HeraSphere #29: What knows your age better than your driver's license?

Hi friends,

"Your vagina knows your age better than your driver's license." stated urologist and pelvic expert Dr. Kelly Casperson at a recent women’s wellness talk I attended in LA.

It took me a while to muster the courage to write this issue. I could barely pronounce Genitourinary Syndrome of Menopause (GSM) when I first heard it. But I've had a version of the same conversation with girlfriends more times than I can count. Recurring UTIs, round after round of antibiotics, doctors moving on. Nobody connecting it to hormones. Nobody mentioning estrogen.

I didn't connect it either until Dr. Casperson's talk. And then I heard Abby Greensfelder, CEO of Everywoman Studios, speak at the Cleveland Park Library about her documentary The Pink Pill: Sex, Drugs & Who Has Control. I learned that UTI is the most common cause of infection-related hospitalization in older, immunocompromised women. An untreated UTI becomes urosepsis with a mortality rate of between 20% and 40%

This issue is for every friend who's had a UTI she couldn't explain. For every woman who's quietly stopped wanting intimacy and assumed that's just what happens in midlife. For anyone who's chalked discomfort up to getting older and kept it to herself — because honestly, who do you feel comfortable telling?

We deserved this information years ago.

TL;DR

• GSM (Genitourinary Syndrome of Menopause) affects at least half of postmenopausal women — and it never fades on its own only progressing over time. Dryness, painful sex, recurrent UTIs, bladder urgency, and low desire are often the same problem with the same root cause: estrogen loss that starts in perimenopause, years before your last period.

• The fix is well-studied and low-risk — most women just don't know to ask for it. Vaginal estrogen is applied locally, acts locally, and treats all of the above. It's available over the counter in the UK and Australia. In the US, it requires a prescription most doctors aren't offering unprompted.

• Testosterone declines in women starting at 30 and directly affects dopamine pathways. Hypoactive Sexual Desire Disorder (HSDD) is a real diagnosis. It has real treatment options.

• You may know more than your doctor on this one because most doctors don’t learn about menopause in medical school. Be prepared with specific asks: vaginal estrogen, a testosterone panel in female context, a pelvic floor PT referral, and if needed, a new provider.

What GSM Actually Is — and Why It Only Gets Worse

• GSM is not just "dryness." It's a full-system tissue change affecting the vulva, vagina, urethra, and bladder — all estrogen-dependent tissue, all declining together. Dryness is the most common symptom, but it often includes burning, urgency, recurrent UTIs, painful sex, and bladder leakage.

• Unlike hot flashes, GSM doesn't self-resolve. Research shows 65% of women have GSM symptoms one year after menopause — and that number climbs to 84% by year six. Without intervention, this only gets worse.

• This starts earlier than most women realize. GSM-like symptoms appear in roughly 15% of premenopausal women. If you're in your early 40s and noticing that intimacy feels different, that you're getting UTIs you can't explain, or that things just feel off — that's not in your head, and it's not random. Your pelvis is sending an early signal worth paying attention to now.

• Only about 4% of women connect their symptoms to GSM. The rest are treated for individual symptoms without anyone addressing the root cause — or told it's normal aging and sent on their way. As Dr. Casperson says: shame and silence don't show up in your lab values, but they absolutely determine whether you ever get help. We've been socialized to keep this particular conversation very quiet.

The 3 Step Solution: Restore, Rebuild, Repair

• Dr. Casperson provides a clear 3 step solution for GSM

• Restore comfort — Vaginal estrogen (local, low-dose, applied directly) replaces what estrogen withdrawal took. It restores tissue integrity, rebuilds the mucosal barrier, and reduces recurrent UTIs by restoring the vaginal microbiome and the mucosal lining that protects against infection. It also improves bladder control. There is no hormone therapy debate — it acts locally, with minimal systemic absorption. Think of it less as HRT and more as “chapstick for your vagina.”

• Rebuild arousal — Blood flow to pelvic tissue is trainable. Stimulation — yes, including vibration — restores circulation to tissue that has been starved of it. Arousal and orgasm increase blood flow to structures that need it to stay healthy. Pleasure is preventive care.

