Interview with Dr. Kelly Casperson, Urologist and Women’s Sexual Health Expert: What You Need to Know About Hormones, Menopause, and Sexual Wellness

There are a few phrases women say over and over when they talk about sex, hormones, and midlife changes: I feel broken. I don’t feel like myself. No one ever explained this to me. That is exactly why this conversation matters.

Dr. Thais Aliabadi and Mary Alice Haney sat down with Dr. Kelly Casperson, a board-certified urologist, sex educator, and host of You Are Not Broken, to talk about the real issues women face in perimenopause and menopause. We covered painful sex, vaginal dryness, low libido, bladder symptoms, testosterone, hormone therapy, and one of the most dismissed symptoms of all: brain fog.

What makes Dr. Casperson’s work so powerful is that she combines science, straight talk, and the kind of practical education many women should have gotten years ago, but never did.

Table of Contents

• From urology to sex education and menopause advocacy
• Why women’s health education still has such big gaps
• Understanding sex pain, low desire, and the many causes behind them
• Vaginal dryness is common, treatable, and often misunderstood
• Why lubrication should be standard, not optional
• Testosterone for women: why this conversation matters
• Genitourinary syndrome of menopause: the term more women need to know
• Brain fog, memory changes, and the fear women rarely say out loud
• When should hormone therapy start?
• What about women with breast cancer or high breast cancer risk?
• What women most need to hear
• FAQ

From urology to sex education and menopause advocacy

How did your career evolve from being a urologist in private practice to becoming such a strong voice in women’s sexual health and menopause?

Dr. Casperson’s story started in a very traditional way. She trained as a urologist, went into private practice, built a successful business, and did all the things that are typically considered career milestones. But about seven years into practice, she hit what one of her mentors had once warned her about: the “seven-year itch.”

She realized she was bored. Not because medicine didn’t matter, but because repeating the same visits and same treatment patterns without deeper growth left her asking a very human question: Is this it?

Then a patient changed everything.

This was a woman she had treated successfully for bladder cancer. They had a close physician-patient bond. One day, that patient sat in her office crying, devastated by a sexless marriage and feeling deeply broken. Dr. Casperson had the tissues in her hand and a realization in her head: she did not know how to help her.

That moment exposed a massive gap in medical training. She had been taught, as many physicians were, that women’s sexual health was too complicated, too time-consuming, and essentially someone else’s problem. Instead of accepting that, she started digging. She spent about a year teaching herself female sexual medicine and eventually realized she could not keep that information to herself.

So she gave herself permission. That was the key. No one was coming to tell her she knew enough. She started speaking publicly, launched her podcast, and found her voice.

From there, the path into menopause medicine became obvious. Once she started educating women about sex, the same concern kept surfacing: what happens to sex during menopause? That question led her deeper into hormones, especially estrogen and testosterone, and into correcting some of the fear and misinformation women have carried for decades.

The result is a body of work that sits right at the intersection of sexual health, hormones, and midlife wellness.

Why women’s health education still has such big gaps

What have you learned from speaking to women outside the exam room, through podcasts and social media, that changed how you see medical care?

One of Dr. Casperson’s biggest takeaways is that most doctors believe they are doing a good job, and individually, many are trying their best. But women are still suffering.

Once she started hearing directly from women online, she saw the pattern clearly. Women were saying things like:

• I’m on my third doctor.
• I’m on my fourth doctor.
• My doctor told me this was normal.
• My doctor told me to come back later.

That disconnect matters. Ten-minute appointments, overloaded schedules, and fragmented care are not enough for nuanced hormone and sexual health concerns. You cannot meaningfully address perimenopause, menopause, libido, pain with sex, sleep changes, and mood changes in a rushed annual visit.

She also highlighted something medicine has historically done poorly: translation. We often hear that we need more research, and yes, we do. But even when good data exists, it can take many years to reach the clinic in a way that actually helps patients. That is where physician educators can play an essential role. They take the science and explain what it means in real life.

That gap is especially obvious in women’s health. Many women still got what Dr. Casperson calls a “disease and pregnancy prevention plan,” not real adult sex education.

So they grow up not understanding pleasure, not understanding anatomy, not understanding what is normal, and not understanding what hormones do throughout the body.

Why do so many women feel broken when it comes to sex?

Because they were never properly taught.

