UNDER THE MIDLIFE HOOD

Dr, Jill Krapf  0:00  

Help is out there. You're not alone. And you can have a very happy healthy vulva and vagina.

Sarah Milken  0:11  

Hey, peeps, welcome to the flexible neurotic podcast. I'm your host, Dr. Sarah Milken. Yeah, you heard that right. I'm a real PhD doctor. Long, long ago, like last fucking year. I was sitting in the midlife funk wondering, was this it for me? That day I realized I needed to get off my ass and start my midlife remix. I dusted off my PhD wipe the menopause, sweat off my forehead, grabbed my golden shit shovel and started digging deep to all my midlife bitches. It's not just luck, coffee and hormones that get you through your midlife remix. It's action steps. Let's do this. Hi, peeps. This is the next episode of The flexible neurotic podcast and I'm Dr. Sarah Milken, the flexible neurotic today I have an interesting guest that is going to help us add to the midlife vagina, vulva and menopause chat we are always having here on this podcast. She is board certified OB GYN who specializes in female sexual pain, vulva and vaginal disorders. She's named as one of the North American menopause society certified menopause practitioners. She's the associate director at the Center for vulva vaginal disorders in Washington DC. And she did her mentorship with Dr. Andrew Goldstein, one of the leading physicians with vulva and vaginal pain. She not only sees patients but she's active in research and as the Associate Editor for the Journal of Sexual Medicine, online access. Her name is Dr. Joe Kraft. Hi, Jill.

Dr, Jill Krapf  1:48  

Hello. Thank you for having me. Oh

Sarah Milken  1:50  

my god, I'm so excited. You're here. I have to tell everyone that I've had the flu this week. So my voice sounds a little bit like Kermit the Frog, which is awesome. But we're gonna get over that. I'm so glad that we were able to schedule this. I know summer is just like a crazy time for everyone. And so I thank you for rearranging your schedule. So today we're going to talk about midlife vaginas Roo, vulva has sex drive, yeast infections, UTIs, painful sex, drive vaginas. And the list goes on. Oh my god. This is what most of us midlife women are talking about and thinking about right, Joe?

Dr, Jill Krapf  2:27  

Absolutely. And this is pretty much my office schedule. Oh my god. This is what I see every day all day. And I absolutely, actually lay love to get people better, and to teach them about vulvar care and vulvar health and really empower women, especially in midlife to really take care of these symptoms, because you do not have to live with a itchy, dry vulva or vagina.

Sarah Milken  2:55  

Oh, my God, that's like news to everyone's ears. Because I think a lot of times when we go to our gynecologist, and we'll get to talk about this later, too. Sometimes we're just like, Wait, do we have to live with this? We've tried 47,000 things and everyone's like, it's in your imagination, or try this or try that. And I don't feel like there's these like clear cut solutions. And that's why when I found you, I was like, Wait, there's someone who specializes in that whole cluster of what's going on down there. I have to get her.

Dr. Jill Krapf  3:24  

Absolutely, I have so many patients that come in, and they think, Okay, this is just my new normal. This is how I'm going to be living and with intimacy, they just accept the fact okay, I guess that I'm not going to be able to enjoy sex anymore with my partner, even though they want to where it gets to the point where it's so painful that they're just like, Oh, this isn't worth it. This isn't enjoyable. And they think that that is just how they're going to live. And they have to accept it. And that's just not true at all. There's so many things that we can do. So we can be comfortable every day. And we can be intimate with our partners again and not have pain and actually have pleasure and desire.

Sarah Milken  4:01  

Oh my god, I can't wait to get into this because it's something that's on all of our minds. I think I've done at least four episodes with gynecologist I know you know all of them because they all follow you. And the response, I get his crazy. They're like, Oh my God, thank you for talking about that. Nobody's talking about that. Like I thought it was supposed to hurt like I thought it was just part of like being this age. And it just seems like we've almost gotten to the point where having those kinds of weird pains is supposed to be normal.

Dr. Jill Krapf  4:28  

And it's a tough time period to because if you think about it, a lot of us are having our kids in our 20s 30s And then finally we get these kids out of the house and what met it's perimenopause and menopause hits and it's the time where we're finally you're empty nesters. You can be intimate, you can have that resurgence with your partner, and then all of a sudden things aren't working and it hurts. So it's very cool how that happens. But it doesn't have to happen that way.

Sarah Milken  4:54  

I know everyone's like, Oh, your kids are away at like pre college programs for the month like you and your husband. I'm like Uh huh, yeah. Right.

Dr. Jill Krapf 5:02  

I hear this all too often. And sometimes it puts it puts pressure on the relationship too because there's an expectation of Oh, the kids are out of the house. But if things aren't working the way that they should, it can put a little pressure on the relationship. Well, I can't

Sarah Milken  5:16  

give like a fair statement because I've had the flu this week. So that's definitely put a damper on it. But still, even if I didn't have the flu, like, I'm not gonna lie, I'm not sure it would be like 50 Shades of you know, the flexible, neurotic and Sarah, let's be honest. So today I want to find today I think we're going to try to find this sweet spot in the middle of this vagina today to dry to itchy to maybe a feeling of like, maybe not perfect, but like finding solutions. We shouldn't be destined to have forever dry aching Volvo's and vaginas. Maybe not perfect, but a hell of a lot better. I really want the intention for this episode. For us to dig deep dive into questions. We should be asking our doctors and potential solutions for the whole gamut of vulva and vaginal issues. Believe me, I've got a million I heard you say something that piqued my interest you wrote? Or you said, What if I told you that there's a condition that over 50% of women develop, and it doesn't get better and it impacts everyone and less than 5% of women can articulate what it is. And less than 13% of doctors will even ask you about it. I mean, Joe, what

Dr. Jill Krapf  6:25  

I mean, when you put it that way, it's like what is going on here. And as a specialist in this, I say that every single day and my patients due to what we're talking about to let the secret out is something called the scientific term is genital urinary syndrome of menopause. And that is a mouthful, we call it G S M for short, which is still a little bit of a scientific term and a mouthful, but it's a little bit better than what it used to be called. So this is the new term for vulva vaginal atrophy.

Sarah Milken  7:00  

I love the atrophy word. It's like, is it falling down? Is it creeping up? Is it turning into wax paper dye? I know but the new term I'm like, well, that kind of sounds complicated too. So like an umbrella for just everything under the kitchen vulva sink.

Dr. Jill Krapf  7:18  

So basically what we're talking about is the tissue, the skin, the mucosa. When it's on the inside, we call it that of the vagina, the vulva as well as the urinary system. So in the past, we really neglected the fact that as we get older and our estrogen and testosterone levels drop, it not only affects the health of the vagina and causes changes to the vagina and the vulva. But it also really changes the urinary system meaning the bladder and the urethra. And so people experience symptoms like having to pee all the time. We call like, very frequency. I think we can all relate to that. Yes. Oh my goodness. Incomplete emptying, feeling like you go to the bathroom and then two seconds later, you're like, What is going are like

Sarah Milken  8:04  

the sneeze pee. I'm like, oh,

Dr. Jill Krapf  8:07  

that the cross your legs? Here? Yeah. sneeze or you laugh at one of your kids jokes. And all of a sudden you all are laughing because Peter Pan

Sarah Milken  8:17  

Okay, so wait, before we get into this. i This has come up like a million times on this podcast. Like we all call it the vagina. But like there's a better term for it. So can you just like break down for us is like the vagina is just like the hole right where the baby would come out and everything else is the vulva.

Dr. Jill Krapf  8:36  

I love that. Okay, so yes, so 95% of the time when we say vagina, we're actually talking about the vulva. So what is the vulva? The vulva is the part that we can see with our eyes. So if you put a mirror like if you'd like open the lips up, see or it's that whole area, okay, pool area. So it includes everything kind of between the legs there so it's your labia majora, which are the typically the hair bearing labia, okay, if anyone has

Sarah Milken  9:03  

hair anymore.

Dr. Jill Krapf  9:07  

And then if you separate that area, then you have your labia minora, which are those small so we are translates to lips and we can think of it like that. You have your labia majora, which are the larger lips that typically have the hair on them if you're going to have that, and then the labia minora, which are the small lips, and then at the top is the clitoris, which we should all know where that is. Yeah, hopefully our partners do too. And then there's the clitoral hood, which is like a little hoodie that goes over the clitoris and everyone's anatomy can be a little bit different. There's variations, typically the labia minora they can either be small, they can stick out a little bit. One can be a little longer than another they can be different colors. All of that is just normal variation. And then when we open up the labia minora there's the most important area of all that no one knows about. And that's called the vestibule hmm,

Sarah Milken  10:00  

That sounds serious. I know. It's like Inspector Gadget,

Dr. Jill Krapf  10:05  

it actually kind of is, has all these little gadgets in it. So basically, the vestibule is that that vaginal opening area, that area right at the opening. And it has really important structures or gadgets, if you will. So the urethra where your urine comes out is if you look at it like a clock, it's at 12 o'clock. So it's right there at the top right under the clitoris. And then on each side of the urethra are these little glands and these little gland openings that produce our natural lubrication. So when we get wet, that's what we're feeling. But we're producing lubrication throughout the day. And that's what's keeping that area very healthy and keeping the tissue plump, and, and resistant to different infections. So we have those little gland openings at the top. And we actually have little gland openings at the bottom of the opening as well.

Sarah Milken  10:56  

Okay, so as we age and are estrogens dropping, are those glands not giving us the moisture that we need.

Dr. Jill Krapf  11:04  

You got it. So those glands you can think of them as little factories. So the input to make the lubrication is hormone, and those glands need estrogen. But more importantly, those plants need testosterone, which is something we don't often think about I know we're talking about sex hormones for females, we think estrogen, estrogen, estrogen, and that's important for the vagina, and it's important for the bulb on the outside. But the vestibule is different. It's actually if we're gonna get really nerdy, yeah, made from a different type of tissue when we're actually forming as babies in the womb. And so that tissue has different characteristics. And that tissue has a lot of receptors for androgens, like testosterone, and it's very testosterone responsive.

Sarah Milken  11:49  

Got it. So I remember talking to a gynecologist once about testosterone, and she said, you know, you could try it, it would definitely help with your sex drive. But there's some women who will get really greasy hair or acne. So what are the sort of side effects of adding that into your regimen,

Dr. Jill Krapf  12:06  

there's two ways that we use testosterone, it's similar to the two ways that we use estrogen because estrogen is used much more, we'll talk about that first. So in menopause, you can use estrogen either in a pill or a patch for hot flashes, night sweats, and then the other symptoms of menopause that we don't often talk about, like brain fog, mood changes, sleep disturbance, weight gain, and so forth. Not funny ones, yes, and all these things that happen. So those are what I call those are a whole body symptoms. So that's

Sarah Milken  12:37  

the HRT version that's going to lead to a pill or powers that sort of hangs over your whole system.

