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Episode
Vanishing Vulvas & Menopause: What's Really Happening with Dr. Karen Tang
~51 min
Episode Brief·YouTube

Vanishing Vulvas & Menopause: What's Really Happening with Dr. Karen Tang

Mary Claire Haver
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TL;DR

The four things you'd lose by not watching

4 items

TL;DR

The four things you'd lose by not watching

4 items
1

Vulvar itching is often misdiagnosed as yeast infection; conditions like lichen sclerosus, eczema, and GSM are common causes.

2

Vaginal estrogen is safe, effective, and should be used preventatively for GSM, not just reactively.

3

Pain with sex is never normal and can almost always be treated with vaginal estrogen, pelvic floor physical therapy, and dilators.

4

Surgical decisions for hysterectomy should involve shared decision-making, with ovarian preservation as default unless high risk.

Protocols

Concrete recipes — what, when, how much, and why

5 items

Vaginal estrogen for GSM

WhatUse vaginal estrogen (cream, tablet, ring) to treat and prevent genitourinary syndrome of menopause.
WhenAt first sign of symptoms or prophylactically in menopause.
DoseTypically a loading dose then maintenance; specifics not given but generic forms available.
For whomPostmenopausal women, also women on birth control or breastfeeding with low estrogen symptoms.
WhyLow estrogen causes tissue atrophy, dryness, itching, pain, and UTIs; vaginal estrogen restores tissue health locally with minimal systemic absorption.
CaveatsVery safe; almost no contraindications. Not recommended for women with estrogen-sensitive cancers without oncology clearance, but risk is low.

Dr. Tang and Dr. Haver strongly advocate for vaginal estrogen as a first-line treatment. They note that systemic hormone therapy is a microdose and insufficient for urogenital symptoms. Vaginal estrogen can prevent narrowing of the vaginal introitus, reduce pain with sex, and decrease UTIs. They mention that in the UK it's over-the-counter and hope for similar in US. Dr. Haver says she gives it prophylactically.

Mechanism

Vaginal estrogen is absorbed locally, thickening the vaginal epithelium, restoring rugae, increasing blood flow, and improving lubrication. It also helps maintain the vaginal microbiome and reduces pH, preventing infections.

Personal experience

I give it prophylactically.

I say we almost look for an excuse to give it. So I give it prophylactically.

Also said
“It's like this medication that like everyone can use. There's almost no risk to it. There's generic versions. It's covered by insurance.”— Highlights accessibility.
“You are better off treating both areas at the same time and maybe we can prevent any of these problems.”— Emphasizes dual treatment.

Pelvic floor physical therapy for painful sex

WhatRefer to pelvic floor physical therapy for evaluation and treatment of dyspareunia.
WhenAs part of workup for pain with sex, especially if muscle spasm or pelvic floor dysfunction suspected.
DoseVaries; typically multiple sessions with home exercises and dilator use.
For whomWomen with pain at the opening or deep pain, vaginismus, or after surgery.
WhyPelvic floor muscles can become tight or spasmodic due to pain, leading to a cycle of more pain. PT can retrain muscles and desensitize nerves.
CaveatsRequires a skilled pelvic floor therapist; not all PTs are trained.

Dr. Tang says she sends everyone for pelvic PT for pain with sex. She notes that dilators are hard to use alone; PT guides proper use. PT can also help with narrowing of the vagina. She says almost 100% of the time PT can help in some way.

Mechanism

PT uses manual therapy, biofeedback, dilators, and relaxation techniques to reduce muscle tension and improve flexibility. It also helps with nerve desensitization.

I send everyone for pelvic PT. I think it can only help. And oh my god. And then especially with pain with sex, almost 100% of the time they can help in some way.

Also said
“The physical therapists help guide you and they help to, you know, retrain the nerves. Like they do all sorts of amazing things.”— Describes PT benefits.

Dilator therapy under PT guidance

WhatUse vaginal dilators to gradually stretch the vaginal opening and reduce pain with penetration.
WhenAfter pelvic PT evaluation, as part of a graded exposure program.
DoseStart with smallest dilator, progress to larger sizes over weeks to months.
For whomWomen with vaginal stenosis, vaginismus, or pain at the introitus.
WhyNarrowing of the vagina from GSM or muscle spasm can be reversed with gradual stretching.
CaveatsShould be done under guidance of a pelvic floor therapist to avoid injury or improper technique.

