18:54
Hysterectomy
literally
means
removal
of
the
uterus
.
Ok
,
it
generally
involves
the
cervix
,
but
if
we
call
it
a
subtotal
or
a
partial
hysterectomy
,
that
means
we're
leaving
the
cervix
.
So
total
hysterectomy
when
I'm
talking
medically
to
my
medical
colleagues
,
is
removing
the
whole
entire
uterus
,
including
the
cervix
.
Subtotal
means
leaving
the
cervix
.
We
don't
usually
use
the
word
partial
.
Mostly
patients
will
sometimes
use
partial
,
but
usually
what
they
mean
by
that
is
that
the
ovaries
were
left
and
a
lot
of
times
the
term
total
hysterectomy
for
a
patient
they're
referring
to
.
They
took
all
my
female
organs
.
I
had
a
total
removal
of
my
female
organs
,
but
again
,
hyster
,
that
word
hyster
,
hysterectomy
,
ectomy
just
means
removal
and
hyster
means
womb
.
So
it's
removal
of
the
womb
.
So
that's
what
that
means
.
But
again
,
commonly
everything
is
sort
of
wrapped
into
that
.
But
it's
a
huge
distinction
and
a
lot
of
times
a
woman
doesn't
even
know
when
I
ask
,
well
,
did
they
leave
the
ovaries
?
And
they're
like
I
don't
know
.
I
had
a
full
hysterectomy
and
then
I'm
still
like
I
don't
know
either
,
because
that's
confusing
to
me
too
.
So
it's
really
important
to
know
,
if
you're
having
a
hysterectomy
,
what
else
is
being
removed
.
So
again
,
there's
the
cervix
,
there's
the
uterus
,
there's
the
tubes
and
the
ovaries
,
and
when
we
say
everything
,
then
I
would
say
that's
a
total
hysterectomy
with
a
bilateral
meaning
both
sides
salpingo
tubes
,
oophorectomy
,
ovaries
.
So
hysterectomy
with
bilateral
salpingo
oophorectomy
To
me
that's
everything
.
So
that's
just
so
we
have
the
terminology
.
So
when
a
woman
has
a
hysterectomy
with
bilateral
oophorectomy
and
salpingectomy
,
I
am
thinking
differently
about
her
hormones
,
because
the
ovaries
are
the
ones
producing
the
hormone
.
So
that's
,
if
she's
pre
or
perimenopausal
,
she's
going
to
go
right
into
surgical
menopause
.
If
she's
already
menopausal
,
she
may
or
may
not
notice
any
significant
abrupt
changes
because
already
her
hormones
were
very
low
to
start
with
.
But
a
pre
or
perimenopausal
woman
usually
is
going
to
have
that
abrupt
change
where
we
do
want
to
have
that
talk
about
how
she's
going
to
feel
right
afterwards
.
Speaker 2
20:59
Sexual
function
.
You
know
there's
been
some
elegant
studies
showing
that
the
cervix
isn't
generally
very
sensitive
to
being
removed
.
Meaning
they've
done
biopsies
of
the
cervix
.
There's
not
a
lot
of
nerve
density
there
but
again
,
some
women
depend
on
their
how
they
feel
their
erogenous
zones
.
Some
women
do
feel
like
having
the
cervix
there
was
important
for
their
sexual
function
.
So
I
think
most
of
the
data
says
there's
no
change
in
sexual
function
regarding
,
like
,
the
presence
or
absence
of
the
cervix
.
But
I
think
that's
a
very
patient
,
specific
thing
.
Speaker 2
21:35
Yeah
,
we
know
,
obviously
,
that
the
main
sexual
organ
is
the
clitoris
and
we're
not
altering
the
clitoris
in
any
way
.
Again
,
clitoris
equals
penis
.
They're
the
same
homologous
structures
and
that's
where
we
get
our
sexual
pleasure
.
But
again
,
it
doesn't
mean
that
some
other
pleasant
sensations
are
coming
from
the
cervix
or
uterus
.
So
the
other
part
of
your
question
is
so
if
a
woman
just
has
their
uterus
removed
,
does
that
change
hormones
?
And
the
answer
is
yes
.
So
whenever
we
dissect
the
uterus
from
the
ovaries
and
the
tubes
,
because
they
are
connected
that
does
interrupt
the
blood
flow
and
generally
puts
woman
into
menopause
one
to
two
years
sooner
than
she
naturally
would
.
So
if
she
was
in
perimenopause
and
kind
of
like
teetering
on
the
edge
,
that
might
be
enough
to
put
her
into
menopause
.
If
she
was
premenopausal
,
it
would
put
her
into
maybe
earlier
perimenopause
and
then
hence
earlier
menopause
,
because
,
again
,
it's
about
blood
flow
to
the
organ
which
is
the
ovaries
.
Speaker 1
22:32
And
how
do
you
tell
that
?
Because
for
those
who
don't
Sexual Function After Hysterectomy
Speaker 1
22:35
have
a
cycle
because
they
don't
have
the
uterus
,
how
do
you
tell
whether
they're
going
through
perimenopause
or
menopause
?
