Dr Ardelle Piper OBGYN: Vulvas, vaginas and so much more!

Sonya:  Ardelle. Oh, my goodness. I can't believe that we have finally made this happen. Welcome to Dear Menopause.

[01:54] Ardelle: Thank you so much for inviting me.

[01:57] Sonya: Oh, my absolute pleasure. And as we were talking before, we hit record on this, this has actually been a long time in the making. You and I met on Instagram, and we have had a back and forth conversation for, gosh, twelve months or more now.

[02:14] Ardelle: Yeah. It's been so exciting to watch you and how your approach has evolved. When we were in Pandemic and all of us were getting onto social media and learning more about our options, I remember seeing you training people in your garage, and we were all in and out of lockdowns over and over again. And it just felt like it sort of, I don't know, give us all sort of this common sense of just trying to figure things out.

[02:44] Sonya: Yeah. It was kind of a way of uniting the world, really, wasn't it? Because the entire world was in the same situation at exactly the same point in time, which probably has not happened before.

[02:57] Ardelle: Yeah. And obviously your ideas of what you want to do with your platform have evolved so much, even in the last year since when I first met you. Absolutely.

[03:05] Sonya: It is exciting. So, Adele, let's introduce yourself for my lovely listeners. Tell us who you are and why you're here today.

[03:15] Ardelle: So I'm a Canadian. I've lived in Canada all my life. I'm an Obstetrician Gynaecologist. So I did go through not only med school, but then the subspecialty training for delivering babies and doing gynaecology. So I have delivered almost 2000 babies over the course of my career. And in the last few years, I chose to specialize in the extra year that I did on menopause training. When I was getting close to the end of my Citrix and gynaecology training, I really had some excellent mentorship from people who were in the menopause world. And I liked how things were slowed down and it was a conversation and it was a risk assessment and it was teaching women about the next phase. And I was really inspired by that. And so when I did that extra bit of training, I was doing more menopause before the pandemic hit. And now it's become my primary gig. This is what I do now. I'm a menopause doctor and I'm proud of it.

[04:11] Sonya: Oh, amazing. And may there be many more to follow in your steps.

[04:15] Ardelle: I sure hope so.

[04:17] Sonya: Yeah, me too. So for today's topic, we thought that it would be a great idea. Collectively, you and I have thrown topics back and forth, but we thought today would be a great opportunity to talk about vaginal and vulgar care and health, obviously, as a part of that.

[04:32] Ardelle: Yes. It's interesting because I think as women are as people are talking more about sexual health, and in particular when it comes to the menopause of world, as people going through menopause are learning more about what's happening to them. Now in menopause, they're looking back and realizing how little they knew about women's care overall. And now they're hitting this pivotal point in menopause and they don't even have the language in order to say what area is painful or dry or when and how it's happening. And so I think hopefully the younger generations are going to play catch up with because they seem to be so open, much more open talking about these things. But in the menopause area, there is a real need for us to talk more about just general normal vulva and vaginal health and care.

[05:21] Sonya: Absolutely. I couldn't agree more. Could not agree more. And I love that for anybody that's listening that is familiar with Amanda Thieves, you and Amanda are doing these WTFs, which is we talk Friday Instagram lives.

[05:37] Ardelle: Because my mom is listening.

[05:42] Sonya: And I loved how a bandit was like, Adele won't let me say what it really says. But you two powerhouses are doing these Instagram lives. And I've loved listening into particularly the topics that have not traditionally been spoken about, particularly on social media and in that live conversational way. It's just so exciting. And I have this image in my mind and I'm hoping this is something we can get into in this chat of Amanda with a donut.

[06:12] Ardelle: Yes, the jelly donut that totally came up sort of organically where we had met for the first time because we have a menopause project that we're working on together and so we had all met together at the house of the home of one of the ladies who's been part of our team. And so we were talking like, women's health and our challenges and such. All weekend we had tasks that we were doing, but then we'd go offline and talk about our personal experiences, and it comes up so often how little women know about vaginal health and vulnerable health. And one thing led to another, and we decided that our first WTF was going to be this kind of centring around this conversation that she and I had where she was saying, it's like, I've just lost the jam in my donut. I just feel like I'm all deflated down there. And I took your advice, and I finally went on to the vaginal estrogen. I've got my jam back. And we just thought, you know, if we want to start this with the bang, then that's the way we're going to do it.

[07:10] Sonya: And it was brilliant and hilariously. I was listening to it in my kitchen whilst I was cooking dinner without my headphones on, and I think my husband walked past, and then my 21 year old son walked past, and they kind of looked at each other and went, is she listening to a podcast about vaginas?

[07:30] Ardelle: I'm talking about jam donuts.

[07:32] Sonya: I was like, hell yeah, I am. Okay, so let's talk about the jam in the donuts.

[07:40] Ardelle: Yes. It's great for us to finally be appreciating that there are so many changes that happen to our bodies internally and externally when we go through menopause and we're not making estrogen anymore. And one of the crucial functions that happens is in the deeper layers of our skin. So I do have women who come to me and say who didn't go on to hormone therapy, for example, and they'll say that they feel like they just saw their skin aging accelerate. And the evidence about should we be putting estrogen on our faces has not been something that's been fruitful in the scientific literature so far. But the vulva and the vagina are skin tissues, and they do, again, have estrogen in their deeper layers. And so whether people are on systemic hormone therapy for their hot flushes and their night sweats, or if that's not for them, if they are on a vaginal product that is specifically a cream or a tablet that is placed in the vagina or their vulva, there are many ways in which it restores the function that you've had in your vagina vulva area prior to menopause.

[08:45] Sonya: Okay, now there's a couple of things in there that I find of interest. So as somebody who has a history of breast cancer cancer, and mine was estrogen and progesterone dominant, so I obviously had all of my treatment. I then went on to Tamoxifen Dabbled in Letrozole, which was like, I turned 90 overnight, was horrendous, went off that back onto the Tamoxifen I have been, I guess, swayed away from using vaginal estrogens as a result of women. Yeah. I'm intrigued to have this conversation because I've read really conflicting information on this recently.

[09:27] Ardelle: Yeah. And I think a lot of the conflicting information has come from conclusions that we've drawn about systemic hormone therapy and being cautious about whether we use estrogen and progesterone in people who've had breast cancer, not because we think that the estrogen and the progesterone themselves are the term is teratogenic. Do we think that estrogen and progesterone actually cause DNA damage and give you a cancer per se? And when I go to every talk that I possibly can about breast cancer, it seems that the consensus is more that it's about the receptors on breast cancer cells that may have progesterone or estrogen on the receptors on them. Because that's what your breasts have. Your breasts are meant to be responding to your hormones. They have throughout all of your menstrual cycles. That's why you have PMS and sore breasts. Right. That's why when you're pregnant, your cup size grows is because your breasts have a fertilizer or a gross response to those hormones being around. And so when there was concern that hormone therapy might be associated with an increased incidence of breast cancer, everything about hormones kind of got flushed down the toilet. Right. 2002 is sort of like this landmark year. And again, I think by now it's becoming an old story to bash the same study over and over again because there are some good things that we learned about the Whi study. But the pivotal thing that happened in 2002 was that the study was published and it made it seem as if estrogen and progesterone were associated with an increased risk of breast cancer. And so then that actually sort of became overgeneralized into women being then afraid or the medical community turning away from estrogen then on all fronts. And what we've learned since is that the vagina and the vulva are very specific in that you can apply creams and products and tablets specifically to those areas where they will make a benefit, where they make contact. So if you are a breast cancer survivor, the evidence is quite supportive at this point that if you use vaginal estrogen products that for one, they have not been shown to be associated with showing an increased risk of your first ever breast cancer. And for two, if you have survived breast cancer, and I shouldn't say survive, if you are a thriver after breast cancer, then we also don't have evidence to say that using these products on your vagina and your vulva increased the incidence of you having a recurrence.

[11:53] Sonya: Okay, great.

[11:54] Ardelle: And that is the science. That is absolutely the science. And we need to be screaming that from their rooftops because so many women are suffering without the very low risk basic products because they get cloaked with all of this mystique around estrogen.

[12:09] Sonya: Yeah. Okay. Well, that's fascinating and I will be having a conversation with my doctor as a result. So let's talk then about what a woman in perimenopause or menopause. What the changes she can expect to experience if she's not using a hormone treatment or if she's not using whether that's a MHT or HRT tablet that she's taking or whether she's using a cream or a gel or a pessary or anything like that. What she can expect. What changes she can expect. And what triggers she should look out for that would send her off to her doctor to have a conversation.

[12:51] Ardelle: Right. And you're bringing this up in the context of saying within perimenopause and menopause. And that's because these are stages in our life where we know that we have estrogen flux. But I'm going to expand that definition to also include other times in your life when you might not be ovulating and are in a low estrogen state. So that means breastfeeding. Women who are breastfeeding save for two years and are breastfeeding quite frequently and then pumping so that they're not ovulating. Those women can have sort of almost a temporary menopausal type state because they're not obviously not making estrogen. Sometimes women who are on a continuous birth control pill so that they aren't taking a break for their periods and they aren't even period. They're withdrawal leads, but they're actually, again, not making their own estrogen, not ovulating. We now have evidence to say that some of those people have more vagina and vulva dryness and difficulties. It's a genetic predisposition that we don't test for very well. So any of these situations in which you are not naturally ovulating on your own and having those fluctuations in your estrogen production from your ovaries okay, I.

[13:54] Sonya: Was just going to ask, does that also include women that use a Mirena.

[13:58] Ardelle: Mirena is interesting because for many women they are still ovulating. But the progesterone in the marina is so strong locally in your uterus that you do not have a period, but you are actually still having ovulation function. So it's different than the Deploy, primarily the Deploy poverty shot because it goes into your arm and gets into your bloodstream. That progesterone that is going through your whole entire body has a role of going to your brain and telling your brain that you have progesterone around. So then your brain goes, well, then we must have ovulated, so we don't want to double ovulate. And so the progesterone is actually the active component in contraception that uses hormones, the Mirena IUD or there's a couple of different name brands like the Kyleena and the JS. There are a few different versions. All of those, I suppose, you can almost draw a little bit of comparison to them and the vaginal estrogen products in that when you take that amount of progesterone and you specifically target it into the uterus. For most women, even though the ovaries are nearby and they're kind of in the vicinity, many people will still ovulate, and they can still tell that they have ovulation discharge. They can still tell that their breasts are tender. And so when those women are coming into their perimenopause and menopause, if they've had an ablation or they have a progesterone, IUD I asked them more specifically to be tracking. Can you tell when you ovulate? Do you ever get lower abdominal pain? Can you tell when your discharge changes? Can you tell when you get breast tenderness and moodiness and other things that would be part of your PMS? And those symptoms end up being more important to know than how they're ovulating.

[15:33] Sonya: Okay. Wow. Fascinating.

[15:34] Ardelle: Yeah. Bunny trail. Good question. Thanks. So, yes, when you have the progesterone on you, you don't know as easily when you are in perimenopause and menopause, because if you are left to your own devices, menopause in its classical definition is an observation that you don't have the same egg supply that you had before, and your ovulations are becoming less and less reliable. And so then that's where we notice first often people's periods getting closer together, and then often they start spreading apart and dropping. And that's how you know you were on your road to finally, at some point, ovulating your last egg. Right? So those last ovulations are often not as viable of an egg. And so how much estrogen they produce and whether or not they actually have the right power in them to even signal an ovulation pathway becomes unpredictable. And so then when you start missing that then becomes a highly estrogen fluctuate stage. So in perimenopause, in breastfeeding, in menopause, once you're over on the other side and you're not having any periods anymore, what women can start to notice is decreasing amounts of vaginal fluid or discharge, more difficulty with arousal, lubrication. There can be a greater predisposition towards east infections. There can be a feeling like you're on the verge of some sort of infection. You can't quite tell what it is. Things down there just feel a little bit dry. They feel a little bit itchy, but you look and it's not like there's yeasty type discharge. It's just really hard to tell what's going on. But you just know that things don't quite feel right. And so that can also display as burning or frequency with urination. It can be that your clitoris just seems like it's not as responsive. It can be that your labia feel like they just can't find the right way to sit in your underwear. It's painful to go on a bike. All of these things about your vulva and your vaginal area just being off from what it was before, and it's not an infection. It's something about the tissue quality itself and the way the vagina and the vulva are all functioning.

[17:44] Sonya: Yeah, okay. And then when somebody has experienced that sensation and they've joined those dots and they're thinking something's not quite right here. At that point, they should definitely go and have a conversation with their GP, which what we call GP first and foremost, to then be referred on to a specialist. Now, at this point, I'd like to kind of talk a little bit about what can happen. And this is because I've experienced this, what can happen if you go to see your GP and they're like, it's your age, it's your thing. For me, it was, well, you've been through breast cancer and you've been in menopause. It's probably a yeast infection, as you mentioned. So here's a really low dose steroid cream and go home, you'll be fine, see you later. And don't do that. Referral on to a dermatologist or a specialist or look at estrogen products and HRT and things like that. Where can that then spiral those conditions into other conditions?

[18:55] Ardelle: Yeah, well, I mean, misdiagnosis is a big problem, right? And misdiagnosis happens both when women are self treating because they're a little bit ashamed of this, or they just don't know how to start the conversation. So women have been using all sorts of vaginal products for decades, right? We have been the victims of marketing for douches and scented vaginal products and this fancy wash or this grooming tool or that. We have been sent all sorts of messaging about how our perineum and our vulva should look and how it should smell and how we should clean it and etcetera. And so we are already sort of programmed to be, unfortunately uncertain and potentially mucking around with things that are not going to fix the problem. So if you go in there to a vagina or a ball, the area that is having problems with low estrogen and the skin is becoming thinner, if you use an over the counter yeast product, that's not going to fix your problem. If you start using douches and such because the odour is different, that's not going to fix your problem. That's only going to disturb your microbiome. Further, if you instead start using some of these fancy scented washes or things, that's not going to help your problem. And so if you're using a steroid cream. If you've been prescribed a steroid cream. That is something that we use specifically for conditions that are dermatologic. Like. Say. Lycan sclerosis. Which is a bit more of an autoimmune thing where you get inflammation and you actually start losing again. I'm trying not to use the medical terminology too much. But the term is losing the architecture of your vulva. Right? Okay. So if you think about your vulva having just like some three dimensional geography to it, right? Your vulva, your jelly doughnut should have some plumpness to it that your labia come in all shapes and sizes, and they do have some lengths to them. Your clitoris and the clitoral hood should have a healthy amount of skin that is able to retract those functions if all of a sudden they start sort of like thinning down and tightening up that specific license corrosive can respond well to a steroid oil. But if you have a problem of low estrogen in menopause, then that's not going to fix that problem. Now you can have both happening at the same time. And I do have people who have been already diagnosed with a condition like lichen sclerosis. So they've been already on a steroid cream. But once you hit menopause and you start going through these changes, you need to have some product that tries to appreciate that low estrogen change. Otherwise using more and more of these Cortisol clobetasol is the term that we use for here in Canada. We'll just overthink the tissue and really not fix the problem in that you need the tissue thicker again.

[21:41] Sonya: Okay. Interesting.

[21:42] Ardelle: Yeah. In Australia, again, it's different in every country. Right. So, like here in Canada, it is possible to have a family doctor who does women's health, who does Paps, or maybe who has a nurse practitioner who is doing a lot of that for them. So people do end up accumulating sort of what they tend to gravitate to, and what they end up seeing a lot of is an area then that they end up learning more. And so we do have some family doctors in Canada who are highly skilled at figuring this out. But in other situations, people need to be referred on to a gynaecologist or to a dermatologist with their eyes and with their diagnostic tools. Can tell you exactly what's going on.

[22:19] Sonya: Yeah. Amazing. And I guess the reason I wanted to kind of go down that path a little bit was just to really shine a spotlight on not suffering in silence and letting these things just happen because somebody tells you that you should.

[22:35] Ardelle: Yes, and that's why I think it's so important that we're having these conversations and that there are good tools out there available. If you are a person who is going through Menopause and you don't know if that's what's happening to you and you don't feel like you've got the right language and the right knowledge in order to be able to. But you've heard about this, then that's where people can go to. My favorite of all time the Australasian Menopause Society. The quality of their handouts that they make for clients is so good because they are targeted topic by topic. And so they're one on vulva vaginal symptoms of menopause goes through what the symptoms are, what are the changes that happen to those tissue areas, what the treatment strategies can be. Moisturizers, lubricants, vaginal, estrogens. And then they have it's only like two or three pages, but then they have all of the scientific references at the bottom. So if you print off something like that and you take it to your doctor and it says right across the top, Australian Menopause Society. And it is a well written concise document that is referenced that can get you really far.

