← The Mel Robbins Podcast
The Mel Robbins Podcast
The Ultimate Guide to Women’s Sexual Health, Hormone Replacement Therapy (HRT) & Menopause
02:14:27
This episode is a MUST listen. Mel calls it one of the most important conversations she has ever had on The Mel Robbins Podcast. Most women don’t know this, and this information could save the life of a woman you love. If you are thinking you’re “fine,” while quietly suffering through symptoms that are treatable, you probably don’t know this life-saving medical fact either. Today, Mel is joined by Dr. Rachel Rubin, MD, a leading urologist and sexual health expert, to talk about hormones, menopause, libido, pelvic health, UTIs, and what’s happening in your body. In fact, since recording this episode, the majority of women on the team have spoken to their doctors about what Dr. Rubin shared. You’re about to hear what she wishes every woman knew sooner: Almost every issue that you're dealing with “down there” is likely related to changing hormones. If you’ve ever dealt with a UTI, leaking, urgency, dryness, painful sex, or that feeling that something is “off” down there, a...
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- [00:00]
A
Hey, it's your friend Mel. And welcome to the Mel Robbins Podcast. What you're about to listen to is the single most important episode that we've ever done about women's health. I'm talking jaw dropping information about hormones, menopause, birth control, pregnancy, UTIs and women's sexual health. Today I'm joined by one of the world's most highly regarded, trusted and renowned urologists and sexual health medical experts who says stop gaslighting yourself. You deserve better when it comes to healthcare. You deserve to be listened to, treated, cared for, informed and empowered through every single change happening in your body and every symptom that you may feel as your hormones go up and down. I mean, how many times do you have to explain away the discomfort, the dryness, the pain and say, oh, it's no big deal, I'm fine, don't worry about me. I know, I just don't feel like myself. I'll push through. Just a little stressed. I know, I know. I'm tired, moody, anxious. Well, I'm going to tell you something. I've said every single one of those things and I bet you have too. But after listening today, you will never say those things again. I hope you not only listen, I truly hope you share this with every woman you know. With your daughters, your sisters, your friends, your partner, your mom, your grandma, your aunt. Because it will not only change her life, what she learns in this episode might just save it. Furniture isn't just how it looks in your home, it's about how it lives in your home. Ashley offers affordable, well crafted pieces designed to handle real life kids, pets, everyday messes, constant use with features like stain resistant performance fabrics that are easy to clean, plus machine washable cushion covers made for daily living. Because when you're investing in your home, you want pieces that look great and are built to last. And with fast reliable delivery right to your room of choice. 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AHS can repair or may even replace covered parts of home systems and appliances, no matter how old. And as a benefit with select plans, you can video chat with a repair expert in real time. American Home Shield don't worry, be warranty. Get 20% off any plan@ahs.com Mel and see promo details. See ahs.com contracts for coverage details, including service fees, limitations and exclusions. Hey, it's your friend Mel. And welcome to the Mel Robbins Podcast. I am so happy you're here. It's such an honor to spend time with you and to be together. And if you're a new listener, I just want to take a moment and welcome you to the Mel Robbins Podcast family. And I'm thrilled that you're listening to this particular episode not only to learn for yourself, but but that you're also listening on behalf of all the women that you care about in your life. Because I want you to consider this episode a life changing and maybe even a life saving resource that you can share for free with women in your life. Our medical Expert today is gonna teach you what every woman should know about menopause, hrt, vaginal health, pelvic floor issues, and the very common hormonal changes that happen to women throughout their lifetime. And she's going to answer all of the questions most of us are searching online alone, secretly, because, let's face it, we're either afraid of talking to our doctors about it or we're too embarrassed to even say the word vagina out loud. Dr. Rachel Rubin is a board certified urologist and one of the nation's foremost experts in sexual health. She is one of only a handful of physicians in the United States with a specialty in sexual medicine for all genders who are who is also training thousands of doctors around the world about prescribing hormones correctly. She is a clinician, a researcher, and a passionate educator who teaches doctors around the world how to properly diagnose and treat sexual health conditions that are often overlooked or dismissed. She is the Director at Large for the International Society for the Study of Women's Sexual Health and she's served as an Associate Editor for the Journal of Sexual Medicine Review and the Video Journal of Sexual Medicine. Today she's here to Teach you what every woman needs to know about sexual health, menopause, hormone replacement therapy, and how to take care of everything down there. So please help me welcome Dr. Rachel Rubin to the Mel Robbins Podcast. Dr. Rachel Rubin, welcome to the Mel Robbins Podcast.
- [05:55]
B
Oh, my gosh, I'm so happy to be here. This is a dream come true.
- [05:59]
A
Well, it's a dream come true for me, too. And by the time you're done listening, you, I know you're going to say to yourself, wow, Dr. Rubin is a dream and a treasure. I'm so happy that I chose to spend time listening to this. How might our life be different or the lives of the women that we love be different if we take to heart everything that you're about to teach us today about hormones, women's sexual health, Just the whole range of topics we're going to cover, much of which you will have never heard in your life before.
- [06:31]
B
Whether you are going through puberty, whether you are going through childbirth, perimenopause, menopause. This is important for your quality of life, your general health, your sexual health. And listening to us today is going to give you the strength and the confidence to learn more and to advocate for yourself so that you live your best damn life.
- [06:54]
A
Oh, I'm here for it. Your best damn life. Let's go.
- [06:57]
B
Dr. Rubin, you having this information will help so many women to share it with. My mission is fully that I believe when you give women information about how their bodies work, they make excellent health care decisions for themselves. And I truly believe when they have good health, good mental health, good community, good support, they are masterful at optimizing their own lives to whatever degree that they want them to.
- [07:25]
A
Oh, I love that. I love that. So, Dr. Rubin, we're gonna cover so much, but I think where I wanna start is what is a sexual medicine doctor versus a urologist?
- [07:37]
B
Yeah, it's a great question. So urologists are genitourinary doctors. So we take care of kidneys and bladders and prostates and penises, but we also take care of urethras and vulvas. Like, we are sexual medicine doctors first and foremost, but we're surgeons as well. So prostate cancer, bladder cancer, kidney stones, which I've had and don't recommend. So this idea that gynecologists are for women, urologists are for men, doesn't make any sense because urologists take care of bladders. And last time I checked, most people have bladders, Right? It doesn't matter if you're a man or a woman, you have A bladder, you can make kidney stones. You have kidneys, you have genitals. And so we think that our gynecologist should know everything about sexual health. But we don't teach them anything about sexual health. We teach them about reproductive health, we teach them about gynecologic cancers, we teach them about gynecology, which has never included sexual medicine unless people have taken an extra interest in it. In urology also, we deal with men's sexual. Think Viagra, think, you know, erections, like, that's how we deal with testosterone for men. We do a lot of this in urology. But women's sexual health has also been historically ignored.
- [08:45]
A
I. This is brand new information. I'm like, almost embarrassed to admit it. I, I literally think primary care gynecologist, primary care gynecologist.
- [08:55]
B
And that's what I find every day when I talk to patients is it never comes up. No one has ever asked me about my sex health. It's never brought up. And so if you have a problem, if you have an issue, where do you go? The obvious choice is, let me go to my primary care, let me go to my gynecologist. But it's not within their curriculum or what they have to learn about. We have to learn about so many things. The word clitoris doesn't appear in what a gynecologist needs to know to graduate her training today, today in 2026. So it's not like, oh, I have a bad doctor. No one taught them. So how are they supposed to give you good advice now? I wish. My dream. I have many dreams, but one of my dreams is that they actually say, I don't know, I didn't learn this. Instead, they so often will say something wrong or untrue or make the patient feel like it's all in their head.
- [09:46]
A
What are the things that a lot of doctors say to women in particular that aren't true or that are wrong in this category of sexual health?
- [09:56]
B
Oh, drink a glass of wine if you have low libido or have pain with sex, read 50 Shades of Gray if you have pain with sex, just have more of it. Oh, this is just about getting older. Oh, that part of your life is over now, so you should find other things to do. Every single day, people come to my clinic with stories of how they've been dismissed, gaslit, told they didn't have anything wrong with them, told them they couldn't see the problem. So it must be all in their head.
- [10:23]
A
Wow. What are some of the symptoms that I'd love For you to normalize that you hear day in and day out so that we all just know the things that you're dealing with. It's not just you. And these are things that you can either make better or that you can get help for or you don't have to live with.
- [10:41]
B
Anytime you find yourself thinking or even telling yourself, oh, this is just how it is getting older. Oh, this is just how it is. Oh, my mother went through this. Oh, my friends all have this right? How many times do you say, oh, I just don't feel like myself or oh, I'm just a little stressed or oh, my mood, I'm, you know, I'm anxious because of X, Y or Z. Well, we've all had stressful situations, but is it worse than it used to be? Do you find yourself waking up at more at night to urinate? Do you find that sex is a little drier, scratchier or more painful? Do you find that your orgasm is either gone missing or takes much longer to have? Do you find that you just don't feel like yourself? These are all things that have a biological basis that if you see someone who is knowledgeable about it can help guide you through this biological basis and give you some biological solutions. Now that's not to discount are wonderful friends in the mental health spaces. Because psychosocial issues affect all of us. I am here to say the biology is also extremely important and we never talk about it. Low libido is a medical condition if you are bothered by it. And we have medical FDA approved solutions in our toolbox that work miraculously for people. And so it is so important that we talk to people about these issues so that they don't leak on themselves when they cough, laugh or sneeze, that they don't get their 10th UTI without asking, hey, can I actually prevent this from happening where they see the right clinician? Because just because it's someone you've worked with for 20 years doesn't mean they're up to date on what's going on with you now.
- [12:18]
A
Well, that makes so much sense, Dr. Rubin. Why can you just give us a brief overview of hormones and what every woman needs to know and I'd love for you to kind of go in the chunks of what is every 20 year old woman, whether she's sexually active or not in that decade. What do you need to know during pregnancy? What do you need to know during perimenopause, menopause and beyond?
- [12:47]
B
So hormones are not good or bad, right or wrong, they shouldn't Come with emotions and feelings and stigma. Okay? They just are. They are. And we're learning more about them every day. And we have so much we have yet to know. But let's take it as what. What do we know today? Well, we know that the ovary makes estrogen, progesterone and testosterone. And we know there's a cyclical way that it is for like made. So kids have no horm. Sex hormones in their body or not significant amounts. And then puberty starts and their gonads start to produce hormones. Their ovaries or their testicles start to produce all these hormones. The testicles produce testosterone predominantly, but boys do make estrogen, right? Men's estrogens are not, are 25. They're not insignificant, which helps their bones. And girls, right, when they have in this, in this pubertal stage, the ovaries are doing these wild fluctuations and they are unpredictable. And I love talking about perimenopause in the way of puberty because we understand puberty, we talk about it, we hold space for it. We don't let teenagers make serious decisions, right? We hold space for it. And so what's happening is estrogen goes up. Progesterone, if you ovulate, the shell of the egg makes progesterone. Throughout the cycle, testosterone is made. We think it peaks during ovulation because that's what gets your libido going, makes you want to make a baby. And that's fluctuating. And sometimes it stabilizes. If you're lucky, you get regular irregularity. So it means every 28 days you're kind of used to this weird 28 day cycle, but you're irregular, right? The first half, when you have your period, your estrogen is low, it's not zero, it's about 50, right? Then that. So you're bleeding, you're at your low. Then it goes higher and higher and it starts to peak at ovulation. And your estrogen might get to 150, maybe 300. You pop out an egg, the shell makes progesterone. And the second half of your cycle, you' progesterone in your body. And when that egg doesn't fertilize, the progesterone drops. And when it drops, that's what sheds your lining. You get your period to start all over again. So you are regularly having these irregular sort of shifts of estrogen in the first half, estrogen and progesterone in the second half. When you are pregnant, your estrogen is 3,000. Okay? An estrogen of 3,000 for about nine months. And then as soon as you have the baby, that 3,000 crashes to zero. Okay? Crashes to zero. And that's brief menopause. So if you. And while you are breastfeeding, you are in menopause, often that whole time, sometimes your periods come back and you start to fluctuate again. But if you are one of those people who breastfeeds and never gets their period back, you are menopausal until you get your periods back. And that comes with every symptom of menopause. The more you understand your hormones and where in your life cycle you are, the more your symptoms start to make sense. Oh, I'm breastfeeding and I'm having hot flashes all the time. My sleep is really disrupted. Yes, the baby's crying, but I. My brain fog. Nobody remembers their birth, you know, because you have so much brain fog, because your estrogen just went from 3,000 to zero. And so the symptoms, the vaginal symptoms, the genital symptoms, the dryness, the irritation, the leakage that's worse, the frequency, the urgency in the UTIs. And then, guess what? Around 35, okay, around your 30s, your testosterone starts to drop precipitously. Okay, so it's not actually about menopause. It's about age. As we get older, our testosterone starts to drop. Or if you've done something before, then to mess with your testosterone, like birth control pills or spironolactone or the other things that we do to mess with our hormone levels. And when your testosterone drops, we think there are consequences. Low libido, increase in UTIs, increase in pain with sex. This is what we're calling perimenopause. And then your regular irregularity of your cycle starts to change. Instead of every 28 days, now it's 35 days, then it's 18 days, then I'm bleeding all the time. And what's happening there is the same thing that was happening in puberty, where your estrogen is going super high and super low. And it's this chaos. And then at some point, the chaos halts to zero. And menopause is a castration event where your hormones just turn off like a light bulb. And sometimes it's a nice smooth ramp, and sometimes it is chaos. And you deserve to be treated, cared for and informed and empowered through every darn cycle that we just talked about. Whether you are in puberty just trying to understand how your body works, whether you are normally in your cycle and you're just trying to understand how your
- [17:31]
A
body works or you have terrible PMS
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B
or if you have tear, or if this, or if it's not normal, which is. There's no normal. None of my patients are book answers. Right. Whether you have pms, Ms. Or PMDD or PCOS or endometriosis or. We see so much pain and suffering because the people are not following the book and they are gaslit and then they are told that it's in their head when they are just not following the rules of the book because the book is old and outdated and no one taught us the updated version.
- [18:03]
A
And by the book, Dr. Rubin, you're here to teach us that every single one of those issues that you just listed that affect women from the moment puberty starts till the moment we're in the grave. Whether it's UTIs or it's pain, or it's itchiness, or it's dryness, or it's painful sex, or any of some of the diseases that you talked about all come down to hormones and are impacted by hormones.
