Why Vaginal Dryness Doesn't Improve Even on HRT

Okay, there's an area of our body as women that we do not talk enough about, and it's not hormones, it's not hot flashes, it's not waking, it's not the symptoms. It's an area of our body, and this area seems to create UTIs that keep coming back. It creates leaking when we cough or sneeze or jump or do these exercises at the gym that used to not create a problem, and it sometimes creates burning that nobody can explain. It creates dryness that my husband jokes is like the Sahara Desert. We'll talk about that in a few minutes. And it also can create in women painful sex.. And a lot of women are embarrassed by these things, so they don't bring it up to their doctor. They don't talk about it with each other. It's one of those things that's kind of hush-hush, and when someone else brings it up, they're like, oh yeah, I have that too. Now, this is not stuff that we have to just accept as normal. It is normal. It is happening. It's not optimal, and it doesn't have to stay optimal. And there are things quietly happening in our bodies that we have not learned about, and today we're going to fix that. So I had to bring back one of my favorite guests. She's one of my really, really good friends. I've had her on the show many times. She is our go-to girlfriend doctor. She has educated us all around hormones and what's shifting and what's happening when we go from perimenopause to menopause. I'm talking about Dr. Anna Cabeca, AKA the Girlfriend Doctor. And we call her that for a reason, by the way. Yes, she's a triple board-certified OB-GYN. She's been on my podcast many times. She's got best-selling books. She's got an incredible clientele. She happens to be my own personal doctor, but she's the Girlfriend Doctor because she explains things to us in a way that I don't think we've been taught before. It's is not the way that most doctors have talked to us. So she's got a way that lands and resonates, and she's going to help get us all fixed up today. Thanks for being here, Anna.

Oh my gosh, always excited to talk with you and catch up with you and also share about this really important— and you said not spoken about enough— topic that leaves women suffering unnecessarily.

You know, I'm going to kind of start with a reel that we just posted right before recording on my social media. We were in, gosh, we were in Vegas together. You, me, my husband, a bunch of us. Dr. Amy Horniman was there and we were having dinner. There may have, may not have been a glass of wine involved, but whatever. That's a different topic. There might have been some supplements involved. However, we were talking about Anna's new product, Velvee, which we'll get into a little bit later. But it's basically a lubricant, but for midlife women, and it's one that is safe and healthy. And it's got— we joked that our friend, Jen Amber, who's a skincare expert, when she checked it out, she instantly read the ingredients and put it under her eyes. And Natalie Jill's like, wait, that's not for your eyes. And Jen was like, well, it could be. It's great, great ingredients. We were talking about it at dinner. And I think there was like 7 of us women and my husband, you know, it was just, he was just with all the girls. And we're talking about all things vaginal, menopause, all, and he's just sitting there taking it. And we were talking about Herbelvée and my husband made a joke about like, "Oh, it fixes the Sahara Desert." And, he said Sierra though, Sierra Desert. So, in our mode, we said, "Let's make a video." So, we made this video where Brooks, my husband, I said it was his debut as an influencer, he knocked on her hotel door, she opened it, and he says, "Dr. Anna, I have an emergency." She says, "What? How can I help you?" And, he said, "My wife is as dry as the Sierra Desert." And, she rescued it with Velveeta. So, we're making light of it, but it's a real thing. So, I guess let's start with that? Like, what is going on down there? Why does that happen?

Yeah, well, it's just like we look at our skin changes, right? And even in our— man, even in our 20s now and 30s, we're worrying about the fine lines and wrinkles, the loss of collagen supporting our muscle, right, for health and longevity. We think about all these things, but we totally don't realize that it's happening to the vulvar, the pelvic area as well. And if it goes unattended, things that happen like incontinence, vaginal dryness, infections, odor. And then of course the rectal area. I would say clitoris to anus, most important anatomy to take care of. And you get anal fissures and hemorrhoids and like, we don't wanna struggle with that after childbirth, let alone, you know, in our 50s, 60s and beyond. And this becomes really a life-threatening issue beyond that because recurrent urinary tract infections and in the elderly, undiagnosed urinary tract infections lead to pyelonephritis or kidney infections, and then septicemia, infection in the blood, and then death. And that happens more often than I care to talk about. But these are issues that affect us and that will affect us unless we're actively taking care of this anatomy. And it's so important from what we put in our bodies, right, to have healthy skin. It's from the inside out and on our bodies and taking care of the vaginal microbiome. All these pieces come into play.

Now, I'm in menopause and you are too, and we're both on— I'm on 60, yeah, 60, and I'm gonna be 55 this summer, and I am on hormone replacement. And a lot of the symptoms with hormone replacement stopped, things like hot flashes, a lot of the brain fog, like a lot of the main things stopped. But the things that did not stop at all from HRT are very specific, and so I want to get into why that's different. The dryness, Vaginal dryness for sure has not changed from HRT for me. Itchy ears. What the heck is going on inside our ear canals? What is that? And then skin changes. So, you know, they— we say when you lose estrogen, your skin starts changing. Even on HRT, I've noticed a big change. Can you— I want to address those 3 things, then we're going to come back, of course, to vaginal.

Yeah. And so this is a couple things with a difference. You know, first of all, the hot flashes, you know, those are going, and our body has stabilized with a majority of those symptoms. But there's still some women that I have met in their 70s that were struggling with hot flashes, but as a result of insulin resistance, not estrogen insufficiency. So we really want to address the root causes of those if women are still struggling with that. But all— many of the other symptoms start to temper off, or we just get more comfortable living with it, let's say. We have to really address that. I hear from so many women, I didn't realize how bad I was feeling until I started feeling good again, right? Yeah.

Oh yeah.

And And so that's such a true issue. And the dryness of our skin, the loss of elasticity, the loss of collagen, the loss of glandular secretions. I mean, it's the dry eyes, the dry ears, right? It's these glands start to dry up. And there's research now in ophthalmology that looks at DHEA for helping with dry eyes, topical DHEA. So yes, you can use my product, Jova, there too. But you know, and I haven't thought about—

By the way, I wanna give a fair warning to my audience. Anna Quebeca, I love her. She's my friend. Remember the movie My Big Fat Greek Wedding, how Windex cured everything?

Oh, totally. Okay.

Anna's Mighty Maca, Julva, and Balance Cream cure everything. It's going to come up for everything throughout this conversation. I'm just going to share.

No matter what I call her with, no matter what I say is wrong.

