While estrogen often steals the spotlight, progesterone is equally vital for women’s health and deserves more attention. Join us as Dr. Tami Rowen shares her expertise on the critical roles of estrogen, progesterone, and testosterone. We explore everything from progesterone’s stabilizing effect on the uterine lining to the impact of birth control on hormonal balance.

Dr. Rowen provides valuable insights into the often-overlooked hormone progesterone and its significance in conditions like PMDD. She also delves into cultural attitudes toward genital grooming, the realities of labial surgery, and societal pressures affecting perceptions of genital appearance.

Highlights:

• Progesterone’s Essential Role: Discover why natural progesterone is crucial for health and how it differs from synthetic hormones in birth control.
• Managing PMDD: Learn about hypersensitivity to progesterone in PMDD and explore treatment options that avoid worsening symptoms with progestin.
• Cultural Perspectives: Understand the influence of societal standards and the porn industry on genital grooming and body image.
• Labial Surgery Insights: Explore the reasons behind labial reconstructions, associated risks, and Dr. Rowen’s approach to managing complications.
• Patient Advocacy: Emphasizing the importance of counseling for labial surgeries and addressing potential sexual sensitivities and outcomes.
• Progesterone Beyond the Uterus: Examine how progesterone impacts brain health, postpartum depression, and overall sexual health.
• Research Challenges: Learn about the difficulties and costs associated with researching progesterone and obtaining FDA approval for testosterone treatments for women.
• Comprehensive Treatment Approach: Highlighting the need for a holistic approach to treating hypoactive sexual desire disorder, including the use of testosterone formulations.

Guest Bio: 

Dr. Rowen is an obstetrician and gynecologist whose care and research focuses on sexual health and transgender health, as well as complex gynecologic care for people with cancer. A lead gynecologic surgeon at UCSF, Rowen has expertise in laparoscopy (surgical diagnostic procedure to examine the inside of the abdomen) and vaginal and vulvar surgery, including especially hysterectomy. She is medical director of perioperative services for the obstetrics and gynecology department.

Rowen earned her medical degree and a master's degree in health and medical sciences through a joint program of the University of California, Berkeley and UCSF. She completed a residency in obstetrics, gynecology and reproductive sciences at UCSF.

Rowen is an international expert in sexual health. She has served as a board member for the International Society for the Study of Women's Sexual Health and as an associate editor for the Journal of Sexual Medicine. She is a sought-after speaker on sexual medicine and has published dozens of papers and book chapters on the topics of sexual health and family planning and safe motherhood in developing countries. She is a member of the International Society for Sexual Medicine, World Professional Association for Transgender Health and American Congress of Obstetricians and Gynecologists.

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Hey, y'all. It's doctor Samina Rahman, Gyno girl. I'm a board certified gynecologist, a clinical assistant professor of Ob GYN at Northwestern Feinberg School of Medicine, and owner of a private practice for almost a decade that specializes in menopause and sexual medicine. I'm a south asian american muslim woman who is here to empower, educate, and help you advocate for health issues that have been stigmatized, shamed, and perhaps even prevented you from living your best life. I'm better than your best girlfriend and more open than most of your doctors. I'm here to educate so you can advocate. Welcome to Gyno Girl presents sex, drugs, and hormones. Let's go.

Hi, everyone. Thanks for joining me today for my podcast. Gyno girl presents sex, drugs, and hormones. I'm super excited to have my friend and colleague here to talk to you about a lot of different important things in sexual health. I'm excited to have doctor Tammy Rowan. She's a board certified Ob GYN and associate professor of Ob GYN at UCSF at the University of California in San Francisco. She's an Ob GyN whose care and research focuses on sexual health, transgender care, as well as complex gynecologic care for people with cancer. She's a lead gynecologic surgeon at UCSF and has an expertise in laparoscopy and vulvar and vaginal surgery.

