Reclaiming Pelvic Floor Health and Vaginal Estrogen with Dr. Aleece Fosnight

In this episode, Mary is joined by Dr. Aleece Fosnight a medical advisor at Aeroflow Urology and a board-certified physician assistant specializing in sexual medicine, women's health, and urology, who brings crucial insights about pelvic floor health and the safety of vaginal estrogen therapy.

Bottom Line Up Front: Urinary incontinence is common but not normal—it's treatable at any age. Vaginal estradiol is safe and effective, with virtually no contraindications, yet misinformation continues to prevent women from accessing this life-changing therapy that can reduce UTIs by over 50%.

The conversation tackles the widespread misconceptions surrounding pelvic floor health and vaginal estrogen therapy. Dr. Fosnight reveals how the healthcare system spends over a billion dollars annually on recurrent UTIs—many of which could be prevented with proper treatment. She emphasizes that systemic hormone therapy doesn't reach genital urinary tissues effectively, making local vaginal estrogen essential for optimal health during and after menopause.

Dr. Fosnight also demonstrates how proper pelvic floor assessment should be standard care, explaining her trauma-informed approach to examinations and why every postpartum woman should receive pelvic floor therapy—a practice already standard in Europe that dramatically reduces long-term complications.

Connect with Dr. Aleece Fosnight: 

• Website: fosnightcenter.com and aeroflowurology.com
• Instagram  @fosnightcenter and @sexmedpa 

Resources:

• American Urology Association Guidelines on Genitourinary Syndrome of Menopause (April 2025) 
• GSM Guidelines Summary Cheat Sheet

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Transcript

Aleece: 50% of our population are gonna go through this at some point in their life. And when something like this, again impacts their cardiac health. Bone health, their brain health, their genital urinary health, like more people die from urinary tract infections because of the changes in hormones than is what is necessary.

we spend over a billion dollars every year on recurrent urinary tract infections, and we know that vaginal estrogen, vaginal estradiol can improve recurrent urinary tract infections by over 50%.

Mary: That was a quote. You just heard it from my next guest, Elise Foss Knight, a board certified physician assistant specializing in sexual medicine, women's health, and urology. She's also a medical advisor at Aero Flow Urology, and in today's conversation we're focusing on. Pelvic floor health as well as bladder health, and tackling the controversy around the current climates and headline news on black box warning labels for vaginal estrogen.

In this episode, [00:01:00] you'll learn about the importance of pelvic floor health, especially after childbirth and in menopause, of course, and the need for proactive pelvic floor evaluations and therapy. You'll also learn the linkage between menopause and urinary incontinence as estrogen declines and learn about some lifestyle recommendations to help address urinary incontinence, and most importantly, have better understanding and clarity around these warnings that are not supported by evidence when it comes to low dose localized vaginal estrogen.

This unnecessary alarm is causing way too much confusion and anxiety among women who might otherwise be benefiting from some of these therapies. And so in this conversation, Elise encourages listeners to get informed and have informed conversations with their healthcare providers and oncologists regarding the safety and efficacy of vaginal estrogen.

Elise also emphasizes that localized estrogen is indeed safe, does not increase the [00:02:00] risk of breast, endometrial, or ovarian cancer, and does not worsen breast cancer recurrence. And she specifically notes that the recent guidelines support the safety of vaginal estrogen with very few, if any, contraindications for its use.

I absolutely love it when my guests come on and disrupt the narrative around women's health, shake things up and encourage women to get educated. After all, knowledge is power, but the application of that knowledge, that's wisdom. But before we begin, here's something you need to know about Elise. Elise Foss Knight has 14 years of experience in private practice in Asheville, North Carolina, and is known for advocating for open conversations around female sexual health and combat the stigma around urinary incontinence, which is often mistakenly viewed as a normal part of aging.

Elise takes a trauma-informed approach to pelvic floor assessments, focusing on patient consent, comfort, and comprehensive [00:03:00] evaluations of pelvic floor muscles. In 2019, Elise opened her own private practice, the Foss Knight Center for Sexual Health, and she's also the founder of the Foss Knight Foundation, which is a nonprofit organization dedicated to the education and training of professionals in the sexual health field and providing funding for access to healthcare services in her local community.

Please join me in welcoming Elise to the Menopause Disruptor Podcast.

Welcome, Dr. Elise to the Menopause Disruptor Podcast. Here to talk about a very important topic of urinary incontinence and other issues that we really need to be paying attention to for our good vaginal health in menopause, pre menopause included, and of course, the years beyond. So welcome to the Menopause Disruptive Podcast.

Aleece: Ah, thank you so much for having me. This is a. A huge topic near and dear to my heart. So it's exciting to be able to have a space to really dive in and, to chat about it. 

Mary: Yes. [00:04:00] And I always like to start right away with what was your journey to led you into this field of medicine as a doctor in the first place?

Aleece: Yeah, it's an interesting story because it actually goes all the way back to my medical training at the University of Kentucky when we were doing a master's thesis on a topic, and we got to choose whatever we wanted to, and I knew that I had. a passion for women's health, but was really struggling with a topic.

All of my colleagues were doing orthopedics, sports, medicine, diabetes, and I was like, Ugh, this doesn't excite me. And so I was actually talking to my mom on the phone when a Viagra commercial came on the television, and I thought, oh my goodness, if there's a blue pill for men, there has got to be a pink pill for women.

And when I started digging into the research, there was not, and I got really pissed off. So I was like, this is a important topic. we're learning about penises and prostates in our training, but we're not talking [00:05:00] about the clitoris or female pleasure. And so this is, something we need to do.