That is the heart of Dr. Casperson’s message. Women often assume something is wrong with them when, in reality, they are missing education, language, and context.

For example:

• Many women think they should be able to orgasm from penetration alone, when most do not.
• Some women have never had an orgasm, not because they are defective, but because of shame, lack of education, or never having learned what their own bodies need.
• Many women have never even looked closely at their own anatomy.

Once women understand the data and the physiology, the shame starts to loosen. The problem is not that they are broken. The problem is that no one gave them adult sex ed.

Understanding sex pain, low desire, and the many causes behind them

When a woman says, “I don’t want to have sex with my husband anymore,” where do you start?

The first thing we have to say clearly is this: there is no single reason.

Painful sex and low libido can happen at any age. In younger women, the causes may include endometriosis, pelvic inflammatory disease, infections, fibroids, anxiety, depression, trauma, or structural concerns. In midlife and menopause, hormones become a much bigger player.

As estrogen declines, vaginal tissue becomes drier, thinner, and less elastic. Testosterone levels also fall. Sex may become uncomfortable or painful. Women may feel more anxious, less confident in their bodies, and less interested in sex, especially if sex now feels like an effort instead of pleasure.

There are also relationship factors, fatigue, resentment, poor sleep, and mental load. Libido is not a simple switch. It is affected by biology, psychology, context, and connection.

That is why symptom-based care matters so much. Instead of assuming every woman has the same problem, we need to ask better questions:

• Is sex painful, dry, or both?
• Has desire changed gradually or suddenly?
• Are there bladder symptoms too?
• Is mood or anxiety part of the picture?
• Is this really about libido, or is this about dread because sex hurts?

Without those distinctions, treatment can miss the mark.

How can women start getting more comfortable with their own anatomy?

Dr. Casperson’s answer was refreshingly simple: use a mirror.

Not as a clinical exercise. Not with pressure to label every structure perfectly. Just to become familiar with your own body.

That alone can be a radical act for women who were raised with shame, silence, or the message to never talk about this part of themselves. She also recommended educational resources such as OMGyes for learning about pleasure and the book Sex for One for women who want to understand orgasm more fully.

The important point is not performance. It is familiarity, comfort, and curiosity.

Vaginal dryness is common, treatable, and often misunderstood

Does vaginal dryness only happen after menopause?

No. And this is one of the most important myths to correct.

Vaginal dryness can begin in perimenopause, sometimes years before periods fully stop. It can also occur with breastfeeding, oral contraceptive use, cancer therapies, and other situations that alter hormone levels in the pelvis.

Menopause does not begin and end with hot flashes. Declining estrogen affects tissues all over the body, including the vulva, vagina, urethra, and bladder. Some women notice symptoms early. Others may not feel the effects until many years after menopause because the tissue changes are cumulative.

If this is an area you want to understand more deeply, Dr. Aliabadi’s clinic has a helpful resource on menopause and vaginal dryness that explains the hormonal changes and treatment options in more detail.

If a woman has vaginal dryness, does it go away on its own?

Usually not, at least not if the underlying issue is low estrogen. Once hormones decline, the tissue does not simply bounce back without support.

That is why waiting for symptoms to become severe is such a bad strategy. Women should not be told to come back only after they have gone a full year without a period, especially if they are already dealing with dryness, pain, and urinary symptoms in perimenopause.

Treat the symptoms. That was a major theme throughout the conversation.

What role does vaginal estrogen play, and can women use it along with systemic hormone therapy?

Yes. In many cases, women can absolutely use both.

Dr. Casperson explained vaginal estrogen as a very low-dose local treatment. It is often described as “skincare for down there,” which is a useful way to understand it. The dose is so low that it does not significantly raise overall hormone levels in the body. That is why many women can use vaginal estrogen even if they are also on an estrogen patch.

Her simple equation was brilliant: if the patch gives you X and vaginal estrogen gives you essentially zero systemically, then X plus zero is still X.

That means local vaginal estrogen can be added to systemic therapy when needed, especially for women whose pelvic symptoms persist despite a patch or other systemic hormone treatment.

Dr. Aliabadi also emphasized that even many women with a history of breast cancer may still be candidates for vaginal estrogen, because absorption is minimal. Of course, treatment decisions should be individualized, but the blanket fear around local vaginal estrogen is often not supported by the data.

