Dr. Kara Dionisio, ND
Episode Summary
What actually happens during perimenopause and menopause, and how do you separate evidence-based menopause care from the conflicting advice about hormone testing, estrogen, HRT, vaginal health and supplements online?
In this episode of Girls Gone Wellness, Jeanette and Victoria speak with Dr. Kara Dionisio, ND, MSCP, a naturopathic doctor and Menopause Society Certified Practitioner, about perimenopause symptoms, menopause diagnosis, hormone testing, DUTCH testing, estrogen, menopausal hormone therapy (MHT/HRT), genitourinary syndrome of menopause (GSM), vaginal dryness, painful sex, low libido, recurrent urinary tract infections (UTIs), vaginal estrogen, progesterone cream and non-hormonal menopause treatments. Dr. Dionisio explains why menopause care often requires more nuance than either “estrogen is dangerous” or “everyone needs hormones.”
The conversation begins by defining the stages of menopause. Dr. Dionisio describes menopause as the final menstrual period, confirmed retrospectively after 12 months without a period when there is no other explanation. The transition leading up to that final period is perimenopause, while the years after are postmenopause. Symptoms may begin well before the final period and can include sleep changes, mood symptoms, hot flashes, night sweats, vulvovaginal symptoms and changes affecting the skin, hair, joints and sexual health.
A major focus is menopause hormone testing. Should you test estrogen or follicle-stimulating hormone (FSH) to determine whether you are in perimenopause? What about DUTCH testing or urinary hormone metabolites? Dr. Dionisio explains that fluctuating hormones during perimenopause can make a single test difficult to interpret and says menopause staging is usually a clinical diagnosis based on age, symptoms and menstrual-cycle changes. She discusses circumstances where blood testing may sometimes provide additional information, particularly when symptoms or menstrual changes occur earlier than expected.
The episode then explores genitourinary syndrome of menopause (GSM), previously called vaginal atrophy. GSM can involve the vulva, vagina and urinary tract and may present with vaginal dryness, irritation, fissures, painful intercourse, urinary symptoms and recurrent UTIs. Dr. Dionisio explains how declining estrogen affects these tissues and why some symptoms may not appear until several years after the final menstrual period.
Sexual health is another major topic. The conversation covers low libido, decreased arousal, orgasm changes and painful sex, while challenging the assumption that healthy sexual desire must always be spontaneous. Dr. Dionisio explains the concept of responsive desire and why desire may develop after arousal begins rather than appearing beforehand. Lubricants are also discussed, including vaginal pH, osmolality and why some scented, warming or tingling lubricants may irritate vulvovaginal tissue.
The episode also takes a detailed look at menopausal hormone therapy (MHT), also commonly called hormone replacement therapy (HRT). Dr. Dionisio discusses the legacy of the 2002 Women's Health Initiative, why fear around estrogen and breast cancer became widespread and why modern hormone-therapy decisions require individualized consideration of benefits and risks rather than blanket recommendations.
Importantly, the episode distinguishes systemic hormone therapy from low-dose vaginal estrogen. Vaginal estrogen is used primarily for GSM and has much lower systemic exposure than whole-body MHT. Dr. Dionisio also discusses recurrent UTIs, stress versus urge urinary incontinence, pelvic-floor physiotherapy, the internet trend of using estrogen cream on the face and why she does not consider topical progesterone cream an evidence-based substitute for appropriately dosed progesterone when endometrial protection is required.
Finally, the conversation explores herbal supplements, lifestyle, nutrition, exercise, sleep, psychosocial health and clinical hypnosis as potential components of menopause care. The central message is that menopause is not a single hormone problem with a single solution: evidence-based care should consider the whole person, the symptoms that matter to them and an individualized risk-benefit discussion.
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What is the difference between perimenopause, menopause and postmenopause?
Perimenopause is the transition leading up to a person's final menstrual period, while menopause refers specifically to that final period and is confirmed retrospectively after 12 months without menstruation when there is no other explanation. Everything after the final menstrual period is considered postmenopause. Dr. Kara Dionisio describes menopause as the “retirement day” of the ovaries.
How do you know if you are in menopause?
Menopause is usually confirmed after 12 consecutive months without a menstrual period, assuming another condition or treatment is not causing the absence of periods. During perimenopause, menstrual cycles may become increasingly irregular before eventually stopping.
What are common symptoms of perimenopause and menopause?
Symptoms discussed in the episode include hot flashes, night sweats, sleep changes, mood changes, vaginal and vulvar symptoms, urinary symptoms, sexual-health changes and changes involving the hair, skin, nails and joints. Dr. Dionisio emphasizes that symptoms vary considerably between individuals and that not every midlife symptom is automatically caused by menopause.
Do you need hormone testing to diagnose perimenopause?
Usually not. Dr. Dionisio explains that estrogen and other reproductive hormones can fluctuate substantially during perimenopause, meaning a single hormone measurement may not reliably show where somebody is in the menopause transition. Menopause staging is generally based on clinical history, age, symptoms and changes in menstrual cycles.
Is an FSH blood test useful for menopause?
Follicle-stimulating hormone (FSH) generally rises as ovarian function declines, but Dr. Dionisio explains that routine FSH testing is often unnecessary for typical menopause assessment. Testing may sometimes be considered when menstrual changes or menopause symptoms occur earlier than expected or when the clinical picture is difficult to interpret.
Is DUTCH testing useful for diagnosing menopause?
Dr. Dionisio does not recommend relying on DUTCH testing or urinary hormone-metabolite testing to determine menopause stage. She argues that it has the same fundamental problem as other hormone testing during perimenopause—rapidly fluctuating hormone levels—while also questioning whether the additional expense meaningfully changes clinical management.
What is genitourinary syndrome of menopause (GSM)?
Genitourinary syndrome of menopause (GSM) describes changes affecting the vulva, vagina and urinary tract that can occur as estrogen levels decline. Symptoms may include vaginal dryness, irritation, reduced elasticity, fissures or bleeding, painful intercourse and urinary symptoms such as recurrent UTIs.
