Urogynecology: What You Need to Know About Pelvic & Sexual Health with Dr. Alexandra Dubinskaya

Hello everyone and welcome back to the vocal pelvic floor where we are telling the truth about pelvic health, sexual health and the gaps in medicine that too many women are forced to navigate alone. Today’s conversation is about the intimate issues women are often taught to normalize, minimize or even hide. Things like leaking, pain, prolapse, recurrent UTIs, painful sex, menopausal changes and

the quiet grief that comes when no one seems willing to connect the dots. My guest today is Dr. Alexandra Dubinskaya, a urogynecologist and sexual medicine specialist whose work really sits at the intersection of pelvic health and medicine, reconstructive care and sexual wellbeing. And I am super excited about this. We are talking about what gets missed, why women’s intimate health is still so fragmented.

and what it looks like when care finally becomes comprehensive, evidence-based, and deeply human. Welcome, welcome, welcome, Dr. Dubinskaya. I hope that I am not messing up your name. I’m gonna say it again because I asked before we hit record and I was like, ⁓ okay, I always get a little self-conscious. But first of all, welcome.

Dr. Alexandra Dubinskaya MD (01:17)

Thank you. Thank you for having me and you’re pronouncing it absolutely, perfectly wonderfully. It’s Alexandra Dubinskaya Thank you for having me.

Dr. Ginger Garner PT, DPT (01:22)

Okay. Okay.

Wonderful. I am so glad that you’re here. It’s such an honor to be able to bring guests like yourself on the show because I know how busy you are. And to that end, I want to give the listeners a little bit of background information on what you’re doing every day so they can appreciate what it is that you do. ⁓ So Dr. Dubinskaya is a Urogyn

which is urogynecologist and sexual medicine specialist in Beverly Hills, California. She specializes in conditions including urinary incontinence, pelvic organ prolapse, recurrent UTIs, interstitial cystitis, ⁓ sexual dysfunction, menopause, all of the things that can go wrong below the belt essentially.

With training in both Russia and the United States, she blends surgical expertise with a holistic patient centered approach to women’s intimate health. She completed fellowship training in female pelvic medicine and reconstructive surgery at Cedars-Sinai and is internationally recognized for advancing sexual literacy and women’s pelvic health. She also serves as chair of the communication committee for the International Society of Sexual Medicine and has contributed extensively to leading journals and textbooks.

Welcome again.

Dr. Alexandra Dubinskaya MD (02:45)

Thank you.

Dr. Ginger Garner PT, DPT (02:47)

So the first question I have is one that seems, if we’re in the healthcare space and peeing in the pelvic and sexual health space all the time, we throw around lingo, you saw your OB or you went to the Urogyn et cetera. But for the listener, let’s just break that down a little bit. How do you explain what Urogynecology is and why does it matter so much in women’s everyday lives?

Dr. Alexandra Dubinskaya MD (03:13)

It’s a great question. And you know, I get that question not only from a patient, from doctors as well. And it’s a little bit sad that we spent as a urogynecologist, we spent so many years in training, perfecting our skills, and then people don’t know about us. ⁓ Well, to simply put, so if you want to do your annual exams like Pap smear, mammogram, you have a fibroid, so you’re trying to get pregnant, that’s obstetrics gynecology that they will see you, they will be able to help you.

Dr. Ginger Garner PT, DPT (03:19)

Hmm.

Yeah.

Dr. Alexandra Dubinskaya MD (03:44)

Traditionally, has been that if you’re a male and you have a problem with urinary symptoms, so with fertility, you go to a urologist. And so where the women who have a problem with urination go. So that space actually covered by urogynecologist. And that’s something that the special training that you receive after doing residency and then you’re doing fellowship.

And it can be done through two specialties. You can be, which we call GYN train, meaning you’re doing the training in gynecology, or you can be urology train and do the residency in urology. And from both of those fields, you can add the fellowship, additional two to three years of training to become urogynecologist. And the areas that we usually cover is anything urination. So, ⁓

peeing with coughing and sneezing, peeing with urgency. You’re just getting to the house, you’re touching the door handle and you just can’t hold anymore. Any issues with prolapse? And prolapse is when the pelvic floor organs kind of shift from its normal position due to different reasons. So it could be like bladder, uterus, posterior wall of the vagina. So we can fix that.

also recurrent, meaning the ⁓ recurrent urinary tract infection, meaning UTI is happening more than two, three times a year. And because historically, usually women who found the Urogyns they were right at the area of like 40s, 50s, 60s and above, it just became natural to also manage menopause for them, like the hormones, because

There is no really formal training in like prescribing hormone replacement therapy in a regular OBGYN residency. And when I treat the patients, I not only surgically addressing their condition, I also want them to feel good and I want them to heal and recover fast. And the hormone replacement is a great basis to it. So it’s kind of like fell in my lap. And when I started doing it, I didn’t realize that it’s not common for people to do that.

And also whenever you have issues from down there, it affects you in so many areas of life. So sexual dysfunction commonly go hand in hand with the pelvic organ prolapse and incontinence. So it’s also became a part of my practice. And I think for a lot of urogynes, they also find themselves in that space.

Dr. Ginger Garner PT, DPT (06:25)

Yeah. So, you your work is at the intersection of urogynecology and sexual medicine because they’re so interrelated. And many people think of those worlds being separate, but I tell patients all the time, there’s not a lot of space down there. So if you have a bladder problem, you’re likely to have a sexual health problem. What really drew you to be interested, you know, in these fields? I’m really curious about your story.

Dr. Alexandra Dubinskaya MD (06:55)

Yeah, well, I did my initial training like medical school and general surgery residency in Russia, and I wanted to train from the best. So I came to the United States and I wanted to make a change. And I realized that I could do it again and not do in general surgery. I really wanted to be like pelvic floor, vaginal health physician. And what helped me to… ⁓

Realize also that that’s my calling. Before getting into residency, I was lucky enough to work as a medical assistant for amazing urology-trained urogyne. And I learned about all these conditions and I was convinced that that’s probably what you learned to treat those conditions in ⁓ Ob-GYN residency. And I really set my goal. Okay, I’m going to go to Ob-GYN residency. And then I soon realized that nothing.

of the topics that I was passionate about were being actually taught formally in a OBGYN residency. So, but in some ways it made it easier for me because I already had so much knowledge from working as a medical assistant ⁓ to help patients who couldn’t just find help from ⁓ like regular doctors. So I soon developed, like we all had this like continuity clinic.

