Interview with Dr. Kelly Casperson, Urologist and Author of The Menopause Moment

Table of Contents

• Overview
• Why this conversation matters
• Interview
• Perimenopause — the basics
• Meet the hormones
• Progesterone: sleep and myths
• Estrogen — dose, symptoms, and safety
• Understanding vaginal atrophy and the “senile vagina” myth
• Sex in midlife — desire, lubrication, and communication
• Testosterone pellets and safety concerns
• The midlife brain and cognitive health
• Alcohol, supplements, and lifestyle
• Menopause as a choice — future directions
• Hormone therapy after breast cancer: a nuanced conversation
• Practical steps — a checklist for the midlife transition
• Final mindset — you are not broken
• Where to start
• Frequently asked questions
• Resources and next steps

Overview

Dr. Thais Aliabadi and Mary Alice Haney sat down with Dr. Kelly Casperson to untangle the noise around perimenopause, menopause, and hormone therapy. Her message is crisp: women deserve straightforward science instead of fear-based medicine. Throughout this interview-style guide we cover the essentials—what perimenopause really means, how testosterone, estrogen, and progesterone affect the body and brain, practical approaches to vaginal atrophy, why local estrogen is often underused, the truth about testosterone for women (and the risks of pellets), how to get desire back in long-term relationships, and lifestyle tools that protect brain health.

Why this conversation matters

We consistently encounter two problems: misinformation and dismissal. Many clinicians either downplay symptoms in midlife women or rely on outdated fears about hormone therapy. Dr. Casperson is focused on giving people the facts so they can make informed choices for quality of life. We want to help you recognize symptoms, understand treatment options, and weigh risks and benefits with real data—not headlines. 

The Interview

What inspired you to write The Menopause Moment, and who is this book for?

We wrote the book because women—both young and older—need clear, practical information about what happens to hormones during midlife and why it matters. Originally, Dr. Casperson included a chapter in her first book and got overwhelming feedback: people wanted more. The Menopause Moment is for anyone approaching or living through perimenopause and menopause who wants the facts so they can decide for themselves.

What’s the biggest myth about hormone replacement therapy right now?

The most persistent myth is that hormone therapy is trying to kill you—that taking hormones guarantees breast cancer, heart attack, or stroke. That fear still drives patients away from treatments that can protect bone health, reduce colon cancer risk, and possibly safeguard cognitive function. The reality is nuanced: HRT carries risks like any medication, but when used thoughtfully and individualized to the patient, it can offer major benefits and is far from universally dangerous.

Perimenopause — the basics

What is perimenopause, and how does it differ from menopause?

Perimenopause is the transition when ovarian function winds down. Think of it as reverse puberty: hormone production becomes irregular and unpredictable, rather than suddenly stopping. Menopause, strictly speaking, means the absence of natural menstrual periods for 12 months. That definition is clumsy because a third of people do not have a final menstrual period due to hysterectomy, birth control, ablation, or IUDs. Perimenopause is a clinical diagnosis based on symptoms—hot flashes, night sweats, brain fog, mood changes, hair thinning, vaginal dryness, and weight shifts—not a single definitive lab test.

How should clinicians and patients approach symptoms in their 30s and 40s?

Clinicians should listen. If someone in her 30s or 40s presents with classic symptoms—sleep disruption, unpredictable periods, hot flashes, mood swings—perimenopause must be on the table. Women often hear they’re “too young,” which leads to dismissal. We emphasize clinical judgment: the common things are common, and perimenopause is common.

Meet the hormones

Walk us through testosterone, estrogen, and progesterone—why each matters in midlife.

We prefer the term neurohormones because these chemicals act widely in the brain and body. Ovaries produce testosterone, estrogen, and progesterone; they all decline during perimenopause, but they fall differently.

• Testosterone—Often unfairly labeled “male” hormone, testosterone is actually the most abundant sex hormone produced by the ovaries. It decreases slowly from our 20s. Its main reputation is libido, but its real effects are broader: motivation, energy, muscle mass, and cognitive focus.
• Estrogen—Crucial for vasomotor stability, vaginal and bladder tissue health, bone, and brain glucose metabolism. Estrogen fluctuates in perimenopause and then declines sharply.
• Progesterone—Protects the uterine lining when estrogen is prescribed and, when given as oral micronized progesterone, improves sleep through GABA metabolites after liver metabolism.