She's a medical director of perioperative services at the Ob GYn department. She also is an international expert in sexual medicine and sexual health. She has served on the board. She has been a board member of the International Society for the Study of Women's sexual health and associate editor for the Journal of Sexual Medicine and an international speaker. Doctor Rowan is probably one of the smartest sexmed doctors that I know. I love listening to her lecture, and I love to actually, like, you know, hear her questions because they're always very on point. And actually, I met Doctor Rowan. I met Tammy, like, eight years ago at Ishwish, and she sort of was like, you can do this.

Sexual medicine is in your realm. And she really encouraged me, and now I'm like, ten years into my own practice and really focused on sex menopause, and I owe a lot of it to her. So thank you, tammy, and thank you for coming to my podcast.

Thank you so much for having me.

She's not someone that comes on social media that often, so it's really a pleasure and a joy that she is going to be here to disparate her vast knowledge on you guys, so you're in for a treat. But, you know, Tammy's done, so she's done so much research, and I've heard her lecture so many times on so many different things. So I just decided to pick some of my favorite topics that she's talked about and then let you guys learn from her because it's really been a fun experience. But before we do that, tammy, I always like to ask my guests, like, how and why they started their journey when it comes to, like, sexual medicine and menopause. Like, what brought you into this field?

That's a great question. So I, you know, I fortunate that I grew up in a very sex positive family. Sex was something that we talked about in my family growing up in a really healthy way, I would argue. And it was something I was always curious about and interested in, had a lot of respect for. And when I was in college, I taught a undergraduate students were able to teach these classes at UC Berkeley on female sexuality. And I was very excited about it and curious, and I learned a lot in that course and also from teaching it. And then when I was in residency, I actually started in medical school. I started doing research into sexual medicine.

I had met a group of urologists because that was really where sexual medicine started and I started doing research with them. But I always thought I was going to be a general Ob GYN with a focus on complex family planning. And it was only really at the end of residency when there was a job available at my institution. And I had to think about what could I offer this institution that they didn't have. And I realized that I'd been doing this research in sexual medicine. I'd been going to these conferences, and it was always this idea that I was going to do it on the side and then said maybe I could make a career out of this. Maybe this is something that I could offer my institution, because at UCSF, there's no shortage of family planning people. And fortunately, I'm at a place that was very supportive of that and I had made enough connections that I was able to really launch that.

And I like thinking about careers that way because you don't, you know, when you're, when I'm 16 thinking, this is what I'm going to do, that was not it. You kind of fall into your niche, and I fell into it kind of by accident.

Right, right. That's really cool. Well, we're glad that you're out there, and I'm glad to be, you know, your friend and colleague and with Ishwish, you know, being on the board with you, it's been great. Okay, so let's talk about some of the stuff that, you know, you've researched about and you've spoken about in the past. The first thing that comes to my mind is last year at the Menopause Society conference, where you spoke about sort of vaginal estrogen in breast cancer survivorship. I know you've done a lot of research on different cancers and sexual, post sexual problems, so we can maybe touch on some of those. But obviously, I think more oncologists, more survivors are now, like, really proponents for their own sexual health. And I think that it's moving in the direction where vaginal estrogen is pretty much accepted as one of the treatments for sexual dysfunction in some of these cancer survivorships.

But can you talk about a little bit about the nuances and why it wasn't actually supported and what are still the roadblocks that are still there for these cancer patients?

I think there's different types of cancer and different fears associated with different types of cancer, but there is this of overarching fear of breast cancer. And there is a misunderstanding that breast cancer is directly related to estrogen exposure and use. And it's very been very hard to kind of debunk that myth. But, you know, anytime someone has any type of cancer, and even if they don't, right, this is one of people's biggest fears when they come into the doctor's office, if they have any complaints, is it cancer? And estrogen, unfortunately, got a bad rap, and there's many different reasons for it. But the main one, I would say, is not because estrogen is necessarily bad, but it's because for things like breast cancer, many of those or most of breast cancer is actually estrogen sensitive, which means if you add estrogen to an existing breast cancer, there is concern that it can make it worse and recur because of that. Because we know these are hormone sensitive cancers, we sometimes then extrapolate or assume then that hormone exposure causes them. And it doesn't matter how much data we have, because we have really good data now to show that it really doesn't cause cancer. It's very hard to tease out that notion that it doesn't cause cancer, but if you have a cancer, it potentially could make it worse.

