The dreaded, uncomfortable, annoying, burning, itchy, achy, irritating vaginal infection. Ladies, we have all been there. And for those unicorns that have never had a vaginal infection such as yeast or bacterial vaginosis, well, you are certainly one of the lucky ones. While a yeast infection or BV is not life-threatening, not fatal, and maybe not an emergency, that does not mean it’s not urgent. Especially vaginal infections that are chronic or keep returning can be incredibly annoying, painful, and frustrating. It is very accurate that once you have a yeast infection or vaginal infection like BV, it can come back over and over. I have had many patients come to see me because no one could help them with their vaginal issues. Not only is it embarrassing and uncomfortable, but often, doctors will blow off vaginal issues. Perhaps it was not expressed enough as an issue. As I know it can be challenging to talk about issues ‘downstairs’ to a stranger, doctor, or no doctor. Geez, most women have told me that their mothers and grandmothers would not go near the subject of anything to do with ‘the vagina.’ So can you imagine telling a doctor you have never met that you are in pain, super itchy, tender, uncomfortable, and not-normal discharge is discharging, a lot… takes a lot of courage to say. As I said, a vaginal infection is not fatal. It might feel like your vagina is on fire, but you will live. Uncomfortably live to say the least. I think it is essential to talk about having a vaginal infection. If you had a sinus infection, no one would bat an eye. If you have an ear infection, that is easy to talk about. It should be the same with vaginal infections. Bacterial vaginosis (BV) and yeast (candida) infections have nothing to do with hygiene and are not contagious. They can happen for many reasons, just like an ear infection or sinus infection. So that leads me to a great question from a reader about her issues with vaginal infections. She says she had 6 yeast infections in six months and more months of grief with no relief. I really feel for this woman because that is not how to live life. After all the treatments she has used and put on/in her poor vagina, she is terrified to put anything else near it. I don’t blame her. But what a predicament to be in. I am sure she is not even contemplating being intimate, let alone sexual, when her poor privates are on fire. I’m sure she is constantly worried that darn infection lurks around the corner at every turn. Here is our reader’s question, which I will answer (we always change the name for privacy).   Melissa’s Question: I am 52. Have Sjogrens and Hashimotos. I have Atrophic Vaginitis. A year ago I started Vagifem for 3 weeks. Yeast infection after. Then I was put on Premarin Cream then yeast again. But I continued with the Premarin. I did this for 6 months and treated 6 yeast infections during this time. Finally I stopped all medications and took a vaginal moisturizer. I did well with this for three months. Then I got another yeast infection or so I thought. This has been a battle for another 2 months. The dr did swabs and everything negative for yeast BV STI. I feel swollen in the vag and when I urinate I feel pain afterward and sitting feels like my vag is hurting. No cystocele or rectocele. I have also reacted to lubes with glycerine or glycol. Now the Dr wants me to start Intrarosa and I am paranoid to start incase I get yeast. Does anyone have any advise as I am at my witts end! I will answer Melissa’s questions plus: What are GSM and Vaginal Atrophy? What is Vagifem? What vaginal Premarin? What is a vaginal moisturizer? What are yeast and BV? What is Interrosa? What is Sjogren’s syndrome What is Hashimotos? How about Estriol for GSM?   What are GSM and Vaginal Atrophy? GSM stands for genitourinary syndrome of menopause. It is a new term that replaces vaginal atrophy. But GSM and vaginal atrophy can be used interchangeably. When a woman enters menopause, her ovaries stop producing estrogen and progesterone. The vaginal cells and tissues respond and maturate to estrogen. So when the estrogen levels drop, you will see changes in the vaginal tissues and cells. Immature vaginal cells are called parabasal cells. Parabasal cells are like baby vaginal cells. You feed them estrogen, and they will grow into mature vaginal cells. When the estrogen levels drop in menopause, you will see changes in the vaginal tissues. It can cause vaginal dryness, pain with intercourse, and even bleeding from the fragile, thin tissues of the vaginal vault. Also, because there is less lubrication and more fragile tissues, it can alter the biome of the vaginal canal. The vaginal canal/vault has a symbiotic relationship with bacteria, yeast, organisms, and flora. When the vaginal tissues and cells change during menopause, this can disrupt the flora balance increasing the risk of vaginal infections. Also, when this flora is disrupted, it can cause an increase in urinary tract infections (UTIs). Disrupting the beneficial bacteria can allow e.coli to travel up the urethra to cause a UTI. Also, estrogen can help tone the urethra (the tube from your bladder to the outside world). When the estrogen levels drop in menopause, the urethra can become more lax, allowing easier access for the e.coli to cause a UTI. And it can cause urinary leakage, also called urinary stress incontinence. You know, jumping jacks, coughing, sneezing, laughing, exercising, anything you are putting a little strain on the bladder can cause a little leakage. I like the new term GSM, even if it is a mouthful to say, genitourinary syndrome of menopause. It explains that more can happen to the vaginal vault and urinary tract than just vaginal dryness.  