- [18:31]
B
Hormones are a part of this story. Yes.
- [18:35]
A
What is one of the big things that doctors or people think they knew that's actually wrong?
- [18:41]
B
Well, that we treat all UTIs just with antibiotics. That's one thing. And that every. Well, you do, you treat the infection, but you have to get to the underlying root cause problem, which is the hormonal shifts that are happening with the woman in front of you.
- [18:54]
A
Wait, you can get UTIs from hormone changes?
- [18:56]
B
Yes, absolutely. And it's so common and in fact that we, we so. So any kind of hormone fluctuation that happens in your body will affect your gen and urinary health. And so when you play with hormones, there are consequences, sometimes good and sometimes bad. So people who are on birth control pills can sometimes get an increased risk of UTIs, people who are breastfeeding, people who are on hormone therapies in breast cancer. So endocrine therapies, anastrozol, tamoxifen, those types of things, perimenopause and menopause can increase your risk of UTIs drastically. Okay? This is an issue called the genitourinary syndrome of menopause, or gsm. Now, it's not just menopause, even though it's called gsm, menopause and we with vaginal hormones. So if you micro dose hormones into the vagina, it fixes your bladder microbiome, it fixes your vaginal microbiome, and it prevents UTIs so massively that our research team of medical students publish that we could save Medicare between 6 and $22 billion a year.
- [20:01]
A
I, I'm, I'm, I don't even know how to interview you because my, my mouth is on the floor right now. I just wanna make sure I got that. So any kind of hormone fluctuation or hormone change or taking hormones. So whether you're talking about somebody in their teens or twenties on birth control or breastfeeding, or somebody taking hormone replacement therapy or on and on and on can have an impact on getting more frequent UTIs. And one treatment is vaginal hormones which is wildly effective and same safe and safe. And doesn't destroy your gut lining the way antibiotics do when you're taking them over and over and over again. Is the only thing.
- [20:43]
B
Yes.
- [20:44]
A
Oh my God. I've never heard this before.
- [20:46]
B
So it's really important. Like the biggest PSA public service announcement that we need is to get this in the ears of every human on earth because women are dying, you and your family members are at risk of dying or being in the hospital or missing your children's events because you're going to urgent care for antibiotics. For the 10th time you stop having sex because every time you have sex you get a urinary tract infection. Most of those problems, not every problem, but majority of those problems are due to hormone fluctuations that are changing the microbiome of the vagina and the bladder. And it can be treated for every aged person, for every person with every medical problem with a micro dosed amount of hormone that is safe for your great grandmother in the nursing home and you can take for life and can cost you as little as $7 a month. And we can go through all of the options because the most important thing is for your family members to hear this. And we advocated for about seven years, we advocated for the American Urologic association to publish guidelines on this exact topic. And so we published those guidelines in 2025. It's my proudest achievement. And in those guidelines it talks about these symptoms of, you know, the hormonal shifts that happen not just in menopause, but in breastfeeding and breast cancer, in birth control pills, in any type of hormonal type of medications that at using vaginal hormones, whether it's vaginal estrogen or vaginal dhea, prevent urinary tract infections by more than half. But Mel, here's the crazy part. We've known about this since the 1990s. We've had products since the 1970s. And yet why don't you and your listeners know this? No one ever talked taught your doctors this. No one ever talked about it publicly because the two dirtiest words in the English language are vagina and estrogen. And so because we can't say those words, no one is prescribing this. And again, because we decided that all women's health goes to gynecology, right? No other doctor needs to know about women's stuff. Because you just go to your gynecologist and I'll be honest, your gynecologist is busy doing life saving work for pregnant women, for women with cancer, that this is not their top priority. But then women are dying of urinary tract infections. And so publishing these guidelines are a huge announcement of. This is so important. And again, not to confuse everybody and we can go over this in more detail, but up until this last year, there were warning labels on the vaginal hormone products, okay? And all hormone products, in fact, there were false, incorrect warning labels that said these products cause stroke, blood clots, heart attacks, probable dementia, and you need to use with progesterone. None of those things are true. Not one of those statements is true. And so we've been advocating for changes of those labels for decades. We went to the fda, we went back to the fda, we wrote letters, we did all of this, but through grassroots advocacy, through social media, through letter writing campaigns, through knocking on every door we could find. Last year we got the FDA to announce that they removed the box labeling on vaginal hormone products. And not only that, to be able to stare down the FDA commissioner eye to eye. And I encourage everyone to watch my five minute testimony because it's really, I'm really proud of it. I got to look at the FDA commissioner and I said, you, box label tried to kill my mother. And I told the whole story of how it tried to kill my mother. And that was in July of 2025. And then in November, we got to stand on stage at Health and Human Services and announce that they were removing the body box label. That box labeling, your doctor, your family doctor, your gynecologist, your urologist, they would give you this medication and then the ladies would take it home and they say, oh my God, this is scary. This says it's going to kill me. And so now that those labels are officially off, it's, it's, it's game changing. And so the PSA becomes, we have to explain to people these medicines were always safe. Not only were they safe, they were life saving medications. And the label was wrong. It was always wrong. And now we have to teach people how to use it, why to use it, how to write the prescriptions. And so I am sort of working nonstop at every angle, both through the FDA to patients every day, to teach clinicians every day because each arm of that is so important to save those lives.
- [25:16]
A
I, I am, I, I just cannot believe this conversation. Dr. Rubin, I have so many more questions, but I want to hit the pause button because what you just said made me think of two friends of mine who are dealing with this right now. And I bet you have people in your life that are coming to mind. So let's give our sponsors a chance to share a few words and I want to give you a chance to share Dr. Rachel Rubin's expertise and this life saving and life changing information with women in your life. Your mom, your sister, your friends, your daughters. Everybody deserves to know this and to have the medical truth. And don't go anywhere. Dr. Rubin is so much more to teach us when we return. So stay with us, Say hello to Alexa and see how the experience is tailored to you. Alexa learns your preferences to serve you better. Planning a vacation? Ask Alexa to recommend a trip to check off your bucket list. Use Alexa to find the name of that song you love, discover new favorite shows or recipes, and do so much more. Ask Alexa anything. And now Alexa is free with prime on your Amazon devices like echo and Fire TV. Get started at Amazon.com alexaplus these days, the online world moves fast. That's why TikTok approaches teen safety with families in mind from the start. On TikTok, teens get over 50 built in protections right when they join. Accounts for teens start private by default for those under 16. There are no direct messages and only friends can comment on their videos. Safety is built in from day one, so peace of mind is already part of the experience. When safety comes first, discovery can follow. Learn more@TikTok.com GuardiansGuide Are you ready to make a change in your life? If you're thinking about going back to school, let me tell you about Southern New Hampshire University. They have more than 200 online degree programs with affordable tuition and industry leading academic support. At snhu, you're not just another student. You're part of an entire community that cares about your success. So what are you waiting for? Visit snhu. Edu Mel to learn more. Welcome back. Welcome back. It's your friend, Mel Robbins. I'm so grateful that you're here. We are learning about what every woman should know about menopause, hrt, vaginal health, pelvic floor issues, and the very common hormonal changes that happen to us throughout our lives from the extraordinary Dr. Rachel Rubin. So, Dr. Rubin, let's just jump right back in. I mean, I don't even know how to summarize what we're talking about because we're talking about hormones and sexual health and UTIs and just your health in general. And you were just explaining something I never knew, which is GSM and the fact that women of all ages get UTIs because of changes in hormones due to birth control, breastfeeding. Like we all thought this was due to sex, it's due to hormones. And that there is a very safe and very accessible preventative treatment of vaginal hormones that can help you prevent this.
- [28:41]
B
It's truly old news that needs to get into all the new ears, right? This is not emerging science. This is not new science. This is life saving medicine that we've known about since the 70s that we've had in the New England Journal of medicine in the 90s. And so the question is, why don't I know about this? And it's truly just marketing. It is marketing that nobody has told doctors this, that has told patients this. Which is why we fought to get these guidelines created, because you cannot argue with guidelines by the American Urologic Association.
- [29:18]
A
First of all, thank you for all of that work and thank you for explaining that. And I want to be sure that we don't move on until we've completely unpacked this.
- [29:28]
B
I love this conversation because it's happening already every single day because of not just me, but so many of my amazing colleagues on social media. They're yelling, they're screaming, and we are saying the same thing over and over and over again. Basic stuff. Gsm, Genitourinary syndrome of menopause is what happens to the vagina, to the vulva, to the bladder, to the urethra, the. The tube that you pee through when hormones change. So like a plant needing water, the vagina needs hormones. Okay, so if we get really simple, you have babies, right? When you're changing it, you have daughters. Correct. You probably remember when you used to change their diaper. It was teensy tiny. It didn't look like grown up genitals. It looks like baby genitals. Right? That is no hormones, okay? That's what happens when there's no hormones. It's very thin, it's very fragile.
- [30:18]
A
Yes.
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B
They pee their diaper all the time.
- [30:20]
A
Oh, yes.
- [30:21]
B
You put that diaper cream, it's a visual. Anyone who's changed a diaper, they. They know this, right? And then puberty happens. Your kids Stop letting you look down there. But puberty happens and there is a surge of hormones. You start changing, you get taller, you get breasts, you get meaner to your mother. But your genitals, they change, they transform, they, they respond to estrogen and testosterone. And so there are things that you can see with your eyeballs, like the labia start to grow, the clitoris grows, the area becomes pink. You can put tampons in, you can have sex, you can lubricate, you can orgasm. This is all because of hormones. And so, so again, when you play with hormones, there are consequences. So anything you do to manipulate hormones can change the health of this tissue. So when perimenopause happens, or other things like breastfeeding or birth control pills or.
- [31:11]
A
So this, this GSM can affect a 20 year old?
- [31:15]
B
It can absolutely affect if you're on birth control. Absolutely.
- [31:17]
A
Okay.
- [31:18]
B
And so because the tissue responds to both estrogen and testosterone, any changes to estrogen and testosterone can affect, affect this tissue. So without those hormones or with a change of, a significant change to those hormones or a fluctuation of hormones, then the tissue can start changing the way that it looks, but it can also start changing the way that it feels. So you see your PH start to change. So the tissue which wants to be acidic, the vagina wants to be acidic so it can fight infection, the acid fights infection, keeps you safe, keeps everything as a healthy microbiome. You start to lose that acidity, The PH starts to rise, bad bacteria start to grow, the good bacteria start to shrink. You can see dryness thinning, maybe it cracks and bleeds, it starts to hurt. Sex becomes painful. Orgasm gets more difficult. Arousal, you don't feel that same blood flow. You can see the labia minora, those inner wings can start to disappear, actually, because women don't know that their genitals are changing in response to changing hormones. But there's so much hope because with microdosing small amounts of vaginal hormones, you can prevent all of this and cure this problem. This isn't like a little bit of lubricant that helps it be more slippery. This is fixing the ph, fixing the microbiome, fighting infections, preventing UTIs, making sex not painful, helping with your natural lubrication. And, and it is not expensive, often covered by your insurance, and prevents urinary tract infections by more than half. So it doesn't even matter if you're sexually active or not. And by the way, it's not just urinary tract infections, it's frequency, it's urgency, it's Leakage.
- [33:04]
A
Wait, what do hormones have to do with frequency, urgency, and leakage?
- [33:08]
B
Because the whole environment, when it has hormones, it's less twitchy, it's less irritated. It is the response to the dryness, the thinness, this irritation where your bladder is just like, oh, I don't feel. I'm. I'm. I'm not feeling great. I'm not feeling my best self right now. And so the hormones fix the bladder as well. And so it is truly it. It's so wild how simple and easy this is. This used to be called vaginal dryness. Atrophic vaginitis. It was just kind of seen as like, oh, yeah, it's a little dry down there. Okay, old lady, here's some lubricant. Oh, here's some moisturizer. No, no. This is urinary tract infections. This is frequency and urgency and leakage and pain with.
- [33:52]
A
This is decades of my life, honestly.
- [33:55]
B
You've felt this? Like, tell people your experience.
- [33:58]
A
Oh, my God. When I was in my mid-20s, I started getting chronic UTIs.
- [34:03]
B
Was your birth control?
- [34:05]
A
Well, I always thought it was because I was having sex with my boyfriend, but it was probably a combination of both.
- [34:10]
B
Yeah.
- [34:10]
A
And I. It became such a problem that I had two hospitalizations where the UTI would start. I would think that the antibiotics got it, but meanwhile, it was traveling up to your kidneys? To my kidneys. I would spike a super high fever and then end up, like, with a UTI that had gone to the kidneys. And then when I had kids. Oh, my God. Once I had kids, it was like two decades of cycling through many perimenopause where I would get so dry and so irritated. I've had constant issues with leaking and with urgency, and it was just called vaginal dryness. And so I would treat a UTI with an antibiotic. I would drink cranberry juice. I would slap some a N D on with a pad in my underwear in order to kind of get through it, and I would just grit and bare.
- [35:05]
B
Can I just say on behalf of all of my colleagues, I'm so sorry that you were not treated to the full extent of our knowledge because we have completely not taught medical professionals the underlying reasons of why this is so important.
- [35:21]
A
Well, I want to just make sure I understand what you mean by vaginal hormone supplements and that this is both something you can just do as part of your protocol to keep your sexual health and. And the hormone balance of your vagina and your urinary tract in balance. But it's Also how you treat it.
- [35:44]
B
So this is really important because it can be part of your hormone regimen and it should be part. So if you're on a patch or an oral estrogen or pellets or anything like that, if you're doing whole body hormone therapy, you still likely need vaginal hormone therapy. So if you think you do still, still.
- [35:59]
A
Well, I literally, like, I'm wearing a patch right now and I popped my ass. My. My progesterone pill last night.
- [36:04]
B
Put anything vaginal.
- [36:06]
A
Like, I just.
- [36:07]
B
Mel Robbins, we are about to change your life.
- [36:09]
A
Thank God. I feel like I need some.
- [36:11]
B
I can't believe this. Oh, my God.
- [36:12]
A
I need some testosterone too. And I think.