Right, exactly. And I think that you were on the paper for confirming that vaginal estrogen is an appropriate treatment option for breast cancer survivors, particularly when it comes to people that have been exposed to aromatase inhibitors. Some of these other medications that deplete you even more of estrogen.

Yeah. So we did a consensus statement between the International Society for the Study of Women's Sexual Health, as well as what at that time was called the North American Menopause Society. Now it's called the Menopause Society, where we really reviewed lots of data, years and years of data. And what we found is that there's really no evidence that suggests that using local vaginal hormones is associated with recursion. That said, you can't really study that. That is such a rare outcome. And for anyone who understands research, you would have to have thousands to millions of people to be able to see a difference in someone who did or did not use estrogen. The best we have are markers of estrogen exposure, blood levels.

What we know is that there are certain vaginal estrogen products that produce lower blood levels than others. And so it's not like a free for all. We don't want people who have a history of a hormone sensitive cancer, estrogen specifically in this case, to have high, approaching premenopausal levels of estrogen. And the vast majority of the products and the ones that we typically recommend, the pills, the ring, those actually don't raise the estrogen levels in any meaningful way.

Right, exactly. Okay. So I think that, you know, and I think most oncologists nowadays are kind of more on board with this as well, because I haven't seen that much pushback with my patients. I don't know what your experience is, where you are, but I think that.

It depends on where you are. Both of us are in big cities in academic centers, so in my academic center, I don't get any pushback. But I, you know, I have family members who were told they couldn't even use vaginal estrogen without a history of breast cancer because it would cause breast cancer. So I think that, you know, as much as we're kind of in the world of everybody, doesn't everyone know this is safe? And I mentioned that at the menopause Society meeting last year. Like, are we still having this conversation? And we are. We need to be, because it's not well understood.

Absolutely. And I think that some of your other work around other cancers, like colorectal and anal cancers, you know, those are just not even really discussed at all in the realm of sexual medicine. I think we hear it at conferences that we attend. But let's talk about the unique things that those survivors go through, the colorectal cancers and the anal cancers who have significant radiation to their pelvis or other chemotherapeutic medications that really impact their sexual function.

Yeah, I think that colorectal cancer is actually really interesting. And one of the things that I am really grateful for at my institution is that we've really created a multidisciplinary approach to this. And I would argue that it's even better than, you know, the gynecologic oncology programming, because the colorectal surgeons and medical providers are very clear that they don't know gynecology. And over time, kind of came to realize they were missing a really vital part of people's lives and counseling. And so almost all those patients now get sent to me, especially before they get radiation. And so there's different treatments, there's, as you said, there's chemotherapy and there's radiation, and it's the rectal and the anal cancer that are mainly getting radiation. And just to take a step back and, you know, talk about how we're so familiar with breast cancer, we talk about it all the time, and I think we're familiar with gynecologic cancers. But this shame that comes with colorectal cancer, especially rectal and anal cancer, creates a whole other level of psychology that's very different and it's really relevant.

And the treatments don't just affect their vaginal health or their sexual health, it also really affects their rectal health and their anal health, which is, you know, really bothersome. I mean, the kind of worst pain, severe symptoms I see are in these patients. And so just kind of dealing with their quality of life issues. And remember, any quality of life issue is going to affect sexual function. You know, the colon cancer patients sometimes, but sometimes get ostomies. The rectal cancer patients definitely will get ostomies because their cancers are so low. And just that in of itself. I've had many patients of the self esteem issues that change.