Can Progesterone Cause Anxiety? Often we get reader/listener questions about their own experience with hormones. We love that readers of our blogs and listeners of the podcast (TheProgressYourHealth Podcast) reach out for more information. If they have concerns and questions, that means many, many other people have the same concerns. A lot of questions we get are hard to get answers online. Honestly, hormones and hormone replacement is an art that should be designed around the patient. Every person taking hormone replacement has different reasons for doing so. Those hormone goals can range from weight loss, mood improvement, insomnia, bone density, energy to sex drive just to name a few. Those of you that are regular listeners/readers, I’m sure, have heard this from me a thousand times over. And I will continue on that soap box, so bear with me. Hormone replacement is not a cookie-cutter approach where one size fits all. It needs to be tailored to the individual. This article is about a recent podcast that we did on a reader question. I feel this is an interesting question because it is about hormone replacement therapy, but there are so many nuances to tease apart. When talking about hormones, everyone is focused on the estrogen and progesterone dosing and not considering the other hormones involved that could be part of the issue. Here is the question (we always change the names of readers and listeners to protect privacy).   From ‘Kathy’ Hi Dr. Davidson. My question to you, is what do you suggest if a woman is on Biest and can’t take the Prometrium because it has the opposite effect and gives her anxiety? Yes, she has a uterus, yes she is on Biest, but what if cream is her only option? Thanks in advance 🙂 – Kathy   There is a lot to tease apart here, but let’s explain a little more thoroughly about the hormone regime she is on.   What is Biest? Biest is an estrogen combination of estriol and estradiol. There are three main estrogens in a female’s body. Those are Estrone (E1), Estradiol (E2) and Estriol E3). Estrone is not commonly used, and it is mainly seen in younger women going through puberty or is made by adipose tissue. Adipose tissue is ‘fat’ tissue, and yes, your fat is like its own endocrine gland, secreting other hormones and estrone (lepton, adiponectin to name a few popular ones). Biest is part of bio-identical hormone replacement, meaning the estriol and estradiol are made from plants to look exactly like what our own bodies make. So if it looks just like what our bodies make, then it will have a better response and fewer side effects. Kathy is taking a Biest cream for her estrogen replacement, which is commonly used as a cream. She applies her biest cream topically, also called transdermally. You can apply your hormone cream to the inner thigh or back of the knee. Because all hormones are fat-soluble, and the inner thigh, as we all know, has an excellent fatty pad there, making it a great site. Applying hormones to thin tissue like the inner arms, can cause quick absorption and then it is eliminated from the system quickly. Plus, inner arms means you could share it when you hug or touch or carry pets or other humans. Some research shows that the neck and face are excellent places for transdermal absorption. But if you love giving kisses to your pets, little ones or family, you could end up sharing your hormones.   Progesterone for Uterus Protection: As Kathy mentioned in her question, she could not tolerate the Prometrium (an oral form of progseterone), and she has a uterus. The reason she mentions this is because it is essential to take progesterone anytime you are taking estradiol/estrogen therapy and you have a uterus. Estrogen loves to grow things, especially the uterine lining. If Kathy did not take progesterone and only took biest (estriol/estradiol), it would be a matter of time before her uterine lining started to increase. This can cause spotting, abnormal uterine bleeding, a period, and an increased risk for uterine cancer.   Oral Progesterone or Cream for Uterine Protection: If you have a uterus and are taking estrogen therapy for hormone replacement it is important to take an oral form of progesterone. The oral form protects the lining much better compared to the cream. I do not think it is appropriate to take progesterone cream when taking estrogen therapy because of the risk of thickening the uterine lining. I do not prescribe less than 100mg of oral progesterone when a woman is taking a form of estrogen therapy and has a uterus. Some women may need a higher dose of progesterone, such as 125-200 mg, or even a little higher. But it really should be oral progesterone. It was asked of me if a progesterone troche could be a replacement for oral progesterone. A troche is a sublingual tablet/gel tablet that you put under your tongue or the side of the cheek of your mouth. It is meant to be sublingually absorbed. Meaning a troche would not be an oral form of progesterone. I have found that the troches are absorbed sublingually, but there is an oral component of it as some of it will be swallowed. But even still, I do not think a troche could protect the uterus as well as a oral form.   What if a Woman with a Uterus just cannot take oral progesterone? There are a few options here. One, would be she just could not take biest. At least in my practice, I would not feel comfortable prescribing any estrogen/estradiol therapy without oral progesterone to protect the uterus. Two, find out if it is the oral progesterone causing the issue. I have run into this issue in the past with patients. And all the time, we find a way to take oral progesterone or find out if it is something other than

