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What No One Tells You About Women, Aging, & Intimacy

This episode will focus on the treatment of sexual dysfunction and urinary incontinence with aging.
What No One Tells You About Women, Aging, & Intimacy
Featured Speaker:
Fenwa Milhouse, M.D
Dr. Fenwa Milhouse is a board-certified, fellowship-trained urologist and specialist in
Female Pelvic Medicine and Reconstructive Surgery (also known as Urogynecology).
She previously worked for the largest private practice in the state of Illinois as the
leading pelvic floor surgeon. She is the founder and owner of Down There Urology.
Dr. Milhouse treats all adult individuals with a focus on the treatment of sexual
dysfunction, urinary incontinence, pelvic organ prolapse, and cosmetic genital
enhancement. She enjoys using social media to destigmatize pelvic floor & sexual conditions, as well as demonstrate the importance of representation in Urology. She is known by the world as “Your Favorite Urologist” and has been featured on several media outlets including
Yahoo Style, HuffPost, Essence Magazine, CNN, Rickey Smiley Morning show, Insider,
MDNEWSLINE, Sex with Dr. Jess, and regularly on She currently sits on the board of Chicago Urological Society. She is an active member in several professional societies including the American Urological Association, the Society for Female Pelvic Medicine & Urogenital Reconstruction, the Sexual Medicine Society of North America, International Society of the Study of Women’s Sexual Health, and the International Society of Cosmetogynecology. Dr. Milhouse is a wife, mother of 3, and lover of food!

Maggie McKay: As women age, our bodies go through a lot of changes affecting so many aspects of our lives, including intimacy, which causes issues that take us by surprise. So today, we'll talk with Dr. Fenwa Milhouse, urologist. And she's going to tell us what no one else will about women, aging, intimacy. There's a lot to cover.

Welcome to Top Docs Podcast. I'm Maggie McKay. Dr. Milhouse, it's such a pleasure to meet you. Will you please introduce yourself?

Dr. Fenwa Milhouse: Hi, Maggie. It's a pleasure to meet you too and to be with the audience. My name is Dr. Fenwa Milhouse. I am a board-certified urologist. I'm fellowship-trained in female pelvic medicine and reconstructive surgery, which is basically the same thing as urogynecology, so I get to treat every adult individual.

I have been in practice for over seven years. I was the leading pelvic floor surgeon at the largest private practice in the state of Illinois, and I recently departed that group. And I'm excited to announce that I am now the owner and CEO of my own urology clinic called Down There Urology based in Chicagoland area where I will continue to see and treat all persons, regardless of gender, gender identity, and really focusing in on pelvic floor dysfunction, sexual dysfunction and other intimate issues.

Maggie McKay: Well, I can see why you've been featured on CNN, The Huffington Post, Essence Magazine, and so many other media outlets. No wonder. You've accomplished a lot in a short amount of time. And you've said urology is your passion and you want to share it with the world. What inspired you to get into this arm of medicine?

Dr. Fenwa Milhouse: Great question. I get asked this every time, and I love telling this story over and over again. I had no idea what urology was when I became a medical student. I found out what it was and I really thought what probably everybody thinks and assumes, is that urology is mainly for men by men. You really don't see a lot of women urologists. And when you think of urology, you think of prostate and other male issues. And certainly, that's a large part of what we do. But it was my encounter with a woman urologist, a black woman urologist, in my second year of medical school that totally just changed my idea of what it meant to be a urologist. Seeing myself in her made me go, "Wow. Okay, I can do this now. I want to see what this is all about." And I will say this, urologists tend to be really excited about what they do. We tend to talk a lot, as you'll find out today, because we enjoy what we do. We get to talk about a lot of things that people tend to hide and be embarrassed about, and we get to help and fix that. And so, when I started to interact more and more with urologists, I realized that this is exactly what I was meant to do. It felt like home. But it all started with just that one encounter. And that is why I will always say that representation absolutely changed my life.

Maggie McKay: Isn't that cool, that one person can make that big of a change in your life and inspire you to go onto the career that you have? Do you stay in touch with her?

Dr. Fenwa Milhouse: I do. We see each other at annual meetings and she knows because she's heard her name probably recounted in my story, Dr. Lenaine Westney, like a hundred times. So, yes.

Maggie McKay: Aw, I love that. She's probably so proud. As women, there are so many things, like we said, we're never told about until it seems like we're in the thick of it, like changes that come with menopause, for example. So, let's start with that, Dr. Milhouse. What changes happen to the vulvas and vaginas with menopause and aging?