Right. We don't talk about that.

Right.

But the radiation is a huge problem because the radiation is going to the pelvis. And the vast majority of women or people with vaginas in this country are not advised or counseled on what that's going to do. And radiation takes time to work. So the way it works is, over the course of six to twelve months, after the treatment finishes, is when you start to see these effects. And the hardest thing is catching people at the end of that, after twelve months, the damage is done. And the best thing about this is if you start early on vaginal treatments, we can actually prevent a lot of the damage.

I think that's one of the big tips is really early prevention also just the discussion around it. I think that that doesn't happen for most patients, and it's very disparaging. I mean, they get so discouraged by it. It's actually one of these things where I feel like, and this is one aspect, you know, sexual health in general isn't addressed by, by most, most oncologists, I think. But if you're at a good institution, then you can get that additional help. But how do patients like, then advocate for themselves in those scenarios? Like, what, what do you usually recommend?

So, you know, what I would recommend to anybody is if they get diagnosed with any of these treatments that, you know, at the beginning, they should ask, could this affect my sexual well being now? Many, many providers aren't going to be able to answer this. And it's an unfortunate reality that we're not preparing the next generation and current providers to talk about how their treatments affect sex. But what I would say is if anyone's getting radiation to their pelvis, it's going to affect their vaginal health. And so if there is a provider that says, no, it's not, I would actually seek another provider, but I would encourage people to go to a gynecologist, actually, who may have experience with sexual health and survivorship before the treatment. And so the ideal scenario is I see somebody before, before they get radiation. And I explained to them, this is what my role is here. This is what could happen to your vagina. These are going to be the steps that we're going to take.

And those almost always include vaginal dilators and vaginal hormones. And again, the vaginal hormone piece gets, people get really nervous. Is this going to cause cancer? And in these patients especially, there is no hormone sensitive colorectal cancer. There is nothing this hormone is going to do that will worsen the cancer they have, nor will it actually cause another cancer. So I strongly encourage them to be using hormones usually leading up into their treatment, just to get the vaginal tissue really healthy. And then after, once they're in treatment, I don't want them putting things in their vagina. Cause the tissue gets really sensitive. And then I like to see them back four to six weeks after their radiation so I can do an exam to assess their vaginal health.

And then now talk about how to use dilators, how to use vaginal estrogen.

So I think that's an important thing for those of you listening that if you know anyone or if you're experiencing this yourself, is to get adequate counseling prior to or find someone that can help you with that. So, okay, the next time, I'm going to just kind of, like, hit you with all the topics. So the next topic I thought about was, you know, last year, obviously, you also gave a very amazing talk on progesterone at Ishwish, at the International Society of the Study of Women's Sexual Health. An educational talk on progesterone. So let's talk a little bit about hormones. I mean, I feel like progesterone doesn't get any attention when we talk about it. It's just there to protect the uterus. But we know that there's so much more to progesterone than that.

We see these new medications for postpartum depression that are out. We know how progesterone affects things like PMDD. So can you just talk a little bit about the different types of progesterone and their impact on our overall health, sexual health? Yeah.

So progesterone, I agree, is really a hormone we don't spend enough time on. Just to be very clear, progesterone is actually almost even a precursor to estrogen and testosterone. It's made from cholesterol, as are all sex steroids. And it can either be converted into what we call glucocorticoids, mineralocorticoids. These are things that can affect stress levels or are kind of influenced by stress levels, but they also can then be converted into estrogen and testosterone. But progesterone itself is only made by an ovary that released an egg. And I think that that's incredibly important because if people are not ovulating, they are not making progesterone. If they are taking synthetic progestins, which is what we find in the majority of birth controls, they are not making natural progesterone.