Can Progesterone Cause Anxiety?
Often we get reader/listener questions about their own experience with hormones. We love that readers of our blogs and listeners of the podcast (TheProgressYourHealth Podcast) reach out for more information. If they have concerns and questions, that means many, many other people have the same concerns. A lot of questions we get are hard to get answers online.
Honestly, hormones and hormone replacement is an art that should be designed around the patient. Every person taking hormone replacement has different reasons for doing so. Those hormone goals can range from weight loss, mood improvement, insomnia, bone density, energy to sex drive just to name a few. Those of you that are regular listeners/readers, I’m sure, have heard this from me a thousand times over. And I will continue on that soap box, so bear with me.
Hormone replacement is not a cookie-cutter approach where one size fits all. It needs to be tailored to the individual. This article is about a recent podcast that we did on a reader question. I feel this is an interesting question because it is about hormone replacement therapy, but there are so many nuances to tease apart. When talking about hormones, everyone is focused on the estrogen and progesterone dosing and not considering the other hormones involved that could be part of the issue.
Here is the question (we always change the names of readers and listeners to protect privacy).
 
From ‘Kathy’
Hi Dr. Davidson.
My question to you, is what do you suggest if a woman is on Biest and can’t take the Prometrium because it has the opposite effect and gives her anxiety?
Yes, she has a uterus, yes she is on Biest, but what if cream is her only option? Thanks in advance 🙂 – Kathy
 
There is a lot to tease apart here, but let’s explain a little more thoroughly about the hormone regime she is on.
 
What is Biest?
Biest is an estrogen combination of estriol and estradiol. There are three main estrogens in a female’s body. Those are Estrone (E1), Estradiol (E2) and Estriol E3). Estrone is not commonly used, and it is mainly seen in younger women going through puberty or is made by adipose tissue. Adipose tissue is ‘fat’ tissue, and yes, your fat is like its own endocrine gland, secreting other hormones and estrone (lepton, adiponectin to name a few popular ones).
Biest is part of bio-identical hormone replacement, meaning the estriol and estradiol are made from plants to look exactly like what our own bodies make. So if it looks just like what our bodies make, then it will have a better response and fewer side effects.
Kathy is taking a Biest cream for her estrogen replacement, which is commonly used as a cream. She applies her biest cream topically, also called transdermally. You can apply your hormone cream to the inner thigh or back of the knee. Because all hormones are fat-soluble, and the inner thigh, as we all know, has an excellent fatty pad there, making it a great site. Applying hormones to thin tissue like the inner arms, can cause quick absorption and then it is eliminated from the system quickly. Plus, inner arms means you could share it when you hug or touch or carry pets or other humans. Some research shows that the neck and face are excellent places for transdermal absorption. But if you love giving kisses to your pets, little ones or family, you could end up sharing your hormones.
 