Oh, you know what? You got to put Balance Cream on it. Nope, nope. You got to put Julva on it. So I'm sorry.

I had to just interject there. Oh, right. I know. Okay, so much— the sunspots, everything else, everything is cured by it. Yeah, yeah, we've got a Windex for that.

Yeah, sorry, continue on.

That's so true. But so you're losing the glandular secretions, the natural glandular secretions around the eyes and maybe around the ears too. A lot of times for ears, dry ears, and I, you know, part of my exam, I look in your ears. Yes, I'm a gynecologist, I do a full executive physical, check all the holes, check them all. Absolutely. And no body fluid is exempt. From evaluation. That is true. So, you know, thinking about things to help with the dry ears is first understand the cause. I mean, get an evaluation. If you're using cotton or Q-tips, I mean, just think, I mean, many of those have chemicals in them, we know. So we want to be careful that we're using organic whenever we're using anything on or in our body. And addressing the oil. So a couple, if there's dry ears, a couple drops of Olive oil in the ear, garlic oil in the ear can be very, very good. I have not explored, I have not explored Julva in the ear yet.

I did. You told me to.

Did it work?

You know what, I love Julva, but not for that.

Not for that?

What worked is, so, because my ears are driving me crazy. And, first of all, is it true that we have estrogen receptors in our ears?

Yes, and progesterone. Okay.

So you told me when I was dying, I knew you were going to tell me either to put Mighty Maca in there or something, but you said put Jolva in there. I'm like, all right, I'm desperate. I'm trying. I also tried putting Estriol in my ears. No. What worked for my ears specifically was I got mineral oil. Somebody sent me a video. It was on TikTok and I copied and it works. Mineral oil. And I bought the nasal spray for allergies.

Exilir, that one?

I don't even know what it was.

Or Afrin.

I don't think it was either of those. It was something was one of some nasal allergy spray that I bought, some generic, whatever. And I mixed mineral oil and 10 sprays of that in a little dropper. And once a week I put a dropper in my ears and it fixed it all.

That's awesome.

So it's not your Windex remedy, but it did work.

It's not my Windex remedy. Yeah, that's interesting. I'm curious if it was just a saline nasal spray and just mixing the mineral oil with some, but you definitely have to let me know.

And it could have just been mineral oil alone just because it, lubricates, like you said, the olive oil would.

The olive oil, the garlic oil, because garlic oil is good because it's also antifungal, and sometimes itching is because of fungus.

Okay.

And so that can have a double benefit there. And again, very moisturizing.

That's a good idea.

Really help.

I'll try that next. That's probably healthier than the other things I did.

Okay, maybe, maybe not. As long as it works, it's good.

But you had told me about— okay, well, sorry, I don't want to, I don't want to interrupt here. So that's the dry ear thing. It's not necessarily the estrogen receptors, or is it? Or What you're saying, it also could be just over time, or what else is creating that, that feeling that they—

it— yeah, yeah, that itching. And you know, when we think of itching skin in general, the one thing that I always think about is liver detoxification and gallbladder detoxification. Itching and, you know, you know, on your skin, anywhere else, we want to make sure those pathways are clear and supported.

So what do you mean by that? So you're saying if they are not detoxing right, or what?

Yeah, well, oftentimes like congested gallbladder can lead to itching, itching like all over body itching, ear itching. And so we can see some of those symptoms, not necessarily gallbladder pain or other issues with fat malabsorption, but we can see some of those issues. And again, detox, decreasing inflammation, addressing the detox pathways, because that's important for our hormones to work better, right?

And how do we do that? How do we address that?

Detox is— I mean, so many ways, right? So many ways we can detox, but one is, um, You know, one of the things that you can do is a gallbladder liver flush, and that's simple. There's many places online to look. Typically what I have my clients do at least once a year is the olive oil with lemon juice shot. Okay. Once in the morning for 7 to 10 days and just eating like a, a clean protein, but like a fish, non-red meat diet for those, and vegetables for those 7 days too. And then you can get a really nice gallbladder flush. There's other things you can add in like malic acid and of course magnesium oxide to keep the bowels moving.

How much olive oil and lemon?

Lemon, um, like a shot glass.

Okay, of olive oil. And how much lemon do you put in it?

A squirt of lemon, or like say a teaspoon.

So you just do that first thing in the morning?

A tablespoon for 7 days.

And then why can't you have red meat with it?

Because red meat, harder to digest than white meat. So our fish, it's hard, a little bit harder to digest. And yeah, and I think that's just been one of the pearls that I've learned over time and that have been practiced over time. It's just avoiding red meat during that gallbladder flush.

And then how do you know if you're actually flushing it? What happens?

Well, sometimes you'll have good, you know, good, more fatty bowel.

Okay.

Bowel movements. You'll feel better. Your skin will be clearer. So that can be something that you experience as well. You really won't experience digestive upset or anything like that. That. So it's just one of those— you, you feel it clearing through your system and emptying, helping empty your bowels. Okay.

How come systemic HRT doesn't address the vaginal dryness and the ears?

Yeah, yeah. And, and that's the issue, because even progesterone orally, estrogen patches, which is very common, doesn't address topically. So adding the topical support. We get systemic, and there's been studies, and, you know, oral estrogen may help incontinence, may increase incontinence. And so there's a lot of questions around that. But we know that topical DHEA, that I've studied the longest now over 20 years, really helps with those issues, really helps with those issues topically. You see, because DHEA converts to testosterone and estrogen, so you get a double whammy. So at the cellular level. And you don't see us just like with topical, you don't see the systemic absorption, but you get the benefit on the skin, on the skin topically. So you'll see that. And that's why, you know, estrogen cream has been working well. DHEA creams have been working well. That can make a difference. And I even say progesterone and pregnenolone, you know, we've been— I've been using now since I experienced frozen shoulder myself, progesterone and pregnenolone cream. That's, yes, My Balance cream. On my shoulders. It was available, and I'm like, okay, it's a fascial issue. Let me try this, because certainly there are hormone receptors in our fascia as well. And, you know, just being an OB-GYN, you know, high levels of hormones in pregnancy, you're super flexible, right? We have— it also increases the relaxin hormone, so you're super flexible, your pelvis is able to expand, and all those good things to have natural childbirth. So Hormones play a big role in that at really high levels in pregnancy to happen to have that effect. And then Dr. Angeli Aki, who trained at Yale and then created Yale's Integrative Medicine Program— she's an internist and an integrative and functional medicine— and functional medicine doctor, and she studied fascia, and she calls it the Cinderella organ. She says it is so important, so crucial for health and vitality, for circulation, for lymphatic flow, for, you know, for everything. And it does get stiffer, right, as we age. That stiffness, that's a result of the fascia. The fascia goes from, you know, head to toe. Our fascia runs from head to toe. And I trained as an osteopathic physician in medical school. And so what I learned was, yeah, every part of the body is connected. You can't separate it. So you have to look at it as its whole. Entity together. And fascia is crucial for, you know, crucial for quality of life and quality of health. So it all made sense when I started really digging into fascia and hormone receptiveness of it and how that can help the pelvic floor, which is my area of interest, as well as other areas of our body, but definitely the pelvic floor.

You mentioned a word that is not mentioned enough a little bit earlier. Pregnenolone. What is that? Why don't we talk about that more?

I don't know why we don't talk about it more, honestly. And I, you know, studying the endocrine hormonal— endocrine system at Emory, we learned all the pathways. From cholesterol, you make progesterone and pregnenolone. And from pregnenolone, we also— and progesterone, we also make DHEA. And then that converts to testosterone and then to estrogen. That's like the pathway. The other pathway is to go to cortisol. And so that's why often in high stress times, you have lower levels of progesterone as well as pregnenolone, but progesterone is most studied. Now, when I was in, in 2010, I was speaking for an Italian regenerative medicine group, and one of the fellow scientists and physicians spoke, gave a whole lecture on pregnenolone. And then that's when I really dove into the benefits of pregnenolone for the brain, for hormones, for energy, for focus. And it's, it's so beneficial. And I think because we have not— again, we can't patent a bioidentical substance. We can patent the form it's distributed in, like the estradiol patches. It's a bioidentical or body-identical, depending on the preference and terminology. It's, uh, it's identical. And yet the patch we can patent. So that's how that we have a bioidentical that's available. Prometrium is the same way. It's a bioidentical progesterone in a patented formula and a patented capsule with a peanut oil base. So, but pregnenolone has not been successfully manipulated or used. However, now at Harvard, they've been studying allopregnenolone for depression, which— so oral progesterone converts to allopregnenolone as well. And they've been studying allopregnenolone at 45 milligrams a day for the treatment of depression, postpartum depression, PMDD. And so I'm looking forward to seeing those studies when they come out.

Did you just say, or did I hear that wrong, that progesterone converts to that? Yep.

Orally.

Orally. So if you take oral progesterone, you're getting that.

You are getting, you're getting allopregnenolone, not pregnenolone, but you're getting a derivative, allopregnenolone, which is associated, which is one of the reasons oral progesterones help us sleep, help us get that better sleep.

Okay. Let me— I want to— I don't want to get too off topic here, but I want to not skip that part. Speaking of progesterone, help us understand. It seems that I hear it's kind of like one of the safest hormones that you could do. I hear that people started in perimenopause or even earlier. I've also heard there are a lot of doctors, kind of old-school training, that say if you've had a hysterectomy or you don't have a uterus, You shouldn't take it. And I want to— can we dive a little bit into that for a minute here? Because I have a client in particular in my groups and she does not sleep. She's maybe slept 1 or 2 hours a night. I so feel for her. It's so infuriating to me. She could not get progesterone prescribed. And the reason she wasn't getting it prescribed is her doctors kept saying, "Well, you don't have a uterus." And I'm thinking, I'm not a doctor, but that just feels like abuse and it's wrong. So help us with all that.

Yeah, it's, it's, they don't understand the science. And they, we did a really good job in the medical system in confusing progestins, the synthetic forms, to, with bioidentical progesterone. And they are completely different.

Can we unpack that for a minute? Like, okay, what, like, what's the difference? And I'll ask you kind of one question at a time here. Otherwise, we'll go on a tangent. But what's the difference with those? Yeah.

So what happened in the 1950s, we, you know, the world was excited by the purple pill, Premarin that came out and it was the solution to everything. And then women started getting endometrial cancer. Yeah, endometrial cancer. So they had to create— and the makers of Premarin, Wyeth-Aristotle, actually worked for them in their drug metabolism department before I went to medical school. And they were like, okay, we need to create something to oppose this estrogen. So you can't patent bioidentical progesterone. So they formulated Progestin, medroxyprogesterone acetate, even though it has the word progesterone in its name, it is not the same thing. And this is very confusing because I've told, you know, I've told people whether— are you on a bioidentical? And someone said, I'm on medroxyprogesterone acetate, it says, so I think that's bioidentical. Like, it's absolutely the worst progestin you can have. And so even though it has that word in the name, it is not the same thing. It is a synthetic progestin. And so they're makers of Premarin were like, okay, we need to get everyone on this progestin. But it had cardiovascular risk. And if women did not have a uterus, they weren't at risk for endometrial cancer. So they weren't given any— that makes sense, right? Which was a blessing in a way, because you didn't want that awful progestin, which we know has an increased risk of causing breast cancer. The progestin, not the progesterone.. And so it's a really big differentiator. And since we've had better forms of progestin, like the norepregnenone, uh, norepregnenolone, those are some of the forms that have been used as synthetic forms, but still it's not as good as bioidentical progesterone. And it's really important to understand that there is no bioidentical progesterone in any birth control pills available on the market. So you're always getting that toxic form when you're on birth control. And so That was then they started to see, okay, well, estrogen can help with everything, so let's try, you know, let's study women in this. And in the 1990s, I think they start, or '80s, they started the HERS trial, and that was to look at women and heart disease on hormone replacement, with or without hormone replacement. And they found that, well, they're on the progestins, they have worse, and if they're on oral estrogen, they have increased risk of stroke. So, okay, we, we can't recommend hormones for cardiac back prevention, right? But they were using again the worst forms that we have available. We have much better options. And so that's how that came into play. Oh, if you don't have a uterus, you don't need pro— you don't need progesterone. But you do need progesterone, not the progestin, because progesterone— we look, and I study this in the brain, and I trained at Emory University in Atlanta, and our neuro ICU was doing IV progesterone in traumatic brain injury patients because they saw better recovery, less edema, you know, quicker return to normal function. And so they were studying— it was called the PROTECT-3 trials, the PROTECT trials. And so looking at that research and understanding the benefits of progesterone in the brain and thinking, you're using hormones in my patients that were highest risk that had come to me with a history of breast cancer, wanted to maintain their brain their energy, their sleep, their sexual function. All of those things were important. So when I started using progesterone in women who'd had a hysterectomy, they'd all come back and say, Dr. Anna, I feel like a cloud has lifted. I feel like a cloud has lifted. And oral forms of progesterone have been shown to be safe, and also topical forms. And so one of the reasons I created my Balance Cream was to provide that topical option of a combination progesterone and pregnenolone for the, of course, topical benefits to skin, among other things. So this is so critically important, with or without a uterus. Progesterone, either topically or orally or vaginally, are great additions. And I, I will take progesterone until I die, there's not a doubt.

Can you do too much of it?

Yes, absolutely, you can do too much of it.

And how do you know?

That can cause moodiness, that can cause irritability, that can cause swelling, you know, high levels of oral progesterone can have overly sedative effect. And so even at low doses, some people are hypersensitive to the sedative effect. And so that's where vaginal can come in handy, or lower doses, extended release forms with a compounding pharmacy that— or quick release, depending. And so there's options we can use depending on your hormone metabolism, right?

The standard dose seems to be between 100 and 200 milligrams. That's what I'm seeing, like depending. And then, so, but there's this whole line of people saying you need 800 milligrams, so, so you have to be careful there is what I'm hearing from you.

Yeah, you have to be careful there because again, we know that the progesterone is converting to the allopregnenolone, and in the studies they're looking at, you know, 45 milligrams of allopregnenolone, which you'll get from 100 milligrams of progesterone. So you'll be doubling that potentially, again depending on your metabolism, with 200 milligrams. And then there are some cases where we need to go to 300, 400 for, you know, the benefits. But I want to say we want to keep that short-term and also try the vaginal route. So vaginal progesterone suppositories can be compounded, can be created and used. And also, you know, oftentimes you can just insert— if you have a nice, you know, progesterone capsule, you can insert that into your vagina and it should dissolve. It should dissolve, especially the gelatin, the clear gelatin progesterone progesterone capsules will dissolve in the vagina, and so you can get it that way. Suppositories more absorb better though.

Hey there, if you're finding value in this episode of Midlife Conversations, I would really appreciate it if you would hit that like button and subscribe. And when that little bell pops up, you want to hit that, that way you are notified of all new episodes so you don't miss a beat. Also, you subscribing and liking helps others find this content, and this allows me to keep growing, keep getting amazing new guests for you, and to keep sharing. Can we talk about cycling progesterone? And, uh, Anna and I have an ongoing— I'm not gonna say argument— discussion where she says, Natalie, you need to cycle your progesterone even if it's just a few days a month. And I say nope, because then I won't sleep. So can we discuss why?

Yeah, so this is, this is an interesting area. So because we always want our hormones to continue working for us, right, we always want to give the opportunity for the progesterone receptors to clear and the the— our HPA axis, we want to support our hormones, not suppress our natural hormones. So higher doses of hormones continuously can suppress our natural production. The best example I can give is testosterone in men, right? Test— they'll, you know, doctors will prescribe testosterone in men and their testicles shrink. So, right, so that— yeah, it absolutely shrinks in these, in these higher levels continuously doses if they're not doing something else in addition to it. We might add Clovid, uh, Clomid, or something else. And so there are options, but that's, you know, again, too high too long is suppressing your body's natural production of testosterone. They get the testicular shrinkage, and if they stop those injections or pellets or whatever, they can go into a severe depression, even suicidal ideations.. And this has been well documented in the research. So I think of that for women. Again, we're less well studied. You know, the— there are seasons for a reason, clearing the receptor site. Uh, one of my colleagues, Dr. Felice Gerish, and I've had a long discussion with her about progesterone, and she will give higher doses cyclically so that women have a period continuously. And, um, so there are differing views and there are others that say, okay, just take it every day. I feel there's a— it depends on the individual, but there's a sweet spot. So you may be unable to take a few days off a month now, but I usually say 3 to 5 days off a month. Maybe it's 1 or 2, or, or 1 or 2 days off a week of your progesterone. And this helps to clear the receptor site, helps to reset and keep your progesterone working better, longer at the lower doses. So we don't have to keep going higher and higher. Dosing too. That's another, another thing I've seen over the 30 years I've been doing this. So there are some benefits there to taking a few days off a month, but again, it may be okay now you can't, but maybe in another few years you'll be able to.

Got it.

Okay, I'm gonna keep on you about it.

Yeah, I know. The only time I skip is if I forget it or something.

Yeah, well, there's a natural reset.

Yeah. Okay, I want to talk about vaginal and specifically what's happening and changing. There's this whole trend of having vaginal rejuvenation done now. Like, first of all, what is that vaginal rejuvenation?

Well, there's different vaginal rejuvenation procedures. There's light, there's laser. And so there's injections, PRP. Those are things that can be done to the labia, the clitoris, the G-spot, the vaginal tissue. And it can be beneficial. What the American College of OB-GYN published, I want to say, you know, maybe over 5 or 5 to 10 years ago, they said they came out with this position statement which they said, okay, these vaginal rejuvenation laser and red light procedures can help in the premenopausal, or specifically the laser rejuvenation can help in that, like the Mona Lisa Touch and different ones like that can help in the peri- or premenopausal patient. But the postmenopausal woman doesn't benefit. Well, and this is my caveat, unless you have adequately, you know, estrogenized, androgenized vaginal and vulvar tissue, it can give you added benefit. Now, these vaginal lasers and, and procedures can be used, yet you have to prepare for it and you have to maintain it, or you're going to be getting that every 6 months, or it's not working and you end up with scarring tissue, decrease sensation. So I'm always, okay, what do I need to do first? Let's address the— address the hormonal tissue first. Clitoris to anus, vaginal tissue, give back some hormones, good glandular secretions, and support the microbiome, which is your first line of defense. Without supporting the microbiome, we now know you're not getting the benefit that you absolutely must have for protection and performance and function. And we can go into that later, but such a critical piece. And we haven't known until recently because we haven't really been studying the vaginal microbiome other than for sexually transmitted infections. We've only looked at pathogens but not the healthy bacteria and identifying that. And it's so fascinating to me. I've really— I'm just really excited about this ongoing research. So addressing these issues, supporting the tissue hormonally, then you Oftentimes you don't need a vaginal rejuvenation procedure, which my plastic surgery colleagues hate, and my GYN surgeons, those doing vaginal rejuvenation, hate me to say that. But I'm also like, okay, can prepare them with these hormones and then maintain them afterwards, and they're going to be— get— you're going to get great results, and your clients will rave about you. Can't, you know, can't ask for more than that.