What forms of vaginal estrogen are available?

Dr. Casperson outlined several options, each with pros and cons:

• Cream: versatile and can be applied internally and externally.
• Tablet: inserted vaginally and often less messy.
• Ring: stays in place for 90 days and is very convenient for some women.
• Intravaginal DHEA: the FDA-approved product prasterone, also called Intrarosa, which converts locally into estrogen and testosterone.

Both physicians expressed a preference for the cream in many cases because it can also be applied to the labia and clitoral hood.

Why does that matter?

Because low estrogen can lead to changes such as labial resorption and clitoral phimosis, meaning tissue can shrink or the clitoral hood can tighten and reduce sensation. A cream can help support the health of those tissues in a way a tablet cannot.

The tablet is popular for women who dislike leakage. The ring can be excellent for women who want a more “set it and forget it” approach, although cost may be a limiting factor.

For women dealing specifically with painful sex, Dr. Aliabadi’s team also has a thorough resource on dyspareunia and menopause that reviews both hormonal and nonhormonal treatment options.

Are there non-estrogen options for vaginal dryness and pain?

Yes. Dr. Aliabadi mentioned several tools that can be part of a treatment plan, depending on the patient:

• Hyaluronic acid vaginal products
• Vitamin E, including compounded preparations she has used successfully
• CO2 laser treatments for vaginal tissue support and elasticity
• Lubricants during sex

Not every woman needs the same combination. Some do well with systemic hormones alone. Others need vaginal estrogen, too. Others want nonhormonal support or need a layered plan.

Why lubrication should be standard, not optional

Should women be using lubrication regularly during sex?

Dr. Casperson’s answer was an emphatic yes.

Her logic was both funny and accurate: the penis is not self-lubricating, the clitoris is not self-lubricating, so why are we making the vagina do all the work?

That line gets at something bigger. Women are often taught to see lube as a sign of failure, age, or dysfunction. It is not. It is a tool. It makes sex more comfortable, more pleasurable, and less irritating to tissue that may already be dry or fragile.

She tends to prefer silicone-based or oil-based lubricants because they last longer and are often better tolerated for dry menopausal tissue than water-based lubricants, which can dry out too quickly. She mentioned Uberlube as one silicone-based option and an oil-based product from Naomi Watts’ Stripes line called Oh My Glide.

Oil-based products should be used carefully if condoms are involved, since oils can compromise latex.

Testosterone for women: why this conversation matters

Is testosterone really a female hormone?

Yes. And many women are shocked to hear that.

Dr. Casperson pointed out that women naturally make testosterone. In fact, women make more testosterone than estrogen, just far less than men do. Yet because testosterone has been culturally branded as a “male hormone,” many women are never told that it has an important role in their own bodies.

That role includes support for:

• Libido
• Energy
• Motivation
• Mental sharpness
• Muscle response and exercise recovery
• General sense of feeling like oneself

That does not mean every woman needs testosterone. It does mean it should not be dismissed out of hand, especially in perimenopause and menopause.

What symptoms might suggest testosterone could help?

The symptoms are often broad and not always easy to measure in a lab. They can include:

• Low libido
• Fatigue or low energy
• Brain fog or a “slow” feeling
• Reduced motivation
• Difficulty building or maintaining muscle despite effort
• A general sense of not feeling like yourself

But both doctors stressed that libido is multifactorial. If a woman is depressed, anxious, in pain, sleep-deprived, resentful, or overwhelmed, testosterone alone may not solve the problem. Hormone treatment works best when it is part of a thoughtful clinical picture, not a simplistic fix.

What forms of testosterone do you prefer for women?

Dr. Casperson strongly favored transdermal cream, usually compounded to an appropriate female dose. Since the United States still does not have an FDA-approved testosterone product specifically for women, doctors often have to work with male products or compounded formulations.

Her typical starting dose is around 5 mg daily in transdermal form, sometimes increasing to 10 mg depending on symptoms and response.

Dr. Aliabadi agreed and made her opinion on pellets very clear: she hates them.

The concerns with pellets included:

• Levels can go too high, too fast
• Hair loss can be dramatic
• The dose is not easily reversible
• They are expensive
• Long-term use is impractical for many women

By contrast, a daily compounded cream gives steadier dosing and more control. Both physicians described the inner thigh as a common application site.

