Three Urologists Walk into a (Side)bar

When I interviewed these three brilliant physicians for a story for Oprah, I realized I didn't have enough space for all of their wisdom. Here, I do.

Activist physicians and women’s health advocates Dr. Rachel Rubin, Dr. Ashley Winter, and Dr. Kelly Casperson are out there on the social media front lines every day, teaching people about the importance of sexual health and the inner workings of their own vaginas.

Since starting this publication, I rarely take on assignments from traditional newspapers or magazines. The pay sucks—think anywhere from $250 to $700 for stories that can take months to research and write—and fighting for space to cover anything related to vaginas always feels like hitting my head against a squeamish, advertiser-and-subscriber-fearing brick wall. Here, if I want to use the word vagina to describe one or drop an f-bomb when warranted, I fucking well will. If readers choose to unsubscribe because of this, that’s okay. I’m building something here I’m proud of. Something I believe has been missing. No shame. No apologies.

I’m also building a community. You! I love that you’re here. I love that we’re all muddling through this weird thing called life in our under-funded, under-researched, under-written-about bodies, together. And I’m grateful both for your words and for your generous support of mine.

However, when Oprah Daily editor Mamie Healey contacted me last month to see if I would research and write a quick 500-word primer on acquiring and affording estrogen, I didn’t hesitate to say yes. Access to and correct information about estrogen and menopausal hormone therapy is a massive barrier to care; Oprah has a much bigger audience than mine; and I saw this as an opportunity to do good: to open more eyes to the realities and life hacks of menopause, a topic that is still barely touched upon in either society, media, or medical schools.

Well, that small 500-word assignment quickly burgeoned into the 2500-word treatise below. Why?

Because accessing and affording estrogen is a far more complicated, deliberately difficult and vague, and absurd quest than either Mamie or I could have ever imagined. Even so, I had to leave off way too many words of wisdom from three sex-med/women’s health advocates I’ve been admiring afar on social media for the past few years: Urologists Dr. Rachel Rubin, Dr. Ashley Winter, and Dr. Kelly Casperson.

I think an important thing that Rachel and Ashley and I—a unique view because we are all urologists—is that we treat men. We see how men are treated. We see how we don't want them to suffer. We see how we don't just tell them they're getting old and to suck it up.

Luckily, here in my own publication, I can publish whatever I want, word count be damned. More saliently, as Dr. Casperson herself kindly pointed out in her voice memo to me, “It's literally the women like you who are changing healthcare in America. It's not top down at this point.” (Thank you, Dr. Casperson.)

I wish I could keep being the bottom-up voice for free, but I can’t. It takes time and resources to do this research, write these stories, seek out the information that has been hidden from us for too long. I have done my best to make all of my science stories here free for all to read, while putting paywalls up on more personal stuff. But today, to say thanks to my paid subscribers, I am providing immediate access below to all of the answers to my questions for the Oprah story from these three brilliant women. I’m sure you will find as much wisdom in their words as I did.

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DR. RACHEL RUBIN, via email

Questions: What is the difference between systemic and vaginal estrogen, and why does this matter? For those who've had estrogen receptor positive breast cancer and can't take systemic estrogen, is it safe to use vaginal estrogen? For those with uteri, how and when must they take progesterone along with the estrogen? For those without, is progesterone needed? Is there a systemic estrogen ring, patch, or gel (like the Divigel I take) that has progesterone already mixed in it? Why is progesterone important for systemic estrogen?

Systemic hormone therapy, often called hormone replacement therapy (HRT) or menopause hormone therapy (MHT) is given to people who are bothered by hot flashes, night sweats or are looking for osteoporosis prevention. We also have evidence for and use testosterone to treat low libido. Local vaginal hormones is used to treat genital and bladder tissue which are very sensitive to the lack of hormones in menopause. People complain of urinary frequency and urgency, vaginal dryness pain with sex and get recurrent urinary tract infections, which can really cause harm to people's bodies.

The symptoms of genitourinary syndrome of menopause can be so severe that people can’t sit, they urinate constantly, their tissue is so dry it crack and bleeds and penetration is like razor blades to the tissue.

It's really important that we understand the difference between systemic hormone therapy and local vaginal hormones. It's important for a number of reasons: