Ask the Expert: Dr. Kelly Casperson on Vaginal & Sexual Health in Menopause

If you know us, you know we love talking about the parts of menopause that make people a little uncomfortable. So, for the second in our Ask the Expert webinar series, we decided to talk about vaginal and sexual health, and we decided to do it with board-certified urologist, author, speaker, podcaster, and expert, Dr. Kelly Casperson. 

About how Dr. Casperson got here: After many years in practice as a urologist, she had a life-changing patient who made her curious to learn everything she could about female sexual wellness.

She became inspired to let the world know that women aren’t broken in the bedroom; they just didn’t get a proper education (and neither did their partners). So, she created a podcast called You Are Not Broken, which consistently ranks in the top 10 in the Apple Podcasts “Medicine” category in the USA. It has been nominated for an AASECT award for three years running. Her book, You Are Not Broken: Stop Should-ing All Over Your Sex Life, is available on Amazon and Audible, and a new edition came out in October 2024. 

She is certified by the Life Coach School and the Menopause Society, and has created online courses and a premier private membership teaching women the fundamentals of their anatomy and physiology, discussing their limiting beliefs, and normalizing normal female sexual function to empower them to live their best love lives. 

She talked with Alloy’s community manager, Rachel Hughes, about hormones, vaginal health, urinary health, and sexual health during menopause and perimenopause.

We highly recommend you watch the whole webinar on our YouTube, but we’ve transcribed some of the highlights here as well.

As always, this interview is for educational purposes only and should not be taken as personal medical advice. It has been edited for brevity and clarity.

Rachel Hughes: Hi, Dr. Casperson! Thank you so much for being here. Let’s get started. In your book, on your podcast, in all of your work, you discuss many misconceptions around women's sexual health, especially in perimenopause and menopause. What do you think are the biggest myths that continue to persist, and why is it important that we dismantle those?

Dr. Casperson: I think the biggest myth that got me into understanding hormones was becoming knowledgeable about female sexual health and the ecosystem of it. How does it work? How do our bodies work? People would say, “Well, you know what happens with menopause…” And I would say, “No, I don’t know what happens with menopause. What happens with menopause?” The biggest myth is that your sex life automatically gets worse or becomes non-existent. Although that can be true for some, it is by no means universal. Conversely, midlife, perimenopause, and post-menopause is actually more of an, and I hate to use this word, awakening. You discover what you want and how you want to feel, and it’s actually a very exciting time. But, if we don’t address symptoms that arise in perimenopause and menopause, it can negatively affect your sex life. 

Rachel Hughes: I love that. Take us to the hormone piece. How do hormonal changes during perimenopause affect vaginal and sexual health? And, can you talk about the role of hormone replacement as a way to address these issues?

Dr. Casperson: Yeah, absolutely. I think the first place we always have to start is defining what menopause and midlife is, because again, I think the myth is it's a hot flash and you can no longer get pregnant. It's a hot flash and your periods stop. Those are symptoms of what’s happening, but that’s not what’s happening. 

Because we are now outliving our ovaries, we have profound body changes everywhere from our skin to our brains to our bones to our genitals to our vaginas because every part of our body is influenced by hormones. Hormones are keys that help unlock the full potential of our cells. And every cell in our body has hormone receptors. 

The other big myth about midlife is that ovaries only make estrogen. Ovaries actually make testosterone, which then gets converted into estrogen. All bodies have testosterone and during our reproductive years we actually have about four times as much testosterone as estrogen. 

Rachel Hughes:

How much testosterone are our bodies making compared to men?

Dr. Kelly Casperson:

About ten percent. And men need estrogen, too. All bodies need hormones. But, we’ve gendered them. And the other thing we’ve done is labeled them sex hormones, which is not true. They work in our brain, they’re neuro hormones, but when we give them the sex hormone moniker, it makes us think of them as extra, because we see sex as extra in our society, and as less important as things that work in the brain. We should emphasize that these hormones are neuro hormones, and they’re bone hormones–they’re not just sex hormones. 

Rachel Hughes:

That's so helpful. Thank you for that. I want to give you space to say a bit more about testosterone, since we have so many questions about it. I do want to let people know that here at Alloy, we don't offer testosterone to our patients and customers yet. But maybe, Dr. Casperson, you could actually amplify why it’s so hard to access. 

Dr. Kelly Casperson: Gender bias and doping in sports. In the 1980s, there was a lot of doping in sports happening all the way up to the level of the Olympics. Congress passed an anti-doping act, and put a bunch of synthetic steroids on a list saying that they needed to be better controlled. And testosterone got thrown onto the list. Testosterone is a naturally occurring hormone that nobody's died of at physiologic levels, ever. And I would also argue that just you taking testosterone will not make you an Olympic athlete. But because it’s on this list, it’s regulated by the DEA, which means that it’s not like other hormones in terms of how it’s prescribed and regulated. So, because of people who cheat in sports, it’s more difficult for you to access a physiologic hormone. 

Rachel Hughes: But, if you’re a woman and go to your physician and say that you have no desire or no libido and would like to be engaging in sex with your partner, you can get a prescription. Is that correct? 

Dr. Kelly Casperson: There's no FDA-approved indication for testosterone in the United States of America. That’s important because insurance covers things that have FDA approvals. So, it’s more about insurance coverage than whether or not you can get it.