Why can menopause cause vaginal dryness and painful sex?
Declining estrogen can cause vulvovaginal tissue to become thinner, less elastic and less well lubricated. Dr. Dionisio explains that these changes can contribute to vaginal dryness, irritation, small fissures and painful intercourse, although sexual symptoms can also have psychological, relational and pelvic-floor contributors.
Why can UTIs become more common after menopause?
Recurrent urinary tract infections can become more common when lower estrogen levels change the tissues and microbiome of the vagina and lower urinary tract. Dr. Dionisio discusses vaginal estrogen as one treatment used in postmenopausal patients with recurrent UTIs, alongside appropriate assessment and treatment of the infection itself.
What is the difference between stress incontinence and urge incontinence?
Stress urinary incontinence refers to urine leakage with increased abdominal pressure, such as coughing, sneezing, laughing or jumping. Urge incontinence involves feeling a strong urge to urinate and being unable to reach the bathroom in time. Dr. Dionisio recommends proper assessment and discusses pelvic-floor physiotherapy as an important treatment resource.
Why does libido often change during menopause?
Sexual desire can change because of hormonal, physical, psychological and relationship factors. Dr. Dionisio discusses vaginal discomfort, life stress, aging parents, changing relationships and career demands alongside hormonal changes, emphasizing that low libido in midlife is rarely explained by one factor alone.
What is responsive desire?
Responsive desire means sexual desire may appear after sexual stimulation or arousal has begun, rather than occurring spontaneously beforehand. Dr. Dionisio explains that many women expect desire to work like a spontaneous “light switch,” but responsive desire can be a normal sexual-response pattern, particularly in longer-term relationships and midlife.
Is vaginal estrogen the same as systemic HRT or MHT?
No. Low-dose vaginal estrogen is primarily used locally for genitourinary syndrome of menopause, while systemic menopausal hormone therapy (MHT/HRT) is intended to affect the whole body. Dr. Dionisio explains that vaginal products use much smaller estrogen doses and generally result in far less systemic exposure.
Is progesterone cream an evidence-based part of menopausal hormone therapy?
Dr. Dionisio does not recommend topical progesterone cream as the progesterone component of systemic menopausal hormone therapy. She explains that when systemic estrogen is prescribed to someone with a uterus, appropriately dosed progesterone or another appropriate progestogen is needed to protect the endometrium, and she does not consider progesterone cream adequately supported for that purpose.
Are there non-hormonal options for menopause symptoms?
Yes. Dr. Dionisio discusses lifestyle, nutrition, exercise, sleep, psychosocial health, selected herbal or supplement trials and clinical hypnosis as possible non-hormonal approaches. She emphasizes, however, that the strength of evidence and effectiveness vary by intervention and by the symptom being treated.
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This transcript has been edited for clarity and readability while preserving the substance of the conversation.
Victoria
Hi, Dr. Dionisio. Welcome to Girls Gone Wellness.
Dr. Kara Dionisio
Hello. Thanks so much for having me.
Victoria
We are so excited to have you here.
I know you're super busy with launching Menoverse. We're absolutely going to touch on that today. You have your own clinic, and you spend hours and hours teaching us and others within our field.
So we're very lucky and grateful to have you here with us today.
Dr. Kara Dionisio
I'm super excited to be joining you. I love what you guys are doing, and I'm always happy to talk about anything menopause-related.
Jeanette
Amazing.
Before we get started, can you tell us a little bit about how you got into naturopathic medicine and then, more specifically, how you started focusing on menopause?
Dr. Kara Dionisio
Sure.
I'm not completely sure how I got into naturopathic medicine.
I did my undergraduate degree and master's in nutrition, and I think that opened my eyes to a different approach to health.
I wanted to have time to spend with patients and foster connections with them, so naturopathic medicine really seemed like the right fit for me.
How I got into menopause is a little different.
I'm about 15 years into clinical practice now. At first, I had a general practice.
Eventually, I couldn't ignore the stories of my patients going through the menopause transition who were really struggling and suffering.
This was before menopause was cool—before all the advocacy and all the noise in the space.
They had nowhere to go.
I really wasn't trained or equipped to manage menopause, support their health or support them through that stage.
It became a problem.
Out of necessity, I realized, “I need to learn this.”
I went back and dove into the research to understand what the standards of care should be, with guidance from the North American Menopause Society.
The research is always where we solve our problems.
Once I had that background education, I felt equipped to support my patients through this really pivotal stage of their lives.
Jeanette
It's so important.
We were talking to Dr. Laurie Alpert about this too.
When we're younger and in that preteen stage, there's a lot of education around getting your first period and what to expect.
Then we get to menopause and people are almost left on their own.
I think it's so important that we have practitioners focused on this area who can help people through it.
Dr. Kara Dionisio
Absolutely.
It is changing, which I love to see.
That brings some new challenges, but conversation is better than no conversation.
I'm really happy to see that happening.
Jeanette
Can you start with a general overview of what menopause is?
How do you know you're in menopause?
I know that's a loaded question, but answer it as best you can.
Dr. Kara Dionisio
I love the simplest definition of menopause, which is: menopause is your last period ever.
If we can pause there, there are some cool things about that one day.
The problem is that we don't know it was your final period until retrospectively.
When you haven't had a period for a full year—and that isn't because of birth control or another reason that could stop your period—then after that year we can say, with as much certainty as we can in healthcare, that your last period one year ago was menopause.
So menopause is one day. It's your last period.
We determine that a year later.
Everything after that final period is called postmenopause.
The transition leading up to it is perimenopause.
Victoria
So menopause is almost an overnight thing. You just don't know it happened until a year later.
Dr. Kara Dionisio
Exactly.
It's one day marking the end of the reproductive stage of your life.
Your periods are done. Your ovaries have retired.
It's like the retirement day of your ovaries.
But for the following year, we're wondering, “Are they going to come back to work?”
Some patients' ovaries go on sabbatical.
They'll take some part-time work.