So when you— when we hear microbiome, we automatically think gut, and there's There's really 3, right? I'm assuming there's 3.

So there's their gut, there's oral, and then there's the vaginal, and there's the bladder.

Bladder. The bladder.

The urobiome. And I'm sure there, there's others actually, but I don't— yeah, so we typically talk about the gut microbiome. There's a skin microbiome. Yeah.

So how do we— so when you are addressing gut microbiome, it's not helping these other areas?

Not necessarily. So the— what we've identified is that the bacteria that are predominant in the vagina— well, so the gut microbiome, the diverse, healthy species you have, the better. The better health, the better longevity. This is well studied, especially indigenous populations. They have a highly diverse gut microbiome and they have low incidence of cardiometabolic disease and cancer. So, but for the vagina, you want a non-diverse— you want a predominantly Lactobacillus species in the vagina. Specifically, there are, you know, 4 or 5 strains that are the most beneficial, and the help— the more we have of those, the less infections, the less odor, the less, etc. But as we ate— so these forms are Lactobacillus crispatus, Lactobacillus gensei, gasseri, and iners, and rhamnosus, all Lactobacilli species. So there's different strains, there's maybe over 100 strains of Lactobacilli species that I know of, and there may be more, but these are— they're different strains of Lactobacillus. And so, or different strains of bacteria. And so these 5 strains of Lactobacillus, and I would add in Lactobacillus reuteri, which has been shown to help with oxytocin production. It's fascinating. So I would say 6 strains that we really want to optimize in the vagina. And so these are, when we take oral, like when we have, how do the bacteria get there? Certainly through transference through the gut. The gut mucosa, into the vaginal, into the epithelium, the uterus, the vagina. Somehow they're getting there. It's still a magical mystery to me. And typically we're, you know, our first exposure to, to a microbiome is through, you know, vaginal birth, right? Through the vaginal microbiome. So we want those healthy lactobacilli, especially pre-pregnancy in there. But as we get older and the pH goes from acidic to alkaline, there's more diverse species in the vagina, less lubrication, so less fuel, and so the pathogenic bacteria will thrive. And with that, increases in HPV and cervical dysplasia and cervical cancer. So it's not just, okay, healthy, healthy vagina for the sake of it, right? It's healthy vagina for longevity and quality of life. And so we want to repopulate that, you know, repopulate the healthy bacteria continue to support the elasticity and the natural glandular secretions of the vagina. And it's getting technical. I know it's getting technical, but I want to make sure— it's so important to understand, like, this is an area of our— it's as important as our mouth, right? We know about our oral microbiome, or, you know, how critical it is for cardiac cancer, all these things that relate to the mouth, to the rest of our body. And I'm going to say the same is true for the vagina and vaginal health.

So Okay, questions here.

So with—

when you go to the store and you're going to buy a probiotic, they have some that are labeled vaginal health probiotics, but they're taken orally. So what's that? Is that a marketing thing, or is that how you—

okay, you can absolutely take them orally, and they've been studied to be used orally. Or that there are vaginal, um, insert probiotics that can also be used. And many of these vaginal oral probiotics can be used vaginally.

So, like, yours is a vaginal one, or is it oral?

But you can use— can— it would be safe to use vaginal.

What do you recommend?

I usually— it's easier and more compliant to use— take 2 capsules a day orally, and we've seen an improvement in the microbiome analysis after the fact. So we've seen improvements with the oral, and I always still say, especially if someone's, you know, we're just starting out and we're just reestablishing the vaginal microbiome, to also use it vaginally or use another vaginal microbiome like Seed VSO1. That's another designed for the vagina. So those are really good ways. Now you can also use these and have a woman in our Girlfriend Doctor community that gave a whole explanation of how she's using these probiotic in, in yogurt and culturing the yogurt to increase the species. And she's been taking 2 a day. She's been doing everything. She's been doing different fermented foods and probiotics for years, and she now has no urgency symptoms, no incontinence symptoms, and that's the only thing she shifted.

So, you know, it can also— I mean, help me understand here, because I think it can be— it's important, yes, it can also be a slippery slope if you've got other underlying things. Let me just explain what I mean here. So we hear you've got to do this for your oral biome, and then your gut biome, and now vaginal. So we're adding in all these probiotics or fermented foods, we're doing all these things, but if you have anything under underlying, like a histamine intolerance or whatever, and you don't address those things first, I feel like it can almost backfire. So can you— do you have anything to say on that? Because I feel like I've seen that happen with women where they're like, they're just upping all the stuff they think they have to do for biome, and now it's a backfire.

Well, it's the whole thing. Like, I would say there are seasons for a reason. So with the vaginal probiotic support, depending— like, my menopausal women, I want them to initially start with 2 Okay, take 2 capsules a day for 2 months, and then, you know, every season take a capsule— I mean, take a bottle. And for my, like, my 20-year-olds where I've studied their vaginal microbiome and they have no lactobacillus, none of the protective species, they're at risk for HPV. And oftentimes I see it with HPV or genital warts or abnormal Pap smears. So they often do well with just, you know, that boost because they have that boost of— I still put them on 2 months because I'm like, let's just, let's just repopulate, let's give it at least 2 months worth. And then I retest at 3 months and I see an improvement. Got it. And then as long as they're maintaining that, a healthy diet, avoiding antibiotics. But if we are eating and living in, you know, and I think of this in so many ways, if we eat out one time, Chick-fil-A one time, we've just gotten a dose of antibiotics. Antibiotics, right? So that is killing off— not only disrupting gut microbiome, it's disrupting the vaginal microbiome.

One order of Chick-fil-A or one dose of antibiotics can do that?

Well, one dose of antibiotics, absolutely. And the antibiotics in food— and it really became apparent to me early on in my practice where I had a patient, a male client I was seeing, and he had incredible penicillin allergy. And he relayed a story to— when I was asking about his reaction, he goes, super sensitive. I had fish and I always ask if it's wild caught, and they said it was, and I ate it, and he immediately had a penicillin reaction. So a full anaphylactic reaction. And I was like, that's crazy, from that one piece of fish, that full anaphylactic. So I think we underestimate the single exposures, the intermittent exposures. Now we're doing everything else right. We've, you know, we're adding that extra fermented food, we're otherwise eating organic and clean. We have to do the best we can. And it is that yin and yang, right? We, you know, detox and retox.