Is
it
based
off
of
just
symptoms
or
is
there
more
blood
work
that
needs
to
be
done
?
Because
I
know
a
lot
of
people
who
just
remove
the
ovary
and
they're
like
I
don't
know
which
way
is
up
or
down
with
my
cycling
.
Speaker 2
22:52
Yeah
,
yeah
.
When
just
the
uterus
is
removed
it
is
tricky
because
,
again
,
we
do
use
bleeding
patterns
as
a
marker
for
menopause
.
But
generally
the
symptoms
are
going
to
be
the
way
to
go
,
right
.
We
love
treating
symptoms
and
when
there's
no
symptoms
it's
like
oh
,
what
are
we
treating
?
You
know
,
I'm
not
really
sure
.
But
when
there's
symptoms
,
we
were
like
okay
,
this
is
clinical
,
bothersome
symptomatology
consistent
with
a
low
hormone
state
.
Speaker 2
23:15
So
again
,
hot
flashes
,
night
sweats
,
mood
changes
,
irritability
,
anxiety
,
depression
,
brain
fog
,
memory
loss
,
hair
loss
,
dry
eyes
,
dry
eyes
,
itchy
ears
,
heart
palpitations
,
musculoskeletal
pain
,
bladder
symptoms
,
all
of
those
things
vaginal
dryness
are
in
in
the
whole
realm
of
something
that
would
be
related
to
perimenopause
,
menopause
,
and
then
the
whole
like
when
do
we
check
labs
?
That's
a
you
know
.
You
know
you
could
always
do
a
point
counterpoint
in
that
,
because
whenever
I'm
counseling
patients
it
goes
something
like
this
we
can
always
check
labs
and
see
where
you
are
If
it's
perimenopause
,
meaning
they
haven't
had
surgery
,
and
they
just
kind
of
want
to
know
where
they
are
.
Almost
always
most
of
the
labs
are
normal
,
because
they
still
have
enough
gas
in
the
tank
and
,
depending
on
if
I
catch
them
on
a
up
cycle
or
a
down
cycle
,
you
know
,
generally
they're
normal
,
except
for
testosterone
.
That's
generally
already
at
a
low
point
.
Speaker 2
24:09
So
I
just
let
them
know
like
we
can
check
these
.
Almost
always
they're
going
to
be
normal
in
perimenopause
,
but
sometimes
women
just
want
to
know
and
I
think
that's
fine
.
It's
a
data
point
and
it's
a
place
to
start
.
But
if
we're
thinking
about
testosterone
replacement
,
we
do
have
clinical
practice
guidelines
that
state
that
we
do
need
to
know
where
their
baseline
is
and
we
do
need
to
make
sure
that
it's
somewhere
in
the
range
that
we
think
that
testosterone
replacement
would
be
beneficial
for
them
.
So
that's
a
place
that
we
do
need
to
check
labs
and
follow
labs
to
keep
them
in
the
safety
range
of
a
normal
female
.
Speaker 1
24:44
Yeah
,
what
are
some
setbacks
with
having
a
hysterectomy
and
taking
as
far
as
the
sexual
function
is
concerned
?
Because
I
know
personally
,
as
someone
who
struggled
,
once
I
got
my
testosterone
,
I
still
struggled
a
little
bit
vaginally
because
it
wasn't
comfortable
,
I
mean
it
just
.
And
then
you've
dealt
with
trauma
,
medical
trauma
,
you
know
,
having
IUDs
inserted
without
pain
medication
,
you
know
name
it
.
It's
probably
happened
,
right
.
And
so
how
do
we
,
what
are
some
of
the
drawbacks
to
that
and
how
do
we
talk
about
that
to
our
doctor
?
Speaker 2
25:20
Right
.
So
I
think
sometimes
,
or
even
even
a
good
doctor
that
talks
about
full
body
replacement
,
might
forget
about
local
vaginal
hormones
,
which
are
also
really
important
.
So
full
body
hormones
,
even
though
they're
called
full
body
or
systemic
hormones
,
they're
actually
not
enough
to
support
the
genitourinary
systems
.
The
genitourinary
systems
Because
,
again
,
full
body
hormones
are
just
getting
a
little
bit
of
gas
in
the
tank
.
We're
not
giving
back
the
full
amount
that
most
women
have
,
and
so
the
genitals
really
suffer
in
that
regard
and
generally
need
local
support
.
So
that's
generally
in
the
form
of
either
vaginal
estrogen
,
either
creams
,
tablets
,
suppositories
there's
vaginal
rings
or
through
other
suppositories
like
DHEA
,
which
converts
to
estrogen
,
testosterone
in
the
cell
level
.
Speaker 2
26:11
So
there's
different
ways
that
we
can
replace
the
hormones
in
the
vagina
.
Which
protects
against
,
you
know
,
pain
with
sex
or
dryness
related
pain
.
Protects
against
overactive
bladder
,
like
urgent
urinary
urgency
,
potentially
leakage
.
It
protects
against
recurrent
UTIs
and
changes
in
sexual
function
.
So
,
again
,
blood
flow
to
the
vulva
,
vagina
,
clitoris
is
really
important
to
maintain
a
healthy
sexual
function
.
All
these
places
are
really
sensitive
to
a
decline
in
hormones
.
Even
if
it's
still
half
a
quarter
gas
in
the
tank
,
it's
not
enough
for
the
genitals
,
Right
,
it's
really
important
.
Speaker 1
26:46
Yeah
,
I
experienced
that
personally
where
it
was
like
I
didn't
know
that
was
even
a
thing
.
Again
,
that
comes
back
to
that
educational
piece
where
you
I
had
this
surgery
but
I
wasn't
really
educated
on
the
hormone
piece
of
it
.
And
to
be
honest
,
I
think
this
is
what's
so
hard
about
navigating
a
hysterectomy
is
the
fact
that
not
many
providers
are
well-versed
in
both
the
hormone
piece
and
the
surgical
piece
to
be
able
to
treat
both
,
and
so
we
oftentimes
just
feel
left
out
in
the
cold
and
we
don't
know
which
way
to
go
.
But
I
know
that
for
me
personally
,
bringing
in
the
vaginal
estrogen
made
a
huge
difference
,
and
it's
not
even
just
for
me
,
for
the
intimacy
aspect
of
it
,
it's
the
dryness
,
the
itchiness
,
the
everything
else
that
goes
along
with
it
.
But
something
that
a
few
of
us
have
talked
about
before
is
that
we
don't
always
know
when
to
use
those
vaginal
supplements
,
because
we
don't
want
it
to
interfere
with
intimacy
.
Speaker 1
27:45
And
we're
already
a
little
self-conscious
or
sometimes
a
little
stressed
about
that
because
of
the
trauma
.
How
do
you
approach
that
with
your
patients
?
Speaker 2
27:53
That's
a
great
question
.
Number
one
women
hate
to
do
things
that
are
cumbersome
,
messy
and
could
potentially
transfer
to
their
spouse
.
Again
,
we're
very
sensitive
to
messy
things
in
and
around
the
genitals
right
,
we
want
to
always
be
clean
and
you
know
all
those
things
.
So
I
like
to
talk
to
patients
about
whatever
they're
doing
,
doing
it
on
a
routine
basis
.
So
you
know
,
probably
the
one
of
the
least
you
know
I
can
talk
about
like
the
least
messy
options
first
.
So
things
that
don't
cause
any
mess
are
vaginal
rings
.
So
I
do
love
vaginal
rings
.
There's
a
hormone
,
full
body
hormone
ring
and
there's
a
local
ring
.
One
is
called
the
fem
ring
,
one
is
called
the
east
ring
.
The
nice
thing
about
the
fem
ring
is
it
does
full
body
support
and
local
support
and
it's
literally
like
just
working
.
It's
just
in
the
vagina
,
just
working
constantly
and
there's
literally
only
mess
is
from
your
natural
lubrication
,
which
is
generally
a
good
thing
,
right
,
supporting
the
natural
lubrication
of
the
vagina
.
Speaker 2
28:50
But
,
again
,
some
women
are
like
ew
,
I
don't
want
something
in
my
vagina
,
and
I
totally
get
that
right
.
Next
is
the
tablets
.
Right
,
the
tiny
little
Vagifim
tablets
and
those
are
usually
twice
a
week
Generally
aren't
going
to
cause
really
.
I
mean
Vaginal Hormone Treatment Options
Speaker 2
29:02
,
there's
super
tiny
tablets
that
dissolve
in
the
upper
vagina
and
generally
don't
cause
hardly
any
mess
or
any
noticeable
anything
.
But
again
,
some
people
that
are
really
green
are
like
I
don't
want
to
be
like
you
know
,
throwing
away
all
this
plastic
applicators
all
the
time
,
et
cetera
,
et
cetera
.
So
there's
there's
that
,
there's
other
inserts
that
are
just
placed
with
the
finger
Invexi
again
,
another
tablet
insert
for
the
people
that
are
really
green
and
want
to
look
out
for
the
environment
.
It
was
kind
of
nice
because
there's
no
applicator
that
comes
with
that
.
Next
is
the
DHEA
suppositories
.
These
come
in
palm
oil
.
So
for
patients
that
are
really
dry
,
I
find
they're
nice
because
it's
a
natural
sort
of
emollient
for
the
vagina
and
it
also
helps
with
the
health
.
Speaker 2
29:42
But
again
,
some
people
are
like
nope
,
that's
too
much
for
me
,
like
I
don't
want
to
see
anything
on
my
underwear
at
all
.
Right
,
you
know
,
every
woman's
different
.
And
then
,
if
it
comes
down
to
the
cream
,
which
is
considered
to
be
like
the
most
messy
.
