Can we talk about the one area of our body that nobody wants to talk about?
Not hormones. Not hot flashes. Not the 2am wake ups. I’m talking about the part of our body that quietly starts breaking down in midlife and creates recurring UTIs, leaking when we sneeze or jump at the gym, burning nobody can explain, dryness that turns intimacy into anxiety, and a level of embarrassment so deep most women won’t even bring it up to their own doctor.
I’ve talked about hormones, gut health, and menopause more times than I can count on this show. But this specific topic, our pelvic and vaginal health, is one we’ve danced around instead of tackled head on. It’s normal. It’s happening to almost every one of us. But normal doesn’t mean we have to just accept it and move on. It doesn’t have to stay this way.
That’s exactly why I brought back one of my favorite people to talk with, Dr. Anna Cabeca. If you’ve listened to this show before, you know her as the Girlfriend Doctor, and there’s a reason for that nickname. She’s a triple board certified OBGYN, a bestselling author, and she happens to be my own personal doctor. But more than her credentials, what makes Anna different is how she explains things. She talks to us the way a trusted girlfriend would, not the way most of us have been talked to by doctors who rush through an appointment and hand us a pamphlet.
This conversation went deep into vaginal and pelvic health in midlife, the hormone myths most of us have been told, and why so many women are struggling in silence with something that is actually very treatable.
Why Vaginal and Pelvic Health Changes So Much in Midlife
We think a lot about the changes happening to our skin as we age. The fine lines, the loss of collagen, the changes in elasticity. What we don’t think about nearly enough is that the exact same aging process is happening to our pelvic and vulvar tissue.
Anna explained that when this area goes unaddressed, women can experience incontinence, vaginal dryness, infections, odor, and issues in the rectal area including fissures and hemorrhoids. She was direct about something most of us have never heard connected to vaginal health: recurrent, undiagnosed urinary tract infections in older women can progress to kidney infections and even become life threatening. This isn’t a cosmetic issue. It’s a health and longevity issue, and it deserves the same attention we give our heart health or our bone density.
The Symptoms That Hormone Replacement Therapy Doesn’t Fix
One of the most useful parts of this conversation was understanding why some symptoms improve dramatically on hormone replacement therapy while others barely budge.
Systemic hormone replacement, whether it’s a patch, a pill, or a cream applied elsewhere on the body, tends to resolve hot flashes and a lot of the brain fog that comes with perimenopause and menopause. But vaginal dryness, ear dryness and itching, and certain skin changes often persist even for women who are consistently using HRT.
Anna explained this comes down to topical versus systemic delivery. Vaginal tissue, ear canals, and eyes all rely on local glandular secretions that systemic hormones don’t fully reach. That’s why topical DHEA, applied directly to the tissue that needs it, has been studied for decades and shown to convert locally into both testosterone and estrogen right at the cellular level, without the same systemic absorption concerns.
If you’ve been on HRT and still dealing with dryness anywhere in your body, this is worth bringing up with your provider specifically, because it may require a targeted, localized approach rather than assuming your systemic HRT should be covering it.
The Progesterone Myth That’s Kept Women Suffering for Decades
This might be the most important thing in the entire conversation, and it’s something Anna sees constantly in her practice: women who have had a hysterectomy being told they don’t need or can’t have progesterone.
Here’s the distinction that gets lost. Progesterone and progestins are not the same thing, even though they share part of a name. Progestins are synthetic compounds, like medroxyprogesterone acetate, that were developed decades ago specifically to protect the uterine lining from the cancer risk created by unopposed estrogen. If a woman doesn’t have a uterus, she doesn’t need something to protect a uterine lining that no longer exists, so many providers simply stopped prescribing anything progesterone related altogether.
But bioidentical progesterone offers benefits far beyond uterine protection. Research out of major academic medical centers has studied IV progesterone for traumatic brain injury recovery, showing reduced swelling and faster return to normal function. Anna has seen women who’ve had hysterectomies describe feeling like a cloud lifted once they started bioidentical progesterone, specifically because of its effects on sleep, mood, and brain function, independent of the uterus entirely.
This distinction between synthetic progestins and bioidentical progesterone also explains a lot of the confusion and fear around hormone therapy dating back to older clinical trials, which largely tested synthetic progestins rather than bioidentical hormones. If you’ve been told progesterone isn’t for you because you don’t have a uterus, it’s worth having a more nuanced conversation with a provider who understands this difference.
The Overlooked Hormone: Pregnenolone
Most of us have heard of estrogen, progesterone, and testosterone. Far fewer of us have heard of pregnenolone, even though it’s essentially the starting material your body uses to build the other hormones we talk about constantly.