Dr. Ginger Garner PT, DPT (07:57)

Hmm.

Dr. Alexandra Dubinskaya MD (08:19)

where you collect the patients and you kind of like follow them for your residency. And I had a great group of patients who I was taking care of with urinary incontinence, pelvic organ prolapse, sexual dysfunction, menopause. And I was not the physician to help with pregnancy because I didn’t feel passionate about it. I didn’t feel like I’m making a significant change in the life of women compared when I was able to help them stop peeing themselves.

or find a way to solve the sexual problem. So it was very rewarding and ⁓ I knew that there is a field of urogynecology that’s very competitive. And I decided that I’m going to give it all. And I was lucky enough to match to the fellowship program at Cedars-Sinai here in Los Angeles. And I received amazing training from one of the best

women urologist in the field. And they were very open-minded in terms of treating also sexual dysfunction. And I think it was just amazing experience, which helped me to shape who I am as a physician and surgeon on my own and how I want to see my practice.

Dr. Ginger Garner PT, DPT (09:37)

Yeah, I love that because patients don’t, they don’t experience their bodies in separate specialties. And so I’m a huge fan of urogynecology because of that. They experience all that in one and coming from someone who spends extensive amount of time with patients, you in pelvic PT, seeing that whole relationship with their body, you know, in the nervous system and seeing that come back to come together.

And the specialty that you provide is just so essential and so often it’s not celebrated, it’s kind of overlooked. People don’t know enough about it. And so that means so many women normalize stuff that shouldn’t be normalized and things get missed. So I know that you have probably, you could talk about this for hours. Like what are the most common pelvic…

Dr. Alexandra Dubinskaya MD (10:35)

Yeah.

Dr. Ginger Garner PT, DPT (10:35)

or sexual symptoms women are told, that’s normal. I hear this all the time. It’s just age. Get used to it, right?

Dr. Alexandra Dubinskaya MD (10:44)

⁓ yeah, every day. And you know, also to your point that people don’t know, I always like kind of like joking, but in being kind of jealous, like all my colleagues who is treating endometriosis or treating like some heart conditions, like, mean, we in Beverly Hills, we treat celebrities all the time, but they can post online on social media how they like save their patients from like heart attack, save the patient from the endometriosis.

And I keep waiting when the peeing yourself and pooping yourself will be normalized so I can post those pictures and they can say like, oh, this doctor helped me to stop peeing in my pants. But I think we have a long road ahead and it’s still like, if you have like a triple bypass surgery, you can talk about it during cocktail hours and everyone gonna like listen to you and feel like, oh, you’re a survivor. But if you say like, hey, you know what? I had the baby and now I’m like peeing myself every time I cough.

Dr. Ginger Garner PT, DPT (11:20)

That’s right. That’s right.

Dr. Alexandra Dubinskaya MD (11:43)

I think everyone started kind of like moving away from you. So, but I think there’s really good changes happening in what people like learn, what people want to know. So I think it’s coming. But back to your question about the most common conditions are from the urinary standpoint, urinary leakage associated with physical activity. if you cough, you sneeze,

or you lift something heavy or you run, the urine comes out. So any increase in abdominal pressure will cause urinary leakage. It’s called stress urinary incontinence. And it’s very common happens due to vaginal birth, due to chronic cough or constipation, and some connective tissue disorders. There is also a condition that called overactive bladder or urinary urge incontinence.

So everyone had that friend who always needs to use a restroom and sometimes that friend is you. So that’s a common condition where you always have to look for the bathroom. You leave the house, you go to pee, come here, like you go to visit your friends, you go to pee, you go to the mall, all the bathroom in the neighborhood. And your hands touching water, the urine comes out. So it happens due to the bladder muscles being overreacted, contracting all the time.

And that contraction perceives this urgency. ⁓ It’s a very annoying condition because it’s unpredictable. And that’s why women suffer a lot with that. And it affects their social life, their mental health, their relationship. Condition such pelvic organ prolapse. And I explained earlier that it’s shifting of the pelvic organs from its normal position due to weakened support system.

Again, some people genetically predisposed to it. One of the major risk factors is the vaginal birth, especially if there was some operative vaginal birth involved, like forceps or vacuum, would increase risk of pelvic organ prolapse. Chronic constipation. ⁓

connective tissue disorders like airless, denless, or chronic heavy weight lifting. So that can also contribute to it. This is some of the classic conditions. In those conditions, we treat as a urogynecologist conservatively with some lifestyle modifications. There is a role for pelvic floor physical therapy. There is a role for medical treatments. And there is a role for surgical reconstruction as well.

Dr. Ginger Garner PT, DPT (14:20)

Yeah, it’s good to just kind of give the umbrella, know, the 40,000 foot view or the umbrella view, whatever metaphor works for the listener. What are some of the things when we talk about sexual health? Because I think that is probably, know, bowel bladder function is stigmatized. I get patients that come in and they know what they’re coming in for, right? They know they’re coming in.

Dr. Alexandra Dubinskaya MD (14:44)

yeah, that’s the best

thing to do. You can always ask them, they will tell you.

Dr. Ginger Garner PT, DPT (14:47)

Yeah, they

know what they’re coming in for and yet they will sit down and go, well, this is unrelated, but, and then they’ll start telling me about sexual health or they’ll say something about bowel health. And yet it tells me that although they know they’re coming to pelvic PT for help, they’re not really fully aware of the entire scope of what we actually talk about. So I always joke, you know, there is no information that is not relevant, you know, about the pelvic girdle. ⁓

You know, and also have people who, singers who, and performing artists who come in and because of their improper voicing and pressurization of the system, they also have leakage just from performing, yelling, things like that. And I work with performing artists all the time to change that pressure management. But getting back to the stigma around sexual health, ⁓ talk to me a little bit about, you know, what women will come in because they don’t want to talk about that. And that’s the one thing they will leave out.

even though it’s on the intake forms, we ask about it, they’ll leave it out because they’re still too uncomfortable to talk about it. And now here we can talk about it in a public space on the podcast. So tell me about some of the types of things that women will come in and they’re told are normal or they’re afraid to talk about regarding sexual health.

