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Episode 14 Transcript

Transgender Pelvic Health with Sally Huber, FPMRS

Erin Everett: Welcome back everybody to Exclusively Inclusive. I’m your host Erin Everett, nurse practitioner. On today’s show, I’m very excited to have a special guest with us, Dr. Sally Huber. Dr. Sally Huber is a urogynecologist at Advanced Gynecology here in Atlanta. Her location is specifically in Buckhead. Dr. Huber completed her undergraduate degree at Columbia University and medical degree at New York Medical College. Sally then went on to complete her residency in gynecology and obstetrics at Emory University. She’s also an Atlanta, Georgia native. After her residency, Sally went to complete her fellowship in female pelvic medicine and reconstructive surgery at Weill Cornell Medical College.

Erin Everett: It was during that time that she received a certification in clinical epidemiology through Joan and Sanford I Weill Graduate School of Medical Sciences. The LGBTQA population is of significant importance to Dr. Huber, and during her fellowship, she was awarded the NIH funded grant for her research in pelvic floor conditions in transgender women. Dr. Huber headed a nationwide collaborative to generate longterm applications that improve the quality of care for transgender women after surgery. Sally is a staunch advocate for the community and we’re so happy to have her on the show with us today.

Erin Everett: All right Sally, so thanks for coming in and chatting with us today. So tell us a little bit about yourself and maybe a fun fact that most people wouldn’t know about you.

Dr. Sally Huber: Hey Erin, thank you so much for inviting me on here. I’m really excited to chat with you a little bit about what I can do to help the LGBTQ population and specifically our trans patients. A little bit about me, I am a urogynecologist. So I was trained in obstetrics and gynecology and then I did a three year fellowship focusing on female pelvic floor health, especially bladder health, sexual health, and dealing with things like pelvic pain, pelvic floor dysfunction. I am from Atlanta, but I was away for several years and I just moved back down here to be closer to family. My wife and I have an adorable 10 month old who is totally running the house right now. So, of course right? It’s just nice to be home, be close to family and start building a practice here.

Erin Everett: Awesome. Well we’re excited to have you back. It’s rare that you come across an Atlanta native. Everyone’s a transfer. So yeah, we’re excited to have you back. So you’re currently working at Advanced Gynecology and when did you move back?

Dr. Sally Huber: I’ve been here for about six months now and we have a few practices. I’m currently in the practice in Buckhead on Peachtree Street near Piedmont Hospital.

Erin Everett: Yeah, that’s super accessible to a lot of our patients too. Just to kind of get started here, what are some of the ways that your office have created a safe space for patients, and particularly trans men?

Dr. Sally Huber: So I find that it’s a lot of the little things that you can do just to introduce the idea to patients that you’re open, and that you’re not going to discriminate, you’re not going to judge, that this is a safe space from just when they walk in the door, having a sign right next to the check-in saying that “We’re an open office that does that discriminate. We accept all gender identities, all sexual orientations, all races,” to on our patient intake forms, asking what their preferred pronoun is, asking what names they would like to be referred to as if it’s not consistent with what’s on their driver’s license or what’s in their medical record.

Dr. Sally Huber: And then when we bring them back to the room, first thing we tell them is “This is a safe place. Everything that we talk about is confidential. If anything makes you uncomfortable, please let us know.” And just reinforcing little things like that. And then when I come in and I do my exam, I explain everything I’m going to be doing with the exam, why I’m doing all of it. And to once again reinforce “If something’s making you uncomfortable, please tell me and we don’t have to do it. Everything is your decision here.” So just letting them know that they do have autonomy and that they do have a voice in what we can do for them. So that’s what we try and do here. Yeah.

Erin Everett: Yeah. So kind of back to stepping to what you mentioned about comfortable exams and explaining everything. Obviously, a lot of patients in general really dislike a speculum exam. In general, it’s not the best fun experience. But particularly for those who may have undergone like sexual trauma, or have other concerns who are trans men who might have a lot of pain in that area. What are some of the ways that you can accommodate that? Are you able to do an exam without speculums? Are you able to skip the stirrups, anything like that to help them feel better?

