#341 | Genitourinary Syndrome of Lactation: How Breastfeeding Can Mimic Menopause

After birth, many women are left blindsided by physical changes they never expected. Vaginal dryness, painful sex, recurring UTIs, and even emotional strain can all show up during breastfeeding — but most mothers are never told why. In this episode, we sit down with Sara Perelmuter, a third-year medical student at Weill Cornell Medical College in New York City. Sara currently serves as president of the Sexual Medicine Research Team and has authored numerous peer-reviewed publications on reproductive and genitourinary health.

Sara explains the hormonal shifts that mimic menopause in the postpartum period, why so many women are suffering in silence, and what the research reveals about both the prevalence of these symptoms and the safe, effective treatments available — including pelvic floor therapy, moisturizers, lubricants, and topical vaginal estrogen.

These symptoms are common, but they are not inevitable. By naming and studying them, we open the door to treatment and better care.

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Transcript

I'm Cynthia Overgard, birth educator, advocate for informed consent, and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Show. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

Hello. Thank you so much for talking with me today. My name is Sarah Perelmuter. I am currently a third year medical student at Weill Cornell, here in New York City in Manhattan. I am originally Canadian, but I decided to pursue my undergrad and masters in England, and then I'm now doing my MD medicine at Cornell. I also serve as the president of the sexual medicine research team with my mentor, Dr Rachel Rubin, where we have come up with this new novel term, the genital urinary syndrome of lactation. GSL, so what is GSL? GSL the genital, urinary syndrome of lactation. So in post the postpartum period, when an individual starts lactating or breastfeeding, basically breastfeeding results in an elevated levels of particular hormones called prolactin, and when we have a high levels of prolactin, that basically triggers a suppression of our other hormones that result in a state in our body that we have low estrogen and low androgens, so low estrogen and low testosterone, and that state can persist as long as lactation continues. And so as a result of those low levels of hormones, a whole collection of genital and urinary symptoms can evolve, and so that's things like vulval vaginal atrophy, vaginal dryness, decreased, lubrication. You could have painful intercourse, as well as urinary symptoms like urinary tract infections and urinary incontinence, and so GSL is this collective term to describe this range of genital and urinary symptoms experienced by postpartum, lactating individual as a result of the hypo estrogenic and hypo androgenic state that they're experiencing. It's a bit like when women go into menopause, very similar state of hormones, and most women aren't even aware of those symptoms when they become menopausal. 

But certainly nobody is talking about this for women who have just had a baby, yeah, absolutely. That's actually where the idea was inspired from genital urinary syndrome of menopause, where we see, in that case, you know, the ovaries are failing, and so you have this deprivation of estrogen and androgens, but it's very similar. So just like menopause in the postpartum period, you'll also have insomnia and hot flashes and all of those classical symptoms that we associate with with menopause, but the most but also common, but less discussed symptoms are also the vaginal dryness, the pain with intercourse, all of those genital symptoms are also very common and prevalent, but no one is also talking about them, and so they're very under recognized. And because of that, a lot of women are just kind of accepting it as a normal part of the postpartum, lactating experience, and they're not offered strategies that do exist to help mitigate some of those symptoms.

Is this something that's newly diagnosed, like, if women went through this 2030, years ago, they just kept it to themselves, or doctors dismissed it and didn't really know what to make of it? I mean, are we is this now something that they recognize? It has a defined set of characteristics, and it's a new diagnosis as of like, what a couple years ago now? Or how long has this been around?

Yeah, so physiologically, we know that there's been this massive drop in hormones after birth for for a long time, but it's never been clinically defined, and so it was in 2024 that my research group, the sexual medicine research team, as well as with Doctor Rubin, we first published a literature review in sexual medicine reviews, and that was a review to just give a name to this term. And so we coined this term, genital urinary syndrome of lactation, because we found that it would be empowering for patients, but also physicians, to be able to name this collection of symptoms with a name, because you can't treat something if you don't have a diagnosis. And so that's what we were essentially trying to do. So in 2024 was our first publication introducing this name. And then in 2025 we had a larger publication in the green journal, which was a systematic review, which was quantifying the prevalence of these symptoms. And we saw very high prevalence of all these symptoms in the vast majority, like 64% vaginal atrophy, above 54% vaginal dryness, and dyspareunia even higher. Dyspareunia is pain with intercourse, and we saw that even up to 60 and 70% and so we also have future research that's being reviewed. Currently, we've just completed a survey. Away from lactating postpartum mothers to try to understand their personal experiences and also specifically their barriers to with their healthcare providers, about talking about these symptoms, about getting the resources that they need. And so in the future, we now have this coin term GSL, but we want to more specifically define the exact criteria. So the criteria right now are kind of the presence of the collection of symptoms that I mentioned, like the vaginal dryness, UTIs, painful intercourse, things like that, very similar to gsm. And so it's a clinically defined syndrome, which means that you don't need to get a blood test, or you don't even really need to have a pelvic exam. It means that if you have the presence clinically of these symptoms that you're experiencing that you can be grouped into having GSL.

How many weeks or months postpartum are you determining whether painful intercourse qualifies as a symptom?

Yeah, absolutely. So in our systematic review, we looked at three time points. So we looked at three months postpartum, six months postpartum, and then a year at 12 months postpartum. So we saw overall, there was a steady decline of the prevalence of painful intercourse. So at three months it was the highest. So that was just over 60% of postpartum individuals who are lactating compared to postpartum individuals who are non lactating, experienced dyspareunia. So we found a significant difference in those two groups. And so at three months it was 60% then at six months, it's slightly declined to 40% and at 12 months, it was just under 30% so we think that likely, over time, there's kind of this re equilibrium of hormones, and that likely contributes to the to kind of reestablishing the baseline hormone levels and contributing to the resolution of this painful intercourse. And so right in the more acute postpartum period, in the several months right after birth is when we see the highest prevalence of these GSL symptoms, especially in nursing women. Yes, particularly.

So, yeah, exactly. So our systematic review specifically compared postpartum women, but the two groups were postpartum women who were lactating versus postpartum women who are not lactating. And in our in our upcoming study, which hasn't been published yet, we actually stratify our groups into three populations, postpartum women that are only exclusively lactating. Then we have a middle group that are postpartum women that are both lactating and also supplementing with formula so doing a mixture of breastfeeding and formula feeding. And then we also have the third group, which is exclusively formula feeding. And so we're trying to see we found, we haven't yet published it, but we found, kind of a dose dependent prevalence and severity of symptoms based on those three groups, with exclusive breastfeeding being the highest prevalence and and going down per group.

Well, this would make sense, because it's most likely related to elevated levels of prolactin and low estrogen. So if you're breastfeeding more, you're going to have higher levels of prolactin, your estrogen levels are going to be lower. And all of these symptoms are basically a result of low estrogen, which is why there is a very available treatment for women who are suffering with these symptoms, which we will get into next. But before that, I wanted to also ask, Did you see any correlation with resolution of symptoms or improvement of symptoms when women got their menstrual cycle back breastfeeding?

Yeah, so that's really interesting as well. So we tracked the the time of the return of the menstrual cycle, and so we found, not surprisingly, women that were exclusively breastfeeding compared to women that were not exclusively breastfeeding, women that were exclusively breastfeeding, they had a longer time until their menstrual cycle returned. So we didn't specifically, we weren't specifically able to compare the time to menstrual cycle resolution, to the symptom severity, but we individually looked at the the like there was a dose dependent relationship between the length of time to menstrual return in exclusively lactating people, and also severity of symptoms and prevalence of symptoms in exclusively lactating individuals. So kind of using those two comparisons, we can draw our own ideas about correlating menstrual resolution with severity, but really the underlying cause is the same. Is the same culprit, which is what you mentioned, which is the prolactin in lactating causes low estrogen and androgens, and that's what both results in the symptoms and, um. On the menstrual cycle, not being present.

This is such a difficult position for postpartum mothers to be in, because one, they are already exhausted, they are frustrated with their post birth bodies, and then to have, you know, low energy, low libido, you know, probably some relationship issues, because they feel like the workload is, you know, unduly on them, and then on top of that, to have pain when with intercourse, when you know their partner wants to have intercourse, and they feel that they should, and they want, they even, may even want to, but they have so much working against them. So did you incorporate in your research, any, was there any tracking of like the emotional aspect or the mental symptoms?

Yeah, so we specifically want looked also at Quality of Life scores and so incorporating into the quality of life. We looked at specifically at things like difficulty in engaging in sexual activity, increased discomfort just in daily activities, as well as the impact on mental health. And so we basically got participants to rate their impact scores on a scale from zero to 100 100 being they had the greatest impact on that quality of life score. And so we found that the highest quality of life impact was on the impact on sexual activity, and that was highest, again in the exclusively lactating group, then specifically for the mental health aspect of quality of life, we found that it was actually quite similarly affected across both across all groups, not necessarily pertaining to exclusive lactation, and that's likely what you kind of pointed to, which is that every every mother is going through this experience, regardless if she's breastfeeding or if she's breastfeeding and formula feeding or just formula feeding, it's still that unanimous experience, and still that overall hormone drop just right post birth, regardless and delivery of the placenta. And so everyone is experiencing such a significant life change at that moment, and so the mental health aspect is is common and prevalent among all postpartum mothers.

Alright, I can ask a couple questions on that. The first is, if I understood what you just said correctly, it's basically this portion of the research was qualitative information that the women themselves quantified, is that correct? So they basically assessed their own comfort level with engaging in sexual activity, their own mental state. They put a number to it. So they we took basically qualitative information and found a way to make it numerical through through the eyes of those women.

Yes, exactly. So this is our in our upcoming survey study that hasn't been published. So we got the postpartum individuals themselves to fill out that survey and to rate their their experiences with GSL or with their postpartum experience in general. And so part of that was exactly as you describe. We got them to to quantitatively score give a number to their experience from zero to 100 their alignment with all of those symptoms, like I mentioned, their impact with mental health, difficulty engaging in sexual activity, and so we allowed them to kind of be able to quantify their experiences in a Data and statistical method.

Okay, I have two more questions. How many women were in this study? Is my next question? Yeah.

So in this study, it was 1406 I think, across multiple platforms, mainly in the United States, but also in several other countries, and they were all within one year of the postpartum period.

And then my other question is, did you only accept women into the study who experienced no tearing, no episiotomy, or did they have all sorts of different vaginal tearing or cutting experiences that may have convoluted the results or influenced the results that you then had to slice and dice and decipher? What did you do about that? Did you start off with like a clean population as far as vaginal tissue being intact, or was that also something you had to figure a way through? What did you do with that?

Yeah, that's a really great point. I'm glad you brought that up. We included everyone, but we had them report if they had a level a degree of tearing or episiotomy during their their birth and essentially what their birth trauma was specifically and so we didn't have a large enough sample size in the each of the individual types of tearing cohorts to do specific stratified analysis. But is absolutely true that. That those that have tearing will have that residual like focal and very tenderness spots, which will also contribute to pain with intercourse and all of these things and estrogen, it's hypothesized that estrogen could also contribute to maintaining, to wound healing, essentially because estrogen contributes to maintaining a healthy vaginal tissue. And so it's thought that the lack of estrogen, such as in the postpartum lactating period, that could actually impact and impede or cause a longer recovery process in perennial wound injury following birth trauma. And so that's an just another reason that we want to talk about treatment and using vaginal estrogen, which we'll get into more later, for these women, because it not just may help with their GSL and dyspareunia and pain with intercourse symptoms, but it could also significantly impact their ability for their tears to heal, right? And many providers are afraid to prescribe it, even though they know it's an effective treatment for prolonged wounds that aren't healing. Well, they know it's an effective treatment, but they're afraid to use it, because everybody is told that you should not have any estrogen during lactation that it you know that it can affect your milk supply. So we do want to talk about treatment, and we do want to talk about the safety of estrogen during lactation. But before we do that, I wanted to also ask, Was there a correlation, or did you look at the discontinuation rates of breastfeeding as a result of higher scores on the evaluation, did you see a correlation there with with mothers discontinuing breastfeeding early because of these symptoms?

That's a really interesting, interesting correlation that we did not actually conduct. We did see some basic correlations, which were things like, the older the age of the mother, the more likely that they will stop or not be exclusively breastfeeding as long. And we also saw correlation which was the the further the length of time post birth, the more likely that they will not be exclusively lactating. And those correlations which make feasible sense in our society, but we it would be very interesting to try and see if there was the specific reason, if the specific reason for stopping breastfeeding was due to these symptoms, that's something that we should definitely look into more.

Was this study done over a period of time, over the 12 months, with a group of women, or it didn't sound that way. It sounded like you got a group of women. So some women who were looked at were, say, 10 months postpartum. Did they have to reflect upon how they felt at the three month point? Because you weren't actually in contact with them when they were at three months, did they have to remember and reflect?

Yes, so Exactly. So what we did is we did a retrospective survey, and so at one point of time, we conducted the survey and collected responses over, I think it was over three months, but we did not follow a group of women for the 12 months. So when we collected the survey, we said, this is a one time survey that you will complete on your postpartum experiences. But we did not ask them to specifically reflect at times during their postpartum period. We asked them just their current their current symptoms, and then we stratified them based off of their time that they were currently in their postpartum period. So if a three month postpartum mother said, I am having this much dyspareunia, we put them in the three month postpartum group.

And if you had a woman at the six month point, you took her response, but you didn't take a response from her on how she herself was feeling at three months.

Yes, we only took the current responses because there is already a degree of bias that's introduced with self reported studies, which means that the patient has to report and quantify their own experiences, and that can that can vary from person to person, and there can be bias when you're thinking back and remembering and having a different perspective when you're looking back versus when you're in it. So we tried to stratify based on time as best as we could if you were to redo this study, or if there's a new version of it in the future, what are ways that it could be perfected, where you could just take out some of that nebulous data that's so difficult to track? I mean, would it involve tracking the same group of women for 12 months, removing women perhaps who had sexual trauma in their lives, removing women perhaps who suffered birth trauma, or who had perineal tearing, what's you in your in your dream world? If you get the funding to do another research on this, which I'm sure is in your future, I'm sure that's your intention, what would it look like next?

Yeah, absolutely. So two parts to that. I think that first part is tracking the symptoms, and the second part would be randomized. To treatments, right? So the first part would be like a prospect of so tracking people, not looking backwards, but in real time, and following that group of women and and what you hint towards, which is removing any other confounding or contributing variables. And so we did basic exclusion, so if anyone was born with with anatomical anomalies in their genitals, or if they had an underlying hormonal disorder or had to take hormone pills for another sort of reason, we excluded them, but we would, we could even go more specifically with that and and track, for example, the number of of previous children that they've had. And I think it would be really interesting to see if the if GSL symptoms differ if it's your first child versus if it's your fourth child, and so be able to clarify the relationship over time, particularly, as well as remove all the other confounding factors, which could be things like you mentioned, like birth trauma, degrees of tears and also sexual trauma. Yeah, sexual trauma, other history and even like environment and accessibility to resources, whether they had a home birth or institutional and a hospital birth, whether they had a midwife present their education all around birth practices prior to and just be just get as as much comprehensive information as we could.

It would be really interesting too to see to include a history of birth control use or prior history of of contraceptive pills, or maybe even infertility contraceptive medications, fertility drugs. And then I have to imagine that age would play into it too. I mean, I would think a woman having a baby in her 40s might be a little bit more prone to this than a woman having a baby in her early 20s.

Yeah, we would, it's interesting. So to answer kind of two parts to that. The first part is, it would be very interesting to look at the history, specifically of oral contraception, contraceptive pills. We looked at the type of contraceptive method used in that postpartum period, whether it was IUD or the birth control pill or any other or the patch or the implant, things like this, and we looked at to see if that impacted the return of menstruation as well as GSL symptoms. So we did not see any correlation between the type of contraception and any of those outcomes. But we didn't look at the contraception use prior to trying to get pregnant and getting pregnant. So that would be a really interesting part, especially specifically I'd be interested in in kind of the long term or oral contraceptive use, like, for example, women who've been on the pill for, say, at least a decade, and if that differs from from women who have never been on hormonal contraception. And then the second part is with age. It's interesting because it is true that as women approach their 40s and their 50s are getting into this perimenopause and then menopause stage where they're naturally not going to have as much estrogen and androgens in their body. But even regardless, a 20 year old who goes through birth will have that drastic drop after birth regardless, and still, will still be in a Hypo estrogenic and hypo androgenic state. So absolutely, I'd be interested to see, but I would think that so I would hypothesize that they would likely still both experience those low levels, but perhaps the younger woman may be able to kind of equilibrate her hormones in a shorter duration afterwards, because her body is able to produce estrogen still, whereas a protein perimenopause, your body isn't as primed to produce all of those hormones as much.

Or I just had the exact opposite thought, even though I sort of proposed that idea. But maybe a woman in her 20s notices it so much more dramatically, because it is a bigger shift where a woman later in her life might not feel it as much because it's more of a subtle shift. I don't know it'd be really exactly we don't know. No one studied this, so we need to be the ones to figure it out. Women also experience that on the birth control pill?

Yes, yes, absolutely. And so there's also been some talk about, you know, how do we categorize all these syndromes or disorders or, you know, instigators that can trigger these low levels of of estrogen and androgens? And there's also particular types of brain tumors that mess up our hormones, that can cause low levels of those hormones, and certain medications which can cause these low levels of hormones. And so we want to kind of take a step back, and okay, we've decided we've defined GSM. Now we're defining GSL, but actually, is this what are, what are the triggers, more broadly? Because if we. Have treatments and resources, then we can apply them to to any to any cause, because if the treatment is attacking those low levels of hormones, then it should theoretically work, regardless if it's GSM or GSL, you're still trying to address those low hypoestrogenic, low hypo angiogenic state.

I can't help but long to see a category of women in the next study that has never had her hormones impacted chemically by anything, no pill, no estrogen shots or whatever like no birth control pill. I would love to see not only the women who didn't have their birth complicated with trauma or a history of sexual assaults and perineal tears or episiotomies, but the woman whose hormones always had to recenter themselves, always had the opportunity to get that biofeedback to re level themselves. That would be so interesting to me, to see if that transition after the drop after birth, if her body just sort of responds in kind the way it always had to, without interference or assistance. I would be so curious to see that, because hormones are a biofeedback system. They're changing morning, noon and night. They're constantly changing based on everything. And I feel like that would be a valuable thing to look at. If you know, if a woman whose hormones are at a certain level naturally versus someone who is there because she was on the pill for a long period of time, or a woman who has naturally higher estrogen versus a woman who's taking estrogen supplements, that it would be so interesting to see. I think so interesting to see, I think especially women who've never had any hormone, you know, taken exogenously, versus, say, that group of a decade long on birth control pill. And it's interesting, because you know, if you've been on, say, a decade of birth control pill, then you know you go off it, and you can still get pregnant. But you know, it's typically thought that you're sometimes your body needs at least three months to fully build up that uterine line lining, to be able to support a pregnancy. And so I wonder if there's kind of a a longer reset that needs to occur or not. It'd be very interesting to look at.

I imagine the thyroid function plays a role in this too. In so many women are experiencing subclinical hypothyroidism, it pre pregnancy, throughout pregnancy, and then I would imagine that that also has an impact on their on how their body processes, the low estrogen state of lactation. So there are a lot of factors, but I think the most important thing you know in this discussion is that for women who are experiencing this, there is a solution, and it isn't going to impact breastfeeding. I mean, the last thing that we need is for women to be giving up breastfeeding because they are experiencing frequent UTIs, or they can't go back to having intercourse because it's too uncomfortable and painful, and they decide to stop breastfeeding because of it, when they have been told that they can't use estrogen because estrogen is going to impact their milk supply. So let's talk about the treatment.

Yeah, absolutely. So the first step of different types of treatments, you can first do non medical, non pharmacological treatments, and so those are things like vaginal moisturizers, lubrications, and also, specifically pelvic floor physiotherapy, which I had never heard about before this space, but it's so profound and can really have significant effects.

I was going to throw that in earlier as another thing to take note of in a study, you know, the women getting postpartum PT are going to have a better recovery, easier recovery. We also didn't mention if women have had a C section, I'm sorry to interrupt.

Oh, yes, we did. We did look at that in our population, but yes, but absolutely be interesting to see even pre prenatally, people that went to pelvic PT in preparation exactly the birth Yes. Um, but yeah. So in the postpartum period, that is one of the one of the treatments. And in other countries, like France, postpartum pelvic Physiotherapy is actually standard, and it's offered and provided to all postpartum mothers. What a concept, yes, and it is so incredibly hard to find in the US. Like a great pelvic floor specialist, yes, they're worth their weight in gold, because they're treasures.

They're treasures. Yes, completely. They fly completely under the radar. People don't know about them. I've never heard about pelvic physiotherapy, but it can be very, very significant. And so that is one of the treatments. In addition to those other non pharmacological, you know, lubrications, is pelvic floor PT, which is specifically aimed at at the pelvic floor muscles, whether it's strengthening them, sometimes during pregnancy, the ligaments and muscles can be stretched so much that you. Urinary incontinence, you know, where you leak a little bit of urine, where you laugh or sneeze. So they can focus on focus on strengthening it. Conversely, you can have really hypertonic pelvic floor muscles, which can contribute to deep pain with intercourse. And so pelvic floor PTS can help work on those muscles. So just like your back gets knots in the muscles in your back your pelvic floor can also get muscle knots in it, so the pelvic floor PT can help release those pressure points, and so that is also one of a really, a really great resource before we go on. Can you explain vaginal moisturizers and lubrications, how women would use those? Because those are two different things.

Yes, yes, absolutely. So. So basically, it's, it can be there can be multiple different symptoms, essentially. So there can be vaginal dryness, which we like to quantify as just dryness at rest, that can be very uncomfortable, just in daily activities, whereas when we see decreased lubrication, that's when we're specifically talking with arousal, with sexual activity, the the lack of lubrication. And so those are slightly similar but slightly distinct symptoms that we want to define as just vaginal dryness, which is kind of a baseline dryness versus the lubrication during sexual arousal and so So similarly, vaginal lubrication would be specifically more for those sexual encounters, rather than the daily, daily discomfort of of the dryness, whereas vaginal moisturizers would Be for more of that, just baseline day to day, not necessarily pertaining to sexual arousal or desire. Yes. So, So then moving on. Kind of the the star of the show we like to call is vaginal estrogen. And so our study specifically did not quantify it, but there have been previous studies that specifically looked at vaginal topical so we're talking about a cream, a topical cream, that you put on your vulva and your vagina. And when it's topical, it's has this just local effect. And so studies have looked at women who've used topical vaginal estrogen, and they've taken blood samples and look to measure the levels of estrogen in their blood, and they found that when women were using topical vaginal estrogen, they did not see any systemic rise in estrogen in their body, in their Blood. And so that's because when you apply topically, it only has that local effect, and it doesn't go systemically throughout your entire body. And so if it's not when we don't see increased levels in your blood, then it's not able to transfer to your breast milk, to your baby, or affect your breast milk supply, or the quantity, or your ability to breastfeed and all these things. And so we really want to talk about the efficacy ones, but also the safety of estrogen. So topical vaginal estrogen is safe to use while breastfeeding.

Sarah, can you please explain why topical estrogen does not absorb into the bloodstream and go systemically. Is it just that the receptor sites in the vagina and the vulva are extremely receptive and it just binds there and doesn't go anywhere else? Or what's the biochemistry there? How does that work?

So we think we don't know exactly truth be told, but basically that we saw that in that study that was looking at at vaginal estrogen therapy at the time they were using, there was several different sites, but the main one was actually using a vaginal estrogen suppository that was inserted into into the vaginal canal, essentially. And then they also had a cohort that was using a transdermal estrogen patch on breastfeeding women. And so they basically found that even at and they use a range of constant a range of concentrations of estrogen in those vaginal suppositories. And so basically, they found that even at the highest dose of the vaginal suppository, that the level of estrogen in the blood was not significantly different than their than what their baseline level was before starting that estrogen treatment. So we think we don't know exactly the the exact cellular mechanisms. But we think that because those tissues, the vaginal and the vulgar tissues, are so deprived of estrogen, that essentially, when estrogen is administered there, that they and so they they are immediately put to use into those tissues, into. Supporting the collagen growth, the glycogen production, the microbiome of the positive bacteria in your vaginal canal, estrogen supports all those good bacteria to maintain a healthy pH and so estrogen is essentially used, used used up the topical estrogen is used up in that local area. And so that's our current thought as to why systemically, we don't see those high levels of estrogen. Of course, if you take a pill of estrogen orally, you will see that systemic increase, and it would likely also help those symptoms in your Volvo vaginal area, but it would also impact your entire body. So that's really why we like that topical vaginal estrogen.

Do you happen to know in that study how much topical estrogen the women used before their blood was tested?

Yeah, the highest dose was, I think it was, it was, it went up to 200 micrograms.

Was it a single dose and the blood was tested? Or was it women who were told to use it like three times a week for a month? Or yeah, so it was. So the overall study was done over a series of I think it was 12 weeks. I think it was a range of 10 to 20 weeks. And so they tested, they continually tested the blood levels of estrogen over time. Because there was also a thought that there could be accumulating levels over time.