Dr. Alexandra Dubinskaya MD (16:05)

Yeah, absolutely. Well, ⁓ one of the common, again, going back to stress urinary incontinence, it’s very common for postpartum women when they had a baby, they like peeing their pants, they want to have sex, but they’re too afraid to pee themselves or they pee themselves during sex, but they feel like, it’s only happened to me, nobody else talking about it. So probably just something wrong with me. So that’s very common.

Also, the genital urinary syndrome of menopause. So lot of women probably heard about it as a vaginal atrophy, which is not a very sexy term, but basically due to the changes in the hormones, there’s happens, ⁓ the changes in the vaginal tissue happening and it’s affect vaginal dryness, just being aware of your vaginal area, urinary urgency, frequency, frequent urinary tract infection. And for some women it happens kind of very slowly. And for some women it…

Dr. Ginger Garner PT, DPT (16:34)

Yeah.

Dr. Alexandra Dubinskaya MD (16:58)

can be the only presenting symptom of perimenopause menopause. So if sex start hurting and then pelvic floor muscles come into place and the pelvic floor muscles is extremely smart muscles, if something hurts, they will make sure that they do everything that that pain not gonna happen again. So they get tense and now it’s becoming this vicious cycle. ⁓ Everything hurts, muscles tensing up, the more tension they have, the more pain women experience.

then they start experiencing urinary changes because ⁓ when muscles are tense, everything that they support will kind of come up as a symptom. So urinary urgency frequency as well, issues with bowel movements, pain with sexual activity, issues with ⁓ libido because again, with age, with hormonal changes.

where certain life stressor, relationship stressors ⁓ might lose that ability of being just spontaneously aroused and be in the mood. So I treat that also orgasm, being able to generate the topical arousal. And it’s such a multi-level, multi-layer process. You really need to be like,

Dr. Ginger Garner PT, DPT (18:21)

Yeah.

Dr. Alexandra Dubinskaya MD (18:21)

physically

well and fit in order to generate the whole body arousal because everything is involved. Increase in heart rate, increase in our breathing, the flashing of the skin, there is engorgement of the blood vessels in the genital area, vaginal canal getting like more kind of like stretched, a lot of lubrication. So you do need to have good general health in order for all of those changes to happen. And also,

Similarly to men developing erectile dysfunction, women might experience the dysfunction and experiencing orgasm where the clitoral ⁓ erection is not as strong, where it takes them a longer time to achieve orgasm, orgasm feeling muted for different reasons. And this is something that usually women don’t start conversation casually with the doctor and you don’t know like.

which doctor to talk to. And for the doctors, there was multiple studies were done where like doctors feel uncomfortable initiating the conversation in general, but also the older the women are, the more inappropriate they feel that conversation is.

Dr. Ginger Garner PT, DPT (19:26)

That’s so important because, ⁓ like I referenced earlier, I think the most common comment that I get once patients realize, I can talk about sexual health here. This is a space where we can treat that and address it and make referrals when necessary, et cetera, is that women will come in and say that they were told that they have to accept it because it’s aging or menopause.

And what I hear you’re saying and what we know to be true in the evidence base is that is very much treatable and it doesn’t, you don’t lose function as a consequence of age if you’re actually addressing all of the lifestyle factors and all the things that surround it, which is great news.

Dr. Alexandra Dubinskaya MD (20:11)

Isn’t it

crazy how like, can you imagine the same conversation in the plastic surgeon office saying, hey, you know what? I don’t really like this wrinkles. And they were like, well, you just accept it. Like what’s going to happen? The person going to go to another, to another doctor. So I think that’s probably what women should do. If you told that it’s just aging, maybe it’s a place for a second opinion. There is nothing wrong with second opinions.

Dr. Ginger Garner PT, DPT (20:20)

You

That’s right. That’s right. So I think that the take home message in talking about framing the problem is that we don’t have to normalize these things. ⁓ We need to realize, listeners realize very early that if something feels askew with the bladder, with pelvic symptoms, with sexual pain, believe it, it is real and that there is help for that. Because so many women lose years of their life thinking they’re just overreacting.

or the symptoms aren’t that bad, when in reality, they’ve just never had the right framework or the right clinician.

Dr. Alexandra Dubinskaya MD (21:13)

Yeah, I’ve been, usually women are very in tune with their body and if they know that something is off, something is off.

Dr. Ginger Garner PT, DPT (21:21)

Yeah, yes, exactly. So let’s talk about sexual pain and diagnostic blind spots. ⁓ When someone comes in ⁓ with pain, and ⁓ we call that dyspareunia, so that just means painful sex, and that can be defined in so many different ways, where do you begin with them? What are the main things you’re gonna sort through clinically?

Dr. Alexandra Dubinskaya MD (21:46)

Yeah, well, one of the first important thing is like, okay, how old are you? Because different conditions would affect different ages. And if it’s somebody who is younger, we talk about different types of vestibulodynia. We can talk about some hormonal changes due to hormonal birth control, some pelvic floor dysfunction, or endometriosis. Or if the women are a little bit older, they’re more likely to have a genitourinary syndrome with menopause.

And how long has it been present? Is it something that like you never been able to have a pain free sex or you had perfect sex, great sex life, but then something suddenly changed and it’s not happening anymore. And what’s exactly that happened? ⁓ it’s very important to know where exactly the pain located external, like on initial penetration, is it more on a deeper penetration? Is the pain stops when you stop?

having sex or is it tend to linger? ⁓ Is it only with their certain partner, certain toy, or is there is happening with everyone? ⁓ medication you’re taking, because again, there is a lot of medication, not only like a birth control that can affect the tissue quality, but also the medication that produce the same effect on the liver. So increase the sex hormone binding globulin, that’s a special globulin.

that kind of attaches to the hormone and makes the hormone inactive. That’s what the contraception pills do. And that’s what medication like Clomid, the spironolactone can do. Other type of medication for ⁓ lipid control, for hypertension, it’s very important to review them as well because they can contribute. Antidepressant, one of the main side effects is the sexual dysfunction.