But
it
really
depends
and
I
am
a
cream
lover
it
really
depends
on
how
you
use
it
.
So
when
I
talk
to
women
about
the
cream
because
a
lot
of
times
women
need
something
in
the
upper
vagina
and
also
something
at
the
opening
,
because
that's
where
we
usually
feel
a
lot
of
our
symptoms
Usually
the
symptoms
of
irritation
and
itching
and
burning
is
usually
just
right
around
the
opening
of
the
vagina
and
that
area
called
the
vulvar
vestibule
,
which
is
just
right
next
to
the
opening
of
the
vagina
.
That's
where
things
are
the
most
sensitive
.
I
can
have
a
patient
with
the
upper
vagina
that
looks
glorious
,
but
then
their
opening
is
like
red
and
irritated
and
dry
and
sore
,
right
.
Speaker 2
30:30
So
it's
like
sometimes
we
do
need
cream
,
and
the
way
that
I
like
to
use
cream
is
to
actually
put
a
little
pea-sized
amount
on
the
finger
and
rub
it
into
the
tissue
.
If
you
think
about
it
like
moisturizer
or
sunscreen
,
right
,
you
wouldn't
just
like
put
a
dollop
on
your
face
and
then
,
like
you
know
,
walk
away
like
you
rub
it
in
,
right
,
just
like
lotion
your
hands
,
you
have
to
rub
it
in
.
So
if
you
are
someone
that's
concerned
about
the
messiness
of
cream
,
I
recommend
,
just
again
,
a
pea-sized
amount
on
the
finger
and
rubbing
it
into
the
tissue
until
it
is
absorbed
.
Generally
then
you're
not
,
it's
not
messy
,
you're
not
transferring
anything
.
There's
no
,
like
you
know
,
white
creamy
discharge
,
because
women
hate
discharge
.
They
also
hate
cleaning
an
applicator
full
of
cream
and
,
you
know
,
trying
to
get
it
cleaned
.
Speaker 2
31:16
All
these
things
are
cumbersome
,
right
,
and
the
goal
is
to
not
make
it
messy
,
difficult
or
annoying
so
that
we
increase
compliance
and
we're
able
to
actually
treat
the
symptoms
without
it
being
a
cumbersome
situation
.
But
for
patients
that
are
using
the
cream
just
on
the
outside
,
I
really
like
at
least
three
times
a
week
.
So
usually
there's
a
ramp
up
for
all
these
products
of
nightly
for
two
weeks
and
then
it's
a
maintenance
dose
of
two
to
three
times
a
week
.
I
really
like
three
times
a
week
.
You
can't
overdose
on
local
estrogen
products
and
if
it's
used
too
infrequently
it's
not
going
to
work
.
So
I
really
kind
of
like
with
the
cream
,
like
a
Monday
,
wednesday
,
friday
,
take
the
weekend
off
,
kind
of
a
plan
so
that
it's
getting
enough
hormone
to
the
tissue
.
Speaker 1
31:58
That
makes
sense
.
Speaker 2
31:58
I
had
.
Speaker 1
31:59
you
know
it's
interesting
.
I
had
a
friend
of
mine
tell
me
she
goes
,
can
you
ask
,
does
it
change
the
smell
of
the
flora
?
And
I
was
like
,
okay
,
I'll
do
that
.
But
that
is
a
concern
when
you're
dealing
with
the
intimacy
,
like
is
it
going
to
change
my
smell
down
there
?
Is
it
going
to
make
it
different
than
what
I'm
used
to
?
You
know
,
I
think
when
we're
talking
about
,
when
we're
already
maybe
self-conscious
about
intimacy
and
maybe
have
that
trauma
to
add
,
changes
can
be
a
little
intimidating
.
Is
that
a
thing
with
the
vaginal
estrogens
?
Speaker 2
32:34
Um
,
I
can't
,
I
can't
speak
for
everyone's
um
flora
,
but
I
will
tell
you
that
um
,
estrogen
itself
supports
a
healthy
bacterial
environment
and
I'll
just
kind
of
walk
through
how
that
does
.
I'm
going
to
little
like
geek
out
for
a
second
,
but
hopefully
your
listeners
won't
mind
.
But
basically
,
a
healthy
vagina
has
these
really
fluffy
and
big
superficial
cells
.
So
there's
like
a
tiny
little
nucleus
and
then
all
this
glycogen
that's
in
the
cell
.
Lactobacilli
are
the
healthy
bacteria
that
live
in
the
vagina
and
create
a
healthy
,
normal
smell
and
normal
environment
and
they
feed
off
of
the
glycogen
in
these
superficial
cells
.
So
the
lactobacilli
feed
on
the
glycogen
,
they
produce
lactic
acid
which
then
creates
an
acidic
pH
,
usually
around
4.5
or
less
.
That
supports
the
healthy
environment
of
the
vagina
.
Speaker 2
33:29
So
again
,
the
vagina
should
have
a
predominance
of
lactobacilli
.