They'll go on vacation and then decide to pick up a couple of extra shifts.
During perimenopause, we don't know when that final period is going to happen.
Once you've gone the full year, we can say, “Okay, the ovaries are retired.”
That's menopause—the retirement day of your ovaries.
Everything after that is postmenopause.
Victoria
I love that analogy. It makes it sound not so bad.
Dr. Kara Dionisio
My patients love that one.
I'll say, “You made it eight months and then your ovaries said, ‘I really miss my colleagues. I'm going back for one extra shift.’”
Unfortunately, that restarts the 12-month clock.
A patient may start skipping periods, go six months without one and then get one.
They might go eight months and get another.
Generally, the space between periods becomes longer until eventually we reach the full year.
Victoria
When people think of classic menopause symptoms, we think about hot flashes, insomnia and mood changes.
But there are so many symptoms people might not realize can occur during menopause.
What are some of those things you see in patients?
Dr. Kara Dionisio
The symptoms we experience as hormones change during menopause are as individual as the blueprint of the rest of our health.
There are common symptoms, but how and when they show up is unique to each patient.
There are some general patterns.
During perimenopause, we often see more neurological symptoms.
Dr. Alpert spoke about this on your previous podcast.
That's the stage when someone may still be having periods, but they're starting to change or phase out.
We can see sleep and mood changes.
Vasomotor symptoms, such as hot flashes and night sweats, also have a neurological basis.
Those can occur before the final period and well beyond it.
We see different patterns in different patients.
Some people get hot flashes early in perimenopause and they fade around the final period.
Some don't get them until the final period and then they persist afterward.
There's not one pattern I can say is the most common.
They can occur at any stage of the menopause transition.
They can last, on average, for years after the final period.
For some people they're mild, for others moderate, and for some they're extremely severe.
Whatever cookbook your body has decided to follow as a result of those hormonal changes, vasomotor symptoms can show up at many points.
There are other symptoms we often see more commonly after the final period.
Vaginal or vulvar changes—which I know we're going to talk about today—tend to become more common after a longer period of low estrogen.
They're very common postmenopause and may not show up until one, two, three, four or five years after the last period.
At that point, somebody may not even remember to connect it to a menopausal change.
But some women absolutely have vulvovaginal changes before the final period as well.
Those are some of the common ones.
A change in hormone levels can also affect health in other ways.
We see changes involving hair, skin, nails, joints and mood.
Often, wherever somebody is susceptible is where the symptoms show up.
We could probably create a list of 40 or 50 symptoms that women have associated with menopause.
The difficult part is figuring out what is actually from estrogen changes, what is from aging, what is a midlife health change and what may be from another health factor.
It gets messy in the middle.
Clinically, we're trying to understand the patient's symptoms, figure out where they're coming from and determine how to approach them.
Victoria
It's funny because I'm in the thyroid-health space, so whenever something goes wrong, my favourite thing is to blame my thyroid.
I'm like, “That has to be related to my thyroid.”
I see patients in menopause do it too.
One patient told me it took her 20 minutes to park because menopause meant she couldn't parallel park anymore.
Dr. Kara Dionisio
Menopause.
We'll add parallel parking to the list.
Victoria
Exactly.
Okay, we're not going to hold back today.
Tell us your thoughts on the DUTCH test and its use in menopause.
Dr. Kara Dionisio
That brings up the broader issue of hormone testing to determine menopause stage.
On the surface, it seems completely rational.
Our hormone levels fluctuate during perimenopause, but on average they're coming down.
Progesterone may decrease earlier than estrogen during perimenopause.
Eventually the ovaries retire and hormone levels are low.
So it makes sense to think, “Why don't we test the hormones? Let's see where I am on this roller coaster. That will give me or my doctor information to help me because I'm struggling.”
I probably hear daily, “Please test my hormones. I don't know what's happening. I don't understand this. I've never felt this way. Something is wrong. Menopause sucks. Test my hormones.”
The first thing I do is acknowledge that.
I understand your body is changing.
You don't know what's happening.
It's completely valid to say, “Please test something so I can understand what my body is doing.”
Unfortunately, hormone testing usually isn't the answer.
The reason is that we could test your hormones at a moment when an ovary is saying, “I don't want to retire. I love my job,” and they're very active, so your hormones come back high.
Or we could test when the ovaries are saying, “I'm on sabbatical this month,” and hormone levels are very low.
Whenever we use a test—especially a laboratory test—we need to know that the information we're getting is valid.
Is it accurately measuring what we want to measure?
We don't want to base decisions on something that may change dramatically by the hour or day.
We could test hormones when they're extremely low and say, “Yep, your ovaries are retired. You're done.”
Then the following month, the patient gets a period and says, “What happened? I thought you said I was in menopause.”
Or we could test when hormones are high and say, “You're far away from menopause.”
We can make false assumptions or build therapies, supplements, diets and strategies around what is essentially a snapshot in a highly variable process.
Once I explain that to patients, they usually say, “Okay. I understand why we can't rely on that.”
But that means I have a clinical responsibility to explain where they probably are and give them a roadmap of what is happening with their body.
There are different kinds of hormone testing.
Conventional testing might include serum estrogen levels—estrogen in the blood—or follicle-stimulating hormone, or FSH.
FSH is the signal that goes from the brain to the ovary saying, “Why are you slacking off on the job?”
That FSH signal gets higher. It's like the brain shouting at the ovary, “Get back to work!”
And the ovary is saying, “I'm kind of done today.”
FSH generally becomes higher as the ovary becomes less active.
But we generally don't need to test it routinely.
There are special circumstances where testing may help.
If menopause symptoms or menstrual changes are happening earlier than expected—under age 45, and particularly under 40—testing may have a role.
If somebody has had an endometrial ablation or hysterectomy and we can't use menstrual patterns in the same way, sometimes the clinical picture is more complicated and we need additional information.
But generally, hormone testing should not be part of routine menopause staging.
It's a clinical diagnosis based on signs, symptoms, menstrual characteristics and changes in cycle regularity.