So going in depth through the medications. Also any recent surgeries because if somebody had a pelvic surgery, it shifts all the organs around, it affects a lot of nerves. So it will take some time until the function ⁓ will come back. ⁓ And also what’s going on in your life? Because if you don’t like your partner, you’re not gonna have a great sex life. What’s going on in your life?

Dr. Ginger Garner PT, DPT (23:37)

Hmm.

Mm-hmm.

Dr. Alexandra Dubinskaya MD (24:06)

If you have three, four little children or even one little child and you’re so stressed and you sleep deprived and you have a lot of things on your plate, you probably like the sex would be the last thing on your mind. So ⁓ the approach has a special name. It’s called biopsychosocial model where you assess the physical health, mental health.

interpersonal relationship, also like the way how the person was brought up. ⁓ Religion, culture also shapes a lot, like a lot of different ways how we experience sexuality. So it’s also very important.

Dr. Ginger Garner PT, DPT (24:38)

Yes.

Yeah, it is. I’m so glad that you mentioned the biopsychosocial model. It’s how I believe medicine began with looking at the whole person and then it’s gotten siloed and fractured and I think it’s kind of coming back slowly, full circle for people to look at lifestyle, to look at those psychosocial factors and things like diet, sleep, et cetera. For conditions like…

vestibulodendia, pelvic floor dysfunction, recurrent UTIs, ⁓ painful bladder syndrome or interstitial cystitis and hormonal changes. is, the field can feel muddy. It overlaps so heavily and it’s usually not a single diagnosis. There’s, know, when people come in and with pelvic pain, they can easily have four or five, six, you know, diagnoses.

talk a little bit about why it’s still so difficult because when patients come in, I see them, there’s still too much delay. There’s too much delay in diagnosis. Why do you think it’s so difficult for many patients to get a clear diagnosis and help early?

Dr. Alexandra Dubinskaya MD (26:03)

Well, there are multiple reasons. One reason is, again, there is no formal training in those conditions. And there is actually a group called TightLip. It’s an organization that was formed by activists who suffered with vestibulodynia, pelvic floor pain. And they are advocating for OBGYN residency, for urology residency to…

to teach, to learn, the full of vaginal disorders. So I think when you not train and you go through four years of residency believing that there’s gonna be like pregnant people, non-pregnant people needing hysterectomy and pap smear, it’s kind of very difficult to like learn about different types of vestibuladenia. And also because as you said, everything is so intertwined, it’s literally takes

a lot of time from the provider to kind of peel it off and figure out what came first, what we need to address, ⁓ what other treatment modality we can use. Because a lot of treatment modalities in vestibulodinia for different etiologists of vestibulodinia, they’re not FDA approved. We use them off-label. And some physicians don’t feel comfortable doing them. ⁓ Again, going back to how long those visits are.

and how much care and resources does patient take, it does take a special set, like practice set up in order to fulfill those needs. So if you’re seeing 50 patients a day, it’s impossible to have in depth conversation and figure out what’s going on. It’s more like, okay, I’m gonna give you a prescription for lidocaine. You put it wherever it hurts. I’ll see you in three months. So I think…

Dr. Ginger Garner PT, DPT (27:57)

Yeah.

Dr. Alexandra Dubinskaya MD (27:58)

I think that’s some of the reasons. Also keep in mind, we still don’t know much about those conditions. ⁓ There is still so much research needed, ⁓ so much realization how those conditions, most of the time, not just like isolated presentation of one condition, it’s a part of the whole system that something’s going off.

It’s very complex.

Dr. Ginger Garner PT, DPT (28:29)

Yeah, that is also why many providers, you just outlined so many reasons why many providers still miss when a patient says, a person says, ⁓ sex hurts. They miss that because maybe they don’t have the time. Maybe they didn’t have that training and don’t have the ability to do that differential diagnosis or… ⁓

it’s stigmatized, they don’t know where to go from there. And that leaves so many people, ⁓ especially women, without answers. And I am sure that you see this show up all the time, and that is shame, self-blame, when women are dealing with sexual pain. And what are some of the initial things that you can…

How do you begin to help shift that away from self-gaslighting, self-blame, and shame?

Dr. Alexandra Dubinskaya MD (29:32)

Well, I mean, it’s also about discussing of like what the findings are and what can be done. One of the things that’s very validating is, for example, for people who have near proliferative vestibulodynia. So there is a more mass cells, more nerve cell and nerve ending in the vestibular tissue.

Dr. Ginger Garner PT, DPT (29:53)

Hmm.

Dr. Alexandra Dubinskaya MD (29:56)

So one of the treatment options is vestibulectomy. But so for a lot of patients, they feel uncomfortable just going straight to surgery. So in my practice, I usually do biopsy and I have amazing pathologists who do special staining and they can actually calculate and tell me how many muscles there are and how many nerve endings there is. So it’s kind of very helpful and validating for people like, okay, this is the reason why I

have pain. So now let me think if I want to go ahead and do the surgery. Obviously surgery is not for everyone. There’s different cases, but I think actually having that report, pathology report that shows that there is real issue is very helpful. Also for people who, let’s say they have a very like hypertonic tight pelvic floor and they experienced a lot of urinary issues.

They’re not able to have sex. They’re not able to tolerate dilators. Something that I offer in my practice is to do ⁓ the Botox injection in the muscles, because it’s going to relax the muscles. And when you do it a few times, your muscles kind of forget how to be reactive to life settings, the settings where you are, and just in general. And it’s very validating for patients to feel like,

I would say three, four weeks after injection, like, huh, I don’t have this urgency anymore. it kind of feels better. can do like, can do the dilator therapy, do pelvic floor physical therapy. So when the treatment works and gives some relief, I think it’s also very validating that like, so I have something real.

