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You know what “pisses” me off? This article from Medscape: 'Vaginal Dryness' Can Be Fatal. No, Really. Here’s why I find this sort of article SO irritating:

Turning a sensation into a syndrome is a typical scare tactic about menopause. This article conflates vaginal dryness with UTIs and then proceeds to make them into a deadly condition.

I don't argue with the ability of a UTI to become a dangerous or even deadly infection - but presenting UTIs as an unavoidable outcome of vaginal dryness (which this article presents as an unavoidable outcome of menopause) really raises my hackles.

It's the old conventional medical shell game called creating a “new” condition by medicalization + catastrophizing. In my experience, both vaginal dryness and UTIs can be dealt with by a greater understanding of self-care. What we need is more education about self-care, not simply more drugs and exogenous hormones.

This is a HUGE subject which goes straight to the heart of the purpose of STREAM. Here are a few considerations that influence the occurrence of UTIs:

1) Adequate hydration

2) Adequate embodiment to notice what adequate hydration feels like

3) Balanced flora in, on, and around the vulva

4) Balanced gut flora in the person with a vulva and their sexual partners

5) Having the inner authority and know-how to change one's flora locally (on their own vulva) by using easily available probiotics like yogurt and OTC probiotic supplements. 6) Requiring new sexual partners to wash their hands and genitals with a potent anti-bacterial (like povidone-iodine) before vulva contact. Once both of your respective microbiomes get to know each other better, this is usually no longer necessary.

7) Knowing and feeling the connection between one's overly excitable autonomic nervous system (ANS) and persistent UTIs. The pudendal nerve innervates the lower urethra and urethral opening and is a sympathetic nerve. States of sympathetic ANS dominance can drive inaccurate and overactive pudendal nerve signaling. The feeling is one of needing to pee too often.

8) Possessing the self-agency & ability to calm oneself down when feeling spun out.

9) Last (and certainly not least!), learning how and when to squirt to rinse out your urethra and any urethra-adjacent tubes leading into the bladder.

10) Know how to identify the feeling of full genital arousal and engorgement. For the lack of ever having this experience, many people with vulvas are never able to engage their own self-cleansing apparatus (AKA squirting).

Does all of this fall within the scope of practice of STREAM education for oneself and one's clients? You betcha!

This article was behind a paywall. Now you can read it to make up your own mind.

Perspective > Medscape Urology > Sex Matters with Dr Rachel Rubin COMMENTARY

'Vaginal Dryness' Can Be Fatal. No, Really. Sex Matters, With Dr. Rachel Rubin

Rachel S. Rubin, MD

Assistant Clinical Professor, Department of Urology, Georgetown University, Washington, DC; Private Practice, Rachel Rubin, MD, PLLC, North Bethesda, Maryland Disclosure: Rachel S. Rubin, MD, has disclosed the following relevant financial relationships: Serve(d) as a speaker for: Sprout Received research grant from: Maternal Medical Received income in an amount equal to or greater than $250 from: Absorption Pharmaceuticals; GSK; Endo

October 11, 2023 This transcript has been edited for clarity. I'm Dr Rachel Rubin. I am a board-certified urologist who is fellowship trained in sexual medicine. I'm here to tell you that vaginal dryness is killing women. I mean it. It's actually killing women.

What do you mean, Dr Rubin? How is vaginal dryness killing women? We minimize the term vaginal dryness. When women come to our offices and complain of a little vaginal dryness — or they don't even come to our office to complain of it because the doctor can't be bothered with a little vaginal dryness — what they don't understand is that this "little vaginal dryness" is really something called genitourinary syndrome of menopause (GSM). They don't know that because they've never heard of it, and you may have never heard of it either. In 2014, we changed the terms vaginal dryness and vulvovaginal atrophy or atrophic vaginitis to GSM to make it short and simple.

GSM — what does it mean? It's not just a little vaginal dryness. It turns out that all of the genital and urinary symptoms from menopause just get worse over time. The bladder, the urethra, and the vagina have lots of hormone receptors, including estrogen and testosterone. When the body no longer makes those hormones, the system doesn't work very well, and genital and urinary symptoms occur that just get worse over time without treatment. Unlike hot flashes, which tend to go away, GSM does not. What are the symptoms of GSM? Some are sexual: a little vaginal dryness, pain with sex, and worsening orgasm. But there are also genital and urinary symptoms that get worse: itching, burning irritation, rawness, an awareness of their genitals that the patient has never had before. And as a urologist, we see frequency, urgency, and leakage. The thing that kills women is recurrent urinary tract infections (UTIs). Did you know that UTIs account for 7 million visits and hospitalizations annually and 25% of all infections in older people? In fact, apparently one third of the total Medicare expenditure is around UTIs. Not preventing UTIs is costing our healthcare system an enormous amount of money and resources.

Did you know we've had safe and effective treatment options for GSM since the 1970s? Vaginal hormones have existed since the 1970s, but we're using them only for pain with sex and not for GSM. In fact, data show that by using vaginal hormones, we can prevent UTIs by more than 50%. We can save lives using safe, effective, local, low-dose vaginal hormone strategies. And they are safe and effective for all of our patients in pre- and postmenopause.

There are five different treatment options: vaginal estrogen inserts, vaginal estrogen creams, vaginal dehydroepiandrosterone (DHEA), low-dose vaginal estrogen rings, and an oral pill option called ospemifene (Osphena). All are used to treat GSM and will only work if your patient actually uses them and continues to use them.

These treatments are safe. They are effective. They do not increase the level of systemic hormones in the bloodstream. I have many patients with breast cancer who use these products as well. The only patients you may want to talk to your oncology colleagues about is women on active aromatase inhibitors.

We have to understand that UTIs kill people and having GSM is debilitating, often requiring pain medication because it can hurt to sit or to wear pads and our patients' quality of life is severely affected. So please consider learning how to treat GSM. It turns out you don't have to do exams. You don't have to do follow-up. You can give these therapies, and women can use them for life.

Now, if your patient has vaginal bleeding, of course they need to see their gynecologist. But this is something every primary care doctor can and should do. As a urologist, we prescribe a lot of tamsulosin (Flomax) for our male patients to help with urination. Vaginal estrogen or DHEA is basically like Flomax for women, but it prevents UTIs and actually works like sildenafil (Viagra) because it can help orgasm and reduce pain with sex.

You have access to affordable, safe, effective treatment options to treat GSM. So check them out and hopefully change the world.


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