Dr. Fenwa Milhouse: So, just so the audience understands, the vulva is the outside part that we see. We often refer to everything as the vagina, but actually the vagina is just the inner canal. So, menopause causes a dramatic decline in estrogen levels, approximately 95% decline in estradiol levels from premenopausal state as compared to postmenopausal state. That's huge. And this leads to several changes in the vulva and the vagina that we summarize as vaginal atrophy or more appropriately, more recently, summarized or titled as genitourinary syndrome of menopause.

These changes include the following, one, thinning of the vaginal lining, so the actual top layer or the epithelium of the vagina becomes thin. Also with that is the loss of rugae. Rugae are the ridges inside the vagina. So, healthy vaginal tissue, premenopausal tissue, rugae is a predominant, quintessential sign, a sign of healthy tissue. It's those ridges. If you put your finger in your vagina, ladies, you can try to see if you feel those ridges. And what that does is it increases elasticity of the vagina, which is important for sexual function, for sexual pleasure. A smooth vagina absent of rugae is not desirable. It makes penetration more uncomfortable because the vagina is less elastic.

The other thing that can happen is the vagina can become contracted and narrower as we get older. Having penetrative intercourse during and after menopause can help augment or slow down this contraction, but the vagina can actually become narrower, or the vulva particularly.

Decreased vaginal lubrication, this is a very common complaint among postmenopausal women, that vaginal lubrication declines. And one of the most significant consequences that I see in my practice all the time has to do with the change in the vaginal pH. A healthy vaginal pH is acidic, around 4, 4.5, to 3.5. With aging, that pH increases and becomes more neutral, less acidic. And that's not a good thing. What that leads to is it decreases that healthy microbiome, that lactobacilli that you probably hear about. A higher pH makes that healthy bacteria or microbiome lower in concentration, increasing the chance and opportunity for the bad pathogens that contribute to infections, particularly urinary tract infections. And very much indeed menopause is an independent risk factor for recurrent UTIs. So, I see that all the time.

The other thing that happens related to the urinary tract because the urinary tract is derived from the same embryologic line, so when we are developing in our mom's stomach, the same embryologic origin as our genital tract involves some of our urinary tract and also some of our urinary tract contains estrogen receptors. So, the same some of these postmenopausal things also affect our urinary tract. One common complaint I see in aging women is just overall urethral discomfort or urethral burning or itching. So, all of these things can obviously interrupt and affect multiple aspects of your intimate life.

Maggie McKay: That's a lot, Dr. Milhouse. I mean, even at my age, I just learned like four new things that I've never even heard of, didn't know about, not looking forward to.

Dr. Fenwa Milhouse: I know. Well, that's what I'm here for.

Maggie McKay: Exactly. Thank goodness you know about it. What are the common intimacy concerns or issues that happen with age?

Dr. Fenwa Milhouse: So for one, the lack of lubrication and elasticity decreases sexual pleasure. I mean, it makes sense. It's less lubricated, it's less elastic. These are the key components of having pleasurable penetration. Postmenopausal women commonly report increased pain with intercourse, which is going to affect your desire to have intercourse.

Vaginal dryness can also just cause burning on the vulva itself, itching and pain, even without any penetrated sex or anything going inside. I've treated many postmenopausal women who come in complaining and they'll say it feels like their vagina is on fire. So, it can just cause pain, period.

The change in the pH, I already spoke about this, but it decreases the lactobacilli concentration and increases susceptibility to pathogens, and this is basically an important defense mechanism against vaginal infections and UTIs. Menopause is an independent risk factor for recurrent UTIs. It also increases the presence of urethral discomfort or pain. Aging is a risk factor for urinary incontinence and vaginal prolapse.

And then, the changes in our sexual desire or libido are common. Low libido or what we call a medicine hypoactive sexual desire disorder, HSDD, is the most common female sexual dysfunction complaint, really across pre and postmenopausal women. Estradiol and androgens like testosterone are both excitatory for libido, so estrogen is a pro-libido hormone. Obviously, estrogen declines but also androgens decline. You know, contrary to belief, we need testosterone too, not in large amounts as men, but we need it too. And both of those decline with age. Androgens can abruptly drop if you have, A, your ovaries removed surgically. And this decline lowers desire and arousal. And in fact, women aged 45 to 64 years have been found to have the highest prevalence of decreased desire distress according to a very large survey.

Maggie McKay: Wow. Forty-five seems very young, Dr. Milhouse. I don't know.

Dr. Fenwa Milhouse: I'm 40.