- [36:14]
B
So we're gonna have some fun because it's really important. Because if again, here's my mission. If I help you, think of how many millions of people we're going to help. Because what you are have going on is not rare. And so it is so important. And we wrote this in our guidelines. The American Urologic association, we published guidelines on the genital urinary syndrome of menopause in 2025. My favorite guideline, 11, which says people on hormone therapy still should be screened and treated for the genitourinary syndrome of menopause and we should be giving vaginal hormones. So if you have any symptoms, I'll ask. Do you have any symptoms of urinary frequency? Urgency, leakage, UTIs, dryness, pain, anything like that?
- [36:56]
A
I don't have any leakage because I actually ended up getting bladder surgery. It got that bad? Occasionally. Dryness?
- [37:03]
B
Yeah.
- [37:05]
A
Frequency. I go to the bathroom more than I'd like to go.
- [37:08]
B
Women just put up with what's their normal. And so when, like, how often should
- [37:12]
A
I go to the bathroom?
- [37:13]
B
I don't even know when. We add vaginal hormones to your routine in about two to three months, you're gonna send me an email. I can already see it. I'm manifesting this email that says, holy moly. I did not even know how badly I felt. Right.
- [37:27]
A
You know what? I'm gonna admit something. And the team will probably they out me on this. I bet. I use the bathroom here eight or nine times a day.
- [37:34]
B
Yeah, it's a lot.
- [37:36]
A
And that's a symptom of gsm potentially.
- [37:39]
B
Absolutely.
- [37:40]
A
Really?
- [37:40]
B
Yeah.
- [37:41]
A
Holy. I didn't even know that this was something that we could change.
- [37:45]
B
Let's try. The reality is, is adding vaginal hormones has no downside. Literally no downside. Takes about two to three months to maximally get your tissue re this is true rejuvenation. By the way, all that ads for vaginal rejuvenations are crap is real rejuvenation. Because like a plant needing water, think of a dry, cracked, hungry plant, you give it water and it thrives. And so this is what vaginal hormones are to this tissue. So it takes about two to three months to maximally prevent those UTIs and to fix those symptoms. And there are other things to do as well. I'm not saying this is the only thing you have to do, but it is like sunscreen. It is the foundational element. This is the life saving therapy that is going to keep the tissue as healthy and as flourishing as possible. Wow.
- [38:35]
A
Dr. Rubin, I am so grateful that you came to our Boston studios. You know, what you're explaining is making me feel so seen. It's making me understand my body differently. I cannot wait for my two adult daughters to hear everything you've just explained because I've never heard anyone talk about women's health so directly, so clearly and in such an empowering way. And if you're listening right now and saying, wait, oh my gosh, this is me, this is exactly what I've been experiencing, do not keep that insight to yourself. Be generous. Share Dr. Rubin's expertise with your sister, your mom, your friends, your colleagues, your daughters. Because this information could change her life. Don't go anywhere. Dr. Rubin and I are going to be right back after this short break, so stay with us. I love our sponsor, Audible. That's why I want you to check out the well Being Collection from Audible. Because this year it's time for you to take care of yourself. And who better to help you do that than some of the top voices in well being. I listen to Audible all the time, constantly in the car when I'm hanging out around the house. You know, my favorite place to listen is when I'm on a walk. Especially when I'm on a walk on a treadmill because it gets super boring. And this is actually a hack backed by science. Save your favorite audiobook for when you're walking on the treadmill. That way it motivates you to take care of yourself and get your walk in.
- [40:07]
B
How cool is that?
- [40:07]
A
That's what I do. Oh, and by the way, the let them theory, it's also in the Audible well Being collection too. Ready to imagine more for yourself and your family? Kickstart your wellbeing journey with your first audiobook free when you sign up for a 30 day trial at audible.com mail. That's audible.com Mel after your free 30 day trial, an Audible membership is just $14.95 a month and you can cancel anytime. Audible. There's more to imagine when you listen.
- [40:36]
B
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- [41:06]
A
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- [43:31]
B
Oh my gosh, my medical bag. Okay, so we have. Can you see any of this? I can. I'm gonna hold it.
- [43:37]
A
You're holding up a post.
- [43:38]
B
I'm gonna hold it up. Okay, so here we have some vaginal ph paper and actually you vaginal ph paper on Amazon.
- [43:44]
A
Okay.
- [43:45]
B
And the PH of the vagina wants to be four and a half or less. So you take the strip and you just rub it on the inside of your vagina. You could rub it with a Q tip and rub it on this paper. And you would look at the color. And if it's yellow or light green, you're in a less than four and a half, which is an acidic ph. If it's dark blue or a higher ph, that is a sign that your vagina is not acidic enough. And so if a patient says she's on vaginal hormones and we look at the PH and it's not as dark blue, I'm like, wait a minute, are you really using this? Do you have an infection that's explaining why this stuff isn't working? Are you using enough of the thing that we prescribe to you? So this is something a vaginal strip you can buy on Amazon.
- [44:27]
A
Anybody can do this right now and see like if you need.
- [44:29]
B
And you can see if like this is why you're getting urinary tract infection. Even if the ph is normal, you can and should still use vaginal hormones if you're having any symptoms like frequency, urgency, or if you've had any urinary tract infections. We really want to consider a hor, an underlying hormonal cause. Does that make sense?
- [44:47]
A
Yes, makes a lot of sense.
- [44:49]
B
So vaginal hormones are microdosed amount of hormones, a tiny amount. So it is such a minuscule amount that it doesn't change what your patch is doing, your estrogen patch or say someone who's on no hormone therapy. So a 70 year old woman on no estrogen Therapy, her estrogen levels are zero. Okay, zero. If she uses any of these vaginal hormone products, her estrogen level still stays around zero.
- [45:15]
A
Wow.
- [45:15]
B
They may blip up to like 20 for a couple hours. The data shows, by the way, your husband's estrogen is 25. So it blips for a couple hours to 20 and then goes right back down to zero. So these are safe if you have any reason to fear whole body hormone therapy. Vaginal hormones are a different bucket. They don't count. They, they, they do not go throughout your body. So the most common prescription I'm holding up a tube of cream called estradiol. Cream, Cream. This tube of cream. Cash price is $13. Okay, $13. This tube of cream will last you about two and a half months. So that means for about $7 a month, you can prevent UTIs by more than half.
- [45:56]
A
And who do I get that from?
- [45:58]
B
So right now you need a prescription. But the head of the FDA said he's interested in looking at making vaginal estrogen over the counter, which would be game changing because right now, now you have to get a prescription from your doctor. And there's a chance your doctor doesn't know how to write this prescription. So the guidelines which we'll link to tell you how to write the prescription. My website has a free downloadable where you can teach your doctor how to write the prescription. But you take one gram of this cream. So you can put it in an applicator to make one gram, or you can just put it on your finger, on the strip of your finger like you're brushing your teeth when you forgot your toothbrush. And you rub it on the inside walls of your vagina like you put sunscreen on your. You don't glob it in. You rub it in so it's not messy or goopy or gloppy. And you just rub it in and you go on with your day. You do one gram twice a week. A twice a week therapy for $13 a tube can save your life. If you don't like creams. And so many women don't like to put creams in their vagina. I get it. I don't like it very much myself. There are other options. This is a generic product. It's, it's 10 micrograms like, which is a tiny dose of estradiol or estrogen. And it's a suppository. So you take the applic, you press a button and it puts what, a tiny little pill in the vagina and you do it twice. A week at bedtime and you set it and forget it and you're done. It's just so easy to do. And it prevents UTIs by more than half.
- [47:24]
A
Wow.
- [47:24]
B
Now if you really want to set it and forget it, they make a ring. This is called an E string. It is a localized low dose estrogen that you put in the vagina and you leave it in for three months at a time. This is great for your very busy person on the go or your patient who maybe has dexterity issues or dementia in the nursing home is having issues. So we have lots of patients, they come in, we change their ring every three months and they go back. I had a patient who had end stage dementia. Her husband brought her to see me. She was on opioids cuz she was in so much pain and she couldn't sit. And I examined her and I said, I think this is just gsm. I think you just have genitourinary syndrome of menopause. Like she wasn't able to sort of understand. And we were able to put the ring in. And three months later I get a call from her husband and he says, I would pay any amount of money in the world for that ring because you saved my wife. She has quality of life, she's off opioids, she sits without pain. I'm so grateful to you. It's a beautiful story of quality of life matters. And so each product has their own benefits. It's a toolbox, which is so great because not every woman is going to want the same product.
- [48:35]
A
And I would hope that if you're listening and you know somebody that works in a nursing home or you know somebody who has someone in their family, family who is struggling with dementia or in a nursing home. The stories that you hear of elderly women living with chronic UTIs is, I mean it's a very, very common story. And a ring like this and one appointment could change the quality of their life.
- [49:07]
B
And it's so important, truly I can't, can't express it enough of how the nursing homes need to get on board with this, how we need to be helping patients with this because this is all preventative. So if you do have an infection, yes, you need to be, see a doctor, get a culture. If you're symptomatic, you know, you need treatment with antibiotics. But we have so much antibiotic resistance happening, gut issues that are happening because of all the antibiotics that we're giving people. So anything we can do to prevent this problem. And nothing prevents urinary tract infections to the Level that vaginal hormones do. And so getting this, the warning labels coming off because they were never correct is so monumental.
- [49:49]
A
And it's the same treatment whether you are a 20 something on birth control and having chronic UTIs like I did, or you're a menopausal person, or you're a woman in her 80s or 90s in a nursing home. It's the same treatment.
- [50:03]
B
Totally same treatment. If you had been on your birth control, I probably would have convinced you to get a hormonal iud, which doesn't typically cause the problem.
- [50:11]
A
I actually got one.
- [50:12]
B
Yeah.
- [50:12]
A
Yes. And then I didn't have issues for a while.
- [50:14]
B
Yeah. That's why. Because so the, the marina doesn't shut your. So it doesn't change ovulation. Okay. So it's a hormonal iud, but it's a progestin and it's a very micro dosed amount of progestin. So it doesn't go through your whole body. It just coats the uterus to keep the lining thin so that you don't implant and, and have a baby. I'm not a gynecologist. That's the best I can do as a urologist. But what it doesn't do, what birth control does, is it turns your ovaries off. It shuts down your ovaries and it adds back high doses of fake estrogen and a fake progestin. It doesn't add back testosterone. Every woman on a birth control pill has a low testosterone state. And, and that's a problem because remember, the genitals are full of testosterone receptors. And so it throws off your microbiome, which is why you had pain with sex or, or UTIs and all of these issues around sex. Right. Because it's a sexual organ. So an iud. Right. Doesn't. Your ovaries now are making testosterone again. They're making estrogen again. They're making progesterone again. So they give the genitals what they need. And you. That's why you stop getting UTIs. Wow.
- [51:17]
A
You mentioned your mom.
- [51:18]
B
Yeah, I would love to tell this story, actually. So this is really personal. This issue got really personal for me and my family. My mom was a nurse and my mom was. My mom and I had a challenging relationship, as many mothers and daughters do. And she was an amazing lady. Amazing, incredible talent, talented, creative woman who didn't quite believe in herself the way that, you know, she didn't quite see herself the way that everybody else saw her. She really was a superhero. And my mom, after Covid. She developed a lung condition of pulmonary fibrosis that was pretty sad and was progressing and she needed oxygen. And my mom was a lady who lived the crap out of life. And if she didn't have the quality of life she wanted, you know, she wasn't, she wasn't really happy to, to do more. So she decided, and her doctors decided to get a lung transplant. And so my mom got a lung transplant and didn't really wake up from the lung transplant. It didn't go well. And she was in the ICU for about six months. Oh my God. She was in Houston at the time. We were, I was in Washington, D.C. building my practice, doing all this advocacy work, yelling and screaming and seeing patients. And we were navigating this ICU stay. Now ultimately she woke up from a coma and got another lung transplant and ultimately decided to. We couldn't get her out of the icu. But, but during the six month hospital stay, I said to the doctor she was very sick. And I said, you know, I'd really like to start her home dose of vaginal hormones because my mom is immunocompromised, her immune system is off. She is at risk of getting a urinary tract infection. She's got a catheter in place. I'm a urologist. We're working on these guidelines. I know that she could die of urosepsis very quickly. And I said, I'd like to start her home dose of vaginal estrogen. Estrogen. And they looked at me like I was insane. They said, little girl, don't you know your mother's very sick? I said, yes, I know my mother's very sick, but I also know the data and I know that this could save her life. And they said, well, don't you know hormones cause blood clots and strokes and heart attacks? And I said, that's not true. I know the data. That's absolutely not true. So I showed them the data. I wrote up a whole thing. I sort of clutched my pearls and said, do you know who I am? They didn't really care, to be honest, but they said, okay, do whatever you want. We don't care what happens. Sure, you can do the vaginal estrogen, but you have to convince the ICU team. So I go to the ICU team. I said, okay, here's the data. Here's what we should do. They said, don't you know it causes blood clots? I said, no, it doesn't. It doesn't cause blood clots. Here's the data. So they said, okay, fine, do whatever you want. You're a doctor, you can, you know, you can do this, but show us how to write the prescription. So I'm in Houston and I'm typing out how to write the prescription in their medical record because they have no idea. Well, then the pharmacy calls and they said, well, we can't dispense this to the icu. There's a big warning alert that said this causes blood pressure clots. The box says it right here, it says it causes stroke, blood clots, heart attacks, probable dementia. And your mother is so sick. And I said, I know my mother is so sick and I know the data. I'm on the guidelines committee. I know this better than almost anybody else in the world. I want you to give the prescription. So they sent up this tube of estrogen to her hospital room and the nurses look at it and they said, we've never seen that medicine before. We don't know how to give it. They didn't send it with the applicator and they didn't send it with any instructions. And so I did what any good daughter would do, is I put on gloves and I did it and I showed them how to do it. And what was so beautiful was because I couldn't be there every day, but my dad and my brother were. And they advocated every twice a week because what happens for anyone who's been in the icu, and I see you and I hear you and I'm so sorry for what you're going through. What I found out was right. What we know is that every week the team changes.
- [54:56]
A
Yeah.
- [54:57]
B
And we had to do it all over again.
- [54:58]
A
My God.