Dr. Jill Krapf  12:42  

Yes, that's hormone therapy. And it's supposed to help a bit with the vagina as well. And sometimes it does. And sometimes it's not quite enough because it's, it's going through the whole body, right. And then we have a different form of estrogen, which is called low dose, local estrogens. Okay, and these can be in a cream, a pill, they can be in a ring, there's many different forms of those, and those are used vaginally, or sometimes we put them on the vestibule that area I was talking about. And that treats that GSM that we were talking about the vaginal dryness and the vulvar pain and the pain with insertion and so forth. And the risks with these two medications, even though they're both estrogen, the risks are very different because the dosage of the local low dose estrogen is a fraction of what the systemic or the whole body hormone therapy estrogen is. And it's the same when we're talking about testosterone. No testosterone is used off label because it's not FDA approved for women in the United States at least. And so the reason that we would use whole body testosterone, meaning a testosterone cream that we would rub into the calf, would be something called hypo active sexual desire disorder, each s di D, which is a fancy way of saying that you have a low libido and it bothers you got it. Now that's different than if someone needs a little bit of hormone at the gland opening because of pain with sex or dryness and those local symptoms that would be treated with a topical gel or cream that contains a little estrogen and a little testosterone at a fraction of the dose. And so the risks are much different. You don't typically get high levels of estrogen of estrogen or testosterone in the bloodstream. So you're not going to get the acne or hair growth or any of them

Sarah Milken  14:31  

through social so what is that? What's the D H E, a thing that people are talking about? Like a lot of women are messaging me like, Oh, I get this from a compounding, pharmacy and blah, blah, blah. Is that what you're talking about? No, this

Dr. Jill Krapf  14:43  

is different. So you can think of DHEA is kind of between so it is a precursor to estrogen and androgens so basically it's inserted into the vagina, and in the tissue of the vagina. It gets turned into these hormones. So it's almost like giving someone Get the ingredients to make their own within the tissue. Now there is an FDA approved version called prostor, Roan or intra Rosa is the brand name. And then it can also be compounded and available that way. So this is a little bit different than compounding estradiol, which is estrogen with a little bit of testosterone in the gel that we put at the openings. Is there

Sarah Milken  15:21  

any downside? If let's just say you're taking HRT or not, you kind of still feel like you have like some of the you know, sex pain or dryness, is there any downside to using the testosterone mixed with estrogen? Not at all.

Dr. Jill Krapf  15:38  

Oftentimes, I'll have patients that have the hot flashes, night sweats, they're on the hormone therapy, whether usually a patch, because it tends to be a little bit safer, but the pill is fine as well, depending on your risk factors. So they're on that as well as, if you have a uterus, you want to be on progesterone, which you take at bedtime, and it helps you sleep, which is kind of nice. Oh, wow. So they may be on that for those whole body symptoms. But sometimes it's just not enough. And so it's not uncommon to need to do a vaginal estrogen in the form of a tablet, or inserting a cream to help. And then what the missing link often is, even after all of that, they're feeling pretty good. The vagina on the inside is good, they're not having that yellow discharge or anything like that. But if they're still having pain with insertion rate at the rate at the opening, it may be because that vestibule is not getting any love, right, their whole body is getting the hormone the inside of the vagina is getting the hormone. But what's often missing is we need a little bit at the opening. And so in that case, sometimes gynecologist will take a little extra dial cream or estrogen cream and put that at the opening. But sometimes that's not enough. And we need a little testosterone mixed in.

Sarah Milken  16:44  

Got it. So is there any so if you were going to your doctor, could you start with the testosterone mixed with the estrogen? Or is it better to kind of like do one then do the other and kind of try it out? I feel very

Dr. Jill Krapf  16:57  

comfortable prescribing testosterone and prescribing these preparations. So I never put somebody on estrogen alone at that area unless they have some sort of contraindication which would be very rare. Okay. So for me, I think that anybody that has that hormonally associated pain, or oh, I

Sarah Milken  17:14  

have it, I talk about this all the time, but I'm 47 I still take birth control pills. I know it's super controversial for a lot of people, but it's worked for me until now. And my thought is like, let's just do something as long as it works. But I have started experiencing some of the burning, so I just got the estrogen cream prescribed to me. Of course, it's been sitting in my bathroom for two weeks, and I'm like, Okay, fuck do I really want to start this? I don't know what I'm doing. But now I'm like, wait, maybe I want it with the testosterone, how maybe we'll go 50 Shades of Grey.

Dr. Jill Krapf  17:47  

I know. And when you apply it to the to the vestibule like that the amount of absorption is extraordinarily low. Sometimes I'll give it to people to do vaginally, but we do it much less often. Because the way that I say it is when you put it at the vestibule, it's like putting chapstick on your lips, right? There's not a lot absorbed into the body, if any at all.

Sarah Milken  18:06  

Like if you were sitting on a mirror and you're talking about the vestibule like where are you not putting the cream, you're not putting it on your lips and all of that, but you're just putting it like where your tampon would go.

Dr. Jill Krapf  18:17  

Yes. So it's basically the ring right inside the small labia. So if these are your labia right here, okay, you if you insert your finger or two about the crease, that's where we go, oh, the place that hurts. Interesting. It's right at that opening. It's at the very bottom the outlets of the

Sarah Milken  18:40  

audit. It's interesting because it was only for the first time I my husband is going to die when he's listening to this, but that I like when we were done. I was like, Oh my God, my vagina is on fire. Oh my god, I'm gonna die. Oh my god, it's burning. But it was the first time I had ever had that before.

Dr. Jill Krapf  18:54  

Yes, it can be very scary when something like that happens because we don't know what's going on. Oh my god. And what I find is that many of my patients automatically think, oh my gosh, I have an infection.

Sarah Milken  19:06  

No, I know. And that was blue too. So I was like, what's happening here.

Dr. Jill Krapf  19:10  

And I always recommend lubricant, but sometimes lubricant, it's a bad day to kind of get you there. But then if you get to a certain point and the hormones aren't working, they used to be it's, you need something a little bit more.

Sarah Milken  19:21  

Right. And that was gonna be another question for you for you is, is there a difference between like, the goodness of like real lubrication that your body is producing, even if you're using something to create it versus sort of like using eyedrops like a lube. Do you know what I'm saying? Like

Dr. Jill Krapf  19:40  

do I know what you're saying? I think lubrication however you can get it is good, but the difference is if your body is naturally producing a low level of lubrication during the day when you're not sexually active, just like your eyes, it's keeping the tissue of that opening healthy and it prevents micro abrasions and it prevents thinning And it prevents, you know, which can lead to infection. So it's similar to your eye. You know, you might not be crying all of the time, but your eyes are constantly producing a layer of lubrication. If they're not doing that, then you're going to start to have dry eye symptoms like burning and itching. It's the same with the vulva.

Sarah Milken  20:16  

How often would you use these creams?

Dr. Jill Krapf  20:18  

So I compound it because the testosterone is not FDA approved for women. So it needs to be compounded. At least that's what we have. I compound it in a gel formulation just because it's more soothing. Yes, it's wonderful. Everybody calls it the you know, it's like magic. If you have the right diagnosis, you have to make sure the diagnosis is correct, of course. So it has be estradiol, which is estrogen at the same dosage as your FDA approved clean version, your estradiol cream, or your esterase cream, so same exact estrogen dosage, and then the testosterone just a little bit. It's a very small amount, and it's in a gel formulation. And that goes right on the vestibule that opening area we talked about and for my my women who are menopausal I have them do it once a day to the opening.

Sarah Milken  21:00  

Now can you have sex in the same day that you use it?

Dr. Jill Krapf  21:04  

You absolutely can I just say don't put it on right before sex because then you'll that doesn't make sense, right? It's not like

Sarah Milken  21:10  

you're transferring anything weird to your partner?

Dr. Jill Krapf  21:13  

No, that's completely fine and absorbs pretty readily. And you just want to use it either in the morning or in the evening, it really doesn't matter. You just put it right at that opening, rub it in for about 30 seconds or so once a day, and you're good to go.

Sarah Milken  21:26  

Wow. Okay, there we go. So I'm definitely going to look back into that because a gel sounds a lot less messy than a cream for some reason, do gels absorbed faster,

Dr. Jill Krapf  21:35  

they may absorb a little bit faster, you don't have to rub them in quite as much as a cream or an appointment. So it's pretty well tolerated. And that tissue picks up hormone pretty well. So it works. Now sometimes treating the vestibule is not enough and people need a vaginal estrogen as well. Vaginal estrogens are typically inserted two maybe three times a week, right? So it's less often because the vaginal tissue absorbs more right than the opening tissue just like something in your mouth. Put a pill in your mouth. It absorbs better than something on your lips. And so some people need both they needed usually a tablet because it's less messy. So an estrogen tablet twice a week, and then they put their gel on the opening once a

Sarah Milken  22:16  

day. Okay, so if I'm going to the gynecologist and I'm like, Okay, I'm Peri menopausal. I do take birth control pills or someone else, you know, take something else. But sex hurts like what am I trying to get from them? Because a lot of times a gynecologist meeting is like 15 minutes, okay, you're not dying. Let's move on. You know, it's it's not the same level of detail that we're talking about with you. So what can we be asking our gynecologist so that we're not just sort of given the loop.

Dr. Jill Krapf  22:48  

Understood. And you have to remember that I'm a specialist. So I this is what I see. I don't deliver babies. I don't take out uteruses, I don't deal with paps. And viva you used to I used to I have the experience, but it's not what I do anymore. And so when people come to my door, they're at that higher level where they've tried, you know, lubricant, they've tried maybe some estrogen cream, and it hasn't worked for them, and so forth. And I'm also looking for other causes. What we're talking about now is purely hormone related causes. But there are other things that can be going on in that area, I would say most gynecologist, they may not feel comfortable doing a compound that includes testosterone, although I think that things are changing, there's actually a really great physician statement and guidelines that came out of is Swish, which is International Society for the Study of women's sexual health, that goes over how to use all of these hormones, including testosterone, and that's a great resource. So I think things are coming around. But what your gynecologist may feel more comfortable with would be at least a vaginal estrogen, tablet or cream, and perhaps putting a dollop of vaginal estrogen right at that opening area as well. And then the way to get around that actually is if estrogen alone isn't working, and then something like the DHEA that we were talking about, because some of it is converted to testosterone, it actually as it filters down, it kind of gets those glands.

Sarah Milken  24:04  

So who's an estrogen cream person who's a DHEA person and who's an estrogen plus testosterone? Like, is there an order to start in?

Dr. Jill Krapf  24:12  

No, not really, these are all options. But there's some downsides. Like, for example, the vaginal DHEA, that's FDA approved, can be a bit pricey. So there's considerations with that as far as insurance coverage and things, you know, things like that. I would say from an FDA standpoint, if you want to try to get testosterone or try to get androgens in the mix, that's the option that we have. However, we can compound testosterone, you know, if you feel comfortable with that, and it's really much less expensive. So a specialist like myself, would feel comfortable doing that and I can ultimately get the same results, maybe even a better result. So these are all different options. Just like there's different birth control options, right? Not everything is going to be right for every single person, you know, you have to look at the patient's values. If they say Oh, I really don't want anything messy. or I really don't feel comfortable doing this or doing that. Then I listen. And we talk about the options, and then we come up with a plan.

Sarah Milken  25:07  

So you're a vulvar specialist. So if somebody wanted to find you, and they were not in Washington DC, is that what we would be looking up in our cities?

Dr. Jill Krapf  25:19  

Yes. So there's directories that are available. And so you can look at the find a provider directory at a swish, which is that society that I was telling you about, there's also directories through other societies and then menopause. providers who are certified are a part of the North American menopause society or NAMS. We are menopause certified providers. And so we actually have to take a test and it's a pretty hard test, to become a certified practitioner for menopause through Nan's and they have their own directory of people who have been certified and who have passed those qualifications. So there's definitely ways to find us I know it's a little bit difficult to find somebody.

Sarah Milken  26:00  

Now if I have a gynecologist and you know, there's a lot of people who say that their hormone specialist or menopause specialist, how is that different from a vulvar specialist, the differentiation that you're also looking at skin and all of that too.

Dr. Jill Krapf  26:16  

You're absolutely right. So I specialize in skin conditions and that area as such as lichen sclerosis Lichen Planus, like in simplex product, so all of these things,

Sarah Milken  26:25  

those all auto immune, not all of them,

Dr. Jill Krapf  26:28  

so many of them are lichen sclerosis, and like implants are auto immune, lichen simplex chronic host is actually an itch scratch cycle. So it's brought on by some sort of contact, irritation cycle and then it itches. And then you scratch it, and then you know, around it, like Dockage it can be so so then we need to look at different types of infections. There can be fungal infections of the skin in that area, there can be bacterial infections in that area. And so I specialize in all of that in addition to that Unitas so some people have vaginal discharge and vaginal infections that they just keep getting and getting and getting, whether it be chronic yeast infections, or whether it be bacterial vaginosis or something called D ay b, which stands for discriminative, inflammatory vaginitis, which often does not get picked up by your general gynecologist as well who

Sarah Milken  27:22  

picks that up. I mean, obviously, you pick it up. I've had a few yeast infections this year, I'm much better than I used to be. I go to the gynecologist and I'm like, Oh my God, my vagina is on fire. It's itchy. It says it's not. And then it comes back negative. And I'm like, what is happening? No, I need a solution.