[23:37] Sonya: Yeah, and I refer back to the AMS all the time. I love their website, I love their documentation. On the other side of their website, which is super helpful for women, particularly here in Australia or New Zealand, is that you can search for an AMS registered practitioner in your area off their website. And I'm often referring women back to that. So I will definitely link into the show notes the AMS website because they are an incredible resource.

[24:05] Ardelle: Agreed.

[24:06] Sonya: Yes. Now let's then talk about getting the jam back in the donut and the impact that that can have on your sex life as well.

[24:16] Ardelle: Yes. So again, I think that the conversation has been too narrow when women really haven't been offered options unless they're having vaginal dryness, ie. Problems with intimacy. Right. Because again, you have to appreciate the way the vulva and the vagina are on sort of a day to day basis versus when you actually want to have intimacy. There is a different function that happens there. Right. And so I think when we've had too much of a heteronormative focus to vaginal care for women, it's ended up sort of diminishing their vagina to just something that is only something that you notice if you're having heteronormative intimacy. The way your vagina and your vulva feel day to day is different than that arousal function. So the ways in which estrogen then impacts for both of these is, as we've kind of mentioned already before, the thickness of the actual mucosal surface inside your vagina. If you think about your vagina being sort of a moist, yes, it's a skin tissue, it's a skin barrier, but it's almost a little bit more like the inside of your cheek, the inside of your mouth, compared to being like the epithelialized skin on the outside. Right. So that vagina is meant to have thickness to the tissue. It's meant to be able to shed off skin cells as part of if it's normal function. That's how we use this term of the vagina being a self-cleaning oven. It takes out the last bits of your last period. If you've had intimacy, it all comes out in that discharge. Right? And so that function is very important for the vagina to be healthy on a day to day basis. And when you lose estrogen, it happens on all the layers of the skin. So deep down you have less blood vessels. Well, if you have less blood vessels and you have less blood flow, sexual function is about more blood flow. Right. So again, if women can think about their vagina and their clitoris as being more of an erectile tissue, the way we are quite comfortable thinking about males and their erectile tissue, right. In order for you to experience pleasure, you need to have more blood flow to the area that brings more sensation. It sort of feeds healthy nerves. It has been shown in research that when you are aroused, your vagina actually tends to elongate a little bit. And so if you have intimacy without that arousal process happening, then you don't have as much lubrication. You potentially might have more of a feeling of discomfort if your partner hits up against your cervix. There are all these different things that happened as part of arousal that really are benefited by estrogen, having been around already so that those tissues are healthy. And so it is about sexual function and the lubrication, but it is about the vaginal health and having less infections day to day. It is about the comfort of how your vulva feels on a day to day basis and it is about your bladder. And that's why the terminology in the last few years has been upgraded from just vaginal atrophy, which is just your vagina's atrophy. That became obvious that it was very negative terminology to be using that with women. But then the term that they came up with instead is genital urinary syndrome of menopause, which is a bohemian. But it is trying to appreciate that it is your genital area, it is your vaginal area. It is a syndrome because it affects your relationships, it affects how you feel about yourself, and it is associated with menopause again, so trying to normalize the fact that this is part of the menopause consequences. And so if you see it as a normal consequence to that reproductive phase that we all go through, then maybe we can do a better job of talking about it and treating it.

[28:06] Sonya: Yeah, so cool. Now, one of the questions that came to my mind then when you were talking was I've heard I haven't been told this personally, but I've heard women that have been told use it or lose it. So continuing to have a healthy sex life and regular sex and integral intimacy, whatever you want to call it, is actually beneficial to the health of your genital area. Yes.