It's a constant—

it's a constant process, believe me. Yeah. And yeah, so I think it's important to understand that also the chemicals that we use, the tampons, the washes, soaps, etc., all have hormone disruptors and are, you know—

is that why it's bad about douches and things like that?

It's one of the— one of the reasons. And the vagina is naturally self-cleaning, so we don't want to disturb the healthy microbiome. But we do want to clear unhealthy bacteria, and typically you do that with supporting your— I say the frontline defense, so that Lactobacilli species.

So what happens if you have— like, I'm, I'm going to go through this. I, I'm getting— I had my old root canal extracted. I have to get— I'm getting a ceramic implant replaced, and the reason I haven't booked that appointment yet is I have to be on antibiotics for a week when I do that. And it, to me, it was like so counterproductive. I'm like, I'm taking out a root canal 'cause I go to a biological dentist and I'm trying to be healthy, but now I got to take antibiotics to put the ceramic implant in. What, what do you do in those cases?

Yeah, so even though it's okay if you're taking an antibiotic that it'll kill off a probiotic, so you're wasting your money, I'm like, oh, I would waste my money anyway. So I typically have my patients take their antibiotic depending if you're taking it once a day or twice a day, but if they take it in the morning, use the probiotic at night so you're not completely getting behind. Right, you're always supporting the system. So I do that, it'll cost them an extra, you know, 10 days, $10 maybe at most to do that, and it's so worth it.

So you just do— basically you're balancing it out, you're trying to refix that. Okay. Yeah.

Okay.

Um, let's talk about your— some of the topical stuff. So I'm gonna start with Jolva, and then we'll get into sort of Elvay. But like, can you tell us the story of why you created Jolva and what that is? I know I use it every night because you told me to, but help. Yeah, why did you create it?

So I I created Jolva to help really my patients who had a history of breast cancer. And they were— yeah, so back in 1999, the story, back in 1999, I was, uh, you know, fresh in my private practice in Southeast Georgia and had this beautiful 63-year-old woman who was the 5'10", 150 pounds, black horn-rimmed glasses, salt-and-pepper hair, very imposing individual, head of— president of a biotech company. And she comes into my office and she You know, my doctors at Emory have told me that since I had DCIS, I am not a candidate for any hormones. And that was her diagnosis was 8 years, several years before. She goes, I'm dry. It hurts to have sex. I love my husband and I'm a woman of the '60s. And this is really important to me. And I'd rather die than live this way.

Wow.

Her words, her words. And here I am, you know, fresh resident, mom, all this stuff.. And I was like, okay, well, I don't have an answer, but I can go to the research. And she goes, I brought you research. And, and she was, I mean, again, the head of a biotech firm. And so we dug into the research of testosterone vaginally, you know, estrogen, testosterone, even, even, um, with sublingually, we looked at it, and topically, as well as DHEA, and as estrogen vaginally. And so, okay, there's, and progesterone, and we looked at all of the research. And so that really, I really thank her Doreen Schumacher is her name, and God bless her, I followed her through, through many years. At 73, her bones were better than they were at 63, and she was still having an active sex life. And at 83, I went to listen to her read her memoirs. She published her memoirs. I mean, that's the kind of vitality you want to see in an individual, right? Where at 63, she was ready to die, ready to die. And she's not alone. I know many people listening probably, you know, have experienced that or know someone who has. Has. Or, you know, and that is— I'm so proud of her bravery for talking to me about this. So no matter what, talk to your physicians. If they don't know, you know, you've planted a seed or helping them learn. And that, that was important to me. That helped me. And so from there, I started working with the compounding pharmacy. I mean, there's not— nothing that I learned at Emory was able to help me. Yeah, they didn't. And I'm one of the best universities in OB-GYN in the world, in my opinion, in training.. And I, and I didn't have that, but I was able, I was a researcher before I went to medical school. I understood drug metabolism. And so I really loved studying it. And then I was able to help through word of mouth as a referral for other clients who were in similar situations. And I just continued to learn. So when I, you know, and I created compounds and creams and all of these things for my patients. So when I burnout from my practice, part of my story. And retired my practice in 2014, 2015. My patients were like, Dr. Anna, no one will give us your potions, lotions, and creams.

Because you would have it done at a compounding pharmacy. Okay. And what was specific? What were you putting in it?

Well, it depended. It depended on the individual. Yeah, it really depended. So sometimes it was— oftentimes it was just DHEA. Sometimes it was vaginal testosterone and DHEA. Sometimes it was a combination of testosterone, estrogen, DHEA, and progesterone. So it was really like— and then I did, you know, other sexual arousal creams and things like that. And so, so that was really important because it helped resolve incontinence issues, vaginal dryness issues, elasticity, helped with orgasm, sexual function, all of these, all of those issues. And so I committed to my patients that I would create something over-the-counter that was even better than anything I could write on a prescription pad. And I researched and I studied and I, you know, tried many different, you know, combinations of different things. And that's how I came up with Jolva. And I put in, you know, Alpine rose plant stem cells, which are amazing stem cells. It's why they are in high, very high-priced cosmetics. And the DHEA in its micronized form with a very absorbent and trying different bases so that it really absorbs and is very tissue healing. And so, and with pelvic floor exercises, it just turns— I would say pelvic floor exercises till we die.

Yeah.

So it turns back the hands of time.

And where do you— when you put it on, where are you supposed to put it?

So you want— I would say clitoris to anus, because the clitoris will atrophy. And I just saw a funny Instagram someone sent me, and she's like, I took a mirror and I looked down there and the clitoris was gone. And it was like, it was gone. And, and I— and I'm a gynecologist, so I always talk you know, we'll tell a client, okay, your clitoris looks healthy, or it's starting to, to shrink a little bit, so we need to, you know, add some hormone back. Because you can be using vaginal hormones and it's not going to help the clitoris, right? It is designed for pleasure, and I want to keep that healthy, right? You want to keep the clitoris and the labia healthy, and the opening to the vagina. I usually have my pelvis down here, but I was doing something, so I don't have it with me. But in the opening of— and the opening of the vagina, they call that the vulvar vestibule. Vestibule. Okay, the, you know, areas you separate the lips, you see the vulvar, that thinner, less rugated tissue, and that's the vulvar vestibule. That's where you have your glands coming in from the— where the urethra is from above. You have the Skene's glands, you have the Bartholin's glands, and you have sebaceous glands. Those dry up. Those dry up if they are not— you know, if we don't pay attention to it, not just with the hormones, the DHEA, but now adding back the vaginal microbiome support. It's just— so you put that—

and do you put it inside too?