Dr. Ginger Garner PT, DPT (31:42)

Yeah, that validation piece is huge. I think oftentimes that that can be begin to be the biggest piece that puts shame, you know, to bed because so many women internalize these symptoms as failure, as a personal failure, instead of recognizing them simply as a health care issue that deserves treatment and care. Yeah.

That also brings up something we’re kind of like shifting into. ⁓

a part of the conversation that’s kind of an evolution in life, which is menopause hormones, you know, and sexual health as well. And we know, I mean, how much with genitourinary syndrome of menopause or GSM can affect the bladder, vulvar, vaginal tissues, pelvic floor function, and sexual wellbeing in so many ways. What are some of the biggest education gaps

you see around menopause and sexual health, or maybe another way of putting it is, what do you want women to know about menopause and sexual health? Because I think there’s a lot of misinformation out there, mostly couched as, it’s just age, get used to it, libido goes away, function goes away, there’s vulvovaginal atrophy, there’s nothing you can do.

Dr. Alexandra Dubinskaya MD (33:06)

Yeah, I would love to imagine like everything that you said, but that conversation happening in urology office and the doctor says, there’s nothing you can do. There is no more erection for you. That’s it. You reached your quota. That’s it. ⁓ That would never happen. ⁓ Even like the man would be like on his dying bed and the urologist still would give them Viagra to like enjoy life.

Dr. Ginger Garner PT, DPT (33:16)

Ha!

Dr. Alexandra Dubinskaya MD (33:32)

So, and for women, is like so much protection, like can she able to tolerate this side effect? So ⁓ I hear you. Well, I would say a few things that I would like women to know is first is perimenopausal symptoms appear significantly sooner and earlier than ⁓ your periods disappear. So if you start feeling that something is off, something is off.

Again, it might not be a perimenopause. It might be some thyroid dysfunction, which is very common. ⁓ It could be some just slight hormonal changes. So it’s very reasonable to check your blood levels. And it’s not something that’s ⁓ indicated technically. And I’m sure a lot of women see the providers who would say, it’s not indicated. We’re not going to check it. ⁓

Dr. Ginger Garner PT, DPT (34:24)

I hear that a lot.

Dr. Alexandra Dubinskaya MD (34:25)

We have like aura ring, we have all this like fertility trackers. We love to see our data. Like why not? We know that between day two and day 10, it’s kind of more predictable pattern of changes. And we can see like, okay, if your FSH is rising a little bit higher, there might be something, you know, once in a while you can find some…

Dr. Ginger Garner PT, DPT (34:34)

Mm-hmm. Mm-hmm.

Dr. Alexandra Dubinskaya MD (34:51)

Findings that you were not expecting and also testosterone. We all start losing testosterone now in the mid-30s. Why not help yourself and give a little bit of boost and take it and feel good? Life is too short to ⁓ not use hormones. I think it’s important to be aware of it. If something is going off, you feel a little bit more anxiety, a little bit more mental health issues, it also could be part of the perimenopause. ⁓

Dr. Ginger Garner PT, DPT (34:57)

All right.

Yeah.

Dr. Alexandra Dubinskaya MD (35:21)

If it’s me, I would try hormones first before going to any antidepressants or anything like that. Obviously, every case is different, but in general, if it’s a new findings from nowhere. ⁓ Know that there is no limited amount of age that you’re allowed to be on the hormone replacement therapy. Sometimes women ask me, and I tell them, because they ask me, how long can I be on the hormone replacement therapy?

Dr. Ginger Garner PT, DPT (35:34)

Yeah.

Dr. Alexandra Dubinskaya MD (35:50)

Well, answer is as long as you want to feel good, look good and live longer, take it. The moment you stop wanting all those things, then it’s time to stop. And I think another thing to know is hormone replacement is I think the most natural way to age because if you think about it, if somebody has diabetes and doesn’t have any insulin,

We don’t give them like chamomile tea and tell them to do yoga and journal. We give them insulin. All other things are great, but there is some core things that needs to be done. So giving yourself back what was lost, that’s actually gonna improve longevity and the most natural and logical thing to do.

Dr. Ginger Garner PT, DPT (36:23)

Right.

Mm-hmm. Mm-hmm.

Yeah, that was a really good analogy. I’ve also often think about if someone has hypothyroidism, they’re not just saying, tough it out. You’re getting the hormones that you need and the replacement that you need. we definitely need to put to bed the argument that menopause is a quote natural event that you should just be able to go through with nothing because women didn’t even have the life expectancy back then to.

have any treatment that we have now. So we don’t even know. And that’s why it makes it so important for us to follow through and replace those things now because everything that you have talked about so far, there’s urgency frequency, recurrent UTIs, tissue sensitivity, atrophy, dryness, loss of libido, painful intercourse, all of those things women often don’t realize are connected.

and can be a universal experience during perimenopause to menopause, but they don’t have to be if we’re in front of it. Yeah.

Dr. Alexandra Dubinskaya MD (37:50)

Exactly,

Dr. Ginger Garner PT, DPT (37:53)

And that brings up an important point too about just in menopause and sexuality, think medicine still avoids the conversation in general. ⁓ Maybe it’s because of the lack of training that nothing is standardized ⁓ and all the training on menopause, for example, has to be after. ⁓ Like so much of the training that we really get that’s effective for us as clinicians happens after we are done with formal training.

Dr. Alexandra Dubinskaya MD (38:20)

Thank

Dr. Ginger Garner PT, DPT (38:21)

But it’s still maybe, and maybe it’s cultural stigma, know, religion, ⁓ social conditioning. There’s so many reasons why the menopause sexuality conversation is not yet happening as it should. It’s changed a lot in the last two years, thankfully, but not fast enough. Yeah, you know, historically it’s left women feeling confused, isolated.

Dr. Alexandra Dubinskaya MD (38:36)

Yeah.

Dr. Ginger Garner PT, DPT (38:45)

⁓ feel like they’re somehow disappearing into their own bodies and they don’t even recognize their bodies anymore. ⁓ But the good news is we can talk about treatment options. We can talk about multidisciplinary care. And you’re fellowship trained in reconstructive surgery, but your work is also clearly broader than surgery alone. So what helps you decide when conservative care is appropriate versus when surgery is appropriate? How do you help patients make those decisions?