So when I got into the research, all of my articles were coming from urology journals. And it's interesting because I actually worked for a urologist when I was in high school, so full circle coming back. And so that led me into my urology love of talking about pelvic health bladders talking about important issues like sexual health, sexual wellness importance of optimizing pleasure for women.

And so I've been working in the field for 14 years now. Opened up my own private practice five years ago in Asheville, North Carolina to continue to really focus on women's sexual health. 

Mary: Oh, that is such an important field of medicine, field of women's health in general. But I applaud you for really stepping up and recognizing that there was a gap, correct?

Filling that gap with your desire to make a [00:06:00] difference. And so just why does menopause trigger incontinence in the first place? 

Aleece: So when we are looking at the role of menopause in our life. The definition is actually from the menopause society when you are a year after having your final menstrual period.

But for me, that definition needs to inclu include so much more, and it is the decline of estrogen mostly from the ovaries where we start to see those symptoms. And as a reminder, estrogen has over 400 functions in our body. In particular in our pelvis. And one of the fun, interesting facts that we don't often talk about is.

The fact that embryologically, the top part of the vaginal canal and the bottom part of the bladder and the urethra are made out of the same tissues. So when we think about menopause and the changes that are happening in the pelvis, it's a much more inclusive term to use genital urinary [00:07:00] as the umbrella term that we would use.

So it's not just impacting the vagina, it's impacting the bladder as well. And so as, yeah, those estrogen. Levels are coming down, and even testosterone as those levels are coming down, there's a lot of changes that occur in the lower urinary tract. So we have decrease, changes in the pH, changes in the microbiome thinning of the supporting tissues, and that also includes that urethra.

So now it becomes more irritated. It becomes more that we have to go to the bathroom more frequently. Our muscles are not as strong as they once were in the pelvic floor, and so that urethra isn't as compliant either, and so there may be some leaking or urgency that are go that occurs with it. 

Mary: So. Is there a prevalence for women though, just to still not talk about it, let alone go and get this checked?

And I'm talking about women even as early as 30, perhaps 35, or we still think, we might [00:08:00] just be in the reproductive phase. Many women may not have even started their family. And so when that happens, it's often chalked up to something else, not related hormonally. Correct. Is there more of a prevalence for women just to avoid it?

And what can we be doing to start informing women early enough to always have that check? Just like a pap test, to still have our urinary, our genital urinary tract functioning optimally? 

Aleece: The misconception is that any kind of urinary incontinence is normal. And I love to break down this myth of it is not normal, but it could be common.

And so there's a difference, right? That we should not accept the fact that what we are dealing with and what we're feeling. Is a normal process of where we are in our lifespan, but it is often been chalked up [00:09:00] and dismissed to women. Oh, you've had two babies. Oh, you're just not focusing on your pelvic health.

Oh, you're just in menopause. That this is something you just have to deal with and that's not true. This is something that if recognized early, can be treated and not be a disruptor in your life, in your activities of daily living. So oftentimes women just chalk it up that this is just happening. And while we are having more conversations around bladder health and pelvic health, there's still a lot of stigma and shame and embarrassment that go along with this is that I, am having to change my clothes because I just peed my pants and nobody really wants to talk about this, even though it is a normal function in our body.

Mary: Oh my goodness. So what are some of the, different types, if you will of incontinence that show up during perimenopause, even in our postnatal [00:10:00] years as well, soon after childbirth? What are the different types and how can we look for them? just the minor leakage is one thing, but what are some of the other key symptoms to be on the guard for?

Aleece: So there's three common types of urinary incontinence that we see in this timeframe. Okay? There are more in general, but ones that are specific to this are gonna be stress incontinence. Okay? Urge incontinence, and then a combination of both. So you can have dual or mixed incontinence. So stress incontinence is the type of leakage that you have when you cough, sneeze, laugh, exercise, move your body.

That a lot of times is secondary to the urethra not having as much support as it once did. The second one is urge incontinence. That's the one where you. You gotta go to the bathroom very quickly. You feel this sudden need to go to the bathroom and on your way to the restroom you're having a little bit of leaks on your way there.

We sometimes can also see some [00:11:00] urinary frequency that is associated with that urge incontinence. And then the third one again, is a combination of both of those. So you may have an experience both leaking when you cough and sneeze or, and then the sudden urgency to have to run to the restroom very quickly.

Mary: Yes. And I always blamed it on having my child, I said, is the reason why I pee my pants. 

Aleece: Yeah. And while, pregnancy is a big risk factor and then mode of delivery. So a lot of people think that they can get by with having a C-section. Right. And that's not always the case. It is the fact that you're pregnant and that's putting a lot of extra pressure on your pelvic floor.

But we can reverse and improve those changes that have occurred. I was very fortunate enough to do one of my rotations while I was in school over in Europe. I was there with a urogynecologist and one of the very first things that I learned while I was over there is everybody postpartum, no matter mode of [00:12:00] delivery, gets to go to pelvic floor therapy.

Like it was just this automatic referral over to a pelvic floor therapist. Unbelievable. A, we see a lot less urinary incontinence and pelvic floor prolapse, and I might over in Europe, and my guess is that this is why. So I don't understand why it hasn't fallen suit here in the United States, but I encourage so many women to not just go after delivery, go before you get pregnant, have somebody evaluate your pelvic floor ahead of time.

So important. 

Mary: And that's so funny 'cause we just don't think of pelvic floor health in general. Overall health in terms of keeping those muscles nice and strong and we'll go to the gym to exercise the muscles of the body. Pelvic floor often hits. Put in the background, much like you had said, because no attention has been really drawn to it here in North America and applaud the UK for leading the [00:13:00] charge.