Dr. Sally Huber: There are certain things you can do. And this all goes hand in hand with explaining to them at the start what we’re doing and why we’re doing it, and then coming up with what’s going to make them most comfortable. If they did prefer an exam in the frog leg position, if they would prefer an exam that was just a digital exam without a speculum, if they would prefer just to have a speculum exam, we will do what we can to make them feel comfortable but also be thorough and do our appropriate screening and evaluation.

Dr. Sally Huber: We also do have a surgery center available if we are concerned that there is some significant pathology that we need to look very closely at, we can always take them to the surgery center, put them under a lighter anesthesia, once again with their consent, so that we can take a close look and we don’t have the uncomfortable aspect of being awake in office to do that. I will also do, for trans men, even though they have been taking testosterone and even though they may be at lower risk for having HPV or cervical cancer, cervical dysplasia, they still need to be screened.

Dr. Sally Huber: And so we can try and accommodate a blind pap swab if needed. Once again, as long as the sample is okay, if the pap smear comes back where it’s conclusive, then we’ll need to have another discussion. But we reinforce the fact that, as long as they have female genital organs, for their health, we need to continue screening them and whatever way we can accommodate them, we will work with.

Erin Everett: Oh, that’s awesome. And I had no idea that it was even an option to go to a surgical center and do that. I’m sure it’s not the common scenario, but even the fact that it’s an option is probably very reassuring for a lot of people.

Dr. Sally Huber: Yeah. Yeah. It is always our option that if we need to do something like that, we have the ability to do that. And then the other thing I want to say with that too is with trans men, but any patient that comes through our office, from the LGBTQIA population, a lot of them, like you said, are victims of sexual trauma or domestic violence. And so the biggest thing is communication. And I tell patients every step of the exam that I’m doing as I’m doing it, so that they aren’t surprised. And I also go slowly so that nothing catches them off guard.

Dr. Sally Huber: And I find that when patients are caught off guard and when they’re uneasy with something, their pelvic floor contracts, which makes our exam much harder. But if you’re able to calmly discuss it with them as you’re doing it, the pelvic floor tends to relax and you’re able to access the organs a lot easier. So I would encourage any providers listening to this to always make sure that you’re doing that during your exam because it really will make everyone’s lives a lot easier.

Erin Everett: Yeah, absolutely. And I think that is a very valid point. You never want to surprise anybody who’s already anxious about the exam. And so another thing on this subject, do you find that when we’re talking about trans men in general, and I know this is kind of a little bit off topic, but IUDs, are they a feasible option? Do you find it more challenging to insert those into trans man? I have a lot of conversations with my patients about whether they’re having persistent menses even while they’re therapeutic on their T, or if they want to utilize it for a contraceptive use. Do you think that the exam is more challenging and if not or if so, is there a timeline on how long they’re on testosterone to where you would or would not see it as a feasible option?

Dr. Sally Huber: So I’ve found that it’s really patient dependent. We’re talking about trans men kind of in a bucket as far as being on testosterone for a various length of time. Obviously trans men that have just recently started testosterone are going to be very different than trans men that have been on testosterone for many, many years. But that being said-

Erin Everett: Right. And that has to do with the lack of estrogen, right? And the atrophy and the tissues and things like that?

Dr. Sally Huber: Right.

Erin Everett: Yes. Okay. Just wanted to clarify that.

Dr. Sally Huber: Right. Exactly. Yep. Yes, yes. So essentially when trans men are on testosterone for an extended length of time, it puts them into something like a menopausal picture in cisgender women where the vagina becomes narrowed, it becomes smaller, it becomes less compliant. The tissue is just thinner and more easily irritated as well. And then along those lines too, once they’ve been on testosterone for a while, the cervix changes.