• Repair desire — Low desire is not psychology dressed up as physiology. Testosterone starts declining in women at age 30 and directly affects dopamine pathways — motivation and reward, not just mood. Hypoactive Sexual Desire Disorder (HSDD) is a recognized medical diagnosis. Most doctors never ask about it. Most women never hear it named. Naming it matters, because it shifts the conversation to "there is a hormonal mechanism here and it can be addressed."

Why This Conversation Wasn’t Happening — and Practical Tips for Speaking with Your Doctor

• There was a black box warning on vaginal estrogen until November 2025, a legacy of the widespread fear caused by the Women's Health Initiative study.

• Despite the fact that local vaginal estrogen has negligible systemic absorption and a fundamentally different risk profile, doctors were afraid to prescribe it. FDA Commissioner Makary calling the original WHI fallout "one of the greatest mistakes in modern medicine." The warning is going away, but the prescribing culture it created will take longer.

• Visit your doctor prepared with specific asks. Vaginal estrogen. A testosterone panel interpreted in a female context — most labs use male reference ranges, which renders women "normal" at levels that are clinically insufficient. A referral to a pelvic floor physical therapist — seeing one annually, the way you'd see a dentist, is an option almost no one is told about.

• Find a provider who actually knows this area. Not every OB/GYN or primary care doctor is current on GSM — and that's not an insult, it's a reality of how little menopause training exists in medical education. The Menopause Society has a certified practitioner finder — these are clinicians who have passed a specific exam in menopause medicine. ISSWSH has a similar directory for sexual health specialists. The right provider won't make you feel embarrassed for bringing this up.

• Last, but not least…vaginal estrogen can be used for facial rejuvenation. The estrogen receptors in facial skin respond to it similarly to vaginal tissue — improved elasticity, hydration, and collagen. It's not indicated for this use, and I'm not recommending it. But my doctor friends swear by it, and I'm asking my own doctor about it at my next appointment.

What I Will Be Watching This Week

• The Pink Pill: Sex, Drugs & Who Has Control hits Paramount+ on Friday, March 6 — three days before International Women's Day, which feels exactly right. Producer Abby Greensfelder’s talk about it at the Cleveland Park Library has stayed with me.

• The film follows entrepreneur Cindy Eckert's decade-long fight to win FDA approval for Addyi — the first drug ever approved to treat low sexual desire in women. She sold the company for $1 billion the day after approval, then got it back for almost nothing when the acquiring company collapsed under scandal.

• The film asks the question “who has access to pleasure and who doesn’t?” Why there was no serious research on the human clitoris until recently. Why medical institutions systematically overlooked women's sexual needs while normalizing dozens of drugs for male erectile dysfunction. Why the FDA that approved more than twenty drugs for men's sexual health spent years blocking the one drug designed for women.

What I'm Taking Away

Our vaginas are shriveling, and this is "a story that was kept from us" to quote Abby Greensfelder. A medical system that researched men first and called it universal. A culture that taught us the conversation was embarrassing. A generation of doctors who graduated knowing almost nothing about menopause or women's sexual health, and who mostly never went back to learn.

I'm asking my own doctor different questions now. I'm paying attention to signals I'd been quietly ignoring. And I’m going to try vaginal estrogen on my face!

Start listening to your pelvis. She's been trying to tell you something.

Going to listen to mine now,

Lilly

P.S. Know a friend who's been dealing with UTIs she can't explain — or who's quietly accepted that intimacy is just uncomfortable now and assumed that's just how it is? Send this to her. That's exactly who it's for.

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Note: While I love diving deep into research and sharing what I've learned about women's health and wellness, I want to be crystal clear: I'm a passionate health advocate and researcher, not a medical professional. Think of me as your well-informed friend who does extensive homework – but not your doctor.

Everything I share in HeraSphere comes from careful research and personal experience, but it's meant to inform and inspire, not to diagnose or treat any medical conditions. Your body is uniquely yours, and what works for one person might not work for another. Always consult your healthcare provider before making significant changes to your diet, exercise routine, or wellness practices, especially if you have underlying health conditions or take medications.

ICYMI, here are a few past issues that you may enjoy: