Deborah Howell (Host): Perimenopause and menopause are a natural part of the aging process, and a common symptom often associated with hormonal changes is pain. I'm Deborah Howell. And today, we'll talk with Dr. K. Lauren de Winter, a board-certified fellowship-trained urogynecologist with Praxis Urogynecology at Memorial Care Long Beach Medical Center, about what causes pelvic pain during menopause, and how the specialized medical teams and the Pelvic Health Center at Memorial Care Long Beach can help treat women who are experiencing these symptoms. Dr. de Winter, it's so nice to have you with us today.

K. Lauren de Winter, MD: Hello. Nice to talk to you too.

Host: Well, thanks for making the time. So, I'm wondering what causes pelvic pain during menopause. Is it related to a change in hormones?

K. Lauren de Winter, MD: Absolutely. So, a lot of the hormonal-related causes of pelvic pain actually stop when you go into menopause, but it causes a whole new set of them when your estrogen and progesterone levels start to go down. So before, you worry about endometriosis and pain with your periods. But after those all go away, several years typically after menopause, you start developing what's called genitourinary syndrome of menopause, which everybody just calls atrophy.

So, atrophy is related to the vulva, the vagina. It bothers women during sexual intercourse, but it can also kind of affect you when you're sitting or moving, the skin on the outside can be affected. And it's because those areas have all these hormone receptors to estrogen, progesterone and testosterone, and you lose those hormones and they start to drop precipitously really quickly right at the time of menopause.

Host: Ah, just one of the joys of being a woman, right?

K. Lauren de Winter, MD: Exactly.

Host: So, what are some of the painful symptoms that women might experience?

K. Lauren de Winter, MD: On the outside skin, a lot of women will have itching, burning, tight sensation or pain when they're sitting or moving a little bit. On the inside, especially during sex, women often feel dryness, a lack of lubrication, sharp pain, an absence of that stretch that that skin on the inside is supposed to have. And so, it often keeps women from being sexually active as they go into, you know, some of their continuing to be really good years.

Host: You know, we're all pretty stoic about pain as women, but when is it time for a woman experiencing these symptoms to seek help from a physician?

K. Lauren de Winter, MD: So in my opinion, it's earlier, when these symptoms start. Those changes that you get at menopause, they happen slowly. So, it's usually over the course of about five years, but some women get dryness and some of those early changes even during the menopausal transition. So if you start getting them then, you can start treatments that'll prevent those changes from ever occurring. Personally, I will probably start therapy as soon as I go through menopause, so I may never get the extent of those changes to the vagina that you see whenever women get five to ten years out and haven't had any treatment.

Host: Okay. Now, here's the good part. What are some options available for women who are experiencing pelvic pain during menopause?

K. Lauren de Winter, MD: That's the very good thing, there are a lot of options. If you're going through the menopause transition where you're having hot flashes and night sweats and sort of some of the other symptoms, a really good option is to be on hormone replacement therapy, which is estrogen or estrogen and progesterone systemically for your whole body, and that affects your bladder, your vagina, your pelvis in general, and that can be a good way to fix both problems at the same time, sort of hot flashes and pelvic symptoms. But if those hot flashes aren't really bothersome, you can also just use a very topical form of estrogen. And that is my favorite thing for people to use because it doesn't get into your bloodstream at high amounts. You can even use it sometimes if you've had breast cancer in the past. It's an extremely safe way to use it. And it only affects those tissues topically, kind of like a cream or you can use it as a suppository. And so, if you're someone that says, "I can't use hormones" or "I don't want to use hormones," there's even some new medications that have come out and over-the-counter options that can be used that don't have any hormones at all.

Host: Wow. Incredible. I mean, when I grew up, it was just the little tiny patch you put on.

K. Lauren de Winter, MD: Yeah, exactly. One of the first things like the North American Menopause society recommends, which is a great resource for all of this, is actually hyaluronic acid, which is the kind of face cream that you put on at night to keep your skin on your face stretchy and wrinkle-free and things like that. They have them in suppositories and creams for the vagina and you can use those as sort of a long-term moisturizer. I tell people it's kind of like lotion for your vagina, but it keeps it moisturized and stretchy, it doesn't have any hormones at all in it. And then, you can kind of use lubricants with sex and that works quite well.

Host: Amazing. Getting better every, every day as a patient. Now, are there medications or supplements to treat all this and also any dietary changes that might be helpful?

K. Lauren de Winter, MD: There haven't been any dietary changes that I know of that have been helpful, but there are a lot of over-the-counter and things that you can purchase without having to see a doctor, which is nice. There's vaginal lubricants that you can use if your issues are only with intercourse. I really like silicone-based ones like Uberlube, but a lot of women do well with just natural oils, like coconut oil works really nicely and most people don't have issues with it.

There's another topical one called Replens or glycerin-based suppositories. I don't like those quite as much, but some women really like those. They can add moisture. If your issues are just on the outside, I often recommend women a DHEA cream, which is like a Julva, which can work really, really well. Are you wondering more about what's on the inside or what's on the outside?

Host: Just kind of a panacea.

K. Lauren de Winter, MD: Yeah, there's a whole bunch. They've even done studies on apricot kernel oil and buckthorn oil. Apricot kernel oil you put in vaginally, and buckthorn oil you take orally, and those both have been shown in some clinical studies to be helpful.

Host: And very, very natural.

K. Lauren de Winter, MD: Yeah, exactly. So, you can kind of go any direction. You can go toward a more, you know, FDA approved, very safe, effective route or you can say, "I want to be on the very, very natural route" and go toward the over-the-counter types.

Host: I love it. Now, how can pelvic health therapy and maybe exercise help?

K. Lauren de Winter, MD: Absolutely. So, pelvic health therapy is usually in the form of pelvic floor physical therapy. So for women that have developed tight muscles in response to these changes to the tissue, there's physical therapists who can basically help with pelvic pain on the inside. I tell my patients that it's sort of like when you get a massage on your back for tight muscles. There's physical therapists who can show you relaxation techniques and do manual sort of physical ways to release those muscle tension, and it can make it so much more enjoyable to have sex or just to sit comfortably in your own body. So, I do recommend that highly.

Host: Yeah. Let your body do the work.

K. Lauren de Winter, MD: Exactly.

Host: Now, what are the effects if symptoms are left untreated?

K. Lauren de Winter, MD: So typically, atrophy gets worse and worse over time, especially with a lack of stimulation. So, you end up having pain and so you stop having intercourse, right? It's just kind of a normal response to that. But a lot of women, their atrophy will get worse and worse when they don't have any regular sexual stimulation. So, sex actually keeps blood flow in the area. It helps with pain and dryness. But if you stop, basically the vagina gets shorter and tighter over time. And so, it's hard to get it back to a place where it's possible to have intercourse for some women, not for everybody. But the tissue gets less stretchy and it physically gets shorter over time, which is not ideal for having sex.

Host: Incredible. I had not heard that visual reference before, so now we've got that visual reference.

K. Lauren de Winter, MD: Sorry about that.

Host: So, let's try to prevent that. Anything can women do, maybe start when they're younger to get ahead of these symptoms?

K. Lauren de Winter, MD: Yeah, exactly. So, I would recommend starting quite young when you start getting those changes. Like if you've noticed dryness has started to be a problem for you, if you've noticed that you're having more pain or it feels like you can't get the same sort of sexual stimulation that you got in the past, those are the times to make a change and to do something about it. Because when it gets really far along, it's very hard to get your vagina back into the shape that it was in the past and get your pelvis back into shape. So if you can get on it earlier, it is very helpful for like, you know, ounce of prevention, right?

Host: Yes. Yes, the "Come on, shorty. You can do it." All right. Can you tell us a little bit about the Pelvic Health Center at Long Beach Medical Center and its unique advantages? Because I know there are many.

K. Lauren de Winter, MD: Absolutely. So, the pelvic health center is a collaboration of a bunch of different doctor types. So, there's a bunch of physicians, you know, urogynecologists, urologists, colorectal surgeons, gastroenterologists. And our goal is to make sure that from a medical perspective that we take care of women with complex pelvic issues. But we also have this beautiful advantage of being affiliated with all of these physical therapy groups in the area who can also add on to that. So, we can not just from a, you know, traditional medical standpoint, but also from a physical therapy standpoint, get women to the place that they want to be. It's especially helpful for women with really complicated histories or if they got a mesh therapy for prolapse in the past if their prolapse is coming back. Prolapse is when the vagina kind of falls down like a hernia, not usually a painful condition, but very, very bothersome, and it can lead to pelvic floor dysfunction where they have bowel issues, bladder issues. And having a whole team of people there makes sure that each of those issues is taken care of in a really comprehensive way.

Host: I love it. It takes a village and it sounds like you have a wonderful one happening.

K. Lauren de Winter, MD: Thank you.

Host: Anything else you'd like to add to our conversation?

K. Lauren de Winter, MD: I think this is a topic that women are very-- it's like kind of a shameful thing. It's something that women don't talk about very much. I rarely have a woman in my clinic come to me and tell me about this. It's something I standardly ask every single woman that comes through the door. And for women over the age of 55, the answer is almost always yes to some extent or at some point in their lives. So, you're not the only one out there that's having discomfort with sex or dryness and having issues with that. I think that physicians just don't ask about it enough. And patients, either they've been shut down in the past when they've asked about it, and so they don't end up getting good care, or they're just ashamed or have resigned themselves to the fact that that's not going to be part of their life anymore. And I think that's really sad, and I don't think that has to be the case.

Host: Well, this is such great information and compassion, Dr. de Winter. Thanks for offering it. Thanks for being with us today and making the time.

K. Lauren de Winter, MD: Of course. No problem. I really appreciate being here.

Host: And to learn more about the Pelvic Health Center, you can visit memorialcare.org/pelvichealth or call (562) 933-8255. If you enjoyed this podcast, you can find more like it in our podcast library and be sure to give us a like and a follow if you do. That's all for this time. I'm Deborah Howell. Have yourself a terrific day.