They seem to be ahead in a lot of women's health issues and we're just playing catch up. So again, thanks to the like of yourself, we're starting to move that yardstick in the right direction. But now that we've talked about the pelvic floor, let's dive in. What should we be doing now? Early enough? To keep our, pelvic floor strength up, through all of our stages of our lives.

Not just pregnancy, but obviously going right through to post menopause years. 

Aleece: Absolutely. So first of all is recognition. I think that's the biggest thing is that you do have a pelvic floor, right? and what does that mean, and what are the muscles involved? when we see our muscles and we see.

Things changing. Like we go to the gym and we're doing bicep curls, or you're working on your triceps and you can see that definition and that change and the strength. It's much easier to comprehend, but when we don't see our pelvic floor muscles, sometimes it's a trickier one to be like, wait, we have muscles [00:14:00] there, and what do they do?

But we can definitely see a, change when you are focusing on those pelvic floor muscles so you can see strength, especially if you're symptomatic. Meaning that again, if you have incontinence or you're having pain with penetrative or sexual activities or even defecation, so we have to remember right, the pelvic floor is essential to those three things.

So, I love my pelvic floor therapist, colleagues 'cause they always explain it. They work with patients to help them, pee poop and have sex better. So. Oh, perfect. I know, I love it. Yeah. And I really resonate with that because we should have some humor and laughter around the pelvic floor, especially again, when there is, again, so much shame and stigma around it.

But having a pelvic floor physical therapist really evaluate your pelvic floor, I think is one of the first things that you can do to see how is your pelvic floor functioning. I think there is a an awareness and We take for granted, that's what I went, we take for granted that our pelvic floor is fine, right?

[00:15:00] It's usually in our twenties or thirties. We're not really thinking about those sorts of things, but really we're seeing a lot more people sitting. They're not as active as they once were. Most jobs are now can be remote or virtual from at home. Also with increased anxiety, there actually can be more tight pelvic floor muscles.

And this is a great opportunity to talk about the difference between tight. Pelvic floor muscles and strong pelvic floor muscles, right? I think of tight muscles, and I explain this as like your shoulders, if your shoulders are really tight, right? You can't go do and function the way you want to. But if you have neutral shoulders that are strong and it can engage when you need them to, that's the type of muscle that you're wanting to, same thing in your pelvic floor.

So I don't like, a lot of times when we interchange those words of tight and strong. Yeah. But you can have somebody evaluate that for you, so you can see it's really more difficult for you to evaluate that on your own. And the other thing that I really value from my training doing my rotation over in Europe [00:16:00] was that the physician that I was working with actually assessed people's pelvic floor.

I was like, this is fantastic. I wasn't taught this. you, do your pelvic exams and you're going straight for that cervix and doing paps, and then you're done. But we forget that there are so much more beautiful anatomy between where the vulva and where the cervix is. And that includes, again, the, vulva and the clitoris and the pelvic floor muscles.

So I really took that with me so that when I was doing pelvic floor examinations. Doing pelvic exams that I was also assessing the pelvic floor muscles too, and being really cognizant and mindful of what I'm looking at and what I'm feeling and how the patient is reacting as well. 

Mary: Okay. So how do you conduct an assessment?

Aleece: Yes, absolutely. first of all, I get consent and permission from my patients. Okay. That is an my, we do trauma informed pelvic exams. unfortunately female identified individuals have a lot of trauma both medical trauma and sexual [00:17:00] trauma that in their histories. And so we talk about it ahead of time.

I always interview my patients clothed first before I actually do the pelvic exam. How I walk through my patients with it is. I will let, them get into that lithotomy position and I ask permission. Let me know when it's okay for me to uncover. So I'll uncover when they give me that permission. I always touch their inner thigh, and there's a trick to this.

not only does it help to create trust with my patient, right, they know my touch, right? And I'm not going straight to their genitals. But I also get to see if there is tension in the adductors and those inner thighs as well. And we can often find that if there is tension in those. Thighs that you're gonna have tension in that pelvic floor also.

So I will palpate down the inner thigh. I will go up over the mons or where the pubic bone is, and I'll go up the other thigh. And then I'm palpating actually externally over the vulva. So over the labia manure. And the manure, because that's your first layer of your, pelvic floor muscles. You've got three major layers to your pelvic floor [00:18:00] muscles.

So that's your superficial one. And then I will go look in all the necks and crannies is what I tell my patients. I'm peeling back the clitoral hood. I'm peeling back the labia to look in, in all of those crevices. And then I will take one finger. Do a mono manual exam. So, if we're here with the vagina, right, I'm gonna just touch here on the outside and get right to that vaginal opening, and I'm really assessing stretch elasticity and is there any pain?

I'm also looking at the color and consistency of the tissues too, to see if there's any. Hormonal changes. This is right. Really key when we're talking about any sort of hormonal change, whether that's perimenopause, menopause, lactation, anything, or people who are on birth control PRIs that maybe that is suppressing their endogenous hormones, that can also cause changes to the pelvic floor.

And to those genital urinary tissues, though it's, there's a category and a lot of m processing that I'm doing just with this very simple exam. But it's so important. Yeah. And then I go a little bit farther in to check [00:19:00] the median part of the pelvic floor muscles.

That is a lot of times where people who have penetrative pain with sexual activity will say, oof. Yeah, that's uncomfortable. That's painful. What I'm looking for there too is trigger points. It's the same thing that we would look for with a massage therapist, like in our shoulders, right? Those little knots that we feel they actually manifest themselves in those pelvic floor muscles 'cause they're muscles.

Yep. And then I go into those deeper muscles, which are important for the bladder. Which is like your co dismissal. That one's gonna be really important as a kind of hammock sling to support the bladder as well as around that urethra as well. So, and a lot of people go, gosh, that must take you a really long time to do Elise.