It is not FDA approved for vaginal use, so it's not an FDA drug. Now, can you use it during sex? Is it perfectly safe? The ingredients are clean enough to eat. That's why you can put it on your lips, around your eyes, all those good things. So, uh, and this is— if it's— if, if I say to put it in the vagina, it becomes an FDA drug.

So, so it's not, it's not an official statement, but it's safe if you happen to not listen and do it.

Okay. It's absolutely safe. Like, men can use it like for a lubricant. They can use it on their penis and it's perfectly, perfectly safe.

Got it.

So as a moisturizer for their penis too. So it can help with these intimate areas so that, you know, and then we think about all the things that we do that we have used in the vagina that can disrupt the vaginal microbiome. So I'm really picky about that.

So why did you make Velveve then, if you already have Julva?

So because Julva helps reverse the hands of time, and that is like a once a day— once a day, you can, you know, use it during sex, but it's a once a day option. And to support sexual function, we know that lubricants are beneficial and increase the pleasure and repeatability frequency of sex. Right. So it increased pleasure. And, and also because I wanted something— many women will have sex sex, and they'll say, I feel, you know, irritated afterwards, I have some burning, now I have an odor, vaginal odor. Say, you know, it's all a result of multiple things. Definitely the dryness, the loss of the healthy bacteria, and then a lot of the chemicals that are in lubricants. So I wanted— as a gynecologist, I started looking, and, you know, the last thing I wanted to do, honestly, was create a lubricant because it requires a 510 FDA approval, which is hundreds of thousands of dollars and lots of research, lots of studies, and dealing with the FDA. So, but I wanted to because it was so important to me that we have something water-based, clean, not hormonally disruptive, safest thing I can create for the microbiome because I'm trying so hard to get the vaginal glandular tissue and the bacteria healthy. And, you know, and our natural secretions and all of that good stuff. So I don't want anything to hurt the progress we've made. So, and, and many of my clients, over half my clients, said they use lubricants even in addition to Jolva. Made things better, made things great, like the vagina of a 25-year-old. But even in our 20s, lubricants can help increase sensitivity and pleasure, especially for longer sexual encounters, right? Not one and done. So that's why I wanted to create something healing also. So the aloe vera and the hyaluronic acid in a water base with, you know, the cleanest ingredients. So it has propanediol, it has no glycerin, no parabens, no propylene glycol, none of these chemicals that you can even see in estrogen gel that are toxic, right? That are like—

when you're going to the store and you're buying like one on the shelf, is that all the toxic stuff in there?

Well, depends on— it depends on which one. There have been a couple that I really love that was a good clean— Good Clean Love is one. Yes.

But like, if you just go to CVS, for example, usually it's going to be—

it's— you'll see like, it's going to be— yeah, like KY Jelly or whatever. KY Jelly is toxic. Do not use ever KY Jelly. Do not use it. And I was a big fan of coconut oil until I understood long-term use can disrupt the vaginal microbiome. And I, you know, I loved— and I even would make coconut oil like an MCT oil with aloe vera that's like your DIY lubricant. That is good. But long-term, like, if it depends on the frequency you're having intercourse, you know, then you want something that's going to be restorative. I wanted something that was also going to be restorative to the tissue and healing, especially again, as we get older, tissue trauma.

So, and I'll make sure I link all this up in the show notes. You also, if you want to try some of these things, she keeps Brooks supplied with all of it. In fact, it's funny, Anna, every time she has like some, like a new promotion or something, she'll send us a little gift thing. There's always a note to Brooks in there. Like, uh, last time she sent me Mighty Maca, it was for Brooks. This time, like, it's always like for Brooks now. I've, I've become obsolete. It goes to Brooks.

Yeah, totally. The Belvay goes to Brooks.

And that Mighty Maca apparently now too.

Yes. Yep.

While we're on Mighty Maca, can you explain to people what that is?

Oh yeah, Mighty Maca is the food supplement that I created, or the combination of superfoods that I created from my healing journey around the world in 2006 and 2007 when I had been diagnosed with infertility and early menopause. And honestly, by the grace of God, I learned about these different healing foods like maca from Peru. It helps with fertility, helps with hormones, helps with energy, and is called the Peruvian Viagra. So as a scientist, I wanted to study about this superfood, to understand this indigenous healing herb. I mean, everything in modern medicine had failed me. 6 rounds of fertility treatments failed me. All of that had been devastating to me. And so I'm like, okay, let me start taking the maca. And so I started taking the maca, but I couldn't stand the taste. I'm from a family of chefs and gourmands and gastronomiques. And I was like, okay, well, what else? There's gotta be superfoods that taste good too. And what are other benefits? So I started combining additional, like, based on the science, based on the indigenous wisdom, this combination of superfoods and into my daily routine as we traveled around the world. And, you know, with the grace of God and the hand of God in this, for sure, I, you know, reversed my early menopause and I started having cycle, and then I became pregnant with a child I thought I would never be able to have. Wow.

Yep.

And so I I, when I came back, I was like, well, I need to, I need to keep using this. Yeah. And I need it for my patients. And so I created Mighty Maca Plus. So it's been around since officially 2009, and, um, you know, have, I've had customers on it since that time. So it's one of my favorite foundational, it's one of the functional medicine favorites that really, because of the combination of, of 30 superfood ingredients It helps on multiple areas— inflammatory pathways, detoxification pathways— and it's adaptogenic, it's an adaptogenic formula. So we see improvements in our body's ability to make hormones and use hormones. So in case studies that we've had, we've seen improvements in DHEA and cycle— women cycle day 21 progesterone. So I've, you know, many women— we have lots of Mighty Maca babies, we like to call them— that had a history of miscarriage or issues with fertility. That's again one of my foundations. It is my I'm like, it's your window every day.

Every day.

It's my Windex.