Dr. Jill Krapf  27:37  

Absolutely. And that's what makes us so tricky, because there's only one type of nerve receptor in this vestibule area. And actually, the vagina itself has very little nerve endings, right? When we're feeling that itching, discomfort, wrongness, you know, that we know it's just like something's not right down there. It's usually the vestibule because there are tons of nerve endings in the vestibule that opening area. So even with a yeast infection, if there's yeast up in the vagina, it doesn't become bothersome until that discharge gets down to the vestibule and then it flares everything up. And then you have all the symptoms. So as far as testing goes, it's a little tricky, because a lot of your regular gynecologist which I you know, I did that for many years. In addition to starting a sexual health clinic, our tools and resources that we have available are mainly tests that are just looking for specific things. They're looking for sexually transmitted infections, like gonorrhea and chlamydia, and they're looking at certain types of yeast to usually they're looking at. So we call yeast, Candida usually is common. So Candida albicans, is the most common and then there's another one called Candida glabrata. And so these tests are really only picking up those two types of yeast. If you have a different type or a non albicans type. It's not going to show up on your normal testing.

Sarah Milken  28:52  

Would it be the same solution though?

Dr. Jill Krapf  28:54  

Not necessarily. Not necessarily. And so that's what makes it really tricky. Oftentimes, people with an inflammatory discharge, meaning they're having like a yellow sticky copious discharge, when it touches that vestibule, and in the vulva, it sticks like glue on that area, that's called D IV, we can see that and women of all ages, when it's in menopause, we tend to call it a trophic badge and itis that was the old term for that yellow sticky, or I haven't

Sarah Milken  29:20  

had that yet. Watch me wake up with it tomorrow, but

Dr. Jill Krapf  29:23  

you know, no, because we're talking about it. But if you do, you'll know

Sarah Milken  29:29  

No, but I get that like, itchy off. This is annoying feeling. And then I go and she's like, No, you don't have it. And I'm like, Nah, no, I do.

Dr. Jill Krapf  29:36  

Exactly. And so you know, there's many things like that can be going on which changing our practice. And I think what the future is going to hold is some of these next gen sequencing vaginal swabs. So now there's companies coming out and there's there's two types. There's ones that I can order for the patient. They can self collect, or I can collect them but I have to sign off on them. And it looks at exactly what's in the vagina. Everything thing that's in the vagina. And then it gives me recommendations on on basically how to treat it. And then there's the the patient centered ones that do not require a sign off by a doctor. And those are doing similar things. They're looking at what's in the vagina and giving you a readout, but there's not somebody interpreting it for you. So the issue is that the technology is a little ahead of what our understanding is of the vaginal microbiome and what we know to do about it. So I can tell you what's in the vagina. But I may not be able to tell you exactly how to fix it, because the research isn't there yet.

Sarah Milken  30:33  

Got it. Got it. Okay, so, I saw on Instagram a few days ago that you listed a bunch of things that perhaps the average gynecologist may not be looking for. So I'm just gonna read them off and we can talk about each one quickly. So the first one was scar tissue is covering the clitoris.

Dr. Jill Krapf  30:51  

Yes, this is a big, big, big one. I'm a gynecologist, so I'll own it. But in our training, we are taught to look at the outside vulva. However, the main show is usually the cervix, right? We're doing the speculum exam, we're doing the Pap smear. That's kind of the main show. And so we need to take a step back and really look at the vulva. If we examine the clitoris and we really pull back the clitoral hood. It's amazing what we can find. And I think for any gynecologist I think the important thing to know is, that should be a part of our routine exam but it's not always ask a patient if they're having clitoral pain. A lot of times patients will not tell you because they don't know if it's normal or not. They're not sure what to do about it. How I

Sarah Milken  31:36  

know that sounds stupid, but like what's clitoral pain? Like? Yeah, how do you know your clitoris

Dr. Jill Krapf  31:40  

is hurting? Like if your clitoris is hurting you like No, you wouldn't,

Sarah Milken  31:45  

because like that's where you would have clitoral orgasm is the spot where it's hurting. Yeah, so

Dr. Jill Krapf  31:50  

oftentimes people have, they don't like to be touched in that area, they don't like to touch that area, there can be discomfort. And this can be the there can be a scar tissue associated with a different autoimmune conditions like lichen sclerosis. So lichen sclerosis is a likely autoimmune skin condition that causes a lot of inflammation. And that inflammation leads tissue to stick together that shouldn't and it causes a bit of scarring, which basically attaches the clitoral hood to the clitoris. And over time, and some people can actually cover it completely where you can't see your clitoris at all. One of the issues with that is that some people will have decreased orgasm or will take really long time to orgasm or they can no longer orgasm at all from the clitoris because it's covered so it makes it more difficult.

Sarah Milken  32:34  

If I were to look in the mirror with a mirror, could I see it myself? your clitoris? Yeah, like if it had stuff on it? Yeah. So

Dr. Jill Krapf  32:43  

you should be able to pull back the hood of your clitoris like you would pull a hoodie off of your head.

Sarah Milken  32:50  

My husband will really want will enjoy watching this whole scene. Oh, we'll lock him out.

Dr. Jill Krapf  32:55  

Oh, I have something even better. So for people with Lycan sclerosis that have the scarring, there's a number of things that we can do to address it. But one of the kind of final steps is I do a very minor procedure where I uncover her I uncover the clitoris My

Sarah Milken  33:08  

God, circumcision. Exactly like

Dr. Jill Krapf  33:11  

a circumcision and OBGYN is actually do newborn baby boy circumcisions. And so it's exactly the same time. My God, it's really funny. But a part of the postoperative instructions that I give patients is they really have to push back that hood and pop out the clitoris and I call it popping out the turtle head.

Sarah Milken  33:31  

Oh my god, I think I'm gonna have to do a self exam. And anyone who's listening to this will be doing a self exam also. Okay,

Dr. Jill Krapf  33:38  

I think there's gonna be a lot of clitoris popping.

Sarah Milken  33:43  

Oh my gosh. Okay, so, but I did listen to you talk about scar tissue that like in our minds, we think of a scar tissue is like we actually see a scar. But when I read your information, it actually just kind of looks like crunched up fused up skin,

Dr. Jill Krapf  33:59  

right? Yes. And that's what we typically see it's a stickiness is how I describe it. And this is uncommon. Don't get me wrong, you know, most people are not going to have this. But it is associated with pain conditions in that area. Because people aren't moving the clitoral hood. They're not washing the area because it hurts. They're not interacting with that area with receptive oral sex and things like that. So it's associated when there's pain at the vestibular pain of the vulva, and then it's associated with conditions that lead to scar tissue formation like lichen sclerosis and Lichen Planus. Got it? And it's important for people to know about these things because you should know your body. The biggest thing that I have patients say is I wish I would have looked earlier to see what my baseline was. Because oftentimes, they don't realize that something's off until it's really uncomfortable or something's really wrong. And then they look and they're like, I don't think I always looked like that. Right. Not sure what they actually looked like.

Sarah Milken  34:55  

No, I agree and you're not it's very rare that you're going to be like doing selfies down there. Somehow unless

Dr. Jill Krapf  35:00  

you have a problem, right? So I have to say that a lot of my patients have an entire file on their phone. And I don't blame them. You know, I don't blame them. Because this is an important part of who we are. When something goes wrong. We, you know, it's natural to be very concerned about it. Oh, please, I

Sarah Milken  35:16  

take pictures in mosquito bites and send them to my doctor. It's like a whole thing. Okay, so in terms of vulvar pain conditions, we can have the sex pain, the daily burning sensations in factions like this is all within your specialty. And I guess the beauty and all of this is basically you're saying that these disgusting feelings that we're having there are solutions to them and to not accept from a doctor, oh, you're fine. There's nothing we can do. We've tried everything, just deal with it.

Dr. Jill Krapf  35:46  

Absolutely. That is 100% what I'm saying. And a lot of times when people have pain or symptoms in this area, they're given a diagnosis of something called vulvodynia, which essentially means so Odin, a was the little known Greek goddess of pain. So it Didya like an allodynia is an abnormal pain response. And vulvodynia translates to an abnormal pain response of the vulva. So by giving someone a diagnosis, we're essentially saying you have bulbar pain. And we're not going any further to delineate a cause or causes. And so it's not unexpected that the treatment would be a mystery, because basically, we're giving them saying you have a stomach issue. Yes. It's like saying, chest pain. Yeah. Are you having chest pain? Because you're having a heart attack? Or are you having chest pain? Because you eat something spicy? You know? Yeah, we really need to get to the bottom of it. And we need to think about it in a little bit of a different way.

Sarah Milken  36:38  

Okay, so when we're going to the gynecologist, the things that are should could be on the top of our minds to make sure it gets checked is the clitoral hood. Is there any sort of junk and scarring and waxy tissue fused together? tightness, I know you're going to talk about tightness of the pelvic floor. And that's like a big thing for you. So I definitely want to talk about that the irritation and dryness of the vestibule.

Dr. Jill Krapf  37:03  

Yes, so the muscles are a big part of this. If you think about it, anything that causes irritation symptoms, if you've been living with this for more than a few days, then it's not unusual that your muscles are going to start to guard and start to tighten in response. Because, you know, that's the difference between acute pain and more chronic pain. So chronic pain in the vulva is really defined as having three months or more of pain. And once someone gets into that realm where they've been dealing with this for three months, then it's really really common to have muscle involvement because your body is always on guard and your pelvic floor is on guard.

Sarah Milken  37:41  

So how does a doctor assess that, like, if you're having pain with sex, and you're using a lubricant, whatever, you're saying that some of that pain can be because those muscles in there are too tight.

Dr. Jill Krapf  37:52  

You are correct. So there's muscles that are arrayed under the skin of the vulva. And there's muscles that are extending from that area, almost like a bowl, at the bottom of our pelvis, it's holding all of the organs up our bladder in the front, our vagina and our uterus in the center, and then our rectum in the back. And then in the very back, we have our sacrum with our tailbone. And so when these muscles are tight, all muscles in our body have blood flow that runs through them, and it provides oxygen which keeps the muscles functional. It's like the the fuel that our muscles need to work. If these muscles are constantly tired, it interrupts that it basically produces something called lactic acid, which causes a burning sensation. And when that gets to the vestibule, remember that has a lot of nerve endings, it causes a burning, rawness, discomfort sensation. So it's

Sarah Milken  38:40  

interesting. I'd never thought about lactic acid, like I mean, obviously, if I haven't worked out for a long time, and then I suddenly do and then I feel like I have all this fire juice running through my legs. That's lactic acid, but I never thought about it. There.

Dr. Jill Krapf  38:53  

Yes. And you know, the other issue is, the pelvic floor muscles are not like the muscles of our arm, right? They're more nondescript. If someone told you, okay, tighten and release your pelvic floor, you would need some sort of instruction on how to do that. They would have to tell you something more than a

Sarah Milken  39:12  

cable though. Like if you told me squeeze your vagina onto something. I could do that right now as we talk. But yeah, anything outside of that? I don't think I could.

Dr. Jill Krapf  39:22  

Exactly and there's different ways to do it. And most people are doing it wrong. Is that a cable? Yes, technically, that's a cable. The problem is that people think of cables as the tightening response, but they're not doing the release. So they're tightening, tightening, tightening, tightening, and they're not taking the time to release. It's similar to exercise. If you look at elite athletes, elite athletes, they are stretching just as much maybe more than actually doing the activity like swimmers are on the massage table for much longer than they are actually swimming. And so it's the release component that we're not good at and by promoting tables, tables, tables, it's actually me Making some of these conditions worse if people are not given proper instruction.