But really, I actually timed it. It takes me not more than 30 extra seconds to do that than what somebody else would do on a regular exam. So it doesn't add more time to my day or. delaying patient care. It actually is a really easy, quick thing that [00:20:00] you can do. 

Mary: Yes. Yeah. Time spent on observation or, Testing, examining is probably time saved in dealing with an issue that could be prolonged and worsen. And on that note, if it goes unchecked, because let's face it, not all of us are gonna have you as our doctor who's very thorough and very gentle and knows what to look for. So when these things do go uncheck, because we'll go in for a regular pap.

Incontinence is not normally the focus unless we bring it up and we may get a referral to a physiotherapist who specializes in compel, specializes pelvic floor health. so what will happen if it just goes on a little bit prolonged? does it mean incontinence could become a prolapse, for example?

Aleece: It definitely could. Okay. What we typically see as the trajectory of. Incontinence, pelvic health happens. [00:21:00] We know over time that those muscles continue to get weak. That hormonal changes continue. This is one of the biggest things that I was really excited about to see and read in the American Urology Associations guidelines that just came out in April of 2025.

Specifically talking about genital urinary syndrome of menopause. Yes. The, when menopause is talked about. We often think about hot flashes, vasomotor symptoms, right? Irritability, and that eventually will go away. We'll get through this process and we'll get to the other side and we'll be okay. The difference with genital urinary syndrome and menopause is that it's chronic and it's progressive.

It is not going to get better. We have to intervene or we're gonna see recurrent urinary tract infections. Increased urgency and frequency burning with urination, pelvic organ prolapse, pain with sexual activity. This is not gonna get better. We are not doing yet our, [00:22:00] patients any good if we don't ask.

And so I love to also empower patients to say. I heard this on a podcast or I read this on social media, bring it up. I love it. I encourage, my patients love me because I leave this creative space for them to talk. Right. It's a, it's, us working together as a team and I think it's really essential for providers to do that, is to leave this open space for you to have a great, productive conversation.

It allows you to talk about a concern that they have, debunk some myths. There are, there's. Not always good information that's out there either though. It creates an opportunity for us to really dig into it and, why that's not maybe the best information. Talk about the evidence and then say, I'm glad that you brought that up.

Is that a big concern for you right now? How can we address it? What do you wanna do about it? Because this is also a team, right? A partnership of us working together to find what's the best thing we can do for you [00:23:00] as an individual. 

Mary: Right? Yes. And now that we have these journals, these medical journals, and the research backed by science.

Literally print it off and hand it to our doctor. And on that note is, there's still such a growing population, and I say growing because we still have a lot of young and new doctors entering into the field of family medicine that still have not received the education, let alone. The doctors that are still in healthcare have not ever received information.

And even though the ghosts of the 2002 Women's Health Initiative have surely by now disappeared into the ether, they don't, it lingers. And that just, it's like a really bad rumor that just keeps passed on and passed on, and the lack of education, so. As a doctor, as in your specialty, and you encourage your patients to share this information with their entire healthcare team, [00:24:00] encouraging them, get educated, take the evidence, present your case to your doctor to in hopes of re of achieving shared decision making in their healthcare plan.

But then it's received with, resistance, we will say pushback. Push back. Because in a way, we're challenging a doctor's credibility and their experience by saying, your answer's not good enough. Here's what the report is. So how would you encourage women to come up against the, these challenges?

Aleece: Right. First of all, you've gotta be able to find a provider that you feel comfortable with, and I get I, that's not easy. And by the time that most of my patients come to see me, they've seen three or four or more providers that they've met with that resistance, just like we talk about. And until. The medical community realizes that, again, it's a working relationship with your patient and that, your patient's not [00:25:00] challenging you.

I'm glad that you brought that up because we see so much of that. they're challenging my authority and I'm like, oh my goodness. Absolutely not. They're curious. They wanna know information. They're thirsty for this information about what's going on with their body and for years we've never talked about it.

Yeah. This is the other thing that I get from my patients that I've heard. With their interactions with other clinicians is that, this is just normal. You just have to deal with, and menopause is natural, but so are flacid penises, and we have Viagra and Cialis to help with those. We have science, right?

Yeah. So we need to validate and understand. How menopause is impacting people and the comorbidities that are associated with it. And until we change the education from the root, right, this is, coming from the top down when the patients are coming into the office, we need to start at the bottom.

We need to start at that foundational information and talk about menopause and why it is so important, right? 50% of our [00:26:00] population are gonna go through this at some point in their life. And when something like this, again impacts their cardiac health. Bone health, their brain health, their genital urinary health, like more people die from urinary tract infections because of the changes in hormones than is what is necessary.

we spend over a billion dollars every year on recurrent urinary tract infections, and we know that vaginal estrogen, vaginal estradiol can improve recurrent urinary tract infections by over 50%. Wow. Okay, Elise. I know. I'm sorry. I'm getting really 

Mary: no. Nice to hear. Yeah. That's the name of this podcast.

Disrupt, disrupt. I love it. Yes. Disrupt. Disrupt. Totally. Yes. Dropped a bomb. I was going really swimmingly. And then nobody thinks about this Urinary tract infections as a co mobility. Huge money being put into this healthcare area of healthcare [00:27:00] that's being completely ignored, sidelined, forgotten about, dismissed.

And of course, as women, our social contract construct has taught us to don't talk about it. This is embarrassing. This is, don't wanna be feeling that shame. Holy cow. Alright. This should be the headlines that should be going up in the news, not the ridiculous headlines. Correct. I'm good with you. Yes.