- [54:59]
B
And so it gave some. Something for my dad and my brother to advocate. It gave them something they could control. And so it was really, actually beautiful because every like Monday and Thursday, my dad would call me, he'd say, like, I talked to the nurse, I made sure it was on the med list, I made sure it's got, you know, they're going to give it, I'll tell them what to do. And it was something they could control. Now my mother woke up from her coma and she came out of it and she knew that we were doing this and we were advocating and she was really proud and you know, she thinks I'm a little ridiculous. But anyway, ultimately my mother decided, decided to go on hospice and. And my mother passed in November. Now what's so beautiful about this story? Actually, she passed on my 10 year wedding anniversary, which I thought was a little sad, but what happened On February 12, 2026, the FDA officially removed the label. And it's my mom's birthday. What? Right.
- [55:47]
A
Oh, my God. You're gonna make me cry. They did it on your mom's birthday.
- [55:51]
B
I know it was my mom's birthday, but again, this is the universe universe in that on my mom's birthday, the FDA announced that they started to remove the labels that say, causes stroke, blood clots, heart attacks, probable dementia. The label doesn't exist. Like, the warning label no longer exists. It never should have existed. And so it was so incredible to get to have that story. Right. And to. She didn't get to see me on stage announcing the label removal. She didn't get to experience all of the. That. But she's up somewhere.
- [56:22]
A
What's her name?
- [56:23]
B
Carol Ruben. Yeah. And so she's somewhere up there, you know, helping with all of this stuff.
- [56:29]
A
What a beautiful, beautiful, beautiful story. Thank you for sharing that. I mean, how incredible. What does that mean to you? Especially the part that the label started getting removed on her birthday after she died.
- [56:48]
B
Honestly, the. The movement that's been happening, the interest in this, the guidelines coming out, the labels getting changed, the. The groundswell of grassroots women standing up and saying, no more. It's so beautiful. It's so overwhelming. And I. I just. In the world, which is a very scary and wild place right now, to see these glimmers of hope, to see that when you take action and you work in community and you get loud about something you believe in, and you actually see things change again, taking action is what gives you hope. And I tell my patients that every day, is that we keep taking action. We show up, we get loud. It's truly remarkable. And. And I. To be a part of this has been. I mean, I have no words. Right. It just really is absolutely incredible.
- [57:43]
A
You know, you've shared so much about this topic of GSM and vaginal estrogen, and just so it is very clear who exactly should be on vaginal estrogen. Dr. Rubin?
- [57:58]
B
Yeah. So there's no one who can't have vaginal estrogen is really important. There is no one who is contraindicated or shouldn't have these products. There is what we call shared decision making, in that you have to want it, and your doctors have to want to give it, and you have to come to this conclusion that it's the right thing for you. And in my opinion, it is the right thing for you. Um, and if you have any urinary symptoms, frequency, urgency, leakage, any pain with sex, dryness, if you've had a uti, you should be considered for vaginal hormones. That's if you've had a history of breast cancer, if you've had a history of any types of cancer, because quality of life is so important. And dying of a UTI doesn't sound very good to me. And so we must weigh. There is bar. There is no data to show harm in these products. In fact, a paper, paper came out two years ago that said looked at 50,000 women with active breast cancer and those who took vaginal estrogen died less. So there are more papers out there that show less mortality. So dying less if you use vaginal hormones than if you don't. There are even observational papers that show people who take vaginal estrogen have fewer heart attacks, strokes, things like that. And I think it's because, I mean, again, maybe these women are sexually active, they're more active, they're more interested in their health so that we see these health outcomes. But you shouldn't suffer. You shouldn't suffer. And, and so many people, they are constantly feeling itching, burning dryness, awareness of your genitals. They're grabbing at their pants, they can't wear pants anymore. They can't sit through their mahjong game, they can't go visit their kids, they can't pick up their grandkids without leaking. And there are therapies and treatments that are inexpensive, that are safe, and that if you use, will work. Now, if you don't use them, if they stay in your bathroom drawer, if you can't afford them, do not work. But again, this tube, this tube of cream, a generic tube of estradiol cream can be as little as $13 a tube, cash price, without insurance. So they are now accessible. And so the, if they become over the counter, even better. Right? The more we can get this in the hands of the people who need it, the better.
- [60:11]
A
And if the person who's listening is not in perimenopause or menopause yet, they're younger.
- [60:17]
B
Yeah.
- [60:17]
A
So still a candidate for vaginal.
- [60:19]
B
Absolutely. So if you're breastfeeding. We actually published. I have the greatest research team in the world. You have a good team, Mel. I've heard about your team. You have a great team. I have an incredible this. I started a grassroots research group. We published in the biggest obgyn journal last year on gsl, the genitourinary syndrome of lactation. The fact is, when you, you are breastfeeding, you're in menopause, and every gynecologist knows this but they forgot to tell all of us, and they forgot to tell us that actually vaginal hormones were safe. And so GSM and GSL are the same thing. Right. Genitourinary syndrome of lactation. So when you have a breastfeeding patient or lactating, pumping patient. Right. They will also have frequency, urgency, leakage, more UTIs, pain with sex, dryness, low libido. They have all of those things. And vaginal hormones are safe for them, don't affect your milk supply, and should be used commonly. And in fact, we've done even more research that shows very few of these patients are actually offered a vaginal hormone therapy and it's being really underused.
- [61:23]
A
Wow. Wow. You know, one of the reasons why I'm so glad we're talking about this is I think that you live with a lot of things as a woman and you don't realize it's actually an issue. Like, I just assume that the reason why I go to the bathroom at work like seven or eight times in a workday is because I drink a lot of water. Or maybe, maybe, you know, the bladder surgery that I had and the sling that my bladder is in is couple years, I don't know, five or six years old now. Maybe there's something going on there I don't like. I, I just assume, okay, well, this is just something I live with.
- [61:57]
B
And we see this every day. And again, this is why medicine, the way that it is currently set up, is not meant for women or men.
- [62:04]
A
And here's the other thing. Here's the other thing about it is that it feels like this thing that what am I going to do? Make an appointment to go to a urologist? What am I going to do? Go, go to my gynecologist? Who's got time for that? And is it even an issue or is it just like my body? And when you said the thing about like grabbing at your pants or, you know, feeling a little dry or things feel a little uncomfortable, like, is this even an issue or is this just how things are? You know what I mean?
- [62:31]
B
And that's the challenge. Because I'll be honest, medicine is not meant for people. Because if you come to my office and we only have 10 minutes, which is what most doctors, doctor's office visits are, and we sit down for 10 minutes, do you think I'm really going to get to know you, Mel, in 10 minutes I could be the smartest doctor in the world? Do you think I'm going to know? Or it's going to be high up on My list to ask you if you're grabbing at your pants because you have some vaginal irritation. That is not going to be 1, 2, 3, 4, or 27 on my list of things to talk to you about in 10 minutes. And so medicine is broken because we are missing the rich, beautiful lives of our, our patients. And so I have taken myself out of the system and I'm still trying to figure out how to, how do we do that in a big accessible way. But this idea of your support system matters. How you learned about sex matters, how you feel about your own libido or if you have pain with sex, like that matters to you and the person you are with, it matters deeply. And so, yes, you don't find yourself going to make an appointment because you don't even know that there's someone who would listen. And so that's what we're trying to change this idea of it matters to you. There is someone who it matters to, like another clinician. And, and I always think of it like a pit crew. You have to kind of bring in the people into your pit crew when you have space for it, because you don't always have the space or the energy for all the things at once.
- [63:54]
A
Right.
- [63:54]
B
If you listen to your podcast, you know, you can't do all the things in, in one day. You have to kind of meet yourself where you are and give you what you need. But if sexual health or urinary health, health or quality of life is important to you, there is a growing movement of clinicians who deeply care about these issues too. We don't have the clinicians to do the work. And that's where I struggle because there are not enough people who know how to write estrogen prescriptions. It's simple. I can do it. If I can do it, anyone can do it. And that's why we have to teach. We have to get loud. So it's not just enough for me to do this podcast and yell and scream and say, hey, this is really important because women are knocking on doctors doors every day now and being told, no, they're being told, this isn't real, this is all in your head. Or because these, these clinicians, they're not bad people. They're, they're doing a lot of things, but they were never taught how to do this. And then there's the fact that we decided not to study women at all, right, in science. And so we're 30 years behind and we don't have enough funding, we don't have enough research money. So There's a reason your doctor doesn't know anything about the this topic.
- [64:59]
A
And but you know what we do have? We have you. And so we can go to your website and we are going to link to absolutely everything in the show notes and in fact, you have a printout that you can take to your doctor to explain the guidelines on this and how to prescribe it. And so you are making it easier for us. But by being here and sharing all this and teaching us about our bodies and about these life changing and life saving options for ourselves, our daughters, our mothers, our grandmothers, our sisters, you are empowering us to be part of the positive change that needs to happen when it comes to women's health.
- [65:38]
B
I had a woman in my office just this week. She came to see me with debilitating pelvic pain where her goal to work with me was, I want to be able to pick a job where I'm not afraid of being at work because of my urinary pain. And what caused her urinary pain? Pain? Birth control pills and spironolactone for her acne.
- [65:59]
A
What? Hold on a second. Birth control pills and that medication for hormonal acne?
- [66:05]
B
Yes.
- [66:06]
A
Which I have two daughters in their
- [66:09]
B
20s, so those medicines work to block testosterone and so that's why they help with the acne. Now, I'm not saying you should never be on these medications, but when you play with hormones, there can be consequences. And for this patient, it was causing horrible vulvar pain and urinary pain and urinary tract infections and pain with sex. But she didn't even come to see me, the sex doctor, about her pain with sex. It was, I can't have a job that I go to. I have to do remote work from home because I am so afraid of being in a place with urinary pain and planning my whole life around it.
- [66:44]
A
Well, here's the thing that I think is really important. And I think it's important because in your 20s, as a woman and your 30s, you just kind of think UTIs are a byproduct of having sex. And what you're saying is if you are somebody that tends to get them more frequently before you just blame it on sex, and you keep trying to get antibiotics and chugging your cranberry juice, that you should go to the doctor and you should ask for a prescription, prescription of vaginal hormones, because the research is clear that it is safe. And if you simply use it twice a week, it prevents 50% of the UTIs that you're going to get.
- [67:27]
B
It should. Now, we need more data on using these products in people, young people. But the reality is, is you won't hurt anybody. You're not going to hurt anybody using these products. The question is, is the birth control affecting things so much that it will override this, which, I don't know. I think it would be okay, but considering other forms of BIR that don't alter testosterone levels. So that's where we love IUDs and things like that, because they don't alter your body's formation of these hormones. And so we have to be thinking broader about urinary tract infections from a hormonal lens. You know, it's very frustrating because there are people looking at vaccines for UTIs. These very expensive research projects for UTIs, which I'm all about UTIs, are a massive problem for our healthcare system. But we are not effectively using these vaginal hormone products. My colleague out at Stanford just published a paper a couple weeks ago ago in jama, and it looked at Medicare patients. Okay. It looked at over a million patients with Medicare with a diagnosis of a symptom of GSM. So frequency, urgency, leakage, UTI, vaginal pain, any of those. 1. You haven't had one symptom only.
- [68:36]
A
Which means you have UTIs based on hormone fluctuation.
- [68:40]
B
Yep. You had a symptom of GSM. Only 9% of patients were given a prescription. 9%.
- [68:48]
A
So other than being very effective in preventing UTIs, what else does vaginal hormones do for a woman of any age?
- [68:57]
B
Yeah. So besides preventing UTIs, it's essentially Viagra for women.
- [69:01]
A
Why do you call it that?
- [69:02]
B
Because it helps with sexual health. It helps. So Viagra is actually a wonderful muscle relaxer that helps men get erections. It helps women get erections, too, and I'm happy to talk about that. It is a great relaxation drug that increases arousal. Vaginal hormones help with arousal, help with lubrication, help make sex not painful. So it's a fabulous sex drug, best sex drug ever invented. And so I call it Women's Viagra because it truly is. But actually, people don't know this, but Cialis, which is Viagra's cousin, we give to men all the time for urinary symptoms, frequency, urgency, things like that. It's a great drug to take every day, a small dose every day for urinary symptoms. And vaginal hormones help with urinary symptoms. So it is essentially Viagra. Viagra, but also prevents UTIs. So how is this information not given this? It's so here's the crazy thing. When the FDA came out and said we're removing these warning labels on estrogen products, not one person out there said that these labels should be in place for vaginal hormones. That's how safe and effective these products are. Is no one disagrees with me, which is so wild. And yet women aren't getting what they need. I have so many women who come to me who said, I am so tired of thinking about my genitals all the time. It's an awareness. So when we talk about vaginal dryness, we think of it as a cutesy old lady thing of, oh, a little vaginal dryness. It's actually not true. It is a dryness so significant that it affects your quality of life day to day.
- [70:37]
A
How do you know? Because that sounds like it's cracking and bleeding. Like, what is enough to, to affect. Just like thinking about it.
- [70:42]
B
It's just thinking about it. Adjusting yourself, thinking about the dryness of your skin down there and other places. Right. That, that's what. Remember I said, like a plant needing water. Right. The tissues, the skin, the inner tissues, the outer tissues need hormones to feel robust. And so that's where the reality is. Using these products do not hurt you if you're on hormones already. You can add them to your hormone regimen if you're not on hormones. This is, this is not whole body hormone therapy. It is localized lowd dose hormone therapy that is safe for your great grandmother or people with any history.
- [71:20]
A
And so, or a college student or a high school student that's having constant UTI issues.
- [71:25]
B
And that's where we really need to get the advocacy and the research going, because this is not just a menopause problem.
- [71:33]
A
Dr. Rubin, can you just explain a little bit about like how the, how hormones. Like, I'm still trying to understand how hormones impact like peeing and infections. Does that make sense? Like, I kind of feel kind of dumb that I don't know a lot about this, but to me, I would never think that hormones have anything to do with the amount of times I go to the bathroom, whether or not I have trouble going to the bathroom. How, how is it connected?
- [72:04]
B
Yes. So the bladder and the vagina are very close together and they are filled with estrogen and testosterone receptors. So they are constantly looking in their environment for hormones to be around. And there are times when hormones are around a lot and there are times when they fluctuates and when those receptors are empty, they don't like it. Right. So they change. And so without hormones, the tissue changes, the acidity changes. And if you, you know, the vag like and wants to be acidic, and if it is not acidic, the evil bacteria starts to grow. There becomes a dysbiosis, meaning the, the. The right culture invite the right environment of bacteria changes to what ends up being the wrong environment of bacteria. Okay, so here's where sex becomes important. Because now you don't have a strong acidic base. And then if you have sex and if your partner ejaculates inside of you, well, remember guys, I'm a urologist, so ejaculate is a big of basic material. Now, I don't mean basic. Like every man is basic. We can have that conversation. But it is a big load of ph. High ph, because acid base, big basic material. And so that also then throws off your microbiome even more.
- [73:24]
A
Can I ask a question I'm almost embarrassed to ask?
- [73:26]
B
No, no, no, please.
- [73:28]
A
Okay. Is there testosterone transform.
- [73:33]
B
Not. That's a great question, actually. I don't think so.
- [73:36]
A
Okay, so we're just dealing with hormone.
- [73:38]
B
Just that, like. Okay, just the fish.
- [73:40]
A
Okay, so just the fish. But it's the ph aspect.
- [73:43]
B
Ph aspect. And because that's actually not a stupid question, it's a fabulous question.
- [73:47]
A
And, and because ph is one of the things that hormones help regulate.
- [73:52]
B
Yes.
- [73:53]
A
And when the ph gets whacked, regardless of whatever age you. It screws up the microbiomes of your vagina of the urinary tract, which makes you more prone to infection.
- [74:06]
B
Right.
- [74:06]
A
Am I tracking correctly?
- [74:08]
B
You're tracking correctly.
- [74:09]
A
So if anything's off, whether it's ph or hormone imbalance or you're on birth control or acne medication, or you're breastfeeding and that kind of whacks your hormones, period.
- [74:20]
B
It may affect your microbiome, which makes you more susceptible to urinary tract infections. If. And so again. Or dryness or dryness or itchiness, which feel. Okay, this is where it's. It's very interesting. Sometimes it feels like you have a urinary tract infection, but actually just because you have pain, burning and irritation, often times it's not an infection.
- [74:39]
A
What is it?
- [74:40]
B
It's the dryness and the scrapy rug burn from basically something hormone imbalance from rubbing against. Right. If sex is a high contact sport. Right, Sex is a contact sport. So if you have this hard, rigid thing or a device or fingers or whatever it is rubbing against against. Think of a sunburn. Think of irritated, dry, uncomfortable tissue. Guess what's going to happen? It's going to hurt. It's going to burn, it's going to be irritated. And so we see so many people who think they have UTIs and they don't even get examined and no one asks them questions or they just go to urgent care and we throw antibiotics at them and we've lost the art of doing a physical exam on people. That's a whole other mission of mine, is get people to know how to examine genitals. But oftentimes it's not actually a uti. It's pain from the abrasions and the irritation from the act of intercourse itself.
- [75:36]
A
Wow. And your hormones have a huge role to play in all of that.
- [75:42]
B
Yeah. And keeping the tissue strong and supportive and lubricated and thick and able to withstand the high intensity sport of sexual activity.
- [75:51]
A
Well, based on everything you're teaching us, I don't know why every single woman of every single age. Age isn't prescribed or hopefully soon, because of your advocacy, able to buy vaginal hormones over the counter and using it twice a week just for our overall health.
- [76:09]
B
This is why we're so excited about the interest in this. This is why I leave my children in my practice to fly here, to come do this, because this is so important. There is nothing to sell. These are generic products. There's no industry around this. There's no money in this. This isn't like there's no. This is truly like the public service announcement that is so needed. All I'm doing here is taking a problem that we have always known about with science, that we have always had with a product that is safe. And all I'm doing it is packaging it and marketing it and saying every woman on earth needs to know about this. And mind you, up until last year, all these, these products said that, that cause stroke, blood clots, heart attacks, probable dementia, which was zero percent true for all hormones, let alone microdosing vaginal hormones. And it is so exciting because the science, this is truly bipartisan and scientifically backed. No one disagrees here. And, and to have an issue that is so impactful that can change so many lives. It's not like no one's going to say I'm wrong. They're just going to say they're undereducated about it, which is why we're showing up with guidelines. We're showing up with, you know, how to do it and we're YouTube channels,
- [77:26]
A
everything in the show notes.
- [77:28]
B
That's why I can't be quiet.
- [77:29]
A
I'm GLAD you're not. Dr. Rubin, can you talk about hormones and HRT.
- [77:35]
B
I love talking about hormone therapy. I, I was so blessed with mentorship and mentorship. I, this is why I mentor so much. Because it truly, this, this cannot die with my, the people above me and it cannot die with me. We must spread the information and teach as much we as. As we can. Hormone therapy has been around for a very long time and got a very bad reputation in the early 2000s when a big NIH study came out and said hormones cause breast cancer and cardiovascular disease. And unfortunately, the NIH did a press conference. I don't know if you've ever seen an NIH press conference. I certainly haven't seen anything else make an NIH press conference. The NIH held a press conference before the study was even published. Published. And they got on stage and they said, hormones are dangerous. They cause breast cancer and cardiovascular disease. And we're halting this study early. Well then the paper shows up at all the, this is before social media. So the paper shows up at the doctor's offices. This was a 2002, I believe the Women's Health Initiative, which is what the study was called. It was top of the fold. Every newspaper Matt Lauer got on tv, every news agency got on TV and said, throw your hormones in the garbage. These are going to kill you.
- [78:44]
A
And it's really important, especially if you're not my age or older, to understand that this one incident in the media and in medicine profoundly negatively impacted women's lives for decades.
- [79:07]
B
Overnight, hormone prescriptions went to zero. Billion dollar industry went to zero. Zero. And we have known forever that hormone therapy prevents fractures, prevents osteoporosis, massively helps with hot flashes and night sweats and sleep and, and genital and urinary health. That's what hormone therapy is for, is for symptoms for women who suffer, and so many women suffer for very long time. And this, this press conference made all of that go away in one day. And once the papers came to doctors offices and the ones who actually read it said, well, wait a minute, that's not what this says. That doesn't make any sense. And my clinic is full of hormone therapy patients and they all look pretty damn good. I don't understand what they're talking about. Well, what ended up happening was they misinterpreted the data so badly and they marketed it so badly and we could never get back from that. And actually because of that one press conference, the FDA at the time, time put a blanket label with a big box around it on all hormone products. Everything that's A hormone product that says these products cause stroke, blood clots, heart attacks, probable dementia. Well, that study was based on just one pill, one dose of hormone therapy. It had nothing to do with the patch that you're on or the progesterone that you take. It had nothing to do with test like it had nothing to do with modern day hormone therapy. Especially didn't have anything to do with vaginal hormone therapy, which is localized, low dose. And even in that study, women who only took vaginal hormones had less. No cancer risk, no breast cancer risk. That was published on. So this one study changed the course and trajectory.
- [80:48]
A
Just the study. It was the way the media reported it and the freaking hysteria that it created.
- [80:54]
B
Hysteria.
- [80:55]
A
And for two decades it was just believed that HRT was dangerous and you shouldn't do it and it's going to cause cancer and all this stuff. And so millions and millions and millions of women who would have benefited, whose quality of life would have improved, were either denied it, not offered it, too scared to ask for it. And isn't it true that even some of the researchers came out and said the research was flawed?
- [81:22]
B
Yeah. And that they came out and said, wait a minute, we didn't all agree to this. We didn't all agree to the way this was written and how it was marketed. And the tragedy, and this is an American tragedy, actually a world tragedy. The tragedy is not only did women lose access and never get access to these therapies, but we now have generations of doctors who never learned how to write prescriptions or ask the questions. Ask any doctor. You know, we get no training. And the data is very clear on this. We get no training in medical school, we get no training in our residencies. That's even gynecology and primary care, where you would expect training. Forget the orthopedic surgeon who's dealing with the fractures or the neurologist who's dealing with headaches or sleep doctors who are dealing with the sleep issues. Hormone therapy is not in their toolbox to offer. And modern day hormone therapy, that really has much lower risk than the hormone therapy that was studied in that big study. So even that's those hormones were pretty safe. The hormones we use today are even safer. And so the track tragedy is all around because we have so much work to do. Not just to teach women why they should go ask for it, but it is likely that they're going to show up to a clinician who doesn't know how to write the damn prescription. And again, I say this all the time. If I can do this as a urologist, you can do this as an ER doctor, as a primary care doctor, as a gynecologist. And so I, I think my, my thesis statement of our work today is there are no grownups coming to save the day. Okay? There's no grownups. We are. Are the grownups. And we have to roll up our sleeves and do the work ourselves sometimes.
- [83:00]
A
Well, I think one of the things that is incredibly fascinating about what you've, what you've been teaching us is that if, if, if you are, you know, female, you either go to a primary care gynecologist, I don't even think about going to a urologist, you know, unless I'm having severe bladder problems. And yet, what we now know about hormones is that for women in particular, particular, your hormone health is a part of the equation for every single medical issue that you face, whether it's a UTI or frozen shoulder or brain fog or brittle bones or any symptoms that you're feeling, you know, downstairs, all of it.
- [83:38]
B
And that makes perfect logical sense, Mel, because you have hormone receptors in your eyeballs, in your ears, in your hair follicles, in your gut, in your bladder, in your genitals, in your bones and muscles and tendons. Like there's hormone receptors everywhere. And so, of course. Right. But if your doctor never learned how to ask the questions or write the prescription, it will never be a part of your toolbox. And so that's not to say all medical problems are due to hormone issues. Of course not. But how can, how can the rheumatologist deal with inflammation and not talk about estrogen therapy? How can the orthopedic surgeon or the bone health doctor talk about osteoporosis but not estrogen?
- [84:23]
A
Well, I'm sitting here even just thinking about the fact that after I had my daughter, Sawyer, I had severe postpartum depression. Nobody even considered estrogen and hormone therapy as part of, like, maybe something that we should be talking about.
- [84:38]
B
This is actually where it gets even more. Okay, so I'm going to tell you two stories that are going to make you really angry. Story number one is there are FD new FDA approved medications for postpartum depressions. They are based in progesterone based therapies. Okay. They are based in hormonal therapies. I started a course that it's online. People can take it whenever they want of how to prescribe hormone therapy. And I had psychiatrists pour into my, my DM saying, well, my malpractice insurance said I wouldn't be covered if I prescribed hormone therapy. I said, what are you talking about? Mental health is so helped with hormone therapy. You are crazy for not learning hormone therapy.
- [85:20]
A
If you also think about it, like, just think about PMS and the ups and downs of your moods and the fact that all of the symptoms around pms, whether it's moodiness or it's cramping or it's dryness or it's bloating again.
- [85:35]
B
So for you thinking that all your care should be by gynecology, who also don't know how to prescribe hormone therapy. I mean, some do. And if they take an extra training, where are the psychiatrists? Where are the neurologists? Where like, like this, when you have depression, you go to that person. Not so. So it's a nightmare. We're living in a nightmare because not enough clinicians know why this is important. So one good piece, I want to say one piece of hope because this is actually beautiful. The head of the gynecology association, it changes every year or two, okay. Happened to be this amazing doctor from Yale, old school male gynecologist who loves hormone therapy, understands hormone therapy, understands why the studies were misinterpreted. And he happened to be in charge of the gynecology association the day the announcement came out. And when all of the newspapers went to him because they said, what does the gynecology association say? He stood up and he said, this is good for women. Period, end of sentence. Now they can talk to their doctors about what they really need. And these labels, like, were never appropriate. It was so good. But he said something further that was so beautiful. He said, those warnings labels stopped decades of research. They stopped decades of doctors wanting to do this. Because how can you prescribe something, some, something that is safe? But the box from the FDA says, stroke, blood clots, heart attacks, dementia. How can you get away with prescribing it? We did because we knew the data so well, we thought. But the regular clinicians are not going to do that. These box labels just got removed on my mom's birthday. February 12, 20, 20, 26, right? May she rest in peace. This box labeling gets removed just this past February. Now the real work begins. Now we get to teach people how to do this. Now we get to teach the clinicians. Now we convince the rheumatologists and the neurologist and the orthopedic surgeons why this is essential for them to give good care for women. And so we're going to teach them what we've known for 30 years. And women are going to do better.
- [87:42]
A
Let's talk about testosterone.
- [87:43]
B
Love it.
- [87:44]
A
Okay, so who is it for? What does it help? And what are the biggest misconceptions, Dr. Rubin, that you hear?
- [87:50]
B
Okay, so we have four major buckets when we're talking about hormone therapy.
- [87:55]
A
Okay?
- [87:55]
B
Whole body estrogen.
- [87:57]
A
What's that?
- [87:58]
B
Estrogen patch, estrogen pill, estrogen pellet or estrogen gels. Any type of higher dose estrogen that's there to prevent osteoporosis, help with high hot flashes, night sweats. It ends up helping with your hair, skin and nails as well. But it's really meant for preventing osteoporosis or treating your hot flashes and night sweats. That's whole body estrogen. Okay, then there is if you have a uterus, you or. Or you want to consider it. Even if you don't have a uterus, there's whole body progesterone. Now, progesterone protects your uterus from thickening of the. If the estrogen is used, it thickens the uterine lining. The progesterone keeps the lining thin, prevents uterine cancer. So if you have a uterus, you need some kind of progesterone. And it also can help with sleep and mood. So I don't know if you've noticed any sleep benefits with your progesterone, but it can help with sleep. So that's why some people without a uterus like to take it. But estrogen and progesterone is like yin yang, especially if you have a uterus. So there's whole body estrogen, whole body progesterone, whole body testosterone, which we're going to talk about right now. And the fourth bucket we've talked about is vaginal hormones, which is separate from all the. The other three. And so the toolbox is you can have some of the toolbox. You don't need to have all the toolbox.
- [89:10]
A
You said there are four types. You've got full body estrogen, full body progesterone, you've got vaginal estrogen and full body testosterone. So let's talk about testosterone. Who's it for?
