Understanding Pelvic, Urinary, and Sexual Health in Menopause with Dr. Shenelle Wilson

Dr. Shenelle Wilson is a urologist in Kennesaw, Georgia, who provides reconstructive surgery for individuals of all backgrounds with a wide range of pelvic health concerns. Her practice specializes in pelvic health, hormone replacement therapy, and urinary and sexual issues for both men and women. Fluent in both Spanish and English, she takes great pride in providing exceptional patient-centered care as she works one-on-one with individuals to address their unique needs. She received the Young Urologist of the Year Award from the American Urological Association, where she has been a member since 2013. Dr. Wilson has a passion for increasing diversity in urology, and as a result, she founded the nonprofit organization Urology Unbound, which focuses on the recruitment, retention, and promotion of underrepresented urologists.

She recently did a webinar with our Community Manager, Rachel Hughes, about the intersection between menopause, hormone replacement therapy, pelvic health concerns, and urinary and sexual issues for women.

We’re sharing some of their conversation, which has been edited for brevity and clarity below. To watch the entire webinar, head over to our YouTube! Please note that this webinar is for educational purposes only and should not be used as personal medical advice. 

Rachel Hughes: Welcome. There's a lot to get into. If you could just start by laying the groundwork: How does menopause specifically impact pelvic health? What are the most common issues that arise?

Dr. Shenelle Wilson: Definitely. So, first, let’s talk about the genitourinary syndrome of menopause (GSM). It used to be referred to as vulvar vaginal atrophy, but we have progressed, and our knowledge has increased, and we’ve learned there’s a spectrum. It’s not just the thinning of vaginal tissue, but there are a lot of other symptoms people experience, like vaginal dryness, decreased lubrication and sensitivity, pain with urination, overactive bladder urge, incontinence, decreased arousal and desire… There’s a range of symptoms.

Rachel Hughes: We got a lot of questions about urinary issues and incontinence. I know there are different types. Can you talk a little bit about what those are? 

Dr. Shenelle Wilson: Definitely. So there are quite a few urinary symptoms and urinary incontinence types. There’s stress urinary incontinence, which is leaking with activity, coughing, sneezing, laughing, jumping up and down, working out, and standing from a seated position. That’s increased abdominal pressure, and that stress causes that leakage. Then, there’s urge urinary incontinence, which is part of the spectrum of overactive bladder. And, you can have both, which we call mixed urinary incontinence. It’s important to know the difference between the two because they’re treated differently. With stress incontinence, we have to physically put an obstruction or something to stop the leakage. That could be doing pelvic floor strengthening exercises to increase the sphincter tone in the pelvic floor muscles and Kegels, which most people know about. Or, we could put a pessary in. That’s a physical obstruction that sits under the urethra. We also have minimally invasive surgical procedures. The most important thing to know is that stress urinary incontinence is not treated with medications. 

When it comes to urge incontinence, I like to look for three things I can easily modify before we start on medications. First, I want to know if you’re going through menopause. Is your vaginal tissue de-estrogenized? Because then, estrogen can help. Next, I look for constipation, which is a huge factor in pelvic floor conditions. Lastly, I look for caffeine intake. Caffeine is a known bladder irritant. And, if you’re going through menopause, you may be tired and your caffeine intake may increase. So we look at these things first, and we can go from there.

Rachel Hughes: Thank you. I’m skipping ahead, but one question somebody asked is about vaginal estrogen. Is it really all that we hear it is?

Dr. Shenelle Wilson: It is. Absolutely. I don't understand why in 2024 vaginal estrogen is not just over the counter. I don't understand how we can sell tobacco over the counter and alcohol over the counter–we know the effects those can have–and yet we’re so worried about estrogen that you need a prescription for that. Women get UTIs. It costs the healthcare system, it costs women. They can get sepsis, and they can die from them. And it’s unnecessary. We’ve known for so many years that we can give them vaginal estrogen. I’m always surprised when I get consulted that there is someone in the ER with a UTI and they’re 72. I ask, are they on estrogen cream? And they’re not. But we can prevent this. I don’t think about hormones as medicine, to be honest. I just think about it as replacing what we made before. 

Instead of getting on some expensive medication that has a thousand other side effects and can mess up your liver, it can just give your vagina back the estrogen that it used to have that's going to thicken your vaginal tissue. It brings that back, it helps to support your glands. We have natural protection against UTIs by our cells and our tissue that's down there, but when it gets thin, we lose that barrier. Our vaginal pH changes. It makes it easier for bacteria to grow, for yeast to grow. And so our entire flora changes when we don't have estrogen down there. And so just giving it back can reestablish that normal flora. I tell folks, it doesn't matter if you're on systemic estrogen, you still need vaginal estrogen because the systemic estrogen gets used up everywhere else. Again, we have receptors for estrogen in our blood vessels, in our brains, all throughout our bodies. So whatever we're taking, it doesn't get to our vagina in the same amounts. So most of my patients who are taking MHT are on both systemic estrogen and vaginal estrogen. And it is completely safe. Rachel Hughes: So I want to get into some of our questions that have come in: “I experience significant pain during intercourse. Also, my husband feels bigger than he used to and it's embarrassing for me, and hard to talk about. What could be causing this and what treatments are available? I understand vaginal estrogen, but isn’t it too late for that?