Women's health, the history of it for are too long. Okay. Wow. You have talked about vaginal estradiol. I think it's time that we start getting into this topic. I wanna also talk about some bladder irritants, things that we can do from a holistic perspective and our lifestyle, of course, from what we consume.

But let's talk about vaginal estradiol as SubPac. Is it all for the listeners? Is it safe? Can we use it with Regular, like transdermal or gel or cream, estrogen and progesterone. and let's talk about all its [00:28:00] benefits 

Aleece: when you are using systemic hormone therapies to help support you through your menopause transition.

What we don't get a lot of conversation around is the decreased permeability of systemic. Hormones into those genital urinary tissues. So while we think that by supporting our system and we're putting this estrogen patch on, and we're, taking our testosterone creams and gels and we're rocking and rolling, it doesn't get to the genital urinary tissues.

So you have to go locally. And that's another again, myth. A lot of my patients come in thinking that they are okay because they're using a transdermal estradiol formulation. So you can definitely use both a systemic and a local estrogen formulation to help to support your body. And it's safe and that's one of the things that I'm so happy with these guidelines.

Like I said, that just came out because they have [00:29:00] that in there. there is very few, if any, contraindications for someone to not use vaginal estrogen. One of the biggest things that I always tell people that if you have any kind of. Abnormal uterine bleeding, abnormal vaginal bleeding. We've gotta figure that out first, right?

That's gonna be the biggest thing. But we know that localized vaginal estrogen cream does not increase your risk of breast cancer. It does not increase your risk of endometrial cancer or ovarian cancer. It does not increase the recurrence or make your breast cancer worse. If you are currently having breast cancer, like we know that information.

Everything is local. It very little of it actually gets absorbed systemically. So that's again, the conversation that you should be having with your oncologist too. I had a wonderful appointment with one of my patients yesterday who has a history of breast cancer and has been very resistant to increase her use of vaginal estrogen cream.

She wanted to use [00:30:00] the, littlest amount, but she was having recurrent urinary tract infections. She was having pain with sexual activity just always felt uncomfortable, even with sitting and doing other activities. And so I said this was our appointment from the time before. I said, hear me out.

And we increase the frequency. I'm gonna meet you where you're at. I want you to feel comfortable. That's how you're gonna be successful in this journey. But hear me out. What about using it more frequently? She was only using it about three times a week and just using the tiniest amount that she could with her finger and I, we talked about it.

She said can I give it a month, Elise, I'm gonna use it every day. I delete it through it for a month and I stall her back. And guess what? She's so much better. She has less. She hasn't had a urinary tract infection in over a month. Okay? She has less urinary urgency, no burning with urination. Sexual activity is much more pleasurable, and she also had an oncology appointment with her breast oncologist in the meantime, who absolutely [00:31:00] blessed the vaginal estrogen cream and said yes.

Do it. To do it every day. You are fine. The research. Yes. 

Mary: So good. 

Aleece: Oh my gosh. what an amazing feeling. Not just for me, but for my patient. She feels better and to have that okay, by her oncologist, there's this huge fear. She doesn't wanna have a recurrence of her breast cancer. She wants to live, she's got kids, got a family, got a career.

Right. And so we don't wanna do anything that's gonna disrupt that. I have two rules in my practice. I always tell people, right, do no harm. I, but the second one is, whatever we do has to work. And so, that is where it was a beautiful process to see with her feeling so much better. 

Mary: That is wonderful to hear that.

And it's just prompted me to think, okay, so if we have women that are experiencing urinary tract infections at a young age, and we're talking pre-menopausal years, [00:32:00] is vaginal, estrogen, estradiol safe? 

Aleece: If we have ruled out everything else, that's a cause. Yes, totally safe. Completely safe. There's again.

Very little, if any negative side effects that go along with it. One of the interesting side effects is increased vaginal discharge and when somebody has not had vaginal discharge in a really long time, and that vaginal discharge, let me say, is a normal thing, right? Our vaginas are self-cleaning ovens.

We make about tablespoon of vaginal discharge every single day. Like it's okay to have a little bit on your underwear or on your pants. Totally fine. So it's just creating that normalization of this is a good thing. This is the things that we want. But many women who are on birth control pills experience vaginal dryness and can have increased urinary tract infections.

It's not always based off of like coital sexual activity, but it could be, right? And so those are the things, if we have ruled everything out, try a little bit [00:33:00] of local estrogen cream. Like it's not gonna hurt for you to try it for a couple of weeks, see what happens. But most of the time they're gonna feel better.

So this is also the case after lactation. We also have a new terminology, right? Genital urinary syndrome of lactation. And this was something that I experienced after my first kiddo. I went for my six week postpartum checkup and I was like, alright, I'm totally feeling this dryness that my, my menopausal women are feeling, can I do estrogen cream?

And she was like, oh no, just give it a couple more weeks and maybe it'll get better. I was like, but I don't feel good now. And so I did my own digging asked. I went back and asked for some estrogen cream. I was really nervous that maybe it was gonna affect my milk supply, but again, it doesn't absorb very much systemically and started using it and was like, oh my goodness.

I feel so much better, right? I didn't need to have to give it another six weeks or whatever else. I didn't have to stop breastfeeding my baby. Oh, it was an option for [00:34:00] me to use and it didn't. Like I said, IM impact. My milk supply may be different for everybody, but it's, an option. So anything that is going to hormonally change the genital urinary system, no matter what it might be.

Women deserve to have local vaginal estrogen cream as an option. 

Mary: I love that. That's the title of this episode right there. Women deserve to have vaginal estrogen cream. Now, what is the difference between estradiol cream and estro? Is there a difference? 

Aleece: There is a very good difference. So when we think about estradiol is E two.