- [89:19]
B
Okay, so testosterone is a human hormone. It is not a gendered hormone. That was very old politics from a very long time ago. And we have to move on. Men make estrogen and testosterone. Women make estrogen and testosterone. Let's quit talking about how one is for boys and one is for girls. It's not true. It was never true. Move on. Okay. Testosterone is a human hormone that we all make regularly. But here's where Politics gets in. Okay, so testicles make testosterone and adrenal glands, these cute little hat like organs that live above your kidney. Kidneys also make testosterone. So for women, their ovaries make testosterone and their adrenal glands make testosterone. For men, their testicles make testosterone. For women. As they get into their 30s, their, your testosterone starts to naturally drop. For men, there is also an age related decline, but it is not as sharp or as castration like as estrogen is for women in menopause. Men, can I always say, I use a gas tank analogy. Men get to like, you know, sometimes have half a tank. If they're really symptom, they'll get a quarter of a tank. They never get to zero. Women's estrogens do get to zero. Their testosterone doesn't get to zero, but it does drop in your 30s. Testosterone. My, my thesis statement on testosterone, it's not that serious, people. We want it to be serious. It feels serious. There's all this emotion, there's all this stuff going on about testosterone. It truly is not that scary or serious. We do many scary, serious things as doctors. This is the least scary thing that I do. So for both, for everybody, right? So if a man comes to see me and he's feeling kind of down, he falls asleep at dinner, his erections aren't as strong, his libido's getting a little low, and his Testosterone is below 300 and he has symptoms, I'm going to give him testosterone and he's going to feel amazing. Okay? The testosterone deficiency can happen at any point. So if you have any symptoms of testosterone deficiency like I just described, you should get a blood test at any age. At any age. So symptoms are low libido, low energy, erectile dysfunction, osteopenia, you know, so sexual symptoms, energy symptoms, mood symptoms. So we know testosterone helps men's moods. And so again, men's testosterone, there are guidelines. It's, there's about 27 different products. There's different ways to do it. Injections, pills, gels, pellets, all these FDA approved things, things that happen for women. We have no FDA approved testosterone product for women.
- [91:55]
A
None.
- [91:56]
B
Zero.
- [91:57]
A
Really?
- [91:57]
B
It's approved in Australia, New Zealand, South Africa and England.
- [92:02]
A
Wait, why?
- [92:04]
B
There was a study that happened. A billion dollars went into it. They studied testosterone and the FDA came back and said, okay, there's five years of data. It shows that it works for libido, it shows that it's safe. There was no major, you know, scary things that happened. Let's go back and talk about it. And the FDA came back and said, you know, women have breast tissue. It was around the time that Women's Health Initiative study came out, 2002. So around then. And they said, denied, we need five more years of data and another billion dollar study. I don't know if you know anybody who works in pharma, but they were not going to do another billion dollar study and no one was going to put another five years. So it died. So it's approved in Australia, it's approved in New Zealand, it's approved in South Africa and it's approved in England. And if it's safe enough for those people, people. And we have global consensus. So we actually have a paper called the global consensus on testosterone therapy in women. You can read it, just google that. Do we agree on anything as a globe? We agree on nothing as a globe. But that paper says global consensus that testosterone therapy is safe for women and works.
- [93:05]
A
Since we've talked about vaginal estrogen and we've talked about testosterone, I'm now leaning in going well if I just want to reduce it down to one thing, if I was going to do both vaginal estrogen, estrogen just as something preventative and for my hormone health and I'm thinking about doing testosterone, which now doc, you got me thinking about doing testosterone. Is DHEA an option?
- [93:32]
B
I'm so glad you asked because here's where dose matters. Okay, so vaginal DHEA is again micro dosing into the vagina to help with the local microbiome prevent UTIs pain with sex. It doesn't create a high enough testosterone level to help with your libido. The way that we get from whole body to testosterone and we don't think that the whole body testosterone is high enough to get to the vaginal issues which is why your patch doesn't isn't strong enough to fix your GSM symptoms. So there is a, a role for instead of vaginal estrogen just using vaginal DHEA so you don't have to do both, you could just use vaginal dhea. The one reason why we talk about estrogen so much is it's less expensive. So often patients can't get the vaginal dhea. Hey, if you're listening world, we would love vaginal DHEA to be over the counter. We would love for it to be affordable or covered by insurance because again, this is life saving therapies that should not cost hundreds of dollars for our patients.
- [94:31]
A
So should you think about the DHEA as like vaginal estrogen plus if vaginal estrogen alone isn't doing the job. And one of the reasons why we started with vaginal estrogen is because, because there has been a lot of advocacy, thanks to you and others, that has made the price drop down. And now hopefully, fingers crossed, it might even become something that's over the counter.
- [94:54]
B
No question. And you understand it so perfectly. And it is, it's like it's sort of. That plus because we don't often use it first line just for accessibility. If it was sort of all options on the table, the vaginal DHEA would be my first choice because it adds the androgen on onto it, which the tissue needs, both estrogen and testosterone. So we like dhea. I love dhea, but I don't have access to it for all my patients. And we're, we're, we have such a broad audience here that that's why you. I don't sort of start with that because why, why dangle something in front of you that you can't access?
- [95:28]
A
Okay, so how do I know my testosterone is low?
- [95:31]
B
So it's, it's. Now it's safe for women. It works for women. The science, this is not cardiovascular research. So it's not as precise as we wish it were because no money goes into women's health and we don't have a product. So the way the guidelines state is that we check a testosterone both in men and women. Actually not, because there is a number specifically that will tell me that you have low testosterone or not low testosterone. But if you come to see me and we talk and it comes up that your libido is low, that you're doing great on estrogen and progesterone therapy, but you feel like they're, you know, that it's not perfect, you know, and libido is the biggest driver that we see with the most data. Although patients tell me a lot more improves, then I would check a total testosterone. And as long as the total testosterone was not astronomically high, then you would qualify for a trial of testosterone therapy. And we use generic, very inexpensive male testosterone and we dose it out for a woman, which is about one tenth the dose. And what happens after about four to six months, Sometimes earlier, but in my opinion, it takes about four to six months. That's when women come back to see me and they say, I feel like myself again. Dr. Rubin. They say, oh, my gosh, my sex drinks are back. Oh, my gosh, arousal is easier. That orgasm was easier. I could actually orgasm without a device. Oh, my gosh, Dr. Rubin. I watched TV and my body just felt the tinglies. Again. They say you actually the data shows and people report their stress incontinence gets a little better. Again, major stress incontinence. There are things to do, but the urethra, the tube that you pee through is surrounded by testosterone receptors also.
- [97:13]
A
Really?
- [97:13]
B
So if it. Again, think, think muscle, right? If you're building muscle, you're building muscle in your pelvic floor, you're building muscle in your urethra. So the other thing my patients will say is, oh, I feel like the gains. I'm working. And I see you working hard, Mel, at your exercise, trying the gains that you make. I'm trying. You, you notice them a little bit more, you get a little more credit. Right. Because we see now again, the data is mostly around libido, but libido is a mood. So there's more data that's come out of our friends in England about mood
- [97:42]
A
improvement, mental health improve seeing in your patients other than the libido we're seeing,
- [97:47]
B
people say their mood is better, we're seeing their urinary symptoms are better, their arousals and orgasms are better, their lubrication is better. We definitely see improvements in libido. And I would say it's, it's the funniest part of it is the thing I see the most is the, the words I feel like me. And that's the magic words, right? When. So estrogen and progesterone, you feel, feel better. Yes, like a lot better. Like magically better. I often start with estrogen and progesterone for many people because the hot flashes are so bad, the sleep is so bad. So if you can get that, they feel so much better. But the testosterone, when we add it is. I'm back to me. I have a patient that I had recently. I just love this so much. And, and she, she said to me, because remember, testosterone drops in your 30s.
- [98:33]
A
So it's not.
- [98:34]
B
Yes, testosterone drops in your 30s. It's not about menopause. It's actually age related. So in your 30s, if you have low levels libido, pain with sex changes in your arousal or orgasm in your 30s, there is likely a biological basis and it is likely has something to do with testosterone. So, so this woman comes to see me, she's in her 60s, menopause consult, you know, typical menopause consult. And we're giving her whole body estrogen, whole body progesterone, testosterone, vaginal hormones. And she comes to see me and she says, Dr. Rubin, I used to be able to orgasm, three mouths, magical times. And they went away, and they went away in my 30s. And I always thought it was from my headache medicine. I was on amitriptyline at the time. And I lost my ability to have three magical orgasms. Well, Dr. Rubin, six months into testosterone, I'm in my early 60s, they're back. And it was just, she had never even thought that she could ask for them to come back. And it was so beautiful because that's not what, what brought her in to see me. And yet it was the unintended magical consequences of this therapy that is not FDA approved for women. Global consensus that it works and not that serious. There's no major risks, there's no major side effects. Actually, I believe very strongly that when you give women information about how their bodies work, they make just excellent healthcare decisions for themselves. I'm not here to tell you what to take, what to do. I'm here to share the menu with you. I'm here to share the toolbox with you and to let you decide what you want to put into, into your body. I have a patient who's actually lives in my neighborhood and I never see her in the neighborhood because she's always at work and she's busy. But one day she's walking her dog and she sees me walking home from dropping the kids off at school. And she runs up to me, and I only know her from the sort of the exam room and everything. And she runs up to me, she says, Dr. Reuben, I'm sorry to bother you on your walk. She said, I just had to tell you my testosterone finally kicked in. I said, oh, that's so great. How long did it take? She said, it took five months, Dr. Rubin, but it finally kicked in. And I have to tell you something, she said, I finally feel back to me and guess what? I just quit my job because I'm starting my own thing. And she was so excited to just quit her job, start her own consulting business and kick all of the ass. And that's what I see every day in my clinic is when you take someone who has castrate levels of hormones or fluctuating levels of hormones and, and they choose to use different things to help with their quality of life and their sexual health, their health, their hormonal health, whatever it is, they, they get this energy, they get this strength, this inner strength. It ends up helping their relationships, it helps their work, it helps their at home with their children, it allows them to sleep, it allows them to make decisions not in survival. And I think that's the beautiful thing is they are. You watch them go from, I'm just here because it hurts. I'm here because I get UTIs. I'm here because I'm in survival. And then I get to sit there with popcorn and watch them get to thriving and making great decisions for themselves. And I want that for everyone. I can't be everyone's doctor. I've tried. It doesn't work. Like, I can't be everyone's doctor, but I want every woman to have access to what my neighbor had access to. Why not? It's empty evidence based. It's fda. Most of it's FDA approved. Maybe not for women, but it's actually FDA approved. It works. There's decades of research. Why can't we have that for everyone? So I love that story because it just shows that it's so much more than libido. And it's about strength and hope and like, agency. Right? Like, that's what we're doing here.
- [102:18]
A
So how do you prescribe testosterone?
- [102:21]
B
Okay, so again, not that serious. It feels scary because. Okay, again, politics again. In the 1990s, there was a big dope coping scandal where all these bodybuilders got testosterone in trouble. And these bodies that have to do
- [102:32]
A
with women's health, it has a lot
- [102:33]
B
to do with women's health because these bodybuilders got us in trouble. And everyone was afraid that everyone was abusing testosterone. So the FDA and the dea, the Drug Enforcement Agency, put a big old label on testosterone that made it a controlled substance. So when you prescribe testosterone, you need a DEA license like you are prescribing opioid opioids. So that provides challenges for people writing the prescriptions, which is why we're advocating to the FDA to change that. Maybe by the time this airs, they'll have made an announcement that they've changed it. But anyway, we use generic testosterone. There's lots of ways to give testosterone, but this is the most inexpensive way that we have found. This costs about $8 per month. Because a tube of this generic testosterone, my male patients would use the whole tube every day. They'd squeeze the whole tube out, rub it all over their chest when we tell women to do it. You use bigger than a pea size, sort of a glob of testosterone. It's a gel. So I put about double that. And then I would put it on my leg every single day. So you just put it on your leg? I'm putting it on my leg right now. I'm wearing clitoris socks. I Don't know if everyone can see, but my socks are, have clitorises on them, but you just rub it on your, on your leg, you wash your hands and you go on with your day. So for me, so for me, I pee first thing in the morning. I have a, my, my testosterone on a shelf right where I pee. My ankle's exposed. I put a blob. I, it's 0.5 milliliters. So if you want to be super precise, you can take a syringe and fill it up with the testosterone and it's half a milliliter. So just, you could push half a milliliter. Just, it's a, a little bigger than a piece kind of a blob, like a lima bean, I would say. It's, it's, it's, it's not so precise. That's why we need a product and we need actual testosterone for women. But it's not that serious people, because it's not risky. We give transgender patients 10 times the dose of testosterone and their, their health outcomes are fine. So this is 1/10 the dose. This is, we don't give 10 times the amount of aspirin to people said
- [104:28]
A
it takes four months for most people to start to even feel it.
- [104:31]
B
It's wild. So there's really, we don't see many side effects. I always say think horny teenagers. So sometimes oily skin, acne, hair growth, hair loss, but even then that's much higher doses for most people. This is where we get nervous about the things like pellets. I'm not against pellets. For anyone who doesn't know, pellets are these very expensive, almost look like tic tacs that are placed underneath your butt cheeks basically. And they give you long acting hormones over a few months. And they often cost a lot of money and they are not regulated by the fda. And if the dose is too high, you can't take them out. So that's when you can see side effects. So we typically recommend this more generic, easier way to do it so that you don't get, get the side effects.
- [105:12]
A
I'd love to have you talk a little bit about what you wish we knew that medicine has ignored.
- [105:20]
B
There was a full page article in the New York Times science section and full page science in 2022 was about how I give women a mirror and I show them their own genitals and I talk about their body parts. I say, this is your labia majora. This is your labia minora. This is your clitoris. The title of the article was, half the world has a clitoris. Why don't doctors study it? And the brilliant author, Rachel Gross, who is so magnificently brilliant, and she wrote a book called Vagina Obscura, and every chapter goes into why we don't know anything about the uterus, why we don't know anything about the clitoris, why don't we know anything about the ovaries? And. And she does a beautiful, beautiful job. She's truly brilliant. And she wrote this article in 2022. And like most things in our. Our. Our world, the New York Times was like, we don't want to publish this. Nobody. This isn't interesting to our readers. And it was the most shared article in 2022. It went viral.
- [106:15]
A
That doesn't surprise me, and I'll tell you why. I've had three children. I am 57 years old. I have never once in my life had a medical doctor, a gynecologist, a nurse practitioner, or any healthcare professional ever hold. Hold up a mirror and show me that the. The. That part of my body ever.