[28:33] Ardelle: Right. Well, you know, and that's terminology I find to be very interesting. I mean, I heard that terminology when I was a resident, right. Use it or lose it. And I appreciate that the concept was if you have a sexual partner or if you don't have a sexual partner, it doesn't matter. It is good to maintain and to keep up the sexual side of your being. Right. And so if you have a relationship, then if you have frequent sexual encounters, then that does let you be assessing the area. It does let you be moisturizing and lubricating as it needs to happen. It does continually tell your pelvic muscles to relax in order to accommodate for intimacy. And so I think that's where that terminology came around. But I fully acknowledge that it's somewhat derogatory right, in suggesting especially when you have women who are truly having pain, having more sex is not going to get rid of their pain. It is potentially only going to. Be making it worse if you have dryness in menopause, having sex, yes, is a good stimulation to the tissue, but it's not going to cure your genital urinary syndrome of menopause. So I think it's good for us to be encouraging that we should be open minded to women having sexual function far beyond what has been sort of culturally considered to be something that we were comfortable talking about. We should be fully acknowledging that healthy sexuality can happen for decades beyond your menopause, and so we should be encouraging that. But I think sometimes. Again. Some of these handy little rhymes and tropes and things are too general to really sort of appreciate the depth and the breadth of the problems that women can have when they go through menopause and are not having good sexual function. Relationships. Stress the job that is not turning out the way you want it to do you make that one last leap in order to get one more promotion? Well, you don't feel that you can because you've got these horrible hot flushes, you're exhausted all the time. You don't feel your brain can function as it did before, and now you've got vaginal giants and it's causing problems in your relationship. Sexuality and libido and desire and all of these other concepts that relate to choosing to engage in intimacy are affected by all these other things that happen to us in menopause as well. And so women should never, ever be in a situation where they feel that they have to force themselves into sexual activity because otherwise, well, if I don't use it, I'm going to lose it. I better force myself. I better just grit my teeth and just make it through this because I don't want to not have this option later. I think we deserve more conversation around that.

[31:20] Sonya: Yeah. So powerful and so incredibly true. So thank you for taking my comment and expanding out into that, because that is so important for women to hear. So important for women to hear. There was a question that came to mind which has disappeared from my menopause brain. No, it's back. Is there a change in the architecture, the function of the vulva and the vagina once you move into that postmenopausal phase? Because a lot of what we talk about through the perimenopause and menopause is due to the hormone fluctuations. So once you move into post menopause and those hormones do actually settle, do we experience different changes then?

[32:11] Ardelle: Yeah. So we do see that the amount of hair on the pubic area can be less once you get into menopause hair growth. Again, you shouldn't think that this is rocket science. Your hair growth pattern changes when you go into puberty and you start making those sex hormones. So why wouldn't it change again when you're not making as many of them? Now, of course, if you go into hormone therapy, that might change that a little bit. But again, the evidence there of saying that hormone therapy, when we use it in these very low sustainable, what we feel are very safe doses of systemic hormone therapy. Is that going to stall or reverse things like hair loss changes? I wish it was that simple. Right. But there are so many other things that are also at play when you talk about things like hair changes. But all that said, we do see that people have a change in the quality of their pubic hair. We do see that the deeper layers of the vulva where there is both vascularity and when there are collections of fat that cause the plumpness to the vulva tissue itself, those things can diminish and change. And then of course the lady themselves might be a bit smaller than they were in your high reproductive years. Any woman who's been pregnant remembers that her labia changed. Right. So those high estrogens and those high hormones of pregnancy do cause even a temporary change in your vulva structure. Right. So of course we should then acknowledge that it's going to change as well when you go through those stages of menopause.

[33:43] Sonya: Okay, awesome. Yes. I think it's important to talk about what happens post menopause as well because we are spending so much time and look, my field of passion, more so than expertise is around the perimenopausal, that small window of menopause. But it's important for women to understand what it looks like postmenopausal as well, I think.

[34:05] Ardelle: Yeah, exactly. And we do see that women will have different sexual function as we go through our decades. And again people have had a change of partner even if they've stayed with the same partner. Women do have different wiring, whether it's because of the maturity of nerves, whether it's because of the stressors in our lives that might change our parasympathetic and sympathetic messaging in our brain, all the dopamine and serotonin that are also part of orgasm. We do see that women's sexual responsiveness, what feels good to them, what results in an orgasm that can change over time and it's not necessarily a problem. Of course you don't see it as a problem. Usually if it gets better and there are women who will say that their sexual life does continue to get better and it's because they are adapting often to those changes or they are letting go in a different way that lets them experience sexuality differently. And so again, I think sometimes when we're caught in these assumptions that the best sex we ever had was in our twenty s, then you're not opening yourself up to the possibility of different types of intimacy, different types of connection, different types of confidence in your body so that you are willing to explore things that you didn't before and same thing with your partner. Right? And so I think sometimes we need to move away from just that conversation about sex. Are you having it? How many times are you having an orgasm, all those goal and sort of like count numbers, related sort of markers of success and instead move into what the experience is. Is it pleasurable? Is it something that you look forward to? It doesn't necessarily matter how awesome it's happening, if what it is, it's satisfying and it's good and it's something that you enjoy now and maybe it's very different than it was before.