That is the estro estrogen in your body that you make in your reproductive years. That's what helps to lubricate your joints, build collagen in your skin, give you those feminine characteristics, help to lubricate the vagina. As we go through perimenopause and menopause, the estrogen turns into estro. It has a much higher affinity to those estrogen receptors, but is a [00:35:00] weaker hormone, so you're not actually gonna get the benefits that you would from the estradiol component.

So I'm an estradiol girl through and through, and that's what I prefer. 

Mary: Okay, so even a woman who's post menopause, oh yeah. Should be opting for an estradiol vaginal cream as opposed to estro, correct? Yes. Okay.

Ha. I'm gonna have to be having a conversation with my doctor. I have an estro vaginal cream now. I found I'm just revealing so much personal stuff on my show. Oh my goodness. It humanizes you? Yes. Yeah. It humanize me and I, if I'm supposed to be here breaking down the taboos, then I better be a leader.

I better be marching to the beat of my own drum. But I have found that initially it's oh, I'm, seeing some success for the incontinence. 'cause this is why I needed it. I requested and worked with my daughter to enter into that decision. But then after a period of [00:36:00] time, it's it tapered off and then now it's just plateaued.

But there was no real wow, I'm super excited about this. It's kinda yeah, it's okay. So I guess I have two choices. Opt for an estradiol cream, or would I increase my frequency? 

Aleece: So you could do both. Oh, that would be okay. And you have the estro cream right now. So utilize that. And that's why I always tell my patients, if you've got it, use it.

Right. And I think increase the frequency. And I will often do that with my patients who start to wane in their symptoms a little bit. Most of the time we are talking to patients about using it frequency of like on a daily basis for several weeks and then they can back down and use it maybe two to three times a week.

Most of my patients too, that are coming to me from a different provider are only using it twice a week. And while that can be helpful for some people, I find that's just not enough for most. Yeah. So increasing it to either every [00:37:00] other day or three times a week can be really helpful. 

Mary: Okay, that's great advice.

So now let's talk about some other therapies that we can do naturally. One being. Being aware of what irritants, irritating foods and beverages for the bladder. So what can we be doing to optimize bladder strength just through our simple lifestyle choices. 

Aleece: First of all, when I have this conversation with my patients, I will talk to 'em about what are the things that we can do rather than take away.

I, when we limit a lot of times or people think that we're taking away something that they really enjoy, it's not fun. It's not pleasurable. Yeah. Coffee, listen, I'm with you on that one. I, love my coffee. It's a ritual for me in the morning and I feel like it gets my day going. So rather than having necessarily to take something away, we talk about can we limit how much we're actually intaking?

But the biggest thing, and I, would again, wouldn't be doing [00:38:00] justice if I wasn't talking about water. As a urology, pa water is so important. Most people do not drink enough water. So when we think about the way that our bodies processed through our kidneys and we're filtering out all of the waste products, if that is super concentrated and we have a lot more waste products in.

One volume that can be super irritating to our bladder. So a simple thing you can do is just increase your water intake, okay? Typically 80 to a hundred ounces of water every day, unless there is another medical need for you not to have that much water is really what we should be drinking. Most people are not hydrated.

When we're drinking that much water. We also do wanna talk a little bit about electrolytes because we can te sometimes wash away those. So a little electrolytes in your water can be helpful. Usually once a day is all that you need, but if we can dilute our urine and make it less concentrated automatically, you should have less irritation.

Then yes. The other things to think about are gonna be yes, your coffees, 'cause it's got caffeine in there, your citrus, your spicy [00:39:00] foods chocolate. Oh. So the darker the chocolate the better, though it has less caffeine. So that's another way that you can get by with it just a little bit. Artificial sweeteners are gonna be another one that I really try to avoid with patients or limit on that.

And then alcohol. Alcohol is gonna be another one that we wanna limit. And for lots of reasons right here in the United States, the US. A surgery in general is really looking at putting a label on our alcohol of it causing cancer. We see a big increase of breast cancer and colon cancer with alcohol consumption.

Mary: Oh my gosh, yes. Alcohol is just bad for many reasons. So now. That aside in terms of what we can consume and limit, what are other things in terms of the strengthening the pelvic floor? We've heard about pelvic floor therapy and other treatments, and of course the classic Kegels. Do they work? Are they effective?

How should that treatment be applied? 

Aleece: Correct. Most people don't know how to even engage their pelvic [00:40:00] floor. So one of the things that I will encourage my patients to do, and it may feel a little foreign to you, but you could either sit on your hand or place one finger in the vagina. When you do that and you try to squeeze and lift.

Right? So those are two things. It's not just squeezing around. We wanna lift and pull up towards our belly button. Right? It's usually what else you have, but try to create an image. Is what I really try to tell my patients. So we wanna squeeze around that finger and then lift that finger up into the pelvis, like towards our belly button.

That is a great way to engage those he upper muscles. If you are sitting on your hand, you can feel this lift up from your hand and then it coming back down is another way to know that you've actually engaged those pelvic floor muscles. Now, if you're sitting there and you feel bulging right when you're trying to lift, that means that you're not having that coordination with your pelvic floor.

That's a great. Reason to go see a pelvic floor therapist. 

Mary: Oh, yes. Or if 

Aleece: you're trying to squeeze and you're like, I, feel like [00:41:00] I'm squeezing, but it's just not lifting as much. You could have a tight pelvic floor and so you're not getting as much contraction or shortening of that muscle because it's already shortened.

So you can't, do a kegel if a muscle is already tight. Right. So that's another reason to go seek pelvic floor assistance. And most of the time you can go see them once a week for just a handful of times. The goal is for you to be able to do these on your own. So that's how you can engage those pel for muscles.