Dr. Tang mentions that dilators are hard to use on your own; PTs help with technique and progression. This is part of the comprehensive approach to dyspareunia.

Mechanism

Dilators provide mechanical stretch, desensitizing the tissues and retraining the pelvic floor muscles to relax.

It's very hard to use a dilator on your own if the vagina is narrow. People don't know what to do or how to insert it. The physical therapists help guide you.

Biopsy for persistent vulvar itch or lesion

WhatPerform a biopsy of any persistent vulvar lesion or area of itching that does not respond to treatment.
WhenIf a patient has a persistent itch, especially postmenopausal, or a visible lesion that is not healing.
DoseN/A
For whomPostmenopausal women with persistent vulvar symptoms, especially those with risk factors.
WhyTo rule out vulvar intraepithelial neoplasia (VIN) or vulvar cancer, which can present as itching.
CaveatsLow threshold for biopsy; can be done in office.

Dr. Tang shares a story of a nursing home patient with vulvar cancer that was dismissed as irritation. She emphasizes that vulvar cancer is rare but must be considered. She says 'you always have to have a low threshold to consider non-yeast things'.

Mechanism

Biopsy provides histologic diagnosis.

Personal experience

I've definitely had a patient, I can't remember when this was, who literally she was in like a nursing home. ... it was like a vulvar cancer and they just been sitting on it cuz they're like, 'Oh, just like older women just have itchy vulvas.'

Post menopausal patient with persistent itch or something that's not going away like a little lesion, got to biopsy it because it could be something that's more concerning. You just save someone's life.

Also said
“You always have to look at it. You always have to have a low threshold to kind of consider non yeast things.”— Reinforces the need for thorough evaluation.

Antiviral therapy for herpes prodrome

WhatStart Valtrex (valacyclovir) at the first sign of prodrome (tingling) to prevent or reduce herpes outbreak.
WhenAt the onset of prodrome symptoms before ulceration.
DoseAs prescribed; typically a short course.
For whomIndividuals with recurrent genital herpes.
WhyEarly treatment can abort the outbreak or reduce severity.
CaveatsRequires prescription; should be discussed with doctor.

Dr. Tang mentions that herpes is a common cause of vulvar burning/itching and often comes with a prodrome. She advises patients to learn their signal and start medication early.

Mechanism

Antiviral inhibits viral replication.

Take your Valtrax. You know, you'll learn when you have that signal to start taking your vow tracks and hopefully we can head off the ulceration before it comes.

What's new

Personal practice updates, fresh positions, predictions

4 items

Lichen sclerosus causes vulvar architecture loss

around 5-7 minutes

Lichen sclerosus is a chronic inflammatory condition that can cause scarring and fusion of the labia, leading to 'vanishing vulva'.

Why this matters: Many women and clinicians mistake symptoms for yeast infections, delaying diagnosis and treatment.

Background

Previously, vulvar itching was often attributed to yeast or irritation without considering skin conditions.

Dr. Tang explains that lichen sclerosus is an autoimmune condition that causes intense itching and can lead to loss of labia minora as they fuse to labia majora. It requires biopsy for diagnosis and treatment with potent topical steroids. If untreated, it can cause scarring and increase risk of vulvar cancer. The condition is underdiagnosed because patients are often told it's just a yeast infection.

There's something called lychen sclerosis which is a chronic inflammatory condition causes horrible itching. It can cause scarring. You can lose we say lose the architecture or people have heard this on social media like your vulva disappear.

Also said
“That's one of the things can make your vulva disappear like your lips like the labia minora can literally like go away with ly and scerosis like it just kind of fuses to the labia majora”— Describes the mechanism of fusion.

GSM also occurs during lactation and birth control

around 20-22 minutes

Low estrogen states from breastfeeding and hormonal birth control can cause similar symptoms to menopause, termed 'genital urinary syndrome of lactation'.

Why this matters: This expands the population at risk beyond menopausal women.

Background

Previously, GSM was only associated with menopause.