You would think so that the women were told to keep taking it all along at some period, at some periodic rate, every few days, or something.

Yes, I'm not sure. To be honest, I'm not sure the exact frequency that they that they took it like whether it was weekly or not, or how many times per week it was, but over time, over the several weeks, over the study, they didn't see like a gradual increase in blood levels at all. And so that, to some extent, was reassuring for me.

Yeah, and it makes so much sense that topical, if you're going to do it, that topical is definitely the way to go over anything systemic in the whole body. And you would have to probably take a lot more by way of pill for it to even reach the vaginal tissue. So it does make sense that it's, it's a recommendation you would have overtaking the pill. What other things were you going to say on this before we jumped in with all these questions on it?

No, that was the main thing. I also want just to, basically, to get back to some of our findings I found interesting in our upcoming survey study. We looked at these different treatments, but we also want to look at the barriers to attaining these treatments and the healthcare interactions between patient and healthcare provider. And so we saw first of all that the type of treatment used, whether was those moisturizers, pelvic floor, PT, vaginal estrogen, the type of treatment used was significantly associated to the status of lactation, so whether the the patient was exclusively lactating or non exclusively lactating. And so we do see that residual hesitation, whereas in the group of exclusive lactating participants, that they're more hesitant to take hormone vaginal estrogen, compared to the non medical, non medication, types of treatments. But then also, more significantly, I thought that half of our participants were not offered any sort of treatment, and even and there was a significant proportion that did not even have a conversation with their health care provider about it because they felt uncomfortable, or their health care provider didn't bring it up so they didn't want to bring it up as a topic. But really interestingly, while half of participants were not offered a treatment by the health care provider, 80% so a majority of participants reported that they tried to use some type of treatment. So that suggests that many patients are trying to seek out treatments independently because their healthcare providers are not counseling them appropriately, are not providing them the resources or the education to what is available. And so our next focus is we also want to talk and specifically also target health care providers and give them the education as well. We want to do both patient and health care provider education so that health care providers can provide and help in accessibility and resources for those postpartum patients. So we have to educate the postpartum patients on what they're experiencing that is normal, but they don't have to suffer. But then also empower the healthcare providers with these studies and the data so they feel they feel safe and equipped in to prescribe the treatments that are readily available to their patients.

It's going to be really important that you guys include lactation consultants in your healthcare education, because most mothers are seeing their OB or midwife at six weeks and then not again, not again, until maybe they're pregnant again, and so they're certainly not having that conversation with them at six weeks, because even if they were reporting any discomfort at that time, it would be sort of written off as well. You're six weeks postpartum. That's normal. Give it time. But obviously the lactation consultant might be the person that is seeing them at three months or four months down the line, in a perfect opportunity to discuss that.

That's a great point. And absolutely the idea is to also make it integrative, so not just OB GYN, but also primary care providers and also, specifically pediatricians, because, like you said, the postpartum mother is going to the pediatrician weekly, then monthly, much more, much more regularly than they're seeing their obstetrician. And so if the pediatrician is also aware and is checking in on, for example, postpartum depression, they can also be equipped on the knowledge of what other experiences that could be significantly impacting their quality of life, and therefore the baby's quality of life. It'll be a happy day When pediatricians start having that conversation. Let me tell you, yeah. Well, Sarah, this has been so informative and really helpful. And if there is anything else that you want to wrap up, or say, before we wrap up, please do. But I think the important thing is that women know that these are really common, really normal symptoms with lactation, and it doesn't mean anything is wrong with them, and that if they are suffering with it, or it is making them want to stop breastfeeding, that there are good solutions before they get to that point.

Yeah, absolutely. You just said it right there, which is that these symptoms are absolutely normal. They are common. But that doesn't mean that you just have to tough them out. Right? Motherhood already in the postpartum period, is already such an intimate, stressful, crazy experience, and they should not have to suffer through them, especially alone, especially when we have these treatment and resources that can help address these symptoms. And so they should absolutely feel empowered to look up our research, to bring our papers to their observations and do some of that work themselves, if they so need to, because there are treatments and care out there, and we're trying to scream it from the rooftops, but know that that we are hoping to, you know, make all of this much more accessible in the future. 

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