It
also
has
a
little
bit
of
other
things
gardenerella
,
yeast
,
et
cetera
,
like
a
smaller
amount
.
And
again
,
it's
all
about
keeping
things
in
balance
with
the
pH
to
keep
a
normal
smell
.
Um
,
the
way
,
the
way
nature
intended
,
if
we're
supporting
the
normal
,
healthy
layers
of
the
vagina
with
having
those
superficial
fluffy
cells
,
which
are
the
healthy
cells
that
are
made
when
we
have
enough
estrogen
,
then
it
supports
that
natural
lower
pH
,
which
is
a
good
,
healthy
environment
for
the
vagina
.
So
hopefully
,
that'll
help
.
Speaker 1
34:06
Yeah
,
I
mean
,
these
are
all
valid
questions
and
concerns
that
people
have
and
something
that
I
think
maybe
we
can
touch
on
a
little
bit
more
is
that
reoccurring
pain
after
surgery
,
specifically
vaginally
,
doesn't
always
mean
your
hormones
are
off
.
It
could
mean
something
else
is
a
little
bit
more
sinister
.
And
can
you
speak
to
that
a
little
bit
and
we
have
,
you
know
,
we're
balancing
our
hormones
,
but
things
are
still
not
right
,
whether
that's
in
the
urinary
tract
or
whatever
.
There's
got
to
be
other
things
that
can
contribute
to
that
as
well
.
Speaker 2
34:42
Absolutely
so
.
I'd
say
in
the
immediate
,
like
immediate
post-op
course
,
the
most
common
is
a
UTI
bladder
infection
because
most
women
have
had
instrumentation
of
the
bladder
and
urethra
during
hysterectomy
.
That's
a
part
of
the
procedure
to
look
in
the
bladder
and
urethra
and
then
a
lot
of
times
there's
a
part
of
the
procedure
to
look
in
the
bladder
and
urethra
and
then
a
lot
of
times
there's
a
Foley
catheter
that's
been
inserted
either
at
the
time
of
surgery
or
even
sometimes
is
needed
for
a
short
amount
after
surgery
if
there's
any
difficulty
with
urination
.
So
UTIs
are
probably
the
most
common
source
of
immediate
pain
and
quote-unquote
complications
after
a
hysterectomy
.
Now
,
in
absence
of
that
,
the
vulva
,
urethra
and
bladder
are
all
again
really
sensitive
to
declines
in
hormones
and
can
just
even
feel
like
a
UTI
when
it's
not
a
UTI
.
So
just
urgency
,
frequency
,
sometimes
even
some
pain
with
urination
,
because
when
the
urine
sprays
on
the
sensitive
vulva
it
feels
irritated
.
So
there
can
be
hormonal
changes
of
the
bladder
,
urethra
,
vulvar
,
vestibule
that
are
just
caused
like
general
irritation
and
inflammation
.
But
then
we
also
think
about
the
other
larger
musculoskeletal
system
,
so
the
pelvic
floor
muscles
themselves
.
So
most
women
that
have
had
a
chronic
pelvic
pain
condition
their
muscles
have
been
trying
so
hard
to
guard
against
pain
they
don't
even
know
they're
doing
it
.
But
a
lot
of
times
the
muscles
are
extremely
tight
and
tender
.
Even
though
the
uterus
,
cervix
,
potentially
tubes
and
ovaries
are
gone
,
that
muscles
are
still
remembering
all
that
pain
and
are
still
like
,
super
tight
.
Speaker 2
36:15
And
working
with
a
good
pelvic
floor
physical
therapist
can
teach
patients
.
Okay
,
this
trauma
is
now
improved
,
but
I
need
to
relearn
how
to
relax
my
pelvic
floor
Because
a
lot
of
it's
unconscious
.
You
know
some
people
carry
tension
in
their
you
know
their
upper
back
and
they're
walking
around
like
this
right
.
And
some
people
keep
tension
in
their
pelvis
,
especially
patients
that
have
pelvic
pain
,
and
it's
teaching
them
how
to
do
deep
diaphragmatic
breathing
,
understanding
how
their
body
feels
and
again
,
relaxing
the
pelvic
floor
,
and
that
usually
does
take
some
time
,
especially
patients
that
have
had
chronic
pain
for
a
long
time
.
Speaker 2
36:52
There
can
still
be
some
you
know
,
I
hate
to
say
it
implants
still
.
You
know
that
were
maybe
not
found
,
but
sometimes
some
implants
are
still
on
the
bowel
or
inside
the
abdominal
cavity
of
some
places
that
still
cause
some
lingering
pain
.
So
that's
also
possible
.
But
again
,
after
surgery
,
generally
that
significantly
improves
and
then
again
,
sometimes
it's
a
nerve
that's
just
super
inflamed
.
Okay
.
So
nerves
over
time
get
sensitized
to
pain
and
it's
called
nerve
sprouting
,
create
additional
fibers
that
basically
are
upregulated
and
just
sense
pain
more
easily
than
normal
nerves
that
are
have
not
been
traumatized
.