Sarah Milken  40:03  

So if you go to your gynecologist and you're like Okay, check my clitoral hood. It's just the weirdest thing. Weirdest Sure. Yeah, under the hood. Like I'm finally picking up my car today, which is actually true after they've been holding it hostage for two months. Okay, so check my clitoral hood. Let's see. How do they know if you have tightness of the pelvic floor? How do you examine for that?

Dr. Jill Krapf  40:22  

So with any pain at the vaginal opening, we do something called a cotton swab test. And this is the standard test to determine what the associated factors are with vulvodynia or with the stipulate Dinya. So vulvodynia being pain of the vulva, the whole genital area, vestibular Dinya, being pain of the vestibule, that opening area and most of the time, if someone's having pain, pain with sex, that's superficial pain, meaning with insertion. It's the stimula Dinya. when it occurs when that area is touched, we call that provoked vestibular dedhia. All of these different terminologies and remember what the clitoris is only if someone's really having clitoral pain, right? If you're not having clitoral pain. Yeah, sure, check that area out, right, you hear a lot, you're probably fine. But looking to the vestibule, you can actually push with a Q tip on the muscle insertion points which are down at the bottom of the opening. And the person will have burning in that area with just the touch of a Q tip. And I'll say, Okay, give me your pain scale on a scale of one to 10. Eight out of 10 like jumping off the table. And so that's how you can figure it out. And then in addition, you do an internal exam and instead of going off and filling the cervix and the uterus and the ovaries, which we all all gynecologist will do every patient has had that experience, you actually feel down and you feel to the side and you feel the pelvic floor muscles, each individual one. And those should feel like the consistency of cooked lasagna noodles in normally, but in someone who has tight or hypertonic or overactive pelvic floor muscles, they feel like bungee cords.

Sarah Milken  41:55  

Interesting. Okay, so we're hoping for lasagna,

Dr. Jill Krapf  41:59  

we're hoping for lasagna, we don't want bungee cord.

Sarah Milken  42:03  

But I guess my question is if your gynecologist and you're doing a Pap smear, and you're doing an internal exam, and you feel bungee cords, are you going to say something to the patient unless they say to you, hey, sex really hurts. I mean,

Dr. Jill Krapf  42:15  

probably not. And most most gynecologist This is changing. But most of them ecologists and neurologists, this isn't just gynecologist are not well trained in evaluating the pelvic floor, I had additional training in how to evaluate the pelvic floor and a lot of instruction from pelvic floor physical therapists and a lot of experience in it. I think my opinion as a gynecologist who specializes in these conditions, the one thing that a gynecologist can do that would make a huge difference is to routinely evaluate the pelvic floor when they're doing their bimanual internal exam, or at the bare minimum, evaluate the pelvic floor and someone who's complaining of sexual pain. The thing is, though, you don't know what, what tight feels like unless you know what normal feels like. Yeah, so I was in academics prior to private practice. And so I taught I ran a resident clinic I was the attending and was overseeing things. And we would I would have the residents evaluate pelvic floors, so they could feel what it feels like because it embarr invariably, when they go out into practice, you know, yes, you get the abnormal bleeding and all this stuff that we're really well trained in, what you get a ton of pain with intercourse, low libido, like all of these things that we don't get great training and during residency, because they're not the acute things that are coming into the hospital setting.

Sarah Milken  43:31  

Yeah, like your vagina fell out, you know, I'm Yes, like, unless you're going to die. There's nothing that we can do for you. And I think that's what's so hard for women in this age group. It's like, we have all these weird sensations and things that we haven't had before, but we can't necessarily find solutions for them.

Dr. Jill Krapf  43:47  

It's so tough. And the same with pregnancy. When someone's pregnant, they get all of the attention. They're being seen on a regular basis, you know, up to weekly near the end, and then all of a sudden, you have a baby. So I have three children myself, when I had my first kid, I'm an OB GYN I was trained in this I deliver 1000s of babies. I was postpartum having night sweats because that's what happens after you have a kid and your estrogen levels plummet. And I'm like, what is happening to me? Or something? Am I like what's wrong? I had to like Google it.

Sarah Milken  44:16  

I know. I remember like breastfeeding and I would like sweat and then I'd stop sweating. And I'm like, Oh, my God, am I gonna die here?

Dr. Jill Krapf  44:23  

No one tells you all these things and even as an OBGYN resident, you know, young attending at the time. I didn't even know the ins and outs of it. I became such a better doctor after I had kids. Let me tell you,

Sarah Milken  44:35  

it's amazing. Okay, so basically, if we go to the gynecologist, we can't just accept vulvodynia. Now, I think there are answers.

Dr. Jill Krapf  44:47  

Yes. So the the approach is to ask, okay, what do you think is causing my pain? You know, could it be related to hormones if you're perimenopausal or menopausal, then you can talk about that low dose vaginal estrogen, whether that be a tablet that you do twice a week, you can ask for the cream and, and put that inside twice a week. But also take a pea sized amount and put it at the opening. Or you can ask for something like if that doesn't work, you can ask for something like progesterone or intra Rosa, which is that DHEA. All of those are well accepted.

Sarah Milken  45:19  

You could How long do you have to give something to see if it's working,

Dr. Jill Krapf  45:23  

you should know if vaginal estrogen is working in a couple of weeks, you may not be 100%. You know, it takes a little time a few weeks, but you should know if it's working or not. Most people are better in about four to six weeks from that standpoint. So that's the hormonal piece of this. And then the other piece of this is from a pelvic floor muscle standpoint, if you notice burning if you're having bladder symptoms like urinary frequency and complete emptying, if you're having bowel symptoms like constipation, and you're drinking a ton of water, it's just not going away. If your jaw clench your teeth grinder, you have lower back pain or hip pain. Are

Sarah Milken  45:57  

you writing my mind?

Dr. Jill Krapf  46:00  

Any of those asked for a referral for a pelvic floor physical therapist, get a referral most OBGYN would be happy to give you a refund. I

Sarah Milken  46:09  

tell you, I've spoken to a couple here just for my podcasts. I haven't interviewed one yet. They're all booked. 100% booked, you would think it was like somebody was getting their eyelashes done.

Dr. Jill Krapf  46:20  

It's just as important. I mean, it's

Sarah Milken  46:23  

amazing. So tell me, I mean, I know. And I actually know there's a company here in LA that's like franchising these pelvic floor therapy centers. Because it's such a popular thing. I think

Dr. Jill Krapf  46:34  

it's actually gotten worse since the pandemic. So we used to kind of morbidly joke that the COVID was a pandemic of the pelvic floor, because I had so many patients coming in with hypertonic, overactive pelvic floor for a number of reasons, right? People are working from home, they're not taking natural breaks, they're sitting all day, they're in chairs that are not great. But for many reasons. And so yes, physical therapists have their jobs cut out for them, because there are tons of people that need that care. So

Sarah Milken  47:04  

what is a physical therapy of your vagina looked like like tic tic. I mean, I've had physical therapy on my shoulder, my knee, but what's going on down there,

Dr. Jill Krapf  47:12  

it's very different than physical therapy on your shoulder or your knee. And the biggest thing is, don't go to a shoulder person, if you need physical therapy for your vagina, please. Now there's people that have special training, they actually have doctorates, and they have additional training and pelvic floor physical therapy. And it's a combination of a couple of different things. There's the education piece of, okay, where's my pelvic floor, right? Because when you go to physical therapy on your shoulder, usually something happened to your shoulder, you know that that happened, you might have an x ray that shows or an MRI or whatever that shows what happened. And you don't know what your shoulder is right, you can see your shoulder, you can move your shoulder and you know what doesn't move the physical therapy or with the pelvic floor, it's a little bit less clear, you need to be taught the proper technique to engage your pelvic floor. And you also need to be taught how your pelvic floor connects with the rest of your body. So for example, your pelvic floor is the bottom of a cylinder. It's like a soda can it's the bottom of the soda can, what's the top your diaphragm, what controls your breathing? And so a lot of times, people will do breathing exercises like diaphragmatic breathing, and pelvic floor physical therapy. And if you don't know why you're doing it, you're like, okay, my vagina hurts. Why am I breathing? Like, why are you? Yeah, but there's actually a lot of science behind it. So if the pelvic floor is the bottom of the soda, can the diaphragms the top your abdominal muscles are the front, we know there's a lot of issues with that anyone who's been pregnant knows that there can be weakness there. And then there's the muscles or the back or the back. And so by expanding your diaphragm, you're expanding that pelvic floor, which is bringing blood flow into the muscles, which is washing out that lactic acid. And then through mind body connection, you're keeping those muscles released and relaxed, even when you're not consciously thinking about it, which is the key.

Sarah Milken  48:56  

So are they sticking their hands inside of you at all? Like is there any of that component.

Dr. Jill Krapf  49:00  

So that's the other component of pelvic floor physical therapy, it's called Myo fascial. Release. So essentially, you can access the pelvic floor through the vagina in females, men who have pelvic floor issues too, in order to x access the pelvic floor for them, guess where we need to go? So I think we have the better deal. Yeah. But basically, the idea here, if those pelvic floor muscles are like bungee cords, you can release them manually, and that basically releases them. And it also teaches the patient through biofeedback, where the muscles are tight, and then they can tighten and release them on their own as well. And this is where one s one therapy and dilator therapy come into play as well. So you can use a dilator or want to basically do myofascial release on yourself and those would be home exercises.

Sarah Milken  49:53  

Interesting. That's a lot of homework now. Oh my gosh, okay, well, that's all A lot to think about. I want to talk about something that I affectionately call crotch swamp on my Instagram.

Dr. Jill Krapf  50:09  

Especially now it's July,

Sarah Milken  50:11  

and you're in Washington DC sweating your vajayjay off.

Dr. Jill Krapf  50:15  

Absolutely. Record numbers of patients coming in with these complaints right now.

Sarah Milken  50:21  

Okay, what is going on? Do our vaginas sweat? Do they not sweat? Is the vulva sweat? Is it just a swamp? What's happening down there?

Dr. Jill Krapf  50:30  

So there are sweat glands on on the vulva on the outside. And it's kind of a poorly designed place. It doesn't get much air, it's kind of tucked in there. There's, there's hair, there's just a lot of things on wrinkles. So much stuff. So the important thing is to let your vulva air out when you're able to, okay, and really using breathable fabrics, loose fitting fabrics in that area changing after going to the pool with all the chlorine with COVID. Right, changing limiting irritants and allergens to that area. These are going to be the keys to kind of keeping everything healthy.

Sarah Milken  51:10  

Okay, so like I find that if I work out and I leave my you know, Mom leggings on the whole day, I don't change my underwear. I don't do what I call on Instagram, the core area rinse where I just sort of like shower from the belly button down and maybe a little armpit, then I feel like I'm in yeast infection land. Am I imagining that?

Dr. Jill Krapf  51:30  

No, you're not. The deal with yeast is that yeast lives in an odd us naturally, we all have a certain level of yeast that is around what causes symptoms is when there's a yeast overgrowth. So if there's too much yeast, then it causes the symptoms because it's irritating those nerve endings. It's causing the discharge, it's embedding into the tissue, it's causing the itching and so forth. So we're never going to get rid of yeast. Now, some people have never had a yeast infection in their lives. And then there's people that literally look at like a piece of bread and they get a yeast infection. What's the answer to that? Well, we're starting to uncover this with some research. There's actually genes that have been discovered that are turned on and people who get recurrent yeast infections where they do not recognize the yeast and they don't suppress it naturally. So it gets out of hand. And so not only do you have to identify the yeast, and when I say identify the yeast, not every yeast infection is a vaginal yeast infection. So typically, we think of yeast in the vagina as being like that cottage cheese discharge, the itching, burning and so forth. When it gets down to the vestibule like we were talking. There can also be yeast around the anal area causing evil. And there can also be yeast embedded in the vulvar tissue, like between the labia in those skin folds and around the clitoris, that doesn't quite get off into the vagina. And that's more like a baby diaper rash. Right? It's like, and that's the sweaty, kind of, you know, moist environment that leads to some of the yeast but it does. People will say, Well, I feel like I have a yeast infection, but I don't have any discharge. And then you go to your gynecologist, what do they do? They take a swab. Where do they take it from? inside the vagina? It comes back negative because there's not yeast overgrowth in the vagina. The yeast is embedded on the skin like a baby diaper rash. Like I know the folds in all the folds around the anus and it goes untreated.