When we look at urinary metabolite testing such as DUTCH testing, it has the same basic problems I just described with hormone testing.
It also has the added problem that we don't have the same level of clinical-trial validation.
There's research comparing it with serum hormone testing, but then I ask: why spend hundreds of dollars on a test that's being compared with a much less expensive blood test?
We don't have enough validity data to say, “Here's what we're measuring, here's exactly what it means and here's how this should change treatment.”
Another issue is that a patient receives a beautiful 12-page report, and a clinician may base decisions on it.
The patient may leave with six or ten supplements intended to “detox estrogen.”
We're not necessarily solving a problem.
We may actually create problems.
Hormone testing is a topic filled with misinformation.
But ultimately, patients just want to understand their bodies.
I don't blame them for wanting the test.
We can address that need by having informed practitioners who can explain what is happening.
Jeanette
I find it a little sad because people in menopause are looking for answers.
These tests can sometimes be used in a way that takes advantage of how desperate somebody is for an explanation.
Dr. Kara Dionisio
I hope it isn't intentional.
But we sometimes think of testing as harmless.
A test should follow the same scientific principles as any other medical intervention.
It should have appropriate sensitivity and specificity.
It should change the clinical course.
It should change what we do.
It should help rule disease in or out.
We don't have that foundation for routine use of this kind of testing in this situation.
Jeanette
I want to talk about estrogen because I find it gets demonized a lot, especially during menopause.
Patients can blame estrogen for so many symptoms—weight gain, vaginal dryness and everything else.
Is estrogen directly causing these symptoms? Is the relationship more indirect?
Dr. Kara Dionisio
Estrogen has definitely been villainized.
At the same time, we've now swung the pendulum.
We went from “estrogen is bad, estrogen causes cancer, we need to detox estrogen, estrogen causes weight gain and all this bad stuff” to “estrogen is awesome, the Women's Health Initiative was wrong, everybody should be on estrogen until they die.”
We should bathe in estrogen.
Put it on our faces.
Put it on our nails.
Have a patch and a cream.
“I'll die with my estrogen patch on.”
We've swung the pendulum all the way over.
When we course-correct major historical problems, perhaps that's a natural inclination.
But unfortunately, medicine rarely lives at the extreme ends of the pendulum.
It lives in nuance and context, which we're not very good at—especially on social media.
When we look at estrogen, we have to consider what it does for a specific symptom in a specific patient.
For vasomotor symptoms, there are likely other mechanisms happening in the brain and nervous system, but lower estrogen is certainly an important factor.
Some women are susceptible to hot flashes and night sweats when estrogen drops.
The vagina, vulva and bladder also love estrogen.
Those tissues work differently when estrogen is lower, and some women become symptomatic.
Mood is more nuanced.
Some women are very sensitive to estrogen changes. Some may be sensitive to progesterone changes.
So I think about estrogen on a sliding scale.
For some symptoms, perhaps estrogen explains nearly all of it.
Vasomotor symptoms would be high on that scale.
Mood may be further down.
Yes, estrogen is implicated, but it doesn't exist in a vacuum.
There may be lifestyle factors, a previous mental-health history or significant life circumstances.
Hair, skin and nails are another example.
Could estrogen contribute? Yes.
But maybe the patient also isn't eating enough protein and has low iron.
When somebody asks, “Is estrogen the culprit? Is it good or bad?” the answer is again about nuance, context and the individual person.
Jeanette
I'm glad we touched on that.
On social media, somebody will say with complete certainty that estrogen is causing every single symptom you're experiencing.
It's important to acknowledge the nuance.
Dr. Kara Dionisio
Absolutely. That's a big pet peeve of mine.
Jeanette
Let's switch gears into the genitourinary side of menopause.
These are the topics patients sometimes whisper about or work up the courage to mention to their family doctor: vaginal dryness, painful sex, decreased libido and pelvic-floor changes.
When patients come in with classic menopause symptoms, are you proactively asking them about genitourinary symptoms too?
Dr. Kara Dionisio
Absolutely.
I think it's prudent for all healthcare professionals to at least create enough space and trust to have these conversations.
My practice is obviously biased because it's completely focused on menopause, but these questions are built into my intake forms.
Patients know from the beginning that these are topics we may discuss.
One of the superpowers of naturopathic practice is having enough time and space with patients to build a trusted therapeutic relationship where they feel comfortable asking these questions.
That isn't to say they don't trust their other health professionals.
It's just harder to build that in a seven-minute visit when there are multiple other things to address.
It can be difficult to bring up something that feels sensitive.
Some patients are very hesitant.
Others are like, “Here's what's happening. My girlfriends and I have talked about this. We need to solve it.”
There's a spectrum.
But creating the expectation that “we can talk about this here, we're going to have a trusted clinical conversation and we're going to figure out what is happening” is very important.
The prevalence estimates for genitourinary or vulvovaginal changes around menopause are all over the place depending on the study, but they're high.
A large proportion of patients will have some change involving the vulva, vagina or bladder as estrogen declines.
Victoria
I love that we're talking about it more.
For the generation of women going through menopause right now, a lot of this was traditionally taboo.
I want to tell patients, “Vagina is not a swear word.”
We can say the word.
You don't have to whisper or make up a cute little name for it.
I hope we continue that conversation.
Dr. Kara Dionisio
Absolutely.
All our body parts are important, but the vulva and vagina can have an emotional charge and consequences beyond what we associate with an elbow.
No offence to elbows.
An elbow surgeon might disagree with me.
But I have patients say, “Dr. Kara, I can't sit down. I crack and bleed. I can't wear jeans. I can't ride my bike. I have to plan my day around my bladder. My partner is frustrated. Sexual activity is too painful. Even if it weren't painful, I have low libido. I'm worried about my relationship.”
For some people, the consequences are mild.
For others, they're significantly affecting their quality of life, work, daily activities and relationships.
That's why this topic is so important.
We don't want to miss the person who is really suffering.