Dr. Tang and Dr. Haver discuss that lactation suppresses ovarian function, leading to low estrogen and symptoms like vaginal dryness, pain with sex, and UTIs. Similarly, birth control pills suppress ovulation and can cause low estrogen symptoms. Dr. Rachel Rubin coined the term 'genital urinary syndrome of lactation' to highlight this. Many women on birth control or breastfeeding are not asked about vaginal symptoms.

And just to throw it out there, because a lot of people don't realize that the birth controls, you know, they are suppressing your ovaries, a lot of times people will feel like some low estrogen symptoms, including sometimes pain with sex or vaginal dryness.

Also said
“So, lactation and breastfeeding, birth control, like there all these things where our estrogen levels are suppressed.”— Lists the low estrogen states.

Preventative use of vaginal estrogen

around 15-18 minutes

Dr. Haver and Dr. Tang advocate for using vaginal estrogen prophylactically to prevent GSM changes, not just treat symptoms.

Why this matters: Shifts from reactive to preventive care in women's health.

Background

Traditionally, treatment was only offered after symptoms became intolerable.

They argue that systemic hormone therapy is a microdose and insufficient to protect the urogenital system. Vaginal estrogen is safe, low-risk, and can prevent narrowing, pain with sex, and UTIs. Dr. Haver says she gives it prophylactically. They note that in the UK it's over-the-counter, and there's a push for OTC in the US.

Personal experience

I give it prophylactically.

I say we almost look for an excuse to give it. So I give it prophylactically.

Also said
“Menopause hormone therapy is a micro dose compared to what your body was making in your premenopausal years. It is unreasonable to think that for the next 30 years this micro dose is going to be enough to penetrate that general urinary system.”— Explains why systemic HT is insufficient for urogenital symptoms.
“The prevention is so huge because again so much of the menopause and women's health in general is you're sort of like reacting.”— Highlights the shift to prevention.

Pain with sex is never normal

around 25-30 minutes

Both doctors emphasize that painful sex is never normal and can almost always be treated.

Why this matters: Challenges the myth that pain with sex is an inevitable part of aging.

Background

Many women are told to just accept it or relax.

Dr. Tang explains that a detailed history (where, when, positions) helps identify cause: vulvar, pelvic floor, or deep. Treatment includes vaginal estrogen, pelvic PT, dilators, and sometimes surgery. She says she has never had a patient she couldn't help. Dr. Haver shares that she is having the best sex of her life at 57.

Personal experience

I'm having the best sex of my life. I'm 57.

Is pain with sex ever normal? No, never. But should we ever accept that? Common does not equal normal and you don't have to suffer from it.

Also said
“I don't think I've ever had a situation where a patient had pain with sex that we couldn't at least get it almost all under control so they could have satisfying sex.”— Shows treatability.

Recommendations

Products, supplements, and tools mentioned in the episode

5 items

Vaginal estrogen (generic)

Product

Recommended for GSM symptoms and prevention. Available as cream, tablet, or ring. Generic versions are covered by insurance.

Both doctors strongly endorse vaginal estrogen as safe and effective. Dr. Haver uses it prophylactically. They note it's over-the-counter in the UK and hope for US availability.

vs alternatives

Compared to systemic hormone therapy, vaginal estrogen is more targeted and has minimal systemic absorption. Compared to vaginal DHEA, it is generic and cheaper.

Personal experience

I give it prophylactically.

It's like this medication that like everyone can use. There's almost no risk to it. There's generic versions. It's covered by insurance.

Also said
“I say we almost look for an excuse to give it.”— Shows enthusiasm.
Find Vaginal

Vaginal DHEA (Intrarosa)

Product

An alternative to vaginal estrogen, especially for women who want both estrogen and testosterone effects. Branded, not generic, may have insurance issues.

Dr. Tang rarely uses it because patients prefer estrogen and it's easier. Dr. Haver has prescribed it a few times for patients who request it after learning about it from experts like Rachel Rubin. It converts to both estrogen and testosterone locally.

vs alternatives

Compared to vaginal estrogen, DHEA provides additional androgen effects but is more expensive and may require compounding.

