15 Minutes With: Ashley Winter, M.D., Talks Urology, Sex and All Things Vaginas

Ashley Winter, M.D., is the chief medical officer at Odela Health and a urologist and sexual medicine specialist. She uses social media (primarily Twitter) to help clear up misconceptions about women’s health and communicate the truth about all things vaginas.

Winter was exceptionally generous with her time, and our “15 minute” chat actually lasted an hour. We talked about everything from her viral tweet about which way to wipe after peeing (spoiler alert: it doesn’t really matter) to the importance of vaginal estrogen for perimenopausal and postmenopausal women.

Our interview follows, edited for clarity and length.

HealthyWomen: You've become quite a well known figure advocating for women's health and providing sex-med and urology tutorials on Twitter. How did that come about?

Dr. Winter: You know, I wish I could pinpoint exactly what happened. I've just tried to be consistent in my messaging, but also a real human, and I think that has been appealing to people. I remember probably three years ago, near the start of the pandemic, when people were just sitting around a lot, an eye doctor tweeted his favorite people on Twitter to follow, and I was one of them. I got a big following off that.

HealthyWomen: What were some misconceptions you had about women and urology at the start of your medical studies? And how do those misconceptions persist in society?

Dr. Winter: I initially went into urology because I learned about it after a female family member went to a urologist, and I heard about the procedure — a cystoscopy, which looks at the inside of the bladder and urethra. And I was like, “Oh, that sounds kind of cool.” So I looked into what urology was and I got interested in it.

I realized that women were also patients of urologists, which I came to understand that a lot of people did not know. People often thought that a urologist was the male equivalent of an OB-GYN. But they’re not — they see all genders.

Also, there are certain things that are definitely not sex specific, like kidney stones, bladder cancer, blood in the urine. We address all of those things. And in addition to male infertility and male sexual function, we provide care for female sexual function, which is a huge part of my career. It’s a space that doesn't have a lot of ownership in the traditional medical environment. A lot of what women get in healthcare is reproductive healthcare.

Another big issue was that some people wouldn't want to see me because I’m a woman. But some who were hesitant came to see me anyway, and after they had a visit with me, were like, “Oh, you're really cool.” I’ve been able to change certain people's conceptions about what a urologist should be just by existing in my career and doing my job. I imagine, like in any traditionally male-dominated field, if you show up and do a great job, then people say, “Oh, I see now that women can do that.”

HealthyWomen: You’re also doing a lot to dispel a lot of misconceptions about urology on Twitter and Instagram. Can you tell us about that?

Dr. Winter: Yes, that's true. There's so much misinformation on social media regarding health information, and I think that really came to national prominence at the beginning of the pandemic. There were people saying things that were not based in science. That was when I really pushed up my social media presence because I realized that many physicians direct their online content toward other doctors. And we really have an obligation to focus toward the broader community.

I think about it as a general consumer: How would I want to approach areas that I'm not an expert in? You know, when I’m picking a sunscreen, I like watching YouTube videos from a dermatologist. We can all share in this kind of casual exchange, and I'm really excited to share what the scientific information actually is.

HealthyWomen: You recently tweeted that women don't need to wipe from front to back after they pee and it got quite a reaction. It went viral. Can you tell us about that?

Dr. Winter: To clarify, what I meant by that was you don't have to wipe front to back over the vulva. After you pee, you can either wipe starting at the back of your vulva forward, or behind your urethra forward, or you can start in the front of your urethra and go backwards. Certainly, I don't mean that you should take a piece of toilet paper and smear from your anus all the way front. But which direction you go over your urethra area does not matter. I felt it was important to dispel this myth because blaming the direction you wipe can make you feel ashamed and might discourage you from getting treatment.

HealthyWomen: There’s an idea out there that women get UTIs from sleeping around with men. Is that true?

Dr. Winter: Women have a short urethra — shorter than men. It does appear they get UTIs more easily. And definitely there are some women who have a higher chance of getting a UTI after sexual activity. That said, UTIs are not an STD or an STI, meaning they're not sexually transmitted. It's not like your partner has a urinary tract infection and they spread it to you. But being exposed to the bacterial environment on a partner and having that bacteria close to the opening of your urethra appears to, in some sensitive people, lead to them getting a UTI.

It also does appear that if you have a new partner, you may have an increased chance of getting a UTI. That said, it's not like the number of partners causes UTIs. It’s the introduction of a new partner. And again, that's not the case for everybody.

HealthyWomen: Can you talk about the G-spot and end the debate once and for all: Does it exist?

Dr. Winter: Yes and no. No, in the sense that there is not a magic button that if you find it, and you just press down on it, a woman will have an outrageous orgasm. But is there tissue that can be accessed from the inside of the vagina that has relevance for sexual desire? Yes.