Progesterone for Uterus Protection:
As Kathy mentioned in her question, she could not tolerate the Prometrium (an oral form of progseterone), and she has a uterus. The reason she mentions this is because it is essential to take progesterone anytime you are taking estradiol/estrogen therapy and you have a uterus. Estrogen loves to grow things, especially the uterine lining. If Kathy did not take progesterone and only took biest (estriol/estradiol), it would be a…

When is it too Late to Start HRT?
Recently we received a great question/comment from a listener of our podcast (The Progress Your Health Podcast). I’ll call her ‘Jenny’ (because I never reveal any personal information for the sake of privacy). Jenny was wondering if she is too far into menopause to be able to take bio-identical hormone replacement therapy.
She has been post-menopausal for the last ten years, using an estradiol vaginal insert for her GSU/vaginal atrophy. Her pharmacist thought that changing her prescription and implementing bio-identical hormone replacement could help with her bones, cholesterol, and heart protection. This is an excellent question, as many other women have these same thoughts.

Am I too old to take/start bio-identical hormone therapy?
Are hormones going to help my cholesterol?
Is hormone therapy going to help reduce the risk of cardiovascular disease?
Can hormone replacement help with bone density?

Below is the question from our podcast listener:
 
Hi
I am a healthy and uber fit 60 yr woman who has been menopausal for ten years. My chief complaint is GSM. I have been on 10mcg Vagifem for this entire time, 3-6/week. Well-controlled. My cholesterol is 7! LDL 3.5 / HDL 3.28
I saw a pharmacist who is a BHRT specialist, and she recommends:
.25mg BiEst, 100mg progesterone and +- testosterone depending on levels. She thinks this will balance my hormones better, possibly improve my lipid profile, and protect my heart and bones. Am I too late in the game for BHRT? Do you agree with her suggestions?
 
What is GSM?
GSM stands for genitourinary syndrome of menopause. It is a new term that replaces vaginal atrophy. GSM and vaginal atrophy can be used interchangeably. Vaginal atrophy occurs when the estrogen levels drop causing changes in the vaginal tissues. Estrogen really primes the vaginal cells and will maturate them from parabasal cells into mature vaginal cells. When the estrogen drops in menopause, the tissues can become dry, with less lubrication and the tissues can become more fragile. This is where you will find pain or even bleeding (from the tissues tearing) with intercourse.
I like the term GSM, genitourinary syndrome of menopause because when the estrogen drops it can cause so much more than just dry, fragile vaginal tissues. It can cause the flora of the vaginal vault to change. This increases the risk of vaginal infections such as yeast/candida and bacterial vaginosis. It can also cause more increased risk for urinary tract infections. As well as urinary stress incontinence. The urethra (the tube that connects the bladder to the outside world, aka the toilet), can become more lax when the estrogen levels drop in menopause.
This can cause urinary leakage with coughing, jumping, laughing, exercising, sneezing, doing crunches, jogging, walking, you get the drift. GSU/vaginal atrophy can be so mild that women do not even notice any changes. And other women can have such severe symptoms that they cannot even go for a walk without the tissues chaffing and causing pain.
Jenny had been using an estradiol vaginal insert (vagifem) to help with her GSM/vaginal atrophy symptoms and was getting excellent results. Ideally when using an estrogen vaginal application, the estrogen is not supposed to enter the bloodstream and just provide local symptoms relief. In my personal experiences with patients, I have found increased estradiol levels, when only using an estradiol insert.
So while in theory, the estradiol is only supposed to stay localized to the vaginal vault, it could be matriculating into the bloodstream. This is why I usually only use estriol vaginally for GSM. Estriol will not enter the bloodstream and will stay localized to the vaginal tissues. Estriol will also not have an effect on the uterus and cause thickened endometrial lining as you woul…