Progesterone is really important in the uterus. It basically stabilizes the lining of the uterus and gets it ready for a pregnancy. It also blocks the stimulatory effects of estrogen, which means that if you don't have progesterone over time, excess estrogen can actually lead to overstimulation and even cancer. So progesterone is actually necessary to prevent cancer. So people who aren't getting regular periods, even if they're not worried about pregnancy, they are at risk of cancer. It's a huge problem and a miss sometimes, I think in health, it's just.

To clarify the end of the lining of the uterus.

Yeah, the lining of the uterus, sorry to be clear. So that's natural progesterone. And natural progesterone actually doesn't stimulate all of these other receptors. This is the key thing about these synthetic progesterone is that because progesterone can turn into all these different types of molecules, we have receptors in our body that are sensitive. So it can act almost like taking a steroid like prednisone, that would act on a glucocorticoid receptor, for example. Right, or some of these, or a testosterone receptor. So what happens is when we make synthetic progestin, and the reason we make synthetic progestins is that natural progesterone is not well absorbed. So we can take it in a pill form.

That pill can be placed in the vagina, but it doesn't really get into the bloodstream in any meaningful, in a strongly meaningful way, and certainly not if you use it as a cream, which a lot of people try to do. So we use these synthetic forms that stimulate the same receptors. They're very good at protecting the uterus. They're good at blocking the effects of estrogen. They tell the body that you already released an egg, and so then the body doesn't release an egg. And that's how they work as a birth control. It's a really, it's an incredibly important molecule. The problem is these synthetic progestins also then target other types of receptors.

So some will act like testosterone. And people are like, why am I getting acne? Because those receptors are getting stimulated. Some actually block testosterone receptors and are treated. They're good for treating acne. Others make people feel more bloated because they're acting like a steroid. And each one is a little bit different. And that's why when we talk about different birth controls, people respond differently to birth controls because the main difference in all birth control pills is the progestin type.

Right.

And then in talking about those progesterones and how they work, you know, you've always talked about how premenstrual dysphoric disorder is actually, you know, a very significant problem for women. I think that, you know, they suffer a lot. They get gaslit by their physicians or clinicians, and they just don't get the help they need. But it is truly a sensitivity to progesterone, right?

Yeah. So by definition. So PMDD is a very misunderstood condition. So premenstrual dysphoric disorder has pretty strict criteria for diagnosis, and it is related to symptoms associated with the luteal phase. And what that means is the second half of the menstrual cycle, after the egg has been released and progesterone is being made, people will get mood symptoms, irritability, trouble sleeping, lots of different kind of emotional dysregulation. And it gets better when the period starts. And the reason for that is because progesterone is made, kind of starts being made halfway through the cycle, peaks about the third week, and then starts to drop. And when someone gets their period, when they bleed, it's actually the withdrawal of progesterone that's causing that bleed.

And that's why the symptoms get better. And so it really is a hypersensitivity. And we know this because if you stop people's periods altogether, you give them a medication that makes them not ovulate, they're not making estrogen or progesterone. Their symptoms go away. If you add back the estrogen, the symptoms don't come back. But if you add back the progesterone, their symptoms come back. And that's been shown in multiple studies. And so that's really the definition.

And if somebody is on a birth control pill, for example, where they're taking a medication that has progestin every single day, they can't actually have PMDD. And that's the biggest misunderstanding where I'll see people who are like, I'm on birth control pills, I'm getting these mood symptoms every month. It's PMDD. And by definition, it actually can't be. It doesn't mean they're not having mood symptoms, doesn't mean we shouldn't take it seriously. But it's not hormonally based.

Right. And I think that those patients suffer so much because they feel like a Jekyll and hide, like, half the, half the month they're feeling great, and the other half they can't get along with their significant others. Like, people are annoyed with them. They have emotional outbreaks. They really fall apart in a lot of ways. And it is so distressing that sometimes there are higher rates of depression, anxiety, all the things that people experience, and they oftentimes just don't get the right treatment. You're right in saying with this progesterone sensitivity, some of the treatment options, if it is hormonal regulation, that's what we're trying to accomplish as well, is a medication that doesn't have an actual progestin in it, but acts like a progestin, right? Yes. Yeah.