Dr. Alexandra Dubinskaya MD (39:14)

Well, it’s kind of patient decision. What I usually tell my patient, if you have a prolapse but you’re not bothered by it, nobody should tell you it’s a time to fix it. And some people might have a very small prolapse but bothered by it a lot. OK, so we can fix it. ⁓ So I think it’s a lot about shared decision making. ⁓ Whichever decision you make,

Dr. Ginger Garner PT, DPT (39:33)

Yeah.

Dr. Alexandra Dubinskaya MD (39:41)

that’s great, I just want to make sure that I tell you all the options that’s out there and you pick the one that works for your lifestyle. And I can kind of guide and correct of like, ⁓ this is great decision, or you know what, maybe we should consider this adjustment. But ultimately, medical versus surgical, it’s for the patient.

Dr. Ginger Garner PT, DPT (40:04)

Yeah, that’s such an important point. And I think that’s, if all women could have a provider like that, that is very person-centered, that puts the decision-making with them and presents them with all the options. And one of the things that we talked about before we pressed record, because I think, talk about stigma and taboo conversations and stuff, and women, ⁓ historically, know, women and families going, and I was…

talking about this with another colleague earlier this week, of women and families and previous generations going, we don’t talk about that, right? We don’t talk about the fill in the blank. We don’t talk about, you know, whatever that may be. And sexuality is one of those, sexual health is one of them. So one of the things that we were mentioning before we hit record, y’all, was the role of conservative therapies and things like that, which can help so much with sexual health and…

Of pelvic floor PT, you know, I’m a little bit of a biased fan of pelvic floor PT, but that plays a role too in the outcomes you want for your patients. But let’s talk a little bit about like pelvic health tools and toys and all of those things that I have a whole like toy basket. It’s more of a cart, a cart full of toys that I have in my clinic that I’ll pull out and it just…

destigmatizes everything, know, it’s we have a sense of humor about it. ⁓ Like my newest model here, for those of you watching on YouTube, here’s my newest model. It’s the whole clitoris, but she has her, ⁓ well, it’s not an arm, but one of the arms raised in the air. And I wanna put a little sign on it that just says something like vaginal estrogen or DHEA for everybody or something like that.

Dr. Alexandra Dubinskaya MD (41:41)

I love it.

Yeah, put it in the water, huh?

Dr. Ginger Garner PT, DPT (41:59)

and take it to the clinic.

Yes, exactly, exactly. But let’s talk a little bit about those tools and toys like vibrators and pelvic health and other conservative means for helping patients out because you can throw the proverbial sexual health ball a long way by using those things.

Dr. Alexandra Dubinskaya MD (42:16)

100%. So one of the, think, number one tool that I love and always recommend is the vibrators, because we know that vibration dilates the blood vessels and brings more blood flow. So the more blood flow you have in the area, kind of rehabilitates the area. Think about rehabilitation if you’ve broken your leg and you go and they start moving your leg. So make sure that the blood flow goes there. ⁓

and also just it decreases the pain, it improves the blood flow. We also did a study at Cedars-Sinai where we gave women vibrators and tell them to use it two to three times a week. Just topically, the orgasm was not the goal, it’s just the use of vibration and they used it for three months. And we actually noticed significant improvement in the symptoms of the pelvic organ prolapse.

Dr. Ginger Garner PT, DPT (43:02)

Mm-hmm.

Dr. Alexandra Dubinskaya MD (43:13)

there was a positive trends into the improvement of stress urinary incontinence, urge urinary incontinence, improvement of the vaginal atrophy like nonsclerosis. They also notice improvement in sexual function and mental function. So there is definitely more research is needed, but all of those findings, are like, yeah, that’s true. Like that will help. So people who have

Dr. Ginger Garner PT, DPT (43:25)

video.

Mmm.

solid.

Dr. Alexandra Dubinskaya MD (43:41)

Like think about when you bring your kids to the pediatrician and they do injections, sometimes they have this vibration like ice cold and the vibration, which vibration compete with those pain receptors. So you experience pain less. And there was a study was done when the women with ⁓ provoked vestibulodinia was using the vibration and it’s actually decreased the amount of pain they have. And they were able to have like insert the dilators vaginally.

Dr. Ginger Garner PT, DPT (43:51)

Mm-hmm.

Dr. Alexandra Dubinskaya MD (44:10)

So that’s definitely helpful if you have a tight pelvic floor. Like what would you do to your back muscles? If you have a tight muscles, you would use your teragun. You will use the massage. So the pelvic floor muscles is exactly the same. You just need to kind of like find them and get a little bit of guidance how to get there. So some vibration is really good for the pelvic floor. And I always recommend that. There is also dilators.

However, I always feel so sad talking about dilators because I feel like it’s such an isolating experience when you sit with those dilators probed and you just have to put them in the vagina, keep sitting, then put another one and you’re of bored and annoyed and you’re attached to that place. So I usually recommend to either get the vaginal dilators with like built-in vibration

Or at least use vibrator in addition because it also will prepare the tissue, prepare the muscles. At least you’re having fun. Like if you need to put something in the vagina, like add some fun to it because just bare dilators is a little bit ⁓ boring. Yeah.

Dr. Ginger Garner PT, DPT (45:21)

I love that.

Yeah, I love that. The other

⁓ thing about vibration is for different Hertz frequencies, and I find that there’s not a… We need more research. I’ll just say that on the different Hertz frequency for stimulation, because in pelvic floor research for PT, ⁓ we see that the different layers of the pelvic floor respond differently under different inputs. And of course, that speaks to a whole other area of research.

Dr. Alexandra Dubinskaya MD (45:38)

Yeah.

Dr. Ginger Garner PT, DPT (45:54)

But the other thing that I’ve noticed too is that, and help with pelvic organ prolapse and incontinence and improvement of pelvic floor symptoms is that the vibration, in addition to all of the awesome things that you listed, can almost help stimulate and kind of wake up the pelvic floor in a way that different, other static inputs don’t. So I think the different frequencies that can be in vibrators and therapy ones, sometimes are 80,

hertz frequency, sometimes it’s 110, can be really interesting for stimulating the layers of the pelvic floor to get that improvement. So it’s just such a promising area. And I think most women think about it in terms of just like arousal or orgasm as being kind of the end goal, but it’s not necessarily. There’s so many other benefits to it.