Sarah Milken  53:24  

I haven't had the tissue on yet. I've had everything else though. Yeah, that sounds really pretty.

Dr. Jill Krapf  53:30  

My patients get a lot of that it's pretty easily treated and most people so we will do a topical anti use preparation. If there's a lot of scratching and inflammation, I'll add a very mild steroid to the topical just to kind of bring down the the is that like a nice statin? Yeah, something like a nice statin or Clotrimazole depending on how it looks. You can tell if you see enough of this.

Sarah Milken  53:50  

You can go you like Oh, I know that because I've had a vagina on fire many times. Well, yeah, absolutely. Yeah, I have a nice day out. And in my Metis, my travel medicine bag for the burning vagina. It's very important,

Dr. Jill Krapf  54:01  

very important. And then the idea here is if someone's prone to recurrent infections, the idea here is to really try to suppress the the overgrowth, right, so you can do that through diet, there certain foods that can be triggers, and people know kind of a little bit what their triggers might be, whether it's alcohol or simple sugars and so forth. And then the other thing is, is really, you know, you can re infect yourself through reuse of towels in that

Sarah Milken  54:29  

I'm obsessed with using new towels.

Dr. Jill Krapf  54:32  

What I tell my patients that have recurrent infections is take a dry washcloth, use that for the vaginal and anal evolve or an anal area, throw it in the wash, you can reuse that full towel for whatever else you want. But in that area, you want to use that little wash cloth dry and then put it in the

Sarah Milken  54:50  

wash. It's so true. Like my kids are on these summer programs and they both take Accutane and I said to them, I'm like you guys are not using fresh washcloths like you do at home. So I went on an was on and got them these sorts of disposable face washcloths. I'm like, do not put that body towel on your face, because we have spent the entire year managing Accutane. Okay, we're not doing bacteria swamps on the face, okay?

Dr. Jill Krapf  55:15  

This is very important to learn.

Sarah Milken  55:19  

I've probably traumatized them, but that's okay. So if you're working out, like, Should we be showering after?

Dr. Jill Krapf  55:26  

Like, ideally, yes. And the other thing to remember is not everyone has the same thresholds when it comes to this, right? If you're one of those people that are prone to infections, then you're going to need to shower after you workout. It's just what you're going to need to do, right? Some people they're not as sensitive to these things, and you find your routine and you find what works

Sarah Milken  55:43  

for ya or the underwear, like changing your underwear and all of that.

Dr. Jill Krapf  55:47  

It's always a good idea and really wearing moisture wicking fabric breathable fabrics. Yeah, that's

Sarah Milken  55:53  

my next question. I mean, obviously, the ideal fabric in my mind is cotton. But most cotton underwear is not like the most attractive and I'm not a lingerie model, but just even looking at myself. I'm like a so what is ideal other than just cotton? I don't

Dr. Jill Krapf  56:08  

have good answers for you. We need to create a company. Nice. Like yeah, you know, cotton and bamboo are breathable fabric. You know, you really want to avoid things like lace and synthetics. The color does not matter. Like in the past, we would say white cotton underwear. There's no reason that yeah, that just doesn't make sense at all. But the cotton is is important or at least a breathable fabric. And

Sarah Milken  56:31  

what about I know urinary like wipes are kind of a hot topic.

Dr. Jill Krapf  56:36  

Yes. So you want to check the ingredient list. Many of these wipes have fragrance in them. They may have alcohol because they're absorbent. Those things you want to stay away from the vulva and your wreath with Okay, now I usually say it's probably best to use a parry bottle if you need water like a squirt bottle and then blot with a non fragranced non dyed

Sarah Milken  56:57  

toilet paper at that point you need to shower.

Dr. Jill Krapf  57:00  

It depends I mean if you're if some people are really irritated just by urine alone, so to shower after every time you pee, it would be a little bit Oh, I

Sarah Milken  57:07  

see every time you pee. But I will tell you sometimes after sex, I don't want to pee because of burns. Is it burning because of micro tears? Why is that burning?

Dr. Jill Krapf  57:15  

There's many different reasons why it can burn, it can burn because of hormonal reasons, because those gland openings are right next to where the urine is coming out. You're in as acidic not Yeah, so if it's touching those irritated glands, it often burns and that can be an indicator and that would be most likely for for that situation. But also, if there are micro tears or fissures or anything like that, it can certainly cause burning, and then burning can be without even the urine touching it. If you have just burning it could be related to the pelvic floor, because all of that action irritated those muscles and release that lactic acid. So a lot of times when people have hypertonic, or tight pelvic floor muscles, they'll often notice that they'll have burning for a few hours after intercourse or after orgasm because of the spasm of the muscles releases that

Sarah Milken  57:57  

oh my god, it's like so much work to be a woman. Right and so much work to be a midlife woman and there's no like magic answer like you think, Okay, fuck it, I'm gonna do HRT, I'm just gonna bring on the big guns, and then it doesn't even solve everything.

Dr. Jill Krapf  58:12  

I think the most important thing is to get a diagnosis. That's, that's your number one, right? You need to know what you're treating before you throw everything at something, right? Because everything has side effects, everything costs money, everything has some sort of downside to it. And so as clinicians, we need to be masters of diagnosis, we owe it to our patients, we need to get to know them. We need to figure out what is going on. We need to explain to them what's going on. So we don't just give them something and not tell them why they're using it or how to use it or how often to use it. This is our responsibility.

Sarah Milken  58:46  

I know but then you're you're like more than just a doctor. You're like a vagina coach.

Dr. Jill Krapf  58:50  

Sometimes I feel that way. Sometimes I feel that way. I joke sometimes that I am there in a chi utrust

Sarah Milken  58:58  

Oh, see, oh my god. I know sometimes I text my gynecologist and I'm like, my vagina is on fire. She's like, okay, When can you come in? And like the reality is is like sometimes I don't want to come in. It's such an ordeal.

Dr. Jill Krapf  59:12  

I know. It's so tough. But a lot of times it's really hard for us to figure out what's going on, especially when someone says that they're burning because everything literally is burning. Everything is

Sarah Milken  59:20  

burning. Okay, let's talk about vagina deodorant. Ah, yes. Okay. Like my brother will openly admit this. He's a very successful businessman. He will be laughing that I'm talking about this, but he uses something called Fresh balls. Okay. And he's like, You don't understand they're, I spray this stuff on my balls. I stay dry. The whole day I play golf. I go to work. It's like heavenly. Like you have to find the female version of fresh balls. And I know some women use sort of like a female deodorant and I'm like, That can't be healthy for you. But I'm asking you is there like a female version of fresh balls like a deodorant? Like it's not even just smell. It's just nobody wants to be wet down there. But then at the same time, we're supposed to maintain moisture down there. It's like a conundrum. Like you're like moisturize your vagina like your face. Well, I don't want to wet vagina moisturize when it's 95 degrees with 100% humidity,

Dr. Jill Krapf  1:00:18  

I totally get you. There's a number of products that are available. There's actually, no I'm not gonna say its controversy. But you know, gynecologist will tell you different things. The way that I feel is always check the ingredient list, know what your sensitivities are, everyone has a different threshold for products. It's easy for me as a gynecologist to say, oh, less is more, you know, your natural, you know, with your natural smell, I get that. But some people feel really uncomfortable with that. And I totally understand it. So I want people to do what works for them, but also limit issues that are going to cause an irritant, or a contact reaction that can kind of lead to other things. So I'm pretty careful with that. I don't recommend using a product like that. But if you feel that you need to, and it works for you, and you're not having any problems with it. Who am I to say that you shouldn't be using it?

Sarah Milken  1:01:07  

I know, I was just like, like, the other day I went to a wedding that was like 1000 degrees. And I thought to myself, God would be so nice if I didn't have like a sweaty vagina for 5000 hours, you know. So I was like trying to get this talc free powder to put in between my inner thighs, but not get it near my vagina. You know, this whole thing. I'm sure people are like, Oh my God, what's wrong with her? But so many women feel this way. Nobody wants to feel that.

Dr. Jill Krapf  1:01:31  

Absolutely. And I think the difference is, you know, with with the vulva and the vagina, the skin is more sensitive, because there's an inside component of it. And that's why I think we have to be a little bit more careful. And you brought up a non talc powder, which is important because we never want to use a talc powder in that area. It's been associated with different forms of cams. Yeah,

Sarah Milken  1:01:49  

no, I know. So I've been like trying to investigate that. And I know some women in this age category like to wear panty liners for like 1000 reasons. What if I spot I'll tell you my anniversary weekend. The first time I've worn white jeans and five years, we go out to dinner. I don't even get my period because I take birth control pills seven days a week, right through the jeans. I never even had that as a teenager like I almost died and I didn't post on Instagram even though I post everything else, because my husband would have been like, okay, you've totally lost your mind. A colonoscopy is one thing, but like your bloody white jeans. That's like a whole other ballgame. But like I understand, like women don't want to spot they don't want to have like leaky pee in their underwear. They don't want to feel moisture. But does the panty liner change your vaginal microbiome?

Dr. Jill Krapf  1:02:36  

No, it doesn't change your vaginal microbiome. The reason that we're cautious with panty liners is because they do wick moisture. And you have to be careful again, with your ingredients, right? We want to make sure that it's the components of that do not have fragrance or do not have irritants and chemicals that can really kind of make things worse in that area. Sometimes, I will see somebody who has redness and irritation and burning and it's literally in the shape of a panty liner. And so you know that that's not agreeing with them. So if at all possible, we recommend cotton using a cotton product like a cotton panty line. Is

Sarah Milken  1:03:14  

there a particular brand I don't know I haven't started the panty liner business yet.

Dr. Jill Krapf  1:03:18  

Now the best thing is not to wear a panty liner. But I understand there's definitely people with leakage and with different things and they're like, Listen, I need to do something like I can't be changing my pants all the time. Yeah, yeah. So you again, you have to do with what works for you in the safest way. There's not a brand that I endorse, but just look for organic cotton panty liners, you will find what works for you

Sarah Milken  1:03:38  

who Okay, let's talk about the vaginal microbiome. I know everyone talks about the stomach, that guy, what's going on? Like, what do we do to maintain the pH and all of that stuff down there? Is there like a midlife checklist?

Dr. Jill Krapf  1:03:51  

This is such a good question. Because the vaginal microbiome is like the final frontier. It's like the area that we do not know about and the research that's coming up out we're really learning more and more and more about this area, which is excellent. There was a big series that was put out by I SSV D, which is one of these societies on vulva vaginal disorders. And it was a special it was like a four or five part special all about

Sarah Milken  1:04:15  

the Vashon. I'm sure your husband really enjoyed that.

Dr. Jill Krapf  1:04:18  

Oh, it was like a manuscript. It was like, Oh, wow, right after Top Gun. We're

Sarah Milken  1:04:23  

gonna watch this. Let's watch

Dr. Jill Krapf  1:04:24  

the five point. Yes. I was on the TV. That would be great. No, so we're really learning much more about this. And I think the issue in the past is a lot of times people would look to probiotics to increase the good bacteria called lacto bacilli. But a lot of that a lot of the probiotics that were developed for vaginal health were utilizing probiotics that we knew worked for the gut. And what we're finding is that the vagina is not the right. I mean, this seems obvious for years, I guess it wasn't. And so as we learn more about the vagina and about the composition and the different bacteria good and and neutral and possibly bad and the overgrowth and things like that. We're developing things that are more helpful. We're just not quite there yet.

