← Rena Malik, MD Podcast
Rena Malik, MD Podcast
How to Take Care of your Clitoris....The Right Way! Ft. Dr. Rachel Rubin
01:33:08
Dr. Rena Malik welcomes Dr. Rachel Rubin to discuss women’s sexual health, from clitoral anatomy and adhesions to hormones, menopause, sexual pain, devices, and communication. This episode offers practical insights for understanding your body, advocating for better care, and normalizing conversations around pleasure.
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- [00:00]
Dr. Rachel Rubin
Every woman over the age of 50 goes to an empty tank. It's fact. It's castration. It is no longer hormones. All I can guarantee you ahead is shit's about to get weird, right? And I think there is this whole timeline of people in their late 30s, 40s and 50s where you really start to nflm not feeling like myself. I remember being told, don't go near the clitoris because you don't want to make your patient uncomfortable. Reena, you and I are urologists. Can you imagine us being told, don't touch the penis? Sex is supposed to be fun. It's supposed to be joyful. It's supposed to be adult playtime and playful. And so if you're not talking about it, trying new things, it's going to get a little stale and a little bit, you know, maybe lonely.
- [00:43]
Dr. Reena Malik
Did you know there's a part of female anatomy that's only job is to provide pleasure? And most doctors never even examine it. In fact, most women have never even seen their own anatomy with a mirror. I'm Dr. Reena Malik, urologist and pelvic surgeon. And welcome back to The Rena Malik, M.D. podcast, your trusted source for leveling up your health, relationships and sex lives with evidence based tools. Today I'm joined by my dear friend and colleague, Dr. Rachel Rubin, urologist and sexual medicine specialist who is redefining the standards of women's health care. She challenges outdated textbooks and has created global education platforms. She is the leading voice for hormonal and sexual health and is literally changing the future of medicine. In this conversation, we are covering so many things. We're talking about the clitoris and why even anatomy textbooks don't show the full, full structure of the clitoris. Clitoral adhesions that affect up to one in five women. The vulvar vestibule, which is a hidden cause of sexual pain, how birth control pills affect sexual function, and what's actually happening to your genitals during menopause. And we talk about vaginal hormones and why only 9% of patients receive this treatment, even though it can be life changing. The conversation about bodies, pleasure and medical education, that should have happened decades ago. Before we get into the conversation, I have to tell you guys about the better sex app. App. This is an app that I designed so that I could reach more of you and help guide you to become better in bed, whatever that means to you. This app personalizes to your goals. If it's just to be better in bed or you're struggling with erectile dysfunction or Low sexual desire. It doesn't matter. This app guides you. It has a 24.7ai support chatbot. It also has daily modules and tasks that you can do to help improve your life and improve your sex life. Check it out today. Estudio.com rena for less than a dollar a day Dr. Rachel Rubin, I'm so happ to have you here.
- [02:36]
Dr. Rachel Rubin
I'm so glad we finally got to do this.
- [02:38]
Dr. Reena Malik
You have been a wonderful friend. And even though we're contemporaries, I found you to be like a mentor at times and someone I can come to when I have questions. And it's just been such a great pleasure knowing you.
- [02:51]
Dr. Rachel Rubin
It's such a joy to be contemporaries because what I learned about mentorship is that I have so many mentors now that are way younger than me that show me how to do the buttons and help me with so many things and then obviously so many people older than me. But it's really this book, wonderful community where we can learn from each other.
- [03:08]
Dr. Reena Malik
Yeah. And, you know, before this, we were talking about how we need to be looking at the couple instead of just the individual man or woman. And I think it's so interesting because a lot of my audience is men, but they do genuinely care about their female partners and making them happy and giving them pleasure. Tell us about your experience in taking care of couples.
- [03:28]
Dr. Rachel Rubin
Yeah, I think it's so important. And we were talking at breakfast this morning about how because we're actually friends in real life, but we were talking about how challenging this is because the way medicine is set up right now is the boys go to the boy doctor and the girls go to the girl doctor, and they never talk to each other or even understand what's happening with the other one. And we minimize biology here. And there is so much biology here that can happen to everybody, and it evolves over your lifespan. And we don't talk about it. And so then there's the whole psychosocial aspect, which is huge, and how you approach this, how you talk about it, how you evolve this intimacy. And there really aren't a lot of doctors to have those conversations. And so we talked about that. There's like 27 fellowships for men's sexual health. There are now two fellowships focused on women's sexual health, but they don't do both. Actually, my fellowship that I did with Irwin Goldstein, who you had on the show, it's the only fellowship in the country that even acknowledges sort of the couple. And I can't tell you how much you easier my job is when I can really work with both sides of the couple.
- [04:38]
Dr. Reena Malik
Yeah. And the issues are similar, but different. Right. Like, the. The. The self conscious, the thoughts, the. The stressors are similar, but they're often dealing with very different physiology and very different issues physiologically that they don't even know what's going on. They just feel like something's wrong with them.
- [04:56]
Dr. Rachel Rubin
And I find I can use things from my toolbox for each one to actually help with the other one. And when you give people sort of a language about their bodies, their anatomy, how their anatomy works, and you can, like, share it with them, it. It kind of opens their eyes of, oh, my gosh. What I find is it's easier to talk about sex when you talk about, like, it's high blood pressure, diabetes, or like, hey, honey, I'm having a surgery. You know, it's so much easier to talk about the biology than it is the feelings and the intimacy. And so sometimes we use the biology as a way to get to the feelings and the intimacy.
- [05:30]
Dr. Reena Malik
Absolutely. Yeah, Absolutely. So let's talk about some of the. The anatomy. Let's talk about the clitoris. As you've mentioned many times, and I have, it is the only organ in the body that's solely there for pleasure, but it's largely ignored. So what do you wish people knew about the clitoris?
- [05:46]
Dr. Rachel Rubin
Oh, I wish so much. Right. So when we trained, our anatomy textbooks don't show the full, entire clitoris. Right. It is what we think of as if you follow the labia minora up those inner wings, then you get to the hood of the clitoris, you pull that back, you'll see the head of the clitoris, the head of the penis. That is the tip of the iceberg. And so there is a shaft of the clitoris, and there are these giant legs of a clitoris that go all the way down to your butt bones. Just like a penis sort of splits into two and goes all the way down to your butt bones. And most people don't know this. Most doctors don't know this because our anatomy textbooks really didn't go into this. And no one taught us the clitoral exam was not a part of a routine exam when you're taught in med school. In fact, I remember being told, don't go near the clitoris because you don't want to make your patient uncomfortable. Reena, you and I are urologists. Can you imagine us being told, don't touch the penis. You may make your patient uncomfortable? It's wild, right? And so people don't understand the anatomy. And then there's this thought that pleasure comes from vaginal penetration, which for most people is not the case. And so it's when you understand that, you realize that you're. You're quite normal in the way that you experience pleasure.
- [06:56]
Dr. Reena Malik
Absolutely. And you were the first person who taught me about clitoral adhesions. So just like men have foreskin and you pull it back and it can get infected, inflamed, stuck. You can get smegma. Women can have the same thing happen.
- [07:11]
Dr. Rachel Rubin
Yeah. So let's talk about this. It's so wild. Okay, so about. We did research in 2017 where we looked at thousands of pictures of clitorises, and about 22% of them had some degree of adhesions. Now, this isn't cancer. This isn't heart disease. It's literally the hood of clitoris gets stuck to the head of the clitoris. I sort of think of it like if you wake up in the morning and your eye is crusted close. You know, you're like, you don't go to the emergency room. You just pick out the eye crusties and open your eye, but you think you can't see. That's a horrible thing. But it's not that serious. It's not. And that's what happens to the clitoris. It gets stuck together. And then we found. We actually asked people what happens when you unstick it. Together, we do a very simple procedure in the office where we separate the hood from the head. It's not cutting. We're not. We're not doing surgery. And 60 to 70% of people said their orgasms improved their arousal, improved their satisfaction. Six women who had never had an orgasm before were able to after this procedure, which was incredible. And my colleagues have since published even more on it. And in replicating that data, which is always very cool when that happens. And so the challenge is, is that no one's ever examined your clitoris.
- [08:22]
Dr. Reena Malik
Absolutely.
- [08:23]
Dr. Rachel Rubin
Ever.
- [08:23]
Dr. Reena Malik
Yeah.
- [08:24]
Dr. Rachel Rubin
And so we became very famous from this fact that we just give people a mirror in. In the exam room, and we're saying, this is your labia majora, this is your labia minora. This is your clitoris. This is your clitoral hood. And it got so much press because that's apparently novel medicine in 2026.
- [08:40]
Dr. Reena Malik
You know, it's so funny. I wrote about that in my book. I said, you know, my dear friend Dr. Rachel Rubin got famous from talking about giving women a mirror in the exam room. And I was like, if I did that for men, I'D be told I was crazy. Like, literally, if I was like, here's your penis, here's a mirror. To look at it, people would literally think I've gone nuts. Right. And it's. It's insane to me that that is, like, really. I mean, it's, it's, it speaks to how far society is from, like, making women's anatomy be normalized. Yeah.
- [09:10]
Dr. Rachel Rubin
And it's so hidden from us, right? Like, men, they pull their pants down, they see everything. You. They see every wrinkle, every vein, and if it changes, they're going to call us, right? They see everything. They're used to looking at their scrotum and their testicles and all of these things all out in the open. And women, there is this gymnastics that has to be done. You can't really see down there unless you're looking and you get a mirror and you're. You're sort of. So you don't always know what's happening. And this is a dynamic part of the body. It changes it. A baby's genitals don't look like a grownup's genitals. And then when you go through hormonal changes or shifts, like in menopause, they change again. But we've been hiding that from women. Not on purpose. It's just that we forgot to tell them, which is a little bit frustrating.
- [09:52]
Dr. Reena Malik
You know, the. When I actually did a clear adhesiolysis, which is the name of that procedure that we do for women with clitoral adhesions, on a young woman with persistent genital arousal syndrome. So she had, for those who are listening, basically, a condition where she always felt like she was aroused and would. And it would be uncomfortable. So it's not actually like a lovely thing. It's actually very, very uncomfortable, very distressing. And patients get so distressed that some become suicidal. It's like a very serious condition. So she came to me, we did an exam, we saw clitoral adhesions, and I lysed the clitoral adhesions, and she got better.
- [10:26]
Dr. Rachel Rubin
It's amazing.
- [10:27]
Dr. Reena Malik
It's amazing. So it's a really important evaluation. So any woman who's listening, please look at your genitalia.
- [10:33]
Dr. Rachel Rubin
We're actually presenting a case at the conference that I'm here for, which is why I'm in California, of a young child from another country who had horrible, horrible pain and irritation in that area of her body. And she went to every doctor they could find in their country, and no one could find, sort of figure out, I don't even know if anyone examined her. The notes just kept saying she needed cognitive behavioral therapy. This was a young child. And the parents, because they had seen our research, brought her to our clinic and she had clitoral adhesions. We brought her the operating room because we didn't want to do anything while she was awake. We usually do it in the office. And it was gone. Like, it literally, she's. She's better, like. And this was to the point of tears every night at bedtime. She was missing school. She was always, you know, like, grabbing at that area when a simple exam and a simple procedure sort of cured it. And so. And that she was already being told at such a young age that she needed cognitive behavioral therapy. Like, you just can't make this stuff up.
- [11:33]
Dr. Reena Malik
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- [12:41]
Dr. Rachel Rubin
I. This was a funny one. So it is scientific fact that labia minora, these little inner wings, people call them lips. I actually don't like that term. It gives me the heebie jeebies. So I like wings. I thought. I thought wings was a cool term. So these, these wings, like babies, they're very small, they're very thin, they're very, very minimal in size. And then puberty happens and they grow, they get fuller. In fact, many times they'll go all the way down to the sort of bottom of the Opening of, like, a full. You know, they fully look like wings. Now, different people have different sh. Sizes, and we really haven't done a good job characterizing why they change size and shape. They are clearly hormone sensitive, but we really don't have much research out there about what hormones are driving these changes. But we know that with menopause, they start to shrink or resorb or disappear. Now, they don't always disappear completely, though. They can. And I. I just, like, made a video about this. And the Internet broke. I went so viral on Tick Tock. They made all these, like, joke videos. It. I'm not on TikTok. I was getting all of these things. Like, you have millions of views. I was in clinic, and within, like, one day, my elementary school had commented on the post and Kim Kardashian had texted someone to ask me about it. Like, was like, is that true? And the person was like, if Rachel says it's true, it's true. So it just went so viral and to the point where other people started talking about it, and then they went viral sort of talking about it, which is so great. I also had people telling me that I should lose my medical license and because I'm clearly spreading fake news. And it was like, no, no. Like, this is like an anatomical medical fact. So this happens. And you're just. There's so much anger about it because it's. So no one told you that this could happen. And we don't talk to women about it. And I think the women are very upset about that.
- [14:36]
Dr. Reena Malik
Yeah, absolutely. And it's. It's crazy, right, because people spend money on genital surgeries to change the shape of their labia to look more like they're not there.
- [14:46]
Dr. Rachel Rubin
And that's what's so challenging, is that, again, so much pornography depicts very small labia. And part of that is probably because a lot of these actresses, a lot of these. A lot of these performers are on birth control pills, which probably changes the size of their labia. Also, people do have surgery and things like that, but, like, big labia, the big are. Are hormonally healthy, probably. And so we don't do enough of teaching young people that actually this is a sign of good hormones and good hormonal status. There's a lot of nerve endings. There's a lot of arousal tissue underneath. And so rushing to a surgery, we've seen a lot of unhappy people because surgeries can sort of hurt nerve endings, which can affect sexual health for some people.
- [15:30]
Dr. Reena Malik
Absolutely. And. And I will say that I think that performers self select, right. Because the performers that do well, you can visualize things better, right? The act better when the labia are not in the way. And so probably one, they get more attention and two, they self select because if you want to be in that field of work, then you need to be able to see what's happening for the audience. So I think that's probably part of it. It's really crazy the things that we're not taught about our own bodies. And I talk about this a lot, but I really think sex ed in this school. And you actually go back to your high school, is it.
- [16:03]
Dr. Rachel Rubin
I do.
- [16:03]
Dr. Reena Malik
And talk about sex ed every year. And there's just so many things that we were not taught and we just are expected to learn somehow.
- [16:13]
Dr. Rachel Rubin
Well, I think it's so interesting, right, because we're not. When are we supposed to learn and how are we supposed to learn? Because you don't really want to hear about this from your mom and your teachers don't really, you know, they can tell you some basic stuff. But like, where do we get this education? Where did you get this? Like, we don't get in medical school. And so this is where doctors become really fumbly and not that good because they weren't taught how to talk about sex. They didn't learn it themselves. They spent most of their 20s in school, so they weren't having fun, most of us. And you know, and, and so it's so challenging. Every year I go back to my high school and every year I expected not to be invited back because I, I, they do not give me any guard rails or any rules. And I went to a small private school and every year I put up a big slide with my cell phone number on it. Actually, I've been doing WhatsApp recently and all the students can start texting me questions and it's so fun because they, they get really, they try to gross me out and they try to like say ridiculous things. And then they realize that I'm actually going to answer their question. I, they can't make me blush and I don't skip a beat. And it was, it's. And then I teach them about anatomy. I teach them how the body works. And then I'll stop every once in a while and I'll answer their questions. And it's such a fascinating thing because there are kids who are doing stuff. Like a lot of. It's usually the seniors that we're talking and then there's ones who are just, you know, like, sort of like can't believe that we're having these conversations. And it's wild. And every year, my. Actually the same principal who was my principal, she'll be in the back of the room, and she'll come up, she'll be like, I learned a few things this year. It's, like, mortifying. It's hilarious.
- [17:49]
Dr. Reena Malik
What is. What is one of the most surprising things that you got asked?
- [17:53]
Dr. Rachel Rubin
They ask a lot about anal sex. They have tons of anal sex questions.
- [17:57]
Dr. Reena Malik
Interesting.
- [17:58]
Dr. Rachel Rubin
Tons of questions about how to get pregnant. You know, a lot of pregnancy questions, a lot of safety questions. You know, they. They have a lot of curiosity about their. Each other's bodies. And I think that's really interesting of, like, well, you know, how can I get my girl. How can I get my boyfriend to know how I orgasm? Well, you need to learn how to orgasm to teach your boyfriend how to orgasm.
- [18:21]
Dr. Reena Malik
Yeah.
- [18:21]
Dr. Rachel Rubin
You know, and I bring in a lot of models. I bring in a lot of, you know, show and tell of, like, here's what it looks like. You know, I think it's. We don't. We don't talk about basics. Like, we don't teach boys how to masturbate or, like, what they should be doing. And. And there's a lot of injuries that can happen. And. And every year, the question. I always think I should write a whole book about all the questions that I get asked. And every once in a while, I'll get texts from these kids, you know, many months or years later of like, hey, you taught me sex ed. I got into this situation, what should I do? And. And, you know, one year, I remember three different women came up to me and said, I have pain with tampons. I thought I was normal, but you're telling me that it's not normal. And that was really cool because we got to get them, you know, potentially to help sooner than they normally would have gotten help, because it's. You should. You know, things shouldn't hurt. There shouldn't be pain.
- [19:10]
Dr. Reena Malik
That's so amazing. I wonder if you actually, like, studied this in an empirical way and looked at, like, their outcomes of pleasure and set relationship satisfaction, like, years down the line. I bet you it'd be higher.
- [19:21]
Dr. Rachel Rubin
And it's interesting because it's. It's sort of like you give them the perm. Like, they sort of get shocked of, like, oh, like, it's okay to talk about this. And I think, you know, they've already had sex. Said, this is more just like, ask the sex doctor anything. And so I don't Go into all of the doom and gloom and scare tactics. I'm there to talk about pleasure and fun and joy and can. You know, they've done lots with consent, they've done all this stuff, but really talking to them about like. But like, you deserve pleasure and here's how it happens. And know your body. And if you know your body, then you can advocate for it and you can talk about it. And it's just wild, right? You see these kids that are. They can't even talk to each other, and yet they are touching each other's bodies in ways that are so intimate, so, so personal, but they don't have the language. And so when you can work. And I love that we do it all together. So the boys and the girls, everyone's together because then they have that shared language of like, we should be able to talk about periods. We should be able to talk about masturbation. We should be able to talk about orgasm. And you should use the words of like, what it is you like. And if you don't know what you like, you should probably find out, because how are you going to tell a partner, you know, and expect them to know what you like?
- [20:22]
Dr. Reena Malik
Yeah, they can't read your mind.
- [20:24]
Dr. Rachel Rubin
It's this fascinating thing, right? And it's wild. Like, I find with maybe you think this too. Like with my patients, the young ones who have sex problems, by the way, everyone will have a sex problem at some point in their life. Like, that's inevitable. And so I actually feel really bad for my older patients who start developing problems in their 70s and they have no language around it. Like, I and my younger patients, even though it's terrible that they have problems, they learn language, they. They actually figure they. They learn how to communicate. And I think they're better at sex ultimately than these other people who are just kind of winging it in this silent dance pants for a while.
- [21:03]
Dr. Reena Malik
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- [22:58]
Dr. Rachel Rubin
Well, and also again, who do you talk to if you have questions or problems or issues? Right. The pediatrician doesn't really get taught how to counsel about this. The primary care doc, it's not their expertise. Like my dream, I have so many dreams, but one of my dreams is to have a clinic where you go every couple of years for like, just like you go to a well child visit, you go for like an age appropriate sexual health visit where maybe you start just with anatomy, then maybe it gets to questions about consent and masturbation. Like it, you just form this relationship where you realize there is a place to go when I have questions. So if something goes wrong, it's not. I have to search on the Internet secretly late at night and no one knows. And then you end up on some shady, you know, thing. It's, hey mom, can I go see the, you know, can I go to this clinic or you know, how to kind of. I just think it would be, gosh, this world would be such a different place, right, if we had access to like good information.
- [23:57]
Dr. Reena Malik
Absolutely, 100%. I mean, I think that I know that you probably do this too. But I talk to my kids about sex and about masturbation and about pornography and try to leave the door open so they can ask me questions all the time. And my son is starting to read older books and he'll be like, mom, what's the clitoris? And we talk about it because I think it's so important. And I do feel like even if we don't have that yet, we don't have that sort of come to this clinic and learn about sex. The parents can learn and start learning how to talk to their kids. Because guess what? You're with them all the time. And if they feel comfortable talking to you, that's amazing.
- [24:32]
Dr. Rachel Rubin
You should have my friend Carrie Leff on the show. She is this amazing doctor in Detroit who does a lot of sex ed for, you know, she's these programs where they do sex ed and the whole curriculum. And she's taught me a couple things that I love. You know, one is don't call them private parts. She's like, call them personal parts. And I just think that. Think that's beautiful, right? This idea of they're not private, they're personal to you. And when you have something that's personal, you share it with the people you want to share it with, but they're, you know.
- [24:58]
Dr. Reena Malik
Yeah.
- [24:58]
Dr. Rachel Rubin
And the other thing that she said, which I think is so beautiful, is she says, you know, talking to your kids about sex should not be one 30 minute conversation. It should be 31 minute conversations. It should be something that is just talked about all the time. You can start at the zoo and talk about how elephants procreate. You can, you know, watch TV shows and have these little moments of like, you know, explaining interactions. Cars are great places because you're not looking at each other and you can have these conversations. And I just think, again, the more we aren't afraid of it because they, the kids are like dogs. They smell fear, right? They smell awkward. They smell fear. They know when you're uncomfortable with something. And if we shut it down and we show, you know, I think one of the things that makes us good urologists is we show up confident and competent in these topics. And so we talk about these things again, like it's, you know, I don't know, somebody else's high blood pressure. High blood pressure, right. Like, we talk about it very easily. And I find that's what makes these patients so comfortable talking to us about it. Right. Because we don't flinch. If we flinched, they probably. It would probably be a different story.
- [25:59]
Dr. Reena Malik
Well, Maybe you and I don't flinch, but I'm certain there are people who do flinch, which is unfortunate, but hopefully we're changing that a little bit. Let's talk about sex. What are the top five things you think people need to know to have good sex?
- [26:12]
Dr. Rachel Rubin
Top five things people need to know to have great sex? I mean, I think education is the obvious. Number one, if you know your body specifically, and you know how to like education. Number one, communication. Number two is every sexual experience you have is a new sexual experience, I mean, even with the same partner. And so this idea, you know, from encounter to encounter is going to change. There are numerous different ways that people can experience pleasure. There's so many different ways that you can, you know, learn about each other's bodies and areas of pleasure. There's always more learning to do. And then if you have a different sexual encounter with somebody else, whole new ball game, right? And so the more you understand. Understand your body and then you can talk about it with the person, you know, obviously, the more fun you're going to have, and you get to decide how much fun you have. So I would say education, communication. You know, again, great sex is biopsychosocial. And I think we minimize. I think on the male side, we minimize psychosocial, and on the female side, we minimize biology.
- [27:14]
Dr. Reena Malik
Yeah.
- [27:15]
Dr. Rachel Rubin
And I think we need to do a lot better about understanding that everybody is biology with feelings and, you know, sort of an upbringing and baggage. Like, we all have that. And I think that's important is. Is that, you know, I think there's a whole lot more biology than we give it credit for. Everybody's too serious these days. Everything's so serious and terrible and awful, and it's really hard to. We've been through a lot. I think pandemic wrecked us, and we did nothing to heal from the collective trauma of pandemic. And we are in this giant sex recession where people are not connecting, they're not communicating. They are in their little insular bubbles, you know, surrounded by people who are saying all the same things that they are, and they're really struggling. And sex is supposed to be fun and joyful and pleasurable. And again, people, there's a lot of bad stuff out there. And so we have to find ways to bring the fun back, I think, because people deserve pleasure. You deserve pleasure. You deserve fun. But on the flip side, like, no one's ever died because they didn't have an orgasm, Right? Like, this is the other challenge.
- [28:22]
Dr. Reena Malik
Well, you could argue that maybe they have died. We just can't attribute it exactly to the orgasm.
- [28:26]
Dr. Rachel Rubin
Not enough orgasms.
- [28:28]
Dr. Reena Malik
I mean, you know, because there is a mortality benefit to more sex. Right. So there's actually data that supports that people who have sex 52 times a year, like once a week, live longer than people who don't.
- [28:38]
Dr. Rachel Rubin
I think there's cardiovascular benefit, I think it's connection, I think it's movement. I think being able to have sex. Right. Sex is a high context, tech sport. And so and, and what I find is there are no age limits to when people like you don't ever have to stop having sex. You can at any point stop having sex. Yeah, but if it's important to you and your partner, then it's important, it should be important to your doctors and there should be ways to sort of have pleasure. And then also knowing that penetration is not the only pathway to great sex.
- [29:08]
Dr. Reena Malik
Absolutely. And you know, we've talked about it here on this channel, but like on this podcast about like how you need a certain VO2 max to have sex.
- [29:15]
Dr. Rachel Rubin
Sex.
- [29:15]
Dr. Reena Malik
Right. And so if you don't take care of your health in a multitude of ways, specifically resistance training and cardiovascular training in some shape or form, like at some point it may become physically difficult for you to have sex. And so if that's important to you, that needs to be a part of your lifestyle.
- [29:30]
Dr. Rachel Rubin
And it's really important that if you have a vagina and you are in menopause age, that things do change. It is a very hormonally sensitive structure. And so without hormones, the tissue gets thin, it gets raw, it gets irritated, and not only is there vaginal dryness, but significant pain with sex. And as so many of your listeners know, it also comes with a lot of urinary problems. Frequency, urgency, leakage, and then you can be very high risk of urinary tract infections. And so using vaginal hormones can be life saving for anybody of any age, of any history to really help. So sex isn't painful and that you don't get urinary tract infections.
- [30:10]
Dr. Reena Malik
Yeah, and we've said it before, we'll say it again. There is no risk of cancer, blood clots, stroke. Really anything untoward with vaginal hormones?
- [30:18]
Dr. Rachel Rubin
Yeah, so these local low dose vaginal hormones is essentially micro dosing. It's super small dose and it absolutely heals the tissue, it improves lubrication, it changes the ph in the microbiome and so all the good bacteria can grow and the bad bacteria get, gets suppressed. And it, it truly is better than Viagra. Right. So it female Viagra truly exists because it helps with arousal, it helps with orgasm. So this is vaginal estrogen or vaginal dhea. There's a cream you could do twice a week. There's a suppository you could do twice a week. Vaginal DHEA is every night. So you could choose any of those options. There's even a ring. You could set it and forget it for three months. And so this is why we. We actually have helped publish guidelines last year by the American Urologic association on this issue, which is called genitourinary syndrome of Menopause, or GSM. And we have developed all these free trainings on YouTube. We have a whole YouTube channel about it on our website. We have a whole pocket guide of like, bring a piece of paper to your doctor, say, hey, I want this prescription, which links to all the information. Because actually, one of our colleagues just published on this is like Medicare patients with a diagnosis of this problem, 9% get a prescription. Nine, nine.
- [31:32]
Dr. Reena Malik
You know, that's wild to me because you. I know you know, you know this, but we prescribe this like candy. Like every woman who is perimenopausal or menopausal and has symptoms or even doesn't have symptoms, but maybe worried about getting symptoms, gets offered this in. In my clinic.
- [31:47]
Dr. Rachel Rubin
9%, you are a unicorn. You're a magician unicorn. We appreciate you greatly.
- [31:54]
Dr. Reena Malik
That's wild. Yeah, that's wild to me. 9%.
- [31:57]
Dr. Rachel Rubin
So sad.
- [31:57]
Dr. Reena Malik
It really is. It's. It's as if.
- [31:59]
Dr. Rachel Rubin
If.
- [31:59]
Dr. Reena Malik
Look, if. If a man came in with erectile dysfunction, everyone is getting offered Viagra or Cialis, but not every woman is getting
- [32:08]
Dr. Rachel Rubin
offered like, this is these 9% with a diagnosis. Like, that's what's so depressing because it's so much. So many people have this problem that are not getting a diagnosis code and so eat those with a diagnosis, 9% get a prescription. So we have so much work to do. This is why we just do not stop yelling.
- [32:25]
Dr. Reena Malik
Yeah. It's so important. So we've talked about exercise and we've talked about hormones. What other like lifestyle, diet changes do you think people need to make to have great sexual desire, arousal and just sexual function?
- [32:40]
Dr. Rachel Rubin
I mean, truly, if it's good for your heart, it's good for your genitals. And so anything, you know, there's a. The data is a little bit. Anytime you have nutrition data, exercise data, it's a little murky. There's been some data on Mediterranean diet. You want to, to fix sleep apnea, you need to be Sleeping, you want to check hormones. Testosterone. If you're a woman, you want to consider menopause. Hormone therapy. Um, we know dopamine is very important. So a lot of medications like antidepressants can hurt sexual health, either lower libido or delay orgasm. And so there are medications that could boost libido. We have two FDA approved medication, one is addi, one is V, that help with low libido but also work with other sexual problems. So, so it's, they help with arousal and orgasm and satisfaction as well, which are great to have in our toolbox. And so, and the other thing that we've published on recently is really devices and erotica. And we as clinicians must get comfortable talking to our patients about devices and erotica because they work, they're fabulous, they're great education tools, and it gives your patients permission and getting them to understand. I think we need to do a better job of bringing in devices into the bedroom and getting everyone on board with it. Because we wear eyeglass, you know, we get all sorts of other aids that we need or, or things that I get in my car to drive, like I need my phone to check my email.
- [33:59]
Dr. Reena Malik
Like, like we have like weighted blankets and weighted eye masks and, you know, fancy mattress pads and all sorts of stuff.
- [34:05]
Dr. Rachel Rubin
We use technology for so many things, right? We are, and so getting comfortable and, and again, devices, the device industry is so deliciously beautiful now compared to, you know, sort of when we were growing up. And so it's, you can go down on Amazon, you can, you find it at CVS today. And again, understanding that vibration can be extremely helpful to access the clitoris and the internal sort of parts of the clitoris. And so it doesn't make you a bad partner, it actually makes you a good partner if you bring in devices into the bedroom. And so we really want to encourage sort of that. We know erotica is very helpful, whether it's reading erotica, listening to erotica, watching erotica. Again, the brain likes fantasy. It likes new things. It likes danger, it likes, it likes excitement. It likes to think about things that you maybe would never do. That doesn't mean you want to do them. It means that, that you like watching or listening or hearing about those types of things. And so just giving that permission, it's, it's funny. I, I, I was taking care of a patient the other day. We go to a similar clinic with veterans and I had this, this veteran with me and I was talking her, with her about this, this show on HBO that's gone crazy. Viral called Heated Rivalry. And I say heated, like HRT is not hormone replacement therapy anymore. It's heated rivalry Therapy. And it's. This is a show that went totally crazy viral. It was a Canadian streaming show that got picked up by HBO and is now one of the most watched ever TV shows right now. And it's six episodes. It's based off from a book. And it's about these gay hockey players, like these two very macho rival hockey players that fall in love and, and have a lot of erotic moments. And then also this very kind. Have you watched it? It's, it's incredible. How many times have you watched it?