Is testosterone useful for women, and how is it dosed?

We use testosterone clinically for low libido and the constellation of symptoms that come with low energy and motivation. International guidelines suggest roughly one-tenth of the average male topical dose—often about 5 mg per day in cream form. Because absorption varies, some patients start at a lower dose, for example, 3 mg daily, and titrate upward based on response and labs.

We also watch for side effects when dosing is too high: acne, oily skin, increased facial hair, rare frontal hair thinning, and the serious risk of clitoral enlargement. Those side effects remind us to follow the principle: start low, go slow.

Should people take testosterone in the morning or at night?

It is individualized. Some people find testosterone energizing and prefer morning dosing; others notice improved sleep and take it at night. There isn’t a definitive study that dictates the timing, so we tailor it to the patient’s experience.

Progesterone: sleep and myths

Why does progesterone help sleep, and who should take it?

Oral micronized progesterone is metabolized in the liver to GABAergic compounds that enhance sleep. Women with midlife insomnia often see a meaningful benefit. The myth that people without a uterus cannot take progesterone is false. Even after a hysterectomy, progesterone can help with sleep. And if someone has a history of endometriosis, progesterone remains important because estrogen alone can reactivate endometriosis implants.

Estrogen — dose, symptoms, and safety

How do we know when the estrogen dose is too high?

Symptoms of excess estrogen include anxiety, breast tenderness, and sometimes increased mood lability. The safe practice is to start low and go slow, especially in older patients who have been estrogen-free for a long time. If someone is truly suffering, we may increase the dose more quickly so they can feel relief quickly and regain function.

What about local vaginal estrogen—who should be on it and when?

Vaginal estrogen is one of the strongest preventive health tools for genitourinary health. A low-dose vaginal estrogen product used about twice weekly often reverses dryness, pain with sex, urinary urgency, frequency, and recurrent urinary tract infections by restoring the local microbiome and tissue integrity.

We recommend starting early when symptoms begin. Even if someone is not sexually active, treating vaginal atrophy prevents pain, rawness, UTIs, and later complications. Think of local estrogen as skincare for the vulva and vagina—a cheap, safe, and effective preventive measure.

Understanding vaginal atrophy and the “senile vagina” myth

Is the “use it or lose it” idea about vaginal tissue true?

The “use it or lose it” phrase has been misinterpreted. Early studies were correlation-based: women with less atrophy reported more sexual activity. Correlation does not equal causation. However, there is a sliver of truth—blood flow and stretching matter. Increased blood flow to the vulva supports tissue health.

Importantly, putting something into the vagina that causes pain or is not pleasurable is not a solution. We should never prescribe sex that feels like a chore under the guise of prevention. Instead, we should treat atrophy directly with local estrogen, and when appropriate, encourage pleasurable, gradual genital stimulation that increases local blood flow.

How do we recognize vaginal atrophy?

Typical signs are dryness, pain with sexual activity, decreased sensation, splitting or cracking of the vulvar skin, and even thinning or resorption of the labia minora. Some people notice difficulty with orgasm or diminished intensity. A 50 to 90 percent prevalence range is often cited—this is a very common problem and is underdiagnosed.

What real-world tools help short-circuit atrophy?

Beyond vaginal estrogen, topical therapies and devices that increase blood flow have shown promise. External vibration therapy applied to the vulva without intent to orgasm improved blood flow, reduced some atrophic symptoms, and helped sexual function in trials. This points to the fact that nonpenetrative, pleasure-focused stimulation can improve tissue health without forcing intercourse.

How should vaginal estrogen be applied for the best results?

We have a “cream bias.” Vaginal estrogen comes as rings, tablets, and creams. Creams let us target the vulva and the six o’clock entrance—the area that often thins and tears first. Rubbing a low-dose cream gently onto the labia minora and clitoral hood is effective skincare. Twice a week is the standard starting frequency for many low-dose products, with individualized adjustments as needed.

Sex in midlife — desire, lubrication, and communication

How do we get sex back when desire fades in long-term relationships?