Sarah Milken  1:05:07  

So there aren't any sort of basic things that you would do for that at this point.

Dr. Jill Krapf  1:05:13  

There are the research is not there yet, I can tell you, you know, from experience, and from the research that is available, there are things that I tried to do with people that have recurrent infections. So first of all, we know that with the bathroom of microbiome, there's different community states, we can fit them, like different neighborhoods. We have type one is predominated by lactobacillus crispatus, which is a type of good bacteria, like the guard cells of the vagina, and this is associated with healthy vagina. So these vaginas, they're, you know, they don't really get many bacterial vaginosis infections, or yeast infections or anything like that. It's, it's like the where you want to be right, it's the hotspot, right? And then there's another neighborhood or community state, that's also pretty good Lactobacillus gasseri. And we don't know quite as much about it, but it seems to be a good place. And then the third one is like the bacillus enters, and this is the transitional one. It's like, sometimes it's good. And then it gets pretty shady at night, right? Like,

Sarah Milken  1:06:12  

that's like stevia is okay, sometimes, but not all the time. Yeah.

Dr. Jill Krapf  1:06:16  

So this one can be okay. But then it can like flip into bacterial vaginosis zone pretty fast. Oh my God. And so there are probiotics and vaginal probiotics that utilize lactobacillus crispatus and Lactobacillus gasseri. And so the idea here is if we introduced some of the that good good bacteria, maybe it will colonize and it will prevent overgrowth of some of the bad

Sarah Milken  1:06:37  

bacteria, as the research shown that it does, in fact, do that we're not

Dr. Jill Krapf  1:06:40  

there yet. We're really not there yet. Any studies that have really been done are really at the pilot level, we're lacking funding for this type of research. Like I said, it's the next frontier. So

Sarah Milken  1:06:49  

do you take anything for your vagina microbiome?

Dr. Jill Krapf  1:06:52  

I don't? Yeah, I don't know. I think that if you have issues, you have issues, if you don't, then less is more, because it's true. Some people can go to the other side. I've had people I've had patients that are taking too many probiotics. Yeah, and they make their vagina too acidic. We want our vagina to be a bit acidic, right? They make it too acidic. And then they get a crazy discharge called, we call it syphilitic vaginosis. It's a diagnosis that's contested. But I have seen it a handful of times with people who are taking like mega doses a probiotic. But you can actually do more harm than good if you kind of go to the other side.

Sarah Milken  1:07:25  

So are there like at home pH strips to check your vagina acidity?

Dr. Jill Krapf  1:07:29  

There are but I don't encourage people to do that. You know, if you're doing all of this, it's like a full time job.

Sarah Milken  1:07:36  

No, trust me. I have so many other full time jobs. I mean, like I could not add to this. Yeah, you

Dr. Jill Krapf  1:07:41  

can't be the vagina monitor. Oh,

Sarah Milken  1:07:43  

my God, my kid. My teenagers and my husband are like, Why did you become the midlife vagina person? I'm like, I don't know, because I'm a midlife woman trying to find out answers to all of this. It's hard.

Dr. Jill Krapf  1:07:52  

It's one of those things where if you're part of the club, if you have it, and you're having these symptoms, yes. Like, you may do things like that. And if it's not causing you anxiety, and it's benefiting you, and you're getting better, and you have a team that you're working with, and you're figuring it out, yeah, fine. But it doesn't have to be an extra thing if you're not having symptoms.

Sarah Milken  1:08:09  

Now, let's talk about stress and vulvar conditions. Yeah, stress and anxiety. I mean, like, look, stress and anxiety. Everyone's like, take the stress and anxiety out of your life, and you're going to solve your gut, and you're going to solve your mental health, I mean, really,

Dr. Jill Krapf  1:08:24  

which causes more stress and anxiety, right? You're not solving any? Exactly. So here's the deal. stress affects our bodies, of course, and we don't 100% Understand how everything works, we know that it's connected, but we haven't figured out the key to it. And it's probably because there's not a key to it, right? We know that cortisol increases inflammation, and that affects our gut health. It affects our vaginal health and affects many different things. There's a connection between anxiety and stress and pelvic floor tightness, which makes sense because think about it when you're stressed out. What do you do? Shoulders, go up your necks cranked clench your jaw, you start getting migraines.

Sarah Milken  1:09:01  

Yeah. And if that penis is coming at you, you're gonna start clenching your vagina, because you're like, Oh, my God, it's gonna hurt, it's gonna burn, it's gonna hurt.

Dr. Jill Krapf  1:09:07  

Yes, there's that anticipatory response that clenches up. And there's a pretty strong connection between what we call pain related anxiety, which is different than generalized anxiety, right? This is you have a certain condition or you have pain, and some something threatens that, and then you respond actually appropriately, which is to guard or to tighten. But the problem is that after time and time again, you kind of become adapted to that response, and it becomes a vicious cycle. And when that happens, then you stay in that heightened heightened state. And that's what causes

Sarah Milken  1:09:38  

the symptoms and is that what you talk about is the pain loop? Yes, exactly. Okay. Now, what about doctors who are like who patient comes in and they're complaining about a million different things and they're like, take an SSRI that's going to make you happier and solve all of your problems. Like what are your thoughts on that?

Dr. Jill Krapf  1:09:55  

So it's obviously not going to fix everything you really need to figure out if there's a hormone issue, if there is a muscle issue, if there's a skin condition, then obviously it's not going to address that it's really important to address all of the considerations. However, the brain does play a role in all of this. Of course it does, it always does. And so you know, to kind of calm the brain down a little bit and to deal with some of that pain related anxiety is really just a part of the treatment plan. It depends on the patient. And sometimes I will recommend an SSRI, in addition to obviously, treating all of the components of pain, I consider it a component just like a hormonal component, a muscular component, and then there's a pain related anxiety component.

Sarah Milken  1:10:41  

But what's interesting about the SSRI and like birth control pills, like I want the birth control pills, not because I think I'm getting pregnant necessarily, but because I want the estrogen. But then the birth control pills kind of kills your libido, then you take an SSRI that kills your libido. So it's sort of like finding that like perfect recipe of all these different ingredients to make your, I don't know, your sexual, vaginal health perfect or seemingly perfect.

Dr. Jill Krapf 1:11:09  

The thing is that there's nothing that has all benefit and downside, and it's true. The problem with birth control pills are that they're metabolized or broken down by the liver. And so they increase something called sex hormone binding globulin, which is s hBg. This floats around in our bloodstream and essentially attaches to testosterone and makes it inactive, so it doesn't work. So when that testosterone that's bound flows down to those gland openings it's producing are like lubrication, it doesn't work at those land openings, and those glands don't have the testosterone they need to function properly. And that's why we not only see these type of symptoms with the dryness and the pain, with with intercourse, due to the glands we not we did not only sent in menopause, and perimenopause, we also can see that in the postpartum time period, when someone's breastfeeding, we can see it in younger women who are taking birth control pills. And obviously, not everyone has that side effect. But we think that some people are born with weak testosterone receptors at the gland opening. So if you decrease the testosterone to a critical value, and you have weak testosterone receptors that don't bind it very well, then you start getting the symptoms. So a lot of this is how the body works kind of an interplay. And so that would be you know, when when you get to that midlife, that menopausal time period, if the birth control pill is no longer serving you, it may be a good idea to talk to your doctor about a patch, like hormone therapy, because it actually does not increase x woman binding globulin.

Sarah Milken  1:12:32  

I know it's been in the conversation for a while I'm just, you know, it's like when something's like working for a minute, you're like, Okay, why am I going to change the recipe right now? Like I had a month long bleed, like, last December. It was like the worst month of my life, not the worst, but close to it. And I was like, Okay, now I'm back on track, like, I don't want to change anything, am I going to gain 1000 pounds? If I go off of birth control pills, and move to a ring or a patch? I don't want to put a ring in? Is that gonna feel weird?

Dr. Jill Krapf  1:13:00  

You know what I mean? I'm like, Ah, it's a tough balance. And you know, to speak to that younger women who go on hormone therapy at appropriate age menopause, they're more likely to get some abnormal bleeding with that, that can be a bothersome side effect of hormone therapy. So really, you know, there's nothing perfect. Some of it is, a lot of it's education, but some of it's trial and error between you and your doctor. Because what works for you may not work for me.

Sarah Milken  1:13:26  

Like I've been on birth control pills for I'm embarrassed to even say for how long decades? And people are like, isn't that bad for you? I'm like, Yeah, but when I'm not on birth control pills, I'm a lunatic.

Dr. Jill Krapf  1:13:39  

Fair enough. And you have to know how it interacts with you. Right? There's a certain percentage of people that have side effects with different medications. Same with birth control pills, there's a certain percentage of people that will have you know, mood changes that they just can't deal with. Or they'll have the vaginal dryness that they can't deal with their pain with sex, just like any other side effects like nausea. You know, some people have it, some people don't, if you have it, the key is that you need to know that is one of the side effects. So you're not just suffering for years and years and years, thinking that this is normal or thinking that there's something wrong with you and it's actually maybe just not the best medication for Yeah, I

Sarah Milken  1:14:12  

also think that like from what I've heard that birth control pills are like six times more estrogen maybe than HRT, yeah, so I'm like, wait a second, how am I gonna go down so much and not be a mental case? And no one's been able to like justify that to me

Dr. Jill Krapf  1:14:29  

gets tricky because they're measured in different ways. And the delivery system is different. So it's kind of comparing apples to oranges a bit. But yes, these are all considerations as you transition from, you know, a Peri menopausal or pre menopausal to to menopause and then beyond.

Sarah Milken  1:14:44  

Oh, my God, okay. Well, I'm gonna have to come see you. When we do the Washington DC part of the college trip. We've already done everything else essentially. Okay, now, this is like the $10 million question. Well, maybe not 10. But women are coming to you They're like, okay, sex hurts this the all these different things, and my libido is down. What about just that the research showing that every five to seven years, we're craving novelty. And we've been married to the same person for 14,000 years. You know what I mean? Like, how are you dealing with that in your practice?

Dr. Jill Krapf  1:15:20  

Well, the first thing is if someone is having pain, with intercourse, it's really hard to touch the libido issue, because if something hurts every time you do it, you're not going to want to do it. I mean, that's just how that's a fair statement. That's fair, right? And so I do have patients that come in, and they're like, Yeah, you know, sex hurts, and I have no desire, and I feel so guilty. And I don't know why my spouse is still with me, because I feel so bad. And it's like, whoa, like, we need to figure out what's going on with the pain first. And then once we get you functional, let's see how you're feeling. If your libido is still low at that point, then there's definitely things that we can do. But it doesn't make sense for me to give you a pill or an injection to make you super horny, if you're going to be having pain, really bad.

Sarah Milken  1:16:05  

And I don't think a pain or like a pill or injection is going to solve the fact that you've been married to the same guy for 40 years, or the same woman or whatever.

Dr. Jill Krapf  1:16:14  

Exactly. There's so many things at play with these dynamic. And so that's why it's so important to really address the whole person really get to know them, figure out what's going on, you know, we have sex therapists or not.

Sarah Milken  1:16:27  

That was my next question. At what point are you like, Okay, we're good. No, no, it's a sex therapist time.

Dr. Jill Krapf  1:16:32  

Absolutely. So I you know, just like, just like any other doctor, I can deal with, like first step approaches, but when it gets into like, true sex therapy, I'm not a sex therapist, right?

Sarah Milken  1:16:42  

Like, I have my own sex issues at home.

Dr. Jill Krapf  1:16:45  

I mean, yeah, I'm so I'm a Beauvoir specialist, I can deal with the pain and the skin conditions on get you better, I'll do some first step approaches, right. But if it's good, you know, if we get you better, and you're still having low libido, and I also, you know, do hormones, right, so I can do that part. But if I get everything fine there, and you're still having issues in your relationship, or with yourself, more importantly, than absolutely we need, we need a sex therapist. And, and it shouldn't be an afterthought, it actually, ideally, all of this should happen at the same time. So I should be working with the physical part with the hormone part with the muscle part. And someone should be seeing a sex therapist or a regular therapist, some sort of mental health provider at the same time, because there is a big mental component as well as a physical component as well as a social component.