Victoria
Another topic people can be scared to discuss is sexual health.
We talked with Dr. Alpert about how a lot of women say, “This is just how it is. I'll deal with it. I'll be intimate with my husband because it makes him happy, but I'm not really enjoying myself and it's painful.”
There are more sexual symptoms than I even realized.
There's low libido, painful sex, bleeding after intercourse, decreased arousal and orgasm changes.
What kinds of symptoms do you see women dealing with?
Dr. Kara Dionisio
They're common.
At one point I added up several months of my intake forms because I wanted to understand the issue in my own clinical practice.
Low libido or low sex drive was listed as a top-five concern on about 65% of my intake forms.
And that's only the people who proactively listed it.
It doesn't include patients who said, “Oh yes, that's a problem too,” once I asked.
It is very common.
And I might get some flack for saying this, but in some ways it's also not surprising.
Our bodies are changing.
Our hormones are changing.
Of course sexual health may change.
When we look at research, distress related to sexual-health changes tends to peak around midlife.
Sexual-health concerns are generally divided into areas such as desire, arousal, orgasm and pain.
The prevalence of different issues may be higher in younger or older populations depending on the specific problem.
But the amount of distress—the degree to which it bothers women—can peak in midlife.
I think that's partly because it's such a big change and it's happening alongside so many other life changes.
Sexual-health problems at this stage are multifaceted.
We have vulvovaginal health changes.
If sex hurts, your brain isn't going to say, “This sounds like a fantastic idea.”
Then we have the context of the midlife sandwich.
Relationships may be changing.
Children may be growing up.
Parents are aging.
We may be at the height of our careers.
There are a lot of biopsychosocial changes happening.
So the answer to sexual-health changes isn't simply, “Your hormones changed,” or “Here's testosterone.”
We have to look at the factors contributing to it.
We also need to reframe how we think female sexual response and sexual desire are supposed to work, because most of us learned about that from movies, and movies are not reality.
Victoria
How do we help women regain confidence in this area?
As Taylor Swift would say, how do we “shake it off”?
Dr. Kara Dionisio
My 12-year-old would love the Taylor Swift reference.
First things first: if there's pain or vulvovaginal symptoms, that's often one of the more straightforward pieces to address.
We have research.
We know how to treat vulvovaginal symptoms.
If sex becomes more comfortable and pleasurable, you're naturally more likely to want to do it again.
Something as simple as using a lubricant can help.
We can't assume patients know that they can or should use one.
Some people think lubricant is for “other people,” not them.
So sometimes the first conversation is simply, “Have you considered using lube?”
Some patients say, “Absolutely, I already do.”
Others have never really thought about it.
Then we get into which lubricants may be best.
Another major piece is reframing the sexual response cycle.
Most people imagine sex is supposed to look like it does in movies or like the first stage of a relationship.
That's something we call spontaneous desire.
Spontaneous desire is the light-switch feeling: “Oh, I suddenly want to have sex.”
That's common when we're 20.
It's common on vacation.
Research suggests it can be common in approximately the first part of a new relationship.
Maybe your partner empties the dishwasher and suddenly it sparks.
There are situations where it comes and goes.
But spontaneous desire is not necessarily the most common experience most of the time for most women.
Especially during midlife, when all those other factors are happening, responsive desire becomes very relevant.
I like using exercise as an analogy.
You don't want to go to the gym.
You're exhausted.
You're stressed.
You have too much to do.
But you know it will probably be good for you.
You put on your gym shoes—which is the hardest part—get on the treadmill and think, “Why didn't I want to come? This is exactly what I needed for my mood and my day.”
The desire to exercise sometimes doesn't arrive until you're actually doing the squat.
Responsive sexual desire can work similarly.
Sometimes desire doesn't appear until arousal or sexual activity has already begun.
Obviously, this is in the context of safety, consent and a safe relationship or situation.
But sometimes we have to understand that desire may respond to arousal rather than always preceding it.
I have a laminated responsive-desire cycle I use with patients.
We look at what feeds the cycle and what might turn different parts of it.
A positive sexual experience can reinforce that cycle.
There are other factors that do too.
Sometimes patients take that handout home and discuss responsive desire with their partner.
I'm also not a sex counsellor.
If we're getting beyond my scope, then I refer to a counsellor or therapist who can provide additional support.
Victoria
Do you refer out to pelvic-floor physiotherapists or sex therapists as well?
Dr. Kara Dionisio
Absolutely.
Referrals are another superpower.
You have to be able to acknowledge, “Here's where my knowledge ends. Here's where I'm awesome, and here's where we need someone else who's awesome at this other part.”
I have a pelvic-floor physiotherapist who works with me, and that ND-pelvic-physio collaboration is amazing.
These problems are multifaceted.
We're often going to need a team approach.
Interprofessional collaboration and looking at the problem from multiple angles is incredibly valuable.
Victoria
Okay, talk to us about lube science. We can't move on without it.
Dr. Kara Dionisio
First, not everyone is using lubricant.
Sometimes we need glasses.
Sometimes we need a bra.
Sometimes we need lube.
It isn't a failure.
Your body hasn't failed to do something.
It's an aid that can help support your health.
Then we get into the product itself.
Lubricants aren't regulated in the way many people assume.
There can be products on drugstore shelves that are problematic for some women, although not necessarily everyone.
When I look at lubricant formulations, there are two major things I think about: pH and osmolality.
pH is easier to understand.
The vaginal environment is generally acidic.
If you're repeatedly putting a lubricant in that has a pH very different from the vagina, some people who are susceptible to those pH changes may experience microbiome disruption or irritation.
Then we have osmolality.
In very simple terms, a lubricant with very high osmolality can draw water out of the vaginal tissues.
That can be drying and irritating.
Products marketed as warming, tingling, scented or “sensation-enhancing” can sometimes fall into that category.
They sound fun.
But vulvar and vaginal tissue may not be happy about it.
There is actually a test used in lubricant research called the slug mucosal irritation assay.
They put lubricant on slugs and assess mucosal irritation.