Dr. Ginger Garner PT, DPT (00:00)

So that multidisciplinary lens matters so much because women are often bounced from provider to provider and no one is really integrating the full picture. Which then leads us to talking about the phrase that gets bounced around a lot now in medical gaslighting. Which is just, it’s another way of addressing full on dignity in care. And of course, we talk a lot about

medical gaslighting on the podcast, but in the world of intimate health, sexual health, what does that look like to you? Like, what have you seen? What have you heard?

Dr. Alexandra Dubinskaya MD (00:40)

So many different things, don’t even know where to start. But one of the common ones is I see women who just saw the GYN for annual visit and the GYN did exam and said everything looks normal, but there was some symptoms, feeling of like cuts or like something is off and then we do exam and I can see that the clitoral hood is completely fused or there’s like white patches like clearly.

⁓ lightness, sclerosis happening or any other dermatosis. So it’s kind of sad that we don’t teach general OBGYN or any other providers to examine, ⁓ like genital area, ⁓ very inclusively, like retract clitoral hood, see if there is any adhesions and like, look, and if you see that something is off, you can always ask like, Hey, is your genital area always looked like that? ⁓ cause it’s kind of opens up, ⁓

the conversation. Another common one everyone probably heard is like, you don’t want to have sex or you have pain with sex. ⁓ You should probably drink some wine or drink some more. Or if there is pain, here you go, use some lidocaine without even like telling women like, hey, if you’re going to use lidocaine, it’s not going to solve the issue why you’re having pain. Plus it’s probably going to make your partner numb. So

you, someone who having pain with sex at the baseline, now you’re going to be subject to this never-ending intercourse because of the numbing effect of the lidocaine on your partner. ⁓ Also, there’s gas lighting of, you’re already old, why would you even think about sex? Yeah. ⁓

Dr. Ginger Garner PT, DPT (02:14)

Yeah.

⁓ yeah, that’s horrible. Yeah.

And that kind of language from clinicians is like really harmful to women because then they start, they start believing that that’s the norm. I’m just, I’m just anxious. Maybe I have anxiety. Maybe I need to go on, you know, anti-anxiety meds, et cetera. and we know when they come in with these symptoms and so what, you know, what we’re really making a call for here is trauma informed dignity preserving care.

when someone’s talking about the most vulnerable parts of their body and identity.

Dr. Alexandra Dubinskaya MD (02:58)

Yeah. And nobody ⁓ disregards the fact that like, let’s say, being anxious or having other mental conditions will affect like pelvic floor will affect how you experience sexual encounters. There is definitely very tight connection between ⁓ mental health and pelvic floor. ⁓ But I don’t think that you have to put everything.

on the mental part. You also need to make sure to rule out all other ⁓ structural issues, any other abnormalities to be able to say like, you know what, it doesn’t look like anything wrong with your tissue, with your muscles, with your bladder, but it sounds to me like it might be, like your anxiety might be affecting it. And it’s nothing bad with that. We know that people who suffer with anxiety, the more common might have like some hypertonic pelvic floor.

some pelvic floor dysfunction, which would affect sexual experiences. But I think just resorting to, it’s your mental problem affecting it, I don’t think it’s completely right thing to do.

Dr. Ginger Garner PT, DPT (04:12)

Yeah, and I think historically that’s what’s happened with women in the past is maybe they did develop generalized anxiety disorder for real, but it was because of medical gas lighting, not because they were originally an anxious person. So there’s all these different reasons that we can go on to, and women can go on to have these issues. What you said is really, really important and really important. And that is that

if the first line of diagnosis is if they go straight to mental health disorders, then they’re not doing due diligence to look at everything else first and make sure that it’s not a tissue problem, a biomechanical problem, a biochemical problem, or hormones or anything like that. ⁓ So that’s just like, that’s a good green flag for everyone listening. Your provider really should be looking at all of these other things.

not just trying to saddle you straight away with an anxiety problem.

Dr. Alexandra Dubinskaya MD (05:16)

Yeah.

Dr. Ginger Garner PT, DPT (05:17)

Yeah. And that’s part of just, you know, that being believed, you know, that you have an issue that you feel something that is wrong, it doesn’t feel right. It used to feel okay. It doesn’t feel okay now, ⁓ which kind of brings us to like full circle back to the bigger picture, which is sexual literacy. And you’ve done important work around sexual literacy. Like, how do you define that for the listener? Define sexual literacy and…

And why do you believe that it matters so much in women’s health?

Dr. Alexandra Dubinskaya MD (05:50)

Yeah, well, thank you for saying that. I do believe being aware and have a basic knowledge about your body, how you experience pleasure, what do you need to experience pleasure, and ⁓ knowing what’s your variation of normal and what’s completely is not, I think that’s helpful. it’s just being.

of any part of your body, any like biologic function, I think that’s important. And it’s also a big part of our life. ⁓ Same as social interaction, professional development, I think it’s very important. And unfortunately, like these topics, they are not very ⁓ culturally appropriate. So nobody really wanna talk about it. And when women go to the doctors, they also don’t get the same care as let’s say,

men get when they go to urologist. So when I started my fellowship, I was doing it on the base of like urology based program and I was seeing men as well. And it was a very big difference ⁓ coming from like GYN background. And then when you like kind of like briefly ask, so you’re sexually active? Yes, no. You’re having pain? Yes, no. Okay, moving on.

going to this urology base, like, hey, how’s your erections? Are you happy with them? So it’s kind of like, you’re not asking men, are you like, have a partner to be sexually active? You’re focusing on the person and you’re asking, how is it working? But nobody asking women like, hey, how’s your like orgasms? Is it working for you? I mean,

I do and my colleagues in sexual medicine do, but it’s not like a normal question. And it’s not the normal question coming from the provider and from the patient. So it’s very difficult to communicate when both sides have a lot of barriers to discuss those issues. So I think even giving like, helping people to find the right words, right language to communicate to the provider, what to say.