But we have to remember, it's really your core, and this is nipples to knees is what I tell people, right? So it's your hips working together, your lower back, your abdominals, all of that is your core working into that. And if we're thinking about, again, more of our female identified individuals or people who have been pregnant.

Those muscles in your abdominal walls can separate, and that's called a diastasis. That can happen. And when you have a weak core in the area, you could strengthen your, pelvic floor, all you want to, but your abdominal muscles are not gonna help out. And so you could still [00:42:00] have urinary incontinence, pelvic floor, or organ prolapse or even fecal incontinence can happen too.

With that, we often forget that those bowels are right there, and again, they're. They are important too to make sure that your bowel movements are functioning well, 

Mary: like you say, without un control or Yeah, involuntary ion. 

Aleece: Yeah. It happens actually more than what people think. Especially up to a quarter of people with your urinary incontinence also have fecal incontinence.

Mary: Is that right? That's an interesting statistic. Okay. 

Aleece: Yes. Yes. And a lot of it stems from constipation or holding bowel movements. Yes. So, 

Mary: And women often constipation because this is a stress, an outcome of our stress. Yes. Holding everything in and, oh, wow, this is very informative. Now what about [00:43:00] some therapy, the such as sound.

Sound therapy or 

Aleece: what's pelvic floor? So yeah, pelvic floor therapy. You might be thinking of some biofeedback or, yeah. Or some of the almost like a tens unit yeah. Can help to stimulate Yes. That can be really helpful, especially for those individuals that are struggling to find that connection between their brain and their pelvic floor.

Biofeedback is simply you could use a tool for that where there's kind of electrical impulses that are connected. Yeah. Little little stickies. That are attached to around that vaginal opening or around even the anal opening. And that can help to engage those pelvic for muscles and again, have that contraction.

There are all sorts of insertable devices too that have apps that you can get on your phone. So as you squeeze and lift those pelvic for muscles, you can have the person on the screen jumping over like a flower or jumping buildings. Oh, they have all sorts of fun things that you can do. Yes. But you also have to make sure that you're [00:44:00] lowering it too.

Chris, I write that. That's the back and forth. Not only do you wanna squeeze, but you wanna be able to relax and bring it back to neutral. So now you gotta like duck under, a shooting star that's out there in the galaxy, if you're on a space expedition with one of these games or whatever else.

So I really love that for people who are really visual. Yeah. So it's, it can be a great tool to use. Yeah. 

Mary: But why not? you may as well have fun with it, right? Absolutely. Put in the work. Enjoy it. I squeezed so hard. I jumped in Empire State Building. Yeah. About squeezing and bearing.

Yes. Now as a fitness coach and strength training coach, one of the things I am just thrilled about with the Girls' Gone Strong Program, the world's first and leading women's health coaching fitness coaching program is that pelvic floor has received a lot of attention, entire module in a half onto its own.

And one of the things that we like to teach at the beginning of each session with our clients is to do [00:45:00] a connection breath. Whereby if you're lying down your back and you can do it seated, you can do it in, different postures, but lying down the back for one, you feel as the inhale, the natural lift of the lumbar spine just peel away gently off of the floor.

And then with that exhale, you compress the abdominal wall. And then you do feel that squeezing, that lifting up both the front and the back, pulling in and lifting up, or as we say in the yoga the Moula band engage the Moula Banda. Which is right by the root chakra and the hip bones.

And another expression I've heard is feel like you're squeezing your hip bones together now. But then one thing that says is that have your client try to hold as strong as they can, and then back it off slowly till they think they only have about 30% of the engagement. Because you wanna stay right in that range.

Explain to us why we don't want a tight bearing down sensation, but enough of a core engagement that when we're [00:46:00] bearing weight in a strength training class, we have pelvic floor stability and core stability. 

Aleece: It boils down to the abdominal pressure. Ah, it's all, actually, this is what I love about the body and how it's all interconnected, right?

Yeah. So when you are taking a, a breath in, when you go to lift something, right? You're actually in pulling in air into your lungs, which actually acts on your diaphragm. And that diaphragm is gonna push down on that, pelvic floor from your abdominals, right? So if you're already engaging with that pelvic floor, you get this beautiful kind of.

Kind of ecentric, kind of combustion right there in the middle. Yeah. In your core. But if you don't engage your pelvic floor muscles and create some stability when you go to breathe in and that diaphragm descends your pelvic floor is also going to descend, 

Mary: right? 

Aleece: And that's then when you can add more weakness to the pelvic floor.

More prolapse or urinary incontinence can happen as well. 

Mary: Yes. So it's as if you're [00:47:00] applying pressure to counter the pressure that's gonna come in from the diaphragm, just from a natural breath. Correct. I love that. That's a really great analogy or way of explaining it with that visual, and I've just learned something that I could share with clients when we do strengthening.

Very good. Wow. So this has been such an informative conversation. I'm just. Blown away with some of the data, the stats, the issues that you have raised. And thank you for sharing with us that recent report as well on genital urinary syndrome in menopause and even in lactation. So important. I will be sure to link that in the show notes.

Yes. So what's one thing that women could be doing right now to ensure that they have good strong pelvic floor health, no matter what their age 

Aleece: exactly. Again, it's just. I think having that appreciation and knowing that you have a pelvic floor, just like embracing it, this is what I'm gonna work on, [00:48:00] and if you have not had somebody evaluate your pelvic floor, make a call like reach out that I think is so important, start advocating for yourself, empowering for you.

One of the biggest questions I always ask my female identified patients is what's self-care look like for you? What is something every day that you do for you? Most women are givers. We do everything for everybody else. But if you don't put that oxygen mask on you first and then help others, it's not gonna work.