Do you need blood work to decide on testosterone or menopause treatment?

Labs can be useful, but they should not override symptoms.

This was another major theme of the conversation. In menopause medicine, we generally treat the patient, not the lab number. Hormone levels fluctuate in perimenopause and often tell only part of the story.

That said, Dr. Casperson does typically check a baseline testosterone level to make sure she is not treating someone who already has high testosterone, such as a patient with PCOS. She also noted that many standard assays are poor at measuring low testosterone levels in women, so interpretation requires expertise.

Dr. Aliabadi echoed that point. A woman can have a “normal” lab value and still have symptoms that deserve treatment. Another woman can have a low number and feel completely fine.

Symptoms, context, and response to treatment matter more than chasing a perfect number.

Genitourinary syndrome of menopause: the term more women need to know

Why do so many women in midlife suddenly have urinary urgency, frequency, or recurrent UTIs?

Because estrogen affects the urinary tract, too.

Dr. Casperson explained the term genitourinary syndrome of menopause, or GSM. This includes changes in the bladder, urethra, vulva, and vagina caused by estrogen loss. It goes far beyond dryness.

Symptoms may include:

• Urinary frequency
• Urgency
• Getting up at night to urinate
• Burning or irritation
• Pain with sex
• Recurrent urinary tract infections
• Some types of bladder leakage

This is why women can feel blindsided. They may think menopause happened years ago, so why are urinary symptoms showing up now? The answer is cumulative hormone loss in pelvic tissues over time.

And one of the most striking takeaways from this conversation was this: vaginal estrogen can reduce recurrent UTIs by 50 to 60 percent.

That is huge.

Dr. Casperson also noted that vaginal estrogen can be as effective as certain overactive bladder medications, specifically anticholinergics, without the same burden of side effects like cognitive issues and increased fall risk.

For women with recurrent infections, this is a major treatment avenue to understand. Dr. Aliabadi’s clinic has additional information on UTIs in middle-aged and postmenopausal women, including why estrogen loss changes vaginal flora and urinary health.

Brain fog, memory changes, and the fear women rarely say out loud

Is brain fog in perimenopause and menopause real, and does it get better?

Yes, it is real. And yes, for many women, it gets better. But not always quickly, and not always completely.

Brain fog can show up as forgetfulness, poor concentration, losing words, slower processing, and the unsettling feeling that your brain is no longer working the way it used to. It is one of the symptoms that women often worry means something far more serious.

Dr. Casperson emphasized that current evidence does not suggest menopausal brain fog is the same thing as dementia, which is reassuring. But that does not mean it is trivial. Women are struggling at work, in relationships, and in daily functioning because of untreated symptoms.

She also shared her view that estrogen appears to be neuroprotective when started around the menopause transition, and that testosterone likely plays a meaningful role in brain health as well. While no one is recommending hormone therapy solely as a blanket prevention strategy for dementia at this point, the data around the brain deserves far more attention than it gets.

If cognitive changes are one of your biggest concerns, Dr. Aliabadi’s page on menopausal memory loss and brain fog offers a useful overview of common patterns and practical strategies.

When should hormone therapy start?

Do women need to wait until they are officially in menopause before starting treatment?

Absolutely not.

This is one of the most frustrating myths in women’s health. A woman does not need to be twelve months without a period before her symptoms are taken seriously. If she is 48 and has hot flashes, night sweats, brain fog, fatigue, vaginal dryness, painful sex, anxiety, and sleep disruption, we do not need to pretend nothing is happening just because she still gets a cycle sometimes.

Both doctors emphasized preventive care over “come back when it’s worse” care. The two years before the final period are also a time of major bone loss, which makes the wait-and-suffer model even harder to justify.

The principle here is simple: if the symptoms are there, the conversation should start.

Can women stay on hormones long term?

Dr. Casperson’s answer was memorable: many women fully intend to be buried with their patch.

That answer reflects how life-changing hormone therapy can feel for women who benefit from it. The fear surrounding hormones has been amplified for years, especially after the Women’s Health Initiative shifted public perception so dramatically. But hormones were once among the top-selling medications in the country, and current use is a small fraction of what it used to be.

Both doctors made the case that, for appropriately selected patients, long-term use can be reasonable. The bigger issue is not only safety, but access. Women who understand their options and can obtain treatment may have very different health outcomes from those who spend ten years untreated because they were told to just tough it out.