It's really tricky because the majority of these people are actually put on birth control pills because they're like, well, if we regulate your cycle and you don't have hormonal fluctuations, your symptoms are going to get better. The problem is that the majority of birth control pills have progestins that look like progesterone. So they're basically getting the hormone that causes the symptoms every single day. And progesterone. We don't know about the importance of progesterone in other tissues, though it does seem that the majority of body tissues actually have progesterone receptors. There has not been enough research to tell us how important progesterone is in the brain, for example. But in gynecology, we know that progesterone is absolutely necessary in the uterus if someone's getting estrogen. And estrogen is critical to bone health and heart health and skin health and many things.

So you can't just turn someone's hormones off completely. They'll be in menopause. They'll have both the emotional side effects of that, but also the physical side effects. So you have to have estrogen, but if you have estrogen, you need to also have a progestin or progesterone, at least a minimum for uterine health. And this is where it gets really tricky in treatment. And there are some nuanced ways. There are some medications that provide estrogen but then block its effect at the uterus, and they don't act like a progesterone, which is great. And then there also are some progestins.

The main one I think of is drospirinone. That is the only progestin that's been shown to actually be beneficial in PMDD. And that's because its molecular structure looks so different from progesterone.

Right. And it's also, you know, one of the ones that, you know, you might get for treatment of acne or other things because it also has an anti testosterone, sort of because it acts negatively at the androgen receptors as well.

Yeah. And that's partly because of the mineral corticoid. I talked about those, you know, that little pathway, and that's because that's the pathway it goes towards.

Right, exactly. So, I mean, I do think progesterone, there's probably a lot more to it if we studied it more, like, we'd probably learn so much more about the brain health, too, I think when, if that research ever comes up. But it doesn't seem like there's that much interest overall, except when the postpartum period. That's the other new drug that came out. That's.

Yeah. Allopregnenolone so it does appear pregnancy is a very high progesterone state. And there is really a thinking now that postpartum depression is related to the huge drops in progesterone. But the way some of these medications work is by stimulating and blocking progesterone response receptors. They're quite. They're a little bit complex. They're also very expensive, but it probably is progesterone. And as you said, it's because, you know, the more we learn about this, the more we realize that there are progesterone receptors in the brain, and there are people studying this.

But we're decades behind where we should be. You know, estrogen has gotten a lot of research. Progesterone really hasn't.

Right. And so I think that, you know, hopefully in the next decade, we might learn more that might be more beneficial to women's mental health. I think because of that, progesterone is probably so critical in the brain, but we just haven't unraveled all of it, I guess. And then. So the other hormone discussion I want to throw at you is in the testosterone realm, because I know you've been on the papers for HSTD and hypoactive sexual desire disorder when it comes to midlife women, and I know you're not on social media, but testosterone is getting a lot of, like, negativity on, you know, instagram these days. There's a lot of people like, you know, too many women are trying to get testosterone. And there's obviously more nuance in treating someone with hypoactive sexual desire disorder. But it is one of the things, per our guidelines and per research, that has been shown to benefit women in midlife.

Why do you think, and I asked James Simon when I had him on my podcast, too, because he's obviously done a lot on testosterone as well. But why do you think there's been so much in terms of not being able to get even an FDA approved product here in the United States for women for hyperactive sexual desire disorder?

So, as doctor Simon is really the expert on this, and he's done so much research, and I know the data on this very well, is that in order to satisfy the FDA requirements for really safety monitoring, the cost of a testosterone trial would probably be north of a billion dollars. There is not enough money. And because I mentioned earlier that for breast cancer and vaginal estrogen, for example, the number of people that you would need to enroll to show that those. And when we do research, remember, we do a, ideally, we do a placebo and we do the treatment arm. Right. And then you need to follow people over time to see if there's a difference in occurrence. Now, breast cancer is not a particularly rare cancer, but you're going to see that many people in both groups are going to get breast cancer. And in order to see that, if there's any difference between those that took testosterone and those that didn't, you would need a billion dollars to recruit enough people and follow them out for long enough.