So, right. And that's, I like to be that real person in the room with them and giving them the permission. And I think it, again, humanizes that. we're all guilty of doing this. I fall guilty of doing it too, but I try as much as I can to practice what I preach and empower my women that you can do this and it doesn't have to be big.

What is five minute? That you can do, for yourself on a daily [00:49:00] basis, the great place to start. So that would be one of the things that I would do to go ahead and start, engage in those pelvic floor muscles and just even sit while you're sitting here listening to this podcast and want you think about what does that look like to lift that pelvic floor, lift it to your belly button.

Hold it. How does that feel in your body? Where are you feeling that energy? Where is that going? And so again, having that connection to your body is so key with this process. 

Mary: Yeah. Sometimes that sensation just feels like a gust of wind or a fresh breath coming up from the navel or, the, vaginal area right up, into the chest, into the throat.

So breathing life and just. Era that 

Aleece: it's so energizing, so, so energizing. I will say the caveat to that, if somebody is a holder, if you know that you have anxiety TMJ or clenching or hold, if you know you're holding, I know if you're holding your belly. You already have a tight pelvic floor, so doing engaging [00:50:00] in those pelvic floor exercises may not be as beneficial for you.

You can do the opposite though. Let's go back to that diaphragm. The diaphragm is gonna be your friend in helping to down regulate those pelvic floor muscles. So doing belly breaths. Breathing in for if you can breathe in for eight seconds. And hold it and breathe out for six. And then breathing and do that, we call it box breathing, right.

But it's more rectangular breathing is what you're gonna be doing. And so that can be super helpful then to unlocking that tension in your pelvic floor. But that's, one of the other things that can be really helpful for individuals. 

Mary: Amazing. Can you 

Aleece: clone yourself 

Mary: El Gosh, 

Aleece: I wish. 

Mary: Everybody are just like you.

You're so on board and engaging and empathetic, compassionate. That's exactly what our healthcare system needs. I'm so thrilled that you were able to share with us you're genius and that we can shout this on the rooftops and get it out on the airways. [00:51:00] It's brilliant work you're doing. Thank you so much for sharing, and I'll be sure to get all of those important links in the show notes, including where people can find you.

So tell us yes. 

Aleece: I have the Smite Center for Sexual Health in Asheville, North Carolina. So you can go to our website, which is just phosphite center.com. If you wanted to follow us on Instagram, we're at Smite Center or myself, which is at Sex Med pa. Ooh, 

Mary: like it, that one. Okay. Make sure that's all the show notes.

Thank you so much for your, brilliance, your time, your energy, and and really shifting the way we think, act and treat menopause. 

Aleece: It has been my pleasure. Thank you so much for having me.

Mary: I have several takeaways from this conversation with Aleece Fosnight, but I'm gonna take the opportunity in this closing to draw attention to Genitourinary syndrome of menopause, also known as GSM, and it was brought up in this conversation. Dr. Aleece is elated that this report came out in April, 2025, and in my group of menopause doulas and women who work in the menopause arena, we shared this on our WhatsApp chat.

So much excitement came out of it. So I wanna take this opportunity since it was important part of this conversation. To draw more attention to it. This is important. This is the kind of disruption I like to do. The education piece I bring to this area in Women's Health Curate the most relevant recent evidence-based research backed information so that you can make informed decisions about your health and make shared decisions with your healthcare team.

So this report that came out from the American Urological Association is a comprehensive clinical guideline that is endorsed also by the Menopause Society. First of all, the purpose and the scope of this report is to bring attention to what GSM is, which refers to the. Vulvovaginal urinary and sexual symptoms that are caused by reduced estrogen and androgen levels during menopause.

This study aims to help clinicians identify, diagnose, and manage GSM to improve quality of life, while also minimizing risks. Key recommendations that came out shared decision making central to care. Treatment plans must reflect patient's values, preferences, and goals. Which means the patient comes first.

Second, screening and diagnosis. Clinicians should screen at risk patients and use trauma-informed care where appropriate, which Aleece spoke about. Low dose local vaginal estrogen cream is strongly recommended for dryness, discomfort, dyspaurenia, which is painful. Sex and prevention of recurrent urinary tract infections.

UTIs. Non-hormonal therapies also include vaginal moisturizers and lubricants, but alternative supplements still lack supporting evidence as a viable non-hormonal therapy, as well as laser treatments because there's still not enough current evidence to support use for GSM symptoms. Cancer considerations why we were seeing the black box warning labels, low dose vaginal, estrogen, and even DHEA do not appear to increase risks of breast or endometrial cancers.

These warnings that we're seeing on the labels are based on outdated information that is not current to the research surrounding women's hormonal health. GSM is incredibly common and we often giggle about it, laugh about it, joke about it. When we sneeze, we pee. When we cough, we pee, and that is only one part of the symptoms.

Painful sex is another part or the urge to go frequently. GSM affects up to 77% of women during an after menopause, but it's still very much under reported and often goes untreated. So that burning, that dryness, the itching, painful sex urinary symptoms, even UTIs. Take caution. Have a conversation with your doctor.

GSM is treatable. You don't have to live with these symptoms and your quality of life comes first. If you wanna learn more about Aleece and the worksheet he does for a trauma informed patient care. Her links are in the show notes. She's at aeroflowurology.com, and also on Facebook and Instagram at Aeroflow Urology.

And just to make things easier for what I just summed up, I have included a link to a one page guideline. It's a summary of the 2025 Genitor Syndrome of Menopause GSM report that came out from the American Urology Association. Check it out, stay informed, and take it to your doctor. Have that conversation.

The goal is to reach shared decision making in your healthcare, but you need to make those informed decisions for your health first.