And again, it’s not like everyone is clueless. We all have Google, we have GPT, we have all those resources. And obviously all of us Google our symptoms and doing all of it and doing research. And I actually encourage research. I learn a lot from my patients because they know they have a problem. So they go like a full deep dive in that problem. So it’s actually good. Bring it up, bring all this information so we can discuss.

I think it’s important in knowing that you’re not the only one. There’s plenty of other people who suffering with the same and some things we know about and some things we still don’t have enough knowledge. So let’s figure it out together. But I do think it’s very important part of ⁓ womanhood and just general health.

Dr. Ginger Garner PT, DPT (09:03)

Yeah. So, you know, what I’m hearing then is, you if you could change one thing in how medicine approaches women’s pelvic and sexual health, it would first be that the questions get asked, right? Don’t glaze over sexual health. Ask women, you know, how is arousal, how is the orgasm? Is it working for you? ⁓ In addition, which is incredibly important because that’s been brought up several times ⁓ on this season and on the podcast.

is that the questions aren’t even being put on the inventory. They are just being skipped altogether. So if we can start asking those questions as clinicians and make sure that we don’t glaze over that, is there anything else that you would add about what you want to see change moving into the future?

Dr. Alexandra Dubinskaya MD (09:50)

Well, it would be nice if social media wouldn’t ban your videos the moment you use words like sex, vagina or anything. Like it’s not going to happen if you say penis, but if you say anything related to women’s body, like you being basically like your video being banned, put under probation. And it’s interesting. I was posting video on YouTube and

Dr. Ginger Garner PT, DPT (09:58)

Yes.

Mm-hmm.

Dr. Alexandra Dubinskaya MD (10:16)

Like all the words, like questionable words were silent. So when somebody left a comment, like, why are you silencing those words? And I’m like, because I want you to get this video. Cause if I’m not going to do it, it’s gonna, and like, you’re never going to see it. The algorithm will like put it on the back burner. And unfortunately, like this part of ⁓ our life is still being banned. If you make a product related to that area of life.

You also can’t advertise, you can’t sell. It’s very hard.

Dr. Ginger Garner PT, DPT (10:51)

Yeah, gosh, that is such a good point. And I see that all over the place. I see people in ⁓ sexual medicine, in sex therapy, amazing people, and in pelvic health too. We have to do the same thing where there’s always a disclaimer, where we’re putting stars or spelling sex, S-E-G-G-S, just so we can actually get our stuff up on Instagram. yeah, I totally agree.

150,000%. So that means we’re still going to have people out there like our listeners who might still be silently struggling with symptoms. They’ve either been told aren’t a big deal or, you and they’ve been minimized about it or blown off or just completely ignored. What do you want them to hear the most today? What do you want them to hear?

Dr. Alexandra Dubinskaya MD (11:48)

that they’re not alone. And it’s not only them whom I feel uncomfortable initiating conversation. There’s actually good studies were done on asking the questions was like what the barriers are. And providers also scared to ask the question. they feel uncomfortable. Like the older the woman gets, the more uncomfortable provider are to like actually talk about it. So I think once you know,

that another person across from you, as uncomfortable as you are, I feel like it’s kind of empowering and you can just go for it. Just ask the question because the wrong, like what’s the worst case scenario that person will say like, ⁓ I have no idea what you’re talking about. I can’t help you with that. Okay, that’s fine. You already helped me with other stuff. Thank you. And you can ask, do you know anyone who can help you or, ⁓

Dr. Ginger Garner PT, DPT (12:34)

Mm.

Dr. Alexandra Dubinskaya MD (12:43)

I will move on and we’ll find another doctor. And I tell, like, I’m a part of this big private practice group and I tell other physicians from different specialties, like, you don’t have to treat sexual dysfunction if you don’t want to. It’s totally fine. I don’t want to treat heart failure and you don’t want me to treat your heart failure, but just know this is my card. If there are people who need help, feel free to send it to me or feel free to ask me a question and I’ll help. ⁓

So I think just knowing that either you or another person needs to do it and both people are uncomfortable, just go for it. Just ask for help.

Dr. Ginger Garner PT, DPT (13:23)

Yeah, yeah. is, you know, knowing that you may have to ask a couple of people. mean, hopefully you’ll be, you’ll land in a good spot, you know, the first time because there’s a lot of shame and embarrassment around it. But realizing that it is pelvic health, is sexual health. They are both intertwined and they should be asking you about this. And if they aren’t, that’s a yellow flag. Should hopefully, you know, as a listener, make you feel more comfortable about knowing that you can confidently go in.

and just put that out there and ask about it because it is, ⁓ it’s not just appropriate, it’s essential.

Dr. Alexandra Dubinskaya MD (13:59)

Yeah, and it’s always like there is a phrases that sounds neutral, but kind of like opens the door. You can always say like, you know what, I’m having issues with my sexual life. Is it something you can help me with or know someone who can help me with?

Dr. Ginger Garner PT, DPT (14:14)

Yeah, yeah, absolutely. And that is why we’re here, to make sure everybody gets the help they need and pointed in the right direction. Alexander, thank you so much for being here. Will you tell everyone where they can find you?

Dr. Alexandra Dubinskaya MD (14:31)

Of course. Well, first of all, thank you so much for having me here. I can be found on Instagram, TikTok, Facebook, and YouTube. Dr. Eurogyn as a D-R-U-R-O-G-Y-N. You can find the videos. YouTube has longer videos about the procedures, little bit longer topics. So feel free to watch and reach out with questions.

Dr. Ginger Garner PT, DPT (14:35)

Absolutely.

It has been ⁓ such a pleasure to have you on the show. I know, I know, I know, I know that we’re going to have you back again at some point because there’s so much more that we could talk about and do deep dives on. But thank you again so much for being here. And everyone, will put where you can find ⁓ her in the show notes. So don’t worry about that. And please share this with if this has resonated with you, please share it with ⁓ people that you care about and realize that

⁓ There’s no need to feel embarrassed. Pelvic health care is also sexual health care, so ask away and there are plenty of places ⁓ for you to find hope and for you to find help.