- [35:55]
Dr. Reena Malik
Just once.
- [35:55]
Dr. Rachel Rubin
Okay, so you're, you know, you're.
- [35:57]
Dr. Reena Malik
I'm still A newbie, apparently.
- [35:58]
Dr. Rachel Rubin
15 of people have watched it more than five times. So people are really into this show and what has. It's causing all of these heterosexual people to be like, wow, I find watching two men have sex extremely pleasurable erotic. What does that say about me? Or what does that mean for me? And was this good? Is this bad? Why do I like this so much? And it's not the act of sex, but it's watching their emotions, their feelings and their relationship. And so I was talking to this patient about it and she goes, wait, I like really like that type of pornography. And I, I've never said that out loud before. And I thought there was something wrong with me. And I was like, no, no, there's nothing wrong with you. Like, this is what lots of people like. And this is. And you could see like her, like she just like light, like everything, kind of like relaxed a little bit. And she was so excited to talk to me about it and I taught her about the. So it was just again, the normalize and can talk about these things. People feel a lot less sort of alone in this.
- [36:57]
Dr. Reena Malik
Absolutely. I mean, look, it's, it's, it's fantasy. It doesn't mean that you necessarily want to participate. You just want to watch it or you just enjoy it. Like, who cares? Right? But yeah, absolutely. I mean there's just, there's, there's so much importance in, in giving people permission, right? Especially like we. You and I see older patients, particularly veterans, right. And I will talk to them about toys and sometimes they're like, oh, no know, like they, they're so shut off to it. But I've also had patients like, well, I've never tried. Which one should I get? What should I do? And I think it's really important. Like, I'll, I'll tell My male patients. Although, you know, you can get, like vibrating cock rings, right. And that can be great to help you maintain an erection. Also be pleasurable for your partner and you. Or if you're having trouble getting to. If you're having delayed ejaculation, sometimes these toys can really help. And so I think just realizing, like, yes, it's okay, you're allowed to experiment and try different things. Things.
- [37:49]
Dr. Rachel Rubin
Absolutely. The clitoris likes vibration. The penis also likes vibration. The perineum likes vibration. And so getting devices for couples and playing with devices and different devices. Again, sex is supposed to be fun. It's supposed to be joyful. It's supposed to be adult playtime and, and playful. And so if you're not talking about it, trying new things, doing, you know, it's going to get a little stale and a little bit, you know, maybe lonely. And so this is where I think people tend to go into their own heads or their own spaces and live their own sex lives sort of by themselves because they're afraid of sort of communicating and having these conversations with their partners.
- [38:26]
Dr. Reena Malik
Absolutely. You talked about Viagra. There was, we recently published a paper on looking at Viagra for cardiovascular risk mitigation, or basically reducing cardiovascular risk in postmenopausal women. What did you find?
- [38:40]
Dr. Rachel Rubin
Well, this was just a wonderful paper that was just recently published in the Journal of Sexual Medicine, where it's more in theory of. Like here we know that men who take Viagra cialis have decreased risk of cardiovascular problems, strokes, heart attacks, actually at least less dementia, which is so fascinating because these are sort of increased blood flow, you know, more than to just your penis. But they increase blood flow and they help with all of these things. Now, we know when you give women Viagra cialis, it increases blood flow to their clitoris. They have better arousal. It's just that nobody prescribes this to women because. Because women aren't complaining of arousal problems. Typically they've got dryness, they've got pain, they have low libido. And so we use a lot of these drugs sort of as an adjunct to these other things that we do. But we, this paper really looked at, well, why aren't we looking at this for cardiovascular benefit in women? And it's so frustrating because in order to pull off a trial, you need money. And these are generic drugs that, you know, there's not a lot of money in this. And so. And you also have to get your cardiovascular cardiology people to care, which is very hard to do. Right. Because as a urologist, it's hard to look at cardiovascular markers. So there's a lot of interest in this, and we would love to pull off a study, but we just got to figure out how.
- [39:51]
Dr. Reena Malik
Yeah, I think it's interesting, you know, I've heard this before, that women don't complain of arousal issues, but I don't think they have the language. They don't complain about arousal issues. Like, they don't really know what that means outside of, like, oh, maybe my lubrication is inadequate, which is not all of arousal. Right. I think there's more to it, and they can't see their arousal. Like, they can't see an erection of their clitoris necessarily. And so I think they don't really know.
- [40:14]
Dr. Rachel Rubin
It's a huge problem in sex research because, as we say, shit in, shit out. Right? If you're. If you have bad data that you're working with, you're going to get a bad. Like, you're not going to have anything that makes sense. And the way we ask the questions are so bad. And women have. Like, with men, it's okay, but your erection is different than your orgasm, which is different than your ejaculate, which is different than your libido. And we tend to lump. Like, do you have female sexual dysfunction? Right. Like, it's sort of like when I go to conferences, like, this is. Listen, I just went to a conference. Big, big conference, Mayo Clinic. And you have a. Like a whole panel about different aspects of erectile dysfunction. And then it's like, okay, you get 15 minutes to talk about all of female sexual dysfunction, you know, and you're just like, you can never get into the weeds because you're still staying so broad. Which I'm glad. I'm grateful that I had the opportunity to speak on this. But again, and it's so challenging because we do. We've got libido problems, arousal problems, orgasm problems, and then pain. And then there's hormones that play a role in all of it as well.
- [41:15]
Dr. Reena Malik
Absolutely. And I think it is. It is so important to think about all those different things for women listening or for partners who care about their female partners. Like, figure out what is really. Try to figure out what you're feeling. Try to articulate it. Don't be afraid to, like, really go in the weeds, whatever you can say about what you're feeling, because it gives us a more information. Right. Your doctor may not have the tools, but they certainly can find out. They can look into it and they can ask. And I think the other thing is if a doctor Says, oh, go drink a glass of wine or you're okay. The right answer would be, I don't know what to do for you, but I can find someone to refer to you.
- [41:52]
Dr. Rachel Rubin
I'll give you a perfect example. I had a DM just a couple days ago from a patient of mine who is a fellow physician. And her husband went to the doctor and he's got some low testosterone. And the primary care doctor says, oh, we gotta give you testosterone. And they gave him testosterone. And not the dose I would give, but they gave him testosterone. And she says, well, you know, I'm on testosterone. And he scoffs at her and says, there's no data for women on testosterone and there's no possible reason why you should need that. That. And so he's, he literally doesn't know the data. There's global consensus, by the way, that testosterone works for women, for libido. Global consensus. And he's confidently telling this woman, who is a doctor who knows the data, who is benefiting from testosterone. It's been life changing for her. And he's telling her that there's no data and she shouldn't be taking testosterone while he is prescribing her husband testosterone. I mean, you cannot make this stuff up. So why can't? Why when it comes to women's health, can you just, they just say, like, this is not my specialty, this is not my area of expertise. Like, how hard is it to say those words?
- [43:02]
Dr. Reena Malik
Yeah, I really don't understand, like, if you just don't know, like, you are misinformed. Right? That doctor is misinformed. Maybe there wasn't data when he was training. Right. But there is now, and he's misinformed. It's frustrating. It really, really is. Let's talk about the vulvar vestibule. So I think, think this is a part of vulvar anatomy that every woman and partner should know about because it's, it's really valuable and important and a cause of pain for a lot of people.
- [43:30]
Dr. Rachel Rubin
It's so important and it is so wild how basic anatomy is completely missed on the doctor and the patient and it gets completely hidden. So we talked about those inner wings, those labia minora. Well, if you spread them to the side like a book, you open them up like a book book. Then right in front of your face is an oval shaped strip of tissue that surrounds the urethra, the tube that you pee through, and it surrounds the opening of the vagina, which is the inside part. And that tissue is called the vulvar vestibule. Now, it's very sensitive, hormonally mediated tissue. And so if you think of like the outside of your cheek and the inside of your cheek, they're very close together, but they're very different, right? One is very skin and thick and tough and the inside of your cheek is very delicate, very sensitive. And, you know, would react, so, you know, would react differently to different, you know, sort of things. And so the skin of the labia majora and the labia minora are our skin. They're tougher. And then this strip of tissue right at the opening is like the inside of your cheek. It's like this very delicate mucosal surface that is essentially the same as the, the bladder, right? So the bladder turns into the urethra and then the same tissue surrounds the opening of, of the vulva and vagina. It's called the vestibule because it's sort of the entrance, like as you then go inside to the vaginal canal. This area is often the reason why people have pain with sex. Pain with tampons, UTIs, interstitial cystitis, you know, post sex pain, you know, things like that. It is often in this tissue. And because this tissue is so sensitive to hormones, as I always say, when you play with hormones, there are consequences. Sometimes good, sometimes bad. Things like birth control pills can affect this tissue. Breastfeeding, menopause, gender affirming, hormone therapy, you know, surgical menopause, breast cancer therapies that affect hormones. There are so many medicines and things people do, acne medications that can affect testosterone levels because this tissue is very sensitive to both estrogen and testosterone. And also a lot of inflammation can happen on this tissue. And so we see increase in mast cell issues come up in this tissue as well. And so the problem, your doctor often was not taught that this exists, nor were they ever taught how to examine it. It's very easy to examine, by the way you spread the labia minor open, you take a Q tip and you poke at the tissue. And if it hurts, you have a problem. It shouldn't hurt. But what do the doctors do is they take a speculum and they put it into the vagina and then they open the speculum and completely bypasses so you can't see it. So your doctor will say, oh, everything looks normal. Put the speculum in. Oh, everything looks normal, you're normal. This is all in your head. And that has been going on for decades and decades. Women are told their bodies are normal. It's all in their head. To the point where patients come to see me and they're like, I've been to 10 doctors and no one's been able to figure out why I have pain. And I don't think you're going to be able to find it either. And you get that Q tip out and you find their pain because they don't have pain everywhere. They just have pain in this part of their body and they just go like they're in disbelief. Right. That you can find their pain.
- [46:46]
Dr. Reena Malik
It is so important. And you mentioned many things that affect it. Another thing that sometimes we see is when women get recurrent yeast infections or recurrent STIs. This can also affect the vestibule.
- [46:59]
Dr. Rachel Rubin
Yeah, absolutely. It's very sensitive tissue. So any kind of infection can bring inflammation. And then again, sex, we said, is a high concept contact sport. So if you have something scraping against this tissue, creating like an inflammatory response, it's kind of like people will describe it like sandpaper, like shards of glass, like cutting, burning, stinging, cracking, tearing. These are sort of the words that we get from people. And for some people, they can't have penetrative activities. For some people they can, but they are going to pay for it later. And for some people, it affects their urinary health. So they got more frequency urgency, they've got constipation. This one's wild. I get patients who don't. Can't have sex, but their pelvic floor muscles are so tight, they have horrible constipation. And that's sort of their only sort of symptom. This tissue, again, it's so hormonally sensitive. And so we want to make sure it has optimized optimal hormone hormones, whether it's a vaginal dhea, a topical estrogen, a topical estrogen, testosterone. You want to keep it hormonally healthy. If a patient's on birth control pills, we often try to get them to have a hormonal iud, which doesn't affect hormones as much. And then you also want to look at their pelvic floor. So. So the muscles underneath can cause pain here. So working with pelvic floor physical therapists, sometimes we'll put Botox in pelvic floor muscles, which can be sort of lifechanging for patients. And then, you know, sometimes there's an inflammatory thing that's happening that you have to navigate as well. And very rarely we'll need to do surgery on this part of the. The body.
- [48:28]
Dr. Reena Malik
Yeah, yeah. And you've mentioned birth control a few times. So one you mentioned it earlier when you talked about the labia shrinking and another when we just talked about the vestibule. So let's talk a little bit how that works and why does it change the hormones?
- [48:40]
Dr. Rachel Rubin
Yeah. So I love birth control as a concept, right. I love the idea for women having control over their bodies and when they reproduce and pregnancy is extremely dangerous with high complication rates and people die in childbirth. So I, I, I love the idea of contraceptives. I love vasectomies too. They're, they're a great form of contraception. But again, as I said, when you play with hormones, there are consequences. Sometimes those are very good consequences, like not getting pregnant. And sometimes they're, you know, sort of negative consequences. Everyone who takes oral birth control pills that stop the, the way they work is they stop the ovary from making its own estrogen, progesterone and testosterone. And so anyone who takes a birth control pill, pill turns off their ovaries production of testosterone. And if we believe testosterone is important for the pelvis, the vulva, the clitoris, the libido, which we know, we know the penis is a testosterone driven organ. We know male libido is affected, male muscle, male bone is affected by testosterone. And so if we think like, it just makes logical sense and we have data too, but like, it makes logical sense that it's important for women. And so that's how birth control works. So what you see in the data is mixed here because again, many people on birth control feel very confident in their sexuality. They feel more in control, so they have better sex life, better sex outcomes. But there is a growing area of research where you see people with lower libido, pain with sex, you know, vulvar complaints, things like that. And I think it's important that we explain these possible side effects to our patients. Now, IUDs don't usually turn off the ovary. And so they can like Prevent. We like IUDs because they are, you set it and forget it. But then also they, your body is still making its own hormones.
- [50:24]
Dr. Reena Malik
Hormones, absolutely. So important, I think, so important for people. I mean, I talked about this with Erwin too. But I think it's so important that we're not actually counseling women on this. I wasn't counseled on it when I got put on birth control when I was younger. I don't think that women are getting the appropriate counseling about how this could affect their hormones.
- [50:41]
Dr. Rachel Rubin
I think that's where so much of the anger is right now, is people are just like, could you just tell me right you didn't tell me about perimenopause. You didn't tell me about menopause. You didn't tell me about my clitoris and the full anatomy. Every time I've gone viral, girl, it is for that exact reason where people are like, why didn't I know that? Like, I am a smart, educated, went to cot, like, and I didn't know that. Right. Like. And so it's. It's kind of giving those moments of, like, hey, I bet you didn't know this about your body. And I think women are just pissed. I think the men are pissed, too, because, like, they want to know what's going on too. Like, I can't tell you how cool it is to have a male partner, partner stand behind me and see a vulvar vestibule exam and realize that he's like. Like it's not him. Like, that she is essentially a sunburn on her vulva that hurts. And so it's. There's this empathy that comes with actually seeing the problem and understanding the problem. And so again, birth control is not good or bad, right or wrong. But like any medicine or anything you do or do not do to your body, there are potential risks and benefits and side effects. Sex.
- [51:48]
Dr. Reena Malik
Absolutely. And the thing is, I think that I don't know if it's taught in OB GYN residency, but I don't remember learning this in medical school about oral contraceptives.
- [51:56]
Dr. Rachel Rubin
So I once got into a screaming match with a urogynecologist in my area when I was a resident because I was following the data and actually knew what was going on. And. And he. And I yelled, we're yelling at each other. And he was saying, birth control doesn't have side effects. It doesn't have side effects. And it was just like, yell, he doesn't like me very much. But that's okay.
- [52:16]
Dr. Reena Malik
Well, you're right and he's wrong. So it is what it is. In the vein of hormones. Let's talk a little bit about menopause. You learned how to treat menopause, as did I, after leaving residency, after sort of being trained as urology, realizing that there was just not many people. In fact, we had this conversation. I don't know if you remember it, actually, when we were in your clinic. And I said, well, who's treating menopause? And you see, I said, aren't the gynecologists treating it? And you said, no, no one's treating it. And that was actually what prompted me to learn about it. But why do you think that one people are not learning it. And what prompted you to learn about it?
- [52:52]
Dr. Rachel Rubin
Medicine is a dumpster fire of brokenness right now and probably for a long time. We have decided as a society that there is one type of doctor that is responsible for everything that has to do with women. And I'll tell you, the gynecologists are a little busy right now, right? They get these 10 minute visits, they put your legs up in stirrups, they make you get your mammogram, they, they're responsible for your breast health, your bone health, your brain health, your heart health. They're responsible for you being safe and like, you know, and like they are on call every few nights, up all night delivering babies, dealing with emergency surgeries, like emergency life and death. You and I have never had a call as bad as what a weekly call is like for an OB gyn. And, and no one cares. Okay? So when you have a room where you deliver a dead baby baby, and then you go to the next room and it's the best moment of that person's life, right, because they're having their first baby, let's just say. And then you have to go to clinic the next day to talk about someone's libido or hot flashes and you get 10 minutes to do it. So the idea that the gynecologist can do this or. And they're not taught any of this, by the way, none of this in residency. In fact, I was just at a conference and I was sitting at the bar and there's a gynecologist sitting, sitting there and she didn't know who I was. And, and I said, oh, I'm a urologist, I do sexual health. And she says, oh, I like, I, I've never written a testosterone prescription. Everyone's coming in asking me for testosterone. I said, oh, it's really easy, I'm happy to tell you. And I explained it to her and I taught her the dosing. And she looks at me and she goes, well, maybe it's not because I'm afraid to write testosterone. I just don't want to see these patients. She said, they take too long along. They fill up your clinic. I don't want to be known as the person who does this because I do a whole lot of other things. And that's the truth bomb, right? Like, and she does do a lot of other things and she does important things. And so the question is, whose responsibility this is half the population. And so primary care is swamped, right? Gynecology is swamped Everyone else wants to be a surgeon. Like who takes care of these people? It cannot be niche medicine. And so we're struggling. So it's kind of all hands on deck. Which is why I created a course course to teach doctors how to prescribe hormone therapy. Because no one else is stepping up to the plate. Right. Right now. How many ways can you learn how to prescribe a GLP? 1. Probably 572. Like if you go online, there's probably a million courses. We have very few courses and, and continuing medical education to teach people how to write prescriptions for hormone therapy, why you need to do, why you should consider it, how to counsel patients. But even just what does dose and what pharmacy do you use? So it really doesn't exist. And that's crazy in 2026 that it really doesn't exist. So our friend Heather Hirsch has a great course. I started a course. Right. There are few now. There's like Harvard's putting out an ICME that's happening in March that people can go to. But there really aren't that many opportunities to learn how to do this. And it really is all hands on deck. Anyone who wants to learn how to do this, like, join us. We need you and we need any evidence based practitioners out there who are like really able to meet patients where they are and give them customized advice.
- [56:04]
Dr. Reena Malik
Absolutely. Because there are some serious consequences to prescribing this the incorrect way. Right. And you can't just play with hormones. Right?
- [56:12]
Dr. Rachel Rubin
Yeah. You want, listen, you want knowledgeable clinicians and that unfortunately it's getting. It's very hard to find in the menopause space right now. I think think there are a lot of people doing things in ways that maybe I wouldn't do them. But patients are hungry for answers. They just want to feel like themselves. They want to feel like they're doing everything that they can do to stay as strong and as healthy and as hot as possible. And like, patients deserve shared decision making and they deserve to work with someone who's gonna like fight with them for them. Right. And fight alongside them.
- [56:48]
Dr. Reena Malik
Yeah. Yes, absolutely. And I think that you sort of describe menopause as a total body castration event, which I think it is a really interesting way to put it because I think you and I also see men with low testosterone and they feel horrible, they feel miserable. They do not feel like themselves. They are not productive members of society like they used to be. They are unhappy. But this is what happens to every woman.
- [57:15]
Dr. Rachel Rubin
It is wild because there is nothing more joyful Than taking a man who is of Testosterone in the 200s, getting them to like the five or six hundreds and with a weekly injection. And I can't tell you, they're like three minute visits where they're like, Reuben, I feel great. I have so much energy. I'm back at the gym. My, my partner is happy. My libido is back up. My pills are working fine for erections. I'm so happy. Please give me refills. Blood counts look good. Testosterone levels look good. See in six months, right, like, like the, the joy, like I have all these men, male patients out there who think I am the greatest human on earth for a three minute visit, you know, after we counseled and all of those things. And they're feeling so good and, and it's so funny because, you know, some of our other, like our endocrinology colleagues, our primary care colleagues, they are not as sort of cavalier about male testosterone as the urologists are. Like, we really, because we really love quality of life and we love, love talking to patients about stuff like that. And then these patients go back to those doctors and they're like, okay, like you're, you know, like, what do they say? Like, these patients are so happy and
- [58:22]
Dr. Reena Malik
so well, they just tell them their heart is going to explode.
- [58:26]
Dr. Rachel Rubin
Which it's not. It's not in. That data is not. So that's when men, you know, again, if you think of it like a gas tank, their gas tank is like, you know, a little bit low. It's like a quarter tank. Every woman over the age of 50 goes to an empty tank. Tank. It's, it's fact, it's castration. It is no longer hormones. And I'm sorry, people don't like that word, but that's what's happening. And we do not castrate men willy nilly, nor should we castrate women the same, you know, and sort of not fight back. And we have tech, like I would not be able to see without my contact lenses. Like not at all. Since first grade, I would not. I can't see anything. Okay. And so I use technology so that I can be a surgeon and like live in this world and like do things. So we have, have incredible bioidentical hormone therapy that can help prevent osteoporosis, help with hot flashes and night sweats, help get you feeling like yourself again, you know, help the genital and urinary symptoms. I'm not going to apologize for wanting my patients to optimize their sexual health, their quality of life and live their Best life. Because I will tell you, my grandmother was 90 in the nursing home with dementia and cracked ribs. And that is not the life that I want. Right. Like, that's not good aging to me, nor. And if that's what I'm fighting against, like, the data is so clear to me that it's about strength and prevention and doing everything you can while your body is functioning. Right. And so that includes eating well and exercising and lifting. But it also includes discussions about hormone therapy, correct?
- [60:02]
Dr. Reena Malik
Absolutely. So let's talk about what actually happens to your entire body when your estrogen drops during perimenopause and menopause.
- [60:11]
Dr. Rachel Rubin
It's super interesting. So actually in your 30s, your testosterone starts to drop. And no one talks about this. And I do think it's important. It's actually not a menopause problem. It's sort of as you age, I guess you could call it perimenopause. But. But your testosterone starts. So you still might be having your periods normally, but you still kind of don't feel like yourself. Maybe your stress incontinence gets a little worse, maybe your libido goes a little bit down, maybe you're getting urinary tract infections or BV infections or yeast infections every once in a while after sex, but you just don't quite feel like you. And menopause, the average age of menopause, which is the full castration event where your estrogen is zero, you know, that's kind of 45 to 55. So all you 40 year olds out there, you're not too Young. Right. Like 45 to 55 is a reasonable normal age to be fully menopausal.
- [60:59]
Dr. Reena Malik
Yeah. And we know recognize Ricky Martin at the Super Bowl. You should be listening.
- [61:03]
Dr. Rachel Rubin
Exactly. And he's aging in reverse. And I don't understand that at all. It was literally amazing. But so, so if perimenopause, if we say things start getting weird about 10 years before that, you're talking 35 to 45. So for you 30 year olds, like, this is, you're, you're not too young. I had a reporter just talk to me this morning about how the algorithm, she's 39 and the algorithm is feeding her constant things about perimenopause and it's creating a lot of anxiety. I'm like kind of conflicted there because I was like, you actually do need to learn about this. You need to know what's happening. Because all I can guarantee you ahead is shit's about to get weird. Right. And I think there's this whole timeline of people in their late 30s, 40s and 50s, where you really start to nflm not feeling like myself. And it's kind of different for everyone. And people fight back. They're like, well, this is just aging. And like, what's the difference? Difference, right. Like, I, I don't know. And like, again, eyeglasses, like, I choose to wear contact lenses. So why wouldn't you add hormones to help with some of these symptoms if it helps you and if it works? And really, what are you afraid of? So when I teach people, it's like sort of, what are you scared of? We give birth control pills all the time to people this age, which is very high dose, you know, sort of very, very high dose synthetic hormone therapy is, is essentially. So people are prescribing hormone therapy. They're just doing it as the birth control control form. And so we try to teach like there are other ways to potentially do it to try to alleviate some of your patient symptoms.
- [62:30]
Dr. Reena Malik
It's so important to have these conversations. And yes, everyone's experience is going to be different, right? Not everyone is going to have this crazy, chaotic hormonal fluctuation. Just like everyone doesn't have crazy periods, right? Everyone is a little bit different. And you shouldn't have really, really painful periods. But some people have more, some people have less, right? There is a variation of normal, normal. And I think similarly, like, your experience may be different, but there is going to be a change.
- [62:54]
Dr. Rachel Rubin
And this is where I really like the education piece, because when I can educate my patients on the toolbox, the different forms of hormone therapy, right? We're talking estrogen, progesterone, testosterone for the whole body. We're talking about vaginal hormones. When we talk about that toolbox that they all have different products that you can use in different doses and different forms. The more my patients understand the toolbox toolbox, the more they can play with the toolbox, right? And they will find throughout their 40s and 50s, they may play in different ways. And it's not a one size fits all. But the magic words for me is when the patient comes back and says, I'm back, I feel like myself again, right? We got it. We hit it, right? And the challenge with perimenopause is there's a lot of wild fluctuations. And that is sort of a challenge, which is why birth control for some people is a good idea, because it, it flattens out the fluctuations. But there are other ways to consider doing it too.
- [63:46]
Dr. Reena Malik
Yeah. When do you determine, like, for someone who's on birth control. Should they just stay on it if they're doing okay, versus should they try to switch to menopausal therapy?
- [63:55]
Dr. Rachel Rubin
It's a completely individualized discussion. I have many patients who choose to stay on it. I have some who will add testosterone because remember, birth control shuts down your ovary. It adds back fake estrogen and fake progestin. It doesn't do anything to testosterone. I'm like, why don't they put testosterone in the birth control pill? Right. Like, that would be great. So, so we do have patients who add testosterone and vaginal hormones to their birth control pill. We have patients who choose to maybe get an IUD and then use menopause hormone therapy with estrogen, progesterone, testosterone, you know, sort of different variations of it. And vaginal hormones, of course. Because actually, even if you're on whole body hormone therapy, vaginal hormones are still very much needed and, and should be prescribed.
- [64:36]
Dr. Reena Malik
Absolutely. The, the one big thing that I talk about a lot causes recurrent UTIs. And so I'll have women who are already on systemic hormone therapy, but they're getting UTIs and tell them you need to start vaginal estrogen. And they get confused because, like, I'm already on estrogen. I said, well, no, it doesn't actually affect the local tissue. So if you want the local benefits, meaning more lubrication, no pain with sex, prevention of UTIs, you need the vaginal.
- [64:59]
Dr. Rachel Rubin
And for anyone who's nerdy and listening, we. This is a guideline statement number 11 in the American Urologic association that says it's my favorite guideline state statement that patients are on systemic hormone therapy should still be screened and offered treatment for the genital urinary symptoms. So we've got guidelines to, you know, to really say this is something we should be offering.
- [65:18]
Dr. Reena Malik
Do you think? And this is obviously, I don't think we have clear data on this yet. Do you think that DHEA is better than regular estrogen?
- [65:26]
Dr. Rachel Rubin
I think if I have, I was in charge, which nobody ever wants that to happen. I would. If vaginal DHEA were available, it would be my first line because again, we know that the genital tissue and the bladder tissue is androgen sensitive, so to both estrogen and testosterone. And DHEA is the only FDA approved product that we have that does both. And so I love it. I think it's great. It's just often difficult for our patients to access and, and not always well covered. But I think it's a fabulous product
- [65:57]
Dr. Reena Malik
and it's not the Same as oral DHEA supplements. So DHEA that's prescribed by your doctor, correct? Absolutely. Let's talk about. I think the thing that patients struggle with when they're starting menopausal therapy is that they. It's finding the right dose for them. Right. Because sometimes the estrogen is too high and they have bleeding or discomfort. What is your approach to that? How should patients approach that?
- [66:20]
Dr. Rachel Rubin
Yeah, so again, it depends a little bit if they are perimenopausal. Right. So you're normally reproductive age, your estrogen probably shifts between like 50 to 150, down to 50. When you're pregnant, your estrogen is 3,000, and when you're in menopause, it's zero. And so we're looking at between zero and 3,000 as our range, where we don't want you to be up to 3,000, like pregnancy. But if you're talking between 0 and 150, you know, that's kind of the range with which we often play. And it depends because in perimenopause, your ovaries can do some wild things. I've seen patients have estrogen like 900 hundred, a thousand, you know, these wild high fluctuations. And no one's trying to get those down. Let's remind ourselves, like, no one's castrating those women. No one's running around with those women telling them their estrogen has to be lower. No one's checking their estrogen levels. And so if you're in perimenopause, there are patients who will start getting breast tenderness a lot because the fluctuating hormones of their own ovaries doing, they'll get hot flashes, they'll get night sweats. And a lot of. Lot of it is that fluctuation from 900 to 0 and back, back up. And so we try, at least with those patients, I tend to either to try to like, make their estrogen not zero. So I give them a little bit of gas in their tank, but they may not need a high dose because their ovaries are still producing estrogen. Now, if you've been fully menopausal for, you know, haven't bled in over a year, and you haven't had estrogen around, then, you may want to start with kind of a medium or low dose just to prevent, you know, the side effects, which can be breast tenderness, bleeding, things like that. So you go a little bit slower sometimes with those patients. So it really depends. Again, it's not like a one size fits all. I often tell patients, start with 05. You know, and, you know, cut it in half, go up or down and kind of use a medium dose to kind of play with that.
- [68:08]
Dr. Reena Malik
I think the other important thing, what I tell my patients is like, look, it, it is going to be variable. Everyone is individual. There's not more is not better and less is not like inferior. It really depends on how your body responds to it. And, and it's interesting to me that we just started talking about checking estrogen levels on people getting transdermal estrogen, meaning gels or patches, because we've been doing that for testosterone for years because we know that 20% of guys don't absorb their testosterone.
- [68:36]
Dr. Rachel Rubin
You're such a logical urologist. I love your brain because it just uses logic and unfortunately that doesn't exist in the real world. Yeah, it's a challenge because we know men don't absorb testosterone topically very well. Well, so why would women be all that different? And, and I think we struggle with this. We do, I do. We do have patients that do not absorb the topical estrogens. And so we play, you know, again, there are role, there's a role for oral estrogen, there's a role for injectable estrogen. And again, if you know the toolbox and you have some understanding of the toolbox, you can play within the toolbox. But it is not, not every patient who gets the same dose of a package patch absorbs it the same way.
- [69:16]
Dr. Reena Malik
Absolutely. And I think that it's so important that, yeah, it's okay to check the hormones. I actually had a friend of mine, a mutual friend of ours, call me. My gynecologist refuses to check my estrogen, but I'm on transdermal estrogen and I don't feel great. And I think I might not be absorbing it. And I was like, yeah, it's very reasonable in that circumstance. What are other circumstances where you think it's reasonable to check levels?
- [69:38]
Dr. Rachel Rubin
I mean, if you're on a good dose of hormones and you're having symptoms still. Right. If you're still in hot flashes, nights and sweats, you know, you're just not feeling good. I'll tell my patients all the time, if you have like a really bad day, you know, certainly you, it doesn't mean it's going to be the answer. But like, I had a patient, she wore a fem ring. And that's a ring, an estrogen ring, high dose estrogen ring that goes in the vagina for three months. She's a marathon runner, like super, super elite athlete. And she had been Doing great. And she calls me one day and she's like, I feel awful. All my symptoms are back, back. You know, I feel terrible. I said, oh my gosh, like, how old is your ring? You know, sometimes it runs out. Let's check. So she goes to the lab, she gets her lab, and her estrogen is 3. Right. And I was like, this doesn't make sense. You need to take your ring out and change it. And so she goes to the bathroom, she tries to take her ring out, she can't find it. So what probably happened is she had a big bowel movement. Something happened, she beared down, the ring fell out and she didn't notice. And so she wasn't getting any estrogen. And so again, did we need the last lab to tell us that? No. We probably could have started with the estrogen check for the ring, but it's just a good story of like, her symptoms, you know, were telling us something was wrong.
- [70:45]
Dr. Reena Malik
Right. What about before getting any therapy? So, like, I think there's a lot of confusion. Right. There's a lot of people getting blood tests, and as you mentioned, perimenopause is like a roller coaster. And so getting a random blood test is not useful. But when is it useful for patients to check? And how should they know that they're getting a blood test that's actually going to give them some information?
- [71:04]
Dr. Rachel Rubin
Yeah, it's a huge challenge because again, I think when patients come in and say, I want you to check my hormones, that's the language they're using to say, I don't feel good and I want something to help me and I want validation here and I want numbers to help explain the way that I feel, because I think you're going to just tell me to do more yoga and deep breathing. And there has to be another reason.
- [71:26]
Dr. Reena Malik
Right.
- [71:26]
Dr. Rachel Rubin
And I think in moments like that, we need to take a second and instead of putting our. Well, let me tell you how hormones work and let me tell you why you're wrong and, and you're stupid for even asking me that question.
- [71:38]
Dr. Reena Malik
It.
- [71:38]
Dr. Rachel Rubin
It doesn't help. I think there are a lot of labs out there right now that are pushing a lot of hormone testing and a lot of expensive hormone testing, which I don't agree with. But I think if we understand the roller coaster of the hormone fluctuations, then there are certain points where you could check. The guidelines are clear that you should check it. You can check a total testosterone at any point, and that is very guideline driven. So if your doctor says we. That hormones are not helpful. You could show them the testosterone guidelines and say, hey, a total testosterone is helpful. And then I find again, and this is just one of the ways that I was taught is that when you check if you have your period, that's kind of you're at your low. And so if you check around the time where you have your period, so maybe day one, two or three, you know, check that estrogen level, how low do you go? Right. If I have a patient who's 38 and her day two estrogen is seven, I don't love that for her bones, right? I don't love it. And do I have all the data in the world to say that she should be. But it tells a story. It helps me tell a story. Now the next day her estrogen could go to 200. Right. And that's a challenge. Right. And the more your patients understand the roller coaster and they understand that and I think again, the way technology is advancing so quickly, I think this is going to be a very interesting space to watch because I think we've got continuous glucose monitors. I think we'll have continuous hormone monitors. Not so far in the future.
- [73:01]
Dr. Reena Malik
I agree.
- [73:01]
Dr. Rachel Rubin
And I think the book is going to have to be rewritten because I bet you most people do, do not follow the book that we were all taught. And so we have to be, for any doctors listening or clinicians listening, we have to be play doh. Everything is different now. There are so many things in medicine that did not exist when we were in training and we have to be willing to be humble and, and, and have some humility and this ability to say like, wow, we're going to learn new things and we're going to get it wrong sometimes and we're going to get, we got this wrong and we're going to get more things wrong. But like we have to be Plato. Like little bit.
- [73:35]
Dr. Reena Malik
Yeah, absolutely. And I think it's, it's just so important. And yeah, I do think continuous hormone monitoring is coming and I think it's going to be very useful. But also it's going to be very preyed upon.
- [73:46]
Dr. Rachel Rubin
It's going to have a lot of unintended consequences and there's going to, and like with all things there's going to be. Right, there are people who are. And we've seen it with the continuous glucose monitors, right. The amount of anxiety that it builds, the amount of, you know, there's a lot of bet you see all the people who talk about it non stop and then you stop hearing from them for A while, right. And they put it away. They're obsessed with it, and then they put it away. And, and so I think, like, all things like, it's, it's like, I mean, look at operating with a robot, right? You and I didn't train, you know, fully on the robot started to come in when we were kind of towards the end of our training. And now they use a robot for everything, right. And it becomes the technology is there. So you're like, okay, we're going to use it. And then like, do you need it? Well, now we don't know. Know how to do open surgery. You know, like, there's, there's pros and cons.
- [74:29]
Dr. Reena Malik
Let's talk about women with IUDs or anything that's suppressing. Well, IUDs I think, are more specific because you can't really stop an iud. How do they know when they are going to be in perimenopause or when hormone therapy might be useful for them?
- [74:43]
Dr. Rachel Rubin
So IUDs are great because they make you not bleed, but they're also a little bit challenging because then you don't know sort of what's going on with your periods. Are you skipping periods? Where are you? And I think this, again, is where education is so important. Important of nflm. Not feeling like myself. So I have a friend who wasn't feeling like herself and just kind of was feeling awful. And she had an IUD in place and we spot checked her hormone levels, but you didn't even need to do that. We started her on an estrogen patch because her uterus is protected. And she started an estrogen patch. She was on vaginal estrogen and she decided to use testosterone. And when I tell you she's a completely, like, transformed human being and she's in her early 40s and it is just like night and day. And she has an energy and a, you know, she's at the gym way more and her libido is up and she's feeling like herself, which is great because she's got a big C suite position now and she's, you know, working harder than ever, but she feels like she can do it. And it's so fun to watch. But again, is that what everybody should do? No, but, like, you have to have the, these conversations of, like, what do you want to, you know, what makes sense for you and how are you feeling?
- [75:52]
Dr. Reena Malik
Absolutely. I think there's been a lot of discussion about brain health and heart health benefits with hormone therapy, which is sort of controversial in the data What? How do you consult patients on that?
- [76:03]
Dr. Rachel Rubin
I am not a neurology researcher, nor a cardiovascular researcher. I always say, like, I'm a boner doctor, not a bone doctor. And I really it, it. To me, it's such a ridiculous conversation that is happening in this fake place called the Internet where people are fighting over non reality things that are happening. Everyone's saying is like, oh, the influencers are telling women to take hormone therapy to prevent dementia, and they're evil influencers. None of the influencers are saying that. Influencers are saying, hey, look at Lisa Moscone's data. Hey, look at all this interesting data out there. There. You know, libido helps with your testosterone, helps with libido. Libido is a mood. Like, could it affect. You know, we see some. Some studies show benefits for brain. You know, we have data showing decreased cardiovascular disease. So. So people are talking about data. No one is seeing a patient in their clinic who says, the only reason I want hormone therapy is to prevent heart attacks, like, that patient doesn't exist. And to say that patient exists, like, come find me, because that patient has low library libido, urinary tract infections, osteopenia, she has hot flashes, night sweats, and she's not sleeping and she's not feeling like herself. That is like many indications where hormone therapy is absolutely beneficial for that patient and should be discussed. So the idea that patients are coming to you saying, well, I need to take this to prevent dementia, that's not true. Patients are coming in saying, I don't feel like myself. I have all these symptoms, and I'm interested in the brain data out there. Hey, so am I. I'm also interested in the brain data out, out there. So I think it's a ridiculous conversation that's happening and it's distracting from the point. The real problem, which is nobody knows how to write goddamn hormone prescriptions, right? Like, like, I don't care that they're fighting about this on the Internet. When you are giving the primary care doctors an excuse of saying, I don't need to learn how to do this. You do need to learn how to do this. In fact, you absolutely should know how to write an estrogen prescription, a progesterone prescription, a vaginal hormone prescription, and yes, you can learn how to write a testosterone prescription prescription. And so every doctor, honestly, I think orthopedic surgeons should learn how to write hormone therapy prescriptions because people die of fractures. Like, it's wild to me. I think neurologists should learn how to write hormone Prescriptions. I think rheumatologists absolutely should learn how to write hormone therapy prescriptions. Literally, endocrinologists don't know how to write hormone therapy prescriptions. I go and speak at academic centers, at endocrinology departments, and I was like, how embarrassing nursing that a urologist is teaching a bunch of endocrinologists how to write estrogen patches. Right. Like, this is basic stuff, but we are fighting about the minutiae on the Internet. It boggles my mind how dumb that conversation is.
- [78:41]
Dr. Reena Malik
Yeah. And I think the way I tell people is like, yes, there may be benefit. It is not 100% proven, if you ask me, based on what I see in men's health, because there's an abundance of data on testosterone benefits that probably there is, but I can't say for, for sure, right? Like, I can't say with 100% certainty that it's going to cause any prevention of dementia or it's going to do be cardio protective. But you know, to some degree. Well, cardio protection, there is some good data on that, but I think in general, like, it doesn't. Yeah, you're right. They're not there for that purpose. There was an interesting paper that you were involved in that looked at treating menopause might actually impact patients who are considering plastic surgery.