[35:58] Sonya: Yeah. Quality over quantity.

[36:00] Ardelle: Yeah. And I think that's a really important part of the conversation. And to loop around again to the vaginal estrogen products, I think, again, in the physician culture, we need to be looking at these products as being very beneficial for women's health, whether they are sexually active or not, because the bladder irritation and urgency and infections are a real problem for women that are not sexually active. And potentially even women who then do accumulate the things that happen to us as we get older, arthritis in our hands, or women who are in long term care, they still deserve to have good vaginal and vulgar care. And so that can be a challenge when you have patients who are potentially not able to deliver those medications themselves and they might need the help of their caregivers around them, but it still makes an impact on their health. I think it's important. And I'm glad you asked the question about sexuality as we move into that post menopause phase. If you're menopause at 50 and you live to 90, there's a whole lot of vulgar and vaginal health that's happening for the rest of your life.

[37:10] Sonya: Yeah, it's really interesting. I have an incredibly vivid image of going to visit my grandmother before she passed. Literally days before she passed, she had been taken out of her long term care and she was at home so that she could and the family had gathered around. She was sitting in the family lounge room and she was surrounded by her children and their children, and she was scratching at her vaginal area. And I was probably 20 I'm talking 32 years ago. This is probably a memory, but at the time I remember and she was being told to stop by my aunt. My aunt was like, kind of grabbing her hand and go, stop doing that, stop doing that. And it's an image that's really stayed with me for many reasons. You might be now going through my experience with menopause and the changes that I've experienced with my vagina and my vulval area. I link it back to what she must have been feeling and experiencing. And it breaks my heart to think that she was almost being treated like a child, like, stop doing that, don't do that. But she must have been in so much discomfort.

[38:31] Ardelle: Exactly right. I was listening to a podcast just yesterday about the week and do hard things. And in that context, they were talking about on the flip side of that, because you were saying it almost felt like she was sort of being treated like a child and sort of being told. And the way that we treat little boys versus little girls when it comes to just understanding their genital function, obviously for little boys, things are visible where for little girls, they're not. And that kind of starts that sort of whole process of either visual obvious feedback from something that is connected to versus something becoming like mystique and sort of and your brain can sort of like take over from what is physically happening because you can't actually see what's physically happening on the inside of your vagina. Right, yeah. And when you think about the way we as a culture have sort of treated that developmental phase and when I think about, like, when I used to work on geriatric wards and the difficulties that the staff would have when there were clients or residents there who still obviously had sexual interest. And how do you decide when those are in their best interest? And when have they found a relationship that is appropriate for them to pursue? How much do you protect one person and how much of that is patronizing? And how do we address this in people in that age group? That could be a whole other conversation.

[40:06] Sonya: I think that definitely could be a whole other conversation. And when we went into without meaning to.

[40:13] Ardelle: But it is the spectrum, right. What we're talking about today is vagina involved with health, which is something that changes over the spectrum of our lives. Right. And then the topic of today is obviously like, how is it that it's happening so dramatically differently? And how women feel about the vagina and vulva function around that time of menopause? Because, let's face it, at that point, we are adults. When you're in puberty, what do I remember about any sort of wisdom I had when I was in puberty? None. Right. You go through puberty as sort of not a very wise person. We're going through a menopause with more wisdom and with more experience. And so I think it makes it a more impactful phase for us, even though it's just the mirror image, the flip side of puberty. And because you are losing something that now you've been used to having for the last 40 years of your life, it is something that deserves way more attention and way more treatment than what we've been doing.

[41:11] Sonya: Yep. And this is why we're having these conversations and why I'm so incredibly grateful to you as particularly somebody that is you're a OBGYN, as you call them, a Canada gynaecologist for those of us here in Australia and New Zealand. And one thing that I've noticed is that in the UK, in North America, Canada, there are more of these conversations being had by practitioners at your level.

