The Curbsiders Internal Medicine Podcast

Episode #507: "Swinging the Pendulum on Menopause Care" with Dr. Rachel Rubin

Release Date: December 8, 2025

Overview

This episode features Dr. Rachel Rubin, a board-certified urologist and nationally acclaimed expert in sexual medicine, sharing practice-changing insights on menopause care. The discussion centers on the evolving evidence base and shifting guidelines for menopause hormone therapy (MHT), debunking long-standing myths about hormone risks, and empowering clinicians to feel more confident offering comprehensive menopause care, including systemic and vaginal hormone therapies. Dr. Rubin also explores practical prescribing, barriers to care, and her advocacies, aiming to make menopause care accessible, evidence-based, and deeply patient-centered.

Key Topics & Discussion Points

The Shifting Landscape of Menopause Care

Timestamps: 08:45 – 16:23

• Current Climate: There's a cultural and clinical movement toward open discussions about menopause and MHT. Social media and high-profile advocacy have pushed for transparency and greater access.
  • Dr. Rubin: “I think it’s more than a moment. I think it’s a movement.” (10:10)
• Old vs. New Guidance: Traditional advice regarding "lowest dose, shortest time" for hormone therapy is giving way to nuanced, patient-centered, shared decision-making as supported by the newest guidelines (2022 Menopause Society).
• Why Inertia Persists: Inertia in medical education, risk aversion, and systemic sexism have historically led to undertreatment of menopausal symptoms.
  • Dr. Williams: “There’s also some benign neglect combined with sexism… the underlying thought is… I heard these things could cause harm, but the vasomotor symptoms are not going to kill you…” (11:52)

The Women’s Health Initiative (WHI): Lessons and Misinterpretations

Timestamps: 13:29 – 16:23

• WHI Overview: The original WHI trials used older, oral synthetic hormones in a population that was older than the typical symptomatic menopausal patient.
• Reassuring Data: Recent WHI follow-up publications show no increased risk of heart attack or stroke in women under 70 on MHT; with estrogen alone, decreased breast cancer risk and mortality.
  • Dr. Rubin: “Even the WHI didn’t show the harm that we’re so worried about with systemic hormone therapy... hormones are not all the same thing. You can no longer bucket all hormones together and say hormones are good or bad, right or wrong.” (15:00)

Update on FDA Black Box Warnings

Timestamp: 08:08

• Recent Changes: The FDA is moving to remove black box warnings regarding breast cancer, dementia, and cardiovascular risk (except for endometrial cancer) from all estrogen-containing hormone products.
• Impact: Labeling is only the first step; continued education for clinicians and patients is crucial to realigning perceptions with current evidence.
  • Dr. Rubin: “Changing the labeling is step one… step two is teaching all the nuances… step three is advancing the research.” (24:22)

Barriers to Care: Why Clinicians Are Reluctant

Timestamps: 12:19 – 16:23

• Educational Gaps: Many doctors are never taught the practicalities of prescribing MHT and so avoid the subject.
• Medical-Legal Fears: Warning labels and patchy evidence have enabled clinicians to avoid learning or recommending MHT, fearing medico-legal consequences.

Practical Management: Prescribing Menopause Hormone Therapy

Timestamps: 38:59 – 61:56

• Shared Decision-Making: Dr. Rubin’s approach: Begin with detailed history, understanding patient goals, fears, and readiness; provide homework based on preferred learning style.

• Vaginal Estrogen as a First Step: Safe for virtually all women (including breast cancer survivors) and underused for genitourinary syndrome of menopause (GSM). It prevents UTIs, eases pain, and restores vaginal health.

• Systemic Hormones: Estrogen (patches, gels, rings), progesterone (micronized preferred; 100mg nightly common), and sometimes testosterone. Not all patients need all therapies.

• Dosing: Avoid underdosing (e.g., 0.025 mg patch often insufficient); typical starting dose may be 0.05 mg. Labs for hormone levels are optional but can aid in troubleshooting.

  “You start with a couple that you feel comfortable with, and then you stay curious, you listen to podcasts, you read books… that’s what makes this medicine actually kind of fun.” — Dr. Rubin (52:50)

Addressing Special Cases (e.g., 60-year-old, 10 years post-menopause)

Timestamps: 29:17 – 41:49

• Patient Stem: 60-year-old, well-controlled hypertension, prediabetes, first-degree relative with breast cancer.
• Risk Assessment: No compelling data that properly prescribed MHT (especially transdermal) raises CV risk below age 70; breast cancer risk nuanced—micronized progesterone carries less risk than older formulations.
• Absolute Contraindications: Active breast cancer, advanced liver disease; even prior VTE or breast cancer require nuanced, individualized shared decision-making.
  • “Take the easy ones, my friends… For the hard ones, bump it up to the experts. But we need primary care to be helping with the bread and butter easy things.” — Dr. Rubin (35:42)

Prescribing Vaginal Estrogen: Tips & Tricks

Timestamps: 43:58 – 47:10

• Creams: Can be applied with finger (not just applicator), massaged into vaginal walls twice weekly.
• Cost-Saving Tips: GoodRx (~$30), Cost Plus Drugs (~$13/tube).
• Alternatives: Estradiol 10 mcg inserts (convenient, often covered by insurance); Estring ring (can use w/o progestin in uterus).
• Pearl: Don't just dab on urethra—needs full vaginal application for pH shift and UTI prevention.
• Pitfall: Confusing systemic and local rings.

Combining Therapies

Timestamps: 49:26 – 55:18

• Additive Therapy: Systemic MHT rarely sufficient for GU symptoms—vaginal estrogen often co-prescribed.
• Stepwise Intro: Avoid overwhelming patients with multiple new meds at once; start low, add as symptoms persist or emerge.
• Early Bleeding: Evaluate structural causes if persistent; some bleeding expected in early months.

The “Five Things” in the Menopause Toolbox

Timestamps: 61:56 – 63:53

1. Systemic estrogen
2. Progesterone
3. Testosterone
4. Vaginal hormones (estrogen or DHEA)
5. Vulvar vestibule therapy: Compounded estrogen/testosterone creams for specialized pain/vestibulodynia (often referral-level care)

Testosterone in Menopause

Timestamps: 65:11 – 70:32

• Indications: Mainly for low libido; dosing with men's FDA-approved gel (tiny doses), applied to calf/skin (“a lima bean” amount, ~1 tube lasts a week or more).
• Safety: Voice deepening, hirsutism rare at proper doses; much smaller risk vs doses used in gender affirmation.
• Access: 10-month supply for ~$100, often easier than compounding.
• Controversy: No FDA-approved female product in US; politics and regulatory inertia blamed.

Perimenopause and Special Situations

Timestamps: 81:11 – 85:30

• Transition Management: No formal guidelines; options include "ride it out," traditional OCPs (“elegant but less natural”), or steady “tank” with patch + progestin-IUD + testosterone.
• Contraception Consideration: Always address, but not always necessary (permanent sterilization, same-sex partners, etc.).

Duration of Therapy: Is There an End Point?

Timestamps: 86:02 – 88:28

• Systemic Therapy: No mandatory stop; shared decision, especially if started early. Some evidence for ongoing benefit in older women; transdermal preferred in older ages.

• Vaginal Hormones: Indefinite/lifelong use is common and supported.

  “We don’t really recommend taking people off hormone therapy anymore… the data doesn’t support that.” – Dr. Rubin (86:25)

Advocacy & Resources

Timestamps: 90:07 – 91:40

• Support for Clinicians: Encouragement for primary care providers to engage, learn, and practice menopause medicine.

• Recommended Societies:

  • International Society for the Study of Women’s Sexual Health (ISSWSH)
  • Menopause Society (formerly NAMS)

  “Just listening to this podcast means that you know more about this than most clinicians out there.” — Dr. Rubin (90:52)

Notable Quotes & Memorable Moments

• “You do not have to be perfect to get important messages out there. Do it messy. Build those muscles… Progress over perfection.” — Dr. Rubin (06:31)
• “To deny a woman vaginal estrogen, which is safe for every human on earth… is insanity.” — Dr. Rubin (20:07)
• “It truly is incredible. I see these patients who you would say are unhelpable, and to watch their mental health get restored, to watch them sleep again, to watch their relationships improve…” — Dr. Rubin (28:03)
• “If you have a uterus, you should protect it with progesterone. That does still need a big warning because that is true.” — Dr. Rubin (53:12)

Practical Pearls

• Starting Doses: Start patch at 0.05mg twice weekly; lower (0.025mg) usually insufficient.
• Vaginal estrogen is underprescribed: Essential for preventing UTIs/genitourinary symptoms.
• Transdermal > Oral: For most, preferred due to lower thromboembolic risk.
• Monitor symptoms, not just labs: Titrate therapy based on patient response.
• Don’t Overwhelm: Introduce therapies stepwise; bring patients back within a few months for feedback.
• Education matters: An informed patient is a compliant patient.

Important Segments with Timestamps

• Myths & Old Guidelines Debunked – 13:29–24:22
• Practical Prescribing (Vaginal & Systemic) – 38:59–61:56
• Managing Bleeding & When to Worry – 79:20–80:39
• Testosterone Therapy Details – 65:11–70:32
• Perimenopause Complexity – 81:11–85:30

Resources & Suggested Reading

• 2022 Menopause Society (NAMS) guidelines (see show notes)
• American Urologic Association's guidelines for genitourinary syndrome of menopause
• Dr. Rubin’s social media, YouTube, and website
• International Society for the Study of Women’s Sexual Health (ISSWSH)

Summary Take-Home Points

Dr. Rubin urges clinicians to:

• Challenge folk wisdom, black box warnings, and outdated MHT dogma with current evidence.
• Embrace shared decision-making and a tailored, holistic approach to menopause care.
• See vaginal estrogen as essential, safe, and underutilized.
• Get practical experience and consult up for complex cases, but own the "easy wins" as primary care.
• Remember: Menopause is a quality-of-life issue with real health consequences and deserves open, evidence-based care.

“You are the people who I want to work with every single day. Medicine is so lucky to have you… don’t give up. You can do this. We’ll help.” — Dr. Rubin (90:09)

For more, follow Dr. Rubin and The Curbsiders, and check the links in the episode show notes for comprehensive guideline documents and educational resources.