So
those
are
all
the
things
I
kind
of
think
about
when
I'm
thinking
about
you
know
,
post-op
public
pain
.
Those
are
all
the
things
I
kind
of
think
about
when
I'm
thinking
about
you
know
post-op
pelvic
pain
.
Speaker 1
37:39
You
know
,
something
that
I
hear
a
lot
of
people
experience
is
bladder
spasms
even
after
.
I
think
that's
something
that
people
don't
really
know
how
to
address
.
Do
hormones
help
that
,
or
is
that
really
you
need
to
have
like
Botox
or
you
know
a
block
?
In
there
somehow
.
But
do
hormones
help
with
that
?
Speaker 2
37:58
Absolutely
.
Or
you
know
a
block
in
there
somehow
.
But
do
hormones
help
with
that
?
Managing Post-Surgery Pain
Speaker 2
38:05
Absolutely
.
So
that's
what
we
term
the
genital
urinary
syndrome
of
menopause
.
So
we
know
that
obviously
,
again
,
hormones
support
the
whole
body
,
but
the
genitals
and
the
urinary
system
are
really
really
exquisitely
sensitive
to
decline
in
hormones
.
Speaker 2
38:12
So
the
bladder
can
have
bladder
spasms
,
like
I
got
to
go
.
I
got
to
go
right
now
,
so
urine
,
that's
called
urinary
urgency
and
then
frequency
,
like
I
went
to
the
bathroom
but
like
30
minutes
later
I
feel
like
I
have
to
go
again
,
you
know
.
So
that's
like
feeling
like
you
have
to
go
all
the
time
,
or
sometimes
even
what
we
call
an
incomplete
,
a
sense
of
incomplete
emptying
where
it's
like
I
know
I
just
went
,
I
haven
sensitive
to
anything
,
any
sort
of
bladder
filling
.
A
lot
of
times
that's
associated
with
urinary
leakage
,
which
is
of
course
even
more
bothersome
.
It's
like
one
thing
to
have
to
go
a
lot
and
that's
another
thing
to
be
leaking
.
Speaker 2
38:48
So
my
first
line
approach
is
hormone
replacement
locally
,
so
meaning
vaginal
estrogen
products
,
especially
when
it's
time
related
to
a
change
in
hormones
.
So
that's
where
I
start
just
replenish
the
local
tissues
.
But
a
lot
of
times
there
are
additional
therapies
that
are
needed
.
You
know
behavior
,
lifestyle
,
pelvic
floor
,
physical
therapy
,
learning
how
to
strengthen
the
muscles
,
and
then
there's
advanced
therapies
Botox
,
nerve
stimulation
.
That
can
also
be
done
if
things
aren't
responsive
to
behaviors
,
physical
therapy
and
hormones
.
Speaker 1
39:21
Right
,
something
that
you
just
brought
up
which
I
think
we
need
to
talk
just
a
little
bit
more
about
,
and
that
is
the
role
of
mental
health
professionals
when
it
comes
to
making
such
a
big
shift
in
your
body
and
in
your
life
,
and
I
know
a
lot
of
people
who
have
hysterectomies
and
oophorectomies
.
They
have
a
sense
of
grief
and
loss
and
then
,
on
top
of
that
,
they
are
still
struggling
with
their
sexual
health
,
and
how
do
you
help
patients
that
come
into
your
office
who
are
still
struggling
with
a
lot
of
this
?
Because
that's
a
huge
change
and
huge
shift
in
someone's
body
and
part
of
their
identity
,
in
a
way
100%
.
Speaker 2
39:58
There's
actually
one
of
my
colleagues
,
libby
Chang
.
She's
extensively
published
on
the
concept
of
the
value
of
the
uterus
and
she
actually
developed
a
questionnaire
about
women
and
their
how
much
value
they
put
on
their
genital
organs
.
So
it's
like
it's
about
a
third
a
third
,
a
third
to
a
third
of
patients
like
don't
really
care
,
one
way
or
the
other
,
the
uterus
doesn't
make
them
feel
any
more
or
less
womanly
.
But
then
there's
a
third
that's
like
no
,
this
really
makes
me
feel
womanly
.
And
then
there's
a
third
like
I
hate
it
,
get
it
out
of
my
body
.
You
know
so
it's
just
an
interesting
dynamic
,
but
if
you
don't
ask
the
question
,
we
don't
know
.
Speaker 2
40:30
So
the
women
that
is
are
thought
to
be
more
bothered
by
hysterectomy
,
or
women
that
really
strongly
valued
the
presence
of
their
uterus
as
a
sense
of
their
identity
and
their
womanhood
,
meaning
like
this
is
where
my
babies
grew
,
this
is
how
I
feel
.
You
know
that
I'm
a
woman
and
now
I
don't
have
this
,
and
it
really
is
detrimental
to
their
mental
health
.