- [106:43]
B
And. And that's why it went viral, because it's so simple. And we find that still today, we give women access to their own body. So while I'm examining them, this is your labia majora. This is your labia minora. This is your clitoris. This is your clitoral hood. This is your vulva, vulvar vestibule. This is your pelvic floor. And we can go through all of those details. In 20, 20, 2017, we looked at thousands of pictures of women's genitals, and we found that 23% of all women who come into the clinic have what's called clitoral adhesions.
- [107:11]
A
What is that?
- [107:12]
B
Okay, So I was.
- [107:14]
A
23% is one out of every four women.
- [107:16]
B
One out of every four women as a clitoral adhesion. So I always wear sleeves for this purpose. So for everybody not here, I have my sleeve over my fist.
- [107:26]
A
Okay. So she's pulled her. Her sweater over her arm.
- [107:30]
B
So her arm, you cannot see my by hand.
- [107:31]
A
Yes. Is hiding in there.
- [107:33]
B
Okay. So every clitoris has a prepuce or a hood or a foreskin, just like a penis that is not circumcised. Now, a penis that is not circumcised, when a man gets an erection, the foreskin goes back behind the head of the penis, and then it looks like a circumcised penis, that mushroom head that goes around a penis, and you can pull back and. And men with a foreskin you should pull it all the way back so you can see the whole head of the penis. Well, a clitoris and the penis are the same organ. It's exact same organ. They're made up all of the same tissues. They look the same under the microscope. They're the same. So every clitoris has a hood. Okay. And you should be able to pull the hood back to see the whole head of the clitoris, which looks like the head of a penis has a rim around the edge called the corona. Same as with a penis. But 23% of the time, you cannot pull it all the way back. It's stuck.
- [108:28]
A
Really? And that's what a clitoral adhesion is. It means the hood of it is.
- [108:34]
B
It's stuck.
- [108:35]
A
And how could be.
- [108:37]
B
And okay, so here's. So in 2017, we were the first to publish. We were the first to publish that it is either mild, where you can see most of the head of the clitoris, moderate, where you can see a little less, or very severe, where you can't see it at all. And you. You can't pull it back. Okay. 23% of the time.
- [108:55]
A
23% of the time.
- [108:56]
B
Yeah. This was published in 2017, and that was all of the world's literature on this problem.
- [109:01]
A
If you have clitoral adhesion.
- [109:04]
B
Yeah.
- [109:05]
A
Does it impact your ability to orgasm? Like what?
- [109:08]
B
What so. So up in 2017. We had no idea. This was just an observation of. Okay, 23% of people have this. So what does it mean? Is it normal? No doctor is taught how to examine the clitoris or ever routinely examines the clitoris. Can you imagine a. I'm a urologist. If I was told, don't examine the penis, don't touch a man's penis. You might make him uncomfortable. What if you have a clitoral problem? What kind of doctor do you go see? There is no doctor trained in the clitoris. There is a part of your body.
- [109:37]
A
They don't train you in this.
- [109:38]
B
No, no one. In fact, when you are a medical student learning to do a pelvic exam, no one teaches you to go near the clitoris. So a penis, lots of things can go wrong with it, right? So much can go wrong with penis. Couldn't all the same things go wrong with a clitoris? Of course they can, but nobody's looking. So 2017, you are Dr. Rubin. I'm looking people. 2017, all we knew was that people have these adhesions. Then I had three Brilliant. Oh, my God, Mel. These. These students are going to change the world. Three brilliant medical students who came to me and said, reuben, we got to know more. So they wrote up the irb, they looked at all the data and we have, we do a very simple procedure in the office. And you can go to the vid video Journal of Sexual Medicine to watch us do this procedure. It's published. And we do this procedure where it's kind of, it's, it's not that serious, Mel. It's kind of like have you ever woken up and you've had eye crusties? So to the point where your eye is shut. Okay, that's an emergency. You're blind, you can't see, you've got eye cre, but you're like, I'm not. I don't need to go to the emergency room. I can just pick off these crusties and open my eye. It's essentially what we're doing here. We stretch the tissue. We, we, we open it up so that you can separate between the plane, between the hood and the head. So we do an office based procedure. Mild numbing agent. It's not surgery. There's no cutting, there's no stitches or anything like that. And so the medical students asked these patients and said, well, what happened? What happened? Well, some of these patients come with pain. They have pain in their clitoris. They feel like there's a hair in there. If you ever had an eyelash in your eye, it's not cancer, but you can't do anything unless that eyelash. So we have people who every time they try to stimulate or touch their clitoris, it hurts, it's irritated, it's uncomfortable. How many people are walking around saying, I don't like oral sex because they're schmutz under their clitoris and it irritates the crap out of them? A lot of women, Mel, a lot of women, 23% in fact, don't like, like their clitoris being touched because it's irritating. And this by the.
- [111:33]
A
Oh my God.
- [111:35]
B
Some have symptoms of decreased arousal, decreased orgasms. So we see. Ask them all. The Data is remarkable. 60 to 70% improvement in arousal, orgasm satisfaction. 70% decrease in pain, if you had it. And the kicker. So these students are presenting this research to me. It's my research, but they actually looked at it. I was drinking water. I'll never forget this one was drinking water. And they showed me this piece of data that made me cartoon spit out water all over my computer. Because of the patients who had never had an orgasm in their lives, six were able to orgasm with clitoral Stimulation. After this procedure, I couldn't even believe it myself. And I'm the one doing the procedure. Since then some of my colleagues have replicated the data. We've gotten the word out. So more people are showing up with these issues. This is not a rare problem. We were just at the Women's Sexual Health conference this year. It was in Long Beach, California. And for the first ever time in history they did video abstracts where we presented video, video research. And the very first video abstract was a case report that our team team did of a 7 year old that came to see us from western Canada. Their parents found us from our research that we had done. And this little girl, since she had language said there is something sticking, there's something stuck under my clitoris. Once she learned the word for clitoris she would point to it, she would talk about it and it was so distressing that the parents were beside themselves. Everything was a fight. She was. So she went to doctors in Canada and they tried to help but they didn't know they were looking at. And they offered her cognitive behavioral therapy. In the notes the seven year old they were said you need cognitive behavioral therapy. The parents never gave up. They believed this child. Thank God for these parents. They're, they're just the most amazing people in the world. They brought her to my clinic. I heard the story and I gave her this mirror, I actually gave her this mirror and I showed her these models and I'm talking to the parents and, and, and the child and we're talking about it and it with the mirror and I, I, we, we then examined her and she saw everything we were doing and we saw that she had a co completely like it was completely closed. And I said is this where your pain is? And she said yes. And she saw it and she saw what was happening and she saw my models of nor of what normal was and she saw pictures of normal and she saw that. And you saw this seven year old girl feel believed for the first time truly in her life by a doctor right there in that moment. And so we ended up bringing her to the operating room because I didn't want to do a procedure of her awake. And she woke up and her pain was gone. It was gone, completely gone. She stopped complaining, she stopped pulling, she stopped agonizing. It was, it was gone. But we have a huge problem here because the doctors in Canada didn't know how to do this. The doctors in America don't know how to do this. And these parents can't keep coming. It may read here Right. This is like eye crusties. The eye crusties might come back. They can't afford to come to Washington, D.C. every time this happens. This is not a rare problem. This is 23% of people on an organ that no one has ever been bothered to study.
- [114:35]
A
Wow. What was the result of diagnosing the clitoral adhesion and then doing a simple office procedure that changed it?
- [114:46]
B
So in this study, and this was again, only 41 patients, in this study, since there have been published reports of even more patients than this, we had 76% improvement in sexual arousal, 64% in the improvement ability to orgasm. 38% of the patients who had never had an orgasm were able to orgasm after this procedure. 83% were very satisfied with the procedure. And this isn't major surgery, Right? This isn't like body mutilation. This is literally like opening your eye after having eye crest.
- [115:19]
A
But it's more importantly mo, none of us know.
- [115:21]
B
Nobody knows.
- [115:22]
A
One in four women have this. And it's impacting your life or your ability to orgasm or experience pleasure or you're feeling discomfort. To know that, that the simple procedure and just being aware of this has such profound positive impacts.
- [115:40]
B
Listen, we need more data, but the very first thing people can do is get a mirror at home and look at your own body.
- [115:47]
A
Why don't you show us what we're supposed to see?
- [115:49]
B
So, all right. This is really important, Mel, because you don't go to a doctor for face pain, okay? The reason you don't go to a doctor for face pain is because you have a lot of parts on your face. And there's a lot of different doctors that you go to to for your face. So you don't show up at the dentist because you have eye pain. You don't show up at the dermatologist because you have a lip problem or a teeth problem or a throat eye. Like, people don't even have the language for their genitals. They say down there they use innuendo. They have some stupid name for it, or God forbid, they call it a vagina, where the parts that you can see are the vulva, not even the vagina. And vulva is a stupid name too, because there's no vulva for men. Like, so the more, you know, know your own body parts, the more you, as a patient can show up and say, there is a problem with my clitoral hood. There is a problem with my vulvar vestibule.
- [116:38]
A
What is a vulvar vestibule? Exactly?
- [116:40]
B
You don't even Know what it is? How are you going to show up to the doctor when that is the most common reason people have pain with sex?
- [116:45]
A
Wait, the most common reason people have pain with sex is vulvar vestibule.
- [116:50]
B
Pain in the vulvar vestibule. What is that exactly? Mel, let's talk anatomy. My favorite topic in the world. So this is a pelvis, okay? This is a pelvis. I'm holding up a pelvis. You've got these big bones, and the pelvis is basically surrounded by big, giant muscles, which we call the pelvic floor. It's basically a bowl. The pelvis is a bowl, and the lining of the bowl is filled with thick, big, giant muscles. And I don't know about Boston. I trained in Boston. I went to college in Boston, did medical school in Boston. But, man, in D.C. we have a lot of tight asses. And what happens is these pelvic floor muscles get really. Can get really tight. Just like your neck muscles can get tight or your back muscles can get tight. And when you have tight muscles in your pelvis, it can cause constipation, it can cause urinary frequency, urinary urgency and pain with sex, because these muscles surround the hole that you are trying to have a speculum exam or a tampon or devices or a penis or whatever you want to put in there. The rectum is where poop comes out of. And if that is tight, it's hard to get poop out. And so it can hurt or it can cause constipation. And we spend all day long using our pelvic floors and not exercising them, not training them. And if they have. Have a problem or say a watermelon comes out of them like a child's head, we don't even think about rehab. If you got a knee replacement, you would go to physical therapy three times a week. If you have three children come out of your vagina or out of your abdominal muscles, if you have a C section, barely anyone gets told to go to rehab and retrain their muscles. Okay, never. But it's the most important thing in the world. So pelvic floor physical therapists are highly trained professionals who are trained to rehabilitate and help help these muscles if they're too tight, if they're too weak, if they are not working, like any muscles in the body can have problems. These muscles are no different. Does that make sense, Mel?
- [118:46]
A
Very much so.
- [118:47]
B
Okay, so it's all muscle. And then on top of the muscle is you're going to have the part that you can see. So if you take a mirror. So this is a model, a very silicone model of a vulva. And you have a labia majora. Right. So this is the labia majora. It's just skin and under the outer lips. The outer labia. Right. And. And it. It's just skin. But if you push on it, the muscles are underneath. Then you have the labia minora, which a lot of people call lips. I don't know why. I find it kind of icky. I call them wings. Wings. I think wings just sounds like the
- [119:22]
A
thing that I was calling. So I was calling it the wrong thing.
- [119:24]
B
That's okay. So labia majora is the pad that's sort of outside of the labia minora. And that flattens out in menopause, by the way. We don't really know why, but it's. It can get flattened. Then there's the labia minora, or those inner wings. And those come in all shapes and sizes, but they're hormonally sensitive.
- [119:40]
A
They're hormonally sensitive.
- [119:41]
B
Babies have very small ones. You grow them in puberty and they resorb and disappear in menopause.
- [119:46]
A
They get smaller in menopause.
- [119:47]
B
They get smaller in menopause. So remember, when you play with hormones, there are consequences. So likely birth control affects the size of the labia. Likely things like spironolactone, likely breastfeeding. All the changes with hormones can probably change the size of size of the labia. So when women go get surgery to alter the size of their labia, they do. I beg. It's a billion dollar industry. Mal, where have you been? Labiaplasties are one of the most common procedures. Women will show up to get their labias operated on. Yeah. Because they feel they're too floppy or they get in the way. They can be uncomfortable for women. And I'm. If you want to do with your body, you do whatever you want. But there are nerves in there that are important for sexual health. And so we see a lot of people, patients who have. They think they're abnormal when really big labia are hormonally healthy labia. So we don't educate on what normal labia are. If you follow those inner wings up, you get to the hood of the clitoris. Okay. So you follow the inner wings, the inner labia up, and you get to the hood of the clitoris. If you pull back those wings, you will see the very tip of the tip of the head of the clitoris. So right here you follow the labia up and you get to. To the tip, which is like the tip of the iceberg. So penises, Right. Have a tip of the head of the penis. That's not the only part that you touch during sex or an intimacy. Right. There's this whole shaft thing. And actually penises are. There's the shaft, and then they split into two and they go into legs that go all the way to a man's butt bones. Well, guess what? The clitoris is the same.
- [121:21]
A
It splits into two and goes through
- [121:22]
B
a button two and goes all the way down to your butt bones. So if you go back and forth on your butt bones and you feel your sitz bones.
- [121:28]
A
Yeah.
- [121:29]
B
That's where your clitoris inserts.
- [121:30]
A
Shut up.
- [121:31]
B
Which means there is a reason why vibrators feel so good anywhere along the lines of the labia majora, because that's where your clitoris lives. So the tip of the iceberg. But the legs are underneath the labia majora, so they go down the whole
- [121:46]
A
length of the wings. Whoa.
- [121:49]
B
So it basically sits like that.
- [121:51]
A
Wow.
- [121:52]
B
And so this is why. But it's all underneath the surface, my friends. If a penis were completely buried and there was nothing to touch, nothing to. How would a man have an orgasm? Well, the vibrator companies would be gajillionaires, not just billionaires. But the point is, is your clitoris, which is a penis, it's the same thing. How do you fully activate it? Well, you have to activate it from underneath the surface. And you've had wonderful guests on that, have talked about pleasure and things like that. But the truth is, is that this is not the inside canal, the vagina, which is where penetration happens.
- [122:25]
A
Yes.