We explain responsive versus spontaneous desire. Spontaneous desire—sudden, out-of-the-blue want—is rare as life accumulates responsibilities. Responsive desire is more common: it grows with context, touch, and connection. To recreate earlier heat, we recommend adding novelty, planning getaways without kids, changing locations, or intentionally making out like you used to. Small changes—dressing differently, complimenting a partner, watching them do something they excel at—can reignite interest because our brains respond to novelty and admiration.

What practical sexual health tips do you give patients?

• Stop faking orgasms: We need honest communication.
• Use lube: Silicone or oil-based lubricants tend to work better in midlife because water-based lubricants are often absorbed and can feel cold.
• Be on vaginal estrogen: Treat the tissue; do not wait until sex becomes painful.
• Prioritize communication: Talk about what feels good, what doesn’t, and reframe sex as shared pleasure, not performance.
• Consider testosterone when low libido and low energy are present: Testosterone can restore motivation and capacity for arousal in appropriate patients.

Testosterone pellets and safety concerns

Why are pellets controversial?

Pellets deliver a high and sustained dose of testosterone. If dosing causes masculinizing effects—like clitoral enlargement or irreversible hair pattern changes—removal or dose correction isn’t possible until the pellet metabolizes. That permanence and the risk of visible side effects make pellets a poor first choice for many patients. We recommend topical or transdermal approaches with careful monitoring

The midlife brain and cognitive health

Does brain fog get better? What happens to the brain in midlife?

The brain has estrogen receptors and uses estrogen to help metabolize glucose efficiently. During the menopause transition, the brain initially upregulates receptors trying to capture any available estrogen. Over time, if estrogen supply is absent, the brain adapts and may switch to alternate fuel strategies, which, in extreme interpretations, has been described as neurons using nearby cells for fuel. We frame that research carefully—it’s complex and evolving—but it does provide a rationale for why long-term absence of estrogen might relate to cognitive risk like increased Alzheimer’s incidence.

Good news: many modifiable factors protect cognitive health. The top interventions are consistent exercise and quality sleep—aim for seven hours nightly. Supplements like omega-3 fatty acids, vitamin D if deficient, magnesium, adequate protein, and fiber support overall brain health. Avoiding smoking and excessive alcohol, staying socially engaged, and stress management matter too.

Alcohol, supplements, and lifestyle

Where does alcohol fit in the midlife health equation?

We take a conservative view: either avoid alcohol or consume it with awareness of its trade-offs. Alcohol affects sleep quality, hormone metabolism, and liver function. If you choose to drink, do so intentionally and understand how it interacts with mood, sleep, and medications.

Which supplements and lifestyle practices do you recommend?

• Exercise: Prioritize movement—both aerobic and resistance training—for brain and bone health.
• Sleep: Target seven hours nightly.
• Protein and nutrition: Ensure enough dietary protein for muscle maintenance; consider a protein supplement if needed.
• Omega-3s: Support cognitive function in diets that are low in fish.
• Vitamin D and magnesium: Test levels and supplement as indicated.
• Limit alcohol and avoid smoking: Both are large, modifiable risks for long-term health decline.

Menopause as a choice — future directions

Can menopause ever be optional?

The idea is under active research. Some scientists investigate methods to keep ovarian follicles functioning longer or to restore their hormonal outputs. The goal is not necessarily to keep people menstruating in their seventies but to preserve the hormonal milieu that supports brain, bone, and genitourinary health. This is an emerging field and raises big ethical, social, and public-health questions. We are optimistic about scientific progress but also mindful of responsible use.

Hormone therapy after breast cancer: a nuanced conversation

Is hormone therapy absolutely contraindicated after breast cancer?

No. Blanket statements that no hormone therapy is allowed are too broad. Data are limited but growing. Local vaginal estrogen for genitourinary symptoms is widely considered low risk and often described as skin-care-level dosing. Some hormone experts and oncologists are now evaluating individualized risk-benefit decisions for systemic therapy. Testosterone data are evolving, and in some studies, testosterone did not raise estradiol appreciably and provided symptom relief, including in women on aromatase inhibitors. The bottom line: decisions should be individualized in collaboration with oncology, gynecology, and the patient, recognizing both cancer risks and the harms of untreated menopause symptoms.