And it's just never going to happen. It's never going to happen. There was actually a company that said they were going to do this, and it's a fascinating story, and they had incredibly good preliminary data. But in their phase three trials, the placebo was actually as good as the treatment, and the treatment was phenomenally effective. We're talking four more satisfying sexual events per month, which is on the order of what the Viagra study showed. So you would say, wow, this drug really works. Well, whatever was in that placebo gel did the same thing. And that's the other limitation in sexual medicine drugs, is the placebo effect is super strong, you know, and so anything that beats placebo clearly works, and anything that doesn't, doesn't necessarily not work.

It just, you know, it becomes a lot harder. And that's actually the last real trial that was done on testosterone. And I think that put the nail in the coffin.

That was it. And that's. That goes back to how in sexual medicine, we do a biopsychosocial approach, because there is a biology to it, but there's also, like, the other aspects that when you treat them, sometimes it helps as well, and most of the times, multidisciplinary, so you can't treat one in a vacuum. So when you have a patient who is midlife and has hypoactive sexual desire disorder, do you use the FDA approved male testosterone for them? And what has been. You were like, yeah.

So my approach is, you know, again, I think it's really important to always come up, people with a biopsychosocial model. Now, in the peri and post menopause, the place that I think we sometimes miss diagnosis is sexual pain disorders that are contributing to low desire. And so that's one of the most important things when I'm doing an assessment, is making sure that if someone's having pain, there's no treatment I'm going to give them. That's going to overpower what pain does to the brain. Similarly, if someone's in a bad relationship, I can't give them a medication that's going to get them out of that relationship, you know, and bad relationships make people not want to have sex. So we clear, you know, so we.

Can'T do husband replacement therapies.

That's. Yeah, you know, a partnerectomy. Partnerectomy, you know, and I've had those. You know, I've had those referrals where people get sent to me because, you know, they're like, oh, this person should be on medication. And a quick history makes it clear that, no, this actually, you know, this. There's more to their HSCD, but when there isn't, when it truly is, is hypoactive sexual desire disorder in the period, especially postmenopausal patient. I do favor testosterone, and I use the male formulations, the 1% gel, in a one 10th to one 20th dose. We always say one 10th, but the truth is, cis woman.

So me and you, for example, our testosterone levels are about one 10th to one 20th. And so you want to be somewhere in there, and so people can get a PPD syringe, and they can, you know, just draw, you know, half a Cc or 0.2 or 0.3, you know, rub it on a hair bearing area and then wait and see.

Right. And we usually give it six months, and then hopefully you have some improvement overall. Okay, the last thing, Tammy, because I know we're running out of time, I want to talk about female genital dissatisfaction. You've done work on that. And we talked about. We talked about labiaplasties all the time and how the rates are going up. You live in California and San Francisco. I know that you probably.

When I lived in LA, I saw a ton of it as well. Tell us what you've studied in terms of female dissatisfaction when it comes to their genitals.

Yeah, so my first big study, actually, is probably the biggest study. I'm going to go to my grave, being known as the genital grooming expert, because I published a study looking at a representative sample of premenopausal women and their grooming habits, and we found that a significant number were grooming, not the majority doing it regularly, but the majority having ever groomed. And it was very much. There was a lot of differences based on race, class, education. And it became very clear that this is very much a cultural phenomenon, that not everybody is doing this, but the reasons they were doing it was what I found most interesting. Most of them were doing it because they thought their partner wanted them to, and many were doing it just to even go to the doctor's office. And that was always striking to me as a gynecologist. And the reason I wanted to study this is because they're always apologizing in the room.