Dr. Sally Huber: And so as far as putting in an IUD, sometimes that makes it a little harder to place the IUD through the cervix because the cervix doesn’t have that estrogen feeding it anymore to keep it open and patent. So back to the question though, if I have a trans man who’s coming in asking for an IUD, the first thing I’m going to do is an exam and just see, one, what their comfort level is like. Two, is it going to be easy for me to place it in the office? And then kind of base that conversation off of that exam.

Dr. Sally Huber: The other options that’s available to them are Nexplanon, an implant in the arm, that works in a similar way as the IUD. And then obviously you don’t want to give them any sort of estrogen containing birth control pills because obviously that kind of counteracts what their goal is. But the first thing I do is I do an exam because sometimes a patient can be in testosterone for years and have a totally patent, healthy, cis-gender-like vagina that you can easily place an IUD in versus someone that’s only been on testosterone for a year or two, and they have total vaginal stenosis and atrophy. So it really depends.

Erin Everett: Okay. Yeah no, that’s really informative. Do you see the sensation of menses in the Nexplanon the same as you would with a Mirena?

Dr. Sally Huber: Yes, actually it does make menses a little less regular. They may have spotting here and there and it may not be quite as dramatic as the Mirena, but it works in a similar way. So patients will have lighter if not absent menses.

Erin Everett: Okay. And then going back to the estrogen now, you said that with estrogen containing oral contraceptives that you wouldn’t necessarily recommend those when they’re taking testosterone because it might be counterintuitive to their transition, whereas we won’t really see, at least I haven’t seen in my experience, a lot of halting in secondary sex characteristics. But I have found, and you might be able to support this, that sometimes it is harder to get the cycle to stop. Is that what you mean with the estrogen containing contraceptives?

Dr. Sally Huber: Yes. Yes.

Erin Everett: Yeah. Okay. Yeah. Because they’ll still get the deeper voice and things like that. But yeah, their cycle will continue most likely.

Dr. Sally Huber: Right. The secondary sex characteristics will kind of maintain, but yeah. Ovulatory functions.

Erin Everett: Yeah. I just wanted to clarify that.

Dr. Sally Huber: Now-

Erin Everett: Go ahead.

Dr. Sally Huber: The other option, and there’s not a lot of literature out there about this, but is the option of vaginal estrogen cream in trans men, especially the ones that are still wishing to maintain penetrative intercourse ability, the ability to have sex with a penis or a dildo. Now the benefit with vaginal estrogen is that it has a very low systemic absorption, which means only a very small amount of the estrogen gets into the blood system.

Dr. Sally Huber: And so it works locally in the vagina but also the bladder as well to keep that tissue healthy. So once again, there’s not a lot of data on that, but anecdotally I have patients that have been on it and I’m sure you have as well, to use something like that especially when they want to maintain a patent vagina for sexual activity or for their self appearance.

Erin Everett: Yeah. I’m so glad you actually mentioned that because you’re right, there’s not a lot of literature, especially in trans men, but anecdotally I have used it a fair amount. And I’ve also used it too for like you said, painful intercourse, maintain the patency, but I have found it also helps reduce recurrent BV infections I think from the pH changes. So yeah, I actually use it a lot. Well, I wouldn’t say a lot, but I definitely offer it up for patients under those circumstances. So I’m glad that you are using that too and you’ve noticed the similar effects yeah. That’s awesome. I think it’s a really great option that depending on the provider, it’s not always being offered for trans men. And I think it can kind of get neglected because we sometimes assume that they’re not using that organ for penetrative intercourse, which is just honestly not the case a lot of the times.

Dr. Sally Huber: Yes, absolutely. I think that that’s one thing that we as providers could be better about is understanding that just because someone is trans doesn’t mean that they don’t enjoy sex and they don’t enjoy a variety of sexual activities.

Erin Everett: Right. Or that they have-

Dr. Sally Huber: … And should always kind of approach that topic with them.