- [122:25]
B
And that's why so few women orgasm with penetration. It's not because they're broken. It's because that not how orgasm works. So the more our patients can understand how orgasm works, understand their own anatomy, understand what feels good for them, we don't. I have never had a man come to see me, Mel. I see a lot of men. I've never had a man come to see me, say, Dr. Reuben, I'm broken. I can't have an orgasm. I'm just rubbing my inner thigh over and over again. And no matter how hard I rub my inner thigh, I can't orgasm. Why have I never had that console? Because every man knows he has to stimulate his penis to orgasm. Yet I have women come to see me and say, I mean, penetration. And it's not doing anything for me. Well, a little up, a little Outside, right. Like you might need vibration. Like this is normal. And so education is so important here because we educate boys and men how a penis works. And there's no doctor who examines the clitoris.
- [123:24]
A
Dr. Rubin, what is the vulva vestibule? Is it. Is it the wings? Is that what that is?
- [123:29]
B
No. Okay, so you go to the clitoris, you pull back, see if you have adhesions. Well, now we keep opening those wings.
- [123:35]
A
Okay.
- [123:36]
B
There is a rim of tissue that surrounds the inside lining of the labia. So if you spread like a book, those labia, you spread it open. It's everything you can see at the surface. So the urethra is the tube you pee through, and the tissue above it, around it and below the opening of the hole that the vagina is in is called the vulvar vestibule. This tissue is the most important part of the body that you've never heard of before. Why is it important? Because the labia is skin. It's tough like skin. Right. The vulvar vestibule is delicate and thin, and it is actually made up of bladder tissue. And so just like your mouth or your outside of your cheek and the inside of your cheek are different, the skin of the labia is very tough and, And. And. And safe. That vulva, our vestibule, is thin, fragile, hormonally sensitive, and it's the bladder tissue. So if that is dry and irritated and doesn't have hormones and scrapes against something over and over again. In a high contact sport like sex, you can have urinary symptoms, frequency, urgency, leakage, pain with sex, feelings of a uti, but not actually have an infection. So we do what's called a Q tip test, one of the most important tests. You can do this at home. You take a Q tip, you can touch the labia, and you see you won't have pain. Then you can spread the labia and touch this area of the vulvar vestibule, and you'll say, oh, that feels like a uti. Oh, that feels like it's not supposed to hurt. It should have no pain. And yet so many women have pain there because of their birth control pills or menopause or their breast cancer treatments or things like that, because of the hormonal changes that happen in this tissue
- [125:19]
A
is impacting the health of that tissue and causing pain.
- [125:22]
B
Yeah. And so vaginal hormones help. Help with this tissue.
- [125:26]
A
You say, Dr. Rubin, that sex shouldn't hurt. What are the most common causes of pain with penetration that you're seeing?
- [125:33]
B
So there's really the two major problems. There's a third one that's a little bit smaller. But the two giant problems are, number one, hormonal changes. So anything that can affect your hormones, birth control, acne, medications, breastfeeding, endocrine therapy for breast cancer, cancer, perimenopause and menopause that is so common to have pain with sex and so treatable with vaginal hormones, which we talked about it like, so treatable, like, amazingly treatable. The second most common problem is. Often comes with. The first problem is when your muscles are really, really tight. And so if you have tight, tight, tight, tight muscles, think squeeze your eyes close as much as you can. It's hard to sort of stretch that tissue and get it to open. So what often happens? The hormones cause the, like a sunburn like pain. Your body guards and tightens to prot. You, you fix the sunburn. The body is still tight. And that's where our rehab, our physical therapy friends come in and dilation, dilators, vibrators, things that rehab the tissue. Because you have to fix the sunburn, fix the tissue, and then the muscles have to be healed. But the muscles can have problems on their own. You could have hip problems, you could have back problems, you could have endometriosis causing muscle problems. Or you can have all these things that cause pelvic floor tightness. Not as common are problems with nerves. So you can have too many nerve endings in that part of your body. And there are surgeries that sometimes we have to do for this problem. The most important message I can tell your amazing listeners is sex should not be painful, and you deserve a diagnosis. Just like you don't show up with face pain. You want to know, is it like, where is the problem? Is it the teeth? Is it the teeth? And just like there is a specialist all over your face, there are specialists and much fewer for this part of the genitals because we haven't valued or cared about this part of the body for women. So it is likely that your general doctor, who you've been seeing for a long time isn't necessarily, they might be, but isn't necessarily trained in the specific diagnosis. So we do have many patients travel to see different. Some of us who are specialized, there's, there's, there's, you know, 1700 within our women's sexual health specialty. Not everyone is a doctor, but there, there's, there's not enough of us. There's not enough specialists. But sometimes, sometimes you have to go find someone who's going to give you a Diagnosis, because that matters then for treatment. And that's where the mirror comes in handy, because when you can see what's going on again, you never heard of a vulvar vestibule.
- [128:01]
A
And it took me, never my life,
- [128:02]
B
but it took me two seconds to explain it. And it made so much sense to you that hormonal treatments would be helpful for that, right? It took two seconds. So to be able to give women information about their diagnosis. I didn't realize how much medicine that was like even before they get the treatment. Just the validation that what they have is real and it's diagnosable and they can see it with their eyeballs, life changing, life changing.
- [128:27]
A
I would love to focus on a couple recommendations of exactly what to do once you start to understand everything that you're talking about. If someone only has a 10 minute appointment with their, you know, gynecologist or their primary, primary care doctor, what exactly should they say to be taken seriously?
- [128:54]
B
I think it's really important for patients to educate themselves in as much detail as they possibly can and find doctors who they can work with as part of their pit crew. And I actually think it, it's important for patients to go to doctors and say, hey, I know you didn't learn everything in med school and I know you don't know everything. And I, I, I am really interested in this topic. Do you know someone or are you the right person to help me with these problems?
- [129:20]
A
Oh, I love the way you just framed that. Are you the right person?
- [129:23]
B
Are you the right person to help me with these issues? Because so many of your clinicians, I know a lot about the things, I know a lot about there. If you ask me about diabetes right now, I would look crazy. And I don't know anything about diabetes. I don't know anything about thyroid hormones. I don't, I mean, I know a little bit, but like, but I am not an expert in the things I not an expert in. Your doctor doesn't know everything. And the key is to find someone who is curious, who is kind, who is thoughtful, who is willing to be a member of your pit crew. But I've never fixed a patient on my own. I want to be very clear about that. I have never fixed a patient by myself. The patients who do the best are the ones who have a team and they are the center of the team. They are the boss, the CEO, the, the race car driver, and they take a, they take responsibility of the team. You have to understand what you get in 10 minutes and you have to come Prepared, but also show some kindness and to your clinician because they don't want to spend 10 minutes with you either. They also would like to spend more time with you, but your insurance company doesn't give a crap. They only want you to have 10 minutes. And so I think the bad guy is not always the doctor who is under educated in some of these issues. Issues. It's the system as a whole.
- [130:35]
A
If you are a healthcare provider, a nurse, a doc, somebody who is in the medical profession and this is all new information to you because I also think this is one of those episodes that people are gonna send to their sister or brother who's a nurse, they're gonna send to their partner who may be a doctor, they're gonna send to their friend who's the gynecologist of the friend group and say, oh my gosh, like you got to hear this where what is the best place for a medical professional or somebody working in healthcare to go to become more educated about what you've just shared.
- [131:13]
B
You can learn new things. Your clinician can learn new things. Whether it's taking my course online while you drive to work. The Menopause Society has great content. Isswish, the International Society for the Study of Women's Sexual Health. Health ISS WSH.org has a great Find a provider and hormone course. There are more ways to learn how to do this more than ever before. My friend Heather H has awesome content. Kelly Casperson has an amazing podcast and is a dear friend of mine. Iswish has amazing content. They have patient facing materials called proa website. We've had thousands of people take our course and actually say, oh wait a minute, I can do this as a dermatology, dermatologist, as a plastic surgeon, as a rheumatologist, as a neurologist, orthopedic surgeon, orthopedic surgeon. You can learn how to do this and you can do it quite easily. And so if I give you the building blocks and the confidence to say, hey, if I can do this as a urologist, you certainly can do this and here I will help mentor you. That's really what it's going to take. But I'm hopeful for there's more money in this than ever before. There's more industries in this than ever before.
- [132:18]
A
Dr. Rubin, if you could speak directly to the person that that's listening, if they take one action from everything that you've shared with us, what would that one thing that's the most important thing
- [132:30]
B
to do be so education is the most important thing and by listening to this, you can check that box off. You're incredible. By investing in your body, your education and your knowledge, you cannot go wrong. You have to learn yourself to figure out who do I need to go see to get my customized answer. Because you, you deserve it, right?
- [132:50]
A
So Dr. Rubin, for somebody who's been hanging on every word and now you've opened the door, we want to walk through and just jump in and learn even more. Where do we go?
- [133:03]
B
We're all lifelong learners. I'm learning new things every single day. And so a great place is to follow me on social media because you can learn the new things that I'm learning while it's happening. That's Dr. Rachel Rubin on social media. Our website is a wonderful place for education. So Rachel Rubin md.com you can find our courses, our, our updates, our newsletters, very popular. We tell you about all the new research that's going on, which is really excellent. And then this has been an insane year. Not only were we able to announce the FDA box label changes, but I have been a part of three incredible documentaries that are all able to be watched now. Right now get on your TVs and start watching the first one. I couldn't be more proud of Paramount plus and it's called Pink Pill. You to watch this documentary, your jaw will go on the floor. And this documentary got made. It is all about the drug that is FDA approved for lobido and how hard it was to get advocacy through through the fda. It is a must watch movie. It only got made because I did a free zoom call for a friend of mine and there was a producer in the audience and the movie got made because of that. I'm in it. I'm not the main star of it and it is fabulous. The second thing that's a must watch is the Balance documentary series again. Balance. Balance. It's called Balance. It is all about perimenopause. It is these lady monks who are also documentary filmmaker that were going through perimenopause. It's so fascinating. They were like, wait a minute, I am like doing yoga and mindfulness and my soul is great. Why am I having hot flashes, night sweats and I can't sleep? And they go on this spiritual journey to learn everything they can about perimenopause and hormones. So they interview all of the experts. They go on their own journey. Journey. It's a four part series on Apple tv. It is absolutely fabulous. I'm in it. I'm not the star, but I have Some really funny lines in it that I think will make you laugh. Obviously, I. Women urologists have to be funny, by the way. It's kind of a rule. And then the third one is the M Factor before the pause. So the M Factor was a great PBS documentary about menopause. And they just made the prequel about pre menopause. And so again, so they interviewed so many experts, all about perimenopause. I'm in it. I'm not the star. This is like the best. I always say I have sidekick energy. Like, I love being in things, but not like the main event, which is why this makes me very uncomfortable now. But these three documentaries are just showing how much excitement there is about this topic, how much that people want to know about it. So check out our podcast, check out the books that are out there. Follow us all on social media. We are building an army of education and advocacy, and we would love to have you join us.
- [135:42]
A
I absolutely love that. And what I really appreciate is that you've empowered us to be honest with ourselves about the things that we're living with that we may not have to live with. Like, there are things that I learned today that I wouldn't even thought to make a list and go talk to somebody or learn more. And so I just. I am on the floor about everything that you have shared with us today. This has been absolutely extraordinary. Dr. Rubin, what are your parting words?
- [136:11]
B
You matter. Your life matters so deeply. And you deserve a team of around you to help you with that and get you to whatever your goals are. And I just wish you all of the success and the optimized life ever, because you deserve all of that.
- [136:28]
A
Well, Dr. Rachel Rubin, you are a gift to all of us. On behalf of every single woman that will listen to this, I just want to thank you for the work you're doing, for the research that you're doing, for the advocacy that you've been doing. You are saving women's lives. You're changing medical care for women. And I think this is just the beginning. And it's a real honor to spend this time with you. And I am absolutely grateful for you, for the work, for everything that you taught us today. Thank you.
- [137:06]
B
Thank you so much for having me.
- [137:07]
A
Of course. It won't be the last time, I'm sure. And I also want to thank you. Thank you for caring enough about yourself and the other other women in your life, for listening to this, for sharing this. I have so much that I'm now thinking about. I have so many people that I Am sharing this with. I'm sure you feel the same. I cannot wait to hear your feedback about this. And I'm really honored that you and I are now gonna be a part of a wave of positive change that spreads around the world, one woman at a time, based on what we've learned and how empowered we now feel. Feel. To take better care of ourselves and to advocate for the things that we deserve and need in our lives. And in case no one else tells you today, I wanted to be sure to tell you, as your friend, that I love you and I believe in you, and I believe in your ability to create a better life. And as Dr. Rubin just said, you get one life. And I really want you to be proactive about advocating for yourself and doing what you need to do to feel good in your life and in your body. And everything you learn today is going to help you do that. All right, I'll see you in the very next episode. I'll welcome you in the moment you hit play.
- [138:28]
B
How much time you got? Okay, so let's do this. I'm warming up. I'm sorry. I know.
- [138:33]
A
I apologize.
- [138:34]
B
Okay. And also. No, no. So thank you. Thank you, thank you.
- [138:36]
A
You're welcome.
- [138:37]
B
I'm warming up. A.
- [138:38]
A
Excuse me. Sorry, guys.
- [138:41]
B
Bless you. And thank you for doing this with me. I know I'm very long winded.
- [138:44]
A
You're unbelievable. Every time one of my daughters calls about a uti, and I have a UTI again, and I have. Oh, you're on acne medication. Oh, like, you know, have we done a PhD thing?
- [138:55]
B
I know you want to talk about HRT today, but I think my mind has changed that we should only talk about heated rivalry therapy today.
- [139:05]
A
Well, if you just watch heated rivalry, you don't need testosterone because it's going to turn you on so much. Thank you.
- [139:13]
B
Thank you so much for having me.
- [139:15]
A
Of course. It won't be the last time, I'm sure. Oh, and one more thing. And no, this is not a blooper. This is the legal language. You know what the lawyers write and what I need to read to you. This podcast is presented solely for educational and entertainment purposes. I'm just your friend. I am not a licensed therapist, and this podcast is not intended as a substitute for the advice of a physician, professional coach, psychotherapist, or other qualified professional. Got it? Good. I'll see you in the next episode.
- [139:56]
B
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- [140:18]
A
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