[41:38] Ardelle: Yeah.

[41:39] Sonya: Unfortunately, that's not quite happening here yet. I got a beautiful email during the week from a random listener actually, who found my email address and drop me an email. And she was like, I'm so grateful for your podcast and I really wish more GPS would listen to it, or I really wish you could find a way to get GPS to listen to it. Really resonated that. Unfortunately, we're not having the high level practitioner conversations in a public forum that we need.

[42:08] Ardelle: But you know what, if we keep on putting it out there, it does get picked up, right? If you keep on doing your podcast, these things are evergreen now, right? People will find out about you and they'll go back and read it. When I started talking more and more about sexual health, when I was being invited to do just basic menopause chats and I would always tag on to the end of my tips for the right moisturizers and lubricants, all of a sudden was having family doctors stick around until the very end. They were there until the very last Q and A and I could see them. This is a day pre pandemic. I could see that as soon as I start talking about over the counter moisturizers and lubricants, their pens are out and they're writing it all down and they're making notes because they haven't learned this anywhere else. And so I think the more we put this information out there, the more it is going to get picked up.

[43:01] Sonya: That's what we hope. And I think we are definitely seeing.

[43:04] Ardelle: A shift, which is but do you feel that your listeners would want something that is practical when it comes to just like how to care for your vagina and your vomit in like three minutes?

[43:15] Sonya: Yes, please.

[43:17] Ardelle: So, first off, if you think you are going to the perimenopause and menopause stages and you are experiencing some of these symptoms like what we have discussed, please realize that highly likely this has something to do with your menopause and being low on estrogen. So there are things that everyone can do. One, reduce irritants. So if you are not wearing breathable clothing, again, people can get into banks as to how much do we have for scientific evidence about this. And well, some of this is logical, right? If you are wearing leotards and tight skinny jeans with polyester underwear underneath, your ball is not breathing very well. So reduce the irritants. Let your skin be breathing. Get rid of excessive soaps. Soaps and things with fragrance will disturb the nice skin on your vulva. The vulva is what you see on the outside. So that can be something that you can use a very simple cleanser. Use something that is Dermatologic society approved here in Canada. And a few of these ones that are like so affordable in the drugstore, they're unscented, they're hypoallergenic, they're meant to be for sensitive skin. They're approved by dermatologists. Something like that. If you can use it on your face, you can use it on your vulva, right? So pick something that is very simple. You don't have to spend a lot of money. Moisturizers for your vulva can be something as easy as just a basic oil, right? So a little bit of coconut oil, a little tiny bit of almond oil. There are some products out there that are marketed to be for your vulva beware because again, you don't need to have something that smells like a Pina Colada. If you're going to get a vulva moisturizer, try to pick something that looks like it's pretty basic, very simple ingredients. Don't look for a bunch of fancy fragrances or tingling stuff. Just try to be as minimalist as you can with your vulva care. Okay? And then when it comes to your vagina, for years doctors have been saying please don't douche, please don't have anything else that goes up into your vagina. Leave your vagina as much as you can alone. But if you're going through the stages of menopause and your vagina is becoming dry, then yes, please do consider that there are moisturizing products, there are lubricants that you can use specifically when you have intimacy. Again, solo or partnered intimacy. The vulva and the vaginal tissues are much happier if they don't have too much friction in like tugging and tearing on them. So use moisturizers and lubricants again, that are not irritating liberally and a low threshold for people going to their physician to have a discussion about some of these products that can be vaginal creams or tablets or a ring. In Canada, we now actually do have an oral tablet that you take so you would find this interesting. The Tamoxifen that you were on is a category medication called a selective Estrogen receptor modulator. And so we do now actually have a new product here in Canada. I don't know if there is there in Australia yet where it's an oral tablet, but it works in kind of the way that family of medications does, in that it specifically does target the estrogen receptors in your vagina and your vulva in a positive fashion. And so we are newly now making that available to people here in Canada. And I think it is a good option for people who don't have the dexterity or just don't have the comfort in placing things specifically topically on their vagina and their violet. But there are options out there, so please don't suffer in silence. Let's all talk a little bit more about what we do for our vulva and our vaginal care and let's make sure that those estrogen products get out there.

[46:46] Sonya: Yeah, amazing. Thank you so much for wrapping that up so beautifully and so important.