They're always apologizing for their grooming. I mean, it's not just, like, my socks, my this, my that. But it's like, I'm sorry I didn't shave. And I'm like, why would I care? Why would I care what your grooming looks like? You know? And it just made me realize, you know, it's really an unfortunate aspect of being a woman, that we're that self conscious, that a safe and space like the doctor's office, you still are self conscious about your genitals. And so then a follow up study at the same cohort was looking at genital satisfaction in general. And again, we found that it was very culturally based. It was based on people's education levels, on their race, on their age. And so that's really my takeaway from this, that it's not a given.

Right? Oh, all people are dissatisfied or all people are grooming is that this is actually really culturally influential. And I think that I would, you know, the idealist in me would love to somehow change the culture so people can just be kind of happy and recognize that there's a huge variation. I am a surgeon, and I do do labial, you know, reconstructions and labiaplasties when there's a functional impairment.

Right.

Because I think that it can be really functionally, you know, disruptive to people. You know, where they have trouble with sex, they have trouble with exercise. I don't think there's anything wrong with that. And even for those that for a cosmetic reason, that want to do it, I'm not here to judge what people do, you know, like, people. What people need to do to feel good in their bodies. I'm all about that. I just want to make sure people understand the risks, because what I'm seeing now is botched labiaplasties. And those are really heartbreaking.

They're heartbreaking, yeah. And I think, you know, when we see it for functional reasons, it's a lot of the extended labia that get caught into the vagina during intercourse. They get caught in your underwear, something. People can't wear bathing suits. They kind of hang out, and it can be very distressing for patients. And, of course, like you said, some patients just don't like the way it looks, and that's fine, too. But I'm like, you have done it for functional reasons, and it's really important to have someone know how to repair it in a correct way, because if you get the little ridges or the. Or they go too deep.

Right. We know the crew are right behind them.

Yeah. And sexual dysfunction, that they get really bad sexual dysfunction. Yeah, I agree. And one thing to note is that most people, almost everybody who gets labial reduction are people who have excess labia menorah. But that's actually normal. There have been studies looking at all across different types of vulvas, and the majority of people have larger labia minora than majora. I want to make that very clear. But unfortunately, what people think is normal or ideal doesn't look like that.

Right. It's smaller labia minora. Exactly.

The porn industry.

Well, and the porn industry, by not grooming, right now, I see labias and we see vulvas more than we ever used to before. So people are much more self conscious now. Is that because people always say, oh, it's because porn. I'm like, well, is porn reflecting society? Right. Or is society reflecting porn? We don't know. You don't, you know?

Yeah, exactly. And I think that, you know, when it comes, we see the elongated labia. But as two people who really look at vulvas all the time, like, we see the regression, too. And post menopause, it's like, in sclerosis. And so, like, sometimes I'm like, this is like the labia that some people want. And then, you know, with it being on birth control pills and whatever, their labia just shrink up. And then other times, it's like, really, your labia or menorah are disappearing. And people get very much distraught by that.

Like, you know, just having lost their labia. Like, it's very distressing for a lot of patients. So it's just a whole spectrum, and it varies so much.

I agree. And the other thing is, labia minora have a lot of nerve endings. And so we got to be really clear that when we start taking parts of the labia minora off, we are changing people's sexual sensitivity.

Absolutely. And I think as long as a patient knows, that goes in counsel, knowing that potentially more painful sex, orgasm, some of these things can happen. Hopefully they don't, and in the right hands, they won't. But you never know with different patients. And so I think the proper counseling is always important.

Totally agree.

Yeah. All right, Tammy, I can talk to you forever because you're such a wealth of knowledge, but I want to be cognizant of your time. So I really appreciate you coming. Like like I said, doctor Rowan doesn't show up on social media that much, so it's a real pleasure to have her and so I thank you once again. Remember, I'm Gyno Girl. Gyno Girl presents sex, drugs and hormones. I'm here to educate so you could advocate for yourself. Please join me next week for my next episode.

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