Pregnenolone sits at the top of the hormone production pathway. Your body converts cholesterol into pregnenolone, and from there into progesterone and DHEA, which then convert into testosterone and estrogen. During periods of high stress, your body can preferentially shunt pregnenolone toward cortisol production instead, which may be part of why chronic stress correlates with lower levels of these other hormones.
One reason pregnenolone hasn’t gotten mainstream attention is simply commercial. Bioidentical compounds are difficult to patent, so pharmaceutical development has focused more on delivery systems for hormones like estrogen and progesterone rather than pregnenolone itself. That’s beginning to shift, with newer research looking at how the body converts oral progesterone into a related compound being studied for depression and postpartum mood disorders. This is an area worth watching as more research emerges.
Should You Cycle Your Progesterone?
Another nuanced topic covered in this conversation is whether women should take progesterone continuously or cycle it, taking a few days off each month.
The reasoning behind cycling comes down to receptor sensitivity. Continuous, high dose hormone exposure over time can cause the body’s own receptors to become less responsive, similar to what happens with testosterone therapy in men, where continuous high doses can suppress the body’s natural production. Taking a short break, even just a few days a month, allows receptor sites to reset and can help the same dose continue working effectively over the long term rather than requiring escalating doses.
This is a highly individual decision that depends on your specific symptoms, your dose, and how your body responds, which is exactly why working with a knowledgeable provider matters so much here rather than following a generic protocol.
The Vaginal Microbiome Is Its Own Ecosystem
We’ve all heard about the gut microbiome by now. What’s less commonly discussed is that the vagina has its own distinct microbiome, and it works in the opposite direction from your gut.
While gut health thrives on diversity, with a wide range of healthy bacterial species associated with better metabolic health and lower cancer risk, vaginal health depends on the opposite. A healthy vagina is dominated by just a handful of specific lactobacillus strains. As estrogen declines with age, the vaginal pH shifts from acidic to more alkaline, allowing a more diverse and less protective bacterial population to take over. This shift is associated with increased risk of infections, odor, and even higher rates of HPV and cervical changes.
Supporting this ecosystem isn’t just about comfort. It plays a meaningful role in long term protection and tissue health. Oral probiotics containing specific lactobacillus strains have been shown to improve the vaginal microbiome, and for women just starting to rebuild this ecosystem, a more concentrated approach for the first couple of months followed by ongoing maintenance tends to show the best results.
One important caution from this conversation: a single course of antibiotics, or even a single meal containing antibiotic residue, can disrupt this delicate bacterial balance. If you know you need antibiotics for a procedure or illness, taking a probiotic at a separate time of day can help minimize the disruption rather than eliminating your support entirely.
Vaginal Rejuvenation Procedures: What to Know First
With the rise of laser and light based vaginal rejuvenation procedures, it’s worth understanding what the research actually supports. According to guidance referenced in this conversation, these procedures tend to show more benefit in premenopausal women, while postmenopausal women often don’t see the same results unless the tissue has first been adequately supported hormonally.
Without addressing hormone levels and the vaginal microbiome first, these procedures may need to be repeated every six months to maintain results, and can potentially lead to scarring or decreased sensation over time. The more effective approach discussed here is addressing hormonal tissue health and microbiome support first, which often reduces or eliminates the need for a procedure altogether.
The Bigger Lesson: Decision and Vision
Beyond the clinical details, one of the most powerful takeaways from this conversation wasn’t about hormones at all. It was about mindset. When asked how she stays consistent with the habits that support her own health, Anna’s answer was refreshingly simple: decision and vision.
Most of us jump straight to action, searching for the right supplement or the right protocol, without first getting clear on why we’re doing it and what it will actually feel like once we get there. Getting specific about your reason and your vision for the outcome, whether that’s better sleep, a better sex life, or simply feeling like yourself again, tends to create far more lasting change than jumping straight into another routine.
The Bottom Line
Vaginal and pelvic health in midlife isn’t something to be embarrassed about, and it isn’t something you have to simply tolerate. Whether it’s understanding the real difference between progestins and bioidentical progesterone, learning why topical support matters even while on HRT, or discovering the role your vaginal microbiome plays in long term health, there are real, practical steps available.
Dr. Anna Cabeca’s full product line, including Julva, Velvet, Mighty Maca, and Balance Cream, is linked below for anyone who wants to explore these options further. As always, work with a provider who understands bioidentical hormones and can help you find what’s right for your specific body.
Products mentioned:
Julva https://dranna.com/nataliejill
Balance Cream https://dranna.com/nataliejillbalance
Mighty Maca http://dranna.com/nataliejillmaca
Velve http://dranna.com/natalievelve
The contents of the Midlife Conversations podcast is for educational and informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always consult with a qualified healthcare provider. Some episodes of Midlife Conversations may be sponsored by products or services discussed during the show. The host may receive compensation for such advertisements or if you purchase products through affiliate links mentioned on this podcast.
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by Natalie Jill
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