Sarah Milken  1:17:32  

I know it was really funny. My friend was talking to me the other day, and she's like, Yeah, I'm just like, not in the mood, I gotta go see a hormone Doctor, I have to get it all together. And she goes, I don't even think I could have sex with Tom Cruise right now. And she goes, that's the point where I know that there's like, really something wrong. And I almost died when she said,

Dr. Jill Krapf  1:17:53  

there's so much to unpack there. Oh, my goodness, I don't even know where to start. But the other thing about it is that we also have to give ourself a bit of grace, because there's different types of desire. There's responsive desire, and their spontaneous desire. And just knowing this is really important, because it's how our minds and our bodies work. And it's the difference a lot of times between different people as well as possibly different, you know, different genders as well. And so spontaneous desire is you're thinking about sex all the time, like, you're just, you know, not maybe not all the time, but you're thinking about it a lot, right? It just kind of comes spontaneously, or your partner walks by and you think about it, right? They look good. Oh, I want to have sex, right? Most women do not fall in that. I couldn't agree more. Most women are not thinking about sex at all. Like they're literally thinking about everything else.

Sarah Milken  1:18:44  

I'm like, or like, my husband's going to pick up my car right now that's been at the dealership for two months. And like, oh, maybe there's like a repayment in that scenario. Different than spontaneous around. So

Dr. Jill Krapf  1:18:56  

you're thinking about literally every every everything else, but that but if your partner kind of comes on to you, maybe you're like, oh, okay, maybe I could do this. And then it kind of starts and you get started. And all of a sudden, you're having fun, and you're enjoying it and everything's good. And then you're glad you did it, you know. And so that's receptive desire, and that is much more common among females than spontaneous desire. It's like, it's kind of like going to the gym. I mean, there's some people that love to go to the gym, they're thinking about the gym all the time. They go to the gym every day. It's like you, they have to they love it, they get a lot of benefit out of it, right. So there's people that are like, they don't really like to go to the gym, but like, Yeah, me

Sarah Milken  1:19:35  

too. It's like, yeah, everyone's like a runner's high. I'm like, There's no fucking high.

Dr. Jill Krapf  1:19:38  

I don't have a runner's high. How much running do you have to do to get a runner's high? Because

Sarah Milken  1:19:45  

there's no runner's high over here.

Dr. Jill Krapf  1:19:47  

Oh my goodness, but you can imagine and it also has to do with orgasm and things like that. Like if you get a runner's high every time you run you're probably gonna run a lot more. I've never had one then you

Sarah Milken  1:19:59  

know where do Do you add in vibratory medicine?

Dr. Jill Krapf  1:20:02  

Yes. So that comes with arousal. So basically, vibration is stimulating the tissue and it's increasing blood flow to the tissue. And so there can be not only therapeutic benefit from doing that, there's actually, you know, when we're talking about tight pelvic floor and things like that there's ones and dilators that have vibratory function that bring in blood flow. And that's the idea there. But yeah, there's a lot of different devices that have been explored that can really help with arousal with orgasm. And then from there also a therapeutic benefit for other types like a muscle dysfunction.

Sarah Milken  1:20:35  

No, do you think there's a difference between like, external vibration and internal vibration? And should we be doing both? Like, what's, what is the doctor order?

Dr. Jill Krapf  1:20:44  

Ah, well, you know, it's individualized, right? It's kind of everybody likes something different. And maybe vibration helps. And that's what you love. Or maybe you do it. And it's like, too intense. The biggest thing is to really give yourself the permission to explore these things that are available, right? Ideally, it should be fun and exciting and not like an obligation, right? And so keeping lines of communication open, being kind to yourself trying different things, you know, if internal or external, it's all like what you like,

Sarah Milken  1:21:15  

Yeah, I like that idea of that kind of midlife permission. Yeah. Because even you know, you've been married for a long time, you're like, oh, let's try this, the person could take it the wrong way. You know, there's a lot involved in all of these things, you don't suddenly just become like the 50 shades of grey house.

Dr. Jill Krapf  1:21:32  

Absolutely. And, you know, some of this is hard to navigate, because you're right, it's all about the dynamic with your partner. But I think that, you know, it starts with you touching or cuddling or incorporating that into your routine, you know, if you touch you know, their shoulder as you walk by, if you're, you know, these things kind of lead to more desire lead to more activity, it's really not the end goal, you know, it should always be the feeling that you get in the pleasure, or it doesn't have to be orgasm, necessarily. It doesn't the end script is not penis and vagina, right, like we're taught. And so there's a lot of other ways that we can I experience pleasure, and it needs to be more pleasure and connection focus instead of activity focused.

Sarah Milken  1:22:13  

No, I couldn't agree more. I love that. And I think that that's something that we're all kind of grappling with in this sort of time of life. Anyway, it's like reconnecting with ourselves, reconnecting with our spouses, you know, our kids going off to college, it's so many different kind of reconnections, that we're trying to figure out where we're at. And then sometimes we feel shame, or we feel guilty or like, I don't know, I hope that this podcast like and I think it has, because I get so many messages is really just reassuring women that this is all within the range of normal.

Dr. Jill Krapf  1:22:48  

Yes, I think everyone can relate to everything that we're talking about. It is a time of reconnection. Because, you know, for most people, the previous years or decades, were really they had different focuses, right? We go through different stages in our lives, and the worth, different things are important in our career, family, whatever is important to you in your life. And so it is a time of transition where things change. And sometimes you find that if you were focusing, for example, on children and raising them and getting them through school, all of a sudden, you have to reconnect with your spouse in a different way, because the mutual focus isn't on the kids anymore, right? And so that can be a really tough time for people to kind of find themselves again and then find their partner again. And you really are finding yourself again, because you put so much emphasis into other things and then all of a sudden you are like oh my goodness, I have to do something for myself,

Sarah Milken  1:23:38  

and you're refunding your vagina Well, and

Dr. Jill Krapf  1:23:41  

that's where it starts.

Sarah Milken  1:23:44  

It might start itching, it might start burning, it might start stretching. I mean, there's so many things. Okay, now let's just talk about vulvar maintenance. The thought of lotioning my vagina makes me want to die because I can't even like put lotion on my body in the summer. So tell me what we're supposed to be doing to maintain our vaginas.

Dr. Jill Krapf  1:24:01  

Our vulva is our Volvo. So it's similar to your face, right? Some people need more, and some people need less, right? Everyone's a little bit different. You know, in midlife, some people develop acne, right? Some people have, you know, more sun damage.

Sarah Milken  1:24:16  

I have melasma Yes, which I think is a lot from my birth control pills. I have to be honest, it

Dr. Jill Krapf  1:24:21  

probably is actually, everyone's dealing with different things right. And so you basically just need to do whatever is going to keep things healthy. You know, if you're someone that is not having a lot of dryness or the skin is already supple and healthy, then you don't necessarily need to use a vulvar moisturizer. However, if you're noticing that the skin is not supple, if it's, if it feels itchy or dry or thin, you know, you may want to incorporate a bullhorn moisturizer and you're going to be more likely to do that because it's going to feel good and so you're gonna keep doing it. Whereas if you don't need it, you're gonna be like, why am I doing why? Or maybe

Sarah Milken  1:24:55  

if you use it at night, so at least when you wake up in the morning, you're I don't know the thought of like putting vaginal cream on and then walking out into 100 degrees. I'm like,

Dr. Jill Krapf  1:25:03  

No, I usually say you do it after a shower or a tub. So you want to do it at nighttime and you want to make sure that you're rubbing it in completely so it's completely absorbed into your skin. So if you're doing all of those things, you're not going to get as much of that sticky feeling. And then you want to find a consistency that works for you. There's different vulvar moisturizers that are thick like a Vaseline like, see that makes me want to die. Well, that's not for you then. And then there's ones that are more like a lotion that are a bit thinner, that are going to absorb a lot faster. And maybe that would be a better option.

Sarah Milken  1:25:34  

Are there specific brands you like? There? Are

Dr. Jill Krapf  1:25:37  

I very careful about addressing different products, always check the ingredient list.

Sarah Milken  1:25:42  

But what are the NO NO ingredients? Yeah,

Dr. Jill Krapf  1:25:45  

so you want to stay away from glycerin, you want to stay away from fragrances. If you're sensitive to those things. If you are sensitive to parabens, like if you don't tolerate normal sunscreens, then you need to stay away from parabens. It's gonna be different for everybody. But those are the big no no's that we commonly see why you do have an Amazon

Sarah Milken  1:26:03  

storefront, don't you on your Instagram?

Dr. Jill Krapf  1:26:05  

I do. So I basically had so many people. I'm like, What do I use? What products should I use? And, you know, at first I was like, I'm like, very careful, because I didn't want to door you know, look like I was endorsing. And yeah, above all.

Sarah Milken  1:26:19  

I mean, honestly, what are you making three pennies on? It's that's not the point.

Dr. Jill Krapf  1:26:23  

No, that's not the point. So it got to the point where it's like people need help. Yeah, no, I know. And actually, the thing that made me think of it is I went to my dermatologist because I had a little rosacea on my chin. And I was like, Well, what do I use? And she's like, Okay, well, you should use this. And she gave me like a specific product. And it was like something I could get it at a drugstore. And I was so grateful. And it actually worked. And I was really happy about it. And I was like you know what, you have to tell us what it is. Oh, it's just like set of fill but was it's for the read this it was like the redness, one. And so I was like, This is what people want. They want to know what to do. Like they don't want this.

Sarah Milken  1:26:56  

That's why I do this podcast because I'm like, I don't want to just like talk about vagina theory. I want you to fucking tell me what I need to do to stop all of these itchy, Bertie yucky feelings?

Dr. Jill Krapf  1:27:06  

Exactly. And I'm like, why am I holding back on recommending things if I know what my patients tell me works, if I've looked up personally, all the ingredients and bowl product list. If I've done all the research on this stuff, maybe that I am in a position to say, hey, maybe you should do this. And as long as I include, you know, different price points and different access rate, then it will be fine. And I give people options. Because that's not everyone's the same. If there was one product that worked for everyone, then you know, like, yeah, then it would be the most famous product. So basically, what I did was I'm like, Well, how can I do this? So I am an Amazon addict, I get every single day and my

Sarah Milken  1:27:41  

husband is like, what's happening here? Oh, I

Dr. Jill Krapf 1:27:45  

know. I know. It's just it's easy. And it's like, then you can visually see it. You know what it looks like if you want to get at the drugstore, fine. But I just like to order it and it comes to my door. So I looked into the Amazon storefront and I was like, oh, what will people think, right? Well, people

Sarah Milken  1:27:58  

go, I logged in, I was like scouring and I have to like go back and like read and like start ordering but I didn't have time.

Dr. Jill Krapf  1:28:04  

Well, I was worried because I was like I'm a doctor and I'm I have integrity. I don't want people to think I'm selling but people want answers. Yes, they do. And eventually, that's what it came down to. So I was like, You know what, I'm going to do this. And if I make five cents, I'm going to donate it to research,

Sarah Milken  1:28:18  

education. And then after you do I saw that that was Misasa. So it

Dr. Jill Krapf  1:28:22  

takes money to get IRB approved. It takes money to do these things with education and research. So all of the proceeds like the five cents is going towards research and I donate of my personal you know, I donate to a support network and, and things personally as well. Now, if you need some recommendations, or some things that are good options, then it is available. And the other thing I do is, you know, what's really helpful is for my for surgery that I do, I have like a bunch of postoperative, like, you know, like sitz bath and ice packs and things that I like people to have. And they're always like, Well, what do I get? How do I get it? I actually have a post operative section and it's so oh my god,

Sarah Milken  1:28:56  

that's amazing. I wish I had that for my colonoscopy. But I actually created that. So when I after my colonoscopy, I did an episode like a solo episode on it. And I was like, and then by this, this, this, this and this.