Erin Everett: Right. Or that they even have genital dysphoria because not everybody does.

Dr. Sally Huber: Yes. Yes. Exactly.

Erin Everett: Awesome. Okay. So one of the things I wanted to bring up to you as well as we had discussed kind of briefly, but the Healthy People 2020 had published some initiatives as it pertains to the LGBTQ community. So for their goals for creating safe spaces for care, and increasing access and utilization of routine health screenings. And actually when I was reading them, they actually cited that women who identified as lesbian or bisexual were more likely to have chronic illness but less likely to receive routine gynecological exams. So I don’t know what your thoughts are on that or what we could be doing as providers to change that number. But where do you think the reason for that is and things that we could be doing to make a difference there?

Dr. Sally Huber: I think that there are a lot of reasons that women from that community are hesitant to come in to see not only gynecologist, but anyone in primary care to address some of those problems. A lot of them are social reasons, concern that they might be discriminated against, concern that their concerns won’t be taken seriously, or that there’ll be some sort of judgment as far as their lifestyle and “choices.” I’m using quotes for a reason. And then they also just aren’t sure where to go. So I think that that really inhibits a lot of not just lesbian and bisexual women, but trans men and women from seeking the care that they need. Now as far as medical problems and prevalence of medical conditions. Lesbian women do have a higher risk for obesity, tobacco use, and alcohol use as well, just based on population data.

Dr. Sally Huber: And as a result, they theoretically are at higher risk for things like diabetes, lung cancer, cardiovascular disease. So screening and kind of frequent checkups is really, really important for this population as a whole. But then also too, we need to make sure that they’re getting the right gynecological care and the appropriate screening. We already talked a little bit about pap smears and how those are still important, but also regular breast cancer screening, evaluating for signs of ovarian cancer and uterine cancer.

Dr. Sally Huber: And then when they come in for their well woman visits, making sure that you’re screening for cardiovascular disease, high cholesterol, diabetes, and that you’re appropriately counseling them on those things. And then the other thing too that’s really important is when they do come in, ask them about domestic violence, because a lot of lesbian and bisexual women are victims of domestic violence. But it’s just not the typical ones that you hear about in the news. Same sex partner domestic violence is a thing. And sometimes women are hesitant to disclose that whether they’re in a same sex or different sex relationship , so I always screen patients for that as well.

Erin Everett: Okay. And so how do you normally screen for that? Are you giving them a questionnaire or are you personally asking them?

Dr. Sally Huber: So it’s part of our questionnaire, honestly, I’ve never had anyone answer yes, just based on what’s on a questionnaire because it’s such a personal question. And so I always bring it up with them as well. You just ask them if they feel safe at home, do they feel safe with their partners? And have they ever been forced to engage in these sort of sexual activities that they didn’t feel comfortable with? It’s three simple questions, I find that talking about those three different things if there’s something there, it’ll get brought up. And then making sure I’m doing that when I first see them while they’re dressed, they’re not sitting on the table. It’s not the middle of the exam. It’s just a very kind of casual discussion we’re having where they don’t feel like they’re in a compromised position.

Erin Everett: Yeah, I think that’s actually what you just said there is really important, because having obviously my own personal experiences with gynecologists, I’ve had several different styles, and the one that I currently see now actually will talk to you in their office before going in and doing the exam. And I think that does make a patient feel a lot more comfortable to have a conversation and divulge information when you’re not sitting half naked on a table in front of them feeling really vulnerable. So I think that’s really an awesome that you do that for your patients.

Erin Everett: So you also mentioned though that trying to get women in for their health screenings and things like that. Obviously like you said, that’s really important for transgender women too, your office and you actually did a lot of extra training in transgender women and their pelvic floor dysfunction and especially post-surgical pelvic floor issues. So what type of things can you do for those patients as far as what kind of regular health screenings they may or may not need, and what kind of issues you see sometimes pop up after surgery?

Dr. Sally Huber: Yeah, well, so I kind of made this subspecialty in my practice because I’ve always been interested in trans health care. And as I was going through my training, I found that a lot of trans women, they’ll have their gender confirming genital surgery and then you don’t really hear anything afterwards about what happens to them. And when I did a little deeper diving, I realized that pelvic floor dysfunction is really prevalent in this group of women after surgery.

Dr. Sally Huber: I mean, it’s not surprising. You’re doing one, maybe two, maybe three, major surgeries to the perineum, and the genital tract, and including the bladder and sometimes the rectum. And of course they’re going to have changes in their bladder function and their vaginal function. And I think that urogynecologists are in a special position where they’re very familiar with the anatomy and the function of all these organs and they can provide some of that aftercare and monitoring for some of these things.

Dr. Sally Huber: And by conditions I’m talking about things like overactive bladder, I mean up to 33% of transgender women after surgery will have urgency, frequency, waking up at night to go to the bathroom, urinary incontinence, urine spraying is upwards of 60% of women will have that. And then vaginal function, when the new vagina is created the biggest thing that stressful is frequent dilation and starting sexual intercourse. And sometimes even looked at women can develop, strictures in their vagina, stenosis, they can have trouble with their dilations, they can get infections.

Dr. Sally Huber: and so I’m trying to position myself as that provider here in Atlanta that they can go to to address some of those things. Because a lot of times their surgeons who perform these surgeries are in other states. And so for things that need kind of closer monitoring and frequent visits, it’s hard to fly up to see their surgeon every time. And so it depends on what they come in presenting with. But I can do things such as small vaginal revisions, releasing some strictures, treating any abrasions for the bladder. If they have overactive bladder, there are a variety of medications and procedures we can do to help relieve that, including if they have a urethral stricture, relieving that. If they have urinary incontinence, doing things to help them control their urine stream.

Dr. Sally Huber: And then a lot of just general pelvic floor work because I’ve also found that a lot of women after surgery have what we call high tone pelvic floor, which basically means the musculature and all the support system that’s keeping everything in place is just really inflamed and irritated. And that’s how we do to a lot of things, not just surgery but just a life of living in a body that they felt was foreign to them. And so now that they have the genitalia that they want and that they need to have, they need to kind of reorient how their pelvic floor works. And so I do a lot of work with them as far as releasing some of that tension and letting them kind of learn how their body is going to be working from now on.

Dr. Sally Huber: So it really depends on what they come in with. But it runs the gamut as far as what can happen after surgery. But the great thing is that even with some of these problems down the road, I mean satisfaction after surgery is incredibly high and I’ve never had a patient come in saying “I wish I didn’t have this done.” They always are happy with it and my job is to just make their quality of life as optimal as it can be and make them love their new body.

Erin Everett: Well we’re so excited to have you in Atlanta. I cannot tell you over the last four and a half years that I’ve been serving this population, how many times I would have loved to have you in my back pocket for certain issues that have come up from my patients post operatively. Because like you said, a lot of these patients get surgery done in Arizona, Chicago, New York, San Francisco, it’s nowhere usually very close by. So not only is it out of state, it’s usually expensive areas to fly to and it’s cumbersome.

Erin Everett: So to have somebody here that can help troubleshoot a little of those things is going to be amazing. So we’re really excited about that. You mentioned infection. I was curious about this because I do have several women who have undergone surgery and troubleshooting kind of vaginal infections in that group. Obviously prior to meeting you, I’ve had to kind of self navigate some of that. And we often do swabs but everybody has different kind of opinions on that. And I have met with a different surgeon who does actually the vaginoplasties who recommends doing just a regular culture and treating based on that, but also said that depending on the type of tissue that they can get traditional bacterial vaginosis. So what is your experience with that? What do you see as more of the common pathogens? Is it just really so varied?