The most well-known use of testosterone in women is libido. There’s actually a global consensus on it. You can google the consensus and pull up the paper and bring it to your physician, which I recommend, because it legitimizes the medical aspect of testosterone. 

Your libido comes from your brain. We have testosterone receptors in our brains. Libido is a mood, and it’s affected by many things: How socially acceptable is it for you to be a sexual person? What did your religion tell you about sex? How's your relationship with your partner? How's your body image? How well are you sleeping? Libido is very complex. Testosterone is one part of it, but many people will say when they get on hormone therapy, whether that's estrogen or testosterone, “I feel more like myself.” And I guarantee you a woman who feels more like herself feels more like her sexual self than somebody that's like, I don't know what body I'm in anymore, because perimenopause is challenging that whole thing.

Rachel Hughes: Thank you. We're going to pivot to vaginal estrogen. There's this growing awareness around the use of vaginal estrogen, thanks in part to people like you. Can you explain how vaginal estrogen works; why it might even be crucial for women? And I'm thinking about women in their older thirties. Maybe they’re entering into perimenopause, maybe they haven’t thought of it, maybe they haven’t even heard of it. So even if they're not experiencing significant sexual dysfunction or other challenges in other ways, could you speak about why vaginal estrogen is, in fact, so important?

Dr. Casperson: Yes. Vaginal estrogen can come in creams, tabs, rings–those are the most common formulations. Vaginal estrogen is very low-dose. I like to call it skincare for down there. 

Like I said previously, we have hormone receptors everywhere in our bodies. We have tons of estrogen receptors in our bladders, vaginas, vulvas, and clitorises. And when you don’t have hormones, all sorts of things can happen. You may have bladder issues, urinary tract infections, burning with urination, getting up at night to urinate, bladder leakage–your labia minora may even go away. So, you use vaginal estrogen. And you should use it for preventative health–we really have to switch the paradigm. Why are you waiting to get sick and have problems before you get treatment? We know that genitourinary syndrome of menopause (issues with the genitals and bladder) happens in 50-80 percent of women, and you can have symptoms before your period ends.

Currently, vaginal estrogen has an FDA warning on it that says very scary things like probable dementia, blood clots, high blood pressure, scary stuff. It's inaccurate. And we currently have a grassroots petition going on to send letters to the FDA to get it removed. Because truth in medicine is important. Facts are important. The risks on the label matching the science behind them, that’s important. Vaginal estrogen is incredibly safe and incredibly effective. Dr. Rachel Rubin did this research: If you put every woman over the age of 65, Medicare people, on vaginal estrogen, you’ll save Medicare $1.2 billion per year in urinary tract prevention alone.

Rachel Hughes: Amazing. Let’s get to some questions: “I wondered how Dr. Casperson approached the treatment of clitoral atrophy and/or loss of sexual sensation.”

Dr. Casperson: This brings up the point about prevention. We know that clitoral atrophy can happen. But why should we wait for it to happen? Why wait for your labia to disappear? Why wait for sex to become painful? It’s better to keep the skin healthy and hopefully not have to undo years of low hormones. I love estrogen cream because you can put it not only in the vagina, but also on the labia minora, around the clitoris, and you can target specific spots. And if estrogen alone doesn't help, then we also can add testosterone to that locally. And this is a good time to say that there's a difference between systemic hormones, meaning hormones that you're using to go into your whole body, and local/vaginal hormones, which is a much lower dose targeted to those tissues. You are allowed to be on both systemic and local at the same time. But I think it can be confusing to people when they're new to this conversation about the different doses and routes. We tend to do local treatment first for clitoral atrophy and lack of sensation, but we do know that both systemic estrogen and testosterone can help with sexual function as well.

Rachel Hughes: Thank you for that. That's so helpful. What do you recommend as a treatment for no libido if you cannot get testosterone?

Dr. Casperson:

My book, You Are Not Broken: Stop Should-ing All Over Your Sex Life. Libido is complicated. So the first thing you need when you have no libido is to get educated about libido–and it’s incredibly complex. You’ll learn that everything affects libido. It’s not just testosterone, it’s not just estrogen, it’s not just your age. 

The other big myth about libido is that it should be spontaneous or you're broken. That's not true. And the other myth is that you shouldn't have to do anything to get turned on or be sexual. You absolutely do. You warm up to go to the gym–you also need to warm up to have an hour of sex. We didn't get good adult sex education, so we believe everything Hollywood tells us: You should just be hot and ready to go all the time, and you should want sex all the time, and nothing should affect that. And you're broken if you don't have that. That's what Hollywood tells us, right? Hollywood's wrong. That's a curated planned story they're giving you. So the first thing you need when you have low libido is education about libido. And then you go from there. But I have saved marriages with this book. I've actually ended a marriage with this book because somebody was like, I realized that I'm worthy of love. 

People feel horrifically broken. They don't understand libido, they don't understand sex, and they think the answer's just in a hormone. Hormones are great, and they can be helpful, but if you just throw on a hormone and you don't have that education, you're not going to get the full benefit.

Rachel Hughes:

Thank you so much for being here.

Dr. Kelly Casperson:

Thank you!

For more of their great conversation, head to our YouTube, To learn more about future webinars and events, follow us everywhere @myalloy.