Dr. Shenelle Wilson: It’s never too late for vaginal estrogen to have some benefit. The longer something has gone on, the longer it might take to address it, so don’t expect immediate fixes! But, in terms of what it could be, it could be a variety of things. So, you should get a good physical exam and a good history to be taken by a physician who will listen to you and understand your concerns and symptoms.

Rachel Hughes: Thank you. Can you talk a little about prolapse, vaginal and bladder,  what's happening, and how to address it? My understanding is that vaginal estrogen can be helpful in staving off those two situations. Is that correct? Dr. Shenelle Wilson: So, the easiest way to think of prolapse is almost like a hernia. The vagina has three walls. It's got the anterior wall, between the bladder and the vagina, the posterior wall, between the rectum and the vagina, and then there's the apex. That's where the cervix, or just the top of the vagina, when there's no longer a cervix and uterus are. So all of those areas can start to weaken and then the underlying organs can start to descend down. And so that's what the prolapse is. Prolapse is graded. There's four stages. Stage one, you could have it, I could have it, we could all have it. You don't usually know if there's stage one. That's something that someone might just tell you. You have stage one prolapse. Stage two is when it starts. It may start to get bothersome for people. It feels like you have a tampon in but you didn’t put it in far enough and it’s irritating. If a prolapse is stage two, I recommend pelvic floor physical therapy, watching what activities you’re doing, and vaginal estrogen. Vaginal estrogen will thicken the tissue and increase elasticity. It won’t solve a later stage prolapse, but it will decrease sensitivity and help with lubrication.

Rachel Hughes: Thank you. We have another question: “I’ve experienced clitoral pain and soreness. It’s awful. But, I’m worried about vaginal estrogen. I’ve had cancer. I’m told coconut oil should help. Is this true?”

Dr. Shenelle Wilson: So, this question is kind of hard to answer. Why is the clitoris hurting? Do you have a stricturing stenosis around the clitoris? Is there something that’s actually wrong with the clitoris? Or is it just the tissue? 

Vaginal estrogen probably would be helpful. I do a lot of compounded estrogen testosterone cream when I’m looking at hormonal issues. But it might not just be a hormonal thing. So you should get a physical exam to make sure.

Coconut oil is definitely safe, and if it’s helping, go for it. It’s not going to do anything bad. But it’s also not going to replace hormones. There are quite a few position papers that have been put out by the oncology societies, gynecologic societies, and I’m pretty sure urology as well. We’ve all put out position statements saying that the use of vaginal estrogen in patients who have had cancer is completely safe and not contraindicated. Rachel Hughes: Great. Next question: “Can you comment on changes in spontaneous desire and our arousal related to menopause and on how they’re treated?”

Dr. Shenelle Wilson: Definitely. So desire and libido, those are always difficult for folks to get their heads around. Even me, and I’m a sex medicine therapist. It took me a while to realize my libido was down. It doesn’t mean you don’t enjoy sex. It doesn’t mean you don’t want it sometimes. But it’s a decreased desire that is bothersome to you that you notice is problematic to you. 

When I have patients concerned about their libido, I check their testosterone. If there’s somewhere to intervene there, that’s where we’ll start to intervene. Arousal is more of a physical change. Engorgement, blood flow, elongating of the vaginal canal. Those things can technically happen without libido, but they do tend to go hand in hand. So it’s about understanding whether you have an issue with one, the other, or both, and then treating them.

Rachel Hughes: Let’s talk about Kegels. Dr. Shenelle Wilson: Let’s. I love talking about Kegels because we kind of throw it around as a catchall, and there are reasons to do them, but there are also reasons not to. Kegels are specifically for stress urinary incontinence. It’s a type of pelvic floor strengthening exercise, but it’s not the only type. And you never want to do it while you’re peeing. I have so many patients who come in and say they do that, but please don’t ever do that. The way you do is, you do a good squeeze and you want to sustain it for at least two seconds. I tell people to work their way up to five or seven seconds. You want to do at least 10 in a row, and I tell people to do it three times a day in different positions. So, 10 times laying down, 10 times sitting up, 10 times standing. And spread them out throughout the day. I like people to do a deep diaphragmatic breath in between those squeezes so they can fully relax the sphincter. 

Rachel Hughes: Thank you for that. Is there anything you want us to know before we wrap up here? 

Dr. Shenelle Wilson: Yes. If you’re having issues and bringing them up to your physician and they’re not being taken seriously or not being addressed, that’s a problem. If that happens, find somebody else. Things like leaking are not normal. I hear so many people say, “Oh, well, they told me I would leak. I had babies!” But that’s not the case. You don’t have to leak. So you don’t want to have a physician who is writing you off. 

Rachel Hughes: Thank you so much.

Dr. Shenelle Wilson: Thank you!

There’s a lot more where that came from, so we highly encourage you to watch the whole webinar on our YouTube!

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