Maggie McKay: Uh-oh. All right. Well, make the most of the next five years, right? I guess it's one good thing about being over 60. So, what treatments are available to help women who suffer from intimacy issues?

Dr. Fenwa Milhouse: So, I've talked about all these changes, right? And you're probably thinking, "Well, what the heck? Like, you're just giving us all this bad news. What can be done?" The good news is there are things that absolutely can be done to help. You should not have to suffer through these changes without seeking treatment. And I think a lot of what we're conditioned to believe via society and historically even with medicine is that these women issues aren't really important. We have not dedicated a lot of time and research to really help. And a lot of patients, a lot of women patients, just figure, "Well, it's normal. I can't really do anything about it. I shouldn't complain. Let me just bear it."

So, to answer your question, for lubrication and vaginal dryness, personal lubricants are essential. They're so readily available. Personal lubricants are over-the-counter at your pharmacies, online, they're non-prescription. There are several different types, water-based, silicone-based, oil-based lubricants. You probably have a personal lubricant, oil-based personal lubricant in your kitchen counter, that vegetable oil, that canola oil. Yes, I have a whole YouTube video I'm dedicating to personal lubricants, so be sure to subscribe because I'm going to talk all about the different types.

But, yeah, there's no shame to utilizing these things to make sex and intimacy more pleasurable. What we urogynecologists, urologists, sexual medicine specialists really, really love is vaginal estrogen. Vaginal estrogen increases blood flow, elasticity. It decreases the vaginal pH. Remember, we want it to be lower. This all translates into an improved vaginal tissue quality that has less atrophy, more lubricated during sex, less vaginal irritation and pain and a decreased risk of UTIs.

And in fact, one of the main recommendations by the American Urologic Association regarding recurrent UTIs in postmenopausal women is to start vaginal estrogen. It is a standard of care. Some of us use vaginal estrogen before and after doing vaginal surgery to improve the quality of the tissue that we're going to operate on and to reduce postoperative complications. So, it is very safe. It's topical. It has not been shown to increase systemic estrogen levels. And it's safe even to use in women who have had breast cancer. The American College of Obstetrics and Gynecologists, ACOG, supports the use of vaginal estrogen in women with a history of estrogen-dependent breast cancer for these symptoms. Many breast cancer survivors suffer from this, because of a result of their treatment. I prescribe vaginal estrogen extensively, as you can probably tell, because I cannot stress enough how applicable it is for a lot of the things that I see and treat and can help. Estrogen therapy is effective for treating local vaginal symptoms and reducing the risk of UTIs.

The one thing that it probably isn't so effective in is treating decreased libido or desire, unless it's directly related to the vaginal symptom, like, "I don't want to have sex because it burns whenever I do it. I would want to have sex if it didn't burn." Okay, well, then vaginal estrogen may turn that around completely. But a lot of low libido has a lot more involved in it, and low libido, like I said, is the most common sexual dysfunction complaint. Unfortunately, there is actually no FDA-approved treatment for low libido in postmenopausal women. In premenopausal women, there are two FDA options. But technically, they were FDA-approved for premenopausal only.

That doesn't mean treatment doesn't exist. You know, medicine, we do a lot of off-label treatment, safe off-label treatment. A common way that we treat postmenopausal women for low libido is testosterone replacement therapy. And this can be applied for peri, those are women that are around, about to enter into menopause, and postmenopausal women.

While this may not be appropriate for every single person, or every single woman I should say, that has low libido, it is an excellent option for, I would say, most. There are FDA-approved medications. Again, like I said, for premenopausal women, these can be used off-label. I do this all the time for postmenopausal women. These include flibanserin and bremelanotide. These are the FDA-approved medications for premenopausal women that I personally have prescribed in both pre and postmenopausal women. They work in the brain to try to improve desire.

Maggie McKay: That's a lot of good news, Dr. Milhouse, because it's not all doom and gloom. It sounds like it, and no wonder people are afraid of menopause. But thankfully, there are urologists like yourself and preventative or, at least, helpful methods that can help. So, I know you're big on social media to ultimately help your patients. Tell us just quickly, what do you do?

Dr. Fenwa Milhouse: Yeah. So, I love using social media to, number one, educate and inform the public, the medical community, because I realized very quickly early on in my career that no one knows what we do in urology. Like, no one knows the scope of what we do, and that's okay. Like I said, I didn't even know what a urologist was until I got to medical school. I didn't even know that term. And so, because I love this specialty that I am so good at, I want to share that. So education, just sharing this.