So, you know, I— anytime I'm using a supplement or I like to have this, I have a lot of founders on my show because I like to hear the story behind it. Anna's unique. I will share this because, well, one, she's my friend, uh, first and foremost. We were friends before she was an expert on my— in my community and on my show, and before I ever used her products. But her story behind things always fascinates me because it always comes from either her own personal use or her patients. And was it Mighty Maca? Was the story behind Mighty Maca, or was it a different one of your products when you were having to Airbnb out your house or rent out your house? Which product was that?

That was Mighty Maca. Okay.

So I'm probably going to botch it, but what always stood out with me, and I couldn't remember that, I thought it was Mighty Maca, but now it makes sense, is that she was so committed to developing this product, and here she was, a single mom, 4 girls by the way, and putting everything into this product.

Oh wait, that story, that's Jova. That's, that's after hurricane, that's after 2 hurricanes hit us in the, the, well, first hurricane hit us, Hurricane Matthew in Southeast Georgia. I had burnout from my practice, and so that was really like, and committed to making Jova that I was Airbnb-ing my home. So this is—

this is a funny story. So she basically told us— imagine her mom, like, younger girls, and she's saying, we're going to go camping this weekend. And they're like, why are we going? Like, she's not— Anna's not a camper. And like, she's like, we're going camping. But the reason she was telling them we're going camping is she was renting out her home to help pay for her mortgage so she could do this.

Yeah, absolutely. Yeah.

When did you tell your girls the truth? With, not until they were a grown-up?

Um, yeah, yeah, probably, you know, not too many years ago, honestly, when I just started sharing that story.

That's crazy. So I love that story because you were just so committed. Like, it wasn't logical, it was more just like, I have to do this, I have to do this for my patients, I can't leave them empty-handed.

And that's how I feel, you know. I feel like women— I saw my mom struggle and die way too young at 67 years old. And, you know, if I was the doctor now could have been for that, for her then, she'd be living to 100. I have no doubt, right? You know, I don't know, but I know it could have been better quality years. She struggled for over 15 years, 20 years really. And so I hate to see anyone go through that and I see it happening over and over again. So I'm always trying to understand the underlying, underlying reason for the issue, for the symptom, for the, and to address that. Issue. And I think we talked about hysterectomies earlier, and I had a Girlfriend Doctor Club call specifically on this, and I wanted to emphasize it's so important when women— you know, sometimes you absolutely, absolutely need a hysterectomy, but we need to understand what caused the need for the hysterectomy. The uterus is just a victim, yeah, of underlying inflammation, toxicity, you know, methylation defects. You know, other area insulin resistance, you know, these are reasons that we can have the dysfunctional bleeding, the fibroid formation. So underlying— understanding the underlying issues is important even after you've had the uterus removed.

Is there anything you wish I had asked you that I didn't ask you during this conversation?

I don't know, you asked me things I didn't think you were going to ask me, so it's been, it's been really good. I think one of the things is, you know, as we get older, it's having the the motivation— actually, I'm going to ask you, having the motivation to stay consistent with the things that you know help you and being able to invest in yourself in those ways. I mean, you're, you're like my role model for that. So how do you do that? How do you stay consistent?

That's an interesting question, um, and I don't know that I have a great wisdom answer because I— well, I'll come back to what I, what I always share. It's always decision and vision. And I think some of my audience gets tired of me saying that. It's like the foundation of any program I've ever led, any coaching session I've done with clients. I'm a high-performance coach. Anytime I work with anyone, that's the first thing we go with. And I'll tell you why. No matter where you are, no matter what's going on, you can always change the outcome by making a new decision constantly, like new decision. And I'll give you like just an example that has nothing to do with women's health or anything. 2.5 years ago, I was living in a place that I loved in San Diego. And I I decided that I wanted to leave. Now, I decided I wanted to leave because our house had mold, because the housing market had changed. I couldn't have what I wanted. My husband didn't want to live there anymore. My daughter— there's a lot of reasons I made a decision. So, I decided to come to Arizona. And then I was miserable in Arizona. So, 2.5 years, I'm miserable in Arizona. And I could blame everything like, "Well, now it's too late. My husband doesn't want to go back." You have all the reasons just like we do with anything in our life. But I made a decision again, "I'm going back there. I'm going to find a way." That doesn't mean I have to make my husband move back. It doesn't mean I have to uplift. I'm literally a week and a half after recording this, I rented a place in San Diego for the summer. Am I leaving my husband? Absolutely not. Are we going to make it work?

Yes.

We're going to go back and forth, do the things. So, I say it's a decision. So, decision with everything in our lives can change everything. You've made many decisions over— you made a decision to put your house up for rent and go camping with the kids and position it as fun. You made a decision to— so, it's always a decision. That's number Number one, and then the vision is what keeps that decision intact and empowered. It's getting really in touch with what that's going to feel like when you arrive there. So when I think of every product you've created, your vision for it was who you were going to help, how that was going to feel to know that your patients' lives changed, how that was going to feel to be talking about something you're passionate about. It was never led with, "It makes logical sense," or, "This is a nickel and dime thing." It's a, "How is it going to feel?" So to go back to your question, it's always decision and vision. And if ever I'm feeling off track, which is many times in my life in many different areas, I always stop myself and say, what's my new decision? And then why? And that's the vision. So I don't know if that answers the question.

I love that decision and vision is your Windex.

That's my Windex. And people don't love to hear it. They don't. They want, they want like the thing. What's the pill to take?

What's—

and it's like, before you do that, like, what's the decision? And I would say that before anything, like If they're like, I love, I want to try all Anna's products, I'm going to have them all linked below. But you have to ask yourself that too. What's your reason why? Deciding why and what's the vision for it? Better sex life, no dry, you have to know that first. And if you don't have the answer to that, then you skip it because it doesn't make sense then. And I'll say that with literally everything. So I don't know. I think we don't get led wrong when we always lead with decision and vision. Most people go to action first, and that's always wrong.

Just good point.

That's my two cents.

So anyway, good point.

Thank you, and I'm sure this is not the last time I'll have you. I'll have you 20 million more times because I love learning from you, and I always, um, love our conversations. I will link everything below, especially her new Velvée. Why'd you name it Velvée, by the way?

Well, I wanted something like— because velvety feeling. I was thinking, how should it feel, right? How, how it will make you feel, and Silky, that's already taken. Silk was already taken. But yeah, like some velvety slick. Yeah, kind of sexy name.

I love it.

I know, I went through a bunch of names.

Yay, I love it. All right, I will link everything below. Thank you so much, Dr. Anna.

Thank you so much.