Dr. Jill Krapf  1:29:08  

That's what we need. Honestly, just give me a list. Tell me what to tell me what to do. And it makes it so much easier. Yes, I agree. So I got over myself, I put it out there and just know that I donate the proceeds. Oh

Sarah Milken  1:29:19  

my god, and she has such a fun Instagram too. You have to see it. Okay, what about coconut oil?

Dr. Jill Krapf  1:29:24  

Coconut oil is good for some and not good for others, it can definitely kind of clog sweat glands a little bit. So if you're prone to that it's probably not the best. It has some properties that are anti yeast and anti bacteria. But it can also on the other hand has been shown to slightly increase yeast infection risk. So it's kind of a double edged sword. If you use it and you swear by it, and it's working for you great, but it's not going to work for everybody.

Sarah Milken  1:29:49  

But if you take a bath in it and you get out obviously you're going to be sort of coated in it but it's a lot I think to me, it seems like it'd be different than slathering it on post shower

Dr. Jill Krapf  1:30:00  

Yeah, absolutely. I mean, you just have to see what works for you. A lot of people like it because it's natural. The only thing is you have to just be careful with oil based lubricants and condom Tech's condoms because they can actually degrade a latex condom. So even if you're midlife, you know, if you're in a situation with different partners, you always have to be careful, you know, you're probably not gonna get pregnant, right? Or you're not gonna get pregnant, but you could still get a sexually transmitted infection. So if you're using condoms for that reason, you just have to be careful. And I would stick to a silicone or water based lubricant for that.

Sarah Milken  1:30:31  

Now, do you have favorite lubes? I know every gynecologist has mentioned different ones.

Dr. Jill Krapf  1:30:35  

I do. I mean, I put them on my storefront. But you know, like I said, I don't get my like money from the companies. I don't endorse specific products. I think that you know, there's water based lubricants, oil based and silicone based and all of those have pros and cons. So you have to kind of see what you're looking for and what's going to work for you.

Sarah Milken  1:30:51  

Okay, and the Botox that you use in your practice is not Botox for Ugly vagina skin folds. What do you use it for? No, I

Dr. Jill Krapf  1:31:00  

know, my patients that I always joke about Botox. So Botox is essentially a medication that sees where it's injected, it's injected into a muscle, and it affects something called an acetylcholine, which basically releases that muscle, it inhibits the muscles ability to clench, okay, so when I inject it into tight clenched muscles at the vaginal opening, it releases those muscles, and it allows people to basically rehab or retrain those muscles to stay released. And it also allows people to get deeper inside to those deeper muscles, and really release those as well, without all the tightening of getting in there.

Sarah Milken  1:31:38  

Who's a candidate for that? Is that someone who's already started pelvic floor therapy? Is it someone who's like it's so tight, and I don't want to do pelvic floor therapy? Just give me like a one and done.

Dr. Jill Krapf  1:31:49  

Good question. So for me to do Botox, I have to have someone absolutely doing pelvic floor physical therapy, whether that be if they've done it in the past, and they feel comfortable if they're doing home exercises, and I'm teaching them perineal massage and they're doing dilators once or whatever, or if they're ideally going to a pelvic floor physical therapist on a weekly or bi weekly session, and they're getting the physical therapy coaching. So there has to be some sort of retraining of the muscles because the bottom line is anybody who has had Botox knows that it wears off.

Sarah Milken  1:32:20  

Oh, yeah, believe me my foreheads do.

Dr. Jill Krapf  1:32:23  

So it doesn't look like it.

Sarah Milken  1:32:25  

Oh, my God,

Dr. Jill Krapf  1:32:26  

my eyes are do so basically, the Botox in the pelvic floor, because the amount that we use typically lasts for about four to maybe six months, okay? However, if we're retraining those pelvic floor muscles, then after those molecules of Botox have faded away, those muscles remain released because they've been retrained. And so that's what we're looking for. And that's, that's what I see clinically. Usually, I have to do two to three series of Botox because we're hitting different muscle groups, or I'm targeting different muscle groups. But once I release that entire area at the opening, then if they're doing pelvic floor physical therapy, and we're consistent with their exercises, then it's rare to need Botox at a regular basis after that,

Sarah Milken  1:33:13  

do you numb it first?

Dr. Jill Krapf  1:33:15  

I don't, because so the needle that I use is the size of an acupuncture needle. Very, very small. If I were to numb that area with you know, an injection, it would actually hurt more. Yeah, that makes sense. Yeah, doing the Botox and then the you know, some people do Botox when someone's under anesthesia, but that doesn't make sense to me because I am literally fueling the tight muscle and into that tight muscle anesthesia. When someone's asleep, all their muscles are relaxed, and so you can't pinpoint exactly where the tight muscles are. So I don't do it that way. And most of my patients say yeah, like, it's not the most comfortable thing, but it's worth it for ticket the effects that you get. I've had

Sarah Milken  1:33:56  

my whole scalp injected with like PRP and extra salt. I mean, we've all done so many things that hurt.

Dr. Jill Krapf  1:34:02  

Absolutely. And the reality is, you know, if I do three or four injections, it's literally four seconds per injection. So we're talking about 12 to 16 seconds of you know, it's not liking me, but then But then it's fine. I often tell patients you're gonna have more burning from me doing the exam and pushing on all these trigger points than you are from really the the medication.

Sarah Milken  1:34:25  

Oh, I hate pap smears.

Dr. Jill Krapf  1:34:28  

Absolutely.

Sarah Milken  1:34:30  

God yuck, yuck, yuck, yuck, yuck. Okay, so, before we wrap up, I just want to ask you what your one piece of advice is for midlife women trying to get their midlife Volvo's and vaginas up and running high performance, sex the whole thing.

Dr. Jill Krapf 1:34:45  

So my bit of advice is that there are solutions to all of these conditions. There is help out there. You need to find the diagnosis the cause of what's going on. There are specialists and doctors who specialize in this and treat this and really want to see patients who have these conditions. And that help is out there. You're not alone. And you can have a very happy healthy vulva and vagina.

Sarah Milken  1:35:15  

I love that because life is short and we have to get the answers to our vulva and vagina diaries and sagas. I've loved talking to you and picking your brain and asking you all the questions that US midlife women have on our minds finding the sweet spot between neurotic and chill, vagina, vulva, land and a huge part of the midlife remix. If listeners want to find you. Where can they find you?

Dr. Jill Krapf  1:35:38  

I can be found on Instagram at Gil CRAF, MD, and I'm also on the web and I spell

Sarah Milken  1:35:45  

your last name though.

Dr. Jill Krapf  1:35:46  

Oh, yes. So my last name is Kraft. That's que RAPF But the P is silent. It's pronounced CRAF. And my practice is the Center for vulva vaginal disorders. We have an office in Washington DC where I see patients and we have an office in New York City where Dr. Andrew Goldstein sees patients and you can find us on the web@www.vulvodynia.com or www dot CDDVD. That work.

Sarah Milken  1:36:16  

Thank you Dr. Joe Kraft for being on the flexible neurotic podcast. It has been so fun and informative to talk to you.

Dr. Jill Krapf  1:36:22  

Thank you for having me. This has been so fun.

Sarah Milken  1:36:29  

Hey, peeps, it's me again. I listen to this episode with gynecologist OB GYN and vulvar specialist, Dr. Jill Kraft. So I could summarize the golden nuggets for you to have actionable items to start using today. I know that when I listen to a long episode, I'm like, oh my god, I love that. But then I can't even fucking remember the specifics. That's midlife brain. This is why I come back and do a golden nugget summary. In this episode we discuss understanding vaginal and vulvar pain, golden nugget, number one, decreasing pain and increasing pleasure what a concept sounds good to me. Jill tells us that she has so many patients who come in and except that the discomfort and pain they're feeling during sex and intimacy is going to be their new normal. She explains that this is not the case at all. It doesn't have to be of course it can be frustrating because before midlife we have may have been preoccupied with kids or a career. And now that we have free time to be more intimate. Well, maybe some of us if we've kept our libido but that's a whole other issue that we talked about too. We are hit with perimenopause and menopause. Joe reaffirms us by saying, quote, we can be intimate with our partners again, not have pain and actually have pleasure and desire and quote, as long as we put in the work to understand our bodies, we can reach the calm after the storm. Honestly, the calm after the storm is going to Jill's office in Washington DC or her mentor Andrew Goldstein in New York because so many gynecologist that we all go to are like no, no, no, that's normal. Anyway, Golden Nugget number two, know your body inside and out. Sometimes when we are experiencing a problem with our bodies, we don't remember how it was before the issue. Like is this our new normal now that we've lived with it for so long? We ask ourselves, has it always felt like that? Did it always look like this? And not knowing what the real answer as Jill explains that a lot of people don't realize that something's off until it's really fucking uncomfortable or something's really wrong or it looks really weird. It is important, especially in midlife to pay attention to our bodies, how it was before and notice any changes and also grab a mirror when you can. This can help us better understand ourselves and catch any problems early on, rather than too late and obviously finding the right doctors who answer the questions and do a lot of the diagnostic work. Golden Nugget number three, pick your products carefully. There are a lot of different products that are for vaginal discomfort and pleasure. Jael details the importance of researching the products you're interested in. With all the different ingredients the products could cause irritation. Make sure you're keeping track of how your body is reacting to the products and if they are helping or causing more discomfort. This isn't just products that you buy off the shelf. Some research should be done with products or medicines that you're being prescribed by your gynecologist. Not everything works for everyone. Jill explains that you should ask your clinician Why Why am I using this product? How? How is it going to help and how to properly use it. In short, as long as the product works for you and you're not experiencing any negative side effects, then feel free to use what you want Golden Nugget number four, the importance of the vestibule that's such a weird word. It sounds like you're in the game of Clue. Chill explains that the most important area that no one knows about in that whole vaginal region is called the vestibule. The vulva vestibule is the smooth surface that starts below the clitoris and ends at the bottom of the labia menorah. Its borders are formed from the edge of the labia menorah I think you guys might have to get a mirror out. So vestibule contains the opening to the urethra and the vaginal opening. Jill tells us that sometimes the vestibule doesn't get enough attention. And it might be the exact reason why you are experiencing pain during insertion. a gynecologist might prescribe estrogen cream to apply at the opening. Another option Joe recommends using testosterone on that area and mixing it with estrogen. Obviously this is all through your doctor Golden Nugget number five, don't take no for an answer. Jill's main piece of advice is to not give up on finding a solution to your problem. Because it is out there. Sometimes a doctor can give you the whole you're fine. There's nothing we can do. You're just too old. It's just menopause. We've tried everything just deal with it the whole spiel. Jill is here to tell us not to take no for an answer because there is help out there. She explains that if you are not getting the help you need from your primary doctor or gynecologist, then there are specialists you can go to that are more trained in specific areas, vulvar specialists. Midlife is the time that we find answers about everything or at least we try to. We don't need to just accept things the way they are. And I mean everything so just because the process to find the solution isn't easy. It's fucking exhausting. Don't give up. Jill says you're not alone. And you can have a very happy healthy vulva and vagina. Okay, the gold is dripping off these nuggets, rabbit use it there are three things you can do first, subscribe to the podcast. I mean, come on. If you're just listening to it and not subscribing. You're cheating the system just getting it just gives me credit for the podcast and then Apple podcasts promotes it to more people so you're doing me a favor. Second is share with some midlife friends who might like some midlife shit. And third, write an apple review. writing reviews is really annoying. It's an extra step. But guess what? It really helps the podcast grow. You think your little review doesn't matter? But it does. As I always say if you went to a show and everyone said my clap doesn't matter. I'm not going to clap then there would be no clapping. You all matter. DM me, you know I always respond. I'm the only person on my Instagram and of course, follow my instagram at the flexible neurotic on Instagram da love you talk to you soon.