Personal experience

I actually because almost always I the patients like the vaginal estrogen. Like I usually start with the vaginal estrogen and then you know like I can't even remember the last time I've done the DHEA.

This person came out like I haven't we prescribed it a couple times like some patients come in asking for it. They saw something they read something and they want that that two one hit of testosterone and estrogen.

Also said
“We do have androgen receptors in the vulva and so the sex med people are really interesting big on it.”— Explains rationale.
Find Vaginal

Pelvic floor physical therapy

Service

Recommended for any woman with painful sex, pelvic pain, or GSM-related muscle tension.

Dr. Tang sends all her patients with dyspareunia to pelvic PT. She says it can almost always help. PTs use manual therapy, biofeedback, dilators, and education.

vs alternatives

Compared to self-dilation, PT provides guidance and ensures proper technique.

I send everyone for pelvic PT. I think it can only help.

Also said
“The physical therapists help guide you and they help to, you know, retrain the nerves.”— Describes PT role.
Find Pelvic

GoodRx

Tool

Used to get testosterone gel prescribed affordably.

Dr. Haver mentions that Dr. Rachel Rubin taught her how to prescribe testosterone gel through GoodRx, a logistical tip.

Personal experience

Rachel Rubin taught me how to prescribe testosterone gel to get it through Good RX. Like I didn't know about just these logistical things.

Rachel Rubin taught me how to prescribe testosterone gel to get it through Good RX.

Find GoodRx

Bring a support person to doctor visits

Practice

Advice for patients to bring a friend or family member to help remember questions and advocate.

Dr. Tang recommends this especially for patients with brain fog or who feel overwhelmed. The support person can remind the doctor of concerns.

If you feel like you might get overwhelmed, like bring a friend, like bring a spouse, a friend, somebody who Exactly. support person.

Also said
“I love this when when people bring a support person and they chime in.”— Shows doctor's positive view.
Find Bring
Disclosed sponsorships2speaker disclosed

It's Not Hysteria by Dr. Karen Tang

Book Sponsored · disclosed

A book covering common gynecologic conditions and how to navigate them.

DisclosureDr. Tang is the author and guest on the podcast.

Dr. Tang mentions her book in the context of vulvar itching and the chapter titled 'it's not a yeast infection'. The book provides comprehensive information for patients.

The chapter on vaginal stuff in my book, I literally almost did the title, it's not a yeast infection, because so much itching gets chocked up for yeast infections.

Find It's

The New Perry Menopause by Dr. Mary Claire Haver

Book Sponsored · disclosed

A book about perimenopause, its distinct phase, and how to navigate it.

DisclosureDr. Haver is the host and author; the book is promoted in the podcast.

The podcast includes an ad for this book, describing perimenopause as a distinct biological phase often ignored.

Perry menopause is not early menopause. It is its own distinct biological phase and it has been largely ignored.

Find The

Notable quotes

Lines worth pulling out — contrarian, specific, or perfectly phrased

6 items
Common does not equal normal and you don't have to suffer from it.
Powerful reframing of common symptoms as not acceptable.
I'm having the best sex of my life. I'm 57.
Personal testimony that challenges the myth of declining sexual satisfaction with age.
If you wouldn't rub this on your eye, you shouldn't put it on your vulva.
Simple, memorable rule for avoiding irritants.
The prevention is so huge because again so much of the menopause and women's health in general is you're sort of like reacting.
Advocates for proactive, preventive care.
I say we almost look for an excuse to give it. So I give it prophylactically.
Shows strong endorsement of vaginal estrogen.
There's never just one answer. Not for cancer, not for a heart attack. There's never just one thing.
Emphasizes the importance of multiple treatment options.

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Topics covered

vulvar-itchinglichen-sclerosusgenitourinary-syndrome-of-menopausevaginal-estrogenpainful-sexvulvodyniahysterectomy-decision-makingovarian-preservationpelvic-floor-physical-therapyvaginal-dhealow-estrogen-states-lactationbirth-control-low-estrogenherpesvulvar-cancerpatient-advocacyfinding-specialistmigs-specialistdilator-therapybiopsy-vulvar-lesionantiviral-prodrome
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Educational summary of the cited expert source — not medical advice. Open the source recording linked above and consult a qualified physician before acting on any protocol.