But
I
don't
think
that's
the
only
thing
going
on
if
the
blood
flow
has
been
disrupted
or
if
the
ovaries
have
been
removed
,
because
then
we're
talking
about
a
totally
different
situation
where
it's
like
such
a
huge
hormonal
shift
that
the
hormones
are
causing
anxiety
,
depression
,
et
cetera
.
It's
two
things
going
on
and
it's
hard
to
determine
exactly
which
is
happening
.
But
both
need
to
be
supported
and
I'm
absolutely
in
full
support
of
having
a
really
good
mental
health
provider
.
Speaker 2
41:17
Sometimes
a
sex
therapist
is
also
really
important
because
the
symptoms
are
predominantly
sexual
meaning
.
Like
I
have
low
libido
and
now
this
is
causing
a
huge
mismatch
in
my
marriage
and
now
my
spouse
might
want
to
leave
me
and
I
just
don't
have
any
desire
and
like
when
it
goes
down
that
way
,
then
really
the
best
mental
health
provider
is
a
sex
therapist
,
because
they
can
balance
and
they
can
focus
on
a
sexual
health
and
also
they're
pretty
good
also
at
understanding
hormones
and
hormone
changes
.
So
those
are
kind
of
my
I
,
really
.
I
really
.
Unless
there's
zero
sexual
symptoms
,
which
is
rare
,
I
generally
opt
for
sex
therapists
in
this
situation
.
Speaker 1
41:55
Is
there
ways
that
you
help
medically
manage
that
as
well
,
if
they
have
low
libido
beyond
just
the
hormone
replacement
therapy
,
because
there
might
be
those
people
who
really
struggle
still
after
hormone
replacement
therapy
.
Speaker 2
42:08
Yeah
,
yeah
,
so
there's
two
FDA
approved
medications
,
e
erythrobancerin
and
then
Vileci
brimelanotide
,
and
those
work
on
the
neurotransmitters
,
so
those
are
on
label
to
treat
women
that
are
suffering
from
low
libido
.
Of
course
they're
labeled
for
premenopausal
patients
,
so
a
little
bit
we
have
to
go
through
prior
off
to
get
those
that
are
generally
not
not
a
problem
to
get
covered
for
patients
.
After
a
little
bit
of
paperwork
,
after
a
little
bit
of
paperwork
.
So
yeah
,
when
hormones
are
all
plussed
up
,
then
a
lot
of
times
it
is
a
neurotransmitter
issue
if
we're
thinking
about
just
pure
biology
.
But
again
,
I
never
want
to
think
that
it's
just
pure
biology
.
That's
just
why
we
talk
about
like
,
how's
your
relationship
,
what's
going
on
in
your
life
,
what
are
your
stressors
?
Speaker 2
42:54
Because
midlife
is
this
like
very
stressful
time
for
most
women
,
where
their
kids
are
,
you
know
,
teenage
years
,
and
then
their
parents
are
aging
,
they're
usually
their
job
.
If
they're
in
the
job
,
world
is
getting
more
and
more
complex
and
then
their
spouse
is
wanting
to
leave
them
because
they
won't
have
sex
,
but
they're
super
fatigued
and
it's
just
like
,
you
know
,
they
might
have
a
parent
dying
,
like
it
is
just
very
challenging
time
.
So
that's
the
psychosocial
Mental Health and Body Identity
Speaker 2
43:21
piece
that
the
mental
health
slash
sex
therapist
can
also
address
if
there's
any
concerns
in
that
area
.
Because
,
again
,
it's
not
just
biology
.
If
you
hate
your
partner
and
your
partner's
abusive
or
mean
or
whatever
right
,
no
amount
of
hormone
or
neurotransmitter
is
going
to
make
my
patient
like
their
spouse
again
if
they're
an
awful
person
.
So
we
call
that
a
you
know
,
a
boyfriendectomy
or
a
husbandectomy
or
whatever
.
Speaker 1
43:44
Just
excuse
them
out
of
the
room
and
space
.
Yeah
exactly
how
can
patients
and
providers
work
together
to
ensure
accurate
diagnosis
and
treatment
of
pelvic
pains
or
low
libido
or
hormone
imbalances
?
How
can
they
work
together
and
how
can
they
find
a
provider
to
work
with
them
?
Yeah
,
that's
a
really
great
question
.
Speaker 2
44:07
There
are
great
organizations
,
but
basically
there's
a
bunch
of
different
pelvic
pain
societies
that
I
think
it's
always
good
for
patients
to
educate
themselves
because
I
know
it's
probably
not
shocking
but
medical
education
isn't
always
perfect
and
providers
aren't
always
aware
of
everything
.
I
can't
tell
you
and
this
is
I
hate
to
say
this
,
but
I'm
going
to
share
it
anyway
I
can't
tell
you
how
many
patients
come
to
see
me
after
their
hysterectomy
and
bilateral
salpingoephrectomy
having
the
exact
same
pain
they
had
before
,
because
the
pain
was
misdiagnosed
as
endometriosis
and
wasn't
endometriosis
at
all
.