I feel bad for the slugs.
Maybe they're slippery and happy. I don't know.
But when you look at some very common drugstore lubricants, some can cause mild, moderate or severe mucosal irritation in these testing models.
So I recommend choosing products thoughtfully.
Some companies now publish information about pH and osmolality if they've designed the product with those factors in mind.
That's lube science 101.
Jeanette
I did not think we'd be talking about slugs today.
Dr. Kara Dionisio
You never know.
Jeanette
You touched on GSM earlier.
Can you explain what that stands for and what it encompasses?
Dr. Kara Dionisio
Absolutely.
We used to describe many vaginal changes during menopause as vaginal atrophy.
In 2014, there was a major consensus process that changed the terminology to genitourinary syndrome of menopause, or GSM.
I don't necessarily love that my vulva can have a syndrome, but it's probably better than calling it atrophy.
The rationale for changing the terminology was that these changes can affect the genital system—the vulva and vagina—as well as the urinary system and bladder.
It's called a syndrome because it describes a constellation of symptoms that may occur as estrogen levels decline.
The tissues lining the vulva, vagina and parts of the urinary tract are rich in estrogen receptors.
As estrogen declines during the menopause transition, those tissues change.
I explain it to patients using a pillow-top mattress analogy.
When estrogen is present, the tissues lining the vulva, vagina and bladder are more like a nice, thick pillow-top mattress.
The cells are plump and moist.
There's good blood flow.
There are folds, elasticity and healthy tissue structure.
When estrogen declines, those tissues become thinner.
They don't stretch as well.
They're not as lubricated or elastic.
That can contribute to irritation, pain, fissures or little cuts, bleeding and painful intercourse.
That's the basic change we're describing with GSM.
It may show up in the vulva, vagina, bladder or some combination of all three.
Jeanette
Let's talk more about the urinary symptoms.
We hear about urinary urgency and recurrent UTIs in menopause.
Can you explain that?
Dr. Kara Dionisio
There are many possible reasons somebody can have recurrent UTIs.
But if a patient says, “I've hardly ever had UTIs in my life, and now around menopause or postmenopause I'm suddenly getting them over and over,” lower estrogen and GSM become important considerations.
It can be a common sign of GSM.
There are many approaches to recurrent urinary-tract infections.
The acute infection may require an antibiotic.
Sometimes we have someone who has received antibiotic after antibiotic.
But guidelines now also recognize a role for vaginal estrogen in postmenopausal people with recurrent UTIs.
Vaginal estrogen can support healthier tissue and the local microbiome.
When those tissues are healthier, recurrent infections may become less likely.
Then there's urinary incontinence, which is more complicated.
There are several forms, but two common ones are stress incontinence and urge incontinence.
Stress incontinence is also common around pregnancy and postpartum.
That's when you leak urine when you laugh, cough, sneeze or jump on a trampoline.
It often involves increased intra-abdominal pressure along with problems involving the pelvic-floor muscles or urethral support.
Urge incontinence is different.
That's the experience of suddenly feeling a strong urge to urinate and not being able to reach the bathroom in time.
Assessment takes a detailed history.
This isn't something where we can hear one sentence and immediately know exactly what's happening.
The patient needs an appropriate clinical assessment.
For mild incontinence, that may involve a family physician, but this is also an area where a really good pelvic-floor physiotherapist can make an enormous difference.
Jeanette
We actually just had a conversation with a pelvic-floor physiotherapist and learned so much.
It's interesting how many things they can work on—from the sexual side to urinary symptoms.
It's such an important person to have on the healthcare team.
Dr. Kara Dionisio
Absolutely.
Pelvic-floor physiotherapists are definitely an underutilized member of the healthcare team.
Jeanette
Let's switch gears to hormone replacement therapy, or HRT.
It's still a taboo topic for some patients.
Why did HRT become so controversial, and why is the conversation different now?
Dr. Kara Dionisio
This is where I always come back to research.
Someone who knows a lot often questions whether they're actually an expert because the more you know, the more you realize how much there is to know.
Especially online, it can be difficult to figure out who actually knows what they're talking about.
The best place to go is the research—not one paper, but a body of evidence.
That's where I went when I started focusing on menopause five, six or seven years ago.
It's our best estimate of what we currently understand.
A major piece of the HRT story goes back to 2002 and the Women's Health Initiative.
Clinical practice changed enormously based on that study.
It was a very large, very expensive, well-designed trial with more women than we're likely to see in another randomized controlled trial of that size.
In 2002, part of the study was stopped because investigators concluded that a particular hormone-therapy regimen was causing more harm than benefit.
One major goal of the study was to determine whether hormone therapy could prevent cardiovascular disease.
Breast cancer was another outcome being monitored.
The conclusion communicated at the time was that hormone therapy involving estrogen plus a progestogen was associated with increased breast-cancer risk.
There are still arguments about how to interpret parts of that study—statistical significance, study design and what conclusions should have been drawn.
But the real-world result was that hormone therapy use dramatically dropped.
For decades, many women weren't able to access a therapy that may have helped them.
Another important part of the trial is that in participants receiving estrogen without the same progestogen combination, we did not see the same increased breast-cancer signal.
There may even have been a trend in another direction.
So the story was much more complicated than “estrogen causes breast cancer.”
I think the pendulum swung too far in one direction.
But now it's swinging hard in the opposite direction.
You see people online saying, “The Women's Health Initiative was completely wrong. Hormones don't cause breast cancer. Everyone should take estrogen.”
That's also too simplistic.
Now I have patients sitting in front of me saying, “I don't know who to believe. Does this increase my cancer risk? Is it helping me? Should I be on it?”
That's one of the hardest and most rewarding parts of menopause practice.
No medication is simply “good” or “bad.”
The question is: what are the potential benefits, and what are the potential risks for this person?
I can sit with somebody and say, “Here are the benefits I think may apply to you. Here are the risks I see. Are those acceptable to you? How can we reduce those risks?”
The answer is somewhere in the middle.
It requires individualized risk-benefit analysis and shared decision-making between the practitioner and patient.
Victoria
That's important because it's easy to get trapped in one mindset.
With any prescription medication, you need a risk-benefit conversation with your practitioner.
We've also talked with Dr. Jordan Robertson about standards of care.
It's difficult even for Jeanette and me because what we're told can depend on which ND or supervisor we're talking to.
Sometimes it's, “Everybody needs estrogen because it prevents cardiovascular disease.”
Then you hear something completely different from somebody else.
It really highlights why standards of care matter.
Dr. Kara Dionisio
Absolutely.
No decision should be based on belief.
It shouldn't be, “I don't believe in estrogen,” or “I believe estrogen causes cancer.”
The question should be: what does our best interpretation of the body of evidence tell us?
Not every clinician has the time, interest or training to critically appraise every research paper.
But we can defer to well-developed guidelines produced by experts who have done that work.
I'm trained through what was formerly called the North American Menopause Society and is now The Menopause Society.
I earned the designation of Menopause Society Certified Practitioner several years ago.
That provides a framework.
A large group of experts from around the world has reviewed the evidence and developed our best current guidelines.
We reserve the right to change our minds when the evidence changes.
Medicine is rarely black and white.
I wish we had more room for nuance because it's badly missing from this conversation right now.
Victoria
Jeanette and I always say we have to live in the grey area.
On the topic of HRT, let's talk about vaginal estrogen.
Is vaginal estrogen the same as oral or systemic estrogen?
Does it increase estrogen levels in the bloodstream?
Dr. Kara Dionisio
Even though both therapies involve estrogen, they're different.
We just talked about systemic hormone therapy.
I generally use the term menopausal hormone therapy, or MHT, which is increasingly used internationally, although people still say HRT.
Systemic means whole-body.
When we're giving systemic MHT, we may give estrogen plus a progesterone or other appropriate progestogen if the patient has a uterus.
Those hormones circulate throughout the body.
They can affect things like vasomotor symptoms, bone and other systems.
Systemic hormone therapy raises estrogen levels in the blood.
Low-dose vaginal estrogen is different.
It's estrogen at a fraction of the dose used in systemic MHT.
We primarily use it for genitourinary syndrome of menopause.
It's placed in the vagina and can come in forms such as vaginal tablets, creams or a vaginal ring.
At these low doses, the primary effects are on the vagina, vulva and urinary tract.
We can see a small increase in blood estrogen levels during the first couple of weeks in some people.
That's often when the vaginal tissue is very thin and absorbing more of the estrogen.
Somebody might even notice temporary breast tenderness.
Generally, that settles.
Depending on the product, low-dose vaginal estrogen is often used more frequently at the beginning and then at a lower maintenance frequency.
The important thing is that it works while you use it.
If you stop using it, the vaginal dryness or other GSM symptoms can return.
Victoria
I'm glad we clarified that.
There's an internet trend right now where people are using vaginal estrogen cream on their face for skin elasticity and hydration.
What are your thoughts?
Dr. Kara Dionisio
I've watched this trend with interest.
I've actually taken a break from being very active on social media because it can frustrate me.
I want to figure out how to show up responsibly.
With facial estrogen, what I initially saw was companies creating estrogen face creams and saying, “This is evidence-based. It'll make your skin glowy. We have research.”
When I looked at the research being cited, I saw a lot of cell studies or plausibility research.
That's not the same kind of evidence we generally use to decide whether we should routinely put a drug on or in our body.
Then I saw other menopause experts saying, “Wait a minute. We don't really have enough clinical research for this.”
More recently, a company producing one of these products has conducted a randomized controlled trial.
I haven't personally read that RCT yet.
The fact that a company funded a study doesn't automatically mean it's bad or invalid, but it is something to consider when appraising the evidence.
These trends are interesting.
My guess is that topical facial estrogen may help and may be safe.
But as somebody who is evidence-oriented, “probably” doesn't quite do it for me.
I'd like more data before routinely putting estrogen on my face or prescribing it for that purpose.
Some people are comfortable getting ahead of the evidence.
They may say, “I don't want to wait 20 years for my glowy face.”
That's their prerogative.
But an informed decision requires knowing where the research currently stands.
Then the individual can decide what level of uncertainty they're comfortable with.
I personally wouldn't prescribe it at this point.
Jeanette
We also hear a lot about people being prescribed progesterone cream.
What is it used for, and who benefits from it?
Dr. Kara Dionisio
I have no idea.
That's a great question.
I don't know who it's useful for or who benefits from it because we have extremely limited research.
Changing prescribing patterns around topical progesterone in naturopathic and integrative medicine is actually part of my mission.
Functional medicine clinicians often use progesterone cream too.
But when I talk about the body of evidence for menopausal hormone therapy, that evidence is not based on topical progesterone.
We do have substantial evidence comparing different routes of estrogen, including oral versus transdermal estrogen through a patch or cream.
We understand many of the pros and cons of those options.
We don't have the same body of evidence for topical progesterone.
I don't know what outcome we're expecting from it.
I don't know what dose should be used for those claimed outcomes.
But there is one area where I feel very strongly.
If we're using progesterone as part of systemic hormone therapy in someone who has a uterus, the progesterone or progestogen must adequately protect the uterine lining.
Estrogen stimulates growth of the endometrium.
Progesterone counterbalances that effect.
We need specific, adequately studied dosages to prevent excessive endometrial growth.
If you repeatedly stimulate the endometrium with estrogen without adequate protection, that can eventually increase the risk of endometrial hyperplasia and cancer.
We have studies looking at progesterone cream as the protective progesterone component of hormone therapy, and it did not adequately protect the uterine lining.
So I would not use progesterone cream for endometrial protection alongside systemic estrogen.
Oral progesterone also has metabolites produced through first-pass metabolism that may contribute to some of its effects, including effects on sleep.
So that's progesterone cream.
I don't know why we would routinely use it.
Victoria
I love the honesty.
For people who don't want MHT or can't use it, we often hear about estrogenic herbs or progesterone-supporting herbs.
Is that evidence-based? Do you use them?
Dr. Kara Dionisio
Yes and no.
Hormone therapy is the gold standard for treating certain menopause symptoms.
That absolutely does not mean everybody needs it.
Some people need or could benefit from it but choose not to use it.
Some people cannot use it for medical reasons.
Then we're looking at other ways to manage symptoms.
I don't use herbs to “detox estrogen” or expect an herb to reliably increase serum hormone levels and recreate hormone therapy.
But some herbs or supplements may help with individual symptoms.
Unfortunately, the research on many commonly used menopausal herbs and supplements isn't fantastic.
Some studies are okay.
They're often small and have limitations.
I will occasionally trial certain options in somebody who doesn't have other choices and see whether we can achieve symptom relief.
But I wouldn't oversell the evidence.
One of the more evidence-based non-hormonal options for managing some menopause symptoms is actually clinical hypnosis, which is really interesting.
There are approaches that patients can do at home, including programs where they listen for a short period each day.
That can reduce how bothersome some menopause symptoms are.
There are other ways to approach menopause.
They just don't all have the same body of evidence or the same degree of expected benefit as hormone therapy when hormone therapy is indicated.
And there's another major caveat:
Not everything happening to your health at this stage of life is caused by menopause or is going to be fixed by hormone therapy.
We're treating a whole person, not a person who consists only of menopause.
There are many other factors influencing health in midlife.
We need to look at lifestyle, food, exercise, sleep, psychosocial factors, other medical conditions and blood-sugar regulation.
There's a lot to assess.
That's what makes midlife healthcare such a beast of a topic—and also what makes it fun.
At least for me.
Jeanette
You recently launched Menoverse.
Can you tell us about it?
Dr. Kara Dionisio
Menoverse was created by me and my colleague in British Columbia, Dr. Stephanie Bayless, who also focuses on menopause and particularly the mental-health side of menopause and other life stages.
We wanted to create a place for accurate, evidence-informed information for the public and our patients.
We wanted to avoid polarization and create more nuanced conversations.
That's our new baby.
We're figuring it out as we go while both being very busy clinicians.
When I think about improving menopause care, we need really good clinicians.
I love training excellent menopause clinicians.
But we also need really informed patients.
Those two things together are where we're going to start creating meaningful change in midlife healthcare.
Victoria
Jeanette and I always say we're graduating at a perfect time because we have access to clinician databases and education that weren't always available.
I can't imagine graduating and simply being sent out into the wild.
Dr. Kara Dionisio
It used to involve a decade of throwing myself against a brick wall.
It wasn't pretty.
Victoria
We've reached our rapid-fire section.
I'm going to give you a statement and you answer myth, truth or “it depends.”
It's usually “it depends.”
First:
Synthetic hormones are dangerous, but bioidentical hormone replacement is not.
Dr. Kara Dionisio
Long pause.
I'm going with: it depends.
Victoria
Natural therapies for menopause are mostly ineffective. HRT or MHT is basically the only thing we can do for menopause.
Dr. Kara Dionisio
I'd have to change some words in that statement.
It's not the only thing we can do.
Natural therapies can be great for some people's symptoms but are often not enough for others.
So again: it depends.
Victoria
The only thing we can do for decreased libido is encourage more intercourse.
Dr. Kara Dionisio
False.
Counselling somebody to simply have more sex when they don't want to isn't going to solve the problem.
They're just going to be having sex while thinking about their laundry.
Helping them understand the sexual-response cycle and responsive desire is much more useful.
Victoria
Women in menopause have a lower risk of urinary tract infections.
Dr. Kara Dionisio
False.
Victoria
Lubricants are the only solution for vaginal dryness in menopause.
Dr. Kara Dionisio
Definitely false.
But they can be helpful.
Jeanette
We've been myth-busting this whole episode, but at the end of every episode we ask our guests:
If there were one myth in your health space you could debunk once and for all, what would it be?
Dr. Kara Dionisio
I would say:
Estrogen is not the enemy. It helps lots of people, but you don't need to bathe in it.
Victoria
I love it.
Mic drop.
Thank you so much for being here today.
We're very grateful that you took the time out of your busy schedule.
Where can our listeners learn more about you?
Dr. Kara Dionisio
I come and go on Instagram.
If I show up, it means I have something to say and I can stand by it.
You can find me on Facebook and Instagram at Dr. Kara ND.
You can also find Menoverse online.
And you can find me through my website.
If you're in Ontario, I see patients virtually across Ontario and in person in Owen Sound.
Victoria
We'll have all of the information in the show notes.
Thank you so much for being here, Dr. Kara.
Dr. Kara Dionisio
It was really great chatting with both of you.
Thanks for having me.
Jeanette
Thank you.
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Dr. Kara Dionisio, B.Sc, M.Sc, ND, MSCP sees menopause as an opportunity — a chance to rethink how women, patients, and clinicians approach midlife health.
Dr. Kara and her team at Dr. Kara & Associates in Owen Sound, Ontario provide evidence-based care tailored to the unique needs of women in menopause and midlife. To extend this work beyond one-on-one care, she co-founded Menoverse — a platform offering evidence-based menopause education.
A speaker and mentor, Dr. Kara teaches clinicians across North America on menopause and midlife health. As a faculty member of The Confident Clinician, she leads the Menopause Fellowship — training the next generation of menopause clinicians.
Dr. Kara was one of the first NDs to earn the MSCP designation in 2020, and is also trained in pelvic health physiotherapy. She holds a B.Sc from the University of Guelph and an M.Sc in Nutrition & Metabolism from the University of Aberdeen, Scotland — a foundation that shapes her lifestyle-first approach to midlife health. She graduated from the Canadian College of Naturopathic Medicine in 2008.
When she's not in clinic, you'll find her in Owen Sound with her two feisty kids, her red-bearded Irish husband, and one very beagly beagle.
Join her in reshaping menopause as an opportunity for vibrant health.