Rachel Rubin is a board-certified urologist and one of the nation’s foremost experts in sexual health. In this episode, she shares her deep expertise on the often-overlooked topic of women’s sexual health, exploring why this area remains so neglected in traditional medicine and highlighting the critical differences in how men and women experience hormonal decline with age. Rachel explains the physiology of the menstrual cycle, the complex hormonal shifts of perimenopause, and the wide-reaching health risks associated with menopause, including osteoporosis, cardiovascular disease, dementia, and recurrent urinary tract infections. She also breaks down the controversy surrounding hormone replacement therapy (HRT), particularly the damaging legacy of the Women’s Health Initiative study, and provides guidance on the safe and personalized use of estrogen, progesterone, and testosterone in women. With particular emphasis on local vaginal hormone therapy—a safe, effective, and underused treatment—Rachel offers insights that have the potential to transform quality of life for countless women.
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We discuss:
- Rachel’s training in urology and passion for sexual medicine and women’s health [3:00];
- Hormonal changes during ovulation, perimenopause, and menopause: why they occur and how they impact women’s health and quality of life [5:30];
- Why women have such varied responses to the sharp drop in progesterone during the luteal phase and after menopause, and the differing responses to progesterone supplementation [14:45];
- The physical and cognitive health risks for postmenopausal women who are not on hormone therapy [17:45];
- The history of hormone replacement therapy (HRT), and how misinterpretation of the Women’s Health Initiative study led to abandonment of HRT [20:15];
- The medical system’s failure to train doctors in hormone therapy after the WHI study and its lasting impact on menopause care [29:30];
- The underappreciated role of testosterone in women’s sexual health, and the systemic and regulatory barriers preventing its broader use in female healthcare [35:00];
- The bias against HRT—how institutional resistance is preventing meaningful progress in women’s health [46:30];
- How the medical system’s neglect of menopause care has opened the door for unregulated and potentially harmful hormone clinics to take advantage of underserved women [53:30];
- The HRT playbook for women part 1: progesterone [57:15];
- The HRT playbook for women part 2: estradiol [1:05:00];
- Oral formulated estrogen for systemic administration: risks and benefits [1:13:15];
- Topical and vaginal estrogen delivery options: benefits and limitations, and how to personalize treatment for each patient [1:17:15];
- How to navigate hormone lab testing without getting misled [1:24:15];
- The wide-ranging symptoms of menopause—joint pain, brain fog, mood issues, and more [1:31:45];
- The evolution of medical terminology and the underrecognized importance of local estrogen therapy for urinary and vaginal health in menopausal women [1:37:45];
- The benefits of vaginal estrogen (or DHEA) for preventing UTIs, improving sexual health, and more [1:41:00];
- The use of DHEA and testosterone in treating hormone-sensitive genital tissues, and an explanation of what often causes women pain [1:50:15];
- Is it too late to start HRT after menopause? [1:56:15];
- Should women stop hormone therapy after 10 years? [1:58:15];
- How to manage hormone therapy in women with BRCA mutations, DCIS (ductal carcinoma in situ), or a history of breast cancer [2:00:00];
- How women can identify good menopause care providers and avoid harmful hormone therapy practices, and why menopause medicine is critical for both women and men [2:06:00]; and
- More.
Show Notes
Rachel’s training in urology and passion for sexual medicine and women’s health [3:00]
Help us understand how your training in urology led you to what you’re doing today
- When we think of urology, we think about prostates, kidneys, bladders
- But what you forget is that urologists are ultimately the quality of life doctors
- We deal with urination problems and we deal with sexual medicine
“No one cares about erections and orgasm and libido quite the way that a urologist cares… it’s not a gender thing.”‒ Rachel Rubin
- We’re not penis doctors only: we are board certified to take care of everybody’s genital and urinary tracts
- Unfortunately, society has led us to know a lot more about the men’s sexual health and men’s genitals than female genitals
- Rachel trained in urology because she was interested in women’s health, but she was also interested in sexual health, sexual medicine
- She didn’t like delivering babies, didn’t like OB/GYN
- What she loves about urology is that she can see everybody and she can really dive deep on quality of life issues
- The magic of urology is also that you really get to know your patients
- It’s not like when you did surgery, you take out someone’s appendix and you never see them again
- Maybe you do one post-op visit
- Urologists have deep relationships, we’re both surgeons but we actually care about the medical side of these quality of life issues
- As she was going through medical school, she really realized that talking about sexual health and quality of life issues was fun for her
- It’s just been a joy
- She’s been working to further the field of urology to make us better at taking care of women
- Rachel does a lot of educating and teaching to her colleagues about how we really need to care about the whole, everybody
Hormonal changes during ovulation, perimenopause, and menopause: why they occur and how they impact women’s health and quality of life [5:30]
- Peter wants to talk about it from a female standpoint today because there’s a dearth of great information out there and an abundance of garbage information out there
- He appreciates Rache’s breadth of knowledge that covers both sexes, but he wants to talk about women specifically
Menopause: an obvious difference between men and women from an endocrine perspective
- Menopause is a sudden and abrupt loss of sex hormones
- That is in contrast to the way men’s sex hormones decline over time a little more slowly
- Listeners of this podcast are highly erudite
Give a quick overview of what is happening to women in menopause
- Rachel got an interesting email last week that said, “Dr. Rubin, my wife is seeing your practice. Her libido is now like an F1 Formula One race car. And I’m like a 1988 Honda Civic. What can you do for me?”
- Rachel’s gas tank analogy: as men age, sometimes we see a decrease in their gas tank
- Men are feeling low, they’re feeling down, they’ve got erectile dysfunction, low libido
Whereas women at age 52, their gas tank is empty ‒ this is a castration event
- We don’t have many castration events in men’s health
“Menopause is sort of a, your gas tank is officially empty. There’s not much in the tank.”‒ Rachel Rubin
Perimenopause is this time where it’s very erratic
- The gas tank is over full, and then it goes to empty really quickly without warning
- This analogy is helpful when we’re talking to women about the reason you don’t feel like yourself is because there’s just no gas in the tank
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Rachel Rubin, M.D.
Rachel Rubin earned a BS in Biopsychology and Biomedical Engineering from Tufts University. She continued at Tufts, earning her medical degree. She then completed an internship in general surgery at Medstar Georgetown University Hospital. She did her residency in urology at Georgetown University. After this, she completed a fellowship in sexual medicine and prosthetic urology in San Diego with Dr. Irwin Goldstein. Dr. Rubin is one of only a handful of physicians with fellowship training in sexual medicine for all genders.
Dr. Rubin is a board-certified urologist and sexual medicine specialist who works as a clinician, researcher, and educator. She was the former education chair and current Director-at-Large for the International Society for the study of Women’s Sexual Health (ISSWSH). She serves as associate editor for the Journal of Sexual Medicine Review and the Video Journal of Sexual Medicine. Dr. Rubin launched her own practice in 2022 so she could provide patient-centered care with a multidisciplinary approach, working closely with physical therapists, sex therapists, and other medical and behavioral health providers. She is passionate about providing comprehensive care to her patients and sees her role as a coordinator of care for her patients to help them achieve their sexual health goals and improve their quality of life. She also is passionate about educating her patients, hoping to empower them to take control of their own health and advocate for better care. Further, Dr. Rubin works hard to educate other providers to ensure that they are armed with the tools to provide evidence-based, compassionate care to their patients. [Rachel Rubin, MD]
Instagram: @drrachelrubin
Website: rachelrubinmd.com
YouTube channel: @DrRachelRubin