- [79:18]
Dr. Rachel Rubin
Oh, I, we wrote a paper with a plastic surgery resident about, about why the plastic surgeon needs to learn about hormone therapy. Just like we were talking, like, we need plastic surgeons to learn about hormone therapy. Because listen, you have hormone receptors in all of your body. Your skin, your hair, your nails, like your bowels, your, your, your wound healing is so important. Like hormones are so important for wound healing. And so plastic surgeons are doing labiaplasties, they're doing clitoral surgeries, they're doing aesthetic things, they're doing skin care, they're doing so many things, things that are around and breast tummy tucks and breast reconstruction. They are always working with perimenopausal and menopausal patients. And for them to say like, oh, hormone therapy is not my lane. We can't do this is ridiculous. So it was really just a paper going through sort of why the plastic surgeons should care about this. I really, I want a paper in every journal. You know, this is why the geriatrician should care about this. And this is why the ID doctor should care about. About this. Because truly there is no field of medicine that shouldn't care about this topic.
- [80:25]
Dr. Reena Malik
You know, it's so interesting that there's so Much fear around hormones. And this is true because I saw, you know, there was obviously you were on the FDA panel for women and estrogen and removing that black box warning for estrogen. But there's also a panel that was on testosterone and it was mostly about male testosterone. There was some discussion about female testosterone, but it was very interesting. I was part of this group, I don't remember which one it was, but this group online and there was a lot of doctors complaining about how this panel was so biased and how testosterone is so bad for you. And I was literally sitting there and shocked because I was like, one. They do not know the data. They are literally sitting there based on some education they got years ago that's inaccurate.
- [81:12]
Dr. Rachel Rubin
Again, it's this group think mentality and sort of this idea of once you believe something, it is really hard to change people's minds. And I think this is where we're struggling because no one, everyone's excited about GLPs. Everyone's excited about GLPs. Right? You don't have the pitchforks of the people, you know, a little bit. But like most people are learning about them, learning how to prescribe them, they're taking courses, they're getting mentored on it, and they're all about the GLP ones. Right. It's new and new things people can get. Like, keep an open mind. Oh, this is new. Let me learn about it. Well, they already have a, an emotional attachment to the term estrogen and testosterone and there's emotions behind it. And it has to do with these really annoying patients who come asking for, you know, things that, that you think they don't need. These really annoying patients that take too much time and they're asking for things that you don't know how to do. And so you're uncomfortable with it, so you shut them down and instead of just telling them you don't know, you know, and then they go to the meta spas and they get it from, you know, somebody who took a, a weekend course and that. So they must be all be snake oil. So it must all be snake oil. And it's simply not true. Right. But again, these clinicians are trying in their minds to deal with life and death medicine. They're preventing, they're screening for cancer, they're dealing with high blood pressure and diabetes. They don't have time to worry about people's libidos or erections or, you know, muscle mass and things like that. And you're seeing patients more and more care about prevention and care about, about sort of Health, and it's new, and the doctors aren't keeping up so much. There's so much bias, there's so much group think. And even we see it, we see a lot of the emotion. Like the way an endocrinologist is taught to do male testosterone is very different than the way a urologist is taught, and it's way worse on the female side.
- [83:05]
Dr. Reena Malik
What is one thing that you changed your mind on about sexual medicine or menopause therapy since you started started specializing in the space?
- [83:14]
Dr. Rachel Rubin
Oo great question. I. I'm constantly changing my mind. I'm constantly learning new things, which I love. I'm always trying to listen and learn from colleagues. I would say libido is a really perfect example. When I came out of my fellowship in 2016, we had one drug approved for low libido, and the other one was approved, I think, in 2018. And in my mind, I was sort of a surgeon and I, you know, you. You do surgical things and like libido, that's all the psychotic social stuff. And it really was, I think, a lecture by Erwin, who you interviewed, you know, where it showed sort of the neurobiology of libido. And we see patients all the time with SSRI or antidepressant induced sexual problems, low libido, delayed orgasm, cognitive, like, just challenges with sexual health. And there was like this moment I, like, remember this, like, light bulb moment, like, holy crap, if medicine can botch your sexual health, can medicine improve your sexual health? And I got really sort of like, oh, and whose job is it to have these conversations with patients? Because why aren't the psychiatrists prescribing these medicines? You know, why aren't the gynecologists? Why aren't the primary care? And like, no one taught them how to do it. And so I got really loud about it because if not me, then who, right? If I'm not out there prescribing these things and looking like no one else thinks this is their language plane. Because no one else cares enough about sexual health to, like, actually, you know, prescribe. So I use. So I've been a big prescriber and sort of interested in these medicines for lilibido and hormone therapy for low libido. And we've seen just the magic. I mean, we've seen they work in everybody. No, but when they work, it's just. So you're a hero. I mean, you're just a hero when you can help raise dopamine in someone's body and they get this certain surge of Sort of a dopamine, sexual health libido. And it's so fun. So I think that was a big. A big aha moment for me.
- [85:13]
Dr. Reena Malik
Yeah. And, you know, I think that the even bigger thing that we haven't touched on too much is that sexual health is a biomarker of your health. Right. It is not just this thing you do for fun. Right? Yeah, of course it's fun and it's pleasurable, but moreover, it's. It's interconnected to your entire being. Right. It's interconnected into your heart health, your brain health. And like, it should be everybody's lane. It should be. And as you mentioned, I think that it's just so important that anyone who's listening, if you're struggling with sex, it is not something to be ashamed of or something that we just talk about with certain doctors. Like, it is a part of your life and we should make it normal to talk about.
- [85:49]
Dr. Rachel Rubin
Yeah. You know, I've been told over and over in my career, even with people used to work with. Right. Of like, what you do is weird. What you do is weird. You're not going to make enough money. This is not medicine, doesn't value this. This is not real medicine. And we were just talking about how everybody always minimizes us and what we do and what we're capable of. And yet when we pull it out, like, people are so interested in this. Everyone is affected by this. And that's why it's funny because I lecture a lot and I teach a lot about this stuff and. And I don't really speak differently when I'm talking to a group of clinicians versus patients because everyone knows nothing and that nobody knows anything. And so I talked and I know that they're all patients. Everyone in that audience is a patient. And I know because they send me. They come to see me or they send me their. Their partners and. And it is wild how no one was taught how to do this. It never ceases to amaze me. Like, how is it that I have been able to get on the platforms and the stages that I've gotten on? Like, I. What? You know, the smart. The more I learn, the more I feel like I don't know anything thing. And yet, you know, that's how bad it is. Like, there really aren't enough people out there talking about this, teaching about this, and there certainly aren't enough people writing the prescriptions. And that's the challenge is because everyone deserves access to sexual health. Quality of life, sleep, libido, orgasms, you know, feeling like yourself, like everybody deserves that and, and we should be fighting for that a whole lot more.
- [87:22]
Dr. Reena Malik
Yeah. And I think the bigger issue is not that people don't care, it's that medicine doesn't care and is that the insurance companies do not reimburse the care for these issues. They do not reimburse you for the time you spend talking to patients about this. And some of the codes are not even reimbursed. Many of the female sexual codes are not reimbursed by insurance. So a regular physician who needs to put food on the table is not able to see these patients because they literally cannot make ends, ends meet by seeing patients like this. And so it's, it's really comes down to what medicine values or not medicine, but what insurance companies value, which.
- [88:02]
Dr. Rachel Rubin
Yeah, it's. And it's a huge problem.
- [88:05]
Dr. Reena Malik
So where should people find you? Where can they find practice? Your research, your course, everything you're working on.
- [88:10]
Dr. Rachel Rubin
Yeah. So our website's a great place to go. Rachel rubinmd.com we have amazing newsletter that you should sign up for. Our courses can be found found on there. Our free education can be found on there. We have a research team that meets once a month. So if you're a student listening or you want to get involved in research, please join us. And we are always coming up with new ideas and new ways to reach people. So follow me on Instagram Dr. Rachel Rubin. So Dr. Rachel Rubin. And we'd love for you to join along.
- [88:41]
Dr. Reena Malik
Awesome. So we end our podcast with four questions that we ask everyone. It doesn't have to be about sexual medicine. It can be about anything you want. So what is something you know now in life that you wish you knew earlier?
- [88:51]
Dr. Rachel Rubin
I should have been kinder to myself. And that progress over perfection.
- [88:56]
Dr. Reena Malik
Absolutely, Absolutely. What's a non negotiable something you have to do every day?
- [89:00]
Dr. Rachel Rubin
I sleep. I sleep like eight hours a night.
- [89:03]
Dr. Reena Malik
Really?
- [89:03]
Dr. Rachel Rubin
Yeah.
- [89:04]
Dr. Reena Malik
Oh, I love that.
- [89:05]
Dr. Rachel Rubin
I'm neither an early bird or a night owl. It's actually wild how productive I am because I cannot stay up late or get up early.
- [89:14]
Dr. Reena Malik
But that's good. What's a life hack or health hack you'd share with people?
- [89:18]
Dr. Rachel Rubin
It's all mindset work, the whole story. Everything is about your mindset work. And the more you invest in constant mindset work, the better your life truly is. Because your brain is sort of like the default of your brain is weeds. And if you don't cultivate and actually work on it all the time, the weeds will continue to grow. Grow. And that has been absolutely life changing.
- [89:43]
Dr. Reena Malik
If you couldn't be a physician, a urologist, and an entrepreneur as you are now, what would you be?
- [89:48]
Dr. Rachel Rubin
I always joke that I would name nail polish colors because they always have really witty, fun names, but I don't actually ever get my nails painted, so I don't know.
- [89:56]
Dr. Reena Malik
The plight of a surgeon. We never get our nails.
- [89:58]
Dr. Rachel Rubin
I know, I know. That's the best answer I can come up with.
- [90:02]
Dr. Reena Malik
What have you thought of a nail polish color that you like? Like a red or like a. I
- [90:06]
Dr. Rachel Rubin
don't know, I would probably be clitorally the best or something like that. Yeah.
- [90:10]
Dr. Reena Malik
Yeah, I love that.
- [90:11]
Dr. Rachel Rubin
All right, thank you.
- [90:12]
Dr. Reena Malik
Did you guys love that conversation? Because I know I did. And if you are enjoying this conversation and you've been a long time listener, I need one favor from you guys. Hit the subscribe button or the follow button on the podcast platform you're listening on right now. This signals to podcast platforms that this podcast is worth listening to and shows it to more people. And it takes just a couple seconds of your time and it's completely free. Thank you guys so much and as always, want to take care of yourself because you're worth it.