It
was
vulvodynia
or
bladder
pain
syndrome
or
a
variety
of
other
musculoskeletal
pain
conditions
.
And
that
really
fires
me
up
,
because
now
we've
done
a
major
surgery
on
a
patient
,
reeked
to
have
it
on
her
hormones
and
she's
still
not
any
better
from
a
pain
standpoint
.
So
when
I'm
teaching
medical
students
,
residents
,
fellows
,
I
make
sure
that
we
do
a
very
comprehensive
pain
mapping
,
where
we
start
on
the
outside
and
we
slowly
work
our
way
in
covering
all
the
possible
areas
of
pain
.
Because
,
again
,
most
of
the
time
women
just
have
a
speculum
exam
and
then
a
very
uncomfortable
internal
exam
.
We
call
it
bimanual
exam
and
it's
not
very
specific
on
you
know
,
everything's
getting
touched
all
at
one
time
.
And
then
doctors
ask
does
it
hurt
here
?
You
know
,
as
they're
mashing
everywhere
and
the
woman's
like
,
yes
,
it
hurts
everywhere
,
right
,
right
,
and
then
they
get
.
And
then
they
get
signed
up
for
hysterectomy
and
you
know
,
bilateral
salpingoephrectomy
,
and
that's
not
always
the
right
thing
.
Speaker 2
45:42
So
my
point
in
saying
all
that
is
there's
lots
of
pelvic
pain
conditions
,
endometriosis
is
super
common
,
which
is
why
it
gets
,
you
know
,
rightly
so
,
a
lot
of
attention
.
But
some
of
the
other
ones
that
are
also
there
sometimes
are
missed
and
misdiagnosed
and
then
the
woman
actually
gets
the
wrong
treatment
.
So
I
think
knowing
all
the
possible
pelvic
pain
conditions
and
knowing
kind
of
the
classic
symptoms
are
important
.
So
just
really
quickly
,
you
know
,
if
I'm
thinking
about
working
my
way
from
outside
to
inside
,
the
first
thing
I'm
looking
at
is
vulvar
pain
,
so
vulvodynia
.
Then
I'm
looking
,
and
also
the
genitourinary
syndrome
,
menopause
.
Speaker 2
46:18
And
then
I'm
looking
at
is
vulvar
pain
,
so
vulvodynia
,
then
I'm
looking
,
and
also
the
genitourinary
syndrome
,
menopause
.
And
then
I'm
looking
at
the
bladder
,
so
bladder
pain
syndrome
.
I'm
looking
at
the
musculoskeletal
system
,
the
levator
,
so
levator
myalgia
.
I'm
feeling
for
the
bowel
,
the
rectum
as
well
,
because
sometimes
again
there's
implants
there
.
And
then
I'm
touching
the
cervix
,
looking
for
cervicitis
like
an
infection
of
the
cervix
.
And
then
I'm
doing
the
uterus
and
ovaries
separately
to
kind
of
evaluate
those
last
,
because
if
you
have
a
systematic
way
of
approaching
the
pain
evaluation
,
you're
going
to
get
more
information
than
just
a
let
me
mash
all
around
and
see
what
happens
it
is
alarming
to
see
how
many
people
tell
me
I
had
a
hysterectomy
,
I'm
like
why
?
Speaker 1
46:59
And
they're
like
Final Thoughts on Hysterectomy Education
Speaker 1
47:00
I
don't
really
know
.
Speaker 2
47:02
And
I'm
like
that's
a
problem
.
Speaker 1
47:04
You
should
know
why
you
are
having
hysterectomy
.
Speaker 2
47:08
It's
a
big
surgery
.
It
is
and
again
it's
thank
goodness
like
most
gynecologists
are
really
skilled
at
performing
the
surgery
and
complications
are
rare
.
But
it's
still
a
big
surgery
.
It's
a
big
recovery
.
It's
changes
to
the
hormones
.
Potentially
it's
you
know
,
potentially
if
you're
that
woman
that
values
your
uterus
and
now
you
don't
feel
like
a
woman
anymore
and
your
body
image
changes
like
all
.
These
are
really
big
issues
and
shouldn't
be
just
taken
lightly
.
So
again
to
your
point
education
is
huge
,
advocacy
is
huge
,
educating
yourself
before
you
go
into
a
doctor's
visit
is
really
important
.
Speaker 1
47:40
Yeah
,
oh
,
this
was
so
good
.
Thank
you
so
much
for
covering
all
of
this
,
and
I
know
there's
probably
so
much
more
we
could
even
talk
about
,
but
I
just
appreciate
you
sitting
down
and
taking
time
out
of
your
busy
schedule
to
go
over
all
of
these
things
.
I
think
it's
going
to
be
extremely
helpful
for
a
lot
of
people
navigating
this
journey
of
hysterectomy
and
hormones
.
So
thank
you
so
much
for
taking
the
time
.
It's
been
my
pleasure
,
alana
.
Thank
you
.
Until
next
time
,
everyone
continue
advocating
for
you
and
for
those
that
you
love
.