When is it too Late to Start HRT? Recently we received a great question/comment from a listener of our podcast (The Progress Your Health Podcast). I’ll call her ‘Jenny’ (because I never reveal any personal information for the sake of privacy). Jenny was wondering if she is too far into menopause to be able to take bio-identical hormone replacement therapy. She has been post-menopausal for the last ten years, using an estradiol vaginal insert for her GSU/vaginal atrophy. Her pharmacist thought that changing her prescription and implementing bio-identical hormone replacement could help with her bones, cholesterol, and heart protection. This is an excellent question, as many other women have these same thoughts. Am I too old to take/start bio-identical hormone therapy? Are hormones going to help my cholesterol? Is hormone therapy going to help reduce the risk of cardiovascular disease? Can hormone replacement help with bone density? Below is the question from our podcast listener:   Hi I am a healthy and uber fit 60 yr woman who has been menopausal for ten years. My chief complaint is GSM. I have been on 10mcg Vagifem for this entire time, 3-6/week. Well-controlled. My cholesterol is 7! LDL 3.5 / HDL 3.28 I saw a pharmacist who is a BHRT specialist, and she recommends: .25mg BiEst, 100mg progesterone and +- testosterone depending on levels. She thinks this will balance my hormones better, possibly improve my lipid profile, and protect my heart and bones. Am I too late in the game for BHRT? Do you agree with her suggestions?   What is GSM? GSM stands for genitourinary syndrome of menopause. It is a new term that replaces vaginal atrophy. GSM and vaginal atrophy can be used interchangeably. Vaginal atrophy occurs when the estrogen levels drop causing changes in the vaginal tissues. Estrogen really primes the vaginal cells and will maturate them from parabasal cells into mature vaginal cells. When the estrogen drops in menopause, the tissues can become dry, with less lubrication and the tissues can become more fragile. This is where you will find pain or even bleeding (from the tissues tearing) with intercourse. I like the term GSM, genitourinary syndrome of menopause because when the estrogen drops it can cause so much more than just dry, fragile vaginal tissues. It can cause the flora of the vaginal vault to change. This increases the risk of vaginal infections such as yeast/candida and bacterial vaginosis. It can also cause more increased risk for urinary tract infections. As well as urinary stress incontinence. The urethra (the tube that connects the bladder to the outside world, aka the toilet), can become more lax when the estrogen levels drop in menopause. This can cause urinary leakage with coughing, jumping, laughing, exercising, sneezing, doing crunches, jogging, walking, you get the drift. GSU/vaginal atrophy can be so mild that women do not even notice any changes. And other women can have such severe symptoms that they cannot even go for a walk without the tissues chaffing and causing pain. Jenny had been using an estradiol vaginal insert (vagifem) to help with her GSM/vaginal atrophy symptoms and was getting excellent results. Ideally when using an estrogen vaginal application, the estrogen is not supposed to enter the bloodstream and just provide local symptoms relief. In my personal experiences with patients, I have found increased estradiol levels, when only using an estradiol insert. So while in theory, the estradiol is only supposed to stay localized to the vaginal vault, it could be matriculating into the bloodstream. This is why I usually only use estriol vaginally for GSM. Estriol will not enter the bloodstream and will stay localized to the vaginal tissues. Estriol will also not have an effect on the uterus and cause thickened endometrial lining as you would see in estradiol. Jenny’s pharmacist recommended adding in bio-identical hormone replacement (BHRT). This is where the questions we get sometimes don’t have enough information. Did Jenny’s pharmacist want to replace her estradiol vaginal insert? Or did she want to add the biest/progesterone/testosterone in addition to the vaginal application of estradiol? These are two very different scenarios. The biest/progesterone/testosterone BHRT would be a systemic dosing, meaning the goal is to get it into the bloodstream. Biest (which is a combination of estriol and estradiol) would most likely be a transdermal cream/application. As well as the testosterone would be transdermal. Oral dosing of estrogen and testosterone is not well tolerated and puts a burden on the liver and has minimal absorption. Progesterone can be dosed as a transdermal cream or oral. If a woman has a uterus and is taking any estradiol systemically, she should be taking the progesterone orally. Estradiol can thicken the uterine lining when taken without progesterone. Oral progesterone protects the uterine lining better than the cream form. My point being here, taking the biest/progesterone/testosterone systemically may not be enough to help Jenny’s GSM/vaginal atrophy. The vaginal tissues respond much better to a localized application for GSM. I have many women taking their progesterone orally and their biest and testosterone transdermally in addition to a local application of estriol to the vaginal tissues. This is where you get the best of both worlds, a solution to the GSM symptoms plus the benefits of system BHRT. Those benefits range from better sleep, improved libido, ceasing hot flashes and night sweats, improved mood and hair/skin to name a few. So I do not think Jenny should replace her vaginal application with the BHRT. But should consider switching to estriol for the GSM.   Is Jenny too old to start BHRT? The dose that Jenny’s pharmacist recommended was a very low dose of biest. The progesterone at 100mg is a very common dose. I am thinking her pharmacist wanted to start low on the biest and work their way up. It has been ten years since Jenny’s own body was producing hormones. When introducing the hormones after such a length of time can cause side effects. While the .25mg biest is very small,