Dr. Sally Huber: It really varies, especially for women that have the penile inversion vaginoplasty. I think that there’s a lot of variability. Obviously if it’s a colonic vaginoplasty, then it’s probably going to be an E. coli sort of thing. But for penile inversion it really does vary. And I started placing women on vaginal lactobacillus suppositories with the hopes that that kind of introduces the normal vaginal flora that you want into the space and tries to outcompete some of that bad bacteria.

Dr. Sally Huber: Once again, with everything in involving trans healthcare, unfortunately there’s just not a lot of literature. And so like you said, it is provider dependent. Everyone has their own formulations and ideas. Some providers will just have patients use Trimo-San cream with the hopes that that will do it. But yeah, it really does depend. Now, as far as treating patients, I would reserve any sort of treatment unless they’re really bothered by the discharge and it is an impressive amount of discharge.

Dr. Sally Huber: The problem with just kind of treating for every time you have a positive culture is that you’re going to build resistance to things and then you’re going to get stuck where you’re going to have a really bad infection. So I try to talk to patients and say, “If you’re really bothered by this discharge, we can see what it is and if it grows out something significant we can treat it. Otherwise, let’s just leave it be and try some lactobacillus.”

Erin Everett: The other question I had for you when you were talking about overactive bladder postoperatively, how did you kind of decipher between… I mean obviously you’re very knowledgeable on the subject, but just for myself and listeners, decipher between that and prostatitis because I’ve encountered both with patients and sometimes it can be difficult.

Dr. Sally Huber: Yeah, it is. It certainly can be. And I think the first thing when I have a patient who comes in saying that they’re going to the bathroom very frequently, or if they have any urgency to go, or they’re having trouble emptying their bladder even, if they’ve had surgery, I like to do a cystoscopy first just to take a look. And if you see a bold kind of where the prostatic urethra is, then that’s a sign. But also too just by passage of the scope. If it is an inflamed prostate, then you’ll feel it.

Dr. Sally Huber: But you also want to look for any urethral strictures or any signs of infections or stones or anything like that. And then just a good exam since you have the new vagina there, you can do a trans vaginal exam and really feel the bladder base and the prostate and see if anything is painful for them. But my default treatment is to try overactive bladder medications first and then see from there. With prostatitis, they tend to have more pain related symptoms, whereas the overactive bladder, they don’t tend to have a lot of pain. It’s more urgency, frequency, that kind of thing.

Erin Everett: Awesome. Well cool. Thank you for that. That was really informative and helpful and I think having you as a resource in the community is just going to be amazing. So just for listeners, is there a best way to contact you or do you have a social platform or any questions that might be stimulated from listening to this? Where would you like the patients to seek you out?

Dr. Sally Huber: They can always make an appointment to come in to see me. I love just having appointments where we just chat. They shouldn’t feel like they’re going to be walking in and needing an exam. If they just want to talk about things, talk about questions they might have, I’d be happy to talk to them. They can also send me an email. My email is shuber@gyngeorgia.com. Georgia’s all written out. And I am not very social media savvy, so there’s really no good way to find me on there. I’d be happy to see them in person.

Erin Everett: Yeah, that’s great. No, I think that works for a lot of people. Well, awesome. Well thank you so much for your time and we’ll stay in contact. I really appreciate having you.

Dr. Sally Huber: That sounds great. Thank you, Erin.

Erin Everett: Yes, no problem. So once again, thanks for tuning in and I really hope you enjoyed talking with Dr. Sally Huber as much as I did. She is wealth of information and she’s such a wonderful resource to have here in the community. I’m really happy to have her.

Erin Everett: So if you have any questions after our podcast episode today, please feel free to reach out. You can make an appointment with her through her website at Advanced Gynecology or you can email her directly at shber@gyngeorgia.com. That’s shuber@gyngeorgia.com. All those resources will also be posted in the podcast profile. If you have any questions for me, again, feel free to email erin@exclusivelyinclusivepodcast.com, and in the meantime, thanks for tuning in. Stay fierce and live your truth.