The front part of the vaginal wall, near where the urethra passes, has glands that are similar to the prostate in men. There are also a bunch of nerves that run along it that we think are similar to the nerves that go around the prostate in men, which is very important for sexual stimulation, erections, etc. So, you have all this tissue that’s really complex and interesting in the front part of the vagina, like a few inches in. And that’s the area that can potentially lead to orgasm if you stimulate it — and also to what we call female ejaculation or squirting. That can sometimes be urine, but it can also be actual secretion of fluid from the glands around this kind of prostate-like tissue.

It's not like every woman has an orgasm from stimulating that area. That would be like saying every guy primarily orgasms from prostate stimulation.

HealthyWomen: You like to treat UTIs with vaginal estradiol instead of antibiotics. Why?

Dr. Winter: It's not so much that I treat UTIs with vaginal estrogen instead of antibiotics. It's more like I prevent them with it. We know that if you take a bunch of women who are postmenopausal, and you give them vaginal estrogen, it will make their vaginal pH go down back to premenopausal levels. And it will allow this healthy bacteria that's supposed to live there to come back. It also acts like a barrier and prevents the bacteria that can cause UTIs from getting to the urethra.

This is something that has been in medical literature and proven time and time again. It has a very clear effect.

But that really clear concept is so undertaught. I don't don't think it was ever taught to me in medical school. And there was very little, if any, education about that in my six years of urology residency. And then you go out into practice, and you see tons of female patients who are postmenopausal getting antibiotic, antibiotic, antibiotic, for their UTIs.

What I’ve found in my role as a urologist is that people were coming to me for frequent UTIs, or who were perimenopausal or postmenopausal, and I was prescribing the extra vaginal estrogen and I was explaining that link all day, every day in my clinic. It was really stunning to me to have to say again and again that this not only makes people's quality of life dramatically better, it actually saves lives. It can prevent women from getting an infection that travels up their kidney and ends up landing them in the hospital or the ICU or dying.

If you're already on vaginal estrogen and you still get a UTI, which definitely happens but less often, then, of course using an appropriate antibiotic is totally fine.

HealthyWomen: Now let’s talk GSM. What is it and what do you want women to know about GSM that may encourage them to seek treatment?

Dr. Winter: GSM stands for genitourinary syndrome of menopause. And it’s so important to know that term. When I think of all the depictions of menopause that I learned as a kid or in my young adulthood, it was like some woman in the movies having hot flashes or saying, “I'm not in the mood for sex.” So you think of menopause as these total body symptoms like hot flashes, night sweats and changes in behavior.

But there's actually a huge component of menopause that relates to the effect of estrogen levels going down and how that changes the tissue around your bladder, urethra, vulva and vagina.

If we could circle back to that character on television, that woman would say, “Hey, I'm going through menopause. It hurts when I pee,” or, “Hey, I have to go to the bathroom more frequently.” Or, “Hey, sex is painful and I cannot get lubricated in response to arousal.”

Now, not everybody who has menopause goes through those symptoms, but many do. Oftentimes those symptoms can start even before periods completely go away. So somebody could be in perimenopause, the years leading up to menopause, and their periods are irregular, or still happening, but their estrogen levels are going down. And they're getting symptoms like urinary urgency, urinary frequency, burning when they pee, increased urinary infections, lack of lubrication and lack of getting wet in response to arousal — all those symptoms could be a sign of decreasing estrogen.

If you're experiencing any of those symptoms, you really should talk to your healthcare provider about using low-dose vaginal estrogen, because that is the primary treatment for all of those symptoms. It's not the same thing as what we call hormone replacement therapy, which is meant to raise blood levels of estrogen. Vaginal estrogen is really for the local treatment of all those symptoms.

My main tip 1,000 times over for women with GSM is to get yourself some vaginal estrogen. And I promise you, I will use vaginal estrogen once I go through menopause and I will use it forever and I will be buried with my vaginal estrogen.

HealthyWomen: Is there anything we haven't covered that you wish women knew about women's health?

Dr. Winter: I think a big one that I love talking about since we're on kind of the hormone thing is testosterone. Testosterone is in everybody. Testosterone levels in the average adult woman are actually higher than her estrogen levels. It's just that those levels are higher in the average man. So women have less testosterone than men, but everybody has more testosterone than estrogen. Hormones are not black and white: one for men, one for women sort of thing, the way we typically are led to believe.

And testosterone is really important for a lot of things. It’s important for the genital urinary health the same way estrogen is. And if you're on medication that can suppress testosterone, you do have a risk of getting pain with sex, reduced arousal, etc. But it can also affect your levels of desire for sex. And if you’re experiencing low desire for sex, and you're peri- or postmenopausal, using low levels of testosterone can actually be a treatment for that. I've prescribed it many times. I've seen women who have a wonderful response to it.