Practical steps — a checklist for the midlife transition

We recommend a pragmatic approach centered on symptom recognition, evidence-based treatment, and prevention:

1. Track symptoms: hot flashes, night sweats, sleep disruption, mood changes, libido changes, vaginal dryness, urinary urgency, and recurrent UTIs.
2. Ask for a clinical evaluation: perimenopause is often a clinical diagnosis; labs can help, but don’t rule it out.
3. Discuss individualized pros and cons of systemic HRT with a clinician who understands the modern data.
4. Start low and go slow with hormones; prefer topical or transdermal routes when appropriate.
5. Use low-dose vaginal estrogen twice weekly for atrophy prevention or treatment; cream forms help treat the vulva.
6. Consider testosterone for low libido and energy after a careful assessment and shared decision-making.
7. Avoid high-dose pellets as first-line testosterone delivery due to irreversible side effects in some cases.
8. Prioritize exercise and sleep to protect cognitive health and resilience.

Final mindset — you are not broken

The phrase we come back to is simple: you are not broken. Midlife is an inflection point and an opportunity for clarity. With the right information and care, this period can be a time of renewed purpose, strength, and crisp decision-making about how we want to live the remainder of our lives.

Where to start

If you’re feeling off—more anxious, sleeping poorly, losing hair, experiencing painful sex, losing desire—document those symptoms and bring them to a clinician who will acknowledge them rather than dismiss them. Advocate for a conversation driven by facts, not fear. If you want deeper reading, The Menopause Moment offers science and practical guidance to empower your choices.

Frequently asked questions

How do I know if I am in perimenopause?

If you are in your 40s or early 50s and experiencing symptoms like irregular or heavier periods, hot flashes, night sweats, mood changes, sleep disturbance, brain fog, hair thinning, vaginal dryness, or unexplained weight gain, these are classic signs. Perimenopause is a clinical diagnosis. Labs can support, but are not definitive.

Is vaginal estrogen safe for women with a history of breast cancer?

Low-dose vaginal estrogen is considered by many experts to be safe because systemic absorption is minimal and blood levels typically stay in the low postmenopausal range. Oncology and gynecology should discuss each case. For bothersome genitourinary symptoms and recurrent UTIs, local estrogen is often life-changing and may be recommended after individualized counseling.

Will testosterone convert to estrogen and cause harm?

Testosterone does convert to estrogen via the aromatase enzyme, but most studies show that in standard low female doses, serum estradiol does not rise substantially for the majority of patients. Some patients with high aromatase activity might convert more. Monitoring and individualized care guard safety.

How soon will I feel better after starting hormone therapy?

Symptom relief timing depends on the hormone and route. Vasomotor symptoms often improve within weeks of starting systemic estrogen. Vaginal estrogen can begin to improve local symptoms within days to weeks, and full tissue remodeling takes longer. Testosterone effects on libido and energy can be noticed within weeks but typically evolve over months. Always individualize dosing and follow-up.

Are there non-hormonal tools that help cognition and mood?

Yes. Exercise is the most powerful intervention for cognitive health. Adequate sleep (aim for seven hours per night), social engagement, stress management, balanced nutrition, omega-3s, and maintaining healthy blood pressure and glucose all support brain resilience. Limit alcohol and do not smoke.

What lube do you recommend for midlife dryness?

Silicone-based lubricants and oil-based lubricants work well because they are long-lasting and not quickly absorbed into dry tissue. Avoid flavored or perfumed products that can irritate. If you are using condoms, avoid oil-based lubricants because they can degrade latex.

Should I be worried about hair thinning when starting hormones?

Hair follicles react poorly to rapid hormonal shifts. That’s why we advise starting low and going slow. Sudden large changes can shock follicles; gradual titration reduces risk. If hair thinning appears, reassess dosing and route and consult a clinician who understands midlife hair changes.

Resources and next steps

Dr. Casperson’s website and podcast provide additional resources for patients and clinicians. For immediate steps: document symptoms, prioritize sleep and exercise, schedule a clinical visit, and ask questions about vaginal estrogen, progesterone for sleep, and low-dose testosterone if applicable. Remember that the decision to use hormones is personal; our job is to ensure it is informed by data and tailored to you.

This article was created from the video Dr. Kelly Casperson: The Hormone Therapy Myth Your Doctor Is Still Getting Wrong | SHE MD for Dr. Thais Aliabadi’s website.