This is where individualized care matters most. Hormones are not one-size-fits-all, but fear-based avoidance is not evidence-based medicine either.

What about women with breast cancer or high breast cancer risk?

Can women with a history of breast cancer still use vaginal estrogen or testosterone?

According to Dr. Aliabadi, many can use vaginal estrogen because systemic absorption is minimal, and testosterone may also be an option even in women being treated for breast cancer.

This area requires thoughtful, individualized management, but one of the key messages was that women should not assume every hormone-related treatment is automatically off limits.

How do you approach hormone therapy in women at very high risk of breast cancer?

Dr. Aliabadi shared a more specialized perspective from her practice. Because she routinely calculates women’s lifetime risk of breast cancer, she often sees patients with very elevated risk. In select situations, especially in women with gene mutations or very high lifetime risk, she may recommend risk-reducing double mastectomy with reconstruction, followed by hormone therapy when appropriate.

That is obviously not a general recommendation for everyone. It is a highly individualized approach for a very specific population. But it illustrates an important point: breast cancer risk assessment should be part of women’s midlife care, and treatment decisions can be more nuanced than many people realize.

What women most need to hear

If there is one message you want women to walk away with, what is it?

You are not broken.

If sex hurts, if your desire has changed, if you cannot stop peeing, if your brain feels foggy, if your vagina feels dry, if you suddenly do not recognize your own body, that does not mean you are failing. It means you deserve better information and better care.

Midlife hormone changes are real. They affect the brain, bladder, vagina, sleep, libido, and quality of life. Women should not have to whisper about them, apologize for them, or wait until they are miserable enough to be taken seriously.

The combination of science, symptom-based care, and shame-free education is what moves women from confusion to clarity. That is what Dr. Casperson has built her work around, and it is why this conversation matters so much.

FAQs

Can you use vaginal estrogen and an estrogen patch at the same time?

Yes, many women can. Vaginal estrogen is a very low-dose local treatment and generally does not add meaningful systemic hormone exposure. For women whose vaginal or urinary symptoms continue despite systemic hormone therapy, using both can be appropriate.

Does vaginal dryness only happen after menopause?

No. Vaginal dryness can begin during perimenopause and can also occur with breastfeeding, certain birth control pills, and some cancer treatments. You do not have to wait until your periods have completely stopped to seek treatment.

What is genitourinary syndrome of menopause?

Genitourinary syndrome of menopause, or GSM, refers to the changes low estrogen causes in the vulva, vagina, urethra, and bladder. Symptoms can include dryness, painful sex, urinary urgency, frequency, bladder irritation, and recurrent UTIs.

Is lubrication still recommended even if you are using vaginal estrogen?

Yes. Lubrication can make sex more comfortable and reduce friction, especially if tissues are still dry or sensitive. Vaginal estrogen improves tissue health, but lube is still a useful and often essential tool.

Can testosterone help women in perimenopause or menopause?

It can help some women, especially those dealing with low libido, low energy, decreased motivation, or a sense of not feeling like themselves. But treatment should be individualized because libido and energy are influenced by many factors beyond hormones.

Do you need hormone blood tests before starting treatment for menopause symptoms?

Not always. Hormone levels can fluctuate and do not always match how a woman feels. In menopause care, symptoms often guide treatment more than lab numbers, though some clinicians may still check baseline labs in certain situations, especially before prescribing testosterone.

Is brain fog during menopause a real symptom?

Yes. Brain fog is a common and legitimate symptom of perimenopause and menopause. It can include forgetfulness, reduced focus, and slower mental processing. For many women, it improves, but it should not be dismissed.

Do women need to wait until menopause is official before starting hormone therapy?

No. If a woman has symptoms of perimenopause or menopause, that conversation can begin before she has gone twelve months without a period. Treatment should be based on symptoms and individual risk factors, not on an arbitrary wait-until-it-gets-worse model.

To learn more from Dr. Kelly Casperson, you can find her at kellycaspersonmd.com, on Instagram at @kellycaspersonmd, and through her podcast and book, You Are Not Broken.

This article was created from the video What You Need to Know About Hormones, Menopause, and Sexual Wellness | Dr. Kelly Casperson | SHE MD for Dr. Thais Aliabadi’s website.