Perimenopause is the time in a woman’s life prior to entering menopause. Most people are familiar with menopause, which is when the ovaries stop producing hormones and women stop their periods. There are many options to deal with menopause (which is an entirely different podcast and blog). But perimenopause is a completely different animal compared to menopause. Perimenopause is usually between the ages of 40-50. I have seen some women enter perimenopause in their late 30s and well as in their early 50’s. But on average, perimenopause usually hits between the 40 -50. It can last for years. Which is unfortunate because the symptoms can really affect the quality of life. Many women have come to see me and tell me how their hormones are ruining their life. They have been to their general practitioners, gynecologists, PCP only to be told there is nothing wrong. These women end up feeling disregarded and frustrated because they are not finding answers or help. This is because perimenopause is not often discussed. Like I mentioned, everyone is familiar with menopause. But women in perimenopause are dismissed because many do not realize what perimenopause is. When I talk to these women and explain to them, yes it is your hormones causing your unwanted symptoms. They are stunned to find out there is a name for what they are experiencing. It’s called perimenopause.
So let’s get to it! Learn about the top five most common symptoms of perimenopause.
(I tried to put these in order of the most common. But honestly, these five symptoms are all equally common)

Fatigue:

Women in perimenopause are often repeating over and over how tired they are. They are tired of complaining about how tired they are. I’ve had many patients remark on their family members (mainly kids, because they can be so honest), tell them they are repeating over and over how tired they feel.
But it is a different kind of tiredness. It’s more of a mental fatigue. I will ask my perimenopausal patients, ‘if I were to make you take a 3 mile hike with me right now, could you do it’? Which they reply, they could. How can you hike 3 miles and say you’re tired? It is because it is more of a mental fatigue. Yes, they could do the work/activity physically, but mentally they are just not into it.

Loss of Libido:

Speaking of just ‘not into it’. Perimenopausal women often say their libido has not only left the building, it left the stratosphere. There are no physical issues going on here like you would see in menopause. In menopause when the estrogen has dropped dramatically, that can cause vaginal dryness, vaginal atrophy and pain with intercourse. In perimenopause, the estrogen has not declined that dramatically, so the libido issue is more of a mental one. Sex is just not on the brain. Perimenopausal women will say they are not interested or even thinking about sex. A hot-human can strut across your path, and it was like you didn’t even notice them.

Weight Gain:

Weight gain is a common complaint of both perimenopause and menopause. Women in their 40’s will often comment that it felt like they gained 15 pounds overnight. And the sad fact is that this weight gain was not due to any changes in their diet or lifestyle.

Trouble Staying Asleep:

This is a very common issue in perimenopausal women. They have no trouble falling asleep. Your head hits the pillow and you are out in minutes, seconds even. But 3-4 hours later, you are up like it’s morning. And it can take hours to fall back to sleep. And of course by the time you do fall back to sleep, you need to wake up shortly. By morning, you are so tired.

Period changes:

As mentioned earlier, in perimenopause the estrogen has not dropped that much (as you see in menopause). But the progesterone has dived in perimenopause. This can cause period changes. It can cause days and days of s…