Part of that is also de-stigmatizing these conditions. Because again, I'm the down there doctor. I'm treating these kind of intimate areas. We're talking about peeing, we're talking about sex, we're talking about your genitals. And so, I find that there's a lot of shame and stigma that comes along with this. And my mission is to de-stigmatize this. Let's normalize the discussion about these things. Not normalize the conditions, but normalize the discussion about them and be able to talk about them without the shame or the guilt or the embarrassment.

I use humor to do that in my social media, and I am not afraid to make myself the butt of the joke, you know. I talk openly about how I have overactive bladder, for instance. And so, I'll make funny videos and informative things that include me struggling with overactive bladder that really resonate with patients and it's really made a difference in my practice. It's actually given me like more energy and more zest for treating people.

Maggie McKay: Do you have all ages in your practice? Do you see young girls all the way to postmenopausal?

Dr. Fenwa Milhouse: I don't see pediatric patients. Generally, I'm an adult urologist. But I will see a patient like 16, 17-year-olds. I think the youngest patient I've seen is 15 depending on the circumstance. But yes, I see late teens to 99 plus. My oldest patient was 103. I remember this because he gave me a card. Every year, he would give me a card. On his 103rd, he was like, "I'm 103, you know?"

Maggie McKay: So sweet.

Dr. Fenwa Milhouse: Yes, I love it. Yeah, he was very sweet.

Maggie McKay: That's so sweet. Dr. Milhouse, in closing, is there one message that you'd like to get across to women who are aging and have concerns about some of what we talked about today?

Dr. Fenwa Milhouse: Like I was alluding to earlier, we have been conditioned to just deal with a lot of things. We have been conditioned to put up with a lot of things that happen to our body. The one kind of message I would say is you do not have to live with this. You do not have to just suck it up. It's aging. It's normal. You can try to help yourself. There are options. And if you go to a physician or a provider that's kind of minimizing your concerns, trying to just dismiss them, normalize them, keep looking. There are people like me that will take these seriously.

Your intimate health, your sexual health, your urinary health, that is very much a part of your health. Your quality of life is just as important as something like cancer or high blood pressure, okay? Because you're living with that every single day. So, get help. It's there. It's common, but doesn't mean it's normal. We can help you.

Maggie McKay: And don't be embarrassed to ask for help, right? Don't be embarrassed. It's easier said than done. If someone would like to make an appointment with you, where could they find out more or make an appointment?

Dr. Fenwa Milhouse: Sure. So, like I said, I'm opening up my very own practice, video visits and in-person visits, Down There, I love this name. I picked it because literally patients never say vagina or penis. They never say that. They say, "Down there." And I'll laugh and I'll be like, "Down where? Your toes?" They're like, "No, down there." Everybody says down there. So, Down There Urology, it just is perfect. is an excellent way to quickly put in your information and I will personally call you back. Also, you can call our number at 312-620-1803, 312-620-1803.

Maggie McKay: It's so true. I hate to admit it, but I think you'll appreciate it. When my son was maybe four, he came home from school and he said, "What's the name of the girl part?" And I said, "What?" And he said, "Down there, the girl part." And I said, "Oh, there's no name for that," because I didn't know what to say. I was so like taken aback and I'm so ashamed at this point. And then, he said, "Well, what about my parts?" I'm like, "No name. There's no names for those." And then...

Dr. Fenwa Milhouse: "Mom!"

Maggie McKay: I know! And then, he asked my mom, who's very conservative, and she told him the correct names. And he came home from her house like two days later and said, "I know the names now." And I'm like, "Yeah." Anyway, it's ridiculous.

Dr. Fenwa Milhouse: Agree. And no shame. But we all do this, right? It's so funny because like we say arm, we say finger, we say eyeball, but it's a part of our anatomy. It's penis, it's vagina, it's just a part of the anatomy. We've like made it so gross and disgusting for no reason.

Maggie McKay: Exactly. Well, Dr. Milhouse, this has been so fun and informative. Thank you so much for bringing some topics usually not discussed out in the open out in the open, and for giving hope to people who may not have known about the latest treatments to help with menopause, intimacy concerns and more. You know, you covered a lot and we appreciate you and what you do.

Dr. Fenwa Milhouse: Thank you, Maggie, for having me. This was fun.

Maggie McKay: Again, that's urologist, Dr. Fenwa Milhouse, founder and owner of Down There Urology. You can go to to find out more. If you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. This is Top Docs Podcast. I'm Maggie McKay. Thanks for listening.